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3841
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Discharge summary
|
report
|
Admission Date: [**2199-2-18**] Discharge Date: [**2199-2-25**]
Date of Birth: [**2161-10-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Codeine / Tape / Sulfa
(Sulfonamides) / Dipentum / Dilaudid
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
DKA, ARF
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 37 year old female with history of long standing
diabetes, c/b renal failure s/p living related [**First Name3 (LF) **] who
presents with a chief complaint of n/v all day, feelings of
lightheadedness, and FSBS greater than 500 all day. She has an
insulin pump and it is unclear if it was working properly. She
has no other symptoms leading up until today and denies recent
illness or infection, f/c, chest pain, palpitations, dysuria,
diarrhea, headache. She has been unable to take any of her meds
x 1 day including her CellCept, Rapamune and Prograf for the
[**First Name3 (LF) **]. She denies sick contacts.
.
In ED, the patient appeared dry, unwell. Her initial vitals were
97.6 104 91/46 20 100%ra. She had n/v and had coffee grounds in
vomit. Exam was unremarkable aside dry MM; abd exam was benign.
Labs were notable for ARF with a creatinine of 2x her baseline,
leukocytosis to 14,000 with a left shift, AG of 31 with a bicarb
of 7. Her lactate was 2.6 and increased to 3.4 after IVF. An EKG
was notable for lateral ST depressions, CE's were sent and were
essentially negative. She was started on an insulin bolus and
gtt that was rapidly increased to 10 units/hr. She received
stress dose hydrocort to cover her for her [**First Name3 (LF) **] as well as
protonix, Zofran and compazine. At the time of transfer, she had
received 2L NS, and a 3rd/4th with K were running. Blood cx x 2
pending. Renal was called and is aware of the patient.
.
On arrival to the ICU, is ill appearing. She denies nausea after
getting antiemetics. She notes that she and her husband thought
the pump was not working this morning and she attempted to
change the pump infusion kit herself. Apparently, the needle was
not properly inserted and she did not receive any insulin after
about 1pm Saturday. She admits to thirst. She denies shortness
of breath.
Past Medical History:
insulin dependent DM type I x34 years
diabetic nephropathy s/p living-related renal [**First Name3 (LF) **] on
[**2198-1-23**] c/b one episode of rejection
chronic hypotension on high salt diet and florinef as outpatient
hypercholesterolemia
vitamin D deficiency
anemia
ulcerative colitis, s/p colectomy [**2181**]
hx of MRSA
legally blind due to retinopathy
h/o meningitis [**8-8**]
h/o VRE bacteremia - [**2-9**]
Social History:
Lives with her husband. [**Name (NI) **] smoking, occasional alcohol, no drug
use.
Family History:
Numerous family members with type 2 DM (grandmother, aunt, 2
great uncles). History of CAD (great-grandfather), breast
cancer, and colon cancer. Primary pulmonary hypertension
(mother).
Physical Exam:
Vitals: T: BP: 118/63 P: 106 R: 18 O2: 100%ra
General: Sleepy, ill appearing, no acute distress
HEENT: EOMI, PERRL. Sclerae anicteric, MM very dry with coffee
grounds in teeth and on tongue, no thrush
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI SM heard
best at LLSB, radiating up to RUSB and across precordium, no
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Oriented x 3. CN II-XII in tact bilaterally. Strength 5/5
bilaterally.
.
Pertinent Results:
[**2199-2-18**] 04:00AM GLUCOSE-811* UREA N-67* CREAT-3.9*#
SODIUM-135 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-7* ANION GAP-36*
[**2199-2-18**] 05:10AM GLUCOSE-711* UREA N-65* CREAT-3.6* SODIUM-140
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-5* ANION GAP-32*
[**2199-2-18**] 06:30AM GLUCOSE-563* UREA N-63* CREAT-3.4* SODIUM-142
POTASSIUM-4.6 CHLORIDE-112* TOTAL CO2-5* ANION GAP-30*
[**2199-2-18**] 09:21AM GLUCOSE-348* UREA N-62* CREAT-3.3*
SODIUM-146* POTASSIUM-3.8 CHLORIDE-117* TOTAL CO2-13* ANION
GAP-20
Brief Hospital Course:
This is a 37 year old female with Type I Diabetes Mellitus, s/p
renal [**Month/Day/Year **], who presents with diabetic ketoacidosis and
acute renal failure.
# Diabetic Ketoacidosis: Felt to be secondary to insulin pump
malfunction (needle was not inserted properly)and subsequently
not getting insulin. Patient admitted to the MICU where she was
started on an insulin gtt and eventually transitioned to
injectable insulin. Blood sugar remained stable and she was
transferred to the hepatorenal floor. Initially on transfer
patient had multiple episodes of hypoglycemia that improved once
insulin pump was restarted and adjusted. On dishcarge basal rate
on insulin pump was 0.6 units/hr and boluses after meals.
Patient was followed by the [**Last Name (un) **] service. Patient should
schedule appt to follow up with Dr. [**Last Name (STitle) 17255**] in [**1-4**] weeks from
discharge.
# ARF: This was likely prerenal azotemia on top of chronic renal
insufficiency in the setting of DKA. Patient was repleted with
intravenous fluids and Cr improved to baseline of about 2.3-2.4.
She was also continued on her outpatient regimen of
immunosuppression which was adjusted as detailed below.
# Hypotension: On presentation patient was hypotensive likely
given osmotic diuresis from DKA. In addition she has a
longstanding history of hypotension for which she eats a high
salt diet and takes florinef. As noted above, patient was fluid
resucitated and treated for DKA and continued on florinef. Blood
pressure stabilized with treatment of DKA.
# EKG changes: On admission patient noted to have diffuse ST-T
wave abnormalities. Cardiac enzymes remained flat and patient
did not have any chest pain. Woudl suggest getting a repeat ECG
as an outpatient.
# Retropharyngeal Pathology: Patient initially underwent a
non-contrast neck CT on [**2-19**] that showed symmetric fullness of
the retropharyngeal soft tissues because she was experiencing
throat pain. An MRI on [**2-20**] demonstrated a small fluid
collection measuring approximately 3.13 mm x 30.94 mm in
transverse diameter. Patient was seen and evaluated by the ENT
consult team who were concerned about an infectious etiology.
MICU team started patient on broad coverage antibiotics
including levaquin, clindamcyin and fluconazole. A repeat MRI on
[**2-22**] demonstrated interval resolution of fluid collection.
Patient will complete a total of a 14 day course of antibiotics
(she was discharged on a 7 day course). She is scheduled for
outpatient ENT follow up.
# S/p Renal [**Month/Year (2) 1326**]: Patient continued on outpatient regimen
of immunosuppresion. Tacrolimus decreased to 2mg [**Hospital1 **], sirolimus
decreased to 6mg daily. MMF continued at 1000 mg [**Hospital1 **]. Plan is
for patient to have tacrolimus and sirolimus levels checked on
[**2199-2-27**] and follow up in kidney [**Date Range **] clinic on [**2199-3-1**].
# Hypothyroidism: Patient continued on her outpatient regimen of
synthroid (it was temporarily changed to IV while she was having
pain with swallowing).
# Anemia secondary to chronic kidney disease: Patient's
hematocrit on lower end of her baseline- mid 20's. No evidence
of bleeding. She will continue monthly aranesp injections.
# Hypercholesterolemia: Continue on outpatient statin.
# Depression: Continue on outpatient regimen of celexa.
Patient was a FULL code during this admission.
Medications on Admission:
ALBUTEROL
ATORVASTATIN 20mg daily
CITALOPRAM 40 mg daily
Aranesp
Vitamin D2 monthly
FLUDROCORTISONE 0.2 mg Tablet [**Hospital1 **]
VICODIN [**1-4**] Tablet [**Hospital1 **] PRN as needed for pain
NOVOLOG insulin pump
LEVOTHYROXINE 50 mcg daily
MYCOPHENOLATE MOFETIL 1000 mg Tablet [**Hospital1 **]
SIROLIMUS 7 mg daily
TACROLIMUS 4 mg Capsule [**Hospital1 **]
Discharge Medications:
1. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours) for 7 days.
Disp:*84 Capsule(s)* Refills:*0*
4. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed.
6. Fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Phenol 1.4 % Aerosol, Spray Sig: Two (2) Spray Mucous
membrane Q4H (every 4 hours) as needed for pain.
Disp:*qs 1* Refills:*0*
10. Nystatin 100,000 unit/mL Suspension Sig: 5mL MLs PO QID (4
times a day).
Disp:*qs ML(s)* Refills:*0*
11. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Sirolimus 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
Disp:*180 Tablet(s)* Refills:*0*
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-4**] Sprays Nasal
QID (4 times a day).
Disp:*qs 1* Refills:*2*
14. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
15. Aranesp (Polysorbate) Injection
16. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
17. Glucagon Emergency 1 mg Kit Sig: One (1) Injection as
needed for hypoglycemia.
18. Insulin Aspart 100 unit/mL Cartridge Sig: One (1)
Subcutaneous per insulin pump.
19. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN throat
pain
20. Reglan 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
21. Outpatient Lab Work
Please check tacrolimus and rapamycin levels, BUN/Cr, CBC, CHM7
and have results faxed to Dr.[**Name (NI) 17254**] Office. fax
number:([**Telephone/Fax (1) 12146**]
22. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diabetic Ketoacidosis, Acute on chronic renal failure,
retropharyngeal abscess, thrush
Secondary: Status post kidney [**Telephone/Fax (1) **], type 1 diabetes
mellitus
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you were found to be
in diabetic ketoacidosis. You were admitted to the ICU and
started on an insulin drip and eventually transitioned to
injectable insulin. After being transferred to the medical floor
we were able to restart your insulin pump.
During this admission we also treated you for an infection in
your throat. You will need to continue taking antibiotics
(clindamycin, levaquin and fluconazole for another 7 days).
NEW MEDICATIONS:
-Clindamycin 450 mg every 6 hours for 7 days
-Levaquin 250 mg daily for 7 days
-Fluconazole 100mg daily for 7 days
-Ocean Mist nasal spray (over the counter)
-Reglan 5mg every 6 hrs as needed for nasea
-Nystatin Oral Suspension 5mL every 4 hrs for the next week
-Phenol 1.4 % Aerosol, Spray spray in mouth every 4 hrs as
needed for pain
-Maalox/Diphenhydramine/Lidocaine 15 mL by mouth four times a
day, as needed for throat pain- swish and spit
CHANGES in existing MEDS:
-tacrolimus now 2 mg [**Hospital1 **]
-sirolimus now 6mg daily
If you experience fevers, worsening throat pain, elevated blood
sugars or any other concerning symptoms you should contact your
primary care provider or go to the emergency department for
evaluation.
Followup Instructions:
You will need to have your labs drawn on Wednesday [**2199-2-27**] and
have them faxed to Dr.[**Name (NI) 17254**] office- the fax number is
([**Telephone/Fax (1) 12146**].
You are scheduled to see Dr. [**Last Name (STitle) **] on [**2199-3-1**] at 11am.
You are scheduled to follow up with Dr. [**Last Name (STitle) 3878**] from
Otolaryngology.
on [**2199-3-12**] at 1:00pm. The office address is [**Location (un) **],
[**Location (un) 55**]. The office phone number is ([**Telephone/Fax (1) 7767**].
You should follow up with Dr. [**Last Name (STitle) 10088**] at the [**Hospital **] clinic
within 1-2 weeks of discharge. The phone number is ([**Telephone/Fax (1) 17256**].
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
Completed by:[**2199-2-27**]
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10320, 10499
|
7694, 8056
|
10553, 11781
|
3013, 3722
|
316, 326
|
398, 2251
|
2273, 2691
|
2707, 2794
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,231
| 130,032
|
49927
|
Discharge summary
|
report
|
Admission Date: [**2177-5-31**] Discharge Date: [**2177-6-3**]
Date of Birth: [**2114-12-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Nose bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62-year-old female who presented to the ED with epistaxis. She
first had epistaxis from the right nare starting last Thursday.
Initially, she felt fine, but noticed that the bleeding was not
stopping. After approximately 36 hours she began to feel more
lightheaded and dizzy, and was unable to get out of bed because
she was dizzy and short of breath. She had no chest pain, but
she states that she did fall once or twice without any loss of
consciousness. She has otherwise been feeling fine and has not
had any fevers, chills, nausea, or vomiting. She has noticed
dark stools over the past 24 hours.
.
In the ED her HCT was found to be 16.7 with normal platelets and
an INR of 1.3. She was transfued one unit of PRBCs and 3 liters
of NS. She was also found to have renal failure with
hyperkalemia and a metabolic acidosis, and she was given
kayexalate, calcium gluconate, bicarbonate, insulin, and D50 to
treat her hyperkalemia. Nephrology was consulted. Her right nare
was packed, and ENT was consulted. She was started on Cefazolin
for prophylaxis while the packing is in place.
Past Medical History:
1. Microscopic hematuria
2. Chronic Kidney Disease with severe glomerulosclerosis and
vascular disease on renal biopsy
3. GERD
4. Hypertension
5. Hypercholesterolemia
6. Cataracts
7. S/p Cholecystectomy
8. Moderate aortic insufficiency
Social History:
She does not smoke or use IV drugs. She has a rare social drink
of alcohol
Family History:
No family h/o bleeding disorders. Her father died at age 89 of
an MI and was on hemodialysis.
Physical Exam:
ED VITALS: T 99.0, HR 113, BP 95/47, RR 16, O2 sat 100% RA
VITALS: HR 114, BP 128/81, RR 14, O2 sat 100% RA
GEN: A+O, NAD.
HEENT: Right nare packed and surrounded by dried blood. PERRL.
EOMI.
CV: Regular tachycardia, no murmurs.
LUNGS: CTAB.
ABD: Soft, NT, ND. Foley in place with good urine output.
BACK: No CVAT.
EXT: No LE edema.
NEURO: CN II-XII intact bilaterally.
Pertinent Results:
CXR:
Portable chest radiograph was reviewed. The lungs are clear,
the pleura are normal. Convexity at the right cardiophrenic
angle represent a large fat pat. The cardiac silhouette and
mediastinal contours are stable.
.
IMPRESSION:
1. No acute cardiopulmonary process.
.
EKG: Sinus tachycardia, poor baseline, no obvious acute ST
changes.
.
RENAL ULTRASOUND: The right kidney measures 9.5. The left
kidney measures 9.7 cm. There is diffusely increased
echogenicity of the renal parenchyma. In the left kidney,
prominent pyramid is noted, which appear larger than in [**2174**].
Crystalline material is seen layering within a calix. There is
no evidence of hydronephrosis or renal mass. A trace amount of
fluid is seen around the right kidney, which is nonspecific.
The partially distended urinary bladder appears unremarkable.
.
IMPRESSION: Increased echogenicity of the kidneys bilaterally
as well as
increased prominence of the left renal pyramid consistent with
medical renal disease progression since [**2174**]. No evidence of
hydronephrosis.
.
Admission Labs:
[**2177-5-31**] 09:26PM HGB-5.6* calcHCT-17
[**2177-5-31**] 09:20PM GLUCOSE-134* UREA N-157* CREAT-7.3*#
SODIUM-140 POTASSIUM-6.1* CHLORIDE-106 TOTAL CO2-12* ANION
GAP-28*
[**2177-5-31**] 09:20PM TOT PROT-5.2* ALBUMIN-3.2* GLOBULIN-2.0
CALCIUM-9.0 PHOSPHATE-8.2*# MAGNESIUM-1.4*
[**2177-5-31**] 09:20PM PEP-HYPOGAMMAG IgG-409* IgA-19* IgM-543*
IFE-NO MONOCLO
[**2177-5-31**] 09:20PM WBC-12.8*# RBC-1.81*# HGB-5.4*# HCT-16.7*#
MCV-92 MCH-29.6 MCHC-32.2 RDW-17.1*
[**2177-5-31**] 09:20PM NEUTS-75.8* LYMPHS-18.6 MONOS-3.8 EOS-1.4
BASOS-0.4
[**2177-5-31**] 09:20PM HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-1+
[**2177-5-31**] 09:20PM PLT COUNT-177
[**2177-5-31**] 09:20PM PT-14.1* PTT-27.8 INR(PT)-1.3*
Brief Hospital Course:
62 yo female with longstanding CRI who is admitted with severe
epistaxis in the setting of uremia. She was admitted to the
MICU and transfused 4U PRBCs and 1 pack platelets, with a
resolution in bleeding and stabilization of hct (16 -> 28). ENT
was consulted and packed her nose, and recommended Afrin spray
and Keflex for prophylaxis. Hct was stable after transfusion,
so pt. was transferred to the medical floor. On HOD #3 the
packing was removed without incident.
.
2. Renal failure/uremia: the Renal team was consulted and felt
that pt. did not urgently require HD, although she would in the
near future. They recommended starting Calcitriol, continuing
Epogen and Na bicarb. Pt. is to f/u with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr.
[**Last Name (STitle) **] for further HD planning.
Medications on Admission:
1. Niacin 500 mg PO TID
2. Lisinopril 10 mg daily
3. Procrit 5000 units weekly
4. Ferrous sulfate 325 mg daily
5. Celexa 30 mg daily
6. Aspirin 81 mg once daily
7. ? Sodium bicarbonate
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
Disp:*30 Capsule(s)* Refills:*0*
4. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet, Chewable(s)* Refills:*0*
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day) for 2 weeks.
Disp:*1 bottle* Refills:*0*
7. Niacin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. Epogen 10,000 unit/mL Solution Sig: 0.5 mL Injection once a
week: 5000 units once a week .
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Epistaxis in the setting of Uremia
Chronic Renal Insufficiency
Hypertension
Hypercholesterolemia
Discharge Condition:
Improved- epistaxis resolved
Discharge Instructions:
Please call your doctor or go to the ER if you have any further
nose bleeds, lightheadedness or weakness, shortness of breath,
or any other symptoms that concern you.
.
We decreased your dose of Lisinopril to 5 mg once a day. Please
talk with Dr. [**Last Name (STitle) **] about this at your next visit with him.
.
Please do not continue to take your Aspirin.
.
Please continue your Procrit as you were before you came into
the hospital.
Followup Instructions:
Primary Care: You have an appointment with Dr.[**Name (NI) 3588**] on
[**2177-6-9**] at 1:30pm. Please call [**Telephone/Fax (1) 2660**] with questions.
.
Nephrology: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Date/Time:[**2177-7-1**]
2:30
.
The Renal team has contact[**Name (NI) **] [**Name (NI) **] [**Last Name (NamePattern1) **], who is a Nurse
Practitioner in the [**Hospital 2793**] clinic. She will call you to talk
about dialysis options in the future. Please call the Renal
office at [**Telephone/Fax (1) 60**] if you do not hear from her in the next
week.
Completed by:[**2177-6-4**]
|
[
"458.9",
"276.7",
"276.2",
"424.1",
"584.9",
"285.21",
"530.81",
"403.91",
"784.7",
"272.4",
"311",
"285.1",
"276.3",
"585.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"21.01"
] |
icd9pcs
|
[
[
[]
]
] |
6135, 6141
|
4127, 4959
|
324, 331
|
6282, 6313
|
2313, 3376
|
6800, 7446
|
1812, 1907
|
5195, 6112
|
6162, 6261
|
4985, 5172
|
6337, 6777
|
1922, 2294
|
274, 286
|
359, 1444
|
3393, 4104
|
1466, 1704
|
1720, 1796
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,132
| 164,658
|
28323
|
Discharge summary
|
report
|
Admission Date: [**2141-3-20**] Discharge Date: [**2141-4-10**]
Date of Birth: [**2096-2-16**] Sex: M
Service: SURGERY
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
[**2141-3-21**]
EGD
[**2141-3-23**]
1. Exploratory laparotomy.
2. Lysis of adhesions (greater than 3 hours duration).
3. Gastrotomy with gastrostomy tube placement.
4. Oversewing of small bowel ulcers x4.
5. Push enteroscopy.
[**2141-3-27**]
EGD
[**2141-3-28**]
1. Exploratory laparotomy.
2. Push enteroscopy.
3. Duodenotomy.
4. Oversewing of duodenal ulcer.
5. Gastrostomy tube.
History of Present Illness:
The pt is a 45 y/o M with h/o BMI of 72, hypertension, and
dyslipidemia s/p open roux-en-y gastric bypass [**2141-2-21**] who now
presents with syncope and melena for past 2 weeks. The pt also
complained of dizziness and shortness of breath. He denies
abdominal pain, nausea/vomiting. He was given 2500cc of
crystalloid in the ED and 2 units of packed RBCs for a HCT of
21.2. Emergent GI consult was obtained and the pt was
transferred to the ICU.
Past Medical History:
Hypertension
GERD
Dyslipidemia
Chronic low back pain
Osteoarthritis of knee joints and ankles.
Social History:
He has no known food or drug allergies. He denied tobacco or
recreational drug usage, had bourbon daily for 8 years and
quitin [**2131**],and drinks 12 ounce diet cola 4 times a day but has
stopped. He is employed as a production supervisor and is
divorced with 2 daughters ages 14 and 18.
Family History:
Father: [**Name (NI) **], age 71 with cardiac disease s/p CABG x 3 and h/o
of cancer of prostate;
Mother: [**Name (NI) **] age 74 with rheumatoid arthritis and h/o colon CA
on maternal side
Daughter: age 17 with asthma
Physical Exam:
T 98.4 P 116 BP 135/67 R 18 SaO2 98%
Gen - alert and oriented, morbidly obese
Heent - neck supple, no scleral icterus,
Lungs - decreased sounds at bases, otherwise clear
Heart - tachycardic
Abd - obese, soft, nontender, nondistended, healing surgical
wound
Extrem - 1+ pedal edema
Pertinent Results:
[**2141-3-20**] 06:10PM BLOOD WBC-10.4 RBC-2.29*# Hgb-6.7*# Hct-21.2*#
MCV-93 MCH-29.3 MCHC-31.6 RDW-20.3* Plt Ct-406#
[**2141-3-20**] 06:10PM BLOOD PT-14.7* PTT-27.0 INR(PT)-1.3*
[**2141-3-20**] 06:10PM BLOOD Glucose-104 UreaN-23* Creat-0.7 Na-140
K-3.9 Cl-106 HCO3-25 AnGap-13
[**2141-3-20**] 06:10PM BLOOD ALT-30 AST-19 AlkPhos-50 Amylase-77
TotBili-0.2
[**2141-3-20**] 06:10PM BLOOD Lipase-151*
GI BLEEDING STUDY [**2141-3-21**]
Active GI bleeding in the small [**Last Name (un) 12376**] which seems to start at
the 2nd portion of the duodenum.
CT ABDOMEN W/O CONTRAST [**2141-3-22**] 5:44 AM
1) No evidence of retroperitoneal hematoma.
2) Postoperative change in the right pelvis and groin consistent
with recent embolization procedure.
3) Minimal stranding surrounding the pancreas and duodenum,
which may also be post-procedural.
GI BLEEDING STUDY [**2141-3-22**]
Apparent area of bleeding noted in the second portion of the
duodenum, similar in appearance to bleeding study performed
yesterday. The findings were discussed with the clinical team by
Dr. [**First Name (STitle) **].
ABD/PEL/LOWER EXT A-GRAM [**2141-3-27**] 8:46 PM
Similar findings compared to prior study with no evidence of
active extravasation. These findings include a persistently
occluded previously coiled gastroduodenal artery and a
persistantly occluded, coiled inferior pancreaticoduodenal
artery off of the proximal superior mesenteric artery.
ECHO [**2141-3-29**]
Preserved global and regional biventricular systolic function.
Compared with the prior study (images reviewed) of [**2141-1-9**],
the findings are
similar.
Brief Hospital Course:
GI - The pt was admitted for his GI bleed and was volume
resuscitated with transfusions of packed red blood cells, fresh
frozen plasma, and crystalloid. An emergent GI consult was
obtained. An EGD was done which showed a single cratered
non-bleeding 20 x 10 mm ulcer found just distal to the
anastomosis. There were no stigmata of recent bleeding, and
there was no melena in the visualized distal small bowel. This
was followed by a tagged RBC study showing bleeding localizing
to the second portion of the duodenum. An arteriogram was
performed which showed no active extravasation in the expected
vascular territories feeding the duodenum. Successful coiling
of the gastroduodenal artery was empirically performed due to
presence of bleeding localizing to the second portion of the
duodenum on the nuclear medicine study. However, the pt's Hct
continued to trend down and he continued to require transfusions
of packed RBCs. On hospital day 3, he had an Abd/pelvis CT scan
which did not show a retroperitoneal bleed as well as a repeat
tagged RBC scan which again showed bleeding localized to the
second portion of the duodenum. As a result of this study, the
pt had further coil embolization of his gastroduodenal artery.
However, the pt's Hct continued to trend down. On hospital day
4, the decision was made to take the pt to the OR to determine
the source of bleeding. The pt had an exploratory laparotomy,
lysis of adhesions (greater than 3 hours duration), gastrotomy
with gastrostomy tube placement, oversewing of small bowel
ulcers x4, and push enteroscopy which he tolerated well. The
pt's Hct remained relatively stable though he required
intermittent blood transfusions. On hospital day 8, the pt
began passing melenic output from his G tube as well as from
stool. The pt also dropped his systolic blood pressure into the
80s. He was resuscitated with blood transfusions and
crystalloid. He had an arteriogram which showed similar
findings compared to prior study with no evidence of active
extravasation. These findings included a persistently occluded
previously coiled gastroduodenal artery and a persistantly
occluded, coiled inferior pancreaticoduodenal artery off of the
proximal superior mesenteric artery. He had an EGD which showed
blood in the distal esophagus with clotted blood in the gastric
pouch that was able to be lavaged clear. There was a clean based
ulcer that had previously been identified at the
gastrojejunostomy anastamosis. This duodenal ulcer was most
likely the source of the bleeding. The pt returned to the OR on
hospital day 9 for oversewing of this ulcer. He remained
intubated post-operatively for ventilatory support.
Post-operatively, the pt had to be placed on pressors for
hypotension. An echo was obtained to determine if there was a
cardiac etiology to this. The echo showed preserved
biventricular function and he was able to be weaned from the
pressors. Bladder pressure was checked to monitor for abdominal
compartment syndrome. The pt was able to be extubated on
hospital day 14. The pt's Hct eventually stabilized. He was
continued on IV protonix, misoprostol, and sucralfate for his GI
bleed. He was started on a diet and PT was consulted to assist
the pt to get out of bed. He remained stable and was
transferred up to the floor on hospital day 17. During the
remainder of the pt's admission, PT continued to see the pt to
work with his ambulation. The pt was able to increase his
activity level as he worked with PT and the edema that occurred
as a result of the volume resuscitations decreased. He was able
to ambulate independently on discharge.
ID - During the first operation, cultures were sent from the
pt's abdominal fluid.
Broad spectrum antibiotics were started post-operatively as
empiric treatment. Haemophilus species, Capnocytophaga species,
and Veillonella species grew from this sample. On hospital day
5, the pt also spiked a temperature and was pancultured. These
cultures had no growth. The pt spiked another fever on hospital
day 11 and was found to have MRSA line sepsis. The pt was
treated with Vancomycin for this.
FEN - The pt was started on TPN and tube feeds since he was NPO
for an extended period of time. This was discontinued when he
was able to tolerate a diet. He was able to tolerate a
Bariatric stage 5 diet on discharge. The pt was given Lasix to
assist with his diuresis because he had received large amounts
of fluid during his resuscitations. The lasix was discontinued
as the pt was able to auto-diurese adequately.
.
.
[**4-1**] bronch
[**4-2**] extubated
[**4-5**] floor
Medications on Admission:
zantac, colace
Discharge Medications:
1. Misoprostol 100 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3
times a day): via G tube.
Disp:*90 Tablet(s)* Refills:*2*
2. Sucralfate 1 g Tablet [**Month/Year (2) **]: One (1) Tablet PO QID (4 times a
day): via G tube.
Disp:*120 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Year (2) **]: Ten (10)
ML PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*300 ML(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for anxiety.
Disp:*45 Tablet(s)* Refills:*0*
5. Hexavitamin Tablet [**Month/Year (2) **]: One (1) Cap PO DAILY (Daily):
alternatively may use flintstones chewables.
Disp:*30 Cap(s)* Refills:*2*
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day): continue for
the rest of your life.
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*10*
7. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: [**12-13**] teaspoons PO Q4-6H
(every 4 to 6 hours) as needed for pain: breakthrough pain only.
Disp:*250 ML* Refills:*0*
8. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) teaspoon PO
BID (2 times a day): take while using narcotics to prevent
constipation.
Disp:*300 ML* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*5*
10. Ferrous Sulfate-Vitamin C 39-75 mg Tablet [**Month/Day (2) **]: One (1)
Tablet PO once a day: or liquid vitamin with iron & vitamin C.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
morbid obesity, s/p open [**Last Name (un) **] gastric bypass
s/p cholecystectomy
hypertension
GERD
peptic ulcer disease
upper GI bleed
hypercholesterolemia
osteoarthritis
h/o hiatal hernia
central line infection
wound infection
Discharge Condition:
improved
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 28351**]
Date/Time:[**2141-4-19**] 1:45
Provider: [**Name10 (NameIs) **] [**Doctor Last Name 28352**], LDN Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2141-4-19**]
2:00
Completed by:[**2141-4-10**]
|
[
"285.1",
"532.90",
"998.59",
"996.62",
"E879.8",
"997.4",
"567.22",
"272.4",
"518.5",
"530.81",
"531.90",
"682.2",
"532.00",
"724.2",
"278.01",
"715.96",
"568.0",
"401.9",
"V09.0",
"041.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.33",
"96.6",
"54.59",
"44.11",
"45.23",
"33.22",
"44.41",
"99.07",
"44.44",
"45.13",
"96.72",
"46.79",
"88.47",
"99.15",
"99.04",
"43.19"
] |
icd9pcs
|
[
[
[]
]
] |
10104, 10159
|
3776, 8390
|
280, 674
|
10432, 10443
|
2137, 3753
|
11407, 11725
|
1597, 1817
|
8455, 10081
|
10180, 10411
|
8416, 8432
|
10467, 11384
|
1832, 2118
|
232, 242
|
702, 1155
|
1177, 1273
|
1289, 1581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,111
| 176,320
|
29637
|
Discharge summary
|
report
|
Admission Date: [**2132-11-20**] Discharge Date: [**2132-11-23**]
Date of Birth: [**2097-4-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
35M s/p MVC c/o sternal pain,neck pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
35M s/p MVC GCS at scene and in ED c/o sternal pain, rib pain,
neck pain
Past Medical History:
anxiety, depression
Social History:
Neg TOB
occas ETOH
Family History:
N/A
Physical Exam:
Gen: NAD
CV: RRR
Chest: CTA Bil
Abd: soft,NT,ND
Ext: + pulses in all ext.
Pertinent Results:
[**2132-11-23**] 01:20PM BLOOD WBC-5.6# RBC-3.96* Hgb-13.3* Hct-36.0*
MCV-91 MCH-33.4* MCHC-36.9* RDW-13.3 Plt Ct-229
Brief Hospital Course:
Pt admitted with imaging showing sternal, rib fractures
cortications on c-spine film
Patient had an un eventful coarse. tolerated diet, ambulated
cleared by PT , +flatus, + BM , pain controlled.
c-collar removed on HD 2 and discharged on [**2132-11-23**] in good
condition on HD 4.
Medications on Admission:
Effexor 150mg po Qam
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO every [**2-20**]
hours.
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
MVC with sternal and rib fractures,spinal trauma
Discharge Condition:
good
Discharge Instructions:
Call or go to ED for Temp > 101.4, SOB, Nausea and vomiting,
increased pain
Followup Instructions:
2 weeks trauma clinic
[**Hospital 4695**] clinic follow up with Dr [**Last Name (STitle) **] and CT of
cervical-thoracic spine proie to appmt
Completed by:[**2132-11-23**]
|
[
"807.2",
"723.1",
"780.09",
"805.2",
"E812.0",
"807.09",
"861.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1411, 1417
|
815, 1098
|
355, 362
|
1509, 1516
|
673, 792
|
1640, 1815
|
559, 564
|
1169, 1388
|
1438, 1488
|
1124, 1146
|
1540, 1617
|
579, 654
|
277, 317
|
390, 464
|
486, 507
|
523, 543
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6,537
| 152,603
|
21069
|
Discharge summary
|
report
|
Admission Date: [**2128-7-30**] Discharge Date: [**2128-8-5**]
Date of Birth: [**2045-10-14**] Sex: F
Service: NEUROSURGERY
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Right temporal craniotomy for mass resection
History of Present Illness:
82F who presenting to her PCP with increased confusion and
memory
loss for the last six months. A Head CT was done which showed a
large right mass with mass effect and midline shift. After
receiving the Head CT read her PCP advised her to come to the ER
for further evaluation. Patient denies any
headaches/nausea/vomiting/visual changes. PCP does report [**Name Initial (PRE) **] [**4-15**]
lb weight loss over the last 4-6 weeks.
Past Medical History:
MI - [**7-/2122**] - 1 STENT AND DEFIB/PACER
2.5cm Distal Aorta Aneurysm
HYPERCHOLESTEROLEMIA
HYPERTENSION
CHOLECYSTECTOMY
APPENDECTOMY
UTERINE SUSPENSION
SQUAMOUS CELL CARCINOMA
MOTOR VEHICLE ACCIDENT
Social History:
Pt is widowed, lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] complex, and is retired.
Children live nearby. Nonsmoker. No ETOH.
Family History:
mom - died 71 - stomach cancer
dad - died 84 - brain cancer
[**Last Name (un) **] - died 55 emphysema
[**Last Name (un) **] - 86 - h/o prostate CA
sis - died 73 - lung CA
[**Last Name (un) **] - died 77 - colon CA
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T: 98.9 BP: 143/61 HR: 81 R 16 O2Sats 99% RA
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: able to name current president. Able to name pen/watch.
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, 2.5 to 2
mm bilaterally. Visual fields are full to confrontation-
question
of left field cut.
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 [**6-16**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Upon Discharge:
AOx2, pleasantly confused, PERRL, MAE [**6-16**], incision c/d/i with
staples
Pertinent Results:
[**2128-7-30**] Head CT w/ and w/o contrast:
There is an approximately 53 x 36 mm peripherally enhancing mass
centered within the right temporal lobe with extension into the
right frontoparietal region as well with surrounding vasogenic
edema. There is compression of the occipital [**Doctor Last Name 534**] of the
right lateral ventricle and also the temporal [**Doctor Last Name 534**], with
contralateral mild dilatation of the left lateral ventricle.
There is 3 mm of midline shift. There is also minimal
mass-effect on the right middle cerebral artery which is patent.
There is enhancement along the wall of the occipital [**Doctor Last Name 534**] and
posterior body of the right lateral ventricle which is
concerning
for subependymal spread.
There is minimal medial deviation of the uncus without frank
uncal herniation.
[**2128-8-3**] Head CT w/o contrast:
1. Increased amount of blood in the right temporal resection
cavity.
2. Slightly increased amount of epidural blood underlying the
right
craniotomy. However, due to decreased pneumocephalus, the
leftward shift of the septum pellucidum and third ventricle is
stable or minimally decreased.
[**2128-8-4**] Head CT w/o contrast:
1. In comparison to prior study, there is no significant
interval change in the extra-axial and intraparenchymal
hemorrhage and surrounding mass effect in the post-surgical bed.
2. No new hemorrhage or acute major vascular territorial
infarction detected.
Brief Hospital Course:
82F admitted with a newly diagnosis right brain mass. She was
taken to the OR for resection of R temporal mass on [**8-2**]. OR
went well without complications. Post operatively patient was
alert and oriented x 2 and full strength in all extremities.
Post operative head CT showed acute blood in surgical bed.
Prelim patholoy was high grade glioma. Patient was transferred
to step down with stable exam. Patient was also started on a
decadron taper which caused the patient to be very aggitated.
On [**8-3**], aggitation continued, she was given 12.5mg of seroquel.
On [**8-4**], patient was seen in the AM and stable, alert and
oriented x 2, full strength. Throughout the day, patient became
more confused and aggitated. A repeat head CT was ordered and
decadron was ordered as IV. Her Head Ct was stable and she
remained stable overnight. On the mornign of [**8-5**] she was
confused but interactive and much improved since yesterday. She
was screen for rehab and was accepted at [**Hospital **] rehab. She was
discharged to rehab on [**8-5**]
Medications on Admission:
Alendronate
Dicyclomine
Lisinopril
Metoprolol Tartrate
Simvastatin
Trazodone
Vit C
ASA
Calcium Carbonate
Vitamin D
MVI
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
17. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection [**Hospital1 **] (2 times a day).
20. Ondansetron 4 mg IV Q8H:PRN nausea
21. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
22. 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.
23. Dexamethasone 2 mg IV Q6H
24. Neuro Checks
Please do neuro checks q4hours. thank you
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Right Brain Mass
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**8-21**] 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) 3231**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2128-8-23**]
11:30. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain with/ or without
gadolinium contrast.
Completed by:[**2128-8-5**]
|
[
"414.01",
"293.0",
"191.2",
"272.0",
"401.9",
"348.5",
"V45.82",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.06"
] |
icd9pcs
|
[
[
[]
]
] |
7436, 7502
|
4272, 5323
|
285, 332
|
7563, 7563
|
2793, 4249
|
9679, 10565
|
1212, 1428
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5493, 7413
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7523, 7542
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5349, 5470
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7738, 9656
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1473, 1622
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236, 247
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2695, 2774
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360, 794
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1938, 2679
|
1458, 1458
|
7578, 7714
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816, 1019
|
1035, 1196
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,577
| 175,939
|
47836
|
Discharge summary
|
report
|
Admission Date: [**2191-5-28**] Discharge Date: [**2191-6-6**]
Date of Birth: [**2125-5-16**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Metoclopramide / Infed / Heparin Agents
Attending:[**First Name3 (LF) 25504**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
[**2191-5-28**]: ultrasound-guided percutaneous cholecystostomy
[**2191-6-2**]: IR guided PICC placement
History of Present Illness:
Pt is a 66 y/o M with PMH significant for ESRD on HD,
compensated liver cirrhosis c/b esophageal varices, poorly
controlled D2M s/p bilateral BTK amputations, AV fistula
infections (VRE and MRSA) and recently diagnosed pancreatic head
mass likely pancreatic adenocarcinoma from EGD brushings was
admitted to the transplant surgery service [**2191-5-28**] ago for
altered mental status which has persisted over his hospital stay
despite abx (IV zosyn) for GNR found in blood (at [**Hospital 100**] Rehab
facility), lactulose.
He was sent to ED from [**Hospital 100**] Rehab where he resides with
altered mental status. Reports from rehab indicate the patient
had a fever and altered mental status first on [**5-25**] and at that
time was started on empiric vanc/zosyn without a source of
infection. Blood cultures sent that day have since yielded GNRs
in [**12-28**] bottles. Reportedly the patient's mental status improved
and he did not have further fevers over the next two days.
Consequently he was sent to [**Hospital1 18**] ED for further evaluation
since his mental status declined again.
On arrival to [**Hospital1 18**] he continued to be somnolent; blood
pressures were marginal with SBP high 80s / low 90s. Notably
the patient last received HD yesterday via his right IJ tunneled
catheter without complications. In the ED he was arousable to
voice but quickly returned to somnolence, he was unable to
answer history questions but denied pain.
.
Since his admission to the transplant service, he has been found
to have a perforated gallbladder on CT abd s/p IR guided
percutaneous chole since he is not a surgical candidate for
cholecystectomy. His CT was also neg for ascitis for tap. Head
CT has been neg for intra-cranial process or bleed. Blood
cultures here have been neg to date. Also, he has persistently
failed speech and swallow evaluations and is NPO for aspiration
risk. He is on tube feeds via Dobhoff.
.
Patient reports an increased sense that he is dying slowly
because his medical condition is deteriorating. He admits to
diffuse non-localized or radiating abdominal pain and chills.
Denies nausea/vomiting, chest pain/SOB. Had diarrhea
(appropriately from the lactulose), no pain/burning with
urination.
Past Medical History:
ESRD from diabetic nephropathy on HD since [**5-/2183**]
Diabetes mellitus type II for over 20 years on insulin
HTN
Hepatitis C genotype 4
Hep B core Ab positive (negative viral load in [**2185**])
Cirrhosis - [**1-26**] HCV, portal hypertensive gastropathy
Ischemic colitis with GIB ([**2180**]), occ BRBPR; known small bowel
AVMs
Small bowel AVMs
Grade I esophageal varices
Chronic anemia
H/o right AV fistula infection
Gastric Antral Vascular Ectasia
S/p penectomy for necrosis [**1-26**] arterial insufficiency
S/p bilat BKA ([**2179**], [**2183**])
H/o IV drug use (heroin), on methadone since [**2159**]
H/o ESBL Klebsiella wound infections
H/o MRSA, VRE and Clostridium difficile
H/o L hand and finger MRSA osteomyelitides
H/o TB (age 15, Rx with PAS/INH x 2 yrs)
H/o line infections w/MSSA, E. fecalis, Pseudomonas and C.
glabrata
Social History:
Born in [**Location (un) 86**] and most recently lived in [**Hospital 100**] Rehab. He has
several brothers/sisters and four children. Worked with
computers. Has history of [**12-26**] ppd smoking for 10 years. Long
time history of IV drug (heroine use) and has been on methadone
since [**2159**]. Denies EtoH and other illicits currently.
Family History:
Several siblings with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tm:98.7, Tc:96.7, HR:60-70, BP:150/81(110-160/40-80),
RR:18, O2 Sat: 96%RA
GEN: Sick appearing cachetic gentleman lying in bed with feeding
tube in right nostril, no teeth, hypophonic, no acute distress.
Alert, oriented to self but not place (in church) and time
([**Month (only) 404**])
HEENT: Normocephalic, sclera icterus, oropharynx clear, MMM
NECK: No thyromegaly, no lymphadenopathy
CV: Regular rate, normal rhythm, no
murmurs/gallops/regurgitation
PULM: Clear to auscultation bilaterally, mild crackles in the
bases, no wheezing/ronchi, non-labored breathing.
ABD: Soft, decreased bowel sounds, tender to palpation in all
four quadrants, no rebound/guarding
EXT: Bilateral below the need amputation, cool but pulses
palpable in all four extremities. Has 4 fingers on the left.
Nails are dark and clubbed.
SKIN: Difficult to evalaute for spider angioma or palmar
erythema.
NEURO: Alert, interactive, oriented to self but not time or
place. Limited due to inability to follow commands fully.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm:97.7, Tc:93.8, HR:60-70, BP:127/33(110-150/40-80),
RR:18, O2 Sat: 96%RA
GEN: Sick appearing cachetic gentleman lying curled in bed with
feeding tube in right nostril, no teeth, hypophonic, no acute
distress. Opens his eyes with mention of his name but does not
follow commands. Teary.
HEENT: Normocephalic, sclera icterus, oropharynx clear, MMM
NECK: No thyromegaly, no lymphadenopathy
CV: Regular rate, normal rhythm, no
murmurs/gallops/regurgitation
PULM: Clear to auscultation bilaterally, mild crackles in the
bases, no wheezing/ronchi, non-labored breathing.
ABD: Soft, decreased bowel sounds, tender to palpation in all
four quadrants, no rebound/guarding
EXT: Bilateral below the need amputation, cool and non-palpable
pulses in upper extremities. Has 4 fingers on the left. Nails
are dark and clubbed.
SKIN: Difficult to evalaute for spider angioma or palmar
erythema.
NEURO: Opens eyes with mention of name but does not follow
commands.
Pertinent Results:
[**2191-5-28**] 06:21AM BLOOD WBC-13.6*# RBC-3.30* Hgb-10.1* Hct-31.8*
MCV-97 MCH-30.5 MCHC-31.6 RDW-18.0* Plt Ct-162#
[**2191-5-30**] 05:12AM BLOOD WBC-10.3 RBC-2.95* Hgb-8.9* Hct-28.5*
MCV-97 MCH-30.3 MCHC-31.4 RDW-17.4* Plt Ct-146*
[**2191-6-1**] 05:21AM BLOOD WBC-6.4 RBC-3.09* Hgb-9.5* Hct-30.2*
MCV-98 MCH-30.7 MCHC-31.5 RDW-17.2* Plt Ct-136*
[**2191-6-3**] 05:10AM BLOOD WBC-6.7 RBC-3.05* Hgb-9.4* Hct-29.7*
MCV-97 MCH-30.7 MCHC-31.5 RDW-17.5* Plt Ct-163
[**2191-6-4**] 05:45AM BLOOD WBC-7.8 RBC-3.08* Hgb-9.7* Hct-30.0*
MCV-97 MCH-31.4 MCHC-32.2 RDW-17.8* Plt Ct-178
[**2191-6-5**] 06:00AM BLOOD WBC-9.0 RBC-3.47* Hgb-10.7* Hct-33.8*
MCV-97 MCH-30.7 MCHC-31.6 RDW-17.9* Plt Ct-212
[**2191-5-28**] 06:21AM BLOOD Neuts-88.7* Lymphs-8.1* Monos-2.7 Eos-0.2
Baso-0.2
[**2191-5-28**] 06:21AM BLOOD Plt Ct-162#
[**2191-5-30**] 05:12AM BLOOD Plt Ct-146*
[**2191-6-1**] 05:21AM BLOOD Plt Ct-136*
[**2191-6-4**] 05:45AM BLOOD Plt Ct-178
[**2191-6-5**] 06:00AM BLOOD Plt Ct-212
[**2191-5-28**] 06:21AM BLOOD Glucose-192* UreaN-28* Creat-3.1*# Na-140
K-3.4 Cl-100 HCO3-29 AnGap-14
[**2191-5-30**] 05:12AM BLOOD Glucose-70 UreaN-56* Creat-4.6*# Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2191-6-1**] 05:21AM BLOOD Glucose-167* UreaN-40* Creat-4.2*# Na-138
K-4.1 Cl-102 HCO3-23 AnGap-17
[**2191-6-3**] 05:10AM BLOOD Glucose-81 UreaN-29* Creat-3.8* Na-135
K-4.0 Cl-96 HCO3-26 AnGap-17
[**2191-6-3**] 11:00AM BLOOD UreaN-6
[**2191-6-4**] 05:45AM BLOOD Glucose-106* UreaN-17 Creat-2.8* Na-135
K-4.8 Cl-95* HCO3-23 AnGap-22*
[**2191-6-5**] 06:00AM BLOOD Glucose-259* UreaN-30* Creat-4.2*# Na-133
K-5.7* Cl-93* HCO3-23 AnGap-23*
[**2191-6-5**] 02:43PM BLOOD Glucose-307* UreaN-33* Creat-4.8* Na-132*
K-8.1* Cl-92* HCO3-25 AnGap-23*
[**2191-5-28**] 06:21AM BLOOD ALT-19 AST-31 CK(CPK)-78 AlkPhos-119
Amylase-15 TotBili-3.9*
[**2191-5-29**] 01:28AM BLOOD ALT-19 AST-26 LD(LDH)-125 AlkPhos-93
TotBili-1.7*
[**2191-5-28**] 06:21AM BLOOD cTropnT-0.08*
[**2191-5-29**] 01:28AM BLOOD Calcium-9.7 Phos-2.5* Mg-2.1
[**2191-6-3**] 05:10AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.2
[**2191-6-5**] 06:00AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.8*
[**2191-6-5**] 05:21PM BLOOD Calcium-10.1 Phos-4.3 Mg-2.8*
Brief Hospital Course:
The patient is a 66M with cirrhosis and ESRD as well as
pancreatic neoplasm admitted to the surgery service with
perforated cholecystitis as seen on abd CT scan. Broad spectrum
antibiotic coverage (vanc/cefepime/flagyl)was started. He
underwent IR perc cholecystostomy tube placement (8 French
[**Last Name (un) 2823**] catheter) on [**5-28**]. Blood cultures from [**5-28**] isolated staph
coag negative. Bile gram stain were positive for gram negative
rods. Vancomycin was stopped. A 2 week course of flagyl and
cefepime was recommended. Given poor IV access, a right femoral
triple lumen central line was placed. This was removed on [**6-2**]
after a LUE picc was placed. A 28 cm single lumen PICC was
placed via left brachial approach with tip in left subclavian
vein (not SVC). Nephrology followed him and dialyzed him via the
right tunnelled dialysis line on M-W-F schedule. His mental
status wax and waned. On [**6-2**], he was more lethargic and
confused. A lactulose enema was given with slight improvement of
mental status. Speech and swallow evaluation was unable to be
done as patient was confused at that time and could not
participate in evaluation. He was more confused with aphasia
with left arm weakness prompted a non-contrast head CT that
demonstrated no acute process. There was concern that the
Cefepime could be responsible for mental status changes as
Cefepime can cause neuro toxicity as well as Flagyl. Cefepime
was switched to Zosyn on [**6-3**] and Flagyl was d/c'd. His mental
status continued to deteriorate. He passed away on [**6-6**] after a
rapid decline and a change in goals of care to focus on comfort.
Medications on Admission:
(per OMR) amylase/lipase/protease 2caps PO TID with meals,
calcium acetate 667mg PO BID, diphenoxylate-atropine 2.5/0.025mg
PO q4h, doxepin 10mg PO qHS, famotidine 20mg PO qHS, folic acid
1mg PO daily, gabapentin 300mg PO daily, lantus 10Units SC qHS,
Humalog 2Units qAM and ISS with meals and at bedtime, methadone
600mg PO BID (per OMR, not verified!), nadolol 20mg PO daily,
opium tincture 6mg PO QID prn diarrhea, Renagel 1600mg PO TID
with meals, vit B12 500mcg PO daily, loperamide 4mg PO QID prn
diarrhea, iron 325mg PO daily
ALLERG: Cephalosporins (itching), Metoclopramide, Infed
Discharge Medications:
paient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
[**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 25507**]
|
[
"585.6",
"403.91",
"V45.11",
"070.54",
"V49.75",
"V58.67",
"575.0",
"250.00",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"51.01",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10543, 10552
|
8221, 9863
|
339, 446
|
10611, 10628
|
6030, 8198
|
10692, 10836
|
3948, 3981
|
10504, 10520
|
10573, 10590
|
9889, 10481
|
10652, 10669
|
4021, 5027
|
278, 301
|
474, 2711
|
2733, 3574
|
3590, 3932
|
5052, 6011
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,129
| 107,866
|
40141
|
Discharge summary
|
report
|
Admission Date: [**2145-12-9**] Discharge Date: [**2145-12-15**]
Date of Birth: [**2078-7-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mitral valve mass
Major Surgical or Invasive Procedure:
Mitral valve replacement (29MM [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical) [**2145-12-10**]
left heart catheterization, coronary angiogram
History of Present Illness:
This 67 year old white male presented elsewhere with right arm
numbness and tingling which quickly resolved. A transient
ischemic attack was suspected, however, carotid ultrasonography
failed to reveal any significant plaque. Echocardiography
revealed a 1.25cm mass on the atrial side of the posterior
mitral leaflet and a 1.35cm mass on the ventricular side, with
mild regurgitation. He was urgently transferred for surgical
evaluation.
Past Medical History:
Noninsulin dependent diabetes mellitus
s/p coronary stent
coronary artery disease
s/p tonsillectomy
hyperlipidemia
Social History:
Lives with: wife
Occupation: sales- dairy products
Tobacco: none recently
ETOH: social
Family History:
father died at 88yo secondary to complications of valvular
surgery
mother living at [**Age over 90 **]yo
Race: caucasian
Last Dental Exam: 2 weeks ago
Physical Exam:
Admission:
Pulse: 74 Resp: 22 O2 sat: 94%RA
B/P Right: Left: 153/91
Height: Weight: 112kg
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur-none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2145-12-13**] 04:20AM BLOOD WBC-12.8* RBC-3.16*# Hgb-9.7* Hct-27.3*
MCV-87 MCH-30.6 MCHC-35.4* RDW-14.2 Plt Ct-158
[**2145-12-9**] 07:15PM BLOOD WBC-9.2 RBC-4.62 Hgb-14.8 Hct-41.8 MCV-90
MCH-32.1* MCHC-35.5* RDW-12.2 Plt Ct-267
[**2145-12-14**] 04:20AM BLOOD PT-26.3* INR(PT)-2.6*
[**2145-12-13**] 04:20AM BLOOD PT-23.9* INR(PT)-2.3*
[**2145-12-12**] 02:44AM BLOOD PT-16.7* PTT-30.1 INR(PT)-1.5*
[**2145-12-11**] 03:08AM BLOOD PT-15.1* PTT-28.1 INR(PT)-1.3*
[**2145-12-14**] 04:20AM BLOOD Na-136 K-3.7 Cl-101
[**2145-12-9**] 07:15PM BLOOD Glucose-113* UreaN-17 Creat-1.1 Na-140
K-4.1 Cl-103 HCO3-27 AnGap-14
[**2145-12-9**] 07:15PM BLOOD ALT-33 AST-33 LD(LDH)-231 AlkPhos-80
Amylase-38 TotBili-0.5
[**2145-12-9**] 07:15PM BLOOD %HbA1c-5.7 eAG-117
[**2145-12-15**] 04:25AM BLOOD PT-25.8* INR(PT)-2.5*
[**2145-12-14**] 04:20AM BLOOD PT-26.3* INR(PT)-2.6*
Brief Hospital Course:
Following admission preoperative work up was undertaken. Cardiac
catheterization
demonstrated nonobstructive coronary disease. On [**12-10**] he was
taken to the Operating Room where mitral valve replacement was
performed. He weaned from bypass on Propofol and Neo Synephrine
in stable condition. See operative note for details.
He remained stable and was extubated easily and weaned from
pressors. He Remained stable and was transferred to the floor.
Coumadin was begun for the mechanical valve and Heparin was
transiently given until the INR was greater than 2.0.
Physical Therapy worked with him for mobility and beta blockade
was begun and he was diuresed towards his preoperative weight.
He experienced some visual hallucinations and narcotics and
Ultram were discontinued with resolution.
OR cultures were negative and final pathology was pending on the
speciman at discharge. He remained in sinus rhythm.
Arrangements were made for Coumadin management with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 48239**].
Medications, restrictions, precautions as well as follow up were
discussed in detail with him prior to discharge on [**12-15**].
Medications on Admission:
Lopressor 50mg daily
Plavix 75mg daily
metformin 500mg daily
simvastatin 40mg daily
pantoprazole 40mg daily
asa 81mg daily
Discharge Medications:
1. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose).
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).
4. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)) as needed for sleep.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
7. 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*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: take as directed according to INR results.
Disp:*100 Tablet(s)* Refills:*2*
14. Outpatient [**Name (NI) **] Work
PT/INR on [**2145-12-16**], than prn.
Please FAX results to Dr. [**Last Name (STitle) 48239**] (attention:[**Doctor First Name **]) [**Telephone/Fax (1) 88184**],
or phone [**Telephone/Fax (1) 26035**].
Discharge Disposition:
Home With Service
Facility:
southern [**Hospital **] homecare
Discharge Diagnosis:
mitral valve mass
s/p mitral valve replacement
noninsulin dependent diabetes mellitus
hyperlipidemia
coronary artery disease
s/p coronary stent
gastroesophageal reflux
s/p tonsillectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on
Cardiologist: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 48239**] ([**Telephone/Fax (1) 26035**]on [**2145-12-29**] at
1:30pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 58292**] ([**Telephone/Fax (1) 58293**]) in [**5-17**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechanical mitral valve
Goal INR 2.5-3.5
First draw [**12-16**]
Results to Dr. [**Last Name (STitle) 48239**] att:[**Doctor First Name **]
phone:[**Telephone/Fax (1) 26035**] fax:[**Telephone/Fax (1) 88184**]
Completed by:[**2145-12-15**]
|
[
"272.4",
"530.81",
"V45.82",
"434.11",
"421.0",
"V15.82",
"424.0",
"414.01",
"368.16",
"394.9",
"V58.63",
"V58.66",
"250.00",
"518.5",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.24",
"88.72",
"37.22",
"37.33",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
6080, 6144
|
2976, 4154
|
340, 514
|
6374, 6545
|
2096, 2953
|
7385, 8319
|
1243, 1396
|
4328, 6057
|
6165, 6353
|
4180, 4305
|
6569, 7362
|
1411, 2077
|
283, 302
|
542, 984
|
1006, 1122
|
1138, 1227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
330
| 197,569
|
20138+57122+57124+57125
|
Discharge summary
|
report+addendum+addendum+addendum
|
Admission Date: [**2133-2-27**] Discharge Date: [**2133-3-16**]
Date of Birth: [**2065-6-10**] Sex: M
Service: VSU
CHIEF COMPLAINT: Carotid stenosis.
HISTORY OF PRESENT ILLNESS: This patient is well known to
Dr. [**Last Name (STitle) **]. He underwent abdominal aortic aneurysm repair
[**2132-1-15**] endovascular repair for a 5.7-cm abdominal
aortic aneurysm. His postoperative course was complicated by
congestive heart failure and a right groin infection. He
denies any claudication since his repair. He is seen in
followup because of his carotid disease. He has known
asymptomatic carotid disease, 60-69% on the left and 40-59%
on the right. Patient now is admitted for elective carotid
endarterectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Included Coumadin 7.5 alternating
with 5 mg; last dose was [**2-23**], Lasix 80 mg q.a.m. and 40
q.p.m., Toprol 200 mg daily, digoxin 0.5 daily, moexipril 7.5
mg daily, colchicine 0.6 mg daily.
SOCIAL HISTORY: Is significant for smoking. He denies
alcohol use.
ILLNESSES: Include congestive heart failure with ejection
fraction of 55%, chronic atrial fibrillation, history of
hypertension, history of COPD, history of
hypercholesterolemia, history of gout.
PAST SURGICAL HISTORY: Endovascular AAA repair and a type-II
endovascular leak repair.
HOSPITAL COURSE: Patient was admitted to the preoperative
holding area. He underwent a left carotid endarterectomy on
[**2133-2-27**]. He tolerated the procedure well. He was
transferred to the PACU in stable condition. Extubated and
neurologically intact. The patient developed at 4:15 p.m.
respiratory distress. Attempted intubation was unsuccessful.
Patient went into PEA arrest. ACLS protocol was followed.
Patient was successfully intubated and transferred to the
SICU for continued monitoring and care.
It was noted on transfer to the SICU, the patient had unequal
pupils, and a neurology consult was placed. A MRI was
obtained along with a carotid ultrasound. CT of the head was
obtained with contrast. The preliminary report was no acute
hemorrhage. Neurology felt the patient would require a MRI of
the head with multiple areas of restricted diffusion in the
anterior cerebral artery and middle cerebral artery on study.
That was most consistent with embolic phenomena. Source for
embolization needed to be followed up. IV Heparinization
could not be given because of patient's history of GI
bleeding.
Patient continued to be followed by the stroke service.
Recommendations were that we should obtain a MRA of the neck
to assess for evidence of reocclusion. Patient remained in
the SICU intubated. Pulmonary consult was placed. Patient
failed to wean, and they felt this was first of all COPD with
acute respiratory failure, questionable left lower lobe
aspiration pneumonia and a new CVA. Recommended to continue
pressure support. Hold off on aggressive weaning until
patient has improved clinically both from sputum and chest x-
ray and physical exam. Continued on levofloxacin and Flagyl
for presumed aspiration pneumonia. Start bronchodilators,
Atrovent and albuterol nebulizers q.4-6h., Solu-Medrol 40 mg
IV q.12h. for a few days, then can be converted to inhaling
Flovent. Continue diuresis and continue to monitor.
Patient was placed on triple antibiotics of vancomycin and
levofloxacin. He developed a T-max of 103 on postoperative
day 3. They felt this was related to his pneumonia. On
postoperative day 4, a post-pyloric tube was placed for
enteral feeding. He has been on a regular insulin-sliding
scale. Ultrasound of the chest was obtained for a left
pleural effusion. This was not loculated. Vancomycin and
levofloxacin were continued. The patient had significant
amount of secretions, which inhibited extubation and weaning.
Patient underwent bronchoscopy on [**2133-3-4**] secondary to
failure to wean from ventilator. Airways were without lesions
or bleeding. There were copious thick, mucoid secretions
right bronchotracheal tree greater than left. Patient
remained intubated.
By postoperative day 4, the patient continued still to have a
temperature of 101.9 to 101.3. His tube feeds were at goal,
and he remained on the vent. By postoperative day 6, the
patient's temperature curve had improved to 99.8. His
clinical exam was improved. His white count was improved.
On postoperative day 7, the patient's levofloxacin was
discontinued and was begun on Zosyn. His vancomycin was
continued. Still remained intubated with a T-max of 101.2.
Patient was successfully weaned and extubated on
postoperative day 9, that was [**2133-3-7**]. Mental status
was much improved. Tube feeds were continued. POs were held.
Ambulation to chair was begun.
Postoperative day 10, it was noted the patient had some
inflammatory response of the left 5th finger, which was
consistent with gout. Colchicine was reinstituted along with
Indocin with improvement in his inflammatory response.
Initial evaluation by physical therapy was on postoperative
day 10, [**2133-3-9**]. Patient would require rehab prior to
discharge to home. Antibiotics were discontinued. Tube feeds
were continued and gentle diuresis was continued for a 0.5
liter to a liter of fluid. White count was 18.3, hematocrit
27.7.
Fluconazole was added to the patient's antibiotic regimen of
vancomycin and Zosyn on [**2133-3-10**] for persistent sputums
with yeast. Patient was seen by speech and swallow. The
initial evaluation could not be done because the patient was
not awake enough to follow commands. They did feel the
patient might be aspirating and aspiration precautions were
required.
Patient continued to be seen by physical therapy, and they
continued with aggressive pulmonary therapy. The patient was
re-evaluated on [**2133-3-12**] by speech and swallow, who
felt that the patient had questionable signs and symptoms of
aspiration. Was list at the bedside. A video swallow was
recommended. The patient should remain NPO with his tube
feeds, to continue until the swallow was completed.
Infectious disease was requested to see the patient, and
again the recommendations regarding current antibiotic
treatment and length of therapy.
Recommendations were that the right basilar effusions should
be evaluated by CT with drainage if indicated and fluid sent
for culture. Continue meropenem until chest CT is obtained.
Patient also recommended stop vancomycin and fluconazole.
Recommendations of a right thoracentesis and culture of the
fluid was discussed with Dr.[**Name (NI) 5695**] service, that they
did not want to do any further invasive procedure on the
patient and will diurese the patient and follow the pleural
effusion. Patient's temperature curve continued to show
improvement with improvement in his white count. Blood
cultures, which were obtained showed no growth.
Patient was begun on meropenum on [**2133-3-12**]. The Zosyn
was discontinued. The fluconazole was continued. This was
added to his antibiotic regimen secondary to a new right
lower lobe opacity on chest x-ray. Patient underwent an
oropharyngeal video fluoroscopic swallowing evaluation on
[**2133-3-13**]. There was no aspiration or component of
aspiration noted. Recommendations to advance the diet to thin
liquids, and purees, and medicines in thin liquids. As the
patient's mental status improves and overall strength
increases, the team may wish to advance his diet further.
Patient required transfusion on [**2133-3-13**] for hematocrit
of 26. Patient was transferred to the VICU on [**2133-3-13**].
His white count continued to show improvement, and he
continued to be diuresed. At this point, recommendations were
to continue the meropenum for a total of 7 more days, that
was on [**2133-3-14**].
PICC line was requested on [**2133-3-16**] for continued
antibiotics. Patient continued to show improvement in his
respiratory status. Patient was discharged to rehab in stable
condition.
DISCHARGE MEDICATIONS: Acetaminophen liquid 325-650 mg q.4-
6h. p.r.n., moexipril 7.5 mg daily, fluticasone propionate
110 mcg puffs 2 b.i.d., insulin-sliding scale, albuterol
0.083% nebulizers q.6h., ipratropium bromide nebulizers q.6h.
p.r.n., colchicine 0.6 mg daily, Protonix 40 mg q.12h.,
Plavix 75 mg daily, aspirin 325 mg daily, warfarin 5 mg
daily, digoxin 0.5 mg daily, metoprolol 50 mg q.a.m.,
metoprolol 25 mg q.p.m., meropenum 1 gram q.8h. for total of
7 days from [**2133-3-16**].
DISCHARGE DIAGNOSES:
1. Carotid stenoses bilaterally status post left carotid
endarterectomy on [**2133-3-29**].
2. Respiratory failure.
3. Pulseless electrical activity arrest secondary to failed
intubated.
4. Left anterior cerebral and middle cerebral artery infarct
by MRI.
5. Postoperative fever with left lower lobe collapse and
pleural effusion, pneumonia treated.
6. Aspiration pneumonia treated.
7. Gout exacerbation treated.
8. Status post bronchoscopy on [**2133-3-4**].
SECONDARY DIAGNOSES:
1. Chronic atrial fibrillation.
2. Coronary artery disease.
3. History of congestive failure, compensated.
4. History of hypertension controlled.
5. Chronic obstructive pulmonary disease.
6. Blood loss anemia corrected.
Patient should follow up with Dr. [**Last Name (STitle) **] as directed. He
should follow up with neurological service as directed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2133-3-16**] 11:56:11
T: [**2133-3-16**] 12:40:30
Job#: [**Job Number 54150**]
Name: [**Known lastname 5057**],[**Known firstname 126**] Unit No: [**Numeric Identifier 10072**]
Admission Date: [**2133-2-27**] Discharge Date: [**2133-3-24**]
Date of Birth: [**2065-6-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1546**]
Addendum:
Pt to go home with VNA. (change)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - Acute Rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2133-3-24**] Name: [**Known lastname 5057**],[**Known firstname 126**] Unit No: [**Numeric Identifier 10072**]
Admission Date: [**2133-2-27**] Discharge Date: [**2133-3-24**]
Date of Birth: [**2065-6-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1546**]
Addendum:
Pt INR was 6.1 on [**2133-3-20**]..
Pt hospital stay was prolong because of the INR.
In the interim of this hospital stay from [**2133-3-20**] - [**2133-3-24**]
PT worked with the patient. They stated that the pt could go
home instead of rehab.
Also the Pt antibiotic course of Meropenem 1000 mg IV Q8H was
finished on [**2133-3-24**]. Because of this his PICC line was DC'd.
With the above the pt is allowed to go home without VNA
services.
Vascular Surgery talked to Dr. [**Last Name (STitle) **], his cardiologist. Dr [**Name (NI) 10080**] office will be in contact with patient today in
reference to monitering his INR.
To note pt is on PLavix and ASA.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - Acute Rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2133-3-24**] Name: [**Known lastname 5057**],[**Known firstname 126**] Unit No: [**Numeric Identifier 10072**]
Admission Date: [**2133-2-27**] Discharge Date: [**2133-3-24**]
Date of Birth: [**2065-6-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1546**]
Addendum:
[**2133-3-16**] - [**2133-3-20**]
Pt had episodes of bradycardia into the 20 at night. Pt
asymtomatic from episodes of bradycardia.
Cardiology was consulted. They thought that the pt had dig
toxicity. Pt digoxin was dc'd. He remains on lopressor.
The pt's dig level was drawn, he level was WNL. It was diagnosed
by EKG.
On discharge pt is stable.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - Acute Rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2133-3-24**]
|
[
"486",
"401.9",
"274.9",
"443.9",
"427.89",
"433.30",
"272.0",
"998.89",
"518.0",
"997.02",
"414.01",
"427.5",
"434.11",
"518.5",
"496",
"414.8",
"511.9",
"285.1",
"507.0",
"E942.1",
"997.3",
"305.1",
"790.92",
"997.1",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"96.04",
"96.6",
"33.23",
"99.04",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12297, 12527
|
8436, 8910
|
7943, 8415
|
797, 992
|
1366, 7919
|
1283, 1348
|
8931, 9975
|
154, 173
|
202, 770
|
1009, 1259
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,530
| 130,020
|
28436
|
Discharge summary
|
report
|
Admission Date: [**2104-5-9**] Discharge Date: [**2104-6-3**]
Date of Birth: [**2052-11-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Heart palpitations
Major Surgical or Invasive Procedure:
Bronchoscopy
Endotracheal Intubation
Palliative Radiation
History of Present Illness:
Ms [**Known lastname 43672**] is a 51 year old woman with past medical history
significant for melanoma (status post resection in [**2100**] from
right chest) and newly developed asthma (minimally responsive to
inhalers), presenting with acute dyspnea starting one day prior
to admission, found to have large mediastinal mass and atrial
flutter, who is now being transferred to the MICU s/p intubation
after bronchoscopy today. Please see initial admit note for full
details. As she is intubated, history obtained from current
medical records. Brielfy, patient reported difficulty swallowing
and increasing shortness of breath in the past few months. Her
PCP initially diagnosed her with asthma, and started her on
inhalers.
She also reported unintentional 38 lb weight loss. Was evaluted
for dysphagia via EGD which only showed gastritis. Also reports
progressive dyspnea with functional capacity limited to a single
flight of stairs. On the day of admission, she felt worsening
dyspnea and palpitations without chest pain, fevers, syncope,
chills, nausea, vomitting. At OSH, she was found to be in
Aflutter with RVR to 150 bpm. CTA chest was negative for PE, but
revealed large mediastinal mass and pulmonary nodules. She was
initially on diltiazem drip which was transitioned to oral
diltiazem on the floor, during which time she was in NSR
Today patietn underwent bronchoscopy which revealed near total
collapse of the left mainstem bronchus and 50% collapse of the
bronchus intermedius. Trans bronchial biopsy was obtained with
significant bleeding of at least 50 cc. She was electively
intubated and sent to the MICU.
In the MICU, patient appears comfortable on the ventilator. She
is sedated but arousable.
Review of systems:
Limited due to patient on ventilator. Appears comfortable.
Denies pain.
Past Medical History:
MELANOMA
- Shave biopsy in [**2100**] with 0.9-mm deep, [**Doctor Last Name **] level IV,
ulcerated invasive melanoma with 2 mitoses per high-power field
(T1B lesion), lateral margin with melanoma in situ
- s/p wide excision of right chest melanoma with advancement
flap closure and Right axillary sentinel lymph node biopsy
[**1-/2101**]
? Asthma
Social History:
Works cleaning homes, does not smoke, minimal EtOH. Married.
Family History:
Mother with lung cancer, 2 sibblings with skin cancer, father
with skin cancer. No history of heart disease.
Physical Exam:
(MICU Admission Exam)
Vitals: T: BP: 158/74 P: 106 R: 22 O2: 93%
CMV 400 x14, 60%, PEEP 8
General: Intubated, sedated but easily arousable and follows
commands
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on admission:
[**2104-5-9**] 12:34AM PT-12.4 PTT-24.4 INR(PT)-1.0
[**2104-5-9**] 12:34AM PLT COUNT-421
[**2104-5-9**] 12:34AM NEUTS-87.3* LYMPHS-10.6* MONOS-1.2* EOS-0.8
BASOS-0.1
[**2104-5-9**] 12:34AM WBC-9.1 RBC-5.19 HGB-13.3 HCT-42.1 MCV-81*
MCH-25.6* MCHC-31.6 RDW-13.2
[**2104-5-9**] 12:34AM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-1.9 URIC
ACID-4.2
[**2104-5-9**] 12:34AM CK-MB-NotDone
[**2104-5-9**] 12:34AM cTropnT-<0.01
[**2104-5-9**] 12:34AM LD(LDH)-156 CK(CPK)-60
[**2104-5-9**] 12:34AM estGFR-Using this
[**2104-5-9**] 12:34AM GLUCOSE-130* UREA N-9 CREAT-0.4 SODIUM-135
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-19* ANION GAP-20
[**2104-5-9**] 12:50AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2104-5-9**] 12:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2104-5-9**] 12:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2104-5-9**] 01:45PM PT-12.2 PTT-23.6 INR(PT)-1.0
[**2104-5-9**] 01:45PM PLT COUNT-419
[**2104-5-9**] 01:45PM WBC-10.7 RBC-4.54 HGB-11.9* HCT-36.9 MCV-81*
MCH-26.3* MCHC-32.3 RDW-13.0
[**2104-5-9**] 01:45PM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-2.1
[**2104-5-9**] 01:45PM CK-MB-NotDone cTropnT-<0.01
[**2104-5-9**] 01:45PM ALT(SGPT)-34 AST(SGOT)-38 LD(LDH)-208
CK(CPK)-60 ALK PHOS-54 TOT BILI-0.3
[**2104-5-9**] 01:45PM ALT(SGPT)-34 AST(SGOT)-38 LD(LDH)-208
CK(CPK)-60 ALK PHOS-54 TOT BILI-0.3
[**2104-5-9**] 01:45PM GLUCOSE-93 UREA N-10 CREAT-0.4 SODIUM-135
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-24 ANION GAP-17
[**2104-5-9**] 08:28PM O2 SAT-99
[**2104-5-9**] 08:28PM TYPE-ART PO2-345* PCO2-42 PH-7.37 TOTAL
CO2-25 BASE XS-0
Most Recent Labs:
[**2104-6-1**] 04:19AM BLOOD WBC-7.2 Hgb-10.6* Hct-32.4* Plt Ct-294
[**2104-5-30**] 03:59AM BLOOD PT-13.6* PTT-24.1 INR(PT)-1.2*
[**2104-6-1**] 04:19AM BLOOD Glucose-162* UreaN-16 Creat-0.4 Na-139
K-4.3 Cl-103 HCO3-28 AnGap-12
[**2104-6-1**] 04:19AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0
Endobronchial Biopsy on [**5-9**]
Metastatic malignant melanoma.
Tumor cells stain positive for S-100, HMB45, MITF and focally
for MelanA (MART-1). Cells are negative for cytokeratin AE1/3
IMAGES/STUDIES:
ECG [**2104-5-9**]: Atrial flutter with variable ventricular response or
atrial fibrillation. Consider left ventricular hypertrophy. ST-T
wave abnormalities. No previous tracing available for
comparison. Clinical correlation is suggested. TRACING #1
ECG [**2104-5-9**]: Atrial flutter or atrial fibrillation with a
controlled response. Since the previous tracing the rate has
decreased. ST-T wave abnormalities are less prominent. TRACING
#2
ECG [**2104-5-9**]: Sinus rhythm. ST-T wave abnormalities. Since the
previous tracing atrial tachy-arrhythmia is resolved. TRACING #3
CXR [**2104-5-9**]: SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The
mediastinal contour is markedly abnormal, with right tracheal
deviation and right paratracheal abnormal soft tissue density.
There is left main stem bronchus narrowing and subcarinal soft
tissue fullness. A 2 cm right upper lobe pulmonary nodule and
smaller right middle lobe nodular opacity are consistent with
the history of melanoma. There is no evidence of pleural
effusion, congestive heart failure, or pneumonia. Within the
limits of chest radiography, no lytic or sclerotic osseous
lesion is identified. IMPRESSION: 1. Pulmonary metastases,
severe mediastinal lymphadenopathy due to melanoma. 2. No other
finding to explain palpitations.
CXR [**2104-5-9**]: IMPRESSION: Nasogastric tube in satisfactory
position, some upper mediastinal shift.
CXR [**2104-5-10**]: IMPRESSION: Improved right lung consolidation could
have been due to aspiration. Otherwise, stable appearances
since yesterday's chest radiograph.
Staging CT Torso [**2104-5-15**]
1. Extremely large retrotracheal mediastinal adenopathy,
obstructing the left main and lower lobe bronchi, resulting in
left lower lobe collapse.
2. Large pulmonary metastases in the right upper and middle
lobes.
3. Moderate bilateral pleural effusions.
4. No evidence of metastatic disease is noted within the abdomen
and pelvis.
5. The large conglomerate of lymph nodes in the subcarinal
location is
compatible with metastatic disease.
MR [**Name13 (STitle) 430**] [**5-15**]
No significant abnormalities are seen on MRI of the brain with
and without gadolinium
CT Chest [**5-28**]
1)Interval development of patchy consolidation in the right
upper and right middle lobe is most likely due to radiotherapy
and a small right pleural effusion is now moderately large, the
left pleural effusion has slightly increased and remains small.
2)Slight improvement in the right main and left mainstem
bronchial narrowing which remains severe.
CXR ([**2104-6-2**]) - As compared to the previous radiograph, there is
no relevant change. Unchanged extent of the left-sided pleural
effusion with unchanged left atelectasis. Unchanged right hilar
mass and right upper enlargement of the mediastinum. The right
costophrenic sinus is not completely included on the image. No
evidence of newly occurred focal parenchymal opacities.
Brief Hospital Course:
SUMMARY
51 year old woman with past medical history significant only for
locally advanced melanoma s/p wide marginal excision in [**2100**],
presenting with dysphagia, worsening dyspnea, weight loss found
to have large mediastinal mass that completely collapsed her
left main-stem bronchus. She was admitted to the ICU after she
required intubation for hypoxia following a bronchoscopy. She
remained intubated for the duration of her hospitalization, save
for multiple self-extubations with subsequent respiratory
failure on non-invaive ventillation. She received palliative
chemotherapy and 10 doses of XRT to attempt to re-expanded her
collapsed lung. This was unsuccessful. She was ultimately
terminally extubated and placed on comfort measures. She expired
on [**2104-6-3**].
BY PROBLEM
# Mediastinal Mass: She was admitted to ICU following
brochoscopy where she remained intubated given the findings of
significant compression to the left mainstem bronchus with
bleeding periprocedurally. Pathology from the endobronchial
ultrasound was consistent with malignant melanoma. The
hematology oncology service was consulted and brain and
abdominal imaging for staging were obtained. The interventional
pulmonary service was consulted to evaluate for possible stent
placemement but felt she was not a candidate. She was admitted
to the ICU after she required intubation for hypoxia following a
bronchoscopy. She remained intubated for the duration of her
hospitalization, except for several self-extubations with
subsequent respiratory failure on non-invaive ventillation. She
received palliative chemotherapy and 10 doses of XRT to attempt
to re-expanded her collapsed lung. Ultimately, this was
unsuccessful and the patient was terminally extubated and placed
on comfort measures. She expired less than 24 hours after
extubation.
# Pneumonia: She developed fever of over 102, increased
respiratory rate, and copious thick secretions on hospital day
2. There was evidence of left lower lobe infiltrate possibly due
to post-obstructive pneumonia. She was started emperically on
vancomycin and zosyn, which was later changed to vancomycin and
unasyn after sputum culture grew Moraxella. Vancomycin was
discontinued and she finished a 10 day course of unasyn without
recurrence.
# Atrial Flutter: On the floor, She had an episode of rapid
ventricular rate post-procedurally and was started on PO
diltiazem. She spontaneously converted to sinus rhythm, which
she maintained during her hospitalization. TTE as well as chest
imaging demonstrated compression of the left atrium from the
mediastinal mass. Her diltiazem was titrated according to
blood-pressure and frequence of RVR over the course of her
hospitalization. She spent most of the day in 3:1 block but
occasionally required Diltiazem boluses for 2:1 block.
Medications on Admission:
Fluticasone
Albuterol
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"493.90",
"V66.7",
"518.81",
"427.31",
"799.02",
"486",
"427.32",
"197.1",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"34.25",
"96.04",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
11510, 11519
|
8589, 11406
|
333, 392
|
11570, 11579
|
3421, 3426
|
11635, 11645
|
2695, 2805
|
11478, 11487
|
11540, 11549
|
11432, 11455
|
11603, 11612
|
2820, 3402
|
2157, 2230
|
275, 295
|
420, 2138
|
3440, 8566
|
2252, 2601
|
2617, 2679
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
357
| 174,486
|
29355
|
Discharge summary
|
report
|
Admission Date: [**2197-12-6**] Discharge Date: [**2198-1-3**]
Date of Birth: [**2135-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7616**]
Chief Complaint:
found down at home
Major Surgical or Invasive Procedure:
EGD x 3
TIPS
[**Last Name (un) **] tube
Intubation
History of Present Illness:
62 yo m w/ h/o "liver dz", and history of ulcer, who called EMS
due to feeling like he was going to "pass out". Has been feeling
LH for the past day. Due to pre-syncopal symtptoms called EMS.
EMS found the patient to be hypotensive, sbp 60s, and in transit
vomited approx 500cc BRB.
.
Patient reports that he had been in his USOH until approx 3 wks
ago when he noted the onset of post-prandial diffuse abdominal
pain. Desrcibed as mild and crampy. Also noted with taking
pills. Some relief when accompanied by milk. No n/v/d. No prior
hematemesis. No melana. No history of variceal bleeding.
.
In the ED, hypotensive 86/48, vomited 800cc BRB. NGL performed,
returned 500cc BRB and did not clear. 2 14g PIV, placed rec'd 4U
PRBC, 2L NS, octreotide, protonix.
Past Medical History:
"ulcer dz"
"liver dz"
CHF
Social History:
No etoh. +remote smoking history. Stopped 30 yrs ago.
Family History:
NC
Physical Exam:
t 96.2, bp 112/68, hr 68, rr14, 98% 2L NC
Elderly, well appearing male, alert and oriented, w/ NGT in
place draining BRB.
PERRL
OP w/ dried blood.
JVP could not be appreciated
Regular s1,s2. No m/r/g
LCA b/l
Distended, protuberant abdomen. +bs. soft. nt. No fluid wave.
Trace LE edema. No c/c
No asterixis, palmar erythema, gynecomastia, spider angiomata.
Pertinent Results:
ADMISSION LABS:
[**2197-12-6**] 06:40AM WBC-4.8 RBC-2.57* HGB-8.4* HCT-25.0* MCV-97
MCH-32.6* MCHC-33.5 RDW-14.1
[**2197-12-6**] 06:40AM PLT COUNT-98*
[**2197-12-6**] 06:40AM PT-14.4* PTT-25.2 INR(PT)-1.3*
[**2197-12-6**] 06:40AM FIBRINOGE-228
[**2197-12-6**] 06:40AM UREA N-37* CREAT-1.0
[**2197-12-6**] 06:40AM AMYLASE-47
[**2197-12-6**] 06:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2197-12-6**] 07:03AM PO2-122* PCO2-40 PH-7.32* TOTAL CO2-22 BASE
XS--5 COMMENTS-GREEN TOP
[**2197-12-6**] 07:31AM URINE MUCOUS-FEW
[**2197-12-6**] 07:31AM URINE GRANULAR-0-2 HYALINE-[**2-19**]*
[**2197-12-6**] 07:31AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2197-12-6**] 07:31AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-NEG
[**2197-12-6**] 07:31AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2197-12-6**] 07:57AM PLT COUNT-66*
[**2197-12-6**] 07:57AM WBC-6.0 RBC-2.95* HGB-9.9* HCT-28.1* MCV-95
MCH-33.6* MCHC-35.3* RDW-14.3
[**2197-12-6**] 09:19AM FIBRINOGE-246
[**2197-12-6**] 09:19AM PT-14.1* PTT-22.9 INR(PT)-1.3*
[**2197-12-6**] 09:19AM ALBUMIN-3.1* CALCIUM-7.4* PHOSPHATE-2.9
MAGNESIUM-1.6
[**2197-12-6**] 09:19AM LIPASE-35
[**2197-12-6**] 09:19AM ALT(SGPT)-27 AST(SGOT)-28 LD(LDH)-147 ALK
PHOS-88 AMYLASE-47 TOT BILI-0.6
[**2197-12-6**] 09:19AM GLUCOSE-72 UREA N-36* CREAT-0.9 SODIUM-142
POTASSIUM-4.9 CHLORIDE-113* TOTAL CO2-19* ANION GAP-15
[**2197-12-6**] 09:32AM freeCa-1.06*
[**2197-12-6**] 09:32AM LACTATE-2.1* NA+-140 K+-4.9 CL--114* TCO2-21
[**2197-12-6**] 09:32AM TYPE-[**Last Name (un) **] TEMP-35.7 PH-7.33*
[**2197-12-6**] 10:20AM HCT-31.4*
[**2197-12-6**] 12:34PM PT-15.3* PTT-48.1* INR(PT)-1.4*
[**2197-12-6**] 12:34PM PLT COUNT-134*#
[**2197-12-6**] 12:34PM WBC-11.1*# RBC-4.23*# HGB-13.4*# HCT-39.2*
MCV-93 MCH-31.6 MCHC-34.1 RDW-14.6
[**2197-12-6**] 12:34PM CALCIUM-6.5*
[**2197-12-6**] 12:34PM GLUCOSE-104 UREA N-34* CREAT-0.9 SODIUM-140
POTASSIUM-5.7* CHLORIDE-114* TOTAL CO2-16* ANION GAP-16
[**2197-12-6**] 02:31PM PLT COUNT-158
[**2197-12-6**] 02:31PM WBC-10.8 RBC-4.28* HGB-13.3* HCT-39.2* MCV-92
MCH-31.1 MCHC-33.9 RDW-14.8
[**2197-12-6**] 02:32PM FIBRINOGE-205
[**2197-12-6**] 02:32PM PT-14.0* PTT-27.3 INR(PT)-1.2*
[**2197-12-6**] 02:32PM calTIBC-280 FERRITIN-33 TRF-215
[**2197-12-6**] 02:32PM CALCIUM-7.0* PHOSPHATE-3.2 MAGNESIUM-1.5*
IRON-196*
[**2197-12-6**] 02:32PM GLUCOSE-136* UREA N-34* CREAT-0.9 SODIUM-139
POTASSIUM-5.6* CHLORIDE-114* TOTAL CO2-16* ANION GAP-15
[**2197-12-6**] 02:43PM TYPE-ART TEMP-36.7 RATES-14/ TIDAL VOL-700
PEEP-5 O2-50 PO2-146* PCO2-31* PH-7.35 TOTAL CO2-18* BASE XS--7
-ASSIST/CON INTUBATED-INTUBATED
[**2197-12-6**] 05:00PM FIBRINOGE-208
[**2197-12-6**] 05:00PM PT-13.7* PTT-29.0 INR(PT)-1.2*
[**2197-12-6**] 05:00PM PLT COUNT-182
[**2197-12-6**] 05:00PM WBC-13.1* RBC-4.27* HGB-13.6* HCT-39.1*
MCV-91 MCH-31.8 MCHC-34.8 RDW-14.8
[**2197-12-6**] 05:00PM HCV Ab-NEGATIVE
[**2197-12-6**] 05:00PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2197-12-6**] 05:00PM CALCIUM-7.8* PHOSPHATE-3.4 MAGNESIUM-1.6
[**2197-12-6**] 05:00PM GLUCOSE-140* UREA N-34* CREAT-0.9 SODIUM-141
POTASSIUM-4.5 CHLORIDE-114* TOTAL CO2-17* ANION GAP-15
[**2197-12-6**] 05:17PM TYPE-ART RATES-14/ TIDAL VOL-600 PEEP-5 O2-40
PO2-108* PCO2-30* PH-7.35 TOTAL CO2-17* BASE XS--7 -ASSIST/CON
INTUBATED-INTUBATED
[**2197-12-6**] 07:54PM HCT-37.1*
[**2197-12-6**] 09:49PM FIBRINOGE-224
[**2197-12-6**] 09:49PM PT-13.2* PTT-28.1 INR(PT)-1.1
[**2197-12-6**] 09:49PM PLT COUNT-111*
[**2197-12-6**] 09:49PM WBC-10.5 RBC-3.91* HGB-13.0* HCT-35.4* MCV-90
MCH-33.2* MCHC-36.7* RDW-15.2
[**2197-12-6**] 09:49PM CALCIUM-7.9* PHOSPHATE-3.5 MAGNESIUM-2.3
[**2197-12-6**] 09:49PM GLUCOSE-156* UREA N-32* CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-114* TOTAL CO2-17* ANION GAP-13
Brief Hospital Course:
62 yo m w cirrhosis and varices admitted for an upper GI bleed x
2. The following issues were investigated during this
hospitalization:
.
1) GIB: Shortly after admission to the ICU the pt. having
massive hemoptysis with resultant hypotension. He was scoped
emergently after intubation and found to have stage 3 variceal
bleeding which was unable to be stopped with banding. He was
started on Protonix and Octreotide drips with Ciprofloxacin
prophylaxis. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] esophageal balloon was placed with
stabilization of bleeding. He required 12U pRBCs and 7U FFP on
HD1. A TIPS was successfully placed on [**12-8**], but followed by
continued bleeding. He was transfused once more on [**12-22**]. A RUQ
u/s on [**12-21**] an [**12-23**] confirmed patency of TIPS. His hematocrit
remained stable after the transfusion on [**12-22**] and he was
transferred to the general medicine floor for continued
management.
.
2) Liver disease: Etiology is unclear but has been described as
NASH and cryptogenic in nature. There is no report of a liver
biopsy. During this hospitalization, initial work-up revealed
negative hepatology serologies and no evidence of
hemochromotosis. An abdominal CT showed a 1.5 cm lesion in the
right lobe of the liver and AFP is elevated to 13.7. Additional
work-up was deferred given his acute medical problems
necessitating ICU hospitalization. He should pursue further
work-up of this lesion as an outpatient. An appointment has been
scheduled for him in the liver clinic here at [**Hospital1 18**].
.
3) Altered mental status - Etiology unclear, but initially
concerning for anoxic brain injury in the setting of hypotension
upon presention, but repeat imaging showed resolution of initial
changes, which was more suggestive of resolving metabolic
condition (i.e. hepatic encephalopathy). Infectious work-up in
the MICU was negative. On the general floor, the patient was
maintained on Lactulose and Rifaximin for ammonia control. His
mental status gradually and significantly improved and he was
noted to be awake, alert and oriented x 3, often communicative.
He was discharged on Rifaximin and Lactulose, which he should
continue given his TIPS.
.
4) Seizure activity: Patient was observed to be have brief
episodes of tonic-clonic seizure activity on [**12-13**], and
subsequently found to have frequent, intermittent seizure
activity on EEG in the following 24 hours essentially c/w status
epilepticus. He was seen by the neurology consult service and
started on Dilantin. His hospital course was thereafter
significant for no seizure activity. The patient was discharged
on Dilantin with instructions to have Dilantin levels checked,
with goal of 15-20 (corrected for albumin).
.
5) DM: The patient's outpatient Metformin was held given the
extent of his liver disease. His blood sugar was monitored and
treated with an insulin sliding scale and Glargine QHS.
.
6) Ventilator-acquired pneumonia: Pt. was intubated in the ICU
to protect his airway. During this time, he developed a
pneumonia with Coag + Staph aureus growing in his sputum. He was
started on Vancomycin, which was later switched to Nafcillin
once sensitivies came back showing MSSA. He was treated for a
total of 8 days.
.
7) F/E/N: The patient was started on tube feeds in the ICU,
which were continued on arrival to the general medicine floor.
During his hospitalization on the floor, he self d/c'd the
Dobhoff tube twice, the last of which was done the evening
before his discharge from the hospital. Prior to this last self
d/c, the patient had just been started on pureed diet and
nectar-thickened liquids after a speech and swallow evaluation
which showed thin aspiration. Because of this self d/c, there
was not enough time for accurate calorie counts. Thus, it is
important that his nutrition be closely followed on discharge
and tube feeds should be reconsidered if the patient's appetite
or food intake should decline.
Medications on Admission:
lisinopril 10mg QD
protonix 40 [**Hospital1 **]
nadalol 40mg TID
aspirin 81 mg qday
insulin 70QAM 65QPM
metformin 1000 [**Hospital1 **]
cyanocobalmin
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Hospital1 **]: One (1)
Appl Ophthalmic PRN (as needed).
2. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**12-19**] Sprays Nasal
TID (3 times a day) as needed.
3. Levetiracetam 500 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO BID (2
times a day).
4. Phenytoin 100 mg/4 mL Suspension [**Month/Day (2) **]: Two Hundred (200) mg PO
Q 8H (Every 8 Hours).
5. Propranolol 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times
a day).
6. Lactulose 10 g/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO TID (3
times a day): give for goal 3 BMs/day.
7. Rifaximin 200 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times a
day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
9. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
10. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) nebulizer
treatment Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
11. Lantus 100 unit/mL Cartridge [**Last Name (STitle) **]: Fifty Five (55) units
Subcutaneous at bedtime.
12. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: One (1)
unit Subcutaneous QACHS: give per attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Cryptogenic cirrhosis
Esophageal varices
Hepatic encephalopathy
Seizure activity
Diabetes mellitus, Type 2
Ventilator-acquired pneumonia
Liver mass
Discharge Condition:
stable, tolerating po with pureed diet, alert and oriented x3
Discharge Instructions:
You were admitted to the hospital for bleeding from your
stomach, which is a complication of your liver disease. You
were also found to have seizures.
Call your doctor or return to the ER for fevers, chills, nausea,
vomiting, abdominal pain, confusion, lethargy, tarry stool, or
blood in your stool.
It is very important that you take all of your medications as
prescribed. Your doctors [**First Name (Titles) 4801**] [**Last Name (Titles) **] your lactulose to make
sure you are having at least 3 bowel movements per day.
Your doctors at the nursing home need to check your dilantin
levels every other day, and correct this for your albumin. The
equation is: corrected dilantin level = measured dilantin level
divided by [(0.2 x albumin) +0.1]. Your goal corrected dilantin
level is between 15 and 20. If your level is persistently low
or high, your doctors should [**Name5 (PTitle) 138**] your neurologist, Dr. [**First Name4 (NamePattern1) 1104**]
[**Last Name (NamePattern1) 4638**], at [**Telephone/Fax (1) 44**].
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2198-2-28**] 4:30 (Neurology)
.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2198-1-31**] 2:30 (Hepatology)
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 7619**]
|
[
"795.89",
"428.0",
"572.2",
"482.41",
"V58.67",
"573.9",
"571.5",
"518.81",
"456.20",
"286.7",
"345.3",
"572.3",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"03.31",
"96.06",
"96.34",
"96.04",
"45.13",
"96.6",
"99.07",
"96.72",
"38.93",
"39.1",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11292, 11371
|
5681, 9657
|
334, 386
|
11562, 11626
|
1708, 1708
|
12702, 13122
|
1312, 1316
|
9858, 11269
|
11392, 11541
|
9683, 9835
|
11650, 12679
|
1331, 1689
|
276, 296
|
415, 1175
|
1725, 5658
|
1197, 1225
|
1241, 1296
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,067
| 194,931
|
33589
|
Discharge summary
|
report
|
Admission Date: [**2158-4-20**] Discharge Date: [**2158-5-1**]
Date of Birth: [**2080-10-2**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
[**2158-4-20**] Repair of suprarenal aneurysm with 20 mm Dacron tube
graft.
History of Present Illness:
This 77-year-old gentleman has a 6.4 cm
aneurysm of the infrarenal abdominal aorta but involving the
origin of both renal arteries and extending to the level of
the superior mesenteric artery. His left kidney is
nonfunctional and he has a stent in the right kidney.
Past Medical History:
PMH: PVD s/p renal stent [**11-22**], nonfunctioning L kidney, gout,
CRI, GERD, s/p tonsillectomy, colon ca s/p colectomy c/b bowel
obstruction s/p ex lap/LOA, s/p chemorads, s/p hemorrhoidectomy,
CAD, s/p R retinal a embolism, h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear & antral
ulceration [**2146**]
Social History:
pos smoker
pos drinker
Family History:
n/c
Physical Exam:
a/o
nag
cta
rrr
pos bs / surgical scar c/d/i
palp pulses
Pertinent Results:
[**2158-5-1**] 05:52AM BLOOD
WBC-10.2 RBC-3.27* Hgb-10.5* Hct-31.2* MCV-96 MCH-32.1*
MCHC-33.6 RDW-15.2 Plt Ct-530*
[**2158-5-1**] 05:52AM BLOOD
Glucose-108* UreaN-39* Creat-1.3* Na-140 K-4.0 Cl-106 HCO3-24
AnGap-14
[**2158-5-1**] 05:52AM BLOOD
Calcium-9.4 Phos-3.3 Mg-1.8
[**2158-4-27**] 05:33PM
URINE Hours-RANDOM Creat-126 Na-61
URINE Osmolal-514
Brief Hospital Course:
[**4-20**]
Underwent a AAA repair with oout complications. Transfered to
the CVICU in stable condition.
[**4-21**] - [**4-23**]
Extubated with NG tube in place, pressure support
[**4-23**] - [**4-27**]
Transfered to the VICU in stable condition.
Patient noticed to have increase in creat. All nephrotic drugs
held / pt was hydrated. On Dc creat has improved.
Pt also had post operative illeus. This resolved on Dc taking PO
Pt consult pt delined while in the VICU
[**4-28**] - [**5-1**]
PT worked with pt
pt ambulating / taking PO
stable for DC
Medications on Admission:
[**Last Name (un) 1724**]: ASA 325', MVI, diltiazem 180', HCTZ 50', lisinopril 30',
ranitidine 75' prn, atenolol 50', allopurinol 200', vit B12 2',
Plavix 75'
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
10. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-26**]
hours as needed for pain: Do not take with alcohol. Do not
drive.
Disp:*40 Tablet(s)* Refills:*0*
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
AAA, postoperative ileus
.
Secondary: PVD, CAD, nonfunctioning L kidney, gout, CRI, GERD,
colon ca s/p colectomy c/b/ bowel obstruction s/p ex lap/LOA s/p
chemoradiation, s/p hemorrhoidectomy, s/p renal stent [**11-22**], s/p
R retinal artery embolism, h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear & antral
ulceration [**2146**]
Discharge Condition:
Afebrile, vital signs stable, tolerating regular diet,
ambulating, pain well controlled on PO medication.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-28**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**1-22**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery except
increase your diltiazem to 240 mg daily and stop taking
lisinopril. Follow up with your PCP regarding these medications
in [**12-21**] weeks.
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2158-5-11**] 12:45
Completed by:[**2158-8-11**]
|
[
"414.01",
"V45.82",
"V70.7",
"560.9",
"V10.05",
"401.9",
"V45.89",
"V12.51",
"584.5",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.07",
"38.44",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3313, 3362
|
1554, 2112
|
271, 349
|
3793, 3901
|
1174, 1531
|
6763, 6951
|
1077, 1082
|
2321, 3290
|
3383, 3772
|
2138, 2298
|
3925, 6311
|
6337, 6740
|
1097, 1155
|
228, 233
|
377, 645
|
667, 1021
|
1037, 1061
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,936
| 126,501
|
45579
|
Discharge summary
|
report
|
Admission Date: [**2157-10-22**] Discharge Date: [**2157-11-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p Thoracentesis
s/p Cardiac Catheterization with Drug Eluting Stent Placement
History of Present Illness:
mr. [**Known lastname 97194**] is an 89 yoM with PMH CHF, CAD s/p CABG, A-fib, who
presents from rehabilitation with increasing SOB and cough
productive of white sputum. He reports increasing SOB and weight
gain since discharge. According to the family, he has had
worsening SOB and leg swelling since discharge from [**Hospital1 18**] [**10-20**].
Despite the dyspnea, he has been able to participate in physical
therapy at rehabilitation. On the day of admission, the family
reports that he was doing physical therapy in the morning
without difficulty and became acutely short of breath in the
afternoon and had desaturation to 80's. He received his daily
dose of lastix 20mg PO, and was given given an additional 60mg
PO. Denies falling, fever/chills, chest pain/tightness/pressure,
hemoptysis, n/v/d, dysuria.
.
In previous hospital stay, his furosemide dose was decreased
from 80mg PO to 20mg PO and Valsartan 320 mg po was discontinued
for low BP with the plan for his PCP to resume when pressures
could support it. He was also started on cefpodoxime 200 mg [**Hospital1 **]
until [**2157-10-26**] for a complicated UTI.
.
In ED VS were p92, BP136/84, RR:22-24, SaO2 94 on 2L. The ED
reported that he had been given Lasix 80mg IV and did not give
additional lasix. CXR revealed enlargment of previous R>L
pleural effusion, they were unable to exclude pneumonia and he
was started on Levofloxacin 750mg.
Past Medical History:
CHF ([**9-/2157**] LVEF = 30 %)
CAD h/o MI s/p CABG s/p PCI
R>L leg swelling (after CABG vein harvest)
DM, diet controlled
Afib following CABG not anticoagulated
HTN
Colon cancer, s/p partial colectomy with colostomy
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: Admission weight 40.6KG
Vitals - T:97.6 BP:108/56 HR:76 RR:20 02 sat:97% RA
GENERAL: Elderly male in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy
CHEST: Decreased breath sounds in posterior lung fields, dull to
percussion R>L, prominant rales in anterior lung fields BL
CV: Soft diastolic II/VI murmur at LUSB, holosystolic murmur at
apex no S3
ABD: Colostomy in place, well healed surgical scars,
non-distended, BS normoactive, Soft, non-tender, no organomegaly
EXT: R>L pitting edema to the knee. DOrsalis pedis pulses 1+ BL.
NEURO: Prolonged time between questions asked and answers
produced, able to follow simple commands, oriented x3, Cranial
Nerves: CNII-CNXII intact BL, MOTOR [**5-11**] in upper and lower ext.
SKIN: no rash
Pertinent Results:
Admission labs:
[**2157-10-22**] 05:35PM BLOOD WBC-10.2# RBC-3.95* Hgb-11.7* Hct-34.6*
MCV-88 MCH-29.5 MCHC-33.7 RDW-14.4 Plt Ct-403
[**2157-10-22**] 05:35PM BLOOD Neuts-82.1* Lymphs-12.1* Monos-4.5
Eos-0.8 Baso-0.5
[**2157-10-23**] 06:18AM BLOOD PT-14.0* PTT-34.6 INR(PT)-1.2*
[**2157-10-22**] 05:35PM BLOOD Glucose-168* UreaN-15 Creat-0.8 Na-126*
K-5.3* Cl-90* HCO3-28 AnGap-13
[**2157-10-24**] 04:26PM BLOOD LD(LDH)-170 CK(CPK)-24*
[**2157-10-23**] 03:23AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.6
[**2157-10-23**] 11:35PM BLOOD Osmolal-266*
[**2157-10-23**] 11:27AM BLOOD Type-ART pO2-68* pCO2-47* pH-7.45
calTCO2-34* Base XS-7
[**2157-10-22**] 05:56PM BLOOD Lactate-1.6 K-4.4
[**2157-10-24**] 01:43AM URINE Osmolal-282
[**2157-10-24**] 01:43AM URINE Hours-RANDOM UreaN-167 Creat-17 Na-67
K-42 Cl-96
[**2157-10-24**] 02:53PM PLEURAL WBC-875* RBC-[**Numeric Identifier **]* Polys-21*
Lymphs-58* Monos-12* Eos-1* Macro-8*
[**2157-10-24**] 02:53PM PLEURAL TotProt-3.3 Glucose-141 Creat-0.5
LD(LDH)-145 Albumin-2.2
Cardiac enzymes:
[**2157-10-23**] 03:23AM BLOOD CK(CPK)-31*
[**2157-10-23**] 06:18AM BLOOD CK(CPK)-32*
[**2157-10-23**] 11:35PM BLOOD CK(CPK)-32*
[**2157-10-24**] 08:20AM BLOOD CK(CPK)-28*
[**2157-10-22**] 05:35PM BLOOD cTropnT-0.05* proBNP-[**Numeric Identifier 97203**]*
[**2157-10-22**] 05:35PM BLOOD cTropnT-0.05*
[**2157-10-23**] 03:23AM BLOOD cTropnT-0.07*
[**2157-10-23**] 06:18AM BLOOD CK-MB-4 cTropnT-0.06*
[**2157-10-23**] 11:35PM BLOOD CK-MB-3 cTropnT-0.08*
[**2157-10-24**] 08:20AM BLOOD CK-MB-3 cTropnT-0.08*
[**2157-10-24**] 04:26PM BLOOD CK-MB-3 cTropnT-0.12*
MICRO:
[**2157-10-22**] Blood Cultures: negative
[**2157-10-24**] 2:53 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2157-10-24**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2157-10-27**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2157-10-30**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2157-10-25**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes,
and lymphocytes.
[**2157-10-22**] ECG:
Sinus rhythm. Prolonged P-R interval. Left axis deviation.
Intraventricular conduction defect. Left ventricular hypertrophy
with secondary repolarization changes. Compared to the previous
tracing of [**2157-10-15**] the rate is increased slightly. The other
findings are similar.
[**2157-10-22**] CXR:
FINDINGS: Sternal wires remain intact. There is evidence for
prior CABG,
unchanged. Calcifications project over the left lower thorax and
upper
abdomen. There is interval enlargement of the large right
pleural effusion. There is stable small left pleural effusion.
There is bibasilar dependent atelectasis. Cardiac silhouette
appears stable in size.
IMPRESSION: Interval enlargement of the previously noted large
right pleural effusion. Stable left pleural effusion.
[**2157-10-27**] CARDIAC CATHETERIZATION
1. Limited selective arterial conduit angiography revealed 80%
ISRS of
distal LIMA-LAD stent (prior to touchdown) as well as diffuse
disease
distally in the native LAD.
2. Limited hemodynamics showed normal systemic blood pressure of
96/45
mmHg.
3. Successful PTCA and stenting of ISRS of LIMA with 2.5x12mm
Promus
drug eluting stent postdilated to 3.0mm.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal systemic blood pressure.
3. Instent restenosis of prior LIMA stent.
4. Successful PCI of LIMA with DES.
Brief Hospital Course:
Mr. [**Known lastname 97194**] is an 89 y/o gentleman with history of chronic
systolic heart failure (EF 30% [**2157-9-21**]), CAD s/p CABG ([**2149**])
(LIMA-LAD, SVG-OM1, SVG-PDA) s/p NSTEMI [**9-20**] and atrial
fibrillation who was transferred to cardiology from the ICU
after he presented from rehab center, with worsening dyspnea,
hypoxia, and productive cough. He was treated for CHF
exacerbation, and his outpatient diuretic regimen was changed.
Also he had a bloody right pleural effusion secondary to a fall
and rib fracture, and had a thoracentesis which is negative for
infection and malignancy. In addition, he had cardiac
catheterization on [**10-27**] with DES to LIMA b/c of concern for
possible ongoing ischemia given recently elevated troponins. He
has unfortunately been readmitted multiple times recently, so
his fluid status, pleural effusion, and blood pressure were
addressed at length during his stay, and he was discharged home
with PT, telemonitoring, and [**Hospital 1902**] clinic/Cardiology
clinic/Primary care appointments.
.
#. Dyspnea/Hypoxia/Fatigue: CHF exacerbation and also
superimposed effusion.
He has known systolic CHF and valvular pathology that are likely
contributing factors to chronic dyspnea, but his enlarging
pleural effusion as seen on CXR was undoubtedly contributing to
his present picture. He appeared dyspneic and fatigued, with
transient desaturation, so he was brought to the MICU, where he
received nebulizer treatments and IV diuresis. He appeared more
comfortable but was still dyspneic; he underwent thoracentesis
of the right lung during which 1.5L of blood-tinged fluid was
removed (similar to prior admission when he had hemothorax after
a mechanical fall). The fluid was bloody with no evidence of
infection or malignancy. Upon transfer to the Cardiology floor,
his CHF was then treated; BNP was elevated as compared with
prior levels, and family reported history of increased edema on
lower doses of diuretics while at rehab. He was seen by Dr.
[**First Name (STitle) 437**] and Lasix was changed to Torsemide. He diuresed well and
his breathing was back to his baseline level of comfort. He did
not require supplemental O2. He was discharged home on
Torsemide, with home PT and telemonitoring. He will follow up
in [**Hospital 1902**] clinic.
.
#. CAD: with in-stent restenosis, now s/p PCI.
ECG findings as above. Troponin peaked at 0.07 prior to
admission. He denied chest pain. He does have a significant
cardiac history, however, and he underwent cardiac
catheterization that showed 80% ISRS of distal LIMA-LAD stent
(prior to touchdown) as well as diffuse disease distally in the
native LAD. He received DES to LIMA. He continued to be chest
pain free. He was continued on Plavix daily.
.
#. A fib: with good rate control.
He is currently off anticoagulation in the setting of recent
bleeds. He is well rate-controlled on beta blocker.
.
#. Hypertension: not hypertensive during admission
He was recently admitted on [**2157-10-15**] to the medicine service
for altered mental status and a fall, with suspicion for
hypovolemia/hypotension as well as UTI, and his Valsartan dose
had been decreased to 160mg daily. During this stay, his SBP
was mostly 90-120. On the day before discharge, he had an
episode of "feeling tired," with SBP 80's. His Valsartan was
further decreased to 80mg daily, and he has no further
complaints. Orthostatic vital signs were negative for
orthostasis prior to discharge, and he was sent home on
Valsartan 80mg with telemonitoring.
.
#. UTI: Klebsiella UTI.
GNRs in urine on recent admission, found to be pansensitive
(except to TMP/SMX) K. pneumoniae. Pt. received 5 days worth of
ceftriaxone on last admission, with plans for 5 days worth of
cefpodoxime for complicated UTI, and this was completed. He was
asymptomatic during hospital course.
.
#. Colon cancer, s/p partial colectomy with colostomy
He had no issues with his ostomy/output during the admission.
.
#. Hyperlipidemia
He was continued on home Simvastatin
# ?Dysphagia
Patient denied dysphagia, but his wife said that she often
notices him having difficulty swallowing. He was seen by Speech
and Swallow, and was cleared for regular diet.
.
#. Normocytic Anemia: Baseline Hct generally in low 30s.
His Hct was stable through his admission.
.
#. Osteoarthritis
Per recent d/c summary, he was not d/c'd on any analgesics. He
was written for APAP PRN but did not require.
.
#. BPH s/p TURP
He was making urine with foley catheter in place. He was
continued on tamsulosin.
.
#. GERD: on PPI
Continued Omeprazole.
Medications on Admission:
Sotalol 20 mg po bid
Simvastatin 40 mg po daily
Nitroglycerin 0.3 mg SL PRN chest pain
Tamsulosin 0.4 mg po qhs
Omeprazole 20 mg po daily
Multivitamin po daily
Furosemide 20 mg po daily
Aspirin 325 mg po daily
Clopidogrel 75 mg po daily
Docusate Sodium 100 mg po bid
trazodone 25 mg QHS
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. sotalol 80 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day).
3. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain.
4. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure
Coronary Artery Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted becasue you were having worsening shortness of
breath. You were also noted to have low oxygen saturations
therefore you went to the Intensive Care Unit where you had
fluid removed from your right lung. You had 1.5 L taken out. You
tolerated the procedure well and continued diuresis. You were
started on a new diuretic call Torsemide which you will take
once a day. Upon discharge your weight was 64.8 kg (143 lbs).
You should weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes
up more than 3 lbs.
*You will be receiving home telemonitoring.
You also had a cardiac catheterization during your admission.
You had a drug eluting stent placed in one of your coronary
arteries. You were restarted on plavix and should continue until
advised to stop by your cardiologist.
Medication Changes During Your Admission:
-Start Valsartan 80mg daily
-Start Torsemide 20 mg daily
-Stop Lasix
-Continue Plavix 75 mg PO DAILY
Followup Instructions:
CARDIOLOGY
Department: CARDIAC SERVICES
When: [**Name8 (MD) **] [**2157-11-7**] 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: 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
PRIMARY CARE
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
When: [**First Name3 (LF) 766**] [**2157-11-14**] at 11:45AM
Location: COMPREHENSIVE HEALTHCARE LLC
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 53711**]
Fax: [**Telephone/Fax (1) 97204**]
|
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icd9cm
|
[
[
[]
]
] |
[
"00.40",
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"00.66",
"34.91",
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] |
icd9pcs
|
[
[
[]
]
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12842, 12900
|
6861, 11459
|
282, 364
|
13008, 13008
|
3253, 3253
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|
2396, 2413
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|
3269, 4263
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|
1824, 2254
|
2270, 2380
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,995
| 101,468
|
46140
|
Discharge summary
|
report
|
Admission Date: [**2173-12-5**] Discharge Date: [**2173-12-10**]
Date of Birth: [**2107-9-11**] Sex: F
Service: MEDICINE
Allergies:
Gantrisin / Lactose
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
diarrhea and hypotension
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Mrs. [**Known lastname **] is a 66yo female with type I DM, ESRD on HD, recently
discharged after prolonged hospitalization w/ citrobacter UTI
complicated by seizures. Pt complete total 7days tx for UTI w/
tobramycin--abx selection based on citrobacter sensitivities
plus pt's susceptibility to sz's. Pt then dc'd on [**2173-11-26**] to
[**Hospital **] rehab. She was noted to have persistent diarrhea there
and was started on empiric PO vanc on [**12-3**]. Stool C. Diff test
negative x1. Pt noted as being more fatigued, lethargic, with
continued diarrhea. Then, developed hypotension (BP 90/50), at
which time she was brought for eval at [**Hospital1 18**].
.
In ED, BP initially 78/48, and persistently SBP 80s/50s per ED
signout, however ED nursing records show only one pressure
97/58. L femoral triple lumen was placed as pt had no access
other than tessio dialysis cath. Pt admitted to MICU for
hypotension. In the MICU, she was aggressively hydrated & SBP
improved to 90s-120s. Her hypotension was thought to be due to
dehydration in setting of diarrhea. She did not require
pressors. Pt was tx'd w/ flagyl for empiric coverage of cdiff
(toxin negative x2; B-toxin also sent). She was noted to have
positive UA (>50 WBCs, 21-50 RBCs, many bacteria, and moderate
yeast, w/ 0-2 epi's). Urine cx grew only mixed bacterial flora
c/w contamination. Pt was not started on abx for UA--team
reportedly discussed contacting ID regarding need for tx &
choice of tx given pt's prior cx data & risk for sz. (Unclear if
this was done).
Additionally, pt was ruled out for an MI. Given improvement in
BP, her beta-blocker was restarted at 1/2 dose. ACE still being
held.
She underwent HD on [**2173-12-6**], 1.5L removed, which she reportedly
tolerated well.
Her [**Date Range 15338**] were noted to be elevated >400 x2. She was transiently
on insulin gtt, then started on lantus 10u.
She was noted to have sacral decub, which did not appear
infected.
She was started on cipro eye drops for eye crusting over L eye
(which is blind).
.
ROS: Pt c/o intermittent rectal pain [**2-19**] diarrhea. Otherwise,
feeling well. Still some loose stool (w/ rectal tube). Denies,
fever, dysuria, cough, nausea, vomiting. + crustiness in eyes
Past Medical History:
1. DM type 1 x 35 years. Previous admissions for DKA and
hypoglycemic episodes. Her DM is complicated by peripheral
neuropathy, proliferative retinopathy (left eye blindness), and
nephropathy. Followed at [**Last Name (un) **].
2. Chronic renal failure: Appears [**2-19**] to DM and Cr has been 5
over past few months. On hemodialysis.
3. CAD - NSTEMI [**10-23**] in the setting of hospitalization for DKA,
Nuclear stress test [**8-23**]: P-MIBI, without fixed or reversible
defects, normal wall motion. EF 72%.
4. Hypertension
5. History of osteomyelitis, status post left transmetatarsal
amputation.
6. History of herpes zoster of left chest in [**2163**].
7. Bezoar, disclosed on UGI series [**7-/2166**].
8. Achalasia
9. Carpal Tunnel Syndrome
Social History:
She lives at home with her son, who is mentally retarded. Past
history of EtOH use. Ex-smoker, quit in [**2154**]. Previously smoked
for 8yrs. No history of illicit drug use.
Family History:
Mother - DM
Sister - breast ca, DM
Brother - HTN
[**Name (NI) 2957**] - SLE, d. renal failure
Physical Exam:
Vitals: T:97.9 BP:97/47 (90-120/40-50s) P: 100s R: 20 SaO2:100%
on RA
General: thin, cachetic woman, pleasant, resting comfortably in
bed, A&Ox3, answering all questions appropriately
HEENT: Bilateral eyes with crusty white exudate, scleral and
conjunctival injection. L eye blind, lid closed. OP clear. MMM
Neck: supple, no JVD flat
Pulmonary: Lungs CTA bilaterally
Cardiac: sl tachy, Regular rhyth,, nl. S1S2, holosystolic murmur
heard best at LUSB
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no edema, L foot with all toes amputated. 2+ DPs
bilaterally
Skin: Back with large, diffuse stage 1 decub; R tunneled HD cath
C/D/I
Neuro: decreased bulk throughout, appears deconditioned, but no
focal weakness.
Pertinent Results:
[**2173-12-4**] 10:25PM GLUCOSE-92 LACTATE-1.4 NA+-138 K+-5.7*
CL--106 TCO2-23
[**2173-12-4**] 10:25PM HGB-11.8* calcHCT-35
[**2173-12-4**] 10:00PM GLUCOSE-102 UREA N-29* CREAT-4.5*# SODIUM-138
POTASSIUM-5.9* CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
[**2173-12-4**] 10:00PM CK(CPK)-26
[**2173-12-4**] 10:00PM CK-MB-NotDone cTropnT-0.07*
[**2173-12-4**] 10:00PM WBC-7.5 RBC-4.19* HGB-11.4* HCT-36.9 MCV-88
MCH-27.2 MCHC-30.9* RDW-16.5*
[**2173-12-4**] 10:00PM NEUTS-74.0* LYMPHS-19.0 MONOS-6.7 EOS-0.2
BASOS-0.2
[**2173-12-4**] 10:00PM PLT COUNT-197
[**2173-12-4**] 10:00PM PT-13.4 PTT-39.4* INR(PT)-1.2*
[**2173-12-10**] 11:00AM BLOOD WBC-12.7*# RBC-4.14* Hgb-11.2* Hct-36.6
MCV-88 MCH-27.0 MCHC-30.6* RDW-16.5* Plt Ct-284#
[**2173-12-10**] 11:00AM BLOOD PT-17.6* PTT-58.2* INR(PT)-1.6*
[**2173-12-10**] 11:00AM BLOOD Glucose-88 UreaN-16 Creat-3.8*# Na-136
K-5.0 Cl-103 HCO3-24 AnGap-14
[**2173-12-10**] 11:00AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.7*
[**2173-12-4**] CXR - : No consolidation.
[**2173-12-8**] Right Foot XR -
1. No third toe abnormality is seen that suggests osteomyelitis.
2. The displaced proximal metatarsal fracture seen on [**2170-8-13**], have healed with persistent dorsal displacement of
metatarsal shafts relative to the hindfoot.
[**2173-12-8**] CT Head - No evidence of intracranial hemorrhage.
Brief Hospital Course:
65yo with ESRD on HD, type I diabetes, recent citrobacter UTI
c/b seizures was admitted with diarrhea and resultant
hypotension.
.
1. Hypotension.
Patient was admitted from her rehab facility with lethargy and
hypotension. She was found to have initial SBPs in the 70s and
required aggressive fluid resuscitation in the ICU. After fluid
resuscitation, she was transferred from the ICU to the floor,
where her hypotension improved with maintenance fluids,
improvement in diarrhea, and decreased fluid removal during
dialysis. She was slowly restarted on a 1/2 dose of her home
metoprolol. Her lisinopril is still being held and will need to
be restarted as her blood pressure tolerates.
.
2. Diarrhea:
Diff dx includes C. diff or antibiotic associated diarrhea. C.
Diff negative X 3 and Toxin B is still pending. Patient was
treated with oral metronidazole for presumptive C. diff and is
to complete a 14 day course ([**Date range (1) 98145**]). Additional stool
studies such as vibrio, ova and parasites, campylobacter, and
yersinia, and were sent and were unremarkable. Patient's Cdiff
toxin B will need to be followed.
.
3. UTI:
Patient was recently admitted with citrobacter UTI and received
a 7 day course of tobramycin. UA on admission was notable for
likely fecal contamination. Urine culture was negative x 2.
.
4. H/O status epilepticus:
Patient had episode of generalized tonic clonic seizures during
the previous admission and were thought to be secondary to her
citrobacter UTI. No prophylactic anti-epileptic medications were
given.
.
5. ESRD on HD
Patient was continued on her TThSat schedule and received
nephrocaps and calcium carbonate.
.
6. CAD:
Patient has a history of a NSTEMI during a previous admission.
She remained chest pain free and was maintained on her statin,
aspirin, and beta blocker. Her ACEI and beta blocker were held
due to her relative hypotension. [**Name2 (NI) **] beta blocker was started at
1/2 dose. Her ACEI has been held and will need to be restarted
over the next week as her blood pressure tolerates.
.
7. Sacral Decub:
Patient had evidence of sacral breakdown due to her copious
amounts of stool. Wound care was consulted and made several
recommendations, which were listed on the Page 1 summary.
.
8. Type 1 Diabetes Mellitus:
Patient was receiving 10 units lantus. Briefly increased to 14
units lantus, with resulting hypoglycemia to 39. She was then
maintained on a humalog sliding scale and lantus 10 units
without difficulty. Her insulin sliding scale is attached.
.
9. Conjunctivitis: continue cipro eye drops, moisten to allow
eye opening.
.
Code Status: FULL CODE
Contact: son [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 98146**] ([**Telephone/Fax (1) 98147**]
Medications on Admission:
Atorvastatin 80 qd
Lisinopril 20 qd
ASA 81mg
hep SC tid
folic acid 1mg qdaily
tylenol 650 PRN
Metoprolol 75 tid
acidophilus
CaCo3 1250 [**Hospital1 **]
cholestyramine
ciprofloxacin eye drops
EPO with dialysis
colace
10U lantus
lactase with meals
MVI
neutra phos [**Hospital1 **]
omeprazole
senna
vancomycin 125 po qid
lactulose PRN
.
Medications on Transfer:
Heparin 5000 UNIT SC TID
Acetaminophen 325-650 mg PO Q6H:PRN
Insulin SC (per Insulin Flowsheet)
Aspirin 81 mg PO DAILY
MetRONIDAZOLE (FLagyl) 500 mg PO TID Day 1 = [**12-5**].
Atorvastatin 80 mg PO DAILY
Metoprolol 37.5 mg PO TID
Calcium Carbonate 1250 mg PO BID
Nephrocaps 1 CAP PO DAILY
Ciprofloxacin 0.3% Ophth Soln 1-2 DROP BOTH EYES Q4H
Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
7. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
11. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H
(every 4 hours) for 4 days.
12. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection
qHD: Please continue epo with hemodialysis. .
13. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a
day).
14. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
15. Humalog 100 unit/mL Solution Sig: according to scale
Subcutaneous four times a day: Please administer according to
attached sliding scale. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Antibiotic associated diarrhea
2. Hypotension
3. ESRD
.
SECONDARY DIAGNOSIS:
1. Type 1 Diabetes Mellitus c/b retinopathy, neuropathy,
nephropathy
2. ESRD secondary to DM - on HD
3. CAD - NSTEMI [**10-23**] in the setting of hospitalization for DKA,
Nuclear stress test [**8-23**]: P-MIBI, without fixed or reversible
defects, normal wall motion. EF 72%.
4. Hypertension
5. History of osteomyelitis, status post left transmetatarsal
amputation.
6. History of herpes zoster of left chest in [**2163**].
7. Bezoar, disclosed on UGI series [**7-/2166**].
8. Achalasia
9. Carpal Tunnel Syndrome
Discharge Condition:
Stable. Patient is tolerating oral intake, answering questions
appropriately, and has returned to her condition at admission.
Discharge Instructions:
You were admitted to the hospital due to low blood pressures and
diarrhea. Your blood pressure improved with intravenous fluids
and with improvement in your diarrhea. We think your diarrhea
was due to your antibiotics and you are to complete a 2 week
course of the antibiotic flagyl.
.
While you were here, we held your hypertension medications
(lisinopril, metoprolol) because your blood pressure had been
low. We restarted your metoprolol but are still holding your
lisinopril. As your blood pressure improves over the next
several days, you can restart your lisinopril and increase your
metoprolol as needed.
.
Please continue to take the rest of your medications as
prescribed. We have made the following changes to your
medications:
- lisinopril - we are holding this medication. Please restart
over the next several days as blood pressure tolerates.
- metoprolol - we restarted this medication at 1/2 dose. Please
titrate up as tolerated.
- colace, senna, and lactulose - holding in the setting of
diarrhea
.
If you have any light-headedness, shortness of breath, fevers,
chills, night sweats, chest pain, abdominal pain, please seek
immediate medical attention.
Followup Instructions:
- We have scheduled a follow-up appointment for you with your
primary care [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. on [**2173-12-21**] 11:00.
- We have also scheduled a follow-up appointment for you with
[**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Last Name (NamePattern1) 280**] on [**2174-1-6**] 2:00.
- We have scheduled a follow-up appointment with RADIOLOGY on
[**2174-3-2**] 2:45. Please call their office at [**Telephone/Fax (1) 327**] to
reschedule.
- We have scheduled an appointment for you with a podiatrist
[**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM on [**2173-12-28**] 11:00. If you need to reschedule,
please call their office at [**Telephone/Fax (1) 543**].
|
[
"V15.82",
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10689, 10768
|
5798, 8528
|
305, 319
|
11424, 11552
|
4439, 5775
|
12769, 13644
|
3552, 3647
|
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|
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|
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|
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|
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241, 267
|
347, 2571
|
10888, 11403
|
10808, 10867
|
8913, 9284
|
2593, 3343
|
3359, 3536
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,199
| 163,482
|
34045
|
Discharge summary
|
report
|
Admission Date: [**2158-5-13**] Discharge Date: [**2158-5-25**]
Date of Birth: [**2135-7-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
fever, chills, cough, SOB
Major Surgical or Invasive Procedure:
[**5-13**] AVR (Mech),Root abcess debridment and MV patch repair
History of Present Illness:
22 yo M with h/o IVDU (heroin) presented to OSH with presumed
URI. [**3-7**] Blood cultures positive and patient asked to return to
ED where [**4-7**] repeat blood cultures were positive for MRSA. He
was admitted to OSH and started on vanco and gentamicin. Echo
showed aortic valve vegetation, repeat echo showed new
pericardial effusion and systollic right atrial invagination and
he was transferred for further care.
Past Medical History:
Hep C HIV-negative [**First Name8 (NamePattern2) **] [**Hospital1 3494**] testing, Asthma as a child,
R-lobectomy at [**Hospital1 2177**] ~5 years ago
Social History:
+IVDU
+tobacco
works in boatyard
Family History:
NC
Physical Exam:
126/41 114 95% Pulsus 14 mmHg
ill appearing male, diaphoretic in mild-moderate distress
no splinter hemorrhages
coarse crackles bilaterally
well healed surgical scar right flank
abdomen soft, NT, ND
no edema
Pertinent Results:
[**2158-5-13**] 12:52AM PT-16.4* PTT-38.6* INR(PT)-1.5*
[**2158-5-13**] 12:52AM WBC-16.0* RBC-2.96* HGB-9.2* HCT-26.7* MCV-90
MCH-31.2 MCHC-34.6 RDW-13.5
[**2158-5-13**] 12:52AM ALT(SGPT)-19 AST(SGOT)-20 LD(LDH)-209
CK(CPK)-44 ALK PHOS-63 TOT BILI-0.3
[**2158-5-13**] 07:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-5-13**] 05:10PM WBC-33.7*# RBC-2.64* HGB-8.0* HCT-24.7*
MCV-93 MCH-30.3 MCHC-32.4 RDW-13.6
[**2158-5-13**] ECHO
The left ventricle is not well seen. There is a moderate-sized
vegetation on the leftr coronary cusp of the aortic valve. The
non-coronary cusp of the aortic valve appears to be disrupted
and its attachment may have separated from the aortic annulus.
There is an abscess cavity that appears to extend from the non
coronary cusp through the aortic-mitral fibrous continuity and
into the middle anterior scallop of the mitral valve. The
anterior and posterior scallops do not appear involved in this
abscess. The aortic annulus is thickened near the non and left
coronary cusps. Severe (4+) aortic regurgitation is seen. There
is an abscess cavity seen adjacent to the mitral valve (in
continuity with the non coronary cusp of the aortic valve.) An
eccentric, posteriorly directed jet of moderate to severe (3+)
mitral regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is a moderate sized pericardial effusion.
The effusion appears circumferential. There is brief right
atrial diastolic collapse. Echocardiographic signs of tamponade
may be absent in the presence of elevated right sided pressures.
IMPRESSION: Aortic annular abscess that is probably extending
from the non coronary cusp into the middle scallop of the mitral
valve. There does not appear to be a vegetation or perforation
of the mitral valve leaflets. There is also a vegetation on the
left coronary cusp of the aortic valve. Severe aortic
regurgitation and moderate to severe mitral regurgitation are
seen. Small to moderate pericardial effusion that appears to
track with gravity. Most of the effusion is thus posterior to
the heart. There is right atrial diastolic collapse but no frank
tamponade (elevated right sided pressures may mask
echocardiographic signs of tamponade.)
[**2158-5-13**] ECHO
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There is a moderate-sized vegetation on the aortic valve-
left coronary cusp. An aortic annular abscess is seen extending
to the anterior leaflet of the mitral valve. There is a Moderate
to severe (3+) aortic regurgitation is seen. There is a
communication between the aortic root and the left atrium.
5.There is a moderate-sized vegetation on the mitral valve.
Moderate (2+) mitral regurgitation is seen.
6. There is a large pericardial effusion.
7. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2158-5-13**]
at 1430.
Post Bypass
1. Biventricular systolic function is slightly depressed. LVEF=
45%
2. Mechanical valve seen in the aortic position. Leaflets move
well and the valve appears well seated. ( 21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]). Mean
gradient across the valve is 20 mm Hg. Dr [**Last Name (STitle) **] aware.
3. Moderate to severe mitral regurgitation with a posteriorly
directly jet present.
4. Post surgical changes with pledgets and sutures seen on the
left atrial side near the anterior leaflet of the mitral valve.
( Dr [**Last Name (STitle) **] informed)
5. Aorta intact post decannulation
[**2158-5-15**] CT Scan
1. Small postoperative substernal fluid collection as well as
moderate pericardial effusion, both of which demonstrate
peripheral rim enhancement. Although these findings may be seen
in the setting of recent postoperative state, a superimposed
infection cannot be excluded.
2. Small bilateral pleural effusions with associated atelectasis
(right greater than left).
3. Prior right lower lobe lobectomy.
4. Small bilateral patchy opacities in both lungs which may be
infectious or inflammatory in origin or may represent
atelectatic foci.
5. Mild splenomegaly.
Brief Hospital Course:
He was admitted to the CCU. TEE confirmed vegetation on AV and
severe AI, moderate to severe MR. [**Name13 (STitle) **] was taken urgently to the
operating room on [**5-13**] where he underwent an AVR and mitral
valve reconstruction with pericardial patch. He was transferred
to the ICU in stable condition. He was extubated post op. He
was seen by infectious diseases and continued on vancomycin. He
was seen by pain medicine and started on methadone, baclofen and
clonidine with dilaudid for breakthrough. He was transferred to
the floor on POD #2. He was started on coumadin for his
mechanical valve. He was seen by addiction services. On [**2158-5-18**]
a generalized erythematous, maculopapular rash developed. Lasix
was discontinued due to possible sulfa cross reactivity. The
infectious disease and dermatology services were consulted.
Punch biopsies as well as viral specs were sent to pathology
which were negative. It was suspected that the rash was related
to either the lasix or vancomycin. Bumex was thus used for
diuresis and vancomycin was replaced with daptomycin for
treatment of his MRSA aortic valve endocarditis. The remainder
of his postoperative course remained uneventful. He continued
anticoagulation for his mechanical aortic valve with a goal INR
of 2.5-3.0. His coumadin dosing will be managed by the [**Hospital **]
rehabilitation center while a resident there followed by Dr.
[**Last Name (STitle) 62081**] ([**Telephone/Fax (1) 78575**] of [**Hospital6 **] System.
Social worker, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], is working on obtaining a primary
care physician for Mr. [**Known lastname **]. Daptomycin will be continued
until [**2158-6-23**]. He will need weekly CBC's with differentials,
chemistry 7, liver function studies and CPK's while taking
daptomycin. He will follow-up with the [**Hospital1 **] ID service. Mr.
[**Known lastname **] continued to make steady progress and was discharged to
the [**Hospital **] Rehabilitation facility on [**2158-5-25**]. He will
follow-up with Dr. [**Last Name (STitle) **] in 1 month.
Medications on Admission:
Albuterol MDI w spacer, q4-6h PRN SOB, Moxifloxacin 4000 mg PO
daily
Discharge Medications:
1. Outpatient Lab Work
weekly CPK,CBC with diff.,BMP,LFTs
***last dose of Daptomycin [**2158-6-23**]
2. Daptomycin 500 mg Recon Soln Sig: One (1) 550 Intravenous
Q24H (every 24 hours): last dose [**2158-6-23**].
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Dose daily for goal INR of 2.5-3.0.
5. Bumex 2 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
8. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: 12.5mg mg PO Q8H
(every 8 hours) as needed for itching.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 2 weeks.
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: 2ml PICC
line flush.
12. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-4**]
Puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months: Then may discontinue after 1 month.
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
endocarditis now s/p
Hep C, Asthma, R-lobectomy at [**Hospital1 2177**] ~5 years ago, IVDU
Discharge Condition:
Stable.
Discharge Instructions:
1) Monitor wound for signs of infection. these included redness,
drainage or increased pain. Please call surgeon at ([**Telephone/Fax (1) 4044**] for any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting more then 10 pounds for 10 weeks from date of
surgery.
5) No driving for 1 month.
6) Please shower daily. You may wash incision and gently pat
dry. No lotions creams or powders to incision until it has
healed. You should use sunscreen on incision after it has healed
when out in sun.
7) Coumadin for mechanical AVR and patch repair of mitral valve.
Goal INR 2.5-3.0. Please monitor daily INR and dose coumadin
appropriately. Pt will need coumadin follow-up on discharge from
[**Hospital1 **]. Dr. [**Last Name (STitle) 62081**] [**Telephone/Fax (1) 78576**] of [**Hospital 78577**] [**Hospital **] may assume this role. Social Worker [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is
currently working on finding a PCP for the patient.
8) Daptomycin will be continued until [**2158-6-23**]. He will need
weekly CBC's with differentials, chemistry 7, liver function
studies and CPK's while taking daptomycin. He will follow-up
with the [**Hospital1 **] ID service.
9) Bumex for 1 week then reassess.
10) Hibiclens washes and Clobetasol cream to lower extremities.
11) Call with any questions or concerns.
Followup Instructions:
[**Hospital6 12736**] in 2 weeks - Dr. [**Last Name (STitle) 62081**] in 2 weeks
([**Telephone/Fax (1) 78575**]
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 1504**]
Dr. [**Last Name (STitle) **]/[**Hospital **] clinic in 8 weeks or as needed. [**Telephone/Fax (1) 432**]
Completed by:[**2158-5-25**]
|
[
"790.7",
"421.0",
"693.0",
"E944.4",
"305.50",
"447.2",
"493.90",
"593.81",
"041.11",
"423.3",
"427.89",
"070.70",
"E930.8",
"287.0",
"420.99",
"305.1",
"389.15",
"V09.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.61",
"35.12",
"35.39",
"88.72",
"86.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9369, 9442
|
5706, 7802
|
299, 366
|
9577, 9587
|
1302, 5683
|
11053, 11373
|
1055, 1059
|
7921, 9346
|
9463, 9556
|
7828, 7898
|
9611, 11030
|
1074, 1283
|
234, 261
|
394, 814
|
836, 989
|
1005, 1039
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,388
| 139,092
|
37488
|
Discharge summary
|
report
|
Admission Date: [**2105-12-14**] Discharge Date: [**2105-12-17**]
Date of Birth: [**2052-3-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Trazodone / Inderal La / Demerol
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Gabapentin Overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53F with a hx of suicide attempts (per OSH records) presents as
an OSH transfer with no prior medical history to [**Hospital1 18**]
presenting with Gabapentin overdose.
.
The pt presents from [**Hospital3 **] with suspected overdose of
180 of 200 tablets of Neurontin. The pt was found unresponsive
on floor by EMS unresponsive in a chair. Script was written for
240 pills filled on [**2105-12-11**]. Upon arrival to [**Hospital3 **]
initial vitals 97.3 70 118/74 98% intubated. The pt was noted to
have a GCS of 3. Labs notable of WBC 7.4, Hct 41.2, Plt 314.
Coags WNL. Na 135, Ca 8.2, ALT 25, AST 53, ETOH of 223. Urine
Tox positive for barbituates. At the OSH the pt was intubated,
self-extubated, and was subsequently re-intubated.
.
In the emergency department initial vitals CBC WNL lactate of
1.6, BCx sent. Non-Contrast CT Head within normal limits. Been
responsive off of sedation, biting on tube, received KCl 40. QRS
at [**Hospital1 **] 110 -> 150 here. Received 2 amps of bicarb. Has
associated RBBB. Received 2L. On Fentanyl 50, Versed 2. CXR
revealed OGT up, so advanced. ETT pulled back. Pressures and HR
WNL. Gabapentin, renally excreted. 500cc since. 135/73. 71 20
500 5 60%. She received Levofloxacin, Ceftriaxone 1gm IV. 250cc
of UOP.
.
Further history provided by husband. [**Name (NI) **] was concerned for her
over past few days, as patient missed weekly therapy session for
EtOH dependence this past Thursday. Husband reports watching
game with patient and patient's mother. [**Name (NI) **] was not
consuming alcohol at this time. Husband then left, and later
received a call overnight that patient had overdosed and was
being tranferred to OSH.
Past Medical History:
h/o Breast Cancer s/p resection, chemo, XRT
gastric bypass x 2 (? revision)
s/p lap chole
alcohol dependence
Diabetes Mellitus prior to gastric bypass
Social History:
Lives in [**Hospital1 **] with mother. Currently separated from husband.
[**Name (NI) **] children. Works as director of IV therapy at [**Hospital1 2025**]. 1 to 1.5
PPD for "many years". When drinking, bottle of white wine every
night. No other illicit drug use.
Family History:
Sister, healthy. Brother had [**Name2 (NI) **]/trauma c/b DVT, doing well
Physical Exam:
T=96.8 BP 128/67 HR71 RR19 O2=100% on 40% Fi02 and 5 PEEP
PHYSICAL EXAM
GENERAL: Intubated Sedated
HEENT: 1-2mm reactive pupils, symmetric, bilaterally,
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP flat.
LUNGS: CTAB, good air movement anteriorly.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Deferred
.
on discharge
Vitals: 96.9 138/78 65 18 99%RA
Pain: none
Access: PIV
Gen: nad
HEENT: mmm, EOMI, pain along L lateral supraorbital region,
+periorbital swelling, +L subconj hemmorhage
CV: RRR, [**1-9**] SM
Resp: CTAB, no crackles or wheezing
Abd; soft, obese, nontender, +BS
Ext; no edema
Neuro: A&OX3, grossly nonfocal
Skin: no changes
psych: calm, pleasant, denies SI
Pertinent Results:
no leukocytosis
hgb 11 stable
BUN/creat 6/0.6
lfts wnl
b12/folate wnl
.
UA neg
.
S tox etoh 125
U tox +benzo, barbs
.
Resp GS: GPC pair/chairs, cx neg
BC [**12-14**] X2 NTD
.
.
Imaging/results:
CT head [**12-14**]
IMPRESSION: Paranasal sinus inflammatory changes, otherwise
normal study.
.
CT orbit [**12-16**]: no orbital fracture. periorbital soft tissue
swelling.
.
CXR: [**12-14**]: ET tube has been repositioned at the thoracic inlet,
nasogastric tube ends in the stomach. Aeration in the left lung
is improving, but some consolidation remains particularly in the
infrahilar left lower lobe and should be followed to exclude
aspiration pneumonia. Right lung clear. Heart size normal. No
evidence of central adenopathy or pleural abnormality
.
EKG
Normal sinus rhythm with right bundle-branch block and secondary
ST-T wave
abnormalities. Compared to tracing #4 there is no change. RBBB
is old
Brief Hospital Course:
52year old female with MMP including h/o depression, breast
cancer s/p resection/chemo/xrt, gastric bypass, etoh abuse, PSA,
here after neurontin overdose as suicide attempt. Was intubated
on arrival to [**Hospital **] transfered to [**Hospital1 18**]. extubated w/o incident.
Seen by tox. neurontin is renally excreted and so nohting to do
but supportive care since she has normal renal secretion. EKG
w/o acute change, old RBBB. labs stable. pt calm. seen by psych.
plan for psych admission. Restarted Effexor XR at home dose 150.
