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1,699
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27877
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Discharge summary
|
report
|
Admission Date: [**2170-4-9**] Discharge Date: [**2170-6-1**]
Date of Birth: [**2101-8-31**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
SOB x2 days
Major Surgical or Invasive Procedure:
thoracentesis
placement of hepatic drain
picc line
History of Present Illness:
68 y.o. male s/p liver transplant [**2170-3-8**] with h/o HCC [**2-2**]
hemochromatosis, readmitted from [**Hospital3 7**] to ED with 2
day h/o sob/leg edema. Recently admitted with with elevated
creatinine up to 2.7 from baseline of 1.2 and poor nutritional
status as well as diarrhea. He was also found to be c.diff
positive and was started on flagyl.
Pt c/o increasing sob and leg edema since [**2170-4-7**], low grade
temps (100.7) and decreased diarrhea. He c/o DOE but which would
subside with rest. He had been receiving Nutren Pulmonary full
strength at 60cc/hr cycled from 1800 to 1000.
Past Medical History:
1. Hepatocellular carcinoma, diagnosed via CT-guided biopsy
[**6-28**], well-differentiated. Normal AFP 3.4.
2. Cirrhosis, incidentally diagnosed in [**2159**] following
splenectomy for splenic rupture following fall, complicated by
varices and ascites.
3. ? Hemochromatosis diagnosed in [**2162**], but negative HFE,
phelobotomies until 1 year ago. Recently told that he did NOT
have it.
4. Hypertension
5. DM type 2
6. Known partial portal and SMV thrombosis, first seen on
imaging 01/[**2168**].
7. Esophageal varices, status post banding on [**2169-4-11**] and
[**2169-6-6**]
8. Status post splenectomy following traumatic rupture
9. History of TIA
10. Chronic pancreatitis with diffuse duct dilatation, ? IPMN
Social History:
He lives with his wife. They have 4 children, grown. remote hx
smoking, quit >25 years ago. No EtOH.
Family History:
Mother deceased, age 56, stomach cancer. Father deceased, age
74, diverticulitis, DVT, PE. 2 healthy sisters.
Physical Exam:
96.1 122 124/75 33 94%% RA
minimal distress, A&Ox3, upright
perrla, eomi, anicteric
rr, tachycardic,
crackles bilat
abd soft/NT/ND, +BS, inc d/c/i
ext 3+edema
Pertinent Results:
[**2170-4-9**] 11:42AM PT-14.0* PTT-30.0 INR(PT)-1.2*
[**2170-4-9**] 11:42AM WBC-14.2* RBC-3.51* HGB-11.0* HCT-33.1*
MCV-94 MCH-31.3 MCHC-33.2 RDW-19.8*
[**2170-4-9**] 11:42AM ALBUMIN-3.1* CALCIUM-9.0 PHOSPHATE-5.4*#
[**2170-4-9**] 11:42AM CK-MB-NotDone cTropnT-0.17* proBNP-GREATER TH
[**2170-4-9**] 11:42AM ALT(SGPT)-15 AST(SGOT)-41* CK(CPK)-51 ALK
PHOS-106 AMYLASE-16 TOT BILI-0.4
[**2170-4-9**] 11:42AM GLUCOSE-215* UREA N-58* CREAT-2.3* SODIUM-136
POTASSIUM-6.5* CHLORIDE-100 TOTAL CO2-22 ANION GAP-21*
[**2170-4-9**] 11:47AM LACTATE-3.9*
[**2170-4-9**] 12:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
Brief Hospital Course:
He was found to be in chf. CXR showed bilateral effusions. After
receiving IV lasix in the ED, he was sent to the SICU. EF was
25% with severely depressed LV function, with septal
hypokinesis/akinesis and dilated right and left atrium. Liver
u/s showed intrahepatic fluid collection and subdiaphragmatic
fluid collection, new in the interval since [**2170-3-4**]. Abd
CT also showed large bilateral pleural effusions,persistent
stone in distal pancreatic duct with massive pancreatic ductal
dilatation and two fluid collections, one at the dome(72x34mm)
and one periportally (58x77mm). LFTs were normal.
On [**4-9**] a right thoracentesis was performed for 1.8 liters. Fluid
was sent for cell count, cytology and gram stain. RR improved to
low 20's with high O2 requirement. ABG showed worsening PaO2.
Respiratory rate increased to 36 with accessory muscle use and
O2 desat to 82%. He was tachycardic and hypotensive. Lopressor
was given and he was intubated for cardiogenic shock. Vanco and
Zosyn were started for concern for sepsis. PO Vanco was started
for c.diff (c.diff + at rehab). Blood cultures were negative.
On [**4-9**] rectal swab was VRE positive.
Cardiology was consulted and recommendations included diuresis
with avoidance of ace inhibitors. Cardiac cath was recommended,
but given the ARF and pulmonary condition, this was deferred. A
P-MIBI was deferred as well. Levophed was used for BP of 88/56.
Creatinine trend up and CCVHD was started on [**4-11**] for metabolic
acidosis/ARF/hyperkalemia/oliguria. Creatinine increased to as
high as 2.9 with K+ of 6. Urine demonstrated granular casts
indicative of ATN. BP improved and pressors were weaned off.
Lopressor was eventually switched to carvedilol with up
titration of dose and hydralazine was added.
On [**4-10**] a left thoracentesis was done with 1.5 liters removed.
On [**4-10**] bronchoscopy/bal was done. Cultures were negative. He
was extubated. On [**4-12**] he had an episode of afib that converted
to SR. Levophed requirements decreased with preservation of
cardiac output and cardiac index.
On [**4-14**] the pleural tube was capped and he was extubated. A
lasix drip was started with increased urine outputs. This was
stopped on [**4-16**] for metabolic alkalosis. CVVHD was stopped.
Creatinine trended down to 1.6.
On [**4-10**] he had ultrasound-guided drainage of a large left
hepatic abscess. Approximately 150 cc of purulent material was
aspirated. Attempt at aspiration of the right-sided
subdiaphragmatic collection revealed old hematoma, therefore a
catheter was not placed. Under CT, there was successful
placement of a right-sided pigtail catheter with drainage of
approximately 200 cc of pleural fluid. This grew enterococcus
(vanco sensitive), pan [**Last Name (un) 36**] pseudomonas, staph aureus coag +
(pcn & emycin resistent), strep veridans and pan sensitive
pseudomonas. Cultures from thoracentesis from R & L were
negative. Meropenum, fluc and vanco were continued per ID.
Meropenum was switced to zosyn after a ten day course.
On [**4-12**] LFTs increased with ast 2439 from 109, alt 2045 from 12,
alk phos 80 from 82 and t.bili 0.6 from 0.4. INR increased to
1.8. Vitamin K was given x3 days. LFTs then slowly trended back
down. On [**4-24**] a Abd CT was showed bilateral pleural effusions
left more than right and right subdiaphragmatic collection.
Chronic pancreatitis-type picture with pancreatic duct
dilatation and calcification. Mesenteric stranding was diffuse
and also in peripancreatic area. Some mild thickening of the
antrum of the stomach appeared improved. Left hydrocele and free
fluid in pelvis. The left hepatic drain was removed without
incident on [**4-24**]. A bile duct stent was removed. Cytology was
negative for malignant cells.
On [**4-17**] bilateral upper extremity u/s was done for right arm
swelling. Extensive, nonocclusive thrombus extended from right
internal jugular into right cephalic veins.
There were abnormal dampened venous waveforms on the left arm.
The Right C line was removed and he had successful placement of
a 38 cm double lumen PICC into the left basilic vein with tip
terminating in the SVC. IV heparin was initiated for this as
well as for a left ventricle thrombus seen on TTE on [**4-17**] ( A
moderate sized thrombus was seen in the left ventricle (~1.3 cm
diameter). LV systolic function appeared depressed with septal
and apical akinesis/hypokinesis and basal inferior akinesis).
Coumadin was started and heparin was stopped when he became
therapeutic. Goal inr was [**2-3**]. Inr was 3.0 on [**4-27**] on coumadin
3mg qd. Coumadin was later stopped when he became
supratherapeutic to 3.6 on [**5-8**]. Coumadin was not resumed. He
received FFP and 1 unit of PRBC for hct drop to 25.9.
Nutritionally, while intubated he received postpyloric feedings
of Nutren renal. This was stopped once he was extubated. Diet
was advanced and appetite improved dramatically. Cal counts were
excellent. He did complain of diarrhea. Stools were negative for
c.diff x 5. Imodium was started. [**Last Name (un) **] followed for
hyperglycemia adjusting insulin.
He was doing well until [**4-29**] into [**4-30**] when he developed
respiratory distress and was transferred back to the SICU. CXR
and CT scan demonstrated moderate pleural effusion on the left
and large effusion on the right. Therefore, after reversal of
his anticoagulation with FFP and Vit K, Interventional Pulmonary
removed 2.2L of straw-colored fluid during right thoracocentesis
and left a pigtail in place to drain. Gram stain and culture
were negative. He was diuresed aggressively as well. As a part
of the work-up, he underwent a repeat TTE which showed a stable
EF 25-30% without visualizing the LV thrombus seen on prior
TTEs. Ruled out for MI by enzymes and EKG. Cardiology followed
along. His SBP was persistantly elevated on Carvedilol and
hydralazine and a PA catheter was placed to assist with
management. His PA numbers were initially elevated along with
his SVR, and his cardiac output/index was normal. Nitro gtt was
started but did not improve SBP and was therefore d/cd. After
diuresing for several days, his PA and SVR numbers improved.
Isordil was started as well to aid with BP control. He also had
transient ATN with creatine rise leading to a hold on lasix on
[**5-2**], that resolved by [**5-4**] and he was autodiuresing well with
normalizing creatine. TPN was started for 2 days only to aid in
nutrional supplementation. His blood sugars were elevated
requiring a transient insulin gtt while on TPN. By [**5-5**] he was
off supplemental 02 by face mask and was able to tolerate POs
and TPN was stopped. He was transferred back the the floor on
[**5-6**] on room air and tolerating POs.
On [**5-8**] he was transferred back to the SICU for hypotension after
receiving overdiuresis after FFP for pleural tube removal. CXR
showed marked worsening of left retrocardiac opacity. EKG was
without acute change. He required Levophed and 1unit of PRBC. BP
improved and levophed was discontinued. Carvedilol and isordil
were resumed as well as hydralazine. Urine was sent for temp on
[**5-8**]. This was positive for GNR subsequently identified as
pseudomonas. Levaquin was initially started then switched to
meropenum. Blood cultures were sent for temp of 101.3 on [**5-10**].
This came back positive for pseudomonas, but with different
sensitivities therefore ID was consulted. Meropenum was stopped
and tobra was started. He experienced ARF from supra therapeutic
tobra levels and IV contrast for a chest CT. Tobra was switched
to Aztreonam for 18 days. Creatinine trended down to 2.4 from
3.1. Baseline was 1.6. A repeat u/a and cx of urine were sent on
[**6-1**].
LFTs trended up starting on [**5-15**]. On [**5-16**] a transjugular liver
biopsy revealed Central venular hemorrhage, congestion and
hepatocellular drop out, focal bile duct proliferation with
associated neutrophils. No evidence of acute cellular rejection
seen. An ERCP was done to rule out biliary
obstruction/ischemia. This demonstrated contrast extravasation
from the biliary anastomosis site, as well as a stenosis at this
point. There was dilatation of the upstream biliary tree.
Numerous surgical clips were present. He had placement of a
plastic biliary stent across the stricture and leak. LFTs
trended back down with alk phos decreasing to 288 from 1082.
Thoracentesis was done on [**5-31**] of the left lung for 1.3 liters.
Post procedure CXR was improved. Thoracentesis of the right lung
was considered by Int. Pulmonary, but deferred given that he was
not sob and effusion looked such that this could wait. VATS was
deferred.
An u/s of his scrotum was done for complaints of bilateral
swelling with discomfort greater on the right side. This showed
right scrotal fluid collection with multiple septations and low
level echoes, which possibley represented a chronic hydrocele
with proteinaceous debris, although a pyocele could not be
completely excluded. A simple appearing fluid collection within
the left inguinal canal possibly trapped from previous
intra-abdominal ascites was noted. Urology was consulted and
recommended cipro 500mg [**Hospital1 **] x 3 weeks for epididymo-orchitis. ID
concurred with this treatment. He will follow up in outpatient
urology clinic in [**1-2**] weeks.
VNA was arranged for review of vital signs/weight and
cardio-pulmonary assessment. Immunosuppression for discharge
consisted of prograf 0.5mg [**Hospital1 **]. Prednisone 2.5mg qd x 4 more
days then off. Cellcept was on hold. Re-institution was to be
considered on follow up visit [**6-4**]. Pentamidine was also due and
was to be scheduled as an outpatient.
He was cleared for home by PT. He was tolerating a regular diet
and vital signs were stable.
Medications on Admission:
FK 0.5", MMF 500", pred 17.5, valcyte 450 qod, fluc 400', nph 22
qam, sl scale [**Last Name (LF) **], [**First Name3 (LF) **] 325', flomax 0.4', protonix 40',
colace 100" on hold, pentamidine q month
.
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
Disp:*1 * Refills:*1*
3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Procrit 20,000 unit/mL Solution Sig: One (1) ml Injection
once a week.
Disp:*8 * Refills:*2*
10. syringes
for epogen weekly
1 box
refill:1
11. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
12. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
13. Loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
15. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
weeks.
Disp:*42 Tablet(s)* Refills:*0*
16. Lasix 20 mg Tablet Sig: Five (5) Tablet PO twice a day.
Disp:*300 Tablet(s)* Refills:*2*
17. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*2*
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow
sliding scale Subcutaneous four times a day.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CHF
DM II
ARF
R IJ, subclavian, axillary & cephalic vein non-occlusive
thrombus
Left ventricle thrombus
intrhepatic/subdiaphragmatic fluid collection
bilateral pleural effusions
Discharge Condition:
good
Discharge Instructions:
Call Transplant Office [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, inability to take medications, shortness of breath,
increased leg swelling, decreased urine output, jaundice or
increased drainage from liver drain
Labs every Monday and Thursday for cbc, chem 10, ast, alt, alk
phos, t.bili, albumin and trough prograf level. fax to
[**Telephone/Fax (1) 697**] [**First Name9 (NamePattern2) 5035**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13144**], RN
Followup Instructions:
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2170-5-15**] 9:00
schedule f/u TTE
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2170-6-14**] 10:30
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2170-6-4**] 10:20
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-6-11**] 11:30.
Nothing to eat 2 hours prior to test,
Please call [**Hospital 159**] Clinic to schedule follow up appointment
with Dr. [**Last Name (STitle) 770**] in 1 week [**Telephone/Fax (1) 5727**]
Completed by:[**2170-6-1**]
|
[
"574.51",
"604.99",
"428.0",
"E878.0",
"707.03",
"427.31",
"511.9",
"V10.07",
"518.81",
"570",
"789.5",
"998.59",
"008.45",
"573.0",
"038.43",
"429.89",
"403.91",
"996.74",
"250.00",
"584.5",
"572.0",
"785.51",
"577.1",
"286.7",
"453.8",
"E879.8",
"996.82",
"995.92",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.09",
"00.14",
"51.87",
"96.04",
"39.95",
"33.24",
"50.91",
"34.91",
"51.85",
"89.64",
"38.93",
"45.13",
"96.6",
"50.11",
"99.15",
"98.03",
"99.07",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14740, 14802
|
2809, 12606
|
289, 342
|
15024, 15031
|
2149, 2786
|
15574, 16300
|
1840, 1952
|
12859, 14717
|
14823, 15003
|
12632, 12836
|
15055, 15551
|
1967, 2130
|
238, 251
|
370, 967
|
989, 1705
|
1721, 1824
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,953
| 177,901
|
21757
|
Discharge summary
|
report
|
Admission Date: [**2129-8-1**] Discharge Date: [**2129-8-22**]
Date of Birth: [**2088-5-24**] Sex: F
Service: EMERGENCY
Allergies:
Ambisome / Penicillins / Cefepime
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Hypoxemia, tachypnea
Major Surgical or Invasive Procedure:
L IJ Central line placed
History of Present Illness:
Ms. [**Name14 (STitle) **] is a 41 year-old female with AML status post HIDAC
and MRD allo-[**Name14 (STitle) 3242**] [**9-/2127**] with remission but subsequent relapse
with CNS involvement in [**1-/2129**] treated with XRT and IT MEC
chemo with eventual remission. She presented again in [**7-/2129**]
with HC and elevated ICP, and VP shunt was placed. She was
readmitted on [**2129-8-1**] from clinic with altered mental status
and low-grade fever. Her work-up in the hospital included normal
shunt series, normal VP tap (but protein 60) and unremarkable
LP. Work-up further revealed bilateral hilar infiltrates on CXR,
with preserved saturation at presentation. Subsequent imaging
included CT chest which showed bilateral ground glass opacities
with upper lobe predominance. Sputum culture was negative. While
in hospital, she was persistently febrile to 102 on [**8-3**].
Pulmonary was consulted, and bronchoscopy performed on [**2129-8-4**]
showed thin secretions, but was otherwise largely underwhelming.
A BAL grew no organisms, and rapid viral screen was negative.
On the floor, she developed a new oxygen requirement on [**2129-8-7**]
of 2L via NC. Repeat imaging studies also showed progression of
infiltrates, and concern was raised over possible PCP (last
inhaled Pentamidine dose [**2129-7-14**]). She was started on empiric
Rx for PCP with Bactrim and Prednisone on [**2129-8-7**], and
Levofloxacin was added to cover for atypicals. She transiently
defervesced on the floor, but developed progressive hypoxemia
with increasing oxygen requirement to 6L NC, then shovel mask,
and eventually NRB. ABG on floor on shovel mask 70% 7.28/31/71.
Antifungal coverage was added on [**2129-8-9**] (Caspofungin). She was
given Lasix 20 mg IV, then 10 mg IV, with U/O 700mL without much
improvement in her respiratory status. An ICU consult was
called.
Other issues on the floor have included hyponatremia with nadir
to 122, with elevated UOsm and UNa suggestive of SIADH. Renal
has been following.
On arrival to ICU, patient tachypneic, hypoxemic to 70s on RA,
96% on NRB. She denies chest pain, mild non-productive cough.
Past Medical History:
1) AML
- [**9-7**]: Dx with M5 AML. Presented c cholecystitis, found to
have
WBC 56k with 50% blasts and plts 20. Marrow biopsy at [**Hospital1 18**]
showed AML. The cholecystitis perforated, resulting in emergent
open chole complicated by fistula and bleeding and 2 month stay
in MICU. Daily Hydroxyurea was used for maintenence until she
recovered.
She had initial cytogenetic abnormality of inversion-16 which
also had resolved. (7+3) Induction was done when she was
stable.
- [**2127-11-10**] repeat marrow showed a markedly hypercellular marrow
with no blast clusters and CD34+ blasts comprising less than 3%
of the cellularity.
- [**2127-12-4**] started Consolidation with four cycles of HIDAC
- [**2127**]: bone marrow biopsy later shows relapsed acute leukemia.
Salvage therapy with mitoxantrone/etoposide. Course was
complicated by very-delayed count recovery. Marrow bx after day
30 did show evidence of recovering marrow without a clear
increase in blasts although there were some monocyte precursors
noted. They were thought to not resemble her underlying
leukemia.
- d0 [**2128-10-1**] MRD allo SCT.
- [**2129-1-14**]: admission for relapsed leukemia in the CSF and R
bell's
palsy. Base of skull XRT and intrathecal chemotherapy through an
ommaya reservoir ([**2129-1-7**]) placed during her admission
- [**Date range (1) 57171**]: continued on q2week Depo ARA-C, also with
withdrawing immunosuppression. There was noted rising LFTs,
unclear whether [**1-6**] GVH vs the underlying Hep C.
- MEC finished on [**3-20**]
- Biweekly intrathecal depocyt started [**2-7**], last dose [**2129-4-10**]
- DLI [**2129-4-6**]
2. Endocarditis in [**2125**]
3. MI [**2125**]
4. AVR [**2125**]
5. MVR [**2125**]
6. Stroke with left hemiparesis [**2125**]
7. Hepatitis C: HCV Ab positive [**2-/2128**], VL [**4-9**] 22,100,000,
liver biopsy in [**2-7**] with stage 1-2 fibrosis and bile duct
damage likely [**1-6**] hep C but cannot exclude GVHD
8. Asthma: only on prn albuterol MDI
9. GERD
10. h/o coag neg staph, VRE
Social History:
She presently is living in [**Hospital6 **] home. Her
sister-in-law prepares her medications for her. She is widowed
and her husband died from complications related to pancreatitis.
She doesn't have children. She previously worked as a computer
programmer with 2 years college training. She has not worked for
two years and is assisted through [**Social Security Number 57174**]social security disability.
She has a previous history of heroin use which she stopped in
[**9-6**].
Family History:
No family history of malignancy. Her mother has hypertension,
her father had type II diabetes and died from an MI and stroke
at the age of 57, and her brother has HIV.
Physical Exam:
VITALS: Afebrile, BP 108/66, HR 100-110s, RR 24, Sat 92% on NRB.
GEN: Tachypneic, unable to speak with full sentences in moderate
respiratory distress. Anxious.
HEENT: Slightly dry MM. JVP difficult to assess secondary to
respiratory distress.
RESP: Bilateral inspiratory crackles, most prominent at the
upper lung zones posteriorly.
CVS: RRR.
GI: BS present. Abdomen soft, non-tender.
EXT: [**1-7**]+ bilateral LE edema.
Neuro: Oriented to place, year, month.
Pertinent Results:
Laboratory results:
[**2129-8-1**] 11:40AM UREA N-13 CREAT-0.6 SODIUM-133 POTASSIUM-4.9
CHLORIDE-102 TOTAL CO2-22 ANION GAP-14
[**2129-8-1**] 11:40AM WBC-6.4# RBC-3.73* HGB-12.7 HCT-38.5 MCV-103*
MCH-34.0* MCHC-33.1 RDW-16.7*
[**2129-8-1**] 11:40AM NEUTS-66.7 LYMPHS-25.9 MONOS-4.9 EOS-1.9
BASOS-0.5
[**2129-8-1**] 11:40AM CALCIUM-8.7 PHOSPHATE-2.1* MAGNESIUM-1.9 URIC
ACID-2.6
[**2129-8-1**] 11:40AM ALT(SGPT)-45* AST(SGOT)-93* LD(LDH)-236
CK(CPK)-20* ALK PHOS-352* TOT BILI-3.8* DIR BILI-2.5* INDIR
BIL-1.3
[**2129-8-1**] 03:36PM LACTATE-1.3
RELEVANT IMAGING DATA:
[**2129-8-3**] CT CHEST W/O: Multiple focal areas of ground-glass
opacity in both lungs and peribronchial infiltration are more
prominent in the upper lobes, and confluent in the left apex.
There is no pleural or pericardial effusion.
[**2129-8-7**] CT CHEST W/O: Worsening diffuse bilateral patchy ground
glass opacities with an upper lobe predominance. This appearance
is most consistent with an atypical infection such as PCP or
viral pneumonia, as noted previously. Non-infectious etiologies
such as drug reaction could also be considered.
[**2129-8-9**] CXR portable: The previously described extensive
bilateral parenchymal densities are again identified. They have
progressed to a moderate degree in the left mid lung field and
lower lung field whereas on the right base, a certain degree of
regression can be identified. On both films, there is no
evidence of pleural
fluid accumulation in the lateral pleural sinuses.
[**2129-8-10**] CXR portable: Increase bilateral airspace opacities
with decreased lung volumes
Brief Hospital Course:
A/P: 41 year-old female with AML in remission, with progressive
hypoxemic respiratory failure. Family meeting was held yesterday
with Heme-Onc team. Pt will be made CMO this afternoon after her
brothers have spoken to her mother. Otherwise ct with current
treatment.
1) Hypoxemic respiratory failure: The cause of her acute
respiratory decompensation was unclear to the housestaff team.
Within the first day or two of her admission to the [**Hospital Unit Name 153**] there
was a drastic change in her cxray. She now had multilobular
opacities suggestive of an ARDs like picture. She was placed on
broad spectrum antibiotics-Aztreonam, Vancomycin, Flagyl,
Caspofungin, Levoquin along with Bactrim and steroids for
presumptive PCP [**Name Initial (PRE) 31304**]. No nidus of infection was found and
all culture data was negative. She was also started on steroids.
The pt was extremely difficult to ventilation requiring high
PEEP and pressure support. Abdominal paracentesis showed blasts
in her abdomen suggesting reoccurence of her cancer. This is
most likely the cause of her acute failure. Pt was then made CMO
and she was slowly weaned off the ventilator.
2) Hemodynamic instability: Patient was persistently hypotensive
during her [**Hospital Unit Name 153**] stay. Thought to be secondary an underlying
infection, but all culture data was negative. She initially
required Levophed to maintain her urine output and blood
pressure but Dopamine was added in hope to wean the Levophed
down. This was unsuccessfull and she required pressors until her
family decided to change her code status to CMO.
3) Abdominal distention: Patient required extremely high amounts
of Fentanyl and Versed to keep her sedated and synchronous with
the ventilator. Her abdomen continued to increase in size,
thought to be an ileus due to failure of passing stool
(secondary to pain medications). CT scan of the abdomen was done
and did not suggest an obstruction. Her belly was then tapped
and preliminary cytology suggested reoccurence of her Leukemia.
No further intervention was indicated at this time, per
discussion with [**Hospital Unit Name 3242**]. Family was informed of this new information
and they decided to change code status to CMO.
4) Thrombocytopenia: Likely secondary to possible underlying
malignancy. She required multiple platelet transfusions to keep
her platelet level above 30.
5) FEN: Ct with TPN.
6) Ppx: Pneumoboots, no heparin SC given thrombocytopenia. PPI.
Bowel regimen prn. Insulin SS while on high dose steroids.
7) Access: PICC line, femoral a-line, left IJ.
Pt passed away on [**2129-8-22**] after her family decided to change her
code status to CMO. No autopsy was obtained.
Medications on Admission:
Caspofungin
Acyclovir 400 mg IV q 8 hours
Ketoconazole TP [**Hospital1 **]
Levofloxacin 500 mg PO QD
Lactulose prn
Methadone 10 mg PO BID, 5 mg PO prn
Albuterol neb
Benzonanate 100 mg PO TID
Dulcolax prn
Clotrimazole troches
Benadryl prn
Anzemet prn
Folate 1mg PO QD
Guaifenesin q6 prn
Atrovent neb
Topical flagyl
Nystatin oral suspension
Dilatin 100 mg IV TID
Prednisone 40 mg PO BID
Bactrim 350 mg IV q8 hours
Ursodiol 300 mg PO TID
Senna, prochloperazine
Discharge Medications:
Pt passed away on [**2129-8-22**]
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
AML
Acute respiratory failure
Discharge Condition:
Pt died on [**2129-8-22**]
Discharge Instructions:
Pt died on [**2129-8-22**]
Followup Instructions:
Pt died on [**2129-8-22**]
|
[
"V58.65",
"572.3",
"785.52",
"351.0",
"519.1",
"255.4",
"584.5",
"038.9",
"560.1",
"995.92",
"286.9",
"428.0",
"136.3",
"V42.2",
"070.70",
"V15.3",
"287.5",
"518.84",
"V45.2",
"205.00",
"996.85",
"253.6",
"789.5",
"348.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.15",
"99.07",
"33.24",
"54.91",
"96.72",
"38.91",
"96.6",
"96.04",
"00.17",
"96.07",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10615, 10667
|
7348, 10049
|
316, 342
|
10740, 10768
|
5717, 7325
|
10843, 10872
|
5050, 5220
|
10557, 10592
|
10688, 10719
|
10075, 10534
|
10792, 10820
|
5235, 5698
|
255, 278
|
370, 2497
|
2519, 4538
|
4554, 5034
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,898
| 149,685
|
45167
|
Discharge summary
|
report
|
Admission Date: [**2142-1-24**] Discharge Date: [**2142-2-21**]
Date of Birth: [**2075-9-24**] Sex: F
Service: MEDICINE
Allergies:
Latex / Reminyl / Ativan / Xanax
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Right subclavian triple lumen catheter
.
[**2142-2-9**]: 1. Bronchoscopy.2. Attempted video-assisted exploration
of the left pleural space with conversion to a left thoracotomy
and decortication. Dr. [**Last Name (STitle) **].
.
Multiple Bronchoscopies: [**2142-2-5**]; [**2142-2-6**] x 2; [**2142-2-11**]; [**2142-2-12**];
[**2142-2-15**]
.
Endothracheal Intubation: [**2142-2-6**]
.
Arterial line: [**2142-2-7**]
.
Trach and PEG placement: [**2142-2-12**]
.
PICC line placement
History of Present Illness:
66yo female transferred to the MICU after PEA arrest on the
floor.
**
66 yo female with severe COPD, Afib, hx of breast CA who
presented [**2142-1-24**] with respiratory distress most likely secondary
to COPD exacerbation in setting of respiratory infection. She
was treated in the MICU with BIPAP for brief period then
transferred to floor. Due to large loculated pleural effusion on
the left, which was unamenable to bedside thoracentesis, she was
scheduled for a Bronchoscopy/BAL and VATS with IP and thoracic
surgery. On the floor, she was treated with vanc/zosyn/levo.
*
Her hospital course was complicated by development of SVT
(afib/aflutter) and was started on diltiazem and quinidine as
per Electrophysiology team. The hospital course was also
complicated by ?volume overload and acid base imbalances. She
was taken to the OR on [**2142-1-30**] where she underwent decortication
due to difficulty decompressing the lung for VATS as well as
Bronchoscopy. The Bronchoscopy found significant thickened
mucous secretions which were suctioned out and during the
decortication, the patient was found to have a significant
empyema. 3 chest tubes were placed in the OR. The PACU course
was complicated by difficult extubation as well as marginal
respiratory status, CO2 retention (CO2 as high as 95 on ABG) and
acid base imbalance. She was successfully extubated on POD#1 and
transferred to floor on POD#2 on [**2142-2-1**].
*
After [**Hospital **] hospital course notable for: continued pain at
thoractoomy site treated with morhpine/dilaudid, complicated by
some waxing and [**Doctor Last Name 688**] mental status. Transient Afib/flutter
responsive to iv diltiazem. Chest tubes were dc'd on [**2-4**]. She
developed oliguric ATN, followed by renal [**2-5**] who felt due to
prerenal (due to transient inschemia from afib/flutter).
*
Then overnight on [**2-5**], noted to have increasing SOB and
complete white-out of left lung. She underwent bronch which
revealed a thick mucous plud in left mainstem bronchus. She
underwent repeat bronch on [**2-6**] at 14:40 with showed persistent
mucous plugging of L mainstem. Then at 17:20, RN checked gag
reflex which was present, and the patient was given dinner. RN
then noted the patient slumping over and hypoxia, and then code
was called at 17:25pm. Patient was found to be in PEA arrest.
Anesthesia intubated pt and suction showed food-stuffs from ET
tube. She was given epi x 2 and then atropine and bicarb. Spont
circulation resumed at 17:35. Pt was transferred to the MICU.
*
Repeat bronch on transfer to the MICU showed food particles in
the right and left stems, and a therapeutic aspiration was
performed. The ETT was advanced 2 cm to the carina.
Past Medical History:
1. COPD (FEV1 44%, on home O2)
2. Afib
3. h/o R breast ca s/p bx/lumpectomy (no chemo)
4. GIB
5. TTE ([**2-15**] with EF 50%)
6. s/p appy
Social History:
The patient is a former nurses aide, waitress and now volunteers
at the Chaplain's office at B&W as well as at her local church.
She has never been married and does not have any children. She
lives by herself in an appartment complex (intact ADL And IADL)
with a home maker who comes to visit once/week. The patient
admits to having smoked 1ppd x 40+ years but quit 6 months ago.
She continues to report cigarette cravings. She denies any
alcohol or illicit drug use.
Family History:
1. Mother: died from burst hernia and subsequent peritonitis
2. Father: died of throat CA; ex-smoker
3. Sister: DM, CHF, recently passes away in [**May 2141**].
4. No other family left for family.
Physical Exam:
-VS: Tc: 96.9 BP: 108/66 HR: 113 RR: 22 SaO2: 94% on 3L
wt: 230.1lb
-Gen: well nutritioned caucasian female lying in bed wearing NC
in NAD. Pt is conversing in full sentences with no accessory
muscle use.
-HEENT: PERRL, EOMI, anicteric. Non-tender, non-pruritic,
erythematous swelling around both eyes. As per pt, no visual
changes.
-Neck: no retractions, JVD not appreciated
-CV: tachy, regular? s1, s2
-Chest: [**Month (only) **] bs, poor air movement, wheezing bilaterally [**12-17**] way
up back
-Abd: two vertical well healed surgical scars 20cm and 12cm in
mid abdomen, obese, soft, NT, ND, BS+
-Ext: UE: swelling L>R. no c/c/pitting edema (however le is
moderately swollen with non-pitting edema)
-Neuro: CN II-XII grossly intact
Pertinent Results:
-EKG [**2142-1-24**]: SVT/Afutter in 150ss
-CXR [**2142-1-24**]: LL Opacification, obscuring of L CP angle
-CTA [**2142-1-25**]: Negative for PE.
-CXR on [**2142-2-18**]:
SUPINE PORTABLE CHEST: Comparison is made to a prior study dated
[**2142-2-16**]. Tracheostomy tube and left PICC catheter remain
in stable, satisfactory position. Heart is at the upper limits
of normal for size. Mediastinal contours are within normal
limits. As before, there is perihilar fullness and
indistinctness of pulmonary vasculature, in keeping with volume
overload. Allowing for differences in technique, the appearance
is unchanged. There is improved aeration of the left lower lobe,
with some patchy opacities persisting. There is blunting of the
costophrenic sulci bilaterally, suggesting small bilateral
pleural effusions. Numerous surgical clips are visualized in the
left upper abdomen.
IMPRESSION:
1) Stable volume overload.
2) Improved aeration of the left lower lobe
Labs on discharge:
wbc 8.5
hct 28.5
plt 388
na 142
k 4.1
cl 91
bicarb 43
bun 79
cr 3.2
glu 190
ca 8.5
mg 2.2
p 3.9
ABG 7.4/62/87
Brief Hospital Course:
1. Respiratory distress: Due to COPD flare in the setting of
bacterial pneumonia. Pt had a CTA while in MICU initially ruling
out PE which also found loculated left pleural effusions as well
as ascites and anasarca. Pt is s/p bronch and decortication with
chest tube placement for empyema. After her PEA arrest, she
remained in respiratory failure and ultimately underwent bedside
tracheostomy placement by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 57475**] on [**2142-2-12**].
Was unable to be weaned to PS due to low lung compliance,
presumably due to pneumonia, plueral effusion and total body
volume overload. She was placed on lasix drip and was diuresed.
Was able to tolerate PS for a short period of time on [**2142-2-19**]
15/15, and will require a very slow trach wean with trials of PS
each day.
.
A) PNA/Empyema: Pt with LLL infiltrate suggestive of PNA. Pt is
s/p bronch and decortication with chest tube placement for
empyema. Continued on vancomycin/zosyn for presumed
ventilator-associated pneumonia (course finished [**2142-2-19**]). She
received several bronchosopies during the course of her
hospitalization to clear secretions/mucous plugs.
.
C) COPD: Pt with significant COPD as per history (FEV1 44% on
home oxygen). Continued on steroids, Albuterol and Atrovent
MDIs. Steroids were intially weaned on the floor to prednisone
30 qd, but were increased back up to 60 after PEA arrest. She is
now at 40 mg QD, and should get a very slow slow taper, given
her significant problems with bronchoconstriction.
.
D) CHF: Pt with non-pitting edema on LE, mild CHF on CXR and
generalized anasarca with ascites on CT scan suggestive of
volume overload. Pt was actively diuresed on Sat with good
urine output and [**Month (only) **]. in LE edema. TTE was performed [**1-27**]
showing mod depressed cardiac function (EF 45-55%) and ?
diastolic dysfunction (LA and RA dilation, E wave decel 1m/sec
and E/A ratio of 1.43). Repeat TTE on [**2-7**] showed: EF 45-55%
(unchanged), resting regional wall motion abnormalities
including inferior hypokinesis with mild to moderate hypokinesis
elsewhere.Right ventricular systolic function is borderline
normal. (2+) mitral regurgitation. There is moderate pulmonary
artery systolic hypertension (worse than prior). There is a
small pericardial effusion (unchanged)with some echo dense
material in the pericardial space consistent with some
organization. There are no echocardiographic signs of
tamponade. She was given lasix boluses with no effect, and on
[**2-14**] she was started on a lasix drip and diuresed well. She
became alkalotic however on [**2-19**] and lasix gtt was stopped and
patient was switched to Diamox. She will need careful repletion
of her lytes (keep potassium above 4.5) and if she becomes less
alkalotic, would recommend further diuresing her with more
lasix. She will be d/ced on diamox [**Hospital1 **] standing. She is still
>10 kgs up from her dry weight.
.
2. Atrial Fibrillation/Flutter: Pt with multiple episodes of
rapid Afib/flutter. She was initially started on diltiazem and
quinipril due to concern over lung toxicity associated wtih
amiodarone, but continued to have several episodes of rapid afib
both on the floor and again on her transfer to the MICU after
her PEA arrest. Electrophysiology service was consulted and
quinidine was discontinued and the patient was started on an
amiodarone drip and was changed to po amiodarone and continued
on diltiazem. She continued to go in and out of paroxysmal Afib.
She was not anticoagulated given recent VATS and trach/PEG
placement, but this should be re-evaluated again after [**Month (only) 547**]
[**2141**] when is is 1 month post trach and PEG. Plan is to continue
amiodarone 200mg po qd. She needs a follow up appointment in [**Hospital **]
clinic. Please call Electrophysiology Clinic at ([**Telephone/Fax (1) 8793**]
for an appointment. She will need to be discontinued off of amio
given her underlying lung status in the near future.
.
3. HTN: Pt previously off all hypertensives due to episodes of
hypotension in the MICU. She was started back on verapamil but
was changed to diltiazem for better rate control in the setting
of rapid atrial fibrillation. Her blood pressure improved with
this treatment.
.
4. ARF: Pt with steadily increasing BUN/Creatinie since
admission to [**Hospital1 18**]. Renal was consulted and diagnosed ATN due to
hypotension from the relative hypoperfusion during the episodes
of rapid Atrial fibrillation and PEA arrest. Her creatinine
peak was 3.9 and began to improve on [**2-15**] after initiating lasix
drip. Renal feels that her renal function will continue to
improve and she has no indication for dialysis at this time.
Please renally dose all medications and monitor electrolytes
daily.
.
5. Hypercholesterolemia: continue zocor.
.
6. FEN. Volume status was treated as outlined above. Her
electrolytes were repleted for goal K>4.0 and Mg>2.0. She was
started on tube feeds but did not tolerate due to high
residuals. A KUB performed [**2-15**] revealed constipation with good
rectal gas. She was started on standing metoclopramide and
erythromycin for increased gastric motility and aggresive bowel
regiemen including enemas was continued. Given her aspiration,
the team was reluctant to allow her to eat but patient insisted,
understanding the risks of doing this. She had no gag reflex but
was able to tolerate yogurt without aspirating over the last two
days of this admission. She was seen by speech and swallow on
[**2142-2-20**] who placed Passy-Muir valve and recommended NPO and a
video swallow to be performed. This should be done at rehab.
.
7. Anemia. Continued on epogen for anemia of chronic disease.
Had declines in her Hct during this admission thought related to
frequent phlebotomy, did not have ob+ stools. She did get 1
blood transfusion during this admission (pt. had significant
hematomas in the setting of her chest tubes. An SPEP/UPEP was
also sent in setting of renal failure and anemia. This is still
pending at discharge and should be followed up on to rule out
multiple myeloma.
.
8. Prophylaxis: Heparin sub Q TID for DVT prophylaxis, colace
and senna for bowel regimen.
.
9. Constipation. Patient with episodes of constipation and
increased residuals from Tube feeds. She was started on reglan,
lactulose, erythromycin, senna, colace with good effects.
.
10. Access: RIJ central line intially placed then discontinued.
Patient had a PICC line placed on [**2-15**] by IR.
.
11. Code status: Full code
.
12. Communication: Patient has so family but does have a friend
who is her health care proxy -- [**Name (NI) 1123**] [**Name (NI) **].
Medications on Admission:
1. Verapamil
2. Digoxin
3. Combivent
4. Zocor
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
5. Epoetin Alfa 20,000 unit/2 mL Solution Sig: One (1) ml
Injection QMOWEFR (Monday -Wednesday-Friday).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
9. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injectiojn Injection TID (3 times a day): until more mobile.
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): taper slowly over 1 month.
13. Albuterol 90 mcg/Actuation Aerosol Sig: 6-10 Puffs
Inhalation Q2-4H (every 2 to 4 hours).
14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q2-4H (every 2 to 4 hours).
15. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
17. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
18. insulin
1. 12 NPH [**Hospital1 **]
2. Regular insulin sliding scale:
150-200 2 units
201-250 4 units
251-300 6 units
301-350 8 units
351-400 10 units
19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO at bedtime
as needed for constipation: Hold for diarrhea.
20. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
at bedtime: Hold if diarrhea.
21. Lactulose 10 g/15 mL Solution Sig: 30-60 mL PO three times a
day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Nosocomial Pneumonia complicated by empyema
Congestive Heart Failure Exacerbation
Acute Renal Failure due to Acute Tubular Necrosis
Rapid Atrial Fibrillation
Constipation
Diabetes Mellitis Type II
Anemia of Chronic Disease
Chronic Obstructive Pulmonary Disease exacerbation
Pulseless Electrical Activity Arrest
Aspiration
Discharge Condition:
good on vent with settings of AC 550/10/15/35%had one trial for
about 2 hours of CPAP/PS 15/15
Discharge Instructions:
Please call PCP or return if have an increase in shortness of
breath, fevers or pain.
Followup Instructions:
PCP: [**Name10 (NameIs) 357**] follow up with your PCP within two weeks of
discharge from rehab.
Cardiology: Please follow up with Dr. [**Last Name (STitle) **] in one month for
evaluation of your atrial fibrillation/atrial flutter. ([**Telephone/Fax (1) 8998**]
|
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69,904
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44404
|
Discharge summary
|
report
|
Admission Date: [**2139-1-19**] Discharge Date: [**2139-3-8**]
Date of Birth: [**2066-7-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Lumbar puncture ([**2139-1-22**])
History of Present Illness:
Dr. [**Known lastname **] is a 72M left handed psychiatrist with h/o ESRD s/p
ECD renal transplant [**2131**] complicated by bx-proved BK nepropathy
treated with cidofovir now with failing graft (Cr 3.5), diffuse
large B cell lymphoma s/p 6 cycles of R-[**Hospital1 **] ([**Date range (1) 95198**]) and
2xIT MTX and 2xIT ARA-C with bone mets, CAD and CABG x3 [**2130**],
CHF with EF 30% and 2+ MR, DM, depression, and laryngeal ca who
presents from [**Hospital1 **] for evaluation of altered mental status.
As recently as [**2138-11-9**], Dr. [**Known lastname **] was seeing pts as a
psychiatrist after finishing five months of chemotherapy for
lymphoma. His wife notes some paraphasic errors in his speech
and difficulties with abstraction over the past year, but not
major cognitive deficits. He was able to walk with a cane, but
had progressively worsening gait from neuropathy secondary to
diabetes and vincristine. In late [**Month (only) **], he fell four times
in one week and felt significantly weaker so his PCP advised him
to seek medical attention. He was hospitalized [**Date range (2) 95199**].
Recurrent falls thought to be multifactorial with a degree of
spinal stenosis and neuropathy.
He was readmitted [**Date range (1) 95200**] from rehab for AMS.
Admission BUN 103 and Cr 4.4. Found to improve when sedating
medications (lorazepam, oxycodone, modafinil, buproprion,
gabapentin) removed and with HD. No infectious etiology
identified. D/C'ed to [**Hospital1 **].
Over the next two weeks, pt's wife continued to be concerned
about his mental status. Per wife, he was disoriented and
talking about "running marathons." Dr. [**Known lastname **] was seen by his
oncologist on [**2139-1-6**], who also noted disorientation. Thought
possibly due to uremia, but no improvement with HD, so
oncologist did LP. CSF with 8 WBC, 3 RBC, Protein unavailable,
Glucose 105, HHV negative, culture negative, and "clonality not
assessed due to insufficient B cells.:
Dr. [**Known lastname **] continued to stay at [**Hospital1 **]. He improved
slightly, at one point able to get OOB and walk 100ft with
walker and PT. After this improvement, however, his mental
status became progressively worse. Wife describes pt as
disoriented to time and place. He once asked for peanuts when he
was already holding some in his hands. Over the last several
days, these confusional states have gone from intermittent
(worse in early AM and then PM) to continuous. Per wife, today's
hospitalization results from cumulative decline and was not
precipitated by an acute event. Wife does not recall any recent
medication changes or acute illnesses other than above.
REVIEW OF SYSTEMS:
Neurological: Denies HA, neck pain, visual change, difficulties
in hearing, talking, swallowing. Wife notes some paraphasic
errors and difficulty with abstract thought. Also pt seems to
have difficulties with balance and weakness in R side. Pt also
has remote hx of head trauma [**2-10**] MVC as child, possibly
involving damage to ? temporal lobe, and had some seizures as a
child. Some increased urinary urge and frequency but without
incontinence and baseline per wife. [**Name (NI) **] other changes in
bowel/bladder habits.
Gen: No fevers/chills/sweats, SOB, cough, CP, palpitations, abd
pain, N/V/D, dysuria. 5lb weight loss over past year.
Past Medical History:
As per discharge summary [**2138-12-19**]:
1. Diffuse large B cell lymphoma s/p 6 cycles of R-[**Hospital1 **]
([**Date range (1) 95198**]) and 2xIT MTX and 2xIT ARA-C with bone mets in
lumbar spine
2. ESRD s/p ECD renal transplant [**2131**] complicated by bx-proved
BK nepropathy treated with cidofovir now with failing graft (Cr
3.5)
3. CAD s/p NQWMI and CABG x3 [**2130**], now with CHF and EF 30% and
moderate MR/mild AS
4. Stage 1 laryngeal ca
5. IDDM
6. Depression
7. Osteoarthritis status post R total knee replacement [**2126**]
8. light chain lambda gammopathy
9. Hypercalcemia of malignancy
10. HTN
11. BPH
Social History:
Dr. [**Known lastname **] is a psychiatrist who worked part time until his
recent illness. He lives in [**Hospital1 8**] with his wife. [**Name (NI) **] wife
died from breast ca. They have no recent travel hx. He used to
smoke a pipe, but stopped 15 years ago. ETOH <5 drinks/wk. No
illicit drug use.
Family History:
FAMILY HISTORY: Mom with stroke and breast ca. Paternal cousion
with breast ca. Denies other hx of stroke, sz, mental/psych
illness.
Physical Exam:
PE:
Gen: Initially lying in bed with eyes closed, answering
questions in whisper with eyes closed. Later opens eyes and
becomes more alert.
Skin: Many bruises, especially notable on the abdomen.
Heent: Normocephalic, atraumatic. Mucous membranes moist,
oropharynx clear.
Resp: Clear to auscultation bilaterally
CV: Regular rate and rhythm, 2/6 SEM
Abd: Bowel sounds present, abdomen soft, non-tender, and
non-distended. No hepatosplenomegaly or masses palpable.
Extrem: Warm and well-perfused. No arthralgia. ROM full.
NEUROLOGIC EXAM
MS - Awake, alert, interactive. Initially lying in bed with
eyes
closed, answering questions in whisper with eyes closed. Later
opens eyes and becomes more alert. MS varies significantly over
the course of exam. Pt sometimes answers questions quickly and
correctly, sometimes answers the same question (when repeated)
quickly and incorrectly, and sometimes has prolonged processing
times (10-15 seconds to answer the same question he had just
answered). Oriented to person. When asked where he is at
various points in the exam, answers include "[**State 531**], [**Hospital Ward Name 23**]
Building," "[**State 531**], at the phone company," and "[**Hospital3 **]
Hospital." Intermittently gets the month and year correct, then
reports it is [**2136**]. Reports the president is "[**Last Name (un) 2450**]." Naming
intact. When asked to spell world backward, says "WD."
100-7=13. 9 quarters = $1.25. No signs of apraxia. No
left-right confusion.
Cranial Nerves ?????? Pupils equal and sluggishly reactive (2.5 to
2mm); no diplopia; no nystagmus. Saccadic pursuit on lateral
gaze. Impairment of superior and inferior movement of eyes b/l,
worse on inferior.
Intact facial sensation, moderate flattening of R nasolabial
fold, hearing grossly intact, palatal elevation greater on L,
and tongue protrusion is slightly R deviated with full movement.
Sternocleidomastoid and trapezius are strong and normal volume.
Tone - Normal
Strength -
Delt [**Hospital1 **] Tri WrEx FEx WrFl FFlx IP Quad Ham TA G
[**First Name9 (NamePattern2) **] [**Last Name (un) 938**]
L 5 4+ 5- 5 5 5 5 5- 5- 5- 5- 4+
5- 5-
R 5 4+ 4+ 5- 5- 5 5 4 4+ 4+ 4+ 4+
5- 5-
Reflexes -
Biceps Triceps Brachioradialis Patellar Ankle
R 1 1 1 1 0
L 1 1 1 1 0
Extensor response on R and flexor on L. No ankle clonus.
Sensation - LT, temp, vibration symmetric b/l over UEs. LT
diminished on bottom of L foot. Decreased LT and vibration sense
over dorsal aspect of R foot. LT, temp, vibration intact and b/l
symmetric over remainder of LEs. PS intact in index fingers b/l,
[**2-11**] in toes b/l.
Coordination - Past-pointing on finger to nose.
Pertinent Results:
MR [**Name13 (STitle) 430**] with and without contrast- [**2139-1-21**]- Nodular subependymal
enhancement corresponding to FLAIR and T2 abnormality.
The main differential consideration is lymphomatous
infiltration. Small
vessel chronic ischemia may co-exist.
EEG- [**2139-1-20**]- This is an abnormal routine EEG due to
intermittent left
temporal theta slowing and right temporal sharp waves. These
findings
suggest subcortical dysfunction on the left and cortical
irritability on
the right in the temporal regions. No electrographic seizures
were
noted during this recording.
CSF - [**2139-1-22**]
WBC 2, RBC 2, Protein 54, Glucose 98
LDH 87
Gram Stain Negative
Culture negative
Cytology: Rare atypical cells in a background of mature
lymphocytes and monocytes.
Protein electrophoresis (SPEP): No oligoclonal bands
VZV PCR negative
Cryptococcal Ag negative
[**Male First Name (un) 2326**] Virus negative
EKG ([**2139-1-25**]): Sinus tachycardia. Left atrial abnormality.
Prominent QRS voltage suggests left ventricular hypertrophy,
although it is non-diagnostic. ST-T wave abnormalities may be
due to left ventricular hypertrophy but clinical correlation is
suggested. Since the previous tracing of [**2138-12-16**] sinus
tachycardia is now present and QRS voltage is less prominent.
Renal US ([**2139-1-27**]): No hydronephrosis. Linear calcifications
within the transplant kidney may represent non-obstructive
calculi.
CXR ([**2139-1-19**]): No acute intrathoracic abnormality.
CXR ([**2139-1-24**]): Pending
CXR ([**2139-1-25**]): In comparison with the study of [**1-19**], respiratory
motion somewhat degrades the image. The heart is normal in size
and there is no vascular congestion or pleural effusion. No
definite acute focal pneumonia. Broken sternal wires are again
seen.
CXR ([**2139-1-27**]): Left lung is clear. There could be a small region
of new opacification at the base of the right lung above the
elevated right hemidiaphragm, probably mild atelectasis or
superimposition of normal structures. There are no abnormalities
convincing for pneumonia. Pleural effusion, if any, is minimal
on the right. Heart size is normal. Incidental note is made of
possible acute fracture of the left eighth rib more obvious on
the chest radiograph from [**1-25**], and distortion of the
right seventh rib posterolaterally that looks more like a healed
fracture.
CXR ([**2139-1-27**]): NG appropriately placed.
.
[**2138-2-13**] CXR-FINDINGS: Improvement in degree of pulmonary edema
with residual perihilar haziness. An asymmetric area of alveolar
consolidation in the right infrahilar region. The latter may be
due to a resolving area of asymmetrical edema, but infection is
also possible in the appropriate setting. Small pleural
effusions are present bilaterally as well as atelectatic changes
in the left retrocardiac area.
.
LENI [**2-15**]-IMPRESSION: No DVT identified within bilateral lower
extremities.
.
CXR [**2-17**]-FINDINGS: As compared to the previous radiograph, the
monitoring and support
devices are in unchanged position. The pre-existing right basal
opacity is
less dense but slightly more extensive.
The pre-existing left retrocardiac opacity has completely
resolved. There is
no evidence of interval occurrence of focal parenchymal
opacities suggesting
pneumonia. Unchanged size of the cardiac silhouette.
.
Brief Hospital Course:
MICU Course:
Dr.[**Known lastname **] was admitted to the ICU for acute hypoxic
respiratory failure. This was felt to be flash pulmonary edema
secondary to hypertension with BPs 220s/130s. He was maintained
on Bipap. Fluid was removed via HD. He was initially placed on
nitro gtt for BP control. His BP regimen was changed by
increasing his metoprolol to 50 TID, adding back his home
amlodipine 10mg and adding hydral. He had been on an ACE and [**Last Name (un) **]
at home which were held for [**Last Name (un) **]. His CEs were stable. Other
chantges: Keppra redosed for HD. No MTX yet. LENIs negative.
Renal and onc coordintating. Continues to be lethargic. Responds
to questions by noding head yes or no.
NEUROLOGY:
Altered Mental Status - Upon presentation, Dr. [**Known lastname **] had a
waxing and [**Doctor Last Name 688**] level of orientation, frequently talking as if
his daydreams were reality. Focal exam deficits included
impairment of downward gaze, right facial droop, right arm and
leg weakness. MRI with contrast was concerning for metastatic
lymphoma. Infectious causes were also initially in the
differential, especially CMV; however, the infectious work-up
was negative. Toxic/Metabolic work-up was negative. Uremic
encephalopathy not likely in setting or low-for-pt BUN and Cr as
well as continued hemodialysis. Ultimately, the patient was
transferred to the BMT service. He was given a cycle of
intravenous methotrexate and Rituxan. After this treatment, his
mental status was monitored and his mental status did not
improve, and ultimately he was made comfort measures only and
passed away in the hospital.
Seizures - Given concern that the waxing and [**Doctor Last Name 688**] mental
status could suggest seizures, EEG was initially obtained and
revealed intermittent L temporal theta slowing and R temporal
sharp waves, but no seizure activity on EEG. On [**1-24**], Dr.
[**Known lastname **] had several episodes of unresponsiveness to voice and
reports of left leg and arm shaking, clinically concerning for
seizure. He was started on Keppra for seizure prophylaxis, and
the episodes appear to have resolved at the time of transfer to
the BMT service.
CNS Lymphoma - After the MRI with contrast raised concern for
metastatic lymphoma, a follow-up LP was performed. This showed
2 WBC, insufficent for determination of clonality. Cytology
demonstrated a few atypical lymphocytes. SPEP showed no
oligoclonal bands. Beta-2 microglobulin was noted to be
elevated in the CSF.. Intrathecal methotrexate was considered
but neuro-oncology expressed concern that this would not
adequately reach the subependymal region where the metastatses
were seen. The option for IV methotrexate was discussed
extensively with the family, and they expressed interest. He was
ultimately transferred to the BMT service, where he was given a
cycle of intravenous methotrexate. He subsequently received
leucovorin and hemodialysis to minimize methotrexate toxicity.
He had a transaminitis most likely from the methotrexate which
resolved. He was given leucovorin until the methotrexate levels
in his blood were undectable.
Shingles - On [**1-22**], Dr. [**Known lastname **] developed a rash in the right
C3-C5 distribution ending midline. Derm was consulted and
suspected Shingles; DFA which was positive for VZV in setting of
immunosuppression. Dr. [**Known lastname **] was then started on renal dose
acyclovir, briefly switched to famciclovir and then ultimately
ganciclovir per ID recommendations, to cover CMV as well as VZV.
On [**1-26**], given concern for bacterial suprainfection, vancomycin
was started per hemodialysis protocol, with all doses given
during dialysis. He was continued on vancomycin until....
UTI - Initial urine culture showed mixed flora, and UA was
negative. Dr. [**Known lastname **] developed fevers during admission and
repeat urine studies revealed E. Coli (>100,000 colonies,
pan-sensitive except to Bactrim) and Enterococcus
(10,000-100,000 colonies). This was initially treated with
ceftriaxone ([**1-26**]), and then switched to cefepime ([**1-27**]) in the
context of bacteremia (see below), per ID recs. ID also
recommended a renal ultrasound to check for GU reflux in the
context of oliguria; demonstrated no hydronephrosis. They also
recommended considering abdominal CT to further evaluate the
kidneys if renal ultrasound was unrevealing......
Bacteremia / Fevers - Blood culture [**1-25**] grew gram-negative
rods, pan-sensitive. As noted above, Dr. [**Known lastname **] had been
started on Ceftriaxone ([**1-26**]) and later switched to Cefepime
([**1-27**]). On [**1-30**], he was noted to have a fever. CXR was
performed but did not show evidence of an acute lung process. He
was placed on cefepime/flagyl. Flagyl was eventually stopped on
[**2-4**], per ID recommendations......
ESRD- Dr. [**Known lastname **] has ESRD s/p transplant now with failing
graft. He was started back on HD in [**Month (only) 1096**] for concern for
uremic encephalopathy. We continued his hemodialysis regimen
(Monday/Wednesday/Friday) as well as his Prednisone and Bactrim
prophylaxis. He was dialyzed twice in 24 hours post-Gad
administration for his MRI. After he received cycle 1 of
methotrexate, he was dialyzed on several consecutive days to aid
in methotrexate clearance....
NSVT - Dr. [**Known lastname **] was noted to have 10-12 beat runs of VTach
on telemetry, which seemed to coincide with seizure activity. CK
was WNL and Troponin 0.08 in setting of renal failure. The
episodes appeared to resolve once Keppra was on board......
Rib Fracture - CXR did show what appeared to be an acute rib
fracture of the 8th rib and an older fracture of the 7th rib.
There was no history of rib fractures, and the patient does not
appear to be in pain from this......
Pressure Ulcers - Dr. [**Known lastname **] has two sacral pressure ulcers
which are being monitored by the wound consult nurse.......
Medications on Admission:
Acetaminophen 650 mg PO/NG Q6H:PRN Pain
Metoprolol Succinate XL 100 mg PO DAILY
Allopurinol 100 mg PO/NG MWF After dialysis
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO/NG QID:PRN
Nausea
Milk of Magnesia 30 mL PO/NG Q6H:PRN Nausea
Amlodipine 10 mg PO/NG DAILY
Nephrocaps 1 CAP PO DAILY
Bisacodyl 10 mg PR HS:PRN Constipation
Paricalcitol 1 mcg IV Give at dialysis only
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Polyethylene Glycol 17 g PO/NG DAILY [**Month (only) 116**] hold for loose stools
PredniSONE 4 mg PO/NG DAILY
Docusate Sodium 100 mg PO BID [**Month (only) 116**] hold for loose stools
Psyllium 1 PKT PO DAILY:PRN Constipation
Famotidine 20 mg PO/NG Q24H
Senna 1 TAB PO/NG [**Hospital1 **] [**Month (only) 116**] hold for loose stools
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Sulfameth/Trimethoprim DS 1 TAB PO/NG MWF Prophylaxis on
steroids
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary
-CNS Lymphoma
-Herpes zoster
-Altered mental status
Secondary
-End-Stage Renal Disease on Hemodialysis
-Diabetes Mellitus
-Congestive Heart Failure
-Coronary Artery Disease
-Hypertension
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2141-7-11**]
|
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"357.2",
"403.91",
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icd9cm
|
[
[
[]
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[
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"99.25",
"03.31",
"38.93",
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icd9pcs
|
[
[
[]
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] |
18041, 18050
|
11052, 17012
|
325, 361
|
18290, 18307
|
7682, 11029
|
18371, 18509
|
4706, 4824
|
18001, 18018
|
18071, 18269
|
17038, 17978
|
18331, 18348
|
4839, 7663
|
3064, 3714
|
264, 287
|
389, 3045
|
3736, 4355
|
4371, 4674
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,674
| 162,800
|
9579
|
Discharge summary
|
report
|
Admission Date: [**2154-12-18**] Discharge Date: [**2154-12-24**]
Date of Birth: [**2098-3-28**] Sex: M
Service: CSU
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 32491**] is a 56-year-old
man with a history of hypertension, hyperlipidemia, current
smoking, who presented to primary care provider's office with
two weeks of exertional chest burning, relieved with rest.
He thought he was having reflux given his history of GERD,
but does note that it felt somewhat different and this is why
he sought care. The patient denies shortness of breath,
chest pain, and has no cardiac history. At the primary care
provider's office he was noted to have EKG changes from his
baseline, most notably diffuse anterior T-wave inversions,
and was referred to [**Hospital1 **]-MC Emergency Room.
The patient had a cath on arrival, given his concerning EKG
changes. Cath showed a left dominant system with three
vessel disease including an LAD 40 percent proximal lesion
and 90 percent mid lesion, totally occluded after D2, left
circumflex with 40 percent proximal, OM1 small with a 90
percent stenosis, PDA with 90 percent stenosis, and RCA that
was totally occluded proximally with left to right
collaterals, and an EF of 60 percent. CT surgery was
consulted to evaluate for possible surgery.
PAST MEDICAL HISTORY: Significant for hypothyroidism, renal
cysts, chronic renal insufficiency, nephrolithiasis, status
post lithotripsy and cholelithiasis. The patient also states
a history of hypertension.
He has an allergy to sulfa.
CURRENT MEDICATIONS: Altace 10 every day, aspirin 325 every
day, and Indapamine 2.5 every day and Zyrtec.
The patient's vital signs following catheterization showed
temperature 97.4, heart rate 78, blood pressure 150/70,
respiratory rate 20, O2 saturation 100 percent on room air.
Physical exam showed alert and oriented Russian speaking
male. HEENT showed pupils equally round, reactive to light,
extraocular movements intact. Neck was supple, no JVD.
Chest was clear to auscultation bilaterally. Cardiovascular
showed regular rate and rhythm. Abdomen was soft, nontender,
nondistended. Extremities were warm and well perfused with
no clubbing, cyanosis or edema. Pulses 2 plus bilaterally
throughout the lower extremities.
LABORATORY DATA: White count 8.3, hematocrit 41.7, platelets
120,000, sodium 138, potassium 3.7, chloride 98, CO2 29, BUN
17, creatinine 1.4. EKG showed sinus rhythm at a rate of 70
with a PR of 0.24, left atrial enlargement, borderline left
axis with diffuse anterior T-wave inversions.
The patient was admitted to the cardiology service and was
seen by cardiac surgery, however, he initially refused to
consent to surgery and after three days the patient finally
consented to surgery. On [**2154-12-20**] the patient was brought to
the Operating Room. Please see the OR report for full
details. In summary he had a CABG times four with a LIMA to
the diagonal, saphenous vein graft to the distal LAD,
saphenous vein graft to OM and saphenous vein graft to the
PDA. His bypass time was 66 minutes with a cross clamp time
of 54 minutes. He tolerated the operation well and was
transferred from the Operating Room to the Cardiothoracic
Intensive Care Unit.
At the time of transfer the patient was A-paced at 80 beats
per minute with a mean arterial pressure of 74 and a CVP of
80. He had Neo-Synephrine at 0.3 mcg per kilogram per minute
and propofol 20 mcg per kilogram per minute. The patient did
well in the immediate postoperative period. His anesthesia
was reversed. He was weaned from the ventilator and
successfully extubated. The patient was noted on day of
surgery to have ST elevations on the monitor and he was begun
on a nitroglycerin drip following transfer to the
Cardiothoracic Intensive Care Unit.
On postoperative day one the patient remained hemodynamically
stable. His IV nitroglycerin was transitioned to oral
nitrates. He was begun on Beta blockade as well as
diuretics, however, he remained in the ICU for hemodynamic
monitoring.
On postoperative day two his chest tubes were removed as well
as his central venous access, and he was transferred to
______ for continuing postoperative care and cardiac
rehabilitation. Over the next two days the patient had an
uneventful postoperative course. His activity level was
increased with the assistance of the nursing staff and
physical therapy once he arrived on the floor.
On postoperative day four it was decided that the patient was
stable and ready to be discharged to home.
At the time of this dictation the patient's physical exam was
as follows: Vital signs showed temperature 98.7, heart rate
74 sinus rhythm, blood pressure 108/47, respiratory rate 20,
O2 saturation 95 percent on room air. Weight preoperatively
86 kg, at discharge 89.3 kg. Physical exam in general showed
no acute distress. Neurologically alert, responsive, Russian
speaking. Pulmonary clear to auscultation bilaterally.
Cardiac regular rate and rhythm, S1 and S2. Sternum was
stable. Incision with staples without erythema or drainage.
Abdomen was soft, nontender, nondistended with normoactive
bowel sounds. Extremities warm, well perfused with no edema.
Left saphenous vein graft harvest site with Steri Strips,
open to air, clean and dry.
Patient's condition at time of discharge is good. He is to
be discharged home with visiting nurses.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass grafting times four with left internal mammary
artery to the diagonal, saphenous vein graft to the distal
left anterior descending, saphenous vein graft to obtuse
marginal and saphenous vein graft to posterior descending
coronary artery.
2. Hypertension.
3. Chronic renal insufficiency.
4. Hypothyroid.
5. Nephrolithiasis.
6. Gastroesophageal reflux disease.
The patient is to have follow-up in the [**Hospital 409**] Clinic in two
weeks, follow-up with Dr. [**Last Name (STitle) 3357**] in two to three weeks, and
follow-up with Dr. [**Last Name (STitle) **] in four weeks.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg b.i.d.
2. Lasix 20 mg every day times two weeks.
3. Potassium chloride 20 mEq every day times two weeks.
4. Colace 100 mg b.i.d.
5. Aspirin 81 mg every day.
6. Imdur 30 mg every day.
7. Percocet 5/325 one to two tablets q. four to six hours
p.r.n. as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2154-12-24**] 13:10:12
T: [**2154-12-24**] 14:39:06
Job#: [**Job Number 32492**]
|
[
"272.0",
"414.01",
"244.9",
"411.1",
"401.9",
"593.9",
"530.81",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.56",
"37.22",
"88.53",
"36.13",
"39.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5459, 6114
|
6137, 6694
|
156, 169
|
1607, 5438
|
198, 1345
|
1368, 1585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,811
| 107,089
|
36624
|
Discharge summary
|
report
|
Admission Date: [**2155-4-11**] Discharge Date: [**2155-4-17**]
Date of Birth: [**2082-9-17**] Sex: M
Service: MEDICINE
Allergies:
Benadryl
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Trach placement
Bronchoscopy x2
History of Present Illness:
This is a 72-year-old gentleman with a history of HTN, DMII, CAD
s/p CABG in [**2154**] complicated by wound infection, repeat surgical
interventions requiring tracheostomy. The patiet developed
tracheal stenosis and now is status post cervical tracheal
resection and reconstruction that was subsequently complicated
by anastomotic necrosis and dehiscence, requiring reoperation
and t-tube placement. T-tube was removed and tubular silicone
y-stent placed with external fixation. He was recently admitted
to [**Hospital1 18**] from [**Date range (1) 20494**]/10 for a similar complaint of respiratory
distress. At that time, bronch revealed distal migration of the
stent exposing his areas of tracheal stenosis, resulting in
dyspnea. This was corrected with rigid bronch in the OR on [**3-4**]
with immediate resolution of symptoms.
Patient presented to the [**Location (un) **] ER on day of admission for 1
day of worsening SOB c/w previous stent migrations. He did
report some difficulty bringing up secretions. No fever, chest
pain, n/v, or diarrhea. At the OSH ED, pation was observed to
be in respiratory distress with report of stridor. He was given
nebs without improvement. CXR showed left lung white-out. He
was sedated and then intubated by anesthesia through his trach
stoma with a 7.0 ETT with improvement in his respiratory status.
He was transferred here for further work-up by IP.
In the ED, initial VS were: T97.5, 155/59, 77, RR 20-24, O2sat
100% on PS 10/5, FiO2 60%. Pt was in NAD, perhaps mild
increased WOB. Coarse BS b/l. Trach site draining
serosanguinous mucous. Exam otherwise unremarkable. Labs
notable for WBC 14, Creat 2.1 (baseline), CXR without obvious
consolidations, U/A neg with Foley in place. EKG at baseline.
ETT slightly deep but aerating lungs well. As unclear where
tracheal stenosis is, decided not to pull back. IP aware and
plans to bronch on day after admission; patient admitted to MICU
overnight for monitoring. On transfer, VS: afebrile, BP 158/68,
P 70, RR 12-16, O2sat 100% on PS 10/5, FiO2 50% with ABG
7.38/51/227/31.
In the ICU Mr. [**Known lastname 13144**] [**Last Name (Titles) 1834**] bronchoscopy, with IP
performing stent removal during which a large amount of
inflammation/necrotic tissue thought secondary to intubation
through stoma with button hole which had pushed through tissue.
#7 tracheostomy tube placed. He was subsequently weaned off the
vent on [**4-14**] AM and is now on humidified air through trach and
doing well. Of note, he did have moderate growth of MRSA on his
respiratory culture and started a course of vancomycin on [**4-13**],
which will go for a total of 8 days.
.
On arrival to the floor patient denied any SOB. Only complaints
was sore throat from constant coughing and abdominal pain from
muscle strain (also from coughing).
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. 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:
- DM type II
- Diastolic CHF
- CAD s/p emergent CABG (w/ radial and venous grafts) c/b wound
infection, dehiscence "plastic surgery," c/b infection,
tracheostomy
- S/p intubation tracheal stenosis, s/p cervical tracheal
resection and reconstruction that was subsequently complicated
by anastomotic necrosis and dehiscence, requiring reoperation
and t-tube placement. T-tube was removed and tubular silicone
y-stent placed with external fixation.
- Asthma
- CRI
- Colon ca s/p partial colectomy
- S/p cholecystectomy
- Mild aplastic anemia
Social History:
Lives with friend [**Name (NI) **] ([**Telephone/Fax (1) 82870**]), has two sons, able to
do most ADLs (cooking, cleaning); denies smoking, no EtOH, used
to work as commercial photographer for [**Company 2676**].
Family History:
Mother and father both had CAD. Father also with leukemia.
Physical Exam:
On transfer to general medicine floor:
Vitals: T: 98.9, BP: 110/62, HR: 71, RR: 22, SP02: 100% on 10L
trach
Gen: Sitting upright comfortably, trached
HEENT: No scleral icterus, mmm, oropharynx clear
NECK: Trach site dressing is clean, dry, and intact. Some
mucous on NRB positioned below trach.
CV: RRR, nl S1, S2, no murmurs, rubs or gallops. CABG incision
well-healed.
LUNGS: Coarse breath sounds anteriorly. Decreased breath
sounds on left.
ABD: Soft, NT, obese but ND, nl BS, no HSM appreciated.
EXT: 1+ BLE edema (which patient states is chronic). 2+ DP
pulses BL.
NEURO: A&Ox3, nonfocal.
On discharge:
T: 97.8, HR: 67, BP 158/64, SP02: 100% on 10L trach mask
Gen: Sitting upright comfortably, trached
HEENT: No scleral icterus, mmm, oropharynx clear
NECK: Trach site dressing is clean, dry, and intact. Some
mucous on NRB positioned below trach.
CV: RRR, nl S1, S2, no murmurs, rubs or gallops. CABG incision
well-healed.
LUNGS: Coarse breath sounds bilaterally
ABD: Soft, NT, obese but ND, nl BS, no HSM appreciated.
EXT: 1+ BLE edema (which patient states is chronic). 2+ DP
pulses BL.
NEURO: A&Ox3, nonfocal.
Pertinent Results:
Labs on admission:
[**2155-4-11**] 08:50PM URINE AMORPH-FEW
[**2155-4-11**] 08:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2155-4-11**] 08:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-4-11**] 08:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2155-4-11**] 08:50PM PLT COUNT-280
[**2155-4-11**] 08:50PM NEUTS-89.7* LYMPHS-5.8* MONOS-3.8 EOS-0.5
BASOS-0.3
[**2155-4-11**] 08:50PM WBC-13.6* RBC-4.23* HGB-12.4* HCT-36.9*
MCV-87 MCH-29.3 MCHC-33.6 RDW-15.5
[**2155-4-11**] 08:50PM URINE GR HOLD-HOLD
[**2155-4-11**] 08:50PM URINE HOURS-RANDOM
[**2155-4-11**] 08:50PM CK(CPK)-236
[**2155-4-11**] 08:50PM estGFR-Using this
[**2155-4-11**] 08:50PM GLUCOSE-283* UREA N-54* CREAT-2.1* SODIUM-140
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15
[**2155-4-11**] 09:01PM GLUCOSE-273* LACTATE-1.4 K+-4.8
[**2155-4-11**] 11:22PM URINE HYALINE-0-2
[**2155-4-11**] 11:22PM URINE RBC- WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2155-4-11**] 11:22PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-4-11**] 11:22PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2155-4-11**] 11:39PM TYPE-ART TEMP-38.4 RATES-/21 O2-50 PO2-227*
PCO2-51* PH-7.38 TOTAL CO2-31* BASE XS-4 INTUBATED-NOT INTUBA
VENT-SPONTANEOU
ECG [**2155-4-11**]: Sinus rhythm with prolonged A-V conduction. Prior
inferior myocardial infarction. Possible prior anteroseptal
myocardial infarction. Compared to the previous tracing of
[**2155-2-22**] there is no significant change.
Portable CXR [**2155-4-11**]: FINDINGS: Consistent with the given
history, tracheostomy tube is in place. Subsegmental
atelectasis is seen in the left lung base. No focal
consolidation or superimposed edema is noted. There is calcified
plaque at the aortic arch. The cardiac silhouette is grossly
stable in size. No definite effusion or pneumothorax is noted.
Degenerative changes are seen throughout the thoracic spine.
IMPRESSION: Subsegmental left base atelectasis. No definite
consolidation or superimposed edema. Tracheostomy as above.
Portable CXR [**2155-4-13**]: FINDINGS: Comparison is made to previous
study from [**2155-4-11**]. Tracheostomy is identified. There is
tortuosity of thoracic aorta. There are no pneumothoraces or
focal consolidation. There is atelectasis at the left base.
Small left-sided pleural effusion is also seen and this is
unchanged.
Portable CXR [**2155-4-14**]: FINDINGS: In comparison with the study of
[**4-13**], the tracheostomy tube remains in place. There is
increasing opacification at the right base, most likely
consistent with atelectasis and pleural effusion. In the proper
clinical setting, supervening pneumonia must be considered. No
evidence of vascular congestion. The right lung and upper half
of the left lung are clear. Tracheostomy tube remains in place.
Tracheal tissue [**4-13**]: Squamous mucosa with acute and chronic
inflammation, granulation tissue, and focal necrosis.
Brief Hospital Course:
This is a 72-year-old gentleman with a pmhx of CAD, CABG, DMII,
HTN, with tracheal Y stent with external fixation presenting
with acute shortness of breath, likely mechanical from shifting
of stent, now s/p stent removal by IP on [**4-13**] and trach
placement.
.
# DYSPNEA/STRIDOR: Initial dyspnea in this patient may be
multifactorial, with contributions from stent migration (patient
has had similar complications in the past), infection/PNA, or
aspiration. The sudden-onset dyspnea that the patient
experienced most likely relates to the collapse of the left lung
seen on imaging from the OSH. This event may also have been
related to stent displacement occluding the left mainstem
bronchus or to mucous plugging, bronchomalacia, or other
mechanical event. This problem seems to have been corrected
following intubation, as CXR here shows generally clear lungs
although there appears to be a L-sided effusion or ?partial
collapse obscuring the left heart border. Patient has a history
of CAD and is s/p CABG, although last echo shows normal LVEF and
no overt evidence of CHF. Stridor suggests upper airway
constriction, which could be related to underlying
stenosis/post-surgical changes or to upward migration of the
stent. The patient was given albuterol MDI (in place of home
nebs), fluticasone, gabapentin, and sigulair. Mucomyst was held
to avoid bronchospasm and Tussin was held to assist the patient
with clearing secretions. Rigid bronchoscopy on [**4-13**] showed
stent migration, and the stent was removed; necrotic tissue at
the buttonhole was debrided. He was able to be weaned from the
ventillator and maintained on trach mask with good O2 sats. He
was therefore called out to the general medicine floor on [**4-14**].
He returned to the OR on [**2155-4-15**] for repeat rigid bronchoscopy,
during which time IP just "took a look" and saw continued
inflammation and necrotic tissue. The stent was not replaced at
that time, and patient was discharged with a trach. Mr.
[**Known lastname 13144**] will return to [**Hospital1 18**] next week for another
bronchoscopy, at which time stent may be replaced.
.
# LEUKOCYTOSIS: Patient had mild leukocytosis on admission with
elevated PMNs but no bands. This was felt possibly secondary to
inflammation induced by stent displacement vs. underlying
infection (pulmonary source most likely). Patient was afebrile
on admission. Sputum returned with coag + staph (speciated as
MRSA) and the patient developed increased secretions, so he was
covered with antibiotics. Vancomycin was started on [**4-13**]; Mr.
[**Known lastname 13144**] was discharged on doxycycline 100mg Q12 for the next 3
days to complete an 8 day course on [**4-20**].
.
# CHRONIC RENAL FAILURE: Creatinine trending up from baseline of
2.1 to 2.5 during admission, with a creatinine of 2.2 upon
discharge. Urine lytes with Na 56, FeNa 1.69%.
.
# ANEMIA: Likely secondary to chronic disease/renal
insufficiency. Patient takes Procrit injections as outpatient.
.
# MICROSCOPIC HEMATURIA: Patient has had similar findings on
multiple prior U/A's. Could relate to placement of Foley
(traumatic) but cannot exclude underlying bladder pathology.
Review shows large blood but minimal RBCs, ?hemo/myoglobinuria.
CK normal and normal coags. Repeat U/A during admission still
showed blood, but decreased amount from prior. This issue
should be further explored as an outpatient.
.
# DM II: Stable; though with some FS > 200. Home glargine
regimen was increased from 18units QAM to 20units QAM. Patient
was also maintained on an insulin sliding scale during
admission. However, blood sugars still ranged from ~140-250.
.
# CAD: Denied any chest pain. EKG at baseline. Continued on home
meds amlodipine, metoprolol, simvastatin.
.
# HTN: Well-controlled. Continued on Amlodipine 10mg daily and
Lasix 40mg daily.
.
# ASTHMA: Continued on fluticasone, singulair, and albuterol
nebs prn; mucomyst held as above given risks of bronchospasm.
Fexofenadine also held during this admission (loratadine not
formulary).
.
# INSOMNIA: Continued on home trazodone.
.
# ANEMIA: Patient carries a diagnosis of borderline aplastic
anemia. He gets procrit injections every 2 months. He is due
for blood work at Quest labs on [**4-28**], and his PCP will
decide whether or not he needs procrit at that time.
Medications on Admission:
Mucormyst neb 20% vial [**3-7**] mL TID
Albuterol neb 3 mL TID
Amlodipine 10mg daily
Fluticasone 50mcg 2 sprays each nostril twice daily
Lasix 40mg daily
Gabapentin 100 mg three times daily
Glargine 18 units AM
Humalog insulin sliding scale
Metoprolol tartrate 50mg twice daily
Singlulair 10mg daily
Simvastatin 80mg daily
Loratadine 10mg daily
Mucinex 1200 mg PO daily
Trazodone 100 mg PO daily
Tussin 2 tsp TID
Procrit injections Q 2 months (not due at this time)
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Procrit Injection
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO once a day.
14. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day: SLIDING SCALE. AS DIRECTED.
15. Lantus 100 unit/mL Solution Sig: One (1) 20 Units
Subcutaneous QAM.
16. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO
every twelve (12) hours for 3 days.
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Primary:
1. Acute onset dyspnea
.
Secondary:
- DM type II
- Diastolic CHF
- CAD s/p emergent CABG (with radial and venous grafts)
complicated by wound infection, dehiscence "plastic surgery,"
complicated by infection, tracheostomy
- S/p intubation tracheal stenosis, s/p cervical tracheal
resection and reconstruction that was subsequently complicated
by anastomotic necrosis and dehiscence, requiring reoperation
and t-tube placement. T-tube was removed and tubular silicone
y-stent placed with external fixation.
- Asthma
- Chronic renal insufficiency
- Colon ca s/p partial colectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 13144**],
It was a pleasure taking care of you on this admission. You
came to the hospital because of an acute episode of shortness of
breath. It is thought that your tracheal stent migrated into
the wrong position, and that your breathing was made difficult
because a lot of inflammation and edematous tissue in your
airway. The tracheal stent was removed and a tracheostomy was
placed. You will return to interventional pulmonology clinic on
[**4-25**] for further treatment and evaluation.
.
The following changes were made to your medication:
1. STOP taking Tussin
2. STOP taking Mucomyst
3. START taking glargine 20units in the AM
4. START taking albuterol inhaler instead of nebulizer
5. START docycycline 100mg every 12 hours for 3 days through
[**4-20**].
.
Please take all of your medication as provided. Please keep all
of your follow-up appointments.
.
Your oxygen saturation is fine on room air (~99%), but it is
important that you have HUMIDIFIED oxygen for comfort. You will
also need frequent suctioning of your trach.
.
Return to the hospital if you develop worsening shortness of
breath, cough, difficulty breathing, chest pain, nausea,
vomiting, diarrhea, headache, trouble swallowing, pain with
urination, blood in your stools, fever, chills, or any other
concerning signs or symptoms.
Followup Instructions:
Department: INTERVENTIONAL PULMONARY
When: FRIDAY [**2155-4-25**] at 8:00 AM [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: CHEST DISEASE CENTER
When: FRIDAY [**2155-4-25**] at 8:30 AM [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: CHEST DISEASE CENTER
When: FRIDAY [**2155-4-25**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
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"284.9",
"428.30",
"403.90",
"996.59",
"V10.05",
"V45.81",
"519.02",
"478.6",
"585.9",
"518.81",
"518.0",
"250.00",
"493.90",
"599.72",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"96.71",
"97.23"
] |
icd9pcs
|
[
[
[]
]
] |
14957, 14998
|
8775, 13094
|
290, 361
|
15628, 15628
|
5648, 5653
|
17145, 18034
|
4425, 4487
|
13610, 14934
|
15019, 15607
|
13120, 13587
|
15778, 17122
|
4502, 5101
|
5115, 5629
|
3244, 3615
|
230, 252
|
389, 3225
|
5667, 8752
|
15643, 15754
|
3637, 4178
|
4194, 4409
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,782
| 155,848
|
52188+52189+59408
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2191-11-21**] Discharge Date: [**2191-11-29**]
Date of Birth: [**2113-2-9**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: [**Known firstname 2127**] [**Known lastname 107973**] is a 78 year old
woman who is status post a fall out of bed today presenting
with complaint of headache, status post a fall. She has a
significant past medical history including a stroke three
years ago secondary to an embolic stenting procedure
currently on Coumadin, diabetes, glaucoma, malignant breast
cancer, neck mass. The patient hit the back of her head on
the fall. There was no loss of consciousness according to
her daughter. After the fall she did have some dizziness.
The patient also became more lethargic. Her usual INR is
approximately 3.5 and she does have this checked weekly.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: The stenting procedure.
MEDICATIONS AT THE TIME OF ADMISSION: Metformin 500 mg once
per day, Lipitor 10 mg once per day and Coumadin.
PHYSICAL EXAMINATION: Heart rate was 67, blood pressure was
251/80, respiratory rate was 21, O2 saturation was 100
percent. She was in no apparent distress. She was alert and
oriented times three, conversant. Head, eyes, ears, nose and
throat showed pupils were be equal, round and reactive to
light. Extraocular movements were intact. She is
normocephalic, atraumatic, no erythema or ecchymoses. Heart
showed regular rate and rhythm, no murmurs, rubs or gallops.
Respiratory was clear to auscultation bilaterally. Abdomen
was soft, nontender without masses. Sensation was intact, no
known deficits. Motor examination showed good muscle tone,
mild right pronatal drift. She had 5/5 strength bilaterally
in the upper and lower extremities. Deep tendon reflexes
were 2 plus bilaterally - Achilles, patellar, biceps,
brachial radialis. Finger to nose was performed well.
Cranial nerves 2 through 12 were grossly intact.
LABORATORY DATA: At time of admission where white count of
10, hematocrit of 32.0, platelets of 286, PT 23.6, PTT 43.6,
INR 3.5. Sodium 139, potassium 4.90, chloride 103, bicarb
28, BUN 21, creatinine .9, glucose of 194. She had a
urinalysis that showed small blood, few bacteria. Protein
less than 30, glucose was trace and red cells were 6 to 10.
She had a CT that did show a right subdural hematoma with
early falxian herniation.
HOSPITAL COURSE: She was admitted and started on fresh
frozen plasma and vitamin K to reverse her INR. Her systolic
blood pressure was to be maintained at less than 140. The
[**Doctor Last Name 739**] did discuss with family the possibility of
surgery for evacuation of subdural hematoma versus
conservative management. He recommended surgery but the
family preferred to wait and see how she did. She was
admitted to the Surgical Intensive Care Unit for close
monitoring. She had a repeat head CT and did receive some
Mannitol. Her hematocrit did drop from 34 to 32 and she
received two units of packed red blood cells. Her stools
were guaiaced and surgery consult was recommended and they
recommended and abdominal and pelvic CT did not show any
evidence of bleeding. Her INR did reverse to 1.2. She did
have a chest x-ray which did show some fluid overload. She
was diuresed and intravenous was HEP-locked. Her hematocrit
became stable. On [**11-23**] she did complain of difficulty
with her vision and was unable to read. She had left
homonymous hemianopsia and a repeat CT scan was obtained that
did show a hypodensity in the right PCA distribution. She
was seen in consultation by neurology that was consistent
with acute infarct. They recommended blood pressures
maintained in the 150 to 160s, keep head of bed flat and to
hold off on anticoagulation for two to four weeks. She did
continue to improve slowly by steadily neurologically. She
was transferred to the neurology step-down unit. She was
seen in consultation by both occupational therapy and
physical therapy who felt that she would benefit from a
rehabilitation stay. She did have swallowing evaluation
which recommended pureed foods with no liquids, crushed
medications and tongue exercises. She did continue to
improve. Will screen for rehabilitation.
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2191-11-29**] 14:06:30
T: [**2191-11-29**] 15:40:49
Job#: [**Job Number 12218**]
Admission Date: [**2191-11-21**] Discharge Date:
Date of Birth: [**2113-2-9**] Sex: F
Service: NSU
ADDENDUM: Ms. [**Known lastname 107973**] remained an inpatient while she
continued to work with physical, occupational therapy and
speech therapy who recommended acute inpatient
rehabilitation. She remained neurologically intact and
improved on a daily basis with her strength and ability to
ambulate. Her speech still continued to remain garbled,
however, fluent. Her blood pressures at times had been
sporadic anywhere from the 110s to 200 range with a goal
blood pressure range of 130 to 170. On [**11-28**] her Norvasc was
changed from 5 mg to 10 mg daily which did seem to have
better control of her blood pressure.
DISCHARGE INSTRUCTIONS: She should have aggressive physical,
occupational and speech therapy. She should return for
neurological changes. She should keep her blood pressure
between 130 to 170 range. She should continue on aspirin
daily and discuss anticoagulation at follow up which will be
in two weeks with Dr. [**Last Name (STitle) 739**]. She will need a head CT
at that time.
DISCHARGE MEDICATIONS:
1. Atorvastatin calcium 10 mg 1 P.O. daily.
2. Latanoprost 0.005 drops 1 drop at bedtime.
3. Levothyroxine sodium 100 mcg 1 tablet daily.
4. Sertraline 50 mg 1.5 tablets daily.
5. Lisinopril 20 mg 2 tablets daily.
6. Bisacodyl 5 mg tablets delayed release 2 P.O. daily PRN.
7. Heparin 5000 units subcutaneous B.I.D.
8. Aspirin 81 mg chewable P.O. q day.
9. Colace 100 mg P.O. B.I.D.
10. Famotidine 20 mg 1 tablet P.O. B.I.D.
11. Atenolol 50 mg 1 tablet P.O. B.I.D.
12. Norvasc 5 mg 2 tablets P.O. daily.
13. Dorzolamide/timolol 2/0.05 drops 1 drop B.I.D.
14.
Metformin 500 mg 1 P.O. q A.M., and metformin 1000 mg P.O. q
P.M.
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern4) 57890**]
MEDQUIST36
D: [**2191-12-1**] 12:02:46
T: [**2191-12-1**] 14:51:38
Job#: [**Job Number 107974**]
Name: [**Known lastname 17644**],[**Known firstname 1194**] Unit No: [**Numeric Identifier 17645**]
Admission Date: [**2191-11-21**] Discharge Date: [**2191-12-2**]
Date of Birth: [**2113-2-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1698**]
Addendum:
pt continued to improve. PT/OT continued to work with the pt,
and [**Hospital 17646**] rehab. After much discussion, Pt wished to be
sent to [**Hospital1 **]. Pt d/c'd to [**Hospital1 **] on [**12-2**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]
Completed by:[**2191-12-2**]
|
[
"599.7",
"564.00",
"427.31",
"434.91",
"V58.61",
"285.1",
"852.21",
"E884.4",
"250.00",
"276.6",
"368.46",
"V12.59",
"V10.3",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"38.91",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
7149, 7344
|
5629, 7126
|
2405, 5219
|
5244, 5606
|
880, 1017
|
1040, 2387
|
166, 822
|
845, 856
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,330
| 106,589
|
36382
|
Discharge summary
|
report
|
Admission Date: [**2112-7-15**] [**Month/Day/Year **] Date: [**2112-8-5**]
Date of Birth: [**2065-5-16**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2112-7-15**] Bilateral External Ventricular Drain placement
[**2112-7-15**] Diagnostic Cerebral Angiogram
History of Present Illness:
47F who was in her usual state of health until around 3pm this
afternoon when she c/o a severe headache, she than began
vomiting. She was taken to [**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] where a head CT
showed IVH, she was intubated and medflighted to [**Hospital1 18**]. Upon
arrival to the ER, her head CT was reviewed and bilateral EVDs
were placed given the significant IVH.
Past Medical History:
[**2109**]: Thalamic bleed, admitted to [**Hospital1 18**] Stroke, angio showed
[**Last Name (un) **]
[**Last Name (un) **] and 2 small aneurysms near the ventricles. Patient was seen
at [**Hospital1 112**] and underwent bypass surgery with Dr [**Last Name (STitle) **] for [**Last Name (un) **] [**Last Name (un) **].
Depression- was on medication but discontinued secondary to side
effects.
Social History:
Lives at home with husband and young child. Denies EtOH,
tobacco, substance abuse. Was never a smoker, family denies
ETOH.
Family History:
Unknown hx of vascular anomalies
Physical Exam:
ADMISSION PHYSICAL EXAM:
Gen: Intubated, sedated for EVD placement
HEENT: Old R temporal crani scar
Neuro:
No [**Last Name (LF) **], [**First Name3 (LF) 2995**] to stim, bringing torso off the bed, no commands,
PERRL but sluggish, + cough.
[**First Name3 (LF) 894**] PHYSICAL EXAM:
General: thin F in NAD, opens eyes to voice, speaks softly,
often tearful
HEENT: R and L EVD scars well-healed. Staples in place over R
EVD scar. PERRL, mild photophobia (significantly improved).
Negative Kernig/Brudzinski.
Neuro:
-Mental status: AAOx2 (person, place). Comprehension intact.
Follows simple commands, midline and appendicular.
-Cranial nerves: CN II-XII grossly intact. +mild photophobia,
significantly improved.
-Strength: [**5-21**] all extremities
-Sensation: intact throughout
Pertinent Results:
[**7-15**] CT head:
Bilateral IVH, left ventricle fully casted, right ventricle
appears about 80% casted, blood noted in third and fourth
ventricle. No SAH can be appreciated in the OSH scan. Some edema
near the pons.
[**7-16**] CT head: 1. No change in extensive intraventricular blood,
status post bilateral ventricular drain placements.
2. Effacement of the basal cisterns and sulci of the occipital
lobe. Low
lying cerebellar tonsils is concerning for herniation, unchanged
from prior study.
3. Diffuse subarachnoid hemorrhage, slightly increased from
prior.
[**7-16**] Portable CXR:
IMPRESSION:
1. Nasogastric tube courses below the diaphragm with its tip
coiled likely within the stomach. An endotracheal tube remains
in place in satisfactory position. The lungs are well inflated
without evidence of focal airspace consolidation, pleural
effusions, or pneumothorax. Overall, cardiac and mediastinal
contours are within normal limits.
[**7-18**] CT head: IMPRESSION:
1. Interval improvement in hydrocephalus and intraventricular
hemorrhage. No new hemorrhage.
2. Unchanged position of bifrontal approach EVDs.
3. Subarachnoid hemorrhage is no longer visualized, compatible
with evolution of blood products.
[**7-22**] head CT
IMPRESSION:
1. Interval evolution of blood products with improvement in
intraventricular
hemorrhage and no significant change in size of ventricles.
2. Unchanged position of bifrontal approach EVDs.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2112-7-24**]
9:52 AM
IMPRESSION:
Interval removal of a left frontal approach EVD with
post-procedural small
amount of air in the right frontal [**Doctor Last Name 534**] and moderate amount of
air in the
right temporal [**Doctor Last Name 534**].
1. Allowing for the new air in the ventricular system, the right
lateral
ventricle is unchanged and there is no evidence of hydrocephalus
or new mass effect.
2. Right frontoparietal subarachnoid hemorrhage is stable-more
conspicuous on prior exam from [**2112-7-22**]- attention on f/u.
CHEST (PORTABLE AP) Study Date of [**2112-7-25**] 12:48 AM
FINDINGS: In comparison with the study of [**7-21**], there is no
change or evidence of acute cardiopulmonary disease.
Specifically, no pneumonia, vascular congestion, or pleural
effusion.
CHEST PORT. LINE PLACEMENT Study Date of [**2112-7-25**] 8:56 AM
Right PICC line has been inserted with the tip at the level of
mid SVC. Heart size and mediastinum are unremarkable. Lungs
are essentially clear.
[**2112-7-25**] PORTABLE ABDOMEN: Air is seen throughout non-distended
loops of small and large bowel. There is moderate amount of
dense stool throughout colon, particularly at the cecum. No
evidence of pneumoperitoneum on this single supine film.
Osseous structures are unremarkable.
IMPRESSION: Non-obstructive bowel gas pattern.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2112-7-27**]
3:15 PM
CONCLUSION: Status post revision of EVD. Increased air in
frontal [**Doctor Last Name 534**] of the lateral ventricle. Decreased air in the
temporal [**Doctor Last Name 534**] of the right
lateral ventricle. Small amount of blood seen in the bilateral
occipital
horns of the lateral ventricle is unchanged compared to prior
study. No
evidence of hydrocephalus. No evidence of new hemorrhage.
[**2112-7-31**] CT Head w/o Contrast: Decrease in right lateral
ventricular gas and decreased intraventricular blood. Unchanged
position of a right frontal approach ventriculostomy catheter in
the parenchyma adjacent to the left side of third ventricle.
Correlate clinically if this is the desired position. No new
acute hemorrhage is detected
PORTABLE CHEST X-RAY ([**2112-8-4**]): As compared to the previous
radiograph, there is no relevant change. Normal size of the
cardiac silhouette. No acute changes such as pneumonia or
pulmonary edema. No pleural effusions.
NONCONTRAST HEAD CT ([**2112-8-4**]): Status post removal of VP shunt.
Normal postsurgical change. No evidence of acute hemorrhage or
findings to suggest hydrocephalus.
MICROBIOLOGY:
[**2112-7-21**] 11:36 am URINE Source: Catheter.
URINE CULTURE (Final [**2112-7-23**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
[**2112-7-23**] 1:09 pm URINE Source: Catheter.
URINE CULTURE (Final [**2112-7-25**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
[**2112-7-25**] 12:52 am URINE Source: Catheter.
**FINAL REPORT [**2112-7-26**]**
URINE CULTURE (Final [**2112-7-26**]):
GRAM POSITIVE COCCUS(COCCI). ~8OOO/ML.
[**2112-7-25**] 9:55 am CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final [**2112-7-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Reported to and read back by DR. [**First Name (STitle) **] [**Numeric Identifier 82429**], [**2112-7-25**],
1:30PM.
FLUID CULTURE (Final [**2112-7-29**]):
STAPHYLOCOCCUS EPIDERMIDIS. MODERATE GROWTH.
SPECIATION REQUESTED BY DR. [**Last Name (STitle) **] #[**Numeric Identifier 82430**] [**2112-7-27**].
ENTEROCOCCUS SP.. SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
Sensitivity testing performed by Sensititre.
STAPH AUREUS COAG +. RARE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SECOND MORPHOLOGY.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
| ENTEROCOCCUS SP.
| |
CORYNEBACTERIUM SPECIES (DI
| | |
STAPH AUREUS COA
| | | |
STAPH
| | | |
|
AMPICILLIN------------ <=2 S
GENTAMICIN------------ <=0.5 S <=2 S <=0.5 S
<=0.5 S
OXACILLIN-------------<=0.25 S 0.5 S
=>4 R
PENICILLIN G---------- 8 S 0.25 S
RIFAMPIN--------------
<=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S 1 S <=1 S
1 S
[**2112-7-25**] 1:50 pm CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final [**2112-7-25**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Reported to and read back by [**First Name8 (NamePattern2) **] [**Doctor Last Name 5445**] @ 1645,
[**2112-7-25**].
FLUID CULTURE (Final [**2112-7-28**]):
STAPHYLOCOCCUS EPIDERMIDIS. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-3181N [**2112-7-25**].
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-3181N [**2112-7-25**].
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-3181N [**2112-7-25**].
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2112-7-26**] 2:08 pm FOREIGN BODY Site: CATHETER
EXTERNAL VENTRICULAR DRAIN CATHETER.
**FINAL REPORT [**2112-7-28**]**
WOUND CULTURE (Final [**2112-7-28**]): NO GROWTH.
[**2112-7-31**] 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-PICC.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2112-7-31**] 4:42 pm URINE Source: Catheter.
**FINAL REPORT [**2112-8-1**]**
URINE CULTURE (Final [**2112-8-1**]): NO GROWTH.
[**2112-7-31**] 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-PICC.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2112-7-31**] 5:00 pm BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending):
[**2112-8-1**] 11:17 am CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final [**2112-8-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2112-8-4**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2112-8-4**] 5:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
On [**2112-7-15**], Ms. [**Known lastname **] required urgent placement of bilateral
EVDs for obstructive hydrocephalus in the setting of bilateral
intraventricular hemorrhage. The EVDS were placed emergently in
the ED and she was subsequently transferred to the Neuro-ICU
intubated.
The patient was extubated on [**2112-7-16**], HD #2, without event. Her
total drain output was maintained at > 20 mL/hr. On [**2112-7-17**], it
was noted that right EVD drained well with left EVD having
minimal output. Protocol drain trouble shooting efforts,
improved the left EVD output.
On HD #4, [**2112-7-18**], bleeding from EVD site was observed on rounds.
PTT was elevated at 64.8. Patient's subcutaneous heparin was
temporarility discontinued. The head CT remained stable.
On HD #5, [**2112-7-19**], patient's subcutaneous heparin was
re-initiated with a [**Hospital1 **] dosing schedule rather than tid. On
examination, patiet appeared delerious, which was attributed to
sleep deprivation.
On HD #6, [**2112-7-20**], patient remained agiated on examination. We
continued to monitor her closely in the neuro-ICU.
On [**7-21**], PTT was elevated to 57.1, SQH was decreased to 2500
units. She was febrile to 101.1 overnight, urine culture was
sent. Patient reported significant headache and toradol was
added. Her L EVD was clamped in attempt to remove and R drain
remained open.
On [**7-22**], there were no issues with elevated ICPs while L EVD
clamped. A head CT was done which showed stable ventricle size
and L EVD was removed. R EVD was clamped in attempt to removed
as well. She was afebrile overnight. Patient reported pain and
aggitation, she was placed on standing toradol and prednisone.
On [**7-23**],The patient was found to have an enterococcus UTI and was
started Vancomycin. The patients Intercranial pressures were
25-30 and the EVD was opened.
On [**7-24**], The External Ventricular Drain was open and the ICP was
10. The patient had complaints of severe headache and a Head Ct
was performed which was consistent with interval removal of a
left frontal approach EVD with post-procedural small
amount of air in the right frontal [**Doctor Last Name 534**] and moderate amount of
air in the
right temporal [**Doctor Last Name 534**]. Allowing for the new air in the ventricular
system, the right lateral ventricle is unchanged and there is no
evidence of hydrocephalus or new mass
effect. Right frontoparietal subarachnoid hemorrhage is stable.
Ampicillin was added by ICU for the UTI. On exam, the patient
opened eyes to command, exhibited signs of photophobia. The
patient was not answering questions secondary to pain, but did
follow commands in all 4 extremities.
On [**7-25**], The patient had a temperature of 101 overnight and
urine/blood/Cerebral SpinalFluid cultures were sent. The CSF
culture prelim findings were consistent with +3Gram Postive
Cocci and 2+Gram Negative Rods. There was a question that this
may have been a contaminant and a second CSF culture was sent.
The patient was more lethargic in am and this was thought to be
due to fever and lack of sleep. The neurological assessment was
changed to every four hours to allow for sleep. The patient
became more alert as the day progresses and followed command
more readily. The serum sodium was 129. Urine lytes were send
dueto urine output of 200cc /hr for repeated hours and were
consistent with Creatinine of 15, serum sodium 10, potassium 9,
chloride of 16, and Osmolality of 92. Due to poor nutritional
intake the patient was initiated on IVF at 75cc/hr. The
External ventricular drain was open and draining well. The EVD
was level at 10 above the tragus. A Infectious Disease consult
was called to recommend planning for laproscopic Ventricular
Peritoneal shunt and steroid therapy for headache given fevers
101-103 and infection. The White Blood Count was slightly
elevated at 11.1. The patient continued to complain of servere
headache and neck pain. Topiramate (Topamax) 25 mg PO/NG [**Hospital1 **] for
headache was initiated perthe ICU team. A KUB was performed
given temperature of 103 for abdominal tenderness. On exam, the
patient opened eyes to voice and followed intermitent commands.
The pupils were equal reactive. The patient briskly localized.
The patient moved the bilateral lower extremities to command
intermitently.
On [**7-26**], pt continued spiking fevers (Tmax 102.8). Her
antibiotics were switched to Vanc/Meropenam per ID recs for
empiric treatment of meningitis (Vanc also covering her
pan-sensitive UTI). Her EVD was replaced in the OR out of
concern that EVD contamination had caused the meningitis.
On [**7-27**], pt remained confused with persistent photophobia and
meningismus. Head CT assessing EVD position showed Status post
revision of EVD. Increased air in frontal [**Doctor Last Name 534**] of the lateral
ventricle. Decreased air in the temporal [**Doctor Last Name 534**] of the right
lateral ventricle. Small amount of blood seen in the bilateral
occipital
horns of the lateral ventricle is unchanged compared to prior
study. No
evidence of hydrocephalus. No evidence of new hemorrhage. The
Cerebral Spinal Fluid preliminary culture grew gram negative
staph, cornyebacterium (diptheroids), enterococcus (rare
growth). Per infectious disease recommendations antibiotics were
narrowed to Vancomycin 1g every 8 hrs for External Ventricular
Drain-associated meningitis. Severe headaches persist and
patient pain managed with fioricet/dilaudid/topomax.
On [**7-28**], The patient exam was slightly improved exam improved
and the patient was noted to have multiple loose stools. A urine
culture was sent which was negative.
On [**7-29**], The patient experienced fever to 101.8 overnight, The
external ventricular drain was clamped as a trial to see if the
patient would tolerate it. The Intercranial Pressures were low
0-3 in the morning. Intercranial pressures rose, prompting the
right EVD to be re-opened wtih 5 mL of drainage. Pysical
Therapy and Occupational Therapy orders were placed. The foley
catheter was discontinue. The patient has had poor po intake due
to pain and delerium and was initiated on intravenous fluid at a
rate of 75cc/hr.
On [**7-30**], the patient remained agitated during examination. As
her ICPs were [**2-19**], her EVD was reclamped. ICPs remained near 3.
Ms. [**Known lastname **] Foley was replaced per nursing request to optimize
care.
On [**7-31**], patient's examination was dramatically improved.
Agitation was substantially decreased and patient was able to
move all four extremities to command. The EVD remained clamped
with tolerable ICP. Repeat head CT revealed decrease in right
lateral ventricular air and decreased intraventricular blood.
In the afternoon, the patient was febrile to 100.3, a fever
workup was institued and CSF cultures were obtained.
[**8-1**], patient spiked to Tm 102.8. As per ID's recommendations we
change her antibiotics from Vancomycin to Linezolid to rule out
Vancomycin as the source of her fevers. Her EVD was removed and
a CSF sample was sent again. Patient no longer requires ICU
level care and is ready for transfer to a SD unit.
On [**8-2**], patient remained afebrile on the floor; photophobia
mildly improved but still confused and oriented only to self.
Her right EVD staples were removed. CSF cultures have shown no
growth to date since the positive cultures on [**7-25**].
On [**8-3**], Patient self-DC'd her PICC twice, so her Linezolid was
switched to PO (confirmed OK with ID).
On [**8-4**], patient spiked fever to 102.3. Blood cultures were sent
(no growth to date). Chest x-ray showed no infiltrate. Unable to
obtain urine culture as patient incontinent and refusing
straight cath.
On [**8-5**], patient was discharged to rehab.
=====================================
TRANSITION OF CARE:
-Studies pending on [**Month/Year (2) **]: blood cx ([**7-31**], [**8-4**])
-If spikes fever, consider UTI (unable to obtain UCx after pt
spiked fever on [**8-4**])
-Needs right-sided head staples removed on [**2112-8-8**]
-Needs follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks
(phone # [**Telephone/Fax (1) 4296**]). Will need head CT prior to appointment.
Medications on Admission:
none
[**Telephone/Fax (1) **] Medications:
1. Acetaminophen-Caff-Butalbital [**1-18**] TAB PO Q4H:PRN pain
max apap 4g/day
2. Heparin 2500 UNIT SC BID
3. Linezolid 600 mg PO Q12H
Use while patient has no IV access instead of IV dosing
4. Topiramate (Topamax) 25 mg PO BID
5. DiphenhydrAMINE 25 mg PO Q6H:PRN Itch
6. Docusate Sodium 100 mg PO BID
7. Senna 1 TAB PO BID Constipation
[**Month/Day (2) **] Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
[**Hospital3 **] Diagnosis:
Intraventricular hemorrhage
Cerebral AVM
UTI
EVD-associated meningitis
Chronic pain
Hypertention
Acute confusion/delerium
Altered mental status
[**Hospital3 **] Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Hospital3 **] Instructions:
Ms. [**Known lastname **],
It was a pleasure participating in your care at [**Hospital1 **] Hospital. You were admitted to the hospital with
headache, nausea and vomiting. You were found to have
intraventricular hemorrhage (bleeding into the ventricles of
your brain), caused by your [**Last Name (un) 24206**] [**Last Name (un) 24206**] disease. Extraventricular
drains (EVDs) were placed for monitoring and drainage, and you
were admitted to the ICU. In the ICU you developed meningitis -
infection of the fluid surrounding the brain. You were treated
with antibiotics and your meningitis resolved. Your EVDs were
then removed and you were transferred to the medical floor where
your symptoms continued improving. Because you are still too
weak to go home alone, you are being discharged to rehab.
We made the following changes to your medications:
1. STARTED Linezolid 600mg by mouth every 12 hours for your
meningitis. (Last day = [**2112-8-7**])
2. STARTED Fioricet (acetaminophen-caffeine-butalbital) 1-2 tabs
every 4 hours as needed for headache
3. STARTED Topomax (topiramate) 25mg by mouth twice daily for
headache
4. STARTED Benadryl 25mg by mouth every 6 hours as needed for
itching
5. STARTED Heparin subcutaneous 2500mg twice daily to prevent
blood clots in the legs until you are able to walk independently
6. STARTED Colace (docusate) and Senna for constipation
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion, lethargy or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 11314**] to schedule an appointment with Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
|
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icd9cm
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[
[
[]
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[
"96.71",
"03.31",
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"01.27",
"88.41",
"00.14",
"38.93",
"02.21"
] |
icd9pcs
|
[
[
[]
]
] |
12569, 20831
|
326, 437
|
2301, 2312
|
24027, 24392
|
1451, 1486
|
20857, 21525
|
2144, 2282
|
1784, 2016
|
12449, 12511
|
12546, 12546
|
22563, 24004
|
278, 288
|
465, 876
|
3272, 11203
|
21540, 22534
|
898, 1293
|
1309, 1435
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,856
| 157,810
|
1247
|
Discharge summary
|
report
|
Admission Date: [**2195-10-6**] Discharge Date: [**2195-10-21**]
Date of Birth: [**2126-3-16**] Sex: M
Service: Neurosurgery
CHIEF COMPLAINT: The patient with 1.5-day history of feeling
sick.
HISTORY OF PRESENT ILLNESS: This is a 69-year-old
left-handed man with a history of 1.5 days of "feeling sick"
which was further described as dizziness with a sense of
spinning, who reportedly fell down one day prior to
admission, was unable to get up out of bed, and lost control
of his bowels on the day of admission, and was noted also to
have slurred speech in the preceding 24 hours prior to
admission. He was brought to the Emergency Department and
then found to have a right cerebellar bleed on CT scan.
REVIEW OF SYSTEMS: Review of systems was unremarkable in the
past several months prior to admission.
PAST MEDICAL HISTORY: (Past medical history is pertinent
for)
1. A stroke in the middle cerebellar peduncle in [**2193**].
2. History of hernia.
3. History of cholecystectomy.
4. History of abdominal aortic aneurysm repair.
5. History of a myocardial infarction in [**2181**].
MEDICATIONS ON ADMISSION: Current medications include
hydrochlorothiazide, Lipitor, Motrin, Univasc, and Plavix.
SOCIAL HISTORY: Denied use of alcohol. Denied smoking.
Denied use of illicit drugs, and reportedly worked as a parts
coordinator for a mechanic.
RADIOLOGY/IMAGING: CT scan at the time of admission showed
increased ventricular size with mild edema of the right
cerebellar area and blood in the fourth ventricle. There was
hemorrhage also noted in the right cerebellum.
LABORATORY DATA ON ADMISSION: Laboratories at the time of
admission were within normal limits. PT was 12.8, PTT 21.7,
INR 1.1. On physical examination, vital signs were
temperature of 97.5, heart rate 77, respiratory rate 16,
blood pressure 187/88, oxygen saturation 100% on 3 liters at
the time of physical examination. In general, the patient
was noted to be normocephalic and atraumatic but sleepy, yet
arousable. He was alert when aroused and was oriented to the
hospital, and yet thought it was [**2195-11-9**]. He could
repeat the days of the week forward and backwards. Cranial
nerves II through XII were within normal limits with the
exception of mild nystagmus on right lateral gaze and upward
gaze. Motor examination showed no tremor, and muscle
strength of the upper and lower extremities were within
normal limits. Sensory examination to light touch and
pinprick was within normal limits. Coordination showed
finger-to-nose testing on the right to be worse than the
left. Fine alternating movements were intact. Heel-to-shin
was relatively intact with very little evidence of mild
truncal ataxia. Gait was not tested at the time of this
examination.
HOSPITAL COURSE: Due to the clinical and CT findings of the
cerebellar bleed, the patient was admitted to the Intensive
Care Unit. Arrangements were made for an external
ventricular drainage shunt. Blood pressure was controlled
with Nipride, and the patient subsequently underwent
placement of a right-sided ventricular drainage tube. He
tolerated the procedure well, and the fluid was noted to be
under moderate pressure, and the patient was maintained in
the Surgical Intensive Care Unit for several days.
The patient stabilized, and the drain was clamped late on the
[**10-11**]. The patient tolerated the clamping of the drain
without any evidence of hydrocephalus; and, therefore the
drain was removed on [**10-13**]. Follow-up CT scans showed
no recurrence of hydrocephalus. A diagnostic angiogram was
performed on [**10-15**] showing a mild vertebral and mild
basilar artery stenoses. Again, serial CT scans of the head
showed no evidence of recurrent hydrocephalus. The patient
remained moderately confused with occasional errors in place,
time, date, and other simple measures of orientation. He was
occasionally found to be attempting to get out of bed without
assistance, and on rare occasion required restraints for his
safety.
The remainder of the post cerebellar bleed hospitalization
was essentially unremarkable. On the day of and the day
prior to discharge, the patient was noted to be afebrile with
stable vital signs. He was awake, alert and oriented
occasionally to time and place but not date. He was
otherwise felt to be neurologically stable. Arrangements
were made for rehabilitation placement on the stroke unit of
the local rehabilitation hospital, and the patient was
subsequently discharged to the rehabilitation hospital on the
morning of [**2195-10-21**].
MEDICATIONS ON DISCHARGE: (Medications at the time of
discharge included)
1. Univasc 7.5 mg p.o. q.d.
2. Zantac 150 mg p.o. b.i.d.
3. Lopressor 50 mg p.o. b.i.d. (with instructions to hold
the Lopressor if systolic blood pressure was below 100 or
heart rate was below 55 per minute).
DISCHARGE GOALS: Anticipated goals were to include
activities of daily living. Rehabilitation potential was
considered very good.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Name8 (MD) 5474**]
MEDQUIST36
D: [**2195-10-21**] 08:05
T: [**2195-10-21**] 07:10
JOB#: [**Job Number 7786**]
|
[
"431",
"272.0",
"412",
"414.01",
"401.9",
"435.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
4613, 5253
|
1143, 1231
|
2801, 4586
|
749, 832
|
164, 215
|
244, 729
|
1637, 2782
|
855, 1116
|
1248, 1622
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,078
| 152,451
|
7034
|
Discharge summary
|
report
|
Admission Date: [**2101-7-5**] Discharge Date: [**2101-7-12**]
Date of Birth: [**2019-12-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Bactrim / Amoxicillin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**7-6**] cardiac catherization
[**7-7**] coronary artery bypass graft surgery (left internal mammary
artery > left anterior descending, saphenous vein graft > obtuse
marginal, saphenous vein graft > posterior descending artery)
History of Present Illness:
Mr. [**Known lastname **] is a 81 yo M with PMH HTN, CKD s/p nephrectomy for
RCC admitted for prehydration for elective cardiac
catheterization in the morning. He reports having about [**3-6**]
episodes of transient chest pain with exertion over the past
several months. The chest pain occurred while mowing the lawn,
lasted less than once minute, resolved with standing still and
did not return with resuming activity. Denies any associate
symptoms of nausea, vomiting, dyspnea, diaphoresis. He had a
nuclear stress test to further evaluate, report is not available
but per Dr.[**Name (NI) 3101**] recent note, nuclear stress showed EF 68%,
evidence of anterior and anteroapical ischemia with a preserved
EF and evidence of transient ischemic dilatation.
Past Medical History:
1. Hypertension.
2. Chronic renal insufficiency status post nephrectomy for 1-1/2
kidneys and history of renal cell carcinoma. Baseline creatinine
1.5.
3. h/o gastroparesis
4. h/o colon adenoma polyps
5. Gout
6. Schatzki's ring
Social History:
Lives at home with his wife, retired tool maker, current mows
lawn at golf course 5 days per week, denies any h/o tobacco or
ETOH.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS T97.3 BP 170/83 HR 80 RR 18 99% RA 77.4kg
Gen: well appearing, elderly caucasian male, alert and Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP flat, no carotid artery bruits
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, slight basilar
crackles, no wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits. Ventral hernia is soft and
compressible
Ext: warm, no edema or cyanosis, DP's full
Skin: No stasis dermatitis, ulcers, or xanthomas.
Pertinent Results:
[**2101-7-10**] 06:55AM BLOOD WBC-10.8 RBC-3.06* Hgb-10.4* Hct-29.0*
MCV-95 MCH-33.9* MCHC-35.8* RDW-12.8 Plt Ct-128*
[**2101-7-5**] 06:52PM BLOOD WBC-9.1 RBC-4.41* Hgb-14.2 Hct-41.3
MCV-94 MCH-32.2* MCHC-34.4 RDW-13.2 Plt Ct-201
[**2101-7-6**] 11:00AM BLOOD Neuts-68.3 Lymphs-18.8 Monos-7.2 Eos-4.8*
Baso-0.9
[**2101-7-10**] 06:55AM BLOOD Plt Ct-128*
[**2101-7-12**] 04:50AM BLOOD K-4.1
[**2101-7-11**] 05:45AM BLOOD Glucose-119* UreaN-19 Creat-1.6* Na-136
K-3.1* Cl-98 HCO3-29 AnGap-12
[**2101-7-5**] 06:52PM BLOOD Glucose-121* UreaN-25* Creat-1.8* Na-140
K-4.2 Cl-103
[**2101-7-11**] 05:45AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
[**2101-7-6**] 11:00AM BLOOD VitB12-159* Folate-15.8 Hapto-125
Ferritn-457*
[**2101-7-6**] 04:58PM BLOOD %HbA1c-5.9
Normal sinus rhythm with P-R interval equal to 0.14. Late R wave
transition.
T wave abnormalities with T wave inversions and downsloping ST
segment
depressions in leads III and aVF which are new. Compared to the
previous
tracing of [**2101-7-8**] clinical correlation is suggested.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 140 72 [**Telephone/Fax (2) 26272**]4
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 26273**]Portable TTE
(Complete) Done [**2101-7-6**] at 1:36:31 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**]
[**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 11063**] Cardiology
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Street Address(2) 8667**], [**Hospital Ward Name **] 4
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2019-12-19**]
Age (years): 81 M Hgt (in): 68
BP (mm Hg): 159/75 Wgt (lb): 170
HR (bpm): 60 BSA (m2): 1.91 m2
Indication: Left ventricular function. Preoperative assessment
prior to CABG.
ICD-9 Codes: 414.8
Test Information
Date/Time: [**2101-7-6**] at 13:36 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West [**Hospital Ward Name 121**]
[**3-6**]
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.6 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.5 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.4 cm
Left Ventricle - Fractional Shortening: 0.48 >= 0.29
Left Ventricle - Ejection Fraction: 55% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 10 < 15
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 0.88
Mitral Valve - E Wave deceleration time: 239 ms 140-250 ms
TR Gradient (+ RA = PASP): <= 25 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 1.1 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
regional LV systolic dysfunction. No LV mass/thrombus. No
resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Mildly dilated aortic sinus.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Trivial MR. Normal LV inflow pattern for age.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with basal
inferior hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2101-7-6**] 15:43
Brief Hospital Course:
Mr. [**Known lastname **] is an 81 yo M with PMH of HTN, CKD s/p nephrectomy
for RCC admitted for elective cardiac catheterization and
precath hydration. Cardiac catherization revealed coronary
artery disease and he was referred for surgical evaluation. He
underwent preoperative workup and was transferred to the
operating [****] for coronary artery bypass surgery. See
operative report for further details. He received perioperative
vancomycin due to pencillin allergy. He was trasnferred to the
CVICU for hemodynamic monitoring. In the first twenty four
hours he was weaned from sedation, awoke, was extubated but
required reintubation due to apnea. He remained intubated for a
few hours, was neurologically intact and was reextubated without
complications. He was started on beta blockers and diuretics,
transfered to the floor POD 1. He continued to progress but
developed atrial fibrillation POD 3 and was treated with beta
blockers and amiodarone, and converted to normal sinus rhythm.
Physical therapy worked with him on strength and mobility. He
was ready for discharge home POD 5 with VNA services.
Medications on Admission:
Nitroglycerin p.r.n.
allopurinol 100mg daily
aspirin 325 mg p.o. daily.
simvastatin 40 mg p.o. q.h.s.
metoprolol 12.5 mg p.o. b.i.d.
Plavix 75mg daily
amlodipine 10mg qam
furosemide 20mg qam
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day:
please take twice a day for 5 days then decrease to once daily.
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:*0*
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
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:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day) as needed.
10. Ocean Nasal 0.65 % Spray, Non-Aerosol Sig: One (1) Nasal
every six (6) hours as needed for nasal congestion.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Chronic kidney disease
Renal cell cancer
Gout
Benign prostatic hypertrophy
Schatzki's ring
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 20458**] in 1 week ([**Telephone/Fax (1) 26274**]) please call for
appointment
Dr [**First Name (STitle) **] in [**3-6**] weeks ([**Telephone/Fax (1) 4022**]) please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2101-8-4**]
1:30
Completed by:[**2101-7-12**]
|
[
"V10.52",
"274.9",
"585.9",
"411.1",
"786.03",
"427.31",
"403.90",
"V45.73",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.61",
"88.72",
"37.22",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
11167, 11218
|
8382, 9502
|
312, 543
|
11399, 11406
|
2693, 8359
|
11917, 12497
|
1746, 1828
|
9744, 11144
|
11239, 11378
|
9528, 9721
|
11430, 11894
|
1843, 2674
|
262, 274
|
571, 1329
|
1351, 1582
|
1598, 1730
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,559
| 144,469
|
54808
|
Discharge summary
|
report
|
Admission Date: [**2129-5-1**] Discharge Date: [**2129-5-4**]
Date of Birth: [**2064-8-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / aspirin / colchicine
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest and back pain
Major Surgical or Invasive Procedure:
Right Heart Catheterization
History of Present Illness:
Ms. [**Known lastname 112022**] is a 64 year-old female with PMH of diabetes
mellitus, hyperlipidemia, and hypothyroidism who is transferred
from OSH with acute onset of chest/back pain and concern for
aortic dissection. Patient was in her usual state of health
until this morning at 2AM, when she woke up with acute back -
central, bilateral subscapular, and chest pain. The chest pain
was b/l and pressure like in quality. It was exacerbated by
movement and deep inspiration. She felt some SOB, denied
palpitations. Has never had similar pain before. At the same
time, she also had alternating chills/shakes with feeling
extremely hot. Pt was also having diarrhea until 7am. She went
to OSH in the early afternoon (see below for detail) At
baseline, patient walks for 1 hr 3-4 times per week, independent
in ADLs, some sob after walking up a flight of stairs but no
chest pain. Pt is up to date with malignancy screening: last
mammogram 1 year ago was normal, last colonoscopy was in [**2125**],
had 1 polyp, was told to repeat in 5 years. Has traveled to
[**Country 3400**] in [**Month (only) 404**]. No sick contacts, no contact with small
children.
.
Patient initially presented to an OSH where initial vitals were
T 99 HR 120 BP 106/73 RR 24 O2 95 2L. Pain was [**5-15**], relieved
with morphine. Labs relevant for wbc 10.2 hct 38.2 plt 237 Na
136 K 4.2 Cr 0.7 BUN 14 Cl 100 HCO3 26 trop i neg. Per wet read
at OSH, chest x-ray showed marked cardiomegaly and suggestion of
mild infiltrate at L base. CTA chest w/ contrast showed large
pericardial effusion, no PE. There was some concern that
patient had an aortic dissection causing blood to leak into the
pericardium, and she was tranferred to [**Hospital1 18**] for further
evaluation.
.
In the [**Hospital1 18**] ED, initial vitals were T 98.7 HR 114 BP 130/79 RR
23 O2 97 2L NC. CBC and Chem7 were wnl. She underwent another
CTA to urgently evaluate for dissection given acute back pain
and effusion. No dissection was seen per preliminary report,
but a large, nonhemorrhagic pericardial effusion was noted. A
bedside echo showed a large pericardial effusion, but no RV
diastolic collapse or respiratory variation of flow across
mitral or tricuspid valve. A pulsus was between 12 and 16.
Pericardiocentesis was deferred as pt had no signs of tamponade
and she was admitted to the CCU for close monitoring.
.
On arrival to the floor, patient feels okay. States that her
chest pain is now [**3-15**], worse with deep inspiration. No SOB, no
abd pain, no nausea, no palpitations. No joint pains, no rashes.
.
REVIEW OF SYSTEMS
as above
Past Medical History:
DM II
Hyperlipidemia
Hypothyroidism
vocal cord CA [**2114**] with recurrence [**2115**] (details unclear)
Social History:
From [**Country 3400**], French is primary language. Lives in 2 family
house on the [**Location (un) 448**], son lives upstairs
-Tobacco history: smoked for 22 years 2 packs per day, quit in
[**2116**]
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 100.5 BP 123/63 HR 117 RR 22 O2 sat 97 2L NC
GENERAL: WDWN F in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Mucous membranes
slightly dry
NECK: Supple with no JVD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4, no rub. Pulsus 12.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
DISCHARGE PHYSICAL EXAM:
VS afebrile, BP 120-140s/70-90s, HR 94-120s, saturations 96% RA
exam unchanged
pulsus 8 for several days before discharge
Pertinent Results:
Admission Labs:
[**2129-5-1**] 05:35PM BLOOD WBC-10.5 RBC-4.18* Hgb-12.4 Hct-37.9
MCV-91 MCH-29.7 MCHC-32.7 RDW-13.6 Plt Ct-289
[**2129-5-1**] 05:35PM BLOOD Neuts-73.7* Lymphs-20.3 Monos-5.4 Eos-0.3
Baso-0.3
[**2129-5-2**] 04:03AM BLOOD WBC-9.5 RBC-3.87* Hgb-11.6* Hct-36.0
MCV-93 MCH-29.9 MCHC-32.1 RDW-13.6 Plt Ct-262
[**2129-5-1**] 05:35PM BLOOD PT-12.6* PTT-32.9 INR(PT)-1.2*
[**2129-5-1**] 05:35PM BLOOD Glucose-114* UreaN-12 Creat-0.6 Na-137
K-3.9 Cl-102 HCO3-23 AnGap-16
[**2129-5-2**] 04:03AM BLOOD Glucose-98 UreaN-10 Creat-0.6 Na-140
K-3.6 Cl-106 HCO3-26 AnGap-12
[**2129-5-1**] 05:35PM BLOOD ALT-14 AST-16 AlkPhos-74 TotBili-0.7
[**2129-5-1**] 05:35PM BLOOD Lipase-14
[**2129-5-2**] 04:03AM BLOOD cTropnT-<0.01
[**2129-5-1**] 05:35PM BLOOD cTropnT-<0.01
[**2129-5-1**] 05:35PM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
[**2129-5-2**] 04:03AM BLOOD TSH-0.25*
.
URINE:
[**2129-5-1**] 07:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.050*
[**2129-5-1**] 07:30PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2129-5-1**] 07:30PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
.
MICRO:
Blood cultures ([**5-1**]): NGTD
Urine culture ([**5-1**]): NGTD
.
STUDIES:
CT Torso ([**5-1**]):
1. No evidence of aortic dissection or pulmonary embolism.
2. Moderate-size complex pericardial effusion.
3. Coronary artery calcifications, moderate in severity.
4. Bilateral lower lobe atelectasis.
.
ECHO [**5-1**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The aortic valve
leaflets are mildly thickened (?#). The mitral valve leaflets
are mildly thickened. There is a moderate to large-sized
pericardial effusion, predominantly located anterior to the
right ventricle. No right ventricular diastolic collapse is
seen. IVC is of normal caliber with >50% collapse during
inspiration. Respiratory variation with mitral and tricuspid
inflow varies less than 25%.
IMPRESSION: Moderate-to-large pericardial effusion without
echocardiographic signs of tamponade physiology. Grossly
preserved biventricular systolic function.
.
ECHO [**5-2**]:
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is a
moderate to large sized pericardial effusion. There is
accentuated variation in mitral and tricuspid inflows,
consistent with some degree ventricular interdependence. There
are no other echocardiographic signs of tamponade.
IMPRESSION: Moderate-to-large pericardial effusion.
Echocardiographic evidence of elevated intrapericardial
pressure.
.
CXR [**5-3**]:
Moderate enlargement of the cardiac silhouette, due to known
pericardial effusion, with radiologic signs of tamponade. No
evidence of
pulmonary edema
.
Right Heart Cath [**5-3**]:
Assessment & Recommendations
1. Rechallenge with colchicine despite ear swelling yesterday.
2. Repeat echocardiogram in 1 week.
3. Call out to floor today.
.
ECHO [**5-3**]:
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a moderate to large sized pericardial effusion.
Presence or absence of tamponade physiology was not evaluated on
this study.
Compared with the prior study (images reviewed) of [**2129-5-2**],
the anatomic findings are similar.
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
Ms. [**Known lastname 112022**] is a 64 year-old female with PMH of diabetes
mellitus, hyperlipidemia, and hypothyroidism who is transferred
from OSH with acute onset of chest/back pain found to have a
large pericardial effusion.
ACTIVE ISSUES:
# Pericardial effusion/chest pain: Patient p/w chest pain
pleuritic in nature as well as back pain of acute onset. This
was also in the setting of sudden onset chills alternating with
sweats and diarrhea. CTA chest showed moderate pericardial
effusion but no dissection. Etiology was thought to be viral
given concurrent chills and diarrhea. A rapid respiratory viral
screen was attempted but the specimen was inadequate. TB was
considered unlikely because her CT was normal and she lacked
other symptoms. No other sx of rheumatic disease so this was
also thought to be unlikely. TSH was checked and was slightly
low. Malignancy workup was up to date as an outpatient per the
patient.
TTE on admission showed moderate pericardial effusion with no
signs of tamponade despite a pulsus of 14 on admission. Her
chest pain improved with tylenol but was recurrent, so she was
started on colchicine for pericarditis given her allergy to ASA.
Pt developed ear swelling following colchicine which was
relieved with benadryl. Repeat TTE and CXR showed some concern
for increased pericardial pressure and patient was taken to
right heart cath. Right heart catheterization was not indicative
of tamponade physiology, and effusion was deemed too small for
effective pericardiocentesis. It was decided to treat patient as
stable viral pericarditis and rechallenge with colchicine
following benadryl pretreatment. She was tolerating this regimen
at the time of discharge and her pulsus had decreased to 8 for
several days before discharge.
# Sinus tachycardia: HR was in 110s on admission. This was
thought most likely due pain, dehydration, and concurrent viral
infection. She was given several liters of fluid and her HR
improved although she still became tachycardic with exercise.
She did not have tamponade physiology on right heart
catheterization.
# Allergic reaction: Patient has an extensive allergy history to
NSAIDs. She developed ear swelling and redness following
colchicine administraton which she reported was similar to
penicillin and aspirin allergies. There was no throat swelling,
SOB, or change in her voice. She responded to 50mg IV bendadryl.
It was decided to continue treatment with colchicine following
benadryl premedication.
# Hypothyroidism: Initially continued home levothyroxine 175mcg
PO qd. TSH slightly low (0.25), so decreased to 150 mcg daily.
Will need outpatient follow up.
CHRONIC PROBLEMS
# Hyperlipidemia: Continued Crestor 10mg qday
# Diabetes Mellitus: Patient to resume her home regimen at the
time of discharge.
TRANSITIONAL ISSUES:
- repeat TSH as outpatient in about 6 weeks
- will need repeat ECHO in 1 week (ordered in OMR) and then
outpatient cardiology follow-up the following day. Her
colchicine should be tapered per her outpatient cardiologist
based upon symptoms and evidence of effusion resolution on ECHO
Medications on Admission:
ketoconazole shampoo
metformin 500mg po bid
levothyroxine 175mcg PO qd
zyrtec 10mg qd
crestor 10mg
Discharge Medications:
1. ketoconazole Topical
2. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
5. Synthroid 150 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
6. Benadryl 25 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for allergy symptoms: if needed for allergy symptoms
related to colchicine.
Disp:*60 Capsule(s)* Refills:*1*
7. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Primary Diagnosis: viral pericarditis complicated by pericardial
effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 112022**],
It was a pleasure taking care of you.
You were admitted to the [**Hospital1 69**]
for a pericardial effusion, which is fluid around your heart.
You were observed closely and we performed diagnostic tests to
further characterize the fluid (CT scan, echocardiogram, and
right heart catheterization). We think the fluid and pain is
caused by a viral infection and we started medication to help
relieve your symptoms.
You should continue taking all of your medications, except for
the following changes:
Medications started:
1. Colchicine 0.6mg twice daily
2. Benadryl 50mg twice daily, take 30 minutes before colchicine
if needed if you develop an allergic reaction
Medications stopped/changed:
Decrease levothyroxine to 150mcg daily
Follow-up needed for:
1. Evaluate the progress of your symptoms
2. Recheck your thyroid levels in 6 weeks
Followup Instructions:
Name: [**Last Name (un) **]-[**Doctor Last Name **],MAYSABEL
Location: [**Hospital3 **]HEALTHCARE GROUP
Address: [**Location (un) 80096**], [**Apartment Address(1) 19251**], [**Location (un) **],[**Numeric Identifier 10768**]
Phone: [**Telephone/Fax (1) 82482**]
Appointment: Thursday [**2129-5-5**] 10:30am
*Your primary care provider is leaving on [**Name9 (PRE) 2974**] [**2129-5-6**]
for a 2 week vacation. It is very important you follow up before
she leaves.
Department: ECHO LAB
When: THURSDAY [**2129-5-12**] at 10:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2129-5-12**] at 12:20 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY
Address: [**Last Name (un) 39144**], STE#404, [**Hospital1 **],[**Numeric Identifier 39146**]
Phone: [**Telephone/Fax (1) 5424**]
Appointment: Monday [**2129-5-30**] 3:30pm
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"427.89",
"E944.7",
"420.91",
"250.00",
"V10.21",
"272.4",
"276.51",
"244.9",
"388.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
11605, 11653
|
7685, 7940
|
313, 343
|
11771, 11771
|
4237, 4237
|
12828, 14326
|
3390, 3505
|
10960, 11582
|
11674, 11674
|
10837, 10937
|
11922, 12805
|
3545, 4070
|
10525, 10811
|
254, 275
|
7955, 10504
|
371, 2986
|
4253, 7662
|
11693, 11750
|
11786, 11898
|
3008, 3115
|
3131, 3374
|
4095, 4218
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,731
| 181,304
|
17973
|
Discharge summary
|
report
|
Admission Date: [**2161-11-10**] Discharge Date: [**2161-11-17**]
Date of Birth: [**2111-12-22**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Morphine / Ace Inhibitors / Hydromorphone /
Fentanyl / Oxycodone
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Sorethroat/fever
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
Patient is a 49 year old female with history of type 1 diabetes
mellitus status-post pancreas transplant in [**2157**], end-stage
renal disease on peritoneal dialysis, who was transferred from
[**Hospital6 302**] in [**Location (un) 8973**], MA last night for futher
management. She presented to [**Hospital3 **] on the morning of
[**2161-11-10**] with fever to 104, odynophagia, and difficulty
swallowing, as well as lethargy. Per report, she had had three
days of fever, malaise, and sore throat, and was unable to
swallow secondary to pain. As a result, she had not taken any of
her oral medications. She was treated with IV diflucan for
possible candidal esophagitis. She was transferred after IV
formulation of her medications was not available and since her
primary nephrologist is here at [**Hospital1 18**].
.
Of note, she had recently been admitted at an outside hospital
for bleeding from her peritoneal dialysis site. She was treated
with levofloxacin and vancomycin at that time for concern over
peritonitis, however these were stopped as she was not felt to
have an infection. She had an elevated INR at that time. About 4
weeks ago, her immunosuppressive regimen was changed from Imuran
to rapamycin, and her prednisone has been reduced from 5mg to
2.5mg daily. During that hospitalization, she was treated with
Levofloxacin and Vancomycin empirically to cover a potential
peritoneal infection, but these were discontinued prior to
discharge as there was no evidence of peritonitis.
.
Of note, at the time of her recent admission to OSH she had a
tick behind her left ear.
Past Medical History:
Pancreas transplant [**9-/2157**] c/b rejection [**1-9**] treated with
thymoglobulin
DM1 (dx'd age 8) c/b retinopathy, severe peripheral neuropathy,
and CRI (cr 2.6-3.0)
kidney biopsy [**1-9**] c/b perinephric hematoma, bx indicated
changes
c/w DM as well as IgA
hypothyroidism
sarcoidosis
asthma
s/p right BKA
s/p L DP to popliteal bypass
s/p appendectomy
Social History:
former RN, lives with husband, 2 sons.
Family History:
NC
Pertinent Results:
CT torso [**11-11**]
1. Patchy ground-glass opacities are seen throughout the lung
fields
bilaterally. In addition, note is made of consolidation in the
left greater
than right lower lobes.
2. No evidence of abdominal or pelvic hematoma. No focal fluid
collection to
suggest an abscess.
3. The esophagus is fluid filled to the level of the thoracic
inlet. Clinical
correlation is recommended.
