subject_id
int64 12
100k
| _id
int64 100k
200k
| note_id
stringlengths 1
41
| note_type
stringclasses 4
values | note_subtype
stringclasses 35
values | text
stringlengths 449
78.2k
| diagnosis_codes
listlengths 1
39
| diagnosis_code_type
stringclasses 1
value | diagnosis_code_spans
listlengths 1
21
| procedure_codes
listlengths 0
35
| procedure_code_type
stringclasses 1
value | procedure_code_spans
listlengths 1
5
| Discharge Disposition:
stringlengths 0
12
| Brief Hospital Course:
stringlengths 0
12
| Discharge Diagnosis:
stringclasses 1
value | Major Surgical or Invasive Procedure:
stringlengths 0
12
| Discharge Condition:
stringlengths 0
12
| Past Medical History:
stringclasses 1
value | History of Present Illness:
stringclasses 1
value | Social History:
stringclasses 1
value | Physical Exam:
stringclasses 1
value | Pertinent Results:
stringlengths 0
12
| Discharge Instructions:
stringclasses 1
value | Medications on Admission:
stringclasses 1
value | Followup Instructions:
stringlengths 0
12
| Family History:
stringlengths 0
12
| Discharge Medications:
stringclasses 1
value | DISCHARGE DIAGNOSES:
stringlengths 0
12
| PAST MEDICAL HISTORY:
stringclasses 1
value | DISCHARGE MEDICATIONS:
stringlengths 0
12
| [**Hospital 93**] MEDICAL CONDITION:
stringlengths 0
12
| DISCHARGE DIAGNOSIS:
stringlengths 0
12
| MEDICATIONS ON DISCHARGE:
stringclasses 983
values | MEDICATIONS ON ADMISSION:
stringlengths 0
12
| Cranial Nerves:
stringclasses 1
value | HOSPITAL COURSE:
stringlengths 0
12
| FINAL DIAGNOSIS:
stringclasses 974
values | CARE RECOMMENDATIONS:
stringclasses 32
values | DISCHARGE INSTRUCTIONS:
stringlengths 0
12
| PAST SURGICAL HISTORY:
stringclasses 1
value | DISCHARGE LABS:
stringclasses 1
value | Discharge Labs:
stringclasses 1
value | What to report to office:
stringclasses 286
values | Secondary Diagnosis:
stringclasses 1
value | ADMISSION MEDICATIONS:
stringclasses 204
values | DISCHARGE INSTRUCTIONS/FOLLOWUP:
stringclasses 212
values | Review of systems:
stringclasses 1
value | CARE AND RECOMMENDATIONS:
stringclasses 18
values | On Discharge:
stringclasses 1
value | Neurologic examination:
stringclasses 1
value | Discharge labs:
stringlengths 0
12
| Secondary Diagnoses:
stringclasses 1
value | On discharge:
stringclasses 1
value | [**Last Name (NamePattern4) 2138**]p Instructions:
stringclasses 138
values | HOSPITAL COURSE BY SYSTEM:
stringclasses 79
values | HOSPITAL COURSE BY SYSTEMS:
stringclasses 67
values | MEDICATIONS AT HOME:
stringclasses 429
values | MEDICATIONS ON TRANSFER:
stringclasses 1
value | Secondary diagnoses:
stringclasses 1
value | Secondary diagnosis:
stringclasses 1
value | TRANSITIONAL ISSUES:
stringclasses 1
value | PATIENT/TEST INFORMATION:
stringclasses 174
values | IMMUNIZATIONS RECOMMENDED:
stringclasses 1
value | -Cranial Nerves:
stringclasses 297
values | Transitional Issues:
stringclasses 1
value | Incision Care:
stringclasses 388
values | Past Surgical History:
stringlengths 0
12
| Discharge Exam:
stringclasses 1
value | DISCHARGE EXAM:
stringclasses 1
value | Labs on Discharge:
stringclasses 1
value | REGIONAL LEFT VENTRICULAR WALL MOTION:
stringclasses 171
values | PHYSICAL EXAM:
stringlengths 0
12
| Medication changes:
stringclasses 1
value | Physical Therapy:
stringclasses 313
values | Treatments Frequency:
stringclasses 226
values | SECONDARY DIAGNOSES:
stringlengths 0
12
| 2. CARDIAC HISTORY:
stringclasses 715
values | HOME MEDICATIONS:
stringclasses 441
values | Chief Complaint:
stringclasses 1
value | FINAL DIAGNOSES:
stringclasses 83
values | DISCHARGE PHYSICAL EXAM:
stringclasses 1
value | ACID FAST CULTURE (Preliminary):
stringclasses 214
values | Wound Care:
stringclasses 1
value | Blood Culture, Routine (Preliminary):
stringclasses 146
values | Discharge exam:
stringclasses 736
values | Neurologic Examination:
stringclasses 1
value | Discharge Physical Exam:
stringclasses 1
value | ACTIVE ISSUES:
stringclasses 1
value | CLINICAL IMPLICATIONS:
stringclasses 128
values | FUNGAL CULTURE (Preliminary):
stringclasses 365
values | FOLLOW UP:
stringclasses 645
values | PREOPERATIVE MEDICATIONS:
stringclasses 71
values | RESPIRATORY CULTURE (Preliminary):
stringclasses 133
values | SUMMARY OF HOSPITAL COURSE:
stringclasses 286
values | Labs on discharge:
stringclasses 1
value | MEDICATIONS PRIOR TO ADMISSION:
stringclasses 144
values | HOSPITAL COURSE BY ISSUE/SYSTEM:
stringclasses 131
values | SECONDARY DIAGNOSIS:
stringclasses 1
value | FOLLOW-UP APPOINTMENTS:
stringclasses 47
values | Cardiac Enzymes:
stringclasses 1
value | OUTPATIENT MEDICATIONS:
stringclasses 106
values | Review of Systems:
stringclasses 1
value | ADMISSION DIAGNOSES:
stringclasses 50
values | MEDICATION CHANGES:
stringclasses 1
value | Blood Culture, Routine (Pending):
stringclasses 88
values | TECHNICAL FACTORS:
stringclasses 60
values | PHYSICAL EXAMINATION:
stringlengths 0
12
| [**Last Name (NamePattern4) 4125**]ospital Course:
stringclasses 40
values | ADMISSION DIAGNOSIS:
stringclasses 115
values | Physical Exam on Discharge:
stringclasses 198
values | At discharge:
stringlengths 0
12
| RECOMMENDED IMMUNIZATIONS:
stringclasses 3
values | ON DISCHARGE:
stringlengths 0
12
| CHRONIC ISSUES:
stringclasses 1
value | Immediately after the operation:
stringclasses 71
values | Transitional issues:
stringclasses 965
values | FOLLOW-UP PLANS:
stringclasses 188
values | Changes to your medications:
stringclasses 809
values | Upon discharge:
stringclasses 1
value | REVIEW OF SYSTEMS:
stringlengths 0
12
| CARDIAC ENZYMES:
stringclasses 1
value | Cardiac enzymes:
stringclasses 361
values | Medication Changes:
stringclasses 665
values | [**Location (un) **] Diagnosis:
stringclasses 49
values | ACID FAST CULTURE (Pending):
stringclasses 59
values | Discharge PE:
stringclasses 99
values | General Discharge Instructions:
stringclasses 84
values | INDICATIONS FOR CATHETERIZATION:
stringclasses 54
values | WHEN TO CALL YOUR SURGEON:
stringclasses 31
values | Neurological Exam:
stringclasses 73
values | Exam on Discharge:
stringclasses 1
value | CHIEF COMPLAINT:
stringlengths 0
12
| REASON FOR THIS EXAMINATION:
stringlengths 0
12
| Relevant Imaging:
stringclasses 55
values | Active Issues:
stringclasses 353
values | [**Location (un) **] Condition:
stringclasses 42
values | RECOMMENDATIONS AFTER DISCHARGE:
stringclasses 2
values | [**Hospital1 **] Disposition:
stringclasses 38
values | TRANSITIONAL CARE ISSUES:
stringclasses 69
values | [**Hospital1 **] Medications:
stringclasses 41
values | [**Location (un) **] Instructions:
stringclasses 40
values | WOUND CULTURE (Preliminary):
stringclasses 63
values | DISCHARGE FOLLOWUP:
stringclasses 182
values | LABS ON DISCHARGE:
stringclasses 566
values | POST CPB:
stringclasses 1
value | URINE CULTURE (Preliminary):
stringclasses 70
values | Review of sytems:
stringclasses 249
values | Labs at discharge:
stringclasses 119
values | Immunizations recommended:
stringclasses 34
values | AEROBIC BOTTLE (Pending):
stringclasses 26
values | -Rehabilitation/ Physical Therapy:
stringclasses 39
values | FOLLOW UP APPOINTMENTS:
stringclasses 38
values | Mental Status:
stringclasses 1
value | Admission labs:
stringclasses 1
value | HOSPITAL COURSE BY PROBLEM:
stringclasses 131
values | [**Hospital 5**] MEDICAL CONDITION:
stringclasses 14
values | PHYSICAL EXAM UPON DISCHARGE:
stringclasses 47
values | WOUND CARE:
stringclasses 425
values | ANAEROBIC BOTTLE (Pending):
stringclasses 25
values | CURRENT MEDICATIONS:
stringclasses 82
values | FOLLOW-UP APPOINTMENT:
stringclasses 54
values | FINAL DISCHARGE DIAGNOSES:
stringclasses 23
values | TRANSFER MEDICATIONS:
stringclasses 76
values | Upon Discharge:
stringclasses 230
values | HISTORY OF PRESENT ILLNESS:
stringlengths 0
12
| CRANIAL NERVES:
stringlengths 0
12
| CT head:
stringclasses 1
value | Exam on discharge:
stringclasses 111
values | CT Head:
stringclasses 955
values | [**Location (un) **] PHYSICIAN:
stringclasses 130
values | Admission Labs:
stringclasses 1
value | secondary diagnosis:
stringlengths 0
12
| Head CT:
stringclasses 601
values | MRA OF THE HEAD:
stringclasses 48
values | INACTIVE ISSUES:
stringclasses 124
values | ADMISSION LABS:
stringlengths 0
12
| PROBLEM LIST:
stringclasses 49
values | PRIMARY DIAGNOSIS:
stringlengths 0
12
| OTHER PERTINENT LABS:
stringclasses 91
values | PROBLEMS DURING HOSPITAL STAY:
stringclasses 1
value | Medication Instructions:
stringclasses 48
values | IRON AND VITAMIN D SUPPLEMENTATION:
stringclasses 6
values | On admission:
stringlengths 0
12
| ANAEROBIC CULTURE (Preliminary):
stringclasses 227
values | MENTAL STATUS:
stringlengths 0
12
| ADMITTING DIAGNOSIS:
stringclasses 69
values | TRANSITIONS OF CARE:
stringclasses 92
values | Pertinent Labs:
stringclasses 205
values | 3. OTHER PAST MEDICAL HISTORY:
stringclasses 667
values | # Transitional issues:
stringclasses 71
values | [**Hospital1 **] Diagnosis:
stringclasses 24
values | Chronic Issues:
stringclasses 245
values | FOLLOW-UP INSTRUCTIONS:
stringclasses 101
values | CARE AND RECOMMENDATIONS AT DISCHARGE:
stringclasses 2
values | HOSPITAL COURSE: By systems:
stringclasses 1
value | NEUROLOGIC EXAMINATION:
stringclasses 339
values | Treatment Frequency:
stringclasses 26
values | Neurologic Exam:
stringclasses 63
values | DISCHARGE PLAN:
stringclasses 62
values | Active Diagnoses:
stringclasses 63
values | Medications on transfer:
stringclasses 568
values | Past medical history:
stringlengths 0
12
| SOCIAL HISTORY:
stringlengths 0
12
| CONDITION ON DISCHARGE:
stringlengths 0
12
| FLUID CULTURE (Preliminary):
stringclasses 112
values | Meds on transfer:
stringclasses 242
values | Exam upon discharge:
stringclasses 35
values | Other labs:
stringclasses 142
values | Discharge physical exam:
stringclasses 473
values | [**Hospital1 **] Instructions:
stringclasses 22
values | Imaging Studies:
stringclasses 111
values | Post CPB:
stringclasses 96
values |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
6,711
| 124,399
|
46817
|
Discharge summary
|
report
|
Admission Date: [**2168-5-9**] Discharge Date: [**2168-5-13**]
Date of Birth: [**2115-2-18**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
incidental finding of PE on CT
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53-yo-woman w/ MMP including metastatic breast CA was admitted
yesterday w/ PE found incidentally on staging CT of the chest.
She has breast CA metastatic to the liver and lung, complicated
by chronic right pleural effusion, and followed w/ serial chest
CT. On [**5-6**], chest CT demonstrated pulmonary embolus, prompting
her referral to the ED. In the ED, she was HD stable but was
tachycardic, leading to admission to the [**Hospital Unit Name 153**] for close
observation during her early treatment.
<BR>
In the [**Hospital Unit Name 153**], she was treated w/ heparin gtt and remained
hemodynamically stable overnight. She is now transferred to the
OMED service for ongoing care.
<BR>
Currently, she feels at her baseline resp status, w/ mild
dyspnea while talking and walking. She denies any fever,
chills, cough, chest pain, palpitations.
Past Medical History:
1) Metastatic breast cancer: T2-NO, ER/PR + HER-2/neu (-),
diagnosed [**2158**]
-[**2158**]: She was treated with CMF plus tamoxifen and local
radiation.
-[**2162**]: Treated with epirubicin/taxotere after found to have
adrenal met
-[**2162**]-[**2164**]: On Arimidex, then found to have liver mets
-[**2164**]: Started on Xeloda
-[**2165**]: Treated with taxol
-[**2165**]: Phase II study of [**Doctor First Name **] [**Numeric Identifier 99361**] (tyrosine kinase inhibitor)
-[**2165**]: Cancer metastasized to liver and adrenals
-[**2166**]: Has received 2 treatments with gemcitabine
[**2167-8-28**]: thoracentesis with fluid positive for malignant cells
[**2167-10-16**]: Right VATS, talc pleurodesis by Dr. [**Last Name (STitle) 952**] with
placement of pleur-X cath
[**2167-10-30**]: 3rd dose of Gemcitabine
Currently treated w/ Navelbine, last dose 2 wks ago.
2) Malignant pleural effusion s/p pleurex catheter placed [**9-29**]
removed [**3-31**]
3) Asthma
4) Allergic rhinitis
5) GERD
Social History:
lives with husband, 23 year-old daughter, and 6 month-old
grandson. [**Name (NI) 4084**] smoked. No alcohol, cocaine, or IVDU.
Family History:
1. Breast cancer: uncle
2. Lung CA: father, sister
Physical Exam:
Gen: pleasant, conversational woman lying flat in bed, mildly
dyspnic after our interview
HEENT: EOMI, PERRL, OP clear w/ MMM
CV: reg s1/s2, no s3/s4/m/r
Pulm: dullness to percussion w/ decreased BS over right field;
good air movement throughout
Abd: scaphoid, +BS, soft, NT, ND
Ext: warm, 2+ DP B/L, no edema
Neuro: a/o x 3, strength 4/5 throughout LE B/L
Pertinent Results:
[**2168-5-9**] 07:10PM PTT-135.4*
[**2168-5-9**] 12:45PM GLUCOSE-135* UREA N-7 CREAT-0.6 SODIUM-139
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
[**2168-5-9**] 12:45PM ALT(SGPT)-19 AST(SGOT)-49* CK(CPK)-26 ALK
PHOS-301* AMYLASE-63 TOT BILI-0.6
[**2168-5-9**] 12:45PM LIPASE-16
[**2168-5-9**] 12:45PM cTropnT-<0.01
[**2168-5-9**] 12:45PM CK-MB-NotDone
[**2168-5-9**] 12:45PM ALBUMIN-3.6 CALCIUM-10.4* PHOSPHATE-1.9*
MAGNESIUM-1.7
[**2168-5-9**] 12:45PM WBC-6.1# RBC-3.87* HGB-11.6* HCT-38.0 MCV-98
MCH-30.1 MCHC-30.7* RDW-19.5*
[**2168-5-9**] 12:45PM NEUTS-63.3 LYMPHS-28.6 MONOS-6.9 EOS-0.3
BASOS-0.9
[**2168-5-9**] 12:45PM HYPOCHROM-3+ ANISOCYT-2+ MACROCYT-3+
[**2168-5-9**] 12:45PM PLT COUNT-357
[**2168-5-9**] 12:45PM PT-13.6* PTT-29.0 INR(PT)-1.2*
.
CT chest and abdomen [**2167-5-7**]:
1) Interval progression of disease, with [**Month/Day/Year 9140**] of hepatic,
osseous, omental, mesenteric, mediasatinal nodal, and possible
anterior abdominal wall metastases.
2) Pulmonary emboli involving the left main pulmonary artery and
segmental right lower lobe branches.
3) Right-sided concentric pleural thickening with small pleural
effusion. The consolidation and interstitial thickening at the
right base is nonspecific and may relate either to previous
pleurodesis or lymphangitic spread.
Brief Hospital Course:
Briefly, this is a 53-yo-woman w/ breast CA metastatic to liver
and lung, chronic right pleural effusion, and GERD who was found
to have a PE incidentally on CT. She was managed in the ICU on
a heparin gtt and then transferred to the OMED service.
.
# Bilateral PE: The pt was found to have pulmonary emboli
involving the left main pulmonary artery and segmental right
lower lobe branches. She was mildly tachycardic up to 120 this
admission. In the ICU she was started on a heparin gtt and then
she was transitioned to Lovenox on the floor. Her Lovenox will
be managed by Dr. [**Last Name (STitle) 3274**] after discharge. The pt was
instructed several times by nursing on self-injection of
Lovenox.
.
# Breast CA: The pt has disease metastatic to liver, ab
wall/omentum, and lung. She was continued on Megace for appetite
stimulation, zofran for nausea.
.
# Gait instability/Deconditioning: The pt worked with pt prior
to discharge, but she was unable to walk very far without having
to stop. She was satting well on room air. The pt does not
walk around her house much at baseline, and the pt wished to go
home with the assistance of her husband. [**Name (NI) **] PT, home saftey
eval, a wheelchair, and home O2 were arranged for the pt.
.
#Hypercalcemia: Likely related to pts osteolytic lesions. PTH
was wnl. The pt received Zometa 4 mg IV x1 while in hospital.
.
#Tachycardia; The pt had sinus tachycardia throughout her
admission. This did not resolve even after hydration with 1.5 L
NS. She is likely tachycardic due to her PE.
Medications on Admission:
1) Ativan 1 mg QHS prn
2) Protonix 40 mg daily
3) Zofran 8 mg PO BID
4) Lactulose prn
5) Megace 400 mg PO BID
6) Percocet prn
Discharge Medications:
1. Megestrol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
6. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours).
Disp:*60 syringes* Refills:*2*
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
pulmonary embolism
Discharge Condition:
stable
Discharge Instructions:
1. Please take all medications as prescribed. You will need to
administer your Lovenox injections twice daily
2. Please follow up with Dr. [**Last Name (STitle) 3274**] next week
3. Return to the ER or call your doctor [**First Name (Titles) **] [**Last Name (Titles) 9140**] shortness
of breath, chest pain, or any other concerning symptoms
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 3274**] at 2:00 PM on Wednesday [**5-18**]. Please come to [**Hospital Ward Name 23**] [**Location (un) **]. [**Telephone/Fax (1) 15512**]
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"197.0",
"415.19",
"275.42",
"530.81",
"197.2",
"V10.3",
"197.7",
"198.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6613, 6671
|
4167, 5715
|
300, 306
|
6734, 6743
|
2816, 4144
|
7135, 7436
|
2368, 2423
|
5891, 6590
|
6692, 6713
|
5741, 5868
|
6767, 7112
|
2438, 2797
|
230, 262
|
334, 1186
|
1208, 2205
|
2221, 2352
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,868
| 144,969
|
22625
|
Discharge summary
|
report
|
Admission Date: [**2130-5-10**] Discharge Date: [**2130-5-18**]
Date of Birth: [**2069-10-27**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 58653**]
Chief Complaint:
Presented to the emergency room c/o bilateraly lower extremity
paralysis since morning.
Major Surgical or Invasive Procedure:
Decompression Laminectomy T3-9 w/instrumentation
History of Present Illness:
Ms. [**Known lastname 58650**] is a 60 year-old woman with a history of breast
cancer,
evidence of mets on recent scans including large lytic lesion T4
with invasion into spinal canal on CT [**5-5**], now c/o bilateral leg
paralysis since this morning. Of note, pt with some confusion so
history from pt and medical record.
Pt has been at [**Hospital1 **] since [**3-9**] after hospitalization at
[**Hospital1 18**]
for hypercarbic respiratory failure. She reports "not feeling
myself" today, and noticing in the late morning that she was
unable to move her legs. She reports some weakness last night,
and did fall though she is unable to provide details. She needed
help to stand back up.
According to notes from [**Name (NI) **], pt was noted to be confused
this morning and complaining of inabillity to move legs. She was
seen by neurology who recommended transfer for urgent MRI and
neurosurgery consult.
On arrival in [**Name (NI) **], pt with BP 60/p, FSBS 50s, HR 70s. She was
given 1amp D50, 100 thiamine, 1.4mg narcan with improvement in
mental status. However, she remained with leg paralysis.
Past Medical History:
COPD, 2 ppday smoking history
Hypertension
Diabetes mellitus II
Schizophrenia, and ?MR
Breast mass, s/p L mastectomy
OA, knees, b/l
Social History:
The patient is from the [**Location (un) 86**] area. She is a resident at [**Doctor Last Name **]
House. She has several siblings in [**Location (un) **] and in [**State 4565**].
She has smoked 2ppd for many years. She denies alcohol or drug
use.
Family History:
Patient is not aware of any history of COPD/ asthma / atopy.
Physical Exam:
Afebrile
AVSS
Gen: Alert and oriented, No acute distress
Back: incision w/out swelling/erythema/drainage, staples intact,
dressing c/d/i
Extremities: bilateral lower
+[**Last Name (un) 938**]/FHL/AT
+SILT
2+ pulses, wiggles toes
Pertinent Results:
[**2130-5-18**] 05:18AM BLOOD WBC-11.9* RBC-3.38* Hgb-10.3* Hct-29.7*
MCV-88 MCH-30.6 MCHC-34.9 RDW-16.2* Plt Ct-280
[**2130-5-17**] 01:26AM BLOOD WBC-14.1* RBC-3.36* Hgb-10.5* Hct-29.6*
MCV-88 MCH-31.1 MCHC-35.3* RDW-15.8* Plt Ct-319
[**2130-5-16**] 02:37AM BLOOD WBC-10.4 RBC-3.41* Hgb-10.3* Hct-29.9*
MCV-88 MCH-30.3 MCHC-34.6 RDW-16.1* Plt Ct-331
[**2130-5-15**] 02:18AM BLOOD WBC-7.3# RBC-3.24* Hgb-10.0* Hct-28.7*
MCV-89 MCH-30.9 MCHC-34.8 RDW-15.7* Plt Ct-311
[**2130-5-14**] 02:37AM BLOOD WBC-4.8 RBC-3.04* Hgb-9.4* Hct-26.7*
MCV-88 MCH-30.9 MCHC-35.2* RDW-15.4 Plt Ct-288
[**2130-5-13**] 03:41AM BLOOD WBC-4.7 RBC-2.92* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.3 MCHC-34.4 RDW-15.9* Plt Ct-245
[**2130-5-12**] 06:24PM BLOOD WBC-5.3 RBC-3.00* Hgb-9.2* Hct-26.1*
MCV-87 MCH-30.7 MCHC-35.3* RDW-15.7* Plt Ct-192
[**2130-5-12**] 04:11AM BLOOD WBC-5.0 RBC-2.96* Hgb-9.2* Hct-25.5*
MCV-86 MCH-31.1 MCHC-36.1* RDW-16.1* Plt Ct-196
[**2130-5-11**] 04:02AM BLOOD WBC-7.5 RBC-3.44* Hgb-10.2* Hct-29.4*
MCV-86 MCH-29.6 MCHC-34.5 RDW-16.8* Plt Ct-201
[**2130-5-10**] 06:43AM BLOOD WBC-7.3 RBC-3.74* Hgb-11.2* Hct-32.3*
MCV-86 MCH-29.8 MCHC-34.6 RDW-17.1* Plt Ct-246
[**2130-5-9**] 03:20PM BLOOD WBC-9.1 RBC-3.80* Hgb-12.1 Hct-34.2*
MCV-90 MCH-31.8 MCHC-35.2* RDW-15.9* Plt Ct-297#
[**2130-5-9**] 03:20PM BLOOD Neuts-88.2* Lymphs-7.9* Monos-3.8 Eos-0.1
Baso-0
[**2130-5-18**] 05:18AM BLOOD Plt Ct-280
[**2130-5-17**] 01:26AM BLOOD Plt Ct-319
[**2130-5-16**] 02:37AM BLOOD Plt Ct-331
[**2130-5-16**] 02:37AM BLOOD PT-11.4 PTT-19.8* INR(PT)-1.0
[**2130-5-15**] 02:18AM BLOOD Plt Ct-311
[**2130-5-15**] 02:18AM BLOOD PT-11.7 PTT-20.7* INR(PT)-1.0
[**2130-5-14**] 02:37AM BLOOD Plt Ct-288
[**2130-5-14**] 02:37AM BLOOD PT-11.4 PTT-20.8* INR(PT)-1.0
[**2130-5-13**] 03:41AM BLOOD PT-11.2 PTT-20.9* INR(PT)-0.9
[**2130-5-12**] 06:24PM BLOOD Plt Ct-192
[**2130-5-12**] 06:24PM BLOOD PT-11.2 PTT-20.6* INR(PT)-0.9
[**2130-5-12**] 04:30AM BLOOD PT-10.7 PTT-20.4* INR(PT)-0.9
[**2130-5-12**] 04:11AM BLOOD Plt Ct-196
[**2130-5-11**] 04:02AM BLOOD Plt Ct-201
[**2130-5-10**] 06:43AM BLOOD Plt Ct-246
[**2130-5-10**] 06:43AM BLOOD PT-12.1 PTT-21.5* INR(PT)-1.0
[**2130-5-9**] 03:20PM BLOOD Plt Ct-297#
[**2130-5-9**] 03:20PM BLOOD PT-11.4 PTT-21.6* INR(PT)-1.0
[**2130-5-18**] 05:18AM BLOOD Glucose-131* UreaN-25* Creat-0.5 Na-136
K-4.6 Cl-98 HCO3-31 AnGap-12
[**2130-5-17**] 01:26AM BLOOD Glucose-140* UreaN-30* Creat-0.5 Na-139
K-4.4 Cl-102 HCO3-29 AnGap-12
[**2130-5-16**] 02:37AM BLOOD Glucose-154* UreaN-31* Creat-0.5 Na-141
K-4.1 Cl-107 HCO3-27 AnGap-11
[**2130-5-15**] 02:18AM BLOOD Glucose-207* UreaN-33* Creat-0.5 Na-143
K-4.0 Cl-110* HCO3-26 AnGap-11
[**2130-5-14**] 02:37AM BLOOD Glucose-195* UreaN-31* Creat-0.5 Na-139
K-4.0 Cl-106 HCO3-25 AnGap-12
[**2130-5-13**] 02:40PM BLOOD K-3.6
[**2130-5-13**] 03:41AM BLOOD Glucose-190* UreaN-27* Creat-0.6 Na-140
K-3.5 Cl-102 HCO3-29 AnGap-13
[**2130-5-12**] 06:24PM BLOOD Glucose-153* UreaN-23* Creat-0.6 Na-140
K-3.4 Cl-100 HCO3-31 AnGap-12
[**2130-5-12**] 04:11AM BLOOD Glucose-165* UreaN-21* Creat-0.7 Na-140
K-3.9 Cl-96 HCO3-33* AnGap-15
[**2130-5-10**] 06:43AM BLOOD Glucose-149* UreaN-28* Creat-0.7 Na-136
K-5.0 Cl-100 HCO3-29 AnGap-12
[**2130-5-9**] 03:20PM BLOOD Glucose-90 UreaN-41* Creat-1.5* Na-131*
K-4.3 Cl-88* HCO3-33* AnGap-14
[**2130-5-9**] 03:20PM BLOOD ALT-18 AST-29 CK(CPK)-68 AlkPhos-122*
Amylase-32 TotBili-0.6
[**2130-5-18**] 05:18AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0
[**2130-5-17**] 01:26AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
[**2130-5-14**] 02:37AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1
[**2130-5-13**] 02:40PM BLOOD Calcium-8.8 Mg-2.1
[**2130-5-13**] 03:41AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
[**2130-5-12**] 06:24PM BLOOD Calcium-8.3* Phos-3.2 Mg-2.2
[**2130-5-12**] 04:11AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9
[**2130-5-11**] 06:10PM BLOOD Albumin-2.8*
[**2130-5-11**] 04:02AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.6
[**2130-5-9**] 03:20PM BLOOD Calcium-9.6 Phos-5.3*# Mg-3.2*
[**2130-5-11**] 06:10PM BLOOD CEA-1198*
[**2130-5-9**] 03:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-5-12**] 04:44AM BLOOD HoldBLu-HOLD
[**2130-5-11**] 04:12AM BLOOD HoldBLu-HOLD
[**2130-5-17**] 02:01AM BLOOD Type-ART pO2-126* pCO2-43 pH-7.39
calHCO3-27 Base XS-1
[**2130-5-15**] 11:09AM BLOOD Type-ART pO2-79* pCO2-46* pH-7.37
calHCO3-28 Base XS-0
[**2130-5-15**] 02:36AM BLOOD Type-ART pO2-131* pCO2-45 pH-7.32*
calHCO3-24 Base XS--3
[**2130-5-14**] 12:22PM BLOOD Type-ART PEEP-5 pO2-119* pCO2-50*
pH-7.32* calHCO3-27 Base XS-0 Intubat-INTUBATED
[**2130-5-14**] 02:52AM BLOOD Type-ART pO2-126* pCO2-49* pH-7.35
calHCO3-28 Base XS-0
[**2130-5-13**] 06:08PM BLOOD Type-ART pO2-94 pCO2-54* pH-7.34*
calHCO3-30 Base XS-1
[**2130-5-13**] 10:37AM BLOOD Type-ART pO2-109* pCO2-50* pH-7.38
calHCO3-31* Base XS-2
[**2130-5-13**] 03:50AM BLOOD Type-ART pO2-117* pCO2-53* pH-7.40
calHCO3-34* Base XS-6
[**2130-5-12**] 05:19PM BLOOD Type-ART pO2-119* pCO2-42 pH-7.45
calHCO3-30 Base XS-5
[**2130-5-12**] 04:31AM BLOOD Type-ART pO2-80* pCO2-52* pH-7.48*
calHCO3-40* Base XS-12
[**2130-5-11**] 08:45AM BLOOD Type-ART pO2-87 pCO2-40 pH-7.47*
calHCO3-30 Base XS-4
[**2130-5-11**] 08:21AM BLOOD Type-ART pO2-106* pCO2-40 pH-7.46*
calHCO3-29 Base XS-4
[**2130-5-11**] 04:05AM BLOOD Type-ART pO2-75* pCO2-48* pH-7.47*
calHCO3-36* Base XS-9
[**2130-5-10**] 10:06PM BLOOD Type-ART pO2-96 pCO2-51* pH-7.43
calHCO3-35* Base XS-7
[**2130-5-10**] 03:24PM BLOOD Type-ART Rates-16/ PEEP-5 pO2-124*
pCO2-42 pH-7.44 calHCO3-29 Base XS-4 Intubat-INTUBATED
[**2130-5-10**] 11:48AM BLOOD Type-ART pO2-143* pCO2-50* pH-7.40
calHCO3-32* Base XS-5
[**2130-5-10**] 09:16AM BLOOD Type-ART pO2-126* pCO2-59* pH-7.32*
calHCO3-32* Base XS-2
[**2130-5-10**] 07:04AM BLOOD Type-ART pO2-260* pCO2-55* pH-7.33*
calHCO3-30 Base XS-1
[**2130-5-10**] 04:59AM BLOOD Type-ART pO2-171* pCO2-52* pH-7.40
calHCO3-33* Base XS-6
[**2130-5-10**] 03:13AM BLOOD Type-ART Rates-/7 Tidal V-600 FiO2-50
pO2-181* pCO2-54* pH-7.38 calHCO3-33* Base XS-5
Intubat-INTUBATED Vent-CONTROLLED
[**2130-5-10**] 01:42AM BLOOD Type-ART pO2-161* pCO2-55* pH-7.40
calHCO3-35* Base XS-7
[**2130-5-10**] 12:11AM BLOOD Type-ART pO2-166* pCO2-52* pH-7.40
calHCO3-33* Base XS-6
[**2130-5-9**] 09:17PM BLOOD Type-ART pO2-87 pCO2-64* pH-7.35
calHCO3-37* Base XS-6
[**2130-5-17**] 02:01AM BLOOD Lactate-1.3
[**2130-5-15**] 02:36AM BLOOD Lactate-1.6
[**2130-5-13**] 03:50AM BLOOD Glucose-190*
[**2130-5-12**] 04:31AM BLOOD Glucose-168* Lactate-1.2
[**2130-5-11**] 04:05AM BLOOD Lactate-1.5
[**2130-5-10**] 10:06PM BLOOD Lactate-1.4
[**2130-5-10**] 09:16AM BLOOD Lactate-1.2
[**2130-5-10**] 07:04AM BLOOD Lactate-1.4
[**2130-5-10**] 04:59AM BLOOD Glucose-157* Lactate-1.8 Na-133* K-5.1
Cl-100
[**2130-5-10**] 03:13AM BLOOD Glucose-159* Lactate-1.6 Na-133* K-5.0
Cl-99*
[**2130-5-10**] 01:42AM BLOOD Glucose-147* Lactate-1.9 Na-134* K-5.1
Cl-95*
[**2130-5-10**] 12:11AM BLOOD Glucose-110* Lactate-1.5 Na-134* K-4.4
Cl-98*
[**2130-5-9**] 09:17PM BLOOD Glucose-170* Lactate-1.1 Na-133* K-4.9
Cl-94*
[**2130-5-9**] 03:25PM BLOOD Glucose-106* Lactate-1.9 K-4.4
[**2130-5-10**] 04:59AM BLOOD Hgb-11.4* calcHCT-34
[**2130-5-10**] 03:13AM BLOOD Hgb-10.8* calcHCT-32
[**2130-5-10**] 01:42AM BLOOD Hgb-11.4* calcHCT-34
[**2130-5-10**] 12:11AM BLOOD Hgb-10.4* calcHCT-31
[**2130-5-9**] 09:17PM BLOOD Hgb-11.3* calcHCT-34
[**2130-5-17**] 02:01AM BLOOD freeCa-1.07*
[**2130-5-15**] 11:09AM BLOOD freeCa-1.24
[**2130-5-15**] 02:36AM BLOOD freeCa-1.19
[**2130-5-14**] 02:52AM BLOOD freeCa-1.27
[**2130-5-12**] 04:31AM BLOOD freeCa-1.19
[**2130-5-11**] 04:05AM BLOOD freeCa-1.10*
[**2130-5-10**] 10:06PM BLOOD freeCa-1.14
[**2130-5-10**] 09:16AM BLOOD freeCa-1.16
[**2130-5-10**] 07:04AM BLOOD freeCa-1.14
[**2130-5-10**] 04:59AM BLOOD freeCa-1.20
[**2130-5-10**] 03:13AM BLOOD freeCa-1.07*
[**2130-5-10**] 01:42AM BLOOD freeCa-1.16
[**2130-5-10**] 12:11AM BLOOD freeCa-1.12
[**2130-5-9**] 09:17PM BLOOD freeCa-1.17
[**2130-5-11**] 06:10PM BLOOD CA 27.29-Test
Brief Hospital Course:
Ms. [**Known lastname 58650**] was brought in by EMS to the emergency room with
complaints of bilateral lower extremity paralysis, an MRI of the
cervical spine and thoracic spine was performed and revealed
metastatic involvement of T3, T4, and T5 with a severe
compression fracture at T4 and moderate spinal cord compression
from both ventral epidural disease at T4 and dorsal right-sided
epidural disease at T5. No metastatic involving the cervical
spine was observed. A CT scan of the L-spine revealed spinal
stenosis at L4-L5, but no specific metastatic disease.
On [**2130-5-9**], she underwent urgent decompressive laminectomy of
T3-9 with caging. She tolerated the procedure well without any
difficulty or complication. She was transfused 4 units of PRBC
and remained hemodynamically stable. Post-operatively, she
remained intubated and sedated and transferred to the SICU for
further stabilization and monitoring. In the SICU, she was
carefully monitored and her pain controlled. She was closely
followed by Neurology, Oncology, and Medicine services. She was
kept comfortable and extubated on [**2130-5-15**]. Postoperatively, she
continues to make steady progress with her sensory and motor
function steadily improving. She was fitted and given a TLSO
brace to wear in cervical extension at all times while OOB. She
was evaluated by both Physical and Occupational therapy for
strength and mobility training. She was discharged to a
rehabilitation facility in stable condition. She is to followup
with Oncology as an outpt for mapping on [**2130-5-23**]. Radiation
treatments to her T-spine can start after [**2130-5-29**]. She is to
call Dr.[**Name (NI) 58654**] office at [**Telephone/Fax (1) 1228**] for a follow up
appointment in [**12-5**] weeks.
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed for temp > 100.2.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): see sliding scale.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Morphine Sulfate 2-8 mg IV Q2H:PRN pain
hold for sedation or rr < 10
10. Calcium Gluconate 2 gm / 100 ml D5W IV PRN
for an ionized Ca of <1.12
11. Magnesium Sulfate 2 gm / 100 ml D5W IV PRN < 2.0
12. HydrALAZINE HCl 10 mg IV Q6H:PRN
13. Dexamethasone 6 mg IV Q6H
For spinal cord compression. Verbally discussed and cleared by
Ortho NP[**Doctor Last Name **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Spinal cord compression, secondary to breast CA mets
Discharge Condition:
Stable
Discharge Instructions:
Keep the incision/dressing clean and dry. Apply a dry sterile
dressing as needed for drainage or comfort. Staples may be
removed 14-days postop.
If you are experiencing any redness, swelling, pain, or have a
temperature >101.5, please call your doctor or go to the
emergency room for evaluation.
Resume all of your home medication and take all medication as
prescribed by your doctor.
Please call Dr.[**Name (NI) 58654**] office @ [**Telephone/Fax (1) 1228**] for a follow
up appointment in [**12-5**] weeks.
Feel free to call with any questions or concerns.
Physical Therapy:
Activity: Ambulate, WBAT
Treatments Frequency:
Keep the incision/dressing clean and dry. Apply a dry sterile
dressing as needed for drainage or comfort.
If you are experiencing any redness, swelling, pain, or have a
temperature >101.5, please call your doctor or go to the
emergency room for evaluation.
Followup Instructions:
Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2130-7-7**] 8:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17007**] MD [**MD Number(2) 58655**]
Completed by:[**2130-5-18**]
|
[
"428.0",
"V10.3",
"733.13",
"E888.9",
"250.00",
"344.1",
"197.0",
"198.4",
"496",
"336.3",
"197.2",
"401.9",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"99.04",
"96.72",
"81.05",
"81.63",
"96.6",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
13207, 13286
|
10321, 12085
|
409, 460
|
13383, 13392
|
2367, 10298
|
14323, 14622
|
2033, 2096
|
12108, 13184
|
13307, 13362
|
13416, 13975
|
2111, 2348
|
13993, 14019
|
14041, 14300
|
282, 371
|
488, 1596
|
1618, 1752
|
1768, 2017
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,691
| 174,063
|
50329
|
Discharge summary
|
report
|
Admission Date: [**2126-11-22**] Discharge Date: [**2126-12-9**]
Date of Birth: [**2053-12-23**] Sex: M
Service: VSU
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old
gentleman who underwent an endovascular repair of an
abdominal aortic aneurysm with a [**Hospital1 **] stent graft
approximately seven years ago at another institution. This
graft has developed endo leaks twice in the past which have
required endovascular repair. The graft is extremely kinked
and tortuous and has developed yet a third significant endo
leak with aneurysmal expansion and he was advised to have
this graft removed and converted to a conventional repair.
The patient, therefore, presents to [**Hospital1 190**] for open repair of his abdominal aortic
aneurysm with removal of the aortic endo graft.
PAST MEDICAL HISTORY: Significant for hypertension,
hyperlipidemia, abdominal aortic aneurysm, status post
endovascular repair and subsequent endo leak.
MEDICATIONS:
1. Zestril 20 mg p.o. q. Day.
2. Aspirin 325 mg p.o. q. Day.
3. Zocor 20 mg p.o. q. Day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his family. He has a
long smoking history.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Vital signs: Heart rate 62; heart
122/68; saturating 100 percent on room air. General: No
apparent distress. Alert and oriented. Head, eyes, ears,
nose and throat: Normal cephalic, atraumatic. Extraocular
movements intact. Mucous membranes are moist. Heart:
Regular rate and rhythm, no murmurs. Lungs: Distant lung
sounds but clear to auscultation bilaterally. Abdomen soft,
nontender, mild groin bulge in the right inguinal area. No
bruits. 2 plus femoral pulses bilaterally. Extremities:
Clubbing of nail beds but no cyanosis. 2 plus dorsalis pedis
and posterior tibial bilaterally. 5/5 strength. Sensation
is intact. Neurovascular examination: Cranial nerves 2
through 12 are grossly intact.
LABORATORY DATA: Hematocrit of 38.1; platelets 295; sodium
of 137; potassium of 4.6; chloride of 102; bicarbonate of 26;
BUN 18; creatinine 0.8; glucose 91.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2126-11-22**] for removal of
an aortic endo graft and repair of abdominal aortic aneurysm
with an aorta [**Hospital1 **]-iliac graft. For further details of
surgery, please see associated operative note. Initially,
the patient's postoperative course was uncomplicated and he
was doing well. His pain was controlled with the help of an
acute pain service consult. On [**11-24**], the patient began
to report respiratory distress with dyspnea. No acute cause
for his respiratory distress was found. On [**11-25**], while
changing a line, the patient again had respiratory distress.
Chest x-ray showed right lobe patchy infiltrates, consistent
with aspiration. The patient was transferred to the Medical
Intensive Care Unit for aggressive pulmonary toilette and
antibiotics. He was followed by the Surgical Intensive Care
Unit team as well as the vascular team. An electrocardiogram
obtained that day showed ST elevations. The patient was
initially stable hemodynamically but quickly deteriorated
over the course of that day. His agitation increased and his
heart rate and blood pressure went up. The patient had to be
intubated. An nasogastric tube was in place. The patient
was somewhat disoriented and had trouble remembering where he
was on the date. The patient was started on Levofloxacin and
Flagyl for aspiration pneumonia. It was determined on
[**2126-11-25**], the patient had suffered a postoperative
myocardial infarction as he had electrocardiogram changes and
his troponin levels had bumped to 0.51 and his CK MB rose to
13. A cardiology consult was called. The patient had an
echo done that demonstrated an ejection fraction greater than
55 percent. He underwent a head CT to further evaluate his
mental status changes as well as a carotid ultrasound that
showed no significant blockage. His head CT demonstrated an
area of hypo attenuation in the left occipital lobe, in the
territory of the left posterior cerebral artery. This was
consistent with acute stroke. A neurology consult was
obtained. A magnetic resonance scan of the head was obtained
on [**2126-11-30**] and showed normal flow within the
arteries. On this day, the patient self-extubated, but had
to be reintubated for the magnetic resonance scan. The
patient was then extubated on [**2126-12-1**] and tolerated
it well. He was maintained on Levaquin for gram negative rods
that grew out of his sputum. On [**2126-12-2**], the
patient underwent and esophagogastroduodenoscopy for slight
red blood per rectum. A small hiatal hernia was seen. There
was a localized, linear erosion of the mucosa with a central
eschar and surrounding heaped up erythema at the
gastroesophageal junction. There was no active bleeding.
This was presumed to represent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear or
esophagitis. The stomach and duodenum were normal. The
patient was continued on Protonix. The patient was
transfused multiple times throughout his stay in the hospital
for a blood loss anemia, with a goal hematocrit greater than
30. On [**2126-12-3**], the patient underwent a
colonoscopy. Small streaks of clotted blood were seen in the
terminal ileum and cecum and a few also seen in the left
colon. Careful lavage showed none of them were adherent to
any underlying region. Grade two internal hemorrhoids were
noted. A 2 cm patch of erythematous and edematous mucosa was
noted in the sigmoid colon at 30 cm from the anal verge.
There was the suggestion of a central depression but no
distinct ulceration. The surrounding mucosa was entirely
normal. There was no stigmata of bleeding. A biopsy was
taken.
To maintain the patient's nutrition, tube feeds were
necessary to keep his calorie counts high. He also started
p.o. intake after he passed a swallow study on [**12-4**].
On [**2126-12-9**], the patient was stable enough to be
discharged to home with services.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home with services.
DISCHARGE DIAGNOSES:
1. Failed endovascular stent.
2. Postoperative volume fluid overload, corrected.
3. Aspiration pneumonia with respiratory failure, resolved.
4. Postoperative myocardial infarction.
5. Postoperative left occipital stroke.
6. [**Doctor First Name **]-[**Doctor Last Name **] tear/esophagitis.
7. Internal hemorrhoids.
8. Blood loss anemia, transfused, corrected.
9. Abdominal aortic aneurysm.
DISCHARGE MEDICATIONS:
1. Simvastatin 20 mg p.o. q. Day.
2. Aspirin 325 mg p.o. q. Day.
3. Acetaminophen 325 mg to 650 mg p.o. every four to six
hours prn for pain.
4. Lansoprazole 30 mg capsule, p.o. q. Day.
FOLLOW UP: The patient was instructed to follow-up with Dr.
[**Last Name (STitle) **] in two weeks and to call for an appointment. The
patient was also instructed to follow-up with Dr. [**First Name (STitle) **] of the
Neurology Stroke team in two months.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 11988**]
MEDQUIST36
D: [**2126-12-30**] 23:33:38
T: [**2126-12-31**] 07:54:14
Job#: [**Job Number 104935**]
|
[
"518.81",
"996.1",
"997.3",
"553.3",
"428.0",
"997.02",
"455.0",
"507.0",
"525.8",
"997.1",
"285.1",
"458.8",
"410.21",
"562.10",
"401.9",
"E878.2",
"272.4",
"530.7",
"E947.8",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"23.09",
"38.44",
"38.93",
"99.04",
"96.04",
"89.68",
"89.64",
"96.72",
"45.13",
"96.6",
"45.25",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
1212, 1230
|
6219, 6612
|
6635, 6826
|
2144, 6124
|
6838, 7356
|
1253, 2126
|
167, 813
|
836, 1110
|
1127, 1195
|
6149, 6198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,370
| 138,297
|
34172+57902
|
Discharge summary
|
report+addendum
|
Admission Date: [**2183-10-30**] Discharge Date: [**2183-12-16**]
Date of Birth: [**2126-2-8**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Fatigue, weakness
Major Surgical or Invasive Procedure:
Liver biopsy [**11-3**], [**11-9**](?)
Guided Liver Biopsy
[**2183-12-1**]: Exploratory laparotomy, evacuation of
liver hematoma, opening of the diaphragm and evacuation of
about 2 liters of blood from the right chest, placement of
tube thoracostomy, repair of the diaphragm opening and liver
biopsy.
History of Present Illness:
57y F w PMH of HCV cirrhosis s/p OLT [**8-/2183**] with multiple
admissions in last month presented to SICU on [**2183-10-30**] from home
w complaint of worsening fatigue. Family and VNA noted
increasing service need and son and sister who live nearby
report concern about poor endurance as well. She has had a
series of admissions over the last 2 months: transplanted
[**8-/2183**] for HCV cirrhosis and c/o nausea and fevers. Her postop
course was c/b persistent GI symptoms including n/v and poor po
intake requiring tubefeeds. Mid [**Month (only) 359**] (approx 6 weeks post
transplant) LFTs started to go up requiring readmission and
liver bx showed early recurrent HCV. She had intractable n/v
during her 2 week stay. She was discharged home [**10-26**] and
reports worsening fatigue in the 3 days prior to admission.
.
On admission, her LFTs were markedly increased; AST/ALT doubled.
Of note, valcyte dc'd last admission. She currently has CMV
viral load pending. She was continued on home tubefeeds.
.
Currently pt, denies any nausea or vomiting since [**10-21**]. No
current complaints aside from poor appetite, fatigue and
weakness. Believes that she was in similar state of health at
time of discharge on [**10-26**] however was not engaging in ADLs
until she went home and felt extreme fatigue. No fevers at home.
stooling normally. No confusion.
.
ROS:
(+) per HPI
(-) Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, or hematuria.
Past Medical History:
- Chronic hepatitis C infection [**1-14**] remote cocaine use
(genotype 1). Failed two courses of antiviral therapy in [**2166**]
and
[**2168**], interferon nonresponsive.
- Biopsy-confirmed cirrhosis due to chronic hepatitis C
.
PSH:
- [**2183-8-19**] OLT for HCV cirrhosis
- Hysterectomy at age 25 [**1-14**] fibroids
- Umbilical hernia repair as a child
Social History:
Pt lives with her sister in [**Name (NI) 3146**]. She denies smoking, ETOH, or
drugs.
Family History:
Gastric cancer - EGD in [**Month (only) **] did not show any abnormalities.
Physical Exam:
Vitals: Wt 49.3kg T 97.1 BP112/70 HR65 RR18
O2sat100/RA
FS: 158-334
I/O: (ON) 1160/625 BMx2
General: very thin, AAF, appears weak lying in bed, pleasant and
conversational
Skin: No jaundice or rashes, warm, dry and intact, poor skin
turgor
HEENT: EOMI, anicteric, conjunctiva pink, MMM, no oral lesions
Cardiac: RRR, nml S1/S2, no M/R/G
Lungs: Poor respiratory effort, but CTAB
Abdomen: normal BS all quadrants, flat, NT, no guarding or
rebound
Extrem: WWP, no edema, 2+ radial/DP pulses
Neuro: A&Ox3, no asterixis, CN II-XII grossly intact, motor and
sensory function grossly intact
Pertinent Results:
[**10-29**] RUQ U/S [**10-29**]: 1. Normal liver echogenicity. 2. No extra-,
intra-hepatic biliary duct dilatation. 3. Patent hepatic
vasculature with appropriate waveforms. 4. Echogenic material
about porta hepatis, unchanged. 5. Tiny 9-mm punctate echogenic
focus with no internal flow in the right liver lobe,
nonspecific, but likely hemangioma. 6. Slightly delayed upstroke
in the right hepatic artery similar to prior.
.
MRI w/wo contrast
1. No evidence of biliary obstruction. 20 minutes post Eovist
administration, no biliary excretion was seen, indicating
biliary dysfunction. 2. No evidence of portal stenosis,
indicating a successful intervention. 3. Hepatic arterial
anastomosis cannot be assessed on the current study due to
motion limited arterial sequence. 4. Multilobulated cystic
lesion in the uncinate process of the pancreas measuring 1 x 1.2
cm. A followup MRCP is recommended in one year.
.
Chest xray pa/lateral [**2183-11-4**]: As compared to the previous
radiograph, there is no relevant change. Normal size of the
cardiac silhouette. Normal course of the Dobbhoff tube.
Unremarkable structure and transparency of the lung parenchyma,
no evidence of focal parenchymal opacities suggesting pneumonia.
No pulmonary edema. No pleural effusions.
.
RUQ u/s [**2183-11-7**]: 1. Patent vasculature with normal directional
flow and no post-biopsy complication identified. Slight interval
increase in resistive indices withinthe left hepatic artery, as
well as unchanged systolic blunting in right hepatic artery, are
nonspecific but could relate to underlying parenchymal
abnormality. 2. Trace right pleural effusion.
.
UGI series [**11-6**]: Abrupt change in caliber of the third portion
of the duodenum, may represent SMA syndrome
.
Abd KUB [**11-8**]: Portable AP chest radiograph was reviewed in
comparison to [**2183-10-20**]. The jejunal tube is noted with
its tip most likely in the proximal jejunum. Contrast material
is demonstrated in the colon, most likely related to fluoroscopy
obtained on [**2183-11-3**]. There is no evidence of bowel
wall dilatation demonstrated. Air and contrast are seen till the
level of the rectum.
.
CT abd/pelvis wo contast [**11-8**]: 1. Limited evaluation due to the
lack of IV contrast and the presence of oral contrast causing
significant streak artifact from the recent upper GI study.
However, within this limited examination, there is no evidence
of retroperitoneal hematoma. 2. Non-contrast appearance of the
pancreas is within normal limits; however, significant streak
artifact obscures most of the head of the pancreas. 3. Small to
moderate ascites. 4. Mildly thickened distal colon, likely due
to underdistension.
.
[**11-9**] Rush Liver Bx: 1. Prominent bile duct damage with
associated portal/periportal neutrophils and minimal mononuclear
inflammation, as well as numerous apoptotic hepatocytes most
consistent with recurrent viral hepatitis C. 2. No
endothelialitis or other features supportive of acute cellular
rejection are seen. 3. Marked canalicular and hepatocellular
cholestasis with associated neutrophils and feathery
degeneration of hepatocytes. 4. Trichrome and iron stains are
pending and will be reported in an addendum.
.
Note: In comparison to the previous biopsy (S10-47976S), the
current biopsy shows a marked decrease in the mononuclear
component of the portal inflammation, but an increase in the
extent of cholestasis. The amount of bile duct injury remains
unchanged. The worsening of the cholestasis together with the
focal sinusoidal fibrosis on the previous biopsy raises the
possibility of fibrosing cholestatic hepatitis in this patient
in the clinical setting of recurrent HCV with high viral load.
.
Brief Hospital Course:
57 yo W with Hep C cirrhosis s/p Orthotopic Liver Transplant
[**8-21**] with fibrosing cholestatic hepatitis from recurrent
hepatitis C seen on liver biopsy [**11-9**]. , N/V & abdominal pain
secondary to Superior Mesenteric Artery syndrome. HCV viral load
on [**11-9**] was 1,790,000,000. Daily Interferon and Ribavirin were
started. Repeat HCV VL on [**11-16**] was 667,000,000. Bilirubin
peaked at 23.5, and slowly continued to trend down.
Given recent evidence showing a possible advantage of Rapamune
in post-transplant patients with recurrent Hep C, cellcept and
prograf were transitioned to just daily Rapamune. Levels were
checked daily and dose adjusted appropriate. She was continued
on bactrim and valganciclovir for prophylaxis.
She experienced abdominal pain and nausea likely related to
recurrent hepatitis C and superior mesenteric artery syndrome
(as seen on upper GI series), that improved somewhat over the
course of her admission. Work up for infectious etiology was
negative. CT A/P was unremarkable. She received post-pyloric
tube feeds and symptom control with small doses of oxycodone as
needed for pain with IV morphine for breakthrough, and zofran
for nausea. PPI and Reglan were discontinued during this
admission, as the patient felt she was taking too many pills and
this was causing the nausea.
Mood was depressed, and Escitalopram was increasesd to 20 mg
daily. Social Work was consulted and arranged a family meeting
to discuss the continued need for support and frequent visits.
Psychiatry was consulted, who agreed with current medication
management and recommended the possible addition of a stimulant
in the future.
Tube feedings were given. DM was managed with basal, and
sliding scale insulin to obtain reasonable control of the
patient's blood sugar levels. Twice during her admission
bicarbonate decreased with urine lytes revealing a positive
urine anion gap, suggestive of an RTA. On the first occasion she
was hyperkalemic, consistent with a Type IV RTA, and was started
on Fludrocortisone. This was then discontinued secondary to
hypertension and hypokalemia. She also experienced hypernatremia
that resolved with the addition of free water to tube feeds.
Repeat liver biopsy was done on [**11-25**]. She developed worsening
RUQ pain over the following days with subsequent HCT drop to 22
on [**11-28**] from 32 on [**11-24**]. Platelet count had dropped to 93 from
143. Liver duplex was done to evaluate for concern for
hematoma. Duplex demonstarted large subcapsular hematoma. PRBC
and PLT were ordered. During initialy transfusion, she spiked a
temperature to 101. CXR was done for worsening respiratory
function. This revealed opacification of the right hemithorax
consistent with accumulation of a large amount of pleural fluid.
She was sent to IR for angio that showed active extravasation
from R hepatic branch that was unable to be embolized.
She was transferred to the SICU where she intubated for
worsening respiratory status. [**11-27**] CT A/P demonstrated large
subcapsular liver hematoma causing indentation of the left
lateral margin of the liver extending from the dome to the
inferior edge. On [**11-28**] hepatic duplex showed stable size of
hematoma and patent vessels. She received 4U PRBC, 1U FFP, 1U
platelets with lasix after blood products. Hct remained stable
after 4th unit of PRBC. Vanco and zosyn were started.
Pan-culturing was done.
On [**11-30**], she was taken to the OR for exploratory laparotomy,
evacuation of
liver hematoma, opening of the diaphragm and evacuation of about
2 liters of blood from the right chest, placement of tube
thoracostomy, repair of the diaphragm opening and liver biopsy
for post liver biopsy ([**11-25**])hemorrhage. Surgeon was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Postop, she was transferred back to the SICU for
management. CXR on [**12-1**] showed progressive decrease in the
fluid within the right pleural space. CXR on [**12-3**] showed small
R apical PTX with slightly increased pleural effusion. There was
increased LLL atelectasis w/ slight mediastinal shift. On [**12-1**]
zosyn was discontinued. Meropenem was started. She was extubated
on [**12-2**]. Flagyl was added to antibiotic coverage on [**12-4**]. On
[**12-7**] urine culture from [**12-7**] isolated Klebsiella. Meropenum
continued. Repeat Urine culture on [**12-8**] isolated
VRE-Enterococcus faecium. Meropenum was switched to Cefepime on
[**12-10**]. Linezolid was started on [**12-11**]. She was transferred out
of the SICU.
The remainder of the hospital course was notable for stable HCT,
but LFTs continued to rise. Liver dulplex demonstated patent
hepatic vasculature, no biliary duct dilatation, no significant
ascites, small subcapsular fluid collection. She remained
afebrile with stable vital signs. Overall, she was very
debililitated. Tube feeds continued. She was unable to swallow
ribaviron and other pills. PT followed recommending rehab.
Mental status deteriorated. She experienced nausea and vomited
the feeding tube out of position on [**12-14**]. On [**12-14**], she became more
lucid and expressed that she did not want the feeding tube
replaced and wished to cease care/treatments, desiring to go
home. A family meeting occurred and established code status of
DNR/DNI.
Given failure of interferon treatment and decompensation,
palliative care was consulted. The family (sister [**Name (NI) **], proxy,
daughter [**Name (NI) 1446**] and son) were in agreement to transfer to
hospice. [**Hospital 656**] Hospice was contact[**Name (NI) **] and a bed was available.
IV morphine 2mg via picc was given ~ every 1.5hours for
generalized pain. Recommendations from Palliative care for
scheduled morphine elixir were made based on usage of mophine
iv. During the day ([**12-16**]), O2 sat dropped into the 80s and O2
nasal cannula was applied. She was arousable briefly to her name
called, but was too weak to speak.
She was transferred to [**Hospital 656**] Hospice in [**Location (un) 4047**].
Communication: [**Name (NI) **] [**Name (NI) 47598**] (sister) home- [**Telephone/Fax (1) 78752**] cell
[**Telephone/Fax (1) 78753**]
Code status: CMO/DNR/DNI
Disposition: [**Hospital 656**] Hospice
Medications on Admission:
1. prednisone 10 mg Tablet Sig: One (1) Tablet PO Daily
2. metoprolol tartrate 12.5mg PO BID
3. polyethylene glycol 3350 17 gram/dose Powder One dose Daily
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) every 24
hours
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime).
7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
PRN (as needed) as needed for pruritis.
8. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. insulin lispro 100 unit/mL Solution Sig: follow printed
sliding scale units Subcutaneous ASDIR (AS DIRECTED).
10. Miralax 17 gram/dose Powder Sig: One (1) dose PO once a day.
Disp:*30 doses* Refills:*2*
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO prn: every 8 hours
as needed for nausea.
Discharge Medications:
1. morphine concentrate 20 mg/mL Solution Sig: Five (5) mg PO
every four (4) hours: see break thru orders.
2. morphine concentrate 20 mg/mL Solution Sig: 5-10 mg PO prn:
q2 hours as needed for pain.
3. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO prn: q 4 hours as
needed for shortness of breath or wheezing.
4. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 656**] House
Discharge Diagnosis:
Fibrosing Cholestatic Hepatitis from recurrent Hepatitis C
Possible Superior Mesenteric Artery Syndrome
Diabetes Mellitus
Hypertension
Depression
Malnutrition
Hematoma s/p liver biopsy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You will be transferring to [**Hospital 656**] Hospice Facility in [**Location (un) 4047**]
Please call the [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 673**] with
concerns
Followup Instructions:
please contact the [**Hospital1 18**] Transplant Center [**Telephone/Fax (1) 673**] with
questions
Transplant RN coordinator [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23170**] [**Telephone/Fax (1) 16242**]
Completed by:[**2183-12-16**] Name: [**Known lastname 12690**],[**Known firstname 12691**] Unit No: [**Numeric Identifier 12692**]
Admission Date: [**2183-10-30**] Discharge Date: [**2183-12-16**]
Date of Birth: [**2126-2-8**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2800**]
Addendum:
discharge meds: add prograf 0.5mg SL twice weekly. start [**12-18**].
break capsule and place powder under tongue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] House
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]
Completed by:[**2183-12-16**]
|
[
"996.59",
"250.00",
"599.0",
"276.0",
"511.9",
"E878.0",
"303.93",
"E878.1",
"285.1",
"349.82",
"783.7",
"276.2",
"584.9",
"401.9",
"305.23",
"518.0",
"041.3",
"276.8",
"304.23",
"998.11",
"070.70",
"998.12",
"512.8",
"V49.86",
"573.8",
"511.89",
"996.82",
"557.1",
"305.73",
"311",
"E878.8",
"262"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"96.08",
"88.74",
"50.0",
"00.14",
"50.12",
"34.09",
"50.11",
"33.24",
"96.6",
"34.84"
] |
icd9pcs
|
[
[
[]
]
] |
16421, 16630
|
7198, 13442
|
321, 625
|
15292, 15292
|
3474, 7175
|
15643, 16398
|
2768, 2845
|
14378, 14988
|
15084, 15271
|
13468, 14355
|
15431, 15620
|
2860, 3455
|
264, 283
|
653, 2269
|
15307, 15407
|
2291, 2649
|
2665, 2752
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,575
| 166,096
|
13788
|
Discharge summary
|
report
|
Admission Date: [**2163-8-9**] Discharge Date: [**2163-8-12**]
Service: MEDICINE
Allergies:
Metoprolol / Ambien
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
ICU complaint: Hypercarbic respiratory failure, hypotension
Major Surgical or Invasive Procedure:
1. left ORIF
2. Intubation, extubation
History of Present Illness:
Ms. [**Known lastname 41460**] is an 88 y/o Russian speaking female with a h/o
multiple falls who presents s/p fall with a left hip fracture.
She initially fell on [**8-5**] and reportedly had an x-ray done at
that time which did not show any fracture. However since the
first she has been unable to walk due to left hip pain. When the
pain persisted she had another x-ray done which showed a left
femoral neck fracture so she was transferred to [**Hospital1 18**] for
further management.
.
In the ED, initial vs were: 98.8, 89, 158/84, 18, 97% RA.
Imaging was notable for a left hip fracture, head and neck CT's
with no acute process. She was seen by orthopedics who requested
a pelvis CT and given her intermediate HOME score wanted her to
be admitted to medicine for preoperative evaluation and
management. She was given morphine for pain control and
admitted. VS prior to transfer: 98.1, 74, 138/76, 16, 95% on RA.
.
On the floor her initial VS were: 95.9, 152/88, 88, 18, 98% on
RA. She is currently resting comfortably.
.
Review of sytems: unable to obtain as patient is not cooperative
with interview and is combative
Past Medical History:
1. DM type 2 - diagnosed in [**2132**], with neuropathy
2. Coronary artery disease - s/p CABG in [**2151**], s/p MI x3
3. Pancreatic lesion, [**8-/2158**]
4. Chronic pain
5. Renal cell cancer, s/p right nephrectomy in [**2123**], in [**Country 532**]
6. Congestive heart failure
7. Hypothyroidism
8. Depression
9. s/p glaucoma/cataract surgery, bilateral
10. Basal cell carcinoma
11. Multiple falls with hospitalizations, most recently in [**8-10**]
12. s/p cholecystectomy
[**65**]. Spinal Stenosis
14. h/o multiple falls, prior subdural hematoma
Social History:
Lives in an [**Hospital3 **] facility. Denies tobacco, alcohol,
or IVDU.
Family History:
M - diabetes
B - lung cancer
Physical Exam:
On admission to medical floors:
Vitals: T:95.9 BP:152/88 P:88 R:19 O2:98% on RA
General: somnolent, responds to self, not oriented to time,
knows she is in a hospital but not why she is here (per russian
interpreter), no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally anteriorly
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, tender to palpation, limited exam due to
patient uncooperative
Ext: warm, well perfused, 1+ pulses, no edema
Neuro: not oriented to time, able to move extremities
Pertinent Results:
admission labs:
[**2163-8-9**] 12:00PM BLOOD WBC-9.8 RBC-4.65 Hgb-14.2 Hct-43.2 MCV-93
MCH-30.6 MCHC-32.9 RDW-14.9 Plt Ct-221
[**2163-8-9**] 12:00PM BLOOD Neuts-73.2* Lymphs-17.6* Monos-4.0
Eos-4.0 Baso-1.2
[**2163-8-9**] 12:00PM BLOOD PT-12.8 PTT-21.8* INR(PT)-1.1
[**2163-8-9**] 12:00PM BLOOD Glucose-157* UreaN-18 Creat-0.9 Na-138
K-4.3 Cl-104 HCO3-25 AnGap-13
[**2163-8-10**] 07:00PM BLOOD CK-MB-3 cTropnT-0.01
[**2163-8-11**] 03:39AM BLOOD CK-MB-4 cTropnT-<0.01
[**2163-8-10**] 07:00PM BLOOD CK(CPK)-221*
[**2163-8-11**] 03:39AM BLOOD CK(CPK)-340*
[**2163-8-10**] 07:00PM BLOOD Calcium-10.0 Phos-4.1 Mg-2.1
discharge labs:
[**2163-8-12**] 03:46AM BLOOD WBC-14.2* RBC-4.04* Hgb-11.9* Hct-37.7
MCV-93 MCH-29.4 MCHC-31.6 RDW-14.6 Plt Ct-208
[**2163-8-12**] 03:46AM BLOOD Glucose-188* UreaN-23* Creat-0.9 Na-141
K-4.4 Cl-109* HCO3-24 AnGap-12
[**2163-8-12**] 03:46AM BLOOD Calcium-10.0 Phos-3.2 Mg-2.0
studies:
cxr [**2163-8-10**]:
Cardiomediastinal silhouette is unchanged including
cardiomegaly. There is
slight interval improvement in currently minimal pulmonary
edema. Surgical
clips projecting over the mediastinum are unchanged. Small
amount of
bilateral pleural effusion is most likely present.