ETOH level at OSH >200 and 125 here, placed on valium per CIWA
but no evidence of withdrawal here. started on mvi/thiamin/folic
acid. Also noted to have L periorbital swelling and pain and L
subconjunctival hemmorhage that pt noted [**12-15**]. Likely due to
trauma during intubation. CT orbits w/o fracture. No visual
complaints. will resolve on own. Was discharged to psych
facility in stable condition. Her hctz was not resumed as her BP
was well controlled off this, can be resumed as outpt. Her
neurontin was not resumed
Medications on Admission:
effexor 150XR
neurontin ?dose
hctz 25
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Effexor XR 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
depression and suicidal attempt with neurontin overdose
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
you were admitted because you overdosed on neurontin. you were
briefly intubated. you were treated with supportive care. the
neurontin should clear on its own. you will go to a psychiatric
facility on discharge. please try to avoid alcohol and benzos
and barbituates as these can worsen your depression
You had some swelling around left eye and bleeding in eye, this
likley happened when they intubated you. CT scan did not show
any fractures. This will resolve on own. Let doctor know if you
have double or blurry vision or vision loss
Followup Instructions:
please follow up with your primary psychiatrist and doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from psych facility
|
[
"966.3",
"E950.4",
"311",
"V10.3",
"518.81",
"305.1",
"V45.86",
"507.0",
"372.72",
"303.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5891, 5906
|
4409, 5470
|
339, 346
|
6006, 6006
|
3485, 4386
|
6712, 6848
|
2525, 2601
|
5560, 5868
|
5927, 5985
|
5496, 5535
|
6151, 6689
|
2616, 3466
|
280, 301
|
374, 2049
|
6020, 6127
|
2071, 2223
|
2239, 2509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,585
| 152,311
|
5503
|
Discharge summary
|
report
|
Admission Date: [**2100-12-29**] Discharge Date: [**2101-1-7**]
Service: MEDICINE
Allergies:
Norvasc / Cipro I.V.
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Mr. [**Known lastname 22236**] is an 89 y.o. M with systolic CHF (EF 45% in [**9-25**]),
s/p MCA CVA, afib, HTN, and DM II, recently admitted to [**Hospital1 18**]
from [**Date range (1) 8945**] and [**Date range (1) 22237**] for HAP and UTI [**Last Name (un) **] transferred
from [**Hospital **] hosp for hypotension.
History is unclear as obtained from scant OSH records and
patient unable to give history. He appears to have been at NH
when found to sats 81% RA, foley draining dark amber urine. He
was noted to have severe peripheral edema and given levoquin X 1
and lasix 40 mg IV X 1 at OSH. He became hypotensive to 80's at
OSH, placed an EJ and started peripheral neo.
In the ED, initial vs were: T 100, P 81, BP 107/58, R 18, 100%
NRB O2 sat. Patient was given Vanc/Zosyn, tylenol, and 1L NS in
ED. Bladder was changed in ED with UCx very positive and sent to
ICU.
On the floor, he has no complaints. History is obtained mostly
from son as patient only answers with single words.
Past Medical History:
L MCA stroke with right-sided hemiparesis, aphasia [**12/2090**]
Systolic CHF with EF 45-50% in [**9-/2100**]
Mild pulmonary artery hypertension
Atrial fibrillation with slow ventricular response
Heart block s/p [**Company 1543**] Sensia single-chamber pacemaker [**3-25**]
Benign Hypertension
Hyperlipidemia
Type 2 Diabetes
RLE cellulitis
RLE DVT (on coumadin)
s/p IVC filter [**10/2099**]
Sleep apnea (intolerant of CPAP)
Bladder diverticulum w/ ? fungal infection, currently inoperable
per most recent urology note followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]
Recurrent UTIs
Social History:
He does not drink or smoke. Widower with 3 children. Former
pro-baseball scout for numerous pro-teams. Was one of the first
scouts to recruit a minority player (to Philly), and was then
black-listed for this reason for 5 years. He coached for many
many years at [**Location (un) 5871**] college, where he boasted a 100%
graduation rate. Lives in a nursing home, and is visited daily
by his sons, who performs many of the tasks of daily care. He
does not drink, smoke, nor use recereational drugs. Widower with
3 children.
Family History:
Non-Contributory
Physical Exam:
Vitals: Tm/c 97.8, 80s, 100-120s/50-60s, 98% on RA
General: sleepy, appears comfortable, responds to a few
questions, oriented to [**State 350**] & baseball. Does
communicate often appropriately.
HEENT: Pupils small b/l, but reactive to light. Sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, diffuse wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: somewhat firm, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, multipodus boots on.
Skin: Few crusted ulcers on toes
GU: swollen scotum
Pertinent Results:
Discharge Labs:
[**2101-1-6**] 06:23AM BLOOD WBC-12.3* RBC-2.62* Hgb-8.4* Hct-25.2*
MCV-96 MCH-31.9 MCHC-33.2 RDW-15.9* Plt Ct-281
[**2101-1-6**] 07:00AM BLOOD PT-28.7* PTT-42.2* INR(PT)-2.9*
[**2101-1-6**] 06:23AM BLOOD Glucose-68* UreaN-15 Creat-1.4* Na-145
K-3.7 Cl-113* HCO3-25 AnGap-11
[**2101-1-6**] 06:23AM BLOOD Calcium-6.7* Phos-2.7 Mg-1.7
[**2100-12-28**] 11:00PM BLOOD VitB12-1170* Folate-6.5
[**2101-1-5**] 07:57PM BLOOD Tobra-1.2*
Imaging:
[**1-3**] CXR:
There is increased hazy vasculature bilaterally with bilateral
pleural effusions, left greater than right that have increased.
Compared to the prior study, there is dense retrocardiac
opacification consistent with volume loss/effusion/infiltrate.
Compared to the prior study, the amount of pulmonary edema has
increased. An underlying infectious infiltrate particularly on
the left cannot be totally excluded.
[**12-28**] Scrotal U/S:
Significant subcutaneous scrotal swelling with no
hypervascularity and no gas within the tissues identified. This
edema may be due to third spacing but ultrasound is unable to
further characterize. A clinical evaluation is recommended to
exclude a subcutaneous infectious
process, and if further imaging is required, a CT could be
performed.
2) No evidence of an intratesticular mass. No evidence of
epididymitis or
orchitis.
Microbiology:
**FINAL REPORT [**2101-1-1**]**
URINE CULTURE (Final [**2101-1-1**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- 32 R
CEFEPIME-------------- 8 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 2 S <=1 S
MEROPENEM------------- =>16 R <=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 16 S =>128 R
PIPERACILLIN/TAZO----- 16 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
**FINAL REPORT [**2101-1-3**]**
Blood Culture, Routine (Final [**2101-1-3**]): NO GROWTH.
[**2101-1-4**] 6:32 am BLOOD CULTURE Source: Line-PICC 2 OF 2.
Blood Culture, Routine (Pending):
Brief Hospital Course:
An 89 year old gentleman with systolic CHF, chronic foley who
presented from rehab with Psuedomonal/E. Coli urosepsis.
#) Urosepsis: The patient was admitted to the MICU for
management of urosepsis. While there he was maintained on
neosynephrine for 2 days. He was started on Vancomycin & Zosyn.
The patient was called out to the floor on Zosyn & Tobramycin.
Further microbiologic data suggested a treatment change to
Tobramycin & Ceftazidime to be continued until [**2101-1-12**].
Throughout this admission the patient's chronic foley due to
bladder diverticulum remained in place and regularly irrigated.
-Ceftazidime 2g IV Q12h last dose [**2101-1-12**]
-Tobramycin 100mg IV Q24, decrease dose to 80mg on [**2101-1-9**] to
finish course on [**2101-1-12**].
-Foley requires hand irrigation q4-6 hours, no continuous
bladder irrigation.
#) Atrial Fibrillation: The patient has a history of atrial
fibrillation for which he is on chronic anti-coagulation and
metoprolol. Due to his poor PO intake and self-sustained rate
control, the patient will not be continued on metoprolol. His
coumadin was held for much of his admission given a
supratherapeutic INR. He will be discharged on 2mg daily with
PT levels to be followed twice weekly, goal [**12-21**].
#) Chronic DVTs: Anticoagulated as above.
#) Malnutrition/Wound Care (Sacral Decubitus & leg ulcers): The
patient is tolerating limited PO with siginificant aspiration
risk & aspiration events. Other feeding options were discussed
with the family but they have opted to maintain oral feeding.
Of note, the patient has a low Albumin in the 1s with
significant wound care issues as well as significant scrotal
edema. The patient was admitted on Zinc, Vitamin C, & Vitamin B
but due to his poor ability to consume pills these medicines
have not been continued.
#) Leukocytosis: The patient has had a maintained elevated white
blood cell count while admitted. This is likely due to his
ongoing Pseudomonal UTI/chronic foley. An assay for C. diff was
sent off and the results will be called to the accepting
facility.
- If C. Diff positive, will begin Flagyl 500mg IV Q8 at the
discretion of the family.
#) CHF: The patient has a history of Congestive Heart failure.
Given his renal failure and hypotension his lasix was initially
held. Given his tenuous renal failure we have not restarted
Lasix on discharge.
#) Pain: The patient was maintained on a fentanyl patch and with
tylenol and morphine IV. On discharge he will be transitioned
to sublingual or liquid morphine for pain control.
# ARF: The patient has persistent renal failure with baseline
creatinine 0.8, 1. on discharge. All medicines were renally
dosed.
# Hypertension: The patient's beta blocker and ace inhibitor
were not continued.
# Type 2 Diabetes: The patient was continued on an insulin
sliding scale but did not require insulin. We recommend
reducing his finger sticks to once daily only.
# Anemia: The patient had fluctuating blood volume without clear
blood loss other than phlebotomy. He was not transfused on this
admission.
# L heel stage II pressure ulcer: Wound care as above.
# Dementia: The patient has chronic dementia. He was unable to
reliably take food by mouth, however in accordance with the
family wishes he was fed but kept on aspiration precautions.
Medications on Admission:
Medications:
1. Fentanyl 12 mcg/hr Patch 72 hr [**Month/Day (3) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Allopurinol 100 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
5. Multivitamin,Tx-Minerals Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
6. Paroxetine HCl 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
8. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML
Mucous membrane QID (4 times a day).
9. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily) for 4 days.
11. Vitamin A 10,000 unit Capsule [**Last Name (STitle) **]: Two (2) Capsule PO DAILY
(Daily) for 4 doses.
12. Ascorbic Acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day for 4 days.
13. Coumadin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
Target INR [**12-21**]. INR on [**12-16**] was 3.9, so hold dose on [**12-16**] and
recheck.
14. Insulin Lispro 100 unit/mL Solution [**Month/Year (2) **]: qACHS per sliding
scale Subcutaneous ASDIR (AS DIRECTED).
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Year (2) **]: [**11-19**]
Drops Ophthalmic [**Hospital1 **] (2 times a day).
16. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
17. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H
(every 8 hours) for 2 weeks.
18. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Fentanyl 12 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical
QID (4 times a day).
5. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day).
6. Acetaminophen 500 mg/5 mL Liquid [**Hospital1 **]: One (1) PO Q6H (every
6 hours): Please mix with patient's pre-thickened water.
Patient may refuse.
7. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
8. Ceftazidime 2 gram Recon Soln [**Hospital1 **]: One (1) Recon Soln
Injection Q12H (every 12 hours) for 5 days: Last dose [**2101-1-12**].
9. Tobramycin Sulfate 40 mg/mL Solution [**Year (4 digits) **]: 2.5 mL Injection
Q24H (every 24 hours) for 5 days: [**1-7**] to [**1-8**]: 100mg Q24h
Change of Dose:
[**1-10**] to [**1-12**]: 80mg Q24.
10. Morphine Sulfate 5 mg/0.25 mL Solution [**Month/Year (2) **]: Ten (10) mg
Sublingual every four (4) hours as needed for pain.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Drops [**Last Name (STitle) **]: One (1) gtt
Ophthalmic twice a day.
13. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
Please Check PT twice weekly and titrate accordingly to goal INR
[**12-21**].
14. Insulin Lispro 100 unit/mL Solution [**Month/Day (3) **]: ASDIR Subcutaneous
once a day: Please check finger sticks Qam and follow sliding
scale as directed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
1. Sepsis due to bacterial UTI (Pseudomonas and E.coli)
2. Acute on chronic systolic heart failure
3. Acute renal failure
4. Severe malnutrition with albumin <1.5
5. Stage II decubitus ulcers
6. History of DVT status post IVC filter, on coumadin
7. Atrial Fibrillation
8. Dementia
9. Bladder diverticulum with chronic indwelling foley catheter
Discharge Condition:
Vital signs stable, chronically ill.
Discharge Instructions:
You have been admitted to the hospital with a serious urinary
infection. While you were here you were cared for in the
Intensive Care Unit and on the medical wards. You will be
discharged on IV antibiotics for this infection.
Please take all medicines as directed as they have changed. We
have stopped many of your medicines so please check carfeully.
Followup Instructions:
Mr. [**Known lastname 22236**] has the following appointment already scheduled
prior to this admission.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2101-1-21**]
4:00
Dr.[**Name (NI) **] will be following Mr. [**Known lastname 22236**] after discharge.
He can be reached at [**Telephone/Fax (1) 22235**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,266
| 164,101
|
48480
|
Discharge summary
|
report
|
Admission Date: [**2116-1-2**] Discharge Date: [**2116-1-8**]
Service: MEDICINE
Allergies:
Cisatracurium / Milk
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"GIB."
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **] year old male patient of Dr.[**Name (NI) 666**] with a
history of myasthenia [**Last Name (un) 2902**], AF on coumadin, CHF (EF 50%),
critical AS (valve area 0.6) s/p valvuloplasty, CKD (baseline
2.4), dementia and failure to thrive who was discharged two days
ago ([**12-31**]) with a PICC on TPN after presenting with
hypernatremia who now presents with a GIB with a hematocrit down
to 18% from a baseline of ~27%. His family explains that they
first noticed dark red rectal bleeding yesterday. A hct at the
time was 19. He received 2 units of blood over night at his LTAC
but his HCT was still 19.4 this morning. He denies any pain and
according to his family is "acting like himself".
.
Per the ED's discussion with his family he is DNR/DNI and does
not want a central line or an NGT. They would like to give him
blood. Given his history of severe AS he is being admitted to
the ICU. In the ED he received a total of 300cc IVF. A first
unit of blood was started. Vital signs at the time of transfer
were 80s/40s, 78, 100/ra. He was AO to person only.
.
On arrival to the ICU he appeared comfortable. He was alert and
oriented to person and place. He denies any chest pain,
shortness of breath or abdominal pain. He has several family
members with him including 2 daughters and 1 [**Name2 (NI) 12496**]. They
believe the only thing that is bothering him right now is some
pain from a sacral ulcer.
.
Per family and review of records Mr. [**Known lastname 83312**] has been on a
steady decline first noticed last [**Holiday **] (when he slept
through the family [**Holiday **] party) and increasingly constant
over the past six months. Extensive involvement of palliative
team over goals of care, most recently [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**]) most
recently [**12-31**].
.
He has had prior GI workup for GI bleed with his most recent
scoped (both colonoscopy and EGD) in [**2113**]. These were notable
primarily for a small dulefoy lesion, diverticulosis, and
polyps.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies cough, shortness
of breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain. Denies dysuria, frequency, or
urgency.
Past Medical History:
Myasthenia [**Last Name (un) 2902**]
CAD s/p BMS to OM ([**2103**]), neg P-MIBI [**6-24**], mild diffuse 3VD on
Cath [**12-28**]
Permanent Atrial Fibrillation on coumadin
Aortic stenosis - echo [**2-28**] [86 mmHg peak, 56 mmHg mean)
Mild-moderate aortic regurgitation (Echo [**6-28**])
Mild-moderate mitral regurgitation (echo [**6-28**])
Moderate PA systolic hypertension (echo [**6-28**])
Dyslipidemia
Multiple knee replacements
Chronic Renal insufficiency (creatinine 1.6-1.9mg/dl)
Hematuria (S/p TURP, friable mucosa on cystoscopy [**2-28**])
Elevated homocysteine
Arthritis
Gout
GI bleeding (source not identified)
Dementia
Hypothyroidism
C. Diff colitis [**2-27**]
Social History:
Grew up in the [**Hospital3 4414**] in [**Location (un) 86**]. He was the 3rd of 7
children, retired pharmacist. Widower. Has 2 daughters and 3
grandchildren. Uses a walker, lives with daughter (though
recently at [**Name (NI) **]). He has never used tobacco, and drinks
[**3-22**] oz of wine once a week (Sunday) and holidays.
.
Family History:
- Father was a smoker who died in his 60s of lung cancer
- Mother suffered from chronic peripheral edema, died in her 80s
of MI, with h/o HTN, CHF, CAD
- Sister died of liver cancer
- Sister had a blood disorder
He has 2 daughters (54 years - PAF, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 16564**], mitral
regurgitation, low blood pressure; 57 years - low blood
pressure, obesity, spinal stenosis). Patient reports no family
history of colon cancer, prostate cancer, diabetes, CAD, or
depression.
Physical Exam:
Vitals: T: 96.6 BP: 94/64 P: 74 R: 21 O2: 100%/ra
General: Alert, oriented to place, no acute distress
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP at 7cm
Lungs: sparse scattered crackles at bases, no wheeze
CV: irregularly irregular, 3/6 SEM throughout precordium
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley with clear yellow urine
Ext: cool, faint pulses, 2+ edema bilaterally
Discharge exam
VS: Tm:97.3 T:96.3 BP:113/56 HR:64 RR:18 O2 Sats 100 on 2L
.
pain: none
GEN: patient awakes to voice, can follow simple commands,
remains somewhat lethargic, AAOX2 (knows name, DOB and place,
unsure of month, knows year today)
HEENT: MM somewhat dry, CN 2-12 grossly intact, no whitish
membrane at back of throat, just beefy red, has dried blood on
top of head which has been there for several days
NECK: no LAD, no obvious thyromegaly
CV: 3/6 systolic murmur, irregular
RESP: non labored, anterior lung fields mid to end expiratory
rhonchi and wheeze
ABD: obese, not TTP, sparse BS, no HSM
EXTR: PICC in right arm, CDI, not TTP, hands somewhat cold, mild
trace ble edema
neuro: 4+/5 strength in all extremities, sensation intact, MS
improved today
PSYCH: mood and affect wnl
Pertinent Results:
Labs on Admission:
[**2116-1-2**] 02:08PM WBC-7.5 RBC-2.06* HGB-6.2* HCT-19.4*# MCV-94#
MCH-30.1 MCHC-32.0 RDW-22.7*
[**2116-1-2**] 02:08PM PLT COUNT-158
[**2116-1-2**] 02:08PM PT-23.5* PTT-33.3 INR(PT)-2.2*
[**2116-1-2**] 01:01PM HGB-6.3* calcHCT-19
[**2116-1-2**] 12:50PM GLUCOSE-135* UREA N-94* CREAT-1.7*
SODIUM-150* POTASSIUM-4.1 CHLORIDE-116* TOTAL CO2-27 ANION
GAP-11
[**2116-1-2**] 12:50PM estGFR-Using this
Chest X-Ray:
Right PICC tip terminates in the lower SVC. Evaluation of the
cardiac silhouette size is difficult to assess given the
presence of bilateral moderate pleural effusions, right greater
than left, similar compared to the prior study. The heart size
though is likely enlarged. The aorta remains tortuous and
calcified. Bibasilar atelectasis persists. No pneumothorax is
present. IMPRESSION: Continued bilateral moderate pleural
effusions, right greater than left with bibasilar atelectasis.
Brief Hospital Course:
This is a [**Age over 90 **] year old gentleman with a history of severe AS, AF
recently on coumadin, CHF and dementia who is presenting with
severe anemia and hypotension in the setting of a GIB of unclear
etiology.
# Anemia/GIB: presented with an acute GI bleed, unclear if upper
or lower, has a history of prior upper GI lesion along with
diverticulosis. He was treated with blood products, PRBC's and
FFP, GI was consulted and the plan was discussed at length with
his family along with his primary care physician. [**Name10 (NameIs) 227**] his
multiple comorbidities and overall poor baseline health status
the decision was made not to pursue an endoscopic intervention.
The patient was re-started on IV PPI's because of his inability
to tolerate po medications and the families concerns that he was
symptomatic from reflux. The patient was also transfused at the
end of his hospitalization without incident with lasix following
transfusion. His discharge hemoglobin was 8.4, was transfused
at 7.6.
# Hypernatremia
The patient had been previously admitted for hypernatremia. The
patient is lethargic and fluctiations in sodium are likely
without any po intake. 1/2 NS was given to try and correct this
and was ineffective. It was stopped due to concerns of too much
volume with his TPN and blood products.
# Coagulopathy
This is likely due to poor nutrition. The patient was given
vitamin K and his INR corrected to 1.2 on discharge. Vitamin K
can be given on an as needed basis.
#CRF Stage III
Baseline appears 1.7-1.9 was at 1.4 at discharge. Was on
aranesp in past, unclear role at this time and not re-started.
[**Month (only) 116**] limit transfusion requirement in future.
.
##Dysphagia
Thought to be multifactorial (progressive dementia vs. MG),
PEG/G-tube defered 2 months ago. Last admission made NPO and on
TPN, will continue per families request. Electrolytes should be
checked 2-3 times a week to titrate the TPN.
.
#severe AS ([**Location (un) **] 0.6 cm) EF 50%
Continue supportive care, patient may need as need lasix 10 mg
IV for SOB QD. This was dosed previously at his last discharge.
The patient has required a minimal amount of oxygen while here
(1-3L NC).
.
##Myasthenia [**Last Name (un) 2902**] (MG)/Dementia
Was on pyridostigmine 60 Q8H, called pharmacy to see if this can
be given IV-can be given IV but only on short term basis-1.9 mg
Q3-4H because drug has a short half life and also has alcohol
based preservatives which can cause renal toxicity. Continue
supportive care.
.
##chronic AF
Not on AC due to inability to tolerate po coumadin, poor RF
precluded lovenox and now GIB also preculded AC. Patient
appears to be well rate controlled not on po medications
.
# Goals of Care: After initial decision was made not to pursue
an endoscopic intervention, palliative care was consulted to
help with further discussions about his goals of care given his
current GI bleed in the context of extensive medical
co-morbidities. A family meeting was held on [**2116-1-3**], with his
family, primary care physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], palliative care
and ICU team, where a decision was made to make the patient
comfort meausures only. After a long discussion between all
parties involved it was decided that he would remain on TPN as
per the families wishes. The following day on the medical
floor, the family decided to reverse the patient CMO and switch
to DNR/DNI with supportive care but no invasive procedures. A
family meeting was held again with Palliative care and the
family on [**2116-1-7**] and they decided that they wanted the patient
to continue to receive blood and IV medications.
Medications on Admission:
miconazole nitrate 2 % Powder [**Date Range **] [**Hospital1 **] groin
insulin lispro 100 unit/mL Solution as directed
glucagon (human recombinant) 1 mg Recon Soln as dir
heparin, porcine (PF) 10 unit/mL Syringe syringe IV PRN as
needed for line flush.
furosemide 10 mg/mL Solution [**Hospital1 **]: Ten (10) mg Injection once a
day: HOLD FOR SBP<100.
dextrose 50% in water (D50W) Syringe [**Hospital1 **]: as directed
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
TPN
Discharge Medications:
1. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin rash.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
3. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
4. phenol 1.4 % Aerosol, Spray [**Hospital1 **]: One (1) Spray Mucous
membrane Q6H (every 6 hours) as needed for sore throat.
5. acetaminophen 1,000 mg/100 mL (10 mg/mL) Solution [**Hospital1 **]: One
(1) Intravenous Q6H (every 6 hours) as needed for pain.
6. pantoprazole 40 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
7. furosemide 10 mg/mL Solution [**Hospital1 **]: Ten (10) mg Injection once
a day as needed for shortness of breath.
8. Outpatient Lab Work
Please check electrolytes QMWF to titrate TPN at LTAC
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 8**]
Discharge Diagnosis:
gastrointestinal bleeding of unknown origin
hypernatremia
malnutrion
failure to thrive
anemia
Discharge Condition:
Mental Status: Confused - sometimes, AAOX2.
Level of Consciousness: Lethargic but arousable for several
minutes then falls back asleep.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a GI bleed of unknown origin.
You intially were in the ICU for supportive care and blood
products. Your family elected not to pursue aggresive
interventions at this time. You were transfered to the medical
floor and your bloody bowel movements decreased. You continued
to receive TPN and blood products on the floor. You hemoglobin
increased appropriately to blood products the night prior to
discharge.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 665**] in [**1-20**] weeks, please call at
[**Last Name (LF) **],[**First Name3 (LF) 251**] D. [**Telephone/Fax (1) 250**]
Department: CARDIAC SERVICES
When: THURSDAY [**2116-3-5**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**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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10145, 10636
|
12098, 12552
|
4187, 5429
|
2329, 2600
|
187, 195
|
267, 2310
|
5468, 6380
|
11924, 12074
|
2622, 3296
|
3312, 3644
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,206
| 152,305
|
460
|
Discharge summary
|
report
|
Admission Date: [**2138-9-2**] Discharge Date: [**2138-9-7**]
Date of Birth: [**2073-1-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
CC:[**CC Contact Info 3898**]
Major Surgical or Invasive Procedure:
s/p anterior cervical discectomy C2-C3
History of Present Illness:
HPI: 65M was outdoors cutting tree branch when 700# branch hit
him on the head. He was found upside down in his harness with
the
branch on the ground. Found to have L occipital laceration that
was stapled at OSH. GCS 15. Transferred to [**Hospital1 18**] for further
evaluation.
Past Medical History:
htn
Social History:
lives alone
ex wife lives on [**Location (un) 945**]
Family History:
unknown
Physical Exam:
On arrival
PHYSICAL EXAM:
afeb 68 145/70 22 96%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: R 2.5->2mm, L 4->3.5mm, anisocoria from prior L
eye injury according to pt, [**Name (NI) 3899**], L occipital staples.
Neck: Supple. No C-spine tenderness. No neck pain.
Lungs: CTAB.
Cardiac: RRR. nl S1/S2.
Abd: +BS, S, NT/ND.
Extrem: Warm and well-perfused. No cyanosis, clubbing, or edema.
Neuro:
Mental status: AA+Ox3, cooperative with exam, normal affect.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Anisocoric pupils, reactive to light.
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
or
tremors detected. Strength full power [**4-26**] throughout. No
pronator
drift. No Babinski. No clonus.
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 2+ 2+
Left 2+ 2+
Toes downgoing bilaterally.
currently on this day of discharge -
pt is aaox3
non focal neuro exam
ambulatory
pain controlled
speech clear
Pertinent Results:
RADIOLOGY Preliminary Report
MR HEAD W & W/O CONTRAST [**2138-9-6**] 3:44 PM
MR HEAD W & W/O CONTRAST
Reason: rule out infarct or underlying lesion
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with hypodensity within the left cerebellum
REASON FOR THIS EXAMINATION:
rule out infarct or underlying lesion
CONTRAINDICATIONS for IV CONTRAST: None.
MR HEAD
HISTORY: 65-year-old man with left cerebellar hypodensity,
assess for infarct or underlying lesion.
TECHNIQUE: Multiplanar multisequence MR images of the head were
obtained before and after the administration of IV gadolinium.
FINDINGS: Comparison is made to prior head CT from [**2138-9-3**] and
[**2138-9-2**] as well as a prior MR of the cervical spine from
[**2138-9-3**].
There is a small area of T2 hyperintensity with slow diffusion
involving the left cerebellum corresponding to the hypodensity
seen on CT scan. This finding likely represents an infarct.
There is also a small area of T2 hyperintensity and slow
diffusion involving the left inferior posterior temporal lobe
just above the temporal bone which likely represents an area of
contusion. Another small area of T2 hyperintensity with some
minimal slow diffusion and enhancement is seen along the left
lateral temporal lobe which also likely represents an area of
contusion.
Small bilateral subdural hematomas are seen over the temporal
poles as well as a small subdural hematoma over the right
frontal lobe. Tiny amount of blood within the occipital horns of
the lateral ventricles are seen which is decreased in size
compared to [**2138-9-3**].
The previously seen fluid-fluid level within the cisterna magna
is not seen on this study.
There is a minimal amount of deep and periventricular white
matter T2 hyperintensities which likely represents chronic
microangiopathic changes. The ventricles and extra-axial CSF
spaces are unchanged in size or configuration.
Mucosal thickening of the visualized paranasal sinuses are seen.
IMPRESSION:
1. Infarct of the left cerebellum corresponding to the
hypodensity seen on CT scan.
2. Few small contusions of the left temporal lobe.
3. Small bilateral subdural hematomas and decreasing amount of
blood within the occipital horns of the lateral ventricles.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
RADIOLOGY Final Report
CT ORBIT, SELLA & IAC W/O CONTRAST [**2138-9-6**] 4:22 PM
CT ORBIT, SELLA & IAC W/O CONT
Reason: further eval temporal bone fracture, temporal bone CT
per EN
[**Hospital 93**] MEDICAL CONDITION:
65 M s/p head trauma, c/o hearing loss
REASON FOR THIS EXAMINATION:
further eval temporal bone fracture, temporal bone CT per ENT
CONTRAINDICATIONS for IV CONTRAST: None.
CT ORBIT.
HISTORY: 65-year-old male with trauma complains of hearing loss.
TECHNIQUE: CT of the temporal bones was performed with 1.25 mm
axial and coronal and oblique sagittal reconstructions.
FINDINGS: Comparison is made to a prior head CT from [**2138-9-2**] as
well as a concurrent head MR.
The scout images show a new anterior fixation and screws over C2
and C3. There is overlying prevertebral soft tissue swelling,
which likely represents post- surgical change.
Again seen are multiple fractures of the right temporal bone
with approximately 2-mm depression of the bony fragment. One of
the fracture lines extends to the floor of the right middle
cranial fossa but does not appear to extend into any of the
skull base foramina or carotid canal. A nondisplaced fracture of
the right zygomatic arch is again seen.
No fractures extending into the mastoid air cells, middle ear
cavities, inner ear structures are noted. The mastoid air cells
and middle ear cavities are clear. There is no dislocation of
the ossicles. The inner ear structures appear normal.
Calcification of the carotid siphons is seen bilaterally.
There is depression of the right nasal bone.
Minimal mucosal thickening of the maxillary sinuses and the
ethmoid air cells are seen bilaterally. There is moderate
mucosal thickening of the sphenoid sinus. Incidental note is
made of Onodi cells bilaterally with pneumatization of the optic
struts.
Several periapical lucencies around maxillary teeth are seen
which may represent periodontal disease versus periapical
inflammatory lesions.
Note is again made of two small hemorrhagic contusions of the
left temporal lobe and a small hypodensity of the left
cerebellum. Small subdural hematomas of the overlying temporal
lobes bilaterally are again seen.
IMPRESSION: Again visualized is a minimally depressed fracture
of the right temporal bone as well as a nondisplaced fracture of
the right zygomatic arch.
Two small left temporal lobe hemorrhagic contusions, infarct of
the left cerebellum, and small bilateral subdural hematomas are
again seen.
The middle ear cavities and inner ear structures are intact.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SUN [**2138-9-7**] 2:23 PM
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2138-9-5**] 9:47 AM
CHEST (PA & LAT)
Reason: eval for fever source
[**Hospital 93**] MEDICAL CONDITION:
65M POD1 s/p ACDF C2-3, spiking to 103.7 no apparent source
REASON FOR THIS EXAMINATION:
eval for fever source
HISTORY: 65-year-old male one day following spinal surgery with
fever of 103.7.
COMPARISON: None available.
TWO VIEWS OF THE CHEST: Bilateral basilar atelectasis is likely
a postoperative finding. Mild cardiomegaly may be suggestive of
longstanding hypertension. No pneumothorax or effusion is
identified. There is no focus of consolidation to suggest
pneumonia.
IMPRESSION: Bilateral basilar atelectasis, likely postoperative.
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Cardiology Report ECG Study Date of [**2138-9-4**] 11:56:32 PM
Sinus rhythm. Left anterior fascicular block. Non-specific
lateral ST-T wave
changes. Compared to the previous tracing of [**2138-9-4**] no
significant change.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 198 90 366/415 43 -39 104
RADIOLOGY Final Report
MR CERVICAL SPINE W/O CONTRAST [**2138-9-3**] 11:52 PM
MR CERVICAL SPINE W/O CONTRAST
Reason: eval for ligamentous injury
[**Hospital 93**] MEDICAL CONDITION:
65M s/p closed R temporal fx, pneumocephalus, epidural hematoma
C2-3 w indentation of cord, ?C3 fx
REASON FOR THIS EXAMINATION:
eval for ligamentous injury
MR CERVICAL SPINE
HISTORY: 65-year-old male status post closed right temporal
fracture with epidural hematoma at C2/3, question C3 fracture.
Evaluate for ligamentous injury.
TECHNIQUE: Sagittal T1, T2, STIR of the cervical spine extending
from the skull base to the T1/2 level and axial T2 and GRE
images extending from the mid C2 through the C7/T1 levels were
obtained.
FINDINGS: Comparison is made to CT of the cervical spine from
[**2138-9-2**] as well as a head CT from that same date.
The alignment of the cervical spine is normal. There is no loss
of vertebral body heights or intervertebral disc space heights.
There is no prevertebral soft tissue swelling or edema. The
visualized bone marrow signal is normal. There is no evidence of
ligamentous disruption or injury.
The visualized brainstem, cervical cord, and upper thoracic cord
are normal in signal intensity and caliber.
Within the cisterna magna, there is a fluid-fluid level
consistent with layering hemorrhage. Along the left side of the
spinal canal, there is a T1 and T2 intermediate signal intensity
lesion with some blooming on the gradient echo images extending
from the mid portion of C2 through the C3 levels and measuring
approximately 3.3 x 0.9 cm in its greatest craniocaudal and AP
dimensions. This finding most likely represents hemorrhage. This
hemorrhage is distorting the left ventrolateral aspect of the
adjacent cord. This hemorrhage appears to be located within the
thecal sac as opposed to in the epidural space. This hemorrhage
may be either subdural or subarachnoid in location.
Within the superior left cerebellum is a small area of T2
hyperintensity, which may represent an area of contusion.
IMPRESSION:
1. No evidence of ligamentous injury. No bone marrow edema or
loss of vertebral body heights.
2. Either left-sided subdural or subarachnoid hemorrhage
extending from the C2 to the C3 level.
3. Fluid-fluid level within the posterior fossa, which likely
represents a subdural hematoma.
4. Small T2 hyperintensity of the left superior cerebellum,
which may represent an area of contusion.
COMMENT: The above findings were discussed with the trauma team
on [**2138-9-3**] at 11:00 a.m.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: WED [**2138-9-3**] 11:10 AM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2138-9-3**] 5:44 PM
CT HEAD W/O CONTRAST
Reason: please perform exam at 1700 on [**2138-9-3**], please evaluate
for
[**Hospital 93**] MEDICAL CONDITION:
65 year old struck by large tree branch, + LOC
REASON FOR THIS EXAMINATION:
please perform exam at 1700 on [**2138-9-3**], please evaluate for
intracranial pathology
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Struck by a large tree branch and loss of
consciousness.
COMPARISON: CT head [**2138-9-2**].
FINDINGS: Compared to a day prior, there is more obvious
layering blood within the posterior horns of the lateral
ventricles bilaterally. A previously described focus of high
density within a sulcus of the right temporal lobe (2:19) is
likely not significantly changed and may represent a small
amount of subarachnoid hemorrhage. A right middle cranial fossa
hematoma does not appear to have significantly changed in size.
More obvious today compared to a day prior is an approximately
13- mm focus of hypodensity within the left cerebellum.
Previously described fractures including a right temporal bone
fracture extending to the skull base and right zygoma fractures
are better evaluated on the initial trauma head CT. High-density
opacification within the sphenoid sinus and mucosal thickening
within the maxillary and ethmoid sinus is again noted. Left
parietal occipital skin staples are in place with associated
swelling.
IMPRESSION:
1. High-density blood layering within the posterior horns of
lateral ventricles bilaterally is new. Unchanged appearance of
possible right temporal small subarachnoid blood and subdural
blood within the right middle cranial fossa.
2. More obvious small focus of hypodensity within the left
cerebellum may represent axonal injury or evolving infarct. MRI
may be helpful to further characterize as clinically indicated.
3. Multiple skull fractures, better evaluated on the initial
trauma head CT.
Findings discussed with Dr. [**Last Name (STitle) 3903**] at the time of dictation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: [**Doctor First Name **] [**2138-9-4**] 2:24 PM
Brief Hospital Course:
Pt was admitted to the sicu after initial ER eval. Follow up CT
and MRI's were ordered. He was maintained in a cervical collar.
CT scan revealed Epidural hematoma in cervical spine. Follow
up head Ct was stable. He was transferred to the floor on
hospital day # 3. MRI revealed a large left sided HNP and he
was taken to the OR for and ACD at C23 on [**2138-9-4**]. His post
operative course has been uneventful. He did have a small
subcutaneous hematoma on [**2138-9-5**] but this has remained stable.
He was seen by ENT for c/o decreased hearing in the left ear.
Their recommendations were followed and he will follow up with
them in 1 week with audiologic testing. I reviewed CT results
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] today who states that there is no fracture
that extends through any vascular channels. He id have post op
fever on day 2 and cultures will be followed up. Urine analysis
is negative for infection/ He agrees with the plan for d/c home
today.
Medications on Admission:
lisinopril
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Neomycin-Polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops,
Suspension Sig: Four (4) Drop Otic TID (3 times a day) for 4
days.
Disp:*1 1* Refills:*0*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Spinal epidural hematoma
s/p anterior cervical discectomy C2-C3
Right temporal bone fracture / non displaced / closed fracture
decreased left hearing
Discharge Condition:
neurologically stable
Discharge Instructions:
?????? Do not smoke
?????? Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
?????? If you have steri-strips in place ?????? keep dry x 72 hours. Do
not pull them off. If they have not fallen off in 2 weeks time,
you may remove them yourself
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for signs of
infection or swelling / IF YOUR VOICE GETS HOARSE OR YOUR
SWALLOWING IS DIFFICULT OR YOU ARE DROOLING GO TO THE NEAREST
EMERGENCY ROOM OR CALL 911
?????? You may shower briefly without the collar / back brace unless
instructed otherwise
?????? 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
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? 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 - YOU ARE TO LIGHT ACTIVITIES
FOR 6 WEEKS AND NO WORKING FOR 3 MONTHS - PLEASE CALL DR
[**Last Name (STitle) **] IF YOU HAVE ANY QUESTIONS.
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
?????? 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
Followup Instructions:
ENT in 1 week with Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) **] with audiology
testing
Follow up with your PCP with regards to your hospitalization and
BP control. Take your blood pressure medication as previously
ordered.
Dr. [**Last Name (STitle) **] in 6 weeks with xrays of your c-spine at
[**Telephone/Fax (1) **]
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2138-9-7**]
|
[
"997.3",
"401.9",
"801.26",
"E878.8",
"E916",
"805.02",
"802.4",
"801.16",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.51",
"81.02",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
15371, 15377
|
13708, 14725
|
347, 388
|
15571, 15595
|
2258, 2433
|
17621, 18080
|
810, 820
|
14786, 15348
|
11541, 11588
|
15398, 15550
|
14751, 14763
|
15619, 17598
|
861, 1227
|
278, 309
|
11617, 13685
|
416, 697
|
1420, 2236
|
1242, 1404
|
719, 724
|
740, 794
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,952
| 160,186
|
5120
|
Discharge summary
|
report
|
Admission Date: [**2128-5-11**] Discharge Date: [**2128-5-14**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 yo M with a past medical history of ESRD on HD, DM1, CHF
presents from HD with nausea and vomitting. History is unclear
because patient is unresponsive, but history is gathered from
family members and [**Name (NI) **] documentation. Mr. [**Known lastname **] has a history of
noncompliance, and evidently skipped HD on Saturday. He was
found to be weak this morning, and his brother brought him to
HD. At HD, patient was noted to have periorbital edema. He
received 45 minutes of HD and developed nausea and vomitting x1.
Vomitus was grossly nonbloody and guaiac positive, so he was
transferred to [**Hospital1 18**].
.
According to the family, patient was supposed go to HD on
saturday (last HD was the previous Thurday), but did not tell
family why he was not going. They noticed that his face and eyes
were swollen, and sugar was noted to be elevated. He had reduced
po intake over the last 4 days. He was not complainig of
particular symptoms including fevers, chest pain, palpitations
or lightheadedness.
.
At [**Hospital1 18**], patient was A and O x3 but belligerent and refusing
labs and venous access. His HCP was called, and because there
was a question of competence in the past, sister gave approval
to sedate and restrain as needed for appropriate workup. He was
given Haldol 5 mg IM and Ativan 2 mg IM and placed in 4 point
restraints. An 18 G IV was obtained. Serum glucose was found to
be 815 with a gap of 17, so IV insulin 10 U was given. He did
not receive fluids because of concern that the patient is
anuric. Patient refused a rectal, but there was a report of
loose stool last week before the patient was chemically sedated.
CXR was reportedly normal. Blood culture were sent. On transfer,
patient was unresponsive but maintaing his airway, with VS 95,
95/62, 14, 96% RA
.
In the ICU, patient is unresponsive but appears comfortable.
.
Review of sytems:
Not assessed due to mental status.
Past Medical History:
1. Type 1 diabetes with insulin autoantibody receptor syndrome
-since age 16 on insulin, followed by Dr. [**Last Name (STitle) 10088**]
[**Name (STitle) 21002**] hypoglycemic episodes, has required intubation for
altered MS in the past
-high level of anti-insulin Ab
-complicated by nephropathy
-complicated by retinopathy (s/p right eye laser surgery,
repeated [**8-2**])
-on immunosuppression ?? no records at [**Hospital1 18**]
2. End-stage renal disease on dialysis TuThSa
3. Diastolic heart failure
4. Hypertension,
5. Hyperlipidemia
6. Peripheral vascular disease
7. Hypothyroidism
8. Anemia
9. Recent burn on his left upper extremity, now s/p skin graft
10. S/p left first toe distal phalangectomy in [**2127-9-28**]
11. Pancreatic lesions seen on an abdominal CT done in [**2127-5-28**]
Social History:
Lives with parents. Works in construction. No alcohol, drugs, or
tobacco. He has never been married and has two adult children.
His mother is a nurse and helps him managing his medications. He
worked in construction but was laid off.
Family History:
Per OMR, history of DM (Type 1 and 2), RA and HTN.
Mother - Type 2 Diabetes [**Year (4 digits) **], Rheumatoid Arthritis
Maternal Aunt - Type 2 Diabetes [**Name (NI) **]
Nephew - Type 1 Diabetes [**Name (NI) **]
Physical Exam:
Vitals: T: 95.7 ax BP: 144/74 P: 102 R: 8 O2: 98% RA
General: Unresponsive to verbal stiumuli or sternal rub
HEENT: nonicteric sclerae, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, 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:
[**2128-5-11**] 09:40AM BLOOD WBC-4.7 RBC-4.66 Hgb-12.5* Hct-42.0
MCV-90 MCH-26.9* MCHC-29.9* RDW-13.9 Plt Ct-176
[**2128-5-11**] 09:40AM BLOOD Neuts-49* Bands-0 Lymphs-45* Monos-5
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2128-5-11**] 10:19AM BLOOD Glucose-815* UreaN-39* Creat-6.3*# Na-133
K-7.0* Cl-99 HCO3-17* AnGap-24*
[**2128-5-11**] 08:24PM BLOOD ALT-57* AST-20 CK(CPK)-55 AlkPhos-176*
TotBili-0.5
[**2128-5-11**] 08:24PM BLOOD CK-MB-6 cTropnT-0.31*
[**2128-5-12**] 10:00AM BLOOD CK(CPK)-56
[**2128-5-12**] 10:00AM BLOOD CK-MB-4 cTropnT-0.28*
[**2128-5-11**] 04:46PM BLOOD Calcium-9.0 Phos-4.8*# Mg-2.0
[**2128-5-11**] 04:46PM BLOOD Acetone-SMALL Osmolal-339*
[**2128-5-13**] 07:00AM BLOOD TSH-6.2*
[**2128-5-11**] 04:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2128-5-12**] 6:50 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2128-5-15**]**
FECAL CULTURE (Final [**2128-5-14**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2128-5-14**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final [**2128-5-15**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2128-5-14**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2128-5-14**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2128-5-12**]):
REPORTED BY PHONE TO [**Doctor First Name 5257**] FOLEY [**2128-5-12**] 2:50PM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
CXR: No evidence of volume overload.
Brief Hospital Course:
The patient was found to have serum glucose 815 with gap of 17
and was started on an insulin drip for treatment of diabetic
ketoacidosis and admitted to MICU. At this time, the patient
allegedly endorsed active SI and was agitated, requiring
restraints and haloperidol/lorazepam for sedation. Gap was
gradually closed overnight and patient remained hemodynamically
stable. Patient noted to have loose stools in the MICU, found
to be C. difficile positive with no evidence of severe
infection; he was started on Flagyl. His insulin regimen was
titrated with input from the endocrinologists at [**Last Name (un) **]. The
patient remained cryptic as to why he had not been compliant
with his insulin regimen but was cooperative for the remainder
The patient was seen by Psychiatry during the admission due to
his alleged endorsement of SI; however, at the time of
assessment patient repeatedly denied SI. Psychiatry noted that
his father is the patient's guardian, as established in court,
and that his guardian's wishes should determine medical
management.
Following his MICU stay, the patient's blood pressures remained
low but stable as long as most of his blood pressure medications
were held. The patient had no evidence of sepsis; it was felt
that his blood pressure may have been [**12-30**] fluid removal during
dialysis. At the time of discharge, given that the patient's
blood pressures had ranged in the low 100s systolic on a
beta-blocker alone, we discontinued the patient's other
anti-hypertensives on discharge. His blood pressure should be
followed on an outpatient basis and his regimen uptitrated as
warranted.
Medications on Admission:
(per last d/c summary)
# Prednisone 10 mg daily
# Rosuvastatin 20 mg daily
# Minoxidil 5 mg [**Hospital1 **]
# Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID
# Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY
# Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
# Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
# Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
# Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H prn
# Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
# Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
# Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
# Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO once a day as needed for constipation.
# B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
# Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One
(1)capsule, Delayed Release(E.C.) PO twice a day.
# Levemir 8 units Subcutaneous qAM.
# Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) prn
# Bisacodyl 5-10 mg Tablet daily
# Senna 8.6 mg po BID
# Docusate Sodium liquid
# Acetaminophen 325 mg po Q6H prn
# Simethicone 80 mg QID PRN
# Metoclopramide 10 mg po QID prn
# Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
# Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
# Insulin Lispro 100 unit/mL Cartridge as directed
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Polyethylene Glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO once a day as needed for constipation.
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-29**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for
Constipation.
13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
14. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO
three times a day.
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 11 days.
Disp:*34 Tablet(s)* Refills:*0*
17. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous every morning.
Disp:*QS for 1 month * Refills:*0*
18. Insulin Lispro 100 unit/mL Solution Sig: PER SLIDING SCALE
Subcutaneous FOUR TIMES A DAY AS DIRECTED.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. diabetic ketoacidosis
2. hypotension
3. clostridium difficile diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen at [**Hospital1 18**] for diabetic ketoacidosis. You were
treated with insulin and your symptoms improved. You were seen
by the diabetes specialists at [**Last Name (un) **] and your insulin regimen
was adjusted.
You were found to have a low blood pressure during your
hospitalization. We discontinued some of your blood pressure
medications. Your primary care doctor may decide to restart
some of these medications at a later date.
You were complaining of diarrhea during your hospitalization.
We found out that you had an infection with Clostridium
difficile, which is likely causing your diarrhea. You were
started on antibiotics for this diarrhea and should continue to
take antibiotics after you are discharged from the hospital.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following medications were changed:
ADDED metronidazole (flagyl) for treatment of your diarrhea
ADDED insulin glargine
CHANGED insulin humalog sliding scale
DISCONTINUED insulin detemir (levemir)
DISCONTINUED minoxidil
DISCONTINUED diltiazem
DISCONTINUED doxazosin
Followup Instructions:
Department: ADVANCED VASC. CARE CNT
When: MONDAY [**2128-5-17**] at 1 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], Nurse
When: MONDAY, [**6-7**], 11AM.
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Department: [**Hospital3 249**]
When: MONDAY [**2128-6-14**] at 2:35 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2128-5-17**]
|
[
"272.4",
"349.82",
"244.9",
"428.0",
"008.45",
"585.6",
"250.13",
"362.01",
"403.91",
"250.43",
"V45.11",
"428.32",
"250.53"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10839, 10896
|
5951, 7589
|
276, 282
|
11033, 11033
|
4096, 5928
|
12324, 13272
|
3313, 3527
|
9156, 10816
|
10917, 10917
|
7615, 9133
|
11184, 12301
|
3542, 4077
|
230, 238
|
2189, 2226
|
310, 2171
|
10936, 11012
|
11048, 11160
|
2248, 3046
|
3062, 3297
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,991
| 187,693
|
9732
|
Discharge summary
|
report
|
Admission Date: [**2193-4-3**] Discharge Date: [**2193-4-7**]
Date of Birth: [**2153-3-25**] Sex: F
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: A 40-year-old female with
history of non-ST-elevation myocardial infarction in [**2192-7-6**] with stent to the LAD and 50% to the mid LAD, had
instent restenosis in [**2193-1-6**] and then underwent
brachytherapy to the RCA, who presented to [**Hospital3 417**]
with several weeks of chest pain similar to her anginal
equivalent and MI in the past. It started at rest. No
relief with nitroglycerin x3. Radiates to the left arm.
Positive shortness of breath. Troponins have been less than
0.01. With history, will go for cardiac catheterization
evaluation. Still getting chest pain intermittently, but
relieved by morphine sulfate. Was on a Heparin and
nitroglycerin drip with only intermittent relief.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Obesity.
3. Hypertension.
4. Tobacco history.
5. Coronary artery disease: [**2192-7-6**] non-ST-elevation
myocardial infarction, 100% RCA, three stents, 50% mid LAD.
[**2193-1-6**] instent restenosis status post
brachytherapy.
6. GERD.
7. Asthma.
8. Sciatica.
9. Degenerative joint disease.
10. Glomerulosclerosis.
FAMILY HISTORY: Brothers with [**Name2 (NI) 499**] cancer and a MI. Father
with emphysema. Mother with lung cancer.
SOCIAL HISTORY: Quit tobacco in [**2192-7-6**]. Occasional
alcohol. Lives with her 6-year-old daughter.
ALLERGIES: Aspirin under which she develops worsening of her
shortness of breath and asthma flare, tetracycline, sulfa,
Demerol.
MEDICATIONS:
1. Diovan 106 mg q.d.
2. Advair 500/50 two puffs b.i.d.
3. Plavix 75 mg q.d.
4. Crestor 20 mg q.d.
5. Neurontin 300 mg t.i.d.
6. Prilosec 20 mg b.i.d.
7. Vicodin as needed.
8. Trazodone 50 mg q.d.
9. Singulair 10 mg q.d.
10. Flexeril 10 mg t.i.d.
11. Lopressor 75 mg b.i.d.
12. Humibid 3600 b.i.d.
13. Colace 100 mg b.i.d.
14. Zetia 10 mg q.d.
15. Benadryl as needed.
16. Tricor 106 mg q.d.
17. Premarin 0.3 mg q.d.
18. Prozac 40 mg q.d.
19. Omega-3 fatty acids t.i.d.
PHYSICAL EXAM: 82, 119/60, 22, and 99% on room air. Well
appearing in no apparent distress. Pupils are equal, round,
and reactive to light. Moist mucous membranes. No JVD.
Regular rate and rhythm. Positive tenderness to sternum.
Chest was clear to auscultation bilaterally. Abdomen:
Obese, soft. Extremities show no edema, 2+ dorsalis pedis,
1+ femoral pulses.
LABORATORIES: Troponin-T less than 0.01.
EKG: Sinus, 84, normal axis, QTc 430, Q's in III and aVF, no
ST changes as compared to [**2193-2-4**] EKG.
HOSPITAL COURSE:
1. Chest pain: The patient ruled out for myocardial
infarction. However, with her history of disease, patient
underwent a cardiac catheterization. The patient was found
at cardiac catheterization to have mild diffuse instent
restenosis in the mid stent, otherwise hemodynamically normal
and the coronary arteries otherwise were without
flow-limiting stenoses.
The patient was then continued on her cardiac medications.
It was felt that if we attempted aspirin desensitize her
while an inpatient, then she would benefit from the use of
aspirin and Plavix. The patient was sent to the CCU and
underwent aspirin desensitization protocol, which she tolerated
well. She had mild worsening of her asthma attacks, which was
relieved by Benadryl and occasionally albuterol. The patient
found that if she took the aspirin in the evening with her
Benadryl that she takes for sleep, that the asthma exacerbation
did not occur. Aspirin no longer should be considered an allergy
for this patient, and she is going to take this as an outpatient.
2. Hyperlipidemia: The patient's Lipitor was increased to 80
mg q.d.
3. Back pain: This is a chronic issue and was controlled
with Flexeril and Vicodin.
DISPOSITION: To home.
DISCHARGE STATUS: Patient is able to ambulate without any
chest pain or discomfort. Can carry out all activities of
daily living.
DISCHARGE MEDICATIONS:
1. Metoprolol 100 mg b.i.d.
2. Plavix 75 mg q.d.
3. Advair 550 mcg two puffs b.i.d.
4. Neurontin 300 mg t.i.d.
5. Protonix 40 mg q.d.
6. Montelukast 10 mg q.d.
7. Bethanechol 25 mg b.i.d.
8. Docusate sodium 100 mg b.i.d.
9. Zetia 10 mg q.d.
10. Estrogen 0.3 mg q.d.
11. Fluoxetine 40 mg q.d.
12. Vicodin 5-500 mg tablets q.4-6h. as needed for pain.
13. Cyclobenzaprine 10 mg tablet one tablet orally t.i.d.
14. Atorvastatin 80 mg q.d.
15. Valsartan 320 mg q.d.
16. Aspirin one q.d.
17. Benadryl as needed.
FOLLOWUP: The patient will follow up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 29478**], [**Telephone/Fax (1) 3183**] in two weeks by calling
to schedule an appointment.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 610**] 12-[**Doctor First Name **]
Dictated By:[**Name8 (MD) 26705**]
MEDQUIST36
D: [**2193-4-7**] 11:35
T: [**2193-4-9**] 05:14
JOB#: [**Job Number 32856**]
|
[
"272.0",
"401.9",
"414.01",
"786.59",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
1279, 1382
|
4020, 4987
|
2643, 3997
|
2120, 2626
|
184, 895
|
917, 1262
|
1399, 2104
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,074
| 157,155
|
49133
|
Discharge summary
|
report
|
Admission Date: [**2128-8-10**] Discharge Date: [**2128-8-13**]
Date of Birth: [**2076-2-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
tachycardia, worsened right sided chest/abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 year old female with history of hyperlipidemia, hypretension
and colon cancer treated previously with surgery, chemo (FOLFIRI
plus Avastin, previously treated with FOLFOX)and XRT in [**State 9512**]
(approx 1 month ago) with known metastases and progresion of
disease, for which no longer treatment is being received. She
came to [**Location (un) 86**] a few days ago from [**State 9512**] for 2nd opinion and
currently living with her sister. She presents with right sided
trunk (chest & abd) pain along with tachycardia. She has had
ongoing pleuritic right chest pain for 1 month. Also admits to
productive cough. She denies any central chest pain. She denies
any dizziness. She is unable to walk at baseline secondary to
weakness and per her family this has been the case for quite
some time. She is on Vicodin for her pain but in the last 2 days
the pain has been worse. She denies fevers.
Past Medical History:
- colon cancer [**2123**] s/p LN dissection [**2126**]
- hypertension
- Hypercholesterolemia
- nerve system problem, wheelchair bound since [**2111**], describes
that started in her legs and feels numbness/tingling and has
weakness.
Social History:
Single and lives alone. Has 7 children. Came from [**State 9512**] to
[**Location (un) 86**] on Saturday. Was a homemaker. Now living with her sister
in [**Name (NI) 86**]. She has a cousin as well here.
- Tobacco: past smoker, 20 pack year history
- Alcohol: negative
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: 129/76, 126 HR, 98/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breathsounds right base. Otherwise clear.
CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Surgical
scar midline inferior to umbilicus with smaller RUQ scars
GU: foley in place
Skin: Hickman left chest wall with very mild surrounding
erythema, femoral CVL right appears normal
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:
Vitals: 98, 150/85, 105 (90's-100's) regular, RR 14, Sat% 98RA
General: Alert, orientedx3, no acute distress, lying semi-flat
in bed
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: It was difficult to auscultate to her back comfortably
given her neurological condition. Overall air entry is faint
bilaterally posteriorly, right worse than left. no wheezes heard
but fine insp crackles at the right base and axilla.
CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Surgical
scar midline inferior to umbilicus with smaller RUQ scars
Skin: Hickman catheter removed, no tenderness or erythema
Extremities: warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema. hand and feet contracture
Neuro: AOx3, power in proximal muscles in both upper extremities
4+/5. power of proximal muscles in both lower extremties 3+/5.
Pertinent Results:
CBC and coags:
[**2128-8-10**] BLOOD WBC-9.1 RBC-3.77* Hgb-11.1* Hct-31.7* MCV-84
MCH-29.4 MCHC-35.0 RDW-13.0 Plt Ct-368
[**2128-8-12**] BLOOD WBC-9.4 RBC-3.72* Hgb-11.0* Hct-31.3* MCV-84
MCH-29.5 MCHC-35.0 RDW-13.0 Plt Ct-381
[**2128-8-11**] BLOOD PT-13.8* PTT-34.8 INR(PT)-1.2*
[**2128-8-12**] BLOOD PT-13.2 PTT-34.6 INR(PT)-1.1
.
Blood Chemistry:
[**2128-8-10**] BLOOD Glucose-114* UreaN-9 Creat-0.4 Na-138 K-3.9
Cl-103 HCO3-25 AnGap-14
[**2128-8-12**] BLOOD Glucose-90 UreaN-7 Creat-0.4 Na-136 K-4.7 Cl-98
HCO3-27 AnGap-16
[**2128-8-10**] BLOOD ALT-14 AST-22 LD(LDH)-247 CK(CPK)-214* AlkPhos-93
TotBili-0.5
[**2128-8-12**] BLOOD ALT-13 AST-20 LD(LDH)-263* AlkPhos-113*
TotBili-0.5
[**2128-8-10**] BLOOD Lactate-1.0
.
Troponin:
[**2128-8-10**] 11:30AM BLOOD cTropnT-<0.01
[**2128-8-11**] 03:22AM BLOOD CK-MB-2 cTropnT-<0.01
[**2128-8-10**] 11:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
[**2128-8-12**] 07:10AM BLOOD Albumin-3.4* Calcium-9.3 Phos-3.7 Mg-2.2
.
Iron, B12 and folate:
[**2128-8-11**] 03:22AM BLOOD calTIBC-207* VitB12-412 Folate-16.5
TRF-159*
.
Urine:
[**2128-8-10**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-10 Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
[**2128-8-10**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
.
Oncology:
[**2128-8-12**] BLOOD CEA-449*
.
Micro:
blood culture [**8-10**] pending
.
Images:
CT torso with contrast [**2128-8-10**]:
IMPRESSION:
1. No evidence of pulmonary embolus, as clinically questioned.
2. Extensive loculated right pleural fluid, with multiple foci
of nodular
pleural enhancement, concerning for malignant pleural disease.
3. Consolidation of the right middle and right lower lobes, with
markedly
heterogeneous attenuation of the lung parenchyma including
multiple areas of non-enhancement which appear mass-like,
possibly reflecting the presence of necrotic metastases
(suggested by the presence of additional bilateral pulmonary
nodules) versus necrotizing pneumonia, or a combination of the
above.
4. Multiple low-attenuation liver lesions, necrotic mediastinal
lymph nodes
and numerous additional pulmonary nodules, all concerning for
additional sites of metastatic disease.
5. Cholelithiasis.
.
CXR [**2128-8-10**]:
Large right-sided pleural effusion with associated atelectasis,
cannot exclude developing infectious infiltrate, aerated right
and left lung are within normal limits, levoconcave scoliosis
.
EKG: sinus tachycardia rate 125, NANI, TWF I, avL, V4-V6, TWI
II, III and avF. Respiratory variation to QRS height.
.
ECHO [**2128-8-11**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(?? LVEF 50%). The number of aortic valve leaflets cannot be
determined. The mitral valve leaflets are not well seen. There
is a very small circumferential, predominantly anterior
pericardial effusion. There are no echocardiographic signs of
tamponade (based on absence of respiratory variation of MV/TV
inflow as RV could not be well visualized).
IMPRESSION: Very poor technical quality. Left ventricular
function is probably normal, a focal wall motion abnormality
cannot be fully excluded. The right ventricle is not well seen.
No pathologic valvular abnormality seen. Pulmonary artery
systolic pressure could not be determined.
.
CXR [**2128-8-12**]:
AP UPRIGHT VIEW OF THE CHEST: Hickman catheter terminates in the
upper SVC,
as before. Moderate-to-large right-sided pleural effusion has
increased
compared to the prior exam. Apparent widening of the mediastinum
is related
to pleural fluid tracking along the medial aspect of the right
upper lung.
There is no new consolidation. The cardiac silhouette cannot be
evaluated in the setting of large right pleural effusion. Left
hilar contour is normal. There is no overt edema. Dextroconvex
scoliosis of the thoracic spine noted.
IMPRESSION: Increased moderate partially-loculated right pleural
effusion.
Brief Hospital Course:
52 year old woman with hyperlipidemia, hypertension, and colon
cancer previously treated with chemo, surgery, radiotherapy,
followed by progression of disease to lung/liver presented with
sub-acute right chest pleuritic pain and dyspsnea, most likely
due to her poor lung condition.
.
# Tachycardia: Appears sinus on EKG. Most likely secondary to
pain/discomfort though was mildly fluid responsive so may in
part be due to hypovolemia. Less likely PE as CTA was negative.
She was admitted to ICU for further evaluation of her
tachycardia. CT showed no pericardial effusion. Malignancy
itself can cause tachycardia. TTE was obtained to evaluate
compressive physiology, however the images were of poor quality
and some details were not possible to evaluate. TTE showed most
likely a normal ejection fraction with no evidence of tamponade.
On discharge her heart rate was slightly slower (90's-100's)
than admission (120's-140's).
.
# Chest pain: Given location and pleuritic nature, most likely
due to pleural effusion. No leukocytosis/fever or increased
cough to confirm infected. EKG with ST abnormalities and no
prior for comparison. Cardiac enzymes were negative. She was
monitored on telemetry and notable only for tachycardia to 110s.
She was treated with oxycodone and tylenol for pain. Given lack
of findings of Pneumonia on CTA, antibiotics that were started
in the ED were discontinued. Blood cultures sent and are still
pending to this date. She was discharged on Vicodin because she
doesn't have insurance and can't pay for oxycodone. She was also
provided with stool softeners to avoid constipation.
.
# Dyspnea: likely due to pleural effusion. Her saturation was
high 90s on room air. Might be difficult to drain effusion as
locaulated given lack of signs of infection. Given the normal
oxygen saturation on room air and loculated fluid collection and
predominating tumor burden in her Right lung (likely unamenable
to re-expansion) thoracentesis was deferred as unlikely to help
her.
.
# Malignancy: No outside hospital records with the patient.
Requested information from Dr. [**Last Name (STitle) **] at her community hospital
in [**State 9512**]. We received some reports which stated that she has
metastatic colon cancer (KRAS mutation positive) and that she
was for hospice care. Oncology was consulted and recommended CEA
and follow up in the oncology clinic. HIckman line was removed
[**2128-8-13**].
.
# Anemia: Baseline Hgb 11-12 per OSH report. She had no signs of
active bleeding. Hct and Hgb was trended daily and labs sent for
vitamin B12, folate and iron studies which revealed normal B12
and folate, however Iron studies were suggestive of Anemia of
chronic disease, most likely due to her malignancy.
.
# Paralysis: unclear underlying disorder but chronic. More
records need to be obtained from OSH to understand etiology.
.
# Hypertension: currently well controlled, continued her home
anti-hypertensive medication.
.
# Hyperlipidemia: On simvastatin.
.
# Communication: Patient, sister would be HCP; mothers phone
number is [**Telephone/Fax (1) 103086**] [**First Name8 (NamePattern2) 103087**] [**Last Name (NamePattern1) **]. Sisters name is [**Name (NI) **]
[**Name (NI) **].
Medications on Admission:
Vicodin PRN
Metoprolol 25mg PO BID
Simvastatin 80mg PO QHS
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. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
3. simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: You should not drive or drink alcohol
while taking this medication. Only take as directed. DO NOT
TAKE MORE TYLENOL IN ADDITION TO THIS MEDICATION. .
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
metastatic colon cancer
Secondary diagnoses:
Tachycardia
hypertension
hyperlipidemia
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:
It was a great pleasure taking care of you as your doctor.
.
You were admitted to [**Hospital1 69**]
because of right sided body pain (chest and belly) and
difficulty breathing.
.
You were admitted to ICU for further management of your fast
heart rate. Your pain was well controlled with tylenol and
oxycodone.
.
It was found that your heart rate is slightly faster than
normal. CT scan of your chest in concern of a clot in your lung
vessels. Fortunately, the CT scan didn't show any clots in the
vessels of your lung. However, your CT scan did show evidence of
your known cancer.
.
*** The line in your chest was removed prior to your discharge.
***
.
We made the following changes in your medications:
Please START Docusate Sodium tablet 100 mg twice daily
Please START Senna tablet 8.6 mg twice daily as needed for
constipation
Please Continue Vicodin 5-500 one pill every 6 hours as needed
(take only as directed, do not drink alcohol while taking, DO
NOT TAKE ADDITIONAL TYLENOL IN ADDITION TO VICODIN).
Please CONTINUE Metoprolol tablet 25 mg twice daily
Please CONTINUE Simvastatin tablet 80 mg at bedtime
.
.
Please schedule an appointment with a primary care physician if
you have any within/around [**Location (un) 86**]. If not, please call in the
next 2-3 days at [**Hospital6 733**] ([**Telephone/Fax (1) 250**]) to
schedule an appointment with a new primary care physician. [**Name10 (NameIs) **]
you would like, I(Dr [**First Name (STitle) **] [**Name (STitle) **]) will be more than happy to be
your primary care physician.
.
Please follow with your appointment with a new cancer doctor [**First Name (Titles) 3**] [**Last Name (Titles) 103088**]d below.
Followup Instructions:
.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2128-8-25**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2128-8-25**] at 10:00 AM
With: DR. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V46.3",
"719.7",
"785.0",
"V10.05",
"197.0",
"197.7",
"338.3",
"272.4",
"285.22",
"401.9",
"344.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11535, 11541
|
7582, 10794
|
360, 366
|
11690, 11690
|
3640, 7559
|
13562, 14198
|
1856, 1874
|
10903, 11512
|
11562, 11562
|
10820, 10880
|
11866, 13539
|
1914, 2584
|
11627, 11669
|
266, 322
|
394, 1293
|
11581, 11606
|
11705, 11842
|
1315, 1550
|
1566, 1839
|
2609, 3621
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,943
| 143,159
|
17762
|
Discharge summary
|
report
|
Admission Date: [**2125-2-12**] Discharge Date: [**2125-2-20**]
Date of Birth: [**2107-12-4**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 17-year-old young
man who was involved in a roll-over motor vehicle crash on
[**2125-2-12**]. He was restrained and the motor vehicle collision
involved airbag deployment. There was prolonged extrication
reported to be approximately 20 minutes. His [**Location (un) 2611**] Coma
Scale was 3 initially at the scene. He was subsequently
taken to [**Hospital3 3583**]. At [**Hospital1 46**] his GCS was 6. He was
combative, rapid sequence induction was performed, and he was
intubated at [**Hospital1 46**]. Bilateral chest tubes were placed for a
right pneumothorax and left hemothorax. He was subsequently
transferred via LifeFlight ground due to high wind to [**Hospital1 1444**]. On arrival, Mr. [**Known lastname **]
heart rate was 140, blood pressure was 120/palpable and his
heart rate continued to climb to 160. In the trauma bay Mr.
[**Known lastname **] received four units of packed red blood cells. His
endotracheal tube was advanced. A 36 French left chest tube
was placed for persistent hemothorax. A diagnostic
peritoneal lavage was performed which was positive by visual
inspection and he was subsequently taken to the operating
room urgently for an exploratory laparotomy.
PAST MEDICAL HISTORY: None.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives in [**Location 9101**] with his
extended family. He is originally from [**Country 4194**].
PHYSICAL EXAMINATION: On admission his temperature was 36.0
rectally, heart rate 120-160, sinus rhythm, blood pressure
120-150/palpation, respiratory rate intubated, bagged by
valve mask. Pulse oximetry was 100%. In general his GCS was
3. He was intubated, paralyzed, sedated. He was on a back
board with a cervical collar on. HEENT: Pupils were 4 mm to
3 mm bilaterally and reactive. Unable to assess extraocular
movements. Mid face was stable. Tympanic membranes were
clear bilaterally. No malocclusion that was obvious.
Trachea was midline. Chest: Clear to auscultation
bilaterally, no crepitus. Neck: No hematoma, cervical
collar. Genitourinary: No blood a the urethral meatus.
Cardiac: Regular, tachycardic. Abdomen: Soft,
nondistended, fast examination was negative. Back: No
step-offs. Extremities: No obvious deformities, 2+ dorsalis
pedis, posterior tibial and radial pulses bilaterally.
Rectal: Normal tone, heme negative, prostate normal.
Neurologic: Babinski and clonus were absent bilaterally.
LABORATORY DATA: On admission sodium was 141, potassium 3.2,
chloride 112, bicarbonate 22, BUN 16, creatinine 0.8, glucose
255, white blood cell count 22, hematocrit 35, platelet count
245, PTT 31, patient 15.2, INR 1.5, fibrinogen 127, lactate
4.8, amylase 59. Arterial blood gas 7.18/61/269/24/-6.
Serum toxicology screen was negative. Urinalysis showed
large blood, 5 red blood cells. Urine toxicology was
negative except opiates were positive, that is post therapy
with narcotic agents.
RADIOLOGIC STUDIES: Chest x-ray showed an endotracheal tube
which was not visualized on the radiograph due to superior
and malpositioning; nasogastric tube was coiled in the upper
esophagus. Bilateral chest tubes were present, bilateral
small pneumothoraces and a persistent left hemothorax was
identified. Fractures of the left first through sixth ribs
were seen with posterior fractures of ribs five and six being
displaced. The aortic arch was not well seen. Subcutaneous
emphysema was noticed. There was no free air on the AP
pelvis. There was a suspicious area for fracture along the
right sacrum.
CT of the head without contrast showed two punctate areas of
high density within the right frontal cortex consistent with
contusion. There was effacement of the sulci and cisterns
consistent with increased intracranial pressure.
CT of the cervical spine showed no cervical spine fractures,
fractures of the left first rib and right T1 transverse
process were seen.
CAT scan of the abdomen was performed post splenectomy and
showed mottled enhancement, small bowel loops and liver
likely due to reflux and hyperemia after an episode of
hypotension.
CT of the chest with contrast showed no evidence of aortic
tear or dissection, a slight increased density to the
mediastinal fat consistent with hematoma, no pericardial
effusions, dense opacification of both lungs dependently.
Bilateral chest tubes were present.
CT of the pelvis showed the urinary bladder was collapsed.
Bone windows demonstrated fracture of the right transverse
process of C1, left ribs one through six with rib five being
fractured twice; the tip of L3, left transverse process
fracture, fracture through the right sacrum and a
nondisplaced fracture through the right superior pubic ramus.
Thoracic and lumbar spines did not demonstrate any fractures.
A repeat CAT scan on [**2125-2-13**] demonstrated three punctate
areas of hemorrhage in the right frontal lobe at the
[**Doctor Last Name 352**]-white matter interface with basically unchanged CAT
scan.
A CT of the abdomen on [**2125-2-17**] demonstrated bilateral
consolidation of the lower lobes of the lung with left
greater than right, a small amount of free fluid in the
gastrohepatic region but no evidence of abscess or other
fluid collection.
HOSPITAL COURSE: In the emergency room Mr. [**Known lastname **] had a left
scalp laceration stapled. He was subsequently taken from the
Emergency Department trauma bay to the operating room for an
exploratory laparotomy. Upon exploratory laparotomy several
splenic lacerations were observed. A splenectomy was
subsequently performed after a failed splenorrhaphy. Prior
to exploratory laparotomy, a second right-sided chest tube
was placed for persistent pneumothorax. The neurosurgery
service was consulted at the time of operation for urgent
intracranial pressure monitoring given that Mr. [**Known lastname **] did not
receive a head CAT scan and had an altered mental status.
The neurosurgical service placed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ICP monitor
intraoperatively. The initial intracranial pressure was 32
and declined to 23 after 50 grams of Mannitol. Mr. [**Known lastname **]
continued to receive blood products intraoperatively. He
received a total of nine units of packed red blood cells,
four units of cryoprecipitate and 12 units of fresh frozen
plasma. There were no other significant findings at the time
of surgery.
Mr. [**Known lastname **] was subsequently taken to the CAT scanner from the
operating room to image his head, cervical spine, chest and
abdomen. Findings were as above. He was subsequently taken
to the trauma intensive care unit. In the intensive care
unit a Swan-Ganz catheter was placed to monitor his cardiac
filling pressures. Also on the day of admission the
orthopedic surgery service was consulted to evaluate for
multiple fractures including transverse process fractures and
pelvic fractures. The case was discussed with Dr. [**First Name (STitle) 1022**]. The
final recommendations from the orthopedic service were
touchdown weight bearing on the right lower extremity and
nonoperative management.
After a repeat CAT scan showed no change from the original
CAT scan, the [**Last Name (un) **] ICP monitor was discontinued on the
evening of [**2125-2-12**]. Neurosurgery continued to follow Mr.
[**Known lastname **] during his hospital stay. His mental status progressed
and by hospital day number two he was awake and following
commands.
On [**2125-2-13**] Mr. [**Known lastname **] two anterior chest tubes were
discontinued and a follow-up chest x-ray showed adequate
expansion of his lungs. On [**2125-2-14**] the neurosurgery service
was satisfied with the patient's progress and signed off.
On [**2125-2-14**] Mr. [**Known lastname **] failed a spontaneous breathing trial
and remained on the ventilator however he was able to be
extubated on [**2125-2-16**].
On [**2125-2-16**] Mr. [**Known lastname **] was transferred to the floor after
remaining stable in the intensive care unit. He had his
Foley catheter discontinued and he was able to void on his
own. He had his remaining chest tubes discontinued
bilaterally. A follow-up chest x-ray showed adequate
expansion of the lungs. He was also vaccinated post
splenectomy for meningococcus and pneumococcus and H. flu.
While in the intensive care unit Mr. [**Known lastname **] did spike a
temperature as high as 102. He was pancultured. Blood
cultures on [**2125-2-15**] grew out two out of four bottles,
coagulase negative staphylococcus. A sputum culture had Gram
positive cocci. A urine culture was negative. He was
subsequently started on ceftriaxone and vancomycin. Mr.
[**Known lastname **] continued to have a fever while on the floor as high as
102.8 and his white blood cell count rose from 11.4 to 14.
There was concern for an intra-abdominal abscess given his
recent surgery. On [**2125-2-17**] Mr. [**Known lastname **] had a CT of his
abdomen which showed no abscess and some nonspecific
hyperperfusion of the right liver and also bibasilar
consolidation in his lungs. Subsequent cultures were
negative, while he did have some Gram negative rods in his
sputum. At the time of discharge Mr. [**Known lastname **] had been afebrile
for greater than 48 hours and his intravenous antibiotics
were discontinued and he was started on Augmentin for
antibiotic coverage by mouth on which he will be discharged.
Mr. [**Known lastname **] nutritional status was initially maintained with
tube feeds first in the intensive care unit. When he was
extubated he was able to tolerate p.o. foods easily and has
maintained an adequate nutrition status.
Upon transfer to the floor the physical therapy and
occupational therapy teams both evaluated Mr. [**Known lastname **]. They
have worked with him on strength, conditioning and mobility.
At the time of discharge both the physical therapist and
occupational therapist feel that Mr. [**Known lastname **] is safe for
discharge.
DISCHARGE INSTRUCTIONS:
1. Follow up with Dr. [**Last Name (STitle) 519**] in one to two weeks. Call
[**Telephone/Fax (1) 6554**] for an appointment.
2. Follow up with Dr. [**First Name (STitle) 1022**] of orthopedics in two weeks. Call
[**Telephone/Fax (1) 5499**] for an appointment.
3. Touch-down weight bearing on the right lower extremity.
DISCHARGE MEDICATIONS:
1. Augmentin 875 mg p.o. b.i.d. x 7 days.
2. Percocet 1-2 tablets p.o. q. 4-6 hours p.r.n.
3. Colace 100 mg p.o. b.i.d. p.r.n.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 9126**]
MEDQUIST36
D: [**2125-2-20**] 07:55
T: [**2125-2-20**] 08:05
JOB#: [**Job Number 49344**]
|
[
"860.4",
"805.4",
"958.7",
"790.7",
"807.06",
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"865.00",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
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"96.71",
"54.25",
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] |
icd9pcs
|
[
[
[]
]
] |
10599, 10727
|
1465, 1526
|
5493, 10228
|
10252, 10576
|
1677, 5475
|
176, 1408
|
1431, 1438
|
1543, 1654
|
10752, 11063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,496
| 184,415
|
24163
|
Discharge summary
|
report
|
Admission Date: [**2147-11-8**] Discharge Date: [**2147-11-23**]
Date of Birth: [**2088-5-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Talwin Nx / Levaquin / Benicar
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**11-14**] Redo Sternotomy, Aortic Valve Replacement (21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
mechanical)
[**11-8**] Cardiac Catherization
History of Present Illness:
59 year old male with chronic peripheral edema and increasing
shortness of breath progressively over the last year. Presented
to OSH with worsening shortness of breath and diuresised
aggressively.
Past Medical History:
-CAD: 3V-CABG in [**2138**] (LIMA-LAD, SVG-OM, SVG-PDA) at [**Hospital1 756**]
(preceding sx was dyspnea); cath in [**4-/2146**] showing patent grafts
-DM2: Dx [**2132**], has le neuropathy, no retinopathy, not clear
about nephropathy
-CHF
-Ao stenosis
-Mitral regurg
PSH:
-CABG [**2138**]
-Ortho procedure r elbow
-Carpal tunnel [**Doctor First Name **]
-Cataract [**Doctor First Name **]
Social History:
He is from this area and worked as a police officer for 33 years
in [**Location (un) **], now retired. He smoked 1/2ppd for 25 yrs, quit 20yrs
ago. He never drank or used illicit drugs.
Family History:
His father died of pancreatic cancer at 60. His mother had
multiple medical problems, including HF, and died in her 80's.
Two siblings, one with MVP and hypothyroidism.
Physical Exam:
PE: t 97.8, bp 104/48, hr 105, rr 16, 95%ra
gen- obese, pleasant m, looks older than age, functions well,
nad
heent- anicteric, op clear with mmm
neck- jvd to angle of jaw, no thyromegaly or lad
cv- rrr, s1s2, 2/6 systolic murmur heard at all spaces peaks mid
but does not efface s2
pul- moves air well, min to no rales at bases
abd- obese, no obvious fluid wave, nt, nabs, no organomegaly
extrm- no cyanosis, [**1-30**]+ le pitting edema, symmetric; left ankle
slightly warm, minimally tender
nails- no clubbing, no pitting/color changes/indentations
neuro a&ox3, no focal cn/motor deficits
Discharge
97.3 HR 73 SR, b/p 125/61, RR 18, RA Sat 95% wt: 143.6 kg
Neuro: alert and oriented, non focal
Pulmonary: lungs clear bilaterally anterior and posterior
Cardiac: S1S2 crisp click no murmur/rub/gallop
Sternal incision: midline with old scaring to left of incision,
no drainage or erythema, staples intact and sternum stable
Abdomen: Soft, obese, nontender, last BM [**11-23**]
Extremeties: warm and well perfused, pulses +2 except absent
left radial, Edema +3 pitting left leg up to groin, +3 pitting
right to knee
Pertinent Results:
[**2147-11-23**] 04:49AM BLOOD WBC-9.9 RBC-3.30* Hgb-8.7* Hct-26.8*
MCV-81* MCH-26.2* MCHC-32.3 RDW-17.1* Plt Ct-403
[**2147-11-8**] 04:35PM BLOOD WBC-12.0* RBC-3.99* Hgb-10.9* Hct-32.6*
MCV-82 MCH-27.4 MCHC-33.6 RDW-16.9* Plt Ct-330
[**2147-11-11**] 05:33AM BLOOD Neuts-74.4* Lymphs-13.4* Monos-6.1
Eos-5.8* Baso-0.3
[**2147-11-23**] 04:49AM BLOOD Plt Ct-403
[**2147-11-23**] 04:49AM BLOOD PT-22.0* PTT-82.7* INR(PT)-2.2*
[**2147-11-8**] 04:35PM BLOOD Plt Ct-330
[**2147-11-8**] 04:35PM BLOOD PT-14.2* PTT-29.8 INR(PT)-1.3*
[**2147-11-23**] 04:49AM BLOOD Glucose-138* UreaN-21* Creat-1.1 Na-135
K-4.2 Cl-99 HCO3-29 AnGap-11
[**2147-11-8**] 04:35PM BLOOD Glucose-209* UreaN-21* Creat-1.1 Na-139
K-4.3 Cl-97 HCO3-31 AnGap-15
[**2147-11-10**] 07:30AM BLOOD ALT-25 AST-23 LD(LDH)-154 AlkPhos-82
Amylase-39 TotBili-0.7
[**2147-11-9**] 06:26AM BLOOD Lipase-17
[**2147-11-22**] 06:32AM BLOOD Calcium-8.1* Phos-4.4 Mg-2.2
[**2147-11-10**] 07:30AM BLOOD %HbA1c-7.8* [Hgb]-7.3 [A1c]-0.45
SPECIMEN SUBMITTED: AORTIC VALVE LEAFLETS (1).
Procedure date Tissue received Report Date Diagnosed
by
[**2147-11-14**] [**2147-11-14**] [**2147-11-17**] DR. [**Last Name (STitle) **]. FU/nbh
DIAGNOSIS:
Aortic valve leaflets:
Valve leaflets with myxoid degeneration and calcifications.
CHEST (PA & LAT) [**2147-11-22**] 3:53 PM
CHEST (PA & LAT)
Reason: evaluate pleural effusion
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with aortic stenosis pre-op for AVR
REASON FOR THIS EXAMINATION:
evaluate pleural effusion
CLINICAL HISTORY: Aortic stenosis, preop for aortic valve
replacement. Evaluate for pleural effusions.
CHEST: The heart is enlarged. There is previous sternotomy with
aortic valves prosthesis already present. No gross failure is
seen. The costophrenic angles are clear on the AP film. There
may be some blunting posteriorly on the left.
IMPRESSION: No gross failure. No major effusions, possible some
blunting on the left.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
Conclusions:
PRE-BYPASS:
1. Overall left ventricular systolic function is moderately
depressed. Resting
regional wall motion abnormalities include hypokinesis of the
inferior wall
and apical akinesis. The left ventricular cavity size is normal.
2. There are three severely thickened/deformed aortic valve
leaflets. There is
severe aortic valve stenosis with an estimated aortic valve area
of 0.6 cm2.
No aortic regurgitation is seen.
3. Right ventricular chamber size is normal. There is moderate
global right
ventricular free wall hypokinesis.
4. The mitral valve leaflets are mildly thickened and
myxomatous. Mild (1+)
mitral regurgitation is seen.
5. The left atrium is moderately dilated. No atrial septal
defect is seen by
2D or color Doppler.
6. There are simple atheroma in the descending thoracic aorta.
POST-BYPASS:
Drips: Milrinone, epinephrine, norepinephrine, nitroglycerine
1. Well-seated bicuspid mechnical aortic valve with no evidence
of
perivalvular leak. No AR seen. Mean gradiend of 14 mm Hg.
2. Improved [**Hospital1 **]-ventricular systolic function.
3. Mitral regurgitation is improved.
4. Rest of exam is unchanged from pre-bypass.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Admitted for cardiac catherization [**2147-11-7**] which revealed
severe aortic stenisis and patent grafts. He was medically
managed for heart failure. Then [**11-14**] in was transferred to the
operating room and under went aortic valve replacement without
complications, please see operative report for further details.
He was transferred to the CSRU. He was weaned from sedation,
was neurologically intact, and extubated. All pressors and
milirone were weaned off on postoperative day 1. Post operative
day 2 he was ready and transferred to [**Hospital Ward Name **] 2 for continued
diuresis, physical therapy, anticoagulation, diabetes and
respiratory management. He continued to progress over the next
few days and anticoagulation was continued with
coumadin/heparin. On postoperative day 10 his INR was 2.2 and
we was ready for discharge home with VNA services and coumadin
follow up.
Medications on Admission:
-ASA 325 daily
-Torsemide 120mg daily
-Glyubride 5mg [**Hospital1 **]
-Amlodipine 5mg daily
-Carvedilol 6.25mg [**Hospital1 **]
-Metformin 1000mg [**Hospital1 **]
-Glargine 50 untis qHS
-Pantoprazole 40mg daily
-Gabapentin 300mg tid
Transfer
-Same except for Furosemide 80mg tid instead of Torsemide
Was also temporarily on dobutamine, allopurinil
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
12. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
13. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day.
Disp:*qs units* Refills:*0*
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Insulin Sliding Scale
Please continue with your sliding scale of humalog as prior to
admission
16. Lasix 80 mg Tablet Sig: 1.5 Tablets PO twice a day: please
take 120mg twice a day for 1 week and then decrease to 80mg
twice a day for 2 weeks and follow up with Dr [**Last Name (STitle) **].
Disp:*80 Tablet(s)* Refills:*0*
17. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day for 2
days: please take 7.5mg [**11-23**] and [**11-24**] with INR check [**11-25**].
Disp:*30 Tablet(s)* Refills:*0*
18. Outpatient [**Name (NI) **] Work
PT/INR as needed
first check [**11-25**] with results to Dr [**Last Name (STitle) **] fax# [**Telephone/Fax (1) 61388**]
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Aortic Stenosis
Heart Failure
Coronary Artery Disease s/p CABG [**2138**]
Pulmonary Edema
Diabetes
Elevated cholesterol
Hypertension
Gout
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 1 week please call for appointment
Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**3-3**] weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
INR to be checked [**11-25**] with results to Dr [**Last Name (STitle) **] for follow up
on coumadin dosing fax # [**Telephone/Fax (1) 61388**]
Completed by:[**2147-11-23**]
|
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"278.00",
"272.0",
"274.9",
"414.01",
"585.9",
"396.2",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"88.53",
"39.61",
"99.04",
"35.22",
"88.57",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9755, 9816
|
6141, 7040
|
318, 490
|
9998, 10005
|
2677, 4058
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1351, 1523
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4095, 4147
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9837, 9977
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10029, 10448
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1538, 2658
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259, 280
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4176, 6084
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518, 717
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6118, 6118
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739, 1130
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1146, 1335
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,976
| 180,908
|
50645
|
Discharge summary
|
report
|
Admission Date: [**2114-10-24**] Discharge Date: [**2114-10-26**]
Date of Birth: [**2034-6-29**] Sex: M
Service: MEDICINE
Allergies:
Cozaar / Ace Inhibitors / Morphine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain and ventricular tachycardia
Major Surgical or Invasive Procedure:
[**2114-10-24**] - Ventricular tachycardia ablation
History of Present Illness:
80M with significant cardiac history that includes CAD s/p CABG
x2, ischemic cardiomyopathy (EF 20-25%), s/p ICD for inducible
VT who presented with chest pain. He reports substernal chest
pain radiating to the left arm associated with nauseas and
dyspnea began last night at rest around 3AM. He took three SLNG
with improvement but not resolution of symptoms. He also
reports that ICD fired 2 days ago. He had not been feeling well
prior to this but after the shock he felt better.
.
In the ED, the initial vitals were: 96.6 72 149/75 20 96%RA.
Labs notable for CK:53 MB:4 T-trop: 0.06 with creatinine of
2.3. EKG with HR 71, V-paced, left axis, no obvious ST segment
changes. Patient was given aspirin 325mg and sublingual
nitroglycerin with resolution of pain initially. Plan was to
admit patient to [**Hospital Unit Name 196**] under his PCP/cardiologist, Dr. [**Last Name (STitle) **].
Then patient developed chest pain again with telemetry showing
wide complex tachycardia with rate in the 130s. Procainamide
was ordered but not given. EP was called and had difficulty
interrogating ICD. Patient's BP noted to be slightly lower in
the high 90s/low 100s, but otherwise he remained stable.
Carotid sinus massage was attempted w/o success. He was also
attempted to be paced at higher rates, but this would only break
VT for 2-3 beats. So given concern for ventricular tachycardia
patient is being taken to the EP lab for investigation. Of note
blood sugars also in the 600s so given 10 units insulin in ED.
.
In the cath lab, he was noted to have 3 foci for inducible VT,
but the culprit focus for causing his current VT was ablated.
However, the other foci were not intervened on. He was in
normal sinus prior to transfer. In ICU, he was noted to be in
no acute distress, in good spirit, chest pain free. Not
reporting any dizziness or lightheadedness.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
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:
-- CABG: [**2083**] (SVBG to distal LAD, distal LCX, distal RCA), Redo
[**2088**]
-- PACING/ICD: [**Company 1543**] BiV ICD placed [**2104**]
3. OTHER PAST MEDICAL HISTORY:
-- Paroxysmal atrial fibrillation.
-- Cardiomyopathy, related to coronary artery disease.
-- Coronary artery disease, s/p CABG X2, EF 15% on TTE [**2111**].
-- VT storm s/p [**Hospital1 **]-v ICD placement in [**2104**] with a [**Company 1543**]
[**First Name9 (NamePattern2) **] [**Last Name (un) 24119**] generator replacement in [**2108-1-24**].
-- Atrial tachycardia s/p ablation in [**2104**] and [**2105**].
-- Prior history of stroke post-bypass in [**2088**] as well as
another stroke in [**2108**]. Mild residual visual disturbance,
unsteady gait.
-- Prostate CA s/p TURP, so not on warfarin
-- Diabetes (diet controlled)
-- Chronic renal insufficiency (baseline 2.0-2.3)
-- Hx of Hematuria: none recent
-- Hx of bladder stones
-- Tonsillectomy at age 40
-- Mastoidectomy
-- Intermittent vertigo
-- Insomnia: sleeps 2-3 hours/night
Social History:
Lives alone in [**Hospital1 3494**]. Independent in ADLs. No family.
Retired nurse.
Tobacco: none
EtOH: none
Drugs: none
Family History:
- Patient is adopted. Unaware of biological family history.
Physical Exam:
Admission exam:
Vitals: A-V paced, T 97.5 BP 120/66 HR 70 RR 18 SpO2 98/RA
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear
NECK: Supple, No LAD. JVP low
CV: RRR, 2/6 systolic murmur heard best at the LUSB
LUNGS: CTAB anteriorly
ABD: NABS. Soft, NT, obese.
GROIN: access sites bilaterally are c/d/i with no brusing
EXT: 1+ LE edema b/l w/ skin c/w venous stasis changes to the
knees
NEURO: A&Ox3. CN 2-12 grossly intact
PSYCH: Mood and affect was appropriate
Pulses: palpable popliteal pulses bilat, DP/PT dopplerable bilat
Discarge exam: Unchanged from above, except as noted below
EXT: no edema in LEs
Pertinent Results:
Admission labs:
[**2114-10-24**] 08:15AM BLOOD WBC-5.5 RBC-4.22* Hgb-12.6* Hct-36.6*
MCV-87 MCH-29.9 MCHC-34.4 RDW-15.1 Plt Ct-110*
[**2114-10-24**] 07:45PM BLOOD Neuts-71.0* Lymphs-22.7 Monos-4.7 Eos-1.2
Baso-0.4
[**2114-10-24**] 03:25PM BLOOD PT-11.8 PTT-25.7 INR(PT)-1.1
[**2114-10-24**] 08:15AM BLOOD Glucose-621* UreaN-45* Creat-2.3* Na-128*
K-4.2 Cl-87* HCO3-29 AnGap-16
[**2114-10-24**] 08:15AM BLOOD CK-MB-4
[**2114-10-24**] 08:15AM BLOOD cTropnT-0.06*
[**2114-10-24**] 07:45PM BLOOD Calcium-8.9 Phos-3.1 Mg-2.6
Imaging:
CXR ([**2114-10-24**]) -
1. Stable placement of ICD leads.
2. No acute cardiopulmonary abnormality.
EP study ([**2114-10-24**]): Final report not uploaded at time of
discharge summary. Per verbal report, there was an area of
inducible VT found in the RV which was ablated. 3 other areas
of inducible VT were found but not ablated.
Discharge labs:
[**2114-10-26**] 05:07AM BLOOD WBC-6.1 RBC-4.04* Hgb-12.1* Hct-36.1*
MCV-89 MCH-29.8 MCHC-33.4 RDW-14.9 Plt Ct-106*
[**2114-10-25**] 05:22AM BLOOD PT-12.5 PTT-30.6 INR(PT)-1.2*
[**2114-10-26**] 05:07AM BLOOD Glucose-254* UreaN-52* Creat-2.2* Na-134
K-3.7 Cl-95* HCO3-30 AnGap-13
[**2114-10-26**] 05:07AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.2
Brief Hospital Course:
80 y.o. man w/ PMH significant for CAD s/p CABG x2, ischemic
cardiomyopathy s/p ICD (EF 20-25%), s/p ICD for inducible VT who
presented w/ CP that initially resolved w/ SL NTG, had episode
of CP while in the ED went into a wide-complex tachycardia and
now presents to the CCU after EP ablation of VT focus
#Ventricular tachycardia - Pt came to the ED reporting chest
pain and was found to have an episode of VT while in the
emergency room. He has an ICD which did not fire because the
rate was below the ICD threshold. EP was consulted and they
were unable to suppress his VT by adjusting pacer settings. He
was taken to the EP lab where her underwent ablation of a focus
of inducible VT which was thought to be the culprit. Three
others were also found but not ablated. He was subsequently
admitted to the CCU for monitoring. In the CCU, he remained
hemodynamically stable and did not have any recurrent episodes
of VT on telemetry. He will not continue his home maiodarone
after discharge.
#Diabetes - Pt had history of "diet controlled" diabetes. He
was not on any oral hypoglycemics or insulin at admission. His
blood sugars were severely elevated to the 400-500 range at
presentation. He was given insulin via sliding scale during
this admission. An A1c was checked whcih was 13%. [**Last Name (un) **] was
contact[**Name (NI) **] but not formally consulted. [**Name8 (MD) 6**] NP from [**Last Name (un) **]
provided teaching on checking his blood sugar at home. We did
not start long acting insulin and did not discharge him on
insulin as he was being discharged and his insulin dose was not
able to be titrated. At discharge, he has been started on
glipizide 5mg daily and he has been arranged follow-up with
[**Last Name (un) **] soon after discharge (we chose to avoid metformin as a
first [**Doctor Last Name 360**] because of elevated creatinine).
#UTI - UA was very suggestive of UTI with WBC >182. UCx showed
coag-negative staph. We wanted to avoid medications that may
prolong his QTc, and he was given ceftriaxone which he will
continue as cefpodoxime for a total 5 day course.
#CAD - Pt has extensive cardiac history with CABG, re-do CABG
and history of PCI. His presentetion was not suggestive of ACS.
He has a few episodes of CP which were brief and reported to be
similar to what he experiences at home. He did not have any EKG
changes and did not require ntg after arrival to the CCU.
#Chronic systolic CHF (EF=20-25%) - He appeared euvolumic at
admission with only trace LE edema and no evidence of pulmonary
edema on exam. He was initially continued on his home doses of
torsemide and metolazone. These were held at discharge because
he appeared volume depleted after being NPO for the EP procedure
and subsequently having poor PO intake. He was instructed to
discuss restarting this with his cardiologist as an outpatient.
#Hypertension - BP remained well controlled, continued on home
metoprolol and isosorbide dinitrate. Diuretics held at
discharge as above.
#Chronic kidney disease - Cr remained at baseline during
admission. Medications were dosed appropriately.
#Code status this admission: DNR/DNI (confirmed with pt)
#Transitional issues:
-Stopped torsemide and metolazone because of volume depletion at
discharge, has been instructed to weight himself daily and call
PCP/Cardiologist if weight is increasing.
-Stopped amiodarone
-Will follow-up with [**Last Name (un) **] regarding poorly controlled diabetes
-Will continue cefpodoxime for UTI after discharge
Medications on Admission:
1. amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily)
alternating with one tablet every 7 days.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
3. torsemide 20 mg on TuTh, 40mg on SuMoWeFrSa
alternate every other day with 40mg torsemide (2 tabs).
4. metolazone 2.5 mg once week on sunday
5. isosorbide dinitrate 20mg PO TID
6. metoprolol tartrate 75 mg PO BID
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
8. ascorbic acid 1000 mg Tablet PO DAILY
9. cholecalciferol [**2102**] unit Tablet daily
10. cod liver oil Sig: One (1) teaspoon PO once a day.
11. folic acid 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO 1X/WEEK ([**Doctor First Name **]).
4. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 2,000 unit Tablet Sig: One (1)
Tablet PO once a day.
7. folic acid 1 mg Tablet Sig: [**11-26**] Tablet PO DAILY (Daily).
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
9. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
10. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. Test strips
Use to test blood sugar each morning and with each meal
Dispense 120 strips
12. Glucometer
Please dispense one glucometer
13. lancets Misc Sig: One (1) lancet Miscellaneous as
directed: Please provide patient with Delica lancets.
Disp:*120 lancets* Refills:*0*
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
15. metoprolol tartrate 50 mg Tablet Sig: 1 and [**11-26**] Tablet PO
twice a day.
16. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Ventricular tachycardia
Diabetes mellitus
Secondary diagnoses:
Coronary artery disease
Hypertension
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your admission to
[**Hospital1 18**] for chest pain. You were found to have ventricular
tachycardia in the emergency room while you were having chest
pain. You were taken to the EP lab where an area of your heart
which was causing the VT got ablated. You did not have more VT
after the procedure and we stopped your amioradone.
Because you did not eat or drink much in the hospital, we are
holding your torsemide. Please discuss with Dr. [**Last Name (STitle) **] when to
restart this medication. You should also weigh yourself daily
and call Dr.[**Name (NI) 15419**] office if your weight increases by 3
pounds or more.
You were also fouond to have very elevated blood sugars. You
hemgolobin A1c, which measures your blood sugar over the past 3
months, was very elevated. We have started you on glipizide
which will help lower your blood sugar. We have also made an
appointment for you to see a diabetes doctor next week.
The following changes were made to your medications:
STOP amiodarone
START glipizide 5mg by mouth once daily
START cefpodoxime 100mg by mouth twice daily for 4 days
HOLD torsemide until you speak with Dr. [**Last Name (STitle) **]
Followup Instructions:
Name: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 19604**]
Phone: [**Telephone/Fax (1) 6937**]
*Please call your primary care physician to book [**Name Initial (PRE) **] follow up
appointment of your hospitalization. It is recommended that you
follow up next week. Any questions or concerns please call the
office.
Name: [**Last Name (LF) 978**], [**First Name7 (NamePattern1) 7208**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 51381**]
Appointment: Tuesday [**2114-10-30**] 2:30pm
|
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icd9cm
|
[
[
[]
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[
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|
[
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|
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|
335, 389
|
12151, 12151
|
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257, 297
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417, 2822
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4840, 5689
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12166, 12278
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3099, 3941
|
2844, 2906
|
3957, 4079
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,326
| 158,608
|
5321
|
Discharge summary
|
report
|
Admission Date: [**2117-5-14**] Discharge Date: [**2117-5-16**]
Date of Birth: [**2058-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 2026**] is a 58 year old gentlemen with a PMH significant for
HTN, ESRD on MWF HD, seizure disorder, Hepatitis B, and CHF
admitted for altered mental status and fever. The patient was
brought in to [**Hospital1 18**] by EMS after complaining of bilateral leg
pain, HA, NBNB emesis x1, and RUE weakness. Upon initial
presentation to the [**Hospital1 18**] ED, VS 102.4 120 16 175/100 100%RA.
The patient was complaining of left-sided arm and leg weakness
as well as a diffuse HA. Exam was notable for left facial droop,
CXR with bibasilar atelectasis, and ECG was notable for peaked T
waves with a potassium of 6.8. The patient was treated with
bicarb, 10 units regular insulin, 1 amp D50, and kayexalate with
improvement in potassium to 4.8. The patient received gentle
IVF, vancomycin, pip/tazo, and ceftriaxone. An LP was attempted
but the patient refused periprocedurally. Of note, the patient
has a history of dialysis line infections, most recently in [**2113**]
by tip culture and [**2115**] by swab. Following insulin
administration, the patient became persistently hypoglycemic
requiring 3 amps D50 and then continuous infusion for D10 at 100
cc/hr.
The patient was then transferred to the MICU for further
management. Currently, the patient denies HA, weakness, CP/SOB,
f/c/s, n/v/d, abd pain, HA. The patient further denies any
history of recent HA.
.
Review of systems: As per HPI. Patient states that he has a
history of past CVA. Patient is anuri
Past Medical History:
- Seizure disorder, onset of seizures in mid [**2097**] after
starting dialysis. He seems to have seizures quite frequently at
dialysis, per neurology this seems to be attributed to both
non-compliance with the medications, as well as taking his
medications later on those days.
- End stage renal disease on hemodialysis due to hypertensive
nephropathy. [**2-1**] right thigh HD graft placed. Removed from
transplant list [**2-1**]. History of MSSA TDC line infections, most
recently in [**2113**] (tip culture) and [**2115**] (swab).
- Non-ischemic cardiomyopathy, EF 25-30% per echo in [**10/2114**]
- AV fistula, status post thrombectomy [**7-/2114**]
- Hungry bone syndrome status post parathyroidectomy
- Hepatitis B
- Pituitary mass
- LUE AVG thrombectomy [**2115-12-11**]
- Anemia
- Recent L arm fistula repair (declotting) at [**Hospital1 3278**]
Social History:
The patient has a Ph.D. in history and had a successful academic
career until [**2103**], when he went on disability for unclear
reasons. The patient currently lives alone. He is an organist
and choir director at a local church. He denies tobacco, EtOH,
and illicit drugs.
Family History:
F - DM.
M - Deceased age 41 of renal failure.
One son - healthy.
Physical Exam:
Gen: NAD, angry
HEENT: Perrl, eomi, sclerae anicteric. MMM, poor dentition. Neck
supple
Pulm: CTAB
CV: Distant heart sounds. Nl S1+S2.
Abd: S/NT/ND +bs
Skin: Dialysis line insertion site without erythema or
induration.
Ext: Stasis dermatitis
Neuro: AOx3, mild left facial droop. Negative kernig's and
brudzinski's signs.
Pertinent Results:
Admission labs
[**2117-5-14**] 03:07PM
PT-13.5* PTT-24.5 INR(PT)-1.2*
PLT COUNT-282
NEUTS-96.4* LYMPHS-1.9* MONOS-0.6* EOS-0.8 BASOS-0.3
WBC-11.7* RBC-4.79 HGB-13.0* HCT-40.9 MCV-85 MCH-27.1 MCHC-31.7
RDW-17.5*
GLUCOSE-83 LACTATE-1.3 K+-6.1*
DIGOXIN-0.4*
CALCIUM-8.5 PHOSPHATE-6.4* MAGNESIUM-2.0
CK-MB-4
cTropnT-0.06*
LIPASE-92*
ALT(SGPT)-14 AST(SGOT)-21 CK(CPK)-210* ALK PHOS-90 TOT BILI-0.3
GLUCOSE-88 UREA N-79* CREAT-12.8*# SODIUM-135 POTASSIUM-6.8*
CHLORIDE-100 TOTAL CO2-15* ANION GAP-27*
[**2117-5-14**] 07:23PM GLUCOSE-41* K+-4.8
CHEST (PORTABLE AP) Study Date of [**2117-5-14**] 2:59 PM
IMPRESSION:
1. No evidence of pneumonia.
2. Low lung volumes, with likely bibasilar atelectasis and
increased volume
status.
CT HEAD W/O CONTRAST Study Date of [**2117-5-14**] 3:20 PM
IMPRESSION: No acute intracranial process, and no significant
change since
[**2116-7-31**] NECT.
[**2117-5-14**] 3:07 pm BLOOD CULTURE
**FINAL REPORT [**2117-5-18**]**
Blood Culture, Routine (Final [**2117-5-18**]):
BETA STREPTOCOCCUS GROUP C. SENSITIVITIES PERFORMED ON
REQUEST..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2117-5-15**]):
GRAM POSITIVE COCCI IN CHAINS.
REPORTED BY PHONE TO [**Location (un) **] [**Doctor Last Name **] [**2117-5-15**] 09:50AM.
Anaerobic Bottle Gram Stain (Final [**2117-5-15**]):
GRAM POSITIVE COCCI IN CHAINS.
Brief Hospital Course:
Mr. [**Known lastname 2026**] is a 58 year old gentleman with a PMH significant for
ESRD on MWF HD, HTN, seizure disorder, and CHF admitted for
fever, altered mental status, and iatrogenic hypoglycemia.
# Altered mental status/Bacteremia: The patient presented with
altered mental status concerning for infectious delirium,
meningoencephalitis or post-ictal state. His Chest x-ray was
without evidence of infiltrate. Because of the patient's
headache, inattentitiveness, and fever, the patient was treated
empirically for meningitis, recieving one dose of ceftriaxone,
vancomycin, acyclovir, and ampicillin. LP was unable to be
obtained and additional attempts were declined by the patient.
The patient's mental status rapidly improved and full meningeal
antibiotic coverage was discontinued. The patient was
continued on vancomycin for concern of an infected hemodialysis
line (pt has a history of repeated HD line infections). He was
continued on leviteracetam and oxcarbazepine and he remained
alert and oriented times 3 the remainder of his hospitalization.
On the AM of [**2117-5-16**], the patient requested to leave the
hospital against medical advice. At that same time, it was
noted that his blood cultures from admission were positive for
gram positive cocci (eventually beta strep and staph). The
importance of continued IV antibiotics was explained to the
patient who refused to stay in the hospital. In conjunction
with the renal fellow, it was arranged that the patient would
continue to receive IV antibiotics at dialysis.
# Hyperkalemia: The patient had missed a scheduled dialysis
session and presented with a potassium of 6.8. EKG was
concerning for peaked Twaves. The patient was treated with
calcium carbonate, insulin and glucose and repeat ECG with
resolution of ECG changes. His potassium was corrected and he
then underwent hemodialysis with stable post HD potassium.
# Seizure disorder: The patient had a seizure during dialysis,
which is apparently not uncommon for him. On further discussion
with the patient and neurology, it appears the patient does not
take any of his anti-epileptic drugs as an outpatient. While
hospitalized, he was kept on leviteracetam and oxcarbazepine.
# CHF: The patient had no current signs or symptoms of volume
overload. He was continued on ASA 81 mg daily and digoxin.
# HTN: Not currently treated with anti-hypertensives.
# Discharge: The patient left AMA on hospital day 2.
Medications on Admission:
Allopurinol 100 mg daily
Calcium acetate 667 mg tab, 4 tabs with each meal
Digoxin 125 mcg daily
Folate 1 mg daily
Levetiracetam 1000 mg daily
Oxcarbazepine 600 mg daily
Sevelamer 1600 mg tid with meals.
ASA 81 mg daily
Sarna lotion
Discharge Disposition:
Home
Discharge Diagnosis:
Fever, altered mental status
Discharge Condition:
The patient left AMA
Completed by:[**2117-5-18**]
|
[
"041.10",
"428.0",
"518.0",
"345.90",
"E932.3",
"585.6",
"251.1",
"425.4",
"403.91",
"252.8",
"276.7",
"E879.1",
"790.7",
"784.0",
"041.02",
"999.31",
"V15.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7726, 7732
|
4985, 7443
|
337, 351
|
7804, 7855
|
3468, 4962
|
3046, 3112
|
7753, 7783
|
7469, 7703
|
3127, 3449
|
1782, 1862
|
276, 299
|
379, 1763
|
1884, 2740
|
2756, 3030
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,371
| 148,390
|
21632
|
Discharge summary
|
report
|
Admission Date: [**2135-11-12**] Discharge Date: [**2135-11-21**]
Date of Birth: [**2053-9-17**] Sex: F
Service: NEUROLOGY
Allergies:
Phenobarbital
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
Endotracheal intubation
Radial Arterial line placement
History of Present Illness:
82 yo woman wtih history of HTN, HL, TIA, persistent Afib on
Coumadin was transferred from OSH for right parenchymal
hemorrhage. [**11-12**] 2AM, she was noticed to be confused by husband.
Over the day, she remained confused, and she was brought into
OSH ED. There she developed GTC seizure (duration not
documented) and intubated for airway protection. She received
Ativan (unknown amount) which resolved seizure. Head CT showed 2
x2 cm R occipital parenchymal hemorrhage. She was transferred to
[**Hospital1 18**] ED for further care.
ROS:
Unable to obtain from patient.
Past Medical History:
Hypertension
hypercholesterolemia
SDH
TIA
PAF on Coumadin
Social History:
No ETOH,smoking, drugs.
Family History:
non-contributory
Physical Exam:
T98.7 HR105 BP180/66 RR17 SaO2 100% intubated.
General: Intubated, no distress.
HEENT: Conjunctiva not anemic, sclera not icteric.
Neck: supple, no carotid bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, flat, no tenderness
Ext: No arthralgia, no deformities, no edema
Neurological Exam:
Mental status: Opens eyes with voice. Opens and closes right
hand, but inconsistently. Able to follow command to move eyes
with full EOM.
Cranial Nerves: R surgical pupil. L eye reactive, 4 to 3mm. Does
not blink to the threat from the right. Eye closure is weaker at
the left side.
Motor: Keeps flexed arms. Hypotonic at the left arm. Bilateral
legs have spasticity. Poor spontaneous movement at the left.
Sensation: Withdrawal at all extrimeties, more so at the right.
Reflexes: B T Br Pa Ankle
Right 3 3 3 3 3
Left 3 3 3 3 3
Toes up at the left, mute at the right.
Meningeal sign: Negative Brudzinski sign. No nucal rigidity.
Pertinent Results:
Labs:
128 91 7
- - - - - - gluc 125
3.4 23 0.6
CK: 80 MB: Pnd
WBC 8.3 HCT 38.1 PLT 333
N:83.3 L:13.0 M:2.9 E:0.5 Bas:0.1
PT: 31.8 PTT: 37.9 INR: 3.4
Head CT (@OSH): 2 cm x 2 cm R parieto-occipital hemorrhage with
small surrounding edema, no mass effect.
Head CT (@[**Hospital1 18**] ED): Stable size (21x23mm) intraparenchymal
hemorrhage. Small edema, no mass effect.
CT HEAD W/O CONTRAST [**2135-11-16**] 10:45 AM
Again seen is a right parieto-occipital hematoma measuring
approximately 2.7 cm in size with surrounding vasogenic edema
which is not significantly changed allowing for technical
differences. No new intracranial hemorrhages are identified. The
ventricles and sulci are prominent as before. There are
extensive white matter hypodensities which likely represent
chronic microangiopathic changes. Vascular calcifications are
noted bilaterally. The visualized orbits show cataract surgical
changes. right-sided nasogastric tube is in place. The
visualized paranasal sinuses, mastoid air cells, middle ear
cavities are clear. No suspicious bony abnormalities are seen.
IMPRESSION: No significant change in the right parieto-occipital
hematoma with surrounding vasogenic edema compared to [**2135-11-13**].
EKG [**11-12**]:
Technically difficult study
Sinus rhythm with atrial premature complexes cannot rule out
atrial
fibrillation with PVCs
Intraventricular conduction delay
Incomplete LBBB
Inferior/lateral ST-T changes may be due to myocardial ischemia
Since previous tracing of [**2132-9-13**], rhythm more irregular, QRS
interval wider
MRI/A brain:
FINDINGS: The right medial parietal lobe hemorrhage is
re-demonstrated, with a moderate amount of surrounding edema.
Within the hemorrhage is a small fluid level. There iss
extensive high T2 signal within the periventricular white matter
of both cerebral hemispheres, as well as a probable punctate
focus within the right cerebellar hemisphere. These
abnormalities are consistent with chronic small vessel
infarction, and appear to have been present on a prior MR study
obtained at this institution on [**2132-9-12**]. Additionally,
as was noted on the prior study, there are numerous tiny foci of
susceptibility scattered throughout the brain. As many of them
have a somewhat peripheral location, as was suggested before,
amyloid angiopathy may be present, and if so, would certainly
account for the new right medial parietal lobe hemorrhage. There
were no areas of pathological enhancement seen intracranially,
including the area of hemorrhage within the right parietal lobe.
The principal vascular flow patterns are observed, aside from
the proximal basilar artery. This latter finding, in retrospect
was probably present on the prior MR scan and raises the
question of a proximal occlusion or high-grade stenosis of this
vessel.
CONCLUSION:
1. Right parietal lobe hemorrhage, probably related to
underlying amyloid angiopathy.
2. Findings raise the question of a proximal basilar artery
occlusion or high-grade stenosis, likely seen on the prior [**2132**]
study as well.
MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) **] AND ITS TRIBUTARIES
TECHNIQUE: Three-dimensional time-of-flight imaging with
multiplanar reconstructions.
FINDINGS: Unfortunately the image quality of the MR [**First Name (Titles) 56928**] [**Last Name (Titles) **]P images is degraded by extensive overlying T1 hyperintensity
from fat within the skull base. Nevertheless, when reviewing the
source images, there is the impression that the proximal basilar
artery is occluded, aside from a small segment in its distal
portion. As was stated above, this finding was probably present
at the time of the [**2132-9-12**] study.
CONCLUSION: Findings suggest the presence of a proximal basilar
artery occlusion, likely chronic in age. The remaining vascular
tributaries of the circle of [**Location (un) 431**] are patent.
2 chest XRAYS confirm placement of NGT, show no infiltrate, show
some mild left-sided atelectasis
Brief Hospital Course:
82 yo woman wtih history of HTN, HL, TIA, persistent Afib on
Coumadin was transferred from OSH for right parenchymal
hemorrhage. Initial neurological examination showed left
hemiplegia and also possible right side upper motor neuron signs
as well, suggesting a possible old stroke on the left in
addition to new pathology in the right hemisphere. She had been
reversed with FFP and Vitamin K at an outside hospital prior to
transfer to the ER at [**Hospital1 18**], and she received more of each while
at [**Hospital1 18**]. She was loaded with dilantin and transferred to the
ICU for further monitoring on the stroke/ICU service. Head CT
showed a right parieto-occipital hemorrhage. MRI/A confirmed
the location of the hemorrhage, and as several "microbleeds"
were apparent, the etiology of the hemorrhage was felt to be
related to an underlying diagnosis of amyloid angiopathy, with
elevated risk of hemorrhage on coumadin (with supratherapeutic
INR reported as "11"). Her INR normalized after further
reversal and she had no more seizures. She was extubated
without complications. In the ICU, she was noted to have waxing
and [**Doctor Last Name 688**] mental status, thought in part due to the location of
the hemorrhage (right hemisphere) and compounded by worsening of
her baseline hyponatremia.
Her blood pressure was elevated and she was thus maintained on
an esmolol drip in the ICU for several days before being
transferred to the floor. She was maintained on standing
dilantin for seizure control. Her hyponatremia (Na 126 range)
gradually corrected with fluid restriction, and over time it
normalized to her "baseline" of 134 range. Her mental status
improved with this change, and by the time of discharge she was
alert and conversant, despite occasionally falling asleep during
conversation. Though she could not name the hospital itself,
she knew she was in the hospital in [**Location (un) 86**], and she knew the
season was Fall (guessed [**Month (only) 359**], rather than [**Month (only) **]). Her
naming was somewhat poor due to some inattention and
perseveration as well, connoting perhaps a pre-stroke diagnosis
of frontal lobe dysfunction, exacerbated by the hemorrhage
itself. These mental status findings were felt by the stroke
team to likely improve with time. Fluid restriction was
discontinued and salt tabs were continued. She should have her
sodium level rechecked at rehab in [**1-11**] days to ensure stability.
Her swallowing ability was initially impaired following the
cerebral hemorrhage and exacerbated by her decreased level of
alertness. A nasogastric tube was placed for nutrition for
several days before she was felt by swallow specialists to be
safe to take in a modified diet. Calorie counts were
recommended, to ensure adequate caloric intake. A swallow
evaluation should be repeated in several days after discharge in
order to advance her diet further.
Her family was counseled on the increased risks of bleeding
associated with amyloid angiopathy and anticoagulation, and
despite the history of atrial fibrillation, avoidance of
coumadin in the future was recommended. She was started on
Aspirin on [**11-21**], nine days after the hemorrhage.
At discharge, Keppra was started (she was given one dose), with
plans to discontinue dilantin after discharge following one day
of overlap. She should follow up with neurology after discharge
from rehab, or in [**3-13**] weeks.
Medications on Admission:
Coumadin (dose unknown), Simvastatin, Levoxyl, Xalatan,
Lisinopril, Norvasc, Isosorbide, Vicodin.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
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 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO three times a day for 1 days: for three more doses
after initiation of Keppra, then discontinue.
10. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp<100; increase to home dose in one week.
16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
increase to home dose in one week as blood pressure tolerates.
17. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day:
resume home dose in one week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16844**] Rehabilitation Center
Discharge Diagnosis:
Right parieto-occipital cerebral hemorrhage
Amyloid angiopathy
Hyponatremia (acute on chronic)
Discharge Condition:
Improved: mental status improving but still inattentive with
some anomia and oriented to 'hospital,' 'fall [**2135**]' and name.
Residual left-sided weakness (mild, [**4-14**] at best UMN pattern).
Discharge Instructions:
Please [**Name8 (MD) 138**] MD if patient experiences another seizure, or if she
has new signs of stroke or hemorrhage, including acute visual
change, trouble speaking or swallowing, or worsening weakness or
numbness.
Please check chem-7 in [**1-11**] days after discharge to ensure
stability of sodium, considering hyponatremia.
Avoid all coumadin/warfarin.
Continue calorie counts at rehab, and supplement diet as needed.
Please have swallow ability re-evaluated in [**3-14**] days, in order
to consider advancing diet.
Followup Instructions:
1) Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**]
[**Last Name (NamePattern1) 1159**] ([**Telephone/Fax (1) 20587**]) after discharge from rehab.
2) Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] (neurology) after
discharge from rehab (or in [**3-13**] weeks); please call ([**Telephone/Fax (1) 19129**] for an appointment. ([**Hospital1 1170**].)
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
|
[
"E934.2",
"401.9",
"780.39",
"427.31",
"V58.61",
"277.30",
"272.4",
"276.1",
"790.92",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.07",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
11399, 11468
|
6162, 9607
|
306, 362
|
11607, 11807
|
2154, 6139
|
12381, 12928
|
1106, 1125
|
9756, 11376
|
11489, 11586
|
9633, 9733
|
11831, 12358
|
1140, 1466
|
1485, 1485
|
238, 268
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390, 966
|
1640, 2135
|
1500, 1624
|
988, 1048
|
1064, 1090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,334
| 189,423
|
6545
|
Discharge summary
|
report
|
Admission Date: [**2137-3-29**] Discharge Date: [**2137-4-27**]
Date of Birth: [**2081-8-19**] Sex: M
Service: SURGERY
Allergies:
Demerol
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Right leg claudication.
Major Surgical or Invasive Procedure:
Right common femoral endarterectomy and right
femoral popliteal bypass with nonreverse saphenous vein and
angioscopy
The flexible bronchoscope was
passed through the tracheostomy tube which terminated in the
midline position. There was a moderate amount of clear
secretions throughout the airways which were therapeutically
aspirated. There were no endobronchial lesions at the
subsegmental level bilaterally. There was moderate to severe
malacia in the right mainstem bronchus, as well as moderate
malacia in the left mainstem bronchus.
History of Present Illness:
55-year-old gentleman with severe peripheral vascular disease
has had severe disabling claudication of his right lower
extremity. He has some iliac
disease, diffuse common femoral disease, a long segment right
superficial femoral artery occlusion with reconstitution of a
below-knee popliteal artery and good 2-vessel runoff to the
foot.
Past Medical History:
- vocal cord CA s/p radiation/laryngectomy/trach
- chronically elevated WBC (on prednisone for Rx)
- HTN
- R knee replacement
- tonisllectomy
Social History:
non-contrib
Family History:
non-contrib
Physical Exam:
Pt deceased
Pertinent Results:
[**2137-4-27**] 02:16AM BLOOD
WBC-19.5*# RBC-2.79* Hgb-8.5* Hct-25.6* MCV-92 MCH-30.3
MCHC-33.1 RDW-17.3* Plt Ct-332
[**2137-4-23**] 5:05 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2137-5-6**]**
GRAM STAIN (Final [**2137-4-24**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2137-4-26**]):
RARE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA OXYTOCA. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S 4 S
CEFTAZIDIME----------- <=1 S 4 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S 0.5 S
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- <=4 S 16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Cardiology Report ECHO Study Date of [**2137-4-26**]
PATIENT/TEST INFORMATION:
Indication: Congestive heart failure.
Weight (lb): 242
BP (mm Hg): 168/73
HR (bpm): 120
Status: Inpatient
Date/Time: [**2137-4-26**] at 15:08
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W013-0:41
Test Location: West SICU/CTIC/VICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1111**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.3 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.8 cm
Left Ventricle - Fractional Shortening: 0.42 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 80% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aorta - Ascending: *4.0 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 218 msec
TR Gradient (+ RA = PASP): *46 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded. Hyperdynamic LVEF. TVI E/e' < 8, suggesting normal
PCWP (<12mmHg).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal
mitral valve supporting structures. Normal LV inflow pattern for
age.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal
tricuspid valve supporting structures. Moderate PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality - poor apical views.
Conclusions:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Left ventricular systolic function is hyperdynamic
(EF 80%). Tissue velocity imaging demonstrates an E/e' <8
suggesting a normal left ventricular filling pressure. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
To Note:
Pt deceased this hospital course vocal cord CA s/p
radiation/laryngectomy/trach, chronically elevated WBC (on
prednisone).
[**2137-3-29**]
Pt underwent a Right common femoral endarterectomy and right
femoral popliteal bypass with nonreverse saphenous vein and
angioscopy. Pt tolerated the procedure well, there were no
complications. Pt extubated in the OR. Transfered to the PACU in
stable condition.
Once recovered from anesthesia, pt transfered to the VICU in
stable condition.
[**2137-3-30**] - [**2137-3-31**]
Pt did well in the [**Hospital 25075**] transfered to the floor in stable
condition. On [**2137-3-31**] pt was noted to have decrease o2. ABG was
obtained. Trigger was then called. Pt intubated and placed in
the SICU.
Diagnosis of ARDS was made shortly after.
[**2137-4-1**]
The flexible bronchoscope was passed through the tracheostomy
tube which terminated in the midline position. There was a
moderate amount of clear secretions throughout the airways which
were therapeutically aspirated. There were no endobronchial
lesions at the subsegmental level bilaterally. There was
moderate to severe
malacia in the right mainstem bronchus, as well as moderate
malacia in the left mainstem bronchus.
[**2137-4-1**] - [**2137-4-27**]
Pt remained intubated, fevers, multiple attempts at weanig
patient from vent. pulmonary consulted. Input appreciated. Pt
put on Antibiotics / the AB were adjusted to the sensitivities /
multiple bronchs. Pt could not be weaned from vent.
Bronch/BAL->klebsiella oxytoca pan s (except augmentin), GNR#2,
yeast
Thigh U/S w/ 3 collections:prox 2.2x7.7/ distally 5.5x1.3x3.0cm/
medial to knee 3.7x3.2
Sputum->pseudomonas(panS), GNR
CT Chest-consolidation/ground glass infiltrate
Echo->hyperdynamic
In short Pt developed diffuse severe pulmonary edema,
interstitial disease. pt had bouts of being febrile an then
having no fevers. Antibiotics were adjusted according to
sensitivities.
Pulm thought that the pt developed bronchial malachia.
The last attempt to wean from vent / failed. Pt family was
notified. Pt made CMO by family. Shortly after extubation. Pt
passed away.
Medications on Admission:
ASA 325, zoloft 100', quinine sulfate 325, atenolol 100,
prednisone 5', doxepin 10', tramadol 50', nexium 40', celebrex
200', gabapentin 300am/100pm
Discharge Medications:
N/A deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
ARDS
Right leg claudication
Followup Instructions:
Deceased
Completed by:[**2137-5-8**]
|
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"780.6",
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"519.1",
"482.1",
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icd9cm
|
[
[
[]
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] |
[
"38.93",
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"96.6",
"33.24",
"38.18",
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icd9pcs
|
[
[
[]
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8531, 8540
|
6151, 8295
|
292, 833
|
8592, 8602
|
1473, 2940
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8494, 8508
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8561, 8571
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8321, 8471
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8626, 8656
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2966, 6128
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1441, 1454
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228, 254
|
861, 1202
|
1224, 1367
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1383, 1397
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,332
| 186,538
|
11772
|
Discharge summary
|
report
|
Admission Date: [**2152-4-2**] Discharge Date: [**2152-4-30**]
Date of Birth: [**2110-1-16**] Sex: M
Service: MEDICINE
Allergies:
Amphotericin B / Ambisome / Campath
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
40 yo with cml s/p transplant complicated by GVHD presents with
worsening sob.
Major Surgical or Invasive Procedure:
s/p pericardial effusion drainage
History of Present Illness:
Pt is a 40 yo male with a h/o CML s/p MUD (CMV+/+) BMT in [**2147**],
complicated by chronic graft versus host disease of the skin,
lung and liver, in addition to chronic thrombocytopenia. He is
currenlty on Prednisone tx for his severe GVHD of the skin. He
has chronic pulmonary problems with opacities in RML suggestive
of BOOP and is followed by Dr. [**Last Name (STitle) 9504**]. He has been on high
doses of steroids and other therapies for his pulmonary
condition. Pt was seen in clinic on [**2152-3-29**] for worsening sob
and flu like symptoms. Nasal fluid sample confirmed influenza
and he was started on tamiflu. Also of note he was diagnosed
with right subclavian dvt recently and was started on lovenox
which he self d/c'ed 10 days ago because it was causing him
pain. Pt now presents with worsening sob and particularly on
exertion. No chest pain/orthopnea/pnd associated. He does have
cough on lying flat but is afebrile and has no sputum or
haemoptysis. He was evaluated in ER where he was noted to have a
mod-severe size pericardial effusion on non contrast CT. Pt was
given a full dose lovenox for dvt/pe and admitted for further
evaluation.
Past Medical History:
#. MUD allo BMT [**10-8**] for CML, c/b GVHD, chronic
thrombocytopenia, anemia,
Donor Info: donor #[**Numeric Identifier 37214**]
Sex: female,
Age: 37,
# of pregnancies: 4,
ABO donor: Apos,
ABO recipient: Apos,
CMV donor: (+),
CMV recipient:(+)
#. GVHD--symptoms have included severe skin findings,
thrombocytopenia requiring transfusions, bronchiolitis
obliterans and mouth sores. treatment options are limited, since
the patient has also had HUS to calcineurin inhibitors such as
cyclosporine, FK 506, no response to rapamycin, has had multiple
trials of Rituxan as well as trial of endostatin all without
signficant improvement.
#. BOOP due to GVHD. He unfortunately has had multiple prior
therapies including Rituxan, pentostatin, Campath, steroids, and
CellCept. He has had a significant issue as in the past with
cyclosporin and FK-506. The patient had a repeat chest CT in
[**2150-12-8**] to reassess his lung disease. There were no
significant changes in the few opacities that may represent
underlying BOOP since his last scan several months ago.
#. RSV pneumonitis
#. HTN
#. CRI
#. portacath in place
#. chronic right extremity edema
#. episodic spasm of mouth muscles, unclear etiology.
#. Obstructive airways disease, possibly due to GVDH.
Social History:
no EtOH, tobacco, drugs
Family History:
Non-contributory
Physical Exam:
BP 100/60, pulsus of 20, hr 110, sats 93% on 3l, 98
GENERAL: pleasant, well-appearing man in no acute distress.
HEENT: PERRL with anicteric sclerae. Conjunctivae remains dry
and with some injection Oropharynx remains moist with some
erythematous changes on the buccal mucosae.
NECK: Supple with thickening, no JVD visualised.
LUNGS: bilateral scattered rhonchi but good air entry and no
crackles at bases.
HEART: regular rate and rhythm. distant heart sound, no m/r/g.
ABDOMEN: Soft, nontender, and nondistended with normal bowel
sounds and without hepatosplenomegaly appreciated.
EXTREMITIES: Edema of the right upper extremity, chronic per pt.
He has increased thickening in his lower extremities and mild
edema overall.
SKIN: hyperpigmentation on his scalp and face with skin
thickening and lichen planus changes, this remains relatively
stable. Scabbed lesions noted on scalp and face. Thickening of
the skin of his neck, upper chest, back, and arms with
hyperpigmentation changes and discoloration his arms, back, and
upper chest.
Pertinent Results:
CT [**2152-4-2**]:
1. Interval increase in simple pericardial effusion, now
moderate to severe in size. Findings may be cause of patient's
new onset dyspnea on exertion.
2. Resolution of previously noted right-sided pleural effusion
with residual small left-sided pleural effusion and no
interstitial disease or parenchymal opacity suggestive of
underlying pneumonia identified. Grossly stable appearance to
right apical nodular opacity likely related to nodular scarring.
.
[**4-2**] CXR, PA/Lat:
1. Prominent cardiac silhouette, more so than on [**2151-7-23**],
though similar to [**2152-3-29**]. While this could represent an image
obtained in diastole, the
differential diagnosis would include a pericardial effusion.
Clinical
correlation is requested.
2. Stable small left effusion. Subsegmental atelectasis. No
acute
infiltrate. No CHF.
.
[**4-3**] Echo: Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular systolic function is normal. There
is a moderate to large sized pericardial effusion. Greatest
dimension is posterior at 2.0 cm. Less anterior fluid (0.5 -1.0
cm). There is right ventricular early diastolic invagination,
consistent with impaired filling/early tamponade physiology.
.
[**2152-4-5**] Chest CT:
1. New focal right lower lobe consolidation and small right
pleural effusion. This may be due to an acute infectious
pneumonia with parapneumonic effusion given clinical suspicion
for infection.
2. Peripheral and peribronchiolar opacities in the left lower
lobe and
inferior right middle lobe and lingula. Although nonspecific,
these could be due to COP given the clinical history of this
entity.
3. Persistent small left pleural effusion.
4. Moderate pericardial effusion, decreased in size since recent
CT.
.
[**2152-4-10**] CT Chest: Large left lower lobe consolidation is new.
While consolidation in the anterior basal segment of the right
lower lobe has improved, there are new multiple peribronchial
and subpleural ill-defined opacities in the upper lobe lingula
and right middle lobe. There are no bone findings of malignancy.
The upper abdomen is unremarkable.
IMPRESSION: Worsening of either COPD or pneumonia. Decrease in
small pericardial effusion. Enlarging small left pleural
effusion. Coronary calcification. In the right upper lobe,
tubular ill-defined opacity is stable (3A, 18).
.
[**2152-4-13**] CTA:
1. No pulmonary emboli in the central vessels, to the level of
the
subsegmental arteries.
2. Progression of the multifocal consolidations since the prior
study, now
involving both lower lobes, the right middle lobe and the
lingula and, to a lesser extent, the right upper lobe.
3. Moderately large bilateral pleural effusions.
4. Stable small pericardial effusion.
5. Stable right-sided pleural calcifications.
.
[**2152-4-22**] CT Chest:
1. No significant short interval change in the appearance of the
chest, with bilateral lower lobe consolidations, to a similar
degree. Opacities of the right middle lobe and lingula as well
as the portion of the right upper lobe appear similar, with
possible slight increase in nodular opacities in the lingula.
2. Moderate right pleural effusion and small left pleural
effusion are
slightly decreased from the prior study.
3. Small unchanged pericardial effusion.
4. Coronary artery calcifications.
5. Right pleural calcifications.
.
[**2152-4-25**] Echo: EF >55%, Preserved global biventricular systolic
function. Mildly dilated ascending aorta. Compared with the
prior study (images reviewed) of [**2151-4-14**], no pericardial effusion
is identified on the current study. The pleural effusions appear
more prominent.
.
[**2152-4-26**] CXR: Decrease in size of bilateral effusions. Possible
new right
upper lobe infiltrate.
.
Brief Hospital Course:
.
A/P: 40 yo M with history of CML s/p MUD CMV+/+) BMT in [**2147**]
complicated by GVHD of skin, lungs and liver, and chronic
thrombocytopenia admitted for SOB secondary to influenza. His
hospital course was complicated by pericardial effusion with
tamponade physiology s/p drainage of effusion in the CCU,
respiratory distress from Tamiflu resistant influenza and
superimposed bacterial PNA requiring ICU admission.
.
# Pneumonia: The patient was admitted for worsening shortness of
breath and fevers in the setting of a positive DFA for influenza
A. As an outpatient, he was started on Levofloxacin and Tamiflu
for a 2 week course. Upon admission, a CXR showed worsening
infiltrates most concerning for a superimposed bacterial
infection. He was put on Cefepime, Vanc, Azithromycin and
Flagyl but his respiratory status continued to worsen with
persistent fever spikes. Posaconazole was later added for
fungal coverage. A bronchoscopy was performed which showed
persistent influenza A despite 2 weeks of Tamiflu therapy. The
state lab confirmed that the patient was Tamiflu resistant. The
patient was transferred to the [**Hospital Unit Name 153**] when he began to desaturate
to the mid-80s on NRB. A CTA showed no evidence of PE but a
multifocal pneumonia with progression of multifocal
consolidations involving both lower lobes, right middle lobe,
lingula and to a lesser extent, the right upper lobe. He was
started on Amantidine in the ICU for a brief period until
Rimantidine could be obtained (the patient did not experience
any neurologic side effects while on Amantidine). His
antibiotics were broadened to include Zosyn, Ceftazidime,
Posaconazole, Azithromycin and Vancomycin. In the ICU, the
patient required NRB with persistent desaturations with any type
of motion or exertion. He transiently required Bipap when he
began to tire but was never intubated. Additionally, the
patient's immunosuppression was increased while in the MICU for
question of BOOP but the appearance of his CT seemed more
consistent with multifocal pneumonia and not BOOP so his
steroids were tapered back to his home dose. His oxygen
saturation slowly improved and he was transferred back to the
BMT floor. Because of falling platelets down to as low as 63,
the patient was switched from Zosyn to Meropenem which was
thought to have less thrombocytopenic effects. The patient was
followed by the ID service during his hospital course. After >
10 days of antibiotics, the patient was on room air at rest and
his antibiotics were discontinued. He was observed for 3-4 days
off antibiotics without fevers or increased oxygen requirement
at which time he was discharged home with close followup.
.
#Influenza: The patient was started on Tamiflu for influenza and
completed 14 days of Tamiflu. His respiratory status worsened
and he underwent bronchoscopy. The bronchoscopy showed that the
influenza DFA from the bronch was still positive for Influenza
A. The patient was tested for Tamiflu resistant influenza and
this was confirmed. He was switched briefly to Amantidine while
awaiting the pharmacy to obtain Rimantidine (the patient did not
experience any neurologic side effects while on Amantidine). A
repeat influenza DFA was sent and was negative for influenza.
The final viral culture is NGTD and will be monitored for 30
days for evidence of growth of influenza.
.
#Pericardial effusion with tamponade physiology: On admission,
the patient was found to have a moderate pericardial effusion on
CT scan. A pulsus was found to be elevated and an echo showed
evidence of early tamponade physiology. The patient was
transferred to the CCU and the pericardial effusion was drained.
Serial repeat echos showed no evidence of recurrent effusion or
tamponade physiology. The patient was followed by cardiology
during his hospital course.
.
# New atrial fibrillation/flutter: After the patient's
pericardial effusion was drained and the drain removed, he was
found to be in rapid afib/flutter. This was thought to be
secondary to irritation from the pericardial drain. He was put
on Diltiazem for a brief period and converted back to sinus
rhythm shortly afterwards. His Diltiazem was stopped as it was
thought that his atrial fib/fluter was an isolated event in the
setting of pericardial irritation from the drain. However, the
patient had a second episode of atrial fib/flutter with rates to
the 160s. He was given IV diltiazem which slowed his rate, and
then restarted on PO Dilt. Cardiology saw the patient and
recommended switching the patient to a long acting Diltiazem
which the patient tolerated well. He converted back to sinus
rhythm spontaneously. Additionally, the patient was started on
Metoprolol to further slow his rate. He had no further episodes
of flutter during this hospitalization.
.
# Thrombocytopenia: The patient's platelets began to trend down
during his hospital course. This was thought to be [**3-10**] the
multiple antibiotics the patient had been on during his hospital
course including Zosyn and Meropenem. The patient's platelets
were > 200 upon admission and trended down slowly during this
admission. His platelets were as low as 63 while on multiple
antibiotics but began to rise slowly 2-3 days after all
antibiotics were stopped. He will be seen 2 days after
discharge for a count check.
.
#GVHD: Severe on skin, with liver and lung involvement. The
patient was discharged on prednisone 40mg qd. During his MICU
course, his steroids were increased slightly for concern of BOOP
but this was tapered back to his home dose after no improvement
was seen and his pulmonary process appeared to be consistent
with consolidative pneumonia, not BOOP.
.
#CML: No active issues. His platelets declined this admission
from around 200 upon admission to as low as 63, but this was
thought to be secondary to the multiple antibiotics the patient
was put on for his bacterial pneumonia. After stopping his
Meropenem and Zosyn, the patient's platelets improved
spontaneously.
.
#Hypertension: The patient had difficult to control blood
pressures during this admission. His blood pressures had to be
taken in the lower extremity because of RUE DVT and left arm
PICC line. His ankle blood pressures seemed to correlate fairly
well with his upper extremity pressures. His SBPs ranged from
150-190s and his Metoprolol was titrated up for goal SBP 140s.
Additionally, he was put on long acting Diltiazem for atrial
flutter.
.
#RUE edema and DVT: RUE edema is chronic [**3-10**] RUE DVT. Stable
during this admission. Patient chose not to continue Lovenox
injections as an outpatient because he did not see improvement
in the RUE edema.
.
#CRI: stable, monitor
.
#Full code.
.
Medications on Admission:
Allergies: Amphotericin B Ambisome (Intraven.) (Amphotericin B
Liposome) Campath (Intraven.) (Alemtuzumab).
.
Current Meds (confirmed with pt):
Prednisone 40 mg daily
Aacyclovir 400 mg b.i.d.
Cozaar 100 daily
Folic acid 1 mg daily
Pentamadine q month (last [**2151-4-1**])
Levofloxacin 500mg po qd
Tamiflu 1 qd.
.
Discharge Medications:
1. Home Oxygen Therapy
Continuous home oxygen therapy at 1-3L/minutes. For
portability, pulse dose system.
2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
7. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
Disp:*200 ML(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] medical services
Discharge Diagnosis:
.
Primary:
Influenza Pneumonia complicated by bacterial pneumonia
CML
Atrial fib/flutter
Pericardial effusion and tamponade, s/p drainage
Severe GVHD of skin and lungs
.
Discharge Condition:
Still requiring oxygen therapy for ambulation. 93-95% on room
air when at rest. Persistent cough but improving slowly.
Discharge Instructions:
.
You were admitted for influenza complicated by superimposed
bacterial pneumonia, pericardial effusion requiring drainage,
and atrial flutter.
.
Please attend all followup appointments as scheduled.
.
Please take all medications as prescribed:
- Please take your long acting Diltiazem to prevent your heart
from going back into a rapid rhythm called atrial flutter.
- Please take Metoprolol for your high blood pressure.
- You were also given medications for your cough which you can
take on an as needed basis.
.
Please attend all followup visits as scheduled below.
.
Followup Instructions:
.
Please followup on 7F BMT Outpatient area for a counts check by
fingerstick on [**5-2**] at 8am to ensure your platelets
continue to rise.
.
Please call your primary oncologist, Dr. [**Last Name (STitle) **], at
([**Telephone/Fax (1) 6179**] to set up a followup appointment for Thursday or
Friday after your discharge.
.
Please followup with your pulmonologist, Dr. [**Last Name (STitle) 575**], on [**5-11**] at 9:25AM.
.