4. Note is made of intraperitoneal free fluid and air, most
likely secondary
to the patient's peritoneal dialysis.
5. Pancreatic transplant is not well evaluated due to the lack
of IV
contrast, adjacent small bowel loops and intraperitoneal fluid.
EGD [**11-10**]
Normal esophagus, vesicles on epiglottis.
[**2161-11-10**] 09:06PM BLOOD WBC-4.0 RBC-2.53*# Hgb-8.8*# Hct-24.8*#
MCV-98 MCH-34.9* MCHC-35.6* RDW-14.0 Plt Ct-196
[**2161-11-17**] 05:35AM BLOOD WBC-2.8* RBC-2.24* Hgb-7.7* Hct-21.5*
MCV-96 MCH-34.5* MCHC-36.0* RDW-14.9 Plt Ct-135*
[**2161-11-12**] 05:09AM BLOOD Neuts-66 Bands-19* Lymphs-4* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2161-11-13**] 05:25AM BLOOD Neuts-94.0* Lymphs-3.0* Monos-1.7*
Eos-1.2 Baso-0.1
[**2161-11-12**] 05:09AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
Spheroc-OCCASIONAL
[**2161-11-10**] 09:06PM BLOOD PT-27.0* PTT-46.6* INR(PT)-2.7*
[**2161-11-14**] 06:20AM BLOOD PT-41.8* PTT-50.1* INR(PT)-4.6*
[**2161-11-17**] 05:35AM BLOOD PT-15.1* PTT-30.6 INR(PT)-1.3*
[**2161-11-11**] 07:29PM BLOOD Fibrino-670*#
[**2161-11-10**] 09:06PM BLOOD Glucose-56* UreaN-42* Creat-6.2*# Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
[**2161-11-17**] 05:35AM BLOOD Glucose-109* UreaN-52* Creat-6.8*# Na-136
K-3.1* Cl-98 HCO3-32 AnGap-9
[**2161-11-10**] 09:06PM BLOOD ALT-40 AST-61* LD(LDH)-344* AlkPhos-61
TotBili-0.2
[**2161-11-15**] 06:25AM BLOOD ALT-25 AST-36 LD(LDH)-266* AlkPhos-52
TotBili-0.1
[**2161-11-11**] 05:40AM BLOOD Lipase-10
[**2161-11-10**] 09:06PM BLOOD Albumin-2.7* Calcium-8.3* Phos-4.0
Mg-1.5*
[**2161-11-17**] 05:35AM BLOOD Calcium-7.5* Phos-3.1 Mg-1.7 Iron-21*
[**2161-11-11**] 07:29PM BLOOD VitB12-1164* Folate-GREATER TH Hapto-237*
[**2161-11-17**] 05:35AM BLOOD calTIBC-161* Ferritn-761* TRF-124*
[**2161-11-14**] 06:20AM BLOOD %HbA1c-5.5
[**2161-11-12**] 05:09AM BLOOD tacroFK-15.1 rapmycn-25.4*
[**2161-11-16**] 05:25AM BLOOD tacroFK-10.4
[**2161-11-11**] 03:35PM BLOOD Type-ART pO2-163* pCO2-58* pH-7.32*
calTCO2-31* Base XS-2
[**2161-11-11**] 03:35PM BLOOD Glucose-212* Lactate-0.9 Na-130* K-4.4
Cl-95*
Brief Hospital Course:
#49 yo F/ w/ Hx of pancreas transplant, ESRD on PD p/w fevers to
103 and odynophagia/trismus and pain on speech.
.
#Odynophagia/Fever: Pt. was found to have vesicular lesions on
endoscopy. These were sampled for viral DFA but not enough
sample was collected to interpret. ID felt that these most
likely represented HSV lesions but could represent several
things and she was initially started on
acyclovir/vancomycin/zosyn/levofloxacin as it also appeared that
she had a concomittant PNA. She quickly defervesced and was
weaned down to acyclovir and levofloxacin and remained afebrile.
Her serology appeared negative for acute infection w/ HSV,
mycoplasma or VZV. Tularemia titers were pending at time of d/c.
Renal transplant felt that the vesicles may be due to rapamycin
as she had recently been started on this, rapamycin was
supratherapeutic on presentation. Rapamycin was d/c'd and she
was continued on her previous regimen of tacrolimus and
azathioprine. Her symptoms of odynophagia quickly resolved after
the first 2 days in the hospital and she was able to take POs
for several days before d/c.
.
#Pancreas transplant: Pt. had some elevated blood glucose
readings which were felt to be due to the change in dialysate
used while in the hospital. Her HbA1c was indicative of very
good glucose control, she had no abdominal pain and her
lipase/amylase were normal.
.
#ESRD: On PD, pt. did not agree w/ the inpt. regimen that she
was put on and was d/c'd to continue her cycler at home.
.
#PVD: Pt. on coumadin for PVD, has never had stent placed. Was
supratherapeutic on presentation, likely [**3-7**] to not eating
adequately. INR came down w/ PO nutrition.
.
#Respiratory failure: Pt. stopped breathing and became
bradycardic after administration of conscious sedation in the
EGD lab. She was transferred to MICU and given narcan drip. Her
mental status improved and she was transferred out to the floor
the next day.
Medications on Admission:
- Nephrocaps daily
- Fosamax 70mg weekly
- Bactrim 400mg QMWF
- Prilosec 20mg daily
- Synthroid 88mcg daily
- ASA 81mg daily
- Prograf 2mg [**Hospital1 **]
- Rapamune 4mg daily
- Lipitor 40mg daily
- Prednisone 2.5mg daily
- Ambien 5mg PRN
- Imodium 2mg PRN
- Coumadin 2mg alternating with 2.5mg daily
(Per most recent note in OMR)
- B complex
- Vitamin C
- folic acid
- calcitriol 0.25mcg daily
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
Injection QMOWEFR (Monday -Wednesday-Friday).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lidocaine HCl 2 % Solution Sig: One (1) Swallow Mucous
membrane TID (3 times a day) as needed. Swallow
6. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray
Mucous membrane Q8H (every 8 hours) as needed for 7 days.
Disp:*1 bottle* Refills:*0*
7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 6 days.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
14. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
17. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
18. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO once a day.
19. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
20. Outpatient Lab Work
Tacrolimus level faxed to Dr. [**Last Name (STitle) **] Fax #[**Telephone/Fax (1) 697**]
PT/INR faxed to Dr. [**Last Name (STitle) 15170**] #[**Telephone/Fax (1) 49757**]
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
Primary
Vesicular Epiglottitis
Secondary
End stage renal disease on peritoneal dialysis.
Pancreas transplant
Discharge Condition:
Stable
Discharge Instructions:
You have been diagnosed with vesicular epiglotitis, this is most
likely due to herpes simplex infection so you should continue to
take your valacyclovir until [**2161-11-25**].
Please take all of your medications exactly as prescribed. You
will take Valacyclovir 200mg orally once per day until [**2161-11-25**].
You were also diagnosed with pneumonia, so you should continue
to take the levofloxacin (levaquin) until [**2161-11-25**]. We stopped
your sirolimus because it was possibly causing the vesicles in
your throat. You will need to take azathioprine in place of the
Sirolimus 50mg once per day. You will continue to take
tacrolimus 2mg twice per day. We also decreased your warfarin
dose while you are on levofloxacin because the two drugs
interact. You will have to follow up with Dr. [**Last Name (STitle) 15170**] to have
this adjusted. We have given you visous lidocaine, panseptic and
cepacol lozenges to help the pain in your throat. The tessalon
perles are to help with your cough. You should use these only as
much as you need and not any more than directed.
We started you on Procrit (Epoeitin alfa) for anemia, you
will need to inject yourself with this three times per week
(MWF). You can restart your fosamax in 2 weeks. We did not give
you this because it can be extrememly irritating to the throat.
When you do take your fosamax make sure to take it with plenty
of water and to remain sitting upright for at least half an hour
afterward.
If you have any fever, chills, nightsweats, chest pain,
worsening throat pain, fainting, confusion, severe headache,
neck stiffness, bleeding or any other concerning symptoms please
call your doctor immediately or go to the emergency department.
Followup Instructions:
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2161-12-14**] 2:00
Please follow up with Dr. [**Last Name (STitle) 3649**] for continued care of your heel
ulcer. He may also want to consult a vascular surgeon regarding
your thumb.
Please have your labs drawn for your tacrolimus level on
Thursday [**11-19**] and have the tacrolimus level faxed to Dr.
[**Last Name (STitle) **]. Fax #[**Telephone/Fax (1) 697**]. Have your PT/INR faxed to Dr.
[**Last Name (STitle) 15170**] at fax #[**Telephone/Fax (1) 49757**].
Please call your primary care physician [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **].
[**Telephone/Fax (1) 9674**] for an appointment in 2 weeks. Have your PT/INR
faxed to Dr. [**Last Name (STitle) 15170**] at [**Telephone/Fax (1) 49757**].
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2161-11-22**]
|
[
"285.9",
"244.9",
"054.9",
"486",
"V49.75",
"585.6",
"V42.83",
"250.41",
"464.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9377, 9485
|
4996, 6923
|
365, 383
|
9639, 9648
|
2475, 4973
|
11407, 12418
|
2452, 2456
|
7369, 9354
|
9506, 9618
|
6949, 7346
|
9672, 11384
|
309, 327
|
411, 1999
|
2021, 2379
|
2395, 2436
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,448
| 142,206
|
51548+51549
|
Discharge summary
|
report+report
|
Admission Date: [**2118-8-31**] Discharge Date: [**2118-9-1**]
Date of Birth: [**2061-2-6**] Sex: M
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
brain metastasis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 57-year-old male with Burkitt's type lymphoma
originally diagnosed in [**12/2117**] s/p chemotherapy, allogenic stem
cell transplant, and Ommaya shunt placement on [**2117-12-19**] who is
currently admitted for chemotherapy for a solitary temporal lobe
brain met. Pt initially c/o HA and reported this sx to
oncologist. MRI was obtained and he was found to have an
enhancing left temporal lobe mass. Pathological reports showed
this lesion to be a recurrence of his Burkitt's lymphoma. He is
now scheduled to get high dose methotrexate for the brain
lesion. Pt also has a persistent groin seroma secondary to
inguinal lymph node removal that has required draining x 4. Pt
has been in good state of health recently. He reports no fever,
nausea, vomiting, diarrhea, chest pain, SOB, and vision or
hearing changes.
Past Medical History:
1. Irregular heart beat which was extensively worked-up with
Holter monitors, and just felt to be secondary to occasional
PVCs for which he takes atenolol.
2. Abdominal ventral hernia.
3. Pyloric stenosis as an infant.
4. Hypercholesterolemia.
Social History:
He lives in [**Location 912**], [**State 350**]. He is a
product developer at Fidelity. Tobacco - 20 pack year
history, quit in [**2094**]. Alcohol - occasionally, [**3-15**] drinks
per weekend. He has 3 children, 2 daughters, 1 son.
Family History:
No cancer history for colon, breast, ovarian
or lung. No history of lymphomas or leukemias.
Physical Exam:
VS - 96.5 64 18 128/76 99% RA
Gen: sitting in a chair comfortable NAD
Heent: EOMI, MMM, no cervial lymphadenopathy Ommaya reservoir
on r frontal region of skull.
Card: RRR nl S1 S2 no m/r/g
Lungs: CTA b/l no m/r/g
Abd: soft NT ND + BS, mobile solid mass 4 cm x 2 cm on r groin
Ext: pitting edema extending up to knees b/l
Neuro: A & O x3. CN III-XII intact. 5/5 strength throughout.
Pertinent Results:
[**2118-8-31**] 12:34PM PT-12.1 PTT-22.5 INR(PT)-1.0
[**2118-8-31**] 12:34PM PLT COUNT-144*
[**2118-8-31**] 12:34PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL SCHISTOCY-OCCASIONAL
[**2118-8-31**] 12:34PM NEUTS-40* BANDS-0 LYMPHS-18 MONOS-40* EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2118-8-31**] 12:34PM WBC-2.0* RBC-3.44* HGB-11.0* HCT-31.8* MCV-92
MCH-32.1* MCHC-34.8 RDW-17.4*
[**2118-8-31**] 12:34PM ALBUMIN-4.0 CALCIUM-9.0 PHOSPHATE-2.3*
MAGNESIUM-1.7 URIC ACID-5.8
[**2118-8-31**] 12:34PM ALT(SGPT)-29 AST(SGOT)-25 ALK PHOS-131* TOT
BILI-0.7
[**2118-8-31**] 12:34PM GLUCOSE-263* UREA N-32* CREAT-1.0 SODIUM-135
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15
Brief Hospital Course:
A/P 57 yo male w/ Burkitts Lymphoma s/p chemo and BMT admitted
for chemotherapy to treat r temporal lobe solitary metastasis.
Pt was scheduled to get inguinal seroma drainage via US and then
receive methotrexate treatment. However pt remained neutropenic
thought to be secondary to valgancyclovir treatment and as a
result it was deemed best that he go home and return in one week
to receive chemotherapy.
Medications on Admission:
1. Lamivudine 100 mg Tablet qd
2. Ursodiol 300 mg po qd
3. Lopressor 25 mg po bid
6. Vancomycin HCl 1,000 mg IV bid
7. Protonix 40 mg po qd
8. Fluconazole 100 mg po qd
9. MVI
10. Epivir HBV 100 mg po qd
11. Procardia 30 mg po qd
12. Folate 4 mg po qd
13. Valgancyclovir 450 mg po qd
14. Decadron 4 mg tid
15. Levoquin 1 tab qd x 10 days
Discharge Medications:
1. Lamivudine 100 mg Tablet qd
2. Ursodiol 300 mg po qd
3. Lopressor 25 mg po bid
6. Vancomycin HCl 1,000 mg IV bid
7. Protonix 40 mg po qd
8. Fluconazole 100 mg po qd
9. MVI
10. Epivir HBV 100 mg po qd
11. Procardia 30 mg po qd
12. Folate 4 mg po qd
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Burkitt's lymphoma
Discharge Condition:
stable
Admission Date: [**2118-9-2**] Discharge Date: [**2118-9-16**]
Date of Birth: [**2061-2-6**] Sex: M
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
seizure
CNS lymphoma
Major Surgical or Invasive Procedure:
IV HIgh -dose Methotrexate and ARA-C chemotherapy via Omayya
catheter
History of Present Illness:
57 yoM with Burkitt's lymphoma diagnosed [**12-14**] s/p chemoRx wth
CODOX / IVAC / ARA-C in [**9-20**]. Patient retreated with
Rituxan, [**Hospital1 **] / Velcade chemoRx. Ultimately, patient had
allogenetic Tx from brother on [**2118-6-9**]. Since then has had CMV
viremia, Rx with valgancyclovir, VRE bactremia, and persistent
neutropenia with good initial response in terms of his lymphoma,
until presented to clinic with left temporal HAs and imaging
confirmed brain mets which were biopsied by Dr. [**Last Name (STitle) 1338**] and
confirmed high grade diffuse large B-cell lymphoma. Was admitted
on [**8-30**] for onset on high dose methotrexate for CNS lymphoma.
However, MTX therapy was delayed secondary to neutropenia, which
is attributed to valgancyclovir- which was stopped on [**8-30**].
Then morning after discharge on [**9-1**], felt to be more confused
by family and then had a witnesses tonic-clonic self limited
seizure with loss of consciousness followed by clear postictal
state. Initially presented to [**Hospital **] Hospital which confirmed
left temporal mass with post-op changes. Loaded with dilantin
and then had another seizure and transferred here. At [**Hospital1 18**] [**Hospital Unit Name 153**]
was re-loaded on dilantin with keppra and last seizure was on
[**9-2**]- has now been stable on 7Feldberg only with persistent
aphasia.
Past Medical History:
1. Irregular heart beat which was extensively worked-up with
Holter monitors, and just felt to be secondary to occasional
PVCs for which he takes atenolol.
2. Abdominal ventral hernia.
3. Pyloric stenosis as an infant.
4. Hypercholesterolemia.
Social History:
He lives in [**Location 912**], [**State 350**]. He is a product developer
at Fidelity. Tobacco - 20 pack year history, quit in [**2094**].
Alcohol - occasionally, [**3-15**] drinks per weekend. He has 3
children, 2 daughters, 1 son.
Family History:
No cancer history for colon, breast, ovarian
or lung. No history of lymphomas or leukemias.
Physical Exam:
PE: t- 97.5, bp 136/96, hr 68, rr 18, spo2 100% RA
gen- awake, alert male, nad, unable to assess orientation [**3-14**]
aphasia
cv- rrr, s1s2, no m/r/g
chest- CTAB, but will not cooperate with full breaths, port site
dry,
clean and no erythema or tenderness
abd- soft, NT/ND, +BS
ext- no c/c/e
neuro- CNII-XII intact, + receptive aphasia, no orientation, not
able to ID objects, not following commands, 5/5 strength but
poor cooperation with exam, reflexes 2+ bilaterally
Pertinent Results:
[**2118-9-1**] 12:05AM BLOOD WBC-1.6* RBC-3.15* Hgb-10.2* Hct-29.0*
MCV-92 MCH-32.5* MCHC-35.2* RDW-16.9* Plt Ct-134*
[**2118-9-16**] 01:00AM BLOOD WBC-3.9*# RBC-3.49* Hgb-11.1* Hct-30.9*
MCV-89 MCH-31.8 MCHC-35.8* RDW-16.3* Plt Ct-20*
[**2118-9-3**] 04:30AM BLOOD Neuts-10* Bands-0 Lymphs-51* Monos-38*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2118-9-11**] 12:00AM BLOOD Neuts-50 Bands-0 Lymphs-43* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2118-9-1**] 12:05AM BLOOD Plt Ct-134*
[**2118-9-2**] 12:31AM BLOOD PT-11.8 PTT-21.7* INR(PT)-0.9
[**2118-9-16**] 01:00AM BLOOD PT-12.7 PTT-24.1 INR(PT)-1.1
[**2118-9-16**] 01:00AM BLOOD Plt Ct-20*
[**2118-9-4**] 02:00AM BLOOD Fibrino-361
[**2118-9-16**] 01:00AM BLOOD Fibrino-425*
[**2118-9-2**] 12:31AM BLOOD Gran Ct-460*
[**2118-9-16**] 01:00AM BLOOD Gran Ct-[**2094**]*
[**2118-9-1**] 12:05AM BLOOD Glucose-373* UreaN-29* Creat-1.0 Na-133
K-3.1* Cl-94* HCO3-29 AnGap-13
[**2118-9-16**] 01:00AM BLOOD Glucose-113* UreaN-15 Creat-0.9 Na-132*
K-3.8 Cl-98 HCO3-22 AnGap-16
[**2118-9-1**] 12:05AM BLOOD ALT-26 AST-22 AlkPhos-130* TotBili-0.7
[**2118-9-16**] 01:00AM BLOOD ALT-7 AST-12 AlkPhos-152* TotBili-0.4
[**2118-9-5**] 12:00AM BLOOD ALT-19 AST-27 LD(LDH)-677* AlkPhos-136*
TotBili-1.0 DirBili-0.3 IndBili-0.7
[**2118-9-1**] 12:05AM BLOOD Albumin-3.8 Calcium-8.5 Phos-2.2* Mg-1.9
UricAcd-5.4
[**2118-9-16**] 01:00AM BLOOD Albumin-3.9 Calcium-9.0 Phos-2.2* Mg-1.8
[**2118-9-2**] 12:31AM BLOOD Phenyto-6.6*
[**2118-9-14**] 11:15PM BLOOD Phenyto-14.7 Phenyfr-1.8 %Phenyf-12
[**2118-9-1**] 10:00AM BLOOD Cyclspr-133
[**2118-9-16**] 10:50AM BLOOD Cyclspr-114
Head MRI:
IMPRESSION:
1. Slight increase in the size of the left anterior temporal
lobe enhancing mass.
2. Status post biopsy with a residual tract posterior to the
enhancing mass.
3. Increased temporal lobe edema and mass effect, but no
herniation or evidence of hydrocephalus.
4. Tip of the reservoir situated in the right caudate. Position
unchanged.
EEG:
IMPRESSION: This is an abnormal portable EEG in the awake and
drowsy
states due to the presence of a slowed disorganized background
rhythm
with intermittent bursts of generalized delta frequency slowing
and the
presence of occasional left temporal lobe sharp and slow [**Male First Name (un) **] e
isodic
symptoms. The presence of discharges in the left temporal lobe
is
suggestive of a potential epileptic focus due to cortical
dysfunction.
The slow and disorganized background rhythm with intermittent
bursts of
delta frequency slowing is suggestive of a mild encephalopathy.
Brief Hospital Course:
Mr [**Known lastname 882**] was admitted after recently being discharged after
being admitted for a coarse of MTX (not able to be given due to
neutropenia likely caused by valgancyclovir). He was having very
difficult to control seizures on admission.
CNS lymphoma/chemo/cytopenias- These are stable and confirmed on
recent temporal lobe biopsy as being high grade, diffuse large
B-cell lymphoma. Pt had aggressive hydration and alkalinization
of urine and was then given methotrexate as per neuro-med
protocol for chemo responsive CNS lymphoma starting [**2118-9-3**].
MTX was planned to be given at 3.5 g/m^2 but was dose reduced to
2.1 g/m^2 becasue of a creatine clearance of only 59 ml/min
based on a 24 hour urine. US guided drainage of right inguinal
seroma was performed to prevent sequestration of methotrexate in
the seroma. Pt also received intrathecal ARA-C via Omayya
reservoir on [**2118-9-8**] - this was done becasue of a concern for
leptomeningeal invovlment causing a flaccid bladder. However, as
the patient's mental status improved, so did his urine control.
CSF x 2 from his Ommaya was negative for malignant cells. He was
neutropenic s/p chemotherapy and then became febrile on [**9-10**].
There was no clear source, and he had neg blood and urine
cultures throughout. A CSF gram stain was neg, but there were a
few WBCs. Empiric cefepime for fever/neutropenia was initiated
and continued until discharge, as all cultures remained neg, pt
remained afebrile, and his neutropenia had resolved. Neupogen
was continued daily for neutropenia and for one day post-D/C. We
Followed daily ANCs. They initially dropped for several days,
but then reached a nadir of 300 before climbing back to >1000.
He also had a significant drop in his platelets, which were in
the 20s on discharge, but stable and he was without signs of
bleeding/petechiae. XRT was continued while he was an
inpatient.
[**Name (NI) 73501**] Pt continued to seize throughout first few days of
admission and was treated with maximal doses of dilantin.
Keppra and Lamictal were added, as was decadron(due to edema
around brain met) before he stopped seizing. He did have
continued twitching of leg which is a partial epileptic seizure.
This was followed and not treated with ativan. Epilepsy team
evaluated him with another EEG done. They felt the patient had
reflex epilepsy and recommended continued increase in the dose
of the lamictal (50mg in divided doses) on a weekly basis, which
could be done safely as the patient was on a p-450 inducer,
dilantin. The seizures became stable and disappeared during the
last week of his hospital stay. For breakthrough seizures- low
dose ativan- but not needed for focal epileptic seizures of leg.
His lamictal was gradually increased, with the plan of D/Cing
the Dilantin after Lamictal was at full doses. Dilantin levels
were checked daily, with a goal of 15-20. He was sent home on
all 4 of the above medicines.
Anemia - He also had a drop in his Hct after the MTX treatment.
This was watched, and after he continued to dsrop, with
resultant tachycardia, he was transfused 2 units of PRBCs with
good response in his Hct. He was also started on Epogen at this
time.
Mental Status - Initially, patient was aphasic, but this
improved with treatment. Pt had variable course with regards to
his mental function. His short term memory fluctuated. He had
some difficulty remembering short term events. This was thought
to be multifactorial. He may have had some confusion from
continued seizures, ativan tx, and edema from brain mets. He
had improved fairly significantly until fever over weekend.
After this, his confusion increased and he had a lot of trouble
with word finding, attention, and slow answers to questions. He
was usually fairly alert, but couldn't do calculations or
difficult tasks. A fever spike abuot 5 days before his
discharge was felt to be due to the IT ARa-C he received; this
caused his mental status to again decrease, this gradually
cleared as the week went on, but he was not at his complete
baseline when discharged. He is thinking clearly, but the
problem seems to be with an expressive aphasia.
s/p BMT- His cyclosporine was continued while here, but the
levels fluctuated, most likely due to many of the medications
started this admission. The dilantin especially interacts with
the levels of cyclosporine in the body. His doses were adjusted
accordingly, with the knowledge that the decadron he was taking
would also help to prevent GVHD if his levels of cyclosporine
weren't therapeutic. Due to neutropenia and recent transplant,
he was put on or already taking fluconazole, lamivudine, bactrim
DS, and acyclovir. Weekly CMV viral loads were also sent which
remained negative. Continue MVI and folate.
Diarrhea: He had some episodes of diarrhea and was on vanco in
the recent past. Sent C diff which was neg. Also had rectal pain
that was most likely due to the XRT. The pain was treated with
oxycodone effectively. The diarrhea resolved on its own and did
not return.
HTN: He was continued on his home antihypertensives and
maintained good BPs throughout the admission.
He was sent home after his neutropenia resolved with a plan to
return Wednesday [**2118-9-21**] to start another round of MTX
therapy.
Medications on Admission:
1. Lamivudine 100 mg Tablet qd
2. Ursodiol 300 mg po qd
3. Lopressor 25 mg po bid
4. Vancomycin HCl 1,000 mg IV bid
5. Protonix 40 mg po qd
6. Fluconazole 100 mg po qd
7. MVI
8. Epivir HBV 100 mg po qd
9. Procardia 30 mg po qd
10. Folate 4 mg po qd
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. M-Vit Tablet Sig: One (1) Tablet PO once a day.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
6. Nifedipine ER 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Lamivudine 100 mg Tablet Sig: [**2-11**] (half) Tablet PO once a
day.
9. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Dilantin 100 mg Capsule Sig: Three (3) Capsule PO twice a
day.
Disp:*180 Capsule(s)* Refills:*0*
11. Keppra 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*0*
12. Lamictal 25 mg Tablet Sig: Two (2) Tablet PO twice a day:
Start taking 3 tablets, twice a day on Monday.
Disp:*120 Tablet(s)* Refills:*0*
13. Neoral 100 mg Capsule Sig: Two (2) Capsule PO twice a day.
Disp:*120 Capsule(s)* Refills:*0*
14. Epogen 10,000 unit/mL Solution Sig: One (1) mL Injection 3
times per week: Start on Monday.
Disp:*1 syringes* Refills:*0*
15. Oxycodone HCl 5 mg Capsule Sig: One (1) Capsule PO every [**5-17**]
hours as needed for pain.
Disp:*60 Capsule(s)* Refills:*0*
16. magnesium 16 mEq in 800 cc NS
Please give this 4 times per week IV, starting [**2118-9-17**].
17. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO
qmonday,wednesday,friday.
Disp:*12 Tablet(s)* Refills:*0*
18. Decadron 4 mg Tablet Sig: [**2-11**] (half) Tablet PO three times a
day.
Disp:*7 Tablet(s)* Refills:*0*
19. Neoral 25 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
20. Neupogen 480 mcg/0.8mL Syringe Sig: One (1) injection
Injection once a day for 1 days.
Disp:*1 syringe* Refills:*0*
21. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Burkitt's lymphoma
CNS lymphoma
Seizures
Febrile neutropenia
Hypertension
Pancytopenia
Discharge Condition:
Ambulating. Pain well controlled with medication. No O2
requirement. Eating fairly well. Stable. Mental status
improving.
Discharge Instructions:
Please call your doctor or return to the hospital in you
experience any fevers, chills, shortness of breath, or seizures.
Please return Wednesday morning to be readmitted for your next
round of chemotherapy.
Please don't drive while you are out of the hospital due to risk
of seizures.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2119-5-10**] 10:00
|
[
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"788.20",
"200.21",
"276.1",
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"345.90",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.25",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
17385, 17448
|
9745, 15038
|
4559, 4630
|
17579, 17704
|
7166, 9722
|
18040, 18242
|
6563, 6658
|
15339, 17362
|
17469, 17558
|
15064, 15316
|
17728, 18017
|
6673, 7147
|
4499, 4521
|
4658, 6025
|
6047, 6293
|
6309, 6547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,339
| 179,964
|
21231
|
Discharge summary
|
report
|
Admission Date: [**2168-5-1**] Discharge Date: [**2168-5-7**]
Service: TRA
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female who
was admitted to the Emergency Department after falling down
three steps at her [**Hospital3 **] care facility. The
patient denies any loss of consciousness, denies chest pain.
She was alert and oriented at the scene. She was originally
seen at outside hospital and transferred to [**Hospital1 346**] for further care.
The patient had a witnessed fall at her [**Hospital3 **]
facility and is able to recall full event. She states that
she missed a step as she was walking down and then fell the
remainder of the four steps, landing on her left wrist.
PAST MEDICAL HISTORY:
1. Dementia.
2. Hypertension.
3. Atrial fibrillation
PAST SURGICAL HISTORY: Unknown. The patient does have
vertical scar inferior to the umbilicus suggestive of
hysterectomy.
SOCIAL HISTORY: Alcohol and tobacco use is unknown. The
patient lives in [**Hospital3 **] care facility and has family
nearby. Her son is actively involved in her care.
MEDICATIONS ON ADMISSION:
1. Aricept.
2. Cardizem.
3. Zyprexa.
4. Lorazepam.
5. Vitamin C.
PHYSICAL EXAMINATION: The patient was alert and cooperative
and able to answer questions, though mildly confused which
apparently is her baseline due to dementia. Her vital signs
include a temperature of 99.0, heart rate 120 that was
irregular, blood pressure 158/111, respiratory rate 19 and
oxygen saturation 96 percent. Her head was normocephalic and
atraumatic. She was in a cervical spine collar. The pupils
had full extraocular movements and were reactive to light
bilaterally, 3.0 millimeters to 2.0 millimeters. She had
clear lungs to auscultation bilaterally. She was tachycardic
but no murmurs, rubs or gallops. Her abdomen was soft,
nontender, and nondistended. She was guaiac negative with
good rectal tone.
Cervical spine, she had no deformities, no step-off or
tenderness. Her thoracolumbosacral spine/back had no
deformities and no step-offs and no tenderness. She was
tender to palpation of the left forearm. There was no gross
deformity or breakage in skin. The remainder of her
extremities were warm with palpable pulses. She had full
range of motion times four.
LABORATORY DATA: The patient had white blood cell count of
13.5, hematocrit 40.6, platelet count 197,000. Her Chem7 was
unremarkable. Her INR was 1.1. Her urine toxicology screen
was negative. She had an amylase of 39.
RADIOLOGY: The patient had an electrocardiogram which showed
rapid atrial fibrillation. She had a negative fast
examination. Her chest x-ray showed a right upper lobe
opacity versus infiltrate. Her pelvic x-ray was negative. A
CT of the cervical spine showed extensive degenerative joint
disease but no fracture or subluxation. A CT of her head
showed small left frontal contusion versus subarachnoid,
right posterior temporal lobe subarachnoid bleed, and a small
subdural hemorrhoid of the right frontal lobe. CT of the
abdomen and pelvis is negative. Thoracolumbosacral spine
films showed a wedge fracture of the body of T7, unclear
whether this was old versus new. X-ray of the left arm shows
a distal radius fracture, minimally displaced and extra-
articular. The patient had a CT of the thoracolumbosacral
spine which showed the wedge fracture of T7 as well as
postfusion of L3-4 and L4-5.
HOSPITAL COURSE: The patient underwent normal trauma
protocol while in the Emergency Department. She was
transferred to the Intensive Care Unit for monitoring of her
intracranial hemorrhage. Neurosurgery was consulted. Her
systolic blood pressure was maintained below 150. She had
good glycemic control. She had q1hour neurologic checks.
She was given isotonic fluids. She had no focal neurological
deficits throughout her stay. She was loaded with Dilantin
which was continued for six days. A repeat head CT showed no
change in bleed.
The patient came to the hospital with rapid atrial
fibrillation and this was monitored while she was in the
Intensive Care Unit. She was loaded with Amiodarone and
controlled with Diltiazem. She will be discharged on both of
these medications. Prior to discharge, she has been observed
on telemetry on the floor for greater than 72 hours having a
heart rate of 75 going in and out of atrial fibrillation.
The patient was found to have a left distal radius fracture,
minimally displaced and extra-articular in nature. She was
seen by orthopedic hand specialist, Dr. [**Last Name (STitle) **]. There was no
need for reduction or operation. She was given a hand splint
which she is to wear until follow-up with the hand surgeon.
The patient arrived in a cervical spine collar, however,
because of her baseline dementia and worsening nature of her
dementia versus delirium as documented below, her cervical
spine was unable to be cleared clinically. Further
examination of the patient's compression fracture of T7 was
recommended by the spine specialist, however, the patient was
extremely agitated and unwilling to wear the cervical spine
collar and needed to be in soft wrist restraints. Clinical
suspicion for acute injury was very low as the patient was
lucid and at her baseline at the time of the accident and
when she was initially examined. It was felt that the
extraneous material that was restrictive in manner was
contributing to the patient's quite profound delirium. Given
the fact that we could not clear her clinically, it was
potential that the patient would have to wear the cervical
spine collar long term. The risk of cervical spine injury
was discussed at length with the patient's son who agreed to
remove the cervical spine collar in the hopes of clearing her
mental status. The son verbalized understanding of potential
cervical spine risk.
The patient has a baseline dementia which has been
documented. She described as a pleasantly confused woman at
baseline, however, she is usually oriented to herself and to
place. She is functional in the [**Hospital3 **] care
facility. During her hospital stay, she became acutely
delirious, at times kicking and biting at staff.
Consultation from behavioral neurology was obtained with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and medication adjustments were made. He
also proposed limiting the amounts of extraneous tubes or
devices that the patient must wear as previously commented
with regards to her cervical spine collar. Originally the
patient was to be fed with a nasogastric tube as her delirium
was thought to be profound to protect her airway, however,
she became extremely agitated with the nasogastric tube
placed. This was discussed with the son who agreed to have
the nasogastric tube pulled and the patient is able to take
thickened liquids as suggested by her speech and swallow
evaluation and to take her pills. The family understands
that there is a small risk of aspiration but have chosen this
course to stabilize the patient's delirium. At the time of
discharge, the patient has been able to be on the floor for
greater than 24 hours without a sitter. Her delirium has
greatly improved. It is thought that she is closer to her
baseline. She is oriented to herself and was able to be
reminded that she is in the hospital and can retain this
information. She continues to remain somewhat sleepy during
the daytime. It is suggested by behavioral neurology to not
give any Haldol doses after 10:00 p.m. unless it is required
for patient or staff safety. Following this recommendation
has seemed to greatly improve the patient's sleep/wake cycle
as well as her delirium. Benzodiazepines are not recommended
for this patient. Trazodone each night is recommended to
help her sleep with Seroquel given two hours prior to the
Trazodone medication.
DISCHARGE STATUS: The patient will be discharged to an
extended care facility in stable condition. She is alert and
oriented to herself which is her baseline and sometimes aware
of her surroundings. Her heart rate has been stable in the
70s for greater than 72 hours. She is eating a nectar thick
diet and is ambulatory with assistance.
DISCHARGE DIAGNOSES:
1. Intracranial hemorrhage, subarachnoid hemorrhage of the
left frontal lobe, subarachnoid hemorrhage of the right
posterior temporal lobe and small subdural right frontal
lobe.
2. Atrial fibrillation with rapid ventricular response.
3. Left distal radius fracture, minimally displaced and extra-
articular in nature.
4. Dementia.
5. Intensive Care Unit delirium.
6. T7 compression fracture.
FOLLOW UP:
1. The patient is to follow-up in Hand Clinic with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 56210**], in two to three weeks.
2. Neurosurgery - The patient is to follow-up with Dr. [**First Name (STitle) **] at
[**Telephone/Fax (1) 47455**], in four weeks. She will need a head CT
prior to this appointment and can call the above number to
arrange this.
3. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] at [**Telephone/Fax (1) 56211**], to evaluate her midthoracic compression
fracture. She should follow-up with him in three to four
weeks.
4. Behavioral [**Hospital 878**] Clinic - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 56212**], in three to four weeks.
5. There is no scheduled appointment with Trauma Clinic,
however, should the patient have any questions or
concerns, she can call [**Telephone/Fax (1) 42929**], for an appointment.
MEDICATIONS ON DISCHARGE:
1. Albuterol nebulizer two puffs q6hours p.r.n.
2. Heparin 5000 units q12hours subcutaneously.
3. Diltiazem 60 mg p.o. four times a day.
4. Donepezil 10 mg one tablet p.o. q.h.s.
5. Zyprexa 2.5 mg one tablet p.o. once daily.
6. Trazodone 50 mg one tablet p.o. q.h.s.
7. Amiodarone 400 mg p.o. once daily.
8. Haldol 0.5 to 2.0 mg intravenously three times a day as
needed, to note give after 10:00 p.m. unless concerned
about staff or patient safety.
9.
Seroquel 25 mg one tablet p.o. q.h.s. to take two hours prior
to Trazodone medication.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Last Name (NamePattern1) 41037**]
MEDQUIST36
D: [**2168-5-7**] 12:49:53
T: [**2168-5-7**] 15:19:09
Job#: [**Job Number 56213**]
|
[
"852.01",
"805.2",
"E880.9",
"293.0",
"852.21",
"401.9",
"427.31",
"813.41",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8206, 8612
|
9744, 10569
|
1121, 1188
|
3433, 8185
|
821, 922
|
8623, 9718
|
1211, 3415
|
116, 720
|
742, 797
|
939, 1095
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,268
| 120,061
|
28658
|
Discharge summary
|
report
|
Admission Date: [**2108-6-13**] Discharge Date: [**2108-7-4**]
Date of Birth: [**2052-10-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
transfer from OSH with SAH
Major Surgical or Invasive Procedure:
[**6-15**] Craniotomy with clipping of aneurysm
Angio w/ Intra-arterial verapamil
History of Present Illness:
55W transferred from OSH with SAH seen on head CT after
presenting with 2 days of a bilateral frontotemporal headache.
Patient reports 2 days ago, she got out of bed at 3am and was
urinating on the toilet when she had a sudden onset of [**9-4**]
pain
in her head. Denies visual changes, photophobia, fevers or
difficulty walking. Had associated nausea and vomitted x1. No
prior h/o HAs or trauma. No relief with medications at home.
Patient took advil last night and alleve this 7am.
At OSH, 98.7 61-70 20 168-177/92-99 100%RA. She
rec'd reglan, 1g dilantin, morphine sulfate 2mg. Head CT showed
SAH however no report or films were sent.
ROS: Denies runny nose or congestion, ear ache or sore throat.
No
focal weakness, numbness or tingling. Pt feels achy all over and
has a sore throat.
Past Medical History:
Thyroid problem
[**Name (NI) **] past surgeries
Social History:
Social Hx: Denies threats or abuse. Lives with husband, daughter
and grandson at home. Smokes 2 cigarettes per day for past 20
years. Drinks approximately a 6 pack of beer on weekends and
denies cocaine or other illicit drug use.
Family History:
Family Hx: No h/o seizure or stroke.
Physical Exam:
O: BP: 172/96 HR: 50's R: 16 100 O2Sats RA
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL, EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-27**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3.5mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
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 [**3-30**] throughout. No pronator drift
Sensation: Intact to light touch, propioception and vibration
bilaterally. Decreased pinprick and temperature (cold) sensation
in left forearm and left lower extremity below knee.
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 1+ 1+
Left 2+ 2+ 2+ 1+ 1+
Right toe downgoing and left toe upgoing.
Coordination: normal on finger-nose-finger.
Pertinent Results:
[**2108-6-13**] 01:28PM PHENYTOIN-17.3
Brief Hospital Course:
The patient was transferred here on [**6-13**] from an OSH after
presenting with 2 days of bifrontal headache and found to have
SAH on NCHCT. CTA showed a 5mm AComm aneurysm. On [**6-15**], the
patient was taken for craniectomy and aneurysm clipping, to
minimize the risk of bleeding. Post-op head CT was unchanged
from admission. However, on [**6-17**], the patient had a R fixed and
dilated pupil on exam and CT showed bilateral infarction of the
caudate and anterior putamen. Angiogram on [**6-17**] showed residual
aneurysm and mild to moderate vasospasm. Repeat study on [**6-20**]
showed moderate vasospasm of R A1 and the patient was given
verapamil. The patient was extubated on [**6-21**] and head ct was
stable, with the patient following commands. On [**6-22**], the
patient was reintubated for agitation and cerebral angiogram
showed less vasospasm. LENIs were negative. Course was
complicated on [**6-23**] by pseudomonas in the urine culture and the
patient was started on levofloxacin. Plan at this time was HHH
therapy and the patient was extubated on [**6-24**], with goal sbp
160. The patient was following commands at this time, off
decadron, and started on midazolam and haldol PRN for agitation.
She was weaned off HHH therapy and transferred to step down on
[**6-27**], when her sutures were also removed. She began getting OOB
to chair on [**6-28**] and started on seroquel 12.5mg [**Hospital1 **] for mild
sedation and midazolam was discontinued. Repeat head CT on [**7-2**]
was stable.
She is now transferred to rehab on [**7-4**]. Her baseline neurologic
exam now is awake & alert but abulic, speech normal. R CN III
palsy with ptosis and externally deviated eye and non-reactive
pupil. Otherwise intact. She has completed her course of
levofloxacin.
She will have a conventional angiogram in 8wks and will
follow-up with Dr. [**Last Name (STitle) **] at that time. After she is seen by
neurosurgery, she will be evaluated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
from behavioral neurology (appt to be arranged at follow-up appt
with Dr. [**Last Name (STitle) **].
Medications on Admission:
None, other than prn advil and alleve
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Codeine Sulfate 30 mg Tablet Sig: 0.5- 1 tab Tablet PO Q4H
(every 4 hours) as needed for headache.
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
11. Insulin Regular Human 100 unit/mL Solution Sig: Insulin
Sliding scale Injection ASDIR (AS DIRECTED).
12. Phenytoin 100 mg/4 mL Suspension Sig: 8ml PO TID (3 times a
day): please check levels- goal dph level [**9-14**].
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Nimodipine 30 mg Capsule Sig: One (1) Capsule PO Q2H (every
2 hours) as needed for Hold for SBP<100.: please dc [**7-1**].
15. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: please dc [**7-6**]; treatment of
pseudomonas/e. coli in urine.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Cerebral aneurysm with subarachnoid hemorrhage
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please call for any change in mental status; weakness or seizure
Followup Instructions:
Please call Dr.[**Name (NI) 9034**] office ([**Telephone/Fax (1) 2731**]) to schedule an
appointment in 8 weeks. You will need their office to contact
[**Name (NI) 17**] [**Name (NI) 17803**] to schedule a conventional angiogram in 8
weeks.
Completed by:[**2108-7-4**]
|
[
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"378.52",
"435.9",
"530.81",
"041.7",
"599.0",
"786.1",
"997.02",
"794.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.51",
"38.93",
"89.61",
"38.91",
"96.6",
"99.29",
"88.41",
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] |
icd9pcs
|
[
[
[]
]
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7134, 7231
|
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|
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|
7322, 7346
|
3134, 3176
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|
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|
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|
1653, 1878
|
280, 308
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458, 1264
|
2171, 3115
|
1893, 2155
|
1286, 1336
|
1352, 1584
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,516
| 126,367
|
53490
|
Discharge summary
|
report
|
Admission Date: [**2188-11-6**] Discharge Date: [**2188-11-18**]
Date of Birth: [**2147-1-22**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Sulfonamides / Biaxin / Levaquin /
Cefzil / Motrin / Erythromycin Base
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Abdominal pain, lower-extremity edema
Major Surgical or Invasive Procedure:
Attempt at paracentesis, unsuccessful
History of Present Illness:
This is a 41 year-old female with a history of combined
immunodeficiency syndrome, hepatitis C, brittle type 1 diabetes,
and cirrhosis, past cholecystectomy and appendectomy, who
presents with increasing abdominal girth, progressive abdominal
pain, nausea, vomiting, and increasing lower extremity oedema.
She was recently discharged from [**Hospital6 204**] 3 days
PTA where she was reportedly admitted for DKA, and also had
episode of coffee ground emesis requiring blood transfusion.
She reports also experiencing fever to 100.5 while in the
hospital. Per patient, she was also noted to have elevated
ammonia level at OSH. She does not recall and endoscopy being
performed, although she says she was "out of it". Patient
reports she has had a 14 pound weight gain from 121 to 134 lbs
over past several weeks, despite a progressive weight loss from
170 lbs. since [**2187-12-25**]. She reports diffuse abdominal pain
that had been intermittent since discharge, but progressed to
constant and severe over past 2 days.
.
She was seen in [**Hospital **] clinic today for follow-up and referred for
direct admission due to severity of her symptoms. She denies
hematemesis or coffee ground emesis today (reports emesis as
being green/brown). Last ate this morning. She denies
diarrhea, although she was admitted to [**Hospital1 18**] in [**Month (only) 359**] with
diarrhea and found to have cryptosporidium at that time. No
melena or hematochezia. She reports being adherent to her
medications. Her main concern is the progressive lower
extremity oedema. She has not been on loop diuretics in the
past because of a sulfa-allergy.
.
ROS: No cough, shortness of breath or respiratory symptoms. No
chest pain
Past Medical History:
1)Type 1 Diabetes, difficult to control, she has frequent
admissions for AMS from hypoglycemia. Followed at [**Last Name (un) **].
2)CVID: treated with IVIG q2 weeks, last [**10-14**]
3)UTIs
4)Asthma
5)CBP
6)HCV: diagnosed in [**10-31**]. Most recent VL [**8-1**] 7,980,000 IU/mL
Biopsy [**9-1**] showed Grade 2 inflammation, stage 2 fibrosis:
1. Marked portal, periportal, and lobular mixed-cell
inflammation with focal bridging (Grade 3).
2. Marked bile duct proliferation with neutrophils (see note)
3. Trichrome stain: Moderate increase of portal and septal
fibrosis (Stage 2).
7) cryptosporidium, as above
8) ? inflammatory bowel disease (UC)--per patient, last flare
many years ago, not on any treatment
Social History:
lives with fiancee and daughter, smokes [**12-26**] pack per day, denies
any alcohol since [**7-1**], formerly used IV drugs but none since
[**2184**]
Family History:
No family history of diabetes. Multiple family members with
[**Name2 (NI) 109976**] anemia. Mother has hypercholesterolemia and
diverticular disease, father has peripheral vascular disease
Physical Exam:
Vitals: T:98.4 BP:110/72 HR:72 RR:18 O2Sat:100% on RA
GEN: Chronically ill-appearing
HEENT: anicteric
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R
PULM: Lungs CTAB
ABD: Soft, Diffuse exquisite tenderness to palpation with
voluntary guarding, + fluid wave, +shifting dullness, no
rebound, + BS, no masses appreciated
EXT: 2+ oedema to shins, extremities warm
NEURO: alert, oriented to person, place, and time. No asterixis.
CN II ?????? XII grossly intact. Moves all 4 extremities. Strength
[**4-28**] in upper and lower extremities. Patellar DTR +1. Plantar
reflex downgoing. No gait disturbance. No cerebellar
dysfunction.
SKIN: No jaundice
Pertinent Results:
[**2188-11-6**] 05:45PM PT-16.0* PTT-35.8* INR(PT)-1.4*
[**2188-11-6**] 05:45PM PLT COUNT-175
[**2188-11-6**] 05:45PM NEUTS-61.9 LYMPHS-28.4 MONOS-4.2 EOS-4.9*
BASOS-0.7
[**2188-11-6**] 05:45PM WBC-7.5 RBC-4.05* HGB-12.7 HCT-38.2 MCV-94
MCH-31.3 MCHC-33.2 RDW-17.0*
[**2188-11-6**] 05:45PM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-3.0
MAGNESIUM-1.4*
[**2188-11-6**] 05:45PM ALT(SGPT)-318* AST(SGOT)-444* LD(LDH)-250 ALK
PHOS-241* TOT BILI-2.5*
[**2188-11-6**] 05:45PM estGFR-Using this
[**2188-11-6**] 05:45PM GLUCOSE-282* UREA N-11 CREAT-0.6 SODIUM-136
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-20* ANION GAP-17
CT abdomen/pelvis [**2188-11-7**]:
IMPRESSION:
1. Ascites.
2. Extensive lobulated and irregular contours of the kidneys,
likely scarring
from chronic reflux, unchanged.
3. Dependent atelectasis at the lung bases.
4. Small amount of air in the subcutaneous tissue on the right,
might be from recent procedure or subcutaneous injection. Please
correlate
U/S- abdomen [**2188-11-7**] (was ordered to guide paracentesis):
IMPRESSION: No ascites. The paracentesis was not performed.
B/L LENIs [**2188-11-7**]:
IMPRESSION: No lower extremity DVT identified. Please note, the
left distal superficial femoral vein could not be evaluated
given overlying edema
.
ECHO [**2188-11-10**]:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). 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 mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild
pulmonary artery systolic hypertension.
CT head [**2188-11-11**]: IMPRESSION
1. No evidence for acute infarction or hemorrhage.
KUB [**2188-11-11**]:
IMPRESSION:
1. Extensive retained fecal material throughout the colon.
2. Question of mucosal fold thickening in a mildly dilated
air-filled loop of bowel in the left upper quadrant. This could
represent ischemia in the
splenic flexure, and close radiographic followup is recommended.
KUB [**2188-11-12**]:
IMPRESSION: Increasing distention of colonic loops compared to
[**2188-11-12**]. No free air identified.
pCXR [**2188-11-13**]: IMPRESSION: No evidence of free intraperitoneal
air.
CT abdomen/pelvis [**2188-11-13**]:
MPRESSION:
1. Right rectus muscle hematoma, within the right lower
quadrant, may explain patient's symptoms.
2. Moderate distention of colon with fecal residue seen
throughout the colon, and unusual locules of air on the
dependent surface of the colon. While this likely reflects
trapped air within fecal matter, close observation for
development of ischemic symptoms is recommended. However, there
is no direct evidence for ischemia on this study.
3. Ascites, with anasarca.
4. Dependent atelectases in the visualized lung bases.
5. Extensive lobulated irregular contours of the kidneys, likely
reflecting scarring, stable.
KUB [**11-13**]:
IMPRESSION: Moderate gaseous distention of colonic loops,
slightly improved from [**2188-11-12**].
KUB [**11-14**]:
IMPRESSION: Continued moderate gaseous distention of the colon
without
dilated small bowel loops. Findings are consistent with colonic
ileus.
KUB [**11-15**]:
ABDOMEN, SUPINE: The distention within the colon seen on the
prior film has resolved. Appearances are consistent with
resolving ileus.
Brief Hospital Course:
This is a 41 year-old female with multiple medical problems who
presents with abdominal pain and distention, and increasing
lower extremity edema.
# Abdominal pain - Initially, the etiology of abdominal pain was
unclear. The patient is on narcotics as an outpatient for
chronic pain. SBP was on differential, given distention, exam
consistent with ascites, and diffuse tenderness. Attempted
diagnostic paracentesis x 3 unsuccesfully. Later abd CT showed
small ascites, and patient sent down to radiology for u/s guided
paracentesis, but no tappable ascites was found. She was
initially treated emperically with aztreonam for SBP, but given
lack of ascites, this was discontinued after 1 day. On hospital
d#6, she was transferred to the MICU for AMS due to a blood
glucose of 15. She recovered from the hypoglycemia (see below),
but was noted to have worsened abdominal pain. KUB showed
dilated loops of colon, and lactate rose to 4. GI and surgery
were consulted, with concern for bowel ischemia. CT abdomen
repeated on [**11-13**], showing RLQ rectus muscle hematoma (likely
[**1-26**] the attempt at paracentesis), as well as stool and air in
the colon. No evidence ischemia on this CT. She was hydrated,
given an aggressive bowel regimen, and NGT placed to suction.
Surgery did not find evidence of bowel ischemia and felt this
was likely an ileus, probably due to narcotic pain meds and
acute illness. All narcotics were stopped. She began having
bowel movements, and her lactate and exam returned to [**Location 213**]
within one day. NGT removed. Pain improved, and all narcotics
were held in favor of lidoderm patches and warm packs. She then
began to have diarrhea. Cdiff was negative. Reglan and bowel
regimen stopped. Stools became formed. Per her ID physician,
[**Last Name (NamePattern4) **]. [**First Name (STitle) **], the diarrhea is likely [**1-26**] her known cryptosporidium,
which is difficult to irradicate in immunocompromised patients.
She was given IVIG to help, as she was due for her normal dose.
F/u scheduled with Dr. [**Last Name (STitle) 497**] and Dr. [**First Name (STitle) **] from ID.
# LE edema: She ruled out for dvt by LE dopplers. An echo did
not reveal any evidence of heart failure. U/A negative for
protein in the urine. In consultation with the liver team, it
was felt the LE edema was most likely due to decompensating
Hepatitis C cirrhosis, although her last biopsy of the liver in
[**2188-8-25**] revealed only stage II fibrosis. She was given IV
lasix initially, then spironolactone added. Her potassium rose
to 5.3 and spironolactone stopped. Her LE edema improved, but
then she went to ICU and there was concern for ischemic bowel
and lasix stopped. She then got IVFs. Later, back on the
medical floor, gentle diuresis was re-started with oral lasix,
20mg daily. She will follow up with Dr. [**Last Name (STitle) 497**] from liver center
in 1 week to see if her dose needs to be changed.
# Benzodiazepine overuse: Pt was taking Alprazolam at home,
ordered for 0.5mg up to QID prn for anxiety. Per patient and
nursing report upon admission, there was concern that she had
been taking substantially more, up to 5 or 6 mg daily. Due to
concern for confusion, this was stopped and she was briefly on a
CIWA scale to monitor for benzodiazepine withdrawl. Eventually
all benzodiazepines were stopped and pt encouraged to abstain
from this medication as it can accumulate in liver disease and
contribute to encephalopathy.
# Hepatitis C Cirrhosis: As noted above, the patient has stage
II liver fibrosis on her most recent biopsy in [**2188-8-25**].
Transaminases, INR, and Tbili were elevated throughout her
hospitalization, and were lower than previous measures. At the
outside hospital on a prior admission, she had an EGD which was
negative for esophageal varices on [**2188-10-31**]. Hepatology
consulted throughout her hospitalization and there was consensus
that her LE swelling was likely due to cirrhosis that is
progressing. In addition, she did have transient encephalopathy
with asterixis on the floor, treated successfully with
lactulose. The patient will follow up in the liver clinic next
week.
# Cryptosporidium diarrhea- She was continued on Nitazoxanide
500mg PO BID. She did have diarrhea in the final 3-4 days of
hospitalization. Cdiff neg x1, second sample pending. She was
given IVIG on [**2188-11-18**] which she receives monthly at the
[**Hospital1 882**] infusion center. Last dose at [**Hospital1 882**] was [**2188-10-14**].
Outpatient follow up with Dr. [**First Name (STitle) **] from ID was scheduled
[**2188-11-19**].
# Type 1 DM - She had variable blood glucoses. [**Last Name (un) **] was
consulted and followed throughout her hospitalization.
Initially she was frequently low, less than 60. glargine dose
titrated down from 20 units to 13 over several days to
compensate. Then on [**2188-11-12**], her fingerstick was 44 but
inadvertently recorded as 144 and she was given 8 units humalog.
She became unresponsive and FS was 15. Given 1 amp D50 with
improvement to 200s. She went to ICU for monitoring. Later,
after called out to floor, fingersticks were very elevated, up
to 560 on [**11-17**]. Her glargine and Insulin SS were uptitrated.
There were no ketones in urine and no anion gap. Eventually her
BG were controlled with a tighter sliding scale which she will
be discharged on. She will follow up with the NP who saw her in
the hospital, and will be [**Month/Year (2) 653**] by [**Name (NI) **] with an
appointment.
# Hypertension: With diuresis, her BP was between 100 and 120
systolic. Her lisinopril dose was decreased and eventually
stopped. She will likely need it again once her BP stabilizes
and for renal protection given her Diabetes. However, this
should be re-started when appropriate by her outpatient
providers.
#COPD: Continued home regimen of Spiriva, Advair and albuterol
nebs.
# FEN: Diabetic low-sodium diet.
# PPx: Heparin SC, Omeprazole
# Code: Full code
Medications on Admission:
Albuterol
Alprazolam 0.5mg QID PRN
Fluticasone/Salmeterol
Insulin sliding scale
Glargine 20 units QHS
Levalbuterol
Lisinopril 10mg [**Hospital1 **]
Metopclopramide 20mg qAC
Morphine SR 120mg [**Hospital1 **]
Nitazoxanide 500mg [**Hospital1 **]
Omeprazole 20mg daily
Oxycodone 15mg QID
Promethazine
Tiotropium
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation Q6H (every 6 hours) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Insulin Glargine 100 unit/mL Solution Sig: AS DIRECTED BELOW
units Subcutaneous twice a day: Take 10 units in the AM, and 11
units at Bedtime.
7. Insulin Lispro 100 unit/mL Cartridge Sig: as directed units
Subcutaneous three times a day: With meals. Use sliding scale
as directed.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) patch Topical once a day: Place for 12 hours then remove for
12 hourse.
Disp:*30 patches* Refills:*2*
10. Alinia 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
1. LE edema
2. Liver dysfunction, ? early cirrhosis
3. Diabetes type I, complicated by severe hypoglycemia requiring
ICU
4. Ileus
5. Hepatic Encephalopathy
Secondary diagnosis:
1. Diabetes, Type I, with complications
2. Hepatitis C
Discharge Condition:
LE edema improved. No encephalopathy. Stools are now formed.
Discharge Instructions:
You were admitted with abdominal pain and LE edema. It was
found that you did not have any fluid in your abdomen to remove.
Your pain was felt likely due to your chronic liver disease
given your stable CT scan. You also had an ileus (servere
constipation) and some bruising in your R lower abdomen from the
attempt to remove fluid. These likely caused your pain. YOU
MUST NOT USE NARCOTIC PAIN MEDS, because it is dangerous given
your liver disease and constipation.
For your edema, a work up revealed that your edema might be due
to your liver disease. Other causes were ruled out, such as
kidney disease, clots in your leg, and heart failure.
You will need follow up with Dr. [**First Name (STitle) **] from infectious diseases,
as well as Dr. [**Last Name (STitle) 497**] from the liver center, your [**Last Name (un) **]
provider, [**Name10 (NameIs) **] your primary care physician. [**Name10 (NameIs) **] appointments
are listed below. It is extremely important that you keep these
appointments.
MEDICATION CHANGES:
1. Stop Lisinopril
2. Stop MS Contin, and all other pain meds (ie oxycodone)
3. Stop Alprazolam (Xanax)
4. Stop Reglan. It was likely making your diarrhea worse
5. Start taking Lasix 20mg by mouth daily. This will help with
your fluid in the legs
6. Take your insulin as directed in the medication section.
Call your [**Last Name (un) 387**] provider if you have any questions.
7. Continue to take the Nitazanoxide for your infection in the
stool
8. You may use lidocaine patches or warm packs for pain
Call your doctor if you have worsening of your abdominal pain,
increase in fluid on your legs or your abdomen, or
Followup Instructions:
You have an appointment with your liver doctor, Dr. [**First Name (STitle) **]
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2188-11-24**] 3:00
You need to call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 17**] [**Last Name (NamePattern1) 67537**]
([**Telephone/Fax (1) 26330**]) for an appointment in 1 week.
You are scheduled to follow up with your infectious disease
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 457**] on
Date/Time:[**2188-11-19**] 11:30 AM
.
You will be [**Month/Day/Year 653**] by your nurse practictioner at the [**Last Name (un) **]
Diabetes Center, [**Doctor Last Name **], for a follow up appointment soon.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2188-11-18**]
|
[
"338.29",
"962.3",
"493.20",
"571.5",
"560.1",
"279.06",
"998.12",
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"E853.2",
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icd9cm
|
[
[
[]
]
] |
[
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
15406, 15489
|
7826, 13858
|
394, 434
|
15766, 15831
|
4034, 7803
|
17530, 18482
|
3098, 3290
|
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462, 2179
|
15688, 15745
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|
2929, 3082
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,318
| 168,835
|
43728
|
Discharge summary
|
report
|
Admission Date: [**2115-8-28**] Discharge Date: [**2115-9-16**]
Date of Birth: [**2035-2-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Fevers, lethargy, respiratory distress
Major Surgical or Invasive Procedure:
Nasal intubation.
Oropharyngeal intubation.
Tracheostomy with open G-tube placement.
Echocardiography.
History of Present Illness:
80 yo F with h/o meningioma s/p craniotomy/R hemiparesis and
aphasia p/w fever to 105. Pt reportedly complained of back pain
on Monday evening and has had concentrated urine for 2 days PTA.
Per daughters, tolerating [**Name2 (NI) **] without choking but increasing
fatigue/lethargy. no diarrhea. Over the last day PTA, + new
cough productive of small amounts.
In ED, fever to 105, HR 156, BP 132/86, RR 38. Initially 96%
on RA. BP dropped to 86/38 with HR 78-->femoral central line
placed for fluid resuscitation (4L NS), given levo/flagyl. After
fluids, became increasingly dyspneic, requiring 100% NRB.
.
Past Medical History:
1) Left frontal meningioma; was invasive with mass effect
- s/p craniotomy in [**2108**] post operative course complicated by
cerebral edema with bleeding leading to right hemiparesis &
aphasia.
2) History of shunt placement for hydronephrosis
3) Status post J-tube and G-tube placement, removed in [**Month (only) 1096**]
[**2110**]
4) Status post tracheotomy, removed.
5) History of aspiration pneumonia in [**2109**], on thickened liquids
and pureed foods
6) Marked kyphosis, appeared to have worsened after her [**2108**]
surgery.
Social History:
She lives with her daughters. [**Name (NI) **] 24 hour health aide. She is
able to feed herself, communicates with gestures, and can
transfer to a wheelchair with assistance. At baseline, pt is
unable to walk due to her hemiparesis. She is aphasic, but the
family can understand what she wants by her gestures.
.
Family History:
Non-contributory.
Physical Exam:
PE: T 105 86-122/30-60s 78-160 RR 20-35 100% NRB
Gen: severely kyphotic elderly woman lying in bed, will not
respond to commands.
HEENT: Would not open eyes. mmm.
NECK: JVP difficult [**2-20**] to patient's posture.
Cor: Reg S1, S2, limited examination.
Chest: rhonchi, expiratory moaning, few [**Hospital1 **]-basilar rales
Abd: NABS, mild distention, soft, no grimace with palpation.
Ext: +2 DP, 1+ edema, both feet are plantar flexed.
Back: no CVA tenderness
Pertinent Results:
Admission laboratories.
[**2115-8-27**] 11:00PM BLOOD WBC-29.4*# RBC-4.40 Hgb-13.1 Hct-36.5
MCV-83 MCH-29.7 MCHC-35.7* RDW-13.2 Plt Ct-499*
[**2115-8-27**] 11:00PM BLOOD Neuts-90.9* Lymphs-5.5* Monos-3.4 Eos-0.2
Baso-0.1
[**2115-8-27**] 11:00PM BLOOD Glucose-139* UreaN-19 Creat-0.5 Na-132*
K-4.0 Cl-95* HCO3-26 AnGap-15
[**2115-8-27**] 11:00PM BLOOD Albumin-3.6
[**2115-8-28**] 12:18AM BLOOD Type-ART pO2-113* pCO2-32* pH-7.48*
calHCO3-25 Base XS-0
[**2115-8-28**] 03:33AM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-60* pH-7.20*
calHCO3-25 Base XS--6
[**2115-8-28**] 03:47AM BLOOD Type-ART Temp-39.0 FiO2-100 pO2-281*
pCO2-50* pH-7.26* calHCO3-23 Base XS--4 AADO2-401 REQ O2-68
Intubat-NOT INTUBA
[**2115-8-28**] 12:15AM BLOOD Lactate-1.9
[**2115-8-28**] 05:51AM BLOOD Lactate-2.9* Na-135
[**2115-8-28**] 07:27AM LACTATE-1.7
.
EKG: sinus tach@156, RBBB (old), nl axis, old TWI III, AvF, V1.
1mm ST depressions in V2, V4.
.
CXR: Limited study. No focal consolidation. min. atelectasis at
L base.
.
Repeat CXR: Increased opacity LUL--edema vs infiltrate.
.
Echocardiography ([**2115-9-4**])
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets are mildly thickened. No aortic valve stenosis is seen.
Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
structurally
normal. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
Chest CT ([**2115-9-5**])
1. Moderate size, enlarging bilateral pleural effusions probably
responsible for bilateral lower lobe collapse and respiratory
failure.
2. Persistent ascites.
.
Discharge Laboratories
[**2115-9-16**] 04:50AM BLOOD WBC-10.0 RBC-3.29* Hgb-9.8* Hct-28.6*
MCV-87 MCH-29.8 MCHC-34.2 RDW-15.3 Plt Ct-454*
[**2115-9-15**] 04:00AM BLOOD WBC-8.6 RBC-3.22* Hgb-9.8* Hct-28.3*
MCV-88 MCH-30.4 MCHC-34.6 RDW-15.6* Plt Ct-455*
[**2115-9-16**] 04:50AM BLOOD Plt Ct-454*
[**2115-9-2**] 03:55PM BLOOD Ret Aut-0.3*
[**2115-9-16**] 04:50AM BLOOD Glucose-100 UreaN-13 Creat-0.4 Na-131*
K-3.9 Cl-96 HCO3-26 AnGap-13
[**2115-9-16**] 04:50AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.6
[**2115-9-12**] 05:04AM BLOOD calTIBC-139* Ferritn-520* TRF-107*
[**2115-8-30**] 05:06AM BLOOD Osmolal-293
[**2115-9-16**] 04:46AM BLOOD Type-ART pO2-75* pCO2-33* pH-7.54*
calHCO3-29 Base XS-5
Brief Hospital Course:
This is an 80 year-old woman with history of severe kyphosis,
hydronephrosis requiring shunt, s/p craniotomy for invasive
meningioma with post-operative complication leading to R
hemiparesis and aphasia, and prior tracheostomy. She presented
to emergency department the night of [**2115-8-27**] with a [**3-22**] history
of fever, back pain, and productive cough. In ED found to be
febrile with hypotension responsive to fluids. Also with marked
elevated WBC, positve urinalysis and urine culture that
eventually grew out pan-sensitive pseudomonas aeruginosa. Pt
started on levofloxacin and flagyl for empiric coverage of UTI
and community acquired pneumonia. CXR intially unremarkable.
Upon fluid resusciation in [**Name (NI) **], pt noted to develop respiratory
distress. Repeat CXR revealed increased infiltrates. Poor
improvement with non-rebreather mask, ABG revealed hypercarbia.
Pt admitted to MICU for respiratory distress progressing to
respiratory failure secondary to urosepsis. Pt intubated by
anesthesiology, this had be performed intranasally given
markedly severe kyphosis.
Urine culture of pan sensitive pseudomonas reported on HD 2;
levofloxacin changed to ciprofloxacin for 14 d course. Repeat
urine cultures on HD 1 were negative. Pt intially showed some
improvement with defervescence. Her hemodynamic status was
intially somewhat tenous with frequent IVF support required for
low blood pressure and poor urinary output. By [**2115-8-29**] her
hemodynamic status had shown good improvement. Unfortunately,
on [**8-30**] the patient was accidentally extubated during bathing
and had witness aspiration. She was emergently re-intubated
oropharyngeally.
In the week subsequent to this, pt progressed poorly, showing
little sign of being able to wean off mechanical ventilation
(respiratory mechanics demonstrated weakness of respiratory
muscles) and again required frequent IVF boluses for low blood
pressure and poor urinary output. An echocardiogram was
performed to assess whether reduced cardiac function contributed
to this, but in fact revealed a normal EF and no wall motion
abnormalities. It was remarkable for evidence of pulmonary
hypertension. Central line placed by IR for better assessment
of volume status by CVP
On [**2115-9-5**] pt was febrile with tachypnea and increased
respiratory secretions, WBC again elevated, CXR was
unremarkable but sputum gram stain revealed gram positive cocci
on [**9-6**] and vancomycin was therefore started empirically for
ventilator associated pneumonia secondary to presumed MRSA
although pan cultures never grew this out. Pt defervesced after
starting vanomycin and WBC trended downward. By [**9-5**], also, it
was apparent that with the frequent IVF support CVPs had
normalized and that the patient was now volume overloaded
appearing edematous by physical exam. A chest CT did reveal
increased bilateral pleural effusions. Apparently, per
interventional pulmonology, ultrasound revealed these were
actually too small for safe thoracentesis. Gentle diuresis by
lasix gtt was begun. Edema markedly improved over next few
days.
By [**9-10**] it became apparent that patient would require
tracheostomy as she had shown little progress in weaning of
ventilatory support. Tracheostomy, with open PEG placement, was
performed by Thoracic Surgery on [**2115-9-11**] with no complication.
Pt ability to wean markedly improved after this. She tolerated
pressure support ventilation for most of the day and began
undergoing prolonged trials on trach mask as well. In addition
she achieved euvolemic status with diuresis aided by Lasix. She
continued to be afebrile without sign of infection. It was felt
that patient had sufficiently progressed to the point to which
she could be transferred to rehabiliation facility.
.
In summary, this is an 80 year-old woman with baseline right
hemiparesis & aphasia, severe kyphosis who presented with
urosepsis, respiratory failure on [**2115-8-27**]. Hospital course
complicated by difficulty in weaning off mechanical ventilation
and MRSA VAP on [**2115-9-6**]. Now s/p tracheostomy on [**9-11**] with
markedly improved respiratory function.
Major issues of this patient are as follows:
1. Hypoxic, hypercarbic Respiratory Failure, s/p trach/PEG.
Respiratory failure initally secondary to urosepsis and possiby
pulmonary edema from aggressive IVF. Prolonged wean from vent
complicated by VAP and necessitating trach/PEG
-should be ready to wean off ventilatory support shortly
-pulmonary toilet, nebulizers as needed.
-[**9-4**] pleurual effusion seen on chest CT, likely some
contribution of aggressive IVF, interventional pulmonology
called for thoracentesis but apparently found effusions to small
(by ultrasound) to safely tap.
.
2. VAP, gram positive cocci in sputum [**9-6**] likely MRSA, now on
vancomycin (day 1= [**9-6**], 14 day course)
- check vancomycin trough level to maintain in therapeutic
range.
.
3. Fluid status. Initially required aggressive IVF, achieved
normal/high-normal CVP and adequate blood pressure. Urine
output inconsistent however and she eventually required Lasix as
she became volume overloaded.
-[**Month (only) 116**] need to continue Lasix, although no sign of heart failure.
?Intrinsic renal disease, although urine electrolyte studies did
not suggest this.
-has baseline low-normal BP, per Dr. [**Last Name (STitle) 10145**], her PCP, [**Name10 (NameIs) **]
normally 100-110.
-Echo revealed normal cardiac function.
-IVF bolus for hypotension (cautiously, if indicated)
-no pressors indicated.
.
4. Urosepsis, initially fever, back pain and positive urine cx
for pan-sensitive pseudomonas on [**2115-8-27**].
-on ciprofloxacin (d 1 = [**2115-8-30**]) now with three negative urine
cultures since admission, has cleared urine.
.
5. Anemia, s/p hct drop on [**9-2**] with 2 units pRBC transfused.
Has been stable since then.
-low retic count noted. [**Month (only) 116**] need hem-onc follow up.
-hct stable, no need for transfusion, follow daily.
-iron studies.
.
6. Constipation, appears controlled on Senna, Colace.
-continue bowel regimen
6. FEN:
-Tube feeds via G-tube, use Respalor. More concentrated formula
-Will need rehab before able to tolerate PO diet.
.
7. PPX: SC heparin given immobility, proton pump inhibitor,
bowel meds.
.
8. Access: L SC placed by IR [**9-3**]. Also L A-line [**8-31**].
.
9. Code: FULL, discussed and verified with daughters.
.
10. Disposition: Probably will require rehabilitation facility.
Medications on Admission:
Dulcolax supp q 3 days
Tylenol prn
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) Units Injection TID (3 times a day).
3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mL PO DAILY (Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for Fever.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb inh
Inhalation Q3-4H (Every 3 to 4 Hours) as needed.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: 1000 (1000)
mg Intravenous Q 12H (Every 12 Hours): Day 1=[**2115-9-6**]
14 day course to complete [**9-20**].
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mL PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 86**]
Discharge Diagnosis:
Hypoxic, hypercarbic respiratory failure.
Urosepsis.
Ventilator associated pneumonia.
Status post tracheostomy, PEG.
Severe kyphoscoliosis.
R hemiparesis, aphasia.
Discharge Condition:
Good. Able to tolerate prolonged periods off of mechanical
ventilation. Afebrile with no sign of pneumonia or urinary
tract infection. Tolerating tube feeds. Euvolemic with minimal
edema.
Discharge Instructions:
To rehabilitation facility able to manage patients on mechanical
ventilation.
Followup Instructions:
Rehabilitation facility.
|
[
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"486",
"038.9",
"599.0",
"285.9",
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"507.0",
"276.5",
"438.11",
"995.92",
"790.92",
"458.9",
"V09.0",
"564.00",
"428.0",
"041.7",
"518.81",
"438.20"
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icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.04",
"38.91",
"99.07",
"96.72",
"99.04",
"38.93",
"96.6",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
12810, 12881
|
5072, 11583
|
310, 415
|
13089, 13283
|
2484, 5049
|
13409, 13437
|
1963, 1982
|
11669, 12787
|
12902, 13068
|
11609, 11646
|
13307, 13386
|
1997, 2465
|
232, 272
|
445, 1058
|
1080, 1616
|
1632, 1947
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,584
| 131,339
|
21003
|
Discharge summary
|
report
|
Admission Date: [**2166-6-27**] Discharge Date: [**2166-7-5**]
Date of Birth: [**2166-6-27**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname 2916**] [**Known lastname 55810**] is a former 3.38
kg product of a 38 [**5-16**] week gestation pregnancy born to a 32
year old gravida 3, para 2, now 3 woman. Perinatal screens,
blood type 0 positive, antibody negative, RPR nonreactive,
Rubella immune, hepatitis B surface antigen negative, Group B
Streptococcus positive. This was an uncomplicated pregnancy,
with spontaneous onset of labor. The mother received [**Name2 (NI) 38886**]
antibiotics one hour prior to delivery. There was no
maternal fever or fetal tachycardia in labor. The infant was
born via precipitous vaginal delivery under epidural
anesthesia. Apgars were 6 at one minute and 8 at five
minutes. He developed grunting, flaring and retracting in
the Delivery Room and was admitted to the Neonatal Intensive
Care Unit for further evaluation and treatment.
PHYSICAL EXAMINATION: Physical examination upon admission to
the Neonatal Intensive Care Unit revealed weight 3.38 kg,
75th percentile, length 50 cm, 75th percentile. Head
circumference is 33 cm, 50th percentile. General, term
infant in mild respiratory distress. Head, eyes, ears, nose
and throat, anterior fontanelle soft and flat, bruised face,
intact palate, positive red reflex bilaterally. Chest, mild
grunting flaring and retracting, clear and equal breath
sounds. Cardiovascular, soft murmur at the left sternal
border, normal pulses. Abdomen, soft, three vessel cord, no
hepatosplenomegaly. Genitourinary, normal male genitalia,
testes descended into the scrotum. Musculoskeletal, no hip
clicks, no sacral dimples. Skin, pale and pink with blow-by
oxygen, slightly decreased capillary refill. Neurological,
normal tone and activity. Good suck.
HOSPITAL COURSE/PERTINENT LABORATORY DATA: Respiratory -
[**Known lastname 2916**] required nasal cannula oxygen through day of life number
2. He weaned to room air and continued in room air until
discharge. Respiratory rates initially were 60 to 80 per
minute. His tachypnea gradually resolved. At the time of
discharge he is breathing comfortably in room air with a
respiratory rate of 30 to 50. His respiratory distress was
felt to be due to retained fetal lung fluid following his
precipitous delivery.
Cardiovascular - The murmur noted at admission persisted. On
day of life #6, [**Known lastname 2916**] had an electrocardiogram performed
which was within normal limits. A chest x-ray showed normal
heart size and situs with normal pulmonary blood flow. Lower
extremity blood pressures were within normal limits. He
passed an oxygen challenge test, and as these screening
evaluations were all normal, no further cardiology evaluation
was undertaken. If the murmur persists, cardiology consultation
should be undertaken. At the time of discharge his heart rates
are 140 to 160 beats/minute, mean blood pressures are in the 40s
to 50s. He did require one normal saline bolus at the time
of admission for some transient hypotension.
Fluids, electrolytes and nutrition - [**Known lastname 2916**] was initially NPO
and maintained on intravenous fluids. Initial serum glucoses
were 15 and 17. He was treated with a bolus of D10/W in a
continuous infusion. The hypoglycemia resolved. Enteral
feeds were started on day of life No. 1. He is ad lib breast
fed or bottle fed. It was noted that he had some transient
episodes of oxygen desaturation with bottle feeding which did
not occur with breastfeeding; these were mild and resolved
rapidly with a pause in feeding. He is being discharged home
with the recommendation to exclusively breast feed or to
closely monitor him while bottle feeding giving him frequent
rests. He has not had further episodes since the day prior to
discharge. Weight on the day of discharge is 3.325 kg with a
length of 51.5 cm and a head circumference of 33 cm.
Infectious disease - Due to the unknown etiology of the
respiratory distress and the known Group B Streptococcus
status of the mother with less than four hour [**Known lastname 38886**]
prophylaxis, [**Known lastname 2916**] was evaluated for sepsis. A white blood
cell count was 5000 with a differential of 39 percent
polymorphonuclear cells and 14 percent band neutrophils. A
blood culture was obtained prior to starting intravenous
ampicillin and gentamicin. A repeat complete blood count on
day of life No. 1 showed an increasing white count to 20,400
with a differential of 68 percent polymorphonuclear cells and
16 percent band neutrophils. The blood culture was no growth
at 48 hours and antibiotics were discontinued.
Gastrointestinal - Peak serum bilirubin occurred on day of
life 2, total of 7.8/0.3 mg/dl direct. He did not require
any treatment for neonatal jaundice.
Hematology - Hematocrit at birth was 47.5 percent, [**Known lastname 2916**] did
not receive any transfusions of blood products.
Neurology - [**Known lastname 2916**] has maintained a normal neurological
examination during admission and there are no neurological
concerns at the time of discharge.
Sensory/audiology - Hearing screening was performed with
automated auditory brain stem responses, [**Known lastname 2916**] passed in both
ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with parents. The primary
pediatrician is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 **], Family Health, [**Street Address(2) 55811**], [**Hospital1 **], [**Numeric Identifier 55812**]. Phone [**Telephone/Fax (1) 55813**]. Fax [**Telephone/Fax (1) 30446**].
CARE/RECOMMENDATIONS AT DISCHARGE: Feedings - Bottle feeding
with attention to frequent rest periods.
Medications - None.
State newborn screen - Sent on [**2166-6-30**] with no
notification of abnormal results to date.
Immunizations administered - Hepatitis B vaccine on [**2166-6-30**].
Immunizations recommended - Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria, 1. Born at less than 32 weeks gestation; 2. Born
between 32 and 35 weeks with two of the following: Daycare
during respiratory syncytial virus season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school age siblings; or 3. With chronic lung disease.
Influenza Immunization is recommended annually in the fall
for all infants once they reach six months of age, before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
Follow up appointments recommended - Appointment with Dr.
[**Last Name (STitle) **] within five days of discharge.
DISCHARGE DIAGNOSIS: Term male.
Respiratory distress secondary to retained fetal lung fluid.
Suspicion for sepsis, ruled out.
Hypoglycemia.
Cardiac murmur.
REVIEWED BY: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2166-7-5**] 01:57:14
T: [**2166-7-5**] 08:11:34
Job#: [**Job Number 55814**]
|
[
"V30.00",
"770.6",
"V50.2",
"796.3",
"V05.3",
"775.6",
"V29.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55",
"64.0"
] |
icd9pcs
|
[
[
[]
]
] |
5389, 5718
|
6901, 7291
|
1046, 5333
|
5733, 6879
|
171, 1023
|
5358, 5365
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,866
| 191,534
|
45975
|
Discharge summary
|
report
|
Admission Date: [**2160-4-9**] Discharge Date: [**2160-5-6**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Jaundice and Cholangiocarcinoma of the bile duct.
Major Surgical or Invasive Procedure:
1. Staging laparoscopy with laparoscopic intra-abdominal
ultrasound.
2. Classical Whipple pancreaticoduodenectomy.
3. Liver wedge biopsy.
4. Hepaticojejunostomy separate from Whipple procedure.
5. Combined gastrojejunostomy tube (mixed tube) placement.
History of Present Illness:
This 84-year-old woman presented
about a month ago with painless obstructive jaundice. A
workup included an ERCP which revealed a constricting mass
effect in the distal bile duct. Brushings from this procedure
were suspicious for adenocarcinoma. She had a stent placed,
and her jaundice was relieved. A CT scan showed a large mass
in the bile duct a few centimeters in size. There appeared to
be no gross evidence of any metastatic disease either in her
liver or peritoneal cavity. The CT scan did show some
aberrant anatomy including a completely replaced right
hepatic artery flowing directly behind this mass. However,
the portal vein completely opened, and it did not seem to be
a widely infiltrative lesion.
Past Medical History:
Possible HCM
mild AS/mild AI
mild to mod MR
TR/PI
Hypertension
Dyslipidemia
Hypothyroidism
s/p resection of bladder tumor
s/p masectomy for BrCa
Social History:
No EtOH. former smoker.
Family History:
n/c
Physical Exam:
NAD
EOMI, PERRLa
Lungs clear
Heart :RRR
Abd: soft nontender, incision clean dry and intact
Pertinent Results:
[**2160-4-9**] 09:36PM GLUCOSE-110* UREA N-24* CREAT-0.8 SODIUM-142
POTASSIUM-4.8 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14
[**2160-4-9**] 09:36PM WBC-24.3*# RBC-3.38* HGB-10.4* HCT-31.1*
MCV-92 MCH-30.8 MCHC-33.5 RDW-13.8
[**2160-4-9**] 09:36PM PLT COUNT-342
[**2160-4-9**] 09:36PM PT-13.6* INR(PT)-1.2*
[**2160-4-9**] 07:28PM TYPE-ART TEMP-36.8 TIDAL VOL-560 PO2-157*
PCO2-42 PH-7.34* TOTAL CO2-24 BASE XS--2 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2160-4-9**] 07:28PM GLUCOSE-114* LACTATE-3.3* NA+-139 K+-4.2
CL--109
[**2160-4-9**] 07:28PM HGB-10.5* calcHCT-32
[**2160-4-9**] 07:28PM freeCa-1.18
[**2160-4-9**] 07:28PM freeCa-1.18
[**2160-4-9**] 05:51PM TYPE-ART TEMP-36.8 RATES-/8 TIDAL VOL-570 O2
FLOW-1.5 PO2-149* PCO2-38 PH-7.40 TOTAL CO2-24 BASE XS-0
INTUBATED-INTUBATED VENT-CONTROLLED
[**2160-4-9**] 05:51PM GLUCOSE-169* LACTATE-1.9 NA+-138 K+-4.6
CL--109
[**2160-4-9**] 05:51PM HGB-10.6* calcHCT-32
[**2160-4-9**] 04:43PM TYPE-ART O2-39 PO2-148* PCO2-34* PH-7.44
TOTAL CO2-24 BASE XS-0 INTUBATED-INTUBATED
[**2160-4-9**] 04:43PM GLUCOSE-165* LACTATE-2.9* NA+-139 K+-4.2
CL--108
[**2160-4-9**] 04:43PM HGB-10.2* calcHCT-31
[**2160-4-9**] 04:43PM freeCa-1.14
[**2160-4-9**] 03:32PM TYPE-ART O2-55 PO2-162* PCO2-39 PH-7.41 TOTAL
CO2-26 BASE XS-0 INTUBATED-INTUBATED
[**2160-4-9**] 03:32PM GLUCOSE-156* LACTATE-3.6* NA+-138 K+-4.1
CL--108
[**2160-4-9**] 03:32PM freeCa-1.17
Brief Hospital Course:
Pateint was admitted [**2160-4-9**] and operation was preformed. Pt
tolerated the procedure well and and was taken to the PACU in
good condition. POD2 pt found to have asymptomatic Afib w/ RVR,
and was transferred to the ICU for rate control, and RiJ was
converted to a swan and a line placed. per cardiology
amiodarone and beta blocker were started, heparin and tube
feeds. DCCV on [**4-11**] which converted to NSR. [**4-12**] changed IV to
po amio. POD 7 pt transferred back to floor, continued on
whipple pathway. POD 8 - fluid collections were suspected, JP
culture grew enteroccus (no VRE), Prevotella species, vanc
flagyl and levoflox started. PICC placed and CT on POD 9:
.
1. Fluid collection near the region of the pancreatic head
resection site. There is a small portion of the uncinate process
identified. The fluid collection may represent a biloma or
hematoma. An abscess cannot be ruled out, but there is no
history of symptoms suggestive of infection in this patient per
clinical service. There is a smaller collection also present
anterior to the liver between the stomach and liver. Findings
were discussed with the surgical service on [**2160-4-17**]. If
necessary, the fluid collection can be drained percutaneously.
2. Decreased biliary dilatation.
.
POD 10 wound opened for erythema. Culture grew;
PROBABLE ENTEROCOCCUS. HEAVY GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. (pan-sensitive)
PROBABLE ENTEROCOCCUS. SPARSE GROWTH. SECOND
MORPHOLOGY.
.
POD 12 pt given one unit pRBC for HCT 25.7 to 33.8. Vac placed
on wound.
POD 13 c. diff sent x3 for diarrhea and all negative. Right arm
swelling, u/s: no DVT.
POD 18 pt having hematemesis and melenic stools HCT 31-->19,
transferred to ICU. GI consulted. Scoped: clot in entire
stomach remanant- could not identify bleeding source, too much
clot to remove. gastro-jej anastomosis looked ok, old blood in
distal limb and not much by way of blood in proximal limb.
Transfused 5 units PRBC and 2 FFP. Transeferred back to floor
POD 24.
POD 25 vac changed.
POD 27 pt on regular diet w/ Boost supplements. Pt discharged
to rehab in good condition.
Medications on Admission:
lipitor 10'
norvasc 10'
levoxyl 100'
zebeta 10'
Discharge Medications:
1. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 days.
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Cholangiocarcinoma of the bile duct.
Discharge Condition:
Good
Good
Discharge Instructions:
Resume your regular medications. Take all new medications as
directed. Do not drive while taking narcotics.
You may shower tomorrow. Allow water to run over the wound, but
do not scrub. Pat the wound dry. Do not take a bath or swim
until after follow-up appointment. No heavy lifting (> 10 lbs)
for 6 weeks.
Please call your doctor or return to the ER if you experience:
-Fever (> 101.4)
-Inability to eat/drink or persistant vomiting
-Increased pain
-Redness or discharge from your wound
-Other symptoms concerning to you
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 1 week. Call his office,
[**Telephone/Fax (1) 1231**], to arrange the appointment.
|
[
"V10.51",
"198.89",
"998.59",
"398.91",
"196.2",
"285.9",
"244.9",
"V10.3",
"272.4",
"427.31",
"998.32",
"682.2",
"458.29",
"156.8",
"578.1",
"396.3",
"401.9",
"V64.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.12",
"52.7",
"96.6",
"99.04",
"89.64",
"38.93",
"45.13",
"99.15",
"99.62",
"46.39",
"51.37",
"93.59",
"54.21"
] |
icd9pcs
|
[
[
[]
]
] |
6401, 6491
|
3108, 5357
|
309, 564
|
6572, 6585
|
1666, 3085
|
7163, 7305
|
1534, 1539
|
5455, 6378
|
6512, 6551
|
5383, 5432
|
6609, 7140
|
1554, 1647
|
219, 271
|
592, 1307
|
1329, 1476
|
1492, 1518
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,060
| 198,879
|
11460+56240
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-12-23**] Discharge Date: [**2120-12-27**]
Date of Birth: [**2065-7-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
[**12-23**] AVR (19mm on-X valve), MVR (26mm annuloplasty band), TV
repair(ML3 annuloplasty sys)CABGx1 (SVG-RCA)
History of Present Illness:
55 yo F with h/o hodgkins lymphoma and treatment with chemo and
radiation, with serial echos showing progressive valvular
disease and increasing PA pressures.
Past Medical History:
Hypertension, Hyperlipidemia, Coronary Artery Disease (s/p
MI/stent-RCA '[**13**]), [**2083**] s/p tx Hodgkin's @19yo, s/p chemotherapy
and mantle radiation, Cardiomyopathy, Arthritis
Social History:
cares for disabled husband
denies etoh
no tobacco
Family History:
NC
Physical Exam:
NAD HR 91 RR 12 BP 111/91
Lungs CTAB
Heart RRR 2/6 systolic murmur
Abdomen Benign
Extrem Trace LE edema
Superficial and anterior varicosities
Carotids with transmitted murmur and bruit
Pertinent Results:
[**2120-12-26**] CXR: 1) Gradual resolution of the left retrocardiac air
space disease. 2) Gradual resolution of the interstitial most
likely pulmonary edema. 3) Heart size slightly decreased in size
on today's examination. [**2120-12-23**] Echo: PRE CPB The left atrium is
mildly dilated. No spontaneous [**Doctor Last Name **] contrast is seen in the body
of the left atrium or left atrial appendage. The right atrium is
dilated. No spontaneous echo contrast is seen in the body of the
right atrium. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is severe regional left
ventricular systolic dysfunction with septal dyskinesis and
severe apical and distal anterior wall hypokinesis There is
moderate to severe global left ventricular hypokinesis as well
(LVEF = 25 %). There is focal hypokinesis of the apical free
wall of the right ventricle. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Due to co-existing
aortic regurgitation, the pressure half-time estimate of mitral
valve area may be an OVERestimation of true mitral valve area.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is no pericardial effusion. POST
CPB: The patient is receiving milrinone and norepinephrine by
infusion. There is mild right ventricular global hypokinesis
with improved apical function. The left ventricle continues to
show septal dyskinesis and distal anterior apical severe
hypokinesis. The function of the other walls is improved. Left
ventricular ejection fraction is about 30%. Initially after
separation from bypass, a jet of moderate aortic regurgitation
emanating from the bileaflet prosthesis in the region of the
native valve right and left commisure was seen. It appeared to
be a valvular jet. The patient was returned to bypass and a
suture that prevented leaflet closure was removed. After
separation on the second attept the bileaflet prosthesis
appeared mechanically stable with normal leaflet function. There
was still mild to moderate valvular aortic regurgitation though.
Although the regurgitation appeared valvular, suboptimal image
quality prevented complete exclusion of a perivalvualr source.
The jet seen after first attempt was still present but much
improved. Both leaflets appeared to be opening normally. The
peak gradient across the valve was 27 mm Hg with a mean of 18 mm
Hg. The effective valve area was about 1.1 cm2. An annuloplasty
ring was seen in the mitral position. It was well seated. There
was trace mitral regurgitation. The maximum gradient across the
valve was 13.4 mm Hg. A tricuspid annuloplasty ring is also
seen. It is well seated. There is mild tricuspid regurgitation
with a maximum gradient of 7 mm Hg across the valve.
[**2120-12-23**] 03:00PM BLOOD WBC-9.9 RBC-3.08* Hgb-9.7* Hct-27.6*
MCV-89 MCH-31.6 MCHC-35.4* RDW-15.9* Plt Ct-177
[**2120-12-27**] 06:30AM BLOOD WBC-15.9* RBC-2.54* Hgb-7.9* Hct-22.7*
MCV-89 MCH-31.0 MCHC-34.6 RDW-15.9* Plt Ct-237
[**2120-12-23**] 03:00PM BLOOD PT-15.7* PTT-45.4* INR(PT)-1.4*
[**2120-12-27**] 06:30AM BLOOD PT-27.8* INR(PT)-2.8*
[**2120-12-23**] 03:00PM BLOOD UreaN-16 Creat-0.8 Cl-112* HCO3-25
[**2120-12-27**] 06:30AM BLOOD Glucose-108* UreaN-41* Creat-1.3* Na-134
K-5.1 Cl-96 HCO3-28 AnGap-15
[**2120-12-24**] 09:56PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2120-12-24**] 09:56PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
Brief Hospital Course:
Ms. [**Known lastname **] was taken to the operating room on day of admission,
[**2120-12-23**], where she underwent a CABG x 1, AVR, MV repair and TV
Repair. Please see operative report for surgical details.
Following surgery was transferred to the CVICU for invasive
monitoring in critical but stable condition. Later on op day she
was extubated and weaned off inotropes. On post-op day one her
chest tubes were removed and she was transferred to the
telemetry floor. Diuretics and beta blockers were started and
she was gently diuresed towards her pre-o weight. She was
started on Coumadin for her mechanical aortic valve and this was
titrated until her INR was therapeutic. Chest tubes and
epicardial pacing wires were removed per protocol. She worked
with physical therapy during her post-op course for strength and
mobility. She appeared to be doing well and was discharged on
post-op day four. Dr. [**Last Name (STitle) **] will follow her INR and adjust her
Coumadin with a goal INR of 2.5-3 (INR on [**12-27**] is 2.8).
Medications on Admission:
Coreg 25mg [**Hospital1 **], Enalapril 10mg [**Hospital1 **], Lipitor 10mg qd, Aldactone
12.5mg qd, Lasix 20mg prn, Ativan 0.5mg prn, MVI, Glucosamine,
Magnesium
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*1*
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
INR will be followed by Dr. [**Last Name (STitle) **] with goal of 2.5-3. Please
take according to Dr. [**Last Name (STitle) **].
Disp:*50 Tablet(s)* Refills:*1*
10. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day:
Please take two 20mg tablets daily for 10 days, then 20mg daily
until stopped by cardiologist.
Disp:*40 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 11560**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Coronary Artery Disease now s/p Coronary Artery Bypass Graft x 1
Aortic Stenosis/Mitral Regurgitation/Tricuspid Regurgitation now
s/p Aortic Valve Replacement, Mitral Valve Repair, Tricuspid
Valve repair
PMH: Hypertension, Hyperlipidemia, Coronary Artery Disease (s/p
MI/stent-RCA '[**13**]), [**2083**] s/p tx Hodgkin's @19yo, s/p chemotherapy
and mantle radiation, Cardiomyopathy, Arthritis
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week,
Shower,no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks from surgery.
No driving until follow up with surgeon.
Dr. [**Last Name (STitle) **] will monitor INR/Coumadin. [**Last Name (STitle) 269**] will draw blood and
contact him regarding results.
[**Last Name (NamePattern4) 2138**]p Instructions:
[**Hospital Ward Name 121**] 6 in 2 weeks for wound check
Appt has been made for you: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 36608**]
Date/Time:[**2121-1-8**] 2:15pm (Dr. [**Last Name (STitle) **] will also be following
your INR and adjusting Coumadin)
Appt has been made for you: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2121-1-13**] 10:30am
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2120-12-27**] Name: [**Known lastname **],[**Known firstname 194**] E Unit No: [**Numeric Identifier 6518**]
Admission Date: [**2120-12-23**] Discharge Date: [**2120-12-27**]
Date of Birth: [**2065-7-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 674**]
Addendum:
Discharge diagnoses updated.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 6519**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Chonic systolic heart failure
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2121-1-7**]
|
[
"412",
"426.0",
"425.4",
"396.2",
"397.0",
"272.4",
"414.01",
"401.9",
"428.22",
"428.0",
"V10.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"35.22",
"39.61",
"35.33"
] |
icd9pcs
|
[
[
[]
]
] |
9872, 9972
|
5220, 6250
|
331, 445
|
8390, 8396
|
1147, 5197
|
923, 927
|
6462, 7826
|
9993, 10159
|
6276, 6439
|
8420, 8835
|
8886, 9849
|
942, 1128
|
284, 293
|
473, 633
|
655, 840
|
856, 907
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,863
| 150,239
|
47029
|
Discharge summary
|
report
|
Admission Date: [**2189-7-9**] Discharge Date: [**2189-7-12**]
Date of Birth: [**2112-7-5**] Sex: F
Service: [**Year (4 digits) **]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Left Facial Weakness / Droop, Left Weakness in Upper/Lower
Extremity, Dysarthria
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 77-year-old right-handed woman with past medical
history of hypertension, hyperlipidemia, prior right internal
capsule lacunar infarct who presented to an outside hospital on
[**7-9**] with left facial droop, left facial numbness, slurred speech
and left-sided weakness. Patient describes on [**7-8**] evening
speaking with fianc?????? on phone who noted to her that her speech
became slurred. Patient also noted that her left side had
altered sensation felt weak and noted that any ambulation
inadvertently trended towards the right side. Patient
attributed
these symptoms to exhaustion and went to sleep waking up the
next
morning with resolution of sx.
Patient contact[**Name (NI) **] her primary care provider in the morning, with
intention to follow up later that day. Patient's daughter
arrived at her apartment around 14:50 on [**7-9**] at the
recommendation of the primary care provider and noted on the
walk
from the parking lot to her PCP office, patient became dizzy
with
a mild headache, and per her daughter had a prominent left
facial
droop, and was slurring words. On evaluation at the primary
care
provider's office, the patient was immediately transported to an
outside hospital by emergency medical transport. TPa was
administered at 1630 hrs. after CT scan was shown to be negative
for hemorrhage. Of note, left facial numbness and left weakness
did not resolve at which time patient was transported to [**Hospital1 18**]
for further intervention.
On arrival, code stroke was called in ED and patient was sent
for
CTA/P showed no large vessel obstruction or perfusion mismatch.
Serial evaluations of the patient revealed increasing strength
and coordination in her left upper and lower extremities. No
additional intervention was sought for patient as imaging
suggested small vessel process not amenable to angiography.
Past Medical History:
Hypertension
Hyperlipidemia
[**2157**]'s Right Internal Capsule Lacunar Infarct with no residual
deficit
[**2183**] Silent Myocardial Infarction
Irritable Bowel Syndrome
Spondylitis
Social History:
Quit smoking 25 years ago after 30 pack year Tobacco history
Occasional EtOH
Denies any Illicit Substance Abuse
Family History:
Remarkable for mother who had an "embolic stroke"
Physical Exam:
Physical Exam on Admission:
NIH Stroke Scale score was 6:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 1
5b. Motor arm, right: 0
6a. Motor leg, left: 1
6b. Motor leg, right: 0
7. Limb Ataxia: 1
8. Sensory: 1
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 0
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was mildly dysarthric. Able
to follow both midline and appendicular commands. Pt. was able
to
register 3 objects and recall [**3-7**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch except in L V2
distribution where was decreased to LT and PP
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Pronator drift present on
L.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 4 5 5- 4 5 4- 4 4- 5 4+ 4+ 5 4+ 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout except in L V2
distribution as above. No extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
Mild dysmetria on FNF on LUE and HTS on LLE
-Gait: Deferred
Physical Exam on Discharge:
Full strength in upper extremities, Normal gait, mild
unsteadiness with tandem gait. no dysarthria, no facial droop,
EOMI
Pertinent Results:
Labs on Admission:
[**2189-7-10**] 02:09AM BLOOD WBC-6.3 RBC-4.19* Hgb-12.3 Hct-36.2
MCV-86 MCH-29.3 MCHC-34.0 RDW-13.3 Plt Ct-249
[**2189-7-10**] 02:09AM BLOOD Plt Ct-249
[**2189-7-10**] 02:09AM BLOOD PT-11.2 PTT-29.4 INR(PT)-1.0
[**2189-7-10**] 02:09AM BLOOD %HbA1c-6.1* eAG-128*
[**2189-7-10**] 02:09AM BLOOD Triglyc-170* HDL-47 CHOL/HD-3.7
LDLcalc-91
[**2189-7-10**] 02:09AM BLOOD TSH-4.3*
Imaging Studies:
CTA head/neck
1. No definite CT perfusion abnormality to suggest acute
ischemia.
2. No acute intracranial process. Old right basal ganglia
lacunar infarct and evidence of chronic small vessel ischemic
disease.
3. Atherosclerotic calcification of the cavernous internal
carotid artery as well as mild atherosclerotic calcification of
the left carotid bulb and
proximal internal carotid artery, without evidence of
hemodynamically
significant stenosis or occlusion.
4. Incidental findings include 1.1 x 0.9 cm right thyroid
nodule. This may be followed up with non-emergent thyroid
ultrasound if not already performed elsewhere.
MR head w/o contrast
1. There is no evidence of acute or subacute intracranial
process. There is no evidence of diffusion abnormalities to
indicate acute or subacute ischemic changes.
2. Tiny areas with magnetic susceptibility change in the right
basal ganglia, likely reflecting a small chronic hemorrhagic
event as described above.
CT head w/o contrast (24 hr post tPA)
No acute intracranial pathology. Sequelae of chronic small
vessel ischemic disease and old lacunar infarct in the right
basal ganglia.
TTE
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
Although the bubble study was not obviously positive, an
intracardiac shunt cannot be excluded with certainty on the
basis of this technically suboptimal study.
Labs on discharge:
none
Brief Hospital Course:
Ms. [**Known lastname **] is a 77 year-old R-handed woman with PMHx of HTN, HL
and prior R internal capsule lacunar infarct who presented to an
OSH with L facial droop, L facial numbness, slurred speech, LUE
and LLE weakness and was given tPA for presumed stroke after CT
showed no hemorrhage, who was transferred here for possible
neurointervention.
# NEURO: On admission, patient was noted to report improvement
in her left-sided weakness. As noted her CTA/CTP were
unremarkable for angiography or perfusion mismatch, thus
necessitating no further intervention. She was admitted to the
neuro ICU for post-tPA care and monitoring. Further evaluation
of the patient the following morning ([**7-10**]) revealed further
improvement in upper and lower extremity strength with minimal
deficit noted in the left hip flexion. Of note, the patient's
dysarthria also had resolved with the exception of difficulty
with certain phrases involving "ess" sounds. Her left facial
droop had improved with only minimal nasolabial blunting. A
speech and swallow evaluation was called which was unremarkable
for any deficit; as a result a normal diet was started shortly
after which the patient tolerated without incident. Based on
her clinical improvement and non-contrast Head CT evaluation 24
hours s/p tPa administration at the OSH, the patient deemed
stable for transfer to the Neuro Stroke floor service for
further management. Given her CT appearance and her sx, this is
most likely a small vessel infarction. Stroke risk factor w/u
revealed HbA1c of 6.1 and LDL of 91. Advised pt to maintained a
diabetic, low carbohydrate diet. Did increase dose of statin
from 40mg to 60mg qd. Also started low dose Aspirin 81mg qd for
stroke prevention. Pt had a TTE which did not a thrombus.
Bubble study could not conclusively rule out PFO since it was of
suboptimal quality, so she will need a repeat as outpatient.
Passed speech and swallow, was deemed safe to go home by PT/OT
.
# CARDS: Monitored on telemetry, no arrhythmias. TTE as above.
Initially held anti hypertensives for permissive HTN, re-started
on d/c. Started Aspirin 81mg as above.
.
# ENDO: HbA1c 6.1, discussed low carbohydrate diet.
.
# PSYCH: Continued home cymbalta and clonezepam, trazodone.
TRANSITIONS OF CARE:
-Bubble study could not conclusively rule out PFO since it was
of suboptimal quality, so she will need a repeat as outpatient.
-will f/u with Dr.[**Last Name (STitle) **] in stroke clinic
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacy.
1. traZODONE 200 mg PO HS:PRN insomnia
2. Ranitidine 150 mg PO BID
3. DiCYCLOmine 10 mg PO QID anxiety
4. Ropinirole 1 mg PO QAM
5. Atenolol 25 mg PO DAILY
6. Gabapentin 600-900 mg PO TID
self titrates
7. Valsartan 160 mg PO DAILY
8. Simvastatin 40 mg PO DAILY
9. Duloxetine 30 mg PO DAILY
10. Clonazepam 0.75 mg PO QHS
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Clonazepam 0.75 mg PO QHS
3. Duloxetine 30 mg PO DAILY
4. Gabapentin 600-900 mg PO TID
self titrates
5. Ranitidine 150 mg PO BID
6. Ropinirole 1 mg PO QAM
7. traZODONE 200 mg PO HS:PRN insomnia
8. DiCYCLOmine 10 mg PO QID anxiety
9. Valsartan 160 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Simvastatin 60 mg PO DAILY
RX *simvastatin 20 mg 3 Tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **] ([**Location (un) 5028**])
Discharge Diagnosis:
Left Sided ischemic stroke
Discharge Condition:
Full strength in upper extremities, Normal gait, mild
unsteadiness with tandem gait. no dysarthria, no facial droop,
EOMI
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted for a ischemic stroke. You were started on
Aspirin for stroke protection. Your stroke risk factors were
checked. You should continue to not smoke. Your LDL
cholesterol was 91. You were started on a higher dose of
statin. You had a cardiac echocardiogram which could not exclude
a cardiac shunt (communication between [**Doctor Last Name 1754**]) so may need to
be repeated as an outpatient. You were checked for blood glucose
control with a HgB A1c. The level was 6.1. This is close to a
level seen with diabetics. You need to carefully control your
diet as discussed and continue your blood pressure control.
You should continue to eat a low fat healthy diet, and follow up
with your primary care physician and stroke [**Doctor Last Name 878**] as below
It was a pleasure taking care of you.
[**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) **] MD
[**First Name (Titles) 18**] [**Last Name (Titles) 878**] Resident
Followup Instructions:
Stroke [**Last Name (Titles) 878**] in [**4-10**] weeks.
[**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 7394**]
PCP: [**Name10 (NameIs) 99707**],[**Name11 (NameIs) 99708**] [**Telephone/Fax (1) 13312**] for post hospital follow up. [**7-14**]
days.
Completed by:[**2189-7-13**]
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
]
] |
10980, 11054
|
7583, 9844
|
405, 412
|
11125, 11249
|
5267, 5272
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3731, 5097
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7554, 7560
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440, 2303
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5287, 5663
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9865, 10055
|
2325, 2509
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2525, 2640
|
5681, 7535
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,747
| 187,830
|
4051+55538
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-9-30**] Discharge Date: [**2133-10-13**]
Date of Birth: [**2086-3-6**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 47-year-old male with
a history of long-standing type 1 diabetes mellitus, severe
peripheral vascular disease, s/p multiple amputations,
renal failure s/p renal
transplant ten years ago, coronary artery disease, status
post coronary artery bypass grafting, admitted for fever and
left lower extremity cellulitis.
The patient reported the onset of fever the evening prior to
admission to 104?????? at home with rigors, as well as nausea and
vomiting. The patient noticed redness and swelling of the
left lower extremity which started the night prior to
admission. This was very painful to touch. Fevers were not
relieved by Tylenol.
He denied cough, shortness of breath, chest pain,
palpitations, or abdominal pain. He has had regular bowel
movements. He was urinating well. No dysuria. He denied
sick contacts.
PAST MEDICAL HISTORY: Kidney transplant on [**2123-8-25**]. Diabetes since age 11. Right BKA on [**2133-6-16**].
Coronary artery disease status post bypass in [**2126-8-27**].
Multiple finger amputations. Left foot metatarsal amputation
in [**2127**]. History of shingles. Hypertension. Neuropathy.
Gout. Gastroparesis. Anemia. Congestive heart failure.
MEDICATIONS: Aspirin 325 q.d., Insulin Lantus 48 U at
dinner, Humalog at dinner and bedtime, Allopurinol 150 mg
q.d., Rapamune 2 mL q.d., Lopressor 100 b.i.d., Zantac 150
q.d., Prednisone 5 q.d., CellCept [**Pager number **] b.i.d., Advicor 1000 mg
q.h.s., Neurontin 100 t.i.d., Lasix 40 q.d., Reglan 10 q.d.,
Epogen 4000 2 tab a week, Methadone 10 b.i.d., Diovan 80
q.d., Compazine p.r.n., Oxycodone 5 mg p.r.n., Nitrostat 0.4
mg p.r.n., Zaroxolyn 2.5 mg p.r.n.
ALLERGIES: Erythromycin, Protamine.
SOCIAL HISTORY: The patient lives with wife. [**Name (NI) **] previously
worked as a mechanic. He stopped working about a year ago.
History of tobacco; however, he is not currently smoking. He
has social alcohol.
PHYSICAL EXAMINATION: Vital signs: Temperature 103.9??????,
heart rate 108, blood pressure 130/70. General: The patient
was a well-developed, well-nourished male. He was tired and
uncomfortable. He was warm to touch. Alert and oriented
times three. HEENT: Normocephalic, atraumatic. Oropharynx
clear. Dry mucous membranes. Pupils equal, round and
reactive to light. Extraocular movements intact. Neck:
Supple. No jugular venous distention. No lymphadenopathy.
Cardiovascular: Heart sounds normal. S1 and S2. No murmurs
appreciated. Old CABG scar. Lungs: Clear to auscultation
bilaterally. Back: No CVA tenderness. Abdomen: Distended,
soft, no tenderness to palpation. Right lower quadrant scar
(kidney transplant). Extremities: Right BKA. No erythema
or swelling. Left lower extremity foot partially amputated
at the metatarsals. Positive swelling. Redness. Positive
tenderness to palpation. His erythema extends 3 cm
below the patella. No crepitus. Able to flex ankle and
knee. He had chronic dry left heel ulcer.
LABORATORY DATA: White count 19.3, hematocrit 35.3, platelet
count 333, 84% neutrophils, 5% bands; coags within normal
limits.
Ultrasound of the lower extremities negative.
Chemistries with a sodium of 138, potassium 3.6, chloride 98,
bicarb 26, BUN 75, creatinine 2.6, glucose 176.
HOSPITAL COURSE:
1. Left lower extremity cellulitis: The
patient was initially started on Oxacillin; however, the
fevers persisted over the next 24-48 hrs and white cell count
continued to escalate. The patient was switched to Vancomycin and
Zosyn empirically as a result. Shortly thereafter, the patient
developed delirium and the patient's white blood cell count
continued to climb to 30,000, and he was clinically worsening.
He developed worsening renal function and increase in
transaminases as well. Blood tests showed elevated D-dimer and
fibrinogen consistent with sepsis. The patient was taken to the
Operating Room with Vascular Surgery on [**2133-10-5**], for
exploration and debridement. Postoperatively the patient was
taken to the Medical Intensive Care Unit where he was stabilized
and was transferred to the floor on [**2133-10-6**].
In the Medical Intensive Care Unit, a central venous line was
placed, and fluid status was titrated to CVP. CT of the leg did
not demonstrate any abscess but the study was done without
contrast due to renal impairment. MRI was unable to be performed
given that the patient had
a surgical clip in the ethmoid sinus. A LE Ultrasound was done
which did not any focal fluid collections and a gallium scan was
also done which confirmed these findings.
On transfer to the floor on [**2133-10-6**], the patient's
mental status was improving. Surgical culture eventually grew
Oxacillin resistant staph aureus. Antibiotics were narrowed to
Vancomycin alone. He was afebrile for the
remainder of his hospital course. His white blood cell count
slowly trended down and was 11,000 on [**2133-10-12**].
Vancomycin was dosed for levels less than 15. On [**2133-10-12**], a PICC line was placed, and his
Vancomycin is to be continued until [**2133-10-26**].
The Vascular Surgery Service followed the patient throughout
the hospital course and recommended that the patient continue
on antibiotics until the cellulitis had improved. He may
still need a left BKA in the near future depending on his future
course.
2. Acute on chronic renal failure: The patient's creatinine
began to trend up on admission and peaked at 4.0. This was
in the setting of sepsis from the leg infection but with
careful fluid management and supportive treatment, his creatinine
improved back to 2.0 on [**2133-10-12**] close to his baseline.
The patient initially had his immunosuppressants held except
for the Prednisone given that he had an acute infection.
Rapamune was restarted to its prior level of 2 mg
prior to discharge; however, the CellCept continued to be
held per Renal service. Further management per Dr. [**First Name (STitle) 805**],
his nephrologist.
3. Diabetes: Initially the patient's blood sugars were
difficult to control, and the patient was placed on an
insulin drip while he was in the Medical Intensive Care
Unit.
On transfer to the floor, the patient Lantus dose was
increased to 54, and his Humalog Insulin sliding scale was
tightened with improvement and control of his blood sugars.
4. Herpes labialis: The patient had herpes lesions around
his mouth, and given his immunocompromised state, he was
started on Acyclovir for a 14-day course. The lesions
continued to improve throughout the hospitalization.
5. Delirium: The patient's delirium was attributed to a
combination of uremia and infection and had improved to near
baseline at the time of discharge.
6. Elevated LFTs: The patient had transaminases which
elevated to the low 1000s after going to the Operating Room.
This was thought to be either due to shock liver secondary to
hypertension or possible secondary to his anesthetic when he
went to the Operating Room. The LFTs continued to trend down
throughout his hospital course without specific intervention.
DISPOSITION: The patient needs two additional weeks of
intravenous Vancomycin, and a PICC line was placed for this
purpose.
Physical Therapy and Occupational Therapy evaluated the
patient and determined that he would benefit from a short
stay of rehabilitation, and he was transferred to a
rehabilitation facility for skilled nursing care and physical
therapy.
DISCHARGE DIAGNOSIS:
1. Left lower extremity cellulitis, culture positive for MRSA.
2. Acute on chronic renal failure.
3. Delirium from sepsis.
4. Diabetes mellitus.
5. Status post renal transplant.
6. History of severe peripheral vascular disease with
multiple amputations.
7. Coronary artery disease, EF 35-40%.
FOLLOW-UP: The patient will follow-up with his primary care
physician, [**Name10 (NameIs) 3**] well as Renal and Vascular Services.
DISCHARGE INSTRUCTIONS: Instructions were given to the
patient on discharge.
PROCEDURES: Left lower extremity debridement on [**2133-10-5**].
DISCHARGE MEDICATIONS: Allopurinol 150 mg q.d., Metoprolol
100 mg b.i.d., Zantac 150 mg q.d., Reglan 10 mg q.d., Epogen
4000 U b.i.d., Niacin 1000 mg q.d., Heparin 5000 U subcue
b.i.d., Rapamune 2 mg q.d., Prednisone 5 mg q.d.,
Silvadine 1% creme to left lower extremity b.i.d.,
Lantus Insulin 52 U subcue q.h.s., Humalog Insulin per
sliding scale, Morphine 2 mg [**11-27**] q.2 hours p.r.n., Acyclovir
150 mg IV q.24 hours, discontinue on [**2133-10-17**],
Vancomycin 1000 mg IV q.24 hours, discontinue on [**2133-10-26**]. Need to check Vancomycin levels periodically to assure
levels < 15.
ACTIVITY: Out of bed to chair with assistance at least
t.i.d. Physical Therapy to work with strength and functional
mobility.
DIET: Diabetic renal diet.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], M.D. [**MD Number(2) 3405**]
Dictated By:[**Name8 (MD) 17848**]
MEDQUIST36
D: [**2133-10-12**] 13:58
T: [**2133-10-12**] 14:00
JOB#: [**Job Number 17849**]
Name: [**Known lastname 2849**], [**Known firstname **] Unit No: [**Numeric Identifier 2850**]
Admission Date: [**2133-9-30**] Discharge Date: [**2133-10-13**]
Date of Birth: [**2086-3-6**] Sex: M
Service:
ADDENDUM: The patient will not be taking his Cellcept for
the shortterm per the Renal Team. This decision will be
readdressed at the follow up appointment with Dr. [**First Name (STitle) **]
The following changes to medications have been made prior to
the patient's discharge.
1. Add Lasix 40 mg p.o. q.d. prn
2. Neurontin 100 mg p.o. t.i.d.
3. Aspirin 325 mg p.o. q.d.
4. Do not start Diovan for an additional two to three weeks.
5. The dose of Acyclovir has changed to Acyclovir 200 mg
p.o. q.d.
The patient should have Vancomycin levels drawn as a trough
before every third dose and a dose should be held for a level
greater than 15.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2852**], M.D. [**MD Number(2) 2853**]
Dictated By:[**Name8 (MD) 2854**]
MEDQUIST36
D: [**2133-10-14**] 15:57
T: [**2133-10-14**] 16:44
JOB#: [**Job Number 2855**]
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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8215, 8945
|
7606, 8045
|
3445, 7585
|
8070, 8191
|
2110, 3428
|
170, 1001
|
1024, 1869
|
1886, 2087
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8970, 10407
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,744
| 106,032
|
47631
|
Discharge summary
|
report
|
Admission Date: [**2173-7-21**] Discharge Date: [**2173-8-2**]
Date of Birth: [**2106-4-6**] Sex: M
Service: SURGERY
Allergies:
Egg
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
[**2173-7-22**]
Diagnostic laparoscopy and rigid sigmoidoscopy.
[**2173-7-24**]
Colonoscopy
History of Present Illness:
This is a 67 year old male with a medical history of DM, HTN who
presented to an OSH ED with rectal bleeding. The patient reports
that he was in his usual state of health until 10 days ago. He
initially had 3-4 days of constipation which was then followed
by profuse watery diarrhea for 5-6 days which was then followed
by three days of constipation. During that time he had no other
symptoms, no fevers or chills no nausea, vomiting or abdominal
pain. Today, he was feeling well the AM and then he had
tenesmus. He went to the bathroom and felt lightheaded and weak.
He slipped, but did not loose consciousness. He did not have any
bloody stools at the time. His wife called 911 and he was taken
to [**Hospital3 6592**].
.
At the OSH ED he developed frank rectal bleeding, hypotension
(80/34), tachycardia. A CT with contrast was done that showed
colonic and small bowel distention, no free air or fluid, and a
likely rectal impaction. His labs were notable for INR was 5.4,
patient is not anticoagulated. White count 18.4, hematocrit
42.5, platelets 199. Lactate 8.5. Per report, DIC labs positive,
however no values are found in the record. Received 2 L IV
fluid, 2 units FFP, Unasyn, Flagyl. He was also given 1 unit of
PRBCs in route to the [**Hospital1 18**].
.
At [**Hospital1 18**] ED, his initial vitals were 99.9 102 117/84 16 100% 2L
N/c. His labs were notable for PT: 16.1, PTT: 34.7, INR:
1.4,Fibrinogen: 72, D-Dimer: >[**Numeric Identifier 3652**], WBC of 9.9 (N:87 Band:9 L:3
M:1 E:0 Bas:0) and Hct of 36, plts of 205, Creatine of 1.4. GI
was consulted and an anoscopy was attempted, but they were
unable to visualize secondary active bleeding. He was given more
2 U PRBC. Surgery was consulted. ED resident attempted to remove
stool from rectum, but was only able to remove a small amount. A
repeat CT (CTA) done at [**Hospital1 **] showed interval development of
sigmoid and left sided colitis as well as the new development of
ascities. He was then admitted to the MICU for further
management.
.
On arrival to the MICU, pt was ill appearing. He felt warm and
was shivering. He abd was very tender to palpation, he states to
be worse than earlier in the day. He was guarding his abd. He
was given 4mg of IV morphine with minimal change of pain. I
performed a rectal exam which had significant amount of formed
stool and bright red blood around it. Pt had a large BM after
the exam with semi-formed stool with bright red blood coating
it. He had 2 other BM that as per nursing report looked like
"tomato soup". The repeated labs were then notable for
fibrinogen which increased from 72->99, with D-Dimer at [**Numeric Identifier 24587**].
His Hct had trended up from 36->41, and platelets decreased from
205->170s, PT 15/INR 1.3 (down from 5.4 at presentation). He was
given 2L of IV fluids in the OHS, then 3L of IV fluids in the ED
and 2 L in the MICU. He was also given 3 units of blood, 2 FFP.
I then also ordered 1 unit of cryo given concern for DIC. The
surgical team who had already evaluated the pt in the ED was
called back, given that his abd pain was worsening and he still
had blood BMs. His lactate was also trending back up 8.7 in the
OHS-> 1.4 in the ED to 4.4 in the MICU which was concerning for
worsening ischemia.
Past Medical History:
Diabetes
HTN
Toe amputation
Penile implant
retinal surgery
Social History:
He lives with wife, he is now retired and used to work on as a
sales person. He drinks 3-4 beers per day. He denies smoking. No
drugs.
Family History:
Non-contributory. He denies any colon or GI cancer
Physical Exam:
Temp 99.9 HR 102 BP117/84 RR 16 O2 sat 100% 2L NC
General: Alert, oriented, in significant pain, laying in fetal
position
HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: tender diffusely but worse in the lower abdomen, +
bowel sounds, +gaurding, + rebound
Rectal: frank blood mixed with stool, hard stool palpated, no
rectal mass
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: dry skin noted on the skins bilaterally
Pertinent Results:
IMAGING:
OSH CT:
No AAA but prominent vascular calcifications involving the
aorta, diffuse colonic distention, scattered loops of mildly
dilated small bowel, No free intraab gas or fluid, likely rectal
impaction.
[**2173-7-24**] Colonoscopy :
Internal & external hemorrhoids
Otherwise normal colonoscopy to cecum
[**2173-7-21**] CTA Abd/pelvis :
1. Interval development of bowel wall thickening and
hypoenhancement of the left hemicolon raising strong concern for
ischemic colitis. New small volume ascites.
2. Thick, irregularly walled bladder, concerning for infection.
3. Moderate rectal fecal impaction.
4. Possible active GI bleeding along the ascending colon.
[**2173-7-24**] Colonoscopy :
Internal & external hemorrhoids
Otherwise normal colonoscopy to cecum
8//[**8-29**] Head CT :
No acute intracranial process; evidence of mild sequelae of
chronic small
vessel ischemic disease
[**2173-7-21**] 03:00PM WBC-9.9# RBC-4.01* HGB-12.5* HCT-36.7* MCV-92
MCH-31.2 MCHC-34.0 RDW-13.7
[**2173-7-21**] 03:00PM NEUTS-87* BANDS-9* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2173-7-21**] 03:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2173-7-21**] 03:00PM PLT SMR-NORMAL PLT COUNT-205
[**2173-7-21**] 03:00PM PT-16.1* PTT-34.7 INR(PT)-1.4*
[**2173-7-21**] 03:00PM FIBRINOGE-72*
[**2173-7-21**] 03:00PM ALT(SGPT)-21 AST(SGOT)-32 LD(LDH)-207 ALK
PHOS-133* TOT BILI-0.4
[**2173-7-21**] 03:00PM LIPASE-31
[**2173-7-21**] 03:00PM GLUCOSE-289* UREA N-29* CREAT-1.4* SODIUM-141
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
[**2173-7-21**] 05:43PM LACTATE-1.8 NA+-139 K+-4.7 CL--106 TCO2-22
[**2173-7-21**] 08:36PM WBC-12.6* RBC-4.54* HGB-14.2 HCT-41.4 MCV-91
MCH-31.2 MCHC-34.2 RDW-14.0
[**2173-7-21**] 08:36PM GLUCOSE-275* UREA N-31* CREAT-1.7* SODIUM-139
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-19* ANION GAP-18
Brief Hospital Course:
Mr. [**Known lastname **] presented to an OSH ED with history
profuse watery diarrhea for 5-6 days followed by 1-2 days of
constipation and then syncope on standing. At the OSH ED he
developed frank rectal bleeding, hypotension (80/34),
tachycardia
and a CT with contrast showed colonic and small bowel
distention,
and stool impaction. He was given morphine, Unasyn and Flagyl,
transfused PRBC and transferred to [**Hospital1 18**] where he was admitted
to
the MICU. He was transfused again and CTA showed interval
development of sigmoid and left sided colitis as well as the new
development of ascites. He had an elevated lactate, leukocytosis
and tachycardia though was normotensive with IVF and blood
products. He was started on Cefepime/Flagyl. GI was consulted
who felt his clinical picture and rapid decompensation were most
concerning for ischemic colitis. Infectious colitis was also
considered and all stool studies were negative.
.
Patient's abdominal exam continued to worsen, his lactate
increased despite IVF and ABX so surgery was consulted and he
had
an exploratory laparotomy on [**7-22**] that showed diffuse bowel
edema/mucosal inflammation but no necrosis, no resection was
performed. He was transferred to the Trauma SICU and Unasyn
started, Flagyl was continued. On [**7-23**] Unasyn/Flagyl was switched
to Zosyn when OSH called to say he had a GNR in his blood
culture
from ED (pre-antibiotics). He has improved clinically, has been
afebrile and normotensive since [**7-22**] but has had alcohol
withdrawal
and delirium which has complicated his course but is improved
with Diazepam. His GI symptoms have been ascribed to mesenteric
ischemia in a patient with known atherosclerotic disease.
Following his exploratory laparotomy he had a colonoscopy a few
days later which was essentially normal except for hemorrhoids.
Initiating a diet was on hold as he developed DT's and his
nutrition was given via feeding tube. Once his withdrawal
symptoms resolved it took a few days for him to clear the
benzodiazepines and eventually he had a speech and swallow
evaluation and was cleared for a regular diabetic diet.
From an ID standpoint, the team was then called by [**Location (un) 100633**]/[**Location (un) 5503**] micro lab that the GNR had Acinetobacter
Baumannii growing from aerobic blood
culture drawn in the ED prior to antibiotic therapy ([**7-21**]) that
was sensitive only to Collistin and Tigacycline (MIC 4),
intermediate to Zosyn, Levofloxacin, Cefepime, and resistant to
Bactrim, Ceftaz, Cipro, Imipenem, Gentamycin, Tobramycin,
Aztreonam. This was growing in [**12-20**] sets of blood cultures, he
had no more cultures drawn there. The Infectious Disease service
was consulted for their recommendations. He had 2 more sets of
blood cultures done all which were no growth along with stool
cultures. They recommended completing a course of Zosyn as he
was non toxic with a normal WBC and no fevers. He progressed
nicely from that point on.
On two different occasions he failed a voiding trial with
retention in the range of 600-700 mls of urine. His catheter
was replaced this morning and the plan is to try a third voiding
trial once he is more ambulatory.
The [**Last Name (un) **] service was also consulted as his blood sugars were
not controlled and were generally in the mid 200 range. He was
placed on Lantus and was gradually increased to 14 units qPM
with a tighter sliding scale. Prior to admission he was on NPH
[**Hospital1 **].. He has been on a diabetic diet but generally needs
coverage QID.
Following transfer to the Surgical floor he was evaluated by the
Physical Therapy service who recommended a short term rehab
prior to returning home to help increase his mobility and
endurance safely. After a long protracted course he was
discharged on [**2173-8-2**].
Medications on Admission:
diovan 160', crestor 10', asa 81', lisinopril 40', amlodipine
10', metoprolol er 50', lantus, humalog
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) as needed for agitation.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours.
12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
13. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
14. insulin glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous once a day: at 6pm.
15. insulin lispro 100 unit/mL Solution Sig: 0-14 units
Subcutaneous four times a day as needed for per sliding scale.
Discharge Disposition:
Extended Care
Facility:
Cape Heritage, A [**Hospital 671**] HealthCare Center - [**Location (un) **]
Discharge Diagnosis:
1. Ischemic colitis
2. Acute blood loss anemia
3. Acute alcohol withdrawal
4. Bactermia
5. Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with rectal bleeding from poor
blood flow to the bowel which has resolved. You needed multiple
blood transfusions and you also developed alcohol withdrawal
post op which complicated matters. That too has also resolved
but you must never drink alcohol again. You will be offered
counselling and assistance after you are discharged from rehab.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-2**] 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 incision, 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:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-21**] weeks.
Call your PCP for [**Name Initial (PRE) **] follow up appointment when you return home
from rehab.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2173-10-12**] 1:30
Completed by:[**2173-8-2**]
|
[
"790.7",
"557.9",
"401.9",
"455.0",
"291.0",
"303.90",
"788.20",
"250.00",
"285.1",
"584.9",
"789.59",
"276.0",
"455.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.23",
"96.6",
"45.23",
"54.21"
] |
icd9pcs
|
[
[
[]
]
] |
11866, 11969
|
6568, 10394
|
277, 372
|
12122, 12122
|
4629, 6545
|
13986, 14370
|
3903, 3955
|
10546, 11843
|
11990, 12101
|
10420, 10523
|
12305, 13617
|
3970, 4610
|
222, 239
|
13629, 13963
|
400, 3651
|
12137, 12281
|
3673, 3734
|
3750, 3887
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,333
| 198,331
|
7915
|
Discharge summary
|
report
|
Admission Date: [**2120-12-9**] Discharge Date: [**2120-12-13**]
Date of Birth: [**2055-6-21**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins / Sulfa (Sulfonamides) / Stelazine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
BACK AND LEG PAIN
Major Surgical or Invasive Procedure:
Posterior spinal decompression and discectomy
repain of dural tear
History of Present Illness:
CRESCENDO LEG PAIN, CLAUDICATION OVER LAST 6 MONTHS.
LONGSTANDING LOWBACK PAIN.
Past Medical History:
HYPERTENSION
PARKINSON'S DISEASE
DIABETES
Social History:
LIVES WITH CHILDREN AND WIFE
Family History:
NON-CONTRIBUTORY
Physical Exam:
WOUND HEALING PRIMARILY
MOTOR AND SENSORY INTACT
Pertinent Results:
NONE
Brief Hospital Course:
UNDERWENT DECOMPRESSION OF LUMBAR SPINE, CSF LEAK FROM DURAL
TEAR (REPAIRED) CONTROLLED. BED REST FOR 48 HOURS THEN
MOBILIZED.
WOUND REMAINED BENIGN, NO HEADACHES, RESUMED REGULAR BOWEL AND
BLADDER FUNCTION
Medications on Admission:
SAME AS DISCHARGE
Discharge Medications:
1. Perphenazine 8 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Amlodipine Besylate 2.5 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Metformin HCl 500 mg Tablet Sustained Release 24HR Sig: Two
(2) Tablet Sustained Release 24HR PO BID (2 times a day).
Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*60 Tablet(s)* Refills:*2*
9. Codeine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Herniated disk and spinal stenosis
Discharge Condition:
stable, neuro intact, wound sealed and healing
primarilyambulatory
Discharge Instructions:
Keep sound clean and dry
[**Month (only) 116**] shower after 5 kays, no immersion
Followup Instructions:
as planned with Dr. [**Last Name (STitle) 363**] [**Telephone/Fax (1) **]
|
[
"722.10",
"780.57",
"401.9",
"E878.8",
"357.2",
"V10.46",
"295.90",
"332.0",
"250.60",
"998.2",
"412",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.51",
"03.59",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2081, 2140
|
766, 976
|
330, 399
|
2219, 2287
|
737, 743
|
2418, 2495
|
635, 653
|
1044, 2058
|
2161, 2198
|
1002, 1021
|
2311, 2395
|
668, 718
|
273, 292
|
427, 508
|
530, 573
|
589, 619
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,707
| 112,341
|
5348+5349
|
Discharge summary
|
report+report
|
Admission Date: [**2153-5-23**] Discharge Date: [**2153-5-26**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Chest pain, shortness of [**First Name3 (LF) 1440**], abdominal pain, nausea,
vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 60yo female with PMH significant for Mast Cell
Degranulation Syndrome with history of multiple flares who
presents with SOB, chest pain, abdominal pain, and flushing. Per
patient, these symptoms are consistent with her typical flare.
She has an allergist at [**Hospital1 112**]. She was recently discharged from
[**Hospital1 18**] on [**5-17**] after presenting with similar symptoms. She came
to the hospital because she was extremely nauseous and was not
able to take her oral medications. She did inject herself with
an EpiPen prior to coming to the emergency room. She has
symptoms almost every day but got worse yesterday evening. No
recent viral illness.
In the ED initial vitals were T 99 BP 191/120 AR 122 RR 30 O2
sat 100% RA. She immediately received Benedryl 50mg, Albuterol
neb, Dilaudid 2mg IV, Solumedrol 80mg IV, and Zofran 4mg IV. She
received an additional Solumedrol 80mg IV and Dilaudid 6mg IV.
She is being transferred to the MICU for further management.
Past Medical History:
1)Mast cell degranulation syndrome (MCDS)
*** EMERGENCY PLAN *** (as posted in chart)
administer:
1. Epinephrine 0.3cc of 1/1000 SC and repeat x3 at 5 min
intervals if BP <90 systolic in setting of flare
2. Benadryl 25-50 IV q4 hr for 24-48 hrs
3. Solu-medrol 80mg IV/IM
4. Oxygen by mask or cannula
5. Albuterol nebs q2-4 hr prn
6. Dilaudid 2mg IV q 3hrs or PCA pump
7. Zofran 8mg IV q 12h for 24-48 hrs
PRE-MEDICATION for major/minor procedures:
1. Prednisone 50mg po q24 hrs and 1-2 hours prior to surgery
2. Benadryl 25-50mg 1 hour prior to surgery
3. Ranitidine 150mg 1 hour prior to surgery
2)Depression/anxiety
3)Bipolar disorder
4)MI in [**2147**] after receiving cardiac arrest dose epi instead of
anaphylactic dose epi
5)HTN
6)Erosive osteoarthritis
7)GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
8)Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
9)laryngoscopy
9)Anemia, iron studies c/w AOCD
10)Hemorrhoids
11)EGD with vegetable bezoar (?[**12-7**])
12)Status post hysterectomy and oophorectomy
13)h/o MRSA infection (porthacath associated)
14)portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection; portacath
replaced [**2151-6-9**]
Social History:
Born and raised in [**State 4260**]. Father is still living. Has 3 sibs. Pt
divorced approx 2 [**State 1686**] ago after 37 [**State 1686**] of marriage. Husband was
doctor. Pt had worked at magazine and as preschool teacher.
Currently works as ED tech at [**Hospital 2436**] Hosp. Denies legal
problems, denies h/o abuse. Son is HCP [**Telephone/Fax (1) 21738**].
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
vitals T 98 BP AR 106 RR 16 O2 sat 97% RA
Gen: Patient appears tired, currently in no acute distress
HEENT: Dry mucous membranes
Heart: RRR, no m,r,g
Lungs: Poor air movement posteriorly, scattered wheezes
Abdomen: Soft, NT/ND, +BS
Extremities: Mild 1+ bilateral LE edema, swelling of PIP/DIP
joints consistent with underlying osteoarthritis, multiple areas
of ecchymosis on upper extremities
Pertinent Results:
[**2153-5-23**] 03:45AM WBC-6.4 RBC-3.74* HGB-10.2* HCT-32.8* MCV-88
MCH-27.3 MCHC-31.2 RDW-16.0*
[**2153-5-23**] 03:45AM NEUTS-95.0* LYMPHS-3.6* MONOS-1.2* EOS-0.2
BASOS-0.1
[**2153-5-23**] 03:45AM PLT COUNT-255
[**2153-5-23**] 03:45AM CK-MB-NotDone cTropnT-<0.01
[**2153-5-23**] 03:45AM cTropnT-<0.01
[**2153-5-23**] 03:45AM ALT(SGPT)-22 AST(SGOT)-16 CK(CPK)-63 ALK
PHOS-96 TOT BILI-0.2
[**2153-5-23**] 03:45AM LIPASE-32
[**2153-5-23**] 03:45AM GLUCOSE-237* UREA N-15 CREAT-0.9 SODIUM-142
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
[**2153-5-23**] 03:45AM BLOOD cTropnT-<0.01
.
CXR [**2153-5-23**] - Right-sided port again seen with tip overlying the
cavoatrial junction. Cardiac and mediastinal contours are
unchanged. Pulmonary vascularity is within normal limits. There
are no focal consolidations or large pleural effusions. Linear
opacities at the bases bilaterally suggests atelectasis.
IMPRESSION: No evidence of focal consolidation.
Brief Hospital Course:
Ms. [**Known lastname **] is a 59 y.o. F with h/o Mast Cell Degranulation
Syndrome presented with typical MCDS symptoms including SOB,
chest, abdominal pain, diarrhea, admitted to MICU for close
monitoring.
1)Mast Cell Degranulation Syndrome: The patient presented with
nausea/ vomiting, flushing, chest pain, SOB, and diarrhea; these
symptoms are consistent with her usual flares. Per protocol she
received Zofran, dilaudid, Solu-medrol, Albuterol nebs, O2 by
NC, and benadryl. She was continued on these medications on
transfer to the ICU. She did not received any additional
steroids. The MICU team spoke with Dr. [**Last Name (STitle) **], the allergist here
at [**Hospital1 18**] who has seen the patient on prior admissions. He felt
that her current medication regimen was reasonable, and he also
felt that she there is a major anxiety component. She will need
follow-up with her allergist at [**Hospital6 **] who
is an expert in this field. The patient continued to have
recurrent complaints of dyspnea and headache, responsive to
benadryl and dilaudid IV. She also had episoded in which she
appeared markedly anxious, with no evidence of flushing,
developing tachypnea followed by dyspnea which were resolved
with ativan 1mg IV, consistent with panic attack. Prior to
discharge, she had another episode of dyspnea and tachypnea, and
requested treatment with epinephrine via epipen, IV benadryl, IV
dilaudid, IV solumedrol, and albuterol per protocol with
resolution of symptoms. She wanted to proceed with her discharge
home after this episode which occurred while she was waiting for
her discharge paperwork to be competed.