The study and the report were reviewed by the staff radiologist.
.
cxr [**2163-8-11**]:
The ET tube tip currently is in unchanged position approximately
6.7 cm above the carina. The heart size and mediastinal contours
are unchanged. Interval improvement up to almost complete
resolution of interstitial edema is noted.
Right lower lobe opacity most likely consistent with small areas
of
atelectasis.
micro:
urine culture [**2163-8-11**]: pending
Brief Hospital Course:
Ms. [**Known lastname 41460**] is an 88 y/o F with a significant cardiac history
who presents s/p a fall with a left femoral neck fracture.
.
#) Hip Fracture: Pt was admitted for a left femoral neck
fracture, which was successfully repaired by orthopedics. Her
immediate post-operative course was complicated by oversedation
from medications (fentanyl, morphine, etc), leading to
hypercarbic respiratory failure. She was reintubated as she was
in respiratory failure and also deemed full code for the 24 hour
perioperative period. She also had transient hypotension related
to excess metoprolol (is allergic to this as it causes
hypotension, bradycardia), morphine, fentanyl, and propofol and
quickly normalized after holding these medications. Patient was
ruled out for MI and hypotension was thought not to be sepsis
given no fever, white count, lactate elevation, clear CXR, focal
signs/symptoms. U/A was mildly positive and she was started on
CTX, with cultures sent and revealed no growth. She was
extubated the following morning without complications and did
very well from a respiratory standpoint after all the sedating
medications wore off. Her hip pain was controlled with standing
tylenol and oxycodone PRN. Lovenox was continued post
operatively as prophylaxis and should be continued for four
weeks per ortho recs. She was seen by physical therapy who
recommended a rehab stay. She will f/u with ortho after
discharge.
.
#) CAD s/p: continued home isosorbide mononitrate, and aspirin.
Beta blockade was held because of her allergy to beta blockers
leading to severe hypotension, bradycardia.
.
#) CHF: continued her home lasix dose prior to operation, no
evidence of decompensated heart failure prior to operatiion. She
had mild pulmonary edema on chest x-ray after procedure but
remained stable at her home O2 requirement of 2LNC.
.
#) A flutter: Patient was in and out of sinus and a flutter with
only one episode of RVR in the post-operative period. Otherwise
remained in sinus with normal rate. Patient has not been
anticoagulated secondary to falls risk.
#) Hypothyroid: continued home levothyroxine
.
#) Diabetes: continued home glargine, add a humalog sliding
scale, held home humalin with meals while NPO.
.
#) Depression: continued home citalopram
.
#) Glaucoma: continued home eye drops
.
Code: DNR/DNI per documentation from nursing home and discussion
with HCP. Was temporarily reversed to full code in the 24 hour
perioperative period.
Medications on Admission:
-Acetaminophen 650mg TID prn pain
-Regular Insulin Sliding Scale
-Insulin Glargine 8 units QHS
-Citalopram 40mg daily
-Levothyroxine 12.5mcg daily
-Furosemide 40mg daily
-Aspirin 325mg daily
-Latanoprost 1gtt OU QHS
-Senna 17.2mg Q1700
-Isosorbide Mononitrate 30mg QAM, 15mg QPM
-Cosopt 2-0.5% 1gtt [**Hospital1 **]
-Sebulex Shampoo
-Gabapentin 300mg [**Hospital1 **], 100mg
-Flonase 0.05% nasal spray
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day for 1 weeks.
2. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**5-11**]
hours as needed for pain.
3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
QPM (once a day (in the evening)) for 2 weeks.
4. Keflex 500 mg Capsule Sig: One (1) Capsule PO once for 1
days: Take in the morning on 7/911.
5. insulin glargine 100 unit/mL Solution Sig: Eight (8) Units
Subcutaneous at bedtime.
6. Insulin humalog Sig: One (1) units three times a day:
Please resume sliding scale.
7. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Hold if SBP<100.
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO q1700.
13. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**2-6**]
spray Nasal once a day.
15. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM.
16. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: Two
(2) Tablet PO daily.
17. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
18. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QPM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary: hip fracture
.
Secondary: hypercarbic respiratory failure, atrial fibrillation,
hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for a hip fracture. You
required intubation for respiratory distress in the
peri-operative period likely due to the medications that you
received during the surgery. You also had a few episodes of fast
heart rate which resolved with medications.
.
Because of your heart failure, we recommend that you weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs.
.
The following changes have been made to your medications:
-START taking enoxaparin to prevent clots. You should take
lovenox 40 mg daily for 2 wks
-Take one dose of keflex on discharge
-Take tylenol and oxycodone for pain
-STOP taking Isosorbide Mononitrate 30mg every morning and 15mg
every evening as your blood pressures were low during your
hospitalization. These should be re-started at rehab as your
blood pressures tolerate.
-START Calcium/vitamin D
Followup Instructions:
Please follow up with the appointments below:
Department: ORTHOPEDICS
When: THURSDAY [**2163-8-25**] at 11:40 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2163-8-25**] at 11:20 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"E938.3",
"365.9",
"V45.81",
"518.81",
"428.22",
"244.9",
"820.8",
"428.0",
"294.8",
"311",
"458.29",
"357.2",
"584.5",
"E888.9",
"250.62",
"V10.52",
"427.32",
"E942.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8875, 8940
|
4508, 6972
|
287, 327
|
9085, 9085
|
2822, 2822
|
10171, 10880
|
2164, 2194
|
7425, 8852
|
8961, 9064
|
6998, 7402
|
9261, 10148
|
3459, 4485
|
2209, 2803
|
187, 249
|
1402, 1483
|
355, 1384
|
2839, 3442
|
9100, 9237
|
1505, 2056
|
2072, 2148
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,614
| 180,878
|
26494
|
Discharge summary
|
report
|
Admission Date: [**2171-1-10**] Discharge Date: [**2171-3-12**]
Date of Birth: [**2148-1-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Transfer from OSH for management of endocarditis.
Major Surgical or Invasive Procedure:
[**2171-2-11**] Aortic Valve Replacement utilizing a 23 millimeter OnX
ConformX mechanical valve
[**2171-1-28**] Placement of PICC Line
[**2171-1-14**], [**2171-1-18**] Transesophogeal Echocardiogram
History of Present Illness:
Mr. [**Known lastname 65453**] is a 22 year old male with a PMH significant for WPW
and bicuspid aortic valve. He has a history of cardiac arrest
and is status post ablation at age 17. He is an intravenous drug
abuser. He presented to OSH yesterday for bilateral lower
extremity pain and rash. The pain started about 2 weeks prior to
admission, is in his hamstrings, calves, and feet. Pain was so
severe he was unable to stand on his feet. Described as "achy"
quality. No back pain. No numbness, tingling, or weakness. Was
sent home with Percocets and Amoxicillin. Called back to OSH
today for [**4-9**] blood cultures growing GPC in pairs & chains. An
echocardiogram showed a bicuspid aortic valve with large
vegetation. He was subsequently started on Ceftriaxone and
Vancomycin, and transferred to the [**Hospital1 18**] further management and
evaluation. On admission, he denied SOB, CP, lightheadedness,
DOE, PND, and orthopnea. He reports loss of appetite, 20 lb
weight loss and night sweats over several weeks prior to
admission
Past Medical History:
Aortic Valve Endocarditis, Aortic Valve Insufficiency, Bicsupid
Aortic Valve, History of IVDA, Left forearm Abscess, WPW -
history of cardiac arrest and status post ablation at age 17,
Anemia
Social History:
Last IVDU was 3.5 months ago. Denies ETOH. Admits to tobacco,
approximately [**1-8**] pack per day. Lives with his parents.
Family History:
Non-contributory
Physical Exam:
VS - T 97.9, BP 124/59, HR 51, RR 18, O2 sat 100% RA
gen - well-appearing, NAD
HEENT - PERRL, EOMI, OP clr, MM dry
CV - RRR, 2/6 systolic RSB 2ICS; no JVD
chest - CTAB
abd - NABS, soft, NT
skin - no splinter hemorrhages, no Osler or [**Last Name (un) 1003**] lesions
ext - no edema
neuro - CN II-XII intact, strength 5/5 throughout, [**Last Name (un) 36**] grossly
intact to lt touch
Pertinent Results:
[**2171-3-6**] 02:46PM BLOOD WBC-7.5 RBC-3.09* Hgb-9.0* Hct-25.7*
MCV-83 MCH-29.1 MCHC-34.9 RDW-13.9 Plt Ct-408
[**2171-2-11**] 01:56PM BLOOD Fibrino-162#
[**2171-3-5**] 06:45AM BLOOD ESR-43*
[**2171-3-5**] 06:45AM BLOOD ESR-43*
[**2171-3-3**] 09:20AM BLOOD UreaN-10 Creat-1.4* Na-140 K-4.6 Cl-104
HCO3-27 AnGap-14
[**2171-3-1**] 08:00AM BLOOD ALT-14 AST-16 LD(LDH)-214 AlkPhos-92
Amylase-28 TotBili-0.3
[**2171-2-27**] 06:30AM BLOOD VitB12-927* Folate-5.6
[**2171-2-27**] 06:30AM BLOOD TSH-2.7
[**2171-1-16**] 07:00AM BLOOD HIV Ab-NEGATIVE
[**2171-1-16**] 07:00AM
HEPATITIS C VIRUS RNA BY PCR, QUALITATIVE
Test Result Reference
Range/Units
HCV RNA, QUAL, PCR NOT DETECTED
REFERENCE RANGE: NOT DETECTED
THE DETECTION OF HEPATITIS C VIRAL RNA IS BY
REVERSE TRANSCRIPTION OF GENOMIC RNA FOLLOWED
BY PCR AMPLIFICATION.
THIS TEST WAS PERFORMED USING THE COBAS AMPLICOR
(TM) HEPATITIS C VIRUS TEST, VERSION 2.0 ([**Doctor Last Name 8721**]
DIAGNOSTICS).
TEST PERFORMED AT:
[**Company **] [**Doctor Last Name **] INSTITUTE
[**Numeric Identifier 14272**] P.0. BOX [**Numeric Identifier 19430**]
CHANTILLY, [**Numeric Identifier 19431**]
RADIOLOGY Final Report
IN-111 WHITE BLOOD CELL STUDY [**2171-3-6**]
IN-111 WHITE BLOOD CELL STUDY
Reason: PT WITH S/P AVR (MECHANICAL) W/ PERSISTANT POST OP
FEVERS, A ASSESS FOR INFECTIOUS SOURCE
History: 23 year old with mechanical AVR. Persistent post-op
fevers.
DECISION: SPECT views of the chest and upper abdomen were
obtained.
INTERPRETATION: Following the injection of autologous white
blood cells labeled
with In-111, images of the whole body were obtained at 24 hours.
These images show no abnormal areas of increased uptake.
IMPRESSION: Normal white blood cell scan.
Cardiology Report ECHO Study Date of [**2171-2-28**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Evaluation for abscess. H/O
cardiac surgery. Prosthetic valve function.
Height: (in) 67
Weight (lb): 120
BSA (m2): 1.63 m2
BP (mm Hg): 123/46
HR (bpm): 64
Status: Inpatient
Date/Time: [**2171-2-28**] at 21:57
Test: Portable TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W001-0:00
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the
RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR
leaflets move
normally. Paravalvular leak. No masses or vegetations on aortic
valve.
MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral
valve. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or
vegetation on tricuspid valve.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No
vegetation/mass on pulmonic valve.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was monitored
by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient
was sedated for
the TEE. Medications and dosages are listed above (see Test
Information
section). Local anesthesia was provided by benzocaine topical
spray. No TEE
related complications. Echocardiographic results were reviewed
with the
houseofficer caring for the patient.
Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left
ventricular wall thickness, cavity size, and systolic function
are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter
and free of atherosclerotic plaque. Prominent coronary artery
flow is present.
A bileaflet aortic valve prosthesis is present. The aortic
prosthesis leaflets
appear to move normally. A small paravalvular aortic valve leak
is present. No
masses or vegetations are seen on the aortic valve. There is an
echodense
space posterior to the aortic valve prosthesis which likely
represents
postoperative change. The mitral valve leaflets are structurally
normal. No
mass or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation
is seen.
IMPRESSION: Normal functioning aortic valve prosthesis with a
small
paravalvular leak. No aortic root abcess seen. No valvular
vegetations seen.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2171-3-4**] 17:35.
[**Location (un) **] PHYSICIAN:
Cardiology Report ECHO Study Date of [**2171-2-28**]
PATIENT/TEST INFORMATION:
Indication: S/p recent mechanical AVR for SBE. ?evidence of
recurrent endocarditis.
Height: (in) 67
Weight (lb): 120
BSA (m2): 1.63 m2
BP (mm Hg): 94/50
HR (bpm): 66
Status: Inpatient
Date/Time: [**2171-2-28**] at 17:03
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W000-0:00
Test Location: West [**Hospital Ward Name 121**] [**2-8**]
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.5 cm
Left Ventricle - Fractional Shortening: *0.22 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 45% (nl >=55%)
Aorta - Valve Level: *4.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *2.4 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 24 mm Hg
Aortic Valve - Mean Gradient: 16 mm Hg
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A Ratio: 2.00
Mitral Valve - E Wave Deceleration Time: 320 msec
TR Gradient (+ RA = PASP): 15 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2171-2-6**].
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal
motion consistent with prior cardiac surgery. Abnormal septal
motion/position
consistent with RV pressure/volume overload.
AORTA: Moderately dilated aortic root. Normal ascending aorta
diameter.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
There is mild global left ventricular hypokinesis. Overall left
ventricular
systolic function is mildly depressed with akinesis/hypokinesis
of the
inferolateral wall (with a (with an echodense focus in the basal
inferolateral
wall) . Right ventricular chamber size and free wall motion are
normal. There
is abnormal septal motion/position consistent with right
ventricular
pressure/volume overload. The aortic root is moderately dilated.
A bileaflet
aortic valve prosthesis is present. There is an echolucent space
around the
lateral aspect of the prosthetic ring which may represent
post-operative
change but an abscess cannot be exclude. Trace aortic
regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2171-2-6**], a
bileaflet
aortic prosthesis is now in place and left ventricular systolic
function is
now mildly impaired.
No definite vegetation seen but cannot exclude.
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2171-2-28**] 17:31.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
RADIOLOGY Final Report
CHEST (PA & LAT) [**2171-2-28**] 12:59 AM
CHEST (PA & LAT)
Reason: Please evaluate for pneumonia
[**Hospital 93**] MEDICAL CONDITION:
23 y/o M w/ aortic valve endocarditis s/p AVR now w/ temp to
101.6
REASON FOR THIS EXAMINATION:
Please evaluate for pneumonia
REASON FOR EXAMINATION: High temperature in a patient with
prosthetic aortic valve endocarditis.
Upright PA and lateral chest x-ray were compared to the previous
study from [**2171-2-25**].
The patient is status post median sternotomy and aortic valve
replacement. The right PICC line catheter is inserted with its
tip in distal SVC. The cardiac silhouette is within normal
limits in size, but demonstrates left ventricular configuration.
The pulmonary vasculature is normal. No evidence of congestive
heart failure or focal infiltrate is present. No pneumothorax or
pleural fluid is seen.
The previously reported small air collection in the retrosternal
region is unchanged in comparison to the previous chest x-ray.
IMPRESSION: No evidence of active cardiopulmonary process in a
patient after recent aortic valve replacement.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: [**Doctor First Name **] [**2171-2-28**] 4:51 PM
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 65454**],[**Known firstname 1730**] P [**2148-1-28**] 23 Male [**Numeric Identifier 65455**]
[**Numeric Identifier 65456**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (Prefixes) 413**]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 60868**]/dif
SPECIMEN SUBMITTED: THYMUS, AORTIC VALVE LEAFLET.
Procedure date Tissue received Report Date Diagnosed
by
[**2171-2-11**] [**2171-2-11**] [**2171-2-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
Previous biopsies: [**Numeric Identifier 65457**] EXTRACTED TEETH 2 LOWER MOLARS.
DIAGNOSIS
1. Thymus (6 grams, A-B):
Focal calcifications; no diagnostic abnormalities recognized.
2. Aortic valve leaflets (C-D):
Bacterial endocarditis, see note.
Note: Sections show cardiac valve leaflet with organizing
fibrin "vegetations", acute and chronic inflammation,
calcifications, and focal necrosis. Brown-Brenn stained
sections are positive for Gram positive cocci, present singly.
Correlation with microbiologic culture results is recommended
for increased specificity and sensitivity; if indicated
clinically. GMS-stained sections are negative for fungi.
Clinical: Infected aortic valve.
Gross: The specimen is received in formalin labeled with
"[**Known lastname 65453**], [**Known firstname **]" and the medical record number.
Part 1 is additionally labeled "thymus" and consists of a thymus
which weighs 6 grams and measures 1.5 x 4.6 x 1.3 cm. The
specimen sectioned to reveal unremarkable tan and yellow lobular
cut surface with no nodules or other masses noted. The specimen
is represented in A-B.
Part 2 is additionally labeled "aortic valve leaflets" and
consists of two valve leaflets with several detached fragments
of white tissue that measure up to 3.3 x 1.5 x 1.0 cm. The
specimen is sectioned and entirely submitted in C-D.
Cardiology Report ECHO Study Date of [**2171-1-25**]
PATIENT/TEST INFORMATION:
Indication: Endocarditis. Evaluate AOV vegetation
Height: (in) 67
Weight (lb): 130
BSA (m2): 1.69 m2
BP (mm Hg): 118/54
HR (bpm): 82
Status: Inpatient
Date/Time: [**2171-1-25**] at 15:56
Test: Portable TTE (Congenital, focused views)
Doppler: Limited Doppler and color Doppler
Contrast: None
Tape Number: 2006W006-0:16
Test Location: [**Location 11648**]/[**Hospital Ward Name 121**] 6
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.3 cm
Left Ventricle - Fractional Shortening: 0.48 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aorta - Arch: 2.3 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: *2.3 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 21 mm Hg
Aortic Valve - Mean Gradient: 11 mm Hg
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed
given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Normal RV
systolic function.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta. Normal
aortic arch diameter.
AORTIC VALVE: Bicuspid aortic valve. Moderate-sized vegetation
on aortic
valve. Aortic root abscess. Moderate to severe (3+) AR.
MITRAL VALVE: Normal mitral valve leaflets. No MR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
is moderately dilated. Overall left ventricular systolic
function is normal
(LVEF=55%). [Intrinsic left ventricular systolic function is
likely more
depressed given the severity of valvular regurgitation.]
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The ascending aorta is mildly dilated.
5.The aortic valve is bicuspid. There is a moderate-sized
vegetation on the
aortic valve of (0.6 x 1.1) cm. An aortic annular abscess is
seen adjacent to
the right sided bicuspic valve leaflet, in the anterior aspect
of the aortic
root and a smaller one posteriorly. Moderate to severe (3+)
aortic
regurgitation is seen.
6.The mitral valve leaflets are structurally normal. No mitral
regurgitation
is seen.
7.There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2171-1-11**], the
LV function may have decreased while the size of the vegetation
is less. No MR
is seen on the present study but this may be in part due to the
fact that the
previous study was a TEE.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2171-1-25**]
17:31.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2171-1-23**] 10:05 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: eval for evid of septic emboli
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
22 year old man with aortic valve endocarditis, w/ suspected
septic emboli to brain, w/ ? embolic pulmonary focus in RLL.
REASON FOR THIS EXAMINATION:
eval for evid of septic emboli
CONTRAINDICATIONS for IV CONTRAST: None.
CT OF THE CHEST, ABDOMEN, AND PELVIS.
There is a chest radiograph from [**2171-1-20**] as comparison.
CLINICAL HISTORY: Endocarditis. Question of right lower lobe
pulmonary embolism. Evaluate for evidence of septic emboli.
TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis
were obtained post-IV contrast enhancement. Oral contrast was
also administered. Coronal and sagittal images were generated
which were essential in evaluation of the torso.
CT CHEST FINDINGS: There is no thoracic lymphadenopathy. There
is no pericardial or pleural effusion. The heart size is normal.
The aorta and great vessels appear normal.
Lung windows demonstrate a wedge-shaped focus of consolidation
in the right lower lobe which corresponds to the abnormality
seen on the recent chest radiograph. The remainder of the lungs
are clear.
Images of the abdomen demonstrate normal appearance of the
liver, pancreas, adrenal glands, and kidneys. There is no
lymphadenopathy. There are no dilated bowel loops. The portal
vein and splenic vein are patent. The gallbladder is present.
There is no biliary dilatation.
There is a 3.6 x 4.4 x 3.4 cm low-density lesion with an
irregular contour in the posterior aspect of the spleen which
corresponds to the abnormality seen on the recent chest
radiograph. It is mildly hyperdense relative to simple fluid
measuring 20-24 Hounsfield units. The aorta, celiac axis,
proximal hepatic artery, and splenic artery are patent. The
renal arteries are patent. The [**Female First Name (un) 899**] is patent.
There is no free fluid or lymphadenopathy present in the pelvis.
There are no dilated bowel loops in the pelvis.
Bone windows demonstrate no lytic or blastic lesions in the
chest, abdomen, or pelvis.
IMPRESSION:
1. Low-density lesion in the spleen is nonspecific. While this
most likely represents a cyst or perhaps a hemangioma, an
infarct could appear in this fashion as well. There is no other
evidence in the abdomen of embolism.
2. Focal consolidation at the right lung base is also
nonspecific. This could represent a focal septic embolism or
simply focal atelectasis. A followup chest radiograph could be
performed to determine resolution or to evaluate for new
lesions.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) 65458**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: MON [**2171-1-28**] 3:37 PM
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2171-1-23**] 10:05 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: eval for evid of septic emboli
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
22 year old man with aortic valve endocarditis, w/ suspected
septic emboli to brain, w/ ? embolic pulmonary focus in RLL.
REASON FOR THIS EXAMINATION:
eval for evid of septic emboli
CONTRAINDICATIONS for IV CONTRAST: None.
CT OF THE CHEST, ABDOMEN, AND PELVIS.
There is a chest radiograph from [**2171-1-20**] as comparison.
CLINICAL HISTORY: Endocarditis. Question of right lower lobe
pulmonary embolism. Evaluate for evidence of septic emboli.
TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis
were obtained post-IV contrast enhancement. Oral contrast was
also administered. Coronal and sagittal images were generated
which were essential in evaluation of the torso.
CT CHEST FINDINGS: There is no thoracic lymphadenopathy. There
is no pericardial or pleural effusion. The heart size is normal.
The aorta and great vessels appear normal.
Lung windows demonstrate a wedge-shaped focus of consolidation
in the right lower lobe which corresponds to the abnormality
seen on the recent chest radiograph. The remainder of the lungs
are clear.
Images of the abdomen demonstrate normal appearance of the
liver, pancreas, adrenal glands, and kidneys. There is no
lymphadenopathy. There are no dilated bowel loops. The portal
vein and splenic vein are patent. The gallbladder is present.
There is no biliary dilatation.
There is a 3.6 x 4.4 x 3.4 cm low-density lesion with an
irregular contour in the posterior aspect of the spleen which
corresponds to the abnormality seen on the recent chest
radiograph. It is mildly hyperdense relative to simple fluid
measuring 20-24 Hounsfield units. The aorta, celiac axis,
proximal hepatic artery, and splenic artery are patent. The
renal arteries are patent. The [**Female First Name (un) 899**] is patent.
There is no free fluid or lymphadenopathy present in the pelvis.
There are no dilated bowel loops in the pelvis.
Bone windows demonstrate no lytic or blastic lesions in the
chest, abdomen, or pelvis.
IMPRESSION:
1. Low-density lesion in the spleen is nonspecific. While this
most likely represents a cyst or perhaps a hemangioma, an
infarct could appear in this fashion as well. There is no other
evidence in the abdomen of embolism.
2. Focal consolidation at the right lung base is also
nonspecific. This could represent a focal septic embolism or
simply focal atelectasis. A followup chest radiograph could be
performed to determine resolution or to evaluate for new
lesions.
RADIOLOGY Final Report
MRA BRAIN W/O CONTRAST [**2171-1-21**] 5:29 PM
MRA BRAIN W/O CONTRAST
Reason: evaluate for mycotic aneurysm
[**Hospital 93**] MEDICAL CONDITION:
22 year old man with aortic valve endocarditis, on IV abx, with
persistent fever, intermittent throbbing h/a.
REASON FOR THIS EXAMINATION:
evaluate for mycotic aneurysm
MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) **] AND ITS TRIBUTARIES.
HISTORY: Aortic valve endocarditis. On IV antibiotics.
Intermittent throbbing headaches and fever. Assess for mycotic
aneurysm.
TECHNIQUE: 3D time of flight imaging with multiplanar
reconstructions.
FINDINGS: The major tributaries of the circle of [**Location (un) 431**] appear
to be of normal architecture. There is no sign for the presence
of an area of hemodynamically significant stenosis, aneurysm or
vascular malformation.
However, it is to be emphasized that mycotic aneurysms are
frequently located in the peripheral vasculature, and therefore
not necessarily imaged by MR angiography. Also, the standard MR
angiographic sequence does not encompass the entire brain or its
associated vasculature.
CONCLUSION: No definite abnormality seen. However, it is to be
emphasized that if there is serious consideration for mycotic
aneurysm, conventional angiography must be entertained, as it is
a definitive diagnostic modality in that regard.
COMMENT: Though not optimized for soft tissue imaging, there is
demonstration of a moderate sized left maxillary antral mucous
retention cyst. This abnormality was shown quite clearly on the
preceding MR study of [**1-16**].
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: [**First Name8 (NamePattern2) **] [**2171-1-22**] 12:38 PM
Brief Hospital Course:
On admission, additional blood cultures were taken. The
cardiology and ID services were consulted. He was empirically
started on intravenous antibiotics while awaiting speciation and
sensitivities of gram positive cocci. He was maintained on
telemetry, and no conduction abnormalities were noted. He
continued to complain of lower extremity pain which required
narcotics for adequate pain control. Blood cultures eventually
grew out Enterococcus faecalis for which antibiotics were
adjusted accordingly. He was maintained on Ampicillin and
Gentamicin. Despite antibiotics, he was intermittently febrile.
Hepatitis B surface antibody and Hepatitis C virus antibody came
back positive while HIV serology and RPR returned negative. HCV
viral load was negative. A transesophogeal echocardiogram on
[**1-14**] was notable for a bicuspid aortic valve with a large
mobile vegetation on the left ventricular outflow tract side of
the anterior cusp. There was a small (~1.0 x 0.5 cm) echolucent
space posterior to the aortic root (and a smaller space anterior
to the aortic root). An abscess could not be ruled out. At least
mild to moderate ([**1-7**]+) aortic regurgitation was seen. The
neurology service was also consulted for new onset headaches and
persistent lower extremity pain. A head CT scan on [**1-15**]
was unremarkable. Lower extremity ultrasound found no evidence
of deep vein thrombosis. A brain MRI on [**1-16**] was notable
for multiple bilateral foci of lobulated enhancement with
negligible adjacent increased T2 signal. Given the history,
there was concern for septic emboli. A repeat TEE on [**1-18**] confirmed a bicuspid aortic valve with echodensity
consistent with vegetation. There was moderate-severe aortic
regurgitation. Compared with the prior study, the aortic valve
vegetation was slightly larger. In addition, there were two
small (2-4mm) echolucent spaces in the anterior and posterior
aortic root consistent with small abscesses. Given the echo
findings of continued growth of vegetation with abscesses and
persistent fevers despite antibiotics, cardiac surgery was
consulted as his clinical picture suggested poor prognosis for
success of medical management alone. Prior to surgical
intervention, several additional weeks of intravenous
antibiotics was recommended to minimize the risk of intracranial
bleed while on cardiopulmonary bypass. For the next several
weeks, he remained on intravenous antibiotics. Additional
studies included MRI imaging which found no evidence of mycotic
aneurysm. Lower extremity MRI showed lack of intraluminal
opacification in portions of the proximal peroneal and posterior
tibial arteries, suspicious for septic emboli with
thrombophlebitis. MRI also showed nonspecific findings
consistent with infectious myositis of the right thigh. There
was no MRI evidence for abscess or osteomyelitis. CT imaging
showed a nonspecific low-density lesion in the spleen with no
other evidence of embolism in the abdomen. There was also
nonspecific focal consolidation at the right lung base. Physical
examination revealed new [**Last Name (un) 1003**] lesions on his left hand.
PICC line placed on [**1-28**] for continued ampicillin and
gentamicin. Repeat TEE on [**1-29**] showed 3+ AI, 2 AV vegetations.
Dental consult done on [**1-31**]. extractions were recommended prior
to surgery. These were done on [**2-4**]. The patient had no CNS
events for 2 weeks at this point. Another TEE done [**2-6**] showed
vegetations present with small pericardial effusion, but no
tamponade and 4+ AI. Clinical nutrition and social work teams
continued to additional support. Blood cultures continued to be
negative.
AVR done [**2-11**] with 23 mm OnX ConformX mechanical valve.
Transferred to the CSRU in stable condition on epinephrine,
vasopressin and phenylephrine drips. Extubated later that
evening. On POD #1, remained on insulin and nitroglycerin drips.
Beta blockade and coumadin were started. On POD #2, nitro drip
weaned and Cordis removed. He was transferred to the floor to
begin ambulating and med adjustment. Chest tubes and pacing
wires were removed over the next 2 days. He was on a heparin
drip until his INR was therapeutic. The pain management team was
consulted on [**2-15**]. INR rose rapidly to 3.2 and coumadin was held
on [**2-15**]. He will require ampicillin until [**2-25**] and follow up
with ID then. He had fever and night sweats on [**2-16**], but no
fever the following day. On [**2171-2-28**] he had a febrile episode
for which he was restarted on Vancomycin and Zosyn. His PICC
line was discontinued. Surveilliance blood cultures were
negative and there was no elevation in his white count. A
tagged WBC study did not reveal any focal area of inflammation
or infection. Repeat TEE did not reveal any vegetations or
abscess. His PICC catheter tip culture was also negative. His
coumadin was continued for a target INR of 2.5-3.0 for a
mechanical AVR. He is presently being discharged on heparin for
a subtherapuetic INR. He will continue Ampicillin 2gm IV q4 hrs
until [**2171-3-28**].
Medications on Admission:
Percocet, Amoxicillin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Year (4 digits) **]:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Year (4 digits) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
[**Year (4 digits) **]:*30 capsule* Refills:*2*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*0*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Year (4 digits) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*2*
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*2*
9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every [**4-11**]
hours as needed.
[**Month/Day (3) **]:*50 Tablet(s)* Refills:*0*
10. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed by PCP.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
11. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1100 units/hr Intravenous ASDIR (AS DIRECTED).
[**Name Initial (NameIs) **]:*qs qs* Refills:*2*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
[**Name Initial (NameIs) **]:*qs ML(s)* Refills:*0*
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
15. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q4H (every 4 hours).
[**Name Initial (NameIs) **]:*180 Recon Soln(s)* Refills:*2*
16. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
[**Name Initial (NameIs) **]:*120 Tablet(s)* Refills:*2*
17. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
[**Name Initial (NameIs) **]:*40 Tablet(s)* Refills:*0*
18. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (once)
for 1 doses.
[**Name Initial (NameIs) **]:*3 Tablet(s)* Refills:*0*
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
[**Name Initial (NameIs) **]:*qs ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Enterococcal Aortic Valve Endocarditis, Septic Emboli, Aortic
Valve Insufficiency, Bicsupid Aortic Valve, Aortic Root Abscess,
History of IVDA, Left forearm Abscess, WPW - history of cardiac
arrest and status post ablation at age 17, Anemia
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2171-3-21**] 11:30
Schedule coumadin follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 10166**] [**Hospital3 65459**] [**Telephone/Fax (1) 31979**]
Follow up with [**Location (un) 22870**] outpatient addiction treatment
Completed by:[**2171-3-12**]
|
[
"521.00",
"451.19",
"729.5",
"070.30",
"426.7",
"746.4",
"070.70",
"305.1",
"523.4",
"434.10",
"304.00",
"995.92",
"038.0",
"421.0",
"728.0",
"444.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"23.19",
"38.93",
"07.81",
"88.72",
"39.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
33218, 33291
|
25356, 30427
|
371, 573
|
33576, 33583
|
2449, 4285
|
33902, 34262
|
2010, 2028
|
30499, 33195
|
23766, 23876
|
33312, 33555
|
30453, 30476
|
33607, 33879
|
14498, 17843
|
2043, 2430
|
282, 333
|
23905, 25333
|
601, 1637
|
17875, 18144
|
1659, 1853
|
1869, 1994
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,056
| 174,099
|
25959
|
Discharge summary
|
report
|
Admission Date: [**2136-3-25**] Discharge Date: [**2136-4-1**]
Date of Birth: [**2056-12-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Indocin / Iodine; Iodine Containing / Mucomyst
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
2 episodes of congestive heart failure
Major Surgical or Invasive Procedure:
Mitral Valve Replacement(tissue) and RF MAZE procedure via Right
Thoracotomy [**2136-3-26**]
History of Present Illness:
79 y/o male with h/o CABGx5/Asc. Aortic and Hemi-Arch
replacement in [**2132**] who has had multiple episodes of congestive
heart failure with hospitilizations recently. Echo performed at
that time revealed Mitral Regurgitation. More recently repeat
echo revealed severe MR w/ dilated LA. Cardiac cath also
confirmed MR along with patent grafts from prior CABG. He
presented for surgical management for his Mitral Regurgitaion.
Past Medical History:
Coronary Artery Disease/Asc. Aortic Aneurysm s/p CABGx5/Asc.
Aortic Replacement/Hemi-Arch [**2132**]
Atrial Fibrillation since [**12-1**] (on Coumadin)
Hypertension
Hypercholesterolemia
Congestive Heart Failure
IMI [**2114**]
GI Bleed/Ulcer [**2109**]
Amaurosis fugax R. [**6-1**]
Peripheral Vascular Disease
Abd. Aortic Aneurysm s/p Repair in 1007 w/ L. Iliac repair
Malaria [**2075**]
Seasonal Allergies
Deviated Septum
Skin Cancer (face) s/p removal
s/p L. ext. carotid ligation
Social History:
Lives with wife. Retired [**Name2 (NI) 15068**] Officer.
Quit smoking in [**2109**] after 80pk/yr hx.
Drinks ETOH rarely.
Family History:
Mother died of MI at 55
Father and Brother w/ AAA
Physical Exam:
VS: 80Irreg 17 R144/76 L128/72 5'8" 175#
General: Sitting in NAD
Skin: Sl. ruddy chest
HEENT: PERRL, EOMI, Non-icteric
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r w/ well-healed sternal scar
Heart: Irregular rhythm w/ 2/6 SEM
Abd: Soft, NT/ND, +BS w/ healed abd. scar
Ext: Warm, well-perfused [**1-30**]+ edema w/ healed mult. harvest
incision BLE
Neuro: Non-focal, MAE, A&O x 3
Pertinent Results:
[**2136-3-25**] 02:23PM BLOOD WBC-6.6 RBC-5.10 Hgb-15.6 Hct-43.7 MCV-86
MCH-30.6 MCHC-35.7* RDW-15.2 Plt Ct-220
[**2136-3-29**] 02:53AM BLOOD WBC-8.2 RBC-4.23* Hgb-13.2* Hct-36.7*
MCV-87 MCH-31.2 MCHC-35.9* RDW-15.4 Plt Ct-99*
[**2136-3-25**] 02:23PM BLOOD PT-15.5* PTT-30.4 INR(PT)-1.4*
[**2136-3-29**] 02:53AM BLOOD PT-13.7* PTT-31.8 INR(PT)-1.2*
[**2136-3-25**] 02:23PM BLOOD Glucose-99 UreaN-20 Creat-1.3* Na-137
K-7.1* Cl-101 HCO3-24 AnGap-19
[**2136-3-29**] 02:53AM BLOOD Glucose-91 UreaN-14 Creat-0.9 Na-135
K-3.8 Cl-100 HCO3-27 AnGap-12
[**2136-3-29**] 02:53AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1
[**2136-3-28**] 04:37PM BLOOD freeCa-1.08*
[**2136-3-25**] 07:32PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
[**2136-3-25**] 07:32PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
Echo [**3-26**]: PRE-CPB: The left atrium is markedly dilated. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is moderately depressed. Resting regional wall
motion abnormalities include infero septal, inferoir and
inferolateral walls. EF is 30 %. The mitral valve leaflets are
moderately thickened. There is mild mitral valve prolapse of the
posterior leaflet. Severe (4+) mitral regurgitation is seen.
Systolic flow reversal seen in the pulmonary vein. POST-CPB:
Well-seated bioprosthetic valve in the mitral position, with
trace MR and no paravalvular leak. There is no LVOT obstruction.
The post-bypass EF is now 35-40% on inotropic support.
CXR [**3-28**]: No pneumothorax. Improvement in right lower lobe
opacification.
Brief Hospital Course:
Mr. [**Known lastname 64525**] was initially seen in clinic and was admitted prior
to surgery secondary to Coumadin use. He stated he discontinued
Coumadin on [**3-22**] and was started on Heparin along with two
Vitamin K when admitted. He also underwent full pre-operative
work-up. His lab work, including INR, was suitable for surgery
and was brought to the operating room on [**2136-3-26**] where he
underwent a Mitral Valve Replacement and RF MAZE procedure via
Right thoracotomy. Please see op note for surgical details.
Following the procedure he was transferred to the CSRU in stable
condition with Inotropic support and Amiodarone. Later on op day
patient was weaned from sedation and awoke neurologically
intact. He was then extubated. He was weaned off of all
Inotropes by post-op day one and required Nitro for hypertension
(which was weaned off by POD#2). On post-op day two he had
multiple hypoxic events with decrease in his O2 saturations and
PaO2. He underwent a bronchoscopy for a therapeutic aspiration.
Multiple mucus plugs were aspirated from RUL/RLL. Post Bronch it
was noted his gag response had not returned and a bedside
evaluation was performed. He passed the swallow study and
eventually advanced to a regular diet without problems. [**Name (NI) **] on
post-op day two his chest tubes were removed. Mr. [**Known lastname 64525**] was
recovering well post-operatively and transferred to the cardiac
step-down unit on post-op day three. He continued to remain on
amiodarone for atrial fibrillation and Coumadin was started.
Physical therapy followed patient during his post-op period for
strength and mobility. On post-op day 6 he was doing well, but
required further physical therapy rehabilitation. His INR was
above 1.3 and was discharged against medical advice on
Amiodarone and Coumadin. He was informed that should not leave
because his INR was not theraputic. However, after a long
discussion , he wished to leave. He will follow-up in 4 weeks
and earlier with his PCP and Cardiologist.
Medications on Admission:
Lisinopril 5mg qd, Cardizem 240mg qd, Digoxin 0.25mg qd, Lasix
40mg qd,
Albuterol INH prn, Coumadin 5mg/4mg (alternating) with last dose
of 2mg on [**2136-3-22**]
Discharge Medications:
1. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin EC 81 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*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 1
doses.
Disp:*1 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 11485**] VNA
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Repalcement
Atrial Fibrillation s/p RF MAZE procedure
Hypertension
Hypercholesterolemia
Congestive Heart Failure
Discharge Condition:
good
Discharge Instructions:
Can take shower. Wash icisions with water and gentle soap. Do
not take bath. Do not apply lotions, creams, ointments, or
powders.
Do not drive for 1 month.
Do not lift more than 10 pounds for 2 months.
If you develop a fever greater than 101.5 or notice drainage
from your incision, please contact the office immediately.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) 64526**] in [**1-30**] weeks
Dr. [**Last Name (STitle) 64527**] in [**3-2**] weeks
Dr. [**Last Name (STitle) **] in [**1-30**] weeks
Completed by:[**2136-4-1**]
|
[
"443.9",
"934.1",
"414.00",
"428.20",
"427.31",
"412",
"458.29",
"428.0",
"V45.81",
"E912",
"401.9",
"441.4",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.23",
"96.05",
"37.33",
"33.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6748, 6804
|
3730, 5750
|
363, 457
|
6998, 7004
|
2039, 3707
|
1574, 1625
|
5963, 6725
|
6825, 6977
|
5776, 5940
|
7028, 7351
|
7402, 7634
|
1640, 2020
|
285, 325
|
485, 914
|
936, 1419
|
1435, 1558
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,314
| 152,707
|
9065
|
Discharge summary
|
report
|
Admission Date: [**2173-2-11**] Discharge Date: [**2173-2-16**]
Date of Birth: [**2139-3-21**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old,
gravida 3, para 1, who was noted to have an elevated AFP on
[**2173-1-17**]. On [**2-5**], the patient presented for a
level II ultrasound and was found to an intrauterine fetal
demise at 20 weeks. Options were discussed with the patient,
and she elected to undergo D&E. Laminaria were placed on
[**2-9**], and the patient underwent D&E on [**2-10**].
Please see the details of the procedure in the dictated
operative report.
PAST OB HISTORY: In [**2171**] the patient had a cesarean section
at 34 weeks secondary to oligohydramnios and breech
presentation. She had SAB times one in [**2172**]. The patient
has a history of anti-C and anti-......... antibody.
PAST MEDICAL HISTORY: 1. She is status post total hip
replacement secondary to congenital hip abnormality. 2.
Status post appendectomy. 3. Uterine fibroids.
ALLERGIES: ASPIRIN.
MEDICATIONS: None.
SOCIAL HISTORY: No tobacco, alcohol, or drug use.
PHYSICAL EXAMINATION: Vital signs: Normal. Lungs: Clear
to auscultation. Heart: Regular, rate and rhythm. Abdomen:
Gravid consistent with 20-week gestation. Extremities:
Nontender.
HOSPITAL COURSE: 1. D&E: The patient underwent a dilation
and evacuation under ultrasound guidance. The estimated
blood loss was approximately 800 cc. She received 10 U of
intracervical Pitocin, as well as 20 U of Pitocin and 1 L LR
IV, as well as 250 mg Hemabate IM during the procedure. At
the conclusion of the case, ultrasound confirmed that there
was no uterine contents remaining.
Around 6 p.m., the patient had passage of a moderate amount
of clots, approximately 250 cc. There was clot evacuated
from the lower uterine segment, and 1000 mcg Cytotec was
placed rectally. She was also given Methergine at the time.
Reevaluation approximately 2 hours later revealed that the
patient continued to have heavy bleeding. On exam, she was
afebrile with a blood pressure of 120/80 and a heart rate
ranging from 80 to 110. A Foley was placed into the bladder
and returned 100 cc. The fundus was firm, and again there
were clots in the lower uterine segment. Approximately an
additional 500 cc of blood was noted coming from the vagina.
Labs were sent a revealed a hematocrit of 22.3, platelet
count 159, INR 1.3, fibrinogen 187. The patient was given 2
[**Location 16678**], typed and crossed for 2 U of packed red blood
cells, and consented for reevaluation in the Operating Room.
The etiology for her bleeding and now DIC was thought to be
either secondary to ................ versus laceration versus
dilutional coagulopathy versus retained products.
In the Operating Room, the patient was noted to have a small
cervical laceration, as well as a laceration in the posterior
fornix. She also had a small amount of retained tissue. The
lacerations were repaired, and a sharp and suction curettage
were performed. Intraoperatively the patient received a
total of 4 U of packed red blood cells and 3 [**Location 16678**]. Her
estimated blood loss total including the previous procedure
and the time interval between procedures was close to 2 L.
Intraoperatively her hematocrit ............. at 18 and the
fibrinogen ............... at 98. Her INR was 1.4.
Postoperatively the patient was transferred to the Intensive
Care Unit for further management.
2. Hematology: Over the hospital course, the patient
received a total of 7 U of packed red blood cells and 4 [**Location 31319**]. By postoperative day #1, status post her return to the
OR, her DIC had improved with fibrinogen returning to above
200. Her platelets were stable in the 90s. Over the course
of the hospital stay, her hematocrit also stabilized at 26.
3. Pulmonary: Immediately postoperatively the patient
remained intubated and was transferred to the Intensive Care
Unit. She was weaned off the vent on the evening of [**2-11**]. By discharge, the patient had an oxygen saturation of
100% on room air.
4. Cardiovascular: Immediately postoperatively, the patient
had some episodes of hypotension which required pressor
support. By the end of postoperative day #0, the patient was
off all pressor support.
5. Infectious disease: The patient had some elevated
temperatures as high as 101.6?????? on postoperative day #0 and
#1. She was placed on triple antibiotics with Ampicillin,
Gentamicin, and Clindamycin. By postoperative day #3, her
fevers had defervesced, and she was transitioned to p.o.
antibiotics on hospital day #4.
6. Fluid, electrolytes, and nutrition: Once the patient was
extubated, her diet was advanced as tolerated. Her urine
output was excellent throughout the hospitalization. Her
electrolytes were normal overall and were repleted as needed.
7. GYN: From a GYN standpoint, her bleeding postoperatively
was minimal. She was continued on Pitocin for approximately
18 hours and continued on Methergine for 24 hours. Her
bleeding remained minimal throughout her hospitalization.
8. Prophylaxis: While the patient was in the Intensive Care
Unit, she was maintained on Protonix for GI prophylaxis and
Pneumoboots for DVT prophylaxis.
9. Endocrine: Due to her hypotensives episodes, there was
concern for pituitary versus adrenal insufficiency. A random
cortisol was drawn and was low at 3.9. The patient
subsequently underwent a cortisol stimulation test which was
normal. She then had a morning cortisol drawn which was at
the lower end of normal at 12. She was evaluated by
Endocrine who felt that at this time the patient did not have
any evidence of pituitary insufficiency; however, they
recommended a follow-up in [**6-12**] weeks to reassess.
10. TORCH titers: TORCH titers were sent. As of this time,
the CMV, IgG, and toxo-IgG were both positive suggestive of
prior exposure. Toxo-IgM and CMV IgM are pending, as well as
her P-simplex.
11. Psychiatry: During her stay, the patient was evaluated
by social worker who had concern that the patient had
suicidal ideation. A psychiatry consult was called, and the
patient was evaluated. Psychiatry felt that the patient was
safe for discharge and would not harm herself or her
20-month-old baby. She will follow-up with social work in
several days.
DISPOSITION: The patient was discharged home on
postoperative day #5. She was given a prescription to finish
a 5-day course of Doxycycline. She will follow-up with both
Dr. [**First Name8 (NamePattern2) 2491**] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
DISCHARGE DIAGNOSIS:
1. Intrauterine fetal demise at 20 weeks.
2. Status post dilatation and evacuation.
3. Status post exam under anesthesia and repair of cervical
laceration.
4. DIC.
5. Postoperative fever.
6. Rule out pituitary and adrenal insufficiency.
7. Adjustment disorder with mixed emotional features.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS: Doxycycline 100 mg p.o. b.i.d. x 5
days, Percocet [**1-6**] tab p.o. q.3-4 hours.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 31320**], M.D. [**MD Number(1) 31321**]
Dictated By:[**Name8 (MD) 30071**]
MEDQUIST36
D: [**2173-2-16**] 09:10
T: [**2173-2-16**] 09:59
JOB#: [**Job Number 31322**]
|
[
"998.89",
"639.1",
"255.4",
"E878.8",
"632",
"428.0",
"253.2",
"309.9",
"639.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"67.61",
"69.02"
] |
icd9pcs
|
[
[
[]
]
] |
7086, 7437
|
6703, 7002
|
1324, 6682
|
1139, 1306
|
160, 858
|
881, 1064
|
1081, 1116
|
7027, 7062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,551
| 113,392
|
34152+57901
|
Discharge summary
|
report+addendum
|
Admission Date: [**2187-10-5**] Discharge Date: [**2187-10-9**]
Date of Birth: [**2120-3-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Hypotension
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67M s/p Whipple procedure [**2187-7-3**] for ampullary adenoma who was
readmitted post-op intra-abdominal fluid collections [**2187-7-25**],
and again on [**8-16**] for fevers and hypotension and E.Coli
bacteremia, who presents again after transfer from an outside
hospital with fevers and hypotension. Fevers at the OSH were
102.
The patient was discharged on his last admission with PO
antibiotics for 6 weeks (augmentin). His antibiotic course was
stopped just prior to this admission. Feeding as an outpatient
was continued with a dobhoff tube feeds. The patient was seen in
clinic 5 days prior to admission and reported good progress with
weight gain, and was afebrile since his last admission.
Past Medical History:
Past Medical History:
ampullary adenoma, likely diagnosis of familial adenomatous
polyposis, ypertension, coronary artery disease, chronic
obstructive pulmonary disease (COPD), arthritis and peripheral
vascular disease
PSH: Whipple procedure, coronary artery bypass graft (CABG) and
carotid endarterectomy, total abdominal colectomy and end
ileostomy, ex-lap's for SBO, EVAR
Social History:
His social history is significant for positive tobacco. He
smokes half pack per day, no alcohol and no IV drugs use, and no
intranasal cocaine use.
Family History:
Family History:
His family history is significant for his maternal grandfather
that was affected with colorectal cancer, mother that was
affected with polyposis, brother that was affected with
colorectal cancer, 2 daughters that are affected with polyposis,
a grandson that is affected with polyposis, a brother that was
lost to colorectal cancer and a son that is also affected with
polyposis.
Physical Exam:
Vitals- 97.4 97.4 75 100/52 15 97% 2L
Gen- NAD, alert
Head and neck- NC/AT, No JVD
Heart-RRR, SEM at LSB, II/VI
Lungs-clear bilaterally
Abd-soft, osteomy pink, dark green watery stool
Ext-no edema
Pertinent Results:
[**2187-10-6**] 12:12AM BLOOD WBC-7.7 RBC-3.43* Hgb-10.5* Hct-30.4*
MCV-89 MCH-30.6 MCHC-34.5 RDW-16.1* Plt Ct-146*
[**2187-10-7**] 01:12AM BLOOD WBC-5.0 RBC-3.38* Hgb-10.3* Hct-29.2*
MCV-86 MCH-30.5 MCHC-35.3* RDW-16.2* Plt Ct-145*
[**2187-10-7**] 01:12AM BLOOD Glucose-145* UreaN-9 Creat-0.5 Na-137
K-3.8 Cl-110* HCO3-21* AnGap-10
[**2187-10-8**] 06:00AM BLOOD ALT-55* AST-29 LD(LDH)-152 AlkPhos-157*
TotBili-0.4
[**2187-10-6**] 12:12AM BLOOD Lipase-61*
[**2187-10-7**] 01:12AM BLOOD Albumin-2.9* Calcium-7.8* Phos-2.1*
Mg-1.9
[**2187-10-8**] 06:00AM BLOOD Albumin-3.2* Mg-1.7
.
Blood Cultures OSH
E.coli pan-sensitive
.
Brief Hospital Course:
This is a 67 readmitted for hypotension, fevers, in the context
of
prior fluid collection, E.coli sepsis. He was sent from OSH for
1 day of rigors and malaise. Was reportedly hypotensive at OSH
ED, given 4 liters crystalloids w/ transient improvement. BP
90s/50-110/60s on arrival.
CT abdomen @ OSH - per ED report no free air or acute process.
It was reviewed by Gold surgery as having no acute issue/cause
for sepsis.
He was admitted to the SICU. He was Pan culture and started on
Vanc/zosyn.
He responded to IVF and his BP was stable.
Pain - minimal, continue to monitor
CARDIOVASCULAR: Hypotension - low CVP, most likely vasodilatory
[**1-6**] ?infection, given bolus to maintain SBP and responded well.
GI / ABD: He was restarted on PO's and tube feeds
HEMATOLOGY: Stable anemia, follow
ID: OSH blood cultures were pan-sensitive E.coli. He was
discharged home with 2 weeks of Levofloxacin
He was stable at time of discharge and will follow-up with Dr.
[**Last Name (STitle) 468**] in a few weeks.
Medications on Admission:
Simvastatin 10', Aspirin 325', Lopressor 50'', Omeprazole 20',
reglan 10"", dilaudid 1-2q4hp, colace 100"
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] visiting nurses
Discharge Diagnosis:
E.Coli bacteremia
hypotensive
febrile
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* Continue with tubefeedings as directed
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2187-11-12**]
11:00
Completed by:[**2187-10-9**] Name: [**Known lastname 12688**],[**Known firstname **] W Unit No: [**Numeric Identifier 12689**]
Admission Date: [**2187-10-5**] Discharge Date: [**2187-10-9**]
Date of Birth: [**2120-3-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4987**]
Addendum:
The patient was discharged home with Augmentin once/day x 4
weeks.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] visiting nurses
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 4988**] MD [**MD Number(1) 4989**]
Completed by:[**2187-10-9**]
|
[
"458.9",
"496",
"V10.09",
"V45.72",
"790.7",
"V44.2",
"401.9",
"041.4",
"443.9",
"V45.81",
"780.61",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7014, 7223
|
2930, 3942
|
332, 339
|
4962, 4969
|
2283, 2907
|
6367, 6991
|
1669, 2050
|
4098, 4790
|
4901, 4941
|
3968, 4075
|
4993, 6344
|
2065, 2264
|
274, 294
|
367, 1070
|
1114, 1470
|
1486, 1637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,512
| 103,972
|
27677
|
Discharge summary
|
report
|
Admission Date: [**2117-9-3**] Discharge Date: [**2117-9-13**]
Date of Birth: [**2049-1-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2042**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History of Present Illness: This is a 68 yo M with h/o
metastatic melanoma and known brain mets who presents with
increasing delirium over the past week in the setting of
starting Temozolomide chemotherapy. Pt is C2D11 today. Pt was
referred in by oncologist for a infectious/metabolic workup.
.
In the ED, initial VS were 98.4 81 137/86 18 100%. Labs
revealed no leuckocytosis but a Na of 125. Head CT only showed
three known metastatic lesions without evidence of acture
process. EKG showed NSR 81, no ST changes. Blood cx were sent.
CXR showed incr growth of pulm nodule in R lower lobe, no
consolidations or effusions. Of note, pt rec'd 1L NS in ED
prior to transfer.
.
Upon arrival to the ICU, pt is comfortable, conversing
pleasantly. Deneis fevers, sore throat, nasal congestions,
diarrhea, abdominal pain or dysuria. Endorses cough. Also,
endorses constipation. Also, mentions increased urinary
frequency last few days, but denies dysuria.
.
Review of systems:
per HPI, otherwise negative. endorses dry itchy skin on back.
Past Medical History:
melanoma: diagnosed in [**2112**], s/p adjuvant IFN, later
metastasized to the chest wall confirmed by biopsy, s/p adjuvant
GM CSF treatment; that metastasized to the left neck and thigh
status HDIL2 with POD;
enrolled on protocol 08-142 (ipilimumab and Avastin in [**3-/2116**]),
but was discontinued in [**2117-7-2**] for progression of disease:
specifically, a bulky leptomeningeal mass affecting the cauda
equina with significant right lower extremity symptoms for which
was started on temozolomide with EB-XRT to LS spine (dose
reduced to 150 mg/m2 given the radiation field in the
lumbosacral spine). s/p 2 cycles now.
h/o basal cell cancer on the leg
h/o burning injuries
s/p right inguinal herniorrhaphy
Social History:
Denies tobacco (never a smoker), light-moderate EtOH before but
has not drank in last 2 months, no IVDU.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals: T: afebrile BP: 126/76 P: 81 R: 18 O2: 97% on RA
General: AAOx2 (not time), no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx2 (not time), 3/5 strength in RLE, 5/5 strength in
LLE, decr sensation in RLE
Pertinent Results:
ADMISSION LABS:
[**2117-9-3**] 05:40PM BLOOD WBC-8.8# RBC-4.25* Hgb-13.1* Hct-35.4*
MCV-83 MCH-30.8 MCHC-37.0* RDW-14.2 Plt Ct-227
[**2117-9-4**] 03:49AM BLOOD WBC-5.5 RBC-3.82* Hgb-11.8* Hct-32.5*
MCV-85 MCH-31.0 MCHC-36.5* RDW-13.5 Plt Ct-204
[**2117-9-5**] 05:01AM BLOOD WBC-6.5 RBC-3.97* Hgb-12.2* Hct-33.7*
MCV-85 MCH-30.6 MCHC-36.1* RDW-13.5 Plt Ct-209
[**2117-9-3**] 05:40PM BLOOD Neuts-88.7* Lymphs-3.9* Monos-6.6 Eos-0.6
Baso-0.2
[**2117-9-5**] 05:01AM BLOOD Neuts-88* Bands-2 Lymphs-5* Monos-4 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2117-9-5**] 05:01AM BLOOD Plt Ct-209
[**2117-9-4**] 03:49AM BLOOD Plt Ct-204
[**2117-9-3**] 05:55PM BLOOD PT-11.8 PTT-25.7 INR(PT)-1.0
[**2117-9-3**] 05:40PM BLOOD Plt Ct-227
[**2117-9-5**] 02:30PM BLOOD Glucose-133* UreaN-10 Creat-0.7 Na-127*
K-3.9 Cl-89* HCO3-30 AnGap-12
[**2117-9-5**] 05:01AM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-127*
K-3.7 Cl-90* HCO3-29 AnGap-12
[**2117-9-4**] 08:04PM BLOOD Na-126* K-4.0 Cl-89*
[**2117-9-4**] 09:47AM BLOOD Na-125* K-3.8 Cl-88*
[**2117-9-4**] 03:49AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-126*
K-3.9 Cl-88* HCO3-30 AnGap-12
[**2117-9-3**] 11:33PM BLOOD Na-126* K-3.7 Cl-89*
[**2117-9-3**] 05:40PM BLOOD Glucose-96 UreaN-14 Creat-0.7 Na-125*
K-4.8 Cl-84* HCO3-30 AnGap-16
[**2117-9-3**] 05:40PM BLOOD estGFR-Using this
[**2117-9-3**] 05:40PM BLOOD ALT-20 AST-28 LD(LDH)-556* AlkPhos-59
TotBili-0.7
[**2117-9-5**] 02:30PM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8
[**2117-9-5**] 05:01AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8
[**2117-9-5**] 05:01AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8
[**2117-9-4**] 03:49AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.8
[**2117-9-3**] 05:40PM BLOOD Calcium-9.4 Phos-3.2 Mg-1.8
[**2117-9-3**] 05:40PM BLOOD Osmolal-259*
[**2117-9-5**] 05:01AM BLOOD TSH-0.58
[**2117-9-5**] 05:01AM BLOOD Cortsol-20.3*
[**2117-9-3**] 11:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2117-9-3**] CXR: IMPRESSION: Of the two known pulmonary nodules,
presumed metastatic lesions, the one visible in the posterior
segment of the right lower lobe has demonstrated interval
growth. No superimposed acute pulmonary process seen.
.
[**2117-9-3**] CT HEAD: IMPRESSION: Known metastatic implants in the
right inferior frontal and left temporal lobe without evidence
for acute process. Comparison for interval change in size is
limited across modalities.
.
[**2117-9-4**] MRI BRAIN: IMPRESSION: Interval progression of metastatic
disease with several new lesions, many of which are in a
subependymal periventricular location.
.
DISCHARGE LABS:
Brief Hospital Course:
ASSESSMENT/PLAN: 68yo man with metastatic melanoma on
temozolamide admitted for acute delirium and hyponatremia.
Subactue cognitive deficit became acute delirium just prior to
admission. Na 125, Urine Na 29, urine osm all consistent with
SIADH. He was initially given 1L normal saline in the ED. Then,
fluid restriction started in ICU. He was transfered out of the
ICU once Na improved to 127. NaCl tabs were started and sodium
normalized. MRI brain showed progressing brain mets. RPR, B12,
folate, Utox, CXR, EKG, and U/A negative. Cultures negative.
Pallitaive whole brain XRT was started [**2117-9-8**], the last 2
fractions were held so patient could go home with hospice.
.
# Oliguria: Occurred 2 days prior to discharge. Due to
hypvolemia due to decreased po intake as he continued to
deteriorate. Responded to fluid bolus, but incontinent of urine.
I's and O's were followed with a condom catheter.
.
# Acute delirium on presentation: Due to hyponatremia and brain
mets. Mild improvement with corrected hyponatremia. Urine tox
negative. CXR negative. EKG normal. RPR negative. B12 and folate
normal. U/A and urine cx negative. Blood culture negative.
Stopped temozolamide. Hyponatremia was corrected as outlined
below. Benzodiazepines and opiates were avoided but
prescriptions were made available for hospice use as an
outpatient. The patient was continued on dexamethasone started
on [**2117-9-6**]
.
# Hyponatremia: Una 29, high Uosm, low serum osm, euvolemic, all
consistent with SIADH, likely due to worsening brain mets seen
on MRI. Normal TSH, normal AM cortisol. NaCl tabs 3g TID started
[**2117-9-5**]. Na 125 --> 139. Stopped fluid restriction. Continued
NaCl tabs.
.
# CNS mets: Progression of known CNS mets on temozolomide.
Palliative whole brain XRT started [**2117-9-8**], last two fractions
held [**9-13**] and [**9-14**] so he could go home with hospice. Decreased
dexamethasone to 4 mg [**Hospital1 **] and lansoprazole was continued for GI
prophylaxis. Anti-emetics were given prn.
.
# Dysphagia: Face turned red with swallowing food so
dexamethasone was given as an IV. When the patient was
discharged home with hospice, Dexamethasone was changed to an
elixir and Speech/Swallow consult was DC'd.
.
# Odynophagia: The patient was treated with magic mouthwash and
started on fluconazole given his high dose steroids. He was DC'd
with fluconazole elixir for a 14 day course.
.
# Metastatic melanoma: Multiple discussions occured with the
patient's family on the hospital floor on [**9-12**] regarding his
ongoing decline (requiring a two person assist, unable to sit up
in bed, incontinent of urine, oliguric due to poor po intake).
They decided to take the patient home with hospice. The
patient's primary oncologist was notified by email regarding the
family's plans. The patient's last 2 remaining fractions of XRT
were skipped to allow discharge to home hospice.
.
# Right lower extremity pain: responsive to tylenol and
ibuprofen prn (have used the latter sparingly with his brain
mets). Avoided narcotics due to his baseline confusion, but
prescriptions given for home hospice.
.
# Constipation: Resolved with bowel regimen.
.
# Nausea: Anti-emetics as needed.
.
# Anxiety/agitation: Continued home quetiapine (Seroquel).
Avoided benzodiazepines unless necessary. Used haloperidol or
olanzapine (Zyprexa) if needed.
.
# FEN: Regular diet. Stopped water restriction. Replete lytes
prn.
.
# DVT prophylaxis: Heparin SC.
.
# GI prophylaxis: PPI and bowel regimen.
.
# Lines: Peripheral IV.
.
# Precautions: None.
.
# CODE: FULL.
.
Medications on Admission:
Ativan PRN (stopped 2 days ago) anxiety/agitation
Lactulose PRN constipation
Compazine 10mg PRN nausea
Seroquel 25mg qhs
Aloe [**Doctor First Name **] cream PRN dry skin
Discharge Medications:
1. sodium chloride 1 gram Tablet [**Doctor First Name **]: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*2*
2. quetiapine 25 mg Tablet [**Doctor First Name **]: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. prochlorperazine maleate 10 mg Tablet [**Doctor First Name **]: One (1) Tablet PO
Q6H (every 6 hours) as needed for Nausea.
Disp:*20 Tablet(s)* Refills:*0*
4. lactulose 10 gram/15 mL Syrup [**Doctor First Name **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for Constipation.
5. senna 8.8 mg/5 mL Syrup [**Doctor First Name **]: [**5-11**] ml PO twice a day as needed
for constipation.
Disp:*500 ml* Refills:*0*
6. docusate sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: [**5-11**] ml PO twice a day
as needed for constipation.
Disp:*500 ml* Refills:*0*
7. acetaminophen 500 mg/5 mL Liquid [**Month/Year (2) **]: Five (5) ml PO every
six (6) hours as needed for pain.
Disp:*500 ml* Refills:*0*
8. morphine 10 mg/5 mL Solution [**Month/Year (2) **]: one half ml PO every four
(4) hours as needed for pain.
Disp:*100 ml* Refills:*0*
9. Lorazepam Intensol 2 mg/mL Concentrate [**Month/Year (2) **]: one half ml PO
every four (4) hours as needed for agitation, anxiety, nausea,
insomnia.
Disp:*100 ml* Refills:*0*
10. Dexamethasone Intensol 1 mg/mL Drops [**Month/Year (2) **]: Four (4) ml PO
twice a day.
Disp:*250 ml* Refills:*2*
11. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve [**Month/Year (2) **]: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
12. lansoprazole 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
13. fluconazole 40 mg/mL Suspension for Reconstitution [**Last Name (STitle) **]: 2.5
ml PO once a day for 14 days.
Disp:*35 ml* Refills:*0*
14. ibuprofen 100 mg/5 mL Suspension [**Last Name (STitle) **]: [**1-3**] ml PO every six
(6) hours as needed for pain: Use tylenol first, then use
ibuprofen if needed.
Disp:*250 ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice of [**Hospital3 **]
Discharge Diagnosis:
1. Altered mental status (confusion).
2. Hyponatremia.
3. SIADH (syndrome of inappropriate anti-diuretic hormone).
4. Progressive Brain metastases.
5. Metastatic melanoma.
6. Fatigue/weakness.
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for altered mental status
(confusion). This initially was thought to be due to a very low
sodium, a condition called SIADH (syndrome of inappropriate
anti-diuretic hormone), likely a manifestation of melanoma
metastases to the brain as seen on MRI. The sodium level
improved with fluid restriction and salt tablets. The salt
tablets will maintain a correct sodium, so you no longer need to
limit your drinking. Because your delirium did not improve with
correction of the sodium and steroids (dexamethasone), you were
started on radiation therapy. Because you decided to go home
with hospice, you will not receive the last two days of your
radiation.
.
MEDICATION CHANGES:
1. Salt (NaCl) 3g tablets 3x a day.
2. Dexamethasone 4 mg [**Hospital1 **]
3. You may take Docusate Sodium and Senna as needed for
constipation
4. You may take acetominophen (tylenol) liquid for pain, if pain
continues you can use ibuprofen and morphine if needed
5. Fluconazole 100 mg (2.5 ml) daily for 14 days for throat pain
6. Lansoprazole daily
7. You may take lorazepam liquid as needed for agitation,
anxiety, nausea, or insomnia
8. You may take Zofran rapid dissolve tablet as needed for
nausea
Followup Instructions:
FOR QUESTIONS/CONCERNS OR FOLLOW-UP, PLEASE CALL YOUR PRIMARY
ONCOLOGIST DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
Please call radiology at the numbers below if you need to cancel
these appointments.