Completed by:[**2152-4-30**]
|
[
"427.31",
"585.9",
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"287.5",
"403.90",
"482.9",
"516.8",
"423.9",
"996.85",
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icd9cm
|
[
[
[]
]
] |
[
"33.22",
"38.93",
"37.0",
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] |
icd9pcs
|
[
[
[]
]
] |
15942, 16005
|
7803, 14528
|
375, 411
|
16219, 16342
|
4025, 7780
|
16961, 17418
|
2935, 2953
|
14892, 15919
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16026, 16198
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16366, 16938
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2968, 4006
|
256, 337
|
439, 1600
|
1622, 2876
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2892, 2919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,203
| 139,485
|
52375
|
Discharge summary
|
report
|
Admission Date: [**2132-12-2**] Discharge Date: [**2132-12-12**]
Date of Birth: [**2084-1-7**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Morbid obesity
Major Surgical or Invasive Procedure:
1. Diagnostic laparoscopy with conversion to open Roux-en-Y
gastric bypass.
2. Exploratory laparotomy.
3. Placement of gastrostomy tube.
4. Application of fibrin glue to gastro-J and JJ.
History of Present Illness:
[**Known firstname 108243**] has class III morbid obesity, weight 349.8 pounds,
height 69.5 inches and BMI 50.9. Previous weight loss efforts
have included Optifast, off-label prescription weight loss
medications Fenfluramine/Phentermine. He has not tried any
popular weight loss diets or used over-the-counter
ephedra-containing appetite suppressants/herbal supplements. He
does not remember what his weight at age 21 was but he is at his
highest weight currently. He has been struggling with weight
"all my life". Factors contributing to excess weight include
large portions, grazing, late night eating, and too many
carbohydrates in saturated fats and lack of exercise regimen
until recently when he started elliptical and treadmill at a gym
3 times per week. He denied history of eating disorders but does
have eating issues stating that he always eats and is never
satisfied and even if he is full he will still eat. He comments
that the more food he sees the more food he will eat. He does
have depression with ADHD on medication but no hospitalizations
for psychological issues.
Past Medical History:
PMH:
-hypertension
-type 2 diabetes hemoglobin A1c of 7.6%
-obstructive sleep apnea on BiPAP
-hyperlipidemia
-mild asthma
-vertigo
-fatty liver
PSH:
-fistulotomy
-hemorrhoidectomy with rubber band ligation x 2, [**2125**].
Social History:
He denied tobacco or recreational drug usage, no alcohol and has
occasional
caffeinated beverage. He is disabled having been injured at
work with a head injury. He is married living with his wife age
45 and they have two daughters ages 15 and 24 and a
granddaughter living with them.
Family History:
Family history is noted for stroke in his parents and history of
diabetes and obesity. His brother and daughter both had
[**Name (NI) 33554**] gastric bypass procedures done for morbid obesity at
the [**Hospital 882**] Hospital.
Physical Exam:
Vital signs: Temperature 98.3, Heart rate 86, Blood pressure
119/70, Respiratory rate 20, Oxygen saturation 100% on room air
Constitutional: No acute distress, anxious for discharge
Neuro: Alert and oriented to person, place and time
Cardiac: Regular rate and rhythm; no murmurs/ rubs/ gallops;
normal S1 S2
Lungs: Clear to auscultation, bilaterally; no wheezes/ rales/
rhonchi
Abdomen: Soft, non-tender, non-distended, no rebound tenderness
or guarding; g-tube to gravity; JP drain x 1 w/ serous fluid
Wounds: Abdominal midline incision without erythema or
induration
Extremities: No cyanosis, clubbing, edema
Pertinent Results:
[**2132-12-2**] 07:00PM BLOOD Hct-41.6
[**2132-12-3**] 05:29AM BLOOD Hct-40.9
[**2132-12-3**] 12:25PM BLOOD WBC-13.7*# RBC-4.66 Hgb-14.6 Hct-43.4
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.8 Plt Ct-201
[**2132-12-4**] 04:35AM BLOOD WBC-13.9* RBC-4.30* Hgb-13.4* Hct-39.9*
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.8 Plt Ct-176
[**2132-12-3**] 12:25PM BLOOD Plt Ct-201
[**2132-12-4**] 04:35AM BLOOD Plt Ct-176
[**2132-12-3**] 12:25PM BLOOD Glucose-243* UreaN-19 Creat-1.2 Na-141
K-4.2 Cl-101 HCO3-27 AnGap-17
[**2132-12-4**] 04:35AM BLOOD Glucose-225* UreaN-16 Creat-0.9 Na-141
K-4.0 Cl-104 HCO3-27 AnGap-14
[**2132-12-4**] 04:35AM BLOOD Calcium-9.0 Phos-1.9* Mg-1.8
[**2132-12-4**] 08:30AM BLOOD pO2-235* pCO2-48* pH-7.39 calTCO2-30 Base
XS-3
[**2132-12-4**] 08:30AM BLOOD Glucose-237* Lactate-1.4 Na-141 K-4.1
Cl-102 calHCO3-28
[**2132-12-4**] 08:30AM BLOOD freeCa-1.11*
[**2132-12-5**] 02:14AM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.1*
Mg-1.9
[**2132-12-5**] 03:51AM BLOOD Type-ART pO2-69* pCO2-40 pH-7.44
calTCO2-28 Base XS-2
[**2132-12-5**] 02:14AM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.1*
Mg-1.9
[**2132-12-5**] 02:14AM BLOOD ALT-301* AST-107* LD(LDH)-236
CK(CPK)-[**2083**]* AlkPhos-41 Amylase-22 TotBili-2.5*
[**2132-12-5**] 08:24PM BLOOD CK(CPK)-2110*
[**2132-12-5**] 02:14AM BLOOD PT-15.6* PTT-25.6 INR(PT)-1.4*
[**2132-12-5**] 02:14AM BLOOD Plt Ct-148*
[**2132-12-5**] 02:14AM BLOOD WBC-11.7* RBC-3.88* Hgb-12.5* Hct-35.8*
MCV-92 MCH-32.1* MCHC-34.9 RDW-13.8 Plt Ct-148*
[**2132-12-6**] 02:21AM BLOOD Glucose-228* UreaN-16 Creat-0.9 Na-142
K-3.7 Cl-109* HCO3-23 AnGap-14
[**2132-12-6**] 07:28PM BLOOD Glucose-260* UreaN-17 Creat-0.8 Na-144
K-3.3 Cl-111* HCO3-24 AnGap-12
[**2132-12-5**] 02:14AM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.1*
Mg-1.9
[**2132-12-6**] 02:21AM BLOOD Albumin-3.2* Calcium-8.5 Phos-1.7* Mg-1.8
[**2132-12-6**] 04:08AM BLOOD Type-ART pO2-87 pCO2-37 pH-7.45
calTCO2-27 Base XS-1
[**2132-12-6**] 10:32AM BLOOD Type-ART pO2-60* pCO2-37 pH-7.47*
calTCO2-28 Base XS-3
[**2132-12-6**] 07:53PM BLOOD Type-ART pO2-63* pCO2-33* pH-7.49*
calTCO2-26 Base XS-2
[**2132-12-6**] 10:32AM BLOOD Glucose-239* Lactate-1.8 Na-143 K-3.5
[**2132-12-6**] 04:08AM BLOOD freeCa-1.11*
[**2132-12-6**] 10:32AM BLOOD freeCa-1.15
[**2132-12-6**] 02:21AM BLOOD cTropnT-<0.01
[**2132-12-6**] 02:21AM BLOOD ALT-230* AST-82* AlkPhos-48 TotBili-2.0*
[**2132-12-6**] 02:21AM BLOOD Plt Ct-162
[**2132-12-6**] 02:21AM BLOOD WBC-11.8* RBC-3.95* Hgb-12.6* Hct-36.6*
MCV-93 MCH-31.8 MCHC-34.4 RDW-13.7 Plt Ct-162
[**2132-12-6**] 07:28PM BLOOD Glucose-260* UreaN-17 Creat-0.8 Na-144
K-3.3 Cl-111* HCO3-24 AnGap-12
[**2132-12-7**] 01:10AM BLOOD Calcium-8.9 Phos-2.2* Mg-2.0
[**2132-12-7**] 01:10AM BLOOD ALT-187* AST-70* AlkPhos-54 TotBili-1.4
[**2132-12-7**] 01:10AM BLOOD Plt Ct-192
[**2132-12-7**] 01:10AM BLOOD WBC-11.2* RBC-4.00* Hgb-12.6* Hct-37.6*
MCV-94 MCH-31.6 MCHC-33.6 RDW-13.6 Plt Ct-192
[**2132-12-8**] 01:13AM BLOOD Glucose-263* UreaN-16 Creat-0.7 Na-142
K-3.7 Cl-108 HCO3-25 AnGap-13
[**2132-12-8**] 01:13AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8
[**2132-12-8**] 01:13AM BLOOD ALT-144* AST-46* AlkPhos-55 TotBili-1.0
[**2132-12-8**] 01:13AM BLOOD Plt Ct-208
[**2132-12-8**] 01:13AM BLOOD WBC-9.8 RBC-4.21* Hgb-13.3* Hct-39.8*
MCV-95 MCH-31.5 MCHC-33.3 RDW-13.9 Plt Ct-208
[**2132-12-9**] 02:37AM BLOOD Glucose-122* UreaN-22* Creat-0.9 Na-144
K-3.4 Cl-110* HCO3-27 AnGap-10
[**2132-12-9**] 02:37AM BLOOD Plt Ct-228
[**2132-12-9**] 02:37AM BLOOD WBC-11.8* RBC-4.30* Hgb-13.4* Hct-40.5
MCV-94 MCH-31.2 MCHC-33.1 RDW-14.0 Plt Ct-228
[**2132-12-10**] 06:50AM BLOOD Glucose-123* UreaN-24* Creat-1.1 Na-144
K-3.8 Cl-108 HCO3-30 AnGap-10
[**2132-12-10**] 06:50AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9
[**2132-12-10**] 06:50AM BLOOD Plt Ct-220
[**2132-12-10**] 06:50AM BLOOD WBC-12.3* RBC-3.89* Hgb-11.9* Hct-37.0*
MCV-95 MCH-30.5 MCHC-32.1 RDW-14.1 Plt Ct-220
[**2132-12-3**] UGI SGL CONTRAST W/ KUB:
High density material within the JP drain, suggests extraluminal
leak. No
definite leak is visualized, though there is a possible linear
focus of
extraluminal contrast near the gastrojejunostomy. No holdup or
stenosis
[**2132-12-4**] CHEST (PORTABLE AP)
IMPRESSION:
1. Mediastinal and hilar venous engorgement.
2. Retrocardiac atelectasis with possible small bilateral
pleural effusions.
[**2132-12-5**] CHEST (PORTABLE AP)
IMPRESSION:
No pulmonary edema
Brief Hospital Course:
The patient presented to pre-op on [**2132-12-2**]. Pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic gastric banding. The patient was difficult to
intubate due to thickened neck circumference. Also, there was
difficulty placing the [**Last Name (un) **]-gastric tube into the stomach,
therefore, an open Roux-en-Y gastric bypass was performed.
Otherwise, there were no adverse events in the operating room;
please see the operative note for details. Pt was extubated,
taken to the PACU until stable, then transferred to the [**Hospital1 **] for
observation.
On hospital day #1 an UGI was performed, which showed high
density material within the JP drain, suggestive of an
intraluminal leak. Given the results of the study, the patient
was monitored closely with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube to low,
intermittent suction, a JP drain to bulb suction, and strictly
nothing by mouth. The patient remained clinically stable
without abdominal exam changes throughout the day, however,
overnight the patient became persistently tachycardic to the
120s. Therefore, the decision was made to return to the
operating room for exploratory surgical intervention.
On post-operative day #2, the patient underwent an exploratory
laparotomy, placement of a gastrostomy tube and application of
fibrin glue to the gastro-jejunostomy and J-J anastomosis.
Intra-operatively, no leak was identified. There were no
adverse events in the operating room; please see operative note
for details. The patient remained intubated, was brought to the
PACU until stable, then transferred to the surgical intensive
care unit for close observation.
Neuro: The patient was alert and oriented throughout his
hospitalization except for brief period of visual hallucinations
which he experienced in the intensive care unit. The
hallucinations, which were treated with intravenous Haldol,
resolved without further occurrence; pain was initially managed
with a morphine PCA, which required an increase in dosing on
post-operative day #1 due incisional abdominal pain. In the
intensive care unit, the patient was managed briefly with
intravenous morphine, which was transition ed to rectal and then
oral Tylenol, with well-controlled pain.
CV: On post-operative day #1 the patient remained stable from a
cardiovascular standpoint, however, overnight the patient became
persistently tachycardic as described above. Post-operatively,
in the intensive care unit, the patient became hypertensive to
the 170-180s. He was initially managed with intravenous
metoprolol and hydralazine. Labetalol was trialed, but he
eventually required a nicardipine drip. On post-operative day
#6/ #4, intravenous enalapril was added to the regimen as
nicardipine was weaned. The patient was subsequently managed
successfully with intravenous metoprolol and enalapril until he
resumed an oral diet. Oral medication management included
losartan and amlodipine at the suggestion of his primary care
provider who will see him next week.
Pulmonary: The patient self-extubated in the intensive care unit
on post-operative day #3/#1 and was maintained on CPAP. He
developed a brief period of respiratory distress which resolved
once the CPAP mask was adjusted for his [**Last Name (un) **]-gastric tube.
Arterial blood gasses were within acceptable limits at this
time. On the floor, the patient was weaned from oxygen and
maintained on CPAP at night due to known obstructive sleep
apnea. He subsequently remained stable from a pulmonary
standpoint. Good pulmonary toilet, and incentive spirometry
were encouraged
GI/GU/FEN: On post-operative day #1 the patient was NPO, given
intravenous fluids and had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube in place for
decompression of his gastric pouch. Following his UGI study
described above, the patient was kept strictly NPO with a
[**Last Name (un) **]-gastric tube maintained to low, intermittent wall suction.
The JP drain was maintained on bulb suction. Serial abdominal
exams were performed every 2-3 hours until the patient returned
to the operating room. Upon return to the operating room, a
g-tube was placed which remained to gravity throughout the
remainder of his hospitalization. Total parenteral nutrition
was initiated in the intensive care unit and continued until the
patient was tolerating a Stage 3 diet on post-operative day
#10/#8. The patient tolerated an oral diet well. Patient's
intake and output were closely monitored with adjustments made
to the intravenous fluids as needed. Electrolytes were
monitored and repleted as needed routinely. The patient's Foley
catheter was discontinued on post-operative day #8/#6 without
subsequent issues with voiding. On day of discharge, one of the
two JP drains was pulled and the central line was discontinued.
ID: On post-operative day #1 the patient remained afebrile with
a stable white blood cell count. On post-operative day #2,
while in the PACU, the patient spiked a temperature. Pan
culture was performed with negative results. Intravenous
ciprofloxacin and metronidazole were initiated and continued
through post-operative day #9/#7. The patient remained afebrile
without signs and symptoms of infection throughout the remainder
of his hospital course.
Heme: The patient's hematocrit level was monitored routinely
without signs of bleeding.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Hydrochlorothiazide 12.5 mg daily
Avapro 150 mg daily
Lantus insulin 70 units twice daily
Actos 45 mg daily
Metformin 1000 mg twice daily
Simvastatin 10 mg daily
Baby Aspirin 81 mg daily
Modafinil 200 mg twice a day
Strattera 60 mg daily for ADHD
Flintstones Complete multivitamins daily
Vitamin D [**2122**] units
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please crush.
2. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
3. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) Ml PO BID (2
times a day) for 1 months.
Disp:*600 Ml* Refills:*0*
4. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily): Please crush.
5. losartan 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): Please Crush.
Disp:*120 Tablet(s)* Refills:*2*
6. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please Crush.
Disp:*30 Tablet(s)* Refills:*2*
8. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Please crush.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
CARE GROUP
Discharge Diagnosis:
1. Obesity, body mass index of 51.
2. Obstructive sleep apnea.
3. Type 2 diabetes.
4. Hypertension.
5. Metabolic X syndrome
6. Tachycardia, etiology unknown.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**11-7**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
An appointment with your Dr. [**Last Name (STitle) 1699**] has been scheduled for
[**2132-12-17**] at 3 pm. It is imperative that you keep this
appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2132-12-17**] 11:45
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2132-12-17**] 12:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2132-12-24**] 11:00
Completed by:[**2132-12-12**]
|
[
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"401.9",
"518.82",
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"293.0",
"V85.43",
"V64.41",
"272.4",
"327.23",
"V49.87",
"571.8",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"43.19",
"44.39",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
14555, 14596
|
7397, 13364
|
285, 474
|
14798, 14798
|
3042, 7374
|
17103, 17753
|
2164, 2395
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13730, 14532
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|
14973, 15539
|
2410, 3023
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231, 247
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16746, 17080
|
502, 1596
|
15564, 16734
|
14813, 14925
|
1618, 1844
|
1860, 2148
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,626
| 155,583
|
29760+57659
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-2-3**] Discharge Date: [**2120-2-13**]
Date of Birth: [**2039-12-14**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Pericardial Window
[**2-9**] - Splenectomy
History of Present Illness:
80 y/o with hx of HTN, anxiety, several herniated discs,
polyarthralgia on prednisone who was hospitalized at [**Hospital1 **] for
recent pna/sepsis with + blood for strep pneumo and is now
transferred from [**Hospital1 39933**] ICU for further management of PE and
pericardial effusion. Pt was admitted to [**Hospital3 **] on
[**2120-1-20**] for pneumonia. She states that she had a head cold
during the week of admission, she then developed severe chest
pain "sharp/pressure like" on mid substernal and left side of
chest. This was accompanied by nausea/vomiting and diaphoresis.
It lasted ~ 2 hours before she called 911. At [**Hospital3 4107**],
she had CT of chest W/o contrast that showed right upper lobe
consolidation as per CT report and no pleural effusion. she was
diagnosed with pna and sepsis from strep pneumo. Uncertain if
workup was done to r/o MI. As per family, she was in the ICU for
3 days, but was never intubated. She was treated with
ceftriaxone IV and Azitro for total of 7 days. She was discharge
home on [**2120-1-26**] on Ceftin 500mg [**Hospital1 **]. As per family she
developed LE edema R>L while hospitalized. This was thought to
be due to fluid overload and she was given lasix. Since her
discharge she had SOB with min exertion. She denies having any
chest pain or discomfort. Her SOB seem worse yesterday and she
became febrile up to 101 and went back to [**Hospital3 4107**]. She
had a repeat CTA today that showed bibasilar atelectasis,
mod-to-large pericardial effusion (new), bilateral pleural
effusions, RUL PE. She was evaluated by cardiologists. A TTE was
done and that was no tamponade. She was started on heparin drip
for her PE and given concern for bleeding, she was tranfer here
for further evaluation. As per report her SBP of 132 and she had
no pulses, HR in 105-111 on time of transfer. She also had LENIs
prior to transfer that were negative for DVT.
.
Of note, pt has been taking prednisone 10mg PO Qday for
polyarthritic pain. She states that the prednisone was not
helping and she stopped ~ 1 week ago.
.
She arrived in the MICU , except for increase in RR in the low
30s. Her HR is sinus tachy in low 110s-130s, with SBPs in 150s.
Initial pulsus measured at 12. Sating 95-97% on 2L NC. Bedside
echo was performed, which showed RV diastolic collapse and an
echdense effusion. At this time, it was determined that she
would be drained in the morning, as she was maintaining good
pressures at the time. She was [**Hospital 71236**] transferred to the
CCU for further management.
.
On review of systems, she states she did have a fever to 101 at
home prior to presentation to [**Hospital3 4107**]. She denies any
prior history of stroke, TIA, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. S/he denies recent fevers, chills or rigors. S/he denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for stable ankle edema and
mid-shin ankle erythema. Notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY: No known
.
3. OTHER PAST MEDICAL HISTORY:
HTN
Several disc herniations
Kidney stones
Anxiety
Polyarthritis
GERD
Osteoporosis
BCC on the Leg and SCC on the hand
[**Last Name (un) **] during this recent admission in [**Month (only) **] with creatine up to 3.0
Social History:
SOCIAL HISTORY
- Tobacco history: Denies
- ETOH: Social
- Illicit drugs: Denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
Upon presentation to [**Hospital1 18**]:
VS: T= 100.8 BP= 170/61 HR= 109 RR= 34 O2 sat= 95% 2L
GENERAL: Anxious, mild respiratory distress.
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irreg Irreg, no m/r/g.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: + erythema on kid shin bilaterally
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ECHO [**2120-2-4**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Left ventricular wall
thicknesses are normal. Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is a moderate to
large sized pericardial effusion. The effusion appears
circumferential. The effusion is echo dense, consistent with
blood, inflammation or other cellular elements. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
.
ECHO [**2120-2-5**]
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is a small
(1cm) basal inferolateral pericardial effusion without evidence
of tamponade physiology.
Compared with the prior report (images unavailable for review)
of [**2120-2-3**], the pericardial effusion is smaller and tamponade
physiology is no longer suggested.
.
[**2120-2-8**]
Left ventricular systolic function is hyperdynamic (EF>75%).
There is a trivial/physiologic pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
Compared with the findings of the prior study (images reviewed)
of [**2120-2-5**], no major change.
.
Cardiac Catheterization [**2120-2-4**]
COMMENTS:
1. Unsuccessful pericardiocentesis related to probable marked
fibrinous
disease
2. Will likely require surgical drainage: plan to follow any
progression
of tamponade
.
FINAL DIAGNOSIS:
1. Unsuccessful pericardiocentesis related to probable marked
fibrinoid
disease
2. Will likely require surgical drainage: plan to follow for
evidence of
any progression of tamponade
.
Bilateral Lower Extremity Ultrasound [**2120-2-4**]
IMPRESSION: No DVT bilaterally in the bilateral lower
extremities.
.
CT Chest without Contrast [**2120-2-6**]
IMPRESSION:
1. Interval insertion of a right pleural drain and a pericardial
drain with consequent decrease in the size of the right pleural
and pericardial
effusions.
2. New ground glass opacities in the right lower lobe most
likely reflect
re-expansion pulmonary edema; however, in the appropriate
clinical setting, infection may have a similar appearance.
3. The left pleural effusion has increased slightly in size with
more
associated worsening adjacent atelectasis.
Brief Hospital Course:
80 y/o F with a history of hypertension, recent pneumonia, now
with PE, new pericardial effusion with tamponade physiology on
echo, failed drain, now s/p pericardial window, and pigtail
drain placed to R-sided pleural effusion, who was transferred to
the surgical service from medicine for acute exploratory
laparotomy in the setting of acute intra-abdominal bleed.
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________________________________________________________________
Her course as follows while on Medicine Service as per dictation
Medical housestaff:
# Acute Intra-abdominal Bleed: On hospital day 7, at 6:30 AM the
patient's blood pressure was noted to drop to the systolic 70s
after receiving IV morphine for pain. Normal saline boluses were
started, and she was started on neo for pressure support. A
pulsus was 10. Her exam was unchanged, abdomen soft. Her heparin
gtt was stopped due to supratherapeutic PTT. A KUB and CXR
demonstrated no free air and stable effusions. Hct was 27. Broad
spectrum antibiotics (vanc/zosyn/micafungin/flagyl) were
initiated with concern for acute intra-abdominal process, as her
pressor requirement increased and her abdomen became distended
and tense. Lactate peaked at 11.8. A central line and arterial
line were placed, the patient was intubated. She briefly went
into atrial flutter, was cardioverted twice and loaded with a
150mg IV push of amiodarone. Maximum pressor requirement was neo
to 5, levo to 0.5 and dopa 10 and vasopressin to 2.4. A repeat
hct was 17. The rapid transfuser was subsequently activated and
she received a total of 5 units of pRBC and 2 bags of FFP and
total of 7 liters NS on rapid transfuser. The acute care service
was consulted. A CT scan of the abdomen demonstrated diffuse
intraabdominal bleed. She was transferred to the OR for
exploratory laparotomy.
.
#. Effusion: Echo showing RV diastolic collapse. Patient
tachycardic, but augmenting more than adequate pressures.
Possible etiologies included viral, bacterial, malignant,
infiltrative. Pulsus measured [**12-26**]. Effusion found to be
loculated on subxiphoid drain placement. The patient went for
pericardial window. Fluid serosanguinous, exudative with gram
stain positive for PMNs, cultures pending. ID consulted for
recommendations for infectious pericardial effusion, vancomycin
and cefepime were discontinued in favor of ceftriaxone daily,
duration pending .... A repeated echo demonstrated EF 65%,
smaller effusion, no tamponade physiology.
- F/u cytology, culture data
.
#. Pulmonary Embolism: Patient with PE on OSH CT scan. PE
likely provoked by recent hospitalization. She was placed on a
heparin gtt and Coumadin started on hospital day 5 prior to
transfer to floor.
.
#. Pneumonia/Para pneumonic effusion: Patient treated at OSH for
CAP last week with blood cultures positive for pan sensitive
streptococcal pneumonia. She was febrile on admission and
treated empirically with Vanc/Cefepime. Her course was
complicated by para pneumonic effusions/Strep PNA confirmed by
CT imaging. A right pigtail drain was placed by interventional
pulmonology. Report of thick gelatinous fluid removed, and
studies consistent with exudative process. Given concomitant PNA
and strep pneumo bacteremia from OSH, likely para pneumonic
effusion. Her leukocytosis improved with antibiotic therapy.
Pleural drain was pulled.
.
# Urine Culture: Pan cultured while febrile to 101 on HD 3.
Urinalysis demonstrated pyuria. Ceftriaxone for
pneumonia/pericardial effusion continued.
- Urine culture....
.
# Volume overload: Elevated JVP, pitting edema of lower
extremities on admission. Recent echo EF 65%, and prior showed
normal LV wall thickness, cavity size. She was diuresed with IV
Lasix twice daily while in the CCU with good urine output and
improvement in her physical exam.
.
# HTN: Outpatient anti-hypertensives had been held prior to
pericardial window procedure. Patient was initially hypertensive
in the CCU, requiring a nitro gtt for blood pressure control.
She changed to oral labetalol, Valsartan and Lasix. Labetalol
was ultimately discontinued as the patient was noted to be
intermittently hypotensive.
.
# Anxiety: Chronic issue exacerbated by recent illness. She was
treated with zolpidem qHS and Ativan twice daily prn which was
her home dose.
.
#. Steroids for Arthritis: Patient was placed on prednisone 10
mg once a day for arthritis in [**Month (only) 216**]. Abruptly stopped taking
them earlier this week. Will continue to give in-house as had
been on it for several months and in acute illness, may be
adrenal insufficient. She was slowly initiated on a taper.
.
# Guaiac + stool: Brown stool, no melena. Hemodynamically
stable. No source of bleeding evident. She was started on a PPI
and her hematocrit was stable.
.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
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_
_
________________________________________________________________
_
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_
_
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_
________________________________________________________________
Her course as follows after transfer to the Acute Care Surgery
Service:
She was taken to the operating room on [**2-9**] for splenectomy and
taken back to the ICU postoperatively for close hemodynamic
monitoring. In the unit she remained vented until [**2-10**] when she
was weaned and then extubated. Given concern for risk of thrombo
embolus she underwent LENI'S which were negative for DVT and on
[**2-11**] was taken back to the operating room for placement of IVC
filter. She required Lasix for diuresis and Labetalol during her
ICU stay.
She was eventually transferred to the floor where she continued
to progress. ID continued to follow because of her pneumonia and
the final recommendation was to continue the Vanc & Zosyn for a
total of 8 days and after this course completed to start
Ceftriaxone to continue for a total of 3 weeks (this will begin
on [**2120-2-16**]). She has a PICC catheter in place for this purpose.
Of note her Vanc dosing was adjusted on [**2-11**] [**Last Name (un) 4050**] her trough
levels came back at 22, she was decreased from 1 gm q12 to 750
q12; another trough will need to be checked on [**2-14**].
She was given a diet for which she has been able to tolerate and
her pain has been adequately controlled. Her Ambien that she had
been taking at home was stopped prior to discharge and she was
changed to Trazodone given her age and adverse effects of this
medication in the elderly population.
She received her post splenectomy vaccines on day of discharge.
It is likely that she may experience fevers from the vaccines
and so this should be monitored closely.
Physical and Occupational therapy have evaluated her and
recommend rehab after her acute hospital stay.
Medications on Admission:
Benicar 40mg daily
Cefuroxime 500mg [**Hospital1 **]
Diovan/HCTZ 12.5mg [**Doctor First Name **];y
Lasix 20mg daily
Lorazepam 0.5mg [**Hospital1 **] prn
Prazosin 1mg daily
Tramadol 60mh daily
Ambien 10mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. prazosin 1 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
3. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day) as needed for SBP>160: Hold HR<60 or SBP<110 .
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety: home dose .
12. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. 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.
15. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
MG Intravenous Q 12H (Every 12 Hours) for 3 days.
16. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 MG Intravenous Q8H (every 8 hours) for 3 days.
17. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) MG
Injection Q8H (every 8 hours) as needed for Nausea.
18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection twice a day.
19. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
20. ceftriaxone 1 gram Recon Soln Sig: One (1) GM Intravenous
every twenty-four(24) hours for 3 weeks: BEGIN on [**2120-2-16**] .
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 686**]
Discharge Diagnosis:
Spontaneous splenic rupture
Streptococcus Pneumonia
Sepsis
Pleural effusions
Pulmonary embolus
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with [**Hospital 7133**] medical issues
requiring several procedures and operations. Amongst your many
medical issues you were found to have a bleeding spleen which
was removed in the operating room.
You are also being treated for a pneumonia with intravenous
antibiotics which will continue for about 1 month. You will be
followed closely by the Infectious Disease clinic here at [**Hospital1 18**].
Followup Instructions:
Follow up in [**1-7**] weeks in [**Hospital 2536**] clinic, call [**Telephone/Fax (1) 600**] for an
appointment.
You have an appointment with:
Infectious Disease:
Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2120-2-19**] 10:00
You will need to follow up with your rpimary cardiologist and
PCP after discharge from rehab. You or your family will needto
call for an appointment.
Completed by:[**2120-2-14**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 11990**]
Admission Date: [**2120-2-3**] Discharge Date: [**2120-2-13**]
Date of Birth: [**2039-12-14**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9036**]
Addendum:
Spoke with Infectious Disease regarding clarification of
patient's IV antibiotic course. The Vancomycin and Zosyn will
continue through [**2120-2-15**] and on [**2120-2-16**] Ceftriaxone 2 GM's q 24
hours will start and continue through [**2120-2-24**]. This information
was conveyed to the Physician's Asst at [**Location (un) **] Sanai who is
caring for patient.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. prazosin 1 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
3. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day) as needed for SBP>160: Hold HR<60 or SBP<110 .
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety: home dose .
12. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. 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.
15. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 2238**]y (750)
MG Intravenous Q 12H (Every 12 Hours) for 3 days.
16. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 MG Intravenous Q8H (every 8 hours) for 3 days.
17. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) MG
Injection Q8H (every 8 hours) as needed for Nausea.
18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection twice a day.
19. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
20. ceftriaxone 2 gram Recon Soln Sig: Two (2) GM Intravenous
every twenty-four(24) hrs BEGIN on [**2120-2-16**] through [**2120-2-24**] .
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 1777**]
[**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**]
Completed by:[**2120-2-14**]
|
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"289.59",
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"511.9",
"401.9",
"V58.65",
"481",
"423.3",
"415.19",
"420.99",
"E934.2",
"276.2",
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icd9cm
|
[
[
[]
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] |
[
"37.0",
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"34.09",
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icd9pcs
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[
[
[]
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20927, 21156
|
7367, 14177
|
307, 351
|
16844, 16844
|
4867, 6507
|
17480, 18718
|
4017, 4134
|
18741, 20904
|
16702, 16823
|
14203, 14414
|
6524, 7344
|
17020, 17457
|
4149, 4848
|
3639, 3650
|
264, 269
|
379, 3558
|
16859, 16996
|
3681, 3899
|
3580, 3618
|
3915, 4001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,725
| 193,475
|
14635
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 43129**]
Admission Date: [**2151-6-3**]
Discharge Date: [**2151-6-7**]
Date of Birth: [**2084-11-14**]
Sex: F
Service: ENT
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
woman with a history of metastatic melanoma, gastroesophageal
reflux disease, metastatic melanoma was diagnosed in [**2149-12-1**] with a lesion in the left posterior scalp.
MEDICATIONS PRIOR TO ADMISSION:
1. Prilosec
2. Lisinopril
3. Glyburide
4. Baby aspirin
5. Norvasc
6. Labetalol
7. Lipitor
8. Lantus
The patient was admitted after having two weeks of weakness
in the right hand and had having difficulty holding cards and
buttoning up her clothes. The patient came to her doctors
office for a visit and complained of headache and dizziness.
The patient had an magnetic resonance imaging which showed a
lesion in the left posterior parietal region which was much
larger than previous exams and consistent with hemorrhage an
high protenatious fluid. The patient was therefore admitted
to the hospital and preoped for surgery for removal of this
metastatic lesion.
PHYSICAL EXAMINATION: The patient was awake, alert and
oriented times three. Speech was fluent. Finger-to-nose is
intact bilaterally. Her visual fields were full. The pupils
equal, round and reactive to light and accommodation. Her
EOM's are full. She had no diplopia. Face was symmetric.
Sensation was intact. Strength was [**5-6**] in all muscle groups.
She had a fine tremor left greater than right in the upper
extremities. Her reflexes are 2+ throughout. Her toes were
downgoing. She did have extinction to bilateral stimulation
in the right upper extremity. Magnetic resonance imaging
shows 3x3 cm left parietal occipital lesion consistent with
hemorrhage.
The patient was taken to the operating room. The patient was
seen by the neurology service as a consult who agreed with
surgical excision of this lesion. She was placed on anti-
convulsants. She was also seen by medical oncology.
She was taken to the operating room for removal of this
lesion on [**2151-6-4**]. She underwent a left parietal
occipital craniotomy removal of this lesion without
intraoperative complications. Postop she was awake, alert and
oriented times three moving all extremities with no
neurological deficits. Cranial nerves 2 through 12 were
intact. Her vital signs remained stable. She was transferred
to the regular floor on postop day #1. She was followed by
physical therapy and occupational therapy, felt she needed a
short rehabilitation stay prior to discharge home.
MEDICATIONS:
1. Decadron 4 mg p.o. twice a day
2. Amlodipine 10 mg p.o. daily
3. Glyburide 10 mg p.o. twice a day
4. Atorvastatin 40 mg p.o. daily
5. Labetalol 150 mg p.o. twice a day
6. Lisinopril 20 mg p.o. daily
7. Panapranazole 40 mg q 24 hours
8. Colace 100 mg p.o. twice a day
9. Insulin sliding scale.
10. Six doses of insulin.
11. Glargine 14 units at bedtime and sliding scale.
Condition was stable at the time of discharge. She will
follow-up in the brain tumor clinic in one week.
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2151-6-7**] 11:59:16
T: [**2151-6-7**] 12:24:19
Job#: [**Job Number 43130**]
|
[
"197.0",
"V45.81",
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"250.00",
"780.39",
"530.81",
"401.9",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
425, 1089
|
1112, 3294
|
189, 393
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,301
| 119,311
|
45823
|
Discharge summary
|
report
|
Admission Date: [**2167-12-24**] Discharge Date: [**2167-12-25**]
Service: [**Month/Day/Year 662**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
hypotension, tachycardia
Major Surgical or Invasive Procedure:
Bilateral IJ attempts
R femoral CVL placement
History of Present Illness:
88F with s/p high grade MRSA endocarditis s/p prolonged
hospitalization now on suppressive doxycycline, CHF, DM-II,
anuric renal insufficiency on HD, Afib not on AC, and s/p being
dropped off a stretcher at HD 3 days ago resutling in an ICH who
presents from HD for management of hypotension to the 60s and
tachycardia to the 170s. It appears that she was in Afib. Over
the past few weeks she has had to stop dialysis for hypotension
on several occasions. She denies symptoms at those times, but
per her son she slurred her words somewhat more. She has also
had recurrent bouts of nausea and vomiting in that time. She is
diffusely edematous. She denies asymmetric edema. She
unfortunately was dropped off of a stretcher and landed on her
head three days prior to admission. She was seen in the [**Hospital1 18**]
ED, and was found to have an ICH. The family decided to make her
CMO and take her home, but continue dialysis. At her HD session
today she was hypotensive to the 60s and tachycardic to the
170s. She was transfered to the [**Hospital1 18**] ED once again. In the ED
her initial vital signs were 97.2 87/57 134 18 95% on RA. A CXR
showed no focal infiltrates and no pulmonary edema. A RIJ and
LIJ were attempted, but failed. Ultimately, a R femoral CVL was
placed. She was started on neosynepherine ggt for hypotension,
but continued to drop her SBP. Vasopressin, then norepinepherine
were then added and titrated to maximum doses with persistent
hypotension to the 80s. The patient was asymptomatic the entire
time. A repeat head CT showed no interval change in her known
ICH. She was given vancomycin and pip/tazo for possible sepsis,
bolused 750mL NS, and sent to the floor.
.
On the arrival on the floor she was tachycardic to the 170s.
Initially, BPs were not possible to read on her arms or legs. A
large blood pressure cuff was inflated on her arm for a few
minutes, and then a small cuff was placed over the area of her
arm that had been compressed and was thus less edematous. The BP
then read 109/79. She received diltiazem 5mg IV push x 2 and her
pulse ccame down to the 90s. Her SBP was sustained around 100.
.
A discussion was held with her son [**Name (NI) 382**] and daughter. [**Name (NI) **]
DNR/DNI status was confirmed. We further agreed not to perform
further invassive procedures such as Alines. The were told
explicitly that if we cannot support her blood pressure with
medications, that she may die.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
- MRSA endocarditis (on daptomycin X6 weeks, starting [**2167-7-6**])
- S/p CVA (intracranial bleed), aphasic
- Congestive heart failure
- Gout
- Diabetes mellitus, type II
- Chronic renal insufficiency, anuric, on hemodialysis
- Osteoporosis
- Osteoarthritis
- HTN
- PVD
- Venous insufficiency
- Bilateral hip fractures, s/p hip replacement (8 yrs ago)
- S/p MRSA osteo of the R foot
- [**2167-12-20**] fell from stretcher, had intraparenchymal hemorrhage,
and made CMO
Social History:
- Lives with her son
- Widowed in [**2158**]
- Tobacco: distant smoking history
- Alcohol: denies
- Illicits: denies
Family History:
- Mother: deceased MI, HTN, CVA
- Father: deceased prostate CA
- 3 Brothers with cancer
Physical Exam:
GEN: NAD, talking, pale
HEENT: Dry MM, no JVD, L EJ, ecchymosis bilaterally from
attempts at IJs, no cervical, supraclavicular, or axillary LAD
CV: RR, tachy, no MRG
PULM: CTAB with mild crackles at the bases L>R
ABD: BS+, NTND, no masses or HSM, gas on percussion
LIMBS: 3+ pitting edema, arthritic changes to the fingers
SKIN: Stage 2 saccral decubitus
NEURO: A and O x 2, EOMI, moving all limbs, reflexes 1+ at the
biceps tendons bilaterally, 2+ at the L patellar tendon and 1+
and the R patellar tendon
Pertinent Results:
WBC RBC HB HCT MCV RDW PLT
[**2167-12-24**] 7.5 3.92 11.8 36.5 93 17.7 76
[**2167-12-19**] 7.1 3.96 12.0 37.5 95 16.9 76
[**2167-11-24**] 6.6 4.25 12.9 40.3 95 16.7 160
.
GLU BUN CR Na K Cl HCO3
[**2167-12-24**] 131 28 3.2 143 4.4 106 30
[**2167-12-19**] 139 26 2.8 139 3.8 100 31
[**2167-11-24**] 185 141 4.1 100 31
.
Lactate
[**2167-12-24**] 2.3
[**2167-12-20**] 2.1
.
Micro:
No recent positive blood or urine cultures
.
Images:
CHEST (PORTABLE AP) Study Date of [**2167-12-24**] 5:34 PM An AP
radiograph of the chest reveals low lung volumes bilaterally. A
dual-lumen central venous line terminates AT the cavoatrial
junction. There is a left pleural effusion and prominent
interstitial markings bilaterally. Mild cardiomegaly is noted as
well as some fullness to the hila bilaterally. Degenerative
changes are noted at the right glenohumeral joint. IMPRESSION:
Suboptimal image with suggestion of a left pleural effusion,
cardiomegaly, and interstitial opacities, together suggestive of
hypervolemia. We would recommend repeat evaluation with PA and
lateral views for more precise characterization, when clinically
feasible.
.
CT HEAD W/O CONTRAST Study Date of [**2167-12-19**] 1:05 PM There is a
linear focus of hyperdensity adjacent to the left lateral
ventricle in the corona radiata (2:19) which is new since prior
exam and may represent a focus of intraparenchymal hemorrhage.
Prominence of the ventricles and extra-axial spaces is stable
and compatible with age- appropriate volume loss. Subcortical
and periventricular areas of hypodensity are related to chronic
small vessel ischemic disease. There is no mass effect. The
basal cisterns and suprasellar cistern are clear. There is no
fracture. The visualized mastoid air cells are grossly
unremarkable. There is minimal mucosal thickening in the
posterior right ethmoid sinus air cell. Patient is likely status
post bilateral cataract surgery. IMPRESSION: New focus of
hyperdensity in the left corona radiata adjacent to the left
lateral ventricle may represent a focus of intraparenchymal
hemorrhage. Clinical correlation and close followup is
recommended. MRI can help for further assessment.
.
CT HEAT [**2167-12-24**] WET READ -- NO ACUTE CHANGES.
.
[**2167-12-25**] 01:33AM BLOOD O2 Sat-22
[**2167-12-25**] 04:27AM BLOOD O2 Sat-19
Brief Hospital Course:
88F with s/p high grade MRSA endocarditis s/p prolonged
hospitalization discharged on suppressive doxycycline, CHF,
DM-II, anuric renal insufficiency on HD, Afib not on AC, and s/p
being dropped off a stretcher at HD 3 days prior to admission
resulting in an ICH admitted for management of hypotension and
tachycardia. Given her history of high grade MRSA bacteremia,
sepsis was a concern intitially. However, she was febrile for
all of her past bacteremias and is afebrile now. Alternatively,
her hypotension could be due to Afib, PE, cardiogenic shock, or
adrenal insufficiency. Her goals of care are more focused on
palliative care. Her SBPs were initially [**Location (un) 1131**] around 100mmHg
on levophed at max dose, neosynepherine at max dose, and
vasopressin at max dose. Her Afib with RVR was rate controlled
briefly with diltiazem, and her SBP improved somewhat. She was
also extremely edematous. Despite three pressors at max doses
her blood pressure continued to fall and her mental status
worsened. She was treated empirically for sepsis with daptomycin
and pip/tazo. A central venous oxygen saturation was 22%
consistent with a cardiogenic picture. Given her massive edema
over the past week and clinical picture, it was ultimately
believed that she was in caridogenic shock. She was unresponsive
to treatments. Given her goals of care prior to admission were
comfort, she was made CMO and passed away with her family at the
bed side.
Medications on Admission:
- DOXYCYCLINE MONOHYDRATE - 100 mg PO BID
- METOCLOPRAMIDE - 5 mg/5 mL PO 30 min prior to meals
- NEPHROCAPS - 1 Capsule PO DAILY
- SERTRALINE - 12.5 mg PO QOD
- SEVELAMER HCL [RENAGEL] - 1600 mg TID with meals
- ACETAMINOPHEN - 650 mg PO Q4H:PRN pain
- DOCUSATE SODIUM - 100 mg PO BID
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
death
Discharge Condition:
death
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2167-12-25**]
|
[
"274.9",
"V43.64",
"733.00",
"585.6",
"785.51",
"438.11",
"443.9",
"459.81",
"427.31",
"428.33",
"428.0",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8614, 8623
|
6796, 8248
|
305, 352
|
8672, 8679
|
4461, 6773
|
8732, 8860
|
3816, 3906
|
8585, 8591
|
8644, 8651
|
8274, 8562
|
8703, 8709
|
3921, 4430
|
2836, 3170
|
241, 267
|
380, 2817
|
3192, 3665
|
3681, 3800
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,258
| 116,807
|
922
|
Discharge summary
|
report
|
Admission Date: [**2117-2-6**] Discharge Date: [**2117-2-10**]
Date of Birth: [**2041-7-25**] Sex: F
Service: SURGERY
Allergies:
Metrogel / Desipramine / Sanctura
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
R IJ central venous line placement
History of Present Illness:
The patient is a 75-year-old female who complains of
progressively worsening rectal and buttock pain over the past 2
weeks. Upon presenting to the [**Hospital1 18**] ED today, she initially had
a
HR of 77 with a BP of 105/69, but quickly became hypotensive to
56/40 with a heart rate of 98. Sepsis protocol was initiated. A
central line was placed with great difficulty due to
near-complete IVC collapse. She was placed on a norepinephrine
drip and underwent a CT scan when she was somewhat stable. The
scan shows a large pre-sarcal abscess with rim enhancement, and
air and fat stranding tracking to a R hip prosthesis.
On [**2116-12-20**], she underwent a diverting loop colostomy by Dr.
[**Last Name (STitle) **] for a large rectovaginal fistula. Intra-operatively, she
was noted to have stool in the rectum, vaginal and presacral
space, and the posterior/presacral space was cleaned out. She
was
discharged on POD#6. It is noteworthy that prior to her
operation, she did manifest fever and hypotension to SBP of 75.
An echocardiogram was reassuring, with an EF of 65% with trace
valvular disease.
She was evaluated in clinic about two weeks ago by Dr. [**Last Name (STitle) **],
who was not reassured by her progress at that time. She
appeared to be slowly declining with a pelvic choleca situation
which was not amenable to repair due to the prior radiation
damage and poor vascular supply.
Past Medical History:
CAD s/p MI in 94
PVD (s/p aorto-fem bypass and L femoral endarterectomy)
L Breast CA s/p mastectomy in early 90's
Colon adenocarcinoma '[**08**] s/p LAR with Chemo and XRT
SBO s/p XLap with LOA in [**3-20**]
Asthma
Hypothyroidism
Hyperlipidemia
Osteoporosis
ORIF R tibia
Bilateral THR [**2110**]
PAF
Social History:
She lives in [**Location 4288**] with her husband. She is a former smoker
but quit 15 years ago. She reports drinking vodka and fruit
juice "most days." She has worked various jobs throughout her
life and cared for her four children
Family History:
he is unable to give much specific history but reports "everyone
is dead" of different things.
Physical Exam:
Gen: elderly female, NAD, no icterus
HEENT: NC/AT, EOMI, PERRLA bilat., dry MM, without cervical LAD
on my exam
Cor: RRR without m/g/r, no JVD, no bruits
Lungs: CTA bilat.
[**Last Name (un) **]: +BS, soft, ND, NT, no masses
Rectal: large communicating fistula palpable between rectum and
vagina anteriorly. Tender on vaginal and ++ tender on rectal
exam. No perineal erythema
Ext: warm feet, 2+ pitting edema to knees
Pertinent Results:
Labs:
| 138 | 108 | 14 / 83 AGap=13
| 3.7 | 21 | 0.9 \
Ca: 7.1 Mg: 1.7 P: 3.5
ALT: 11 AP: 145 Tbili: 0.4
AST: 15 Lip: 6
Cortsol: 34.3
CRP: Pnd
7.4
25.8 >--< 622
23.5
N:88 Band:4 L:4 M:3 E:0 Bas:1
PT: 19.0 PTT: 54.0 INR: 1.8
lactate 2.8 -> 3.1 -> 3.4
Imaging:
CT [**Last Name (un) 103**]/pelvis with IV contrast:
* 65 x 34 mm collection posterior to the rectum highly
suggestive
of an abscess
* Pockets of air in the fascial planes of the right thigh and
around the right hip joint suggestive of either a fistula or a
developing abscess
* Stable severe compression of L1
* distal limbs of aortobifemoral graft not in continuity with
iliac/femoral vessels
Brief Hospital Course:
Patient admitted to SICU. Started on antibiotics, resuscitated
with fluids, intubated, and placed on pressors. She quickly
deteriorated and had worsening acidosis with a ph as low as 6.9
and lactate greater than 20. She was requiring multiple
pressors and her due to her age and prognosis, it was decided to
speak with the family regarding comfort measures, as there was
no effective long term treatment for the pelvic source of
sepsis. The family agreed. It took about 24 hours to get all
the family members to the hospital to say their goodbyes. Once
they arrived the ETT was removed, pressors and IVFs were
stopped. The patient continued to breath spontaneous and
maintain a blood pressure in the low 80s. After many hours it
appeared that the dying process may take a while longer.
Therefore she was transferred to the floor and treated with an
infusion of morphine for pain control. On [**2117-2-10**] at 0405 am the
patient expired, immedicate cause of death being cardiopulmonary
failure secondary to sepsis. The family was present at the time
of death, and declined an autopsy. The attending physician of
record, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was [**Name (NI) 653**], as well as the chief
surgical resident of the service, Dr. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **].
Medications on Admission:
Amiodarone 200 [**Last Name (LF) 6222**], [**First Name3 (LF) **] 81', Vit B 12, Advair, Folic acid
1', Imdur 30', Combivent, Levoxyl 112, MVI, Toprol 25',
Singulair 10', Nitro 0.3', Omeprazole 40', Oxytol, Oxycodone
10", Plavix 75', Ranitidine 150", Simvastatin 20', Trazadone 50
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis
multiorgan failure
Discharge Condition:
expired
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2117-2-10**]
|
[
"E878.1",
"286.6",
"518.81",
"493.90",
"041.4",
"041.09",
"566",
"998.6",
"414.01",
"619.1",
"424.1",
"244.9",
"E849.8",
"733.00",
"584.9",
"459.2",
"599.0",
"V10.05",
"V10.3",
"038.9",
"285.29",
"440.32",
"427.31",
"428.0",
"996.66",
"V44.3",
"V10.06",
"276.2",
"V43.64",
"V15.82",
"995.92",
"682.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.0",
"38.93",
"96.04",
"96.71",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
5302, 5311
|
3616, 4970
|
307, 343
|
5381, 5561
|
2912, 3593
|
2362, 2458
|
5332, 5360
|
4996, 5279
|
2473, 2893
|
261, 269
|
371, 1773
|
1795, 2096
|
2112, 2346
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,069
| 176,835
|
30535
|
Discharge summary
|
report
|
Admission Date: [**2174-3-13**] Discharge Date: [**2174-3-16**]
Date of Birth: [**2093-8-12**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
tongue, lip swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 5239**] is an 80 y/o W w/ h/o asthma and HTN who p/w severe
swelling of tongue, lips, and throat. This began on the morning
of admission; she first noticed that she could not speak. Her
swelling progressed rapidly, so she went to her sister-in-law's
house and had her drive her to [**Hospital1 **] [**Location (un) 620**]. She denies that she
had trouble breathing during this episode. Of note, she has had
a similar experience twice before, once 4 years ago and once 5
years ago. Neither episode was as severe. She has not been able
to identify any trigger (no new foods, no insect or plant
exposure, etc) other than lisinopril, which she has been taking
for 5-6 years.
.
At [**Location (un) 620**], the patient was treated with epinephrine, Benadryl
50 IV, SoluMedrol 125 mg IV, pepcid 20 mg IV, racemic epi, and a
500 cc NS bolus. ENT evaluated her for a possible surgical
airway; laryngoscopy was consistent with angioedema. ENT
recommended observation, d/c'ing lisinopril permanently, and
decadron 12 mg Q8H. Patient was transferred to [**Hospital1 18**] for further
observation.
.
In the ED, she received 2 albuterol nebs and was admitted to
MICU for close observation. There, she was treated overnight
with Decadron 12 q8h, Benadryl 25 once, and Nebs q6h. She had
improved markedly from admission; she now says she is almost
back to normal, though with a little residual swelling. She is
called out to the floor for further management.
.
ROS: She is otherwise in good health. She denies dyspnea
currently, chest pain, palpitations, lightheadedness, dysphagia,
nausea, vomiting, diarrhea, and dysuria. She does report
"coughing twice today."
Past Medical History:
1. Asthma
2. HTN
Social History:
No alcohol, tobacco (quit 40 years ago), drugs. Lives alone but
is completely independent in ADLs, IADLs.
Family History:
NC
Physical Exam:
VS: T97.1 HR99 BP136/57 RR18 O2 96% 3L NC
Gen: Obese woman appearing younger than stated age in NAD.
HEENT: No visible lip or tongue swelling, questionable neck
swelling; OP clear, PERRL, EOMI, neck supple w/o LAD.
CV: RRR, no m/r/g
Resp: End expiratory wheezes. No rales or rhonchi. No stridor.
Abd: soft, NT, ND, +BS
Ext: warm, well-perfused, + 2 DP pulses
NEURO: alert, oriented
Pertinent Results:
OSH: crea: 1.3, BUN: 27, Trop T 0.014 (normal = <0.01)
[**Hospital1 18**] [**3-14**]:
Chem 7:
140 105 30 200
5.0 24 1.3
CK: 93 MB: Notdone Trop-T: <0.01
WBC: 9.2; Hct: 35.5; Plt: 313
Brief Hospital Course:
Ms. [**Known lastname 5239**] is a pleasant 80 year old woman with a history of
hypertension, treated in part with lisinopril, and asthma who
presented with signs and symptoms of angioedema. Her brief
hospital course by problem is as follows:
.
1. Angioedema.
This was attributed to her lisinopril. She was initially
admitted to the MICU for observation, but she never required
airway support and after a day of high-dose steroids she had
improved dramatically. Her care was continued on the floor,
where a taper of her steroids was begun. She was also treated
with famotidine and diphenhydramine. On discharge, she was given
a prescription for a 7-day steroid taper and was instructed to
follow up with an allergist, whose name and number were
provided, as well as her PCP. *** Her PCP may wish to have her
obtain a MedicAlert bracelet. ***
.
2. Asthma.
She had a flare of her asthma on the planned day of discharge,
which necessitated an additional night in the hospital. This
improved with standing albuterol and ipratropium nebulizers q6h
as she uses at home and an inhaled steroid similar to her
outpatient budesonide. At the time of discharge, she was
breathing comfortably and reported that she was at her baseline.
.
3. Hypertension.
She was started on Nifedipine to control her blood pressure,
which had good effect. She was given a prescription for
Nifedipine XL and was instructed not to use ACE inhibitors in
the future.
.
4. Leukocytosis.
She had a brief increase in her WBC count of one day's duration.
She had no signs of infection, and it was believed that this was
due to steroids. It resolved as the steroids were tapered.
.
5. Anemia.
She was at her baseline hematocrit, although the etiology of
this is as yet unknown. She had no evidence of iron, B12, or
folate deficiency, and her stool was negative for occult blood.
.
6. Chronic renal failure.
She has had an elevated creatinine over the last several months,
with a baseline of 1.2 to 1.4. She remained in this range
throughout her hospitalization, although actually improved to
0.9 on discharge. Further evaluation was deferred.
.
7. Prophylaxis: She was given a bowel regimen PRN, pneumoboots
to prevent DVTs, and an insulin sliding scale while she was on
high-dose steroids.
.
8. Code Status: FULL
.
9. Dispo: She was discharged to home.
Medications on Admission:
Lisinopril
Albuterol
Atrovent
Nifedipine
Beclamethasone
lipitor
.
Allergies: shrimp, scallops, salmon (does not know what her
reaction is)
Discharge Medications:
1. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for lip, tongue, or face swelling for
2 weeks.
Disp:*30 Capsule(s)* Refills:*0*
6. Pulmicort 0.5 mg/2 mL Solution for Nebulization Sig: One (1)
INH Inhalation twice a day.
7. Prednisone 10 mg Tablet Sig: AS DIR Tablet PO once a day for
7 days: Take 4 tablets on Day 1; then take 3 tablets on Days 2 &
3; then take 2 tablets on Days 4 & 5; then take 1 tablet on Days
6 & 7; then stop.
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Angioedema
2. Asthma
3. Acute renal failure
.
Secondary:
1. Hypertension
Discharge Condition:
Good condition, breathing comfortably, ambulating independently,
vital signs stable.
Discharge Instructions:
You have been evaluated for tongue and lip swelling, a condition
known as angioedema. This was most likely due to your ACE
inhibitor, lisinopril. You should avoid taking all ACE
Inhibitors in the future. You have been given a prescription for
a steroid taper; you should complete the entire course of
prednisone even if you feel better. Please take all medications
as directed and please keep all follow-up appointments.
.
If you should develop recurrent swelling, shortness of breath
above your baseline, chest pain, fever/chills, or any other
symptom that is concerning to you, please call your PCP or go to
the nearest hospital emergency department.
Followup Instructions:
An appointment will be made for you with an allergist, Dr.
[**Last Name (STitle) 2603**], to confirm the cause of your symptoms. His office will
contact you to schedule the appointment, but if you have not
heard from them by Friday afternoon ([**3-18**]), please call
[**Telephone/Fax (1) 1723**].
.
Please also call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 19980**] to
schedule an appointment. You should see him in [**12-14**] weeks.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2174-3-16**]
|
[
"585.6",
"272.0",
"403.91",
"493.20",
"584.9",
"285.9",
"995.1",
"288.60",
"E942.9",
"E849.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6299, 6305
|
2822, 5139
|
292, 299
|
6434, 6521
|
2607, 2799
|
7222, 7880
|
2180, 2185
|
5329, 6276
|
6326, 6413
|
5165, 5306
|
6545, 7199
|
2200, 2588
|
231, 254
|
327, 1999
|
2021, 2040
|
2056, 2164
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,231
| 118,653
|
49753
|
Discharge summary
|
report
|
Admission Date: [**2112-4-10**] Discharge Date: [**2112-4-14**]
Date of Birth: [**2056-3-12**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Ciprofloxacin / Methylparaben / Shellfish
/ Paba / Omeprazole
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
somnolence
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 year old woman with history of Sjoren's and DM who presents
with nausea and left flack pain for 6 days duration. Patient
reports dysuria, increased urinary frequency and was concerned
she "had a bladder infection". Left flack pain is similiar to
prior urinary tract infections. She denies fever, chills or
vomiting.
In the ED, initial vs were: T 99 P 66 BP 95/60 R 14 O2 sat 91%
RA. Patient given Ceftriaxone and Morphine for presumed
pyelonephritis. Patient was placed on 4 L oxygen for sat 94-96%.
Patient became increasingly somnelent and ABG demonstrated
hypercarbia. Consequently she was admitted to MICU for possible
BiPap.
Past Medical History:
*Sjogren's/sarcoid overlap syndrome, followed by Dr.
[**Last Name (STitle) 6426**](Rheumatology) and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4702**] (Immuno-Ophtho in
[**Hospital1 8**]). Recent manifestations are mostly articular. She has
failed to respond to many anti-rheumatic drugs in the past
including hydroxychloroquine, methotrexate, azathioprine,
prednisone, penicillamine, leflunomide, daclizumab (IL-2
receptor antagonist). She has also been on TNF blockers
including etanercept and infliximab. In [**2107**], she had a trial of
mycophenolate without improvement. Rheumatology team now plans
to initiate abatacept (Orencia) to address new reactivation of
chronic uveitis which manifested with eye pain. On chronic
steroids.
*Single isolate M.kansasii and M.gordonae [**9-18**] stable CT since
then - decision by pulm and ID to follow symptoms
*Takayasu's arteritis ([**9-18**])
*Centrilobular emphysema (noted on CT [**12-19**])
*Hypercholesterolemia
*Diabetes mellitus secondary to steroid use
*Hypertension
*? Stress fracture of left foot (podiatry at [**Hospital1 112**], [**Hospital1 18**])
* Hypersensitive bladder (Urology- Dr. [**Last Name (STitle) **]
* recurrent UTIs
* Liver Steatosis
* Anemia (chronic disease)
* GERD
* Diverticulosis
* Chronic pain
* Depression
* basal cell CA s/p resection
* s/p hysterectomy
* s/p appendectomy
* s/p 3 surgeries on the jaw for ? neuralgia/osteonecrosis and 3
surgeries on her gums.
* Anxiety and depression
* Autonomic dysfunction
Social History:
Lives with husband and dog. Currently on disability due to
autoimmune disease. Currently smokes 1 pack a day for > 12
years. Denies alcohol or drug use.
Family History:
Notable for mother with MI at age 54. No family history of
autoimmune disease.
Physical Exam:
Physical Exam on Admission
General: Oriented x 3, but fatigues mid sentance
HEENT: Sclera anicteric, dryMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds throughout. No crackles or
wheezes.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender left lower quadrant and flank,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Of note, on the morning after admission the patient was awake
and alert with lacrimation, rhinorrhea, increased yawning,
nausea.
Pertinent Results:
LABS ON ADMISSION:
[**2112-4-10**] 04:30PM BLOOD WBC-8.6 RBC-4.61 Hgb-13.3 Hct-42.5 MCV-92
MCH-28.8 MCHC-31.3 RDW-16.1* Plt Ct-120*
[**2112-4-10**] 04:30PM BLOOD Neuts-74.9* Lymphs-21.2 Monos-3.0 Eos-0.6
Baso-0.3
[**2112-4-10**] 04:30PM BLOOD PT-11.9 PTT-20.9* INR(PT)-1.0
[**2112-4-10**] 04:30PM BLOOD Glucose-196* UreaN-13 Creat-1.1 Na-138
K-4.2 Cl-97 HCO3-30 AnGap-15
[**2112-4-10**] 04:30PM BLOOD ALT-11 AST-13 AlkPhos-113* TotBili-0.2
[**2112-4-10**] 04:30PM BLOOD Lipase-19
[**2112-4-10**] 04:30PM BLOOD ASA-5 Ethanol-NEG Acetmnp-NEG Bnzodzp-POS
Barbitr-NEG Tricycl-NEG
[**2112-4-10**] 11:04PM BLOOD Type-ART O2 Flow-4 pO2-94 pCO2-68*
pH-7.30* calTCO2-35* Base XS-4 Intubat-NOT INTUBA
[**2112-4-10**] 11:04PM BLOOD O2 Sat-85 COHgb-11* MetHgb-0
LABS ON TRANSFER TO FLOOR:
[**2112-4-12**] 03:29AM BLOOD WBC-7.9 RBC-4.30 Hgb-12.9 Hct-39.7 MCV-92
MCH-30.0 MCHC-32.5 RDW-16.1* Plt Ct-124*
[**2112-4-12**] 03:29AM BLOOD Plt Ct-124*
[**2112-4-12**] 03:29AM BLOOD Glucose-87 UreaN-10 Creat-0.8 Na-143
K-3.1* Cl-104 HCO3-32 AnGap-10
[**2112-4-12**] 03:29AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.9
[**2112-4-12**] 11:51AM BLOOD Type-ART pO2-81* pCO2-34* pH-7.51*
calTCO2-28 Base XS-3 Intubat-NOT INTUBA
[**2112-4-12**] 11:51AM BLOOD Hgb-13.3 calcHCT-40 O2 Sat-92 COHgb-4
MetHgb-0
[**2112-4-12**] 11:51AM BLOOD Type-ART pO2-81* pCO2-34* pH-7.51*
calTCO2-28 Base XS-3 Intubat-NOT INTUBA
LABS ON DISCHARGE:
BLOOD GASES:
[**2112-4-10**] 11:04PM BLOOD Type-ART O2 Flow-4 pO2-94 pCO2-68*
pH-7.30* calTCO2-35* Base XS-4 Intubat-NOT INTUBA
[**2112-4-11**] 02:24AM BLOOD Type-ART pO2-73* pCO2-63* pH-7.33*
calTCO2-35* Base XS-4
[**2112-4-11**] 02:48PM BLOOD Type-ART pO2-94 pCO2-60* pH-7.32*
calTCO2-32* Base XS-2
[**2112-4-12**] 11:51AM BLOOD Type-ART pO2-81* pCO2-34* pH-7.51*
calTCO2-28 Base XS-3 Intubat-NOT INTUBA
STUDIES:
EKG ON ADMISSION ([**2112-4-10**]):
Sinus bradycardia. Low T wave amplitude is non-specific.
Otherwise, unstable baseline makes assessment difficult. Since
the previous tracing of [**2111-3-18**] sinus bradycardia is now present.
Otherwise, there may be no significant change.
.
ECHOCARDIOGRAM ([**2112-4-12**]):
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
CT SCAN OF THE CHEST, ABDOMEN, AND PELVIS ([**2112-4-10**]).
CHEST: A right chest wall Port-A-Cath is seen with right IJ
course and
extension into the cavoatrial junction. There is mild
atherosclerotic
calcification along the aortic arch and minimal along the
coronary arteries. A small nodule is seen within the right
thyroid gland measuring approximately 7 mm in diameter. This
finding appears stable from prior. The mediastinal great vessels
appear normal in course and caliber without evidence of aneurysm
or dissection. There is an aortic origin of the left vertebral
artery, a normal variant. The pulmonary arterial tree opacifies
normally and there is no evidence of a central filling defect
through the level of the segmental branches. There is no
mediastinal lymphadenopathy. There is no pericardial effusion.
.
There is bilateral lower lobe posterior consolidation most
compatible with
dependent atelectasis. No worrisome pulmonary nodules or masses
are seen.
There is mild apically predominant emphysema.
.
ABDOMEN: Evaluation of the solid organs is somewhat limited
given the
arterial phase of imaging. The liver and spleen appear grossly
unremarkable. The gallbladder is only partially distended but
appears normal. The adrenal glands are normal in size and
configuration bilaterally. The pancreas is somewhat atrophic,
though there is no focal lesion or evidence of ductal dilation.
The kidneys enhance symmetrically without focal lesions seen.
There is atherosclerotic disease along the abdominal aorta with
mild resultant narrowing along the infrarenal segment and
chronic occlusion of the left common iliac branch as evidenced
on prior studies. There is reconstitution of blood flow in the
left external iliac branch as well as branches of the left
internal iliac artery distal to the bifurcation. No free air or
free fluid is seen. There is no lymphadenopathy. The stomach and
duodenum appear unremarkable.
.
PELVIS: Given the lack of enteric contrast, evaluation for bowel
wall
thickening is limited. There is a suggestion of mild thickening
involving
several loops of jejunum in the left upper quadrant, though
there is no
associated obstruction or fat stranding. The bowel itself does
not appear
dilated. The large bowel contains a large amount of retained
fecal material. No free fluid is seen in the deep pelvis. The
patient is status post prior hysterectomy. Ovaries are not
clearly seen and may also be surgically absent. The urinary
bladder is moderately distended and appears normal.
.
BONES: No worrisome osseous lesions are seen.
.
There are two discrete right-sided renal arteries identified.
Spinal
alignment appears normal without evidence of compression
fracture.
.
IMPRESSION:
1. Stable atherosclerotic plaque within the abdominal aorta with
chronic
occlusion of the left common iliac artery.
2. Equivocal findings of bowel wall thickening involving several
loops of
jejunum in the left upper quadrant.
3. Large amount of fecal loading of the large bowel.
4. No evidence of mesenteric ischemia.
The study and the report were reviewed by the staff radiologist.
.
CT HEAD WITH AND WITHOUT CONTRAST([**2112-4-13**]):
Awaiting final read....
Brief Hospital Course:
Ms. [**Known lastname **] is a 56-year-old female with multiple medical problems
including complex autoimmune disease (Sjogren / sarcoid overlap
syndrome), diabetes, Takayasu arteritis, who presented to the ED
with flank pain and nausea for 6 days, concerning for urinary
tract infection and pyelonephritis. She was admitted to the MICU
after she was found to have altered mental status, hypoxia,
hypercarbia and elevated carboxyhemoglobin.
# Respiratory Failure: On admission, the patient was found to
have mixed hypercarbia and hypoxia. Patient's prior ABGs did not
suggest overwhelming chronic retainer. Patient was on multiple
sedating medications and positive barbituates on toxicology
screen. Patient thought to be hypoventilating due to narcotics
resulting in retention. Carboxyhemoglobin level was 14 on
admission, which was initially felt to be within range of level
of smoker. This HbCO level came down to 4 on hospital day 2.
Methemoglobin level was 0 on admission. ECHO and bubbly study
was performed on [**2112-4-12**] which did not reveal any PFO, ASD or
VSD. bThe patient's hypoxic and hypercarbic status quickly
resolved on BiPAP. After she was trasferred to the Medicine
floor, her oxygen saturation has continued to improve.
.
# Somnolence and altered mental status: Patient was noted to be
somnolent and unable to stay awake for even short conversations
on admission. Unclear etiology but concerning for
narcotic-induced given that the patient was on multiple sedating
medications. Of note, patient became significantly more awake
shortly after receiving a dose of naloxone. All of the patient's
outpatient sedating medications were held for altered mental
status. On hospital day 2, the patient appeared to have symptoms
of narcotic withdrawal with increased rhinorrhea, yawning,
irritability, piloerection, mydriasis, and nausea on the morning
after admission. There was a discussion with her PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 4321**], during her MICU stay which revealed an evolving
medication regimen. Dr. [**Last Name (STitle) 4321**] reportedly sees her about every
2 weeks but doesn't think she has had her medications increased
for several (up to 6) months. On [**3-18**], she added Buspar 5 mg PRN
and increased Propranolol 60 mg once daily extended release.
Also increased Zofran 8 mg TID. Also on [**4-5**], her Trazodone dose
was increased with plan to discontinue Gabapentin and Clonidine,
with plan to do it slowly. Dr. [**Last Name (STitle) 4321**] feels that she is very
compliant with pain medications and is not concerned about
abuse. Discussion with the patient's husband revealed that the
patient has been increasingly tired and sleepy during the past
2-3 weeks prior to admission. Her husband believes that the
patient takes all medications as prescribed but she continues to
take pain medications even when she does not experience pain.
.
The patient's mental status gradually improved over the course
of hospitalization. On the day the patient was transferred to
Medicine floor, she was noted to have impared concentration and
inattention but other neurological exam was essentially benign.
On the day of disposition, patient was alert and oriented, near
her baseline mental status. She was also not experiencing any
pain. She was discharged off all sedating medication, with the
exception of low dose gabapentin to reduce withdrawl from this
long acting medicaiton.
.
Conversation with the patient's PCP to adjust the patient's
medication took place on the day of discharge.
# Carboxyhemoglobinemia: Ongoing problem with elevated levels of
carboxyhemoglobin noted in previous outpatient labs. According
to the husband they have multiple CO monitors at home which have
not had any activity. Carboxyhemoglobin level was 14 on
admission, which was initially felt to be within range of level
of smoker. This HbCO level came down to 4 on hospital day 2. Pt
was advised to have her home inspected and to quit smoking.
# Chronic pain: The patient's outpatient sedating medications
were initially held due to the patient's mental status and were
restarted as her mental status improved. Despite being off all
narcotics as well as her adjuvant pain medications, pt did not
have pain and was happy to be off all her medications.
# Nausea, flank pain: Most consistent with urinary tract
infection versus pyelonephritis however CTA ab/pelvis negative
for ischemia or other acute abnormality and urine cultures
negative. Initially started on ceftriaxone which was
discontinued after urine cultures returned negative.
# ?Bladder Contracticity: Started straight cathing recently for
unclear reasons. Has had to straight cath in the past.
Oxybutynin made her worse; Pyridium made her better. PCP wonders
about interstitial nephritis but has difficulty with following
up with male urologist.
# Depression/Anxiety: Continued Lexapro 20 mg qd. The patient's
buspirone was initially held but resumed at time of discharge.
# Hyperlipidemia: Continued on Lipitor 40 mg qd.
# Hypertension: Unclear whether patient is taking clonidine. It
was continued at 0.1 to reduce symptoms of withdrawl during her
hospitalization, and thought that should tolerate as outpt.
# Sjogren's: Continued on prednisone 10 mg qd.
# Diabetes: Insulin sliding scale while in house.
#Medication reconcilliation: Pt has extensive medicaiton list
which was reduced significantly during this hospitalization.
Despite extensive questioning of a variety of sources including
patient, patient's husband, previous notes, and pt's pharmacy,
numerous different lists were come across. It is truly unclear
which medications patient was taking on admission. Patient's
list was used as the most updated list despite some evidence to
suggest error. However, no one list seemed to be most accurate.
Pt was advised to obtain all of her medications at one pharmacy
(she uses 2 presently), and to keep this one list and continue
to update it and carry it with her.
Medications on Admission:
Restasis
Nystatin swish and swallow four times a day
Prednisone 10mg daily
Fentanyl 125mcg q 72 hrs
Oxycodone 15mg qid
Lyrica 100mg tid
Diazepam 2mg tid
Trazadone 100mg qhs
Odansetron 8mg [**Hospital1 **] prn
ranitidine 200mg [**Hospital1 **]
oxybutin 5mg daily
Pyridium 200mg [**Hospital1 **]
Levoquin 250mg daily
Lexapro 20mg daily
Clonidine 0.1mg daily
Gabapentin 300mg [**Hospital1 **]
Metformin 500mg qod
Buspirone 10mg tid
Propranolol 600mg daily
Vit D 1000U
B12 - 1000mcg daily
Prevident [**Hospital1 **] toothpaste
Fioricet [**2-13**] q 4-6 hr prn
Lidoderm patches
Lidoderm oitment
Bisacodyl 3 tabs qod
Docusate 300mg qod
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Buspirone 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day.
6. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Nystatin 100,000 unit/mL Suspension Sig: Two (2) tsp PO four
times a day as needed for thrush.
9. Propranolol 60 mg Capsule,Sustained Action 24 hr Sig: One (1)
Capsule,Sustained Action 24 hr PO once a day.
10. Oxybutynin Chloride 5 mg Tab,Sust Rel Osmotic Push 24hr Sig:
One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day.
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Disp:*15 Capsule(s)* Refills:*0*
12. Pyridium 200 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for urinary pain.
13. Restasis 0.05 % Dropperette Sig: Two (2) drops in each eye
Ophthalmic twice a day.
14. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO every other day.
15. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
16. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
17. PreviDent 1.1 % Paste Sig: One (1) amount Dental twice a
day.
18. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day as needed for pain: 12 hrs on
and 12 hrs off.
19. Lidocaine 5 % Cream Sig: One (1) amount Topical twice a day.
20. Senna 8.6 mg Capsule Sig: Three (3) Capsule PO once a day as
needed for constipation.
21. Docusate Sodium 100 mg Capsule Sig: Three (3) Capsule PO
once a day.
22. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
primary:
polypharmacy
narcotic overdose
carboxyhemoglobinemia
secondary:
Sjogren's/Sarcoid
Takayasu artertitis
emphysema
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Ms. [**Known lastname **], it was a pleasure to care for you during your
hospitalization. You were noted to be very sleepy on admission.
This is thought to be due your extensive list of medications
that have the side effect of drowsiness. Many of your
medications have been stopped, and this has been discussed with
your primary care doctor. Please stop taking diazepam, fentanyl
patches, fioricet, lyrica, oxycodone, and trazadone as all of
these medications can cause drowsiness. Please stop taking your
gabapentin, a prescription is being provided for a lower dose of
this medication to prevent withdrawl symptoms.
During your hospitalization you were noted to have an elevated
level of carbon monoxide in your blood. This can be due to one
of two things. First it is important to have your home
inspected for carbon monoxide. Please call your local fire
deparment about having a proper home evaluation. The other
cause of high carbon monoxide in the blood is smoking. Smoking
cigarrettes have many harms including poor oxygenation, and
lung cancer. It is highly encouraged that you stop smoking.
Please talk to your doctor about helping you quit smoking.
It is essential that you get your portacath flushed. You refused
waiting for flushing the line prior to your discharge. You have
an appointment for this on Tuesday.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 4321**] [**Telephone/Fax (1) 608**] on [**4-22**] at
3:30 pm.
Previously scheduled appointments:
VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2112-5-12**] 2:30
PVR,EQUIPMENT Date/Time:[**2112-5-12**] 2:30
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2112-5-12**]
3:10
Completed by:[**2112-4-15**]
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27,345
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7731
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Discharge summary
|
report
|
Admission Date: [**2130-2-17**] Discharge Date: [**2130-2-20**]
Date of Birth: [**2075-11-29**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Flagyl
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Right upper quadrant pain
Major Surgical or Invasive Procedure:
[**2130-2-17**]: ERCP
History of Present Illness:
The patient is a 54 year-old female with a history of Crohn's
disease. She is currently without medication and has had no
issues for 12 years. She has a history of 5 abdominal surguries
in the past at [**Hospital1 18**]. She complains of [**2-26**] weeks of right upper
quadrant pain, [**9-3**], dull-achy, radiating to her back, with no
relation to food. She denies nausea/vomiting and has been
tolerating oral intake. Her last bowel movement was on the day
of admission (formed brown). Denies chest pain and shortness of
breath, but does report positive chills. By report of OSH
surgeon - patient reports postive nausea and vomiting for 2
weeks.
Past Medical History:
PMH: Crohn's with 5 abd surgeries in remission >12 years, CAD,
HTN, hypercholesterolemia, benign breast dz, depression,
anxiety, OD blindness
PSH: Cardiac stents x 2 [**2126**], appy, tubal ligation, L-breast
lumpectomy, tonsillectomy
Social History:
Drinks 2-3 alcoholic beverages approximately per week. Smokes
half a pack per day and has for approximately 36 years. Does
not use illicit drugs. Lives with her daughter. [**Name (NI) 1403**] as a
Certified Nursing Assistant.
Family History:
Mother passed away at 64 years old from a myocardial infacrtion.
Father died of a myocardial infarction as well at the age of
68.
Physical Exam:
VS: 102.1, 117, 126/68, 18, 93%room air
Weight: 68kgs
Height: 64inches
GEN:NAD, AAOx3, comfortable, supine
HEENT: Left pupil [**4-27**], EOMI, anicteric
CV: tachycardia, normal S1, S2
RESP: Lungs clear to auscultation bilaterally
ABD: soft, tender to palpation on right upper quadrant, non
distended, postive bowel sounds, + [**Doctor Last Name 515**], no
rebound/guarding, well-healed midline and laparotomy scars
EXT: no clubbing, cyanosis and edema, +2 bilateral pedal pulses
Pertinent Results:
Admission Labs:
--------------
[**2130-2-17**] 06:02PM
ALT(SGPT)-233* AST(SGOT)-141* ALK PHOS-299* AMYLASE-50 TOT
BILI-2.0* LIPASE-43
.
[**2130-2-17**] 05:56PM
WBC-9.0 RBC-4.34 HGB-13.8 HCT-39.0 MCV-90 MCH-31.7 MCHC-35.3*
RDW-13.4 PLT COUNT-212
.
[**2130-2-17**] 03:44AM
GLUCOSE-108* UREA N-7 CREAT-0.7 SODIUM-137 POTASSIUM-4.0
CHLORIDE-105 TOTAL CO2-24 ANION GAP-12 ALT(SGPT)-303*
AST(SGOT)-255* ALK PHOS-306* AMYLASE-36 TOT BILI-1.4 LIPASE-21
CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-1.8 WBC-12.0* RBC-3.98*
HGB-12.6 HCT-35.6* MCV-89 MCH-31.7 MCHC-35.5* RDW-13.6
PLT COUNT-266 LACTATE-1.0 K+-3.9
.
[**2130-2-16**] 11:58PM
ALT(SGPT)-343* AST(SGOT)-393* ALK PHOS-310* AMYLASE-37 TOT
BILI-1.7* WBC-8.6 RBC-4.30 HGB-13.4 HCT-38.3 MCV-89 MCH-31.2
MCHC-35.1* RDW-13.6
.
Imaging:
[**2-16**] U/S: CBD 8mm, trace peri-cholecystic fluid, trace wall
thick, slight distension, (+) stones
[**2-17**] ERCP: sphincterotomy, sludge extraction, peri-ampullary
diverticulum, gaping papilla (recent stone passage?), normal
biliary tree
.
Blood Cultures: [**2130-2-17**] no growth to date
No blood cultures drawn at referring hospital.
Brief Hospital Course:
Patient was transferred from [**Hospital3 3583**] on [**2130-2-17**] for
further evaluation of right upper quadrant abdominal pain and
nausea. She was admitted to the surgical ICU under the care of
Dr. [**First Name (STitle) 2819**]. She was started on intravenous fluid, kept NPO, and
Zosyn was started in preparation for an ERCP. The ultrasound at
the OSH revealed a common bile duct of 8mm, trace
peri-cholecystic fluid, trace wall thickening, slight
distension, (+) gallstones.
.
GI (cholangitis and choledocholithiasis): On arrival to [**Hospital1 18**]
she was febrile to 102.1, wbc 12,000, ALT 343, AST 393, Alk Phos
310, Amylase 37, Total bilirubin 1.7. She was seen and evaluated
by the gastroenterology service. The ERCP revealed a gaping
papilla consistent with recent stone passage and a normal
biliary tree; a sphincterotomy was performed, and sludge was
extracted. The total bilirubin peaked at 2.0 ([**2130-2-17**]) and was
0.9 on day of discharge. The ALT and AST continued to trend down
and the alk. phos remained elevated at 736 on discharge.
Patient was afebrile with a normalized white count. She was
transferred to CC6A on [**2-18**], started on clear liquids and slowly
advanced to a regular diet without adverse effects.
.
Pain: Abdominal pain was managed with Dilaudid intravenously
while NPO and changed to Percocet with a regular diet. Patient
was discharged home with Percocet for pain management. She was
advised to take Colace 100mg twice a day while on narcotics.
.
ID: Patient was started on Zosyn intravenously on admission.
The OSH did not draw blood cultures when she was evaluated in
the Emergency Room. The Blood cultures from [**2-17**] are negative
to date at the time of discharge. The patient was discharged
home on Ciprofloxacin 500mg twice a day and Flagyl 500mg three
times a day for a total of 1week of treatment. Patient was
advised not to drink alcohol while taking antibiotics.
Medications on Admission:
ASA 325mg daily
Lopressor 12.5mg [**Hospital1 **]
Vitorin
Wellbutrin 300mg daily
NG TD
Effexor 75mg daily
B12 twice weekly
Estrogen twice weekly
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*8 Tablet(s)* Refills:*0*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*16 Tablet(s)* Refills:*0*
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis and choledocholithiasis
Discharge Condition:
Stable: Patient afebrile, hemodynamically stable, receiving
Ciprofloxacin and Flagyl for a total of 1 week, tolerating
regular diet.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concerns you.
You may resume all home medications. Take the Antibiotics,
Ciprofloxacin and Flagyl, until all the pills are gone.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) 2819**] in [**1-25**] weeks. Contact number is
([**Telephone/Fax (1) 6347**].
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"272.0",
"555.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
6424, 6430
|
3332, 5272
|
316, 340
|
6510, 6645
|
2192, 2192
|
7715, 7845
|
1546, 1678
|
5467, 6401
|
6451, 6489
|
5298, 5444
|
6669, 7692
|
1693, 2173
|
251, 278
|
368, 1024
|
2208, 3309
|
1046, 1283
|
1299, 1530
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,646
| 179,735
|
40097
|
Discharge summary
|
report
|
Admission Date: [**2185-1-3**] Discharge Date: [**2185-1-8**]
Date of Birth: [**2123-6-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2185-1-3**] Mitral Valve Repair with 28 mm Ring
History of Present Illness:
61 year old male with a history of hypertension and chronic (3+)
mitral regurgitation which has become more severe. He reports
that he has experienced worsening exertional dyspnea and fatigue
with activity over the past year.
He is able to walk a few blocks without getting tired and
tolerates his ADLs, but he has difficulty walking uphill or
climbing stairs. He also describes feeling occasional
palpitations that have awakened him during the night within the
past six months. Cardiac surgery was consulted to evaluate for
surgical intervention.
Past Medical History:
mitral regurgitation s/p mitral valve repair
PMH:
Hyperlipidemia
Hypertension
Malaria
Tuberculosis
Social History:
Lives with: Wife
Occupation: research associate at [**Hospital1 **] [**Location (un) 86**]
Tobacco:quit [**6-3**] year ago
ETOH:occasionally
Family History:
mother had CAD and an MI in her late 60s-early 70s
Physical Exam:
Pulse:69 Resp:18 O2 sat:99/RA
B/P Right:176/98 Left:165/93
Height:5'6" Weight:140 lbs
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur II-III/VI systolic murmur
across precordium and radiating into both carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm x[], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left:+1
DP Right:+2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right:+1 Left:+2
Carotid Bruit Right/Left:murmur radiates to both carotids
Pertinent Results:
Intra-op TEE
Pre CPB:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
A small patent foramen ovale is likely present.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %). [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.
The ascending aorta is mildly dilated. There are simple atheroma
in the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen.
Severe (4+) mitral regurgitation is seen with two jets, one
anterior and the other posterior, the anterior jet appears more
significant although due to the coanda effect it is difficult to
quantify either. There is a ruptured chord at P1-P2. Pulmonary
vein flow exhibits systolic reversal.
Dr. [**Last Name (STitle) **] was notified in person of the results.
Post CPB:
The cardiac output is 3.4L/min, the patient is in NSR on an
epinephrine infusion.
The LVEF is 30-35%.
There is a mitral annuloplasty ring. There is trace to mild
mitral regurgitation. The mitral valve as a peak/mean gradient
of 6/2mmHg.
The visible contours of the thoracic aorta are intact.
There is no aortic insufficiency.
[**2185-1-8**] 03:57AM BLOOD WBC-7.6 RBC-3.07* Hgb-9.2* Hct-26.5*
MCV-86 MCH-29.9 MCHC-34.6 RDW-14.3 Plt Ct-223
[**2185-1-8**] 03:57AM BLOOD PT-31.6* PTT-36.3* INR(PT)-3.2*
[**2185-1-8**] 03:57AM BLOOD Glucose-119* UreaN-31* Creat-1.4* Na-136
K-4.3 Cl-102 HCO3-26 AnGap-12
[**2185-1-3**] 09:49PM BLOOD ALT-14 AST-34 AlkPhos-22* Amylase-28
TotBili-0.2
[**2185-1-3**] 09:49PM BLOOD Lipase-31
[**2185-1-8**] 03:57AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.1
Brief Hospital Course:
The patient was brought to the operating room on [**2185-1-3**] where
the patient underwent Mitral Valve Repair with Dr. [**Last Name (STitle) **]. See
operative note for further details. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. He was
hypertensive on the floor and Coreg, Enalapril and Norvasc were
titrated for better blood pressure control. He went into a rapid
atrial fibrillation on POD# 3 and was bolused with Amiodarone.
He was put on oral Amiodarone with rate controlled atrial
fibrillation at the time of discharge.
He was started on Coumadin for atrial fibrillation and will be
followed by our office this weekend.We will arrange for his PCP
or cardiologist to follow this on Monday [**1-10**]. INR was 3.4 at
the time of discharge with a goal INR of 2.0-3.0. Pt was
instructed to hold dose for today and tomorrow and dosing for
Monday [**1-10**] will be arranged with VNA after labwork is
complete.
By the time of discharge on POD #5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home with VNA in good
condition with appropriate follow up instructions.
Medications on Admission:
ENALAPRIL MALEATE - (Prescribed by Other Provider) - 5 mg
Tablet
- 1 Tablet(s) by mouth twice daily
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) -
Dosage uncertain, PRN
FLAXSEED OIL - (Prescribed by Other Provider) - Dosage
uncertain
IBUPROFEN [ADVIL] - (Prescribed by Other Provider) - Dosage
uncertain, PRN
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- Dosage uncertain
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. warfarin 1 mg Tablet Sig: 1-2 Tablets PO Once Daily at 4 PM:
Take as instructed for INR goal [**3-3**] for A fib on Mon [**1-10**]; do
not take Sat [**1-8**] and Sunday [**1-9**].
Disp:*60 Tablet(s)* Refills:*0*
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] x 2 weeks then 400 mg daily x 2 weeks then as
directed by your cardiologist.
Disp:*120 Tablet(s)* Refills:*0*
10. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*1*
11. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
mitral regurgitation s/p mitral valve repair
postop A Fib
PMH:
Hyperlipidemia
Hypertension
Malaria
Tuberculosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**\
****Target INR for A Fib 2.0-3.0
First blood draw Monday [**1-10**] with results called to the
cardiac surgery office [**Telephone/Fax (1) 170**] prior to 4 pm.
We will arrange for your cardiologist or PCP to followup
coumadin dosing/INR on that day.
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2184-2-4**] at 1:30 PM
Cardiologist Dr. [**Last Name (STitle) 1923**],[**First Name3 (LF) **] [**2184-2-3**] at 3:00 PM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 2573**] in [**5-3**] weeks
Completed by:[**2185-1-8**]
|
[
"997.1",
"424.0",
"401.9",
"745.5",
"285.1",
"427.32",
"E878.8",
"V12.03",
"272.4",
"427.31",
"V12.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
7879, 7937
|
4021, 5832
|
296, 349
|
8093, 8249
|
2056, 3213
|
9293, 9720
|
1225, 1278
|
6310, 7856
|
7958, 8072
|
5858, 6287
|
8273, 9270
|
1293, 2037
|
236, 258
|
377, 927
|
949, 1050
|
1066, 1209
|
3223, 3998
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,659
| 147,333
|
44817
|
Discharge summary
|
report
|
Admission Date: [**2200-12-30**] Discharge Date: [**2201-1-9**]
Date of Birth: [**2122-7-15**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Vancomycin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
+ blood cultures
Major Surgical or Invasive Procedure:
Placement of midline and PICC catheters
Ultrasound-guided thoracentesis
Transesophageal echocardiogram
Virtual colonoscopy
History of Present Illness:
78M Russian speaking, h/o CABG, ICM, CHF (EF ~25% 1+MR, 1+AR),
h/o VT s/p ablation and AICD and pacer placement, h/o Afib on
coumadin, amiodarone induced lung toxicity discharged [**2200-12-28**]
after development of petechial rash in setting of
supratherapeutic INR (3.8), referred to ED after blood cultures
grew [**4-21**] + GPCs. ROS: reports 3 weeks of chills at bedtime,
worse in the past 3d. Petechiae noticed in past 5-7days at home.
No recent antibiotic exposures, weight loss, night sweats, LH,
SOB, CP, weight loss, cough, dysuria, or other complaints. Of
note pt has h/o MRSE bacteremia s/p cath in [**2199**], treated with
IV antibiotics, no record of receiving Vanc in past.
.
In [**Name (NI) **], pt received Vanco 1gm and within 1 hour developed
flushing, HA, itchiness, tachypnea, with SBPs 70's. Pt received
Benadryl 50, Methylpred 125mg IV, Pepcid 20mg IV. Pt then given
Gent, Oxacillin 1G IV, started Levophed, and ABG 7.39/21/71 with
lactate 4.1, SVO2 88%. Received total 4.5L and 3U FFP, 500cc
UOP. Code sepsis called. Reported shortness of breath upon
transfer which resolved upon arrival to ICU.
Past Medical History:
1. CAD; s/p MI [**2185**], CABG, chronic stable angina, last cath with
stent in [**7-21**]: LMCA/CFX
2. ICM
3. VTach; status post ablation/AICD, leads changed [**6-22**].
4. AFib(on Coumadin).
5. Hyperlipidemia
6. Hypothyroidism (secondary to amiodarone toxicity).
7. CKD
8. Amiodarone lung toxicity.
9. Recent petechial rash [**12-22**]: peripheral smear remarkable for
tear drop cells, burr cells, and schistocytes that were
concerning for a hematologic malignancy/ bone marrow process and
pt was advised to f/u with Heme/Onc as an outpt.
10. MRSE bacteremia [**Date range (1) 26740**] post cardiac cath
Social History:
Lives with wife in [**Name (NI) 583**] in an apartment building. Retired
engineer. One son who lives in [**Name (NI) 1468**] and is involved with his
father's care.
Tob: quit 30 years ago; before that 25 year history at 1.5 ppd
EtOH: occasional
IVDA:none
Family History:
Mother with MI, died at 64; Father died at 86 in [**Country 532**] of "old
age"; Son with no medical problems
Physical Exam:
VS: Tm 96.8 BP 85-138/32-66 RR20-37 o2sat: 95-97% 100% NRB
GEN: eldery, talkative, alert, oriented x 3
HEENT:anicteric, OP clear
NECK: L IJ in place oozing.
PULM: clear ant/lat, no wheezing or stridor
CV: distant S1, S2, no obvious murmurs
ABD: soft, NT/ND, NABS
EXT: Warm well perfused, diffuse petechial rash on torso/legs.
1+ pitting edema LE bilat.
NEURO: grossly intact.
Pertinent Results:
EKG: Afib, no sig change from prior. No evidence of atrial
pacing. Wide QRS.
.
CXR: (wet read) L IJ in place. Pacer wires in place. Stable L
sided pleural effusion with possible atelectasis, seen on film
[**6-22**]. No obvious CHF.
Renal U/S: IMPRESSION: Mild bilateral thinning of renal
cortices. No evidence of hydronephrosis or renal infarction.
TTE:
1. The left atrium is moderately dilated. The left atrium is
elongated. The right atrium is moderately dilated.
2. Left ventricular wall thicknesses are normal. There is an
antero-apical left ventricular aneurysm. Overall left
ventricular systolic function is severely depressed. Resting
regional wall motion abnormalities include diffuse hypokinesis
with akinesis of the inferior and anteroapical wall. .
3. Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4. While the views of the aortic valve are limited, it appears
that there is trace aortic regurgitation seen. No mass on the
aoritc valve.
5.The mitral valve leaflets are mildly thickened. No mass seen
on the mitral valve. Trivial mitral regurgitation is seen.
6. There is no pericardial effusion present.
7. There is an echogenic density in the right ventricle
consistent with a pacemaker lead.
Compared with the findings of the prior report (images
unavailable for review) of no change in LV function.
IMPRESSION:
No echocardiographic evidence of endocarditis.
TEE:
The left and right atria are dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is dilated, and there is
severe regional left ventricular systolic dysfunction with
akinesis of the inferior wall and distal anterior wall. The true
apex is not visualized well, but appears to be akinetic, as
well. Right ventricular systolic function appears depressed.
There are simple atheroma in the aortic arch and in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen. No vegetation/mass is seen on the pulmonic valve.
IMPRESSION: No evidence of endocarditis. Severe regional left
ventricular systolic dysfunction. Mild aortic and mitral
regurgitation
Tagged wbc Scan: No localization of infectious source.
LUE U/S: No evidence of LUE DVT
Virtual colonoscopy: Results pending at time of discharge
[**2200-12-30**] 07:00PM BLOOD WBC-19.5* RBC-3.82* Hgb-10.5* Hct-32.5*
MCV-85 MCH-27.5 MCHC-32.4 RDW-23.6* Plt Ct-106*
[**2201-1-4**] 06:10AM BLOOD WBC-7.2 RBC-3.78* Hgb-10.2* Hct-31.8*
MCV-84 MCH-27.0 MCHC-32.1 RDW-23.2* Plt Ct-128*
[**2200-12-30**] 10:20AM BLOOD Neuts-89.8* Bands-0 Lymphs-5.8* Monos-3.3
Eos-0.8 Baso-0.3
[**2200-12-29**] 01:00PM BLOOD PT-25.0* INR(PT)-4.6
[**2201-1-1**] 09:07AM BLOOD PT-34.9* PTT-44.6* INR(PT)-9.3
[**2201-1-3**] 04:30AM BLOOD PT-15.8* PTT-34.6 INR(PT)-1.7
[**2200-12-31**] 02:50AM BLOOD FDP-40-80
[**2200-12-30**] 09:00PM BLOOD Fibrino-195
[**2201-1-4**] 06:10AM BLOOD ESR-7
[**2201-1-2**] 08:10AM BLOOD Ret Aut-1.9
[**2201-1-4**] 06:10AM BLOOD Glucose-90 UreaN-40* Creat-1.9* Na-141
K-4.1 Cl-105 HCO3-22 AnGap-18
[**2201-1-1**] 05:19AM BLOOD ALT-25 AST-37 LD(LDH)-440* AlkPhos-167*
TotBili-1.2
[**2201-1-4**] 06:10AM BLOOD Mg-2.2 Iron-64
[**2201-1-4**] 06:10AM BLOOD calTIBC-361 Ferritn-45 TRF-278
[**2201-1-2**] 04:36AM BLOOD Hapto-173
[**2201-1-4**] 06:10AM BLOOD CRP-15.2*
[**2200-12-31**] 03:11AM BLOOD Lactate-3.2*
Brief Hospital Course:
In the [**Hospital Unit Name 153**] he [**Hospital Unit Name 1834**] Vancomycin desensitization and his
antibiotic coverage was advanced to full-strength vancomycin on
[**1-3**]. His reaction in the emergency department was felt to be
due to Red Man Syndrome. His blood cultures revealed MRSE, but
had no positive blood cultures since [**12-30**]. His ICU course was
also notable for an INR of 9.3 for which no obvious etiology was
found. However, he may have had mild DIC, given finding of
anisocytosis with acanthocytes, burr, and teardrop morphologies.
These findings on peripheral smear should be followed up by
referral to outpatient hematology. He was restarted on lower
dose coumadin shortly before d/c (3mg PO qHS), and was
instructed to have his INR checked on [**1-12**].
Once moved to the wards, Mr. [**Known lastname 95889**] [**Last Name (Titles) 1834**] extensive workup
for the source of his MRSE bacteremia, in consultation with ID
service. Ultimately, TTE, TEE, thoracentesis, conventional
imaging, and tagged wbc scan failed to identify a source for his
bacteremia. Because of the risk of secondary endovascular and/or
pacemaker infection, a decision was made to treat for a total of
6 weeks with vancomycin. EP service was consulted due to
existing PPM and AICD, who stated that given no evidence of
seeding of wires on TEE, and existing comorbidities, they would
not recommend removal of hardware. He had a R PICC placed, and
was arranged for outpatient VNA for vancomycin administration.
He was also set up for outpatient follow-up with ID for
monitoring of renal function and blood counts while on vanc.
During his evaluation, Mr. [**Known lastname 95889**] was also found to be guiaic
positive
and iron deficient. He had a preexisting appointment for
outpatient evaluation with Dr. [**Last Name (STitle) 1940**] in [**Month (only) 404**]; however, we
took this opportunity to request an inpatient consultation.
Because of his extensive comborbities, the GI consultant
recommended a more conservative approach with screening for H.
pylori - which was negative, and virtual colonoscopy, the
results of which are pending at the time of discharge. He was
told to keep his appointment with Dr. [**Last Name (STitle) 1940**] to discuss the
results of his virtual colonoscopy.
While in-house, Mr. [**Known lastname 95889**] was significantly volume overloaded.
He was diuresed with IV lasix without difficulty, but Mr. [**Known lastname 95889**]
was hesitant to be aggressively diuresed, out of concerns about
his renal function, and his belief that his symptoms were no
worse than usual. He is followed in [**Hospital1 18**] heart failure clinic
for long-term monitoring of his volume status, and knows to
contact them with concerns about his heart failure symptoms.
Medications on Admission:
Losartan 50 qd
Synthroid 175mcg qd
Lipitor 40mg qd
ASA 81mg qd
Flomax 0.4mg qd
Plavix 75mg qd
Folate 1mg qd
Vit B12 100mcg qd
Pyridoxine 50mg qd
Lasix 80 mg qAM
Lasix 40mg qhs
FeSo4 325mg [**Hospital1 **]
Imdur 30mg qd
Dofetilitde 250mcg [**Hospital1 **]
Toprol XL 100mg qd
Coumadin 6mg qhs
Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
once a day for 35 days.
Disp:*35 doses* Refills:*0*
2. PICC
Please flush PICC daily per protocol
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR 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. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
13. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
15. Ferrous Sulfate 300 (60) mg Tablet Sig: One (1) Tablet PO
twice a day.
16. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.
17. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
Discharge Disposition:
Home With Service
Facility:
Gentiva/[**Location (un) 86**]
Discharge Diagnosis:
Principal:
1. Coagulase Negative MRSE Bacteremia.
2. Gastrointestinal Bleeding.
3. Iron Deficiency Anemia.
4. Systolic Heart Failure.
5. Red-Man Syndrome/Anaphylaxis to Vancomycin - desensitized.
6. Schistocytes on Blood Smear in context of acute infection
Secondary:
1. Ischemia Cardiomyopathy, EF ~ 15%.
2. Coronary Artery Disease s/p CABG [**2185**], PCI/Stent [**2199**].
3. Atrial Fibrillation.
4. Ventricular Tachycardia - s/p Ablation/DDD-ICD.
5. Hyperlipidemia.
6. Amiodarone Lung Toxicity.
7. Hypothyroidism.
8. Chronic Kidney Disease Stage III/IV.
9. Benign Prostatic Hypertrophy.
Discharge Condition:
Good, on IV antibiotics, afebrile, edema somewhat improving.
Discharge Instructions:
You have been diagnosed with a blood infection. You had several
tests to try to find the source of this infection, but it could
not be localized. You are being discharged home on IV
antibiotics for a total of 6 weeks (5 more weeks at home). It
will be important to see Dr. [**Last Name (STitle) **] in the infectious disease
clinic for monitoring of your blood counts, and your kidney and
liver function while on the antibiotics.
You also had a virtual colonoscopy due to your anemia and
finding of blood in your stool. You were also given lasix for
arm and leg swelling.
You need to have your coumadin level drawn on Monday, [**1-12**] by your visiting nurse. The results should be called to Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 3658**], and Dr. [**Last Name (STitle) **] should tell you
when you should next have your INR checked, and whether you
should change the dose of your coumadin.
You should eat a low salt diet and weigh yourself daily. If your
weight increased by more than 3 pounds, you should call the
heart failure nurses or your physician.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] in infectious disease
clinic on [**1-16**] at 11AM. The clinic is at [**Last Name (NamePattern1) **]
in the basement. You can call [**Telephone/Fax (1) 457**] with any questions.
You have an appointment with Dr. [**First Name (STitle) 437**] in cardiology on [**2-9**] at 3pm. You can call [**Telephone/Fax (1) 3512**] with any questions.
You should see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
within the next 1-2 weeks. You can call [**Telephone/Fax (1) 3658**] for an
appointment.
|
[
"276.2",
"398.91",
"V58.61",
"578.9",
"E930.8",
"413.9",
"995.94",
"244.3",
"280.9",
"E942.0",
"V45.02",
"414.8",
"V45.81",
"511.9",
"038.11",
"427.31",
"600.00",
"272.4",
"584.9",
"585.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.14",
"34.91",
"88.01",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11252, 11313
|
6659, 9452
|
299, 424
|
11949, 12012
|
3013, 6636
|
13134, 13730
|
2491, 2602
|
9793, 11229
|
11334, 11928
|
9478, 9770
|
12036, 13111
|
2617, 2994
|
243, 261
|
452, 1573
|
1595, 2202
|
2218, 2475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,813
| 126,382
|
6727
|
Discharge summary
|
report
|
Admission Date: [**2138-12-8**] Discharge Date: [**2138-12-12**]
Date of Birth: [**2057-12-13**] Sex: M
Service: MEDICINE
Allergies:
Coumadin
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
colonoscopy
History of Present Illness:
80M w PMH of recent bioprosthetic MVR 6 weeks ago presents with
painless rectal bleeding x1. At 12AM overnight, pt got up to
urinate. He felt a sudden urge to have BM. He had large loose
stool followed by bright red blood. Pt filled toilet with blood
and some on the floor. He felt weak and his wife lowered him to
the floor. He was unable to clean himself. His wife called EMS.
During this time he denied having abdominal pain, CP, SOB.
In the ED, VS T97.4, BP 136/80 HR 86 RR 18 99%RA. He had no
abdominal tenderness on exam. Small clots noted on rectal exam
with no evidence of hemorrhoids. HCT was 31.7. Stool guaiac
positive red, purplish color. 2 large bore PIVs were placed.
Patient was type and crossmatched for 2 units and given 1L IVFs.
Past Medical History:
Hypertension
Hyperlipidemia
Diverticulosis
Gastroesophageal reflux disease
Thyromegaly
Raynaud's phenomenon
Prostate Cancer s/p prostatectomy
Osteoarthritis
s/p Right total hip replacement
s/p Left shoulder replacement
s/p Tonsillectomy
s/p Cataract surgery
s/p MVR with bioprosthetic valve
Social History:
Lives with:wife
Occupation:retired investment manager
Tobacco:quit [**2099**]; 1 ppd x 25 yrs
ETOH:couple of drinks/day; no history of withdrawal including
last admission
Active walking, working out daily
Family History:
N/C
Physical Exam:
Vitals: T:Afebrile BP: 152/94 P:95 R: 18 O2: 100RA
General: Alert, oriented, no acute distress lying in bed
HEENT: Sclera anicteric, Dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; midline sternotomy scar well healed
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
[**Last Name (un) **]
Pertinent Results:
[**2138-12-8**] 01:15AM PT-12.1 PTT-23.2 INR(PT)-1.0
[**2138-12-8**] 01:15AM PLT COUNT-385#
[**2138-12-8**] 01:15AM NEUTS-65.2 LYMPHS-20.3 MONOS-5.7 EOS-8.0*
BASOS-0.8
[**2138-12-8**] 01:15AM WBC-4.9 RBC-3.89* HGB-10.1* HCT-31.7* MCV-82
MCH-26.1* MCHC-32.0 RDW-16.3*
[**2138-12-8**] 01:15AM GLUCOSE-114* UREA N-11 CREAT-0.7 SODIUM-137
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2138-12-8**] 04:36PM HCT-26.3*
[**2138-12-12**] 07:10AM BLOOD WBC-6.4 RBC-3.63* Hgb-10.7* Hct-30.3*
MCV-83 MCH-29.5 MCHC-35.3* RDW-16.0* Plt Ct-267
Brief Hospital Course:
80 year old male with PMH of HTN and s/p bioprosthetic MVR who
initially presented with acute blood loss anemia.
1. GI Bleed: Admitted after an episode of painless hematochezia
at home. Initially, the patient was treated with fluid
resuscitation and IV PPI. The patient's b-blocker and aspirin
were stopped and serial hematocrit was monitored every 6 hours,
pending stabilization of bleed. On first day of
hospitalization, patient developed frank hematochezia and became
hypotensive with SBP in 70s-80s. Transferred to the MICU for
further stabilization in consultation with IR and general
surgery. In total, the patient received 8 UpRBC, 5 units NS and
2 units FFP. Serum electrolytes, especially calcium were
monitored carefully and repleted as necessary with massive
transfusion requirement. Hct stabilized in the 27s. The
patient was taken to angiography on the evening of [**2138-11-7**] but
celiac, SMA and [**Female First Name (un) 899**] arteriograms were within normal limits.
Endoscopy was within normal limits on [**12-9**]. Colonoscopy on
[**12-9**] showed diverticulosis in the entire colon, blood in the
mid ascending colon through sigmoid colon and no evidence of
active bleed. On the morning of [**12-10**], patient had another drop
in Hct to 24 and was transfused another UpRBCs. He remained
hemodynamically stable without further melena or hematochezia
and was transferred to floor for further management. On the
medicine floor, the patient was observed for an additional 48
hours with serial hematocrits every 12 hours. Aspirin was held
indefinitely and his B-blocker was restarted (initially at a
lower dose). He had no evidence of active bleed (guiac negative
stool) or symptoms of anemia. Prior to discharge, Hct was 30.3.
Follow up with GI for presumed diverticular bleed was arranged
as outpatient.
2. s/p MVR: stable
3. HTN: As above, the patient's b-blocker was initially held in
the setting of his acute bleed. Once hematocrit had stabilized
and the patient had no further evidence of active diverticular
bleeding, metoprolol was started at a reduced dose of 12.5mg
[**Hospital1 **]. By time of discharge, patient was on home medication
regimen of metoprolol 25mg [**Hospital1 **]
4. Hyperlipidemia: stable, continued on statin throughout
hospitalization
5. GERD: stable, not on medications at home
Medications on Admission:
1. Aspirin 325 mg (E.C.) PO DAILY
2. Lovastatin 20 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Metamucil PRN
5. Centrum silver
6. N acetylcysteine (supplement)
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Metamucil Powder Sig: One (1) PO once a day as needed
for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Lower Gastrointestinal Bleed
Secondary Diagnosis:
status post mitral valve replacement
hyperlipidemia
HTN
Discharge Condition:
hemodynamically stable, hematocrit 29- 30
Discharge Instructions:
You were admitted after having a bloody bowel movement. At
first, we treated you only with intravenous fluids, however the
bleeding worsened. You were transferred to the intensive care
unit for closer monitoring. You received 8 units of red blood
cells. The gastroenterologists performed an endoscopy and
colonoscopy but could not localize the source of bleeding
although there was extensive diverticulosis, or sac-like
protrusions within your large intestine. Most likely the
bleeding was caused by a small artery located within a
diverticulum that broke through the skin into the colon. The
bleeding stopped spontaneously and your blood cell counts
remained stable.
You do not need to make any special modifications to your diet,
although some physicians recommend increasing fiber intake to
increase the bulk of your stool. Also, please avoid foods that
cause your stool to appear red, such as beets.
Please make the following changes to your medication regimen:
1. stop aspirin: ask your cardiologist if you should take this
medication in the future
Please call your physician or return to the emergency room if
you develop any further bloody bowel movements, fever, abdominal
pain, lightheadedness, shortness of breath, palpitations, chest
pain or any other concerning symptoms.
Followup Instructions:
Please follow up with your gastroenterologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
M.D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2138-12-29**] 4:30
Please follow up with your primary care physician, [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **]
[**Name12 (NameIs) 1413**], M.D. Date/Time: [**2138-12-24**] 3:30. Phone number:
[**Telephone/Fax (1) 457**]
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2139-1-6**] 9:40
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2139-3-17**]
9:00
|
[
"272.4",
"530.81",
"285.1",
"458.9",
"V42.2",
"401.1",
"562.12",
"288.60",
"280.9",
"443.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23",
"88.47",
"88.72",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
5630, 5636
|
2814, 5161
|
280, 298
|
5806, 5850
|
2239, 2791
|
7192, 7828
|
1627, 1632
|
5378, 5607
|
5657, 5657
|
5187, 5355
|
5874, 7169
|
1647, 2220
|
232, 242
|
326, 1075
|
5727, 5785
|
5676, 5706
|
1097, 1389
|
1405, 1611
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,644
| 147,982
|
43798
|
Discharge summary
|
report
|
Admission Date: [**2106-10-29**] Discharge Date: [**2106-11-11**]
Date of Birth: [**2056-9-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
neck pain, leg and arm weakness
Major Surgical or Invasive Procedure:
Posterior Laminectomy at C2-C3
History of Present Illness:
Pt is a 50 yo woman with h/o depression/anxiety and Hep C who
presents with ~5-6 days of neck pain, constipation, and urinary
retention as well as right sided weakness and numbness.
She reports that she sat is a massage chair 8 days ago and fell
asleep x1 hour. Unclear what position. She then developed onset
of lower back pain 2 days later by her report to the ED, but she
denies LBP to me. She tells me that her pain has been all in
her
neck and shoulders region. She says that since 6 days ago, she
has had no BM. She also reports that she has not urinated for 6
days. She states that 5-6 days ago, on Saturday, her RLE felt
numb and weak. Since Sunday, she states she has been unable to
walk. Her RUE has also been weak and tingling/numb for about
the
same time frame. She has pain as above. She claims no LBP.
She
also says that her "private area" is numb. Per her report, she
went to the [**Hospital1 112**] ED 4 times in the past week with this story and
was not imaged, given ativan and aleve and sent home. She has
had pain in her abdomen. She says she has not urinated in 5
days.
Here, she has extreme neck pain and was catheterized for 1200 cc
urine. She also continues to have weakness.
ROS: Patient denies any fever, she had some nausea/vomiting. She
had a mild bifrontal HA, now resolved.She had some dysarthria 4
days ago. No dysphagia. + dizziness/LH. No visual changes,
diplopia, hearing changes, or vertigo. No facial symptoms.
Past Medical History:
-h/o depression/anxiety
-Hep C
Social History:
Patient states that she started use IV drugs ~2-3 years ago with
a friend of hers "who wasn't really a good friend." Denies
alcohol use.
.
The patient states that she has a large, very supportive family.
She has 6 children ranging from ages 32 to 14.
Worked as crossing
guard and stopped due to depression.
Family History:
No CAD. No CA. No stroke/sz
Physical Exam:
Upon evalVitals:100.1-->103, 100, 119/74, 32, 97% on RA
Gen:Mod distress due to pain. Pt sleepy after medication.
HEENT:MMM. Sclera clear. OP clear
Neck: Has C-collar on so can't assess meningismus.
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
uatiNeurologic examination:
Mental status: Awake and alert, cooperative with exam sometimes.
Delays answers due to pain often.
Orientation: Oriented to person, place, and date
Attention: Sleepy, but tries to pay attention.
Language: Fluent with good comprehension. No dysarthria or
paraphasic errors
No apraxia, no neglect
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 5 to 3
mm bilaterally. Visual fields are full to finger movement. Fundi
normal bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk and tone bilaterally
No tremor
Pt has severe motor impersistence throughout. She refuses/is
unable to left RUE, but can move at least in plane of bed and
can
use FF fully. She can't lift or hold arm off of bed. Her LUE,
she can initially hold up and has at least 4/5 strength
throughout, but later in exam, refuses/is unable to lift off of
the bed well.
In LEs, she can push me away strongly with both legs and bend
her
knees equally, but will not cooperate with formal strength
testing. She moves both feet and toes at least [**4-7**].
Unable to test pronator drift
Sensation: Very spotty and changes with multiple exams, but LT
and PP are [**Month (only) **] in RLE over L4-S1 regions, but otherwise intact.
Prop and temp normal. Vib increased in RLE. No sensory level to
PP on either side of her body. She does later change and report
less sensation over right lateral thigh, but then says this is
actually the same as the left. Overall, she is distracted by
pain and gives an inaccurate exam.
Reflexes: B T Br Pa Ankle
Right t 1 t 2 2+
Left t 1 t 2 2
Toes were downgoing bilaterally
Coordination: Will not cooperate, but does do FFM with hands
well. Won't lift either arm up to do FNF.
Gait: Refuses/unable
Per ED exam, she has normal perianal sensation, but no sphincter
tone.
on in the ED
Pertinent Results:
[**2106-10-29**]: MRI C/T spine: Markedly abnormal study with evidence
of extensive prevertebral and epidural space inflammatory
process, perhaps originating with the consolidation involving
the medial aspect of the right lung at its apex, by contiguous
extension. There is some ventral impression of the cord,
particularly at the C2 through C4 levels. There is evidence of
extensive secondary leptomeningeal involvement, which may extend
throughout the thoracic spine to the level of the conus. Of
note, there is a strong suggestion of cord intrinsic signal
abnormality, raising the possibility of venous edema related to
septic thrombophlebitis, without cord hemorrhage. Also of note,
the prevertebral process includes apparent defined fluid locules
within the longus [**Last Name (un) **] muscles which may, at least in part,
reach the spinal epidural space via the left C6-7 neural
foramen. Secondary leptomeningeal involvement may extend
throughout the thoracic levels to the level of the conus
medullaris.
Brief Hospital Course:
In brief, the patient is a 50 yo female with history of Hep C,
IVDU and depression who presented with fevers, chills, severe
neck pain and neurologic deficits found to have an epidural and
pre-vertebral abscess at C2-C3.
.
1.) Neuro compromise/spinal abscess/osteomyleitis: The patient
presented with signs and symptoms consistent with cervical
spinal cord compression. Imaging revealed an epidural abscess
and osteomyelitis at C2-C3 (see complete report). She was
started on empiric antibiotics and taken to the OR for C2-C3
laminectomy (please refer to operative report). She was started
on steroids to decrease inflammation around the cord. Wound
cultures from the surgical site revealed Staph aureas which was
sensitive to methacillin. She was started on nafcillin with an
anticipated 6 week course via a PICC line that was placed. She
made gradual improvement in her neurologic deficits and worked
regularly with PT and OT. A repeat MRI on [**2106-11-4**] revealed a
persistent fluid collection, however, the patient was making
steady progress in neurologic recover and remained afebrile, so
the decision was made to continue to follow her exam closely and
monitor for a need for a new operative intervention to drain the
collection. She completed a steroid taper. She will be
discharged with follow-up in the Infectious Disease clinic and
the Neurosurgery Department with a repeat MRI prior to the
Neurosurgery appointment. While on nafcillin she will need
weekly monitoring of LFTs, BUN and Cr.
.
3.) MSSA bacteremia - Patient was bacteremic on admission to ICU
from ED. Found to be MSSA consistent with the species identified
from the surgical specimen. Her blood cultures cleared rapidly
once starting antibiotics. A TTE revealed no valvular
abnormality and she had no signs of septic emboli. By time of
discharge, follow-up blood cultures were negative. She will
receive antibiotics as above.
.
3.) Respiratory failure: Unclear precipitant of resp failure.
Patient extubated without difficulty on [**11-2**]. She was
discharged with normal oxygenation on room air.
.
4.) Hepatitis C - The patient has an ~2 year history of HepC
likely acquired through IVDU. Her LFT were initially elevated
(ALT primarily) but rapidly normalized. Her synthetic function
(INR) was normal. HIV negative. HCV Viral load >700,000. Hep B
serologies reveal non-immune pattern. [**Last Name (un) **] serology was
positive. She will need to complete a Hepatitis B vaccine
series. She received the first dose of Hepatits B vaccine on
[**2106-11-11**]. She should receive her next dose in 1 month and the
final dose in 6 months from now. She should receive a referal
from her PCP to the Liver Center to evaluate her Hep C after her
treatment course for this bacterial infection.
.
5.) Depression: The patient has a questionable history of
depression. Currently not on meds. The patient was evaluated by
social work to help with coping strategies and access to care.
.
6.) Urinary Tract Infection: The patient developed a low grade
fever late in her hospital course. She had no localizing signs
or symptoms. A UA revealed elevated WBC c/w infection. She was
started on 7 days of ciprofloxacin and had her foley catheter
changed. Her fever resolved. At discharge, urine and blood
cultures were pending.
.
7.) Anemia: Unclear etiology. HCT stable. Iron studies were
consistent with mild anemia of chronic disease. Her liver
disease is likely an exacerbating factor. This should be
follow-up as an outpatient.
.
8.) Elevated lipase: unclear etiology no peri-meal symptoms. no
abdominal pain or tenderness. Weekly follow-up with other lab
tests is recommended.
.
9.) FEN: tolerating soft solids well with max assist feeding.
.
10.) PPX: SC heparin, pneumoboots, PPI
.
11.) Access: PICC
.
12.) Code: Full
.
13.) Dispo: to acute rehab with Infectious Disease and
Neurosurgery follow-up and a new PCP
Medications on Admission:
Ativan
Aleve
Motrin
Discharge Medications:
1. Outpatient Lab Work
Please draw the following labs every Monday for the next 5 weeks
(i.e. [**11-15**]): LFTs, Bun, Cr and fax the result to
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3394**] [**Telephone/Fax (1) 1419**]
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) gram
Intravenous Q4H (every 4 hours) for until [**2106-12-12**] weeks.
5. PICC Line Care
PICC Line Care per protocol
6. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back pain.
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for 1 BM daily.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Epidural abscess
Osteomyelitis
.
Secondary:
Hepatitis C
Urinary Tract Infection
Discharge Condition:
stable. afebrile. stable vital signs. improving neurologic
function. tolerating oral medications and nutrition
Discharge Instructions:
You have been evaluated and treated for neck pain and weakness
in your arms and legs. Your symptoms were caused by an
infection around your spinal cord in your neck. You had a
surgery to drain a fluid collection. You will continue to
receive antibiotics for several more weeks to make sure the
infection is treated adequately.
.
Take all the medications as prescribed.
.
Attend the follow-up appointments scheduled for you.
.
You need to make an appointment with a new Primary Care
Physician. [**Name10 (NameIs) **] initiate care at [**First Name8 (NamePattern2) **] [**Hospital3 66399**] outpatient
medicine clinic "Heathcare Associates," you need to call your
insurance company ([**Hospital3 **]) to tell them that you will be
transferring your primary medical care to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
After talking with [**Last Name (NamePattern1) **], you need to call Dr.[**Name (NI) 11574**]
office at [**Telephone/Fax (1) 250**] to talk with the registration department.
.
You will be working with physical therapy and occupational
therapy to rebuild strength in your arms and legs to the best of
their ability.
Followup Instructions:
You have the following appointments scheduled for you:
1) Infectious Disease: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3394**] on on [**2106-12-7**] at 9am
(telephone) [**Telephone/Fax (1) 457**] Date/Time:[**2106-12-7**] 9:00
2) Neurosurgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**5-8**] weeks. Please call
[**Telephone/Fax (1) 2731**] next week to schedule the appointment. You will
need to have another MRI prior to that appointment. The
Neurosurgery office will help to schedule the test for you.
3) Medicine: with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who works with your new PCP [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2106-12-13**] at 3:30pm. Please call [**Telephone/Fax (1) 250**]
to confirm the appointment after contacting [**Name (NI) **] as above.
|
[
"599.0",
"285.29",
"305.60",
"722.71",
"038.11",
"518.81",
"730.08",
"788.20",
"070.54",
"995.92",
"324.1",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11247, 11326
|
5877, 9777
|
349, 381
|
11459, 11574
|
4839, 5854
|
12783, 13701
|
2267, 2297
|
9848, 11224
|
11347, 11438
|
9803, 9825
|
11598, 12760
|
2312, 2625
|
278, 311
|
409, 1873
|
2962, 4820
|
2664, 2946
|
2649, 2649
|
1895, 1927
|
1943, 2251
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,885
| 108,950
|
35340
|
Discharge summary
|
report
|
Admission Date: [**2179-3-8**] Discharge Date: [**2179-3-14**]
Date of Birth: [**2110-3-4**] Sex: F
Service: MEDICINE
Allergies:
Naproxen / Codeine / Aspirin / Oxycontin
Attending:[**First Name3 (LF) 4373**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Patient expired.
History of Present Illness:
Mrs. [**Known lastname 10220**] is a 69 yo F with breast cancer with mets to
peritoneum on complicated by acites requiring 14 paracenteci
since [**9-2**], on navelbine/avastin C2D13 now presents wtih dyspnea
and poor po intake. Patient noticed increased DOE over the last
36 hours with increased labored breathing while walking around
the house and requiring assistance to even walk around the
living room. Patient also reports increased nausea with
vomitting 7-10 times over the last 2 days. Vomitius is
nonbilious, and patient has been unable to tolerate po intake.
Patient often has diarrhea related to Chemo, but reportedly no
diarrhea since Tuesday. Patient was seen by VNA today and BP was
60/p. EMS was called and on arrival BP was 80/p.
.
In the ED, patient was noted to be hypotensive on arrival but
improved with 3 L NS. Inital resident echo was concerning for
pericardial effusion with collapse of RV, but formal TTE by
Cardiology fellow showed no evidence of tamponade. LENIS were
negative for DVT. CT head was negative. CXR was unremarkable.
Vanco/Zosyn was given for initial concern of sepsis. Lytes were
noteable for Na 117 down from 122 earlier in the month and Cr
2.2 from 0.8. Also noted to be neutropenic. Patient refused
central line and code status was reportedly DNR/I.
.
On the floor, patient reports chronic low back pain, and feels
weak and fatigued, but otherwise feels well.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies 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:
Past Medical History:
Breast cancer
- Diagnosed in [**2174**] with an infiltrating lobular carcinoma grade
II, 1.7 cm, multifocal, with 13 out of 29 lymph nodes positive.
The tumor was ER positive, PR positive, and HER-2/neu negative
by both IHC and FISH. She underwent adjuvant chemotherapy after
completion of surgery with Adriamycin and Cytoxan followed by 10
weekly doses of Taxol. She received and completed chest wall
radiation. She was then started on adjuvant Arimidex therapy. In
[**2178-1-25**] she developed right shoulder pain and pain in her
upper abdomen. The abdominal pain prompted workup and apparently
blood work showed a CA [**95**]-29 level of 203. A PET scan revealed
nodularity in her omentum consistent with metastatic disease. A
bone scan reportedly was negative. She was started on high-dose
Faslodex hormone treatment [**2178-3-12**] and progressed on this
in [**2178-7-25**]. She was started on Xeloda in [**8-/2178**] and
continued and recently progressed with her last dose of Xeloda
on [**2178-12-5**].
- S/p Fulvestrant x7 last given [**2178-9-16**]
- Temodar PARP Phase II Trial: Cycle #: 1 Day 1: [**2179-1-13**], went
off trial for for toxicity
- VinORELbine (Navelbine) 40 mg IV day 1 ([**2179-1-21**]), held day 8
and 15 due to neutropenia. (30 mg/m2 - dose reduced by 17% to 25
mg/m2)
.
Other Past Medical History:
1. Breast cancer as above
2. Bladder suspension.
3. GERD
4. Osteoporosis.
5. Left frozen shoulder.
6. Depression and anxiety.
7. Laparoscopic cholecystectomy.
8. Rosacea.
9. Hypothyroidism.
10. Sleep apnea.
11. Rheumatic fever with subsequent dental prophylaxis.
12. Left eye surgery.
Social History:
She is divorced. She is a nonsmoker and drinks alcohol socially.
She is retired and former employee of the Federal government.
She is of Lithuanian origin.
Family History:
Her mother had breast cancer at age 75 and underwent lumpectomy
and radiation therapy. Her maternal aunt had [**Name2 (NI) 499**] cancer in
her 70s. The patient's sister had [**Name2 (NI) 499**] cancer at 55 and two
paternal aunts with breast cancer at age 52 and 70, a paternal
first cousin had renal cancer. She has not undergone genetic
testing.
Physical Exam:
Vitals: T: 96.5 BP: 100/58 P: 116 R:18 O2: 97% 2L NC
General: Markedly cachectic, tired appearing, pale, but NAD
HEENT: Sclera anicteric, dry MM, oropharynx clear without thrush
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ edema of ankles
bilaterally, no clubbing, cyanosis
Pertinent Results:
[**2179-3-8**] 04:20PM BLOOD WBC-1.1*# RBC-3.85* Hgb-12.3 Hct-34.8*
MCV-91 MCH-32.0 MCHC-35.4* RDW-14.5 Plt Ct-270
[**2179-3-9**] 12:28AM BLOOD WBC-1.0* RBC-3.46* Hgb-11.2* Hct-32.3*
MCV-93 MCH-32.4* MCHC-34.7 RDW-14.4 Plt Ct-292
[**2179-3-9**] 04:20AM BLOOD WBC-1.0* RBC-3.40* Hgb-10.8* Hct-31.3*
MCV-92 MCH-31.9 MCHC-34.6 RDW-14.7 Plt Ct-268
[**2179-3-10**] 03:04AM BLOOD WBC-1.2* RBC-3.30* Hgb-10.2* Hct-30.7*
MCV-93 MCH-31.0 MCHC-33.4 RDW-14.8 Plt Ct-311
[**2179-3-9**] 12:28AM BLOOD PT-11.3 PTT-34.4 INR(PT)-0.9
[**2179-3-8**] 04:20PM BLOOD Glucose-100 UreaN-115* Creat-2.2*#
Na-117* K-4.3 Cl-71* HCO3-30 AnGap-20
[**2179-3-9**] 04:20AM BLOOD Glucose-95 UreaN-88* Creat-1.5* Na-126*
K-3.6 Cl-86* HCO3-29 AnGap-15
[**2179-3-10**] 03:04AM BLOOD Glucose-96 UreaN-71* Creat-1.1 Na-130*
K-3.4 Cl-93* HCO3-27 AnGap-13
[**2179-3-9**] 04:20AM BLOOD CK(CPK)-18*
[**2179-3-9**] 02:37PM BLOOD CK(CPK)-18*
[**2179-3-10**] 03:04AM BLOOD CK(CPK)-16*
[**2179-3-9**] 04:20AM BLOOD CK-MB-2 cTropnT-<0.01
[**2179-3-9**] 02:37PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-3-10**] 03:04AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-3-8**] 04:20PM BLOOD proBNP-4631*
.
[**3-8**] Echo:
Overall left ventricular systolic function is normal (LVEF>55%).
Due to suboptimal image quality and focused views, a focal wall
motion abnormality cannot be excluded.. Right ventricular
chamber size and free wall motion are normal. The aortic valve
is not well seen. The mitral valve appears structurally normal
with trivial mitral regurgitation. There is a very small
pericardial effusion, primarily around the right atrium and
basal right ventricle with no echocardiographic signs of
tamponade.
.
[**3-8**] CXR:
(pending final read)
.
[**3-8**] LENIs:
IMPRESSION: No evidence of DVT of either lower extremity.
.
[**3-8**] Head CT:
IMPRESSIONS: No acute intracranial abnormality. No evidence of
intracranial mass, but MRI is more sensitive for the detection
of intracranial lesions and should be considered.
[**3-10**]: KUB
Moderate amount of ascites with largest pocket seen within the
right lower quadrant. Multiple septations are noted compatible
with component
of loculation of the fluid.
[**3-12**]: Request for Pleurx catheterization for palliative
peritoneal ascites drainage.
1. Successful placement of Pleurx catheter in the right abdomen,
with the tip
terminating in the lower pelvis.
2. Removal of one liter of yellow ascites fluid.
.
[**2179-3-13**] 05:23PM BLOOD WBC-5.4 RBC-3.37*# Hgb-10.6*# Hct-33.4*#
MCV-99* MCH-31.4 MCHC-31.8 RDW-14.5 Plt Ct-434
[**2179-3-13**] 05:12AM BLOOD Glucose-86 UreaN-73* Creat-1.3* Na-145
K-4.1 Cl-114* HCO3-22 AnGap-13
[**2179-3-13**] 05:23PM BLOOD LD(LDH)-132 TotBili-1.0 DirBili-0.4*
IndBili-0.6
[**2179-3-13**] 05:12AM BLOOD Calcium-10.2 Phos-3.5 Mg-1.9
[**2179-3-11**] 02:48PM BLOOD CA27.29-744*
[**2179-3-8**] 04:32PM BLOOD Lactate-1.6 K-4.1
Brief Hospital Course:
Patient expired.
69 yo F with metastatic breast cancer prsents with vomitting,
poor po intake and dyspnea and to be in acute renal failure with
hyponatremia. Was tachycardic and complaining of mild chest
tightness. Admitted to the ICU for tachycardia and
hyponatremia, then to the oncology floor. See below for
discussion of each issue.
.
Goals of care: meeting in ICU regarding goals of care and poor
prognosis, then reiterated on the oncology medicine floor:
Code: DNR/I (discussed with patient and HCP), and daughter HCP
[**Name (NI) **] [**Telephone/Fax (1) 80568**]. Focus on comfort with symptom management.
Avoidance of invasive procedures, per family (son, daughter,
sister).
[**Name2 (NI) **] died the morning after being transferred to the ICU.
.
# Altered mental status: Patient does not respond to verbal or
visual stimuli on the floor. Likely d/t progressive metastatic
disease, combined with renal failure, hypotension, pain, SBP
infection, delirium. Pain controlled with IV morphine prn,
treated SBP with ceftriaxone, palliative care following.
.
# Chest Pain: unclear etiology, seemed to be costrochondritis
related as the pain was reproducible. Ruled out for MI with
three sets of negative cardiac enzymes. A V/Q of her chest was
ordered to rule out PE, but the patient was unable to lie flat
and complete the exam so it was aborted. Held anticoagulation
d/t goals of care, no CTA given ARF, could not tolerate V/Q
scan. On the floor, patient unable to verbalize whether chest
pain still present. Pain medications provided.
.
# Hypotenion/Tachycardia: likely was related to underlying
cancer and hypovolemia. Was volume resuccitated with NS and the
LR while in the ICU for the first two days. She was offerred a
CVL in the ED and declined. Her BP improved to SBPs in the 90s,
then 100s with IVFs and remained stable. Initially she seemed
fluid responsive with a decrease in rate from 130s to 110s
(which seemed to be her baseline). She remained tachycardic on
day two of admission without an obvious cause as she seemed
mostly fluid repleted. We continued to bolus her and pursued a
further workup for PE. Initially she had negative LENIs and a
CT was deferred because of ARF. A V/Q scan was performed on
[**2179-3-10**], but she was unable to lie flat for the test and the
test could not be completed. She was bolused periodically
overnight to maintain MAP of over 65. Her tachycardia improved
with IVF boluses prn.
.
# Hyponatremia/Acute renal failure: Based on exam and history,
likely hypovolemic hyponatremia. Most likely Gi losses combined
with third spacing in the setting of ascites. With fluid
resuccitation, she corrected and normalized very quickly but did
not have any neurological changes. She did have a CT head in
the ED that showed no intracranial lesions to explain this. Her
ARF also improved with IVFs and her urine output remained brisk
throughout her hospitalization.
.
# Thrush: Likely due to poor po intake and nausea/vomitting.
Started swish and swallow for her comfort.
.
# Breast Cancer: mid-cycle in her avastin and navelbine. Is
metastatic and has recurrent ascites requiring taps. On
presentation, her abdomen was soft and a therapeutic
paracentesis was deferred because of her hypovolemia, moderate
hypotension and neutropenia. Oncology was consulted and
followed along. Patient to oncology floor, outpatient oncology
attending described poor prognosis. Family meeting regarding
poor prognosis and goals of care; patient not to have further
chemotherapy or interventions/invasive procedures.
.
# Leukopenia: Likely chemo related, as last dose was [**3-1**]. ANC
600 so not yet neutropenic and never needed to be on neutropenic
precautions. On 3 18, her WBC began to recover.
.
# Pleurex catheter placed to help with paracentesis/ascites
drainage. SBP treated with ceftriaxone.
Medications on Admission:
# Octreotide Acetate 100 mcg SQ [**Hospital1 **]
# Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H
# Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
# Multivitamin po daily
# Lorazepam 0.5 mg PO Q4H prn nausea
# Loperamide 2 mg po QID prn
# Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H prn
# Nexium 20 mg daily
# Ondansetron 8 mg Q8H prn
# Compazine 10 mg po Q6H prn
# Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily
# NYSTATIN - 100,000 unit/mL Suspension - 4 mL by mouth four
times
daily as needed for thrush swish and swallow
# SUCRALFATE - 1 gram/10 mL Suspension - 10 ml by mouth as
needed
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Spontaneous bacterial peritonitis
Secondary:
Metastatic breast cancer
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
Completed by:[**2179-3-20**]
|
[
"584.9",
"288.03",
"112.0",
"567.23",
"276.1",
"707.23",
"197.6",
"E933.1",
"707.03",
"244.9",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
12493, 12502
|
7876, 8647
|
307, 326
|
12625, 12644
|
4989, 6781
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12709, 12757
|
4025, 4378
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12465, 12470
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12523, 12604
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11748, 12442
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4393, 4970
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1777, 2169
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260, 269
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354, 1758
|
6790, 7853
|
8662, 11722
|
3549, 3835
|
3851, 4008
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,425
| 164,384
|
31394
|
Discharge summary
|
report
|
Admission Date: [**2163-11-4**] Discharge Date: [**2163-11-4**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Respiratory distress, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo woman with DM, HTN, CAD s/p MI, and peritoneal
carcinomatosis who presented from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] NH today with
hypotension. She was noted to have VS: 82/64, HR 109, RR 16, T
99.2, sat 84% RA, which improved to 94% on 4L mask. She was
referred to the ED for further eval.
.
On arrival VS: BP 60/palp, HR 114, RR 20, sat 85% RA, Temp
100.4. She initially had R femoral cordis then a RIJ sepsis
catheter was placed. She was intubated with etomidate and succ,
started on neo then switched to levophed. She was given 1 gm
vancomycin, azithromycin 500mg iv, cefepime 2gm iv, and flagyl
500mg iv. She received 9L NS. Blood, urine, and sputum cultures
were sent. She received decadron 10mg iv.
.
ROS: Unobtainable.
Past Medical History:
Diabetes
Hypertension
Hypercholesterolemia
CAD, s/p MI with stent to RCA, OMI [**1-/2157**]
depression
right shoulder fracture
polymyalgia rheumatica
right hip fx [**2157**], s/p repair
peritoneal carcinomatosis with malignant cells and cytology from
[**Female First Name (un) 576**] 10/07 per recent [**Hospital1 882**] d/c summary: has f/u at [**Company 2860**]
[**11-8**]
recent admit at [**Hospital1 **] [**10-24**]-? for entercoccus
uti->levofloxacin
Social History:
At rehab after recent [**Hospital1 112**] admission. No current etoh or tobacco
use. Has multiple children/step-children near by.
Family History:
Unknown.
Physical Exam:
VS: T: 95.0 oral HR: 110 BP: 106/55 (levophed 0.3) RR: 16 Sat:
95 CVP: 15
AC 400/20/5/100%
Gen: Elderly woman, intubated, responds to light in eyes by
moving both arms, does not follow commands
HEENT: NCAT, PERRL, sclera anicteric, OP clear, mm moist
Neck: Supple, no LAD, JVP difficult to assess [**1-14**] habitus/edema
CV: tachycardic but regular, no m/r/g, S1, S2 present, difficult
to auscultate [**1-14**] resp
Resp: Inspiratory rhonchi, expiratory wheezes throughout,
decreased BS right middle/lower lung
Abdomen: protuberant, NT, ND, no masses or organomegally, +BS
Ext: No c/c/e, 2+ DP pulses
Neuro: Responsive to light in eyes by moving head/both arms,
pupils minimally responsive 2mm->1.5, DTR's 1+ at patella
bilaterally, no corneal blink
Skin: No rashes
Pertinent Results:
[**2163-11-3**] 10:15PM WBC-15.0* RBC-3.01* HGB-7.9* HCT-27.4* MCV-91
MCH-26.1* MCHC-28.7* RDW-17.7*
[**2163-11-3**] 10:15PM PLT COUNT-365
[**2163-11-3**] 10:15PM NEUTS-90* BANDS-1 LYMPHS-7* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2163-11-3**] 10:15PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL BURR-1+
[**2163-11-3**] 10:15PM ALBUMIN-2.1* CALCIUM-8.7 PHOSPHATE-6.5*#
MAGNESIUM-2.2
[**2163-11-3**] 10:15PM CK-MB-6
[**2163-11-3**] 10:15PM cTropnT-0.21*
[**2163-11-3**] 10:15PM ALT(SGPT)-200* AST(SGOT)-513* CK(CPK)-103 ALK
PHOS-109 TOT BILI-0.3
[**2163-11-3**] 10:15PM LIPASE-13
[**2163-11-3**] 10:15PM GLUCOSE-145* UREA N-47* CREAT-2.5*#
SODIUM-148* POTASSIUM-5.2* CHLORIDE-113* TOTAL CO2-20* ANION
GAP-20
[**2163-11-3**] 11:59PM O2 SAT-94
[**2163-11-3**] 10:22PM LACTATE-7.1*
[**2163-11-3**] 11:59PM LACTATE-4.9*
[**2163-11-4**] 12:45AM PT-19.8* PTT-44.8* INR(PT)-1.8*
[**2163-11-4**] 12:45AM CRP-97.7*
[**2163-11-4**] 12:45AM CORTISOL-29.1*
[**2163-11-4**] 01:02AM LACTATE-4.4*
[**2163-11-4**] 01:02AM TYPE-ART PO2-125* PCO2-40 PH-7.21* TOTAL
CO2-17* BASE XS--11
[**2163-11-4**] 01:44AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2163-11-4**] 01:44AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2163-11-4**] 01:44AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2163-11-4**] 01:44AM URINE GRANULAR-0-2
[**2163-11-4**] 01:44AM URINE CA OXAL-FEW
[**2163-11-4**] 02:40AM LACTATE-5.9*
[**2163-11-4**] 04:30AM PT-22.1* PTT-50.3* INR(PT)-2.1*
[**2163-11-4**] 04:30AM HYPOCHROM-1+ ANISOCYT-OCCASIONAL POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-1+ BURR-1+ TEARDROP-1+ ACANTHOCY-1+
[**2163-11-4**] 04:30AM PLT SMR-NORMAL PLT COUNT-292
[**2163-11-4**] 04:30AM WBC-19.0* RBC-3.05* HGB-8.0* HCT-28.5* MCV-94
MCH-26.2* MCHC-28.0* RDW-17.3*
[**2163-11-4**] 04:30AM NEUTS-94.6* BANDS-0 LYMPHS-2.8* MONOS-2.3
EOS-0 BASOS-0.2
[**2163-11-4**] 04:30AM CORTISOL-22.5*
[**2163-11-4**] 04:30AM CALCIUM-6.7* PHOSPHATE-5.0* MAGNESIUM-1.7
[**2163-11-4**] 04:30AM CK-MB-8 cTropnT-0.33*
[**2163-11-4**] 04:30AM ALT(SGPT)-713* AST(SGOT)-3546* LD(LDH)-7125*
CK(CPK)-160* ALK PHOS-156* AMYLASE-1261* TOT BILI-0.5
[**2163-11-4**] 04:30AM LIPASE-14
[**2163-11-4**] 04:30AM GLUCOSE-198* UREA N-40* CREAT-1.9*
SODIUM-146* POTASSIUM-4.5 CHLORIDE-119* TOTAL CO2-11* ANION
GAP-21*
[**2163-11-4**] 04:40AM freeCa-1.02*
[**2163-11-4**] 04:40AM TYPE-ART TEMP-35.0 RATES-2/ TIDAL VOL-450
O2-100 PO2-94 PCO2-32* PH-7.13* TOTAL CO2-11* BASE XS--17
INTUBATED-INTUBATED VENT-CONTROLLED
[**2163-11-4**] 04:40AM LACTATE-6.9*
[**2163-11-4**] 04:47AM TYPE-MIX PO2-55* PCO2-36 PH-7.08* TOTAL
CO2-11* BASE XS--18 INTUBATED-INTUBATED
[**2163-11-4**] 04:47AM O2 SAT-72
[**2163-11-4**] 06:43AM FIBRINOGE-218
[**2163-11-4**] 06:43AM FDP-80-160*
[**2163-11-4**] 06:49AM LACTATE-6.7*
[**2163-11-4**] 06:49AM TYPE-ART TEMP-35.0 RATES-24/ TIDAL VOL-400
PEEP-5 O2-100 PO2-108* PCO2-28* PH-7.17* TOTAL CO2-11* BASE
XS--16 AADO2-583 REQ O2-95 -ASSIST/CON INTUBATED-INTUBATED
[**2163-11-4**] 08:48AM LACTATE-6.4*
[**2163-11-4**] 08:48AM HGB-10.2* calcHCT-31
[**2163-11-4**] 08:48AM TYPE-ART TEMP-35.9 RATES-24/ TIDAL VOL-400
PEEP-5 O2-80 PO2-75* PCO2-31* PH-7.17* TOTAL CO2-12* BASE XS--16
AADO2-469 REQ O2-79 INTUBATED-INTUBATED VENT-CONTROLLED
[**2163-11-4**] 10:31AM LACTATE-6.3*
[**2163-11-4**] 10:31AM HGB-10.1* calcHCT-30 O2 SAT-94
[**2163-11-4**] 10:31AM TYPE-ART TEMP-37.1 RATES-30/ TIDAL VOL-400
PEEP-5 O2-80 PO2-85 PCO2-28* PH-7.20* TOTAL CO2-11* BASE XS--15
AADO2-462 REQ O2-78 INTUBATED-INTUBATED VENT-CONTROLLED
.