2)Hypertension: Continued on Diltiazem.
3)Anxiety/Depression: Patient has symptoms suggestive of anxiety
and/or panic attacks. She has been evaluated by psychiatry in
the past and was thought to have bipolar disorder. She was
continued on Duloxetine. She was also started on Valium as well.
4)Postmenopausal symptoms: Continued outpatient regimen of
Premarin.
5)Osteoarthritis: Patient is followed closely by Dr. [**Name (NI) 9620**]
here in rheumatology. She was continued on Plaquenil.
Medications on Admission:
Diltiazem HCl 180mg PO daily
Premarin 0.3mg PO daily
Hydroxyzine 25mg PO QID
Ranitidine 150mg PO QHS
Duloxetine 30mg PO daily
Hydroxychloroquine 200mg PO BID
Amphetamine-Dextroamphetamine 15mg PO daily
Fexofenadine 180mg PO BID
Omeprazole 20mg PO BID
Zolpidem 10mg PO QHS
Zofran 8mg PO TID
Asmanex Twisthaler twice a day.
Dilaudid 4mg PO every 4-6 hours as needed for pain.
Fioricet 50-325-40mg PO Q6H PRN
Ativan 0.5mg PO Q4-6 hours PRN
Benadryl 25mg PO Q4-6H PRN
Albuterol MDI
Ferrous Sulfate 325mg PO BID
Zyflo 600mg PO QID
Discharge Medications:
1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO four
times a day.
6. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO at
bedtime.
7. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day.
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q4H (every 4 hours) as needed for flare.
14. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every four (4) hours as needed for shortness of [**Name (NI) 1440**] or
wheezing.
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Amphetamine-Dextroamphetamine 15mg PO daily
Zyflo 600mg PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Mast Cell Degranulation Syndrome
.
Secondary:
- Hypertension
- GERD
- Anemia
- Bipolar disorder
- Depression
Discharge Condition:
Clinically improved, afebrile, VSS
Discharge Instructions:
You were admitted with shortness of [**Name (NI) 1440**] and chest pain
concerning for a flare of your mast cell degranulation syndrome.
Your medications have not changed. Please continue to take your
medication as directed.
.
Please maintain your scheduled follow up listed below.
.
Please seek medical attention if you experience any fevers >
101, chills, increasing chest pain or shortness of [**Name (NI) 1440**],
abdominal pain, flushing, or any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in the Allergy Department of
[**Hospital6 1708**] on [**2153-7-19**] at 10:30am in the
[**Location (un) 55**] Office. Please call [**Telephone/Fax (1) 21743**] with any
questions.
.
Please maintain your scheduled follow up listed below:
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2153-6-4**] 1:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2153-8-22**] 1:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Admission Date: [**2153-5-27**] Discharge Date: [**2153-5-29**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 60yo woman with frequent hospitalizations (last
four days ago) for flares of mast cell degranulation syndrome.
She notes that since her d/c 4 ago she has had progressive
abdominal, backand chest pain which are consistent with her
usual flares. She initially had SOB nad felt her tongue was
swollen and itchy but these have both resolved since arrival
here. She felt dizzy at home, but denies neck or arm pain,
lightheadedness or dizziness. She does report diarrhea and N/V
at home so that she could not hold down POs and came to the ER
today for this reason. Notably she was on a prednisone taper
from her last admission but did not yet step down from 40 to
30mg.
In the [**Hospital1 18**] ER, CXR was negative, she was initially tachycardic
to 120s and RR 30s, sats were in high 90s with no stridor. No
tongue swelling was seen on exam. After her initial treatment
with epinephrine 0.3 x 3, methylprednisolone, benadryl 75,
zofran, dilaudid a total of 6mg and nonrebreather mask (her
usual protocol), she noted improvement with tachycardi and
tachypnea resolved. she was satting well on RA and was admitted
for pain control and inability to tolerate POs.
Past Medical History:
- mast cell degranulation syndrome as above- Followed by [**First Name8 (NamePattern2) 21734**]
[**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also
followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice.
- ADHD
- depression/anxiety
- MI after given wrong dose of epi in anaphylaxis
- HTN
- Erosive osteoarthritis
- GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
- Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
laryngoscopy
- Anemia, iron studies c/w AOCD
- Hemorrhoids
- pt reports EGD demonstrated vegetable bezoar (?[**12-7**]).
- Status post hysterectomy and oophorectomy
- h/o MRSA infection (porthacath associated)
- portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection
- portacath placed [**2151-6-9**]
Social History:
Pt divorced approx 2 [**Month/Day/Year 1686**] ago after 37 [**Month/Day/Year 1686**] of marriage. Husband
was doctor. Currently works as ED tech at [**Hospital 2436**] Hosp.
Denies legal problems, denies h/o abuse. Son is HCP
[**Telephone/Fax (1) 21738**].
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
T: 98.6 BP: 166/84 P: 89 RR:18 O2 sats: 99% RA
Gen: pt cries out in pain periodically, holding abd in pain,
speaking full sentences
HEENT: pupils small but reactive, NCAT, MM dry
Neck: supple, no LAd
CV: RRR, nl S1S2, no R/G/M
Resp: speaks in full sentences, no stridor, CTAB with poor
cooperation
Abd: soft, nondistended, NABS, no HSM, tender to palpation
diffusely (moreso with manual palpation than with deep
compression with stethoscope)
Ext: nl tone and bulk, moves all 4, DP 2+ bilaterally
Neuro: grossly nl
Pertinent Results:
[**2153-5-26**] 05:48AM WBC-5.0 RBC-4.05* HGB-11.0* HCT-34.4* MCV-85
MCH-27.1 MCHC-31.8 RDW-15.9*
[**2153-5-26**] 05:48AM PLT COUNT-331
[**2153-5-26**] 05:48AM GLUCOSE-122* UREA N-13 CREAT-0.8 SODIUM-142
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-29 ANION GAP-12
[**2153-5-26**] 05:48AM CALCIUM-9.2 PHOSPHATE-4.7* MAGNESIUM-2.0
Brief Hospital Course:
Ms. [**Known lastname **] is a 61yo female with mast cell degranulation
syndrome, significant anxiety and multiple admissions for
shortness of [**Known lastname 1440**] presents with symptoms c/w mast cell flare.
1)Mast cell degranulation syndrome: Per her protocol, she was
initially given ondansetron, hydromorphone, methylprednisolone,
albuterol nebs, O2 by NC, epinephrine, lorazepam and benadryl.
She will need follow-up with her allergist at [**Hospital1 **] who is an expert in this field.
2)Transient hypotension: Fluid responsive. Possibly secondary to
opiates. No evidence of infection such as urinary frequency,
increased sputum production, fevers at home. She was continued
on her outpt regimen of antihypertensives without any problems.
3)Depression/anxiety/bipolar: Likely playing a significant role
in recurrent hospitalizations. She was continued on her regimen
of duloxetine and lorazepam. Psychiatry was consulted and
recommended that the Adderall be stopped.
4)Postemneopausal symptoms: She was continued on her home
regimen of Premarin.
5)Arthritis: Continued Plaquenil.
6)Hypertension: Continue Diltiazem.
Medications on Admission:
diltiazem CD 180mg qday
atarax 25 QID
Vivelle dot 0.05 twice per week
ranitidine 300mg daily
cymbalta 60mg qday
plaquenil 200 [**Hospital1 **]
adderal XR 25
fexofenadine 180 [**Hospital1 **]
prednisone taper (just finished 4 days of 40mg, then 30mg x 3d,
20mg x 3d, 10mg x 3d
ambien 10 prn
zofran 8 prn
dilaudid 2 prn
percocet prn
fiorcet prn
epi pen prn
Discharge Medications:
1. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
2. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime.
3. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. Mom[**Name (NI) 6474**] 220 mcg (120 doses) Aerosol Powdr [**Name (NI) **] Activated
Sig: Two (2) Inhalation twice a day.
5. Benadryl 25 mg Capsule Sig: One (1) Capsule PO q4-6 hours.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Zileuton 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
9. Premarin 0.3 mg Tablet Sig: One (1) Tablet PO once a day.
10. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Cromolyn 100 mg/5 mL Solution Sig: One (1) PO once a day.
13. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
14. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO q8h prn.
16. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO q4-6 hours
prn.
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
19. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO q6h prn.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Mast Cell Degranulation Syndrome
Secondary
GERD
Depression
Anxiety
Bipolar disorder
Hypertension
Discharge Condition:
stable, pain free, O2 sat 99% RA
Discharge Instructions:
You were admitted with a mast cell degranulation flare. You were
treated with your anti-histamine/pain protocol and recovered
well.
.
If you have respiratory distress, you should use your epi-pen at
home and call 911 to be transported via ambulance to the
emergency room.
.
In addition, please continue to abide by your Mast Cell
Degranulation
Syndrome Plan:
*** EMERGENCY PLAN *** (as posted in chart)
administer:
1. Epinephrine 0.3cc of 1/1000 SC and repeat x3 at 5 min
intervals if BP <90 systolic in setting of flare
2. Benadryl 25-50 IV q4 hr for 24-48 hrs
3. Solu-medrol 80mg IV/IM
4. Oxygen by mask or cannula
5. Albuterol nebs q2-4 hr prn
6. Dilaudid 2mg q 3hrs
7. Zofran 8mg q 12h for 24-48 hrs
PRE-MEDICATION for major/minor procedures:
1. Prednisone 50mg po q24 hrs and 1-2 hours prior to surgery
2. Benadryl 25-50mg 1 hour prior to surgery
3. Ranitidine 150mg 1 hour prior to surgery
At the recommendation of the psychiatrist, you should stop
taking your Adderall.
Followup Instructions:
You have the following appointments. Please attend them as
directed. Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2153-6-4**] 1:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2153-8-22**] 1:20
In addition, please call your primary care doctor, Dr. [**First Name (STitle) **]
at [**Telephone/Fax (1) 21748**] to make an appointment within the next [**1-3**]
weeks.
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16936, 16942
|
13847, 14984
|
10504, 10511
|
17091, 17126
|
13493, 13824
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17150, 18132
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10450, 10466
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10539, 11727
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11749, 12577
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12593, 12852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,743
| 179,836
|
23780
|
Discharge summary
|
report
|
Admission Date: [**2141-7-29**] Discharge Date: [**2141-8-2**]
Date of Birth: [**2071-1-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 70-year-old female with a history of severe
pancreatitis in [**2134**] requiring extended hospitalization
complicated by a deep vein thrombosis, currently with IVC filter
in place and on Coumadin, recent mild thrombocytopenia being
followed. Ms [**Known lastname 60613**] was in her usual state of health until 3
days ago she developed a headache in the am which resolved on it
owns,
the same thing occurred the following day. She woke up with a
severe headache which caused her to vomit. She went to [**Hospital1 3325**] and was found to have a
SAH over her tentorium, she denies any recent trauma and her INR
at [**Hospital1 46**] was 2.2. She was given Vitamin K and ffp.
Review of systems describes headache and nausea resolved,
fatigue, but otherwise is feeling
well. Denies any fevers, chills, nausea, or vomiting. No chest
pain, shortness of breath, abdominal pain, no change in bowel or
bladder habits. No petechiae.
Past Medical History:
1. Severe pancreatitis in [**2134**]. She was admitted following
syncope, is noted to have necrotizing pancreatitis with multiple
pseudocysts. She underwent percutaneous drainage after biliary
obstruction. Insulin dependent
2. History of VRE.
3. History of C. diff.
4. Type 2 diabetes .
5. Hypertension.
6. Multiple pulmonary nodules. CT scan in followup in [**2136**]
with
a decreased size.
7. Lower extremity squamous cell carcinoma.
8. History coronary artery disease.
9. History of deep vein thrombosis in the setting of
necrotizing
pancreatitis. She has an IVC filter in place. She also
describes a lower extremity deep vein thrombosis approximately
10
years ago after a long flight.
Social History:
She is a hospital chaplain at [**Hospital3 3583**].
She lives alone, does not smoke, does not drink alcohol
Family History:
Coronary artery disease. A maternal aunt had breast cancer in
her 80s
Physical Exam:
On Admission:
O: T: BP: 119/62 HR:83 R 16 O2Sats 100% 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-10**] EOMs full
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-11**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-13**] throughout. No pronator drift
Sensation: Intact to light touch,
Toes downgoing bilaterally
At discharge:
AVSS, afebrile
NAD
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-10**] EOMs full
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
II: Pupils equally round and reactive to light,3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-13**] throughout. No pronator drift
Sensation: Intact to light touch,
Toes downgoing bilaterally
wwp BL UE/LE
Pertinent Results:
CT HEAD W/O CONTRAST [**2141-7-29**]
1. Subdural hemorrhage with layering hyperdense material and
hypodense
material more superiorly, suggestive of a subacute or chronic
component.
2. Focus of hyperdensity in the left frontal lobe at the
[**Doctor Last Name 352**]-white matter junction. Attention on follow up is
recommended
CTA HEAD W&W/O C & RECONS [**2141-7-29**]
1. Nonspecific left frontal lobe hyperdense focus, new since
[**2134**] and without evidence of an underlying vascular lesion.
This could be further evaluated via MRI in order to exclude any
possible underlying mass, if clinically relevant.
2. Mild calcific plaque of the distal internal carotid arteries
bilaterally, and otherwise normal CT angiogram of the head.
[**8-2**]: CT head no formal read, no acute hemorrhage
[**8-2**] LENI: No DVT
[**8-2**]: CXR: No focal consolodation, effusion, pneumothorax
Brief Hospital Course:
70 y/o F on aspirin and coumadin presents with atraumatic SAH
and SDH along tentorium. She was admitted to neurosurgery in the
ICU for close monitoring. Her exam was neurologically stable. A
CTA was done to rule out vascular anomaly and was negative.
There was a hyperdensity in the left frontal area and MRi for
follow up was arranged. On [**7-30**], she remained stable and foley
was removed, diet was advanced, PT was consulted and she was
transferred to the floor. On [**7-31**], patient awaited a floor bed
in the ICU overnight and remained stable. On [**8-1**], patient
remains in ICU pending floor bed. PT/OT was consulted to see
her. In the early am of [**8-2**] she had an episode of headache and
nausea, head CT was stable. Her sat was 88%. CXR was
unremarkable. LENS showed absence of DVT. Her saturation
returned to within normal on room air without intervention. She
was cleared for discharge on [**2141-8-2**] following complete
advancement with PT. [**Last Name (un) **] was consulted for diabetes
management. She will follow up in one week for further
management. No changes were made to sliding scale at this time.
Patient expressed readiness for discharge and all questions were
answered prior to discharge.
Medications on Admission:
Coumadin, Aspirin 81 mg, Calcium
600mg PO QD, Calcium D 500mg QPM, Creon 12,000 PO QD, Ferrous
gluconate 200mg PO QD, Simivastatin 10 QHS, Lantus 23 units SQ
HS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Calcium Acetate 667 mg PO QAM
3. Creon 12 1 CAP PO TID W/MEALS
4. Docusate Sodium 100 mg PO BID
5. Ferrous Gluconate 325 mg PO DAILY
6. Phenytoin Sodium Extended 100 mg PO TID
RX *phenytoin sodium extended 100 mg 1 capsule(s) by mouth three
times a day Disp #*90 Tablet Refills:*0
7. Glargine 23 Units Bedtime
8. Simvastatin 10 mg PO HS
9. Calcium Carbonate 500 mg PO QPM
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic SDH
H/o DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
??????Your Coumadin was STOPPED in the hospital due to your brain
bleeding. Because you have an IVC filter, you should stay off
Coumadin permanently (we confirmed this with your
heme-oncologist Dr. [**Last Name (STitle) 6944**].
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] , to be seen in [**4-14**] weeks.
??????You will need a MRI of the brain without contrast and without
contrast prior to your appointment. This can be scheduled when
you call to make your office visit appointment.
Completed by:[**2141-8-8**]
|
[
"V58.67",
"V12.51",
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"V58.61",
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"V10.51",
"430",
"414.01",
"V45.79",
"432.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7283, 7289
|
5274, 6502
|
283, 290
|
7362, 7362
|
4365, 5251
|
8538, 8925
|
2127, 2199
|
6714, 7260
|
7310, 7341
|
6528, 6691
|
7513, 8515
|
2214, 2214
|
3335, 3446
|
235, 245
|
318, 1259
|
3698, 4346
|
2228, 2379
|
7377, 7489
|
1281, 1986
|
2002, 2111
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,522
| 156,792
|
12202
|
Discharge summary
|
report
|
Admission Date: [**2127-1-6**] Discharge Date: [**2127-1-13**]
Date of Birth: [**2080-6-7**] Sex: F
Service: MEDICINE
Allergies:
adhesive
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 46y/o lady with metastatic melanoma who was
admitted with prolonged confusion after seizure.
.
She was initially diagnosed with melanoma in [**2102**] after the
biopsy of a lesion on her abdomen, for which she underwent
surgical resection. Then in [**2120**], she was found to have
metastatic melanoma after the biopsy of a shoulder mass prompted
further workup and she was found to have brain and lung mets.
She is s/p whole brain XRT, temozolomide, craniotomy with
resection of metastases, cyberknife radiosurgery x10 to mets in
brain and lung, Ommaya reservoir placement in [**2-/2126**], and
Ipilimumab in 5/[**2125**]. She began having seizures in [**2124**] and was
admitted to OMED in [**7-/2126**] for a seizure that was attributed to
her brain mets and her Lamotrigine was uptitrated. She had
headaches for which she was admitted to OMED again in [**10/2126**];
these were alleviated for the most part with steroids and
whenever she has been tapered from these steroids she has
recurrent headache. She is followed by Dr. [**Last Name (STitle) 1729**] and Dr. [**Last Name (STitle) 724**].
.
This admission, she presented to OSH ED after she was found by
her husband to be staring into space. She was transferred here
as her mental status did not clear, and she was admitted to the
ICU with continued altered mental status and transiently unequal
pupils (which resolved after admission to the ICU). CT scan
revealed unchanged 3mm midline shift.
.
Per Dr.[**Name (NI) 6767**] recs, she had been started on Decadron and Keppra
before transfer to [**Hospital1 18**]. In the ICU, her altered mental status
was worked up and was presumed to be due to post-ictal state as
well as edema. She was confused for one day and required
retraints; EEG showed epileptiform discharges, probable
epileptigenic focus in Rt frontal lobe. Rt frontal slowing and
cortical slowing. No overt seizures. She has been kept on
Lamotrigine, Keppra, and Decadron. She is more alert and
oriented and is called out to the OMED floor.
Past Medical History:
Past Oncologic History: Primarily taken from Dr.[**Name (NI) 6767**] notes
form [**2126-11-18**].
- Initially presented with melanoma in-situ in [**2103**] on her
abdominal wall which was resected
- [**2120**] re-presented with a L axiallary nodule found to be LN
with melanoma and multiple other metastatic sites.
- Received 5 weeks of postoperative radiation to the axilla and
upper back.
- Received vaccine therapy in [**State 531**].
- [**12/2122**], she developed severe intermittent headaches and an MRI
showed extensive CNS metastases.
- completed whole brain cranial irradiation on [**2123-2-9**] at
[**Hospital1 756**] and Woman's Hospital,
- s/p 1 cycle of temozolomide at 5/28 schedule at [**Hospital1 756**] and
Woman's Hospital,
- s/p craniotomy by [**First Name8 (NamePattern2) **] [**Doctor Last Name **] on [**2123-3-4**] for removal of
a large right frontal brain metastasis,
- s/p Cyberknife radiosurgery to 4 metastases on [**2123-3-23**] and
[**2123-3-24**]: 2,000 cGy to left superior metastasis, 1,600 cGy to
right frontal resection cavity, 1,800 cGy to right high parietal
metastasis, and 2,200 cGy to left temporal metastasis,
- s/p Cyberknife radiosurgery to a right posterior temporal
lobe metastasis on [**2123-10-27**] to 2,200 cGy,
- received temozolomide at a dose of 150 mg/m2/day x 5 days
from [**2123-11-29**] to [**2124-1-29**],
- started CTLA-4/ipilimumab compassionate use from [**2124-3-16**] to
[**2125-2-20**],
- s/p resection of a right deep jugular metastasis on [**2125-11-12**]
by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.,
- s/p Cyberknife to right upper lung metastasis to 4500 cGy
(1500 cGy x 3 fractions) from [**2125-7-2**] to [**2125-7-6**], and
Cyberknife to left lower lung metastasis to 4500 cGy (1500 cGy x
3 fractions08/04/09 to [**2125-7-9**],
- s/p Cyberknife radiosurgery on [**2125-12-18**] to left parietal (to
2200 cGy), left thalamic (to [**2115**] cGy), and right frontal
metastases,
- s/p Cyberknife radiiosurgery on [**2126-1-28**] to right
cerebellar, left occipital and left frontal metastases, all to
2200 cGy at 79% isodose line,
- status post Ommaya reservoir placement on [**2126-3-7**] by Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **],
- started ipilimumab (CTLA-4) on [**2126-4-17**],
- hospitalized in OMED Service from [**2126-8-11**] to [**2126-8-14**] after
a seizure, and
- hospitalized in OMED Service from [**2126-11-16**] to [**2126-11-17**] for
headache.
OTHER MEDICAL HISTORY:
Hand surgery in [**2104**]
C-section in [**2108**]
Breast implants in [**2112**]
Depression
Social History:
Married and lives with her husband and children. She currently
works part-time at a private school. No tobacco, EtOH or drugs.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
VS: 126/76 67 15 100% RA
GEN: oriented only to self, awake, NAD
HEENT: pupils 4mm and slugglishly reactive but equal. dry MM.
Neck: No pain with flexion of neck.
Spine: No spinal or paraspinal TTP
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: Slowed and slightly slurred speech. Visually recognizes
husband but cannot state his name. CN 2-12 intact. Strength 5/5
throughout. Some difficulty following instructions, but able to
after they are repeated. Slowed and slightly inaccurate finger
to nose. Downgoing toes. Gait not assessed.
DISCHARGE EXAM:
Vitals: Tm/Tc 98.1/96.8, BP 105/55 (100-120)/(55-70), HR 100
(55-100), RR 18, SaO2 96%RA
GEN: NAD
CV: S1, S2, no murmur
PULM: CTA throughout all fields
EXTREM: warm, well-perfused, no edema
NEURO: Knows the date and can spell "world" backwards but cannot
recite months backwards and does not recognize the examiner.
Face symmetric; intact sensation to light touch throughout
extremities and face; UE and LE with 5/5 strength; toes up
bilaterally; speech is fluent but memory is poor; affect is
blunted; gait is normal but intentionally slow
Pertinent Results:
ADMISSION LABS
[**2127-1-6**] 06:45PM BLOOD WBC-6.1 RBC-3.40* Hgb-11.1* Hct-32.5*
MCV-96 MCH-32.7* MCHC-34.3 RDW-13.6 Plt Ct-263
[**2127-1-6**] 06:45PM BLOOD Neuts-82.7* Lymphs-13.8* Monos-2.8
Eos-0.6 Baso-0.2
[**2127-1-7**] 02:18AM BLOOD PT-12.9 PTT-31.1 INR(PT)-1.1
[**2127-1-6**] 06:45PM BLOOD Glucose-102* UreaN-17 Creat-0.7 Na-138
K-4.2 Cl-100 HCO3-27 AnGap-15
[**2127-1-7**] 02:18AM BLOOD ALT-21 AST-22 LD(LDH)-160 AlkPhos-56
TotBili-0.2
[**2127-1-7**] 02:18AM BLOOD Albumin-4.5 Calcium-9.5 Phos-3.3 Mg-2.0
.
OTHER PERTINENT LABS
[**2127-1-10**] 07:15AM BLOOD Folate-19.3
[**2127-1-7**] 02:18AM BLOOD VitB12-940*
[**2127-1-7**] 02:18AM BLOOD TSH-0.61
[**2127-1-7**] 02:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2127-1-7**] 02:48AM BLOOD Lactate-0.9
.
DISCHARGE LABS:
[**2127-1-13**] 05:50AM BLOOD WBC-12.1* RBC-3.32* Hgb-10.8* Hct-33.2*
MCV-100* MCH-32.5* MCHC-32.5 RDW-13.4 Plt Ct-248
[**2127-1-13**] 05:50AM BLOOD Neuts-82.1* Lymphs-11.9* Monos-5.6
Eos-0.1 Baso-0.2
[**2127-1-13**] 05:50AM BLOOD Glucose-108* UreaN-16 Creat-0.7 Na-138
K-3.6 Cl-104 HCO3-27 AnGap-11
[**2127-1-13**] 05:50AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.0
.
MICRO:
- Blood Cx [**2127-1-7**]: negative
- UA/UCx [**2127-1-7**]: negative
- RPR [**2127-1-10**]: negative
.
[**2127-1-6**]: CT head w/o contrast
FINDINGS: Multiple mixed attenuation lesions are again noted,
including
lesions in the cerebellar vermis, posterior right temporal lobe,
left
posterior frontal lobe, the medial parafalcine left frontal and
left parietal lobes, and the right frontal lobe. These were
better assessed on the [**2127-1-2**] MRI. There is extensive white
matter hypodensity likely related to vasogenic edema and
posttreatment changes, similar to [**2127-1-2**]. There an unchanged 3
mm leftward shift of midline structures. A ventriculostomy
catheter is again noted from a right frontal approach
terminating in the third ventricle. The ventricles are stable in
size, with persistent partial effacement of the right lateral
ventricle.
.
There is a right parietal craniotomy. No suspicious lytic or
sclerotic
osseous lesion is identified. Mucosal thickening and a mucus
retention cyst are noted in the left maxillary sinus.
.
IMPRESSION:
Multiple parenchymal metastases, grossly similar to the [**2127-1-2**]
head MRI
allowing for differences in modalities, with unchanged 3 mm
leftward shift of midline structures.
.
.
EEG [**2127-1-7**]
This is an abnormal routine EEG due to the presence of
right fronto-central rare epileptiform discharges which
represent
epileptogenic cortex. It is also abnormal due to the presence of
right
fronto-central focal slowing which represents a focal
subcortical
dysfunction. There were no electrographic seizures noted.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Ms. [**Known lastname 38170**] is a 46y/o lady who has metastatic melanoma with brain
lesions, edema, and midline shift and presented after seizures
with continued altered mental status. During her stay, she was
continued on steroids and an uptitrated antiepileptic regimen.
She had no more seizures and her mental status improved
somewhat, so she was discharged home with service with close
follow-up.
.
# Seizures/Altered Mental Status: likely due to brain mets and
edema.
Upon presentation, the patient was delirious, disoriented with
decreased level of attention. She had transiently unequal
pupils but this resolved with no further interventions. TSH and
B12 are normal, and RPR is negative. CT showed stable 3mm
midline shift. On recent MRI, her cerebral edema seems worse
than before. This could account for her seizures, which began
in [**2125**]. EEG confirms evidence of seizure activity. She was
taking Lamotrigine 150mg [**Hospital1 **] at home (though no blood level was
obtained on admission) and she was started on here. In
addition, prior to transfer she had been started on
Levetiracetam 1000mg [**Hospital1 **] and Dexamethasone 4mg Q6H, tapered
changed to Q8H. She will likely need to stay on steroids in the
long run because she has headache when they are tapered off.
While her level of attention improved during her stay, she still
remained confused and had poor recall. She had no more
seizures. She was cleared by PT to go home, and she was sent
home on Dexamethasone/Lamotrigine/Levetiracetam with home PT,
home OT, visiting skilled nursing, and home health aid. She
will follow up with her Oncologist and Neuro-Oncologist.
.
# Melanoma: metastatic to brain and lung.
She is s/p multiple treatments including chemo, surgery,
radiation, cyberknife, and most recently Ipilimumab. Her
disease seems to be stable surrently. She has noticed worsening
vitiligo. She will follow up with her Oncologist.
.
# Depressed mood: acute on chronic.
She was very depressed about being in the hospital away from her
family. She has been on Escitalopram 10mg daily with some
relief; she does report recent restless legs which are a
possible side effect of SSRIs in general.
She was continued on her SSRI.
Medications on Admission:
escitalopram 10 mg qd
hydrocodone-acetaminophen 5 mg-500 mg q4h prn
juice plus 4 pills qd
lamotrigine 150 mg [**Hospital1 **]
lorazepam 0.5 mg qd
zolpidem 5 mg qhs prn
Dosate sodium 100 mg qd
Flaxseed oil
Multi-Vitamin Hi-Po
omega-3 fatty acids 1,000 mg-300 mg 4 Capsule(s) by mouth once a
day
Discharge Medications:
1. lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
2. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO every four (4) hours as needed for pain.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety/nausea.
4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. multivitamin Capsule Sig: One (1) Capsule PO once a day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every four (4) hours as needed for nausea.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2*
11. 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:*2*
12. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
13. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass
Discharge Diagnosis:
seizures due to metastatic melanoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with continued confusion after a seizure. The
seizures are likely due to brain swelling and brain metastases
from your metastatic melanoma. You were put on another
anti-seizure medication and you are doing better so you are
being discharged home.
.
We made the following changes to your medications:
-start Levetiracetam (Keppra)
-start Dexamethasone
-start Zofran as needed for nausea
-increase Docusate
-add Senna and Bisacodyl
-start Omeprazole
-stop juice plus, flax seed, and omega 3 fatty acids
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2127-1-27**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name **]/ONCOLOGY
When: TUESDAY [**2127-2-11**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], 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
|
[
"V15.3",
"198.3",
"V10.82",
"197.0",
"348.5",
"348.39",
"296.33",
"345.90",
"288.60",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13427, 13482
|
9327, 9752
|
275, 282
|
13562, 13562
|
6526, 7323
|
14260, 14899
|
5131, 5149
|
11901, 13404
|
13503, 13541
|
11583, 11878
|
13715, 14006
|
7339, 9281
|
5164, 5949
|
5965, 6507
|
14035, 14237
|
226, 237
|
310, 2349
|
13577, 13691
|
2371, 4970
|
4986, 5115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,057
| 185,880
|
31997
|
Discharge summary
|
report
|
Admission Date: [**2177-2-10**] Discharge Date: [**2177-3-2**]
Date of Birth: [**2140-3-27**] Sex: F
Service: MEDICINE
Allergies:
Celebrex / Augmentin / Iodine; Iodine Containing / Rofecoxib /
Celecoxib / Sulfa (Sulfonamides) / Adhesive Tape / Shellfish
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
Bilateral lower extremity pain
Major Surgical or Invasive Procedure:
IVC Filter Placement
History of Present Illness:
Mrs. [**Known lastname **] is a 36 year old woman with widely metastatic
cholangiocarcinoma, C. difficile associated diarrhea, esophageal
varices with h/o variceal hemorrhage, and portal hypertension
recently discharged from [**Hospital1 18**] [**2-8**] for ascending cholangitis
and GNR bacteremia. Since discharge she has developed
progressively worsening lower extremity pain and shortness of
breath, especially with exertion. She was seen in clinic today
and sent to the emergency department for evaluation.
.
In the emergency department, her initial VSs were 96.9, 131,
97/70, 16, 100% 2LNC. LENIs demonstrated bilateral DVTs. Because
of her h/o variceal bleeding and guaiac positive stool, plan was
made for IVC filter placement. Due to her contrast allergy,
however, she was started on pre-treatment with methylpredisolone
and diphenhydramine. After discussing with the oncology service,
plan was made for admission to ICU overnight for closer
monitoring, no anticoagulation and CTA and IVC filter
implantation in the morning.
.
Also in clinic, note was made of increasing abdominal
distension. Her last paracentesis was [**2-7**]. She is also having
worsening diarrhea, and metronidazole was started on top of
vancomycin PO for C. difficile associated diarrhea.
Past Medical History:
Widely metastatic cholangiocarcinoma
Esophageal varices s/p variceal hemorrhage and ? banding
Portal hypertension
h/o cholecystitis s/p cholecystectomy
h/o ascending cholangitis [**3-15**] tumor obstruction
Social History:
Denies tobacco, EtOH, illicit drugs
Family History:
HTN, DMII, Breast cancer in maternal aunt
Physical Exam:
Physical exam
Vitals: T: 96.5 BP: 111/76 P: 115 R: 18 SaO2: 99% 2LNC
General: Awake, alert, pleasant, cachectic, appropriate,
cooperative, able to speak in full sentences
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM dry
Neck: no significant JVD
Pulmonary: decreased BS at the bases, lungs otherwise CTA
bilaterally, no wheezes, ronchi or rales
Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, mildly tender, mostly in RUQ, moderately
distended, normoactive bowel sounds, no masses
Extremities: No edema, 2+ radial, DP pulses b/l, no calf
tenderness
Pertinent Results:
[**2177-2-10**] 12:37PM BLOOD WBC-24.0*# RBC-3.98* Hgb-10.7* Hct-33.9*
MCV-85 MCH-27.0 MCHC-31.7 RDW-20.1* Plt Ct-254
[**2177-2-10**] 12:37PM BLOOD Neuts-90* Bands-1 Lymphs-8* Monos-0 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2177-2-10**] 12:37PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL
[**2177-2-10**] 02:35PM BLOOD PT-16.7* PTT-31.7 INR(PT)-1.5*
[**2177-2-10**] 12:37PM BLOOD Glucose-129* UreaN-15 Creat-0.6 Na-131*
K-4.4 Cl-97 HCO3-23 AnGap-15
[**2177-2-10**] 12:37PM BLOOD ALT-81* AST-93* AlkPhos-1427*
TotBili-2.0*
[**2177-2-10**] 12:37PM BLOOD TotProt-6.4 Albumin-2.6* Globuln-3.8
Calcium-8.6 Phos-4.1# Mg-1.9
[**2177-2-11**] 03:51AM BLOOD WBC-11.7*# RBC-3.24* Hgb-9.0* Hct-27.6*
MCV-85 MCH-27.8 MCHC-32.6 RDW-20.2* Plt Ct-176
[**2177-2-11**] 03:51AM BLOOD Glucose-131* UreaN-17 Creat-0.5 Na-132*
K-4.7 Cl-99 HCO3-22 AnGap-16
[**2177-2-11**] 03:51AM BLOOD ALT-63* AST-51* AlkPhos-1141* TotBili-1.3
[**2177-2-11**] 03:51AM BLOOD Albumin-2.5* Calcium-8.1* Phos-4.5 Mg-2.0
[**2177-3-1**] 02:00AM BLOOD WBC-19.7* RBC-3.09* Hgb-9.9* Hct-31.1*
MCV-101* MCH-32.1* MCHC-31.9 RDW-25.3* Plt Ct-170
[**2177-3-1**] 02:00AM BLOOD PT-31.7* PTT-75.6* INR(PT)-3.3*
[**2177-2-21**] 12:00AM BLOOD Fibrino-150#
[**2177-3-1**] 08:29AM BLOOD K-6.6*
[**2177-3-1**] 02:00AM BLOOD Glucose-129* UreaN-53* Creat-2.0* Na-117*
K-9.0* Cl-102 HCO3-11* AnGap-13
[**2177-3-1**] 02:00AM BLOOD ALT-33 AST-269* LD(LDH)-1205*
AlkPhos-808* TotBili-3.9*
[**2177-2-28**] 12:00PM BLOOD Lipase-19
[**2177-3-1**] 02:00AM BLOOD Albumin-1.7* Calcium-6.8* Phos-6.3*
Mg-1.9
[**2177-2-21**] 12:00AM BLOOD Hapto-122
[**2177-2-21**] 12:00AM BLOOD Triglyc-126
[**2177-2-16**] 03:00AM BLOOD Osmolal-277
[**2177-3-1**] 08:29AM BLOOD TSH-12*
[**2177-3-1**] 08:29AM BLOOD Cortsol-30.3*
[**2177-2-28**] 02:00AM BLOOD Lactate-2.9*
[**2177-2-20**] 11:44AM ASCITES WBC-2350* RBC-325* Polys-82* Lymphs-10*
Monos-0 Eos-1* Mesothe-1* Macroph-6*
[**2177-2-20**] 11:44AM ASCITES TotPro-1.0 Glucose-117 LD(LDH)-100
Albumin-LESS THAN
.
PERITONEAL FLUID.
Fluid Culture in Bottles (Final [**2177-2-23**]):
LEUCONOSTOC SPECIES.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
243-3766C
#1, [**2177-2-15**].
Anaerobic Bottle Gram Stain (Final [**2177-2-18**]):
GRAM POSITIVE COCCI IN PAIRS IN SHORT CHAINS.
Aerobic Bottle Gram Stain (Final [**2177-2-18**]):
GRAM POSITIVE COCCI.
IN CHAINS.
.
Reports:
[**2177-2-10**] BILAT LOWER EXTREM VEINS:
IMPRESSION: Bilateral lower extremity DVTs
.
[**2177-2-10**] CXR:
No acute cardiopulmonary process
.
US ABD LIMIT, SINGLE ORGAN [**2177-2-14**] 11:27 AM
FINDINGS: Targeted ultrasound of the four quadrants of the
abdomen demonstrates a large amount of ascites. An appropriate
spot was marked in the right lower quadrant for paracentesis to
be performed by the clinical team.
.
US ABD LIMIT, SINGLE ORGAN [**2177-2-19**] 1:00 PM
FINDINGS: There is a large amount of ascites present. An
appropriate spot was marked in the right lower quadrant for
peritoneal tap.
Review of the CT scan of [**2177-2-6**] shows evidence of a
biliary stent in place, pneumobilia, and mild-to-moderate
intrahepatic biliary dilatation. Ultrasound examination done
today confirms the presence of intrahepatic biliary dilatation,
the degree of dilatation is mild. Many of the biliary radicles
have echogenic foci consistent with air. Note is also made of a
stent running from the common duct down, presumably towards the
duodenum. The diameter of the common duct was just under 8 mm,
it is noted that the patient is status post cholecystectomy.
CONCLUSION: Appropriate spot marked in the right lower quadrant
for peritoneal tap. Mild intrahepatic biliary dilatation. There
is a biliary stent in place.
Brief Hospital Course:
A/P (updated): 36F PMH metastatic cholangiocarcinoma, esophageal
varices with h/o variceal bleed, recent admit for ascending
cholangitis and GNR bacteremia presents with BLE DVT and PE,
worsening diarrhea, and worsening abdominal distension.
.
# Hypotension: likely related to hypovolemia as below. She was
not found to be septic despite repeated evaluations. She was
likely third-spacing much of the volume given during fluid
resuscitation: ascites, anasarca, complicated by poor nutrition
and protein loss in ascites and ascitic fluid removal which was
performed to relieve abdominal discomfort. An attempt was made
to replete intravascular volume with blood products, but this
did not appreciably improve her blood pressure, despite a
hematocrit above 30. During this course, she was treated with
xeloda in an attempt to gain control over her malignancy,
improve comfort and to reduce ascites. However, her disease
continued to progress. Given the progression of her disease
despite attempts at treatment, her continued discomfort, and the
inability to improve her clinical state despite multiple medical
interventions, she was made CMO. Her blood pressure dropped in
the final hours of her life.
.
# Renal failure: She developed renal failure likely from
hypoperfusion from low intravascular volume (see above).
.
# Abdominal distension: Repeated re-accumulation of ascitic
fluid due to portal hypertension and peritoneal studding. RUQ US
shows complete occlusion of right portal vein and partial
occlusion of main portal vein. She received a peritoneal drain
port for symptomatic care. Leukonostoc species and [**Female First Name (un) **] was
cultured in ascitic fluid. She was initially treated with
linezolid and caspofungin, then azithromycin and fluconazole per
ID. She continued to be uncomfortable at the port site and also
continued to leak fluid from other previous paracentesis sites.
Drainage of ascitic fluid resulted in large fluid shifts and
resuccitation with IVF --> interstitial space edema.
.
# Anemia: Unclear cause, likely anemia [**3-15**] inflammatory block -
no hemoptysis, hematochezia. DIC and hemolysis labs wnl. She
received 1U blood 1/11 with appropriate HCT bump to 29.5.
.
# BLE EVT, PE: She presented initially with BLE DVT, bilateral
moderate clot burden PE. Likely due to inflammatory state from
metastatic cholangiocarcinoma and recent infections.
Asymptomatic at rest but tachycardic to 150s with ambulation to
bathroom, likely from poor reserve. No signs of right heart
strain by EKG. Because of bleeding history an IVC filter was
placed. EGD [**2177-2-12**] showed 4 cords of [**3-16**] grade esophogeal
varices not bleeding, gastropathy, and metastasis in 2nd portion
of duodenum. After EGD showed no variceal bleeding, conservative
was started and continued until the goals of care were shifted
to comfort measures.
- Continue to monitor respiratory status
.
# diarrhea: She had considerable diarrhea during her stay. She
had long course of vancomycin PO and no recent positive stool.
Cdiff toxin A neg x 3 and toxin B negative. Fecal culture neg, O
and P negative. The diarrhea may have been partially a result of
her chemotherapy. She was given stool bulking agents for
symptomatic care.
.
# Metastatic cholangiocarcinoma: Before admission, she had
undergone only one cycle of palliative chemotherapy because of
her multiple complications. She was started on capecitabine
1500mg PO BID in an attempt at palliative care and prolongation
of her life for time with her family. Her clinical state
deteriorated despite treatment as above. Many discussion were
held with Mrs. [**Known lastname **] and her husband by the floor team and by
the patient's primary oncologist Dr. [**Last Name (STitle) **]. She was eventually
made CMO given her very poor prognosis and overall decline.
Medications on Admission:
Medications on admission:
Ertapenem 1 gram IV daily
Levofloxacin 500 mg daily
Metronidazole 500 mg three times daily
Vancomycin 250 mg four times daily
Spironolactone 25 mg once daily
Docusate Sodium 100 mg [**Hospital1 **]
Oxycodone 5 mg Tablet q4hrs prn pain
Oxycodone 60 mg Tablet Sustained Release [**Hospital1 **]
Pantoprazole 40 mg Tablet daily
Acetaminophen 325 mg q6hrs prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Widely metastatic cholangiocarcinoma
bilateral DVT
bilateral PE
SBP
.
Secondary:
Esophageal varices s/p variceal hemorrhage and ? banding
Portal hypertension
h/o cholecystitis s/p cholecystectomy
h/o ascending cholangitis [**3-15**] tumor obstruction
Discharge Condition:
expired
|
[
"197.4",
"572.3",
"276.1",
"456.21",
"452",
"415.19",
"287.5",
"567.29",
"197.7",
"155.1",
"453.40",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"54.91",
"45.13",
"38.93",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
10785, 10794
|
6523, 10352
|
415, 437
|
11097, 11107
|
2706, 6500
|
2037, 2080
|
10815, 11076
|
10404, 10762
|
2095, 2687
|
344, 377
|
465, 1736
|
1758, 1967
|
1983, 2021
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
545
| 155,327
|
51178
|
Discharge summary
|
report
|
Admission Date: [**2181-8-13**] Discharge Date: [**2181-8-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Altered mental status, sepsis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. [**Known lastname 7363**] is an 85 year old woman with a history of PVD, mild
dementia and CAD who presented to [**Hospital1 18**] accompanied by her
daughter with 1 day of altered mental status. The patient was in
her usual state of health until 1 day prior admission. Her
daughter noted that she was calling out for people who were not
there. She denies having had any cough or diarrhea. She was
brought to the [**Hospital1 18**] ED where she was found to have positive UA,
lactate of as high as 7.5. Her temperature was noted to be 102
rectally. In the ED, she was given vancomycin and ceftriaxone. A
pre-[**Month (only) **] line was placed in ED, and 1.5L NS were administered.
NGT placement was attempted. On arrival to the MICU the patient
had no complaints. She coughed up some rust-colored sputum
which, according to her daughter, was from an NG tube placement
attempt.
Past Medical History:
1. Diabetes, diet controlled.
2. Coronary artery disease, status post right coronary artery
stent in [**2173-11-9**].
3. CHF; echo in [**2-12**] showed EF=55%, enlarged left atrium,
moderate LVH, mild MS, moderate MR, moderate systolic PA
hypertension
4. dementia
5. Hypertension.
6. Cerebrovascular accident with residual aphasia.
7. Depression.
8. Anxiety.
9. CRI with baseline Cr 1.5-1.6
10. Anemia (baseline Hct 34)
11. multiple myeloma
12. Gout
13. ?Raynaud's disease
14. H/o gallstones but has gallbladder
Past Surgical History:
1. S/p amputation of left 5th toe and right 3rd toe, [**5-15**]
2. Status post left total hip replacement.
3. Status post L4 vertebral plasty on [**2174-12-7**].
4. Status post left ankle fracture reduction.
5. Status post appendectomy.
6. Status post cesarean section times two.
7. Status post traumatic amputation of the fourth right digit.
8. [**2181-4-16**]: Angioplasty of superficial femoral artery, popliteal
artery, tibioperoneal trunk and proximal posterior tibial artery
Social History:
She lives on one floor of a three floor home with her daughter.
She is somewhat independent of her ADL's (ie: can prepare her
own breakfast) but relies on her daughter for a lot of
assistance. She has two children, a grand-daughter and a
great-grandchild. She is a retired hairdresser. She denies
tobacco or alcohol history.
.
Family History:
Father with CAD in his 70's
Physical Exam:
Tmax: 96.2 Tcurrent: 95.3 BP: 109/45 (100s-130s/40s since levo
off)
P: 66 (60s-70s) R: 18 99% 4LNC
I/O: 4967 in/156 cc UOP total (10-16 cc/hr)
CVP: 15
Gen: Pleasant elderly woman in bed in no apparent distress.
HEENT: MMM, sclerae anicteric.
Neck: left IJ in place.
CV: Normal S1/S2, RRR. III/VI HSM at LSB/
Pul: CTA bilaterally no wheezes, rales or rhonchi
Abd: Soft, NT, ND, +BS
Ext: 1+ LE edema bilatereally
Neuro: awake, alert, oriented to hospital.
Pertinent Results:
UCx [**2181-7-13**]:
URINE CULTURE (Final [**2181-7-16**]):
KLEBSIELLA OXYTOCA. > 100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- => 32 R
CEFAZOLIN------------- => 64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 I
CEFTRIAXONE----------- 4 S
CEFUROXIME------------ => 64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 8 I
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- => 128 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- => 16 R
RENAL U.S. [**2181-8-16**] 2:03 PM
1. No evidence of renal abscess.
2. Scarring in the upper pole of the right kidney consistent
with chronic change due to prior infection.
3. Moderate-to-large bilateral pleural effusions.
[**2181-8-12**] 11:10PM WBC-2.4*# RBC-3.73* HGB-10.0* HCT-30.0*
MCV-80* MCH-26.9* MCHC-33.4 RDW-17.2*
[**2181-8-12**] 11:10PM NEUTS-56.2 BANDS-0 LYMPHS-36.3 MONOS-6.5
EOS-0.3 BASOS-0.6
[**2181-8-12**] 11:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2181-8-12**] 11:10PM PLT SMR-NORMAL PLT COUNT-310
[**2181-8-12**] 11:10PM GLUCOSE-227* UREA N-56* CREAT-2.1* SODIUM-134
POTASSIUM-6.0* CHLORIDE-98 TOTAL CO2-21* ANION GAP-21*
[**2181-8-12**] 11:10PM ALT(SGPT)-14 AST(SGOT)-54* CK(CPK)-59 ALK
PHOS-85 AMYLASE-99 TOT BILI-0.7
[**2181-8-12**] 11:10PM LIPASE-74*
[**2181-8-12**] 11:10PM cTropnT-0.08*
[**2181-8-12**] 11:10PM CALCIUM-9.1 PHOSPHATE-5.7* MAGNESIUM-2.4
[**2181-8-12**] 11:45PM PT-14.9* PTT-21.9* INR(PT)-1.3*
[**2181-8-13**] 01:02AM LACTATE-7.5*
[**2181-8-13**] 03:00AM LD(LDH)-471*
[**2181-8-12**] 11:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
[**2181-8-12**] 11:45PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2181-8-12**] 11:45PM URINE RBC-0 WBC- BACTERIA-MOD YEAST-RARE
EPI-[**2-11**] TRANS EPI-[**2-11**]
Brief Hospital Course:
85 year old woman with history of CAD, presents with AMS and
sepsis, found to have MRSA urinary infection.
.
1) Urosepsis: Pt with fever, tachycardia, low BPs, and elevated
lactate on admission and code sepsis was called. Resusitated
with IVFs and placed on levophed x 1 day. Was subsequently
weaned off of levophed with stable BPs during remaining hospital
course. Most likely source was UTI given positive UA and recent
urinary tract infection. Pt has had e.coli and klebsiella in the
past, both sensitive to fluoroquinolones. Pt received vanc/ctx
in ED. In MICU, vancomycin d/c'd and was continued on levaquin.
On transfer to floor, urine culture with MRSA, vancomycin
restarted and levaquin d/c'd. PICC placed for outpt IV
Vancomycin treatment for total of 14 days. Vancomycin trough
level while in hospital therapeutic at 11.0.
.
2) Cardiac: h/o CHF, CAD, HTN. Pt has tendence to get volume
overloaded and symptomatic CHF when her diuretic +/- her ACE are
held. However, given low BP requiring pressors on admission,
ACE-I, BB, and Lasix were held. Once BPs were more stable, all
three were readded without event. ASA was also continued.
.
3) Acute Renal failure: Likely acute on chronic secondary to
prerenal state. Pt's Cr peaked to 2.0 while in house, has since
dropped back to baseline after IVFs.
.
4) DM - Diet controlled as outpt. HISS with QID FS.
.
5) Anemia - baseline Hct in upper 20s low 30s. Iron studies were
consistent with anemia of chronic disease.
.
6) s/p amputation of L 5th toe and R 3rd toe - Wound care
continued.
.
7) Access - PICC.
.
8) Communication - with pt's daughter [**Name (NI) 1154**] [**Name (NI) **]
[**Telephone/Fax (1) 106214**].
.
9) Ppx - Heparin SQ.
.
The pt was discharged to a rehab facility for PT/OT and to
finish her 14 day course of IV Vancomycin for MRSA urinary
infection.
Medications on Admission:
Amitriptilyine 25 mg qday
ASA 81 mg qday
Colace 100 mg [**Hospital1 **]
Fosamax 70 mg qwk
metoprolol 25 mg [**Hospital1 **]
Ranitidine 150 mg [**Hospital1 **]
Timolol eye drops
Zestril 10 mg qday
Furosemide 40 mg qday
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. Heparin (Porcine) 5,000 unit/mL Solution Sig: Five (5) mL
Injection Q8H (every 8 hours).
Disp:*150 mL* Refills:*2*
3. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q48H (every 48 hours) for 10 days.
Disp:*5 gram* Refills:*0*
10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO qhs prn as needed for confusion, agitation.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
MRSA Urinary Infection
Urosepsis
Diabetes Mellitus type II
CAD s/p RCA stent [**11/2173**]
CHF
HTN
s/p CVA c residual aphasia
Depression
Anxiety
CRI
Discharge Condition:
Stable.
Discharge Instructions:
Please take all of your medications as instructed. You will need
to complete a 2 week course of IV Vancomycin for treatment of
urinary infection.
Return to the hospital if you experience any of the following
symptoms: altered mental status, fevers, chills, night sweats,
burning on urination, increased urinary frequency, shortness of
breath, chest pain.
Please take your weight daily.
You will need to follow-up with your primary care doctor within
1 week of discharge.
You are being discharged to a rehab facility to get additional
physical therapy and to complete your course of IV antibiotics.
Followup Instructions:
Please follow-up with your primary care doctor within 1 week of
discharge.
Completed by:[**2181-8-20**]
|
[
"424.0",
"274.9",
"428.0",
"438.11",
"V45.82",
"414.01",
"250.00",
"785.52",
"416.8",
"285.29",
"599.0",
"203.00",
"585.9",
"041.3",
"038.9",
"584.9",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8543, 8608
|
5243, 7073
|
291, 298
|
8801, 8811
|
3131, 5220
|
9461, 9567
|
2612, 2641
|
7341, 8520
|
8629, 8780
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7099, 7318
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8835, 9438
|
1767, 2251
|
2656, 3112
|
222, 253
|
326, 1210
|
1232, 1744
|
2267, 2596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,444
| 191,659
|
46550
|
Discharge summary
|
report
|
Admission Date: [**2132-12-6**] Discharge Date: [**2132-12-12**]
Service: Medicine, [**Doctor Last Name **] Firm
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old
female who was transferred from an outside hospital with a
lower gastrointestinal bleed.
The patient presented to an outside hospital one day prior to
admission after developing persistent and increased bright
red blood per rectum that was associated with
lightheadedness. The patient was unable to quantify how much
blood had passed.
At the outside hospital, the patient was noted to be
hypotensive with systolic blood pressures in the 80s and
heart rate of 60. The patient was treated with 3.5 liters of
crystalloid and 3 units of packed red blood cells. The
patient was also noted to have dynamic changes on his
electrocardiogram.
Prior to Emergency Medical Service, the patient reportedly
passed out. The patient was recently admitted to the
Veterans Administration three weeks prior to admission with a
similar complaint of dark stools for one year. A colonoscopy
that was performed on [**2132-11-30**] at the Veterans
Administration showed internal hemorrhoids, diverticula, and
a bleeding arteriovenous malformation in the ascending colon
that was actively bleeding and was subsequently cauterized.
The patient was discharged to home four days later.
On the day of admission, the patient apparently still had
bright red blood per rectum but denied any chest pain,
shortness of breath, palpitations, abdominal pain, nausea,
vomiting, diarrhea, hematemesis, fevers, chills, cough,
sputum, or lower extremity edema.
The patient was still having persistent dark stools on
admission. The patient reportedly that the bleeding had
stopped after the procedure was done at the outside hospital
but the restarted the day after he was discharged to home.
In the Emergency Department, the patient was typed and
crossed and given fresh frozen plasma and 2 liters of normal
saline. The patient was then subsequently transferred to the
Medical Intensive Care Unit.
PAST MEDICAL HISTORY: (The patient's (Past medical history
is significant for)
1. Coronary artery disease; status post coronary artery
bypass graft.
2. Porcine aortic valve.
3. Hypertension.
4. Basal cell carcinoma.
5. Atrial fibrillation.
6. Gastroesophageal reflux disease.
7. Gout.
8. Urethral stricture.
9. Status post pacemaker placement.
10. Diabetes.
11. Hyperlipidemia.
MEDICATIONS ON ADMISSION: (The patient's medications on
admission were)
1. Nitroglycerin tablets as needed.
2. Aspirin 81 mg by mouth once per day.
3. Lovastatin 20 mg by mouth once per day.
4. Lactulose.
5. Senna.
6. Allopurinol 300 mg by mouth once per day.
7. Hemorrhoid cream.
8. Colace as needed.
9. Iron sulfate.
10. Coumadin 2 mg by mouth at hour of sleep.
11. Metformin 500 mg by mouth every day.
12. Lasix 20 mg by mouth twice per day.
13. Omeprazole 40 mg by mouth once per day.
14. Toprol-XL 50 mg by mouth once per day.
15. Lisinopril 40 mg by mouth once per day.
16. Hydrochlorothiazide 25 mg by mouth once per day.
ALLERGIES: The patient is allergic to BACITRACIN.
FAMILY HISTORY: The patient family history was
noncontributory.
SOCIAL HISTORY: The patient is married and has two
daughters. The patient's does not have a history of any
alcohol, tobacco, or intravenous drug use. The patient
receives all of his care at the [**Hospital1 1474**] Veterans
Administration Hospital. His primary care physician is [**Last Name (NamePattern4) **].
[**Last Name (STitle) 22799**] at the Veterans Administration Hospital.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's vital
signs on admission revealed his blood pressure was 91/41, his
heart rate was 60, his respiratory rate was 17, and his
oxygen saturation was 100% on 2 liters via nasal cannula.
The patient's temperature was 96 degrees Fahrenheit. In
general, the patient an obese elderly gentleman. Head, eyes,
ears, nose, and throat examination revealed the sclerae were
anicteric. The pupils were equal, round, and reactive to
light. The oropharynx was clean and dry. The patient had a
basal cell carcinomatous lesion on his right upper forehead.
Neck examination revealed that the neck was supple. There
was no lymphadenopathy and no bruits. His lung examination
revealed crackles at the bases bilaterally. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. The patient had a 2/6
systolic ejection murmur. There was a midline scar
consistent with his coronary artery bypass graft in the past.
The abdominal examination revealed normal active bowel
sounds. The abdomen was soft, nontender, and nondistended.
There was no hepatosplenomegaly. There were no masses. His
rectal examination revealed brown stool that was mixed with
bright red blood. His extremity examination revealed trace
edema. The pulses were 1+ in the lower extremities. There
were no rashes.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
laboratories on admission were notable for a hematocrit of
24.9 at the outside hospital. At [**Hospital1 190**] the patient's hematocrit was 29.8. At the
outside hospital the patient's creatine kinase was 38 and his
troponin was 0.05. He had an INR of 2.7. The patient's
creatine kinase on admission here at [**Hospital1 190**] was 43. The MB was not done. The troponin
was less than 0.01.
PERTINENT RADIOLOGY/IMAGING: The patient's electrocardiogram
on admission revealed ventricular pacing at 60. There were
ST depressions in leads V3 through V6. There was a biphasic
T wave in leads V4 and V5.
The patient's echocardiogram done in [**2132-11-24**] at the
Veterans Administration remainder unavailable throughout
hospital hospitalization.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
[**Hospital 228**] hospital course was as follows.
1. LOWER GASTROINTESTINAL BLEED ISSUES: The patient
received 6 units of fresh frozen plasma and 6 units of packed
red blood cells during his Medical Intensive Care Unit stay.
The patient's aspirin and Coumadin were on hold for at least
two weeks secondary to his gastrointestinal bleed.
Both the Gastroenterology Service and Surgery Service were
consulted. The patient received a bleeding scan that was
notable for a negative result, and according to the
Gastroenterology Service, the patient was planned for an
outpatient esophagogastroduodenoscopy if the patient remained
stable throughout his hospital stay.
The patient did not have any repeat bleeding throughout his
hospital course, and the patient's hematocrit remained
stable. On admission, his hematocrit was 29. The patient's
hematocrit after the blood transfusions remained stable. The
patient was discharged with a hematocrit of 36.4 on the day
of discharge.
The patient was instructed to follow up at the [**Hospital1 1474**]
Veterans Administration Hospital for an outpatient
esophagogastroduodenoscopy after discharge. The patient also
reported throughout the hospitalization that he had no
further episodes of lightheadedness or dizziness.
2. CARDIOVASCULAR ISSUES: The patient has a history of
coronary artery disease and had dynamic changes on his
electrocardiogram from the outside hospital that was most
likely due to demand ischemia.
The patient's cardiac enzymes were cycled, and the results
were negative for a myocardial infarction. The patient's
antihypertensive medications were held initially throughout
his hospitalization and then restarted on day three of
hospitalization without any complications.
Although the patient was restarted on his beta blocker, and
statin, and ACE inhibitor medications the patient's aspirin
and Coumadin were held secondary to the risk of
gastrointestinal bleeding.
3. CONGESTIVE HEART FAILURE ISSUES: The patient was deemed
to have congestive heart failure exacerbation during his
hospitalization secondary to the extensive fluids and blood
products that were given to the patient for his lower
gastrointestinal bleed. The patient responded very nicely to
intravenous Lasix diuresis.
On the day of discharge, the patient was saturating 93% to
95% on room air and had returned to his baseline weight of
185 pounds.
The patient's pulmonary examination also improved throughout
his hospital course, responding to the Lasix diuresis. On
the day of discharge, the patient's pulmonary examination
revealed that he only had mild crackles bilaterally. The
patient was restarted on his Lasix medication at his
outpatient dose of 80 mg by mouth twice per day on discharge.
The patient was also instructed to weigh himself daily, and
if his weight increased by more than three pounds over two
days he was instructed to take an extra dose of Lasix and see
his primary care physician [**Name Initial (PRE) 2227**].
4. HISTORY OF ATRIAL FIBRILLATION ISSUES: The patient was
rate controlled throughout his hospital stay with a rate of
60 and remained in a normal sinus rhythm throughout his
hospitalization. The patient's anticoagulation with Coumadin
was held throughout his hospital stay secondary to his
gastrointestinal bleed, and the patient was given
instructions to restart his Coumadin after he had seen his
primary care physician in approximately one to two weeks
after he was discharged from the hospital.
5. DIABETES ISSUES: The patient was continued on his
outpatient diabetes medication with Glucophage and
fingerstick checks done four times per day and an insulin
sliding-scale given if necessary. The patient's fingerstick
check remained fairly well controlled throughout his
hospitalization. The patient was discharged on his same
outpatient Glucophage dose.
6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
restarted on a by mouth diet after he was made nothing by
mouth for the bleeding scan and colonoscopy during his
hospitalization. The patient tolerate the by mouth diet and
was advanced to a full regular diet without any
complications.
The patient also developed hyponatremia and a contraction
alkalosis secondary to extensive Lasix diuresis that the
patient received. This contraction alkalosis and
hyponatremia improved over his hospitalization, and when the
patient was discharged his sodium and his bicarbonate were
within normal limits.
7. PROPHYLAXIS ISSUES: The patient was maintained on a
proton pump inhibitor and given pneumatic boots throughout
his hospitalization.
8. CODE STATUS ISSUES: The patient was a full code
throughout his hospitalization.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: The patient's discharge status was to home
with home physical therapy and home [**Hospital6 1587**] to evaluate for safety.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was given very
explicit discharge instructions to follow up with his primary
care physician within one week of discharge and to follow up
with his cardiologist both at the [**Hospital1 1474**] Veterans
Administration Hospital for his congestive heart failure
exacerbation during this hospitalization.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed.
2. Congestive heart failure.
3. Coronary artery disease.
4. Atrial fibrillation.
5. Diabetes mellitus.
MEDICATIONS ON DISCHARGE: (The patient was discharged on the
following medications)
1. Pantoprazole 40 mg by mouth once per day.
2. Allopurinol 300 mg by mouth once per day.
3. Lisinopril 20-mg tablets two tablets by mouth once per
day.
4. Metformin 500 mg by mouth once per day.
5. Metoprolol 50-mg tablets 0.5 tablet by mouth twice per
day.
6. Albuterol and Atrovent nebulizers 1 to 2 puffs inhaled as
needed.
7. Furosemide 80 mg by mouth twice per day.
DISCHARGE DIET: The patient was discharged on a
cardiac-healthy and diabetic diet.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 749**]
MEDQUIST36
D: [**2132-12-15**] 10:17
T: [**2132-12-20**] 02:47
JOB#: [**Job Number **]
|
[
"428.0",
"569.85",
"V45.81",
"414.00",
"427.31",
"411.89",
"V42.2",
"280.0",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3179, 3228
|
11147, 11289
|
11316, 12102
|
2480, 3161
|
10812, 11126
|
5869, 10568
|
10583, 10777
|
152, 2053
|
2076, 2453
|
3245, 5834
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,106
| 159,805
|
2818
|
Discharge summary
|
report
|
Admission Date: [**2110-5-5**] Discharge Date: [**2110-5-15**]
Date of Birth: [**2068-9-7**] Sex: M
Service: MEDICINE
Allergies:
Nitrous Oxide / Bactrim
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
central line placements
paracentesis x 2
History of Present Illness:
41 yo AA M with h/o HIV (dx'd [**2089**]; CD4 147 [**7-2**]; No OIs; on
HAART), chronic Hepatitis B with resultant cirrhosis/ESLD,
thrombocytopenia, DM, and anal condylomata, recently admitted to
[**Hospital1 18**] then seen again in the ED for RLE cellulitis.
.
Yesterday, [**2110-5-4**], he was found down at home in a pool of his
own urine. He was intubated @OSH ED for airway protection and
brought to ape cod hospital where CT demonstrated intasucception
w/SBO, pancolitis, pneumatosis of mid descending colon
suspicious for diffuse ischemic colitis. CT also showed hydropic
gallbladder cirrhosis and small perihepatic ascites. He was
taken to the OR where intasucception was surgically reduced.
There was no evidence of perforation. CXR prior to DC revealed
upper lobe infiltrate.
.
He has been hypoglycemic @ OSH w/BG 40-90. He was given zosyn
for sepsis.
.
OSH spinal tap revealed: glucose 64, protein 63, negative gram
stain, wbc 14, rbc 8556, P33L72. CXR @ OSH was clear. INR on
admission was 3.2
Past Medical History:
HIV, dx'd [**2092**]; CD4 147 [**7-2**]; No OIs; on HAART
Hepatitis B, chronic, c/b cirrhosis/ESLD, currently being eval'd
for transplant candidacy
Hepatitis A
Thrombocytopenia, thought to be from ELSD
Anemia, of chronic inflammation, thought to be from HIV
RLE cellulitis in [**2104**], tx'd with oxacillin then doxacillin
RLE neuropathic pain, meralgia parethetica
Condyloma accuminatum - anal, s/p multiple resections
Allergic rhinitis
Acne vulgaris
Orchitis/epididymitis
Obesity
Bronchitis
Grade II esophagitis
Social History:
Lives at home with his mother in [**Hospital3 **]. Works at Lens
Crafters.
Denies drugs or tobacco. Drinks occasionally. Has hx multiple
tattoos.
Family History:
Father with diabetes.
Physical Exam:
PE:
99.8 SR114 115/47 100% on AC 500X14 w/PEEP5 and FIO2 100%
Intubated, not responding to painful stimuli
Pupils pinpoint; neck supple; sclerae icteric
MMM, mouth and nares w/crusted blood
diffuse ronchi
Nl S1/S2
Obese, distended, midline surgical staples; no BS
wwp X 4; fem line on R
Not responsive. No reflexes.
Pertinent Results:
[**2110-5-5**] 03:40PM FIBRINOGE-123*
[**2110-5-5**] 03:40PM PT-21.8* PTT-38.0* INR(PT)-2.1*
[**2110-5-5**] 03:40PM PLT SMR-LOW PLT COUNT-123*#
[**2110-5-5**] 03:40PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL
[**2110-5-5**] 03:40PM NEUTS-77* BANDS-1 LYMPHS-14* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2110-5-5**] 03:40PM WBC-10.0# RBC-3.11* HGB-8.9* HCT-26.4*
MCV-85# MCH-28.7 MCHC-33.8 RDW-21.7*
[**2110-5-5**] 03:40PM CORTISOL-15.7
[**2110-5-5**] 03:40PM TSH-1.2
[**2110-5-5**] 03:40PM ALBUMIN-2.6* CALCIUM-7.3* PHOSPHATE-5.2*#
MAGNESIUM-2.4 URIC ACID-5.5
[**2110-5-5**] 03:40PM LIPASE-45
[**2110-5-5**] 03:40PM ALT(SGPT)-460* AST(SGOT)-1363* LD(LDH)-1303*
ALK PHOS-156* AMYLASE-165* TOT BILI-6.9*
[**2110-5-5**] 03:40PM GLUCOSE-136* UREA N-26* CREAT-2.0*#
SODIUM-142 POTASSIUM-5.6* CHLORIDE-112* TOTAL CO2-16* ANION
GAP-20
[**2110-5-5**] 05:18PM TYPE-ART PO2-349* PCO2-24* PH-7.45 TOTAL
CO2-17* BASE XS--4
[**2110-5-5**] 05:41PM URINE RBC-[**3-2**]* WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-0 RENAL EPI-0-2
[**2110-5-5**] 05:41PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.034
[**2110-5-5**] 07:59PM CORTISOL-14.5
[**2110-5-5**] 08:15PM TYPE-ART TEMP-37.3 PO2-107* PCO2-27* PH-7.44
TOTAL CO2-19* BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2110-5-5**] 08:47PM CORTISOL-21.9*
[**2110-5-5**] 09:09PM FIBRINOGE-133* D-DIMER-6517*
[**2110-5-5**] 09:09PM PT-21.6* PTT-38.1* INR(PT)-2.1*
[**2110-5-5**] 09:09PM PLT COUNT-103*
[**2110-5-5**] 09:09PM WBC-10.2 RBC-2.78* HGB-7.8* HCT-23.6* MCV-85
MCH-28.3 MCHC-33.2 RDW-22.3*
[**2110-5-5**] 09:09PM CORTISOL-19.9
[**2110-5-5**] 09:09PM HAPTOGLOB-22*
[**2110-5-5**] 10:12PM LACTATE-4.3*
[**2110-5-5**] 10:12PM TYPE-ART TEMP-37.3 PO2-123* PCO2-29* PH-7.41
TOTAL CO2-19* BASE XS--4 INTUBATED-INTUBATED
------------
[**2110-5-10**] CT abdomen/pelvis
MPRESSION:
1. New consolidation or collapse at the left lung base.
2. Significant increase in the amount of ascites.
3. Thickening of small bowel and colonic wall. This is a
nonspecific finding and the differential diagnosis includes
infectious, inflammatory and ischemic processes. However, the
most likely cause is the patient's chronic liver failure. Please
note examination is limited without IV and oral contrast.
4. Distended gallbladder without cholelithiasis or evidence of
cholecystitis.
Brief Hospital Course:
Pt is a 41 yo man with HIV (CD4 257, VL 4780), Hep B (VL > 38
million, cirrhotic) on tenofovir/combivir/abacavir whose present
illness began in early may with a week of diarrhea; subsequently
found unresponsive and incontinent of urine. Brought to OSH
where he was febrile to 102 and hypotensive requiring pressors.
Head CT negative; LP had WBC 14 (N30 L70), RBC 8500, protein 63,
glucose 64. CT of abdomen demonstrated diffuse bowel process
with intussusception; brought to OR at OSH for exlap and
reduction of intussusception (no perf or gangrenous tissue was
visualized). Patinet was treated with Zosyn; Transferred here
for further management on [**5-5**].
Here he was initially treated by MICU with
vanc/cefepime/levo/flagyl/acyclovir. Had negative EEG, CT torso
demonstrated pulmonary infiltrates and colon wall thickening.
Since arrival he appears to have had a postop ileus; no stool
samples have been available for requisite stool studies. He
defervesced, normalized his blood pressure, and was extubated.
On [**5-8**] he was reintubated for bronchoscopy given MICU team
concerns about pulmonary infiltrates; he is now on negative
pressure isolation awaiting serial AFB smears. On [**5-9**] he
developed abdominal distension with an elevated bladder pressure
and surgery was consulted; repeat CT abdomen/pelvis not
particularly revealing. Over the weekend he has been
increasingly distended and developed acute renal failure of
uncertain etiology. He now has enough ascites for the team to
tap.
Issues to deal with:
1. GI process
- needs stool for C dif, microsporidia, cryptosporidia,
isospora, giardia etc
- f/u paracentesis results
2. pulmonary infiltrates
- f/u bronchoscopy cultures
- AFB smears
3. CNS issues; MICU team has asked that HSV PCR be added to OSH
CSF; awaiting this result though I think that this syndrome is
not c/w HSV.
4. Vanc/levo/flagyl are all empiric, I guess for pneumonia
coverage though I'm not so impressed that this is such an active
process, and bowel coverage, until the reason for abdominal
distension gets sorted out, and for C dif.
5. HIV/Hep B
ARVs held with new renal failure--will need to determine when
they can be resumed
Anemia, of chronic inflammation, thought to be from HIV
RLE cellulitis in [**2104**], tx'd with oxacillin then doxacillin
RLE neuropathic pain, meralgia parethetica
Condyloma accuminatum - anal, s/p multiple resections
Allergic rhinitis
Acne vulgaris
Orchitis/epididymitis
Obesity
Bronchitis
Grade II esophagitis
DM
.
Social History:
Lives at home with his mother in [**Hospital3 **]. Works at Lens
Crafters. Denies drugs or tobacco. Drinks occasionally. Has hx
multiple tattoos.
.
Family History:
Father with diabetes.
.
PE:
99.8 SR114 115/47 100% on AC 500X14 w/PEEP5 and FIO2 100%
Intubated, not responding to painful stimuli
Pupils pinpoint; neck supple; sclerae icteric
MMM, mouth and nares w/crusted blood
diffuse ronchi
Nl S1/S2
Obese, distended, midline surgical staples; no BS
wwp X 4; fem line on R
Not responsive. No reflexes.
.
Labs: See end of note
.
Micro: Obtained
.
ECG: Pending
.
CXR: NGT high. ?ETT high. No infiltrates or edema.
.
A/P: 41M w/HIV, ESLD admitted s/p reduction of intasucception
appearing septic.
.
Septic shock- Will obtain cultures of blood (including
mycolitic), urine, sputum (inc PCP and DFA), and stool. Will
obtain [**Last Name (un) 104**] stim test. Will continue IVF resucitation and once
central access obtained, will transduce CVP. Will cont levophed
for goal MAP of >60 and >20cc/hr UOP. Will cover empirically
with zosyn pending culture results. Will check TTE.
.
ESLD- MELD 29. Hypoglycemia very concerning. Will obtain liver
consult. Checking LFTs, coags, CBC.
.
Unresponsiveness- Possible contributors include ammonia from
ESLD, sepsis, uremia, nonconvulsive status. Obtaining labs,
treating sespsis as above. Will obtain EEG. When able to give
POs (no BS now), will give lactulose.
.
Anemia- Checking crit and xfusing to crit >25. Will obtain
further studies as appropriate per MCV, clinical scenario.
.
Respiratory failure- Obtaining CXR for ETT position and to
evaluate for PNA.
.
[**Name (NI) 10271**] Unclear if this is new baseline [**1-30**] HIV and ESLD. Likely
contribution from sepsis. Rxing sepsis as above.
.
Thrombocytopenia- Likely [**1-30**] ESLD and HIV. Will xfuse to plt>10,
>50 prior to procedures, or if bleeding.
.
Access- Has PIV and TLC in femoral position from OSH. Will look
to resite TLC this evening.
.
Code- Presumed full. Awaiting family contact.
.
Contact- [**Name (NI) **] contact family to confirm code status and obtain
ICU consent.
.
PPx- Pneumoboots, PPI, elevate HOB.
.
Dispo- ICU
Neuro:
Reason for consult: Comatose, ? seizures as etiology
41 year old male with HIV (CD4 161, VL 582 [**9-2**]) on HAART, HBV
cirrhosis (VL 6.58 million [**9-2**]) with ESLD (previously on
transplant list but not compliant), ascites, DM2, anal
condylomata s/p resection, admitted to [**Hospital3 **] Hospital on [**5-4**]
after found unresponsive w/ urinary incontinence at home. No hx
of seizure or CNS infection indicated in the records we have
available at present. At OSH had wbc 11, plt 56, acidotic with
bicarb 12, lft's mildly elevated (alt 81, ast 190, alk phos
181), ammonia 223, tox negative (acetaminophen <5). LP with
Glucose 64, Protein 63, 8000 RBC, 14 WBC (33 seg/72 lymph). Head
CT negative for infarct, bleed, edema (we have CT here). CT
abdomen revealed mid-small bowel intussusception, pneumatosis of
mid-descending colon suspicious for diffuse ischemic colitis.
S/p ex-lap on [**5-5**] during which intussusception reduced (no
gangrene). Med-flighted to [**Hospital1 18**] on [**5-5**], on levophed and zosyn.
Here his LFT's are much more elevated with ALT 460. AST 1363,
LDH 1303. Lactate is 4.3. Repeat tox screen negative. Wbc 10
with 77 segs, 1 band. Hct 23.6. Coagulopathic with INR 2.1,
fibrinogen 133, D-dimer 6517. BUN/Cr 26/2.0. Pressors d/c'd
since arrival. Reportedly bit his tongue about 8 pm on [**5-5**], per
nurse not associated with discrete episode of hypertension,
tachycardia, or other change in status.
.
41M w/HIV, ESLD admitted to outside hospital after being found
down; there had surgical reduction of intestinal
intussusception.
was transferred to MICU with sepsis of unclear source, liver
failure,
and acute renal failure.
.
## Shock: patient developed progressive shock during the course
of his stay. Toward the end of his hospital course, he was
placed on on levophed/vasopressin/dopamine for HD support.
hypovolemic as evidenced by low CVPs. Patient becameAnuric.
CVPs16-17 after boluses of IVF. Lactate trending up
(10.8)--likely ischemic gut [**1-30**] abd compartment syndrome.
patient was also placed on stress dosed steroids. He was
treated with antibiotics as above. CVVHD was also started due
to the patient's anuria, but was d/c'd due to hypotension.
Repeated boluses of albumin failed to bring up the patient's
blood pressure so the patient had to remain on pressors for the
rest of the hospital course prior to withdrawal of care.
.
## Abdominal distension. during the course of his stay, patient
appeared to develop compartment syndrome of the abdomen. Pt.
likely w/ progressive ascites w/ some distended bowel. US guided
tap was attempted but terminated [**1-30**] proximity of the liver to
the pocket of ascites. Pt has increased bladder pressures
suggestive of compartment syndrome. Surgery consutled decided
against any intervention due to to patient's very morbid
prognosis. No futher intervention was made regarding this issue
until the patient expired on [**2110-5-15**].
.
## Respiratory failure: Pt was originally intubated and remained
intubated [**1-30**] mental status changes. Gases were looking fine up
until the end of the hospital course when patient developed
lactic acidosis. Was extubated and then required reintubation
[**1-30**] need for bronch given CT findings of upper lobe infiltrates
concerning for TB. Has multifocal pna on CT scan and has been
ruled out for TB based on smears. Remains intubated for mental
status as well as resp. failure. BAL was NGTD. Patient was
terminally extubated when the decision to withdraw care was made
together with the family.
.
## ARF: [**1-30**] ATN due to hypoperfusion, ischemia due to current
abdominal compartment syndrome. ddx includes hepatorenal syn.
Dialysis line was placed and CVVHD was started but stopped soon
after due to low blood pressures. FeNa 5% suggesting ATN, going
against hepatorenal or prerenal. r
.
## MS changes: Likely [**1-30**] hepatic ddx hypoxic encephalopathy
from hypotension/ ddx hepatic encephalopathy. With INR 17,
intracranial hemorrhage is also a possibility. Head CT neg (in
past). No seizures on EEG per neuro. Patient's mental status
failed to improve during the hospital stay. Responsible factors
included hypoxic encephalopathy in addition to hepatic
encephalopathy.
.
## Hep B cirrhosis
Severe transaminitis on admission , treding down, with second
peak recently upon worsening of the abdominal compartment
syndrome. Initial transaminitis likely due to shock liver in
setting of hypotension. Now LFTs trending down likely that the
liver has "burned out." patient odes have distended GB, ?
acalculous cholecystitis, ? perc chole brought up, but procedure
too risky [**1-30**] cirrhosis and underlying coagulopathy. Serologies
were sent, -+ hep b s ag, HBV VL>38K, sending e ag (pending at
the time of death).
.
## Coagulopathy: toward the end of this [**Hospital 228**] hospital stay,
he developed DIC/liver dysfx - low fibrinogen, elev DDIMER, high
INR, schistiocytes on smear. INR getting worse QD. likely due to
combo of sepsis/DIC and ESLD. Replete with cryoppt/FFP if facing
hemostatic challenge or bleeding spontaneously. Supplementing
vitamin K per liver recs was ineffective. Blood products were
transfused.
.
Code- s/p family meeting. CPR not indicated: DNR/DNI. When
family arrived on [**2110-5-15**], after extensive discussion including
the patient's grave prognosis, mental status, and virtually no
chance of recovery due to patient's multi-system organ failure,
a decision to switch goals of care to comfort was made.
Pressors were weaned off, patient was kept comfortable and
expired shortly thereafter. Autopsy was declined.
Discharge Disposition:
Expired
Discharge Diagnosis:
hypoxic encephaolopathy
multifocal pneumonia
end stage liver disese
liver failure
multi-system organ failure
abdominal compartment syndrome
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2110-6-25**]
|
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"276.7",
"280.0",
"571.5",
"599.0",
"507.0",
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"276.52",
"570",
"557.0",
"995.92",
"348.31",
"785.52",
"250.80",
"997.99",
"070.30",
"584.5",
"518.81",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.15",
"38.93",
"00.17",
"99.07",
"96.04",
"39.95",
"54.91",
"96.6",
"96.72",
"38.95",
"33.24",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15249, 15258
|
4968, 7458
|
298, 340
|
15441, 15450
|
2470, 4945
|
15502, 15536
|
7638, 15226
|
15279, 15420
|
15474, 15479
|
2133, 2451
|
242, 260
|
368, 1377
|
1399, 1915
|
7474, 7622
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,924
| 139,887
|
7818+7819
|
Discharge summary
|
report+report
|
Admission Date: [**2127-8-17**] Discharge Date: [**2127-9-2**]
Date of Birth: [**2050-10-10**] Sex: M
Service: CCU Medicine
ADMITTING DIAGNOSIS: Congestive heart failure exacerbation.
HISTORY OF PRESENT ILLNESS: The patient was a 76 year old
male with increasing shortness of breath and paroxysmal
nocturnal dyspnea for a week who was in an outside hospital
until one month ago where he noted increasing shortness of
breath. The patient also notes an irregular heartbeat. The
patient reports increasing paroxysmal nocturnal dyspnea over
the past week and increasing shortness of breath and
increasing pedal edema without any chest pain. The patient
was seen by his primary care physician and Dr. [**Last Name (STitle) **] and
was admitted from home for heparin, transesophageal
echocardiogram and cardioversion on Monday.
PAST MEDICAL HISTORY: New onset atrial fibrillation,
hypertension, coronary artery disease status post coronary
artery bypass graft in [**2118**], chronic renal insufficiency,
congestive heart failure with an ejection fraction of 38%.
Gout. Automatic implanted cardioverter defibrillator with
biventricular pacing. Hypercholesterolemia. Status post
left carotid endarterectomy. Status post left renal stent.
ALLERGIES: No known drug allergies.
MEDICATIONS: Terazosin 4 a day, Cozaar 50 a day, Coreg 12.5
b.i.d., Allopurinol 100 a day, Aspirin 81 q. day, Lasix 80
b.i.d., Lipitor 40 q. day, Isosorbide 60 AM, 30 PM and Senna
6 q.h.s.
SOCIAL HISTORY: The patient has a 25 year two pack per day
smoking history with occasional alcohol and intravenous drug
abuse.
PHYSICAL EXAMINATION:
Vital signs: 110/80, 66, 20 and 95% on room air.
General: Obese male sitting in bed in no apparent distress.
Neck: 12 cm jugulovenous distension at 90 degrees.
Heart: Irregularly irregular, no murmurs or gallops.
Lungs: Clear to auscultation bilaterally, no rales.
Abdomen: Obese, positive bowel sounds, distended.
Extremities: 2+ pedal edema bilaterally.
LABORATORY DATA: Pertinent laboratory data revealed
echocardiogram on [**2127-8-28**] showed left ventricular
ejection fraction of 30%, 2+ mitral regurgitation which may
be underestimated with a biventricular pacemaker.
Electrocardiogram and chest x-ray were pending.
HOSPITAL COURSE: 1. Cardiovascular - Coronary-wise, the
patient has coronary artery disease, status post coronary
artery bypass graft in [**2118**] with an occluded saphenous vein
graft, right coronary artery. The patient was continued on
Aspirin and Lipitor. The patient initially was hypotensive
and his beta blocker was held until his blood pressure
continued to rise. The patient was ruled out for myocardial
infarction with three negative cardiac enzymes and was on a
heparin drip at that time.
Pump, congestive heart failure with ejection fraction of 38%.
Transesophageal echocardiogram showed ejection fraction of
15% with mitral regurgitation and left bundle branch block.
Biventricular pacer with implantable cardioverter
defibrillator was placed. For his decompensated congestive
heart failure the patient was kept on Dopamine and Dobutamine
and all other blood pressure medications were held. The
patient was diuresed effectively with a combination of
Dopamine and Dobutamine and Lasix. The patient was fully
weaned off of the Dopamine and Dobutamine on [**8-23**],
and the patient was then transferred to C-MED. The patient
continued to diurese with decreasing oxygen requirements,
however, the patient was transferred back to the Coronary
Care Unit on [**2127-8-31**] at which point the patient
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-932
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2127-10-9**] 08:04
T: [**2127-10-9**] 08:20
JOB#: [**Job Number 28252**]
eo
Admission Date: [**2127-8-17**] Discharge Date: [**2127-9-2**]
Date of Birth: [**2050-10-10**] Sex: M
Service: CCU Medicine
ADMISSION DIAGNOSIS: Congestive heart failure exacerbation.
HISTORY OF PRESENT ILLNESS: Patient is a 76-year-old male
with increasing shortness of breath and PND for a week, who
was in outside hospital until a month ago, where he noted
increasing shortness of breath. Patient also noted some
irregular heartbeat. The patient reports increasing PND over
the past week, increasing shortness of breath and increasing
pedal edema without any chest pain.
Patient was seen by his PCP and Dr. [**Last Name (STitle) **] and was
admitted from home for Heparin, transesophageal
echocardiogram, and cardioversion on Monday.
PAST MEDICAL HISTORY:
1. New onset afib.
2. Hypertension.
3. CAD status post CABG in '[**18**].
4. CRI.
5. CHF with an ejection fraction of 30%.
6. Gout.
7. AICD with [**Hospital1 **]-V pacing.
8. Hypercholesterolemia.
9. Status post left CEA, status post left renal stent.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Terazosin 4 a day.
2. Cozaar 50 a day.
3. Coreg 12.5 b.i.d.
4. Allopurinol 100 a day.
5. Aspirin 81 q.d.
6. Lasix 80 b.i.d.
7. Lipitor 40 q.d.
8. Isosorbide 60 a.m. and 30 p.m.
9. Senna 6 q.h.s.
SOCIAL HISTORY: Patient 25 year two packs per day smoking
history, occasional alcohol, and no IV drug abuse.
PHYSICAL EXAMINATION: Vital signs: 110/80, 66, 20, and 95%
on room air. General: Obese male sitting in bed in no
apparent distress. Neck: 12 cm JVD at 90 degrees. Heart:
irregularly, irregular, no murmurs or gallops. Lungs are
clear to auscultation bilaterally, no rales. Abdomen:
Obese, positive bowel sounds, distended. Extremities: 2+
pedal edema bilaterally.
PERTINENT LABORATORIES: Echocardiogram on [**12-30**] showed left
ventricular ejection fraction of 30%, 2+ MR, which maybe
underestimated with a [**Hospital1 **]-V pacemaker. EKG and chest x-ray
are pending.
CONCISE SUMMARY OF HOSPITAL COURSE:
1. Cardiovascular: Coronary wise, the patient has coronary
artery disease status post CABG in '[**18**] with occluded SVG and
RCA. Patient was continued on aspirin and Lipitor. Patient
initially was hypotensive and his beta blocker was held until
his blood pressure continued to rise. The patient was ruled
out for MI with three negative cardiac enzymes, and was on a
Heparin drip at that time.
2. Pump: CHF with an ejection fraction of 30%.
Transesophageal echocardiogram showed an ejection fraction of
15% with MR and left bundle branch block. [**Hospital1 **]-V pacer with
ICD was placed. For the decompensated CHF, the patient was
kept on dopamine and dobutamine, and all other blood pressure
medications were held, and patient was diuresed effectively
with the combination of dopamine and dobutamine, and Lasix.
Patient was fully weaned off the dopamine and dobutamine on
[**8-23**], which the patient was then transferred to [**Hospital Unit Name 196**].
Patient continued to diurese with decreasing O2 requirements.
However, patient was transferred back to the CCU on [**2127-8-31**]
at which point, patient creatinine had rise from 2.5 to 3.2,
and patient also had mental status changes with increasing
shortness of breath. Patient was again started on a dopamine
and dobutamine combination with Lasix. Patient then fell
into cardiogenic shock, and in addition, the patient went
into septic shock.
Additionally to this regimen, digoxin was added. Patient,
however, was not able to tolerate his ongoing cardiogenic
shock and septic shock and passed away on [**2127-9-2**] which
patient had no spontaneous respirations. Cause of death is
cardiogenic and combined septic shock.
2. Renal: Patient had chronic renal insufficiency with
bilateral renal artery stenosis. His creatinine had risen
from 2.5 to 3.5. Again, Renal was consulted at this time,
however, due to cardiac issues, patient had further renal
insult with the Lasix, dopamine, and dobutamine combination,
patient however, passed away before his renal issues
resolved.
3. ID: Patient went into septic shock with WBCs increasing
to 45 and temperature up to 102 when transferred back to the
CCU. Patient was started on Levaquin and Flagyl for
aspiration community acquired pneumonia. Patient, however,
passed away secondary to cardiogenic and septic shock before
this issue resolved.
4. GI: Patient while on the [**Hospital Unit Name 196**] service had colonic
pseudo-obstruction, which was resolving. A rectal tube was
placed temporarily to help the colonic pseudo-obstruction.
However, patient remained pseudo-obstructed when the patient
passed away.
5. Pulmonary: Please see cardiac note.
DISCHARGE STATUS: Patient again passed away and no autopsy
was done.
CAUSE OF DEATH: Likely cardiogenic and septic shock.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2127-10-9**] 08:04
T: [**2127-10-9**] 08:27
JOB#: [**Job Number 28252**]
|
[
"038.9",
"599.7",
"424.0",
"428.0",
"560.89",
"585",
"427.31",
"584.5",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.48",
"88.72",
"99.62",
"00.13",
"38.93",
"96.09"
] |
icd9pcs
|
[
[
[]
]
] |
2296, 3963
|
5841, 8876
|
5242, 5813
|
3985, 4025
|
4054, 4583
|
167, 207
|
4605, 5108
|
5125, 5219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,822
| 181,173
|
39696
|
Discharge summary
|
report
|
Admission Date: [**2157-9-26**] Discharge Date: [**2157-10-4**]
Date of Birth: [**2095-10-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
9cm Abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2157-9-26**] Abdominal aortic aneurysm repair with aortobi-
iliac graft.
History of Present Illness:
The patient is a 61-year-old male with a recently thrombosed
popliteal aneurysm that was repaired operatively. During the
course of the workup he was also
discovered to have a large 9.5 cm infrarenal aortic aneurysm. He
was not an endovascular candidate due to inadequate infrarenal
neck. He presents at this time for operative repair.
Past Medical History:
PAST MEDICAL HISTORY: HTN HLD DM Umbilical hernia
PAST SURGICAL HISTORY: Melanoma resection
Social History:
Lives with wife, has 3 children
Smoking 2ppd
Social ETOH
Works as store assistant
Family History:
Both maternal and paternal grandfathers died of MI
Physical Exam:
Vital Signs: Temp: 98.7 HR 53 BP: 155/76 RR: 15 Spo2:
95%
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Normal respiratory effort, abnormal: B/l mild wheezes.
Gastrointestinal: Non distended, No masses, abnormal: Obese,
pulsatile mass in mid abdomen.
Rectal: Abnormal: Guiac neg, normal rectal tone.
Extremities: No [**Month/Day/Year **] edema, No LLE Edema, abnormal: Large R
popliteal aneurysm, L popliteal prominent. [**Month/Day/Year **]: patchy mottling
from below the knee to toes, no change in sensation but mild
weakness at the ankle.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P. Ulnar: P. Brachial: P.
LUE Radial: P. Ulnar: P. Brachial: P.
[**Month/Day/Year **] Femoral: P. Popliteal: P. DP: D. PT: P.
LLE Femoral: P. Popliteal: P. DP: P. PT: P.
Left flank incision CDI, without eythema, + flank edema
Pertinent Results:
[**2157-10-3**] 08:45AM BLOOD WBC-8.4 RBC-3.76* Hgb-11.3* Hct-33.3*
MCV-89 MCH-29.9 MCHC-33.8 RDW-14.8 Plt Ct-228
[**2157-10-1**] 07:00AM BLOOD WBC-6.3 RBC-3.17* Hgb-9.7* Hct-28.7*
MCV-91 MCH-30.6 MCHC-33.8 RDW-14.6 Plt Ct-172
[**2157-9-30**] 05:13AM BLOOD WBC-7.5 RBC-3.04* Hgb-9.3* Hct-27.1*
MCV-89 MCH-30.5 MCHC-34.3 RDW-14.8 Plt Ct-130*
[**2157-9-26**] 09:30PM BLOOD Neuts-86* Bands-7* Lymphs-5* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2157-10-3**] 08:45AM BLOOD Plt Ct-228
[**2157-10-1**] 07:00AM BLOOD Plt Ct-172
[**2157-9-30**] 05:13AM BLOOD Plt Ct-130*
[**2157-10-3**] 08:45AM BLOOD Glucose-174* UreaN-15 Creat-0.8 Na-138
K-4.5 Cl-96 HCO3-33* AnGap-14
[**2157-10-2**] 10:15AM BLOOD Glucose-214* UreaN-16 Creat-0.9 Na-141
K-3.8 Cl-98 HCO3-33* AnGap-14
[**2157-10-1**] 05:15PM BLOOD Glucose-111* UreaN-17 Creat-1.0 Na-137
K-3.6 Cl-100 HCO3-28 AnGap-13
[**2157-9-28**] 11:49AM BLOOD CK(CPK)-1228*
[**2157-9-26**] 11:29PM BLOOD CK(CPK)-726*
[**2157-10-3**] 08:45AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
[**2157-10-1**] 05:15PM BLOOD Calcium-8.3* Phos-3.1 Mg-1.7
[**2157-9-28**] 03:31PM BLOOD Type-ART pH-7.40 Comment-GREEN TOP
[**2157-9-28**] 03:31PM BLOOD K-4.2
[**2157-9-27**] 09:29PM BLOOD Glucose-109* K-4.1
[**2157-9-27**] 01:45PM BLOOD Glucose-153*
[**2157-9-27**] 12:46PM BLOOD Glucose-150* K-4.7
[**2157-9-27**] 09:42AM BLOOD Glucose-121* K-3.1*
[**2157-9-27**]
Final Report
HISTORY: AAA repair, to assess for pulmonary status.
FINDINGS: In comparison with the study of [**9-26**], the tip of the
endotracheal
tube is at the upper clavicular level, approximately 7.3 cm
above the carina.
Right IJ Swan-Ganz catheter is in the right pulmonary artery.
Nasogastric
tube extends to the upper stomach with the side hole above the
esophagogastric
junction.
Continued low lung volumes may account for the mild prominence
of the
transverse diameter of the heart. Atelectatic changes are seen
in the
retrocardiac region and at the right base. The right
costophrenic angle is
now clear and there is no evidence of opacification along the
right lateral
chest wall.
Brief Hospital Course:
[**2157-9-26**] Patient was admitted for a scheduled open AAA repair for
known 9cm aneurysm. Post operatively he was is the PACU
overnight and required ventilation. He had episodes of
hypotension overnight and required fluids and 2 units of PRBC
for surgical acute blood loss and anemia. Epidural infusing and
covering pain. Transferred to ICU, APS following. Pedal pulses
palpable on [**Last Name (LF) **], [**First Name3 (LF) **] Doppler on left. Aline, swan on POD #1. On
propofol drip and vent [**2157-9-27**]. Vent settings weaned POD #2,
extubated. Pain under good control with epidural. Received 1
additional unit of PRBC. Ace wrap to [**Month/Day/Year **] for edema. NGT tube to
suction draining with bilious drainage. [**2157-9-29**] patient was
transferred to VICU. NGT dc'ed and tolerating diet. Labs stable.
Epidural DC'ed. Patient diuresis ed with Lasix IV daily for goal
negative 1Liter daily. Physical therapy following. [**2157-10-4**]
Discharged to Rehab in stable condition. Diureis with oral lasix
as needed should be continued with daily labs checked.
Medications on Admission:
: Carvedilol 25'', Digoxin 0.125', Lisinopril 20', Metformin
1000', Glipizide 5', Simvastatin 10', Aspirin 81'
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. hydromorphone 2 mg/mL Syringe Sig: [**12-25**] Injection Q3H (every
3 hours) as needed for breakthrough pain.
11. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. 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*
13. metformin 500 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
14. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Insulin Sliding Scale
Q4H
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
> 350 mg/dL Notify M.D.
16. Lasix 20 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for diuresis: Please give prn for continued diuresis - admit
weight 104, dc weight 96kg.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
9cm AAA
PMH:
Hypertension
Diabettes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 [**5-31**]
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 [**1-26**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2157-10-18**] 1:00
Completed by:[**2157-10-4**]
|
[
"997.4",
"458.29",
"441.4",
"412",
"401.9",
"444.0",
"285.1",
"E878.2",
"250.00",
"560.1",
"V58.67",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
7246, 7320
|
4318, 5391
|
345, 423
|
7400, 7400
|
2218, 4295
|
10267, 10451
|
1022, 1075
|
5553, 7223
|
7341, 7379
|
5418, 5530
|
7551, 9814
|
9840, 10244
|
885, 906
|
1090, 2199
|
276, 307
|
451, 789
|
7415, 7527
|
833, 862
|
922, 1006
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,486
| 108,125
|
48456
|
Discharge summary
|
report
|
Admission Date: [**2198-3-29**] Discharge Date: [**2198-4-5**]
Date of Birth: [**2133-2-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
leukocytosis
Major Surgical or Invasive Procedure:
Radiation therapy
Hemodialysis
History of Present Illness:
64 M with MMP including CHF, DVT, ESRD on HD, metastatic poorly
differentiated CA, likely NSLCA. He is s/p multiple recent
admissions, most recently from [**3-7**] - [**2198-3-22**] for respiratory
failure requiring intubation, thought due to volume overload
from a missed HD session.
.
He was d/c'ed to rehab on [**3-22**]. Per the patient, he has been
improving at rehab, gaining strength. He has had continued cough
occasiionally productive of a rusty-colored sputum associated
with some dyspnea on exertion, though he is not able to quantify
the amount of exertion required. He denies rest dyspnea, and
denies orthopnea or PND. Aside from the rust-colored sputum, he
denies any frank hemoptysis. He has not had any chest pain, n/v,
f/c/s.
.
He was at [**Location (un) **] hemodialysis where he was noted to have a Hb of
7.1, and sent in to the [**Hospital1 18**] ED for evaluation.
.
In ED, he denied any symptoms including CP, SOB, LH, or fatigue.
A laboratory evaluation revealed a Hb of 7.9 and Hct 27.0 (Hct
prior to discharge appears 26-28, though last Hct 35.4 but no
evidence of transfusion). Labs also remarkable for WBC of 22
with a poly predominance. CXR showed a new left basilar opacity,
thought to represent atelectasis vs infection. He was ordered
for 2U pRBCs, vanco, levoflox, and cefepime.
.
Currently, his only complaint is his chronic neck pain, which is
less well controlled this morning because he may have missed a
dose of his pain medication.
Past Medical History:
#. Onc HX: [**12-11**] pre-renal transplant CT scan chest noted
enlarged RML nodule, w/ subcentimeter FDG avid scattered lymph
nodes. Developed neck pain and found to have C2 pathological
fracture, [**11-22**] cytology demonstrated poorly differentiated
carcinoma. Likely non-small cell lung carcinoma, with RML mass
and metastasis to the cervical and sacral spine. The only
manifestation of his disease currently is cervical neck pain,
s/p pathologic fracture and posterior cervical arthrodesis C1-C3
and palliative XRT.
#. Left Common Femoral DVT: small non-occlusive, possibly
chronic DVT and started on coumadin for a goal INR [**1-7**] in [**1-/2198**]
#. CAD s/p angioplasty D1 [**7-10**] and stents to OM2/3 in [**3-11**]
#. ESRD secondary to FSGS on HD (MWF)
#. Hypertension
#. LLE peroneal nerve palsy [**1-6**] GSW to L leg
#. Thalassemia trait
#. h/o Substance abuse (heroin/cocaine); reports none since [**2163**]
#. CHF w/ EF 35% in [**11-11**], EF 25-30% on [**Date Range 113**] [**2198-1-23**]
#. MR - 2+ on [**Month/Day/Year 113**] in [**11-11**]; now found to be 3+ MR [**First Name (Titles) **] [**Last Name (Titles) 113**]
#. Pathological C2 Fx s/p C1-3 Fusion
#. Parotiditis - [**12-12**] (levo/flagyl)
#. CDiff - [**12-12**]
#. HCV - grade 1 inflammation and stage 0 fibrosis on bx [**2-9**]
Social History:
He was discharge to rehab on [**3-22**]. Patient does not recall where
he is still at rehab, or has been discharged from rehab.
However, he does not think he has been home since. He is
married, with 2 sons. Used to work in construction, + smoker 1
PPD for many years quit recently, rare ETOH, no drugs.
Family History:
Brother with CAD, and kidney disease requiring hemodialysis
Physical Exam:
Vitals - T 98.3, BP 116/72, HR 76, RR 18, O2 sat 97% RA (MD
check)
General - chronically ill appearing male; speech is slow, but
responses are appropriate
HEENT - PERRL, EOMI, OP clr, MM dry, no JVD
CV - RRR, [**2-8**] syst mur
Chest - CTAB
Abdomen - soft, NT/ND, no g/r
Back - gluteal region with stage 2 ulcers
Extremities - Left AV fistula bandaged, c/d/i, with palpable
thrill
Neuro - Oriented to hospital ([**Hospital3 **]) and [**2198-3-6**] (did
not know date).
rectal tone absent, decreased sensation to pinprick in LEs, no
saddle anesthesia to LT. 3/5 strength in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. R
foot internally rotated. Unable to walk. toes upgoing
bilaterally. reflexes not tested.
Pertinent Results:
[**2198-3-29**] 12:10PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2198-3-29**] 12:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2198-3-29**] 12:10PM URINE RBC-[**5-15**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**2-7**]
[**2198-3-29**] 09:35AM GLUCOSE-99 UREA N-27* CREAT-3.0* SODIUM-137
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-30 ANION GAP-17
[**2198-3-29**] 09:35AM CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-1.5*
[**2198-3-29**] 09:35AM WBC-19.6* RBC-3.29* HGB-8.1* HCT-26.2*
MCV-80* MCH-24.5* MCHC-30.8* RDW-17.9*
[**2198-3-29**] 09:35AM PLT COUNT-277
[**2198-3-29**] 09:35AM PT-24.8* PTT-31.4 INR(PT)-2.4*
[**2198-3-29**] 02:19AM TYPE-ART PO2-140* PCO2-47* PH-7.50* TOTAL
CO2-38* BASE XS-12 INTUBATED-NOT INTUBA
[**2198-3-28**] 10:47PM COMMENTS-GREEN TOP
[**2198-3-28**] 10:47PM LACTATE-2.4*
[**2198-3-28**] 09:15PM GLUCOSE-94 UREA N-20 CREAT-2.3*# SODIUM-141
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-34* ANION GAP-14
[**2198-3-28**] 09:15PM estGFR-Using this
[**2198-3-28**] 09:15PM WBC-21.7* RBC-3.49* HGB-7.9*# HCT-27.0*
MCV-77* MCH-22.7* MCHC-29.3* RDW-18.1*
[**2198-3-28**] 09:15PM NEUTS-89.3* BANDS-0 LYMPHS-5.4* MONOS-2.0
EOS-3.3 BASOS-0.1
[**2198-3-28**] 09:15PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ OVALOCYT-1+ TARGET-1+
STIPPLED-1+ TEARDROP-1+
[**2198-3-28**] 09:15PM PLT SMR-NORMAL PLT COUNT-315
[**2198-3-28**] 09:15PM PT-24.1* PTT-30.7 INR(PT)-2.3*
65 year old man with high white count
REASON FOR THIS EXAMINATION:
eval for pna
INDICATION: 65-year-old male with high white count. Please
evaluate for pneumonia.
FINDINGS: Single portable upright chest radiograph is reviewed
and compared to [**2198-3-15**], and to CTA of the chest from [**2198-1-21**].
Cardiomediastinal silhouette is unchanged. Multifocal areas of
opacity scattered throughout both lungs are largely similar to
previous exam, and consistent with metastatic lung cancer.
Dominant right hilar mass is similar in appearance. There is new
streaky opacity at the left lung base, with associated volume
loss, which may represent atelectasis, although underlying
infectious process cannot be excluded. There is no pleural
effusion or pneumothorax. Radiopaque density projecting over the
upper thoracic spine is unchanged in appearance, maybe related
to prior vertebroplasty.
IMPRESSION:
1. New left basilar streaky airspace opacity and volume loss,
may represent atelectasis, although this is concerning for
underlying infection in the appropriate clinical setting.
2. Unchanged appearance of multifocal opacities consistent with
metastatic lung cancer, and dominant right hilar mass.
=======
MR L SPINE W/O CONTRAST [**2198-3-29**] 5:33 PM
MR L SPINE W/O CONTRAST
Reason: eval for cauda equina syndrome, extent of bony mets with
gad
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with bony metastases known to C,L,S spine, now
with decreased rectal tone and urinary retention
REASON FOR THIS EXAMINATION:
eval for cauda equina syndrome, extent of bony mets with
gadolinium
CONTRAINDICATIONS for IV CONTRAST: esrd, will advise renal, pt
to get dialysis post-procedure
INDICATION: 65-year-old with diffusely metastatic adenocarcinoma
and now with decreased rectal tone and urinary incontinence.
Evaluate for cauda equina syndrome.
COMPARISON: MRI of the lumbar spine, [**2197-11-15**].
TECHNIQUE: Sagittal T1, T2, and STIR as well as axial T1 and T2
images through the sacrum were obtained.
FINDINGS: There has been interval development of extensive tumor
infiltration of the sacrum since the prior exam of [**Month (only) 1096**]
[**2196**]. Previously, the patient had a capacious thecal sac
extending into the sacrum. Now there is extensive tumor
infiltration throughout the sacrum, which obliterates the spinal
canal at L5-S1 and presumably infiltrates the nerve roots below
this level. Tumor extends beyond the bony confines of the sacrum
into the posterior soft tissues (5:30). The iliac wings appear
unaffected, and the sacroiliac joints are intact. There is a
defect within the left iliac [**Doctor First Name 362**] posteriorly with T1
hypointense scar tissue extending to the skin consistent with
the patient's prior graft donor site.
The visualized portion of the lumbar spine is unremarkable with
no abnormal signal intensity within the vertebral bodies, conus,
or cauda equina. There is mild edema in the inferior endplate of
L5 and disc desiccation at L5- S1, likely degenerative. The
L5-S1 disc bulges into the sac causing mild indentation of the
thecal sac ventrally.
IMPRESSION: Extensive tumor infiltration of the sacrum with
obliteration of the thecal sac (and presumably the nerve roots)
below the L5-S1 level.
Brief Hospital Course:
64yo M with metastatic poorly differentiated CA, likely NSLCA,
CHF, DVT, ESRD on HD, here with urinary retention/UTI and
compression of sacral nerve roots [**1-6**] metastatic dz.
.
# Cauda equina syndrome. Pt. arrived on floor with sx. of
urinary retention with 1.2L upon straight cath. Further
neurologic exam revealed LE weakness, decreased sensation and
absent sphincter tone. Stat MRI showed sacral involvment of
metastasis and compression of sacral roots. Radiation Oncology
consulted who arranged for emergent radiation therapy with
planned mapping [**2-27**] AM. Decadron initiated as well. The
patient completed a course of radiation therapy by [**2198-4-5**].
Dexamethasone taper has been started on discharge.
Unfortunately, his leg weakness has persisted despite maximal
therapy.
.
# Anemia - Hct 27.0 in ED here, not clearly different from his
baseline during his recent admission. He already received 1U in
the ED. epo @ HD
- guiac neg, no signs of blood loss.
.
# Onc - poorly differentiated histology, likely NSCLC; with mets
to cervical and sacral spine. With neck pain s/p c1-c3
arthrodesis. very poor overall prognosis, but in past
discussions, pt. goals of care to be aggressive. No chemo
currently offered from onc team, but are aware.
- continue oxycodone/oxycontin for pain control
- neck brace as previously ordered - for pain relief. Neck is
otherwise stable.
- [**Year (4 digits) 653**] [**Name (NI) 2270**] [**Name (NI) 1764**] of palliative care who followed during
previous visits. Dr. [**Last Name (STitle) 5717**], his PCP and current attending
aware.
.
# CAD - with prior stenting, and evidence of prior MI by ECG
- continue [**Last Name (STitle) **], [**Last Name (STitle) **], B-blocker, ACE-I, statin, and nitrate
.
# Chronic systolic congestive heart failure - depressed EF of
25-30% in [**2198-1-5**]. The patient developed acute pain and became
hypertensive and had flash pulmonary edema necessitating
transfer to the MICU, where he received emergent hemodialysis
and avoided intubation. He was transferred to the floor where
his care was continued.
.
# HTN - currently well-controlled
- continue B-blocker, ACE-I, and nitrate
.
# ESRD - last HD on [**3-28**]
- renal diet
- nephrocaps
- hemodialysis per routine
.
# Left Common Femoral DVT. The patient had a supratherapeutic
INR and his warfarin was held, it will need to be resumed once
his INR is less than 3.
Medications on Admission:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for neck pain: leave on for 12 hours, then take off for
12 hours.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO please
give once daily on dialysis days only. do not give on days the
patient does not have dialysis.
16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 2 weeks.
17. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection at hemodialysis.
18. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 13 days: last dose due on [**4-3**].
19. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): hold if
sedated or RR < 10.
20. Oxycodone 20 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for Pain: hold if patient is sedated or RR < 10.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) Powder in Packet PO once a day.
11. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: Twenty Five
(25) mcg Injection q2 hours as needed for pain.
15. Dexamethasone 0.5 mg Tablet Sig: Taper as follows PO every
six (6) hours: 2mg PO q6hr for 3 days, then 1mg PO q6hr for 3
days, then 0.5mg PO q6hr for 3 days, and then discontinue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Non-small cell lung cancer metastatic to spine with cauda equina
syndrome;
Pathological C2 fracture, s/p C1-3 Fusion;
Chronic neck pain;
ESRD on hemodialysis;
Chronic systolic congestive heart failure;
Mitral regurgitation;
Coronary artery disease;
Femoral deep venous thrombosis;
Hypertension;
Thalassemia trait;
Left lower extremity peroneal nerve palsy [**1-6**] GSW to L leg;
Recent C. difficile colitis;
Recent VRE urinary tract infection;
Chronic Hepatitis C;
Sacral decubitus ulcer.
Discharge Condition:
Stable. Decreased mobility secondary to Cauda Equina Syndrome.
Also continues with pain from spinal mets with some lethargy due
to narcotic analgesics.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: [**2189**] cc.
Please continue with your dialysis every
Monday/Wednesday/Friday.
Please tell the health-care providers at the extended care
facility if you have: shaking chills, a fever, chest pain,
difficulty breathing, abdominal pain, vomitting, blood in your
stools, if the pain in your neck/back increases or if you
experience a change in mental status. Please take your
medications as prescribed. Please make and keep all of your
follow-up appointments.
Followup Instructions:
1. Continue hemodialysis every Monday/Wednesday/Friday.
2. Please contact your Primary Care Provider ([**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],
[**Telephone/Fax (1) 250**]) and your Oncologist to arrange follow-up
appointments.
|
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"424.0",
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"162.4",
"285.22",
"V09.80",
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] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"39.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15149, 15192
|
9146, 11557
|
300, 333
|
15726, 15880
|
4337, 5897
|
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|
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15904, 16484
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3584, 4318
|
248, 262
|
7391, 9123
|
361, 1833
|
1855, 3172
|
3188, 3492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,612
| 144,737
|
20179
|
Discharge summary
|
report
|
Admission Date: [**2169-3-2**] Discharge Date: [**2169-3-4**]
Date of Birth: [**2121-11-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Bloody vomit
Major Surgical or Invasive Procedure:
EGD [**2168-3-2**]
History of Present Illness:
47 year old man BIBA from men's transitional housing unit after
awaking with blood in his mouth and associated LUQ pain, and
found to have bleeding ulcer in his stomach.
Patient awoke day of admission with nausea and left upper
quadrant pain. He proceeded to throw up frank blood, and
presented to the ED. In the ED, NG lavage showed BRB that did
not clear after 500 cc lavage. He was placed on a PPI gtt and
admitted to the ICU for upper GIB. Patient remained stable over
night and EGD this morning showed 2-3mm ulcer in the fundus of
the stomach with clean base and stigmata of recent hemorrhage.
It was clipped successfully and patient is being transferred to
the floor in good condition.
Currently, patient continue to complain of mild LUQ pain,
although he notes he is hungry. Denies nausea, melena, or
hematochezia. He notes feeling weak the day prior to admission,
but no other localizing symptoms. He has chronic back pain, for
which he takes gabapentin, but denies taking NSAIDS. He has had
previous bleeding peptic ulcer in [**2168-7-1**] treated at [**Hospital1 **]
[**Location (un) 620**]. He also has chronic hepatitis C, but no evidence of
cirrhosis. He states his last drink was 'years ago'.
.
ROS: Positive as above, and for chronic back pain with radiation
into his left knee. Denies fever, chills, headache, cough,
shortness of breath, chest pain, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria
Past Medical History:
-Chronic Low back pain
-Chronic Hep C- per patient was infected by rape at age of 12
y.o.
-PUD with prior UGIB
-Depression, anxiety, ADHD
Social History:
Currently living in a men's transitional housing unit. Out of
work for several years due to back pain. Smokes [**1-2**] ppd for 25
years. Former social EtOH but quit years ago. Reports remote
IVDA
Family History:
Father just diagnosed with rectal cancer at 91, no FH of other
cancers, DM or HTN
Physical Exam:
FEX ON MICU Admission
Vitals: as per Metavision sheet:
General: Well developed, well appearing male in no acute
distress.
HEENT: Oropharynx clear, poor dentition, no signs of infection,
no
lymphadenopathy, sclera anicteric.
Cardiac: Normal S1 S2 regular rate and rhythm, no rubs, murmurs,
or gallops. No jugulovenous distention. Normal PMI.
Pulmonary: Lungs clear to auscultation bilaterally. No wheezes,
rhales, or rhochi.
Abdomen: Soft, nontender, nondistended, normal bowel sounds, no
rebound or guarding, no organomegaly.
Extremities: No edema, cyanosis , or clubbing. No spine
tenderness, no saddle anesthesia.
Neurologic: Cranial nerves II-XII intact, [**5-6**] upper extremity
strength bilaterally. [**5-6**] lower extremity strength b/l. Light
touch sensation intact. No dysdiadokinesia, normal finger to
nose, normal gait. Alert and oriented X 3.
Psychiatric: Normal affect, normal speech, answers questions
appropriately.
Rectal: guaiac neg, no lesions
FEX ON DISCHARGE
PHYSICAL EXAM:
VS - Tm 98.4 Tc 97.9, BP 150/82, HR 71, R 18 , O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple no JVD
LUNGS - CTA bilat, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, mildly TTP LUQ, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ DP.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-6**] throughout, sensation grossly intact throughout, gait
deferred
Pertinent Results:
STUDIES
[**2169-3-4**] Radiology CHEST (PA & LAT)
AP and lateral views obtained with nipple markers. The nodular
opacity seen
on the [**2169-3-2**] 16:44 p.m. x-ray examination is not definitively
identified on the current examination. No acute pulmonary
process is identified. Recommend followup radiograph in four to
six months to confirm stability.
[**2169-3-3**] Radiology CXR WITH NIPPLE MARKERS
No frontal PA view to correlate with the prior film was
obtained.
Nipple markers are in place. The nodule, which appear to overlie
the right
anterior fifth rib near its crossing point with the right ninth
rib on the
film obtained [**2169-3-2**] at 16:44 p.m., is not distinctly identified
on these
views. In the absence of a repeat AP view with nipple markers,
it is difficult to completely exclude whether the nodular
opacity represented a nipple shadow on the prior film.
Recommend additional AP view, similar to that obtained on [**3-2**],
with nipple
markers in place. Alternatively a PA view could be obtained.
.
[**2169-3-2**] CXR IMPRESSION:
No acute intrathoracic process. No evidence of intraperitoneal
free air.
A repeat PA and lateral radiograph with shallow obliques and
nipple markers is
recommended to rule out a nodule in the right lower lobe.
.
[**2169-3-3**] Pathology Tissue: G I BIOPSY (1 JAR
Antral mucosal biopsy- within normal limits
.
EGD [**2169-3-4**]
Erythema in the gastroesophageal junction compatible with Mild
esophagitis. Erythema, congestion and erosion in the stomach
body compatible with Moderate gastritis (biopsy). Ulcer in the
fundus (endoclip). Erythema in the duodenal bulb compatible with
Mild duodenitis. Otherwise normal EGD to third part of the
duodenum
-Follow-up biopsy results.
-The findings account for the symptoms
-Antireflux regimen: Avoid chocolate, peppermint, alcohol,
caffeine, onions, aspirin. Elevate the head of the bed 3 inches.
Go to bed with an empty stomach. Prilosec 40 mg [**Hospital1 **].
- Serial Hct. Treat H. Pylori if biopsies positive.
- Follow-up with Dr. [**Last Name (STitle) **] in clinic in [**3-5**] weeks.
- Avoid Nonsteroidals like Advil, Motrin.
- Patient would need repeat EGD in [**6-9**] weeks once esophagitis
healed up to evaluate for Barretts
.
BLOOD
[**2169-3-2**] 03:45PM BLOOD WBC-7.7 RBC-4.43* Hgb-14.7 Hct-40.7
MCV-92 MCH-33.1* MCHC-36.1* RDW-13.6 Plt Ct-244
[**2169-3-2**] 09:00PM BLOOD WBC-6.3 RBC-3.86* Hgb-12.9* Hct-35.5*
MCV-92 MCH-33.5* MCHC-36.4* RDW-13.6 Plt Ct-217
[**2169-3-3**] 02:58AM BLOOD Hct-35.9*
[**2169-3-3**] 09:21AM BLOOD Hct-37.6*
[**2169-3-3**] 10:05PM BLOOD Hct-36.3*
[**2169-3-4**] 05:55AM BLOOD WBC-5.8 RBC-4.21* Hgb-14.1 Hct-37.9*
MCV-90 MCH-33.6* MCHC-37.3* RDW-13.6 Plt Ct-206
[**2169-3-2**] 03:45PM BLOOD Neuts-60.2 Lymphs-31.3 Monos-5.2 Eos-2.4
Baso-0.8
[**2169-3-2**] 09:00PM BLOOD PT-10.8 PTT-29.7 INR(PT)-1.0
[**2169-3-2**] 03:45PM BLOOD Glucose-99 UreaN-21* Creat-1.6* Na-141
K-4.6 Cl-108 HCO3-23 AnGap-15
[**2169-3-2**] 09:00PM BLOOD Glucose-88 UreaN-19 Creat-1.1 Na-142
K-4.0 Cl-113* HCO3-23 AnGap-10
[**2169-3-4**] 05:55AM BLOOD Glucose-91 UreaN-15 Creat-0.8 Na-140
K-4.3 Cl-106 HCO3-27 AnGap-11
[**2169-3-2**] 03:45PM BLOOD ALT-69* AST-50* AlkPhos-115 TotBili-0.2
[**2169-3-2**] 03:45PM BLOOD Lipase-89*
[**2169-3-2**] 03:45PM BLOOD Albumin-4.1 Calcium-9.8 Phos-3.5 Mg-2.0
URINE
[**2169-3-2**] 09:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2169-3-2**] 09:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2169-3-2**] 09:14PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2169-3-2**] 09:14PM URINE Eos-NEGATIVE
[**2169-3-2**] 09:14PM URINE Hours-RANDOM UreaN-838 Creat-117 Na-161
K-70 Cl-176 Amylase-285 TotProt-8 Calcium-7.9 Phos-58.7 Mg-2.9
Uric Ac-43.1 HCO3-LESS [**First Name8 (NamePattern2) **] [**Doctor First Name **]/Cre-2.4 Prot/Cr-0.1
[**2169-3-2**] 09:14PM URINE Osmolal-770
MICROBIOLOGY
[**2169-3-2**] URINE URINE CULTURE-FINAL
No growth
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
This is a 47 yo M w/ PMH of HCV, prior GIB in [**Month (only) 205**] from peptic
ulcer, presenting with sudden onset of hematemesis and blood in
NG lavage that did not clear; EGD showed 2-3mm ulcer with
associated gastritis.
ACTIVE PROBLEMS
#PUD: Patient with UGIB on presentation, and admitted to MICU as
blood did not clear in NG lavage. PPI gtt was started and
hematcrit was stable overnight in MICU. The morning after
admission, he was found to have 2-3cm bleeding ulcer in fundus
of stomach in addition to diffuse gastritis, esophagitis and
duodenitis on EGD. Ulcer was clipped, and patient was trasferred
to the floor o po PPI. Hematocrit remained stable on the floor
and patient was discharged home with GI follow up with H. pylori
biopsy pending at time of discharge.
#Abdominal pain: Patient with RUQ pain in setting of bleeding GI
ulcer. Of note, patient with question of narcotic abuse and drug
seeking behavior per PCP [**Name Initial (PRE) 12883**]. Patient received IV morphine in
the MICU, but no additional narcotics were provided on the
floor.
# [**Last Name (un) **]: Patient presented with Cr to 1.6 in setting of upper GI
bleed. Resolved and decreased to 0.8 after hydration overnight.
# Lung nodule - Incidentally noted on CXR on admission. Repeat
films with nipple markers did not redemonstrate the nodule.
Recommend repeat film in [**4-7**] months.
CHRONIC PROBLEMS
# Chronic hepatitis C. Patient with known hepatitis C, and
elevated transmaminases. Unknown genotype and never been
treated. CT scan in [**7-/2168**] with no evidence of cirrhosis or
splenomegaly. Synthetic function with INR, albumin and CBC
appear to be grossly normal. No signs of liver masses on CT in
7/[**2168**]. HCV viral load of 17,400,000 IU/mL in [**Month (only) 1096**].
# Back Pain: Chronic. Extensive workup in past, with large
narcotic requirement. Patient currently not on narcotics, and
concern for abuse per PCP. [**Name10 (NameIs) **] treated with gabapentin 800
qid per patient report. Patient was given gabapentin 300 [**Hospital1 **] in
setting of ARF, and increased to tid on the floor. Patient was
discharged without prescription for any add'l pain medication.
He was instructed to avoid NSAIDs.
# Psych: Patient with hx of depression, anxiety and adhd.
Reportedly well controlled, pt denies feeling depressed.
Adderall was held during admission. Clonazepam and sertraline
continued at home dose.
TRANSITIONAL ISSUES
-Will need GI follow with repeat EGD per GI recs
-FU H.Pylori and treat if necessary
-Repeat Chest film in [**4-7**] months to monitor nodule seen on
admission CXR
Medications on Admission:
-Prilosec - has not been taking as prescribed
-Gabapentin 800mg QID per pt
-adderall 30mg TID
-Zoloft 50mg QD
-Klonopin 2mg TID
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. Adderall 30 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. clonazepam 2 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety: Do not drink or drive while taking
this medication.
Discharge Disposition:
Home
Discharge Diagnosis:
Peptic Ulcer Disease
Upper GI Bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 23239**],
You were admitted to the hospital for an episode of bloody
vomit. We did an EGD, which showed an ulcer in your stomach had
started to bleed. We stopped the bleeding and your blood counts
remained stable. You will need to keep taking omeprazole 40 mg
by mouth twice daily and avoid NSAID's (like ibuprofen),
alcohol, and caffeine. You should not eat within 30 minuts of
going to bed. You need to follow up with Dr. [**Last Name (STitle) **] in the [**Hospital **]
clinic in [**3-5**] weeks. You will also need repeat EGD in [**6-9**] weeks.
Followup Instructions:
You will need to follow up with Dr. [**Last Name (STitle) **] in the [**Hospital **] clinic in
[**3-5**] weeks by calling ([**Telephone/Fax (1) 2233**]. It is very important to
make this appointment to ensure healing of your ulcer.
Please follow up with your primary care doctor within the next
week.
|
[
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icd9cm
|
[
[
[]
]
] |
[
"45.13",
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icd9pcs
|
[
[
[]
]
] |
11257, 11263
|
7917, 10550
|
316, 337
|
11343, 11343
|
3906, 7894
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,890
| 124,649
|
36575
|
Discharge summary
|
report
|
Admission Date: [**2105-6-10**] Discharge Date: [**2105-6-17**]
Date of Birth: [**2041-2-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, positive ETT
Major Surgical or Invasive Procedure:
[**2105-6-12**] Coronary Artery Bypass Grafting utilizing the left
internal mammary artery to the left anterior descending artery
with saphenous vein grafts to diagonal and obtuse marginal.
History of Present Illness:
Mr. [**Known lastname 5261**] is a 64 year old male who was referred from [**Hospital 40796**] today after he underwent coronary angiography
following a positive ETT. Catheterization revealed Left Main
disease with 90% stenosis. He was then transferred to [**Hospital1 18**] for
cardiac surgery evaulation.
Past Medical History:
Coronary Artery Disease
Hypertension
Type II Diabetes Mellitus
Dyslipidemia
s/p Traumatic Amputation of Left Hand with Surgical Revision
Social History:
Occupation: self employed.
Last Dental Exam 3-6mo.
Lives with his wife.
[**Name (NI) **]: caucasian
Tobacco: never smoker
ETOH: [**12-5**]/month
Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse: Resp:12 O2 sat: 99% ra
B/P Right: 133/57 Left: 128/55
Height: Weight:
General: No acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
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: n Left:n
Pertinent Results:
[**2105-6-10**] 09:25PM BLOOD WBC-4.8 RBC-4.26* Hgb-13.0* Hct-37.8*
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.1 Plt Ct-234
[**2105-6-10**] 09:25PM BLOOD PT-11.9 PTT-28.0 INR(PT)-1.0
[**2105-6-10**] 09:25PM BLOOD Glucose-181* UreaN-17 Creat-0.8 Na-139
K-4.2 Cl-102 HCO3-29 AnGap-12
[**2105-6-10**] 09:25PM BLOOD ALT-21 AST-21 AlkPhos-41 TotBili-0.3
[**2105-6-10**] 09:25PM BLOOD Calcium-9.1 Phos-3.0 Mg-1.7
[**2105-6-10**] 09:25PM BLOOD %HbA1c-7.0*
[**2105-6-11**] Echocardiogram:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Transmitral Doppler and tissue
velocity imaging are consistent with Grade I (mild) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic arch is mildly dilated. There is a mild
coarctation of the distal 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. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. There is an anterior space which most
likely represents a fat pad.
[**2105-6-11**] Carotid Ultrasound:
There is antegrade right vertebral artery flow. There is
antegrade left vertebral artery flow. Right ICA stenosis <40%.
Left ICA stenosis <40%.
[**2105-6-17**] 06:00AM BLOOD WBC-4.9 RBC-2.64* Hgb-7.9* Hct-24.2*
MCV-92 MCH-30.1 MCHC-32.8 RDW-13.3 Plt Ct-208#
[**2105-6-17**] 06:00AM BLOOD Glucose-212* UreaN-25* Creat-0.8 Na-137
K-4.7 Cl-97 HCO3-31 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 5261**] was admitted to cardiac surgery with left main
disease. He remained pain free on medical therapy and underwent
preoperative evaluation which included a carotid ultrasound and
echocardiogram - see result section for details. His
preoperative course was relatively uneventful and he was
eventually cleared for surgery. On [**6-12**], Dr. [**Last Name (STitle) **]
performed three vessel coronary artery bypass grafting. For
surgical details, please see 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. His CVICU course was uncomplicated
and he transferred to the SDU on postoperative day two. Pacing
wires and chest tubes were removed without complication. He
remained in a normal sinus rhythm without atrial or ventricular
arrrhythmias. Beta blockade was advanced as tolerated. His
preoperative diabetic medications were resumed with fair
glycemic control. Rash was noted on dorsal trunk which was
attributed to Lasix, and subsequently switched to Ethacrynic
Acid at discharge. The remainder of his hospital course was
uneventful and he was medically cleared for discharge on
postoperative day four.
Medications on Admission:
Metformin 1000''
Actos 30'
Novalog SSI
Levamer 18u'
Zocor 80'
Lisinopril 20'
Claratin 10'
ASA 81'
MVI 1 tab daily
Saw [**Location (un) **] 160''
Omega 3 1''
Vit C 500'
Ginko Biloba 60'''
Metoprolol XL 25'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching .
6. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*qs * Refills:*0*
10. Ethacrynic Acid 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*2*
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
12. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
13. Novolog 100 unit/mL Solution Sig: One (1) per home sliding
scale Subcutaneous four times a day.
14. Levemir 100 unit/mL Solution Sig: Eighteen (18) units
Subcutaneous once a day: per home dosing.
15. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Home Health and Hospice
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Hypertension
Type II Diabetes Mellitus
Dyslipidemia
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] (cardiac surgeon) in 4 weeks, call for appt
Dr. [**Last Name (STitle) 5017**] (cardiologist) in 2 weeks, call for appt
Dr. [**Last Name (STitle) **] (PCP) [**Telephone/Fax (1) 70836**] in 2 weeks, call for appt
Please see your endocrinologist in [**12-5**] weeks, call for an
appointment
Completed by:[**2105-6-17**]
|
[
"413.9",
"553.3",
"693.0",
"530.81",
"250.00",
"401.9",
"414.01",
"E944.4",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6773, 6827
|
3650, 4910
|
346, 538
|
6957, 6964
|
1915, 3627
|
7508, 7857
|
1215, 1257
|
5166, 6750
|
6848, 6936
|
4936, 5143
|
6988, 7485
|
1272, 1896
|
282, 308
|
566, 875
|
897, 1036
|
1052, 1199
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,621
| 122,836
|
42970
|
Discharge summary
|
report
|
Admission Date: [**2148-1-13**] Discharge Date: [**2148-1-24**]
Date of Birth: [**2093-9-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 92751**] is a 54 yo man with a PMH of depression, past
suicide attempts, HTN, EtOh abuse with DT's (las drink 1 month
ago), and recent acceleration of his ativan use who was
transferred from [**Hospital3 10310**] Hospital to [**Hospital1 18**] MICU after he
was found down by his parents with empty coumadin and lamictal
bottles near him. Per records, the patient was found the morning
of [**2148-1-13**]
after his parents heard a "thud" and found him lying next to the
bottles not responding. He was brought to OSH and was found to
be minimally responsive. He was intubated and a central line was
placed in the ED. Head CT there showed small fluid collection
abutting the right front lobe not causing mass effect, density
suggests subacute subdural hematoma. Head CT there showed small
fluid collection abutting the right front lobe not causing mass
effect, density suggests subacute subdural hematoma. CT C-spine
showed postop changes C5-7 otherwise no fractures. INR was 1.8,
PTT 38. Tox screen was negative for acetaminophen, salicylates
or alcohol. He was given 10 units IV Vitamin K for the concern
for coumadin O/D & transferred to [**Hospital1 18**] for further
management/neurosurgery evaluation.
Past Medical History:
Depression, prior SA
Bilateral DVT's on coumadin
HTN
Subdural hygroma
s/p C5-7 fusion
Social History:
EtOH abuse - drank about [**12-2**] gallon of vodka/day, now abstinent
Denies tobacco or illicit/recreational drugs. Divorced with two
children.
Family History:
non-contributary
Physical Exam:
GEN:Intubated and sedated
SKIN:Erythema over left forearm, soft
HEENT:Pupils equal and reactive, ET tube in place, NG Tube in
place
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:Swelling/ecchymosis over right foot
NEUROLOGIC: Sedated
Exam off sedation: Pt responds to commands, opens eyes, squeezes
hands, and has jerky motion of both lower extremities but
responding throughout this jerking motion
Pertinent Results:
Admission labs:
[**2148-1-13**] 06:02PM TYPE-ART RATES-/14 PEEP-5 PO2-324* PCO2-44
PH-7.40 TOTAL CO2-28 BASE XS-2 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2148-1-13**] 06:02PM GLUCOSE-138* LACTATE-2.4* NA+-140 K+-3.5
CL--101 TCO2-28
[**2148-1-13**] 06:02PM freeCa-1.20
[**2148-1-13**] 06:00PM GLUCOSE-136* UREA N-10 CREAT-0.8 SODIUM-143
POTASSIUM-3.6 CHLORIDE-103
[**2148-1-13**] 06:00PM ALT(SGPT)-255* AST(SGOT)-119* CK(CPK)-168 ALK
PHOS-135* TOT BILI-0.8
[**2148-1-13**] 06:00PM LIPASE-25
Head CT:
IMPRESSIONS:
1. 8-mm subacute right frontal subdural collection, without
evidence of acute
bleeding. No area of acute intracranial hemorrhage.
2. Mild atrophy of left temporal lobe.
3. Paranasal sinus disease with fluid in the sphenoid sinuses
likely related
to intubation.
Chest CT [**2148-1-13**]:
IMPRESSIONS:
1. Left lower lobe consolidation may represent atelectasis,
infection, or
aspiration. Small right lower lobe ill-defined nodules also
suggest
aspiration.
2. No traumatic injuries within the torso. No fractures.
3. Diverticulosis without diverticulitis.
CT Spine IMPRESSIONS [**2148-1-13**]:
1. No fracture or malalignment of the cervical spine.
2. Status post C5 through C7 fixation and laminectomies without
evidence of hardware complication.
Head MRI [**2148-1-14**]:
IMPRESSION:
No acute infarct seen. Unchanged right frontal subdural. Soft
tissue changes
in the left frontal sinus and sphenoid sinus.
MRI spine [**2148-1-14**]:
IMPRESSION:
New enhancement and increased signal in the posterior soft
tissues with a 1.5- cm fluid collection near the tip of the
spinous process of T1 could be due to trauma or due to new
inflammatory changes. Infection should be excluded by clinical
correlation. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] at the
time of interpretation of the study on [**2148-1-14**]. No epidural
abscess or cord compression seen.
Foot AP/Lat: THREE VIEWS OF THE RIGHT FOOT: There is no fracture
or dislocation. No focal lytic or sclerotic osseous abnormality
is visualized. No radiopaque foreign bodies are present. There
are no soft tissue calcifications. No focal lytic or sclerotic
osseous abnormalities are present. Joint spaces are relatively
preserved.
IMPRESSION: No fracture or dislocation.
Chest X ray [**2148-1-16**]:
FINDINGS: AP single view of the chest has been obtained with
patient in
sitting semi-upright position. Comparison is made with the next
previous
similar study obtained 14 hours earlier during the same date.
Position of NG tube and left-sided subclavian central venous
line unchanged as described earlier. Inspiration status markedly
improved. The left-sided retrocardiac diffuse density seen on
the previous study has now cleared up. One can identify a plate
atelectasis, but as the left-sided diaphragm is well described,
significant pleural effusion and parenchymal infiltrate in this
area is most unlikely. No pneumothorax has developed. Pulmonary
vasculature is not congested.
IMPRESSION: Improvement of previously identified left lower lobe
atelectasis in patient with suspected overdose and previous
respiratory failure.
EMG [**2148-1-18**]:
IMPRESSION:
Complex, abnormal study. The electrophysiologic findings can be
explained most parsimoniously by a severe, subacute (between 3
weeks to 3 months) C7-T1 polyradiculopathy on the right. The
findings cannot be explained by a
posterior interosseous neuropathy in isolation. The preservation
of the medial antebrachial cutaneous response on the right makes
a brachial plexopathy effecting the lower trunk unlikely. There
is also evidence for an underlying, mild, chronic C5-7
radiculopathy on the right. Of note, axonal continuity is
maintained to all muscles tested. If clinically indicated,
repeat testing in three months may be warranted.
Brief Hospital Course:
54 yo M found down at home, intubated in ED for unresponsiveness
after coumadin and lamictal overdose
.
# Unresponsiveness /Fall: In the ED, vital signs were initially
were 99 146/89 HR 86 RR 16 100% The patient was intubated. He
had CT Head which showed right frontal lobe area concerning for
a subdural hematoma. Neurosurgery felt that the CT head changes
were related to post surgical status, and no acute intervention
was needed. CT Torso showed LLL infiltrate concerning for
aspiratin pneumonia; thus pt given Vanc/zosyn. Xray of right
foot done for swelling noted on exam which was negative for
fracture. Labs remarkable for ABG 7.40/44/324, INR 1.7, lactate
2.4, WBC 12.4, trop <0.01, creatinine 0.8. EKG with TWI and ST
depression v4-v6 that resolved on repeat. The patient was
admitted to the MICU where the intitial differential also
included lamictal and coumadin overdose, seizure vs ETOH
Withdrawal vs arrhythmia (given the EKG changes noted in ED that
later resolved) vs PE (the patient was subtherapeutic on
coumadin on arrival) vs Wernickes encephalopathy.
On arrival to the MICU he was responding to commands with
lightened sedation but with clonus and hyperreflexia (not
thought to be new but possibly be more pronounced than
previously described on OMR notes). While he was being examined
by the MICU team off propofol, he started having rhythmic jerky
movements in all limbs, and neuro was called for concerns of
seizures. They noted that the patient was able to stop the
movement for few secs if instructed and was able to follow
commands during these movements. It was thought that the patient
was exhibiting clonus due to toxic metabolic encephalopathy due
to multi medication overdose (lamictal and coumadin) or
withdrawal (alcohol vs benzodiazepines).
.
When the patient was awake to be able to give a history it was
determined that the patient has a history of alcohol abuse with
DTs in the past. However, he stated he has not had alcohol in
over a month. The patien's sister corroborated this story
telling the neurology team that the patient was in a supervised
setting post op in his father's home with sister's assistance
and no alcohol available. She did, however, think that he used
his anti-anxiety and narcotics Rx at an "accelerated rate" and
overdosed in part due to despondence over pain/restrictive
environment. He is normally prescribed 1.5 mg ativan a day. In
light of this information, it was thought that the patient might
be exhibiting withdrawal not from alcohol but from
benzodiazepines so he was started on a CIWA scale with valium.