.
Department: RADIOLOGY
When: TUESDAY [**2117-9-21**] at 1 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: RADIOLOGY
When: TUESDAY [**2117-9-21**] at 1:40 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"276.52",
"198.3",
"788.5",
"344.60",
"780.79",
"293.0",
"V10.82",
"198.4",
"253.6",
"197.0",
"781.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
11391, 11450
|
5470, 9032
|
326, 334
|
11687, 11687
|
2901, 2901
|
13103, 13863
|
2279, 2298
|
9252, 11368
|
11471, 11666
|
9058, 9229
|
11864, 12555
|
5447, 5447
|
2313, 2882
|
1342, 1405
|
12575, 13080
|
264, 288
|
391, 1323
|
5061, 5430
|
2917, 5052
|
11702, 11840
|
1427, 2141
|
2157, 2263
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,476
| 111,674
|
2675
|
Discharge summary
|
report
|
Admission Date: [**2123-5-23**] Discharge Date: [**2123-6-3**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Ischemic right lower extremity
Major Surgical or Invasive Procedure:
[**5-23**]:
1. Aortogram with right lower extremity runoff, third order
catheterization.
2. Brachial artery access with third order catheterization.
3. Right superficial femoral artery antegrade access with
second order catheterization.
4. Mechanical thrombectomy (AngioJet).
5. Infusion for thrombolysis (TPA).
6. Right femoral-popliteal PTA.
7. Right popliteal stent 5 x 40 times two for residual
stenosis.
8. Right peroneal 4 x 40 and 3 x 120 PTA.
[**5-24**] Right lower extremity lytic check/catheter change
[**5-25**] removal of arterial sheath and percutaneous closure,
diagnostic right lower extremity arteriogram, follow-up tibial
thrombolysis, percutaneous balloon angioplasty of the mid
peroneal artery.
History of Present Illness:
The patient is an elderly gentleman who has an entire
aortobiiliac bypass graft with occlusion of the right limb and
femoral-femoral crossover graft. He presented to [**Hospital3 13347**] with knee pain and they thought that he had a septic
knee. He represented with worsening foot pain and discoloration.
He was sent here urgently. When we evaluated him, he had a very
ischemic foot. He had limited sensation, but did have motor,
although it was not completely normal. He had some calf
tenderness.
Physical Exam:
ON ADMISSION:
98.1 76 113/52 16 97% ROOM AIR
NAD
RRR
CTA Bilaterally
soft, ND, NT, NABS
Right extremity: knee tender to palpation with any motion, PT
dopplerable, DP not-dopplerable, cold foot.
Left extremity: DP palpable, PT dopplerable, warm throughout.
.
ON DISCHARGE:
97.8 67 142/60 18 96% ROOM AIR
NAD
RRR
CTA Bilaterally
soft, ND, NT, NABS
Right extremity: warm throughout, knee non-tender, DP/PT
dopplerable.
Left extremity: DP palpable, PT dopplerable, warm throughout.
Pertinent Results:
ON ADMISSION:
[**2123-5-23**] 06:21PM BLOOD WBC-22.6*# RBC-3.81*# Hgb-10.7*#
Hct-31.3*# MCV-82 MCH-28.0 MCHC-34.0 RDW-15.7* Plt Ct-317#
[**2123-5-23**] 06:21PM BLOOD Neuts-93.2* Bands-0 Lymphs-4.8*
Monos-1.6* Eos-0.3 Baso-0.1
[**2123-5-23**] 06:21PM BLOOD PT-14.3* PTT-60.9* INR(PT)-1.3*
[**2123-5-23**] 06:21PM BLOOD Glucose-118* UreaN-57* Creat-2.1* Na-139
K-4.1 Cl-107 HCO3-24 AnGap-12
[**2123-5-23**] 06:21PM BLOOD CK(CPK)-188*
[**2123-5-23**] 06:42PM BLOOD Lactate-1.4
.
ON DISCHARGE:
[**2123-6-3**] 04:50AM BLOOD WBC-8.0 RBC-4.26* Hgb-12.0* Hct-36.4*
MCV-85 MCH-28.1 MCHC-32.9 RDW-16.4* Plt Ct-387
[**2123-6-3**] 04:50AM BLOOD PT-22.5* PTT-62.2* INR(PT)-2.2*
[**2123-5-27**] 07:44AM BLOOD Fibrino-624*
[**2123-6-3**] 04:50AM BLOOD Glucose-111* UreaN-28* Creat-1.3* Na-137
K-4.3 Cl-107 HCO3-24 AnGap-10
[**2123-6-1**] 06:05AM BLOOD CK(CPK)-29*
[**2123-5-29**] 05:15AM BLOOD Lipase-89*
[**2123-6-2**] 12:32PM BLOOD CK-MB-4 cTropnT-0.13*
[**2123-6-3**] 04:50AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.3
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-23**] 6:11 PM
CHEST (PORTABLE AP)
Reason: eval [**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE thrombosis
REASON FOR THIS EXAMINATION:
eval pre-op
EXAMINATION: AP chest.
INDICATION: Right leg thrombosis.
A single AP view of the chest was obtained [**2123-5-23**] at 18:13 and
is compared with the prior study performed [**2118-9-19**].
Cardiomediastinal silhouette is unremarkable. The lungs show no
evidence of acute infiltrate, pleural effusion or pneumothorax.
There is some minimal linear atelectasis in the left base.
IMPRESSION:
Minimal linear basal atelectasis. No other acute process
demonstrated.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-23**] 11:53 PM
CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN
[**Name Initial (PRE) **]: check ETT position
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE ischemia
REASON FOR THIS EXAMINATION:
check ETT position
AP CHEST 1:27 A.M. ON [**5-24**]
HISTORY: Ischemia. Check ET tube placement.
IMPRESSION: AP chest compared to [**5-23**] at 6:13 a.m.:
Moderate-to-severe pulmonary edema is new, accompanied by
increased dilatation of pulmonary arteries though heart size is
normal and unchanged. Pleural effusions may be collecting
posteriorly, but are not substantial in size. ET tube in
standard placement. No pneumothorax.
.
RADIOLOGY Final Report
KNEE (AP, LAT & OBLIQUE) RIGHT PORT [**2123-5-24**] 7:42 PM
KNEE (AP, LAT & OBLIQUE) RIGHT
Reason: assess for [**Hospital 13348**]
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with
REASON FOR THIS EXAMINATION:
assess for sffusion
EXAMINATION: Right knee, 8:20 p.m., on [**5-24**].
HISTORY: Possible effusion.
IMPRESSION: Frontal and a lateral view of the right knee
suggests a small joint effusion in the suprapatellar recess. The
knee is other unremarkable. A vascular catheter lies posterior
to the lower femur and an arterial stent is posterior to the
upper aspect of the tibia.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-25**] 10:40 AM
CHEST (PORTABLE AP)
Reason: assess pulm edema
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE ischemia, MI s/p angio
REASON FOR THIS EXAMINATION:
assess pulm edema
INDICATION: Right lower extremity ischemia, myocardial
infarction.
CHEST, ONE VIEW: Comparison with multiple previous examinations,
the most recent being [**2123-5-24**]. Endotracheal tube is
unchanged in position. Pulmonary edema has resolved. Cardiac,
mediastinal, and hilar contours are now within normal limits.
Bilateral small pleural effusions may be present. No
pneumothorax. Osseous structures are unchanged. A 5-mm round
opacity overlying the right lung field has not been seen on
previous studies and probably represents a confluence of
shadows.
IMPRESSION: Bilateral pleural effusions. Improvement in
pulmonary edema
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-26**] 7:34 AM
CHEST (PORTABLE AP)
Reason: r/o infiltrates
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE ischemia, MI s/p angio
REASON FOR THIS EXAMINATION:
r/o infiltrates
HISTORY: 84-year-old man with right lower extremity ischemia,
myocardial infarction, status post angiogram.
COMPARISON: [**2123-5-25**].
CHEST, AP: Cardiac, mediastinal, and hilar contours are stable.
There is mild pulmonary edema, not significantly changed from
prior exam. The small bilateral pleural effusions appeared to
have slightly increased in size accounting for differences in
technique. Endotracheal tube is in unchanged position.
IMPRESSION: Mild pulmonary edema. Slight increase in size of
small bilateral pleural effusions.
.
Cardiology Report ECHO Study Date of [**2123-5-26**]
Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%)
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure is
16-20 mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is mild regional dysfunction with
focal mild hypokinesis of the distal septum and mid-anterior
walls. The remaining segments contract normally and overall LVEF
is preserved. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (?#) are mildly thickened. There is no aortic valve
stenosis. Trace 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.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction c/w CAD or focal myocarditis.
Moderate pulmonary artery systolic hypertension. Mild mitral
regurgitation.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-5-27**] 9:50 AM
CHEST (PORTABLE AP)
Reason: assess for infiltrates/effusions
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with RLE ischemia, MI s/p angio
REASON FOR THIS EXAMINATION:
assess for infiltrates/effusions
REASON FOR EXAMINATION: Followup of a patient after _____.
Portable AP chest radiograph compared to [**2123-5-26**].
The patient was extubated in the meantime interval. The heart
size is normal. The bibasilar atelectasis and bilateral small
pleural effusion is unchanged, and there is no evidence of
congestive heart failure.
.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2123-5-27**] 8:42 AM
CT HEAD W/O CONTRAST
Reason: r/o cva/[**Hospital 13349**]
[**Hospital 93**] MEDICAL CONDITION:
84 year old man s/p rt popleteal stent and thrombectomy w/MS
changes. Had TPA w/thrombectomy
REASON FOR THIS EXAMINATION:
r/o cva/hemorrage
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post right popliteal stent and thrombectomy
with mental status changes. Head TPA with thrombectomy. Evaluate
for an intracranial hemorrhage or infarct.
TECHNIQUE: Non-contrast head CT.
COMPARISON EXAMINATION: [**2120-5-3**].
FINDINGS: Since the prior examination, there has been
development of an old appearing small right frontal lobe
infarct. The previously noted left frontal lobe infarct is
unchanged. Since the prior exam; however, there are new
periventricular white matter hypodensities, any one of which
could represent a small acute infarct. A MRI would be
recommended if exclusion of an acute infarct is needed.
As before, there are small lacunes in the caudate heads
bilaterally. There is no midline shift, mass effect or
hydrocephalus. There is no intracranial hemorrhage. The mastoid
sinus air cells are hypoplastic.
These findings were discussed with [**First Name8 (NamePattern2) **] [**Doctor Last Name **], the nurse
practitioner [**First Name (Titles) 767**] [**Last Name (Titles) 9686**] Surgery at the time of
dictation.
IMPRESSION:
Since the [**2119**] head CT, there has been interval development of a
small right frontal lobe infarct which appears chronic on this
examination. Numerous additional periventricular white matter
hypodensities are present, any one of which could represent a
small acute infarct. MRI would be needed to exclude that
diagnosis.
There is no intracranial hemorrhage.
.
RADIOLOGY Final Report
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2123-5-31**] 9:58 AM
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT)
Reason: pre-op for bypass
[**Hospital 93**] MEDICAL CONDITION:
84 y/o man presents with MI, cold R foot and hot R knee5/27: R
knee tap by ortho, R peroneal thrombectomy, stent, angioplasty
and placement of lysis catheter5/28 repeat angio, TPA5/29
peroneal cutting balloon, TPA5/30 angio, TPA cath removed
REASON FOR THIS EXAMINATION:
pre-op for bypass
VENOUS STUDY DATED 6
HISTORY: Extensive intervention for a cold right foot, now
requires vein mapping for possible bypass.
FINDINGS: The greater saphenous veins are patent bilaterally.
Please see digitized images on PACS for formal sequential vein
dimensions.
.
RADIOLOGY Final Report
PERSANTINE MIBI [**2123-5-31**]
PERSANTINE MIBI
Reason: 84 YO W/ MI; RT PERONEAL THROMBECTOMY, STENT,
ANGIOPLASTY, TPA [**5-26**] ANGIO, TPA CATH REMOVED
RADIOPHARMECEUTICAL DATA:
10.2 mCi Tc-[**Age over 90 **]m Sestamibi Rest ([**2123-5-31**]);
29.6 mCi Tc-99m Sestamibi Stress ([**2123-5-31**]);
HISTORY: CAD, pre-operative evaluation.
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-99m 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 good.
Left ventricular cavity size is dilated at stress and rest.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium without signs of
reversible or irreversible
ischemia.
Gated images reveal hypokinesis.
The calculated left ventricular ejection fraction is low at 40%.
IMPRESSION: 1. Dilated left ventricle at rest and stress without
ischemic
changes. 2. Hypokinesis with depressed ejection fraction of 40%.
.
Cardiology Report STRESS Study Date of [**2123-5-31**]
IMPRESSION: No anginal symptoms or significant ST segment
changes from
baseline. Nuclear report sent separately.
Brief Hospital Course:
The patient was admitted to Dr.[**Name (NI) 1720**] Vascular Surgery
Service on [**2123-5-23**]. He was acutely taken to the operating room
where he underwent a aortogram with right lower extremity
runoff, third order catheterization, brachial artery access with
third order catheterization, right superficial femoral artery
antegrade access with second order catheterization, mechanical
thrombectomy (AngioJet), infusion for thrombolysis (TPA), right
femoral-popliteal PTA, right popliteal stent 5 x 40 times two
for residual stenosis, and right peroneal 4 x 40 and 3 x 120 PTA
on [**2123-5-23**]. During the procedure the patient became acutely
agitated with an elevated heart rate, and he was electively
intubated. Immediately post-op he was transferred to the CSRU
intubated. TPA infusion was continued into his right lower
extremity and his heart rate contorlled with b-blocker. On POD
1, his cardiac enzymes were elevated (Trop 2.13) and cardiology
was consulted, recommending aspirin, anticoagulation with
heparin drip, HR control with lopressor, and starting lipitor.
His knee was tapped by ortho after an knee xray showed a
possible effusion and cultures were later negative. He
continued to remain intubated and sedated and the TPA infusion
was continued. He was taken back for a right lower extremity
lytic check/catheter change. Please refer to the operative
report for further details. On POD 2, he was again taken back
for a diagnostic right lower extremity arteriogram, follow-up
tibial thrombolysis, percutaneous balloon angioplasty of the mid
peroneal artery. His cardiac enzymes continued rise peaking at
2.41 and then continued to trend downward until discharge. On
POD 4, he was extubated without complications. He was continued
on vancomycin for a possible knee infection and cipro floxacin
was started for a pneumonia (enterococcus). Post-extubation he
had a somnolent mental status with waxing and [**Doctor Last Name 688**] agitation.
Neurology was consulted believed it was post-operative delirium.
His mental status continued to improve daily after
extubation. He continued to remain afebrile and on POD 7 from
the first operation, he was stable for transfer from the CSRU to
the floor. While on the floor, the haperin drip was continued
and his post-operative course on the floor was uncomplicated.
He underwent a PMIBI per cardiology recommendations which showed
a dilated left ventricle at rest and stress without ischemic
changes and hypokinesis with depressed ejection fraction of 40%.
Cardiology felt this was unchanged from his previous studies
and recommeded no further intervention except follow-up on an
outpatient basis. He was started on coumadin in transition from
his heparin drip and was therapeutic by the day of discharge
with an INR of 2.2. He was deemed stable for discharge to a
rehab facility in POD 11 form the first operation. He was
afebrile and tolerating a regular diet. All his lines have been
discontinued without complications and he will be discharged no
14 days of ciprofloxacin for his pneumonia. His Trop level was
0.13. He will follow-up with Dr. [**Last Name (STitle) **] in 1 month with a
duplex of his lower extremities.
Medications on Admission:
plavix 75', lipitor 20', nifedipine 90', lisinopril 10',
metoprolol 25'' asa 81'
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**6-4**]
hours as needed for pain. Tablet(s)
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every
8 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Ischemic right leg, acute thrombosis
MI
Discharge Condition:
Stable
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-30**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**2-28**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Appointments to be made:
Call your primary care MD- Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 13350**] for a
follow-up appointment and INR (Coumadin test). He will manage
your anticoagulation but you MUST CALL FOR APPOINTMENT FOR
INR/blood draw. Goal INR is 2.5-3.0.
Expect to receive a call from Dr.[**Name (NI) 5695**] office to
schedule your appointment and lower extremity duplex. Please
call Dr. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD at [**Telephone/Fax (1) 1237**] to schedule a
follow-up appointment for 1 month from today if you do not hear
from the office within one week. You will need to get a lower
extremity duplex prior to your visit.
.
Scheduled Appointments :
You have a visit scheduled with Cardiology DR. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 10516**] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2123-6-18**] 4:00. he is
located in [**Hospital 23**] [**Hospital Ward Name 13351**]. He is the Cardiologist
that followed you during this hospital stay. You will need close
follow up with Cardiologist as outpatient given your Cardiac
history and inpatient events.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2123-7-13**] 10:15
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2123-11-1**] 2:00
|
[
"444.22",
"585.9",
"272.4",
"V12.59",
"412",
"410.71",
"996.74",
"293.0",
"401.9",
"V10.46",
"V45.81",
"719.06",
"482.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"39.50",
"99.04",
"88.42",
"00.40",
"00.41",
"00.46",
"96.72",
"39.90",
"99.10",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
16941, 17038
|
12687, 15897
|
291, 1029
|
17122, 17131
|
2078, 2078
|
19638, 21104
|
16028, 16918
|
10475, 10717
|
17059, 17101
|
15923, 16005
|
17155, 19041
|
19067, 19615
|
1572, 1572
|
2568, 3197
|
221, 253
|
10746, 12664
|
1057, 1557
|
2092, 2554
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,861
| 124,527
|
25136
|
Discharge summary
|
report
|
Admission Date: [**2159-9-6**] Discharge Date: [**2159-9-9**]
Date of Birth: [**2121-12-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Transfer from OSH with pericardial effusion
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
Mr. [**Known lastname 16791**] is a 37 year old man who works for the government in
the middle east who returned from abroad 3 days PTA with malaise
and fevers to 102 after a long flight. He had decreased
appetite and drank gatorade only for 2 days. He denies nausea,
vomiting, chest pain, SOB at that time. He self medicated with
Amoxicillin and Penicillin at home (unknown quantities). The
fevers persisted and today he became short of breath with
substernal burning and diaphoresis and went to [**Hospital **] hospital
ED. At the OSH, per patient's wife EKG was concerning for
pericaridal effusion and CXR and Echo were done which revealed
pericardial effusion. At OSH, BP 129/92 P 127 T 97.7 RR 18 O2
Sats 97%. He was transferred immediately to [**Hospital1 18**] for further
evaluation and pericardiocentesis. In the cath lab,
equalization of diastolic pressures across [**Doctor Last Name 1754**] and in the
pericardium. Approx. 700cc fluid was drained and RA pressure
came down to 10 and Pericardial pressure to 3. Echo in the lab
revealed trace residual fluid. Pt is frequently screened for TB
and was last screened one month ago and was negative. Denies
night sweats. Does note weight loss of 8 pounds but states that
he frequently fluctuates in terms of weight. No dysuria, no
change in bowel habits, no hematuria, no CP. Pt has a rash on
his chest and groin s/p shaving for images today. No myalgias
or arthralgias. No MS changes noted by pt's wife.
Past Medical History:
MVP with murmur
Stab wound to groin with recent I and D
Car accident [**3-10**]- broke pelvis, s/p Ptx, s/p splenectomy,
shattered rib
Helicopter crash [**2142**] L and R ribs frx and Fractured sternum
Social History:
Lives with wife
Occasional (social) drinker
Smokes [**1-7**] PPD x 3 years
Works for the government in security
Family History:
"[**Last Name 3495**] problem"
Father had kidney ca
Physical Exam:
Vitals 98.7 120/72 110 16 96% O2 RA
HEENT: MMM, PERRLA, EOMI, no pharyngeal exudates, No LAD
CV: RRR No M,R,G s1, s2; No Pulses (8mm Hg); No JVD; No carotid
bruit; 2+ pulses in DP, PT, Radial, Carotid
Lung: Bronchial breath sounds RLL, otherwise CTA B
Abd: Soft, NT, ND, BSNA, No Masses, Midline scar, No HSM
Ext: No C/C/E; L groin site looks good s/p sheath pull. No
hematoma or ecchymosis present. No bruit. R flank wound with
sutures in place; not red, warm, swollen or painful.
Neuro: A and O x 3; CN II-XII intact
Pertinent Results:
[**2159-9-6**] 06:40PM ALBUMIN-3.2*
[**2159-9-6**] 04:45PM OTHER BODY FLUID TOT PROT-5.8 GLUCOSE-80
LD(LDH)-722 AMYLASE-26 ALBUMIN-3.3
[**2159-9-6**] 05:10PM LACTATE-2.5*
[**2159-9-6**] 05:35PM ANISOCYT-1+ MACROCYT-2+
[**2159-9-6**] 05:35PM NEUTS-86.3* LYMPHS-9.2* MONOS-4.3 EOS-0.1
BASOS-0.2
[**2159-9-6**] 05:35PM WBC-26.4* RBC-5.08 HGB-16.7 HCT-50.2 MCV-99*
MCH-32.9* MCHC-33.3 RDW-17.3*
[**2159-9-6**] 05:35PM GLUCOSE-85 UREA N-20 CREAT-1.1 SODIUM-135
POTASSIUM-5.2* CHLORIDE-100 TOTAL CO2-19* ANION GAP-21*
[**2159-9-6**] 06:40PM PT-13.8* PTT-28.1 INR(PT)-1.3
[**2159-9-6**] 06:40PM PLT COUNT-431
[**2159-9-6**] 06:40PM ANISOCYT-1+ MACROCYT-2+
[**2159-9-6**] 06:40PM NEUTS-87.0* LYMPHS-8.2* MONOS-4.4 EOS-0.2
BASOS-0.2
[**2159-9-6**] 06:40PM WBC-26.0* RBC-4.61 HGB-15.2 HCT-45.1 MCV-98
MCH-33.1* MCHC-33.8 RDW-17.4*
[**2159-9-6**] 06:40PM ALBUMIN-3.2*
[**2159-9-6**] 06:40PM ALT(SGPT)-150* AST(SGOT)-34 ALK PHOS-69
AMYLASE-32 TOT BILI-1.2 DIR BILI-0.6* INDIR BIL-0.6
[**2159-9-6**] 06:40PM GLUCOSE-119* UREA N-19 CREAT-1.0 SODIUM-135
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17
Brief Hospital Course:
Mr. [**Known lastname 16791**] is a 37 year old man who comes from OSH with Echo
findings consistent with pericardial effusion and tamponade who
underwent fluoro guided pericardiocentesis on [**9-7**] in the cath
lab.
.
1) Pericardial Effusion. Pt. was febrile on admission x 3 days
with SOB and symptoms consistent pericardial effusion.
Hemodynamics in the lab were consistent with tamponade (700cc
fluid tapped during pericardiocentesis). A pigtail catheter was
placed which drained 200cc of fluid and was removed on day 2
when no further fluid was draining. We sent pericardial fluid
for cultures. Gram stain negative from pericardial fluid but
culture was positive for coag negative staph (which we feel was
a likely contaminant). We sent pericardial fluid for [**Doctor First Name **] and RF
which were negative. AFB smear was negative and acid fast
culture was still pending at time of discharge. Urine protein
levels were not consistent with nephrotic syndrome. TSH was
within normal range. CXR revealed an area of consolidation
consistent with a pneumonia. In addition, the recent stab wound
to his flank presented a likely nidus of bacterial infection.
The patient was treated with IV Ceftriaxone and PO Azithromycin
for broad spectrum coverage of a presumed bacterial pneumonia.
Upon discharge, this was changed to PO Cefepoxime for a total of
a two week course and PO Azithromycin was continued for a total
of 5 days. ID was consulted re: the pericarditis and felt that
this could be pneumococcal in origin (esp. since he is s/p
splenectomy), and given the fact that he self medicated for
several days, this could explain cultures being negative from
the day of admission. Repeat echo showed small residual
effusion in the pericardium.
.
2) Fevers and malaise. Pt was febrile to 102 on day 2 of this
admission. This was presumed to be from a community acquired
pneumonia. Antibiotics as described above were administered.
Pt was afebrile for 24 hours prior to discharge.
.
3) Disposition. Pt requested to be discharged home instead of
extended in-hospital observation with continuation of IV
antibiotics because he is scheduled to return to the Middle East
in one week's time. The risks of discontinuing hospital care
were discussed and understood by the patient and his wife at the
time of discharge. He was also given a prescription for
levofloxacin to bring with him on his travels to take
prophylactically should he become febrile as a bridge to
immediate treatment by a physician.
Medications on Admission:
None
Discharge Medications:
1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 days: take until [**9-11**].
Disp:*2 Capsule(s)* Refills:*0*
2. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
every twelve (12) hours for 10 days: please take all doses thru
[**9-19**].
Disp:*20 Tablet(s)* Refills:*0*
3. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day as
needed for fevers: to start only if develop new fevers after
completion of abx and while arranging for md evaluation.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pericardial effusion/tamponade s/p pericardiocentesis
fevers now resolved
Discharge Condition:
fair
Discharge Instructions:
please [**Name8 (MD) 138**] MD or return to ED for development of fevers,
chills, chest pain, shortness of breath, severe cough or
abdominal pain.
please be sure to complete antibiotics as previously directed
please be sure to seek immediate medical attention if develop
new fevers and be sure to take levaquin while arranging for md
evaluation
Followup Instructions:
please call Echo lab at [**Telephone/Fax (1) 3312**] to arrange for f/u
echocardiogram to assess pericardial effusion in several days.
Order has been placed and they should contact you for this date
via [**Name (NI) 636**] [**Known lastname 63034**] cell phone.
|
[
"481",
"486",
"V45.79",
"423.9",
"420.99"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
7141, 7147
|
4017, 6536
|
359, 379
|
7265, 7272
|
2871, 3994
|
7666, 7930
|
2256, 2310
|
6591, 7118
|
7168, 7244
|
6562, 6568
|
7296, 7643
|
2325, 2852
|
276, 321
|
407, 1886
|
1908, 2111
|
2127, 2240
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,401
| 184,326
|
32152
|
Discharge summary
|
report
|
Admission Date: [**2197-10-31**] Discharge Date: [**2197-11-4**]
Date of Birth: [**2121-10-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
AVR (tissue), CABG X 2
Pertinent Results:
[**2197-11-3**] 06:50PM BLOOD Hct-22.2*
[**2197-10-31**] 04:57PM BLOOD PT-14.1* PTT-36.8* INR(PT)-1.3*
[**2197-11-3**] 06:20AM BLOOD UreaN-25* Creat-1.2* K-4.3
Brief Hospital Course:
Admitted on the day of surgery, taken to the OR for AVR (tissue)
and CABG X 2 on [**2197-10-31**]. Please see operative report for
details 2of procedure. Post-op, she was taken to the CVICU,
weaned from mechanical ventilation, and subsequently extubated.
She was transferred to the telemetry floor, her epicardial
pacing wires were removed, and she was started on Lasix &
Lopressor. Her hematocrit was 22.5, so she was transfused 1
Unit of PRBC's on POD # 3. She remains somewhat fluid
overloaded, and is diuresing. She has remained hemodynamically
stable, and is ready to be discharged to rehab.
Medications on Admission:
Lisinopril 40'
Lasix 20'
Norvasc 5'
Zocor 20'
KCl 10'
Levoxyl 150'
Prozac 20'
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days: then re-evaluate need for continued
diuresis.
14. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
AS
CAD
HTN
hypothyroidism
Discharge Condition:
good
Discharge Instructions:
shower daily, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no driving for 1 month
no lifting > 10# for 10 weeks
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (Prefixes) **] in 4 weeks
with Dr. [**Last Name (STitle) 27267**] in [**2-25**] weeks
with cardiologist in [**2-25**] weeks
Completed by:[**2197-11-4**]
|
[
"414.01",
"401.9",
"244.9",
"V14.5",
"285.9",
"424.1",
"530.81",
"458.29",
"518.0",
"276.6",
"V70.7",
"278.00",
"V43.65",
"511.9",
"272.0",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"35.21",
"89.68",
"39.61",
"99.04",
"89.64",
"39.64",
"36.11",
"36.15",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
2644, 2725
|
509, 1113
|
281, 306
|
2795, 2802
|
325, 486
|
1242, 2621
|
2746, 2774
|
1139, 1219
|
2826, 2977
|
3028, 3205
|
238, 243
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,906
| 158,468
|
1372
|
Discharge summary
|
report
|
Admission Date: [**2118-11-28**] Discharge Date: [**2118-12-2**]
Date of Birth: [**2052-7-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fosamax
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dizziness/palpitations
Major Surgical or Invasive Procedure:
[**2118-11-28**] Aortic valve replacement (21 mm Pericardial)
History of Present Illness:
Ms. [**Known lastname 8320**] is a 66 year old woman with multiple episodes of
palpitations occurring over the last few years. Her episodes are
characterized by a sudden onset of dizziness followed by
palpitations that are regular in nature. She has had no heart
monitoring studies showing any arrythmias. As part of her
work-up she underwent an echocardiogram which revealed severe
Aortic Stenosis with probable bicuspid valve. Therefore, she was
referred for surgical evaluation.
Past Medical History:
Aortic stenosis/Bicuspid AV
Hashimoto's thyroiditis
Irritable bowel syndrome
Hypertension
Dyslipidemia
Ocular migraines
Small joint osteoarthritis
Left Breast lumpectomy
Multiple D&C's
Dialation of Urethral stricture
Tonsillectomy
Social History:
Ms. [**Known lastname 8320**] lives with her husband and is retired. She quit
smoking years ago and drinks one alcoholic beverage per month.
Family History:
Non-contributory
Physical Exam:
Pulse: 83 Resp: 18 O2 sat: 100%
B/P Right: 136/79 Left: 141/88
Height: 4'[**18**]" Weight: 115 lbs
General: Well-developed female in no acute distress
Skin: Warm[X] Dry [X] intact [X]
HEENT: NCAT[X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 3/6 systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema -
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 8321**] (Complete)
Done [**2118-11-28**] at 10:28:58 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-7-20**]
Age (years): 66 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic valve disease. Chest pain.
Hypertension. Shortness of breath.
ICD-9 Codes: 786.05, 786.51, 424.1
Test Information
Date/Time: [**2118-11-28**] at 10:28 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW33-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aortic Valve - Peak Gradient: *55 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 36 mm Hg
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Critical AS (area <0.8cm2). Trace AR.
MITRAL VALVE: Mild mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Trace aortic regurgitation is
seen.
6. Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. AV pacing for
inconsistent atrial capture. Well-seated bo\ioprosthetic valve
in the aortic position. No AI. Gradient now peak 15 mean 10 at
CO = 4.1 L/min. Aortic contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2118-11-28**] 10:43
[**2118-12-2**] 04:20AM BLOOD WBC-9.8 RBC-3.73* Hgb-9.6* Hct-28.8*
MCV-77* MCH-25.8* MCHC-33.4 RDW-18.2* Plt Ct-155
[**2118-12-2**] 04:20AM BLOOD PT-13.5* INR(PT)-1.2*
[**2118-12-2**] 04:20AM BLOOD Glucose-106* UreaN-16 Creat-0.7 Na-138
K-4.5 Cl-101 HCO3-32 AnGap-10
Brief Hospital Course:
On [**2118-11-28**] [**Known firstname 553**] [**Known lastname 8320**] underwent an Aortic valve replacement
with a 21-mm [**Doctor Last Name **]
Magna Ease aortic valve bioprosthesis. The valve data is the
following: Model number 3300TFX, serial number [**Serial Number 8322**]. Please
see the operative note for details. She tolerated the procedure
well and was transferred in critical but stable condition to the
surgical intensive care unit. She was extubated and transferred
to the step down floor by the following day. As she complained
of hoarseness post-operatively, she was seen in consultation by
the ENT service. They recommended humidified air, and her
hoarseness improved. She experienced afib for which she was
placed on amiodarone and coumadin. There was no evidence of
atrial fibrillation on telemetry after the morning of [**12-1**]. By
post-operative day four she was ready for discharge to [**Hospital 8323**]. All follow-up appointments were advised. Her PCP, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was called at discharge to update him
regarding her hospital course. He should be called when she is
discharged from rehab to set up coumadin follow-up.
Medications on Admission:
Cyclobenzaprine 10 mg [**Hospital1 **]
Metoprolol 25 mg [**Hospital1 **]
Amitriptyline 10 mg daily
Simvastatin 20 mg
Synthroid 100 mcg daily
Restasis 0.05% 1gtt [**Hospital1 **]
Lomotil 2.5-0.025mg [**Hospital1 **]
Robinul 1mg [**Hospital1 **]
Lorazepam 0.5mg [**Hospital1 **] PRN
Multivitamin
Vitamin D
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. 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*
7. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg twice a day until [**12-7**] then decrease to 400mg
once a day until [**12-14**] then decrease to 200 mg daily until
follow up with cardiologist .
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. Robinul 1 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*2*
15. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
10 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
16. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: INR goal for afib [**1-19**]. first draw [**2118-12-3**]. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Post operative atrial fibrillation
Hashimoto's thyroiditis
Irritable bowel syndrome
Hypertension
Dyslipidemia
Ocular migraines
Small joint osteoarthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] [**2119-2-1**] 12:00
Cardiologist: Dr [**Last Name (STitle) **] [**2119-2-1**] 12:00
Please call to schedule appointments with your
Primary Care Dr [**First Name (STitle) **] in [**3-21**] weeks [**Telephone/Fax (1) 8324**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2.0-2.5
First draw on [**2118-12-3**]
Please set up coumadin follow-up with PCP on discharge
Completed by:[**2118-12-2**]
|
[
"564.1",
"529.6",
"997.1",
"V15.82",
"401.9",
"427.31",
"285.1",
"E878.1",
"715.98",
"272.4",
"529.1",
"346.80",
"424.1",
"784.42",
"746.4",
"V58.61",
"245.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9708, 9755
|
6254, 7500
|
332, 396
|
9977, 10147
|
2090, 4697
|
11071, 11775
|
1338, 1356
|
7855, 9685
|
9776, 9956
|
7526, 7832
|
10171, 11048
|
4746, 6231
|
1371, 2071
|
269, 294
|
424, 908
|
930, 1163
|
1179, 1322
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,934
| 194,386
|
51851
|
Discharge summary
|
report
|
Admission Date: [**2101-3-11**] Discharge Date: [**2101-3-28**]
Date of Birth: [**2018-1-12**] Sex: F
Service: SURGERY
Allergies:
Nitrofurantoin / Amoxicillin / clarithromycin / Sulfisoxazole /
Gluten
Attending:[**First Name3 (LF) 19859**]
Chief Complaint:
Weight loss, found to have small bowel lymphoma
Intra-abdominal abscess
Major Surgical or Invasive Procedure:
1. Small-bowel resection & anastomosis.
2. Sigmoid [**First Name3 (LF) 499**] resection & anastomosis.
3. TAP Block
4. Exploratory laparotomy.
5. Duodenojejunostomy.
6. Doudenal exclusion
7. Placement of intra-abdominal drains.
History of Present Illness:
The patient presented to her oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**], on
her routine follow up with significant amount of weight loss.
She underwent staging scans which demonstrated a large mass
involving the fourth part of the duodenum, possibly the first
part of the jejunum with some necrotic areas and air within
them; in addition, a second small bowel mass involving the small
bowel. Given the location of the retroperitoneal tumor as well
as the necrotic nature of the tumor, decision was made to
proceed with surgical resection if possible as endoscopic biopsy
would not provide adequate diagnosis.
Past Medical History:
PMH:
- Hypercholesterolemia
- Parkinson's disease
- Celiac sprue
- Diaphragmatic hernia
- Osteoporosis
- Esophageal web
- Hypothyroid
- Polyarthropathy
- lower extremity neuropathy
PSH:
- total abdominal hysterectomy
- tonsillectomy
Social History:
- No tobacco
- Rare EtOH
- Widow w/ 7 children, 2 deceased, lives in senior housing.
Family History:
Parents died of noncancer causes. A brother had [**Name2 (NI) 499**] cancer
and lung cancer, but died of COPD. One of her daughters had
breast cancer.
Physical Exam:
Discharge Exam: Absence of heart sounds, absence of spontaneous
respiration, absence of pupillary reflexes.
Pertinent Results:
Pathology:
SPECIMEN #1: PART 1 (A-L) SMALL BOWEL MASS, EXCISION.
DIAGNOSIS:
EXTENSIVE INVOLVEMENT BY HIGH GRADE T-CELL LYMPHOMA, BEST
CLASSIFIED AS ENTEROPATHY-TYPE T-CELL LYMPHOMA TYPE I (ETCL-I),
WITH PLEOMORPHIC/ANAPLASTIC FEATURES. SEE NOTE UNDER SPECIMEN #2
BELOW.
Microscopic description: Sections show a lymphoma infiltrating
the small intestinal wall, from mucosa to serosa. The lymphoma
is composed of a pleomorphic population of medium to large-sized
cells with hyperchromatic nuclei with variable shapes (round,
doughnut-like, indented forms, etc), and moderate amount of
eosinophilic cytoplasm. Frequent apoptotic bodies and atypical
mitoses are seen. The tumor extends towards the serosa and is
also present in the deep lymphatics. Areas of confluent
??????geographic?????? necrosis are present. In some sections the tumor
extends into the mucosa, where ulceration and granulation tissue
is present. The radial margin ??????stapled margin #1?????? is involved
by tumor, while the radial margin labeled ??????stapled margin #2?????? is
free of tumor. A piece of fibro fatty tissue containing lymph
nodes, which is attached to one radial margin shows lymphoma
cells within the lymph nodes sinuses. Within the ??????stapled
margin #1?????? the bowel mucosa is unremarkable, but the lymphatic
are studded with lymphoma cells. In sections labeled ??????tumor with
adjacent normal bowel?????? and shows small bowel mucosa and
submucosa with extensive involvement by tumor. The tumor is
present in the lymphatics. Lymphoma infiltrates the subcapsular
and medullary sinuses of lymph nodes present in the attached
mesentery.
SPECIMEN #2: PART 2 (M-T) SIGMOID [**Name2 (NI) **], EXCISION.
DIAGNOSIS:
EXTENSIVE INVOLVEMENT BY HIGH GRADE T-CELL LYMPHOMA, BEST
CLASSIFIED AS ENTEROPATHY-TYPE T-CELL LYMPHOMA TYPE I (ETCL-I),
WITH PLEOMORPHIC/ANAPLASTIC FEATURES.
Brief Hospital Course:
During her elective small bowel resection for lymphoma, the
patient was found to have a large retroperitoneal mass
approximately 15 cm in diameter lying over the aorta, IVC in the
retroperitoneum, deep to fourth part of the duodenum, and
pushing into the fourth part of duodenum anteriorly. The
inferior most aspect of this mass was adherent to a mobile part
of sigmoid [**Name2 (NI) 499**] which had perforated into tumor and there were
some necrotic parts to the tumor present. In addition, in the
mid small bowel, she had a large small bowel mass which was
occluding the small bowel lumen. There were multiple large
lymph nodes on the small bowel mesentry. There were no
additional lymphoid deposits in the peritoneal cavity on the
liver, gallbladder, remaining [**Name2 (NI) 499**].
On POD [**2-6**], she had increasing abdominal distension, pain, and
discomfort in the left upper abdomen. On POD 5, a CT
demonstrated a collection of fluid and air concerning for an
abscess and the patient underwent laparotomy. She was found to
have bilious fluid in left side of her abdomen and a small
amount on right side of abdomen. There was bilious fluid
leaking through an opening of retroperitoneal lymphoma through
which the sigmoid [**Month/Day (3) 499**] had perforated. In addition,
examination of small-bowel anastomosis, gastrojejunostomy, and
sigmoid anastomosis did not demonstrate any leak. There was no
intra-abdominal abscess present, though there was a collection
of bilious fluid in upper left paracolic gutter along anterior
abdominal wall. She was transfered to the SICU postoperatively.
She had two drains in place: One in the excluded duodenal
segment and one intraperitoneally. Please see separate op
reports for more specifics.
In the SICU she continued to have increasing pain and her NGT
continued putting out copious fluid. She never had any recovery
of bowel function, not passing any flatus or having any BM's.
Her prognosis was discussed with her and her family thoroughly
and frequently. On POD [**9-9**], palliative care was consulted for
goals of care planning and symptom management. The patient
clearly stated that she did not want any more life prolonging
measures at that time. On HD 15 her TF were stopped. On HD 16
the patients IVF was stopped at the recommendation of paliative
care. The patient was started on a morphine drip at 1 mg/hr and
this was slowly titrated up to 10 mg/hr on HD 18.
On the morning of HD 18, at 10:15 am the patient passed away.
She had no active respirations, no heart sounds and no pupillary
reflexes. The family was informed that she had passed. The
family was offered, and declined autopsy. The [**Location (un) 511**] Organ
Bank was called at the family's request and the bank declined
any tissue due to the patient's cancer. The medical examiner
was contact[**Name (NI) **] who declined autopsy.
Medications on Admission:
Carbidopa/Levodopa (SINEMET) 25/100mg TID, Carbidopa (LODOSYN)
25mg qAM, Rasagiline 0.5mg qAM, Gabapentin 600mg [**Name (NI) 5910**] (per pt),
[**Name (NI) **] 81mg daily, omeprazole 20mg qAM, levothyroxine 88mcg daily,
simvastatin 20mg daily, hydroxychloroquine 400mg daily, calcium
carbonate & MVI
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
T-Cell Lymphoma
Death
Discharge Condition:
N/a
Discharge Instructions:
None
Followup Instructions:
None
|
[
"567.22",
"332.0",
"E878.6",
"557.0",
"790.7",
"041.04",
"355.8",
"997.49",
"560.9",
"560.1",
"244.9",
"569.83",
"579.0",
"272.0",
"276.52",
"202.10",
"733.00",
"415.11",
"V66.7",
"453.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.6",
"45.62",
"45.76",
"45.91",
"54.12",
"44.39",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
7152, 7161
|
3888, 6773
|
403, 633
|
7226, 7231
|
1991, 3865
|
7284, 7291
|
1693, 1848
|
7123, 7129
|
7182, 7205
|
6799, 7100
|
7255, 7261
|
1863, 1863
|
1879, 1972
|
292, 365
|
661, 1316
|
1338, 1574
|
1590, 1677
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,152
| 162,791
|
42896
|
Discharge summary
|
report
|
Admission Date: [**2185-1-11**] Discharge Date: [**2185-1-21**]
Date of Birth: [**2122-12-5**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
shortness of breath, failure to thrive
Major Surgical or Invasive Procedure:
thoracentesis [**2185-1-11**]
History of Present Illness:
Mrs [**Known lastname **] is a 62 year-old woman transfered from pulmonary
clinic with complaint of SOB and failure to thrive at home. She
presented to [**Hospital3 635**] ED 2 weeks ago and remained inpatient from
[**Date range (1) 92600**]. This admission identified a left pleural effusion
and left hilar mass that underwent CT guided biopsy to reveal
small cell lung cancer. She received XRT [**1-3**] and chemotherapy
on [**12-31**] and [**1-6**]. She was evaluated by the [**Hospital 18**] [**Hospital **]
clinic for SOB for which she describes that she has been on 2L
of O2 since her recent discharge. In addition she complains of
anorexia and reports taking very little by mouth.
.
In the ED, initial vs were:T:100.6 HR:102 BP:115/90 RR:32
SpO2:89%. Labs in the ED were notable for K of 2.9, Cr 0.7, Cl
87, and HCO3 42. She was found to be hypoxic to the high 80s on
room air that did not sufficiently improve sufficiently on
supplemental O2 and transiently required BiPap. She underwent
thoracentesis of left pleural effusion in the ED of 1600mL
revealing protein of 2.7, LDH 93 and glucose of 101 with 560
WBCs and 185 RBCs. She received 40 mEq of K, 1g ceftriaxone and
750mg levofloxacin and was admitted to the MICU. Vitals on
transfer were T:96.9 HR:98 BP:140/66 RR:20 100% on BiPAP.
.
On arrival to the MICU the patient was alert and comfortable on
BiPAP with 100% SpO2 and was rapidly titrated to 100% SpO2 2L
NC. Patient denied additional complaints.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Pt presented to [**Hospital3 635**] ED 2 weeks ago at which point a left
pleural effusion was identified with left hilar mass. CT biopsy
revealed small cell lung CA. XRT [**1-3**] and chemotherapy on
[**12-31**] and [**1-6**]. Now hoping to transfer oncologic care to
[**Hospital1 18**].
.
PAST MEDICAL HISTORY:
Small Cell Lung Cancer diagnosed [**12-27**] at [**Hospital3 **] Hospital- s/p
XRT/Chemo
HTN
Appendectomy
Social History:
20 pack year smoker, lives with her husband.
Family History:
noncontributory.
Physical Exam:
ON ADMISSION:
Vitals - T:98.8 BP:132/72 HR:96 RR20: 02 sat:98% on 2L
GENERAL: NAD, lying comfortably on bed with nasal canula
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, anicteric sclera, pale conjunctiva, patent
nares, MMM, nontender supple neck, no LAD, no JVD. Of note pt
with anisocoria R pupil > L by 2mm
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: 5/5 strength bilaterally throughout. Sensation intact and
symmetric throughout. EOMI.
.
AT DISCHARGE:
vitals - AF Tc 98.6 104-130/60s 80s 20 99-100% 5L down to 95% on
2L
HEENT: Corner of right mouth has large mucositis sore with
erythematous base but appears to be healing
Buttocks: erythematous mildly raw area noted
exam otherwise unchanged.
Pertinent Results:
ADMISSION LABS:
[**2185-1-11**] 01:30PM BLOOD WBC-5.5 RBC-3.84* Hgb-13.1 Hct-38.2
MCV-100* MCH-34.1* MCHC-34.2 RDW-14.1 Plt Ct-167
[**2185-1-11**] 01:30PM BLOOD Neuts-86.4* Lymphs-11.7* Monos-0.7*
Eos-1.0 Baso-0.1
[**2185-1-11**] 01:30PM BLOOD PT-12.1 PTT-27.3 INR(PT)-1.1
[**2185-1-14**] 05:50AM BLOOD Gran Ct-110*
[**2185-1-11**] 01:30PM BLOOD Glucose-101* UreaN-18 Creat-0.7 Na-139
K-2.9* Cl-87* HCO3-42* AnGap-13
[**2185-1-11**] 01:30PM BLOOD Glucose-101* UreaN-18 Creat-0.7 Na-139
K-2.9* Cl-87* HCO3-42* AnGap-13
[**2185-1-11**] 01:30PM BLOOD LD(LDH)-531*
[**2185-1-11**] 01:30PM BLOOD TotProt-5.7*
[**2185-1-11**] 11:31PM BLOOD Calcium-7.9* Phos-2.6* Mg-1.0*
[**2185-1-11**] 05:03PM BLOOD Rates-/23 Tidal V-200 FiO2-40 pO2-104
pCO2-50* pH-7.52* calTCO2-42* Base XS-15 Intubat-NOT INTUBA
[**2185-1-11**] 02:53PM BLOOD K-2.9*
[**2185-1-11**] 04:04PM BLOOD Lactate-1.6
STUDIES:
[**2185-1-11**] CT chest w/o contrast
IMPRESSION:
1. Extensive central adenopathy in the left hilus and in the
mediastinum from the supraclavicular to the subcarinal stations.
Left hilar adenopathy and adjacent upper lobe lung mass combine
to severely narrow the left upper lobe bronchus, producing
severe left upper lobe atelectasis. Esophagus and superior vena
cava might be compromised by adenopathy.
2. Coarse interstitial infiltration left lower lobe, probably
combination of atelectasis and obstructed lymphatic drainage.
Pneumonia is another possibility.
3. Severe emphysema. Hyperexpansion and diminished vascularity
in the
superior segment of the right lower lobe could be due to tumor
infiltration affecting the superior segment and basal trunk
bronchi.
4. Possible large left renal and hepatic masses.
pleural fluid analysis [**1-11**]:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, histiocytes, and lymphocytes
ECG [**2185-1-11**]
Severe, profound baseline artifact. Unable to detect rhythm.
However, rhythm appears to be regular. There is a poor R wave
progression suggesting prior anteroseptal myocardial infarction.
Repeat tracing is recommended. No previous tracing available for
comparison.
CXR [**2185-1-11**]
IMPRESSION: Limited exam given no prior studies for comparison
with large
opacity obscuring the majority of the left lung which could be
secondary to effusion and consolidation. Right effusion and
basilar atelectasis with
probable background emphysema.
[**2185-1-12**] left lower extremity ultrasound:
All of the deep veins of the left lower extremity from the groin
to the
popliteal fossa show normal and full compressibility. Color flow
and pulse
Doppler waveforms were normal throughout including the posterior
tibial and peroneal veins. CFV waveforms were symmetrical
bilaterally.
CONCLUSION: Normal study. No evidence of DVT.
RELEVANT LABS FOR HOSPITAL COURSE:
CBC:
[**2185-1-14**] 05:50AM BLOOD WBC-0.6*# RBC-3.24* Hgb-11.1* Hct-32.3*
MCV-100* MCH-34.3* MCHC-34.4 RDW-13.6 Plt Ct-66*
[**2185-1-19**] 06:00AM BLOOD WBC-1.6*# RBC-2.88* Hgb-9.8* Hct-28.8*
MCV-100* MCH-34.0* MCHC-34.1 RDW-13.5 Plt Ct-90*
[**2185-1-21**] 06:56AM BLOOD WBC-11.3*# RBC-3.03* Hgb-10.2* Hct-29.6*
MCV-98 MCH-33.8* MCHC-34.6 RDW-13.6 Plt Ct-124*
DIFFERENTIALS:
[**2185-1-13**] 05:15AM BLOOD Neuts-40.5* Lymphs-53.0* Monos-3.4
Eos-2.4 Baso-0.7
[**2185-1-15**] 06:20AM BLOOD Neuts-11.0* Bands-0 Lymphs-85.0*
Monos-2.0 Eos-1.3 Baso-0.8
ANC:
[**2185-1-16**] 06:15AM BLOOD Gran Ct-50*
[**2185-1-18**] 06:15AM BLOOD Gran Ct-50*
[**2185-1-20**] 06:45AM BLOOD Gran Ct-4290
[**2185-1-21**] 06:56AM BLOOD Gran Ct-8470*
CHEMISTRY:
[**2185-1-20**] 06:45AM BLOOD Glucose-91 UreaN-14 Creat-0.7 Na-136
K-3.2* Cl-96 HCO3-34* AnGap-9
[**2185-1-21**] 06:56AM BLOOD Glucose-84 UreaN-11 Creat-0.8 Na-135
K-3.4 Cl-93* HCO3-36* AnGap-9
Brief Hospital Course:
62 y/o F with recent dx of SCLC presenting [**1-11**] with SOB/FTT,
MICU stay for hypoxia requiring bipap resolved with
thoracentesis. Transferred to OMED for onc management, now with
neutropenia.
#Respiratory distress - On admission pt found to be hypoxic in
high 80s on RA, found with left pleural effusion in the setting
of recent diagnosis of small cell lung cancer, see below. Pt
required temporary MICU stay for BIPAP but was quickly weaned
and satting well on 2-3L NC. Received thoracentesis the evening
of admission with improvement in respiratory status.
Cefepime/cipro/vanc started for CAP, but stopped [**1-12**] and the pt
was afebrile since. IP planned pleurex placement for [**2185-1-14**] and
pt was transferred to OMED. At this point s/p chemotherapy pt's
counts began to nadir and her platelets were 28 so the pleurex
placement was deferred. In addition her respiratory status
remained stable with O2 sats in mid-90s on 2-3L which is her
baseline at home. Her lung exam had improved and the pleurex
placement was deferred. It was never placed as she continued to
maintain good oxygenation on 2L NC.
.
# Small cell lung cancer - 20 pack year smoker now with recent
diagnosis of SCLC. Pt diagnosed [**2184-12-27**] at [**Hospital3 **] hospital,
thought to have pneumonia originally. Pt received 1 session of
radiation therapy on [**2185-1-3**] and carboplatin/etoposide
[**2185-01-05**], [**2185-1-6**], and [**2185-1-7**]. Pt decided she would get her
chemotherapy and oncology treatment at Cape Code Hospital as she
lives more than 2 hours from [**Hospital1 **] and the commute would be too
difficult. Pt will need CT scans for staging.
.
# neutropenia - pt s/p carpoplatin etoposide last dose [**2185-1-7**]
at [**Hospital3 **] hospital. Counts nadired while on the OMED service.
ANC was 50 from [**2185-1-16**]- [**2185-1-18**]. Pt was started on cefepime
as there had been concern for post-obstructive pneumonia in the
MICU and now severely neutropenic with a distant and prolonged
nadir. Pt was started on neupogen [**2185-1-18**]. ANC up to 4290 on
[**2185-1-20**] and on [**1-21**] day of discharge were >8,000. Cefepime
#Anorexia - Pt had c/o dysphagia, yeast found in sputum likely
thrush and she was started on fluc for oral candidiasis. Snet
out on 10 day course of fluc. Tried megace to stimulate
appetite, sent pt home with marinol as pt is extremely
cachectic.
#mucositis - in setting neutropenia pt developed severe
mucositis and extremely decreased PO intake, see anorexia above.
Developed on large granulating sore on right corner of mouth
requiring oxycodone prn. Pt was given lidocaine mouthwash,
caphasol, and started on course of acyclovir given herpetic
appearance of lesion. Pt also continued on fluconazole for 10
day course.
.
#hypokalemic metabolic alkalosis - c/f ATCH release from
neoplasm as this is the 2nd most common syndrome in SCLC after
SIADH. However in the setting of diuretics (pt on HCTZ) it was
difficult to asses. Pt also thought to have contraction
alkalosis from dehydration. Electrolytes were monitored and
repleted prn.
.
#dysphagia/anorexia - pt p/w complaints of dysphagia/FTT.
[**Female First Name (un) 564**] on sputum culture and thought to be candidal
esophagitis.
- continue fluconazole (D#1 [**2185-1-11**] for 7-14d course pending
symptom relief)
- consider megace or remeron if anorexia persists
.
#insomnia - continue outpatient trazodone, Increased it to
25-50mg prn insomnia.
.
#. HTN - Continued HCTZ inpatient. Atenolol was switched to
metoprolol.
.
Pt was maintained as FULL code throughout this hospitalization.
Medications on Admission:
HOME MEDICATIONS:
-Atenolol 100mg daily
-HCTZ 25mg daily
-Tramadol 50mg TID
-Trazodone 25 daily
-Lorazepam 1mg daily
-Allopurinol 300mg daily
-Protonix 40mg daily
-Prochlorperazine 10mg TID:PRN
.
DISCHARGE MEDS FROM CCH [**2185-1-1**]:
- Albuterol Nebulizer
- Levaquin 750mg daily for 4 days
- Nicotine Patch
- Oxygen 2 liters around the clock
- Protonix 40mg daily
- Senokot 2 tabs HS
- Trazodone 25mg daily prn
- Atenolol 100mg daily
- Ultram 25mg q6h prn
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation QID:PRN as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO TID:prn.
4. trazodone 50 mg Tablet Sig: 0.5 to 1 Tablet PO qhs:prn.
Disp:*30 Tablet(s)* Refills:*0*
5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for nausea or anxiety.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
8. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. saliva substitution combo no.2 Solution Sig: Thirty (30)
ML Mucous membrane QID (4 times a day) as needed for mouth
soreness/throatpain/mouth dryness.
Disp:*800 ML(s)* Refills:*0*
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 5 days: DO NOT DRIVE WHILE TAKING
THIS MEDICATION. IT IS VERY SEDATING.
Disp:*30 Tablet(s)* Refills:*0*
12. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
13. lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for sore throat.
Disp:*60 ML(s)* Refills:*0*
14. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
17. potassium chloride 20 mEq Packet Sig: One (1) PO once a
day.
Disp:*30 packets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Medical Supply
Discharge Diagnosis:
PRIMARY
pleural effusions
small cell lung cancer
Mucositis
Neutropenia
SECONDARY:
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
hospitalization. You were admitted with shortness of breath and
low oxygen, and found to have fluid in your lungs. This fluid
was drained, and you went to the ICU to have some breathing
support for a short period of time. You were able to maintain
normal blood oxygen levels with just a nasal cannula and you
were transferred out of the ICU onto the floor. We had planned
to place a catheter in the lungs to drain fluid continuously,
however your breathing was stable and your lungs sounded
relatively clear. The idea was that the chemotherapy would
shrink the tumor if we gave it 1-2 weeks to work, and this would
mean placing a tube would not be necessary. Your breathing
status remained stable and improved. As is to be expected after
receiving chemotherapy, your white blood cell counts dropped
very low. We kept you in the hospital to monitor you while these
cells recovered. We also gave you a very strong antibiotic to
cover for any possible infections. Your counts recovered and we
felt it was fine for you to go home. Your oxygen levels were
stable. We are sending you home with a medication called marinol
that stimulates appetite, as it is very important that you get
nutrition.
We made the following CHANGES to your medications:
STOPPED your atenolol, instead we STARTED metoprolol for blood
pressure (take metoprolol, do not take atenolol)
STARTED albuterol inhaler for wheezing or shortness of breath
INCREASED your trazodone for sleep from 25mg nightly to 25-50mg
nightly (in other words take one half or one whole pill
depending on how much you need)
STARTED oxycodone for pain
STARTED caphasol for mouth dryness
STARTED tylenol as needed for pain
STARTED dronabinol for appetite
STARTED lidocaine mouthwash for sore throat
STARTED fluconazole (take for 5 more days)
STARTED potassium supplements
STARTED oxycodone for pain related to mouth sore
STARTED senna and docusate, two medications for constipation
Followup Instructions:
you will follow up with your oncologist at [**Hospital3 635**] hospital to
continue with treatment. Please call to schedule an appointment
for next week.
You can call Dr.[**Name (NI) 3279**] office at ([**Telephone/Fax (1) 3280**] to schedule
an appointment to see him in clinic at [**Hospital1 18**] if you wish.
|
[
"288.03",
"492.8",
"V15.82",
"518.81",
"287.49",
"707.20",
"276.8",
"162.8",
"276.3",
"401.9",
"780.52",
"528.00",
"E933.1",
"707.03",
"511.9",
"799.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13284, 13345
|
7183, 10777
|
343, 374
|
13485, 13485
|
3433, 3433
|
15640, 15959
|
2415, 2433
|
11286, 13261
|
13366, 13464
|
10803, 10803
|
6230, 7160
|
13636, 14905
|
2448, 2448
|
10821, 11263
|
3171, 3414
|
14934, 15617
|
265, 305
|
402, 1871
|
3449, 6213
|
2462, 3157
|
13500, 13612
|
2230, 2337
|
2353, 2399
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,362
| 149,170
|
42305
|
Discharge summary
|
report
|
Admission Date: [**2148-3-2**] Discharge Date: [**2148-3-7**]
Date of Birth: [**2071-1-29**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
SOB, stridor
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76F with metastatic NSCLC s/p XRT plus pemetrexed x 1 as a
radiation sensitizing [**Doctor Last Name 360**] with known brain mets now presenting
with N/V/D, and b/l lower abdominal pain x 1 day. Pt says she
woke at 3am and vomited a large amount x 1, mostly stomach
contents. She describes her abdominal pain as dull,
intermittent, and radiating bilaterally across the lower abdomen
and pelvis with moderate amount of diarrhea x 1 day. She also
notes mildly increased SOB x 2 days, though she is dyspneic at
baseline and says that her SOB waxes and wanes. Per family, she
was recently undergoing dexamethasone taper and her symptoms
correlated with this. She also describes severe pain coming
from her right shoulder and lateral neck where she has had
ongoing lymph node inflammation x several months.
.
Upon arrival to the ED, she reportedly looked initially well.
With stable vitals and 93% on RA. There was no stridor or
wheezes noted on her exam. Initial labs showed a WBC of 17
(within recent baseline). CXR unchanged. She received a CTA
given concern for PE for which was negative. Head CT was
unchanged. Initial VBG showed 7.44/28/95. UA showed small
leuks and 7 WBCs so given a dose of cipro. EKG was done given
her SOB which showed new infero/lateral ST depressions and TWI
in V1-V3, but no chest pain. She also received 6U insulin for
BG of 411.
.
Pt received albuterol/ipatropium nebs for her SOB, and then was
noted to became stridorous with a hoarse voice (worse than
normal). She received solumederol 125mg, bendadryl 50mg,
famotidine 20mg. A/P and lateral neck XRAY obtained showing
soft tissue xray of neck shouwed some "indentation" of right
side of trachea thought [**3-14**] known enlarged lymph nodes, but no
critical stensosis. Repeat CXR showed new vascular engorgement.
.
ENT called to scope and found to have unilateral vocal cord
paralysis, but no edema (pt reports having history of this at
[**Hospital1 **]). Recommended saline nebs, monitor airway, with plan to
rescope this PM with attending. She received racemic epi x2 and
10mg IV decadron.
.
On arrival to the ICU, pt feels well and back to her baseline.
Has mild SOB now but this is c/w her status prior to
presentation. No abd pain, no n/v/d. VS are 128/72, 85, 96% 2L
Past Medical History:
Past Oncologic History:
NSCLC stage IV adenocarcinoma KRAS, EGFR, and ALK w/t
- [**10/2147**] Developed hoarseness, diagnosed w vocal cord paralysis.
CXR at that time revealed a R lung mass and hilar adenopathy
- [**2147-11-13**] EBUS biopsy of her mediastinal LNs which revealed
NSCLC adenocarcinoma CK7 + and TTF-1 + with some smaller cells
CK5/6 + and a few cells p63 +
- [**2147-11-22**] PET CT revealed an FDG-avid right upper lobe masses
with right hilar, mediastinal, and supraclavicular LAD, an
enlarged FDG-avid portocaval lymph node, and a left adrenal
nodule with low level FDG-uptake
- [**2147-12-7**] Pemetredex 500 mg/m2 as a radiation sensitizing
[**Doctor Last Name 360**], started XRT
- [**2147-12-18**] CT torso with interval progression of disease with
enlargement of all previously measured lesions. No definite new
lesions
- [**2147-12-29**] Completed 2500 cGy to the primary tumor and LNs
- [**2148-1-29**] CT torso showed mixed response with increase in size
of the right supraclavicular node but decrease in size of the
mediastinal and hilar nodes. Mild decrease in size of right
pulmonary nodule. Ill-defined thickening of the left upper lobe
lung parenchyma, ?radiation changes.
- [**2148-2-1**] Presented to clinic with acute SOB, dyspnea, fall.
Found to have new brain mets. Admitted to OMED
- [**2148-2-7**] CK to parietal and occipital mets
- PLANNED [**2148-3-7**] Carboplatin AUC 5 pemetrexed 500 mg/m2
.
Other Past Medical History:
- Vocal cord polyps
- Steatohepatitis
- Elevated LFT's
- Anxiety
- Hypertension
- DM-II
- Hypercholesterolemia
- Depression
- s/p TAHBSO for bleeding [**2123**]
- s/p tonsillectomy [**2080**]
- s/p appendectomy [**2090**]
Social History:
- Tobacco: 2ppd age 14 to age 63, around 100 pack years
- Alcohol: Social
- Illicits: Denies
- Occupation: Retired HR work
- Exposures: Denies
Family History:
- Mother: CHF
- Father: [**Name (NI) **] cancer, age 59
- Sister: Endometrial cancer, age 50
- Son: [**Name (NI) **] tumor, age 47
Physical Exam:
Admission Exam:
Vitals: 128/72, 85, 96% 2L
General: Alert, oriented, no acute distress, hoarse voice
HEENT: Sclera anicteric, MM dry, oropharynx clear. Right eyelid
droop with right pupil 3mm, and left pupil 5mm reactive to light
but slughish b/l
Neck: supple, JVP not elevated. Prominent R>L cervial and
supraclavicular lymphadenopathy. Non-tender
Lungs: basilar crackles, with mild stridor over the neck
anteriorly
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:
ADMIT LABS:
[**2148-3-2**] 08:25AM BLOOD WBC-17.4* RBC-5.80* Hgb-15.7 Hct-47.5
MCV-82 MCH-27.1 MCHC-33.1 RDW-15.8* Plt Ct-210
[**2148-3-2**] 08:25AM BLOOD Neuts-89* Bands-3 Lymphs-3* Monos-2 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2148-3-2**] 08:25AM BLOOD Glucose-411* UreaN-31* Creat-0.5 Na-133
K-4.2 Cl-99 HCO3-18* AnGap-20
[**2148-3-2**] 08:25AM BLOOD CK(CPK)-49
[**2148-3-2**] 08:25AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.5*
.
CARDIAC ENZYMES:
[**2148-3-2**] 08:25AM BLOOD cTropnT-<0.01
[**2148-3-2**] 08:15PM BLOOD CK-MB-10 MB Indx-27.0* cTropnT-<0.01
[**2148-3-3**] 05:05AM BLOOD CK-MB-9 cTropnT-<0.01
.
OTHER STUDIES:
ECG [**2148-3-2**]:
Sinus rhythm. Rightward axis. Right bundle-branch block.
Consider right
ventricular hypertrophy. Compared to the previous tracing the
findings are
generally similar.
.
CXR [**2148-3-2**]:
IMPRESSION: Low lung volumes, slightly limiting evaluation, with
no
radiographic evidence for acute process on this single view.
Lung nodules as seen previously.
.
CT HEAD [**2148-3-2**]:
1. No acute intracranial process.
2. Hypodensities in the occipital lobe are unchanged from
[**2148-2-1**], due to known metastatic lesions.
.
CTA CHEST [**2148-3-2**]:
1. No acute aortic pathology or pulmonary embolism.
2. Unchanged supraclavicular, mediastinal and hilar
lymphadenopathy, with
detailed measurements on CT torso [**2148-1-29**].
3. New pulmonary nodules bilaterally are concerning for
progression of
non-small cell lung cancer, less likely infection. Unchanged
right upper lobe spiculated mass.
4. Moderate right hydronephrosis, unchanged from the prior
study.
.
XRAY NECK SOFT TISSUES [**2148-3-2**]:
IMPRESSION: Leftward deviation of the trachea, likely secondary
to known
right neck mass without significant airway compromise.
.