CXR [**2163-11-3**]: Right lung field white-out suggestive of pleural
effusion with underlying atelectasis vs. consolidation, no clear
tracheal deviation, ETT at level of clavicles (6cm above
carina).
.
Head CT [**2163-11-3**]: No hemorrhage, dilatation of bilateral
superior ophthalmic vein, proptosis and mild bilateral
enlargement of the lateral rectus muscle, which may be seen with
thyroid ophthalmopathy, however, other differential
consideration or enlargement of the superior ophthalmic vein
include cavernous sinus thrombosis
and carotid cavernous fistula.
.
ECG [**2163-11-3**]: Sinus tach (104), left axis (-57), normal
intervals, low voltage, no electrical alternans, Q II, aVF
(new), diffuse TW flattening vs. low-voltage, no ST changes.
Brief Hospital Course:
[**Age over 90 **] yo woman with hypertension, DM, anemia, carcinosis who
presents with septic shock thought to be secondary to pneumonia.
The patient was admitted in shock with elevated lactate, low
blood pressures and was continued on a IVF, levophed,
vancomycin, azithromycin, cefepime, and flagyl. The etiology of
shock at the time of admission was unclear but was most likely
septic given leukocytosis and fever. Pneumonia seemed most
likely given the infiltrate on CXR and clean UA, bacterial
cultures pending. Cardiac dysfunction may also have been
possible secondary to tamponade, metastsis and low voltage EKG,
but there was no elevated JVD or pulsus paradoxus. The EKG did
not show right heart strain suggestive of PE and, a massive PE
is less likely as the patient has been on lovenox. Adrenal
insufficiency seems unlikely with cortisol of 22.5. The patient
was continued on hemodynamic monitoring, fluids, given a blood
transfusion, given an insulin drip and started on dobutamine in
addition to levophed. In addition, urine, blood, sputum cultures
were drawn and a legionella antigen sent. She was noted to be in
multisystem organ failure with elevated LFT's consistent with
shock liver and elevated creatinine consistent with renal
failure. After a discussion with her son - [**Name (NI) **] [**Name (NI) 24735**](her
healthcare proxy)-, her code status was switched to DNR/DNI, and
she was placed on comfort measures. She was extubated and
pressors were discontinued. She was started on a Morphine drip
for dyspnea. She died at 14:10.
Medications on Admission:
tums 2 tabs [**Hospital1 **]
VHC 60mL QID
lovenox 30mg daily: started on most recent [**Hospital1 882**] admit
levofloxacin 500mg po daily x 10 days starting [**10-22**]
simvastatin 20mg qhs
morphine CR 15mg po bid
morphine IR 15mg po q6 prn
tylenol prn
bowel regimen prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
multisystem organ failure
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"199.1",
"570",
"518.81",
"995.92",
"412",
"038.9",
"401.9",
"725",
"486",
"197.6",
"584.9",
"785.52",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9009, 9018
|
7107, 8658
|
260, 266
|
9087, 9096
|
2536, 7084
|
9148, 9290
|
1723, 1733
|
8981, 8986
|
9039, 9066
|
8684, 8958
|
9120, 9125
|
1748, 2517
|
187, 222
|
294, 1079
|
1101, 1559
|
1575, 1707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,649
| 163,190
|
20538+20539
|
Discharge summary
|
report+report
|
Admission Date: [**2114-3-11**] Discharge Date: [**2114-4-18**]
Date of Birth: [**2046-10-20**] Sex:
Service: Thoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 67-year-old female who
was eating at noon time when she developed pain. She was
having a piece of lamb that became lodged in her throat. She
began to cough and dry heave and then began to have severe
abdominal pain. She went to an outside hospital where x-ray
films showed free air under the diaphragm. CT scan showed
free air and a small amount of free air in the distal
mediastinum. She was transferred to [**Hospital6 649**] for further management.
PAST MEDICAL HISTORY: Significant for chronic obstructive
pulmonary disease, asthma, hypertension, morbid obesity, high
cholesterol.
PAST SURGICAL HISTORY: No know surgical history.
MEDICATIONS ON ADMISSION: Prednisone, Valtrex, Advair,
_______, Lipitor, Pulmicort, OxyContin, aspirin, floredil and
Singulair.
ALLERGIES: Penicillin.
PHYSICAL EXAMINATION: She was afebrile, tachycardiac,
normotensive and 100 percent on a non-rebreather. She had
diminished breath sounds but was clear to auscultation. She
had no crepitus in her neck or chest. Abdomen was obese,
tender in the upper abdomen with no guarding. She had an
umbilical hernia.
LABORATORY DATA: Her labs at the time showed a white blood
cell count of 3.1, hematocrit 47.3, platelet count 307.
Chemistries showed a sodium of 140, potassium 5.4, chloride
105, bicarbonate 24, BUN 25, creatinine 0.9 with a blood
sugar of 136. Arterial blood gas at that time showed a pH of
7.37, PCO2 of 35, PO2 of 192, bicarbonate of 21 and a base
excess of -3. Her troponin was mildly elevated at 0.12.
HOSPITAL COURSE: A right internal jugular cord was placed in
the trauma bay and the patient was taken for a swallowing
evaluation, which showed perforation of the esophagus down to
the diaphragm. The patient was taken to the Operating Room
for exploration and repair. Please see the Operative Report
for further details. The patient underwent a thoracoabdominal
exploration and repair of esophageal perforation, omental
patch, a G-tube and a J-tube, and chest tube placement. The
patient was transferred to the Intensive Care Unit
postoperatively.
The [**Hospital 228**] hospital course was very prolonged and I will
now summarize this hospital course by systems.
Neurologically, the patient was kept on sedation early
postoperatively in her course and was able to be weaned from
her sedation. She was kept on her pain medication through her
J-tube after she was awake and extubated. She did well from
this standpoint and was neurologically intact and she went
off the ventilator.
Respiratory wise, the patient required prolonged ventilatory
wean and was unable to be weaned successfully. It was decided
that the patient would undergo a tracheostomy. The patient
was taken back to the Operating Room for a tracheostomy.
Please see Operative Report for further details of this
operation. Again, after performing the tracheostomy, she was
fully weaned from the ventilator and was successfully able to
be taken off of the ventilator. She was ultimately
transferred up to the floor. However, she had multiple
episodes of respiratory difficulty and plugging including
Klebsiella resistant pneumonia requiring multiple
antibiotics. Ultimately, she was put on meropenum to finish a
fourteen day course prior to discharge. She was doing well
after her most recent episode of plugging and was transferred
to the Intensive Care Unit. However, she was able to come off
of the ventilator again and was able to stay on trach mask.
Cardiovascularly, the patient had the elevated troponin
immediately around the time of operation. However, after that
point, she was cardiovascularly stable and had no episodes of
arrhythmia or myocardial infarction or elevated troponin.
Gastrointestinal: She had a G-tube and J-tube placed around
her esophageal perforation. She was able to do well from this
standpoint. Her esophageal perforation healed and she was fed
through her feeding jejunostomy tube. The G-tube was kept to
gravity for prolonged periods of time for ventilation of the
stomach and was ultimately clamped prior to discharge. Again,
the patient was able to tolerated clamping of the G-tube with
low residual output of her tube feeds. The patient was kept
on tube feeds throughout her hospital stay. The patient
tolerated her tube feeds through her jejunostomy tube and
continued to improve from that standpoint. Postoperatively,
from her original operation, the patient began to have
temperatures and an elevated white blood cell count. CT scan
of the abdomen was performed and it was found that the
patient had developed intra-abdominal abscess around her
perforation site. She was taken to Interventional Radiology
where a percutaneous drain was placed and the intra-abdominal
abscess was drained. She continued to improve from that
standpoint and her white blood cell count returned to [**Location 213**].
The patient also had an area of fluctuance around her wound
requiring opening of the wound site and purulent drainage was
evacuated. The fascia was intact. Wet-to-dry dressings were
placed and this area slowly began to heal. The patient
continued to do well from a wound standpoint and was able to
tolerate her tube feeds through her jejunostomy tube. The
pigtail catheter placed in Interventional Radiology continued
to have very low output and the white blood cell count was
normal prior to discharge.
From a genitourinary standpoint, the patient did well. Her
renal output was adequate. She needed Lasix diuresis after
recovering from her initial illness.
From an infectious disease standpoint, the patient had
multiple infections requiring multiple antibiotics including
vancomycin, levofloxacin, Flagyl, gentamycin and also
required fluconazole for fungal infections. Ultimately, her
final infection prior to her discharge was a Klebsiella
resistant pneumonia from her sputum which required a fourteen
day course of meropenum. The patient had a PICC line placed
in Interventional Radiology prior to discharge for this use.
Otherwise, she was afebrile prior to discharge.
From a hematologic standpoint, she required multiple units of
blood around her original operation, fresh frozen plasma to
correct her INR and also required platelets. Her platelet
count dropped postoperatively. Heparin induced antibody was
checked and this was ultimately found to be negative. She
stabilized from a hematologic standpoint after requiring
resuscitation with both blood and fresh frozen plasma and
platelets around her original operation and did not require
any further transfusions after that original time point.
From an endocrinologic standpoint, she was kept on steroids
throughout her hospital stay due to the fact that the patient
presented while taking steroids, which she was also given
stress-dose steroids during her original illness and was then
tapered back down to her original home dose. Furthermore, she
was kept on an insulin drip originally around her operation
and then transitioned to a regular insulin sliding scale for
elevated blood sugars. Her blood sugars were under control
prior to discharge.
From a tubes, lines and drains standpoint, the patient had a
PICC line placed in Interventional Radiology. She had a
tracheostomy tube and pigtail catheter were all in place. Wet-
to-dry dressing changes were done to her wound which was
granulating well prior to discharge. Her chest tubes, which
were placed intraoperatively around her original operation,
were removed after low outputs were achieved and her lung was
totally expanded. As stated previously, the patient had
multiple episodes of respiratory difficulty including
plugging requiring suctioning, Ambu bagging and often
returning to the ventilator. The patient was off the
ventilator for four days prior to discharge.
Physical Therapy was consulted prior to her discharge
assisting with strengthening and ambulation. The patient had
significant deconditioning around her prolonged illness and
it was felt that the patient would benefit from
rehabilitation. Furthermore, due to her multiple respiratory
problems, it was felt that the patient would best be suited
in a pulmonary rehabilitation facility. Prior to discharge,
the patient also underwent a CTA to rule out pulmonary
embolus, which was negative. It was found that her multiple
respiratory problems were most often due to infectious
pneumonias and mucous plugging.
The planned discharge is on [**2114-4-18**] to a rehabilitation
facility in stable condition.
DISCHARGE MEDICATIONS:
1. Meropenum 1 gm intravenously q 8.
2. Albuterol and Atrovent inhalers 1-2 puffs q 6.
3. Ipratropium one neb q 6 p.r.n.
4. Albuterol nebs q 4 p.r.n.
5. Lopressor 25 mg p.o. b.i.d.
6. Miconazole powder 2 percent applied to the effected areas
q.i.d.
7. Heparin subcutaneously 7,500 units q 8 hours.
8. Prevacid oral suspension 30 mg down the G-tube q d.
9. Prednisone 10 mg p.o. q d.
10. Zinc sulfate 200 mg p.o. q d.
11. Ascorbic acid 500 mg p.o. b.i.d.
12. Regular insulin sliding scale.
13. Tylenol 650 mg p.o. q 4 hours p.r.n.
DIET: Her tube feeds were impact with fiber at full strength
at a goal rate of 70 cc per hour. She was also having her J-
tube flushed with water q eight hours.
DISPOSITION: The patient was doing well and in stable
condition. Planned discharge is [**2114-4-18**] depending upon bed
availability.
DISCHARGE DIAGNOSES:
1. Esophageal perforation, status post thoracoabdominal
exploration, esophageal repair, omental patch, G-tube and
J-tube placement, chest tube placements.
2. Chronic obstructive pulmonary disease.
3. Asthma.
4. Respiratory failure, now status post tracheostomy and
prolonged ventilator wean, now on trach mask.
5. Hypertension.
6. Morbid obesity.
7. High cholesterol.
8. Multiple pneumonias including Klebsiella pneumonia.
9. Status post intra-abdominal abscess.
10. Status post pigtail catheter and drainage of abscess
by Interventional Radiology.
11. Wound infection, status post opening of the wound
and drainage with wet-to-dry dressing changes.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: The patient is instructed to follow-up with Dr.
[**Last Name (STitle) 952**] in [**12-1**] weeks, follow-up with her primary care
physician [**Last Name (NamePattern4) **] [**12-1**] weeks and for medication adjustments.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-367
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2114-4-17**] 16:40:46
T: [**2114-4-17**] 17:43:00
Job#: [**Job Number 54944**]
Admission Date: [**2114-3-12**] Discharge Date: [**2114-4-19**]
Date of Birth: Sex: F
Service:
ADMISSION DIAGNOSIS: Esophageal perforation.
HISTORY OF PRESENT ILLNESS: The patient is a delightful 67-
year-old woman with multiple medical problems who is severely
obese who for the past month prior to admission has been
developing some dysphagia. She reported two prior episodes
where she had to induce vomiting to clear food that was stuck
in her esophagus. She reports no weight loss over that period
of time. She had no prior endoscopies.
Earlier in the day on [**2114-3-12**], after eating lunch, she had
some food stuck in her distal esophagus causing her to induce
vomiting to clear it. After this, she subsequently developed
severe chest pain and abdominal pain. She presented to the
local Emergency Room and was transferred with the diagnosis
of a ruptured esophagus. Her imaging studies included a chest
x-ray, which showed free air in the diaphragm and a chest CT
scan, which showed air within the abdominal cavity and air
extending up within the mediastinum, as well as a
Gastrografin swallow, which showed a leak at the
gastroesophageal junction at the level of the diaphragm.
At the time of presentation to the Emergency Room at [**Hospital6 1760**], her heart rate was 150, her
blood pressure was well maintained at 100/50.
HOSPITAL COURSE: She was rushed to the Operating Room and
placed under general anesthesia where she lost her blood
pressure. Of note, she was resuscitated simultaneously. With
resuscitation and Phenylephrine, her blood pressure returned
to approximately 100/50. Her heart rate dropped into the 110s
with hydration. Again, she was placed under general
endotracheal anesthesia with a double-lumen endotracheal
tube, and the operation was commenced. She underwent a left
thoracoabdominal incision with repair of her perforated
esophagus and an omental flap. She also had a drainage
gastrostomy tube placed and a feeding jejunostomy tube.
Flexible bronchoscopy and esophagoscopy were also performed.
She had her abdominal cavity irrigated after the drainage of
a large amount of pus and food stuff. She tolerated the
procedure well and was maintained in the Intensive Care Unit
postoperatively.
She had a relatively routine postoperative course for such a
devastating event in a debilitated patient. It was prolonged,
but not unexpected. She ultimately required a tracheostomy
tube and eventually was discharged to a rehabilitation on
[**2114-4-19**] with the tracheostomy tube in place and weaning
off the ventilator.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern4) 54269**]
MEDQUIST36
D: [**2114-7-10**] 08:40:21
T: [**2114-7-10**] 09:27:35
Job#: [**Job Number 30262**]
|
[
"998.59",
"862.22",
"933.1",
"790.7",
"518.5",
"707.0",
"E915",
"427.31",
"482.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"99.04",
"46.39",
"33.22",
"54.91",
"42.23",
"96.6",
"38.93",
"31.1",
"42.82",
"43.19",
"42.87"
] |
icd9pcs
|
[
[
[]
]
] |
9502, 10179
|
8626, 9481
|
852, 980
|
12067, 13539
|
798, 825
|
10225, 10801
|
1003, 1696
|
10823, 10848
|
10877, 12049
|
662, 774
|
10204, 10213
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,485
| 149,548
|
36947
|
Discharge summary
|
report
|
Admission Date: [**2196-8-25**] Discharge Date: [**2196-9-25**]
Date of Birth: [**2151-3-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
anemia, renal failure, leukocytosis
Major Surgical or Invasive Procedure:
1. EGD
2. Colonoscopy
History of Present Illness:
This is a 45 yo man with cirrhosis c/b known varices, ascites,
followed by [**Doctor Last Name **], is being transfered from St Josephs
after presenting there with shortness of breath and being found
to have leukocytosis and rising creatinine.
.
He initially presented to St. Josephs aprx 30 hrs ago
complaining of shortness of breath of one days duration. His SOB
was more pronounced when climbing stairs and was associated with
chest pain but no diaphoresis. The chest pain was short lived
(seconds) and has not occured since. Apparently two weeks ago he
stopped taking his water pills because his creatinine was noted
to be elvated. His cre improved with this intervention but
during the time he was off diuretics he gained weight (30lb) and
was feeling fatigued. He resumed diuretics last four days ago
but his fluid retention persisted. He also complained of non
bloody vomiting x3 and one episode of non bloody diarrhea. Also
over the last two weeks reports fevers in 101 range that are
intermittent (2x/week) and are associated with chills.
.
At St Josephs he was noted to have an elevated white count of
30K and blood cultures were positive for GPC and GNR ([**2-15**], 4 hrs
of inoculation). A CXR was reported to be negative. He was
empirically started on Ceftaz and metronidazole. Also he is
reported to have ascites but paracentesis was not performed.
Notably he was also noted to have a hematocrit of 21 and INR of
2.1. He was given two units of FFP and two units of pRBCs,
resulting in a INR of 1.6 and a HCT of 25. Per report of the
covering physician he did not have hematochezia, melena or
hematemesis. Finally he was noted to have a significantly
elevated creatine of 6.7, from a baseline of 1.0. His urine
output was low (aprx 10 cc/hr). Per report he did not have any
vital sign instablitiy, including absence of fever or
hypotension. His respiratory status remained stable and his
mentation was at baseline. BPs ranged 100-110s. Also reportedly
he had a poor UOP, but an IVF challenge was not performed.
.
Notably the patient has a history of alcoholic cirrhosis, based
on history of etoh consumption (now abstinent for 6 wks). On
recent evaluation by his hepatologist, he was noted to have a
positive anti-smooth muscle antibody at 1:80, negative [**Doctor First Name **] and
elevated IgG at 2355. His cirrhosis is complicated by esophageal
varices of unknown grade (EGD proven, several months ago, report
unavailable). He takes prophylactic nadolol. He also suffers
from ascites with last paracentesis in [**7-21**] showing 183 WBCs,
24 PMNs, Albumin less than 1, total protein 1.5. He has had a
liver US which was negative for PV thrombosis. He has experience
hepatic encephalopathty in the past which improved with
lactulose and rifaximin. He has been followed by Dr [**Name (NI) **]
and recently was noted to have rising cre to 2.7 and this was
initially thought to be related to his diuretics. These were
discontinued and his cre responded appropriately.
Past Medical History:
EtOH cirrhosis
EtOH Abuse
Gout
s/p appendectomy several yrs ago
h/o HTN now normotensive off all meds
Social History:
lives with wife and sons 10 and 14 yo. Works as an energy
broker. Denies drug or tobacco use. Quit drinking 6 weeks ago
Family History:
Adopted so family hx is unknown
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, tympanic to percussion,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: mild asterixis, + edema to thighs, warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema
Pertinent Results:
[**2196-8-25**] 05:52PM BLOOD WBC-18.0*# RBC-2.32* Hgb-7.7* Hct-21.3*
MCV-92# MCH-33.2* MCHC-36.2* RDW-16.2* Plt Ct-104*
[**2196-8-30**] 05:35AM BLOOD WBC-8.5 RBC-2.90* Hgb-8.9* Hct-26.8*
MCV-93 MCH-30.9 MCHC-33.4 RDW-16.3* Plt Ct-65*
[**2196-9-7**] 05:20AM BLOOD WBC-7.1 RBC-2.29* Hgb-7.4* Hct-21.1*
MCV-92 MCH-32.3* MCHC-35.1* RDW-19.1* Plt Ct-61*
[**2196-9-7**] 01:57PM BLOOD Hct-19.2*
[**2196-9-11**] 06:05AM BLOOD WBC-4.9 RBC-2.88* Hgb-8.8* Hct-25.6*
MCV-89 MCH-30.6 MCHC-34.4 RDW-20.5* Plt Ct-57*
[**2196-9-17**] 05:24AM BLOOD WBC-4.4 RBC-2.34* Hgb-7.4* Hct-21.3*
MCV-91 MCH-31.5 MCHC-34.7 RDW-20.0* Plt Ct-125*
[**2196-9-25**] 05:42AM BLOOD WBC-7.0 RBC-2.31* Hgb-7.3* Hct-22.2*
MCV-96 MCH-31.7 MCHC-33.0 RDW-20.8* Plt Ct-124*
[**2196-8-25**] 05:52PM BLOOD PT-20.5* PTT-49.1* INR(PT)-1.9*
[**2196-8-31**] 04:32AM BLOOD PT-26.5* PTT-55.7* INR(PT)-2.6*
[**2196-9-6**] 05:00AM BLOOD PT-27.8* PTT-57.3* INR(PT)-2.7*
[**2196-9-9**] 01:57PM BLOOD PT-22.2* INR(PT)-2.1*
[**2196-9-14**] 05:03AM BLOOD PT-25.1* PTT-52.3* INR(PT)-2.4*
[**2196-9-19**] 06:26AM BLOOD PT-28.1* PTT-54.3* INR(PT)-2.8*
[**2196-9-20**] 06:01AM BLOOD PT-30.3* PTT-56.1* INR(PT)-3.0*
[**2196-9-24**] 05:11AM BLOOD PT-29.7* PTT-61.3* INR(PT)-2.9*
[**2196-9-25**] 05:42AM BLOOD PT-27.7* PTT-57.6* INR(PT)-2.7*
[**2196-9-17**] 01:53PM BLOOD Fibrino-93*
[**2196-9-22**] 04:50AM BLOOD Fibrino-68*
[**2196-9-19**] 06:26AM BLOOD Ret Aut-2.6
[**2196-8-25**] 05:52PM BLOOD Glucose-78 UreaN-74* Creat-7.0*# Na-115*
K-4.5 Cl-82* HCO3-17* AnGap-21*
[**2196-8-28**] 05:00AM BLOOD Glucose-113* UreaN-67* Creat-4.2*#
Na-130* K-3.3 Cl-97 HCO3-21* AnGap-15
[**2196-9-2**] 06:17AM BLOOD Glucose-115* UreaN-34* Creat-1.4* Na-137
K-3.6 Cl-99 HCO3-26 AnGap-16
[**2196-9-10**] 05:55AM BLOOD Glucose-116* UreaN-43* Creat-2.4* Na-132*
K-3.8 Cl-96 HCO3-24 AnGap-16
[**2196-9-18**] 06:50AM BLOOD Glucose-98 UreaN-24* Creat-1.0 Na-139
K-3.7 Cl-99 HCO3-27 AnGap-17
[**2196-9-22**] 04:50AM BLOOD Glucose-102 UreaN-16 Creat-0.8 Na-133
K-3.6 Cl-97 HCO3-29 AnGap-11
[**2196-9-25**] 05:42AM BLOOD Glucose-134* UreaN-12 Creat-1.0 Na-133
K-4.1 Cl-97 HCO3-28 AnGap-12
[**2196-8-25**] 05:52PM BLOOD ALT-24 AST-45* LD(LDH)-277* AlkPhos-96
TotBili-18.0*
[**2196-9-3**] 05:34AM BLOOD TotBili-15.3*
[**2196-9-11**] 06:05AM BLOOD TotBili-19.2*
[**2196-9-14**] 05:03AM BLOOD ALT-12 AST-35 TotBili-13.6*
[**2196-9-18**] 06:50AM BLOOD AlkPhos-74 TotBili-16.6* DirBili-4.7*
IndBili-11.9
[**2196-9-21**] 05:27AM BLOOD AlkPhos-90 TotBili-14.0* DirBili-4.9*
IndBili-9.1
[**2196-9-24**] 05:11AM BLOOD TotBili-14.0*
[**2196-9-25**] 05:42AM BLOOD AlkPhos-93 TotBili-15.4*
[**2196-9-25**] 05:42AM BLOOD Calcium-9.5 Phos-2.9 Mg-1.8
[**2196-9-22**] 04:50AM BLOOD Ferritn-1244*
[**2196-9-19**] 06:26AM BLOOD VitB12-1892* Folate-16.2 Hapto-<20*
[**2196-8-25**] 05:52PM BLOOD calTIBC-164* Ferritn-1628* TRF-126*
[**2196-8-30**] 05:35AM BLOOD Triglyc-52 HDL-26 CHOL/HD-3.1 LDLcalc-44
[**2196-8-30**] 05:35AM BLOOD AMA-NEGATIVE
[**2196-8-30**] 05:35AM BLOOD PSA-0.1
[**2196-8-30**] 05:35AM BLOOD IgA-547* IgM-152
[**2196-8-30**] 05:35AM BLOOD HIV Ab-NEGATIVE
[**2196-8-25**] 08:10PM BLOOD Lactate-1.7 Na-114*
[**2196-8-26**] 03:32PM ASCITES WBC-410* RBC-2035* Polys-26* Lymphs-20*
Monos-50* Macroph-4*
[**2196-9-9**] 03:09PM ASCITES WBC-25* RBC-2275* Polys-5* Lymphs-8*
Monos-86* Eos-1*
[**2196-9-19**] 08:24AM ASCITES WBC-130* RBC-5025* Polys-4* Lymphs-32*
Monos-13* Mesothe-22* Macroph-29*
[**2196-8-26**] 03:32PM ASCITES TotPro-1.8 Glucose-106 LD(LDH)-98
Albumin-1.0
[**2196-9-9**] 03:09PM ASCITES TotPro-2.8 Albumin-2.0
[**2196-9-19**] 08:24AM ASCITES Glucose-107 LD(LDH)-121
Culture data: All negative studies at [**Hospital1 18**].
Abdominal ultrasound [**8-26**]: 1) Cirrhosis with ascites. 2) New,
partially occlusive main portal vein thrombosis extending into
the left portal vein. Please note, the study is limited because
the right portal vein, splenic vein, portal venous confluence
was not well visualized. 3) Distended gallbladder without signs
of acute cholecystitis. Findings may be due to a fasting state.
ECHO [**8-30**]: The left atrium is dilated. The right atrium is
moderately dilated. 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 (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CTA Abdomen [**9-3**]: 1. Hepatic cirrhosis with evidence of portal
hypertension. A moderate to large amount of ascites is present
in the upper abdomen. An addendum to this report will be issued
when liver volumes are available after image reformatting at 3D
lab. 2. The portal vein, hepatic vein, and hepatic artery are
patent. No anomalous vascular distribution is identified.
Brief Hospital Course:
# Bacteremia: Patient presented to St Josephs with two weeks of
fevers in 101 range that were intermittent and associated with
chills, shortness of breath, leukocytosis and rising creatinine.
At the OSH he had a WBC 30K, blood cultures that grew C.
perfringens and was started on Ceftaz and metronidazole. He was
transfered to [**Hospital1 18**] and admitted to the MICU. In the MICU he was
started empirically on Zosyn for bacteremia of [**Last Name (un) 5487**] source and
his leukocytosis resolved. He had a diagnostic paracentesis done
that was SBP (-). ID was consulted and they recommended for
patient to finish 14 day course of Zosyn which he did on [**9-9**].
He did not have fevers and all cultures done in house were (-)
(including peritoneal fluid, blood and urine). No source was
identified for infection CXR (-), CTA (-) and RUQ U/S (-)the
only possibility was an open cut in L thumb that he had had for
about a month prior to presentation, but he had no osteomyelitis
or soft tissue infection on XR.
.
# ARF: Patient was noted to have a significantly elevated
creatine of 6.7, from a baseline of 1.0, and low UOP on
admission to OSH. On transfer his Cr was 7.0 and it peaked at
7.3 on HD 2. He was started on IVF, albumin, octreotide and
midodrine for presumed HRS. His renal function improved and on
transfer to the floor he was continued on octreotide and
midodrine. On HD 10 his Cr had greatly improved, it had remained
stable at 1.4 and octreotide/midodrine were stopped. He was then
re-started on low dose diuretics. After 2 days of starting
diuretics his renal function worsened so these were stopped. He
was re-started on octreotide/midodrin/albumin and his Cr peaked
at 2.5. His renal function improved over the next 10 days and
HRS treatment was discontinued when creatinine was less than
1.5. Renal function was then monitored for stability and he was
started on low dose lasix and spironolactone, which he
tolerated. He was discharged home on the low dose diuretics to
have lab work in 3 and 5 days post discharge for evaluation of
his renal function.
.
# EtOH Cirrhosis: Patient presented w/ large ascites, jaundice,
HRS(see above) and C.Perfringens bacteremia(see above). Per
history his last drink was ~6 weeks prior to admission. He was
ruled out for SBP as a cause of his acute deterioration, on
initial RUQ U/S there as a question of possible portal vein
thrombus but this was ruled out on abdominal CTA. Transplant
work up was initiated during admission and all of the necessary
studies were done, including colonoscopy. His Tbili remained in
the 15-20 range throughout admission and his Discriminant
Function ranged in the 60s-70s. He underwent an IR guided large
volume paracentesis on [**9-2**] 4L because of increasing abdominal
discomfort caused by large ascites. He had a history of
encephalopathy in the past, lacutlose and rifaximin were
continued through admission and he had minimal encephalopathy at
times. An EGD was done which showed 3 cords of grade I varices
were seen in the lower third of the esophagus and
gastroesophageal junction, these were non-bleeding. Mr.
[**Name14 (STitle) 83358**] was placed on the transplant list after completing
his transplant work-up. Throughout the admission, total
billirubin remained virtually unchanged. LFT's were stable.
His hospital course was prolonged due to his poor health and
lack of improvement. Additionally, his chronic anemia and
coagulopathy was also conerning, but appeared to be stable at
time of discharge. He was discharged home on an increaed
rifaxamin dose along with his lactulose. He remained on the
transplant list at time of discharge. He agreed not to drink
alcohol in the future.
.
# Anemia: Patient presented w/ profound anemia, hematocrit of
21, this was at first concerning for GIB given history of
cirrhosis with esophageal varices but he denied hematochezia,
melena or hematemesis. An EGD was done which showed 3 cords of
grade I varices were seen in the lower third of the esophagus
and gastroesophageal junction, these were non-bleeding. He was
transfused and his Hct responded appropriately. Throughout
admission his Hct continued to drop, requiring 11 blood
transfusions. No source of bleeding was found, hemolysis labs
were equivocal as some of these are already elevated in ESLD,
direct Coombs test was (-). It was thought that the reason for
his anemia was sequestration of RBC's in the spleen because of
ESLD as well as anemia of chronic disease. Last transfusion was
8 days prior to discharge and hematocrit was stable on
discharge.
.
# Hyponatremia: Patient presented with a Na level of 113 this
was thought to be an acute process and he was treated with
hypertonic saline. His Na improved with this intervention, he
was then fluid restricted and his Na continued to improved. Once
level was back to normal he was taken off fluid restriction but
this caused him to become slightly hyponatremic again. He was
kept on 1.5-2L restriction to prevent his from worsening. He was
never symptomatic because of this problem. This was thought to
be due to ESLD with a component of volume overload.
Medications on Admission:
Lactulose 30 ml PO TID
Thiamine HCl 100 mg daily
Folic Acid 1 mg daily
Multivitamin 1 Tablet PO DAILY
Nadolol 20 mg daily
Ursodiol 300 mg TID
Rifaximin 200 mg TID
Zolpidem 5 mg qhs
Spironolactone 100 mg daily
Furosemide 80 mg daily
Rifaximin 200 mg TID
Hydroxyzine HCl 25 mg q6h prn
Ursodiol 300 mg TID
Zofran 4 mg q8h prn
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO TID
(3 times a day).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as
needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
9. Maalox 200-200-20 mg/5 mL Suspension Sig: Fifteen (15) mL PO
every 6-8 hours as needed for heartburn.
10. Outpatient Lab Work
Please have a CBC, Complete Metabolic Panel (including
creatinine), complete LFTs (including Total bilirubin, ALT, AST,
Alk Phos) and PT/PTT/INR on Wednesday, [**2196-9-28**].
Please fax results to Dr. [**Name (NI) **] at ([**Telephone/Fax (1) 82941**].
11. Outpatient Lab Work
Please have a CBC, Complete Metabolic Panel (including
creatinine), complete LFTs (including Total bilirubin, ALT, AST,
Alk Phos) and PT/PTT/INR on Wednesday, [**2196-9-30**].
Please fax results to Dr. [**Name (NI) **] at ([**Telephone/Fax (1) 82941**].
12. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcoholic Hepatitis
2. Hepatorenal Syndrome
3. Cirrhosis
4. Hyponatremia
5. Clostridium Perfringens Bacteremia
Discharge Condition:
Hemodynamically Stable. Afebrile.
Discharge Instructions:
You were admitted to [**Hospital1 18**] because you were found to have a
bacterial infection in your blood, kidney failure, anemia and
low sodium in your blood. Your were first admitted to the ICU
where they started you on the appropriate antibiotics for your
infection. You were started on medication for your kidney
failure and were given blood transfusions for your anemia. An
EGD was done which did not show any active site of bleeding.
You were given a special type of IV fluid with extra sodium to
correct the sodium deficiency in your blood.
After these interventions your were transfered to [**Hospital Ward Name 121**] 10 where
we continued the antibiotics and consulted with the infectious
disease specialists. You completed a 14 day course of IV
antibiotics for your blood infection. We continued you on the
medications to treat your kidneys. Your kidney function
gradually improved over the course of your hospitalization and
we were able to stop the medication. After a few days of stable
kidney function, you were re-started on a low-dose diuretic.
While in the hospital it was decided to list you for liver
transplantation. You underwent all the necessary testing,
including EGD and colonoscopy.
It is important that you DO NOT drink alcohol ever again. The
alcohol is a poison that has damaged your liver. If you
continue to drink you may die. Additionally, you have been
listed for transplant based on the fact that you will not drink
alcohol ever again. If you find yourself struggling with this,
it is advised that you seek professional help with a counselor
or join a support group so that you refrain from having another
drink.
AT NO TIME ARE YOU TO OPERATE AN AUTOMOBILE OR OTHER MOVING
MACHINERY UNTIL YOU HAVE BEEN CLEARED BY A PHYSICIAN TO DO SO.
This is for your safety as well as the safety of others.
When you are at home, it is important that you eat no more than
2 grams of sodium a day. If you eat more sodium, you will
retain more fluid. You should have no more than 1.5 Liters
(1500 mL) of fluid a day. Please try to continue eating habits
similar to those you have had in the hospital. Additionally,
you should be resting while you are at home.
It is also important that you continue taking all of your
medications. You should be having 4 bowel movements per day
with the Lactulose to keep you from becoming encephalopathic
(confused).
CHANGES IN MEDICATION:
STOP Nadolol
STOP Hydroxyzine
STOP Ambien
INCREASE Lactulose to 45 ml by mouth three times a day
INCREASE Rifaxamin to 400 mg by mouth three times a day
DECREASE Lasix to 20 mg by mouth a day
CHANGE Spironolactone to 50 mg by mouth twice a day
Take all other medications as previously prescribed.
If you at any point start experiencing bloody vomiting, bloody
stools, confusion, chest pain, trouble breathing, increasing
abdominal distention, fever > 100.4, chills, worsening jaundice
or any other symptom that concerns you, please conatact the
[**Hospital1 18**] Liver Center or return to the ER for further evaluation.
Followup Instructions:
Please follow-up as listed below:
1. Blood work drawn on [**2196-9-28**] and [**2196-9-30**] and faxed to the
number listed on the prescription pad
2. Contact the Transplant Center on [**2196-9-26**] to arrange a
follow-up appointment for Wednesday, [**2196-10-5**]. An email will be
sent when you are discharged informing them of the necessity of
this appointment.
3. Please arrange to see a dermatologist for evaluation of the
lesion on your left thumb.
4. Please follow-up with your PCP after discharge
|
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30,084
| 173,682
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34353
|
Discharge summary
|
report
|
Admission Date: [**2197-7-7**] Discharge Date: [**2197-7-27**]
Date of Birth: [**2143-12-26**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
High-dose methotrexate, rituximab, and Whole brain irradiation.
History of Present Illness:
[**Known firstname **] [**Known lastname 33754**] is a 53-year-old right-handed woman with a history
of CNS lymphoma involving the basal ganglia, left subfrontal
white matter, and corpus callosum with some associated edema and
mass effect, s/p 2 cycles of induction high-dose methotrexate,
and s/p 1 cycle of high-dose methotrexate and rituximab. She was
initially admitted for scheduled high-dose methotrexate and
rituximab dosing and transferred to the ICU with acute mental
status decline.
During her recent hospitalization from [**2197-6-26**] to [**2197-7-4**] for
third induction cycle of high-dose methotrexate, she develop
mental status changes. It was due to cerebral edema and
encephalopathy developed 2 days after high-dose methotrexate.
Head CT showed midline shift with subfalcine and uncal
herniation in the setting of tumor progression. She was started
on high-dose steroids and rituximab with some improvement in
mental status. She was discharged on dexamethasone.
On re-admission on [**2197-7-7**] for a scheduled cycle of
methotrexate and rituximab, her examination was notable for an
alert metnal status, poor language fluency and comprehension,
equal pupils, right lower facial droop, 3/5 strength in the
right upper extremity, 1-2/5 in the right lower extremity,
absent ankle jerk, upgoing right toe, and impaired pain
sensation on the right side of body. Overnight, the patient was
noted to have declining mental status with minimal
responsiveness, and no purposeful movements. But responded to
pain. MRI was read as revealing no change in her intracranial
mass, surrounding edema or mass effect/midline shift; though her
primary neuro-oncologist did think there was some progression
with mild worsening of midline shift. She received dexamethasone
(increased from 6 mg IV q6h to 10 mg IV q6h), mannitol and
emergent external beam whole brain cranial irradiation.
Past Medical History:
- CNS lymphoma involving the basal ganglia, corpus callosum and
left subfrontal region. Had non-diagnostic brain biopsy on
[**2197-4-26**]. Second brain biopsy confirmed primary CNS lymphoma on
[**2197-6-2**]. S/p 4 induction cycles of high-dose methotrexate
initiated on [**2197-6-5**]. Also receiving rituximab since cycle 3
when she did not appear to be responding to methotrexate alone.
- PICC-associated right upper extremity DVT, diagnosed on
[**2197-6-18**] and had PICC removal.
- Prior gram positive bacteremia
- Hypertension
- Hyperlipidemia
- s/p oophorectomy
Social History:
She lives with husband. She worked as special education teacher.
She has no tobacco, alcohol, or illicit drug use.
Family History:
Non-contributory. But she has one mentally retarded daughter and
a helthy son.
Physical Exam:
ADMISSION EXAMINATION ([**2197-7-7**])
VITAL SIGNS: Temperature is 98.6 F axillary, pulse is 85, blood
pressure is 161/92, respiratory rate is 11, and oxygen
saturation is 98% in room air, and weight is 85.7 kg.
GENERAL: Responsing to painful stimuli only.
HEENT: PERRL approximately 3.5mm to 2mm. Likely right lower
facial droop. Poor visualization of the fundus.
CARDIOVASCULAR: RRR, normal S1 and S2, and no M/R/G.
PULMONARY: Clear to auscultation bilaterally.
ABDOMEN: No tenderness in the left upper quadrant. No rebound or
guarding.
EXTREMITIES: Left upper extremity with diffuse ecchymoses in the
area of removed Port-a-cath.
NEUROLOGICAL EXAMINATION: Responding to sternal rub only. Does
say 'Okay' in response to sternal rub. No responding to nailbed
pressure in the bilateral upper extremities. No doll's eyes.
Right lower facial droop. Unable to assess remainder of CN's.
Tongue appears midline. RUE in contracted posture. Bilateral
upper extremities with contraction in response to movement. No
moving any extremities in response to command. Bilateral lower
extremities without movement. Unable to elicit patellar or ankle
jerk reflexes bilaterally. Appears to have upgoing left great
toe though difficult to assess.
NEUROLOGICAL EXAMINATION AT THE TIME OF DISCHARGE ([**2197-7-27**]):
Neurological Examination: Her Karnofsky Performance Score is 50.
She is awaker, alert, and able to follow commands. She can speak
in full sentences. She is not upset today at all. Cranial Nerve
Examination: Her pupils are equal and reactive to light, 4 mm to
2 mm bilaterally. Extraocular movements are full. She has blink
to threat bilaterally. Her right lower facial droop is
improving.
Hearing is grossly intact. Tongue is midline. Palate goes up in
the midline. Sternocleidomastoids and upper trapezius are
strong. Motor Examination: She can lift her right upper
extremity against gravity. She can move the toes in her right
foot. The left upper has 4/5 strength but her proximal left
lower extremity is weak at 3/5. Her reflexes are 0. Her toes are
mute. Sensory examination is notable to grimace when pain
stimuli are
applied to the extremities. She cannot walk.
Pertinent Results:
[**2197-7-7**]:
Na 138, K 3.4, Cl 102, bicarb 28, BUN/Cr 11/0.3, glucose 115, Ca
9.8, Mg 2.1, Phos 2.9, WBC 5.5, Hct 28.0, platelets 152.
ALT 54, AST 12, LDH 417, T Bili 0.8.
INR 1.2, PTT 42.6
MTX 5.3
[**2197-7-8**]:
Imaging:
MR [**Name13 (STitle) 430**] ([**2197-7-8**]): Prelim report with no change in size of the
mass surrounding edema, ventricular size and periventricular
edema compared to the previous MRI of [**2197-7-1**].
MR [**Name13 (STitle) 430**] ([**2197-7-1**]): Again a large enhancing mass is identified
in the left basal ganglia region with mass effect on the left
lateral ventricle. Compared to the prior study, the enhancing
component of the brain and the lesion in the corpus callosum and
also in the left subfrontal region has decreased. However, the
mass in the left basal ganglia may have slightly increased in
size, now measures 4 x 3 cm compared to 2 x 3.5 cm on the
previous study. There is persistent dilatation of the ventricles
with dilation of both temporal horns indicative of
hydrocephalus. Periventricular edema is also identified.
Extensive edema in the left frontal lobe is seen which might not
have significantly changed since the previous study. There
continued to be uncal herniation on the left and extension of
edema into the left side of the midbrain and pons. No other
areas of abnormal enhancement identified. There is mild midline
shift from the left to the right. IMPRESSION: Since the previous
MRI examination, the component of the tumor seen in the basal
ganglia may have slightly increased in size but the enhancing
lesions in the corpus callosum and left subfrontal region have
decreased. Edema is unchanged and midline shift and mass effect
is also unchanged. The ventricular size is unchanged with
dilated temporal horns and signs of transependymal flow of CSF
and periventricular edema.
Chest X-Ray ([**2197-7-7**]): New left-sided PICC line positioned in
the left brachiocephalic vein. New increased density in the left
base, which may be secondary to film technique
MRI Head on [**2197-7-26**] with improvement in above lesions.
Brief Hospital Course:
1. Altered Mental Status: Patient was found unresponsive on
hospital day 1 after scheduled methotrexate and rituximab
treatment. She was transferred to ICU from [**2197-7-9**] to [**2197-7-14**].
Altered mental status was likely secondary to progression of
intracranial mass/edema. MRI obtained on transfer on [**2197-7-8**]
showed no interval development of acute ischemia or hemorrhage,
but there was evidence of midline shift. ELetrolytes were within
normal limits. EEG was negative for status epilepticus. Patient
was continued on pulse dose steroids and mannitol, and Keppra
for seizure prophylaxis. Whole brain external beam radiation was
started given midline shift. Repeat head CT on [**2197-7-14**] showed
decreased midline shift and edema, and neurologic examination
(right-sided weakness and facial droop) improved on transfer
back to floor. On the floor, the patient did well from a
neurological standpoint. She was more alert and oriented than
before. The patient continued her regimen of radiation,
completing radiation therapy on [**2197-7-27**]. The patient's
methotrexate took longer to clear secondary to third spacing of
fluid. The steroids taper was begun and patient was discharged
on dexamethasone 4 mg daily, to be tapered further by
neuro-oncologist with a follow-up visit in 2 weeks.
2. Abdominal Pain (noted on transfer to floor): Possibly
secondary to diverticular microperforation with spontaneous
resealing by omentum. CT scan showed bowel dilatation and gas in
the portal system. Surgery consult recomendeded a conservative
approach with antibiotics of antibioticsmonitoring the patient's
good clinical status, normal hemodynamics, and absence of
leukocytosis. She was started on a course of
piperacillin-Tazobactam on [**2197-7-15**] with an intended course of
14 days, last day on [**2197-7-29**]. Pain medications were held and
given only after a thorough clinical examination for peritoneal
signs. The patient's vital signs remained stable and no
peritoneal findings were noted. The patient was treated with a
soaps enema, subsequent to which her lactate trended down. The
patient's diet (grounded solids with thininned liquids) after
she was cleared by speach and swallow. A KUB after she diet was
resumed was unremarkable for bowel dilatation or abnormal [**Last Name (un) **]
pattern.
3. CNS Lymphoma: s/p 3 cycles of high-dose methotrexate
combined with rituximab and receiving cranial irradiation c/b
acute encephalopathy. Patient was continued on sodium
bicarbonate per methotrexate protocol, and completed course of
radiation.
4. Hypertension: Patient's systolic blood pressure reached a
peak of 190-200, secondary to increased intracranial pressure,
and recovered with mannitol infusion to SBP 150s on transfer.
Initially the metoprolol was held as it would mask the
monitoring of ICP elevation. After manitol was discontinued,
metoprolol was reinitiated with adequate control.
5. Right Upper Extremity Deep Vein Thrombosis: PICC-associated
clot extending to subclavian was noted on prior admission
[**2197-6-18**], with PICC discontinued; patient was continued on
anticoagulation with enoxoparin. It was stopped temporarily due
to fall in hematocrit, but this remained stable at 24. Patient
was discharged on Heparin S.C. 5,000u TID.
6. Depression with Psychotic Features: Patient reports seeing
her mother in the room. She was started on haloperidol for
psychosis and agitation. She will need to continue haloperidol
0.5 mg PO BID standing, together with Celexa. Her mood and
hallucination features improved.
Medications on Admission:
Home Medications:
- Enoxaparin 90 mg SC Q12H
- Dexamethasone 6 mg IV Q6H
- Levetiracetam 1000 mg IV BID
- Trimethoprim-Sulfamethoxazole 80-400 mg/5 mL Intravenous Q24H
- Pantoprazole 40 mg Daily
- Metoprolol Tartrate 2.5 mg IV Twice daily
- Lactulose 30 ML 3 times a day
- Senna 8.6 mg Daily as needed
- Docusate Sodium 100 mg 2 times a day
- Multivitamin 1 tab po daily
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
4. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: One (1)
Intravenous every eight (8) hours for 2 days: To complete 14-day
course with last day on [**2197-7-29**].
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as
needed for insomnia.
8. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for agitation.
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
12. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Levetiracetam 500 mg/5 mL Solution Sig: One (1) Intravenous
Q12H (every 12 hours).
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
15. Morphine Sulfate 2-4 mg IV Q4H:PRN
16. Lorazepam 0.5-1 mg IV Q4H:PRN
17. Haloperidol 0.5 mg IV BID:PRN
if unable to take PO
18. Dexamethasone 4 mg IV DAILY
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor - [**Location (un) **]
Discharge Diagnosis:
CNS Lymphoma
Encephalopathy
Bowel ischemia
Discharge Condition:
Stable
Discharge Instructions:
You were admited for a planned chemotherapy for your lymphoma.
During your hospitalization you were found to have increasing
somlonence from swelling in your brain and required transfer to
the intensive care unit, as well as medication to help decreased
the swelling in your brain. You tolerated this treatment well
and you were transfered back to the floor. You also were
complaining of abdominal pain for which we gave you antibiotics.
We were able to complete the scheduled chemotherapy and also
radiation treatment.
Please return to the emergency department if you experience
headaches, nausea, vomiting, abdominal pain, fever, chills,
looses or absent stools or any other symptom that concerns you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2197-8-14**]
1:00
|
[
"348.5",
"V58.11",
"453.8",
"557.9",
"996.74",
"348.30",
"202.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"38.93",
"96.6",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
13053, 13129
|
7467, 7479
|
339, 405
|
13215, 13223
|
5354, 7444
|
13978, 14135
|
3066, 3147
|
11453, 13030
|
13150, 13194
|
11058, 11058
|
13247, 13955
|
3162, 5335
|
11076, 11430
|
277, 301
|
433, 2324
|
7494, 11032
|
2346, 2918
|
2934, 3050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,183
| 109,352
|
40890
|
Discharge summary
|
report
|
Admission Date: [**2167-4-1**] Discharge Date: [**2167-4-16**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Right hip fracture after fall
Major Surgical or Invasive Procedure:
Open reduction, internal fixation of right femur
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 79974**] is a [**Age over 90 **] year old male with a history of atrial
fibrillation (not on coumadin or aspirin) and type 2 diabetes
who presents with right hip fracture following a fall.
.
He has had increasing falls of late. As per the family, they
have started to notice both a cognitive as well as physical
decline in the last 6 months.
.
Today he tripped and hit the front of his head (per report, he
couldn't remember when seen on the floor). There was no LOC.
He denies any prodromal sxs, no palpitations, no numb/tingling
in his extremities, no CP, abd pain, no weakness. Per witness
that saw fall, he was backing up when someone was helping him
when he fell. He denies headache or neck pain. He was seen at
[**Hospital3 4107**] where CT head and neck were negative for
fracture but x-rays showed right hip fracture. He was sent to
[**Hospital1 18**] for orthopedics evaluation.
.
In the ED, initial vitals were T 98.0 HR 62 BP 146/58 RR 16 O2
sat 100% RA. Exam was notable for right leg shortening and
external rotation with normal sensation and pulses distally.
Labs notable for Na 125, WBC 15.6, lactate 2.6. CXR showed faint
left retrocardiac opacity and hip x-ray showed oblique spiral
fracture of R trochanteric femur. The pt was seen by orthopedics
who recommended operative repair after medical stabilization.
The pt received levofloxacin 750 mg IV. Vitals prior to transfer
T 96, HR 89, BP 161/65, RR 18, 98% RA.
.
Currently, pt is in [**12-29**] pain (soreness in right hip).
According to family, not on coumadin b/c was d/c'ed when
platelets trended down, and was never restarted. Denies SOB
now, but always has cough and sputum (no change recently). Also
reportedly has a right sided facial droop from bells palsy
(thought [**1-21**] CVA in [**2125**]).
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, shortness of
breath, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
AFIB
NIDDM
? ITP
appendectomy
Hernia repair
CVA in [**2125**]
hernia x 25 years
Social History:
Lives alone in senior living, is independent. Smoked 1 ppd x 22
years, quit 30 years ago. No EtOH now, h/o heavy EtOH usage. No
recreational drugs.
Family History:
Mother died of MI at age 75, Father died [**1-21**] lung issues [**1-21**] war
exposure.
Physical Exam:
ADMISSION:
VS - T 96.1, BP 126/88, HR 78, RR 26, 96/RA
GENERAL - elderly man in NAD, pleasant, answers questions
appropriately, no accessory mm usage
HEENT - NC/AT, Right surgical pupil --> anisocoria, left pupil
reactive
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat anteriorly except some possible
crackles/coarse BS in LLLF, o/w good air movement, resp
unlabored, no accessory muscle use
HEART - IRREG, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, [**12-21**]+ peripheral pulses (radials,
DPs). Right leg externally rotated with shortening.
NEURO - grossly intact, right leg not tested, left leg 4-5/5
motor throughout. A+Ox3
GU: foley in place, very large hernia in scrotum.
DISCHARGE:
99.1 97.2 130/62 (104-130/50-70) 69 (66-72) 20 100%RA
24h 320+ PO / 925++ UOP
8h UOP NR due to incontinence in towel
FS 76-107
GENERAL - elderly man in NARD, A&O x 3, pleasant and conversant
with full sentences, cough decreased
HEENT - MMM, edentulous; R pupil surgical, L PRRL
NECK - supple, no JVD
LUNGS - very faint occasional wheeze at bilateral bases and
decreased BS at L base, o/w moving air well, no crackles or
rhonchi
HEART - irregular, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
GU - enlarged inguinal-scrotal hernia soft with improving
ecchymosis also soft and NT, no erythema, no crepitus, no
fluctuance, no peristalsis palpated. Scrotal edema markedly
improved from prior.
EXTREMITIES - WWP, 1+ edema and with 2+ pedal pulses. R thigh
lateral incisions (2) intact with well-approximated
steri-strips, with e/o serous drainage at proximal edge of
distal incision. No crepitus, redness or fluctuance, but with
dependent improving ecchymosis and edema.
Pertinent Results:
ADMISSION LABS:
[**2167-4-1**] 01:45PM BLOOD WBC-15.6* RBC-4.54* Hgb-13.6* Hct-38.3*
MCV-84 MCH-29.9 MCHC-35.5* RDW-13.1 Plt Ct-231
[**2167-4-1**] 01:45PM BLOOD Neuts-92.0* Lymphs-4.5* Monos-2.8 Eos-0.4
Baso-0.4
[**2167-4-1**] 01:45PM BLOOD PT-13.9* PTT-29.9 INR(PT)-1.2*
[**2167-4-1**] 01:45PM BLOOD Glucose-135* UreaN-7 Creat-0.7 Na-125*
K-4.4 Cl-87* HCO3-24 AnGap-18
[**2167-4-1**] 01:45PM BLOOD CK(CPK)-175
[**2167-4-1**] 01:45PM BLOOD CK-MB-5 cTropnT-<0.01
[**2167-4-2**] 06:45AM BLOOD CK-MB-7 cTropnT-<0.01
[**2167-4-2**] 06:45AM BLOOD Albumin-3.3* Calcium-8.0* Phos-2.8 Mg-1.7
[**2167-4-2**] 06:45AM BLOOD %HbA1c-5.6 eAG-114
[**2167-4-1**] 05:22PM BLOOD Lactate-2.6*
[**2167-4-2**] 06:45AM BLOOD VitB12-709 Folate-4.2
[**2167-4-2**] 06:45AM BLOOD %HbA1c-5.6 eAG-114
[**2167-4-2**] 06:45AM BLOOD Osmolal-255*
[**2167-4-2**] 06:45AM BLOOD TSH-1.2
[**2167-4-2**] 06:45AM BLOOD Cortsol-22.2*
[**2167-4-2**] 06:45AM BLOOD Albumin-3.3* Calcium-8.0* Phos-2.8 Mg-1.7
- CXR:IMPRESSION: Faint left retrocardiac opacity, likely
atelectasis, but cannot
rule out aspiration or early pneumonia.
- HIP X RAY: Significantly displaced right subtrochanteric
femur fracture.
.
[**2167-4-5**] CXR: Frontal view of the chest compared to prior study
from [**2167-4-3**], demonstrates patchy airspace consolidation of
both lower lobes, increased from prior study, consistent with
pneumonia. Heart and mediastinum are otherwise within normal
limits except for calcified aortic arch. Upper lung zones are
relatively clear.
[**2167-4-6**] EKG - Atrial fibrillation. Complete right bundle-branch
block. Occasional ventricular premature beats. Q waves in leads
III and aVF with T wave inversion in those leads. Compared to
the previous tracing of [**2167-4-2**] the T wave changes in leads III,
aVF and V4-V6 are much more prominent. Otherwise, no diagnostic
interval change.
[**2167-4-8**] Scrotal ultrasound: There is a large inguinoscrotal
hernia with loops of bowel in the scrotum, markedly displacing
the right testicle cephalad and left testicle caudally and
anteriorly. The right testicle measures 4.5 x 2.8 x 1.6 cm. The
left testicle measures 3.2 x 2.7 x 1.3 cm. Assessment of
intra-testicular arterial flow is somewhat difficult secondary
to the moderate displacement by the large hernia. Venous flow is
demonstrated in both testicles, but the left testicle has
markedly diminished arterial flow.
Intermittent peristalsis is noted in the herniated bowel
loops, and intraluminal bowel gas causes "dirty" shadowing.
However, in a focal region in the left scrotum, dirty shadowing
is noted without observable peristalsis. While this non-specific
and could represent intraluminal bowel gas in a hypoactive bowel
loop, free air from perforated bowel cannot be completely
excluded.
There is no fluid collection in the scrotum to suggest
hematoma or abscess. The patient did not complain of focal
tenderness during the scan.
IMPRESSION:
1. Large hernia with loops of bowel and fat in the scrotum,
displacing the testicles.
2. Testicle size within normal limits. Relatively diminished
arterial flow in the left testicles. Arterial waveform not
clearly established.
3. No evidence of hematoma or abscess in the scrotum.
4. A focal area of "dirty" shadowing in the left scrotum,
without demonstrable peristalsis, nonspecific and could
represent a hypoactive bowel loop with intraluminal bowel gas
but cannot completely exclude free gas from bowel perforation.
Recommend clinical correlations. If clinical concern remains
high, consider CT study for further evaluation.
[**2167-4-9**] Video swallow:Barium passes freely through oropharynx
and esophagus without evidence of obstruction. There is
aspiration and penetration noted with thin liquids. Otherwise,
there is no gross aspiration or penetration noted with other
consistencies of barium. There is significant residue and slow
swallowing mechanism noted with all consistencies of barium. For
more details, please refer to the speech and swallow division
note in OMR.
[**2167-4-13**] LUE ultrasound
Grayscale, color and Doppler images were obtained of the left
IJ,
subclavian, axillary, brachial, basilic, and cephalic veins.
Normal flow,
compression, and augmentation is seen in all of the vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left arm.
[**2167-4-13**] CXR
Opacification of the left mid and lower lung has increased
compared
to [**2167-4-5**], and is some combination of consolidation,
atelectasis, and effusion. The right lung is clear. Lung volumes
are low, causing exaggeration of the heart size. The mediastinal
contours are normal. There is no pneumothorax. Chilaiditi's sign
is noted (air-filled colon interposed between the liver and
right hemidiaphragm). Dense calcification of the thoracic aorta
is seen. Extensive bilateral carotid calcifications are noted.
Surgical clips are seen in the right upper quadrant of the
abdomen.
IMPRESSION:
1. Increased opacification of the left mid and lower lung is a
combination of consolidation, atelectais, and effusion.
2. Extensive bilateral carotid calcifications.
[**2167-4-13**] HIP XRAY
Patient with a IM rod and gamma nail fixating a right
subtrochanteric femoral fracture with an unchanged 3mm step off
of the lateral corticated margin with stable minimal overiding.
Fracture line is still readily apparent. No clear interval
development of bony bridging. Degenerative changes are noted in
the bilateral femoroacetabular joints with joint space narrowing
and sclerotic change. Degenerative changes are also
noted in the lower lumbar spine with disc space narrowing and
endplate
sclerosis.
Patient appears to have a very large left-sided hernia, possibly
scrotal with significant amount of radiopaque density in bowels,
likley due to prior barium studies.
IMPRESSION: Right subtrochanteric femoral fracture fixated by IM
rod and
gamma nail with unchanged 13 mm lateral step off. No evidence of
hardware
complication or interval healing. Large left-sided hernia,
possibly scrotal, please correlate clinically.
DISCHARGE LABS:
- Na 125
- Cl 93
- HCO3 25
- K 4.0
- BUN 8
- Cr 0.5
- Glu 93
- Ca 7.7
- Mg 1.7
- Phos 3.5
- WBC 3.9
- Hct 30.9
- Plt 199
Brief Hospital Course:
Mr. [**Known lastname 79974**] was hospitalized with a right hip fracture following
a fall and underwent an uncomplicated right open reduction of
his internal fracture with a cephalomedullary nail. Please see
operative report for full details. In the immediate
postoperative period, he was hypoxic with altered mental status
due to difficulty protecting his airway. His hypoxia and airway
issues improved during a short stay in the ICU.
1. Right hip fracture: s/p ORIF on [**2167-4-3**] as above, had
adequate pain control with infrequent Tylenol as needed.
Incision was noted to have continuous serous oozing without
evidence of infection. A 5-day course of Ancef was given.
Patient is to continue prophylactic lovenox for 4 weeks from
[**2167-4-3**]; it was held for one day due to significant ecchymosis
and vitamin K was given to reverse INR. Ecchymosis remained
stable, showed evidence of slow resolution, and lovenox was
restarted. Please continue to monitor ecchymosis, INR, and
incision drainage (staples removed [**2167-4-15**]). Follow up is
scheduled with Orthopedics on [**2167-6-11**]. Pt will need PT for
rehab.
2. Dysphagia/dysarthria: Postop difficulty protecting airway now
improved s/p MICU stay likely [**1-21**] post-intubation swelling. Pt
has had mental decline last 6 mos and family does report a long
history of phlegm production and difficulty clearing his
secretions w/o frank episodes of aspiration or hospitalizations
for PNA. Of note, mental status declined during this
hospitalization, but improved back to baseline. Family notes
tongue swelling and some dysarthria that was worse than baseline
but is also now improved. Speech and swallow eval, video
swallow noted aspiration and penetration with thin liquids and
residue after all consistencies of barium and slow swallowing
mechanism. He was given PPN and advanced to a diet of ground
solids and nectar pre-thickened liquids as well as Magic Cup
dietary supplementation. After reevaluation by the swallow team
his liquids were advanced to thin liquids and PPN was
discontinued. He is to take small bites with multiple swallows.
Please crush all pills and administer with applesauce. Please
assist with meals and check for food pocketing in mouth. Please
administer TID oral care. Please obtain nutrition consultation
within one week of discharge to assess for nutrition needs.
3. PNA: Completed 7 day course of levaquin for PNA on CXR,
clinically remained afebrile with unchanged baseline cough and
no oxygen requirement.
4. Hernia: Inguinal hernia into scrotum that per pt and family
is 25 years old without hernia repair given asymptomatic. [**4-8**]
ultrasound showed herniated loops of bowel with an area that may
either represent hypoactive bowel with intraluminal air or
potentially perf with free air. Pt is without clinical signs of
obstruction or perforation or infection, but would have low
threshold to evaluate with CT scan if he complains of any
abdominal or hernia/scrotum pain, if hernia appears tense, or if
with any fever/white count, nausea/vomiting, or other signs of
obstruction/perforation/incarceration. Normal bowel movement
was guaiac negative on [**4-9**]. He remained with a foley for
comfort during admission, and this was discontinued on [**4-15**]; he
was able to void normally afterwards.
5. Anemia: Received a total of 3 units PRBC transfusion in the
first few days postoperatively, and hematocrit remained stable
thereafter. Blood loss was into subcutaneous space as evidenced
byt RLE ecchymoses. Hematocrit has been stable at ~30.
6. Hyponatremia: to low 120s postop, labs indicated hypovolemic
hyponatremia, which improved with normal saline hydration. He
subsequently redeveloped hyponatremia; cortisol was normal and a
renal consultation found this consistent with SIADH, likely due
to pain as he did not have any concerning medications or history
to suggest another etiology. His sodium has improved with fluid
restriction of 1500mL daily and sodium supplementations. He
will need sodium checked every other day and may stop sodium
supplementation when it is greater than 130. When the sodium is
greater than 133 he can stop the fluid restriction. Please
continue to monitor electrolytes as above.
7. Afib: Pt remained on diltiazem. He is not on home coumadin
or aspirin given history of low platelets, per family. His pills
were crushed in applesauce but it was unclear how much of his
dosage he was able to receive due to dysphagia. His blood
pressure and heart rate remained well-controlled without
additional medications. He reported some occasional
lightheadedness attributed to a combination of dehydration and
atrial fibrillation which led to his unsteadiness and the
inciting fall.
8. Non-insulin dependent diabetes: His home glipizide was held
and he remained on an insulin sliding scale. On arrival his
sugars were in the 190s, but a hemoglobin A1c was 5.6%, and his
sugars remained below 150. Eventually his fingersticks and
sliding scale insulin were stopped as he did not require insulin
for over a week. He is to STOP glipizide and continue diet
modifications on discharge. Labs are ordered to follow; please
have primary physician monitor for good postoperative blood
sugar control.
9. Edema: With fluid restriction and sodium supplementation he
developed diffuse edema. A test dose of Lasix was given and his
serum sodium remained stable. The edema improved markedly with
Lasix and he is to continue Lasix until sodium supplmentation is
stopped.
10. Incidental finding of carotid calcification on chest x-ray:
Will require outpatient follow-up with primary care provider.
Medications on Admission:
Diltiazem CD mg 180 daily
Glipizide 5 mg daily
Tylenol prn pain
Discharge Medications:
1. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: do not exceed 4000mg daily.
3. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day for 2 weeks: discontinue [**2167-5-1**].
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
8. Outpatient Lab Work
CBC, Chem 10, PT/PTT/INR every Monday Wednesday Friday to
monitor hematocrit, hyponatremia, INR. Please have primary
physician monitor these labs and determine when to discontinue
lab draws.
9. Outpatient Physical Therapy
Please evaluate for PT needs following right hip fracture repair
10. Outpatient Speech/Swallowing Therapy
Please follow up aspiration and dysphagia noted on previous
barium swallow video. Please evaluate for ability to advance
diet or need for NPO and parenteral nutrition.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
12. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3
times a day): Discontinue when serum sodium >130. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary diagnosis:
Right intertrochanteric/subtrochanteric hip fracture.
Atrial fibrillation
Large inguinal hernia in scrotum
Syndrome of Inappropriate Antidiuretic Hormone
Secondary diagnosis:
Pneumonia
Dysphagia
Poor nutrition and oral intake
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair.
Discharge Instructions:
Dear Mr [**Known lastname 79974**],
You were hospitalized with a hip fracture and underwent surgery
to repair this fracture. We feel that your fall was due to
lightheadedness from your atrial fibrillation. Please have your
primary physician evaluate your [**Name9 (PRE) 19390**] atrial
fibrillation and work up potential osteoporosis leading to your
hip fracture.
You were found to have low sodium indicating dehydration, and
you were given intravenous rehydration as well as improved
nutrition. Your low sodium continued and you are now on a
fluid-restricted diet with salt replacement. You will need labs
drawn three times a week and can stop the salt replacement pills
when your sodium reaches 130. Please have your primary physician
follow up your fluid and poor nutrition status and determine
whether you need additional nutrition.
You were found to have an aspiration risk from poor swallowing
and your food was modified to help you eat safely. Please have
your rehab facility follow the diet modifications below until
further evaluation:
- PO with assist: Ground solids and thin liquids
a. alternate bites/sips
b. small bites/sips
c. intermittently check mouth for pocketing
- Medications crushed in applesauce
- TID oral care
- nectar thick oral nutritional supplements (magic cup).
You were treated for a pneumonia that we think was a result of
food aspiration. You are breathing well without oxygen.
An ultrasound demonstrated bowel in your inguinal hernia that
has extended into your scrotum. We did not feel there was
clinical evidence of perforation or obstruction as your bowel
movements were normal, non-bloody, and you were without pain.
Please have your physician closely monitor this hernia for
danger signs of pain, obstruction, incarceration, or perforation
of bowel.
You had a foley catheter to help with urinary drainage given
your decrease mobility after the operation. You were able to
urinate after it was removed.
The following changes were made to your medication regimen:
- ADDED Lovenox injections to be discontinued [**5-1**] (4 weeks
after your surgery date).
- ADDED Sodium Chloride 1g tablets three times a day, to be
discontinued when your serum sodium is >130
- ADDED Furosemide 20mg daily
- ADDED Multivitamin and Colace.
- ADDED Albuterol and Ipratropium nebulizers, continue these as
needed.
- STOPPED glipizide.
Please continue taking the rest of your medications as
prescribed.
Followup Instructions:
1. PRIMARY CARE
- Please schedule follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from rehab. You should review your medications and
discuss follow up care for your low sodium, atrial fibrillation,
and hip surgery as well as the finding of carotid artery
calcification.
2. ORTHOPEDIC SURGERY
Department: ORTHOPEDICS
When: THURSDAY [**2167-6-11**] at 11:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2167-6-11**] at 11:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2167-4-16**]
|
[
"250.00",
"E885.9",
"782.3",
"433.10",
"348.30",
"438.83",
"253.6",
"550.90",
"427.31",
"820.22",
"285.1",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
18142, 18239
|
10843, 16498
|
280, 331
|
18528, 18528
|
4640, 4640
|
21162, 22221
|
2722, 2812
|
16613, 18119
|
18260, 18260
|
16524, 16590
|
18692, 21139
|
10698, 10820
|
2827, 4621
|
211, 242
|
359, 2436
|
18455, 18507
|
4656, 10682
|
18279, 18434
|
18543, 18668
|
2458, 2540
|
2556, 2706
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,678
| 170,419
|
24665+24666
|
Discharge summary
|
report+report
|
Admission Date: [**2151-9-26**] Discharge Date: [**2151-10-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13386**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Cervical spine fusion
IR guided PICC placement
PEG tube
History of Present Illness:
History obtained from chart and nursing as pt very demented at
baseline.
Pt is an 81 F admitted from her [**Hospital3 **] facility after
an unwitnessed fall while making her bed. Fall was heard by
co-workers her found her on the floor laying on her right arm
and bleeding from her lip. LOC unclear. At [**Location (un) 620**], her lip
laceration was sutured, a head CT was negative for bleed, CT
neck was abnormal prompting transfer for MRI c-spine and
surgical evaluation. In [**Hospital1 **] [**Name (NI) **], pt was noted to have BL UE distal
weakness, R worse than L. The MRI c-spine showed ? cervical cord
compression. Neurology was consulted and exam was consistent
with this. Pt was initially admitted to trauma surgery service
for further care.
Past Medical History:
Alzheimer's Dementia followed by [**First Name8 (NamePattern2) 26344**] [**Last Name (NamePattern1) 32878**] ([**Hospital1 **])
DM2 on po meds
Hypothyroidism
HTN
OA on Motrin
Neuropathy, unclear origin
s/p L TKR x2
h/x falls
Social History:
Single. Former elementary school teacher. No tob. etoh. drugs.
Has 3 sisters, none married. No kids. Pt lives at the Falls
[**Hospital3 400**] Facility [**Telephone/Fax (1) 62257**]. Per family, pt dresses
herself and feeds herself, and walks well. Meals made by home.
She is "disoriented" at baseline.
Family History:
unable to obtain. Per chart, 1 sister with MR/CP since birth,
well-controlled sz d/o
Physical Exam:
T 97.6 BP 148/65 HR 88 RR 21 O2 100% NRB
Gen: elderly F - difficult to interpret speech at times. not
oriented to place, year.
HEENT: right pupil surgical. left pupil 3-4 mm reactive.
Neck: + anterior neck wound with stereostrips over area. non
tender
CV: RRR. Nl S1, S2. no m/r/g.
Lungs: some coarse breath sounds
Abd: active BS. soft NT. ND. No HSM. No masses.
Extr: trace edema. DP 2+ B/L. radial pulse 2+ B/l.
facial muscles symmetric. sensation intact.
Neuro: pt unable to cooperate with full neuro exam. DIfficulty
with sitting upright and also standing - a combination of
difficulty following commands and also weakness
Pertinent Results:
C-spine ([**Location (un) **]): ? subtle c3-c4 endplate fx.
.
CT Head ([**Location (un) **]): no acute, old infarcts, prominent ventricles.
.
MRI c-spine([**9-26**]):
1. Findings are suggestive of severe spinal stenosis with
possible cord compression at the level of C4-5 and C5-6.
2. Ligamentous injury is noted in the posterior soft tissues
along the posterior elements of the mid cervical spine.
3. Extensive prevertebral soft tissue swelling noted.
.
MRI Head [**9-26**]
1. Diffusion-weighted images demonstrate no acute infarct.
2. The ventricles are prominent, and normal pressure
hydrocephalus cannot be excluded. Please correlate clinically.
.
CT Pelvis: [**9-26**]:
There are no fractures or dislocations. Degenerative changes are
seen in both hip joints with slight loss of joint space and bony
sclerosis.
.
[**9-26**]: CXR: No acute injury
.
ECHO: [**10-6**]:
Conclusions:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal. Resting regional wall motion
abnormalities include mid anteroseptal hypokinesis.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
6.The estimated pulmonary artery systolic pressure is normal.
7.There is no pericardial effusion.
.
[**10-7**]; Upper extremity US:
[**Doctor Last Name **]-scale and color Doppler examination of the right
subclavian, axillary, brachial, basilic, and cephalic veins
demonstrates normal color flow and waveforms. The exam was
limited by patient combativity. No intraluminal thrombus is
noted.
.
[**10-11**]: CT Neck
CT OF THE NECK WITHOUT INTRAVENOUS CONTRAST:
Visualization of fine soft tissue detail in the cervical spine,
particularly in the region of patient's fusion, is limited by
the metallic hardware producing streak artifact. The patient is
status post placement of anterior fusion plate with screws
extending into the C4, C5, and C6 vertebrae as well as C7. The
patient is status post laminectomy with multiple osseous
fragments visualized posteriorly at C4-6. There is thickening of
the prevertebral soft tissues anterior to the operative site
without evidence of large hematoma tracking within the fascial
planes of the neck. The airway appears patent. A nasopharyngeal
airway is in place. There is no pathologic-appearing
lymphadenopathy within the neck.
The visualized portions of the lung apices appear unremarkable.
There is no evidence of hematoma within the visualized portion
of the upper mediastinum.
The scout view shows an infiltrate at the left lung base.
IMPRESSION:
1. Status post laminectomy, fusion and fixation from C4-7.
Thickening of the prevertebral soft tissues in the postoperative
bed without evidence of substantial hematoma to account for a
decrease in hematocrit.
2. Postoperative changes within the neck.
3. Left lower lobe pneumonia
.
[**2151-10-17**]: RUE Ultrasound: UNILATERAL UPPER EXTREMITY ULTRASOUND:
Grayscale and color Doppler son[**Name (NI) 867**] was performed of the left
upper extremity brachial vein, axillary vein, and basilic vein.
The left cephalic vein was not visualized. A PICC line is seen
within the left basilic vein, with good venous flow around it,
without any evidence of intraluminal thrombus. Compressibility
and flow are demonstrated for all of the visualized veins,
without any intraluminal thrombus identified.
.
[**2151-10-17**]: CXR: IMPRESSION: AP chest compared to [**10-6**] and
27.
Left lower lobe consolidation has largely cleared, probably
atelectasis. Lungs are otherwise clear. Tip of the left PIC
catheter projects over the SVC. Heart size is normal. No pleural
abnormality.
.
[**2151-10-20**]: CXR: COMMENTS: Portable erect AP radiograph of the
chest is reviewed, and compared with previous study of [**10-17**], [**2150**].
The tip of the left-sided PICC line is identified in the
superior vena cava. The lungs are clear. The heart and
mediastinum are within normal limits. No pneumothorax is seen.
The patient is status post fixation of the cervical spine.
IMPRESSION: No active lung disease
.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-10-18**] 05:06AM 9.4 3.65* 11.7* 34.2* 94 31.9 34.1 15.0
350
[**2151-10-17**] 06:30AM 11.6* 3.69* 11.8* 35.7* 97 32.0 33.1 14.8
317
[**2151-10-16**] 06:35AM 11.1* 3.66* 11.8* 34.4* 94 32.2* 34.3
14.8 317
[**2151-10-15**] 04:44AM 11.1* 3.57* 11.6* 34.6* 97 32.6* 33.5
14.7 297
[**2151-10-14**] 05:09AM 10.8 3.72* 11.8* 34.3* 92 31.7 34.4 15.1
313
[**2151-10-13**] 11:56AM 10.3 3.62* 12.2 34.3* 95 33.7* 35.5*
15.2 294
[**2151-10-13**] 01:35AM 31.9*
[**2151-10-12**] 09:50AM 11.1* 3.13* 9.9* 28.8* 92 31.6 34.4 15.7*
237
[**2151-10-11**] 07:00AM 17.6* 2.73* 9.0* 25.7* 94 33.1* 35.1*
14.8 252
[**2151-10-10**] 04:25AM 14.4* 2.71* 8.9* 26.1* 96 32.6* 33.9 14.2
228
[**2151-10-9**] 03:50AM 18.8* 2.84* 9.1* 26.6* 94 31.9 34.0 14.4
222
[**2151-10-8**] 04:47AM 18.7* 2.79* 9.0* 26.8* 96 32.3* 33.6 14.2
241
[**2151-10-7**] 04:16AM 17.6* 2.82* 9.4* 27.0* 96 33.5* 35.1*
13.8 206
[**2151-10-6**] 08:22AM 20.3* 3.12* 10.2* 29.4* 94 32.7* 34.7
13.8 189
[**2151-10-5**] 08:12PM 15.2* 3.13* 10.5* 29.6* 95 33.5* 35.5*
13.9 161
[**2151-10-5**] 04:03PM 14.9* 3.17* 10.7* 29.8* 94 33.7* 35.8*
13.8 157#
[**2151-10-4**] 04:49AM 33.5*
[**2151-10-3**] 11:34AM 33.8*
[**2151-10-2**] 05:58AM 10.3 3.61*# 11.9*# 32.9*# 91#1 33.0*
36.2* 14.3
[**2151-10-1**] 03:50AM 10.3 2.59* 8.9* 25.6* 99* 34.3* 34.7 12.5
123*
[**2151-9-30**] 03:59AM 11.2* 2.70* 9.1* 26.6* 98 33.7* 34.2 12.7
166
[**2151-9-29**] 02:58AM 17.3* 2.77* 8.9* 26.5* 96 32.0 33.5 12.9
182
[**2151-9-28**] 12:55PM 27.2*
[**2151-9-28**] 09:30AM 24.2*# 2.81* 9.7* 27.2* 97# 34.6* 35.7*#
12.6 235
[**2151-9-27**] 06:24AM 15.4* 3.42* 11.1* 35.7* 104* 32.6* 31.2
12.6 280
[**2151-9-26**] 12:00PM 16.0* 3.40* 11.7* 33.7* 99* 34.3* 34.6
12.3 24
*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso
Atyps Metas
[**2151-10-15**] 04:44AM 79.0* 13.0* 4.2 3.6 0.3
[**2151-10-13**] 11:56AM 75.2* 15.4* 4.9 4.4* 0.2
[**2151-10-12**] 09:50AM 81.4* 0 10.3* 3.2 4.9* 0.2
[**2151-10-10**] 04:25AM 82.4* 11.3* 2.8 3.3 0.2
[**2151-10-9**] 03:50AM 90.9* 0 6.4* 2.4 0.3 0.1
[**2151-10-5**] 04:03PM 90.7* 0 6.0* 2.4 0.8 0.2
[**2151-9-26**] 12:00PM 89.3* 0 7.0* 2.0 1.4 0.3
*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2151-10-18**] 05:06AM 151* 26* 0.7 141 3.9 101 301 14
[**2151-10-17**] 06:30AM 109* 25* 0.8 141 4.3 100 271 18
[**2151-10-16**] 06:35AM 117* 22* 0.7 138 4.7 98 251 20
[**2151-10-14**] 05:09AM 114* 17 0.7 137 4.7 96 291 17
[**2151-10-13**] 11:56AM 125* 15 0.8 136 4.4 96 301 14
[**2151-10-12**] 09:50AM 122* 16 0.8 138 4.5 98 321 13
[**2151-10-11**] 07:00AM 174* 20 0.8 137 4.5 97 301 15
[**2151-10-10**] 04:25AM 150* 22* 0.7 137 4.2 99 301 12
[**2151-10-9**] 03:50AM 172* 20 0.7 136 3.8 98 291 13
[**2151-10-8**] 04:47AM 115* 17 0.7 137 3.3 102 291 9
[**2151-10-7**] 04:16AM 189* 15 0.7 135 3.8 99 271 13
[**2151-10-6**] 08:22AM 116* 12 0.7 136 4.1 99 261 15
[**2151-10-5**] 08:12PM 167* 13 0.7 135 3.3 98 261 14
[**2151-10-5**] 04:03PM 109* 13 0.7 136 3.5 100 271 13
[**2151-10-4**] 04:49AM 131* 17 0.8 137 3.8 102 261 13
[**2151-10-2**] 05:58AM 87 22* 0.8 138 3.6 104 271 11
[**2151-10-1**] 03:50AM 154* 34* 1.1 139 4.0 105 251 13
[**2151-9-30**] 03:59AM 155* 38* 1.4* 140 4.7 107 231 15
[**2151-9-29**] 02:58AM 109* 35* 1.6* 138 4.1 105 241 13
[**2151-9-28**] 09:30AM 130* 33* 1.6* 139 3.6 101 251 17
[**2151-9-26**] 12:00PM 130* 23* 1.3* 143 4.7 106 241 18
*
Cardiac Enzymes: Negative x 3 (troponins <0.01)
*
CHEMISTRY Albumin Ca Phos Mg
[**2151-10-14**] 05:09AM 8.9 4.6* 1.9
[**2151-10-13**] 11:56AM 8.8 3.6 1.8
[**2151-10-12**] 09:50AM 8.5 4.5 1.7
[**2151-10-11**] 07:00AM 2.8*8.0* 4.4# 1.6
[**2151-10-10**] 04:25AM 7.5* 2.8 1.9
[**2151-10-9**] 03:50AM 2.8*7.5* 2.1* 1.6
[**2151-10-8**] 04:47AM 7.9* 2.8 2.8*
[**2151-10-7**] 04:16AM
* Blood Gasses
[**2151-10-6**] 04:07PM ART 163* 45 7.38 28 1 NOT
INTUBA1
1 NOT INTUBATED
[**2151-10-5**] 09:09PM ART 70* 40 7.45 29 3 NOT
INTUBA1
1 NOT INTUBATED
[**2151-10-4**] 10:15AM ART 100 38 7.47* 28 3
*
Brief Hospital Course:
81 F with PMH Alzheimer's Dementia, DM, hypothyroid, HTN s/p
recent fall that led to C3-4 fracture s/p C3-6 fusion ([**10-4**] by
[**Doctor Last Name 363**], Ortho-Spine) who developed LLL infiltrate concerning for
Aspiration PNA requiring frequent nursing attention for upper
airway suctioning/ inability to clear own secretions now
improved on antibiotic therapy.
On admission to the ED:
Pt admitted to Trauma service on [**2151-9-26**]. Pt was stabilized
with cervical collar and methylprednisolone for soft tissue
swelling. Patient was followed by Geriatic concult service prior
to surgery. Pt was taken to OR on [**10-4**] for cervical spine
fusion by Trauma [**Doctor First Name **]. Post-op Dr. [**Last Name (STitle) **] accepted the patient
onto the geriatric service. Less than 2 hours after tx to
geriatrics, the medicine team had been called > 4 times for
inability to clear secretions and increased nursing needs which
apparently began per nursing records post-op. Due to increased
nursing needs, specifically Q 20 minute suctioning, floor team
requested patient transfer to MICU for closer monitoring. In the
MICU she was weaned to q 4 hours suctioning. There a speech and
swallow evluation demonstrated an inability to handle po intake
of any kind. A Dobhoff was placed.
.
Aspiration Pneumonia: Focal opacity in LLL with desaturation to
high 80s on oximetry unless Q 20 minute suctioning performed x
24 hours. Pt transferred to ICU for increased nursing needs.
- S & S eval done on [**10-1**]--> nectar thin liquids and ground
solids. Pills crushed with purees. On eval [**10-5**] pt noted to be
unable to manage and clear her own secretions requiring NT
suctioning. [**10-7**] S&S: pt not swallowing, needs alternate
feeding method. Received course of Dexamethasone 6 mg IV Q H for
airway edema, d/c'd [**10-7**].
- Treated aspiration pneumonia with Levoquin/vancomycin for
nosocomial coverage.
- [**10-5**] sputum: MRSA+, vanc-sensitive - treated with 7 days of
Vanco. Discontinued on [**2151-10-14**].
- On discharge, pt's respiratory secretions had decreased
substantially - was on glycopyrrolate in house to decrease
secretions - her O2 requirements also decreased in house. She
has been afebrile for at least the past 8 days.
.
#. FEN:
- PEGs have not been shown to decrease aspiration in patients
with dementia.
- [**10-10**]: patient pulled out her Dobhoff tube
- [**2151-10-12**]: PEG placement: this decision is based on the feeling
that the patient may recover the ability to swallow -> hence a
temporary fixture such as a PEG would be warranted.
- PEG placed on [**2151-10-14**] -> started tube feedings on [**10-15**] -> For
rate, see below.
.
3. Cervical cord compression: s/p C3/4 fracture repair with
allograft and plate [**10-4**]. POD #1. Notable soft tissue swelling
pre-op. Post-op, this may be slightly worse. Cervical collar to
be worn when sitting up or not in bed.
- needs to wear soft c-collar when not lying in bed
- [**Female First Name (un) **] chair during the day.
- Patient able to minimally move R arm; very deconditioned and
poor central strength and poor ability to stand by herself. Has
been requiring [**Doctor Last Name 2598**] lifts to move her.
.
4. Pain Control: Tylenol PR 650 mg TID. Try to avoid narcotics
given dementia.
.
5. GU:
- Has had hard time urinating after pulling foley. Tried
multiple times.
.
6. Anemia: baseline Hct is 33. Pt is s/p 2 units PRBCS on [**10-1**].
Hct had trended down to 25.7 -> after 1 unit on [**10-11**], Hct
jumped to 28.8 -> giving another unit on [**2151-10-12**] -> hct 31.9.
34.6 on [**2151-10-15**]. Stable at 34 on [**2151-10-18**]
.
7. DM: FS QID. Insulin SQ for hyperglycemia. We held her oral
hypoglycemics while in hospital - she was on Metformin 500 daily
at home - held in hospital and covered with a SSI. Was
maintained with 10U NPH in AM and 10U NPH in PM. Blood sugars
were well controlled with this regimen.
.
8. HTN: currently borderline. will follow and treat if needed
with PRN hydralazine.
.
9. PPX: Heparin SC, Pneumoboots, Fall precautions, Aspiration
Precautions..
Medications on Admission:
metformin 500', synthroid .075', lisinopril 5', lipitor 10',
seroquel 12.5qhs, motrin 600'''', folate, b12. nemenda 10 mg Q
AM AND PM. Ibuprofen 600 mg QID
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
once a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
hold for SBP<100.
7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO once a day.
9. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
12. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Tubefeeding: Promote w/ fiber Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 70
ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 100 ml water q6h
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 10140**] - [**Location (un) 10059**]
Discharge Diagnosis:
Spinal cord compression
Discharge Condition:
Patient has oxygen requirements of 3-4L, decreased mobility of
right upper extremity. Decreasing oxygen requirements over the
course of her stay.
Able to communicate, but patient has baseline dementia.
Discharge Instructions:
Please contact your primary care provider in case you experience
worsening neck pain, chest pain, shortness of breath that is
worsening or you develop any new difficulties with moving your
extremities.
.
Patient needs to be on aspiration precautions
.
Followup Instructions:
Please call your primary care provider to schedule [**Name Initial (PRE) **] follow up
appointment.
.
Please call your orthopedic surgeon Dr. [**Last Name (STitle) 28003**] for a follow up
appointment.
His office # is [**Telephone/Fax (1) 3573**]. Could not schedule an appt because
of holiday weekend. He wanted to see pt approximately 2 weeks
post discharge from hospital.
Completed by:[**2151-10-22**] Admission Date: [**2151-9-26**] Discharge Date: [**2151-10-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13386**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Cervical spine fusion
IR guided PICC placement
PEG tube
History of Present Illness:
History obtained from chart and nursing as pt very demented at
baseline.
Pt is an 81 F admitted from her [**Hospital3 **] facility after
an unwitnessed fall while making her bed. Fall was heard by
co-workers her found her on the floor laying on her right arm
and bleeding from her lip. LOC unclear. At [**Location (un) 620**], her lip
laceration was sutured, a head CT was negative for bleed, CT
neck was abnormal prompting transfer for MRI c-spine and
surgical evaluation. In [**Hospital1 **] [**Name (NI) **], pt was noted to have BL UE distal
weakness, R worse than L. The MRI c-spine showed ? cervical cord
compression. Neurology was consulted and exam was consistent
with this. Pt was initially admitted to trauma surgery service
for further care.
Past Medical History:
Alzheimer's Dementia followed by [**First Name8 (NamePattern2) 26344**] [**Last Name (NamePattern1) 32878**] ([**Hospital1 **])
DM2 on po meds
Hypothyroidism
HTN
OA on Motrin
Neuropathy, unclear origin
s/p L TKR x2
h/x falls
Social History:
Single. Former elementary school teacher. No tob. etoh. drugs.
Has 3 sisters, none married. No kids. Pt lives at the Falls
[**Hospital3 400**] Facility [**Telephone/Fax (1) 62257**]. Per family, pt dresses
herself and feeds herself, and walks well. Meals made by home.
She is "disoriented" at baseline.
Family History:
unable to obtain. Per chart, 1 sister with MR/CP since birth,
well-controlled sz d/o
Physical Exam:
T 97.6 BP 148/65 HR 88 RR 21 O2 100% NRB
Gen: elderly F - difficult to interpret speech at times. not
oriented to place, year.
HEENT: right pupil surgical. left pupil 3-4 mm reactive.
Neck: + anterior neck wound with stereostrips over area. non
tender
CV: RRR. Nl S1, S2. no m/r/g.
Lungs: some coarse breath sounds
Abd: active BS. soft NT. ND. No HSM. No masses.
Extr: trace edema. DP 2+ B/L. radial pulse 2+ B/l.
facial muscles symmetric. sensation intact.
Neuro: pt unable to cooperate with full neuro exam. DIfficulty
with sitting upright and also standing - a combination of
difficulty following commands and also weakness
Pertinent Results:
C-spine ([**Location (un) **]): ? subtle c3-c4 endplate fx.
.
CT Head ([**Location (un) **]): no acute, old infarcts, prominent ventricles.
.
MRI c-spine([**9-26**]):
1. Findings are suggestive of severe spinal stenosis with
possible cord compression at the level of C4-5 and C5-6.
2. Ligamentous injury is noted in the posterior soft tissues
along the posterior elements of the mid cervical spine.
3. Extensive prevertebral soft tissue swelling noted.
.
MRI Head [**9-26**]
1. Diffusion-weighted images demonstrate no acute infarct.
2. The ventricles are prominent, and normal pressure
hydrocephalus cannot be excluded. Please correlate clinically.
.
CT Pelvis: [**9-26**]:
There are no fractures or dislocations. Degenerative changes are
seen in both hip joints with slight loss of joint space and bony
sclerosis.
.
[**9-26**]: CXR: No acute injury
.
ECHO: [**10-6**]:
Conclusions:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal. Resting regional wall motion
abnormalities include mid anteroseptal hypokinesis.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
6.The estimated pulmonary artery systolic pressure is normal.
7.There is no pericardial effusion.
.
[**10-7**]; Upper extremity US:
[**Doctor Last Name **]-scale and color Doppler examination of the right
subclavian, axillary, brachial, basilic, and cephalic veins
demonstrates normal color flow and waveforms. The exam was
limited by patient combativity. No intraluminal thrombus is
noted.
.
[**10-11**]: CT Neck
CT OF THE NECK WITHOUT INTRAVENOUS CONTRAST:
Visualization of fine soft tissue detail in the cervical spine,
particularly in the region of patient's fusion, is limited by
the metallic hardware producing streak artifact. The patient is
status post placement of anterior fusion plate with screws
extending into the C4, C5, and C6 vertebrae as well as C7. The
patient is status post laminectomy with multiple osseous
fragments visualized posteriorly at C4-6. There is thickening of
the prevertebral soft tissues anterior to the operative site
without evidence of large hematoma tracking within the fascial
planes of the neck. The airway appears patent. A nasopharyngeal
airway is in place. There is no pathologic-appearing
lymphadenopathy within the neck.
The visualized portions of the lung apices appear unremarkable.
There is no evidence of hematoma within the visualized portion
of the upper mediastinum.
The scout view shows an infiltrate at the left lung base.
IMPRESSION:
1. Status post laminectomy, fusion and fixation from C4-7.
Thickening of the prevertebral soft tissues in the postoperative
bed without evidence of substantial hematoma to account for a
decrease in hematocrit.
2. Postoperative changes within the neck.
3. Left lower lobe pneumonia
.
[**2151-10-17**]: RUE Ultrasound: UNILATERAL UPPER EXTREMITY ULTRASOUND:
Grayscale and color Doppler son[**Name (NI) 867**] was performed of the left
upper extremity brachial vein, axillary vein, and basilic vein.
The left cephalic vein was not visualized. A PICC line is seen
within the left basilic vein, with good venous flow around it,
without any evidence of intraluminal thrombus. Compressibility
and flow are demonstrated for all of the visualized veins,
without any intraluminal thrombus identified.
.
[**2151-10-17**]: CXR: IMPRESSION: AP chest compared to [**10-6**] and
27.
Left lower lobe consolidation has largely cleared, probably
atelectasis. Lungs are otherwise clear. Tip of the left PIC
catheter projects over the SVC. Heart size is normal. No pleural
abnormality.
.
[**2151-10-20**]: CXR: COMMENTS: Portable erect AP radiograph of the
chest is reviewed, and compared with previous study of [**10-17**], [**2150**].
The tip of the left-sided PICC line is identified in the
superior vena cava. The lungs are clear. The heart and
mediastinum are within normal limits. No pneumothorax is seen.
The patient is status post fixation of the cervical spine.
IMPRESSION: No active lung disease
.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-10-18**] 05:06AM 9.4 3.65* 11.7* 34.2* 94 31.9 34.1 15.0
350
[**2151-10-17**] 06:30AM 11.6* 3.69* 11.8* 35.7* 97 32.0 33.1 14.8
317
[**2151-10-16**] 06:35AM 11.1* 3.66* 11.8* 34.4* 94 32.2* 34.3
14.8 317
[**2151-10-15**] 04:44AM 11.1* 3.57* 11.6* 34.6* 97 32.6* 33.5
14.7 297
[**2151-10-14**] 05:09AM 10.8 3.72* 11.8* 34.3* 92 31.7 34.4 15.1
313
[**2151-10-13**] 11:56AM 10.3 3.62* 12.2 34.3* 95 33.7* 35.5*
15.2 294
[**2151-10-13**] 01:35AM 31.9*
[**2151-10-12**] 09:50AM 11.1* 3.13* 9.9* 28.8* 92 31.6 34.4 15.7*
237
[**2151-10-11**] 07:00AM 17.6* 2.73* 9.0* 25.7* 94 33.1* 35.1*
14.8 252
[**2151-10-10**] 04:25AM 14.4* 2.71* 8.9* 26.1* 96 32.6* 33.9 14.2
228
[**2151-10-9**] 03:50AM 18.8* 2.84* 9.1* 26.6* 94 31.9 34.0 14.4
222
[**2151-10-8**] 04:47AM 18.7* 2.79* 9.0* 26.8* 96 32.3* 33.6 14.2
241
[**2151-10-7**] 04:16AM 17.6* 2.82* 9.4* 27.0* 96 33.5* 35.1*
13.8 206
[**2151-10-6**] 08:22AM 20.3* 3.12* 10.2* 29.4* 94 32.7* 34.7
13.8 189
[**2151-10-5**] 08:12PM 15.2* 3.13* 10.5* 29.6* 95 33.5* 35.5*
13.9 161
[**2151-10-5**] 04:03PM 14.9* 3.17* 10.7* 29.8* 94 33.7* 35.8*
13.8 157#
[**2151-10-4**] 04:49AM 33.5*
[**2151-10-3**] 11:34AM 33.8*
[**2151-10-2**] 05:58AM 10.3 3.61*# 11.9*# 32.9*# 91#1 33.0*
36.2* 14.3
[**2151-10-1**] 03:50AM 10.3 2.59* 8.9* 25.6* 99* 34.3* 34.7 12.5
123*
[**2151-9-30**] 03:59AM 11.2* 2.70* 9.1* 26.6* 98 33.7* 34.2 12.7
166
[**2151-9-29**] 02:58AM 17.3* 2.77* 8.9* 26.5* 96 32.0 33.5 12.9
182
[**2151-9-28**] 12:55PM 27.2*
[**2151-9-28**] 09:30AM 24.2*# 2.81* 9.7* 27.2* 97# 34.6* 35.7*#
12.6 235
[**2151-9-27**] 06:24AM 15.4* 3.42* 11.1* 35.7* 104* 32.6* 31.2
12.6 280
[**2151-9-26**] 12:00PM 16.0* 3.40* 11.7* 33.7* 99* 34.3* 34.6
12.3 24
*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso
Atyps Metas
[**2151-10-15**] 04:44AM 79.0* 13.0* 4.2 3.6 0.3
[**2151-10-13**] 11:56AM 75.2* 15.4* 4.9 4.4* 0.2
[**2151-10-12**] 09:50AM 81.4* 0 10.3* 3.2 4.9* 0.2
[**2151-10-10**] 04:25AM 82.4* 11.3* 2.8 3.3 0.2
[**2151-10-9**] 03:50AM 90.9* 0 6.4* 2.4 0.3 0.1
[**2151-10-5**] 04:03PM 90.7* 0 6.0* 2.4 0.8 0.2
[**2151-9-26**] 12:00PM 89.3* 0 7.0* 2.0 1.4 0.3
*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2151-10-18**] 05:06AM 151* 26* 0.7 141 3.9 101 301 14
[**2151-10-17**] 06:30AM 109* 25* 0.8 141 4.3 100 271 18
[**2151-10-16**] 06:35AM 117* 22* 0.7 138 4.7 98 251 20
[**2151-10-14**] 05:09AM 114* 17 0.7 137 4.7 96 291 17
[**2151-10-13**] 11:56AM 125* 15 0.8 136 4.4 96 301 14
[**2151-10-12**] 09:50AM 122* 16 0.8 138 4.5 98 321 13
[**2151-10-11**] 07:00AM 174* 20 0.8 137 4.5 97 301 15
[**2151-10-10**] 04:25AM 150* 22* 0.7 137 4.2 99 301 12
[**2151-10-9**] 03:50AM 172* 20 0.7 136 3.8 98 291 13
[**2151-10-8**] 04:47AM 115* 17 0.7 137 3.3 102 291 9
[**2151-10-7**] 04:16AM 189* 15 0.7 135 3.8 99 271 13
[**2151-10-6**] 08:22AM 116* 12 0.7 136 4.1 99 261 15
[**2151-10-5**] 08:12PM 167* 13 0.7 135 3.3 98 261 14
[**2151-10-5**] 04:03PM 109* 13 0.7 136 3.5 100 271 13
[**2151-10-4**] 04:49AM 131* 17 0.8 137 3.8 102 261 13
[**2151-10-2**] 05:58AM 87 22* 0.8 138 3.6 104 271 11
[**2151-10-1**] 03:50AM 154* 34* 1.1 139 4.0 105 251 13
[**2151-9-30**] 03:59AM 155* 38* 1.4* 140 4.7 107 231 15
[**2151-9-29**] 02:58AM 109* 35* 1.6* 138 4.1 105 241 13
[**2151-9-28**] 09:30AM 130* 33* 1.6* 139 3.6 101 251 17
[**2151-9-26**] 12:00PM 130* 23* 1.3* 143 4.7 106 241 18
*
Cardiac Enzymes: Negative x 3 (troponins <0.01)
*
CHEMISTRY Albumin Ca Phos Mg
[**2151-10-14**] 05:09AM 8.9 4.6* 1.9
[**2151-10-13**] 11:56AM 8.8 3.6 1.8
[**2151-10-12**] 09:50AM 8.5 4.5 1.7
[**2151-10-11**] 07:00AM 2.8*8.0* 4.4# 1.6
[**2151-10-10**] 04:25AM 7.5* 2.8 1.9
[**2151-10-9**] 03:50AM 2.8*7.5* 2.1* 1.6
[**2151-10-8**] 04:47AM 7.9* 2.8 2.8*
[**2151-10-7**] 04:16AM
* Blood Gasses
[**2151-10-6**] 04:07PM ART 163* 45 7.38 28 1 NOT
INTUBA1
1 NOT INTUBATED
[**2151-10-5**] 09:09PM ART 70* 40 7.45 29 3 NOT
INTUBA1
1 NOT INTUBATED
[**2151-10-4**] 10:15AM ART 100 38 7.47* 28 3
*
Brief Hospital Course:
81 F with PMH Alzheimer's Dementia, DM, hypothyroid, HTN s/p
recent fall that led to C3-4 fracture s/p C3-6 fusion ([**10-4**] by
[**Doctor Last Name 363**], Ortho-Spine) who developed LLL infiltrate concerning for
Aspiration PNA requiring frequent nursing attention for upper
airway suctioning/ inability to clear own secretions now
improved on antibiotic therapy.
On admission to the ED:
Pt admitted to Trauma service on [**2151-9-26**]. Pt was stabilized
with cervical collar and methylprednisolone for soft tissue
swelling. Patient was followed by Geriatic concult service prior
to surgery. Pt was taken to OR on [**10-4**] for cervical spine
fusion by Trauma [**Doctor First Name **]. Post-op Dr. [**Last Name (STitle) **] accepted the patient
onto the geriatric service. Less than 2 hours after tx to
geriatrics, the medicine team had been called > 4 times for
inability to clear secretions and increased nursing needs which
apparently began per nursing records post-op. Due to increased
nursing needs, specifically Q 20 minute suctioning, floor team
requested patient transfer to MICU for closer monitoring. In the
MICU she was weaned to q 4 hours suctioning. There a speech and
swallow evluation demonstrated an inability to handle po intake
of any kind. A Dobhoff was placed.
.
Aspiration Pneumonia: Focal opacity in LLL with desaturation to
high 80s on oximetry unless Q 20 minute suctioning performed x
24 hours. Pt transferred to ICU for increased nursing needs.
- S & S eval done on [**10-1**]--> nectar thin liquids and ground
solids. Pills crushed with purees. On eval [**10-5**] pt noted to be
unable to manage and clear her own secretions requiring NT
suctioning. [**10-7**] S&S: pt not swallowing, needs alternate
feeding method. Received course of Dexamethasone 6 mg IV Q H for
airway edema, d/c'd [**10-7**].
- Treated aspiration pneumonia with Levoquin/vancomycin for
nosocomial coverage.
- [**10-5**] sputum: MRSA+, vanc-sensitive - treated with 7 days of
Vanco. Discontinued on [**2151-10-14**].
- On discharge, pt's respiratory secretions had decreased
substantially - was on glycopyrrolate in house to decrease
secretions - her O2 requirements also decreased in house. She
has been afebrile for at least the past 8 days.
.
#. FEN:
- PEGs have not been shown to decrease aspiration in patients
with dementia.
- [**10-10**]: patient pulled out her Dobhoff tube
- [**2151-10-12**]: PEG placement: this decision is based on the feeling
that the patient may recover the ability to swallow -> hence a
temporary fixture such as a PEG would be warranted.
- PEG placed on [**2151-10-14**] -> started tube feedings on [**10-15**] -> For
rate, see below.
.
3. Cervical cord compression: s/p C3/4 fracture repair with
allograft and plate [**10-4**]. POD #1. Notable soft tissue swelling
pre-op. Post-op, this may be slightly worse. Cervical collar to
be worn when sitting up or not in bed.
- needs to wear soft c-collar when not lying in bed
- [**Female First Name (un) **] chair during the day.
- Patient able to minimally move R arm; very deconditioned and
poor central strength and poor ability to stand by herself. Has
been requiring [**Doctor Last Name 2598**] lifts to move her.
.
4. Pain Control: Tylenol PR 650 mg TID. Try to avoid narcotics
given dementia.
.
5. GU:
- Has had hard time urinating after pulling foley. Tried
multiple times.
.
6. Anemia: baseline Hct is 33. Pt is s/p 2 units PRBCS on [**10-1**].
Hct had trended down to 25.7 -> after 1 unit on [**10-11**], Hct
jumped to 28.8 -> giving another unit on [**2151-10-12**] -> hct 31.9.
34.6 on [**2151-10-15**]. Stable at 34 on [**2151-10-18**]
.
7. DM: FS QID. Insulin SQ for hyperglycemia. We held her oral
hypoglycemics while in hospital - she was on Metformin 500 daily
at home - held in hospital and covered with a SSI. Was
maintained with 10U NPH in AM and 10U NPH in PM. Blood sugars
were well controlled with this regimen.
.
8. HTN: currently borderline. will follow and treat if needed
with PRN hydralazine.
.
9. PPX: Heparin SC, Pneumoboots, Fall precautions, Aspiration
Precautions..
Medications on Admission:
metformin 500', synthroid .075', lisinopril 5', lipitor 10',
seroquel 12.5qhs, motrin 600'''', folate, b12. nemenda 10 mg Q
AM AND PM. Ibuprofen 600 mg QID
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
once a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
hold for SBP<100.
7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO once a day.
9. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
12. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Tubefeeding: Promote w/ fiber Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 70
ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 100 ml water q6h
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 10140**] - [**Location (un) 10059**]
Discharge Diagnosis:
Spinal cord compression
Discharge Condition:
Patient has oxygen requirements of 3-4L, decreased mobility of
right upper extremity. Decreasing oxygen requirements over the
course of her stay.
Able to communicate, but patient has baseline dementia.
Discharge Instructions:
Please contact your primary care provider in case you experience
worsening neck pain, chest pain, shortness of breath that is
worsening or you develop any new difficulties with moving your
extremities.
.
Patient needs to be on aspiration precautions
.
Followup Instructions:
Please call your primary care provider to schedule [**Name Initial (PRE) **] follow up
appointment.
.
Please call your orthopedic surgeon Dr. [**Last Name (STitle) 28003**] for a follow up
appointment.
His office # is [**Telephone/Fax (1) 3573**]. Could not schedule an appt because
of holiday weekend. He wanted to see pt approximately 2 weeks
post discharge from hospital.
Completed by:[**2151-10-22**]
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83,255
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50839
|
Discharge summary
|
report
|
Admission Date: [**2169-1-5**] Discharge Date: [**2169-1-11**]
Date of Birth: [**2085-6-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
ERCP [**2169-1-6**]
PICC line placement [**2169-1-9**]
History of Present Illness:
83 year old female with a history of biliary obstruction due to
tumor with metal stents presenting to an OSH on [**1-3**] with an
episode of weakness/incontinence found to have polymicrobial
bacteremia/sepsis. The patient was treated for a UTI on [**12-21**]
with Macrobid. On [**2169-1-2**] she was being assisted to the
bathroom by her husband and became acutely weak and incontinent
of urine. She was taken to the OSH ED where she had a fever of
104 and a SBP in the 70s (per report). Full ROS at OSH was
negative. Patient does not remember the episode and cannot
provide further history at this time.
No discharge summary or hospital course was provided by the OSH.
From the provided data, her blood cultures from the OSH are
positive for E. coli, Klebsiella a 3rd GNR and GPC. She was
treated initially with levofloxacin, but changed to Imipenim and
gentamicin with improvement in her clinical status. A CT of the
abdomen demonstrated persistent biliary dilatation concerning
for stent obstruction. There were also questionable liver
lesions with decreased enhancement surrounded by increased
enhancement concerning for abscess. She also developed AF with
RVR necessitating a diltiazem gtt.
The patient was transferred to [**Hospital1 18**] on [**2169-1-5**] for ERCP
evaluation of her metal biliary stents given CT findings. She
is afebrile and clinically stable on transfer.
Currently, she complains of irritation by the Foley, but denies
headache, blurry vision, dry mouth, thirst, difficulty/pain with
swallowing, chest pain, shortness of breath, palpitations,
nausea, heartburn, vomiting, abdominal pain, diarrhea,
constipation (though notes no BM in 1 week), new weakness,
numbness or tingling.
Past Medical History:
-Biliary obstruction/malignant stricture s/p ERCP X 2 and 2
metal stents--last placed in [**9-12**]. Thought to be
cholangiocarcinoma, no clear pathologic diagnosis made. By
report, evaluated by surgical team, thought not to be a surgical
candidate.
-Diabetes mellitus, type 2
-Hypertension
-Coronary artery disease
-Parkinson's disease
-diastolic CHF
-Vaginal Carcinoma
-s/p Cholecystectomy
-Urosepsis d/t E. coli and Proteus
-Bacteremia due to VRE in [**9-12**] treated with 2 week course of
Linezolid
-Bacteremia due to E. coli in [**9-12**] treated with 2 week course of
Ceftriaxone.
-Atrial fibrillation
-Hyperlipidemia
Social History:
lives with husband in [**Name (NI) 3320**] no children. Dependent for
ADLs--has VNA and husband cares for her, no tobacco or drugs,
occassional alcohol. Retired tax examiner for the state.
Family History:
mother died of heart disease
Physical Exam:
VS: 98.3 136/63 p67 R20 99RA
Gen: elderly female, non-toxic.
HEENT: PERRL, OP clear, MMM
Neck: No JVP
Car: RRR. No mrg.
Resp: CTA-ant/lat
Abd: soft, nontender, nondistended + BS
Ext: [**1-6**]+ LE edema B.
Neuro: CN II-XII intact. Masked facies. Non-focal.
Skin: warm/well perfused, several dry patches, no rash, no
jaundice. Area L hip bandaged for superficial pressure ulcer.
Pertinent Results:
Admission Labs:
[**2169-1-5**] 06:04PM WBC-25.6*# RBC-4.26 HGB-11.5* HCT-35.4*
MCV-83 MCH-27.1 MCHC-32.6 RDW-17.7*
[**2169-1-5**] 06:04PM NEUTS-91.3* LYMPHS-6.0* MONOS-2.5 EOS-0
BASOS-0.1
[**2169-1-5**] 06:04PM PLT COUNT-120*#
[**2169-1-5**] 06:04PM PT-14.0* PTT-20.6* INR(PT)-1.2*
[**2169-1-5**] 06:04PM ALT(SGPT)-8 AST(SGOT)-27 LD(LDH)-152 ALK
PHOS-139* TOT BILI-1.1
[**2169-1-5**] 06:04PM GLUCOSE-111* UREA N-36* CREAT-0.8 SODIUM-142
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-11
[**2169-1-5**] 06:04PM ALBUMIN-2.8* CALCIUM-9.8 PHOSPHATE-2.7
MAGNESIUM-1.9
OSH ([**Date range (1) 69929**]-[**Date range (1) **]) Labs
WBC 26.6(87P,8B)->33.7(84P,6B)->30.1(87P,7B)->25.2
HCT 37.6->28.7->30.5->31.8
Plt 245->201->109->93
PT/INR ([**1-5**]) 11.4/1.1
Cr 1.44->1.32->1.08->0.75
Alb 1.9
TB 1.9->1.5->1.2
AP 198->134->128
AST 46->35->30
ALT <5->24->7
TNI 0.12 ([**2169-1-2**])
BNP 733 ([**1-3**])->1508 ([**1-4**])
UA: neg LE, neg nit, 1+ gluc, trace acetone, 1.015
OSH Micro:
[**2169-1-2**]: Blood culture-E. coli (Amp R, Cipro R, [**Last Name (un) **] Augmentin,
Aztreonam, Cefazolin, Cefoxitin, Ceftriaxone, fent, imipenem,
zosyn)
[**2169-1-2**]: Urine culture-negative
[**2169-1-2**]: Blood cluture: K. pneumonia, other GNR
[**2169-1-4**]: Blood culture: GNR, GPC
[**2169-1-4**]: Blood culture: GPC
[**2169-1-4**]: Sputum culture: Yeast
OSH studies:
1. CXR: vascular congestion in right upper lung, unchanged since
[**1-3**] without active lung disease.
2. CT abd/pelvis ([**1-3**]): double biliary stent catheter in place
with evidence of continued biliary obstruction throught the
liver--not improved. Liver shows areas of decreased enhancement
in posterior right lobe and in the anterior left lobe with no
definite mass effect seen suspicious for possibility of
infections at that site. In the anteriormost portion of the
left lobe, a low area of decreased enhancement surrounded by
increaseed enhancement extend over a diameter of 2 cm which
could represent early formation of an abscess even though no
clear-cut abscess is definitely identified. Spleen is
unremarkable. Large amount of retained stools in rectum
compatible with fecal impaction.
3. CT head without contrast: no actue abnormality identified,
sinus disease and left mastoiditis. Small vessel disease
ECGs:
[**1-2**]: Sinus tachycardia at 112 bpm with PACs, TWI in III, no ST
changes. Q waves in II/III/aVF
[**1-3**]: NSR, axis change from [**1-2**]
[**1-4**]: AF with RVR, maintained axis change from [**1-2**]
[**2169-1-5**]: NSR, normal axis (same as [**1-4**]), normal intervals, TWI
V1-V4 (new), biphasic T waves V5-V6, poor baseline d/t
Parkinson's tremor but otherwise, no ST changes.
.
Cardiac Echo [**2169-1-6**]:
IMPRESSION: Normal left and right ventricular systolic function.
Mild mitral regurgitation. Evidence of elevated left sided
filling pressures.
.
ERCP [**2169-1-6**]:
Biliary Tree: There were multiple filling defect that appeared
like sludge in the upper third of the common bile duct, right
main hepatic duct and left main hepatic duct,within the metallic
wallstents.
Procedures: Multiple stone fragments and sludge were extracted
successfully using a 11 mm balloon.
Impression: Stent obstruction by stones and sludge was found -
stents were dredged using a balloon.
(stone extraction)
.
CXR for PICC placement:
PORTABLE UPRIGHT CHEST RADIOGRAPH: The left PICC terminates over
the mid
right atrium and can be pulled back 4 to 5 cm to the lower SVC.
The
nasogastric tube has been removed. The cardiomediastinal is
stable and within
normal limits. The lungs are clear.
.
LE Dopplers [**2169-1-6**]:
IMPRESSION:
1. No DVT of the right lower extremity.
2. Probable thrombus of a deep vein of the left calf, likely one
of the
paired posterior tibial veins.
.
CT Abd [**2169-1-6**]:
IMPRESSION:
1. Intrahepatic biliary ductal dilatation with peri-biliary
enhancement
consistent with cholangitis. Anteriorly in the left lobe,
multiple hypodense
collections with enhancing rims, consistent with multiple
abscesses. The
largest measures approximately 2 cm and may be amenable to
percutaneous
sampling if desired, but is not likely amenable to catheter
drainage at its present size.
2. Vague region of parenchymal enhancement at the apex of
dilated ducts could represent obstructive tumor mass, but its
margins are difficult to define.
3. Interval increase in small bilateral pleural effusions, small
pericardial effusion, and small amount of ascites.
4. Interval increase in size of enhancing pericardial lymph
node.
5. Evidence of thrombosis of the posterior right portal vein,
resulting in
heterogeneous perfusion of the posterior right lobe of the
liver.
6. 9-mm pancreatic hypodensity, not previously visualized. While
it is too
small to characterize, findings suggest a cystic lesion such as
a dilated side branch or an isolated cystic lesion. If desired,
this can be further
evaluated with MRCP.
.
MICRO:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2169-1-11**]):
Feces negative for C.difficile toxin A & B by EIA.
.
Blood Culture [**2169-1-5**] (multiple bottles):
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
.
Blood cultures [**2169-1-6**]: continued positive with above.
Blood cultures [**Date range (1) 105716**]: results still pending; please
follow up final results.
.
Urine culture: negative
MRSA screen: negative
.
Discharge labs:
WBC 11.3 Hgb 9.8 HCT 29 PLT 340
Na 142 K 3.9 Cl 105 HCo3 32 BUN 7 Cr 0.5 Glu 84
PT 20 PTT 38.5 INR 1.9
.
[**2169-1-10**] CPK 10 AST 26 ALT 6 AlkPh 135 Tb 1.4
Brief Hospital Course:
83 year old female with history of biliary obstruction,
polymicrobial bacteremia from cholangitis presented with biliary
sepsis. Patient was transferred from [**Hospital3 3583**] in
[**Location (un) 3320**], MA.
.
# Sepsis/Biliary obstruction/Liver abscesses: At the OSH she was
hypotensive with leukocytosis and polymicrobial bacteremia, with
E. coli, Klebsiella, GPC, and VRE from blood cultures. Had
negative UA/Urine culture and CXR for pneumonia. Source is
biliary, with additional concern for liver abscess on CT scan.
Culture data was faxed from the OSH and showed: 1) enterococcus
sensitive to gent and streptomycin, 2) E.coli sensitive to gent,
imipenem, and cephalosporins, and 3) Klebsiella pansensitive
except to amp. On transfer to the floor from [**Hospital Unit Name 153**], she was
transitioned to linezolid and gentamicin alone.
.
The repeat CT abd/pelvis showed multiple abscesses in the liver
adjacent to where the stents are placed in the anterior portion
of the left lobe. The largest collection is 1.5 cm; additionally
there are a couple of subcm foci. Also seen is intrahepatic
ductal dilation/cholangitis. The radiologist also suspects a
mass centrally at the porta hepatis as intrahepatic ductal
dilation is present (but no mass is visualized). Per radiology
none of the collections would be amenable to drainage.
She underwent ERCP on [**2169-1-6**] and had both sides of her stents
flushed with sludge removed.
.
ID was consulted, and antibiotics were changed from Linezolid
and Gent to Ceftriaxone and Daptomycin on [**1-10**] due to the
duration of treatment that will be required. Patient will
follow up with [**Hospital **] clinic and have repeat imaging of her liver to
ensure clearance of infection/abscesses.
**She will also need weekly lab monitoring on Daptomycin:**
CBC, LFT's, CPK, BUN/Cr
Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] of Infectious Disease at
[**Telephone/Fax (1) 432**].
At the time of discharge, several blood cultures remain pending,
please follow up final results.
.
# Diarrhea
Patient was noted to have ongoing loose stools for which patient
has a flexiseal. Patient has been tested and resulted c-diff
negative x 1.
.
# Cholangiocarcinoma: Discussion with family to clarify goals of
care revealed that patient is not planning on surgery or
chemo/XRT given extremely poor prognosis of cancer.
.
# Atrial fibrillation: Paroxysmal. She was continued on digoxin.
The patient has remained in normal sinus rhythm. CHADS score is
4, and she was placed on Lovenox with transition to coumadin.
- resumed Lovenox [**2169-1-9**] s/p PICC placement for coumadin bridge
- INR 1.9 at time of discharge
- Coumadin dosing: 5 mg po q 1600 since [**2169-1-9**].
Please follow INR and titrate coumadin dosing as appropriate.
.
# Left lower extremity DVT: The patient was noted to have
right>left lower extremity swelling so lower extremity dopplers
were obtained which showed a probable thrombus of a deep vein of
the left calf, likely one of the paired posterior tibial veins.
The patient was started on a heparin gtt with a goal PTT of
50-70, and then transitioned to Lovenox/coumadin.
- on lovenox/coumadin
.
# Diastolic CHF/ECG changes: The patient had a positive single
troponin value at the OSH and 2 measured/elevated BNP levels.
Has LE edema and is on chronic Lasix at home. ECG from [**2169-1-2**]
to [**2169-1-3**] demonstrated a change in axis and co-incides with
chills/rigors/shortness of breath noted in one of the consultant
notes. ECG here with new TWI V1-V4 and maintainance of new axis
since [**1-2**]--cycled enzymes; Trp 0.05 but CK-Mb remained
negative. She was continued on aspirin and a statin. A TTE was
obtained which showed an EF of >55%, but elevated PCWP.
- Currently appears euvolemic and BUN/Cr stable
- restarted Lasix [**1-10**]
.
# Concern for aspiration: There was concern that the patient
aspirated her pm meds so her meds were changed to IV and speech
and swallow c/s was requested. She had an NGT placed, which she
self-d/c'd. She remained NPO until [**2169-1-9**] when Speech and
swallow cleared patient for modified diet.
S+S Recommendations:
Regular Diabetic/Consistent Carbohydrate Consistency: Ground;
Nectar prethickened liquids 1. PO intake of nectar thick liquids
and ground solids. 2. Pills crushed with puree. 3. 1:1
supervision with all pos. 4. Continue Q8 oral care.
.
# Parkinson's Disease: She was continued on Sinemet.
.
.
CODE: DNR/DNI
Access: PICC
Dispo: d/c'd to [**Hospital 169**] Center, [**Location (un) 3320**].
Medications on Admission:
Medications at home: simvastatin 10 mg daily, lasix 40 mg daily,
omeprazole 40 mg daily, albuterol 2 puffs/4x day, singulair 10
mg daily, MVI, prazosin 2 mg [**Hospital1 **], mirapex 0.375 mg tid,
carbidopa/levodopa 25/100 mg three times per day
Medications at transfer from rehab: Albuterol neb q4h, SSI,
Lovenox, Protonix 40 mg IV daily, simvastatin 10 mg qhs,
singulair 10 mg daily, MVI, Aspirin 81 mg daily, gentamicin 120
mg IV daily since [**1-3**], nystatin, imipenim/cilastin 250 mg IV
q6h, pramipexole 0.375 mg tid, sinemet 25/100 mg three
times/day, digoxin 0.25 mg IV q4h X 4 doses (received X 4),
vancomycin 1 gm IV q24h, digoxin 0.125 mg po daily, propafenone.
Diltiazem gtt stopped [**2169-1-5**] at 12 am. Phenylephrine ordered,
unclear if received.
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebs
Inhalation Q6H (every 6 hours) as needed for wheezing.
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) inj Subcutaneous
Q12H (every 12 hours) for until INR >2 days.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: please follow INR and titrate dose accordingly.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. 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.
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. CeftriaXONE 1 g IV Q24H Start: In am
15. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) per
sliding scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
# Biliary sepsis
# Biliary obstruction
# Liver abscesses
# Cholangiocarcinoma
# Paroxysmal atrial fibrillation
# Left lower extremity DVT
# Chronic diastolic CHF
# Parkinson's disease
Discharge Condition:
stable
Discharge Instructions:
Please seek medical attention if you develop fevers, chills,
changes in mental status, abdominal pain, or any other concerns.
Followup Instructions:
Please continue to take antibiotics as prescribed. You will
need to follow up with Infectious Disease doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]
and have repeat imaging to determine the total duration of
antibiotics.
.
Patient will need weekly lab monitoring on Daptomycin:
CBC, LFT's, CPK, BUN/Cr
Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] of Infectious Disease at
[**Telephone/Fax (1) 432**].
.
Appointment:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2169-2-13**] 10:00
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67,906
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50179+59230
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-7-28**] Discharge Date: [**2178-9-11**]
Date of Birth: [**2126-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea, Hemoptysis
Major Surgical or Invasive Procedure:
intubated [**7-28**]
tracheotomy [**8-14**]
peg placement: [**8-14**]
aterial line: [**9-3**]
PICC line: [**2178-9-7**]
Dialysis Catheter: [**2178-9-9**]
History of Present Illness:
History of Present Illness: 51 yo M with a history of COPD (on
continuous home oxygen 4-6L/min), moderate restrictive lung
disease, OSA on CPAP, morbid obesity, chronic DVT (on coumadin)
and anxiety BIBEMS with complaints of dyspnea and hemoptysis,
found to be profoundly hypoxic. Short of breath for 3 days,
coughing yesterday. When EMS arrived, the patient was apparently
able to answer the door, sat was 50 on room air (ran out of O2).
NRB to 80's. He reported subjective fevers. He denied chest
pain. He also was describing vague neck pain. Per the patient's
HCP, the patient's oxygen tank exploded on Sunday, creating a
cloud of dust and debris. The police and fire dept came to the
house and recommended that the patient and his mother evacuate,
but the patient chose to stay home.
.
In the ED, initial vs were: 96.6 96 127/71 28 95% on NRB. On
exam, he was in obvious respiratory distress with mild crackles.
A CXR showed volume overload. His labs were notable for an INR
of 10, an ABG of 7.34 71 92 on NRB. Patient was given a dose of
methylprednisolone, albuterol nebs, which he did not tolerate
well. He was also started on Bipap with a full facemask, which
he also didn't tolerate well. BP was initially in the mid 90's,
but at one point dropped lower possibly to the 70's, so he also
received 1L fluid. Bipap was then stopped, and he was restarted
on NRB, currently satting in mid-high 80's, at a rate of
20's-30's. He was taken for CTA to rule out PE, and not reversed
downstairs out of concern for overshooting without knowing if
there was a PE present. FFP was ordered but not given.
.
Upon arrival to the MICU, was noted in respiratory failure, was
intubated, aline and CVL were placed after receiving 4 units FFP
and 10IV vitamin K. 3L of NS were given and dopamine was started
initially through a peripheral IV.
.
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:
COPD oxygen dependent
Obstructive Sleep Apnea
Anxiety
Morbid Obesity
Chronic LLE DVT
Social History:
Patient lives with his elderly mother. [**Name (NI) **] denies any history of
tobacco, etoh, or drug use. He uses a motorized chair for most
mobility.
Family History:
Noncontributory
Physical Exam:
Vitals: T: 97.1 BP: 95/52-152/89 P:65 R:25 O2: 94%, tracheostomy
tube, CMV/Assist/Autoflow
General: Alert, arousable to sound
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Poor air movement throughout with diffuse rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Loud P2.
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding.
G-tube in place,loss, ulceration of skin at left lateral border,
exquisitely tender to touch, no erythema or discharge
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. No
rash, trace to 1+ edema
Pertinent Results:
Labs on Admission: [**2178-7-28**]
WBC-7.6 RBC-4.54* Hgb-10.7* Hct-36.3* MCV-80* RDW-17.3* Plt
Ct-178
Neuts-81.7* Lymphs-10.4* Monos-5.5 Eos-2.1 Baso-0.3
PT-86.6* PTT-52.4* INR(PT)-10.5*
Glucose-153* UreaN-10 Creat-0.7 Na-143 K-3.1* Cl-102 HCO3-29
AnGap-15
ALT-13 AST-22 LD(LDH)-266* AlkPhos-61 TotBili-0.5
Lipase-22
Calcium-8.5 Phos-3.6 Mg-2.0
Lactate-2.7*
.
Other labs:
[**2178-8-22**] Hgb-6.7* Hct-22.3*
[**2178-9-4**] WBC-19.4*
[**2178-8-24**] calTIBC-151* VitB12-1287* Folate-15.2 Ferritn-288
TRF-116*
[**2178-8-30**] Hapto-<20*
[**2178-7-29**] Triglyc-79
[**2178-9-2**] TSH-5.2* T3-84 Free T4-1.6
[**2178-8-24**] Cortsol-19.3
[**2178-9-10**]: HG: 8.6, HCT 27.7, PLT: 103, WBC: 8.1,
CR: 2.4,Glucose: 91, Na: 139, K+: 4.0, CL: 103, NaCO3:26, BUN:
26, CR: 2.4
glucose: 91, PT/PTTINR: 21.1/69.1/2.0
CK-CKMB/TROP: 55/0.17
ALT/AST:[**1-28**]
ALK PHOS/T-BILI: 58/0.3,
AMYLASE/LIPASE: 86/40
Micro:
[**2178-8-26**] Urine culture: [**Female First Name (un) **] PARAPSILOSIS. >100,000
ORGANISMS/ML..
[**2178-9-1**]. [**2178-8-31**], [**2178-8-30**] C. diff negative
[**2178-8-30**], [**2178-9-1**] and [**2178-9-2**] blood cultures: no growth to date
[**2178-8-27**], [**2178-8-24**], [**2178-8-23**], [**2178-8-21**], [**2178-8-20**], [**2178-8-19**], [**2178-8-17**],
[**2178-8-3**]: No growth
[**2178-8-30**] 9:13 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2178-8-31**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2178-9-4**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
MEROPENEM------------- =>16 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
Other studies:
[**2178-7-28**] CTA: 1. Technically limited study, with no evidence of
central pulmonary embolism though evaluation to the segmental
and subsegmental branches is limited. 2. Severe centrilobular
emphysema with new superimposed widespread airspace
consolidation involving the entire lung fields, predominantly
with most significant involvement involving the bilateral lower
lobes, for which the differential includes infectious
etiologies, hemorrhage, or edema.
[**2178-8-24**] Echo: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size is mildly increased
with free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**2178-8-20**] CT abd/pelvis w/: 1. Enlargement of the right iliacus
muscle from hematoma formation. There is no evidence for active
or arterial extravasation within this hematoma. Would recommend
clinical correlation with instrumentation of the patient's right
groin. No other hematomas identified. 2. Improved appearance but
still persistently markedly distorted lung bases with severe
emphysematous and bullous changes. Extensive subcutaneous
emphysema in the anterior chest wall, demonstrating improvement.
3. Soft tissue density material in the anterior right hemithorax
may be a small area of resolving hemothorax as there is also an
additional small locule of air on the most nondependent portion
of the right anterior hemithorax. 4. No abnormal findings in the
pancreas, gallbladder, or liver. 5. Marked colonic fecal
loading. No bowel obstruction.
[**2178-8-20**] Gallbladder U/S: No gallstones. No sludge identified on
this ultrasound. No evidence of cholecystitis and no biliary
dilatation seen.
[**2178-9-1**] BLE U/S: No evidence of DVT.
[**2178-9-2**] CT head w/o: No intracranial hemorrhage or edema.
Unchanged moderate mucosal thickening of the sphenoid sinuses.
[**2178-9-2**] Renal U/S: Markedly limited exam; no evidence of
hydronephrosis or abnormal echogenic areas to suggest the
presence of a fungus ball as questioned.
[**2178-9-8**]:
CT ABD/PELVIS Study limited due to lack of IV contrast. No large
fluid collections seen. Enlargement of the right iliacus muscle,
with similar appearance compared to prior study, likely
hematoma.
CXR:
[**2178-9-10**].
The tracheostomy tip is 7.3 cm above the carina. The
double-lumen central
venous catheter line terminates at the level of mid SVC.
Cardiomediastinal
silhouette and widespread extensive parenchymal consolidations
are grossly
unchanged with questionable minimal improvement at the level of
the left
perihilar area. Overall, the findings are more extensive than on
[**2178-9-3**], but overall unchanged since [**2178-9-6**].
Brief Hospital Course:
51 y/o male with a history of severe mixed obstructive and
restrictive disease presents with hemoptysis, and hypoxic and
hypercarbic respiratory failure.
# Hypoxic and Hypercarbic Respiratory Failure: The initial
insult was inhalation injury from oxygen tank explosion on top
of severe underlying bullous emphysematous lung disease.
ARDsnet ventilation conducted given suspicion for [**Doctor Last Name **]. He was
empirically covered for CAP. On [**8-2**], patient developed
subcutaneous emphysema, likely due to bleb rupture. This
severely progressed into pneumomediastinum and subcutaneous
emphysema propagating down both arms and into the chest.
Improved by CXR. Continuing to follow with serial CXR. Thoracics
followed pt's care as well. Trached and peged on [**2178-8-13**].
Currently patient is on CMV assist with PSV trial today.
Receiving albuterol and Ipratroprium.
# Resistant Pulmonary Pseudomonas:
The patient recently grew resistant pseudomonas on his sputum,
sensitive to tobramycin and gent only. Colistin sent to outside
lab. He is currently on tobramycin day [**8-18**] and ID is following,
redosing by level given dialysis.
# Sedation - Patient transitioned from versed/fentanyl to
propofol with goal of trach mask. However, patient failure SBT.
The patient still had pain and anxiety with fentanyl patch and
boluc (propofol had to be d/c'd for pancreatitis picture).
Increased to fentanyl drip on [**2178-9-5**] possibly for short term
pain control [**3-9**] pancreatitis, with drip now dc'd. Currently
requiring methadone,fentanyl patch + boluses, needs more for
dressing changes with standing clonazepam for anxiety.
# Hypotension - likely in the setting of decreased preload with
PEEP. Was on dopamine via peripheral access. Was switched to
levophed for improved ionotropy and then slowly weaned
off.Currently off pressors, maintaining MAPS in 80s.
# Pancreatitis: elevated amylase/lipase on [**9-5**], likely [**3-9**]
propofol. Stopped propofol, made NPO, given pain control. Cont
to monitor labs.
.
# Constipation - pt had constipation, without BM for 2 weeks.
GI consulted. Pt was placed on senna, colace, lactulose, soap
suds enema, gastrografin enema, and golytely with resolution of
stool backup to R colon.
#Persistent funguria with parapsilosis: The patient is on
fluconazole with goal to treat him for 14 days (day 13/14). He
was on amophtericin bladder washes which now dc'd given negative
urine cultures.
# Thrombocytopenia: etiology unknown. Decreased over last week,
down to 103 today, being monitored closely. Heparin dc'd as INR
at goal of 2.0, will continue warfarin.
#Atrial fibrillation: While in the MICU the patient developed
intermittent A. fib. He was rate controlled with metoprolol and
is in NSR now.
#Renal failure: Likely [**3-9**] AIN and ATN from medication and
hypotension. Getting HD on MWF. Kidneys starting to recover,
remains at risk of nephrotoxicity on tobramycin.
#Acute blood loss anemia: The patient had GI bleeding, bleeding
from his trach site, and a retroperitoneal bleed found on CT.
His heparin gtt was temporarily stopped. His goal HCT is > 28.
He was tranfused with pRBCs when necessary to maintain that
hematocrit. His hematocrits have been stable so his heparin gtt
was restarted to continue bridge to warfarin. INR now
therapeutic, heparin dc'd.
#H/O DVT: BLE U/S do not show DVT. Restarted warfarin [**9-5**].
Currently on warfarin only after being bridged with heparin.
Continuing to monitor coags.
# Skin breakdown: wound care consult for trach site ulceration
and right buttocks wounds.
# G-tube: Ulceration around g-tube site. Needs g-tube dressing
site change q2-3 weeks. Last dressing was placed [**2178-9-10**].
# Social - after discussion with brother and family pt's brother
states that pt had expressed desire to live and therefore wants
everything done.
# Dispo: Considering transfer to LTCF.
Medications on Admission:
Citalopram 20 mg Tablet
Fluticasone 50 mcg/Actuation Spray
Furosemide 20 mg Tablet daily
Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]
Prednisone 4 mg daily
Spironolactone 25 mg Tablet daily
Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device daily
Warfarin 12.5mg daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Inhalation Lung Injury
Hypoxic and Hypercarbic Respiratory Failure
Pseudomonas Pneumonia
Acute Renal Failure requiring Hemodialysis
Gastrointestinal Bleed
Atrial Fibrillation
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital due to very low levels of
oxygen in your blood. You need to be placed on a ventilator to
support your breathing and allow your body to get enough oxygen.
It is likely that your oxygen tank exploding damaged your lungs
and contributed to the need the ventilator. You needed a
tracheostomy and feeding tube because you have been unable to
get off the ventilator. You also developed a bad pneumonia that
is being treated with antibiotics through a special intravenous
line called a PICC. On your anticoagulation for your history of
chronic deep vein thrombosis, you developed a gastrointestinal
bleed which has resolved and you have tolerated being restarted
on your coumading. You do have a right iliacus hematoma from
this episode. You also developed kidney failure which was
treated with dialysis while your kidneys had a chance to
recover.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-10-13**] 2:30
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2178-11-24**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-12-14**] 10:00
Stay in contact with providers above while in rehab facility.
Follow up as recommended by rehab provider.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Name: [**Known lastname 7456**],[**Known firstname 133**] Unit No: [**Numeric Identifier 16996**]
Admission Date: [**2178-7-28**] Discharge Date: [**2178-9-11**]
Date of Birth: [**2126-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
See attached.
Chief Complaint:
dyspnea, hemoptysis
Major Surgical or Invasive Procedure:
Tracheostomy
Central Venous Line
Hemodialysis Catheter Placement
PICC Line Placement
Central Venous Catheter
History of Present Illness:
History of Present Illness: 51 year old male with a history of
COPD (on continuous home oxygen 4-6L/min), moderate restrictive
lung disease, OSA on CPAP, morbid obesity, chronic DVT (on
coumadin) and anxiety with complaints of dyspnea and hemoptysis,
found to be profoundly hypoxic. Short of breath for 3 days,
coughing yesterday. When EMS arrived, the patient was apparently
able to answer the door, sat was 50 on room air (ran out of O2).
NRB to 80's. He reported subjective fevers. He denied chest
pain. He also was describing vague neck pain. Per the [**Hospital 1325**]
health care proxy, the patient's oxygen tank exploded on Sunday,
creating a cloud of dust and debris. The police and fire dept
came to the house and recommended that the patient and his
mother evacuate, but the patient chose to stay home.
.
In the ED, initial vs were: 96.6 96 127/71 28 95% on NRB. On
exam, he was in obvious respiratory distress with mild crackles.
A CXR showed ?volume overload. His labs were notable for an INR
of 10, an ABG of 7.34 71 92 on NRB. Patient was given a dose of
methylprednisolone, albuterol nebs, which he did not tolerate
well. He was also started on Bipap with a full facemask, which
he also didn't tolerate well. BP was initially in the mid 90's,
but at one point dropped lower possibly to the 70's, so he also
received 1L fluid. Bipap was then stopped, and he was restarted
on NRB, currently satting in mid-high 80's, at a rate of
20's-30's. He was taken for CTA to rule out PE, and not reversed
downstairs out of concern for overshooting without knowing if
there was a PE present. FFP was ordered but not given.
.
Upon arrival to the MICU, respiratory failure, was intubated,
arteial line and Central Venous Line were placed after receiving
4 units FFP and 10IV vitamin K. 3L of NS were given and dopamine
was started initially through a peripheral IV.
.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
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:
COPD oxygen dependent
Obstructive Sleep Apnea
Anxiety
Morbid Obesity
Chronic LLE DVT
Social History:
Patient lives with his elderly mother. [**Name (NI) **] denies any history of
tobacco, etoh, or drug use. He uses a motorized chair for most
mobility.
Family History:
Noncontributory
Physical Exam:
On Admission
Vitals: T: 95.1 BP: 97/63 P: 92 R: 26 O2: 98% on NRB with
grunting
General: Alert, severe respiratory distress with grunting and
screaming
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated but with brisk upstroke, no LAD
Lungs: Poor air movement throughout with diffuse rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Loud P2.
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. No
rash, trace to 1+ edema
On Discharge:
Afebrile, blood pressure 90s/50s by aline, heart rate 60,
oxygenation 98% on ventilator CMV PEEP 5, FiO2 40%, Tv 550, f
25.
General: Alert to voice, interactive, NAD
HEENT: NCAT, no scleral icterus, MMM, trach in place with
ulceration on Left side of trach. No JVD
PULM: Coarse B/L breath sounds anteriorly, no wheezes, BL
symmetric chest wall expansion
CV: RRR w/o MGR
Abd: Obese, w/ G-tube in place. Soft. NTND. +BS.
Ext: warm, well perfused, trace B/L pitting edema. No Clubbing
or cyanosis.