His mental status improved considerably with this regimen.
The patient was also evaluated by psychiatry who did not elicit
suicidal ideation. The patient told the team that he took [**9-18**]
pills of Warfarin w/Lamotrigine because he "wanted to go to
sleep." However, in talking with the patient's father, he stated
that he feels that his son is not safe to go home and may
actually be a danger to himself. Therefore, psych determined
that the patient should be section 12 with a 1:1 sitter.
The pateint was deemed stable for the medicine floor and was
transferred. There he continued to improve, with no
disorientation. He was alert with good concentration. He was
maintained on CIWA scale but only required 2 doses of diazepam
for anxiety. He did not score above 10 on the CIWA scale. He
was maintained on telemetry and had a few episodes of
tachycardia to the 150s which was thought to be normal sinus
rhythm. Because this only happened when he was getting up from
bed and walking it was thought that he was orthostatic and
deconditioned from lying in bed for so long. He was hydrated
with IV fluids and orthostatics were checked and were negative.
He was encouraged to walk around 3 times a day each day.
# Suicide attempt: As stated above the patient denied suicide
attempt with the overdose, but rather states he was just trying
to make himself go to sleep by taking all of the medications.
He was evaluated by psych who also talked to the patient's
father who thought the patient would be a danger to himself at
home. For this reason and the fact that the patient has prior
suicide attempts he was made section 12 and kept a 1:1 sitter.
His fluoxetine was restarted at 60 mg a day on [**2148-1-21**] but no
other psychiatric medications were restarted. TSH was checked
and was normal at 3.1. The patient was discharged to an
inpatient pschiatric facility.
.
# Subderual hematoma/hygroma: The patient has a chronic right
frontal hygroma and was evaluated by neurosurgery who felt that
this was resolving and no intervention was needed. They also
felt that there was no contraindication to coumadin. Per
neurosurgery, the patient will need a follow-up head CT as an
outpatient in 4 weeks (end of [**Month (only) 958**]). He should call
[**Telephone/Fax (1) 327**] and hit extension #1 to book this appointment. He
should follow up with neurosurgery after he gets this CT. He
can call the following number to schedule this appointment:
([**Telephone/Fax (1) 88**].
.
# Pulmonary infiltrate: CT chest showed evidence of aspiration
PNA. The patient was afebrile but initially had a mild
leukocytosis so he was given vanc/Zosyn for 3 days. Antibiotics
were stopped because the patient was not exhibiting symptoms and
was afebrile. He continued to not have any symptoms of
pneumonia including shortness of breath, cough, chest pain, or
fever.
.
# DVT's: The patient had bilateral lower extremity DVTs
diagnosed at a recent admission, for which he was discharged on
coumdain. After his overdose on coumadin he was given 10 mg IV
vitamin K at the OSH. During this hospitalization his initial
INR was 1.7 so his coumadin was held. His INR trended down to
1.0. Neurosurgery felt that it was ok to restart his coumadin
so the patient was bridged with lovenox [**Hospital1 **]. His INR remained
at 1.0 for several days so his coumadin dose was increased to 10
mg for two days before titrating back to 4 mg a day. The day of
discharge his INR was 1.4. The patient should continue to get 4
mg (his home dose) coumadin and have his INR checked every day
until he is theraputic (INR [**1-3**]). At that time he can
discontinue the lovenox injections.
.
# right hand palsy: The patient was noted to have a right hand
palsy where he was unable to extend his right fingers. It was
recommenced by Dr. [**Last Name (STitle) 363**], his neurosurgeon, that he get an EMG
study. The findings of this study were: "Complex, abnormal
study. The electrophysiologic findings can be explained most
parsimoniously by a severe, subacute (between 3 weeks to 3
months) C7-T1
polyradiculopathy on the right. The findings cannot be explained
by a
posterior interosseous neuropathy in isolation." Neurology
recommended that the patient follow up with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]
W. and have a repeat EMG in three months. The patient can call
([**Telephone/Fax (1) 2528**] to schedule the follow up appointment and ([**Telephone/Fax (1) 21904**] to schedule the EMG study. The patient was evaluated
by Occupational Therapy who priovided a daytime and a nighttime
splint which he should continue to wear. The patient noted
subjective improvement of his wrist extension, but no
improvement of his finger extension the day of discharge.
Medications on Admission:
MEDICATIONS AT HOME: (per OMR d/c summary/OSH notes)
Senna 8.6 mg prn
Docusate 100mg prn
Lamotrigine 75 mg
Famotidine 20 mg Q12H
Thiamine 100 mg
Multivitamin
Folic Acid 1 mg
Fluoxetine 60 mg
Dulcolax 10 mg Suppository prn
Acetaminophen 650 mg prn
Warfarin 4 mg qd
Oxycodone 5mg q6 prn
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day.
8. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for arm pain.
9. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
10. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Location (un) 10059**]
Discharge Diagnosis:
Primary diagnosis:
Lamictal overdose
Coumadin overdose
Secondary diagnosis:
Subdural hematoma
Depression
bilateral DVTs
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You came to the hospital after you were found down on the
ground. You told us that you overdosed on Lamictal and
Coumadin. You were intubated and monitored in the intensive
care unit. We gave you medicines to treat you for
benzodiazepine withdrawal and supportive measures until the
medications you overdosed on cleared from your system. You were
evaluated by the neurosurgeons who thought that your head did
not have evidence of bleeding. They would like you to follow up
with a repeat head CT in 4 weeks and see them in outpatient
clinic. You can call to schedule these appointments (see
below).
You were also evaluated by the psychiatrists who thought that
you might be in danger of hurting yourself. They think you
would benefit from inpatient psychiatric treatment. Please
follow their recommendations regarding restarting your
medications for depression, some of which we have held during
this hospitalization.
You were also noted to have a right hand paralysis that you
first noticed after your initial fall back in [**Month (only) 404**]. You had
an EMG study performed which showed some abnormailities in the
nerves in your arm. The neurologists would like you to follow
up with them and have a repeat EMG in 3 months. Please see
below for the numbers to call to schedule these appointments.
You were also seen by occupational therapy who stated you should
wear a resting splint when you sleep as well as a dyamic brace
during the day when you are doing activities.
We restarted you back on your blood thinners for your blood clot
in your legs. You should continue to take both the lovenox
shots twice a day as well as the coumadin once a day and have
your blood drawn every day until your INR level is theraputic
(between 2 and 3). At that time you can stop the lovenox shots
and just continue with the coumadin.
Pleas note the following changes to your medications:
Please Stop Lamictal
Please Stop Fluoxetine
Please change your oxycodone to 10 mg every 4 hours as needed
for arm, neck, shoulder pain
Please continue lovenox 60 mg twice a day until your INR is
between 2 and 3.
Please continue to take the rest of your medications as
prescribed.
It was a pleasure taking part in your care.
Followup Instructions:
To evaluate your subdural hematoma you will need to get another
head CT in a few weeks (mid [**Month (only) **]) and then follow up with the
Neurosurgeon, Dr. [**First Name (STitle) **]. In order to schedule the Head CT you
should call [**Telephone/Fax (1) 327**] and hit extension #1. You can then
call the following number to schedule the appointment with Dr.
[**First Name (STitle) **]: ([**Telephone/Fax (1) 88**].
You will also need to have a repeat EMG study and follow up with
a neurologist for your right hand palsy. Please call ([**Telephone/Fax (1) 21904**] to schedule the EMG study (in mid [**Month (only) 116**]). Please call
([**Telephone/Fax (1) 2528**] to schedule the follow up appointment with Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] in neurology for an appointment after you get the
EMG study.
Please follow up with your primary care doctor after you are
discharged from [**Doctor First Name 1191**] for a post hospitalization check up.
|
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icd9cm
|
[
[
[]
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[
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328, 334
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,523
| 188,128
|
28302
|
Discharge summary
|
report
|
Admission Date: [**2171-5-16**] Discharge Date: [**2171-6-6**]
Date of Birth: [**2121-10-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
49 year old female with persistent vegetative state secondary to
a pontine bleed in [**7-/2170**], with tracheostomy and PEG tube, and
history of pseudomonal UTI (also ? history of MRSA), and NSTEMI
with EF 35-40% at [**Hospital1 2177**] in [**9-/2170**], presenting from rehab with
fever and hypotension.
.
Per rehab records, the patient had a fever of 102.5 on the night
of [**4-15**] at around 11 p.m., with BP 101/69 at the time. She was
given vancomycin and ceftriaxone, and had blood cultures drawn.
Over the next hour of so, her BP was noted to decline to 79/42
at which point she received 2 liters of normal saline, and had a
dose of flagyl added as well. A dopamine drip was started at
rehab and she was transported to [**Hospital1 18**].
.
Vital signs on arrival to the ED were T103, HR 113, BP 65/37,
98% on AC, 600x8, 40%, PEEP 5. She recieved 3 liters of normal
saline and had a right IJ precept catheter placed, with mixed
venous O2 sat 92%. She was changed to norepinephrine from
dopamine (started at rehab) after right IJ placed. EKG revealed
sinus tachycardia initially with TWI and ST depressions in
V3-V6, however while there she also experienced atrial
fibrillation with rapid ventricular response, with heart rate
decreasing with fluid administration. Labs were notable for
hematocrit of 22 - she was ordered for PRBC transfusion. She had
a positive UA with mod LE and 11-20 wbcs. CXR demonsrated mild
CHF with a possible infiltrate at the left base. She received
vancomycin, ceftriaxone, and zosyn
Past Medical History:
1) Pontine hemorrhage in [**7-/2170**], with resultant persistant
vegetative state, treated at [**Hospital1 18**] where she received a
tracheostomy and PEG tube.
2) Hypertension
3) Pseudomonal UTI at [**Hospital1 2177**] in 9/[**2170**].
4) NSTEMI, medically managed, at [**Hospital1 2177**] in 9/[**2170**]. EF 35-40% on
echo after the MI.
Social History:
Social History: Former smoker, was previously living with a
boyfriend, now lives at [**Hospital3 672**] rehab.
Family History:
Family History: non-contributory
Physical Exam:
PHYSICAL EXAMINATION: 102.6, 115/63, 102 (sinus tach), AC
600x10, 40%, PEEP 5, Pip 27. CVP 14 in ED, ScvO2 96.
GENERAL: Obese hispanic female, unresponsive to painful stimuli,
with tracheostomy, ventilated.
HEENT: Pupils are 2-3 mm and fixed. No occulocephalic reflex.
She has a 2cm ulcer on the right occiput and posterior aspect of
right pinna.
NECK: Trach collar in place, right IJ central line.
COR: RR, tachycardic, no murmurs.
LUNGS: Coarse breath sounds, with scattered rhonchi.
ABDOMEN: G tube (modified foley catheter) in place, no obvious
erythema or exudate. Diminished bowel sounds.
BACK: Large gluteal pressure ulcer with clean borders, no
surrounding erythema, however very deep with exposed underlying
subcutaneous tissues.
EXTR: Large pressure ulcer on posterior left heel with necrotic
eschar. No edema.
NEURO: Pupils not reactive, extremities flaccid with increasing
tone very distally in the DIPs, PIPs, and ankles. Mute plantar
response. Twitching of left lower lip.
Pertinent Results:
[**2171-5-16**] 04:19AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2171-5-16**] 04:19AM URINE RBC-0-2 WBC-[**11-26**]* BACTERIA-MANY
YEAST-OCC EPI-0 TRANS EPI-0-2
[**2171-5-16**] 04:57AM WBC-11.5* RBC-2.32*# HGB-7.2*# HCT-22.4*#
MCV-97 MCH-31.3 MCHC-32.4 RDW-16.2*
.
[**5-16**] Cxr:
CHEST, AP PORTABLE: The patient has a tracheostomy. The heart is
markedly enlarged with mild pulmonary edema. In addition, there
is a left lower lobe opacity obscuring the left hemidiaphragm
suggesting atelectasis or pneumonia. No definite effusion. No
pneumothorax.
IMPRESSION: Mild congestive heart failure. Left lower lobe
opacity, atelectasis versus pneumonia.
.
EEG [**5-16**]:
IMPRESSION: This was an abnormal routine portable EEG due to the
presence of sharp waves in the right central region, suggestive
an area
of cortical hypersynchrony. These discharges did appear rhythmic
at 1Hz
briefly but no clear clinical correlate was appreciated. At
other
times, twitching the mouth was noted, however only muscle
artifacts were
seen and no clear epileptiform discharges were seen to correlate
with
these movements. However, focal motor seizures involving a very
small
seizure focus may not have a clear electrographic correlate. The
slow
background is suggestive of a diffuse encephalopathy
.
echo [**5-17**]:
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is a small to moderate sized pericardial effusion most
prominent inferior to the basal left ventricle and around the
right atrium with minimal fluid anterior to the right ventricle
and around the left ventricular apex. Hemodynamic significance
is not suggested (but can be masked with ventilated patients).
IMPRESSION: Preserved global biventricular systolic function.
Small-moderate pericardial effusion as described above.
.
[**5-24**] echo:
Conclusions:
The left atrium is normal in size. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size is normal. Right ventricular systolic function is
borderline 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. The pulmonary artery systolic
pressure could not be determined. There is a moderate to large
sized pericardial effusion. The effusion appears
circumferential. The effusion is echo dense consistent with
probable hematoma with partial organization. There is no
definite echocardiographic evidence for tamponade but the right
ventricle may be compressed. Clinical correlation recommended.
Compared with the prior study (images reviewed) of [**2171-5-17**],
the pericardial effusion is now much larger and more organized.
.
[**5-27**] echo:
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. The mitral
valve leaflets are structurally normal. The estimated pulmonary
artery systolic pressure is normal. There is a moderate sized
(1cm anterior to right ventricle, 1.5cm around LV apex and
lateral to left ventricle), circumferential, partially
echo-filled pericardial effusion with mild right atrial and
intermittent right ventricular diastolic collapse consistent
with impaired fillling/tamponade physiology.
Compared with the prior study (images reviewed) of [**2171-5-24**],
the effusion is similar in size. There is increased echogenicity
of the effusion c/w
progressive organization and right atrial diastolic collapse is
more obvious c/w increased pericardial pressure/tamponade
physiology.
.
[**2171-5-30**] echo:
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is a moderate sized pericardial effusion.
The effusion appears circumferential. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2171-5-28**], the effusion is similar in size, but now appears more
consolidated (less liquid).
.
D/c labs:
CHem 7 WNL, notable for BUN 30. hct 25.9, ABG 7.42/37/117/25
Brief Hospital Course:
49 year old female in a persistent vegetative state secondary to
a pontine bleed in [**7-/2170**], with history of NSTEMI and EF 35%,
pseudomonal UTI, and history of MRSA, presenting with
hypotension/sepsis.
.
# Sepsis/Hypotension: The patient was admitted with sepsis on
the basis of hypotension, tachycardia, leukocytosis, fever, and
suspected source of urine versus pneumonia. The patient was
treated with sepsis protocol for goal MAP > 60, CVP > 12, hct >
25. The patient improved with fluids, blood, levophed and
antibiotics. As her pressure improved with the above measures
she was weaned off the levophed. She had an ECHO to ensure her
cardiac function was not contributing to her hypotension and her
ECHO showed preserved global biventricular systolic function.
She also had a normal [**Last Name (un) 104**]-stim test, ruling out adrenal
insufficiency as a cause for her hypotension. She was noted to
have a UTI with klebsiella and proteus, and a sputum with
pseudomonas. She was treated with zosyn and improved, though
spoke to infectious disease as her BAL later showed
ACINETOBACTER BAUMANNII in addition to pseudomonas. At this
time tobramycin was added and was dosed by levels. The patient
had muliple negative blood cultures. She will complete a 21 day
total course of tobramycin (last dose 6/8). Tobra peaks and
trough were checked; maintain trough <2 and peak [**6-16**], adjust
accordingly. Check every 2 days, please call for pending peak
value.
.
# Pericardial effusion: On screening chest xray, it was seen
that the patient had a newly enlarged cardiac shadow. She had
an echo on [**5-17**] to evaluate this that showed a mod pericardial
effusion. Echo [**5-24**] with a mod to large effusion without
echocardiographic tamponade: effusion circumferential, echodense
with evidence of organization and a clot around RV. The patient
was followed and remained stable hemodynamically with no
tamponade. Given the possible clot in the echo she had aspirin
and heparin stopped. As of [**5-27**] echo with tamponade physiology,
could not be intervened by cards in cath lab. CT surgery then
consulted in case urgent pericardiocentesis needed. The patient
underwent an attempted at percutaneous drainage of the effusion
without success. Given her hemodynamic stability, further
attempts at drainage were deferred.
.
# Afib w/RVR: The patient had multiple episodes of Afib with RVR
that responded to a dilt gtt initially. On one episode of the
atrial fibrillation, the patient became hypotensive requiring
pressors. With cardioversion and and a diltiazem drip, her
atrial fibrillation resolved. Her diltiazem drip was weaned off
and she remained stable on amiodorone. She will be discharged
to complete 3 weeks of total oral amiodarone at which time the
amiodarone dose will decrease to 200 mg daily. TFTs and LFTs
should be monitored every few months.
# Anemia: The patient had decreased hematocrit on arrival, but
she responded to 1 unit of packed red cells. She had guaiac
negative stool and gastric fluid. A cause for her initial anemia
was not identified, though her hematocrit remained stable
throughout her course and was improved at discharge.
.
# Hypernatremia: The patient had elevated sodium throughout her
course and improved with increasing free water in her tube
feeds. This should be monitored periodically to maintain normal
serum sodium level.
.
# Respiratory failure: The patient is chronically on a vent
secondary to persistent vegetative state. She was continued on
the vent and adjustments were made as needed, based on her blood
gas. She became slightly hypoxic due to overload, but with one
dose of lasix she was stable. She will continue the vent at
rehab and adjustments should be made based on her blood gas
results.
.
# Coronary artery disease: The patient had an NSTEMI at [**Hospital1 2177**] in
[**9-/2170**], she was medically managed with ASA and beta-blocker at
that time, but was not on any medications for this on admission.
The patient had elevated enzymes, but her ck was flat and her
troponin trended down so this was not considered acs. She likely
had demand ischemia with her anemia. Based on her risk factors
she was started on statin and ASA. A beta-blocker should be
started in the future if her pressure can tolerate it.
.
# Seizure activity: Patient with chin movements, EEG was
somewhat abnormal so neurology was called for assistance with
interpretation. The patient was continued on keppra with no
further issues.
.
# Pontine Hemorrhage, persistent vegetative state: This was a
stable issue and the patient was continued on tube feeds and
ventilation.
.
# Multiple ulcers: The patient had multiple skin ulcers that
were evaluated by the wound nurse and did not appear infected.
She did well with wound care and should continue to have the
wounds cared for at rehab.
.
#Recto-vaginal fistula: On [**6-2**], it was noted that there was
stool in the vaginal vault. A peliv exam confirmed this. A GYN
consult was obtained who performed a methylene blue test and
cofnirmed the presence of a fistula. They did not feel that
there was urgent need for repair. They requested a [**Month/Year (2) 4338**] with coil
to evaluate the fistula; however, this was difficult to obtain
in the inpatient setting. We reccomened obtaining this as an
outpt and following up with GYN as an outpt.
.
# Nutrition: The patient's PEG tube was not working so she was
fed tube feeds through an NG tube. She had her tube replaced by
IR ([**5-24**]) during her admission, and will continue tube feeds at
rehab. For her nutrition she will be on vitamin c and zinc
until [**5-30**] and should have free water boluses adjusted based on
her sodium levels.
.
# PICC: d/c with PICC. Please d/c when abx finished.
.
# Dispo: The patient was discharged in stable condition to a
long-term care facility.
Medications on Admission:
Tylenol elixir 650 mg QID PRN
Keppra 500 mg Q12 hours
Zinc 220 mg daily
Vitamin C 500 mg [**Hospital1 **]
MVI
Feosol 325 mg daily
Nexium 40 mg daily
Combivent 4 puffs QID
H2O flushes to GT 400 cc Q3 hours
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Tylenol 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO four times a day as
needed for pain.
3. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day): through tube.
4. Zinc Sulfate 220 (50) mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily) for 9 days: until [**5-30**].
5. Ascorbic Acid 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2
times a day) for 9 days: until [**5-30**].
6. Therapeutic Multivitamin Liquid [**Month/Year (2) **]: One (1) Cap PO DAILY
(Daily): until Tube feeds at 50 cc/hr.
7. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Year (2) **]: One (1) PO DAILY
(Daily): 325 mg daily.
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Month/Year (2) **]: Two
(2) Puff Inhalation Q6H (every 6 hours).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**1-8**]
Drops Ophthalmic PRN (as needed).
12. Tobramycin Sulfate 40 mg/mL Solution [**Month/Day (2) **]: Four (4) mL
Injection Q 36 H () for 8 days.
13. Amiodarone 200 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY
(Daily) for 2 weeks.
14. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day:
to start after 400 mg dose completed.
15. Ofloxacin 0.3 % Drops [**Month/Day (2) **]: Ten (10) Drop Otic DAILY (Daily)
as needed for otitis externa for 7 days.
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (2) **]: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary:
1. Sepsis caused by urinary tract infection and pneumonia
2. Chronic respiratory failure
3. Hypernatremia
4. Paroxysmal atrial fibrillation
5. Loculated pericardial effusion
.
Secondary:
Persistent Vegetative State
Decubitus wounds
Discharge Condition:
stable, afebrile
Discharge Instructions:
1. Patient admitted with sepsis and found to have UTI and
pneumonia. The hospital course was complicated by exudative
pericardial effusion but was discharged with stable
hemodynamics.
.
2. Complete course of antibiotics for 21 days.
.
3. Return for fevers, chills, hypotension, abdominal distention.
Followup Instructions:
1. Would follow-up with Dr. [**Last Name (STitle) **] in 1 week
.
2. GYN: Would call [**Telephone/Fax (1) 2664**] to scheudle a follow up after
[**Telephone/Fax (1) 4338**] is completed.
.
[**Telephone/Fax (1) 4338**]:
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2171-6-21**] 8:20
NPO four hours prior.
|
[
"619.1",
"V44.0",
"780.39",
"780.03",
"482.1",
"599.0",
"707.04",
"518.83",
"038.8",
"041.3",
"999.9",
"996.79",
"285.29",
"785.52",
"438.89",
"428.20",
"412",
"276.0",
"707.8",
"428.0",
"423.0",
"707.07",
"427.31",
"414.01",
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icd9cm
|
[
[
[]
]
] |
[
"96.56",
"33.21",
"96.72",
"38.93",
"37.0",
"99.04",
"37.21",
"43.11",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16732, 16787
|
8744, 14587
|
327, 342
|
17072, 17091
|
3459, 8721
|
17439, 17785
|
2418, 2436
|
14843, 16709
|
16808, 17051
|
14613, 14820
|
17115, 17416
|
2451, 2451
|
2473, 3440
|
276, 289
|
370, 1892
|
1914, 2257
|
2289, 2386
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,921
| 135,037
|
15765
|
Discharge summary
|
report
|
Admission Date: [**2171-7-10**] Discharge Date: [**2171-7-11**]
Date of Birth: [**2111-9-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
pneumonia, EtOH & benzodiazepine intoxication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59 M with past medical history significant for heavy EtOH abuse,
COPD and multiple recent admissions for pneumonia and EtOH
withdrawal, found down today laying on a sofa. No report of
trauma. Yesterday the patient had a chest x-ray that showed
pneumonia; upon sobering he stated that he has been coughing and
was told to back to the ED for treatment of his pneumonia.
In the ED, initial VS were T 98, HR 88, BP 95/48, RR 14, SpO2
88% RA. On arrival, the patient was intoxicated and observed
overnight until sobriety. Portable CXR showed RLL infiltrate
that appeared improved from prior CXR on [**7-4**]. Labs were notable
for a serum EtOH level 265, positive serum benzos, Na 149,
lactate 1.8, and elevated bicarb 35. This morning, the patient
was found to be hypoxic to 87-88% on 6L NC. He was placed on a
NRB for about 20 min; O2 sat improved, then he was switched back
to nasal cannula with O2 sat 94-95% on 6L NC. He received
levofloxacin and will receive flagyl. The ED team was concerned
that the pneumonia seen on CXR did not fully account for the
degree of hypoxia, and ordered a CTA to rule out PE, however,
patient became upset and refused CTA so it was not performed.
The complained of alcohol withdrawal symptoms and received
ativan 0.5mg IV.
Of note, the patient has been hospitalized at least four times
over the past month, leaving AMA and eloping on most of his
hospitalizations. Most recently he eloped from the ED 2 days ago
([**7-8**]) after being searched by [**Hospital1 18**] police and before being
seen by an ED attending. In the past, he has threatened nursing
staff "I will come back and shoot you" and "I want you dead." He
has used profanities toward staff, has been uncooperative
requiring security involvement, leather restraints and
pharmacologic interventions.
On arrival to the MICU, the patient is lethargic and somewhat
somnolent, but becomes irritated when he is asked questions. He
is cursing at staff, but answering questions. During the
interview, when notified that he would not be receiving
methadone, he pulled out his IV and threatened to leave AMA.
Upon standing and putting on his clothes, he reported that he
felt too weak to leave, and decided to stay.
Past Medical History:
1. EtOH abuse
2. COPD
3. h/o PNAs
4. s/p [**Hospital1 8751**] w/ multiple fractures, splenectomy, jaw repair in
[**2161**]
5. chronic pain [**12-27**] [**Month/Day (2) 8751**] injuries
6. h/o hypercarbic respiratory failure
7. S/p splenectomy [**2161**]
8. Tobacco abuse
Social History:
Currently homeless, living at the [**Hospital1 **] Shelter in [**Location (un) 14307**]. He has been staying there for several months. He smokes 1
ppd. He drinks daily, at least 1 quart. He says that he would
even fight to get his alcohol. He says that he was sober for 10
years until both of his sons got into a car accident and died.
He used to be a roofer and helped to build many of the roofs of
the local hospitals in [**Location (un) 86**] area.
Family History:
Mother died from breast cancer. The father was a fireman and he
believes he died from lung cancer.
Physical Exam:
ADMISSION EXAM
General: somnolent, oriented to person/place/month/year, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Very poor inspiratory effort (pt not cooperative), poor
air movemement, very faint crackles heard at the bases R>L
Abdomen: soft, non-distended, midline scar s/p splenectomy,
bowel sounds present, no organomegaly, no tenderness to
palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, no focal deficit, gait deferred, no
asterixis
Psych: Agitated, non-cooperative
PATIENT LEFT AMA
Pertinent Results:
[**2171-7-10**] 10:03AM BLOOD WBC-4.4 RBC-4.22* Hgb-13.9* Hct-43.3
MCV-103* MCH-32.9* MCHC-32.1 RDW-15.9* Plt Ct-159
[**2171-7-9**] 11:45PM BLOOD Glucose-126* UreaN-6 Creat-0.5 Na-149*
K-3.3 Cl-105 HCO3-35* AnGap-12
[**2171-7-9**] 11:45PM BLOOD ALT-52* AST-65* AlkPhos-120 TotBili-0.3
[**2171-7-9**] 11:45PM BLOOD Calcium-9.2 Phos-4.7* Mg-1.5*
[**2171-7-9**] 11:45PM BLOOD ASA-NEG Ethanol-265* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
# Pneumonia: Patient had been admitted recently for hypoxia and
pneumonia and had left on [**7-5**] after receiving only 2 days of
treatment with levofloxacin and flagyl. However, sputum culture
from that admission grew coagulase + staph resistant to
levofloxacin. CXR performed on admission did show improvement of
the RLL infiltrate previously see on [**7-4**]. In the ED, the patient
received a dose of levofloxacin and flagyl. After arriving to
the MICU, the patient complained of being subjectively short of
breath, although physical signs were unconcerning. Patient was
started on bactrim ds 1 tab po q12hr based on sensitivity
patterns from the sputum culture. Patient left AMA on hospital
and antibiotic day 2.
# COPD: Given shortness of breath as well as history of greenish
sputum production, consideration was paid to potential
contribution of COPD exacerbation. Patient was offered
ipatropium and albuterol nebs, which he refused. Patient left
AMA as above.
# Alcoholism: Patient was actively abusing alcohol and presented
to the ED intoxicated. During our interview, he threatened to
leave AMA to go drink. He also refused to speak with social
worker. Ciwa scale was initiated q2hr with diazepam. Patient
required 60 mg diazepam over the course of the first 24 hrs.
Patient then left AMA>
# Chronic pain: Patient reported a history of chronic pain in
the context of multiple MVAs and surgeries. He claimed to be on
methadone, but during his last admission [**Date range (1) 45401**], his PCP was
[**Name (NI) 653**] and states that he has not prescribed the patient
methadone in 1 month because of aberrant behavior and repeatedly
negative urine tox screens. When told that he would not be
receiving methadone, the patient decided to leave AMA, but then
changed his mind because he said he felt too weak. Subsequently,
he left AMA.
# Tobacco abuse: Smoking cessation counseling and nicotine patch
were offered. Patient refused. Patient subsequently left AMA.
Discharge Disposition:
Home
Facility:
Patient left AMA
Discharge Diagnosis:
Pneumonia, EtOH, & Benzodiazepine intoxication
Discharge Condition:
Left AMA
Discharge Instructions:
N/A
Patient left AMA
Followup Instructions:
N/A
Patient left AMA
Completed by:[**2171-7-11**]
|
[
"491.21",
"303.01",
"V60.0",
"305.1",
"305.40",
"338.21",
"482.49",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6681, 6715
|
4681, 6658
|
319, 325
|
6805, 6815
|
4215, 4658
|
6884, 6935
|
3342, 3444
|
6736, 6784
|
6839, 6861
|
3459, 4196
|
233, 281
|
353, 2558
|
2580, 2853
|
2869, 3326
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,020
| 171,446
|
41867
|
Discharge summary
|
report
|
Admission Date: [**2173-12-13**] Discharge Date: [**2173-12-26**]
Date of Birth: [**2123-7-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
Intubation, TIPS procedure unsuccessful
History of Present Illness:
Patient is a 50 yo male with a PMH of hepatitis C, alcoholic
cirrhosis who was brought to [**Hospital 8**] Hospital by EMS on [**12-13**]
after being found down in his own hematemesis. He has been
assaulted the day prior and had been kicked in the chest stomach
and leg. He had been drinking [**1-17**] gallons of ETOH the night
prior. He initially reported abdominal pain and loss of
consciousness, unclear for how long. He was hypotensive to
94/36. He was given 3L NS. His initial hematocrit was 10 and on
repeat was 8, platelets were 60, INR 2.6. Blood alcohol level
was 149, anion gap 27, bicarb 7, creatinine 2.7, BUN 17, glucose
135. He was given 4 units of PRBCs and 2 units FFP. He began
vomiting frank blood for total volume 1.1 L. He was intubated
for endoscopy and upper airway protection. An upper endoscopy
was performed and 17 varices were banded which controlled his
bleeding. He received an additional 4 units PRBCs, 6 units of
platelets and 6 units of platelets.
Past Medical History:
Alcoholic cirrhosis
Hepatitis C
Pancreatitis
Spinal fracture
[**First Name4 (NamePattern1) **] [**Name (NI) **] [**Name (NI) **]
PTSD
Suicical Ideation
Anemia- baseline hematocrit 30
Glaucoma
Alcohol withdrawal with seizures and hallucinations
Social History:
Homeless. Drinks 1 pint to 1 gallon of liquor per day. Has a
brother who lives nearby.
Family History:
unknown
Physical Exam:
T: 98.2, P: 110, BP: 95/72, RR: 25, 100% on RA
General: intubated, sedated
HEENT: Sclera anicteric, 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
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
patient expired
Pertinent Results:
[**2173-12-14**] 12:14PM BLOOD WBC-3.6* RBC-3.21* Hgb-9.7* Hct-26.7*
MCV-83 MCH-30.4 MCHC-36.4* RDW-14.9 Plt Ct-76*
[**2173-12-14**] 08:26AM BLOOD WBC-3.4* RBC-3.31* Hgb-9.8* Hct-27.6*
MCV-83 MCH-29.7 MCHC-35.6* RDW-14.8 Plt Ct-76*#
[**2173-12-14**] 04:19AM BLOOD WBC-3.5* RBC-2.97* Hgb-8.9* Hct-24.6*
MCV-83 MCH-30.0 MCHC-36.2* RDW-15.1 Plt Ct-45*
[**2173-12-13**] 11:06PM BLOOD WBC-2.9* RBC-2.94* Hgb-8.7* Hct-24.7*
MCV-84 MCH-29.7 MCHC-35.4* RDW-14.8 Plt Ct-58*
[**2173-12-13**] 11:06PM BLOOD PT-21.0* PTT-35.2* INR(PT)-1.9*
[**2173-12-13**] 11:06PM BLOOD Plt Smr-VERY LOW Plt Ct-58*
[**2173-12-14**] 04:19AM BLOOD PT-19.4* PTT-29.9 INR(PT)-1.8*
[**2173-12-14**] 04:19AM BLOOD Plt Ct-45*
[**2173-12-14**] 08:26AM BLOOD Plt Ct-76*#
[**2173-12-14**] 12:14PM BLOOD Plt Ct-76*
[**2173-12-14**] 04:19AM BLOOD Glucose-114* UreaN-36* Creat-2.9* Na-147*
K-3.7 Cl-100 HCO3-28 AnGap-23*
[**2173-12-13**] 11:06PM BLOOD Glucose-135* UreaN-32* Creat-2.5* Na-143
K-3.6 Cl-100 HCO3-20* AnGap-27*
[**2173-12-14**] 04:19AM BLOOD CK(CPK)-1075*
[**2173-12-13**] 11:06PM BLOOD ALT-1738* AST-[**Numeric Identifier 71446**]* LD(LDH)-7620*
AlkPhos-87 TotBili-3.1*
[**2173-12-14**] 12:28PM BLOOD Type-ART Temp-37.9 Rates-18/6 Tidal V-450
PEEP-12 FiO2-50 pO2-80* pCO2-32* pH-7.52* calTCO2-27 Base XS-3
Intubat-INTUBATED
RUQ US: [**2173-12-19**]
FINDINGS: There are no focal hepatic lesions. The portal vein
shows sluggish
flow but is patent. The hepatic vasculature show normal
waveforms and are
patent. There is sludge in the gallbladder, but no acute
cholecystitis.
There is moderate-to-large amount of ascites. No intra- or
extra-hepatic
biliary dilatation. Pancreas not visualized due to overlying
bowel gas.
IMPRESSION: Sluggish flow but patent portal vein. Normal hepatic
vein and
hepatic artery.
CT HEAD [**2173-12-16**]
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or
infarction. The ventricles are normal in size and configuration.
The sulci
are globally markedly prominent, indicating considerable diffuse
cortical
atrophy. No fracture is identified. There is extensive
opacification of the bilateral ethmoid air cells and sphenoidal
sinuses. The maxillary sinuses were not imaged. The frontal
sinuses have not formed. The mastoid air cells and middle ear
cavities are clear bilaterally.
IMPRESSION:
1. No acute intracranial process.
2. Extensive bilateral sinus disease.
3. Marked diffuse cortical atrophy, unusually severe for the
patient's age.
Brief Hospital Course:
Patient is a 50 yo male with PMH of hep C and EtOH cirrhosis who
presents after being found down with massive hematemesis and
initial Hct 10 now s/p 8 units PRBCs, 6 units platelets and 8
units FFP and banding of 17 varices who developed acute
hepatitis, respiratory failure and ventilator associated
pneumonia.
#Variceal Bleed: Patient had massive hematemesis [**2-17**] variceal
bleed with nadir Hgb of 2.8, Hct of 8.8 who underwent EGD with
banding and massive transfusion. His HCT became stable. Active
type and screen was maintained. He was kept on octreotide drip
x 5 days and PPI drip for 5 days. He was then changed to
pantoprazole 40 mg iv BID. He had been initially intubated for
airway protection and 24 hours after extubation, he was called
out to the general medicine floor. The following day Code Blue
was called for respiratory/cardiac arrest in this patient (s/p
12 minutes of rescucitation), likely secondary to repeated
episode of GI bleed. He was transferred back to the ICU. Given
ongoing GI bleeding, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] was placed with good effect. He
then was scheduled to undergo an emergent TIPS procedure which
was not successful. The patient was transferred back to the ICU,
and TIPS was attempted the next day, but was once again
ultimately unsuccessful. a family meeting was held and given
lack of therapeutic options, and patient's poor prognosis,
family decided to stop supportive measured. Patient at this time
was on two pressors, and continued to ooze blood from mouth and
nares. [**Last Name (un) **] tube was discontinued, and his pressors were
stopped. At this point patient was extubated. He passed within
several minutes of being extubated with family at bedside. Time
of death was recorded as 1:20 on [**2173-12-26**]. Immediate cause of
death was felt to be variceal bleeding and acute renal failure,
chief cause of death was cirrhosis.
#Acute respiratory failure- in setting of being found
down/hematemesis initially; intubation was prolonged due to
ventilator associated pneumonia. He was extubated, but
reintubated in setting of cardiac arrest due to repeat bleed
and aspiration.
.
#Acute renal failure: likely secondary to shock in setting of
initial bleed. He required CVVH during both ICU admissions.
#ETOH abuse: patient's last drink [**12-12**]. Has had seizures and
hallucinations in the past with alcohol withdraw. He was
monitored for signs of alcohol withdrawal. He was given daily
thiamine. Patient was eventually converted to [**Last Name (LF) 3225**], [**First Name3 (LF) **] above.
Transitional Issues: Family requested no autopsy, and body to be
transported to patient's country of origin. I provided patient's
brother with a letter, stating that his brother has died and if
the passport services could expedite issuing a passport, if
possible.
Medications on Admission:
Multivitamin
Omeprazole
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
Completed by:[**2173-12-28**]
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13,988
| 123,095
|
3157
|
Discharge summary
|
report
|
Admission Date: [**2100-9-22**] Discharge Date: [**2100-10-1**]
Date of Birth: [**2026-2-26**] Sex: M
Service: MICU-ORANG
HISTORY OF PRESENT ILLNESS: This is a 74 year old gentleman
with type 2 diabetes mellitus, hypertension and a positive
tobacco history who presented to the Emergency Department for
acute onset of chest pain that awoke him out of bed early
morning, nine out of ten substernal chest pain, no radiation,
no diaphoresis. Positive nausea and vomiting times two; no
shortness of breath. He never has had chest pain like this
prior. No fever or chills, no cough.
REVIEW OF SYSTEMS: Review of systems reveals two months of
increasing fatigue, decreased exercise tolerance. No
abdominal pain, no change in bowel movements.
In the Emergency Department, the patient had a temperature of
95.6 F.; heart rate of 60; blood pressure of 160/110;
respiratory rate of 16, saturating 100% O2 on two liters
nasal cannula, in moderate distress with several episodes of
vomiting.
EKG showed new T wave inversion in II, III and AVF with no ST
elevation or depression. The patient was given
Nitroglycerin, Lopressor, aspirin, heparin, morphine with
decrease in the chest pain to five out of ten. CK enzymes
were 74, troponin less than 0.3. Cardiology was consulted
for question of ischemia. Prior to Cardiology consultation
in the Emergency Department, the patient then developed
change in his characterization of pain to the epigastric
area. CT scan was done which showed a Type B aortic
dissection originating at the left subclavian to the level of
the diaphragm. At that point, the heparin was discontinued.
CT Surgery was consulted and it was felt that there was no
indication for surgical intervention, recommended medical
management only. Cardiology consultation was in agreement.
The patient was started on heart rate and blood pressure
control with Nipride and Esmolol. The patient lost
intravenous access prior to initiation of these intravenous
drips. Before the central access was obtained, his heart
rate increased to the hundreds and his systolic blood
pressure into the 210s. A right femoral central line and a
right radial arterial line were placed without complication.
The patient at that point resumed on his intravenous blood
pressure medications with a decrease in his systolic blood
pressure to 120s and heart rate to the 70s. At that point,
the patient was transferred to the floor during which he was
lying more comfortably and states that chest pain had
decreased. Positive nausea and complaint of increased
thirst.
PAST MEDICAL HISTORY:
1. Type 2 diabetes melitis with last hemoglobin A1C of 5.2;
history of increased fingersticks secondary to dietary
indiscretion.
2. Metastatic prostate cancer status post radiation therapy
with radiation proctitis with resistance to androgen therapy.
3. Hypertension.
4. Gout.
5. Osteoarthritis.
6. HCV positive with low viral load, increased liver
function tests at baseline.
7. History of RPR positive with treponemal antibody positive
([**2098-5-1**]).
8. Orbital cellulitis ([**2100-1-1**]).
9. Borderline hypercholesterolemia.
Primary care physician is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
MEDICATIONS:
1. Glyburide 2.5 mg twice a day.
2. Hydrocortisone 20 mg q. a.m. and 10 mg q. p.m.
3. Hytrin 5 mg twice a day.
4. Indomethacin 25 mg p.r.n.
5. Ketoconazole 400 mg twice a day.
6. Leuprolide 22.5 mg every ten weeks.
7. Zoledronic acid 4 mg every ten weeks.
ALLERGIES: He has an allergy to Niferex which causes
anaphylaxis and an allergy to ACE inhibitors which causes
angioedema.
SOCIAL HISTORY: The patient has a positive tobacco history
of [**12-2**] pack a day times 40 years; continues to smoke. Former
alcohol use, former intravenous drug use. The patient lives
alone and has three children.
PHYSICAL EXAMINATION: Upon presentation to the Medical
Intensive Care Unit, his examination revealed he was
afebrile; heart rate 84; blood pressure 143/80; respiratory
rate 27; oxygen saturation 92% on room air. On general
examination, this is an elderly male who looks uncomfortable
but is in no acute distress. Head and Neck examination:
Pupils are minimally constrictive, but equal. Mucous
membranes were dry. No jugular venous distention. Neck is
supple. Carotids are two plus with no bruits. Chest is
clear to auscultation. Cardiac examination is regular rate,
normal S1, S2. Abdomen is obese, soft, nontender, positive
bowel sounds. Extremities with no lower extremity edema.
Distal pulses two plus, radial pulses two plus bilaterally.
Neurologic examination is alert and oriented; motor strength
five out of five bilaterally. Sensation intact bilaterally.
LABORATORY: His labs on examination were white blood cell
count of 5.2 with a differential of 52, neutrophils 40,
lymphocytes 7, 9 monos, and 1 eosinophil. Hematocrit 35.5,
platelets 337, INR is 1.1. Sodium 135, potassium 3.2,
chloride 101, bicarbonate 23, BUN 22, creatinine 1.2.
Glucose is 405. Calcium is 8.5 with free calcium of 1.04.
Albumin is 3.4. The PSA is 2.6. ALT is 61, AST 73, alkaline
phosphatase 121, amylase is 88, total bilirubin 1.1, lipase
39, lactate 1.8.
Repeat CK was 31 with troponin of 0.4.
EKG shows T wave inversions in II, III and AVF with normal
sinus rhythm at 60.
CT scan of the abdomen shows:
1. [**Location (un) 11916**] type B aortic dissection beginning just distal
to the left subclavian artery takeoff extending to the
diaphragmatic hiatus. Extra-luminal contrast within a mural
hematoma associated with dissection at the level of the
aortic arch.
2. Prominent iliac vessels, 1.5 centimeters.
3. Emphysematous changes in the lungs.
4. Scattered mediastinal nodes.
5. Sclerotic areas throughout the skeleton.
Chest x-ray shows stable compared with prior in [**2098-5-31**].
New minimal left basilar atelectasis.
Abdominal ultrasound with fatty infiltration of the liver,
hyper dense focus in the gallbladder wall with no stones.
HOSPITAL COURSE BY ORGAN SYSTEMS:
1. CARDIOVASCULAR: The patient was medically managed for
his aortic dissection with blood pressure and heart rate
control. The goal was a systolic blood pressure between 120
and 130 and heart rate between 60 to 70. On transfer to the
Medical Intensive Care Unit, the patient's Esmolol drip was
changed to Labetalol for dual blood pressure and heart rate
control with titration and the patient was continued on
Nitroprusside drip.
On the third hospital day, both the Nitroprusside and
Labetalol drips were turned off secondary to low systolic
blood pressure and heart rate. At that point, the patient
was started on a p.o. anti-hypertensive regimen starting with
p.o. Labetalol at 200 mg p.o. twice a day. Cardiology was
re-consulted to follow-up with request for recommendations of
blood pressure control. At that point, Amlodipine was
started at 5 mg q. day. Hytrin was also started at 5 mg
twice a day given the patient's history of benign prostatic
hypertrophy as well as anti-hypertensive effect.
The patient's Labetalol was increased to 300 mg twice a day.
The Nipride drip had to be restarted secondary to increase in
the patient's systolic blood pressure to the 170s despite his
oral regimen. The Labetalol was discontinued and the patient
was started on Metoprolol, initially at 25 mg p.o. three
times a day. His Amlodipine was increased to 10 mg p.o. q.
day.
The patient developed pain secondary to bladder irrigation
and his systolic blood pressure would rise during his spastic
pain episodes. The Metoprolol was increased to 75 mg three
times a day and the patient was given one dose of 5 mg of
Metoprolol when his systolic blood pressure reached the 170s.
Given that the patient remained on Nipride, there was a push
to wean secondary to fear for development of cyanide
toxicity. The Lopressor was at that point increased to 100
mg twice a day. The patient was given Hydrochlorothiazide 15
mg q. day.
The patient also had Minoxidil at 10 mg twice a day added.
On the above medications, the patient had adequate blood
pressure and heart rate control, however, his systolic blood
pressure then began to fall; the patient was given repeated
fluid boluses with minimal improvement. His
anti-hypertensive medications at that point were withheld and
his blood pressure began to rise but still remained less than
one systolic blood pressure of 130.
At this point, evaluation for change in his blood pressure
was undertaken and the patient was found to have
Staphylococcus aureus sepsis, explaining the hypotension.
When the patient's blood pressure began to rise with clinical
improvement of his sepsis, he was restarted on low dose
Metoprolol and adjusted accordingly for elevation in his
heart rate and systolic blood pressure.
The patient was increased to 100 mg p.o. twice a day;
Amlodipine was restarted at 5 mg p.o. q. day; Hytrin was
started at 5 mg p.o. twice a day. Further blood pressure
control was curtailed secondary to the patient choosing to
leave the hospital against medical advice in order to attend
to personal affairs.
When the patient left, his systolic blood pressure was within
goal range, between 120 to 130 and his heart rate was less
than 70; however, it is not known HOSPITAL COURSE:w his blood
pressure will change as he continues to improve from his
sepsis and as he begins to have increased activity.
During the [**Hospital 228**] hospital course, he was monitored
closely for evidence of worsening aortic dissection. He had
a repeat CT scan during his hospital course secondary to
decreased urine output, which showed no change in the aortic
dissection since presentation. The case was discussed with
Cardiothoracic Surgery who recommended that the patient
follow-up with CT scan in one month in order to evaluate.
The patient was monitored on Telemetry through his hospital
course. The patient developed sinus arrhythmia, during which
he was asymptomatic. Repeated electrocardiograms showed no
ST wave changes. The patient then continued to have normal
sinus rhythm with occasional PACs.
2. INFECTIOUS DISEASE: During the [**Hospital 228**] hospital
course, he was found to have a fever, at which point he was
pan cultured with chest x-ray. Urinalysis showed increased
white blood cells and many bacteria, but also squamous
epithelial cells. Culture was negative for growth. The
patient was unable to produce sputum for culture. Chest
x-ray showed new bibasilar bilateral increased opacities,
left greater than right with pleural effusions. Differential
diagnosis was atelectasis versus infiltrate.
At this point, the patient was started empirically on
Levaquin. His blood cultures then came back with four out of
four bottles of Gram positive cocci. The patient, at that
point, was started on Vancomycin. His right radial arterial
line and right femoral lines were both pulled secondary to
erythematous appearance and likely source of bacterial
infection. Sensitivities on the blood cultures came back
with Methicillin sensitive Staphylococcus aureus. The
patient was taken off of the Vancomycin and then started on
Oxacillin intravenously.
He received two doses of intravenous Oxacillin prior to
leaving the hospital, after which he was given a prescription
for Dicloxacillin. One set of surveillance blood cultures
were able to be drawn which were no growth as of the last
hospital day.
Discussion with Infectious Disease regarding whether the
patient should follow-up with echocardiogram: Given that the
source of infection was likely line and it was removed, they
did not feel that an echocardiogram was required. Also, they
recommended that given that the patient has a fibrin clot
with the aortic dissection, it would be prudent to do four
weeks of p.o. antibiotic therapy versus two weeks.
3. RENAL: The patient had decreasing urine output with very
dark urine. This was thought to be secondary to hypovolemia,
but there was concern for renal artery ischemia secondary to
presence of aortic dissection, decreasing renal clearance
secondary to intravenous contrast dye insult. The patient
was given fluid boluses with minimal increase in his urine
output.
At that point, the patient was reevaluated via CT scan for
ischemia to the renal artery which was negative. The patient
was given pre-hydration and post-hydration fluid given the
second dye load.
The patient's urine output improved, but then the patient
developed frankly bloody urine with clots. This was thought
to be possibly be due trauma via the Foley, which was also
causing the patient pain. The Foley was removed, but then
the patient had minimal urine output. At that point a three
way Foley was placed with flush. The patient was started on
Ditropan and morphine for pain.
Urology was consulted who recommended that a 20 French Foley
be placed with continuous bladder irrigation, titrating to
clear. This caused considerable pain to the patient and the
irrigation was discontinued with the occasional flushes
p.r.n. The patient, at that point, had decreasing clots.
He had evidence of bladder spasm with episodic pain for which
he was given morphine. The Ditropan was increased in dose.
His bladder spasm symptoms resolved and his hematuria
improved, but did not resolve.
At the time of discharge, the patient had a condom catheter,
without any evidence of urinary retention symptoms. The
patient was continued on his Ketoconazole 400 mg twice a day
for his prostate cancer therapy. The patient was also given
one dose of Leuprolide 2.5 mg given that it was the time for
this dose. The Zedronic acid was held, however, given his
decreased urine output.
4. ENDOCRINE: The patient had elevated blood sugars at the
time of admission. He was placed on an insulin drip with
titration to keep his blood sugars between 80 to 120. He was
weaned off the insulin drip and started on NPH at 35 units in
the morning and 14 units at bedtime with regular insulin
sliding scale adjustment according to fingersticks. His NPH
was withheld secondary to bouts of hypoglycemia during his
sepsis because of somnolence and decreased p.o. However, as
the patient began to take in full p.o., his standing insulin
doses were resumed.
Given that the patient left early, he was not able to be
transitioned to an oral diabetic [**Doctor Last Name 360**], or taught how to
administer insulin. Therefore, he was instructed just to
continue his outpatient dose of Glyburide 2.5 mg twice a day.
The patient has a history of Ketoconazole induced borderline
Addison's Disease. He is on a standing hydrocortisone of 20
in the morning and 10 in the evening. During his sepsis, his
doses were doubled to hydrocortisone of 40 and 20, which was
maintained for three days, at which point the patient was
then returned to his usual standing doses.
4. GASTROINTESTINAL: The patient has baseline elevated
liver function tests with fatty liver and history of HCV. He
was maintained on a bowel regimen during his hospital course
secondary to his narcotics to avoid constipation.
5. PULMONARY: The patient had tobacco history with evidence
of emphysematous changes. He did not require supplemental
oxygen. Given the chest x-ray findings which were felt to be
likely secondary to atelectasis, given that the crackles on
his lung examination cleared with the coughing, the patient
was started on incentive spirometry.
6. NEUROLOGICAL: The patient had a change in mental status
during his sepsis. It was felt that his increased somnolence
was likely secondary to his infection as well as morphine
administration secondary to pain. The morphine was
discontinued and the patient was given Tylenol only p.r.n.
which he did not require.
The patient had an episode of agitation for which he was
started on Zyprexa. This was discontinued whenever patient
returned to his baseline.
7. FLUIDS, ELECTROLYTES AND NUTRITION: The patient had his
electrolytes repleted p.r.n. He had consistently low
magnesium levels for which he was started on magnesium oxide
standing at 800 mg p.o. three times a day.
8. PROPHYLAXIS: The patient was maintained on Protonix and
Pneumo boots throughout his hospital course.
DISPOSITION: The patient stated that he needed to leave the
hospital secondary to issues at home which he needed to take
care of. It was explained at length to the patient and to
his son that his blood pressure was not under adequate
control yet and that he was still recovering from sepsis.
The patient understood that he was taking a risk with his
health, but refused to stay, stating that he needed to attend
to these personal matters at home.
DISCHARGE INSTRUCTIONS:
1. He was instructed to return to the Emergency Department
immediately for symptoms of chest pain or fever.
2. The patient was scheduled for episodic follow-up visit at
the [**Hospital 191**] Clinic with Dr. [**Last Name (STitle) **], who had the next available
appointment.
DISCHARGE MEDICATIONS: He was given prescriptions for the
following medications:
1. Metoprolol 100 mg p.o. twice a day.
2. Dicloxacillin 500 mg p.o. q. six times one month.
3. Protonix 40 mg p.o. q. day.
4. Magnesium oxide 800 mg p.o. three times a day.
5. Amlodipine 10 mg p.o. q. day.
6. He was instructed to continue his Glyburide at 2.5 mg
p.o. twice a day.
7. Hydrocortisone 20 mg p.o. q. a.m., 10 mg p.o. q. p.m.
8. Hytrin 5 mg twice a day.
9. Ketoconazole 400 mg twice a day.
DISCHARGE DIAGNOSES:
1. Type B aortic dissection.
2. Hypertension.
3. Methicillin sensitive Staphylococcus aureus sepsis.
4. Diabetes mellitus.
5. Hematuria.
6. Metastatic prostate cancer.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 9296**]
MEDQUIST36
D: [**2100-10-2**] 16:00
T: [**2100-10-2**] 16:26
JOB#: [**Job Number 14897**]
|
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|
3662, 3866
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62
| 116,009
|
8344
|
Discharge summary
|
report
|
Admission Date: [**2113-2-15**] Discharge Date: [**2113-2-19**]
Date of Birth: [**2044-5-8**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
altered mental status, hypotension
Major Surgical or Invasive Procedure:
R IJ central line
History of Present Illness:
68 y/o M with SLE who p/w 1d hx of dysuria, polyuria, chills,
mental status changes. Driving with wife and drove onto grass [**Street Address(1) 29525**]. States urine was "bright red" with increasing
urgency, called PCP and was told to go to hospital. En route,
had episodes of n/v, worsening mental status. Denies pain.
In ED, initially given ASA, lopressor, then MUST protocol
started. Got 4.5L IVFs, started on levophed/vasopressin.
Lactate=4.4; Given dose of levo/flagyl. T 101.3 HR 115 BP 129/63
RR 18 96% on RA. Dirty urine.
In MICU, weaned off pressors. Switched to GENT for empiric
coverage of GNR bacteremia. Started on Fluconazole emperically
for yeast in the blood. Hydrated with IVF and remained
hemodynamically stable.
Transferred to Medicine on [**2112-2-17**].
Past Medical History:
SLE- on plaquenil
Social History:
doesn't smoke, [**4-14**] glasses wine/night
Married, no children, retired writer
Family History:
non-contributory
Physical Exam:
On admission [**2113-2-15**]
vitals: T 101.3, BP 129/63, HR 115, RR 18, 96% RA
Gen: ashen appearing, cachectic, but NAD
HEENT: PERRLA/EOMI; MMM; OP Clear
PUlM: CTA b/l. no r/r/w
CV: Normal S1/S2. tachycardic. no m/r/g
ABD: BS present, soft, NT/ND
EXT: no edema, warm
Neuro: A&O x 3. downgoing toes b/l. 5/5 strength
skin: no rash/lesions
Neck: R neck hematoma, RIJ in place
*
On transfer from MICU [**2113-2-17**]
vitals: 97.9, BP 122/70, HR 47, RR 20 , 95% on RA
Gen- well appearing, sitting up in bed, communicating
appropriately
HEENT- PERRLA/EOMI. no scleral injection. OP w/ mild posterior
pharyngeal erythema.
Neck- supple. R IJ central line in place
PULM- CTA b/l. no r/r/w
CV- RRR. no m/r/g. normal s1/s2
ABD- soft, NT/ND. NABS
EXT- 2+ pedal edema b/l. No joint swelling or redness.
NEURO- A&O x 3. CN II-XII intact.
SKin- no diaphoresis, no rash
Pertinent Results:
Admission labs:
*
WBC-2.0* RBC-4.29* Hgb-13.5* Hct-39.7* MCV-93 MCH-31.4 MCHC-33.9
RDW-13.6 Plt Ct-151
Neuts-78* Bands-7* Lymphs-13* Monos-2
Gran Ct-1680*
Glucose-125* UreaN-20 Creat-0.9 Na-138 K-3.3 Cl-105 HCO3-23
AnGap-13
BLOOD ALT-15 AST-18 AlkPhos-42 Amylase-32 TotBili-0.3
Albumin-2.7* Calcium-6.8* Phos-0.8* Mg-1.3*
BLOOD Cortsol-36.6*
BLOOD Genta-0.8*
BLOOD Type-[**Last Name (un) **] pO2-35* pCO2-37 pH-7.40 calHCO3-24
BLOOD Lactate-4.4*
*
Micro:
Blood Cx [**2-14**]: Enterobacter (4/4 bottles) pansensitive, Yeast
Urine Cx [**2-15**]: Negative
Blood Cx [**2-17**]: no growth to date
Blood Cx [**2-18**]: no growth to date
*
Radiologic Studies:
CXR [**2113-2-15**]: negative for failure/infiltrate
CT abdomen [**2113-2-18**]: gallstones w/ gallbladder wall edema,
moderate bilateral pleural effusions, normal colon with no
evidence of diverticulosis/diverticulitis
*
Transthoracic ECHO [**2113-2-15**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**2-12**]+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Brief Hospital Course:
Brief [**Hospital **] Hospital Course is outlined below:
1) Enterobacter bacteremia: The patient was initially admitted
to the ICU on the MUST protocol based on a lactate of 4.4. He
was mildly hypotensive and febrile to 101.4. He was aggressively
hydrated with IVF and empirically initiated on amp/gent. He was
briefly placed on levophed/vasopressin pressors but was able to
be weaned off by his second hospital day. Blood cultures from
admission grew enterobacter in [**5-15**] bottles, pan sensitive. In
addition cultures were positive for yeast, unspeciated upon
discharge. Fluconazole was added to his regimen and ampicillin
was discontinued. The source of his infection was unclear,
although urine source was suspected given dirty urine on
admission. Admission urinalysis showed >50 RBCs, >50 WBC's and
moderate leukocytes, although urine cultures were negative. The
patient was transferred to the medicine service on [**2-17**], hospital
day #3. ID was consulted and recommended a switch to levaquin
based on culture sensitivities. Flagyl was also added for
empiric GI coverage pending further evaluation. CT abdomen was
performed and demonstrated no evidence of abscess or bowel
pathology. There was mention of gallstones and gallbladder wall
thickening suspicious for cholecystitis. However the patient
remained afebrile with no abdominal pains and normal liver
function tests. Given his clinical stability with maintenance of
his blood pressure off IVF, tolerance of PO intake, and absence
of fever, he was discharged to home on [**2-19**]. He was discharged
home on PO levaquin and PO fluconazole for a 14 day course based
on ID recommendations. Flagyl was discontinued. He will
follow-up with his PCP [**Last Name (NamePattern4) **] [**2-12**] weeks.
2) Rheumatoid arthritis- previoiusly on plaquenil, so relatively
immunosuppressed. Granulocyte count on admission= 1680, so he
was not neutropenic. He was re-started on plaquenil after he was
clinically stable.
3) Anemia: secondary to SLE likely. Goal HCT>27. Hct remained
>30 through his hospital course. Initital decrease in hematocrit
was likely secondary to IVF hydration.
4) Edema: Noted peripheral edema following IVF hydration. He was
also noted to have bilateral pleural effusions by CT scan, also
likely secondary to aggressive fluid resuscitation. He was not
started on lasix since he was able to autodiurese well, with >2
liters off over the last 24 hours prior to discharge.
5) Mental status change: Initially delirious on admission,
likely secondary to his underlying infection. Once infection
cleared his mental status improved back to baseline. No further
evaluation was performed.
Medications on Admission:
home meds: plaquenil 200mg/400mg alternating days
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO EVERY OTHER DAY (Every Other Day).
2. Hydroxychloroquine Sulfate 200 mg Tablet Sig: Two (2) Tablet
PO EVERY OTHER DAY (Every Other Day): alternate days with 200mg
dose.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Enterobacter bacteremia (pan-sensitive)
Secondary Diagnosis:
1. SLE
2. Rheumatoid arthritis
Discharge Condition:
good. hemodynamically stable. afebrile.
Discharge Instructions:
Report fever, chills, lightheadedness, stomach pains or bleeding
to your PCP.
Please complete your antibiotic regimen as prescribed below.
Stay well-hydrated. Drink at least [**4-14**] 8oz glasses of water each
day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1007**] in [**2-12**] weeks at phone #
[**Telephone/Fax (1) 10492**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
[
"710.0",
"714.0",
"038.49",
"112.5",
"285.9",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6948, 6954
|
3681, 6347
|
316, 335
|
7113, 7154
|
2209, 2209
|
7419, 7671
|
1300, 1318
|
6448, 6925
|
6975, 6975
|
6373, 6425
|
7178, 7396
|
1333, 2190
|
242, 278
|
363, 1144
|
7059, 7092
|
2225, 3658
|
6994, 7038
|
1166, 1185
|
1201, 1284
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,551
| 170,532
|
45822
|
Discharge summary
|
report
|
Admission Date: [**2194-8-17**] Discharge Date: [**2194-8-29**]
Date of Birth: [**2149-12-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
Shortness of breath/Fatigue
Major Surgical or Invasive Procedure:
Pleurex drain placement by interventional pulmonology
History of Present Illness:
patient is a 44yoF with congenital developmental delay who
presented to OSH with fevers, shortness of breath, weight gain,
and lower extremity swelling for several weeks. Patient's
parents noted lower extremity swelling, left greater than right
for last several months. Presented to her PCP [**Name Initial (PRE) **] 1 week PTP
who felt she may have heart failure and started empiric diuresis
(patient is adverse to testing and becomes very anxious)
Started on 40 mg PO lasix daily at that time with moderate
improvement in her LE swelling. . Regarding her fevers,
temperatures reported to be in the 101 region intermittingly for
about last 2 weeks. Additionally having sore throat, copious
rhinorrhea, dry cough, which per report appeared to improve.
Three days PTP however became febrile again. per patient's
family, she has had no changes in baseline mental status, and
has not had any vomiting, chest pain, abd pain, diarrhea, or
dysuria although patient is a poor historian. No sick contacts.
.
At the OSH found to be hypoxic at 89-92%. Improved on 5L NC and
treated empirically with Lasix and Levofloxaicn. OSH xray
showed diffuse underlying interstitial lung disease, a new large
L pleural effusion, small R pleural effusion, mild congestive
failure, LLL consolidation, ?RLL consolidation as well. CT chest
at [**Hospital1 **] [**Location (un) 620**] showed interstitial edema, LLL collapse, b/l
pleural effusions, and small pericardial effusion. The patient
was transferred from [**Hospital1 **] [**Location (un) 620**] to [**Hospital1 18**] for further evaluation
.
In the ED, patient was afebrile satting 97% on 5L. She was
given Vancomycin 1gm IV for possible pneumonia and was admitted
to the MICU for possible thoracentesis and further management.
.
In the ICU, patient was diuresed with 20 mg IV lasix.
Thoracentesis was considered but deferred given patients
stability and anticipated difficulty for performing
thoracentesis in this patient with mental retardation. Her
vitals remained stabily in the high 90's/low 100's. She
continued to saturate in the 90-95% range on 2L NC. She was
diuresed for a total volume of 720 cc's negative. BP's ran in
the high 90's/low 100's systolic (her baseline). An ECHO was
performed which failed to show evidence of heart failure (EF
55%), but did confirm trivial pericardial effussion as well as
possible small PFO.
.
On call out to the floor patient was afebrile, HR of 101, BP
98/51, RR 26-33, satting 95% on 2L NC.
.
Review of systems (conducted with assistance from patient's
Mother and Father).
(+) Per HPI
(-) Denies chills, night sweats. Denies headache, sinus
tenderness. 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:
- Developmental delay
- born with "X,Y male chromosome" per her mother's report. No
records to review. Had surgical correction so that she is
brought
up as a female.
- Seizure Disorder (last seizure [**2167**]) on phenobarb since age of
18
- CKD (had bilateral kidney dysfunction due to congenital
bladder valve) Unknown creatinine baseline
- Osteoporosis
- MVR
- Allergic rhinitis
- Asthma
Social History:
- Tobacco: none
- Alcohol: none
- Illicits: none
Lives at a group home during the week with five other tenants,
and lives with parents on the weekend.
Family History:
Per OMR and parents ->
F: HTN, high cholesterol, prostate cancer.
[**Doctor Last Name 22583**]: DM.
MGF: heart disease.
Maternal great grandmother mastectomy in 50's.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97 HR of 101, BP 98/51, RR 26-33, satting 95% on 2L
NC.
General: Alert, interactive, able to follow simple commands, no
acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, well circumscribed nontender 1cm subcutaneous
nodule in left supraclavicular area.
CV: Tachycardic, Normal S1/S2, no murmurs or rubs
Lungs: Right sided sounds with mild rhonchi in upper lung fields
with mild crackles at bases and decreased BS at the lower bases.
Left lung is mildly rhonchoruous in ULF, very decreased breath
sounds starting at the mid lung field. No wheezes.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: Warm, well perfused, equal and palpable pedal pulses b/l,
no clubbing, cyanosis, trace pitting pedal edema b/l L>R with no
TTP.
Neuro: not answering questions consistently, but able to follow
commands. Family confirms this is patient's baseline neurologic
function.
.
DISCHARGE PHYSICAL EXAM:
Vitals: no morning vitals, RR 22, 89% 5L and shovel mask
GENERAL: sitting up in bed, occassional cough, not verbal but
interactive
HEENT: OP clear
CARDIAC: RRR, S1/S2, no mrg
LUNG: diffuse rhonchi, L>R
M/S: moving all. extremities well, +cyanosis, +pitting edema
Pertinent Results:
ADMISSION LABS:
[**2194-8-17**] 11:33PM BLOOD WBC-8.8 RBC-5.09 Hgb-14.5 Hct-41.9 MCV-82
MCH-28.6 MCHC-34.7 RDW-13.8 Plt Ct-241
[**2194-8-17**] 11:33PM BLOOD Neuts-84.3* Lymphs-8.9* Monos-5.5 Eos-1.0
Baso-0.2
[**2194-8-17**] 11:33PM BLOOD Glucose-114* UreaN-16 Creat-1.1 Na-139
K-4.2 Cl-100 HCO3-26 AnGap-17
[**2194-8-17**] 11:33PM BLOOD ALT-11 AST-17 LD(LDH)-206 CK(CPK)-72
AlkPhos-108* TotBili-0.3
[**2194-8-17**] 11:33PM BLOOD CK-MB-3 cTropnT-<0.01
[**2194-8-17**] 11:33PM BLOOD TotProt-6.9 Albumin-3.5 Globuln-3.4
Calcium-9.0 Phos-3.8 Mg-2.1
[**2194-8-17**] 11:33PM BLOOD Phenoba-27.3
[**2194-8-17**] 11:33PM BLOOD TSH-1.3
[**2194-8-18**] 10:23PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2194-8-18**] 10:23PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2194-8-18**] 10:23PM URINE RBC-5* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
.
MICRO:
[**8-17**], [**8-23**] BLOOD CULTURE NO GROWTH TO DATE
[**8-17**] URINE CULTURE NO GROWTH FINAL
[**8-19**] RESPIRATORY VIRAL SCREEN NEGATIVE
[**8-19**] PLEURAL FLUID GRAM STAIN AND CULTURE NEGATIVE
.
CYTOLOGY:
[**2194-8-19**] 03:30PM PLEURAL WBC-2750* RBC-5750* Polys-31*
Lymphs-44* Monos-0 Eos-1* Meso-3* Macro-20* Other-1*
[**2194-8-19**] 03:30PM PLEURAL TotProt-5.1 Glucose-100 LD(LDH)-397
Albumin-2.7
POSITIVE FOR MALIGNANT CELLS,
consistent with metastatic adenocarcinoma.
.
IMAGING:
[**8-18**] TTE: The left atrium and right atrium are normal in cavity
size. A few microbubbles are seen in the left heart very late
after intravenous injection c/w transpulmonic passage (small PFO
cannot be fully excluded, but less likely). The estimated right
atrial pressure is 5-10 mmHg. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic 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 high normal.
There is a trivial/physiologic pericardial effusion. Very
prominent bilateral pleural effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Prominent bilateteral pleural effusion.
.
[**8-19**] BILATERAL LENIS: Grayscale, color, and pulse Doppler
son[**Name (NI) 493**] imaging was performed of the bilateral common
femoral, superficial femoral, popliteal, peroneal and posterior
tibial veins. Normal compressibility, flow, and augmentation was
demonstrated.
IMPRESSION: No DVT in either lower extremity.
.
[**8-21**] VIDEO SWALLOW: Barium passes freely through the oropharynx
without evidence of obstruction. There was no gross aspiration
or penetration. For details, please refer to speech and swallow
division note in OMR.
IMPRESSION: No aspiration of thin and nectar-thick liquids in
exam limited by patient cooperation.
.
[**8-23**] CT NECK, THORAX, ABDOMEN, PELVIS: CT CHEST WITH CONTRAST:
There are multiple bilateral supraclavicular nodes, the largest
on the left, measuring 16 x 16 mm (3:10). The thyroid gland is
normal in appearance. There is a 17 x 15 mm upper paratracheal
node (3:18). There are multiple prevascular lymph nodes, the
largest measuring 28 x 14 mm (3:25). There is a lower right
paratracheal node measuring 15 x 12 mm (3:27) and a subcarinal
lymph node measuring 39 x 19 mm (3:35). There is bilateral
hilar adenopathy with a left-sided hilar node measuring 16 x 14
mm (3:31) and a right-sided hilar lymph node measuring 19 x 14
mm (3:32). There is no evidence of pulmonary embolism.
There is interlobular septal thickening bilaterally and diffuse
alveolar
ground glass opacity consistent with diffuse pulmonary edema.
The trachea, right main bronchus and segmental and subsegmental
branches of the right main bronchus are patent. The left lower
lobe bronchus is abruptly narrowed (400B:33). There is dense
consolidation of the left lower lobe with hypoattenuating areas
within the lung parenchyma which may be due to ischemia or
hypoperfusion. There is right lower lobe consolidation.
There are diffuse peribronchovascular nodular areas within the
lungs
bilaterally, predominantly within the mid and lower zones. No
dominant
pulmonary mass is identified to suggest a lung primary. No
endobronchial
lesion is identified. There are large bilateral pleural
effusions. The heart is normal in size. No pericardial effusion.
CT ABDOMEN:
The liver is normal in appearance without focal liver lesion.
There is no
intra- or extra-hepatic ductal dilatation. Both adrenal glands,
spleen and pancreas are normal. The portal veins and hepatic
veins are patent.
Both kidneys enhance and excrete contrast symmetrically without
evidence of hydronephrosis. There is an 11 mm caliceal
diverticulum within the upper pole of the left kidney (3:67).
There is a cortical scar in the lower pole of the left kidney
(3:75). There is no retroperitoneal or mesenteric adenopathy.
There is no free air or free fluid. The aorta is of normal
caliber.
CT PELVIS: There is apparent thickening of the cecal tip, which
is of
doubtful significance (3:105). There is no pathologically
enlarged
mesenteric, intrapelvic or inguinal adenopathy. Urinary bladder
is normal in appearance. The rectum and sigmoid are normal in
appearance. The uterus is not identified. There is no free fluid
or free air.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion
identified.
Moderate degenerative changes of the left SI joint with some
joint space
narrowing present. Moderate degenerative changes with anterior
osteophyte
formation at T11-L1. Congenital cervical vertebral fusion noted
of C5-C7.
IMPRESSION:
1. Diffuse pulmonary abnormalities including ground glass
opacity and septal thickening and nodular and
peribronchovascular densities. The findings are consistent with
pulmonary edema and additional neoplastic and/or infectious
airspace disease. In the setting of positive pleural cytology,
mediastinal adenopathy and obstructive disease in left lower
lobe, findings are concerning for diffuse malignancy. Pulmonary
edema may be noncardiogenic or due to lymphatic obstruction.
2. While no definite dominant mass is identified to suggest a
lung primary, abrupt narrowing of the left lower lobe bronchus
with dense left lower lobe consolidation is noted suggesting a
focal or endobronchial mass at that location. Hypoattenuating
areas within the left lower lobe consolidation suggest
infarction/hypoperfusion.
3. Large bilateral pleural effusions.
4. Cecal wall thickening which is of doubtful significance. A
definite
primary neoplastic lesion is not identified in the abdomen or
pelvis.
DISCHARGE LABS:
As patient was CMO, no labs were drawn daily on discharge.
Brief Hospital Course:
Ms. [**Known lastname **] is a 44 year old female with congenital
developmental delay who presented initially to [**Hospital1 **] [**Location (un) 620**] with
fever, shortness of breath, weight gain, and lower extremity
swelling then transferred to the MICU for with suspicion of
bilateral pneumonia and left sided pleural effusion. She was
later found have adenocarcinoma of unknown primary (likely lung
versus breast) with likely lymphangitic spread to lung.
.
# Adenocarcinoma: Found in pleural fluid, unknown primary.
Oncology service was consulted and are following. CT torso
showed likely lymphangitic spread rather than pneumonia.
Possible primary in lung with many enlarged lymph nodes in neck,
no evidence for primary cancer in abdomen. No mets to liver.
EGFR testing was never sent per decision of initial oncology
evaluation team and the fact that there was not enough tissue in
the initial cell block.
.
# Possible Healthcare Associated Pneumonia: Upon admission,
patient had a CT scan from the outside hospital which was
concerning for multifocal, bilateral pneumonia. She was
initially treated with levofloxacin and unasyn. However, after
repeat CT and the discovery of adenocarcinoma in the pleural
fluid, the thought was that this may actually be lymphangitic
spread of adenocarcinoma. She did have a leukocytosis and
spiked a low grade fever x1. Thus, she was continued on the
unasyn. A video swallow was performed to rule out aspiration as
a cause of pneumonia. Sputum, pleural fluid, and blood cultures
as well as respiratory viral panels have been negative.
.
# Hypoxia: Her saturations remained chronically 90-93% on 6L
nasal cannula and 100% by facemask during the first parts of her
admission. By CT and physical exam, her lung function is
severely compromised. Furosemide IV helps some, however, she
does not have much room in her blood pressure to titrate this
and it is not proven to be effective in malignancy. She was
transferred to the [**Hospital Unit Name 153**] for further management of ongoing
hypoxia with oncology and interventional pulmonology following.
She was transferred out of the [**Hospital Unit Name 153**] with CMO measures, satting
81-83% at times on 15L.
.
# Pulmonary effusions: Pleural fluid results positive for
adenocarcinoma of unknown primary. Initial thoracentesis
performed [**8-19**] removed 1200 ml fluid, however, effusions
reaccumulated quickly. Interventional pulmonology placed a
Pleurex drain (on left). The drain put out an initial 2L, but
then was non-productive for 36 hours and at the request of the
family was removed for comfort of the patient.
.
# Borderline hypotension and tachycardia: During admission, she
was persistently with systolic blood pressures 90s-100s. Her
parents report that this is the baseline for her. There was not
concern that this represented sepsis as she did not have other
signs pointing toward an infection.
.
# Elevated international normalized ratio (INR): Upon
admission, she had an elevated INR, possibly from poor PO
intake. Repleted with Vit K.
.
# Chronic Kidney Disease (CKD): Present on admission, Creatinine
remained stable.
.
# Osteoporosis: Continued Vitamin D and calcium supplementation.
.
# Distant history of seizure disorder: Phenobarbital level
within normal limits. Continue home dose.
.
# History of thyroid nodule: TSH wnl. No masses seen on CT neck
to explain source of adenocarcinoma. Outpatient follow-up was
recommended.
.
TRANSITIONAL ISSUES: The decision for the patient to remain
DNR/DNI with comfort care measures only was discussed at length
in a family meeting on [**2194-8-27**]. There was clear confirmation
from the family that the patient would not want to be in the
hospital anymore, that she would not want the pleurex drain in,
nor would she want blood draws, chemotherapy side effects, or
anymore invasive investigations into the origin of her
malignancy. Arrangements were made with Old [**Hospital **] Hospice for
the family to transition home with the appropriate materials for
comfort care.
Medications on Admission:
LASIX - 40mg PO QAM
POTASSIUM CHLORIDE - Unknown Dose
PHENOBARBITAL - 97.2 mg Tablet - [**Hospital1 **] at 7 AM and 7 PM
CALCIUM - 500 mg Tablet PO BID
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit PO Daily
Discharge Medications:
1. Home O2
Please provide home oxygen for Ms. [**Known lastname **] with nasal cannula
for delivery. O2 at 15 liters continuous. This is for comfort
measures to aid with air hunger at end of life.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) tablespoon PO
BID (2 times a day) as needed for constipation.
Disp:*30 mL* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
4. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough, dyspnea.
Disp:*1 bottle* Refills:*0*
5. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed for SOB,
cough.
Disp:*14 nebulizer treatment* Refills:*0*
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation Q4H
(every 4 hours) as needed for cough, SOB.
Disp:*14 nebulizer treatment* Refills:*0*
7. lorazepam 0.5 mg Tablet Sig: 0.5-2 mg PO Q4H (every 4 hours)
as needed for agitation/restlessness/insomnia.
Disp:*60 tablets* Refills:*0*
8. phenobarbital 97.2 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
9. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
Five (5) mg PO Q4H (every 4 hours).
Disp:*60 mL* Refills:*0*
10. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
5-20 mg PO every 4-6 hours as needed for pain or air hunger.
Disp:*60 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Cancer (primary unknown, likely lung)
Pneumonia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - always. (baseline cognitive delay)
Discharge Instructions:
Dear Ms. [**Known lastname **],
.
You were admitted to the hospital because you were having
difficulty breathing. You were found to have pneumonia and also
an accumulation of fluid around your lungs--called a pleural
effusion. We gave you antibiotics for your pneumonia. You have
a special type of IV--called a PICC line--which can stay in for
extended periods of time to complete your antibiotics.
.
Unfortunately, when we drained the fluid from around your lungs,
we found cells of cancer. You underwent a CT scan of your body
to find the cancer was likely from your lungs.
.
The following changes were made to your medications: hospice
care medication list included in this discharge packet.
Followup Instructions:
none scheduled at this time, patient may see PCP as often as
desired during hospice care
Completed by:[**2194-8-30**]
|
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[
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419, 3322
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|
18475, 18523
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3344, 3737
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3753, 3906
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5109, 5373
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,677
| 137,776
|
43343
|
Discharge summary
|
report
|
Admission Date: [**2151-1-4**] Discharge Date: [**2151-1-13**]
Date of Birth: [**2076-1-16**] Sex: F
Service: MEDICINE
CHIEF COMPLAINT: Melena times one week.
HISTORY OF PRESENT ILLNESS: Patient is a 75-year-old female
who presents with melena times one week. Today she vomited
blood and it appeared to obtain coffee ground. She also
complains of abdominal pain and nausea. In the Emergency
Department, nasogastric lavage revealed coffee ground
material but no active bleeding or bright red blood. Shortly
thereafter, she vomited large amount of bright red blood and
became transiently hypotensive along with bradycardic.
Intravenous fluid, normal saline was given wide open through
two large-bore IVs. Patient transferred to Surgical
Intensive Care Unit for esophagogastroduodenoscopy. Patient
was given three units of packed red cells and two bags of
FFP.
PAST MEDICAL HISTORY: Hypertension, glaucoma, history of
congestive heart failure, history of thrombocytopenia,
history of arteriosclerotic disease, history of transaminitis
15 years ago, no diagnosis made.
MEDICATIONS: Lasix, Cardizem, eye drops.
ALLERGIES: Question Tylenol.
SOCIAL HISTORY: No tobacco, no alcohol. No history of
transfusions. The patient lives with one of her two
daughters. [**Name (NI) **] has worked in the past as a hairdresser.
FAMILY HISTORY: Negative for liver disease of any kind,
negative for lupus.
PHYSICAL EXAMINATION: Blood pressure 147/68. Heart rate 83.
Respiratory rate 16. Temperature 97.9. Generally lethargic.
Head, eyes, ears, nose and throat exam, normocephalic,
atraumatic, extraocular movements intact. Sclerae are
anicteric. Neck supple, no lymphadenopathy. Chest clear to
auscultation bilaterally. Cardiac, regular rate and rhythm,
loud systolic ejection murmur, [**3-2**] at right upper sternal
border. Abdomen soft, diffuse tenderness, positive bowel
sounds. Rectal, melena. Extremities, no cyanosis, clubbing
or edema. Good peripheral pulses. Neurologically alert and
oriented times three.
ADMISSION LABORATORY DATA: White blood cell count 5.9,
hematocrit 33.4, drop from 46.9 on previous records.
Platelets 75,000, INR 1.5, PT 15.3, PTT 31.6. Sodium 142,
potassium 4.5, chloride 111, bicarbonate 24, BUN 46,
creatinine 1.1 which is at baseline, glucose 99.
Electrocardiogram, normal sinus rhythm at 76 beats per
minute.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for upper gastrointestinal bleed.
Gastrointestinal. Patient underwent endoscopy in the
Surgical Intensive Care Unit. Patient found to have Grade 3
varices. Patient had antibiotics prior to procedure, given
ASD. Patient found to have varices of the distal [**12-30**] of the
esophagus, large clot in the body and fundus, normal antrum
and normal duodenum. As noted, patient had 4 bands distally.
Patient given octreotide bolus and then continuous infusion.
Patient also begun on Inderal. Prilosec was also initiated.
Patient underwent abdominal ultrasound which was negative for
portal vein thrombosis, no hepatomas seen. For
encephalopathy, patient was begun on lactulose with mild
improvement. Because of continued confusion, patient
underwent ultrasound guided paracentesis to rule out
spontaneous bacterial peritonitis. A small amount of fluid
was obtained. Fluid contained 625 white blood cell, 29%
polys, 625 red blood cells. Patient was begun on Ceftriaxone
for treatment of SVP. Subsequent peritoneal cultures were
negative. Patient received five days of Ceftriaxone.
Patient remained in the hospital for repeat
esophagogastroduodenoscopy. On [**2151-1-12**], patient underwent
repeat esophagogastroduodenoscopy. Patient received pre and
post procedure antibiotics including Ampicillin and
gentamicin. Patient had two varices which were banded.
During hospital course, patient became increasingly awake and
alert. Patient had no asterixis, was able to walk around and
was eating and walking by herself at end of hospital stay.
Additionally, patient's hepatology serologies returned.
Patient found to be Hepatitis C positive. Additionally,
Hepatitis B surface antigen negative, surface antibody
positive. Hepatitis B core antibody also positive. [**Doctor First Name **], AMA
also negative.
Patient was not requiring lactulose at end of hospitalization
and was maintaining quite well. Because of SVP diagnosis,
patient was begun on maintenance Cipro for prophylaxis. For
portal hypertension, patient was continued on Inderal 20 mg
b.i.d.
2. Cardiovascular. Patient had evidence of hypertension
after initial esophagogastroduodenoscopy procedure. Patient
was begun on Inderal, captopril and briefly required a
Nipride drip. On [**2151-1-5**], patient developed hypoxia and chest
x-ray was consistent with congestive heart failure. Patient
was diuresed and also given nebulizer treatments with
improvement. Patient was given Inderal 20 mg b.i.d. Zestril
was increased to 40 mg q.d. Additionally, Aldactone was
added 25 mg po b.i.d. Patient underwent echocardiogram which
revealed mild dilatation of right and left atrium, small
left-right shunt across ASD, a secundum defect, mild mitral
regurgitation. Ejection fraction greater than 55%, moderate
pulmonary hypertension, small pleural and pericardial
effusion.
3. Heme. Patient's hematocrit remained stable in the 30s.
Patient received three units of packed red cells on
admission. At time of discharge, patient's hematocrit was
36.3. Platelets remained low most likely secondary to portal
hypertension for her elevated INR and patient given Vitamin K
for several days.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSES:
1. Hepatitis C cirrhosis.
2. Esophageal varices, status post upper gastrointestinal
bleed, status post esophagogastroduodenoscopy times two
with banding.
3. Spontaneous bacterial peritonitis.
4. Hypertension.
5. Glaucoma.
6. ASD.
DISCHARGE MEDICATIONS:
1. Aldactone 25 mg po b.i.d.
2. Inderal 20 mg po b.i.d.
3. Zestril 40 mg po q.d.
4. Ciprofloxacin 750 mg po q. week.
5. Prilosec 20 mg po q.d.
6. Lactulose 30 cc po q. 4 hours prn constipation.
7. Alphagan 1 drop o.u. b.i.d.
8. Trusopt 1 drop o.u. b.i.d.
FOLLOW-UP: Patient to follow-up with Dr. [**Last Name (STitle) **] in one week.
Patient to follow-up in [**Hospital 6283**] Clinic on [**2-12**] at 10:30 a.m. with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6756**], M.D. [**MD Number(1) 6757**]
Dictated By:[**Last Name (NamePattern1) 33491**]
MEDQUIST36
D: [**2151-2-11**] 22:09
T: [**2151-2-11**] 22:09
JOB#: [**Job Number 93331**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"54.91",
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icd9pcs
|
[
[
[]
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1365, 1426
|
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|
5991, 6771
|
2401, 5628
|
1449, 2383
|
154, 178
|
207, 885
|
908, 1168
|
1185, 1348
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,054
| 191,001
|
49319
|
Discharge summary
|
report
|
Admission Date: [**2147-2-3**] Discharge Date: [**2147-2-16**]
Date of Birth: [**2097-8-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Nausea, vomiting, headache
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
49F with metastatic colon CA (lung, adrenal), SLE s/p failed
renal transplant x2 now on PD, who now p/w headache and malaise.
Of note, she was C1D1 of xeloda, xelox, and oxiplatin on [**2147-1-23**].
She states that she has had nausea and weakness since Tuesday.
She continued to go to work on Tuesday and Wednesday despite
nausea and vomiting. When she got home on Wednesday, she was so
tired that she lat down on the couch and slept through most of
the next day. Her appetite has been decreased as well. She
denies f/c. She denies dysuria, diarrhea, admits to occasional
non-productive cough. She has had a constant R sided headache
involving R side of face, r neck, and R shoulder for the past 2
days.
She presented to Dr.[**Name (NI) 8949**] clinic describing these
symptoms. Vitals were as follows: BP 136/101, p 133, T 98.6, rr
18, sats 100%. She was sent for an head MRI to work up the
headache and admitted as a direct admit to 7 [**Hospital Ward Name 1950**].
On arrival to the floor, she was noted to be tachycardic to 118
with bp down to 90/59 satting 97 on RA. She was appearing well
watching TV and fully awake and alert though was in pain.
Past Medical History:
Her medical history is complicated by lupus and associated renal
failure status post two kidney transplants with recent worsening
of her kidney function concerning for transplant failure. She
has had a peritoneal dialysis catheter placed in preparations to
begin peritoneal dialysis. Otherwise, she has a seizure disorder
status post CVA in [**2137**], osteoporosis, arthritis status post
bilateral lower extremity fracture in [**2144**] after a fall and
peritoneal dialysis catheter placement.
Social History:
Lives in [**Location **], works as med records librarian and pharmacy
manager. Lives alone. Denies smoking. Drinks 6 drinks/month. No
illicit drugs.
Family History:
Multiple relatives with cancer, including GM with stomach cancer
and grandfather with unknown type of cancer.
Physical Exam:
VS: Temp: 98.1 BP: 90/59 HR: 118 RR: 20 O2sat 97 RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachy, reg rhythm. holosystolic murmur LLSB radiating to
apex
ABD: nd, +b/s, soft, nt, PD site c/d/i, no erythema or drainage.
No tenderness over the tranplant
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: AAOx3. Pupils equal, 3mm and reactive. Cn II-XII intact.
5/5 strength throughout. No sensory deficits to light touch
appreciated. No pronator drift. 2+DTR's-patellar and biceps.
Pertinent Results:
**************Admission Labs****************
WBC-12.3* RBC-3.58* Hgb-11.0* Hct-33.5* MCV-93 MCH-30.6
MCHC-32.8 RDW-19.4* Plt Ct-496*
PT-12.7 PTT-23.0 INR(PT)-1.1
Glucose-102 UreaN-26* Creat-3.3*# Na-139 K-3.6 Cl-104 HCO3-23
AnGap-16
ALT-13 AST-31 LD(LDH)-571* AlkPhos-138* Amylase-64 TotBili-0.3
Albumin-3.1*
**************MICROBIOLOGY****************
[**2147-2-4**] 3:44 pm CSF;SPINAL FLUID Source: LP TUBE #3.
GRAM STAIN (Final [**2147-2-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2147-2-7**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
CRYPTOCOCCAL ANTIGEN (Final [**2147-2-5**]): Negative
Rapid Respiratory Viral Antigen Test (Final [**2147-2-7**]):
Respiratory viral antigens not detected.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
C.DIF - Negative x 2
[**2147-2-11**] 7:25 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2147-2-11**] 3:27 pm ASPIRATE Site: SINUS Source: Sinus.
GRAM STAIN (Final [**2147-2-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2147-2-13**]):
RARE GROWTH OROPHARYNGEAL FLORA.
**************RADIOLOGY****************
CXR [**2147-2-3**] 10:23 PM
IMPRESSION: No evidence for pneumonia.There is no significant
change compared to previous.
MRI HEAD [**2147-2-3**]
official read P, per neuro-onc there is no acute process or
bleed
CTA chest [**2147-2-6**]
1. No pulmonary embolism.
2. Unchanged appearance of bilateral pulmonary metastastes and
dominant right upper lobe mass.
3. Left upper lobe pneumonia.
4. New left lower lobe collapse, which could be secondary to
upward
compression by new large volume ascites in the abdomen, or could
be due to
mucous plug, although no definite plug is visualized.
5. Small pericardial effusion, and trace left pleural effusion.
6. New large volume ascites.
MR HEAD W/O CONTRAST [**2147-2-8**] 8:58 AM
1. New susceptibility artifact, perhaps from the right side of
the mouth since the prior study of five days ago. Please
correlate clinically.
2. No central findings to explain the new facial nerve palsy. If
there is clinical concern for an upper motor neuron facial
palsy, additional imaging with an IAC protocol can be performed.
3. Persistent fluid/mucosal thickening in the mastoid air cells
bilaterally.
4. Assessment for meningitis or focal lesions like masses,
metstases is limited due to lack of IV contrast. If necessary
for further management, this can be performed after appropriate
precautions like dialysis.
CTA NECK W&W/OC & RECONS [**2147-2-10**] 12:45 PM
1. No evidence of abscess, mass or lymphadenopathy.
2. No vascular abnormalities.
3. Mass-like opacity in the right lung apex. Correlation with
chest imaging is recommended.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2147-2-10**] 12:44 PM
Scattered tiny foci of soft tissue density in the frontal and
ethmoid air cells. Mucosal irregularity of the inferior
turbinates bilaterally. These could indicate chronic
inflammatory changes.
CT ORBITS, SELLA & IAC W/ CONTRAST [**2147-2-14**] 11:24 AM
No abnormality in the region of the temporal bone facial canal
is seen.
Brief Hospital Course:
49F with metastatic colon CA, s/p renal transplant, who p/w
headache and SIRS.
# SIRS: Unclear etiology. Presented with leukocytosis,
tachycardia, and tachypnea. She was afebrile, though on
prednisone. Given h/o headache, an MR head was performed that
was negative by report. Since she was hypotensive and
tachycardic and had been suffering from N/V and poor po intake,
we aggressively rehydrated her. Her BP stabilized, however her
HA persisted. U/A was clean, CXR unrevealing, peritoneal
dialysis fluid was negative, and BCx negative. An LP was
performed out of concern for meningitis. LP studies showed NL
glucose and protein, 1 WBC in CSF, negative cryptococcal Ag,
cultures negative, HSV negative. She was briefly on
vanc/ceftriaxone/ampicillin (D1=[**2-4**], D/C [**2-5**]), also received
one dose of dexamethasone. Acyclovir was continued until HSV PCR
returned. On day of transfer to ICU, pt developed new hypoxia
and fever, CXR was concerning for question of new retrocardiac
infiltrate, vs effusion (volume overload with wt gain of >5 lbs
since admission), so CTX was begun empirically (D1 = [**2-6**]). A
CTA chest was significant for LUL PNA along with LLL collapse
and was negative for PE. She was started on vancomycin and zosyn
to cover for likely HAP and was weaned off of high flow 100%
face mask down to 2 L nasal cannula on the day of transfer back
to the OMED floor. By time of discharge, had completed full
course of antibiotics for presumed pneumonia and had been
treated presumptively for C.dif until all cultures returned
negative. Was discharged without supplemental oxygen having
successfully weaned to room air prior to discharge.
# Hypoxia - on [**2-6**] pt developed new desaturation to 88% on RA.
CXR was as above. concern for infection (immunosuppressed),
aspiration given patient's complaints of dysphagia (see below),
and volume. CTX was started. Additionally, for fear of volume
overload, pt was given 40mg Iv Lasix (still urinates) and PD
frequency was increased per renal team. However, pt also
developed sinus tachycardia to 140s. In syndrome of sinus tach
and hypoxia, PE was considered and pt was started on heparin gtt
and ordered for stat CT-A. This plan was run by renal team
(given contrast load). She was transferred to the ICU overnight
given concern for peri-septic physiology and worsening hypoxia.
As above, vancomycin and zosyn were started for treatment of HAP
and CTA was negative for PE. The following day, her respiratory
status had improved markedly and she was no longer hypotensive
or tachycardic to the 130s. She was then called out to the OMED
team for further care. She then completed an 8 day course of
antibiotics for CAP and was weaned from oxygen. Upon discharge
she was ambulatory without need for supplemental oxygen.
#. Headache: Unclear etiology. DDx include IC bleed, mets,
meningitis, ICA dissection, and migraine. Has been persistent
for 3 days. Neuro exam without deficits, head MRI was negative
for acute stroke or tumor. Carotid dissection is considered
given the unilateral nature of the symptoms. However there is no
cranial nerve palsy or Horner's syndrome. Also concerning for
meningitis given low-grade fever and photophobia but LP studies
negative. Seemed to respond to imitrex x 1 and fioricet. D/c'ed
Zofran (side fx = HA). Given concern for intracranial
infectious vs malignant process, patient had two LP with
cultures as described above, all negative. Cytology did not
reveal leptomeningeal tumor spread, though the sample may have
been inadequate. Ultimately evaluated with CT sinus/orbits to
evaluate CN tracts and evaulate for other etiology. These too
were negative. Given all negative findings, patient opted to
return home versus undergo an additional large volume LP for
cytology. Plans to have outpatient neurology follow-up.
#. ESRD: At home, pt had been missing PD sessions because of
fatigue. Renal following here for PD in-house. Continued
immunosuppression sirolimus and tacrolimus (levels checked [**2-5**]
were not true troughs [**2-18**] timing of draw). Dosages, along with
prednisone, were adjusted per renal recommendations. She was
discharged on doses as recommended per Renal consult.
# Anemia: Likely from chemotherapy, although cancer marrow
infiltration also possible. No other etiologies for bleed. Hct
stable throughout. Transfusion threshold throughtout stay was
for Hct < 25.
# Nausea/vomiting: Chief complaint at home, but was not an issue
here. Continued anti-emetics, but discontinued zofran given pt's
HA.
# Metastatic Colon CA: C1D1 of xeloda, xelox, and oxiplatin on
[**2147-1-23**]. Deferring further oncological management currently.
# SLE - Stable as outpatient but consulted Rheumatology given
concern that headache and neurological findings could be
attributed to SLE. Per Rheum consult, this is unlikey to be
related to SLE flair. ESR, CRP elevated, but complement WNL.
[**Doctor First Name **], dsDNA, lupus anticoagulant, anticardiolipin Abs- Negative.
# Multiple CN palsies - Left UMN CN 7, IX and likely L recurrent
laryngeal nerve all acutely nonfunctional. Neurology consulted
and followed throughout her stay. Repeat LP [**2-9**] with elevated
inflammatory markers, lymphocytosis. No lesion on MRI. As above,
no convincing evidence for meningitis. MRI/MRA: No central
findings to explain new facial nerve palsies. CT sinus and CTA
neck: no dissection or tracking sinusitis. Head MRI with
contrast [**2-13**] without anatomical explaination. Per Rheum
consult not SLE cerebritis. Per Neurology consult, would
recommend larger volume LP for cytology. This was discussed
with patient, but she decided to defer this option to the
outpatient setting. Another consideration would be
leptomeningeal spread of her colon cancer, although this is very
uncharacteristic of this malignancy. Will continue Oncology and
Neurology follow-up upon discharge.
# Dysphagia: Pt c/o mild dysphagia. Acute onset to both liquids
and solids. No obvious lesion on MRI. Despite this complaint she
was reqesting a regular diet. s/s evaluation was ordered and
revealed profound dysphagia with multiple diet modification.
Was also seen by ENT for this issue which revealed new L vocal
cord and pharyngeal paralysis. No intervention was available.
She will follow-up as an outpatient with ENT as needed. Given
diet modifications upon discharge.
Medications on Admission:
Prednisone 5 daily
Sirolimus 2mg daily
tacrolimus 1mg [**Hospital1 **]
Acetaminophen
Aspirin 81 mg Tablet
Calcium Carbonate [Tums] (OTC)
diphenoxylate-Atropine [Lomotil] 2.5 mg-0.025 mg Tablet
one or two Tablet(s) by mouth every four hours prn diarrhea
Ferrous Sulfate [FerrouSul] 325 mg (65 mg) Tablet
Furosemide [Lasix] 20 mg Tablet 1 Tablet(s) by mouth daily
Nifedipine [Nifedical XL] 60 mg Tab,Sust Rel Osmotic Push 24hr
Trimethoprim-Sulfamethoxazole [Bactrim] 400 mg-80 mg Tablet 1
Tablet tiw
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
6. Nifedical XL 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One
(1) Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fevers.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO every eight (8) hours as needed for
heartburn.
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-18**]
Drops Ophthalmic Q1H (every hour).
Disp:*1 bottle* Refills:*2*
12. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic HS (at bedtime).
Disp:*1 tube* Refills:*2*
13. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*150 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Metastatic colon cancer
Secondary: SLE, s/p renal transplant, seizure disorder,
osteoperosis
Discharge Condition:
Hemodynamically stable and afebrile
Discharge Instructions:
You were admitted for headache and malaise with subsequent
diagnosis of pneumonia. Also with multiple nerve abnormalities
and no clear diagnosis to explain your various nerve
abnormalities.
Please take all medications as prescribed. You will be provided
with a list of medications to continue taking as an outpatient.
Please return to the hospital for fever, chills, shortness of
breath, rash, diarrhea or for any other sypmtom which is
concerning for you.
Recommended Diet changes:
1. Use strict aspiration precautions:
- Thin liquids
- Soft solids, add extra sauce or condiments to help keep foods
moist and ease transition
- Pills whole with water as tolerated
2. PO intake only with use of the following aspiration
precautions:
- Left head turn with slight chin tuck
- SMALL sips of liquid with bites of food
- Alternate between bites of food and sips of liquid to help
clear pharyngeal residue
- No straws
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2147-2-20**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 26384**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2147-2-20**] 9:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2147-2-24**] 9:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4253**], Phone: [**Telephone/Fax (1) 45043**] Date/Time:
[**2147-3-17**] 9:30
|
[
"197.0",
"288.60",
"995.90",
"733.00",
"486",
"585.6",
"V10.05",
"784.0",
"785.0",
"518.0",
"780.39",
"285.22",
"710.0",
"996.81",
"787.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
15096, 15102
|
6718, 13099
|
341, 359
|
15248, 15286
|
3084, 3803
|
16250, 16852
|
2244, 2355
|
13647, 15073
|
15123, 15227
|
13125, 13624
|
15310, 16227
|
2370, 3065
|
4323, 6695
|
275, 303
|
387, 1543
|
1565, 2061
|
2077, 2228
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,149
| 105,919
|
24953
|
Discharge summary
|
report
|
Admission Date: [**2155-9-26**] Discharge Date: [**2155-10-3**]
Date of Birth: [**2092-12-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
post prandial satiety, bloating and distension for two months
Major Surgical or Invasive Procedure:
endoscopic cystgastrostomy complicated by gastric perforation
History of Present Illness:
The patient is a 62 year old female with a past medical history
significant for a laproscopic cholecystectomy in [**2154-12-28**]
for gallstone pancreatitis and a negative intraoperative
cholangiogram, who presented with early satiety and bloating for
two months, with occasional bilious vomiting. In Februuary
[**2154**], the patient was readmitted for abdominal pain. An MRCP
done at that time was negative except for some soft tissue
swelling in the body of the pancreas. A CT scan done one month
priot to this admission demonstrated a 12 cm pseudocyst, and a
repeat CT scan 2 weeks priot to admission showed no increase in
the size of the pseudocyst. Her liver function tests have
always been normal. She denies any bleeding, weight loss,
fevers, or jaundice.
Past Medical History:
glaucoma, hypercholesterolemia, appendectomy, colon resection
for leiomyoma, tonsillectomy, right breats cyst, right knee
surgery
Social History:
Quit smoking ten years ago, drinks two-three glasses of wine per
day
Family History:
none
Physical Exam:
General: no apparent distress
HEENT: sclerae anicteric, pupils equal round and reactive to
light
Neck: supple
Lungs: clear to ascultation bilaterally
Heart: regular rate and rhythum, no murmurs
Abdomen: soft, bowel sounds +, very distended, minimal
tenderness, no rebound or guarding
Extremities: no clubbing, cyanosis or edema, full range of
motion
Neurologic: no focal deficits, alert and oriented X3
Pertinent Results:
[**2155-9-26**] 10:30AM BLOOD WBC-5.0 RBC-5.09 Hgb-14.5 Hct-42.8 MCV-84
MCH-28.5 MCHC-33.9 RDW-12.9 Plt Ct-292
[**2155-9-26**] 07:43PM BLOOD WBC-13.1*# RBC-4.79 Hgb-14.3 Hct-41.4
MCV-86 MCH-29.8 MCHC-34.6 RDW-12.8 Plt Ct-318
[**2155-9-27**] 03:35AM BLOOD WBC-10.5 RBC-4.68 Hgb-13.8 Hct-39.6
MCV-85 MCH-29.5 MCHC-34.9 RDW-12.9 Plt Ct-255
[**2155-9-28**] 05:55AM BLOOD WBC-7.5 RBC-4.65 Hgb-13.6 Hct-40.2 MCV-86
MCH-29.3 MCHC-33.9 RDW-12.9 Plt Ct-260
[**2155-9-26**] 10:30AM BLOOD PT-12.5 PTT-27.2 INR(PT)-1.0
[**2155-9-26**] 10:30AM BLOOD Plt Ct-292
[**2155-9-26**] 07:43PM BLOOD PT-12.8 PTT-23.2 INR(PT)-1.1
[**2155-9-26**] 07:43PM BLOOD Plt Ct-318
[**2155-9-26**] 07:43PM BLOOD Glucose-180* UreaN-14 Creat-0.9 Na-139
K-3.9 Cl-102 HCO3-27 AnGap-14
[**2155-9-27**] 03:35AM BLOOD Glucose-138* UreaN-10 Creat-0.7 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-14
[**2155-9-28**] 05:55AM BLOOD Glucose-131* UreaN-7 Creat-0.8 Na-140
K-4.3 Cl-105 HCO3-26 AnGap-13
[**2155-9-26**] 10:30AM BLOOD ALT-24 AST-24 AlkPhos-62 Amylase-27
TotBili-0.7 DirBili-0.1 IndBili-0.6
[**2155-9-26**] 07:43PM BLOOD ALT-140* AST-146* AlkPhos-71 Amylase-25
TotBili-0.6
[**2155-9-27**] 03:35AM BLOOD ALT-137* AST-83* AlkPhos-63 Amylase-26
TotBili-0.9
[**2155-9-28**] 05:55AM BLOOD ALT-86* AST-34 AlkPhos-59 TotBili-1.0
[**2155-9-26**] 07:43PM BLOOD Calcium-8.5 Phos-4.3 Mg-1.8
[**2155-9-27**] 03:35AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.6
[**2155-9-28**] 05:55AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.7
[**2155-9-30**] 05:25AM BLOOD WBC-4.2 RBC-4.61 Hgb-13.5 Hct-38.9 MCV-84
MCH-29.3 MCHC-34.7 RDW-12.8 Plt Ct-277
[**2155-9-30**] 05:25AM BLOOD Plt Ct-277
[**2155-10-1**] 05:50AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-140
K-4.4 Cl-105 HCO3-25 AnGap-14
[**2155-10-2**] 06:00AM BLOOD Glucose-101 UreaN-7 Creat-0.8 Na-141
K-4.1 Cl-105 HCO3-24 AnGap-16
[**2155-10-1**] 05:50AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9
[**2155-10-2**] 06:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.9
Brief Hospital Course:
The patient was admitted on [**2155-9-26**] for an elective endoscopic
cystgastrostomy, which was complicated by gastric perforation.
Three 10Fx5cm double pigtail stents were placed during the
procedure, but the pseudocyst most likely separated from the
gastric wall at some point during stent placement. A CT scan
done at that time showed findings consistent with tension
pneumoperitoneum causing compression of the IVC, presumably due
to a leak of air from the stomach into the retroperitoneum and
in the intraperitoneal space. The plan was made by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] to decompress her with angiocatheter placement, keep her
NPO, begin orogastric tube drainage,and begin Ampicillin,
Levofloxacin, Flagyl, and Fluconazole prophylactically. The
patient was transferred to the intensive care unit in stable
condition for further monitoring. An abdominal X-ray
demonstrated increased free peritoneal. An angiocatheter was
placed and a gush of free air was released. The patient felt
much better. On postprocedure day one, the patient was doing
much better and was transferred to the floor. On postprocedure
day two, the patient again did well, however there was some
scant bloody drainage from her OG tube. On postprocedure day
three, her abdominal examination was benign and she was
afebrile. She passed bowel movements and flatus. Her OG tube
was removed. She was started on sips of clears on postprocedure
day five. Her diet was advanced to clears and then soft pureed
diet on postprocedure day six. The patient continued to look
excellent and was discharged home on postprocedure day seven
after having completed her full antibiootics course.
Medications on Admission:
glaucoma eye drops
Discharge Medications:
1. Betimol Ophthalmic
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatic pseudocyst
Discharge Condition:
good
Discharge Instructions:
Please come to the ER with fevers > 101.4. Come to the ER with
increasing abdominal pain or distension, nausea or vomiting or
significant change in bowel habits. Please continue to take
Protonix until atleast your follow-up visitw with Dr. [**Last Name (STitle) **].
Please continue with a soft diet until follow-up visit.
Followup Instructions:
Please call Dr.[**Name (NI) 2829**] office to schedule a follow-up
appointment for one week from this Monday.
Completed by:[**2155-10-3**]
|
[
"272.0",
"E878.8",
"568.89",
"577.2",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.4",
"54.91",
"52.93"
] |
icd9pcs
|
[
[
[]
]
] |
5881, 5887
|
3874, 5585
|
376, 439
|
5953, 5960
|
1936, 3851
|
6333, 6474
|
1492, 1498
|
5654, 5858
|
5908, 5932
|
5611, 5631
|
5984, 6310
|
1513, 1917
|
275, 338
|
467, 1237
|
1259, 1390
|
1406, 1476
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,665
| 156,932
|
43483
|
Discharge summary
|
report
|
Admission Date: [**2116-7-21**] Discharge Date: [**2116-8-1**]
Date of Birth: [**2041-10-14**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Nitroglyn
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
abdominal pain, distention, vomiting
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy
2. Right inguinal hernia repair with mesh via separate
incision.
History of Present Illness:
The patient is a 74-year-old gentleman who
presents with a three day history of progressive nausea,
vomiting, obstipation, failure to pass any stool or flatus,
as well as profound right lower quadrant tenderness. He had a
history of vomiting up to 20 times a day, accompanied by vague
grampy abdominal pain and decreased flatus. he was recently
seen at an osh whre he was discharged with gastroenteritis. The
patient had no fever or chills.
Past Medical History:
1. Status post mitral valve annuloplasty in [**2115-5-21**].
2. Esophageal spasms secondary to achalasia.
3. Chronic fatigue.
4. Anemia.
5. History of gastrointestinal bleed.
6. History of paroxysmal supraventricular tachycardia;
status post direct current cardioversion.
7. Obstructive sleep apnea.
8. Chronic headaches.
9. Anxiety.
10. Hypertension.
11. Cerebrovascular accident; status post left occipital
stroke.
12. First-degree atrioventricular block.
13. Chronic renal insufficiency (with a bowel sounds
creatinine of 1.4 to 1.8).
14. History of cholecystectomy
[**26**]. History of Appendectomy
16. Myelodysplastic sydrome with intramedullary hemolysis
Social History:
worked as an executive in hospital cleaning, stopped in [**2097**].
quit smoking and drinking over 30 years ago. Married, has grown
children and grandchildren
Family History:
father and mother had [**Name2 (NI) 499**] cancer in their 50s and 60s.
Physical Exam:
Temperature 100.5, Pulse 108, Plood pressure 110/48,
Respirations 18,
Exam:
General: No apparent distress. Jaundiced (which is his
baseline)
Cardiac: tachy, with systolic ejection murmur. no jugular venous
distention
Lungs: decrease breath sounds at the bases bilaterally
Abdomen: soft, distended. Right paramedian incision with no
hernia. Positive fror right lower quadrant/peripubic mass in
inguinal region that is tender and firm. No rigidity, rebound
or guarding
Rectal: no masses, enlarged prostate, heme negative
Extremities: warm, well perfused
On discharge, the patient's abdomen was soft. He had 2 well
healing incisions that were clean dry and intact with staples in
place.
Pertinent Results:
CT abdomen and pelvis [**2116-7-21**]:
IMPRESSION: 1) Small bowel obstruction with a transition point
within the mid to distal small bowel and wall thickening within
small bowel. No evidence of pneumatosis, mesenteric gas, or
portal venous gas.
These findings were discussed with the surgical team responsible
for this patient's care shortly after interpretation.
2) Sigmoid diverticulosis.
Brief Hospital Course:
The patient was diagnosed with a small bowel obstruction with a
transition point and the patient was taken to the operating room
for an emergent exploratory laparatomy and right inguinal hernia
repair. The patient, from the beginning of his stay, began
having intermittent SVT. He had one episode in the ED that was
resolved with adenosine. He had a post op hematocrit of 27, for
which he recieved 2 units of packed red blood cells. The
patient was placed on telemetry, and had a two further
occurence of SVT that required IV lopressor and diltiazem, and a
diltiazem drip was started. Cardiology was conuslted and their
recommendations wer followed. The hematology oncology team also
saw the patient on postoperative day 1, and suggested continuing
the prednisone for his myelodysplastic syndrome. the patient
was rate controlled and switched to intermittent metoprolol and
diltiazem, On postoperative day 2 the patient was sent to the
surgical VICU with telemetry on this regimen for his heart
control. he was also started on his home medications. The
patient had an echocardiogram on post op day 3, because the
patient had continued intermittent, spontaneously resolving
bouts of SVT. Cardiology also felt that this might be
intermittent atrial tachycardia, but suggested no further
changes in his management. He was slightly confused and not at
his baseline, and a CT was done which was negative.
Pn post operative day 4, we were called to the bedside for
decrease oxygen saturation to 89%. The patient was unarousable
and non verbal. He was diaphortic. He had not had any recent
sedative/pain control. The patient had an ABG that was
7.06/85/75/26/-8. Given his respiratory failure and CO2
narcosis, anesthesia was called and the patient was intubated
for respiratory failure. He was transferred from the VICU to
the surgical intensive care unit. The patient also began
receiving amiodirone for his episodes of rapid heart rate. he
remained stable on the vent on postoperative day 5, although he
continued to have intermittent runs of SVT, and like all
previously episodes, he remained completely hemodynamically
stable otherwise. He also was receiving tube feed for
nutritional support
Weaning from the ventilator was started on post operative day 6.
he continued to be given lasix for respitroaory assistance.
His INR jumped to 6.0, and FFP and vitamin K were given to
correct this. He was extubated on post operative day 6. he
remain somnolent, moving all extremities, but was weak. His
tube feeds were held over concern of aspiratoin, but on post
operative day 7 the patient's mental status began improving and
his tube feeds were restarted. He had one unstable run of SVT
that converted after 1 dose of adenosine, and 2 stabe runs of
SVT that converted after vagal maneuvers. He was evaluated by
speech and swallow who demonstrated no aspiration. On
Postoperative day 9, the patients tube feeds were discontinued,
he was started on clear liquids. His mental status had
improved. He had increased his lopressor to 150 TID.
He was transferred to the floor in stable condition. He
continued to have intermittent bouts of stable SVT. He was
evaluated by physical therapy and occupational therapy for his
qualification for rehab. He was tolerating a regular diet
without difficulty.
Medications on Admission:
Epogen 40,000 unitls/ml q friday, coumadin 5 mg qd, prilosec 20
mg qd, prednisone 10mg qd, aspirin 81 mg qd, accupril 10 mg qd,
lorazepam 0.5mg tid, metoprolol 25 mg TID, Cartia XT 180 mg qd,
fluoxetine 20mg qod, neurontin 100mg tid, omeprazole 20 mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO QOD
(every other day).
Disp:*15 Capsule(s)* Refills:*2*
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 injections* Refills:*2*
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
12. Diltiazem HCl 180 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO QD (once a day).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) **]
Discharge Diagnosis:
Small bowel obstruction
status post emergent exploratory laparatomy and right inguinal
hernia repair
Supraventricular tachycardia
Blood loss anemia requiring transfusion
respiratory failure requiring intubation
Status post mitral valve annuloplasty in [**2115-5-21**].
achalasia.
Chronic fatigue.
History of gastrointestinal bleed.
History of paroxysmal supraventricular tachycardia;
status post direct current cardioversion.
Obstructive sleep apnea.
Chronic headaches.
Anxiety.
Hypertension.
History of Cerebrovascular accident; status post left occipital
stroke.
First-degree atrioventricular block.
Chronic renal insufficiency (with a bowel sounds
creatinine of 1.4 to 1.8).
history of Myelodysplastic sydrome with intramedullary hemolysis
Discharge Condition:
Good
Discharge Instructions:
[**Name8 (MD) **] MD with any spiking fevers, worsening abdominal pain,
intractable nausea or vomiting, inability to tolerate food.
You can shower, but you should do it with assistance until you
regain your strength.
you should not do any heavy lifting of objects heavier than 10
pounds for the next 6 weeks.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) **] in [**11-22**] weeks. You will
need to have your staples removed
You should follow up with your primary care physician [**Last Name (NamePattern4) **] [**11-22**]
weeks
You should follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in cardiology on
[**2116-9-1**] at 12:30 pm at [**Hospital Ward Name 23**] 7 for arrhythmia follow up.
|
[
"428.0",
"936",
"585",
"584.5",
"789.5",
"518.82",
"550.90",
"285.1",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"54.19",
"99.04",
"96.08",
"96.71",
"53.03",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8072, 8145
|
3008, 6333
|
326, 421
|
8936, 8942
|
2591, 2985
|
9301, 9727
|
1794, 1867
|
6637, 8049
|
8166, 8915
|
6359, 6614
|
8966, 9278
|
1882, 2572
|
250, 288
|
449, 894
|
917, 1601
|
1617, 1778
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,221
| 163,211
|
50890
|
Discharge summary
|
report
|
Admission Date: [**2119-10-5**] Discharge Date: [**2119-10-13**]
Date of Birth: [**2049-10-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
CABGx4 (LIMA->LAD, SVG->OM1-OM2, SVG->PDA), AVR 21mm [**Doctor Last Name **],
septal myomectomy [**10-6**]
History of Present Illness:
69 yo M with known AS, cath on day of admission showed LM and
3VD. Pt was transferred to [**Hospital1 18**] for surgical evaluation.
Past Medical History:
DM, GERD, HTN, AS, Herpetic neuralgia, BPH, Esoph stricture s/p
dilitation
Social History:
widowed
lives alone
retired machinist
no etoh, tob
Family History:
NC
Physical Exam:
HR 70 BP 139/61
NAD, lying in bed
A&O x 3, MAE, nonfocal
CTAB
RRR, S1S2, [**5-19**] blowing SEM
Abdomen Soft, NT
Extrem warm, no edema
2+ pulses t/o
Edentulous
Pertinent Results:
[**2119-10-11**] 05:57AM BLOOD Hct-25.2*
[**2119-10-10**] 05:24AM BLOOD WBC-11.1* RBC-2.97* Hgb-9.4* Hct-26.7*
MCV-90 MCH-31.6 MCHC-35.2* RDW-15.0 Plt Ct-172
[**2119-10-10**] 05:24AM BLOOD Plt Ct-172
[**2119-10-9**] 02:42AM BLOOD PT-12.7 PTT-25.6 INR(PT)-1.1
[**2119-10-11**] 05:57AM BLOOD UreaN-70* Creat-1.5* K-4.3
[**2119-10-10**] 05:24AM BLOOD Glucose-136* UreaN-66* Creat-1.7* Na-137
K-4.7 Cl-102 HCO3-23 AnGap-17
[**2119-10-9**] 02:42AM BLOOD Glucose-118* UreaN-44* Creat-1.6* Na-133
K-4.3 Cl-102 HCO3-24 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 15685**] was admitted to the CSRU and started on heparin and
NTG drips. He had chest pain and was taken to the operating room
on [**2119-10-6**] where he underwent a CABG x 3, AVR and septal
myomectomy. He was transferred to the ICU in critical but stbale
condition. He was extubated later that same day. He remained on
neo through POD #3. He was transfused 2 units PRBCs. He was
transferred to the floor on POD #3. He did well postoperatively.
His BUN and creatinine rose slightly and his lasix was
discontinued. His foley was reinserted after he was unable to
void. Flomax was started. His foley catheter was removed after
24 hours and he was able to void. Mr. [**Known lastname 15685**] developed atrial
fibrillation which converted to normal sinus rhythm with
amiodarone and beta blockade. A nutrition consult was obtained
for help with his eating habits given his diabetes and coronary
artery disease. He has remianed in NSR for more than 48 hours,
and is now ready to be discharged home.
Medications on Admission:
ASA 325', Doxazosin 2', Protonix 40', Amitriptylline 25',
lisinopril 20', Metformin 500", Glyburide 5'
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. 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*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
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:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: then 200 mg daily until seen by cardiologist.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
DM, GERD, HTN, AS, Herpetic neuralgia, BPH, Esoph stricture s/p
dilitation
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 17996**] 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2119-10-13**]
|
[
"401.9",
"429.3",
"788.20",
"424.1",
"414.01",
"600.01",
"250.00",
"427.31",
"530.81",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"36.13",
"36.15",
"35.21",
"39.61",
"35.98"
] |
icd9pcs
|
[
[
[]
]
] |
4041, 4090
|
1523, 2540
|
326, 435
|
4209, 4217
|
979, 1500
|
4516, 4721
|
779, 783
|
2693, 4018
|
4111, 4188
|
2566, 2670
|
4241, 4493
|
798, 960
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283, 288
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463, 597
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619, 695
|
711, 763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,293
| 118,903
|
9342
|
Discharge summary
|
report
|
Admission Date: [**2121-4-29**] Discharge Date: [**2121-5-7**]
Date of Birth: [**2057-6-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Hypotension and respiratory failure
Major Surgical or Invasive Procedure:
R carotid endarterectomy (aborted)
Endotracheal intubation
Persantine MIBI
Cardiac catheterization
History of Present Illness:
63AAM with PMH significant for CAD s/p CABG [**2103**], T2DM, PVD,
presenting after becoming hypotensive in OR during CEA. Mr.
[**Known lastname 634**] had been experiencing two syncopal and several near
syncopal episodes over the last several months. He had a carotid
U/S done, which demonstrated tight R ICA stenosis of 80-99%. He
was scheduled for an elective CEA on the day of admission.
.
In the OR, Mr. [**Known lastname 634**] experienced hypotension to SBP 50s-60s
10-15 minutes after inducing anaesthesia, shortly after the
first incision. He was administered epinephrine, atropine, and
neosynephrine gtt. ABG at that time: 7.09/68/100, with lactate
8.0, glucose recorded as 22. Intraoperative TEE was done, which
demonstrated a markedly dilated RV cavity, severe RV free wall
HK, and abnormal septal motion/position c/w RV volume/pressure
overload. EF 30%. The procedure was aborted, and he was given a
bolus of IV heparin, and transferred to the CCU for further
management.
.
Upon arrival to the CCU, initial vent settings were AC
650/15/5/100% FIO2. PAC hemodynamics demonstrated PCWP 18-20,
Systolic PAP 80s. 7.40/32/94, MVO2 74%. Dopamine gtt was started
at 5mcg/kg/min to keep MAP>60, which was weaned off. Heparin gtt
was held pending CTA chest [**12-19**] significant oozing around R neck
incision site and site of L SC Cordis catheter. CTA chest
ordered to r/o PE, which appears to be negative. CT did
demonstrate ground glass opacities, patchy in places. Given
lasix 40mg IV x 1. Initial CK 174(6), trop 0.20.
Past Medical History:
CAD s/p CABG [**2103**]. SVG to PDA, SVG to OM2, LIMA to LAD
CHF: Ischemic, EF 15-20%. Sats 90-91% RA at baseline, has
refused supplemental home O2 in past.
T2DM
PVD s/p L BKA [**2103**], amputation of all R toes [**2117**], s/p
aorto-bifemoral artery and fem-[**Doctor Last Name **] bypass [**2105**], s/p L
ulnar-ulnar vein graft [**2114**]
R Carotid stenosis - 80-99% [**3-22**]
GERD
s/p CCY [**2116**]
s/p penile implants [**2107**], [**2117**]
Social History:
Married, quit smoking [**2103**] after 60py hx.
Family History:
NC
Physical Exam:
T: 97.5F BP: 111/57 HR: 66 RR: 15 SaO2: 96% on AC
650x15/5/100%
Gen: Intubated, sedated
HEENT: PERRL
Neck: Surgical dressing in place over R carotid, c/d/i, staples
intact beneath with no visible oozing. No bruits
CV: PMI displaced and nondiscrete, RRR, no m/r/g
Chest: CTA anteriorly. Median sternotomy scar well healed
Abd: Soft, ND, hypoactive BS, no HSM
Extr: L BKA, L PT dopplerable, no LE edema
Neuro: Sedated, intubated
Pertinent Results:
CTA Chest:
CTA CHEST:
No pulmonary embolus. The main pulmonary artery is enlarged
measuring 3.3 cm in caliber. Right and left pulmonary arteries
are at the upper limits of normal in size. A Swan-Ganz catheter
is in place with its tip in the right middle lobe pulmonary
artery. No contrast is within the aorta; therefore, its
evaluation is limited. There is no ascending or descending
aortic aneurysm. The right ventricle and right atrium are
enlarged. No shunting of contrast from the right to the left
heart. The patient is status post CABG.
CHEST CT WITHOUT AND WITH CONTRAST:
Within the anterior segment of the right upper lobe, there is
extensive interstitial thickening peripherally and along the
bronchovascular bundles with bronchiectasis. This is mostly
within the inferior aspect of the anterior segment. There are
other scattered areas of peripheral interstitial thickening and
bronchiectasis including within the right lower lobe, minimally
medially within the right middle lobe, within the anterior
lingula, and within the anterior segment of the left upper lobe.
Some of these areas also have some honeycombing. These findings
are all consistent with chronic scarring. The etiology of this
predominantly interstitial lung disease is uncertain, and the
differential is large. It has slowly progressed since [**2115-4-5**]
chest x- ray. Superimposed on this, there is right lower lobe
atelectasis and some airspace disease that could represent mild
aspiration. The left lower lobe is completely collapsed.
Obstructing lesion is not evident on this study and unlikely.
The left lower lobe bronchus has a large amount of fluid within
it. Aspiration or pneumonia within this lobe cannot be excluded.
There are shotty mediastinal lymph nodes with a pretracheal node
measuring 1.1 cm in short axis. These are likely reactive. No
axillary or hilar lymphadenopathy. Within the upper abdomen,
there are no definite abnormalities. NG tube is in expected
position.
BONE WINDOWS: Changes from prior median sternotomy for CABG are
noted. There is multilevel thoracic disc degeneration. No
concerning lytic or sclerotic lesions.
IMPRESSION:
1. No pulmonary embolus. Enlarged main pulmonary artery and
right heart. This may be secondary to chronic lung disease.
2. Chronic interstitial lung disease with bronchiectasis and
honeycombing has progressed mildly since [**2115-4-5**] chest x-ray.
The pattern is not specific and differential considerations are
broad.
3. Completely collapsed left lower lobe. Pneumonia or aspiration
within this region cannot be excluded.
.
Intraoperative TEE:
Conclusions:
The left atrium is dilated. The right atrium is dilated. The
inferior vena cava is dilated (>2.5 cm). There is severe
regional left ventricular systolic dysfunction. Overall left
ventricular systolic function is severely depressed. Resting
regional wall motion abnormalities include mid and basal
inferior, inferoseptal walls. The right ventricular cavity is
markedly dilated. There is severe global right ventricular free
wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload.
There are complex (mobile) atheroma in the descending aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
Impression:
Marked dilatation of RV with severe depression of RV systolic
function and accompanying moderate TR. No presurgery images are
available to compare. However, cardiac function reported to be a
dilated RV with mild depression of RV systolic function. Severe
global LV hypokinesis (overall LVEF 25-30%) with focalities in
inferior walls (basal and mid) Apex is not clearly seen and the
focal wall motion abnormalities may be missed.
.
Persantine MIBI:
INTERPRETATION: 63 yo man (h/o type II DM, CABS and ischemic
cardiomyopathy) was referred for a CAD evaluation following a
hypotensive event in the OR resulting in aborted CEA. The
patient was
administered 0.142 mg/kg/min of persantine over 4 minutes. No
chest,
back, neck or arm discomforts were reported during the
procedure. In the
presence of diffuse baseline abnls, the ECG is difficult to
interpret
for ischemia during the procedure. The rhythm was sinus with
frequent
multiformed VPDs noted during the procedure. The hemodynamic
response to
the persantine infusion was appropriate. Three min post-MIBI,
the
patient was administered 125 mg aminophylline IV.
IMPRESSION: No anginal symptoms with an uninterpretable ECG.
Nuclear
report sent separately.
.
Nuclear Imaging:
The image quality is good.
Left ventricular cavity size is enlarged.
Resting and stress perfusion images reveal a severe fixed
inferior wall defect.
Gated images reveal severe global hypokinesis.
The calculated left ventricular ejection fraction is 18%.
IMPRESSION: Severe fixed inferior wall defect. Global
hypokinesis. EF 18%.
.
Cardiac Catheterization:
COMMENTS:
1. Selective coroanry angiography of this right dominant system
demonstrated three vessel CAD. The LMCA was moderately
calcified. The
LAD had a proximal 60% stenosis. The LCX and RCA were totally
occluded
proximally.
2. Arterial conduit angiography demonstrated a widely patent
LIMA to the
distal LAD which had moderate diffuse disease.
3. Vein graft angiography demonstrated a totally occluded graft
to the
RCA. The SVG to OM1 was widely patent with retrograde filling of
the
LCX.
4. Resting hemodynamics demonstrated minimally elevated left
sided
filling pressures with LVEDP=16. Right sided filling pressures
were
mildly elevated with RVEDP=18 mmHg. There was pulmonary artery
hypertension with PASP=60 mmHg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild diastolic biventricular dysfunction.
3. Severe pulmonary hypertension.
4. Patent LIMA to LAD
5. Occluded SVG to RCA.
6. Patent SVG to OM1.
.
[**2121-4-29**] WBC-6.2 Hct-48.4 MCV-88 Plt Ct-117*
[**2121-5-7**] WBC-6.0 Hct-41.0 MCV-88 Plt Ct-175
.
[**2121-5-6**] PT-12.5 PTT-26.1 INR(PT)-1.1
.
[**2121-4-29**] Glucose-205* UreaN-43* Creat-1.3* Na-138 K-4.1 Cl-101
HCO3-22
[**2121-5-7**] Glucose-105 UreaN-19 Creat-0.8 Na-140 K-4.0 Cl-106
HCO3-23
Calcium-9.1 Phos-2.9 Mg-1.8
.
[**2121-4-29**] CK(CPK)-174(6), 205(7), 177(5)
[**2121-4-29**] TropT: 0.20, 0.26, 0.09
.
[**2121-4-29**] %HbA1c-8.2*
Endotracheal sputum cx:
GRAM STAIN (Final [**2121-4-30**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2121-5-5**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
ASPERGILLUS FUMIGATUS. RARE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
Brief Hospital Course:
1) Hypotension: Most likely due to induction of anesthesia in
OR, treated by volume rescuscitation that led to pulmonary
edema. Initially, there was suspicion of pulmonary embolus,
given elevated RV dilatation and elevated PA pressures on
intraoperative TEE. Subsequent CTA ruled this out, however.
Cardiac ischemia leading to LV and subsequent RV failure was
considered, and initial cardiac enzymes were mildly elevated;
howerver, there was no evidence of clearly new iscemic changes
on ECG, and troponin elevations were in context of mild ARF, or
may have reflected mild global ischemia from hypotensive
episode. His hypotension resolved with initial fluid
resuscitation, and was not an ongoing issue during his
hospitalization.
.
2) CAD: s/p CABG in [**2103**]. ECG showed significant longstanding
conduction disease, but no clear evidence of acute ischemic
changes as above. A persantine MIBI was done prior to discharge
as part of pre-operative cardiac evaluation prior to further
attempts at carotid endarterectomy or stenting. Official read of
MIBI showed only fixed inferior wall defect; however, per Dr. [**Name (NI) 5454**] read, there appeared to be evidence of peri-infarct
reversible changes. Mr. [**Known lastname 634**], therefore, was taken for
cardiac catheterization on [**5-6**]. Cath revealed 3VD s/p CABG,
patent LIMA to LAD, patent SVG to OM1, and occluded SVG to RCA
with collaterals. No intervention was done. He had no
complications from his cath. He was continued on ASA and lipitor
throughout his stay. His plavix was held, but pt was told to
restart this upon discharge home, with expected cessation again
prior to any carotid interventions.
.
3) Pump: Initially intubated due to evidence of flash pulmonary
edema on exam and chest CT. He was diuresed 3L without
difficulty, and extubated without complication. He was restarted
on his home doses of carvedilol and quinapril when BP had
stabilized.
.
4) Pulmonary fibrosis: Intitial CT chest demonstrated evidence
of interstitial lung disease and bronchiectasis with
honeycombing. Evidence of these changes were also seen on [**2115**]
CXR, and thought to have been mildly progressive since then.
Chest CT also suggested total collapse of LLL. While intubated,
therefore, pulmonary team did bronchoscopy to address possible
mucous plugging that could interfere with attempts to wean vent.
Bronchoscopy demonstrated widely patent bronchi with tethering
of airways, consistent with pulmonary fibrosis. No clear
infectious cause was evident, and no pulmonary secretions could
be collected for analysis. Sputum culture from ETT did grow
aspergillus, which, per pulmonary team, is common in patients
with bronchiectasis, and did not require treatment in absence of
clinical evidence of pneumonia. Per previous notes, Mr.
[**Known lastname **] baseline SaO2 is 90% on RA, thought to be [**12-19**] to his
interstitial lung disease. He had refused home O2 in past, but
agreed to it during this admission. He was sent home on 3L home
O2, with instructions to f/u with his PCP [**Last Name (NamePattern4) **] [**5-10**]. He should be
referred to a pulmonologist in the area at that time for further
management of his pulmonary fibrosis.
.
5) Carotid stenosis: CEA was aborted in setting of hypotensive
episode and respiratory failure. [**Month/Year (2) **] surgery team followed
while in-house. He had a thorough preoperative cardiac
evaluation while in-house. He has a follow-up neck CTA and
appointment with [**Month/Year (2) 1106**] surgery on [**2121-5-21**], with possible
subsequent carotid stenting procedure to follow.
.
6) DM: A1C found to be elevated at 8.2%. Maintained with SSI.
His lantus was restarted and increased to 30U qHS [**12-19**] elevated
blood sugars. He was maintained on a diabetic diet while
in-house.
.
7) GERD: Continued PPI in-house
Medications on Admission:
Plavix 75mg PO qD (held [**4-24**])
Folic acid 1mg PO qD
Nexium 40mg PO qD
K-dur 20mEq qD
ASA 81mg PO qD
Accupril 5mg PO qD
Lipitor 10mg PO qD
Coreg 3.125mg PO bid
Torsemide 20mg PO qD
Nitro patch [**11-20**] patch qD
Oxcodone 20mg PO tid
Novolog
Lantus 26 qHS
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Oxycodone 5 mg Tablet Sig: Four (4) Tablet PO every eight (8)
hours as needed for pain.
5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Quinapril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Insulin
Lantus 30U qHS
Sliding scale Novolog as you were previously
8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
12. Nitroglycerin TD
[**11-20**] patch qD, as you have previously
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary edema.
Carotid stenosis
Pulmonary fibrosis
Discharge Condition:
Good. Breathing at baseline.
Discharge Instructions:
You were admitted to the ICU after an exacerbation of your heart
failure. You had a cardiac catheterization that did not
demonstrate any coronary artery lesions that needed stenting.
Please return to hospital if you experience worsening shortness
of breath, chest pain, or for any other problems that concern
you.
You should use 3L of home oxygen at all times.
You should eat a low sodium diet. You should weigh yourself
daily and call your physician if your weight increases or
decreases by more than 3 pounds.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2121-5-21**] 3:45
.
You have an appointment to have a CT of your neck 11:15am on
[**5-21**], before your appointment with Dr. [**Last Name (STitle) **]. You should
go to the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical Center. You can call
[**Telephone/Fax (1) 327**] with any questions.
.
You have an appointment with your primary care doctor, Dr.
[**Last Name (STitle) 31678**], on [**5-10**]. You can call him at [**Telephone/Fax (1) 31938**] with any
questions.
.
You should follow up with your cardiologist, Dr. [**Last Name (STitle) 20948**],
within the next 4 weeks.
.
You have an appointment with your diabetologist, Dr. [**Last Name (STitle) 12982**], on
[**5-11**].
|
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"433.10",
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"V64.1",
"518.0",
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
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"89.64",
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"88.57",
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icd9pcs
|
[
[
[]
]
] |
15160, 15166
|
9969, 13802
|
303, 404
|
15262, 15294
|
2988, 8761
|
15856, 16711
|
2517, 2521
|
14114, 15137
|
15187, 15241
|
13828, 14091
|
8778, 9946
|
15318, 15833
|
2536, 2969
|
228, 265
|
432, 1963
|
1985, 2436
|
2452, 2501
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,292
| 136,350
|
19505
|
Discharge summary
|
report
|
Admission Date: [**2100-12-13**] Discharge Date: [**2100-12-22**]
Date of Birth: [**2034-10-29**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain and right lower extremity numbness and tingling.
Major Surgical or Invasive Procedure:
Anterior fusion T11-L2
Posterior fusion T11-L2
History of Present Illness:
Ms. [**Known lastname 16590**] [**Last Name (Titles) 1834**] a previous lumbar fusion. She has
experienced a compression fracture above the level of her
previous fusion and has now developed a kyphosis. She has right
leg numbness. She now presents for surgical intervention.