CXR [**2148-3-3**]:
IMPRESSION:
1. Right hilar and mediastinal lymphadenopathy with an
associated right upper lobe opacity are known to represent the
patient's lung carcinoma. No focal airspace consolidation is
seen to suggest pneumonia. There is persistent elevation of the
right hemidiaphragm, unchanged. The left lung is hyperinflated
consistent with known underlying emphysema. Heart remains
somewhat prominent with a left ventricular configuration
suggestive of left ventricular hypertrophy. No evidence of
pulmonary edema or pneumothorax. Scattered degenerative changes
in the thoracic spine with no acute bony abnormality
appreciated.
.
PATIENT DID NOT HAVE LABS DRAWN NEAR DISCHARGE TIME AS SHE WAS
CMO.
Brief Hospital Course:
77 yof with history of NSCLC with metastases to the brain,
presenting with increasing SOB, found to have stridor in the ED
with concern for vocal cord paralysis.
# SOB/Stridor: Pt initially presenting with worsening SOB for 2
days in setting of steroid taper. Per report, stridor was not
noticed until she had been in the ED for a while. ENT scoped
and noted left vocal cord paralysis which they felt likely
explained the stridor. However, the patient reports that this
had been noted last [**Month (only) 216**] at [**Hospital3 4107**] so unclear if this
would have caused acute decline. Of note, neck XR in the ED
showed some possible tracheal indentation thought secondary to
her lymphadenopathy which could have caused the stridor and
improved with steroids. Pt also may have component of volume
overload given prominent interstitial markings on CXR, but the
remainder of her exam is consistent with hypovolemia. Given her
radiation treatment, she may have component of phrenic nerve
palsy which could explain her air hunger. Pt was treated with
Heliox, which improved her symptoms. ENT was consulted and
offered to fix her mobile cord, with the understanding that it
may improve her voice but worsen her dyspnea, which Pt refused.
Pt was also offered a trach with the explanation that this will
allow her to breathe better, allow fixation of her cord and
speak better w/ bypass valve, but patient refused. Radiation
oncology did not feel that her stridor would be improved with
further radiation. Per her outpatient oncologist, proceeding
with tracheostomy will not correct her swallowing difficulties,
and may complicate them, and Pt was expressly not interested in
a feeding tube. Palliative care was consulted, and Pt chose to
transition to comfort care on [**3-5**] after discussion with her
daughters. Pt was placed on cooling mist face mask, and given
fentanyl patches for her R shoulder pain. She also received
morphine for her pain and dyspnea. Pt was also receiving
lorazepam 1mg IV q6 for agitation and anxiety. On transfer to
the floor patient continued to have pain issues, eventually put
on morphine drip as she was CMO, continued fentanyl patch, and
ativan PRN for comfort until she passed away.
.
# Anion gap acidosis: Appeared to be DKA. Pt with known T2DM,
and hyperglycemic to 411 in ED. Her chemistry and urine
consistent with DKA (Gap of 16, 10 ketones in the urine).
Possible etiologies include recent high dose steroids, or
infection (possible UTI seen on UA). Pt was initially on an
insulin drip, which was discontinued once Pt was transitioned to
comfort care.
# NSCLC: Metastatic to the brain. Pt s/p Premetrexed x1 and
radiation. Plan per outpatient oncologist was to start
carboplatin 5AUC and pemetrexed on [**2148-3-7**]. Pt chosed to be
transitioned to comfort care on [**3-5**].
.
# EKG changes: Pt with diffuse ST depressions and TWI new from
prior EKG. Diffuse nature is more suggestive of demand ischemia
in the setting of her stressed state from her shortness of
breath. Trop negative x2.
.
# UTI: Pt with 7 WBC in urine in the setting of 3 epi's.
Received 1 dose of cipro in the ED. It is possible that a UTI
could have tipped her into DKA. UCx was negative, no further
treatment.
.
# Anxiety: Pt on ativan 0.5mg po QHS prn at home, increased to
1mg iv q6hrs PRN agitation or anxiety once Pt was transitioned
to comfort care.
.
# Htn: On atenolol as outpt, which was discontinued once Pt was
transitioned to comfort care.
.
Patient passed away on the evening of [**3-7**].
Medications on Admission:
-albuterol 90mcg inhaler 2 puffs QID prn SOB/wheeze
-Atenolol 50mg po daily
-Citalopram 20mg po daily
-Dexamethasone as directed with chemo
-Folic acid 1mg po daily
-Lorezepam 0.5 mg PO QHS PRN chemo related insomnia and severe
nausea
-Metformin 1000mg [**Hospital1 **]
-Ondansetron 8mg po TID prn nausea
-Compazine 10mg po q6h PRN nausea
-Spiriva 18mcg po daily
-albuterol nebs
-aspirin 81mg po daily
-omeprazole 20mg po daily
Discharge Medications:
None, patient deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
|
[
"787.20",
"300.00",
"272.0",
"250.12",
"V15.82",
"599.0",
"401.9",
"780.01",
"162.3",
"V66.7",
"198.3",
"787.01",
"196.1",
"518.82",
"519.19",
"411.89",
"478.31",
"789.09",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
11929, 11938
|
7867, 11403
|
315, 321
|
11997, 12014
|
5363, 5792
|
12078, 12189
|
4509, 4641
|
11881, 11906
|
11959, 11976
|
11429, 11858
|
12038, 12055
|
4656, 5344
|
5809, 7844
|
263, 277
|
349, 2623
|
4110, 4333
|
4349, 4493
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,848
| 164,890
|
43796
|
Discharge summary
|
report
|
Admission Date: [**2148-7-27**] Discharge Date: [**2148-8-1**]
Date of Birth: [**2067-12-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
CC: MICU transfer, admitted for black diarrhea
Major Surgical or Invasive Procedure:
Endoscopy: showed ulcer in duodenal bulb (no visible vessel),
antral erosions, small tear at GE junction
History of Present Illness:
HPI: Ms. [**Known lastname **] is an 80 year-old woman with history of HTN,
chronic mesenteric ischemia s/p celiac stent on [**2148-7-15**]
presenting with black diarrhea x 12 hours. For over a year, she
has had crampy abdominal pain after eating, regardless of the
content of the meal. She has lost 30 pounds since the cramping
began secondary to anorexia. She was feeling fine until the
night prior to admission when she had worse cramps and awoke the
morning of admission with dark diarrhea. She denied any
lightheadedness or dizziness, but she states that she was very
weak and pale. In the ED, a nasogastric lavage was positive for
coffee grounds (cleared with 200cc). An abdominal CT with
contrast showed a completely stenosed SMA distal to the stent
but no evidence of infarcted bowel. In the ICU, she was closely
monitored and seen by GI and [**Date Range **] surgery. An upper GI
endoscopy was performed on [**7-28**] which showed a large ulcer in the
duodenal bulb, a small tear at the GE junction, and linear
antral erosions. She received two transfusions in the ICU and is
now being transferred to the general medicine floor.
Past Medical History:
PMHx: HTN, high cholesterol
Social History:
SocHx: Patient lives at home alone and is fully functional with
her ADL's. She has a distant tobacco history (quit 30 years ago)
Family History:
FamHx: Mother died at age [**Age over 90 **] of bladder cancer, father died of
CHF/COPD. Sister s/p CABG, brother in good health.
Physical Exam:
Physical Exam:
Vitals: T 96.1-100.0, BP (96-147)/(27-57), P 52-78
Gen: Pleasant, comfortable, no acute distress. Skin warm and
pink.
HEENT: EOMI, PERRL, OP clear, anicteric
Neck: Supple, no carotid bruit, no cervical lymphadenopathy
Heart: RRR, normal S1/S2, III/VI systolic murmur heard best at
LUSB
Lungs: clear to auscultation bilaterally
Abd: soft, non-tender, non-distended, + bowel sounds
Back: No costovertebral angle tenderness, no spinal tenderness
GU: Foley in place, draining yellow urine
Ext: 2+ DP pulses bilaterally, warm, no clubbing/cyanosis/edema
Neuro: CN II-XII intact, strenth [**5-31**] bilaterally both upper and
lower extremities
Pertinent Results:
Studies:
EGD [**2148-7-28**]: small tear at GE junction. Linear antral erosions.
Large ulcer in duodenal bulb without visible vessel. Friable &
erythema & erosions in the duodenal bulb and descending
duodenum.
.
[**2148-7-27**] 01:30PM WBC-20.7*# RBC-3.49* HGB-10.5* HCT-29.7*
MCV-85 MCH-30.1 MCHC-35.4* RDW-13.9
.
[**2148-7-27**] 01:30PM ALT(SGPT)-22 AST(SGOT)-39 LD(LDH)-547* ALK
PHOS-47 AMYLASE-37 TOT BILI-0.2
.
[**2148-7-27**] 01:30PM GLUCOSE-139* UREA N-29* CREAT-0.9 SODIUM-138
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
.
[**2148-7-27**] 10:03PM HGB-10.4* calcHCT-31
Brief Hospital Course:
Ms. [**Known lastname **] is an 80 year old female with past medical history of
HTN and one year history of crampy abdominal pain, 2 weeks s/p
stented celiac, presenting with dark diarrhea, admitted for GI
bleeding to the MICU. She received two units of PRBC's
throughout her admission. She was fluid resuscitated the first
night of admission, and the next day EGD showed a small tear at
GE jxn, ulcer in duodenal bulb. Hematocrits were stable
afterward, and she was transferred to the floor. She had a
leukocytosis upon transfer to the floor, which is resolved at
the time of discharge. U/A and culture were negative, Chest
X-ray was negative.
The patient was discharged in stable condition, with stable
hematocrit and tolerating PO. She will continue to take empiric
therapy for H. Pylori (ampicillin and clarithromycin) for a 14
day course ending on [**8-13**]. She will continue to take aspirin
and plavix per [**Month/Year (2) 1106**] surgery. She has been advised to follow
up with the [**Hospital **] clinic in [**7-4**] weeks for repeat endoscopy.
Medications on Admission:
Meds:
- Diovan (held upon admission)
- Plavix 75mg po qd
- ASA
- Norvasc 5mg po qd (held at admission)
- Zocor 20mg po qd
- Levothyroxine
- Fosamax d/c'd by primary care, [**2-29**] nausea.
Discharge Medications:
Meds:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*20 Tablet(s)* Refills:*0*
6. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
Disp:*24 Tablet(s)* Refills:*0*
7. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 2 weeks.
Disp:*24 Capsule(s)* Refills:*0*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. 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*
10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed s/p stent in celiac artery, discharged on plavix and
aspirin.
Discharge Condition:
Stable. Hematocrit stable, tolerating PO, pain free.
Discharge Instructions:
Please take all of your medications as prescribed. Please
continue to take antibiotics (ampicillin, clarithromycin) for 2
weeks (last dose [**2148-8-13**]). Please also continue to take aspirin
and plavix, unless you detect melena or bleeding agian. If you
have any dark stools, uncontrollable pain, nausea, vomiting,
decreased appetite, or other concerning symptom, call your PMD
or return directly to the emergency room.
Followup Instructions:
Please follow up with your PMD Dr. [**Last Name (STitle) 2204**] within one week. In
addition, please follow up with Dr. [**Last Name (STitle) **] in 2 week.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2148-8-1**] 3:00
Please follow up with the [**Hospital **] clinic in [**7-4**] weeks for repeat
endoscopy to evaluate your duodenal ulcers.
|
[
"401.9",
"E935.3",
"041.86",
"424.1",
"272.0",
"532.40",
"557.1",
"285.1",
"535.51",
"E934.8",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"96.33"
] |
icd9pcs
|
[
[
[]
]
] |
5799, 5805
|
3285, 4346
|
361, 468
|
5920, 5975
|
2667, 3262
|
6449, 6909
|
1848, 1979
|
4586, 5776
|
5826, 5899
|
4372, 4563
|
5999, 6426
|
2009, 2648
|
275, 323
|
496, 1635
|
1657, 1686
|
1702, 1832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,063
| 116,777
|
19220
|
Discharge summary
|
report
|
Admission Date: [**2169-12-12**] Discharge Date: [**2169-12-22**]
Date of Birth: Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 55 year old
male with a history of coronary artery disease with a
myocardial infarction at age 20, also history of diabetes
mellitus, and cerebrovascular accident, who was transferred
emergently to [**Hospital1 69**]
catheterization laboratory from outside hospital. The
patient was diaphoretic the p.m. of admission, reportedly
took his medicines and went to bed. He was then found
unresponsive in bed by his family and EMS was called. He had
a prolonged code in the field by EMS and was given initially
2 mg of Atropine and 6 mg of Epinephrine and was transferred
to the outside hospital Emergency Department. At the outside
hospital Emergency Department, he was found to be in
ventricular fibrillation and given Epinephrine and followed
by defibrillation times three, followed by Lidocaine and
followed by one more defibrillation attempt, which resulted
in sinus tachycardia with a rate of 140 and systolic blood
pressure of 110/50, and fingerstick of 36. He then became
hypotensive at 53/35 and developed PEA and was given
Epinephrine times two. He was then started on Levophed and
Dopamine and transferred to [**Hospital1 188**].
At the time of transfer, cardiac catheterization revealed
ulceration of the left main artery along with a stump
occlusion of the left anterior descending and diagonal
arteries. A DS stent was placed in the left main and a
Hepacoat stent was placed in the diagonal. The left anterior
descending was noted to be totally occluded and could not be
crossed. He was then transferred to the CCU in critical
condition on multiple pressors, not responsive, with dilated
pupils.
HOSPITAL COURSE: As noted above, the patient was transferred
to the CCU in critical condition on multiple pressors
including Levophed and Dopamine. He was unresponsive with
noted dilated pupils. Neurology was consulted and
recommended apnea test, which was done and, subsequently the
day after admission, the patient was declared clinically
brain dead. There was much difficulty in maintaining his
blood pressure. On [**2169-12-22**], discussion was held with his
family concerning the severe nature of his condition. It was
decided to withdraw care and he was pronounced dead at 11:05
p.m. on [**2169-12-22**]. The family was present. Autopsy was and organ
donation were declined.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 14268**]
MEDQUIST36
D: [**2170-3-31**] 16:41
T: [**2170-4-1**] 08:27
JOB#: [**Job Number 52374**]
|
[
"785.51",
"429.9",
"410.01",
"438.20",
"276.2",
"250.00",
"276.6",
"348.8",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.47",
"88.56",
"96.71",
"88.42",
"36.05",
"37.23",
"36.06",
"36.07",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
1808, 2767
|
158, 1790
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,364
| 162,541
|
50651
|
Discharge summary
|
report
|
Admission Date: [**2122-6-17**] Discharge Date: [**2122-6-23**]
Date of Birth: [**2045-1-21**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Hayfever
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Patient is a 77M male w/ Wegener's, ESRD on HD (from
ANCA-positive GN) who presents with BRBPR and HCT down to 17
from 36.
.
Mr [**Known lastname 1005**] was admitted in [**Last Name (LF) 404**], [**First Name3 (LF) 116**] and [**Month (only) **] for
hematochezia, clearly painless in the last two episodes. In all
cases, he stopped bleeding spontaneosuly and had a HCT similar
to baseline. Colonoscopies in [**Month (only) 404**] and [**Month (only) **] showed many
diverticuli and AVMs (esp in the Cecum and ascending colon). He
also had large internal hemorrhoids, for which he was started on
steroid enemas.
.
His symptoms actually started last week when he had a few
episodes of BPBPR that self-resolved. He had no abdominal pain,
no N/V. Given that he had been worked up before and the bleed
had stopped, he did not seek any medical attention. He did well
until last night around 10pm when he had more BPRBR. He had more
episodes overnight with the last being at 5am. He had five total
episodes of BRBPR. He felt weak and dizzy.
.
Given that he was symptomatic, he presented to the [**Hospital1 18**] ED
where his Hct was found to be ~18 (baseline of 36). In the ED,
initial vs were: T- 99.2, HR-91, BP-149/59, RR-16, SaO2- 100%.
He was hemodynamically stable and did not have any further
episodes of bleeding in the ED. Had a negative NG lavage. He was
evaluated by GI and the surgery teams who recommended close
montioring of symptoms/Hct and admission to MICU. He received 1U
PRBC in the ED.
.
On arrival to the MICU, he was doing well. Denied any dizziness,
chest pain, shortness of breath, lightheadedness, abdominal
pain, nausea, vomiting, fevers or chills. His last bloody BM was
at 5AM today.
.
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.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
- Wegeners Disease
- ESRD on HD from ANCA-positive glomerulonephritis dx [**2112**]
- Gout
- Depression
- Hyperlipidemia
- Glaucoma
- h/o Septic thrombophlebitis
- h/o Cellulitis of the right upper extremity
- h/o Gastrointestinal bleed secondary to NSAID use
- h/o Diverticulitis
- s/p Left inguinal hernia repair
Social History:
Retired butcher. Denies tobacco, alcohol or illicit drug use.
Originally from [**Male First Name (un) 1056**]. Has two daughters that are very
involved in his care. Lives with his wife and two daughters.
Family History:
His mother had some form of kidney disease.
Physical Exam:
VS Afeb BP 180/100's HR 70's
gen: pleasant, NAD, alert/oriented x3
heent: MMM, no LAD
cv: regular with II/VI systolic murmur radiating to carotids
resp: lungs clear b/l, no wheezing/rales/rhonchi
abd: soft, nt, nd, nabs, no sacral edema
ext: trace to 1+ b/l pitting edema around ankles, L arm AV graft
with audible bruit.
skin: normal turgor, no visible rashes.
Pertinent Results:
Labs on Admission: [**2122-6-17**] 10:30AM
WBC-5.3 RBC-1.83*# Hgb-5.5*# Hct-16.9*# MCV-92 Plt Ct-198
PT-14.4* PTT-25.8 INR(PT)-1.2*
Glucose-171* UreaN-45* Creat-7.0* Na-143 K-4.6 Cl-104 HCO3-29
AnGap-15
Calcium-8.5 Phos-4.7* Mg-2.0
[**2122-6-19**]: Tagged RBC Scan:
No evidence for active GI bleedling.
[**2122-6-18**]: Colonoscopy
Blood in the cecum and scant blood in the terminal ileum;
Angioectasia in the cecum (thermal therapy); Grade 1 internal
hemorrhoids. Diverticulosis of the whole colon. Otherwise normal
colonoscopy to 15cm terminal ileum
Recommendations: Likely bleeding source from cecal AVM not fully
visualized given blood. Cautery performed on one visible AVM.
Diverticula did not appear to be bleeding. Repeat Endoscopy in
two weeks for assessment and cautery of angioectasias.
Discharge Labs: [**2122-6-23**] 05:17AM
WBC-6.1 RBC-2.93* Hgb-9.2* Hct-28.0* MCV-95 Plt Ct-146*
Glucose-82 UreaN-25* Creat-4.9*# Na-136 K-4.0 Cl-95* HCO3-33*
AnGap-12
Calcium-8.1* Phos-4.9* Mg-1.9
Brief Hospital Course:
#GI Bleed: Patient has history of known diverticuli, large AVM
in cecum, internal hemorhoids. Colonoscopy performed revealing
cecum AVM blood clots, likely the source of the bleed. GI
cauterized AVM at that time. The patient continued to have
bloody bm after colonoscopy and blood was transfused until HCT
stabalized and GI bleeding stopped. He was also given DDAVP in
the ICU given concern for uremic platelets worsening his bleed.
GI has recommended that the patient follow up in 2 weeks for a
repeat colonoscopy to asses AVM. General surgery has scheduled
hemorrhoidal banding as well. The patient's hematocrit was
stable for 48 hours prior to discharge on a regular diet.
#ESRD: Secondary to Wegener's disease, on HD. Continued to have
HD while inpatient on M, W, F. His medication list was
reconciled with his HD medication list prior to discharge, and
his daughter was instructed to confirm medication changes with
his HD center the day following discharge as well.
#HTN: While in the ICU the patient had HTN up to the 180s,
likely secondary to fluid overload from several units of PRBCS.
He was on valsartan as an inpatient, with systolic blood
pressures of 160. In discussion with Renal no further titration
of his blood pressure medications was pursued as they plan to
remove more fluid at HD and monitor in that setting.
#Thrombocytopenia: Patient had a transient decrease in his
platelet count, thought likely to be secondary to dilution from
multiple blood transfusions. His platelet count was increasing
at the time of discharge, and no further evaluation was pursued.
#Right hand erythema: On the day of discharge patient was noted
to have mild right hand swelling and pain at the site of a prior
IV. Swelling improved with elevation and hot packs. Area was not
concerning for infection at the time of discharge. The patient
and his daughter were told to monitor for increased pain or
erythema at that site.
Medications on Admission:
Paroxetine HCl 20 mg once daily
Simvastatin 20 mg daily
Valsartan 80 mg Tablet daily
Acetaminophen 325-650 q6h prn
Allopurinol 100 mg qod
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol q6h prn
Bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.
Bimatoprost 0.03 % Drops Ophthalmic
Calcitriol 0.25 mcg Capsule Oral
Omeprazole 20 mg Capsule [**Hospital1 **]
Mycophenolate Mofetil 500 mg [**Hospital1 **]
Sodium Bicarbonate 650 mg [**Hospital1 **]
Vitamin B-12 Oral
FerrouSul Oral
Colace Oral
Loratadine 10 mg qday prn
Percocet 5-325 mg q6h pr
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Valsartan 40 mg Tablet Sig: Two (2) 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).
9. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
AVM of Cecum
GI bleed
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with GI bleeding thought to be secondary to
hemorrhoids, an AV malformation, and diverticula. Your bleeding
stopped, and your blood counts remained stable for over 48 hours
prior to discharge while you were on a regular diet.
One of your kidney medications was increased. No other changes
were made to your home medications.
Followup Instructions:
Please call to schedule a follow-up appointment with your
primary care doctor within one week of discharge. Please report
to dialysis tomorrow, and come to the surgical clinic on Friday
for banding of your hemorrhoids.
Department: HEMODIALYSIS
When: WEDNESDAY [**2122-6-24**] at 12:00 PM
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2122-6-26**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIGESTIVE DISEASE CENTER
When: MONDAY [**2122-7-13**] at 7:30 AM
With: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **], 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) 3202**]
Campus: EAST Best Parking: Main Garage
|
[
"285.21",
"365.9",
"287.5",
"V45.11",
"276.6",
"562.10",
"272.4",
"311",
"695.9",
"585.6",
"455.0",
"582.9",
"446.4",
"285.1",
"274.9",
"584.9",
"569.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7898, 7904
|
4552, 6480
|
322, 335
|
7977, 7977
|
3530, 3535
|
8528, 9551
|
3087, 3132
|
7078, 7875
|
7925, 7956
|
6506, 7055
|
8160, 8505
|
4347, 4529
|
3147, 3511
|
2091, 2511
|
274, 284
|
363, 2072
|
3549, 4331
|
7992, 8136
|
2533, 2849
|
2865, 3071
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,835
| 162,690
|
50008
|
Discharge summary
|
report
|
Admission Date: [**2193-7-21**] Discharge Date: [**2193-7-24**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 89-year-old woman with a history of Parkinson
disease and dementia, who was recently discharged from this
institution with a diagnosis of bacterial cystitis and presents
agains with hyperglycemia. The patient has a history of labile
blood sugars and had a measured blood sugar at her nursing home
in the 700s. The patient was given her regular insulin doses
along with an extra dose of Humalog, which did not lead to
considerable improvement in her blood glucose. The patient
denied any diaphoresis, polyuria, lightheadedness, or abdominal
pain, though her account of events is unreliable due to
dementia. At the nursing home the patient's vitals were T 97.7,
HR 82, BP 100/70, RR 20, O2 97%. Labs showed creatinine of 1.5,
but an anion gap of 33.
In the ED, initial vital signs were T 97.4 HR 86 BP 144/73 RR 16
O2 sat 99%. For her hyperglycemia, the patient received insulin
10 U IV, followed by an insluin drip at 5 units per hour. The
patient was given several liters of IV fluid and had her
potassium replenished. The patient also received doses of
vancomycin and piperacillin-tazobactam for presumed UTI as
urinalysis still showed pyuria.
On the floor, the patient denied that she was experiencing any
pain. She seemed comfortable, if confused.
Past Medical History:
- Parkinson's disease
- Dementia
- Gastroesophageal reflux disease.
- History of peptic ulcer disease.
- Gastroparesis.
- Irritable bowel syndrome with constipation predominance.
- Lactose intolerance.
- Hemorrhoids.
- HTN
- Hyperlipidemia
- Hypothyroidism
- anemia (on aranesp)
- Diabetes Mellitus
- Right breast cancer in [**2170**].
- Spinal stenosis.
- Depression.
- Osteoporosis
- Urinary retention & overflow incontinence
Social History:
Lives at [**Location 10140**]. Uses a wheelchair, no longer walking.
Feeds self. Transfers to toilet on own. Prior approximate 20
pack-year smoking history but not currentl. No ETOH. Daughter
very involved in her care though lives in [**State 7080**].
Family History:
Sister with DM.
Physical Exam:
ON DISCHARGE:
96.8 141/71 74 18 99%RA
General: Inattentive, hallucinatory
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: CTAB, good air movement
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; no CVA
tenderness
Skin: sacral decubitus ulcer w/out surrounding erythema
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: Alert, oriented to person and to hospital, not oriented
to time, inattentive. Pt believes her daughter is there when,
in reality,she is not. Poor movement of lower extremities, but
can move toes. Decreased ROM of upper extremities, w/
cogwheeling / +tone.
Pertinent Results:
Admission Labs:
WBC-18.4*# RBC-3.65* Hgb-11.3* Hct-35.0* MCV-96 MCH-30.9
MCHC-32.3 RDW-14.7 Plt Ct-486*#
Neuts-92.9* Lymphs-3.9* Monos-2.6 Eos-0 Baso-0.5
PT-11.9 PTT-17.3* INR(PT)-1.0
Glucose-569* UreaN-45* Creat-1.7* Na-140 K-4.6 Cl-98 HCO3-17*
AnGap-30*
Calcium-9.8 Phos-4.7* Mg-1.9
pO2-177* pCO2-30* pH-7.38 calTCO2-18* Base XS--5
Lactate-8.0* K-4.5
Glucose-436* Lactate-3.8* K-4.2
UA- Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.017 Blood-NEG Nitrite-NEG
Protein-NEG Glucose-1000 Ketone-80 Bilirub-NEG Urobiln-NEG
pH-5.0 Leuks-LG RBC-8* WBC-101* Bacteri-NONE Yeast-NONE Epi-<1
Dishcarge Labs:
WBC-6.4 RBC-3.21* Hgb-9.8* Hct-29.3* MCV-91 MCH-30.5 MCHC-33.4
RDW-14.8 Plt Ct-315
Glucose-120* UreaN-18 Creat-0.9 Na-136 K-4.0 Cl-104 HCO3-25
AnGap-11
Calcium-8.6 Phos-2.8 Mg-2.0
Chest XRay ([**7-21**]): Portable AP upright chest radiograph is
obtained. The lungs are well expanded and clear bilaterally,
though the generalized lucency of the lungs suggests underlying
emphysema. No pleural effusion or pneumothorax is seen.
Cardiomediastinal silhouette appears grossly stable and within
normal limits. The bony structures appear intact, though
demineralized.
EKG ([**7-21**]): Sinus rhythm. Left anterior hemiblock. Incomplete
right bundle-branch block. Compared to the previous tracing of
[**2193-7-18**] no significant change.
Video Swallow ([**7-23**]): FINDINGS: Barium passed readily through
the oropharynx into the esophagus without evidence of
obstruction. There is mild delay in swallow initiation with
tongue pumping compatible with provided history of Parkinson's
disease.
There was penetration with nectar-thickened barium, but no other
preparations aside from small amount of aspiration with attempt
to coordinate thin liquids and pill swallowing. Pill swallowing
was aborted. There were no other episodes of aspiration or
penetration. For full details, please see speech and swallow
division note in the online medical record.
IMPRESSION:
1. Penetration with nectar-thickened barium.
2. Aspiration with attempt to coordinate pill swallowing and
thin liquids.
Brief Hospital Course:
Hospital Summary:
The patient is an 89-year-old woman with a history of Parkinson
disease, dementia, who was recently treated at this institution
for a urinary tract infection with ciprofloxacin and
re-presented with hyperglycemia. Her hyperglycemia and ketosis
resolved and she was treated for a UTI.
===============================================
Active Issues:
===============================================
# Diabetic Keotacidosis/ Diabetes Mellitus Type 2: The patient
reportedly had BG to the 700s while at her nursing home and upon
transfer to the ED her BG was 569. She had an anion gap of 25
with ketonuria in her urine consistent with diabetic
ketoacidosis. No signs of ischemia on EKG and no other
localizing signs of infection so UTI thought most likely cause
of hyperglycemia and DKA. Attempts to control her blood glucose
with subcutaneous insulin were unsuccesful and she was started
on an insulin drip. This led to closing of her anion gap and
better control of blood glucose values so that insulin drip was
weaned off the day after admission. She was transferred to the
floor. While on the floor, her fingersticks ranged from
122-350, and she was treated with 10/2 NPH and a humalog insulin
sliding scale. She had a normal anion gap. [**Last Name (un) **] consulted
regarding her insulin regimen. The sliding scale is attached to
this discharge summary.
# Cystitis: The patient had been treated with ciprofloxacin for
a UTI diagnosed on her previous addmission, despite this she had
continued pyuria on her re-presentation to the hospital. She
was given a dose of Vanc/zosyn while in the ED, this was changed
to ceftriaxone in the MICU. She was started on Vanc/ceftriaxone
and maintained for three days. Her original pre-treatment urine
culture never grew organisms. A repeat UA on [**7-23**] again showed
WBCs and leuk +, but no growth to date. She is sent home on
cefpodoxime 100mg [**Hospital1 **], for a total 14 day course (to be
completed on [**8-3**]). After completion of her antibiotic
course, she should have a urinalysis and culture sent, to assess
treatment success. On her previous admission, it was discovered
that she had a question of an irregular mass in her bladder on
US. At that time, cystoscopy was deferred, as it would not have
changed their clinical management and given her multiple
comorbidities pursuing a potential malignancy was not consistent
with the goals of care discussed with her daughter. In the case
of recurrent UTI after this prolonged course of ceftriaxone, we
recommend an outpatient consultation with urology to assess
whether there is an object in bladder and if it would be
something removable to allow better clearance of UTI.
# Positive Blood Cultures: GP cocci in clusters x1 bottles
blood, continued vanc/ceftriaxone for3 days. Since gram positive
cocci in clusters growing in only one bottle with negative
follow up cultures and as she grew coagulase negative staph this
was thought likely to be contaminant and vancomycin was stopped.
# Acute Renal Failure: The patient presented with a creatinine
of 1.7. Her baseline appears to be 1.1-1.5. Now 0.9 on day of
discharge. Was likely from prerenal hypovolemia in setting of
hyperglycemia and possible inadequate access to free water.
With treatment of her hyperglycemia with liberal fluids, CKI
corrected.
# Delirium: Pt's delirium significant in the MICU. Much improved
on floor. Orientation and attention wax and wane. Was likely
MICU delirium in the setting of underlying neurological disease
and infection. Have d/c'd lines/tubes and drains as possible,
and avoided benzos and anticholinergics.
# Sacral Pressure Ulcer: Seems to be chronic. Non-erythemetous
and well-kept. Kept clean and dry throughout.
# Parkinsons: Stable. Dementia symptoms uncovered more as
encephalitis clears (pill-rolling tremor). Continued
carbidopa-levidopa.
# Hypertension: Hypertensive transiently to 170, in setting of ?
missed dose of HTN medications yesterday. Continued amlodipine
and metoprolol therapies. Was on IV hydral x1 [**7-24**] due to
inability to take solid pills (in setting of pending
speech/swallow eval), but have continued on home orals in
crushed form.
# Swallowing: Pt evaluated by speech and swallow specialists
with video swallow. Pt assessed as appropriate for mechanical
soft foods, thin liquids, pills whole or crushed, with strict
aspiration precautions.
======================
Inactive Issues
======================
# Depression: Continued home Lexapro therapy.
.
# Hyperlipidemia: Continued home simvastatin therapy.
.
# Hypothyroid: Continued home levothyroxine.
=============================
TRANSITIONAL ISSUES:
=============================
-Cefpodoxime 100mg [**Hospital1 **] x10 days after discharge (14d total
course).
-Please take urinalysis and ucx after finish of antibiotics to
assess treatment success.
-Appreciate swallow/nutrition recs.
-If recurrent UTI, f/u with outpt urology to consider
cystoscopy.
-Pt noted to rarely request water and very sensitive to
dehydration. Will need careful monitoring of fluid status and
encouragement to drink if showing signs of dehydration.
Medications on Admission:
calcitriol 0.25mg daily
omeprazole 20mg daily
levothyroxine 50mcg daily
mvi
miralax
carbidoba/levodopa 25/100 [**Hospital1 **]
cranberry 450mg tab
virtron 125mg daily
dorzolamide 2% eye drops to left eye TID
metoprolol 25mg po bid
colace
artificial tears
amlodipine 2.5mg daily
lexapro 20mg daily
simvastatin 20mg daily
procrit injection sc weekly
tylenol prn
MOM
bisacodyl
fleets enema
NPH 13U after breakfast
ISS
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
10. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for constipation.
14. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
16. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous at breakfast: with breakfast.
Disp:*600 units* Refills:*0*
17. NPH insulin human recomb 100 unit/mL Suspension Sig: Two (2)
units Subcutaneous once a day: in evening .
Disp:*300 * Refills:*0*
18. Humalog 100 unit/mL Solution Sig: as per sliding scale
Subcutaneous as per sliding scale.
Disp:*300 units* Refills:*0*
19. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
20. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
21. Tylenol 325 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
22. Procrit Injection
23. Procrit Injection Sig: One (1) Once a week.
24. cranberry 450 mg Tablet Sig: One (1) Tablet PO once a day.
25. Vitron Sig: One [**Age over 90 **]y Five (125) mg once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 10140**] Nursing Center - [**Location (un) 10059**]
Discharge Diagnosis:
Primary Diagnosis:
hyperglycemia
.
Secondary Diagnoses:
urinary tract infection
Parkinson's Disease
MICU Encephalopathy
Hypertension
chronic renal insufficiency
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
.
It was a pleasure taking care of you.
.
You were admitted to the [**Hospital1 69**]
from your nursing home because you had very high blood sugar
level. You were admitted to the medical intensive care unit to
control your blood sugars. Over the course of your
hospitalization, your blood sugars improved, and your insulin
regimen was decided upon in consultation with the experts at the
[**Hospital **] Clinic.
.
Additionally, your urine had bacteria in it, which we think may
have triggered your hyperglycemia. We treated you with IV
antibiotics while you were in the hospital, and will send you
home with an oral antibiotic. You should take the antibiotic
for ten more days after you leave the hospital. On your last
hospitalization, you had something that may be a clot or a mass
in your bladder. We recommend that you follow-up with a
urologist as an outpatient to determine whether this finding in
your bladder may have some responsibility for your recurrent
urinary tract infections.
.
We have not changed any of your usual outpatient medications,
except for the addition of the antibiotic (cefpodoxime).
Followup Instructions:
You should be seen by your doctor at your nursing home within 48
hours of your return to your nursing home.
We are also working on arranging a urology appointment for you
to examine your bladder and further investigate why you are
having recurrent infections. You may call the urology department
directly by calling the main [**Hospital1 18**] number [**Telephone/Fax (1) 2756**].
|
[
"285.9",
"250.12",
"584.9",
"733.00",
"707.03",
"349.82",
"V58.67",
"530.81",
"536.3",
"596.9",
"564.1",
"585.3",
"294.10",
"788.38",
"599.0",
"331.82",
"788.20",
"244.9",
"276.52",
"271.3",
"V12.71",
"403.90",
"311",
"272.4",
"707.20",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12986, 13081
|
5253, 5605
|
266, 272
|
13286, 13286
|
3138, 3138
|
14635, 15019
|
2313, 2330
|
10875, 12963
|
13102, 13102
|
10436, 10852
|
13461, 14612
|
2345, 2345
|
13158, 13265
|
2359, 3119
|
9932, 10410
|
213, 228
|
5620, 9911
|
300, 1575
|
3154, 5230
|
13121, 13137
|
13301, 13437
|
1597, 2027
|
2043, 2297
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,775
| 160,582
|
3824
|
Discharge summary
|
report
|
Admission Date: [**2123-8-28**] Discharge Date: [**2123-9-4**]
Date of Birth: [**2067-2-5**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Aloe [**Doctor First Name **]
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
PCP: [**Name10 (NameIs) 17149**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 17150**]
.
CHIEF COMPLAINT: N/V/HA
.
REASON FOR MICU ADMISSION: hypertensive emergency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 y.o. F s/p failed kidney transplant on PD with low dose
immunosuppression presented with 3 days of worsening dry cough
associated with shortness of breath and post-tussive N/V. Last
night she missed some of her dialysis because of weakness and
SOB. Today she presented to the ED for headache. Of note, had
2 weeks of SOB diagnosed with asthma this past week, seen by
pulmonologist who put her on symbicort. 3 days ago developed HA,
migraine with N/V. No CP but cough nonproductive.
.
In the ED, initial VS: VS 99.4 76 247/116 20 98% on 2L.CXR with
volume overload, pulm edema, LLL consolidation. Given
evo/vanc/ceftriaxone. Did not draw BCx. BP 200/100s. Started on
nitroprusside drip. Labetolol 20x2 dropped HR 60s. Renal will do
peritoneal dialysis tonight. On cellcept and prednisone. Put on
nitroprusside at 0.6mcg/hr. Given dilaudid for headache and it
has improved. EKG NSR 76 TWI in V1 old and TWF in lead III. CT
head negative. Dialysis fluid cultures pending. VS prior to
leaving ED 99 [**Telephone/Fax (2) 17151**]%2L. Renal was consulted for
urgent/emergent dialysis.
.
Currently, patient endorsed dyspnea that improved with an
albuterol inhaler. She reported that her labetolol was recently
decreased after she was diagnosed with asthma. She endorsed some
cough and had one episode of vomiting dark guaic+ bilious
material afterward. She had missed medications in last couple of
days because of N/V. She endorsed worsening dypnea on exertion
and at rest, orthopnea (increased amount of pillow use) and PND.
She denies CP, back pain, fever, chills, diplopia or blurry
vision, lightheadness or myalgias. She denied sick contacts. She
endorsed a headache that had improved to [**2-2**]. Her left arm is
chronically swollen from shoulder injury.
.
ROS: Denies night sweats, vision changes, rhinorrhea,
congestion, sore throat, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1. membranous glomeruloneprhitis, s/p cadaveric renal transplant
in [**2118**] with recurrent GN
2. ESRD on peritoneal dialysis 2x daily (since [**8-3**])
3. GI sarcoma (rectal) with surgery and postop radiotherapy in
[**2111**]
4. Histiocyosis X with thymectomy
5. Multinodular Goiter
6. hypertension
Social History:
Recently retired(from housing manager) because of left shoulder
pain and swollen left arm, denies any smoking, alcohol, or drug
use. Lives with son and grandson.
Family History:
Aunt and cousin who had breast cancer, father had prostate
cancer. Lupus nepritis in sister, who died of lupus. Otherwise
no ESRD.
Physical Exam:
General Appearance: Thin, Anxious
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t)
Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), S3
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : bases b/l), (Breath Sounds: Crackles : 2/3 up from
bases b/l)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not
assessed
Pertinent Results:
MICROBIOLOGY:
[**8-28**] Dialysis gram stain and cultures: negative
[**8-29**] Blood, urine, legionella cultures: negative
.
STUDIES:
[**8-3**] Echo The left atrium is elongated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 0-10mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild to moderate ([**11-27**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**11-27**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2115-11-7**], the degree of MR [**First Name (Titles) **] [**Last Name (Titles) **] appreciated
have slightly increased.
.
[**8-28**] CT head: PFI negative
.
EKG: NSR at 80, NA, NI, no acute STTW changes, slight peaked Ts
in V2-V5
.
CXR: edema, L effusion vs infiltrate
.
Admission labs:
[**2123-8-28**] 02:45PM BLOOD WBC-11.8*# RBC-3.18* Hgb-7.3* Hct-24.1*
MCV-75.9* MCH-23.1* MCHC-30.4* RDW-21.9* Plt Ct-269
[**2123-8-28**] 02:45PM BLOOD Neuts-89.1* Lymphs-5.8* Monos-3.6 Eos-1.3
Baso-0.3
[**2123-8-28**] 02:45PM BLOOD PT-16.0* PTT-25.5 INR(PT)-1.4*
[**2123-8-28**] 02:45PM BLOOD Glucose-99 UreaN-103* Creat-16.7*#
Na-147* K-5.5* Cl-98 HCO3-26 AnGap-29*
[**2123-8-28**] 02:45PM BLOOD estGFR-Using this
[**2123-8-28**] 02:45PM BLOOD ALT-20 AST-17 CK(CPK)-148* AlkPhos-81
TotBili-0.5
[**2123-8-28**] 02:45PM BLOOD Lipase-74*
[**2123-8-28**] 09:08PM BLOOD Lactate-1.1
Cardiac enzymes:
[**2123-8-28**] 02:45PM BLOOD CK-MB-4 cTropnT-0.24*
[**2123-8-29**] 12:41AM BLOOD CK-MB-4 cTropnT-0.20* proBNP->[**Numeric Identifier **]
[**2123-8-29**] 06:50AM BLOOD CK-MB-4 cTropnT-0.22*
Iron studies:
[**2123-9-2**] 07:05AM BLOOD calTIBC-226* Ferritn-644* TRF-174*
[**2123-9-2**] 07:05AM BLOOD Calcium-8.2* Phos-6.3* Mg-1.7 Iron-21*
Brief Hospital Course:
56 y.o. F s/p failed kidney transplant on PD with low dose
immunosuppression had 2 weeks of SOB diagnosed with asthma who
presented to ED with N/V/ and HA found to have hypertensive
emergency.
.
# Hypertensive emergency: Manifested initially as pulmonary
edema. EKG without ischemic changes. Patient recently endorsed
lowering of labetalol dose after being diagnosed with asthma.
Also missed peritoneal dialysis due to dyspnea as well as
missing po anti-hypertensives due to nausea. In the ED,
labetalol was given by mouth. In the ICU, pt was on
nitroprusside gtt and labetalol gtt. The patient had difficult
to control blood pressurs and needed both IV drips to maintain
goal SBP in 150-160s. Her nausea improved with better blood
pressure control, and her home oral anti-hypertensives were
re-introduced while labetalol and nitroprusside were weaned off.
However, overnight on [**8-30**], her BPs increased again to SBP
180-200s and would need labetalol gtt with bolus IV labetalol
and hydralazine. This was weaned off by the next morning with
increase of po medications. She was also started on lasix,
lisinopril, and her clonidine patch was increased. Her
labetalol was also increased to TID dosing but could not be
increased further due to heart rate. The patient was also
maintained on peritoneal dialysis while in the ICU. Nephrology
also followed that patient during ICU stay. Cardiac enzymes were
cycled and ruled out for MI. The patient was transferred to the
floor, for further blood pressure managment. Her blood pressure
remained labile, so her daily furosemide and clonidine [**Month/Day (1) 4319**]
were increased, and aliskerin was added to her anti-hypertensive
regimen.
# Dyspnea: This was likely due to worsening pulmonary edema and
heart failure as CXR consistent with volume overload. She did
miss [**First Name (Titles) **] [**Last Name (Titles) 4319**] of her home lasix due to nausea to home and also
missed a PD session. She was treated with PD sessions and
albuterol nebs as needed. TTE was also repeated without much
change from prior. Upon arrival to the floor, the patient was
breathing comfortably and had excellent oxygen saturation.
# ESRD: She was maintaned on peritoneal dialysis. Renal
followed. Resumed prednisone and cellcept, renal gel and
calcitriol.
# Leukocytosis: On admission, consolidation could not be ruled
out so started vancomycin, levofloxacin and cefepime; however,
pt remained afebrile. All cultures remained negative. All
antibiotics were stopped. She had no leukocytosis after [**8-29**],
one day after admission.
# Nausea/Vomiting: Likely secondary to uremia. ACS ruled out
with enzymes. Supported with medications. The patient continued
to be nauseous upon transfer to the floor, and vomited her first
round of medications on the floor, after taking them with small
sips of water. From that point forward, though, her nausea was
significantly decreased, and the patient had excellent relief
with lorazepam.
.
# Anemia: Patient as anemic with baseline hct ~27 and on procrit
for anemia of chronic disease. With guiac + emesis concern for
UGI bleed although hemodynamics does not support hypovolemic
instability. Active T&S maintained. Transfused 1 pRBC. [**Hospital1 **] IV
PPI initially, then changed to po. Her EPO injections were held,
to avoid worsening of her hypertension. Her hct remained
relatively stable from that point forward, in the mid-20's.
# Headaches: CT head negative. Migraine improved with blood
pressure control. The patient had repeated headaches on the
floor, but did not consider them migraines.
# Upper extremity swelling: The patient reported having
undergone evaluation with multiple imaging modalities over the
past year, all of which were unrevealing. Upper extremity
ultrasound during this admission revealed no venous thrombosis.
Medications on Admission:
-Procrit 25,000 unit/mL SC every 2 weeks
-Tricor 48 mg PO daily
-Renvela 800 mg 2 Tablet(s) by mouth tid with meals
-Clonidine 0.3 mg/24 hr Weekly Transderm Patch
-Multivitamin Tab PO daily
-Calcitriol 0.25 mcg by mouth daily
-Prednisone 5 mg by mouth once daily
-symbicort
-Docusate Sodium 300 mg daiy prn constipation
-Amlodipine 10 mg by mouth once a day
-PhosLo 667 mg Cap 4 Capsule(s) by mouth tid with meals
-Labetalol 200 mg Tab Oral Twice Daily
-Lisinopril 80 mg PO Daily
-Cellcept 500mg PO BID
Discharge Medications:
1. Prednisone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
4. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
5. Procrit 10,000 unit/mL Solution Sig: One (1) Injection once
a week.
6. Renvela 800 mg Tablet Sig: Two (2) Tablet PO three times a
day.
7. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday): use with 0.3 mg patch - total
0.4 mg.
Disp:*4 Patch Weekly(s)* Refills:*0*
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Colace 100 mg Capsule Sig: Three (3) Capsule PO once a day
as needed for constipation.
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
15. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
17. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive emergency
.
End Stage Renal Disease, status-post renal transplant
Anemia
Upper extremity edema
Allergic rhinitis
Discharge Condition:
Medically stable for discharge home
Discharge Instructions:
Ms [**Known lastname 17152**],
.
You were admitted to the hospital after your blood pressure was
found to be severely elevated in the emergency room. It was
thought that some of the symptoms you have been experiencing
were related to the high blood pressure. You were initially
admitted to the medical ICU for continuous blood pressure
treatment and monitoring. Eventually, you were weaned off some
of the blood pressure medications, and you were considered
stable enough for transfer to the regular medical floor. Your
blood pressure continued to improve, and you were ultimately
discharged with a new regimen of blood pressure medications.
.
We made the following changes to your medication regimen:
* Increased CLONIDINE patch to 0.4 (0.3 plus 0.1).
* Increased LABETALOL to 300mg three times daily.
* Started ALISKIREN for blood pressure.
* You can also take BENZONATATE as needed for cough.
.
Please take your blood pressure daily as instruced and call your
physician if your blood pressure is over the previously
discussed limits. It is important that you do this.
.
Please call your doctor or return to the emergency room
immediately if you experience any of the following:
-Severe headaches
-Vision changes
-Nausea/vomiting, or inability to take your blood pressure
medications for any other reason
-Severe chest pain or abdominal pain
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2123-10-19**] 11:20
.
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2123-11-12**] 9:50
.
Please call to make a followup appointment with your
nephrologist, Dr. [**Last Name (STitle) **], and the PD nurses at the earliest
appointment you can get.
.
Please call your PCP to make an appointment to be seen within
two weeks.
|
[
"V45.11",
"285.21",
"729.81",
"241.1",
"V10.06",
"288.60",
"428.0",
"790.92",
"276.2",
"787.01",
"346.90",
"493.00",
"V42.0",
"403.91",
"428.33",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
12129, 12135
|
6239, 10077
|
492, 499
|
12305, 12343
|
3963, 5126
|
13736, 14281
|
3010, 3143
|
10630, 12106
|
12156, 12284
|
10103, 10607
|
12367, 13713
|
3158, 3944
|
5878, 6216
|
394, 454
|
527, 2488
|
5136, 5265
|
5281, 5861
|
2510, 2815
|
2831, 2994
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,753
| 164,253
|
54770
|
Discharge summary
|
report
|
Admission Date: [**2100-9-22**] Discharge Date: [**2100-9-28**]
Date of Birth: [**2019-1-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vicodin / Cipro / Polysporin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81 year old female hx of Afib on coumadin, diverticulosis, and
myasthenia [**Last Name (un) 2902**] presented to PCP [**Name Initial (PRE) 151**] 2 d BRBPR. Per her
report she was reccently started on a new medication for her MG
(mestinon 30 mg QID) earlier in the week. The week prior to her
presentation her INR had been at goal of 2.0, she then noticed
blood in her stool and red blood on the paper towel. The next
morning she was continuing to have blood on the toilet paper and
noticed the toilet water was red tinged. She called her PCP who
checked an INR which was elevated to 8.0. She went to [**Hospital3 635**]
hospital where crit was 29.0 and INR was 6.1. She was given 2 U
FFP, 5 of Vitamin K PO and transferred to [**Hospital1 18**].
.
In the ED, initial VS were: 94 in sinus, 166/68, 20, 97% 3LNC
Hematocrit was 24.0 and INR 2.5
.
She got a CXR, was type and screened and cross matched for 2
units. Guiaic showed flecks of BRB, no active bleeding. GI was
consulted who said they will evaluate her in the morning. Did
go into Afib with RVR to the 160s before being transferred to
ICU and was transfused 2 units of pRBCs.
.
On arrival to the MICU, patient's VS: 98.1, 184 afib, 154/80,
98% 4L NC. She was intially given 5 mg IV lopressor with
immediate conversion to sinus rhythm.
Past Medical History:
-Afib on coumadin, diagnosed post operatively for a hip fracture
in [**2099-2-7**]. Not on cardiac meds, follows with Dr.
[**Last Name (STitle) 13834**] in Tuscon AZ for management of her coumadin.
-Diverticulosis - diagnosed many years ago, has had 3
colonoscopies in past 10-15 years
-Myasthenia [**Last Name (un) **] - diagnosed [**8-24**] of this year by
-Neurologist (Dr. [**Last Name (STitle) **], [**Location (un) 9101**]). As per daughter, had
positive [**Name (NI) 111965**] antibodies.
Social History:
former smoker, quit 25-30 years ago, denies EtOH, denies drugs
Family History:
father had CHF, mother died of MI, siblings had pulmonary
fibrosis
Physical Exam:
On Admission
Vitals: 98.1, 184 afib, 154/80, 98% 4L NC.
General: Alert, oriented, no acute distress, very thin and frail
appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
symmetric pstosis.
Neck: supple, JVP not elevated, no LAD
CV: irregular, tachycardic unable to appreciate murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, 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, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
On Discharge:
Pertinent Results:
Admission Labs:
[**2100-9-21**] 11:45PM PT-25.8* PTT-36.6* INR(PT)-2.5*
[**2100-9-21**] 11:45PM PLT COUNT-423
[**2100-9-21**] 11:45PM NEUTS-74.6* LYMPHS-18.4 MONOS-5.2 EOS-1.1
BASOS-0.7
[**2100-9-21**] 11:45PM WBC-6.5 RBC-2.81* HGB-8.1* HCT-24.2* MCV-86
MCH-28.7 MCHC-33.3 RDW-15.1
[**2100-9-21**] 11:45PM ALBUMIN-2.6*
[**2100-9-21**] 11:45PM ALT(SGPT)-39 AST(SGOT)-79* ALK PHOS-151* TOT
BILI-0.4
[**2100-9-21**] 11:45PM estGFR-Using this
[**2100-9-21**] 11:45PM GLUCOSE-108* UREA N-17 CREAT-0.6 SODIUM-135
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-12
[**2100-9-22**] 04:00PM GLUCOSE-186* UREA N-21* CREAT-0.6 SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-12
[**2100-9-22**] 04:00PM CALCIUM-8.2* PHOSPHATE-3.3 MAGNESIUM-2.0
[**2100-9-22**] 03:39PM TYPE-ART TEMP-36.6 O2 FLOW-7 PO2-75* PCO2-36
PH-7.48* TOTAL CO2-28 BASE XS-3 INTUBATED-NOT INTUBA
[**2100-9-22**] 03:39PM GLUCOSE-207* LACTATE-1.4 NA+-135 K+-3.8
CL--102
Discharge Labs:
Imaging:
Preliminary Report:
CT CHEST W/O CONTRAST Study Date of [**2100-9-22**]
CONCLUSION:
1. Moderate-to-severe circumferential pericardial effusion is
nonhemorrhagic. This study is not tailored to rule out
tamponade. However, we do not have any indirect sign of
tamponade. A cardiac son[**Name (NI) **] is suggested.
2. Ascending aorta is dilated up to 5.8 cm and its border is not
well
Preliminary Reportdefined. If clinical concern of acute aortic
process remains, a C+ exam is suggested.
3. Bilateral moderate pleural effusion is more prominent on the
left side.
Portable TTE (Complete) Done [**2100-9-23**]
IMPRESSION: Low-normal left ventricular systolic function.
Dilated aortic root with probable small sinus of Valsalva
aneurysm of the right coronary cusp and severe aortic
regurgitation. At least mild mitral regurgitation - diastolic
mitral regurgitation is present, in keeping with severe aortic
regurgitation. There is a moderate circumferential pericardial
effusion without frank tamponade. However, the RV wall looks
hypertrophied, suggesting pulmonary hypertension (signs of
tamponade may be absent with elevated right sided pressures).
Also, the presence of severe aortic regurgitation means that
pulsus paradoxus is insensitive to assess inter-ventricular
interaction.
Compared with the prior study (images reviewed) of [**2100-9-22**],
the current study is more complete. The findings are probably
unchanged.
CHEST (PA & LAT) Study Date of [**2100-9-22**]
FINDINGS: There is moderate cardiomegaly, possible pericardial
effusion, and a moderate left and small right pleural effusion.
A tortuous aorta is seen with aortic arch calcifications. There
is no pneumothorax and no focal lung consolidation.
Vertebroplasty material is seen in the upper lumbar spine.
Portable TTE (Focused views) Done [**2100-9-22**]
IMPRESSION: Suboptimal image quality. There is probably
moderate/severe aortic regurgitation with a a sinus of Valsalva
aneurysm of the right coronary cusp. Mildly hypokinetic
ventricular function. Moderate-sized pericardial effusion
without evidence of frank tamponade, although the right atrium
does not fully dilate during atrial diastole, suggesting either
low filling pressures or early tamponade.
Brief Hospital Course:
#Pericardial Effusion: A CXR done on admission noted a left
pleural effusion. A bedside thoracentesis was to be performed,
however on ultrasound the heart was noted to be close to the
wall. A chest CT was done [**9-22**] which was remarkable for a small
to moderate left effusion with a significant pericardial
effusion and ascending thoracic aorta aneurysm. An echo was
performed [**9-22**] at the bedside due to concern for tamponade which
showed probable moderate/severe aortic regurgitation with a a
sinus of Valsalva aneurysm of the right coronary cusp, moderate
sized pericardial effusion without evidence of frank tamponade,
although the right atrium does not fully dilate during atrial
diastole, suggesting either low filling pressures or early
tamponade. A formal echo was performed on [**9-23**] dialted aortic
root with probable small sinus of Valsalva aneurysm of the right
coronary cusp and severe aortic regurgitaton, a moderate
circumferential pericardial effusion without frank tamponade.
Cardiology was consulted who recommended CT with contrast due to
concern for dissection; CT showed dissection of the thoracic
ascending aorta with possible rupture into pericardium. CT
surgery was consulted who recomended surgery but the patient
declined. She was medically managed with HR and blood pressure
control but continued to decline over the next several days with
increasing oxygen requirements eventually requiring 100% on a
non-rebreather. The patient and her family made the decision to
be made comfort measures only on [**9-27**]. She was given morphine
and she passed away with her family at her side on the morning
of [**2100-9-28**].
# Atrial fibrillation with RVR: Patient has history of atrial
fibrillation on coumadin diagnosed post operatively for a hip
fracture in [**2099-2-7**]. Coumadin was held in setting of GI
bleed. She was given 5 mg IV metoprolol x2 and rates slowed to
the 120's. She then had a likely vagal episode and became
acutely bradycardic with a 6 second pause. The episode resolved
spontaneously and the patient reverted back to atrial
fibrillation. The patient was transitioned to 25 mg metoprolol
TID but remained in a-fib with rvr. She was placed intermitantly
on diltizem drip and converted to NSR with rates in the 60s.
When the decision was made to make her CMO, these were
discontinued.
#Bright red blood per rectum: The patient present with bright
red blood per rectum in the setting of an elevated INR of 8.0
and HCT of 29.0. Her hematocrit dropped to 24.2. She received
2 units pRBCs and had an appropriate rise in hematocrit. The
INR was corrected with 2 units FFP and 5 mg vitamin K x 2.
Gastroenterology was consulted who felt this was likely a lower
GI bleed, most likely diverticular or AVM, exacerbated in the
setting of elevated INR. Also on the differential diagnosis are
hemorrhoids and malignancy. She did have a colonoscopy in [**2098**]
that did not show any polyps, making malignancy unlikely. The
patient's hematocrit stabled and she had no further episodes of
bleeding.
# Hypoxia: Patient with intermittent desaturation. Etiology
likely multifactorial secondary to pericardial effusion and poor
reserve with underlying myasthenia. The CXR did not show any
evidence of acute infection. She was placed on nasal cannula to
maintain oxygen saturation >92%. Please see above, but the
patient had increasing oxygen requirments eventually requiring
100% on a non-rebreather. At that time the patient made the
decision to be made CMO.
# Myasthenia [**Last Name (un) **]: The patient was recently diagnosed with
myasthenia after 3 years of progressive symptoms. She had a
positive anti-acetylchoine receptor antibody and was started on
pyridostigmine with little improvement. She was recently starte
on mestinon. Neurology was consulted regarding diagnosis and
treatment and concern for underlying malignancy with
paraneoplastic syndrome. They recommended monitoring vital
capacity and negative inspiratory force. Neurology weighed in
regarding possibe surgery and advised that the patient may have
a slower recovery coming off of the vent. The patient and her
family made the decision to be made comfort measures only on
[**9-27**]. She was given morphine and she passed away with her family
at her side on the morning of [**2100-9-28**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 2.5 mg PO DAILY
2. FoLIC Acid 400 mcg PO DAILY
3. Warfarin 2 mg PO DAILY16
4. ALPRAZolam 0.25 mg PO QHS
5. Paroxetine 10 mg PO DAILY
6. Pyridostigmine Bromide 30 mg PO Q6H
7. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral qd
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"518.82",
"787.22",
"427.89",
"416.8",
"V15.82",
"569.85",
"427.31",
"511.9",
"358.00",
"276.69",
"530.3",
"790.01",
"V49.86",
"423.0",
"368.2",
"V66.7",
"423.9",
"V64.2",
"441.03",
"783.21",
"V10.83",
"E934.2",
"424.1",
"578.1",
"562.12",
"374.32",
"401.9",
"V15.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11152, 11161
|
6362, 10693
|
331, 337
|
11213, 11223
|
3114, 3114
|
11280, 11291
|
2289, 2358
|
11119, 11129
|
11182, 11192
|
10719, 11096
|
11247, 11257
|
4097, 6339
|
2373, 3080
|
3095, 3095
|
264, 293
|
365, 1669
|
3130, 4080
|
1691, 2192
|
2208, 2273
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
935
| 132,801
|
15793
|
Discharge summary
|
report
|
Admission Date: [**2185-10-28**] Discharge Date: [**2185-11-15**]
Date of Birth: [**2113-2-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
gentleman status post fall off a horse which was unwitnessed.
He was found on the trail with his riding helmet beside him.
He was able to give his name but was otherwise disoriented.
He was transferred to [**Hospital **] Hospital. By report his GCS
was 14, but he had no purposeful movement. Head CT showed
traumatic subarachnoid hemorrhage with bifrontal contusions,
multiple convexity skull fractures with no significant
displacement, no more than thickness of the bone, one small
area of pneumocephalus on the base of the thalamus.
The patient was seen by the Ophthalmology Service for the
left frontal skull fracture which extended into the left
orbital roof. No surgical intervention was needed. His
globes were intact, and there was no need for surgical repair
of the orbital roof. The patient was also seen by CT Surgery
for question of an esophageal [**Hospital 1994**].
The patient was intubated and sedated in the OR on Propofol.
When lightened, he was restless, unable to focus, moving all
extremities, left greater than right. He did not open his
eyes or follow commands. He localized with his left upper
extremity. He had withdraw in the bilateral lower
extremities. In the right upper extremity, he lifted
against gravity but weaker than the left. Right pupil was 4
mm and reactive, left is irregular and nonreactive, surgical.
He did have cornuals, gag, and cough.
The patient had repeat head CT on [**2185-10-29**], which
was unchanged from the previous day CT. On [**2185-10-31**], the patient was awakened and attentive. Left pupil was
surgical, right was 4.5 down to 4.0 and reactive. He had
purposeful movements of the left greater than right. Smile
was symmetric.
The patient had MRA/MRV to rule out stroke as the cause for
right upper extremity weakness which was negative. It was
unclear as to the cause of the decreased movement in the
right upper extremity. We recommended weaning from the
ventilator and weaning sedation.
The patient had repeat chest CT. Thoracic Surgery felt there
was a low probability of an esophageal [**Last Name (LF) 1994**], [**First Name3 (LF) **] prophylaxis
antibiotics were discontinued on [**10-31**]. On [**2185-11-4**], the patient opened his eyes and followed voice. He
occasionally followed commands. He continued with
right-sided weakness. Ophthalmology was consulted again who
said that he showed evidence of healing corneal abrasions.
The patient will need follow-up with outpatient
ophthalmologist after discharge.
The patient was extubated on [**11-3**] and transferred to
the regular floor on [**11-4**]. He was seen by Physical
Therapy and Occupational Therapy and found to require acute
rehabilitation prior to discharge to home.
DISCHARGE MEDICATIONS: Lopressor 50 mg p.o. b.i.d. hold for
systolic blood pressure less than 110, heart rate less than
55, Hydralazine 20 mg p.o. q.6 hours, hold for systolic blood
pressure less than 110, heart rate less than 55, Nystatin
ointment 1 application topically q.i.d. p.r.n. to affected
areas, Insulin sliding scale, Captopril 25 mg p.o. t.i.d.,
hold for systolic blood pressure less than 100, Erythromycin
ophthalmic ointment 0.5% O.U. at h.s., Nystatin oral
suspension 5 cc p.o. q.i.d., Heparin 5000 U subcue q.12
hours.
CONDITION ON DISCHARGE: The patient's neurologic status
improved greatly. He was awake and alert and oriented times
[**1-16**], moving all extremities, but continued with some
right-sided weakness. He was following commands and was out
of bed ambulating with assistance.
FOLLOW-UP: He will need to follow-up with Dr. [**Last Name (STitle) 1132**] on one
month with repeat head CT. He was stable at the time of
discharge.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2185-11-15**] 09:54
T: [**2185-11-15**] 09:53
JOB#: [**Job Number 45458**]
|
[
"801.20",
"707.0",
"918.1",
"401.9",
"802.6",
"E884.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2941, 3454
|
161, 2917
|
3479, 4103
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,547
| 167,388
|
46941
|
Discharge summary
|
report
|
Admission Date: [**2116-12-14**] Discharge Date: [**2116-12-23**]
Service: SURGERY
Allergies:
Nsaids / Aspirin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Embolization of the branch of middle colic artery with 6
microcoils at the level of marginal artery.
Extended right hemicolectomy with primary anastomosis.
History of Present Illness:
85 y/o female with PMH significant for atrial fibrillation, CHF,
diastolic dysfunction, HTN, and peptic ulcer disease with past
GI bleeds admitted throught the ED with bright red blood per
rectum. Pt reports that she had approximately six episodes of
bright red blood per rectum overnight. She reports that it was a
large amount which filled the toilet bowl. These episodes of
bleeding were associated with abdominal cramping. She denies any
feelings of dizziness or lightheadedness. Pt called EMS and was
brought to the ED for further evaluation. In further discussion,
no hematemesis, nausea, or vomiting. Pt denies CP, SOB, and
cough. Pt reports that her appetite has been normal lately and
she has not had any abnormal weight loss.
Past Medical History:
atrial fibrillation
restrictive lung disease
PUD
urinary incontinence
vulvar melanoma,
status post total abdominal hysterectomy and oophorectomy for
endometrial cancer in [**2115-10-9**]
right cerebellar meningioma (dx'ed [**12-11**]), non-bleeding,
calcified, cleared by neurosurgery for anticoag for afib
GI Bleeding secondary to gastric erosions.
Social History:
Patient lives at home alone. She denies smoking, ETOH, or IVDU
Physical Exam:
On Admission:
PE: G: Elderly obese female, NAD. Covered in blood.
HEENT: MMM, anicteric sclerae
Neck: Obese
Lungs: CTA, BS BL, No W/R/C
Cardiac: RR, NL rate. NL S1S2. No murmurs
Abd: Soft, NT, ND. NL BS. No HSM.
Ext: No edema. 2+ DP pulses BL.
Neuro: A&Ox3. Appropriate. No gross deficits
Skin: Chronic venous stasis changes. Tight skin.