Pertinent Results:
On Admission
[**2178-7-28**] 09:18PM TYPE-ART TEMP-35.7 PEEP-31 O2-70 PO2-138*
PCO2-57* PH-7.39 TOTAL CO2-36* BASE XS-8 INTUBATED-INTUBATED
[**2178-7-28**] 09:18PM LACTATE-1.6
[**2178-7-28**] 09:03PM GLUCOSE-132* UREA N-8 CREAT-0.6 SODIUM-145
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-32 ANION GAP-12
[**2178-7-28**] 09:03PM CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-1.9
[**2178-7-28**] 06:34PM TYPE-[**Last Name (un) **] PO2-52* PCO2-71* PH-7.34* TOTAL
CO2-40* BASE XS-8
[**2178-7-28**] 06:34PM O2 SAT-82
[**2178-7-28**] 06:32PM TYPE-ART PO2-139* PCO2-64* PH-7.35 TOTAL
CO2-37* BASE XS-7
[**2178-7-28**] 06:32PM LACTATE-1.1
[**2178-7-28**] 06:06PM PT-19.9* PTT-35.0 INR(PT)-1.8*
[**2178-7-28**] 06:06PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 418**]-1.021
[**2178-7-28**] 06:06PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2178-7-28**] 06:06PM URINE RBC-10* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0
[**2178-7-28**] 04:50PM TYPE-ART PO2-97 PCO2-71* PH-7.31* TOTAL
CO2-37* BASE XS-5
[**2178-7-28**] 04:50PM LACTATE-0.9
[**2178-7-28**] 03:10PM TYPE-ART PO2-90 PCO2-89* PH-7.23* TOTAL
CO2-39* BASE XS-6
[**2178-7-28**] 02:08PM TYPE-ART TEMP-35.1 RATES-28/ O2-80 PO2-115*
PCO2-100* PH-7.16* TOTAL CO2-38* BASE XS-3 AADO2-352 REQ O2-64
-ASSIST/CON INTUBATED-INTUBATED
[**2178-7-28**] 01:11PM TYPE-ART TEMP-35.3 RATES-26/ TIDAL VOL-520
PEEP-8 O2-80 PO2-75* PCO2-107* PH-7.13* TOTAL CO2-38* BASE XS-2
AADO2-385 REQ O2-68 -ASSIST/CON INTUBATED-INTUBATED
[**2178-7-28**] 01:11PM LACTATE-0.6
[**2178-7-28**] 01:11PM O2 SAT-88
[**2178-7-28**] 11:53AM TYPE-ART PO2-91 PCO2-105* PH-7.12* TOTAL
CO2-36* BASE XS-1
[**2178-7-28**] 11:53AM O2 SAT-93
[**2178-7-28**] 11:46AM GLUCOSE-146* UREA N-11 CREAT-0.7 SODIUM-143
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-34* ANION GAP-9
[**2178-7-28**] 11:46AM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.0
[**2178-7-28**] 11:46AM WBC-9.4 RBC-4.38* HGB-10.3* HCT-35.3* MCV-81*
MCH-23.5* MCHC-29.1* RDW-17.4*
[**2178-7-28**] 11:46AM PLT COUNT-193
[**2178-7-28**] 11:46AM PT-34.3* PTT-44.4* INR(PT)-3.5*
[**2178-7-28**] 08:12AM TYPE-ART RATES-/24 PO2-92 PCO2-71* PH-7.34*
TOTAL CO2-40* BASE XS-8 INTUBATED-NOT INTUBA
[**2178-7-28**] 08:12AM TYPE-ART RATES-/24 PO2-92 PCO2-71* PH-7.34*
TOTAL CO2-40* BASE XS-8 INTUBATED-NOT INTUBA
[**2178-7-28**] 07:53AM COMMENTS-GREEN TOP
[**2178-7-28**] 07:53AM LACTATE-2.7*
[**2178-7-28**] 07:45AM GLUCOSE-153* UREA N-10 CREAT-0.7 SODIUM-143
POTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-29 ANION GAP-15
[**2178-7-28**] 07:45AM estGFR-Using this
[**2178-7-28**] 07:45AM ALT(SGPT)-13 AST(SGOT)-22 LD(LDH)-266* ALK
PHOS-61 TOT BILI-0.5
[**2178-7-28**] 07:45AM LIPASE-22
[**2178-7-28**] 07:45AM cTropnT-<0.01
[**2178-7-28**] 07:45AM CK-MB-3 proBNP-250*
[**2178-7-28**] 07:45AM WBC-7.6 RBC-4.54* HGB-10.7* HCT-36.3* MCV-80*
MCH-23.6* MCHC-29.6* RDW-17.3*
[**2178-7-28**] 07:45AM NEUTS-81.7* LYMPHS-10.4* MONOS-5.5 EOS-2.1
BASOS-0.3
[**2178-7-28**] 07:45AM PLT COUNT-178
[**2178-7-28**] 07:45AM PT-86.6* PTT-52.4* INR(PT)-10.5*
On Discharge
[**2178-9-11**] 02:36AM BLOOD WBC-8.1 RBC-2.91* Hgb-7.7* Hct-26.1*
MCV-90 MCH-26.5* MCHC-29.6* RDW-20.3* Plt Ct-109*
[**2178-9-11**] 02:36AM BLOOD Neuts-81.9* Lymphs-10.8* Monos-5.2
Eos-1.6 Baso-0.3
[**2178-9-5**] 05:37AM BLOOD Neuts-85* Bands-2 Lymphs-2* Monos-6 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-1*
[**2178-9-5**] 05:37AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Schisto-OCCASIONAL
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 16997**]
[**2178-9-11**] 02:36AM BLOOD Plt Ct-109*
[**2178-9-11**] 02:36AM BLOOD PT-28.0* PTT-46.4* INR(PT)-2.7*
[**2178-9-1**] 02:00AM BLOOD Fibrino-477*
[**2178-8-31**] 02:01AM BLOOD Ret Aut-1.9
[**2178-9-11**] 02:36AM BLOOD Glucose-85 UreaN-41* Creat-2.5* Na-139
K-3.5 Cl-104 HCO3-27 AnGap-12
[**2178-9-7**] 03:51AM BLOOD Amylase-86
[**2178-9-2**] 02:00AM BLOOD ALT-12 AST-24 CK(CPK)-49 AlkPhos-58
Amylase-115* TotBili-0.3
[**2178-9-1**] 02:00AM BLOOD LD(LDH)-424*
[**2178-9-7**] 03:51AM BLOOD Lipase-40
[**2178-9-11**] 02:36AM BLOOD Phos-5.7* Mg-2.0
[**2178-9-11**] 02:49AM BLOOD Type-ART pO2-124* pCO2-70* pH-7.25*
calTCO2-32* Base XS-1
Other Studies
[**2178-8-26**] Urine culture: [**Female First Name (un) **] PARAPSILOSIS. >100,000
ORGANISMS/ML..
[**2178-9-1**]. [**2178-8-31**], [**2178-8-30**] C. diff negative
[**2178-8-30**], [**2178-9-1**] and [**2178-9-2**] blood cultures: no growth to date
[**2178-8-27**], [**2178-8-24**], [**2178-8-23**], [**2178-8-21**], [**2178-8-20**], [**2178-8-19**], [**2178-8-17**],
[**2178-8-3**]: No growth
[**2178-8-30**] 9:13 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2178-8-31**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2178-9-4**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
MEROPENEM------------- =>16 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
Other studies:
[**2178-7-28**] CTA: 1. Technically limited study, with no evidence of
central pulmonary embolism though evaluation to the segmental
and subsegmental branches is limited. 2. Severe centrilobular
emphysema with new superimposed widespread airspace
consolidation involving the entire lung fields, predominantly
with most significant involvement involving the bilateral lower
lobes, for which the differential includes infectious
etiologies, hemorrhage, or edema.
[**2178-8-24**] Echo: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size is mildly increased
with free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**2178-8-20**] CT abd/pelvis w/: 1. Enlargement of the right iliacus
muscle from hematoma formation. There is no evidence for active
or arterial extravasation within this hematoma. Would recommend
clinical correlation with instrumentation of the patient's right
groin. No other hematomas identified. 2. Improved appearance but
still persistently markedly distorted lung bases with severe
emphysematous and bullous changes. Extensive subcutaneous
emphysema in the anterior chest wall, demonstrating improvement.
3. Soft tissue density material in the anterior right hemithorax
may be a small area of resolving hemothorax as there is also an
additional small locule of air on the most nondependent portion
of the right anterior hemithorax. 4. No abnormal findings in the
pancreas, gallbladder, or liver. 5. Marked colonic fecal
loading. No bowel obstruction.
[**2178-8-20**] Gallbladder U/S: No gallstones. No sludge identified on
this ultrasound. No evidence of cholecystitis and no biliary
dilatation seen.
[**2178-9-1**] BLE U/S: No evidence of DVT.
[**2178-9-2**] CT head w/o: No intracranial hemorrhage or edema.
Unchanged moderate mucosal thickening of the sphenoid sinuses.
[**2178-9-2**] Renal U/S: Markedly limited exam; no evidence of
hydronephrosis or abnormal echogenic areas to suggest the
presence of a fungus ball as questioned.
[**2178-9-8**]:
CT ABD/PELVIS Study limited due to lack of IV contrast. No large
fluid collections seen. Enlargement of the right iliacus muscle,
with similar appearance compared to prior study, likely
hematoma.
[**2178-9-10**]:
CXR: The tracheostomy tip is 7.3 cm above the carina. The
double-lumen central
venous catheter line terminates at the level of mid SVC.
Cardiomediastinal
silhouette and widespread extensive parenchymal consolidations
are grossly
unchanged with questionable minimal improvement at the level of
the left
perihilar area. Overall, the findings are more extensive than on
[**2178-9-3**], but overall unchanged since [**2178-9-6**].
Brief Hospital Course:
Brief Hospital Course:
51 y/o male with a history of severe mixed obstructive and
restrictive disease presents with hemoptysis, and hypoxic and
hypercarbic respiratory failure.
#1 Hypoxic and Hypercarbic Respiratory Failure: The initial
insult was inhalation injury from oxygen tank explosion on top
of severe underlying bullous emphysematous lung disease.
ARDsnet ventilation conducted given suspicion for [**Doctor Last Name **]. He was
empirically covered for CAP. On [**8-2**], patient developed
subcutaneous emphysema, likely due to bleb rupture. This
severely progressed into pneumomediastinum and subcutaneous
emphysema propagating down both arms and into the chest.
Improved by CXR. Continuing to follow with serial CXR. Thoracics
followed patient's care as well. Trached and peged on [**2178-8-13**].
Currently patient is on CMV assist with PSV trial today.
Receiving albuterol and Ipratroprium. Patient's home prednisone
was stopped and could be restarted once pseudomomas infection
treated and cleared.
#2 Resistant Pulmonary Pseudomonas:
The patient recently grew resistant pseudomonas on his sputum,
sensitive to tobramycin and gent only. Colistin sent to outside
lab. He is currently on tobramycin day [**9-18**] and ID is following,
redosing by level given dialysis. Has a tobramycin level
pending on discharge day and dosing will occur by torbamycin
level. Patient current on day [**9-18**] tobra course, which may be
shortened to 10 day course if pending sputum from [**2178-9-9**] is
negative for pseudomonas. Patient will need daily tobramycin
levels with goal level >2.
#3 Sedation - Patient transitioned from versed/fentanyl to
propofol with goal of trach mask. However, patient failure SBT.
The patient still had pain and anxiety with fentanyl patch and
boluc (propofol had to be d/c'd for pancreatitis picture).
Increased to fentanyl drip on [**2178-9-5**] possibly for short term
pain control [**3-9**] pancreatitis, with drip now dc'd. Currently
requiring methadone, fentanyl patch, needs more for
dressing changes with standing clonazepam for anxiety.
#4 Hypotension - likely in the setting of decreased preload with
PEEP. Was on dopamine via peripheral access. Was switched to
levophed for improved ionotropy and then slowly weaned
off.Currently off pressors, maintaining MAPS in 60s.
#5 Pancreatitis: elevated amylase/lipase on [**9-5**], likely [**3-9**]
propofol. Stopped propofol, made NPO, given pain control.
Amylas /lipase levels resolved.
.
#6 Constipation - pt had constipation, without BM for 2 weeks.
GI consulted. Pt was placed on senna, colace, lactulose, soap
suds enema, gastrografin enema, and golytely with resolution of
stool backup to R colon. patient on a standing bowel regimen
with no constipation and rectal tube in place.
#7 Persistent funguria with parapsilosis: The patient was on
fluconazole, treated him for 14 days, last day [**2178-9-11**]. He
was on amophtericin bladder washes which now dc'd given negative
urine cultures.
#8 Thrombocytopenia: etiology unknown. Decreased over last week,
down to 103 today, being monitored closely. Heparin dc'd as INR
at goal of 2.0, will continue warfarin. Will need to be
followed.
#9Atrial fibrillation: While in the MICU the patient developed
intermittent A. fib. He was rate controlled with metoprolol and
is in NSR now. Is anticoagulated on warfarin.
#10 Renal failure: Likely [**3-9**] AIN and ATN from medication and
hypotension. Getting HD on MWF. Kidneys starting to recover,
remains at risk of nephrotoxicity on tobramycin. Patient remains
off spironolactone and lasix.
#11 Acute blood loss anemia: The patient had GI bleeding,
bleeding
from his trach site, and a retroperitoneal bleed found on CT.
His heparin gtt was temporarily stopped. His goal HCT is > 28.
He was tranfused with pRBCs when necessary to maintain that
hematocrit. His hematocrits have been stable so his heparin gtt
was restarted to continue bridge to warfarin. INR now
therapeutic, heparin dc'd. Hct has been stable, still restarting
coumadin from heparin.
#12 H/O DVT: BLE U/S do not show DVT. Restarted warfarin [**9-5**].
Currently on warfarin only after being bridged with heparin.
Continuing to monitor coags.
#13 Skin breakdown: wound care consulted for trach site
ulceration
and right buttocks wounds. Care to continue per wound consult
recommendations.
# G-tube: Ulceration around g-tube site. Needs g-tube dressing
site change q2-3 weeks. Last dressing was placed [**2178-9-10**].
# Social - after discussion with brother and family pt's brother
states that pt had expressed desire to live and therefore wants
everything done. Full code.
Medications on Admission:
Citalopram 20 mg Tablet
Fluticasone 50 mcg/Actuation Spray
Furosemide 20 mg Tablet daily
Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]
Prednisone 4 mg daily
Spironolactone 25 mg Tablet daily
Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device daily
Warfarin 12.5mg daily
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
Disp:*QS MDI* Refills:*2*
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-20 Puffs Inhalation Q4H (every 4 hours).
Disp:*QS MDI* Refills:*2*
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*60 ML(s)* Refills:*2*
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*QS * Refills:*2*
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*QS * Refills:*2*
6. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day).
Disp:*300 ML(s)* Refills:*2*
7. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
Disp:*QS * Refills:*2*
8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
9. Sodium Chloride 0.9% and heparin. Flush 10 mL IV PRN line
flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline and
heparin daily and PRN.
10. Pantoprazole 40 mg PO Q24H
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*QS Patch 72 hr(s)* Refills:*2*
14. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
15. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM.
Disp:*90 Tablet(s)* Refills:*2*
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash/puritis.
Disp:*QS * Refills:*0*
18. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
21. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) Inhalation twice a day.
Disp:*QS MDI* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Inhalation Lung Injury
Hypoxic and Hypercarbic Respiratory Failure
Pseudomonas Pneumonia
Acute Renal Failure requiring Hemodialysis
Gastrointestinal Bleed
Atrial Fibrillation
Acute blood loss anemia
persistant funguria
hypotension
pancreatitis
constipation
Secondary:
COPD
Anxiety
Chronic LLE DVT
Discharge Condition:
Fair.
Afebrile, blood pressure 90s/50s by aline, heart rate 60,
oxygenation 98% on ventilator CMV PEEP 5, FiO2 40%, Tv 550, f
25.
Discharge Instructions:
You were admitted to the hospital due to very low levels of
oxygen in your blood. You need to be placed on a ventilator to
support your breathing and allow your body to get enough oxygen.
It is likely that your oxygen tank exploding damaged your lungs
and contributed to the need the ventilator. You needed a
tracheostomy and feeding tube because you have been unable to
get off the ventilator. You also developed a bad pneumonia that
is being treated with antibiotics through a special intravenous
line called a PICC. On your anticoagulation for your history of
chronic deep vein thrombosis, you developed a gastrointestinal
bleed which has resolved and you have tolerated being restarted
on your coumadin. You do have a right iliacus hematoma from this
episode. You also developed kidney failure which was treated
with dialysis while your kidneys had a chance to recover. You
are currently on day [**9-18**] of tobramycin for Pseudomonas. Your
dosage needs to be changed based on the level of tobramycin in
your blood and whether or not you receive hemodialysis.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1385**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 23**]
Date/Time:[**2178-10-13**] 2:30
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 1119**]
Date/Time:[**2178-11-24**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16998**], RN, CS Phone:[**Telephone/Fax (1) 23**]
Date/Time:[**2178-12-14**] 10:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2178-9-11**]
|
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icd9cm
|
[
[
[]
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[
"33.21",
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"96.6",
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"96.72",
"96.04",
"43.11",
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"38.91",
"33.24",
"38.95",
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] |
icd9pcs
|
[
[
[]
]
] |
35335, 35401
|
28008, 32641
|
15625, 15735
|
35752, 35885
|
19441, 27962
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37000, 37663
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18284, 18301
|
32985, 35312
|
35422, 35731
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32667, 32962
|
35909, 36977
|
18316, 18910
|
18924, 19422
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17651, 17989
|
15566, 15587
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15791, 17632
|
3780, 4122
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18011, 18098
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18114, 18268
|
4134, 8921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,106
| 104,466
|
2847
|
Discharge summary
|
report
|
Admission Date: [**2195-8-28**] Discharge Date: [**2195-9-2**]
Date of Birth: [**2120-3-18**] Sex: M
Service: MEDICINE
Allergies:
Omeprazole
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 y/o M with a history significant for COPD with 2L home O2
requirement, CHF, A-fib and recent hospitalization at [**Hospital1 18**] in
[**Month (only) 205**] for PNA and hyponatremia, from which he left AMA, who
presented to PCP the morning PTA for evaluation of vomitting and
was referred to [**Hospital1 18**] ED after labs revealed Na 111. N.B. the
patient and his wife speak primarily Italian but together are
able to provide a coherent history.
.
He is here with his wife who explains that he has "not been
himself" for the past week--low energy, no appetite. Mr.
[**Known lastname 13858**] confirms that he has not been eating much, and is
unsure why. Reports an 8-10lb weight loss over the past [**2-26**]
weeks. Admits also to cough and SOB, with "doubling" of his
home O2 requirement to be comfortable. He has also had nausea
and vomiting for two days, and also admits to thirst. Denies
fevers/chills, CP, palpitations, abdominal pain, diarrhea and
constipation.
.
Notably, during his prior admission, he presented with
hyponatremia to the mid 120??????s which corrected with 50mg
hydrocortisone x7 days. He was not discharged home on steroids.
.
On presentation to the ED VS T98 HR73 BP151/75 RR18 O2Sat100%
(FiO2 unclear). [**Name2 (NI) **] in the ED he had a CT head which was WNL,
a CXR with evidence of hyperinflation but no evidence of PNA.
Labs were significant for serum Na 111 BUN 9 Cr 0.8, urine Na
37, and Uosm 272. He was started on IVF at 125 cc/hr and also
received vancomycin 1g and levofloxaacin 750mg IV for presumed
pneumonia. Given the severity of the hyponatremia, he was
admitted to ICU for further management.
Past Medical History:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (on [**2-25**].5L O2 by NC at
home)
ATRIAL FIBRILLATION
CONGESTIVE HEART FAILURE (EF 30%), class 3
HEADACHE
TINNITUS
HYPERCHOLESTEROLEMIA
ESOPHAGITIS, REFLUX
IMPOTENCE, ORGANIC ORIGIN [**2182-10-3**]
CARDIOMYOPATHY [**2184-10-18**]. Non-infarct related cardiomyopathy,
status post dual-chamber ICD in [**2187**]
VENTRICULAR ECTOPY
BACK PAIN
GOUT
Social History:
Lives in [**Location (un) **] with wife. Denies alcohol intake and
tobacco in the past 10 years. 50py history. Has sons who live
nearby and are involved in his care.
Family History:
Denies FH of heart disease, cancer, diabetes.
Physical Exam:
Admission Physical Exam:
VS: T95.2 BP123/64 HR78 RR15 O2Sat96% on 2L NC
Gen: Cachectic, barrel-chested, pursed-lip breathing
HEENT: Dry mucus membranes, PERRL
Neck: JVD 7cm
Pulm: Poor air movement, no wheezing. Trace RLL crackles.
CV: Faint heart sounds
Abd: Soft, NT/ND. Active BS.
Extrem: B/l 1+ pitting ankle edema.
Skin: Warm and well-perfused.
.
Discharge Physical Exam:
Pertinent Results:
Admission Labs:
[**2195-8-27**] 10:54PM WBC-4.8 RBC-4.30* HGB-12.3* HCT-35.3* MCV-82#
MCH-28.7 MCHC-35.0 RDW-15.4
[**2195-8-27**] 10:54PM NEUTS-74* BANDS-2 LYMPHS-13* MONOS-7 EOS-3
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2195-8-27**] 10:54PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL ELLIPTOCY-1+
[**2195-8-27**] 10:54PM PT-17.3* PTT-39.5* INR(PT)-1.5*
[**2195-8-27**] 02:15PM UREA N-9 CREAT-0.8 SODIUM-111* POTASSIUM-3.8
CHLORIDE-68* TOTAL CO2-33* ANION GAP-14
[**2195-8-27**] 02:15PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-75
AMYLASE-84 TOT BILI-1.3
[**2195-8-27**] 10:54PM GLUCOSE-144* UREA N-10 CREAT-0.8 SODIUM-109*
POTASSIUM-4.3 CHLORIDE-67* TOTAL CO2-31 ANION GAP-15
[**2195-8-27**] 02:15PM DIGOXIN-<0.2*
[**2195-8-27**] 10:54PM CK(CPK)-84
[**2195-8-27**] 10:54PM CK-MB-4 cTropnT-<0.01
.
Microbiology:
Blood cultures ([**8-28**]): pending
.
Imaging:
CHEST, PA AND LATERAL VIEWS ([**8-28**]):
Evaluation is limited by exclusion of the right costophrenic
sulcus.
Lungs are hyperexpanded with flattened diaphragms and widening
of the AP diameter. There is relative hyperlucency of the lungs
suggesting chronic obstructive lung disease. Small left pleural
effusion is present as well as a residua of a prior infection in
LLL. Heart size is enlarged as before. There is tortuosity of
the thoracic aorta and enlargement of the pulmonary arteries.
Two leads follow a normal course from the left-sided battery
pack terminating in the expected region of the right atrium and
right ventricle. There is no overt edema.
.
CT head ([**8-28**]): IMPRESSION: No acute intracranial abnormality.
.
Discharge Labs:
[**2195-8-31**] 07:45AM BLOOD WBC-4.4 RBC-4.11* Hgb-12.2* Hct-36.0*
MCV-88 MCH-29.6 MCHC-33.8 RDW-15.5 Plt Ct-232
[**2195-9-2**] 03:20AM BLOOD PT-22.7* INR(PT)-2.1*
[**2195-9-2**] 03:20AM BLOOD Glucose-103* UreaN-21* Creat-0.9 Na-135
K-4.5 Cl-93* HCO3-39* AnGap-8
Brief Hospital Course:
75M with history significant for COPD, CHF, recent admission for
PNA and hyponatremia from which he left AMA, who presented with
hyponatremia in the setting of two days of n/v and ~1 week of
poor PO intake.
.
# Hyponatremia: The patient's history and physical exam was
consistent with volume depletion, with Na of 107. Following
hydration, the Na did not entirely correct, indicating a
possible component of SIADH secondary to COPD and recent PNA.
In addition, the patient had recently been on steroids and there
was concern for adrenal insufficiency. The final diagnosis is a
combination of dehydration, SIADH, and adrenal insufficiency.
Resolved with hydration and steroids.
.
# Adrenal Insufficiency: Per Endocrinology, recent Cosyntropin
stimulation testing revealed a mildly suppressed
hypothalamic-pituitary-adrenal axis, with a low baseline
cortisol level and an insufficient response to ACTH stimulation.
This is most likely secondary to chronic inhaled steroid
therapy, though recent treatment with Prednisone (last given on
[**2195-8-4**]) may have contributed. The presenting symptoms of
nausea, vomiting, weight loss, and hyponatremia were considered
to be partially due to this insufficiency. He was treated with
hydrocortisone at tapering doses. He was discharged with
instructions to take hydrocortisone 20 mg qam and 10 mg qpm. He
was also given a script for 100 mg im, in case he is unable to
take po doses. He will follow-up in the [**Hospital 6091**] clinic on
[**9-9**].
.
# COPD: Severe, with home O2 requirement and use of multiple
nebs. No exacerbation during this admission. During the
admission, the patient did not have an increased O2 requirement.
Home regimen continued. His oxygen saturation with ambulation
dropped to 80%, though he was not dyspneic. His serum
bicarbonate level rose to 39, though his venous pH was 7.35.
.
# A-Fib: AICD in place. Chronically on coumadin with INR 1.5 on
admission. EKG shows he is ventricularly paced, no ischemic
changes. Coumadin was continued through his stay and his INR
was therapeutic at the time of discharge. Home amiodarone and
digoxin were continued. He did have an episode of higher rates,
for which diltiazem 30 mg po q6h was started. As his HRs
remained stable during the rest of the admission, diltiazem was
stopped at the time of discharge, to avoid excessive nodal
blockade and interaction with other medications.
.
# CAD
# CHF, chronic, systolic: No sign of volume overload on exam or
CXR. His home furosemide was initially held, then restarted.
His weight at the time of discharge was 127.5 lbs. He is not on
a beta blocker. His [**Last Name (un) **] has been held recently due to relative
hypotension.
He had frequent PVCs and NSVT, including a 19 beat run of NSVT
(asymptomatic). Electrolyte levels were normal. Cardiac
biomarkers were negative. These runs were likely from
myocardial scar.
.
# Hyperlipidemia: continued statin
.
# Anemia: Hct was stable during this admission, though has been
lower recently than previously. Defer further work-up to
outpatient setting with PCP.
Medications on Admission:
1. Atorvastatin 20 mg daily
2. Colchicine 0.6 mg daily
3. Digoxin 125 mcg
4. Fluticasone-salmeterol 250/50mcg 1 whif INH [**Hospital1 **]
5. Furosemide 20 mg daily
6. Ipratropium-albuterol 18mcg/90mcg 2 puff INH QID
7. Nitroglycerin 0.3 mg SL prn
8. Pantoprazole 40 mg daily
9. Tiotropium bromide
10. Valsartan 160 mg daily
11. Warfarin 2.5 mg daily
12. Amiodarone 200mg PO daily
13. Aspirin (dose uncertain)
14. Guaifenesin prn
Discharge Medications:
1. hydrocortisone Sig: One Hundred (100) MG Intramuscular ONCE
as needed for if unable to take oral hydrocortisone for 1 doses.
Disp:*1 DOSE* Refills:*2*
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) PUFFS Inhalation four times a day as needed for shortness of
breath or wheezing.
8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation 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. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM: take
every morning.
Disp:*30 Tablet(s)* Refills:*0*
15. hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO QPM: take
10 mg every evening.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Art of Care
Discharge Diagnosis:
Hyponatremia
Adrenal insufficiency
CHF, chronic, systolic
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You were admitted with a potentially life-threatening
electrolyte abnormality (low sodium). Please take your
medications exactly as prescribed and ask your physician what to
do if you miss a dose or have to change any doses.
-Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
-You should continue to take hydrocortisone (steroid medicine),
20 mg every morning, and 10 mg every evening. If you are unable
to take this medicine by mouth, then you can inject 100 mg of
hydrocortisone in your muscle. You will be given scripts for
both. You have an appointment to see Dr. [**Last Name (STitle) **] of
Endocrinology on Wed [**9-9**], at which point adjustments to the
dose will be determined.
-You should see your primary care doctor, Dr. [**Last Name (STitle) 58**], on Mon
[**9-7**].
-Lightheadedness may be a sign that your blood pressure is too
low, and that you need more steroid medicine. If this happens,
please call Dr. [**Last Name (STitle) 58**] or Dr. [**Last Name (STitle) **].
-You should continue to use supplemental oxygen at home.
-If you develop fever, chest pain, shortness of breath,
worsening cough, lightheadedness, nausea, abdominal pain, or any
other concerning symptoms, please call Dr. [**Last Name (STitle) 58**] or go to
the emergency department.
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: MONDAY [**2195-9-7**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5080**], MD [**Telephone/Fax (1) 3329**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2195-9-9**] at 12:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2195-10-20**] at 10:30 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: TUESDAY [**2195-10-20**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"253.6",
"428.0",
"274.9",
"425.4",
"V46.2",
"427.69",
"255.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10080, 10122
|
4988, 8077
|
284, 290
|
10229, 10229
|
3031, 3031
|
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|
2572, 2619
|
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|
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|
10380, 11700
|
4700, 4965
|
2659, 2985
|
232, 246
|
318, 1964
|
3047, 4683
|
10244, 10356
|
1986, 2372
|
2388, 2556
|
3012, 3012
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,595
| 168,323
|
30014
|
Discharge summary
|
report
|
Admission Date: [**2115-7-3**] Discharge Date: [**2115-7-16**]
Date of Birth: [**2061-6-9**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Levaquin
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53 year old male with history of refractory follicular lymphoma
status post matched unrelated non-myeloablative allogenic stem
cell transplant, who is admitted from the clinic with fevers and
neutropenia. Since his last hospitalization ([**2115-5-17**] -
[**2115-5-23**]) when he was admitted with pseudomonas and MSSA
pneumonia and treated with 10 days of zosyn, he had initially
felt relatively well until several days ago. He notes that about
one week ago, he noted a worsening cough productive of green
sputum. He also notes that he has been having worsening nasal
congestion. He notes chills, generalized weakness and fatigue.
He denies nausea, vomitting and diarrhea. He notes unchanged PO
intake. He was seen in clinic on [**2115-6-26**] and was started on
augmentin for a 7 day course and despite this continued to have
the above symptoms.
.
Pt was initially seen in clinic on [**7-3**] following a 7 day course
of augmentin for his nasal congestion/productive cough. Since
his admission he was started on zosyn and vancomycin with
improvement in his symptoms until the morning of [**7-5**] when he
began having significantly increased frequency in his cough as
well as increased sputum production. He also began having
hemoptysis (states it was the color of cranberry juice) which he
had not had previously. His O2 requirement increased from nasal
cannula to a non rebreather and he was transferred to the [**Hospital Unit Name 153**]
for increasing O2 requirement. In the [**Hospital Unit Name 153**] he was noted to have
a worsening pneumonia on cx-ray and was treated with aztreonam
and zosyn for pseudomonas pneumonia. His O2 requirements have
since decreased. His counts have also come up and he is now no
longer neutropenic. He is on 4 L NC at time of transfer. He
currently feels well and denies SOB, palpitations, fevers, and
chills.
.
ROS:
No chest pain, palpitations, difficulty breathing, dyspnea on
exertion, PND, orthopnea, hemoptysis, headaches, congestion,
sore throat, difficulty swallowing. No N/V/D/C, abdominal pain.
No GU symptoms.
Past Medical History:
Oncologic History:
Patient underwent matched unrelated non-myeloablative allogenic
stem cell transplant with fludorabine and Cytoxan on [**2114-11-15**].
He was diagnosed with grade II follicular lymphoma in [**2112**] after
presenting with lymphadenopathy of the neck. His lymphoma was
resistant to multiple courses of chemotherapy, and he then
underwent transplant in [**2114**].
.
His post-transplant course was complicated by tooth abscesses
requiring extractment. While on antibiotics after extractment,
he developed rashes, which were felt to be secondary to GVHD or
drug-related. He also had several bouts of CMV viremia with
colonic involvement causing diarrhea, which improved with
Valcyte, however he had difficulty tolerating this medication
secondary to reduced cell counts. He has had repeated difficulty
with rashes, and had another skin biopsy in [**3-/2115**] that finally
confirmed GVHD of the skin. Over this time, he has been treated
with steroids and had improvement of his rashes, however again
has had recurrences of his CMV. He was most recently admitted
last month for fevers and worsening cough, work-up for which was
unrevealing.
His primary oncology team has been using PUVA treatment for this
while attempting to taper his steroids.
.
Other Past Medical History:
1. Follicular lymphoma as noted above.
2. CMV viremia, colitis
3. GVHD of skin and liver
4. Left inguinal hernia
5. Borderline positive Hepatitis B core antibody
6. Hypertension
7. Hyperglycemia while on steroids
Social History:
Patient is married and has three children. He formerly worked as
an electrician. He does not smoke or drink alcohol.
Family History:
There is no family history of lymphoma or other hematologic
diseases.
Physical Exam:
VS: T 98.3 HR 80 BP 145/85 O2 Sat 94% 4 L NC
GEN: NAD, AOX3, appears comfortable
HEENT: MM dry, OP clear
CARD: RRR, no m/r/g
PULM: Poor air movement, diffuse rales
ABD: soft, NT, mild distention, no masses
EXT: WWP, skin darkening and extreme dryness
NEURO: Grossly normal
Pertinent Results:
Lab results on admission:
[**2115-7-3**] 10:25AM PLT SMR-LOW PLT COUNT-95*
[**2115-7-3**] 10:25AM WBC-2.2*# RBC-3.49* HGB-10.6* HCT-33.5*
MCV-96 MCH-30.4 MCHC-31.6 RDW-18.1*
[**2115-7-3**] 10:25AM GLUCOSE-256* UREA N-19 CREAT-0.9 SODIUM-134
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-21* ANION GAP-18
[**2115-7-3**] 10:22PM LACTATE-2.2*
[**2115-7-3**] 04:37PM PT-12.4 PTT-27.0 INR(PT)-1.0
.
Lab results on discharge:
[**2115-7-16**] 12:00AM WBC-5.1 RBC-2.90* Hgb-8.6* Hct-27.5* MCV-95
MCH-29.7 MCHC-31.2 RDW-19.0* Plt Ct-80*
[**2115-7-15**] 12:00AM Neuts-81* Bands-2 Lymphs-15* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2115-7-16**] 12:00AM Gran Ct-3620
[**2115-7-16**] 12:00AM Glucose-152* UreaN-16 Creat-0.7 Na-136 K-3.6
Cl-102 HCO3-27 AnGap-11
[**2115-7-16**] 12:00AM ALT-34 AST-16 AlkPhos-263* TotBili-0.8
[**2115-7-16**] 12:00AM Calcium-8.6 Phos-2.5* Mg-1.7
.
CT sinuses ([**2115-7-3**]):
1. Since [**2114-12-24**], worsened paranasal sinus changes with
air-fluid levels within the left maxillary sinus and sphenoid
sinus which in the right clinical setting may represent acute
sinusitis. Worsened fluid/mucosal thickening involving the
mastoid air cells bilaterally and the left middle ear cavity.
2. There is lucency surrounding the cochlea bilaterally
consistent with otospongiosis. The differential, however, would
also include otosyphilis.
.
CT chest ([**2115-7-3**]):
Mixed interval changes, with essential resolution of lingular
abnormality and slight improvement of right basilar abnormality,
but development of new foci of ground glass attenuation within
the left lower lobe, superior segment right lower lobe and both
upper lobes. Although these findings may be due to infection,
cryptogenic organizing pneumonia and graft- versus- host disease
are additional considerations in the post-transplant setting.
.
Brief Hospital Course:
Patient is a 53 year old male with past medical history of
refractory follicular lymphoma, status post allogenic stem cell
transplant in [**10-29**] complicated by GVHD and CMV colitis,
admitted with neutropenic fever, found to have an acute MSSA and
pseudomonas sinusitis and pseudomonas pneumonia.
.
# Pneumonia: s/p bronch on last admission with pseudomonas and
MSSA pna sensitive to zosyn. On this admisison, again with
pseudomonas pna sensitive to zosyn. Also with pseudomonas and
MSSA sinusitis. Initially started on vanc and zosyn. On third
day of admission, O2 requirements increased, requiring
non-rebreather and transferred to the unit. In the unit started
on aztreonam in addition to zosyn and vanc until [**7-9**], aztreonam
discontinued with continued clinical improvement and recovery of
WBC. Transferred back out to the floor with continued clinical
improvement, and weaning of O2, deescalated antibiotics to just
zosyn for 3-5course. Prior to d/c ambulatory sat was 94% RA.
Continued PCP [**Name9 (PRE) **] with atovaquone and posaconazole.
.
# Sinusitis: With MSSA and pseudomonas sinusitis. Symptoms
improved dramatically on zosyn. Continued sinus care with NS
irrigations TID.
.
# Hyperbilirubinemia: With elevated bilirubin, with both direct
and indirect components. No lab evidence of hemolysis.
Medications reviewed without new inciting [**Doctor Last Name 360**]. GVHD flare a
possibility. Trended down without intervention.
.
# Neutropenia: Unclear etiology, possibilities include infection
and resultant marrow supression versus medication effect.
Valgancyclovir has been discontinued with negative viral load.
Counts recovered with improvement of pneumonia.
.
# Hypotension: Hypotensive on [**7-5**] to SBP 70s, requiring 4 L
volume resucitation. Started stress dose steroids given chronic
steroids for GVHD x 1 day. Resumed on maintenance dose of
prednisone. Remains normotensive.
.
# Lymphoma: On maintenance Rituxan therapy as outpatient.
- Continued prophylaxis with posaconazole, atorvaquone,acyclovir
.
# GVHD: Has known GVHD of both skin and liver. Continued home
regimen of prednisone as above. Also continued cyclosporine.
Medications on Admission:
- Augmentin 875/125 (day # 8)
- Atovaquone 1500 mg daily
- Calcitriol 0.25 mcg daily
- Clobetasol 0.05% cream [**Hospital1 **]
- Clonidine 0.1 mg [**Hospital1 **]
- Docusate sodium 100mg [**Hospital1 **]
- Neoral 50 mg [**Hospital1 **]
- Folic acid 1 mg daily
- Lamivudine 100 mg daily
- Pantoprazole 40 mg daily
- Pentamidine inhaled monthly (last dose [**2115-5-31**])
- Posaconazole 200mg/5mL TID
- Prednisone 30 mg
- Valcyte 450 mg daily
- Monthly IVIG
- Multivitamin 1 qd
- Vitamin E 400 units daily
Discharge Medications:
1. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 gm Intravenous Q6H (every 6 hours): Last dose on
[**2115-8-14**].
Disp:*qs * Refills:*0*
13. Heparin Flush 10 unit/mL Kit Sig: [**2-26**] mL Intravenous as
directed: To each lumen prn following normal saline flushes per
protocol.
Disp:*90 flushes* Refills:*2*
14. Normal Saline Flush 0.9 % Syringe Sig: [**6-1**] mL Injection as
directed: Please flush each lumen before and after each infusion
and PRN.
Disp:*90 flsuhes* Refills:*2*
15. Line Care
Please perform line care per protocol.
Please perform central line dressing changes weekly and prn.
16. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*180 Capsule(s)* Refills:*2*
18. Posaconazole 200 mg/5 mL Suspension Sig: Two Hundred (200)
mg PO TID (3 times a day).
19. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
20. Petroleum Jelly Gel Sig: One (1) application Topical
daily ().
21. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
22. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*1*
23. One Touch Basic System Kit Sig: One (1) kit
Miscellaneous three times a day: Please use glucometer to check
blood sugar TID.
Disp:*1 kit* Refills:*2*
24. Lancets Misc Sig: One (1) lancet Miscellaneous three
times a day: Please provide patient w/ compatible lancets to be
used w/ glucometer TID.
Disp:*90 lancets* Refills:*2*
25. One Touch Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] three
times a day: Please provide patient w/ compatible strips, to be
used w/ glucometer TID.
Disp:*90 strips* Refills:*2*
26. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
27. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO twice a day.
28. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day.
29. Saliva Substitution Combo No.2 Solution Sig: Thirty (30)
solution Mucous membrane four times a day.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary diagnosis:
- Pneumonia
- Acute sinusitis
Secondary diagnoses:
- Graft-versus-host disease
- Lymphoma
Discharge Condition:
O2 sat 95% on RA
CMV ([**2115-7-15**]) not detected
Discharge Instructions:
You were admitted with a severe pneumonia and sinusitis. You
were monitored in the intensive care unit for a short time for
your high oxygen requirement. You have been started on
antibiotics for treatment of your pneumonia. You will continue
taking the antibiotic (called ZOSYN) at home until [**2115-8-14**].
.
While here, you were also found to have elevated blood glucose
levels, concerning for diabetes. This may be due to your
steroids or to your infection. You were seen by [**Last Name (un) **] who
recommended starting on a medication called GLIPIZIDE to help
control your blood sugar. You will need to monitor your
fingersticks at home to make sure your blood glucose level does
not get too low. You should begin to follow a low carbohydrate,
diabetic diet to help control your fingersticks. If your
fingersticks are less than 75 or if you feel hypoglycemic, you
should call your doctor, Dr. [**Last Name (STitle) **], and discuss whether or not you
should continue taking your medication.
.
You have several new medications:
* You should continue taking the IV antibiotic (ZOSYN) until
[**2115-8-14**]
* You have also been started on GLIPIZIDE, a medication to treat
diabetes, which you should take daily.
* You should NO LONGER take VALGANCYCLOVIR. Instead, you will
take ACYCLOVIR 400mg PO three times a day until further notice
from [**Doctor First Name **] and Dr. [**First Name (STitle) **].
* You have been given an inhaler called COMBIVENT to use as
needed until you are better from your pneumonia.
* You should resume your NIFEDIPINE upon your return home.
* All your other medications are unchanged.
.
Please contact Dr. [**First Name (STitle) **], your primary care physician, [**Name10 (NameIs) **] go to
the emergency room if you experience any fever >100.0, chills,
worsening cough, difficulty breathing, chest pain, palpitations,
difficulty keeping down food or drink, diarrhea, rash or any
other concerning symptoms.
Followup Instructions:
Please follow up with:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**] (in Dr.[**Name (NI) 14047**] office) on Friday, [**2115-7-19**] at
11:30am. Please call their office if you have any questions or
concerns about this appointment.
.
Dr. [**Last Name (STitle) **] at [**Last Name (un) **] on [**2115-7-25**] at 4:430pm. Please call their office
at phone number [**Telephone/Fax (1) 2384**] if you have any questions about
this appointment.
Completed by:[**2115-7-19**]
|
[
"786.3",
"458.9",
"519.9",
"782.4",
"482.1",
"780.6",
"461.9",
"288.00",
"996.85",
"401.9",
"202.00",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12098, 12150
|
6304, 8474
|
290, 296
|
12303, 12357
|
4445, 4457
|
14349, 14844
|
4065, 4136
|
9030, 12075
|
12171, 12171
|
8500, 9007
|
12381, 14326
|
4151, 4426
|
12241, 12282
|
4865, 6281
|
247, 252
|
324, 2387
|
12190, 12220
|
4471, 4851
|
3700, 3914
|
3930, 4049
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,292
| 188,354
|
53444
|
Discharge summary
|
report
|
Admission Date: [**2121-11-3**] Discharge Date: [**2121-11-18**]
Date of Birth: [**2049-8-27**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Nsaids /
Naprosyn / Versed / Oxycodone
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
left toe pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72yo female with h/o DM2, ESRD on HD, CHF, s/p TKA,
hypothyroidism, COPD on home 2L, OSA admitted to vascular
service on [**11-3**] for mgmt of ischemic left toe ulcer transferred
to the MICU for AMS and respiratory acidosis.
.
Per family, protracted hospital course began in late [**Month (only) 216**]. At
that time hospitalized at [**Month (only) **] on [**9-23**] for "stomach bug". She was
treated for dehydration and discharged to rehab after 3d stay.
During that hospitalization note made of small pressure ulcer on
left heel, left toe. Patient was discharged to rehab were
worsening heel pain limited participation in PT. Patient
underwent I&D of left LE ulcer on [**10-17**]. At that time she was
placed on standing oxycodone 5mg Q6hr for heel pain. Per family
after initiation of meds patient noted to be "solumulent".
Increasing somulence promptped admission to [**Hospital6 **]
on [**10-21**] for AMS. At that time sats "low" BP 90/40, HR 90s T99.2.
(baseline SBPs 100s). Labs notable for CK 773, elevated
biomarkers, WBC at that time 16.5, echo 55% with pulmonary htn,
PA systolic pressure of 70mmHg. A nuclear stress showed
questionable apical ischemia, with an EF 39%. During that
admission she was noted to have ischemic LLE ulcers and a sacral
decub. MRI L food showed no osteo. Cx grew MRSA. Pt was
allegedly discharged on vanc and pain meds. Increased periods of
lethargy and hypotension were attributed to pain medications. Of
note during that hospitalization HD on 20, 21 (mri with
contrast), 22 (fluid mgmt) missed.
Patient again discharged to rehab on [**10-31**] and again found to be
somulent and unrousable with SBPs in 90s. At that time taken to
[**Month/Year (2) **]; En route to [**Name (NI) **] pt was noted to be lethargic, SBPs 80s-90s,
WBC 19.4 with 7% bandemia, MB 16.4 and trop 2.4. Pt was
determined to have NSTEMI, EKG showed low voltage. CE
downtrended. No aspirin given hx of allergy. SBPs 90s-100s. AMS
was felt to be [**3-12**] opiates.
they d/c oxycodone and started on tyl3; swabbed left heel +
MRSA, ?amptuation therefore transfered to [**Hospital1 **] for 2nd vascular
surgery opinion
.
On the vascular surgerical service patient maintained on hep
gtt; and started on vanco, flagyl and cipro. Vascular studies
obtained. No opiate medications administered. Per chart biopsy
SBPs 70s-90s. On evening of [**11-5**], gas obtained for unknown
reasons with ph 7.14, no follow interventions performed.
On morning of transfer patient noted to be more lethargic with
consistently poor VBG. Decision made to transfer to the medical
ICU for evaluation and treatment.
.
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
PTSD; childhood abuse
History of dissociative episode
Breast Cancer - Left lumpectomy and radiation
ESRD on HD
Afib
Gout
HTN,
Hypothyroidism
DM,
CHF
Osteo,
Depression
CAD
Pulm HTN
COPD
Anemia,
Hx MRSA
History GI bleed
Ischemic Colitis
carotid endarterectomy
Social History:
Widowed.
- Tobacco: h/o smoking
- Alcohol: social
- Illicits: denies
Family History:
CAD, DM
Physical Exam:
General: Arousable, occasionally following commands,
HEENT: Sclera anicteric, dry, oropharynx without gross exudates
or lesions
Neck: supple, JVP hard to discern in setting of habitus but not
grossly elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs:
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: cool, poor perfusion, thready dopplerable pulses, general
anasarca; left arm AVF with overlying bandage: good thrill and
bruit
.
Patient Deceased on [**2121-11-18**]
Pertinent Results:
CT Head:
FINDINGS: There is no evidence of intracranial hemorrhage,
edema, shift of
normally midline structures, hydrocephalus, or acute large
vascular
territorial infarction. Periventricular and subcortical white
matter
hypodensities are consistent with chronic small vessel ischemic
disease. Mild prominence of the ventricles and sulci are
consistent with age-related involutional change. Calcifications
are seen of the bilateral cavernous carotid and vertebral
arteries. Aside from minimal mucosal thickening or fluid within
the right sphenoid sinus, the visualized portions of the
paranasal sinuses are well aerated. Opacification of multiple
bilateral mastoid air cells versus congenital under
pneumatization of the mastoids is noted. Aerosolized secretions
are seen within the nasopharynx. The imaged osseous structures
are grossly unremarkable.
IMPRESSION: No acute intracranial process.
.
VENOUS DUPLEX, LOWER EXTREMITY
Duplex evaluation was performed of both greater saphenous veins.
Right
greater saphenous vein is patent with diameters of 0.16-0.48.
The left greater 0.22-0.44.
IMPRESSION: Patent bilateral greater saphenous veins with
diameters as noted. On the right, there are somewhat diminutive
features calf to ankle. On the left, diminutive features from
the knee to ankle
.
ARTERIAL DOPPLER LOWER EXTREMITY
Doppler evaluation was performed of both lower extremity
arterial systems at rest. All waveforms are monophasic at the
femoral to the dorsalis pedis
artery. Pulsed volume recordings show significant artifact
complicating the readings, but are dampened throughout, more
significantly on the left than on the right.
IMPRESSION: Somewhat difficult study due to noncompressible
vessels and
significant patient movement, but significant aortobiiliac or
proximal femoral artery occlusive disease. In addition, there is
likely severe multilevel disease, especially on the left side
with flow deficit to the ankle and forefoot.
Brief Hospital Course:
72yo female with h/o DM2, ESRD on HD, CHF, s/p TKA,
hypothyroidism, COPD on home 2L, OSA initially admitted to
vascular service on [**11-3**] for mgmt of ischemic left toe ulcer,
transferred to the MICU for AMS and respiratory acidosis. After
protracted hospital course and refractory
pain/hypotension/decreased respiratory drive she was made CMO in
MICU on [**11-15**] and she expired on [**2121-11-18**] at 12:05pm.
.
# Goals of care. Patient with protracted hospital course with
evidence of refractory hypotension, altered mental status and
chronic pain. After extensive discussion with the family, MICU
team and palliative care consultants decision made to transition
to DNI/DNR. Patient made CMO on [**11-15**]. She was treated with
Morphine drip with Q30min Morphine boluses. She expired on
[**2121-11-18**] at 12:05pm with her son and daughter at bedside. PCP
was notified and death report/certificate completed.
.
# Respiratory Acidosis. Unclear duration (acute v chronic) as
well as etiology. Little former data to compare recent findings.
In addition, dialysis dependance makes tracking HCO3 in chem
panels unreliable. However suspected this was an acute and
chronic problem in patient with known COPD. Posible etiolgies
include: depression of the central respiratory center by
cerebral disease or drugs, inability to ventilate adequately due
to neuromuscular disease (e.g., myasthenia [**Last Name (un) 2902**], AML, GBS),
severe hypothyroid, or airway obstruction related to COPD
exacerbation. Patient without e/o COPD exacerbation (no wheeze).
?med effect however no note of recent narcotic/benzos since
admission on [**11-3**]. Patient electively intubated to improve
ventilation and therefore improve acid base status. Its unclear
what caused acute decompenation. Patient has not received
narcotics in several days. ?acute central process causing
hypoventilation. Head CT without sign of acute intracranial
abnl. Decision made to aggressively remove fluid via CVVH to
optimize respiratory status. Patient extubated on [**11-11**]. Still
unable to maintain respiratory drive and on [**11-15**] was made CMO.
She expired of hypercarbic respiratory failure on [**2121-11-18**] at
12:05pm.
.
# Hypotension. Per report baseline SBPs 90s-100s. Though initial
SBPs readings unreliable; A-line placed for more accurate
monitoring. Initial A-line readings with notable hypotension
(SBPs 70-80s). Etiology: infection/sepsis vs AI vs pre-renal vs
hypothyroid. Random cortisol wnl. TFTs consistent with some
degree of thyroid dysfunction and home levothyroxine increased
being mindful of recent NSTEMI. Thought hypotension likely
reflective of underlying vasdilation in setting of infection.
Cultures returned + C.diff and imaging c/w with possible VAP
Patient increasingly difficult to wean from pressors
.
# ESRD on HD. Renal consulted. Currently underoging CVVH in the
ICY for aid in electrolyte mgmt and volume status.
.
# NSTEMI. Labs with evidence of previous cardiac insult. Unclear
if in house values represent evolving/improvement of known
NSTEMI or if is illustrating recent volume overload and demand.
TTE in house very limited however demonstrates overall nl left
ventricular systolic function without gross valvular abnl.
Patient continued on hep ggt and started on ASA as well as full
dose statin.
.
# Altered mental status. Per report patient less interactive
over preceding 24hrs. On exam patient with waxing and [**Doctor Last Name 688**]
attention as well as asteristix. ?delerium in setting of
toxic-metabolic derangement. Head CT without acute process. LFTs
wnl. No recent opioid or sedating medication exposures. Chem
panel with BUM 30, creatinine ~6. TSH elevated and T4 low.
Increased levo from 75->100mcg. Treat any potential infection
with vanc/[**Last Name (un) 2830**]. Sedating medications avoided.
.
# Ischemic left extremity/PVD. Patient with extensive PVD with
barely dopplerable bilateral LE pulses. Recent MRI without
evidence of osteo. Vascular following for mgmt of ischemic
ulcers. Patient maintained on hep ggt and statin continued. for
anti-inflammatory properties. Per vascular hep ggt discontinued
and no further intervention planned.
Medications on Admission:
Lantus 40u QD
Lactobacillus 2tabs
Levothyroxine 137mcg QD
lorazepam 0.5mg tab
Metoprolol 6.25 [**Hospital1 **]
Nephrocaps QD
Nitro SL prn
Zofran 4mg prn
pantoprazole 40mg QD
Sertaline 150mg QD
Simvastatin 40mg QD
Tiotroprium 1puff QD
Trazadibe 25mg QD prn
Vanc per HD
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypercarbic Respiratory Failure
End Stage Renal Disease
Ischemic foot ulcers
Discharge Condition:
Deceased
Discharge Instructions:
Pt deceased
Followup Instructions:
Pt deceased
|
[
"496",
"244.9",
"V66.7",
"707.15",
"707.03",
"327.23",
"276.1",
"707.22",
"410.71",
"707.14",
"V10.3",
"416.8",
"V49.86",
"008.45",
"733.00",
"276.2",
"285.21",
"038.9",
"V43.65",
"440.23",
"250.80",
"995.92",
"583.81",
"518.81",
"403.91",
"585.6",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.95",
"38.91",
"96.72",
"96.04",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10946, 10955
|
6413, 10594
|
362, 368
|
11075, 11085
|
4441, 4441
|
11145, 11160
|
3858, 3868
|
10913, 10923
|
10976, 11054
|
10620, 10890
|
11109, 11122
|
3883, 4422
|
3023, 3473
|
309, 324
|
396, 3004
|
4450, 6390
|
3495, 3755
|
3771, 3842
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,058
| 159,555
|
21318
|
Discharge summary
|
report
|
Admission Date: [**2143-4-9**] Discharge Date: [**2143-4-11**]
Date of Birth: [**2087-7-1**] Sex: M
Service: NEUROLOGY
Allergies:
Ativan
Attending:[**First Name3 (LF) 11344**]
Chief Complaint:
Seizure and hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 55 M w/ hx GM seizures (followed by [**Hospital1 2025**] seizure service
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] at [**Hospital1 18**]), OSA, mental retardation p/w
typical seizure at home [**4-8**] at night and was taken to [**Location (un) 620**].
History is obtained from mother and chart. Per the mother the
patient has been well as of late. No recent complaints of
fevers, chills, nausea, vomiting, diarrhea. He has been eating
well and taking his meds as instructed. This AM his mother heard
his foot banging against the wall and found him seizing with
eyes deviated to the right. His last seizure was about 4 months
ago. She called EMS. En route to [**Location (un) 620**], he was given valium
10mg, this aborted the seizure. He got an additional 5mg of
valium at [**Location (un) 620**]. On presentation to [**Location (un) 620**], was hypotensive
to SBP 90's and peripheral dopamine was initiated and also found
to have a trop of 0.4. He was transferred to [**Hospital1 18**] for further
care. In [**Hospital1 18**] ED, still required dopamine. Also found to have
CHF on CXR, ? bilateral opacities, and was given levofloxain for
possible PNA.
.
On arrival to the MICU he was quite agitated. Asking the staff
to leave him alone. Denied any specific pain at this time.
Past Medical History:
1. seizures since age 4 years
2. h/o meningitis as an infant
3. OSA
4. mental retardation
5. hyponatremia, baseline serum sodium ranges 128-133
6. s/p transoral biopsy of right anterior tonsillar pillar ulcer
in [**12-25**]; pathology consistent with acute and chronic
inflammation
Social History:
The pt lives in a group home. He smokes one pack of cigarettes
per day x roughly 30 years. There is no history of alcohol or
illicit drug use.
Family History:
No other family members with seizures.
Physical Exam:
T 96.1 BP 97/76 HR 98 RR 18 O2sats 100% RA
Gen: Agitated, not answering questions or following directions
Heent: PERRL, anicteric, mmm
Neck: EJ on right side, no obvious JVD
Heart: RRR, no m/r/g
Lungs: Decreased breath sounds at the bases with faint crackles,
otherwise good air movement
Abd: Soft, NT, ND + BS, no HSM
Ext: No edema, extremities are warm with 1+ DP/PT pulses
Neuro: Currently lethargic and unable to do exam as patient not
following commands. He does move all 4 extremities to pain.
Pertinent Results:
Chest X-ray on [**2143-4-9**]:
SINGLE AP UPRIGHT BEDSIDE CHEST RADIOGRAPH: There has been
resolution of mild interstitial edema, however bibasilar
consolidations persist and are
suspicious for pneumonia. No sizeable pleural effusions and no
pneumothorax seen. Cardiac, mediastinal, and hilar contours are
normal.
IMPRESSION: Improved volume status. Persistent bibasilar
opacities
are concerning for pneumonia.
Echocardiogram on [**2143-4-9**]:
Conclusions:
The left atrium is normal in size. A 2x1.5cm echogenic "mass" is
seen within the wall of the right atrium c/w ? Hematoma vs.
intramural thrombus. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
There is moderate regional left ventricular systolic
dysfunction with severe hypokinesis/near akinesis of the
inferior, inferolateral and anterolateral walls. The remaining
segments contract well. No masses or thrombi are seen in the
left ventricle. Transmitral and tissue Doppler imaging suggests
normal diastolic function, and a normal left ventricular
filling pressure (PCWP<12mmHg). There is focal basal right
ventricular free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Left ventricular cavity enlargement with extensive
regional left and right ventricular systolic dysfunction
suggestive of multivessel coronary artery disease. Right atrial
wall thickening as described above. If clinically indicated, a
chest CT may be able to better derine the abnormality of the
right atrial free wall.
Brief Hospital Course:
55 year-old male with history of mental retardation, grand mal
seizures who presented with typical seizure, hypotension and
elevated troponin.
.
# Hypotension - Patient's normal systolic blood pressure around
120's. Presented to outside hospital with seizure, given valium
and then noted to be hypotensive requiring dopamine. Also noted
to have troponin leak of 0.4 and possible new CHF on CXR. Here,
ECHO showed evidence of global cardiac hypokinesis. Decreased EF
potentially contributing. Less likely ACS with downtrending
enzymes, asymptomatic, minimal ECG changes. Potential infectious
contribution with evidence of pneumonia on chest x-ray. Also
potentially adrenally insufficient. However, lactate normal and
patient making excellent UOP (actually negative since
admission). Hypotension could be due to excessive UOP from DI,
central salt wasting. Patient was successfully weaned off
dopamine drip. Patient has low sodium but is high for his
normal range. No signs of bleeding and Hct stable. Patient
mentating well. He was given IVF boluses with goal of keeping
euglycemic. Patient was continued on Ceftriaxone and Clindamycin
for 14 day course to cover for pneumonia. No growth to date on
blood cultures and negative urine cultures x2. Most likely
etiology of his hypotension from PO valium given for his
seizures given rapid resolution and negative lactate.
.
# Troponin leak - Pt with no recent chest pain, but had non
specific TW flattening in the lateral leads. Both CPK and trop
were elevated initially but CPKs could be elevated in setting of
seizure and all enzymes now trending down. Troponin leak likely
due to catecholamine [**Doctor First Name **] in setting of prolonged seizure,
although literature not consistent w/ troponin elevation in
seizure. Mother [**Name (NI) 382**] declined central line and cardiac
catherization at this time. Per cardiology, held off on heparin
gtt or lovenox given downtrending cardiac enzymes. Patient was
continued on aspirin and plavix was discontinued. Followed
serial EKGs. Patient will follow-up with Cardiology as an
outpatient and get an outpatient ECHO in [**4-26**] weeks and a cardiac
MRI. He was also instructed to avoid QT prolonging medications
as this interval was borderline high on this admission. Given
his depressed ejection fraction of 35% he would also likely
benefit from initiation of a beta blocker or ACE inhibitor once
he is further out from this episode of hypotension.
.
# pneumonia: patient had evidence of pneumonia on CXR. Afebrile
but elevated WBC. Potentially secondary to aspiration during
seizure vs. prior aspiration event. Initially started on
levo/flagyl now stopped because both lower seizure threshold.
Continued ceftriaxone and clindamycin as above. Followed up
sputum/blood cultures.
.
# [**Name (NI) **] Pt with stable anti-epileptic regimen. Per discussion
with his mother as been taking his meds as prescribed. Given
extra dose of dilantin with low level yesterday. Neurology
evaluated and notes that patient at baseline. This am dilantin
and depakote levels in ideal range. Continued dilantin and
depakote. Diazepam PRN for seizures. Magnesium repletion
keeping >2. Follow-up appointment with his outpatient
neurologist was scheduled.
.
# [**Name (NI) 4964**] Pt with volume overload on initial CXR per radiology
however BNP <5 and repeat CXR had no further evidence of CHF
despite decreased EF on ECHO. Satting well on room air at 99%.
Well compensated currently. If needed can give lasix but held
for now. Will need to follow weight as an outpatient and
reassess in follow-up regarding ability to maintain fluid
balance. Advised a low sodium diet (2g) at discharge.
.
# Atrial mural mass: unclear etiology at this time. Patient was
scheduled for an outpatient cardiac MRI and repeat surface
echocardiogram in [**4-26**] weeks. He will follow-up with Cardiology
as an outpatient.
.
# Hyponatremia- Has chronic hyponatremia in the range of
128-133. Currently stable at baseline. Continued salt tabs.
.
# FEN- regular diet. Continued CaCO3, Folate, vit D, B complex,
Mag. Give additional Mgoxide to keep >2.0.
.
# PPx- Heparin SC. No indication for PPI. PT/OT were asked to
consult patient for home safety and possible outpatient therapy.
.
# Access- Right EJ, PIV. Declined central line.
.
# Code- FULL
Medications on Admission:
-Depakote 1500mg po TID
-Dilantin 100 mg/100 mg/200 mg
-Folate 1mg po BID
-NaCl 2g po TID
-Magnesium 400mg po BID
-Calcium 1250mg po qday
-vitamin B complex
Discharge Medications:
1. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day): give at 8am and 11am *Brand name only*.
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO DAILY AT 9PM (): give at 9pm. *Brand Name Only*.
4. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO TID (3
times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: 2.5 Tablet,
Chewables PO DAILY (Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 8 days: until [**4-19**].
Disp:*64 Capsule(s)* Refills:*0*
13. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 13 days.
Disp:*26 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnoses:
Hypotension
Tonic-clonic seizure
Likely Aspiration pneumonia
Troponin leak (Peak CK 304 Tnt 0.73)
Right atrial mural mass
Secondary diagnoses:
Mental retardation
Obstructive sleep apnea
Chronic hyponatremia (b/l 128-133)
Chronic tonsillitis
Discharge Condition:
Good
Discharge Instructions:
Please take medications as prescribed. Please check with your
primary care physician before starting any new medications as
your QT interval was borderline prolonged. You will also need
to be eventually started on either a beta blocker or an ACE
inhibitor due to your depressed left ventricular ejection
fraction (35%).
Please keep your follow-up appointments.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Attempt to adhere to 2 gm (low) sodium diet.
If you have any prolonged, frequent or tonic-clonic seizures or
any other worrying symptoms, please call your primary care
phyisican Dr. [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 19980**]) or return to the
emergency room.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (Cardiology) Phone: [**Telephone/Fax (1) 2934**]
Date/Time: [**2143-5-15**] 3:00
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2143-6-7**] 11:30
Provider: [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 19980**]
Date/Phone: [**2143-5-13**] 10:45
Fax: [**Telephone/Fax (1) 19981**]
Cardiac MRI Phone: [**Telephone/Fax (1) 9559**]
We have ordered this exam. They will contact you with a place
and time once this order has been processed.
Echocardiogram Phone: [**Telephone/Fax (1) 128**]
Date/Time: [**2143-5-8**] 11:00
Location: [**Hospital Ward Name 23**] [**Location (un) **]
Completed by:[**2143-4-15**]
|
[
"327.23",
"276.1",
"345.10",
"428.0",
"507.0",
"458.9",
"429.9",
"317"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10305, 10354
|
4525, 8844
|
291, 298
|
10659, 10666
|
2710, 4502
|
11472, 12311
|
2134, 2174
|
9052, 10282
|
10375, 10517
|
8870, 9029
|
10690, 11449
|
2189, 2691
|
10538, 10638
|
228, 253
|
326, 1649
|
1671, 1955
|
1971, 2118
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,202
| 119,174
|
46214
|
Discharge summary
|
report
|
Admission Date: [**2132-1-5**] Discharge Date: [**2132-2-4**]
Date of Birth: [**2045-12-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 25518**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
arthrocentesis
thoracentesis
picc line placement
History of Present Illness:
86 y/o female with longstanding hypertension, CAD, known
mild-moderate mitral regurgitation, CKD, paroxysmal atrial
fibrillation, h/o CVA with left-sided hemiparesis, OA requiring
opioids, and known MRSA colonization who presented to [**Hospital 6451**] Hospital from rehab with high-grade fevers. The
patient was recently discharged from [**Hospital3 417**] with a CVA
in the setting of uncontrolled hypertension and acute on chronic
renal insufficiency. The night before she was returned to [**Hospital 6451**] she was found to have a temperature of 103. She denied
any nausea, vomiting, dysuria, cough or sputum production. She
further denied any headache or vision changes. She was sent back
to [**Hospital3 417**] the following day when she was continuing to
have persistent fevers. The admitting physician further noted
that the patient did not have have a Foley catheter or any
peripheral or central lines.
On presentation the patient was febrile to > 102F, had a WBC
count of 13.7, PMNs 82%, and bands 12%. The patient was started
empirically on Vancomycin and Oxacillin. Her initial blood
cultures grew out MRSA. ID was consulted and suggested that she
be switched from Oxacillin to Linezolid as a prior culture had a
MIC > 1 for Vancomycin. A TTE was performed and did not reveal
any vegetations but did reveal moderate MR. [**First Name (Titles) **] [**Last Name (Titles) **] which
normally run high were in the 70s. The patient was aggressively
volume resuscitated (the exact amt is unclear) and her pressures
improved. She developed atrial fibrillation with RVR. She was
tried on a Diltiazem drip but become hypotensive. She was then
loaded with Digoxin and her heart rate improved. At some point
during her hospitalization, she was noted to have a swollen left
knee. An arthrocentesis was performed showing high WBC count and
cultures grew out GPCs.
The patient rapidly improved over 72 hours and her family
requested transfer to [**Hospital1 18**] under the care of Dr. [**Last Name (STitle) 13114**]. Her VS
at transfer were: 98.5, 153/86, 86, 18, 96% on 1L.
On arrival to [**Hospital1 18**], the patient was complaining of back pain
and SOB. Her initial VS were 98-148/65-88-22-96%/3L. The patient
had minimal end expiratory wheezing and decreased BS at the left
base. A CXR revealed pulmonary edema and cardiomegaly.
Review of systems: otherwise negative.
Past Medical History:
1. Coronary Artery Disease
2. Paroxysmal Atrial Fibrillation
3. h/o CVA (right frontotemporal with left-sided hemiparesis)
4. Hyperlipidemia
5. Hypertension with hypertensive heart disease
5b. Mitral regurgitation
6. Gout
7. Diabetes
8. Chronic MRSA Colonization
9. CKD (with AOCKD during a recent hospitalization in the
setting of contrast and volume depletion)
Social History:
Born in [**Country 2045**] but later moved to the U.S. Used to live at home
with her daughter but was recently transitioned to rehab. No
prior alcohol of tobacco use
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Her mother died at 80 y/o age from unknown causes. Father died
before the patient was born of unknown causes.
Physical Exam:
VS: T=97.4 BP=95/49 HR=58-64 RR= 16-20 O2 sat=100% on CPAP
GENERAL: NAD. Nonresponsive. CPAP in place.
HEENT: NCAT. Sclera anicteric. pinpoint, non responsive pupils
bilaterally. Equal pupils. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. No xanthalesma.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Soft apical holosystolic murmer inside
left anterior axillary line. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles. Left pigtail
in place in back of the chest draining yellow serous fluid.
ABDOMEN: Soft, ND.
EXTREMITIES: Cool. Radial pulses bilaterally 2+. DP pulses
bilaterally difficult to palpate.
Pertinent Results:
Labs on Admission:
[**2132-1-5**] 09:20PM WBC-10.9 RBC-3.37* HGB-9.5* HCT-28.0* MCV-83
MCH-28.2 MCHC-33.9 RDW-13.3
[**2132-1-5**] 09:20PM NEUTS-89.3* LYMPHS-7.4* MONOS-3.0 EOS-0.2
BASOS-0.1
[**2132-1-5**] 09:20PM PLT COUNT-209
[**2132-1-5**] 09:20PM PT-11.8 PTT-45.3* INR(PT)-1.0
[**2132-1-5**] 07:25PM CK(CPK)-47
[**2132-1-5**] 07:25PM CK-MB-2 cTropnT-0.06*
[**2132-1-5**] 09:20PM GLUCOSE-155* UREA N-26* CREAT-1.3* SODIUM-138
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15
Microbiology:
blood cultures: [**1-5**], [**1-6**], [**1-7**], [**1-8**]: staph aureus
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
blood cx: [**1-9**], [**1-10**], [**1-12**]: NGTD
L knee fluid: [**1-7**]
GRAM STAIN (Final [**2132-1-7**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2132-1-10**]): NO GROWTH.
pleural fluid: [**1-12**]
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
Imaging:
MRI L spine: [**1-7**]
1. Mild STIR hyperintensity of L3-L4 to L5-S1 intervertebral
discs with mild endplate STIR hyperintensity along the adjoining
endplates of L3-L4, L4-L5 and L5-S1 vertebrae. These likely
represent degenerative changes. However, if there is continued
clinical concern for infection, nuclear medicine scan or follow
up imaging after correlation with labs such as ESR is advised.
2. Degenerative changes of the lumbar spine, most notable at
L4-L5 level where there is moderate spinal canal and moderate
bilateral neural foraminal stenosis.
3. No abnormal enhancement in the lower cord or soft tissues.
CT torso: [**1-8**]
1. No CT evidence for abscess. Of note, in the absence of
intravenous
contrast, a small abscess could go undetected.
2. Enlarged pulmonary arteries, suggestive of pulmonary
hypertension.
3. Left pleural effusion with adjacent atelectasis.
4. 14-mm mediastinal lymph node.
Echo: [**1-9**]
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Left ventricular function
is globally normal. Cannot exclude focal wall motion
abnormality. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve, but cannot be fully excluded due to suboptimal
image quality. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is a probable vegetation on the mitral valve at
the base of the posterior leaflet, best seen in the parasternal
views (clips 2,4). An eccentric, anteriorly directed jet of
moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a very small pericardial
effusion. The effusion appears circumferential.
IMPRESSION: Possible vegetation on posterior mitral valve
leaflet. Dense mitral annular calcification which obscures views
of mitral valve. Moderate-to-severe anteriorly directed mitral
regurgitation. Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Moderate
tricuspid regurgitation. Moderate pulmonary hypertension.
***LJS Comment: 1-1.5-CM vegetation at the annular attachment of
the central scallop of the posterior mitral leaflet***
CXR: lateral decubitus [**1-13**]
There is a very small layering pleural effusion, which likely is
not of substantial clinical significance, especially when
correlated with a chest CT of [**2132-1-8**]. The heart remains
enlarged and limits evaluation of the left lung base.
CXR: [**1-15**]
1. No pneumothorax.
2. Pulmonary edema is either unchanged or slightly worse
compared to study
done three hours earlier. Study limited due to patient motion.
Brief Hospital Course:
86 y/o female with CAD, h/o CVA, atrial fibrillation transferred
from an outside hospital with high-grade MRSA bacteremia, septic
arthritis and found to have mitral valve endocarditis with
severe mitral regurgitation. Hospital course complicated by
progressive dyspnea requiring transfer to the ICU. Based on
poor prognosis with inability to tolerate worsened MR and
multiple medical comorbities, the family decided to withdraw
care and make patient comfort measures only. After patient left
the ICU on [**1-15**], her clinically status initially began to
improve and antibiotics were continued along with fluid bolusing
and diuresis. However, she again began to decline and
comfort-focused care was reinitiated. Her family was available
to her at bedside at almost every moment of the day and night
including her daughter and HCP, [**Name (NI) **], 2 grandsons,
grand-daughter, cousin and church family/friends. [**Name (NI) **] daughter
made the decision to transition her to the hospice service.
Patient died the night of [**2132-2-3**] and her family was notified.
# mitral valve MRSA endocarditis: transferred from an OSH with
high grade MRSA bacteremia with septic left knee from unclear
source. Despite treatment with therapeutic vancomycin, patient
continued to have fevers and blood cultures positive for MRSA
from [**1-5**] - [**1-9**]. Repeat (initial study performed at OSH) TTE
on [**1-9**] showed likely mitral valve endocarditis with worsening
of underlying mitral regurgitation. As patient complained of
persistent lumbar pain and intermittent abdominal discomfort,
she underwent a CT torso and MRI spine which showed no evidence
of septic emboli. She also underwent repeat left knee
arthrocentesis on [**1-7**] which showed +PMNs but negative culture
(see below). On [**1-15**], she underwent diagnostic and therapeutic
thoracentesis with no evidence of empyema but +PMNs. Once blood
cultures had sterilized and patient had been afebrile for >
24hrs, picc was placed with plan for 6+ weeks of antibiotic
treatment with vancomycin as dictated by infectious disease
team. Unfortunately patient did not tolerate severe MR and
developed cardiogenic shock. She was then transitioned to
comfort-focused care and thus antibitoics were stopped.
# Dyspnea: Hospital course was marked by recurrent subjective
dyspnea and tachypnea, becoming more persistent towards end of
hospital course. Etiology was felt to be due primarily to
pulmonary edema secondary to worsened mitral valve
regurgitation. However, patient splinting, atelectasis and left
sided pleural effusion were all likely contributors to
underlying respiratory distress. For management of pulmonary
edema, patient initially managed with lasix bolus prn to
maintain urine output goal of -1L/day with adequate HR control/
afterload reduction to maintain cardiac output. Patient was
found to have more frequent episodes of flash pulmonary edema
marked by tachypnea, wheeze and severe anxiety. These episodes
were managed with ativan, morphine and lasix boluses with
temporary response. On [**1-15**], patient underwent thoracentesis
with pigtail catheter placement with approximately 400cc serous
straw-colored fluid removed. Respiratory status continued to
deteriorate despite interventions and on the afternoon of [**1-15**]
patient again had an episode of respiratory distress. CXR at the
time showed worsened edema and no evidence of pneumothorax.
Patient was transferred to the ICU for initiation of NIPPV.
Based on subsequent conversations with the family, decision was
made to remove BiPAP and focus on comfort measures onl.
#. acute on chronic kidney injury: presented with increase in
creatinine due to prerenal azotemia versus septic shock vs
medication nepjrotoxicity vs septic emboli from staph
endocarditis. Initially, renal function stabilized at 1.3-1.5,
however with worsening hemodynamic instability and progressive
diuretic requirements to manage pulmonary edema, acute kidney
injury worsened.
#. septic knee: Patient s/p arthrocentesis at [**Hospital3 417**]
Hospital with culture revealing GPCs, most likely MRSA. Repeat
arthrocentesis by orthopedics [**1-7**] showed persistent PMNs but
negative culture. Orthopedics was consulted and recommended
conservative therapy with antibiotics.
#. Atrial Fibrillation: presented with afib with RVR not on
coumadin per PCP. [**Name10 (NameIs) 98251**] was uptitrated to 8mg [**Hospital1 **] and with
treatment of underlying infection, patient initially returned to
[**Location 213**] sinus rhythm however had return of atrial fibrillation
with RVR later in admission.
#. CAD: had troponin leak on hospitalization but stabilized.
#. OA with Chronic Pain: Patient transferred with (reportedly
Fentanyl, though none found) and Lidocaine patches in place.
Patient also required Percocet PRN. MRI negative for abscess/
discitis. She was transitioned to morphine drip as
comfort-focused care was initiated.
#. Diabetes: Humalog ISS initially.
#. Hypertension: Patient's lisinopril and amlodipine were held
given use of [**Location **], which was also eventually stopped as care
was focused on comfort.
#. Hyperlipidemia: Initially continued Simvastatin.
Medications on Admission:
1. Acetaminophen
2. Amlodipine 5 mg PO daily
3. Clopidogrel 75 mg PO daily
4. Docusate sodium 100 mg PO BID
5. Fentanyl patch
6. Lidocaine patch 1 patch daily
7. Simvastatin 40 mg PO QD
8. [**Location 98251**] 40 mg PO BID
9. Trazodone 25 mg PO QHS PRN insomnia
10. Lisinopril 5 mg PO daily
11. Insulin Sliding Scale
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
MRSA bacteremia
Secondary:
1. Coronary Artery Disease
2. Paroxysmal Atrial Fibrillation
3. h/o CVA (right frontotemporal with left-sided hemiparesis)
4. Hyperlipidemia
5. Uncontrolled Hypertension
6. Gout
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
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"584.9",
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"V49.86",
"414.01",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.97",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
14691, 14700
|
9085, 14292
|
309, 359
|
14959, 14969
|
4373, 4378
|
15025, 15036
|
3352, 3579
|
14659, 14668
|
14721, 14938
|
14318, 14636
|
14993, 15002
|
3594, 4354
|
2745, 2767
|
264, 271
|
387, 2726
|
4393, 9062
|
2789, 3153
|
3169, 3336
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,069
| 181,968
|
25260+57414
|
Discharge summary
|
report+addendum
|
Unit No: [**Numeric Identifier 63236**]
Admission Date: [**2136-10-2**]
Discharge Date: [**2136-10-25**]
Date of Birth: [**2057-11-28**]
Sex: M
Service: VSU
CHIEF COMPLAINT: Left carotid stenosis.
HISTORY OF PRESENT ILLNESS: This is a 78 year-old gentleman
who was initially evaluated for carotid stenosis for
potential carotid stenosis for potential carotid stenting but
he was not a candidate for stenting. He would require a left
carotid endarterectomy. The patient is now admitted for a
left carotid endarterectomy. The patient's previous history
is significant for a parietal stroke in [**Month (only) 216**] of this year
from which he fully recovered.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Xanax 1 mg at bedtime, Lasix 40 mg
daily, Coreg 3.125 mg b.i.d., Bilan 80 mg q.d., Coumadin 5 mg
q.d. which had been held for 4 days.
PAST ILLNESSES: Includes left parietal cerebrovascular
accident in [**2136-8-20**], a history of chronic atrial
fibrillation, anticoagulated. History of coronary artery
disease, status post coronary angioplasty of the right
coronary artery in [**2134**], history of congestive heart failure
compensated in [**2135**]. History of type 2 diabetes. History of
left vocal cord cancer, status post resection in [**2133-8-20**], History of squamous cell carcinoma of the left thorax
and leg, status post excision, history of Factory D Leiden
deficiency. History of hypertension.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) **] admits to 3 drinks per day and is a former tobacco
user. Has not smoked since [**2126**].
PHYSICAL EXAMINATION: Vital signs: Blood pressure 122/59,
heart rate 80, respirations 16, O2 saturation 95% on room
air. General appearance: This is a white male in no acute
distress and oriented x3. Head, eyes, ears, nose and throat
examination was remarkable for left carotid bruit. Heart is
irregular-irregular rhythm with a I/VI systolic ejection
murmur. Lungs are clear to auscultation bilaterally.
Neurological examination is intact.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2136-10-2**]. He underwent
a left carotid endarterectomy without complication and was
transferred to the post anesthesia care unit in stable
condition. Patient developed atrial fibrillation and
bradycardia requiring Neo-Synephrine support. His rule out
was negative. The patient developed on [**2136-10-4**] at
about 3 A.M. in the morning mental status changes associated
with hypoxia with a pCO2 of 80 and CO2 of 67. The chest x-ray
showed possible [**Location (un) 22533**] hump. The patient was begun on IV
heparin. CTA was obtained which showed a left lower lobe
pulmonary embolus. Patient became aphasic with right sided
flaccidness. The heparin was discontinued. CTA of the head
was obtained which showed a large hemorrhagic stroke. He was
given 2 units of fresh frozen plasma and a unit of platelets.
He required Neo-Synephrine and dobutamine for blood pressure
control. Neurosurgery was consulted. The patient was begun on
a Dilantin load and he underwent on [**10-5**] a left
parietal frontal craniotomy with evacuation of hemorrhage.
Intraoperatively the patient experienced asystole but was
resuscitated. Inferior vena cava filter was placed. Because
of history of atrial fibrillation the patient was admitted to
the thoracic Intensive Care Unit for continued care. The
patient continued on a prednisone taper. He developed
transient thrombocytopenia. His heparin dependent antibodies
were negative. EPS was consulted secondary to the patient's
atrial fibrillation and bradycardia. They felt that a
pacemaker was not indicated at this time although external
pacemaker leads were applied. A nasogastric tube was placed
on [**10-6**] and tube feeds were begun. The patient was
noted to have a left neck hematoma which was stable. A
[**10-7**] a CPAP was tried. The patient failed. The
patient was begun on Zosyn for gram negative rods in his
sputum culture and a right lower lobe infiltrate on chest x-
ray. White count at that time was 7.4. Levofloxacin was added
on [**10-9**] to his Zosyn for broader pseudomonas coverage
in his sputum. On [**10-10**] the patient was finally
extubated. A swallowing study was done at the bedside. The
patient did show signs of aspiration with delayed swallowing.
The study was terminated because of concern for respiratory
compromise and the patient remained n.p.o. on tube feeds. On
[**10-11**] the patient self discontinued his tube feed and
his arterial line. The Dobhoff was replaced. IV
heparinization was started slowly. On [**10-13**] the
patient was transferred to the vascular Intensive Care Unit
for continued monitoring and care. Physical therapy and
occupational therapy evaluations were begun. On [**10-15**]
the patient desaturated to an O2 of 59%. He was transferred
to the Intensive Care Unit. He required IV Lasix and
Lopressor for rate control. And nebulizers and aggressive
pulmonary care. On [**10-16**] patient remained in the
Intensive Care Unit. Stool for C difficile was sent and
patient's stool was positive and patient was started on
[**Month (only) 63237**]. On [**10-17**] a repeat swallow was attempted but
held secondary to the patient being n.p.o. for a PEG
placement.
On [**9-21**] the patient underwent endoscopic percutaneous
gastric tube placement. The patient continued to do well,
tolerated his tube feeds. On [**10-21**] patient was
transferred to the vascular intensive care unit for continued
monitoring and care. On [**2136-10-23**] physical therapy
continued to work with the patient. IV heparin and
Coumadinization conversion was continued. Renal screening was
begun. The patient will be discharged to rehabilitation when
he is in a steady therapeutic INR state of 2 to 3.0. The
patient will follow up with Dr. [**Last Name (STitle) **] as directed post
discharge from rehabilitation. He should follow up with his
primary care physician.
MEDICATIONS AT TIME OF DISCHARGE: Artificial tear ointment
.1% p.r.n. as needed, eye drops 1.4/0.6% 1 to 2 drops o.u.
p.r.n., econazole nitrate 2% powder to effected area p.r.n.,
aspirin 81 mg, alrestatin 20 mg q.d., albuterol sulfate
solution inhaled q 6 hours as needed, Lasix 40 mg q.d.,
Valsartan 80 mg q.d., rosiglitazone 4 mg daily, alprazolam 1
mg at bedtime, Carbatrol 3.125 mg b.i.d., vitamin E capsule 1
daily, Ventolin 200 mg t.i.d., warfarin 5 mg at h.s. for a
goal INR of 2.0 to 3.0. Regular Humulin insulin q 6 hours as
follows: Glucoses less than 120, no insulin; 121 to 140 - 4
units; 141 to 160 - 7 units; 161 to 180 - 10 units; 181 to
200 - 13 units; 201 to 220 - 16 units; 221 to 140 - 19 units;
241 to 260 - 22 units; 261 to 280 - 25 units; 281 to 300 - 28
units; 301 to 320 - 31 units; greater than 320 - notify
physician. [**Name Initial (NameIs) 63237**] 500 mg t.i.d. for a total of 7 more days.
DISCHARGE DIAGNOSES: Carotid artery stenosis, left with
known parietal cerebrovascular accident in [**2136-8-20**].
Postoperative atrial fibrillation, bradycardia requiring
vasopressor support, resolved.
Postoperative hypoxia with mental status changes.
Pulmonary embolus of the left lower lobe on [**2136-10-4**].
Left parietal frontal hemorrhagic stroke on [**2136-10-4**].
Postoperative thrombocytopenia, transient with negative HIT
panel.
Postoperative pseudomonas pneumonia, treated.
Postoperative aspiration by evaluation.
Postoperative left neck hematoma, stable.
SURGERIES: Included left carotid endarterectomy on [**2136-10-2**].
Left parietal frontal craniotomy with evacuation of
hemorrhage on [**2136-10-4**].
Endoscopic PEG placement on [**2136-10-18**].
Patient's INRs should be monitored closely while he remains
on [**Year (4 digits) 63237**]. Goal INR is 2.0 to 3.0. Coumadin dosing should be
adjusted accordingly. Patient should follow up with Dr.
[**Last Name (STitle) **] post rehabilitation. Patient will continue on
his tube feeds of Respalor full strength with a goal rate of
60 cc per hour. Residual should be checked q 4 hours and held
if residual greater than 100 cc. Patient will remain strict
n.p.o. All medications should be given through nasogastric
tube. Patient should be evaluated at rehabilitation as he
neurologically progresses for possibility of reinstituting
oral feeds.
Patient's activity level is bed rest to chair.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2136-10-23**] 12:01:42
T: [**2136-10-23**] 13:41:24
Job#: [**Job Number 63238**]
Name: [**Known lastname 193**],[**Known firstname 33**] Unit No: [**Numeric Identifier 11201**]
Admission Date: [**2136-10-2**] Discharge Date: [**2136-10-29**]
Date of Birth: [**2057-11-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 726**]
Addendum:
[**2136-10-29**] Patient remained in hospital perfamily request and
discussion with Dr. [**Last Name (STitle) **]. He has conmpleted his
antibiotics course.Will d/c on 7.5 coumadin qHs. Continue to
moniter inr.dialy until patient in steady thearpeutic state.
goal 2.0-3.0. Patient can followup with Dr. [**Last Name (STitle) **] when
d/c'd from rehab. call for appointment [**Telephone/Fax (1) 11071**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**]
Completed by:[**2136-10-29**]
|
[
"433.10",
"415.11",
"431",
"482.1",
"427.31",
"997.02",
"496",
"997.3",
"997.1",
"998.12",
"507.0",
"008.45",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"38.7",
"43.11",
"86.04",
"96.72",
"96.6",
"96.04",
"38.12"
] |
icd9pcs
|
[
[
[]
]
] |
9445, 9674
|
6914, 9422
|
733, 1443
|
2076, 6892
|
1639, 2058
|
181, 205
|
234, 706
|
1460, 1616
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,493
| 109,078
|
41121
|
Discharge summary
|
report
|
Admission Date: [**2149-5-7**] Discharge Date: [**2149-5-9**]
Date of Birth: [**2068-8-4**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
radiofrequency ablation
hypertension
Major Surgical or Invasive Procedure:
radiofrequency ablation [**2149-5-7**]
History of Present Illness:
Mrs. [**Last Name (STitle) **] is a pleasant 80yoF with a history of carcinoid s/p
ilial resection and now radio-frequency ablation of a known
liver metastasis, depression, OSA, hypothyroidism, breast cancer
s/p resection/radiation, who is admitted to the ICU following
her liver met RFA with hypertension to the 240s/160s and
hypoxia.
.
Her presentation began with chronic abdominal pain, diarrhea and
vomitting in the early in the early [**2137**] for which she was
frequently hospitalized. She underwent ex-laparotomy in [**2140**]
with a resection of her terminal ilium which pathology revealed
as carcinoid tumor. Following surgery, the patient had almost
complete resolution of her symptoms. However, she continued to
have mild diarrhea in the form of one to two episodes a day and
this frequency slowly increased over the years. She underwent a
negative GI workup with her outpatient gastroenterologist. She
developed sweating and flushing. An abdominal CT in [**9-/2148**]
showed a 2cm solitary liver lesion suspicious for a met, and it
enhanced on an octreotide scan in [**10/2148**] that otherwise showed
no other metastatic burden. Biopsy around that time showed
metastatic carcinoid. She did have a hospitalization for
hypertensive urgency and thereafter began octreotide depot
injections. Due to incomplete control over her symptoms over
the following months, she was referred for selective management
of the liver mass with RFA.
.
She underwent uncomplicated RFA on [**2149-5-7**]. Post-procedure, she
was noted to have increasingly labile blood pressures with a
peak of 240/160. She developed a new oxygen requirement,
saturating in the low nineties on 4LNC. Of note, she uses
home-oxygen set at 5L with activity. She does not require oxygen
at rest. She does have baseline pulmonary dysfunction of unclear
etiology as her [**Name (NI) 11149**] are reportedly normal.
.
On transfer to the ICU, her initial vital signs were: T 96.3
BP142/54 P64 RR19 Sat96/4LNC. She is comfortable and
sleeping. She has no lingering pain from her procedure. She
had mom[**Name (NI) 12823**] chest pain post procedure lasting a few seconds.
No headaches or confusion. Denying current chest pain or
pressure, no shortness of breath. No abdominal pain, nausea,
vomiting. No hematuria, dysuria.
Past Medical History:
adapted from recent oncologist note, confirmed for accuracy with
patient.
- Carcinoid as above
- Early stage breast cancer noted on screening mammogram treated
with resection and radiation. Core biopsy [**8-/2145**] demonstrated
grade I, ER and PR positive, HER-2 negative invasive ductal
carcinoma. She underwent left partial mastectomy 10/[**2144**].
Pathology confirmed Stage I grade 1 invasive ductal carcinoma
with papillary features but without angiolymphatic invasion.
Reexcision for close margins showed no evidence of residual
cancer. Recieved 6100cGy radiation therapy to left breast and
axilla from [**11/2145**] to [**1-/2146**] (No lymph node sampling.)
- Hx of lung nodules followed with imaging which resolved on
chest CT [**2148-8-28**]. [**2137-12-21**] CT showed a 1.2 cm partially
solid nodule in the right lower lobe, stable compared to CT
[**2147-6-7**]. CT [**2148-2-26**] showed a 6 mm right lower lobe
nodule diminished in size and c/w with inflammation.
- Arthritis/DJD
- Asthma
- History of O2 desaturation (to 87%) with activity. Followed
with [**Year (4 digits) 11149**].
- Sleep apnea. Uses CPAP since [**2145**]
- Depression.
- Hypothyroidism since the age of 36.
- Sjogren's disease
- unspecified "[**Last Name **] problem" followed by cardiology
- hemochromatosis carrier
.
ONCOLOGIC HISTORY: In brief, Ms. [**Known lastname 8071**] is an 80 year old
woman who
neuroendocrine tumor of the ileum with positive lymph nodes
found
on laparotomy in [**2140**] after a prolonged course of abdominal
pain,
diarrhea and vomiting. Following surgery her symptoms improved
but she continued to have mild diarrhea. The frequency increased
from [**12-8**] stools per day after surgery to up to 10 times a day
the
fall of [**2147**]. GI work-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] was negative.
Concurrent with slowly progressive diarrhea, the patient also
reports flushing and sweating which increased significantly over
the past few years. CT [**2148-9-25**] showed a new 2 cm solitary
liver enhancing lesion suspicious for metastasis (CT [**2-13**] to
r/o
aortic aneurysm normal by report). Octreotide scan at the time
demonstrated only the hepatic lesion and biopsy of the liver
lesion [**2148-10-8**], demonstrated metastatic carcinoid. In fall
[**2147**] she also had a hypertensive urgency requiring
hospitalization. The patient started on octreotide 20mg IM
qmonth
in [**10/2148**] and increased to 30mg on [**2149-2-26**] due to lack of
response. Of note, prior to starting octreotide the patient
sought consultation with us [**2149-3-10**]. We found her Chromogranin
A
to be elevated at 17 (normal 1.5 to 15) and started her on short
acting octreotide and increased her long acting octreotide to
40mg qmonth as of [**2149-3-21**].
In further detail-
1. Admission on [**2141-1-12**], for which the patient underwent a
diagnostic laparoscopy with laparotomy and resection of 60 cm of
her ileum in the setting of recurrent partial small bowel
obstruction. At surgery, she was noted to have an apparent
implant within the mesentery, the mesenteric border of the
intestine. The pelvis was free of any evidence of tumor. The
uterus and ovaries were noted to be absent as was the appendix.
The cecum, [**Year (4 digits) 499**], liver, stomach, and the remainder of the small
intestine appeared normal. In the mid to terminal ileum, there
were two areas of carcinomatous involvement of the small
intestine extending into the bowel from the mesentery. There
was
a 3-cm diameter node within the small intestinal mesentery.
There were smaller firm shotty lymph nodes along the superior
mesenteric artery, but it was not clear that these were involved
with carcinoma. Because of the possibility that this
represented
carcinoid, gross resection of all tumor was performed by
performing a resection of the small intestine and the associated
mesentery removing approximately 50 to 60 cm of the ileum.
2. Pathology from the above laparotomy confirmed carcinoid
tumor
in the ileum. The proximal and distal resected margins were
negative for tumor, [**4-12**] lymph nodes were positive for metastatic
carcinoid tumor.
3. On [**2147-1-13**], the patient underwent an endoscopy. This was
done to rule out carcinoid. Biopsies were obtained including a
biopsy of the rectosigmoid [**Year (4 digits) 499**] that was consistent with a
hyperplastic polyp. Minute intramucosal lymphoid aggregate was
identified.
4. On [**2147-2-13**], the patient underwent a biopsy of a hep
positive right lower lobe lesion under CT guidance. This did
not
reveal any evidence of cancer. Multinucleated giant cells as
well as benign appearing epithelial cells and macrophages were
present.
5. On [**2148-9-9**], the patient underwent pulmonary function
testing. This revealed mild airflow limitation on [**Year (4 digits) 11149**] with no
significant improvement post bronchodilator administration.
Notation was made of normal lung volumes. There was moderate
impairment in diffusion capacity. The patient's DLCO was
reported at 49% of predicted. Overall, there were changes in
lung function compared to the previous study performed on
[**2148-4-23**].
6. On [**2148-10-9**], the patient underwent a left liver fine
needle
aspirate that was notable for tumor cells consistent with
carcinoid tumor. The tumor was noted to be low-grade.
7. On [**2148-10-23**], the patient underwent an octreotide scan that
was notable for a small focus of increased tracer uptake in the
anterior aspect of the left liver lobe. No other abnormal foci
were seen in the chest, abdomen, and pelvis.
.
Past Surgical History:
- Left ankle fracture open reduction in [**2141**].
- Abdominal hernia repair [**2142**] after exploratory laparotomy.
- Bladder surgery.
- Cholecystectomy.
- TAH-BSO.
- Lumbar disc repair laminectomy.
- Left knee replacement in [**2146**].
Social History:
Widowed. Lives alone [**Last Name (un) **]. Three children, 12 grandchildren
and 8 great grandchildren.
Former smoker: 37-pack-year history. Quit in [**2117**].
Etoh. about 2 glasses a week.
Family History:
5 siblings. 3 children.
Hemochromatosis: Son, daughter and grandson
Sister: [**Name2 (NI) 499**] cancer in late 60s and uterine cancer
Physical Exam:
Vitals: T 96.3 BP142/54 P64 RR19 Sat96/4LNC
General: she is alert and oriented times three, answering
questions appropriately. Appears fatigued.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles appreciated at the bases but no wheezes
auscultated
CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM at the
right second ICS without radiation.
Abdomen: wound dressing with slight serosang. Implanted
hardware felt at the periumbilical area, says it was hernia
mesh. Mild tenderness in the right, not palpated aggressively
due to carcinoid
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
1. Labs on admission:
[**2149-5-8**] 05:22AM BLOOD WBC-7.9 RBC-3.92* Hgb-12.4 Hct-35.7*
MCV-91 MCH-31.6 MCHC-34.6 RDW-14.1 Plt Ct-181
[**2149-5-8**] 05:22AM BLOOD PT-13.3 PTT-22.5 INR(PT)-1.1
[**2149-5-8**] 05:22AM BLOOD Glucose-120* UreaN-12 Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-25 AnGap-16
[**2149-5-8**] 05:22AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
.
2 Labs on discharge:
.
3. Imaging/diagnostics:
- CT abdomen: 1. Technically successful radiofrequency ablation
of biopsy-proven enlarging metastatic carcinoid within segment
III for palliative purposes. No immediate post-procedural
complications. 2. Unchanged persistent moderate-to-severe
right-sided hydronephrosis seen on
prior exams with delayed enhancement of the right kidney related
to the
underlying obstruction. Unchanged biliary dilatation of
uncertain etiology. 3. No interval change to two additional
small hypoattenuating subcentimeter hepatic lesions within
segment VII and segment VII/VIII dating back to [**9-25**] [**2147**] CT
exam.
.
Brief Hospital Course:
Mrs. [**Known lastname 8071**] is an 80yoF with carcinoid, depression, OSA, breast
cancer history, asthma, hypothyroidism who is admitted to the
[**Hospital Unit Name 153**] following RFA of a hepatic carcinoid met due to
hypertension and hypoxia.
.
# HYPERTENSION: Labile blood pressue with significant
hypertension is common in carcinoid- the so-called "carcinoid
crisis" that can be precipitated by palpation, anesthesia,
chemotherapy, or occur spontaneously. Her hypertension is most
likely caused by release of a host of neuroendocrine vasoactive
mediators released from these tumors, through possible
mechanical stimulation during RFA or through the anesthesia
induction process. Her BP has since corrected to the normal
range. Continued on IV octreotide, howm antihypertensives, and
one dose of IV hydralazine.
.
# METASTATIC CARCINOID: Now status post radio frequency
ablation of the hepatic met for symptoms despite octreotide.
Will continue her standing pre-procedure doses of octreotide of
100 mg TID.
.
# HYPOXIA: Developed decreased sats prior to [**Hospital Unit Name 153**] transfer,
though improved to the mid-90s on 3L prior to discharge. She
does have a baseline oxygen requirement with activity and a
poorly-described diagnosis of chronic lung disease. Patient
treated with bronchodilators. Spoke to primary care doctor
regarding outpatient follow-up with pulmonologist to workup
underlying lung disease. She will resume her home oxygen upon
discharge.
.
# CONFUSION: She has poor short term memory and is at times has
poor attention. Her daughter verified she is at her baseline
mental status. She received a CT head on [**2149-5-8**] which was
negative for acute hemorrhage.
.
Her additional medical problems were treated with her home
medications without complication.
.
She was DNI but OK to rescusitate for this admission.
Medications on Admission:
-ANASTROZOLE [ARIMIDEX] 1 mg po qd
-CEVIMELINE [EVOXAC] 30 mg po qd
-DILTIAZEM HCL 120 mg po qd
-DIPHENOXYLATE-ATROPINE [LOMOTIL] 2 tablets qid prn diarrhea
-FLUTICASONE-SALMETEROL [ADVAIR DISKUS] [**Hospital1 **]
-FUROSEMIDE [LASIX] 40 mg po qd
-LEVOTHYROXINE 88 mcg po qd
-LISINOPRIL 10 mg po qd
-MONTELUKAST [SINGULAIR] 10 mg po qd
-OCTREOTIDE ACETATE 100mcg 3 times a day
-OCTREOTIDE ACETATE 40 mg depot IM q 3-4 weeks
-OPIUM TINCTURE 10 mg/mL - 0.2-0.3 cc(s) by mouth 4-5x/day
-PAROXETINE HCL 20 mg po qd
Discharge Medications:
1. Arimidex 1 mg Tablet Sig: One (1) Tablet PO once a day.
2. cevimeline 30 mg Capsule Sig: One (1) Capsule PO once a day.
3. diltiazem HCl 120 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
4. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: Two (2)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. octreotide acetate 100 mcg/mL Solution Sig: One Hundred
(100) mcg Injection Q8H (every 8 hours).
11. octreotide acetate Intramuscular
12. opium tincture 10 mg/mL Tincture Sig: 0.2-0.3 cc PO [**3-11**]
times a day as needed.
13. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Hypertension
Hypoxia
Carcinoid tumor
.
SECONDARY DAIGNOSES:
- Arthritis
- Asthma
- Obstructive sleep apnea
- Depression
- Hypothyroidism
- Sjogren's disease
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Discharge Instructions:
Ms. [**Known lastname 8071**], you were admitted to the [**Hospital1 827**] because your blood pressure was very high and you
needed supplemental oxygen after your radio-frequency ablation.
Your blood pressure improved and you no longer needed oxygen
prior to discharge. We gave you some pain medications to treat
your abdominal pain. We also scanned your head to make sure you
did not have a bleed, which was negative.
.
Medications:
ADDED:
- Oxycodone 2.5 mg by mouth every 4 hours as needed for pain for
1 week. Please do not drive for operate heavy machinery while on
this medication.
It was a pleasure caring for you. We wish you a speedy
recovery.
Followup Instructions:
Please make an appointment and follow-up with your primary care
doctor within the next 7 days. Please have him/her help you set
up follow-up appointments with your outpatient pulmonologist
We made you an appointment with your oncologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]
When: [**2149-5-21**] @ 8:30 AM
Location: [**Hospital1 18**] - DIVISION OF HEMATOLOGY/ONCOLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 53952**]
Fax: [**Telephone/Fax (1) 13345**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2149-5-10**]
|
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"209.72",
"311",
"V10.91"
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icd9cm
|
[
[
[]
]
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[
"50.24"
] |
icd9pcs
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[
[
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]
] |
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|
338, 378
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,640
| 147,458
|
38475
|
Discharge summary
|
report
|
Admission Date: [**2112-3-29**] Discharge Date: [**2112-4-8**]
Date of Birth: [**2065-4-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
pre-syncope, rapid heart rate, BRBPR
Major Surgical or Invasive Procedure:
Atrial flutter ablation
Trans-esophageal echo
Colonoscopy under monitored anesthesia care
History of Present Illness:
46 year old male from jail with a history of hypertension with
CP and SOB for 2 weeks off and on. He describes the pain as a
substernal punch that last for a few seconds. It may occur more
frequently when standing up although this is not clear. He is
unable to lie flat because he feels like he get the chest pain
at that time. The pain usually occurs 4-5 times per day. He was
in the shower and was almost past out although never lost
consciousness. He has been having lightheadedness for a few
weeks, most notable when in the bathroom or when standing. After
almost passing out he was brought the the ED where he was noted
to havea rapid heart rate (see below).
.
He notes that he has been on metoprolol, aspirin and hctz but
stopped the metoprolol this am (?) although he thinks his doctor
in jail had him stop it two weeks ago when he initially
complained of being lightheaded.
.
Patient also reports that he has had 15 years of bloody bowel
movements. He says that he has 15-20 bowel movements a day and
that most of them are bloody (both in the toilet bowel and on
the toilet paper). He has never had this worked up. It may occur
more frequently when he drinks alcohol although this is unclear.
[**Name2 (NI) **] does say that it has been getting worse in the past 2 weeks.
.
Finally, of note he was recently seen in [**Hospital1 2177**] (aprox 2 months
ago) for high blood pressure (to SBP 200).
.
He was brought to [**Location (un) 620**] initially and then send to [**Hospital1 **] ED.
.
[**Location (un) 620**] labs:
k: 5
BUN/Cr: 22/1.9
Alb: 3
hct: 41.3
Trop: <0.01
CK: 58
.
[**Location (un) 620**] CXR: normal.
.
[**Location (un) 620**]: ECG: flutter at 2:1 conduction, HR: 152
.
Neehdam ED course: AFlutter 150, rec'd Dilt 10 IV, PPI IV, 3 L
IV NS
.
In the ED, initial VS were: 97.3 156 113/91 18 100. No chest
pain. Was given 2 g ca (to prevent hypotension from excess
dilt), dilt 20mg IV last ECG with HR 60 in fib (not flutter)
Dilt 30 po x2.
.
Vitals on transfer were 91, 119.69, 96% RA.
.
On the floor, he was not having any symptoms. No chest pain, no
palpitations. Heart rate was in the 70s.
Past Medical History:
HTN
renal cyst removed
appendectomy
Social History:
prior EtOH abuse (used to drink 1/5th vodka or scotch daily but
stopped 46 days ago), occasional cocaine use, once per month.
Sexually active with women.
HIV negative 2 months ago at [**Hospital1 2177**]
Currently incarcerated for aprox 1 month for armed robbery/
aggressive behaviour Tob: none
Family History:
M died of MI at 54
F died of MI at 66
sister died in [**2102**]
No Hx of IBD or cancer
Physical Exam:
Admission:
VS afebrile, 79, 133/74, 100% RA
Gen: muscular young M in NAD. +pectus deformity.
HEENT: EOMI, PERRLA, MMM, OP clear
CV: no JVD. nl S1, S2. RRR no murmurs appreciated
LUNGS: CTAB/L no wheeze
ABD: +BS soft mild distention, NT. aorta was not enlarged by
palpation. No abdominal bruits.
EXT: no edema, R-groin site c/d/i, tender to palp
LUE erythema and tenderness over previous basilic vein IV site
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**11-28**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred.
Pertinent Results:
Admission labs:
[**2112-3-29**] 09:50PM BLOOD WBC-7.4 RBC-5.08 Hgb-12.1* Hct-37.5*
MCV-74* MCH-23.8* MCHC-32.2 RDW-14.1 Plt Ct-207
[**2112-3-29**] 09:50PM BLOOD PT-12.6 PTT-24.1 INR(PT)-1.1
[**2112-3-30**] 09:20AM BLOOD ESR-22*
[**2112-3-29**] 09:50PM BLOOD Glucose-93 UreaN-20 Creat-1.7* Na-143
K-4.6 Cl-110* HCO3-23 AnGap-15
[**2112-3-29**] 09:50PM BLOOD ALT-12 AST-17 AlkPhos-54 TotBili-0.2
[**2112-3-30**] 09:20AM BLOOD CK(CPK)-67
[**2112-3-29**] 09:50PM BLOOD cTropnT-<0.01
[**2112-3-30**] 09:20AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2112-3-29**] 09:50PM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.1 Mg-1.8
[**2112-3-29**] 11:51PM BLOOD D-Dimer-417
[**2112-3-30**] 09:20AM BLOOD TSH-1.5
[**2112-3-30**] 09:20AM BLOOD CRP-16.4*
[**2112-3-30**] 09:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2112-4-5**] 01:35PM BLOOD Lactate-1.0
.
Anemia w/u:
[**2112-3-31**] 07:35AM BLOOD calTIBC-333 VitB12-323 Folate-12.8
Ferritn-45 TRF-256
.
Micro:
[**2112-3-30**] 6:35 am STOOL CONSISTENCY: NOT APPLICABLE
O & P ADDED ON [**2112-3-31**] AT 0130.
**FINAL REPORT [**2112-4-2**]**
FECAL CULTURE (Final [**2112-4-2**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2112-4-1**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2112-3-30**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
OVA + PARASITES (Final [**2112-3-31**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
Micro:
[**2112-4-2**] 8:08 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2112-4-5**]**
FECAL CULTURE (Final [**2112-4-4**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2112-4-4**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2112-4-5**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final [**2112-4-4**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2112-4-4**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2112-4-4**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2112-4-3**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2112-3-30**] 12:04 pm URINE Source: CVS.
**FINAL REPORT [**2112-3-31**]**
URINE CULTURE (Final [**2112-3-31**]): NO GROWTH.
.
u/a negative [**3-30**]
.
[**3-30**] echo:
The left atrium and right atrium are normal in cavity size. No
left atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). The estimated right atrial pressure is 0-5
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. There appears to be a mild coarctation
of the distal aortic arch. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
?Mild coarctation of the distal aortic arch. If clinically
indicated a thoracic CT or MR or a TEE would be better able to
anatomically define the possible mild aortic coarctation.
.
[**3-30**] CXR:
IMPRESSION: PA and lateral chest reviewed in the absence of
prior chest
radiographs:
Mild-to-moderate cardiomegaly is exaggerated by a pectus
deformity of the
sternum. Aside from a band of linear atelectasis inferior to the
left hilus, the lungs are clear. There is no pulmonary edema and
no pleural effusion or evidence of central adenopathy and the
hila are normal size. Findings do not suggest pulmonary embolism
in order to exclude that diagnosis. Incidental note made of
healed left lower lateral rib fractures.
.
[**3-30**] CT abd/pelvis:
IMPRESSION:
1. Colonic wall thickening and mild surrounding inflammatory
change involving the ascending, transverse, and descending
colon. The sigmoid colon and rectum are difficult to evaluate as
they are collapsed. The terminal ileum also appears thickened.
Findings are likely inflammatory or infectious in nature. There
are no secondary signs of ischemia, although this cannot be
fully excluded.
2. 6-mm non-obstructing proximal right ureteral stone with
proximal ureteral thickening, likely reactive. Mild dilatation
of the right ureter in its mid portion, which may be due to
prior passed stone.
3. Focal left renal cortical scarring and two punctate
non-obstructing
stones.
.
[**4-3**] renal u/s:
1. Non-obstructing 7-mm stone at the right UPJ, with a right
extrarenal
pelvis, with no evidence for right hydronephrosis.
2. Focal cortical thinning in the left kidney without
hydronephrosis or
obstructing nephrolithiasis on the left. Small cyst at the lower
pole of the left kidney.
.
[**4-4**]:
b/l UE u/s:
IMPRESSION: Occlusive thrombus seen within the basilic veins
bilaterally. On the right arm, the thrombus is in the forearm
below the antecubital fossa. In the left arm, the thrombus is in
the forearm and extends into the antecubital fossa.
.
[**4-5**]:
TEE: There is no pericardial effusion. There is left ventricular
hypertrophy. Left ventricular systolic function appears mildly
to moderately depressed (LVEF ?40%) in focused views.
TEE: No spontaneous echo contrast or thrombus in the left
atrium/left atrial appendage. Mildly to moderately depressed
global left ventricular systolic function. Depressed right
ventricular systolic function. Mild aortic regurgitation. Simple
atheroma in the aortic arch and descending thoracic aorta.
.
[**4-7**] COLONOSCOPY:
FINDINGS:
Lumen: Evidence of a previous end to side ileo-colonic
anastomosis was seen at the ascending colon.
Mucosa: Normal mucosa was noted in the whole examined colon, at
the anastomosis and in the neoterminal ileum.
Cold forceps biopsies were performed for histology at the small
bowel, Ileum.
Cold forceps random biopsies were performed for histology
throughout the whole colon.
Protruding Lesions Medium-sized internal hemorrhoids were noted.
IMPRESSION: Previous end to side ileo-colonic anastomosis of the
ascending colon
Normal mucosa in the colon and neo-terminal ileum. Internal
hemorrhoids (biopsy)
Otherwise normal colonoscopy to neoterminal ileum
Recommendations: Await biopsy results
F/U with inpatient GI consult team
.
[**4-7**] BIOPSIES pending
.
Brief Hospital Course:
46 yo M with h/o HTN presents with 2 weeks of increasing bloody
BMs, pre-syncope and found to have A-flutter/fib with RVR.
.
# A-fib/flutter: New diagnosis per patient. Patient in/out of
primarily flutter with variable conduction, mostly 2:1, (with
occasional NSR or afib, but after a couple of days was without
the afib episodes, and was only flutter/NSR).
Initially, went into sinus after IV and po dilt; then in/out of
fib/flutter with variable block and with variable HR from 40s to
140s, also sometimes in sinus rhythm. Then more persistently in
aflutter with HR in 140s, treated with uptitration of diltiazem,
then per cardiology transitioned to beta-blocker with
uptitration of metoprolol. Tried IV amiodarone load, but without
change from aflutter in 140s, discontinued amiodarone after the
load and went back to metoprolol for rate control, with doses
varying from 75 tid to 100 qid, with caution regarding BP
(mostly SBP 100-130) and concern for potential to throw a clot
if converted to sinus given not anticoagulating in setting of GI
bleed.
Thought that atrial arrhythmia may be due to volume loss from
bloody BM's and diarrhea, or from inflammatory state related to
IBD/colitis.
Felt that chest pain/pre-syncope/SOB were related to
tachycardia, as symptoms were worsen with rising HR (but often
even when tachycardic to 140s patient could be asymptomatic).
Given CHADS 2 score of 1 (hx of HTN), would likely only need to
be anticoagulated with aspirin, but held given GIB.
Ruled out MI with 2 sets of negative cardiac enzymes. Also
considered drugs as causative perhaps d/t cocaine-induced
hypertension and secondary arrhythmia, although he had a
negative tox screen on admission. Echo without CHF and also
without evidence of right heart strain plus with negative
d-dimer less likely PE. + aortic coarctation perhaps
contributing to hypertension and secondary atrial arrhythmia.
TSH wnl. Without pain or fever.
Cardiology and electrophysiology were consulted - without being
able to rate control the aflutter after multiple days and
medication regimens, then went to TEE to ensure no intracardiac
thrombus, which was followed by atrial flutter ablation. This
was complicated by a respiratory arrest due to oversedation with
medications, requiring Narcan and flumazenil for reversal and
monitoring overnight in the CCU post-procedure. On return to the
floor he was in normal sinus rhythm in the 50s-60s, with
hypertension to the 160s-180s. TEE with concern for
tachyarrhythmia-induced cardiomyopathy and depressed EF, so
medications were adjusted to include metoprolol tartrate 25mg
[**Hospital1 **] and lisinopril, which can continue to be adjusted as needed
as an outpatient. He will need follow-up of this cardiomyopathy
and his post-ablation care, and has been scheduled for an
outpatient appointment with cardiology here at [**Hospital1 18**]. He was
started on Lovenox and then Coumadin for bridging prior to
discharge, and he will have a goal INR of 2.0-3.0 for at least
three months post-ablation.
.
# BRBPR: Differential includes ischemic, inflammatory,
infectious; favor inflammatory given lack of pain and good
appetite point away from ischemic, given long duration seems
less likely to be infectious and also negative infectious w/u
thus far, including stool studies. Colitis seen on CT scan
abd/pelvis. Twice prepped for colonoscopy but failed attempts
due to tachycardia of aflutter in 150s and so discomfort on the
part of anesthesia to perform the colonoscopy in that setting.
Plan for attempt at colonoscopy after atrial arrhythmia ablated.
In the interim, GI was consulted, and patient was empirically
treated with antibiotics (ceftriaxone/flagyl). Although patient
continued with BRBPR, its frequency decreased, and his Hct
remained stable in 35-38 range without need for transfusion.
Colonoscopy ultimately did not show colitis, but did show
internal hemorrhoids, as well as a surprising finding of a prior
abdominal surgery. Felt hemorroids to be most likely source of
BRBPR. Biopsies taken to assess for microscopic colitis, which
are pending on discharge, and patient will need follow-up with
gastroenterology, which has been scheduled.
.
# Bilateral basilic vein clots: after amiodarone administration,
patient's b/l antecubital regions were TTP and erythematous, and
they worsened over 2 days. u/s of b/l UE's showed b/l basilic
vein clots. treated with warm compresses, but did not treat with
antibiotics as clinically appeared superficial thrombophlebitis
and not cellulitis. ultimately started on anti-coagulation for
post-ablation care, which may be helpful in treating these
superficial upper extremity vein thrombi.
.
# Respiratory arrest: Pt suffered a respiratory arrest in the
setting of excess sedation for his atrial flutter ablation.
Reversed easily with Narcan and flumazenil, but required
overnight observation in the CCU without further complication.
.
# ARF vs CRI: Unclear baseline. Perhaps pre-renal in setting of
bloody diarrhea; or could be [**12-29**] renal scarring seen on CT scan
as more of a chronic process; or could be [**12-29**] long-standing
hypertension in setting of h/o cocaine use & aortic coarctation.
Treated with IVF hydration, and saw Cr waver around 1.7-1.9
steadily. Improved after ablation, perhaps poor forward-flow was
partially causative, currently improved to 1.4 on discharge.
.
# Anemia: Fe and B12 deficient, started repletion of both,
thought that this could be d/t malabsorption in setting of
colitis, or due to malnutrition.
.
# Aortic coarctation: incidentally seen on echo; needs MRI
outpatient follow-up, per cardiology.
.
# Hypertension: Treated with metoprolol and lisinopril. Given
concern for tachycardia-induced cardiomyopathy, would like to
uptitrate lisinopril as tolerated.
Medications on Admission:
Metoprolol
hctz
aspirin
Discharge Medications:
1. Outpatient Lab Work
Please check CBC, Chem 7 panel, and PT/INR on Monday [**2112-4-11**].
Please check PT/INR as needed in the future to monitor for
therapeutic anticoagulation with Coumadin.
2. Lovenox 150 mg/mL Syringe Sig: 130mg injection Subcutaneous
once a day for 7 days: Continue until INR therapeutic for 24
hours (goal INR [**12-30**]).
Disp:*7 syringes* Refills:*1*
3. Coumadin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Goal
INR [**12-30**].
Disp:*150 Tablet(s)* Refills:*1*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for systolic blood pressure <110.
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: Half Tablet PO BID (2
times a day): Hold for HR<60 or SBP<105.
Disp:*30 Tablet(s)* Refills:*2*
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*80 Capsule(s)* Refills:*1*
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Cyanocobalamin 100 mcg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
Disp:*75 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location 85622**] of Correction
Discharge Diagnosis:
Internal hemorrhoids
Atrial flutter
Atrial fibrillation
Aortic coarctation
Anemia
Bilateral basilic vein thrombi
Hypertension
Respiratory arrest
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 fast heart rate, bloody
stools, and lightheadedness. The bloody stools are likely due to
internal hemorroids, seen on colonoscopy. The associated blood
loss likely resulted in the lightheadedness and contributed to
the cardiac arrhythmia such that you felt chest pain, shortness
of breath, and a fast heart rate.
.
Controlling your heart rate was difficult to do with
medications, so you had an ablation to reset the heart rhythm,
which was successful.
.
You have a new set of medications to take, please see attached.
.
You will take lovenox (for approximately 5-7 days) to complete a
bridge while you start taking coumadin. Your goal INR is [**12-30**],
once you are at that goal for 24 hours, then you can discontinue
the coumadin. INR checks should ensure it is between [**12-30**], and
your coumadin dose should be titrated as needed.
Followup Instructions:
Please attend the following appointments:
.
Gastroenterology (for diarrhea & bloody stool follow-up, and to
review biopsy results):
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2112-4-27**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Cardiology:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2112-5-4**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"453.81",
"403.90",
"285.1",
"455.2",
"611.1",
"280.9",
"305.61",
"305.03",
"427.32",
"281.1",
"584.9",
"799.1",
"E937.9",
"747.10",
"427.31",
"427.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.26",
"37.34",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
18005, 18066
|
11021, 16797
|
351, 443
|
18255, 18255
|
3680, 3680
|
19311, 20126
|
2972, 3061
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|
18087, 18234
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16823, 16849
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18406, 19288
|
3076, 3661
|
275, 313
|
471, 2584
|
3696, 10998
|
18270, 18382
|
2606, 2643
|
2659, 2956
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,568
| 173,420
|
54211
|
Discharge summary
|
report
|
Admission Date: [**2114-9-19**] Discharge Date: [**2114-10-2**]
Date of Birth: [**2047-6-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Influenza Virus Vaccine / Shellfish Derived / Egg / Adhesive
Bandage / Heparinoids
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
recurrent sternal wound infection
Major Surgical or Invasive Procedure:
[**2114-9-25**] Right subpectoral latissimus flap transfer and
closure of sternal wound
History of Present Illness:
The patient is an unfortunate 67-
year-old who is well-known to our service. Back in [**2113-4-24**]
she underwent a sternotomy for coronary revascularization.
Unfortunately this separated. We closed with an omental flap
back in [**2113-4-24**]. The wound separated, and since that time,
she has had 3 other operations in an attempt to reclose. Each
operation was basically a debridement operation of a
sequestrum of left-sided dead cartilage with treatment with
the V.A.C. She was seen in the office about 10 days ago and
actually the wound looked great, and then suddenly she came
in with high fevers and infection again. I felt that it was
necessary for her to have a radical debridement this time and
definitive flap closure. The V.A.C. procedure clearly was not
working, and I think the reason for this is that the exposed
cartilage, though viable when we complete our debridement, is
now being contaminated by a very aggressive multi-resistant
Pseudomonas the patient carries in this wound, and I suspect
that the cartilage is dying back. We need to have definitive
debridement and then placement of healthy muscular tissue,
and definitive closure without any open wounds to get this
closed. It was difficult to convince the patient to go ahead
with surgery; but I think she understands that ultimately she
could die of sepsis if this is not done. We cannot guarantee
success. She does have a known meningioma that she has
refused treatment previously.
Past Medical History:
- Diabetes
- Hypertension
- CAD s/p prior RCA stenting c/b ISR x 2, Cypher stenting in
[**2106**] for NSTEMI, s/p CABG x 2 with LIMA-LAD, SVG-PDA [**3-/2113**]
- MVR [**3-/2113**]: 25 mm [**Company 1543**] mosaic porcine valve
- Non sustained polymorphic VT s/p [**Company 1543**] ICD placement [**2-24**]
- Chronic sternal wound infection since [**4-1**] with multiple
highly resistant organisms
- VTE on warfarin
- HIT (Heparin-induced thrombocytopenia)
- Mengingioma, formerly on chronic steroids
- Osteopenia/porosis
- s/p TAH-BSO
- h/o C diff
- depression
- anxiety
- hypercholesterolemia
- H/o large post cath RP hematoma, [**2105**]
- Gastroesophageal reflux disease
- History of pulmonary nodules, followed by serial imaging
- History of H. pylori
- History of GI bleed in the setting of anticoagulation
Social History:
Currently at [**Hospital 1459**] Nursing and Rehab. She has a brother and
sister who are her supports and she plans to live with her
brother when discharged from rehab. Past smoker (30 pk yr), no
EtOH or drugs. Currently in a wheelchair at baseline.
Family History:
Father died at age 50 of an MI and "enlarged heart." Brother
with drug abuse. Mother had depression and panic attacks, DM.
Physical Exam:
Tc: 97.1 BP:127/44 HR:78 RR:18 SaO2:96% RA
General: pleasant, nad, chronically ill-appearing
HEENT: op clear, mmm, no lesions; no cervical LAD
Neck: supple, no LAD, no thyromegaly
Cardiovascular: RRR, no MRG
Respiratory: CTA bilat w/o wheezes/rhonchi/rales
Back: no spinous process tenderness, no CVA tenderness
Gastrointestinal: +bs, soft, non-tender, non-distended
Musculoskeletal: moving all extremities, non-focal
Lymph: no cervical, axillary or inguinal LAD
Skin: sternal wound with area of dehischence with + purulent
drainage soaking gauze dressing. + surrounding erythema. + mild
TTP and mild warmth.
Neurological: aaox3, cn 2-12 intact
Pertinent Results:
[**2114-9-29**] 05:41AM [**Month/Day/Year 3143**] WBC-9.5 RBC-3.58* Hgb-10.5* Hct-31.0*
MCV-86 MCH-29.4 MCHC-34.0 RDW-16.0* Plt Ct-205
[**2114-9-28**] 04:35AM [**Month/Day/Year 3143**] WBC-13.3* RBC-3.99* Hgb-11.7* Hct-34.6*
MCV-87 MCH-29.3 MCHC-33.9 RDW-16.1* Plt Ct-190
[**2114-9-27**] 01:54AM [**Month/Day/Year 3143**] WBC-16.0*# RBC-4.57# Hgb-13.4# Hct-39.7#
MCV-87 MCH-29.4 MCHC-33.9 RDW-15.9* Plt Ct-212
[**2114-10-1**] 05:22AM [**Month/Day/Year 3143**] PT-28.2* INR(PT)-2.8*
[**2114-9-30**] 04:45AM [**Month/Day/Year 3143**] PT-25.3* INR(PT)-2.4*
[**2114-9-29**] 05:41AM [**Month/Day/Year 3143**] PT-19.2* INR(PT)-1.8*
[**2114-10-1**] 05:22AM [**Month/Day/Year 3143**] Glucose-88 UreaN-15 Creat-0.8 Na-135
K-3.8 Cl-102 HCO3-24 AnGap-13
[**2114-9-30**] 04:45AM [**Month/Day/Year 3143**] Na-136 K-3.3 Cl-100
[**2114-9-29**] 05:41AM [**Month/Day/Year 3143**] Glucose-94 UreaN-15 Creat-0.7 Na-139
K-3.2* Cl-100 HCO3-31 AnGap-11
[**2114-10-2**] 06:43AM [**Month/Day/Year 3143**] WBC-10.1 RBC-3.71* Hgb-10.9* Hct-33.6*
MCV-91 MCH-29.2 MCHC-32.3 RDW-16.5* Plt Ct-286
[**2114-10-2**] 06:43AM [**Month/Day/Year 3143**] PT-27.6* INR(PT)-2.7*
[**2114-10-2**] 06:43AM [**Month/Day/Year 3143**] Glucose-86 UreaN-15 Creat-0.8 Na-137
K-3.7 Cl-104 HCO3-24 AnGap-13
Brief Hospital Course:
The patient was admitted for further management of her sternal
wound infection. ID was consulted, as they have been following
her. She was started on Daptomycin and Cefepime. Dr. [**First Name (STitle) **]
was also consutled from PRS, as he is very familiar with her
case. The patient went to the OR on [**2114-9-25**] for Right
subpectoral latissimus flap transfer and closure of her sternal
wound with Dr. [**First Name (STitle) **]. Dr. [**Last Name (STitle) **] assisted in the sternal
debridement. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU for
observation and recovery.
Hematology was consulted for the patient's history of HIT and
VTE. It was recommended to discontinue anti-coagulation, so
coumadin was stopped. Antibiotics were adjusted according to
cultures. The patient was transferred to the floor for further
recovery. She did display dysphagia, and speech/swallow
consultation was performed. Diet recommendations were made.
The patient received a PICC for long-term antibiotic therapy.
She was discharged back to her nursing home residence, [**Hospital 1459**]
Rehab and Nursing. She will continue to be followed by ID and
PRS.
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - Dosage
uncertain
ARIPIPRAZOLE - (Prescribed by Other Provider) - Dosage
uncertain
CITALOPRAM - (Prescribed by Other Provider) - Dosage uncertain
DIVALPROEX [DEPAKOTE] - (Prescribed by Other Provider) - Dosage
uncertain
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - Dosage
uncertain
HYDROCODONE-ACETAMINOPHEN [VICODIN] - (Prescribed by Other
Provider) - Dosage uncertain
HYDROXYZINE HCL - (Prescribed by Other Provider) - Dosage
uncertain
IPRATROPIUM-ALBUTEROL [DUONEB] - (Prescribed by Other Provider)
- Dosage uncertain
LISINOPRIL - (Prescribed by Other Provider) - Dosage uncertain
LORAZEPAM - (Prescribed by Other Provider) - Dosage uncertain
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - Dosage
uncertain
NYSTATIN - (Prescribed by Other Provider) - Dosage uncertain
OMEPRAZOLE - (Prescribed by Other Provider) - Dosage uncertain
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - Dosage
uncertain
SIMVASTATIN - (Prescribed by Other Provider) - Dosage uncertain
WARFARIN - (Prescribed by Other Provider) - Dosage uncertain
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - Dosage uncertain
BISACODYL - (Prescribed by Other Provider) - Dosage uncertain
CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider) -
Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
Dosage uncertain
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) -
Dosage uncertain
INSULIN REGULAR HUMAN - (Prescribed by Other Provider; sliding
scale) - Dosage uncertain
MAGNESIUM OXIDE [MAG-OXIDE] - (Prescribed by Other Provider) -
Dosage uncertain
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. aripiprazole 1 mg/mL Solution Sig: 2.5 PO DAILY (Daily):
2.5mg daily.
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal DAILY (Daily).
14. Colistin 75 mg IV Q12H
15. Daptomycin 400 mg IV Q24H
16. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): see attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1459**] Care and Rehabilitation Center
Discharge Diagnosis:
PRIMARY
Chronic Sternal Osteomyelitis
SECONDARY
Diabetes
Hypertension
Coronary Artery Disease
Venous Thromboembolus on warfarin
Heparin Induced Thrombocytopenia
Gastroesophageal Reflux
Depression
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Maintain occlusive dressings to sternal and latissimus wounds
until follow-up with Dr. [**First Name (STitle) **], no baths or swimming, and look
at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2114-10-24**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2114-11-21**] 11:00
Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 1416**] Thurs, [**2114-10-11**], 1:15pm
***Please check weekly CBC with
differential, BUN/Cr, ESR/CRP, LFTS and CK
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
Completed by:[**2114-10-2**]
|
[
"V12.51",
"V15.82",
"V43.3",
"V88.01",
"272.0",
"733.00",
"041.7",
"787.20",
"250.00",
"790.7",
"412",
"041.11",
"V58.61",
"530.81",
"V45.81",
"707.03",
"300.4",
"733.90",
"998.83",
"401.9",
"E878.2",
"V09.81",
"410.72",
"V45.02",
"998.59",
"707.22",
"730.18"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.41",
"77.61",
"38.97",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
9486, 9568
|
5165, 6377
|
383, 473
|
9817, 9817
|
3885, 5142
|
10983, 11723
|
3081, 3205
|
8096, 9463
|
9589, 9796
|
6403, 8073
|
10092, 10960
|
3220, 3866
|
310, 345
|
501, 1962
|
9832, 10068
|
1984, 2797
|
2813, 3065
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,078
| 159,659
|
4737+55602
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-7-1**] Discharge Date:
Date of Birth: [**2068-9-25**] Sex: F
Service:
CHIEF COMPLAINT: Shortness of breath
HISTORY OF PRESENT ILLNESS: Ms [**Known lastname **] is a 60 year old woman
with coronary artery disease, non-ST elevation myocardial
infarction in [**2126-11-17**] with left circumflex stent,
diabetes, hypertension, chronic obstructive pulmonary disease
on home oxygen, history of severe anxiety who presented to
the Emergency Room with dyspnea on exertion over the past one
to two weeks. Per the patient's family she has not been
taking her Lasix for several weeks after a recent psychiatric
admission, discharge recommendations do not include this
medication. Per family, the patient also has been suffering
from one week of cough, productive of sputum. Her anxiety
has significantly worsened and she was then treated with
Xanax for her symptoms. On the day of admission, in addition
to her progressive shortness of breath she also experienced
palpitations. After the call to Emergency Medical
Technicians she was transferred to the [**Hospital6 649**] with respiratory rate of 28 to 32, initially
94 to 97% on 3 liters of nasal cannula with a pulse of 130,
blood pressure 140/90. Over the course of the evening in the
Emergency Room the patient saturations fell, requiring
nonrebreather and eventually bypass.
PAST MEDICAL HISTORY: 1. Coronary artery disease, status
post myocardial infarction in [**2126-11-17**] with PCI to the
left circumflex. An ejection fraction by catheterization at
that time demonstrated 47%. 2. Diabetes mellitus. 3.
Hypertension. 4. Congestive heart failure. 5. Chronic
obstructive pulmonary disease. 6. Cataract surgery. 7.
Anxiety.
OUTPATIENT MEDICATIONS: Aspirin, Metoprolol, Glucotrol XL,
Lasix, Seroquel, Celexa, Remeron, Xanax q. 4 hours.
ALLERGIES: Reglan causing dystonia.
SOCIAL HISTORY: The patient worked as a [**Doctor Last Name 19914**] until one
year prior. She smokes one and a half packs per day. She
has a history of alcohol use, no illicit drugs.
PHYSICAL EXAMINATION: Heartrate 129, blood pressure 129/64,
respiratory rate 20, sating 97% on biPAP, 20/10, set of IMs
330. Physical examination in general revealed somnolent
elderly woman, sedated on biPAP, not following commands.
Head, eyes, ears, nose and throat, normocephalic, atraumatic,
pupils equal, round and reactive to light, biPAP in place.
Neck supple, distended external jugular. Cardiovascular,
tachycardiac, distant S1 and S2. Pulmonary, decreased
breathsounds at the bases with mild wheezes. No crackles.
Abdomen, soft, nontender, nondistended, normoactive bowel
sounds. Extremities, 3+ pitting edema bilaterally. Pulses
not palpable. Feet, cool and dry.
LABORATORY DATA: White count 8.2, differential 82
neutrophils, 11 lymphocytes, 5 monocytes, 1 eosinophil.
Hematocrit 37.8, platelets 270, sodium 139, potassium 4.0,
chloride 96, bicarbonate 31, BUN 14, creatinine 0.8, glucose
241, calcium 10.1, magnesium 1.7, phosphorus 3.6. Cardiac
enzymes, creatinine kinase 39, troponin less than 0.3 with
subsequent creatinine kinases and troponins all negative.
Coagulation screen, PT 14.6, INR 1.4, PTT 27.
Electrocardiogram demonstrated sinus tachycardia at 130, left
atrial enlargement, minimal lateral flattening and ST
depressions when compared with electrocardiogram of [**2126-12-7**]. Chest x-ray, bilateral pleural effusions and upper
zone redistribution.
EMERGENCY DEPARTMENT COURSE: Ms [**Known lastname **] received Ativan, Lasix
greater than 1.5 liters diuresed, however, oxygenation
continued to deteriorate, requiring intubation.
HOSPITAL COURSE: Cardiovascular - Ms [**Known lastname **] was transferred
to the Cardiac Care Unit for further management of her
congestive heart failure exacerbation. She underwent
placement of a Swan-Ganz catheter which demonstrated elevated
pulmonary artery diastolic pressures, approximately 60/35
with a wedge of 36 on admission. She underwent diuresis of
greater than 7 liters during her hospitalization stay with
subsequent improvement in her hemodynamics as well as
pulmonary function. She was maintained on Milrinone as well
as Neo-Synephrine for hemodynamic management during her
diuresis. These medications were able to be weaned on [**2129-7-9**]. Her medical regimen at this time includes
Spironolactone and Lasix 80 mg p.o. q. day. Plans include
the addition of Captopril, however, the patient has poorly
tolerated her recent trials of small dose Captopril with
subsequent hypotension. Plans are for gentle fluid
equilibration and repeated trials of ACE inhibitor.
Ischemia, the patient ruled out for ischemia by cardiac
enzymes. She was maintained on her outpatient regimen
including Aspirin and Lipitor. Her beta blocker was held
given her acute congestive heart failure exacerbation, plan
to be restarted as an outpatient.
Rhythm, the patient maintained sinus rhythm throughout
hospitalization. She did experience persistent tachycardia
which is felt likely secondary to hypotension, infection
which was felt likely secondary to a combination of initially
infection cardiomyopathy, anxiety, and subsequently
hypovolemia.
Infectious disease - The patient with significant sputum
production and history of productive cough as well as
temperature spikes. Initial sputum sample is demonstrated,
Methicillin-sensitive Staphylococcus aureus. Initial
coverage included Vancomycin, Levofloxacin. Her Vancomycin
was eventually narrowed to Oxacillin and subsequently
Dicloxacillin p.o. for Methicillin-sensitive Staphylococcus
aureus pneumonia. She will also continue a 14 day course of
Levofloxacin for a possible vent-associated pneumonia.
Pulmonary - With the treatment of her congestive heart
failure and pneumonia, the patient's pulmonary function
improved and she was able to be weaned and extubated on [**2129-7-6**]. She will continue to require pulmonary support
including nasal cannula oxygen. She is currently at her home
level. She will also require pulmonary toilet as well as
continuation of her inhalers for her chronic obstructive
pulmonary disease.
Neurological - Sedation, the patient required significant
levels of Benzodiazepines to achieve sedation, initially with
a Versed drip. After extubation, she was able to be
transitioned to p.o. medications including initially Xanax
but transitioned to Klonopin on [**2129-7-9**]. The patient
has a history of significant anxiety and Benzodiazepine
dependence. She was also continued on her Celexa and
Seroquel in-house and occasionally required Haldol prn for
agitation. The patient will need a formal psychiatry
consultation for assistance in managing her anxiety disorder.
Prophylaxis - The patient was maintained on Lansoprazole and
pneuma boots for protection while hospitalized.
Access - The patient had a right internal jugular quarter
Swan-Ganz catheter placed on [**2129-7-1**].
This hospital course dictated for the dates through [**2129-7-9**].
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2129-7-9**] 23:32
T: [**2129-7-10**] 07:26
JOB#: [**Job Number 19915**]
Name: [**Known lastname 3305**], [**Known firstname 1677**] Unit No: [**Numeric Identifier 3306**]
Admission Date: [**2129-7-1**] Discharge Date: [**2129-7-13**]
Date of Birth: [**2068-9-25**] Sex: F
Service: CCU
ADDENDUM TO HOSPITAL COURSE: Repeated attempts of low-dose
Captopril resulted in hypotension, and the patient was
restarted on her beta blocker. She tolerated a dose of 3.125
of Carvedilol b.i.d., and this should be continued as an
outpatient. She was started on digoxin for her congestive
heart failure and had a dose of 0.125 mg p.o. q.d. without a
load. Her levels should be followed-up as an outpatient by
her primary care provider. [**Name10 (NameIs) **] diuretic dosage was increased
to Lasix 80 mg p.o. b.i.d. with spironolactone 25 mg p.o.
b.i.d. for maintaining her volume status. This dose may be
adjusted as an outpatient as needed.
ADDENDUM TO INFECTIOUS DISEASE: The patient completed a ten
day course of dicloxacillin and levofloxacin and remained
afebrile with a normal white count at the time of discharge.
PULMONARY: The patient's oxygenation status remained stable
on her home oxygen requirements of 4 liters by nasal cannula.
Physical Therapy recommended home oxygen with 4 liters by
nasal cannula at rest and 5 liters with activity.
PSYCHIATRY: The patient was evaluated by psychiatric
consultation, who recommended continuing Celexa and Remeron
and avoiding benzodiazepines for anxiety symptoms. They
recommend follow-up with outpatient psychiatry and
discontinuation of Seroquel.
DISPOSITION: The patient was discharged in stable condition
to home.
DISCHARGE DIAGNOSIS:
1. Congestive heart failure.
2. Coronary artery disease.
3. Diabetes mellitus.
4. Chronic obstructive pulmonary disease.
5. Hypertension.
6. Anxiety disorder.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Carvedilol 3.125 mg p.o. b.i.d.
3. Atorvostatin 10 mg p.o. q.d.
4. Lasix 80 mg p.o. b.i.d.
5. Spironolactone 25 mg p.o. b.i.d.
6. Glipizide XL 5 mg p.o. q.d.
7. Digoxin 0.125 mg p.o. q.d.
8. Mirtazapine 15 mg p.o. q.h.s.
9. Celexa 30 mg p.o. q.d.
10. Albuterol and Atrovent nebulizers p.r.n.
11. Flovent four puffs p.o. b.i.d.
12. Colace 100 mg p.o. b.i.d.
13. Dulcolax 5 mg p.o. q.h.s. p.r.n.
DISCHARGE PLAN:
1. The patient should follow-up with her primary care
provider in one to two weeks.
2. The patient should have her blood drawn for a digoxin
level and panel 7 within one week and have these results
faxed to her primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at
[**Telephone/Fax (1) 3307**].
3. The patient should consider following up with an
outpatient cardiologist if her primary care provider, [**Name10 (NameIs) 3308**] is
listed as a cardiologist, is not comfortable with managing
her heart failure symptoms.