Past Medical History:
HTN, COPD, RA since [**10**] y/o age, GERD
COPD, Afib, stres test wnl, ECHO [**2099**] EF 60-65%
Social History:
Previous tobacco user
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**2-19**] [**Last Name (un) 938**]/FHL on the right;
sensation diminished right leg; reflexes diminished at quads and
Achilles
Pertinent Results:
[**2100-12-21**] 04:55AM BLOOD WBC-13.3* RBC-3.40* Hgb-9.8* Hct-29.8*
MCV-87 MCH-28.9 MCHC-33.1 RDW-14.7 Plt Ct-185
[**2100-12-20**] 04:39AM BLOOD WBC-16.8* RBC-3.45* Hgb-9.9* Hct-30.0*
MCV-87 MCH-28.7 MCHC-33.0 RDW-15.0 Plt Ct-167
[**2100-12-19**] 02:26AM BLOOD WBC-14.8* RBC-3.48* Hgb-10.0* Hct-30.1*
MCV-87 MCH-28.6 MCHC-33.0 RDW-15.1 Plt Ct-156
[**2100-12-18**] 07:11AM BLOOD WBC-12.4* RBC-3.98* Hgb-11.7* Hct-33.8*
MCV-85 MCH-29.4 MCHC-34.6 RDW-15.1 Plt Ct-161
[**2100-12-20**] 04:39AM BLOOD Glucose-101 UreaN-10 Creat-0.5 Na-139
K-3.5 Cl-98 HCO3-33* AnGap-12
[**2100-12-19**] 02:26AM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-139
K-3.6 Cl-101 HCO3-32 AnGap-10
[**2100-12-18**] 07:11AM BLOOD Glucose-119* UreaN-14 Creat-0.5 Na-141
K-3.2* Cl-107 HCO3-27 AnGap-10
Brief Hospital Course:
Ms. [**Known lastname 16590**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a
thoracolumbar fusion T10-L2. She was informed and consented for
the procedure and elected to proceed. Please see Operative Note
for procedure in detail.
After the anterior fusion she developed an aspiration pneumonia
and was placed on levoquin and clindamycin. A PICC line was
placed. A chest tube was placed after the anterior thoracotomy
and subsequently discontinued during the posterior procedure.
Post-operatively she was administered antibiotics and pain
medication. Her catheter and drain were removed POD 2 and she
was able to take PO's. Her pain was well controlled. She will
return to clinic in ten days. She was discharged in good
condition.
Medications on Admission:
ASA, Hydrocodone, Digoxin, Lasix, Lisinopril, Metoprolol,
Nexium, Prednisone (5mg a day), Zocor, Arava, Actonel
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
9. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: Please follow
heparin flush PICC guidelines.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Thoracolumbar kyphosis for compression fracture
Post-operative blood loss anemia
Post-operative fever
Aspiration pneumonia
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Activity as tolerated
NO bending, twisting, or lifting >5-10lbs
TLSO brace when OOB
Treatments Frequency:
Please continue to change the dressings daily with dry, sterile
gauze.
Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.
Completed by:[**2100-12-22**]
|
[
"427.31",
"997.3",
"998.11",
"722.11",
"507.0",
"496",
"737.10",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"03.90",
"80.51",
"81.04",
"78.69",
"84.52",
"84.51",
"77.89",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
4279, 4364
|
2239, 3043
|
381, 430
|
4531, 4538
|
1451, 2216
|
5000, 5116
|
912, 917
|
3206, 4256
|
4385, 4510
|
3070, 3183
|
4562, 4769
|
932, 1432
|
4787, 4883
|
4905, 4977
|
283, 343
|
458, 737
|
759, 857
|
873, 896
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,119
| 162,398
|
29278
|
Discharge summary
|
report
|
Admission Date: [**2154-6-5**] Discharge Date: [**2154-6-14**]
Date of Birth: [**2093-10-11**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Presents for scheduled surgery
Major Surgical or Invasive Procedure:
[**6-5**] Partial left thyroid lobectomy
[**6-7**] Tracheostomy placement
[**6-13**] CT guided liver biopsy
History of Present Illness:
Ms. [**Known lastname 70382**] is a 60 year old female who presented earlier this
year with a
smooth symmetric goiter which was causing some compressive
symptoms but was totally benign by biopsy and in fact
indicative of Hashimoto's. She had several things going on in
her personal life at that time and by the time surgery was
scheduled, she had some increasing shortness of breath and in
the last several days, some change in her voice. On exam, the
area appeared unchanged and she was brought to the operating
room for scheduled surgical resection of her thyroid.
Past Medical History:
Past Surgical History:
Right hip replacement
Social History:
Married, lives with husband, 2 glasses wine/night. Nonsmoker
Family History:
Family members with benign thyroid disease
Pertinent Results:
Operative note [**6-5**]:
Goiter with compressive symptoms
secondary to advanced aggressive thyroid cancer with invasion
of trachea and pharynx.
OPERATION:
1. Neck exploration.
2. Extensive dissection left neck.
3. Partial left thyroid lobectomy.
Operative note [**6-7**]:
Thyroid cancer and respiratory
failure.
PROCEDURES: Flexible bronchoscopy and 8-0 Portex
tracheostomy tube.
CT chest [**6-6**]:
IMPRESSION:
1) Large thyroid mass/phlegmon which encases and narrows the
trachea to the diameter of the endotracheal tube extending from
the level of the cords to approximately 5 cm above the carina.
2) Large enhancing mass located between the left kidney and
pancreatic tail. Further evaluation with dedicated abdominal
imaging is recommended.
3) 2 cm right hepatic lesion which is not fully characterized on
this single phase study but most likely represents a hemangioma.
CT abdomen/pelvis [**6-10**]:
IMPRESSION:
1. 5.0-cm enhancing mass in the left upper quadrant, with
necrotic center. The mass lies between the left kidney and
pancreatic tail and may arise from the left adrenal gland.
Although metastasis from thyroid cancer should be considered,
additional considerations include primary adrenal neoplasm such
as pheochromocytoma (in which case, multiple endocrine neoplasia
could be considered). Other adrenal neoplasm such as
adrenocortical carcinoma could be considered. Less likely,
considerations are nonfunctioning islet cell tumor related to
the pancreas and gastrointestinal stromal tumor.
2. Two hypervascular lesions in the liver are concerning for
metastases from thyroid cancer.
3. Fibroid uterus, with 3.3-cm heterogeneous mass with internal
calcifications adjacent to the uterus on the left, which may
represent a calcified exophytic fibroid. Attention to this area
on followup examination is recommended.
CT guided biopsy [**6-13**]:
IMPRESSION:
1. Successful biopsy of the abdominal mass. Pathology results
are pending.
Pathology report:
Thyroid: Resection Synopsis
MACROSCOPIC
Specimen Type: Left lobe, partial.
Tumor Site: Left lobe.
Tumor focality: Extensively involves the left lobe.
Tumor Size (largest nodule): Cannot be determined (see
Comment).
MICROSCOPIC
Histologic Type: Poorly differentiated carcinoma, favor
follicular carcinoma. See comment.
EXTENT OF INVASION
Primary Tumor: pT4a: Tumor more than 4 cm, limited to the
thyroid or with minimal extrathyroidal extension (e.g.,
extension to sternothyroid muscle or perithyroid soft tissues).
See comment.
Regional Lymph Nodes: pNX: Cannot be assessed.
Lymph Nodes
Number examined: 0.
Distant metastasis: pMx: Cannot be assessed.
Margins:
Involved by carcinoma. Specified margin: inked tissue edge.
Venous/Lymphatic (Large/Small Vessel) Invasion: Present.
Comments:
The tumor is a poorly differentiated carcinoma.
Immunohistochemical studies show the tumor cells are positive
for cytokeratin cocktail, TTF-1 and thyroglobulin and are
negative for calcitonin. These results confirm the tumor is of
thyroid origin. The tumor is felt to be either a poorly
differentiated papillary carcinoma or a poorly differentiated
follicular carcinoma; the latter is favored.
The size of the tumor is difficult to determine as it involves
the entire thyroid lobe.
The tumor invades into perithyroid soft tissue and, therefore,
is at least a pT3 tumor. However, as per the online operative
note, the tumor may actually be a pT4 tumor.
Discharge labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2154-6-14**] 06:45AM 6.9 3.64* 11.8* 33.1* 91 32.5* 35.8* 13.4
578*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2154-6-14**] 06:45AM 578*
TSH
[**2154-6-7**] 03:00AM 0.89
THYROID T4 T3 calcTBG TUptake T4Index Free T4
[**2154-6-7**] 03:00AM 6.8 46* 0.90 1.11 7.5 1.2
IMMUNOLOGY Anti-Tg Thyrogl
[**2154-6-8**] 02:42AM 2396*1 UNABLE TO 2
Brief Hospital Course:
Ms. [**Known lastname 70382**] was admitted to the surgical service for a
scheduled thyroidectomy, intra-operatively she was found to have
an advanced aggressive thyroid cancer with invasion of the
tracheal and pharynx, final pathology revealed poorly
differentiated carcinoma, favor follicular carcinoma, T3/T4.
Post-operatively she was extubated but developed respiratory
distress and stridor; POD 2 she underwent a flexible
bronchoscopy and placement of 8-0 Portex tracheostomy tube.
Endocrinology and oncology service were consulted, a CT scan
demonstrated no axillary, mediastinal, or hilar lymphadenopathy;
there was a retroperitoneal enhancing mass, no bone lesions
suspicious for malignancy, and a right hepatic lesion was also
seen. The retroperitoneal mass was biopsied prior to discharge
home with pathology results pending. She was to follow-up with
Dr. [**Last Name (STitle) **], oncologist on [**6-27**] to discuss chemotherapy
treatment options.
POD [**4-1**], she was extubated without difficulty and oxygenating
well on humidified tracheostomy collar, she was evaluated by
speech and swallow therapy and did not demonstrate signs or
symptoms of aspiration, her diet was slowly advanced to regular
with thin liquids and pills to be taken with whole liquids which
she tolerated well. She was also evaluated for a Passy-Muir
valve; she was unable to tolerate the placement and was found to
have increase tracheal pressures and reported difficulty
exhaling, she was to follow-up as an out-patient for
re-evaluation of the PMV.
Post-operatively she had episodes of delirium and agitation
related to diagnosis, tracheostomy, and ICU admission;
psychiatry was consulted with recommendations of using Seroquel
at bedtime and Haldol. Her mental status and coping skills
improved dramatically over the course of the hospitalization, at
the time of discharge her anxiety was well controlled with small
doses of Ativan as needed and Trazodone at bedtime. She had a
supportive family and out-patient psychiatry therapy was
offered.
Throughout her hospitalization she was also followed by
respiratory therapy for care of the tracheostomy. She was
oxygenating well on a humidified 35% trach. collar while in bed,
but could ambulate independently off oxygen without respiratory
distress, multi-dose inhaler treatments continued every [**4-5**]
hours. She was able to change the inner cannula independently
and could expectorate her secretions with minimal suctioning
required.
She was discharged home in stable condition on [**6-14**] with
visiting nurse services and home respiratory care, all oxygen
supplies were to be delivered to her home. She was tolerating a
regular diet, afebrile, voiding without difficulty, and
ambulating independently. Her pain was well controlled with
Percocet. She was to follow-up with Dr. [**Last Name (STitle) **] in [**1-1**]
weeks, oncology [**6-27**], and speech and swallow therapy in [**1-1**]
weeks.
Medications on Admission:
Multivitamins
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 unit* Refills:*0*
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*1 unit* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
Disp:*100 mL* Refills:*0*
5. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
Disp:*1 unit* Refills:*0*
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 unit* Refills:*0*
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain: Take with food
DO NOT TAKE WITH ATIVAN.
Disp:*20 Tablet(s)* Refills:*0*
11. Oxygen 28%-50% Sig: 28%-50% oxygen continous.
Disp:*1 tank* Refills:*2*
12. Stationary suction/portable suction Sig: with Yankower
catheter once a day: and 14Fr suction catheters.
Disp:*99 box* Refills:*2*
13. 8 Portex with #8 inner cannula Sig: One (1) four times a
day.
Disp:*99 cannulas* Refills:*2*
14. Cool mist compressor Sig: With 02 titration continuous.
Disp:*1 tank* Refills:*2*
15. Speech and swallow evaluation Sig: Passy-Muir Valve
Please evaluate for Passy-Muir valve: Pt. with unresectable
thyroid cancer and tracheostomy.
Disp:*1 0* Refills:*0*
16. Trazadone 25-50mg qhs prn
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6549**] Med Services
Discharge Diagnosis:
Thyroid carcinoma
Tracheostomy
Abdominal mass
Discharge Condition:
Stable
Discharge Instructions:
Notify MD or return to the emergency department:
*Increased or persistent pain
*Fever > 101.5
*Shortness of breath, difficulty clearing secretions, or mucus
plug
*Increased secretions, inability to clear secretions, or change
in character of secretions
*Inability to swallow or breath
*If incisional/tracheostomy site develops redness or drainage
*If biopsy site develops redness, bruising, or bleeding
*Inability to pass gas, stool, or urine
*Nausea, vomiting, diarrhea, or abdominal distention that lasts
longer than 24 hours
*Chest pain or palpitations
*Any other symptoms concerning to you
You may shower, be careful with tracheostomy and try to avoid
water from entering the opening
No swimming
Slowly increase your daily activities including walking
throughout the day
Please keep all scheduled appointments
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2154-6-27**] 3:00
Follow-up with Dr. [**Last Name (STitle) **] in [**1-1**] weeks, call [**Telephone/Fax (1) 9**]
for an appointment
Follow-up with Dr. [**Last Name (STitle) **] (cardiothoracic surgeon who
placed tracheostomy) if there are any problems or difficulties
with the tracheostomy, call [**Telephone/Fax (1) 170**] for an appointment
Follow-up for speech and swallow therapy, and possible
evaluation for a Passy-Muir valve, they will contact you for an
out-patient appointment
Completed by:[**2154-6-14**]
|
[
"518.81",
"300.00",
"300.29",
"193",
"519.19",
"196.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"06.39",
"96.6",
"96.04",
"96.71",
"40.11",
"31.1",
"40.41",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
10013, 10081
|
5210, 8158
|
342, 452
|
10171, 10180
|
1276, 4731
|
11046, 11676
|
1213, 1257
|
8222, 9990
|
10102, 10150
|
8184, 8199
|
10204, 11023
|
4747, 5187
|
1095, 1118
|
272, 304
|
480, 1049
|
1071, 1071
|
1134, 1197
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,151
| 197,798
|
24514
|
Discharge summary
|
report
|
Admission Date: [**2197-5-3**] Discharge Date: [**2197-5-12**]
Date of Birth: [**2146-3-27**] Sex: M
Service: SURGERY
Allergies:
Codeine / Flagyl
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
worsening pelvic pain and fevers to 104
Major Surgical or Invasive Procedure:
cystoscopy, right ureteral stent removal and placement, right
nephrostomy tube placement
History of Present Illness:
This patient is a 50 year old male with a history of rectal
cancer complicated by enterocutaneous fistula and pelvic
recurrence, status post fistula takedown and mesh resection,
Crohn's disease, and right ureteral stent placement on [**2197-3-19**],
who presented to [**Hospital1 18**] on [**2197-5-3**] with fevrs to 104, malaise,
chills, rigors, and abdominal pain. His pain has been worsening
for the past 2 weeks. It is located in the rectal/pelvic area
as well as his penis. The pain is exacerbated with urination.
On the night prior to admission, he developed a fever of 100.8.
On the morning of admission, he went to an outside hospital,
where he was found to be febrile to 104 with a WBC of 11.6 (N76,
Bands 17). His createnine wa also noted to be elevated to 1.6
(baseline 1.2). In addition, a CT scan demonstrated a urine
leak and a questionable new entero-uretero fistula. He receievd
Ciprofloxacin and was transferred to [**Hospital1 18**].
Past Medical History:
Crohn's, EC fistula, HTN, SBP, Rectal CA, PE-IVC filter ('[**79**]),
peripheral neuropathy
PSH: s/p R ureteral stent ([**2197-2-24**])
Crohn's Disease
- Ex lap for abcess drainage/debridement ([**2196-4-21**]),
-Removal of Right [**Month/Day/Year **]/Rectum/Anus and repair recuurent vent
hernia w/ Marlex/Gortex mesh ([**2196-1-26**])
-Ventral Hernia Repair ([**2192**]) with remolval of left [**Year (4 digits) 499**]
-SBO, secondary to parastomal hernia ([**2191**])
-Transverse Loop Colostomy ([**2179**])
- I&D periredctal abscess
Stage II Rectal Adenocarcinoma
Flagyl-induced peripheral sensory neuropathy
S/p DVT L thigh
HTN
Social History:
Lives at home with his wife; worked as a ski instructor;
EtOH: none
Smoking: quit 18 yrs ago (1 ppd for 20 yrs)
Family History:
Aunt with [**Name2 (NI) **] CA;
Father with MI;
Physical Exam:
VS- Temp 100.6, HR 97, BP 132/64, RR 18, SaO2 99% RA
Gen: NAD, uncomfortable
HEENT: PERRL, EOMI, no sceral icterus
Lungs: CTA b/l
Heart: RRR, S1S2
Abdomen: Left ostomy with stool and gas, soft, moderately tender
and the RLQ, normoreactive bowel sounds, no rebound or guarding,
well healed midline incision
Extremities: warm, no c/c/e
Pertinent Results:
[**2197-5-3**] 09:16PM BLOOD WBC-11.7* RBC-4.32* Hgb-10.7* Hct-33.4*
MCV-77* MCH-24.8* MCHC-32.1 RDW-19.5* Plt Ct-295#
[**2197-5-4**] 10:35AM BLOOD WBC-8.2 RBC-3.63* Hgb-9.2* Hct-27.9*
MCV-77* MCH-25.4* MCHC-33.1 RDW-19.3* Plt Ct-216
[**2197-5-11**] 06:25AM BLOOD WBC-5.9 RBC-3.52* Hgb-8.7* Hct-27.7*
MCV-79* MCH-24.7* MCHC-31.4 RDW-18.5* Plt Ct-430
[**2197-5-3**] 09:16PM BLOOD Neuts-83.8* Bands-0 Lymphs-10.1*
Monos-5.7 Eos-0.1 Baso-0.4
[**2197-5-3**] 09:16PM BLOOD PT-28.7* PTT-31.1 INR(PT)-3.0*
[**2197-5-11**] 06:25AM BLOOD PT-12.1 INR(PT)-1.0
[**2197-5-3**] 09:16PM BLOOD Glucose-97 UreaN-13 Creat-1.4* Na-136
K-3.7 Cl-102 HCO3-21* AnGap-17
[**2197-5-11**] 06:25AM BLOOD Glucose-106* UreaN-16 Creat-1.0 Na-140
K-4.1 Cl-106 HCO3-25 AnGap-13
[**2197-5-3**] 09:16PM BLOOD Albumin-3.8 Calcium-8.3* Phos-2.9 Mg-1.7
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**2197-5-3**] for high fevers,
abdominal pain and an uretero-enteral fistula on a CT scan. He
was admitted to the surgery service of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**]. He
was kept NPO. Pancultures were sent which subsequently came
back negative. A foley was placed. He was started on broad
spectrum antibiotics (Vancomycin and Zosyn). Coumadin was held.
Urology was consulted and immediately responded. They decied
that the patient should have a percutaneous nephrostomy tube
placed and then a nephrostent without side holes. That night on
the floor, the patient had persistent fevers to 103 and was
transferred to the ICU for more close monitoring. He was
otherwise hemodyhnamically stable. His WBC was 11 on HD 2. He
continued to spike fevers, with a Tmax of 105. On HD 3, he was
febrile to a maximum temperature of 104, and his WBC was 6. He
was making excellent urine output and his urine was
clear/yellow. He later had placement of a 10 French
percutaneous right nephrostomy tube by interventional radiology.
He also had attempted removal of a previously placed double-J
stent. Snaring could be achieved, however, during manipulation
for removal, the patient experienced rigors and tachycardia and
therefore, removal was terminated. A double lumen PICC line was
placed and TPN was started (32 kcal/kg, 1.5 g of protein/kg).
The amount of his nephrostomy drainagge was compatible with
total diversion of his right kidney. On HD 4, his Tmax was 102.
On HD 5, his Tmax was 99.8 and he was transferred to the floor.
On HD 6, his PICC was leaking at the insertion site, so we
began giving him TPN through his port. His PICC was
discontinued. He was started on a regular diet, which he
tolerated well. His WBC was 3. Vancomycin was discontinued.
On HD 7, a CT scan was performed, which demonstrated a
ureteroenteric fistula, with a probable (although the site is
not seen) fistula between the distal right ureter and a long
inflammatory fistulous tract/fluid and gas collection that
extends to the midline and likely fistulizes into an adjacent
loop of small bowel. Please see full report for details. On HD
9, his double J stent was removed from the right ureter without
complications by Dr. [**Last Name (STitle) **] of Urology. A new Nephrotube was
placed by IR with no side holes. He tolerated the procedure
well. On HD 10, he was discharged home. His foely was left in
and should not be removed, per Urology. He is to follow up with
Dr. [**Last Name (STitle) **] in 2 weeks. He is also to follow up with IR, who may
decide to cap his nephro-tube if he is doing well. His coumadin
will be restarted and managed by his local hospital. He is to
start chemotherapy, and then follow-up with Dr. [**Last Name (STitle) 957**] will
also be arranged.
Medications on Admission:
neurontin 1200''', fentanyl pathc 75', iron, coumadin 2',
oxycodone PRN
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
2. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4
days.
Disp:*8 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation for 1 months.
Disp:*50 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
right ureteroenteral fistula
Discharge Condition:
good
Discharge Instructions:
Please call or come to the ED with any fevers > 101, nausea,
vomiting, abdominal pain, or any other worrisome issues that may
arise. You must leave your Foley in at all times. Please take
all of your medications as prescribed. Please follow up with
your local hospital about your coumadin dosing as you normally
would. You may restart your regular dose of coumadin. Please
continue to take the Ditropan for bladder spasms as needed.
Please apply dry derssing (guaze) to your abdominal drainage
area daily. Please make an appointment to begin chemotherapy
ASAP.
Followup Instructions:
please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up in
2 weeks at ([**Telephone/Fax (1) 4276**]
Please call the office of Dr. [**Last Name (STitle) 957**] to follow up in 2 weeks
after the start of your chemotherapy, at ([**Telephone/Fax (1) 376**]
Please follow up with the interventional radiologist Dr. [**Last Name (STitle) 380**]
at [**Telephone/Fax (1) 53983**]
Completed by:[**2197-5-12**]
|
[
"E931.5",
"V10.06",
"593.82",
"995.91",
"555.9",
"357.7",
"996.1",
"401.9",
"038.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"55.03",
"97.62",
"57.32",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
7270, 7276
|
3472, 6344
|
315, 406
|
7349, 7356
|
2632, 3449
|
7971, 8400
|
2214, 2263
|
6466, 7247
|
7297, 7328
|
6370, 6443
|
7380, 7948
|
2278, 2613
|
236, 277
|
434, 1394
|
1416, 2068
|
2084, 2198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,521
| 101,331
|
13640
|
Discharge summary
|
report
|
Admission Date: [**2177-1-5**] Discharge Date: [**2177-1-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
AMS, hypothermia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86yo man with h/o CAD, DM2, HTN, CRI, mild pancytopenia,
admitted from NH after diarrhea x3d, weakness and falls x1d,
found in the ED to have profound hypothermia to 87 degrees,
bradycardia to 25 bpm, BP 90/palp, hypoxia to 88% on NRB. Was
given atropine in ED with poor HR response; given warmed IVF and
bear hugger with good temperature response.
In ED, also received 2 units PRBCs for anemia, Vanc and Levaquin
for possible sepsis. Was sent to the MICU for eval and
treatment.
Past Medical History:
1. CAD x/p CABG X 2
2. CHF (EF 60-65%), dry weight 134 lbs
3. CRF with baseline creatinine of 2.6-3.6
4. DMII
5. Anemia- [**5-21**] EGD negative and colonoscopy negative
6. GERD
7. HTN
8. OA
9. Spinal stenosis
10. pna tx [**8-21**]
11 thrombocytopenia
Social History:
Lives at [**Location **] [**Hospital3 **]. Son is HCP.
[**Name (NI) **] tobacco.
No EtOH.
Family History:
Noncontributory
Physical Exam:
On presentation to ED:
Vitals: T87.8 oral (really), HR 20, BP 90/palp, RR 18, 88% on
NRB
Gen: ill-appearing, elderly, frail man
HEENT: PERRL, EOMI, anicteric, R pupil surgical, L reactive
Neck: supple, JVP flat
CV: distant hs, brady, regular, no mgr
Lungs: CTA b/l
Abd: soft, nt nd, +bs, no organomegaly
Rectal: guaiac negative per ED staff
Ext: no LE edema, 1+ DP pulses
Neuro: responding verbal commands, MAE
Skin: cool, dry
Pertinent Results:
[**2177-1-5**] 12:20AM BLOOD WBC-1.6*# RBC-2.77* Hgb-9.2* Hct-26.2*
MCV-94 MCH-33.1* MCHC-35.1* RDW-16.1* Plt Ct-21*#
[**2177-1-5**] 06:50AM BLOOD WBC-2.5*# RBC-2.58* Hgb-8.2* Hct-23.8*
MCV-92 MCH-31.7 MCHC-34.3 RDW-16.0* Plt Ct-38*#
[**2177-1-5**] 08:40AM BLOOD WBC-2.8* RBC-2.54* Hgb-8.1* Hct-23.4*
MCV-92 MCH-31.7 MCHC-34.4 RDW-16.5* Plt Ct-37*
[**2177-1-5**] 07:42PM BLOOD WBC-4.0 RBC-2.63* Hgb-8.1* Hct-24.3*
MCV-92 MCH-31.0 MCHC-33.6 RDW-16.5* Plt Ct-35*
[**2177-1-6**] 05:10AM BLOOD WBC-4.9 RBC-3.36*# Hgb-10.6*# Hct-30.7*#
MCV-92 MCH-31.5 MCHC-34.5 RDW-16.1* Plt Ct-50*
[**2177-1-7**] 05:00AM BLOOD WBC-4.8 RBC-3.54* Hgb-11.0* Hct-32.4*
MCV-91 MCH-31.1 MCHC-34.1 RDW-16.7* Plt Ct-44*
[**2177-1-8**] 05:20AM BLOOD WBC-5.7 RBC-3.36* Hgb-10.8* Hct-30.4*
MCV-91 MCH-32.1* MCHC-35.5* RDW-16.2* Plt Ct-52*
[**2177-1-5**] 12:20AM BLOOD Neuts-85* Bands-0 Lymphs-11* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2177-1-6**] 05:10AM BLOOD Neuts-83.2* Lymphs-9.8* Monos-6.2 Eos-0.8
Baso-0
[**2177-1-5**] 12:20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2177-1-5**] 12:20AM BLOOD PT-13.8* PTT-35.3* INR(PT)-1.2
[**2177-1-5**] 12:20AM BLOOD Plt Smr-VERY LOW Plt Ct-21*#
[**2177-1-5**] 06:50AM BLOOD Plt Ct-38*#
[**2177-1-5**] 08:40AM BLOOD Plt Ct-37*
[**2177-1-5**] 07:42PM BLOOD Plt Ct-35*
[**2177-1-6**] 05:10AM BLOOD Plt Ct-50*
[**2177-1-7**] 05:00AM BLOOD Plt Ct-44*
[**2177-1-8**] 05:20AM BLOOD Plt Ct-52*
[**2177-1-5**] 12:20AM BLOOD Gran Ct-1240*
[**2177-1-5**] 08:40AM BLOOD Ret Aut-1.7
[**2177-1-5**] 12:20AM BLOOD Glucose-199* UreaN-101* Creat-3.5* Na-142
K-5.8* Cl-114* HCO3-16* AnGap-18
[**2177-1-8**] 05:20AM BLOOD Glucose-40* UreaN-97* Creat-4.1* Na-144
K-4.5 Cl-110* HCO3-22 AnGap-17
[**2177-1-5**] 12:20AM BLOOD CK(CPK)-105
[**2177-1-5**] 06:50AM BLOOD ALT-33 AST-22 LD(LDH)-155 CK(CPK)-70
AlkPhos-80 Amylase-36 TotBili-0.3
[**2177-1-5**] 07:42PM BLOOD CK(CPK)-102
[**2177-1-6**] 05:10AM BLOOD ALT-39 AST-31 LD(LDH)-180 CK(CPK)-114
AlkPhos-84 Amylase-56 TotBili-0.5
[**2177-1-6**] 05:10AM BLOOD Lipase-25
[**2177-1-5**] 12:20AM BLOOD CK-MB-16* MB Indx-15.2* cTropnT-0.02*
[**2177-1-6**] 05:10AM BLOOD CK-MB-12* MB Indx-10.5* cTropnT-0.07*
[**2177-1-5**] 12:20AM BLOOD Calcium-8.0* Phos-5.8* Mg-2.5
[**2177-1-8**] 05:20AM BLOOD Calcium-8.8 Phos-5.4* Mg-2.0
[**2177-1-5**] 06:50AM BLOOD calTIBC-196* Ferritn-731* TRF-151*
[**2177-1-5**] 06:50AM BLOOD TSH-9.0*
[**2177-1-6**] 05:10AM BLOOD TSH-7.3*
[**2177-1-6**] 05:10AM BLOOD T4-3.9* calcTBG-1.08 TUptake-0.93
T4Index-3.6*
[**2177-1-5**] 06:50AM BLOOD Cortsol-22.5*
[**2177-1-7**] 05:00AM BLOOD Cortsol-21.5*
[**2177-1-7**] 05:50AM BLOOD Cortsol-41.0*
[**2177-1-6**] 05:10AM BLOOD Vanco-12.2*
[**2177-1-5**] 12:40AM BLOOD pO2-83* pCO2-49* pH-7.31* calHCO3-26 Base
XS--2 Comment-NONE SPECI
[**2177-1-8**] 11:17AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.015
[**2177-1-8**] 11:17AM URINE Blood-LGE Nitrite-POS Protein-100
Glucose-TR Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG
[**2177-1-5**] 06:50AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2177-1-8**] 11:17AM URINE RBC-86* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
[**2177-1-5**] 06:50AM URINE RBC->50 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2177-1-8**] 11:17AM URINE Hours-RANDOM UreaN-582 Creat-47 Na-80
[**2177-1-8**] 11:17AM URINE Osmolal-431
[**2177-1-6**] 7:48 pm URINE
**FINAL REPORT [**2177-1-7**]**
URINE CULTURE (Final [**2177-1-7**]): NO GROWTH.
[**2177-1-6**] 5:10 am BLOOD CULTURE Site: ARM
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
Brief Hospital Course:
A/P: 86yo man with h/o CAD, DM2, HTN, CRI, pancytopenia, a/w
hypothermia, bradycardia, profound pancytopenia, found to be
hypothyroid.
.
1. Hypothyroidism, Primary: patient was found to have TSH on
admit of 9.0, repeat was still elevated at 7.3; T4 was low at
3.9, c/w primary hypothyroidism; pt was started on Synthroid
112mcg/day. [**Last Name (un) **] stim test was negative. Endocrine was consulted
and did not feel many of his symptoms were secondary to
hypothyroidism. They wanted to decrease his synthroid to 50 mcg,
recheck his TSH in 1 week and then decrease again to 25 mcg.
This should be done at rehab.
2. Bradycardia: thought likely [**2-19**] hypothyroidism, maintained on
on tele, had episodes of brady down to 35s occassionally with
longest pause 2.2 seconds. Cardiology evaluated while the
patient was in the MICU, said that the patient did not require
pacer but to continue to monitor for drops in pressure or
symptoms, which patient did not have during his hospital stay;
thought likely to resolve as Synthroid takes effect. Will need
outpatient follow up.
.
3. Hypotherm: also likely [**2-19**] hypothyroidism, will warm as
needed for now. Did not improve with synthroid. On discharge has
temp of 92.7, so there is likely a central cause for this of
unknown etiology. The patient should be followed closely, if his
temp drops farther, he should be rewarmed.
4. Pancytopenia: patient was noted on admission to have WBC 1.9
down from baseline 6.0, Hct 26.2 down from baseline 30, plts 21
down from baseline 90-100. Patient currently receiving Epogen
?5000 or 20,000 units/week, received at the VA, but not followed
by a Hematologist. Has had fairly stable counts until [**2174**]. In
[**11-19**] anemia began, and was thought to be [**2-19**] kidney disease.
EGD and cspy in [**5-21**] were negative for bleed, iron studies were
c/w anemia of chronic disease with low retic count 1.7%. Heme
recommended increasing his Epo to 40,000 units per week, which
was initiated while he was in house on the night prior to his
discharge. Heme also noted that his peripheral smear contained
strange-looking cells suspicious for myelodysplastic process.
They do not feel that a BM biopsy would change his management,
but plan to follow him in clinic. Of note, the patient's WBC
count returned to the patient's normal range, his hct remained
stable after receiving 2 units PRBCs. His plt count remains low
but is slowly trending upwards. He has had no evid of bleeding
but we are holding ASA given this significant risk (he has a h/o
falls)
.
5. Blood sugars: pt has h/o DM2, was started on RISS as
glyburide was held, then patient became hyponatremic, possibly
because of hypothyroidism; was on a D5W drip briefly, RISS
adjusted to keep sugars in check; pt seems very sensative to
insulin at bedtime when he is not eating, so this scale was
decreased compared to his daytime dosing. If patient needs to be
started on a oral hypoglycemic, he should not be restarted on
his glyburide as it is renally cleared. Glipizide can be
considered.
.
6. ARF: pt's creatinine bumped to 4.1 from 3.5 on day prior to
discharge; likely prerenal in setting of overdiuresis, net
negative 1700 day prior. Rehydrated gently with 500cc, rechecked
BUN and Cr afterwards with resolution. Baseline Cr 3.5.
.
7. Constipation: possibly [**2-19**] hypothyroid, increased bowel
regimen
.
8. CAD: CEs flat, ASA held [**2-19**] low platelets; cont statin;
holding BB [**2-19**] AVB, bradycardia. He should not be restarted on a
beta blocker.
.
9. CHF: patient was initially felt to be a bit overloaded [**2-19**]
his CXR and his clinical presentation; this was thought to be
due to a combination of bradycardia, anemia and possible
infection; TTE showed LVH but no evid of worsening heart
function with LVEF>55%. Pt was initially diuresed with Lasix
40mg IV as needed, then became overdry with bump in creatinine,
was given some fluid back via NS boluses, and is being
discharged euvolemic.
.
10. ?LLL pna: thought to have evid of pna (?aspiration) on
initial CXR, started Levaquin x 7days ( started on [**1-6**] to stop
[**1-12**]). Needs 1 more day.
.
11. HTN: continued prazosin, increased to 2 mg prasozin at
night, also increased Hydralazine. We avoided ACEI given
ARF/CRI, and avoided BB given profound bradycardia.
.
12. Code: DNR/DNI
13. Communication: Son [**Name (NI) **] [**Name (NI) 18965**]
Medications on Admission:
ASA 325 qd
protonix 40 qd
lipitor 10 qd
glyburide 2.5 qam
iso mono 30 qd
zoloft 50 qd
MOM
epogen ?20,000/week vs 5000/week
prazosin 1mg qd
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Prazosin HCl 1 mg Capsule Sig: One (1) Capsule PO QHS (once a
day (at bedtime)).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO QHS (once a day (at bedtime)) as needed.
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q8H (every 8 hours) as needed.
9. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection QMOWEFR (Monday -Wednesday-Friday): per Heme
recommendation patient should stay on this dose rather than
return to his 5000 unit/week prior regimen.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): especially important while on iron; please hold
only for diarrhea.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q8H (every 8 hours) as needed.
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 5 days.
14. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Hydralazine HCl 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every
6 hours).
17. Prazosin HCl 2 mg Capsule Sig: One (1) Capsule PO QHS (once
a day (at bedtime)).
18. Outpatient Lab Work
You should have TSH checked in 1 week. If improved, should have
synthroid dose decreased to 25 mcg.
19. Insulin
Continue insulin sliding scale.
FS QID and insulin QID.
150-200 2 units
201-250 4 units
251-300 6 units
301-350 8 units
351-400 10 units
AT night, this sliding scale should be decreased by one unit.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
1. Hypothyroidism, primary
2. Pancytopenia(anemia,leukopenia,thrombocytopenia), with
dysmorphic blood cells
3. Bradycardia, thought secondary to hypothyroidism
4. Hypothermia, thought secondary to hypothyroidism
5. Constipation, thought secondary to hypothyroidism
6. Congestive heart failure exacerbation, likely related to
bradycardia and possible pneumonia
7. Acute renal failure on top of chronic renal insufficiency,
thought secondary to overdiuresis
8. Difficult to control sugars, thought secondary to diabetes
mellitis plus hypothyroidism
9. Possible left lower lobe pneumonia, seen on chest X-ray
Discharge Condition:
Stable, still hypothermic
Discharge Instructions:
Please continue to take all medications as prescribed and to
follow the plan laid out by your healthcare team.
If you develop chest pain, shortness of breath, palpitations,
confusion, dizziness, decreased urine or stool output,
lightheadedness, loss of consciousness, please call or have
someone else call 911 immediately to be brought to the nearest
emergency room for evaluation and treatment.
Followup Instructions:
Please set up an appointment with Dr. [**Last Name (STitle) 5762**] upon discharge to be
re-evaluated in the week after leaving the hospital. You will
need to have labs drawn to check your renal (kidney) function
and your thyroid function, and will also need to be seen
regarding your congestive heart failure.
You should also be seen by your eye doctor at [**Hospital 13128**].
|
[
"780.99",
"284.8",
"427.89",
"584.9",
"276.1",
"403.91",
"428.0",
"507.0",
"244.9",
"564.00",
"530.81",
"V45.81",
"250.02",
"715.90",
"E944.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11970, 12041
|
5311, 9698
|
279, 286
|
12691, 12718
|
1675, 5232
|
13163, 13545
|
1195, 1212
|
9888, 11947
|
12062, 12670
|
9724, 9865
|
12742, 13140
|
1227, 1656
|
223, 241
|
5258, 5258
|
5288, 5288
|
314, 796
|
818, 1071
|
1087, 1179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,877
| 172,753
|
53382+59519
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-1-27**] Discharge Date: [**2175-1-30**]
Date of Birth: [**2135-5-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
LE edema, increasing abd girth
Major Surgical or Invasive Procedure:
hepatic venogram via R IJ approach
History of Present Illness:
39 year old female with pertinent history of essential
thrombocythemia diagnosed in [**1-10**] by bone marrow biopsy in the
setting of unprovoked IVC and bilateral lower extremity
thromboses and associated thrombocytosis and splenomegaly,
chronically anticoagulated on coumadin, presenting with LE
edema. She was originally seen by her PCP [**Last Name (NamePattern4) **] [**1-16**] with
complaints of lower extremity edema. INR 3.7 and plts 440,000.
MRI/MRA abdomen was ordered that was not done until [**1-26**] that
showed extensive hepatic venous thrombosis and ascites that was
compatible with Budd Chiari syndrome. The pt states her abdomen
has since appeared larger and more swollen since she saw her
PCP.
Past Medical History:
1) IVC thrombosis: Diagnosed in [**10-10**] when she presented with
bilateral lower extremity swelling. US revealed complete
thrombosis of bilateral lower extremity venous systems, as well
as the infrahepatic IVC. She was started on coumadin. Etiology
initially unclear, however thrombocytosis was noted, in addition
to splenomegaly, prompting referral to [**Date Range 1978**]. A diagnosis
of essential thrombocytosis was made via bone marrow biopsy in
[**1-10**] demonstrating increased large atypical megakaryocytes
constent with the diagnosis.
2) Essential thrombocytosis: See above, diagnosed in [**1-10**] via
bone marrow biopsy demonstrating increased large atypical
megakaryocytes. BCR-ABL negative (CML as cause of splenomegaly
ruled out).
3) Ovarian cysts: Followed by periodic ultrasound, always
changing in appearance, with hemorrhagic components, thought to
be likely physiologic.
4) Iron deficiency: Diagnosed during [**10-10**] admission, treated
with iron with normalization of iron indices.
5) B12 deficiency: Diagnosed during [**10-10**] admission, treated with
cyanocobalamin.
6) Uterine fibroids: s/p fibroid surgery in [**2168**]
Social History:
Single, works as a hairdresser. Denies tobacco, etoh, IVDU.
Family History:
2 aunts with DM, HTN. No history of clots in the family, lupus.
Physical Exam:
T97 P 82-92 120-145/80s 99% RA
Gen - alert and oriented x 3
Skin - no telangectesias/spider angiomatas
HEENT -op clear, no petechiae/gum bleeding
CV - s1s2 no m/r/g
Lungs -cta x 2
Abd - very distended with ascites, +fluid wave, no tenderness,
+bs
Ext - 2+ edema
Pertinent Results:
[**2175-1-27**] 01:15PM BLOOD WBC-8.6 RBC-5.71* Hgb-14.3 Hct-44.4
MCV-78* MCH-25.0* MCHC-32.2 RDW-16.7* Plt Ct-479*
[**2175-1-28**] 03:00AM BLOOD WBC-7.2 RBC-4.85 Hgb-12.4 Hct-36.6
MCV-76* MCH-25.6* MCHC-33.9 RDW-16.6* Plt Ct-396
[**2175-1-27**] 01:15PM BLOOD Neuts-74.3* Lymphs-14.7* Monos-4.5
Eos-2.7 Baso-3.7*
[**2175-1-29**] 02:00AM BLOOD PT-22.5* PTT-82.6* INR(PT)-2.2*
[**2175-1-28**] 08:28PM BLOOD PTT-69.6*
[**2175-1-28**] 11:53AM BLOOD PTT-150*
[**2175-1-28**] 03:00AM BLOOD PT-28.2* PTT-150 IS HIG INR(PT)-2.9*
[**2175-1-27**] 01:15PM BLOOD PT-26.8* PTT-35.9* INR(PT)-2.7*
[**2175-1-28**] 03:00AM BLOOD Glucose-105 UreaN-10 Creat-0.8 Na-140
K-3.7 Cl-108 HCO3-23 AnGap-13
[**2175-1-27**] 01:15PM BLOOD Glucose-94 UreaN-9 Creat-0.9 Na-141 K-4.6
Cl-106 HCO3-28 AnGap-12
[**2175-1-29**] 02:00AM BLOOD ALT-28 AST-34 AlkPhos-75 TotBili-0.6
[**2175-1-28**] 03:00AM BLOOD ALT-30 AST-37 LD(LDH)-351* AlkPhos-75
TotBili-0.8
[**2175-1-27**] 01:15PM BLOOD ALT-37 AST-53* AlkPhos-90 Amylase-161*
TotBili-0.9
[**2175-1-27**] 01:15PM BLOOD Lipase-47
[**2175-1-29**] 02:00AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.8
.
MRI/MRA abd: FINDINGS: There has been interval development of
ascites within the abdomen. Additionally, there has been
interval development of complete thrombosis of the right
hepatic, middle hepatic, and left hepatic veins. The liver is
drained through an accessory left hepatic vein supplying segment
VI and there are multiple intrahepatic collateral veins that
drain into this segment VI accessory vein. There is no evidence
for thrombus in the intra-hepatic IVC, however, the intrahepatic
IVC is very flat and attenuated, likely secondary to hypertrophy
of the caudate lobe. There is a peripheral arterial enhancement
pattern of the liver compatible with the interval development of
Budd-Chiari. Again seen is extensive nonocclusive thrombus
within the infra-hepatic IVC, extending to the level of the
venous bifurcation. Multiple retroperitoneal collaterals are
seen below the bifurcation, with no native common iliac,
external, or internal iliac veins seen. Lited visualization of
the adrenal glands, kidneys and pancreas is unremarkable.
Multiplanar 2D and 3D reformations as well as subtraction images
were essential in demonstrating multiple perspectives for this
dynamic series. IMPRESSION: 1. Interval development of
extensive hepatic venous thrombosis, intrahepatic venous
collaterals, and ascites, compatible with Budd-Chiari. There is
patent venous drainage from the liver through an accessory
segment VI vein. The intra- hepatic IVC is patent but
attenuated. 2. Nonocclusive thrombus within the IVC extending
from the infra-hepatic IVC to the iliac bifurcation.
Retroperitoneal collaterals replace the native common iliac,
internal, and external iliac veins.
.
HEPATIC VENOGRAPHY: See hospital course, official read pending
at time of discharge
.
[**1-30**] LIMITED ULTRASOUND OF THE ABDOMEN: Comparison was made
with the prior MRI dated [**2175-1-26**]. There is moderate
amount of ascites in bilateral lower quadrants. No significant
ascites is demonstrated in upper quadrant on this exam.
IMPRESSION: Limited study of the abdomen. Moderate amount of
ascites in bilateral lower quadrants.
.
Brief Hospital Course:
39 yo F with h/o essential thrombocythemia c/b bilateral LE
DVTs, infrahepatic IVC clot, and L renal vein clot on coumadin
presented with increasing LE edema and abdominal girth with
MRI/MRA abdomen with findings suggestive of Budd Chiari now s/p
IR visualization of portal venous system demonstrating extensive
hepatic venous thrombi, with collateralization and drainage of
the vessels via an accessory vein into the IVC switched to
Lovenox for anticoagulation.
.
#) Budd-Chiari - She went to IR on [**1-29**] to have a venogram. IR
visualized extensive hepatic venous clots, with
collateralization and drainage of the vessels via an accessory
vein into the IVC. Because of this, she could not be given local
lysis with TPA. At this time the heparin was restarted and she
was transferred to the floor. She remained stable overnight and
had an ultrasound of her liver on the day of discharge which
revealed moderate ascites. Per liver, no indication to tap her
ascites at this time given her asymptomatic status. LFTs were
stable throughout with a slight increase in Amylase to 161 on
admission, 141 on discharge. ALT and AST were WNL.
.
#) Essential thrombocythemia - hx of multiple thrombi. She was
transitioned to Lovenox from Heparin on the day of discharge
with education as to how to administer self-injections. She was
discharged on [**Hospital1 **] Lovenox (100mg) for long-term anticoagulation
and scheduled for follow up with heme-onc in 3 days. Per
heme-onc, no need for Hydrea at time of discharge but this will
be reevaluated on Friday at her follow up appointment. As to our
assessment she will need platelet suppression to prevent
occlusion of the single draining collateral hepatic vein which
could result in a disastrous acute on chronic Budd Chiari
syndrome.
.
#) Code-full
.
#) Communication- with patient and her patients
.
#) Dispo: To home
.
Medications on Admission:
COLACE 100 mg [**Hospital1 **]
COUMADIN 7.5 mg 4xs/wk
COUMADIN 5 mg 3xs/wk
DULCOLAX 5 mg qdprn
SENNA 8.6 mg 1 tab qd
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) Syringe
Subcutaneous [**Hospital1 **] (2 times a day).
Disp:*60 Syringes* Refills:*5*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a
day as needed for constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Budd-Chiari syndrome
Essential Thrombocythemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for swelling secondary to your occludied liver
veins (Budd-Chiari syndrome) and your symptoms have improved.
You will need close follow up for your Essential Thrombocythemia
and your liver disease as well.
.
Take all medications as prescribed.
.
Follow up per below.
.
Seek medical attention immediately if you experience new
symptoms including shortness of breath, dizziness, increased
swelling, fevers, abdominal pain, or other new concerning
symptoms.
Followup Instructions:
With Heme/Onc (Dr. [**Last Name (un) 5561**]) [**Hospital Ward Name 23**] 9 at 10:30am Friday [**2-3**] - [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]-[**Doctor Last Name **] will call you with any change in
plan.
.
Call ([**Telephone/Fax (1) 1582**] tomorrow to schedule a liver appointment
with Dr. [**Last Name (STitle) **] in [**Month (only) **] (between the 7th and 15th is
possible).Provider:
.
[**2175**] appointments:
.
[**Last Name (LF) 17512**],[**First Name7 (NamePattern1) 8826**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Date/Time:[**2175-3-24**] 9:30
.
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2175-3-24**] 9:30
Name: [**Known lastname **] [**Known lastname **],[**Known firstname 18011**] Unit No: [**Numeric Identifier 18012**]
Admission Date: [**2175-1-27**] Discharge Date: [**2175-1-30**]
Date of Birth: [**2135-5-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12135**]
Addendum:
Just prior to the patient leaving, Heme onc recommended starting
Hydrea at 1000mg/day and gave a prescription to the patient.
As per the discharge summary, she will follow with heme onc on
Friday of this week (Friday [**2-3**]) In addition, the patient will
also follow with transplant surgery as an outpatient.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 12140**] MD [**MD Number(2) 12141**]
Completed by:[**2175-1-30**]
|
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icd9cm
|
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9004, 10501
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2392, 2457
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8042, 8356
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8406, 8454
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7900, 8019
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8507, 8981
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276, 308
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410, 1124
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,114
| 155,854
|
10903+56182
|
Discharge summary
|
report+addendum
|
Admission Date: [**2155-3-29**] Discharge Date: [**2155-4-9**]
Date of Birth: [**2083-10-4**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 2078**]
Chief Complaint:
dysnpea
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
This is a 71 y.o. gentleman with CAD (s/p CABG '[**46**]), multiple
PCI, ICM (EF 30%) with known restrictive lung disease (on 3L
home O2), anemia presented from [**Hospital3 24768**] (where he
presented with ? PNA with progressive dyspnea) for evaluation
for acute coronary syndrome with elevated CK but flat TN. When
he arrived he was in marked pulmonary edema improved with
diureses.
(-)N/V/C/D/Wt change/f/c. No travel. No known dietary
indiscretion or med changes. No pre-syncope. +PND/orthopnea
Past Medical History:
1. CAD s/p CABG'[**46**] (LIMA to LAD, SVG to OM2, SVG to diag, SVG to
PDA), s/p PTCA/stent LMCA to D1 [**7-18**], plaque prolapse s/p
restent [**10-18**], instent rethrombosis during stent, repeat stent
Cath [**6-18**]: PTCA/stent SVG to OM1, repeat cath [**6-18**] stent of
LMCA, LAD, D1 (not CABG candidate). Repeat cath [**8-18**] PTCA of
the D1 stent and beyond the stent with balloon.
2. CHF: EF 40%, 1+ MR, E/A>1
3. Restrictive lung disease, on [**3-20**] L home o2 ([**3-19**] diaphragmatic
injury during thoracotomy, also component of OSA)
4. Hyperlipidemia
5. DM
6. s/p CVA [**2142**]
7. Prostate ca s/p XRT
8. Appendectomy
Social History:
Lives with girlfriend. Quit tobacco [**2121**], 40 pk yr hx. Quit
EtOH [**2121**].
Family History:
non contributory
Physical Exam:
T:99.5 BP:120/79 HR:90 100% on NRB. Wt:104 kg.
Gen: NAD a/o x 2
HEENT: PEARLA. OP (-)
CV: RR, No S3/S4. III/VI SM at LLSB to axilla. no bruits. JVP
at 11.
Pulm: Rales b/l 1/2 up
ABD: S/NT/ND No bruits
Ext: 1+ DP/radial b/l
Neuro: Motor [**6-19**]. [**Last Name (un) **] GI to LT. CN II-XII GI. Gait WNL.
Pertinent Results:
AP portable chest [**2155-4-6**] at 8:40 a.m.: No apparent change in
the position of the left subclavian central venous catheter
whose tip is in the left brachiocephalic vein. There is opacity
at the right cardiophrenic angle, which appears increased when
compared to prior study, but this may be secondary to lesser
inspiration. The patient is in mild failure.
-------------------
Blood and urine Cx: Negative to date ([**4-9**])
Echo [**2155-4-1**]:
Left Atrium - Long Axis Dimension: *4.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.6 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.2 cm
Left Ventricle - Fractional Shortening: *0.18 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 25% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aorta - Arch: 2.7 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: *2.8 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 31 mm Hg
Aortic Valve - Mean Gradient: 18 mm Hg
Aortic Valve - Valve Area: *2.2 cm2 (nl >= 3.0 cm2)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.70
[**2155-3-29**] 10:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2155-3-29**] 10:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2155-3-29**] 07:59PM TYPE-ART PO2-148* PCO2-53* PH-7.43 TOTAL
CO2-36* BASE XS-9 INTUBATED-NOT INTUBA
[**2155-3-29**] 07:59PM LACTATE-1.4
[**2155-3-29**] 07:29PM GLUCOSE-314* UREA N-23* CREAT-1.0 SODIUM-135
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-35* ANION GAP-11
[**2155-3-29**] 07:29PM ALT(SGPT)-17 AST(SGOT)-61* LD(LDH)-775*
CK(CPK)-715* TOT BILI-0.8
[**2155-3-29**] 07:29PM CK-MB-1 cTropnT-0.02*
[**2155-3-29**] 07:29PM ALBUMIN-3.2* CALCIUM-8.5 PHOSPHATE-2.3*
MAGNESIUM-1.9
[**2155-3-29**] 07:29PM WBC-5.9 RBC-3.64* HGB-9.1* HCT-28.9* MCV-80*
MCH-25.0* MCHC-31.5 RDW-18.3*
[**2155-3-29**] 07:29PM PLT COUNT-184
[**2155-3-29**] 07:29PM PT-15.5* PTT-28.8 INR(PT)-1.5
Brief Hospital Course:
71yo male w/ known prostate ca, CAD s/p CABG, multiple PCI,
ischemic CMY EF 30%, restrictive lung dz on home o2 (usual
3liters), metastatic prostate CA, anemia, xferred from [**Hospital 35462**] (where presented for progressive dyspnea/ ? PNA) for ?
ACS w/ elevated CKs, but flat troponins. Marked cardiogenic
pulmonary edema, hypotensive (responded to fluids) on arrival
that improved w/ diuresis. He was intially admitted to the
cardiology (telemetry floor).
EVENTS:
[**2154-4-2**] = Patient became hypotensive w/SBP in 60-70s wtih some
response to fluid boluses. Has had approx 2.5Liters via 500cc
boluses with his pressures holding in 90's and HR in 80s.
Patient's creatinine bumped to 2.3, and his urine output
dropped. EKG was unchanged, but cardiac enzymes were cycled and
CK were mildly elevated. Mid day it was reported that a temp of
100.6 had not been recorded on the vitals sheet. A potential
septic workup was initiated as a source of the hypotension w/
CXR (? retrocardiac PNA vs CHF), ABG (okay, not acidotic),
lactate (up to 2.4 from 1.6), chemistries w/ no anion gap. Blood
and urine cultures sent and initiation of Zosyn and Vancomyocin
empirically. Additionally, patient has been complaining of
increasing pain secondary to his prostate cancer. We increased
his morphine to 2-4mg from 2mg, however [**Month/Day/Year 2449**] have been
informed to give judisciously if signs of respiratory
depression/somnolence. Patient began exhibiting waxing/[**Doctor Last Name 688**]
delirium x2 days which he has had several episodes of today.
MICU was made aware. AT 5pm started to improve after 3rd liter
of NS. BP 105, mentation okay, o2 sats stable on 3 liters at
94% (note has EF 30%).
[**2154-4-3**] = Patient initially doing much better, maintaining
pressures, improved mentation, improving creatinine and urine
output, better pain control w/PCA. Received central line
secondary to non-functional peripherals and possible need for
future fluid boluses/reliable line. Continuing zosyn/vanc, with
cultures pending. At end of day, developed substernal chest
tightness w/increased depression on lateral leads. Relieved
w/nitro and rate controled w/10mg of IV lopressor(pushed 5 and
5). Heparin drip started, cardiac enzymes cycled. He was
admitted to the CCU and taken for cardiac cath:
SIGNIFICANT DATA:
CATHETERIZATION:
1. Three vessel coronary artery disease.
2. Instent restenosis of the first diagonal branch.
3. Patent LIMA->LAD, SVG->OM2.
4. Successful PTCA of first diagonal.
COMMENTS:
1. Selective coronary arteriogram of this right dominant system
revealed
angiographic evidence of three vessel coronary artery disease.
The LMCA
had mild diffuse disease. The LAD was totally occluded after the
first
diagonal branch. The first diagonal branch had a focal 95%
instent
restenosis distally. The LCX had moderate diffuse disease
throughout its
course with a totally occluded lower pole OM1 filling with
collaterals.
The RCA was not engaged.
2. Graft angiography revealed a patent LIMA->LAD and a patent
SVG->OM2.
3. Successful PTCA of the first diagonal branch with a 2.5x15mm
balloon.
Final angiography revealed 30% residual stenosis, no dissection.
The chest pain was thought to be demand ischemia in the setting
of pneumonia and anemia. On [**4-6**] he was transferred back to the
cardiology floor. Issues of hospital course briefly summarized
below.
______________________________________________________________
## DECOMPENSATED SYSTOLIC HEART FAILURE: volume overload on
exam. Stable oxygenation on 4 liters O2.
Echo ([**4-1**]) with EF 25% (see data) with mild pulm HTN and 1+MR
[**Name13 (STitle) **] had been on toprol xl 200 daily, changed to metoprolol 50 po
bid. Daily weights, I/Os, and 2 gram Na diet were maintained
He was approximately 3300cc negative after lasix and zaroxoyn
(given during red cell infusion) and nitro gtt.
Discharge weight of 102 kg, 94% on 2L NC. D/C'd on 40 lasix
[**Hospital1 **] and lisinopril 2.5.
__________________________________________
## CAD. Complex mulitvessel disease. MB fractions and
Troponins do not suggest MI. No episodes of Chest pain. (see
above and see data for cath result from [**4-7**].)
- Aspirin
- metoprolol 50 [**Hospital1 **] (titrate to HR of 80 or less)
- plavix 75 daily
- He was started on a statin and low-dose ACE-I.
___________________________________________________________
## Generalized weakness: Likely multifactorial.
Deconditioning/edema / ?myositis / pain syndrome.
-diuresis as above, will consider further eval if unresolving.
-PT eval once pulmonary condition improves and additional volume
removed.
-Will monitor CK on statin
- No fevers x 48 hours at time of D/C. Temp runs in the 98-99
range.
- Blood cultures Negative to date. Urine cultures NTD
___________________________________________________________
## DYSPNEA: probably mostly related to decomp HF on top of
underlying restrictive lung disease (home O2 baseline 3liters)
and ? PNA. Apparently had febrile illness prior to admit to
[**Hospital 11047**] hospital.
- continued Levoquin (started [**3-26**]) through [**4-1**] to complete 7
day, then Vanco/Zosyn until [**4-7**], then Levofloxacin 250 (last
dose should be on [**4-14**])
______________________________________________________
## DIABETES TYPE 2:
- unclear what dose of 70/30 is optimal. Has been on 50 units
[**Hospital1 **] last admit, and says he take 100 units [**Hospital1 **] when eating
optimally.
given poor po (which may also reflect the degree of pulm edema
+/- carcinoma), will undershoot dose and uptitrate as needed.
- continued ISS
__________________________________________________________
## ANEMIA: multifactorial. progressive despite recent procrit
escalation. Guaiac (-). ? Anemia of chronic disease (due to
prostate ca) Hct on D/c 30.8.
- xfuse PRBC today
- dose with procrit
____________________________________________________________
## PELVIC DISCOMFORT:
robable bladder spasm [**3-19**] foley catheter
-UA neg, UCx pending
-increased oxybutinin to 10mg today, monitored for
anticholinergic side effects
-On duragesic patch with prn morphine
______________________________________________________________
## PAIN SYNDROME: related to bony pain from prostate ca. Lucid
now on exam. Will offer prn morphine and calculate narcotic
requirement and then dose duragesic appropriately.
- morphine prn
## Mental status: Per wife he is at his baseline. Thinks
president is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] but is A/O x 3 otherwise. Knows
horseracing details and current events, but does not follow
politics. Good attention. Non-focal neuro exam.
## Occasional Hypotension: Initially thought to be sepsis vs.
CHF. Patient is still somewhat orthostatic. Repeating BP
usually with normal values. His baseline SBP is in the
90s-100s. It is in the low 90s in the AM. On D/C BP was 100/60
with HR in the 80s-90s. Afebrile with negative blood cultures.
Echo w/o effusion, with EF 25%.
## CRI: BLC 1.5. Due to diabetes. Cr during admission ranged
from 1-2.3. Was 1.7 on D/C prior to decreasing ACE-I dose to
2.5.
_________________________________________________________
## PROPHYLAXIS:
sc heparin, protonix
____________________________________
## ACCESS: Had left Subclavian central line which was
discontinued on [**4-9**] per instructions that patient is not able
to be transferred to rehab with access. Will likely need to
place a peripheral IV on admission.
## CODE: full
## DISPO: To Rehab in [**Location (un) 11790**], RI. Per PT: would benefit from
[**Hospital 3058**] rehab.
Medications on Admission:
Metoprolol 100 [**Hospital1 **], ASA, Plavix, Isosorbide 20 tid, lasix 80
tid, lovenox 60 [**Hospital1 **], prevacid, neurontin 300 tid, actos 15
daily, duragesic 25, levoquin 500 daily, NTG paste.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
ASDIR Injection once a day: sliding scale.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
11. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
12. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QHS (once a day
(at bedtime)).
14. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days: last dose on [**4-14**].
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
19. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
hold for Cr>1.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11790**] Health Center
Discharge Diagnosis:
Pneumonia
Congetive Heart Failure with EF 30%
Coronary Artery Diseae
Prostate Ca
Anemia
Restrictive Lung Diseae
Discharge Condition:
stable at 104/67, 77, 97% 2L, Wt of 101 kg
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1000 cc
Please notify doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] chest discomfort, palpitations,
shortness of breath, lightheadedness, cough, fevers or other
symptoms of concern.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 24717**] [**Telephone/Fax (1) 24721**] after leaving
rehabilitation.
Completed by:[**2155-4-9**] Name: [**Known lastname **],[**Known firstname 6281**] Unit No: [**Numeric Identifier 6282**]
Admission Date: [**2155-3-29**] Discharge Date: [**2155-4-9**]
Date of Birth: [**2083-10-4**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**Location (un) 5244**]
Addendum:
This is an addendum to the discharge diagnoses
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4215**] Health Center
Discharge Diagnosis:
Pneumonia
Congetive Heart Failure with EF 30%
Coronary Artery Diseae
Prostate Ca
Anemia
Restrictive Lung Diseae
Non-Q Wave Myocardial Infarction
[**First Name8 (NamePattern2) 1197**] [**First Name11 (Name Pattern1) 1198**] [**Last Name (NamePattern1) 5245**] MD [**Doctor First Name 1199**]
Completed by:[**2155-4-23**]
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"198.5",
"428.0",
"038.9",
"V10.46",
"285.22",
"486",
"593.9",
"784.7",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"36.07",
"99.04",
"88.56",
"99.07",
"37.22",
"36.01",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15105, 15165
|
4296, 10676
|
274, 300
|
14137, 14182
|
1982, 4273
|
14551, 15082
|
1612, 1631
|
12149, 13897
|
15186, 15536
|
11927, 12126
|
14206, 14528
|
1646, 1963
|
227, 236
|
328, 835
|
10691, 11901
|
857, 1494
|
1510, 1596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,731
| 152,436
|
38693
|
Discharge summary
|
report
|
Admission Date: [**2138-6-12**] Discharge Date: [**2138-6-16**]
Date of Birth: [**2100-10-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
known Aortic Stenosis with worsening fatigue,DOE
Major Surgical or Invasive Procedure:
Aortic valve replacement with a 19-mm St. [**Male First Name (un) 923**] Regent mechanical
valve, model number 19AGFN-758, serial number [**Serial Number 85961**].
History of Present Illness:
This is a 37 y/o female with hypertension, hyperlipidemia and
known aortic stenosis with worsening fatigue and dyspnea on
exertion.The patient is in generally good health but has noticed
mild exertional dyspnea and fatigue ongoing over the past year.
At a routine visit with her PCP, [**Name10 (NameIs) **] was noted that the patient
had a louder murmur than on prior examinations. The murmur was
first noted as a child, during a sports physical. The patient
completed an ECHO on [**2138-3-27**] in Tennesee. The study
revealed moderately calcified aortic cusps with an aortic
velocity of 4m/sec corresponding to a peak gradient of 64mmHG
and a valve area of 0.7 sq cm. There was mild AR, mild
concentric
LVH, evidence of decreased LV diastolic compliance and the LVEF
was 60%. About four months ago the patient reported chest
tightness, dyspnea, lightheadedness and diaphoresis while
jogging. There was no loss of consciousness. On [**2138-5-3**] the patient had a syncopal event while on the treadmill.
The patient reports dizziness, chest tightness, shortness of
breath and lightheadedness with increased heart rate during
exertion relieved with rest. The patient walks briskly 3x/week
but usually has symptoms. She denies rest symptoms and no
further syncopal episodes. [**2138-5-28**] Ms.[**Known lastname 65411**] [**Last Name (Titles) 1834**] an
elective cardiac catheterization. No coronary disease was
revealed. She is now referred for aortic valve replacement with
Dr.[**Last Name (STitle) **].
Past Medical History:
HTN
Hyperlipidemia
Panic attacks
Anxiety
Depression
Left Bell??????s palsy-currently taking Prednisone and completed a
course of acyclovir
Obesity
PSH:
Laparoscopy x 3 2' endometriosis. Last 1 approx. 12yo
Social History:
Lives with: Boyfriend, [**Name (NI) **].Moved from Tennesee ~6weeks ago.
Occupation: Working in shipping and receiving.
ETOH: Social ETOH and denies illicit drug use.
Home Services: Denies.
Contact person upon discharge: [**Name (NI) **] (boyfriend). His cell
phone# is [**Telephone/Fax (1) 85962**].
Family History:
FH: Non-contributory.
Physical Exam:
Pulse:80 Resp:16 O2 sat: 100%R/A
B/P Right: 123/75 Left:
Height: 5' Weight:165LBs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur, SEM V/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit (B) Right: 2+ Left:2+
Pertinent Results:
[**2138-6-16**] 05:10AM BLOOD WBC-6.9 RBC-3.17* Hgb-8.9* Hct-26.8*
MCV-84 MCH-28.0 MCHC-33.2 RDW-13.8 Plt Ct-234
[**2138-6-12**] 01:18PM BLOOD WBC-6.9 RBC-3.42* Hgb-9.7* Hct-28.6*
MCV-84 MCH-28.3 MCHC-33.9 RDW-13.9 Plt Ct-114*#
[**2138-6-16**] 05:10AM BLOOD PT-23.0* INR(PT)-2.2*
[**2138-6-12**] 01:18PM BLOOD PT-12.9 PTT-36.6* INR(PT)-1.1
[**2138-6-14**] 07:50AM BLOOD Glucose-105* UreaN-13 Creat-0.6 Na-137
K-4.2 Cl-103 HCO3-28 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 6118**] [**Hospital1 18**] [**Numeric Identifier 85963**] (Complete)
Done [**2138-6-12**] at 1:13:55 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2100-10-31**]
Age (years): 37 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Congenital heart disease. Left
ventricular function. Prosthetic valve function.
ICD-9 Codes: 746.9, V42.2, 424.1, 746.4
Test Information
Date/Time: [**2138-6-12**] at 13:13 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 56 ml/beat
Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm
Hg
Aorta - Annulus: 1.8 cm <= 3.0 cm
Aorta - Sinus Level: 2.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.2 cm <= 3.0 cm
Aorta - Ascending: 2.6 cm <= 3.4 cm
Aortic Valve - Peak Gradient: *108 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 73 mm Hg
Aortic Valve - LVOT VTI: 22
Aortic Valve - LVOT diam: 1.8 cm
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary
veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Hyperdynamic LVEF >75%.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal aortic diameter at
the sinus level. Normal descending aorta diameter. No atheroma
in descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Critical AS (area <0.8cm2). Moderate (2+)
AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve is bicuspid. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Moderate
(2+) aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
Post CPB #1
1.Preserved [**Hospital1 **]-ventricular systolic function.
2. Prosthetic valve in aortic position. Well seated and stable.
3. One of the leaflets seemed to be demonstrating incomplete
closure during diastole, leading to an ecentric high velocity
jAI et of moderate intensity.
4. Peak gradient across the valve 50-60 mm Hg with a
hyperdynamic LV and a mean gradient of 18 mm Hg.
Post CPB# 2
1. Preserved [**Hospital1 **]-ventricular systolci function.
2. Mechanical valve in aortic position. Well seated and
demonstrating good leaflet excursion.
3. Trace valvular AI consistent with the expected 'washing
jets".
4. No Other change
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2138-6-12**] 13:24
?????? [**2131**] CareGroup IS. All rights reserved.
Brief Hospital Course:
[**2138-6-12**] Ms. [**Known lastname 65411**] was taken to the operating room and
[**Known lastname 1834**] Aortic valve replacement (# 19-mm St. [**Male First Name (un) 923**] Regent
mechanical valve)with Dr.[**Last Name (STitle) **]. Please see operative report for
further details. She tolerated the procedure well and was
transferred to the CVICU for further invasive monitoring. She
awoke neurologically intact and was extubated without
difficulty. She was weaned off pressors. All lines and drains
were discontinued in a timely fashion, without complications.
Beta-Blocker/Aspirin and diuresis was initiated. Anticoagulation
with Coumadin was inititiated for goal INR 2.0-3.0 mechanical
AVR. Ms.[**Known lastname 65411**] continued to progress and was transferred to the
step down unit for further monitoring on POD#1. Physical therapy
consulted for evaluation of her strength and mobility. On POD# 4
her INR was therapeutic and Dr.[**Last Name (STitle) **] cleared her for discharge to
home with VNA. As discussed with [**Doctor First Name 8513**], Dr.[**First Name (STitle) **] [**First Name (STitle) **]'s
(Cardiology)RN, Dr.[**First Name (STitle) **] will follow the INR/Coumadin dosing. All
follow up appointments were advised.
Medications on Admission:
PREDNISONE - (Prescribed by Other Provider) - 50 mg [**First Name (STitle) 8426**] -
one
[**First Name (STitle) 8426**](s) by mouth daily
PREDNISONE - (Prescribed by Other Provider) - 10 mg [**First Name (STitle) 8426**] -
one
[**First Name (STitle) 8426**](s) by mouth daily
ASPIRIN - (Prescribed by Other Provider) - 325 mg [**First Name (STitle) 8426**] - one
[**First Name (STitle) 8426**](s) by mouth daily
GARLIC - (Prescribed by Other Provider) - Dosage uncertain
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- 1,000 mg Capsule - one Capsule(s) by mouth daily
Discharge Medications:
1. Warfarin 1 mg [**First Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily): INR
goal=2.0-3.0.
Disp:*90 [**Last Name (Titles) 8426**](s)* Refills:*2*
2. Hydromorphone 2 mg [**Last Name (Titles) 8426**] Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 [**Last Name (Titles) 8426**](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 [**Last Name (Titles) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Last Name (Titles) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 [**Last Name (Titles) 8426**], Delayed Release (E.C.)(s)* Refills:*2*
5. Ranitidine HCl 150 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2
times a day).
Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2*
6. Prednisone 20 mg [**Last Name (Titles) 8426**] Sig: Three (3) [**Last Name (Titles) 8426**] PO DAILY
(Daily).
Disp:*90 [**Last Name (Titles) 8426**](s)* Refills:*2*
7. Warfarin 5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once) for 1
days.
Disp:*1 [**Last Name (Titles) 8426**](s)* Refills:*0*
8. Metoprolol Tartrate 25 mg [**Last Name (Titles) 8426**] Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 [**Last Name (Titles) 8426**](s)* Refills:*2*
9. Furosemide 40 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO DAILY (Daily)
for 1 weeks.
Disp:*7 [**Last Name (Titles) 8426**](s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Bicuspid Aortic Valve, s/p Aortic valve replacement with a 19-mm
St. [**Male First Name (un) 923**] Regent mechanical valve
Hyperlipidemia
Panic attacks
Anxiety
Depression
Left Bell??????s palsy-currently taking Prednisone and completed a
course of acyclovir
Obesity
Discharge Condition:
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with Dilauded
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema:
Discharge Instructions:
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.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of sternal wound.
**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) **] on [**2138-7-23**] at 1pm.
Please call to schedule appointments with your
Primary Care: Dr.[**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] #[**Telephone/Fax (1) 8506**] in [**2-8**] weeks
Cardiologist: DR.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] #[**Telephone/Fax (1) 8506**] in [**2-8**] weeks
DR.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Cardiologist) will follow INR/Coumadin dosing.
VNA to call in INR level to [**Hospital 197**] clinic: RN-[**Doctor First Name 8513**]
#[**Telephone/Fax (1) 8506**], ext# 1307. First INR call in on [**2138-6-17**]
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Completed by:[**2138-6-16**]
|
[
"300.00",
"746.4",
"272.4",
"V58.65",
"351.0",
"285.9",
"401.9",
"278.00",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12581, 12644
|
8746, 9988
|
329, 495
|
12976, 13214
|
3275, 6968
|
14074, 15012
|
2610, 2634
|
10630, 12558
|
12665, 12934
|
10014, 10607
|
13238, 14051
|
7017, 8723
|
2649, 3256
|
240, 291
|
2511, 2594
|
524, 2040
|
2062, 2272
|
2288, 2495
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,176
| 145,484
|
30147
|
Discharge summary
|
report
|
Admission Date: [**2183-1-15**] Discharge Date: [**2183-2-3**]
Date of Birth: [**2137-10-22**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**Known firstname 3507**]
Chief Complaint:
Transfer s/p Fall with hemothorax
Major Surgical or Invasive Procedure:
Chest Tube Insertion
Decortication
(both at prior hospital)
History of Present Illness:
45 yo M s/p fall from ladder. Fell 6 feet off a ladder [**1-6**]
landing on his left side on paint cans. Initially admitted to
OSH with 5 rib fractures, no ptx, no hemothorax. However
developed repiratory distress [**1-8**] and CXR with effusion. Chest
tube placed with 1800cc of blood output. ABG at the time was
7.08/91/96 on 100% NRB and the patient was intubated and
transferred to ICU.
.
While in the ICU the patient had a great deal of restlesness
thought to be [**12-27**] alcohol withdrawal. Chart reports ? of
possible DT's. Also began spiking fevers [**1-10**] to 104. Cultures
taken and patient placed on vanc, primaxin (imipenem). This was
eventually changed to oxacillin (pt grew MSSA).
.
Patient also taken to OR [**1-14**] for decortication of the L lung
and resection of the 8th rib. The surgery was done to remove a
retained hemothorax. The 8th rib was removed because it was
fractured and displaced in such a way that it was entering the
pleural space.
.
Eventually transferred to [**Hospital1 18**] MICU for further management.
Past Medical History:
Snowmobile Accident [**2174**] - L hip fracture -> LHR; L ankle fx
L elbow fx - [**2164**]
Social History:
Denies tobacco. Drinks 12 beers/day. Abuses percocet, vicodin.
Family History:
NC per wife
Physical Exam:
OSH
Past 24h in OSH
Tm 102.5 (consistently >101) BP 120's-140's/70's-80's P
100's-110's
RR 10's-20's O2 94-97%
I/O 4279/2698 (2375urine/83 chest tube)
.
Initial Eval in MICU:
VS 102.3 132/78 88
Respiration PS 15/5 FiO2 60%; RR 24; ABG 7.42/50/86/34
Gen - lying in bed, intuated, sedated
HEENT - PERRL 3mm->1mm, MMM
Neck - supple, no LAD
Cor - RRR no murmurs
Chest - decrease BS on L base
Abd - distended, timpanetic, + BS
Ext - w/wp, trace edema
Neuro - response to painful stimuli with mvt of ext x 4
Pertinent Results:
Labs from OSH:
[**1-14**]
Hct 30.9
WBC 12.4
Plt 381
INR 1.11
PTT 29.2
Na 144
K 3.8
BUN 19
Cr 0.9
.
Radiology from OSH
[**2183-1-6**] CT A/P (prelim report)
- L rib fractures, LLL consolidation
- bibasilar atelectasis
- no free air in abd
- liver, kidney, spleen intact
.
[**2183-1-8**] TTE
- normal EF, normal wall motion, concentric LVH, normal valves
.
[**2183-1-7**] MR LS spine
- [**Last Name (un) **] disk disease L5-S1, small broad based disc herniation
and narrowing of both neural foramen.
.
[**2183-1-12**] Abd XR
- modest distention of colon
.
[**2183-1-7**] Facial XR - no orbital foreign body
.
[**2183-1-15**] CXR - ETT and NGT in good position. 3 chest tubes. L
subclavian in place. Mod left effusion. L lung base air
broncograms representing contusion vs. pna.
.
Micro Data OSH
[**1-14**] pleural effusion - Gm Stain (few WBC, no organisms), Cx
NGTD
[**1-9**] sputum - Gm stain GPC, Cx - MSSA
[**1-9**] bld cx - neg x 2
[**1-7**] u cx - neg
.
CT Chest
FINDINGS: An endotracheal tube tip terminates in the distal
trachea. A nasogastric tube tip extends into the stomach. The
heart, pericardium, and great vessels appear normal. No central
pulmonary emboli are seen. There is bilateral lower lobe
atelectasis, the right side incompletely visualized, and small
bilateral pleural effusions. Two left-sided chest tubes remain
in place. In the left lung apex there is circumferential pleural
thickening with small foci of air seen throughout the right
pleural space consistent with post-procedure changes. The
central airways are patent.
.
OSSEOUS STRUCTURES: Multiple left-sided rib fractures are seen,
but are incompletely visualized given the technique.
.
IMPRESSION:
1. Small amount of pleural fluid/thickening and small foci of
pleural air on the left are consistent with small hemothorax,
given the multiple left-sided rib fractures. Two left-sided
chest tubes remain in place.
2. No central pulmonary embolism. Normal caliber of the thoracic
aorta
.
CXR [**1-24**]:
SEMI-UPRIGHT AP CHEST RADIOGRAPH: Left-sided pleural effusion
has decreased slightly. Retrocardiac consolidation persists,
likely due to atelectasis. The right lung field is clear.
Cardiomediastinal silhouette is stable. Left lateral rib
fractures are unchanged. Left IJ line with tip in the proximal
SVC.
.
IMPRESSION: Slight decrease in left-sided pleural effusion with
persistent retrocardiac consolidation that is likely atelectasis
.
CT Head [**1-25**]
FINDINGS: No intra- or extra-axial hemorrhage is identified.
There is no mass effect, shift of normally midline structures,
or hydrocephalus. Density of the brain parenchyma is normal. The
visualized paranasal sinuses and mastoid air cells are clear.
The soft tissues appear unremarkable.
.
IMPRESSION: No intracranial hemorrhage or mass effect
Brief Hospital Course:
45 yo M s/p rib fractures from fall complicated by hemothorax.
S/p L pulm decortication and 8th rib removal [**1-14**] and transfer
to [**Hospital1 18**] [**1-15**].
.
# L rib fractures, hemothorax - Initial fall off ladder [**1-6**].
Hemothorax drained (1800cc) with chest tube [**1-8**]. Pulmonary
decortication [**1-14**] with removal of 8th rib. Patient continued
to have possible contusion/effusion of L lung base on CXR.
Chest tubes eventually removed; effusion tapped (see below).
Needs repeat CXR within the next few months to ensure resolution
of effusion.
.
# Respiratory Failure - Patient intubated [**1-8**]. Eventually
extubed per [**Hospital Unit Name 153**] team.
.
# Recurrent Fevers - Patient with recurrent fevers to 102. This
was prior to and after his recent surgery. Culture data from
OSH positive only for MSSA in sputum on [**1-9**]. Patient on
imipenem/vanc until [**1-12**] when he was changed to oxacillin.
Also with LLL consolidation vs. contusion. Patient had very
extensive fever workup (RUQ U/S, multiple blood/urine/sputum
cultures; Left effusion tapped and no growth).
?Drug fevers? Abx eventually d/c'd and patient defervesced
without additional signs/sx of infection.
.
#HTN: started on lopressor 25 mg [**Hospital1 **] with good effect.
.
#Delerium: pts mental status slowly cleared after extubation.
Cognative impairment likely secondary to narcotics, benzos, and
ICU delerium. Resolved during his time on the floor as Ativan
and Fentanyl were tapered. Psych consulted and agreed with
assessment.
.
#Drug/EtOH Abuse: per patient's wife, pt had been abusing EtOH,
oxycodone and vicodin as an outpatient. SW consulted; pt to
enroll in outpatient detox. No clear signs of EtOH withdrawl
though patient required large doses of benzos/narcotics for
sedation.
Medications on Admission:
None
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical Fall
Rib Fractures
Hemothorax s/p Decortication
Hypertension
Delerium, resolving
Discharge Condition:
stable
Discharge Instructions:
Please continue your meds as listed. Please make sure you follow
up with your PCP. [**Name10 (NameIs) 357**] avoid the use of alcohol or narcotic
medications.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 71845**] Appointment should be in
[**6-3**] days
|
[
"293.0",
"401.9",
"780.6",
"860.2",
"E881.0",
"518.0",
"304.00",
"303.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
7028, 7034
|
5029, 6836
|
301, 362
|
7170, 7179
|
2216, 5006
|
7386, 7547
|
1661, 1674
|
6891, 7005
|
7055, 7149
|
6862, 6868
|
7203, 7363
|
1689, 2197
|
228, 263
|
390, 1449
|
1471, 1563
|
1579, 1645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,643
| 194,657
|
44931
|
Discharge summary
|
report
|
Admission Date: [**2177-11-5**] Discharge Date: [**2177-11-11**]
Date of Birth: [**2104-1-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillin V
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
hypoxia, pulmonary embolism
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 73 yoF s/p CABD x 4 vessel on [**2177-10-10**] at [**Hospital1 498**],
who was at [**Hospital3 **] rehab when she developed shortness of breath
and hypoxia starting yesterday morning. Symptoms began as
palpitations while brushing teeth and then she was noted to have
decreased O2 sats & SOB. Of note, she has been on O2 since
being discharged from [**Hospital1 498**] on [**2177-10-16**] s/p CABG. At [**Hospital1 80956**] as part of the work-up for the hypoxia,
she was found to have multiple large PE's though she remained
hemodynamically stable. She was started on heparin ggt, got
lasix 40 mg PO x 2, metoprolol 12.5 mg, lisinopril 2.5 mg, and
transferred here; she also received mucomyst. Of note, she
reports good activity levels over the last three weeks at rehab
and is up and about walking the floors and climbing [**11-29**] flight
stairs.
.
In the ED here on transfer, VS were T 98.8, BP 128/72, HR 78, RR
18, 95% NRB (desatted to 90% on 6LNC). CT chest showed a
left-sided effusion and a large right-sided PE with multiple
other PE's throughout bilaterally, as well as evidence of right
heart strain with a flattened intraventricular septum.
Cardiology was consulted and felt there was no indication for
percutaneous embolectomy given she is HD stable. Attempts have
been made to contact CT surgery regarding risks of lytics with
recent CABG.
.
Currently she denies SOB. She reports a sensation of
"tightnight" that is bandlike bilaterally acrosss her chest,
which has been going on since her CABG. She otherwise denies
HA, lightheadedness, SOB currently, CP, abd pain, change in
BM's, N/V, change in urinary frequency/urgency. She reports
feeling thirsty though she is noted ot have a face mask on.
.
Past Medical History:
CAD s/p recent NSTEMI
CABG [**2177-10-10**] at [**Hospital1 498**] (LIMA->LAD, SVG->diag->OM, SVG->RCA),
DM-- insulin dependent, followed at [**Last Name (un) **]
HTN
Hypercholesterolemia
EF 60-65% on last echo post-op
Transient post-op AFib
Osteoporosis
Social History:
Former elementary school teacher. Smoked [**11-28**] [**11-29**]
PPD for 40 years, quit 20 years ago. Denies EtOH or illicit
drugs.
Family History:
No premature CAD or SCD
Physical Exam:
On admission:
VS in the ED: T 98.8, BP 128/72, HR 78, RR 18, 95% NRB (desatted
to 90% on 6LNC)
VS on arrival to the floor: T 96.8, BP 111/53, HR 81, RR 14, 93%
on 15L NRB
GENERAL: elderly woman, in bed, NAD, comfortable, wearing face
mask
HEENT: poor dentition, OP clear, MM dry
LUNGS: crackles halfway up left base, no rhonchi
CARDIO: RR, no m/r/g
ABD: obese, soft, NTND
EXTREMITIES: no LE edema, legs symmetric, no cords, no
erythema/warthm, no TTP
NEURO: AA, Ox3, conversant, speaking in full sentences, CN II -
XII in tact, moving all extremities
SKIN: no rashes, mid-line sternal incision healing well
At discharge:
Temp Max: 98.7 Temp current: 98.2 HR: 66-78 RR: 20 BP:
96-118/49-69 O2 Sat:96% 2L but 95% RA. Desat to 87% on RA with
ambulation
24 hour I= 765 O= 1280
8 hour I= 60 O= 300
Weight: 89.5 (89.3) kg
FS: 168/138/233/131
Tele: 60-70's, no VEA
Gen: alert, oriented, NAD
HEENT: supple, no JVD
CV: RRR, No M/R/G, distant. Sternotomy well approximated with no
drainage.
RESP: [**Month (only) **] BS throughout, right LL crackles, no wheezes
ABD: obese, soft, NT
EXTR: 1+ edema at ankles, feet warm.
NEURO: a/o
Pulses: palpable
Skin: intact
Access: PIV
Pertinent Results:
Admission labs [**2177-11-5**] notable for Cr 1.5 (baseline 0.9-1.1; 1.3
on [**10-17**] discharge from CABG), PTT 150, INR 1.5, Hct 34.8
(baseline), plt 274, negative trop/CK
Trace protein on UA, otherwise negative
.
[**2177-11-5**] ADMISSION CTA CHEST:
1. Extensive bilateral pulmonary emboli, as proximal as the
distal right main pulmonary artery and involving bilateral lobar
branches supplying all lobes bilaterally, with segmental and
subsegmental involvement as well. Slight bowing of the
intraventricular septum, concerning for possible right heart
strain.
2. Large left pleural effusion with associated overlying
atelectasis.
3. Emphysema with pulmonary nodules as above. Given the history
of cigarette use, followup with a dedicated CT of the chest is
recommended in 6 months.
4. Indeterminate right adrenal lesion. Further characterization
can be obtained with adrenal protocol MRI or CT.
5. Atrophic left kidney with numerous hypodensities, some of
which are
characterized as simple cysts, others of which are too small to
characterize.
.
ECG [**2177-11-5**]: Sinus rhythm. Low limb lead QRS voltage. Prolonged
QTc interval. Findings are non-specific
TTE [**2177-11-6**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is dilated with focal
basal free wall hypokinesis. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. Probable
diastolic dysfunction. The right ventricle is not well seen but
may be dilated with mild basal hypokinesis. No pathologic
valvular abnormality seen. Moderate pulmonary artery systolic
hypertension. These findings could be consistent with a
pulmonary
Admission:
[**2177-11-5**] 02:45PM BLOOD WBC-6.9 RBC-3.89* Hgb-11.2* Hct-34.8*
MCV-90 MCH-28.9 MCHC-32.2 RDW-15.1 Plt Ct-274
[**2177-11-5**] 02:45PM BLOOD PT-16.8* PTT-150* INR(PT)-1.5*
[**2177-11-5**] 02:45PM BLOOD Glucose-93 UreaN-25* Creat-1.5* Na-139
K-4.3 Cl-100 HCO3-28 AnGap-15
[**2177-11-5**] 02:45PM BLOOD cTropnT-<0.01
[**2177-11-6**] 06:14AM BLOOD CK-MB-2 cTropnT-<0.01
[**2177-11-5**] 02:45PM BLOOD CK(CPK)-27
[**2177-11-6**] 06:14AM BLOOD CK(CPK)-26
[**2177-11-5**] 02:45PM BLOOD CK-MB-NotDone proBNP-1453*
[**2177-11-5**] 02:45PM BLOOD Calcium-9.6 Phos-4.4 Mg-2.3
[**2177-11-5**] 02:49PM BLOOD Glucose-95 Lactate-1.1 Na-141 K-4.4
Cl-97* calHCO3-30
Discharge:
[**2177-11-11**] BLOOD WBC-6.3 RBC-3.14 Hgb-9.3* Hct-28.4 MCV-91 Plt
Ct-184
[**2177-11-11**] BLOOD PT-19.4 PTT-121.8 INR(PT)-1.8*
[**2177-11-11**] BLOOD Glucose-108 UreaN-23* Creat-1.3 Na-140 K-4.1
Cl-105 HCO3-24 AnGap-15
Brief Hospital Course:
73 yoF s/p CABG in [**10-6**] a/w large clot burden of bilateral
PE's; hemodynamically stable with no indication for
embolectomy/lytics on admission.
.
#. PULMONARY EMBOLISM:
The patient developed sudden worsening shortness of breath and
hypoxia starting on the morning of [**11-4**]. She was brought to an
OSH, where she was found to have multiple large PE's. She was
started on heparin ggt, got lasix 40 mg PO x 2, metoprolol 12.5
mg, lisinopril 2.5 mg, mucomyst and transferred to [**Hospital1 18**] for
further management.
On admission, CT chest showed a left-sided effusion and a large
right-sided PE with multiple other PE's throughout bilaterally,
as well as evidence of right heart strain with a flattened
intraventricular septum. The patiient remained hemodynamically
stable, so embolectomy was not pursued. She was observed
overnight in the MICU, and transferred to the floor the
following day. She was started on warfarin after 48hrs of full
anticoagulation with heparin gtt. She remained hemodynamically
stable thoughtout her hospital course. Her O2 was weaned to
room air, but with some desaturations to 87% with ambulation.
Her INR at discharge was 1.8 on 5mg coumadin. She will be
bridged with lovenox until 24hrs of therapeutic anti-coagulation
on coumadin. Given her PE were in the setting of surgery she
should continue anti-coagulation for a minimum of [**1-31**] months.
.
#. Acute on Chronic Kidney disease: On admission the patient's
creatine was up from her baseline of 0.8-1.0 to 1.5. This was
likely due to contrast induced nephropathy and pre-renal
etiology. Her lisinopril and lasix were held. Her creatinine
was improving at the time of discharge to 1.3. She was
restarted on lasix 20mg daily and lisinopril 2.5mg daily at the
time of discharge.
.
#. Pulmonary nodules: On CTA scattered non-calcified nodules are
visualized, primarily on the right with the largest measuring
5mm in the right
middle lobe. Given her history of cigarette use, followup with
a dedicated CT of the chest is recommended in 6 months.
.
#. LEFT PLEURAL EFFUSION: Patient with left plerual effusion
seen on CTA. Thought to be secondaryto post-op changes. The
effusion should be followed up as an outpatient for resolution.
.
#. HTN: Her BP meds were held initially for monitoring if
hypotension in the setting of PE's. She remained hemodynamically
stable and was restarted on restart metoprolol tartrate 12.5
[**Hospital1 **], amlodipine 10 mg, lisinopril 2.5mg daily.
.
#. HYPERCHOLESTEROLEMIA: she was continued on her home
simvastatin 20 mg
.
# CORONARIES: s/p CABG [**2177-10-10**] at [**Hospital1 498**] (LIMA->LAD,
SVG->diag->OM, SVG->RCA). Stable with no complaints of ongoing
ischemia or angina. She was continued on ASA, simvastatin. Her
metoprolol and lisinopril were restarted as above.
.
# PUMP: The patient's ECHO on admission wwas EF 55%, diastolic
dysfxn, RV may be dilated with mild basal hypokinesis and
moderate pulmonary artery systolic hypertension. Her ECHO was
consistent with known PE. The patient was restarted on here
lasix 20mg daily ([**11-29**] her home dose given her ARF) and remained
euvolemic at the time of discharge.
.
# RHYTHM: The patient has a h/o post-op AFib on amiodarone. She
remained in NSR. She was anticoagulated given her PE. She was
monitored on tele and contined on amiodarone.
.
#. DIABETES: The patient was continued on glargine 34 units QHS
and covered with an ISS.
.
#. COPD: Patient with a distant smoking history. She was
continued on combivent inhalers Q4 hrs PRN
.
#. ANXIETY/DEPRESSION: stable and continued on citalopram 40 mg
and ativan 0.5 mg [**Hospital1 **] PRN
.
# Adrenal Lesion: Incidental finding of an indeterminate
hypodense lesion in the right adrenal gland measures 30 x 25 mm.
Further characterization can be
obtained with adrenal protocol MRI or CT as an outpatient.
Medications on Admission:
Simvastatin 20 mg daily
Aspirin 81 daily
Metoprolol tartrate 12.5 [**Hospital1 **]
Lisinopril 2.5 daily
Albuterol/ipratropium nebs prn
Insulin glargine 34 units daily
Insulin sliding scale
Citalopram 40 daily
Amiodarone 200 mg daily
Cyanocobalamin 1000mcg daily
Folic acid 1 mg daily
Zolpidem 5 mg qhs prn
Lorazepam 0.5 mg [**Hospital1 **] prn
Oxycodone prn
Docusate 100 mg [**Hospital1 **]
Fe So4 325 mg daily
Lasix 40 mg [**Name (NI) 244**] (unclear when started)
Took Fosamax at home, Was taking Januvia, Metformin and
Glipizide at home.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Outpatient Lab Work
Please check PTT/PT/INR daily while pt on Heparin drip and
adjust heparin gtt and coumadin according to results. Goal PTT
is 60-100 and goal INR 2.0-3.0.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
10. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID (3 times a day) as needed for itching.
17. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q12H (every 12
hours) as needed for anxiety.
18. Insulin Glargine 100 unit/mL Solution Sig: Thirty Four (34)
units Subcutaneous at bedtime.
19. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: per attached scale units Intravenous every hour.
20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Pulmonary Emboli
Coronary Artery disease s/p CABG
Diabetes Mellitus
Dyslipidemia
Hypertention
Anemia
Osteoporosis.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had some blood clots in your lung and required heparin and
coumadin, 2 blood thinners, to prevent the clots from getting
bigger. You will need to take coumadin for at least 6 months and
maintain a coumadin level of 2.0-3.0. You will need oxygen when
you walk for some time but this should get better as the clots
go away. The CAT scan showed: Emphysema with pulmonary nodules
as above. Indeterminate right adrenal lesion. Given the history
of cigarette use, followup with a dedicated CT of the chest and
adrenal protocol is recommended in 6 months.
.
Medication changes:
1. Start Coumadin to keep the blood thin and prevent worsening
of the blood clots.
2. Decrease the lasix to 20 mg daily
3. Heparin intravenous drip to prevent the blood clots from
getting bigger. The heparin can be stopped with the INR is
2.0-3.0.
.
Followup Instructions:
Primary:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 9347**] Date/time: [**11-13**] at
10:00am.
.
Cardiology:
[**Last Name (LF) 171**], [**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 62**] Date/time: Mon [**12-22**] at
11:20am.
.
Pulmonology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**]
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2177-12-24**] 3:40 Please call to confirm all above appts.
.
Needs CT of chest and adrenal protocol in 6 months to evaluate
lesions seen during this hospital stay.
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13348, 13420
|
7076, 10940
|
302, 309
|
13579, 13579
|
3764, 7053
|
14574, 15214
|
2538, 2564
|
11532, 13325
|
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|
10966, 11509
|
13724, 14279
|
2579, 2579
|
3201, 3745
|
14299, 14551
|
235, 264
|
337, 2094
|
2593, 3187
|
13593, 13700
|
2116, 2372
|
2389, 2522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,745
| 184,689
|
52140
|
Discharge summary
|
report
|
Admission Date: [**2145-12-27**] Discharge Date: [**2146-1-12**]
Date of Birth: [**2092-6-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
severe anemia, supertherautic INR
Major Surgical or Invasive Procedure:
R femoral central line
History of Present Illness:
53 yo f with PMH significant for CAD (LAD 60-70%) with AVR (St.
Jude's valve), for hx endocarditis, h/o mitral valve
endocarditis now with 4+ MR, PVD, Hepatitis C and a history of
GIB presents with 4 days of lethergy, SOB, and chest pain which
has been intermittant for many months. She was in her USOH until
a few weeks ago when per OMR notes, she was beginning to feel
fatigued, SOB, and chest pain. She r/o for an MI in [**Month (only) 1096**] and
had a stress with fixed defects. The pt was seen by her PCP [**Last Name (NamePattern4) **]
[**12-24**] with the same complaints, lethergy, SOB and chest pain. At
that time she was guaiac negative. Her HCT on [**12-1**] was 35, [**12-24**]
was 24, and on admission was 17.
She denies taking any over the counter, prescription, or illicit
medications. She has not changed her diet. Denies melena, BRBPR,
hematemesis, or bleeding of any kind. She has been feeling
lightheaded. She has had nausea and anorexia. Her chest pain is
dull, left sided, and not associated with exertion. It is
relieved by rubbing. No changes in coumadin dose.
Today she went to clinic where she had her PT/INR and HCT
checked. She had been on lovenox over the weekend because her
Friday INR was high??. The monitor in clinic could not read her
HCT, indicating that it was low. In the ED she was 99.1, 128/60,
18, 99% RA. Her BP dropped to the 80's briefly but came up with
volume. Labs showed that she had a HCT of 17 nad INR of 8. She
was given PRBC 2units, 4 liters of NS, FFP 2 units, Vit K 2.5
SC, Protonix 40 IV, Hydrocort 100 IV, maalox, and anzemet. She
refused an NG lavage and did not want to speak with the GI fellw
saying that she would not want an endoscopy or colonoscopy. She
also refused a foley.
Past Medical History:
1. Recurrent endocarditis, first aortic then mitral involvement
s/p
AVR with St. Jude's valve in [**2137**] c/b embolic CVA and seizure.
MRV possible will be replaced in the future.
2. chronic venous stasis
3. PVD - s/p left fem ant tibial bypass graft with saf vein for
non healig ulcers [**1-/2142**]
4. venous stasis ulcer for 4 years, s/p failed skin graft. .
plastics considering VAC.
5. anemia, iron deficiency
6. h/o UGIB [**1-20**] gastritis with Hct of 23 -
EGD [**2144-7-13**]:
Normal EGD to third part of the duodenum, Erythema in the antrum
compatible with gastritis
Colonoscopy [**2144-7-7**]:
Incomplete exam, reason for exam: dark blood per rectum
EGD [**2144-7-7**]:
Medium hiatal hernia, Schatzki''s ring, Otherwise normal EGD to
second part of the duodenum
7. IV drug use on methadone
8. Hepatitis C - hep c viral load [**2143**]-over 2 mill.no bx done
9. peripheral neuropathy
10. hearing loss (ad)
11. mild gastritis
12. s/p CABG, CAD with 60-70% LAD lesion, rt. dominant - PMIBI
on [**11-22**] showed fixed defects.
Social History:
Has a history of IV heroin use 20 years ago, denies any current
drug use. Denies current tobacco use but used to smoke [**12-20**]
cigarettes/day for 15 years. Denies any EtOH use. She currently
lives with her mother and is on disability.
Family History:
No family history of DM, CAD, or HTN.
Physical Exam:
VS: T 98, HR 77, BP 94/46, RR 18, SaO2 99-100%/2L
Gen: NAD female
HEENT: NCAT, MMM. adentulous
CV: RRR, nl S1, S2, III/VI holosystolic murmur with a late
systolic click. JVD 6CM
Chest: crackles at the left base, otherwise clear
Abd: soft, nontender, slightly distended, BS+. No HSM
Ext: PP 2+, no edema. 15x4cm venous stasis ulcer with
granulation tissue. bone was exposed.
Neuro: alert, conversant, appropriate, though very poor insight.
Skin: warm and dry
Pertinent Results:
[**2145-12-27**] 05:13PM WBC-8.1 RBC-2.26* HGB-6.8* HCT-19.8* MCV-88
MCH-30.2 MCHC-34.4 RDW-16.1*
[**2145-12-27**] 05:13PM PLT COUNT-203
[**2145-12-27**] 05:13PM PT-18.0* PTT-36.7* INR(PT)-2.3
[**2145-12-27**] 05:13PM RET AUT-3.6*
[**2145-12-27**] 02:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2145-12-27**] 02:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2145-12-27**] 02:15PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2145-12-27**] 01:32PM K+-4.4
[**2145-12-27**] 01:32PM HGB-6.2* calcHCT-19
[**2145-12-27**] 01:20PM GLUCOSE-96 UREA N-22* CREAT-0.6 SODIUM-135
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-12
[**2145-12-27**] 01:20PM ALT(SGPT)-11 AST(SGOT)-23 LD(LDH)-280*
CK(CPK)-88 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1
[**2145-12-27**] 01:20PM CK-MB-NotDone cTropnT-<0.01
[**2145-12-27**] 01:20PM HAPTOGLOB-<20*
[**2145-12-27**] 01:20PM WBC-6.3 RBC-1.96*# HGB-5.6*# HCT-17.1*#
MCV-87 MCH-28.5 MCHC-32.7 RDW-16.9*
[**2145-12-27**] 01:20PM NEUTS-67.2 LYMPHS-27.6 MONOS-4.0 EOS-0.9
BASOS-0.3
[**2145-12-27**] 01:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+
[**2145-12-27**] 01:20PM PLT COUNT-276
[**2145-12-27**] 01:20PM PT-33.0* PTT-48.5* INR(PT)-8.2
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2145-12-27**] 7:49 PM
CHEST (PORTABLE AP)
Reason: eval for PNA
[**Hospital 93**] MEDICAL CONDITION:
53 year old woman with chest pain, anemia, crackles on exam
REASON FOR THIS EXAMINATION:
eval for PNA
INDICATION: Chest pain, anemia and crackles on exam. Evaluate
for pneumonia.
COMPARISON: [**2145-11-22**].
UPRIGHT AP CHEST: The patient is post median sternotomy.
Cardiomegaly is unchanged. There is upper zone vascular
redistribution and perihilar haze consistent with mild
congestive heart failure. No pleural effusion or pneumothorax.
No consolidation to suggest pneumonia.
IMPRESSION: Mild congestive heart failure.
Brief Hospital Course:
53 yo female with h/o with CAD, AVR secondary to endocarditis,
Hepatitis C and a history of GIB admitted with severe anemia,
supertherapuritc INR, and chest pain.
1. Anemia: Pt has a history of recurrent GI bleeds of unclear
etiology. She was guaiac positive during this admission,
although her stool remained brown. She had a Hct of 17 and INR
of 8, but she had no evidence of RP bleed, ICH, etc. She was
also ruled out for an MI. She received a total of 5 units pRBC,
and her Hct subsequently remained stable. Pt refused a gastric
lavage, and she required pursuasion to undergo any other
work-up. She did, however, agree to capsule endoscopy. The
results of this study were pending at the time of discharge. Of
note, she had a very similar admission one year ago ([**12-23**])
during which she left AMA without intervention. It was thought
that pt likely had GIB in setting of elevated INR, in addition
to having low grade hemolysis. At time of discharge, Hct was
36, and she appeared hemodynamically stable. She was provided
with home services, as well as follow-up within 2 weeks. She is
to f/u with both PCP and GI.
2. Coagulopathy: Pt has been taking coumadin for her AVR; also,
she had been taking lovenox in the days prior to admission. It
was unclear why she was supratherapeutic with INR of 8, but pt
may have confused the coumadin dosing. She was reversed with FFP
and vit K with good effect. Coumadin was restarted shortly
after admission, and she was bridged with a heparin drip while
waiting for INR levels to be therapeutic. However, given that
she received multiple doses of vitamin K at admission, it was
difficult to achieve therapeutic anticoagulation. After
consulting with Dr. [**Name (NI) 437**], pt's cardiologist, felt that it was
acceptable to use lovenox for bridge therapy. Both she and her
mother (with whom she lives) have used lovenox in the past, and
they were taught once again, prior to discharge. Pt will be
followed up in the [**Hospital3 **].
3. Hypotension: Patient's normal baseline BP is in the 90's -
100's systolic. She was hypotensive to the 70s in the ED. This
was likely secondary to hypovolemia as it stablized after volume
repletion. She was restarted on enalapril and lasix, and she
had no further episodes of hypotension.
4. CHF/Severe mitral regurgitation: The patient takes Lasix 40
mg daily as an outpatient. This was held initially as she
appeared stable despite receiving multiple blood transfusions.
Daily lasix was restarted when pt c/o SOB and had pitting edema
in lower extremities; did not have rales and never has rales as
a manifestation of volume overload. Her symptoms were improved
with diuretics.
5. PVD: The patient has a chronic venous stasis ulcer on LLE.
Seen recently by plastics and did not have any signs of
infection on LLE x-ray. She was followed by plastics in-house
who recommended that she continue dressing changes daily.
6. H/o IV drug use - Continue methadone and given letter for
home service prior to d/c to make sure pt has medication at
home.
7. Seizure d/o: Continued tegretol at home dose.
8. Code status: full
Medications on Admission:
ACETAMINOPHEN 500MG--[**12-20**] by mouth every day as needed for pain
COUMADIN 7.5 MG nightlt
ENALAPRIL MALEATE 5MG--Take one tablet every day
FERROUS SULFATE 325(65)MG--One by mouth twice a day
FLONASE 50MCG--2 sprays each in the morning every day
FLUCONAZOLE 200 MG--One by mouth twice a day
FUROSEMIDE 40 MG--One tablet by mouth every morning
HYDROCORTISONE 0.25%--Apply to affected area twice a day
LOVENOX 40 mg/0.4mL--take by subcutaneou injection twice a day,
12 hours apart - recieved this over the weekend.
METHADONE HCL 10MG--40mg per program
PERCOCET 5-325MG--One tablet(s) by mouth qd to [**Hospital1 **] prn pain as
needed for pain
PROTONIX 40MG--One every day
TEGRETOL XR 200MG--Take one tablet by mouth twice a day
MIRALAX 17 g (100%)--[**12-20**] packet by mouth once a day for
constipation
Discharge Medications:
1. Methadone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. Enoxaparin 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 14 days.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
Primary:
GIB
.
Secondary:
1. St. [**Male First Name (un) 923**] aortic valve replacement in [**2137**].
2. History of endocarditis (staph, strep, candidal)
3. History of hepatitis C.
4. Peripheral vascular disease with nonhealing LE ulcers.
5. Cerebrovascular disease.
6. Hypertension.
7. Reflux disease.
8. Anemia.
9. Coronary artery bypass graft in [**2137**].
10. History of gastrointestinal bleed (-) colonoscopy x2; (-)
angio in [**2138**].
Discharge Condition:
good
Discharge Instructions:
Please return for further care if you have fever, chills,
weakness, lightheadedness, acute shortness of breath, chest
pain, fainting, blood in your sputum or stool, tarry stool,
abdominal pain, nausea, vomiting or any other symptoms that are
concerning to you.
.
Please keep the appointments that have been scheduled for you -
the details are provided below.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD Phone:[**Telephone/Fax (1) 6331**]
Date/Time:[**2146-1-28**] 11:45
.
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2146-2-1**] 11:40
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2146-5-26**]
|
[
"707.15",
"440.23",
"V43.3",
"304.01",
"070.70",
"428.0",
"401.9",
"286.9",
"578.9",
"285.1",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11129, 11167
|
6075, 9207
|
306, 330
|
11657, 11664
|
3967, 5488
|
12071, 12493
|
3433, 3472
|
10067, 11106
|
5525, 5585
|
11188, 11636
|
9233, 10044
|
11688, 12048
|
3487, 3948
|
233, 268
|
5614, 6052
|
358, 2097
|
2119, 3158
|
3174, 3417
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,180
| 161,383
|
25604
|
Discharge summary
|
report
|
Admission Date: [**2149-6-23**] Discharge Date: [**2149-7-7**]
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
Bladder Cancer
Major Surgical or Invasive Procedure:
Cystectomy with urinary diversion
History of Present Illness:
Large bladder ca found. Causes difficulty with voiding.
Past Medical History:
A-fib
Chronic renal insufficiency
Anemia
Indwelling foley
Pacemaker
Social History:
3 pack/day smoker, quit [**2118**]
Family History:
NC
Physical Exam:
Gen: AAOx3 NAD
CV: S1 S2 RRR
CHest: CTA B/L
Abd: pos BS, soft NT/ND, midline incision C/D/I, JP incision
C/D/I
Extrem: no edema
Pertinent Results:
[**2149-7-3**] 07:15AM BLOOD WBC-8.6 RBC-4.01* Hgb-10.8* Hct-33.3*
MCV-83 MCH-26.9* MCHC-32.4 RDW-20.4* Plt Ct-227
[**2149-6-30**] 06:35AM BLOOD WBC-9.7 RBC-4.12* Hgb-11.1* Hct-33.8*
MCV-82 MCH-26.9* MCHC-32.7 RDW-19.5* Plt Ct-209
[**2149-6-29**] 07:25AM BLOOD WBC-15.7* RBC-4.50* Hgb-12.1* Hct-36.1*
MCV-80* MCH-26.8* MCHC-33.5 RDW-19.0* Plt Ct-201
[**2149-6-28**] 06:00AM BLOOD WBC-14.5* RBC-4.50* Hgb-12.0* Hct-37.2*
MCV-83 MCH-26.6* MCHC-32.2 RDW-19.3* Plt Ct-200
[**2149-6-25**] 05:30AM BLOOD WBC-17.2* RBC-3.49* Hgb-9.1* Hct-27.7*
MCV-79* MCH-26.0* MCHC-32.9 RDW-19.4* Plt Ct-132*
[**2149-6-24**] 02:37PM BLOOD WBC-24.6* RBC-3.91* Hgb-10.6* Hct-30.7*
MCV-79* MCH-27.1 MCHC-34.5 RDW-18.9* Plt Ct-198
[**2149-6-23**] 07:00PM BLOOD WBC-16.7* RBC-4.43* Hgb-11.0* Hct-33.8*
MCV-76* MCH-24.9* MCHC-32.7 RDW-19.9* Plt Ct-236
[**2149-6-26**] 04:40AM BLOOD PT-13.5* PTT-32.5 INR(PT)-1.2
[**2149-6-25**] 05:30AM BLOOD PT-13.9* PTT-37.8* INR(PT)-1.3
[**2149-6-23**] 07:00PM BLOOD PT-13.4* PTT-28.9 INR(PT)-1.2
[**2149-7-5**] 06:50AM BLOOD K-5.1
[**2149-6-29**] 07:25AM BLOOD Glucose-96 UreaN-24* Creat-1.5* Na-136
K-4.0 Cl-105 HCO3-20* AnGap-15
[**2149-6-28**] 06:00AM BLOOD Glucose-80 UreaN-24* Creat-1.5* Na-139
K-4.2 Cl-105 HCO3-23 AnGap-15
[**2149-6-24**] 02:37PM BLOOD Glucose-89 UreaN-24* Creat-1.4* Na-141
K-4.3 Cl-113* HCO3-21* AnGap-11
[**2149-6-23**] 10:10PM BLOOD Glucose-94 UreaN-31* Creat-1.6* Na-139
K-5.0 Cl-107 HCO3-22 AnGap-15
[**2149-7-5**] 10:30AM BLOOD CK(CPK)-15*
[**2149-6-25**] 05:30AM BLOOD CK(CPK)-71
[**2149-6-24**] 09:30PM BLOOD CK(CPK)-72
[**2149-6-24**] 02:37PM BLOOD CK(CPK)-73
[**2149-7-5**] 10:30AM BLOOD CK-MB-2 cTropnT-0.03*
[**2149-6-25**] 05:30AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2149-6-24**] 09:30PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2149-6-24**] 02:37PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2149-7-5**] 06:50AM BLOOD Mg-2.0
[**2149-7-4**] 10:25AM BLOOD Mg-1.7
[**2149-7-3**] 07:15AM BLOOD Mg-1.7
[**2149-6-25**] 05:30AM BLOOD Calcium-7.5* Phos-3.2 Mg-2.5
[**2149-6-24**] 02:37PM BLOOD Calcium-7.6* Phos-2.7 Mg-1.8
[**2149-6-23**] 10:10PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.6
[**2149-6-27**] 03:34PM BLOOD Type-ART Temp-37.0 pO2-97 pCO2-39 pH-7.37
calHCO3-23 Base XS--2 Intubat-NOT INTUBA
[**2149-6-24**] 08:45PM BLOOD Type-ART O2 Flow-3 pO2-124* pCO2-48*
pH-7.36 calHCO3-28 Base XS-1 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2149-6-24**] 07:20PM BLOOD Type-ART PEEP-5 FiO2-50 pO2-214* pCO2-48*
pH-7.35 calHCO3-28 Base XS-0 Intubat-INTUBATED Vent-SPONTANEOU
[**2149-6-24**] 10:22AM BLOOD Type-ART pO2-272* pCO2-43 pH-7.36
calHCO3-25 Base XS--1
[**2149-6-24**] 08:41AM BLOOD Type-ART FiO2-50 pO2-291* pCO2-36
pH-7.47* calHCO3-27 Base XS-3
[**2149-6-24**] 02:58PM BLOOD freeCa-1.18
[**2149-6-24**] 08:41AM BLOOD freeCa-1.18
Brief Hospital Course:
Pt was admitted on [**2149-6-23**] the day before surgery and was
evaluated as ready for surgery. He stayed in the PACU post op
and was followed by the ICU team. He was on periop ancef/flagyl
x3d and flagyl for total of 10 days for his C diff. He had good
B/P control, good pain control, and no complications in PACU.
He had an epidural that was D/C'd on POD #2. Tx to CCU on POD#1
then tx to floor POD #2. Ostomy nurse came by and saw him on
the floor. He had some red warm areas on buttocks and heels
that were at risk for breakdown - he was adequately treated to
avoid complications of this and never had a problem. When he
came to the floor he had some confusion and decreased mental
status on the floor. This waxed and waned somewhat. Hypoxic,
metabolic, and infectious etiologies were ruled out and it was
most likely an ICU/Hospital delirium. This gradually improved
over the course of his stay. He ambulated and walked down the
hallway with a walker and the help of the nursing staff. Had
diarrhea for several days - CX C. diff pos. Finished Flagyl and
was started on 14 days of oral vancomycin. Diarrhea improved.
He was restarted on his home meds and his diet was advanced as
tolerated. He was given several boluses to keep his urine
output up. JP drain was D/C'd on POD #6 and site was sutured
shut. On POD #10 he c/o severe shoulder pain. Cardiac enzymes
were neg and EKG showed no changes. Pain resolved on own in
<30min and never returned. Pt was placed at his old rehab
facility and is in good condition for discharge. Pt was
discharged to rehabilitation on [**2149-7-7**] in good condition.
Medications on Admission:
Digoxin 0.0625'
Midodrine 5'
Protonix 40'
Coreg 3.125"
Betoptic 0.25% OU"
Alphagan 0.15 OU TID
FeSO4 325'''
Lipitor 10 QHS
Xalatan 0.005% OD QHS
Discharge Medications:
1. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days.
Disp:*32 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*0*
4. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*20 drops* Refills:*2*
5. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop
Ophthalmic Q8H (every 8 hours).
Disp:*20 drops* Refills:*2*
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
Disp:*20 * Refills:*2*
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Disp:*20 appl* Refills:*0*
9. Midodrine 5 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24
Hours).
Disp:*30 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Cape [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Bladder Cancer
Discharge Condition:
Good
Discharge Instructions:
Normal level of capable activity
If you have fever >101.5, severe pain, intractable vomiting or
diarrhea, chest pain, shortness of breath, decreased urine
output, significant bleeding or discharge from wound, or
anything else that causes you concern, pleae return.
Regular ostomy care.
Followup Instructions:
Call Dr.[**Name (NI) 19910**] office for an appointment ([**Telephone/Fax (1) 6441**]
Completed by:[**2149-7-7**]
|
[
"427.31",
"V58.61",
"799.4",
"599.7",
"198.82",
"293.0",
"719.41",
"593.9",
"425.4",
"V45.01",
"008.45",
"188.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"57.71",
"56.51",
"89.64",
"03.90",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6925, 7027
|
3535, 5163
|
286, 321
|
7086, 7093
|
733, 3512
|
7427, 7543
|
566, 570
|
5358, 6902
|
7048, 7065
|
5189, 5335
|
7117, 7404
|
585, 714
|
232, 248
|
349, 407
|
429, 498
|
514, 550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,995
| 196,634
|
45941
|
Discharge summary
|
report
|
Admission Date: [**2174-7-23**] Discharge Date: [**2174-7-27**]
Date of Birth: [**2107-9-11**] Sex: F
Service: MEDICINE
Allergies:
Gantrisin / Lactose
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Fever and mental status changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 yo F with PMH of DM1, ESRD on HD, recent septic arthritis s/p
wash out on [**2174-7-1**] who recently finished a course of vancomycin
for septic joint and flagyl for C.diff who presented on [**2174-7-23**]
to the ED with fevers and altered mental status. Patient is
currently living in NH at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] and had a fever to 103
at HD. She was also drowsy and there was concern for altered
mental status. She complained of left knee pain and diarrhea
(both on going for a while). In the ED, she was febrile to 102.2
adn HR 122, BP 109/66, O2sat 100% RA. She had a right femoral
line placed because of difficult IV access and became
transiently hypotensive to SBP 70s. She was given IVF and
vancomyin IV 1g x1, ceftriaxone 1g IV x1 adn vancomycin 125mg PO
x1. She was sent to the MICU for further care.
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. Followed by Dr. [**Last Name (STitle) **].
3. CAD - NSTEMI [**10-24**] in the setting of hospitalization for DKA,
Nuclear stress test [**8-24**]: 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
10. Recent femoral head neck fx. [**2-19**] trauma in [**1-25**]
11. MRSE HD line infection [**1-25**] treated with 3 weeks vancomycin
12. h/o vaginal bleeding with ? endometrial polyp
13. L knee Corynebacterium septic arthritis? unclear if
contaminant or real -treated with 4 weeks of vancomycin in [**6-26**]
14. C diff. recent treatment stopped on [**2174-7-19**]
Social History:
She lives at [**Location **]- [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. She has two sons, one of whom
is mentally retarded. Past history of EtOH use. Ex-smoker, quit
in [**2154**]. Previously smoked for 8yrs. No history of illicit drug
use. States that she has not had sexual intercourse or sexual
activity in "a long time."
Family History:
Mother - DM
Sister - breast ca, DM
Brother - HTN
[**Name (NI) 2957**] - SLE, d. renal failure
Physical Exam:
T: 97.3 BP: 160/80 HR: 93 RR: 18 O2 100% RA
Gen: Cachectic. Pleasant, resting in bed.
HEENT: L eye shut (chronic) No conjunctival pallor. No icterus.
MMM. OP clear.
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, good BS BL, No W/R/C. R HD tunneled cath, no signs
of infection
ABD: NABS. Soft, NT, ND. No HSM. R fem line, no signs of
infection
EXT: WWP, 2+ PT, 1+ DP pulses BL. Trans-metatarsal amputation
of L foot. Left knee warm, edematous, wound c/d/i. Decreased
ROM [**2-19**] pain.
SKIN: Stage III sacral decubitus ulcer midline lower back, Stage
I decubitus in anal region
NEURO: AOx2. Baseline dementia. Motor/sensation grossly intact.
Gait assessment deferred.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2174-7-26**] 05:15AM BLOOD WBC-6.0 RBC-3.96* Hgb-10.7* Hct-35.7*
MCV-90 MCH-27.0 MCHC-29.9* RDW-17.9* Plt Ct-240
[**2174-7-25**] 06:39AM BLOOD WBC-5.9 RBC-3.75* Hgb-10.0* Hct-34.0*
MCV-91 MCH-26.8* MCHC-29.6* RDW-17.6* Plt Ct-244
[**2174-7-24**] 04:54AM BLOOD WBC-11.0 RBC-4.15* Hgb-11.0* Hct-37.4
MCV-90 MCH-26.4* MCHC-29.3* RDW-17.6* Plt Ct-237
[**2174-7-23**] 11:45PM BLOOD Hct-31.4*
[**2174-7-23**] 07:50PM BLOOD WBC-8.3 RBC-4.15* Hgb-10.9* Hct-37.5
MCV-90 MCH-26.2* MCHC-29.0* RDW-16.9* Plt Ct-235
[**2174-7-23**] 07:50PM BLOOD Neuts-81.1* Lymphs-12.4* Monos-5.7
Eos-0.4 Baso-0.3
[**2174-7-27**] 07:25AM BLOOD Glucose-170* UreaN-13 Creat-3.8*# Na-136
K-4.9 Cl-106 HCO3-20* AnGap-15
[**2174-7-23**] 07:50PM BLOOD Glucose-199* UreaN-7 Creat-2.8* Na-144
K-3.5 Cl-104 HCO3-31 AnGap-13
[**2174-7-23**] 07:50PM BLOOD CRP-14.3*
.
[**2174-7-27**] 10:47 am URINE Source: Catheter.
URINE CULTURE (Pending)
.
[**2174-7-24**] 5:11 pm BLOOD CULTURE Source: Line-HD line.
Blood Culture, Routine (Pending)
.
[**2174-7-24**] 10:57 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2174-7-26**]**
FECAL CULTURE (Final [**2174-7-26**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2174-7-26**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2174-7-25**]):
PREVIOUSLY POSITIVE C. DIFFICILE TOXIN WITHIN ONE WEEK.
RESULT
UNLIKELY TO CHANGE WITHIN ONE WEEKS INTERVAL OF TIME.
SUBMIT NEW
SAMPLE GREATER OR EQUAL TO ONE WEEK AFTER ORIGINAL SAMPLE
IF
CLINICALLY INDICATED.
.
[**2174-7-23**] 11:00 pm JOINT FLUID LEFT KNEE.
**FINAL REPORT [**2174-7-24**]**
GRAM STAIN (Final [**2174-7-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
.
[**2174-7-23**] 9:15 pm URINE Site: CATHETER
**FINAL REPORT [**2174-7-27**]**
URINE CULTURE (Final [**2174-7-27**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
FULL WORK UP REQUESTED PER DR. [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **] #[**Numeric Identifier 97824**] ([**2174-7-26**]).
YEAST. >100,000 ORGANISMS/ML. OF TWO COLONIAL
MORPHOLOGIES.
LACTOBACILLUS SPECIES. 10,000-100,000 ORGANISMS/ML..
.
[**2174-7-23**] 7:50 pm BLOOD CULTURE VENIPUNCTURE #2 R GROIN .
Blood Culture, Routine (Pending) X2
Brief Hospital Course:
66 yo F with PMH of DM1, ESRD on HD, recent septic arthritis s/p
wash out on [**2174-7-1**] who recently finished a course of vancomycin
([**7-23**]) for presumed septic joint and flagyl ([**7-19**]) for C. diff who
presented on [**2174-7-23**] to the ED with fevers and altered mental
status.
.
In the MICU her antihypertensive agents were held [**2-19**]
hypotension. [**Month/Day (2) 1957**] was consulted to evaluate for continued
septic knee as a source of infection. Her knee was tapped and
was benign with no growth on culture. She continued to have
profuse diarrhea and was considered to have flagyl failure for
her C diff. The MICU team felt that she was likely septic from
urosepsis (pus in her foley- she only makes a small amount of
urine given her ESRD). Blood cultures at that point showed no
growth to date. ID was consulted in the MICU and she was started
on PO vancomycin and IV flagyl for C diff, IV vancomycin for
empiric coverage for her knee, and cefepime for her dirty u/a
with gram negative bacteria). Blood pressure remained stable in
the MICU and pt was afebrile.
.
# Sepsis of undetermined origin: Pt had numerous potential
sources of infection on admission: most likely [**2-19**] C. diff,
treatment failure. Pt had recently been admitted to the
hospital and was discharged with a course of flagyl for C. diff.
Pt finished her regimen on [**2174-7-19**]. Shortly after finishing
her course of flagyl the pt's profuse diarrhea returned.
Although the urinary tract is concerning given her history of
pus in the Foley, pt is oliguric (per history only voids once
every couple of days) and this may account for the appearance of
her urine. Furthermore results from the urine culture yielded
lactobacillus (native organism) and yeast --although the pt no
longer has a Foley in place she was treated with one dose of
fluconazole. Potential seeding from ?septic L knee, although
fluid analysis currently negative for infection --knee exam does
not appear to support current septic arthritis and pt has
finished her full course of vancomycin. Potentially tunneled HD
line, although the site has remained free of erythema,
fluctuance, drainage or pain --cultures pending. Possibly sacral
decubitus ulcer stage III. ID was consulted and they thought
that the pt's presentation was most likely [**2-19**] C. diff. and not
urosepsis. On admission the pt received vancomycin PO/IV,
flagyl IV and cefepime IV for continue C. diff coverage as well
as possible urosepsis (as well as potential source from knee).
One day prior to discharge the pt's cefepime and vancomycin IV
were discontinued --flagyl IV was changed to flagyl PO. It was
felt that the pt only needed treatment for C. diff. Although
the pt's diarrhea has not completely resolved it has slightly
improved. The pt was discharged on a vancomycin PO taper for a
total of 6 weeks [**2-19**] her treatment failure from flagyl after her
recent admission.
.
# Diarrhea: Most likely [**2-19**] C. diff, flagyl failure from
previous treatment. Still positive for C. diff toxin, although
recently treated for C. diff (full course of flagyl finished on
[**7-19**]). Pt's salmonella, shigella and campylobacter studies were
negative. Rectal tube d/c one day after admission, pt's diarrhea
slightly improved. Sent out on vancomycin taper for 6 weeks.
.
# Diabetes: Pt has had very poor control as an outpatient. Pt
was started on NPH in the MICU and subsequently changed to
Lantus 10 units on the floor. Pt's FSBS was 57 on [**7-26**] AM
--Lantus decreased to 8 units. Pt's FSBS was 59 on [**7-27**] AM. Pt
has adequate PO intake. Concern for stacking of SSI doses
during the day in the setting of ESRD. Pt required a total of
10 units of correction during lunch and dinner on [**7-26**]. Could
either change the lantus from bedtime to morning or adjust the
afternoon SSI --decided to keep the lantus at bedtime and to
decrease the SSI for lunch and dinner. Pt will be discharged on
Lantus 8 units at bedtime with an adjusted SSI.
.
# Sacral decubitus ulcers: Pt has stage III in the midline of
lower back and stage I near the anal verge. Likely [**2-19**] frequent
bed rest s/p recent arthrotomy and synovectomy. Wound care
assessed and recommended DuoDerm and Allevyn dressing changes
q3days or prn. The pt was repositioned frequently and was given
a soft mattress. Pt was also given vitamin C. Pt will need to
be repositioned frequently at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] and was encouraged
to work with their PT as tolerated.
.
# Recent L knee ?septic arthritis: Pt is s/p arthrotomy with
anterior
synovectomy on [**7-1**] for question of septic arthritis. CRP and
ESR are down and joint fluid with negative gram stain. Finished
full course of vancomycin on [**7-23**]. Orthopedics evaluated the
knee again during this admission and they did not think any
further intervention was required. Pt's pain was well controlled
during the admission. Knee had minimal edema, no erythema or
effusion. Joint cultures pending.
.
# ESRD: Pt continued outpatient regimen of HD Tues, Thurs, Sat.
No complications with hyperkalemia. Sevelamer decreased to
800mg TID, continued Nephrocaps.
.
# Altered mental status: Pt appears to be at baseline mental
status now per family. Improved throughout MICU stay with
hydration and antibiotics. Most likely [**2-19**] sepsis.
.
# CAD: Pt has history of NSTEMI, had +troponins (peaked to 0.11)
this admission but low CKs. Elevated troponins likely [**2-19**] renal
failure and recent MICU admission for sepsis. Pt asymptomatic.
No concerning changes on EKG. Pt was continued on a statin and
ASA. ACEI and BB held secondary to hypotension in the MICU.
Metoprolol was titrated up as SBP tolerated and pt was
discharged on her normal dose of both metoprolol and lisinopril.
.
# Depression: Pt very irritable and depressed per family.
Discussed with family and pt the addition of Celexa --they hope
that this will help to motivate the pt to engage with PT more
often. Pt started on Celexa 10mg PO qdaily to be titrated up to
20mg PO qdaily in a week.
.
# Family meeting: Son [**Name (NI) **] and his wife met with Dr. [**Last Name (STitle) 724**],
Dr. [**First Name (STitle) **] and [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] on the day of discharge to discuss
goals of care and to open a discussion about end-of-life care.
Family aware of [**Hospital **] medical condition and the severity. Family
knows that the pt will need definitive placement in a long-term
facility. Family discussed frustration [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] --do
not think that pt is interacting enough with the
staff/residents. Not as active as she could be. Family is
actively searching for new placement that will be closer to
them.
# Access: Pt had right fem line d/c [**7-26**]; HD tunneled line
accessed; PIV placed [**7-25**] and dysfunctional on [**7-26**]. Pt
discharged with only her HD tunneled line.
.
# PPX: heparin SQ for DVT ppx, PPI per outpatient regimen.
.
# Comm: son--> [**First Name8 (NamePattern2) **] [**Known lastname **] Phone: [**Telephone/Fax (1) 97825**]
.
# CODE: Full code--> confirmed with son, [**Name (NI) **] [**Name (NI) **].
Discussed status with family at a meeting with [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] and
status remains FULL CODE
Medications on Admission:
Atorvastatin 80mg po daily
Aspirin 325 mg po dails
Sevelamer 1600 po TID
Lisinopril 30mg po Qday
Metoprolol 75mg po TID
Glargine 29 units
Ferrlecit 12.5 3x/week
Os-Cal+D500 mg
Prilosec 20 daily
Nephrocaps 1 mg daily
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Citalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: After 7 days titrate up to 20mg daily. .
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
11. Vancomycin 125 mg Capsule Sig: see instructions Capsule PO
see instructions for 6 weeks: 125mg PO QID x 7 days followed by
125mg PO BID x 7 days followed by 125mg PO qdaily x 7 days
followed by 125mg PO qod x 7 days followed by 125mg PO every 3
days x 14 days.
12. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
13. Ferrlecit 12.5 mg/mL Solution Sig: as directed Intravenous
3 times a week.
14. Aranesp SureClick -Polysorbate Subcutaneous
15. Os-Cal 500 + D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
- C. difficile septicemia
- Stage III/IV sacral decubitis ulcer
Secondary:
End stage renal disease
Diabetes mellitus
Hypertension
Coronary artery disease
Discharge Condition:
Stable
Discharge Instructions:
You were treated in the hospital for a severe infection of your
gastrointestinal (GI) tract. Your diarrhea was most likely
caused by bacteria. You were started on antibiotics in the
hospital to treat the infection and you will need to continue
these antibiotics as an outpatient. You will be given these
instructions.
You will need to take an antibiotic called vancomycin to treat
your infection. You were also given an antidepressant called
Celexa to help you with your mood. The dosing of your diabetes
medications was also changed because your blood sugars are too
low in the morning. You should continue to take vitamin C, this
will help with your ulcers. Your dose of sevelamer was also
decreased.
There were no other changes made to your medications.
You should follow-up with your PCP at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **].
Please call your doctor or return to the ED if you experience
any worsening in symptoms including increasing diarrhea, fever,
chills, chest pain, shortness of breath or any other concerning
symptoms.
Followup Instructions:
Your PCP will need to see you at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **].
Completed by:[**2174-8-3**]
|
[
"E879.1",
"E849.7",
"583.81",
"V18.0",
"E879.6",
"996.64",
"008.45",
"250.53",
"038.9",
"707.03",
"530.0",
"V17.49",
"362.02",
"995.92",
"357.2",
"V15.82",
"403.91",
"585.5",
"711.06",
"996.62",
"414.01",
"V16.3",
"250.43",
"785.52",
"250.63",
"569.41",
"412",
"V49.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15441, 15514
|
6275, 7446
|
310, 317
|
15722, 15731
|
3725, 6252
|
16856, 16990
|
2778, 2873
|
13999, 15418
|
15535, 15701
|
13759, 13976
|
15755, 16833
|
2888, 3706
|
239, 272
|
345, 1207
|
7460, 11494
|
11509, 13733
|
1229, 2391
|
2407, 2762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,727
| 191,656
|
36065
|
Discharge summary
|
report
|
Admission Date: [**2119-2-24**] Discharge Date: [**2119-3-1**]
Date of Birth: [**2041-9-11**] Sex: M
Service: UROLOGY
Allergies:
Lidocaine
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
hypotension/post-op s/p nephrectomy
Major Surgical or Invasive Procedure:
Left radical nephrectomy
History of Present Illness:
Mr. [**Known lastname 1852**] is a 77 year old male with past medical history of
COPD and a left renal mass who is now s/p L nephrectomy and is
admitted to the ICU with post-op hypotention and delirium. The
patient had approximately 200 cc of EBL in the OR; however, per
anesthesia reports, he had labile blood pressures throughout his
surgery, ranging from 100-180 systolic. He had an epidural
placed for pain control prior to the OR, and was maintained on
neosynephrine for blood pressure support during the procedure.
He additionally rec'd 4L of fluid during the procedure for blood
pressure support.
On arrival to the floor, the patient was agitated, attempting to
get out of bed, unable to follow commands, but alert. This
began to slowly improve with redirection.
ROS: Unable to obtain. Denies pain.
Past Medical History:
Renal tumor, likely renal cell carcinoma with possible
metastatic disease to lungs, diagnosed in [**12-17**]
COPD
?CAD
Pilonidal cyst s/p removal
Neck cyst removal
Social History:
Per OMR: The patient is married x 55 years, though he has been
separated for the past five years. He has one son and one
daughter who died of a brain aneurysm. He is retired and lives
in [**Location (un) **]. He smoked one-half to one pack per day x65 years
but quit after his left renal mass was noted. He denies ETOH.
Family History:
Per OMR: Father with history of alcoholism and died of an MI.
Mother died of melanoma. No family history of kidney cancer.
Physical Exam:
pertinent for delirious, no rashes, bandages left sided to
midline incision post surgery without drainage/c/d/i, no c/c/e,
no ecchymoses, RIJ in place
Pertinent Results:
[**2119-2-24**] 09:11PM GLUCOSE-189* UREA N-17 CREAT-1.1 SODIUM-137
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14
[**2119-2-24**] 09:11PM ALBUMIN-3.0* CALCIUM-8.2* PHOSPHATE-3.6
MAGNESIUM-2.0
[**2119-2-24**] 09:11PM WBC-12.6* RBC-3.71* HGB-11.1* HCT-32.8*
MCV-88 MCH-29.9 MCHC-33.9 RDW-16.0*
[**2119-2-24**] 09:11PM PT-14.2* PTT-28.4 INR(PT)-1.2*
[**2119-2-24**] 05:08PM TYPE-ART PO2-205* PCO2-41 PH-7.37 TOTAL
CO2-25 BASE XS--1
[**2119-2-24**] 05:08PM GLUCOSE-138* LACTATE-1.6 NA+-136 K+-4.1
CL--105
[**2119-2-24**] 05:08PM HGB-11.7* calcHCT-35
[**2119-2-24**] 05:08PM freeCa-1.11*
[**2119-2-24**] 03:26PM TYPE-ART PO2-143* PCO2-40 PH-7.40 TOTAL
CO2-26 BASE XS-0
[**2119-2-24**] 02:18PM TYPE-ART TEMP-36 RATES-/8 TIDAL VOL-600
O2-50 PO2-105 PCO2-48* PH-7.37 TOTAL CO2-29 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
Imaging:
PET scan [**2119-2-16**]:
IMPRESSION: 1. Large left renal lesion comprised of an FDG-avid
solid superior portion with SUVmax 6.9 and a septated photopenic
inferior component surrounded by an FDG-avid capsule is
worrisome for malignancy. 2. Non-FDG-avid spiculated left lung
lesion tethering towards a large pleural plaque abutted by a
semisolid lesion may represent scarring, a malignant neoplasm
can not be excluded. 3.
FDG-avid soft tissue nodule in the subcutaneous tissues of the
right breast may refpresent a superficial infection or a
pilonidal cyst and bears watching. Clinical correlation is
suggested. 4. Enlarged prostate contains calcifications and
shows low-grade FDG avidity. 5. Non-enlarged FDG-avid left
internal jugular node bears watching.
CXR post-op: CVL in distal IVC, no pneumothorax or infiltrate
Brief Hospital Course:
77 year-old male with a history of COPD who presents for
post-operative monitoring after a left nephrectomy.
[**Hospital Unit Name 13533**]: ([**Date range (1) 81832**])
Pt was admitted to the [**Hospital Unit Name 153**] for labile BP requiring vasopressors
from the OR s/p left nephrectomy, pleural biospy, hilar lymph
node and 10th rib biopsies for labile BP. Pt was initially on
vasopressor support in the Ed however upon transfer to the [**Name (NI) 153**]
pt was maintaing a SBP 90-100s without vasopressors. Pt was also
noted to be in a state of delirium which most likely was
post-anesthesia delirium given his age and the use of versed.
After overnight observation pt's mentation cleared and he was
fully orientated.
Patient was transferred to the floor on POD 1 in stable
condition. His diet was advanced as tolerated and he was
tolerating a regular diet by POD 3. His catheter was removed on
POD 3 and he was able to void without difficulty. He was
evaluated by physical therapy who recommended visiting nurse
care for assistance with ambulation. He was discharged with VNA,
tolerating a regular diet, pain controlled and voiding
independently.
Medications on Admission:
Advair
Spiriva
Lopressor dc'd due to lower extremity edema
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): use while taking narcotics.