Pertinent Results:
[**2116-12-20**] 03:02AM BLOOD WBC-12.0* RBC-3.12* Hgb-9.7* Hct-29.1*
MCV-93 MCH-31.2 MCHC-33.4 RDW-14.2 Plt Ct-275
[**2116-12-15**] 04:18AM BLOOD WBC-9.7 RBC-3.57* Hgb-10.8* Hct-31.1*
MCV-87 MCH-30.1 MCHC-34.6 RDW-14.5 Plt Ct-178
[**2116-12-15**] 12:44AM BLOOD Hct-29.1*
[**2116-12-14**] 05:35PM BLOOD WBC-7.0 RBC-3.02* Hgb-9.2* Hct-25.1*
MCV-83# MCH-30.4 MCHC-36.6* RDW-14.5 Plt Ct-150
[**2116-12-14**] 04:00PM BLOOD Hct-23.5*
[**2116-12-14**] 06:10AM BLOOD WBC-9.6 RBC-3.12* Hgb-9.6* Hct-28.3*
MCV-91 MCH-30.8 MCHC-34.1 RDW-13.7 Plt Ct-242
[**2116-12-14**] 03:45AM BLOOD WBC-11.5* RBC-4.14* Hgb-12.4 Hct-36.1
MCV-87 MCH-30.0 MCHC-34.4 RDW-13.9 Plt Ct-264
[**2116-12-20**] 03:02AM BLOOD Plt Ct-275
[**2116-12-19**] 01:59AM BLOOD PT-13.9* PTT-36.8* INR(PT)-1.3
[**2116-12-14**] 07:40AM BLOOD PT-15.7* PTT-37.4* INR(PT)-1.7
[**2116-12-14**] 03:45AM BLOOD Plt Ct-264
[**2116-12-14**] 03:45AM BLOOD PT-24.0* PTT-46.2* INR(PT)-4.2
[**2116-12-15**] 09:38PM BLOOD Fibrino-301
[**2116-12-20**] 03:02AM BLOOD Glucose-84 UreaN-13 Creat-0.6 Na-144
K-3.7 Cl-105 HCO3-29 AnGap-14
[**2116-12-15**] 04:18AM BLOOD Glucose-120* UreaN-9 Creat-0.7 Na-145
K-5.3* Cl-109* HCO3-28 AnGap-13
[**2116-12-14**] 03:45AM BLOOD Glucose-150* UreaN-18 Creat-1.0 Na-143
K-4.1 Cl-106 HCO3-26 AnGap-15
[**2116-12-20**] 11:00AM BLOOD Calcium-9.0 Phos-2.4* Mg-2.2
[**2116-12-14**] 03:45AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
[**2116-12-18**] 03:05AM BLOOD Type-ART Temp-37.2 Rates-/22 O2 Flow-3
pO2-76* pCO2-38 pH-7.45 calHCO3-27 Base XS-2
[**2116-12-14**] ECG
Atrial fibrillation with a moderate ventricular response.
Borderline low voltage diffusely. Vertical QRS axis. Slow R wave
progression. Non-specific ST-T wave changes. QTc interval
prolongation. Compared to the previous tracing of [**2115-12-24**] QTc
interval is longer.
[**2116-12-14**] Interventional Radiology:
1. Active bleeding was confirmed angiographically at the hepatic
flexure, best accessed through a middle colic branch coming off
the proximal superior mesenteric artery.
2. Successful embolization of the branch of middle colic artery
with 6 microcoils at the level of marginal artery with good
residual collateral flow at the end of the procedure and
cessation of angiographic extravasation.
[**2116-12-14**] GI bleeding study
IMPRESSION: Positive GI bleeding study with extravasation of
tracer identifiedwithin the region of the hepatic flexure of the
colon.
[**2116-12-15**] CXR Findings consistent with congestive heart failure.
[**2116-12-16**] CXR IMPRESSION: Central venous catheter in satisfactory
position. Endotracheal tube also likely satisfactory allowing
for flexed position of the neck.
2. Worsening congestive heart failure with probable asymmetrical
right perihilar pulmonary edema. Superimposed process such as
aspiration in this area cannot be excluded given the presence of
a large hiatal hernia.
[**2116-12-19**] CXR Right jugular CV line is in mid SVC. There is a
large hiatal hernia as previously demonstrated and probable
atelectases at both lung bases difficult to evaluate in this
single frontal view in the presence of a large hiatal hernia. No
pneumothorax. Surgical clip overlies left superior mediastinum.
Brief Hospital Course:
85F with a h/o afib on coumadin admitted to medicine ICU for
BRBPR. INR on admission was 4.2 and hct had dropped from 36.5
to 28.3 over 2 hours. She was given Vitamin K and tranfused
with 5 units of prbcs and 6 units of FFP. She was taken to IR
where a branch of the middle colic artery was coiled and good
collateral flow identified. GI was also consulted and
recommended colonscopy if pt continued to bleed. Although she
did not exhibit continued profuse bleeding per rectum, serial
hematocrits continued to drop despite transfusion and the
decision to take the patient to the OR for a right hemicolectomy
was made. She tolerated the procedure well and was transferred
to the SICU and remained intubated overnight. On POD1, pt was
intubated but could answer questions. She remained in afib with
RVR that did not respond to lopressor and was placed on a
diltiazem infusion. Her BP was closely monitored. She
exhibited signs of CHF with pulmonary edema present on CXR.
Geriatrics was also consulted. On POD2, pt's hct remained
stable and she was diuresed and later extubated. On POD4, pt
was transferred to floor with telemetry. She was started on
clears and continued to be diuresed. The remainder of her
course, pt advanced to regular diet and her pain was controlled
with PO analgesia. She did express concern regarding going home
alone. PT was consulted and recommended rehab for 1-3 weeks.
On POD6 pt had purulent drainage from her incision site. A few
staples were removed and about 20ml of pus necessitated from the
wound. The wound of opened and cleaned. No fascia defect was
noted. The patient was placed on ABx and kept in the hospital
for one more day of observation. On POD 7, pt was stable and
d/ced to rehab on abx with instructions for [**Hospital1 **] wet-to-dry
dressing changes in stable condition.
Medications on Admission:
1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4H (every
4 hours).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO BID (2 times a day).
3. Venlafaxine 37.5 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Quinapril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. coumadin 2.5mg daily
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4H
(every 4 hours).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO BID (2 times a day).
3. Venlafaxine 37.5 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Quinapril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4-6H (every 4 to 6
hours) as needed for breakthrough pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Lower gastrointestinal bleed with focal localization to hepatic
flexure of the colon.
Wound infection
Discharge Condition:
Stable
Discharge Instructions:
You may restart your home medications except the coumadin. You
may take a shower, but keep your wound covered and dry. We have
given you a prescription for an antibiotic called keflex
(cephalexin) for your wound infection. Please fill and take as
instructed. Call a physician or go to the emergency room if you
experience fever >101.4F, pain unrelieved by medication,
intractable nausea or vomiting, or pus/fluid draining from your
wound site.
Followup Instructions:
Please call Dr.[**Name (NI) 2829**] clinic at [**Telephone/Fax (1) 476**] to schedule a
follow-up appointment in [**2-9**] weeks.
Follow-up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks to manage
your anticoagulation.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7909**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2117-2-12**] 9:30
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/GYN NON-PPS CC8
Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2117-2-15**] 2:45
Completed by:[**2116-12-23**]
|
[
"578.9",
"998.59",
"V10.82",
"428.32",
"401.9",
"427.31",
"428.0",
"682.2",
"V10.42",
"E878.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"99.07",
"99.04",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
8855, 8933
|
5214, 7053
|
252, 411
|
9079, 9087
|
2007, 5191
|
9583, 10225
|
7793, 8832
|
8954, 9058
|
7079, 7770
|
9111, 9560
|
1648, 1648
|
185, 214
|
439, 1177
|
1662, 1988
|
1199, 1551
|
1567, 1633
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,963
| 168,832
|
3480+55469+55470+55471
|
Discharge summary
|
report+addendum+addendum+addendum
|
Admission Date: [**2177-10-4**] Discharge Date:[**2177-11-24**]
Date of Birth: [**2125-12-24**] Sex: M
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
male with a history of human immunodeficiency virus infection
who was transferred from [**Hospital3 1280**] Hospital for management
of severe pancreatitis.
The patient apparently presented to [**Hospital3 1280**] Hospital on
[**2177-9-30**] following three days of severe abdominal
pain. Initially, the patient was believed to have had a
perforated viscus. However, further evaluation suggested
that the etiology of the patient's severe abdominal pain was
actually pancreatitis. His lipase level was greater than
[**2175**]. Initially, he hemoglobin and hematocrit were within
He was admitted to their Intensive Care Unit initially,
mainly due to the severe elevation of his lipase. At that
time he was very clinically stable. A CT of his abdomen
revealed nonhemorrhagic pancreatitis. Within 24 hours,
however, the patient became severely hemoconcentrated with a
hematocrit of 56%. His serum calcium dropped to 6.9 mg/dL.
His serum phosphate level dropped to 1 mg/dL. His lactate
level, though not confirmed, was reported at almost 60, and
the patient also developed a marked increase in his creatine
kinase to over 8000.
The patient's abdomen became markedly distended, his
respirations became increasingly labored, so he was intubated
for respiratory distress. Antibiotics were initially started
with ceftriaxone, but then changed empirically to imipenem.
He was also treated with intravenous esmolol for an episode
of supraventricular tachycardia. His partner requested that
he be transferred to [**Hospital1 69**] for
further care.
MEDICATIONS ON TRANSFER: Heparin, Effexor, total parenteral
nutrition, Fentanyl patch, Valium, nitroglycerin paste,
Sandostat, esmolol, Vasotec, nifedipine, imipenem.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus disease diagnosed in [**2162**].
His CD4 in [**2177-6-1**] was in the 500 range. His CD4 nadir
was 150 in [**2170**]. He does have a history of Kaposi sarcoma on
his legs in [**2167**] as his only acquired immunodeficiency
syndrome defining condition to date. In [**2176-12-2**] he
had been started on a new antiretroviral regimen of
stavudine, lamivudine, and Kaletra.
2. Hypertension.
3. An episode of abdominal pain diagnosed as pancreatitis
in [**2150**].
4. Kidney stones.
5. Herpes simplex stomatitis.
6. Psoriasis.
7. Depression.
ALLERGIES: SULFA and DAPSONE. He developed a rash with both
of these. He also developed fever and low-grade rash with
NEVIRAPINE.
SOCIAL HISTORY: The patient does not smoke and only drinks
rare amounts of alcohol.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 103.8,
blood pressure 165/70, pulse 130, respiratory rate 10,
satting 99%. In general, the patient was sedated and
intubated. Head, ears, nose, eyes and throat revealed
ET-tube in place. Chest was clear to auscultation
bilaterally. Cardiovascular was hyperdynamic, tachycardic,
and regular. The abdomen was mildly distended, soft, with no
bowel sounds. Extremities were with no edema. Neurologic
examination revealed unresponsive to stimuli. Pupils were
miotic and reactive bilaterally.
LABORATORY DATA ON PRESENTATION: White blood cell count 7.7,
hematocrit 35, platelets 125. Sodium 147, potassium 3.6,
chloride 105, bicarbonate 30, blood urea nitrogen 16,
creatinine 0.8, glucose 158. ALT 57, AST 111, alkaline
phosphatase 61, total bilirubin 3.8. Calcium 7.8,
magnesium 2.2, phosphate 2.1. Albumin 2.7, pH of
7.43/55/124, lactate 3.3, amylase 195, lipase 45.
RADIOLOGY/IMAGING: Abdominal CT from [**2177-10-1**],
showed diffuse pancreatitis with no evidence of free air or
necrosis. No abscesses were seen. There was fatty
infiltration of the liver, small bilateral pleural effusions
were noted. There was positive pelvic and abdominal fluid
present.
Echocardiogram revealed left ventricular hypertrophy and
normal ejection fraction. There was a septal wall motion
abnormalities noted, trace mitral regurgitation. No
vegetations were noted.
Electrocardiogram revealed sinus tachycardia with left atrial
enlargement, poor R wave progression was noted.
HOSPITAL COURSE:
1. GASTROINTESTINAL: The patient was admitted with severe
pancreatitis. He was treated empirically with antibiotics;
initially with imipenem for a prolonged course. Serial CT
scans were followed of his abdomen to evaluate the
progression of his pancreatitis. Evidence of necrosis of his
pancreas was noted; however, there was no evidence to suggest
an infected phlegmon.
The Surgery Service was following as a consultant on the
case. Given the gradual improvement of the patient's
pancreatitis, though slow, they recommended conservative
supportive management. Discussion was held regarding whether
to aspirate fluid from near the pancreas. However, given the
severity of his pancreatitis, it was felt any interventional
procedures in the region of his pancreas could potentially
worsen his course.
He was aggressively supported from a nutrition and
electrolyte standpoint. He remained on total parenteral
nutrition during essentially the bulk of his entire course in
the hospital. With regard to his pancreatitis, CT scan on
[**2177-11-4**] showed minimal radiographic findings for
pancreatitis.
It was not entirely clear as to the etiology of his
pancreatitis at that point in time. He has no strong history
of alcohol use. He has no history of gallstones. There is
some thought that it could be related to his human
immunodeficiency virus antiretroviral regimen. That is not
entirely clear at this point; however, his antiretrovirals
have been held since his admission to the hospital.
On [**2177-10-25**], the General Surgery Service evaluated
the patient regarding the possibility of acalculous
cholecystitis. The patient had a rising total bilirubin
which went to 2. His alkaline phosphatase had also elevated
over the course of several days. Given his long/severe
illness, Surgery felt that he certainly was at risk for
acalculous cholecystitis. They recommended a HIDA scan.
On the HIDA scan, the gallbladder was not visualized, and
this was interpreted as a positive study. Radiology was
called in to place a cholecystostomy tube. This was done on
[**10-26**]. This tube needs to stay in for at least three
weeks to allow a track to mature. He was placed empirically
on ciprofloxacin and Flagyl to cover his biliary tree while
he was draining via the cholecystostomy tube. His total
bilirubin and alkaline phosphatase defervesced over the
course of the next few days.
The patient was fed, as noted above, via total parenteral
nutrition during the course of this admission.
Gastrointestinal was unable to place an endoscopic post
pyloric feeding tube due to fair amount of edema near the
pylorus. Eventually an oral gastric tube was placed, and
tube feedings were eventually started via the oral gastric
tube which the patient tolerated gradually as morphine was
weaned off as sedation.
2. INFECTIOUS DISEASE: The patient had persistent spiking
very high temperatures throughout the course of his
admission. His temperatures at one point had spiked to 105
or greater for several days. No clear source of infection
ever grew from culture data. Most of the culture data
appeared to grow what were likely colonizers including
enterococcus. As noted above, the patient was on a long
course of imipenem. He also had Diflucan on board for fungal
coverage of his pancreas.
He was treated with a 2-week course of ciprofloxacin and
Flagyl for acalculous cholecystitis, and he had a
cholecystostomy tube placed for drainage.
The patient was found to have fairly significant sinusitis.
The otolaryngology service was consulted, and they performed
a sinus aspiration; however, this aspirate did not grow
anything that appeared to be a pathogen.
The patient eventually developed a rash which was felt to be
secondary to imipenem given the 3-week course. His imipenem
was discontinued, and he was covered empirically with
levofloxacin, Flagyl, and vancomycin. These were then
changed as Infectious Disease recommended not treating
enterococcus which grew in his urine.
A lumbar puncture was performed on [**2177-10-30**]. The
cerebrospinal fluid was not impressive for evidence of a
meningitis as there was only 1 white blood cell in tube #4.
The patient did grow Staphylococcus epidermitis from an
arterial line blood culture as well as from the arterial line
tip that was discontinued. He was treated with a 7-day
course of vancomycin.
Eventually, the patient's fever curve defervesced to the
point where he became afebrile for several days. At the time
of this dictation, the patient has been afebrile. He
currently remains on vancomycin to treat the arterial line
infection.
3. EARS/NOSE/THROAT: The patient had notable left-sided
neck swelling. This was concerning for abscess or for
lymphadenopathy. The ENT Service and General Surgery Service
both evaluated the patient.
An ultrasound was performed which showed possible suggestion
of reactive lymphadenopathy. A CT scan of the neck was then
performed as followup, and this showed no evidence of
pathologic lymph nodes, and there was also no evidence of
abscess.
The Dental Service was also consulted to evaluate his mouth
as he had a significant tongue lesion. The tongue lesion
gradually improved, and the Dental Service felt there was no
concern based on their clinical examination that there could
be a dental abscess as the source of his fevers.
4. PULMONARY: The patient remained intubated and on the
ventilator for essentially the bulk of his admission to the
Medical Intensive Care Unit. He did have bilateral pleural
effusions; however, his ventilatory status was relatively
stable throughout admission. He did have one period where he
had increasing oxygen requirements. However, this appeared
to be in the setting of positive fluid balance and mild
congestive heart failure. Diuresis with good results seemed
to improve his oxygenation, and this resolved as an issue.
The patient had a tracheostomy performed during this
admission, and on [**2177-11-12**], the patient began trials
on trach mask ventilation. The patient seemed to be
tolerating this quite well. If anything, the main impediment
in extubating from the ventilator was mainly regarding levels
of sedation on Ativan and morphine drips.
5. CARDIOVASCULAR: The patient was hypertensive throughout
most of his admission. It was entirely clear as to the
etiology of the tachycardia and hypertension. There was some
concern that he could have been withdrawing from alcohol,
though that seemed unlikely given he does not have a
significant alcohol use history. At one point, the patient
required continuous intravenous labetalol drip to control his
blood pressure and pulse. Eventually this was discontinued.
The recurrence of his hypertension and tachycardia seems now
to be in the setting of titration down of his Ativan and
morphine drip sedations.
Currently, the patient is being maintained on increasing
doses of Lopressor as well as an ACE inhibitor. Labetalol
was started orally to add alpha blockade for potential
withdrawal-type symptoms that he may be experiencing as
sedation is weaned off.
6. NEUROLOGY: There were several episodes early on during
the patient's admission where he had episodes of what
appeared to be rigors or seizures. These often seemed to be
in the setting of being severely hypertensive and
tachycardic. His neurologic examinations during these
episodes was not strongly suggestive of seizure. An
electroencephalogram was performed to rule out this
possibility, and the electroencephalogram did not show any
evidence of seizure-like activity. These episodes
spontaneously resolved, and there have been no episodes of
rigors in the last two weeks of his admission.
As noted, it appears right now that the patient may be
suffering some withdrawal symptoms from Ativan and morphine
sedation being weaned off. He has symptoms of diaphoresis,
tachycardia, and hypertension. He does deny being in any
discomfort; however, he will be symptomatically treated as
necessary. Ativan on a low-dose scheduled basis will be
started which can also be weaned gradually.
7. RENAL: Early in the course there was some suggestion
that the patient had rhabdomyolysis with creatine kinases in
the 8000 range with negative MB fractions. That did resolve
with aggressive hydration. He has generally maintained good
urine output, and his creatinine has been stable throughout
this admission.
8. HEMATOLOGY: The patient's hematocrit fluctuated
throughout admission. At some points he did require
transfusions with packed red blood cells. Hemolysis
laboratories were negative. There was no evidence of DIC.
There was no evidence of active gastrointestinal bleeding.
A bone marrow biopsy was performed by the patient's primary
care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2148**]. This showed no evidence of
malignancy or overt infection. Unfortunately, cultures were
not performed by the Microbiology Laboratory.
9. FLUIDS/ELECTROLYTES/NUTRITION: The patient was
maintained on total parenteral nutrition throughout the
course of this admission. He did have quite a good response
to parenteral nutrition, and his albumin at the time of this
dictation was 3.7. He has been transitioned to tube
feedings. There has been some trouble with residuals on his
tube feeds, and this is felt likely to be related to the
level of continuous narcotics he is receiving for sedation.
Currently, though, he is tolerating increases in his tube
feeds, and eventually we will transition off the total
parenteral nutrition.
10. ACCESS: The patient has had multiple central lines
placed and removed out of concerns for infection. At this
current time, the patient will have a peripherally inserted
central catheter line placed on [**2177-11-14**], for longer
term intravenous access. He also has a tracheostomy and an
oral gastric tube. We plan to have him evaluated by Speech
and Swallow Service to assess his swallowing functioning as
he may be able to soon start oral feedings.
11. OPHTHALMOLOGY: The patient had an evaluation by the
Ophthalmology Service for concerning eye lesions. They felt
that this was most likely exposure keratitis. They also
performed a funduscopic examination at the bedside and felt
that there was no evidence for cytomegalovirus retinitis at
this time. He was treated with erythromycin eye ointments,
and his eyes were taped closed to prevent further exposure.
The findings near his eyelids have significantly improved
over the course of the last few weeks.
12. DERMATOLOGY: The patient had a fairly significant
sacral/coccyx decubitus ulcer. The Surgery Service did
evaluate the ulcer and was unable to express pus from it.
They debrided some of the tissue surrounding the ulcer.
There was good vitalized tissue in the region that they
debrided. He was maintained on b.i.d. dressing changes with
Duoderm and Santyl cream applied to the ulcer. Surgery did
not feel that his ulcer was overtly effected.
DISCHARGE DIAGNOSES:
1. Severe pancreatitis.
2. Acalculous cholecystitis.
3. Hypertension.
4. Persistent high fevers.
5. Status post tracheostomy.
6. Sinusitis.
7. Rhabdomyolysis.
8. Question imipenem allergy with rash.
9. Psoriasis.
10. Depression.
11. History of kidney stones.
12. History of herpes simplex stomatitis.
MEDICATIONS ON DISCHARGE: (At the time of this dictation)
1. Nystatin swish-and-swallow.
2. Univasc 15 mg p.o. b.i.d.
3. Carafate 1 g t.i.d.
4. Santyl cream q.d. to coccyx.
5. Peptamen tube feeds.
6. Vancomycin 1 g q.12h. to complete on [**2177-11-14**].
7. Insulin sliding-scale.
8. Combivent meter-dosed inhaler.
9. Reglan.
10. Lopressor 75 mg p.o. b.i.d.
11. Labetalol 200 mg p.o. b.i.d.
12. Ativan 1 mg intravenous q.6h.
13. Demerol 100 mg intravenous q.4h. p.r.n.
14. Tylenol p.r.n.
15. Haldol p.r.n.
16. Morphine p.r.n.
Note: There will be a Discharge Summary Addendum to follow
this Discharge Summary upon the patient's discharge to
rehabilitation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 16017**]
MEDQUIST36
D: [**2177-11-13**] 16:53
T: [**2177-11-13**] 15:52
JOB#: [**Job Number **]
Name: [**Known lastname 2510**], [**Known firstname **] Unit No: [**Numeric Identifier 2511**]
Admission Date: [**2177-10-4**] Discharge Date:
Date of Birth: [**2125-12-24**] Sex: M
Service:
ADDENDUM:
DISCHARGE MEDICATIONS: Lopressor 100 mg by NG tube tid,
Ativan 1 mg IV q 6 hours, Labetalol 800 mg OGT [**Hospital1 **], Nystatin
swish and swallow 5 cc q 6 hours, Univasc 50 mg through NG
tube [**Hospital1 **], Carafate 1 gm by NG tube tid, Regular Insulin
sliding scale, Combivent 6 puffs q 6 hours, Reglan 10 mg IV
tid, Vancomycin 1 gm q 12 hours, discontinue on [**2177-11-30**],
Levofloxacin 500 mg IV q d, discontinue [**2177-11-30**], Flagyl 500
mg IV q 8 hours, discontinue [**2177-11-30**], Vitamin C 500 mg by NG
tube [**Hospital1 **], Zinc Sulfate 200 mg by NG tube q d, prn Demerol 100
mg IV q 4 hours, Tylenol 650 mg by NG tube q 4-6 hours prn,
Haldol 4 mg IV q 8 hours prn, MSO4 1-2 mg IV or subcu q 4-6
hours prn, Lactulose 30 cc by NG tube tid prn.
OTHER TREATMENTS:
1. Please check viral load.
2. Please check CD4 count.
3. Please desensitize patient to Bactrim for PCP prophylaxis
as per patient's outpatient ID attending, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
4. Discontinue T tube mid [**Month (only) **], about [**2177-12-8**].
5. Wet to dry dressings to decubitus ulcer tid.
Dictated By:[**Name8 (MD) 2512**]
MEDQUIST36
D: [**2177-11-21**] 16:39
T: [**2177-11-21**] 18:49
JOB#: [**Job Number 2513**]
Name: [**Known lastname 2510**], [**Known firstname **] Unit No: [**Numeric Identifier 2511**]
Admission Date: [**2177-10-4**] Discharge Date:
Date of Birth: [**2125-12-24**] Sex: M
Service:
ADDENDUM: On [**11-17**] the patient continued to be febrile with
temperatures up to 104.6. On further evaluation it was
discovered that he had a large decubitus ulcer. Plastic
surgery was contact[**Name (NI) **] and evaluated the patient and felt
convinced that the ulcer was rather shallow and they
recommended normal saline wet to dry dressings tid and also
continued antibiotic coverage for 21 days. The patient was
started on Vanco, Levo and Flagyl on [**2177-11-18**] and to complete
a course of 21 days. Ongoing discussions occurred regarding
a gallium scan that was obtained on the 21st after 48 hours
of injection. The gallium scan is reported preliminarily as
negative with no evidence of infection. The patient
continues to have fevers though the fever curve is down.
Over the last 24 hours has been around 100 to 101, was
104-105 before. The patient was seen by neurology on
[**2177-11-18**] and they felt that the patient's generalized
weakness was from deconditioning and a toxic metabolic
picture from his general medical condition. The patient had
occasional tachypnea while in the unit, prompting his
pressure support to be increased to 25 and his PEEP to 5.
Over the last two days, the 20th and the 21st the patient's
pressure support was decreased, most recently to 10. The
patient is very anxious at baseline and becomes tachypneic
during those episodes. His amylase and lipase have
normalized. His LFTs continue to show total bilirubin is
mildly elevated, last check was 2.5 on [**2177-11-21**] with a normal
amylase. I have discussed patient's T tube with surgery who
recommend keeping the tube in for [**1-4**] more weeks for
discontinuation at some point in mid [**Month (only) **]. Would continue
to follow LFTs. The patient also had a Dobbhoff tube placed
at bedside for feedings and his feedings were also changed to
Ultracal with a goal rate of 100 cc per hour.
The other important addended issue is that the patient has a
CD4 count of 217 with the infectious disease doctors
[**First Name (Titles) 2514**] [**Last Name (Titles) 2515**] against PCP. [**Name10 (NameIs) **] patient is
allergic to Sulfa and Dapsone. Please see page 1 for further
details about decision regarding recommendations for PCP
[**Name Initial (PRE) 2515**].
CONDITION ON DISCHARGE: Improved.
DISCHARGE DIAGNOSIS: As above.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Name8 (MD) 2512**]
MEDQUIST36
D: [**2177-11-21**] 16:03
T: [**2177-11-21**] 17:22
JOB#: [**Job Number 2516**]
Name: [**Known lastname 2510**], [**Known firstname **] Unit No: [**Numeric Identifier 2511**]
Admission Date: [**2177-10-4**] Discharge Date: [**2177-11-24**]
Date of Birth: Sex: M
Service:
DISCHARGE SUMMARY ADDENDUM: This is an addendum to a
previously dictated discharge summary. Please see previous
discharge summary for details of discharge medicines and the
hospital course.
The patient was in the hospital for an additional two days
waiting for availability of a rehabilitation bed. The patient
had no change in his status, no change in his medicines. He
continued to have fevers but plan after his negative gallium
scan was that he was not going to be kept in the hospital for
this. The patient's plan was to follow up with his Infectious
Disease doctor and to consider desensitization from Bactrim
as previously noted.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Name8 (MD) 2512**]
MEDQUIST36
D: [**2178-5-13**] 15:02
T: [**2178-5-18**] 09:19
JOB#: [**Job Number 2517**]
|
[
"E879.8",
"707.0",
"789.5",
"577.0",
"038.19",
"428.0",
"996.62",
"575.10",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.72",
"41.31",
"31.1",
"51.03",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
15330, 15652
|
16864, 20628
|
20686, 22045
|
15679, 16840
|
4270, 15308
|
151, 1730
|
1756, 1899
|
1921, 2635
|
2652, 4251
|
20653, 20664
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,723
| 127,135
|
6897+55794
|
Discharge summary
|
report+addendum
|
Admission Date: [**2209-7-31**] Discharge Date: [**2209-8-20**]
Date of Birth: [**2146-1-30**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
"sepsis, pneumonia"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 63 yo Cantonese-only speaking male with h/o type 2
diabetes, hypertension, medullary sponge kidney (with chronic
renal insufficiency) who now presents minimally responsive and
lethargic from home. Patient was not seen over the weekend by
family which is unusual, went to check in on him today and found
in fetal position in bed. Called EMS. Blood glucose was in 300s.
Patient did not c/o of any illness prior to being found
minimally responsive.
.
In the ED, initial vs were: 98.6 146 132/108 16 98%. A left IJ
was placed for access. Pt had fever to 104.8 in ED. Pt was
given PR Tylneol. EKG showed sinus tachycardia at 143. Blood cx
and urine cx were sent and pt as given Vanc/Cefepime. CT head
was neg for any acute intracranial process. CT torso showed a
RLL pnemonia. UA was neg for infection. Utox and Stox were
neg. Labs revealed normal bicarb, normal lactate and Cr of 4.9
(baseline of 2.5). CBC showed WBC of 11.7 with 7% bands. Pt
received a total of 4L NS but was still hypotensive with SBP in
80s. Thus, Levophed was started prior to transfer to ICU.
Vitals on transfer were T 99.9 HR 83 BP 81/63 RR 14 O2 sat
100% on 4L.
.
On arrival to the ICU, pt is somnolent, noncommunicative.
Daughter at bedside states that he was in his USOH on Saturday.
Past Medical History:
1. Type 2 diabetes mellitus
2. Chronic renal insufficiency (baseline creatinine of 2.1-2.5)
3. Hypertension.
4. Nodularis porrigo; status post phototherapy.
5. Medullary sponge kidney.
Social History:
lives at home alone. denies T/E/D.
Family History:
NC
Physical Exam:
Vitals: T: 97.7 BP: 94/57 P: 90 R: 13 O2: 95% on 4L NC
General: somnelent, not responding to voice, touch
HEENT: sclera anicteric, dry mucous membranes, bilat eyelids
crusty and with drainage
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation, bilat crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no erythema or ulcers
Pertinent Results:
Admission Labs: [**2209-7-31**]
URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0
URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-150 KETONE-10
BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG
URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.009
PT-11.2 PTT-32.1 INR(PT)-0.9
PLT SMR-NORMAL PLT COUNT-192
WBC-11.7* RBC-4.31* HGB-13.1* HCT-38.0* MCV-88 MCH-30.5
MCHC-34.6 RDW-14.0
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
CALCIUM-10.9* PHOSPHATE-3.9 MAGNESIUM-1.4*
LIPASE-36
ALT(SGPT)-53* AST(SGOT)-84* CK(CPK)-764* ALK PHOS-63 TOT
BILI-1.4
GLC-388* UREA N-72* CREAT-4.9*# SODIUM-142 POTASSIUM-4.2 CL-101
CO2-22
LACTATE-1.8
[**2209-8-10**] 05:51AM BLOOD Hapto-342*
[**2209-8-7**] 04:22AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
[**2209-8-6**] 08:33PM BLOOD HIV Ab-NEGATIVE
[**2209-8-7**] 04:22AM BLOOD tTG-IgA-2
[**2209-8-7**] 04:22AM BLOOD HCV Ab-NEGATIVE
EKG [**7-31**]:
Sinus tachycardia with increase in rate as compared with
previous tracing
of [**2201-4-28**]. Otherwise, no diagnostic interim change.
CXR [**7-31**]:IMPRESSION: Opacity over the right midlung corresponds
to right lower lobe pneumonia revealed on subsequent CT Torso.
CT CHEST ABD PELVIS [**7-31**]: IMPRESSION:
1. Right lower lobe pneumonia.
2. Atrophic left kidney.
KUB [**8-2**]:IMPRESSION: Mildly dilated loops of small bowel,
suggestive of ileus, although not entirely specific.
Renal US [**8-3**]:IMPRESSION:
1. No evidence of nephrolithiasis or hydronephrosis.
2. Atrophic left kidney.
3. Subcentimeter lower pole right renal cyst.
4. Medullary sponge kidney.
KUB [**8-2**]:IMPRESSION: Small [**Last Name (un) 12376**] distension without clear
colonic gas concerning for small bowel obstruction.
Stable KUBS on [**8-3**] - clinically without SBO.
RUQ US [**8-7**] IMPRESSION:
Limited abdominal ultrasound with normal liver echogenicity.
There is no
biliary dilatation.
Gastrointestinal mucosal biopsies:
A. Antrum: Corpus/antral mucosa with focal, mild edema and
vascular congestion.
B. Duodenum: Duodenal mucosa, within normal limits.
C. Terminal ileum: Small intestinal mucosa, within normal
limits.
D. Random colon: Colonic mucosa, within normal limits.
Cultures were all negative for Cdiff, C.diff PCR, legionella.
There were + blood and urine cultures likely due to
contamination of coagulase negative staph. Urine culture from
[**2209-8-17**] showed 10-100,000 enterococcus sensitive only to
Linezolid
Discharge Labs: [**2209-8-20**] 07:20AM
WBC-6.5 RBC-3.90* Hgb-12.1* Hct-35.6* MCV-91 Plt Ct-343
Glucose-143* UreaN-64* Creat-3.2* Na-139 K-4.7 Cl-102 HCO3-25
AnGap-17
Brief Hospital Course:
63 yo Cantonese-only speaking male with h/o type 2 diabetes,
hypertension, medullary sponge kidney (with chronic renal
insufficiency) admitted with altered mental status and fever,
found to have a RLL pneumonia. He subsequently developed profuse
diarrhea of unclear etiology. Infectious workup has been
negative. Pt empirically treated for C.diff with PO vancomycin,
but this was stopped ultimately when c diff PCR returned
negative. He was also found to have a new insulin dependence
for which he was started on 70/30 and a sliding scale. Hospital
course was complicated by renal failure; detailed below.
# Sepsis/Pneumonia, resolved: In the ICU, the pt was
hypotensive, was given several boluses of IVF, but still
required support on Levophed, in the setting of pneumonia. Pt
was given Vanc/Cefepime in ED and CT revealed RLL pneumonia. UA
was neg for infection. Blood and urine cx were sent and were
unrevealing of an infectious cause. Other less likely sources
of infection included GI (though CT abd/pelvis negative), CNS
(no LP performed), skin/soft tissue. Upon arrival to ICU, abx
were narrowed to CTX/Levo for severe CAP. There were no
indications for HCAP coverage and no suspicion for aspiration.
Pt was able to be weaned off Levophed by the next morning and
his BPs remained stable. Lactate bumped up to 3, then trended
down to wnl. ABX were changed to cefepime/vanco on the 5th day
of his course due to a lack of improvement in fevers and the
onset of diarrhea. He continued IV antibiotics for a total 8
day course.
# DKA, DM: His anion gap metabolic acidosis on admsision was
likely due to DKA given ketones in UA. Tox screen was neg. Pt
was agressively hydrated with 4L NS in ED, then [**3-14**] more L of LR
in ICU. Pt was given 10U regular insulin, then started on 8U/hr
insulin gtt. A few hours later, anion gap closed. K was
repleted as needed. Once blood glucose went <250, pt was
switched to D5 1/2 NS. Pt was then transitioned to SC NPH [**Hospital1 **]
with ISS, and diet was advanced. [**Last Name (un) **] was consulted and per
their recs, he was switched to Lantus with an ISS. However, the
patient's family was unable to accomodate administering insulin
3 times a day so his regiment was changed to Humulin 70/30 18
units SC BID. His daughter will administer his evening insulin,
and his son will administer his morning insulin. Both were given
diabetic teaching prior to discharge, and patient is being set
up with a home VNA for additional monitoring and diabetic
teaching.
# AMS/Toxic encephalopathy: Differential was broad including
electrolyte abnormality (labs wnl), intracranial pthology (CT
head neg), toxins (Utox and Stox neg), hypoxia/hypercarbia
(satting well on 4L NC), endocrine abnormalities, CNS infection
but most likely [**1-11**] sepsis vs DKA. RLL pneumonia was treated as
above. DKA was treated as above. ABG revealed metabolic
acidosis. CT head in ED showed no acute intracranial process.
MS improved significantly back to baseline with treatment of
DKA.
# Acute on Chronic renal failure: The patient's Cr on admission
was 4.9 with baseline of 2.5. He has a history of medullary
sponge kidney. His acute renal failure was initially thought to
be pre-renal but urine sediment and high FENA were more
suggestive of ATN [**1-11**] ischemia from hypotension. Nephrotoxins
were avoided and meds were renally dosed. I/Os were monitored
with a Foley. Cr downtrended. The renal team followed the
patient throughout his admission. With the diarrhea, the
patient's HCO3 was persistently low despite LR so a HCO3 gtt was
started and electrolytes monitored [**Hospital1 **] - ultimately his acidosis
and acute renal failure resolved. Calcitriol was initiated
given hypocalecemia. He should have repeat electrolytes checked
two days after discharge; prescription for lab draw was given to
patient. At the time of discharge he was auto-diuresing with
urine output of 2-3L per day. He was encouraged to drink to
thirst when he is discharged home. He should be set up with
outpatient nephrology as he has not seen a nephrologist in
several years.
#Rhabdomyolysis: The patient was also in rhabdomyolysis with
CK>700 upon admission which rose during his hospitalization. He
recieved aggressive IVF resuscitation and CK eventually trended
towards normal.
# Diarrhea: On [**8-2**], patient was noted to have diarrhea. He
had copious watery diarrhea (3L a day) for several days, with
negative C diff and stool studies including microsporidium and
giardia; viral cultures, O&P were negative. TTG and IgA were
negative C.diff PCR was negative. EGD and Colonoscopy with
biopsies were all negative. Ultimately his diarrhea resolved.
Diarrhea was ultimately felt to have most likely resulted from a
culture negative viral enteritis.
#Transaminitis: They were likely [**1-11**] rhabdomyolysis and
downtrended. RUQ U/S was unremarkable for any acute disease.
Hepatitis serologies showed immunity to Hep B.
#Hypertension:The patient was on metoprolol and cozaar at home.
Cozaar was held given [**Last Name (un) **]. The patient's BP meds were
discontinued and he remained normotensive with blood pressures
in the low 100's prior to discharged. These medications can be
restarted prn.
#Conjunctivitis: The patient had some evidence of conjunctival
irritaiton and was treated with erythromycin ophthalmic with
improvement.
#Anemia - he developed severe anemia during the hospitalization
felt to be due to a combination of multiple factors including
malnutrition, CKD, significant phlebotomy, and possibly viral
myelosuppression. He required a blood transfusion - one unit
was given on [**2209-8-10**] with improvement of hct from 22 to 28. Hct
remained stable after. There were no clinical signs of
bleeding.
Medications on Admission:
- Atenolol 25 mg by mouth once per day.
- Glucotrol-XL 5 mg by mouth once per day.
- Hydroxyzine 50 mg by mouth three times per day.
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
2. Glucometer
Glucometer
Please dispense one, use as directed.
3. lancets Misc Sig: One (1) Miscellaneous four times a
day.
Disp:*qs qs* Refills:*0*
4. glucose test strips
please dispense QS
QID
No reflills
5. needles
Insulin Needles - 21 gauge
QID
Dispense: QS
6. syringes
please dispense qs
QID
No refills
7. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: As directed units Subcutaneous twice a day: 17 units in the
morning and 16 units at night. Check your blood sugar before
taking your insulin and call your primary care doctor before
taking your insulin if your blood sugar is below 100.
Disp:*1 month's supply* Refills:*2*
8. Outpatient Lab Work
Please have a Chem 7 checked on [**2209-8-22**] and have the results
faxed to your primary care doctor, Dr.[**Last Name (STitle) **], at [**Telephone/Fax (1) 26001**].
9. Humalog 100 unit/mL Solution Sig: As directed units
Subcutaneous twice a day: Please administer according to the
sliding scale you were provided with.
Disp:*1 month's supply* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Severe diarrheal illness with resultant acute kidney injury and
massive volume depletion, etiology unknown, but felt to
represent a viral enteritis
Chronic kidney disease
Diabetes, insulin-dependent
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 are being discharged home for further management of your
diabetes. Your daughter will give you your insulin at night, and
your son will give you your insulin in the morning. You will
also have a visiting nurse to ensure your blood sugars are
staying within a safe range. You will need to follow-up with
your primary care doctor within one week of discharge and get a
referral to a kidney specialist. You will also need to follow-up
at the [**Hospital **] clinic for your diabetes.
Followup Instructions:
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up
appointment within one week of discharge. You should also keep
the following previously scheduled appointments:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2209-9-13**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Name: [**Known lastname 1105**],[**Known firstname **] [**Last Name (un) 4465**] Unit No: [**Numeric Identifier 4466**]
Admission Date: [**2209-7-31**] Discharge Date: [**2209-8-20**]
Date of Birth: [**2146-1-30**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1824**]
Addendum:
Prior to discharge the patient was found to have 10-100,000
enterococcus in his urine. He was asymptomatic, afebrile, and
with a normal WBC, and this was felt to represent asymptomatic
bacteriuria rather than a true urinary tract infection. As a
result, no antibiotics were given. If the patient develops
symptoms he should have a repeat UA and urine culture sent.
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
[**First Name11 (Name Pattern1) 634**] [**Last Name (NamePattern4) 1837**] MD [**MD Number(2) 1838**]
Completed by:[**2209-8-20**]
|
[
"728.88",
"275.41",
"284.1",
"372.30",
"008.8",
"275.3",
"753.17",
"692.9",
"250.12",
"038.9",
"790.4",
"560.1",
"486",
"518.81",
"250.42",
"995.92",
"585.4",
"785.52",
"584.5",
"403.90",
"599.0",
"276.0",
"276.50",
"276.8",
"349.82",
"455.3",
"041.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"45.25",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14631, 14839
|
5188, 10968
|
289, 295
|
12605, 12605
|
2486, 2486
|
13296, 14608
|
1890, 1894
|
11152, 12291
|
12383, 12584
|
10994, 11129
|
12787, 13273
|
5013, 5165
|
1909, 2467
|
229, 251
|
323, 1607
|
2502, 4996
|
12620, 12763
|
1629, 1821
|
1837, 1874
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,729
| 145,106
|
22182
|
Discharge summary
|
report
|
Admission Date: [**2106-9-7**] Discharge Date: [**2106-9-11**]
Date of Birth: [**2052-6-19**] Sex: M
Service: MEDICINE
Allergies:
Antidepressants O.U. Classifier
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Cough and DOE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(history is difficult to obtain as patient is poor historian)
54 year-old M with severe COPD on home O2 (noncompliant), OSA,
HTN, multiple psychiatric diagnoses admitted with cough and
respiratory distress.
The patient complains of 2 months of intermittent left sided
chest pressure, dry cough x 2 weeks and progressive dyspnea.
Per patient, the chest pain is worse in the morning /night,
improves with activity and is not affected by deep breath. He
presented to the ED because he was having difficulties sleeping
through the night due to shortness of breath. He denied any
fevers, abdominal pain, change in bowel movements, dysuria or
leg swelling.
In the ED, initial VS: T 97 P 97 BP 144/92 SaO2 100% on NRB. O2
was weaned to RA with patient becoming hypoxic in the 80% on RA.
Initial labs notable for leukocytosis to 16.8 with mild left
shift. VBG with pH of 7.33 and bicarb of 32. While in the ED,
he complained of chest discomfort, given ASA PR and morphine
with resolution of symptoms and EKG with no acute changes. Also
noted to be agitated, requiring 5mg halidol x 1. Given
nebulizers, azithromycin/ ceftriaxone/ levo and admitted to the
MICU for further evaluation and treatment.
On arrival to the MICU, patient breathing comfortably on NRB,
with SaO2 of 100%. He was drowsy and repeatedly dozed off
during interview while rest of speech was garbled and difficult
to understand. ABG revealed 7.25/ 80/ 64. Of note, patient had
similar presentation in [**1-27**] where he underwent emergent
intubation for hypoxic resp distress.
ADMITTING TEAM ACCEPT NOTE:
See the MICU Green Admission note for further details. Briefly,
this is a 54M with severe COPD on home O2 (noncompliant), OSA,
HTN, multiple psychiatric diagnoses admitted with cough and
progressively worsening dyspnea. In the ED, the patient was
initially 100% on NRB, but became hypoxic in the 80% when weaned
to RA. Initial labs notable for leukocytosis to 16.8 with mild
left shift. VBG with pH of 7.33 and bicarb of 32. While in the
ED, the patient was given nebulizers,
azithromycin/ceftriaxone/levofloxacin and admitted to the MICU
for further evaluation and treatment. Of note, patient had
similar presentation in [**1-27**] where he underwent emergent
intubation for hypoxic resp distress.
On arrival to the MICU, patient was continued on levofloxacin
and started of prednisone 60 mg for assumed COPD exacerbation.
Initial ABG revealed 7.25/80/64, but improved to 7.31/71/100. He
weaned from NRB to 3L NC, and was satting 94% on 3L NC at the
time of transfer.
On the floor, the patient reports feeling tired, but breathing
comfortably with on nasal cannula. Patient is asking for BiPAP
in order to sleep, for which respiratory therapy has been
notified. Patient denies chest pain.
Past Medical History:
- Incontinence, wears "diapers"
- HTN
- COPD
- OSA on home BiPAP 16/8
- LBP
- Type II diabetes
Past Psychiatric History:
- Dx: [**Date Range 8372**], ADD, OCD since teenage years.
Hosps: first age 15, last 3 years ago, for bipolar symptoms.
Says total of "three dozen."
Previous treatments; ECT x 3, last 7 years ago.
Reports becoming manic on "all the antidepressants."
Outpt: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for psychopharm and therapy, in
[**Location (un) **] [**Telephone/Fax (1) 57903**].
Denies h/o SAs/SIb or violence to others.
Lives in [**Location 57904**] independent housing, attends [**Location (un) 15852**] house.
Social History:
per OMR as unable to obtain from pt due to mental status
Lives alone in [**Hospital1 **] Family and Social Services Apartment in
Brooline ([**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **]). Says that he has a undergrad degree
from SUNY [**Location (un) **] and took some master's level courses in Pol
science and history. Mother lives in [**Name (NI) **], [**Name (NI) 531**]. He speaks
to her by phone several times per day and she provides him some
financial support. On SSDI. No arrest history. Has not worked
since being a social studies and English teacher in the
[**2065**]-80s.
- Tobacco: 1 ppd x many years
- Alcohol: denies
- Illicits: denies
Family History:
Father, sister, [**Name2 (NI) **]. aunt with bipolar.
Physical Exam:
VS: Temp: afebrile BP: 104/55 HR:86 RR: 17 O2sat 87% on 35%
FiO2
GEN: lethargic, repeatedly dosing off during exam, garbled
speech
HEENT: PERRL, EOMI, anicteric, MMM
NECK: no jvd, no thyromegaly or thyroid nodules
RESP: breathing comfortably with no accessory muscle use, CTA
b/l with limited air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: oriented x 3
Pertinent Results:
Admission labs:
[**2106-9-7**] 09:50PM BLOOD WBC-16.8*# RBC-4.89 Hgb-13.8* Hct-41.5
MCV-85 MCH-28.3 MCHC-33.3 RDW-13.1 Plt Ct-264
[**2106-9-7**] 09:50PM BLOOD Neuts-76.8* Bands-0 Lymphs-17.3*
Monos-3.9 Eos-1.3 Baso-0.7
[**2106-9-7**] 09:50PM BLOOD PT-13.2 PTT-24.3 INR(PT)-1.1
[**2106-9-7**] 09:50PM BLOOD Glucose-108* UreaN-17 Creat-0.6 Na-140
K-5.1 Cl-100 HCO3-32 AnGap-13
[**2106-9-8**] 05:51AM BLOOD CK(CPK)-178
[**2106-9-7**] 09:50PM BLOOD cTropnT-<0.01
[**2106-9-8**] 05:51AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.0
[**2106-9-7**] 09:50PM BLOOD Valproa-33*
[**2106-9-7**] 09:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2106-9-7**] 10:01PM BLOOD pH-7.33* Comment-GREEN TOP
[**2106-9-8**] 02:43AM BLOOD Type-ART pO2-64* pCO2-80* pH-7.25*
calTCO2-37* Base XS-4 Intubat-NOT INTUBA
[**2106-9-7**] 10:01PM BLOOD Glucose-103 Lactate-1.1 Na-140 K-4.6
Cl-93* calHCO3-35*
[**2106-9-7**] 11:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022
[**2106-9-7**] 11:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2106-9-7**] 11:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Discharge Labs:
[**2106-9-11**] 10:55AM BLOOD WBC-9.9
[**2106-9-11**] 10:55AM BLOOD Creat-0.6 HCO3-40*
[**2106-9-11**] 01:07PM BLOOD Type-ART pO2-138* pCO2-73* pH-7.37
calTCO2-44* Base XS-13 Intubat-NOT INTUBA
Studies:
[**9-7**] CXR: Bibasilar nodular opacities, more pronounced within
the left lung base, which may represent an infectious process.
[**9-7**] CT Head: 1. No acute intracranial process. Minimal white
matter hypodensity, compatible with sequelae of chronic small
vessel ischemia.
2. Right cheek subcutaneous nodule for which clinical
correlation is advised.
[**9-7**] CTA Chest: 1. No pulmonary embolus or acute aortic
syndrome. Limited subsegmental evaluation.
2. Scattered ground-glass opacities with a centrilobular,
peribronchovascular distribution with suggestion of peripheral
tree-in-[**Male First Name (un) 239**] opacities also noted. In the setting of esophageal
distention and fluid, with small tracheal secretions, this is
most compatible with aspiration.
3. Mild centrilobular emphysema, as on prior study.
4. Resolution of prior left lower lobe collapse.
5. Patulous esophagus with air-fluid level, as seen on prior
studies. A non- emergent upper GI evaluation could be considered
for further evaluation.
Esophogram: The esophagus is diffusely dilated with abundant
tertiary
contractions. The gastroesophageal junction appears widely
patent; however, there is holdup of barium as well as a barium
tablet at the GE junction. The barium tablet passes with
multiple sips of water. There is proximal escape, with residual
barium seen in the esophagus throughout the duration of the
study. Evaluation of esophageal motility is limited due to
substantial residual barium in the esophagus.
IMPRESSION: Esophageal dysmotility.
Brief Hospital Course:
54 y/oM with severe COPD on home O2 (noncompliant), OSA, HTN,
multiple psychiatric diagnoses admitted with acute
hypercapnic/hypoxic respiratory distress
1. Acute respiratory distress: Pt admitted to MICU with ABG
showed hypercapnic, hypoxic respiratory failure with pH 7.26,
CO2 80, O2 64. CTA showing multiple scattered ground-glass
opacities with a centrilobular, peribronchovascular distribution
with suggestion of peripheral tree-in-[**Male First Name (un) 239**] opacities consistent
with infectious process. Concern for aspiration given dilated
esophagus with air fluid level seen on CT. Started on Levaquin
and Prednisone, and CPAP and hypoxia resolved. Anaerobic
coverage was not started this admission despite concern for
aspiration as pt was so stable, afebrile, and clinically
improving. Subsequent ABG's with resolutin of O2 and more
consistent with chronic respiratory acidosis in setting of known
COPD and pt quickly called out of MICU.
On the floor pt noted to be RA ambulating 70%'s, resting RA mid
80%'s, 3L NC 95%, and looked very well, no respiratory distress
even when ambulating, although tired. CPAP was encouraged as
well as NC to 90-93%. He may benefit from official Pulmonology
f/u, as he does not appear to have been seen by Pulm in our
[**Hospital1 18**] records. This should likely be arranged through Atrius,
given his Atrius PCP. [**Name10 (NameIs) **] was also encouraged to wear his home O2
and use his CPAP at night as these may play a large part in his
low O2 levels. He was discharged to complete a steroid taper and
5d Levaquin course.
2. Esophageal dysmotility: Pt was seen to have air-fluid level
in esophagus and dilated esophagus, so had barium swallow
showing esophageal dysmotility and dilated esophagus, but no
achalasia or strictures. Given that this was not clinically
apparent, no cough, dysphagia, etc. it was decided to defer
further management to outpt GI followup, which should be
arranged with Atrius GI as well.
3. Leukocytosis: likely related to pulmonary infection. resolved
on discharge
4. Psych: Home psychiatric medications reconciled with outpt
psychiatrist Dr. [**First Name (STitle) **]: clonazepam 1mg [**First Name (STitle) **], divalproex 1000mg
QAM and 500mg QPM, sertraline 12.5 hs, thiothixene 10 mg hs,
clozapine 200 mg hs.
5. OSA: History of severe OSA with AHI of 29.8, RDI of 40.3
with desaturations as low as 78% requiring BiPAP. Bicarb is
elevated and ABG shows hypercarbia consistent with noncompliance
with nocturnal BiPAP. He was encouraged to use the BiPAP and we
explained that not wearing BIPAP will likely lead to respiratory
failure.
Medications on Admission:
- combivent inhalher
- clonazepam 100mg daily
- divalproex 100mg [**Hospital1 **]
- lisinopril 10mg daily
- MVI
- sertraline 25mg QHS
- symbicort 2 puffs [**Hospital1 **]
- terazosin 5mg daily
- xalantan 0.05% [**First Name9 (NamePattern2) **] [**Male First Name (un) **]
Discharge Medications:
1. Combivent 18-103 mcg/Actuation Aerosol Sig: [**11-21**] Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO [**Month/Day (2) **] (4 times a
day).
3. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
4. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QPM (once a day (in the
evening)).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. multivitamin Oral
7. sertraline 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. thiothixene 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
10. clozapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): 1 drop both eyes.
12. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2)
Inhalation twice a day.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days: last dose tomorrow [**2106-9-12**].
Disp:*1 Tablet(s)* Refills:*0*
16. nicotine (polacrilex) 2 mg Gum Sig: One (1) Gum Buccal Q1H
(every hour) as needed for wanting one.
Disp:*1 Gum(s)* Refills:*0*
17. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 6 doses: 40mg daily [**Date range (1) 57910**]
20mg daily [**Date range (1) 35167**]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
1. COPD exacerbation
2. Pneumonia, possibly aspiration
3. Esophageal dysmotility
4. Baseline hypoxia
Discharge Condition:
Mental Status: Clear and coherent but with psychiatric disease
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 57898**],
You were admitted to [**Hospital1 18**] for low oxygen levels and found to
have a possible pneumonia. You were treated with antibiotics and
steroids for any possible contribution of your underlying COPD.
You were also seen to have esophageal dysmotility and dilatation
but without strictures, which means your esophagus does not
propel food normally. You should follow up with a GI doctor
about this, and be careful when you are eating or laying down.
Your breathing status improved but your oxygen levels were still
stably low; therefore we recommend that you wear home oxygen at
all times and use your CPAP machine and consider seeing a
pulmonologist.
The following changes were made to your medication regimen:
- CHANGED clonazepam to 1 mg four times daily
- CHANGED divalproex to 1000 mg in the morning and 500 mg in the
evening
- CHANGED sertraline to 12.5 mg at night
- STARTED levofloxacin 750 mg daily through [**9-12**]
- STARTED prednisone. 40 mg daily (2 tablets) [**Date range (1) 57910**], then
20 mg daily (1 tablet) [**Date range (1) 35167**].
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) 41875**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Monday [**2106-9-13**] at 2:30 PM
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2261**]
Please schedule pt to see a [**Hospital1 **]
GI doctor within the next month for esophageal dysmotility.
[**Telephone/Fax (1) 2296**].
|
[
"518.81",
"799.02",
"530.5",
"491.21",
"250.00",
"327.23",
"305.1",
"V46.2",
"300.3",
"296.80",
"507.0",
"724.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12676, 12753
|
8085, 10708
|
305, 311
|
12897, 12897
|
5085, 5085
|
14192, 14657
|
4512, 4567
|
11030, 12653
|
12774, 12876
|
10734, 11007
|
13075, 14169
|
6315, 6660
|
4582, 5066
|
252, 267
|
339, 3114
|
6669, 8062
|
5101, 6299
|
12912, 13051
|
3136, 3805
|
3821, 4496
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,532
| 130,690
|
26433
|
Discharge summary
|
report
|
Admission Date: [**2132-2-9**] Discharge Date: [**2132-2-15**]
Date of Birth: [**2058-1-23**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Male First Name (un) 4578**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Patient is a 74 yo M with h/o papillary urothelial carcinoma s/p
resection BCG treatment in [**2125**] presents with chest pain.
.
The patient was in his usual state of health until around 2pm
today. He is in the process of selling his house and moving and
had been lifting and moving boxes today. He developed left sided
chest pain around 2pm and it occurred intermittently throughout
the day. Each episode lasted a few minutes at a time. The pain
is described as a "pressure" that is relieved with rest and
worsens with exertion. The pain did not radiate and he denies
SOB, diaphoresis, lightheadedness, nausea, palpitation,
pleurisy. He denied abdominal pain, numbness, tingling,
weakness. He denied pleuritic chest pain, LE edema or pain.
Around 6pm, he went to dinner with his son who recommended he go
to the [**Name (NI) **] given the persistence of his symptoms. He presented to
[**Hospital1 **]-[**Location (un) 620**], where initial vital signs were T- 97.9 HR- 74, BP
146/75, Resp: 17, SaO2 100% on RA. Exam there was non-focal. EKG
had Qs in septal leads and left axis deviation. He was found to
have troponin 0.149, so he was given full dose aspirin and
started on heparin with transfer to [**Hospital1 18**] for ACS.
.
On arrival to the ED, vital signs were T- 97, BP- 63, BP-
134/78, RR- 20, SaO2- 100% on RA. The was continued on heparin
gtt and admitted to cardiology for further evaluation.
.
Currently, T- 98.7, BP- 142/84, HR- 64, RR- 18, SaO2- 100% on
RA. he is comfortable and reports his chest pain is much
improved. He says the pain is "barely noticable" and rates it as
a [**12-25**]. Denies shortness of breath, diaphoresis, dizziness, LH
or syncope.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- h/o papillary urothelial carcinoma, low grade, s/p
transurethral resection of bladder tumor [**1-/2126**] c/b clot
formation requiring clot evacuation and fulguration & s/p BCG
treatment in [**2125**]
- h/o GIB, likely lower with negative EGD result (superficial
antrum erosion) [**7-/2127**]
- prolapsed internal and external hemorhoids
- h/o colon polyps, last colonoscopy [**2132-11-29**]
- diverticulosis
- headache
- h/o PNA
- gout
Social History:
Retired, used to work at [**Company 22916**] in sales. Widower. Planning on
moving to [**Location (un) 20338**], FL soon. Ex-smoker, quit 35 yrs ago, [**12-17**] ppd x
25 years. Drinks occasional EtOH with no history of drug use.
Family History:
No history of early MI, diabetes.
- colon cancer
- brother with ? liver cancer
- father died at 88, mother died at 94
Physical Exam:
VS - T- 97.0, HR- 63, BP- 134/78, RR- 20, SaO2- 100% on RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, no focal
deficits, gait deferred.
Pertinent Results:
Admission labs:
[**2132-2-10**] 06:30AM BLOOD WBC-4.6# RBC-4.42* Hgb-12.5* Hct-38.0*
MCV-86 MCH-28.4 MCHC-33.0 RDW-13.5 Plt Ct-174
[**2132-2-11**] 04:08AM BLOOD Neuts-89.1* Lymphs-8.5* Monos-1.1*
Eos-1.1 Baso-0.2
[**2132-2-10**] 06:30AM BLOOD PT-10.9 PTT-72.8* INR(PT)-1.0
[**2132-2-10**] 06:30AM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-139
K-4.1 Cl-104 HCO3-28 AnGap-11
[**2132-2-10**] 06:30AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1 Cholest-151
.
Pertinent Labs
[**2132-2-10**] 02:21AM BLOOD CK-MB-8 cTropnT-0.16*
[**2132-2-10**] 06:30AM BLOOD CK-MB-7 cTropnT-0.10*
[**2132-2-11**] 04:08AM BLOOD CK-MB-6 cTropnT-0.07*
[**2132-2-10**] 09:44AM BLOOD %HbA1c-5.5 eAG-111
[**2132-2-10**] 06:30AM BLOOD Triglyc-52 HDL-53 CHOL/HD-2.8 LDLcalc-88
Discharge labs:
[**2132-2-14**] 05:28AM BLOOD WBC-5.3 RBC-4.14* Hgb-11.8* Hct-35.1*
MCV-85 MCH-28.4 MCHC-33.5 RDW-13.8 Plt Ct-135*
[**2132-2-13**] 07:28AM BLOOD Neuts-81.5* Lymphs-12.6* Monos-3.8
Eos-1.8 Baso-0.4
[**2132-2-14**] 05:28AM BLOOD Glucose-88 UreaN-13 Creat-0.9 Na-138
K-4.3 Cl-105 HCO3-26 AnGap-11
[**2132-2-11**] 07:30AM BLOOD ALT-13 AST-25 AlkPhos-55 TotBili-0.6
[**2132-2-14**] 05:28AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2
Imaging:
Micro:
[**2132-2-11**] 2:48 am BLOOD CULTURE Source: Venipuncture.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
.
Blood cultures 2/29 and [**2-14**] pending at discharge
.
EKG [**2132-2-9**] 9:31:30 PM
Sinus rhythm. Normal tracing. Compared to the previous tracing
of [**2126-2-8**]
no change.
Rate PR QRS QT/QTc P QRS T
65 172 98 402/410 65 -18 63
.
CXR [**2132-2-11**] 2:39 AM
Patient is rotated to the left, which should increase the
relative opacity of
the right hemithorax. Instead, there is greater density on the
left, which in
the presence of elevation of the left hemidiaphragm is
presumably atelectasis.
Followup suggested to exclude effect of aspiration. Right lung
is clear. The
heart size is normal, and there is no appreciable pleural
abnormality.
.
CT CHEST W/O CONTRAS [**2132-2-11**]
IMPRESSION:
1. There is no interstitial pulmonary abnormality. Bronchial and
parenchymal
changes in the left lower lobe accompanying small hiatus hernia
and areas of
esophageal distention suggest aspiration, and raise question of
esophageal
motility abnormality.
2. Coronary atherosclerosis.
3. Sternal demineralization, predominantly in the manubrium not
necessarily
pathologic should be interpreted in light of any other findings
that point to
osseous infiltration.
.
TRANSTHORACIC ECHO [**2132-2-12**] at 2:38:20 PM
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF 50-60%). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: Preserved biventricular systolic function.
.
Sestamibi Stress ([**2132-2-14**])
patient exercised for 10 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol (~ 5.2
METS),
representing a fair exercise tolerance for his age. The test was
stopped at an achieved submaximal target workload of 80%
age-predicted
HR max. No chest, neck, back, or arm discomforts were reported
by the
patient throughout the study. There were no significant ST
segment
changes throughout the study (normalization noted in lead V2
during
exercise). The rhythm was sinus with rare, isolated apbs and
vpbs
throughout the study. Appropriate blood pressure and heart rate
responses to exercise.
.
IMPRESSION: No anginal type symptoms or ischemic EKG changes to
achieved worload. Nuclear report sent separately.
INTERPRETATION:
Left ventricular cavity size is mildly enlarged.
Attenuation corrected resting and stress perfusion images reveal
uniform tracer
uptake throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 52%.
IMPRESSION: 1. Normal myocardial perfusion for the level of
exercise achieved.
2. Mild left ventricular enlargement. 3. Normal LVEF = 52%
Brief Hospital Course:
74yoM with h/o papillary urothelial carcinoma admitted on
[**2132-2-9**] from [**Hospital1 **]-N for acute onset CP (trop peaked at 0.16, no
ischemic EKG changes) who was transferred to the ICU on [**2-11**] for
fevers /hypotension and was found to have Pseudomonal sepsis.
.
# Pseudomonal sepsis:
Overnight on HD 2 the patient developed high fevers and became
persistently hypotensive. He was transferred to the ICU where
cultures were sent but patient had no obvious source of
infection based on exam. Chest imaging suggested possible
aspiration pneumonia, but urine culture from [**2-11**] was negative
and u/a from [**1-/2049**] was negative. He was initially given a dose
of Vanc and Zosyn on the floors, which was switched in the ICU
to ceftriaxone and Azithromcin to cover for possible lung
sources and atypical coverage. He remained normotensive and was
transitioned to Levofloxacin, and was transferred back to the
medical floors. Cultures were pending at the time of transfer
out of the ICU, but resulted shortly thereafter as gram negative
rods later confirmed as pseudomonas. The patient was started on
cefepime 2g q12h (d1 = [**2-12**]) with plan for 2 week course.
Abdominal source of infection was considered as the patient had
a history of diverticulosis, however, in the absence of
associated symptoms or exam findings, further evaluation with
imaging was not pursued. The patient remained afebrile from [**2-11**]
and w/o leukocytosis from [**2-12**]. Subsequent blood cultures were
negative for >24hours prior to discharge. A PICC line was placed
and the patient was discharged on IV Cefepime.
.
# NSTEMI:
Patient presented with anginal symptoms and found to have
elevated troponins with normal CK-MB with no significant EKG
changes. The patient was initially treated with ASA, heparin
drip, statin and BB with plan for cardiac catheterization. This
was deferred in the setting of bacteremia. Cardiac echo later
revealed no wall motion abnormalities. Exercise stress test with
Sestamibi revealed no anginal type symptoms or ischemic EKG
changes and normal myocardial perfusion. Upon further review, in
the absence of significant underlying CAD risk factors and
presence of bacteremia, the patient's presentation was felt to
be more likely representative of demand ischemia.
Medications on Admission:
None (used to take allopurinol for gout but not in years)
Discharge Medications:
1. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H
(every 12 hours) for 12 days: (14 days total, day 1 = [**2132-2-13**]).
Disp:*48 grams* Refills:*0*
2. aspirin 81 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*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
DEMAND MYOCARDIAL ISCHEMIA
GRAM NEGATIVE SEPSIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 20137**],
You were admitted to the hospital for chest pain and suspected
to be having a heart attack. You were treated first with
medications with plan to get a cardiac catheterization to check
for a blocked artery. Before this could be done, you developed a
severe bloodstream infection for which you had to be transferred
to the intensive care unit.
.
A stress test showed that your heart muscle is working well.
Based upon this test, we suspect that you may not have had a
heart attack but rather had heart muscle stress in the setting
of a bloodstream infection.
It is important to take daily aspirin, which we started to
protect you heart. Please follow up with a cardiologist for
further evaluation after your infection is fully treated. See
below for appointment details.
You were found to have bacteria, Pseudomonas, growing in your
blood. The original source of the infection was probably a
pneumonia. You were started on antibiotics and improved rapidly.
You will need to be treated with two weeks of the intravenous
antibiotic, Cefepime.
Medication changes
START Aspirin (helps prevent blood clots in arteries)
START Cefepime (antibiotic for infection), infuse every 12 hours
for 2 weeks with the assistance of a visiting nurse/infusion
company
It was a pleasure taking care of you.