[**First Name8 (NamePattern2) 77**] [**First Name8 (NamePattern2) 2448**] [**Name8 (MD) **], M.D. [**MD Number(1) 2449**]
Dictated By:[**Last Name (NamePattern1) 3309**]
MEDQUIST36
D: [**2129-7-13**] 02:11
T: [**2129-7-13**] 18:34
JOB#: [**Job Number 3310**]
|
[
"276.5",
"482.41",
"250.00",
"518.81",
"304.10",
"428.0",
"496",
"276.3",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"89.64",
"96.6",
"89.68"
] |
icd9pcs
|
[
[
[]
]
] |
9154, 9589
|
8965, 9131
|
7588, 8944
|
1764, 1890
|
2101, 3650
|
131, 152
|
181, 1374
|
9605, 10494
|
1397, 1739
|
1907, 2078
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,973
| 131,872
|
45670
|
Discharge summary
|
report
|
Admission Date: [**2154-12-6**] Discharge Date: [**2154-12-11**]
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Back pain, food impaction
Major Surgical or Invasive Procedure:
Endoscopy
Rigid Bronchoscopy
History of Present Illness:
The patient is a 92-year old female with PMH significiant for
HTN, known esophageal diverticulum, and GERD who was brought to
the ED by her family after a large [**Holiday **] meal and concern
for an episode of food impaction. Given her complaints of severe
back pain and drooling her family felt she had food "caught in
her throat" because she had nearly identical symptoms twice in
the past with prior occurrences of food impactions. One day
prior to presentation she reported noticing worsening dysphagia,
increased oral secretions and drooling. She also began
complaining of intrascapular pains near the midline of her upper
back region. On initial emergency room presentation, vitals were
Temp: 97.9, HR:70, BP: 209/90, RR:18, and O2 saturation 100% on
room air. EKG showed normal sinus rhythm at 68 bpm with left
axis deviation and no acute ST changes. She received 2 mg IV
morphine and 10 mg IV hydralazine for SBPs in the 200 range.
.
She was initially admitted to the [**Hospital Unit Name 153**] for scoping but after a
prolonged procedure she desaturated and became hypoxic with
oxygen saturations in low 80s despite supplemental oxygen.
Therefore she was intubated for airway protection and
transferred to the [**Hospital Ward Name **] to the operating room in order to
undergo a rigid bronchoscopy/endoscopy to effectively and safely
relieve the patient's impaction. Of note, per anesthesia
reports, the patient's left lung was suctioned repeatedly and
noted to have copious mucous. There was some concern for an
aspiration event given these findings. Intraoperatively, lowest
BP was 100/40 and highest was 200/100 and her O2 saturations
ranged from 94-100%.
.
Ms. [**Last Name (Titles) **] brief post-operative ICU stay was remarkable for
some short-lived hypotension which was attributed to heavy
Propofol dosing. She was gradually weaned off of sedation and
given several small 250cc/500cc IVF boluses and her blood
pressures recovered. She was successfully extubated on [**2154-12-8**]
and continued to have oxygen saturations in the low to mid 90s
range on 2-4L NC. She was advanced to a soft PO regular diet
which she tolerated well. Of note, during her [**Hospital Unit Name 153**]/MICU course
her labs included a Hematocrit drop from the mid-30s range to a
Hct of 27-28 which was likely secondary to dilutional effects.
She had no other active signs of bleeding. Hospital course was
also notable for poorly controlled hypertension. She refuses to
take home BP medications but has allowed IV Hydralazine for SBPs
> 180s during this hospital stay.
.
On arrival to the regular medical floor the patient was still
afebrile and had O2 saturations of 96-97% on 2L NC. She
complained of a "sore, dry throat" which is likely from recent
intubation. Otherwise, BP was stable with 150s/60s measures and
she denied any cough, chills, chest pains, palpitations,
abdominal pain,nausea, emesis or diarrhea. She stated she still
felt a little "fuzzy" from her sedatives in the ICU. She was
able to speak in full sentences with no distress on 2L NC and no
accessory muscle use noticed.
.
Past Medical History:
-Hypertension
-GERD /Gastroesophageal Reflux Disease
-Esophagitis
-Esophageal diverticulum (wide neck) s/p food impaction X2
requiring EGDs, [**5-11**] and another one 1-2years ago
-Osteoporosis
-h/o T11 and T12 compression fractures
-Dyslipidemia
Social History:
The patient still works as supervisor at City [**Doctor Last Name **]. She lives
with her son and her daughter lives nearby and is also closely
involved. At baseline, well functioning, A&OX3. No current
etoh/tobacco/illicit drug use.
.
Family History:
Mother had hypertension later in life in her 50s, otherwise
non-contributory.
Physical Exam:
Physical Exam:
Vitals: T: 97.9, HR: 67, BP: 157/66, RR: 20, O2 97% on 2L
oxygen, Weight: 52 kg
GENERAL: Alert and oriented to person, place and time but some
memory deficits noted. No acute distress. Breathing comfortably
on 2L NC. Voice hoarse and soft.
HEENT: PERRLA, sclera anicteric, moist mucosal membranes, EOMI
CARDIAC: RRR, S1/S2 appreciated, II/VII systolic murmur at
LRSB/apex, no rubs, gallops,clicks.
RESPIRATORY: Clear to auscultation bilaterally, slighly
decreased lung sounds at left basilar region. No wheezes,
crackles or Rhonchi
ABD: soft, non-distended, normo-active bowel sounds throughout
EXT: Warm and well perfused, 2+ DP and PT pulses, no clubbing or
cyanosis, no edema distally.
NEURO: CNs [**2-19**] grossly in tact, no focal sensory or motor
deficits, gait deferred
SKIN: no rashes, no lesions
.
Pertinent Results:
ADMISSION LABS:
[**2154-12-6**] 11:45AM PLT COUNT-315
[**2154-12-6**] 11:45AM NEUTS-84.6* LYMPHS-12.3* MONOS-2.6 EOS-0.4
BASOS-0.2
[**2154-12-6**] 11:45AM WBC-8.1 RBC-3.75* HGB-12.0 HCT-34.2* MCV-91
MCH-32.1* MCHC-35.2* RDW-13.4
[**2154-12-6**] 11:45AM GLUCOSE-117* UREA N-18 CREAT-1.0 SODIUM-146*
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-30 ANION GAP-15
[**2154-12-8**] 10:22AM BLOOD WBC-12.7* RBC-3.04* Hgb-9.7* Hct-28.7*
MCV-94 MCH-31.8 MCHC-33.7 RDW-13.3 Plt Ct-230
[**2154-12-8**] 02:35AM BLOOD Glucose-93 UreaN-24* Creat-0.9 Na-139
K-3.4 Cl-106 HCO3-24 AnGap-12
.
.
CARDIAC ENZYMES:
[**2154-12-10**] 07:00AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2154-12-10**] 01:04AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2154-12-9**] 04:50PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2154-12-10**] 07:00AM BLOOD CK(CPK)-79
[**2154-12-10**] 01:04AM BLOOD CK(CPK)-87
[**2154-12-9**] 04:50PM BLOOD CK(CPK)-97
.
.
[**2154-12-6**] EKG: rate 80s, sinus rhythm, prolonged P-R interval.
Compared to the previous tracing of [**2154-12-6**] P-R interval has
increased.
.
PRIOR EGD REPORTS:
EGD [**11-14**] and [**1-14**]; A single diverticulum with large opening was
seen in the middle third of the esophagus. There was no evidence
of retained food
EGD [**5-11**]: food stuck in diverticulum with esophagits.
.
[**2154-12-6**] CXR: Air-fluid level in the superior mediastinum likely
representing fluid within the esophageal diverticulum. Minimal
atelectasis at the right lung base with no acute cardiopulmonary
process.
.
[**2154-12-6**] THORACIC SPINE XRAY: Interval progression of T11 and
T12 compression fractures with 50% loss of height and no gross
retropulsion. Suspected progression of upper thoracic
compression fractures as well although not well evaluated on
this study.
.
[**2154-12-7**]: CXR: Comparison is made to the radiograph of the same
day performed 18:40 hours. Endotracheal tube terminates at the
thoracic inlet. Aorta is somewhat ectatic and calcified. Heart
is top normal in size. There continues to be a small left
pleural effusion and left lower lobe atelectasis. Right lung is
clear.
.
[**2154-12-10**] PA AND LATERAL CXR:Patient now extubated. No signs of
acute CHF. Bilateral mild-to-moderate amount of pleural effusion
might be remnant after previous CHF episode. No new acute
pulmonary infiltrates.
.
[**2154-12-10**] BARIUM SWALLOW: Esophageal diverticulum arising from the
anterior mid esphagus. Findings consistent with known history of
traction diverticulum. Markedly abnormal esophageal motility,
with essentially no peristaltic activity appreciated and no
clearance of barium contrast from the esophagus while in the
prone position.
.
DISCHARGE LABS:
[**2154-12-11**] 06:10AM BLOOD WBC-5.6 RBC-3.26* Hgb-10.2* Hct-29.7*
MCV-91 MCH-31.4 MCHC-34.5 RDW-13.4 Plt Ct-300
[**2154-12-11**] 06:10AM BLOOD Glucose-91 UreaN-13 Creat-0.9 Na-143
K-3.5 Cl-107 HCO3-28 AnGap-12, Mg-1.6
Brief Hospital Course:
# Hypoxia/Respiratory Failure: The patient is a [**Age over 90 **]-year-old
female with known esophageal diverticulum who presented to the
ED with dysphagia, drooling and chest pain secondary to food
impaction. She also had some associated shortness of breath.
Soon after admission the GI service was called. An attempted UGI
endoscopy and food disimpaction proved to be prolonged,
difficult and unsuccessful. The patient did not tolerate this
prolonged procedure well and developed hypoxia and tachypnea.
Therefore, she was sedated and intubated for airway protection
and transferred to the operating room for disimpaction via
endoscopy/rigid bronchoscopy. A large food bolus was
successfully removed. Rigid bronchoscopy was complicated by a
suspected aspiration event at left lung as copious amounts of
secretions were suctioned. She remained intubated for several
hours post-operatively for ongoing airway protection. On
[**2154-12-7**] a CXR showed small left pleural effusion and left lower
lobe atelectasis. Right lung was clear on imaging. A day later
she was successfully weaned and extubated after RSBI 45 in the
MICU. She continued to recuperate well until the morning of
[**2154-12-10**] when she was noted to have worsening shortness of breath
with walking and minimal exertion with physical therapy team.
She developed a new cough and rhonchi on posterior lung exam.
Given her recent intubation and complaints of a mild cough,
there was concern for post-aspiration pneumonia. Fortunately, a
follow-up PA and Lateral CXR showed no infiltrates. She remained
afebrile but had a mild leukocytosis to 12 range. Incentive
spirometry was given for atelectasis prevention. Oxygen
saturations were monitored closely with low flow 2L 02 via nasal
cannula provided initially, then patient gradually weaned to
room air. She improved steadily and by time of discharge she had
ambulation saturation levels >94%.
.
# Hypotension: The patient has hypertension at her usual
baseline with average SBPs ranging from 140-170s,per family.
Soon after her food disimpaction procedure/rigid bronchoscopy
she developed marked hypotension which was attributed to her
propofol sedation. Sepsis was also in the differential given her
aspiration risks and early question of pneumonia. A
post-procedure pneumothorax was also entertained but fortunately
ruled out on CXR. She was given small IVF boluses of 250cc and
500cc and propofol was weaned off. She recovered soon thereafter
and was extubated without complications. Pressures were stable
upon transfer to the general medical floor. Patient's blood
pressure was in the 150s/60s range upon transfer from the MICU
to the medical floor and urine output remained well above
30cc/hour.
.
# Impacted Diverticulum: The patient has a known esophageal
diverticulum complicated by intermittent episodes of food
impaction. She was initially brought to the ED after developing
severe back pain and drooling consistent with her previous
episodes of food impaction. As above, GI was not able to fully
disimpact patient with inital attempted endoscopy. She underwent
thoracic procedure with rigid bronchoscopy /endoscopy in OR for
eventual successful disimpaction. Upon eventual stabilization
and transfer to the medical floor from the ICU she complained of
intermittent "burning" at her mid-sternum. She was ruled out for
any cardiac etiology with 3 sets of cycled enzymes from
[**Date range (1) **]. Cardiac enzymes were unremarkable and EKG benign.
Maalox and low dose Morphine provided relief of her chest pains
and suspected dyspepsia /gastric reflux symptoms. Ranitidine was
prescribed at time of discharge for ongoing acid reflux
protection. During her hospital stay, the speech and swallow
team evaluated Mrs. [**Last Name (STitle) **] and recommended soft solids, thin
liquids and advised patient to sit upright >80 degrees during
meals. A more formal follow-up Barium Swallow study showed
esophageal diverticulum arising from the anterior mid-esophagus,
consistent with traction diverticulum. There was markedly
abnormal esophageal motility with essentially no peristaltic
activity appreciated and no clearance of barium contrast from
the esophagus while in the prone position. Upon discharge, the
patient was set up for close outpatient follow-up with Dr.
[**Last Name (STitle) **].
.
# Hypertension: The patient stated that her usual blood pressure
ranges from 160s to 180s systolic. She received 10 mg IV
hydralazine during her recent endoscopy after systolic
pressures rose into the 200s. It was felt that there was no
urgent need to correct below 170s systolic given HTN chronicity.
She was given several doses of hydralazine as needed for high
pressures. She has known non-compliance with home HTN
medications and initially refusing medications on this
admission. She was counseled on the benefits of therapy on
several occasions and ultimately agreed to start taking daily
Diovan for better blood pressure control. Through her hospital
course her HTN gradually tapered and it was within 140-150s
systolic by time of discharge.
.
# Hypernatremia: The patient had low sodium levels noted upon
transfer to MICU post-operatively. Given weight of 52 kg, her
calculated free water deficit was 1.1 liters. She then developed
high Na levels to 146 range. She was given maintenance 1/2 NS
IVFs overnight from [**Date range (1) 12714**] and her sodium improved from 146
to 139 and slowly stabilized.
.
# Normocytic anemia: Appears to be a chronic issue and when
trended is similar to prior levels/labs. She had a few drops in
Hct which were felt to be secondary to dilutional effects from
IVFs. Hct dropped from 33 to 27 range and then returned to 29 by
time of discharge. No note of positive guaiac stools. No
evidence of active bleeding. She will plan to follow-up on her
anemia as an outpatient for ongoing workup with her primary care
provider.
.
# Prophylaxis: She was continued on subcutaneous heparin for DVT
protection and continued on daily Protonix for GI protection,
with PRN Maalox supplemented for additional breakthrough reflux
symptoms.
.
#Fluids, Electrolytes and Nutrition: The patient was continued
on gentle IVFs PRN, and electrolytes were monitored daily and
repleted as needed. Diet was slowly advanced to soft solids and
thin liquids.
She was maintained as a full code status for her hospital
course. Communication occurred daily directly with the patient
and her son and daughter. She was also given typed letters per
request to present to her employer regarding her recent illness
and absence from her job. Lastly, she was set up for close
follow-up with Dr. [**Last Name (STitle) **] on [**2154-12-16**] and with Dr. [**Last Name (STitle) **]
in the [**Hospital1 18**] Thoracic division.
.
Medications on Admission:
Coenzyme Q
vitamins
herbal supplements
.
Discharge Medications:
1. CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
2. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 weeks.
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Use as needed for constipation .
Disp:*30 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Esophageal diverticulum
Dysphagia
GERD / Gastroesophageal Reflux Disease
.
Secondary:
Hypertension
Compression fractures
Hyperlipidemia
Discharge Condition:
At time of discharge, the patient was in good condition with no
acute pain complaints, stable vital signs and improvement in her
swallowing difficulty.
Discharge Instructions:
It was a pleasure taking care of you during your hospital stay
here at [**Hospital1 69**] ([**Hospital1 18**]).
You were admitted with difficulty swallowing, drooling and
gastric reflux symptoms. An endoscopy or image study of your
throat and esophagus was performed and your symptoms were due
the lodging of some food in your esophagus. You have a condition
called esophageal diverticulum.
.
Swallowing studies show that you are at an increased risk for
choking when eating if food particles accidentally go into your
lungs instead of your stomach. It is very improtant that you eat
a diet that is soft consitency foods.
.
You are also advised to make sure you are sitting fully upright
with meals. Please follow-up with Dr. [**Last Name (STitle) **] in a week to
manage your esophageal condition on an long term basis.
.
Please return to the emergency room if you experience chills,
fevers, vomiting, chest pain, palpitations, worsening cough,
shortness of breath, drooling, trouble swallowing or any other
health concerns.
.
Medications Instructions:
-Please continue to take your daily Diovan for better control of
your high blood pressure.
.
-Please continue to take daily Ranitidine medication as
prescribed for relief of your acid reflux symptoms.
.
Consider starting a daily multivitamin and please start taking
Vitamin D and Calcium supplements.
.
-Otherwise, continue taking your usual home medications as
prescribed by your doctor prior to this hospital admission.
.
.
-
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 7273**] on [**12-16**] at 8:50am in the Atrium Suite, [**Location (un) **] of [**Hospital Ward Name 23**] Building on [**Hospital Ward Name 516**] [**Hospital1 18**]. (Phone
#[**Telephone/Fax (1) 5808**])
Follow-up with Dr. [**Last Name (STitle) **] on [**12-24**] at 11:30 am in
the Chest Disease Center, [**Location (un) **] [**Hospital Ward Name 121**] Building, [**Hospital1 **] I.
(Phone#[**Telephone/Fax (1) 82336**])
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2154-12-17**]
|
[
"E915",
"403.90",
"530.6",
"733.13",
"518.5",
"285.9",
"935.1",
"507.0",
"530.81",
"585.3",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"45.13",
"98.02"
] |
icd9pcs
|
[
[
[]
]
] |
15102, 15108
|
7790, 14546
|
246, 277
|
15297, 15451
|
4880, 4880
|
16985, 17709
|
3942, 4021
|
14638, 15079
|
15129, 15276
|
14572, 14615
|
15475, 16962
|
7544, 7767
|
4051, 4861
|
5473, 7528
|
181, 208
|
305, 3401
|
4896, 5456
|
3423, 3672
|
3688, 3926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,489
| 166,861
|
2572
|
Discharge summary
|
report
|
Admission Date: [**2184-8-19**] Discharge Date: [**2184-8-23**]
Date of Birth: [**2140-7-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
lethargy.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
44 M h/o EtOH cirrhosis, grade 1 esophageal varices, h/o
UGIB/LGIB, (MELD=34), developed increased abdominal girth and
worsening abdominal pain over past 3-4 days. He describes
diffuse upper abdominal pain, no focal RUQ or LUQ pain. 2d PTA,
he notes 2 episodes of hemetemsis, dark blood, no bright red
blood, +coffee grounds, ~1 cup volume. Pt also describes 2-3d of
dark, tarry stools, no BRBPR.
.
On morning of admission, pt sent to ED by his wife [**1-9**]
increasing lethargy. Pt presented to the ED with VS: 96.8 120
112/60 20-40 98%2L. He was felt to be in "intermittent
respiratory distress." He was noted to have FSBS=45, and given
[**12-9**] amp d50. Diagnostic tap performed showed +SBP (+WBC, many
+RBC), pt given CTX 1g x 1. HCT=25 (baseline 26-28), and given
?hememtesis, pt given 1U PRBC. He was seen by the liver fellow,
who was not initially concerned about GIB. Given concern for
HRS, he was given 5% dextrose 75cc/hr (total 500cc given upon
arrival to MICU). Tbil was 13.0 (baseline 3.0) ABD USN showed
common bile duct dilation (2mm->10mm currently), and plan was
made for MRCP in AM. pt also recevied 2mg IV ativan and
lactulose was written for. abd usn showed CBD dilation, tbil
13.0.
Past Medical History:
1. ETOH cirrhosis, Grade 1 esophageal varices [**8-12**],
diverticulosis/polyp [**12-12**]
2. Iron Deficiency Anemia
3. HTN
4. Hypercholesterolemia
5. Gout
6. Gastritis
7. GERD
8. Splenomegaly
9. Chronic leukopenia/thrombocytopenia
Social History:
denies tobbacco, 1 pint whiskey alcohol, IVDU. painter,
disability. lives with wife.
Family History:
alcoholism
Physical Exam:
VS: 95.9 126 89/73 79.3 kg 28 99%2L NC
GEN: uncomfortable, shallow rapid breath, jaundiced.
HEENT: PERRLA, EOMI, sclera icteric, OP clear, MMM, no LAD, no
carotid bruits. 8-10 cm JVD.
CV: regular, tachy, nl s1, s2, no m/r/g.
PULM: CTA B, no r/r/w.
ABD: firm, distended, +RUQ tenderness to palation, + BS, liver
appreciable 3-4 cm below costovertebral angle. + spider angioma.
EXT: warm, 2+ dp/radial pulses BL.
NEURO: alert & oriented x 3, though lethargic. CN II-XII grossly
intact. 4/5 strength symmetric @ triceps, biceps, delts, hip
flexion, dorsoflexion, plantarflexion, limited by lethargy.
Pertinent Results:
[**2184-8-19**] 01:35PM BLOOD WBC-4.1# RBC-2.59* Hgb-8.7* Hct-25.1*
MCV-97# MCH-33.5*# MCHC-34.6 RDW-17.0* Plt Ct-57*
[**2184-8-20**] 10:08AM BLOOD WBC-5.9 RBC-2.76* Hgb-9.0* Hct-25.6*
MCV-93 MCH-32.5* MCHC-35.0 RDW-17.0* Plt Ct-34*
[**2184-8-20**] 11:45PM BLOOD WBC-6.2 RBC-2.82* Hgb-9.4* Hct-26.8*
MCV-95 MCH-33.1* MCHC-34.8 RDW-17.1* Plt Ct-59*#
[**2184-8-21**] 11:45AM BLOOD WBC-6.1 RBC-2.88* Hgb-9.3* Hct-26.5*
MCV-92 MCH-32.2* MCHC-35.0 RDW-17.4* Plt Ct-39*
[**2184-8-21**] 11:36PM BLOOD WBC-6.2 RBC-3.05* Hgb-10.1* Hct-28.5*
MCV-93 MCH-33.1* MCHC-35.4* RDW-17.9* Plt Ct-36*
[**2184-8-22**] 12:09PM BLOOD WBC-5.2 RBC-3.36* Hgb-10.8* Hct-30.6*
MCV-91 MCH-32.0 MCHC-35.1* RDW-18.0* Plt Ct-38*
[**2184-8-19**] 01:35PM BLOOD PT-20.4* PTT-50.7* INR(PT)-2.0*
[**2184-8-20**] 04:40AM BLOOD PT-22.7* PTT-52.2* INR(PT)-2.2*
[**2184-8-20**] 11:45PM BLOOD PT-18.6* PTT-42.6* INR(PT)-1.8*
[**2184-8-22**] 03:39AM BLOOD PT-19.9* PTT-41.7* INR(PT)-1.9*
[**2184-8-19**] 01:35PM BLOOD Glucose-45* UreaN-32* Creat-3.0*# Na-125*
K-3.8 Cl-95* HCO3-11* AnGap-23*
[**2184-8-20**] 04:40AM BLOOD Glucose-66* UreaN-36* Creat-3.4* Na-126*
K-4.0 Cl-97 HCO3-11* AnGap-22*
[**2184-8-20**] 11:45PM BLOOD Glucose-68* UreaN-45* Creat-4.1* Na-128*
K-3.4 Cl-98 HCO3-12* AnGap-21*
[**2184-8-21**] 11:36PM BLOOD Glucose-74 UreaN-53* Creat-4.9* Na-133
K-4.0 Cl-101 HCO3-11* AnGap-25*
[**2184-8-22**] 12:09PM BLOOD Glucose-89 UreaN-60* Creat-4.8* Na-135
K-3.5 Cl-103 HCO3-14* AnGap-22*
[**2184-8-19**] 01:35PM BLOOD ALT-67* AST-454* CK(CPK)-196*
AlkPhos-150* Amylase-38 TotBili-13.5*
[**2184-8-20**] 11:40AM BLOOD ALT-41* AST-227* LD(LDH)-342* CK(CPK)-107
AlkPhos-79 TotBili-15.4*
[**2184-8-21**] 05:29PM BLOOD ALT-30 AST-117* LD(LDH)-178 AlkPhos-94
TotBili-20.0*
[**2184-8-22**] 12:09PM BLOOD ALT-30 AST-99* LD(LDH)-198 AlkPhos-104
TotBili-21.9*
[**2184-8-19**] 01:35PM BLOOD cTropnT-0.02*
[**2184-8-19**] 07:40PM BLOOD CK-MB-19* MB Indx-13.3* cTropnT-0.02*
[**2184-8-20**] 04:40AM BLOOD CK-MB-13* MB Indx-11.4* cTropnT-<0.01
[**2184-8-19**] 07:40PM BLOOD Calcium-6.4* Phos-4.9* Mg-1.0*
[**2184-8-21**] 04:26AM BLOOD Albumin-3.2* Calcium-8.9 Phos-4.5 Mg-2.3
[**2184-8-22**] 12:09PM BLOOD Albumin-3.0* Calcium-8.1* Phos-3.9 Mg-2.2
[**2184-8-19**] 01:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-9.9
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2184-8-19**] 10:25PM BLOOD Type-ART pO2-94 pCO2-26* pH-7.32*
calTCO2-14* Base XS--10
[**2184-8-20**] 07:08AM BLOOD Type-ART pO2-80* pCO2-27* pH-7.31*
calTCO2-14* Base XS--11
[**2184-8-20**] 05:25PM BLOOD Type-ART pO2-56* pCO2-31* pH-7.31*
calTCO2-16* Base XS--9
[**2184-8-20**] 06:55PM BLOOD Type-ART Tidal V-600 PEEP-5 FiO2-50
pO2-87 pCO2-30* pH-7.32* calTCO2-16* Base XS--9
Intubat-INTUBATED
[**2184-8-21**] 04:18PM BLOOD Type-ART Temp-38.2 Rates-/15 Tidal V-500
PEEP-10 FiO2-50 pO2-90 pCO2-46* pH-7.19* calTCO2-18* Base XS--10
-ASSIST/CON Intubat-INTUBATED
[**2184-8-21**] 09:30PM BLOOD Type-ART Temp-36.1 Rates-24/ Tidal V-600
PEEP-10 FiO2-50 pO2-49* pCO2-27* pH-7.35 calTCO2-16* Base XS--8
Intubat-INTUBATED Vent-CONTROLLED
[**2184-8-19**] 04:39PM BLOOD Lactate-2.4*
[**2184-8-20**] 05:25PM BLOOD Glucose-80 Lactate-1.3 Na-125* K-3.3*
Cl-100
.
STUDIES:
[**2184-8-19**] CXR: No acute cardiopulmonary process
[**2184-8-19**] EKG: sinus tach, nl intervals, axis, no STE/STD, TWI in
III (old).
.
[**2184-8-19**] ABD USN:
1. Diffusely, echogenic liver, likely representing cirrhosis or
fatty liver or combination of both, with massive splenomegaly
with hemangioma, and moderate ascites and gallbladder edema as
noted previously. Normal direction but low and non-phasic flow
in the portal vein, due to portal hypertension.
2. Increase in size of dilated CBD measuring 1 cm. No
obstructing stone or mass is seen on this ultrasound; however,
the evaluation of distal CBD somewhat is limited. Please
correlate with lab values, and if indicated, please consider
MRCP for further evaluation.
Brief Hospital Course:
A/P:
44 M EtOH cirrhosis, presented to ED with lethargy, hemetemesis,
increasing abdominal girth and pain, found to have +SBP in ED,
and diagnosed with HRS [**1-9**] rising creatinine tx with
octreotide/midodrine, course complicated by respiratory failure
[**1-9**] poor mental status resulting in intubation. goals of care
ultimately switched to comfort measures only [**1-9**] poor prognosis
and pt expired.
.
.
# cirrhosis: meld=34. h/o UGIB/LGIB, and recent NSAID use,
continues to drink EtOH daily, found to have +SBP in ED. pt
followed by liver service with concern for HRS, ulimatley course
complicated by respiratory failure [**1-9**] poor mental status, HRS,
and overall prognosis felt poor. goals of care switched to
comfort measures only [**8-21**], and pt expired [**8-22**].
.
# +SBP/ascites - pt continued on ceftriaxone for SBP 1g q24h,
with plan for consideration of repeat tap in 3d to ensure
clearing infection.
.
# varices - hct baseline 26-28, down to 25 on admission, and 22
on admit to ICU.
pt transfused 2U PRBC now with appropriate bump in HCT and
stablization of HCT. pt continued on PPI IV BID. EGD deferred
as pt not felt actively bleeding per liver fellow. nadolol held
in setting of ?GIB however.
.
# ARF - concerning for hepatorenal syndrome - baseline
creatinine normal (0.9-1.0), up to 3.0, concerning for HRS
versus abdominal compartment syndrome (bladder pressure measured
25, thus performed 1.4L therapetuic paracentsis, repeat bladder
pressure 15). pt given 1L 5% albumin in ED. and given
additional 1L NS now, as well as 1L D5W + folate, thiamine, mvi
to complete fluid challenge. urine lytes failed to improve, and
pt started on octreotide, midrodine per liver fellow. he was
also treated with albumin 1.5 mg/kg ~ equals 100mg albumin of
25% albumin on day 1 (now) and on day 3, per HRS protocol.
unfortunately creatinine continued to rise to 4.8. no evidence
of hydronephrosis on abdominal usn [**8-19**].
.
# encephalopathy - lethargic on presentation to MICU, pt had
been on lactulose last admission, though not taking this
currently, could also represent infection (SBP vs UTI). pt
treated for SBP as above, and started on lactulose without
significant improvement in mental status, likely [**1-9**] hepatic
encephalopathy.
.
# alcohol withdrawal - pt continues to actively drink etoh, he
was treated with bananna bag overnight, thiamine/folate
repletion qdaily, and valium 5-10mg iv/po per CIWA.
.
# elevated tbil - likely [**1-9**] etoh cirrhosis, AP is 100s, lower
than previously. however abd usn shows increase dilation of CBD
(2mm ->10 mm), however no evidence of cholecysistis (no stones,
mild edema c/w cirrhosis), afebrile, no wbc count, though
+bandemia. given meld, pt too sick for ERCP, and plan for MRCP
deferred given stable AP. pt covered with flagyl in addition
to CTX as above for biliary tree infectious coverage.
.
# coagulopathy - likely [**1-9**] poor synthetic function, rising
2.0->2.2. pt treated with vitamin k 5mg po x 3d. held off on
FFP for now, however if hct dropping, will give FFP tonight.
.
# thrombocytopenia - baseline 70-100s, down to 30s, will
transfuse for >30 given concern for active bleeding. ?uremic
platelets. given 1U platelets on admission for ?procedure
(MRCP) in am, though this was deferred.
.
# hyponatremia - felt likely [**1-9**] cirhosis. pt treated with free
water restriction 1L once eating, and kept NPO while intubated.
.
.
# respiratory - elevated RR, likely [**1-9**] shallow breathing due to
abdominal ascites versus respiratory compensation for metabolic
acidosis. initial ABG 7.32/26/94 on 2L NC. given abdominal
compartment syndrome (bladder pressure 25), removed 1.4L via
therapeutic paracentesis (no need for additional albumin per
liver fellow).
however respiratory status continued to worsen, and pt
electively intubated for airway protection, however he self
d/c'd ETT tube [**8-21**], which was replaced after confirming initial
goals of care with wife. ultimately decision made to switch
goals of care to comfort measures only and ETT removed.
.
.
# cardiac - no known h/o CAD, however elevated troponin this
admission. feel ACS unlikely given no EKG changes. CE
followed, no asa/plavix given bleeding.
.
# rythym - sinus tachycarida - likely [**1-9**] volume depletion
versus etoh withdrawal vs infection (SBP). HR trending down
130s->108 with abx, IVF. lytes repleted, and pt maintained on
telemetry.
.
# pump - elevated JVP, though clearly intravascularly depleted.
pt treated with IVF as above given HRS.
.
# acid base - using 7PM labs and ABG, 7.32/26/94, gap =17,
delta-delta = 5, corrected HCO3 = 17, thus pt has both AG
acidosis and non gap acidosis. ddx of AG acidosis likely
includes starvation ketosis, ARF, lactic acidosis (trending
down). non-gap acidosis ? [**1-9**] diarrhea (though pt denies) versus
RTA, though feel unlikely. pCO2 = 26, reflects appropriate
compensation for metabolic acidosis (expected PCO2 = 1.5(12) + 8
+/- 2 = 24-28). no osmolar gap: calculated osm = (2(127) +
59/1.8 + 34/2.8 + 0/4.6 = 269, measured osm = 279, gap = 10.
plan was to trend hco3, if < 13, consider po bicitra or iv
repletion (if ph declining).
metabolic acidosis likely driving respiratory rate.
.
.
# ID/bandemia - most likely [**1-9**] SBP, blood cultures pending, not
urinating currently, no diarrhea, CXR clear. lactate trending
down. bcx show +group b strep bacteremia on [**8-19**]. peritoneal
fluid cx ngtd. pt treated with ctx/flagyl.
.
.
# hypoglycemia - etiology unclear (?sepsis), required amp d50 in
ED, receiving D5W currently with fluid repletion, followed Q2H
overnight, and d/c in AM as normalizing.
.
.
# R knee pain - h/o gout. +effusion, not especially warm on micu
admit. no erythema. plan was for tapping knee in future once pt
more stable, for now will follow and treat symptomatically with
ultram prn pain.
.
.
#FEN: k, calcium, mg, replete agreesively. pt kept NPo, and
given IVF as above, given 1L IVF NS only, and used 5% albumin
(500cc) for fluid repletion otherwise, as preferred in
cirrhotics.
.
#COMM: wife ([**Name2 (NI) **]) [**Telephone/Fax (1) 13007**] (work), [**Telephone/Fax (1) 13008**]
(h), PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Location (un) **]) [**Telephone/Fax (1) 13009**].
.
# DISPO: pt initially full code, however felt to have extremely
poor prognosis per liver fellow given worsening HRS, GIB, and
worsening mental status. after extensive discussion with
family, decision made to switch goals of care to comfort
measures only, and pt expired.
Medications on Admission:
Medications (on last discharge summary [**1-14**]):
[allopurinol 200 QD]
nadolol 20mg po qdaily
thiamine 100mg po qdaily
sucralfate 1 mg po qid
ranitidine 150mg po bid
ferrous sulfate 325 mg po bid
.
.
Medications pt taking currently:
ibuprofen 8-12 tablets qdaily for knee/abdomen pain.
iron, b12, mvi.
Discharge Medications:
pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired.
Discharge Condition:
pt expired.
Discharge Instructions:
pt expired.
Followup Instructions:
pt expired.
|
[
"456.8",
"274.9",
"303.01",
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"357.5",
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"571.1",
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"789.5",
"291.2",
"535.31",
"288.50",
"799.02",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"96.72",
"96.04",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
13475, 13484
|
6500, 13084
|
325, 331
|
13539, 13552
|
2587, 6477
|
13612, 13626
|
1941, 1953
|
13439, 13452
|
13505, 13518
|
13110, 13416
|
13576, 13589
|
1968, 2568
|
276, 287
|
359, 1567
|
1589, 1823
|
1839, 1925
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,058
| 146,270
|
40326
|
Discharge summary
|
report
|
Admission Date: [**2121-11-22**] Discharge Date: [**2121-11-24**]
Date of Birth: [**2077-10-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Clotted LUE AV graft
Major Surgical or Invasive Procedure:
Failed thrombectomy in Interventional Radiology ([**2121-11-22**])
Revision of arterial and venous components of LUE AV graft
([**2121-11-23**])
History of Present Illness:
Patient is 44 y/o M with a h/o HTN and DM with ESRD on dialysis
transferred from FMC [**Last Name (un) 77720**] as direct admit after noted to have
clot in LUE AV graft. Unable to proceed with dialysis. Receives
dialysis Tues, Thurs, Sat. Dialysis for 3.5 year. R arm AV
fistula placed in [**2118**] and clotted despite [**3-19**] revision
procedures. L arm fistula placed in [**2121-6-14**], which failed. L
arm AV graft placed [**2121-7-15**], which is current access.
Denies pain, weakness, change in sensation, swelling, or loss of
circulation in arm.
Past Medical History:
HTN
Insulin-dependent diabetes since [**2114**]
gout
h/o MRSA septicemia [**2121-7-8**]
Social History:
patient is a prisoner at FMC [**Last Name (un) 77720**]; denies tobacco, alcohol, or
illicit drug use
Family History:
HTN in father and grandparents, diabetes in father and paternal
grandfather, no h/o kidney disease
Physical Exam:
Vitals:
Temp 96.9,
BP - 138/78mm Hg
HR - 92/min
RR - 19/min
SpO2 - 97% on room air
CVS - S1 S2 heard, no murmurs
RS - bilateral normal breath sounds
GI - soft, non tender or distendeed
NS - alert and oriented to time, place and person.
Left UE - bruit +, thrill+, pulses intact, no motor deficits
Pertinent Results:
[**2121-11-22**] 02:55PM PT-12.6 PTT-22.8 INR(PT)-1.1
[**2121-11-22**] 02:55PM PLT COUNT-194
[**2121-11-22**] 02:55PM WBC-7.3 RBC-4.43* HGB-14.1 HCT-41.0 MCV-93
MCH-31.9 MCHC-34.4 RDW-14.7
[**2121-11-22**] 02:55PM CALCIUM-9.9 PHOSPHATE-4.2 MAGNESIUM-2.7*
[**2121-11-22**] 02:55PM BLOOD Glucose-143* UreaN-69* Creat-12.3* Na-135
K-5.0 Cl-95* HCO3-25 AnGap-20
[**2121-11-24**] 08:45AM BLOOD Glucose-119* UreaN-60* Creat-11.8*#
Na-136 K-6.2* Cl-97 HCO3-28 AnGap-17
[**2121-11-24**] 08:45AM BLOOD WBC-8.1 RBC-4.28* Hgb-13.5* Hct-39.9*
MCV-93 MCH-31.5 MCHC-33.8 RDW-14.8 Plt Ct-176
Brief Hospital Course:
44 M who was admitted to the transplant surgery service with a
thrombosed left upper extremity arterio venous graft. On
[**2121-11-22**], thrombectomy of the graft failed in Interventional
Radiology following which the patient underwent revision of the
arterial and venous components of the graft on [**2121-11-23**]. Post
operatively, there was a palpable thrill and audible bruit over
the graft site. There was no neurological deficit and pulses
were intact. The patient has undergone hemodialysis after the
revision of the graft on [**2121-11-23**] and [**2121-11-24**]. His creatinine
has improved from 12.3 on admission to 11.8 today. His serum
potassium was 5.8 on [**2121-11-23**] and 6.2 on [**2121-11-24**] for which he
underwent hemodialysis.He is now being discharged back to his
facility.
Medications on Admission:
allopurinol 100 mg daily,
metoprolol 50 mg [**Hospital1 **],
lisinopril 20 mg daily,
amlodipine 10 mg daily,
simvastatin 20 mg daily,
vit b12 100 mcg,
Renagel 3200 TID with meals,
insulin: NPH 28 QAM/ 14 QPM, 6 units reg insulin QPM, RISS,
Benadryl 50 mg prn itching
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Clotted left upper extremity AV graft
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Return to the hospital if you have any bleeding or oozing from
your incision, any numbness or tingling in your arm, or any loss
of motor function. After 48 hours you may shower, pat incision
dry afterwards. No bathing or soaking arm for at least two
weeks. No heavy (greater than ten pounds) lifting with left arm
for at least two weeks.
Followup Instructions:
Please call Dr. [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 77070**] for a
follow-up appointment in 2 weeks.
Completed by:[**2121-11-24**]
|
[
"V12.04",
"250.00",
"585.6",
"996.73",
"403.91",
"443.9",
"V58.67",
"414.01",
"E878.2",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.42",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
3942, 3948
|
2368, 3173
|
338, 485
|
4030, 4030
|
1758, 2345
|
4546, 4768
|
1319, 1420
|
3491, 3919
|
3969, 4009
|
3199, 3468
|
4181, 4523
|
1435, 1739
|
278, 300
|
513, 1071
|
4045, 4157
|
1093, 1183
|
1199, 1303
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,514
| 117,057
|
2006
|
Discharge summary
|
report
|
Admission Date: [**2109-9-1**] Discharge Date: [**2109-9-6**]
Date of Birth: [**2047-9-9**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
A 61 year old gentleman was seen in the ED with after reporting
he was having lower extremity swelling, dizziness, and falling
down. He feels this was related to an atenolol allergy. In the
ED, his vitals were T 100.8, BP 135/72, HR 45, and 94% on RA. He
was given lasix 20 mg and aspirin in the ED. He additionally
complained of chest pain, dyspnea and diaphoresis though he was
unreliable in the ED. Per there report, he was responsive to
sternal rub and answered limited questions for them. He reports
that he was given a prescription for atenolol at [**Hospital1 2177**] but has a
history of atenolol allergy.
.
In the ED, VS: 100.8 135/72 45 16 94%RA. He received Aspirin
325mg, albuterol, Lasix 20mg PO.
.
Upon arrival to the floor, patient was altered and minimally
responded to strenal rub. He was given narcan with good effect.
He was transiently hypotensive, though became hypertensive
without any intervention. He underwent Head CT which was
negative for bleed. Upon arrival to the MICU, unable to obtain
further history due to patient's altered mental status.
Past Medical History:
- h/o Anti-social personality disorder
- s/p STEMI w/ BMS in LAD in [**10-1**], due to GI bleed stopped
plavix cont only aspirin
- Malignant hypertension: thought to be secondary to medication
non-compliance, but had hypotension during recent admission in
[**10-31**] and BP meds were cut back. (most likely due to Clonidine
effect: overdose/withdrawal)
- Pulmonary embolus: Recurrent [**Month/Year (2) 11011**] s/p IVC filter, not on
coumadin due to noncompliance
- Heroin abuse: methadone maintenance clinic [**Street Address(2) 11016**]
daily at 7AM (most recent daily dose on [**Month (only) 462**] 135 mg daily.
- Hepatitis B previous infection, now sAg negative
- Hepatitis C, undetectable HCV RNA [**3-29**]
- Chronic obstructive pulmonary disease
- Gastroesophageal reflux disease
- PTSD ([**Country 3992**] veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease baseline Cr 1.5
Social History:
Unable to obtain, reports of homelessness. Not currently
employed; recieves "money from the government". Denies smoking,
ETOH or recent drug use.
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
Vitals: HR 79, BP 152/75, RR 23, 92% on ???, afebrile
Gen: moaning in bed, one word answers
HEENT: dilated pupils, equal round and reactive to light
CV: RRR, no m/r/g
Pulm: diffuse wheezes
Abd: obese, soft, NT, ND, bowel sounds present
Ext: pitting b/l LE edema
Neuro: moving all extremities
Exam on discharge:
vitals: stable, 95-99% RA, afebrile > 48 hours
psych- mood appropriate
lungs- CTA bilaterally, no wheezes
CV- RRR, no m,r,g
Abd- soft, NT, ND, active BS, decreased superficial venous
distention
Ext- lower extremity chronic venous stasis
Pertinent Results:
Labs on admission:
GLUCOSE-126* UREA N-33* CREAT-1.7* SODIUM-142 POTASSIUM-3.6
CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
ALT(SGPT)-18 AST(SGOT)-38 LD(LDH)-290* CK(CPK)-166 ALK PHOS-76
TOT BILI-0.4
ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-1.9
WBC-4.2 RBC-3.19* HGB-8.5* HCT-27.3* MCV-86 MCH-26.6* MCHC-31.1
RDW-15.5
PLT COUNT-150
PT-14.7* PTT-31.0 INR(PT)-1.3*
PT-15.9* INR(PT)-1.4*
TYPE-ART PO2-249* PCO2-36 PH-7.37 TOTAL CO2-22 BASE XS--3
O2 SAT-99
URINE HOURS-RANDOM
URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-POS
GLUCOSE-100 UREA N-32* CREAT-1.7* SODIUM-143 POTASSIUM-4.4
CHLORIDE-107 TOTAL CO2-20* ANION GAP-20
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
WBC-6.8 RBC-3.52* HGB-9.8* HCT-31.2* MCV-89 MCH-28.0 MCHC-31.5
RDW-15.3
PLT COUNT-150
TYPE-ART PO2-95 PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1
LACTATE-0.7
O2 SAT-97
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
LACTATE-1.7
cTropnT-<0.01
CK-MB-4 proBNP-8124*
ALBUMIN-4.4
D-DIMER-1008*
WBC-5.6# RBC-3.02* HGB-8.3* HCT-25.9* MCV-86 MCH-27.3 MCHC-31.9
RDW-15.7*
NEUTS-76.2* LYMPHS-16.6* MONOS-3.9 PLT COUNT-170
.
IMPRESSION:
No evidence of acute intracranial abnormalities.
The study and the report were reviewed by the staff radiologist.
Head CT- No evidence of acute intracranial abnormalities
Repeat CXR- Rapidly improving right lower lobe opacity favoring
aspiration or atelectasis over an infectious pneumonia
Labs at discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
3.9* 3.06* 8.4* 26.1* 85 27.3 32.0 16.2* 156
PT PTT INR(PT)
13.5* 31.0 1.2*
Glucose UreaN Creat Na K Cl HCO3 AnGap
161* 18 1.3* 139 3.6 102 28 13
Brief Hospital Course:
Patient is a 61 year old male with coronary artery disease
status post myocardial infarction, history of pulmonary embolus
status post inferior vena cava filter not on coumadin due to med
non-compliance, chronic obstructive pulmonary disease, and
history of drug abuse, admitted with dyspnea and altered mental
status.
1. Altered mental status: The patient presented with altered
mental status upon admission to the floor from the emergency
department. He was then immediately transferred to the ICU for
further care, as there was concern for an atenolol overdose,
with a heart rate in the 40s. He has a history of overdosing on
medications while hospitalized. Narcan was given with good
response, suggestive of a narcotic overdose. The patient then
had an episode of flash pulmonary edema, which was managed well
with lasix IV. Urine tox screen was positive for methadone and
benzodiazepines. The patient's altered mental status improved
on [**9-2**], and the patient became alert and oriented x 3. CIWA
scale was started after transfer from the ICU to the floor, and
was discontinued the next day after patient did not score.
Initially, psychotropic meds were held. As mental status
improved, methadone and benzodiazepine therapy were restarted
with recommendations from the psyciatry consult service. The
patient tolerated this well, and seroquel and duloxetine were
also restarted. It was thought that the patient's diminished
mental status upon presentation was secondary to mild renal
insufficiency in the setting of methadone and benzodiazapine
therapy. The patient was evaluated by psychiatry, given his
history of anti-social personality disorder, depression/anxiety,
and polysubstance abuse in remission. Psychiatric evaluation
revealed a patient who was not psychotic, and did not have any
active, acute psychiatric issues, and was deemed to have
capacity. There were no further mental status changes during
the remainder of his hospitalization.
2. Pulmonary Edema: The patient developed acute shortness of
breath, tachypnea, and wheezing upon arrival to the ICU. Plain
chest film at this time showed evidence of pulmonary edema and
fluid overload. It was likely that the patient developed
pulmonary edema, possibly in the setting of hypertension
following Narcan administration. The patient responded well to
lasix IV. Patient also experienced brief increased oxygen
requirement on the floor, which again improved with lasix and
bronchodilator/anti-cholinergic therapy. The patient was
discharged on room air with clear lung sounds and no subjective
shortness of breath.
3. history of pulmonary embolus status post inferior vena cava
filter. He was initially placed on heparin gtt in the ICU;
however, after a conversation with the patient's PCP, [**Name10 (NameIs) **]
heparin gtt was stopped and the patient's anticoagulation was
held. The patient is a poor candidate for Coumadin, given his
persistent noncompliance. Anti-coagulation was held during his
hospitalization secondary to medical non-compliance, and the
patient was discharged without anti-coagulation.
4. polysubstance abuse in remission. Patient has history of
substance abuse. He is on methadone maintance at baseline. The
methadone clinic was called today, and the patient's current
dose is 125 mg daily. He was thus restarted on his methadone
after his mental status improved, and was continued on this dose
for the duration of his hospital course.
5. UTI - The patient began complaining of dysuria and found to
have a urine culture postive for pansensitive E. coli. He was
started on ciprofloxacin and told to complete a 7 day course
6. CAD - He had been discharged previously on metoprolol, but
this was not restarted while in the hospital secondary to
systolics in the 100s. He is scheduled for follow up and should
restart his metoprolol at that time. He was continued on his
outpatient dose of Aspirin, simvastatin and lisinopril.
7. COPD - He was maintained on his nebulizers (albuterol,
atrovent).
8. GERD - Stable. continuted pantoprazole.
All other medical issues remained stable. No other medication
changes were made.
Medications on Admission:
Med List per OMR:
Albuterol
Clonazepam 2mg PO TID
Duloxetine [Cymbalta] 30mg PO daily
Fluticasone-Salmeterol 1 puff PO BID
Furosemide 40mg PO daily
Methadone 135mg Sig unknown
Nadolol 20mg PO daily
Omeprazole 20mg PO BID
Oxycodone-Acetaminophen [Percocet] dose unknwon
Quetiapine [Seroquel] 100mg PO daily
Simvastatin 40mg PO QHS
Spironolactone 25mg PO Daily
Tamsulosin [Flomax] 0.4mg PO Daily
Tiotropium Bromide 18mg Inh Daily
Aspirin 325mg PO daily
Docusate Sodium 100mg PO BID
Multivitamin 1 tab PO Daily
Senna 8.6 mg PO BID:PRN
Discharge Medications:
1. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 5 doses.
Disp:*5 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheezing.
Disp:*1 MDI* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Advair HFA 115-21 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day.
Disp:*1 disc* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*0*
11. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
altered mental status
urinary tract infection
acute on chronic congestive heart failure
Secondary Diagnoses:
- h/o Anti-social personality disorder
- s/p STEMI w/ BMS in LAD in [**10-1**], due to GI bleed stopped
plavix cont only aspirin
- Hypertension: thought to be secondary to medication
non-compliance, but had hypotension during recent admission in
[**10-31**] and BP meds were cut back. (most likely due to Clonidine
effect: overdose/withdrawal)
- Pulmonary embolus: Recurrent [**Month/Year (2) 11011**] s/p IVC filter, not on
coumadin due to noncompliance
- Heroin abuse: methadone maintenance clinic [**Street Address(2) 11016**]
daily at 7AM (most recent daily dose on [**Month (only) 462**] 135 mg daily.
- Hepatitis B previous infection, now sAg negative
- Hepatitis C, undetectable HCV RNA [**3-29**]
- Chronic obstructive pulmonary disease
- Gastroesophageal reflux disease
- PTSD ([**Country 3992**] veteran)
- Anxiety / Depression
- Chronic kidney disease baseline Cr 1.5
Discharge Condition:
Stable, at baseline mental status, no longer somnolent,
tolerating psychotropic medications.
Discharge Instructions:
You were admitted to the hospital with some shortness of breath,
chest discomfort, and leg pain. You were also very sleepy.
After being admitted, your medical team had difficulty waking
you up, and you were transferred to the ICU. You received
medication to help you wake up and breath better, and you were
transferred to the general medical floor. You then continued to
get better, and you started receiving your regular medications.
You were seen by your psychiatrist in the hospital as well. You
had another episode of shortness of breath, which was likely due
to mild bronchitis and a small amount of fluid in your lungs.
IV medication improved your symptoms. You received some
physical therapy, did well, and you were discharged on [**2109-9-6**],
and will follow up with your doctors next week.
No changes were made to your medications.
You will continue to receive your daily methadone from the
Narcotic [**Hospital 11026**] Clinic Methadone Services at [**Street Address(2) 11027**].
Please follow up with Dr. [**Last Name (STitle) 10990**], on [**2109-9-11**] at 11:00 a.m. and
please see your PCP on the same day at 3:55 p.m.
Please call your PCP [**Last Name (NamePattern4) **] 911 if you develop shortness of breath,
chest pain, difficulty urinating, trouble walking, excessive
diarrhea, sleepiness, or any other concerning medical symptoms.
Followup Instructions:
Please follow up with your Psychiatric provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10990**], on
[**2109-9-11**] at 11:00 a.m.
Appointment with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11028**], at [**Hospital1 2177**] on [**2109-9-11**] at 3:55
pm.
You have an appointment with gastroenterology on [**2109-9-25**] at [**Hospital1 2177**]
|
[
"412",
"403.90",
"E935.1",
"428.0",
"300.4",
"427.89",
"428.23",
"301.7",
"304.01",
"285.21",
"496",
"585.9",
"V45.02",
"584.9",
"070.54",
"414.01",
"E939.4",
"292.12",
"599.0",
"070.32",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11188, 11194
|
5077, 5408
|
309, 315
|
12247, 12342
|
3264, 3269
|
13753, 14136
|
2590, 2679
|
9810, 11165
|
11215, 11215
|
9253, 9787
|
12366, 13730
|
2694, 2987
|
11344, 12226
|
249, 271
|
4818, 5054
|
343, 1417
|
3006, 3245
|
11234, 11323
|
3284, 4798
|
5424, 9227
|
1439, 2410
|
2426, 2574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,837
| 159,406
|
47579
|
Discharge summary
|
report
|
Admission Date: [**2188-4-15**] Discharge Date: [**2188-4-23**]
Date of Birth: [**2118-8-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Worsening fatigue
Major Surgical or Invasive Procedure:
[**2188-4-15**] CABG X 3 (LIMA>LAD, SVG>LPL, SVG>AM)
History of Present Illness:
Mr. [**Known lastname **] is a 69 year old male with known coronary artery
disease and end stage renal disease. He requires hemodiaylsis
and is currently being evaluated for renal tranplantation. Prior
to kidney transplantation, he will require coronary
revascularization. Currently his only complaint is worsening
fatigue. He denies chest pain, shortness of breath, orthopnea
and PND. Overall, he feels relatively well on medical therapy.
He remains relatively inactive secondary to frequent dialysis
three times per week.
Past Medical History:
Coronary Artery Disease - s/p Multipe PCI/Stents
History of Multiple MI's - most recent [**2187-9-5**]
End-stage Renal Disease on Hemodialysis
Right Brachicephalic Av Fistula [**2187-12-6**]
Tunnelled Dialysis Catheter [**2187-8-5**]
Diabetes Mellitus Type II - now Insulin Dependent
Hypertension
Elevated Cholesterol
Neuropathy
Peripheral Vascular Disease
Pacemaker Insertion [**2186-7-6**]([**Company 1543**])
Appendectomy
Bilateral Lower Extremity ORIF
Social History:
Lives alone, ambulates independently without assistance. Retired
form the sheriff's department. Recently separated from his wife
and lives alone; he has four children. Tobacco: 15 pack-year
smoking history, but quit 15 years ago. ETOH: has an occasional
glass of wine.
Family History:
There is no family history of sudden death. Extensive family
history of cardiac disease including early MIs (50s) and
multiple family members with diabetes. Mother died at age 58 due
to cerebral hemorrhage and also had h/o DM2. Father died at age
65 of a cerebral hemorrhage and also had h/o DM2. Brother died
at age 74 due to complications of DM1.
Physical Exam:
PREOP EXAM
Vitals: 142/64, 82, 14
General: WDWN male in no acute distress. Right Brachicephalic
AVF noted along with Right Subclavian Tunnelled catheter.
HEENT: Oropharynx benign, EOMI, PERRL
Neck: Supple, no JVD. No carotid bruits noted.
Lungs: CTA bilaterally
Heart: Regular rate and rhythm
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema. Dependent rubor noted
Pulses: 1+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted, decreased sensation noted in both lower
extremities
Pertinent Results:
[**2188-4-15**] INTRAOP TEE:
Prebypass: 1. No atrial septal defect is seen by 2D or color
Doppler. 2.There is severe regional left ventricular systolic
dysfunction.. Overall left ventricular systolic function is
severely depressed (LVEF= 25%). with mild global RV free wall
hypokinesis. 3.There are simple atheroma in the descending
thoracic aorta. 4.The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**2-6**]+) aortic regurgitation is seen. 5.The mitral valve leaflets
are mildly thickened. Mild to moderate ([**2-6**]+) mitral
regurgitation is seen.
Post Bypass: 1. Patient is being AV paced and receiving an
infusion of phenylephrine and epinephrine. 2. LV systolic
function is slightly improved. LVEF 30%. 3. Mild mitral
regurgitation present. 4. Aorta intact post decannulation.
[**2188-4-23**] 08:19AM BLOOD WBC-14.7* RBC-3.31* Hgb-10.1* Hct-29.2*
MCV-88 MCH-30.5 MCHC-34.6 RDW-14.8 Plt Ct-210
[**2188-4-21**] 06:00AM BLOOD WBC-10.8 RBC-3.25* Hgb-9.6* Hct-28.2*
MCV-87 MCH-29.7 MCHC-34.2 RDW-14.6 Plt Ct-144*
[**2188-4-15**] 11:23AM BLOOD PT-15.4* PTT-51.1* INR(PT)-1.4*
[**2188-4-23**] 08:19AM BLOOD Glucose-240* UreaN-48* Creat-4.8* Na-136
K-4.3 Cl-97 HCO3-28 AnGap-15
[**2188-4-21**] 06:00AM BLOOD Glucose-153* UreaN-59* Creat-5.3*# Na-136
K-4.3 Cl-98 HCO3-27 AnGap-15
CHEST (PA & LAT) [**2188-4-22**] 4:10 PM
CHEST (PA & LAT)
Reason: ? effusion
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? effusion
TYPE OF EXAMINATION: Chest PA and lateral.
INDICATION: Status post bypass surgery. Evaluate for effusion.
FINDINGS: PA and lateral chest views obtained with patient in
upright position is analyzed in direct comparison with a
preceding chest examination of [**2188-4-17**]. Moderate cardiac
enlargement, status post bypass surgery, permanent pacer with
dual electrodes and wide-bore double-lumen catheter terminating
overlying the right atrium are unchanged. No evidence of
pneumothorax. Pulmonary vasculature unaltered, thus no evidence
of interstitial or alveolar edema. There exists some mild
blunting of the lateral pleural sinuses confirmed by some
blunting of the posterior pleural sinuses as seen on the lateral
view. On the preceding study, the lateral pleural sinuses were
free (single view chest x-ray examination). In comparison with
the preoperative chest examination of [**4-10**] (PA and lateral
view), the pleural sinuses are free.
IMPRESSION: Mild-to-moderate bilateral pleural effusions noted
postoperatively after bypass surgery. No evidence of CHF or
acute parenchymal infiltrates. Further followup is recommended.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent coronary artery bypass
grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please see
seperate dictated operative note. Following the operation, he
was brought to the CVICU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated without
incident. He weaned from inotropic support without difficulty.
Aspirin and Plavix were resumed, and he continued on his routine
dialysis schedule. He otherwise maintained stable hemodynamics
and transferred to the SDU on postoperative day two.
His platelet count dropped as low as 66K but by discharge, his
platelet count normalized. A postop HIT assay was negative. He
was intermittently transfused with PRBC to maintain hematocrit
near 30%.
He did experience some urinary retention which did require foley
re-insertion on postoperative day four. By discharge, he
continued to have difficulty voiding, his foley was reinserted
again, and he was started on flomax. He should have urology
follow up at rehab.
He continued dialysis without complication and was followed
closely by the renal service. At discharge, there were no new
recommendations.
Throughout his hospital stay, he had several episodes of atrial
fibrillation. He was started on an amiodarone load and coumadin.
Plavix was dc'd.
All incisions were healing well without evidence of infection.
Sternal staples should be removed on postoperative day 21.
He intermittently complained of difficulty hearing and should
also have ENT follow up.
Due to steady clinical improvements, he was eventually cleared
for discharge to rehab on postoperative day 8.
Medications on Admission:
NPH 68am/38pm, Plavix 75 qd, Norvasc 5 qd, Imdur 30 qd, Zocor 80
qd, Lisinopril 10 qd, Toprol 100 qd, Prilosec 20 qd, Aspirin 81
qd, Lasix 40 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed.
7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic [**Hospital1 **] (2
times a day).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous once a day: QAM.
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous at bedtime: QPM.
12. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale Subcutaneous four times a day.
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: then 400 mg daily x 7 days, then 200 daily
ongoing until stopped by cardiologist.
14. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime for 2
doses: Check INR [**4-25**] and dose accordingly for goal INR 2-2.5
for atrial fibrillation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease - s/p Coronary Artery Bypass Grafting
Postop Urinary Retention
PMH: Chronic Systolic Heart Failure, End-stage Renal Disease on
Hemodialysis, Diabetes Mellitus - Insulin Dependent,
Hypertension, Elevated Cholesterol, Neuropathy, Peripheral
Vascular Disease
Discharge Condition:
Stable
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call for redness or drainage from surgical wounds
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
-Please make appointment with Dr [**Last Name (STitle) **] in 1 month.
-Please make appointment with Dr [**Last Name (STitle) 100553**] in 2 weeks.
-Please make an appointment with ENT Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 100554**] if diminished hearing continues.
Completed by:[**2188-4-23**]
|
[
"996.72",
"250.40",
"443.9",
"V17.3",
"V18.0",
"458.29",
"V45.82",
"424.0",
"997.1",
"412",
"997.5",
"428.0",
"287.5",
"403.91",
"427.31",
"V45.01",
"288.60",
"428.22",
"285.21",
"998.0",
"788.20",
"585.6",
"272.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.12",
"99.61",
"39.95",
"89.60",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8670, 8742
|
5339, 7005
|
338, 392
|
9066, 9074
|
2654, 4071
|
9397, 9748
|
1728, 2079
|
7200, 8647
|
4108, 4138
|
8763, 9045
|
7031, 7177
|
9098, 9374
|
2094, 2635
|
281, 300
|
4167, 5316
|
420, 945
|
967, 1425
|
1441, 1712
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,437
| 111,823
|
11797
|
Discharge summary
|
report
|
Admission Date: [**2179-11-25**] Discharge Date: [**2179-12-2**]
Service: Coronary Care Unit
CHIEF COMPLAINT: Status post fall.
HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male with history of CA quadriplegia secondary to motor
vehicle accident in [**2155**], but without significant cardiac
history, presents status post fall while ambulating in the
EMERGENCY DEPARTMENT of [**Hospital 21807**] [**Hospital **] Hospital. He is
being transferred from the Emergency Department to the CCU
Service for suspected hemodynamically significant
chronotropic insufficiency.
The patient has been well until the date of admission, when
he presented to the [**Location 21807**] VA Emergency Department
with upper respiratory infection symptoms and subjective
fevers. As he was being evaluated by the Triage Staff, he
reportedly fell forward any unidentified precipitant. He
suffered multiple facial lacerations. Responders at the
scene noted that he was lethargic, but arousable, with a
blood pressure of 63/36, heart rate 55, temperature 97, and
normal oxygen saturation. He denied loss of consciousness,
light headedness, headache, palpitations, chest discomfort,
nausea, vomiting, or shortness of breath. He states that he
has fallen a couple of times in the past, but these were
attributed by the patient to loss of balance. When asked if
the loss of balanced played a part in this fall, he was
unable to say yes or no.
The patient was placed on dopamine drip and stabilized his
blood pressure. Initial evaluation included blood, urine
cultures. Skull films were negative. Heard CT did not show
evidence of hemorrhage. Cardiac enzymes and EKG were
negative for evident signs of ischemia. Neck CT, however,
did show evidence of a new C4 to C6 cord compression in the
setting of an old disk herniation. He was transferred to the
[**Hospital1 69**] emergency department on
the dopamine drip for a MRI of the neck. Heart rate was
reportedly stable in the 50s to 60s throughout his [**Location 37286**] VA stay.
In the [**Hospital1 69**] Emergency
Department, the staff attempted to wean the patient from the
dopamine. However, he was noted to be become hypotensive to
the 60 to 80 systolic range and bradycardiac in the 30s. The
EKG tracings during this episode revealed sinus bradycardia
with numerous pauses, some as long as two seconds. For this
reason, it was suspected that the patient was having
chronotropic insufficiency and he was thus referred to the
Coronary Care Unit Team for evaluation.
Neck MRI, although limited by the patient noncompliance,
showed possible evidence of central cord compression. The
patient also reported decreased numbness and weakness in his
upper extremities; however, he denied any bowel or bladder
incontinence, loss of consciousness, palpitations, light
headedness, shortness of breath, fever, nausea, vomiting,
diarrhea, or dysuria.
PAST MEDICAL HISTORY: The patient is status post motor
vehicle accident in [**2155**], complicated by a CA fracture and
subsequent quadriplegia. The patient is presently able to
walk with a walker; hypertension; cholelithiasis status post
appendectomy; ventral hernia, status post transurethral
resection of the prostate; osteoarthritis.
MEDICATIONS: Aspirin.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives alone. There is no
current tobacco or alcohol use.
FAMILY HISTORY: History is noncontributory.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: GENERAL: [**Age over 90 **]-year-old male in no acute distress
with racoon eyes and new sutured laceration over the right
eyebrow. VITAL SIGNS: 97.5; heart rate 75; blood pressure
150/85 on a 7.5 mcg/kg per minute drip of dopamine. Regular
rate and rhythm 16; 96% on two liters. Urine output 1500 cc
over 8 hours in the ED. HEENT: Bilateral racoon eyes,
PERRLA, EOMI, multiple abrasions/lacerations on the forehead.
Oropharynx clear. NECK: Neck in collar, no posterior
tenderness. CHEST: Chest was clear to auscultation
anterolaterally. CARDIOVASCULAR: Normal S1 and S2,
bradycardia, no murmurs, rubs, or gallops, diminished heart
tones. ABDOMEN: Soft, nontender, positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGICAL:
Oriented to name, place and time. Decreased motor strength
in the right upper extremity, [**3-11**] wrist extension. Left
upper extremity: [**3-11**] tricep extension, hand grip [**2-8**] in
wrist flexion and extension [**2-8**]. Right lower extremity [**4-10**];
left lower extremity [**4-10**]. Toes downgoing on the right,
upgoing on the left. Gait not tested.
LABORATORY DATA: Studies revealed the white count of 6.4,
hematocrit 36.2, platelet count 226,000. Sodium 137,
potassium 3.8, chloride 107, bicarbonate 21, BUN 19,
creatinine .9; CK of 452, index 1%, troponin .04. EKG from 8
am that morning revealed sinus bradycardia of 56, PR interval
240, QRS 76, and QT corrected 413 with possible P-pulmonale.
Rhythm strip in the ED showed sinus bradycardia with numerous
sinus pauses, but no evidence of Wenckebach; longest pause
two seconds.
Neck MRI was inconclusive on admission secondary to patient's
claustrophobia and inability to remain in the proper position
during the scan.
HOSPITAL COURSE: The patient was placed on decadron IV,
which was subsequently tapered over a one week period for the
question of cord compression. Neurosurgery evaluated the
patient and did not feel that he required surgery at that
time. They suggested a three to ten week period with a
cervical neck collar in place and followup with Dr. [**Last Name (STitle) 1327**] in
three weeks and to continue on the Decadron taper.
The MRI was read to show some degenerative changes at the C3
to C6 with resultant spinal canal stenosis with history of
prior cervical spinal injury. There was evidence of cord
compression at the C3 to C6 levels.
CARDIOVASCULAR: The patient presented with bradycardia and
hypotension requiring dopamine drip. It is unclear what
precipitated this event, but most likely the hypotension and
bradycardia counted for the patient fall as opposed to being
secondary to fall.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit and maintained on his dopamine drip.
.................... were placed at the bedside and the
patient was taken off beta blockers and negative
chronotropics. He was placed on telemetry overnight.
Echocardiogram was done, which showed a mildly dilated left
atrium. The left ventricle was normal. There was
hyperdynamic left ventricle with an EF greater than 75%,
normal RV, moderately thickened and reduced systolic
excursion of the aortic leaflets, mild aortic stenosis, no
aortic insufficiency, one to two plus mitral regurgitation,
2+ tricuspid regurgitation, mild pulmonary artery systolic
hypertension, no effusion.
The patient's maximum CK values peaked at 1143, although the
MB portion had always remained negative. Therefore, the CK
was probably secondary to crush injury versus rhabdomyolysis.
Due to negative CKMB and lack of ischemic EKG changes, there
was no reason to believe that an ischemic event had occurred.
The EKG did show sinus node dysfunction and sinus pause; also
a first degree A-V block.
The patient was brought to the EP Laboratory for a pacemaker
insertion. A DDD pacemaker was placed. No A-V testing or
pacing was done or right atrial catheter secondary to
patient's delirium and agitation. The patient remained on
four microgram of dopamine in the peripheral IV after the
pacer insertion. The patient became delirious and agitated
in the EP laboratory and immediately upon return to the CCU
he was given Haldol for control. The patient had one episode
of sustained narrow complex tachycardia up to a rate of 150
with no decrease in the blood pressure or change in mental
status. He was given a 2.5 mg IV Lopressor push, which
reverted him back to his paced rhythm. The patient was
ultimately weaned off dopamine and maintained his pressures
after completion of the weaning.
The patient was then started on low dose beta blocker when
his blood pressure could allow. After being stabilized, the
patient, on [**2179-11-28**] was transferred to the floor. Pacer
was functioning well and no cardiac issues were evident
following the pacer placement and weaning of pressors.
Although, the patient did have two to three episodes of PVC
triplets, but a very small amount of ectopy, otherwise he
remained asymptomatic.
PULMONARY: The patient presented to the [**Hospital **] Hospital with the
complaints of cough and question of bronchitis. He also
displaced increased pulmonary vascular congestion on chest
x-ray. The patient was started on Levofloxacin and Flagyl
secondary to patient's high risk of aspiration. Sputum gram
stain showed greater than 25 PMNs, greater than 10
epithelium, 4+ oropharyngeal flora and 2+ gram-negative rods.
Chest x-ray showed no effusion, mild increase in the right
lower lobe opacity. No air bronchogram. Questionable loss
of partial left diaphragmatic line and question of pneumonia.
The patient was maintained on Levofloxacin and Flagyl and had
rhonchi and slight wheezing on examination. Therefore, the
patient was also placed on Atrovent nebulizers p.r.n.
HEMATOLOGY: The patient was transfused one unit of packed
red blood cells for hematocrit less than 30. The patient's
hematocrit remained stable after this transfusion in the low
30s at the time of discharge.
INFECTIOUS DISEASE: The patient presented to [**Location 37287**]
VA secondary to URI symptoms. Urine culture and sputum
culture were negative at [**Hospital1 188**].
HOSPITAL COURSE: He remained during the stay and the white
count never went above 9.8, although he did display a
bandemia on admission of 8%. The patient had also been on
corticosteroids since admission, which may have caused
demargination. The patient displaced no signs of systemic
infection, except for possible localized bronchitis or
pneumonia, which was treated with Levofloxacin and Flagyl.
At the time of discharge, the patient was without any cardiac
complaints. His DDD pacer had been placed without problems.
Neurologically, he had been placed in a hard cervical collar
for at least three to ten weeks. He is on a Decadron taper,
and he will require neurological rehabilitation as an
outpatient. The patient has question of pneumonia versus
bronchitis, which is actively being treated with Levaquin and
Flagyl and Combivent nebulizers, p.r.n.
DISCHARGE DIAGNOSES:
1. Status post DDD pacemaker insertion.
2. Status post cervical spine injury with cord compression.
3. Status post bradyrhythmia.
4. Status post motor vehicle accident in [**2155**] with C8
fracture and quadriplegia, hypertension, cholelithiasis,
status post appendectomy, status post transurethral resection
of the prostate, osteoarthritis, ventral hernia.
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg p.o.b.i.d.
2. Decadron 4 mg p.o.q.12h. times one day, then 3 mg p.o.
q.12h. times one days, then 2 mg p.o.q.12h. times one day,
then 1 mg p.o. q.12h. times one day and 1 mg p.o.q.d.times
one day.
3. Flagyl 500 mg p.o.t.i.d. until [**2179-12-4**].
4. Levofloxacin 250 mg p.o.q.d. until [**2179-12-4**].
5. Protonix 40 mg p.o.q.d.
6. Heparin 5000 units subcutaneously b.i.d. until the
patient is out of bed and mobile.
7. Colace 100 mg p.o.b.i.d..
8. Enteric coated aspirin 81 mg p.o.q.d.
9. Regular insulin sliding scale.
The patient should take a cardiac low-salt, low cholesterol
diet. The patient will be discharged to rehabilitation with
plans to followup with the Neurosurgery physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1327**]
in three weeks. The patient should continue C-collar use for
at least three weeks until followup and possibly for a
ten-week course in total.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 15885**]
MEDQUIST36
D: [**2179-12-1**] 15:53
T: [**2179-12-1**] 16:05
JOB#: [**Job Number **]
|
[
"336.9",
"401.9",
"507.0",
"427.89",
"293.0",
"112.0",
"721.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"96.6",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
3456, 3485
|
10594, 10957
|
10980, 12168
|
9730, 10573
|
3508, 5320
|
123, 2932
|
2955, 3351
|
3368, 3439
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,785
| 133,209
|
46774
|
Discharge summary
|
report
|
Admission Date: [**2104-12-15**] Discharge Date: [**2104-12-25**]
Date of Birth: [**2047-12-23**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
-paracentesis [**2104-12-17**]
-NG tube placement [**2104-12-21**]
History of Present Illness:
56-year-old woman with metastatic colorectal cancer, extensive
peritoneal mets presents with abdominal pain and distention for
2 days. The patient has known malignant ascites and has had
therapeutic paracentesis in the past. Two days prior to
admission, she started feeling her abdomen getting more
distended and painful, mostly on the right side. There was no
nausea or vomiting. No diarrhea or constipation. No fevers or
chills. She has poor PO intake and has been drinking most warm
water at home. With the persistent abdominal pain, she called
her oncologist's office and was advised to come to the ED.
.
Of note, knowing that her abdomen was getting distended and a
paracentesis might be needed, patient had stopped her daily
warfarin 4 mg 2 days prior to admission.
.
Her most recent chemotherapy was 6 days PTA with oxaplatin and
bevacizumab. She has also been taking capecitabine for months.
.
In the ED, T 98.4, HR 108, BP 135/77, RR 18, 100%RA. Her INR was
found to be 6.7. Hct 21 (from 30 last week). Abd/pel CT scan
showed extensive loculated ascites with possible new liver mets.
She received a total of 16 mg of IV morphine, also ondansetron,
and 5 mg of oral vitamin K.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, congestion. Denies
chest pain or tightness, palpitations. Denies cough, shortness
of breath, or wheezes. Denies nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rashes or skin
breakdown. No numbness/tingling in extremities. No feelings of
depression or anxiety. All other review of systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
# Metastatic colon cancer:
- [**10/2097**]: found to have RLQ abscess, mass at ileocecal valve.
Bx showed invasive adenocarcinoma
- [**2098-1-2**]: right colectomy by Dr. [**First Name (STitle) **] [**Name (STitle) 99263**]. Path showed
moderately differentiated invasive adenocarcinoma measuring 7 cm
at ileocecal valve, no LVI, invading the subserosa; distant
margins negative but tumor present at radial margin; [**4-3**] lymph
nodes positive, stage (Stage IIIB) T3N1.
- [**Date range (3) 99264**]: FOLFOX6 x 5 cycles (10 weeks treatment)
- [**2098-4-30**]: RUE DVT DVT associated with portacath
- [**Date range (1) 99265**]: weekly 5FU/LV x 3
- [**Date range (1) 99266**]: admitted to [**Hospital1 112**] for enteritis related to chemo
- [**8-/2098**]/[**2098**]: weekly 5FU/LV
- [**4-/2099**]: colonoscopy negative
- [**10/2103**]: Abd/pel CT showed large ascites and left adnexal
mass; pelvic ultrasound with 2 large masses in the left adnexa,
multiple serosal implants and implants on endometrium and right
ovary
- [**11/2103**]: biopsy of omental mass with metastatic adenocarcinoma
consistent with colon primary; CEA normal; KRAS testing positive
for exon 2 mutation at codon 12 GGT>GCT
- [**12/2103**]: started treatment with weekly CPT-11
- [**1-/2104**]: weekly 5FU added
- [**3-/2104**]: progression of her disease. Pelvic mass spanning 23 x
13 cm. Started capecitabine, bevacizumab, oxaplitain.
.
OTHER MEDICAL HISTORY:
RUE DVT related to portacath
Social History:
Lives alone. Retired in [**2103-11-25**] as school principal. Her
sister [**Name (NI) **] [**Name (NI) 99267**] ([**Telephone/Fax (1) 99268**]) and friend [**Name (NI) **] [**Name (NI) 15281**]
are her health care proxies.
Family History:
Her mother might have had an aunt with cancer.
Physical Exam:
VS: T 99.4, BP 102/64, HR 105, RR 16, 97%RA
GEN: middle-aged woman in NAD, AOx3
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: Regular rhythm, normal rate, 3/6 systolic murmur heard
throughout precordium
Pulm: CTAB no crackles or wheezes
Abd: tense, distended, tympanic, diffusely tender but greatest
at RUQ and RLQ, BS present, no rebound/guarding
Extremities: no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Pertinent Results:
[**2104-12-15**] 10:52AM LACTATE-1.2
[**2104-12-15**] 10:35AM GLUCOSE-121* UREA N-8 CREAT-0.7 SODIUM-137
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
[**2104-12-15**] 10:35AM ALT(SGPT)-8 AST(SGOT)-12 LD(LDH)-230 ALK
PHOS-58 TOT BILI-0.3
[**2104-12-15**] 10:35AM HAPTOGLOB-352*
[**2104-12-15**] 10:35AM WBC-7.7 RBC-2.25* HGB-7.0* HCT-21.5* MCV-96
MCH-31.2 MCHC-32.7 RDW-18.7*
[**2104-12-15**] 10:35AM NEUTS-81.6* LYMPHS-11.5* MONOS-6.3 EOS-0.2
BASOS-0.5
[**2104-12-15**] 10:35AM PLT COUNT-283
[**2104-12-15**] 10:35AM PT-59.3* PTT-91.7* INR(PT)-6.7*
[**2104-12-15**] 05:41PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->=1.035
[**2104-12-15**] 05:41PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG
.
IMAGING:
# CXR [**2104-12-15**]: No acute intrathoracic process. No evidence of
pneumoperitoneum
.
# Abd/pel [**2104-12-15**]: (prelim) Massive loculated abdominal ascites
with complex components of peritoneal implants. Mildly distended
small bowel up to 3.3 cm in R hemiabdomen, without free air. Two
subcentimeter liver hypodensities, not fully characterized, but
concerning for mets. Much of colon compressed; mid upper abd
anastomosis within normal limits.
Brief Hospital Course:
56-year-old woman with metastatic colorectal cancer presents
with abdominal pain likely from worsening malignant ascites.
.
# Abdominal pain: Abd/pel CT showing worsening ascites and
possibly liver mets. Similar to prior episode that required
therapeutic paracentesis. Pt received paracentesos on [**12-17**] with
improvment in pain (2L off), and fluid culture was negative to
date so no concern for SBP. She did not have peritoneal signs
on exam, but abdomen remained markedly distended and tender in
the upper quadrants. Her pain was controlled with ocycontin and
PRN oxycodone. On [**12-19**] pt noted to be vomitting and without BM
in almost a week. Given increased distension, there was concern
for SBO and KUB showed partial obstruction likely [**2-26**] to
peritoneal mets. She was made NPO at this time and started on
IVF. NG tube was placed with improvement of symptoms with
decompression. She developed fevers and tachycardia and was
transferred to the ICU for concern for sepsis. She was started
on vanco and Zosyn for broad spectrum coverage. Her pain control
regimen was escalated to IV morphine.
.
# Anticoaguluation INR: INR 6.7 on admission, likely from
interaction between capecitabine and warfarin (on warfarin for
H/O of UE DVT). Her INR was allowed to trend down in the
setting of parcentesis, and pt received 2 [**Location 16678**] prior to the
procedure. The next day, pt was started on lovenox for her DVT
history. Lovenox was d/c in the ICU given elevated INR and
concern for bleeding.
.
# Anemia: Admission Hct was 21 which was down from 30 the prior
week. She was guaiac negative and nowo history of BRBPR or
melena. She received 2U of PRBC for 3 days from [**Date range (1) 29692**].
Initially she had poor Hct response but after her 2 Units on
[**12-18**] she had 6pt Hct increase from 22.5-->28.7. Hct
subsequently trended back down but stabilized at ~25. We feel
that her anemia is likely related to her chemo, as there was no
obvious bleeding and hemolysis labs were negative.
.
#ARF: Pt noted to have a creatinine bump to 1.5 from 0.9 with
subsequent slow upward trend after this. Initially thought to
be [**2-26**] volume depletion in the setting of poor PO intake and
vomitting. Urine lytes revealed a FeNa of 0.1% further
supporting a pre-renal etiology and urine eosinophils were
negative. On [**12-21**] pt was noted to have poor urine output, so
renal u/s obtained which showed No evidence of hydronephrosis.
Minimal prominence of left collecting system, similar to recent
CT. Her renal falure was ultimately felt to be most likely due
to a combination of prerenal and contrast induced nephropathy.
Medications were dosed appropriately for renal impairment.
NSAIDS and other nephrotoxic medications were avoided. Despite
this, her creatinine continued to elevate.
.
# Metastatic colorectal cancer: currently on [**Female First Name (un) **], oxaplatin, and
capecitabine. Disease has been progressing despite treatment.
.
# Goals of Care: A family meeting was held on [**2104-12-25**] with the
Ms. [**Known lastname 10793**] sister, her HCP, as well as other family members.
The decision was made to make the patient comfort measures only
and she was placed on a morphine drip. The patient passed away
at 1:05PM.
Medications on Admission:
lisinopril 5 mg daily
warfarin 4 mg daily
lorazepam 1 mg qhs prn anxiety/insomnia
omeprazole 20 mg daily
Doxepin 10-20 mg qhs
Discharge Medications:
Patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient deceased
Discharge Condition:
Patient deceased
Discharge Instructions:
Patient deceased
Followup Instructions:
Patient deceased
|
[
"785.52",
"197.6",
"276.51",
"584.5",
"560.89",
"197.7",
"293.0",
"338.3",
"789.51",
"V45.72",
"285.9",
"V10.05",
"V12.51",
"584.9",
"567.21",
"E947.8",
"569.83",
"038.9",
"790.92",
"V87.41",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
9164, 9173
|
5681, 8947
|
322, 391
|
9233, 9251
|
4398, 5658
|
9316, 9335
|
3891, 3940
|
9123, 9141
|
9194, 9212
|
8973, 9100
|
9275, 9293
|
3955, 4379
|
1625, 2130
|
268, 284
|
419, 1606
|
2152, 3635
|
3651, 3875
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,795
| 111,680
|
41432
|
Discharge summary
|
report
|
Admission Date: [**2107-3-3**] Discharge Date: [**2107-3-5**]
Date of Birth: [**2048-2-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
near syncope, hypotension
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**3-3**]
History of Present Illness:
Ms. [**Known lastname **] is a 59 year old female with a PMH of near syncopal
episodes, ventricular ectopy, and hypothyroidism who presents
with hypotension in the setting of right groin pressure
following cardiac catheterization.
Briefly, patient complained of 3 episodes of near syncope in the
past several months (one episode possibly inciting a motor
vehicle collision). She describes a sensation of fluttering in
her chest accompanied by lightheadness and near- fainting.
Denies any associated chest pain, nausea/ vomiting, diaphoresis
or other symptoms. Extensive evaluation by her cardiologist
showed sinus bradycardia with ventricular ectopy for which she
was started on metoprolol. Echo in [**2104**] showed EF of 45% with
mild global hypokinesis and repeat in [**2105**] showed EF improved to
50% with grade II diastolic dysfunction.
Following her last episode of near syncope, she presented to her
cardiologist. EKG showed new inferolateral repolarization
changes compared to her prior EKG from [**2106-12-29**]. She
was admitted to an OSH on [**2107-3-2**], where she was r/o for MI
and had a stress test which reported showed a small fixed
deficit (offical read pending). Of note, she did have an
episode of bradycardia and low BP overnight which improved with
IVF. Transferred to [**Hospital1 18**] for catheterization.
Cardiac catheterization showed clear coronaries, patient
tolerated well with no immediate complications. Following
angioseal placement and during application of right groin
pressure to acheive hemostasis, patient complained of intense
pain and had a likely vagal episode: acutely diaphoretic,
dropped BP to 60s and HR to 40s. Episode resolved spontaneously
but given concern for possible RP bleed left arteriogram was
performed which showed no evidence of dissection or bleed.
Transferred to the CCU for overnight hemodynamic monitoring.
Upon arrival to CCU, patient comfortable, only complaining of
mild right groin pain. Review of systems was negative, denying
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. S/he
denies recent fevers, chills or rigors. S/he denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (-)
Hypertension
2. OTHER PAST MEDICAL HISTORY:
- hypothyroidism
- sinus bradycardia
PAST Surgery:
- Partial Hysterectomy
- Total knee on the right
- Sinus surgery
Social History:
Lives with husband, works as x-ray technician
- Tobacco history: former, quit > 25 yrs ago
- ETOH: drinks 1 glass wine daily
- Illicit drugs: denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Father: MI at the age of 58
Physical Exam:
On Admission:
VS: T=Afebrile BP=88/50 HR=63 RR=20 O2 sat= 95 %RA
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 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
FLANK: no tenderness noted either on right or left
EXTREMITIES: No c/c/e. Pain on palpation of right groin but no
hematoma or bruits,
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2107-3-3**] 09:38PM Hct-39.9
[**2107-3-3**] 09:38PM PT-13.0 PTT-20.5* INR(PT)-1.1
Discharge Labs:
[**2107-3-5**] 08:20AM WBC-4.8 RBC-4.24 Hgb-14.0 Hct-41.2 MCV-97
MCH-32.9* MCHC-33.9 RDW-12.2 Plt Ct-192
[**2107-3-5**] 08:20AM Glucose-94 UreaN-14 Creat-0.9 Na-138 K-4.1
Cl-101 HCO3-31 AnGap-10
[**2107-3-5**] 08:20AM Calcium-9.0 Phos-3.6# Mg-2.1
[**2107-3-4**] 03:16AM Ferritn-67
[**2107-3-5**] 08:20AM Metanephrines (Plasma)-PENDING
Studies:
Cardiac Cath [**2107-3-3**] - COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated no angiographically apparent, flow limiting,
coronary artery disease. The LMCA, LAD, LCx, and RCA were all
normal in appearence.
2. Limited resting hemodynamics revealed noral systemic blood
pressure, with a central aortic pressure of 115/73 mmHg.
3. Right femoral angiography revealed a high stick above the
pelvic rim.
4. 6F angioseal deployed successfully, without evidence of RP
bleed on angiography.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. High common femoral artery stick without evidence of RP
bleed.
TTE [**2107-3-4**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears depressed (ejection
fraction 30 percent) with a continuous gradient of worsening
hypokinesis from base (mild) to apex (severe). There is no
ventricular septal defect. The right ventricular free wall
thickness is normal. Right ventricular chamber size is normal.
with borderline normal free wall function. The ascending 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 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.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 59-year-old female with HTN, HL, chronic
palpitations and recurrent episodes of syncope and near syncope
transferred for cardiac cath in setting of EKG changes and
abnormal stress test without significant lesions found on
cardiac cath.
# Near-syncope and AVNRT: The patient has had multiple past
episodes of near syncope with lightheadedness and palpitations.
These episodes have increased in frequency in the past few
months with associated palpitations. Outpatient Holter monitor
reportedly showed PVCs. Cardiac catheterization showed no
coronary artery disease. She should avoid any heavy lifting for
the next week. While in the CCU she had an episode of SVT to the
170s with associated nausea that resolved spontaneously after a
few minutes. Review of telemetry was consistent with AVNRT.
Electrophysiology was consulted. They recommended a TTE that
showed decreased EF and hypokinesis. EF may have been slightly
more depressed than previously noted due to recent SVT. EP
recommended ablation of the AVNRT and cardiac MRI to further
evaluate for structural heart disease. They also recommended
blood tests for cardiomyopathy. The patient had a normal TSH at
the OSH prior to transfer and reported a recently negative HIV
test. Serum ferritin was within normal limits at 67 and plasma
metanephrines were also ordered and pending at discharge.
Patient was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to further
characterize her heart rhythm when she has presyncopal episodes.
Her history is not consistent with neurogenic etiologies such as
seizures. If this additional cardiac evaluation is unrevealing,
she may have some degree of autonomic dysfunction and may
benefit from referral to autonomic clinic. In light of her
recent car accident, she was advised to stop driving until the
etiology of her symptoms is better understood and resolved.
# Hypotension: The patient became hypotensive and bradycardic in
the setting of pressure being applied to her groin post-cath.
The episode was most likely vasovagal in nature. Her blood
pressure returned to [**Location 213**] and hematocrit remained close to
baseline over the following 24 hours. There was no evidence of
retroperitoneal bleed by angiography performed in cath lab. She
remained hemodynamically stable thereafter.
# Chronic systolic CHF: TTE showed EF of 30% with a continuous
gradient of worsening hypokinesis from base (mild) to apex
(severe), which may have been overestimated given the episode of
SVT earlier in the day. There were no signs of volume overload.
Metoprolol and lisinopril were initially held in the setting of
hypotension and restarted on discharge. She will return for
cardiac MRI as an outpatient.
# Hyperlipidemia: Stable. Patient continued on home
simvastatin.
# Hypothyroidism: Stable with normal TSH at OSH. She was
continued on her home levothyroxine.
Medications on Admission:
- metoprolol 25mg
- lisinopril 2.5 mg
- zantac 150mg
- levoxyl 100mcg
- simvastatin 20mg QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Chest Pain
Vasovagal hypotension
Atrioventricular nodal reentrant tachycardia (AVNRT)
Secondary Diagnosis:
Dyslipidemia
Hypothyroidism
Sinus bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were
admitted because of concern that you were having a heart attack.
Your cardiac catheterization showed normal heart vessels. You
did not have a heart attack.
You had a fast heart rhythm known as AVNRT (atrioventricular
nodal reentrant tachycardia). You were seen by the
electrophysiologists who recommended an ablation procedure to
prevent this rhythm from coming back. They also recommended a
cardiac MRI to further evaluate the heart. They will try to
arrange both of these studies on the same day and will contact
you with further details. You will be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor, which you should bring to your appointment with
Dr. [**Last Name (STitle) **].
Because of your history of lightheadedness and the symptoms you
had with the fast heart rate in the hospital, we recommend that
you DO NOT drive until your doctors have a [**Name5 (PTitle) **] sense of what
is causing these episodes as you could have another car
accident.
Also DO NOT LIFT MORE THAN [**4-12**] POUNDS FOR THE NEXT WEEK.
Please take your medications as described.
Followup Instructions:
Dr.[**Name (NI) 1565**] office will call regarding the scheduling of
your ablation procedure and cardiac MRI.
We have made the following appointments for you. Please be sure
to bring your [**Doctor Last Name **] of Hearts monitor when you come for your
appointment with Dr. [**Last Name (STitle) **].
Name: [**Last Name (un) **],[**Last Name (un) 75760**] A.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 86648**], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 75761**]
Appointment: Friday [**3-11**] at 12PM
Name: [**Last Name (LF) **],[**First Name3 (LF) **] MD
Location: CLIPPER CARDIOVASCULAR ASSOCIATES
Address: [**Location (un) 90135**], [**Location (un) **],[**Numeric Identifier 12023**]
Phone: [**Telephone/Fax (1) 65733**]
Appointment: Monday [**3-14**] at 1:45PM
Completed by:[**2107-3-5**]
|
[
"428.22",
"V43.65",
"428.0",
"780.2",
"997.2",
"427.89",
"786.59",
"272.4",
"244.9",
"E879.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
9516, 9522
|
6430, 9372
|
326, 361
|
9738, 9738
|
4442, 4442
|
11133, 12005
|
3324, 3471
|
9543, 9543
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9398, 9493
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5446, 6407
|
9888, 11110
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3486, 3486
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261, 288
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389, 2898
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9670, 9717
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4458, 4544
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9562, 9649
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3500, 4423
|
9753, 9864
|
3023, 3141
|
3157, 3308
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,767
| 152,871
|
15847
|
Discharge summary
|
report
|
Admission Date: [**2166-6-2**] Discharge Date: [**2166-6-6**]
Date of Birth: [**2116-10-19**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 45556**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49yo woman with hsitory of metastatic melanoma since [**1-12**] with
brain metastases since [**1-15**] presented with 1-2 wks of increasing
level of weakness, fatigue, and decreased endergy. Progressive
weakenss in legs to point that she could not get off the toilet
yesterday. She also notes incresasing levele of dyspnea,
non-productive cough, and bilateral anterior chest tightenss.
Chest pressure is described as a tightness that is aggravated
with cough/breathing. She has no other anginal symptoms. She
also reports decreaseed appetite and poor po intake. She denied
any increased headache or new altered sensation/paresthesias.
ED course: received 1L NS and 8mg of Decadron po.
Past Medical History:
1. Metastatic melanoma:
- [**2163-11-11**] underwent a left chest wide excision with
a concurrent left axillary node sampling with treatment of a 5
mm deep ulcerated invasive melanoma, which showed prominent
perineural invasion as well as microsatellitosis. One out of
three lymph nodes were positive. The primary lesion was in the
left lateral chest, fairly close to the axilla.
-In [**2163-12-11**], a left axillary dissection was done with
19 normal nodes.
-6 months of standard interferon therapy that
was discontinued because of multiple side effects.
-saw Dr. [**Last Name (STitle) 519**] on [**2166-1-29**], and underwent a biopsy of the
left medial breast mass consistent with melanoma.
-chest, abdomen, and pelvic CT was done on [**2-5**], [**2166**], which showed a right hilar mass with adjacent
mediastinal lymph nodes suspicious for primary or secondary
carcinoma.
-MRI brain [**2166-2-9**] showed multiple small solid
enhancing lesions. There was a 1.3 cm solid lesion in the right
frontal lobe with a 1 cm lesion in the left basal ganglia and an
8 mm lesion within the left temporal lobe with edema.
-[**2166-3-11**], SRS was given to the left anterior
medial temporal lobe, right anterior frontal lobe, and left
putamen.
-[**2166-4-23**], mental status change noted - MRI done showed
large increase in the size and edema of the metastases; she was
admitted to the neurology service and started
on high-dose Decadron. She was discontinued on [**2166-4-28**],
with improvement.
2. Deaf, bilateral hearing aids x5 years, reads lips
3. status post Umbilical hernia repair ~20 yrs ago
Social History:
Married, lives with husband. Was certified nurses asst x13 yrs,
not working currently. +Tob, 1 [**1-12**] ppd for ~35 pk-yr history.
Rare EtOH.
Family History:
Mom with [**Name2 (NI) **] CA s/p L mastectomy. Dad died of MI. Sister, kids
healthy.
Physical Exam:
98.1, 96, 24, 124/70, 92% on 4L nc
gen: thin, ill appearing woman with frequent dry cough
heent: OP clear, mucous membranes moist
cv: hyperdynamic s1,s2, tachycardic; no JVD
resp: decreased breath sounds bialterally with diffuse
crackles throughout
abd: soft, NABS, no HSM, no tenderness
extr: no c/c/e
neuro: 4/5 strength throughout
skin: papular erythematous rash on left upper back
Pertinent Results:
[**2166-6-2**] 11:00AM WBC-22.6* RBC-4.36 HGB-13.1 HCT-38.2 MCV-88
MCH-30.1 MCHC-34.4 RDW-14.2
[**2166-6-2**] 11:00AM NEUTS-92* BANDS-7* LYMPHS-0 MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2166-6-2**] 11:00AM ALBUMIN-2.6*
[**2166-6-2**] 11:00AM ALT(SGPT)-34 AST(SGOT)-36 LD(LDH)-789*
CK(CPK)-200* ALK PHOS-202* TOT BILI-0.2
[**2166-6-2**] 11:00AM GLUCOSE-580* UREA N-15 CREAT-0.5 SODIUM-128*
POTASSIUM-3.9 CHLORIDE-89* TOTAL CO2-23 ANION GAP-20
[**2166-6-2**] 10:18PM CALCIUM-8.0* PHOSPHATE-2.4*# MAGNESIUM-1.5*
[**2166-6-2**] 10:18PM GLUCOSE-417* UREA N-13 CREAT-0.5 SODIUM-128*
POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-21* ANION GAP-15
[**2166-6-2**] 11:49PM URINE RBC-2 WBC-3 BACTERIA-MANY YEAST-NONE
EPI-<1
[**2166-6-2**] 11:49PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
*
Radiologic Studies:
[**6-2**] Bilateral LE U/S- negative for DVT
[**6-2**] Head CT- Interval decrease in vasogenic edema surrounding
several metastatic foci. These foci, especially the right
frontal lesion, contain areas of increased attenuation
consistent with hemorrhage. No new lesions are identified.
[**6-2**] CTA- Negative for PE. Innumerable nodules and masses, many
of which are coalescent, throughout both lungs. The larger
nodules/ masses demonstrate cavitation.
[**6-4**] CXR- Progression of advanced pulmonary abnormalities
Brief Hospital Course:
Hospital Course:
49 y/o woman with history of metastatic melanoma who presented
with worsening fatigue, dyspnea, non-productive cough, and found
to have diffuse pulmonary metastatic disease by chest CT with
questionable secondary infection. She was initially treated with
DTIC 100mg/m2 x one dose and empiric antibiotic coverage for PCP
and CAP. She developed increasing respiratory distress, with
hypoxemic respiratory failure refractory to diuresis and NIPPV.
The patient did not wish for intubation and per discussion with
patient, family and primary oncologist, she was made comfort
measures only. She was given morphine for comfort and passed
away on [**2166-6-6**]. Her husband and daughter were present at her
bedside.
Medications on Admission:
Meds on transfer to [**Hospital Unit Name 153**]:
ceftriaxone 1g q24
bactrim 400 IV q8
heparin SC 5000 U [**Hospital1 **]
docusate 100mg [**Hospital1 **]
dexamethasone 4mg TID
lasix 40mg prn
pantoprazole 40 PO q24
sliding scale insulin
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"486",
"276.5",
"251.8",
"197.0",
"198.3",
"276.1",
"E932.0",
"V10.82",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5782, 5791
|
4738, 4738
|
276, 282
|
5838, 5843
|
3315, 4715
|
5895, 5901
|
2801, 2888
|
5754, 5759
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5812, 5817
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5493, 5731
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4756, 5467
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5867, 5872
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2903, 3296
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229, 238
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310, 1002
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1024, 2623
|
2639, 2785
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,029
| 106,306
|
13407
|
Discharge summary
|
report
|
Admission Date: [**2109-10-8**] Discharge Date: [**2109-10-28**]
Date of Birth: [**2066-10-31**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Ceftazidime / Carbamazepine
Attending:[**First Name3 (LF) 848**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
-[**Location (un) **] t-tube removed and replaced with regular
tracheostomy tube
-Tunneled HIckman catheter
History of Present Illness:
40-year-old bed-bound, hemiplegic, minimally-to-non-verbal woman
with history of [**Doctor Last Name **] encephalitis (Dx at age 8), on 4x
AEDs at baseline, s/p Left partial (parietal) hemispherectomy in
[**2085**] (age 19) and s/p VNS placement, who now presents with
several break-through GTC seizures witnessed at a Neurosurgery
appointment for battery replacement surgical planning. She has
daily focal seizures at baseline -- primarily causing twitching
of her Right eyelind -- which are resistant to hemisphereotomy,
VNS placement, and four AEDs. She also has occasional
break-through GTC seizures. She also has a h/o episodes of
aspiration pneumonia requiring intubation, subsequent tracheal
stenosis, and is now s/p tracheostomy, then T-tube placement
[**2101**].
Her VNS battery was at 0.55 years of life remaining back in [**Month (only) 116**]
of [**2108**], but it could not be replaced at that time because the
venous access requested by Neurosurgery could not be established
at that time (Dr. [**Last Name (STitle) 739**] insisted on a port-a-cath,
placement of which in the OR by Thoracic was unsuccessful). On
the DOA [**10-8**], while she was at her Neurosurgery appointment (Dr. [**Name (NI) 14232**] office) for preoperative evaluation for her VNS battery
replacement, she had multiple seizures involving eye deviation
to the left, drooling, and cyanosis. Each seizure lasted less
than one minute. From 12:30 to 4:30pm, there were 15-20
seizures. In the past when she has had these seizures, it was a
sign that she had an underlying infection, such as aspiration
pneumonia, UTI, or G-tube site infection.
In the ED on admission, she received lorazepam 2mg IM and then
phenobarbital 60mg IV. Of note, her phenytoin dose was decreased
several weeks ago due to an elevated level of unclear cause. Her
phenobarbital level was good at that point (mid-30s), but her
phenytoin level of 7 was much lower than Dr.[**Name (NI) 3536**] goal of
20-25 in this patient, so she was bolused with 500mg IV
phenytoin.
ROS: The patient has chronic abdominal pain, which she continues
to have today. At baseline she understands speech and is
minimally verbal, with phonation (has T-tube since [**2101**],
replaced once here since) that is understood only by family, not
by her outpatient Neurologist/Epileptologist (Dr. [**First Name (STitle) 437**]. She
has a right hemiplegia, with contracted/flexed RUE. Does not
take PO (G-tube meal bolus feeds). No recent problems with
fever, vision, hearing, cough, vomiting, diarrhea, urination, or
new weakness.
Past Medical History:
1. [**Doctor Last Name **] encephalitis
2. Epilepsy
3. Partial left hemispherectomy at age 19 complicated by right
hemiparesis and partial aphasia
4. Mental retardation
5. Left thoracolumbar scoliosis
6. Vagal nerve stimulator implanted [**12-7**], needs battery change
7. h/o Aspiration pneumonias, now on scopolamine patch
8. S/p PEG placement using T tube
9. S/p tracheostomy
10. MRSA line infection in the past
11. Hx multiple UTIs, Urosepsis (enterococcus, VRE, other)
12. Difficult venous access requiring femoral sticks
13. Constipation
14. Mood disorder, on SSRI; also Zyprexa
Social History:
No history of tobacco, alcohol, illicit drug use. Lives in a
group home.
Family History:
Unremarkable. No h/o seizures or [**Doctor Last Name **]
Physical Exam:
On admission in the ED:
Gen: Lying in bed, NAD
HEENT: NC/AT
Neck: Supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Trach site c/d/i. Clear to auscultation bilaterally .
Wearing face mask.
Abd: +BS soft, nontender. G-tube site c/d/i.
Ext: no edema
Neurologic examination:
Mental status: Awake, alert. Follows commands. Tries to talk
and says a few words but dysarthric and difficult to understand.
Says her name but when asked where she is she points to her mom
and nurse to have them answer the question.
Cranial Nerves:
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V1-3: Sensation intact V1-V3.
VII: Right facial droop (baseline).
VIII: Hearing grossly intact.
Motor:
Tone is increased in the right arm, with the wrist and fingers
flexed on that side.
Delt; C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7
Left 5 5 5 5 5
Right 1 3 2 1 1
.
Legs withdraw to noxious, no spontaneous movement. The ankles
are plantarflexed at rest and do not fully dorsiflex to 90
degrees.
.
Deep tendon Reflexes:
.
Biceps: Tric: Brachial: Patellar: Achilles Toes:
Right 1 1 1 1 1 MUTE
Left 1 1 1 1 1 MUTE
.
Sensation: Intact to light touch on all extremities.
.
Coordination: Finger-nose-finger dysmetric on left; unable to
test other limbs due to weakness.
One seizure witnessed during the exam. The patient had eye
deviation to the left, drooling, and arrest of purposeful
movement for about 1 minute. She returned to baseline several
minutes after the episode.
Pertinent Results:
Labs on admission ([**2109-10-8**]):
[**2109-10-8**] 04:25PM BLOOD WBC-3.0* RBC-3.74* Hgb-11.6* Hct-35.6*
MCV-95 MCH-30.9 MCHC-32.5 RDW-15.0 Plt Ct-212
[**2109-10-8**] 04:25PM BLOOD Neuts-40.5* Lymphs-51.6* Monos-4.3
Eos-2.7 Baso-0.8
[**2109-10-8**] 04:25PM BLOOD PT-14.2* PTT-37.3* INR(PT)-1.2*
[**2109-10-8**] 04:25PM BLOOD Glucose-87 UreaN-18 Creat-0.6 Na-138
K-4.3 Cl-104 HCO3-26 AnGap-12
[**2109-10-11**] 08:24PM BLOOD ALT-28 AST-21 AlkPhos-175* TotBili-0.3
[**2109-10-10**] 02:09AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.8 Mg-2.0
[**2109-10-9**] 01:54AM BLOOD TSH-4.5*
[**2109-10-9**] 01:54AM BLOOD Free T4-0.78*
[**2109-10-9**] 01:54AM BLOOD Cortsol-5.3 (AM cortisol morning after
admission)
[**2109-10-10**] 03:08PM BLOOD Cortsol-22.3* (baseline for Syntropin
stim test)
[**2109-10-10**] 03:55PM BLOOD Cortsol-29.4* (30min after ACTH)
[**2109-10-10**] 05:02PM BLOOD Cortsol-34.9* (60min after ACTH)
[**2109-10-8**] 04:25PM BLOOD HCG-<5
[**2109-10-9**] 10:41AM BLOOD Type-ART pO2-73* pCO2-41 pH-7.39
calTCO2-26 Base XS-0
[**2109-10-10**] 03:28PM BLOOD freeCa-1.20
***********
AED levels:
-Phenytoin/Phenobarbital:
[**2109-10-17**] 01:54AM BLOOD Phenyto-18.4
[**2109-10-16**] 02:11AM BLOOD Phenyto-19.1
[**2109-10-15**] 04:27AM BLOOD Phenyto-20.1*
[**2109-10-14**] 01:59AM BLOOD Phenyto-19.9
[**2109-10-13**] 01:12AM BLOOD Phenyto-20.2*
[**2109-10-12**] 02:51AM BLOOD Phenoba-31.2 Phenyto-19.4
[**2109-10-11**] 01:26AM BLOOD Phenyto-18.0
[**2109-10-10**] 02:09AM BLOOD Phenyto-17.7
[**2109-10-9**] 01:54AM BLOOD Phenyto-17.4
[**2109-10-8**] 04:25PM BLOOD Phenoba-36.4 Phenyto-7.0*
-Keppra:
[**2109-10-8**] 11:05PM BLOOD LEVETIRACETAM (KEPPRA)- 78.6 (uln
@1500bid=70)
-Zonisamide:
[**2109-10-8**] 11:05PM BLOOD ZONISAMIDE(ZONEGRAN)- 11.6 (10-40)
***********
[**2109-10-28**] 04:22AM BLOOD WBC-7.0 RBC-2.93* Hgb-9.3* Hct-27.5*
MCV-94 MCH-31.7 MCHC-33.7 RDW-15.3 Plt Ct-280
[**2109-10-28**] 04:22AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-140
K-4.0 Cl-105 HCO3-29 AnGap-10
[**2109-10-27**] 06:08AM BLOOD ALT-15 AST-15
[**2109-10-28**] 04:22AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8
[**2109-10-27**] 06:08AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.8 Mg-1.9
[**2109-10-13**] 05:23PM BLOOD Osmolal-272*
[**2109-10-19**] 09:53AM BLOOD TSH-3.9
[**2109-10-28**] 04:22AM BLOOD Phenoba-28.3 Phenyto-20.0
Brief Hospital Course:
Initial hospital/ICU course:
42 year old female with h/o [**Doctor Last Name **] encephalitis s/p left
hemispherectomy in [**2085**], presents with increased seizures. At
baseline, she has focal seizures involving right eye twitching,
but she presented with multiple breakthrough seizures involving
eye deviation to the left, drooling, and cyanosis. In the past
when she has had these seizures, it was a sign that she had an
underlying infection. Given the patient's history, the
presentation was concerning for underlying infection versus low
AED levels. Also of note, her AED battery was supposed to be
changed back in [**2109-4-6**], when it had only 0.55 year's power
remaining, so it is probably near-dead now, and this may have
contributed her seizures on DOA as well.
By system/problem:
Neuro/epilepsy:
Under Dr.[**Name (NI) 3536**] guidance, Ms. [**Known lastname **] was monitored on LTM-EEG
for nearly a week in the ICU, up until transfer to the floor. No
clinical or electrographic seizures, beyond the intermittent
occurrence of skew-deviation/eye-twitching/nystagmoid eye
movements clinically, and on LTM, her typical pattern of
left/frontocentral spike/spike-and-slow-wave baseline abnormal
EEG. Phenytoin level was subtherapeutic at 7 on admission (had
been taking 50mg tid), and came up to 19-20 after a few IV loads
of 100-500mg followed by increasing her baseline dose to 75mg
tid (albumin low at 3.1, so this corresponds to a dose in Dr. [**Name (NI) 10875**] target range of 20-25 if her albumin were normal). may
have Phenobarb remained stable and therapeutic in the mid-30s.
Zonegran came back therapeutic (10) on admission but was
incrased for better seizure control and Keppra was
supratherapeutic (76) c/w her dosing of greater than 3g/d.
Regarding her VNS replacement, this procedure was deferred until
[**11-7**] for complete replacement because wires were
cut/damaged as this was discovered during surgery. A venous
mapping study was performed by IR and a Hickman tunneled femoral
catheter was placed for her vns change.
Pulm/ID, Pneumonia:
Ms. [**Known lastname **] arrived with leukopenia, hypotension, and hypothermia.
Thus, she was treated for SIRS on clinical grounds. Initially,
no definitive infectious source was identified. Blood and
urinalysis/urine cultures were negative/no growth on admission
and afterwards. A c.diff a/b toxin screen sent later in her stay
was negative as well. She did have small bibasilar
consolidations, however, so she was started on linezolid (rather
than vanc, due to a remote h/o vancomycin-resistant
enterococcus) and cefepime and clindamycin was started to add
coverage for anerobes, with c/f aspiration pneumonia given her
recent breakthrough seizures and already tenuous
pulmonary/tracheal anatomy (tracheal stenosis with long-standing
T-tube). She was coughing frequently and a bronch was performed
by IP due to inability to pass a suction catheter through her
[**Location (un) **] T-tube. The bronch showed substantial obstruction
from granulation tissue within the T-tube, so it was removed,
the trachea was dilated, and the tube was replaced with a
regular tracheostomy tube. ID was consulted, and suggested
discontinuing first clindamycin and then all abx, and said pt OK
for nsgy battery replacement if stable for 24h off abx.
Subsequently, however, her first quality sputum cultures
(previous attempts were unsuccessful due to her tracheal
stenosis pre-dilation/tube-replacement) -- from a mini-BAL [**10-12**]
and BAL [**10-13**] -- each grew out pseudomonas (cefepime-sensitive),
so she was re-started for another 7d course of cefepime IV. She
completed her course of Cefepime but also developed a rash from
this. The rash cleared after discontinuation of the drug. Of
note she recieved her 7D course. She is deemed a colonizer of
pseudomonas.
CV/hypotension:
Ms. [**Known lastname **] was on a norepinephrine gtt intermittently for moderate
hypotension over the first several days of her stay in the ICU.
After 3-4d, she developed transient diabetes insipidus with UOP
of 3-500mL/h and serum Na of up to 147, which was treated with
vasopressin gtt, which incidentally allowed rapid weaning of the
norepi gtt. Two bedside TTEs were unremarkable/normal.
Endo/thyroid/HPA/DI:
An elevated TSH of 4 and slighly low free T4, along with
hypothermia and hypotension (in the setting of unclear ID
process or not) along with a serum cortisol of 5 (thought to be
inappropriately normal even at 2am in a patient thought to be
septic) all prompted an Endocrinology consult shortly after
admission. They recommended following up the thyroid studies
later, as an outpatient given their limited utility in the acute
setting. They also recommended an ACTH stim test the following
afternoon, which revealed a baseline daytime level of 22 (normal
/ appropriate), and a 60min post-ACTH stimulation level of 38,
also wnl. See above w.r.t. transient episode of DI, treated with
vasopressin gtt.
GI:
Patient fed via G-tube with continuous TFs.
After her ICU stay she was transferred to the floor where she
had an uncomplicated course. There were seizure breakthrough and
she was relaoded with dilantin IV for a level 20-25 uncorrected.
The group home was instructed and trained in proper trach and
catheter upkeep.
Medications on Admission:
Zyprexa 5 mg Tab
1 Tablet(s) via GT daily
Singulair 5 mg Chewable Tab
2 Tablet(s) via GT once daily
Fleet Enema 19 gram-7 gram/118 mL
([**Known lastname 65**] unavailable)
Keppra 500 mg Tab
3 Tablet(s) via GT in the am; 2 tabs at noon; and 3 tabs at
night
Zonisamide 100 mg Cap
3 Capsule(s) via GT q pm
DuoNeb 0.5 mg-2.5 mg/3 mL Neb Solution
1 vial vis neb every 4 hours while awake
Phenobarbital 30 mg Tab
1 Tablet(s) via GT q pm
Phenobarbital 60 mg Tab
1 Tablet(s) via GT in the am and 1 tab at 2p; and 1 tab po prn
for seizures per protocol
Tylenol 325 mg Tab
([**Known lastname 65**] unavailable)
Diazepam 10 mg Tab
1 Tablet(s) via GT 1 hour prior to medical/gyn exam
Potassium Chloride SR 20 mEq Tab, Particles/Crystals
1 Tab(s) via GT q am
Guaifenesin 100 mg/5 mL Oral Liquid
15cc GT Q6hr as needed for chest congestion
Simethicone 60 mg Tab
([**Known lastname 65**] unavailable)
Colace 100 mg Cap
1 Capsule(s) GT twice a day
Ducodyl 5 mg Tab
([**Known lastname 65**] unavailable)
Dilantin Infatabs 50 mg Chewable
1 Tablet(s) by mouth three times per day
Acidophilus Cap
1 Capsule(s) GT once a day
Scopolamine 1.5 mg 72 hr Transderm Patch
1 patch transdermally with change every 72 hours
Prevacid SoluTab 30 mg Rapid Dissolve
1 Tablet(s) via GT once a day
Miralax 17 gram/dose Oral Powder
1 tsp GT daily GT with 8oz of water
Fluoxetine 20 mg Cap
1 Capsule(s) by gt once daily
Feeds: Fibersource HN @50cc/hr, continuous
Discharge Medications:
1. montelukast 5 mg Tablet, Chewable [**Known lastname **]: Two (2) Tablet,
Chewable PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
2. levetiracetam 100 mg/mL Solution [**Known lastname **]: Fifteen (15) ml PO BID
(2 times a day): LeVETiracetam 1500 mg NG [**Hospital1 **]
Morning and evening dose
Order was filled by pharmacy with a dosage form of Solution and
a strength of 100 MG/ML .
Disp:*qs * Refills:*2*
3. levetiracetam 100 mg/mL Solution [**Hospital1 **]: Ten (10) ml PO DAILY
(Daily): LeVETiracetam 1000 mg NG DAILY
Afternoon dose
Order was filled by pharmacy with a dosage form of Solution and
a strength of 100 MG/ML.
Disp:*qs * Refills:*2*
4. phenobarbital 20 mg/5 mL Elixir [**Hospital1 **]: Fifteen (15) ml PO BID
(2 times a day): PHENObarbital 60 mg NG [**Hospital1 **] Morning and 2pm
doses Order was filled by pharmacy with a dosage form of Elixir
and a strength of 20 MG/5 ML .
Disp:*qs * Refills:*2*
5. phenobarbital 20 mg/5 mL Elixir [**Hospital1 **]: 7.5 ml PO QPM (once a
day (in the evening)): PHENObarbital 30 mg NG QPM Order was
filled by pharmacy with a dosage form of Elixir and a strength
of 20 MG/5 ML .
Disp:*qs * Refills:*2*
6. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO Q6H
(every 6 hours) as needed for Fever/Pain.
Disp:*qs * Refills:*0*
7. phenobarbital 20 mg/5 mL Elixir [**Hospital1 **]: Fifteen (15) ml PO DAILY
(Daily) as needed for Generalized seizure >5 minutes, or more
than 3 generalized seizures in one hour.: PHENObarbital 60 mg NG
DAILY:PRN Generalized seizure >5 minutes, or more than 3
generalized seizures in one hour. Do not use for focal seizures.
Order was filled by pharmacy with a dosage form of Elixir and a
strength of 20 MG/5 ML .
Disp:*qs * Refills:*0*
8. guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for Chest congestion.
Disp:*qs * Refills:*1*
9. simethicone 40 mg/0.6 mL Drops, Suspension [**Hospital1 **]: One (1) PO
QID (4 times a day) as needed for Gas pains.
Disp:*qs * Refills:*2*
10. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2
times a day) as needed for constipation: Docusate Sodium 100 mg
PO BID
Give meds by GT only.
.
11. scopolamine base 1.5 mg Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
12. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*qs Tablet,Rapid Dissolve, DR(s)* Refills:*2*
13. fluoxetine 20 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO DAILY
(Daily): Fluoxetine 20 mg NG/peg DAILY
.
Disp:*qs * Refills:*2*
14. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
[**Last Name (STitle) **]: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
Disp:*qs * Refills:*1*
15. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
16. zonisamide 100 mg Capsule [**Last Name (STitle) **]: Four (4) Capsule PO QPM (once
a day (in the evening)).
Disp:*120 Capsule(s)* Refills:*2*
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
Disp:*qs * Refills:*2*
18. phenytoin 50 mg Tablet, Chewable [**Last Name (STitle) **]: 1.5 Tablet, Chewables
PO TID (3 times a day) as needed for epilepsy.
Disp:*100 Tablet, Chewable(s)* Refills:*2*
19. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed for groin itching.
Disp:*1 * Refills:*0*
20. camphor-menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical
QID (4 times a day) as needed for rash/itching.
Disp:*1 * Refills:*0*
21. triamcinolone acetonide 0.1 % Ointment [**Last Name (STitle) **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for rash.
Disp:*1 * Refills:*0*
22. heparin, porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Heparin
Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g.Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
Dispense QS x 30 [**Last Name (un) 32460**]
.
Disp:*qs ML(s)* Refills:*3*
23. Outpatient Lab Work
[**2109-11-5**]: Lab: CBC with Diff. Chem 10.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
1. Epilepsy
2. Tracheal stenosis
3. Pseudomonas pneumonia
4. Autonomic/neuroendocrine abnormalities (hypothermia,
hypotension, and hypothyroidism, and transient diabetes
insipidus) of unclear etiology
Discharge Condition:
x
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Mental Status: Confused.
Discharge Instructions:
x
You were admitted for increase in seizures. You were treated for
this in the ICU. You were also treated for a pneumonia with
cefepime and ultimately found to have a chronic colonization of
the airways. For your seizures we gave you dilantin and
increased you zonegran. You were also found to have a broken VNS
which will be replaced in 2 weeks by neurosurgery. During your
stay you had a hickman catheter placed which should stay in
place at least until your surgery. You also had your trach tube
replaced for an updated one (#7 cuffed Portex Per-fit trache).
You will need a blood test done on [**11-5**]. you are to
call Dr [**Last Name (STitle) **] office with the results. YOu are to have your VNS
changed by Dr [**Last Name (STitle) **] (neurosurgery) on [**11-7**], his number
is [**Telephone/Fax (1) 3231**]
Followup Instructions:
x
-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**]: Neurology Time/date:Please call to make an
appointment in 4 weeks. The Phone#: ([**Telephone/Fax (1) 40691**]
-Dr [**Last Name (STitle) **]: Neurosurgery tentative OR appointment for [**11-7**]. Call [**11-5**] with lab results to Dr [**Last Name (STitle) **] office
[**Telephone/Fax (1) 3231**].
-Lab slip prescribed for [**2109-11-5**]. CBC w/ diff. Chem 10.
PT/PTT/INR.
Completed by:[**2109-10-28**]
|
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"342.81",
"996.2",
"701.5",
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"E878.8",
"139.8",
"273.8",
"345.51",
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"88.66",
"00.14",
"33.21",
"88.67",
"86.05",
"88.61",
"31.74",
"96.04",
"97.23",
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] |
icd9pcs
|
[
[
[]
]
] |
19191, 19274
|
7895, 13176
|
312, 422
|
19518, 19596
|
5575, 7872
|
20489, 20969
|
3726, 3784
|
14672, 19168
|
19295, 19497
|
13202, 14649
|
19647, 20466
|
3799, 4062
|
265, 274
|
450, 3011
|
4340, 5556
|
19611, 19623
|
4086, 4086
|
3033, 3619
|
3635, 3710
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,547
| 127,546
|
43700
|
Discharge summary
|
report
|
Admission Date: [**2152-2-1**] Discharge Date: [**2152-2-9**]
Service: MEDICINE
Allergies:
Cipro / Nitrofurantoin / Acyclovir / Bactrim
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Capsule Endoscopy
History of Present Illness:
84 yo female with pmhx DM2, HTN, hyperlipidemia, s/p R CVA who
presents with weakness and fatigue for the past several days.
She usually walks with a walker but has been so weak over the
past week that she is using her scooter and dropping objects.
Her daughter noted that today her pallor had changed to pale
yellow. Initial hematocrit found to be 14.5 with INR of 7.
Denies hematochezia and usually has dark stools [**2-12**] chronic iron
therapy. Denies epigastric pain/burning or any other abdominal
pain. No episodes of cp, but 3 days ago had episode of nausea
and diaphoresis without vomiting or sob. Reports an episode of
epistaxis 2 weeks ago but denies all other bleeding. Patient is
anticoagulated for DVT in left superficial femoral vein ([**4-17**])
diagnosed after fem-[**Doctor Last Name **] bypass surgery. No recent medication
changes. Initial vs in ED were: T 99.2 P 74 BP 121/50 R 16 O2
sat 100% RA. Patient had guaic positive dark stool. Cordis was
placed. Pt was given 10 u subq vitamin k, 2 u ffp and one unit
of prbc in the ED. GI was consulted in ED and recommended IV
ppi, npo, NG lavage when INR < 2, scope once stable in the unit.
On presentation to the ICU, patient's vs were: T 96.2 BP
119/53 P 81 R 16 O2 sat 100% on 2l nc. She reported feeling much
better after blood in the ED. No dizziness, cp, sob, abd pain,
n/v, stool today.
Past Medical History:
DM x 20 + years, on oral hypoglycemics
HTN
s/p b/l hip replacement with chronic hip pain
constipation
chronic UTI's on prophylactic Keflex
hypercholesterolemia
s/p CVA- (right-sided)
osteoporosis
lumbo-sacral arthritis
disc disease with spinal stenosis at L3-4 level
DJD b/l hips
Social History:
Lives alone but has pca and home care with her most of the time.
No history of smoking, no alcohol, no drug use. IADLs-cooking.
Needs help with bathing, toilet, laundry. Daughter [**Name (NI) **] lives
nearby.
Family History:
NC
Physical Exam:
Physical exam upon MICU admission:
VS: Temp: 99.2 BP: 119/53 HR: 81 RR: 16 O2sat 100% on 2 L nc
GEN: pleasant, comfortable, NAD, pale
HEENT: NCAT,PERRL, EOMI, anicteric, sclera are pale, MM dry, op
without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, 2/6 sem at LUSB, hsm at apex, S1 and S2 wnl
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, pulses dopplerable b/l
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
RECTAL: dark guaic positive stool
Pertinent Results:
EKG: rate 74, rhythm sinus, axos normal, no LVH or BBB, TWI I,
AVL, v4-v6. Likely demand ischemia in setting of anemia.
.
Imaging:
.
Echo: [**2-17**]: EF > 75%, nl LV diastolic fxn, +1 AR, 2+ MR
.
[**11-16**] EGD:
Medium hiatal hernia (biopsy)
Schatzki's ring
Patchy erythema and petechial erythema in the whole stomach
compatible with hemorrhagic gastritis (biopsy)
Ulcer in the antrum (biopsy)
Erythema in the duodenal bulb compatible with duodenitis
Ulcer in the duodenal bulb
(biopsy)
Otherwise normal EGD to second part of the duodenum
.
[**11-16**] cscope:
[**Last Name (un) **] 1 internal hemorrhoids
Dark pigmentation in the whole colon compatible with melanosis
coli from laxative use
Polyp in the cecum (polypectomy)
Polyp in the cecum (biopsy)
Otherwise normal colonoscopy to cecum
CXR:new right IJ cv line distal tip projects at the expected
location of the proximal SVC. there is a kink in the cv line
adjacent to the transverse process of the right C6-C7.
Brief Hospital Course:
84F h/o HTN, hyperlipidemia, DM2, DVT s/p fem-[**Doctor Last Name **] bypass on
warfarin with supratherapeutic INR and LGIB, hematocrit 14.5.
.
# Presumed GI Bleed: Patient presented to the emergency room
with HCT to 14, ? of melana, but she takes iron pills at home.
INR 7.4. She was transfered to the ICU where she remained
hemodynamically stable. She recieved total of 4units PRBCs.
She also recieved 2 units FFP and vit K 10 mg SQ. Endoscopy and
Colonoscopy performed without any clear source of bleed. She
was called out to the floor where she remained stable and her
HCT remained stable. Capsule endoscopy was done and the results
were pending at the time of discharge. All of her
anticoagulation and antiplatelet medications were stopped. She
will follow up with her PCP and establish [**Name Initial (PRE) **] time course to
restart her meds. HCT will be checked 2 days after discharge
and again at her follow up PCP [**Name Initial (PRE) 648**].
.
# DVT: LENIs redone in house, DVT still present on left. Her
INR was corrected and coumadin was held. coumadin was not
restarted at the time of discharge. She will need to follow
closely with her PCP to decide if and when coumadin should be
restarted in the future.
.
#PVD - The patient's ASA and Plavix were held while in house
because of her bleeding. Her surgeon was contact[**Name (NI) **] in regards
to her antiplatelet agents. Her pcp will decide along with her
surgeon the timing of restarting these agents.
.
# HTN: Lisinopril dose was increased and home dose of metoprolol
was decreased.
.
# DM: continued glipizide. Cont neurontin for neuropathy.
.
# Osteoporosis- PCP should restart fosamax as outpatient
.
# OA- continue fentanyl patch per home regimen
Medications on Admission:
ASA 81 mg QD
plavix 75 mg qd
fentanyl 50 mcg Q72 hours
Iron sulfate 325 mg TID
fosamax 70 mg qwk
lasix 40 mg QD
neuronitn 300 mg [**Hospital1 **]
glipizide 2.5 mg QD
lipitor 40 mg QD
metoprolol 25 mg [**Hospital1 **]
lisinopril 20 mg QD
.
Allergies: ciprofloxacin, nitrofurantion, acyclovir, bactrim
Discharge Medications:
1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
3. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. Gabapentin 300 mg Tablet Sig: One (1) Capsule PO twice a day.
5. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
6. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
Care Tenders
Discharge Diagnosis:
Anemia of unclear etiology
Diabetes
Hypertension
DVT
Peripheral Vascular disease
Discharge Condition:
HCT stable
Discharge Instructions:
You were seen in the hospital for low blood counts. A
colonoscopy and endoscopy were performed that did not show a
source of bleeding. A capsule study was done and at the time of
discharge the results are still pending. You blood levels have
been stable while in the hospital after receiving the blood
tranfusions.
.
We stopped all of your blood thinners because of the bleed. We
also stopped your lasix. We increased the dose of your
lisinopril to 40mg daily and decreased your dose of metoprolol
to 12.5mg daily. We also started a medication for your stomach.
Please discuss all of your medications with Dr. [**Last Name (STitle) 2450**].
.
Please keep all of your appointments listed below.
.
Either return to the emergency room or call your primary care
physician if you have any chest pain, shortness of breath,
bleeding, pain in the legs, or other symptoms of concern to you.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] and make a follow up appointment in
[**2-14**] weeks.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2152-2-14**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2152-2-16**] 1:40
Completed by:[**2152-2-10**]
|
[
"535.50",
"453.41",
"272.4",
"443.9",
"562.10",
"357.2",
"V58.61",
"724.02",
"250.60",
"401.9",
"569.89",
"584.9",
"578.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.19",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
7043, 7086
|
3967, 5704
|
259, 294
|
7211, 7224
|
2972, 3944
|
8161, 8591
|
2235, 2240
|
6054, 7020
|
7107, 7190
|
5730, 6031
|
7248, 8138
|
2255, 2953
|
211, 221
|
322, 1688
|
1710, 1992
|
2008, 2219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,807
| 169,603
|
6949+6950
|
Discharge summary
|
report+report
|
Admission Date: [**2117-12-7**] Discharge Date: [**2117-12-20**]
Date of Birth: [**2047-6-7**] Sex: M
Service: MICU ([**Hospital Ward Name 332**])
HISTORY OF THE PRESENT ILLNESS: The patient is a 70-year-old
male with an extensive past medical history including CAD,
status post MI complicated by congestive heart failure with
an ejection fraction of 20%, hypertension, type 2 diabetes,
end-stage renal disease, status post cadaveric renal
transplant in [**2115**] on chronic immunosuppression with a recent
prolonged ICU admission from [**2117-9-14**] to [**2117-11-11**] for sepsis, congestive heart failure, acute renal
failure, sigmoid diverticulitis, status post colectomy with a
hospital course at that time complicated by pneumonia with
failure to wean, status post trach and PEG placement who now
presents with fever, change in mental status and lethargy.
Over the past week, the patient was noted to have increased
secretions. He was started on treatment with ceftazidime for
pneumonia and urinary tract infection and had been on Flagyl
empirically to prevent Clostridium difficile infection given
his prolonged antibiotic course.
Three days prior to his presentation, the patient was noted
to be more lethargic by his family. Two days prior to
admission, the patient was spiking temperatures to 102 and
was demonstrating decreased mental status. He would not
squeeze his wife's hand or open his eyes. His mental status
persisted. Per the family, the patient had no complaints of
headache, neck stiffness, abdominal pain, or change in
colostomy output. There was no change in the sacral
decubitus. The patient did have increased secretions. The
patient had been discharged with a central line that had been
resighted one week prior to his admission here in the
hospital while he was at rehabilitation. The patient was
also complaining of thirst. The patient denied any rashes.
In the Emergency Department, the patient's temperature was
100.1, blood pressure 85/40, heart rate 78, respirations 34.
He was having oxygen saturations of 94% on 50% trach collar.
The patient was pan cultured and found to have a decreased
blood glucose and given 1 amp of D50 IV, 2 liters normal
saline, 1 liter D5 half normal saline, 200 cc normal saline
boluses times two. The patient spiked a temperature to 104.5
in the ED and was given Tylenol.
He was started on Zosyn 4.5 grams IV, vancomycin, and
dexamethasone in addition to being started on Levophed as his
blood pressure was not maintained with fluid boluses alone.
He was evaluated by the Infectious Disease Service, Renal
Service, and Transplant Service and transferred over to the
[**Hospital Ward Name 516**] of the ICU.
PAST MEDICAL HISTORY:
1. End-stage renal disease secondary to diabetes and
hypertension, status post left cadaveric renal transplant in
[**2115-5-28**] on immunosuppressives.
2. Hypertension.
3. Type 2 diabetes.
4. Status post cerebrovascular accident in the left middle
cerebral artery distribution in the year [**2114**].
5. Coronary artery disease, status post anterior septal MI
with a Persantine MIBI on [**2117-9-21**] showing a severe
fixed defect in the distal apical and anterior inferior walls
with mild improvement in the perfusion of the inferior wall
suggesting mild viability.
6. History of anemia.
7. Depression.
8. Status post appendectomy.
9. Status post cholecystectomy.
10. CHF with an EF of 20-30% with 2+ mitral regurgitation
with severity very underestimated. Right atrial dilation,
left ventricular dilation, decreased LV and RV systolic
function. He has hypokinesis of all walls and 2+ tricuspid
regurgitation.
11. History of cataracts.
12. Sigmoid diverticulitis.
13. Status post colectomy with Hartmann's procedure with
colostomy.
14. Stage IV sacral decubitus ulcer.
ALLERGIES: NKDA. The patient describes reaction to vancomycin
for which he gets "burning sensation" with infusion.
ADMISSION MEDICATIONS:
1. Amiodarone 400 mg p.o. q.d.
2. Aspirin 81 mg p.o. q.d.
3. Erythropoietin 40,000 units subcutaneously q. week.
4. Heparin 5,000 units subcutaneously q. eight hours.
5. Prevacid 30 mg p.o. b.i.d.
6. Reglan 5 mg p.o. t.i.d.
7. Lopressor 25 mg p.o. b.i.d.
8. CellCept [**Pager number **] mg p.o. b.i.d.
9. Prednisone 10 mg p.o. q.d.
10. Tacrolimus 1 mg p.o. b.i.d.
11. Zoloft 1 mg p.o. q.d.
12. Zinc 20 mg p.o. q.d.
13. Percocet p.r.n.
14. Bactrim 0.5 tablets double strength Tuesday, Thursday,
and Saturday.
15. Bicitra.
16. Tylenol p.r.n.
17. NPH 45 units subcutaneously q. 12 hours.
18. Regular insulin sliding scale.
19. Ceftazidime 1 gram q. 24 hours from [**2117-11-29**] to
[**2117-12-6**].
20. Flagyl p.o. t.i.d. which he took from
[**2117-11-30**] through [**2117-12-10**].
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
102.8, heart rate 120, blood pressure 135/47 on Levophed, MAP
76, oxygen saturation 99% on assist control. General: He
was trached, obtunded, breathing pattern on assist control
was abnormal. HEENT: The pupils were reactive to light.
The oral mucosa was dry. Heart: Tachycardiac, S1, S2.
Lungs: He had coarse breath sounds bilaterally, moving air
in all lung fields. Abdomen: Soft, nontender, nondistended,
although he was obtunded. Bowel sounds were decreased. He
was obese with colostomy bag with brown stool. Extremities:
Slightly cool, shotty pulses. Neurologic: Obtunded, no
response to pain. Skin: He had a large sacral decubitus.
LABORATORY/RADIOLOGIC DATA: White count 14.5, hematocrit
35.3, platelets 244,000, MCV 91, neutrophils 65.4, bands 0,
lymphocytes 28.9, monocytes 3.9, eosinophils 1.5, basophils
0.3. PT 13.4, PTT 28.3, INR 1.2. Sodium 155, potassium 4.7,
chloride 127, bicarbonate 21, BUN 57, creatinine 1.0, glucose
483, calcium 9.5, magnesium 2.2, phosphorus 2.5, CK 12, MB
not done, troponin 0.29. Cortisol 21.1, ALT 23, AST 34,
amylase 93, lipase 27, alkaline phosphatase 203, total
bilirubin 0.3, albumin 2.4, total protein 7.4. The U/A
showed 30 protein, small leukocytes, greater than 50 RBCs,
greater than 50 WBCs, occasional bacteria, and [**3-31**]
epithelials. His lactate was 2.4. His gas was 7.33, 30, 66.
Chest x-ray showed improved pulmonary edema, right lower lobe
pneumonia, left subclavian tip in the mid SVC, no
pneumothorax, status post tracheostomy, unchanged.
Head CT revealed no acute hemorrhage, no mass.
EKG revealed 80 beats per minute, sinus, left axis deviation,
increased PR interval, no right or left atrial enlargement,
no left or right ventricular hypertrophy, no acute ST-T wave
changes, poor R wave progression, no Q waves.
Sputum Gram's stain showed greater than 25,000 epithelials,
4+ gram-positive rods, 2+ gram-positive rods. Blood cultures
times two were pending.
ASSESSMENT: This is a 70-year-old male with a history of
hypertension, type 2 diabetes, coronary artery disease, CHF,
EF 20%, end-stage renal disease, status post cadaveric renal
transplant on chronic immunosuppressants who presented to the
ER with change in mental status admitted with sepsis.
HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient's
initial sepsis was thought secondary to both pneumonia and
possibly a urinary tract infection. The [**Hospital 228**]
rehabilitation called to report that the patient's extended
spectrum beta lactamase resistant Klebsiella growing from his
sputum. The patient was continued on a 14 day course with
meropenem with completion of the meropenem due on [**2117-12-20**]. The patient also had suggestion of a urinary tract
infection from his urinalysis on admission; however, a urine
culture was not originally sent and thus it is not clear
whether he actually had growth from his urine. A follow-up
culture that was done with the initiation of antibiotics
showed evidence of yeast. The patient was treated with a
seven day course of fluconazole to treat his Candiduria given
his immunocompromised state.
The patient also came in with a central line and had blood
cultures which grew out Staphylococcus epidermidis. The
patient's line was changed and he was treated with a seven
day course of vancomycin for a question of a line infection.
He was continued on Bactrim for PCP prophylaxis given that he
is on chronic steroids. Of note, when the patient was
afebrile and without a white count, he had a sputum sent
which revealed pan resistant Pseudomonas in the sputum except
did show sensitivity to colistin. The patient did not show
any evidence of infection including no evidence of fever,
leukocytosis, and no increased ventilatory requirement.
Thus, it was thought that he was colonized rather than had a
pathogenic infection with this particular strain of
Pseudomonas.
2. SACRAL DECUBITUS ULCER: The patient has a large stage IV
sacral decubitus ulcer. He is closely followed by Plastic
Surgery who debrides inactively. The patient had an MRI of
the area which did not show evidence of osteomyelitis.
Tissue culture was positive for pan resistant Pseudomonas and
vancomycin-resistant Enterococcus. His pathology of the bone
to assess for active inflammation and invasion of the bone is
still pending at the time of this dictation. The patient has
active inflammation per the pathology and the Pseudomonas is
colistin sensitive. We will need to address treatment with
linazolid and colistin. If there is no active inflammation
then the patient will not need to be treated with aggressive
antibiotics but only with aggressive local wound care.
3. CARDIOVASCULAR: The patient had a troponin leak in the
setting of sepsis. Once he was over his initial hemodynamic
instability, he was restarted on his beta blocker, continued
on his aspirin. Given his history of a low ejection fraction
and a history of nonsustained ventricular tachycardia, he was
continued on Amiodarone 400 mg q.d. Discussion for an ICD
placement will be discussed at a later time.
4. RENAL: The patient was with a history of end-stage renal
disease status post cadaveric renal transplant now on
immunosuppression. The patient had developed renal failure
in the setting of hypotension and acute tubular necrosis with
a peak creatinine of 1.9. His creatinine stabilized back to
normal after treatment for sepsis. His prednisone dose was
decreased to 7.5 mg p.o. q.d. and his tacrolimus was
continued at 2 mg p.o. b.i.d. The patient's CellCept was held
and will be continued to be held for the duration of his
hospitalization. This will be reinitiated by Nephrology if
deemed appropriate at a later time.
5. ENDOCRINE: The patient has type 2 diabetes. He was
initially treated with an insulin drip during his acute
septic phase and then transitioned to his usual NPH 45 units
b.i.d. and regular insulin sliding scale.
6. RESPIRATORY FAILURE: The patient was initially placed on
assist control during his septic phase and was quickly weaned
back to trach collar without difficulty. The patient had an
abundance of secretions requiring increased suctioning,
otherwise without evidence of hypercarbia or hypoxic
respiratory failure.
7. ACCESS: The patient had a left upper extremity PICC
placed on [**2117-12-15**].
The remainder of this discharge summary including the
discharge diagnoses and discharge medication list will be
dictated by the house officer taking over the care of this
patient.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern4) 26118**]
MEDQUIST36
D: [**2117-12-19**] 02:14
T: [**2117-12-19**] 14:34
JOB#: [**Job Number 26119**]
Admission Date: [**2117-12-7**] Discharge Date: [**2117-12-20**]
Date of Birth: [**2047-6-7**] Sex: M
Service: [**Hospital Ward Name **] ICU
ADDENDUM: ____________ hours secondary to sepsis, which took
days. The family declined an autopsy.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern4) 26118**]
MEDQUIST36
D: [**2117-12-27**] 08:38
T: [**2117-12-27**] 08:54
JOB#: [**Job Number 26120**]
|
[
"785.52",
"276.2",
"707.0",
"038.8",
"996.81",
"584.5",
"996.62",
"276.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"77.69",
"86.22",
"99.04",
"96.72",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7079, 12130
|
3958, 4771
|
4786, 7061
|
2732, 3935
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,954
| 146,053
|
4691
|
Discharge summary
|
report
|
Admission Date: [**2126-12-1**] Discharge Date: [**2126-12-13**]
Date of Birth: [**2058-7-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Right Flank Pain, diarrhea
Major Surgical or Invasive Procedure:
Central venous line and arterial line placment
Exploratory laparotomy, splenic flexure take-
down, total abdominal colectomy, Rectal Hartmann's formation
with
end ileostomy , feeding gastrojejunostomy, and [**Doctor Last Name 406**] drain
placement.
History of Present Illness:
68F recently hospitalized [**Date range (1) 4359**] for pyelonephritis
requiring ICU admission and was discharged on Cefpodoxime.
Returns with right flank pain, nausea and low grade fever.
Past Medical History:
PMH:
hypertension
nephrolithiasis
chronic low back pain (s/p SI steroid injection [**2126-9-17**], mri
l-spine [**2126-10-13**] negative for compression)
hypercholesterolemia
gerd s/p lap nissen fundoplication
gastritis
hiatal hernia
stable pulmonary nodules (6mm, 3mm, bilateral, likely
granulomas)
Social History:
Social Hx:
Married, lives with husband in [**Name (NI) 10059**]
20 years x 1 ppd tobbacco, quit 15 years ago. [**4-6**] glasses wine
per week, denies IVDU.