Disp:*60 Capsule(s)* Refills:*0*
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
5. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
renal cancer
Discharge Condition:
stable
Discharge Instructions:
- resume medications
- f/u with Dr. [**Last Name (STitle) 3748**] in 1 week for staple removal
- return to emergency for pain, fevers, chills, or other
concerns
Followup Instructions:
1 week
Completed by:[**2119-3-1**]
|
[
"189.0",
"458.29",
"293.0",
"496",
"E938.4",
"197.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.24",
"55.51",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
5649, 5707
|
3732, 4891
|
305, 331
|
5763, 5771
|
2031, 3709
|
5982, 6018
|
1720, 1845
|
5000, 5626
|
5728, 5742
|
4917, 4977
|
5795, 5959
|
1860, 2012
|
230, 267
|
359, 1172
|
1194, 1360
|
1376, 1704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,919
| 177,475
|
47199
|
Discharge summary
|
report
|
Admission Date: [**2185-8-28**] Discharge Date: [**2185-9-19**]
Date of Birth: [**2145-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fever, abdominal pain
Major Surgical or Invasive Procedure:
1. Debridement of abdominal wall abscess
History of Present Illness:
Mr. [**Known lastname 34682**] is a 39 year-old male with h/o Prader-Willi
Syndrome, T2DM, HTN, s/p trach and PEG, recent treatment for c.
diff, recent treatment for VAP and UTI, and recent initiation of
HD [**3-3**] ARF on CRI of unclear etiology, who presents from [**Hospital 100**]
Rehab after experiencing fever and diffuse abdominal pain. On
[**8-26**], his temp was found to be 100.5, with slight tachycardia
to 105. He was given 1 dose vanc IV at HD on [**8-26**] for erythema
and discharge from G-tube site, and restarted on PO vanco for
suspicion of c. diff, although pt had no diarrhea. His vent
settings had been stable at PS 15/5 on FIO2 35% with RR 20-24
and Vt 300-400mL with mod white secretions, but on [**8-27**], RT
noted increased secretions and decreased Vt to 240-300mL with
temp climbing to 102F. CXR was reportedly non-diagnostic [**3-3**]
large body habitus. BCx were sent on [**8-26**], which had no growth
after 24h. Sputum was also sent for culture, and gram stain
demonstrated many GNR and mod GPR, with 5-10 PMNs/HPF and 0-5
epis/HPF. UA was turbid and positive for UTI, with UCx pending.
Wbc was found to be elevated to 32, with elevated alk phos to
500s. Given one dose ceftaz 2gm on [**8-27**] and sent to ED for
further evaluation.
.
Per [**Hospital 100**] Rehab notes, Mr. [**Known lastname 34682**] has bilateral heel decubs.
He also is thought to have possible DVTs, but with inconsistent
exam, d-dimer, and inconclusive LENIs. He is being
anticoagulated, but found to be subtherapeutic on Coumadin 7.5mg
PO qD, and was being treated with IV heparin bridge.
.
In the ED, initial VS were T 102.4F, BP: 124/93, HR: 121, RR:
29, SaO2 96% His initial labs were notable for an elevated wbc
to 32.5 (83% PMN, 5% bands) with lactate 1.8, a mild
transaminitis (AST 59, ALT 73), elevated alk phos at 1178 with a
normal tbili of 0.8, and normal amylase/lipase. INR was elevated
at 1.8. CXR was uninterpretable. Due to his morbid obesity, Mr.
[**Known lastname 34682**] could not undergo CT scan, and had no informative
imaging done. He was given vancomycin and cefepime, and
transferred to the [**Hospital Unit Name 153**] for further management.
.
Mr. [**Known lastname 34682**] was last discharged from [**Hospital1 **] on [**8-2**] after a
prolonged stay for ARF of unclear etiology. After multiple
failed attempts at HD access in OR, had cut-down tunneled L IJ
Perma Cath placed. Also had acetinobacter PNA and Klebsiella UTI
during this admission, s/p Unasyn x 14 days, ending [**7-31**].
Covered prophylactically for recent c. diff with PO vanc, ending
[**8-14**].
Past Medical History:
Prader Willi Syndrome
Morbid obesity
T2DM
CRI with baseline creatinine 1.8-2.0
OSA
Mental retardation
Hypothyroidism
Status post tracheostomy and PEG tube placement
Social History:
Resident at [**Hospital 100**] Rehab. No smoking, ethanol or drug use.
Family History:
Family history of diabetes.
Physical Exam:
VS: Tmax: 100.9 yesterday afternoon, Tc: 97.8 BP: 128/41 HR: 86
AC 450x16 FiO2 0.35 SaO2 99%, PEEP 8
General: Morbidly obese AA male, sleeping, arouses to voice but
not responding to questions.
HEENT: NC/AT, JVD unable to appreciate [**3-3**] habitus.
Neck: Trach c/d/i.
Pulmonary: clear anteriorly
Cardiac: Distant HS, RR, nl. S1,S2 no rub appreciated.
Abdomen: Obese, soft, foley catheter taped into place in former
PEG site. dressing soaked with clear drainage. no clear
tenderness. absent bowel sounds.
Extremities: 1+ BLE edema, abd wall edema.
Pertinent Results:
[**2185-8-28**] 02:11AM PT-18.9* PTT-33.8 INR(PT)-1.8*
[**2185-8-28**] 02:11AM PLT COUNT-329#
[**2185-8-28**] 02:11AM NEUTS-83* BANDS-5 LYMPHS-4* MONOS-5 EOS-1
BASOS-0 ATYPS-1* METAS-1* MYELOS-0 NUC RBCS-2*
[**2185-8-28**] 02:11AM WBC-32.5*# RBC-3.37* HGB-8.3* HCT-27.1*
MCV-81* MCH-24.5* MCHC-30.4* RDW-18.7*
[**2185-8-28**] 02:11AM FREE T4-0.5*
[**2185-8-28**] 02:11AM TSH-38*
[**2185-8-28**] 02:11AM ALBUMIN-2.7* CALCIUM-9.0 PHOSPHATE-4.9*#
MAGNESIUM-1.9
[**2185-8-28**] 02:11AM LIPASE-22 GGT-687*
[**2185-8-28**] 02:11AM ALT(SGPT)-59* AST(SGOT)-73* ALK PHOS-1178*
AMYLASE-27 TOT BILI-0.8
[**2185-8-28**] 02:11AM GLUCOSE-182* UREA N-50* CREAT-4.3* SODIUM-138
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-28 ANION GAP-20
[**2185-8-28**] 02:21AM LACTATE-1.8
[**2185-8-28**] 03:30PM PTT-51.4*
Brief Hospital Course:
Plan:
1) Shock:
Patient was admitted in septic shock secondary to abdominal wall
abscess surrounding his G tube insertion site. Patient's
additional sources included acinetobacter pneumonia, VRE in
abdominal wound, pseudomonal pneumonia, and yeast in the
abdominal wound. For antibiotics, patient was started on a
course of caspofungin, tobramycin, and daptomycin. Given
patient's obese body habitus, most radiological imaging is not
useful in this patient. Patient completed a two week course of
antibiotics s/p OR debridement.
2) Respiratory failure:
Patient was started on a trach during his last admission and per
his family would like to maintain current settings. Patient had
moderate secretions during this admission and was started on
daptomycin and tobramycin for treatment of acinetobacter and
pseudomonal pneumonia.
3) Renal failure:
During [**7-5**], patient developed renal failure of unclear etiology
and has been on hemodialysis since [**7-5**]. During this admission,
patient initially required CVVH due to poor renal function and
then was transitioned back to hemodialysis without
complications.
4) h/o DVT:
This diagnosis was made clinically, due to patient's calf pain
and inability to obtain adequate imaging. Patient was
supratherapeutic while taking coumadin and heparin. Given the
risks of maintaining patient on heparin or coumadin, coumadin
was discontinued.
5) Anemia:
Likely secondary to renal failure and chronic phlebotomizing.
Patient's Hct remained stable during this admission.
6) T2DM:
Has always been poorly controlled (HbA1C 11.2 [**3-6**]). Patient's
blood sugars however have been adequately controlled with
current regimen of Glargine 60U with breakfast and sliding scale
insulin. Pt's sliding scale upon discharge was to start with
8units of regular insulin from 121-160 and then increasing by 4
units for every 40 increase in BG above 160.
7) Hypothyroidism:
Patient's TSH suggests hypothyroidism, although unclear the
accuracy of the diagnosis since thyroid levels were assessed
while patient was already in the ICU. Patient was initially
started on just Levothyroxine PO 75 which was then converted to
IV levothyroxine 150 for improved absorption.
8) FEN:
Patient was maintained on Nepro Full strength with Beneprotein,
40 gm/day at a goal rate of 45 mL/hour. Residual Check: q4h Hold
feeding for residual >= : 150 ml
Flush w/ 50 ml water Before and after each feeding
Medications on Admission:
MV 1 Cap PO qD
Heparin IV gtt at 1800U/hr
Coumadin 7.5mg PO qD
Bupropion 75mg PO qD
Lactinex x 2 [**Hospital1 **]
Albuterol-Ipratropium MDI 8 puffs q4h
Vitamin C
SSI, Lantus 24U qD, Lispro 6U with lunch
Levothyroxine 100mcg IV
Calcium Acetate 667mg x 2 PO TID with meals
Oxycodone-Acetaminophen 5-325mg PO Q4-6H prn
Nepro 45mL/hr
Discharge Medications:
1. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO DAILY (Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q6H (every 6 hours).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 60 units
Subcutaneous q breakfast.
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection q ACHS: Please administer insulin according to the
following sliding scale. If BG 141-200, please give 8 units. If
BG 201-240, give 12 units. If BG 241-280, give 16 units. If BG
281-320, give 20 units. If BG 321-360, give 24 units. If BG
361-400, give 28 units. .
12. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
1. Septic Shock
2. Abdominal Wall Debridement s/p abdominal abscess surrounding
G tube insertion site
3. Pseudomonal and Acinetobacter pneumonia
Discharge Condition:
Fair. Patient is alert, interacting appropriately, and
tolerating tube feeds and dialysis.
Discharge Instructions:
- Please take all medications as prescribed.
- Please follow-up with your primary care physician 1-2 weeks
after discharge.
Followup Instructions:
- Please follow-up with your primary care physician 1-2 weeks
after your discharge.
|
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18,094
| 110,135
|
45436
|
Discharge summary
|
report
|
Admission Date: [**2114-11-13**] Discharge Date: [**2114-11-22**]
Date of Birth: [**2039-8-6**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Hydralazine / Ace Inhibitors / Diovan / Heparin Agents
Attending:[**First Name3 (LF) 826**]
Chief Complaint:
hypoxia/tachypnea, fever
Major Surgical or Invasive Procedure:
Left subclavain line
History of Present Illness:
Ms. [**Known lastname 349**] is a 75yo woman with h/o ESRD on HD, DM2, CHF,
afib and CAD who presented to the ER today from her NH with
complaint of fever to 103.8, chills, diaphoresis and confusion.
On arrival to the ER she was found to have temp 101.0, HR 126,
bp 180/86, and to be satting 82% on RA which improved to mid-90s
on 4LNC. Chest XR showed continued and possibly increased R
pleural effusion. She complained of midl abdominal pain, and CT
abd/pelvis was unremarkable except for known enlarged
gallbladder. She was given 1LNS, vanco and levo and was sent to
HD where they were able to remove 1.2L. While at HD, the
patient spontaneously desaturated to the 80s on 4LNC and
required 50% face mask to regain sats of the mid-90s. ABG at
that time showed 7.36/58/271. Stat CXR showed R pleural
effusion but no clear pna. She received nebs and zosyn and was
transferred to the MICU for further care.
.
In the MICU the patient had a bedside ultrasound to evaluate her
effusion which showed no safe area for diagnostic tap. After a
few hours in the MICU she dropped her pressures to as low as
sbp78. She was given 1500cc total of NS. Central line was placed
in a sterile fashion (LIJ) and she was started on levophed. Her
blood cultures returned 4/4 bottles GPC in clusters.
Past Medical History:
- R pleural effusion tapped in [**7-29**] neg for malignant cells or
infection (attempted tap x 3 without success, on fourth attempt
were able to remove 200cc only)
- CAD: cath [**11-26**] with 3VD, s/p cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to RCA.
- atrial fibrillation
- pulmonary HTN
- hypertension
- hyperlipidemia
- DM2
- Severe lumbar spondylosis and spinal stenosis s/p laminectomy
in [**2110**]
- basal cell carcinoma
- CHF: echo [**1-28**] shows 55% EF
- hyperkalemia
- ESRD on HD since [**2111**] after IV contrast for cath
- Osteomyelitis T5-T6 on suppressive vancomycin for 3 months
([**2113-4-13**] was day 1)
- MRSA bacteremia from HD line infection
- mild-to-moderate cord compression [**Date range (1) 3046**]/05 and evaluated by
neurosurgery felt mild and did not put patient at risk for cauda
equina syndrome.
- urosepsis
- several HD line changes
Social History:
Lives at [**Hospital **] [**Hospital **] Nursing Home since [**2111**] and has been
bedridden since that time [**1-25**] spinal stenosis. Past tobacco
(quit [**2111**] 10py). Has three children - daughter nad son both in
[**Name (NI) 86**] area and split her HCP. Widowed in [**2108**]. Retired -
worked in retail clothing.
Family History:
Father died of CVA at 64yo. Mother died of MI at 86yo. Brother
had CAD. Grandmother had T2DM
Physical [**Year (4 digits) **]:
102.0, 92, 150/40, 100% on 50% face mask, 28
gen: responds appropriately to questions, increased work of
breathing, quite tachypneic, diaphoretic, severe kyphosis
heent: PERRL (constricted), NCAT
neck: unable to estimate jvp given pt inability to turn head
cor: rrr, s1s2, no r/g/m
pulm: scattered wheezes, decreased BS at right base
abd: soft, ntnd, +bs, no hsm
ext: no c/c/e, w/w/p
Pertinent Results:
[**2114-11-13**] 10:30PM LACTATE-2.1*
[**2114-11-13**] 10:20PM GLUCOSE-142* UREA N-22* CREAT-1.9* SODIUM-141
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-31 ANION GAP-10
[**2114-11-13**] 10:20PM CALCIUM-7.0* PHOSPHATE-2.1* MAGNESIUM-1.4*
[**2114-11-13**] 10:20PM VANCO-7.6*
[**2114-11-13**] 10:20PM WBC-9.5 RBC-3.43* HGB-11.3*# HCT-32.3*#
MCV-94 MCH-32.8* MCHC-34.9 RDW-14.4
[**2114-11-13**] 10:20PM PLT COUNT-83*
[**2114-11-13**] 10:20PM PT-16.6* PTT-27.6 INR(PT)-1.5*
[**2114-11-13**] 10:20PM FDP-10-40
[**2114-11-13**] 06:41PM GLUCOSE-194* UREA N-21* CREAT-2.0* SODIUM-140
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-36* ANION GAP-13
[**2114-11-13**] 06:41PM CALCIUM-8.7 PHOSPHATE-2.7 MAGNESIUM-1.6
[**2114-11-13**] 06:41PM CORTISOL-43.6*
[**2114-11-13**] 06:41PM WBC-12.5* RBC-4.47 HGB-14.4 HCT-42.6 MCV-95
MCH-32.1* MCHC-33.7 RDW-14.5
[**2114-11-13**] 06:41PM PLT COUNT-92*
[**2114-11-13**] 06:41PM PT-14.6* PTT-25.8 INR(PT)-1.3*
[**2114-11-13**] 06:41PM FIBRINOGE-654* D-DIMER-4952*
[**2114-11-13**] 05:40PM TYPE-ART PO2-271* PCO2-58* PH-7.36 TOTAL
CO2-34* BASE XS-5
[**2114-11-13**] 05:40PM LACTATE-2.2* K+-4.5
[**2114-11-13**] 05:40PM HGB-15.2 calcHCT-46
[**2114-11-13**] 10:11AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2114-11-13**] 10:11AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM
[**2114-11-13**] 10:11AM URINE RBC-[**2-25**]* WBC-[**2-25**] BACTERIA-NONE
YEAST-NONE EPI-0-2
[**2114-11-13**] 10:00AM GLUCOSE-168* UREA N-35* CREAT-2.8* SODIUM-137
POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-29 ANION GAP-16
[**2114-11-13**] 10:00AM estGFR-Using this
[**2114-11-13**] 10:00AM ALT(SGPT)-25 AST(SGOT)-32 LD(LDH)-244
CK(CPK)-20* ALK PHOS-205* AMYLASE-45 TOT BILI-0.4
[**2114-11-13**] 10:00AM CK(CPK)-22*
[**2114-11-13**] 10:00AM LIPASE-20
[**2114-11-13**] 10:00AM CK-MB-2 cTropnT-0.07*
[**2114-11-13**] 10:00AM CK-MB-NotDone cTropnT-0.08*
[**2114-11-13**] 10:00AM ALBUMIN-3.5
[**2114-11-13**] 10:00AM CALCIUM-9.1 PHOSPHATE-3.2 MAGNESIUM-1.7
[**2114-11-13**] 09:45AM LACTATE-1.3
[**2114-11-13**] 09:35AM WBC-12.0* RBC-4.48# HGB-14.4# HCT-42.5#
MCV-95 MCH-32.2* MCHC-33.9 RDW-14.4
[**2114-11-13**] 09:35AM NEUTS-85* BANDS-10* LYMPHS-0 MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2114-11-13**] 09:35AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2114-11-13**] 09:35AM PLT COUNT-89*
.
.
ECHO: [**2114-11-14**]
Conclusions:
1. The left atrium is mildly dilated. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic
(EF>75%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
6.There is mild pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Impression: No echocardiographic evidence of endocarditis seen.
.
CXXR [**2114-11-14**]
IMPRESSION: No change is demonstrated in large right pleural
effusion and atelectasis of the right lower lobe. An infectious
process cannot be excluded.
The left lung is unremarkable. The left subclavian line tip
terminates in the left brachiocephalic vein.
.
.
Discharge Labs:
Hct 31 WBC 7.6 Plt 180; Na 137 K 4.3 BUN 15 Crt 2.6
Brief Hospital Course:
#MRSA sepsis: Pt was admitted to the MICU and started on
vancomycin and zosyn for antibiotic coverage. Once
sensitivities returned as MRSA, the zosyn was discontinued. Her
blood pressures were low on initial presentation so the patient
was given bolus IV fluids and levophed. Her CVP was maintained
above 8. She was eventually weaned off of the levophed. An
extensive workup for the source of infection was limited by
patient's wishes. She had a TTE which was negative but refused
an MRI of the spine. The patient was afebrile during the ICU
course. Surveillance cultures were negative after [**2114-11-14**].
She will receive long duration therapy with 6wks of Vancomycin
to cover for osteomyelitis, as she has had this in the past.
Her most recent vanco level was pending at time of discharge.
.
#Heparin Induced Thrombocytopenia: The patients platlet count
continued to fall during her ICU stay. Heparin products were
held and sent off HIT Ab labs which eventually came back
positive. Her central line was also discontinued which was
pre-treated with heparin.
.
#ESRD: The patient has ESRD and received dialysis through her
fistula while in the MICU. No complications. Last dialysis was
on [**2114-11-22**]. Pt required extra sessions of dialysis because of
HD-related hypotension, which limited the extent of dialysis
that could be done in one session. She was started on EPO
4000units with dialysis for CKD-related anemia.
.
#CAD: continue pt's BB and plavix. allergy to asa and ace.
.
#Chronic back pain w/ spinal stenosis: continue outpt morphine
SR 30 qMon-Wed-Fri, and IR 15 q6h prn, as well as lidoderm
patch. pt appears to be at her baseline back pain, however we
wanted to do an MRI to rule out osteomyletis or epidural abscess
but the patient refused.
#[**Female First Name (un) 564**] UTI: Ms [**Known lastname 349**] had [**Female First Name (un) **] in her urine and was
started on a 7d course of fluconazole 200mg daily. This will
completed on [**2114-11-22**]. She does not have a foley catheter and
makes 20-30cc urine/day.
.
#DM: pt was continued on humalog sliding scale. Her glucose was
well controlled with this.
.
#H/o Afib: pt was in sinus rhythm throughout her hospital stay.
.
#CAD: no evidence of ischemia during hospital stay. Pt
continued on outpatient CAD regimen.
Medications on Admission:
metoprolol 12.5mg po bid
prilosec 20mg po qday
folic acid 1mg po qday
plavix 75mg po qday
lidoderm patch on 8am off 8pm
vitamin C 500mg po bid
ms contin 30mg po qMWF
calcium carbonate 500mg po tid
calcitriol 0.5mg qmwf
celexa 20mg po qday
klonopin 0.5mg po bid
duonebs prn
morphine IR 15mg po q4 prn
Discharge Medications:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q8AM-8PM ().
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous QHD (each hemodialysis): Continue until [**12-26**], [**2114**].
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
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).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QMOWEFR (Monday -Wednesday-Friday).
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
11. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H (Every 3 to 4 Hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
19. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ml
Injection ASDIR (AS DIRECTED): TO BE GIVEN WITH DIALYSIS
(4000units QHD).
20. Insulin Lispro (Human) 100 unit/mL Solution Sig: 2-10 units
Subcutaneous ASDIR (AS DIRECTED): sliding scale
151-200 give 2u,
201-250 give 4u,
251-300 give 6u,
301-350 give 8u,
351-400 give 10u,.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary
MRSA Sepsis
End stage renal disease on Hemodialysis
Heparin Induced thrombocytopenia
.
Secondary:
Diabetes mellitus type II
Spinal stenosis
Congestive heart failure
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
Please continue to take all medications as prescribed. You will
need to have a long course of vancomycin (an antibiotic) for
your blood infection, this will likely be for 6 weeks.
.
If you have chest pain/pressure, fevers/chills, shortness of
breath, nausea/vomiting, or any other concerning symptoms please
call your PCP or come to the ED.
.
1. Take medications as directed.
2. Attend all follow up appointments.
.
Your last Hemodialysis was on Thursday [**2114-11-22**]
.
Please **AVOID HEPARIN PRODUCTS** you had a reaction to it that
caused your platelet count to drop.
Followup Instructions:
Please follow up with your PCP/NH physician--[**Name10 (NameIs) 2113**],[**First Name3 (LF) 2114**] R.
[**Telephone/Fax (1) 608**]
|
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82,319
| 132,286
|
40740
|
Discharge summary
|
report
|
Admission Date: [**2118-6-19**] Discharge Date: [**2118-7-18**]
Date of Birth: [**2065-5-27**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
bilateral leg weakness
Major Surgical or Invasive Procedure:
tracheostomy, PEG
plasma exchange
History of Present Illness:
Ms. [**Known lastname 32624**] is a 53 year-old left-handed female with a
medical history significant for anxiety and a recent diagnosis
of
diverticulitis (2 months previous) who presents with a 1-day
history of acute onset bilateral leg weakness and a tingling in
her fingers and toes.
The patient first noted the onset of a tingling/pins and needles
sensation in her fingers and toes bilaterally one day prior to
presentation ([**2118-6-18**]). She says that her toes felt like
"frostbite." She reports that this tingling sensation then
extended up to the level of her knees. She also reported feeling
tingling around her lips. She tried taking two advil as well as
Xanax to relieve this sensation, but the sensation persisted.
She
then noticed that around 8PM the night prior to presenation, she
had some difficulty ambulating due to weakness in both of her
legs. She felt that she needed to support herself against the
wall when walking or she would fall. On the morning of
presenation, she felt that the weakness had worsened and she did
indeed fall while trying to ambulate to the bathroom. She says
that she stood up from the bed and her legs buckled beneath her,
causing the fall. She did not sustain any significant injuries
from the fall. She denies any other recent trauma. Given the
worsening weakness, she presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital on
[**2118-6-19**].
At [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], she was found to be afebrile with a WBC of 4.9.
She had a negative urine tox screen. She had an LP which was
clear and colorless with 1 WBC, 1 RBC, normal glucose, and
mildly
elevated protein (48). She had a non-contrast head CT, which
showed no intracranial hemorrhage but did reveal chronic lacunar
infarctions in the right basal ganglia and right midbrain. She
was transferred to the [**Hospital1 18**] ED for further neurological
evaluation of her weakness. In the [**Hospital1 18**] ED, she was stable with
vital signs T: 98.2, P: 89, BP: 152/91, RR: 18, O2 sat 98% RA.
.
Of note, the patient reports a recent diagnosis of
diverticulitis, which presented approximately 2 month ago with
bloody diarrhea. This was diagnosed by CT scan and she was
treated with a course of ciprofloxacin and flagyl. She is
scheduled to have a colonoscopy on [**2118-6-22**]. She also reports a
sore throat, sneezing, and watery eyes approximately 2 weeks
ago,
which she thought were due to seasonal allergies.
.
On neuro ROS, the patient endorses the feeling that she has to
urinate but is unable to do so. She denies headache, loss of
vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty,
difficulties producing or comprehending speech, bowel or bladder
incontinence.
.
On general review of systems, the patient endorses feeling short
of breath over the last two days. She says that while walking up
stairs on [**2118-6-17**], she was out of breath, which is unusal for
her. She also noticed some mottled skin over her thighs for the
last two days. She denies fevers, chills, night sweats, recent
weight loss or gain, cough, chest pain or tightness,
palpitations, nausea, vomiting, diarrhea, constipation or
abdominal pain, arthralgias or myalgias.
Past Medical History:
- Diverticulitis, diagnosed 1 month ago.
- Anxiety.
- Ectopic pregnancy [**2096**].
Social History:
The patient lives by herself in [**Location (un) 5028**], MA. She
has a boyfriend. She works at TD bank as a branch manager. She
reports a glass of wine daily. She denies current use of tobacco
or any other drugs. She has a distant smoking history. She is an
active tennis player.
Family History:
The patient's father had Alzheimer disease and died of
MI. Her mother died of a stroke. Both her parents had
hypertension and diabetes.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.2, P: 89, R: 18, BP: 152/91, SaO2: 98% RA.
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W.
Cardiac: RRR, nl. S1S2, no M/R/G noted.
Abdomen: Soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: Distal extremities cold to touch. 2+ distal pulses
bilaterally.
Skin: Mottled skin over bilateral thighs.
.
Neurologic examination:
.
- Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name DOW backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt. was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**3-31**] at 5 minutes. The pt. had good
knowledge of current events. There was no evidence of apraxia
or
neglect. There was no evidence of
left-right confusion as the patient was able to accurately
follow
the instruction to tough left ear with right hand.
.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 4 5 4- 4 5 4
R 5 5 5 5 5 5 5 5 5 4- 4 5 4
.
- Sensory: No deficits to light touch or pinprick. Decreased
vibratory sense in lower extremities (8 seconds at right ankle,
6
seconds at left ankle).Proprioception decreased in great toes,
intact at the ankle. Proprioception intact in upper extremities.
.
- DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
Plantar response was mute bilaterally.
.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF. HKS difficult to assess due to weakness.
.
- Gait: Not tested given patient's weakness.
***DISCHARGE EXAM:
NEURO: Awake, eyes open, mouthing words appropriately. PERRL 4
to 2mm, EOMI without nystagmus. Facial musculature full
strength.
Moving upper extremities to command, not antigravity. Neck
flexion 3+, extension 4. Delt 3+, tri 2, [**Hospital1 **] 1, wrist 0, fingers
1, lower extremities 0.
Sensation intact to light touch.
DTR: areflexic, toes mute
Pertinent Results:
ADMISSION LABS:
[**2118-6-19**] 01:20PM BLOOD WBC-5.3 RBC-4.66 Hgb-14.6 Hct-42.2 MCV-91
MCH-31.4 MCHC-34.7 RDW-13.3 Plt Ct-253
[**2118-6-19**] 01:20PM BLOOD PT-12.2 PTT-31.6 INR(PT)-1.0
[**2118-6-19**] 01:20PM BLOOD Glucose-107* UreaN-9 Creat-0.6 Na-143
K-3.9 Cl-108 HCO3-25 AnGap-14
[**2118-7-1**] 04:08AM BLOOD ALT-147* AST-75* AlkPhos-191* TotBili-0.3
IgA-228
DISCHARGE LABS:
[**2118-7-18**] 02:56AM BLOOD Glucose-124* UreaN-18 Creat-0.3* Na-139
K-3.5 Cl-104 HCO3-27 AnGap-12
[**2118-7-18**] 02:56AM BLOOD WBC-7.8 RBC-2.55* Hgb-8.0* Hct-23.6*
MCV-93 MCH-31.2 MCHC-33.7 RDW-16.0* Plt Ct-386
MICROBIOLOGY:
HBsAb-POSITIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
HCV Ab-NEGATIVE
MYCOPLASMA PNEUMONIAE ANTIBODY IGM-Test
CAMPYLOBACTER JEJUNI ANTIBODY, [**Doctor First Name **]-Test
FECAL CULTURE (Final [**2118-7-5**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2118-7-4**]): NO CAMPYLOBACTER
FOUND.
CMV Viral Load (Final [**2118-6-25**]):
CMV DNA not detected.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2118-6-20**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2118-6-20**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2118-6-23**]):
NEGATIVE <1:10 BY IFA.
CMV IgG ANTIBODY (Final [**2118-6-21**]):
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2118-6-21**]):
POSITIVE FOR CMV IgM ANTIBODY BY EIA.
REPORTS:
EMG
Abnormal study. There is electrophysiologic evidence for a
severe
demyelinating polyradiculoneuropathy, as in [**Month/Day/Year 7816**]-[**Location (un) **]
syndrome. The
reduction in CMAP amplitudes to below 20% of normal values
indicates that
recovery will be prolonged and possibly incomplete.
Brief Hospital Course:
53 yo female with complaints of SOB, BL LE weakness and numness
and tingling in her BL upper extremities.
NEURO:
Neurologic examination revealed LE weakness and areflexia,
concerning for [**First Name9 (NamePattern2) 7816**] [**Location (un) **] Syndrome (GBS). LP showed
borderline elevated protein at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
The patient was admitted to the ICU for close monitoring since
her respiratory status was tenuous. She did develop respiratory
failure and was intubated [**6-24**].
She received IVIG X 5 doses ([**Date range (1) 34115**]). Over the next 1 week,
she did not demonstrate significant improvement. She therefore
underwent 5 sessions of plasma exchange ([**Date range (1) 89081**]). After this,
she did have slight improvement in proximal upper extremity
strength.
She had neuropathic pain as part of her GBS, which responded to
gabapentin, nortriptyline, and Ultram for breakthrough pain.
Narcotics were not effective.
Workup for the initial cause of GBS was unrevealing (ie CMV,
EBV, mycoplasma, campylobacter, C. jejuni).
EMG was done 3 weeks into the course, which showed severe axonal
and demyelinating polyneuropathy. This predicts a very long
recovery time (~6 months), and there is a chance she will not
recover 100%.
CV:
Patient developed autonomic instability associated with GBS. She
would become tachycardic to the 140s and hypertensive to SBP 220
with any pain or anxiety. She received prn labetalol,
hydralazine, and was started on standing metoprolol. This
problem has improved significantly, and we began to slowly
decrease her metoprolol. This can likely be stopped in the
coming weeks.
Pulmonary:
Respiratory failure due to GBS. CTA was done to rule out PE. s/p
trach [**2118-7-6**]. She has had difficulty weaning vent settings below
PEEP of 10. She tolerates a PM valve for 5-10 minutes to allow
her to speak.
Gastrointestinal:
s/p PEG [**7-16**], tolerating TF. Patient had transaminitis of
unclear etiology (likely medication related) that stabilized in
AST/ALT in the 100s. Please continue to trend intermittently to
ensure resolution.
Renal:
Early in course, had hyponatremia likely [**3-2**] combination of
adverse effect of IVIg and [**Month/Day (2) 7816**]-[**Location (un) **]; improvement on fluid
restriction and hypertonic saline 3%. This resolved in the 2
weeks before discharge.
Hematology:
HCT trended down, particularly during plasma exchange and after
the PEG placement. She received 1 U PRBCs on [**7-17**] with stable
post-transfusion HCT.
Endocrine:
RISS with glucose goal < 150.
Infectious Disease:
s/p course of vanco, cefepime, tobramycin for VAP. She remained
afebrile after this treatment course.
Psych:
Patient has anxiety and takes Xanax at baseline. She initially
had severe anxiety attacks, that coupled with her autonomic
disturbance, led to extreme tachycardia and hypertension. She
was started on seroquel, and continued to receive Ativan prn,
which helped tremendously.
Medications on Admission:
- Xanax 0.5 mg PRN anxiety.
- Multivitamin.
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: [**1-30**] PO Q6H (every
6 hours) as needed for pain fever.
2. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
3. senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO HS (at bedtime).
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO twice a
day.
5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q6H (every 6 hours) as needed for wheeze.
6. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) as needed for anxiety.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
13. gabapentin 600 mg Tablet Sig: Two (2) Tablet PO three times
a day as needed for neuropathic extremity pain.
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
16. nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
17. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP less than 110, HR less 60
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
[**First Name9 (NamePattern2) 7816**] [**Location (un) **] syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Neuro Status: neck flexion 3, extension 4, delt [**4-1**], [**Hospital1 **]/tri 2,
wrist 0, fingers 1. No movement in lower extremities. Areflexic,
toes mute.
Discharge Instructions:
You were admitted for [**First Name9 (NamePattern2) 7816**] [**Location (un) **] (GBS). You were treated
with IVIG and plasma exchange. You will recover over the next
several months.
Followup Instructions:
You have an appointment with Neurology
Drs. [**Last Name (STitle) 1206**] and [**Name5 (PTitle) 1968**]
[**10-25**], 2:30 pm
[**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
[**Telephone/Fax (1) 44311**]
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
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72,207
| 123,500
|
43152
|
Discharge summary
|
report
|
Admission Date: [**2159-4-2**] Discharge Date: [**2159-4-11**]
Date of Birth: [**2108-8-25**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 50 year-old woman with a history of non-small
cell lung cancer with recent meningitic spread, s/p recent XRT,
with lower extremity weakness, who presents with a sacral ulcer
and abdominal pain. She was recently admitted to [**Hospital1 18**] [**2159-2-22**]
when she presented with increasing lower extremity weakness. MRI
was suggestive of leptomeningeal spread, and LP was
confirmatory. She received high-dose steroids and a total of 10
radiation treatments. She was discharged to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
There she has been mostly bed-bound but being moved back and
forth to wheelchair most days. She was aware that she had a
sacral ulcer and believes that bandages were being changed
regularly. She has mild pain at that site that has not changed
recently. For the past two weeks she has also had constant [**7-2**]
abdominal pain that she calls her "gas pain". It is located in
the periumbilical region and is described as sharp in nature.
She has had some associated nausea without vomitting. She has
been constipated and receiving multiple laxatives with no BM for
the past two days. No blood in bowel movements. She did not have
fevers or chills until the day prior to admission when she noted
chills. No fever was recorded. Of note she has an indwelling
Foley catheter BP at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] was found to be 70/palpable,
HR 120s, O2 Sat 88% on RA. She was transferred to [**Hospital1 18**] for
further management.
In the ED, VS initially T 97.3, BP 99/71, HR 138, RR 20, O2 Sat
100% on 6L. She had a CT of her torso that demonstrated air
adjacent to a sacral decubitus ulcer. She was given 3 L NS,
vancomycin 1 g IV, Zosyn 4.5 mg IV, morphine 4 mg IV, dilaudid 1
mg IV, and ASA 325 mg PO x 1. She was admitted to the ICU for
further managment.
.
Review of systems was positive as per HPI. Review was negative
for chest pain or palpiations. Negative for shortness of breath,
cough. No pain around her indwelling catheter. Positive for
ongoing lower extremity weakness that has been slowly worsening
since her discharge. Positive also for diplopia with rightward
gaze. No numbness or tingling.
.
Past Medical History:
Past Medical History:
-anxiety/panic attacks
-lung cancer as below (per recent note of Dr. [**Last Name (STitle) **]:
.
Mrs. [**Known lastname **] was found to have three pulmonary nodules on CT
scan on [**2151-4-5**]. On [**2151-12-8**], right upper lobectomy revealed
stage I, 1.1 cm poorly differentiated large cell carcinoma with
negative bronchial and vascular margins, no pleural or vascular
involvement, and no involved lymph nodes.
.
Ms. [**Known lastname **] did well until [**2153**] when she developed worsening
dyspnea. CT demonstrated increase in size of left lingular
nodule. PET scan was negative, but she underwent a left
VATS/wedge resection which demonstrated a 0.6 cm poorly
differentiated large cell carcinoma. It was felt that this was
another primary stage I tumor.
.
In [**2156**], she developed left-sided chest wall discomfort and
swelling at the site of her previous wedge resection. CT in
[**5-/2157**] was unremarkable. U/S of the swelling showed a
heterogeneous soft tissue mass. Biopsy of this lesion on
[**2157-7-12**] revealed metastatic poorly differentiated NSCLC. PET
scan [**2157-8-3**] was notable for an FDG avid left chest wall mass,
SUV 16.4, consistent with recurrent disease. There was also a
single left 8mm axillary node with an SUV of 2.7. She underwent
resection of the mass on [**2157-8-26**]. The mass was a 4 x 4 cm
poorly differentiated adenocarcinoma, histologically similar to
her previous tumor, and involving the chest wall. Three ribs
needed to be resected to get a good margin around the tumor.
There were multiple nodules seen and the superior nodule was
noted to be metastatic moderately differentiated adenocarcinoma
on pathology. All margins were negative, but there was concern
for lymphangitic spread. She was started on cisplatin/docetaxel
on [**2157-9-26**] and began XRT to the left chest wall in 2/[**2157**]. She
did not complete chemotherapy due to side effects, but did
complete XRT. In [**3-/2158**], she developed pain in the left axilla
and left chest wall. CT chest on[**2158-4-20**] showed an enlarged
left axillary lymph node and increase in the soft tissue
component of the left chest wall lesion in the area of her prior
surgery. Biopsy of the lymph node was consistent with NSCLC. PET
on [**2158-5-15**] showed interval development of an FDG avid,
enlarged soft tissue mass in the left axilla, abutting the chest
wall, with adjacent FDG avid adenopathy. There was also
increased avidity in the region of the left lateral sixth rib at
the site of the prior resection, concerning for recurrent
disease. She started carbotaxol, and avastin on [**2158-6-8**]. She
completed 3 cycles of treatment but it was held on [**2158-7-27**] due to
grade [**12-26**] side effects of fatigue, leg cramps, neuropathy, pain
and weight loss. Her PET scan on [**2158-9-14**] showed disease
progression. She was started on Alimta [**2158-10-11**]. CT [**2158-12-4**]
showed increase in her left axillary lymph node. Avastin was
added on [**2158-12-14**]. She completed 3 cycles of Alimta + Avastin.
.
In [**1-/2159**], she presented with lower extremity weakness and
diplopia with rightward vision. MRI was suggestive of
leptomeningeal spread of her lung cancer, confirmed by LP. She
started dexamethasone with a taper completed on [**2159-3-27**] and XRT
to the brain and spine, completed on [**2159-3-7**].
Social History:
The patient lived in [**Location 686**] with her husband until her
recent admission for weakness since when she has been residing
at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Prior to that she had recently completed
training to become a counselor. She previously smoked a half
pack per day but none for the past month. She has no children of
her own, but four stepchildren who visit often.
Family History:
No family history of lung cancer or other malignancy.
Physical Exam:
Vitals: T 94.6, BP 118/64, RR 18, HR 123, O2 Sat 100% on 4L NC
Gen: frail appearing middle aged woman huddled under
bear-hugger, shivering
HEENT: dry mucous membranes, oropharynx clear
Cardiovascular: regular rate and rhythm, tachycardic, no murmurs
Lungs: clear bilaterally
Back: 2 cm x 2 cm open ulcer just superior to the coccyx, packed
with gauze, moderate amount of white discharge, tender to
palpation, no surrounding erythema or crepitus
Abdomen: nondistended. Tender to palpation diffusely in the
periumbilical and epigastric region. No rebound or guarding.
Extremities: 1+ pitting edema up to the ankles, distal pulses
present, R posterior thigh with mirapex bandage in place
Neuro: 2/5 strength of lower extremities in proximal and distal
muscle groups bilaterally, sensation to light touch intact. [**3-27**]
strength of the upper extremities bilaterally. Cranial nerves
[**1-4**] intact with the exception of R lateral gaze palsy.
Pertinent Results:
Admission labs:
[**2159-4-2**] 10:35AM WBC-4.1 RBC-3.21* HGB-10.8* HCT-32.2*
MCV-101* MCH-33.7* MCHC-33.6 RDW-14.4
[**2159-4-2**] 10:35AM NEUTS-87* BANDS-3 LYMPHS-9* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2159-4-2**] 10:35AM GLUCOSE-78 UREA N-18 CREAT-0.8 SODIUM-130*
POTASSIUM-7.0* CHLORIDE-88* TOTAL CO2-29 ANION GAP-20
[**2159-4-2**] 10:35AM ALT(SGPT)-32 AST(SGOT)-48* CK(CPK)-91 ALK
PHOS-159* TOT BILI-0.4
[**2159-4-6**] 07:50AM BLOOD WBC-5.9 RBC-2.92* Hgb-9.1* Hct-28.2*
MCV-96 MCH-31.2 MCHC-32.3 RDW-16.1* Plt Ct-104*
[**2159-4-11**] 06:15AM BLOOD WBC-8.8 RBC-2.73* Hgb-9.1* Hct-27.1*
MCV-99* MCH-33.3* MCHC-33.5 RDW-16.1* Plt Ct-189
[**2159-4-8**] 08:00AM BLOOD PT-13.0 PTT-30.5 INR(PT)-1.1
[**2159-4-10**] 06:50AM BLOOD Glucose-91 UreaN-8 Creat-0.7 Na-137 K-4.0
Cl-98 HCO3-30 AnGap-13
[**2159-4-2**] 10:20PM BLOOD ALT-18 AST-17 LD(LDH)-149 CK(CPK)-34
AlkPhos-116 TotBili-0.2
[**2159-4-9**] 07:10AM BLOOD CK-MB-6 cTropnT-0.08*
[**2159-4-9**] 04:05PM BLOOD CK-MB-6 cTropnT-0.07*
[**2159-4-10**] 06:50AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.8
[**2159-4-4**] 04:40AM BLOOD Hapto-410*
[**2159-4-2**] 11:35AM URINE RBC-[**10-12**]* WBC-21-50* Bacteri-MOD
Yeast-NONE Epi-0 TransE-[**1-25**]
[**2159-4-2**] 11:35AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD
[**2159-4-2**] 11:35AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2159-4-9**] 09:13AM URINE RBC-<1 WBC-10* Bacteri-FEW Yeast-NONE
Epi-0
[**2159-4-9**] 09:13AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
MICRO
Blood cx and urine cx all NGTD
IMAGING
LUE US IMPRESSION: No evidence for DVT.
CXR [**4-2**] FINDINGS: In comparison with the study of [**2158-10-11**],
there is little change in
the appearance of the heart and lungs. Post-surgical changes at
the lung base
and apparent fibrotic streak in the left mid zone are both less
prominent.
Old healed rib fracture on the right is again seen.
CXR [**4-9**]:
FINDINGS: In comparison with the study of [**4-2**], there is little
change and no evidence of acute focal pneumonia. Post-surgical
changes are again seen at the left base and there is evidence of
old healed rib fractures on the right.
CT Torso [**4-2**]:IMPRESSION:
1. New large right sacral subcutaneous gas tracking anteriorly
along the
puborectalis muscle, this finding needs to be clinically
correlated. Air
tracks to the coccyx.
2. No evidence of pulmonary embolism.
3. Left axillary nodule, left paratracheal nodule, and left
paraspinal lesion are all similar in size. Multiple pulmonary
nodules are redemonstrated, though some appear new.
4. Striated left renal nephrogram, which may indicate
pyelonephritis in the appropriate clinical context, recommend
comparison with urinalysis.
5. Very Large amount of stool throughout the rectum and colon.
6. Persistent left adnexal hyperdensity, recommend comparison
with pelvic
ultrasound if clinically indicated.
Brief Hospital Course:
A 50-year-old woman with metastatic lung cancer and lower
extremity weakness secondary to leptomeningeal spread presents
with hypotension, hypothermia.
.
# Hypotension and hypothermia: Most likely secondary to sepsis.
Source suspected as below. She was responsive to fluid boluses,
with MAP >65 and did not require CVP monitoring or pressors. She
had one episode of hypotension with mild lightheadedness on the
floor with SBP 80s which repsonded to 1L fluid bolus. She was
normotensive with baseline SBP 90s prior to discharge. We
continued to hold her lisinopril given persistent low BPs
# Urinary tract infection: Most likely source of septic picture.
UA with moderate bacteria, 21-50 WBC. Clinical signs of
pyelonephritis. She has a chronic indwelling Foley that likely
contributed. Regarding the likely microbiology, she recently had
a pan-sensitive E Coli during her previous admission that was
treated with 3 days of Bactrim. However, given recent
hospitalization and long-term care facility wtih indwelling
catheter, she is also at risk for resistant micro-organisms.
She was initially covered with Zosyn. Foley catheter was changed
(reportedly had not been done at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] in 5 weeks).
Cultures showed mixed bacterial flora. Antibiotics were changed
to levofloxacin and she remianed afebrile and hemodynamically
stable on levofloxacin alone. She has to complete 4 days of 14
day course.
.
# Sacral Decubitus Ulcer: Contributing factors including
prolonged immobilization with lower extremity paresis, recent
XRT, and recent steroid use. There was initially concern for
necrotizing fasciitis given air tracking along puborectalis on
CT abdomen. Surgery recommended that urgent surgical debridement
was not indicated. Wound does appear to have an infectious
component, and would be concern for resistant bacteria given
recent hospitalization and LTC facility but cx were all no
growth so vanco was discontinued. Dressings were changed as per
surgery with duoderm to sacral wound eschar, wet-dry packing
within wound itself. Plastics was considering a skin flap, but
after discussion decided against it. Wound care recs included in
DC planning as recommended.
.
# Abdominal pain: Chronicity was difficult to tease out, but
most likely cause is pyelonephritis. Possible contribution from
constipation. CT abdomen did not show any acute intra-abdominal
process. She was given a bowel regimen and pain was managed
aggressively once blood pressure recovered.
.
# Anemia: discharge hematocrit was 41 one month ago, fell to 32
on admission and as low as 21 later that evening. Likely
contribution from bone marrow suppression secondary to recent
XRT and widespread cancer. Concern for bleeding, although no
evidence of such on CT torso. Hemolysis unlikely given normal
Tbili and elevated hapto. She received 1 unit pRBC with a more
than adequate bump in her Hct, raising the possibility that the
Hct 21 was not real. Hct subsequently fell again. She received
another unit of pRBC. Repeat hemolysis labs showed no evidence
of hemolysis. HCT subsequently remained stable around 26-28.
.
# Hypoxia: Unclear etiology. Resolved over the first 12 hours
of admission.
.
# LUE swelling: Pt noted to have mild LUE edema on exam. LUE US
negative for DVT.
.
# Chest tightness: Pt c/o chest wall tightness intermittently
which was constant and worse with movement. She has focal chest
wall tenderness left chest wall/rib cage where lidocaine patch
is and where she has ahd pain in the past. ECG unchanged from
prior with q waves II, II, AVF. Felt unlikely to be cardiac
since reproducible on exam and ECG without acute changes.
Continued lidoderm patch and she had no further complaints.
Biomarkers showed stable troponin and normal CK and MB.
.
# Metastatic NSCLC c/b near paralysis and multifocal pain:
Patient currently with good pain control now back on home
regimen and with MS contin increased to TID dosing. Continued
PO dilaudid for breakthrough pain. She was seen by palliative
care here and discussions were started about hospice care. She
should continue to be seen by hopice for discussions of
palliative care at nursing facility. For malnutrition, she was
continued on dronabinol and ensure supplements.
Medications on Admission:
Folic Acid 1 mg daily
MS Contin 60 mg [**Hospital1 **]
hydromorphone 4-8 mg q4h PRN
mylanta 30 cc q4h PRN
nicotine patch 14 mg daily
vitamin b12 1000 mcg daily
marinol 2.5 mg [**Hospital1 **]
heparin SC 5000 Units SC daily
nefazodone 200 mg daily
fleet enema PRN
bisacodyl PRN
lorazepam 1 mg daily PRN
MOM PRN
ibuprofen PRN
senna PRN
ondansetron PRN
dexamethasone taper completed [**2159-3-27**]
PEG PRN
prilosec 20 mg daily
MVI
Vit D3 400 IU [**Hospital1 **]
acetaminophen PRN
proair HFA 2 puffs q6h PRN
promethazine 25 mg PRN
.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q8H (every 8 hours).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB or
wheeze.
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. B-12 DOTS 500 mcg Tablet Sig: Two (2) Tablet PO once a day.
11. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
13. Nefazodone 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q 24 HOURS ().
17. Promethazine 25 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for nausea.
18. Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
19. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days. Tablet(s)
21. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
22. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn, gas
pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnosis
Sepsis secondary to UTI vs pyeloneprhitis
Sacral pressure ulcer
Secondary Diagnosis
Metastatic Non Small cell Lung Cancer
Chronic pain
Depression
Discharge Condition:
hemodynamically stable, SBP 90s-100s, O2 sats 90s room air, HR
90s
Discharge Instructions:
You were admitted to the hospital with low blood pressure,
likely from a urinary tract infection. We treated you with an
antibiotic called levofloxacin and stopped your lisinopril and
your blood pressure improved.
We made the following changes to your medications:
1. We increased your MS Contin to three times daily
2. We added levofloxacin for 14 days (4 more days)
3. Your lisinopril was stopped secondary to low blood pressure
Please return to the ER or call your primary oncologist if you
develop lighthededness, dizziness, chest pain, shortness of
breath, or any other concerning symptoms.
Followup Instructions:
You have the following appointmetns scheduled.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5778**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2159-4-26**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2159-4-26**]
10:30
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2159-4-30**]
8:35
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21,413
| 139,625
|
45363
|
Discharge summary
|
report
|
Admission Date: [**2168-10-7**] Discharge Date: [**2168-10-9**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 80-year-old
gentleman with multiple medical problems including coronary
artery disease, peripheral vascular disease, hypertension,
chronic renal insufficiency, hypercholesterolemia, anemia,
with a recent admission for congestive heart failure and new
onset atrial fibrillation, failed cardioversion times two,
and received biventricular pacemaker, and recently started on
Coumadin. Since his last hospitalization the patient has
been feeling weak and has noticed black stools.
He was initially admitted to the Medical Intensive Care Unit
on this admission and transferred out to the floor on
[**2168-10-8**]. He [**Year (4 digits) **] any syncope, falls, bright red
blood per rectum, or a history of gastrointestinal problems
prior to this admission. He said that he had been feeling
weak since he was discharged in [**2168-7-26**] and has noticed
several black stools on the days prior to admission. He says
he uses aspirin once per day for cardiac protection, but he
[**Year (4 digits) **] any other nonsteroidal antiinflammatory drug use. He
[**Year (4 digits) **] any abdominal pain, nausea, or vomiting.
He was initially admitted to the Medical Intensive Care Unit
from to the Emergency Department on [**2168-10-7**] after
he was noted to have a hematocrit of 22 (down from his
baseline of 30). A nasogastric lavage in the Emergency
Department was negative, and he received vitamin K and fresh
frozen plasma and was sent to the Medical Intensive Care
Unit. He received a total of two units of fresh frozen
plasma, vitamin K, and three units of packed red blood cells,
Protonix 40 mg twice per day and was seen by Gastrointestinal
in the Medical Intensive Care Unit.
He had an esophagogastroduodenoscopy on [**10-8**] which
showed nodularity and petechiae in the esophagus, antral
erosions in the stomach; consistent with aspirin and
nonsteroidal antiinflammatory drug induced erosive
gastropathy. Erosions in the distal bulb of the duodenum.
It was recommended that serum Helicobacter pylori serologies
be checked and a repeat esophagogastroduodenoscopy be done in
five to eight weeks. His aspirin was discontinued. Per
Gastrointestinal, it was felt appropriate to restart his
Coumadin in approximately three to four days after discharge
and to continue Protonix 40 mg by mouth twice per day
indefinitely.
There were no other problems in the Medical Intensive Care
Unit, and his hematocrit rose after the transfusions, and he
was hemodynamically stable. Therefore, it was felt
appropriate to transfer him out to the regular Medicine
Service.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
(a) Status post cardiac catheterization in [**2167**].
(b) Status post right coronary artery percutaneous
transluminal coronary angioplasty and stent.
2. Congestive heart failure (with an ejection fraction of
20%).
3. Peripheral vascular disease; status post arthrectomy.
4. Carotid stenosis; status post carotid endarterectomy in
[**2163**].
5. Hypertension.
6. Hypercholesterolemia.
7. Chronic renal insufficiency.
8. Renal artery stenosis.
9. Nephrolithiasis.
10. Anemia.
11. History Bell's palsy.
12. Gout.
13. History of femoral-popliteal bypass and aortofemoral
bypass.
14. Status post biventricular pacemaker placement in [**2168-9-26**].
15. Atrial fibrillation.
16. Hypothyroidism.
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: Mr. [**Known lastname **] [**Last Name (Titles) **] any alcohol use. He reports
a 50-pack-year smoking history and says he quit 20 years ago.
He lives at home with his wife. [**Name (NI) **] [**Name (NI) **] any other drug
use.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER: (From the Medical Intensive Care
Unit)
1. Protonix 40 mg by mouth twice per day.
2. Gemfibrozil 600 mg by mouth once per day.
3. Lipitor 10 mg by mouth once per day.
4. Nortriptyline 10 mg by mouth q.h.s.
5. Amiodarone 200 mg by mouth once per day.
6. Allopurinol 300 mg by mouth once per day.
7. Synthroid 25 mcg by mouth every day.
8. Ambien 5 mg by mouth q.h.s.
9. Tylenol by mouth as needed.
10. Metoprolol 12.5 mg by mouth twice per day.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs of a temperature of 97.8 degrees
Fahrenheit, his blood pressure was 150/82, his heart rate was
79, his respiratory rate was 20, and his oxygen saturation
was 99% on room air. In general, Mr. [**Known lastname **] was alert and
oriented times three. In no acute distress. He was very
pleasant. Head, eyes, ears, nose, and throat examination
revealed no scleral icterus. His pupils were equally round
and reactive to light. His extraocular muscles were intact.
There was no conjunctival pallor. His oropharynx revealed
the mucous membranes were moist. There were no lesions or
exudates. His cardiovascular examination revealed a 2/6
systolic ejection murmur heard best at left upper sternal
border. His had normal first heart sounds and second heart
sounds. His lungs were clear to auscultation bilaterally.
His abdomen was soft, nontender, and nondistended. He had no
palpable hepatosplenomegaly. He had a well-healed midline
scar. Extremity examination revealed no evidence of
clubbing, cyanosis, or edema. His pulses were 2+ and
symmetric.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on transfer revealed a complete blood count with a white
blood cell count of 7.7, his hematocrit was 28.6, his mean
cell volume was 90, and his platelets were 354. His
prothrombin time was 14.7, and his INR was 1.4, and his
partial thromboplastin time was 28.7. Chemistries revealed
his sodium was 138, potassium was 4.3, chloride was 105,
bicarbonate was 20, blood urea nitrogen was 48, and his
creatinine was 2.4 (up from his baseline of 2). He had
Helicobacter pylori serologies pending from his
esophagogastroduodenoscopy.
PERTINENT RADIOLOGY/IMAGING: Of note, an echocardiogram in
[**2168-7-26**] revealed an ejection fraction of less than 25%,
left atrial mild dilation, 1+ aortic regurgitation, 1+ mitral
regurgitation, and severe global left ventricular
hypokinesis.
His esophagogastroduodenoscopy on [**2168-10-8**] revealed
no blood in the stomach, small prepyloric benign ulcerations
with no evidence of active bleeding, small duodenal
ulcerations, and mild diffuse gastritis. In the middle third
of the esophagus was noted patchy nodularity and petechiae of
the mucosa with a stigmata of recent bleeding. This was also
noted in the lower third of the esophagus. It was remarked
that this was likely due to his nasogastric tube but should
be re-evaluated with a repeat endoscopy in five to eight
weeks.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: While on
the Medicine Service.
1. GASTROINTESTINAL ISSUES: Given his history of upper
gastrointestinal bleed and admission to the Medical Intensive
Care Unit, the patient was followed by the Gastrointestinal
Service when he came out to the floor. He was
hemodynamically stable the whole time, and his stools
remained occult-blood positive. This was felt likely to be
secondary to continued passage of the blood that he had bled
before. There seemed to be no other signs of rebleeding.
He was continued on his Protonix 40 mg by mouth twice per
day. His aspirin was discontinued, and he was advised that
he was never to take aspirin again. His hematocrit and
coagulations were followed when he came to the floor, and his
hematocrit remained stable in the 28 to 30 range until the
day of discharge. It was felt safe to discharge him home on
[**2168-10-9**]. He had a repeat endoscopy scheduled with
Gastroenterology prior to discharge.
As an outpatient, the patient was never to use nonsteroidal
antiinflammatory drugs or aspirin again. He was to be
continued on his Protonix 40 mg by mouth twice per day, and
he was to have a repeat endoscopy in five to eight weeks; as
scheduled per Gastroenterology. He was allowed to restart
his Coumadin on the Tuesday after discharge.
2. CARDIOVASCULAR ISSUES: The patient has a history of
congestive heart failure with an ejection fraction of less
than 25%. He was continued on his beta blocker and Lasix as
needed once he came to the medicine floor. It was felt
appropriate at this time to restart his beta blocker given
the stability of his blood pressure and his hematocrit and no
further evidence of bleeding.
He also has a history of recent new onset atrial
fibrillation; status post biventricular pacemaker placement.
He was continued on his amiodarone, and his Coumadin was held
in the setting of a recent gastrointestinal bleed. Per
Gastroenterology, he was to restart his Coumadin on the
Tuesday after discharge. There was no evidence of atrial
fibrillation while he was admitted.
He also has a history of coronary artery disease and ruled
out for a myocardial infarction on admission to the Medical
Intensive Care Unit. He was continued on his beta blocker.
His aspirin was to be held indefinitely. He was continued on
his Lipitor at 10 mg by mouth once per day. He was also
transfused for a hematocrit of less than 30 in the setting of
coronary artery disease.
Lastly, the patient also has a history of hypertension. Once
he came to the floor, he was continued on his metoprolol 12.5
mg by mouth twice per day. His other hypertensive
medications had been held in the Medical Intensive Care Unit
and were restarted on discharge. This included hydralazine
10 mg by mouth q.6h.
3. PULMONARY ISSUES: The patient has a history of
congestive heart failure, as previously mentioned, with an
ejection fraction of less than 25%. He was given Lasix with
transfusions in the Medical Intensive Care Unit with no
evidence of pulmonary edema or hypoxia.
4. RENAL ISSUES: The patient has a history of chronic renal
insufficiency, and on transfer to the floor his creatinine
was 2.4. It was felt that this was most likely due to
hypovolemia in the setting of a gastrointestinal bleed.
After looking back over old records, it was realized that
this was his baseline creatinine and no further investigation
was necessary.
5. ENDOCRINE ISSUES: Due to his history of hypothyroidism,
the patient's was continued on Synthroid. No thyroid
function tests were tested on this admission.
6. MUSCULOSKELETAL ISSUES: The patient was seen by Physical
Therapy prior to discharge who felt that he was strong and
safe to go home on his own.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed; likely secondary to erosive
gastropathy.
2. Coronary artery disease.
3. Congestive heart failure.
4. Hypertension.
5. Hypercholesterolemia.
6. Chronic renal insufficiency.
7. Anemia.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg by mouth twice per day.
2. Gemfibrozil 600 mg by mouth once per day.
3. Lipitor 10 mg by mouth once per day.
4. Nortriptyline 10 mg by mouth q.h.s.
5. Amiodarone 200 mg by mouth once per day.
6. Allopurinol 300 mg by mouth once per day.
7. Synthroid 25 mcg by mouth every day.
8. Ambien 5 mg by mouth q.h.s.
9. Metoprolol 12.5 mg by mouth twice per day.
10. Isordil 10 mg by mouth three times per day.
11. Hydralazine 10 mg by mouth q.6h.
12. Coumadin (to be restarted on the Tuesday after
discharge).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his primary
care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) in one week.
2. The patient was also to have a repeat endoscopy in five
to eight weeks after discharge which has been scheduled by
Gastroenterology.
3. The patient was strictly instructed never to use aspirin
or nonsteroidal antiinflammatory drugs again.
4. The patient was instructed to continue his Protonix 40 mg
by mouth twice per day indefinitely.
5. The patient was instructed to restart his Coumadin on the
Tuesday after discharge, with INR checks and followup per Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
6. The patient had serum Helicobacter pylori serologies
checked at his endoscopy which were to be followed up for
proper treatment if necessary by Gastroenterology.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 14268**]
MEDQUIST36
D: [**2168-10-19**] 20:56
T: [**2168-10-22**] 14:25
JOB#: [**Job Number 96855**]
|
[
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"578.1",
"244.9"
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icd9cm
|
[
[
[]
]
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[
"45.13"
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icd9pcs
|
[
[
[]
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10882, 11423
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11456, 12601
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6906, 10610
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121, 2716
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3868, 6872
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2739, 3485
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,232
| 173,423
|
38143
|
Discharge summary
|
report
|
Admission Date: [**2132-5-30**] Discharge Date: [**2132-6-3**]
Date of Birth: [**2055-3-15**] Sex: M
Service: MEDICINE
Allergies:
Nitroglycerin
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
A-line placement
History of Present Illness:
77 yo s/p repair of ascending aortic aneurysm vs type A
disection [**2115**], HTN, HLD, CAD (non obstructive [**2122**]) who
presents with acute onset of worsening shortness of breath.
.
Patient states that on the morning of [**5-29**] he awoke and felt
short of breath when walking to the bathroom. He noted wheezing
and had to stop and catch his breath. He felt very short of
breath while showering and his wife made him come to the
hospital. He denies chest pain during this time. No new back
pain besides chronic low back pain. No dizziness, palpitations,
orthopnea, fever, chills. No recent travel or prolonged periods
of immobility.
.
Of note patient does occasionally have difficulty with feeling
short of breath with acitivity. Which has been going on for a
longer period of time. Also, he notes occasionally waking from
sleep short of breath. He denies having to increase number of
pillows he is sleeping on.
.
In the emergency department CTA was performed given history of
aortic aneurysm. CTA revealed acute versus acute on chronic Type
B Aortic [**Date Range **]. EKG unchanged from prior. Vascuar consulted
given above noted finding.
.
In the vascular ICU patients blood pressure was controlled with
Captopril 70mg TID, Hydralazine 25mg Q6H, Nifedipine CR 120mg
Daily, Hyralazine 20mg IV PRN, and Nicardipine gtt. On the
evening of transfer to the CCU the nicardipine gtt had been off
for approx 8 hours with stable blood pressures <140. Patient was
evaluated by both vascular and cardiac surgery (Dr. [**Last Name (STitle) 914**] who
did not feel that he was an operative candidate at this time
given need for open repair.
.
On evaluaton evening of [**5-31**] patient felt that his breathing was
much better and noted no chest or back pain.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: coronary artery disease (Cath [**5-/2123**], non
obstructive CAD [**6-12**]- negative 'mibi' stress test)
3. OTHER PAST MEDICAL HISTORY:
--s/p repair of ascending aortic aneurysm vs disection [**2115**]
--obesity
--paraesophageas hernia
--sleep apnea (noncompliant on CPAP)
--renal insufficiency (baseline creatinine 1.6-1.7)
--diverticulosis
--chronic back pain
--hematuria
--benign prostatic hypertrophy
--vertigo
Social History:
Retired constructon worker, Bus Driver. Married with 6 children.
- Tobacco history: None
- ETOH: None
- Illicit drugs: None
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: died when he was 13-14 unclear cause
- Father: unknown
Physical Exam:
On Admission:
PHYSICAL EXAMINATION:
VS: BP=123/52 HR=80 RR=15 O2 sat= 98%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dentures in place on
top.
NECK: Left EJ. JVP not elevated.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No
S3/S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
On Discharge:
Gen: A/O, NAD, sitting in chair
HEENT: supple, no JVD
CV: RRR, no M/R/G, sternotomy scar
RESP: CTAN post, no crackles
ABD: soft, NT, ND
EXTR: trace peripheral edema
NEURO: A/O
Extremities: trace pitting peripheral edema
Pulses: palp bilat
Right:
Left:
Skin: intact
Pertinent Results:
On Admission:
[**2132-5-29**]
CBC: WBC-7.2 Hgb-13.4* Hct-39.3* MCV-93 Plt Ct-241
BMP: Glucose-90 UreaN-17 Creat-1.5* Na-143 K-3.9 Cl-107 HCO3-25
AnGap-15
Calcium-9.4 Phos-3.5 Mg-2.6
Coags: PT-14.2* PTT-25.2 INR(PT)-1.2*
[**2132-5-30**]
D-Dimer-5647*
ABG: pO2-101 pCO2-28* pH-7.50* calTCO2-23 Base XS-0
cTropnT-<0.01
On Discharge:
[**2132-6-3**]
CBC: WBC-6.6 Hgb-12.3* Hct-36.0* MCV-91 Plt Ct-211
BMP: Glucose-95 UreaN-16 Creat-1.6* Na-141 K-3.9 Cl-108 HCO3-25
AnGap-12
Calcium-9.1 Phos-2.4* Mg-2.5
.
Other Results:
-CTA Chest ([**2132-5-29**]): IMPRESSION: Thoracic aorta [**Year (4 digits) **]
involving the descending aorta distal to the suture lines from
prior aortic [**Year (4 digits) **] repair, with posterolateral extent
extending to the superior aspect of the celiac axis with imaging
characteristics suggesting acute [**First Name7 (NamePattern1) 11916**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]; however,
true chronicity cannot be determined due to lack of prior images
for comparison.
.
-CXR ([**2132-5-30**]): Widened mediastinum. PICC ends in Right
Atrium.
.
-Lower Extremity Dopplers ([**2132-5-30**]): No evidence of DVT in
either leg
.
- ECG( [**2132-5-29**]): Sinus 56, LAD, PR prolongation, RBBB, TWI
precordial leads v1-v6 stable from prior.
.
- ECHO ([**2132-5-30**]): The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic (EF 75%). Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is no pericardial effusion.
Brief Hospital Course:
77 yo s/p repair of type A [**Year (4 digits) **] in [**2115**], HTN, ?CAD (non
obstructive [**2122**]) who presented with acute onset of worsening
shortness of breath and was found to have a type B aortic
[**Year (4 digits) **].
.
ACTIVE DIAGNOSES:
# Type B Aortic [**Year (4 digits) **]: On presentation to the ED, CT scan
was performed showing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11916**] Type B [**Last Name (NamePattern4) **]. In the
vascular ICU patients blood pressure was controlled with
Captopril 70mg TID, Hydralazine 25mg Q6H, Nifedipine CR 120mg
Daily, Hyralazine 20mg IV PRN, and Nicardipine gtt. On the
evening of transfer to the CCU the nicardipine gtt had been off
for approx 8 hours with stable blood pressures <140. Patient was
evaluated by both vascular and cardiac surgery (Dr. [**Last Name (STitle) 914**] who
did not feel that he was an operative candidate at this time
given need for open repair. In the CCU and on the floor, pt
remained stable and asymptomatic. His blood pressure medications
were titrated to maintain SBP goal of less than 140. The
patient's blood pressure was optimized and adjusted prior to
discharge to include nifedipine 60 mg qd, lisinopril 40 mg qd
(changed from home captopril TID) and metoprolol XL 100 mg qd.
.
# Shortness of Breath: Pt presented with acute onset of
shortness of breath the morning of admission. ABG at the time
showed respiratory alkalosis. D-Dimer was elevated but lower
extremity dopplers showed no evidence of DVTs and CT showed no
indication of PE. Etiology of dyspnea unclear at this time. No
signs of infection on physical exam or imaging. No clinical
evidence of heart failure though ECHO shows diastolic
dysfunction. Given pt's history sleep apnea and history of non
compliance with CPAP, pulmonary HTN could also be contributing.
Deconditioning also possible. Shortness of breath improved over
the course of [**Hospital **] hospital stay. Recommend PFTs as an outpt for
further characterization of his dyspnea.
.
CHRONIC DIAGNOSES:
# CAD: Pt has a questionable history of CAD given his cath in
[**2122**] did not show signs of obstructive disease and his [**2127**]
stress test was negative. However, pt was taking full-strength
ASA daily, which was continued during his hospitalization.
.
# Chronic Renal Insufficiency: Stable. (Cr 1.5-1.6)
.
# Sleep Apnea: Stable. Pt is non-compliant with CPAP.
.
# HLD: Stable. Continued Pravastatin.
.
# BPH: Stable. Continued tamsulosin.
.
TRANSITIONAL ISSUES:
1. hypertension: During this patients hospital course, his blood
pressure regimen was adjusted from previous home medications. He
is now taking lisinopril instead of captopril, lower dose
nifedipine and metoprolol was added. He will need blood pressure
follow up and possible further modifications.
2. SOB: would recommend outpatient PFTs to further define the
etiology of his SOB
3. pending labs include pending final result of blood cultures
from [**5-30**] (NGTD)
Medications on Admission:
--nifedipine CR 60mg daily
--pravastatin 40mg daily
--captopril 50 mg three times daily
--zolpidem 5mg at bedtime as needed
--tamsulosin 0.4mg daily
--meclizine 12.5mg three times daily as needed
--albuterol MDI [**12-9**] inhalations every 4-6 hours as needed
--aspirin 325 mg daily
--Nexium 40 mg daily
--Zolpidem 5 mg po at hs prn insomnia
Discharge Medications:
1. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for dizziness.
7. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Dissecting Aortic Aneurysm
Hypertension
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had trouble breathing and a CT scan of your torso showed
another aortic aneurysm with some bleeding around the vessel. We
think this has developed over a weeks to months and plan to
surgically repair this in the next few weeks. The plan is to
control your blood pressure and heart rate for now. You will
need to have a stress test and an ultrasound to look for
blockages in the arteries in your neck. You will also have some
breathing tests done. All these tests will be done to make sure
you will do well in surgery. It is very important that you go to
all of your follow up appts. Please call Dr. [**Last Name (STitle) 36055**] if you
develop weakness, fatigue, dizziness, abdominal pain, trouble
breathing or any other unusual symptoms.
Please check your blood pressure at home twice daily and call
Dr. [**Last Name (STitle) 36055**] if your blood pressure top number is more than 160
for more than one [**Location (un) 1131**].
.
We made the following changes to your medicines:
1. Decrease nifedipine to 60 mg daily
2. Decrease the aspirin to 81 mg daily
3. STOP taking Captopril, take Lisinopril instead to lower your
blood pressure
4. START Metoprolol to lower your heart rate and your blood
pressure.
5. START Pantoprazole to treat your heartburn
Followup Instructions:
Department: CARDIAC SURGERY
When: TUESDAY [**2132-6-24**] at 2:00 PM
With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) **]
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 43431**]
Appt: [**6-4**] at 5pm
Location: [**Location (un) 2274**]-[**Location (un) **], Cardiology Testing
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Appt: [**6-10**] at 7:30am
NOTE: This appt is for a cardiology stress test. You may also
need a regular follow up appt in cardiology as well. The office
will call you within 24 hours to let you know if any other appt
is needed. Also, a packet of information will be mailed to you
discussing how to prepare for this test. IF you have any
questions, please call the office at number above.
Department: VASCULAR SURGERY
When: THURSDAY [**2132-6-19**] at 9:15 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2132-6-4**]
|
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icd9cm
|
[
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[]
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14,987
| 165,426
|
4082
|
Discharge summary
|
report
|
Admission Date: [**2150-11-13**] Discharge Date: [**2150-12-4**]
Date of Birth: [**2096-9-3**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Penicillins / Lipitor
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
right knee pain/swelling
Major Surgical or Invasive Procedure:
S/P hardware removal of right knee and space immobilizer
placement
History of Present Illness:
This 54 year old with history of DM, HTN s/p total knee
replacement presenting with acute worsening of right knee pain.
He reports fevers at home and not feeling himself. His wife
noted that he had some slurring of his speach at home which she
felt was due to how dry he was. He reports that he has had this
knee pain for three days and has been unable to bear any weight.
He had a fever at home to 102 the day before yesterday. He has
had no chest pain, no shortness of breath, no belly pain, no
urinary symptoms. He also noted that his blood sugars had been
very difficult to control.
In the ED Ortho tapped his knee and got 70 cc of purulent
fluid. He was hypotensive to 70/45 so the sepsis protocol was
initiated. He was given Vanco, Levofloxacin, and started on an
Insulin drip. He was also given 6 liters NS and Levophed was
started peripherally. On transfer up here he had continued knee
pain, no chest pain or shortness of breath. His BP remained
with SBP in the 90-110s.
.
During his stay in the MICU, was found to have positive blood,
urine, and knee joint aspirate cultures for MSSA on [**11-13**].
Blood cultures grew out 6/6 bottles. His MAP was supported with
fluid boluses and levophed for goal MAP>60. His levophed was
eventually titrated off, his lactate trended down, and his WBC
count trended downward as well. An echo (TTE) was performed
that did not show any masses or vegetations. IV Vanc and Gent
were continued. He was transferred to the [**Hospital Unit Name 153**] for surgical
management of his R knee, removal of hardware/potential source
of sepsis. On arrival to [**Hospital Unit Name 153**], c/o right knee pain and RUQ
pain. VSS. Sepsis greatly resolved, normal WBC ct, afebrile,
hypertensive. With elevated total bili with elevated direct
bili, clinical jaundice. RUQ ultrasound with dopplers neg for
portal vein thrombosis, pos for gallstones and mild gall bladder
wall edema, poss [**3-4**] underlying liver ds, no biliary ductal
dilitation, diffuse nodularity of liver c/w cirrhosis,
splenomegaly. Pt with known h/o hep C, untreated, and alcoholic
cirrhosis. His amylase and lipase were not elevated, and his
LFTs are only slightly elevated. Liver was consulted, and it
was felt to be not optimal at this time to take him to the OR,
given that his sepsis has largely resolved/held at bay with IV
antibiotics, no emergent need to take to OR. Orthopedics aware
and would like to be notified when pt is stable from LIver
standpoint on the medical floor to go for surgery.
Also, for his antiobiotic therapy, he underwent Cefazolin
desensitization upon arrival to [**Hospital Unit Name 153**], and is to continue this
for 6 weeks per ID recommendations. He will need placement of a
PICC line and this was ordered today.
Past Medical History:
1. DM
2. HTN, baseline BP is 200
3. total knee replacement
4. Chronic knee pain
5. Asthma
6. H/O drug abuse
7. COPD
8. Alcoholic hepatitis
9. Hepatitis C
10. Osteoarthritis
Social History:
Lives with wife, smokes a pack a day but reports he has not
smoked in 6 days, drinks a 12 pack of beer a day but reports he
has not had any EtOH in [**6-5**] days
Family History:
No CAD or cancer
Physical Exam:
Temp 95.4 Pulse 66, BP 96/53, RR 18, Satting 98% on RA
Gen: alert, oriented, cooperative male slightly sedated from
pain medication in NAD
HEENT: MM dry, anicteric sclera, PERRL
Lungs: clear to auscultation bilaterally, no crackles or wheezes
CV: RRR, nl S1S2, no murmers
Abd: obese, soft, non tender, liver approx 12 cm, smooth
Ext: no edema, left knee warm and tender to palpation on lateral
aspect.
Skin: no rashes
Neuro: grossly intact
Pertinent Results:
[**2150-11-13**] 09:58AM SED RATE-103*
[**2150-11-13**] 09:58AM PLT SMR-LOW PLT COUNT-142*
[**2150-11-13**] 09:58AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2150-11-13**] 09:58AM NEUTS-76* BANDS-8* LYMPHS-6* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-4*
[**2150-11-13**] 09:58AM WBC-9.4# RBC-3.30* HGB-11.4* HCT-34.5*
MCV-105* MCH-34.4* MCHC-32.9 RDW-12.0
[**2150-11-13**] 09:58AM CRP-235.3*
[**2150-11-13**] 09:58AM CALCIUM-9.5 PHOSPHATE-4.1 MAGNESIUM-1.7
[**2150-11-13**] 09:58AM LIPASE-11
[**2150-11-13**] 09:58AM ALT(SGPT)-71* AST(SGOT)-80* ALK PHOS-74
AMYLASE-12 TOT BILI-3.6*
[**2150-11-13**] 09:58AM GLUCOSE-524* UREA N-40* CREAT-1.9*
SODIUM-130* POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-16* ANION
GAP-25*
[**2150-11-13**] 10:09AM LACTATE-6.8*
[**2150-11-13**] 10:29AM LACTATE-5.8*
[**2150-11-13**] 10:29AM TYPE-ART TEMP-37.1 O2 FLOW-4 PO2-86 PCO2-29*
PH-7.36 TOTAL CO2-17* BASE XS--7 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2150-11-13**] 10:30AM JOINT FLUID NUMBER-FEW SHAPE-RHOMBOID
LOCATION-I/E BIREFRI-POS COMMENT-c/w calciu
[**2150-11-13**] 10:30AM JOINT FLUID WBC-[**Numeric Identifier 17951**]* RBC-[**Numeric Identifier 17952**]* POLYS-95*
LYMPHS-2 MONOS-3
[**2150-11-13**] 11:26AM PT-16.6* PTT-28.3 INR(PT)-1.9
[**2150-11-13**] 11:45AM URINE RBC-0-2 WBC->50 BACTERIA-OCC YEAST-NONE
EPI-[**12-20**]
[**2150-11-13**] 11:45AM URINE BLOOD-MOD NITRITE-POS PROTEIN->300
GLUCOSE->1000 KETONE-TR BILIRUBIN-MOD UROBILNGN-4* PH-5.5
LEUK-MOD
[**2150-11-13**] 11:45AM URINE COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025
[**2150-11-13**] 12:40PM GLUCOSE-403* UREA N-39* CREAT-1.8*
SODIUM-130* POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-15* ANION
GAP-21*
[**2150-11-13**] 12:50PM LACTATE-6.2*
[**2150-11-13**] 02:15PM PT-16.9* PTT-30.0 INR(PT)-2.0
[**2150-11-13**] 02:15PM PLT SMR-LOW PLT COUNT-139*
[**2150-11-13**] 02:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2150-11-13**] 02:15PM NEUTS-83* BANDS-3 LYMPHS-3* MONOS-11 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2150-11-13**] 02:15PM WBC-11.7* RBC-2.89* HGB-9.8* HCT-29.6*
MCV-102* MCH-34.0* MCHC-33.2 RDW-11.7
[**2150-11-13**] 02:15PM cTropnT-<0.01
[**2150-11-13**] 02:15PM GLUCOSE-363* UREA N-36* CREAT-1.4* SODIUM-133
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-15* ANION GAP-17
[**2150-11-13**] 02:41PM LACTATE-4.4*
[**2150-11-13**] 03:18PM LACTATE-4.0*
[**2150-11-13**] 04:35PM O2 SAT-96
[**2150-11-13**] 04:35PM LACTATE-3.4*
[**2150-11-13**] 04:35PM TYPE-[**Last Name (un) **]
[**2150-11-13**] 06:00PM HCT-29.3*
[**2150-11-13**] 06:00PM CALCIUM-8.0* PHOSPHATE-2.1*# MAGNESIUM-1.5*
[**2150-11-13**] 06:00PM LD(LDH)-148
[**2150-11-13**] 06:00PM GLUCOSE-335* SODIUM-136 POTASSIUM-3.8
CHLORIDE-105 TOTAL CO2-18* ANION GAP-17
[**2150-11-13**] 06:07PM O2 SAT-73
[**2150-11-13**] 06:07PM LACTATE-2.8*
[**2150-11-13**] 06:07PM TYPE-MIX COMMENTS-GREEN TOP
[**2150-11-13**] 07:09PM O2 SAT-98
[**2150-11-13**] 07:09PM LACTATE-2.4*
[**2150-11-13**] 07:09PM TYPE-ART TEMP-36.3 PO2-114* PCO2-28* PH-7.37
TOTAL CO2-17* BASE XS--7 INTUBATED-NOT INTUBA
[**2150-11-13**] 07:09PM TYPE-ART TEMP-36.3 PO2-114* PCO2-28* PH-7.37
TOTAL CO2-17* BASE XS--7 INTUBATED-NOT INTUBA
[**2150-11-13**] 08:16PM CORTISOL-34.3*
[**2150-11-13**] 08:32PM LACTATE-2.4*
[**2150-11-13**] 09:09PM CORTISOL-45.9*
[**2150-11-13**] 09:33PM CORTISOL-47.1*
[**2150-11-13**] 11:53PM PT-15.9* PTT-27.3 INR(PT)-1.7
[**2150-11-13**] 11:53PM PLT COUNT-171
[**2150-11-13**] 11:53PM WBC-14.0* RBC-3.09* HGB-10.7* HCT-31.4*
MCV-102* MCH-34.5* MCHC-34.0 RDW-13.3
Brief Hospital Course:
54 year old male with history of HTN, Hep C and alcoholic
cirrhosis (Childs C), COPD presenting with MSSA sepsis and
septic arthritis of right knee. Once transferred to the floor,
the patient was continued on supportive care, including IVF and
cefazolin 2gm IV q8hrs for sepsis and desensitization as per
recommended protocol. Patient's mental status was initially
obtunded but gradually improved daily to normal on [**11-23**] as
infection was brought under control (WBC [**Month (only) **] to normal on [**11-24**]
as cefazolin continued), and vital signs stabilized. Blood
cultures on [**11-15**] x 2, [**11-16**] x 2, and [**11-17**] were all negative.
Urine culture [**11-15**] negative, but repeat on [**11-22**] showed yeast.
Repeat urine cx ordered and pending. Likewise, [**11-25**] blood
cultures x 2 also pending. Patient was discontinued from IVF on
[**11-20**] and allowed PO hydration. On [**11-23**] patient had temp spike
to 100.7 and levofloxacin was added. Temperature dropped to
100.1 on [**11-24**] and then to afebrile status thereafter. Liver
team followed patient's course the entire time and initially
recommended delay of surgery given concern over patient's poor
liver fxn and risk of general anesthesia. However, on [**11-23**]
liver team determined risk of mortality during surgery at
approximately 20%, but decided increasing infection risk of
leaving hardware in outweighted risk of surgery. Due to
increasing size of patient's right knee, repeat tap was
performed by ortho but nothing was aspirated. During this time,
ID continued to follow patient as well and became concerned on
[**11-23**] of increasing edema as well as erythema, tenderness, and
warmth of patient's right knee. On [**11-24**] ID recommended stat
hardware removal surgery and full right leg MRI until surgery
could be performed as edema, erythema, tenderness, and warmth
appeared to spread down patient's calf and up to mid-thigh.
Patient was kept NPO and given two units PRBC on [**11-24**] in
anticipation of surgery. On [**11-25**], MRI of right leg was
attempted but unable to be completed due to patient
noncompliance and movement. Patient was taken to OR at
approximately 7pm on [**11-25**] for right knee hardware removal.
.
1. Sepsis: Now greatly resolved. All follow-up cultures
negative, except urine, which revealed yeast, being treated with
7 days of diflucan. Continue cefazolin 2g IV q8 (will need 6
weeks of IV abx at least, per ID recs). Pt will need weekly CBC
and BUN/Cr checks with results faxed to the patient's ID fellow.
The patient will follow up with both ID and ortho in [**5-6**] weeks.
Once ensured that the infection has cleared, the patient will
undergo removal of the knee spacer with subsequent
re-implantation of a functional knee prosthesis.
.
2. Hyperbilirubinemia, clinical jaundice - Bilirubin improving
from a peak of 14.8 on [**11-18**], now down below 3. Likely cause is
cirrhosis from EtOH/Hep C as well as the patient's septicemia.
The patient was followed by the liver team during this
admission, and will follow up with the liver service as an
outpatient. Pt should continue lactulose and Rifamixin, in
addition to Atenolol.
.
3. DM: The patient is currently being managed well on NPH and a
regular insulin sliding scale. This regimen should be continued
throughout the [**Hospital 228**] rehab stay.
.
4. Prophylaxis: The patient is being maintained on heparin SQ
prophylaxis for DVT. The patient is not a good lovenox
candidate due to his history of varices and risk of GI bleeding.
This should be continued at least through the patient's next
orthopedics appointment.
.
5. COPD: The patient was maintained on albuterol inhalers and
nebs during his stay with no problems.
.
6. Anemia -- No clear etiology, but likely from large thigh
hematoma, chronic alcohol abuse, and liver disease. Was
transfused several times during his hospitalization. Hct was
stable at time of discharge. The patient should continue on EPO
after discharge. Pt has been intermittently guiac positive
during his stay.
Medications on Admission:
Tramadol
Albuterol
Atarax prn
Diazepam 10mg qHS prn
Flonase
Insulin NPH 30 qAM, 20 qPM
Protonix 40mg daily
Atenolol 50mg daily
Clarinex prn
Doxazosin 4mg qHS
Lescol 40mg daily
Lisinopril 40mg daily
Nifedipine EF 30mg daily
Vicodin prn
Paxil 20mg qHS
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Cefazolin 10 g Recon Soln Sig: Three (3) gms Injection Q8H
(every 8 hours).
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
8. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) units
Injection QMOWEFR (Monday -Wednesday-Friday).
9. Heparin Flush (100 units/ml) 1 ml IV DAILY:PRN
picc
10. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
12. Hydromorphone 2 mg/mL Syringe Sig: 1-2 mg Injection Q3-4H
(Every 3 to 4 Hours) as needed.
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u
Injection TID (3 times a day).
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed.
16. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO 1X/WEEK
([**Doctor First Name **]).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
20. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
21. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Five (35) units Subcutaneous QAM.
22. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous QHS.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
Septic joint s/p hardware removal and placement of joint spacer
Septicemia
Hyperbilirubinemia
Discharge Condition:
Stable
Discharge Instructions:
1) Please take all of your medications as prescribed
2) Return to the ED or call your PCP if you have worsening SOB,
chest pain, leg pain, cool feet, loss of sensation or movement
in right leg, nausea, fevers, chills, or abdominal pain.
3) Please refrain from all alcoholic beverages
Followup Instructions:
Please contact Dr. [**Last Name (STitle) 8499**] at [**Telephone/Fax (1) 7976**] for an
appointment in the next 4-6 weeks. Call Dr. [**Last Name (STitle) 7111**]
(Orthopedics) at ([**Telephone/Fax (1) 17953**] for an appointment in [**5-6**] weeks.
Call Dr. [**First Name (STitle) 2643**] (Liver doctor) at ([**Telephone/Fax (1) 2306**] for an
appointment in [**5-6**] weeks.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2150-12-28**] 9:30
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11713**] Date/Time:[**2151-1-6**] 10:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2151-2-3**] 2:15
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2150-12-4**]
|
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icd9cm
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[
[
[]
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3402, 3568
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,712
| 111,022
|
46181
|
Discharge summary
|
report
|
Admission Date: [**2187-9-25**] Discharge Date: [**2187-10-18**]
Date of Birth: [**2105-9-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2187-10-9**] - Coronary bypass grafting x2 with left internal mammary
artery to left anterior descending coronary artery, reverse
saphenous vein single graft from the aorta to the first obtuse
marginal coronary artery.
[**2187-10-3**] - Cardiac Catheterization
History of Present Illness:
Ms. [**Known lastname **] is an 81 year old woman with multiple medical
problems, including DM, chronic renal insufficiency, recent
NSTEMI (3 weeks prior to admission)did not have cardiac
catheterization secondary to poor renal function, diastolic CHF,
requiring lasix gtt on last admission, discharged without lasix,
but recently started on Lasix 20mg po by Dr. [**Last Name (STitle) **] on an
outpatient visit, who presents with 3-4 days of progressive
shortness of breath with intermittent substernal chest pressure.
She has had increasing trouble walking around the house and even
completing full sentences. Her visiting nurse visited her
yesterday and instructed her to call her doctor; her doctor
referred her to the ED today. The chest pressure did not radiate
anywhere but was associated with some nausea and diaphoresis.
.
In the ED, EKG showed an old LBBB, and first set of cardiac
enzymes were negative. She was given 40mg IV Lasix. The chest
pressure resolved with the addition of oxygen. Given an elevated
D-dimer, a heparin drip was entertained; however, given the
presence of alternate explanations for shortness of breath in
conjunction with elevated INR (3.8), it was not.
.
Of note, she has had two nosebleeds in the past week which
resolved with pressure and application of ice. She had an
episode of nausea and vomiting last night after dinner, as well
as decrease in appetite. She denies fevers, chills, abdominal
pain, muscle cramps, lower extremity edema, constipation. She
has had looser stools since she was discharged from the hospital
several weeks ago, likely secondary to being discharged on senna
and colace.
Past Medical History:
1) PVD s/p cath
2) HTN
3) DMII-HgAlc 6.1% on [**2187-8-20**] at OSH
4) hypercholesterolemia
5) Rheumatic Fever
6) hypothyroidism
7) peptic ulcer disease
8) Recent Urinary Tract Infection-On admission to OSH, patient
moderate leukocyte esterase and 30-40 WBC. Treated with
bactrim.
9) s/p thyroidectomy
10) s/p hysterectomy
11) s/p R mastectomy [**3-16**] breast ca
[**92**]) Chronic renal insufficency-Baseline Cr of 2.0. At OSH, Cr
trended upwards from 2.0 on admission to 2.6 at discharge.
Social History:
Ms. [**Known lastname **] is a widow who lives alone. She denies current
tobacco, alcohol, or drug use. In the past, she smoked and has
a thirty pack year history.
Family History:
Non-contributory
Physical Exam:
Admission:
Vitals: T 98.1, BP 154/61, HR 78, RR 16, Sat 94%RA
Gen: Appears in mild respiratory distress, unable to complete
full sentences
HEENT: EOMI, PERRL, OP clear
Neck: No carotid bruit, no JVD appreciated (but + hepatojugular
reflex)
Cardiac: RRR, normal S1/S2, no m/r/g appreciated
Lungs: Crackles [**2-13**] way up bilaterally. No wheezes.
Abd: Soft, obese, non-distended, non-tender, normal active bowel
sounds. No hepatosplenomegaly. + hepatojugular reflex.
Back: No CVA tenderness
Ext: No clubbing, cyanosis, peripheral edema. 1+ DP pulses
bilaterally
Skin: No rashes appreciated
Neuro: A&O x 3, moving all four extremities
Discharge:
VS T98.2 HR 62SR BP 159/69 RR 18 O2sat 97%/2LNP
Gen: NAD
Neuro: A&Ox3, nonfocal exam
CV RRR, sternum stable incision CDI
Pulm CTA-bilat
Abdm: soft,NT/+BS
Ext: Warm 1+ pedal edema bilat. Bilat leg wounds CDI
Pertinent Results:
[**2187-9-25**] 11:33PM CK(CPK)-48
[**2187-9-25**] 11:33PM CK-MB-NotDone cTropnT-0.02*
[**2187-9-25**] 05:22PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2187-9-25**] 05:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2187-9-25**] 05:22PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2 RENAL EPI-0-2
[**2187-9-25**] 04:57PM K+-4.0
[**2187-9-25**] 04:30PM GLUCOSE-183* UREA N-36* CREAT-1.6* SODIUM-135
POTASSIUM-6.0* CHLORIDE-97 TOTAL CO2-22 ANION GAP-22*
[**2187-9-25**] 04:30PM estGFR-Using this
[**2187-9-25**] 04:30PM CK(CPK)-89
[**2187-9-25**] 04:30PM CK-MB-NotDone cTropnT-<0.01 proBNP-[**Numeric Identifier 6338**]*
[**2187-9-25**] 04:30PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.2
[**2187-9-25**] 04:30PM WBC-11.6* RBC-3.88* HGB-10.6* HCT-32.1*
MCV-83 MCH-27.3 MCHC-33.0 RDW-15.5
[**2187-9-25**] 04:30PM NEUTS-78.5* LYMPHS-15.2* MONOS-5.3 EOS-0.8
BASOS-0.2
[**2187-9-25**] 04:30PM PLT COUNT-627*
[**2187-9-25**] 04:30PM PT-34.8* PTT-41.3* INR(PT)-3.8*
[**2187-9-25**] 04:30PM D-DIMER-2051*
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2187-10-17**] 08:00AM 11.0 3.53* 10.2* 32.0* 91 28.7 31.7 16.5*
618*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2187-10-17**] 05:55AM 92 26* 1.8* 135 5.0 100 22 18
[**2187-10-17**] 05:55AM 15.2* 33.5 1.4*
[**2187-9-25**]-BILATERAL LOWER EXTREMITY VEIN DOPPLER ULTRASOUND:
Grayscale and Doppler
examination of the bilateral common femoral, superficial femoral
and popliteal
veins were performed. Normal compressibility, augmentation,
waveforms and
Doppler flow is demonstrated. There is no evidence of
intraluminal clot.
Renal US [**2187-9-29**]-
1) No hydronephrosis.
2) Hypoechoic nodule in upper pole of left kidney not
definitively
identified on recent priors. In absence of clinical signs to
suggest an acute pathology, recommend follow-up in [**4-17**] months to
reevaluate.
Cardiac Cath 8/22/07-1. Coronary angiography of this right
dominant system revealed a LMCA
with an eccentric 60% lesion extending into the ostial/proximal
portion
of the LCX. The LAD was without significant coronary disease.
The RCA
was without apparent angiographic significant disease.
2. Resting hemodynamics revealed severe systemic hypertension
with an
SBP of 176 mm Hg. Left sided pressures were severely elevated
with an
LVEDP of 32 mm Hg.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Markedly elevated LVEDP suggestive of severe diastolic
dysfunction.
[**2187-10-5**]- CT-chest w/o contrast-
1. Extensive calcifications of the ascending aorta, normal in
caliber.
2. Mediastinal lymphadenopathy of uncertain significance.
3. Upper normal limit size of pulmonary arteries. Small left
pleural
effusion.
[**2187-10-5**]-Echo-Symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Diastolic LV dysfunction with
elevated filling pressures. Mild mitral regurgitation.
[**2187-10-6**]-Femoral U/S bilateral-
No pseudoaneurysm or hematoma.
[**2187-10-9**] ECHO
PRE-BYPASS:
1. Mild spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). A left atrial appendage thrombus cannot be
excluded.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Overall left ventricular systolic function is severely
depressed (LVEF= 25%.
4. The right ventricular cavity is mildly dilated.
5. There are complex, mobile atheroma in the aortic arch. There
are complex
(>4mm) atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. Trace aortic regurgitation is
seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened.
Post bypass
1. Initial attempt at coming off CPB was associated with severe
MR and high PA pressures . Back on CPB and started milrinone and
epinephrine.
2. Septal and anteroseptal walls of the LV shows improved
function. RV
function unchanged.
3. Trace mitral regurgitation present.
4. Aorta intact post decannulation.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2187-10-16**] 1:32 PM
CHEST (PA & LAT)
Reason: r/o effusion
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with CAD to go for CABG
REASON FOR THIS EXAMINATION:
r/o effusion
TYPE OF EXAMINATION: Chest PA and lateral.
INDICATION: Coronary artery disease, scheduled for bypass
surgery. Evaluate for effusion.
FINDINGS: AP single view of the chest has been obtained with
patient in sitting semi-upright position. Comparison is made
with a similar preceding study of [**2187-10-11**]. There is mild
blunting of the lateral pleural sinuses confirmed by blunting of
the posterior pleural sinuses in the lateral view. The amount is
considered mild to moderate. There remain some linear densities
on the left base, but these densities have not progressed in
comparison with the previous study. On the right base, the
previously identified linear atelectasis has improved with only
one remaining. Also, the previously existing perivascular haze
has improved slightly. No new parenchymal infiltrates are
identified. Position of previously described right-sided
internal jugular vein approach central venous line is unchanged.
The previously existing post-operative mediastinal widening has
regressed.
IMPRESSION: Improvement of post-operative changes.
Mild-to-moderate amount of bilateral pleural effusions. No
pneumothorax or any other complication.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2187-9-25**] for further
management of her shortness of breath and NSTEMI. Diuresis was
initiated and cardiac enzymes were negative. Her BNP was noted
to be quite elevated. A lower extremity ultrasound was negative
for a deep vein thrombosis. Her renal function stuides suggested
some mild renal failure. A renal ultrasound was performed which
showed no hydronephrosis and a hypoechoic nodule in upper pole
of left kidney not definitively identified on recent priors. A
[**4-17**] month follow-up was recommended. Slowly her renal function
improved. She was treated for a urinary tract infection. Ms.
[**Known lastname **] continued to have episodes of chest pain treated with
nitroglycerin with relief. Her coumadin was reversed with the
plan for a cardiac catheterization. A cardiac catheterization
was performed which showed left main and circumflex artery
disease. Heparin was continued. Given the anatomy and severity
of her disease, the cardiac surgical service was consulted for
surgical management. She was worked-up in the usual preoperative
manner including a carotid duplex ultrasound which showed
moderate plaque with bilateral 40-59% carotid stenosis. She was
tranfused to maintain a hematocrit of greater then or equal to
30%. Plavix was allowed to clear while her INR normalized in
anticipation of surgery. A superficiall phlebitis was treated.
On [**2187-10-9**], Ms. [**Known lastname **] was taken to the operating room where she
underwent coronary artery bypass grafting to two vessels.
Postoperatively she was taken to the intensive care unit for
monitoring. On postoperative day one, Ms. [**Known lastname **] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. A hematology consult
was obtained for thrombocytosis however her platelets quickly
normalized and it was assummed she had a reactive
thrombocytosis. Amiodarone was started for atrial fibrillation.
On postoperative day two, Ms. [**Known lastname **] was transferred to the step
down unit for further recovery. She was gently diuresed towards
her preoperative weight. The physical therapy service was
consulted for assistance with her postoperative strength and
mobility. Coumadin was resumed for anticoagulation. Over the
next several days the patient worked with PT to increase
endurance without much gain, it was decided she would benefit
from a short rehabilitation stay and on POD 9 she was
transferred to rehab.
Medications on Admission:
Aspirin 325mg daily
Levothyroxine 150mcg daily
Pantoprazole 40mg [**Hospital1 **]
Clopidogrel 75mg daily
Epoietin Alfa 10,000 units/mL QMoWeFr
Cyanocobalamin 500 mcg daily
Atorvastatin 40mg daily
Warfarin 5mg QHS
Metoprolol 75mg [**Hospital1 **]
Ferrous sulfate 325mg daily
Ipratropium Neb Q4H
Fexofenadine 60mg [**Hospital1 **]
Senna 8.6mg [**Hospital1 **]
Calcium Acetate 667 PO TID with meals
Metformin (unknown dose)
Lasix 20mg daily (recently started by cardiologist)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day:
Adjust dose to target INR 1.5-2.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): 40mg QD x 10 days then decrease to 20mg QD.
12. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**])
units Injection Q Mo-We-Fri.
15. Ferrous Sulfate 325 (65) mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 245**] [**Hospital6 **] Hospital
Discharge Diagnosis:
CAD s/p CABG
Congestive heart failure exacerbation, supratherapeutic INR
Diastolic heart failure
Coronary artery disease, status post myocardial infarction
Atrial fibrillation
peripheral vascular disease
hypertension
hypercholesterolemia
chronic renal insufficiency
diabetes
hypothyroidism
peptic ulcer disease
Discharge Condition:
stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Contact surgeon at ([**Telephone/Fax (1) 1504**]
with any wound issues.
2) Report any weight gain of greater the 2 pounds in 24 hours or
5 pounds in 1 week.
3) No lifting greater the 10 pounds for 10 weeks.
4) No driving for 1 month.
5) You may wash incision and gently pat it dry. No swimming or
bathing until wound has healed. Please shower daily. No lotions,
creams or powders to incision until it has healed.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] [**Telephone/Fax (1) 8506**]
Dr. [**Last Name (STitle) **] [**2190-10-29**]:20am [**Telephone/Fax (1) 2386**]
Please call all providers for appointments.
Completed by:[**2187-10-18**]
|
[
"428.0",
"682.3",
"584.9",
"428.30",
"585.9",
"999.3",
"997.1",
"411.1",
"285.9",
"403.90",
"427.31",
"410.72",
"414.01",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"38.93",
"36.11",
"39.61",
"37.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
14209, 14281
|
9721, 12212
|
341, 607
|
14636, 14645
|
3903, 6389
|
15199, 15536
|
2992, 3010
|
12735, 14186
|
8339, 8381
|
14302, 14615
|
12238, 12712
|
6406, 8302
|
14669, 15176
|
3025, 3884
|
282, 303
|
8410, 9698
|
635, 2275
|
2297, 2792
|
2808, 2976
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,371
| 152,180
|
45979+45980+45981+45990
|
Discharge summary
|
report+report+report+report
|
Admission Date: [**2185-10-3**] Discharge Date: [**2185-10-8**]
Date of Birth: [**2127-6-10**] Sex: M
Service: .
HISTORY OF PRESENT ILLNESS: This is a 58 year old gentleman
with a history of severe low back pain with anterior thigh
pain and knees, no pain below knees. He has occasional right
heel pain. The patient has a history of multiple back
surgeries including a micro diskectomy, an L3, S1 fusion, L4,
S1 fusion, and an open reduction and internal fixation of his
left fibula and right calcaneous in [**2156**]. The patient
presents today to have a reoperative L2 to L3 decompression
and an L2, L3 fusion using pedicle screws and iliac crest
line graft.
PAST MEDICAL HISTORY:
1. Non-insulin dependent diabetes mellitus.
2. Hypertension.
3. Carpal tunnel syndrome.
MEDICATIONS:
1. Oxycodone 15 mg q. four.
2. MS Contin 75 mg q. six.
3. Ultram 100 mg three times a day.
4. Neurontin 600 mg four times a day.
5. Lodine XL 600 three times a day.
6. Glyburide.
7. Univasc.
8. Hydrochlorothiazide.
PHYSICAL EXAMINATION: Blood pressure 123/63; heart rate 78;
SAO2 96% on room air. Lungs clear. Heart rate, regular rate
and rhythm, no murmurs. Abdomen obese, soft, nontender, no
masses. Pupils equally round and reactive to light and
accommodation. Extraocular muscles are full. Two plus
carotids; no thyromegaly. Extremities with five out of five
in both upper extremities; five out of five by flexion,
decreased sensation in legs bilaterally, four plus out of
five foot dorsiflexion. Feet were warm.
HOSPITAL COURSE: The patient was brought to the Operating
Room on [**2185-10-3**], where he underwent a re-operative L2, L3
decompression and L2, L3 fusion using pedicle screws and
iliac crest bone graft.
Postoperatively, the patient was awake, alert, and oriented
times three, blood pressure 140s to 160s. Heart rate 83; 18;
95%. The patient was on a ventilator post surgery. He was
extubated overnight and placed on a morphine PCA pump,
started on Kefzol one gram q. eight, Venodyne and
subcutaneous heparin. He had two drains to suction.
On his first postoperative day, he was awake, alert and
oriented, moving all extremities times command. Grasp, NIT
were both five out of five. Dressing was clean, dry and
intact. His postoperative hematocrit was 30.9. He was to be
using a brace at all times when out of bed.
He had his coagulation studies closely checked due to a large
amount of drainage out of both Hemovac drains. His
coagulation and DIC screening came back negative and his
drain output continued to be high, however, did slow down
over the next day.
He had lying films which showed good position of hardware on
his first postoperative day. The Pain Service was also
consulted. He was placed on Dilaudid PCA, to continue with
MS Contin and Neurontin. His PCA was increased.
On the [**7-5**], his drains had decreased in the
amount of output overnight. He was doing more comfortably
with pain control. He continued to be on the Dilaudid PCA
throughout that day.
On the [**7-6**], the patient's hematocrit was 28.3 and
he received one unit of blood. Also, his right drain was
discontinued. He had been out of bed to chair. His PCA pump
was stopped. He was seen by Physical Therapy on the 30th who
felt that he would need home Physical Therapy. He also had
his brace modified by adding tongues to the overlap area
laterally, to decrease the chance of skin impingement.
On the 31st he had his Foley catheter discontinued. He had
been on a regular diet and has been getting out of bed with
Physical Therapy. His hematocrit on the 31st was 27.7 and he
was given another unit of packed red blood cells and we will
be checking a follow-up one on [**10-8**], prior to
discharge. He worked well with Physical Therapy and they
felt that he could go home safely with home Physical Therapy.
He is going to have home Physical Therapy and a home nursing
check for wound check.
DISCHARGE INSTRUCTIONS:
1. His follow-up appointment will be on [**10-19**], at
09:20. He needs to have x-rays done and then follow-up with
Dr. [**Last Name (STitle) 1327**] on 10:20 on the 12th for a wound check and staple
removal.
DISCHARGE MEDICATIONS:
1. Colace 100 mg twice a day.
2. Atenolol 25 mg q. day.
3. Moexipril 15 mg q. day.
4. Hydrochlorothiazide 25 mg p.o. q. day.
5. Gabapentin 300 mg, take 600 mg twice a day.
6. Oxycodone 5 mg, one to three tablets q. three to four
hours as needed for pain.
7. Glyburide 2.5 mg, take one p.o. twice a day.
8. Morphine sulfate 60 mg SA tablets, take one every six
hours as needed for pain.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2185-10-7**] 14:59
T: [**2185-10-7**] 15:37
JOB#: [**Job Number 97888**]
Admission Date: [**2185-10-3**] Discharge Date: [**2185-10-10**]
Date of Birth: [**2127-6-10**] Sex: M
Service: Neurosurgery
ADMISSION DIAGNOSIS: Back and bilateral foot pain.
SECONDARY DIAGNOSES:
1. Hypertension.
2. Diabetes mellitus.
CHIEF COMPLAINT: Back, bilateral leg and foot pain.
DIAGNOSIS: L2-3 stenosis, spondylolisthesis.
HISTORY OF PRESENT ILLNESS: Patient has had multiple back
surgeries in the past L4, S1 fusion in '[**80**], L3, S1 fusion in
[**4-7**], L2, 3 microdiscectomy [**9-8**]. Patient is having
continuing pain radiating to the leg, neuropathy in the feet.
CT [**2185-2-9**] shows severe spinal stenosis compressed thecal
sac.
PAST MEDICAL HISTORY:
1. Diabetes mellitus. The patient's diabetes is controlled
with oral medications. Last hemoglobin A1C is 7.9.
2. Hypertension.
3. GERD.
RELEVANT PAST SURGICAL HISTORY:
1. [**2184-9-7**] the patient had a L2, 3 microdiscectomy.
2. [**2184-4-7**] L3-S1 fusion.
3. In [**2180**] L4-S1 fusion.
MEDICATIONS AS AN OUTPATIENT:
1. Atenolol.
2. Moexipril.
3. Hydrochlorothiazide.
4. Glyburide.
5. Peroxetine.
6. Oxycodone.
7. MS Contin.
ALLERGIES: Questionable codeine allergy causing
hallucinations.
PHYSICAL EXAMINATION: Generally: Obese male, who seems
uncomfortable. Regular, rate, and rhythm, no murmurs, rubs,
or gallops. Abdomen is obese, soft, nontender, no masses, no
hepatosplenomegaly. Pupils are equal, round, and reactive to
light and accommodation, constricted, ROMI, 2+ carotid, no
thyromegaly. Extremities: [**4-11**] upper extremity strength, [**4-11**]
thigh flexion, decreased sensation in the legs bilaterally.
Foot: 4+/5 foot dorsiflexion, 2+ femoral pulses DP and PT
pulses bilaterally. Feet are warm bilaterally.
ASSESSMENT AND PLAN: L2-3 spinal stenosis,
spondylolisthesis. Plan is L2-3 decompression, fusion
pedicle screw, ICBG.
BRIEF HOSPITAL COURSE: On [**2185-10-3**], the patient underwent
L2-3 fusion decompression. Patient tolerated the procedure
well postoperatively in the PACU. In the ICU the patient was
extubated without event. Postoperative hematocrit was 29.8
down from 34.9 preoperatively. Postoperative white blood
cell count was 8.8. Postoperative chemistries were within
normal limits. Glucose is 192. Magnesium was slightly low
at 1.4.
Patient was placed on bed rest of head of bed elevated
greater than 30 degrees. Patient was treated with Ancef
perioperatively 1 gram IV q8. Venodynes and subQ Heparin
were initiated for DVT prophylaxis. Patient's pain was
managed with a Morphine PCA. He had two drains placed and
both were set on suction postoperatively.
His laboratories on postoperative day two were within normal
limits. Hematocrit was slightly increased to 30.9.
Patient's diet was advanced at that time which he tolerated
well. He was out of bed with a brace at all times, which was
a TLSO. Foley was D/C'd without events. Patient was
transferred to the floor. Patient had standing lumbosacral
films, which showed good placement of hardware and no
interval change. Patient's drain output was monitored
closely.
Hematocrits trended down on postoperative days three and four
to the high 20 range, and he was transfused two additional
units of packed red blood cells. There is a questionable
transfusion reaction, however, the patient remained stable at
all times. The patient received a total of 5 units of packed
red blood cells during this stay. Patient was mildly febrile
on postoperative day four leading him to stay in the hospital
for an extra couple of days.
Hemovacs were D/C'd without events. Postoperatively, the
patient was out of bed with Physical Therapy doing well. He
was kept in the hospital because of a mild fever and
hematocrits trending down. There was no source of fever
identified. It was attributed to atelectasis. Hematocrit
was rechecked after transfusion and day of discharge was
31.1.
DISCHARGE INSTRUCTIONS: Patient will be discharged home with
services for Physical Therapy and wound check. Patient will
be returning in two weeks for staple removal and in three
weeks for x-rays. He will receive Morphine sulfate p.o. for
pain and iron for his anemia.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Name8 (MD) 19808**]
MEDQUIST36
D: [**2185-10-10**] 09:48
T: [**2185-10-11**] 05:30
JOB#: [**Job Number 97889**]
Admission Date: [**2185-10-3**] Discharge Date: [**2185-10-10**]
Date of Birth: [**2127-6-10**] Sex: M
Service: Neurosurgery
CHIEF COMPLAINT: Back, bilateral leg, and foot pain.
PHYSICAL EXAMINATION: He ambulates with a cane. Straight
leg raise is negative bilaterally. Strength examination:
5/5 strength in bilateral iliopsoas, hamstrings, quadriceps,
dorsiflexion, [**Last Name (un) 938**], and plantar flexion. He does not have
Achilles reflexes on the left, but on the right he is 2+.
EMG shows chronic bilateral polyradiculopathy, left greater
than right lower extremities.
Lumbosacral spine x-ray shows mild loss of disk height at L4,
L5. Moderate-to-severe L5-S1.
MRI of the lumbosacral spine shows disk dessication at L4,
L5, C5, S1, moderate central lateral stenosis. Right lateral
L4-5 disk herniation, L4-5 secondary increased facet disk
bulge, L4-5 high facet and a disk bulge and a disk bulge
interforaminally at L4.
ASSESSMENT AND PLAN:
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Name8 (MD) 19808**]
MEDQUIST36
D: [**2185-10-10**] 09:39
T: [**2185-10-11**] 05:20
JOB#: [**Job Number 97890**]
Admission Date: [**2185-10-3**] Discharge Date: [**2185-10-10**]
Date of Birth: [**2127-6-10**] Sex: M
Service: Neurosurgery
CHIEF COMPLAINT: Back, bilateral leg, and foot pain.
PHYSICAL EXAMINATION: He ambulates with a cane. Straight
leg raise is negative bilaterally. Strength examination:
5/5 strength in bilateral iliopsoas, hamstrings, quadriceps,
dorsiflexion, [**Last Name (un) 938**], and plantar flexion. He does not have
Achilles reflexes on the left, but on the right he is 2+.
EMG shows chronic bilateral polyradiculopathy, left greater
than right lower extremities.
Lumbosacral spine x-ray shows mild loss of disc height at L4,
L5. Moderate-to-severe L5-S1.
MRI of the lumbosacral spine shows disc dessication at L4,
L5, C5, S1, moderate central lateral stenosis. Right lateral
L4-5 disc herniation, L4-5 secondary increased facet disc
bulge, L4-5 high facet and a disc bulge and a disc bulge
interforaminally at L4.
ASSESSMENT AND PLAN:
DOCTOR REQUESTS THIS CHART TO BE DELETED.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Name8 (MD) 19808**]
MEDQUIST36
D: [**2185-10-10**] 09:39
T: [**2185-10-11**] 05:20
JOB#: [**Job Number 97890**]
|
[
"722.93",
"401.9",
"518.0",
"790.01",
"997.3",
"250.00",
"738.4",
"999.8",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"77.79",
"81.08"
] |
icd9pcs
|
[
[
[]
]
] |
6767, 8782
|
4214, 5018
|
1568, 3955
|
8807, 9450
|
5749, 6077
|
5092, 5132
|
10762, 11818
|
5040, 5071
|
10702, 10739
|
5262, 5556
|
5578, 5726
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,705
| 187,860
|
46282
|
Discharge summary
|
report
|
Admission Date: [**2104-8-14**] Discharge Date: [**2104-8-15**]
Date of Birth: [**2044-11-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
angioedema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: This is a 59 year-old female with a history of HTN who
presents with new lip swelling. Patient started on ACE
inhibitor on [**7-31**]. She initially she noted a cough that would not
resolve and was not associated with any other URI symptoms. She
also noted a rash ('red, raised bumps') on her b/l arms that
resolved on its own and was not itchy. Several days later she
noted L sided upper lip swelling which resolved on its own. The
following Monday she noted feeling dizzy and 'not like herself'.
She was able to take her granddaughter to [**Name2 (NI) 98417**] but otherwise
spent the rest of the day in bed. Today she woke up with both
right and left sided lip swelling and came to the ED.
She currently does not feel short of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] changes in her
voice, racing heart beat, trouble swallowing, itchiness.
She denies every feeling itchy, having abdominal pain, N/V,
diarrhea. She does note her peripheral edema (which is baseline
for her) has gotten a little worse since she has moved back to
[**Location (un) 86**]. She has not had any fevers, chills, and has not had any
sick contacts to her knowledge. She does not have any food or
seasonal allergies. She has not had any new foods or any recent
travel outside the country.
In the ED, patient was initially admitted to observation unit HR
72 138/65 RR13 SO2 100% on RA. She was given benadryl 50 mg IV x
2, prednisone 60 mg po, 20 mg po pepcid, 125 mg IV solumedrol,
and seen by ENT. Laryngoscope negative for supraglottic or
glottic edmea, R TVC paretic, L TVC normal, airway patent. She
was transferred to the ICU because her symptoms seemed to
initially worsen despite medical evaluation. In the ICU she was
continued on dexamethasone 10 mg IV q 8hr given at 22:00, 06:00
on [**2104-8-15**] and was then d/c'ed. She also received benadry 25 mg
IV at 11:00 on [**2104-8-15**]
<br>
ROS:
GEN: [+]WNL, no fevers, chills, night sweats, fatigue,
weightloss/weight gain
HEENT: [ ]WNL, no vision changes, no tinnitus, no loss of
hearing, no dysphagia, + mild headache [**1-6**] , no sinus
tenderness, no rhinorrhea no congestion.
CV: [ X]WNL - no chest pain - no upper back pain
RESP: [ ]WNL + dry cough now resolved with d/c of lisinopril
no shortness of [**Month/Year (2) 1440**], no orthopnea, - PND
GI: [X ] WNL- no abdominal pain, nausea, no emesis, no
diarrhea, no constipation, heartburn, hematochezia,
melana, change in bowel habits
GU: [X] WNL- no dysuria, hematuria, hesitancy, or change in
frequency, change in bladder habits, vaginal discharge
SKIN: [X]WNL no rashes, lesions, pressure ulcers
NEURO:[X] WNL no weakness, paresthesias, numbness, headaches,
dizziness
MUSCULOSKELETAL: [X]WNL no arthralgias, myalgias
PSYCH: [ ]WNL No sadness or hallucinations.
All other review of systems negative.
Past Medical History:
Past Medical History
Hypothyroidism. Dose of synthroid decreased to 75mcg qd on
[**2104-7-31**]
Breast cancer - dx'd in [**2100**]. Treated with lumpectomy and XRT
Rheumatic fever as a child.
s/p thyroidectomy for goiter, now Hypothyroid
Lupus
Fibromyalgia
OA
s/p MVA in [**2086**], residual chronic neck pain
Chronic pain right head and right side of neck,s/p
herpes-related [**Last Name (un) 39070**] Hunt Syndrome
tracheal stenosis, s/p thyroid surgery
s/p cholecystectomy
need ppx abx prior to dental procedures
[**First Name9 (NamePattern2) 10259**] [**2096-4-26**]
CMY? per patient
Arrythmia- PACS- baseline per patient
<br>
Past Surgical History
Thyroidectomy at age 12
Tuboligation [**2068**]
Surgical Heart Bx confirming myocarditis and enlarged heart
[**Year (4 digits) 10259**] [**4-/2096**]
Surgical bx R [**2088**]/[**2089**]
Surgical bx R breast [**2100-12-7**]
Multiple Lumpectomies [**2101-1-11**], [**2101-2-8**],
[**2101-3-7**], 5/[**2100**].
Ovarian surgery for benign disease [**10/2101**]
Social History:
no tobacco, etoh, drugs. Her daughter died approximately seven
years ago. The pt moved to [**Location (un) 9012**] to help raise her
granddaughter. Now, she has recently
returned to the [**Location (un) 86**] area. She lives with her cousins. She was
a contractor for the CDC where she was an administrative
manager. Independent of ADLS an IADLs. She drives and manages
her own accounts. In the chart there is a typed list of her
surgeries which she manages herself.
Family History:
One aunt had breast cancer. no colon cancer.
Physical Exam:
Vitals: T: 98.3 BP: 112/61 HR: 57 RR: 13 O2Sat: 98% on RA
Orthostatics checked on night of discharge by me personally:
Laying 130/60, HR = 68, Standing BP = 120/60, HR = 80
No symptoms of dizziness
GEN: Well-noursing middle-aged woman in no apparent distress
with visible significant swelling of upper and lower lips
HEENT: EOMI, PERRL, sclera anicteric, right eye with more tear
formation, sclera slighly injected, MMM,
NECK: no bruits, no stridor, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: 1+ bilateral pedal edema, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: No rashes noted.
Pertinent Results:
[**2104-8-15**] 04:56AM BLOOD WBC-10.2# RBC-4.47 Hgb-12.7 Hct-37.8
MCV-84 MCH-28.4 MCHC-33.7 RDW-12.7 Plt Ct-312
[**2104-8-15**] 04:56AM BLOOD PT-12.7 PTT-27.7 INR(PT)-1.0
[**2104-8-15**] 04:56AM BLOOD Plt Ct-312
[**2104-8-15**] 04:56AM BLOOD Glucose-154* UreaN-15 Creat-1.0 Na-138
K-3.8 Cl-102 HCO3-25 AnGap-15
[**2104-8-15**] 04:56AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
[**2104-8-15**] 04:56AM BLOOD TSH-0.20*
Brief Hospital Course:
Assesment: This is a 59year-old female with a history of
hypothyroidism, breast cancer s/p lumpectomy, RT and lupus who
presents with worsening lower lip swelling thought to be
angioedema secondary to allergy to lisinopril.
Plan:
# Angioedema: Patient was seen in the ER for angioedema. ENT
evaluated her and did not see any abnormality in the airways
other than lip swelling. Patient was admitted to the ICU for
respiratory monitoring. Lisinopril was stopped and OMR allergy
was put in. Patient was instructed not to take lisinopril again.
Benadryl and Decadron were started and edema improved. She did
not have any airway compromise. She was then called out the
floor.
# Hypothyroidism: Her outpatient dose of levothyroxine was
recently decreased. Her TSH returned low at 0.2 thus patient
counselled to follow up with her PCP for further monitoring of
her thyroid function. She was discharged on the lower dose of
synthyroid 75 mcg qd.
# Hypertension: patient intitially started on lisinopril/HCTZ
for hypertension after having been on spironolactone/HCTZ. She
was discharged on HCTZ 25 mg po qd with strict instructions to
monitor her BP with her home BP. She has a follow up appointment
with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] on [**8-21**] for further monitoring.
# Osteoarthritis: patient usually takes OTC medications for
joint pain as needed.
-tylenol prn pain
# Lupus: stable, not currently on any treatments for lupus.
# FEN: Tolerated regular diet on dischargee.
.
# Access: PIV
.
# PPx: PIV
.
# Code: FUll
.
# Dispo: d/c'ed home in the care of her cousins.
.
# Comm: cousin [**Name (NI) 2155**] [**Name (NI) **], [**Telephone/Fax (1) 98418**]
[**8-15**]
Medications on Admission:
synthroid 88mcg qd-> 75 mcg qd.
lisinopril/hctz 20/25 1 tab qd
vitamin E
vitamin C
cod liver oil
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
3. Outpatient Lab Work
Chem 7 on [**8-18**]. Results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Dame [**Telephone/Fax (1) 3650**].
4. Benadryl 25 mg Capsule Sig: One (1) Capsule PO four times a
day.
Disp:*120 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Angioedema
Secondary diagnoses:
1. Breast cancer
2. Lupus
3. Tracheal stenosis s/p thyroid surgery
4. Rheumatic heart disease
5. Cardiomyopathy
Discharge Condition:
Good, not orthostatic, ambulating independently, discharged into
the care of her cousins with whom she lives.
Discharge Instructions:
You were admitted with lip swelling (angioedema) in the setting
of starting on lisinopril on [**2104-7-31**]. You were seen by the ENT
- ears, nose and throat specialists who determined that your
airway was open/patent without concerns for compromise.
If you have an shortness of [**Year (4 digits) 1440**], lip swelling, slurred
speech, difficulty swallowing, chest pain, light headedness
orther symptoms that concern you please seek urgent medical
attention. I can be emailed at [**University/College 98419**] should
you have any questions.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 3070**]
Date/Time:[**2104-8-21**] 11:30
Please call [**Telephone/Fax (1) 2349**] to make an appointment to see an ENT
specialist in the next week. You were seen by Dr. [**First Name (STitle) **]
[**Name (STitle) 98420**], M.D. and your case was staffed with Dr. [**First Name (STitle) **] the ENT
attending.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
|
[
"E942.9",
"425.4",
"995.1",
"244.9",
"710.0",
"401.9",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8327, 8333
|
5976, 7674
|
300, 306
|
8543, 8655
|
5542, 5953
|
9246, 9829
|
4692, 4739
|
7823, 8304
|
8354, 8354
|
7700, 7800
|
8679, 9223
|
4754, 5523
|
8408, 8522
|
250, 262
|
334, 3158
|
8373, 8387
|
3180, 4192
|
4208, 4676
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,105
| 126,787
|
45854
|
Discharge summary
|
report
|
Admission Date: [**2190-9-6**] Discharge Date: [**2190-9-12**]
Date of Birth: [**2120-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
1) Colonoscopy [**2190-9-7**]: multiple diverticulosis throughout colon
(no bleeding at time of exam)
2) Tagged red blood cell scan [**2190-9-8**]: brisk GI bleeding likely
in region of descending/sigmoid junction
3) Mesenteric angiogram [**2190-9-8**]: no evidence of active bleeding
on SMA and [**Female First Name (un) 899**] arteriograms
History of Present Illness:
CC:[**CC Contact Info 97648**].
HPI: Mr. [**Known lastname 74940**] is a 70 y.o. M with hx of diverticulosis,
remote prior UGIB, HTN, now presenting with BRBPR. Patient
initially noticed small amounts of red blood in stool - occuring
once daily during the last 2 weeks. On day of admission, he had
a normal brown BM in the morning, followed by the passage of a
large amount of dark red blood, which filled the surface of the
toilet bowl.
.
He was admitted to the floor and subsequently had 8 more
episodes of painless bloody bowel movements with bright red
blood in bowl. No melena. He had a syncopal episode after
large BM, witnessed by his wife - this happened when he sat in
his chair and did not fall or hit his head. Orthostatic vitals
signs were normal, BP stable in low 100s, but normally 150s as
home. He was subsequently transferred to the ICU after he was
noted to have large Hct drop from 41 --> 36.6
Past Medical History:
PMHx:
-UGIB in [**2181**] with MICU admission- gastric ulcer cauterized-no
further bleeding episodes
-Diverticulosis- seen on colonoscopies in [**2183**] and [**2189-11-30**].
-Polyp removed [**2183**] (adenoma)
-HTN
-nephrolithiasis
-?early Alzheimer's
Social History:
retired programmer, works in real estate, lives at home with
wife
no tobacco; occasional EtOH
Family History:
mother with [**Name (NI) 5895**]
Physical Exam:
97.6 BP 107/75 HR 68 RR 18 97% RA
pleasant, NAD
EOMI, MMM
RRR, normal S1 and S2
lungs clear bilaterally
abd soft, nontender, bowel movements: dark red blood with clots
neuro exam nonfocal
no edema
Pertinent Results:
Hct 41 ---> 36.6 on initial presentation
COLONOSCOPY [**2190-9-7**]
Findings: Excavated Lesions Multiple diverticula were seen in
the whole colon. Diverticulosis appeared to be severe.
Impression: Diverticulosis of the whole colon
Tagged RBC scan [**2190-9-8**]
IMPRESSION: Brisk GI bleeding likely in region of
descending/sigmoid junction.
SMA and [**Female First Name (un) 899**] arteriogram [**2190-9-8**]
IMPRESSION:
No evidence of active bleeding on SMA and [**Female First Name (un) 899**] arteriograms.
Brief Hospital Course:
70 yo man with remote hx UGIB, known diverticulosis who
presented with BRBPR at home and proceeded to have multiple
episodes in-house with significant Hct drop
1) LOWER GI BLEED SECONDARY TO DIVERTICULOSIS
Several episodes BRBPR ([**7-9**]) on admission to the floor, noted
to have Hct drop from 41 --> 36.6 as well as syncopal episode.
He was thus transferred to the ICU for close monitoring and
blood transfusions. Upon transfer to the ICU, his BRBPR
initially resolved, though his Hct continued to slowly drift
down. NG lavage revealed only clear fluid that was
heme-negative. He went for urgent colonoscopy by the GI service
and would found to have extensive diverticulosis although no
active bleeding was seen. He then had recurrent BRBPR,
prompting urgent tagged RBC scan which suggested bleeding in the
sigmoid colon region. However, subsequent angiography of the
SMA and [**Female First Name (un) 899**] did not reveal an active bleeding vessel and thus no
intervention was performed. He was also seen by the surgery
consult team in case an urgent colectomy would be needed
Following the above procedures, his symptoms actually stabilized
and he had no further episodes BRBPR in-house. He received in
total 2 units PRBC this admission, and his Hct has been stable
in the 27-30 range for the last 4 days.
His GI team recommends close monitoring for bloody stools, but
he does not need specific follow-up in their clinic at this
time. Should he have recurrent bleeding, he should return to
the hospital immediately.
I have recommended close f/u with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4127**] and have
given him a prescription for a Hct check this week in outpatient
lab, with the result to be forwarded to his PCP. [**Name10 (NameIs) **] last Hct
was 27.4 on the day of discharge. I have not yet started Fe
supplements as he is to closely monitor his stools in the coming
weeks. He is to hold his aspirin for now, pending further
instructions from his PCP.
He has been given specific instructions to return to the
hospital for any recurrent signs of bleeding or lightheadedness.
In case of recurrent LGIB, he would need urgent GI and surgical
evaluations again.
Pneumonia and flu vaccine were administered this admission.
I have spoken to his PCP's weekend coverage (Dr. [**First Name8 (NamePattern2) 714**]
[**Last Name (NamePattern1) 97649**]) and provided her with an update as well.
Medications on Admission:
Home medications:
ASA 81mg
Sertraline 50mg po daily
Aricept 5mg po qhs
Allopurinol 100mg po daily
Zantac 150mg [**Hospital1 **]
Vit E
MVI
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Outpatient Lab Work
Please draw CBC and forward results to Dr. [**First Name (STitle) **] [**Name (STitle) 4127**]([**Telephone/Fax (1) 97650**]
(please note this is a phone number. I am unable to obtain fax
number due to weekend)
3. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed, likely secondary to diverticulosis
Diverticulosis
Hypotension secondary to GI bleed, resolved
Acute blood loss anemia, now stable
Discharge Condition:
stable
Discharge Instructions:
Please monitor your stools for any recurrent bleeding or
darkening of stools (black). If you have any signs of bloody
stools or develop lightheadedness, please contact your physician
and return to the hospital.
Please have your blood drawn sometime this week at your PCP's
office (bring the lab prescription we have provided). Your last
hematocrit level on [**2190-9-12**] was 27.4.
Also recommend seeing your PCP sometime in the next 1-2 weeks.
We have held your blood pressure medications for now. Please do
not take aspirin or ibuprofen for now. You can discuss with at
your PCP visit when you can resume these medications. Please
bring this paperwork for him.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4127**] on Monday ([**Telephone/Fax (1) 8897**] and
schedule a follow-up for the next 1-2 weeks. Please have your
bloodwork drawn this week as well.
Dermatology at [**Hospital1 18**]:
Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2190-9-16**] 1:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2190-9-12**]
|
[
"403.90",
"780.2",
"585.3",
"285.1",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
6006, 6012
|
2832, 5270
|
326, 672
|
6202, 6211
|
2292, 2809
|
6929, 7489
|
2021, 2055
|
5458, 5983
|
6033, 6181
|
5296, 5296
|
6235, 6906
|
2070, 2273
|
5314, 5435
|
274, 288
|
700, 1617
|
1639, 1894
|
1910, 2005
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,404
| 123,232
|
49383
|
Discharge summary
|
report
|
Admission Date: [**2118-10-7**] Discharge Date: [**2118-11-29**]
Date of Birth: [**2049-8-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / raw egg yolk / Bactrim / flu shot
Attending:[**First Name3 (LF) 3963**]
Chief Complaint:
Abnormal labs
Major Surgical or Invasive Procedure:
PICC line
Lumbar puncture
Thoracentesis
History of Present Illness:
69 year old female with a questionable history of sarcoidosis
with massive LAD leading to lymphedema and a recent left-sided
ureteral stenosis s/p stent ([**2118-8-24**]) presents from rehab
with elevated creatinine, hyponatremia, and hyperkalemia. She
is complaining of pain of her lower extremities and backside,
but she has not had any fevers or chills. She is mostly
concerned about her sarcoidosis and wants to "start treatment
already and stop playing around with medications". She is
frustrated that she does not have the energy to do anything and
feels like she has no purpose, like she's just doing what the
people at the nursing home tell her to do. Per the nursing home
records, her labs were notable for Hct 29.2, Na+ 119 (from 122
on [**10-2**]), K+ 6.2 (5.7 on [**10-2**]), creatinine 3.4 (up from 2.0 on
[**10-2**]). Due to the trend of the labs, she was sent to [**Hospital1 18**] for
further evaluation and management.
She has had a history of presumed sarcoidosis since [**2112**], though
no definitive diagnosis has ever been made because her biopsy
results have been inconclusive. She had been refractory to
high-dose steroids and her subclavicular lymphadenopathy has
left her with massive lymphedema. Her course has been
complicated by multiple hospitalization and rehab stays since
[**2118-1-23**], punctuated by an episode of severe hypercalcemia
and a 30-lb weight loss, along with electrolyte abnormalities.
She was seen by [**Hospital1 18**] Rheumatology (Dr. [**First Name (STitle) **] [**Name (STitle) 1667**]) in [**Month (only) **]
[**2118**] and was referred for a repeat biopsy. This biopsy, too,
was rather atypical for sarcoidosis, though the read seems to
indicate a diagnosis favoring sarcoidosis. However, it has not
been steroid-responsive. As such, she was started on
methotrexate and other diagnoses such as lymphoma were
considered, but not confirmed by biopsy. Her muscle weakness has
been attributed to steroid myopathy. Upon seeing her rise in
creatinine, methotrexate was stopped and Rheumatology wanted to
start Imuran. Prior work-up showed negative [**Doctor First Name **] and ANCA, ESR of
18, and an abnormal SPEP with a IgG lambda monoclonal population
of about 3% of the total protein population.
Renal (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]) was consulted around the time of her
admission to [**Hospital1 **] [**Location (un) 620**] for a similar set of circumstance
(though she was hypokalemic at that time) and outlined the
following issues: (1) Creat 1.5 with low grade proteinuria
(UP/Cr ~1.5), (2) Edema with hypoalbuminemia (mid 2s), (3)
Hyponatremia of likely multifactorial etiologies, (4) Left
ureteral obstruction with stent placed in [**Location (un) **] in [**Month (only) **], as
above.
In the ED, initial vitals were: 99.3 80 101/52 18 100% RA. Exam
was notable for AAOx3, but occasionally confused at times and
yelling, severe LE edema bilaterally with ulcers on right
lateral lower leg, left dorsal aspect of foot, and left calf.
Repeat labs here showed Na+ 114, K+ 6.5, and creatinine 3.2.
EKG unremarkable with normal sinus rhythm and no peaked T waves,
but received calcium gluconate and IV regular insulin for
treatment of hyperkalemia. She was given morphine for pain
control. Urinalysis showed pyuria and many bacteria, so she was
started on Cipro as well. Urology was consulted and recommended
a non-contrast CT of the abdomen/pelvis, completed prior to her
arrival to the ICU. Renal U/S showed moderate left
hydronephrosis, new in comparison to prior study from [**2118-8-28**]
with visualization of the renal stent (patient reports passing
the stent). After a phone call from the ICU admitting team, she
was given a dose of steroids given her abrupt cessation of prior
high-dose steroids. She is being admitted to the ICU for severe
hyponatremia, hyperkalemia, and [**Last Name (un) **].
On arrival to the MICU, she reiterates her concern about
sarcoidosis treatment and wants to be more comfortable in the
bed. She is coherent, carrying on a conversation, and alert and
oriented.
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:
- Lymphadenopathy with lymphedema causing anasarca and
hypercalcemia, unresponsive to high-dose prednisone with
atypical histiocytes with proliferation in the left nodes
----questionable diagnosis of sarcoidosis since [**2112**] with lung
findings and inconclusive biopsy, presumed to have sarcoidosis
----started on methotrexate on [**2118-10-4**]
----supraclavicular LN biopsy: Atypical histiocyte-[**Doctor First Name **]
proliferation, favor sarcoidosis (post-steroid treatment)
----multiple coccyx and LE ulcers
- Left-sided ureteral stenosis, s/p stenting in [**2118-8-24**]
- Adrenal mass: large 3 cm adrenal gland mass, increased in size
from [**Month (only) 956**] to [**2118-5-24**]
- Spinal stenosis
- Hypertension
- Hypercholesterolemia
- Thyroid disease
- GERD
- Depression
Social History:
Denies alcohol or tobacco. She is a retired computer engineer.
She has been hospitalized and at rehabs since [**2118-1-23**].
Family History:
No family history of inflammatory or immune diseases.
Physical Exam:
Admission Exam: Physical Exam:
Vitals: T: 96.7, BP: 105/60, P: 75, R: 14 O2: 98% on RA
General: Alert, oriented, no acute distress, able to carry on a
conversation
HEENT: Sclera anicteric, dry MM, oropharynx clear, PERRL
Neck: supple, JVP flat, no LAD
CV: Regular rate and rhythm, III/VI holosystolic murmur
obscuring S2, no rubs or gallops
Lungs: bibasilar crackles, no wheezes, rales, rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, with significant 4+ edema
and remarkable skin sloughing off her left forefoot with healing
ulcers along the anterior surfaces of her toes. Scaling over
her right extremity. Spongy, pitting edema extends all the way
up her legs to her groin and lower back
Skin: multiple stage 2 and 3 ulcers along gluteal folds
Neuro: CNII-XII intact, strength not assessed, grossly normal
sensation, gait deferred
ON DISCHARGE
Pertinent Results:
ADMISSION LABS
[**2118-10-7**] 03:45PM PLT SMR-NORMAL PLT COUNT-187
[**2118-10-7**] 03:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-OCCASIONAL TEARDROP-OCCASIONAL
[**2118-10-7**] 03:45PM NEUTS-92* BANDS-2 LYMPHS-6* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2118-10-7**] 03:45PM WBC-7.3 RBC-3.12* HGB-9.7* HCT-29.5* MCV-95
MCH-31.1 MCHC-32.9 RDW-19.7*
[**2118-10-7**] 03:45PM CORTISOL-33.8*
[**2118-10-7**] 03:45PM TSH-5.4*
[**2118-10-7**] 03:45PM OSMOLAL-290
[**2118-10-7**] 03:45PM CALCIUM-7.7* PHOSPHATE-8.2* MAGNESIUM-2.1
[**2118-10-7**] 03:45PM GLUCOSE-154* UREA N-114* CREAT-3.2*
SODIUM-114* POTASSIUM-6.5* CHLORIDE-81* TOTAL CO2-22 ANION
GAP-18
[**2118-10-7**] 05:09PM K+-6.2*
[**2118-10-7**] 08:21PM LACTATE-2.5*
IMAGING
[**2118-10-7**] CT Abd/Pelvis
IMPRESSION: 1. Limited study due to lack of IV contrast
demonstrates mild left hydronephrosis and hydroureter with the
point of transition likely in the proximal to mid left ureter
but not clearly identified. No stent or renal stones are
identified. 2. Mesenteric lymphadenopathy as well as inguinal
and iliac lymphadenopathy raises the question of
lymphoproliferative disease. Mild mesenteric haziness. 3.
Bilateral small pleural effusions. 4. Moderate subcutaneous
edema.
[**2118-10-7**] Renal U/S
IMPRESSION: Moderate left hydronephrosis with no ureteral stent
seen.