Followup Instructions:
Name: [**Name6 (MD) **] [**Name8 (MD) **],MD
Specialty: Internal [**Name8 (MD) **]
When: Tuesday [**2-19**] at 9:45am
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**]-[**Location (un) **]/WESTW
Address: [**Street Address(2) 21600**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 17753**]
Department: CARDIAC SERVICES
When: TUESDAY [**2132-3-4**] at 2:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"276.8",
"411.89",
"995.91",
"455.3",
"458.9",
"716.90",
"530.81",
"V15.82",
"455.0",
"V10.51",
"287.5",
"486",
"038.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11146, 11198
|
8386, 10686
|
335, 357
|
11290, 11290
|
3722, 3722
|
12793, 13474
|
3043, 3162
|
10794, 11123
|
11219, 11269
|
10712, 10771
|
11441, 12770
|
4472, 8363
|
3177, 3703
|
2083, 2318
|
285, 297
|
385, 2064
|
3738, 4456
|
11305, 11417
|
2340, 2780
|
2796, 3027
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,949
| 146,288
|
23602
|
Discharge summary
|
report
|
Admission Date: [**2157-2-12**] Discharge Date: [**2157-3-26**]
Date of Birth: [**2098-4-11**] Sex: M
Service: MEDICINE
Allergies:
Motrin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
transferred from OSH with high grade MRSA bacteremia
Major Surgical or Invasive Procedure:
1. Bioprosthetic Aortic and Mitral valve replacement.
2. Aortic arch reconstruction.
3. Coronary Artery Bypass Graft (SVG->RCA).
4. Dual Chamber [**First Name3 (LF) **] placement-[**Company 1543**] SIGMA SDR 303B
5. Right ocular Pars plana vitrectomy, fluid-air exchange,
endolaser photocoagulation, and 5000 centistoke silicone oil
tamponade.
6. Central Venous Access.
7. Endotracheal Intubation.
8. Cardiac Angiography.
History of Present Illness:
58 yo male with PMH sig for COPD s/p recent intubation,
anxiety/depression, gerd, psorisasis presented to [**Hospital 16843**]
Hospital on [**2157-2-4**] with weakness, dehydration and nausea.
Prior to initial presentation, he was intubated at [**Hospital 16843**]
Hospital for COPD exacerbation/PNA. He had a Right SC line at
that time. He was found to have MRSA sepsis requiring Levophed.
On [**2-7**] he was found to have staph endopthamitis. He underwent
vitreous injection with vanco and amikacin. Also noted right toe
pain thought to be secondary to SBE. Blood cultures postitive
for MRSA from [**2-4**] through [**2-12**]. Upon arrival to [**Hospital1 18**] on
[**2157-2-12**] his Vanc level was noted to be 7.7 and he had initially
been admitted to the MICU at the [**Hospital1 18**]. In [**Hospital1 18**] ICU, he
initially required Epinephrine and NS boluses for pressure
support. [**Last Name (un) **] stim test WNL. He was re-admitted to the ICU on
[**2-24**] after an episode of hypotension and rigors which had
responded to IVF and went to the CCU on [**2-25**] for concern of
endocarditis and abcess for further monitering. On [**2-28**] he
underwent AV reconstruction, MVR and aortic arch reconstruction.
His subsequent course has been complicated by right sided PNA
and hypotension. He is being called out of MICU on [**2157-3-18**].
Past Medical History:
1. COPD s/p multiple intubations: no trach, No home O2, PFT's
unknown.
2. anxiety/depression
3. gerd
4. psoriasis
Social History:
No IVDU, No EtOH: Quit smoking 10years ago. Lives with son and
ex-wife. Performs all ADL's on his own: No Home O2.
Family History:
Brother with schizophrenia
Physical Exam:
On admission to MICU
T 102.1, HR=98-113, BP=86/46-96/50, 18, 98% 6 liters nasal
canula.
Gen: pleasant elderly male lying comfortably in bed, NAD
HEENT: Right pupil 5mm, left pupil 4mm
MMM, anicteric, OP clear, no thrush
CV: distant, RRR, nl S1S2
Lungs: expiratory rhonchi, bibasilar crackles, no wheezes
Abd: Soft, NT/ND, pos BS, No HSM
Ext: Warm LE with 2+ DP/PT pulses, 1 plus bilateral lower
extremity edema
Neuo: Alert oriented times three. EOMI, neck supple.
.
On discharge,
O: t 96.4, BP 123/68 (90-120/60-70), HR 80, R 20, O2 94% on RA
Gen: NAD
CV: distant heart sounds, regular
Chest: distant BS but improved, fewer rhonchi, mild exp wheezes;
no pain on palpation of incision; incision without drainage or
erythema
Abd: + BS, soft, NT
Ext: no edema, 2+ DP
Neuro: 2-3/5 grip strength on right, [**2-22**] grip on left
Pertinent Results:
** admit labs **
[**2157-2-12**] 09:26PM WBC-12.9* RBC-4.25* HGB-12.9* HCT-39.4*
MCV-93 MCH-30.3 MCHC-32.7 RDW-13.8
[**2157-2-12**] 09:26PM NEUTS-93.3* BANDS-0 LYMPHS-4.0* MONOS-2.1
EOS-0.4 BASOS-0.1
[**2157-2-12**] 09:26PM PLT SMR-NORMAL PLT COUNT-138*
[**2157-2-12**] 09:26PM PT-14.8* PTT-28.1 INR(PT)-1.4
[**2157-2-12**] 09:26PM GLUCOSE-135* UREA N-12 CREAT-0.8 SODIUM-135
POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-35* ANION GAP-8
[**2157-2-12**] 09:26PM ALT(SGPT)-124* AST(SGOT)-78* LD(LDH)-332* ALK
PHOS-111 AMYLASE-26 TOT BILI-0.8
[**2157-2-12**] 09:26PM ALBUMIN-2.5* CALCIUM-7.8* PHOSPHATE-2.4*
MAGNESIUM-2.1
[**2157-2-12**] 09:33PM LACTATE-2.8*
..
** discharge labs **
[**3-26**]:
WBC: 14.3*
Hct: 28.9*
plt: 472
PTT: 51.2*
INR: 1.7
Glu: 72
BUN: 32*
Cr: 1.5*
Na: 138
K: 5.1
Cl: 107
HCO3: 22
Random Vanco: 25.3
.
**Microbiology**:
Blood cx + for MRSA on [**5-3**], [**Date range (1) 60406**]; neg since then
.
[**2-28**] AORTIC ASCEUDIRY pos for MRSA
.
[**3-15**] BAL: neg for growth
.
c diff neg x 4, c diff toxin B negative
.
** Cardiac Studies **
TEE [**2157-2-14**]:
1. No spontaneous echo contrast or thrombus is seen in the body
of the left atrium/left atrial appendage or the body of the
right atrium/right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler.
2. Overall left ventricular systolic function is mildly
depressed.
3.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.
4.The aortic valve is bicuspid. The aortic valve leaflets are
severely
thickened/deformed. While the views are limited, there maybe a
small mobile (<0.3 cm) mass which may be a vegetations on the
aortic valve. Mild to moderate ([**11-21**]+) aortic regurgitation is
seen.
5.The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen.
6. No vegetation/mass is seen on the pulmonic valve.
7. There is a trivial/physiologic pericardial effusion.
.
TTE [**2157-2-14**]:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%).
3.The aortic valve leaflets are moderately thickened. The aortic
valve is not well seen. No masses or vegetations are seen on the
aortic valve. There is moderate aortic valve stenosis. Mild to
moderate ([**11-21**]+) aortic regurgitation is seen.
4.The mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Trace mitral
regurgitation seen.
5.There is a small pericardial effusion. There are no
echocardiographic signs of tamponade. No echocardiographic
evidence of endocarditis.
.
TTE [**2157-2-24**]:
1. The left ventricular cavity is mildly dilated. LV systolic
function appears depressed.
2. The aortic valve leaflets are severely thickened/deformed. A
mobile, moderate sized mass is probably present on the aortic
valve with a possible aortic annular abscess. Mild (1+) aortic
regurgitation is seen.
3. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
4. There is mild pulmonary artery systolic hypertension.
5. There is a small pericardial effusion.
6. Compared with the findings of the prior study (tape reviewed)
of [**2157-2-14**], the aortic mass and possible abscess are new.
.
Cardiac Cath [**2157-2-25**]:
1. Coronary angiography of this right dominant system revealed
single
vessel coronary artery disease. The left main coronary artery,
LAD, and
LCX had no angiographically apparent flow limiting stenoses. The
RCA
had a 60% stenosis in the mid vessel.
2. Resting hemodynamics revealed normal right sided filling
pressures
(mean RA pressure was 5 mm Hg and RVEDP was 7 mm Hg). Pulmonary
artery
pressures were normal (PA pressure was 27/16 mm Hg). Left sided
filling
pressures were low (mean PCW pressure was 5 mm Hg). Cardiac
index was
normal (at 4.8 L/min/m2). Central arterial pressures were low
(aortic
pressure was 84/53 mm Hg).
3. The aortic valve was not crossed secondary to the aortic
valve
vegetation.
.
TEE [**2157-2-25**]:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. There is mild regional left
ventricular systolic dysfunction. Resting regional wall motion
abnormalities include inferior and inferolateral hypokinesis.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic root, the ascending
aorta, the descending aorta, and the abdominal aorta. There are
complex (>4mm and/or mobile) atheroma in the aortic arch. The
aortic valve leaflets are severely thickened/deformed with
fusion of the left and right aortic valve leaflets, leading to a
functionally bicuspid valve. There are multiple moderate-sized
vegetation on the aortic valve, specifically on the left and
right coronary cusps. An aortic annular abscess is seen that
involves the fibrous continuity of the mitral and aortic valves.
There is probably severe aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is a moderate-sized vegetation on the mitral
valve. Trivial mitral regurgitation is seen. There is no
pericardial effusion. IMPRESSION: Aortic root abscess.
Endocarditis of the aortic and mitral valves.
.
CT head [**2157-2-13**]: Two discrete foci of decreased attenuation,
which likely
represent lacunar infarcts. Foci of hemorrhage or parenchymal
edema
identified.
.
Right UE U/S [**2157-2-14**]: No evidence of right upper extremity DVT
.
CT head [**2157-2-14**]: No evidence of acute intracranial hemorrhage,
mass effect, or abnormal enhancement. Please note that MRI with
gadolinium would be more sensitive in evaluating for subtle
signs of infection if there is clinical need for further
evaluation of this patient.
.
CT Chest/Abdomen/Pelvis [**2157-2-14**]:
1. Wedge shaped perfusion defects in the spleen consistent with
infarcts. It is not possible to distinguish bland from septic
emboli. Correlate clinically in this patient with known
endocarditis
2. Small to moderate bilateral pleural effusions. Small amount
of low attenuation fluid in the pelvis and left pericolic
gutter, consistent with ascites.
.
CXR [**2-16**]: Increased left lower lobe consolidation with increased
effusion, probably representing worsening pneumonia. No CHF.
.
LE Dopplers [**2157-2-16**]:
No evidence of DVT within the left lower extremity. However,
there is a small popliteal artery aneurysm, with thrombus within
the aneurysmal sac. Normal flow is demonstrated within the
popliteal artery at this level.
.
Left LE Plain film [**2157-2-16**]:
The cortex of the mid shaft of the tibia appears thickened and
undulating, which could represent either a chronic stress
reaction or chronic osteomyelitis. There is nonspecific
nonaggressive periosteal new bone formation along the posterior
aspect of the proximal tibia as well. No focal lytic lesion is
detected. If clinically indicated, further assessment with MRI
or bone scan could be performed.
.
Duplex ultrasonography: [**2157-2-17**]:
1. No evidence of right common femoral or popliteal artery
enlargement.
2. An aneurysm with thrombus present is identified within the
left popliteal artery.
.
MRI head [**2157-2-16**]:
Multiple cortical lesions most suggestive of embolic infarction,
many of ring enhancing appearance suggesting abscess formation.
Possible right middle cerebral artery bifurcation aneurysm.
.
CT head and CT angiogram [**2157-2-17**]:
No CT evidence of aneurysm. Multiple enhancing cortical lesions
within the cerebral cortex that were seen on the prior MRI from
[**2157-2-17**], are likely beyond the resolution of this CT
angiogram.
.
MRI T spine [**2157-2-17**]:
No evidence of osteomyelitis nor discitis. No epidural
abnormalities are identified.
.
MRI C-Spine [**2157-2-17**]:
No epidural abscesses, osteomyelitis, nor discitis identified.
Degenerative changes throughout the cervical spine. Severe
neuroforaminal stenosis bilaterally at the level of C5-C6 and on
the left side at the level of C6-C7.
.
Left foot plain film [**2157-2-19**]: No evidence for osteomyelitis.
Probable old healed fracture of distal shaft of third
metatarsal.
.
Right upper extremity venous ultrasound [**2157-2-23**]: 1. No deep
venous thrombosis in the right internal jugular, subclavian,
axillary, brachial, basilic, or cephalic veins. 2. Incomplete
evaluation for possible fluid collection about the peripheral IV
site. No images of this area are included.
.
MRI of the CAVLES [**2157-2-23**]: Unremarkable MRI of the calves
bilaterally. No fluid collection or abscess identified.
.
CT Abomen/Pelvis [**2157-2-24**]: 1) Since [**2157-2-14**], there has been
interval development of 2 new splenic infarcts. Again it is not
possible to distinguish bland from septic emboli. 2) Decrease in
bilateral pleural effusions. 3) Resolution of ascites.
.
CTA [**3-23**]: No pulmonary embolism or aortic dissection.
Postoperative changes noted within the mediastinum.
Brief Hospital Course:
A/P: 58 y/o man admitted [**2-12**] from an OSH with MRSA
endocarditis now s/p AV reconstruction, MVR, and aortic arch
reconstruction on [**2-28**]. Post operative course in MICU
complicated by PNA.
.
1. MRSA endocarditis- Pt admitted to outside hospital with
septic physiology and blood cx from [**2-4**] grew out MRSA. He was
started on vancomycin but on [**2-11**] BCx still grew + GPC in
pairs/clusters. TTE at OSH with AV thickening and pt was
transferred to [**Hospital1 18**]. ID was consulted on admission and
recommended adding gentamycin. A TEE at [**Hospital1 18**] showed a bicuspid
aortic valve with severely thickened/deformed leaflets. A small
mobile (<0.3 cm) mass which may be a vegetation was also seen on
the aortic valve. Pt developed hypotension requiring initiation
of pressors. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was negative. A TEE on [**2-25**]
showed AV abscess and new MV vegetation. Blood cx from [**2-22**],
[**2-23**], [**2-24**] all came back positive for MRSA. CT surgery took pt to
OR on [**2-28**] for homograft root reconstruction, AV canal
reconstruction with pericardial patch, AVR, MVR, and CABG x1
vessel (SVG-RCA). Blood cx from day of surgery were still
positive for MRSA but since that day, pt has had negative
cultures. Rifampin was added on [**3-4**]. On Day #8 of gent, it
was stopped [**12-22**] rising creatinine. Pt will continue rifampin
and vancomycin for 6 week course. CBC, creatinine and LFTs
should be checked once a week and send to the ID physician's
office. Vancomycin levels should be checked daily and the
medication dosed for trough <20.
.
2. Pneumonia: Pt was initally started on levaquin for yellow
sputum and a left lower lobe consolidation. On [**3-11**] (11 days
post-op) pt developed a rising wbc and large diffuse right lung
consolidation. Zosyn was started. He had a bronchoscopy on
[**3-15**] with negative cultures. Pt was treated with a three-week
course of levaquin and zosyn for ventilated-associated
pneumonia.
.
3. Splenic infarcts: As a complication of MRSA endocarditis, pt
developed splenic infarcts. CT abdomen was negative for splenic
infarcts.
.
4. Brain Infarcts: MRI performed on [**2-16**] demonstrated multiple
cortical lesions suggestive of embolic infarction. Noted was a
possible right middle cerebral artery bifurcation aneurysm but
CT angiogram on [**2157-2-17**] was without evidence of aneurysm. Pt
was maintained on coumadin. Towards the end of the hospital
course, pt developed right hand weakness and numbness. Neuro
was reconsulted and stated that he had a cortical hand
consistent with his dx of cortical emboli. He was maintained on
coumadin and ASA. Pt was given lovenox until his INR was close
to therapeutic.
.
5. Complete heart block: Pt's post-op course was complicated by
the development of complete heart block with no escape rhythm.
Temporary wires were placed until pt's infectious issues
resolved and [**Company 1543**] Sigma DR [**Last Name (STitle) 4448**] was placed on [**2157-3-8**].
Flutter pace termination failed on [**3-10**]. Pt was started on
amiodarone load. He had one episode of asymptomatic
non-sustained ventricular tachycardic (12-beats) and he was
started on carvedilol. He is anticoagulated with coumadin with
a goal INR of [**12-23**]. His INR fluctuated between 1.4 and 3.9 while
on coumadin and therefore should be monitored closely. He
received Lovenox until his INR was close to therapeutic towards
end of hospital stay. His INR should be checked regularly until
it is stable between 2 and 3. Pt will get cardioversion as an
outpatient and follow-up in device clinic.
.
6. MRSA ophthalmitis and retinal detachment: On transfer to
[**Hospital1 18**] ICU, pt was complaining of seeing spots. An ophthamology
consult was placed and it was determined that pt had MRSA
ophthalmitis (endogenous) R>L, with right retinal detachment.
Vancomycin and amikacin were injected into his vitreous on [**2-7**].
Pt then underwent retinal detachment repair with silicone oil
placement on [**2-22**] with Dr. [**Last Name (STitle) **]. He will follow up with
ophthalmology as outpt.
.
7. Acute renal failure- Pt's baseline creatinine is 0.7 to 0.8.
During his hospital stay, he developed ATN from gentamicin and
hemodynamic insults and his creatinine rose to a peak of 2.1.
Renal was consulted, gentamycin was stopped, meds were renally
dosed and his creatinine slowly declined. On day of discharge,
his creatinine was 1.3.
.
8. Diarrhea: Pt developed diarrhea while on tube feeds. He was
c diff negative x 4 and c diff toxin B was still pending at time
of discharge. He was treated with a 10-day course of Flagyl.
.
9. COPD: Pt has severe baseline COPD and developed a severe PNA
in the right middle and lower lung fields. Given his severe
COPD, he was started on solumderol for a possible COPD flare and
this was slowly tapered down. He was continued on standing
nebs. He required oxygen to keep his oxygenation in the low
90s. Oxygen was stopped towards the end of his hospital course
when he was able to maintain his sats in the mid-90s on room
air.
.
10. CAD s/p CABG: S/p cardiac catheterization on [**2-25**]. Notable
for left main, LAD and LCX with no angiographically apparent
flow limiting disease. RCA with 60% mid-stenosis. During CT
[**Doctor First Name **], had CABG x 1 (SVG-RCA). Echo with EF of 30-35% with
inferior/apical HK. Continued ASA.
.
11. Anemia- Iron studies consistent with anemia or chronic
disease. Hct stable.
.
12. Left popliteal aneurysm with thrombus: Vasc surgery
consulted. Recommended repeat ultrasound in next few months and
no surgery indicated if less than 2 cm.
.
13. Glucose intolerance while on steroids: Regular insulin
sliding scale
.
14. Psych: Pt was depressed during hospitalization. His zoloft
was increased and he was started on zyprexa.
.
15. FEN: Pt initially tube feeds during acute phase of illness.
As he improved, the NGT was pulled and he was able to tolerate a
po diet with Boost supplementation. Pt had some episodes of
hyperkalemia (asx) to a high of 6.4 which resolved after
stopping his tube feeds and putting him on a low K diet. He did
require 2 doses of kayexalate but this caused him to have
cramping abd pain and nausea/vomiting.
.
16. Nose Bleed: On day of discharge, pt had a nose bleed likely
[**12-22**] Lovenox. His Lovenox was stopped because his INR was close
to therapeutic. His PTT was elevated to 51. This should be
followed.
Medications on Admission:
Home Meds:
Zoloft 150 mg daily
Lipitor 20 mg
Combivent 4-5x/day
Medications upon transfer:
1. MED Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift [**2-24**] @ [**2054**]
2. MED Sertraline HCl 150 mg PO DAILY [**2-24**] @ [**2054**]
3. MED Pantoprazole 40 mg PO Q24H [**2-24**] @ [**2054**]
4. MED Ipratropium Bromide Neb 2 NEB IH Q6H [**2-24**] @ [**2054**]
5. MED Acetaminophen 325-650 mg PO Q4-6H:PRN [**2-24**] @ [**2054**]
6. MED Docusate Sodium 200 mg PO BID [**2-24**] @ [**2054**]
7. MED Senna 2 TAB PO BID
8. MED Miconazole Powder 2% 1 Appl TP TID:PRN [**2-24**] @ [**2054**]
9. MED Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10. MED Zolpidem Tartrate 5 mg PO HS:PRN [**2-24**] @ [**2054**]
11. MED Morphine Sulfate 0.5-2 mg IV Q6H:PRN [**2-24**] @ [**2054**]
12. MED Atropine Sulfate Ophth 1% 1 DROP OU [**Hospital1 **] [**2-24**] @ [**2054**]
13. MED Calcium Carbonate 500 mg PO TID W/MEALS [**2-24**] @ [**2054**]
14. MED Vitamin D 800 UNIT PO DAILY [**2-24**] @ [**2054**]
15. MED Oxycodone 5 mg PO Q4-6H:PRN [**2-24**] @ [**2054**]
16. MED Heparin 5000 UNIT SC TID [**2-24**] @ [**2054**]
17. MED Vancomycin HCl 1000 mg IV Q12H [**2-24**] @ [**2054**]
18. MED Benzonatate 100 mg PO TID [**2-24**] @ [**2054**]
19. MED Aspirin EC 325 mg PO DAILY [**2-25**] @ 0035
20. MED Olanzapine 2.5 mg PO BID [**2-25**] @ 1003
21. MED Gentamicin 140 mg IV Q8H
22. MED Atropine Sulfate 0.5 mg IV X1:PRN symptomatic
bradycardia & hypotension
[**Month (only) 116**] repeat up to 2 mg total (including Atropine during
procedure).
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
6. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours): last dose [**2157-4-14**].
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QID
(4 times a day).
11. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QHS (once a day (at bedtime)).
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): last dose [**2157-4-4**].
13. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Decrease to maintenance dose (200mg qd) on [**2157-3-29**].
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
16. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Sertraline HCl 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
19. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
20. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): decrease to 10mg on [**3-28**]; stop on [**3-30**].
21. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q24H (every 24 hours): last dose on [**4-14**].
22. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 grams
Intravenous Q8H (every 8 hours): last dose on [**2157-3-31**].
23. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection ASDIR (AS DIRECTED): according to regular
insulin sliding scale.
24. Coumadin 2 mg Tablet Sig: 1.5 Tablets PO at bedtime: take
3mg on night of [**3-26**] and decrease to 2mg on [**3-27**]; adjust for INR
[**12-23**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16844**] Hospital - [**Location (un) 1157**]
Discharge Diagnosis:
Primary:
1. MRSA Mitral and Aortic Endocarditis and Aortic Root Abscess.
2. Septic Shock.
3. Complete Heart Block s/p dual chamber [**Location (un) 4448**].
4. Acute Renal Failure.
5. Septic Embolism - Multifocal brain infarct and microabscess.
6. Right Upper Extremity Hemiplegia.
7. Right Ocular MRSA Endophthalmitis and Retinal Detachment.
8. Systolic Heart Failure - EF ~ 30%.
9. Atrial Flutter.
10. Non-Sustained Ventricular Tachycardia.
11. Left popliteal aneurysm with thrombus.
12. Steroid induced diabetes mellitus.
13. ICU Psychosis.
14. Acute Situational Depression.
15. Antibiotic associated diarrhea - C. Difficile negative.
16. Malnutrition of moderate degree.
Secondary/PMH:
1. COPD s/p multiple intubations.
2. Anxiety and Depression.
3. GERD.
4. Psoriasis.
Discharge Condition:
Stable, afebrile
Discharge Instructions:
Medications as prescribed.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 7933**] within 1-2 weeks of discharge.
.
Infectious Disease: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13076**], MD Where: LM [**Hospital Unit Name **] INFECTIOUS DISEASE Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2157-4-12**] 9:30
.
NEUROLOGY: Please call [**Telephone/Fax (1) 1694**] to make an appointment with
Dr. [**First Name (STitle) **] (neurology stroke clinic) in the next 4-6 weeks.
.
CARDIOLOGY:
DEVICE CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2157-5-10**] 2:00
[**Known firstname **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2157-5-10**] 2:30
.
OPHTHALMOLOGY: Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 253**]. Please call to make an
appointment to be seen in the next 3-4 weeks.
.
[**Last Name (NamePattern4) 60407**]ERY: Dr. [**Last Name (Prefixes) **], [**Telephone/Fax (1) 15550**]; [**2157-4-21**], 2pm, [**Street Address(2) 60408**].
.
Vascular Surgery: you need to have follow-up of your popliteal
aneurysm. Please call [**Telephone/Fax (1) 1237**] to make an appointment.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"426.0",
"486",
"428.21",
"491.21",
"E932.0",
"112.0",
"038.11",
"360.01",
"414.01",
"442.3",
"584.5",
"785.52",
"995.92",
"V09.0",
"421.0",
"427.1",
"434.11",
"361.01",
"444.89",
"251.8",
"996.62",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"14.74",
"14.54",
"35.23",
"38.45",
"14.75",
"88.56",
"88.72",
"39.61",
"36.11",
"37.72",
"88.41",
"96.6",
"33.24",
"35.21",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
23273, 23356
|
12554, 19068
|
319, 743
|
24175, 24193
|
3307, 12531
|
24268, 25613
|
2417, 2445
|
20710, 23250
|
23377, 24154
|
19094, 20687
|
24217, 24245
|
2460, 3288
|
227, 281
|
771, 2131
|
2153, 2269
|
2285, 2401
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,178
| 106,068
|
4769
|
Discharge summary
|
report
|
Admission Date: [**2160-7-1**] Discharge Date: [**2160-7-8**]
Date of Birth: [**2080-9-15**] Sex: M
Service: MEDICINE
Allergies:
Zithromax / Heparin Agents
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
shaking chills
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
79 year old male with history of possible mastocytosis with
recurrent episodes of anaphylactoid reactions with an infectious
prodome presents with shaking chills x 2 days, 1 day of diarrhea
self resolving, 1 day pharyngitis, and temp to 100.5 at home. He
started taking prednisone per Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] (allergist)
instructions yesterday. At PCP office on day of admission, rapid
strep was negative. After returning home, he became acutely
dyspneic (particularly on exertion) along with shaking chills
and was instructed by his PCP to go to ED. In ED T 100.3, RR in
30s, O2 initially 89% on RA, improving to 97% w/ 2L. Initial BP
127/58 then dropped to 96/41. A sepsis line was placed and he
was given vanc/levo/clinda/ceftriaxone. He was also given
decadron 10 mg IV X 2. He was then admitted to the medical ICU
for further management.
ROS:
positive: fever, chills, diarrhea, lower extremity edema "from
norvasc"
negative: denied headache, sinus tenderness, rhinorrhea, cough,
shortness of breath, chest pain or tightness, palpitations,
nausea, vomiting, constipation or abdominal pain. No dysuria.
Denied arthralgias or myalgias. No recent travel. Recent bridge
partner ill with an upper respiratory tract infection.
Past Medical History:
1. Anaphylactoid reactions for which hospitalized on several
occasions in late '[**43**]'s and required ICU/pressors
2. HTN
3. hyperlipidemia
4. type 2 dm (last a1c 6 [**9-25**])
5. gout
6. fixed inferior defect on stress mibi '[**56**]
Social History:
lives w/ wife in [**Name (NI) 701**], remote pipe smoking 20 years ago.
Winter home in [**State 108**].
Family History:
Noncontributory
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.3P: 99 R:24-30 BP:107/47 SaO2: 94% on 2L CVP 14
General: Awake, alert
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MM dry, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated R IJ in place
Pulmonary: Lungs with bibasilar crackles.
Cardiac: Distant, RRR, no M/R/G noted
Abdomen: soft, obese, NT/ND, hypoactive bowel sounds, no masses
or organomegaly noted.
Extremities: 1+ lower ext edema,2+ radial, DP and PT pulses b/l.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
Pertinent Results:
Laboratory studies on admission:
GLUCOSE-118 UREA N-26 CREAT-1.3 SODIUM-142 POTASSIUM-3.4
CHLORIDE-108 TOTAL CO2-20
CK(CPK)-42 CK-MB-NotDone cTropnT-<0.01
WBC-5.2 RBC-3.71 HGB-11.1 HCT-32.3 MCV-87 MCH-29.9 MCHC-34.3
RDW-15.3
PLT COUNT-148
[**2160-7-1**] 05:05PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.027
GLUCOSE-180* UREA N-27* CREAT-1.1 SODIUM-140 POTASSIUM-3.5
CHLORIDE-105
[**2160-7-1**] CXR: The right internal jugular vein catheter tip is in
the SVC. No pneumothorax. Unchanged cardiomediastinal contour. A
small left basilar atelectasis.
[**2160-7-1**] Neck CT: Air within musculature of the right temporal
and mandibular region; air within small veins in the right
anterior neck region extending down into the superior- anterior
mediastinum.
[**2160-7-1**] CTA chest: No evidence of pulmonary embolism. Bibasilar
atelectasis. Increase of bony densities in the laminae of
several upper thoracic component vertebrae, which in the absence
of a primary malignancy, most likely represent degenerative
changes. Non-pathologically enlarged mediastinal lymph nodes.
[**2160-7-6**] CT Abd/pelvis w/ contrast: No intra-abdominal malignancy
or lymphadenopathy identified. Cholelithiasis without evidence
of cholecystitis
Brief Hospital Course:
79 year old male with recurrent anaphylactoid reactions presents
with sore throat, fever, and hypotension.
1) Fever/hypotension: The patient was admitted to the medical
ICU, where he was volume resuscitated and empirically covered
with ceftriaxone/clindamycin (for possible retropharyngeal
abscess on Neck CT). He was evaluated by the ENT service, who
examined the patient and felt that retropharyngeal abscess was
unlikely. The patient rapidly improved with
antibiotics/steroids, similar to prior episodes he has had since
[**2151**]. He was transferred to the general medical floor on
[**2160-7-5**]. The etiology of his presenting symptoms remain unclear
(infectious vs immunologic). The infectious disease service was
consulted. They felt that, while possible, bacterial infection
was unlikely, and that the patient likely had a reaction to a
viral illness. They recommended a 10 day course of antibiotics
(initially ceftriaxone/clindamycin, transition to levofloxacin
prior to discharge). At time of discharge, strongyloides
serologieis and HCV PCR were pending. Urine cultures and blood
cultures had no growth to date. Dr. [**Last Name (STitle) 2603**] of allergy, who
follows Mr. [**Known lastname 20008**] as an outpatient, was also consulted. At time
of discharge, serum tryptase and serum IgE, obtained to
determine whether this episode was consistent with an allergic
reaction, were pending.
2) Pancytopenia/Possible immunodeficiency: Initially, the
patient was noted to have a low CD4 (repeat check showed high
CD4 count) as well as depressed igG subsets. HIV Antibody and
viral load were negative, and the infectious disease service
felt that, even if the patient were immunosuppressed, his
clinical picture was not consistent with an opportunistic
infection. In terms of malignancy work-up, hematology/oncology
was consulted for possible bone marrow biopsy (given mild
pancytopenia), which will be performed when the patient follows
up with them as an outpatient. His last colonoscopy was in [**2154**]
and was negative except for diverticulosis. PSA, SPEP/UPEP were
negative during this hospitalization. In order to look for
lymphadenopathy that could suggest malignancy or lymphoma, he
underwent an Abd CT [**7-6**], which showed no evidence of
LAD/malignancy. [**7-1**] chest CTA had showed only small
non-pathologically enlarged mediastinal lymph nodes. The patient
will have a repeat IgG level/subsets and CD4 checked as an
outpatient 2 weeks following discharge. If CD4 count falls
again, PCP prophylaxis may be considered. If IgG is persistently
low, the patient may benefit from Ig infusions.
3) Hyperlipidemia: The patient's lipitor, which had been held in
the setting of acute illness, was restarted prior to discharge
4) Edema/mild CHF: EF 50-55%, [**12-24**]+ MR, impaired LV relaxation.
Following transfer to the floor, the patient was noted to have
marked lower extremity edema, which improved with furosemide
diuresis. This likely represents fluid overload in the setting
of volume resuscitation while in the ICU. There were no EKG
changes suggesting myocardial ischemia. His norvasc was
discontinued, as this could contribute to his edema. He was
started on low dose furosemide, and will have his electrolytes
checked within 1 week followed discharge to ensure stability.
Addition of an ACE inhibitor for afterload reduction, may be
considered as an outpatient.
5) DM-II: The patient was initially placed on a regular insulin
sliding scale, after which he was restarted on
glipizide/rosiglitazone with adequate blood sugar control
6) Code: Full
Medications on Admission:
Norvasc 5 mg PO daily
Rosiglitazone 8 mg PO daily
Glipizide 5 mg PO daily
Atorvastatin 40 mg PO daily
Prednisone/Pepcid prn
Discharge Medications:
1. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-24**]
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Disp:*1 MDI* Refills:*2*
5. spacer
use as directed
dispense: 1
refills: 0
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: hypotension
Secondary: anemia, hyperlipidemia, hypertension, lower extremity
edema, type II diabetes
Discharge Condition:
The patient is hemodynamically stable and ambulating with a
walker without difficulty.
Discharge Instructions:
Please take all medications as prescribed. Your amlodipine has
been discontined (may be restarted at the discretion of your
primary care physician). You will continue levofloxacin to
complete a 10 day course. You have been started on furosemide
given your lower extremity swelling. You should not take
ranitidine/prednisone, unless directed to do so by your
allergist or primary care physician.
Please call your primary care physician or come to the emergency
room if you develop shortness of breath, wheezing, fevers,
chills, lightheadedness, or other symptoms that concern you.
Followup Instructions:
1) Primary Care: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 133**]) within 1-2 weeks following discharge.
- Provider: [**Name10 (NameIs) 20009**],[**Name11 (NameIs) 5557**] [**Name Initial (NameIs) **]. ([**First Name9 (NamePattern2) **] [**Location (un) **]) [**Location (un) **] INTERNAL
MEDICINE (NHB) Date/Time:[**2160-7-14**] 11:45
- you should have your sodium, potassium, and creatinine checked
when you follow-up with your primary care physician.
2) Oncology: Dr. [**First Name (STitle) **]; HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2160-7-11**] 9:30 a.m.
3) Allergy: Please call Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] ([**Telephone/Fax (1) 1723**]) on [**7-9**]
to discuss results of laboratory tests
- repeat IgG and T cell subsets in 2 weeks
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2160-7-16**]
|
[
"272.4",
"038.9",
"284.8",
"424.0",
"274.9",
"995.91",
"250.00",
"079.99",
"276.51",
"428.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8560, 8566
|
4144, 7727
|
300, 324
|
8720, 8809
|
2873, 2892
|
9438, 10480
|
2021, 2038
|
7901, 8537
|
8587, 8699
|
7753, 7878
|
8833, 9415
|
2709, 2854
|
2053, 2067
|
246, 262
|
352, 1624
|
2906, 4121
|
2628, 2692
|
1646, 1884
|
1900, 2005
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,842
| 162,017
|
37847
|
Discharge summary
|
report
|
Admission Date: [**2199-10-2**] Discharge Date: [**2199-10-25**]
Date of Birth: [**2179-12-14**] Sex: F
Service: MEDICINE
Allergies:
Meropenem
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
Fever, diarrhea, laboratory abnormalities.
Major Surgical or Invasive Procedure:
-Dilation and curettage, removal of redundant suture material
from the perineum ([**2199-10-4**])
-Irrigation and debridement, staged, of the sacroiliac joint and
ilium. Exchange of antibiotic beads ([**2199-10-4**])
-Irrigation and debridement, aggressive bone curettage to left
sacroiliac joint and ilium. Placement of antibiotic beads
([**2199-10-3**])
-Embolization of superior gluteal artery (post-operative, due to
bleeding with falling hematocrit)
-PICC line placement ([**2199-10-17**])
-Multiple transfusions (> 20) of red blood cells, platelets,
fresh frozen plasma and cryoprecipitate (over course of SICU
stay)
History of Present Illness:
This is a 19 year old G1P1 with delivery date [**2199-9-20**] with no
significant past medical history who was admitted on [**2199-10-2**],
11 days s/p vaginal delivery with episiotomy with progressive
weaknes, non-bloody diarrhea, back and abdominal pain. She
presented to an urgent care center in [**Location (un) 3844**] with
buttock/back pain, and was found to be hypotensive with low plt
count. She was seen at [**Hospital3 25150**] with WBC 10.8 with 29
bands and plt of 21. Cr of 3.8. She was given fluids and started
on a dopamine gtt and transferred to [**Hospital1 18**].
She was seen in the ED by OBGYN and hematology services (for
thrombocytopenia). She received 9-10 L of fluids while there.
She remained hypotensive and in significant pain, and was
transferred to the SICU for further management.
Past Medical History:
G1P1001 s/p NSVD with episiotomy.
No other significat past medical history.
Social History:
Patient lives in [**Location **], [**Location (un) 3844**] with her mother, father
and [**Name2 (NI) 1685**] brother; her boyfriend also lived with her family
while she was there. She has a newborn daughter named [**Name (NI) 52041**]. She
is a never smoker. She has not used alcohol since she became
pregnant. She dropped out of high school when she became
pregnant, but prior to this illness had been attending night
school to get her GED.
Family History:
Non-contributory.
Physical Exam:
(On transfer to the medicine floor from SICU)
Vitals: T: 97.6, BP: 122/80, P: 82, R: 21, O2: 98% on 5L NC
General: Awake, slightly slurred speech with flat intonation,
oriented to person, [**Hospital3 **], date (can state year,
daughter's birthday), no distress
HEENT: Sclera anicteric, MMM, oropharynx clear, small 3-5 mm
hemorrhagic lesions on lips (do not appear new), NGT in place
Neck: supple, JVP not elevated but wave prominent, no LAD, some
petechiae/oozing near site of L ? IJ line removal earlier today
Lungs: No wheeze or rales, soft ronchi heard anteriorly on L
chest but not throughout lung fields, air entry audible
throughout lung fields but BS diminished especially on R side
CV: Tachycardic, normal S1 + S2 (with physiologic splitting), no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, striae
present across abdomen
GU: Foley draining clear yellow urine
Ext: Diffuse anasarca, 2+ pulses, no cyanosis or clubbing.
Neurologic: CN II-XII intact, stregth 4+/5 in most muscle groups
([**5-7**] in plantar/dorsiflexion), sensation intact across all
dermatomes. Gait not tested.
Pertinent Results:
[**2199-10-1**] 11:23PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2199-10-1**] 11:23PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-10-1**] 11:23PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2199-10-1**] 11:23PM URINE AMORPH-MOD
[**2199-10-1**] 11:23PM WBC-7.7 RBC-3.64* HGB-9.7* HCT-29.0* MCV-80*
MCH-26.7* MCHC-33.5 RDW-14.8
[**2199-10-1**] 11:23PM NEUTS-68 BANDS-24* LYMPHS-2* MONOS-1* EOS-1
BASOS-0 ATYPS-0 METAS-4* MYELOS-0 NUC RBCS-1*
[**2199-10-1**] 11:23PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL BURR-2+
TEARDROP-OCCASIONAL
[**2199-10-1**] 11:23PM PLT SMR-VERY LOW PLT COUNT-22*
[**2199-10-1**] 11:23PM PT-15.2* PTT-30.1 INR(PT)-1.3*
[**2199-10-1**] 11:23PM FIBRINOGE-479*
[**2199-10-1**] 11:23PM LIPASE-12
[**2199-10-1**] 11:23PM ALT(SGPT)-54* AST(SGOT)-83* ALK PHOS-234* TOT
BILI-1.9*
[**2199-10-2**] 02:27AM TYPE-CENTRAL VE PO2-66* PCO2-25* PH-7.25*
TOTAL CO2-11* BASE XS--14 COMMENTS-GREEN TOP
[**2199-10-2**] 04:35AM CORTISOL-47.4*
[**2199-10-2**] 04:35AM FSH-<1.0* LH-<1.0 PROLACTIN-117* TSH-2.9
[**2199-10-2**] 04:35AM HAPTOGLOB-303*
[**2199-10-2**] 04:35AM ALBUMIN-2.2* CALCIUM-6.7* PHOSPHATE-2.3*
MAGNESIUM-2.0
[**2199-10-2**] 04:29PM TYPE-ART TEMP-35.5 O2 FLOW-4 PO2-64* PCO2-30*
PH-7.26* TOTAL CO2-14* BASE XS--12 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2199-10-3**] 12:00AM freeCa-1.06*
[**2199-10-2**] 10:34PM TYPE-[**Last Name (un) **] PO2-42* PCO2-43 PH-7.13* TOTAL
CO2-15* BASE XS--15
******** PATHOLOGIS AND RADIOGRAPHIC FINDINGS ********
Pathology Tissue: LEFT ILIUM, NECROTIC BONE
DIAGNOSIS:
A. Bone, left SI joint:
Fragments of necrotic bone.
No definitive osteomyelitis is identified.
B. Ileum, left:
Fragments of necrotic bone.
No definitive osteomyelitis is identified.
Clinical: Pelvic abscess. Gross:
The specimen is received fresh in two parts, both labeled with
the patient's name, "[**Known lastname 84661**], [**Known firstname 24853**]", and the medical record
number.
Part 1 is additionally labeled "necrotic bone left SI joint." It
consists of multiple fragments of soft hemorrhagic bony tissue
aggregating 4 x 1.8 x 1.4 cm, represented in cassette A and
decalcified at the bench.
Part 2 is additionally labeled "left ileum." It consists of
hemorrhagic bony fragments of tissue aggregating 2.5 x 2 x 0.4
cm entirely submitted into cassette coded B and decalcified at
the bench.
========
Echocardiogram [**2199-10-2**]:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Normal diastolic function. Mild mitral regurgitation
in a structurally-normal valve.
========
Chest x-ray [**2199-10-2**]:
SINGLE UPRIGHT VIEW OF THE CHEST: A right internal jugular
catheter terminates in the lower SVC. Lungs demonstrate
increased interstitial opacities and Kerley B lines. There is
hilar fullness and mild cephalization of pulmonary vasculature.
The heart size is slightly enlarged. There is no mediastinal
enlargement. There is no pneumothorax or lobar consolidation. No
pleural effusions are noted.
IMPRESSION:
1. Right internal jugular catheter terminates in the lower SVC.
2. Mild interstitial edema and fluid overload. Right hilar
fullness most likely related to fluid overload. However, if
there is clinical concern for lymphadenopathy followup imaging
recommended following treatment of fluid status.
========
Transvaginal US [**2199-10-2**]:
INDICATION: 19-year-old female 11 days postpartum with sepsis
and severe crampy pelvic pain. Evaluate for retained products or
ovarian pathology.
COMPARISON: No prior study available for comparison.
FINDINGS: Transabdominal and transvaginal ultrasound were
performed, the latter for better evaluation of the endometrium
and ovaries. The uterus easures 12.7 x 6.8 x 9.3 cm. The
endometrial cavity contains a small amount of fluid and
echogenic debris. There is no vascularity within the debris. The
left ovary is normal. The right ovary was not visualized. There
is a small amount of free fluid within the pelvis.
IMPRESSION:
1. Fluid and echogenic debris within the endometrial cavity
without vascularity may represent blood, but devascularized
retained products of conception cannot be excluded.
2. Small amount of free fluid within the pelvis.
3. Normal left ovary. Right ovary not visualized.
========
Abdominal US with doppler [**2199-10-2**]:
INDICATION: 19-year-old female with direct bilirubinemia,
thrombocytopenia and possible sepsis. Evaluate liver and
gallbladder for pathology and perform Doppler to rule out clot.
COMPARISON: No prior study available for comparison.
ABDOMINAL ULTRASOUND: The liver echotexture is normal without
focal
abnormality. There is no intra- or extra-hepatic biliary ductal
dilatation and the common bile duct measures 3 mm. The
gallbladder wall is thickened up to 1 cm. However, the
gallbladder is relaxed without stones, sludge, or
hypervascularity. The spleen is enlarged measuring up to 16.5
cm. The bilateral kidneys demonstrate increased echogenicity,
which is a nonspecific finding; however, in the setting of
apparent sepsis, pyelonephritis is not excluded. The aorta is of
normal caliber throughout, although the distal aorta is not well
visualized. There is trace ascites and bilateral pleural
effusions.
LIVER DOPPLER: The main portal vein is patent with hepatopetal
flow. The right and left portal veins are normal. The hepatic
arterial and venous vessels are also patent with normal flow and
waveforms.
IMPRESSION:
1. Normal liver echotexture and vascularity.
2. Gallbladder wall thickening without other son[**Name (NI) 493**] signs
of acute cholecystitis, likely reflects third spacing.
3. Echogenic kidneys, a nonspecific finding. However, in the
presence of apparent sepsis, pyelonephritis can not be excluded
and clinical correlation is recommended.
4. Splenomegaly.
5. Bilateral pleural effusions and trace ascites.
========
CT Abdomen/pelvis [**2199-10-2**]:
INDICATION: 19-year-old female 11 days postpartum with
episiotomy presents
with sepsis of unclear etiology, acute renal failure, liver
failure, and white blood cell count of 48. Evaluate for abscess,
appendicitis, colitis, or other intra-abdominal abnormality.
COMPARISON: Abdominal and pelvic ultrasounds performed the same
day.
TECHNIQUE: MDCT-acquired axial images were obtained from the
lung bases to the pubic symphysis without IV contrast due to the
acute renal failure. Oral contrast was administered. Coronal and
sagittal reformats were displayed and essential in delineating
the anatomy and pathology.
CT ABDOMEN WITHOUT IV CONTRAST: There are bilateral pleural
effusions, right greater than left, with associated atelectasis.
However, underlying infection cannot be excluded.
The liver demonstrates diffuse low attenuation without focal
mass lesion. There is no intra- or extra-hepatic biliary ductal
dilatation. The gallbladder demonstrates a thickened wall,
similar to ultrasound performed earlier the same day. In
addition, there is low attenuation material in the gallbladder,
likely sludge. The pancreas and right adrenal gland are
unremarkable. There are two tiny calcifications within the left
adrenal gland without associated mass lesion. The spleen is
enlarged measuring up to 16.4 cm. Two 1.5-cm splenules are noted
in the splenic hilum. The kidneys are symmetric without evidence
of hydronephrosis or stones. The opacified stomach and
intra-abdominal loops of small bowel are unremarkable. Oral
contrast does not make it to the large bowel, however, the
intra-abdominal loops of large bowel are unremarkable. The
appendix is not definitely visualized, but there are no
secondary signs of appendicitis.
There is mild diffuse stranding in the subcutaneous fat and
mesentery and a small amount of fluid in the right paracolic
gutter consistent with
generalized edema. There is no mesenteric or retroperitoneal
lymphadenopathy meeting CT criteria for pathologic enlargement.
CT PELVIS WITHOUT IV CONTRAST: There is a 4 cm pocket of gas
within or adjacent to the left iliacus muscle and smaller
locules of gas tracking into the sacroiliac joint, left S1
neural foramen and left piriformis and gluteus minimus muscles.
The left piriformis muscle is slightly larger than the right and
there is miminal phlegmonous material adjacent to the piriformis
muscle. There is associated rarefaction of the posterior left
iliac bone with apparent erosion of the medial cortex (2:72).
The uterus is bulky, but consistent with postpartum state. There
is a small amount of free fluid in the pelvis, measuring simple
fluid attenuation. There are a few small locules of gas within
the urinary bladder, presumably related to the in situ Foley
catheter. The adnexa, sigmoid colon, and rectum are
unremarkable. There is no pelvic or inguinal lymphadenopathy
meeting CT criteria for pathologic enlargement.
BONE WINDOWS: Aside from the left iliac bone findings described
above, there is no suspicious lytic or sclerotic osseous lesion.
IMPRESSION:
1. Small phlegmonous density anterior to the left sacroiliac
joint and possibly continuous with the joint space, with pockets
of gas within the left iliacus, piriformis and gluteus minimus
muscles with associated rarefaction of the posterior left iliac
bone, highly suspicious for septic arthritis of the left
sacroiliac joint and associated osteomyelitis.
2. Small bilateral pleural effusions with associated
atelectasis. Underlying pneumonia cannot be excluded.
3. Low attenuation of the liver is likely related to acute
hepatitis or generalized edema.
4. Gallbladder sludge not seen on ultrasound, but may be related
to fasting state. Gallbladder wall thickening is likely related
to diffuse edema rather than acute cholecystitis.
5. Splenomegaly.
6. Small amount of free fluid within the pelvis.
ADDENDUM: On additional review of the images, in addition to
rarefaction, there are small locules of gas within the left
posterior iliac bone.
========
Pathology [**2199-10-4**]:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 84662**],[**Known firstname **] [**2179-12-14**] 19 Female [**-9/3912**]
[**Numeric Identifier 84663**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/mtd
SPECIMEN SUBMITTED: Bone from Left Sacro Iliac Crest, EMC.
Procedure date Tissue received Report Date Diagnosed
by
[**2199-10-4**] [**2199-10-4**] [**2199-10-8**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
Previous biopsies: [**-9/3879**] LEFT ILIUM, NECROTIC BONE LEFT
SI JOINT.
DIAGNOSIS:
1. Necrotic bone (A-B): Consistent with acute osteomyelitis
(see note).
2. Endometrial curettings (C-F): Decidua with necrosis and
acute inflammation; smooth muscle fragments with reactive
changes; stains for bacteria are negative.
Note: The tissue is very distorted; multiple levels are taken.
Clinical: Left-sided pelvic infection.
Gross:
The specimen is received fresh in two parts, both labeled
"[**Known lastname 84661**], [**Known firstname 24853**]" with her medical record number.
Part 1 is additionally labeled "bone sacroiliac bone left, ?
necrotic bone". The specimen consists of multiple fragments of
bone that measures 3.5 x 0.6 x 0.3 cm in aggregate. There is a
fragment of cortical bone and multiple fragments of what appear
to be hemorrhagic possibly necrotic soft marrow. The specimen is
submitted entirely in A-B/decal.
Part 2 is additionally labeled "EMC". It consists of fragments
of tan-red tissue that measure in aggregate 4 x 3 x 0.5 cm. The
specimen is submitted entirely in cassettes C-F.
A-B are decalcified at the bench.
========
Chest x-ray [**2199-10-9**]:
REASON FOR EXAMINATION: Followup of a patient with septic shock.
Portable AP chest radiograph was compared to [**2199-10-8**].
The ET tube tip is just above the level of the clavicular heads
approximately 5 cm above the carina. The right internal jugular
line tip is at the level of low SVC. There is interval extensive
progression of the parenchymal opacities currently involving the
entire lungs with bibasilar dense consolidations. Thus, the
bilateral pleural effusion cannot be excluded. Within the
limitations of this study, the cardiomediastinal silhouette
appears to be unchanged.
The above-described changes might represent significant rapid
progression of infection or superimposed pulmonary edema on the
pre-existing abnormalities within the lungs. ARDS would be
another possibility and should be correlated with clinical
findings.
========
Liver/GB US [**2199-10-9**]:
FINDINGS: The gallbladder has a similar appearance with no
change in the luminal volume. Again there is gallbladder wall
thickening which is entirely nonspecific and could be related to
the known hypoalbuminemia. A trace amount of pericholecystic
fluid is noted. No gallstones are seen. Patient is intubated and
therefore we cannot evaluate for son[**Name (NI) 493**] [**Name (NI) **] sign. The
visualized liver demonstrates normal echotexture and size. There
is normal hepatopetal flow in the main portal vein. There is a
right pleural effusion.
IMPRESSION: Stable appearance of nonspecific gallbladder wall
thickening which is likely to be related to third spacing. The
appearance is not suggestive of acute cholecystitis, and
furthermore the stability of gallbladder volume would also argue
against acute cholecystitis.
========
CT torso [**2199-10-9**]:
HISTORY: Septic shock. Status post drainage of septic left hip,
now with spiking fevers.
COMPARISON: CT abdomen and pelvis performed [**2199-10-2**],
aortic angiogram [**2199-10-3**] and right upper quadrant
ultrasound [**2199-10-9**].
CT CHEST
64-row MDCT was performed from the thoracic inlet to the base of
the lung. Intravenous contrast was not administered.
The tip of the endotracheal tube is in good position, 3.8 cm
above the carina. There are diffuse patchy pulmonary opacities
throughout both lungs somewhat sparring the left upper lobe.
Findings are consistent with diffuse multifocal pneumonia and/or
superimposed ARDS. Compared to the prior study, there is a
stable moderate-sized right pleural effusion and a
moderate-sized left pleural effusion. The left effusion has
increased slightly in size since the prior study. There is dense
consolidation in both lung bases with air bronchograms.
Superimposed aspiration should be considered.
CT ABDOMEN
64-row MDCT was performed from the base of the lung to the iliac
crest. Oral and intravenous contrasts were not administered.
The liver is unremarkable. There is high-density material in the
dependent portion of the gallbladder consistent with vicarious
excretion likely from the prior angiogram of [**2199-10-3**].
The spleen is enlarged along the cephalocaudad axis measuring
18.5 cm. However, the transverse diameter of the spleen is
relatively [**Name2 (NI) 15015**] measuring 4.4 cm. The size of the spleen is
unchanged since the prior study.
The right adrenal gland is unremarkable.
There is punctate calcification within the left adrenal gland
which was stable from the prior CT scan. This may represent the
sequelae of prior adrenal hemorrhage. Correlation with any
relevant past medical history is
recommended.
The abdominal aorta is normal in caliber. There is a
small-to-moderate amount of ascites lateral to the liver which
measures an average of 8.7 Hounsfield units consistent with
simple fluid.
Both kidneys are grossly abnormal. The right kidney measures 9.9
cm in the sagittal axis and the left measures 12.0 cm in the
sagittal axis. There is linear density involving the renal
cortices bilaterally. The renal cortices measure up to an
average of 85 Hounsfield units. The overall attenuation of the
kidneys is decreased and there is an appearance of striated
corticomedullary junction. These findings would be consistent
with possible ATN and delayed enhancement of the renal cortex
secondary to IV contrast administration on [**10-3**].
Reportedly, the patient is making urine, but has an elevated
creatinine of approximately 3.
In the upper pole of the right kidney is a 19 mm relatively
low-attenuation area which is poorly defined. This is best
appreciated on series 300B, image 43. This was not present on
the prior study or at least was not evident. This may represent
focal inflammatory or infectious region within the right kidney.
However, there is no surrounding perinephric fat stranding
making the possibility of infectious or inflammatory lesion less
likely. Clinical correlation is advised.
CT PELVIS
64-row MDCT was performed from the iliac crest to the symphysis
pubis. Oral and intravenous contrasts were not administered.
There is high-density material within the colon, likely from
prior ingested oral contrast on [**10-2**]. There is a
surgical defect in the left iliac bone with high-density rounded
material. This is consistent with recent debridement and
placement of antibiotic capsules. Metallic densities are also
noted in the distribution of the left superior gluteal artery
related to recent catheter embolization. There is no evidence of
a pelvic abscess. There is diffuse anasarca. Specifically,
there is no evidence of a drainable fluid collection around the
left hip.
The uterus is slightly enlarged consistent with postpartum
state. A Foley
catheter is noted in the dependent portion of the bladder. There
is air in the anterior aspect of the bladder.
BONE WINDOWS: There are no lytic or blastic lesions.
MULTIPLANAR REFORMATTED IMAGES. Coronal and sagittal multiplanar
reformatted images were performed.
IMPRESSION:
1. Diffuse bilateral pulmonary opacities with bilateral pleural
effusions. Findings could be consistent with multifocal
pneumonia or ARDS. Underlying aspiration should also be
considered.
2. Enlarged spleen in the craniocaudad dimension of unclear
clinical significance.
3. Diffusely abnormal kidneys. The kidneys are normal in size.
However, there is a rim of high density attenuation surrounding
both kidneys. This may be related to vicarious excretion of
contrast and delayed nephrogram from IV contrast administration
approximately one week ago in the setting of acute renal
failure.
4. Low-attenuation lesion measuring approximately 2 cm in the
upper pole of the right kidney which is poorly defined. In the
proper clinical setting, this may represent a focal abscess or
inflammatory focus. However, there is no surrounding perinephric
fat stranding which would often be associated with an infectious
or inflammatory etiology.
5. Ascites and anasarca.
6. Vicarious excretion of contrast in the gallbladder.
7. Postoperative and post-embolical changes in the left iliac
bone and distribution of the left superior gluteal artery.
8. Compared to the prior study, the attenuation of the liver has
increased and now measures approximately 48 Hounsfield units,
previously measuring 43 to 44 Hounsfield units. The spleen
measures 40 Hounsfield units.
CT Pelvis ([**10-21**]):
IMPRESSION:
1. New left sacral small hypodense foci may represent focal
areas of
osteopenia versus new areas osteomyelitis; close attention on
followup is
recommended.
2. Left sacral linear lucency may represent developing
insufficiency
fracture; again close attention on followup imaging is
recommended.
3. Expected post surgical changes in left iliac bone and soft
tissues.
========
Chest x-ray [**2199-10-14**]:
IMPRESSION: AP chest compared to [**10-13**], 5:22 a.m.:
No endotracheal tube is seen below C6, the upper margin of this
film. Nasogastric tube ends in the upper stomach. Right jugular
line tip projects over the low SVC. Lung volumes are lower and
there is greater opacification generally particularly in the
right lung. This could be little changed, could be due primarily
to the loss of positive pressure ventilator support, but is also
concerning for progression of underlying abnormality, presumably
edema, cardiogenic or otherwise. Small right pleural effusion is
presumed. There is no pneumothorax.
========
ECG [**2199-10-15**]:
Sinus rhythm at upper limits of normal rate. No previous tracing
available for comparison.
========
Pelvis plain film [**2199-10-17**]:
COMPARISON: CT dated [**2199-10-9**].
REPORT: A ring is projected over the superior aspect of the
symphysis pubis with a tubular lucency here also seen, barely
appreciated. Coils and clips are projected over the left
quadrant. There are multiple rounded radiopaque bodies projected
over the left iliac bone, which probably represents antibiotic
impregnated beads. The bowel gas pattern appears grossly
unremarkable.
CONCLUSION: Status post antibiotic bead placement.
Normal-appearing bones and soft tissues.
========
Pelvis plain film [**2199-10-21**]:
Single AP view of the pelvis obtained weightbearing. There is
asymmetry of the acetabular roofs, approximately 8 mm higher on
the left. However, overall the pelvis appears symmetric and
congruent. Slight left convex rotary scoliosis suggested in the
lower lumbar spine. Embolization coils and skin staples again
noted.
========
CT pelvis [**2199-10-21**]:
STUDY: CT of the pelvis without contrast was performed. Coronal
and sagittal reformatted images were generated.
COMPARISON STUDY: [**2199-10-9**].
FINDINGS: There is a surgical defect in the left iliac bone with
round high density pellets which is consistent with the
previously described I&D, and subsequent antibiotic pellet
placement. Patchy hypodensities are seen in the left sacrum just
medial to the left SI joint (400B; 36, 38). Additionally, a
linear lucency is seen in the left sacral ala (38; 27).
High-density material projecting in the distribution of the left
superior gluteal artery is consistent with catheter embolization
material. Postoperative changes consistent with a left lateral
inguinal approach are seen including a 6 cm x 6 cm x 9 cm fluid
collection in the left inguinal subcutaneous soft tissue, likely
postoperative simple fluid/ seroma. There is also a small amount
of free fluid in the pelvis. Skin staple line is also seen
projecting over this area.
A small locule of air within the bladder likely represents
recent catheterization; mild enlargement of the uterus likely
represents recent postpartum state.
IMPRESSION:
1. New left sacral small hypodense foci may represent focal
areas of osteopenia versus new areas osteomyelitis; close
attention on followup is recommended.
2. Left sacral linear lucency may represent developing
insufficiency fracture; again close attention on followup
imaging is recommended.
3. Expected post surgical changes in left iliac bone and soft
tissues.
******** MICROBIOLOGY DATA ********
Wound swab [**2199-10-3**]:
Log-In Date/Time: [**2199-10-3**] 1:19 am
TISSUE Site: BONE LEFT SI JOINT BONE.
SWAB RECEIVED FOR ACID FAST CULTURE.
GRAM STAIN (Final [**2199-10-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2199-10-6**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2199-10-17**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 10900**] [**Last Name (NamePattern1) 10901**] @ 11:55 AM ON
[**2199-10-5**].
FUSOBACTERIUM NECROPHORUM. SPARSE GROWTH.
BETA LACTAMASE NEGATIVE.
Identification and sensitivities performed by [**Hospital1 **]
laboratories.
SENSITIVE TO METRONIDAZOLE (<=0.5 MCG/ML).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
FUSOBACTERIUM NECROPHORUM
|
CLINDAMYCIN----------- <=0.5 S
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2199-10-3**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Final [**2199-10-18**]): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2199-10-3**]):
NO FUNGAL ELEMENTS SEEN.
========
Wound tissue [**2199-10-3**]:
Log-In Date/Time: [**2199-10-3**] 1:19 am
TISSUE Site: BONE LEFT SI JOINT BONE.
SWAB RECEIVED FOR ACID FAST CULTURE.
GRAM STAIN (Final [**2199-10-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2199-10-6**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2199-10-17**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 10900**] [**Last Name (NamePattern1) 10901**] @ 11:55 AM ON
[**2199-10-5**].
FUSOBACTERIUM NECROPHORUM. SPARSE GROWTH.
BETA LACTAMASE NEGATIVE.
Identification and sensitivities performed by [**Hospital1 **]
laboratories.
SENSITIVE TO METRONIDAZOLE (<=0.5 MCG/ML).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
FUSOBACTERIUM NECROPHORUM
|
CLINDAMYCIN----------- <=0.5 S
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2199-10-3**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Final [**2199-10-18**]): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2199-10-3**]):
NO FUNGAL ELEMENTS SEEN.
========
Tissue [**2199-10-4**]:
BIOPSY SACROILIAC LEFT.
**FINAL REPORT [**2199-10-11**]**
GRAM STAIN (Final [**2199-10-4**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2199-10-10**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 84664**] [**Last Name (NamePattern1) **] [**2199-10-9**] @ 11:45 AM.
BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final [**2199-10-10**]): NO ANAEROBES ISOLATED.
========
Swab [**2199-10-4**]: ENDOMETRIUM.
**FINAL REPORT [**2199-10-6**]**
GRAM STAIN (Final [**2199-10-4**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2199-10-6**]): NO GROWTH.
========
Sputum culture [**2199-10-6**]:
Source: Endotracheal.
**FINAL REPORT [**2199-10-10**]**
GRAM STAIN (Final [**2199-10-6**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2199-10-10**]):
Commensal Respiratory Flora Absent.
ENTEROBACTERIACEAE. SPARSE GROWTH. UNABLE TO IDENTIFY
FURTHER.
sensitivity testing performed by Microscan.
CONFIRMATION PENDING.
CEFEPIME: <=2 MCG/ML. MEROPENEM : <=1 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTERIACEAE
|
CEFEPIME-------------- S
CEFTAZIDIME----------- <=2 S
CIPROFLOXACIN--------- <=0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- S
PIPERACILLIN---------- <=8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
========
NOTE: All other blood, urine, sputum, stool and catheter tip
cultures were negative.
Brief Hospital Course:
On presentation she was hypotensive with bandemia,
thrombocytopenia, acute renal failure (creatinine > 3) with
fluid refractory shock requiring three pressors. She was
evaluated by the OBGYN and hematology services in the ED, and
felt to have a process unrelated to retained POC and a
presentation consistent with SIRS (considered responsible for
the thrombocytopenia). Initial imaging of the pelvis was highly
concerning for septic arthritis of the left sacroiliac joint and
associated osteomyelitis. She was electively intubated prior to
emergent pelvic exploration. Peri-intubation the patient was
transiently without a pulse and 3 chest compressions were
performed with return of spontaneous circulation. She was taken
to the OR on [**2199-10-3**] for left sacroiliac joint debridement. The
procedure was complicated by significant bleeding which required
arteriogram and gelfoam to the left superior glutal artery. She
returned to the operating room on [**2199-10-4**] for repeat washout and
exchange of antibiotics beads, and dilation and curettage.
Initial antibiotic coverage included vancomycin, Zosyn,
ciprofloxacin and flagyl. Clindamycin was added on [**2199-1-4**].
Cultures from the wound grew fusobacterium necrophorum.
Postoperative course was complicated by ARDS and persistent
oxygen requirement despite attempts at diuresis with lasix drip.
She also had intermittent fevers although no additional
infectious sources were identified. She self extubated on
[**2199-10-15**] and was stable from a respiratory status since that
time. Renal function improved from a creatinine of 3.1 on
admission to 1.0. Thrombocytopenia resolved. She was transferred
to the medicine service from orthopedics on [**10-18**].
After transfer, her oxygen was quickly weaned off from 5 L to
room air within 2 days. She was followed by orthopedics service
who recommended touch-down weight-bearing to left with full
weight-bearing on the left leg. Her appetite improved and NGT
was removed, and she was converted to oral antibiotics and her
PICC line was removed. Her affect was initially very flat,
although she was oriented x 3 and answered questions
appropriately. This may have been secondary to residual
delerium, although given her very severe illness and temporary
pulselessness, some degree of anoxic brain injury cannot be
ruled out. Her affect improved over the course of her stay on
the medical floor, with improvements in eye contact, voice
intonation, facial expression and personability, although
impairments in all areas remained noticeable. According to her
family, her affect at discharge was not yet back to baseline
(they describe her as bubbly and animated).
Per orthopedic team, she should continue daily injections of
Lovenox until her follow-up appointment in orthopedics clinic in
early [**Month (only) **].
From an infectious standpoint, she should continue ciprofloxacin
and metronidazole to complete a six-week course from [**10-11**]. This course will end on [**11-22**].
She has worked with physical therapy who has recommended
discarge to rehab facility. Medications at time of discharge
include Flagyl, ciprofloxacin, Lovenox, Percocet as needed, and
stool softeners as needed.
******** OPERATIVE REPORTS ********
I&D [**2199-10-3**]:
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] K.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on MON [**2199-10-7**]
10:39 AM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 84663**]
Service: Date: [**2199-10-3**]
Date of Birth: [**2179-12-14**] Sex: F
[**Year (4 digits) **]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4158**]
PREOPERATIVE DIAGNOSIS: Sepsis, left sacroiliac joint
infection, left ilium osteomyelitis.
POSTOPERATIVE DIAGNOSIS: Sepsis, left sacroiliac joint
infection, left ilium osteomyelitis.
PROCEDURE: Irrigation and debridement, aggressive bone
curettage to left sacroiliac joint and ilium. Placement of
antibiotic beads.
INDICATIONS: Mrs. [**Known lastname 84661**] is a 19-year-old young lady who
delivered a baby 11 days ago. She presented to [**Hospital1 18**] with an
acute picture of septicemia and hypotension. She now presents
emergently to the operating room for debridement, given her
significant degree of hemodynamic instability.