Family History:
Sister died at 55 of MI.
Brother with heart problems.
Physical Exam:
Initial Physical Exam - ER- [**12-1**]
NAD
Dry MM, OP clear
CTAB
RRR
soft, ND, diffusely TTP
(+) CVAT R>L
Skin - wwp
Pertinent Results:
Admission Labs
-----------------
[**2126-12-1**] 02:57PM BLOOD WBC-13.7*# RBC-3.81* Hgb-12.9 Hct-35.5*
MCV-93 MCH-33.7* MCHC-36.2* RDW-12.8 Plt Ct-570*#
[**2126-12-1**] 02:57PM BLOOD Neuts-89.2* Bands-0 Lymphs-6.2* Monos-3.8
Eos-0.7 Baso-0.1
[**2126-12-1**] 02:57PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Schisto-OCCASIONAL
[**2126-12-1**] 02:57PM BLOOD Plt Ct-570*#
[**2126-12-1**] 02:57PM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-125*
K-4.0 Cl-90* HCO3-21* AnGap-18
[**2126-12-1**] 09:35PM BLOOD ALT-39 AST-45* AlkPhos-215* Amylase-43
TotBili-1.1
[**2126-12-1**] 09:35PM BLOOD Lipase-31
[**2126-12-2**] 03:54AM BLOOD Albumin-2.6* Calcium-7.6* Phos-3.7#
Mg-1.5*
[**2126-12-2**] 01:53AM BLOOD Cortsol-26.5*
[**2126-12-2**] 02:31AM BLOOD Cortsol-30.6*
[**2126-12-1**] 02:58PM BLOOD Lactate-2.0
Discharge Labs
-------------------
WBC- 12.3; Hct- 30.9;
CT Scan
-----------------
CT OF THE ABDOMEN AND PELVIS, CT UROGRAM
INDICATION FOR STUDY: Urinary tract infection, pyelonephritis,
failed antibiotic treatment, evaluate for abscess.
Comparison is made with recent CT scan from [**2126-11-25**].
TECHNIQUE: Following a non-contrast image acquisition, the
patient was administered 130 cc Optiray diffusely and helical
scan obtained through the abdomen and pelvis during excretion of
contrast.
FINDINGS: ABDOMEN WITH CONTRAST: Again seen are small bilateral
pleural effusions with bibasilar atelectasis, not significantly
changed from the prior study. A small amount of ascitic fluid is
newly noted adjacent to the liver and spleen. The liver has an
unremarkable appearance. Please note that portal venous flow
cannot be evaluated on this study. The spleen is not enlarged
but again noted are multiple perisplenic variceal vessels which
have been present in prior studies. The precise etiology of
these variceal vessels is uncertain. Head, body and tail of the
pancreas are unremarkable. No intra or extrahepatic bile duct
dilatation is present. Gallbladder is unremarkable. A small
amount of widely distributed ascitic fluid is noted in the upper
abdomen. Again noted are features consistent with pyelonephritis
in the left kidney with poor perfusion in multiple areas, no
focal abscess is identified within the left kidney. The extent
of perfusion anomalies in the left kidney is not appreciably
changed. Contrast is being excreted into the left and right
ureters.
PELVIS WITH CONTRAST: Ureters are well visualized down to
insertion into the bladder. Ascitic fluid is again noted in the
pelvis of uncertain etiology. This is not appreciably changed in
volume when compared with the prior study. No adnexal masses or
cystic lesions are identified.
BONE WINDOWS: Multiple subchondral lucencies are present in the
hip joint, consistent with degenerative change. No suspicious
lytic or blastic lesions are identified elsewhere in the
visualized skeleton.
IMPRESSION:
1. Thick and thin slab coronal and sagittal reformatted images
again demonstrate the presence of severe pyelonephritis in the
mid and lower poles of the left kidney with no evidence for
abscess formation.
2. New small amount of ascitic fluid. The etiology of this
ascitic fluid which surrounds the upper spleen is uncertain.
Again noted are extensive perisplenic variceal vessels.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 3265**] was evaluated in the emergency department at
[**Hospital1 18**] on [**2126-12-1**] for right flank pain and low grade fevers.
She had recently been discharged from [**Hospital1 18**] for
UTI/pyelonephritis. During her stay in the ED she became septic
with low blood pressure and temperature spike at 103.2(R). Her
WBC count was 13.7 and her urine showed moderate WBCs and
bacteria. A CT scan showed left pyelonephritis. A right SC
central line was placed for resuscitation. She was admitted to
the MICU under the care of the medicine team and was placed on
sepsis protocol. Levophed was administered to maintain adequate
perfusion pressures. A cortisol stem test was positive and
steroids were provided. Vancomycin and Ceftaz were started for
empiric coverage pending cultures.
On HD2 her BP had stabilized. She complained of worsening
abdominal pain. She was more distended and had diarrhea.
Surgery was consulted. An NGT was placed and she was made NPO.
Flagyl was started. Stool cultures were sent.
At HD 3 her stool cultures were positive for c. difficile. TPN
was started and she remained NPO. Her WBC was elevated at 31.1.
At HD 4 she was febrile, tachycardic, and in moderate distress
with worsening abdominal exam. Fluid resuscitation was continued
to maintain blood pressure and urine output. She developed
lactic acidosis. She was taken to the operating room for an
exploratory laparotomy, splenic flexure take-down, total
abdominal colectomy, Rectal Hartmann's formation with end
ileostomy, feeding gastrojejunostomy, and [**Doctor Last Name 406**] drain placement.
She tolerated the procedure and was taken to the ICU intubated
and sedated. From this point her care was transferred to the
surgery service.
At POD 1 she remained intubated to allow for diuresis. Trophic
tube feeds were started. She was extubated later that day
without complication. Her Ceftaz was discontinued and she
remained on the Vancomycin/Flagyl. Her steroids were weaned.
At POD 3 she was doing better. She was afebrile and with
adequate urine output. She was transferred to the floor. Her
drain was discontinued. At POD 5 her diet was advanced as
tolerated and physical therapy was consulted for discharge
planning. The wound nurses were consulted to evaluate and teach
ostomy care. Her rectal tube was removed.
At POD 6 she was tolerating a regular diet. Her foley was
removed but she had urinary retention and her catheter was
replaced. She remained with edema/fluid and lasix was given for
diuresis. Her central line was discontinued.
At POD 7 her catheter was removed, Lasix was started daily for
diuresis. She was unable to void after removing the catheter and
the foley was replaced a second time.
At POD 8 she was discharged to home in good condition. She went
home with VNA support for ostomy care and cycled tube feedings
at night - Replete [**4-6**] at 60ml/hr. Home physical therapy was
arranged. The urinary catheter remained. She was to continue her
home medications and was sent on one week's worth of Lasix 20mg
and Potassium. Her labs were to be checked every other day and
faxed to Dr.[**Name (NI) 11471**] office to monitor electrolytes. She was to
follow up with Dr. [**First Name (STitle) 2819**] on [**12-19**].
Medications on Admission:
spironolactone/hctz 25/25 PO DAILY
enalapril Maleate 20 mg PO DAILY
fluvastatin 20 mg PO QD (lescol)
alprazolam 0.25 mg PO TID PRN
tizanidine 2-4 mg PO TID PRN back pain (skeletal muscle
relaxant)
tramadol 50mg PO TID
amitryptiline 0.25 mg po qhs
vit b6 100mg qdaily
ca 600 mg po bid
vit d 400 IU po qdaily
fish oil
folic acid 400mg po bid
Discharge Medications:
1. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Temazepam 15 mg Capsule Sig: One (1) Capsule PO once a day.
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO three times
a day as needed.
4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Spironolacton-Hydrochlorothiaz 25-25 mg Tablet Sig: One (1)
Tablet PO once a day.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lescol 20 mg Capsule Sig: One (1) Capsule PO once a day.
9. Tizanidine 2 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 1
weeks.
Disp:*7 Tablet(s)* Refills:*0*
11. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
12. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
C. diff toxic pseudomembraneous colitis with sepsis
Urinary Retention requiring replacement of bladder catheter
Malnutrition
Hypertension
Discharge Condition:
Good
Discharge Instructions:
Please call or contact for:
* Fever (>101 F)or chills
* Abdominal Pain
* Decreased output from ostomy
* Misplacement or pulling out of feeding tube or catheter
* Redness or drainage from incision or feeding tube site
* Dark, cloudy, or foul smelling urine
* Any other concerns
Please continue your home medications. We will be adding Lasix
and Potassium to be taken until you see Dr. [**First Name (STitle) 2819**] in clinic.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in clinic on the [**Location (un) 470**] of the
[**Hospital Unit Name **]. Your appointment is [**12-19**] at 2:30pm. The
office number is ([**Telephone/Fax (1) 6347**].
Completed by:[**2126-12-13**]
|
[
"276.2",
"995.92",
"V13.01",
"788.20",
"263.9",
"038.3",
"401.9",
"590.10",
"785.52",
"724.2",
"008.45",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"00.17",
"99.15",
"38.91",
"96.07",
"45.8",
"44.32",
"38.93",
"46.21"
] |
icd9pcs
|
[
[
[]
]
] |
9612, 9670
|
4882, 8170
|
341, 594
|
9852, 9858
|
1534, 4859
|
10333, 10592
|
1326, 1381
|
8561, 9589
|
9691, 9831
|
8196, 8538
|
9882, 10310
|
1396, 1515
|
275, 303
|
622, 812
|
834, 1136
|
1152, 1310
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,176
| 101,611
|
7030
|
Discharge summary
|
report
|
Admission Date: [**2116-4-29**] Discharge Date: [**2116-5-13**]
Date of Birth: [**2052-9-4**] Sex: F
Service: ENT
HISTORY OF PRESENT ILLNESS: The patient was admitted with a
history of laryngeal squamous cell carcinoma status post
supraglottic laryngectomy in [**2107**]; no chemotherapy or
radiation therapy at that time. The patient subsequently had
a right neck mass which was a recurrence in [**2114**]. At that
time, she had chemotherapy with Cisplatin and 5FU plus
radiation therapy and had a tracheostomy done at that time in
[**2114**]. The Tracheostomy was then closed later in [**2114**].
The patient presented recently to [**Hospital 26260**] Hospital on
[**2116-4-25**], to the Emergency Department in respiratory
distress and was intubated orally with laryngoscope and much
difficulty. CT of the neck was consistent with recurrent
disease. There was an attempt in the Operating Room on [**2116-4-28**], to extubate with fiberoptic evaluation, which
revealed however, that she had edematous AE fold, 1-2 mm
airway, poor vocal cord abduction, and the patient had
stridors after extubation and was then reintubated at that
time and transferred to the [**Hospital1 **] Hospital
for further management.
The patient presented on [**2116-4-29**], in the evening, to
have her tracheostomy redone tomorrow.
PAST MEDICAL HISTORY: As above, as well as alcohol abuse,
intravenous drug abuse, hypothyroidism, depressions, sleep
apnea, hepatitis C, herpes zoster.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: Colace, Albuterol, Atrovent, Solu-Medrol 40 mg
b.i.d., Prevacid 30 mg b.i.d., Synthroid 50 mcg q.d., Remeron
15 mg q.h. p.r.n., Ativan p.r.n., Vancomycin.
SOCIAL HISTORY: The patient denied alcohol or intravenous
drug abuse currently, as well as tobacco.
PHYSICAL EXAMINATION: General: On presentation, the patient
was awake, was communicative, but intubated. She was
communicative via writing on a pad. Neck: Exam revealed old
scars from post radiation therapy treatment changes. The
larynx was fairly mobile. Lungs: She had decreased breath
sounds of the left lung base. Extremities: There was trace
edema bilaterally of the lower extremities.
ASSESSMENT AND PLAN: This was a 52-year-old woman with
recurrent laryngeal cancer with airway obstruction secondary
to her second recurrence of the disease. She was admitted
under Dr. [**First Name (STitle) **] to the Surgical Intensive Care Unit with a
plan for tracheostomy. The patient was taken to the
Operating Room on [**2116-4-30**].
HOSPITAL COURSE: She underwent tracheostomy and rigid
laryngoscopy. Findings were that of a small anterior mass,
anterior to the left vocal cord. Biopsy was sent to
Pathology. She was then returned to the SICU. The patient
had her vent-trach weaned and was then transferred to the
floor on [**5-1**], which was postoperative day #1, at [**Hospital6 1760**] on postoperative day #3 from
the previous operation.
Postoperatively, the patient was kept on Vancomycin. She had
a good cough. The tracheostomy and the airway were patent
and well secured. Physical Therapy helped with ambulation.
It was noted that she had right arm swelling, and she had had
a PICC line in the right arm which was then removed, and
subsequently the PICC line was placed in the left side.
On [**2116-5-4**], the patient was found to have a deep venous
thrombosis in the right upper extremity on ultrasound and was
treated with Heparin. She was continued on Heparin, and when
she was therapeutic, she was started on Coumadin with a goal
INR around 2.0. She also had a Hematology/Oncology consult.
A CT of the head and neck was done which did not reveal
obvious recurrent disease. The patient also a had a right
arm elevation ...................., in addition to her
Heparin and Coumadin ..................
The Foley was discontinued successfully. She continued to
have a good airway and patent tracheostomy. Finally on the
17th, the INR was 2.2. Heparin was discontinued. The
patient was kept on Coumadin ............... and Vancomycin.
Plans were made for discharge home with services on [**5-13**].
The patient was seen by Respiratory during her hospital
course. She was able to cough and clear her secretions. She
is going home on Vancomycin. She is to get her INR checked
via her primary care physician [**Name Initial (PRE) 20515**].
DISCHARGE MEDICATIONS: She will go home on all of her
preoperative medications, as well as saline bolus.
FOLLOW-UP: She is to have follow-up with Dr. [**First Name (STitle) **] in [**8-8**]
days.
[**Name6 (MD) **] [**Last Name (NamePattern4) 13798**], M.D. [**MD Number(1) 13799**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2116-5-13**] 09:21
T: [**2116-5-13**] 10:59
JOB#: [**Job Number 26261**]
|
[
"451.83",
"518.81",
"V02.62",
"161.8",
"482.41",
"999.2",
"491.21",
"V09.0",
"518.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"31.43",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
4410, 4850
|
2570, 4386
|
1828, 2552
|
164, 1341
|
1364, 1703
|
1720, 1805
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,568
| 126,757
|
50111
|
Discharge summary
|
report
|
Admission Date: [**2183-3-1**] Discharge Date: [**2183-3-4**]
Service: MEDICINE
Allergies:
Bactrim / Nsaids
Attending:[**First Name3 (LF) 1631**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **] year old woman [**Hospital 100**] Rehab resident with multiple
medical problems including atrial fibrillation/atrial flutter,
diastolic congestive heart failure, and hypertrophic obstructive
cardiomyopathy transferred to [**Hospital1 18**] ED for respiratory distress.
Per EMS, patient oxygen saturation was 89% on 4 liters nasal
cannula which increased to 100% on 15 liters, heart rate in 70s,
blood pressure 150/90, respiratory rate 32 and with crackles in
all lung fields bilaterally. EMS gave patient lasix 40mg IV and
1 sublingual nitroglycerin.
.
In ED, oxygen saturation in the 80s on non-rebreather and
patient was transiently placed on positive pressure noninvasive
mask ventilation for ~2 hours. Pt was also given another 40 IV
lasix in emergency department.
.
Upon arrival to ICU, patient's oxygen saturation was 99-100% on
4 liters nasal cannula, having produced ~400cc urine since
arrival from the nursing home. When asked about the events
leading to her hospitalization, she remembers developing right
upper quadrant abdominal pain followed by acute worsening of her
shortness of breath. Patient and her daughter state that this is
exactly how her previous episodes of acute pulmonary edema have
presented. Per daughter, patient had a "high salt" meal
yesterday night, including "salmon lox."
.
Patient's daughter reports ~six episodes of acute pulmonary
edema requiring hospitalization over the past 5-6 months,
primarily at [**Hospital 882**] Hospital and [**Hospital1 18**].
.
ROS: Denies chest pain, palpitations, bright red blood per
rectum, melena, or other complaints.
Past Medical History:
1. diastolic congestive heart failure (ejection fraction 70%)
complicated by frequent admissions with acute pulmonary edema
2. atrial flutter/atrial fibrillation
3. hypertrophic obstructive cardiomyopathy (left ventricular
outflow tract 16)
4. Non-Q wave myocardial infarction [**2176**]
5. Hypertension
6. Hyperlipidemia
7. Chronic renal failure
8. Hypothyroidism
9. Anemia
10. Arthritis
11. Diverticulosis
12. Status post GI bleed secondary to NSAIDs
13. Peripheral vascular disease
14. Status post cataract repair
15. Status post motor vehicle accident 15 years ago
16. History of pelvic fracture
Social History:
Retired microbiologist in [**Country 532**]. Daughter who is an attending
neurologist at the [**Hospital 789**] [**Hospital **] Hospital. Lives alone, daughter
nearby, health aide 2h/day, 7days/week. Walks with a walker.
She is widowed. There is no history of alcohol or tobacco or
recreational drug use.
Family History:
4 sisters all died of cancer, various causes including lung ca
and possibly ovarian ca. One daughter died of metastatic cancer
in [**2173**] primary site unknown, presumed to be ovarian.
Physical Exam:
99.1 116/62 82 26 97.3 5L
Gen: pleasant, elderly F in NAD
Skin: C/D/I, no rashes appreciated; PIVs
Neck: full ROM, LVD elevated to near mandible
HEENT: OP clear, MMM, EOMI, anicteric sclera
Heart: S1S2, irreg irreg, II/VI SM @ apex
Lungs: CTA B, bibasilar crackles
Abdom: soft, obese, slight tenderness to deep palp at RUQ, no
rebound, no guarding, NABS
Extrem: 1+ bilat pitting edema @ ankles, trace bilat DP pulses,
full ROM in upper extrem
Neuro/Psych: A&Ox3, conversant, appropriate, fluent speech
w/Russian accent, follows commands.
Pertinent Results:
Labs on admission:
WBC 8.8 Hct 33.8* Plt Ct 217
Neuts 90.6* Lymphs 7.3* Monos 1.3* Eos 0.8 Baso 0.1
.
PT 12.3 PTT 19.3* INR(PT) 1.1
.
Glucose 245* UreaN 33* Creat 1.7* Na 141 K 3.7 Cl 100 HCO3 30
AnGap 15
.
ALT 14 AST 21 CK(CPK) 54 AlkPhos 93 TotBili 0.4 Lipase 33
.
[**2183-3-1**] 06:05AM BLOOD CK-MB NotDone cTropnT <0.01 proBNP 8933*
[**2183-3-1**] 05:22PM BLOOD CK-MB 2 cTropnT <0.01
[**2183-3-2**] 04:05AM BLOOD CK-MB 3 cTropnT 0.01
.
Calcium 8.8 Phos 5.2* Mg 1.7
.
UA negative
.
Studies:
CHEST (PORTABLE AP) [**2183-3-1**]: Mild CHF.
.
ABDOMEN (SUPINE ONLY) PORT [**2183-3-1**]: Borderline distended loops
of small bowel in the central abdomen may represent early or
partial small bowel obstruction. Given the limited nature of the
study if clinical concern persists, repeat radiograph with
supine and upright views would be helpful to further
characterize these findings.
.
Cath ([**8-30**]): no CAD (30% LCx).
.
ECHO ([**11-30**]): symmetric LVH w/EF>55%, dilated LA, [**1-27**]+ MR.
.
ECG: Afib@100, nl axis, nl QRS int, QTc slightly prolonged. LVH.
ST/TW changes discordant from large QRS diffusely. Unchanged
from old ECG except for rate.
Brief Hospital Course:
This is a [**Age over 90 **] year old woman from [**Hospital 100**] Rehab resident with MMP
including atrial fibrillation/atrial flutter, diastolic
congestive heart failure, and hypertrophic obstructive
cardiomyopathy who presented with acute pulmonary edema that
stabilized with IV nitro, lasix, and transient CPAP, now stable
on room air. No clear precipitant except possibly dietary
indiscretion.
.
# Respiratory distress/CHF exacerbation: Stabilized after nitro
drip, IV lasix, CPAP and now on NC. Chest x-ray and BNP also
supported congestive heart failure as likely etiology.
Precipitant may have been dietary indiscretion but patient also
had some epigastric/right upper quadrant pain. Cardiac enzymes
were cycled and were negative x3. ECG showed early repol but no
ischemic-appearing acute ST changes. HR was only in 70-80s
throughout episode so it was not thought that rapid afib was
contributing. No clinical or radiological evidence of pneumonia.
No signs or symptoms to suggest pulmonary embolism at this time.
Patient was monitored on for her atrial fibrillation and rate
controlled with metoprolol XL. Patient also continued on
amiodarone. Patient was aggressively diuresed with good effect.
Lisinopril was resumed on [**2183-3-2**]. Patient's oxygen was weaned
from 4L and at time of discharge was sat'ing 95% on room air.
.
Incidentally, a 5mm calcified granuloma was seen on chest x-ray.
No interstitial process or opacities were seen otherwise and
patient's wheezing, oxygen requirement and breathing improved
dramatically with diuresis only. As a result, there was a low
suspicion for amiodarone lung toxicity. Patient will need a
follow-up chest CT to follow-up the new calcified granuloma.
.
# Renal: Creat 1.7 at admission (baseline ~1.0-1.4), possibly
related to poor perfusion during acute CHF exacerbation, now
improved. UA negative. Good UOP. Patient was resumed on ACE-I
[**2183-3-2**].
.
# Afib/Flutter: Currently in Afib @ 80-100s. As stated above,
don't believe contributed to worsening CHF. Continued on Toprol
XL and amiodarone. Continued on coumadin, goal INR 2-2.5
.
# CAD: clean coronaries on cath in [**8-30**]. Continued statin.
.
# Anemia: low-normal MCV. Iron studies in [**11-30**] consistent with
anemia of chronic disease but with adequate iron stores
(ferritin 150). Hematocrit has been stable. No signs or symptoms
of active bleeding.
.
# Hypothyroidism: continued Synthroid at outpatient dose
.
# FEN: low-Na+ diet; repleted lytes as patient diuresed
.
# Prophyl: SC heparin, protonix, regular insulin sliding scale
was discontinued since fingersticks were not elevated.
.
# Code: upon clarification with pt's daughter, FULL CODE.
.
# Dispo: discharge to rehab.
.
# Communication: [**Doctor First Name 9046**] [**Telephone/Fax (1) 104619**]
Medications on Admission:
1. amio 200 daily 2. lisinopril 2.5 daily 3. Toprol XL 250
daily 4. simvastatin 20 daily 5. warfarin 1-3 mg daily
(titrating) 5. furosemide 20 mg daily 6. Synthroid 112 mcg
daily 7. pantoprazole daily 8. folic acid 9. colace, senna
10. ferrous sulfate 325 daily 11. vitamin B12 500 mcg qM,Thurs
12. rec'd Pneumovax
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 2.5 Tablet Sustained Release 24HRs 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 1 days: Please titrate with goal INR [**2-28**].
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-27**]
Drops Ophthalmic PRN (as needed).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please check daily wts and titrate lasix dose
accordingly to keep wt the same.
15. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO once
a day.
16. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO qMon,
qThurs.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
primary diagnosis:
1. diastolic congestive heart failure exacerbation
2. new calcified lung nodule in right lower lobe
.
secondary diagnosis:
2. atrial flutter/atrial fibrillation
3. hypertrophic obstructive cardiomyopathy
4. history of diverticulosis
Discharge Condition:
Oxygen saturation 95-96% on room air
Afebrile
Discharge Instructions:
Please take medications as prescribed.
.
Please keep your follow-up appointments.
.
Please check your PT/INR labs daily and have your primary care
physician adjust your warfarin dose accordingly. Goal INR
2.0-3.0.
.
Please have your primary care physician [**Name9 (PRE) 702**] with [**Name Initial (PRE) **] chest
CT to evaluate a 5-mm calcified granuloma in the right lower
lobe seen on chest x-ray.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
.
Adhere to 2 gm sodium diet
.
Fluid Restriction: 1 liter
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD (PCP)
Phone: [**Telephone/Fax (1) 142**]
Date/Time: Tues [**2183-3-18**] 3:30pm
Please call to schedule sooner if you are able to bring someone
who could translate.
.
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD (CARDIOLOGY)
Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2183-3-31**] 2:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1636**]
Completed by:[**2183-3-4**]
|
[
"425.1",
"272.4",
"427.31",
"403.91",
"414.01",
"285.9",
"443.9",
"585.9",
"428.31",
"427.32",
"412",
"244.9",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9457, 9530
|
4810, 7597
|
243, 249
|
9826, 9874
|
3634, 3639
|
10457, 11030
|
2861, 3049
|
7973, 9434
|
9551, 9551
|
7623, 7950
|
9898, 10434
|
3064, 3615
|
183, 205
|
277, 1897
|
9693, 9805
|
9570, 9672
|
3653, 4787
|
1919, 2521
|
2537, 2845
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,474
| 185,490
|
54874
|
Discharge summary
|
report
|
Admission Date: [**2104-6-28**] Discharge Date: [**2104-7-4**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Asystolic arrest
Major Surgical or Invasive Procedure:
IJ CVL placement
History of Present Illness:
Patient is a [**Age over 90 **]yo M s/p asystolic arrest who presents from OSH
fro therapeutic hypothermia post cardiac arrest.
[**Name (NI) **] son reports that in the days prior to admission, he
was having more 'cold' (a productive cough). [**Name (NI) **] son also
reports vomiting and difficulty maintaining PO intake. Patient
was on Levaquinn for treatment of UTI; he completed a coure
approximately 2 days ago.
Per report the patient was last noted to have received a cup of
something to drink from a home health-aid and then went to bed.
Reportedly, 30 minutes later, the patient was found in his bed
unresponsive. His family began chest compressions and EMS was
called. He received epinephrine times 3 in the field and was
intubated. He was then transferred to [**Hospital3 **]. At [**Hospital1 **], he was started on Levophed. Upon starting Levophed,
the patient's SBP at OSH was noted to be in the 140s. He was
then transferred to [**Hospital1 18**] for therapeutic hypothermia post
cardiac arrest.
In the [**Hospital1 18**] ED, the patient was noted to be breathing over the
vent. He was given Fentanyl and midazolam boluses. A bedside
ECHO in the ED showed an EF of approximately 10%. Exam was
notable for a lack of corneal reflexes as well as a gag. Pupils
were noted to be fixed and dialted. Post-arrest team was
consulted in the ED. CXR in the ED was notable for right LL
opacity concerning for aspiration PNA. An A-line was placed in
the ED. For access: PIV in EJ, R femoral line, and Left IO.
Patient had a head CT that showed no evidence of acute bleed.
Levophed was able to be weaned to 0.03mcg/mg/min and dopamine
was started. The patient maintained MAPs in the 60s on the
combination of dopamine and Levophed.
On arrival to the MICU, the patient is intubated. He is on
Levophed 0.1mcg/kg/min.
Past Medical History:
--CHF
--HTN
--BPH
--TIA
--Decubitus ulcer
Social History:
Lives at home with his family being responsible for his care.
Non-smoker. No EtOH.
Family History:
Non-contributory
Physical Exam:
Admission:
General: Unresponsive, diffusely cool, no pupilalry or corneal
reflexes
HEENT: ETT in place, pupils nonreactive
Cor: RRR, no murmurs
Lungs: CTAB anteriorly
Abd: soft, nondistended
Ext: cool
Discharge: expired
Pertinent Results:
[**2104-6-28**] 11:15PM BLOOD WBC-6.5 RBC-3.42* Hgb-8.6* Hct-30.1*
MCV-88 MCH-25.2* MCHC-28.6* RDW-17.2* Plt Ct-159
[**2104-6-30**] 04:13AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Burr-2+ Acantho-1+
[**2104-6-28**] 11:15PM BLOOD PT-26.8* PTT-49.0* INR(PT)-2.6*
[**2104-6-28**] 11:15PM BLOOD Fibrino-219
[**2104-6-29**] 03:32AM BLOOD Glucose-126* UreaN-20 Creat-1.1 Na-126*
K-3.7 Cl-94* HCO3-17* AnGap-19
[**2104-6-29**] 03:32AM BLOOD ALT-113* AST-295* LD(LDH)-530*
CK(CPK)-545* AlkPhos-150* Amylase-128* TotBili-0.9
[**2104-6-28**] 11:15PM BLOOD Lipase-5
[**2104-6-28**] 11:15PM BLOOD cTropnT-0.33*
[**2104-6-29**] 03:32AM BLOOD CK-MB-25* MB Indx-4.6 cTropnT-0.41*
[**2104-6-29**] 10:15AM BLOOD CK-MB-36* MB Indx-5.6 cTropnT-0.41*
[**2104-6-29**] 10:10PM BLOOD CK-MB-49* MB Indx-7.7* cTropnT-0.35*
[**2104-6-30**] 04:13AM BLOOD CK-MB-50* MB Indx-9.7*
[**2104-7-1**] 02:45AM BLOOD CK-MB-20* MB Indx-10.5* cTropnT-0.38*
[**2104-6-29**] 03:32AM BLOOD Albumin-2.0* Calcium-7.4* Phos-2.6*
Mg-1.6
[**2104-7-1**] 03:28PM BLOOD Hapto-95
[**2104-6-29**] 03:32AM BLOOD Osmolal-267*
[**2104-6-29**] 10:15AM BLOOD TSH-1.5
[**2104-6-30**] 02:06PM BLOOD T3-49* Free T4-0.84*
[**2104-7-1**] 03:28PM BLOOD Cortsol-44.4*
[**2104-6-28**] 11:15PM BLOOD Digoxin-0.8*
[**2104-6-30**] 04:13AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2104-6-28**] 11:33PM BLOOD Type-ART Rates-20/10 PEEP-5 FiO2-100
pO2-46* pCO2-69* pH-7.10* calTCO2-23 Base XS--10 AADO2-604 REQ
O2-98 -ASSIST/CON Intubat-INTUBATED
[**2104-6-28**] 11:23PM BLOOD Glucose-139* Lactate-7.3* Na-125* K-4.6
Cl-97 calHCO3-21
[**2104-7-1**] 09:05PM URINE Hours-RANDOM Na-63 K-12 Cl-50
[**2104-7-1**] 09:05PM URINE Osmolal-162
[**2104-6-28**] 11:58 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
Daptomycin Sensitivity testing performed by Etest.
Daptomycin = 1.0 MCG/ML. BETA LACTAMASE NEGATIVE.
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
gentamicin. Screen predicts NO synergy with penicillins
or
vancomycin. Consult ID for treatment options.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
GRAM VARIABLE RODS. ANAEROBIC. UNABLE TO FURTHER
IDENTIFY.
ANAEROBIC GRAM NEGATIVE ROD(S).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ENTEROCOCCUS FAECALIS
| |
AMPICILLIN------------ <=2 S
CLINDAMYCIN----------- =>8 R
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- 8 S
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S 1 S
TTE: The left atrium is normal in size. The interatrial septum
is bowed towards the left atrium c/w increased RA pressure.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is severe global left ventricular
hypokinesis. Quantitative (biplane) LVEF = 18 %. No masses or
thrombi are seen in the left ventricle.The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. There is abnormal diastolic septal motion/position
consistent with right ventricular volume overload. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. The study is inadequate to
exclude significant aortic valve stenosis, but severe stenosis
is not suggested. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-17**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Symmetric left ventricular
hypertrophy and right ventricular cavity enlargement with global
biventricular hypokinesis. Mild-moderate mitral regurgitation.
Pulmonary artery hypertension.
NCHCT: 1. No acute hemorrhage or mass effect. White matter
hypodense areas.
Subtle/equivocal loss of the [**Doctor Last Name 352**]-white matter differentiation
is compatible
with known history of prolonged cardiac arrest. Consider MRI if
not CI if
clinically indicated for better assessment of infarction.
2. Moderate paranasal sinus disease.
EEG: This is an abnormal continuous ICU monitoring study because
of
burst suppression pattern. The bursts consist of [**12-16**].5 Hz high
amplitude
delta with superimposed [**4-20**] Hz theta activity lasting one to two
seconds and
the interburst interval varies from 10 seconds to several
minutes. In the
last few hours of the study, the bursts become more frequent
lasting four to
six seconds. These findings are indicative of very severe
diffuse cerebral
dysfunction likely due to anoxic insult to the brain in the
context of cardiac
arrest. No electrographic seizures are recorded. Compared to the
prior day's
EEG, the bursts have become frequent lasting four to six
seconds.
Renal U/S: Technically limited study showing no hydronephrosis
or stones in
the right kidney. Views of the left kidney show no gross
hydronephrosis but
are technically inadequate. Pelvic ascites is noted.
Brief Hospital Course:
[**Age over 90 **]yo M s/p asystolic arrest times 2 transferred from OSH for
hypothermic protocol and further management.
# s/p asystolic arrest: Likely developed in the setting of
aspiration PNA. The patient was hypothermic without active
cooling at admission and required active re-warming and
continued warming pads after re-warming to maintain physiologic
temp. Only evidence of neurologic activity was occasionally
overbreathing the vent, no pupillary or corneal reflexes upon
rewarming. CT head at admission showed possible early loss of
[**Doctor Last Name 352**] white matter differentiation. EEG showed at first burst
suppression but eventually showed no brainwave activity.
Multiple family meetings were held with the son and daughters
and the patient was eventually transitioned to focusing on
comfort and expired soon after pressors were withdrawn.
# Shock: Patient required [**1-18**] pressors throughout ICU admission,
likely multifactorial from cardiogenic shock with very low LVEF
and possible RV strain with [**Last Name (un) 13367**] sign, also with septic
shock component with multiple organisms in the blood. Femoral
line pulled and IJ CVL placed. He was put on broad spectrum
antibiotics with Vanc/Zosyn at admission for possile aspiration
PNA. He was empirically started on a heparin gtt for possible PE
based on RV findings on TTE. He was very sensitive to heparin
dosing and heme/onc was consulted and recommended Vit K to
improve therapeutic range of heparin, INR. He became immediately
hypotensive when pressors were stopped. Outpt. CHF regimen of
beta blocker, lasix, ACEI held. Endocrine consulted for concern
for hypothyroid causing myxedema given high TSH but felt this
likely represented sick euthyroid.
# [**Last Name (un) **]: Cr elevated and continued to trend up with minimal/no
urine output. Renal was consulted but he was not felt to be a
candidate for RRT.
# Decubitus ulcers: Patient with 3 stageable decubitus ulcers on
his sacrum, left heel, and right shin. Wound was consulted.
# Foley trauma: Pt. required urology to place Foley under
cystoscopy using Seldinger technique. He developed worsening
penile and scrotal edema in setting of gross volume overload.
Medications on Admission:
--ASA 325mg daily
--Carvedilol 12.5mg [**Hospital1 **]
--Digoxin 125mcg daily
--Lasix 10mg daily
--Levaquin 500mg daily
--Lisinopril 5mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Asystolic arrest
2. Anoxic brain injury
3. Acute kidney injury
4. Sepsis
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
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"507.0",
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"263.9",
"287.5",
"518.81",
"995.92",
"600.00",
"707.03",
"707.24",
"428.22",
"286.9",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.97",
"57.32"
] |
icd9pcs
|
[
[
[]
]
] |
11182, 11191
|
8752, 10960
|
274, 293
|
11310, 11319
|
2600, 4369
|
11371, 11377
|
2325, 2343
|
11154, 11159
|
11212, 11289
|
10986, 11131
|
11343, 11348
|
2358, 2581
|
4413, 8729
|
218, 236
|
321, 2143
|
2165, 2209
|
2225, 2309
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,301
| 101,057
|
19352+57045
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-12-24**] Discharge Date: [**2163-1-21**]
Date of Birth: [**2098-5-17**] Sex: M
Service: Neurosurgery.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
male who was admitted to [**Hospital1 69**]
from [**Hospital6 5016**] on [**2162-12-24**] status post a
headache with vomiting. Head CT showed a frontal
subarachnoid hemorrhage. The patient was intubated at the
outside hospital and transferred to [**Hospital1 190**] for further management.
HOSPITAL COURSE: On admission, the subarachnoid hemorrhage
extended into the pons. He had evidence of hydrocephalus,
and a vent drain was placed. He went to arteriogram which
showed no evidence of a source of bleeding. He had his blood
pressure controlled with Nipride and labetalol. He was
started on an insulin drip for high blood sugars. He was
extubated on [**2162-12-25**]. He had a repeat head CT which
showed no changes. He was awake, alert, moving all
extremities, and following commands bilaterally.
On [**2162-12-26**], he had a repeat head CT which showed
intraventricular blood with intracerebral blood continuing.
His labetalol drip was discontinued, and he was continued on
a Nipride drip. He had an increase in creatinine up to 2.1.
Admission creatinine was 1.0. He had Lopressor added for
blood pressure control, and Nipride was discontinued. He was
continued on nimodipine for prevention of vasospasm.
The Renal Service was consulted due to his acute renal
failure. He was placed on a Lasix drip which started on
[**2162-12-28**] and was discontinued on [**2163-1-1**]. He continued
to be on an insulin drip to keep his blood sugars under
control. Neurologically, he was alert, following commands,
moving all extremities but confused and disoriented to place
and time. He was occasionally agitated with tremors. He was
also placed on renal dose Dopamine to help with kidney
perfusion and urine output.
On [**2162-12-28**], he also had difficulty with respiratory
distress and was intubated. He was put on propofol and
sedated. He remained intubated until [**2163-1-4**] and then was
extubated again. His neurologic status waxed and waned. He
had episodes where he was very lethargic and not moving his
extremities very well. He had CT and MRI of the C-spine
which showed no evidence of cord compression.
On [**2163-1-8**], his BUN and creatinine were 59 and 1.8. At
this point, he was off Lasix drip. Neurologically, he was
awake, moved his right arm against gravity. He was
impersistently following commands and externally rotated both
his lower extremities with some withdrawal to noxious
stimulation. He continued to have a ventilator drain in
place. He became hypernatremic with sodiums of 149-150. His
BUN and creatinine continued to be 59 and 1.8. He had
Methicillin resistant Staphylococcus aureus in his sputum.
The patient was started on Lasix 40 mg p.o. t.i.d. for fluid
overload. The patient's drain was raised to 15 cm above the
tragus on [**2163-1-11**] which he tolerated. He continued to
have high sodium levels of 152. He continued on Lasix t.i.d.
for fluid overload.
He had a bed-side swallow evaluation on which he had some
oral apraxia, but they obtained a video swallow, which he did
pass. However, post procedure, he did vomit. It was felt
that because his mental status was not completely improved,
he should hold off on feeding. Mental status did improve,
and he did start on a regular diet.
On [**2163-1-14**], the patient's drain had been clamped for 24
hours. He had a head CT which showed mild to moderate
ventricular dilatation. The patient's drain was then left
clamped until [**2163-1-16**] when a repeat head CT showed no
further dilatation, and the drain was discontinued.
The patient had his diet advanced, was to be out of bed with
Physical Therapy and was transferred to the regular floor on
[**2163-1-17**]. He has remained neurologically stable with
stable vital signs. He has tolerated a regular diet. He has
been out of bed with physical therapy and requires acute
rehabilitation.
DISCHARGE MEDICATIONS:
1. Metoprolol 125 mg p.o. b.i.d., hold for heart rate less
than 50, systolic blood pressure less than 100.
2. Bacitracin ointment to his head suture site t.i.d.
3. Insulin sliding scale.
4. Levofloxacin 500 mg p.o. q.24 hours.
5. Famotidine 20 mg p.o. q.day.
6. Epogen 40,000 units once a week intravenously.
7. Venlafaxine 37.5 mg p.o. b.i.d.
8. Heparin 5000 units subcutaneously q.12 hours.
9. Nimodipine 60 mg p.o. q.4 hours.
10. Albuterol inhaler one to two puffs q.6 hours p.r.n.
CONDITION: The patient's condition is stable.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 1132**] in one
month with repeat head CT at that time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2163-1-20**] 15:19
T: [**2163-1-20**] 15:34
JOB#: [**Job Number 52658**]
Name: [**Known lastname 9800**], [**Known firstname **] Unit No: [**Numeric Identifier 9801**]
Admission Date: Discharge Date: [**2163-2-10**]
Date of Birth: Sex: M
Service: Neurosurgery
The patient's date of discharge was delayed until [**2163-2-10**].
Original dictation was done on [**2163-1-21**]. The patient's
condition remained stable. The patient was being screened
for rehab and awaiting guardianship, therefore, his discharge
was delayed. The patient was also seen by [**Hospital 616**] clinic for
rising blood sugars and his sliding scale was increased and
he was started on a daily dose of insulin. There was also
note of possible clot in the lower extremity, although the
patient had ABIs performed and they were within normal
limits, sometimes softly elevated in diabetes with
calcification of the vessels, but no acute changes. There
was no surgical intervention required at that time.
The patient's condition remained stable and he was,
therefore, discharged to rehab on [**2163-2-10**] in stable condition
with followup with Dr. [**Last Name (STitle) 8374**] in one month.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 14-133
Dictated By:[**Last Name (NamePattern1) 366**]
MEDQUIST36
D: [**2163-5-2**] 12:20
T: [**2163-5-2**] 12:25
JOB#: [**Job Number 9802**]
|
[
"276.0",
"431",
"276.4",
"482.41",
"428.0",
"780.39",
"584.5",
"401.9",
"331.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.91",
"96.04",
"88.41",
"02.2",
"96.6",
"38.91",
"96.72",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4107, 6410
|
517, 4084
|
176, 499
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,520
| 111,969
|
25116
|
Discharge summary
|
report
|
Admission Date: [**2113-12-4**] Discharge Date: [**2113-12-26**]
Date of Birth: [**2043-2-11**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
pancreatic head mass
Major Surgical or Invasive Procedure:
s/p Whipple procedure [**2113-12-5**]
History of Present Illness:
Patient is a 70yF who developed epigastric pain in [**Month (only) **] of
[**2112**]. She was seen in [**Location (un) 3844**], ultimately had a stent
placed, which was replaced three months later. This was on the
findings of a biliary stricture. She subsequently has had an
endoscopic ultrasound at [**Hospital1 18**] and stent exchange which
confirmed a
distal bile duct stricture and likely pancreatic head mass. A
short-segment metal stent has been replaced into apposition and
she has achieved excellent relief of any obstructive jaundice
symptoms. Since her biliary obstruction was relieved, she has
not had any further jaundice or any other symptoms of pruritis,
nausea, vomiting or anorexia.
Past Medical History:
open CCY 40yrs ago, s/p back surgery, CAD w/three vessel CABG
[**2104**], s/p hysterectomy, multiple laser eye surgeries secondary
diabetic retinopathy, HTN, IDDM, s/p CVA [**2108**], glaucoma
Social History:
No tobacco, no EtOH, no environmental exposures. Lives with
husband who has [**Name (NI) 2481**] disease.
Family History:
father-MI, DM
sisters-lung cancer, leukemia, DM
Physical Exam:
Gen: awake, pale, NAD
HEENT: EOMI, nares patent, oropharynx without erythema/exudate
Neck: no masses, trachea midline
CV: well healed sternotomy incision, II/VI systolic murmur,
otherwise RRR
Resp: coarse BS bilaterally but generally CTA
Abd: soft, NT/ND, incision clean and dry with steri-strips in
place, JP drain site with mild erythema but no discharge/oozing
Ext: no c/c/e
Neuro: aao x 4
Pertinent Results:
[**2113-12-22**] 05:08AM BLOOD WBC-7.6 RBC-2.98* Hgb-9.6* Hct-27.6*
MCV-93 MCH-32.3* MCHC-35.0 RDW-14.7 Plt Ct-132*
[**2113-12-21**] 06:30AM BLOOD WBC-10.5 RBC-2.92* Hgb-10.0* Hct-27.3*
MCV-94 MCH-34.2* MCHC-36.6* RDW-14.9 Plt Ct-131*
[**2113-12-22**] 05:08AM BLOOD Plt Ct-132*
[**2113-12-21**] 06:30AM BLOOD Plt Ct-131*
[**2113-12-24**] 04:39AM BLOOD Glucose-122* UreaN-21* Creat-0.8 Na-144
K-3.2* Cl-108 HCO3-29 AnGap-10
[**2113-12-23**] 05:30AM BLOOD Glucose-157* UreaN-20 Creat-0.8 Na-140
K-3.6 Cl-103 HCO3-29 AnGap-12
[**2113-12-22**] 05:08AM BLOOD Glucose-231* UreaN-19 Creat-0.7 Na-136
K-3.9 Cl-101 HCO3-30 AnGap-9
[**2113-12-18**] 06:00AM BLOOD CK-MB-5 cTropnT-0.21*
[**2113-12-24**] 04:39AM BLOOD Calcium-7.5* Phos-4.2 Mg-1.8
[**2113-12-23**] 05:30AM BLOOD Calcium-7.3* Phos-3.5 Mg-1.9
Brief Hospital Course:
Patient admitted and underwent an uncomplicated
pancreaticoduodenectomy on [**2113-12-5**]. She was transferred stable
to the recovery room and then to the floor. POD1-POD8 she
remained stable with no adverse postoperative events. Her diet
was advanced to regular diabetic diet and she was out of bed. On
POD8, however, she developed an episode of hypotension to the
80's systolic and had new onset vomiting. She remained afebrile,
however, her urine output decreased to marginal levels. She was
transferred to the intensive care unit where aggressive
resuscitation was performed as well as cardiac enzymes. Her
cardiac enzymes returned elevated with a troponin of 0.71. Her
ekg did not show any acute changes. Upon transfer to the ICU, an
NGT was placed revealing large amount of bilious fluid. She was
kept NPO. During the course of her ICU stay, her troponins
gradually trended down. Cardiology consulted and recommended
heart rate control and a heparin gtt for a presumed NSTEMI. Her
heparin gtt was discontinued and she had no other cardiovascular
events.
From a nutrition standpoint, she was kept NPO in the ICU and TPN
was started for nutrtion. She was placed on erythromycin. On POD
12 she was transferred back to the floor with an NGT in place
and remained NPO. On POD 13 her NGT was clamped however she
developed emesis with few hundred cc's of bilious fluid
expressed from NGT. She was continued with the NGT until POD 16
when she was able to pass a clamping trial with no
nausea/vomting and it was discontinued. At this point, her diet
was slowly advanced from sips which she tolerated well. At
discharge, she was tolerating a regular diet. Of note, she did
develop loose stool with C. Diff testing positive. She was
started on flagyl for her colitis.
During her hospital stay, her blood sugars were noted to be
elevated to >200. [**Last Name (un) **] consult was initiated and the patient
was controlled with an insulin sliding scale as well as lantus.
She was briefly maintained on an insulin drip, however, at the
time of discharge her blood sugars were adequately controlled
with a sliding scale/lantus combination.
Medications on Admission:
coumadin, lantus, potassium, lasix 20', mvi, synthroid,
quinapril 40'', atenolol 50', darvocet, tegretol 100'', clonase,
tamezopam, amytriptyline 100', seroquel 25', xalantan, zocor 20'
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 5450**]
Discharge Diagnosis:
pancreatic head mass
C. Difficile colitis
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 9886**] office or come to the emergency room
if you have fever, persistent abdominal pain, redness or oozing
from your surgical sites, dizziness/weakness, or shortness of
breath.
Please do not drive while taking pain medications. You may
shower, the steristrips on your abdominal wound will fall off on
their own.
Please take all of your discharge medications as instructed.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 468**] in [**9-29**] days, call
[**Telephone/Fax (1) 2835**] for an appointment.
Completed by:[**2114-1-16**]
|
[
"414.01",
"250.00",
"293.0",
"438.20",
"410.71",
"V58.67",
"285.1",
"576.1",
"536.3",
"157.0",
"576.2",
"997.1",
"585.3",
"V45.81",
"008.45",
"197.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"38.93",
"88.56",
"03.90",
"52.7",
"88.53",
"88.57",
"37.22",
"99.15",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5125, 5187
|
2756, 4889
|
335, 375
|
5273, 5280
|
1937, 2733
|
5731, 5891
|
1460, 1509
|
5208, 5252
|
4915, 5102
|
5304, 5708
|
1524, 1918
|
275, 297
|
403, 1105
|
1127, 1321
|
1337, 1444
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,260
| 184,153
|
2718
|
Discharge summary
|
report
|
Admission Date: [**2108-12-3**] Discharge Date: [**2108-12-13**]
Date of Birth: [**2045-4-2**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) /
Shellfish Derived
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
SOB, leg edema
Major Surgical or Invasive Procedure:
Placement and removal of right internal jugular dialysis
catheter by interventional radiology
History of Present Illness:
Ms [**Known lastname 13474**] is a 63 yo F with h/o severe diastolic heart failure
(EF 55%) w/ RV failure, severe TR, AF (not on coumadin due to
GIB), PFO closure ([**3-29**]). ulcerative colitis, HTN and pulmonary
hypertension who presented to Dr.[**Name (NI) 3536**] office today with
complaints of increasing SOB, and inability to walk due to leg
edema for the past month. She has noted a 45 lbs. weight gain
and admits to med non-compliance with torsemide.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, cough. She
denies recent fevers, chills or rigors. (+) Loose dark stools
(not black/tarry) and has seen a small amount of blood mixed w/
stool and in toilet paper. All of the other review of systems
were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope. (+) 3 pillow orthopnea.
Past Medical History:
1. CARDIAC RISK FACTORS: Hyperlipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: NONE
-PERCUTANEOUS CORONARY INTERVENTIONS: RHC (see below)
-PACING/ICD: NONE
3. Diastolic LV failure
4. Pulmonary hypertension
5. RV systolic dysfunction
6. Tricuspid regurgitation
7. Atrial fibrillation not on anticoagulation due to GIB
8. Ulcerative Colitis
9. Liver disease
10. Alcohol abuse, remote
11. Ventral hernia repair
12. Back surgery
[**11**]. History of GI bleed, [**10-28**] with 5cm duodenal ulcer
14. Hypokalemia
15. Hyponatremia
16. Hyperlipidemia
Social History:
The patient is married. Husband is mentally ill. She has very
supportive children and 17 grandchildren.
-Tobacco history: Denies
-ETOH: Drinks when she is upset, cannot quantify. Does not drink
when feeling well.
-Illicit drugs: Denies
Family History:
Father with MI at age 68. Mother with breast cancer at 52.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to the tragus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly irregular, normal rate. S1, S2. No m/r/g. No
thrills, lifts. +S3.
LUNGS: Resp were unlabored, no accessory muscle use. bibasilar
crackles [**12-24**] of the way up the lung fields, wheezes or rhonchi.
ABDOMEN: obese, soft, NTND. No HSM or tenderness. edema to the
umbilicus
EXTREMITIES: No c/c/ +4 pitting edema.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
[**2108-12-3**] 05:08PM BLOOD WBC-3.6* RBC-3.00* Hgb-8.2* Hct-25.5*
MCV-85# MCH-27.3 MCHC-32.0 RDW-15.7* Plt Ct-216
[**2108-12-4**] 07:35AM BLOOD WBC-3.3* RBC-2.91* Hgb-7.7* Hct-24.6*
MCV-84 MCH-26.5* MCHC-31.4 RDW-15.8* Plt Ct-205
[**2108-12-5**] 07:45AM BLOOD WBC-3.6* RBC-2.90* Hgb-7.7* Hct-25.4*
MCV-88 MCH-26.6* MCHC-30.4* RDW-15.5 Plt Ct-195
[**2108-12-11**] 06:51AM BLOOD WBC-5.4 RBC-2.61* Hgb-6.9* Hct-22.5*
MCV-86 MCH-26.3* MCHC-30.5* RDW-14.9 Plt Ct-232
[**2108-12-12**] 07:00AM BLOOD WBC-5.0 RBC-2.51* Hgb-6.7* Hct-22.7*
MCV-91 MCH-26.8* MCHC-29.6* RDW-14.9 Plt Ct-196
[**2108-12-13**] 07:20AM BLOOD WBC-5.7 RBC-2.59* Hgb-6.7* Hct-22.2*
MCV-86 MCH-25.7* MCHC-30.0* RDW-15.0 Plt Ct-260
[**2108-12-6**] 03:49AM BLOOD Neuts-66.0 Lymphs-12.1* Monos-15.5*
Eos-5.9* Baso-0.4
[**2108-12-3**] 05:08PM BLOOD PT-15.5* PTT-28.9 INR(PT)-1.4*
[**2108-12-5**] 03:05PM BLOOD PT-15.4* PTT-31.3 INR(PT)-1.4*
[**2108-12-5**] 07:44PM BLOOD PT-15.6* PTT-32.8 INR(PT)-1.4*
[**2108-12-8**] 04:01AM BLOOD PT-14.1* PTT-32.9 INR(PT)-1.2*
[**2108-12-11**] 06:51AM BLOOD PT-14.2* PTT-31.1 INR(PT)-1.2*
[**2108-12-12**] 07:00AM BLOOD PT-13.8* PTT-32.9 INR(PT)-1.2*
[**2108-12-3**] 05:08PM BLOOD Glucose-90 UreaN-54* Creat-1.8* Na-136
K-3.7 Cl-95* HCO3-27 AnGap-18
[**2108-12-4**] 12:30AM BLOOD Glucose-109* UreaN-55* Creat-1.8* Na-135
K-4.2 Cl-98 HCO3-27 AnGap-14
[**2108-12-4**] 07:35AM BLOOD Glucose-94 UreaN-56* Creat-1.8* Na-137
K-3.9 Cl-98 HCO3-29 AnGap-14
[**2108-12-12**] 07:00AM BLOOD Glucose-91 UreaN-41* Creat-2.0* Na-131*
K-4.2 Cl-102 HCO3-21* AnGap-12
[**2108-12-12**] 04:45PM BLOOD Glucose-105 UreaN-44* Creat-2.0* Na-129*
K-3.8 Cl-97 HCO3-21* AnGap-15
[**2108-12-13**] 07:20AM BLOOD Glucose-92 UreaN-52* Creat-2.0* Na-132*
K-3.6 Cl-99 HCO3-21* AnGap-16
[**2108-12-5**] 03:05PM BLOOD ALT-4 AST-40 LD(LDH)-176 AlkPhos-227*
TotBili-0.8
[**2108-12-3**] 05:08PM BLOOD Calcium-9.3 Phos-3.6 Mg-2.2
[**2108-12-4**] 12:30AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.1
[**2108-12-4**] 07:35AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
[**2108-12-12**] 07:00AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.1
[**2108-12-12**] 04:45PM BLOOD Calcium-9.7 Phos-4.2 Mg-2.1
[**2108-12-13**] 07:20AM BLOOD Calcium-9.1 Phos-5.0* Mg-2.0
[**2108-12-6**] 03:49AM BLOOD Triglyc-39 HDL-47 CHOL/HD-2.4 LDLcalc-58
[**2108-12-12**] 04:45PM BLOOD Osmolal-280
[**2108-12-5**] 07:44PM BLOOD TSH-5.1*
[**2108-12-5**] 07:44PM BLOOD Free T4-1.2
[**2108-12-10**] 10:59AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2108-12-10**] 11:12AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2108-12-6**] 03:50AM BLOOD PEP-NO SPECIFI
[**2108-12-10**] 10:59AM BLOOD C3-132 C4-25
[**2108-12-10**] 10:59AM BLOOD HCV Ab-NEGATIVE
[**2108-12-5**] 08:10PM BLOOD freeCa-1.13
[**2108-12-6**] 04:04AM BLOOD freeCa-0.90*
[**2108-12-6**] 10:15AM BLOOD freeCa-0.88*
[**2108-12-10**] 12:00AM BLOOD freeCa-1.21
[**2108-12-10**] 04:52AM BLOOD freeCa-1.22
[**2108-12-10**] 11:04AM BLOOD freeCa-1.15
[**2108-12-6**] 03:09PM URINE Color-[**Location (un) **] Appear-Cloudy Sp [**Last Name (un) **]-1.009
[**2108-12-5**] 09:31PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.010
[**2108-12-6**] 03:09PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
[**2108-12-5**] 09:31PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
[**2108-12-6**] 03:09PM URINE RBC->1000 WBC->50 Bacteri-MANY Yeast-NONE
Epi-0
[**2108-12-5**] 09:31PM URINE RBC->50 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2108-12-5**] 09:31PM URINE Hours-RANDOM UreaN-173 Creat-60 Na-49
TotProt-390 Prot/Cr-6.5*
[**2108-12-6**] 03:09PM URINE Hours-RANDOM
[**2108-12-6**] 03:09PM URINE Hours-RANDOM Creat-40 Albumin-59.5
Alb/Cre-1487.5*
[**2108-12-9**] 08:21AM URINE pH-5 Hours-24 Volume-100 Creat-71
TotProt-168 Prot/Cr-2.4*
[**2108-12-13**] 01:24AM URINE Hours-RANDOM UreaN-143 Creat-35 Na-33
[**2108-12-5**] 09:31PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
Osmolal-298
[**2108-12-13**] 01:24AM URINE Osmolal-288
[**2108-12-9**] 08:21AM URINE 24Creat-71 24Prot-168
PERTINENT LABS:
SPEP - no abnormalities
UPEP - multiple protein bands, no monoclonal immunoglobulin,
negative for bence-[**Doctor Last Name 49**] protein
Imaging:
CXR: [**2108-12-3**]
In comparison with study of [**2108-4-5**], there is some enlargement
of the cardiac silhouette with mild indistinctness of pulmonary
vessels consistent with elevated pulmonary venous pressure.
Probable bilateral
pleural effusions. Minimal atelectatic changes at the bases. The
relative
discordance between the cardiac size and pulmonary vascularity
raises the
possibility of underlying cardiomyopathy or pericardial
effusion.
ECHO: [**2108-12-6**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. A septal occluder device is seen across the
interatrial septum with small amount of persistent interatrial
shunting (direction of the shunt difficult to pinpoint based on
this study). . A small secundum atrial septal defect is present.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
55%). The right ventricular cavity is moderately dilated with
mild global free wall hypokinesis. There is abnormal diastolic
septal motion/position consistent with right ventricular volume
overload. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The tricuspid valve leaflets fail
to fully coapt. Severe [4+] tricuspid regurgitation is seen. The
pulmonary artery systolic pressure could not be determined, but
is likely elevated given high right atrial pressures and RV
volume overload. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Dilated right ventricle with mild global systolic
dysfunction and volume overload. Low-normal left ventricular
systolic function. Severe tricuspid regurgitation.
Amplatzer-type atrial septal occluder with trace residual
shunting.
Compared with the prior study (images reviewed) of [**2108-9-14**],
right ventricle is slightly smaller. LV function does not appear
as vigorous and LV cavity is slightly larger, possibly in part
due to better filling. The other findings are similar.
Renal U/S [**2108-12-6**]:
1. No hydronephrosis of the right kidney or left kidney.
2. Doppler examination inadequate due to patient body habitus.
Brief Hospital Course:
# ACUTE DECOMPENSATED DIASTOLIC HEART FAILURE: Patient was
initially admitted to the cardiology service for diuresis. She
did not respond to increasing doses of intravenous diuretics
including a furosemide drip, and remained massively volume
overloaded, with risk of pulmonary edema and respiratory
distress. She was transferred to the CCU where she was started
on ultrafiltration and >30L of fluid were removed. She was
bolused Lasix 80mg IV and started on a Lasix drip prior to
transfer back to the floor, in addition to standing Potassium
40mEq [**Hospital1 **]. Metoprolol was restarted at home dose 25mg PO BID. On
the floor the patient did not respond to increasing doses of IV
lasix. She was then transitioned to her home dose of oral
torsemide with initiation of metolazone with acceptable urine
output, and discharged home w/PT & VNA. She will have close
follow up with her outpatient cardiology providers within one
week of discharge to monitor her fluid status, electrolytes, and
renal function.
# CORONARIES: No history of CAD
# RHYTHM: Patient has a history a-fib that was rate controlled
as an outpatient. She was not on anti-coagulation embolization
prophylaxis given her history of severe GI bleed and ulcerative
colitis. She was rate controlled during her hospitalization with
metoprolol.
# Acute on Chronic Kidney Disease: Patient had a baseline Cr of
1.2-1.4. On admission it was 1.8, and increased to 2.1 with
diuresis and poor forward flow. Patient was maintained on
ultrafiltration for several days, with improvement of Cr to 0.8.
Renal U/S was negative for hydronephrosis. SPEP and UPEP were
negative for monoclonal bands. After transfer to the floor her
Cr began to increase and it was 2.0 upon discharge.
# UC: Patient with history of Ulcerative Colitis, she was
continued on home dose Mesalamine and had no issues.
#. Anemia: Patient's Hct was 25 on admission. It remained stable
during hospitalization in the 22-25 range. This was thought to
be due to a combination of anemia of chronic inflammation and
chronic renal failure.
Medications on Admission:
1. Omeprazole 20 mg [**Hospital1 **]
2. Folic Acid 1 mg daily
3. Ferrous Sulfate 325 mg daily
4. HCTZ 25 mg daily
5. Aspirin 81 mg daily
6. Torsemide 20 mg [**Hospital1 **]
7. Trazodone 25 mg HS
8. Mesalamine 2.4 g daily
9. Gabapentin 200 mg HS
10. Metoprolol Tartrate 25 mg [**Hospital1 **]
11. Albuterol 90 mcg IH q4h PRN
12. Oxycodone 5 mg [**Hospital1 **] PRN
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
10. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO QHS PRN as needed
for insomnia.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis:
- Decompensated acute on chronic diastolic heart failure
Secondary diagnoses:
- Chronic renal insufficiency, stage III
- Anemia
- Ulcerative colitis
- 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 due to decompensated heart failure and fluid
overload. The fluid was removed both by intravenous diuretics
and then ultrafiltration was required. After significant fluid
removal, you were close to your baseline, and discharged home.
Please be sure to take your medications exactly as prescribed to
help avoid further medical problems in the past.
The following changes have been made to your medications:
- START metolazone 2.5 mg daily
- CONTINUE torsemide, however ensure you are taking 40 mg TWICE
A DAY
- STOP Hydrochlorothiazide (HCTZ) 25 mg
No other changes were made.
Please be sure to follow diet recommendations to avoid fluid
retention, including limiting your fluid intake to 1500 mL (1.5
Liters) a day, and restricting your salt to less than 2 grams
day.
Please be sure to weigh yourself every morning, call Dr.[**Name (NI) 3536**]
office if weight goes up more than 3 lbs in one day.
You will need to have blood work done on [**2108-12-18**] at your
follow up with [**Doctor First Name **] and Dr. [**First Name (STitle) 437**].
Followup Instructions:
Please be sure you attend your follow up appointments:
1) Cardiology: You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP,
on [**2108-12-18**] at 3:00 PM. The phone number for the office is
[**Telephone/Fax (1) 62**]. You will need to have blood work done at this
appointment.
2) Primary care: Dr. [**Last Name (STitle) **] [**Last Name (NamePattern5) **], on [**2108-12-27**], at
2:00 PM. The phone number for his office is ([**Telephone/Fax (1) 3346**].
3) Gastroenterology: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 497**], on [**2109-2-1**], at 11:40 AM. The phone number for his office is
[**Telephone/Fax (1) 2422**].
|
[
"285.21",
"585.3",
"403.90",
"789.59",
"416.8",
"272.4",
"427.31",
"278.00",
"428.33",
"397.0",
"428.0",
"424.0",
"556.9",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"38.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
13409, 13458
|
9780, 11841
|
357, 453
|
13693, 13693
|
3166, 7216
|
14958, 14989
|
2264, 2438
|
12256, 13386
|
13479, 13479
|
11867, 12233
|
13870, 14935
|
2453, 3147
|
13577, 13672
|
1522, 1995
|
303, 319
|
15014, 15692
|
481, 1426
|
13498, 13556
|
13707, 13846
|
7232, 9757
|
1448, 1502
|
2011, 2248
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,364
| 195,461
|
24585
|
Discharge summary
|
report
|
Admission Date: [**2189-6-26**] Discharge Date: [**2189-6-29**]
Date of Birth: [**2119-5-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 year old man with a PMH of COPD on 4L home O2, HTN, sleep
apnea s/p Y stent placement on [**2189-6-24**] for bronchomalacia who
presented with dyspnea. Stent placement was uncomplicated, and
he was discharged home the day after the procedure. That night,
he was able to sleep and eat comfortably, however, the following
day he had increasing shortness of breath and and difficulty
pulling up mucous from his lungs. He measured his temperature at
101 and went to the ED. He was admitted to the ICU for
monitoring, was kept on NRB and given levofloxacin, ceftriaxone
and solumedrol. CXR was negative for acute cardiopulmonary
process. He was then transitioned over to prednisone and his
ceftriaxone was stopped.
.
At home, his baseline is ambulating without a walker or cane.
Past Medical History:
1. Bronchomalacia: s/p Y stent placement [**2189-6-24**] by IP
2. COPD: On 3L home O2 prior to stent, discharged on 4L. Two
previous COPD related hospitalizations. PFTs ([**6-23**]): FVC 81%;
FEV1 69%
3. Sleep apnea: Evaluated in [**10-21**]: Severe complex
sleep-disordered breathing with profound desaturations. Does not
use CPAP at home.
4. HTN
5. Hemorrhoids: s/p removal and recurrence
6. Colonic polyps
7. Bilateral hearing loss: does not require hearing aids
8. Umbilical hernia repair
9. S/p removal of appendix
10. S/p T&A before age 12
Social History:
Lives in [**Location 2624**] with his daughter (his health care proxy.)
Patient has a 60 pack year history, quit 9 years ago. Occasional
EtOH use, denies illicit drug use.
Family History:
One brother died of MI in 80s, another brother died of AIDS
comlications, and another died of a lung infection
Physical Exam:
Vitals: T: 97.6 BP: 136/66 P: 104 O2Sat: 93% on 4L
Gen: Obese man in NAD, lying in bed breathing heavily but
comfortable
HEENT: Clear OP, MMM
NECK: Supple, No LAD
CV: RRR. NL S1, S2. No murmurs, rubs or gallops
LUNGS: Decreased breath sounds throughout, CTAB, pursed lip
expirations
ABD: +BS, obese, soft, NT abdomen
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. CN II-XII intact (unable to hear finger rub bl.)
5/5 strength deltoids/finger extensor and flexors/
iliopsoas/plantar flexors.
Pertinent Results:
[**2189-6-25**] 03:50AM TYPE-ART TEMP-37 PO2-169* PCO2-39 PH-7.41
TOTAL CO2-26 BASE XS-0 INTUBATED-NOT INTUBA
[**2189-6-26**] 06:45PM PLT SMR-NORMAL PLT COUNT-214
[**2189-6-26**] 06:45PM WBC-14.2* RBC-5.87 HGB-17.2 HCT-50.7 MCV-86
MCH-29.2 MCHC-33.8 RDW-14.6
[**2189-6-26**] 06:45PM CK-MB-4
[**2189-6-26**] 06:45PM cTropnT-<0.01
[**2189-6-26**] 06:45PM CK(CPK)-1052*
[**2189-6-26**] 06:45PM GLUCOSE-100 UREA N-25* CREAT-1.6* SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
[**2189-6-26**] 06:48PM TYPE-MIX PO2-41* PCO2-42 PH-7.39 TOTAL CO2-26
BASE XS-0
.
IMAGING:
[**2189-6-26**] CXR: IMPRESSION: No evidence of acute cardiopulmonary
process.
.
7/13/080 CXR: The cardiac silhouette and mediastinum is grossly
within normal limits. There is minimal basilar atelectasis on
the left side. The rest of the lung fields appear clear.
Brief Hospital Course:
Patient was admitted to the MICU with shortness of breath,
hypoxia, a temperature of 101.6 and a WBC of 14.2. He was
started on solumedrol IV for two doses with good response and
then switched to prednisone 60MG PO. He was also started on
levaquin. He was afebrile and his dyspnea had improved by day #2
of admission, and he was transferred to the medicine floor. He
had an expected leukocytosis once started on steroids. Finger
sticks showed elevated glucose and he was started on an insulin
sliding scale. He was evaluated by physical therapy and was
asked to use 4L continuous oxygen at home which was arranged
for. He was discharged home with 10 days of Prednisone taper, 7
days of Levofloxacin and Insulin sliding scale to cover his
elevated glucose.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
Disp:*QS 1 mth QS 1 mth* Refills:*2*
2. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
3. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) as needed.
4. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
8. Prednisone 10 mg Tablets, Dose Pack Sig: One (1) Tablets,
Dose Pack PO once a day: 40MG for 4 days, 20MG for 3 days, 10MG
for 3 days.
Disp:*25 Tablets, Dose Pack(s)* Refills:*0*
9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*3 Tablet(s)* Refills:*0*
10. Mucinex DM 60-1,200 mg Tab, Multiphasic Release 12 hr Sig:
One (1) Tab, Multiphasic Release 12 hr PO once a day as needed
for cough: Take once a day for seven days, then you can take as
needed.
Disp:*30 Tab, Multiphasic Release 12 hr(s)* Refills:*1*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime: please take this
while you on are the steroids.
Disp:*10 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. Lancets Misc Sig: One (1) lancet Miscellaneous four
times a day for 10 days.
Disp:*40 40* Refills:*1*
13. Glucose Meter, Disp & Strips Kit Sig: One (1)
Miscellaneous four times a day for 10 days.
Disp:*QS 10 days QS 10 days* Refills:*0*
14. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
unit Injection four times a day as needed for for finger stick >
150 for 10 days.
Disp:*QS 10 days QS 10 days* Refills:*0*
15. Insulin Syringe 1 mL 28 X 1 Syringe Sig: One (1) syringe
Miscellaneous four times a day for 10 days.
Disp:*QS 10 days QS 10 days* Refills:*0*
16. Oxygen 4 lts per minute continuous
Oxygen saturation on [**1-18**] lts was 85%
17. Home Nebulizer Machine
18. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous [**Hospital1 **] (2 times a day).
Disp:*QS 1 mth QS 1 mth* Refills:*2*
19. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Dyspnea
Discharge Condition:
Good
Discharge Instructions:
You were evaluated for increased shortness of breath. You will
receive prescriptions for medications you should take at home.
If you have any worsening shortness of breath, cough or phlegm
production, please seek [**Hospital 62077**] medical attention.
.
You will continue the antibiotic, levofloxacin, and take it
every other day starting tomorrow ([**6-29**]) until [**7-5**].
.
You will take prednisone and decrease the dose as follows:
40MG for 4 days starting on [**6-29**]
20MG for 3 days
10MG for 3 days
.
You will take Mucinex for 7 days and then you can take it as
needed.
.
You will need to do finger stick checks for blood sugar, as
prednisone can make the blood sugar increase. Please follow the
instructions attached.
Followup Instructions:
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2189-7-6**] 9:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2189-7-6**] 9:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2189-7-6**] 10:30
.
You should follow up with Dr. [**Last Name (STitle) 62078**] in the next few weeks.
Please call to make an appointment.
.
You should follow up with your primary care provider in the next
few weeks. Please call to make an appointment.
.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2189-6-30**]
|
[
"493.22",
"585.9",
"272.4",
"327.23",
"519.19",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
6653, 6711
|
3466, 4226
|
340, 346
|
6763, 6770
|
2581, 3443
|
7549, 8291
|
1928, 2040
|
4249, 6630
|
6732, 6742
|
6794, 7526
|
2055, 2562
|
281, 302
|
374, 1152
|
1174, 1723
|
1739, 1912
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,154
| 166,504
|
27472
|
Discharge summary
|
report
|
Admission Date: [**2155-11-21**] Discharge Date: [**2155-11-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Delerium, Urinary Tract Infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a [**Age over 90 **] year old male with complicated medical
history pertinent for Vascular dementia, history of stroke, CAD
and CHF who presents from his PCPs office for evaluation of
delerium. Per referral form the patient was seen for evaluation
of weakness, confusion and falling. The patient was sent to the
ED with concern for ? TIA.
Of note, the patient is not accompanied by anybody at time of
interview. The patient's family was called per numbers provided
in OMR, a voice mail was left requesting family contact myself
to discuss patient to get a sense of how far from baseline
patient currently is. Unfortunately, limited records and history
is otherwise available at time of admission.
On arrival to the floor the patient reports no specific
complaints except for feeling cold as weel as tenderness with
palpation in his RUQ and overlying rib. He initially denies
fevers, chills, dyspnea, the patient denies any dysuria but does
report urinary frequency.
ED Course: In the ED the patient was noted to have Tmax of
101. He had labs revealing for Creatinine 3.8, WBC 15.3, Hct
32.4. He was determined to have a non-focal neuro exam and UA
was ++ for UTI. The patient was given 1L NS and IV Cipro and
transferred to the floor for ongoing care.
On arrival to the floor no additional fluids were given as
the patient appears mildly volume overloaded. 1 hour later the
patient was noted to develop increased RR, hypoxia, and
wheezing. A stat CXR was obtained revealing new pulmonary edema
without effusions.
Past Medical History:
Vascular Dementia
CKD
Anemia of Chronic Disease
Gout
PUD complicated previously by UGIB
CAD
Chronic Diastolic CHF
Essential Hypertension
BPH
Social History:
Social History: Per OMR patient lives at [**Street Address(2) **]. The
patient himself does not remember.
Tobacco: Patient smoked in his 20s
ETOH: None
Illicits: None
Family History:
No strokes, heart attacks, or cancers
Physical Exam:
Vitals: 99.1, 143/71, 92, 22, 90% RA -> 97% 2L
General: The patient is an elderly male, frail appearing,
tremulous at times, smells of urine. Patient is pleasant,
attempts to answer questions, in NAD
HEENT: NCAT, EOMI, sclera anicteric. No photophobia
Neck: JVP 7-8cm, no meningisums.
Chest: Course sounds anterior. Posterior with crackles
bibasilar, Left > right as well as intermittent end expiratory
wheezing
Cor: RRR, harsh III/VI systolic murmur at RUSB as well as
separate III/VI systolic murmur at apex, radiating to axillae
Abdomen: firm but not rigid. Healed right subcostal scar. Mod
tenderness in RUQ, more so over lower rib than soft tissue, mod
voluntary guard, no rebound.
Rectal: Guaiac negative
Ext: no edema
Neuro:
Orientation: Patient oriented to name only. Does not know
hospital, year, or where he lives
CN II-XII: Intact, no facial asymmetry
Motor:
Delt Bic Tri Hip Flex Leg Flex Leg Ext Foot Flex Foot
Ext
R [**5-12**] 5/5 [**5-12**] 5/5 [**5-12**] 5/5 [**5-12**] [**5-12**]
R [**5-12**] 5/5 [**5-12**] 5/5 [**5-12**] 5/5 [**5-12**] [**5-12**]
Sensation: Intact to soft touch over face, trunk, extremities
Reflexes: 2+ at patella bilaterally
Cerebellar: Mild undershoot with left hand, right relatively
intact
Gait: Patient able to hold balance standing with wide base,
Romberg negative. Gait not attempted as patient requires walker
at baseline
Pertinent Results:
Admission Labs:
[**2155-11-21**] 06:16PM WBC-15.3* RBC-3.64* HGB-11.1* HCT-32.4*
MCV-89 MCH-30.5 MCHC-34.2 RDW-18.1*
[**2155-11-21**] 06:16PM NEUTS-90.1* LYMPHS-5.5* MONOS-3.9 EOS-0.1
BASOS-0.3
[**2155-11-21**] 06:16PM PLT COUNT-139*
[**2155-11-21**] 06:16PM PT-14.8* PTT-27.9 INR(PT)-1.3*
[**2155-11-21**] 08:07PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2155-11-21**] 08:07PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2155-11-21**] 08:07PM URINE RBC-[**3-12**]* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0
[**2155-11-21**] 06:28PM LACTATE-1.7
[**2155-11-21**] 06:16PM GLUCOSE-127* UREA N-58* CREAT-3.8* SODIUM-136
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
[**2155-11-21**] 06:16PM ALT(SGPT)-11 AST(SGOT)-17 CK(CPK)-66 ALK
PHOS-153* TOT BILI-1.2
[**2155-11-21**] 06:16PM LIPASE-43
[**2155-11-21**] 06:16PM cTropnT-0.08*
[**2155-11-21**] 06:16PM CK-MB-2 cTropnT-0.07*
[**2155-11-21**] 06:16PM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-3.6
MAGNESIUM-2.2
.
[**2155-11-23**] 06:55AM BLOOD CK-MB-26* MB Indx-10.3* cTropnT-2.18*
proBNP->[**Numeric Identifier **]
[**2155-11-24**] 05:14AM BLOOD CK-MB-15* MB Indx-10.1* cTropnT-2.92*
[**2155-11-24**] 04:51PM BLOOD CK-MB-13* MB Indx-12.3* cTropnT-3.37*
[**2155-11-25**] 04:58AM BLOOD CK-MB-12* MB Indx-7.5* cTropnT-3.55*
.
ECHO:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate global
left ventricular hypokinesis (LVEF = 30-35 %). No masses or
thrombi are seen in the left ventricle. with depressed free wall
contractility. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (area <0.8cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2153-11-2**],
the degree of AS calculated is now severe and the LVEF is now
depressed.
.
CXR [**11-24**]: As compared to the previous examination of [**11-24**], [**2155**], the bilateral parenchymal opacities have increased in
extent. In addition,
moderate peribronchial cuffing and interstitial markings are
seen. These
changes suggestive of interval recurrence of mainly interstitial
overhydration. There is no CT evidence of pleural effusions. The
size of the cardiac silhouette is moderately enlarged
Brief Hospital Course:
[**Age over 90 **] year old male with medical history pertinent for CAD, Chronic
Diastolic CHF, prior stroke with vascular dementia who presents
with altered mental status, fever and UTI now with pulmonary
edema.
.
#. Aortic Stenosis / Acute on Chronic Diastolic CHF - The
patient presented with CHF excerbation clinically in the setting
of a UTI and increased cardiac demand. The patient was initially
diuresed with lasix. Cardiac Enzymes were initially checked and
were found to be flat, however over the course of the
hospitalization the patients troponins continued to trend up.
EKF revealed sinus tach with lateral ST depressions. An echo was
performed which revealed severe AS (details above). BNP was
found to be >70,000. Cardiology was consulted. The patient was
not found to be a surgical candidate for valvuloplasty or aortic
valve replacement. The patient was subsequently made CMO and the
patient subsequently expired on [**11-26**] two days after admission.
.
#. Altered Mental Status/Delerium: Neurologic exam relatively
non-focal except for lack of orientation in the setting of a
UTI. The patients mental status did not improve to baseline
during his hospital course. CT of the head was without acute
intracranial hemorrhage or mass effect.
.
#. Urinary Tract Infection: Patient at chronic care facility but
no prior history of resistant organisms. The patient was
initially treated with Ceftriaxone. Urine cultures were
unrevealing.
.
#. Acute Renal Failure - Patient with Creatinine 3.8 with last
value 3.1 in [**2153**]. No available Creatinine between 2 time
points, very possible 3.8 represents worsening renal function
rather than acute kidney injury. During the patients hospital
course the patients Cr trended up from 3.8 to 5.2 while
diuresing the pt for an an acute systolic CHF exacerbation.
.
In the setting of inability to adequeately treat the patients
underlying severe AS, the decision was made by the family to
make the pt comfort measures only. The pt expired the morning of
[**11-26**].
Medications on Admission:
Metoprolol 50mg twice daily
Imdur 30mg daily
Norvasc 10mg daily
Lipitor 20mg daily
Colchicine 0.6mg daily
Allopurinol 100mg daily
Protonix 40mg twice daily
Multivitamin once daily
Iron 65mg daily
Lasix 40mg daily
Lisinpril 20mg daily
Procrit [**Numeric Identifier **] every 2 weeks
SLN 0.4 q 2 hr PRN
Prozac 20mg daily
Exelon 4.6mg/24hr daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
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"410.71",
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"414.01",
"403.90",
"285.29",
"584.9",
"290.41",
"396.8",
"599.0",
"600.00",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8953, 8962
|
6537, 8560
|
298, 304
|
9013, 9022
|
3758, 3758
|
9078, 9088
|
2243, 2282
|
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8586, 8930
|
9046, 9055
|
2297, 3739
|
225, 260
|
332, 1877
|
3774, 6514
|
1899, 2041
|
2073, 2227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
469
| 177,871
|
27257
|
Discharge summary
|
report
|
Admission Date: [**2175-4-1**] Discharge Date: [**2175-4-7**]
Date of Birth: [**2175-4-1**] Sex: M
Service: NB
IDENTIFICATION: [**First Name8 (NamePattern2) 66844**] [**Known lastname 66845**] is a 6 day old former 35 [**5-7**] wk
infant with feeding immaturity and neonatal abstinence syndrome
being transferred from the [**Hospital1 **] NICU to the [**Hospital3 **]
Special Care Nursery.
HISTORY: [**First Name8 (NamePattern2) 66844**] [**Known lastname 66845**] was admitted to the NICU due to
prematurity and respiratory distress. He was born at 35-5/7
weeks to a 27-year-old gravida 4, para [**2-3**] mother with past
OB history notable for a SVD at 39 weeks in [**2164**] and a C-
section at 35 weeks in [**2171**]; SAB x1.
PAST MEDICAL HISTORY:
1. Charcot-[**Doctor Last Name **]-Tooth disease.
2. [**Doctor Last Name 13534**]-Parkinson-White status post ablation.
3. Asthma.
4. Mitral valve prolapse.
5. Depression on paroxetine 30 mg per day and p.r.n.
lorazepam.
6. Nephrolithiasis with chronic pain during pregnancy;
initially treated with Percocet progressing to
hydromorphone infusion at 2.5 mg per hour in the week
prior to delivery. Also receiving dolasetron.
PRENATAL SCREENS: Blood type A-positive, DAT negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune, group B Strep status unknown.
ANTENATAL HISTORY: Estimated date of delivery is [**2175-5-1**]
for an estimated gestational age of 35-5/7 weeks. Pregnancy
complicated by maternal conditions and medications as
detailed above and by preterm labor at 25 weeks which was
treated with magnesium sulfate and betamethasone at that
time.
Mother presented in spontaneous labor leading to a cesarean
section under epidural anesthesia. Membranes were ruptured at
time of delivery yielding clear amniotic fluid. There were no
intrapartum fever or other clinical evidence of chorioamnionitis.
She did not receive intrapartum antibiotic
therapy.
NEONATAL COURSE: Infant cried at delivery, orally and
nasally bulb suctioned, dried. Free-flow oxygen administered.
Apgars 7 and 9 at 1 and 5 minutes. In the NICU, infant was
noted to have grunting respirations, intercostal retractions,
and occasional apnea.
PHYSICAL EXAM UPON ADMISSION: Birth weight 2.595 kilograms,
OFC 34.5 cm, length was undocumented at that time. HEENT:
Anterior fontanel is soft and flat, nondysmorphic. Intact
palate. Mouth and neck: Normal. Nasal flaring. Red reflex
visualized bilaterally. Chest: With grunting respirations,
moderate intercostal retractions, improved with nasal CPAP.
Clear breath sounds bilaterally with few scattered coarse
crackles. Cardiovascular was well perfused with regular rate
and rhythm. Femoral pulses: Normal. Normal S1, S2, no murmur.
Abdomen: Soft nondistended. Liver 2 cm below the right costal
margin. No splenomegaly, no masses. Bowel sounds: Active.
Anus appears patent. GU: Normal penis. Testes descended
bilaterally. CNS: Active, responsive to stimuli. Tone:
Appropriate for gestational age and symmetric. Moves all
extremities. Suck, root, and gag: Intact. Integument:
Erythema toxicum over neck and trunk. Musculoskeletal: Normal
spine, limbs, and hips and clavicles.
HOSPITAL COURSE BY SYSTEMS: Respiratory: Due to increased
work of breathing on CPAP, infant progressed to intubation and
surfactant administration. Peak ventilator settings were 25/5
with a rate of 25 and 40% with a blood gas of 7.36, 40, 95,
24, and -2. He received 1 dose of surfactant and was
extubated at 24 hours of age, and has been room air breathing
comfortably since that time. There has been no evidence of
apnea or prematurity. Currently breathing 30s-40s with O2
saturations 95-97%.
Cardiovascular: Infant has remained hemodynamically stable
throughout without need for cardiovascular support.
FEN: Infant was initially NPO until cardiorespiratory stability
was achieved, and had normal glucose screens and electrolytes.
on IV fluid and normal electrolytes as well. Enteral feedings
were introduced on day of life 2 with Enfamil 20, and advanced
gradually to 120 cc/kg/day. Infant is currently feeding mostly
PG with gradually improving PO intake. Breast feeding and breast
milk were initially held due to maternal medication use, but
could be initiated in the future if desired. Infant has been
voiding and stooling normally, and ast electrolytes were on [**4-5**] with a sodium of 142, a K of 4.9, chloride 114, and a
bicarbonate of 15. Further increase in feeding volumes and/or
calories is anticipated.
GI: A serum bilirubin was obtained on day of life 3 with a
state screen which was 10.5/0.3. It peaked on day of life 4
at 13.5/0.3 at which time the baby was placed under
phototherapy. The phototherapy remained in place for 24 hours
and was discontinued for a bilirubin of 7.9/0.3, with a rebound
level of 8.7/0.3 on the day of transfer.
Due to concern for one mucousy stool and several heme-positive
stools, a KUB was obtained on [**4-6**] which was reassuring,
although with a paucity of bowel gas. Repeat KUB on [**4-7**] was
normal. Physical exam revealed a soft, flat belly with no
distention, active bowel sounds, and baby continued to feed
without difficulty.
Hematologic/ID: A CBC and blood culture were obtained upon
admission due to the respiratory distress. The white blood
cell count was 11.2 with 21 polys and 1 band, hematocrit 44.9
and platelets 359,000. The blood culture remains negative.
The antibiotics of ampicillin and gentamicin were
administered for 48 hours. Baby has remained clinically well
since the discontinuation of the antibiotics.
Neurologic: The baby was followed for neonatal abstinence
syndrome in view of maternal narcotic use for chronic pain
and due to increasing scores on day of life 2, the baby was
started on neonatal opium solution (equivalent 0.4 mg morphine
per mL) with the initial dose being 0.35 mL by mouth every 4
hours. This was increased to 0.4 mL every 4 hours later on day 2
of life due to persistently elevated NAS scores, but since then
scores have remained stable at 4-6. Dose of neonatal opium
remains 0.4 mL PO q 4 hours.
On examination, Coltson had some irritability and some mild
tremors, mildly increased tone, and a high-pitched cry. This
has improved with the neonatal morphine. He does have an
excoriated buttock.
Social: Parents are married. Mother has a complex medical
history and has a supportive family in place. Plans for
transfer to [**Hospital3 **] for continued convalescent
care and weaning of neonatal morphine and maturation of
feeding skills is planned, and parents are in agreement with
that at this time.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Level II nursery at [**Hospital3 38285**].
NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 19267**] [**Last Name (NamePattern1) 1349**] in [**Location (un) 5028**].
CARE AND RECOMMENDATIONS: Feedings currently are Enfamil 20
at 120 mL per kilogram.
Medications are neonatal morphine, neonatal opium solution
0.4 mL p.o. PG every 4 hours which is a total dose of 0.9 mL
per kilogram per day.
Car seat position screening is recommended before discharge.
State newborn screen was obtained on day of life 3 and was
noted to have an increased 17OHP, and a repeat will be sent
on [**4-7**] prior to transfer to [**Hospital3 **].
Immunizations received are none to date.
Immunizations recommended are 1. Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for infants
who meet any of the following 3 criteria: 1) born at less
than 32 weeks; 2) born between 32-35 weeks with 2 of the
following: Daycare during RSV season, smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 3) infants with chronic lung disease.
2. Influenza immunization is recommended annually in the fall for
all infants once they reach 6 months of age. Before this age and
for the 1st 24 months, immunization against influenza is
recommended for household contacts and out-of-home caregivers.
Follow-up appointments scheduled will be primary care
pediatrician after discharge.
DISCHARGE DIAGNOSES: Prematurity at 35-5/7 weeks, surfactant
deficiency, rule out sepsis, feeding immaturity and neonatal
abstinence syndrome.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) 55876**]
MEDQUIST36
D: [**2175-4-7**] 03:10:29
T: [**2175-4-7**] 05:38:51
Job#: [**Job Number 66846**]
|
[
"774.2",
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icd9cm
|
[
[
[]
]
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[
"93.90",
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icd9pcs
|
[
[
[]
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6700, 6880
|
8178, 8555
|
6907, 8156
|
3252, 6654
|
6669, 6676
|
2276, 3223
|
776, 2261
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,082
| 155,059
|
28154
|
Discharge summary
|
report
|
Admission Date: [**2191-5-4**] Discharge Date: [**2191-5-20**]
Date of Birth: [**2115-9-25**] Sex: F
Service: SURGERY
Allergies:
Metronidazole / Tape
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
ab distension
Major Surgical or Invasive Procedure:
ex-lap/LOA/ileocecal bypass
History of Present Illness:
Ms [**Name13 (STitle) **] is a 75 year old female, h/o protein losing
enteropathy and a few recurrent ?sbos - still in question but
resolved with conservative management. TOday comes in again with
abdominal distension, n/v x 3 d (but none today) - inability to
tolerate solids (which happens alot). no flatus > 24hrs (but
says
doesnt usually pass much). A KUB was done which showed dilated
small bowel loops and airl fluid levels.
Past Medical History:
protein losing enteropathy
history SBO in [**8-1**], treated with NGT
Childbirth x8 with 5 c-sections
Social History:
Smokes 2pk/day x 55 years. She drinks occassionally. She lives
on [**Location (un) **]. Husband was a principal in [**Hospital1 **]. He passed away
7 years ago of leukemia. She has 8 children (4 sons, 4
daughters) all in [**Name (NI) **] or [**Location (un) **]
Family History:
Mother with breast cancer in her 60's, died at age 80 of "old
age", Father died of MI age 59, sister with protein losing
enteropathy, brother with CAD
Physical Exam:
afebrile, VSS
NAD
RRR, CTAB
abd: soft, NT, no rebound no guarding, very distended/tympanitic
no c/c/e
Pertinent Results:
Admission labs:
UA+
Na139 101 30 90
4.0 25 0.7
ALT: 12 AP: 182 Tbili: Alb: 3.1
AST: 14 LDH: 166 Dbili: TProt: 6.1
[**Doctor First Name **]: 54 Lip: 65
WBC6.6 12.6 428 HCT 39.1
PT: 12.1 PTT: 27.1 INR: 1.0
KUB: air fluid levels and idlated SB loops
CT [**2191-5-4**] IMPRESSION:
1. High-grade small-bowel obstruction with a transition point in
the right pelvis, very similar in appearance to the study of
[**2191-3-8**]. Small amounts of ascites as described above.
2. Irregularity and heterogeneity of the uterus as seen on prior
studies. This abnormality is adjacent to the area of the
transition point mentioned in #1.
3. Increase in the size of a lobulated right lower lobe lung
lesion.
4. Stable compression deformities of T11 and L1.
CT chest 4/10/8
IMPRESSION:
1. Two lung lesions are suspicious for malignancy, a 16-mm right
upper lobe lesion contiguous with an area of partially-resolved
pneumonia, unchanged since [**2191-2-25**] and a nearly 3 cm
subpleural right lower lobe mass increased in size slightly in
the interim.
2. Moderate-to-severe emphysema.
3. Multifocal pneumonia substantially cleared and pleural
effusions decreased or resolved.
4. One small liver lesion warranting ulstrasound study.
[**5-16**] CXR
In comparison with the study of [**5-12**], the degree of pulmonary
vascular congestion has substantially decreased. Bilateral
pleural effusions are seen, much worse on the left. Probable
atelectatic changes at the bases, again more prominent on the
left. There is some patchy opacification just above the minor
fissure on the right. In view of the high fever, this could
represent a developing pneumonia and should be carefully
evaluated on subsequent studies.
[**5-17**] KUB
Air-fluid levels are consistent with ileus; no evidence of
complete bowel obstruction.
Brief Hospital Course:
The patient was admitted to Red Surgery for management of her
SBO and abdominal pain. The patient was initially managed
conservatively with NGT decompression and NPO status. The
patient continued on TPN as she was on at home. The patient
failed conservative management, so the decision was made to take
the patient to the operating room. On [**5-8**], the patient
underwent a laparotomy, lysis of adhesion, enterocolostomy,small
bowel biopsy. The patient tolerated the procedure well with no
complications and an EBL of 100cc. For further detail of the
procedure please refer to the operative note. Post operatively,
the patient was hypotensive and started on a Neo drip, and she
was then transfered to the TICU for further care. On POD 2 the
patient was febrile to 103.8 and weaned off neo. On [**5-11**], her
PICC was removed and TLC placed. GPC's were found in blood so
Vanco was started. On [**5-12**], she developed new AF w/RVR, was
started on a dilt/lasix gtt, and an ECHO done was normal.
Furthermore, her Ucx was positive w/Ecoli so she was started on
cipro and later changed to Gent [**2-26**] fluoroquinolone resistance.
On [**5-14**] the patient was transfered to the floor in fair
condition and rate controlled. The patient's discharge was
delayed secondary to physical therapy concerns about the
patient's independence status. Furthermore, secondary to the
patient's poor po intake, TPN was continued. On [**5-16**] the
patient spiked a temp to 101.5 and the CVL was d/c'd and the
patient maintained on D10W until PICC could be placed. On [**5-19**],
the patient self d/c'd her PICC accidentally. On [**5-20**] a PICC
was replaced via IR without complication. Upon discharge, the
patient was afebrile with all vitals stable other than O2
saturation, ambulating on O2 independently, tolerating po feeds
but still on TPN, and with pain controlled on po pain
medication.
Physical therapy was consulted to help rehabilitate the patient.
The patient progressed well with physical therapy, but the
ultimate decision was made to d/c the patient home with oxygen
[**2-26**] desaturations to the mid 80's on ambulation.
The spiculated lung mass found on CT was refered to
interventional pulmonology for work up and management. The
patient will be managed as an outpatient and will be discussed
in multidisciplinary clinic.
Medications on Admission:
furosemide 40qd, TPN, mirtazipine 15mg 1.5tabs qHS
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO at bedtime.
4. Oxygen
[**1-26**] LPM continuous via nasal cannula
pulse dose conserving
Device for portability
5. TPN
Non-Standard TPN
Volume(ml/d) 1300
Amino Acid(g/d) 65
Branched-chain AA(g/d)0
Dextrose(g/d) 218
Fat(g/d) 45
Trace Elements will be added daily
Standard Adult Multivitamins
NaCL 80
NaAc 20
NaPO4 40
KCl 50
KAc 0
KPO4 0
MgS04 10
CaGluc 10
Famotidine(mg) 0
Insulin(units) 10
Zinc(mg) 10
Cycle over (hrs.) 12
Start at [**2183**]
Decrease rate to 0 (ml/h) at 0800
Stop at 0800
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Take 1 tablet twice a day for 7 days then drop it down to
1 tablet daily.
Disp:*60 Tablet(s)* Refills:*2*
7. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
SBO
Discharge Condition:
Fair - requiring Home O2
Discharge Instructions:
Please call Dr.[**Name (NI) 1482**] office [**Telephone/Fax (1) 2981**] or come to the
Emergency Department if you experience any of the following:
- Fever > 101.5 or chills
- Inability to tolerate food or water
- Uncontrolled nausea or vomiting
- Increased redness or drainage from your incision site
- Uncontrolled pain
- Anything else of concern
You may leave your incision uncovered. You may shower but do
not soak the incision for 2 weeks.
You may resume taking your home medications. You will be given a
prescription for bactrim. You should take this until your
prescription is finished.
You will be going home on TPN as you were on before hospital
admission.
You will also be going home on Oxygen therapy. A visiting nurse
will assist you with everything.
The visiting nurses will replace the bandage daily for you.
Followup Instructions:
Please call Dr.[**Name (NI) 1482**] office to schedule a follow up
appointment for 1-2 weeks. His office number is [**Telephone/Fax (1) 2981**].
Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 18313**] to schedule a
follow up appointment for your lung nodule.
Please call your Primary Care Physician and your
Gastroenterology physician to make follow up appointments with
them. Among the topics will be your TPN regimen and your
Diltiazem.
|
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icd9cm
|
[
[
[]
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[
"99.15",
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icd9pcs
|
[
[
[]
]
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6888, 6939
|
3329, 5679
|
293, 323
|
6987, 7014
|
1496, 1496
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7893, 8384
|
1206, 1358
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5781, 6865
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6960, 6966
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5705, 5758
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7038, 7870
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1373, 1477
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240, 255
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351, 784
|
1512, 3306
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806, 910
|
926, 1190
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,638
| 145,761
|
26449
|
Discharge summary
|
report
|
Admission Date: [**2155-4-24**] Discharge Date: [**2155-4-25**]
Date of Birth: [**2094-3-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cefepime
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61 yo F with h/o 3 vessel CAD, s/p stent to LCX in [**2154-12-23**],
ischemic cardiomyopathy, CHF with h/o cardiogenic [**Year (4 digits) **], severe
MR, atrial fibrillation who presented to [**Location (un) 620**] with SOB. She
describes a gurgling in her chest. Her vitals on arrival to
[**Location (un) 620**] were HR 140, BP 137/70, RR 30, 91% NRB. She was given
lasix 100 IV and 3 nitros and dropped her pressure to the 70's.
SHe was started on dopamine gtt of 5 and was also given ASA and
started on heparin and transferred to [**Hospital1 18**]. Her VS on arrival
to [**Hospital1 18**] were HR 96 BP 121/75, 16, Pox 92% 15L FM. She diurese
about 900 cc since getting the lasix. On arrival to the CCU, she
said her breathing was better. She states she has been taking
her medications as provided by her NH. She said they also have
her on a low salt diet. She does not check her weight.
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. Denies recent fevers, chills or rigors.
Cardiac review of systems is notable for chest pain, dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea. She thinks
her ankle edema is improving. She denies palpitations, syncope
or presyncope.
.
EKG demonstrated SR, rate 103, LAD, slightly prolonged QRS
Past Medical History:
-Syncope 3yrs ago
.
PAST MEDICAL HISTORY:
-Coronary Artery Disease (3VD, not a surgical candidate, s/p
stent to LCX in [**12/2154**])
-CHF, h/o cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] 20-30%
-Severe MR, moderate TR
-Atrial fibrillation on amiodarone
-Syncope 3yrs ago
-Neck pain, eval in 2/99 at [**Hospital1 336**] with some fibromyalgia points,
occured after viral syndrome
-Iron deficient Anemia
-Fibromyalgia
-Diverticulosis
-Internal Hemorrhoids
-Osteopenia
-Cluster A personality (schizoid) with question underlying
dementia, court order made for her to be DNR/DNI at last
admission
-Gastritis
-Bursitis
-Adrenal adenoma
Social History:
Patient lives in a boarding house.
She denies any cigg, ETOH, or illicit drug use.
She denies being sexually active; no inter-personal
relationships; no family or friends involved.
Family History:
n/c
Physical Exam:
VS: T 98 BP 103/79 HR 100-120 RR 12-16 O2 99% on 5L NC
I/O 0/900/8 hour
Gen: well appearing, breathing comfortably.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Neck: + elevated JVP above clavicle while sitting up straight
CV: tachy, regular, normal S1, S2. No m/r/g. +S4.
Chest: crackles up half way
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: trace ankle edema, +bilat foot drop
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Pertinent Results:
Admission Labs:
[**2155-4-24**] 01:25AM BLOOD WBC-19.5*# RBC-5.20# Hgb-13.3# Hct-41.7#
MCV-80* MCH-25.6* MCHC-31.9 RDW-19.1* Plt Ct-287
[**2155-4-24**] 01:25AM BLOOD Neuts-87* Bands-0 Lymphs-7* Monos-5 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2155-4-24**] 01:25AM BLOOD PT-13.3* PTT-86.3* INR(PT)-1.2*
[**2155-4-24**] 01:25AM BLOOD Glucose-199* UreaN-25* Creat-1.7*#
Na-132* K-4.3 Cl-93* HCO3-28 AnGap-15
[**2155-4-24**] 01:25AM BLOOD CK(CPK)-93
[**2155-4-24**] 08:43AM BLOOD Lipase-28
[**2155-4-24**] 01:25AM BLOOD cTropnT-0.39* proBNP-4131*
[**2155-4-24**] 01:25AM BLOOD Calcium-9.0 Phos-5.9*# Mg-2.2
.
CXR [**2155-4-24**] (1am): Perihilar vascular congestion, bilateral
pleural effusions consistent with pulmonary edema. There is
likely adjacent bibasilar atelectasis, though areas of
aspiration and/or consolidation at the lung bases is not
excluded. Repeat radiographs following appropriate diuresis is
recommended to assess for underlying infection.
.
CXR [**2155-4-24**] (7am): Marked improvement up to almost complete
resolution of pulmonary edema. Decreased but still present
bilateral pleural effusions.
.
[**Month/Day/Year **] [**2155-4-24**]: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
severely dilated. Overall left ventricular systolic function is
profoundly depressed (ejection fraction [**10-11**] percent): the
entire posterior and lateral walls are thin and fibrotic; the
entire posterior wall is aneurysmal and dyskinetic; the inferior
free wall is severely hypokinetic; the rest of the left
ventricle is at least moderately hypokinetic. There is no
ventricular septal defect. Right ventricular chamber size is
normal. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen.
Brief Hospital Course:
61 yo F with h/o 3 vessel CAD, s/p stent to LCX in [**2154-12-23**],
ischemic cardiomyopathy, CHF with h/o cardiogenic [**Year (4 digits) **], severe
MR, atrial fibrillation who presents with SOB felt to be
secondary to CHF exacerbation.
.
1. SOB/CHF: Most likely etiology is CHF exacerbation. Last [**Year (4 digits) **]
in [**1-29**] showed LVEF 20-30%. Unclear if she may have had small
NSTEMI with trop of 0.39 or if this is from the CHF. She was
slightly volume overloaded on exam and CXR was consistant with
pulmonary edema. Unclear what precipitated her decompensation.
She was given 100mg IV lasix in the ED and responded well to
this with 1L urine output. She was initially continued on 80mg
IV lasix daily and reached her goal of negative 1L/24hour
period. She was then put back on her outpatient dose of 100mg
PO lasix and given boluses IV as needed to maintain a negative
fluid status. Patient was initially placed on dopamine for
hypotension following nitro in ED. This was weaned off while in
the CCU and her BP remained stable. It is recommended to
restart HF regimen of ACEI when BP tolerates and renal function
returned to baseline. Unclear why she was not on HF betablocker
but presumably because of blood pressure drops. Aldactone should
also be considered in the future once this episode has fully
resolved. A [**Date Range **] was performed that showed an interval worsening
of her systolic failure with LVEF 10-20% and thin and fibrotic
posterior and lateral walls. The patient has a scheduled follow
up appointment at the heart failure clinic.
.
2. CAD: Patient was started on heparin gtt given possibility of
NSTEMI. She refused cath and has known 3VD. She was continued on
medical management with ASA, plavix. It should be considered to
add a betablocker if BP allows. Her statin was held because of
h/o elevated LFTs.
.
3. Rhythm: H/O PAF. Continued amiodarone. It was felt that she
was not a good candidate for anticoagulation given her poor
compliance.
.
4. Schitzoid: Continued Mirtazapine, haldol
.
5. Elevated WBC: Was found to have a UTI. Pt was started on
bactrim, to be taken for one more day after discharge. Urine
culture was pending on discharge.
.
6. ARF: Likely secondary to poor perfusion from CHF. Avoided
nephrotoxins, held ACEI. Cr of 1.5 on discharge. Complete
resolution should be followed up after discharge.
.
7. Iron def anemia: procrit was held because of increased
hematocrit from baseline.
.
8. FEN: Low salt, heart healthy
.
9. PPX: SQ heparin, PPI
.
10. Access: PIV
.
11. Code: DNR/DNI
Medications on Admission:
Allopurinol 100 mg daily
Amiodarone 200 mg daily
Asa 81 mg Daily
Lasix 100 mg daily
Levothyroxine 25 mcg daily
Lisinopril 2.5 mg daily
MS contin 30 mg [**Hospital1 **] and 60 mg QHS
Protonix 40 mg daily
Plavix 75 mg daily
Procrit 4000 units QMWF
Iron 325 mg daily
Haldol 2.5 mg [**Hospital1 **]
Mirtazapine 15 mg daily
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
5. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO HS (at bedtime).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO QAM (once a day
(in the morning)).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 1 days: last day [**2155-4-26**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis:
1. Severe systolic heart failure, EF 10%
2. urinary Tract Infection, uncomplicated
3. Acute renal failure
Secondary Diagnoses:
1. Coronary Artery Disease
2. Atrial fibrillation
3. Iron deficient Anemia
4. Fibromyalgia
5. dementia
6. gastritis
Discharge Condition:
good, baseline mental status, oxygenating well on 2-3L nasal
cannula
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
.
You were admitted with a CHF exacerbation. it is very important
to have yourself weighed everyday and if weight has increased
>3lbs, speak with your physician to see if additional lasix is
needed.
.
your lisinopril has been held due to acute renal failure
Followup Instructions:
Heart failure clinic: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2155-5-26**] 9:00
|
[
"427.31",
"294.8",
"414.8",
"785.51",
"397.0",
"535.50",
"428.23",
"584.9",
"414.01",
"V45.82",
"410.71",
"428.0",
"301.20",
"424.0",
"599.0",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
9263, 9347
|
5232, 7781
|
286, 293
|
9654, 9725
|
3226, 3226
|
10159, 10312
|
2616, 2621
|
8151, 9240
|
9368, 9368
|
7807, 8128
|
9749, 10136
|
2636, 3207
|
9515, 9633
|
1232, 1730
|
243, 248
|
321, 1213
|
3242, 5209
|
9387, 9494
|
1795, 2401
|
2417, 2600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,232
| 147,092
|
14121
|
Discharge summary
|
report
|
Admission Date: [**2129-11-25**] Discharge Date: [**2129-12-17**]
Date of Birth: [**2066-9-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
sepsis and gangrene of the right foot
Major Surgical or Invasive Procedure:
[**11-25**] - PROCEDURE: Right below-the-knee guillotine amputation.
[**12-6**] - PROCEDURE: Closure of right below-knee amputation.
[**12-6**] - PROCEDURE: 1. Bronchoscopy and tracheostomy 2. Upper
endoscopy and placement of percutaneous endoscopic gastrostomy.
History of Present Illness:
63 y/o M c/ R foot wound on vac at home, s/p multiple
debridements, presented to ED [**11-24**] septic with R foot gangrene
Past Medical History:
1. ESRD on HD [**2-25**] DM and HTN (since [**6-27**] on Tu-Th-Sat)
2. DM
- Retinopathy
- Neuropathy in calves and feet
3. HTN
4. Hyperlipidemia
5. Chronic cough
6. s/p cataract surgery
7. OSA
8. History of Tobacco abuse
Social History:
Lives with wife. Two-pack-year for 20 years. Quit 20 years
ago. Alcohol 3 times per week. He was a heavy drinker in the
past of unclear significance.
Family History:
Diabetes Mellitus Type II
PAD
Increase cholesterol
ESRD on HD (M/W/F), transplant list,
HTN
Physical Exam:
N/A
pt expired
Pertinent Results:
[**2129-12-15**] 02:29AM BLOOD
WBC-11.1* RBC-2.58* Hgb-7.7* Hct-23.6* MCV-92 MCH-29.7 MCHC-32.5
RDW-20.5* Plt Ct-234
[**2129-12-16**] 09:30AM BLOOD
PT-17.6* PTT-43.7* INR(PT)-1.6*
[**2129-12-15**] 02:29AM BLOOD
Glucose-162* UreaN-57* Creat-7.3*# Na-140 K-4.1 Cl-102 HCO3-26
AnGap-16
[**2129-12-3**] 02:44AM BLOOD
ALT-389* AST-144* AlkPhos-219* Amylase-24
BLOOD CULTURE
AEROBIC BOTTLE (Final [**2129-12-1**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2129-11-28**]):
REPORTED BY PHONE TO [**First Name9 (NamePattern2) 42078**] [**Doctor Last Name 42079**] [**2129-11-26**] 8AM.
CITROBACTER FREUNDII COMPLEX.
Trimethoprim/Sulfa sensitivity testing available on
request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
FINAL SENSITIVITIES.
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
gentamicin. Screen predicts NO synergy with penicillins
or
vancomycin. Consult ID for treatment options.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
| ENTEROCOCCUS FAECALIS
| |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
IMIPENEM-------------- <=1 S
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S
PENICILLIN------------ 8 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ 8 I
VANCOMYCIN------------ =>32 R
Brief Hospital Course:
[**11-25**] - Pt admitted throught the ER / sepsis / ischemic foot
Sent to the OR for immediate Amputaton
In holding area of OR - He 'coded' in pre-op, becoming
asystolic, with an initially failed intubation, entering the
esophagus. Forty-five minutes elapsed before his
cardiorespiratory state was stable, with an unclear duration and
degree of cerebral hypoperfusion. He received multiple shocks,
Epinephrines.
Transfered to the CVICU in critical condition
CVICU PEA, then asystole, then PEA again. Pt started on pressors
/ resp support / pan cx'ed
Pt critical / Bedside PROCEDURE: Right below-the-knee
guillotine amputation.
Pt recieved line / cxr
Broad spectrum Antibiotics started
STAT
ECG
ECHO
CTA CHEST
CT ABDOMEN
CT PELVIS
CT HEAD
Pt experiences shock liver / Transplant consulted
[**11-26**] - pt never recovered had ABD US
IMPRESSION:
1. Patent portal vein.
2. Periportal and gallbladder wall edema, in addition to ascites
and small pleural effusions is consistent with third spacing.
Hypoechoic appearance of the liver is compatible with hepatic
congestion or hepatitis.
3. No evidence of intra- or extra-hepatic biliary ductal
dilatation.
[**11-26**] - [**12-3**]
During sedative medication pt was weaned He has been
unresponsive whilst awake, and periods of sleep have been
associated with hypotension and apnea. He did not show apparent
spontaneous movement.
[**12-4**]
Require Insulin drip for increase BS - [**Last Name (un) **] [**First Name9 (NamePattern2) 42080**]
[**Last Name (un) **] followed pt / guidelines adhered to
Nuerolgy consulted
Mr [**Known lastname 805**] is likely in a persistant vegetative state with
cardiorespiratory support. Despite the withdrawal of sedatives,
he has not regained a meaningful level of consciousness, instead
only exhibiting some, but not other, brainstem reflexes, and
neither myotatic nor noxious spinal reflexes.
The disturbance of consciousness is suggestive of disruption of
the rostral brainstem, hypothalamus, basal forebrain, or diffuse
cortical injury. MRI will help resolve the cause of his coma,
and now coma vigil, but it is unlikely that improvement in his
level of consciousness will occur. Importantly, there is no
other obvious sytemic cause to his impaired consciousness, such
as electrolyte or metabolic disturbance, and his blood gases and
temperature are within the normal range. One final test that may
be considered, to exclude renal encephalopathy, is blood ammonia
level. Since patient has been ongoing hemodialysis, we will
repeat neurological examination to confirm his neurological
state.
The absence of spinal reflexes are either due to peripheral
neuropathy or damage to spinal motorneurons. In the context of
asystole, spinal infarction is possible. Mr [**Known lastname 805**] has absent
oculocervical reflexes, which are more likely to be due to
brainstem damage, than to symetric bilateral damage to either
the eighth, or both the third and sixth cranial nerves. However,
rest of the brainstem examination is relatively intact including
the presence of blink to threat, the corneal reflex and gag
reflex.
Overall, Mr [**Known lastname 805**] is likely to be in a persistant vegetative
state, with quite limited meaningful neurological recovery if
not none. In view of the hiatus since the asystolic event, may
only recover marginally, and remain presistantly vegetative.
Nonetheless, repeat serial examination will be performed to
document any trends in his neurological function. Similarly, an
electroencephalogram may provide some further information about
the degree of forebrain activity and ruling out subclinical
seizures
[**12-5**] - Thoracics consult / followed / PT DNR following shock
liver
[**12-6**] Pt brought down for Closure of right below-knee
amputation, 1. Bronchoscopy and tracheostomy 2. Upper endoscopy
and placement of percutaneous endoscopic gastrostomy.
[**12-7**] EEG This is an abnormal portable EEG due to the slow and
disorganized background rhythm. This is suggestive of a moderate
encephalopathy which may be seen with medication effect, toxic
metabolic abnormalities, or infections. There were no regions
of focal slowing and no epileptiform discharges noted.
[**12-7**] PICC placed for access
[**12-7**] - [**12-17**]
pressure support / intubated / TF / DNR
broad spectrum antibiotics continued / CX's followed
echo
Multiple family meeting to determine pt status / family
unwilling to make CMO. Pt still requires full sedation / TF /
Pressure support / fluid resusitation
[**12-17**]
Family [**Last Name (un) 42081**] CMO
Morphine drip
Pt expires shortly after
Medications on Admission:
[**Last Name (un) 1724**]: NPH 23/15, albuterol, norvasc 5', ASA 81', Bumex 1',
carvedilol 12.5'', flumisonide (home), fosinopril 40',
metoprolol 50', metolazone 5 QOD
Discharge Medications:
n/a
pt expired
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
N/A
pt expired
Discharge Condition:
N/A
pt expired
Discharge Instructions:
N/A
pt expired
Followup Instructions:
N/A
pt expired
Completed by:[**2129-12-28**]
|
[
"997.1",
"518.5",
"585.6",
"785.52",
"285.9",
"038.9",
"730.07",
"250.72",
"785.4",
"427.5",
"348.1",
"403.91",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"96.72",
"31.1",
"96.04",
"84.15",
"43.11",
"39.95",
"84.3",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8596, 8677
|
3710, 8339
|
354, 621
|
8735, 8751
|
1351, 3687
|
8814, 8860
|
1207, 1301
|
8557, 8573
|
8698, 8714
|
8365, 8534
|
8775, 8791
|
1316, 1332
|
277, 316
|
649, 774
|
796, 1019
|
1035, 1191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,357
| 128,463
|
52903
|
Discharge summary
|
report
|
Admission Date: [**2145-4-27**] Discharge Date: [**2145-4-30**]
Date of Birth: Sex: F
Service: Gynecology
HISTORY OF PRESENT ILLNESS: This is a 55-year-old female gym
teacher who presented to the operating room for a
sacrospinous colpopexy and anterior and posterior repair of
her vaginal apex prolapse.
The patient had undergone a total vaginal hysterectomy 16
years prior and recently noted a [**Doctor Last Name **] and prolapse of her
vagina. The patient was then seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and
the decision was made to proceed with a vaginal
reconstructive procedure. The risks and benefits were
discussed, and consent was obtained.
BRIEF SUMMARY OF HOSPITAL COURSE: On hospital day one,
postoperative day zero, the patient underwent a vaginal apex
sacrospinous colpopexy as well as an anterior and posterior
colporrhaphy. The surgery was significant for a large blood
loss of approximately 2 liters. The patient was treated for
this intraoperatively with 7 liters of crystalloid and 1 unit
of packed red blood cells. Her hematocrit prior to procedure
was over 40, and during the procedure nadired at 30. The
patient remained hemodynamically stable. Operatively, there
was oozing from several vessels that were difficult to locate
and cauterize; however, excellent hemostasis was
finally achieved, and the surgery was completed. Please see the
Operative Note for details.
The patient remained intubated postoperatively until
postoperative day one, at which time she was extubated. She
had a low potassium which was treated with potassium
replacement, and her potassium, electrolytes, and hematocrit
were followed and found to be stable and normalized. The
patient's hematocrit normalized at 25.
On postoperative day one, the patient was extubated and
transferred to the regular Gynecology floor. The patient was
able to ambulate. She was tolerating and regular diet, and
the Foley remained in place. On postoperative day two, the
Foley catheter was discontinued and the patient voided
spontaneously. The patient's pain was always well
controlled.
By postoperative day three, the patient was ambulating
without difficulty. Her pain was well controlled on by mouth
pain medications, she was tolerating a regular diet, and
voiding spontaneously. The decision was made to discharge
the patient home.
DISCHARGE DIAGNOSES:
1. Vaginal vault prolapse.
2. Sacrospinous colpopexy with anterior and posterior repair
on [**2145-4-27**].
CONDITION AT DISCHARGE: Good.
MEDICATIONS ON DISCHARGE: The patient was discharged on all
of her outpatient medications as well as Motrin and Tylenol.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in approximately six
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19144**]
Dictated By:[**Name8 (MD) 6269**]
MEDQUIST36
D: [**2145-4-30**] 11:40
T: [**2145-5-1**] 08:20
JOB#: [**Job Number 109070**]
|
[
"E878.8",
"401.9",
"998.11",
"618.5",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"70.50",
"70.77",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2427, 2548
|
2597, 2693
|
2727, 3134
|
758, 2406
|
2563, 2570
|
163, 729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,981
| 173,438
|
43848
|
Discharge summary
|
report
|
Admission Date: [**2119-8-17**] Discharge Date: [**2119-9-7**]
Date of Birth: [**2056-3-10**] Sex: F
Service: SURGERY
Allergies:
Macrodantin / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal pain/distention
Recurrent small bowel obstruction
Major Surgical or Invasive Procedure:
1.Exploratory laparotomy, lysis of adhesions (1
hour), small bowel resection and anastomosis x1.
2.Percutaneous endoscopic gastrostomy.
History of Present Illness:
63 year old woman with C5 tetraplegic s/p (MVA 30 years ago).
Patient
has baseline partial ventilation dependence at night. She has
had multiple prior obdominal surgeries with use of the abdominal
wall bilaterallt for tissue transfers. She had been admitted and
managed medically earlier this
month for SBO (d/c'd [**8-15**]). She re-presented on this occasion
with increased abdominal distention that had progressed
throughout the day on [**8-16**] and resulted in her going to [**Hospital 6451**] hospital, There she had a CT that showed a distal SBO
and she was transferred to [**Hospital1 18**] for further care.
Past Medical History:
C5 quadraplegic s/p MVA has chronic trach with ventilator
dependence at night. Anemia, recurrent UTIs, active decubiti R
ischium. suprapubic tube, hyponatremia, s/p bladder augmentation
using a cecal pedicle, L hip recurrent decubiti s/p use of
abdominal wall flaps for treatment of chronic L hip
osteomyelitis, now with VAC treatment. History of adrenal
insufficiency.
Social History:
no smoking, no drinking, no EtOH. Lives with husband who is
her primary caretaker
Family History:
non-contributory
Physical Exam:
vitals: T97.8, HR 104, BP145/79, 98% 4L
GEN: NAD, NGT placed
NEURO: quad
PULM: diminished bt clear B/L
CV: RRR
ABD: +BS, soft/NT, healed transverse and vertical scar. Extreme
attenuation of the entire abdominal wall.
Pertinent Results:
[**2119-8-17**] 01:20AM PT-12.0 PTT-28.2 INR(PT)-1.0
[**2119-8-17**] 01:20AM WBC-8.1 RBC-3.50*# HGB-11.1*# HCT-33.0*#
MCV-94 MCH-31.7 MCHC-33.6 RDW-15.5
[**2119-8-17**] 01:20AM NEUTS-92.0* LYMPHS-4.3* MONOS-3.3 EOS-0.3
BASOS-0.2
[**2119-8-17**] 01:20AM GLUCOSE-70 UREA N-20 CREAT-0.3* SODIUM-137
POTASSIUM-2.8* CHLORIDE-103 TOTAL CO2-21* ANION GAP-16
[**2119-8-17**] 01:20AM PHOSPHATE-3.3 MAGNESIUM-1.8
[**2119-8-17**] 04:27PM TYPE-ART PO2-186* PCO2-46* PH-7.33* TOTAL
CO2-25 BASE XS--1
[**2119-8-19**] 04:41AM BLOOD calTIBC-85* Ferritn-676* TRF-65*
[**2119-8-17**] 01:26AM BLOOD Lactate-0.6
[**2119-8-17**] 03:18PM BLOOD freeCa-1.14
ABDOMEN (SUPINE ONLY) [**2119-8-17**] 3:15 AM
Dilated loops of small bowel suggestive of small-bowel
obstruction. Limited evaluation of the colon and intrapelvic
loops of bowel.
Pathology Examination
[**Known lastname **],[**Known firstname **] A. [**2056-3-10**] 63 Female [**-8/2639**]
[**Numeric Identifier 94175**]
SMALL BOWEL (1).
Procedure date Tissue received Report Date Diagnosed
by
[**2119-8-17**] [**2119-8-18**]
Segment of small intestine with diffuse acute serositis
extending to one resection margin; submucosal acute
inflammation, edema, and vascular congestion with focal
hemorrhage are also present.
CT ABDOMEN W/CONTRAST, CT CHEST W/CONTRAST [**2119-8-23**] 12:50 PM
1. Multifocal pneumonia demonstrated by tree-in-[**Male First Name (un) 239**] opacities
diffusely bilaterally and consolidation and volume loss within
the right greater than left lower lobe.
2. Small 6 mm left lower lobe pulmonary nodule. Recommend
followup CT following resolution of pneumonia.
3. Mediastinal, hilar, and subclavicular lymphadenopathy.
Although this may be related to pneumonia, given the size and
distribution of this lesion, other etiology should be considered
such as lymphoma or sarcoid. Recommend correlating with
patient's clinical history.
4. Tiny liver hypodensities in segment II and segment VII that
are not completely characterized. Further evaluation with MRI or
multiphasic CT is suggested if clinically indicated.
5. Moderate ascites.
6. Diffuse small bowel wall thickening. This finding is fairly
nonspecific, however the most likely possibility is diffuse
edema secondary to third spacing, which is consistent with
surrounding ascites.
7. Mild-to-moderate right hydronephrosis and hydroureter.
8. Ill defined heterogeneous area within the region of the
patient's neobladder on the right side. The differential
includes collapsed segment of an ileal pouch, cervical or lower
uterine segment mass, or bladder mass. A fluoroscopic evaluation
of the neobladder could be performed to evaluate for bladder
mass. A pelvic ultrasound could further delinate the location of
this lesion.
CT CHEST W/CONTRAST [**2119-9-3**] 11:44 AM
1. Distended fluid-filled colon raises the possibility of
superficial colitis. No wall thickening or evidence of
transmural colon disease.
2. Persistent collapse of the lower lobes bilaterally.
3. Improved peribronchial inflammatory changes in the right
middle lobe and tree-in-[**Male First Name (un) 239**] centrilobular inflammatory opacities
in the upper lobes bilaterally.
4. Decrease in size in mediastinal lymphadenopathy.
5. Hypodensities in the liver are too small to be characterized.
6. Ascites.
7. Mild improvement in small bowel wall thickening.
8. Unchanged mild-to-moderate hydronephrosis on hydroureter.
9. Stable ill-defined heterogeneously enhancing area in the
region of the patient's neobladder on the right
[**2119-8-19**] 10:37 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2119-8-22**]**
GRAM STAIN (Final [**2119-8-19**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2119-8-22**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 4 S
MEROPENEM------------- 2 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
[**2119-8-20**] 9:20 am BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2119-9-1**]**
GRAM STAIN (Final [**2119-8-20**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2119-8-22**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 4 S
MEROPENEM------------- 4 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
FUNGAL CULTURE (Final [**2119-9-1**]):
YEAST.
[**2119-9-4**] 9:34 am STOOL CONSISTENCY: LOOSE Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2119-9-4**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
Brief Hospital Course:
The patient re-presented with SBO as described in the HPI above.
She remained in ICU care throughout given her vent and nursing
needs. She was given GI/DVT prophylaxis throughout her stay. She
was taken to surgery for LOA and resection of a strictured
segment of small bowel. She tolerated this surgery well and
recovered rapidly, but then developed a pseudomonal pneumonia.
She was treated with appropriate antibiotics but had a major
setback on her ventilator status. She therefore became depressed
and refused to eat. She was seen by psychiatry and started on
pharmacotherapy for her advanced situational depression. She
accepted placement of a PEG for long term nutrition given her
low PO intake and difficulty with swallowing. She was evaluated
on HD 17 for a question of intra-abdominal abscess/complication
given her increased WBC and episodes of hypotension but none was
found. This resolved and she remained stable up to just before
d/c. She then had an episode of altered mental status associated
with bradycardia. We wished to work that up but her husband
nonetheless insisted on taking her home AMA. She will go home
with close care by her husband who is very skilled in her long
term needs, and care, as well as home nursing care and
apropriate services. The rest of her hospital stay is described
below by systems.
NEURO: she is C5 quad x 30 years, and received appropriate
nursing care given this, there was no changes. She expressed
throughts of suicide and depression and psychiatry was c/s on HD
11 to help with her mental health needs. She has subsequently
started to feel much better, have increased hope, concentration,
better sleep and continues on citalopram upon d/c.
PULM: She required ventilation during the evenings with her home
regimen, and was slowly weened down on the rate of SIMV. She was
treated for pseudomonas and klebsiela pna after +sputum and BAL
after bronch on HD 13.
CV: she remained stable, through had minimal hypotension around
HD 15-17, which responded to fluids/Abx, worry of sepsis and no
source of infection was found. otherwise no issues.
GI/FEN: The patient received ABD washout, LOA and SBR as
described, plus a PEG for inadequate PO and continued TF
requirements. C.diff was NEG after concern secondary to multiple
loose stools which have subsequently resolved.
HEME/ID: She received ABX tx for pneumonia as described above
through her hospital stay and will be d/c'd on Nafcillin.
slightly elevated WBC as described above which was evaluated.
She had PNA and UTI and this has resolved upon d/c
GU/RENAL: UTI tx appropriately, continues w/ foley
Wound. Continues to have wound vac on chronic L inguinal/abd
wound. No changes.
Medications on Admission:
Oxycodone, fludrocortisone, ambien, ativan, flovent,
prilosec, nafacillin
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day).
2. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: One (1)
Intravenous Q6H (every 6 hours).
Disp:*qs 120* Refills:*0*
3. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed: PICC line care per
protocol.
Disp:*qs 60 ML(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Appl Topical [**Hospital1 **] prn as needed for rash: under breasts.
Disp:*1 1* Refills:*0*
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
q4 h prn as needed for wheeze.
Disp:*1 1* Refills:*2*
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO q8h prn as
needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
10. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO hs prn as needed for
insomnia.
Disp:*30 Tablet(s)* Refills:*0*
11. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous DAILY (Daily) as needed: to flush line.
12. PICC line care per protocol
13. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: One (1)
Intravenous Q6H (every 6 hours).
Disp:*120 * Refills:*0*
14. Tube feeds
Replete w/fiber Full strength-OK to start [**2119-9-8**]
-Additives: Banana flakes, 3 packets per day
-Starting rate:80 ml/hr; Do not advance rate Goal rate:80ml/hr
-Cycle?: Yes, starting now Cycle start:1800 Cycle end:0800
-Residual Check:q6 Hold feeding for residual >= :100 ml
Flush w/ 50 ml water q6h
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
1.Small bowel obstruction
2.Pneumonia
3.Hypotension
Discharge Condition:
stable, off vent with trach and PEG
Discharge Instructions:
Please call your PCP or seek Emergency care if you experience
fever greater than 101.4 F, nausea/vomiting, severe abdominal
pain, chills, problems with your feeding, or any other symptoms
that are worrisime to you.
Followup Instructions:
PLease follow up with Dr. [**Last Name (STitle) **] in [**3-18**] weeks, or earlier if you
have problems or issues that need urgent but not emregency
attention. Please call [**Telephone/Fax (1) 6429**] to arrange an appointment.
Completed by:[**2119-9-7**]
|
[
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"482.0",
"780.79",
"344.03",
"V55.6",
"599.0",
"V55.0"
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"54.59",
"93.59",
"43.11",
"53.9",
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] |
icd9pcs
|
[
[
[]
]
] |
12850, 12913
|
7946, 10628
|
353, 492
|
13009, 13047
|
1919, 7923
|
13310, 13569
|
1649, 1667
|
11250, 12827
|
12934, 12988
|
10654, 11227
|
13071, 13287
|
1682, 1900
|
254, 315
|
520, 1138
|
1160, 1532
|
1548, 1632
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,176
| 155,479
|
31197
|
Discharge summary
|
report
|
Admission Date: [**2162-9-6**] Discharge Date: [**2162-9-21**]
Date of Birth: [**2094-2-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2162-9-6**] Four Vessel CABG(left internal mammary artery to left
anterior descending, vein grafts to diagonal, obtuse marginal
and posterior descending artery)
Superficial sharp debridement of distal portion of sternal wound
([**9-21**])
History of Present Illness:
Mrs. [**Known lastname 31394**] is a 68 year old female with worsening shortness
of breath, and abnormal stress test. She underwent cardiac
catheterization in [**2162-7-18**] which revealed severe three vessel
coronary artery disease. LV gram was notable for for an ejection
fraction of 45-50% with trivial mitral regurgitation. Abdominal
aortography showed an abdominal aortic aneurysm which involved
the renal arteries. Based upon the above, she was referred for
cardiac surgical intervention.
Past Medical History:
-Coronary Artery Disease
-Chronic Obstructive Pulmonary Disease
-Hypertension
-Peripheral Vascular Disease - prior stenting Left Lower
Extremity
-Abdominal Aortic Aneurysm
-Hysterectomy
Social History:
Heavy smoker, over 2 packs per day for 50 years, quit
approximately 3 months prior to admission. She denies ETOH. She
is retired and lives with her daughter.
Family History:
Brother with MI at age 72
Physical Exam:
Vitals: 144/69, 96 beats per min, resp 14, sat 97% RA
General: WDWN female in NAD
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD, no carotid bruits noted
Lungs: CTA bilaterally, occasional wheezing noted
Heart: Regular rate and rhythm, no murmur or rub
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 1+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2162-9-6**] ECHO
Pre bypass: The left atrium is mildly dilated. No mass/thrombus
is seen in the left atrium or left atrial appendage. The left
ventricle is not well seen. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. There is mild
global left ventricular hypokinesis (LVEF = 40-45 %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity
imaging are consistent with Grade III/IV (severe) LV diastolic
dysfunction. The right ventricular cavity is mildly dilated.
Right ventricular systolic function is normal. There are complex
(>4mm) atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
Post bypass: Preserved biventricular function. LVEF 45%. MR
remains mild.
Aortic contours intact. Remaining exam unchanged. All findings
discussed with surgeons at the time of the exam.
[**2162-9-10**] CT Scan
IMPRESSION: Small quantity of retrosternal fluid; amount is
within the range that can be seen in the early postoperative
stage; however, if there is high suspicious of infection, direct
sampling of fluid may be helpful.
Multifocal ground glass opacities likely due to mild fluid
overload.
Localized dehiscence of the sternum at the most distal fragment
with separation of 1 cm. Incompletely imaged aneurysmal
dilatation of the infrarenal abdominal aorta. Patient is
post-CABG. Native coronary arteries are heavily calcified.
Brief Hospital Course:
Mrs. [**Known lastname 31394**] was admitted and underwent coronary artery bypass
grafting by Dr. [**Last Name (STitle) **]. For surgical details, please see
seperate dictated operative note. Following the operation, she
was brought to the CSRU for invasive monitoring. On
postoperative day one, she awoke neurologically intact and was
extubated without incident. She weaned from inotropic support
without difficulty. Low dose beta blockade was initiated while
Aspirin and Plavix therapy were resumed. She was transfused with
PRBC to maintain hematocrit near 30%. Her CSRU course was
otherwise uneventful and she transferred to the SDU on
postoperative day three. She was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility.
Mrs. [**Known lastname 31394**] developed a sternal click following several days
of coughing. A CT scan was obtained which showed a mild
localized dehiscence of the sternum at the most distal fragment
with separation of 1 cm. The remainder of her sternum was intact
and stable. Strict sternal precautions were implemented and
zosyn was started for antibiotic coverage. This was
discontinued, and PO Levofloxacin was started. She has remained
afebrile. The distal portion of her sternal wound was
superficially debrided at the bedside on [**2162-9-21**]. Mrs. [**Known lastname 31394**]
continued to make steady progress and was discharged home on
[**2162-9-21**]. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist
and her primary care physician as an outpatient.
Medications on Admission:
Verapamil 240 qd, Lisinopril 20 qd, Plavix 75 qd, Aspirin 81 qd,
Xanax prn, Albuterol, Spiriva, Advair, Lasix 20 qd, Simvastatin
80 qd
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. 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*
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
7. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
12. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*1 MDI* Refills:*0*
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
16. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash under the breasts.
Disp:*1 bottle* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
COPD
HTN
PVD - prior stenting Left Lower Extremity
Abdominal Aortic Aneurysm
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
To [**Hospital Ward Name 7717**] on Friday, [**9-24**] at 11am for wound check
Dr. [**Last Name (STitle) **] in [**4-22**] weeks, call for appt
Dr. [**Last Name (STitle) 73633**] in [**2-20**] weeks, call for appt
Dr. [**Last Name (STitle) 14016**] in [**2-20**] weeks, call for appt
Completed by:[**2162-9-21**]
|
[
"440.23",
"998.89",
"707.15",
"250.00",
"998.32",
"401.9",
"414.01",
"496",
"E878.8",
"E878.2",
"E849.7",
"305.1",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"36.15",
"77.61",
"38.93",
"39.61",
"99.04",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
7761, 7826
|
3905, 5519
|
340, 584
|
7982, 7989
|
2001, 3882
|
8325, 8640
|
1510, 1537
|
5704, 7738
|
7847, 7961
|
5545, 5681
|
8013, 8302
|
1552, 1982
|
280, 301
|
612, 1109
|
1131, 1319
|
1335, 1494
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,620
| 106,830
|
34553
|
Discharge summary
|
report
|
Admission Date: [**2168-8-7**] Discharge Date: [**2168-8-14**]
Date of Birth: [**2126-3-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42 yo man who fell [**9-21**] feet and struck occiput with LOC for 5
minutes. Reportedly landed on concrete. Amnestic to event and
mildly confused. Was initially taken to [**Hospital6 5016**]
where he was found to have SAD, SDH and T12-L3 transverse
process fractures as well as L2 compression fracture.
Past Medical History:
None
Social History:
Lives at home with his wife, 4 children, and mother in law
Family History:
non-contributory
Physical Exam:
On the day of discharge
Gen: NAD alert and oriented x4
CV: Regular rate and rhythm
Pulm: Lungs clear to auscultation bilaterally
abdomen: soft NT, ND
extremities: no clubbing/cyanosis/edema
Neuro: equal strength bilaterally upper and lower extremities,
equal sensation.
Pertinent Results:
[**2168-8-7**] 07:40PM PLT COUNT-210
[**2168-8-7**] 07:40PM WBC-20.3* RBC-4.73 HGB-14.2 HCT-43.1 MCV-91
MCH-30.1 MCHC-33.0 RDW-12.7
[**2168-8-7**] 07:42PM ASA-NEG ETHANOL-30* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-8-7**] 07:42PM AMYLASE-49
[**2168-8-7**] 07:42PM estGFR-Using this
[**2168-8-7**] 07:42PM GLUCOSE-125* UREA N-15 CREAT-1.0 SODIUM-138
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-21* ANION GAP-19
[**2168-8-7**] 07:43PM PT-12.6 PTT-27.6 INR(PT)-1.1
[**2168-8-7**] 07:57PM GLUCOSE-110* LACTATE-4.3* NA+-142 K+-3.9
CL--101 TCO2-22
CT HEAD [**8-7**]
1. Extensive bilateral subarachnoid hemorrhage, left greater
than right with
mild rightward subfalcine herniation and slight increase in
edema in the
temporal lobes bilaterally. Partial effacement of the
suprasellar and
quadrigeminal cisterns. Recommend close followup.
2. Small subdural hematomas along the left frontal and temporal
lobes as well
as the falx.
3. Non-displaced right occipital bone fracture extending to the
foramen
magnum.
CT L-spine [**8-7**]
Comminuted compression fracture of L2 vertebral body. Right
transverse process fractures of T11 through L3, with T11 and T12
transverse processes oblique and L1 to L3; complete transverse
process fractures with lateral displacement.
CTA Head/Neck [**8-8**]
Stable appearance of subarachnoid hemorrhage and subdural
hemorrhage. Suboptimal vascular study. No definite sign for the
presence of an aneurysm.
MR [**Name13 (STitle) **] [**8-8**]
No evidence of neural compressive changes secondary to L2
fracture. Please see above report. No spinal cord compression
identified elswhere in the spine as well.
CT HEAD [**8-11**]
IMPRESSION:
1. Increasing left frontotemporal edema, which may be due to
progressive
infarction in the MCA territory versus contusion. The normal
appearance of
the left MCA on CTA of the head [**2168-8-8**] makes contusions
slightly more
likely. If clinical management will change based on
differentiation of these entities, an MRI/MRA of the brain could
be obtained.
2. Slightly increased mass effect and rightward subfalcine
herniation with no evidence of uncal herniation. Also no
evidence of hemorrhage.
Brief Hospital Course:
42 yo man who fell [**9-21**] feet and struck occiput with LOC for 5
minutes. Reportedly landed on concrete. Amnestic to event and
mildly confused. Was initially taken to [**Hospital6 5016**]
where he was found to have SAD, SDH and T12-L3 transverse
process fractures.
CTA of Head/Neck were performed on presentation to r/o any
vascular malformations or injuries secondary to the pt's right
occipital bone fracture extending to the foramen magnum. There
were no documented abnormalities.
Neurosurgery evaluated the pt for multiple intracranial
hemorrhages which were stable other than contusion/edema.
Repeat CT scans of the head documented stability of the
hemorrhage. Pt was initially loaded with Dilantin and was
transitioned to Keppra for seizure prophylaxis.
Spine evaluated the pt and he was fitted for a TLSO brace for
multiple thoracic and lumbar fractures. Pt worked with PT and
was eventually cleared.
Pt's pain control was transitioned from IV Dilaudid to PO pain
meds before discharge. Pt was tolerating PO intake, passing
bowel movements and functioning with TLSO brace. Pt has
scheduled follow-up with both Neurosurgery and Spine.
Medications on Admission:
none
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*1*
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-13**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while using dilaudid for pain control to
prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: take as needed for constipation
associated with Pain medications.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Subdural hemorrhage, bilateral subarachnoid hemorrhage,
mild cistern loss
Basilar skull fracture extending into foramen magnumn
Comminuted compression fracture of L2 vertebral body
right transverse process fracture of T11-L3 with t11-12 having
oblique fractures. L1-L3 complete transverse process fractures
with displacement
Right psoas hematoma
Discharge Condition:
hemodynamically stable, tolerating oral intake, voiding without
difficulty, pain is well controlled with an oral regimen.
Discharge Instructions:
Please return to the emergency room if you experience:
increasing shortness of breath, new chest pain, uncontrollable
nausea/vomiting, have acute mental status change/confusion, or
experience new weakness or loss of sensation in your
extremities.
Spine:
You have been fitted with a TLSO brace. This should be worn at
all times when you are out of bed. You may take it off when
laying flat in bed.
Medications:
you have been prescribed anti-seizure medications. These should
be taken for the next month until you have followup with the
Neurosurgeons. At that appointment they will tell you whether
you should continue taking the medication.
You are also being prescribed pain medications. please be aware
that these can cause sedation/confusion and you should NOT
operate heavy machinery or consume alcohol while taking these
drugs.
Take all medications as ordered
Followup Instructions:
Neurosurgery: Please follow-up with Dr. [**Last Name (STitle) 23813**] in 4 weeks.
You will need a repeat CT scan of the head without contrast.
Please call [**Telephone/Fax (1) 1669**] to set up the appointment and the CT
scan.
Ortho spine: Please follow-up with Dr. [**Last Name (STitle) 363**] in 1.5 weeks. Call
([**Telephone/Fax (1) 11061**] for a f/u appointment. You will need xrays prior
to your appointment. The scheduler will help you set this up.
Completed by:[**2168-10-27**]
|
[
"293.0",
"E884.9",
"V64.1",
"805.4",
"919.0",
"348.5",
"E849.0",
"852.22",
"801.22"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5165, 5171
|
3321, 4478
|
318, 324
|
5566, 5690
|
1105, 3298
|
6608, 7098
|
781, 799
|
4533, 5142
|
5192, 5545
|
4504, 4510
|
5714, 6585
|
814, 1086
|
274, 280
|
352, 661
|
683, 689
|
705, 765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,581
| 135,814
|
48224
|
Discharge summary
|
report
|
Admission Date: [**2103-8-6**] Discharge Date: [**2103-8-9**]
Service: PCU
HISTORY OF PRESENT ILLNESS: This is an 85-year-old woman
with a history of coronary artery disease, status post
coronary artery bypass graft times two in [**2094-12-27**],
hypertension, diabetes mellitus, and hypercholesterolemia,
who presented with increasing frequency and severity of her
anginal symptoms for five days and was found to be in
intermittent AV block on admission. For the past few months,
patient has had increasing fatigue. She has had chronic
intermittent neck tightness and jaw pain, which is her
anginal equivalent for years, but since Wednesday, [**8-1**], has had increasing frequency and severity of these
episodes associated with weakness, lightheadedness, and
diaphoresis. The patient usually is doing some form of mild
exertion like combing her hair when these episodes have
occurred. She has taken sublingual nitroglycerin with some
of these episodes with questionable relief. No associated
dyspnea, nausea, vomiting or cough. Episodes last seconds to
minutes. She does experience palpitations with these
episodes.