[**2118-10-10**] CT Chest
CONCLUSION:
1. Left soft tissue mass tracking around left subclavian
vessels and going to left supraclavicular area is unchanged
since [**2118-2-23**]. A left supraclavicular lymph node biopsy
has been done in [**9-4**]; even if the pathologic report mentionned
possible sarcoid, the radiologic appearance, however, is
non-specific and malignant disease is also included in the
differential diagnosis. All the smaller less than 1 cm central
lymph nodes are unchanged. 2. Bilateral non-hemorrhagic
moderate pleural effusions are new since [**2118-2-23**] and are
increased since recent abdominal CT of [**2118-10-7**]. 3.
Mixed evolution of the pulmonary nodules. Some of them are new,
others are worse and some of them have improved. In lower
lobes, the lung nodules cannot be compared because of
compressive atelectasis and pleural effusions. 4. Bronchial
wall thickening with atelectasis in lower lobe could be related
to aspiration. 5. Right adrenal lesion is unchanged since
[**2118-2-23**].
Echo [**2118-10-14**]
IMPRESSION: Suboptimal image quality. Moderate functional mitral
stenosis. Mild aortic stenosis.Mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function. Dilated ascending aorta. No discrete
vegetation or pathologic regurgitation identified.
[**2118-10-19**] PFT
IMPRESSION: The FVC is moderately reduced. The FEV1 is severely
reduced. The FEV1/FVC ratio is normal. Flow-Volume Loop:
Moderately reduced flows and volume excursion with very mild
expiratory coving and an early termination of exhalation. DLC:
The diffusing capacity corrected for hemoglobin is moderately
reduced. Results are consistent with a restrictive ventilatory
defect and moderate gas exchange defect. The FVC may be
underestimated due to an early termination of exhalation.
[**2118-11-1**] Brain MRI
1. 5-mm left frontal enhancing lesion with slow diffusion.
Differential diagnosis includes neoplastic process (which is
favored), or small infarction. Recommend clinical correlations
and short-term imaging follow up to assess for interval changes.
2. Extensive white matter disease.
3. Paranasal sinuses disease as described above.
[**2118-11-4**] Renal U/S
FINDINGS: The right kidney measures 9.0 cm and the left kidney
measures 7.3 cm. There is no evidence of hydronephrosis, stone,
or mass in either kidney. The urinary bladder contains a Foley
and is not distended. Small right pleural effusion and small
ascites are present.
IMPRESSION: No hydronephrosis in either kidney. The bladder
contains a Foley catheter and is decompressed.
[**2118-11-8**] CT Chest, Abdomen, + Pelvis
IMPRESSION:
1. Left supraclavicular mass appears similar in size and likely
compresses the left subclavian vein, accounting for the left arm
swelling.
2. Moderate bilateral pleural effusions which are simple fluid
in density. Although chylothorax is possible due to thoracic
duct obstruction from the supraclavicular mass, it is less
likely because the fluid density would be expected to be lower
given the high fat content of lymphatic fluid.
3. Stricture of the intrahepatic portion of the IVC as well as
at a point just superior to the bifurcation may be due to
sclerosis or post-treatment changes. Although this may account
for some of the patient's anasarca, non-anatomic causes should
also be pursued.
4. Stable indeterminate right adrenal nodule may reflect
involvement with
lymphoma.
5. New splenic infarction.
6. Diffuse dilation of the large bowel consistent with ileus.
7. No significant active lymphadenopathy within the chest,
abdomen or pelvis aside from the supraclavicular mass discussed
previously.
8. Trace ascites.
9. Severe multilevel degenerative disc disease.
[**2118-11-8**] CXR
IMPRESSION: AP chest compared to [**11-2**] and 12: Previous
mild pulmonary edema has resolved, but small bilateral pleural
effusions and bibasilar atelectasis remain. There is no
pneumothorax. Heart size is normal. Tip of the right PIC line
ends in the right atrium, and would
need to be withdrawn 4.5 cm to reposition it in the low SVC.
Heart size is normal. Upper lungs are clear.
[**2118-11-9**] LUE U/S
No DVT in the left upper extremity.
[**2118-11-13**] CXR
Heart is normal in size and demonstrates left ventricular
configuration. The aorta is tortuous and calcified. Previously
present bibasilar atelectasis has nearly completely resolved,
and small pleural
effusions have decreased in size with minimal remaining
effusions.
[**2118-11-14**] MRI head:
IMPRESSION:
Slightly decreased diffusion abnormality, with more pronounced
decrease in enhancement of left frontal lesion. This may
reflect a subacute infarct, although the diffusion abnormality
has not changed as rapidly as would be expected for an infarct
of this size, or may reflect an underlying mass lesion such as
from lymphoma. If untreated, a lymphoma deposit should
progress, and not recede as this has. If the patient has
received systemic therapy for lymphoma, it is possible that we
are observing a partial response. Continued followup for
resolution or change is recommended to help to differentiate
between these potential etiologies.
[**2118-11-16**] RUQ Ultrasound:
1. No intra- or extra-hepatic biliary ductal dilatation.
2. Sludge-filled gallbladder.
3. Small bilateral pleural effusions and trace ascites.
[**2118-11-23**] CT TORSO - IMPRESSION:
1. High-grade small bowel obstruction with the transition point
in the distal
ileum. New moderate volume ascites, but no free air.
2. Enlarging bilateral pleural effusions with right lower lobe
atelectasis.
Probable mild pulmonary edema.
3. Stable splenic infarction.
4. No lymphadenopathy within the abdomen, or pelvis. 3.0 cm
left
supraclavicular mass is unchanged from [**2118-11-8**].
5. Stable peripheral splenic infarct.
6. Stable indeterminate right adrenal nodule.
[**2118-11-26**] ABDOMINAL PLAIN FILM
1. Gaseous dilatation of the small bowel, increased compared to
CT performed
[**2118-11-23**] with gas evident distally. Findings consistent
with partial
small bowel obstruction with less likely consideration given to
ileus (given
presence of SBO on recent CT).
2. Bibasilar opacifications, likely combination of effusions
and atelectasis.
MICROBIOLOGY
[**2118-10-11**] Blood cx ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES:
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of
gentamicin. Screen predicts possible synergy with selected
penicillins or vancomycin. Consult ID for details. HIGH LEVEL
STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin.
Screen predicts possible synergy with selected penicillins or
vancomycin. Consult ID for details.. Daptomycin Sensitivity
testing performed by Etest. Daptomycin = 3.0 MCG/ML.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ 1 S
Bottle 2- Gran neg rods in aerobic and anaerobic
[**10-12**], [**10-13**], [**10-14**], [**10-17**], [**10-22**], [**11-7**] Blood Cultures: No
growth
[**2118-10-24**] PICC tip culture: No growth
[**2118-11-5**] and [**2118-11-8**] Urine Cx: Mixed flora consistent with
contamination
[**2118-11-10**] CSF Cryptococcal antigen: Not detected
[**2118-11-10**] CSF Culture: PENDING
[**2118-11-11**] Blood EBV: PENDING
[**2118-11-11**] Pleural Fluid Culture: PENDING
PATHOLOGY
[**2118-10-11**] Bone Marrow Immunophenotyping: Non-specific T cell
dominant lymphoid profile; diagnostic immunophenotypic features
of involvement by leukemia/lymphoma are not seen in specimen.
Correlation with clinical findings and morphology (see
S12-[**Numeric Identifier 103418**]) is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas as due to topography, sampling or
artifacts of sample preparation.
[**2118-10-11**] Bone Marrow and Core Biopsy
DIAGNOSIS: CELLULAR BONE MARROW WITH INVOLVEMENT BY CLASSICAL
HODGKIN LYMPHOMA. By immunohistochemistry, CD20 stains scattered
cells. Rare cells, morphologically consistent with diagnostic
[**Doctor Last Name **]-Sternberg cells, are positive for CD30 and PAX5. CD15
stains neutrophils and bands and together with CD45 is difficult
to appreciate reactivity among large atypical cells.
[**2118-10-14**] Tissue Slides: Pending
[**2118-11-10**] CSF Cytology
Negative for malignant cells. Lypmhocytes present.
[**2118-11-11**] Pleural Fluid Immunophenotyping: PENDING
ENDOCRINE LABS
[**2118-10-27**] 06:55AM BLOOD 17 HYDROXYPROGESTERONE-Test
[**2118-10-27**] 06:55AM BLOOD ANDROSTENEDIONE-PND
[**2118-10-27**] 06:55AM BLOOD Testost-<12 DHEA-SO-13 SHBG-42
[**2118-10-13**] 05:50AM BLOOD Cortsol-42.9*
[**2118-10-7**] 03:45PM BLOOD Cortsol-33.8*
[**2118-10-7**] 03:45PM BLOOD TSH-5.4*
[**2118-10-8**] 05:06PM BLOOD PTH-282*
[**2118-10-8**] 05:06PM BLOOD Free T4-1.2
[**2118-10-15**] 05:39AM BLOOD VitB12-384 Folate-GREATER TH
[**2118-10-31**] 07:30AM BLOOD Cortsol-28.0*
[**2118-11-10**] 11:45AM BLOOD Cortsol-22.9*
[**2118-11-10**] 12:15PM BLOOD Cortsol-33.8*
[**2118-11-10**] 01:33PM BLOOD Cortsol-40.9*
DISCHARGE LABS
Brief Hospital Course:
69 year old female with a history of questionable sarcoidosis
with inconclusive prior biopsies, mesenteric LAD with
lymphedema, and recent left-sided ureteral stenosis, presenting
with hyponatremia with hyperkalemia and acute kidney injury,
found to have decreasesing WBC count (ANC 16), intermittent
hypotension, and blood cultures postitive for enterococcus and
gram negative rods. Patient had a bone marrow biopsy diagnostic
for Hodgkin's Lymphoma.
1. Pancytopenia: On [**2118-10-10**], patient developed progressive
pancytopenia. Bone marrow toxicity due to recent methotrexate,
ciprofloxacin, and bone marrow invasion from recently diagnosed
Hodgkin's disease were considered as possible etiologies.
Patient had a positive blood culture growing GNR's and sepsis
was also considered as an etiology of pancytopenia. Bone marrow
biopsy from [**10-11**] showed classical Hodgkin Lymphoma. Patient was
started on Neupogen and Leucovorin and counts improved (WBC 9.2,
ANC was >4K, HCT 25.2, PLT 59) prior to transfer to BMT. Counts
remained stable with expected decreases after AVD therapy.
Received neupogen and blood products
2. Hodgkin Lymphoma: Patient has a 6+ year history of
lymphadenopathy and lymphedema that was previously though to be
due to Sarcoid. However, her Sarcoid was refractory to steroids.
Several providers have questioned the diagnosis of Sarcoid given
patient's lack of response to steroids and her multiple biopsies
which, by report, were inconclusive but most likely consistent
with Sarcoid. Patient's CT scans seemed more consistent with a
lymphoproliferative etiology (i.e. ALPS - autoimmune
lymphoproliferative syndrome; lymphoma). SPEP showed trace
abnormal band, identified as monoclonal IgG lambda, representing
3% of total protein. Patient had a bone marrow biopsy on [**10-11**]
showing classical Hodgkin Lymphoma, which is stage IV given bone
marrow involvement. Upon Hem Onc and Pathology review of outside
hospital slides, [**Doctor Last Name **]-Sternberg cells were identified on prior
biopsies as early as [**2112**]. Patient was transferred to the BMT
unit. She had pulmonary function tests showing a decreased DLCO
and was therefore started on AVD chemotherapy with C1D1 on
[**2118-10-21**]. Bleomycin was not given due to potential pulmonary
toxicity. Patient tolerated her first cycle well without
significant side effects.
Patient had a brain MRI demonstrating a lesion in her left
frontal lobe that was very concerning for Hodgkin's. Given the
invasiveness of a brain biopsy, a lumbar puncture was performed.
CSF cytology was negative for malignancy; unfortunately, that
result did not definitively rule out CNS Hodgkins. A repeat
brain MRI 2 weeks after the initial scan showed decrease in size
of brain lesion, which was deemed more consistent with subacute
infarct by neuro-oncology.
Patient was also noted to have pleural effusions, which would
render her ineligible for high dose methotrexate, an [**Doctor Last Name 360**]
commonly used to treat CNS Hodgkins. Therefore, patient had a
thoracentesis on [**2118-11-11**] showing a chylous effusion. Cytology
showed no evidence of malignant cells. The effusion
reaccumulated.
3. Bacteremia: Patient had an episode of hypotension on [**10-11**] and
blood cultures were drawn. The culture drawn off of her PICC
grew vancomycin-sensitive enterococcus faecium at approximately
19 hours. Her peripheral bottle grew gram-variable rods at
approximately 36 hours. Patient was afebrile. She was started on
Vancomycin [**10-12**] and Meropenem [**10-13**]. Her PICC line was not
pulled due to massive edema and concern for loss of access.
Patient's PICC was pulled on [**2118-10-25**] and she received 4
additional days of antibiotics. Surveillance blood cx remained
negative. Meropenem was restarted on [**11-12**] given concern for
cellulitis
4. Hyponatremia with hyperkalemia: On presentation to MICU,
patient's sodium level was 114. She appeared mildly symptomatic
from her hyponatremia with mental status changes (presumably
different than her baseline), but it appeared to have been a
somewhat slow decline to 114. She did not have any concerning
EKG findings. Given her history of high-dose steroids and
possibly quick taper to 10mg of prednisone daily in order to
start methotrexate, adrenal insufficiency was considered and
high-dose stress steroids were administered without effect.
Cortisol level before steroid administration was wnl.
Hypovolemic hyponatremia, paraneoplastic syndrome/SIADH, thyroid
disease, and hypervolemia from her lymphedema (though this has
been long-standing and Na+ is new), were all considered. She
was on a fluid restriction and reportedly on diuretics
(furosemide + metolazone?) at outside facility, so hypovolemia
was considered the most likely scenario and she was continued on
fluid resuscitation with good result and Na+ increase at the
appropriate rate of 0.5mEq/hr. As she was volume resuscitated,
her urine electrolytes of urine Na+<10 seemed to indicate
appropriate sodium avidity and subsequent appropriate ADH
release. She continued to improve back to her baseline on mid
to high 120s with more volume. TSH known to be slightly
elevated prior to admission, with recent increase in her
levothyroxine dosing. After beginning chemotherapy with AVD,
patient was again found to be hyponatremic. A renal work-up was
negative for hydronephrosis and again demonstrated sodium
avidity with UNa <10, making appropriate ADH in the setting of
intravascular depletion most likely. Patient received salt tabs
and was started on TPN with good result. Sodium returned to her
baseline of high 120's-low 130's.
5. Acute on chronic kidney injury: Patient was found to have an
acute on chronic kidney injury upon presentation. Her renal
function improved dramatically with IV hydration. Creatinine
downtrended to 0.9. The Nephrology service was consulted given
evidence of a 1.2g protein/creatinine ratio. The renal team felt
there was no urgent indication for biopsy and that proteinuria
was likely secondary to recent frequent shifts in intravascular
volume causing intrinsic renal disease. Patient's Cr was stable
at 0.7 prior to transfer to BMT. On the BMT service, Cr was
stable at 0.5-0.8. She then had a subsequent episode of [**Last Name (un) **] with
Cr of 1.2. This was felt to be due to intravascular depletion in
the setting of limited PO intake and patient was started on TPN
and received gentle fluids with return of Cr to baseline.
6. Anarsarca vs. Lymphedema: Patient's edema is most likely
secondary to her large mesenteric LAD prevented effective venous
return. It is has been complicated by remarkable edema and
pressure ulcers on her coccyx and along her thighs and lower
extremities. Her edema is likely worsened by her hypoalbuminemia
as a result of mild proteinuria from her renal disease.
Patient's edema improved with compression bandages of lower
extremities and with her first cycle of AVD. An MRI showed that
her left supraclavicular mass was likely compressing the left
subclavian vein and causing LUE edema. She continued to have
anasarca despite interval decrease in size of mesenteric lymph
nodes after AVD, and required aggressive diuresis with IV lasix.
7. Ulcers and Skin Breakdown: Patient was noted to have diffuse
skin weeping, and miltiple buttock and bileral lower extremity
ulcers and escars. These were felt to be related to her edema.
She was followed by wound care and Dermatology was consulted,
who determined her lesions were unlikely to be fungal or
vasculitis and did not recommend biopsy. Surgery was consulted
for possible debridement of necrotic escars and recommended
waiting on debridement until after patient's counts have
recovered from chemotherapy. Patient received daily wound care.
8. Hypocalcemia with hyperphosphatemia: [**Name (NI) **] PTH was
elevated at 282. It was felt that hypocalcemia may have been
exacerbated by low Vitamin D and phosphate retention and
precipitation in setting of acute renal failure [**2-24**] dehydration.
Her urine Ca was low (0.3), suggesting appropriate renal
conservation of calcium in setting of hypocalcemia. Patient has
been hypercalcemic in the past; unclear what her phosphate and
creatinine levels were at that time. She was started on weekly
Vitamin D [**Numeric Identifier 1871**] IU and her electrolytes were repleted as needed.
9. Hypothyroidism: Patient's TSH was slightly elevated at 5.4 on
presentation. Free T4 was normal at 1.2. She developed
hypothermia and was found to have TSH of 11 and low FT4, so
endocrine was consulted and she was started on IV levothyroxine,
absorption of PO levothyroxine may have been impaired by gut
edema.
10. Adrenal Mass: Patient was noted to have a 2.5 cm adrenal
mass, stable in size from [**Month (only) 956**] to [**2118-5-24**]. Morning cortisol
was not low. DHEAS, testosterone, 17-OH progesterone, and SHBG
were WNL. A cortisol stimulation test was normal. Given lack of
endocrinologic laboratory abnormalities, mass may represent
lymphoma. [**Month (only) 116**] consider referral to an endocrinologist upon
discharge.
11. Narcotics/Chronic Pain: Throughout admission, patient often
requested additional pain medications in spite of oversedation.
Her medications were titrated to a combination regimen of both
short and long acting oxycodone, with good reported pain
control. Patient's daughter approached RN to share concerns that
her mother was abusing narcotics and had been addicted to
narcotics for many years. On [**10-31**], patient was observed by her
nurse hiding her morning oxycontin dose in a pill bottle, and
her nurse found 2 additional oxycontin pills in the bottle.
Thereafter, patient was observed taking all narcotics doses.
12. Small bowel obstruction: Patient developed a small bowel
obstruction of unclear etiology. She had no history of
abdominal surgery and CT failed to reveal obstructive masses,
though exam is limited. NG tube was placed for decompression
and she was placed on bowel rest.
13. Hypernatremia: Patient developed hypernatremia, likely due
to gastrointestinal losses (from small bowel obstruction),
insensible water losses, and concomittant inability to take PO
fluids in the setting of clinical deterioration.
Patient progressively developed altered mental status and
tachypnea. While there was no one clear precipitant, it is
likely that she succumbed to her multiple decompensated medical
problems. After discussion with her daughter and health care
proxy, the decision was made to make her comfort measures only.
Palliative care was consulted and she received supportive care
with morphine, lorazepam, and haloperidol as needed for comfort.
She expired on [**2118-11-29**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from nursing home records.
1. Bisacodyl 10 mg PR HS:PRN constipation
2. Milk of Magnesia 30 mL PO DAILY:PRN constipation
3. PredniSONE 10 mg PO DAILY
4. Senna 1 TAB PO QHS
5. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
6. Heparin 5000 UNIT SC TID
7. Pravastatin 40 mg PO HS
8. Ondansetron 4 mg PO BID:PRN nausea
9. Polyethylene Glycol 17 g PO DAILY
10. Acetaminophen 650 mg PO Q 8H
11. Guaifenesin [**6-2**] mL PO Q6H:PRN cough
12. Sodium Chloride 1 gm PO BID
13. Ondansetron 4 mg PO QAM
14. Levothyroxine Sodium 162.5 mcg PO DAILY
15. Oxycodone SR (OxyconTIN) 30 mg PO QHS
16. Oxycodone SR (OxyconTIN) 20 mg PO QAM
17. Nystatin 500,000 UNIT PO QID
18. FoLIC Acid 1 mg PO DAILY
19. Famotidine 20 mg PO DAILY
20. Lorazepam 0.25 mg PO BID:PRN anxiety
21. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
22. Gabapentin 100 mg PO HS
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Hodgkin Lymphoma
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2119-1-1**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"41.31",
"99.15",
"38.97",
"03.31",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
29440, 29449
|
17726, 28444
|
323, 364
|
29510, 29519
|
6979, 17703
|
29571, 29604
|
5943, 5998
|
29412, 29417
|
29470, 29489
|
28470, 29389
|
29543, 29548
|
6044, 6960
|
4525, 4972
|
270, 285
|
392, 4506
|
4994, 5782
|
5798, 5927
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,488
| 182,355
|
1376
|
Discharge summary
|
report
|
Admission Date: [**2177-8-18**] Discharge Date: [**2177-8-23**]
Date of Birth: [**2103-11-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
74 y/o f with cad, chf, copd admitted with pna/copd exacerbation
and sepsis.
.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 year old female with severe COPD who presents with severe
SOB. Intubated in ED for respiratory failure and CAP.
Subsequent hypotension and and tachycardia, requiring IVF's and
levophed in ED. Also was autopeeping. Started on CTX, Vanc,
solumedrol/bronchodilators. WBC 20 with 20% bands, ARF,
prerenal. No further information able to be obtained.
Past Medical History:
1. COPD on 2L home oxygen
2. DVT in past
3. CAD status post MI [**3-4**]
4. CHF
5. HTN
6. Pnemonia [**8-31**]
7. History of tachyarrhythmia
Social History:
Lives with husband. Former heavy smoker.
Family History:
Noncontributory
Physical Exam:
Vitals: 98.2, 112, 81/42, 30
Gen: Petite female in NAD, intubated
HEENT: PERRLA
Cor: RRR, NL S1 and S2, SEM
Lungs: Ventilator BS throughout, depressed on L
Abd: Soft, NTND, +BS
Ext/Lines: R IJ, no edema
Neuro: sedated
Pertinent Results:
[**2177-8-17**] 09:00PM WBC-19.9* RBC-4.44 HGB-12.7 HCT-36.9 MCV-83
MCH-28.5 MCHC-34.4 RDW-14.8
[**2177-8-17**] 09:00PM NEUTS-76* BANDS-21* LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2177-8-17**] 09:00PM PT-12.8 PTT-32.0 INR(PT)-1.1
[**2177-8-17**] 09:00PM PLT SMR-NORMAL PLT COUNT-157#
[**2177-8-17**] 09:00PM LACTATE-3.6*
[**2177-8-17**] 09:00PM TOT PROT-6.2*
[**2177-8-17**] 09:00PM CK-MB-NotDone
[**2177-8-17**] 09:00PM CK(CPK)-87
[**2177-8-17**] 09:00PM GLUCOSE-134* UREA N-46* CREAT-1.4*
SODIUM-131* POTASSIUM-3.5 CHLORIDE-82* TOTAL CO2-36* ANION
GAP-17
[**2177-8-18**] 12:57AM LACTATE-3.0*
[**2177-8-18**] 01:40AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2177-8-17**] 11:44PM TYPE-ART PO2-53* PCO2-64* PH-7.31* TOTAL
CO2-34* BASE XS-2
........
[**8-17**] CXR
IMPRESSION: Asymmetric pulmonary edema superimposed on severe,
bullous emphysema
.........
[**8-17**] EKG
Sinus tachycardia. Other than a more rapid rate, no diagnostic
change from the
previous tracing of [**2177-3-16**]. The tracing continues to show right
axis
deviation, left ventricular hypertrophy by voltage in the
precordial leads,
and non-specific ST-T wave abnormalities.
..........
[**8-20**] ECHO
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. There
is moderate
global left ventricular hypokinesis (anterior wall appears
slightly more
hypokinetic). The aortic valve leaflets are severely
thickened/deformed. There
is severe aortic valve stenosis. Trace aortic regurgitation is
seen. The
mitral valve leaflets are moderately thickened. Moderate (2+)
mitral
regurgitation is seen. The mitral regurgitation jet is
eccentric. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial
effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2177-3-17**], the
overall LVEF has significantly decreased and the degree of
aortic stenosis
detected is now severe.
................
[**8-22**] CT Head
Today's examination is compared to the prior from [**2177-6-13**].
Again, there are small areas of periventricular white matter
hypoattenuation, which likely relates to chronic microvascular
ischemic changes. However, there is no evidence of an
intracranial hemorrhage. The [**Doctor Last Name 352**]-white matter differentiation
is otherwise preserved. There is no midline shift, mass effect
or hydrocephalus.
IMPRESSION: Chronic microvascular ischemic changes without
evidence of acute intracranial hemorrhage or infarct. No midline
shift.
..........
[**8-23**] MRI
FINDINGS: The diffusion images demonstrate multiple small foci
of slow diffusion involving the left frontal and both
parietooccipital lobes. Small foci of slow diffusion are also
seen in both cerebellar hemispheres. Several of these foci are
also visualized on T2 and FLAIR images. Findings are indicative
of multiple acute small cortical and subcortical infarcts. There
is no mass effect or hydrocephalus. A small focus of low signal
on susceptibility-weighted images in the left corona radiata
basal ganglia region indicate a small area of chronic blood
products from previous hemorrhage. There is no hydrocephalus or
midline shift seen.
IMPRESSION: Multiple small areas of acute infarcts in both
cerebral and cerebellar hemispheres as described above. No mass
effect or hydrocephalus. Other changes as above
Brief Hospital Course:
A/P:
1.)Respiratory failure - Patient presented with SOB and
respiratory failure and was found to have PNA on CXR with
bilateral lower lobe opacities, as well as mild CHF,
superimposed on severe emphysema. The patient was intubated and
ventilated. Empiric antibiotics were started to cover community
acquired PNA and sepsis. Once blood, urine, and sputum cultures
were obtained antibiotics were tailored appropriately. Attempts
at weaning the patient were unsuccessful. The patient also had
severe AS and mild CHF contributing to the respiratory picture,
and she was gently hydrated in the setting of sepsis.
Albuterol, atrovent, and solumedrol were given for treatment of
COPD. However, once the patient suffered a CVA (see below),
goals of care were reassessed and the patient was extubated,
became apneic, and passed away from respiratory distress.
.
2.)Sepsis - Patient was hypotensive and tachycardica. Blood
cultures grew MRSA in [**3-3**] bottles. GPC were found on gram stain
of the sputum, but nothing grew, and MRSA grew in the urine.
She was treated with broad spectum empiric antibiotics but
eventually tapered to vancomycin, as staph aureus was sensitive
to this. Hypotension was also treated with gentle fluid boluses
in setting of AS. There was a concern for endocarditis with her
valve, and a TTE was done that showed worsening AS and EF, but
no vegetations. However, the suspicion for endocarditis
remained high, especially after her CVA that showed evidence of
multiple acute emboli. The patient required pressors
throughout her hospital stay to maintain pressures. Once it was
determined that recovery from CVA would be minimal, it was
decided to withdraw all artificial support and the patient
passed within one hour of extubating and removing pressors.
.
3.) R-sided paralysis - No evidence of ICH on CT, but MRI showed
multiple areas of acute infarct, thought to be d/t endocarditis
in the setting of a dilated [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/t severe AS. Neuro was
involved and made recommendations to start ASA, maintain
pressures 140-160, and obtain carotid U/S. While these
maneuvers were attempted, it was difficult to maintain SBP in
setting of sepsis. Ultimately it was decided that the multiple
new acute infarcts would be detremental to the patient's quality
of life, and that she would not wish to live in such a
compromised state, and pressors were withdrawn.
.
4.)ARF - Initially was prerenal, but evolution led to muddy
brown casts on sediment, suggestive of ATN, likely d/t
hypotension in setting of sepsis. UOP markedly improved and Cr
normalized.
.
5.)CAD - CK and troponins elevated and peaked. Elevated enzymes
represented demand ischemia in setting of critical AS,
infection, and hypotension. Dr. [**Last Name (STitle) **] of cardiology saw the
patient and determined that cardiac cath was not indicated at
the time.
.
6.) Hyperglycemia - Insulin gtt with good control
.
7.) Thrombocytopenia- stabalized at 65, [**12-1**] normal. HIT Ab was
negative. Meds such as vancomycin and protonix were likely
contributors.
Medications on Admission:
Budesonide
CaCo3
Vit D3
MVI
Lipitor
Fomoterol
ASA
Dilt-SR
Prednisone
Lasix
Neurontin
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
"518.81",
"410.71",
"V09.0",
"424.1",
"995.92",
"038.11",
"428.0",
"434.11",
"486",
"491.21",
"287.4",
"414.01",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8244, 8253
|
4975, 8080
|
396, 402
|
8303, 8313
|
1294, 4952
|
8366, 8373
|
1023, 1040
|
8215, 8221
|
8274, 8282
|
8106, 8192
|
8337, 8343
|
1055, 1275
|
277, 358
|
430, 785
|
807, 948
|
964, 1007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,913
| 161,612
|
38675
|
Discharge summary
|
report
|
Admission Date: [**2122-4-23**] Discharge Date: [**2122-4-27**]
Date of Birth: [**2054-12-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Epinephrine
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
dyspnea and stridor
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
67 y/o F with hx of subglottic stenosis, treated with laser in
[**2118**], who presented to OSH in [**State 2748**] on [**4-21**] with worsening
dyspnea and stridor. Approximately 2 weeks prior to her
presentation, she developed a cough, fevers, and productive
sputum consistent with a URI. She was treated with abx and
prednisone 20 mg for 1 week as an outpatient. She was noticing
worsening shortness of breath and new audible stridor. For
several months prior to presentation, she had noted SOB with
activity. She could not longer walk up three flights of stairs
without palpitations and extreme SOB. As these last two weeks
have progressed, she has had worsening SOB with only minimal
activity and now is having SOB at rest.
.
At the OSH, initial vs were stable. During her hospitalization,
she was monitored in the ICU. She was started on solu-medrol 125
mg daily x2 days and then was tapered to solu-medrol 40 mg q6hr.
She was also treated with duonebs q6hrs. Per the [**State 2748**] ICU
team, her stridor improved and she subjectively started to feel
better. A flexible largyngoscopy was done by ENT and showed no
laryngeal edema, normal true vocal cord motion. No stenotic
segment was seen. She was also started on nexium.
.
On the floor, she looks comfortable. Has audible stridor but is
moving air well throughout all lung fields. She complains of
feeling like she has shortness of breath at rest, but is
improved from her admission. She denies chest pain, fevers,
chills (except for those 3 weeks ago), nausea, vomiting,
diarrhea, dizziness, vision changes, pedal edema. She says she
fell about a month ago, but no recent falls. ROS is otherwise
negative except for that mentioned above
Past Medical History:
- Subglottic stenosis: symptoms of obstruction started in [**2108**]
that initially treated as asthma, but diagnosed with subglottic
stenosis in [**2118**]. She underwent laser excision, tracheostomy in
[**2119**], underwent 8 procedures and later decannulated in [**Month (only) **]
[**2119**].
- Hypothyroidism
- Hypertension
- Fibromyalgia
- Migraine
- Anxiety
- Allergic Rhinitis
- Hx of mercury poisoning as child
- s/p Tonsillectomy
- s/p Hysterectomy
Social History:
- Married, lives with her roommate who is her POA; independent.
- Tobacco: Non-smoker
- Alcohol: Denies
- Illicits: Denies
Family History:
dad with lung cancer, mom with [**Name2 (NI) 499**] cancer
Physical Exam:
On admission
Vitals: T: 97.0, BP: 117/84, P: 93, R: 20, O2: 96% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2122-4-23**] 04:40PM BLOOD WBC-17.7* RBC-4.33 Hgb-12.1 Hct-37.9
MCV-88 MCH-28.0 MCHC-32.0 RDW-14.2 Plt Ct-250
[**2122-4-23**] 04:40PM BLOOD Glucose-129* UreaN-25* Creat-0.7 Na-143
K-4.4 Cl-105 HCO3-25 AnGap-17
[**2122-4-23**] 04:40PM BLOOD TSH-0.13*
.
CT Trache [**4-24**]
There is a focus of tracheal narrowing in the subglottic region,
which perists
on inspiratory and expiratory images. a small nodule is seen on
the left
lateral tracheal wall just above the carina. there is narrowing
of the airway
at this point on expiratory images as well. additional moderate
narrowing of
the lobar and segmental bronchi is seen with expiration, with
associated mild
airtrapping. no focal puolmonary consolidation, effusion or
pneumothorax.
left basilar atelectasis. final read pending recons.
Brief Hospital Course:
67 y/o F with hx of subglottic stenosis who presented with
worsening dyspnea and stridor and transferred to [**Hospital1 18**] for
further management and IP evaluation.
.
# Dyspnea / Subglottic stenosis: has known subglottic stenosis
that has been progressing over the last few months; seems to
have had an exaccerbation with a recent URI and did not recover
completely. On [**4-24**], bronchoscopy revealed severe subglottic
stenosis measuring 7mm-8mm. Patient was transferred from the
MICU to the floor on HD #2. GI consulted per IP recs to evaluate
for role of reflux in stenosis as well as optimal mgmt. GI would
recommend pH probe/impedence study, but that would require 24
hours and usually done as an outpatient (and off of PPI in order
to document presence of GERD). Could do EGD to look for gross
evidence of uncontrolled GERD, as outpt. Thoracic [**Doctor First Name **]
consulted to evaluate for need for possible tracheal resection.
IP performed rigid bronchoscopy [**4-27**] w/ dilation. Pt
discharged w/ plans for f/u w/ thoracic for tracheal resection.
- outpatient thoracic sx f/u
- outpatient GI f/u
.
# Hypothyroidism: continue armour thyroid
.
# Anxiety: continued ativan and valium
Medications on Admission:
- Armour thyroid 90 mg daily
- Astepro 137 mg [**1-24**] spray per nostril daily
- Vivelle dot 0.05 mg patch two patches weekly
- Maxalt 10 mg daily prn migraine
- Mucinex 1 tablet Q12 prn
- Reglan 10 mg daily PRN nausea
- Sumatriptan 20 mg nasal spray Q2hr prn
- Sumatriptan 100 mg Q2hr PRN migraine
- Tramadol 50 mg Q6hr PRN headache
- Valim 5mg Qday PRN anxiety
- Albuterol 90 mcg Q6hr PRN dyspnea
- Clonazepam 1 mg [**Hospital1 **] prn anxiety
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every six (6) hours as needed for wheezing.
2. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day) as needed for
conjestion.
3. Thyroid 90 mg Tablet Sig: One (1) Tablet PO once a day.
4. Astepro 0.15 % (205.5 mcg) Spray, Non-Aerosol Sig: [**1-24**] Nasal
once a day.
5. Vivelle-Dot 0.05 mg/24 hr Patch Semiweekly Sig: Two (2)
patches Transdermal once a week.
6. Maxalt 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for migraine.
7. Reglan 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for nausea.
8. Sumatriptan 20 mg/Actuation Spray, Non-Aerosol Sig: One (1)
Nasal Q2hr.
9. Sumatriptan Succinate 100 mg Tablet Sig: One (1) Tablet PO
Q2hr as needed for migraine.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
12. Diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for anxiety.
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
14. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough for 20 days.
Disp:*60 Capsule(s)* Refills:*0*
15. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) Inhalation every six (6) hours as needed for
wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Subglottic Stenosis
Discharge Condition:
A&Ox3, self ambulation
Discharge Instructions:
You were admitted to the hospital because of your difficulty
breathing. This is because of your subglottic stenosis. You
underwent rigid bronchoscopy with dilation for treatment.
We have made the following changes to your medications:
1. We have started you on pantoprazole for gastroesophageal
reflux disease.
2. We have started you on Benzonatate for cough
Followup Instructions:
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2122-5-27**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1105**]
Address: 6 [**University/College **] DR, [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 85914**]
Phone: [**Telephone/Fax (1) 85915**]
Appt: [**5-22**] at 8:30am
CT surgery will contact you to schedule a follow up appointment
for tracheal resection.
If you have not heard from them, please call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 27079**] for more information.
Completed by:[**2122-4-28**]
|
[
"519.19",
"729.1",
"346.90",
"401.1",
"786.1",
"300.00",
"288.60",
"790.29",
"244.9",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.99",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
7450, 7456
|
4157, 5363
|
327, 341
|
7529, 7554
|
3344, 4134
|
7964, 8881
|
2711, 2772
|
5863, 7427
|
7477, 7508
|
5390, 5840
|
7578, 7787
|
2787, 3325
|
7816, 7941
|
268, 289
|
369, 2070
|
2092, 2552
|
2568, 2694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,105
| 107,625
|
45855
|
Discharge summary
|
report
|
Admission Date: [**2194-12-20**] Discharge Date: [**2194-12-31**]
Date of Birth: [**2120-3-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD with small bowel enteroscopy
Colonoscopy
Intubation
SMA angiography
History of Present Illness:
74 y/o gentleman with the hx of diverticualr disease, GERD and
Parkinson disease who intially presented with melena and
weakness that led to a fall.
.
He intially noticed dark stool X 2, without red blood, normal
consistency. He didn't have any abdominal pain, nausea or
vomiting. . On Saturday was in the shower he started feeling
weekness and nausea and slid down without hitting his head. His
wife was there and helped him to stand up. She says he didn't
loose his consiousness. After she stood him up, he slid down
again. After that she was able to stand him up and he didn't
have any more nausea. He denies weight loss or dyspepsia. He had
similar episode in [**2189**] when it turned out to be lower GI
bleeeding b/o diverticulosis.
.
On the floor he was noted to have guaiac pos brown stool, he was
noted to be orthostatic (133/66 supine to 78/47 standing), and
had one small and 1 large volume maroon colored stool, noted to
have BUN 42. Given one unit red cells on floor, temp with
RBC's,and treated with tylenol.
.
On arrival to the MICU, he was asymptomatic and the above hx was
obtained from himself and his wife.
.
s/p: 11 unit of blood, hct not bump, maroon melanotic stool. 1
unit of FFP and 1 bag of plaletes, calcium is being followed.
[**Hospital1 656**] (neurologist) has been following. Surgery aware. IR
aware. CTA: active arterial extravasation in the small bowel.
10am SMA anguiography. No extravasation on non selective and
selective runs supplying the small bowel with active
extravasation on CT. Manual pressure applied.
.
VS: HR 53 sinus, 92/56 on neo at 1, 99% on AC 500/14/5/0.4
.
Past Medical History:
Parkinson's disease
seizures
plantar fascitis
depression,
gout
lower GI Bleed in [**2189**]
GERD
Social History:
lives with his wife at home, does't smoke or drink alcohol.
Family History:
father had MI at the age of 57
Mother dementia when she was 75 yo
Physical Exam:
Vitals: afebrile 139/78, P-93, 100% RA
General: Alert, oriented, no acute distress . Oriented X2, does
not know the president and has very poor short term memory
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU:foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
Rectal: light Brown stool with black specks. External hemmrhoids
non bleeding visualized.
Pertinent Results:
Admission Labs:
[**2194-12-20**] 08:55AM BLOOD WBC-13.1* RBC-2.92*# Hgb-9.3*# Hct-27.5*#
MCV-94 MCH-31.8 MCHC-33.7 RDW-13.4 Plt Ct-252
[**2194-12-20**] 08:55AM BLOOD Neuts-81.7* Bands-0 Lymphs-11.5*
Monos-2.4 Eos-3.8 Baso-0.6
[**2194-12-20**] 08:55AM BLOOD Glucose-111* UreaN-41* Creat-1.3* Na-145
K-4.3 Cl-111* HCO3-25 AnGap-13
[**2194-12-20**] 08:55AM BLOOD LD(LDH)-119 Amylase-63 TotBili-0.2
[**2194-12-20**] 08:55AM BLOOD Iron-103
[**2194-12-20**] 08:55AM BLOOD calTIBC-319 Hapto-169 Ferritn-24* TRF-245
Imaging:
EGD: Erythema and erosion in the gastroesophageal junction
Mild friability and erythema in the stomach
Polyps in the fundus
Gastric mass
Normal mucosa in the duodenum
Small hiatal hernia
Otherwise normal EGD to third part of the duodenum
Recommendations: Serial hcts. Allow clears. Prep for [**Last Name (un) **]
tomorrow. Should have repeat egd in [**5-8**] weeks to evaluate lesion
in the stomach body as well as the GE junction. [**Hospital1 **] PPI.
[**2194-12-22**] Small Bowel Enteroscopy:
Impression: Diverticula in the proximal jejunum and mid jejunum
(injection)
The presence of jejunal diverticuli and the CT angiographic
findings are highly suggestive, but not diagnostic, of small
bowel diverticular bleeding.
[**12-23**] Small bowel enteroscopy:
Impression: Multiple large divertiula noted in the mid jejunum.
Multiple small ulcers noted between diverticula and on
diverticular edges
No active bleeding or bleeding site noted
The point of maximum reach of the enteroscope was tattooed
Otherwise normal small bowel enteroscopy to mid jejunum
[**2194-12-24**] 12:37 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2194-12-27**]**
GRAM STAIN (Final [**2194-12-24**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
RESPIRATORY CULTURE (Final [**2194-12-27**]):
MODERATE GROWTH Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PER DR.
[**Last Name (STitle) **],[**First Name3 (LF) **] PAGER
[**Numeric Identifier 97652**] [**2194-12-26**].
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Urine cultures negative
Blood cultures negative to date
Colonoscopy:Large internal hemorrhoids with stigmata of recent
bleeding were noted [ overlying clot ].
Diverticulosis of the sigmoid colon and descending [**Last Name (un) **]
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
74 y/o gentleman with the h/o diverticular disease, GERD and
Parkinson disease presents with melena and weakness that led to
a fall.
.
# GI Bleed: The patient had a history of dark stools/melena for
3 days. On rectal exam, he has brown stool with black specks. We
initially suspected lower GI bleed due to diverticulosis and
given painless nature, however upper GI bleed thought possible
too. Hct dropped from baseline 44 in [**3-/2194**] to 25.0 on
admission. Patient required massive transfusion protocol for
first 2 days in the ICU. GI was consulted. Started on IV PPI,
electively intubated for EGD, which was negative for bleed.
Given the multiple transfusions without appropriate increase in
Hct, CTA performed to attempt localization of bleed. CTA of the
abdomen noted blush in mid-jejunum, suspicious for jejunal
source of bleed. Attempted IR embolization failed. Push
enteroscopy showed multiple diverticula in the small bowel
without active bleeding. Patient then had a balloon enteroscopy,
which again showed many jejunal diverticula with some
ulceration/friability the edges but did not have any active
bleeding. Colorectal surgery was consulted and recommended
laparoscopic small bowel resection as a possible definitive
treatment, however his bleeding appeared to be stabilized at
that time, so this was not pursued urgently. Bleeding slowed on
the hospital days 4 and 5, allowing for transfer to the medical
floor. Colonoscopy performed, showed large internal hemorrhoids
with stigmata of recent bleeding were noted [overlying clot].
Diverticulosis of the sigmoid colon and descending colon,
Otherwise normal colonoscopy to cecum. Hct remained stable. He
was continued on a PPI. He should follow up in colorectal
surgery for evaluation of hemorrhoidectomy.
.
# Pneumonia: While intubated electively for EGD, patient
experienced fevers and increasing leukocytosis. Started having
increasing secretions and CXR concerning for pneumonia, so
started on cefepime, cipro and vancomycin on [**2194-12-24**]. Sputum
culture grew Klebsiella. The pt was extubated with no
difficulty. CXR and fevers improved after start antibiotics.
Sputum cultures were positive for Klebsiella sensitive to
ciprofloxacin so antibiotics were narrowed on [**2194-12-28**]. He did
receive a day of ceftriaxone on [**2194-12-30**] when his WBC rose from
[**10-12**] but he remained afebrile. The patient was discussed with
ID who felt that ciprofloxacin was likely adequate but that it
would not be unreasonable to treat with levofloxacin for better
respiratory coverage. I would recommend completing 14 days of
antibiotics.
.
# Agitation/Delirium: The patient became increasingly agitated
while in the ICU and was given small doses of ativan and
seroquel with good results. On the floor, the family felt the
Seroquel did not help so it was d/ced. He did require ativan on
the floor at night for intermittent agitation but his
neurologist recommended avoiding psychotropic meds. The patient
was re-oriented as much as possible.
.
# Weakness and fall: Very likely due to the anemia with GI
bleed, with underlying Parkinsons. PT evaluated the patient and
recommended rehab.
.
# Parkinson disease: Treated by Dr. [**Last Name (STitle) 1693**] in the outpatient.
Continued home medication. Dr. [**Last Name (STitle) 1693**] followed the patient while
in house. The patient has been delirious given his ICU
hospitalization, infection etc., but seems to be making slow
improvement. His neurologist predicts slow but gradual
improvement.
.
# Gout -His last attack more than 10 years ago. Continued home
allopurinol
.
# Seizure: last one in [**2190**]. Continued home levitiracetam .
.
#Hypernatremia - the patient had Na of 148 and was given D5W
overnight and his sodium normalized.
.
#CODE - FULL
Medications on Admission:
Allopurinol 100 mg PO/NG DAILY
MEMAntine 10 mg Oral [**Hospital1 **]
Escitalopram Oxalate 5 mg
LeVETiracetam 250 mg PO/NG DAILY
Multivitamins 1 TAB PO/NG DAILY
Ranitidine 150 mg PO/NG HS
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. escitalopram 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q 4 HR PRN () as needed for shortness of breath or wheezing.
9. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: until [**1-6**]. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Upper GI Bleed
VAP
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were hospitalized for a GI bleed. You received blood
transfusions and underwent a colonoscopy. You likely had
jejunal bleeding prior to admission which now appears to have
stopped. You also had evidence of possible bleeding from your
hemorrhoids. Your blood counts are now stable. You also
developed a pneumonia while in the hospital and was treated with
antibiotics. Because you are now weak from your acute
illnesses, you are being discharged to a rehab facility.
Followup Instructions:
You should follow up with your PCP [**Last Name (NamePattern4) **] [**1-2**] weeks or after you
leave the rehab.
You also have the following appointments in gastroenterology.
You should also follow up with colorectal surgery to be
evaluated for hemorrhoidectomy. You can call [**Telephone/Fax (1) 160**] to
schedule an appointment.
Department: DIGESTIVE DISEASE CENTER
When: MONDAY [**2195-2-2**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: MONDAY [**2195-2-2**] at 11:30 AM
|
[
"585.9",
"280.0",
"562.02",
"331.0",
"553.3",
"535.50",
"274.9",
"332.0",
"276.0",
"276.9",
"455.2",
"530.81",
"486",
"403.90",
"276.2",
"345.90",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"45.13",
"96.71",
"88.47",
"45.23",
"46.85",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11229, 11319
|
6378, 10172
|
314, 388
|
11382, 11382
|
3130, 3130
|
12060, 12834
|
2242, 2310
|
10410, 11206
|
11340, 11361
|
10198, 10387
|
11560, 12037
|
2325, 3111
|
266, 276
|
416, 2028
|
3147, 6355
|
11397, 11536
|
2050, 2149
|
2165, 2226
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,413
| 174,852
|
14917
|
Discharge summary
|
report
|
Admission Date: [**2147-1-5**] Discharge Date: [**2147-1-10**]
Date of Birth: [**2102-3-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 44 year-old female with a history of alcohol abuse
and psychosis N.O.S who was transferred to the ED with altered
mental status. Pt arrived hypertensive and tachycardic. She was
admitted to an inpatient psychiatric facility today with a
Section 12. She was sent from the psych facility for question of
D.T.'s.
.
In the ED, initial vitals were T 99.6 BP 160/90 HR 120 RR 20
97%RA. She was given a total of 180 mg of IV valium without much
effect. Because of her altered mental status, discussion about a
diagnosis of meningitis was begun. She was given appropriate
doses of vancomycin and ceftriaxone. No LP was able to be
obtained given the patient's behavior. Head CT was negative for
any acute pathology. CXR was WNL. She was given a banana bag and
NS. EKG notable for just sinus tachycardia.
.
Upon arrival to the ICU, she was quite agitated and had to be
restrained. Her records were reviewed. She initially was brought
to [**Hospital6 10353**] on [**2147-1-4**] by EMS when she was found
outside her house, agitated and hallucinating. She is s/p
assault several days ago, having been punched in the face by
someone whose house she was staying at. She admitted to being
"off her meds." At [**Hospital1 392**], she was medically cleared for an
inpatient psych facility. She continued to have confused speech
at [**Hospital1 392**]. She was then transported to [**Hospital1 **] and was given the
diagnosis of psychotic disorder N.O.S.
.
ROS: Unable to be obtained.
Past Medical History:
(per records):
Depression
HTN
Alcohol abuse
Social History:
She was recently assaulted about 3 weeks ago per records.
Family History:
Unable to obtain
Physical Exam:
On presentation:
Vitals: 98 180/107 107 15 98% on RA
GEN: Agitated, not able to follow commands, thrashing in bed.
HEENT: Old, healing B/L periorbital ecchymosis, L > R. PERRLA,
EOMI, MMM, OP clear.
NECK: No JVD.
CV: RRR, no M/G/R, normal S1 S2, radial pulses +2.
PULM: Lungs CTAB, no W/R/R.
ABD: Soft, NT, ND, +BS, no HSM, no masses.
EXT: No C/C/E, no palpable cords.
NEURO: Agitated, thrashing in bed. Unable to cooperate with
exam.
SKIN: Periorbital ecchymoses as above.
Pertinent Results:
HEAD CT: No acute process
Brief Hospital Course:
MICU COURSE:
44 y/o female admitted from an inpatient psych unit for concern
for EtOH withdrawal. Patient received 180 mg valium in the ED
without effect. Concern for acute psychosis vs. alcohol
withdrawal.
# Altered mental status: Transferred here for concern for acute
alcohol withdrawal. Patient with unknown prior psychiatric
history though per OSH record, has psychosis NOS. Per patient,
last drink was 6 days prior to admission though she was
delirious at time of admission so history unreliable. Also had
transaminitis and hyperbilirubinemia on admission. Patient had
no fevers per records and no leukocytosis, cultures were sent
and were negative. She received one dose of meningitis
treatment in ED which was not continued on the floor. Patient
was delirious and combative on admission to ICU. Emergent
psychiatric consult obtained who recommended continuing CIWA
scale with valium for likely EtOH withdrawal. Morning after
admission patient continued to be delirious and psychiatry was
concerned about benzodiazapine intoxication and valium was held.
Agitation treated with haldol standing and prn with good effect.
Day prior to transfer from ICU pt's mentation improved, she was
fully orientated with no hallucinations, psychiatry recommended
discontinuing Diazepam and restarting pt's Buspirone and
Paroxetine, Haldol was also changed to PRN. Pt's altered mental
status most likely due to Etoh withdrawal with psychosis. Per
psychiatry, they felt more of her inpatient issues were related
to substance abuse, and did not requiring inpatient psychiatric
admission. The patient was seen by social work and given follow
up options. The patient has follow up with her psychiatrist
arranged the week after discharge and with her PCP. [**Name10 (NameIs) **] pt did
not want her d/c summary sent to her psychiatrist for unclear
reasons.
.
# Abuse: Pt had sustained a punch to the face several weeks
prior to admission, still has eccymosis over bilateral cheeks.
The person who punched her was her reported roommate who is in
jail. The patient will be staying with one of her friends after
discharge, and the safety of the situation was assessed by
social work prior to discharge.
.
# Pancytopenia: On admission was pancytopenia, thought to be
secondary to chronic alcohol use. No prior values for
comparison. No evidence of hemolysis on labs. Her pancytopenia
had resolved with just mild anemia with hct of 34 at discharge.
.
# Hyperbilirubinemia: Total bili was 3 on admission and slowly
trended down. Likely [**1-23**] EtOH use. RUQ u/s showing
cholelithaisis but no cholestasis. Bilirubin was normal at
discharge.
.
# Transaminitis: Very mildly elevated on admission, normalized.
RUQ ultrasound as above.
# HTN: Per OSH record, had been on clonidine 0.1mg po tid, had
not taken recently. Given hypertension to 200's systolic and
tachycardia to 110's clonidine withdrawal could have contributed
and so patient was started on clonidine patch 0.3g/day. BP's
decreased after clonidine and valium/haldol dosing as above.
Medications on Admission:
Home Medications (per records):
Trazadone 100 mg PO QHS
Clonidine 0.1 mg PO TID
Klonopin 1 mg PO BID and 2 mg PO QHS
Buspar 15 mg PO TID
Wellbutrin SR 150 mg PO daily
Prozac 40 mg PO daily
Medications given in ED at [**Hospital1 392**]:
Ativan, Haldol, Clonazepam, Fluoxetine.
Medications at [**Hospital 1680**] Hospital:
Trazadone 100 mg PO QHS
Clonidine 0.1 mg PO TID
Klonopin 1 mg PO BID and 2 mg PO QHS
Buspar 15 mg PO TID
Wellbutrin SR 150 mg PO daily
Prozac 40 mg PO daily
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
2. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a
day).
Disp:*270 Tablet(s)* Refills:*2*
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Delirium tremens
Acute alcohol withdrawl
Discharge Condition:
stable
Discharge Instructions:
You were admitted with acute alcohol withdrawl and delirium
tremens (hallucinations related to alcohol withdrawl). You were
admitted initially into the intensive care unit for treatment.
Your symptoms resolved. You were also followed by psychiatry
while you were here.
.
You need to stop drinking alcohol, as this is dangerous for your
health and you can die if you continue to drink. Your liver
function may also worsen.
.
Please follow up with your psychiatrist and primary care doctor
as scheduled.
.
Call your doctor or return to the ER for recurrent withdrawl,
hallucinations, confusion, chest pain, dehydration,
nausea/vomiting, tremors, or any other concerning symptoms
Followup Instructions:
Please follow up with your primary care doctor or a new one of
your choosing. You can call [**Telephone/Fax (1) 250**] to schedule an
appointment here with a primary care doctor if you need one.
.
Please follow up with Dr. [**Last Name (STitle) 43712**] this Friday morning 1/23/009
at 10:30 AM
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43713**] (psychiatrist) and
Ms. [**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) **] (therapist), N. [**University/College 7709**] [**Location (un) **] Counseling
Center: [**2147-1-17**], Tuesday, 2:30 PM.
.
Please call the following for outpatient substance abuse
counseling:
* [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 2678**] Substance Abuse Clinic ([**Telephone/Fax (1) 43714**], [**Location (un) 43715**], Unit [**Unit Number **]) Wednesday and Thursday 11 AM, group tx.
* N. [**University/College 7709**] Mental Health ([**Telephone/Fax (1) **]) for intake appt. Tx
will be [**Location (un) **] Counseling Center.
|
[
"920",
"E960.0",
"401.1",
"298.9",
"782.4",
"311",
"291.0",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6727, 6733
|
2589, 2807
|
335, 341
|
6818, 6827
|
2538, 2538
|
7552, 8597
|
2008, 2026
|
6163, 6704
|
6754, 6797
|
5657, 6140
|
6851, 7529
|
2041, 2519
|
274, 297
|
370, 1849
|
2548, 2566
|
2823, 5631
|
1871, 1917
|
1933, 1992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,175
| 129,794
|
22051
|
Discharge summary
|
report
|
Admission Date: [**2196-8-7**] Discharge Date: [**2196-9-6**]
Date of Birth: [**2145-6-14**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
OLT [**2196-8-27**]
temporary HD line placement
History of Present Illness:
This is a 51 year-old male with Hepatitis C cirrhosis, h/o SBP,
with new diagnosis of SBP, GPC + blood culture, hypotension,
transferred from medical floor for persistent hypotension, low
urine output despite fluid resucitation. Called to see patient
for SBP in 80's despite 150mg of 25% albumin and 1 liter NS IVF.
Also with low urine output. 70cc concentrated urine since
midnight. Mentating well. No complaint of lightheadedness or
dizziness, fever, chills, or abdominal pain.
.
Patient initially developed fevers, fatigue, sweats and chills
the day prior to admission. He denies N/V, diarrhea,HA, CP, SOB,
cough or dysuria. He has abdominal pain at baseline, which is
unchanged. Temp at home today was 100.5. Of note, pt was seen in
liver clinic on [**8-4**] and had a therapeutic paracentesis at that
time (2L off). Peritoneal fluid demonstrated only 45 WBCs at
that time.
.
In the ER [**8-7**], he presented with a temp of 101.6 (102.9 max).
BCx were sent, IVFs were started and he received 2L NS and 1 gm
of tyelenol. BP intially was 104/82, trended down to 88/31 and
then trended back to the low 100s. A paracentesis was done and
peritoneal fluid showed 785 WBC with 72% polys. He was treated
with levaquin 500 mg IV x 1, Flagyl 500 mg IV and vancomycin 1
gm IV. He was admitted to the medicine floor, and recieved an
additional 500cc NS bolus for low BP in 80's systolic overnight.
.
On [**8-8**], blood cultures returned preliminarily with 1 out of 4
positive GPC. In addition, creatinine was up to 2.5, from 1.8
the evening prior. He was started on octreotide/midodrine for
hepatorenal syndrome. In addition, given his hypotension, he was
given additional 150mg of 25% albumin + 1 liter NS prior to
transfer to ICU.
Past Medical History:
-Hep C cirrhosis on liver transpalant list: HCV Genotype 3A
-DVT s/p IVC filter in these setting of Tamoxifen which he was
on for breast tenderness secondary to liver disease and
Aldactone.
- hepatic encephalopathy
- gastroesophageal varices, Grade III
- hypersplenism
- 2 episodes of staphylococcal septicemia, the source of which
was not identified (he has had none of these since [**Month (only) 1096**]
[**2194**])
- likely right-sided scrotal hydrocele
- chronic anemia and thrombocytopenia
Social History:
Denies ETOH/tobacco
Lives with his parents
Family History:
Mother with MI. Denies FH of cancer.
Physical Exam:
Vitals: T 98.3, BP 84/46, HR 80, RR 20, 100% RA, Wt 109kg
I/O 2160i/70+ out; BMx 1
General: Awake, alert and oriented x 3, jaundiced
HEENT: NC/AT, PERRL, EOMI, scleral icterus. Dry MM.
Neck: supple, no jvd
Chest: gynecomastia b/l
Pulm: CTAB; no r/r/w
Cardiac: RRR, nl S1/S2, 2/6 M RUSB w/ radiation to carotids
Abdomen: soft, distended with ascites, protuberant umbilicus;
NT; b/l paracentesis sites w/o purulent drainage or cellulitis
Ext: 1+ b/l LE pitting edema, 1+ DP pulses b/l
Neurologic: Alert & Oriented x 3. CN 2-12 intact. No asterixis
Pertinent Results:
[**2196-8-7**] 08:16PM PT-19.5* PTT-39.8* INR(PT)-1.9*
[**2196-8-7**] 08:16PM PLT COUNT-64*
[**2196-8-7**] 08:16PM NEUTS-82.7* LYMPHS-8.0* MONOS-6.6 EOS-2.5
BASOS-0.4
[**2196-8-7**] 08:16PM WBC-13.4*# RBC-2.76*# HGB-9.9*# HCT-28.4*
MCV-103*# MCH-35.9* MCHC-34.8 RDW-20.1*
[**2196-8-7**] 08:16PM LIPASE-50
[**2196-8-7**] 08:16PM ALT(SGPT)-30 AST(SGOT)-49* ALK PHOS-145*
AMYLASE-32 TOT BILI-5.0*
[**2196-8-7**] 08:16PM GLUCOSE-108* UREA N-30* CREAT-1.8*
SODIUM-132* POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-28 ANION GAP-10
[**2196-8-7**] 08:34PM LACTATE-1.8
[**2196-8-7**] 09:00PM ASCITES WBC-785* RBC-175* POLYS-72* LYMPHS-2*
MONOS-1* EOS-1* MESOTHELI-6* MACROPHAG-18*
[**2196-8-7**] 09:00PM ASCITES TOT PROT-0.3 GLUCOSE-145 LD(LDH)-28
TOT BILI-0.2 ALBUMIN-<1.0
Brief Hospital Course:
MICU course:
This 51 yo male with hepatitis C cirrhosis presented with fevers
and found to have SBP believed secondary to recent paracentesis.
He was transferred to MICU as he began to become hypotensive
and had oliguric acute renal failure raising concern for both
sepsis and hepatorenal syndrome. He underwent diagnostic
paracentesis revealing elevated WBC consistent with SBP, gram
stain negative. He was continued on
vancomycin/levofloxacin/flagyl and changed to vancomycin when
cultures grew out Strep viridans sensitive to vancomycin.In
addition, the patient underwent large volume paracentesis
(approximately 1.5 L) and received colloid support with albumin.
He had a TEE that ruled out endocarditis.
The patients blood pressure and urine output subsequently
improved with creatinine returning to baseline. He remained
afebrile in the MICU. The patient also underwent workup for
liver transplant and was subsequently placed on the candidacy
list.
He experienced hypotension: Likely secondary to bacteremia
and HRS. Recieved blood transfusions and albumin in the MICU,
and he was continued on octreotide and midodrine. His diuretics
were intiatially held then resumed. Cr peaked at 3.3 in the
MICU, but then began trending down toward his baseline prior to
coming back to the floor.
FLOOR COURSE: Pt came to the floor with PICC line for 14-day
course of vancomycin and Cr coming back to baseline. Renal
function started worsening again. Sodium fell as low as 127
concerning for development of hepatorenal syndrome. Cipro was
started for SBP prophylaxis.
He was transferred back to the SICU on [**8-23**] for worsening
hepatorenal disease. MELD score was 40. He experienced a
traumatic foley catheter insertion requiring urology
consultation for bleeding. PT/PTT/INR were 36.2/81/4.0
respectively. He was given 3 units FFP and PRBC. The Renal
consult service followed noting oliguria and possible need for
CVVHD. A temporary HD line was placed.
On [**8-27**] he was taken to the OR for orthotopic liver
transplant by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] assisted by Drs. [**First Name (STitle) **] [**Name (STitle) **]
and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21082**]. The donor liver was Hep B core positive. He
was given HBIG during the anhepatic phase and then qd for 2
days. Lamivudine was started postoperatively. He received
solumedrol and cellcept induction immunosuppression. Please see
operative report for details. EBL was 6 liters. He was
transfused with 13 units of PRBC, 15 units FFP, cryo and
platelets. Two retroperitoneal drains were placed. He was sent
to the SICU postop where he did well. Postop liver duplex
revealed doppler flow with normal direction of flow seen within
the main portal vein, hepatic veins, and main and left hepatic
arteries. The right hepatic artery was not identified. A repeat
duplex was done demonstrating a patent hepatic artery. LFTs
trended down daily. He required CVVHD for creat of 3.6. CVVHD
was stopped on pod 2. He required PRBC and plt for a few days
post op for HCTof 24 and plt of 37. He was extubated on [**8-28**].
Diet was advanced. Solumedrol was tapered. Prograf 1mg [**Hospital1 **] was
initiated on POD 1. Lasix was given for anasarca. Creatinine
increased to 4.1 on POD 5. Lasix was also stopped per renal
consult recommendations. The previous days prograf level was
12.4. Prograf was decreased to 2mg [**Hospital1 **] from 3mg [**Hospital1 **]. The lateral
drain was removed on POD 5. The medial drain continued to drain
large volumes as high as 2 liters. He was given IV hydration.
The drain was removed on POD 10. A purse string suture was
placed for leaking of large amounts of serosang drainage.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained for hyperglycemia. Lantus insulin
was started in addition to a humalog sliding scale. The
temporary HD line was removed. His diet was advanced. Caloric
intake was ~1390 kcals. Physical therapy consult cleared him
for home with a rolling walker. The plan was for him to recover
at his sister's home in N.H. with VNA services.
On [**9-4**] he had a liver duplex for elevation in alk phos. Hepatic
veins were patent. The hepatic artery was poorly visualized
again, but the wave forms demonstrated appropriate flow. LFTs
trended down to ast of 20, alt of 94, alk phos or 179 and t.bili
of 2.3. Creatinine decreased to 3.5. Prograf was decreased to
1.5mg [**Hospital1 **] for a level of 12.5.
He was discharged in stable condition, ambulatory, tolerating a
regular diet and with stable vital signs.
Medications on Admission:
propranolol 20 mg t.i.d.
rifaximin 400 mg qd
lactulose 30 cc twice to 3 times per day
omeprazole 20 mg b.i.d.
furosemide 80 mg AM, 40 mg PM
sucralfate 1 gram t.i.d.
Aldactone 100 mg [**Hospital1 **] (per notes appeared increased to 300 mg qd
at clinic)
Cipro 750 mg once a week
Reglan 5 mg TID
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QOD ().
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: Ten (10)
ML PO DAILY (Daily).
7. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Continue use as long as you are taking narcotics.
Disp:*60 Capsule(s)* Refills:*2*
10. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous once a day.
Disp:*480 units* Refills:*2*
11. TEDS
Please provide one pair TEDS support stockings, size large
12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
13. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
S/P Orthotopic liver transplant
Acute Renal Failure
Steroid induced glucose intolerance
Discharge Condition:
Stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if you experience any of the following
symptoms: fever,chills, nausea, vomiting, diarrhea, pain over
the incision site or liver, jaundice, an increase in abdominal
girth or fluid in your legs or any other symptoms concerning to
you. Monitor weight and report a gain of 3 pounds or more in 2
days
Have labs drawn every Monday and Thursday and have them faxed to
the Transplant office at [**Telephone/Fax (1) 697**].
CBC, Chem 10, AST, ALT, Alk Phos, Albumin, T Bili and trough
Prograf Level
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2196-9-8**] 12:50
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2196-9-8**]
11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2196-9-15**] 2:50
Completed by:[**2196-9-6**]
|
[
"998.59",
"999.8",
"E932.0",
"251.8",
"571.5",
"570",
"070.71",
"584.7",
"567.29",
"038.0",
"572.4",
"995.91",
"286.7",
"289.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"51.22",
"50.59",
"99.07",
"38.95",
"99.04",
"99.00",
"88.72",
"54.91",
"38.93",
"99.05",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
10360, 10443
|
4140, 8778
|
316, 366
|
10575, 10584
|
3342, 4117
|
11156, 11601
|
2721, 2760
|
9123, 10337
|
10464, 10554
|
8804, 9100
|
10608, 11133
|
2775, 3323
|
258, 278
|
394, 2124
|
2146, 2644
|
2660, 2705
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,845
| 118,263
|
11172+11173
|
Discharge summary
|
report+report
|
Admission Date: [**2148-6-12**] Discharge Date: [**2148-6-19**]
Date of Birth: [**2122-3-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
suicide attempt
Major Surgical or Invasive Procedure:
intubation, extubation
History of Present Illness:
26 yo F w/ depression, anxiety, asthma, here with overdose of
unknown compound. Per her father, she has been depressed
recently secondary to a breakup with her boyfriend. Also father
states there has been familial issues as well as work issues
possbily involving litigation. She has also been drinking
alcohol along with her medications. Shitory of alcohol abuse,
cigarettes, and marijuana use. She had recently expressed intent
to take an overdose of clonazepam and to kill herself to friend
in [**Name (NI) 4565**] over the phone. She spoke with her father of the
night prior to admission and appeared very depressed. He was
worried and called the police to check on the pt. but there were
no outward signs of problems in the apartment. He drove up from
NY and found her sprawled out on the floor minimally responsive
and with "erratic breathing." There were 2 empty bottle of in
the apartment - Klonipin and Seroqule. EMS was called and she
was brought to the [**Hospital1 18**] ED. In the ED: initial vs: HR 112 BP
110/60 RR 12 02 sat 100% NRB-->98%RA She was given 0.4mg narcan
without effect. C02 was 32 on capnography. Her head ct was
negative.
.
MICU course - Pt was intubated and started on Clindamycin for
possble aspiration PNA. As per MICU team, pt to be treated for
total of [**4-3**] day. Pt was extubated without complication [**6-15**]
AM. Pt also with elevated CKs which trended down with IV fluids.
On transfer to the floor, patient is hysterically crying.
Stating she is having difficulty breathing.
Past Medical History:
PMH:
depression - bipolar?
anxiety
asthma
multiple ear infections in childhood
multiple episodes of PNA/bronchitis in last number of year
Social History:
[**University/College **]graduate student. works with ex-offenders.
+tobacco use, +etoh use, h/o marijuana use, states she "hates
her job."
Family History:
mother and sister with depression and SA.
Physical Exam:
PE: VS: T 95.9 HR 109 BP 132/86 RR 16 02sat 97@ on RA
GEN: responds to command, confused, does not respond to
questions
HEENT: dry MM, pupils are dilated and equal bilaterally, color
contacts in place, disconjugated gaze.
CV: tachy, no murmurs
PULM: CTAB
ABD: soft, NT, ND, present but hypoactive BS
EXT: WWP, no edema
NEURO: does not answer questions, awake and following commands
Pertinent Results:
[**2148-6-12**] 06:50PM FIBRINOGE-362
[**2148-6-12**] 06:50PM PLT COUNT-296
[**2148-6-12**] 06:50PM PT-14.8* PTT-24.0 INR(PT)-1.3*
[**2148-6-12**] 06:50PM WBC-10.6 RBC-5.03 HGB-15.8 HCT-45.5 MCV-90
MCH-31.4 MCHC-34.8 RDW-12.0
[**2148-6-12**] 06:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2148-6-12**] 06:50PM OSMOLAL-301
[**2148-6-12**] 06:50PM ALBUMIN-5.2* CALCIUM-10.3* PHOSPHATE-4.0
MAGNESIUM-2.1
[**2148-6-12**] 06:50PM LIPASE-13
[**2148-6-12**] 06:50PM ALT(SGPT)-21 AST(SGOT)-36 LD(LDH)-176
CK(CPK)-1896* ALK PHOS-68 AMYLASE-163* TOT BILI-0.3
[**2148-6-12**] 06:50PM GLUCOSE-107* UREA N-15 CREAT-1.1 SODIUM-149*
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-22 ANION GAP-23*
[**2148-6-12**] 06:54PM freeCa-1.04*
[**2148-6-12**] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2148-6-12**] 07:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2148-6-12**] 07:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2148-6-12**] 07:00PM URINE UCG-NEGATIVE
.
admission ECG: normal axis, nsr, rate 108, qt<400, no sttw abn.
STUDIES: CT head neg for acute process
.
EKG - [**6-14**] -Technically difficult study Sinus rhythm upper
normal rate Low lead QRS voltages Normal ECG Since previous
tracing of [**2148-6-13**], heart rate slower
.
chest x-ray [**6-13**] - The lung volumes are relatively low. At the
bases of the right lung, a focal area of consolidation with air
bronchograms is seen. This change would be consistent with
aspiration. In addition, there is a small right-sided pleural
effusion. The left lung is unremarkable. The size of the cardiac
silhouette is within the normal range. The hilar and mediastinal
contours are unremarkable.
Brief Hospital Course:
A/P: 26 yo F w/ pmh of depression s/p overdose on seroqual and
alcohol. Now s/p MICU stay with intubation. Now extubated being
treated for aspiration PNA and followed closely by psych for
suicidal ideation.
.
# Overdose:
- tox screen positive for methadone and tricyclics. Seraquel can
give false pos. tricyclic levels. CK levels down, QTc interval
closed.
- tried to get EKG today, will repeat tomorrow
- hold all home psych meds as per psych notes
- psychiatry consult- see OMR note for details - haldol 1 mg PO
TID PRN for agitation, no valium
- social work consult ordered
- cont [**11-28**] sitter
- section 12 can't leave AMA
- psych transfer to inpatient bed today
.
# Pulmonary:
- pt extubated s/p MICU stay, stable on room air
- will start Advair, d/c all other nebs
- pt stable on room air, soft call on the aspiration PNA, will
d/c all antibiotics at this time
.
# Depression: hold medications
- psych, social work.
.
#FEN
- replete lytes PRN, regular diet
- CK elevated on admission, decreased to 400s with fluids, no
longer needs IV fluids, renal function excellent, no need to
check daily lytes
.
#ACCESS: none
.
#PPx: heparin sq, bowel regime
.
#CODE: FULL
.
#COMMUNICATION: patient, father [**Doctor First Name **] [**Telephone/Fax (1) 35969**])
.
#DISPO: patient is medically stable for treatment in inpatient
psychiatric facility with continued outpatient medical
managment.
.
[**First Name8 (NamePattern2) **] [**Name6 (MD) 35970**] [**Name8 (MD) **], M.D., M.S.
Medications on Admission:
albuterol
clonazepam 1mg tid
fluoxetine 10mg qdaily
lamictal 200mg qdaily
seroquel 400mg qhs
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for agitation.
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Albuterol 90 mcg/Actuation Aerosol Sig: [**11-29**] Inhalation every
six (6) hours as needed.
8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -[**Hospital1 **]
Discharge Diagnosis:
1) Suicide attempt
2) Asthma, depression, anxiety
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital after a suicide attempt which
invovled seroquel overdose and alcohol use. You were intubated
in the MICU. You have been foloowed closely by psychiatry as
well as internal medicine during your stay here. You should
continue to take all of your medications as prescribed. You
should follow up with your PCP once you are discharged for
routine medical care. You should continue to see an outpatient
psychiatrist as indicated by the psychiatry team.
Followup Instructions:
As per inpatient psych facility
Completed by:[**2148-6-19**] Admission Date: [**2148-6-19**] Discharge Date: [**2148-6-21**]
Date of Birth: [**2122-3-18**] Sex: F
Service: PSYCHIATRY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1678**]
Chief Complaint:
"I wanted to f****** die."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
26 yo woman w/ hx of depression and
question of bipolar disorder s/p ingestion of psychiatric
medications (seroquel, klonipin, lamictal) several days ago in
apparent suicide attempt; psych consulted for eval of
suicidality. Per hx given by [**Hospital **] medical team, who has spoken
with the pt's father, earlier in the week in the context of a
fight with her boyfriend patient threatened suicide. The pt's
bf
called her father, who spoke with the patient, found her to be
angry and threatinging to take pills. When he arrived at her
apt
on the night of [**6-12**], he found her minimally responsive. In [**Name (NI) **],
pt agitated and confused, tox screen positive for tricyclics,
benzodiazepines, methadone, pt admitted to ICU for monitoring.
Pt had episode of respiratory distress thought to be c/w
aspiration pheumonitis, was intubated, and extubated today, when
psychiatry consulted.
On evaluation, pt is somewhat confused, hostile, and minimally
cooperative. She initially states "I don't feel like talking to
a fu***** shrink," tells me that she is a SW, asks if I know
what
a Section 12 is, tells me she would like to sign it, then says
she needs to leave the hospital soon. Initially the pt denies
all recollection of events preceeding ingestion; says last thing
she remembers is having one beer, watching family [**Male First Name (un) **], and
taking
excess medication. She will not reveal precipitant for
ingestion. She initially states "I wanted to fu***** die," said
she always wants to die, so she took unknown quantity of
seroquel
and lamictal to "carry out my plan." She then states that she
did not want to die, she just wanted to sleep; cannot say if she
believed she was taking a lethal dose. Notes now "I made a huge
mistake." Endorses anger, shame, and guilt. Says that her
outpt
treaters are not helping her and her mother caused her to be
bipolar b/c mo is bipolar. Continued to be hostile using
profanity throughout interview. Poor insight into severity of
action, future oriented and preoccupied with not losing job.
Interview kept brief due to increasing pt irritation and lack of
cooperation; pt also with mild confusion/distractibility.
Pt's family not currently available to provide collateral.
Past psychiatric history:
Per ICU team, pt has long hx of depression and multiple inpt
psychiatric admissions, first at age 13. Pt reports hx of
bipolar disorder but would not elaborate. Pt denies prior SA.
Unclear past medication trials. Currently has psychiatrist,
Dr.[**Last Name (STitle) 35971**] at Southern [**Hospital 12162**] Health Center.
Past Medical History:
PMH:
depression - bipolar?
anxiety
asthma
multiple ear infections in childhood
multiple episodes of PNA/bronchitis in last number of year
Social History:
Pt minimally forthcoming. Appears
to have both parents living. Reports she is a SW and is
attending [**Doctor Last Name **] graduate school of social work and has
internship at [**University/College **]. Per ICU resident, recent break up w/ BF.
+tobacco, +etoh use, h/o marijuana use. States she "hates her
job."
Family History:
mother and sister with depression and SA.
Physical Exam:
Physical Exam: Benign physical exam on admission to [**Hospital1 **] 4.
VS: 100 70 115/67 14 98%
MSE: Young white female with discheveled hair, poor eye
contact,
sitting in bed, NAD, behavior WNL. Speech soft volume, NL r/t.
TP- Generally organized, occasionally confused. TC- Denies
current SI. Recent SI as in HPI. No evident psychosis. Mood:
"I'm angry at myself, and guilty." Affect: Tense, irritable.
I/J: Poor/Poor. Alert, oriented to [**Hospital1 18**], not oriented to date
other than month/year. Became confused when counting back
through the days of [**Month (only) 205**] to try to figure out date.
Non-cooperative with rest of cognitive exam.
Pertinent Results:
[**2148-6-21**] 07:10AM BLOOD WBC-6.5 RBC-4.04* Hgb-12.5 Hct-35.4*
MCV-88 MCH-31.0 MCHC-35.5* RDW-12.8 Plt Ct-386#
[**2148-6-21**] 07:10AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-139
K-3.8 Cl-105 HCO3-26 AnGap-12
[**2148-6-21**] 07:10AM BLOOD ALT-24 AST-16 CK(CPK)-37 AlkPhos-60
TotBili-0.2
[**2148-6-21**] 07:10AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0
Brief Hospital Course:
The patient was admitted to the inpatient psychiatry unit
after being medically cleared on the medical floor. [**Hospital 35972**]
medical floor she did require a short period of intubation for
respiratory distress related to her suicide attempt.
The patient was initially noted to be hostile and
uncooperative while being seen by the consult service while on
the medical floor. When ready for transfer to psychiatry she was
noted to be calmer and signed in voluntarily.
While on the floor the patient stated her life had turned
around and she was glad to be alive. She was especially glad
that all of her social support (father, boyfriend, and mother)
were coming together to help her. On questioning she stated that
this attempt on her life was an effort to draw her support
together rather than a true desire to die. It was repeatedly
emphasized that in her miguided attempt to reach out, she nearly
died. Throughout this stay however she continued to minimize,
repeating that "everything is totally different" and that she
would never make an attempt on her life again. We attempted to
temper the patients extreme and abrupt turnaround and were met
with a low frustration tolerance and irritability. The patients
insight is certainly impaired.
Also during this stay, the patient made several statements
concerning for Axis II traits including idealizations of her
parents getting together and boyfriend moving back from the west
coast as a result of her suicide attempt. It should also be
noted that after 1 or 2 meetings she idealized her relationship
with the consulting psychiatry resident and was asking to
transfer her outpatient psychiatric care to him. She stated to
the team, "I feel empty all the time."
In general her presentation was concerning for Axis II traits
on top of a major depression rather than a bipolar illness. Our
concern with her impulsivity and alcohol use was discussed with
the patient.
On the second hospital day the patient was strongly in favor
of discharge, and the team felt that she was safe to return home
with close outpatient follow-up as she was not at imminent risk
for another attempt on her life. When presented with the option
of discharge plus a partial program vs. staying on the unit the
patient was angry and irritable as she felt a partial was not
necessary, but agreed to the partial program. On the day of
discharge a family meeting was held with the patient, her
father, her boyfriend, and the social worker. It was there
agreed that it would be safe for the patient to return home,
especially as her boyfriend would be staying with her and her
father remaining in [**Name (NI) 86**] for the short-term. Prior to
discharge appotiments were made for the patient with her PCP,
[**Name10 (NameIs) 35973**], the [**Hospital1 1680**] Partial Program. In addition the
patient expressed interest in obtaining a therapist, and she
will be assigned one at her visit with her psychiatrist.
Medications on Admission:
Meds (outpt):
Lamictal 200mg PO QHS
Seroquel 400mg PO QHS
Klonipin 1mg PO TID
Prozac 10mg PO QD
Meds (inpt):
Albuterol neb Q4H PRN sob/wheeze
Famotidine 20mg PO BID
Levo 750mg PO QD
Vanco 1000mg IV Q12h
Heparin SC
Discharge Medications:
Albuterol MDI 1-2 puffs every 6 hours as needed for shortness of
breath
Advair 100/50 1 INH twice a day
Remeron 7.5mg PO at bedtime
Discharge Disposition:
Home
Discharge Diagnosis:
Axis I: Major Depressive Disorder
Axis II: Borderline traits vs. disorder
Axis III: Asthma
Discharge Condition:
stable with resolution of symptoms since admission
Discharge Instructions:
Take all your medications as prescribed. Keep all of your
follow-up appointments. Return to the ED if you have thoughts of
hurting yourself or anyone else.
Followup Instructions:
1.) Psychiatry - Dr. [**Last Name (STitle) 14303**] at [**Hospital1 **] Counseling
Appointment for Wednesday, [**6-26**] at 9:45 AM.
at [**Street Address(2) 35974**]., [**Location (un) 538**], MA
2.) Therapist - You will be assigned a therapist at your visit
with Dr. [**Last Name (STitle) 14303**].
3.) Primary Care - Dr. [**Last Name (STitle) 35975**] at SJPHC
Appointment for Tuesday, [**6-25**] at 11:45 AM
at [**Street Address(2) 18787**], [**Location (un) 35976**], MA
Completed by:[**2148-6-21**]
|
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,729
| 154,008
|
4869
|
Discharge summary
|
report
|
Admission Date: [**2195-10-2**] Discharge Date: [**2195-10-8**]
Date of Birth: [**2114-9-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / lovastatin / furosemide
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2195-10-2**]
aortic valve replacement(tissue 25mm), coronary artery bypass
grafting times two with Left Internal Mammary Artery to Left
Anterior Descending artery and reverse Saphenous Vein Graft to
Obtuse Marginal artery.
History of Present Illness:
This 80 year old man with a history of polymyalgia rheumatica on
chronic steroids and aortic stenosis that has been followed by
serial echocardiograms for many years. He has noted a decline in
his activity tolerance over the past six months. Dyspnea with
limited amounts of activity and several episodes of exertional
lightheadedness with no syncope. He is now being referred for
cardiac catheterization to assess his aortic valve.
Past Medical History:
Severe Aortic stenosis
Hypertension
Hyperlipidemia
Polymyalgia rheumatica on chronic steroids
Recent nose bleeds requiring cauterization (aspirin since d/c'd)
Thrombocytopenia
GERD
Right sided sciatica
Gout
Hard of hearing (right sided hearing aid)
Carpal tunnel syndrome bilaterally (wearing splints at night)
Arthritis
Right shoulder surgery for a "separation"
Social History:
lives with his wife and is retied.
He does not smoke cigarettes.
Consumes [**3-17**] alcoholic beverages per week.
He denies use of illigal drugs.
Family History:
Father died at age 77 from unknown causes, might have had a
stroke. Mother with "cardiac disease", dying in her 50's from a
"giant embolism"
Physical Exam:
Admission exam:
Pulse:58 B/P Right: Left:138/62 Resp:20 O2 sat:100% RA
Height:175cm Weight:93.4kg
General:NAD, AAOx3,No focal deficits
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [] grade _3/6_____
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:+1 Left:+1
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:Cath site Left:+2
Carotid Bruit: None
Discahrge exam:
VS 98.9 76 120/62 18 97% RA
wt 102.1kg
Gen: NAD
Neuro: A&O x3, MAE. nonfocal exam
Pulm: CTA-bilat
CV: RRR, no murmur. Sternum stable-incision CDI
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused. 2+ pedal edema bilat
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
BP (mm Hg): 129/69 Wgt (lb): 207
HR (bpm): 56 BSA (m2): 2.10 m2
Indication: Aortic valve disease. Coronary artery disease. Left
ventricular function.
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.7 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.4 cm
Left Ventricle - Fractional Shortening: 0.44 >= 0.29
Left Ventricle - Ejection Fraction: >= 65% >= 55%
Left Ventricle - Stroke Volume: 125 ml/beat
Left Ventricle - Cardiac Output: 7.02 L/min
Left Ventricle - Cardiac Index: 3.35 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.03 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *26 < 15
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *5.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *106 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 67 mm Hg
Aortic Valve - LVOT pk vel: 1.19 m/sec
Aortic Valve - LVOT VTI: 33
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.3 m/sec
Mitral Valve - E/A ratio: 0.69
Mitral Valve - E Wave deceleration time: *343 ms 140-250 ms
Pulmonic Valve - Peak Velocity: 1.1 m/sec <= 1.5 m/sec
Findings
This study was compared to the prior study of [**2195-2-6**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). TDI E/e' >15,
suggesting PCWP>18mmHg. No resting or Valsalva inducible LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Normal aortic arch diameter. No 2D or Doppler
evidence of distal arch coarctation.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Calcified tips of papillary
muscles. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor subcostal
views.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>65%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no left ventricular outflow obstruction
at rest or with Valsalva. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved regional and excellent
global biventricular systolic function. Increased PCWP.
Compared with the prior study (images reviewed) of [**2195-2-6**],
the aortic valve gradient is slightly higher.
Admission labs:
[**2195-10-2**] 11:21AM PT-15.3* PTT-29.9 INR(PT)-1.4*
[**2195-10-2**] 11:21AM PLT SMR-LOW PLT COUNT-88*
[**2195-10-2**] 01:45PM UREA N-17 CREAT-0.7 SODIUM-141 POTASSIUM-3.9
CHLORIDE-113* TOTAL CO2-21* ANION GAP-11
[**2195-10-2**] 01:46PM freeCa-1.05*
[**2195-10-2**] 01:03PM WBC-15.9*# RBC-2.81* HGB-8.4* HCT-25.1*#
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.1
Discharge Labs:
[**2195-10-8**] 06:09AM BLOOD WBC-8.0 RBC-3.06* Hgb-9.1* Hct-27.7*
MCV-91 MCH-29.9 MCHC-33.0 RDW-14.5 Plt Ct-171
[**2195-10-8**] 06:09AM BLOOD Plt Ct-171
[**2195-10-6**] 05:23AM BLOOD PT-13.2* PTT-29.4 INR(PT)-1.2*
[**2195-10-8**] 06:09AM BLOOD Glucose-117* UreaN-24* Creat-0.7 Na-135
K-4.2 Cl-96 HCO3-31 AnGap-12
Radiology Report CHEST (PA & LAT) Study Date of [**2195-10-7**] 1:38 PM
Final Report: A small right and moderate-to-large left pleural
effusion are unchanged since the prior exam yesterday. Central
pulmonary vascular
congestion has significantly improved. Sternotomy wires are
intact and
mediastinal clips are in unchanged position. A right-sided
internal jugular catheter tip remains in the low SVC.
IMPRESSION: Stable small right and moderate-to-large left
effusions.
Brief Hospital Course:
The patient was a same day admission and was brought to the
Operating Room on [**2195-10-2**] where the patient underwent an Aortic
Valve Rreplacement(tissue 25mm) and Coronary artery bypass
grafting times two with Left Internal Mammary Artery to Left
Anterior Descending artery and reverse Saphenous Vein Graft to
Obtuse Marginal artery. His cardiopulmonary bypass time was 90
minutes with a crossclamp of 73 minutes.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He had some
post-operative bleeding and was transfused with several units of
packed red blood cells, fresh frozen plasma and received
Protamine with resolution of bleeding. Post-operative day one
found the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable. Over the next 48hours he was weaned
from pressor support and beta blockers were initiated, the
patient was gently diuresed toward his preoperative weight.
On POD3 the patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued per cardiac surgery guidelines without
complication. The patient worked with the physical therapy
service for assistance with strength and mobility. By the time
of discharge on post-operative day 6 the patient was ambulating
with assistance, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to Life Care
Center of [**Location 15289**] in good condition with appropriate
follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Allopurinol 100 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH [**Hospital1 **]
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Pravastatin 10 mg PO DAILY
7. PredniSONE 6 mg PO DAILY
8. Calcium Carbonate 500 mg PO DAILY
9. Vitamin D [**2183**] UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Aspirin EC 81 mg PO DAILY
if extubated
3. Docusate Sodium 100 mg PO BID
4. Milk of Magnesia 30 mL PO DAILY:PRN constipation
5. Omeprazole 20 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH [**Hospital1 **]
7. Vitamin D [**2183**] UNIT PO DAILY
8. Calcium Carbonate 500 mg PO DAILY
9. Allopurinol 100 mg PO DAILY
10. Pravastatin 10 mg PO DAILY
11. PredniSONE 6 mg PO DAILY
12. Metoprolol Tartrate 12.5 mg PO BID
hold HR<55 SBP<100
13. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*50 Tablet Refills:*0
14. Metolazone 5 mg PO BID
15. Furosemide 40 mg PO BID
16. Potassium Chloride 20 mEq PO BID
Hold for K > 4.5
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
aortic stenosis
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Ultram
Sternal Incision - healing well, no erythema or drainage
Edema- 2+ bilat
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check-Cardiac Surgery Office Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2195-10-20**] 10:30
Surgeon- Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2195-11-4**] 1:15
Cardiologist- [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2195-11-5**] 7:40
Please call to schedule the following:
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 3329**] in [**5-14**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2195-10-8**]
|
[
"414.01",
"274.9",
"272.4",
"V58.65",
"427.32",
"285.9",
"458.29",
"511.9",
"E878.2",
"354.0",
"E849.7",
"287.5",
"401.9",
"725",
"530.81",
"716.90",
"998.11",
"389.9",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"35.21",
"38.93",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10665, 10732
|
7774, 9417
|
320, 548
|
10816, 10979
|
2641, 6563
|
11659, 12446
|
1577, 1720
|
9894, 10642
|
10753, 10795
|
9443, 9871
|
11003, 11636
|
6957, 7751
|
1735, 2622
|
261, 282
|
576, 1010
|
6579, 6941
|
1032, 1397
|
1413, 1561
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,955
| 116,283
|
1581
|
Discharge summary
|
report
|
Admission Date: [**2142-9-9**] Discharge Date: [**2142-9-18**]
Date of Birth: [**2080-10-27**] Sex: M
Service: SURGERY
Allergies:
Tetracycline / Percocet
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
end stage renal disease
Major Surgical or Invasive Procedure:
1) s/p cadaveric kidney transplant
History of Present Illness:
Mr. [**Known lastname 9201**] is a 62-year-old male with end-stage renal disease
who underwent pretransplant evaluation and after risk-suitable
workup is now ready for
transplantation after a donor organ became available. The
crossmatch was negative and the ABO compatibility was confirmed.
He has had no recent changes in his health status, including no
recent cough, chest pain or shortness of breath, or fevers.
Please see the results section of this discharge summary for the
results of his pre-op work-up.
Past Medical History:
1) Coronary artery disease, status post CABG in the year [**2136**],
s/p multiple PCI's
2) End-stage renal disease secondary to polycystic kidney
disease and is on hemodialysis.
3) Status post failed renal transplant.
4) GERD.
5) Peptic ulcer disease
6) Mitral regurgitation.
7) Diabetes mellitus type 2.
8) Hypertension.
9) Hyperlipidemia.
10) Peripheral vascular disease.
11) Gout.
12) Status post appendectomy.
13) Depression and anxiety.
Social History:
Lives at home with his wife and one of his children.
Family History:
Notable for CAD, diabetes mellitus,
hypertension, and a sister with kidney disease.
Physical Exam:
A+O x 3.
Afebrile, vital signs stable in the pre-operative holding area.
Cor: systolic murmur
Lungs: bil. rales.
Abd S/NT/ND. His prior kidney transplant incision has healed
nicely without evidence of wound breakdown or discharge.
LE His femorals are 2+ and equal bilaterally.
Pertinent Results:
[**2142-9-9**] 11:30PM WBC-5.7 RBC-4.37* HGB-13.6* HCT-40.9 MCV-93
MCH-31.1 MCHC-33.2 RDW-15.0 PLT COUNT-146*
[**2142-9-9**] 11:30PM UREA N-74* CREAT-10.1*# SODIUM-141
POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-19* ANION GAP-30*
[**2142-9-9**] 11:30PM CALCIUM-9.6 PHOSPHATE-7.8*# CHOLEST-130
[**2142-9-9**] 11:30PM ALT(SGPT)-8 AST(SGOT)-9 LD(LDH)-144
[**2142-9-9**] 11:30PM TRIGLYCER-101
[**2142-9-9**] 11:30PM PT-14.5* PTT-27.7 INR(PT)-1.4
CMV (-)
EBV (-)
Sinus rhythm
Left atrial abnormality
Low limb lead QRS voltages
Probable right ventricular conduction delay
Consider prior inferolateral myocardial infarct
Clinical correlation is suggested also for possible in part RV
overload
Since previous tracing of [**2142-9-10**], tachyarrhythmia absent
Renal Transplant Ultrasound [**9-11**]
1. Normal perfusion with normal RI of 0.8 of transplanted
kidney.
2. A complexed superficial fluid collection in the left lower
quadrant inferior to the transplanted kidney, probably
representing hematoma, seroma, or lymphocele.
3. Empty bladder with Foley catheter, which cannot be further
evaluated.
Echo [**9-11**]
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal
hypokinesis of the inferior and inferolateral walls. [Intrinsic
left ventricular systolic function may be more depressed given
the severity of valvular regurgitation.]The aortic valve
leaflets (3) are moderately thickened. Aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Severe (4+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior report (tape unavailable for review) of
[**2140-4-27**], the severity of mitral regurgitation is increased. And
pulmonary artery systolic hypertension is now identified.
KUB [**2142-9-17**]
There are gas-filled loops and non-dilated small bowel gas in
the colon, and no obvious evidence for intestinal obstruction or
free intraperitoneal gas on the suboptimal film.
Brief Hospital Course:
This 61 year old male was admitted for cadaveric kidney
transplant. He underwent a successful transplant [**9-10**] along
with a left inguinal hernia repair. Given his significant
cardiac history he was monitored in the PACU then transferred to
the SICU after extubation. He required pressor support
following the surgery. Immunosuppressants were started
intra-operatively per the standard protocol. He also required
an intermittent insulin drip to tightly control his blood
glucose. Cardiology was consulted to help in management of the
patient post-operatively given his hypotension and pre-op
history. They recommended a temporary hold on plavix and to
hold aggrenox. Aspirin was continued. He initially made 25-35cc
of urine per hour but this decreased to 189 cc for the 24 hrs on
POD 3. This was due to delayed graft response. On POD 4 the
patient received a treatment of hemodialysis for fluid
overload-- this decreased his weight from 79.9 to 76.0 kg
(pre-op weight 64).
On POD [**4-21**] the patient's diet was advanced to full. His urine
output rose to 990 cc for the day on POD 7. His Cr dropped to
5.1 from over 8 previously. The renal transplant service
(following) felt he would no longer need hemodialysis. He
complained of nausea and vomiting while taking [**Last Name (LF) 9202**], [**First Name3 (LF) **] this
was discontinued. In addition, his Cellcept was tapered to 500
[**Hospital1 **]. LFT's and an EKG were also checked to r/o any biliary or
cardiac disease, and these were at baseline. He was started on
levoquin x 7 day course for a UTI on POD 5, sensitivities
pending at time of discharge. Otherwise, his home medications
were restarted, with the exception of aggrenox as cardiology
could find no reason to continue this. He was tolerating a
regular diet and he remained afebrile.
Before discharge the patient's foley was reinserted for urinary
retention. This should be continued for 2 weeks, when a voiding
trial can be conducted.
His immunosuppressive regimen was maintained per protocol
throughout his hospital course. Daily Prograf levels were
checked and his doses adjusted accordingly. His Prograf level
was stable at approximately 10 on 4 mg [**Hospital1 **]. He received ATG x 4
doses per protocol. His Cellcept was tapered to 500 mg [**Hospital1 **] for
nausea and vomiting.
Medications on Admission:
ASA325, folate, prilosec 30, lopressor 100, plavix 75, Dig.125
MWF, aggrenox 75 [**Hospital1 **], neurontin 100TID, isosorbide 40 TID,
trazadone 50 QHS, lactulose 30.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Diphenhydramine HCl 25 mg Capsule Sig: [**12-17**] Capsules PO Q12H
OR QHS PRN () as needed for sleep.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection [**Hospital1 **] (2 times a day).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO MON/WED/[**Female First Name (un) **]
().
10. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
syringe Subcutaneous ASDIR (AS DIRECTED): Bedtime
Glargine 6 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-50 mg/dL [**12-17**] amp D50 [**12-17**] amp D50 [**12-17**] amp D50 [**12-17**] amp D50
51-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 0 Units
161-200 mg/dL 4 Units 4 Units 4 Units 0 Units
201-240 mg/dL 6 Units 6 Units 6 Units 2 Units
241-280 mg/dL 8 Units 8 Units 8 Units 3 Units
281-320 mg/dL 10 Units 10 Units 10 Units 4 Units
.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP < 100, HR < 60.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
17. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
18. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
20. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 4 doses.
21. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] Center - [**Location (un) 701**]
Discharge Diagnosis:
End stage renal disease s/p cadaveric kidney transplant.
Discharge Condition:
Stable.
Discharge Instructions:
1) Please call Dr.[**Name (NI) 670**] office or return to the ED if you
have increasing abdominal pain, fevers > 101.5 F, redness around
or drainage from your wound, or a drop-off in urine output.
2) Sponge bath only until staples come out at your first
follow-up visit. The incision may get wet but do not soak or
scrub it.
Followup Instructions:
1) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-9-20**] 1:10 PM
2) Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-9-25**] 3:40 PM
3) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-10-1**] 3:20 PM
Completed by:[**2142-9-18**]
|
[
"276.2",
"753.12",
"357.2",
"550.90",
"996.81",
"424.0",
"250.60",
"443.9",
"599.0",
"274.9",
"600.91",
"584.5",
"V45.81",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.95",
"53.01",
"55.69",
"00.93",
"96.71",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
9193, 9274
|
4030, 6353
|
306, 343
|
9375, 9385
|
1833, 4007
|
9759, 10243
|
1436, 1521
|
6570, 9170
|
9295, 9354
|
6379, 6547
|
9409, 9736
|
1536, 1814
|
243, 268
|
371, 884
|
906, 1350
|
1366, 1420
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,152
| 174,477
|
27944
|
Discharge summary
|
report
|
Admission Date: [**2199-12-24**] Discharge Date: [**2200-1-10**]
Date of Birth: [**2146-10-2**] Sex: M
Service: SURGERY
Allergies:
Strawberry
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Severe intermittent claudication with infrarenal aortic and
common iliac artery occlusion
Major Surgical or Invasive Procedure:
[**2199-12-24**]
PROCEDURES:
1. Aortobifemoral bypass with 12 x 6 aortobifemoral graft.
2. Abdominal pelvic aortogram with iliac artery runoff.
3. Thrombectomy of aortobifemoral graft with [**Doctor Last Name **]
embolectomy catheters.
4. Bilateral iliac artery angioplasty and stenting with 7
mm self-expanding stent grafts via bilateral femoral
cutdown.
[**2199-12-24**]
PROCEDURES: Exploratory laparotomy, evacuation of intra-
abdominal hematoma and open packing of the abdomen.
[**2199-12-25**]
OPERATION PERFORMED: Abdominal washout and removal of
packing and temporary abdominal closure.
[**2199-12-28**]
PROCEDURE: Exploratory laparotomy, washout and delayed
abdominal closure.
History of Present Illness:
This 54-year-old gentleman has had severe disabling claudication
for 2 years. This was originally thought to be a [**Last Name **] problem.
[**Name (NI) **] has been unable to walk.
Ultimately an MRA was done which showed that his infrarenal
aorta was occluded along with his common iliac arteries down to
the iliac bifurcation, which both external iliac arteries were
severely diseased with patent common femoral arteries and
reasonable runoff distally. He was advised to have an
aortobifemoral bypass.
Past Medical History:
hyperlipidemia, a cyst resection from his neck in [**Month (only) **]
[**2198**], an abscess removed from his neck in [**2176**], rhinoplasty in
[**2173**] and tonsillectomy in [**2156**].
Denies a history of anemia.
Social History:
Mr. [**Known lastname 4469**] is a divorced attorney
Tobacco: 40 pack year smoker
ETOH: social
Admits to prior use of MJ, LSD, cocaine in past
Family History:
Mother w/history of colon cancer in her 40's - treated
successfully. Now 82yo alive and well. Father deceased from
melanoma at 38yo.
No h/o CAD
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness, Open wound
VAC dressing in place
GROIN: B/L groin incisions C/I, some serous drainage noted
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2200-1-8**] 05:13AM BLOOD
WBC-11.5* RBC-3.43* Hgb-10.0* Hct-31.8* MCV-93 MCH-29.3
MCHC-31.5 RDW-16.2* Plt Ct-606*
[**2200-1-5**] 03:05AM BLOOD
PT-15.6* PTT-27.2 INR(PT)-1.4*
[**2200-1-8**] 05:13AM BLOOD
Glucose-108* UreaN-18 Creat-1.0 Na-141 K-4.2 Cl-106 HCO3-25
AnGap-14
[**2200-1-6**] 03:35AM BLOOD
ALT-64* AST-71* AlkPhos-116 TotBili-2.3*
[**2200-1-8**] 05:13AM BLOOD
Calcium-8.1* Phos-2.9 Mg-1.9
[**2200-1-3**] 07:50AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-0-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1
[**2200-1-3**] 7:55 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2200-1-3**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2200-1-5**]):
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
RUQ US:
FINDINGS: The liver is diffusely echogenic. No focal hepatic
lesions are
identified. There is no intra- or extra-hepatic biliary ductal
dilation. The common duct measures 3 mm. The portal vein is
patent, with forward flow. The gallbladder is nondistended and
normal in appearance. There are no gallstones. There is no
gallbladder wall edema or pericholecystic fluid. The spleen is
normal in size. There is no free fluid in the right upper
quadrant.
IMPRESSION: Normal gallbladder. No biliary ductal dilation.
Echogenic liver consistent with fatty infiltration. Other forms
of liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
Brief Hospital Course:
[**2199-12-24**]
Mr. [**Known lastname **],[**Known firstname **] was admitted on [**12-24**] with severe intermittent
claudication
with infrarenal aortic and common iliac artery occlusion. He
agreed to have an elective surgery. Pre-operatively, he was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preperations were made.
It was decided that she would undergo a:
PROCEDURES:
1. Aortobifemoral bypass with 12 x 6 aortobifemoral graft.
2. Abdominal pelvic aortogram with iliac artery runoff.
3. Thrombectomy of aortobifemoral graft with [**Doctor Last Name **]
embolectomy catheters.
4. Bilateral iliac artery angioplasty and stenting with 7
mm self-expanding stent grafts via bilateral femoral
cutdown.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, transferred to the PACU for further
stabilization and monitoring.
He was hypotensive in the PACU with a large volume requirement.
He dropped his hematocrit from 31 to 26. His abdomen became
increasingly tense and he was showing signs of abdominal
compartment syndrome and we decided to re-explore him.
He was taken back to the OR, he then [**Doctor Last Name 1834**] a Exploratory
laparotomy, evacuation of intra - abdominal hematoma and open
packing of the abdomen. He was closely monitored. Because of
his excessive bleeding a Heme Onc consult was obtained. The
Bleeding was thought to be from DIC.
Heme / Onc reccomendations:
1) pRBC's to keep Hct>30
2) cryoprecipitate to keep fibrinogen >100
3) FFP while actively bleeding to help correct coagulopathy
4) Platelets to keep counts above 50K (while actively bleeding)
5) Check DIC panel and CBC with coags every 3-4 hours.
6) Dose of desmopressin, for vWF deficiency
The patient did recieve all of the above. His Abdomen was left
open. He was then transferred to the CVICU for further recovery.
While in the CVICU he recieved monitered care.
Peri operative AB
[**2199-12-25**]
He was taken back for Abdominal washout and removal of packing
and temporary abdominal closure.
He was then transferred to the CVICU for further recovery. While
in the CVICU he recieved monitered care. He remained in guarded
condition. His cagulopathy improved. Was 10 liters positve.
lasix drip for fluid overload.
Remained intudated, on pressors.
Recieved bronchoscopy for RUL collapse
Peri operative AB
[**2199-12-26**]
Remained in the CVICU, intubated, IV lasix continued, aggressive
electrolytes repletion. Neo for BP control. Resp acidosis, Tube
feeds.
General Surgery was consulted for open Abdomen.
[**2199-12-27**]
Remained paralyzed and sedated, Pressors DC'd. BP improved, c/w
vent wean, NPO with TF, HLIV, Good UOP.
Peri operative AB
[**2199-12-28**] - [**2199-12-30**]
PROCEDURE: Exploratory laparotomy, washout and delayed abdominal
closure.
Remained paralyzed and sedated, BP stable on nitro, c/w vent
wean, NPO with TF, HLIV, Good UOP.
Peri operative AB DC'd.
Bronchial Specimans: HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE
NEGATIVE. Pt started on Ampicillan. He recieved these antbiotic
untill time of DC.
Wet to Dry dressing changes to abdomen.
[**2199-12-31**]
Paralytic DC'd, remained sedated, BP stable on nitro, c/w vent
wean, NPO with TF, HLIV, Good UOP.
C/W ampicillan
Vac dressing placed on abdomen.
CVL change. Pt still with WBC
[**2200-1-1**] - [**2200-1-2**]
Paralytic DC'd, remained sedated, BP stable on nitro, c/w vent
wean, NPO with TF, HLIV, Good UOP. Lasix drip
C/W ampicillan for PNA, Cipro and flagyl started. Wound looked
psuedomonial, Flagyl for increase stool. C-Diff negative.
Treated emperically
[**2200-1-4**]
Pt extubated, lasix drip DC'd - put on IV lasix, speech and
swallow - TF stopped. Mecahnical soft diet started. c/w
antibiotics as above.
[**2199-1-5**] - [**2199-1-9**]
Transfered to the VICU, When stable he was delined. He continued
to have decreased PO intake. Nutrition Consult obtained. Calorie
counts. No need for TF. Encouraged to take PO for nutrion.
He did fail voiding trial. Flomax started. Foley replaced.
A PT consult was obtained. Recommended Rehab. Case management
involved. Placed successfully
He progressed with physical therapy to improve her strength and
mobility. He continues to make steady progress without any
incidents. He was discharged to a rehabilitation facility in
stable condition.
Medications on Admission:
simvastatin 20'
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-28**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO QID (4
times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-1**]
hours: prn for pain.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] Center - [**Location (un) 701**]
Discharge Diagnosis:
1. Severe intermittent claudication with infrarenal aortic and
common iliac artery occlusion
2. Intra-abdominal hemorrhage following aortobifemoral bypass.
3. Open abdomen status post aortobifemoral bypass graft with
abdominal compartment syndrome
4. Open abdomen
5. Hyperlipidemia
6. DIC, requiring massive amounts of fluid resusitation,
including blood products, FFP, cryo.
7. Right upper lobe collapse, post op - bronchoscopy
8. Hospital aquired PNA
9. Urinary retention requiring foley and flomax
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-29**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2200-1-23**] 10:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2200-1-16**] 2:00
Completed by:[**2200-1-10**]
|
[
"518.0",
"286.6",
"996.74",
"E878.2",
"518.81",
"998.89",
"272.4",
"482.2",
"276.2",
"440.8",
"788.20",
"998.12",
"440.0",
"729.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"88.47",
"54.63",
"38.93",
"54.12",
"39.79",
"96.72",
"39.25",
"38.04",
"54.64",
"38.44",
"39.41",
"88.42",
"38.08",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9668, 9749
|
4391, 8916
|
361, 1070
|
10294, 10294
|
2759, 4368
|
13237, 13578
|
2023, 2169
|
8982, 9645
|
9770, 10273
|
8942, 8959
|
10439, 12811
|
12837, 13214
|
2184, 2740
|
232, 323
|
1098, 1604
|
10308, 10415
|
1626, 1846
|
1862, 2007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,456
| 147,366
|
14261
|
Discharge summary
|
report
|
Admission Date: [**2190-9-2**] Discharge Date: [**2190-9-9**]
Service: MEDICINE
Allergies:
Nitroglycerin / Plavix
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Syncope, melena
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy
History of Present Illness:
Mr [**Known lastname 42375**] is an 84-y/o F with HTN, CAD (s/p stenting), GERD, PUD
and depression, who presents to the ED today after a syncopal
episode and was found to have several large melanotic stools.
.
The pt reports she has noted some increase in her usual GERD sxs
over the last few days, as well as some new, diffuse abd pain.
The abd pain is described as [**5-15**], "achy" and "annoying" in
nature, but non-radiating. Earlier today the pt noted that both
sxs were even worse than they had been. She was at her [**Hospital 4382**] - having just moved from a NH earlier in the day - and
was seated in a chair when she noted the sudden onset of
lightheadness and felt like she was going to faint. The onset of
sxs were not associated with any change in her activity (i.e.,
standing or stress); the pt does not think she lost
consciousness and denies any resultant trauma. She denies any
associated CP, palpitations, SOB. The pt was taken to the ED for
evaluation where she was noted to have a large melanotic stool;
she reports she had never had anything similar in the past. The
pt was treated with a PPI and hydralazine for an SBP in the
240s, and planned for admission to the floor, however she
subsequently had two additional large bowel movements and thus
is admitted to the MICU for closer monitoring.
.
On ROS, the pt denies the sxs described above. Additional she
has noted no fevers, change in vision or weight. She did note
some chills earlier in the day today. No trouble swallowing. No
diaphoresis or exertional dyspnea. No nausea or vomiting. No
urinary sxs including frequency, urgency or dysuria.
Past Medical History:
- hypertension
- coronary artery dz s/p BMS to RCA in [**2184**]
- peptic ulcer disease
- gastroesophageal reflux disease
- tension headaches
- depression
Social History:
Retired clerical worker. Lifelong non-smoker. No EtOH. Lives now
in an [**Hospital3 **] facility. Daughter involved in care.
Family History:
Mother died in her 70s from PNA. Father died in 80s from unclear
cause.
Physical Exam:
VS: T 98.4, BP 159/74, P 64, R 18, 94 RA
Gen: Well-appearing elderly female, no acute distress.
HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD.
Chest: Bilateral crackles at the bases.
Cor: Normal S1, S2. RRR. No murmurs appreciated.
Abdomen: Soft, non-tender and non-distended. +BS, no HSM.
Extremity: Warm, without edema. 2+ DP pulses bilat.
Neuro: Alert and oriented x 3. CN 2-12 intact. Motor strength
intact in all extremities. Sensation intact grossly.
Pertinent Results:
[**2190-9-2**] 06:50PM WBC-15.5* RBC-3.81* HGB-11.9* HCT-35.7*
MCV-94 MCH-31.2 MCHC-33.2 RDW-13.2
[**2190-9-2**] 06:50PM NEUTS-89.9* LYMPHS-7.6* MONOS-2.0 EOS-0.3
BASOS-0.1
[**2190-9-2**] 03:00PM GLUCOSE-159* UREA N-43* CREAT-1.9* SODIUM-138
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-21* ANION GAP-17
.
EGD: ([**2190-9-3**])
Blood in the stomach
Medium hiatal hernia
Non-bleeding erosions in the Hiatal hernia
Erythema in the antrum
Otherwise normal EGD to second part of the duodenum
[**2190-9-9**] 06:55AM BLOOD WBC-9.2 RBC-3.34* Hgb-10.4* Hct-30.6*
MCV-92 MCH-31.1 MCHC-33.9 RDW-13.2 Plt Ct-268
[**2190-9-5**] 02:51AM BLOOD PT-13.0 PTT-25.3 INR(PT)-1.1
[**2190-9-5**] 02:51AM BLOOD Plt Ct-195
[**2190-9-9**] 06:55AM BLOOD Plt Ct-268
[**2190-9-9**] 06:55AM BLOOD Glucose-100 UreaN-27* Creat-1.1 Na-138
K-4.0 Cl-103 HCO3-27 AnGap-12
[**2190-9-2**] 03:00PM BLOOD CK(CPK)-76
[**2190-9-3**] 01:35AM BLOOD CK(CPK)-43
[**2190-9-3**] 08:00AM BLOOD CK(CPK)-56
[**2190-9-3**] 07:29PM BLOOD Amylase-30
[**2190-9-8**] 11:53PM BLOOD CK(CPK)-65
[**2190-9-9**] 06:55AM BLOOD CK(CPK)-62
[**2190-9-2**] 03:00PM BLOOD CK-MB-NotDone
[**2190-9-2**] 03:00PM BLOOD CK-MB-NotDone
[**2190-9-2**] 03:00PM BLOOD cTropnT-<0.01
[**2190-9-3**] 01:35AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-9-3**] 08:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-9-8**] 11:53PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-9-9**] 06:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-9-9**] 06:55AM BLOOD Calcium-9.8 Phos-2.6* Mg-1.8
[**2190-9-3**] 11:29AM BLOOD Type-[**Last Name (un) **] Temp-36.1 FiO2-21 pO2-55*
pCO2-50* pH-7.30* calTCO2-26 Base XS--1 Intubat-NOT INTUBA
Comment-ROOM AIR
.
[**2190-9-4**] 9:45 am URINE Source: Catheter.
**FINAL REPORT [**2190-9-7**]**
URINE CULTURE (Final [**2190-9-7**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2190-9-4**] TTE: The left atrium is normal in size. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). There is a mild resting left ventricular outflow tract
obstruction. There was no change in the left ventricular outflow
tract gradient with Valsalva maneuver. Right ventricular chamber
size and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
systolic function. Mild resting LVOT gradient likely a result of
the small left ventricular chamber size and hyperdynamic
function.
Brief Hospital Course:
84 yo female presents with syncopal episode and multiple
melanotic stools. EGD w/ blood in stomach, but no active
bleeding site. HCT has been relatively stable as have VS.
.
#GIB: The pt had an EGD performed by the GI service which
demonstrated blood in stomach, and non-bleeding erosions in the
Hiatal hernia, but no active bleeding site. Unclear why pt had
red blood in stool if source is from UGI tract, since pt does
not seem to be bleeding large/brisk volumes. The pt's HCT and VS
remained stable and she did not require transfusion. The pt was
treated first with IV PPI [**Hospital1 **] and then transitioned to PO
dosing. Her home ASA was held in the setting of the GIB.
Restarting her ASA regimen should be addressed in the future as
an outpatient. In addition the need for further GIB work up,
including a colonoscopy would be discussed as an outpatient.
.
#Syncope: Multiple possible etiologies were considered including
vasovagal, arrythmia, or hypoglycemia. The pt's history was not
particularly suggestive for any of these. The syncopal episode
was likely a combination of hypovolemic and vasovagal induced
hypotension. The patient's PCP confirm that Ms. [**Known lastname 42376**] [**Last Name (Titles) **] is
often liable, and she is orthostatic at baseline. An echo was
obtained without major valvular findings to explain syncope. The
echo did show a mild functional LV outflow obstruction and
hyperdynamic EF which showed be followed up as an outpatient.
.
# CAD s/p sent: Pt complained of sharp substernal chest pain,
reproducible, and worse with cough throughout the admission.
This pain was low suspicion for ACS and she was given cough
suppressant for control of the pain. The family had concern that
she often complains of this nature of chest pain and that this
would repeatly bring her to the ED. The patient was told that
the sharp chest pain, reproducible with cough and palpation of
the chest is unlikely to be cardiac in nature and does not
require emergent follow up. However Ms. [**Known lastname 42375**] was encouraged to
notify medical personal if she experiences chest pain of a
different nature. During this hospitalization the pt also
complained of [**1-14**] substernal pressure in the setting of SBP of
210/95. Given her cardiac history the patient was ruled out with
cardiac enzymes x 3. There were no EKG changes as well. This
pressure type pain did not reaccure but the pt was told to
return to the ED if this pain reoccurred.
.
#ARF: Cr originally elevated to 1.9 on admission has returned to
prior baseline with hydration.
.
#HTN: The patient's BP was liable throughout the admission
rapidly changing from SBP > 200 to orthostatic hypotension
walking with PT. The spikes in BP were not accompanied by
palpatations, diaphoresis or other sympathetic symptoms making a
pheo unlikely. The orthostatic hypotension noted by PT with
ambulation was improved with IVF. The pt's PCP confirmed that
this BP pattern is not new for the patient and he prefered to
keep the patient on her home regimen instead of a more
aggressive regimen adopted in the hospital to prevent
orthostatic hypotension and further syncope. Further monitoring
of the patient's BP and adjustments to medications may be
warranted as an outpatient.
.
# Asymptomatic bactiuria: PT had leukocytosis on admission
which has resolved. Suspected possible UTI but [**9-4**] Ucult shows
Ecoli only 10,000-100,000 organisms /ml. The pt remained
afebrile, hemodynamically stable, asymptomatic of urinary
complaints. THerefore there was no reason to treat.
.
#Depression/psych: Home medication regimen was continued.
.
#Hypothyroid: Home levothyroxine was continued.
.
#) FEN:
- regular/cardiac diet
.
#) PPx: PPI, pneumoboots, held heparin SQ in setting of GIB.
.
# CODE: full
.
#) DISP: [**Hospital3 **]
Medications on Admission:
ASA 81 mg daily
Zetia 10 mg daily
Synthroid 25 mcg daily
Seroquel 12.5 mg at bedtime and q8 hrs PRN
Effexor XR 150 mg daily
Klonopin 0.25 mg [**Hospital1 **]
Vit B12 500 mcg daily
atenlol 50 mg daily
Protonix 40 mg daily
Fersol 325 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
APAP PRN
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Seroquel 25 mg Tablet Sig: .5 Tablet PO at bedtime.
6. Seroquel 25 mg Tablet Sig: .5 Tablet PO every eight (8) hours
as needed for aggitation.
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Clonazepam 0.5 mg Tablet Sig: .5 Tablet PO BID (2 times a
day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Mucinex 600 mg Tablet Sustained Release Sig: [**1-6**] Tablet
Sustained Releases PO twice a day as needed for cough.
Disp:*120 Tablet Sustained Release(s)* Refills:*0*
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 2 weeks: apply to groin for fungal
infection.
Disp:*qs one tube* Refills:*0*
13. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Esophogeal erosions
Hiatal hernia
hypovolemia /vasovagal syncope
Colon diverticulosis
Acute renal failure now resolved
Hypertension
.
secondary diagnosis:
coronary artery disease
GERD
Depression
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital with syncope (passing out).
You were found to have blood in your stool, for which we
evaluated you with endoscopy. This showed small erosions in your
esophogus which was likely the source of the bleeding. The
bleeding stoped and your blood counts have remained stable. The
GI doctors suggest that [**Name5 (PTitle) **] have a work up and possible
colonoscopy as an outpt, you should discuss this with Dr.
[**Last Name (STitle) 656**]. Your passing out was do to your low blood volume and
your low blood pressure with standing. Your dizziness improved
with fluids.
.
Your blood pressure was very liable during this admission. It
got very high at times, but it also droped low when you were
standing. Your PCP told as that this pattern is not new for you.
The low blood pressure got better with fluids and you were able
to walk around without symptoms.
.
Your chest pain was evaluated and is not from your heart, you
did not have a heart attack. It is likely musculoskeletal and
make worse with your cough.
.
We made the following changes to your medication regimen:
Your aspirin was stopped.
You were given nystatin cream to use on your groin for a rash -
you can use this for 2 weeks.
You were give Mucinex for a cough. Take this [**1-6**] pills two times
per day as needed.
.
Please follow up with Dr [**Last Name (STitle) 656**] as detailed below. ([**9-15**] at
1:15PM) If you have another episode of passing out, increased
Chest pain, SOB, dizziness, blood in your stool, or other
symptoms worrisome to you call your doctor or go to the
emergency room.
Followup Instructions:
You have an appointment with your PCP: [**Name10 (NameIs) **] [**Last Name (STitle) 656**]: [**2190-9-15**] at
1:15am. At that time you should discuss whether to add Aspirin
back to your medication regimen, it is being held because of
your bleeding in your gut. In addition you should discuss the
need for further work up of your intestinal bleeding, including
colonoscopy with Dr. [**Last Name (STitle) 656**].
Completed by:[**2190-9-12**]
|
[
"311",
"578.1",
"401.9",
"780.2",
"553.3",
"533.90",
"562.10",
"276.52",
"285.1",
"530.81",
"V45.82",
"412",
"584.9",
"244.9",
"530.89",
"414.01",
"458.9",
"307.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11881, 11938
|
6464, 10274
|
244, 272
|
12177, 12184
|
2874, 6441
|
13823, 14266
|
2261, 2334
|
10617, 11858
|
11959, 12093
|
10300, 10594
|
12208, 13800
|
2349, 2855
|
189, 206
|
300, 1924
|
12114, 12156
|
1946, 2103
|
2119, 2245
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,378
| 113,657
|
23213
|
Discharge summary
|
report
|
Admission Date: [**2156-1-8**] Discharge Date: [**2156-1-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
claudication
Major Surgical or Invasive Procedure:
peripheral angiography and stent placement in Left Superficial
Femoral Artery
History of Present Illness:
Pt is a [**Age over 90 **] yo man with htn, hyperlipidemia, PVD, experienced as
pain in both calves when walking one block and resolving with
rest, who presented for stenting of his femoral artery. He had
ABIs which were also diminished bilaterally
(0.82 right ankle, 0.66 left ankle). Lower extremity doppler
evaluation
showed triphasic waveforms in bilateral common femoral arteries
and
evidence of a left SFA occlusion.
Past Medical History:
1. PVD-s/p atherectomy and stenting of left SFA
2. Bilateral Renal Artery Stenosis
3. Hyperlipidemia
4. Hypertension
5. Knee and hip replacement surgeries
6. s/p PPM
Social History:
Lives alone in [**Location 8391**] in [**Hospital3 **]. One son. 50 pack
year history of smoking quit 50 yrs ago. Drinks accasional
highball. Retired from construction work.
Family History:
Mother with MI in 40's.
Physical Exam:
Afebrile 145/60 64 12 99% on RA
NAD. Alert. OP clear with MMM.
L carotid upstroke diminished with bilateral bruits.
RRR soft S1, normal S2. Soft systolic murmurs at RUSB and LLSB.
No rubs or gallops
Lungs clear to auscultation
Abd is soft NTND. Normal BS. No bruits
R groin without minimal ecchymoses no hematoma. No bruit and 1+
pulse.
No peripheral edema. Bilateral LE warm.
Pertinent Results:
Catheterization:
BRIEF HISTORY: [**Age over 90 **] yo man with hypertension and dyslipidemia
referred
for peripheral arteriography to evaluate significant bilateral
leg
claudication (L>R). He had ABIs which were also diminished
bilaterally
(0.82 right ankle, 0.66 left ankle). Lower extremity doppler
evaluation
showed triphasic waveforms in bilateral common femoral arteries
and
evidence of a left SFA occlusion.
INDICATIONS FOR CATHETERIZATION:
Peripheral vascular disease, claudication, positive noninvasive
ischemia
evaluation
PROCEDURE:
Peripheral Catheter placement was performed via the RFA.
Peripheral Imaging was performed of the AA and bilateral LE.
Peripheral PTA was performed of the R SFA.
Peripheral Stenting was performed of the R SFA.
Peripheral Atherectomy was performed of the R SFA.
**PTCA RESULTS
LSFA
**BASELINE
STENOSIS PRE-PTCA 100
**TECHNIQUE
PTCA SEQUENCE 1
GUIDING CATH [**Last Name (un) **]
GUIDEWIRES SPATRACO
INITIAL BALLOON (mm) 3.0
FINAL BALLOON (mm) 6.0
# INFLATIONS 7
MAX PRESSURE (PSI) 120
**RESULT
STENOSIS POST-PTCA 0
SUCCESS? (Y/N) Y
PTCA COMMENTS: Initial angiography revealed a 70% lesion at
the
origin of the SFA and a mid-segment occlusion of the SFA in the
left
lower extremity. Heparin was started prophylactically. A 7
French [**Last Name (un) 12297**]
sheath was advanced into the left CFA. The total occlusion of
the left
SFA was crossed with moderate difficuly using a Shinobi wire
followed by
an angled stiff Glidewire. Atherectomy was performed on th
eproximal SFA
using a Silverhawk LS device with good result. We were unable to
deliver
the Silverhawk device distal to the total occlusion, so the
occlusion
was dilated with a 3.0 x 20 mm Saavy balloon using 3 inflations
of 6
ATM. We were still unable to deliver the atherectomy device so
the
diecsion was made to proceed with stenting of the left SFA. A
7.0 x 56
mm Dynalink stent was deployed across the lesion and a 4.0 x 60
mm Saavy
balloon was used to dilate the stent at 120 ATM. Angiography
demonstrated a filling defect at the proximal edge of the stent
so a 7.0
x 100 mm Dynalink stent was deployed proximal to the first stent
in
overlapping fashion and both stents were dilated with the 4.0 x
60 mm
balloon using 3 inflations of 6 ATM. Final angiography revealed
no
residual stenosis, no apparent dissection, and normal flow.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 13 minutes.
Arterial time = 1 hour 13 minutes.
Fluoro time = 29 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 214 ml
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 5000 units IV
Other medication:
Fentanyl 50 mcg iv
Cardiac Cath Supplies Used:
- [**Company **], ANGLED GLIDEWIRE, 180
.014 GUIDANT, [**Location (un) **]/CORE, 130CM
.014 CORDIS, SHINOBI, 300CM
7F COOK, [**Last Name (un) 28712**], 55
7F FOXHOLLOW, SILVERHAWK ES
7 GUIDANT, DYNALINK 56, 80
7 GUIDANT, DYNALINK .018, 100
COMMENTS:
1. Access was obtained in retrograde fashion via the RFA using a
6
French short sheath.
2. Resting hemodynamics revealed no significant pressure
gradient
between AO and either common femoral artery.
3. Abdominal aortography revealed nild diffuse athersclerotic
disease.
4. The renal arteries were single bilaterally. The left renal
artery had
a 70% proximal stenosis and minimal blush was noted in the left
kidney.
The right renal artery had a proximal 70% stenosis.
5. Selective angiography of the right lower extremity revealed
no
significant disease in the CIA or EIA. The SFA was subtotally
occluded
at the adductor. The popliteal had no significant disease. The
AT and PT
were occluded with the PA filling the foot.
6. Selective angiography of the left lower extremity revealed no
significant disease in the CIA or EIA. There were mild luminal
irreguarities in the CFA. The SFA was totally occluded in its
mid
segment and reconstituted just above the popliteal artery. The
popliteal
artery was not obstructed.
7. Successful atherectomy of the proximal left SFA (see PTA
comments).
8. Successful PTA and stenting of the mid SFA with overlapping
7.0 x 100
mm and 7.0 x 56 mm Dynalink stents which were postdilated with a
6.0 mm
balloon. Final angiography revealed no residual stenosis, no
apparent
dissection and normal flow (see PTA comments).
FINAL DIAGNOSIS:
1. Bilateral SFA and infrapopliteal disease.
2. Bilateral renal artery stenosis.
3. Successful atherectomy, PTA, and stenting of the left SFA.
.
.
Right femoral vascular ultrasound:
Right common femoral artery and common femoral vein are widely
patent, without pseudoaneurysm or AV fistula. No large hematoma
is identified within the soft tissues of the right groin.
IMPRESSION:
No evidence of pseudoaneurysm, AV fistula or hematoma within the
right groin.
Brief Hospital Course:
Pt was taken to the catheterization lab and a stent was placed
in the left superficial femoral artery. At the end of the
procedure it was very difficult to attain hemostasis at the
right groin access site. As there was concern for development
of hematoma or pseudoaneurysm, pt was admitted to the CCU where
he was monitored closely and had multiple stable hematocrit
checks. A femoral vascular ultrasound was performed at the
right groins site and showed neither pseudoaneurysm or hematoma.
Pt was stable and was discharged to home with plan to return at
a later date for stenting of the right femoral artery.
Medications on Admission:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
2. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Prazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
2. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Prazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 30 days.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Outpatient Lab Work
please check potassium, BUN, creatinine and call into nurse
practitioner [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **] at [**Hospital1 336**] ([**State 59677**]) -
[**Telephone/Fax (1) 59678**].
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
2. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Prazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 30 days.
Disp:*30 Tablet(s)* Refills:*3*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Outpatient Lab Work
please check potassium, BUN, creatinine and call into nurse
practitioner [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **] at [**Hospital1 336**] ([**State 59677**]) -
[**Telephone/Fax (1) 59678**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Peripheral Vascular Disease
Hyperlipidemia
Hypertension
Discharge Condition:
Good, stable.
Discharge Instructions:
Continue your medications as directed. We have started one new
medication called Plavix (clopidogrel) that you should take
everyday from now on.
You will have the other leg fixed on [**2156-1-22**]. You do not need
to see Dr. [**First Name (STitle) **] prior to this. You will see [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **]
at your primary care doctor's office this Tuesday for a blood
check.
Drink plenty of fluids at home.
Followup Instructions:
You have an appointment with [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **] (Nurse
Practitioner) on Tuesday, [**1-13**], at 10:40 a.m. at your
Primary Care Doctor's office at [**Hospital1 336**] ([**State 59677**]).
You should have your blood drawn at that time to check on your
kidney.
You will also need to see Dr. [**First Name (STitle) **] as directed. You are
scheduled to have the same procedure on your other leg on
[**2156-1-22**].
Completed by:[**2156-1-28**]
|
[
"440.21",
"V43.64",
"401.9",
"428.0",
"593.9",
"V43.65",
"272.0",
"443.9",
"440.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"88.45",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
10607, 10664
|
6598, 7213
|
274, 353
|
10763, 10778
|
1645, 2064
|
11283, 11778
|
1205, 1230
|
8137, 10584
|
10685, 10742
|
7239, 8114
|
6114, 6575
|
10802, 11260
|
1245, 1626
|
4020, 6097
|
2097, 4001
|
222, 236
|
381, 807
|
829, 997
|
1013, 1189
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,143
| 168,582
|
6453
|
Discharge summary
|
report
|
Admission Date: [**2119-7-18**] Discharge Date: [**2119-7-19**]
Date of Birth: [**2033-10-3**] Sex: M
Service: MEDICINE
Allergies:
Bactrim DS
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Fatigue and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85M with h/o A-fib presents with fatigue and weak x 2 weeks and
anemia per labs by VNA. Patient report previously ambulatory
with walker, over past two weeks has noted difficulty with
standing up without assistance and is unable to ambulate without
assistance. Found to have anemia and dehydration per lab values
by VNA. Denies any known gross bleeding. Has not noted BRBPR,
melena or other sources of bleeding. Patient currently on Fe
supplementation, states he is unsure how long he has been taking
Fe. Denies CP, SOB, dysuria, hematuria. Has cough productive of
brown sputum which is consistant with baseline since diagnosis
of lung cancer 3 months ago, which patient has elected not to
treat. Patient endorses orthopnea and some difficulty with
breathing which is consistant with states On home 02. [**Name (NI) **]
son reports a recent 5lb weight gain, up from a prior weight of
145.
In the ED, initial VS were: HR103 BP129/75 RR22 94%
On arrival to the MICU, patient noted to be tachycardic,
disoriented to time(knows year but not month or date), and has
difficulty with speech apparently secondary to dyspnea.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure, or palpitations. 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:
Diabetes mellitus type 2
Hypertension
Hypercholesteremia
Difficulty with swallowing
Coronary artery disease
Congestive heart failure
Peripheral vascular disease
Chronic venous insufficiency in the legs
Urinary incontinence
Gout
Osteoarthritis
Chronic kidney disease
Retinal detachment
Past Surgical History:
S/p right hernia repair
S/p cataract removal
S/p thyroid adenoma excision
S/p TURP
S/p tonsilectomy
Repair of Zenker's diverticulm
Social History:
Tobacco: 15 pack years, quit 20 years ago
Alcohol: None and none in the past
Occupation: Lives with son, daughter and wife. Retired doctor [**First Name (Titles) **] [**Last Name (Titles) 24809**]l surgery.
Family History:
No lung cancer or congenital lung diseases
Father: Died of old age (70s) but had a history of a colectomy
of unknown reason
Mother: Deceased age 57 unknown reasons.
Physical Exam:
Vitals: T:97.9 BP:120/62 P:122 R:27 O2:92%
General: Alert, disoriented to date but knows year, location and
name. mild respiratory difficulty
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Regular rhythm, tachycardic, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: moderate crackles at bilateral bases
Abdomen: soft, non-tender, mild fluid wave
GU: foley in place
Ext: bilateral lower extremity edema with thickened and dark
skin over bilateral lower extremities distally
Neuro: strength grossly intact throughout, normal sensation,
PERRL
Pertinent Results:
Admission Labs:
[**2119-7-18**] 02:00PM BLOOD WBC-13.9* RBC-2.61*# Hgb-7.6*# Hct-24.1*#
MCV-92 MCH-29.2 MCHC-31.7 RDW-18.9* Plt Ct-238
[**2119-7-18**] 02:00PM BLOOD Neuts-86.0* Lymphs-7.3* Monos-5.1 Eos-1.2
Baso-0.3
[**2119-7-19**] 03:37AM BLOOD PT-15.2* PTT-29.3 INR(PT)-1.4*
[**2119-7-18**] 02:00PM BLOOD Glucose-225* UreaN-53* Creat-1.3* Na-124*
K-7.1* Cl-90* HCO3-25 AnGap-16
[**2119-7-18**] 04:57PM BLOOD CK(CPK)-94
[**2119-7-18**] 04:57PM BLOOD CK-MB-3 cTropnT-0.32* proBNP-6389*
CXR ([**2119-7-18**]) - Reaccumulation of small right-sided pleural
effusion since [**6-12**].
Discharge Labs
[**2119-7-19**] 03:37AM BLOOD WBC-15.0* RBC-3.06* Hgb-9.0* Hct-27.8*
MCV-91 MCH-29.5 MCHC-32.5 RDW-17.8* Plt Ct-204
[**2119-7-19**] 03:37AM BLOOD Neuts-89.3* Lymphs-5.1* Monos-3.9 Eos-1.3
Baso-0.3
[**2119-7-19**] 03:37AM BLOOD Glucose-152* UreaN-46* Creat-1.2 Na-130*
K-5.4* Cl-95* HCO3-28 AnGap-12
[**2119-7-19**] 03:37AM BLOOD CK(CPK)-102
[**2119-7-19**] 03:37AM BLOOD CK-MB-3 cTropnT-0.35*
[**2119-7-19**] 03:37AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.1
Blood cultures: No growth x24 hours
Brief Hospital Course:
Assessment and Plan:85 year old male with h/o lung cancer
presenting with increased weakness x2 weeks and noted to be
anemic on recent outpatient labs. Patient is DNR/DNI and states
does not want invasive management.
# Anemia: Likely slow GI bleed given no history of BRBPR or
melena, HCT dropped from 41.3 in [**2119-5-14**] to 24.1. GI evaluated
and determined no cause for emergent endoscopy. On further
discussion with patient and family, patient not interested in
endoscopic evaluation or treatment of potential bleeding source.
Patient does consent to trial of blood transfusion for
palliation of symptomatic anemia and received 2 units PRBCs.
Hematocrit increased 24.1-->27.8, although this repeat
hematocrit was drawn before completion of the second unit
transfusion. IVF were held since the patient was euvolemic.
# Shortness of breath: Likely combination of anemia, pleural
effusions, and CHF. Patient and family met with palliative care
and decided not to pursue any interventions or further workup.
Lasix dose was halved, and prescribed morphine, Ativan, and
atropine drops for comfort.
# Elevated Troponin: Patient without symptoms of myocardial
ischemia, normal CK and CK-MB, and no acute ischemia on ECG.
Most likely represents demand ischemia from tachycardia vs false
positive due to renal insufficiency. Troponin trended 0.32 to
0.35, CK-MB remained wnl. Patient not currently interested in
percutaneous coronary intervention if that were to become
indicated.
# Hyponatremia: Likely due to intravascular volume depletion,
improved 124-->130 with volume resuscitation with PRBCs.
# A-fib: patient with prior history of A-fib with RVR, takes
metoprolol for rate control. Metoprolol held in setting of
possible GI bleed, restarted once Hct stabilized.
# Pleural effusion: patient with chronic right pleural effusions
s/p pleurex placement. Undergoes weekly drainage of fluid from
pleurex catheter. No interventions made.
# Lung Cancer: patient has stated he does not desire treatment
for his lung cancer and has opted for comfort measures only.
# CHF: Lasix held in setting of potential intravascular
depletion, discharged home on half dose.
# CAD: Aspirin held in setting of GI bleed.
Transitional Issues:
Medication Changes
CHANGED Lasix 20mg to 10mg
STARTED Lorazepam 1 mg PO Q6H:PRN anxiety
STARTED Atropine Sulfate 1% 2 DROP SL PRN secretions
STARTED Morphine Sulfate (Conc Oral Soln) 5 mg PO Q4H:PRN pain
or breathlessness
Patient and family met with palliative care nurse practitioner,
stated awareness of risks of not intervening and a desire to
return home to hospice care.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Aspirin 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Allopurinol 200 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Insulin SC Sliding Scale Fingerstick QACHS, QPC2H Insulin SC
Sliding Scale using HUM Insulin
Discharge Medications:
1. Allopurinol 200 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Aspirin 81 mg PO DAILY
9. Furosemide 10 mg PO DAILY
10. Insulin SC
Insulin SC Sliding Scale using HUM Insulin
11. Lorazepam 1 mg PO Q6H:PRN anxiety
12. Atropine Sulfate 1% 2 DROP SL PRN secretions
13. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q4H:PRN
pain or breathlessness
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Anemia
Secondary:
Chronic kidney disease
Diabetes mellitus
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with weakness and fatigue and were found to have very
low blood counts. You were given blood transfusions to increase
your counts. You were offered further evaluation with an
endoscopy to look for a possible source of bleeding in your
gastrointestinal tract but you declined. Per your wishes, you
were discharged home with hospice.