PROCEDURE IN DETAIL: The patient was brought to the
operating room and after successful induction of general
anesthesia the patient's left sacroiliac area was exposed using
the most lateral window of an ilioinguinal exposure. This
involved incising the skin, elevating the iliacus from the
anterior pelvic surface
exposing the sacroiliac joint. Copious amounts of watery dark
fluid of significant necrotic odor was extruded from the SI
joint. This was serially irrigated and lavaged and then a large
cortical window approximately 8 x 3 cm was performed on the
anterior aspect of the ilium and immediately lateral to the
sacroiliac joint. Significant amounts of necrotic bone were
curettaged and burred. This was foul-smelling, non-bleeding,
clearly necrotic bone. No purulence was noted just watery brown
liquid from the SI joint.
Towards the final stage of the curettage using a bur. Profuse
bleeding was noted coming from the underside aspect of the
sciatic notch. I suspect that bleeding was coming from the
superior gluteal artery secondary to the aggressive debridement
required to remove the necrotic bone. I tamponaded the bleeding,
inserted antibiotic beads including Tobramycin and vancomycin
and proceeded to close the wound . The bleeding appered
controlled durign wound closure.
I informed the surgical ICU team to monitor hematocrit in the
following hours in the case of persistent bleeding from the
surgical site. Ig so , I recommended to proceed with angiography
for control of potential superior gluteal artery bleed if
bleeding
persisted. I personally contact[**Name (NI) **] the angiography team to notify
them of the case pending the intial postoperative course
The patient tolerated the surgical procedure well and was
able to transfer back to the ICU .
========
Superior gluteal artery embolization [**2199-10-3**]:
INDICATION: 19-year-old woman status post left iliac debridement
for osteomyelitis with subsequent bleeding from the left
superior gluteal artery with active bleeding seen during surgery
and hematocrit drop from 26 to 13.
ANESTHESIA: General anesthesia, and approximately 5 ml of local
lidocaine. The patient was intubated prior to procedure.
OPERATORS: Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 9441**], the attending radiologist, who
was present and performed the procedure.
PROCEDURE: As the patient was intubated, the risks and benefits
of the procedure were explained to the patient's mother and
informed consent was
obtained over the telephone with a witness. The patient was
brought to the angiography suite and placed supine on the table.
The patient was prepped and draped in standard sterile fashion.
A preprocedure timeout and huddle were performed per [**Hospital1 18**]
protocol. After local anesthesia with approximately 5-10 cc of
lidocaine 1%, access was gained into the right common femoral
artery with a 19-gauge needle. A 0.035 Bentson guidewire was
advanced through the needle into the abdominal aorta. The needle
was removed and a 5 French sheath was inserted. The sheath was
connected to a continuous side-arm flush. A 5 French Omniflush
catheter was then advanced over the [**Last Name (un) 7648**] wire under
fluoroscopic guidance and the wire was advanced into the left
internal iliac artery. As the location of the bleeding was known
after discussion with the orthopedic [**Last Name (un) 5059**] and due to the
patient's acute renal failure, a selected arteriogram of only
the left iliac artery was performed. A C2 cobra catheter was
advanced over the wire and an arteriogram of the left internal
iliac artery demonstrated active contrast extravasation from the
left superior gluteal artery. Based on the diagnostic findings,
the decision was made to perform embolization. Gelfoam was
administered proximal to area of bleeding within the left
superior gluteal artery. A microcatheter then was advanced
through the Cobra catheter and placed distal to the area of
active extravasation. This artery was embolized with a total of
10 coils, five distallly and five proximal to area of active
bleeding. A final run of the left internal iliac artery
demonstrated no active bleeding from the left superior gluteal
artery.
As the patient was in acute renal failure, Visipaque was used
and the patient was well hydrated and premedicated with
bicarbonate. A total of 100 cc of Visipaque was used during the
arteriogram.
Due to the request from the team as the previous arterial access
was difficult to obtain, the right femoral artery sheath was
left in place and secured with 0 silk stitch. The need for
continuous flushing of this sheath with 60 cc of saline per hour
was discussed with the SICU team and orders were entered.
IMPRESSION: Area of active bleeding seen from left superior
gluteal artery with subsequent embolization with gelfoam and
coils with good angiographic result and no immediate
complications.
========
I&D and exchange of antibiotic beads [**2199-10-4**]:
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] K.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on MON [**2199-10-7**]
10:51 AM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 84663**]
Service: Date: [**2199-10-4**]
Date of Birth: [**2179-12-14**] Sex: F
[**Year (4 digits) **]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4158**]
PREOPERATIVE DIAGNOSES: Left sacroiliac septic joint and
septic ilium.
POSTOPERATIVE DIAGNOSEIS: Left sacroiliac septic joint and
septic ilium.
PROCEDURE:
1. Irrigation and debridement, staged, of the
sacroiliac joint and ilium.
2. Exchange of antibiotic beads.
INDICATIONS: Ms. [**Known lastname 84661**] is presenting for a staged
procedure regarding her infected pelvis. We will now remove
the existing antibiotic beads and place a new set of beads.
PROCEDURE IN DETAIL: The patient was brought to the
operating room, and after successful induction of general
anesthesia, was placed in the supine position. Via the
previously
made left lateral window of the ilioninguinal exposure the wound
was
reopened. Significant amounts of old clot and hematoma were
debrided. The wound was copiously irrigated down to the level of
the bony cavity which was irrigated with multiple liters of
pulse lavage solution and the antibiotic beads were applied
after removing the old set. The was no evidence of odor or other
sign of persistent worseingin necrosis of the bone. Some
additonal curetagge of the cavity was performed and cultures
were sent again.
The wound was then closed after there was no active bleeding
using Vicryl sutures and staples at the skin.
No drains were used.
[**Known lastname **]'S STATEMENT: Dr. [**Last Name (STitle) 1005**] was present for the
entire procedure and then referred the case to the GYN
service to perform a D and C.
========
D&C and removal of suture material from perineum [**2199-10-4**]:
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 84665**]
**NOT REVIEWED BY ATTENDING**
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 84663**]
Service: Date:
Date of Birth: [**2179-12-14**] Sex: F
[**Year (4 digits) **]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 50701**], [**MD Number(1) 84666**]
SERVICE: OB/GYN.
PREOPERATIVE DIAGNOSES:
1. Echogenic material on the uterus.
2. Sepsis.
POSTOPERATIVE DIAGNOSES:
1. Echogenic material on the uterus.
2. Sepsis.
PROCEDURES: Dilation and curettage, removal of redundant
suture material from the perineum.
ASSISTANT: [**Name6 (MD) **] [**Name8 (MD) 32005**], MD.
ANESTHESIA: General endotracheal anesthesia.
IV FLUIDS: 100 mL.
URINE OUTPUT: Not measured separately from the orthopedics
case which was done just prior to the D&C.
ESTIMATED BLOOD LOSS: Minimal.
SPECIMEN: Endometrial curettings sent to pathology.
ANTIBIOTICS: The patient continued on clindamycin, Unasyn
and vancomycin that she was previously on before the
operating room.
INDICATIONS: The patient is a 19-year-old female in G1, P1,
status post a spontaneous vaginal delivery on [**2199-9-20**], who presented with left hip pain that was making her
have difficulty sitting and standing but denied any fever,
chills, abdominal pain. The patient also had some loose
stools since her delivery but was otherwise feeling well. The
patient had a precipitous delivery and only received a local
anesthesia at the perineum at the time of delivery. She had a
small perineal laceration which was repaired and reported
normal amount of vaginal bleeding and cramping since delivery
but no excessive abdominal pain or fevers. The patient
presented on [**10-2**] to urgent care. She was found to be
septic and in shock and was sent from the outside hospital in
[**Location (un) 3844**] to [**Hospital1 **] given her septic
state. The patient presented with hypotension and required
pressors for blood pressure support. She was started on
vancomycin, Zosyn and Flagyl. A pelvic ultrasound revealed a
small amount of free fluid within the pelvis, some debris
without vascularity in the uterus and no evidence of
vascularity. There was no clinical evidence on exam of
retained products of conception. A CT of the abdomen and
pelvis was done which revealed gas within the left iliac and
piriformis and phlegmon which was seen in the left sacral
iliac joint. Given these concerning findings and the
patient's concerning state, she was taken to the operating
room where she underwent an incision and drainage of the left
iliac bone and after coming out of the operating room, her
hematocrit fell precipitously and she was taken to the
interventional radiology for an embolization of the superior
gluteal vessel which was found to be bleeding. The patient
was taken back to the operating room today for repeat
incision and drainage of the clot from the bleeding as well
as any infection as well as antibiotic bead placement by
orthopedics. Although there were no obvious signs of
retained products of conception, it was discussed that a D&C
could be performed to sample the contents of the uterus and
to culture them for another possible site of infection.
FINDINGS: Uterus was sounded with a Pipelle to 14 cm and the
patient had a normal cervix and vagina. The vagina had a
first-degree perineal laceration which had been repaired and
noted. The extra suture material which looked like 0-Vicryl
was trimmed and hemostasis was noted. There was no evidence
of excessive bleeding or infection on exam.
PROCEDURE: The patient was taken to the operating room from
the ICU, intubated and sedated. The orthopedics team
completed their portion of the surgery in the supine
position, and when they had completed their portion of the
operation, the patient was then placed in the dorsal-
lithotomy position with the [**Doctor Last Name **] stirrups in order to
support the patient's left thigh given resection of her bone.
The exam under anesthesia revealed an approximately 1-cm
dilated cervix, however, her swelling from her fluids did not
allow for the fundus to be felt on bimanual exam.
A time-out was taken per operating room protocol. The patient
was continued on her clindamycin, Zosyn and vancomycin. She
had pneumatic compression boots which were on and working.
The patient was prepared and draped in normal sterile fashion
and speculum placed and the cervix visualized. The posterior
lip of the cervix was grasped with a ring forceps and the
uterus was sounded with an endometrial sampling Pipelle to 14
cm. Three passes of the Pipelle were used to collect samples
of endometrium. A sample was sent for aerobic and anaerobic
culture as well as sent to pathology for examination. A very
gentle sharp curettage was performed after dilating the
cervix easily to a #25 [**Location (un) 1662**] dilator. The sharp curette
revealed somewhat slick lining of the uterus. However, the
curettings appeared to be old blood and decidua. There are no
obvious signs of retained products of conception or infection
within the uterus in the contents that were curetted. The
ring forceps was then removed and the blood cleared from the
vagina. There was no evidence of any ongoing bleeding. The
perineum was examined and the first-degree perineal
laceration had some redundant Vicryl suture which was cut and
removed. Hemostasis was noted. The patient tolerated the
procedure well and was placed again in dorsal supine
position. The patient was kept intubated and sedated for
transfer back to the ICU. The sponge and needle counts were
reported as correct per operating room staff.
Medications on Admission:
None.
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Please continue to take through.
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] home care
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Sepsis (most likely seconday to Fusobacterium necrophorum)
Acute respiratory distress syndrome
Systemic inflammatory response syndrome
Osteomyelitis of left sacroiliac joing (secondary to
Fusobacterium necrophorum)
Acute renal failure
Hypertension
Delerium
Seconday diagnoses:
Post-partum state
Recent episiotomy
Discharge Condition:
Stable - able to tolerate regular diet, O2 sat 99-100% on room
air, afebrile, still very weak (generalized) but improving daily
Discharge Instructions:
You were admitted to the hospital for treatment of infection in
the left sacroiliac joint. You underwent surgical debridement
and you were started on antibiotics to treat the infection. With
this treatment, your symptoms improved. Please continue to take
your medicines as prescribed, and please note your follow-up
appointments below.
.
Until you hear otherwise from your orthopedic [**Last Name (LF) 5059**], [**First Name3 (LF) **] NOT
bear full weight on your left leg (touch-down weight bearing
only, as you have been doing in your physical therapy sessions
in the hospital).
.
We made the following changes to your medicines:
-we ADDED ciprofloxacin
-we ADDED metronidazole
-we ADDED Percocet for pain control
-we ADDED Lovenox (until your orthopedic follow up visit)
-we ADDED stool softeners to help prevent constipation
.
Please call your doctor or return to the emergency room if you
have fever, worsening pain in the hip, persistent
nausea/vomiting, depression, difficulty coping with the stress
of illness or motherhood, or other any other symptoms that are
concerning to you.
Followup Instructions:
1. Orthopedics - Dr. [**Last Name (STitle) 1005**] (and NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
[**2199-11-5**] 9:00 AM [**Telephone/Fax (1) 1228**]
- Your sutures will be removed at this visit. Please continue
Lovenox until this time and then follow the advice of your
physician regarding the need to continue anticoagulation.
2. OBGYN - Please schedule an appointment to follow up with your
OBGYN doctor [**First Name (Titles) **] [**Location (un) 3844**] for 2-4 weeks from discharge (or
when you are home from rehab) if you have no further issues
related to your pregnancy or episiotomy. If any problems arise,
you should be seen sooner.
3. Primary care - You will need to establish care with a primary
care physician. [**Name10 (NameIs) **] will most likely be easiest for you to
arrange care with a physician close to [**Name9 (PRE) **]. However, if you
would like to follow up with a primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 18**], you
may call the [**Hospital3 **] clinic at [**Telephone/Fax (1) 250**].
**if you have any symptoms concerning for infection (fever,
increasing pain at surgical site), or if you would like to
contact the infectious disease clinic, the number to call is
[**Telephone/Fax (1) 457**].**
Completed by:[**2199-10-25**]
|
[
"584.5",
"401.1",
"286.6",
"287.5",
"518.81",
"511.9",
"785.52",
"041.84",
"998.11",
"359.81",
"276.2",
"995.92",
"427.5",
"038.9",
"285.9",
"711.08",
"570",
"293.0",
"730.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"77.69",
"38.93",
"69.02",
"80.89",
"96.6",
"39.79",
"96.72",
"99.60",
"99.21"
] |
icd9pcs
|
[
[
[]
]
] |
50313, 50370
|
32402, 49564
|
315, 940
|
50747, 50877
|
3594, 28225
|
52014, 53330
|
2356, 2375
|
49620, 50290
|
50391, 50391
|
49590, 49597
|
50901, 51991
|
2390, 3575
|
29820, 32379
|
233, 277
|
968, 1781
|
50410, 50726
|
1803, 1880
|
1896, 2340
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,541
| 105,261
|
44529
|
Discharge summary
|
report
|
Admission Date: [**2135-7-27**] Discharge Date: [**2135-8-20**]
Date of Birth: [**2085-9-21**] Sex: F
Service: MED
Allergies:
Penicillins / Sulfonamides
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fever and low back pain
Major Surgical or Invasive Procedure:
endotracheal intubation & mechanical ventilation
tracheostomy
History of Present Illness:
49 yo morbidly obese female who weighs 310 lb with hx of IDDM,
MRSA bacteremia, and low back pain was transferred from [**Hospital1 **]
[**Location (un) 620**] today. Pt initially presented to [**Hospital1 **] [**Location (un) 620**] with 16
hour history of fevers and left low back pain. She also
complained of dysuria and abdominal discomfort 3 days prior to
admission and was seen by her PCP but her urine culture was
negative. The night prior to admission, she experienced fever
of 101.5, chills, and diaphoresis. She was initially admitted
to [**Hospital1 **] [**Location (un) 620**] for evaluation of her fever and flank pain. She
was initially treated with Levaquin but was started on
Vancomycin 1g q12 once the blood culture grew out MRSA. Blood
culture was positive for MRSA on multiple occasion and showed no
growth on [**7-25**]. Patient continued to spike fever with Tm=105.1
on [**2135-7-26**]. At that time Gentamycin was added for synergy after
ID consult. TEE was done which was negative for any valvular
vegetation. Patient has left paraspinal tenderness with high
grade MRSA bacteremia of unknown source, MRI of the L spine was
recommended to rule out epidural abscess. However, patient is
claustrophobic and can only do either open MRI or MRI under
general anesthesia. For that reason, patient was transferred to
[**Hospital1 18**] to have the MRI done under general anesthesia. Dr.
[**Last Name (STitle) 1338**] from neurosurgery is aware of her. Today, pt was on 2L
oxygen but came to the hospital with 5L. Patient now requiring
face mask to keep her saturation.
Past Medical History:
Non insulin dependent diabetes
Hypertension
Status post cholecystectomy
Obesity
Asthma
Fibromyalgia
Social History:
Mother lives with her at home- she has been sick recently with
cellulitis [**Month (only) **]-[**Month (only) 116**], requiring hospitalization. No recent
travel. Works as case manager at facility/NH for MR patients.
Patients on case load have been MRSA/VRE positive. Denies
tobacco, ETOH, drugs. HCP is mother: [**Telephone/Fax (1) 95392**]
Family History:
noncontributory
Physical Exam:
VS: T 101.2 BP 134/50 HR 102 R 24-40's O2 sat 5 L
Gen: breathing in labor with face mask, diaphoretic
HEENT: PERRL, EOMI, MMM, sweaty
Lungs: distant breath sound, crackle on right posterior exam,
diffuse wheezing.
Cor: distant heart sound, murmurs appreciated at outside
hospital but difficult to assess with her heavy rapid breathing
and oxygen.
Abd: Obese, difficult to assess liver, spleen.
Ext: 1+ edema bilaterally.
Musc: Warm to touch and slight erythema of left lumber
paraspinal region. +Tenderness to palpation.
Neuro: Alert, oriented. CN II-XII grosssly intact.
Pertinent Results:
[**2135-7-28**] 04:42AM BLOOD WBC-10.6 RBC-4.20 Hgb-11.3* Hct-34.5*
MCV-82 MCH-27.0 MCHC-32.9 RDW-14.5 Plt Ct-277
[**2135-8-3**] 04:58AM BLOOD Neuts-80.6* Lymphs-11.6* Monos-5.6
Eos-1.9 Baso-0.4
[**2135-7-28**] 04:42AM BLOOD PT-12.8 PTT-31.6 INR(PT)-1.1
[**2135-7-28**] 04:42AM BLOOD Plt Ct-277
[**2135-8-18**] 04:30AM BLOOD Eos Ct-740*
[**2135-7-28**] 04:42AM BLOOD Glucose-123* UreaN-12 Creat-0.5 Na-141
K-3.2* Cl-98 HCO3-32* AnGap-14
[**2135-7-29**] 04:30AM BLOOD ALT-63* AST-53* LD(LDH)-230 AlkPhos-321*
TotBili-0.9
[**2135-7-28**] 04:42AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9
[**2135-7-28**] 01:06AM BLOOD Type-ART Temp-38.6 Rates-/30 O2-100
pO2-102 pCO2-53* pH-7.39 calHCO3-33* Base XS-5 AADO2-576 REQ
O2-92 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2135-7-28**] 01:57AM BLOOD Type-ART Temp-38.3 Rates-/30 O2-100
pO2-82* pCO2-55* pH-7.39 calHCO3-35* Base XS-6 AADO2-594 REQ
O2-95 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2135-7-28**] 01:06AM BLOOD Lactate-1.1
Brief Hospital Course:
Ms [**Known lastname 8520**] had positive blood cultures from OSH for MRSA, here
she had multiple blood cultures which were pertinent only for 1
bottle of coag neg staph. She did have persistently positive
sputum for MRSA with sparse gram negative rods speciated as
klebsiella & enterobacter. Urine negative, TEE negative, CT
abdomen unrevealing. tagged WBC scan negative.
Was on Vanc for 28 days & Cipro for 14 days. Had persistent
fevers to 102, ? was for drug fever vs persistent PNA.
CT scan showed RLL & LLL consolidation. Bronch & BAL was done.
Was intubated for worsening tachypnea, required sedation while
intubated [**2-28**] agitation.
Was extubated ~[**8-11**], but developed stridor & ? neg pressure pulm
edema requiring urgent reintubation.
Was trached on [**8-19**] & tolerated wean to trach collar well.
Infectious disease service followed here & helped manage
antibiotic regimen.
Medications on Admission:
Vancomycin 1.5 gm q.12
Gentamycin 100 mg IV q.8
HCTZ 25 mg qd
ASA 325 mg qd
Advair 50/500
Vasotec 10 mg qd
[**Doctor First Name **] 60 mg qd
Avandia 4 mg qd
Prilosec 40 mg qd
Lopressor 12.5 mg [**Hospital1 **]
RISS
Heparin 5000 units sq tid
Senna 2 tablets q hs
Lactulose prn
Effexor 150 mg qd
Singulair 10 mg qd
Nortriptyline 10 mg qhs
Tylenol prn
Ibuprofen prn
Morphine sulfate 4 mg IV q2h prn
Lasix prn responding well
Lanazolid ordered at OSH but never received.
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed.
2. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Lorazepam 2 mg/mL Syringe Sig: 0.5-1.0 mg Injection Q4H
(every 4 hours) as needed for agitation/anxiety.
6. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Pneumonia
2. MRSA
3. Respiratory failure - resolved
4. s/p tracheostomy
Discharge Condition:
good
Discharge Instructions:
1. Trach collar maintenance
2. Physical therapy/occupational therapy to increase your
strength
Followup Instructions:
Call case management department here at [**Hospital3 **] for help
finding a new primary care physician
|
[
"482.41",
"518.81",
"V09.0",
"038.11",
"285.9",
"250.00",
"401.9",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.91",
"96.04",
"31.1",
"38.93",
"96.6",
"96.72",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
6122, 6194
|
4105, 5007
|
306, 369
|
6313, 6319
|
3125, 4082
|
6463, 6569
|
2499, 2516
|
5524, 6099
|
6215, 6292
|
5033, 5501
|
6343, 6440
|
2531, 3106
|
243, 268
|
397, 1998
|
2020, 2122
|
2138, 2483
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,583
| 183,263
|
52266+59415
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-6-16**] Discharge Date: [**2123-6-25**]
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
change in mental status and foul smelling urine
Major Surgical or Invasive Procedure:
incision and drainage of right lower extermity clot
left arterial line
History of Present Illness:
[**Age over 90 **] yo female with mmp who is being treated with Lovenox for DVT
found in [**3-20**], with hx of frequent UTIs and Urosepsis with
resistent Klebsiella (most recent positive cx in [**4-17**]), who was
in NSOH living with grand-daughter until 2 days ago when she was
noticed to have increased somnolence, and stopped taling. She
had diarrhea last week and decreased PO intake over the past few
days. She has stopped talking today which is unusual for her
and usually indicates an infection.
Family does notice she seems to have a tender L leg. She is
unable to walk at baseline She has had increased leg edema over
the last several days. She has an upcoming appointment in
clinic with Dr. [**First Name (STitle) **] on Monday. Code status was reviewed and
patient is Full Code at this point.
.
In the ED, has positive UA. Started on meropenem. LENI shows
residual clot seen adjacent to vessel walls in the L
CFV/SFV/[**Doctor Last Name **]. Normal waveforms demonstrated. All vessels were
patent.
Past Medical History:
- DVT [**3-20**] on lovenox
- Right TKR, wheel-chair bound
- HTN
- s/p CVA - left thalamic and cerebellar with residual
right-sided
hemiparesis.
- PMR
- h/o asymptomatic R subclavian aneurysm
- mild dementia
- cataracts
- Fe deficiency anemia--EGD [**8-/2111**] showed gastritis & H pylori.
Did not want antibiotics. Treated with Zantac. Colonoscopy (-)
- CHF Echo [**6-14**] EF 40% inf wall hypoK mod AS area 3cm, peak
gradient 60, mean 38. 1+AI. pMIBI neg [**6-15**] with fixed inf defect
- UGIB due to PUD seen on EGD, [**2119**]
- s/p pacer for complete heart block by Dr. [**Last Name (STitle) 1911**].
Social History:
lives with two grandchildren who provide 24 hour care and also
has VNA.non-ambulatory s/p Right TKR, uses wheel-chair. On last
admit was recommended for thickened liquid puree diet.
Physical Exam:
98.9 108/92 74 19 100% RA Wt 102#, 4'8"
Gen: elderly, answers with one word, NAD, responds to questions
and commands
HEENT: MMD, eomi, pupils constricted, prior surgery,
Chest: cta anterior
CV: s1s2 3/6 SEM loudest at LUSB (creshendo-decreshendo)
Abd; hypoactive BS, soft, NTND
Ext: LLE with 2+ edema, no purulence or fluctuance
Neuro: Responds to questions with one word answers, nods head,
follows commands, moves all limbs
Pertinent Results:
Admission labs:
[**2123-6-16**]
7:35p
147 115 18 AGap=15
-------------< 92
4.4 21 0.8
93
4.7 \ 11.2 / 232
/ 33.7 \
N:64.9 L:29.4 M:3.7 E:1.9 Bas:0.2
ColorStraw AppearClear SpecGr1.019 pH 5.0 UrobilNeg
BiliNeg LeukTr BldSm NitrPos ProtTr GluNeg KetNeg RB0-2
WBC21-50 BactMany YeastNone Epi0
CHEST (PA & LAT) [**2123-6-16**] 8:42 PMTECHNIQUE AND FINDINGS: PA and
lateral chest x-ray dated [**2123-6-16**] is compared to the PA and
lateral chest x-ray of [**2123-3-17**]. There is a new large right
pleural effusion. The heart displays stable enlargement. The
mediastinal and hilar contours are unremarkable. The lungs show
no focal areas of consolidation to suggest pneumonia. There is
mild prominence of the perihilar pulmonary vasculature with
peribronchial cuffing indicating mild congestive heart failure.
Left- sided pacemaker is in unchanged position. The aorta is
calcified throughout its course.
IMPRESSION: Interval development of right-sided pleural
effusion. Mild congestive heart failure. No focal areas of
consolidation to suggest pneumonia.
UNILAT LOWER EXT VEINS LEFT [**2123-6-16**] 8:03 PM
IMPRESSION: Interval partial recanalization of the left common
femoral, superficial femoral, and popliteal veins.
Cardiology Report ECHO Study Date of [**2123-6-22**]
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left
ventricular systolic function is severely depressed with global
hypokinesis
and akinesis of the distal anterior wall /antero-septum and
apex. 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
severely
thickened/deformed. There is severe aortic valve stenosis. 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. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The
pulmonary artery systolic pressure could not be determined.
There is no
pericardial effusion.
Compared with the findings of the prior report (tape unavailable
for review)
of [**2120-6-28**], the LVEF has significantly decreased and the aortic
stenosis is
now severe.
IMPRESSION: Severe aortic stenosis with severely depressed LVEF.
Regional wall
motion abnormalities c/w CAD (multivessel).
[**2123-6-20**] 11:52 am URINE Site: CATHETER
**FINAL REPORT [**2123-6-21**]**
URINE CULTURE (Final [**2123-6-21**]): NO GROWTH.
[**2123-6-16**] 7:35 pm URINE Site: CATHETER
**FINAL REPORT [**2123-6-18**]**
URINE CULTURE (Final [**2123-6-18**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
GRAM NEGATIVE ROD #1. >100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
Brief Hospital Course:
1) UTI: The patient was found to have a positive UA on
admission. Given her history of ESBL resistant Klebsiella UTIs
in the past, she was treated with imipenem for 7 days per ID
(Started [**2123-6-16**]). Her urine culture showed fecal contamination,
but repeat urinalysis and culture was negative after 5 days of
treatment with Imipenem.
2) CHF with severe AS / pulmonary edema / pleural effusion - On
the second morning of admission, the patient became markedly
hypertensive and hypoxic with ABG showing respiratory acidosis:
7.15/60/129. She had been given fluid boluses overnight for
decreased urine output. She was felt to be fluid overloaded and
also hypertensive which led to pulmonary edema and given lasix
and nitro paste. She had unchanged EKG and a small troponin leak
in the setting of increased demand, CXR showed pulmonary edema
with pleural effusion which was felt to be likely CHF related.
She reponded well to BiPAP while in [**Hospital Unit Name 153**] and was back to room
air for the remainder of admission. She got an echocardiogram
which showed EF of 30% and AV area of 0.7 cm2, worse than
previous echo in [**2120**]. She was converted to long acting Toprol.
An ACE was considered but used with caution given her AS.
3) RLE swelling: The patient had a swollen bump on her left leg
which appeared red, warm and fluctuent. General surgery was
called to I&D this area. It revealed old clot with culture and
gram stain negative on prelim results. She was treated with
morphine for pain in this area after the procedure. Three days
later, it spontaneously started bleeding and surgery was called
to bedside. Pressure was applied. The recommendation was to
discontinue wet to dry dressings as these can remove the scar
tissue and exacerbate bleeding.
4) altered mental status - After beginnig the antibiotic
therapy, the patient returned to baseline per granddaughter
which was cooperative, responsive, and oriented occasionally
only to herself. The night of [**6-22**] pt was less responsive after
1:30 am (got 2 mg morphine at 12:30 am for pain and SOB until 8
am. Head CT was negative and glucose was normal. This resolved
by 9 am so narcotic was most likely cause, and morphine was used
sparingly after this.
5) Bleeding/anemia: Her HCT was stable during admission until
the AM of [**6-21**] when the RN noted bleeding out of L LE I&D site
AND left old a-line site. Pressure held and hemostatsis
obtained. LMWH was at therapeutic level of 0.7, but her HCT down
to 23 the next and family refused transcusion less than 25. Her
lovenox decreased to qd dosing given her risk to bleed, family
reluctance to transfusion, and that her repeat U/S showed
recaunulazation (despite qd dosing and 0.3 LMWH). She received 1
unit pRBC with lasix in the middle and had no shortness of
breath or bleeding. She did not rebleed from this area or the
left wrist in the last four days of admission and her HCT was
stable around 30.
6) DVT: Treatment was continued for DVT previously noted. Her
lovenox was changed to [**Hospital1 **] dosing as factor X level was
subtherapeutic.
7) HTN: Her lopressor was continued but changed to metoprolol.
Isordil was added to help with BP control. An ACE inhibitor
could also be considered but both agents used with caution given
her AS.
8) hypernatremia - she was noted to be hypernatremic on
admission. Her imipenem was changed to D5 water and free water
intake was encouraged. She was maintained on low salt diet. Her
sodium improved to normal.
9) PMR - She was continued on prednisone 1 mg.
10) FEN: per swallow eval last admit, the patient should be on
thickened liquid puree diet, and is at risk for aspiration.
Family does not want feeding tube and feels this risk is
acceptable. Aspiration precautions.
11) Her code status remained FULL during admission. This was
extensively discussed with granddaughter and HCP [**Name (NI) **] [**Name (NI) 24052**]
[**Telephone/Fax (1) 108082**] pager [**Telephone/Fax (1) 108083**].
Medications on Admission:
Prednisone 1 mg Tablet Sig
Metoprolol Tartrate 25 mg [**Hospital1 **]
Acetaminophen
Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment prn
Furosemide 40 mg Tablet QD
Pantoprazole Sodium 40 mg QD
Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig
Enoxaparin Sodium 40 mg/0.4mL QD
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) injection
Subcutaneous once a day.
Disp:*60 injection* Refills:*2*
6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
Disp:*1 bottle* Refills:*4*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours as needed for shortness of breath
or wheezing: and give extra dose of lasix for unresponsive
shortness of breath.
Disp:*30 nebulizers* Refills:*2*
10. Atrovent 0.02 % Solution Sig: One (1) nebulizer Inhalation
every 6-8 hours as needed for shortness of breath or wheezing:
and give extra dose of lasix for unresponsive shortness of
breath.
Disp:*30 nebulizers* Refills:*2*
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
12. adverse reaction
no opiates or benzos!
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Urinary tract infection
Pulmonary edema
Hypertension
congestive heart failure
bleeding
Secondary:
deep vein thrombosis diagnosed in [**3-20**], on lovenox
polymyalgia rheumatica
dementia
Discharge Condition:
patient was breathing comfortably on room air, was responsive,
oriented only to herself. She was at her baseline per family.
Discharge Instructions:
You are being discharged to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Please take the medication regimen listed below.
If you have fevers, chills, bleeding, shortness of breath or
other concerns, please call your doctor or return to the ED.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 250**] in [**2-14**] weeks
after discharge from rehab.
Name: [**Known lastname 15553**],[**Known firstname 17668**] Unit No: [**Numeric Identifier 17669**]
Admission Date: [**2123-6-16**] Discharge Date: [**2123-6-25**]
Date of Birth: [**2024-5-6**] Sex: F
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 2544**]
Addendum:
Due to concern of the Isordil dropping the patient's blood
pressure in the setting of AS, this was discontinued at
discharge. In addition, the lovenox will be continued but
stopping this could be considered at the next follow up
appointment. These issues were discussed with the patient's
daughter, [**Name (NI) **].
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) injection
Subcutaneous once a day.
Disp:*60 injection* Refills:*2*
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
Disp:*1 bottle* Refills:*4*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours as needed for shortness of breath
or wheezing: and give extra dose of lasix for unresponsive
shortness of breath.
Disp:*30 nebulizers* Refills:*2*
10. Atrovent 0.02 % Solution Sig: One (1) nebulizer Inhalation
every 6-8 hours as needed for shortness of breath or wheezing:
and give extra dose of lasix for unresponsive shortness of
breath.
Disp:*30 nebulizers* Refills:*2*
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
12. adverse reaction
no opiates or benzos!
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 163**] - [**Location (un) 164**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2545**] MD [**MD Number(2) 2546**]
Completed by:[**2123-6-25**]
|
[
"599.0",
"428.0",
"285.1",
"799.4",
"518.81",
"041.3",
"428.40",
"682.6",
"424.1",
"276.0",
"453.40",
"438.20",
"725",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.91",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
14817, 15046
|
5873, 9853
|
263, 335
|
12067, 12193
|
2677, 2677
|
12513, 13336
|
13359, 14794
|
11857, 12046
|
9879, 10169
|
12217, 12490
|
2230, 2658
|
176, 225
|
363, 1383
|
2694, 5850
|
1405, 2015
|
2031, 2215
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,006
| 144,856
|
37327
|
Discharge summary
|
report
|
Admission Date: [**2130-8-31**] Discharge Date: [**2130-8-31**]
Date of Birth: [**2101-9-17**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
s/p VF arrest
Major Surgical or Invasive Procedure:
Cardiopulmonary Resuscitation
History of Present Illness:
28 yo male with a history of left ventricular non-compaction,
ADHD, asthma, anxiety, allergic rhinitis, and FH of sudden death
at 47 who presented s/p VF arrest, down for estimated 6 minutes
at home prior to EMS arrival.
At outside hospital, there was some question regarding whether
or not patient might have had massive PE, so he was given bolus
of 10,000u heparin plus drip. He was transferred to [**Hospital1 18**] via
helicopter, intubated on epi + dopamine drips.
Patient was last hospitalized in [**10/2129**] at [**Hospital1 18**] when he
presented for increased DOE and was diagnosed by cardiac MRI
with left ventricular non-compaction, noted to have EF=20-30%.
Past Medical History:
1. CARDIAC HISTORY:
Left Ventricular Non-compaction
Systolic Heart Failure (EF 20-30%)
.
2. OTHER PAST MEDICAL HISTORY:
-asthma
-ADHD
-dyspepsia
-allergic rhinitis
Social History:
(Per OMR records, could not confirm)
-Tobacco history: None.
-ETOH: None
-Illicit drugs: None
-Lives with mother and two cats. Works as a dishwasher.
Family History:
(Per OMR records)
His maternal grandmother died suddenly of "rheumatic heart
disease," though his mother questions the diagnosis since she
never had rheumatic fever. No family members have structural
heart disease. His mother endorses palpitations at times and had
a recent normal cardiac stress test. One of his aunts fainted in
church at 16.
Physical Exam:
Intubated and sedated.
Unable to examine, as patient arrested immediately upon transfer
to CCU.
Pertinent Results:
STAT LABS send during CPR on admission.
[**2130-8-31**] 10:23AM BLOOD Type-ART Temp-36.7 pO2-26* pCO2-116*
pH-7.05* calTCO2-34* Base XS--4 Intubat-INTUBATED
[**2130-8-31**] 10:36AM BLOOD Type-ART pO2-10* pCO2-141* pH-7.00*
calTCO2-37* Base XS--3
[**2130-8-31**] 10:16AM BLOOD WBC-30.1*# RBC-4.08* Hgb-11.7* Hct-36.3*
MCV-89# MCH-28.7 MCHC-32.2 RDW-13.8 Plt Ct-252
[**2130-8-31**] 10:16AM BLOOD Neuts-82.8* Lymphs-13.6* Monos-2.5
Eos-0.4 Baso-0.8
[**2130-8-31**] 10:16AM BLOOD PT-15.7* PTT-150* INR(PT)-1.4*
[**2130-8-31**] 10:16AM BLOOD Glucose-350* UreaN-13 Creat-1.2 Na-147*
K-6.2* Cl-112* HCO3-24 AnGap-17
[**2130-8-31**] 10:16AM BLOOD ALT-45* AST-59* CK(CPK)-127 AlkPhos-85
TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2130-8-31**] 10:16AM BLOOD CK-MB-2 cTropnT-0.05*
[**2130-8-31**] 10:16AM BLOOD Calcium-9.4 Phos-7.2*# Mg-2.2
[**2130-8-31**] 10:23AM BLOOD Lactate-7.2*
[**2130-8-31**] 10:23AM BLOOD freeCa-1.29
Brief Hospital Course:
28M with hx of left ventricular non-compaction transferred via
helicopter from outside hospital, intubated on heparin, dopamine
and epinephrine drips, for induced-hypothermia protocol s/p VF
arrest at home.
Immediately upon arrival to CCU, patient was noted to have
bradycardia and PEA arrest. CPR was initiated immediately with
administration of epinephrine and atropine. He went into VF and
was shocked a few times, then became asystolic. Cardiopulmonary
resuscitation continued with chest compressions and
administration of epinephrine, atropine, calcium, magnesium.
Femoral venous and arterial lines were placed into right groin
emergently. Lactate was 7, noted to be improved from 11 at
outside hospital s/p initial VF arrest. CPR was continued for a
total of about 50 minutes, and patient was pronounced dead at
10:45am. His mother was in the waiting room and aware.
Arterial blood gases were very abnormal, suggesting very little
possibility of regaining brain function should patient have
survived the resuscitation: PaO2 was <30 and PCO2 was >100,
similar to values at the outside hospital. Difficulty with
oxygenation and ventilation suggested to medical team that
patient may have experienced a massive Pulmonary Embolism at
home which could have caused his initial arrest rather than his
LV non-compaction, which was presumed to be the cause of his
initial arrest. He had been started on heparin drip at the
outside hospital after a 10,000u bolus. Patient was seen by
medical examiner for a post-mortem.
Medications on Admission:
unable to confirm on admission
Discharge Medications:
-
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac arrest
?Pulmonary Embolism
Discharge Condition:
Expired
Discharge Instructions:
-
Followup Instructions:
-
|
[
"427.89",
"427.41",
"415.19",
"427.5",
"428.0",
"V17.41",
"428.20",
"493.00",
"314.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.60",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
4471, 4480
|
2836, 4364
|
310, 342
|
4559, 4569
|
1896, 2813
|
4619, 4624
|
1419, 1764
|
4445, 4448
|
4501, 4538
|
4390, 4422
|
4593, 4596
|
1779, 1877
|
257, 272
|
370, 1046
|
1189, 1235
|
1251, 1403
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
699
| 162,523
|
12216+56343
|
Discharge summary
|
report+addendum
|
Admission Date: [**2188-1-12**] Discharge Date: [**2188-1-25**]
Date of Birth: [**2148-1-24**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 39 year old
male who was an unrestrained driver involved in a rollover
motor vehicle accident. He was partially ejected from the
vehicle. He had a prolonged extrication time, approximately
30 minutes and was found unresponsive by paramedics at the
scene and intubated. The patient was transferred to an
outside medical facility where he had some left side crepitus
noted. He had a left chest tube placed for relief of this
pneumothorax. The patient, at that time, was noted to be
hypotensive and had a diagnostic peritoneal lavage performed
which was negative. The patient's chest x-ray at that time
showed a pneumothorax on the opposite side, on the right
side, for which another chest tube was placed. The patient
was packaged and prepared for transfer through [**Hospital1 346**], however, upon wheeling the patient
away from that facility, he was found to be hypotensive
initially and then had an asystolic arrest. Two additional
bilateral chest tubes were placed with relief of bilateral
tension hemopneumothoraces with return of perfusing cardiac
rhythm.
The patient was stabilized for transfer to [**Hospital1 346**]. Upon arrival in our Trauma Bay,
the patient was intubated, sedated, and paralyzed. The
patient had three chest tubes in place and was
hemodynamically stable.
HOSPITAL COURSE: Trauma work-up at our facility revealed
bilateral pneumothoraces with minimal hemothoraces,
adequately drained by his chest tubes. However, persistent
air leaks were noted and it was identified that the patient'a
proximal ports of his chest tubes were out of the chest.
During the CT scan, he became hypotensive and these tubes had
to be emergently advanced with good result.
The patient's trauma series revealed multiple rib fractures
and hemopneumothoraces as stated above. The patient had a
head CT scan which was negative and a CT scan of the cervical
spine which showed a tiny C5 avulsion fracture which was
non-displaced. CT scan of his chest revealed bilateral
pulmonary contusions, bilateral consolidation and a left
clavicular fracture. CT scan of his abdomen and pelvis
showed a minimal amount of free fluid consistent with his
diagnostic left clavicular fracture. CT scan of his abdomen
and pelvis showed a minimum amount of free fluid consistent
with his diagnostic peritoneal lavage. The patient also
noted to have multiple bilateral rib fractures.
The patient's plain film also on a later read revealed
question of a left iliac [**Doctor First Name 362**] fracture which was
non-displaced. The patient also was noted by a consultation
by Orthopedic Surgeons to have a glenoid fracture in addition
to a humerus fracture.
The patient was transferred to the Surgical Intensive Care
Unit where two fresh sterile chest tubes were placed and his
three other chest tubes were removed. He required
intermittent pressor support and aggressive fluid
resuscitation. Neurosurgery was consulted and determined
that this C5 fracture was nondisplaced, not requiring any
specific therapy, however, that the patient should be in a
hard collar for six weeks.
The patient developed pulmonary infiltrate and some fevers
for which he was started on Ceftriaxone for some Gram
negative rods growing in his sputum. On hospital day four,
the patient was taken to the Operating Room by the Orthopedic
surgeons for open reduction and internal fixation of his
humeral fractures; the patient tolerated this procedure well
without any complications.
Postoperatively, he was transferred back to the Surgical
Intensive Care Unit where he underwent a prolonged
ventilatory wean. The patient was extubated but noted to be
somewhat confused and initially combative. The patient was
thought to be withdrawing from alcohol and was started on
Ativan drips to control this. He progressed very well.
Mental status improved. He was transferred to the floor. On
the floor, he continued to do well with slowly improving
mental status. Psychiatry was consulted for care of this and
recommended a slow Ativan wean and slow Haldol wean.
The patient's antibiotic course was completed. Follow-up
chest x-ray revealed resolution of his consolidations and the
patient's sputum became normal. He began working with
Physical Therapy and advanced to a regular diet which he
tolerated well and will be discharged to rehabilitation.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-349
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2188-1-24**] 08:52
T: [**2188-1-24**] 10:40
JOB#: [**Job Number 38197**]
Name: [**Known lastname **], [**Known firstname 6898**] Unit No: [**Numeric Identifier 6899**]
Admission Date: [**2188-1-12**] Discharge Date:
Date of Birth: [**2148-1-24**] Sex: M
Service:
The patient will be discharged to rehabilitation.
DISCHARGE MEDICATIONS:
1. Haldol 2 mg p.o.q.6.h. around the clock, wean as
tolerated.
2. Ativan 0.5 mg p.o.q.6h.p.r.n. agitation.
3. Dilaudid 0.5 to 2 mg p.o.q.4h.p.r.n.
4. Multivitamin, one p.o.q.d.
5. Protonix 40 mg p.o.q.d.
6. Heparin subcutaneously 5000 units b.i.d.
DIET: The patient will have a regular diet.
DISCHARGE DIAGNOSES:
1. Bilateral pneumothoraces, resolved.
2. Bilateral hemothoraces, resolved.
3. Bilateral pulmonary contusions, resolved.
4. Multiple rib fractures.
5. Left clavicular fracture.
6. Multiple left humerus fractures.
7. Small intraventricular hemorrhage, all resolved.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 389**] 02-349
Dictated By:[**Last Name (NamePattern1) 6453**]
MEDQUIST36
D: [**2188-1-24**] 08:53
T: [**2188-1-24**] 10:59
JOB#: [**Job Number 6900**]
|
[
"E816.0",
"860.4",
"807.4",
"958.7",
"807.09",
"853.06",
"805.05",
"998.89",
"812.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"96.6",
"79.31",
"38.93",
"34.04",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
5369, 5879
|
5047, 5348
|
1491, 5024
|
160, 1472
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,475
| 104,621
|
15590
|
Discharge summary
|
report
|
Admission Date: [**2124-10-20**] Discharge Date: [**2124-11-21**]
Date of Birth: [**2066-9-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient was a 58-year-old
man who was admitted to the Neurology Service on [**10-20**].
He initially presented to [**Hospital **] Hospital on [**10-18**] with
the acute onset of left-sided weakness. A right
.................... hemorrhage was diagnosed by noncontrast
head CT. While at [**Hospital **] Hospital, the patient fell, and
the thalamic hemorrhage expanded. It was not clear whether
the hemorrhage resulted in the fall or the fall resulted in
expansion of the hemorrhage. He was transferred to the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2124-10-20**].
The initial exam documented that he was awake, obeying
commands, had a right gaze preference, and that he had left
arm ................... and face weakness. He was witnessed
to have three generalized tonic clonic seizures on admission.
Ativan and Dilantin were started at that time.
Although it was felt that his hemorrhage was a typical
occasion for hypotensive bleed ...................., rapid
increase in size despite control of blood pressure and
increased right temporal edema suggested the possibility of
an AVM or dual sinus thrombosis. Conventional angiogram as
normal. The patient blood pressure was controlled with IV
drips in the unit, and Labetalol was discontinued on [**10-24**]. He did require intermittent Hydralazine and Lopressor
for blood pressure control.
His exam was fluctuating, but he had no overt seizures since
presentation. For this reason, an EEG was obtained that
showed generalized background slowing. While in the
Intensive Care Unit, the patient had an induced sputum which
showed gram-positive cocci. He was treated initially with
Vancomycin and then with Oxacillin. Mannitol was started on
[**10-24**] for the fear of increased intracranial edema, and
noncontrast head CT showed increased edema. Mannitol was
discontinued the next day.
Since that time, the patient had reasonable control of his
blood pressure. He has been transferred to the Neurology
Floor for further management.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Alcohol abuse.
3. Atrial fibrillation times five years off Coumadin for two
years. 4. Depression. 5. Question of history of
myocardial infarction 6. Hiatal hernia.
MEDICATIONS ON ADMISSION: Digoxin, Paxil, Tagamet, Aspirin,
Albuterol inhaler.
MEDICATIONS ON TRANSFER TO NEUROLOGY: Tylenol p.r.n., Paxil
20 mg p.o. q.d., Digoxin 0.25 mg p.o. q.d., Albuterol
inhaler, Dilantin 200 mg IV q.8 hours, Colace, Insulin
sliding scale, Zantac 150 mg IV b.i.d., Oxacillin 2 g IV q.6
hours, Neutra-Phos, Hydralazine 20 mg IV q.6 hours, Lopressor
75 mg p.o. b.i.d.
ALLERGIES: SULFA.
SOCIAL HISTORY: Unable to be obtained.
FAMILY HISTORY: Unable to be obtained.
PHYSICAL EXAMINATION: Vital signs: The patient was
afebrile, blood pressure 132/68, heart rate 96, oxygen
saturation 100%. General: He appeared older than stated
age. Difficult to arouse. HEENT: Dry mucous membranes.
Neck: No thyromegaly or carotid bruits. Pulmonary: Coarse
breath sounds throughout. Cardiovascular: Atrial
fibrillation. No murmurs. Abdomen: Soft and nontender.
Positive bowel sounds times four. Extremities: There were
1+ peripheral pulses. No edema. [**Month (only) **]: He was
sleeping but aroused by name being called loudly. He kept
his eyes open for a minute before falling back asleep. He
did not attempt to communicate. He blinks to threat.
Right-sided gaze preference. Pupils equal and reactive. He
had ................... strength in right hand. He could
squeeze with good effort. He moved right leg back and forth.
Left side was flaccid. Toes upgoing in the left, and
downgoing in right. Reflexes 3 in the upper extremities, 1+
at the patella, no ankle jerks.
LABORATORY DATA: White count 13.5, hematocrit 35.5 platelet
count 220; sodium 140, potassium 3.7, chloride 110, bicarb
26, BUN 19, creatinine 0.5, glucose 141, calcium 8.0,
magnesium 1.8, phosphate 3.0.
Head CT showed a large right .................. hemorrhage.
HOSPITAL COURSE: As noted above, the patient was initially
admitted to the Neurology [**Month (only) **]. After being transferred to
the Neurology floor on [**10-28**], he was continued on
Mannitol with an osmolality of 308. The patient's mental
status did not improve on Mannitol. His edema did not
resolve on CT. He was therefore tried on an empiric course
of Decadron, a 10 mg bolus followed by 4 mg p.o. q.6 hours.
The patient's alertness improved on the Decadron, and
follow-up head CT demonstrated somewhat less edema with
decreased flattening of the ventricle. The patient became
more alert, and the Decadron was tapered over two weeks. The
patient's Oxacillin was discontinued after a ten-day course.
He has had no further issues with pneumonia.
The patient continue to make progress. He was more alert,
although still not moving the left side of his body which has
remained hemiplegic. He was not taking adequate oral intake,
so he was evaluated by Gastroenterology for placement of PEG
tube. The PEG tube could not be placed because of his
ascites which was noted on ultrasound, and gastroesophageal
varices which was seen on EGD.
His current examination shows that he is awake and alert. He
does not know the date but knows that he was in [**Hospital6 1760**]. His eye movements are full
to both sides. His pupil are equal. He has a left facial
droop, and his head was turned to the right. He is
hemiplegic on the left side. His toes are upgoing in the
left.
The patient will be discharged to rehabilitation on [**2124-11-21**].
DISCHARGE DIAGNOSIS:
1. Right .................. hemorrhage.
2. Hypertension.
3. Portal hypertension complicated by varices.
DISCHARGE MEDICATIONS: Lopressor 75 mg p.o. b.i.d., Colace
100 mg p.o. b.i.d., Paxil 20 mg p.o. q.d., Zantac 150 mg p.o.
b.i.d., Digoxin 0.25 mg p.o. q.d., Lactulose 30 cc p.o. q.6
hours, Nadolol 20 mg p.o. b.i.d.
FOLLOW-UP: The patient will follow-up with myself, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**].
CONDITION ON DISCHARGE: He is discharged in fair condition.
DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 13.140
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2124-11-20**] 18:04
T: [**2124-11-20**] 18:17
JOB#: [**Job Number 45082**]
|
[
"572.3",
"482.41",
"456.21",
"780.39",
"431",
"427.31",
"518.81",
"305.00",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"45.13",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2890, 2914
|
5912, 6232
|
5780, 5888
|
2446, 2832
|
4216, 5759
|
2937, 4198
|
161, 2201
|
2224, 2419
|
2849, 2873
|
6257, 6536
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,071
| 175,239
|
47785
|
Discharge summary
|
report
|
Admission Date: [**2142-10-11**] Discharge Date: [**2142-10-12**]
Date of Birth: [**2084-9-7**] Sex: F
Service: MEDICINE
Allergies:
Tramadol / Abacavir
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
HD
History of Present Illness:
58 y/o anuric HD dependent female with HIV on HAART (last CD4
94), CKD stage V on HD ([**1-10**] HTN, dialyzed MWF via L CVL), RUE
AVG (ligation and subsequent excision ([**2142-9-15**]), HCV with liver
biopsy [**3-/2137**] (grade II inflammation) who p/w RUQ pain and
vomiting starting at 4 pm today after HD.
.
Of note, pt recently admitted from [**Date range (1) 100888**] on surgery service
for right arm arteriovenous graft infection. She underwent
excision right arteriovenous graft. GPC bacteremia on blood
cultures [**2142-9-13**]. Graft cultures speciated as enterobacter.
She completed vancomycin for 2 weeks at [**Year (4 digits) 2286**], and
ciprofloxacin PO daily for 2 weeks.
.
Pt reports RUQ pain, intermittent, +chills. Denies fevers. No
diarrhea, constipation, cough/cold sx. Reports vomiting,
non-bloody. No HA, visual changes. Reports she missed her BP
pills yesterday and today due to nausea/vomiting. Of note, pt
does not make urine.
.
In ED, initial VS - initial VS were: 8, 98.6, 53, 226/101, 18,
100%. EKG showing sinus brady 48, NA, Qtc 461. Lactate wnl. Alk
phos slightly above baseline. RUQ US showing stones, no
cholycystitis. CXR showing no acute process. Transplant surgery
notified, and they are aware and recommend MICU admission. CT
A/P negative for acute process. Overall, "no SBO. Distal colonic
wall thickening is more likely related to underdistension than
colitis, but clinical correlation recommended. Polycystic
kidneys. High density streaks in peritoneum unchanged since
[**2137**], could be related to a barium spill. CT head showed no
acute proces.
.
Pt started to develop worsening SOB, and there was a ? of mild
pulmonary edema. SBP was 240s at this time. Nitro gtt started at
0.2 mcg.
.
Vitals on transfer - BP 215/117, HR 72, RR 18, 100% 2L NC.
Access - 20G, HD line, R EJ.
.
On arrival to the MICU, mental status is alert.
.
Review of systems:
(+) Per HPI. (+) HA
(-) Denies fever, night sweats, recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies diarrhea,
constipation, changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
HIV on HAART
CKD stage V on HD ([**1-10**] HTN)
RUE AVG, ligated [**2142-6-15**]
Hep C: Liver biopsy [**3-/2137**] showed focal mild-to-moderate portal
chronic inflammation with focal periportal extension (grade II).
HTN
Diverticulosis
High-grade adenomatous polyp
Social History:
no current IV drug use, no current etoh or smoking
Family History:
non-contributory
Physical Exam:
Vitals: 97.6, 222/120, 72, 18, 100 RA
General: Alert, but somewhat sleepy, oriented, mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1, prominent S2, grade III
holodystolic murmur heard best at LSB
Lungs: mild crackles at bases, no wheezes, rales, ronchi
Abdomen: soft, minimally tender RUQ, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Labs on Admission:
[**2142-10-11**] 12:35AM BLOOD WBC-3.5* RBC-3.99* Hgb-11.9* Hct-39.0
MCV-98 MCH-29.9 MCHC-30.5* RDW-17.3* Plt Ct-148*
[**2142-10-11**] 12:35AM BLOOD Neuts-66.3 Lymphs-26.5 Monos-4.9 Eos-1.4
Baso-0.9
[**2142-10-11**] 12:35AM BLOOD Plt Ct-148*
[**2142-10-11**] 01:41PM BLOOD WBC-3.2* Lymph-25 Abs [**Last Name (un) **]-800 CD3%-56
Abs CD3-449* CD4%-25 Abs CD4-200* CD8%-31 Abs CD8-246
CD4/CD8-0.8*
[**2142-10-11**] 12:35AM BLOOD Glucose-110* UreaN-27* Creat-5.9* Na-137
K-4.2 Cl-93* HCO3-29 AnGap-19
[**2142-10-11**] 12:35AM BLOOD ALT-18 AST-39 CK(CPK)-52 AlkPhos-490*
TotBili-0.7
[**2142-10-11**] 12:35AM BLOOD Lipase-39
[**2142-10-11**] 12:35AM BLOOD CK-MB-2 cTropnT-0.02*
[**2142-10-11**] 12:35AM BLOOD Calcium-10.3 Phos-3.9 Mg-2.1
[**2142-10-11**] 01:41PM BLOOD PTH-2913*
[**2142-10-11**] 12:48AM BLOOD Lactate-1.8
.
Labs on Discharge:
[**2142-10-12**] 03:29AM BLOOD WBC-3.3* RBC-3.63* Hgb-10.7* Hct-34.7*
MCV-96 MCH-29.6 MCHC-30.9* RDW-17.1* Plt Ct-137*
[**2142-10-12**] 03:29AM BLOOD Neuts-56 Bands-0 Lymphs-40 Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2142-10-12**] 03:29AM BLOOD Plt Ct-137*
[**2142-10-12**] 03:29AM BLOOD Glucose-87 UreaN-41* Creat-8.1*# Na-136
K-4.3 Cl-94* HCO3-30 AnGap-16
[**2142-10-12**] 03:29AM BLOOD ALT-20 AST-34 LD(LDH)-174 AlkPhos-415*
TotBili-1.1
[**2142-10-11**] 01:41PM BLOOD GGT-62*
[**2142-10-12**] 03:29AM BLOOD Albumin-4.2 Calcium-10.0 Phos-4.8* Mg-2.0
[**2142-10-11**] 01:41PM BLOOD PTH-2913*
.
CT head without contrast [**10-11**]:
IMPRESSION:
1. No acute intracranial process.
2. Opacification of the left mastoid air cells may be due to
inflammatory or infectious process.
.
CT abd/pelvis without contrast:
IMPRESSION:
1. No evidence of bowel obstruction, diverticulitis or renal
stones.
2. Left and sigmoid colonic wall thickening with mild stranding
along the
medial wall of the descending colon is most likely
undersitension and chronic abnormality rather than mild colitis,
though clinical correlation is needed.
3. Polycystic kidneys with some new intermediate density lesions
and some
increased in size and a septated left cystic lesion. Outpatient
MRI is
recommended in no more than 6 months to assess further.
4. Cholelithiasis without CT evidence of cholecystitis.
5. 4 mm right middle lobe nodule needs no follow- up if patient
is low risk for malignancy. 12 month f/u chest CT if patient is
high risk for a
malignancy.
.
CXR PA and lateral:
IMPRESSION: Vascular engorgement and early pulmonary edema, due
to volume
overload, and/or cardiac insufficiency.
.
Liver/gallbladder US [**2142-10-11**]:
IMPRESSION:
Cholelithiasis without evidence of cholecystitis. Polycystic
kidneys are
partially imaged and not completely evaluated, though no overtly
concerning lesion is seen in their visualized portions.
Brief Hospital Course:
58 y/o anuric HD dependent female with HIV on HAART, HCV, CKD
stage V on HD, RUE AVG ligation and subsequent excision
([**2142-9-15**]), who p/w RUQ pain, nausea, and vomiting, and is
admitted to MICU for hypertensive emergency.
.
# HTN emergency: pt presented with SBP in 230s and evidence of
vascular engorgement and early pulmonary edema with volume
overload, classifying her HTN as HTN emergency. Head CT was wnl.
No EKG evidence of strain or ischemia was seen. Etiology of
elevated BP was likely related to nausea/vomiting/missing BP
pills at home, along with pain. Baseline SBP 140-160 per review
of clinic notes. Of note, mental status was alert. She was
started on nitro gtt with goal SBP 180 but was d/ced in the PM
after normalization of her pressures. We continued home
lisinopril and home metoprolol. Pain control was achieved with
IV morphine. Patient tolerated HD performed in the ICU and was
discharged after overnight stay.
.
# RUQ pain: RUQ US showed cholelithiasis without cholecystitis.
CT A/P showed no SBO. Distal colonic wall thickening is more
likely related to underdistension than colitis. No fever or
jaundice, or evidence for cholecystitis. Elevated alk phos may
suggest infiltrative disease. Recommend repeating outpatient
LFTs and w/u with possible MRCP if alk phos remains elevated.
Consider outpt cholecystectomy for biliary colic, now resolved.
.
# CKD stage V on HD ([**1-10**] HTN): gets dialyzed on MWF. Renal team
performed UF on hospital day 1, and HD on Friday (hospital day
2). Continued sevelamer, nephrocaps. Of note, patient's PTH
returned as 2913. Pt will start IV zemplar at HD for ? secondary
vs. tertiary hyperparathyroidism.
.
# HIV: on HAART. Last CD4 94 (22%) and VL 71 copies/ml. We
continued atazanavir, raltegravir, ritonavir, lamivudine. On
discharge, CD4 count pending. Pt may require bactrim ppx
depending on CD4 count. Pt was set up with ID appt on discharge.
.
# HCV: liver biopsy [**3-/2137**] showed focal mild-to-moderate portal
chronic inflammation with focal periportal extension (grade II).
.
# Hx of right arm arteriovenous graft infection/excision right
arteriovenous graft: GPC bacteremia on blood cultures [**2142-9-13**].
Graft cultures speciated as enterobacter. She completed
vancomycin for 2 weeks at [**Year (4 digits) 2286**], and ciprofloxacin PO daily
for 2 weeks. No signs of infection locally or systemically. Bcx
pending on d/c.
.
# 4 mm right middle lobe nodule: per radiology, needs no
follow-up if patient is low risk for malignancy. 12 month f/u
chest CT if patient is high risk for a malignancy.
Communicated above with oupt PCP.
.
# Transitional issues:
- follow up CD4 count, and start bactrim prophylaxis depending
on result.
- Started IV zemplar at HD (Dr [**Last Name (STitle) 7473**] [**Name (STitle) 82414**]) given high PTH
values (2913).
- 4 mm RML nodule, which requires repeat evaluation and possible
CT if high risk for malignancy
- ID appt re: HIV care as outpt
Medications on Admission:
1. sevelamer carbonate 800 mg Tablet [**Name (STitle) **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. B complex-vitamin C-folic acid 1 mg Capsule [**Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
3. atazanavir 150 mg Capsule [**Name (STitle) **]: Two (2) Capsule PO DAILY
(Daily).
4. raltegravir 400 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
5. ritonavir 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
6. lamivudine 10 mg/mL Solution [**Name (STitle) **]: 25 mg PO DAILY (Daily).
7. docusate sodium 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. lactulose 10 gram/15 mL Syrup [**Name (STitle) **]: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
10. polyethylene glycol 3350 17 gram/dose Powder [**Name (STitle) **]: One (1)
PO DAILY (Daily).
11. heparin (porcine) 1,000 unit/mL Solution [**Name (STitle) **]: One (1)
Injection PRN (as needed) as needed for line flush.
12. aspirin 81 mg Tablet, Chewable [**Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
13. acetaminophen 325 mg Tablet [**Name (STitle) **]: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
14. lisinopril 20 mg Tablet [**Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
15. metoprolol succinate 100 mg Tablet Extended Release 24 hr
[**Name (STitle) **]: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
16. oxycodone 5 mg Tablet [**Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet [**Name (STitle) **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. B complex-vitamin C-folic acid 1 mg Capsule [**Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
3. atazanavir 150 mg Capsule [**Name (STitle) **]: Two (2) Capsule PO DAILY
(Daily).
4. raltegravir 400 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
5. ritonavir 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
6. lamivudine 10 mg/mL Solution [**Name (STitle) **]: Twenty Five (25) mg PO
DAILY (Daily).
7. senna 8.6 mg Tablet [**Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. docusate sodium 100 mg Capsule [**Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
9. lactulose 10 gram/15 mL Syrup [**Name (STitle) **]: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
10. polyethylene glycol 3350 17 gram/dose Powder [**Name (STitle) **]: One (1)
packet PO DAILY (Daily).
11. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. lisinopril 20 mg Tablet [**Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
13. metoprolol succinate 100 mg Tablet Extended Release 24 hr
[**Name (STitle) **]: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
14. oxycodone 5 mg Capsule [**Name (STitle) **]: [**12-10**] Capsules PO every four (4)
hours as needed for pain.
15. zemplar qhd
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- hypertensive emergency
.
SECONDARY:
- end stage renal disease, on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you in the hospital. You were
admitted to the intensive care unit due to very high blood
pressures, likely a result of nausea/vomiting, inability to take
your home pills, and a shortened [**Known lastname 2286**] session the day
before.
.
While you were here, we controlled your blood pressure with IV
medications. Your blood pressure responded nicely. You are being
discharged on your home blood pressure regimen of metoprolol and
lisinopril.
.
While you were here, we also checked some blood tests related to
your kidneys. Your PTH levels were high and the kidney team will
add a new IV medication called zemplar with your [**Known lastname 2286**].
.
MEDICATION CHANGES
- addition of IV zemplar with [**Known lastname 2286**]
.
No other changes were made to your medications. Please follow-up
with your outpatient appointments below. Please seek medical
attention for any concerns.
Followup Instructions:
Appointments:
1) Department: [**Hospital3 249**]
When: THURSDAY [**2142-10-18**] at 3:50 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **], MD
[**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] linical Ctr [**Location (un) 895**] Campus:
EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
2) Department: INFECTIOUS DISEASE
When: TUESDAY [**2142-10-30**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2142-10-12**]
|
[
"042",
"070.54",
"574.20",
"403.91",
"V12.72",
"585.6",
"518.89",
"787.01",
"V45.11",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12716, 12722
|
6532, 9148
|
294, 298
|
12846, 12846
|
3725, 3730
|
13971, 14783
|
2993, 3011
|
11217, 12693
|
12743, 12825
|
9518, 11194
|
12997, 13948
|
3026, 3706
|
2218, 2619
|
242, 256
|
4583, 6509
|
326, 2199
|
3744, 4564
|
12861, 12973
|
9171, 9492
|
2641, 2908
|
2924, 2977
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,871
| 108,789
|
35127
|
Discharge summary
|
report
|
Admission Date: [**2103-10-22**] Discharge Date: [**2103-11-3**]
Date of Birth: [**2055-6-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Transferred from OSH with hyperglycemia, AMS
Major Surgical or Invasive Procedure:
Intubation [**2103-10-22**]
Extubation and re-intubation [**2103-10-26**]
Extubation [**2103-10-30**]
CT head
TTE
History of Present Illness:
This is a 48yo generally healthy male who presented to an OSH
w/new onset MS changes x hours and new onset hyperglycemia. Per
pt's wife, he had been well when she left for work on the day of
presentation. When she returned home, he was slurring his
speech, having muscle weakness, and lost urinary continence. She
was concerned that he was having a stroke and called 911.
At the OSH, he had BG of 2300, CT head negative, CXR clear,
Insulin drip was started. He received 5.4 L IVF and 40mEq
potassium. There, he was hypertensive and tachycardic to the
130s. Cardiac enzymes were negative x 1. He was sating 100% on
NRB with ABG 7.17/50/244, AG of 46.
.
In the [**Hospital1 18**] ED, T 100.6 HR 127 BP 149/102 RR 25 O2sat was
initially 92%6LNC, then 25-30 98%NRB, MS improved. Pt received
300cc IVF, 20mEq potassium repletion for K 2.8. A second set of
cardiac enzymes were negative.
.
On ROS, the patient's wife endorses pt had cough x 2 weeks,
nonproductive. She otherwise denies pt having had any fevers,
chills, weight change, nausea, vomiting, abdominal pain,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity edema,
urinary frequency, urgency, dysuria, lightheadedness, vision
changes, headache, rash or skin changes.
Past Medical History:
[**Name (NI) **] pt hasn't seen a doctor in years and is "healthy".