On the day of admission, the patient went to see her
Cardiologist, Dr. [**Last Name (STitle) 1147**], where an electrocardiogram showed
a question of second degree AV block. She was then sent to
the Emergency Room at [**Hospital1 **] Hospital where
she was found to have intermittent complete heart block on
electrocardiogram with an atrial rate of 60 and a junctional
escape rhythm of 40. She was hemodynamically stable. She
has had no recent fevers, chills, dysuria, abdominal pain,
diarrhea or bright red blood per rectum. She has had
increased exacerbation of her seasonal allergies recently.
In the Emergency Room, she was given atropine and one
sublingual nitroglycerin with good response. Intermittently
in the Emergency Room, she went into normal sinus rhythm and
then back into complete heart block. She was also having
intermittent bigeminy and trigeminy. Transcutaneous pads
were placed and she was started on a nitroglycerin drip. On
the night of admission, an A line was placed in her left
wrist radial artery and after several hours after admission,
she did go into normal sinus rhythm with PR prolongation.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft times two in [**2094**]. Saphenous vein graft to
first circumflex and first diagonal branch, left dominant,
normal left ventricular function, negative Persantin thallium
in [**2100**], history of stable angina, patent graft on
catheterization in [**2095**].
2. Noninsulin dependent diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia.
5. Peripheral vascular disease, status post left femoral
popliteal bypass [**2100-12-27**].
6. Hypothyroidism, status post radiation for nodular
hyperthyroidism.
7. Peptic ulcer disease in the past.
8. Cholecystectomy in [**2101-11-26**], status post endoscopic
retrograde cholangiopancreatography with common bile duct
stone extraction and spincterotomy in [**2102-11-27**].
9. Bilateral cataract surgery.
10. Osteoarthritis.
11. Superficial skin cancer treated with topical
fluorouracil.
12. History of shingles.
13. Total abdominal hysterectomy.
MEDICATIONS:
1. Trental 400 b.i.d.
2. Diovan 160 mg q.d.
3. Vascor 300 mg q.d.
4. Imdur 240 mg q.d.
5. Aldactone 25 mg q.d.
6. Lipitor 20 mg q.d.
7. Sectral 200 mg q.d.
8. Lasix 20 mg q.d.
9. Glyburide 2.5 mg q.d.
10. Synthroid 25/50 mcg q.o.d.
11. Vitamin D.
12. Vitamin E.
13. Calcium.
14. Sublingual nitroglycerin prn chest pain.
ALLERGIES: Penicillin causes a rash.
FAMILY HISTORY: Mother with diabetes mellitus, coronary
artery disease, CVA, breast cancer. Father with cerebral
hemorrhage. Sister with coronary artery disease, diabetes
mellitus, breast cancer, renal cancer. Brother with
pancreatic cancer.
SOCIAL HISTORY: Patient has two children. She lives alone
in a house with stairs. She is not a smoker and drinks
alcohol rarely.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.7. Pulse
40-50s. Blood pressure 110/70. Respiratory rate of 16. 02
saturation 97% on room air. General: Elderly obese woman in
no apparent distress. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic. Pupils equal, round and reactive
to light. Extraocular muscles were intact. Oropharynx
clear. Neck: No lymphadenopathy, jugular venous pressure at
14 cm, [**Doctor Last Name **] A waves noted. Trachea midline.
Cardiovascular: Normal S1, S2, positive S3, no S4, 2/6
systolic murmur at the left lower sternal border radiating to
the apex. Pulmonary: Right greater than left bibasilar
crackles, no wheezes. Abdomen: Soft, nondistended, normal
active bowel sounds, nontender, no hepatosplenomegaly.
Extremities: Warm, pulses intact bilaterally, trace edema
bilaterally, chronic vascular insufficiency dermatitis, small
1 x 1 macules on both shins.
PERTINENT LABORATORIES: White blood cell count 8.9,
hematocrit 36, platelets 163,000. Differential 66%
neutrophils, 25% lymphocytes, 4% monocytes, 2% eosinophils,
1% basophils. Sodium 142, potassium 4.4, chloride 105,
bicarbonate 23, BUN 41, creatinine 1.4, glucose 227, anion
gap 18, calcium 9.3, phosphorus 3.4, magnesium 2, protein
7.1, albumin 4.2, troponin less than 0.3. CK number one 106,
CK number two 91, CK number three 80. Total cholesterol 163,
HDL 43, MV number one 3, PT 13.4, PTT 31.6, INR 1.2, LDL 70.
TSH 12.
Electrocardiogram: Complete heart block with atrial rate of
60 and low junctional escape rhythm with narrow QRS complex
at 40 beats per minute, no ST-T wave changes consistent with
ischemia. Stress thallium [**2100-11-26**]: Anginal type
symptoms in the absence of electrocardiogram changes, no
fixed or reversible defects.
Chest x-ray [**8-6**]: Left ventricular enlargement,
equivocal upper zone redistribution and pulmonary vasculature
consistent with mild congestive heart failure. No
consolidation or pleural effusion present.
IMPRESSION: This is an 85-year-old woman with a history of
coronary artery disease, status post coronary artery bypass
graft times two, hypertension, diabetes and
hypercholesterolemia who presented with unstable angina and
complete heart block.
HOSPITAL COURSE:
1. Cardiovascular system:
A. Coronaries: Patient was continued on aspirin and
Lipitor. She was placed on a nitroglycerin drip to titrate
for chest pain. A myocardial infarction was ruled out with
negative CKs and troponin. At first it was thought to do a
cardiac catheterization given her unstable angina and
complete heart block not knowing the relationship between
them, but then it was thought to be an intrinsic arrhythmia
rather than being caused by ischemia. On the second day of
admission, the patient's electrocardiogram showed sinus
bradycardia with prolonged PR interval. She was weaned off
the nitroglycerin drip and did not require any more drip or
sublingual nitroglycerin. On [**8-7**], the patient had a
DDD pacemaker placed and electrocardiogram with and without
magnet following the procedure was within normal limits.
B. Myocardium: The patient was in mild congestive heart
failure on admission. She was continued on her Diovan.
Reportedly, her left ventricular ejection fraction was 70%.
Her diuresis was initially held secondary to her low blood
pressures on admission. An echocardiogram to evaluate her
ejection fraction function was considered, however, it was
decided to defer this to outpatient management. She is
continued on her Imdur, Aldactone, and on hospital day number
two, she was restarted on her home dose of Lasix for preload
reduction.
C. Conduction: Patient was in complete heart block on
admission, thought to be either secondary to underlying
ischemia versus intrinsic conductive disease. It was thought
more likely for her to have intrinsic conductive disease.
She was maintained on telemetry. Beta blocker and calcium
channel blocker were avoided until after her pacemaker was
placed. Her electrolytes were repleted as needed. Patient
did not become unstable prior to having the pacemaker placed,
so she did not need temporary wire to be placed. Atropine 1
mg intravenous was placed at the bedside but did not need to
be used. On second day of admission, the patient was back in
sinus rhythm with PR prolongation. On [**8-7**], the
patient had a DDD pacemaker placed without complication. She
tolerated this well. She was placed on vancomycin
intravenously for 48 hours as prophylaxis and her beta
blocker and calcium channel blocker were restarted. A chest
x-ray following her pacemaker placement confirmed adequate
placement as well as no pneumothorax. On discharge, the
patient was instructed to keep her incision dry for one week
and not to raise her left arm higher than horizontal for four
to six weeks. She was also advised to use Tylenol for pain
around the incision site.
2. Pulmonary: The patient had bibasilar crackles on
admission as well as some trace peripheral edema and mild
congestive heart failure by admission chest x-ray. Her
oxygen saturations and urine output were followed closely and
were stable. She was on two liters nasal cannula originally
but then went to room air. Goal balance for her was
maintained at even to negative. She was placed on her home
dose of Lasix on hospital day number two. Chest x-ray on
[**8-8**] to assess her pacemaker showed pacemaker leads
adequately placed. No pneumothorax. It was decided to defer
echocardiogram to the outpatient setting. On discharge, her
02 saturations were stable on room air.
3. Renal: Patient was in mild renal insufficiency on
admission. This seemed to be baseline for her based on past
hospitalizations, BUN and creatinines. On [**8-8**], her
BUN and creatinine improved slightly to 31 and 1.2.
4. Endocrine: The patient has a history of noninsulin
dependent diabetes mellitus. Her glyburide was held and she
was placed on a sliding scale regular insulin. Her blood
glucose remained fairly stable throughout her hospital stay.
Patient's TSH was checked and she was continued on her home
dose of Synthroid. Her TSH was found to be elevated at 12,
however, on further questioning the patient did report that
recently her Synthroid was increased. However, this seemed
to cause an increase in her anginal symptoms so the dose was
decreased again. It was decided to leave her dose as it was
at home and to advise the patient to see her [**Month (only) **]
in the near future for monitoring her thyroid function.
5. Fluid, electrolytes and nutrition: The patient's goal
fluid balance was maintained at even to slightly negative.
Patient tolerated a cardiac, [**Doctor First Name **] diet while she was in the
hospital.
6. Prophylaxis: Subcutaneous heparin, Protonix.
7. Lines: Left radial A line and left peripheral
intravenous. Patient's A line was removed on [**8-7**]
and her peripheral IV was kept in.
8. Code status: Full.
CONDITION OF DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS:
1. Trental 40 mg t.i.d.
2. Diovan 160 mg q.d.
3. Vascor 300 mg q.d.
4. Imdur 120 mg b.i.d.
5. Aldactone 25 mg q.d.
6. Lipitor 20 mg q.d.
7. Sectral 200 mg q.d.
8. Lasix 20 mg q.d.
9. Glyburide 2.5 mg q.d.
10. Synthroid 25/50 mcg q.o.d.
11. Vitamin D.
12. Vitamin A.
13. Calcium.
14. Sublingual nitroglycerin prn.
15. Aspirin 81 or 325 mg q.d.
DISCHARGE INSTRUCTIONS:
1. Patient to follow-up with her primary care physician,
[**Name10 (NameIs) **] and Cardiologist within one to two weeks.
Patient has an appointment to follow-up in Pacemaker Lab in
one week after admission.
2. Patient is to be considered for an echocardiogram to
evaluate ejection fraction function as an outpatient.
3. Patient to see her [**Name10 (NameIs) **] about her Synthroid
dose.
4. Patient to keep her incision dry for one week.
5. Left arm not to go higher than horizontal for four to six
weeks.
6. Patient has an appointment scheduled with the Pacemaker
Lab on [**8-17**] at 11:30 a.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2103-8-14**] 20:11
T: [**2103-8-14**] 20:11
JOB#: [**Job Number **]
|
[
"272.0",
"401.9",
"244.9",
"411.1",
"250.00",
"428.0",
"V45.81",
"414.01",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
3662, 3892
|
11087, 11440
|
6288, 11064
|
11464, 12346
|
4048, 6270
|
114, 2269
|
2291, 3645
|
3909, 4025
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,013
| 149,584
|
30332
|
Discharge summary
|
report
|
Admission Date: [**2201-6-17**] Discharge Date: [**2201-6-27**]
Date of Birth: [**2131-1-9**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Elective Admission for Spinal Surgery
Major Surgical or Invasive Procedure:
elective spinal fusion of T11-S1 with L3 osteotomy
History of Present Illness:
70 y/o female with a h/o HTN, Raynaud's, and scoliosis s/p
multiple surgeries, who is transferred to medicine following
elective spinal fusion of T11-S1 with L3 osteotomy, complicated
by pulmonary embolism with hypotension and flash pulmonary
edema.
.
Postoperatively, the patient initially developed hypotension
requiring transient pressor support and peri-operative blood
loss requiring a total of 6 units of PRBCs. Pressures stabilized
and the patient was transferred to the ortho/spine floor.
However, on [**6-22**], she again triggered for hypotension to 70/40.
She was also noted to have elevated creatinine to 2.6 from a
recent baseline of 1.5, but a prior baseline of 0.9-1.1. She was
also bolused several liters for low UOP with no improvement in
her blood pressure. Medicine consult was obtained at that time.
The patient underwent EKG that showed S1Q3T3 pattern with right
heart strain. She underwent echo that showed a dilated globally
hypokinetic right ventricle, new moderate pulmonary
hypertension, and moderate TR. LENIs were negative. With
persistent hypotension the patient then underwent V/Q scan that
showed pulmonary embolism. The patient was started on a heparin
drip without bolus, as she had just completed spinal surgery.
.
The patient then went into flash pulmonary edema, and was
transferred to the MICU. She was diuresed, and did not require
intubation. The patient diuresed well on 10 mg IV lasix [**Hospital1 **].
.
She currently complains of some wheezing and lower extremity
edema. She is otherwise without pain and states that she
shooting pain down her legs, with which she first presented, has
resolved.
Past Medical History:
- HTN
- scoliosis, chronic low back pain s/p mult fusions c/b LE
weakness
- shoulder arthritis
- gout
- Raynaud's
- anemia - sees heme/onc once a year for possible MGUS
Past Surgical History:
- 2 stage thoracolumbar fusion (T10-L5) [**2196**]
- Aborted Anterior fusion L3-S1 Stage I, IVC injury [**6-/2200**]
- posterior L5 laminectomy, L5-S1 fusion [**10/2200**]
Social History:
Retired teacher, lives with her husband and has two sons. Denies
any tobacco, alcohol or recreational substance use.
Family History:
htn and arthritis, son with type II DM
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVD difficult to assess
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diminished at the bases with some trace bibasilar
crackles, no other adventitious sounds appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, pboots present
Neuro: nonfocal
.
DISCHARGE EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: JVD to 1 cm below jaw
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pitting edema bilaterally
Pertinent Results:
ADMISSION
[**2201-6-24**] 05:30PM BLOOD WBC-6.2 RBC-3.13* Hgb-9.6* Hct-30.2*
MCV-97 MCH-30.8 MCHC-31.9 RDW-14.6 Plt Ct-294
[**2201-6-24**] 05:30PM BLOOD Glucose-96 UreaN-37* Creat-1.8* Na-131*
K-4.9 Cl-100 HCO3-23 AnGap-13
[**2201-6-24**] 05:30PM BLOOD Calcium-8.8 Phos-4.4 Mg-1.9
.
PERTINENT
[**2201-6-22**] 06:44PM BLOOD CK-MB-3 cTropnT-0.05*
[**2201-6-23**] 02:02AM BLOOD CK-MB-3 cTropnT-0.07*
[**2201-6-23**] 03:04PM BLOOD CK-MB-3 cTropnT-0.05*
[**2201-6-22**] 06:44PM BLOOD Cortsol-23.7*
[**2201-6-24**] 05:30PM BLOOD Osmolal-282
[**2201-6-22**] 10:50AM BLOOD Glucose-144* UreaN-34* Creat-2.7* Na-128*
K-5.3* Cl-97 HCO3-24 AnGap-12
[**2201-6-17**] 02:39PM BLOOD Glucose-166* UreaN-44* Creat-1.5* Na-135
K-4.6 Cl-105 HCO3-21* AnGap-14
[**2201-6-22**] 06:44PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2201-6-22**] 06:44PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2201-6-22**] 06:44PM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-0
NonsqEp-
[**2201-6-22**] 06:44PM URINE CastGr-1* CastHy-16*
[**2201-6-24**] 05:00PM URINE Osmolal-277
[**2201-6-22**] 06:44PM URINE Osmolal-382
.
DISCHARGE
[**2201-6-26**] 05:08PM BLOOD WBC-5.1 RBC-3.21* Hgb-10.1* Hct-30.5*
MCV-95 MCH-31.5 MCHC-33.2 RDW-14.7 Plt Ct-362
[**2201-6-27**] 01:03AM BLOOD PT-23.9* PTT-92.8* INR(PT)-2.3*
[**2201-6-26**] 05:08PM BLOOD Glucose-97 UreaN-27* Creat-1.1 Na-135
K-4.3 Cl-99 HCO3-28 AnGap-12
.
Urine Studies:
[**2201-6-21**] 12:47AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2201-6-21**] 12:47AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
[**2201-6-21**] 12:47AM URINE RBC-1 WBC-18* Bacteri-FEW Yeast-NONE
Epi-4 TransE-<1
.
MICRO:
[**2201-6-26**] BLOOD CULTURE -PENDING
[**2201-6-26**] URINE CULTURE-PENDING
[**2201-6-25**] BLOOD CULTURE -PENDING
[**2201-6-22**] URINE CULTURE-NEGATIVE
[**2201-6-22**] MRSA SCREEN-NEGATIVE
[**2201-6-22**] BLOOD CULTURE -PENDING
[**2201-6-22**] BLOOD CULTURE -PENDING
[**2201-6-21**] URINE CULTURE-NEGATIVE
[**2201-6-17**] MRSA SCREEN-NEGATIVE
.
IMAGING:
CXR ([**6-21**]) - Small left pleural effusion and new left infrahilar
consolidation are most readily explained by atelectasis, but
there is no way to exclude pneumonia. The upper lungs are clear.
The heart is top normal size. No pneumothorax.
.
CXR ([**6-22**]) - Heart size and mediastinum are unchanged in
appearance including cardiomegaly. Bibasal atelectasis and
bilateral pleural effusion is unchanged. No appreciable
pneumothorax is seen.
.
ECHO [**6-22**]
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular cavity
is mildly dilated with moderate global free wall hypokinesis and
apical sparing (+ Mconnells sign for acute pulmonary embolism).
No aortic regurgitation is seen. No mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is a
very small pericardial effusion. There are no echocardiographic
signs of tamponade.
.
ECHO [**6-23**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is unusually small. Overall
left ventricular systolic function is low normal (LVEF 50%). The
right ventricular free wall thickness is normal. The right
ventricular cavity is dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate to
severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is a small pericardial effusion. There
are no echocardiographic signs of tamponade.
.
Compared with the findings of the prior study (images reviewed)
of [**2201-6-22**], the appearance of mitral regurgitation is
increased, but may be so due to technical factors. The left
ventricular ejection fraction is reduced, most likely as a
result of ventricular interaction with a pressure and volume
overloaded right ventricle.
.
V/Q SCAN [**2201-6-23**]:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views
demonstrate subsegmental defects in the right lower lobe and
left lower lobe.
.
Perfusion images in the same 8 views show several subsegmental
defects in the right lower lobe and left lower lobe which
match, along with several subsegmental defects in the right and
left upper lobes which do not match.
.
Chest x-ray shows small left pleural effusion and left
infrahilar consolidation
.
The above findings are consistent with a moderate likelihood of
pulmonary embolism.
.
CXR [**2201-6-26**]:
There are lower lung volumes. Large right and small-to-moderate
left pleural effusions have decreased. They are associated with
adjacent atelectasis. Cardiomegaly is accentuated by the low
lung volumes. There is mild vascular congestion. There is no
evident pneumothorax. Lumbar spine hardware is partially
imaged.
Brief Hospital Course:
70 year old woman with history of HTN, Raynaud's, and scoliosis
s/p multiple surgeries, initially admitted for elective spinal
fusion of T11-S1 with L3 osteotomy, admitted to the MICU with
hypotension, found to have a PE, complicated by right heart
strain and flash pulmonary edema; now improved.
#Spinal fusion of T11-S1 with L3 osteotomy: Patient admitted
for spinal fusion with osteotomy for symptomatic scoliosis with
sicatica. Following surgery, patient's leg pain improved.
Surgical site remained C/D/I and patient without evidence of
hematoma. Neurologic exam remained intact throughout admission.
The patient was evaluated by physical therapy, and was able to
walk the hallway with a brace in place prior to discharge. She
must wear the brace when getting out of bed. The patient was
maintained on oxycontin, oxycodone, gabapentin, and
cyclobenzaprine for pain control. She will follow up with Dr.
[**Last Name (STitle) 363**] as previously arranged on discharge.
#Pulmonary embolism - Patient with large pulmonary embolism,
provoked by spinal surgery. At onset, pulmonary embolism caused
hypotension with right heart strain as seen on EKG and ECHO.
The patient was started on coumadin and a heparin drip to bridge
(day 1 [**2201-6-23**]). She was continued on the heparin drip until
therapeutic on coumadin for 24 hours. The patient should
maintain INR between [**2-6**] at all times. As she recently had
spinal surgery, INR not to exceed 3.0. If patient becomes
subtherapeutic in the future, must be bridged with heparin, per
spine surgeon. Lovenox contraindicated in this patient given
history of spinal surgery. The patient should undergo
transthoracic echo in 6 weeks to follow up cardiac function with
resolution of pulmonary embolism. Please check INR on [**6-29**] and
adjust coumadin dosing as needed.
#Flash pulmonary edema/acute right heart failure - Due to large
volume of fluids and blood administered for hypotension in the
setting of massive PE. LVEF 55% on most recent TTE, however now
with right heart strain. The patient was diuresed with IV lasix
following episode of flash pulmonary edema, and volume status
improved. Patient continues to have lower extremity edema and
JVD to 1 cm below jaw, requiring further diuresis on discharge.
The patient was discharged on lasix 20 mg PO daily. She should
continue on this medication until she becomes euvolemic.
Baseline weight 140lbs. Weight at discharge was 164.6lbs. She
should undergo an electrolyte check on [**2201-6-29**] for stability
following diuresis. At that point, a decision can be made about
whether it is necessary to continue oral lasix. Patient was not
on any diuretic therapy prior to the current admission.
.
#[**Last Name (un) **] - During admission, creatinine peaked at 2.7 in the setting
of right heart failure. [**Last Name (un) **] prerenal due to poor forward flow
based on urine lytes. Likely also a componenet of ATN given
episodes of hypotension. Creatinine returned to baseline with
diuresis from lasix, and possibly post-ATN autodiuresis.
.
#Hyponatremia - Sodium decreased from 135 to 126 in the setting
of volume overload, consistent with hypervolemic hyponatremia.
Resolved with diuresis.
.
#HTN - Home antihypertensives held in the setting of hypotension
from PE. Following stabilization in the MICU, the patient was
started on lasix. [**Last Name (un) **] was resumed at discharge.
.
# Gout - Chronic. The patient was continued on allopurinol.
.
# Code: Full (confirmed with patient)
=========================================
TRANSITIONAL ISSUES:
# Patient to continue lasix until euvolemic. Dry weight 140
lbs.
# Patient should undergo INR and electrolyte monitoring every
other day starting [**2201-6-29**] while on coumadin and lasix. Goal
INR [**2-6**].
# Patient to follow up with PCP and ortho/spine on discharge
from rehab.
# Multiple blood cultures pending at discharge
Medications on Admission:
Home Medications:
Gabapentin 300mg QHS
Flexeril 5mg prn (takes ~weekly)
Metoprolol 25mg daily
Diovan HCTZ Oral 160 mg-12.5 mg daily
Allopurinol 100 daily
folic acid 800mcg daily
zyrtec 10mg daily
Calcium, Vit D, fish oil, glucosamine, flaxseed daily
Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. Gabapentin 300 mg PO HS
3. Cyclobenzaprine 5 mg PO TID:PRN spasms
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Diovan HCT *NF* (valsartan-hydrochlorothiazide) 160-12.5 mg
Oral daily
6. FoLIC Acid 1 mg PO DAILY
7. ZYRtec *NF* 10 mg Oral daily
8. Benzonatate 100 mg PO TID
9. Docusate Sodium 100 mg PO BID
10. Furosemide 20 mg PO DAILY
11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
12. Multivitamins 1 TAB PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
14. Calcium Carbonate 500 mg PO QID:PRN heartburn
15. Oxycodone SR (OxyconTIN) 20 mg PO Q12H pain
16. Warfarin 3 mg PO DAILY16
17. Pantoprazole 40 mg PO Q24H
18. Outpatient Lab Work
Check INR on Monday [**2201-6-29**]. (Pt is on coumadin); Goal INR =
2.0-3.0; do not exceed 3.0 as pt had recent spinal surgery.
Check electrolytes on Monday [**2201-6-29**]. Pt is on lasix.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
elective spinal fusion of T11-S1 with L3 osteotomy
pulmonary embolism
acute right heart failure
acute kidney injury
anemia
hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires brace
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital for an elective spinal fusion
of T11-S1 with L3 osteotomy. During your hospitalization, you
were found to have a blood clot in your lungs that decreased
your blood pressure. You were started on coumadin to help thin
your blood and prevent progression of the blood clot. You were
also started on a medication called lasix to help remove the
extra fluid from your body, caused by the strain on your heart
from the blood clot. Your weight at discharge is 164.6 lbs (up
from 140lb).
You were discharged to rehab. You should have blood work
checked regularly to monitor your INR (how thin your blood is)
and your electrolytes. You should follow up with Dr. [**Last Name (STitle) 363**] as
previously scheduled. You should also call to schedule an
appointment with your primary care physician on discharge from
rehab.
MEDICATIONS CHANGED THIS ADMISSION:
START coumadin 3 mg daily
START tessalon perles 100 mg three times daily as needed for
cough. SWALLOW WHOLE, DO NOT CHEW.
START lasix 20 mg daily
START docusate sodium 100 mg twice a day
START bisacodyl as needed for constipation
START oxycontin 20 mg twice a day as needed for pain
START oxycodone 5mg every 4 hours as needed for breakthrough
pain
Followup Instructions:
Please schedule an appointment with your primary care physician
[**Name Initial (PRE) 176**] 1 week of discharge from rehab:
Name: [**Last Name (LF) 72176**],[**First Name3 (LF) **] C.
Location: SEASIDE INTERNAL MEDICINE
Address: [**Street Address(2) 72177**], [**Location (un) **],[**Numeric Identifier 24720**]
Phone: [**Telephone/Fax (1) 72178**]
Fax: [**Telephone/Fax (1) 72179**]
.
Please call for an appointment with Dr. [**Last Name (STitle) 363**], Ortho/Spine on
Monday [**2201-6-29**]:
Phone: ([**Telephone/Fax (1) 11061**]
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,038
| 136,058
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10296
|
Discharge summary
|
report
|
Admission Date: [**2144-12-21**] Discharge Date: [**2144-12-25**]
Date of Birth: [**2080-3-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2144-12-21**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag, SVG to Ramus, SVG to PDA)
History of Present Illness:
64 y/o male with known history of coronary artery disease s/p
stenting in [**2137**] and VF arrest in [**2141**] presented c/o chest pain.
Admitted in [**11-28**] where he underwent a cardiac cath which
revealed instent restenosis in Ramus, RCA occlusion and LAD
disease. Referred for surgical revascularization.
Past Medical History:
Coronary Artery Disease s/p Percutaneous Coronary Intervention
with stenting [**2137**], VF arrest [**2141**] s/p AICD placement, Diabetes
Mellitus, Hypertension, Hypercholesterolemia
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. No IVDU or illegal
drug use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: 70 14 118/52 72" 190#
Gen: Well-developed, well-nourished male in no acute distess
Skin: Warm and dry
HEENT: Unremarkable
Neck: Supple, Full range of motion
Chest: Clear to auscultation
Heart: Regular, rate and rhythm, -murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, -edema
Neuro: Alert and oriented x 3, grossly intact
At Discharge:
VS:T:98.7/98.5, BP:101/50,p:62,RR 20, 98% R/A O2SAT,
FSBS:192-203
Gen: A&O x3,NAD
HEENT:WNL
CVS:RRR
Lungs:CTA
Abd: benign
Ext:(R)open harvest site C/D/I, (L)EVH site C/D/I
Neuro: grossly intact
Pertinent Results:
[**2144-12-21**] Echo: Pre-CPB: Wires from an [**Month/Day/Year 3941**] are seen. No
spontaneous echo contrast is seen in the left atrial appendage.
Left ventricular wall thicknesses and cavity size are normal.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion. Post-CPB: The patient is
A-Paced, on low dose Phenylephrine. Normal biventricular
systolic fxn. No AI. Trace MR [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact
[**Known lastname 34233**],[**Known firstname **] R [**Medical Record Number 34234**] M 64 [**2080-3-22**]
Radiology Report CHEST (PA & LAT) Study Date of [**2144-12-25**] 9:53 AM
[**Hospital 93**] MEDICAL CONDITION:
64 year old man s/p CABG
REASON FOR THIS EXAMINATION: eval for pleural effusions
Final Report
REASON FOR EXAMINATION: Followup of pleural effusion in a
patient after CABG.
PA and lateral upright chest radiograph was compared to [**12-23**], [**2144**].
Heart size is stable. The post-sternotomy wires appears intact.
The
pacemaker defibrillator lead tip is in the right ventricle.
The lungs are clear. There is small pleural effusion, bilateral,
appears to be unchanged compared to the most recent study. No
evidence of failure is present. Minimal atelectasis seen in the
lingula. Small left apical
pneumothorax is seen unchanged.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) **]
[**2144-12-24**] 05:33AM BLOOD WBC-4.9 RBC-2.67* Hgb-8.7* Hct-24.6*
MCV-92 MCH-32.6* MCHC-35.4* RDW-13.2 Plt Ct-149*
[**2144-12-21**] 12:13PM BLOOD WBC-5.8 RBC-2.83*# Hgb-9.2*# Hct-25.5*#
MCV-90 MCH-32.4* MCHC-36.0* RDW-13.2 Plt Ct-167
[**2144-12-21**] 01:42PM BLOOD PT-13.9* PTT-35.8* INR(PT)-1.2*
[**2144-12-21**] 12:13PM BLOOD PT-15.6* PTT-27.9 INR(PT)-1.4*
[**2144-12-24**] 05:33AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-137
Cl-102 HCO3-33*
[**2144-12-25**] 05:23AM BLOOD WBC-5.3 RBC-2.69* Hgb-8.6* Hct-24.5*
MCV-91 MCH-31.9 MCHC-35.0 RDW-13.2 Plt Ct-190
[**2144-12-25**] 05:23AM BLOOD Plt Ct-190
[**2144-12-21**] 01:42PM BLOOD PT-13.9* PTT-35.8* INR(PT)-1.2*
[**2144-12-25**] 05:23AM BLOOD Glucose-127* UreaN-10 Creat-0.8 Na-136
K-4.6 Cl-99 HCO3-33* AnGap-9
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit and on [**12-21**] he was brought to
the operating room where he underwent a coronary artery bypass
graft x 4. Please see operative report for surgical details. In
summary he had CABG x4 with LIMA-LAD, SVG-Diag, SVG-Ramus,
SVG-PDA. He tolerated the operation well and following surgery
he was transferred to the CVICU for invasive monitoring in
stable condition. He did well in the immediate post-op period
and was was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one he was started on
beta-blockers and diuretics. He remained hemodynamically stable
and was transferred to the telemetry floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. He continued to progress and on POD 4 he was
discharged to home with visiting nurses. All follow up
appointments were advised.
Medications on Admission:
Simvastatin 20mg qd, Amlodipine 5mg qd, Ramipril 10mg qd, Toprol
XL 50mg qd, Niacin 250mg qd, Byetta 5mg [**Hospital1 **], Prandin 2mg [**Hospital1 **],
Levemir 15 units qhs, Aspirin 81mg qd, Flovent, Testim 1% patch
qd, Imdur, Omeprazole 20mg qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-26**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
13. Byetta 5 mcg/0.02 mL Pen Injector Sig: resume preop schedule
Subcutaneous twice a day.
14. Levemir 100 unit/mL Solution Sig: resume pre-oop schedule
Subcutaneous at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: s/p Percutaneous Coronary Intervention with stenting [**2137**],
VF arrest [**2141**] s/p AICD placement, Diabetes Mellitus,
Hypertension, Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 2912**] in [**2-23**] weeks
Completed by:[**2144-12-25**]
|
[
"996.72",
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icd9cm
|
[
[
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icd9pcs
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334, 438
|
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|
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|
7921, 8085
|
1158, 1240
|
5503, 7054
|
2818, 2843
|
7156, 7383
|
5232, 5480
|
7434, 7898
|
1255, 1618
|
1632, 1827
|
284, 296
|
2874, 4294
|
466, 780
|
802, 987
|
1003, 1142
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,802
| 126,242
|
26168
|
Discharge summary
|
report
|
Admission Date: [**2120-12-4**] Discharge Date: [**2120-12-7**]
Date of Birth: [**2057-1-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
trauma transfer
Major Surgical or Invasive Procedure:
right forehead lacerations repaired x 2 [**2120-12-4**]
right shin laceration repaired [**2120-12-4**]
intubation in ED [**2120-12-4**]
left radial a-line [**2120-12-4**]
NGT [**2120-12-4**]
central line left subclavian site [**2120-12-6**]
History of Present Illness:
63yM s/p fall, trauma transfer from OSH with known SDH and IP
bleed. Found at bottom of stairwell. GCS of 11 at OSH. No
apparent LOC, but confused and unable to ambulate when found by
wife. Intubated at OSH for CT scan showing R frontal SDH and L
frontal SDH and IP bleed at falx. Ct head also showed Right
maxillary sinus, zygomatic arch fractures, right lateral orbital
wall fracture with extension into the infraorbital fissure,
possible fracture of the roof of the right orbit.
Past Medical History:
Vascilitis NOS
hx ischemic CVA
DM
HTN
diverticulitis [**2102**]
glaucoma
basal cell carcinoma
asymptomatic sinus arrythmia
hypercholesterolemia
hyperhomocystinemia on folate therapy
CRI (baseline 1.2 to 1.5)
factor V leiden mutation, heterozygous state
autoimmune sensory neural hearing loss causing right-sided
deafness.
alopecia universalis
mesenteric ischemia from small vessel vasculitis s/p small
bowel resection
Social History:
Pt was manager at Lucent Technology
15 pack year tobacco hx, quit 30 years ago.
no ETOH
lives in [**Location 7658**], MA and is married.
Pt has children.
Family History:
Mother died of CVA at 67yrs old
Father died of prostate cancer at older age, MI at earlier age
of 67
no clotting or bleeding hx in family
Physical Exam:
T HR 104 irregular 162/79 100%
intubated
breath sounds equal Bilaterally
HEENT: OU pupil 3 to 2 mm, + corneal reflexes, large R
temporal/forehead laceration about 3 to 4 cm each. full
thickness
CV: irregular rate, tachcardic
+BS, NT, ND
good rectal tone and guaic negative
spontaneous movement on right, decreased on left
skin degloving injury to right anterior shin about 3 x 5 cm.
Pertinent Results:
[**2120-12-4**] 11:06PM HCT-30.6*
[**2120-12-4**] 10:03PM TYPE-ART PO2-99 PCO2-33* PH-7.43 TOTAL CO2-23
BASE XS-0
[**2120-12-4**] 10:03PM GLUCOSE-155* LACTATE-2.2* K+-4.7
[**2120-12-4**] 10:03PM freeCa-1.06*
[**2120-12-4**] 05:05PM HCT-29.1*
[**2120-12-4**] 01:27PM TYPE-ART PO2-298* PCO2-35 PH-7.43 TOTAL
CO2-24 BASE XS-0
[**2120-12-4**] 01:27PM LACTATE-2.4*
[**2120-12-4**] 01:20PM HCT-27.4*
[**2120-12-4**] 08:00AM GLUCOSE-179* UREA N-15 CREAT-1.3* SODIUM-138
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-18* ANION GAP-15
[**2120-12-4**] 08:00AM ALT(SGPT)-23 AST(SGOT)-23 AMYLASE-74 TOT
BILI-0.1
[**2120-12-4**] 08:00AM LIPASE-33
[**2120-12-4**] 08:00AM CALCIUM-7.5* PHOSPHATE-2.5*
[**2120-12-4**] 08:00AM WBC-17.1* RBC-2.94* HGB-8.2* HCT-23.2*
MCV-79* MCH-28.0 MCHC-35.6* RDW-16.3*
[**2120-12-4**] 08:00AM NEUTS-81.8* LYMPHS-8.2* MONOS-7.9 EOS-1.8
BASOS-0.3
[**2120-12-4**] 08:00AM PLT COUNT-322
[**2120-12-4**] 08:00AM PT-12.7 PTT-21.3* INR(PT)-1.1
[**2120-12-4**] 07:45AM PT-13.2 PTT-19.4* INR(PT)-1.2
[**2120-12-4**] 07:03AM LACTATE-3.3*
[**2120-12-4**] 07:45AM FIBRINOGE-42*
[**2120-12-4**] 07:03AM LACTATE-3.3*
[**2120-12-4**] 07:03AM HGB-9.0* calcHCT-27
[**2120-12-4**] 06:50AM UREA N-17 CREAT-1.3*
[**2120-12-4**] 06:50AM AMYLASE-84
[**2120-12-4**] 06:50AM ASA-NEG ETHANOL-25* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2120-12-4**] 06:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2120-12-4**] 06:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2120-12-4**] 06:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2120-12-4**] 06:49AM GLUCOSE-205* LACTATE-3.5* NA+-140 K+-6.4*
CL--107 TCO2-17*
[**2120-12-4**] 06:49AM HGB-8.8* calcHCT-26
TIB/FIB (AP & LAT) RIGHT [**2120-12-4**] 11:23 AM
No specific localizing history is available. Allowing for this,
no fracture is detected involving the tibia or fibula. Vascular
calcification is present. Assessment of the right knee and ankle
are quite limited on these views. If there is clinical concern
for injury to either joint, then dedicated views of that joint
would be recommended for full assessment.
T - L spine: [**2120-12-4**]
IMPRESSION:
1) Limited exam without evidence of fracture or listhesis in the
thoracic or lumbar spine. See comment.
2) Slight prominence of the superior mediastinum. Is there any
clinical concern for mediastinal injury? If so, additional
work-up is recommended. In any event, a dedicated upright PA
view should be considered when the patient is stable.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2120-12-4**] 9:00 AM
CT HEAD W/O CONTRAST
Reason: reevalaute known head injury
[**Hospital 93**] MEDICAL CONDITION:
s/p fall from stairs
REASON FOR THIS EXAMINATION:
reevalaute known head injury
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Reevaluate known head injury.
TECHNIQUE: Non-contrast head CT scan.
FINDINGS: No preceding head imaging studies from this hospital
are available. Therefore, it is impossible to assess for any
interval changes of the following abnormalities:
There is a moderate-sized left parafalcine acute subdural
hemorrhage causing minor impression upon the left parasagittal
cortex. There is a smaller acute left frontal temporal subdural
hemorrhage, again causing slight impression upon the adjacent
cortex. There is also presumed small quantity of acute subdural
hemorrhage seen extending along the leaves of the tentorium on
both sides. There is no definite sign for intraaxial hemorrhage.
There is a question of a tiny amount of hemorrhage sedimenting
within the left occipital [**Doctor Last Name 534**], as seen only on image 18.
There is no hydrocephalus, shift of normally midline structures,
or visible minor or major vascular territorial infarction. There
are small air-fluid levels seen within both maxillary sinuses
with extensive opacification of both ethmoid sinuses by soft
tissue material. There is moderately extensive opacification of
the sphenoid sinus. There is minimal mucosal thickening within
the left frontal air cell. The sinus abnormalities are likely
inflammatory in origin. No other overt osseous pathology is
seen.
CONCLUSION: Multicompartmental acute subdural hemorrhages.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: WED [**2120-12-4**] 7:31 PM
RADIOLOGY Final Report
CT 150CC NONIONIC CONTRAST [**2120-12-4**] 6:52 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: evalaute for solid organ injury
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
s/p fall from stairs, severe head trauma
REASON FOR THIS EXAMINATION:
evalaute for solid organ injury
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post fall downstairs with severe head trauma,
evaluate for solid organ injury.
COMPARISONS: None.
TECHNIQUE: Axial MDCT images through the abdomen and pelvis with
IV contrast per trauma protocol. Coronal and sagittal
reformatted images were performed.
CT ABDOMEN WITH IV CONTRAST: There are small bilateral pleural
effusions. No evidence of pneumothorax or contusion at the lung
base. There is trace amount of atelectasis at the left lung
base. The visualized portion of the heart and pericardium are
normal. Liver, gallbladder, pancreas, stomach, and proximal
small bowel is normal. The NG tube tip is in the body of the
stomach. The spleen demonstrates multiple ill-defined hypodense
areas, likely consistent with laceration/contusions. There is no
subcapsular hematoma. The splenic vessels at the hilum are
intact. No evidence of arterial extravasation. Multiple
exophytic, likely simple cysts within the kidneys, greater on
the right. There is no free air or free fluid in the abdomen.
The intra- abdominal small bowel appears normal.
CT PELVIS WITH IV CONTRAST: The intrapelvic large and small
bowels are unremarkable. There is no evidence of mesenteric
hemorrhage. Foley catheter in a nondistended bladder. No free
fluid in the pelvis. No abnormal lymphadenopathy. No evidence of
arterial extravasation in the deep pelvis.
BONE WINDOWS: No evidence of spinal or rib fracture. Specific
attention to the ribs adjacent to the spleen demonstrate no
evidence of fracture. Mild degenerative changes and bilateral
spondylolysis at the L5 level. Isolated bone islands in the
iliac bones.
Coronal and sagittal reformatted images confirm the above
findings. Sagittal images confirm the spine is intact.
IMPRESSION:
1) Moderately sized splenic contusions/lacerations; no
subcapsular hematoma and no evidence of vascular injury/arterial
extravasation.
2) No evidence of other solid organ injury, fracture, or other
traumatic injury throughout the abdomen and pelvis.
3) Small bilateral pleural effusions.
4) Bilateral, exophytic, likely simple renal cysts.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 64894**]
Approved: WED [**2120-12-4**] 10:13 AM
RADIOLOGY Final Report
TRAUMA #2 (AP CXR & PELVIS PORT) [**2120-12-4**] 6:41 AM
TRAUMA #2 (AP CXR & PELVIS POR
Reason: r/o injury
[**Hospital 93**] MEDICAL CONDITION:
s/p fall from stairs
REASON FOR THIS EXAMINATION:
r/o injury
INDICATION: Known severe head injury, patient fell downstairs.
TRAUMA TWO SERIES: No prior studies for comparison. Portable AP
chest with underlying trauma board straightens endotracheal tube
in good position, with its tip 5 cm above the carina. The heart
size is normal. There is no pneumothorax. Subtle opacity in the
left lower lobe likely represents atelectasis rather than
contusion. Mediastinum is within normal limits for AP technique.
No evidence of rib or clavicular fractures. Single AP view of
the pelvis demonstrates no evidence of fracture or dislocation.
The sacrum is suboptimally visualized. The SI joints are
congruent.
IMPRESSION:
1) No evidence of traumatic injury within the chest and pelvis;
underlying trauma board limits sensitivity.
2) Endotracheal tube in good position.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: [**First Name8 (NamePattern2) **] [**2120-12-5**] 7:39 AM
RADIOLOGY Final Report
CT RECONSTRUCTION [**2120-12-5**] 9:46 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: IV contrast only - rule out evolution of splenic
laceration/
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
s/p fall from stairs, severe head trauma, intubated for airway
protection
REASON FOR THIS EXAMINATION:
IV contrast only - rule out evolution of splenic
laceration/infarction, r/i intrabdominal bleeding
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Fell from stairs with severe head trauma one day
ago, prior CT demonstrating splenic laceration/contusions.
Evaluate for interval change.
COMPARISONS: CT abdomen and pelvis of [**2120-12-4**].
TECHNIQUE: Axial MDCT images of the abdomen and pelvis with IV
contrast per trauma protocol. Coronal and sagittal reformatted
images were performed.
CT ABDOMEN WITH IV CONTRAST: Again demonstrated are small
bilateral pleural effusion/atelectasis, unchanged from the prior
study. The liver is unremarkable without traumatic injury. The
gallbladder contains excreted contrast but is otherwise normal.
Again demonstrated in the spleen are multiple organizing
contusions, slightly more prominent than on the prior day's CT.
There is no evidence of subcapsular hematoma or arterial
extravasation to suggest arterial injury. NG tube tip in the
stomach. The pancreas and adrenal glands are unremarkable. The
stomach and proximal small bowel are grossly normal. There is no
free air in the abdomen.
CT PELVIS WITH IV CONTRAST: Again multiple likely simple
exophytic cysts are demonstrated in the kidney. Following the
lateral cortex of the mid portion of the left kidney, there are
two segmental areas of hypoattenuation, which likely represent
segmental infarcts. This was not present on the prior abdominal
CT. Kidneys otherwise enhance normally and excrete contrast in a
normal fashion. There is no evidence to suggest small bowel
injury or mesenteric hematoma. Foley catheter in an otherwise
nondistended bladder. No free fluid in the deep pelvis.
BONE WINDOWS: No suspicious lytic or blastic lesions are seen.
Again, bone windows demonstrate no evidence of fracture.
IMPRESSION:
1) Organizing splenic contusions. No subcapsular hematoma or
arterial extravasation.
2) Interval development of two segmental areas of underperfusion
in the left kidney, compatible with segmental infarction, not
present on the prior CT. Multiple areas of cortical scarring
bilaterally suggestive of chronic infarction.
3) Small bilateral pleural effusion/atelectasis, unchanged from
prior study.
4) Multiple bilateral, exophytic, likely simple renal cysts.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: [**First Name9 (NamePattern2) **] [**2120-12-6**] 11:04 AM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2120-12-5**] 9:06 AM
Reason: r/o interval change of known subdural
[**Hospital 93**] MEDICAL CONDITION:
63 year old man s/p fall with SDH
REASON FOR THIS EXAMINATION:
r/o interval change of known subdural
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Evaluate for interval change of known subdural
hematoma.
TECHNIQUE: Non-contrast head CT scan.
COMPARISON: [**2120-12-4**].
FINDINGS: Again seen is a moderate-sized left parafalcine
subdural hematoma with minimal impression upon the left
parasagittal cortex, not significantly changed from the study of
one day prior. The small left frontotemporal subdural hematoma
is unchanged in size as well. Hemorrhage seen along the
tentorium on both sides is unchanged as well.
There is a large area of low density in the right temporal and
parietal lobes with foci of increased density, with these
findings suggesting an evolving hemorrhagic contusion. There is
a smaller similar area in the left frontal lobe, again likely a
hemorrhagic contusion.
Alternatively, but much less likely, the large area of low
density in the right temporal and parietal lobe also raises the
possibility of evolving venous infarction.
A small amount of hemorrhage is seen layering in the left
occipital [**Doctor Last Name 534**], seen on series 2, image 14.
There is a small focus of low attenuation seen left of the
fourth ventricle on series 2, image 8, not well appreciated on
the prior study, but seen on the patient's scanned in study from
an outside hospital of [**2120-12-4**].
There is no hydrocephalus or shift of normally midline
structures. There is fluid in the maxillary and ethmoid sinuses,
likely related to the patient's intubated state.
Findings were discussed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] on [**2120-12-5**].
IMPRESSION:
1. Bilateral hemorrhagic contusions, right greater than left in
the temporal lobes. These have become more visible since the
prior study.
2. Stable appearance of left parafalcine and left frontotemporal
subdural hemorrhages.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: [**First Name8 (NamePattern2) **] [**2120-12-5**] 8:15 PM
[**12-6**]: CT head: Right maxillary sinus and zygomatic arch fractures
as well as right lateral orbital wall fracture with extension
into the infraorbital fissure as described above. Possible
fracture of the roof of the right orbit as well.
[**12-6**] TEE: [**12-2**]+ MR, EF 55%.
Brief Hospital Course:
Pt transfered from OSH intubated. Pt seen in ED and admitted to
trauma service and takent to the Trauma intensive care unit.
by systems
NEURO: neurosurgery was consulted and assessed patient with b/l
SDH and possible evolving contusion. Pt on dilantin for seizure
prophylaxis. Head CT shows worsening CVA. MRI/MRA of head/neck
pending. MRI of C-spine pending. Neurology consulted. on
profofol and morphine sulfate.
[**12-6**] CThead: Stable appearance of subdural hemorrhages and
bilateral hemorrhagic contusions. Right maxillary sinus and
zygomatic arch fractures as well as right lateral orbital wall
fracture with extension into the infraorbital fissure as
described above. Possible fracture of the roof of the right
orbit as well.
CV: no pressors. on metoprolol for rate control.
Echo [**12-6**]: Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
3. The aortic valve leaflets are mildly thickened.
4. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-2**]+)
mitral regurgitation is seen.
5. No cardiac source of embolus seen.
RESP: on ventilator. CPAP & PS: .40/540x17/peep 5/psv 5
GI: dobhoff. Abdominal CT obtained for dropping HCT in setting
of possible splenic injury.
FEN: tube feeds. 1. NPO as Diet except Meds; 2. Tubefeeding:
Promote w/ fiber Full strength; Starting rate: 10 ml/hr; Advance
rate by 10 ml q4h Goal rate: 70 ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml Flush
w/ 30 ml water q6h.
RENAL: possible new left renal infarct, foley, good UOP.
HEME: dropping HCT. max 30.6 and low 24.5. Pt transfused 1
unit.
ENDO: DM, SSI, on methylprednisolone
ID: no antibiotics
TLD: LSC TLC, dobhoff, foley, L radial aline
wound: 2 R forehead lacs with 4-0 prolene on [**2119-12-5**], R shin with
3-0 nylons on [**2119-12-5**].
imaging as per pertinent results: MRI head, neck, carotid US
pending
consulted: rheumatology, neurosurgery, neurology
prophylaxis: hep SQ, protonix
dispo: TICU, possible transfer to [**Hospital3 **].
Code status: DNR.
Medications on Admission:
Meds on admit (per d/c summary at [**Hospital1 1774**] [**2120-3-28**]):
1. lisinopril 20 mg daily
2. protonix 40 mg daily
3. Bactrim prophylaxis
4. Folate
5. ASA 81 mg
6. Glyburide (felt to be hyperglycemic induced by steroids)
7. Cytoxan 125 mg daily (didn't tolerate and was subsequently
changed to monthly infusions)
8. Prednisone 60 mg daily, had tapered to 10 mg by [**2120-9-30**] and
was still tapering by 1 mg per month
Discharge Medications:
Latanoprost 0.005% Ophth. Soln. 1 DROP OU HS
Heparin 5000 UNIT SC TID
Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation
Insulin SC (per Insulin Flowsheet)
Sliding Scale
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Phenytoin 100 mg IV Q8H
Metoprolol 5 mg IV Q6H hold for bp < 110, hr < 60
Morphine Sulfate 2 mg IV Q4H:PRN
Methylprednisolone Na Succ 10 mg IV Q24H
Potassium Chloride 20 mEq / 250 ml NS IV PRN K<4
Magnesium Sulfate 2 gm / 100 ml D5W IV PRN Mg<2
Calcium Gluconate 2 gm / 100 ml D5W IV PRN iCa<1.1
Pantoprazole 40 mg IV Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1774**] Medical Center
Discharge Diagnosis:
Right frontal subdural hematoma
Left frontal subdural hematoma
intraparenchymal bleed at falx
splenic laceration vs infarct
right forehead head laceration
right shin laceration
Vascilitis NOS
hx ischemic CVA
ischemic colitis s/p bowel resection
DM
glaucoma
Discharge Condition:
fair
Discharge Instructions:
Code Status: Do not resuscitate (DNR/DNI) Patient already
intubated, DNR Corroborated with Dr. [**Last Name (STitle) 51267**].
Medications as per medication sheet.
NPO
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Reddness/swelling/discharge from wounds
* Anything that concerns you.
vent settings:
CPAP & PS: .40/540x17/peep 5/psv 5
Followup Instructions:
Please see your Neurologist (Dr. [**First Name (STitle) 1169**] or Dr. [**Last Name (STitle) 1057**] at [**Hospital1 3343**] as soon as you arrive there.
You may follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital1 18**] if desired
in 4 weeks. Please call ([**Telephone/Fax (1) 7394**] to schedule an
appointment.
Please follow-up with your Rheumatologist Dr. [**Last Name (STitle) **] [**Name (STitle) **]
when you arrive at [**Hospital3 2358**]. Please call [**Telephone/Fax (1) 64895**] to
schedule a visit.
Please keep all previously scheduled appointments proir to this
hospitalization.
Completed by:[**2120-12-7**]
|
[
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"801.21",
"802.4",
"427.31",
"891.0",
"401.9",
"802.8",
"518.0",
"865.00",
"E888.8",
"593.2",
"365.9",
"721.3",
"250.00",
"511.9",
"873.42",
"593.81",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"88.72",
"38.91",
"86.59",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
19791, 19852
|
16579, 18529
|
329, 572
|
20153, 20160
|
18548, 18737
|
20580, 21237
|
1725, 1864
|
19217, 19768
|
14015, 14049
|
19873, 20132
|
18763, 19194
|
20184, 20557
|
1879, 2273
|
274, 291
|
14078, 16277
|
600, 1084
|
16286, 16556
|
1106, 1538
|
1554, 1709
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,679
| 199,385
|
23797
|
Discharge summary
|
report
|
Admission Date: [**2185-7-15**] Discharge Date: [**2185-8-4**]
Date of Birth: [**2116-9-30**] Sex: F
Service: SURGERY
Allergies:
Demerol
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
Parastomal hernia repair and take down of colostomy with
re-siting to the right side of abdomen.
History of Present Illness:
This patient had undergone a series of bouts of intestinal
obstruction. This last time she was in fact given an upper GI
series and small bowel follow through and when she came to the
hospital, she had some barium and a nest of bowel in the pelvis.
It was not clear exactly what the cause of obstruction was but
she did not pass much gas nor was she able to get rid of her
nasogastric tube. The colostomy was prolapsed and it appeared on
CT scan that she had an area of a kink in the small bowel which
was a transitional point. This in fact was the case but it was
also a place where she was obstructed with barium.
Past Medical History:
rectal CA ([**Month (only) **]-[**2170**])
diabetes
HTN
high cholesterol
parastomal hernia ([**2177**])
Social History:
Patient lives with son, long time smoker, denies alcohol use.
Family History:
noncontributory
Physical Exam:
afebrile, hemodynamically stable
patient in mild distress at presentation
Chest-CTAB
CV-RRR, -MRG
Abd: soft, mildly tender to palpation, no stool or gas at ostomy
site, large parastomal hernia on the left, decreased bowel
sounds
Pertinent Results:
[**2185-7-26**] 08:00PM BLOOD WBC-19.0* RBC-3.37* Hgb-10.9* Hct-31.7*
MCV-94 MCH-32.3* MCHC-34.3 RDW-16.1* Plt Ct-397
[**2185-8-1**] 04:42AM BLOOD WBC-9.3 RBC-2.92* Hgb-9.2* Hct-26.8*
MCV-92 MCH-31.6 MCHC-34.3 RDW-16.0* Plt Ct-368
[**2185-7-20**] 04:33AM BLOOD Glucose-264* UreaN-11 Creat-0.5 Na-135
K-3.8 Cl-104 HCO3-23 AnGap-12
[**2185-8-2**] 04:02AM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-136
K-4.0 Cl-100 HCO3-26 AnGap-14
[**2185-7-31**] 02:06AM BLOOD calTIBC-163* Ferritn-208* TRF-125*
[**2185-7-24**] 03:46AM BLOOD calTIBC-281 Ferritn-179* TRF-216
[**2185-7-17**] 04:04AM BLOOD Folate-11.8
[**2185-7-15**] 09:21PM BLOOD calTIBC-374 Ferritn-50 TRF-288
Brief Hospital Course:
The patient was admitted for the question of small bowel
obstruction. On CT scan she had an area of twisted bowel along
with her large parastomal hernia. Her ostomy output had no
stool or gas in it. She was taken to the OR to resolve these
issues. In the OR she had a large amount of barium in the small
intestine which was moved into the cecum. She had a
hyperkalemia directly following surgery which resolved with an
insulin drip. She was admitted to the ICU for this purpose.
Her blood sugars were difficult to control post-operatively and
she was maintained on the insulin drip for the first 3 days
post-operatively. It was also difficult to ween her from her O2
needs post-op (this was most likely due to her very long smoking
history). Eventually she was restarted on her home metformin
and was able to come off of oxygen therapy. On day 3
post-operatively gas and stool appeared at her ostomy following
a bowel regimen of colace and mineral oil. She was discharged
home to follow-up with Dr. [**Last Name (STitle) 957**] in clinic. She was
tolerating PO intake at discharge and was in good condition.
Medications on Admission:
atenolol 50
pravastatin 40
FeSO4 325
metformin 500
xanax 1mg HS
Discharge Medications:
1. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO twice a
day for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Mineral Oil Oil Sig: 2.5 MLs PO DAILY (Daily).
Disp:*20 ML(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
stable, good
Discharge Instructions:
Please return if:
1. fever > 101
2. not passing stool out of your ostomy site
3. abdominal pain
4. inability to tolerate oral diet
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 957**] in his clinic next Wednesday,
[**8-10**] at 10:00AM.
|
[
"272.0",
"996.1",
"936",
"518.0",
"250.02",
"560.81",
"552.21",
"E947.8",
"276.51",
"V10.06",
"305.1",
"276.7",
"997.3",
"569.69",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.52",
"96.07",
"46.42",
"54.59",
"99.17",
"46.10",
"53.61",
"38.93",
"99.21",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
3790, 3841
|
2225, 3345
|
290, 389
|
3909, 3924
|
1542, 2202
|
4103, 4214
|
1259, 1276
|
3459, 3767
|
3862, 3888
|
3371, 3436
|
3948, 4080
|
1291, 1523
|
227, 252
|
417, 1036
|
1058, 1164
|
1180, 1243
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,393
| 168,198
|
10153
|
Discharge summary
|
report
|
Admission Date: [**2116-12-25**] Discharge Date: [**2117-1-1**]
Date of Birth: [**2032-11-22**] Sex: M
Service: SURGERY
Allergies:
Tetanus
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
esophageal carcinoma
Major Surgical or Invasive Procedure:
laproscopic esophagogastrectomy + J-tube placement
History of Present Illness:
83-year-old man who has had Barrett's esophagus with some
dysplasia.He has had biopsies recently, which have been read
here as intramucosal carcinoma. He has had no symptoms of
esophageal obstruction.He is being admitted to the [**Hospital1 18**] for
esophagectomy anf J tube placement.
Past Medical History:
PMH: GERD, prostate cA
PSH: TURP, umbilical hernia repair, tonsillectomy, excision of
a vocal cord polyp
Social History:
ex smoker,quit smoking 25 yrs ago
Occasional alcohol drinker
Family History:
father:emphysema
mother : kidney failure
Physical Exam:
Vitals:T= 98.1,HR-74,,BP 138/57,RR=18, Sat =95%/1.5 NC
Gen: NAD, AOx3
HEENT: MMM, anicteric, EOM-I
CVS: reg,no m/r/g
Pulm: no resp distress,ctabl
Abd: Soft,mildly distended ,mildly tender,J tube in place
LE: no c/c/e
wound:c/d/i,no erythema or ecchymosis
Pertinent Results:
[**2117-1-1**] 07:45AM BLOOD WBC-12.1* RBC-3.53* Hgb-11.5* Hct-32.5*
MCV-92 MCH-32.5* MCHC-35.4* RDW-13.9 Plt Ct-233
[**2116-12-31**] 07:45AM BLOOD WBC-9.1 RBC-3.47* Hgb-10.9* Hct-31.6*
MCV-91 MCH-31.5 MCHC-34.6 RDW-13.5 Plt Ct-177
[**2116-12-29**] 07:35AM BLOOD WBC-8.9 RBC-3.20* Hgb-10.4* Hct-29.6*
MCV-92 MCH-32.4* MCHC-35.1* RDW-13.4 Plt Ct-143*
[**2116-12-28**] 02:00AM BLOOD WBC-15.3* RBC-3.51* Hgb-11.1* Hct-32.4*
MCV-92 MCH-31.5 MCHC-34.1 RDW-13.6 Plt Ct-146*
[**2116-12-27**] 01:39AM BLOOD WBC-16.6* RBC-3.75* Hgb-12.1* Hct-34.0*
MCV-91 MCH-32.4* MCHC-35.7* RDW-13.8 Plt Ct-137*
[**2116-12-26**] 12:13AM BLOOD WBC-16.2*# RBC-3.84* Hgb-12.3* Hct-34.6*
MCV-90 MCH-32.0 MCHC-35.6* RDW-13.8 Plt Ct-144*
[**2117-1-1**] 07:45AM BLOOD Plt Ct-233
[**2116-12-31**] 07:45AM BLOOD Plt Ct-177
[**2116-12-29**] 07:35AM BLOOD Plt Ct-143*
[**2117-1-1**] 07:45AM BLOOD Glucose-94 UreaN-25* Creat-0.7 Na-140
K-4.6 Cl-104 HCO3-26 AnGap-15
[**2116-12-31**] 07:45AM BLOOD Glucose-111* UreaN-26* Creat-0.8 Na-138
K-4.3 Cl-103 HCO3-28 AnGap-11
[**2116-12-28**] 02:00AM BLOOD Glucose-97 UreaN-25* Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-29 AnGap-9
[**2116-12-25**] 05:39PM BLOOD Glucose-143* UreaN-26* Creat-1.1 Na-139
K-4.2 Cl-106 HCO3-22 AnGap-15
Brief Hospital Course:
The patient was admitted to the [**Hospital1 18**] for esophagectomy and J
tube placement for esophageal carcinoma. The procedure went as
planned. The patient was taken to the ICU as per pathway.His
postop check was normal. His pain was well controlled on
dilaudid PCA. Chest tube was to suction and showed no leak.On
POD 1 chest tube was put to water seal.He remained NPO and tube
feeds were started via the J tube.On POD 2 his abdomen felt
distended and his J tube was clamped and the patient's tube
feeds were restarted in the evening.The patient's NG tube was
d/ced on POD3.On POD4 the patient was put on roxicet for pain
control and PCA was d/ced.Foley was d/ced and the patient voided
without any difficulty.On POD 5, the patient underwent a barium
swallow study which showed no leak at the anastomosis. The
patient's diet was advanced to sips and then to clears on POD 6
which he tolerated well. His chest tube was removed. The chest
xrays showed a stable pneumothorax. On POD 7, the patient's JP
drain and staples were taken out.On the day of discharge the
patient's tube feeds were being cycled to goal, he was
tolerating clears,voiding normally,ambulating with
assistance,and his pain was well controlled. He will follow up
in Dr[**Name (NI) 1482**] clinic in [**1-11**] weeks.
Medications on Admission:
pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day
MVI
Zocor 20 mg,po 1tab once a day
Discharge Medications:
1. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for rash on back.
Disp:*2 tubes* Refills:*2*
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*250 ML(s)* Refills:*0*
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. menthol-cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for throat irritation
.
Discharge Disposition:
Extended Care
Facility:
Renaissance Garden - [**Location (un) 5087**]
Discharge Diagnosis:
esophageal ca
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr[**Name (NI) 1482**] office or call the ER if you have any
of the following symptoms:
Fever greater than 101,Chills,Abdominal pain,Abdominal
swelling,Nausea and vomiting,Vomiting blood,Difficulty
swallowing,Diarrhea,Constipation,Blood in stool,Black
stool,Shortness of breath,Pain with breathing,Coughing up
blood,Wheezing,opening of incission, redness around incission or
bleeding.
You may take all your home meds.You are also being discharged on
pain meds which cause drowsiness. Please donot drive or operate
heavy machinery while you are on them.
Please keep your incission dry at all times. It is ok to shower.
Please donot take a tub bath till your first clinic visit.
Followup Instructions:
Please call Dr [**Last Name (STitle) **] for an appointment in [**1-11**] weeks.PH
([**Telephone/Fax (1) 1483**]
Completed by:[**2117-1-1**]
|
[
"512.1",
"272.4",
"V10.46",
"530.81",
"V15.82",
"414.01",
"E878.2",
"V45.82",
"E849.7",
"150.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.52",
"46.39",
"96.6",
"43.5",
"42.40"
] |
icd9pcs
|
[
[
[]
]
] |
4572, 4644
|
2473, 3762
|
289, 342
|
4702, 4702
|
1219, 2450
|
5566, 5710
|
884, 927
|
3955, 4549
|
4665, 4681
|
3788, 3932
|
4853, 5543
|
942, 1200
|
229, 251
|
370, 660
|
4717, 4829
|
682, 789
|
805, 868
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,975
| 146,690
|
15511+56661
|
Discharge summary
|
report+addendum
|
Admission Date: [**2122-3-8**] Discharge Date: [**2122-3-20**]
Date of Birth: [**2041-6-29**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Motrin / Levaquin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Endotracheal intubation
Placement of right sided CVL
Bronchoscopy ([**2122-3-14**])
History of Present Illness:
80 y.o. woman w/ pmh CAD s/p CABG, DM, presenting from [**Hospital **]
rehab with fever and shortness of breath. Per the patient's
daughter, and staff at [**Hospital **] rehab, the patient has had one
week of fevers and altered mental status. Her altered mental
status coincided with the initiation of baclofen and dilaudid
one week ago. She only received one dose and this has been
discontinued. Per daughter, the patient was quite somnolent on
the dilaudid and did not return to her normal mental status
until this past wednesday. On [**3-8**] her oxygen saturation at
[**Hospital **] rehab was 80% on RA, and increased to 90% on 3L. She was
therefore transferred to [**Hospital1 18**]. On presentation to the
emergency room her vitals were 100.8, 101, 163/73, 18, 99% 3L.
EKG showed 1mm ST depressions in V4-V5. BNP was 4995. CXR
showed multifocal pneumonia. The patient was started on
azithromycin, vancomycin, and piperacillin/tazobactam. She wa
salso given hydromorphone 1mg IV X1. While in the ED she became
progressively more tachypneic, with respiratory rate as high as
30, and she was therefore admitted to the ICU.
.
On review of symptoms, the patient reports chronic left
arm/shoulder muscle spasms which also cause headaches. She also
reports orthopnea, which has been worsening over the past two
weeks. She denies PND. She reports diminished appetite. She
denies abdominal pain, hematochezia or melena, or dysuria. She
reports right hip pain worse with movement. she is able to
ambulate with a walker. She denies dysphagia.
Past Medical History:
-s/p R Hip hemiarthroplasty after fracture in [**2111**].
-Right hip washout and head replacement [**2122-1-17**]
-s/p b/l TKR
-CRI
- DM x 5 to 6 years c/b neuropathy
- CABG x1 and bioprosthetic AVR in [**2119**]
- hypothyroidism
- hypertension,
- diverticulitis
- hyperlipidemia
-endometriosis
- s/p appendectomy,
-s/p TAH-BSO,
- status post right carpal tunnel release, status post
tonsillectomy.
-s/p Nissen
Social History:
Retired, lives alone. Denies Tobacco use. Admits to being a
recovering alcoholic (no alcohol in 35 yrs).
Family History:
Non-contributory
Physical Exam:
On admission
T=99.1 BP=172/74 HR=89 RR=25 O2=100 % FiO2 50%, high flow mask
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. MMM. OP clear. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= 8cm. vertical scar over sternum.
LUNGS: crackles bilaterally [**2-17**] way up
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: trace pitting edema bilaterally.
SKIN: scar over right hip.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
LABORATORY RESULTS:
======================
On presentation
[**2122-3-8**] 07:00PM BLOOD WBC-8.2# RBC-2.99* Hgb-9.5* Hct-26.0*
MCV-87 MCH-31.8 MCHC-36.6* RDW-17.4* Plt Ct-354
[**2122-3-8**] 07:00PM BLOOD Neuts-74.1* Lymphs-14.0* Monos-5.9
Eos-5.8* Baso-0.3
[**2122-3-9**] 05:30AM BLOOD PT-13.9* PTT-26.4 INR(PT)-1.2*
[**2122-3-8**] 07:00PM BLOOD Glucose-134* UreaN-15 Creat-1.2* Na-140
K-3.2* Cl-102 HCO3-25 AnGap-16
[**2122-3-8**] 07:00PM BLOOD ALT-8 AST-17 LD(LDH)-379* CK(CPK)-68
AlkPhos-49 TotBili-0.4
On discharge:
WBC 10.4, HCT 33.3, PLT 346
Glucose 143 BUN 44 Cr 1.5 Na 137 K 4.2 Cl 96 HCO3 28
RADIOLOGY AND OTHER STUDIES:
=============================
CXR [**2122-3-8**]
CONCLUSION: New diffuse, confluent alveolar opacities throughout
both lungs. The appearances are highly concerning for a
multifocal pneumonia, possibly with superimposed edema
CXR [**2122-3-10**]:
IMPRESSION: AP chest compared to [**3-8**] and 23.
Involvement of the lower lungs and diffuse infiltrative
abnormality has
progressed, upper lobe involvement remains more severe, some of
the
abnormality is probably edema but whether the initial insult was
asymmetric
edema or pneumonia depended on patient positioning at the time,
as described in the report. Heart size normal. No pneumothorax
CT Chest [**2122-3-12**]:
The study was obtained during the expiratory cycle of
intubation. Within the limitations of this study technique,
airways appear to be patent with no endobronchial obstruction
demonstrated. The lungs are extensively and
diffusely involved by areas of ground-glass opacity with septal
thickening and small foci of consolidation. These findings have
been gradually progressing since [**2122-3-8**] chest
radiograph and mostly new compared to [**2-6**]. The
radiological appearance is consistent with diffuse alveolar
hemorrhage. Differential diagnosis might include pulmonary edema
(given the presence of pleural effusion and known cardiac
history). Infection is less likely given the diffuse character
of the findings and mostly ground-glass rather than
consolidative pattern. The ARDS might be considered in
differential diagnosis, although the presence of pleural
effusions is against that entity.
There are no bone lesions worrisome for malignanc
EKG [**2122-3-8**]: NSR rate 100, normal axis, normal PR, QRS interval,
No LVH, ST depressions in V4-V5 under 1mm, compared to baseline.
CHEST CT [**2122-3-12**]: The lungs are extensively and diffusely
involved by areas of ground-glass opacity with septal thickening
and small foci of consolidation. These findings have been
gradually progressing since [**2122-3-8**] chest radiograph
and mostly new compared to [**2-6**]. The radiological appearance is consistent with diffuse
alveolar hemorrhage. Differential diagnosis might include
pulmonary edema (given the presence of pleural effusion and
known cardiac history). Infection is less likely given the
diffuse character of the findings and mostly ground-glass rather
than consolidative pattern. The ARDS might be considered in
differential diagnosis, although the presence of pleural
effusions is against that entity.
CXR [**2122-3-18**]: There is gradual slow improvement in the widespread
parenchymal consolidations between [**3-13**] and [**2122-3-17**]
with significant relatively [**Name2 (NI) **] and prominent improvement
between [**2122-3-17**] and current chest radiograph which
suggests resolution of underlying pulmonary edema. There are
still present widespread opacities more of interstitial pattern
on the current study. There is no interval increase in pleural
effusion. The NG tube tip is in the stomach.
Brief Hospital Course:
80 y.o. woman presenting with fever, hypoxia, and dyspnea, with
CXR worrisome for multicfocal pneumonia.
#.Hypoxia: On presentation the patient had bilateral infiltrats
on chest radiograph presumed to be consistent with multifocal
pneumonia. She also had an elevated BNP suggesting some degree
of pulmonary edema. She was initially started on vancomycin,
pipercillin-tazobactam, and azithromycin for coverage of HAP (as
she came from a [**Hospital1 1501**]). On the morning of the 24th after
presentation she became acutely more hypoxic and subjectively
dyspneic with worsening of her bilateral infiltrate pattern.
This was interpreted as likely flash pulmonary edema so she was
treated with NTG, furosemide, and rate control with BB with some
improvement though she remained dyspneic. Echo showed diastolic
failure but no significant systolic dysfunction. She was
diuresed for two liters of volume loss with improvement in her
peripheral edema but when she again became acutely short of
breath that evening repeat CXR showed no interval improvement in
her infiltrates. She then required intubation on the 25th for
persistent hypoxia and tiring. She also had a BAL, which
demonstrated diffuse alvelolar hemmorhage. Multiple auto-immune
labs were sent for concern of an auto-immune or vasculitic
etiology but were ultimately negative. ID consult was obtained
and pt was transiently covered for flu, until viral cultures
were negative. Pt was also transiently treated with
Methylprednisone given concern for possible immune process or
DLI but stopped out of concern for causing mental status
changes. Pt was then aggressively diuresed, with continued
improvement in respiratory status. She was successfully
extubated and required decreasing amount of supplemental oxygen
to 2L NC at discharge. At time of discharge, pt was stable on
regimen on Lasix 40mg PO BID.
#.Acute Renal Insufficiency: In the setting of aggressive
diuresis pt developed mild prerenal acute renal failure. At
discharge pt's Cr was 1.5 and goal for diuresis was even.
#.Altered Mental Status: After initiation of steroid treatment
for pt's pulmonary distress, pt became unresponsive to verbal
stimuli and intermittently agitated. She received ativan, which
worsened her status, and thus agitation was treated with haldol.
Once steroids were stopped, she gradually improved to be alert
and oriented x2 (confused on year), calm and appropriate. At
discharge she had not required haldol for ~4days.
#.Hypertension: Pt was maintained on her outpt regimen with the
exception of a short period of time when was unable to take POs
due to agitation and AMS. During this time she was managed with
IV nitro drip.
#.Hip Hemiarthroplasty: The patient is s/p washout [**2122-1-17**], which
grew MSSA. She had been maintained on nafcillin at her [**Hospital1 1501**] and
this was initially continued. Prior to discharge pt was started
on Bactrim DS [**Hospital1 **] per ID recs to complete a 6 month course. She
is to follow up with ID in several months and have weekly BUN/Cr
drawn and results sent to the [**Hospital **] clinic (Dr [**First Name (STitle) **]
#.CAD: The patient is s/p CABG and bioprosthetic AVR. She had a
mild troponin bump and possible lateral T wave changes at
presentation though enzymes remained flattened with negative
CK's. Cardiology consult thought unlikely to have had an ACS.
#.Hypothyroidism: She was continued on her home levothyroxine.
#.DM II: Pt's FS were checked QID and she was maintained on ISS
#Pain: Pt's chronic neck and left shoulder/arm pain was treated
with lidocaine patch, percocet and acetominophen.
Medications on Admission:
aspirin 81mg PO Daily
Acetaminophen 325 mg Tablet (2) Tablet PO Q 8H
Amlodipine 5 mg Tablet (2) Tablet PO DAILY
Calcium Carbonate 500 mg Tablet, Chewable (1)Tablet, Chewable PO
TID W/MEALS
Cholecalciferol (Vitamin D3) 400 unit Tablet two Tablet PO DAILY
Docusate Sodium 100 mg Capsule(1) Capsule PO BID
Conjugated Estrogens 0.3 mg Tablet (1) Tablet PO DAILY
Lidocaine patch 5% Qd for 12 hours.
Ferrous Sulfate 325 mg Tablet(1) Tablet PO DAILY
Gabapentin 300 mg Capsule (1) Capsule PO TID
Lisinopril 20 mg Tablet (2) Tablet PO DAILY
Omeprazole 20 mg Capsule, Delayed Release(E.C.) (1)
Capsule (Daily).
Simvastatin 40 mg Tablet (2) Tablet PO DAILY
Clobetasol 0.05 % Cream (1) Appl Topical [**Hospital1 **]
Levothyroxine 100 mcg Tablet (1) Tablet PO DAILY
Nafcillin 2 g IV Q4H
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia
Secondary diagnosis: Hypertension, hyperlipidemia
Discharge Condition:
Stable, breathing on 2L NC O2.
Discharge Instructions:
You were admitted with fever, low blood oxygen, and shortness of
breath, and your chest xray from admission was concerning for
pneumonia. A breathing tube was placed to help you breathe. You
were treated for pneumonia and you did improve. The breathing
tube was removed and you were able to tolerate breathing with
nasal canula oxygen. During this admission you had a reaction to
steroids, where you developed mental status changes. After the
steroids were stopped your mental status improved to baseline.
.
.
During this admission the following medication changes were
made:
.
Amlodipine was INCREASED to 10mg daily.
Lidocaine patch 5% was INCREASED to 3 patches every 12 hours.
.
Nafcillin was CHANGED to bactrim. Please STOP taking your
Nafcillin.
.
Omeprazole was CHANGED to famotidine. Please STOP omeprazole.
.
A medication called LABETOLOL was ADDED for better blood
pressure control. Please continue to take this medication.
.
Acetominphen was STOPPED because you are now taking Percocet,
which contains acetominophen. Percocet was ADDED.
.
All of your other home medications remain the same.
.
.
If you develop worsening shortness of breath, fever greater than
101, chest pain please call your doctor or return to the
emergency room.
Followup Instructions:
Orthopedic follow up:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2122-3-27**] 9:05
.
Infectious diseases follow up:
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2122-4-23**] 10:00
.
[**Hospital 100**] Rehab: Please make an appointment for the pt to see her
PCP (Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 3259**]) when she is discharged from rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Name: [**Known lastname 8252**],[**Known firstname **] Unit No: [**Numeric Identifier 8253**]
Admission Date: [**2122-3-8**] Discharge Date: [**2122-3-20**]
Date of Birth: [**2041-6-29**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Motrin / Levaquin
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
Please see below:
Brief Hospital Course:
Please note that pt did NOT have MSSA in hip but had coag neg
staph.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2122-3-21**]
|
[
"583.81",
"786.3",
"428.0",
"518.81",
"414.00",
"585.9",
"584.9",
"482.9",
"357.2",
"428.31",
"038.9",
"250.40",
"403.90",
"995.91",
"799.02",
"V42.2",
"250.60",
"E849.7",
"E932.0",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"33.23",
"99.15",
"38.93",
"96.72",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14005, 14242
|
13912, 13982
|
303, 388
|
11499, 11532
|
3227, 3733
|
12823, 12834
|
2541, 2559
|
11415, 11426
|
10527, 11305
|
11556, 12800
|
2574, 3208
|
13031, 13889
|
3747, 6856
|
256, 265
|
416, 1968
|
11447, 11478
|
8952, 10501
|
1990, 2402
|
2418, 2525
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,169
| 120,094
|
10801
|
Discharge summary
|
report
|
Admission Date: [**2153-4-16**] Discharge Date: [**2153-4-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
s/p Thoracentesis on [**4-19**] and [**4-25**]
History of Present Illness:
Mr. [**Known lastname 12982**] is an 85yo M w/ a PMH of CHF, CAD, afib, HTN,
dyslipidemia and PVD who presented to his regularly scheduled EP
appointment. At his appointment, it was felt that the patient
had worsened SOB, increased peripheral edema, and what looked
like a cellulitis vs. thrombophlebitis in his LUE. His radial
pulse was not palpable and it was felt that the patient needed
admission for management of his CHF and for [**Known lastname 1106**] surgery's
evaluation of his LUE.
.
The patient and his son note that the patient had been well up
until 3 months ago when he was first admitted for pneumonia.
Since that time, it has been a downward spiral and the patient
has been bouncing in and out of rehab. The son notes that the
patient never had an issue with fluid management until then and
was on a steady dose of diuretics for approximately 4 years
prior to his admission 3 months ago.
.
He was most recently discharged from [**Hospital1 18**] on [**2153-4-11**] after a 6
day stay for CHF exacerbation. It was felt at the time that his
symptoms were due to miscommunication about his lasix doses (was
taking 80mg QD instead of 80 QAM/40 QPM). He was aggressively
diuresed with IV lasix and then switched back to PO lasix. Per
the son, the patient's left hand was starting to get a little
swollen prior to discharge.
.
Since discharge, the son feels that Mr. [**Known lastname 12982**] has steadily
declined. The rehab has commented on increased abdominal girth,
swelling in his "mid section" (the patient states that his
scrotum gets pinched by his clothes), as well as worsening
swelling in his legs and now left arm. He denies any orthopnea
or PND. Can not assess for DOE as pt is ambulating minimally
lately. He states that he has only minimal SOB and does not
require oxygen at the nursing home. However, he does state that
he sometimes finds it hard to catch his breathe. He denies any
chest pain or pressure. He denies any LH or dizziness. He denies
any pain in his left arm and does not think that he had an IV in
that arm during his last admission. He states that his arm is
sensitive to touch, but not frankly painful. Last night, the
patient notes that he had trouble sleeping but can't tell if it
was due to shortness of breath or discomfort. He spent the night
sitting up in a chair and feels like the rehab center just
wasn't able to take care of him anymore. He feels "relieved"
that he's here.
.
On review of systems, he denies any prior history of stroke
(though son states head CT in past showed evidence of old
infarcts), TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope. Is notable for significant
edema.
Past Medical History:
# CHF: global hypokinesis, EF 30% in [**2-11**]
# Hypertension
# Afib on coumadin
# CAD: h/o MI approximately 7 years ago with stenting at [**Hospital1 112**]
- per son, had multiple angioplasties in [**2147**], then stent at [**Hospital1 112**]
# NIDDM: dx'd [**2111**]
# s/p Guidant dual chamber ICD [**2147**], upgrade to BiV device in
[**9-9**]
# s/p Hernia repair
# CRI (baseline Cr 1.5)
# Bilateral CFA/PFA endarterectomies and patch angioplasties
[**2153-2-20**]
Social History:
He is a widower who has been in rehab for 3 months; prior to
that, he lived with a girlfriend. [**Name (NI) **] [**Name (NI) **] is very involved in
his care, is his HCP. Pt is a retired calligrapher/artist
(retired last year). Smoked ~1ppd x 40 yrs, quit at age 60. Rare
glass of wine.
Family History:
3 brothers, 2 sisters had heart attacks or "heart trouble". F
died of esophageal cancer at age 69, M died in her 60s after a
stroke. He is the last of his family members still alive.
Physical Exam:
VS - T 96.9, BP 133/63, HR 68, RR 20, sats 95% on RA
Gen: WDWN elderly male in NAD. Oriented x3. Pleasant,
cooperative, but hard of hearing.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP up to his jawline at 45 degrees.
CV: Irreg irreg, normal S1, S2. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at base on
left, decreased breath sounds approximately [**3-10**] of the way up on
the right.
Abd: Soft, NTND. Unable to determine HSM due to body habitus. +
BS throughout. + pitting edema in his flanks. No fluid wave.
Ext: LUE has open wound (covered by bandage) and is grossly
edematous. + erythematous and warm, extending from hand up to
his elbow. Radial pulse not palpable but is easily dopplerable.
RUE is not swollen but has multiple ecchymoses. Bilateral LE are
woody and swollen, with 2+ pitting edema up to his thighs. Shins
are erythematous, scaly and warm.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP dopplerable PT dopplerable
Left: Carotid 2+ DP dopplerable PT dopplerable
Pertinent Results:
LABS on admission:
[**2153-4-16**] 06:01PM BLOOD WBC-8.2 RBC-4.18* Hgb-12.6* Hct-39.3*
MCV-94 MCH-30.1 MCHC-31.9 RDW-15.6* Plt Ct-274
[**2153-4-16**] 06:01PM BLOOD PT-23.8* PTT-33.3 INR(PT)-2.4*
[**2153-4-16**] 06:01PM BLOOD Glucose-163* UreaN-48* Creat-1.6* Na-135
K-5.1 Cl-95* HCO3-30 AnGap-15
[**2153-4-16**] 06:01PM BLOOD ALT-27 AST-37 LD(LDH)-308* AlkPhos-130*
TotBili-0.6
[**2153-4-16**] 06:01PM BLOOD Albumin-3.9 Calcium-8.9 Phos-4.4 Mg-2.5
[**2153-4-17**] 06:55AM BLOOD Digoxin-0.9
.
[**2153-4-24**] 11:25PM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2153-4-25**] 06:45AM BLOOD LD(LDH)-239 CK(CPK)-37* CK-MB-3
cTropnT-0.13*
.
[**2153-4-24**] 11:25PM BLOOD Hapto-137
[**2153-4-17**] 06:55AM BLOOD Digoxin-0.9
[**2153-4-24**] 10:34PM BLOOD Lactate-1.4
[**2153-4-24**] 11:25PM BLOOD ALT-1 AST-17 LD(LDH)-196 CK(CPK)-37*
AlkPhos-89 TotBili-0.6
.
LABS on discharge:
[**2153-4-29**] 06:00AM BLOOD WBC-7.4# RBC-3.45* Hgb-10.2* Hct-32.2*
MCV-93 MCH-29.6 MCHC-31.7 RDW-16.3* Plt Ct-280
[**2153-4-29**] 06:00AM BLOOD PT-22.8* PTT-35.6* INR(PT)-2.3*
[**2153-4-29**] 06:00AM BLOOD Glucose-125* UreaN-47* Creat-1.5* Na-139
K-4.4 Cl-101 HCO3-31 AnGap-11
[**2153-4-29**] 06:00AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.1
.
IMAGING:
MICRO:
[**2153-4-16**] blood cx - no growth
[**2153-4-19**] urine cx - no growth
[**2153-4-19**] blood cx - no growth
[**2153-4-19**] sputum cx - gram stain >25 PMNs, <10 epis; 2+ GNR; resp
cx sparse growth OP flora, moderate growth yeast
[**2153-4-19**] pleural fluid cx - gram stain 1+ PMNs, no microorgs;
fluid cx no growth
[**2153-4-22**] Blood culture - no growth
[**2153-4-23**] Blood Cx - NGTD
[**2153-4-23**] Urine cx - no growth
[**2153-4-24**] Blood Cx x 2 - NGTD
[**2153-4-23**] sputum - sparse oropharyngeal flora
[**2153-4-24**] Stool - C.Difficile negative
[**2153-4-25**] Sputum Cx - mod oropharyngeal flora
[**2153-4-25**] Pleural fluid - NGTD
[**2153-4-29**] Urine Cx NGTD
.
IMAGING:
EKG [**2153-4-16**] demonstrated ventricular pacing, with fusion beats;
rate 91; no ST or TW changes.
.
[**2153-4-16**] CXR: Moderately large right pleural effusion with
associated
atelectasis; right basilar consolidation cannot be excluded.
.
[**2153-4-16**] LUE U/S: No evidence of DVT in the left upper extremity.
.
[**2153-4-19**] CT head: No acute intracranial abnormalities. No
significant change since [**2151-11-30**] of encephalomalacia of the
left frontal
and right parietal lobes and right motor strip. No significant
change in enlargement of the ventricles.
.
[**2153-4-19**] XR LUE:
1. No definite acute fracture or dislocation.
2. Severe degenerative changes of the first MCP and first CMC
joints with prominent subchondral cyst formation. Additional
erosion of the carpus is also seen, nonspecific.
3. Unusual appearance of the soft tissues likely reflects an
external wrap or bandage.
4. Degenerative change of the acromioclavicular joint with
adjacent foci of mineralization that may reflect old trauma.
.
[**2153-4-20**] ART DUPLEX:
Duplex and color Doppler of both inguinal areas demonstrate
patent common femoral arteries. There is no evidence of graft
involving either inguinal region. There is a simple fluid
collection within the right and left inguinal regions noted.
.
[**2153-4-20**] LATERAL DECUB:
Residual moderate right pleural effusion is apparently at least
partially loculated laterally lower right hemithorax and has an
intrafissural component as well.
.
[**2153-4-25**] Chest XRay: Large right pleural effusion, which is not
significantly changed accounting for differences in position.
There is associated opacity, suggesting atelectasis, although
underlying pneumonia is not excluded. No significant interval
change.
.
[**2153-4-25**] Chest XRay (s/p thoracentesis): Significant interval
improvement in right pleural effusion consistent with interval
thoracentesis. Persistent small left pleural effusion and
pulmonary [**Month/Day/Year 1106**] congestion.
Brief Hospital Course:
85yo M w/ PMH of ischemic CM (EF 30%), CAD, DM, HTN, afib and
PVD, presenting with CHF exacerbation and pleural effusion who
was also diagnosed with pneumonia, transferred to MICU for
hypotension possibly from sepsis and then transferred back to
Cardiology floor once hemodynamically stable.
.
# CV
1) CAD: Pt has known h/o CAD with multiple PCI and interventions
done in [**2147**]. No evidence of active ischemia during
hospitalization. Continue aspirin, beta-blocker was decreased
from toprol 100 qday to metoprolol 37.5mg [**Hospital1 **] due to low blood
pressure. Continued statin (ACEI held).
.
2) RHYTHM: V-paced currently, but irregular. V sensing and
pacing per interrogation [**4-17**]. Monitored on telemetry throuhout
hospitalization. Had been on coumadin as an outpatient.
Transitioned to heparin for thoracenteses then transitioned back
to coumadin when INR therapeutic. INR 2.3 on [**2153-4-30**].
.
3) CHF: EF 30% on ECHO [**2-11**]. Peripheral edema, though
intravascularly euvolemic.
Continued digoxin. Gently diuresed with prn iv lasix while an
inpatient. Switched to lasix 40mg po bid for outpatient regimen
on [**4-29**]. This dose may need to be adjusted as an outpatient.
.
# Hypotension/sepsis: Resolved now, s/p MICU stay and briefly on
dopa though off since [**4-25**]. Prior to MICU pt had fever without
leukocytosis. All Cx data negative or no growth to date
including pleural fluid from 2 thoracenteses. CXR felt to be
consistent with possible pneumonia and given fever despite
antibiotics, his antibiotic coverage was broadened to zosyn in
addition to vancomycin (which was he was already on for possibl
cellulitis). Thoracentesis on [**4-19**] and [**4-25**] consistent with
transudate with cultures no growth to date. He passed his
cortisol stimulation test while in the MICU. Blood pressure was
stable from [**4-26**] on.
.
# Hypoxemia: The patient had hypoxia likely related to both CHF,
pleural effusion, and pneumonia. He was satting well on 2L NC on
[**4-29**] and actually satting well (94-95%)on room air on day of
discharge. Vancomycin was continued for 12 day course. Zosyn
was added on [**4-24**] and to be stopped after 10 day course ([**4-24**] -
[**5-3**]). Gently diuresed with prn lasix (as above). s/p
thoracentesis on [**4-19**] and [**4-25**].
.
# ID: The pt had PNA on CXR and on exam has bibasilar crackles.
Started on Zosyn [**4-24**] (change from levo) and has been on Vanco.
GPCs on sputum gram stain. Plan for 10 days of Zosyn in addition
to completed vancomycin course. CDiff negative. s/p 2
thoracenteses as above with evidence of infection/empyema.
Sputum and urine cultures no growth to date.
.
# Anemia: Pt has baseline hct 33, now stable at 31. pt had trace
guaiac positive stools earlier in admission. Hemolysis labs
negative. Hematocrit remained stable.
.
# LUE Edema: Improved. Differential initially DVT vs. cellulitis
vs. thrombophlebitis vs. [**Month/Year (2) 1106**] insufficiency. s/p [**Month/Year (2) **]
surgery evaluation and it was felt that it was not arterial
insufficiency. Left upper extremity was negative for deep
venous thrombosis and XRay negative for fracture. [**Month/Year (2) **]
surgery recommended treating with Vancomycin and arm appear
improved with both antibiotics and ACE bandages.
.
# CRI: Baseline Cr is 1.5 and remains at baseline. Renally
dosed medications.
.
# Foot pain: No narcotics as caused mental status changes.
Continued tylenol and neurontin.
.
# Sundowning: patient was noted to be agitated at night. His
sleep wake cycle seemed to be off (awake at night and sleeping
off and on during the day). Suspect that much of this is due to
being in the hospital setting. Started zyprexa 2.5mg po qhs
prn.
.
# R heel ulcer: No evidence of infection. Per [**Month/Year (2) 1106**] imaging,
has poor perfusion to LE bilaterally. Wound Care with wet to
dry dressings daily and aloe vesta applied. [**Month/Year (2) **] surgery
consulted as [**Last Name (un) 8585**].
.
# DM: Holding glipizide while inpatient. Covered with insulin
sliding scale and monitored finger sticks.
.
# Access: PICC line (placed [**4-23**]) and in good position and
working order.
.
# PPX: anticoagulated, continued PPI and bowel regimen
.
# Code: DNR but can intubate as was discussed with son while
patient in MICU. (Code status was reversed from DNR/DNI, as
collaborated with attending)
.
# Dispo: to rehab to complete 10 day course of Zosyn (already
completed vancomycin). He is to follow-up with cardiologist as
an outpatient. His INR was stable on coumadin and should be
followed as outpatient (INR 2.3 on day of discharge)
Medications on Admission:
Atorvastatin 10 mg PO DAILY
Aspirin 81 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Digoxin 125 mcg PO DAILY
Spironolactone 12.5 mg PO QOD
Metoprolol Succinate 100 mg PO DAILY
Docusate Sodium 100 mg PO BID
Ramipril 5 mg PO DAILY
Warfarin 2 mg PO HS
Furosemide 80 mg PO QAM, 40 mg PO QPM
Glipizide 2.5 mg PO BID
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Zosyn 2.25 g Recon Soln Sig: One (1) Intravenous every six
(6) hours for 3 days: last day [**5-3**].
12. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
15. Outpatient Lab Work
Please have bloodwork drawn to check PT/INR 3-4 days after
discharge from the hospital. Goal INR 2.0-3.0.
16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name9 (NamePattern2) 35258**] [**Hospital1 656**]
Discharge Diagnosis:
Primary diagnosis:
Cellulitis
CHF
Pneumonia
.
Secondary diagnosis:
CAD
PVD
Afib
DM
CRI
Discharge Condition:
Good. Afebrile.
Discharge Instructions:
You were admitted with a CHF exacerbation and cellulitis of your
left arm. You were diuresed and treated with IV antibiotics with
improvement in both medical issues. You were seen by [**Hospital1 1106**]
surgery who monitored both your arm and your legs for healing.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500mL/day
.
Please take all medications as prescribed.
.
Please keep all follow-up appointments.
.
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever, chills, shortness of breath,
difficulty breathing, worsening swelling of your legs or arms,
worsening pain in your feet, or any other worrisome symptoms.
.
We have held your ramipril and spironolactone.
Followup Instructions:
Please keep all your follow-up appointments:
VAS,BIOCARE [**Name8 (MD) **] LMOB (NHB) Date/Time:[**2153-6-14**] 1:00
.
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2153-6-14**]
2:00
.
Please schedule follow up appointment with Dr. [**Last Name (STitle) **] 2-3 weeks
after discharge from rehab ([**Telephone/Fax (1) 9530**].
.
Please schedule a follow-up appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 35256**] [**Telephone/Fax (1) 35257**] within 2 weeks after
discharge from rehab.
.
Please continue to have PT/INR checked, it should be checked [**4-8**]
days after discharge from the hospital. INR was 2.3 on [**4-30**].
Goal range 2.0-3.0.
Completed by:[**2153-4-30**]
|
[
"V58.67",
"511.9",
"599.0",
"585.9",
"038.9",
"V58.61",
"250.00",
"729.5",
"682.3",
"414.8",
"V45.82",
"486",
"729.81",
"428.0",
"427.31",
"401.9",
"799.02",
"995.92",
"V53.32",
"707.14"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"00.17",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15971, 16056
|
9589, 14223
|
266, 315
|
16187, 16205
|
5658, 5663
|
17042, 17063
|
4208, 4392
|
14579, 15948
|
16077, 16077
|
14249, 14556
|
16229, 17019
|
4407, 5639
|
17087, 17872
|
223, 228
|
6521, 7906
|
343, 3393
|
7915, 9566
|
16144, 16166
|
16096, 16123
|
5677, 6502
|
3415, 3888
|
3904, 4192
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,599
| 166,852
|
26425+26426
|
Discharge summary
|
report+report
|
Admission Date: [**2184-1-11**] Discharge Date: [**2184-1-16**]
Date of Birth: [**2111-6-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Vancomycin / Rifampin
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
tranferred to [**Hospital1 18**] for SAH found on CT scan at OSH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 72 year old male with metastatic lung CA to the brain, s/p
craniectomy for resection of a cerebellar mass in [**2183-8-16**] by
Dr. [**Last Name (STitle) **] was transferred from [**Hospital3 **] today. The
patient was being treated there for a pneumonia for which he
completed his antibiotics and he had a change in mental status
yesterday. He had a head CT which showed SAH and IVH. There was
no report of any trauma or falls so this was presumed to be a
non-traumatic SAH. The patient does not have a headache or
dizziness at this time. He is on his way to have stat head CT.
Past Medical History:
1. MDR E. Coli and Pseudomonal Catheter Associated Sepsis/UTI
2. Acute Renal Failure.
3. Urinary Retention.
4. Meatal Tear.
5. Traumatic Comminuted C7 Verterbral Fracture [**2182-1-2**]
6. ORIF/Laminectomy/Instrumentation/Posterior Fusion [**2182-1-23**]
7. CSF Leak - [**Year/Month/Day 409**] infection s/p drainage and dural repair
[**2182-2-9**]
8. Incision and drainage and hardware exchange [**2181-2-12**]
9. MRSA Meningitis/MRSA Pneumonia
10. Diastolic Heart Failure.
11. Non-ST Elevation Myocardial Infarction
12. Coronary Artery Disease s/p CABG x 3
13. Left Occipital Stroke vs MRSA Cerebritis
14. Pulmonary Embolism/RLE DVT - Provoked
15. Non-Sustained Ventricular Tachycardia
16. Hypersensitivity Desquamative Dermatitis (Rifampin vs
Vancomycin)
17. BUE Paresis - mild, BLE paresis L>R.
18. GI Bleed.
19. Nosocomial LLL Pneumonia
20. Anemia - multifactorial: Illness, blood loss, CKD.
21. Stage III Sacral Ulcer.
22. MRSA/VRE Colonization
23. Candidemia
24. Pseudomonal line sepsis.
25. Diabetes Mellitus Type II.
26. Hypertension
27. Hypercholesterolemia
28. L3-L4 Fusion
29. BPH
30. Chronic Kidney Disease Stage III with Proteinuria (baseline
cr
Social History:
Former tobacco use - quit 26 yrs ago, did smoke 4 ppd x 32 yrs
Alcohol - quit 26 yrs ago
Married, 2 daughters, 3 grandchildren
Chares multi-family home with daughter
Retired [**Name2 (NI) 29798**]
Family History:
Sister died of cancer.
2 brothers and father died of MI.
Physical Exam:
PHYSICAL EXAM:
T:95.7 BP:144/70 HR:80 RR:20 O2Sats:96% RA
Gen: Patient is a cachectic looking man who was shivering and
sleeping when I went into his room.
HEENT: Pupils: left 3-1 mm, right 2-1 mm EOMs-intact
Throat: He is mouth-breathing, sounds raspy and has some mucus
over his uvula.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. There is a healing ulcer on the
sole of his left foot as well as a small ulcer on the left heal.
Neuro:
Mental status: Sleeping, but arouses to voice, cooperative with
exam, normal affect.
Orientation: Oriented to person, place only.
Language: Patient has vocal paralysis. His is able to whisper.
Cranial Nerves:
I: Not tested
II: Pupils unequal, but round and reactive to light bilaterally.
Left 3-1 mm, right 2-1 mm. 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: No abnormal movements, tremors. Strength 5/5
biceps/triceps/grip bilaterally. Stength [**3-20**] bilateral lower
extremities. Unable to test drift due to right shoulder pain.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Pertinent Results:
CT from [**Hospital3 **] [**2184-1-10**]:
"Axial images of the brain are submitted for interpretation.
There is an old burr hole defect in the right frontal convexity.
The patient is also status post occipital craniectomy for
excision of a left cerebellar tumor.
There is a small amount of IVH layering in the occipital horns
of
the lateral ventricles. There is also a small focus of SAH at
the left posterior parietal convexity.
At the base of the brain, there is increased attenuation within
the basilar artery. This may be artifactual, but could also be
the source of the bleed. Further imaging evaluation with MRA or
conventional angiography may be helpful to further evaluate the
source of the bleed.
There is opacifiacation of the mastoid air cells bilaterally.
There is bilateral ethmoid and left maxillary sinus mucosal
swelling. A 9 mm mucosal retention cyst versus polyp is noted
in
the right frontal sinus.
Impression: Small amount of IVH layering in the posterior horns
of the lateral ventricles bilaterally. Small focus of SAH at the
left posterior parietal convexity."
Labs:
Na 137 Cl 103 BUN 38 Glu 120
K 4.7 CO2 24 Cr 1.5
WBC 12.6 Hgb 11.0 Hct 32.2 Plts 229
coags are pending at this time
[**2184-1-11**] 03:36AM PT-13.0 PTT-29.5 INR(PT)-1.1
[**2184-1-11**] 03:36AM WBC-12.6*# RBC-3.52* HGB-11.0* HCT-32.2*
MCV-92 MCH-31.2 MCHC-34.1 RDW-15.0
[**2184-1-11**] 03:36AM PLT COUNT-229
[**2184-1-11**] 03:36AM GLUCOSE-120* UREA N-38* CREAT-1.5* SODIUM-137
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
Brief Hospital Course:
Pt was admitted to the neurosurgery service for close neuologic
monitoring. Repeat CT showed: IMPRESSION:1. Small amount of
intraventricular blood layering in the occipital horns of the
lateral ventricles. Possible small focus of subarachnoid
hemorrhage of the left parietal lobe parasagittally. No mass
effect.
2. Post-surgical changes of the posterior fossa related to prior
cerebellar mass resection. 3. Opacification of bilateral mastoid
air cells, likely inflammatory in origin. His neurologic exam
remained at baseline with waxing and [**Doctor Last Name 688**]. He was transferred
to the floor. He was seen by PT and OT. His diet was given via
PEG. He was seen by [**Doctor Last Name **] care with the follow ing
assessment/recomendations: He is s/p penile implant x 3
(previous 2 removed due to infection
per OMR) There are several ulcerations on the base of the
penile
shaft and just below the glans. The left base of the shaft has
dry eschared tissue, right aspect has yellow fibrinous tissue.
The tissue adjacent to the glans is dry and eschared. There
does
not appear to ba any s/s of infection.
Coccyx: healing Stage III pressure ulcer. (known from previous
admissions) The tissue is now partial thickness, right gluteal
approx. 1.5 x 2 cm. There is no drainage from the site. The
periwound tissue is intact with mild skin irritation.
Left heel: intact pigmented tissue approx 1 x 0.5 cm, stable
with no surrounding s/s of infection
B/L Lower legs with dry flaky tissue. There is a pale red, dry,
patchy rash on his lower legs and feet. ? etiology.
Goals of [**Doctor Last Name **] care: prevention of infection and skin breakdown
Recommendations: Pressure relief per pressure ulcer guidelines
Support surface: First Step Select MRS
[**Last Name (STitle) **] and reposition every 1-2 hours and prn off back
Heels off bed surface at all times- Multipodis Splints to B/L
LE's
If OOB, limit sit time to one hour at a time and sit on a
pressure relief cushion, 4" Foam
Elevate LE's while sitting.
Moisturize B/L LE's and feet [**Hospital1 **] with Aloe Vesta Moisture
Barrier Ointment.
Foam cleanser to the coccyx/gluteal tissue.
Pat the tissue dry.
Apply a thin layer of Critic Aid Clear Moisture Barrier
Ointment
daily and prn or every 3rd cleansing.
Penis: Consider urology evaluation since he has a penile
implant in place with multiple ulcerations. Ulcers may be
related to trauma from previous external cath??
Cleanse the penile shaft with normal saline.
Pat the tissue dry.
Apply Bacitracin Ointment to the open ulcer right aspect of the
penile shaft [**Hospital1 **]. Leave other sites intact for now.
Left heel: Moisturize with Aloe vesta Moisture Barrier ointment
[**Hospital1 **], float heel with Multipodis Splint.
Monitor rash LE's and feet. If condition worsens, consult
Dermatology for evaluation.
Support nutrition and hydration.
Notify MD [**First Name (Titles) **] [**Last Name (Titles) **] care nurse [**First Name (Titles) **] [**Last Name (Titles) **] or skin deteriorates.
His care was discussed with his daughter and it was ultimately
decided for placement at facility.
Medications on Admission:
Medications prior to admission:
ranitidine, pravachol, proscar, folic acid, flomax, actigall,
KCL, sarna, aloe [**Doctor First Name **], neutrophos, beneprotein, zinc, vit. c,
heparin SC that was d/c'd at rehab
Discharge Medications:
1. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
via feeding tube.
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. FoLIC Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Metoprolol Tartrate 25 mg Tablet Sig: [**12-17**] Tablet PO TID (3
times a day).
7. Neutra-Phos [**Telephone/Fax (3) 4228**] mg Powder in Packet Sig: 1.5 packet
PO TID (3 times a day).
8. Zinc Sulfate 220 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
injection Subcutaneous twice a day: 28 units NPH qAM
32 units NPH qPM.
11. Sarna Sensitive 1 % Lotion Sig: One (1) Appl Topical DAILY
(Daily) as needed.
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day: via feeding tube.
13. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours).
14. Morphine 10 mg/5 mL Solution Sig: [**12-17**] PO Q4H (every 4
hours) as needed.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
16. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
18. Bacitracin-Polymyxin B Ointment Sig: One (1) Appl
Topical Q6H (every 6 hours) as needed.
19. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: [**12-17**] PO Q6H
(every 6 hours) as needed for itching.
20. Morphine 10 mg/mL Solution Sig: 2-4 mg Intravenous Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Intracerebral hemorrhage
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR HEAD INJURY
?????? Take your pain medicine as prescribed
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
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
Followup Instructions:
NO FORMAL FOLLOW UP NEEDED. CALL FOR ANY PROBLEMS.
Completed by:[**2184-1-16**] Admission Date: [**2184-1-16**] Discharge Date: [**2184-2-5**]
Date of Birth: [**2111-6-19**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Rifampin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
tachypnea, hypoxia, somnolence
Major Surgical or Invasive Procedure:
none
History of Present Illness:
We were called to see patient who was noted to be increasingly
lethargic, tachypneic, with slightly increasing oxygen
requirement. The patientis a 72M w/ multiple medical problems
including NSCLC metastatic to the brain, recent SAH, DM2, CAD
s/p CABGx3, HTN, chronic kidney disease who was admitted on
[**2184-1-16**] with altered mental status and hypoxia. He was intubated
and found to have a Psuedomonas pneumonia. He was started on
cefipime, linezolid, levofloxacin with resolution of his mental
status changes and fevers. He was extubated on [**1-22**] and sent to
the floor.
.
While on the floor he triggered briefly for hypoxia, thought to
be due to mucous plugging. He was noted to be coughing up large
amounts of purulent sputum. On [**1-28**] he coughed up ?TF into his
face mask and likely aspirated some. Since then he has become
more somnolent and tachypneic and secretions have been copious
with the appearance of tube feeds.
.
On the floor he was tachynpeic to the 30s with increased work of
breathing. He was initially satting in the mid- to upper-90s on
a shovel mask with 100% humidified oxygen. ABG was 7.44/34/71
and he was placed on a non-rebreather. After transfer to the
unit, his O2sat was noted to drop to the mid-80s on NRB. Repeat
ABG was 7.44/38/55. The patient's SBP dropped to 80 and Levophed
was started through his LIJ CVL. Anesthesia was called and the
patient was intubated for hypoxic respiratory failure.
.
The patient's wife and daughter arrived at the hospital and a
family meeting with the palliative care attending was held. The
family expressed that they thought he might want everything done
although they admitted they were not sure and that they were
waiting for his physicians to say nothing more could be done.
However, they clearly stated they wanted him to be resuscitated,
knowing that he might not survive a resuscitation attempt.
Past Medical History:
1. MDR E. Coli and Pseudomonal Catheter Associated Sepsis/UTI
2. Acute Renal Failure.
3. Urinary Retention.
4. Meatal Tear.
5. Traumatic Comminuted C7 Verterbral Fracture [**2182-1-2**]
6. ORIF/Laminectomy/Instrumentation/Posterior Fusion [**2182-1-23**]
7. CSF Leak - [**Year/Month/Day 409**] infection s/p drainage and dural repair
[**2182-2-9**]
8. Incision and drainage and hardware exchange [**2181-2-12**]
9. MRSA Meningitis/MRSA Pneumonia
10. Diastolic Heart Failure.
11. Non-ST Elevation Myocardial Infarction
12. Coronary Artery Disease s/p CABG x 3
13. Left Occipital Stroke vs MRSA Cerebritis
14. Pulmonary Embolism/RLE DVT - Provoked
15. Non-Sustained Ventricular Tachycardia
16. Hypersensitivity Desquamative Dermatitis (Rifampin vs
Vancomycin)
17. BUE Paresis - mild, BLE paresis L>R.
18. GI Bleed.
19. Nosocomial LLL Pneumonia
20. Anemia - multifactorial: Illness, blood loss, CKD.
21. Stage III Sacral Ulcer.
22. MRSA/VRE Colonization
23. Candidemia
24. Pseudomonal line sepsis.
25. Diabetes Mellitus Type II.
26. Hypertension
27. Hypercholesterolemia
28. L3-L4 Fusion
29. BPH
30. Chronic Kidney Disease Stage III with Proteinuria (baseline
cr
Social History:
Former tobacco use - quit 26 yrs ago, did smoke 4 ppd x 32 yrs
Alcohol - quit 26 yrs ago
Married, 2 daughters, 3 grandchildren
Shares multi-family home with daughter
Retired [**Name2 (NI) 29798**]
Family History:
Sister died of cancer.
2 brothers and father died of MI.
Physical Exam:
expired
Pertinent Results:
[**2184-1-16**] 07:10PM URINE HOURS-RANDOM UREA N-646 CREAT-66
SODIUM-77 POTASSIUM-53 CHLORIDE-78
[**2184-1-16**] 07:10PM URINE OSMOLAL-510
[**2184-1-16**] 07:10PM URINE UHOLD-HOLD
[**2184-1-16**] 07:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2184-1-16**] 07:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2184-1-16**] 07:10PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2184-1-16**] 07:02PM LACTATE-3.1*
[**2184-1-16**] 06:50PM GLUCOSE-107* UREA N-40* CREAT-1.7* SODIUM-144
POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-28 ANION GAP-17
[**2184-1-16**] 06:50PM ALT(SGPT)-14 AST(SGOT)-21 CK(CPK)-16* TOT
BILI-0.3
[**2184-1-16**] 06:50PM LIPASE-16
[**2184-1-16**] 06:50PM cTropnT-0.04*
[**2184-1-16**] 06:50PM ALBUMIN-3.5 CALCIUM-10.3* PHOSPHATE-4.2
MAGNESIUM-1.9
[**2184-1-16**] 06:50PM CORTISOL-30.7*
[**2184-1-16**] 06:50PM CRP-198.5*
[**2184-1-16**] 06:50PM WBC-18.2* RBC-4.15* HGB-12.7* HCT-39.0*
MCV-94 MCH-30.7 MCHC-32.7 RDW-15.1
[**2184-1-16**] 06:50PM NEUTS-70.9* LYMPHS-14.9* MONOS-4.1 EOS-9.7*
BASOS-0.3
[**2184-1-16**] 06:50PM PLT COUNT-467*
[**2184-1-16**] 06:50PM PT-14.0* PTT-29.5 INR(PT)-1.2*
[**2184-1-16**] 05:55AM GLUCOSE-194* UREA N-37* CREAT-1.4* SODIUM-141
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-19
[**2184-1-16**] 05:55AM CALCIUM-9.4 PHOSPHATE-3.3 MAGNESIUM-1.7
[**2184-1-16**] 05:55AM WBC-12.4* RBC-3.71* HGB-11.3* HCT-34.4*
MCV-93 MCH-30.4 MCHC-32.8 RDW-15.8*
[**2184-1-16**] 05:55AM PLT COUNT-404
[**2184-1-16**] 05:55AM PT-12.9 PTT-32.1 INR(PT)-1.1
[**2184-1-15**] 06:10AM GLUCOSE-171* UREA N-40* CREAT-1.4* SODIUM-145
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-24 ANION GAP-16
[**2184-1-15**] 06:10AM CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-2.0
[**2184-1-15**] 06:10AM WBC-10.9 RBC-3.42* HGB-10.9* HCT-31.9* MCV-93
MCH-31.7 MCHC-34.0 RDW-16.0*
[**2184-1-15**] 06:10AM PT-13.2 PTT-31.8 INR(PT)-1.1
Brief Hospital Course:
Pt came to the MICU and was intubated for hypoxemia. His course
was complicated by pseudomonas pneumonia and aspiration
pneumonia. Pt was supported by pressors in the ICU and was kept
alive on the breathing machine. On the day of the patient's
death, he stopped making urine and his blood pressure dropped.
Shortly thereafter, in view of the patients ventilator
requirements, his worsening blood pressure, his dx of terminal
lung cancer, the decision was made to make the patient CMO. He
was extubated and expired shortly thereafter with his family at
his bedside.
Medications on Admission:
Pravastatin 40 mg daily
Metoprolol 12.5mg TID
Insulin 28units NPH QAM, 32units NPH QPM
Insulin Sliding Scale
Finasteride 5mg daily
Tamsulosin 0.4mg QHS
Doxycycline 100mg daily
Ursodiol 300mg daily
Folic Acid 1mg daily
Neutraphos 1.5 packet TID
Zinc Sulfate 220mg daily
Ascorbic acid 500mg daily
Sarna Lotion
Bacitracin-Polymixin B Ointment Q6H PRN
Morphine 1-2mg PO Q4H PRN
Morphine 2-4mg IV Q4H PRN
Acetaminophen 325-650mg Q6H PRN
Pantoprazole 40mg daily
Diphenhydramine 12.5-25mg PO Q6H
Albuterol INH
Heparin 5000U SubQ TID
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock
Metastatic lung cancer
Acute on chronic renal failure
cardiopulmonary arrest
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
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[
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,762
| 105,157
|
12619
|
Discharge summary
|
report
|
Admission Date: [**2186-5-21**] Discharge Date: [**2186-5-24**]
Date of Birth: [**2125-9-25**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is a 60 year-old female with
a history of peptic ulcer disease and lower back pain was
recently prescribed Motrin 400 tid for the past two months.
She was in her usual state of health until three days prior
to admission when she noted an increase in her left lower
back pain along with weakness, malaise and headache, possibly
a fever as well. She had dull right upper quadrant pain for
two to three days.
On the morning of admission the patient had a syncopal event
after a bowel movement. She then presented to the [**Hospital1 346**] EW. In the EW the patient had one
large melanotic stool and a repeat syncopal event. Blood
pressure at that time was 30/palp. The patient was
resuscitated with normal saline and NG lavage revealed
coffee-grounds and clear with normal saline. She was started
on a two unit transfusion of packed red blood cells and seen
in consultation by the gastroenterology service with plans
for EGD in the morning.
PAST MEDICAL HISTORY:
1. Peptic ulcer disease in the remote past.
2. Lower back pain.
MEDICATIONS AT HOME:
1. Zantac.
2. Ambien.
3. Motrin 400 milligrams po tid.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is from [**Country 11150**], in the US for one
year. She lives with her son. She denies alcohol or tobacco
use. Denied herbal medications.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit for close observation. Her ICU
course was uncomplicated without further transfusion. EGD was
performed in the morning of [**2186-5-23**] which revealed
erythema, congestion and friability pre pylorically which was
consistent with gastritis. There was diverticulum in the
posterior bulb and the distal bulb as well. There were also
signs consistent with duodenitis.
After a stable and acute course the patient was felt stable
for transfer to the medical floor.
Physical examination at the time of transfer to the medical
floor. Vital signs - pulse 79, blood pressure 139/65, O2
saturation 100%, respiratory rate 23. Examination - in
general no apparent distress. HEENT exam - pupils are equal,
round and reactive to light. Anicteric sclerae. Mucous
membranes are moist with no lymphadenopathy. Chest is clear
to auscultation bilaterally. Cardiovascular - regular rate
and rhythm with S1, S2, no murmurs, rubs, or gallops. Abdomen
- soft, nontender, nondistended, normoactive bowel sounds.
Back revealed no spinous process tenderness. There is
tenderness to palpation bilaterally of the paraspinal muscle
of the lumbar region. Extremities - no cyanosis, clubbing or
edema. Neurologically - cranial nerves II through XII are
grossly intact. Motor was [**5-14**] bilateral upper and lower
extremities. Further neurologic examination was hindered by
language barriers despite the use of the patient's son as
translator.
LABORATORY DATA: At the time of admission [**2186-5-21**] at 10 in
the morning hematocrit 19.4 after two units of packed red
blood cells 31.8. The patient's hematocrit remained stable at
around 31 thereafter. Liver function tests ALT 6, AST 10,
alkaline phosphatase 50, total bilirubin 0.1, lipase 31, H
pylori antibody was sent in and was negative.
FURTHER COURSE IN HOSPITAL: Upon transfer to the medical
floor the patient's hematocrit remained stable. She was
followed closely. Initially she was maintained on strictly
NPO for 24 hours following the endoscopy. She was then
advanced to clears which she tolerated well with no change in
her hematocrit. She was also maintained on Protonix IV and
was strictly prohibited from using Ansaids.
For her lower back pain the etiology remained unclear and was
difficult to determine given the language barriers as
described above. There were no red flags for urgent MRI or
imaging at that time. She was given analgesia with Tylenol.
Her back pain did slowly resolve over the remaining days of
the hospitalization in the general medical floor.
On [**2186-5-24**] the patient's hematocrit was stable, she was
tolerating a po diet and her back pain was mostly resolved.
She was deemed to be stable for discharge home with close
follow up by her primary care physician within one week.
DISCHARGE INSTRUCTIONS: The patient was advised not to take
any Ansaids, Motrin, Advil or ibuprofen. She was advised to
return to the ER or contact the [**Name (NI) 191**] triage phone number
should she experience any weakness, numbness, tingling,
dizziness, lightheadedness.
DISCHARGE MEDICATIONS:
1. Protonix 40 milligrams 40 milligrams po bid times two
weeks and then q day times one month.
FOLLOW UP APPOINTMENTS: She will follow up with her PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] on [**2186-5-30**] and with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17185**] of the
Gastroenterology service on [**2186-7-3**].
FINAL DIAGNOSIS:
1. Gastric ulcers.
2. Duodenal ulcers.
3. Anemia requiring transfusion.
4. Hemodynamic instability.
5. Lower back pain.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36
D: [**2186-5-28**] 16:59
T: [**2186-5-29**] 10:12
JOB#: [**Job Number 39007**]
|
[
"E935.9",
"458.9",
"780.2",
"532.00",
"729.5",
"724.5",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.34",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
1293, 1311
|
4656, 4753
|
1535, 4356
|
5084, 5462
|
4380, 4633
|
1218, 1277
|
4777, 5067
|
162, 1108
|
1130, 1197
|
1328, 1518
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,780
| 137,618
|
20598
|
Discharge summary
|
report
|
Admission Date: [**2136-6-11**] Discharge Date: [**2136-6-14**]
Date of Birth: [**2057-9-22**] Sex: F
Service:VASCULAR
HISTORY OF PRESENT ILLNESS: This is a 78 year old Cantanese
female initially evaluated for right calf claudication on
[**2136-5-24**] to [**2136-5-28**] where she underwent an
arteriogram at that time by Dr. [**Last Name (STitle) **] which demonstrated
the abdominal aorta was widely patent but a diffusely
diseased infrarenal aorta. There were single renal arteries
bilaterally and brisk filling nephrograms. There was
bilateral patent common iliac and external iliac arteries and
internal iliac arteries. On the right lower extremity the
patent common femoral and profunda femoris superficial
femoral artery was occluded throughout its length. The mid
popliteal artery reconstitutes and then occludes. The
below-knee popliteal artery reconstitutes and is patent
throughout its length. The anterior tibial is occluded at
its origin. The posterior tibial is quite small and patent
and actually might be a collateral. The peroneal is patent
but diseased in its proximal portion. It subsequently
occludes distally and then reconstitutes above the ankle.
The peroneal reconstitutes via collaterals and is of good
caliber. The posterior tibial remains occluded and the small
plantar arteries are reconstituted in the foot. The patient
has had symptoms of claudication for the last several years
with progression in her symptoms. She initially could walk
one to two blocks but now within the last week has developed
right breast pain. She has also noticed toe tip color
changes of blue to black with an interdigital ulcer in the
fourth web space. She now returns for elective
revascularization.
PAST MEDICAL HISTORY: Coronary artery disease, Type 2
diabetes insulin dependent, hypertension,
hypercholesterolemia, cataracts. The patient's Persantine
MIBI done on [**5-28**] was negative for ischemic changes with
an ejection fraction of 58%. Ultrasound of the carotids
showed less than 40% disease bilaterally.
PAST SURGICAL HISTORY: Coronary artery bypass grafts times
three in [**2122**] for angina.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: 70/30 insulin 42 units q. AM and
30 units at h.s., Metformin 500 mg b.i.d., Nifedipine 30 mg
q.d., Cozaar 50 mg b.i.d., Aspirin 81 mg q.d., Simvastatin 80
mg at h.s., Lopressor 50 mg b.i.d., Protonix 40 mg q.d.,
Nitroglycerin 0.3 sublingual prn.
LABORATORY DATA: White count was 8.3, hematocrit 37.6,
platelets 260,000. BUN 18, creatinine 1.1, potassium 4.0.
Electrocardiogram was with normal sinus rhythm with a first
degree atrioventricular block with an inferior infarct of
undetermined age. The chest x-ray was remarkable for some
right upper lobe haziness which might be secondary to
tuberculosis exposure. There is no acute failure noted.
HOSPITAL COURSE: The patient was brought to the Preoperative
Holding Area. She underwent a right common femoral to
below-knee popliteal with a Composite greater saphenous vein.
She tolerated the procedure well and was transferred to the
Post Anesthesia Care Unit in stable condition with a
dopplerable dorsalis pedis at the end of the procedure which
was triphasic in character. In the Recovery Room the
resident was called to see the patient because of nausea and
vomiting with electrocardiogram changes. There were T wave
inversions in V4 through V6. The patient had serial enzymes
monitored. Her total creatinine kinase peaked at 398. Her
creatinine kinase MB were negative and her troponin levels
were negative. The patient was made NPO, intravenous
Nitroglycerin was instituted for afterload reduction and
hematocrit was 28.3 and she was transfused. On
postoperative day #1, there were no over night events. Her
post transfusion hematocrit was 27.8. The patient ruled out
for myocardial infarction on postoperative day #2. Her
preoperative medications were reinstituted. Her hematocrit
was 31.1. BUN was 11, creatinine 0.7. Her physical
examination was unremarkable and she had a dopplerable
dorsalis pedis and posterior tibial bilaterally. The diet
was advanced as tolerated. Fluids were heparin-blocked. She
was allowed to be up in a chair. Rehabilitation screening
was instituted and they felt that she would benefit from
[**Hospital 5735**] rehabilitation prior to being discharged to home.
The remaining hospital course was unremarkable. She had
postoperative metatarsal pulse volume recordings, saying it
was just 9 mm on the right and 2 mm on the left.
She was discharged in stable condition. The wounds were
clean, dry and intact. She had a functioning graft pulse.
DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg q. 4-6 hours prn.
2. Simvastatin 10 mg q.d.
3. Protonix 40 mg q.d.
4. Aspirin 325 mg q.d.
5. Metformin 500 mg t.i.d.
6. Oxycodone acetaminophen tablets one to two q. 4-6 hours
prn for pain. Colace 100 mg b.i.d.
7. Nifedipine CR 30 mg q.d.
8. Warfarin 1 mg q.d. Goal INR 1.5 to 2.5.
9. Losartan 50 mg b.i.d.
10. Metoprolol 75 mg b.i.d.
The patient was continued on her home regimen with 70/30
insulin with 42 units at breakfast and 30 units at h.s. with
a regular sliding scale before meals and at [**Hospital 21013**], as
follows- Breakfast, lunch and dinner sliding scale, glucoses
less than 150 no insulin, 151 to 200 2 units, 201 to 250 4
units, 251 to 300 6 units, 301 to 350 8 units, 351 to 400 10
units, greater than 400 notify a physician. [**Name10 (NameIs) **] sliding
scale glucoses less than 150 no insulin, 151 to 200 1 unit,
201 to 250 2 units, 251 to 300 3 units, 301 to 350 5 units,
351 to 400 6 units, greater than 400 notify a physician.
FOLLOW UP: The patient follow up-wise should see Dr. [**Last Name (STitle) **]
in two weeks time for skin clip removal. Ambulation is
essential distances. Full weightbearing, she should elevate
the operative leg when sitting in a chair.
DISCHARGE DIAGNOSIS:
1. Superficial femoral artery tibial disease, status post
right common femoral to below-knee popliteal with Composite
greater saphenous.
2. Coronary artery disease, with postoperative ST changes,
rule out negative.
3. Dyslipidemia treated.
4. Diabetes, Type 2 insulin controlled.
5. Gastroesophageal reflux disease, stable.
6. Blood loss anemia, transfused, corrected.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2136-6-14**] 17:33
T: [**2136-6-14**] 18:03
JOB#: [**Job Number 55073**]
|
[
"707.15",
"440.24",
"997.1",
"E878.8",
"250.00",
"272.0",
"401.9",
"414.00",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.29",
"89.64",
"99.04",
"89.61"
] |
icd9pcs
|
[
[
[]
]
] |
4699, 5692
|
5954, 6602
|
2221, 2872
|
2890, 4676
|
2087, 2194
|
5704, 5933
|
167, 1744
|
1767, 2063
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,587
| 107,351
|
7618+7619
|
Discharge summary
|
report+report
|
Admission Date: [**2150-1-12**] Discharge Date: [**2150-1-17**]
Date of Birth: [**2077-8-1**] Sex: M
Service: Medical Intensive Care Unit with transfer to [**Company 191**]
internal medicine firm.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old man
with multiple medical problems including admission to the
medical Intensive Care Unit in [**2149-11-8**] to [**2149-12-9**]
for urosepsis complicated by myocardial infarction,
congestive heart failure, and worsening renal failure
resulting in initiation of dialysis. During this admission
the patient had a prolonged intubation for hypoxic
respiratory failure secondary to his congestive heart
failure. The patient had been discharged to [**Hospital1 **] Care
Hospital on [**1-2**] where he was noted to have melena for 24
hours with a hematocrit drop from 34 to 28%. He was
transfused two units of packed red blood cells with only some
compensation of his hematocrit to 31.6. He was sent to the
Emergency Room on [**2150-1-12**] for evaluation where he was
hypotensive to 70/48 and started on IV fluids and Dopamine.
An NG lavage was negative for bright red blood or coffee
grounds. Due to his hypotension and history of nosocomial
infection, she was given Vancomycin and Ceftazidime and
transferred to the medical Intensive Care Unit for further
management.
REVIEW OF SYSTEMS: The patient reported feeling sleepy and
lethargic. He denied chest pain, shortness of breath, or
abdominal pain.
PAST MEDICAL HISTORY: Coronary artery disease status post
cardiac catheterization with LAD stent on [**2149-12-15**], status post
myocardial infarction [**11-8**], congestive heart failure with an
EF of 25-30%, type 2 diabetes times 20 years, peripheral
vascular disease status post toe amputation times two, atrial
fibrillation, pseudomonas urinary tract infection [**2149-11-8**], hypertension, chronic renal insufficiency, now on
hemodialysis Monday, Wednesday and Friday, gout, chronic
lower extremity edema, obstructive sleep apnea on C-PAP,
history of MRSA pneumonia, history of GI bleed with no EGD or
colonoscopy report available.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Protonix 40 mg po q day,
Captopril 12.5 mg po tid, Levaquin 250 mg po q day, Day 8 of
15, Epogen 5,000 units three times per week, Colace 100 mg po
bid, Lipitor 40 mg po q h.s., Nephrocaps 1 tablet po q day,
NPH 10 units subcu q a.m., 6 units subcu q p.m., Paroxetine
20 mg po q day, Reglan 5 mg po qid, Calcium Carbonate 500 mg
po tid, Digoxin .125 mg three times per week.
SOCIAL HISTORY: The patient quit tobacco 20 years ago and
quit alcohol use 4-6 weeks prior to admission. The patient
is married and has a daughter.
PHYSICAL EXAMINATION: Temperature 99.8, heart rate 80, blood
pressure 131/51, respiratory rate 26, oxygen saturation 97%
on four liters. In general this is a lethargic but alert and
elderly man in no acute distress. HEENT exam indicated
pupils are equal, round and reactive to light, there was a
right subconjunctival hemorrhage, had dry oral mucosa. The
neck was supple with no jugular venous distention. A Quinton
catheter was in place in the right subclavian position.
Cardiovascular exam indicated regular rhythm, normal S1 and
S2, no murmurs, gallops or rubs. Chest was clear to
auscultation bilaterally. On abdominal exam the patient had
bruising on his lower abdomen which was soft, nontender, non
distended with normal bowel sounds. He had a rectal bag in
place with black, running stool. On extremity exam the
patient had 2+ peripheral pulses and no edema. He does have
a small ulcer on his left lateral shin with an eschar. On
his back he had a stage II sacral decubitus ulcer.
Neurologically the patient was alert and oriented to place,
month, year and current events. He responded to verbal
commands and was moving all extremities against gravity. EKG
indicated normal sinus rhythm. Chest x-ray indicated an
elevated right hemidiaphragm, unchanged from previous study
on [**12-29**]. There was no congestive heart failure or
infiltrates. Remainder of his laboratory studies were
notable for a white blood count of 28.4 with differential of
74% neutrophils and 20% lymphocytes, hematocrit 31.6, BUN 69,
creatinine 6.1, glucose 188. Urinalysis indicated specific
gravity of greater than 1.030, nitrites positive with 3-5
white blood cells and a few bacteria. Arterial blood gas
indicated a PH of 7.31 with a PCO2 40 and PAO2 of 62.
Lactate level was 2.3. Blood cultures times two were sent as
was a urine culture and a C. diff.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for management of a GI bleed. He was continued on
Dopamine and slowly weaned off over the course of the first
two hospital days. He was transfused one unit of packed red
blood cells for a hematocrit of 25.9 on hospital day #2 and
was transfused another 2 units of packed red blood cells on
hospital day #3. The renal team was consulted and suggested
DDAVP and ultrafiltration without Heparin on hospital day #2
as well as initiation of conjugated estrogens. The GI
service saw the patient on hospital day #2 and felt that he
was not actively bleeding since his blood pressure was stable
and his blood counts were stable and it was therefore opted
for upper and lower endoscopy when his coagulation parameters
were optimized. On the evening of hospital day #2 the
patient had development of transient new first degree AV
block. Amiodarone and Digoxin were held. On hospital day #3
the patient was transferred to the floor. As all of his
cultures were negative antibiotics were discontinued. On
hospital day #4 the patient received upper and lower
endoscopy. Upper endoscopy indicated normal esophagus,
stomach and duodenum with the exception of a small polyp in
the stomach which was likely hyperplastic. Colonoscopy
indicated localized discontinuous granularity with friable
erythematous mucosa in the ascending colon. There was no
active bleeding. These findings were thought to be
consistent with ischemic colitis. As the patient was not
actively bleeding and was status post myocardial infarction
on last admission, he was restarted on 81 mg of Aspirin. He
was also restarted on his Amiodarone for rate control. The
patient was to be seen by physical therapy and occupational
therapy whose evaluations are pending at the time of this
discharge dictation. He was being screened for placement in
an acute rehabilitation facility. The patient was to
follow-up with his primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 1683**].
DISCHARGE DIAGNOSIS:
1. Ischemic bowel.
2. Congestive heart failure.
3. Coronary artery disease.
4. End stage renal disease on hemodialysis.
5. Type 2 diabetes mellitus.
6. Peripheral vascular disease.
7. Atrial fibrillation.
8. Hypertension.
DISCHARGE MEDICATIONS: Protonix 40 mg po q day, Captopril
12.5 mg po tid, enteric coated Aspirin 81 mg po q day, Epogen
5000 units three times per week with hemodialysis, Colace 100
mg po bid, Lipitor 40 mg po q day, Amiodarone 200 mg po q
day, Nephrocaps one tablet po q day, Paxil 20 mg po q day,
Reglan 5 mg po qid, TUMS 500 mg po tid, NPH 10 units q a.m.,
6 units q p.m.
DISPOSITION: The patient was to be discharged to an acute
rehabilitation facility.
CONDITION ON DISCHARGE: Improved.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2150-1-16**] 17:43
T: [**2150-1-16**] 18:31
JOB#: [**Job Number 7718**]
Admission Date: [**2150-1-12**] Discharge Date: [**2150-1-21**]
Date of Birth: [**2077-8-1**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old man
with multiple medical problems who is status post recent
medical Intensive Care Unit admission from [**2149-11-8**]
through [**2149-12-9**] for urosepsis complicated by
myocardial infarction, congestive heart failure, worsening
renal failure resulting in initiation of dialysis and
prolonged intubation for hypoxemic respiratory failure
secondary to congestive heart failure. The patient was
discharged to [**Hospital1 **] Care Hospital on [**1-2**]. At [**Hospital1 **] the
patient was noted to have melena times 24 hours with a drop
in hematocrit from 34 to 28. He was transfused two units of
packed red blood cells with a resultant hematocrit of 31.6.
He was then sent to the Emergency Room for evaluation where
he was noted to be hypotensive at 72/48 on arrival. He
received 500 cc of normal saline and was started on a
Dopamine drip with an increase in his blood pressure to
160/54. NG lavage in the Emergency Room was negative for
blood. The patient was pancultured and given Vancomycin and
Ceftazidime. He was transferred from the medical Intensive
Care Unit for evaluation.
REVIEW OF SYSTEMS: The patient referred to feeling sleepy
and lethargic. He denied chest pain, shortness of breath or
abdominal pain.
PAST MEDICAL HISTORY: Coronary artery disease status post
catheterization with left anterior descending artery stent on
[**2149-12-15**], status post MI in [**2149-11-8**]. Congestive heart
failure with an ejection fraction of 25-30%. Type 2 diabetes
mellitus times 20 years. Peripheral vascular disease status
post toe amputation times two. Atrial fibrillation.
Pseudomonas urinary tract infection in [**2149-11-8**].
Hypertension. Chronic renal insufficiency now on
hemodialysis Monday, Wednesday and Friday. Gout. Chronic
lower extremity erythema and edema. Obstructive sleep apnea,
on C-pap. Anemia of chronic disease on Epogen. History of
Methicillin resistant staph aureus pneumonia. History of GI
bleed with no documented EGD or colonoscopy.
ALLERGIES: No known drug allergies.
MEDICATIONS: Protonix 40 mg po q day, Captopril 12.5 mg po
tid, Levofloxacin 250 mg po q d, day 8 of 15, Epogen 5,000
units three times per week with hemodialysis, Colace 100 mg
po bid, Lipitor 40 mg po q h.s., Nephrocaps one tablet po q
day, NPH 10 units q a.m., 6 units q p.m., Paroxetine 20 mg po
q day, Reglan 5 mg po qid, Calcium Carbonate 500 mg po tid,
Digoxin 0.125 mg po tiw.
SOCIAL HISTORY: The patient quit smoking tobacco 20 years
ago, he quit drinking alcohol 4-6 weeks prior to admission.
PHYSICAL EXAMINATION: Temperature 99.8, heart rate 80, blood
pressure 131/51, respiratory rate 26, oxygen saturation 97%
on four liters. In general, this is a lethargic but alert
elderly gentleman, chronically ill appearing, answering
questions. HEENT: Indicated pupils are equal, round and
reactive to light. There was a right subconjunctival
hemorrhage and dry oral mucosa. The neck was supple with
full range of motion. There was no jugulovenous distension.
A right subclavian Quinton catheter was in place and the site
appeared clean, dry and intact. Cardiovascular exam
indicated regular rate and rhythm, normal S1 and S2, no
murmurs, gallops or rubs. Lungs were clear to auscultation
bilaterally. Abdominal exam indicated bruising on the lower
abdomen. The abdomen was soft, nontender, non distended with
normal bowel sounds. The patient had a rectal bag in place
with black, runny stool. On extremity exam the patient had
no edema, he had an ulcer with an eschar over his left
lateral shin. Back exam indicated stage 2 sacral decubitus
ulcer with no rash and no vertebral body tenderness.
Neurologically the patient was alert and oriented to place,
month, year and current events. He moved all four
extremities against gravity. Reflexes were symmetric.
LABORATORY DATA: EKG indicated normal sinus rhythm. Chest
x-ray indicated increased right hemidiaphragm, unchanged from
[**12-29**]. There was no congestive heart failure or infiltrate.
White blood count was 28.4 with 74% polys and 20% lymphs.
Hematocrit 31.6. Chem 7 was remarkable for BUN of 61,
creatinine 6.1 and glucose 188, LFTs were notable for an
alkaline phosphatase of 248. Cardiac enzymes were negative.
Urinalysis indicated a specific gravity of 1.030, nitrite
positive, [**2-10**] white blood cells and a few bacteria. Arterial
blood gases indicated a PH of 7.31, PACO2 40 and PAO2 of 62.
Lactate was 2.3. Blood cultures, urine cultures and C. diff
cultures were sent and were negative.
HOSPITAL COURSE: In the medical Intensive Care Unit the
patient was continued on Dopamine drip and slowly weaned off
with good hemodynamic stability. He was transfused a total
of 3 units of packed red blood cells, following which his
hematocrit remained stable. The patient continued
hemodialysis three times per week. The patient was also
started on conjugated estrogen therapy in the setting of a GI
bleed. The patient was evaluated by the GI service on
hospital day #2 and felt that he was not actively bleeding
since his blood pressure was stable and his blood counts were
stable as well. On the night of hospital stay #2 the patient
developed a transient, first degree AV block and the
Amiodarone and Digoxin were held. On hospital day #3 the
patient was transferred to the floor for further work-up of
his GI bleed. Upper endoscopy was performed on hospital day
#4 and indicated the presence of a polyp in the stomach body
which was described as likely hyperplastic. There was no
active bleeding. Colonoscopy was also performed and
indicated ischemic appearing ascending colon with no evidence
of any active bleeding. As all of the patient's culture
results came back negative, Vancomycin was discontinued. The
patient was also restarted on his Amiodarone and Aspirin
given that there was no evidence of a current GI bleed. The
patient was evaluated by physical therapy who recommended
aggressive daily physical therapy given his degree of
deconditioning. On hospital day #5 the patient was noted to
be lethargic with decreased responsiveness. A chest x-ray
indicated a slight increase in congestive heart failure.
Arterial blood gases indicated a PH of 7.29, PACO2 of 49 and
PAO2 87. An EKG was obtained which indicated no ischemic
changes. Urinalysis was sent which came back consistent with
a urinary tract infection. Urine cultures were sent and the
patient was started on Ciprofloxacin. Following initiation
of antibiotic therapy, the patient's mental status improved
dramatically and he remained at baseline for the remainder of
his hospital stay. The patient was evaluated by the speech
and swallow service who deemed him appropriate for thick
liquids and pureed foods. At the time of this dictation the
patient was being screened for placement in an acute
rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Ischemic bowel, status post ? lower GI bleed.
2. Coronary artery disease.
3. Congestive heart failure with 25% ejection fraction.
4. Type 2 diabetes mellitus.
5. Peripheral vascular disease.
6. Atrial fibrillation.
7. Hypertension.
8. End stage renal disease on hemodialysis.
9. Obstructive sleep apnea.
10. Chronic lower extremity edema.
11. History of MRSA pneumonia.
DISCHARGE MEDICATIONS: Cipro 500 mg po q day through
[**2150-1-24**], Tylenol 650 mg po q 4-6 hours prn, enteric coated
ASA 81 mg po q day, Amiodarone 200 mg po q day, Prevacid slow
rate 30 mg po bid, Epogen 5000 units with hemodialysis,
Captopril 12.5 mg po tid, Paroxetine 20 mg po q d, Nephrocaps
one tablet po q day, Reglan 5 mg po q 6 hours, Calcium
Carbonate suspension 500 mg po tid, Lipitor 40 mg po q h.s.,
NPH 10 units subcu q a.m., 6 units subcu q p.m.
The patient was to have hemodialysis three times per week.
DISPOSITION: At the time of this dictation it was
anticipated that the patient would be discharged to an acute
rehabilitation facility.
CONDITION ON DISCHARGE: Improved.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2150-1-20**] 19:32
T: [**2150-1-20**] 19:54
JOB#: [**Job Number 18077**]
|
[
"585",
"410.12",
"276.5",
"707.0",
"250.80",
"112.2",
"578.1",
"557.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15171, 15811
|
14764, 15147
|
12444, 14743
|
10464, 12426
|
9017, 9134
|
7861, 8997
|
9157, 10321
|
10338, 10441
|
15836, 16138
|
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