Your furosemide (lasix) dose was reduced to 10mg daily
Followup Instructions:
You will be seen by a hospice care team at home. They will
provide you with medications to keep you comfortable.
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2119-7-28**] at 11:20 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GERONTOLOGY
When: THURSDAY [**2119-9-7**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GERONTOLOGY
When: TUESDAY [**2119-10-10**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"428.0",
"403.90",
"V15.82",
"578.9",
"V49.86",
"280.0",
"411.89",
"414.01",
"250.00",
"459.81",
"274.9",
"272.0",
"285.21",
"276.7",
"162.9",
"276.1",
"443.9",
"585.9",
"V46.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8169, 8218
|
4431, 6643
|
303, 310
|
8355, 8355
|
3320, 3320
|
9019, 10158
|
2540, 2706
|
7618, 8146
|
8239, 8334
|
7069, 7595
|
8531, 8996
|
2167, 2299
|
2721, 3301
|
6664, 7043
|
1474, 1836
|
232, 265
|
338, 1455
|
3336, 4408
|
8370, 8507
|
1858, 2144
|
2315, 2524
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,161
| 180,396
|
32135
|
Discharge summary
|
report
|
Admission Date: [**2181-10-24**] Discharge Date: [**2181-11-26**]
Date of Birth: [**2097-12-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
evolving MI after recent LAR complicated by anastomotic leak
Major Surgical or Invasive Procedure:
[**2181-10-24**] - cardiac catheterization and placement of bare-metal
stents x5
[**2181-10-26**] - percutaneous pelvic drain placement
[**2181-11-14**] - bronchoalveolar lavage
[**2181-11-15**] - percutaneous pelvic drain placement and paracentesis
[**2181-11-16**] - decompressive laparotomy
[**2181-11-16**] - abdominal exploration and washout
[**2181-11-18**] - abdominal exploration, washout, and closure;
placement of open G-tube
[**2181-11-19**] - bronchoalveolar lavage
History of Present Illness:
[**Known firstname **] [**Known lastname 75196**] is an 83 year old gentleman who underwent
lower anterior resection and diverting ileostomy [**2181-10-16**] for
rectal carinoma at [**Hospital1 18**]-[**Location (un) 620**]. He developed feculent output
from the intraoperatively placed JP on POD 5, but remained
afebrile with stable WBC suggesting appropriate control of the
anastomotic leak. The WBC rose today, however, and an abdominal
CT was planned, but the pt became acutely hypotensive,
tachypneic, and diaphoretic this morning. He was intubated for
respiratory distress. EKG showed q waves and 1 to 1.[**Street Address(2) 1755**]
elevation inferiorly, with ST depressions in lateral leads.
Labs showed CPK 68, Trop 3.570, Cre 2.8, lactate 1.9. ECHO with
LVEF 30-35% with akinesis of the inferior, inferoseptal, and
inferolateral walls (no priors for comparison). With a
diagnosis of acute inferior myocardial infarction, the patient
is being transferred to [**Hospital1 18**]-[**Location (un) 86**] for cardiac
catheterization.
Past Medical History:
Diabetes mellitus
Dyslipidemia
Hypertension
CKD Stage III (Cr 1.6-2.1)
BPH
PVD s/p atherectomy and PTA of left popliteal, TPT and PT
s/p tonsillectomy
rectal cancer s/p LAR colectomy
Social History:
Quit smoking as a teenager, no ETOH, no known chemical
exposures. His son [**Name (NI) 892**] is the HCP.
Family History:
unavailable
Physical Exam:
On admission:
VS: T=afebrile, BP=128/86, HR=90 (NSR), RR=17, O2 sat=100%
GENERAL: WDWN male moving around in bed. Intubated. Very slow
to respond, but occasionally following simple directions
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple without JVD.
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: Ant fields CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Midline vertical incision with staples in
place; non-oozing, no purulence, C/D/I. No HSM or tenderness. No
abdominial bruits, +BS. brown effluent from JP drain in pelvis,
ostomy pink with large amt liquid output.
EXTREMITIES: Trace LE edema (symmetric). Cool extremities.
SKIN: see above re: scars.
PULSES:
Right: Carotid unable to palpate [**1-2**] CVL, Femoral unable to
palpate [**1-2**] femoral sheath, DP 1+ PT 1-
Left: Carotid 2+ Femoral 1+ DP 1- PT 1-
Pertinent Results:
[**10-24**] UCx: E. COLI.
[**10-24**] BCx: CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C.
SEPTICUM.
[**10-24**] cdiff: POSITIVE
[**10-25**] cdiff: negative
[**10-26**] cath tip: NGTD
[**10-26**] BCx: NGTD
[**10-26**] presacral fluid cx: BACTEROIDES FRAGILIS
[**10-26**] cdiff: negative
[**10-27**] sputum: NGTD
[**11-5**] MRSA: negative
[**11-11**] UCx: NGTD
[**11-11**] sputum: KLEBSIELLA OXYTOCA resistant to zosyn, sensitive
to cefepime
[**11-11**] BCx: NGTD
[**11-12**] MRSA: negative
[**11-14**] BAL: yeast, KLEBSIELLA OXYTOCA sensitive to cefepime
[**11-15**] BCx: pend
[**11-15**]: pelvic abscess: YEAST
[**11-15**]: ascites: NGTD
[**11-15**] BCx (mycolytic): NGTD
[**11-15**] BCx (m. furfur): NGTD
[**11-17**] BCx: pending
[**11-19**] MRSA: negative
[**11-20**] urine: NGTD
[**11-20**] BAL: KLEBSIELLA OXYTOCA
.
IMAGING:
[**10-25**]:CT Torso:anastomotic leak
[**10-25**]:ECHO Severe global left ventriculaure systolic function.
Normal right ventricular size and function.
[**10-29**]:White matter hypodensities without mass effect are likely
related to
chronic small vessel ischemic disease.No evidence intracranial
bleed.
[**11-8**]:pouchogram:No evidence of extraluminal leak.
[**11-12**] ECHO - EF 35%
12/13 CXR - some increase in the lung volumes
[**11-13**] RUQ US - large amt of R intraperit ascites. Non-distended
gallbladder containing small amt of sludge & tiny stones. No
intrahepatic biliary dilatation. CBD and pancreas not well
visualized.
[**11-14**]: CT abdomen: anastomatic leak; pelvic drain superficial,
likely just subq
[**11-16**] CXR: continued opacification in the retrocardiac region
consistent with volume loss in the left lower lung
[**11-17**] ECHO: similar to prior study from [**11-12**]. mild to moderate
LV systolic dysfunction w/ severe hypokinesis of the
inferior/inferiolateral walls. LVEF 35%
12/18 CXR: redemonstration of small pleural effusions and
increased density in the retrocardiac area c/w atelectasis or
consolidation. mild vascular congestion vs. low lung volumes.
[**11-18**] CXR: No significant interval change
[**11-18**] KUB: Limited study demonstrating findings consistent with
ascites
[**11-19**] CXR: Small stable bilateral pleural effusions and
associated
atelectases with continued mild pulmonary edema
[**11-21**] CXR: Increased bilateral pleural effusions, increased
moderate pulmonary edema
[**11-22**] CXR: maybe mild increase in extent of R pleural effusion.
otherwise unchanged.
[**11-23**]: kidney US shows: no hydronephrosis and color Doppler flow
to the kidneys bilaterally
[**11-25**] CXR: no other relevant changes
.
[**2181-10-24**] 11:11PM BLOOD WBC-19.9* RBC-2.48* Hgb-7.7* Hct-22.4*
MCV-90 MCH-31.0 MCHC-34.3 RDW-16.4* Plt Ct-248
[**2181-11-26**] 03:38AM BLOOD WBC-19.0* RBC-3.44* Hgb-11.2* Hct-33.6*
MCV-98 MCH-32.4* MCHC-33.2 RDW-26.1* Plt Ct-100*
.
[**2181-10-24**] 11:11PM BLOOD PT-27.5* PTT-81.1* INR(PT)-2.7*
[**2181-11-26**] 03:38AM BLOOD PT-19.6* PTT-41.6* INR(PT)-1.8*
.
[**2181-10-24**] 05:50PM BLOOD Glucose-208* UreaN-69* Creat-2.9*#
Na-132* K-4.6 Cl-99 HCO3-21* AnGap-17
[**2181-11-26**] 03:38AM BLOOD Glucose-105* UreaN-129* Creat-4.2* Na-134
K-5.2* Cl-102 HCO3-18* AnGap-19
.
[**2181-10-24**] 05:50PM BLOOD ALT-73* AST-150* LD(LDH)-294* AlkPhos-110
TotBili-0.5
[**2181-11-26**] 03:38AM BLOOD ALT-47* AST-74* AlkPhos-303*
TotBili-17.8*
.
[**2181-10-24**] 11:11PM BLOOD CK-MB-10 MB Indx-5.0 cTropnT-2.75*
[**2181-11-22**] 02:47AM BLOOD CK-MB-2 cTropnT-0.29*
.
[**2181-10-25**] 04:37AM BLOOD Albumin-3.0* Calcium-6.9* Phos-4.6*
Mg-1.8
[**2181-11-24**] 01:43AM BLOOD Albumin-3.0* Calcium-8.5 Phos-5.0* Mg-2.4
.
Brief Hospital Course:
The patient was transferred from [**Hospital1 18**]-[**Location (un) 620**] to [**Hospital1 18**]-[**Location (un) 86**]
for management of the MI, for which he underwent a cardiac
catheterization involving placement of 5 bare-metal stents by
interventional cardiology on [**2181-10-24**]. Care was provided in the
SICU. The following day an abdominal CT showed a pre-sacral
abscess insufficiently controlled by the operatively-placed JP
drain, for which a CT-guided pigtail catheter was placed by
interventional radiology on [**2181-10-26**]. Broad-spectrum IV
antibiotics were continued consisting of Vancomycin and Zosyn.
Nutrition was provided with TPN.
He recovered from the septic and cardiogenic shock. The
patient's mental status was slow to awaken, Head CT on [**10-29**] was
negative for acute pathology, all sedation and narcotic
medication was held, and eventually his mental status improved
to permit extubation, and eventually transfer to the floor on
[**2181-11-6**]. Aspiring and plavix were continued. Nutrition was
transitioned to tube feeds via an NGT; he failed swallow
evaluations. High ileostomy outputs revealed CDiff enteritis,
for which IV Flagyl and later vancomycin via both NGT and enema
(via the distal limb of the ileostomy) were instituted. Later,
banana flakes and lomotil were added to slow down the ileostomy
output. LFTs were mildly elevated, with INR ~2.0; a RUQ U/S was
negative and presumably due to malnutrition and sepsis. The
acute component of his renal failure stabilized with creatinines
returning close to his baseline, although he continued to have a
metabolic acidosis, possibly from intrinsic renal dysfunction
and/or from GI losses. The broad-spectrum antibiotics were
discontinued after a 14-day course. A gastrograffin enema on
[**2181-11-7**] revealed no anastomotic leak; the JP drain was
subsequently discontinued.
On [**2181-11-11**], pt developed respiratory distress followed by PEA
arrest. ALCS was instituted and entailed 1 mg of epinephrine,
2mg of atropine, 2 amps of bicarb, and 2 min of CPR. Pt was
intubated and returned to the SICU; presumptive causes were
aspiration versus persistent metabolic acidosis. Broad spectrum
antibiotics were reinstituted due to a new and persistent
leukocytosis and low-level pressor requirement. A
bronchoalveolar lavage revealed a klebsiella PNA, resistant to
zosyn, so the zosyn was switched to cefepime. Abdominal CT scan
revealed persistence of the the anastomotic leak, a residual
sacral collection, and dislodgement of the pigtail drain. A new
pigtail catheter was placed into the collection on [**2181-11-15**] by
interventional radiology. The recent CT also revealed
large-volume ascites; abdominal exam revealed significant
distension and the ventilator pressures were increased as well.
Accordingly, a therapeutic paracentesis was performed on
[**2181-11-15**]. Patient received 2u FFP before the procedures.
[**Name (NI) 1917**], pt developed worsening abdominal distension as
well as grossly bloody ileostomy output, with a Hct that was now
17 from 27, and rising pressor requirements. He was
aggressively resuscitated with transfusions to correct his
coagulopathy and anemia, ultimately totalling 10u of PRBC, 10u
FFP, and 2u Plt (despite the recent cardiac stents due to
life-threatening hemorrhage), as well as vitamin K, over the
next 8 hours. The ileostomy output ceased but he developed
worsening abdominal distension, increasing peak inspiratory
pressures, increasing pressor requirements, consistent with an
abdominal compartment syndrome. He was taken emergently to the
OR on [**11-16**] for decompressive laparotomy, evacuation of 6500cc
of clot, but no bleeding source could be identified; no bowel
ischemia was noted. The abdomen was packed and left open.
Correction of coagulopathy continued over the next 12 hours, the
PRBC requirements slowed, and he returned to the OR for the
planned second look. Several oozing sites from the
retroperitoneum persisted, these were oversewn, and the abdomen
was again packed and left open. Over the next 48 hours the
resuscitation plateaued and transfusion requirements minimized;
he returned to the OR on [**11-18**] for closure and placement of a
G-tube.
In light of holding the aspirin and plavix, cardiac enzymes were
cycled and noted to be rising. Echocardiogram revealed no
evidence of new MI and cardiology consult agreed, with
recommendation to resume antiplatelet therapy once able, which
was done one week later. The patient did develop atrial
fibrillation and hypotension, initially unresponsive to
beta-blocker and calcium-channel-blocker but later successfully
restored to sinus rhythm after amiodarone and electrical
cardioversion x4. He remained on two pressors, at stable doses,
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] monitor utilized for hemodynamic monitoring.
Worsening pulmonary mechanics consistent with ARDS warranted
placement of an esophageal balloon, which enabled increasing the
PEEP significantly. Later, his renal function declined with
rising creatinine and progressive oliguria, leading to worsening
volume overload. The hepatic failure also continued to evolve,
with bilirubins approaching 18. In light of the multi-system
organ failure and poor prognosis, the pt's HCP declined dialysis
and later decided to make the patient CMO. After receiving the
last rites by the pastor, the patient was extubated, started on
morphine gtt, and expired at 17:40 on [**2181-11-26**].
Medications on Admission:
MEDICATIONS (home):
-Cartia XT 180mg daily
-Lisinopril 40mg daily
-ASA 81mg daily --> stopped 2 weeks ago
-Simvastatin 20mg daily
-Humalog 75/25 insulin, 22-24 U qAM and 12-22U before supper
-NPH [**3-12**] U qHS
MEDICATIONS (on transfer):
Midazolam 8mg/hr --> D/C'd en route due to hypotension
Fentanyl 50mcg/hr --> D/C'd en route due to hypotension
Heparin gtt
Norepinephrine IV
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
rectal cancer
DM
HTN
anastomotic leak
MI
sepsis
acute-on-chronic renal failure
hepatic failure with coagulopathy
respiratory failure
intraperitoneal hemorrhage
Discharge Condition:
expired
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
Completed by:[**2181-11-27**]
|
[
"E878.1",
"272.4",
"276.0",
"038.9",
"567.22",
"E878.2",
"560.1",
"482.0",
"263.9",
"599.0",
"600.00",
"V44.2",
"403.90",
"286.9",
"729.73",
"276.3",
"785.51",
"996.59",
"008.45",
"998.59",
"518.81",
"785.52",
"789.59",
"584.5",
"276.1",
"568.81",
"276.2",
"410.41",
"154.1",
"427.31",
"250.00",
"585.3",
"427.5",
"443.9",
"997.4",
"572.8",
"995.92",
"570",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"96.6",
"38.91",
"00.40",
"96.04",
"54.19",
"00.66",
"37.23",
"00.48",
"54.59",
"88.56",
"54.91",
"54.12",
"43.19",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
12848, 12857
|
6862, 12387
|
367, 846
|
13060, 13069
|
3242, 6839
|
13132, 13178
|
2264, 2277
|
12819, 12825
|
12878, 13039
|
12413, 12796
|
13093, 13109
|
2292, 2292
|
267, 329
|
874, 1918
|
2306, 3223
|
1940, 2124
|
2140, 2248
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,896
| 171,997
|
52065
|
Discharge summary
|
report
|
Admission Date: [**2177-1-2**] Discharge Date: [**2177-1-17**]
Date of Birth: [**2107-1-16**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Nonhealing fifth toe ulcerations
bilaterally over the last three months.
HISTORY OF PRESENT ILLNESS: This is a 69 year-old black male
with a past medical history of coronary artery disease,
fifth toes bilaterally that occurred after ingrown toenails
were removed at a local Emergency Room in [**2176-9-9**].
Since then the patient has been admitted to the [**Hospital1 18**] for
preoperative preparation for surgical revascularization that
was deferred and postponed secondary to unstable angina. The
patient underwent a angioplasty of the left anterior
descending coronary artery with stenting in [**2176-11-9**].
any constitutional symptoms. Risk factors include coronary
artery disease, hypertension, borderline diabetes,
hypercholesterolemia and nicotine abuse. He has a forty five
pack year history of smoking, which he has not smoked for the
last ten years.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Chronic renal insufficiency with a
baseline creatinine of 1.5, which peaked post cardiac
catheterization to 2.2. Peripheral vascular disease,
arthritis, cerebrovascular accident right sided in [**2167**].
PAST SURGICAL HISTORY: Coronary artery bypass graft in [**2167**]
with right greater saphenous vein harvest, left femoral BK
popliteal in situ saphenous vein, right carotid
endarterectomy in [**2157**], right knee arthroscopy.
MEDICATIONS: Diovan 150 mg q.d., Tricor 160 mg q.d.,
Atenolol 100 mg q.d., Hydrochlorothiazide 25 mg daily,
Nifedipine XL 30 mg q.d., Percocet for pain.
SOCIAL HISTORY: He is single. He is a former smoker. He
has occasional alcoholic beverage.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: Vital signs, blood pressure 128/86.
Pulse 61. Respiratory rate 18. Room air 02 sat is 97%. The
HEENT examination was unremarkable. He has bilateral carotid
bruits versus transmitted murmur to the carotids. Pulse
examination shows palpable carotids, brachial, radial and
femoral pulses bilaterally. The right popliteal is
dopplerable. The dorsalis pedis pulse and posterior tibial
pulse are monophasic dopplerable signals. On the left the
popliteal is palpable. There is absent dorsalis pedis pulse
by palpation doppler signal and a monophasic posterior tibial
pulse. There are bilateral bruits of the femoral arteries.
The lungs are clear to auscultation. There was a regular
rate and rhythm. He has a 4/6 systolic ejection murmur best
heard over the left sternal border. Abdomen is obese,
nontender, nondistended. He has 2+ edema of the lower
extremities. He has necrotic ulcers of the left and right
fifth toe proximal tip.
HOSPITAL COURSE: The patient was admitted and placed on bed
rest. He was begun on Levofloxacin and Flagyl. Subcutaneous
heparin was begun for deep venous thrombosis prophylaxis. An
MR of the lower extremities was done to evaluate his lower
extremity disease. The patient underwent on [**2177-1-6**] arterial
duplex, which showed a patent left femoral popliteal graft so
this is seen at the distal anastomosis and distal native
vessels. Vein mapping was also done of the lesser saphenous
vein. Cardiology was requested to see the patient for risk
verification prior to surgery. Recommendations were to
discontinue the Procardia XL secondary to bradycardia and
begin Lipitor 10 mg q.d., aspirin 325 mg daily, continue
Atenolol at the current dosing. The patient underwent on
[**2177-1-8**] a left re-do femoral in situ saphenous vein graft to
the posterior tibial with lesser saphenous vein and
angioscopy. He tolerated the procedure well. He had a graft
pulse and a dopplerable left posterior tibial pulse at the
end of the procedure. He was transferred to the PACU in
stable condition.
He did develop atrial fibrillation intraoperatively.
Cardiology was requested to see the patient and amiodarone
load was begun. Aspirin was continued and the beta blocker
was begun at 25 mg of Lopressor b.i.d. Serial CK were
obtained. The patient's troponin level was flat on this
surgery. His postoperative hematocrit was 23 and he required
2 units of blood for correction. He was continued on his
Amiodarone. He continued to do well and on postoperative day
two was transferred to the regular nursing floor for
continued monitoring and care. He continued to do well and
underwent his second surgery on [**2177-1-13**]. He underwent a right
above knee femoral popliteal bypass graft with nonreverse
saphenous vein. He tolerated the procedure well and was
transferred to the PACU with a dopplerable right dorsalis
pedis pulse. He remained hemodynamically stable. His
postoperative hematocrit was 29. He was transferred to the
VICU for continued monitoring and care. He was continued on
perioperative Levofloxacin and Flagyl. He did develop a low
grade temperature of 100.8.
He underwent on [**2177-1-14**] bilateral fifth toe amputation without
incident. He was returned to the nursing floor in stable
condition. He did have a sinus tachycardia. His hematocrit
was 26.3. He was transfused. Serial troponin levels were
obtained. The initial one was 2.2. He peaked at 47 with
peak CKs in the 1200 and MB peaked at 26. He was continued
to be beta blocked and his hematocrit was monitored. He was
begun on Amiodarone. The Lopressor was discontinued
secondary to bradycardia. Ambulation was begun on day two
post toe amputation with healing sandals. The patient was
transferred from the VICU on [**2177-1-16**]. He was de-lined. His
hematocrit remained stable at 29. He had no recurrent atrial
fibrillation and was converted to a normal sinus rhythm with
his Amiodarone. The remaining hospital stay was
unremarkable. Physical therapy felt the patient could be
discharged to home when medically stable.
DISCHARGE MEDICATIONS: Dilaudid 2 to 4 mg po q 3 hours prn
for pain, Percocet tablets one to two q 4 to 6 hours for
pain. Amiodarone was started on [**2177-1-14**] with 400 mg b.i.d.
This was continued until [**1-15**]. On [**1-16**] his Amiodarone was
changed to 400 mg q.d. and was decreased to 200 mg q.d. for a
total of three weeks. This will continue from [**2177-1-16**] to
[**2177-2-7**]. The patient was restarted on his Lopressor 25 mg
b.i.d. His perioperative antibiotics were not continued post
discharge. He was begun on Coumadin 5 mg q.d. INR should be
checked on a daily basis until the patient is at a
therapeutic level of 2.0 and 2.5. Ferrous sulfate 325 mg
t.i.d. was begun. Zantac 150 mg q.d,. Hydrochlorothiazide 25
mg q.d., Lipitor 10 q.d., Colace 100 mg b.i.d., Norvasc 5 mg
q.d., aspirin 25 mg daily, Ferbirate 67 mg q.d.
DISCHARGE DIAGNOSES:
1. Ischemic bilateral fifth toe ulceration status post left
and right bypass graft status post bilateral fifth toe
amputation.
2. Perioperative myocardial infarction by elevated troponin
levels.
3. Atrial fibrillation converted with Amiodarone.
4. Blood loss anemia corrected.
Follow up should be in two weeks. Skin clips remain in until
seen by Dr. [**Last Name (STitle) **]. He can weight bear as tolerated with
healing sandals, ambulate essential distances only. Wounds
were clean, dry and intact and he had functioning grafts at
the time of discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2177-1-17**] 07:54
T: [**2177-1-17**] 08:25
JOB#: [**Job Number 107770**]
|
[
"440.24",
"997.1",
"401.9",
"280.0",
"410.91",
"593.9",
"V45.81",
"427.31",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"84.11",
"39.49",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
6779, 7620
|
5927, 6758
|
2792, 5903
|
1319, 1679
|
1832, 2774
|
1794, 1809
|
157, 231
|
260, 1065
|
1088, 1295
|
1696, 1774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,623
| 102,400
|
29225
|
Discharge summary
|
report
|
Admission Date: [**2182-12-1**] Discharge Date: [**2182-12-12**]
Date of Birth: [**2121-8-3**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Back pain status-post fall
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central line placement
History of Present Illness:
61 year-old male s/p fall down ~[**8-21**] stairs 1 day prior to
presentation to an area hospital. He does not recall the events
surrounding his fall, but awoke at home the next day and was
unable to move his lower extremities. He complained of back pain
and was initially seen at [**Hospital 8641**] Hospital where a CT scan
revealed an L1 burst fracture without obvious spinal cord
damage. He was then transferred to [**Hospital1 18**] for continued care.
Past Medical History:
HTN
COPD
left TKA
s/p esophagectomy
Social History:
1 ppd smoker, +EtOH daily, denies IVDU.
Family History:
Noncontributory
Physical Exam:
VS: 97.2, 106, 164/92, 13
GEN: NAD, NCAT, EOMI
CV: RRR
PULM: CTAB, nl chest wall excursion
ABD: soft, nt/nd, pelvis stable, nl rectal tone.
EXT: no gross deformity. MAE. Strength 5/5 bilaterally.
Sensation intact to lt touch.
BACK: +TTP bony midline, lumbar spine.
Pertinent Results:
TRAUMA #2 (AP CXR & PELVIS POR Clip # [**Clip Number (Radiology) 70280**]
IMPRESSION: Limited study. Tortuous aorta. Opacity in the
right apex, which may represent atelectasis, consolidation, or
contusion. Further assessment by CT scan is recommended if
clinically indicated.
------------
CT T-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 70281**]
IMPRESSION:
1. L1 burst fracture with posterior retropulsion of a fracture
fragment in the spinal canal. There is greater than 50% loss of
the spinal canal diameter at this level.
2. No additional fractures are seen.
3. Destruction of the posterolateral aspect of the right sixth
rib, with
associated soft tissue density. Characterization is limited as
this lesion is at the perimeter of the field of view. While
this may represent scar from prior resection, further evaluation
with CT chest is recommended when the patient's condition
stabilizes.
4. Status post esophagectomy with gastric pullthrough.
5. Emphysema. Pleural calcification along the right lung base
is consistent with prior asbestos exposure.
6. Left adrenal adenoma.
7. Atherosclerosis.
8. Diverticulosis.
--------
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 70282**]
IMPRESSION: No evidence for hemorrhage, mass effect, or acute
ischemic
changes.
-------
L-SPINE (AP & LAT) Clip # [**Clip Number (Radiology) 70283**]
IMPRESSION:
L1 vertebral body compression fracture. The degree of vertebral
body collapse is unchanged.
-------
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] as a trauma transfer from [**Hospital 8641**]
hospital after a fall down stairs resulting in amnesia to the
event and an L1 burst fracture diagnosed at [**Location (un) 8641**]. He was
intubated in the emergency department after sudden onset of
respiratory distress secondary to aspiration following the
administration of Ativan. He was then transferred to the Trauma
SICU on ventilator support.He remained on ventilatory support
secondary to a significant pneumonitis and was treated with
Ceftriaxone IV; this was later changed to Ciprofloxacin, he has
3 more days to complete his course. He was eventually extubated
and then required re-intubation secondary to acute respiratory
distress and declining mental status. On HD # * he was
successfully extubated and transferred to the regular nursing
unit. He has required nasal oxygen at 2-3 L/min with saturations
>93%; his FiO2 requirements have been decreased because of his
history of COPD and should be eventually weaned off. He was
started back on his Albuterol and [**Doctor First Name **] as this was part of
his home medication regimen; Albuterol neb treatments have been
administered intermittently during his hospital stay.
He was evaluated by the Orthopedic Spine service, who determined
that his fracture was nonoperative in nature and he was fitted
for a TLSO brace; this is to be worn at all times. He will
follow up with Dr. [**Last Name (STitle) 1352**], Spine Surgery, in 2 weeks. Neuro
exams off sedation remained stable throughout his stay,
consistently moving all extremities.
His blood pressure was elevated throughout his hospital stay; he
initially required IV Lopressor & Hydralazine. He was later
changed to oral Diltiazem and HCTZ; it is likely he will require
further adjustment of his medications to control his blood
pressure during his rehab stay.
He was also noted to be agitated during his initial
hospitalization and required Haldol and was also placed on
Ativan per CIWA scale for alcohol withdrawal. He was also
started on a clonidine patch for DT prophylaxis. His mental
status currently is awake, alert, oriented X2, cooperative with
care. He is likely experiencing a delirium related to his fall
and recent respiratory infection (head CT imaging was negative
for any intracranial processed).
He was evaluated by PT & OT and it was recommended that he go to
a short term rehab facility in order to improve function.
Medications on Admission:
Paxil, Inhalers
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Disp:*15 Suppository(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) dose
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) dose
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection [**Hospital1 **] (2 times a day).
11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): hold for SBP <110.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
s/p Fall
Lumbar (L1) spine fracture
Aspiration pneumonitis
Discharge Condition:
Good.
Discharge Instructions:
Call your doctor or return to the emergency department if you
experience any of the following: fever, worsening back pain,
weakness, numbness or tingling in your legs or feet, inability
to walk, any new or concerning symptom.
You need to wear your TLSO brace at all times when out of bed.
Wear this brace until you are seen in follow up with Dr.
[**Last Name (STitle) **].
Followup Instructions:
You will need to follow-up with Dr. [**Last Name (STitle) **] (Orthopedics Spine
Service) in two weeks; call [**Telephone/Fax (1) 1228**].
You may also follow up in the trauma clinic; call [**Telephone/Fax (1) 6429**]
for an appointment.
Completed by:[**2182-12-12**]
|
[
"305.00",
"E880.9",
"507.0",
"805.4",
"492.8",
"401.9",
"518.82",
"518.81",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"96.71",
"96.04",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
6836, 6981
|
2813, 5282
|
298, 347
|
7083, 7091
|
1287, 2790
|
7513, 7783
|
968, 985
|
5348, 6813
|
7002, 7062
|
5308, 5325
|
7115, 7490
|
1000, 1268
|
232, 260
|
375, 834
|
856, 894
|
910, 952
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,380
| 164,009
|
37140
|
Discharge summary
|
report
|
Admission Date: [**2188-12-24**] Discharge Date: [**2188-12-27**]
Date of Birth: [**2128-9-8**] Sex: F
Service: NEUROSURGERY
Allergies:
Bactrim / Levaquin / Shellfish Derived
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Cerebral Angiogram
History of Present Illness:
Ms. [**First Name8 (NamePattern2) **] [**Known lastname **] is a 60 yo RH woman with a history of
HTN and HLD presenting following 1 day of severe headache, found
to have a 4-5 mm L MCA aneurysm on CTA. Ms. [**Known lastname **] reports
that yesterday morning she woke up with a severe headache. She
states the pain was [**11-15**] and constant, located at the back of
her head and neck. This was associated with some nausea, but no
vomiting, and lightheadedness. She came downstairs, and ended
up
passing out in the kitchen and hitting the back of her head.
She
was then taken to [**Hospital 11485**] hospital, where she underwent a NCHCT
which was normal. She had an LP which showed 1118 RBCs and
6WBCs
in tube 1 and 625 RBCs and 5 WBCs in tube 4. She had a CTA
which
was initially read as normal, and was discharged home at 1am.
Apparently at 2am the CTA was reread, to show a 4-5 mm aneurysm
at the L MCA bifurcation. A message was left at home, which she
recieved the following morning and she came back into the ED.
As
they did not have aneurysm coiling capabilities, she was
transferred to [**Hospital1 18**].
Past Medical History:
HTN
HLD
Paroxysmal atrial tachycardia
Generalized anxiety disorder
Social History:
Social Hx: Lives in [**Location 27340**] with her significant other [**Name (NI) **].
Currently works as a dietician. No EtOH, smoking or illicits
Family History:
Family Hx: Mother died at age 71. Father died at age [**Age over 90 **] of 'old
age' Brother died at age 46 of CAD.
Physical Exam:
PHYSICAL EXAM:
O: BP: 144/78 HR: 72 R 14 O2Sats 96% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2mm EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. 2/6 systolic murmur at RUSB
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-8**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-10**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 3 2
Left 2 2 2 3 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2188-12-24**] 06:16PM BLOOD WBC-6.0 RBC-3.69* Hgb-11.5* Hct-32.2*
MCV-87 MCH-31.1 MCHC-35.6* RDW-12.8 Plt Ct-299
[**2188-12-25**] 02:07AM BLOOD WBC-6.6 RBC-3.59* Hgb-11.1* Hct-31.4*
MCV-87 MCH-31.0 MCHC-35.5* RDW-12.7 Plt Ct-304
[**2188-12-26**] 06:20AM BLOOD WBC-5.8 RBC-3.86* Hgb-11.7* Hct-33.7*
MCV-87 MCH-30.3 MCHC-34.7 RDW-13.4 Plt Ct-302
[**2188-12-24**] 06:16PM BLOOD Glucose-96 UreaN-13 Creat-0.8 Na-141
K-4.3 Cl-108 HCO3-24 AnGap-13
[**2188-12-25**] 02:07AM BLOOD Glucose-100 UreaN-18 Creat-0.9 Na-140
K-4.6 Cl-108 HCO3-27 AnGap-10
[**2188-12-26**] 06:20AM BLOOD Glucose-96 UreaN-15 Creat-0.8 Na-138
K-4.2 Cl-103 HCO3-24 AnGap-15
[**2188-12-24**] 06:16PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
[**2188-12-25**] 02:07AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.2
Brief Hospital Course:
60F trasferred for further evaluation of L MCA aneurysm. During
her admission she had a syncopal episode and work-up was
negative. Most likely due to vaso-vagal response. Neurologically
she was intact. She had a cerebral angio for further evaluation
of aneurysm wich we will watch at this time. No intervention.
There was some concern for spinal AVM so she MRI C-spine was
done and showed no sign of venous dilitation. She tolerated
diet and she was then cleared to go home on [**2188-12-27**]
Medications on Admission:
Lisinopril 10mg
Lipitor 20mg
Celexa 40mg
Ativan 1mg [**Hospital1 **]
ASA 81mg (last taken at 2am on [**2188-12-24**])
Discharge Medications:
.
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 3 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO QID (4 times a day) for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
L MCA aneurysm
Discharge Condition:
Mental Status:Clear and coherent
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in [**3-12**] weeks. Please call
[**Telephone/Fax (1) 1669**] to schedule an appointment.
|
[
"780.2",
"427.0",
"784.0",
"300.02",
"272.4",
"401.9",
"437.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5295, 5301
|
4122, 4618
|
311, 332
|
5360, 5360
|
3338, 4099
|
7326, 7472
|
1760, 1880
|
4787, 5272
|
5322, 5339
|
4644, 4764
|
5419, 6384
|
6410, 7303
|
1910, 2171
|
263, 273
|
360, 1486
|
2463, 3319
|
5374, 5395
|
1508, 1577
|
1593, 1744
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,619
| 167,269
|
45217
|
Discharge summary
|
report
|
Admission Date: [**2182-3-27**] Discharge Date: [**2182-4-3**]
Date of Birth: [**2104-1-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is a 78 year-old male with a history of CHF (EF 15%)
and atrial fibrillation who presents with a dry cough and
shortness of breath.
Recently admitted ([**Date range (1) 96630**]) with shortness of breath secondary
to heart failure. A repeat echo at that time showed worsened
dilated cardiomyopathy (EF of [**9-28**]%) with severe tricuspid
regurgitation. He was placed on a lasix drip and HCTZ was added,
with good response. At the time of discharge, his regimen
included lasix 160mg [**Hospital1 **], HCTZ 25mg daily, and carvedilol 12.5mg
[**Hospital1 **]. Digoxin was discontinued. His weight at the time of
discharge was reportedly 138 pounds.
Over the last few days, patient reports increasing shortness of
breath and cough. Has stable 2 pillow orthopnea and PND
(although he gets poor sleep at baseline). Denies any dietary
indiscretion (reports very low salt intake) or medication
non-compliance. No chest pains or discomfort at rest or with
exertion. He collects his urine daily and has noted about 1200cc
daily, which has not changed. He deniesy any lower extremity
edeam. Can walk around his home and states that he continues to
make his own breakfast.
In the ED, T 96.1, BP 70/58, HR 68, RR 20 and 02 sat 94% on 4
liters. His BP fell to 66/40, but he continued to mentate well.
250cc or IVF were given.
A RIJ was placed under sterile conditions. CVP was measured at
20-25. Dopamine was started. Levaquin/Flagyl were given.
Initially was admitted to the [**Hospital Ward Name 332**] ICU. There, a lasix ggt was
started with 120cc of urine in one hour. His coumadin was held
in the setting of an oozing right IJ site. Given that his
hypotension was felt to be cardiogenic in nature, he was
transferred to the CCU for further care.
Upon arrival to the CCU, the patient continued to feeling mildly
short of breath while lying flat. There was no difference with
raising the head of the bed.
Past Medical History:
PAST MEDICAL HISTORY:
1. Heart disease:
(a) Cardiac Risk Factors: Diabetes, Hypertension
(b) Percutaneous coronary intervention ([**2177-1-27**]):
Right dominant system showed widely patent arteries.
(c) ICD ([**2180-2-25**]): Defibrillator placement, model 7278, serial #
[**Serial Number 96626**].
(d) Non-ischemic restrictive cardiomyopathy (diagnosed [**2176**])
- Presumed secondary to amyloid
- EF 15% ([**2-13**])
(e) Atrial fibrillation
- s/p ablation [**3-11**]
(f) Severe tricuspid regurgitation
(g) Mild/Moderate mitral regurgiation
.
OTHER PAST HISTORY:
1. Chronic Kidney Disease: baseline SCr 2.2-2.3
- Secondary to hypertensive nephrosclerosis as well as a
component of persistent renal underperfusion from heart failure
2. Diabetes mellitus: A1c ([**1-16**]): 8.7
3. Hypertension
4. MGUS --> Amyloid: diagnosed in [**2166**] with positive kappa
monoclonal spike and presence of Bence [**Doctor Last Name **] protein in urine.
Repeat SPEP in [**3-/2177**] revealed 9% monoclonal kappa spike and
quantitative 1604.
- Diagnosed with Amyloidosis on abdominal fat pad biopsy
([**2180-2-21**])
5. Pulmonary Hypertension
6. Anemia: microcytic; previously thought to be secondary to
iron deficiency
7. Hypothyroidism: not currently on meds
8. Depression
9. Prostate Cancer s/p resection
10. Multiple Abdominal Hernias s/p repair
11. s/p repair bilateral carpal tunnel syndrome
12. s/p bil knee replacement
13. s/p repair rectal prolapse
Social History:
Patient currently living at rehab s/p recent hospital admission.
Previously lived with wife and daughter in [**Location (un) 686**]. Used to
be in the navy as a cook. Quit smoking >25 yrs ago. Quit
drinking a few months ago.
Family History:
He was raised with a [**Doctor Last Name **] family but knows some family
history. His father died of myocardial infarction; his mother
died in her 80s and had a history of myocardial infarction. His
identical twin died in battle in [**Country 10181**]. He has a half-sister
with history of myocardial infarction at age 50 and systemic
lupus erythematosis, a half-brother who died of diabetes at age
30, and a half-brother with history of head trauma and
myocardial infarction at approximately age 56.
Physical Exam:
VS: T 94.5 BP 86/70 --> 96/50 HR 77 RR 17
Gen: Elderly male, lying flat in bed in no distress. Talking and
coughing during interview. Oriented to person, "[**Hospital1 18**]" and
"[**2182-3-26**]".
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: RIJ in place with some oozing around dressing. Could not
assess right veins. Left EJ was dilated and left IJ was ~3cm
above the clavicle while flat.
CV: Irregularly irregular with a normal S1/S2, normal S1, S2.
II/VI systolic murmur was heard at lower sternal borders
Chest: Decreased BS 1/2 up on right; decreased [**12-13**] on left; no
crackles heard.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
ADMIT LABS: [**2182-3-27**]
WBC-5.0 RBC-4.63 Hgb-11.6* Hct-36.8* MCV-80* MCH-25.1* MCHC-31.6
RDW-25.3* Plt Ct-171
Neuts-69.5 Lymphs-20.2 Monos-6.6 Eos-2.4 Baso-1.3
Hypochr-2+ Anisocy-3+ Poiklo-1+ Microcy-3+
COAGS:
PT-29.2* PTT-43.2* INR(PT)-3.0*
CHEMISTRIES:
Glucose-107* UreaN-94* Creat-3.2* Na-135 K-3.5 Cl-96 HCO3-29
AnGap-14
Calcium-8.9 Phos-4.2 Mg-2.9*
MISC:
proBNP-[**Numeric Identifier 96631**]*
TSH-8.4*
Free T4-1.6
Digoxin-0.3*
Lactate-2.1*
BLOOD GAS:
Type-MIX pO2-35* pCO2-50* pH-7.37 calTCO2-30 Base XS-1
Intubat-NOT INTUBA
OTHER:
[**2182-3-30**] Albumin-3.1*
CXR ([**2182-3-27**]):
1. Persistent interstitial pattern, raising concern for a
chronic interstitial disease especially considering persistence
since CT of [**2181-7-10**]. This is nonspecific but could
potentially be due to amiodarone lung toxicity. Further
evaluation could be performed with pulmonary function testing
and high- resolution CT if warranted clinically.
2. Persistent small left and increasing moderate right pleural
effusion. Apparent elevation of right hemidiaphragm could
reflect a more substantial subpulmonic component.
Brief Hospital Course:
1. Congestive heart failure:
Known history of severely depressed EF, 15-20%. Also with severe
TR and mild to moderate MR. Recently admitted for CHF requiring
lasix drip for diuresis 10 days ago and returned with 10# weight
gain and increased SOB/DOE. He was initially admitted to the
CCU and placed on a dopamine gtt (6mcg/kg/min) and lasix gtt
(10mg/hr) to assist with forward flow and diuresis. This was
initially mildly successful at removing 2-3kg of fluid but he
could not tolerate the dopamine due to tachycardia exacerbating
his atrial fibrillation and this was weaned off. He eventually
became resistant to the lasix gtt and this was transitioned to
PO. When this was not effective, bumetonide was tried (later
with HCTZ) with better effect. Given his poor prognosis and his
frequent hospitalizations, [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] from hospice care was
called to help coordinate his transition to home with hospice
given his end stage heart failure. The patient stated that he
wished to be at home with family and understood the gravity of
his condition as well as his poor prognosis and declined rehab
or an inpatient hospice facility.
2. Rhythm: History of atrial flutter s/p ablation; now with
atrial fibrillation. Given his end stage heart failure and his
desire to be home with hospice, his ICD was disabled on [**3-29**] in
accordance with his wishes. His INR was elevated during his
stay and he was sent home off coumadin.
3. CAD: Most recent cardiac cath did not show evidence of CAD.
Is on ASA, which we was continued.
4. Chronic kidney disease: SCr above baseline on admission,
likely due to renal hypoperfusion. Initially SCr remained
stable, but later in course increased (2.7 --> 3.6), then again
trended down towards discharge. Given his poor prognosis and in
accordance with prior patient's wishes, HD was not offered at
this time.
5. UTI: [**10-29**] WBC with bacteria and leukesterase. Treated with
Cipro 500mg daily x7 days.
6. Diabetes mellitus: Used a HISS while in house.
7. Anemia: Aranesp as outpatient.
8. Depression: Continued prozac.
Medications on Admission:
1. Ferrous Sulfate 325 qd
2. Fluoxetine 10 mg qd
3. Aspirin 325 mg qd
4. Glipizide 1.25 mg [**Hospital1 **]
5. Furosemide 160 mg [**Hospital1 **]
6. Hydrochlorothiazide 25 mg qd
7. Carvedilol 12.5 mg [**Hospital1 **]
8. Warfarin 2 mg PO QMOWEFR
9. Warfarin 3 mg PO TUTHSASUN
Discharge Medications:
1. Roxanol Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1 hour
as needed.
Disp:*30 mL* Refills:*0*
2. Syringe Syringe Sig: One (1) cc Miscellaneous q1hour: to
be used with Roxanol sublingual.
Disp:*50 * Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: [**12-11**] Capsules PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
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. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*15 15* Refills:*2*
11. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO
Q6H (every 6 hours) as needed for cough.
Disp:*5 5* Refills:*2*
12. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*30 Capsule(s)* Refills:*2*
13. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Home oxygen
Patient will need 4L/min continuous home oxygen therapy for room
air saturations of 83%.
15. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): Give 30 prior to Lasix or Bumex.
Disp:*30 Tablet(s)* Refills:*2*
16. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
1. Congestive heart failure.
Secondary Diagnoses:
1. Chronic Kidney Disease:
2. Diabetes mellitus
3. Hypertension
4. Amyloid
5. Pulmonary Hypertension
6. Anemia
7. Hypothyroidism
8. Depression
9. Prostate Cancer s/p resection
10. Multiple Abdominal Hernias s/p repair
11. s/p repair bilateral carpal tunnel syndrome
12. s/p bil knee replacement
13. s/p repair rectal prolapse
Discharge Condition:
Afebrile, vital signs stable, tolerating POs, ambulating with
assistance.
Discharge Instructions:
You were admitted with heart failure and need aggressive
diuretic treatment for resolution of your symptoms.
1. Please take all medication as prescribed.
2. Please attempt to make all medical appointments.
3. Please return to the Emergency Room if you have any
concerning symptoms.
Weigh yourself every morning and call Dr. [**First Name (STitle) 437**] if your weight
increases by > 3 lbs. You should continue to adhere to 2
gram/day sodium diet.
Followup Instructions:
You have the following appointments scheduled:
DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2182-4-8**] 2:30
|
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"428.0",
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"244.9",
"250.00",
"599.0",
"397.0",
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icd9cm
|
[
[
[]
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[
"38.93",
"00.17"
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icd9pcs
|
[
[
[]
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] |
10980, 11051
|
6638, 8772
|
334, 342
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11481, 11557
|
5492, 6615
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12056, 12234
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4029, 4533
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9098, 10957
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11072, 11111
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8798, 9075
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11581, 12033
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4548, 5473
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11132, 11460
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274, 296
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370, 2301
|
2345, 3770
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3786, 4013
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,472
| 181,274
|
33122
|
Discharge summary
|
report
|
Admission Date: [**2160-1-7**] Discharge Date: [**2160-1-18**]
Date of Birth: [**2080-6-21**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Called by Emergency Department to evaluate ICH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 77002**] is a 79-year-old right-handed man with an
unknown medical history who presents with acute right sided
weakness, found to have a left thalamic intraparenchymal
hemorrhage. He is a poor historian and alternate sources of
information are limited, but it appears he was in his USOH until
around 8 pm last evening. He had just finished dinner, stood up
to go upstairs, and suddenly fell. He did not lose consciousness
or suffer head trauma. He believes he fell due to sudden
weakness. He was taken to [**Hospital **] Hospital, where he was noted
to
have a right facial droop, right-sided weakness, and dysarthria.
He was also noted to have SBP in the 200s. CT showed an
intraparenchymal hemorrhage (images reviewed) in the left basal
ganglia. He was placed on a nipride gtt and transferred to
[**Hospital1 18**].
Here, his initial BP was 220/96; the nipride gtt was titrated
up.
Mr. [**Known lastname 77002**] [**Last Name (Titles) 15797**] headache, loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. [**Last Name (Titles) **] difficulties
comprehending
speech. [**Last Name (Titles) **] numbness, parasthesiae. No bowel or bladder
incontinence or retention. [**Last Name (Titles) **] difficulty with gait.
On review of systems, he [**Last Name (Titles) 15797**] recent fever or chills. No
night
sweats or recent weight loss or gain. [**Last Name (Titles) **] cough, shortness of
breath. [**Last Name (Titles) **] chest pain or tightness, palpitations. [**Last Name (Titles) **]
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. [**Last Name (Titles) **]
arthralgias or myalgias. [**Last Name (Titles) **] rash.
Past Medical History:
Report of a kidney tumor, details unavailable at this time
COPD
Social History:
Long smoking history, reportedly quit in recent months.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 96.8 P: 81 R: 16 BP: 170/86 (- 220/96) SaO2: 93%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Wheezes bilaterally.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 2 (to name and "hospital").
Able to relate history but only in generalities. Inattentive,
able to name [**Doctor Last Name 1841**] backward only to [**Month (only) **]. Language is fluent
with intact repetition and comprehension. Normal prosody.
There
were no paraphasic errors. Pt. was able to name both high and
low frequency objects. Speech was markedly dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**1-10**] at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils 5 to 4 and sluggish on right, 3 to 2mm and brisk on
left. VFF to confrontation. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Lid droop on right
slightly
more than left.
V: Facial sensation intact to pinprick.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 4 4+ 4 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 3 3 3 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
Dysmetria due to weakness on right FNF.
-Gait: Deferred.
Pertinent Results:
[**2160-1-7**] 06:08PM CK(CPK)-203*
[**2160-1-7**] 06:08PM CK-MB-7 cTropnT-0.03*
[**2160-1-7**] 08:21AM CK(CPK)-216*
[**2160-1-7**] 08:21AM CK-MB-8 cTropnT-<0.01
[**2160-1-7**] 08:21AM CHOLEST-128
[**2160-1-7**] 08:21AM %HbA1c-5.9
[**2160-1-7**] 08:21AM TRIGLYCER-73 HDL CHOL-65 CHOL/HDL-2.0
LDL(CALC)-48
[**2160-1-7**] 02:52AM GLUCOSE-110* UREA N-15 CREAT-0.8 SODIUM-142
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-28 ANION GAP-11
[**2160-1-7**] 02:52AM CALCIUM-8.2* PHOSPHATE-3.6 MAGNESIUM-1.7
[**2160-1-7**] 02:52AM WBC-6.9 RBC-3.63* HGB-11.6* HCT-34.0* MCV-94
MCH-32.0 MCHC-34.1 RDW-14.7
[**2160-1-7**] 02:52AM PLT COUNT-310
[**2160-1-6**] 11:46PM GLUCOSE-98 UREA N-17 CREAT-0.8 SODIUM-143
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-29 ANION GAP-13
[**2160-1-6**] 11:46PM estGFR-Using this
[**2160-1-6**] 11:46PM ALT(SGPT)-12 AST(SGOT)-21 LD(LDH)-337*
CK(CPK)-108 ALK PHOS-99 TOT BILI-1.0
[**2160-1-6**] 11:46PM cTropnT-<0.01
[**2160-1-6**] 11:46PM CK-MB-4.8
[**2160-1-6**] 11:46PM CALCIUM-8.5 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2160-1-6**] 11:46PM WBC-7.0 RBC-4.11* HGB-13.4* HCT-38.9* MCV-95
MCH-32.5* MCHC-34.3 RDW-14.8
[**2160-1-6**] 11:46PM NEUTS-74.4* LYMPHS-14.8* MONOS-5.2 EOS-5.3*
BASOS-0.3
[**2160-1-6**] 11:46PM PLT COUNT-325
[**2160-1-6**] 11:46PM PT-11.9 PTT-26.2 INR(PT)-1.0
[**2160-1-6**] 11:45PM GLUCOSE-100
[**2160-1-6**] 11:45PM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-1.8
[**2160-1-6**] 11:45PM WBC-6.5 RBC-3.90* HGB-12.4* HCT-36.7* MCV-94
MCH-31.8 MCHC-33.8 RDW-14.8
[**2160-1-6**] 11:45PM NEUTS-76.0* LYMPHS-14.7* MONOS-4.0 EOS-4.7*
BASOS-0.6
[**2160-1-6**] 11:45PM PLT COUNT-294
[**2160-1-6**] 11:45PM PT-12.3 INR(PT)-1.0
[**2160-1-6**] CT/CTA head:
HEAD CT: A region of acute hemorrhage is identified in the left
thalamus,
measuring 21 x 17 mm and exerting moderate mass effect on the
atrium of the
left lateral ventricle. Focal hypodensities are noted in the
pons and in the
white matter of the frontal lobe, reflecting old lacunar
infarcts. The right
lateral ventricle, third and fourth ventricles are normal in
caliber and
configuration. No fractures are identified.
HEAD AND NECK CTA: The carotid and vertebral arteries and their
major
branches are patent. There is a region of focal narrowing in
the left
internal carotid artery just before it enters the carotid canal.
No intimal
flap is seen, but the location and configuration of this
narrowing suggests
prior dissection. There is no evidence of aneurysm formation.
The distal
cervical internal carotid arteries measure 5 mm in diameter on
the left and 5
mm in diameter on the right. Incidental note is made of a
fenestrated
right vertebral artery with the right PICA arising from the
smaller component.
IMPRESSION:
1. Acute left thalamic hemorrhage exerting moderate mass
effect on the left
lateral ventricle. Old lacunar infarcts in the pons and frontal
lobe white
matter suggest hypertension as an etiology.
2. Focal narrowing of left internal carotid artery just before
it enters the
carotid canal with no evidence of acute dissection, but features
suggesting a
prior dissection.
3. No aneurysm, acute thrombus or acute dissection.
MRI head [**2160-1-7**]:
FINDINGS: Again seen is acute hemorrhage in the left thalamus
with
surrounding vasogenic edema, resulting in minimal mass effect on
the left
lateral ventricle with bowing of the septum pellucidum. No
enhancing lesions
are visualized, but a repeat study could be considered following
resolution of
the hematoma.
Extensive white matter disease is largely periventricular. Also
seen are
several hyperintense lesions within the pons. These findings
are consistent
with microangiopathic changes.
There is small DVA of the right frontal lobe as seen on the CTA.
Cataract
surgical changes are seen in the right globe. Mucosal changes
are seen in the
maxillary and ethmoid sinuses.
IMPRESSION:
1. Acute hemorrhage in the left thalamus resulting in minimal
mass effect of
the left lateral ventricle. No enhancing lesions are
visualized, but consider
repeat study following resolution of hematoma.
2. Extensive periventricular white matter disease consistent
with
microangiopathic changes.
CXR [**2160-1-6**]:
FINDINGS: No previous images. Hyperexpansion of the lungs is
consistent with
chronic pulmonary disease. Given this, the cardiac silhouette
is at the upper
limits of normal in size and there is mild tortuosity of the
aorta. Relative
prominence of the central pulmonary vessels with rapid tapering
suggests some
underlying pulmonary arterial hypertension. No evidence of
acute pneumonia.
NCHCT [**2160-1-9**]:
FINDINGS: There has been no interval change in the left
thalamic
intraparenchymal hemorrhage. No new hemorrhage, edema, mass
effect, or
infarction is seen.
New since the prior study are air-fluid levels in the maxillary
sinuses
bilaterally, worse on the left. This may reflect the
development of
sinusitis.
IMPRESSION:
1. No new hemorrhage. No change in left thalamic hemorrhage.
2. Interval development of bilateral maxillary sinus air-fluid
level,
suggesting the development of sinusitis.
Brief Hospital Course:
Mr. [**Known lastname 77002**] is a 79-year-old man who was admitted with an
intraparenchymal left thalamic hemorrhage.
1. Neuro: ICH. Given the left thalamic hemorrhage, the patient
was admitted to the neurologic ICU for further monitoring and
management. He was not initially intubated, but required an IV
nipride drip for BP managment. On rounds the morning after
admission, the patient was noted to have a left [**Name (NI) 77003**] (ptosis
and miosis) in addition to a right upper motor neuron facial
droop with associated dysarthria, right sided hemiparesis, right
upper extremity ataxia. Serial head CTs showed improvement in
bleed. His blood pressure was kept under 160 systolic and MAP <
130 using IV nipride and eventually IV hydralazine; his blood
pressure was well controlled with oral agents once he came out
to the floor. His blood pressure goal can be lowered to <
140/90, which should be achieved with oral agents.
He was called out to the neurology floor after 3 days in the
ICU. He showed gradual improvement of his weakness. He can be
given DVT prophylaxis at this point, but other anti-coagulation
should be avoided until neurology follow-up. Similarly,
anti-platelet agents should be avoided.
2. PULM: COPD. He had multiple episodes of mucus plugging. Most
of these episodes of hypoxia responded to deep suctioning, but
he did have one desaturation on the floor that did not respond
initially. A code blue was called and he was emergently
intubated and transferred back to the unit. He did well, though,
and was extubated and returned to the floor within 48 hours.
After that, as his strength returned, his respiratory status
improved, eventually getting off all supplemental oxygen.
Albuterol and atrovent nebulizers were provided around the
clock.
3. CV: BP control as above.
4. GI: C. diff diarrhea. He had two positive C diff tests and
was started on Flagyl. This improved, but the Flagyl should be
continued through [**1-28**] for a 14-day course.
5. FEN: The patient initially failed a speech and swallow
evaluation, and a Dobhoff tube was placed. Due to delirium, he
removed this and had it replaced two times. A video swallow
study after about a week showed improvement, and he was cleared
for pureed solids and nectar-thickened liquids. This may be
advanced as he continues to improve.
6. GU: He had a urinary tract infection associated with an
indwelling Foley catheter and was started on ciprofloxacin. This
should be continued through [**1-22**] for a 7-day course.
7. CODE: FULL
8. DISPO: Per PT, OT, and SLP recommendations, he was discharged
to rehab.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection [**Hospital1 **] (2 times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP < 100 or HR < 60.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours) as needed.
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) AS
DIR Injection ASDIR (AS DIRECTED): SLIDING SCALE.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days: Continue through [**2160-1-28**].
11. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 5 days: Continue through [**2160-1-22**].
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) INH Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary:
1. Left thalamic intraparenchymal hemorrhage
Secondary:
1. COPD
2. Crohn's disease
Discharge Condition:
Good condition, satting in low 90s on room air, tolerating
pureed diet, mild residual right-sided weakness ([**4-12**]).
Discharge Instructions:
You were evaluated for right-sided weakness and were found to
have a bleed in your head. Please take all medications as
directed and keep all follow-up appointments.
If you have any further symptoms such as weakness, numbness,
difficulty swallowing, difficulty speaking, dizziness, or any
other symptom that is concerning to you, please call your PCP or
your neurologist or go to the nearest hospital emergency
department.
Followup Instructions:
You have the following appointment in [**Hospital **] CLINIC:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2160-3-17**] 2:00
Please call [**Telephone/Fax (1) 2574**] to update your registration information
prior to this appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
Completed by:[**2160-1-18**]
|
[
"599.0",
"496",
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"431",
"401.9",
"996.64",
"041.4",
"276.52",
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"555.9",
"008.45",
"473.9"
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"96.04",
"38.93",
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icd9pcs
|
[
[
[]
]
] |
14056, 14128
|
9984, 12582
|
363, 369
|
14264, 14386
|
4831, 6542
|
14858, 15289
|
2365, 2383
|
12640, 14033
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14149, 14243
|
12608, 12617
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14410, 14835
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3497, 4812
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2398, 2903
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276, 325
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397, 2188
|
6552, 9961
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2918, 3480
|
2210, 2276
|
2292, 2349
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,876
| 113,508
|
43347
|
Discharge summary
|
report
|
Admission Date: [**2189-8-3**] Discharge Date: [**2189-8-5**]
Date of Birth: [**2149-8-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
39 year old male with DM1, h/o depression and polysubstance
abuse, Hep C who presents with lethargy and polydipsia after not
taking his insulin for 2 days. He reports that his lost his
glucometer and insulin. Over the past 2 days he developed nausea
and lethargy and polydipsia. He felt warm to the touch per his
girlfriend, but [**Name2 (NI) 15598**]'t take his temperature. He also was more
confused the evening prior to admission. He additionally
complined of [**5-21**] chest pressure, non-radiating which lasted [**2-11**]
hours. No associated SOB, cough, or urinary symptoms.
.
In the ED, T 97.6 HR 110 , BP 137/64 R 16 O2 sats 96 % on RA. K
7.0 with AG of 25, and pH 7.22 pCO2 27 pO2 103 and glucose above
the dectable range on fingerstick with a serum glucose of 753
and peaked T waves, on ECG he receieved calcium gluconate 1 amp
x1, 3 L NS, insulin 10 unit IVx1 and insulin drip at 10 units
per hour, ASA 325 mg po x1. On arrival to the ICU he reported
feeling better. Denies CP or SOB.
Past Medical History:
Past Psych History:
-Patient's Psychiatrist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78730**] at [**Hospital1 **], whom the
patient has been seeing for the past 2 years for
psychopharmacology.
-Therapist: No present therapist. Pt had been seeing [**First Name4 (NamePattern1) 1060**]
[**Last Name (NamePattern1) **] for 2 years but stopped seeing her.
-inpatient hospitalizations including [**Hospital1 **], [**Hospital1 18**],
FH. Last hospitalization [**9-15**] at [**Hospital1 18**]. Second to last
hospitalization was at Bayridge last
year- around [**9-13**]. He reports that his presentation has been
similar with each presentation with depression, SI and PSA.
-Although patient denies history of [**Last Name (LF) **], [**First Name3 (LF) **] [**First Name3 (LF) **], he has history
of multiple suicide attempts. During a past admission, he
reported cutting his wrists at 18yo, and h/o multiple o/d
attempts with most recent [**3-15**] requiring ICU stay at FH. He
reports h/o attempted asphyxiation.
-Per [**Name (NI) **], pt reports a prior diagnosis of BPAD- he denies manic
sxs, stating that he predominantly presents with "depression and
anger".
-Per [**Name (NI) **], h/o assaultive behaviors with h/o jail time for
assault and battery. He reports that his last jail sentence was
3 years ago. He denied present legal issues, stating that his
parole ended [**12-14**].
Past Medical History:
DM type 1 (poorly controlled)
Hepatitis C
Polysubstance abuse
Social History:
Currently lives with his daughter and is a plumber. Has been
sober from EtOH and substances for the last 3 years until
relapsing a few days ago with EtOH and cocaine. Former heroine
user. Quit smoking 3 yrs ago.
Family History:
Mother, Father, one brother with ETOH dependence
Physical Exam:
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender:
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**2189-8-5**] 04:28AM BLOOD WBC-4.9# RBC-4.11* Hgb-12.0* Hct-35.8*
MCV-87 MCH-29.3 MCHC-33.7 RDW-13.6 Plt Ct-163
[**2189-8-5**] 04:28AM BLOOD Glucose-187* UreaN-12 Creat-1.0 Na-137
K-4.3 Cl-112* HCO3-17* AnGap-12
[**2189-8-5**] 04:28AM BLOOD Calcium-7.3* Phos-1.8* Mg-1.5*
[**2189-8-3**] 08:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
DKA - Upon admission to the [**Hospital Unit Name 153**], the patient's diabetic
ketoacidosis was treated with IV fluids and an insulin drip.
During the course of his first 12 hours of admission, his
hyperglycemia decreased from 436 to a goal of between 100-200
with 25 units/hours insulin drip. The patient had an anion gap
of 21 in the ICU, which closed by the morning of admission. He
also received 8 liters NS IVF. After his serum glucose was
stabilized and his anion gap closed, he was converted back to
his home lantus, but at a reduced dose of 20 units SQ QHS, which
was increased to 30 units SQ QHS the morning of discharge. He
was also placed on a insulin glargine sliding scale, as
recommended by endocrinology.
Hyperkalemia - The patient had an elevated potassium up to 6.8
with ECG changes, specifically peaked T waves. He was given 1
gram of calcium gluconate and his potassium stabilized and on
the morning of discharge was 4.3.
Chest discomfort - The patient reported chest discomfort
described as pressure for 1 hour the day of admission. The pain
resolved prior to admission, and during the length of his
hospital stay he reported no similar symptoms or chest pain.
His ECG did not demonstrate any changes and his cardiac enzymes
were negative x2.
CAD - Received 81 mg ASA PO daily.
Polysubstance abuse - Urine tox screen was negative.
Depression - Received home dose of wellbutrin SR.
Hepatitis C - Stable during admission.
Medications on Admission:
Bupropion SR 150 mg 1 tab po daily
Insulin lantus 30 units SQ QHS
Insulin lispro at sliding scale dose
OTC
ASA 81 mg po daily
Multivitamin 1 tab daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
3. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
Disp:*900 units* Refills:*2*
4. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day.
Disp:*1000 units* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Diabetic ketoacidosis
Secondary
1. Hepatitis C
Discharge Condition:
good
Discharge Instructions:
You were admitted for diabetic ketoacidosis. This was due to not
taking your insulin. It is very important that you follow your
diabetic regimen including measuring your blood glucose at least
4 times a day and taking appropriate insulin.
Please return to the ED if you develop symptoms including
nausea, vomiting, or abnormally high blood glucose levels.
Please take all of your medications as directed.
Please keep all of your follow up appointments.
Followup Instructions:
You have an appointment today, [**2189-8-5**], at 2pm at the [**Hospital **]
Clinic with [**First Name9 (NamePattern2) 32887**] [**Doctor Last Name 1726**]. At that time, you will get a new
glucometer.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2189-11-13**] 11:20
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-11-2**] 4:20
Completed by:[**2189-8-5**]
|
[
"070.70",
"276.7",
"305.90",
"311",
"250.13",
"414.00",
"584.9",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6275, 6281
|
4163, 5618
|
291, 298
|
6383, 6390
|
3766, 4140
|
6895, 7463
|
3087, 3138
|
5820, 6252
|
6302, 6362
|
5644, 5797
|
6414, 6872
|
3153, 3747
|
230, 253
|
326, 1325
|
2777, 2841
|
2857, 3071
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,908
| 171,333
|
14178
|
Discharge summary
|
report
|
Admission Date: [**2167-8-3**] Discharge Date: [**2167-8-7**]
Date of Birth: [**2121-7-14**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male
with past medical history significant for hepatitis C and
alcoholic cirrhosis with a history of variceal bleed status
post banding and recently admitted for hepatic
encephalopathy, discharged [**2167-8-1**].
He had been doing well over the weekend, however, on the
morning of the 21st, he was found by family to be
unresponsive and incontinent of stool. The family called
911, and the patient was taken to [**Hospital3 417**], where he
was found to be lethargic, but still arousable, but he was
abusive and combative with the staff. At [**Hospital3 417**], his
head CT scan was negative. His creatinine which is at a
baseline at 1.3 was at 2.2. His ammonia level was 162, and
he was given 1 mg of Ativan for his combativeness. The
patient was transferred to [**Hospital3 **] Hospital.
PAST MEDICAL HISTORY:
1. Hepatitis C virus.
2. Cirrhosis.
3. Patient is on the transplant list. He failed interferon
therapy.
4. Esophageal varices status post banding.
5. History of alcohol abuse.
6. Suspected hepatocellular carcinoma (HCC).
7. Recent admissions for fevers, mental status changes, and
encephalopathy.
8. Chronic renal failure.
MEDICATIONS ON ADMISSION:
1. Lactulose prn.
2. Nadolol 40 mg po q day.
3. Lasix 20 mg po q day.
4. Aldactone 50 mg [**Hospital1 **].
5. Ursodiol 300 mg tid.
6. Protonix 40 mg q day.
SOCIAL HISTORY: The patient has a history of alcohol abuse.
He quit one year ago. No smoking, no IV drug use.
ALLERGIES: No allergies to any medicine. The patient lives
with his wife.
PHYSICAL EXAMINATION ON ADMISSION: His blood pressure was
100/57. His heart rate was 60. Respiratory rate 12, and he
was 100% 2 liters oxygen by nasal cannula. HEENT: Pupils
are equal, round, and reactive to light and accommodation.
Neck is supple, no lymphadenopathy. Cardiovascular:
Regular, rate, and rhythm, no murmurs. Chest was clear to
auscultation bilaterally. Abdomen is soft, nontender to
palpation, nondistended, bowel sounds were hypoactive.
Extremities: He had [**2-16**]+ pitting edema in his ankles up to
his calves. Neurologically he was disoriented, somnolent,
but moving all four extremities.
LABORATORIES OF SIGNIFICANCE ON ADMISSION: His hemoglobin
was 11.2, hematocrit 32, which was near his baseline of
32-33. His INR was 1.7. His complete blood count was
significant for creatinine of 1.9 which is higher than his
baseline of 1.2-1.3. Urinalysis showed large blood, 21-50
red blood cells, [**3-18**] white blood cells, few bacteria. Tox
screen negative. Urinalysis was negative for nitrates and
leukocyte esterase. Ammonia level on admission was 87, which
was up from 22 at the last admission.
CT SCAN OF THE HEAD: Was negative.
ABDOMINAL ULTRASOUND: From the previous admission showed a
small nodular liver with appropriate direction of blood flow.
Small ascites, splenomegaly, no hydronephrosis, plus
cholelithiasis, but no bile duct dilatation.
The patient was admitted to the Intensive Care Unit to
observe his airway as there was a chance that he would need
to be intubated.
1. GI: Hepatic encephalopathy. The patient had several
recent admissions this summary for hepatic encephalopathy.
There were no localizing symptoms, no fever, white blood cell
count. Increased white blood cell count suggests infection
as an inciting factor. The patient has been compliant with
his diet, but it was possible that he had increased protein
intake, although it was difficult to get this history on
admission. Again, there is a possibility that there was a GI
bleed or that the patient had decreased lactulose intake.
He was kept NPO while he had decreased mental status. He was
put on a low protein diet once he was able to tolerate po.
He was continued on his standing dose of lactulose with a
goal of [**3-17**] bowel movements per day, and the Liver Service
was consulted. On the evening of the 22nd, the patient was
transferred out of the unit as his mental status had
improved.
While in the Intensive Care Unit, the patient's Lasix and
aldactone were held. The patient's mental status continued
to improve while in the Intensive Care Unit. The Liver
Service was consulted, and decision was made to transfer the
patient to a medicine bed on the evening of the 22nd. The
patient was continued on lactulose. In the Intensive Care
Unit, it was noted that the patient's hematocrit was dropping
and his stools were guaiac positive. His hematocrit nadir
was 25 on the morning of the 23rd, so the decision was made
to further evaluate this with colonoscopy and endoscopy,
which were done on the [**8-6**].
Given the patient's history of questionable hepatocellular
carcinoma, he has three nodules on his liver which has not
been biopsied. More extensive evaluation for possible
metastases was done. The patient was sent for a bone scan,
which showed he had increased activity diffusely within his
abdomen likely secondary to ascites. More focal tracer
activity in the region of his liver representing acute
inflammatory process (hepatitis C), posttraumatic activity in
the left 7th rib. No evidence of osseous metastases.
The patient also had a CT scan of the chest, which showed no
evidence of pulmonary metastases. Again, it was noted that
the patient does have a gallstone. On the 23rd, the patient
was transfused 2 units of packed red blood cells. His
follow-up hematocrit again was in the range of 32-33 which is
his baseline.
On the 24th, the patient had colonoscopy which showed that he
had rectal varices, and a small sessile 5 mm nonbleeding
polyp. There was no biopsy done secondary to his platelets
being 54 and his INR of 1.7. An EGD was done on the same day
which showed that he had varices in the lower [**1-16**] of the
esophagus and middle [**1-16**] of the esophagus. He had erythema,
and congestion, and nodularity, and a normal vascularity in
the antrum, which is consistent with gastropathy.
No other GI workup was done at this time. The patient was
continued on his Protonix q day. He was told to continue
taking lactulose 30 cc prn for goal of [**3-17**] bowel movements
per day. He was started on Flagyl in the Intensive Care
Unit. He was told to continue taking 250 mg [**Hospital1 **] until he
receives his transplant. The aldactone would be restarted on
Monday as an outpatient, and his Lasix was discontinued.
2. Renal: The patient had acute on chronic renal failure on
admission. His Lasix and aldactone were discontinued in the
Intensive Care Unit. The patient's creatinine improved
towards his baseline of 1.2-1.3, and on the day of discharge,
it was 1.0.
When the patient was in the Intensive Care Unit, the Renal
Service was consulted. Their recommendations were to hold
the Lasix and to address the issue of questionable GI bleed
and optimize his volume status which was done.
3. Cardiovascular: The patient has a history of blood
pressure in the range of 90/60. After the colonoscopy and
endoscopy on the 24th, his nadolol was increased to 60 q day,
however, the patient's blood pressure dropped to the 80
systolic, and while he was asymptomatic, the decision was
made to resume his normal dose of nadolol of 40 q day.
4. Anemia secondary to blood loss versus dilutional effect:
There was no active bleeding once the patient arrived to
Medicine from the Intensive Care Unit. He received a
transfusion of 2 units of packed red blood cells. His
hematocrit remained stable throughout his hospital stay.
5. Fluids, electrolytes, and nutrition: The patient was
given a low sodium-low protein diet. Nutrition therapy did
teaching with the patient about dietary intake.
The patient was discharged on the 25th.
DISCHARGE INSTRUCTIONS: He was to continue taking lactulose
30 cc as often as needed to have a goal of [**3-17**] bowel
Emergency Room if becoming increasingly confused, having
difficulty speaking, if he was experiencing lightheadedness
or dizziness when he got up from a sitting to standing
low, to followup with Urology on his appointment, [**8-10**],
Dr. [**Last Name (STitle) 42189**] for his evaluation of microscopic hematuria. To
followup in the Liver Clinic with Dr. [**Last Name (STitle) **] on [**8-13**] at
9:15 am, and to continue taking all of his medications as he
was before with the following changes: He is take Flagyl 250
mg po bid until he receives his transplant. To continue
taking Protonix. The Lasix was discontinued, and he was to
restart his aldactone on Monday, [**8-10**].
FINAL DIAGNOSES:
1. Hepatic encephalopathy.
2. Cirrhosis.
3. Hepatitis C.
4. Esophageal varices status post esophagogastroduodenoscopy,
no evidence of bleeding.
5. Rectal varices status post colonoscopy, no bleeding.
6. Anemia secondary to blood loss versus dilutional effect,
status post transfusion of 2 units of packed red blood cells.
7. Question hepatocellular carcinoma.
8. Chronic renal failure.
9. Cholelithiasis.
SURGICAL INVASIVE PROCEDURES DURING HIS STAY:
1. EGD.
2. Colonoscopy.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Metronidazole 250 mg tablet po bid.
2. Ursodiol 300 mg capsule po tid.
3. Protonix 40 mg po q day.
4. Lactulose 30 cc prn.
5. Nadolol 40 mg q day.
6. Restart taking his aldactone 50 mg po bid on Monday, [**8-13**].
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2167-8-7**] 14:32
T: [**2167-8-18**] 15:28
JOB#: [**Job Number 42190**]
cc:[**Last Name (NamePattern4) **]
|
[
"585",
"211.3",
"456.8",
"584.9",
"155.0",
"287.5",
"070.54",
"571.2",
"572.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9152, 9161
|
9184, 9713
|
1359, 1516
|
7855, 8636
|
8653, 9130
|
164, 986
|
2372, 7830
|
1008, 1333
|
1533, 1727
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,967
| 198,090
|
9496
|
Discharge summary
|
report
|
Admission Date: [**2124-1-10**] Discharge Date: [**2124-1-14**]
Date of Birth: [**2048-10-26**] Sex: F
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: The patient is a 75 year-old
female with a history of coronary artery disease dating back
to approximately one year ago. She had a cardiac
catheterization in [**2122-10-11**] which was significant for
three vessel disease, but with good collaterals. She has now
recent onset of unstable angina.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Colectomy for colon cancer several years ago.
2. Appendectomy.
3. Status post varicose vein stripping bilaterally 30 years
ago.
4. Total abdominal hysterectomy / bilateral
salpingo-oophorectomy.
5. Bilateral cataract surgery.
6. Cholecystectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 milligrams po q day.
2. Hyzaar 12.5 / 50 milligrams q day.
3. Atenolol 25 milligrams q day.
4. Tagamet.
5. Norvasc 5 milligrams q day.
6. Imdur 60 milligrams q day.
7. Lasix 20 milligrams q day.
8. KCL 20 milligrams q day.
9. Estrogen 0.225 milligrams q day.
PHYSICAL EXAMINATION: Blood pressure 139/66, heart rate 55,
respiratory rate 14, 02 sat 95% on room air. Cardiac -
regular rate and rhythm. Abdomen - soft, nontender,
nondistended. Pulmonary - clear to auscultation bilaterally.
Extremities - no edema, bilateral pulses palpable.
HOSPITAL COURSE: The patient had a cardiac catheterization
performed on [**2124-1-5**]. The findings were as
follows: right dominant system with three vessel coronary
artery disease. Left main coronary artery was normal. LAD
was diffusely diseased with 80% mid vessel stenosis and 70%
immediately distal the second diagonal branch. Left
circumflex area was totally occluded proximally and two
large, obtuse marginal branches filled via collaterals from
the LAD. The right coronary artery was totally occluded
proximally in the right posterior descending artery filled
via collaterals from the LAD. EF 59%. Mild inferior [**Known lastname **]
hypokinesis with mild MR. [**Name13 (STitle) **] intervention was performed.
On [**2124-1-10**] a coronary artery bypass graft times
three was performed by Dr. [**Last Name (STitle) 1537**]. The LIMA went to the LAD,
left radial to OM, right radial to RCA. The pericardium was
left open and arterial line and right IJ triple lumen
catheter inserted. Ventricular and atrial pacing wires were
placed and mediastinal pleural tubes were also placed. The
patient was transferred to the ICU postoperatively. She was
rapidly extubated. She had an episode of postoperative
atrial fibrillation for which a Amiodarone drip was started.
This was later converted to the oral form of Amiodarone. A
Neo-Synephrine and Nitro drip were appropriately weaned.
On postoperative day two the patient's pleural and
mediastinal tubes were removed.
On postoperative day three the patient was stable and
transferred to the floor. Her Foley was discontinued on
postoperative day three.
On postoperative day four the patient's wires were
discontinued and she was stable for transfer to a
rehabilitation facility.
LABORATORY DATA AT DISCHARGE: White count 7.6, hematocrit
26, platelet count 168,000. Sodium 137, potassium 4.1,
chloride 107, bicarb 21, BUN 14, creatinine 0.8, glucose 115.
INS calcium 1.14.
Her sternum and artery sites radially were stable with no
drainage throughout the admission.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Ecotrin.
2. Aspirin 325 milligrams q day.
3. Lasix 20 milligrams [**Hospital1 **] times seven days.
4. KCL 20 milligrams [**Hospital1 **] times seven days.
5. Colace 100 milligrams po bid.
6. Percocet one to two tablets po q four to six hours prn.
7. Amiodarone 400 milligrams [**Hospital1 **] for seven days, then 400
milligrams q day times 14 days.
8. Imdur 60 milligrams po q day times 90 days.
9. Atenolol 25 milligrams po q day.
DISCHARGE STATUS: Rehabilitation facility.
DISCHARGE INSTRUCTIONS: Follow up with primary care
physician in three weeks. Follow up with Dr. [**Last Name (STitle) 1537**] in four
weeks.
DIAGNOSIS:
1. Status post coronary artery bypass graft times three.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2124-1-14**] 09:02
T: [**2124-1-14**] 09:17
JOB#: [**Job Number 32308**]
|
[
"V10.05",
"411.1",
"997.1",
"401.9",
"414.01",
"427.31",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"38.63",
"39.61",
"36.19"
] |
icd9pcs
|
[
[
[]
]
] |
3539, 3548
|
3571, 4063
|
909, 1193
|
1494, 3243
|
4088, 4547
|
590, 883
|
1216, 1477
|
3258, 3517
|
173, 471
|
493, 567
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,508
| 177,115
|
7144
|
Discharge summary
|
report
|
Admission Date: [**2197-12-31**] Discharge Date: [**2198-1-6**]
Date of Birth: [**2150-10-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Malaise, cough, fever
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Mr. [**Known lastname 931**] is a 47 M with DM1 s/p kidney/pancreas transplant
on chronic prednisone, HTN, CRI, who presented with a
non-productive cough, SOB, malaise, increase in LE edema, and
fever 100.1 starting [**12-28**]. The patient thought he may have
pneumonia and went to [**Hospital3 6592**] for assessment. At [**Hospital1 **],
his Cr 3.6 from baseline Cr 2.0. WBC 16.4 with Bands 5. CK
389, MB 24, MBI 6.6, TropT 7.84, BNP [**Numeric Identifier 26568**]. An EKG showed
evidence of an anterolateral STEMI, and patient was transferred
to [**Hospital1 18**] for further management.
.
The patient was transferred to [**Hospital1 18**] transplant surgery service
because of his previous kidney/pancreas transplant. O2 sat was
99% RA. He was given IVF 75/hr, which was stopped a few hours
later. The Cards fellow requested transfer to [**Hospital Ward Name 121**] 3, and a
trigger was called on [**Hospital Ward Name 121**] 3 for O2 sat 93% on nonrebreather.
He was given lasix 40 IV before transfer to CCU on monitoring.
.
In the CCU, EKG showed 1-2 mm STE V2-V6; Q waves V2-V5, I, AVL;
STE in AVR, AVL, suggesting an anterolateral STEMI and proximal
LAD infarct that occurred several days prior. CK 267, MB 17,
Trop 6.19. In the early am, the case was discussed with Dr.
[**Last Name (STitle) **] (interventional attending) who did not wish to take
patient to the cath lab immediately. The patient was found to
have a systolic murmur. No valvular pathology was noted on
previous TEE (normal EF with normal wall motion). A bedside TTE
was performed to assess mechanical complication of STEMI. TTE
showed EF 30%, 1+MR, mid anterior wall and apex akinetic, no
thrombus.
Past Medical History:
DM1 x 12 yo
R toe amputation
Osteopenia
Urethral stricture
Penile implant
Sleep apnea history
Kidney/pancreas transplant [**2183**]:
His kidney transplant is present in his RLQ, pancreas transplant
is in his LLQ (enteric conversion was performed where pancreas
was moved from bladder to GI). He had one rejection episode in
[**2183**], but transplant has generally taken well on prednisone and
prograf. Since the pancreas transplant, the patient has not
required any insulin since [**2183**], and he does not need to check
his blood glucose at home. He has been completely compliant
with his medications, and has not been taking ASA.
Social History:
No ETOH, 20 pky smoker, quit [**2183**] before transplant, smokes
marijuana rarely, no heroin, no cocaine. Married with 2
children, works for [**Company 11293**].
Family History:
Brother - MI at age 52, died from this MI
Father - MI at age 53, died from this MI
No CVA
Physical Exam:
VS: 97.7 / 135/85 / 70 / 20 / 94% on NRB
GEN: Abdominal breathing but not overtly SOB, alert, appears
comfortable
HEENT: JVD to 8 cm, no LAD, PERRL, no carotid bruits
LUNGS: Rales 1/2way up both lungs
HEART: 3/6 systolic murmur increasing on inspiration, [**4-17**]
systolic murmur radiating to axilla, no r/g, no S3, no S4
ABDOMEN: Kidney transplant in RLQ, Pancreas transplant in LLQ,
+BS, soft, nonobese, ND NT
NEURO: [**6-16**] motor, CN 2-12 intact
SKIN: No rashes, telangiectasias, bruises, petechiae
EXTR: Trace bilateral LE edema, no c/c, 1+ R DP pulse,
nonpalpable L DP pulse
Pertinent Results:
[**2197-12-31**] 11:15PM PT-13.5* PTT-29.6 INR(PT)-1.2*
[**2197-12-31**] 11:15PM PLT COUNT-230
[**2197-12-31**] 11:15PM ALBUMIN-3.4 CALCIUM-8.4 PHOSPHATE-4.3
MAGNESIUM-2.3
[**2197-12-31**] 11:15PM LIPASE-21
[**2197-12-31**] 11:15PM GLUCOSE-129* UREA N-62* CREAT-3.7*#
SODIUM-139 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-18* ANION GAP-17
.
[**2198-1-1**] 06:00PM CK 203*
[**2198-1-1**] 10:41AM CK 263*1
.
[**2198-1-1**] 06:00PM CKMB 13* MBI 6.4* TropT 6.62*1
[**2198-1-1**] 10:41AM CKMB 17* MBI 6.5* TropT 6.19*1
[**2198-1-1**] 04:50AM CKMB 20* MBI 6.9* TropT 6.09*
.
CXR: IMPRESSION: PA and lateral chest compared to the most
recent prior chest radiograph, [**2195-6-1**]:
There is a severe interstitial pulmonary abnormality
predominantly in the lower lungs with some coalescence in the
right middle and lower lobes accompanied by small bilateral
pleural effusions. This could be due to pulmonary edema except
that the heart is normal size and there is no mediastinal,
pulmonary or hilar vascular engorgement. Alternative
explanations are acute interstitial pneumonia or acute
myocardial infarction.
.
TTE: Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated with severe hypokinesis/akinesis of the distal half of
the septum and anterior walls and distal inferior and lateral
walls. The apex is akinetic and mildly aneurysmal. No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. There is moderate aortic
stenosis (AoVA = 0.8cm2). Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
CAD (mid-LAD territory). Moderate pulmonary artery systolic
hypertension.
.
Adenosine MIBI: IMPRESSION: 1. Moderate, predominantly fixed
perfusion defect involving the mid-distal anterior wall, the
apex, and the distal septum. 2. Marked left ventricular
enlargement. 3. Severe global hypokinesis, with superimposed
apical dyskinesis. LVEF=18%.
.
Adenosine MIBI:
SUMMARY OF DATA FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
mg/kg/min.
METHOD:
Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi.
Tracer was
injected approximately one hour prior to obtaining the resting
images.
Two minutes after the cessation of infusion of dipyridamole,
approximately three times the resting dose of Tc99m sestamibi
was administered IV. Stress images were obtained approximately
one hour following tracer injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is adequate.
Left ventricular cavity size is markedly enlarged.
Resting and stress perfusion images reveal uniform moderate,
predominantly fixed perfusion defect involving the mid-distal
anterior wall, the apex, and the distal septum.
Gated images reveal severe global hypokinesis, with superimposed
apical
dyskinesis.
The calculated left ventricular ejection fraction is 18%.
IMPRESSION: 1. Moderate, predominantly fixed perfusion defect
involving the
mid-distal anterior wall, the apex, and the distal septum. 2.
Marked left
ventricular enlargement. 3. Severe global hypokinesis, with
superimposed
apical dyskinesis. LVEF=18%.
.
[**1-5**] CXR: CHEST: Comparison is made with the prior chest x-ray
of [**1-4**]. The perihilar interstitial opacities, most
marked in the anterior segment of the right upper lobe are again
seen. This pattern of interstitial infiltrate would be unusual
and prolonged for simple failure and I suspect the presence of
pneumonia in addition. The size of the effusions has decreased
consistent with improved failure, but I doubt the infiltrates
are caused by this.
IMPRESSION: Persistent perihilar infiltrates, pneumonia is
suspected.
Brief Hospital Course:
This is a 47 M with DM1, kidney/pancreas transplant [**2183**], HTN,
CRI, who is here s/p anterolateral STEMI, presenting with
shortness of breath which is likely attributed to a CHF
exacerbation.
.
1. CARDIAC:
A. CAD: This patient was admitted with evidence of an
anterolateral STEMI on EKG with STE V2-V6; Q waves V2-V5, I,
AVL; STE in AVR, AVL. The EKG suggested a proximal LAD infarct.
This infarct likely occurred several days PTA given the
precordial Q waves and the falling CKs. The peak recorded CK was
362. However, given the suspected time course, the true peak was
likely much higher. Cardiac catheterization was deferred due to
the patient's renal failure and because he was already many days
out from his MI. The patient therefore, underwent an adenosine
MIBI. This showed a fixed perfusion defect involving the
mid-distal anterior wall, the apex, and the
distal septum. It also showed depressed systolic function with
an EF of 18% and
severe global hypokinesis, with superimposed apical dyskinesis.
The patient was started on ASA 325, lipitor 80, and metoprolol
50 TID. Hydralazine 10 mg Q6 was also started for BP control.
Once the patient's renal failure improved, a low dose ACEI was
started. The patient was asked to have a chem 7 drawn on Monday
[**1-8**] and to follow up with his PCP for further titration of his
BP and other cardiac medications.
.
B. Pump: The patient was admitted to the floors with a CHF
exacerbation s/p an anterolateral STEMI. He was transferred to
the CCU for increasing respiratory distress secondary to volume
overload and CHF. The patient was diuresed with lasix with good
effect and his hypoxia resolved. An echo was done which showed
and EF 30%, AS with valve area 0.8, and akinesis of the apex,
distal half of the septum anterior and lateral walls. An
adenosine MIBI showed an EF of 18% with a fixed perfusion defect
as described above. The patient was initially kept on heparin
for the apical akinesis and low EF, with the intention of
bridging to coumadin. However, given the patient has a h/o
hemorrhagic CVA, the heparin was stopped and the coumadin was
not started. It was decided that the risk of future cerebral
hemorrhage was greater than the risk of thrombus formation and
emobilization [**3-16**] the apical akinesis. The patient was
discharged on lasix 40mg QD given his elevated BNP and low EF.
He was also discharged on ACEI and metoprolol for their
cardioprotective effects. The patient will likely need a repeat
echo in approximately 3 mo after maximum medical therapy and
possible consideration of an ICD placement given his low EF.
.
C. Rhythm:
The patient was maintained in NSR throughout the duration of his
hospitalization. he was started on metoprolol and monitored on
telemetry w/o event.
.
2. Respiratory distress: The patient was admitted to the CCU in
respiratory distress from florid pulmonary edema. Initially he
was sating 94% on a NRB. The pt also has a 20 pky smoking
history and a h/o obstructive sleep apnea. He was not on home
oxygen, and was never on CPAP or Bipap. Given his obvious volume
overload, the patient was diuresed with lasix and put on a nitro
drip. His O2 requirement diminished quickly and the nitro drip
was weaned off. The patient's dyspnea resolved completely. He
was also afterload reduced with hydralazine and lisinopril once
his Cr stabilized. Although serial CXR showed possible b/l PNA,
the patient never had a productive cough. ID was consulted and
did not recommend treating for CAP. Transplant nephrology was
also following the patient and did not recommend empiric
treatment for CAP.
.
3. Acute on CRI: The patient was admitted with Cr 3.7 which
increased to 4.1 upon diuresis from a baseline Cr 2.0. Urine
lytes were sent and FEurea was 29% indicating pre-renal cause
for the acute component of his renal failure. Although the
patient was clearly total body volume overloaded, he likely
likely had poor forward flow due to his diminished systolic
function from his recent STEMI. Although his creatinine
increased slightly upon diuresis, his Cr slowly decreased to
2.9. Upon restarting low dose lisinopril, his Cr bumped modestly
to 3.1. Therefore, we will have him get a chem 7 checked two
days after discharge to follow up on his Cr and potassium
levels. Transplant nephrology was involved during throughout his
hospitalization.
.
4. Leukocytosis/fever: The patient's WBC 16.4 upon admission
the patient also spiked fevers to 102 but did not exhibit any
localizing symptoms of infection. Urine and blood cultures were
negative. Urine legionella Ag was sent but pending upon
discharge. His stool was negative for C.diff x 1. CXR showed
possible b/l PNA. However, the patient denied any productive
cough and did not show any clinical signs of infection. As the
patient was diuresed, the b/l perihilar opacities seen on CXR
improved. Therefore, the perihilar opacities on CXR were thought
to be due to CHF> and the fever and leukocytosis were attributed
to his STEMI and atelectasis.
Given the patient is a transplant patient and is
immunosuppressed on chronic prednisone treatment, ID was
consulted concerning the fevers. They supported the idea of
holding off on antibiotic treatment given the lack of clinical
symptoms of PNA. By the time of discharge, the patient had been
afebrile for >24hrs. He was advised to call his PCP if he
continued to experience fevers.
.
5. Hypertension: Initially the patient was put on a nitro drip
to maintain his SBP between 130-150. This was done to prevent
flash pulmonary edema while also maintaining sufficient
perfusion to his renal transplant. For BP control the patient
was started on Toprol 150 QD and hydralazine. Once his RF began
to resolve, he was started on a low dose ACEI and his
hydralazine was discontinued.
.
6. Renal/Pancreas transplant: The patient was followed by
transplant nephrology during his hospitalization. Has not needed
insulin since pancreas transplant [**2183**]. His tacrolimus levels
were checked QD and were maintained between [**6-17**]. He continued to
receive Prograf 2 QAM, 1 QPM and prednisone 12.5 QPM. He was
advised to follow up with transplant physicians upon discharge.
.
7. Anemia: The patient has a baseline Hct 32, likely due to ACD
and iron deficiency. which was stable during his
hosptialization.
.
Medications on Admission:
Tacrolimus 2 QAM, 1 QPM
Prednisone 12.5 QPM
Labetalol 600 [**Hospital1 **]
Diltiazem 120 [**Hospital1 **]
Discharge Medications:
1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
2. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please check Chem 7 (Na, K, Cl, HCO3, BUN, Cr)
Please get these labs drawn on Monday [**1-8**]
Please fax the results to Dr. [**Last Name (STitle) 15473**] fax: ([**Telephone/Fax (1) 21178**] phone:
([**Telephone/Fax (1) 26569**].
12. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Outpatient Physical Therapy
Please refer patient to outpatient cardiac rehabilitation
program
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Anterolateral ST elevation MI
Fevers; unknown etiology now resolved
Systolic Heart failure, EF 18%
.
Secondary:
Diabetes
s/p pancreatic/kidney transplant
Osteopenia
History of urethral stricture
Sleep apnea
Discharge Condition:
Good. Patient is hemodynamically stable with O2 saturation > 95%
on room air.
Discharge Instructions:
1. Please take all medications as prescribed
.
2. Please keep all outpatient appointments
.
3. Please return to the hospital or seek immediate medical
attention for symptoms of shortness of breath, chest pain,
dizziness, loss of consciouness or continuing fevers.
.
4. Please take your temperature daily. If you continue to have
elevated temperatures you should call your primary care
physician or Dr. [**Last Name (STitle) **] to discuss additional necessary
workup.
Followup Instructions:
1. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15473**]
next week. Please call Dr.[**Name (NI) 26570**] office at [**Telephone/Fax (1) 673**] to
make an appointment.
.
2. Please get your blood drawn on monday and have the results
sent to Dr.[**Name (NI) 26570**] office [**Telephone/Fax (1) 673**]. It is very important
you have blood work performed to ensure your renal function is
normal. You will be given a lab appointment slip to have this
performed at your PCPs office or lab facility. Please have the
results sent to your PCP.
.
3. It is very important that you have close follow up with Dr.
[**Last Name (STitle) **] as well given some kidney dysfunction on admission.
Please call the office of Dr. [**Last Name (STitle) 26571**] at ([**Telephone/Fax (1) 3618**] to make
an appointment to be seen within two week's time. As above, it
is important you have lab values checked early next week so that
your current medical regimen may be monitored.
.
4. You will need follow up with Cardiology given your recent
myocardial infarction and need for ongoing monitoring and
titration of your new cardiac medications. You should call the
cardiology office at ([**Telephone/Fax (1) 5909**] to set up an appointment
with Dr. [**Last Name (STitle) **] within one month.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2198-3-6**]
|
[
"285.9",
"403.90",
"584.9",
"996.81",
"780.6",
"428.0",
"288.60",
"424.1",
"585.9",
"V42.83",
"414.01",
"410.01",
"250.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15936, 15942
|
7948, 14251
|
295, 302
|
16202, 16282
|
3591, 7925
|
16798, 18286
|
2879, 2970
|
14408, 15913
|
15963, 16181
|
14277, 14385
|
16306, 16775
|
2985, 3572
|
234, 257
|
330, 2022
|
2044, 2682
|
2698, 2863
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,563
| 177,755
|
16290
|
Discharge summary
|
report
|
Admission Date: [**2154-8-19**] Discharge Date: [**2154-8-23**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Insertion of Metronic Dual Chamber Adapta L pacemaker
History of Present Illness:
[**Age over 90 **]M with a history of CAD s/p CABG in [**2124**] and recent admissions
([**8-6**]) for inferior STEMI s/p DES in SVG-LAD and CP r/o MI ([**8-17**],
d/c'ed [**8-18**]), CHF, paroxysmal atrial fibrillation (not on
anticoagulation) p/w substernal chest pain, and was found to
have A-fib w/ RVR.
.
His symptom started at 3pm. He was asleep, and woke up because
of chest pain. Pain was described as midsternal, with radiation
to both arms, very similar to the pain he had during prior
ischemic events, but gradually worsening to [**11-11**], with no
diaphoresis, sob, n/v. He tried two sl nitro, but did not help.
.
Of note, he was recently admitted for an inferior wall STEMI
with peak CK-MB of 41 and troponin of 1.03. He underwent urgent
cardiac cath for revascularization with occluded SVG-RCA. Cath
was complicated by hypotension with IABP insertion. Repeat
angiography of SVG-LAD revealed 95 % stenosis of its ostium and
underwent PTCA and one drug-eluting stent. Post-procedure ECHO
showed EF 30 % similar to previous baseline. He was subsequently
discharged with plavix, aspirin, atorvastatin, and lisinopril.
He was placed on low-dose beta blockade but experienced
bradycardia.
.
In the ED, initial vitals were 113 91/63 12 98% 1L Nasal
Cannula.
Pt rated pain [**11-11**] upon arrival. He had ASA 325 X1, 4mg
Morphine IV x1 which helped. He also received Amiodarone bolus
of 150 mg over 15 mins x2. Heart rate dropped from 125 bpm to 96
bpm after 2nd dose. Then Amiodarone gtt started at 1mg/hr. Pt
states pain is 0/10 at this time.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope, claudication.
.
Other ROS is notable for vision loss (only perceptable to light)
on the right side. Pt unclear about when it started exactly, but
likely within a month. Pt also c/o hesitency during urination,
which has been a chronic issue.
He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2124**] and 2 vessel SVG stenting in [**2148**] followed by
failed attempt to open an occluded OM branch on [**3-/2149**] due to
persistent angina.
-PERCUTANEOUS CORONARY INTERVENTIONS:
s/p DES to SVG-RCA and SVG-LAD ([**2148**]). SVG to OM known occluded.
3. OTHER PAST MEDICAL HISTORY:
- CAD s/p MI, CABG, PCI as above.
- AAA s/p repair
- Chronic systolic CHF (EF 25-30%)
- Hyperlipidemia
- Chronic kidney disease (baseline creatinine 1.6-2.2)
- s/p L carotid endarterectomy [**2143**]
- s/p cholecystectomy
- GERD
- hearing loss
- Nephrolithiasis
- Mesenteric ischemia (celiac artery stenosis, occluded [**Female First Name (un) 899**])
- Dizziness
- Chronic pleural effusion s/p talc pleuridesis
Social History:
Lives alone, but sons lives within [**Street Address(2) 46372**] and involved
in care. No HHA or other help at home. Quit smoking >40y ago;
used to smoke 3ppd x 20 years. No alcohol. No recreational
drugs.
Family History:
Father died of MI in 70s
Physical Exam:
ADMISSION EXAM
VS: T=97.6 BP=105/60 HR=91 RR=19 O2 sat= 99% on 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No visual acuity on
the right, Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
NECK: Supple with JVP of 2 cm above clavicle
CARDIAC: irregularly irregular rhythm, good s1, s2 with no
murmurs appreciated.
LUNGS: No chest wall deformities, Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
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+
EXT: 2+ pitting edema to ankles bilaterally
DISCHARGE EXAM
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Visual acuity on the
right is only limited to sensation of light, Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: No JVP elevation
CARDIAC: irregularly irregular rhythm, good s1, s2 with no
murmurs appreciated.
LUNGS: No chest wall deformities, Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
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+
EXT: 2+ pitting edema to ankles bilaterally
Pertinent Results:
ADMISSION LABS
[**2154-8-18**] 09:18AM BLOOD WBC-5.3 RBC-3.51* Hgb-11.2* Hct-33.3*
MCV-95 MCH-31.9 MCHC-33.7 RDW-15.7* Plt Ct-111*
[**2154-8-19**] 07:50PM BLOOD Neuts-82.2* Lymphs-12.9* Monos-3.6
Eos-0.9 Baso-0.5
[**2154-8-18**] 01:11AM BLOOD PTT-48.2*
[**2154-8-18**] 09:18AM BLOOD PT-15.1* PTT-42.2* INR(PT)-1.3*
[**2154-8-18**] 09:18AM BLOOD Glucose-155* UreaN-33* Creat-1.8* Na-140
K-4.5 Cl-103 HCO3-30 AnGap-12
[**2154-8-18**] 09:18AM BLOOD CK-MB-4 cTropnT-0.25*
.
PERTINENT LABS
[**2154-8-19**] 07:50PM BLOOD cTropnT-0.24*
[**2154-8-20**] 05:31AM BLOOD CK-MB-14* MB Indx-13.6* cTropnT-0.51*
[**2154-8-20**] 11:35AM BLOOD CK-MB-15* MB Indx-13.8* cTropnT-0.62*
[**2154-8-20**] 05:31AM BLOOD Digoxin-0.7*
.
DISCHARGE LABS
[**8-23**] COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2154-8-23**] 06:10 4.0 3.44* 10.9* 31.8* 93 31.6 34.2 15.5 110*
[**8-23**] RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2154-8-23**] 06:10 951 35* 1.8* 141 4.2 104 30 11
.
PERTINENT STUDIES
# Portable CXR [**8-17**]
UPRIGHT AP VIEW OF THE CHEST: The patient is status post median
sternotomy, CABG. There is moderate enlargement of the cardiac
silhouette which is unchanged. The aorta is mildly tortuous and
diffusely calcified, which is stable. Multiple calcified
mediastinal and hilar lymph nodes are again demonstrated. There
is mild pulmonary vascular congestion. Increasing opacification
of the right lung base may represent worsening atelectasis,
pulmonary edema, or infection. Blunting of the right
costophrenic angle is redemonstrated suggestive of a small
pleural effusion. There is no pneumothorax. No acute osseous
abnormalities are seen.
IMPRESSION:
1. Mild pulmonary vascular congestion.
2. Increasing patchy opacity in the right lung base may reflect
worsening
atelectasis, edema, or infection. Small right pleural effusion,
unchanged.
.
# Portable CXR [**8-21**]
INDICATION: [**Age over 90 **]-year-old man with tachybrady syndrome status post
dual-chamber pacemaker implant using the axillary vein. Question
any pneumothorax.
The lungs are well expanded and show mild bilateral interstitial
opacities. The cardiac silhouette is top normal. The
mediastinal silhouette and hilar contours are normal. No pleural
effusions or pneumothorax is present. A left-sided pacer
terminates with its leads in the right atrium and right
ventricle appropriately. Sternal wires are intact.
IMPRESSION:
Mild interstitial edema. No pneumothorax.
.
# CXR PA/Lateral [**8-22**]
FINDINGS: Lungs are well expanded. Left lung field is clear
without vascular congestion or pulmonary edema. The right lung
shows chronic apical changes with scarring and nodular
thickening of the apical pleura and a prominent minor fissure
which are unchanged since at least [**2153-10-3**]. Compared with
radiograph on [**8-21**] and after accounting for difference in
positioning and technique, there is mild worsening of the right
lower lobe opacity with obscuring of the right hemidiaphragm.
Blunting of the right pleural sulcus is likely due to tiny
pleural effusion or pleural scarring with retraction and has
been present since at least [**2153-10-3**]. Cardiomediastinal
and hilar contours are unremarkable. The aorta is tortuous.
Pacemaker leads are in standard positions and unchanged from
prior exam on [**8-21**]. Sternotomy wires
are intact. There is no evidence of pneumothorax.
IMPRESSION:
1. Pacemaker leads in standard position in right atrium and
ventricle.
2. No evidence of pneumothorax.
3. Mild interval worsening of right lower lobe opacification.
Otherwise,
unchanged from exam on [**2154-8-21**].
Brief Hospital Course:
[**Age over 90 **]M with a history of CAD s/p CABG and multiple stents, CHF,
paroxysmal atrial fibrillation p/w substernal chest pain, A-fib
w/ RVR, but later developed sinus bradycardia and underwent
pacemaker placement.
.
# A-fib with RVR
Patient presented with A-fib with RVR in the setting of recent
STEMI s/p restenting of SVG-LAD. On presentation he was in
[**11-11**] chest pain with HR in 110-120s with no evidence of
ischemia on EKG, but a slight increase in cardiac enzymes on the
second day, consistent with demand ischemia. A decision of
chemical conversion was made after first seen in the ED, given
his intolerance to b-blocker and good response to amioderone for
SVT during prior admission. Pt responded well to amiodarone,
with complete resolution of chest pain and tachycardia.
However, he later developed mixed sinus / junctional bradycardia
in 30-40s with stable blood pressure. We discontinued
amiodarone. EP consult was initiated. After discussing with
patient and his family, a decision was made to place a
pacemaker. Patient tolerated the procedure well without
complications. We hope with the pacemaker, patient would be
able to tolerate optimal medical management for his A-fib to
prevent rapid ventricular rate and demand ischemia. Of note,
patient has a CHADS score of 3, but was never treated wit
anti-coagulation. After discussing with family, we decided not
to start anti-coagulation, given his age and risk of
life-threatening bleeding.
OUTPATIENT ISSUES:
- Increased amiodarone to 200 mg daily
- Started metoprolol succinate 50 mg daily
.
# CAD:
Patient had recent STEMI s/p stent placement in SVG-LAD. His
chest pain on presentation was not associated with EKG changes.
There was a transient slight elevation of cardiac enzymes,
likely a result of demand ischemia secondary to rapid
ventricular rate during A-fib. Heparin drip was provided
initially given the unclear ACS picture on presentation, but
stopped shortly afterwards. His home medications were
continued, including aspirin, plavix, pravastatin and isosorbid
mononitrate. We temporarily discontinued lisinopril because of
patient's low blood pressure.
OUTPATIENT ISSUES:
- Changed to pravastatin from atorvastatin for insurance
purposes.
- Please consider restarting lisinopril if patient's blood
pressure tolerates
.
# CHF
Patient has a documented history of CHF likely secondary to his
long standing CAD, with stable LVEF at 30% and mild to moderate
MR on recent ECHO. Of note, he had a history of refractory
pleural effusion requiring talc pleuridesis. During this
hospitalization, we temporarily discontinued his furosemide
given his bradycardia. Nonetheless, patient maintained stable
volume status without clinical evidence of CHF. Patient was
discharged on only his morning dose of furosemide considering
the lack of need for diuresis during this admission.
OUTPATIENT ISSUES:
- Changed to furosemide 80 mg qAM only (from 80 mg qAM and 40 mg
qPM). Please optimize diuresis as needed.
.
# Right eye vision loss
Patient reported vision loss in his right eye for an unknown
duration, likely started during his recent hospitalization for
STEMI. He was seen by our ophthalmology team, and was found to
have a subretinal hemorrhage, involving the macula. This
unfortunate incident could have potentially happened in the
setting of anti-platelet treatment for his cardiac problems.
OUTPATIENT ISSUES:
- Patient has an outpatient ophthalmology appointment on [**8-26**].
CHRONIC ISSUES
# HTN
Patient has a documented history of HTN. However, he was
hypotensive to normotensive throughout this hospitalization. We
temporarily discontinued his lisinopril, isosorbid mononitrate
and furosemide, and restarted him on isosorbid mononitrate,
decreased dose of furosemide, but no lisinopril.
OUTPATIENT ISSUES
- please consider restarting lisinopril given patient's history
of CAD and CHF.
.
# Chronic renal insufficiency
Patient's Cr was at his recent baseline of 1.8-2.0. It appeared
that his renal insufficiency only started to worsen in the past
two years. His renal insufficiency could certainly be a result
of poor forward flow secondary to CHF. However, patient did
endorse symptoms associated with BPH, and was found to have
moderate retention despite spontaneous urination. The
post-renal obstruction could be a component causing his renal
insufficiency, and potentially be reversible.
OUTPATIENT
- please consider evaluation for BPH
.
# GERD
Patient has a documented history of GERD. We continued his home
medicine Ranitidine 150 mg daily.
.
TRANSITIONAL ISSUES
- Patient has a code status of DNR/DNI. It was temporarily
reversed to full only during the pacemaker placement.
- Patient has cardiology appointment on [**9-2**], Ophthalmology
appointment on [**8-26**] and primary care appointment on [**9-4**].
Medications on Admission:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO MONDAY,
WEDNESDAY, AND FRIDAY ().
2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM and 0.5
QPM.
4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain .
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day. Disp:*30 Tablet(s)* Refills:*2*
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Medications:
1. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. Outpatient Lab Work
Please check Chem-7, CBC on Monday [**8-26**] with results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**]
Fax: [**Telephone/Fax (1) 7531**]
15. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Caregroup
Discharge Diagnosis:
Acute Coronary Ischemia Type 2
Acute on Chronic Systolic congestive heart failure
Atrial fibrillation with rapid ventricular response
Chronic Kidney Disease
Hypertension
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 with chest pain and a fast heart rate. The
medicines you were given caused your heart rate to be too low
and a pacemaker was inserted on [**2154-8-21**]. Your chest pain is gone
but because you still have blockages in your arteries, you will
probably have more chest pain in the future. Chest pain that
lasts only seconds and goes away completely should not be
concerning. Chest pain that lasts more than seconds can be
treated with one nitroglycerin tablet every 5 minutes, no more
than 2 tablets total. If you still have chest pain after
nitroglycerin tablets or if the chest pain is severe, call 911
or Dr. [**Last Name (STitle) **]. Your urine has some bacteria in it, you have been
started on antibiotics for a 7 day course.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Take pravastatin instead of atorvastatin. This will be
covered by your insurance.
2. Increase amiodarone to 200 mg daily to prevent atrial
fibrillation and a fast heart rate
3. Start Metoprolol succinate daily to prevent chest pain
4. Decrease furosemide to 80mg in the morning for now. If you
see that your rate is increasing, Dr. [**Last Name (STitle) **] can increase the
dose again.
5. Stop lisinopril for now, Dr. [**Last Name (STitle) **] will restart it if needed
as your blood pressure has been low.
6. Start ciprofloxacin to treat the bacteria in your urine
.
Please get labs checked on Monday [**8-26**] when you are at the
[**Hospital Ward Name 23**] clinical center. You can bring the prescription for the
labs with you.
Dressing can come off the pacer site on Saturday and you may
shower. Do not remove the steri strips. No soap over the
incision site. No lifting more than 5 pounds or reaching over
your head with your left arm for 6 weeks.
Followup Instructions:
Department: [**Hospital3 1935**] CENTER
When: MONDAY [**2154-8-26**] at 1:05 PM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2154-9-2**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2154-9-2**] at 3:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: WEDNESDAY [**2154-9-4**] at 8:30 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"585.9",
"369.8",
"V13.01",
"403.90",
"427.81",
"272.4",
"530.81",
"389.9",
"410.42",
"427.31",
"V45.82",
"V45.81",
"414.01",
"428.23",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
16101, 16141
|
8797, 13630
|
230, 286
|
16355, 16355
|
5156, 8774
|
18441, 19806
|
3574, 3600
|
14587, 16078
|
16162, 16334
|
13656, 14564
|
16538, 18418
|
3615, 5137
|
2619, 2890
|
180, 192
|
314, 2510
|
16370, 16514
|
2921, 3334
|
2532, 2599
|
3350, 3558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,802
| 136,987
|
29381
|
Discharge summary
|
report
|
Admission Date: [**2173-11-25**] Discharge Date: [**2173-11-30**]
Date of Birth: [**2102-8-12**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
71M with MDS referred from clinic with exertional dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71M with MDS, diagnosied in novemeber. Has been feeling better
after starting prednisone, hydroxyurea, and danzol when earlier
this week started feeling poor. Had malaise, night sweats,
subjective fevers, as well as cough. developed SOB on excertion
several days ago, but was concerned when he noticed hematemasis
yesterday. He presented to clinic but had an acute
decompensation going up stairs
with extreme SOB and was sent to ED. It is associated with mild
substernal chest pain, but denies radiation. Has had
diaphoresis, but had been diaphoretic since starting his
medications.
Mr. [**Known lastname 70576**] was in his usual state of health until
approximately [**2173-8-20**] when he noted the insidious onset
of low back pain. This occurred while he was driving to
[**State 622**]. The pain persisted and he returned to the [**Location (un) 86**]
area. He was initially seen by his primary care doctor who
noted a white blood count of 14,800 and platelet count of
51,000. An MRI revealed abnormal bone marrow signal, but no
space-occupying lesion. He was referred to Dr. [**Last Name (STitle) 40508**] for
further evaluation. He was noted to have an increased number of
monocytes. Dr. [**Last Name (STitle) 40508**] performed a bone marrow aspirate and
biopsy, which revealed a hypercellular marrow for the age.
There was evidence of trilineage dysplasia. Increased numbers
of monocytes with a left-shifted hematopoiesis. Megakaryocytes
were present but
with atypical forms. On CT scan, he was noted to have an
enlarged spleen. His pain in his low back has continued.
In the ED, the patient had a temp of 100.1, BP 180s/70s, sats in
80s.
ECG demonstrated NSR with a LBBB, (no old for comparison). WBCs
were 53.3; Gran count [**Numeric Identifier 70577**] and 67 Platelets. Heme onc
recommended against ASA. He had a CXR with bilateral opacities
c/w PNA vs. CHF. He was given Ceftriaxone, steroids, started on
Nitro drip and given 20mg Lasix IV.
ROS: He notes progressive pain in both lower extremities. He
denies any fevers or night sweats. Notes increasing fatigue and
easy bruising. Denies any oral lesions, gingival hypertrophy,
cough,or skin lesions
Past Medical History:
MDS - Chronic MyeloMonocytic Leukemia, diagnosed in [**Month (only) 321**],
cytogetics unknown.
HTN
Gout
CAD - s/p CABG in [**2161**]
s/p appendectomy [**2162**]
Social History:
He has a 40-pack-year history of cigarette smoking, stopped
approximately 15 years ago. He drinks approximately two drinks
at night. He worked as a sheet metal cutter.
Family History:
There is no family history of any underlying hematological
disorders.
Physical Exam:
96.6 149/63 69 94% O2 Sats on 4L NC
Gen: A 71-year-old man in no acute distress, oriented x3
HEENT: Clear OP, MMM, Sclerae is anicteric, no oral lesions. No
gingival hypertrophy
NECK: Supple, No JVD, No cervical, supraclavicular, or occipital
adenopathy.
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**];
Well-healed midline sternotomy scar
LUNGS: Decreased BS and scattered ronchi LLL and RLL with LML
bronchial breath sounds, No W/R/C, No egophany
ABD: Soft, NT, ND. NL BS. No HSM; The spleen is palpable, [**5-27**]
cm below the left costal margin, liver edge 2 cm below the right
costal margin. No ascites, no inguinal lymph adenopathy, no
testicular masses. Scar from prior appendectomy.
EXT: No edema. 2+ DP pulses BL; Trace ankle edema. Pulses are
present in both lower extremities.
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-21**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
CXR [**11-25**]: COMPARISONS: There are no prior studies available for
comparison. The heart is enlarged. The aorta appears tortuous.
There are multiple median sternotomy wires at the midline and
multiple small clips overlying the left heart border and
midline. Bilateral patchy opacities with sparing of the apices
and prominent pulmonary vessels favor pulmonary edema. However,
there is a rounded area of lucency seen in the right middle lobe
area that could
represent underlying cavitary pneumonia. There is a small
right-sided pleural effusion. The patchy opacities obscure the
left costophrenic angle and a left pleural effusion cannot be
completely excluded. IMPRESSION: Given underlying cardiac
history, CHF is favored. Underlying pneumonia cannot be excluded
on this examination. Recommend serial follow-up examinations.
.
EKG: NSR with a LBBB
.
Brief Hospital Course:
The patient is a 71M with MDS referred from clinic with
exertional dyspnea, hypoxia to the 80s, found to have PNA vs.
CHF on CXR. He had a brief course in the MICU on admission
given his desaturations.
.
1. Hypoxia: On CXR, there was a question of pulmonary edema
given rapid interval improvement, however he clinically did not
have signs of CHF. He was given Lasix in the ED, but he did not
get any more on the floor and improved with only antibiotics.
Thus, his hypoxia was thought to be secondary to community
acquired pneumonia. He was maintained on Ceftriaxone and
Levaquin and was discharged on a 7 day course of Levaquin and
Cefpodoxime. Induced sputum culture grew gram negative rods and
gram positive cocci in pairs. Legionella and PCP were negative.
Rapid viral was negative, and viral culture was pending at the
time of this discharge summary. He was requiring 4L NC on
admission to the floor, but was quickly weaned down to room air,
and was satting 98 on RA at the time of discharge. He should
return to see Dr. [**First Name (STitle) 1557**] in 3 days for a sat check and to assure
he is doing well.
.
2. CMML: Continued [**Hospital1 **] prednisone at home doses, continued
hydroxyurea and danazol.
.
3. HTN: Stable at this time. Continue home meds, Amlodipine 5
mg PO DAILY and Metoprolol 12.5 mg PO BID
.
4. Gout: Stable at this time. Continued Allopurinol 100mg po
BID
.
5. CAD: No ASA. Cont. BB and CCB. Lipitor 20mg po qday
Medications on Admission:
Presnisone 20mg po AM 10mg po PM
Allopurinol 100mg po BID
Hydroxyurea 500mg po Qday
Norvasc 5mg po Qday
Lipitor 20mg po Qday
Atenolol 25 mg po Qday
Nitroglycerin
Citalopram 10mg po Qday
Danazol 200mg po Qday
Omeprazol 20mg po Day
Indomethacin 25 mg po prn
Colchicine 0.6mg po daily
Diclofenac 75mg po prn.
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
7. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Danazol 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Pneumonia
.
Secondary diagnosis:
CMML
MDS
CAD s/p CABG
HTN
Gout
Discharge Condition:
Good
Discharge Instructions:
You were admitted for a severe pneumonia. You are being
discharged on antibiotics for your pneumonia, be sure to
complete the full weeklong course of antibiotics.
.
Please call your doctor if you continue to have difficulty
breathing, shortness of breath, chest pain, fevers > 100.5,
chills.
Followup Instructions:
You have an appointment to see Dr. [**First Name (STitle) 1557**] on [**12-3**] @ 2:30pm,
you can reach his office at: Phone:[**Telephone/Fax (1) 3237**]
.
You also have the following appointments made:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2173-12-7**] 9:30
|
[
"401.9",
"486",
"599.0",
"274.9",
"205.10",
"V45.81",
"584.9",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7824, 7830
|
5024, 6481
|
332, 339
|
7957, 7964
|
4135, 5001
|
8306, 8668
|
2937, 3008
|
6837, 7801
|
7851, 7851
|
6507, 6814
|
7988, 8283
|
3023, 4116
|
235, 294
|
367, 2548
|
7903, 7936
|
7870, 7882
|
2570, 2733
|
2749, 2921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,248
| 103,808
|
32173
|
Discharge summary
|
report
|
Admission Date: [**2197-8-24**] Discharge Date: [**2197-8-31**]
Date of Birth: [**2142-5-31**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Demerol
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
headache, nausea, left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55yo woman with PMH significant for stroke with right
hemiparesis and language difficulties, breast cancer,
hypertension, s/p R CEA who presents as a transfer from an OSH
with headache, nausea, and left hemiparesis. History is limited,
as the OSH reports are brief and do not include old records or
new reports, the patient will only comply with some history and
examination due to pain, and her family cannot be reached
(husband [**Name (NI) **] [**Telephone/Fax (1) 75253**] was called without any answer,
daughter reportedly on the way). The patient reports symptoms of
right sided headache and nausea with vomiting beginning around 3
or 4pm. She says the left sided weakness occurred sometime
around the same time. She presented to [**Hospital 8641**] Hospital, where
she was noted to have "decreased LOC," "L facial," and "L
weakness." A neurology consult was called - notes are "dictated"
but not
provided. A brief neurology note reports left neglect, left
hemiparesis, and old right hypesthesia. She was given morphine
2mg IV x 1, 4mg IV x 1, zofran 4mg x 1, and dilaudid 0.5mg x 1
(2205). She had a head CT, which was reported as "negative" to
the accepting ED attending, though did not come with a report.
She was then transferred to [**Hospital1 18**].
She reports that her prior stroke caused right sided weakness
and numbness of the face, arm, and leg, as well as speech
difficulties (unclear if dysarthria or aphasia). She reports
these have improved or resolved, and that this speech is not as
bad as her prior stroke. She feels her headache is improved
after treatment at [**Location (un) 8641**] (though severely worsened after
movement in the CT scanner). She reports history of migraines,
which are different from this in both severity and diffuseness.
Past Medical History:
hypertension
stroke x 2 as above
s/p right carotid endarterectomy
breast cancer 4yrs ago, s/p surgery and XRT, not active per pt
chronic low back pain
Social History:
married, has at least one daughter. [**Name (NI) **] EtOH, smoked x 1yr, quit
2wks ago by report
Family History:
noncontributory
Physical Exam:
VS: T 98.3, HR 53, BP 165/63, RR 14, SaO2 100%
Gen: appears uncomfortable
HEENT: NCAT, MMM, OP clear
Neck: R scar, but no bruits appreciated
CV: RRR, nl S1, S2, II/VI systolic murmur
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm and dry
Neurologic examination:
Mental status: Awake and alert, cooperative with exam at first,
but then after CT reports severe headache and will not fully
cooperate. Oriented to name, though slow in saying first name
(says last name when asked name). Says year is "200...4", does
not say month. However, able to tell some history of current
symptoms and past events. Speech is nonfluent with repetition
and naming affected. +dysarthria. No right-left confusion.
Cranial Nerves: Pupils equally round and reactive to light, 5 to
3mm bilaterally. No RAPD. blinks to threat bilaterally, L>R.
Extraocular movements intact bilaterally without nystagmus.
Sensation absent V2-V3 and right V1, feels it slightly in left
V1. Facial asymmetry, with right side of mouth open and left
closed, but right moving more and left not moving much at all;
forehead moves bilaterally. Hearing intact bilaterally. Palate
cannot be visualized. No gag, +cough. When asked to put out
tongue, puts it deviated far left, but able to move it to the
right easily.
Motor: Flaccid left arm and leg, left leg externally rotated. No
observed myoclonus, asterixis, or tremor. RUE and RLE full
strength, LUE and LLE 0/5.
Sensation: Reports decreased sensation on the right, and absent
to noxious (nailbed pressure) on the left.
Reflexes: 2 and symmetric throughout (?R>L). Toe downgoing on
right, mute on left.
Coordination and gait: not tested
Discharge exam:
MS- alert and oriented x3. Speech fluent.
CN- functional left facial droop, disappears with distraction or
complex phonemic speech. PERRL. EOM's full. tongue at midline.
Motor- left hemiparesis resolving. + [**Doctor Last Name 60437**] sign. Protects
face with left arm drop.
Reflexes- normal, symmetric throughout.
Pertinent Results:
[**2197-8-24**] 01:00AM BLOOD WBC-7.1 RBC-4.43 Hgb-14.4 Hct-41.3 MCV-93
MCH-32.4* MCHC-34.8 RDW-14.0 Plt Ct-294
[**2197-8-24**] 01:00AM BLOOD Neuts-78.4* Lymphs-18.5 Monos-3.0 Eos-0.1
Baso-0.1
[**2197-8-26**] 07:50AM BLOOD PT-11.8 PTT-27.0 INR(PT)-1.0
[**2197-8-26**] 07:50AM BLOOD Glucose-67* UreaN-13 Creat-0.8 Na-144
K-4.1 Cl-109* HCO3-26 AnGap-13
[**2197-8-24**] 01:00AM BLOOD ALT-24 AST-27 CK(CPK)-150* AlkPhos-179*
Amylase-51 TotBili-0.5
[**2197-8-24**] 02:07PM BLOOD CK-MB-5 cTropnT-0.05*
[**2197-8-26**] 07:50AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.3
[**2197-8-24**] 02:07PM BLOOD %HbA1c-5.9
[**2197-8-24**] 02:07PM BLOOD Triglyc-120 HDL-38 CHOL/HD-3.1 LDLcalc-56
[**2197-8-24**] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2197-8-24**] 02:05PM BLOOD FACTOR V LEIDEN-PND
IMAGING:
CT HEAD W/O CONTRAST [**2197-8-26**] 11:37 AM
FINDINGS: A small amount of subarachnoid blood in the left
frontal sulci is resolving. There are no new areas of
subarachnoid hemorrhage. There is no shift of the normally
midline structures or major vascular territorial infarct. There
is no hydrocephalus. Osseous structures and paranasal sinuses
are unchanged.
IMPRESSION:
1. Resolving left frontal subarachnoid hemorrhage.
CT HEAD W/O CONTRAST [**2197-8-24**] 1:28 AM
No prior comparison studies are available. There is a small
amount of subarachnoid blood in left superior frontal sulci
(2:24). There is a second focus of small amount of hemorrhage
overlying a left frontal gyrus (2:19). No mass effect or shift
of normally midline structures. Ventricles and cisterns are
normal in size. No evidence of major vascular territorial
infarct.
Partially visualized is an interrupted tooth projecting into the
left maxillary sinus. The sinus and mastoid air cells are clear.
Bony structures and surrounding soft tissue structures are
unremarkable.
IMPRESSION:
1. Small amount of subarachnoid hemorrhage in the superior left
frontal region.
2. Small amount of acute hemorrhage overlying a left frontal
gyrus, most likely also representing subarachnoid hemorrhage.
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 (images after cough and Valsalva
maneuver are technically uboptimal). Left ventricular wall
thickness, cavity size and egional/global systolic function are
normal (LVEF >55%) No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No cardiac source of embolism identified. Normal
global and
regional biventricular systolic function.
MR HEAD W/O CONTRAST [**2197-8-24**] 5:53 PM
FINDINGS: Small linear foci of T2 and FLAIR prolongation in the
sulci of the left frontal lobe correspond with the known area of
subarachnoid hemorrhage on the CT scan of [**2197-8-24**], and
represent a small amount of chronic subarachnoid blood. No new
areas of hemorrhage are identified. No masses or mass effect are
seen. Ventricles and sulci are normal in configuration.
MR angiography and MR venography were also performed, and show
no aneurysms or vascular malformations.
There is no evidence of infarction.
IMPRESSION: Small amount of linear high T2 signal in the left
frontal lobe corresponding with the known area of subarachnoid
hemorrhage. No aneurysms or other vascular malformation. No
evidence of infarction.
Speech and Swallow Consultation:
Mrs. [**Known lastname **] presented with a moderate oral dysphagia and a mild
to moderate delay in swallow initiation. However once the
pharyngeal swallow was started, it was functional and no residue
was seen. The pt did not aspirate today, but the pyriform
sinuses filled completely before the swallow [**2-3**] swallow delay
and it is therefore recommended she use a chin tuck with the
thin liquids. She was able to manage moist, ground solids, but
did not feel comfortable and is requesting pureed solids at this
time. Pill should be crushed and given with purees.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 4, mild-moderate dysphagia with
consistencies restricted because of retention in the oral
cavity.
RECOMMENDATIONS:
1. Suggest a PO diet of thin liquids and pureed consistency
solids.
2. Use a chin tuck when drinking liquids.
3. No straws.
4. Place solid food on the right side of your mouth.
5. Alternate between bites and sips as needed.
6. All pills crushed with purees or in liquid form.
Brief Hospital Course:
55yo woman with history of stroke (with right
weakness/numbness), R CEA, HTN, breast cancer 4yrs ago, who
presents as a transfer from an OSH with right-sided headache,
nausea, vomiting, dysarthria, and left hemiparesis. On
presentation to this hospital, she was disoriented, with a
nonfluent aphasia including difficulty with repetition,
dysarthria, decreased bilateral facial sensation, an unclear
facial asymmetry, no gag (but cough present), left tongue
protrusion, left hemiparesis, and left hemisensory loss. Head CT
revealed a left parietal subarachnoid hemorrhage.
Her neurologic exam was difficult to localize, as her
examination was not entirely consistent. Is it was odd to have
left sided symptoms and a left sided lesion. MRI/MRA was
obtained to rule out possibility of venous sinus thrombosis or
multiple emboli to explain her symptoms. MRA did not reveal
aneurysm to explain her subarachnoid hemorrhage. Her daily
aspirin therapy was held. She was covered on an insulin sliding
scale for tight glycemic control.
The patient had an acute "thunderclap" headache over the weekend
resulting in repeat CT evaluation. There were no acute changes
by head CT. Her headache was intially treated with dilaudid IV,
then tapered to her chronic dose of methadone.
Further examination and history revealed the patient has
significant psychosocial stressors with history of interpartner
violence/abuse. The patient had an event prior to discharge
consisting of violent shaking movements with her eyes closed and
bilateral arms thrashing. This is strongly suggestive of a
pseudoseizure or behavioral event given 90% of seizures occur
with eyes open and deviation to one side. Furthermore the event
demonstrated complete resolution of her prior left sided
hemiparesis, garnering further support for conversion. A repeat
Head CT was without any changes to suggest new neuropathology.
Her prior subarachnoid hemorrhage seen on admission has nearly
completely resorbed. Further physical therapy will greatly
benefit her expected continued recovery for her deficits. She
will follow up with Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 877**] in the neurology
department at [**Hospital1 18**] once discharged from rehab.
Medications on Admission:
methadone 20mg qid prn pain
lipitor 40mg daily
ASA 81mg daily
plavix 75mg daily
doxycycline 100mg [**Hospital1 **] (for acne)
lunesta 3mg qhs
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Insulin Regular Human 100 unit/mL Solution Sig: dose per
sliding scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 17921**] Center - [**Location (un) 5450**], NH
Discharge Diagnosis:
Left Frontal Subarachnoid Hemorrhage
Conversion Disorder
Discharge Condition:
Stable. Resolving left hemiparesis- antigravity at discharge.
Resolving left facial droop. Positive [**Doctor Last Name 60437**] Sign. Protects
face with left arm drop.
Discharge Instructions:
You were admitted and found to have a subarachnoid hemorrhage
and left sided weakness. The bleeding in your brain was small
and stable by repeat CT scans. You should expect your deficits
to resolve very rapidly.
Please contiue to take all medications as prescribed.
Call your doctor or 911 if you experience any symptoms of chest
pain, shortness of breath, new weakness, numbness or tingling.
Followup Instructions:
Please seek the guidance of a psychiatrist or other mental
health professional for further support with your life stresses.
Please call [**Telephone/Fax (1) 2574**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 877**] and Dr. [**First Name (STitle) **] on the Neurology service at
[**Hospital1 18**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"430",
"V12.59",
"300.11",
"401.9",
"724.2",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12378, 12464
|
9364, 11592
|
321, 328
|
12565, 12736
|
4467, 9341
|
13180, 13598
|
2438, 2455
|
11785, 12355
|
12485, 12544
|
11618, 11762
|
12760, 13157
|
2471, 2706
|
4131, 4448
|
243, 283
|
356, 2132
|
3179, 4115
|
2745, 3163
|
2730, 2730
|
2154, 2307
|
2323, 2422
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,098
| 159,138
|
49070
|
Discharge summary
|
report
|
Admission Date: [**2170-5-7**] Discharge Date: [**2170-5-15**]
Date of Birth: [**2110-1-10**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Hydrocodone
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior/Posterior fusion with instrumentation L3-S1
History of Present Illness:
60 yo female with history of gastric bypass, bilateral hip
replacements also with lumbar stenosis not relieved with
physical therapy or injections. Now presents for surgical
therapy.
Past Medical History:
gastric bypass
bilateral hip replacements
Social History:
Denies
Family History:
N/C
Physical Exam:
Decreased range of motion of the cervical spine and lumbar
spine. Her strength is good throughout the upper extremity
including deltoid, biceps, triceps, wrist extension-flexion,
finger extension-flexion and intrinsics. Her sensation is
intact to light touch. She has a negative [**Doctor Last Name 937**] sign. Her
motion in terms of hips are good with the hip repalcements. Her
strength in terms of hip flexion, abduction/adduction, knee
extension and flexion, ankle dosiflexion and plantar flexion are
[**4-20**]. Deep tendon reflexes are 1+ and symmetric at the knees and
Achilles with down going toes. She has a negative straight leg
raise on exam today.
Pertinent Results:
[**2170-5-11**] 07:00PM BLOOD WBC-4.8 RBC-3.05* Hgb-9.5* Hct-27.5*
MCV-90 MCH-31.1 MCHC-34.5 RDW-13.9 Plt Ct-96*
[**2170-5-11**] 03:24AM BLOOD WBC-5.4 RBC-3.08* Hgb-9.8* Hct-27.6*
MCV-90 MCH-31.7 MCHC-35.4* RDW-14.1 Plt Ct-87*
[**2170-5-10**] 03:53AM BLOOD WBC-6.1 RBC-2.94* Hgb-8.9* Hct-26.0*
MCV-89 MCH-30.5 MCHC-34.4 RDW-14.5 Plt Ct-70*
[**2170-5-9**] 03:01AM BLOOD WBC-6.2 RBC-2.83* Hgb-8.9* Hct-24.7*
MCV-88 MCH-31.5 MCHC-36.0* RDW-14.7 Plt Ct-105*
[**2170-5-8**] 06:17PM BLOOD WBC-5.7 RBC-3.12* Hgb-9.9* Hct-27.6*
MCV-88 MCH-31.7 MCHC-35.8* RDW-14.6 Plt Ct-79*
[**2170-5-8**] 01:39PM BLOOD Hct-24.7*
[**2170-5-8**] 11:30AM BLOOD WBC-5.5 RBC-2.72* Hgb-8.4* Hct-24.1*
MCV-89 MCH-30.8 MCHC-34.7 RDW-14.4 Plt Ct-99*
[**2170-5-8**] 08:30AM BLOOD WBC-4.9 RBC-2.67* Hgb-8.1* Hct-24.3*
MCV-91 MCH-30.2 MCHC-33.1 RDW-14.7 Plt Ct-83*
[**2170-5-8**] 05:15AM BLOOD WBC-5.4# RBC-2.86* Hgb-8.9* Hct-26.8*
MCV-94 MCH-31.0 MCHC-33.2 RDW-14.4 Plt Ct-89*
[**2170-5-8**] 01:39PM BLOOD PT-13.6* PTT-26.2 INR(PT)-1.2*
[**2170-5-8**] 10:05AM BLOOD PT-13.5* PTT-27.3 INR(PT)-1.2*
[**2170-5-11**] 03:24AM BLOOD Glucose-108* UreaN-16 Creat-1.3* Na-142
K-4.5 Cl-107 HCO3-26 AnGap-14
[**2170-5-10**] 03:53AM BLOOD Glucose-130* UreaN-14 Creat-1.1 Na-138
K-4.2 Cl-106 HCO3-26 AnGap-10
[**2170-5-9**] 02:34PM BLOOD Glucose-122* UreaN-15 Creat-1.1 Na-137
K-4.0 Cl-105 HCO3-26 AnGap-10
[**2170-5-8**] 01:39PM BLOOD Glucose-181* UreaN-19 Creat-1.3* Na-139
K-4.1 Cl-107 HCO3-24 AnGap-12
[**2170-5-9**] 03:26AM BLOOD Lactate-1.0 Na-135 K-3.9
[**2170-5-8**] 11:35AM BLOOD Glucose-192* Lactate-2.2* Na-138 K-4.2
Cl-110
[**2170-5-8**] 08:01AM BLOOD Glucose-151* Lactate-1.6 Na-138 K-4.6
Cl-110
Brief Hospital Course:
Ms. [**Known lastname 1968**] [**Known lastname **] was admitted to the Orthopaedic Spine service
under the care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]. She was informed and
consented for an anterior/posterior lumbar fusion over the
course of two days and she agreed. Please see operative notes
for procedures in detail.
After her posterior procedure she was transfered to the SICU for
hematocrit monitoring where she was left intubated and sedated
over night. She required three units of blood while in the unit
and her hemaotcrit stabilized.
POD3/2 she spiked a transient fever to 103 degrees but quickly
defervesed. Chest x-ray and cultures were all negative. She
was subsequently transferd to a floor bed for further care.
She received 48 hours of antibiotics and her foley was removed.
She was able to work well with physical therapy and gain
strength and balance. She was discharged to rehab in good
condition.
Medications on Admission:
see list
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
3. Paroxetine HCl 20 mg Tablet Sig: Four (4) Tablet PO QPM (once
a day (in the evening)).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
9. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Lumbar stenosis L3-S1
Post-op anemia
Discharge Condition:
Good
Discharge Instructions:
Please continue to take you pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any other
concerns.
Physical Therapy:
Activity: Out of bed w/ assist
Lumbar corset for ambulation
Treatments Frequency:
Please continue to change the dressing daily with dry sterile
gauze
Followup Instructions:
Please keep the appointments that have been made for you.
Completed by:[**2170-5-15**]
|
[
"998.11",
"721.3",
"V58.69",
"285.1",
"401.9",
"300.00",
"722.52",
"V45.3",
"V43.64",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.06",
"99.04",
"99.07",
"84.52",
"99.05",
"81.62",
"81.08"
] |
icd9pcs
|
[
[
[]
]
] |
5079, 5168
|
3050, 4012
|
285, 339
|
5249, 5256
|
1364, 3027
|
5674, 5763
|
657, 662
|
4071, 5056
|
5189, 5228
|
4038, 4048
|
5280, 5480
|
677, 1345
|
5498, 5560
|
5582, 5651
|
236, 247
|
367, 552
|
574, 617
|
633, 641
|
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