Social History:
Lives with wife, currently unemployed. ~ 5 beers/week. [**3-17**]
cigarettes daily. Occassional marijuana. Drinks 5-6 mountain dew
daily and does not generally drink fluids without sugar in them.
Family History:
Mother died of complications of scleroderma. Otherwise, negative
for DM, cardiac disease, and cancers.
Physical Exam:
Vitals: T: 102.5 BP: 106/61 HR: 136 RR: 36 O2Sat:97% on 100%NRB
GEN: tachypneic, lethargic, initially aware he is hospitalized
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dryMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2
PULM: tachypneic, decreased BS at bases BL, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords, diminished DP/PT pulses
NEURO: oriented to "hospital" only. CN II ?????? XII grossly intact.
Moves all 4 extremities. Unable to complete neuro exam due to
noncompliance.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs:
[**2103-10-22**] 10:15PM BLOOD WBC-19.6* RBC-4.88 Hgb-15.1 Hct-47.6
MCV-98 MCH-30.9 MCHC-31.7 RDW-13.7 Plt Ct-251
[**2103-10-22**] 10:15PM BLOOD Neuts-88* Bands-1 Lymphs-6* Monos-3 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2103-10-22**] 10:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2103-10-22**] 10:15PM BLOOD PT-13.5* PTT-23.9 INR(PT)-1.2*
[**2103-10-22**] 10:15PM BLOOD Glucose-1317* UreaN-50* Creat-2.3*
Na-153* K-2.8* Cl-116* HCO3-22 AnGap-18
[**2103-10-22**] 10:15PM BLOOD CK(CPK)-898*
[**2103-10-23**] 02:07AM BLOOD ALT-55* AST-36 AlkPhos-221* TotBili-0.2
[**2103-10-23**] 05:36AM BLOOD Lipase-641*
[**2103-10-22**] 10:15PM BLOOD CK-MB-5
[**2103-10-22**] 10:15PM BLOOD cTropnT-<0.01
[**2103-10-22**] 10:15PM BLOOD Calcium-8.6 Phos-2.8 Mg-2.8*
[**2103-10-28**] 12:00AM BLOOD calTIBC-191* Ferritn-719* TRF-147*
[**2103-10-23**] 02:07AM BLOOD %HbA1c-13.4*
[**2103-10-30**] 01:05AM BLOOD Triglyc-457*
[**2103-10-23**] 02:07AM BLOOD Acetone-NEGATIVE Osmolal-414*
[**2103-10-23**] 07:26PM BLOOD TSH-0.36
[**2103-10-23**] 02:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-10-22**] 10:21PM BLOOD Type-[**Last Name (un) **] FiO2-100 pO2-52* pCO2-53*
pH-7.24* calTCO2-24 Base XS--5 AADO2-608 REQ O2-99 Intubat-NOT
INTUBA
[**2103-10-22**] 10:21PM BLOOD Glucose-GREATER TH Lactate-2.2* Na-159*
K-2.9* Cl-114*
Other labs:
[**2103-10-31**] 05:18AM BLOOD WBC-23.6*# RBC-3.56* Hgb-11.2* Hct-32.5*
MCV-91 MCH-31.4 MCHC-34.4 RDW-13.0 Plt Ct-434#
[**2103-10-31**] 03:30PM BLOOD Hct-31.3*
[**2103-11-1**] 07:40AM BLOOD WBC-21.0* RBC-3.41* Hgb-10.7* Hct-30.7*
MCV-90 MCH-31.3 MCHC-34.8 RDW-13.7 Plt Ct-457*
[**2103-11-2**] 07:30AM BLOOD WBC-17.8* RBC-3.43* Hgb-10.6* Hct-31.2*
MCV-91 MCH-30.8 MCHC-33.8 RDW-12.8 Plt Ct-454*
[**2103-10-30**] 01:05AM BLOOD Glucose-254* UreaN-52* Creat-2.9* Na-141
K-3.8 Cl-106 HCO3-24 AnGap-15
[**2103-10-30**] 08:02PM BLOOD Glucose-65* UreaN-44* Creat-2.3* Na-146*
K-3.1* Cl-110* HCO3-26 AnGap-13
[**2103-10-31**] 03:30PM BLOOD Glucose-226* UreaN-37* Creat-1.9* Na-141
K-3.6 Cl-107 HCO3-24 AnGap-14
[**2103-11-1**] 07:40AM BLOOD Glucose-89 UreaN-30* Creat-1.7* Na-140
K-3.7 Cl-105 HCO3-24 AnGap-15
[**2103-11-1**] 07:40PM BLOOD Glucose-216* UreaN-25* Creat-1.6* Na-133
K-3.8 Cl-101 HCO3-21* AnGap-15
[**2103-11-2**] 07:30AM BLOOD Glucose-108* UreaN-21* Creat-1.4* Na-138
K-4.2 Cl-106 HCO3-23 AnGap-13
[**2103-10-29**] 04:23AM BLOOD ALT-67* AST-62* LD(LDH)-300*
CK(CPK)-2860* AlkPhos-81 TotBili-0.3
[**2103-11-1**] 07:40AM BLOOD ALT-103* AST-99* LD(LDH)-440* AlkPhos-82
TotBili-0.4
[**2103-11-2**] 07:30AM BLOOD ALT-99* AST-85* AlkPhos-71 TotBili-0.4
[**2103-10-30**] 01:05AM BLOOD Lipase-154*
[**2103-11-1**] 07:40AM BLOOD Lipase-174*
[**2103-11-2**] 07:30AM BLOOD Lipase-162*
[**2103-10-23**] 07:26PM BLOOD CK-MB-9 cTropnT-0.03*
[**2103-10-24**] 09:07AM BLOOD CK-MB-7 cTropnT-0.03*
[**2103-10-28**] 11:40AM BLOOD CK-MB-2 cTropnT-<0.01
[**2103-10-28**] 12:00AM BLOOD calTIBC-191* Ferritn-719* TRF-147*
[**2103-10-23**] 02:07AM BLOOD %HbA1c-13.4*
[**2103-11-2**] 07:30AM BLOOD Triglyc-268* HDL-26 CHOL/HD-7.9
LDLcalc-125 LDLmeas-120
[**2103-10-23**] 07:26PM BLOOD TSH-0.36
Significant Radiology:
[**2103-10-24**] Abd U/S:
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease, including more significant hepatic
fibrosis or cirrhosis, cannot be excluded on the basis of this
examination.
2. Limited visualization of the pancreas.
3. Dilated fluid-filled bowel.
4. Spleen not examined.
[**2103-10-27**] CT Head without contrast:
HEAD CT WITHOUT IV CONTRAST: There is no hemorrhage, edema, mass
effect, or shift of normally midline structures. There is no
evidence of major vascular territorial infarction. The
ventricles and sulci are normal in size and configuration for
the patient's age. The left maxillary sinus demonstrates
aerosolized mucosal secretions, which may be related to
intubation.
IMPRESSION: No hemorrhage, edema, or mass effect.
[**2103-10-29**] TTE:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Diastolic function could not be
assessed. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Brief Hospital Course:
48 yo [**Male First Name (un) 4746**] who has not been to a physician in many years and no
known medical diagnosis presented on [**10-22**] w confusion,
weakness, slurred speech and was found to have blood sugar in
[**2094**] range and corrected sodium of 175 at local ED, was
transferred to [**Hospital1 **], was intubated for airway protection and
treated with iv fluids and insulin. Briefly needed to be on
pressors [**1-13**] low bp likely from significant dehydration and
hypovolemia. He also had leukocytosis w bandermia on admission,
so there was also concern for sepsis, so pt was started on
Vanc/Zosyn/levo. U/A and CXR were negative and with the
exception of a contaminated blood culture on [**10-23**], cultures
remained negative until [**10-31**]. On [**10-31**] types of
stenotrophomonas and a pan-sensitive klebsiella were grown from
[**10-25**] sputum cultures and pt was started on bactrim for tx of
possible pna with stenotrophomonas & pan-[**Last Name (un) 36**] klebsiella
He was also in ARF and had transaminitis and elevated lipase
presumed [**1-13**] hypovolemic shock. Abd US showed echogenic liver
consistent with fatty infiltration.
Friday [**10-26**] he was thought to have a fixed and dilated R
pupil and underwent a stat head CT which was unremarkable.
Neurosurgery was also consulted and noted anisocoria with the L
pupil being larger than the right but both reactive to light. He
was briefly extubated that day but had to be reintubated for inc
resp distress attributed to laryngeal edema as his total fluid
balance was +15 L. He was given racemic Epi, decadron, heliox
and lasix but continued to be tachypnic and with BPs in the
215/120 range. He was then emergently re-intubated. He was
successfully weaned and extubated on [**10-30**] without event.
Steroids were stopped [**10-31**]. He was transferred to floor on
[**11-1**].
This morning, pt is sitting in chair comfortably. He spoke
with nutritionist on thursday and learned more about diabetes.
He has also been learning how to inject insulin from nurses. He
has no complaints to report today
AP: 48 M w new onset diabetes presents with hyperglycemic
hyperosmolar nonketoacidosis
.
# Hyperosmolar Nonketosis (HONK): now essentially resolved.
Still has mildly elevated Osmolality of 324
.
# Diabetes Mellitus:
- Appreciate [**Last Name (un) **] input
- Pt given lantus and humalog sliding scale instructions at ds
as per Dr.[**Name (NI) 80202**] recommendation from [**Last Name (un) **]
- Scripts for glargine/humalog pen given to wife, prescription
already filled and pt was using insulin pen before dc
-Pt was also started on Metformin as Cr decreased down to 1.4.
[**Last Name (un) 3390**] should recheck BMP at visit and if >1.5 discontinue the
metformin
- Apprecitae Nutrition and RN going over diabetes education and
insulin use. Pt has been taught insulin administration, checking
finger sticks and following sliding scale
- Aspirin 81mg qD
.
# Leukocytosis: on presentation to ICU, had bandemia, fever,
therefore treated as sepsis w/ Vanc, zosyn, levo which were
eventually d/c'ed and now on Bactrim for sputum cx growing 2
types of stenotrophomonas & pan-sensitive klebsiella. His
elevation in White count likey from steroids as was downtrending
at discharge. Pt remained afebrile on floor with stable vitals
and decision was made to treat possible pna with 7 day course of
bactrim (4 more days p dc)
- f/u cultures remained neg at discharge.
-Pt has new [**Last Name (un) **] appt on [**11-9**] and it is recommended that [**Month (only) 3390**]
check CBC, bMP and LFTS to ensure that these are resolving. DC
summary faxed to [**Month (only) 3390**]'s office
.
# Acute renal failure: Presented with Creatinint of 7 but did
not need dialysis. At discharge cr was steadily decreasing and
was down to 1.4. Nephrology was initially following but signed
off. Recommend that [**Month (only) **] recheck BMP at visit
# Hypertension: bp normal, initially hypotensive [**1-13**] volume
depletion and ?sepsis, tx w fluids and pressors in ICU but then
became hypertensive was temporarily placed on hydralazine but
has not needed it on the floor. Pt discharged on no bp meds as
on floor SBP ranged in 100-120 range without medications
# Transaminitis: elevation first seen on [**10-23**], thought [**1-13**]
shock liver/pancreas although HONK can elevate pancreatic
enzymes. Abd US on [**10-24**] showed echogenic liver consistent with
fatty infiltration but other forms of liver disease cannot be
ruled out
- LFTs/lipase continue to trend down. Recheck w [**Month/Year (2) **]. [**Name10 (NameIs) **] not
normalized, consider further workup such as hep panel etc
# Sacral wound - pt had an unstagable wound at gluteal fold
which required dressing change daily. Pt was set up with home
VNA for wound care and for diabetes monitoring.
.
# Access: CVL removed [**10-31**], PIVs in place
.
# FEN: diabetic diet
.
# Code: Full
# Dispo: [**First Name8 (NamePattern2) **] [**Last Name (un) **], can dc today and have fu [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] clinic.
Pt educated on symptoms of hypoglycemia and told to check blood
sugar right away for symptoms or take [**Location (un) 2452**] juice, regular
soda or hard candy. Pt told to call [**Last Name (un) **] for low blood surgars
or sugars >300 at [**Telephone/Fax (1) 2378**] and ask to speak with the doctor
on call.
Pt also is establishing new [**Telephone/Fax (1) **]. [**Name Initial (NameIs) **]'s office called, they will
follow VNA orders. DC summary faxed to their office on day of
discharge.
Medications on Admission:
None
Discharge Medications:
1. Lantus Solostar 300 unit/3 mL Insulin Pen Sig: One (1)
injection Subcutaneous at lunch: Please give yourself 30 units
at lunch .
Disp:*6 pens* Refills:*2*
2. Humalog KwikPen 100 unit/mL Insulin Pen Sig: as directed
injection Subcutaneous four times a day: as directed. Please use
separate sliding scale printed for you at discharge.
Disp:*10 pens* Refills:*2*
3. BD Insulin Pen Needle UF Orig 29 x [**12-13**] Needle Sig: One (1)
needles Miscellaneous five times a dy.
Disp:*qs needles* Refills:*2*
4. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day.
Disp:*120 strips* Refills:*2*
5. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*120 lancets* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
9. Aquacel Hydrofiber Dressing 4 X 4 Bandage Sig: One (1)
bandage Topical once a day: as per wound care directions.
Disp:*30 bandage* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
home health and hospice of [**Location (un) **]
Discharge Diagnosis:
New diagnosis of diabetes
HONK
ARF - resolving
Transaminitis - resolving
Pneumonia
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital with blood sugars of [**2094**]. You
have diagnosis. You initially needed to be on breathing machine
but you recovered well. You will need to check your blood sugars
atleast four times daily. Please follow instructions carefully.
We have set you up with a primary care doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]
appointment. Please keep them. Please contact your [**Name2 (NI) 387**]
doctors with [**Name5 (PTitle) 691**] questions regarding your blood sugars.
If you notice symptoms of low blood sugar such as shaking,
sweating, confusion, decreased alertness, check your blood sugar
right away or give your self [**Location (un) 2452**] or apple juice, regular soda
or hard candy
If your blood sugars are greater than 300-400 or less than 70,
please call [**Last Name (un) **] at [**Telephone/Fax (1) 2378**] and ask to talk to the doctor
on call
On Monday, please call Eni at [**Last Name (un) **] at [**0-0-**] and ask
that you be set up with Diabetes education within the week as
per DR. [**Last Name (STitle) 9978**]
Followup Instructions:
1. [**Last Name (un) **]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], NP at [**Last Name (un) **] on [**11-13**], at 4PM. Call
[**Telephone/Fax (1) 4847**] if you need to change this appointment
2. Dr. [**Last Name (STitle) **], ph: [**Telephone/Fax (1) 80203**]. [**Last Name (NamePattern1) 80204**],
[**University/College **]-Hitchcock [**Location (un) 8117**], [**Numeric Identifier 30090**]. Fax [**Telephone/Fax (1) 80205**]. Appt is
Friday, [**2106-11-8**]:00AM
|
[
"401.9",
"707.25",
"V58.67",
"276.0",
"250.13",
"584.5",
"427.89",
"518.81",
"707.03",
"482.0",
"785.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14578, 14656
|
7697, 13283
|
359, 475
|
14783, 14790
|
2952, 2952
|
15920, 16420
|
2111, 2216
|
13338, 14555
|
14677, 14762
|
13309, 13315
|
14814, 15897
|
2231, 2933
|
275, 321
|
503, 1789
|
2969, 4373
|
1811, 1880
|
1896, 2095
|
4385, 7674
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,512
| 152,600
|
34791
|
Discharge summary
|
report
|
Admission Date: [**2150-7-4**] Discharge Date: [**2150-7-22**]
Date of Birth: [**2097-1-22**] Sex: M
Service:
Note that the patient was admitted between [**2150-7-4**], and
[**2150-7-22**], however, discharge summary is missing and I
am asked to dictate it at this point.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] was a 54-year-old man
with cirrhosis, known cholelithiasis, transferred from an
outside facility with a small bowel obstruction. He had
previously been admitted to this facility as well but had it
resolved and left AMA. At the time of the current admission,
he had return of abdominal pain and distention which was
severe. He had a medical history of hepatitis C, cirrhosis,
alcohol abuse, thrombocytopenia and leukopenia from
myelosuppression, anxiety and depression. He had previously
undergone a diagnostic laparoscopy in [**2150-4-9**] which had been
planned to be a cholecystectomy but that was abandoned by the
surgeon secondary to his intra-abdominal anatomy and
difficulty.
He had a complicated social situation living with his mother,
divorced with two children. Active smoker and drinker.
History of heroin in the past. He was no methadone.
HOSPITAL COURSE: At the time of admission, he was toxic
appearing with a distended, diffusely tender abdomen. This
worsened on repeat examination with signs of peritonitis. CT
scan was concerning for internal hernia with concern for the
integrity of the bowel as far as ischemia.
He was brought to the operating room for laparotomy. The
high risks were discussed at length with him. The operative
findings included a frozen abdomen with a foreshortened and
fibrotic mesentery. He had abdominal wall varices which
required control and essentially an intra-abdominal cocoon
lining which was unable to be initially entered. Some
adhesions were able to be lysed as there was a dilated loop
of bowel that was visualized superficially and given these
findings as well as the ability to decompress the abdominal
contents, the operation was stopped at that juncture and open
abdomen was left with a dressing.
He was brought back to the operating room over the next few
days on several occasions for re-evaluation. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] assisted with the operation on [**2150-7-6**]. He was
found to have a small piece of dead bowel which appeared to
be terminal ileum and cecum and this had an associated
perforation. The ends of the bowel were left stapled off. I
was still unable to round the entirety of it and abdomen was
left packed with drains. He continued to require intensive
care unit care during this point-in-time. Subsequently, he
was brought back to the operating room with leakage of bile.
A tube ileostomy was created and again a VAC was placed.
During this time, intensive care unit care continued. He
continued to be fairly stable but in the intensive care unit
setting. Given the extenuating circumstances of his abdomen
and the inability to provide definitive care and management,
our best case scenario was adequate drainage of the
ileostomy; however, he was really unable to achieve any
significant parenteral nutrition. Ultimately the patient's
family as well as the patient were involved in making
decisions regarding his care. He was able to be extubated
and was awake during this time for these conversations.
Social work and palliative care were also involved. He was
maintained on CMO care in the intensive care unit because of
his high nursing needs. He continued to have high drainage
from his abdominal wounds. He was kept comfortable. The
patient and family were in agreement that CMO was appropriate
care and he was therefore kept there in the intensive care
unit with comfort measures only until his death on [**2150-7-22**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 71138**]
Dictated By:[**Last Name (NamePattern4) 79676**]
MEDQUIST36
D: [**2151-2-24**] 14:46:54
T: [**2151-2-24**] 15:11:13
Job#: [**Job Number 79677**]
|
[
"789.59",
"557.0",
"574.20",
"070.54",
"511.9",
"560.81",
"707.03",
"788.5",
"E878.6",
"287.5",
"997.5",
"571.5",
"486",
"569.62",
"567.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"54.59",
"99.04",
"54.72",
"54.3",
"46.73",
"46.20",
"45.73",
"54.23"
] |
icd9pcs
|
[
[
[]
]
] |
1224, 4135
|
321, 1206
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,251
| 161,499
|
49002+49003
|
Discharge summary
|
report+report
|
Admission Date: [**2104-3-26**] Discharge Date: [**2104-4-12**]
Date of Birth: [**2040-6-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Penicillins / Zestril
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
CP and SOB
Major Surgical or Invasive Procedure:
thoracentesis
History of Present Illness:
63 yo F with NSCLC s/p chemo and radiation now presenting with
worsening dyspnea and intermittent CP. Pt reports that for the
last 3-4 days has had decreased energy and feeling like her
breathing has been shallow. +cough productive of clear/opaque
white sputum and had a few episodes of vomiting after vigorous
coughing. No fevers but had night sweats x several nights.
States 2 days ago had one episode of CP in middle of chest which
felt like an intense pressure/squeezing. Occurred while she was
watching tv. Had no SOB, N/V, diaphoresis at the time. Took an
aspirin and states the pain resolved after a few minutes and has
not returned. States her SOB has generally been a little better
this week, but noticed that upon trying to get dressed to come
to the ED it took her several hours b/c she kept having to stop
to take breaks to catch her breath.
.
On arrival in the ED she had a temp of 100.4, HR 140, nml BP, RR
28, O2sat 91% on RA. Recieved 1L NS, Tylenol 1gm, Levofloxacin
500mg IV, and Flagyl 500mg IV. CTA showed PE and heparin gtt was
started.
.
Onc history: In [**8-23**] presented with cough x 1 month - CXR showed
a LUL mass. Bronch showed adenocarcinoma that was felt to be
unresectable as it was invading the mediastinum. Has been
treated by Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] in medical oncology. Was treated
with cisplatin and etoposide x 2 cycles and repeat CT's showed
overall large mass having shrunk in size, but increase in the
number of pulmonary nodules. Thus, she was changed to Taxotere
and received 3 cycles but then developed a rash on her hands and
feet, neuropathy, and increased SOB so this was stopped. She has
recently decided to enroll in a clinical trial but has not yet
started chemotherapy treatment. This was due to start on
Thursday with Alimta, bevacizumab, and oxaliplatin. She is on
folic acid and received vitamin B12 shot last week in
anticipation for starting therapy.
.
ROS: Also c/o white, non-painful spots in mouth for the last 2
days. Had 3 episodes of diarrhea a few days ago - last was 2
days PTA. Last BM yesterday which was nml. Denies hematemesis,
dark stools, bloody stools. No other bleeding.
Past Medical History:
-NSCLC as above
-HTN
-hypercholesterolemia
-seasonal allergies
-Pelvic inflammatory disease
-lipoma
-genital warts
-seasonal allergies
Social History:
works at [**Hospital3 1810**] as administrator, lives with son
and grandson, mother of 2 with 4 grandchildren, no etoh use,
+smoking, however down to 4-5cigs a day, not sexually active.
Family History:
thalasemia, G6-PD defciency, breast ca in aunt at age 60, father
died of lung ca, no CAD/DM
Physical Exam:
VS: 99.2, HR 127, BP 138/71, RR 44 (19-40), O2sat 95% on 2L NC,
wt 60.7kg. Pulsus: [**5-24**] (although difficult to auscultate given
tachypnea)
GEN: sitting in bed, visibly tachypneic, becomes more SOB upon
talking. No use of accessory muscles.
HEENT: PERRL, MMM
Chest: + absent breath sounds over middle and lower L lung.
Crackles at base of R lung.
CV: tachy, regular, no murmurs or rubs. no JVD.
ABD: soft NT/ND, +BS with +lipoma on right iliac crest
Ext: no edema.
Neuro: non-focal.
Pertinent Results:
CTA: 1. Pulmonary embolus at the right lower lobe.
2. Increased bilateral pleural effusions, large on left.
3. Diminished aeration of the left lung, obscuring known
carcinoma. While there is certainly atelectasis present,
coincident pneumonia cannot be excluded.
4. Small right-sided pulmonary nodules minimally changed.
5. New areas of narrowing in the left main bronchus and the left
upper lobe bronchus.
6. Small pericardial effusion.
.
HEAD CT:
1. No evidence of acute intracranial hemorrhage.
2. Unchanged appearance of the brain compared to [**2103-8-20**],
with evidence of chronic microvascular infarction.
.
ECHO [**3-27**]: 1. The left atrium is dilated.
2. The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%).
3. A huge pleural effusion is present.
4. There is a small, loculated (mostly anterior and medial)
pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements.
.
[**3-24**] PORTABLE AP CHEST: There is near complete opacification of
the left lower lobe and probably a combination of effusion and
left lower lobe atelectasis. There is also opacification of the
left upper lobe with probable increase in loculated effusion.
Partial aeration of the lingula. The right lung field is clear.
Heart size cannot be assessed.
.
ECG: sinus tachy at 135. nl intervals, nl axis, +LAE, no ST/T
abnmlities. No RV strain.
.
CTA [**3-26**]
1. Pulmonary embolus at the right lower lobe.
2. Increased bilateral pleural effusions, large on left.
3. Diminished aeration of the left lung, obscuring known
carcinoma. While there is certainly atelectasis present,
coincident pneumonia cannot be excluded.
4. Small right-sided pulmonary nodules minimally changed.
5. New areas of narrowing in the left main bronchus and the left
upper lobe bronchus.
6. Small pericardial effusion
.
LENI [**3-27**]
IMPRESSION: No evidence of deep vein thrombosis.
.
pCXR [**3-28**]
There is continued large loculated left pleural effusion with
near total opacification of the left lung. The patient's known
carcinoma in the left lung is obscured.
There is continued small right pleural effusion. The right lung
appears clear, otherwise. No pneumothorax is identified.
Brief Hospital Course:
63 yo F with Non small cell lung cancer (NSCLC) status post
chemo and radiation who presented with worsening dyspnea and
intermittent chest pain. Her dyspnea was multifactorial due to
a diagnosed pulmonary embolism, increased left sided pleural
effusions, left lung consolidation and a new area of narrowing
noted in the left main bronchus that was initially concerning
for external compression.
1. Malignant Effusion
The IP team initially performed a thoracentesis that removed 1L
of bloody fluid that was positive for malignant cells. The IP
then subsequently performed a throscopy in order to attempt
complete drainage of the pleural effusion and talc pleurodesis.
During the procedure it was noted that the pt had multiple
loculated effusions and an irregular appearing pleural surface
which would make it ineffective for successful pleurodesis to
occur. The procedure was complicated by a loculated hemothorax.
CT surgery was consulted and subsequently the patient underwent
a VATS with removal of a large clot (coagulated blood from
hemothorax), lysis of adhesions and placement of a chest tube
and a Pleurex catheter. The pt's oxygenation was noted to
gradually improve but she was informed of the low likelihood of
successful pleurodesis. The chest tube was removed, and with the
Pleurex catheter still in place, the pt was transferred to the
[**Hospital Ward Name **]. Pt subsequently had her Pleurex catheter drained
twice while she was an inpatient, and was sent home with close
follow up in CT [**Doctor First Name **] clinic for prn Pleurex catheter drainage as
needed.
.
2. PULMONARY EMBOLISM:
The pt was noted to have a filling defect at an early
bifurcation to the posterior basilar segment of the right lower
lobe on CTA on initial presentation. This PE was likely
secondary to her hypercoagulable state due to the underlying
malignancy. The pt was treated with a heparin drip and was
transitioned to Lovenox. Pt was started on coumadin, and due to
complications with securing Lovenox on her weekend of discharge,
the patient was placed on a once daily Fondaparinux 7.5mg qD
bridge until therapeutic on her coumadin. Pt was to have an INR
check the Monday after discharge.
.
3. Narrowing of L main bronchus:
A Chest CT on admission revealed a LUL collapse with concern of
left main bronchus compression. The consolidation/collapse
could have represented atelectasis vs. post-obstructive
pneumonia, and patient was placed on Levaquin/Flagyl for empiric
post-obstructive PNA coverage. The pt then underwent a flexible
bronchoscopy which showed a near total collapse of the left main
stem bronchus with passive exhalation (extrinsic) and complete
collapse of left upper lobe bronchus which the IP team thought
that was due to extrinsic compression of the bronchi by the
pleural effusion. An attempt was made to aerate the lung by IP
but the procedure was not successful. Because patient remained
afebrile with a normal WBC, her Abx were discontinued as the
consolidation likely represented atelectasis.
.
4. ECHO dense pericardial effusion:
The pt was noted to have a small, loculated (mostly anterior and
medial) pericardial
effusion. The effusion was noted to be echo dense, consistent
with blood, inflammation or other cellular elements. Patient
had a normal pulsus paradoxus, and no RV strain or tamponade
physiology was seen on ECHO. No further intervention was
undertaken.
.
5. Persistant tachycardia:
The pt was noted to have stable tachycardia (likely from PE and
hypoxia) that persisted throughout her hospitalization. Despite
patient oxygenating well on 4L NC, her tachycardia persisted.
Pt was instructed to f/u with her PCP as an outpatient to ensure
this resolves.
.
6. History of HTN:
The pt's BP remained stable without medications.
.
7. NSCLC:
In [**8-23**] the pt presented with cough x 1 month. A CXR at the time
showed a left upper lung mass. A bronchoscopy showed
adenocarcinoma that was felt to be unresectable as it was
invading the mediastinum. The pt has been treated by Dr. [**First Name8 (NamePattern2) 553**]
[**Last Name (NamePattern1) **] (in medical oncology) with Cisplatin and Etoposide x 2
cycles and repeat CT's have shown an overall decrease in size of
the mass, but increase in the number of pulmonary nodules. Thus,
the pt was changed to Taxotere and received 3 cycles but then
developed a rash on her hands and feet, neuropathy, and
increased shortness of breath so this chemotherapeutic [**Doctor Last Name 360**] was
stopped. She has recently decided to enroll in a clinical trial
but has not yet started chemotherapy treatment. This new regimen
comprises of Alimta, bevacizumab, and oxaliplatin. She was on
folic acid and received vitamin B12 shot a week prior to
admission, in anticipation for starting therapy. However, it was
decided that initiation of the new chemo regimen will be
deferred to an out-patient follow-up with Dr. [**Last Name (STitle) **].
.
DISPO -
FULL CODE. Patient was discharged on 4L NC, and on Fondaparinux
bridge until therapeutic on coumadin. Pt is to f/u with her
oncologist Dr. [**Last Name (STitle) **].
Medications on Admission:
Meds at home:
Aspirin 325 daily
B6
Multivitamin
Tylenol prn
.
Meds on transfer:
ambien 5mg qhs prn
dolasetron prn
flagyl 500mg tid
levo 50mg daily
folate 1mg daily
pantoprazole 40mg daily
aspirin 325 daily
nystatin suspension qid
mvi
acetaminophen
heparin gtt
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous once a day for 1 weeks.
Disp:*7 injections* Refills:*0*
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Home Oxygen
Please provide a portable oxygen tank to provide home oxygen at
4liters/min
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Non-small cell lung cancer
Pulmonary Embolus
LUL collapse
Left pleural effusion s/p thoracentesis, thorascopy, VATS c
pleurodeisis, and Pleurex catheter placement
Discharge Condition:
Stable
Discharge Instructions:
Plesae report to the nearest emergency department if you have
fever, chills, nausea, vomiting, diarrhea, greater difficulty
breathing or pain.
.
There has been a change in your medications - please take them
as below.
.
You have been scheduled for some follow-up appointments. Please
have the VNA check your INR (coumadin level) on Monday - fax
results to Dr.[**Name (NI) 17513**] office.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (works with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**]). Date/Time:
[**2104-4-22**] at 4:00pm.
.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 553**] [**First Name8 (NamePattern2) **] [**Doctor Last Name **]. Phone: ([**2104**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2104-4-14**] Admission Date: [**2104-4-18**] Discharge Date: [**2104-5-4**]
Date of Birth: [**2040-6-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Penicillins / Zestril
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
chest pain, pericardial effusion
Major Surgical or Invasive Procedure:
pericardiocentesis
History of Present Illness:
63yo F with NSCLC s/p chemo and XRT, recent PE on Coumadin,
L-sided pleural effusion s/p VATS and pleurX catheter [**4-5**], with
CP and SOB. Found to have moderate-sized pericardial effusion
without signs of tamponade, and ? STEs. She had a recent
hospitalization from [**Date range (1) 102876**] for pulmonary embolism and
malignant pleural effusion. She had experienced some mild
substernal chest pressure during that admission that was felt to
be GERD. She had no further episodes of chest pressure until
yesterday. Onset while watching TV, [**5-28**], with some SOB with
deep breathing, no associated N/V/LH/D/ha, not relieved by
Tylenol x 4. She has also had increased LE edema, although she
states it has been progressive for a long time. She denies
worsening orthopnea, PND.
.
In the ED, she was afebrile with HR 110s, BP 95/53. She
received levo/Flagyl for suspected postobstructive pneumonia,
CTA to look for PE, 4L NS. Her EKG was read as having possible
ST elevations inferiorly. TTE showed moderate-sized pericardial
effusion without tamponade. The chest pressure resolved in the
ED, spontaneously per the patient.
Past Medical History:
1. NSCLC: dx [**8-23**], L-sided, s/p 2 cycles cisplatin and etoposide
with XRT, s/p 3 cycles taxetere [**11-23**], malignant pleural
effusion s/p VATS and PleurX catheter on [**4-5**], on 4L home O2
2. PE: dx [**3-24**], on Coumadin
3. PID
Social History:
works at [**Hospital1 **] as administrator, lives with son and
grandson, + tobacco history but quit months ago, denies EtOH and
drug use
Family History:
thalasemia, G6-PD defciency, breast ca in aunt at age 60, father
died of lung ca, no CAD/DM
Physical Exam:
vitals- T 98.1, HR 140, BP 141/88, RR 37, O2sat 96% 4L NC
General- chronically-ill-appearing woman, tachypneic but appears
comfortable
HEENT- sclerae anicteric, dry mucus membranes
Neck- JVP flat
Lungs- decreased breath sounds throughout L lung, decreased
breath sounds at R base, dullness to percussion throughout L
lung
Heart- tachycardic at 140, no rub, murmur, gallop
Abd- soft, NT, ND, NABS, no organomegaly
Ext- 2+ pitting edema 2/3 up calf b/l, 2+ CP/PT pulses b/l
Neuro- A&Ox3, CNs grossly intact, strength grossly intact and
symmetric
Pertinent Results:
[**2104-4-18**] 07:15PM WBC-18.8* RBC-3.56* HGB-9.1* HCT-28.1*
MCV-79* MCH-25.7* MCHC-32.5 RDW-19.2*
[**2104-4-18**] 07:15PM NEUTS-93.0* LYMPHS-2.9* MONOS-3.4 EOS-0.5
BASOS-0.2
[**2104-4-18**] 07:15PM PLT COUNT-707*
[**2104-4-18**] 07:15PM PT-39.0* PTT-31.2 INR(PT)-4.4*
[**2104-4-18**] 07:15PM GLUCOSE-116* UREA N-14 CREAT-0.5 SODIUM-143
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15
[**2104-4-18**] 07:15PM ALT(SGPT)-30 AST(SGOT)-38 CK(CPK)-15* ALK
PHOS-344* AMYLASE-52 TOT BILI-0.3
[**2104-4-18**] 07:15PM ALBUMIN-2.8* CALCIUM-8.5 PHOSPHATE-2.6*
MAGNESIUM-1.5*
.
EKG: sinus tach at 139bpm, normal axis and intervals, <1mm STE
in II/III, <1mm ST depression in V1
.
CXR: Interval re-aeration of a significant portion of the left
mid and lower lung zones; no other interval change, compared to
study on [**2104-4-8**].
.
CTA chest:
1. No PE.
2. New moderate-amount pericardial effusion, measuring up to
20HU. Fluid along the descending and ascending aorta, of unknown
etiology. Clinical correlation and further work-up is
recommended.
3. Decreased left locurated pleural fluid.
4. Coronary artery calcification.
5. Persistent collapse of the left upper lobe with narowwed
airway
.
TTE: The left atrium is normal in size. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Right
ventricular chamber size and free wall motion are normal. There
is a moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.
.
TTE ([**2104-3-27**]):
1. The left atrium is dilated.
2. The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%).
3. A huge pleural effusion is present.
4. There is a small, loculated (mostly anterior and medial)
pericardial effusion. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements.
Brief Hospital Course:
.
# Dyspnea: Her chronic dyspnea is felt primarily secondary
non-small cell lung cancer with left malignant pleural effusion.
She had a minimal amount of pleural fluid drained by IP via
PleurX catheter already in place two times during the admission.
She had stable O2 requirement. She underwent
pericardiocentesis for possible symtpomatic improvent, and she
experienced minor improvement in her shortness of breath
afterwards. She had some reaccumulation of her pericardial
effusion after the procedure, but it was stable on repeat TTE,
so it was felt to be an unlikely contributor to her symptoms.
.
# Pericardial effusion: On admission, she had mild tamponade on
exam. She likely had a constrictive component as well with a
Kussmaul's sign, and evidence of pericarditis on EKG. She
underwent pericardiocentesis on [**4-22**], with drainage of ~450cc of
bloody fluid. Her pericardial drain was pulled after 2 days
without significant drainage. TTE after the procedure shows
reaccumulation of an organizing effusion, with no tamponade.
Her effusion was stable on a repeat TTE. Pericardial window was
therefore felt to be not indicated.
.
# PE: Her PE was diagnosed in [**3-24**] and she has been on Coumadin
as an outpatient. Her INR was supratherapeutic on admission.
She received 4U FFP before pericardiocentesis. Her Coumadin was
held for several days because her INR remained therapeutic,
likely secondary to poor nutritional status and antibiotics.
After it began to drift down, she was restarted on Coumadin at a
lower dose. As regular lab draws are not consistent with her
wishes regarding goals of care, Coumadin was discontinued upon
discharge.
.
# Leukocytosis: She had a persistent leukocytosis between 16 to
25 throughout her stay. She was treated empirically for
post-obstructive pneumonia with a 7-day course of levofloxacin
and Flagyl. She was afebrile throughout her stay. Her UA was
clear.
.
# Anemia: Her baseline hematocrit is between 28-31. She
received 1U PRBC in an attempt to improve her symptoms, but
experienced no change.
.
# FEN: She appeared total volume overloaded but intravascularly
dry, likely due to her low oncotic pressure from
hypoalbuminemia. She had very poor po intake throughout her
stay due to lack of appetite. She also had hypernatremia
thought secondary to intravascular depletion that improved with
free water repletion.
.
# Social: Oncology and Palliative care followed her throughout
her stay. She had lengthy discussions with them and the primary
team regarding her goals of care. She decided she would like to
be DNR/DNI with home hospice, and would not want further
hospitalizations. She indicated that she wanted all home
services decisions made by her son, as she did not feel she
could make those decisions. Family support at home was being
coordinated. However, her respiratory status worsened while
still at the hospital. She expired on [**2104-5-4**].
.
Medications on Admission:
ASA 325mg qd
HCTZ
Coumadin
Folic acid
MVI
Vitamin B6
Discharge Medications:
patient expired
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Pericardial effusion
Left pleural effusion
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
Completed by:[**2104-5-25**]
|
[
"272.0",
"162.3",
"401.9",
"289.82",
"518.0",
"511.8",
"423.8",
"518.82",
"197.2",
"799.02",
"427.89",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"34.04",
"34.92",
"34.91",
"99.04",
"34.09",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
21148, 21167
|
18063, 21005
|
13835, 13856
|
21254, 21271
|
16130, 18040
|
21335, 21381
|
15458, 15551
|
21108, 21125
|
21188, 21233
|
21031, 21085
|
21295, 21312
|
15566, 16111
|
13763, 13797
|
13884, 15024
|
3987, 5842
|
15046, 15288
|
15304, 15442
|
11078, 11259
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,215
| 190,218
|
26141
|
Discharge summary
|
report
|
Admission Date: [**2198-3-28**] Discharge Date: [**2198-4-7**]
Date of Birth: [**2124-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Cephalosporins / Gabapentin / Ace Inhibitors
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
[**2198-3-28**] left heart catheterization, coronary angiogram
[**2198-3-29**] coronary artery bypass
graftx5(LIMA-LAD,SVG-Dg,SVG-RI,SVG-OM,SVG-PDA)
History of Present Illness:
This patient 73 year old male followed by Dr [**Last Name (STitle) **] for his CAD
which is medically managed. The patient recently had a
prolonged episode of chest pressure lasting throughout the day
that came and went for 5-10 minutes. It went through to the back
on occasion, but was predominantly anterior. There was no
diaphoresis. He did not seek medical help. He saw his PCP and
was subsequently started on Levaquin for a respiratory infection
for which he had had a sputum culture a week or so before. A
stress echocardiogram on [**2198-3-13**]. The images were suboptimal
and the ECG portion was strongly positive with a 2 mm planar ST
segment depression in leads V4 through V6 and associated ST
segment elevation in aVL and persisted for greater than 10
minutes into ecovery. A cath today reveals 40% LMm99% mid LAD
w/r->L collaterals,70% proximal circumflex into origin of OM1,
60% OM 2 lesion and 80%Mid/70% distal/90%PDA lesions. He is
admitted for urgent CABG.
Past Medical History:
Hypertension
Hyperlipidemia
Tobacco use
COPD
Asthma
Obstructive sleep apnea - uses CPAP
Abdominal pain/chronic constipation
Irritable bowel syndrome
Traumatic stress disorder
GERD
Anxiety
Depression
Chronic Low back pain
s/p Catatact surgery
Social History:
Indian (born in [**Country 9819**])
Last Dental Exam:yrs ago
SOCIAL HISTORY: Lives with wife. Retired assembly worker
Discharge contact: [**Name (NI) 64854**] [**Name (NI) 11482**], wife. C: [**Telephone/Fax (1) 64855**]
H: [**Telephone/Fax (1) 64856**]
Home Care Services: None
Tobacco: [**3-26**] cigarettes daily
ETOH: None
Recreational drug use: Denies
Family History:
Family history of HTN
Physical Exam:
Pulse: Resp: O2 sat:
B/P Right: Left:
Height:71" Weight:195
General:WDWN in NAD
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [n] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2 Left:2
DP Right2: Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
[**2198-3-28**] Cath: 1. Selective coronary angiography of this right
dominant system demonstrated three vessel coronary disease. The
LMCA had a 40% distal lesion. The LAD had a 99% mid-vessel
lesion and the distal vessel filled partially via right to left
collaterals. The LCX had a 70% proximal stenosis extending into
the origin of a high-rising OM1. There was also 60% stenosis in
OM2. The mid RCA had an 80% mid-vessel lesion and a 70% distal
lesion. There was also a 90% stenosis in an early rising PDA. 2.
Limited resting hemodynamics revealed normotension.
.
[**2198-3-28**] Carotid U/S: 40-59% stenosis in the right internal
carotid artery and less than 40% stenosis in the left internal
carotid artery.
.
[**2198-3-29**] Echo: PRE-BYPASS: No spontaneous echo contrast 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
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 ascending aorta is mildly dilated. There are
complex (>4mm) atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results at time of surgery.
POST-BYPASS: The patient is in sinus rhythm. The patient is on
no inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged.Tricuspid regurgitation is unchanged.
The aorta is intact post-decannulation.
[**2198-4-4**]: Echocardiogram: The left atrium is normal in size.
Left ventricular wall thicknesses and cavity size are normal.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The number of aortic
valve leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is borderline pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
CXR: [**2198-4-7**]: left-sided pleural effusion is virtually
unchanged. There is unchanged evidence of a retrocardiac
atelectasis. Moderate cardiomegaly without acute pulmonary
edema. Unchanged appearance of the sternal wires.
[**2198-4-6**] WBC-13.2* RBC-2.96* Hgb-8.9* Hct-25.4* MCV-86 MCH-30.1
MCHC-35.0 RDW-15.3 Plt Ct-336
[**2198-3-28**] WBC-11.1*# RBC-3.81* Hgb-11.5* Hct-31.8* MCV-83
MCH-30.1 MCHC-36.1* RDW-14.2 Plt Ct-231
[**2198-4-7**] PT-19.7* INR(PT)-1.9*
[**2198-4-6**] PT-16.5* INR(PT)-1.6*
[**2198-4-5**] PT-14.6* INR(PT)-1.4*
[**2198-4-7**] UreaN-16 Creat-1.0 Na-132* K-4.7 Cl-100
[**2198-4-6**] Glucose-114* UreaN-14 Creat-1.1 Na-133 K-4.4 Cl-99
HCO3-26
[**2198-3-28**] Glucose-282* UreaN-19 Creat-1.1 Na-131* K-3.9 Cl-96
HCO3-26
[**2198-4-6**] Mg-2.0
Micro: [**2198-4-3**] URINE CULTURE (Final [**2198-4-4**]): NO GROWTH.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 11482**] [**Last Name (Titles) 1834**] a cardiac cath on
[**3-28**] which revealed severe coronary artery disease and he was
admitted for surgical work-up for pending bypass surgery.
On [**3-29**] he was brought to the Operating Room where he [**Month/Day (4) 1834**]
coronary artery bypass graft x 5. Please see operative report
for surgical details. Following surgery he was transferred to
the CVICU for invasive monitoring in stable condition. His
chest tubes and cardiac pacing wires were removed per protocol.
Respiratory: extubated on POD2 secondary to anxiety. Aggressive
pulmonary toilet, nebs and his inhalers were restarted. He
titrated off oxygen with room air saturations of 98%. The left
lower lobe effusion improved.
Cardiac: episode of atrial fibrillation on [**2198-4-4**] which he
converted to sinus rhythm with IV beta-blockers. Echocardiogram
was done and revealed a trivial physiologic pericardial
effusion. EF normal. His cardiologist Dr. [**Last Name (STitle) **] recommended
Carvedilol 50 mg QAM and 25 mg QPM on discharge.
Heme: warfarin was started [**2198-4-4**]. On discharge his INR was 1.9
he was given 2.5 mg of warfarin. Next INR Monday [**4-9**] and
follow-up with his cardiologist Dr. [**Last Name (STitle) **]. Warfarin doses: [**4-6**]
5 mg (INR 1.6), [**4-5**] 5 mg (INR 1.4) [**4-4**] 5 mg.
GI: Abdominal distention with RUQ tenderness was noted which
improved once bowel function return. He tolerated a regular
diet.
Renal: volume overload. gently diuresed. His Foley was replaced
for urinary retention. Flomax was started. Renal function normal
with good urine output. His electrolytes were replete as needed
Wound: Left lower extremity cellulitis at VasoView site. 7 Day
course of Levofloxacin was started. Sternal incision with small
area of drainage DSD with Betadine swab was initiated. He will
follow-up as an outpatient in the wound clinic next week.
Pain: well controlled with narcotics. Neuro: non-focal.
Disposition: he was seen by physical therapy and deemed safe for
home. He was discharged on [**2198-4-7**] with Home VNA and will
follow-up as an outpatient.
Medications on Admission:
Lorazepam 1mg tid prn
Amlodipine 2.5mg daily
HCTZ 25mg daily
Losartan 50mg [**Hospital1 **]
Aspirin 81mg daily
Buspirone 30mg daily
Proair HFA 90mcg 2puff qid prn
Carvedilol 25mg [**Hospital1 **]
Spiriva 18mcg daily
COMBIVENT QID
Discharge Medications:
1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 4 weeks.
Disp:*30 Patch 24 hr(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. buspirone 30 mg Tablet Sig: One (1) Tablet PO once a day: 1
tablet in am
2 tablets at bedtime.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
13. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day) for 10 days.
Disp:*40 Tablet Extended Release(s)* Refills:*0*
14. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
15. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO QAM.
16. carvedilol 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO as directed.
Disp:*90 Tablet(s)* Refills:*2*
18. warfarin 1 mg Tablet Sig: One (1) Tablet PO as directed.
Disp:*100 Tablet(s)* Refills:*2*
19. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: [**1-22**]
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
20. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) inhale Inhalation once a day.
21. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: Two
(2) puffs Inhalation four times a day.
22. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
23. guaifenesin 600 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day.
Disp:*60 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass graft x 5
Hypertension
Hyperlipidemia
chronic obstructive pulmonary disease
Asthma
Obstructive sleep apnea - uses CPAP
chronic Abdominal pain/chronic constipation
Irritable bowel syndrome
Traumatic stress disorder
gastroesophageal refux
Anxiety
Depression
Chronic Low back pain
s/p Catatact surgery
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check appointment Wednesday [**2198-4-11**] 11:00 am in the [**Last Name (un) 2577**]
Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Surgeon: Dr. [**First Name (STitle) **]([**Telephone/Fax (1) 170**]on [**2198-5-8**] at 1pm in the [**Last Name (un) 2577**]
Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]([**Telephone/Fax (1) 2258**])-office will call
with an appointment
Please call to schedule appointments with:
Primary Care: Dr. [**Last Name (STitle) 30186**]([**Telephone/Fax (1) 3530**]) in [**4-26**] weeks
Warfarin for atrial fibrillation: INR Goal 2.0-2.5
Warfarin follow-up with Atrius. Next blood draw Monday [**2198-4-9**]
The office will call you on Monday with warfarin instructions.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2198-4-7**]
|
[
"530.81",
"427.31",
"E878.2",
"682.6",
"327.23",
"311",
"788.20",
"411.1",
"493.20",
"276.69",
"414.01",
"401.9",
"511.9",
"575.0",
"998.59",
"300.00",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.14",
"36.15",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11157, 11215
|
6153, 8327
|
337, 489
|
11609, 11815
|
2804, 6130
|
12654, 13820
|
2160, 2183
|
8607, 11134
|
11236, 11588
|
8353, 8584
|
11839, 12631
|
2198, 2785
|
283, 299
|
517, 1500
|
1522, 1765
|
1858, 2144
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,924
| 149,426
|
44062
|
Discharge summary
|
report
|
Admission Date: [**2142-6-14**] Discharge Date: [**2142-7-10**]
Date of Birth: [**2079-10-15**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Duodenal mass
Major Surgical or Invasive Procedure:
Classical pancreaticoduodenectomy w/open cholecystectomy
History of Present Illness:
Patient is a 62 year old male who presented with chest pain,
migrating to the epigastrium. Cardiac workup was negative, but
EGD showed a duodenal abnormality. Endoscopic ultrasound was
performed on [**5-11**] and biopsies were obtained. These biopsies
did not show overt malignancy, but were inconclusive. They
described chronic active duodenitis with areas of pyloric
mucinous metaplasia of the villous epithelium. Furthermore,
there was focal ulceration and granulation tissue and
inflammatory exudates. Although there no neoplasm was
identified directly, there was suspicion from the pathologist as
well the gastrointestinal endoscopy referral, that this harbored
a malignancy based on its gross morphologic appearance. As far
as symptoms, the patient denied any jaundice, itching, abdominal
or back pain, weight loss, nausea, vomiting, flushing, ascites,
diarrhea, steatorrhea, fever or chills. The patient elected for
the definitive procedure to be performed on [**5-15**], with the
intent of an open exploration and biopsy of this duodenal mass.
Past Medical History:
1. Duodenal mass, suspicious for carcinoma of pancreatic head
2. s/p pancreaticoduodenectomy w/open cholecystectomy
3. CAD s/p stent
4. DM type 2
5. HTN
6. Arthritis
7. Hypercholesterolemia
Social History:
1ppd, quit 23 years ago. Alcohol history is significant only for
occasional use. He has no known environmental exposures.
Family History:
non contributory
Physical Exam:
General: Well nourished, well appearing in no apparent distress
Head and neck: Pupils equal round and reactive to light, neck
supple, trachea midline. no cervical lymphadenopathy
Cardiac: regular rate and rhythm
Lungs: clear to auscultation bilaterally
Abdomen: obese, soft non tender non distended with no masses
Extremities: no clubbing, cyanosis or edema
Neuro: alert and oriented times 3, with normal motor strength
and sensation bilaterally
On discharge, the patient had an open abdominal wound with a
draining pancreatic fistula. The primary origin of the fistula
is in the midline of the wound, with a secondary origin on the
left side of the wound. He has an ostomy bag collecting the
drainage from the left side of the wound, while wet to dry
dressings cover the non draining, right side of the wound.
Pertinent Results:
Pathology:
DIAGNOSIS:
Whipple resection, six parts:
1. Gallbladder, cholecystectomy (A):
Gallbladder with no significant pathologic change.
2. Lymph node, Whipple, biopsy (B-C):
One benign lymph node.
3. Lymph node, of importance, biopsy (D-E):
One benign lymph node.
4. Cystic duct and wall (G):
Unremarkable cystic duct.
5. Pancreas and duodenum, Whipple resection (F, H-MA):
A. Chronic duodenitis with focal submucosal
fibrosis. See note.
B. Pancreas with mucinous metaplasia of ducts and
patchy chronic inflammation.
C. Ten unremarkable lymph nodes.
6. Stomach, antrectomy (NA-XA):
A. Stomach with chronic inactive gastritis.
B. Duodenum with no significant pathologic change.
Note:
The grossly appreciated duodenal stricture is likely secondary
to the submucosal fibrosis. This focus may be the site of a
prior duodenal ulcer.
Sections of the pancreatic and bile duct margins need to be
submitted and if significant pathology is found, an addendum
will be issued.
ADDENDUM:
Sections of the pancreatic and bile duct margin (cassettes AB
and BB) are benign. benign pancreatic parenchyma is seen in
cassettes [**Last Name (un) **] and ZA.
Focally within the duodenum (section DA), there is a benign
submucosal neuroma.
[**2142-6-19**]: CT scan abdomen
IMPRESSION:
1) Post operative fluid and air in the resection bed as well as
mesenteric and omental fat stranding are consistent with recent
surgery.
2) No evidence of focal abscess or bowel obstruction.
3) Fatty liver.
4) Bilateral lower lobe atelectasis, possibly related with some
degree of consolidation.
[**2142-6-22**]: CT scan abdomen
IMPRESSION: 1. Persistent and unchanged amount of fluid and air
within the resection bed, mesenteric, and omental fat, which are
consistent with the recent surgery. Drainage catheter runs
through this fluid collection. 2. No loculated or organized
fluid collections are seen. 3. Fatty liver. 4. Bilateral lower
lobe atelectasis with small right sided pleural effusion.
[**2142-6-25**]: CT abdomen
The previously demonstrated collection has necessitated onto the
anterior abdominal wall. No significant fluid collection is now
identified. No attempt at drainage was made.
WOUND CULTURE (Final [**2142-6-27**]):
ENTEROBACTER SPECIES. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER SPECIES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
FLUID CULTURE (Final [**2142-6-30**]):
ENTEROBACTER ASBURIAE. HEAVY GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
GRAM POSITIVE COCCUS(COCCI). IN CHAINS. GROWING IN
BROTH ONLY.
UNABLE TO GROW FOR FURTHER IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER ASBURIAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
JP Amylase [**6-22**]: 2876
Amylase wound fluid [**6-26**]: 37,600
Brief Hospital Course:
The patient was admitted on [**6-14**] for biopsy and resection of
a duodenal mass. The patient tolerated the procedure well, but
was admittted to the intensive care unit for continued
mechanical ventilation over night. The patient had persistent
low blood pressures and hypotension requiring aggressive fluid
resuscitation. He was extubated on post operative day one
without difficulty. He was maintained on a insulin drip for
glucose control, and continued to have fluid resucitation. The
patient pulled out his NG tube on Post operative day 2. Patient
also had some confusion and the patient attempted to get out of
bed. A sitter was assigned for the patients saftey. On post
operative day 4, the patient had a temperature spike to 102.8.
His incision was noted to be erythematous, and cultures were
sent, and he was started on antibiotics for a suspected wound
infection. On post operative day 5 the patient had increaseing
abdominal distention and a abdominal xray was not concerning for
obstruction. HIs Foley was dicontinued, but his diet was not
advanced secondary to his abdominal discomfort. A NG tube was
also replaced. His wound ws reopented on post operative day 6
and the patient was started on unasyn for his wound infection.
He was given twice daily dressing changes from wet to dry. His
NG tube was removed and he was started on sips on post operative
day 7, and clears on post operative day 8. His JP amylase was
2816 on post opeartive day 9. The drainage from his wound began
to increase and there was concern that the patient had a
pancreatic fistula exiting through his wound. Several CT scans
were obtained to evaluate placement of a drain, however the
radiologists did not feel that a drain placement would be
possible, and that the fluid collection actually decreased in
size on the repeat scan. The ostomy team was consulted for
wound management, and decided to use an ostomy bag to control
the drainage. Fluid sent from the wound demonstrated a very
hisgh amylase and the drain output continued to increase,
putting over 300-500cc/day out of the abdominal drain. On post
operative day 14, the decision was made to srate the patient on
TPN and make him NPO, since the drain output was nearly
700cc/day on a regular diet and taking ocretotide. A PICC line
was placed and nutrition services was consulted to assist in his
TPN management. He continued to be seen by the ostomy nurse [**First Name (Titles) 1023**] [**Last Name (Titles) **]d in managing the fistula. His fluid was positive on
enterobacter, so the patient was placed back onto unasyn, and
later transitioned to PO augmentin. He required dressing
changes up to 5-6 times a day, due to the high output. His TPN
was optimized, however his blood glucose levels at times were
consistently over 200 despite an escalating sliding scale.
Increased levels of insulin were added to his TPN regimen to
gain better control. On post operative day 16 the drain output
decreased to 200cc over the 24 hour period. It was down to 115
cc on post operative day, with 80 cc coming from the wound an an
addtional 35 cc from the JP drain. His drain output decreased
to a manageable level for a rehab facility. He continued to be
NPO, on TPN, taking ocretotide with TID to QID dressing changes.
He was otherwise symptom free, hemodynamically stable, and in
good condition. He will be treated with a total of 2 weeks of
antibiotics from the last positive culture.
Medications on Admission:
Lipitor, lisinopril, methotrexate, Folic acid, glipizide,
glucophage, ranitidine, celebrex
Discharge Medications:
1. Octreotide Acetate 0.1 mg/mL Solution Sig: One (1) Injection
Q8H (every 8 hours).
Disp:*90 injections* Refills:*2*
2. Rofecoxib 12.5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for tinea pedis.
Disp:*1 tube* Refills:*1*
8. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
9. 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*
10. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
11. Hydromorphone HCl 2 mg/mL Syringe Sig: One (1) Injection
Q6H (every 6 hours) as needed.
Disp:*30 syringe* Refills:*0*
12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
13. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
1. Duodenal mass, suspicious for carcinoma of pancreatic head
2. s/p pancreaticoduodenectomy w/open cholecystectomy
3. Pancreatic fistula
4. Wound infection
5. coronary artery disease s/p stent
6. Uncontrolled Diabetes type 2
7. hypertension
8. Arthritis
9. Hypercholesterolemia
10. Acute hypotension
Discharge Condition:
Good
Completed by:[**2142-7-9**]
|
[
"998.6",
"518.0",
"535.60",
"998.59",
"511.9",
"211.2",
"250.92",
"577.1",
"696.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"52.7",
"03.90",
"51.22",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12068, 12116
|
6823, 10279
|
348, 407
|
12461, 12495
|
2729, 6800
|
1859, 1877
|
10420, 12045
|
12137, 12440
|
10305, 10397
|
1892, 2710
|
295, 310
|
435, 1490
|
1512, 1704
|
1720, 1843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,511
| 116,682
|
28304
|
Discharge summary
|
report
|
Admission Date: [**2193-9-6**] Discharge Date: [**2193-9-13**]
Date of Birth: [**2149-9-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine / Platinum Complexes / Aspirin / Shellfish
Derived
Attending:[**First Name3 (LF) 14689**]
Chief Complaint:
Enlarging Flank Mass, Sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43-year old female with stage IV ovarian ca on home hospice care
and recently identified left flank mass presenting with rapidly
increasing size of mass with concurrent increasing L hip pain.
1.5 wks ago, patient reports that her nurse identified a small
mass on her L flank. Pt was seen on [**8-29**] by her oncologist, who
recommended imagine. On CT, mass was identified as tumor, fluid
collection with connection to colon. At that point, after
discussion with radiology, it was decided not to tap the mass.
She was started on cipro for treatment of presumed adbominal
infection. Patient reports that the mass responded to the abx,
decreasing in size. However, on Thursday AM of this week, the
patient reports that the mass began to rapidly enlarge and
became increasingly painful. In addition patient reports
increasing fatigue and weakness, along with decreased PO intake
and urinary output. Denies fevers, chills, N/V, change in ostomy
output.
.
She is admitted tonight for management of this mass.
.
In the ED, initial vital signs were: T98.8 93 81/52 16 100 .
Patient was given 1.5L of NS. No central line was placed as per
patient's wishes, 2 PIVs placed.
.
On the floor, patient's vitals were 90/50 90 17 100% RA. She
complained of pain over L flank and hip and was given 4mg IV
morphine and started on a bolus of 500cc NS
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, or changes in bowel habits. Denies dysuria.
Past Medical History:
Clear cell ovarian Cancer
([**2189**]) TAH-BSO, appendectomy, omentectomy
([**7-12**]) sigmoid resection w end colostomy for perforated
diverticulitis
Anemia - requiring regular RBC transfusions
L Hip Pain - requiring regular steroid injection
Diabetes
Hypothyroidism
HTN
Social History:
Patient lives alone; is on home hospice. Her father is her HCP.
Does not smoke or drink.
Family History:
Mother with NHL, tongue CA, died of "strep throat." Father has
a pacemaker.
Physical Exam:
On admission -
VITALS: T99.2, BP 92/58, HR 93, RR 19, SaO2 99%RA
GENERAL: Thin, chronically ill-appearing woman, laying in bed
in pain
HEENT: EOMI, PERRL, no LAD
CHEST: Clear to auscultation bilaterally
CARDIAC: RRR, nl S1/S2, no mrg
ABDOMEN: +BS, ostomy bag in place with dark hue around site and
minimal substance in bag, mild tenderness at ostomy site
FLANK: L flank with 15cm ovoid ulceration with surrounding
ecchymosis and partially overlaid eschar, tender to touch
EXTREMITIES: No edema bilaterally
SKIN: Cool, gradeII sacral decub w mild surrounding erythema
NEURO: AOx3, CNII-XII grossly intact
On discharge:
Tm/Tc: 99.2/98.4 BP 98/60 (92-112/50-67) P 92 (88-104) R 16
Sat 100%RA
I/O: 24h: 2128 (960 PO, 1168 IV)/650
GENERAL: Thin, chronically ill appearing woman, lying in bed in
NAD
HEENT: NCAT, EOMI, PERRL, mild [**Month/Year (2) 11395**] on tongue.
CHEST: Clear to auscultation bilaterally, no w/r/r audible on
anterior exam
CARDIAC: RRR, nl S1/S2, no m/r/g
ABDOMEN: +BS, ostomy bag in place, diffuse tenderness to light
touch on left abdomen, slightly tender on right, voluntary
guarding present; dressing in place over left flank wound
BACK: pressure ulcer on gluteal cleft, eroded skin (stage 3
likely) with surrounding erythema and serosanguinous drainage
EXTREMITIES: Left leg with increased swelling, 2+ pitting edema.
Upper thigh and groin on left side with increased swelling and
erythema, 20 cm area from right hip to groin. Right leg with no
c/c/e.
NEURO: AOx3, CNII-XII grossly intact
Pertinent Results:
====
Labs
====
[**2193-9-6**] 06:45PM PT-15.7* PTT-30.6 INR(PT)-1.4*
[**2193-9-6**] 06:45PM PLT COUNT-439
[**2193-9-6**] 06:45PM NEUTS-92* BANDS-0 LYMPHS-3* MONOS-5 EOS-0
BASOS-0
[**2193-9-6**] 06:45PM WBC-31.2*# RBC-2.76* HGB-7.5* HCT-22.8*
MCV-83 MCH-27.1 MCHC-32.8 RDW-16.4*
[**2193-9-6**] 06:45PM estGFR-Using this
[**2193-9-6**] 06:45PM GLUCOSE-181* UREA N-104* CREAT-4.0*#
SODIUM-132* POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-15* ANION
GAP-26*
[**2193-9-6**] 08:31PM LACTATE-1.7
[**2193-9-6**] 10:00PM URINE AMORPH-NONE
[**2193-9-6**] 10:00PM URINE RBC-0-2 WBC-[**3-8**] BACTERIA-FEW YEAST-NONE
EPI-0-2 RENAL EPI-0-2
[**2193-9-6**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2193-9-6**] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2193-9-13**] 09:10AM BLOOD WBC-14.5* RBC-2.85* Hgb-7.8* Hct-24.3*
MCV-85 MCH-27.4 MCHC-32.1 RDW-16.8* Plt Ct-205
[**2193-9-13**] 09:10AM BLOOD PT-21.5* PTT-30.9 INR(PT)-2.0*
[**2193-9-13**] 09:10AM BLOOD Glucose-122* UreaN-45* Creat-1.3* Na-137
K-3.9 Cl-104 HCO3-22 AnGap-15
[**2193-9-13**] 09:10AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.6
=========
Radiology
=========
[**2193-9-7**] Abdomen/Pelvis CT with PO contrast:
IMPRESSION:
1. Interval severely worsening and spread of subcutaneous air
along the left
posterolateral pelvic wall, compatible with aggressive tissue
necrosis.
2. Hyperdense material is seen within the necrotic tissue,
compatible with
extraluminal oral contrast from enterocolonic fistulization to
the necrotic
tissues. Small amount of free air is noted along the left
lateral pelvic
cavity. Recommend consideration for surgical consult for
extensive surgical
debridement.
3. Grossly unchanged large amorphous mid pelvis mass with fluid.
No
percutaneously drainable fluid collection.
4. Unchanged bilateral hydronephrosis and hydroureter.
5. Cholelithiasis without acute cholecystitis.
6. Unchanged hypodensity in segment V of the liver, in
completely evaluated
======
Micro
======
[**2193-9-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2193-9-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
Brief Hospital Course:
43y/o lady with stage IV ovarian cancer, presenting with
enlarging left flank mass previously identified as being
composed of tumor, fluid collection, air, c/w progression of
tumor vs expansion of infection.
.
#Flank Mass: enlarged since it was originally identified on
[**2193-8-29**] (less than 2 weeks ago). There was concern for
expanding intraabdominal infection, so Vanco/Cefepime/Flagyl
were started. The patient declines any major intervention, but
in case there was a percutaneously accessible fluid collection
that could be drained and offer pain relief, a CT was obtained.
It appears that the mass is composed of necrotic tissue and that
no such collection is visualized. There has been progression of
disease, and possible enterocolonic fistulalization to the
necrotic tissues. Blood cultures remained negative, so patient
was transitioned from cefepime and flagyl IV to cipro and flagyl
po for planned 14 day course. Doxycycline was added to added [**9-12**]
for some concern of LLE cellulitus near this mass. Given her
MRSA status, we felt she deserved MRSA coverage. We plan to
continue this for 10 days.
.
#Acute renal failure, likely prerenal vs. obstructive: admitted
with Cr 4.0 (baseline 1.1), in setting of poor appetite x1wk,
and rapidly expanding infection, consistent with obstruction vs
hypoperfusion [**2-5**] to poor PO intake vs shock. Her low-normal
Na/Cl/HCO3 support poor PO intake. CT scan also revealed some
hydronephrosis. She received aggressive volume rescucitation
with normal saline and her creatinine improved to 1.3 on the day
of discharge.
.
#Stage IV Ovarian Cancer: very poor prognosis. She has multiple
abdominal masses, and was in [**Hospital 68721**] hospice care. She is known
to palliative care, is DNR/DNI, does not wish to have central
line. Her Oncologist (Dr. [**Last Name (STitle) 68722**] was aware of her
admission and reinforced that her goals of care are centered on
patient comfort.
.
#Anemia: chronic anemia requiring regular transfusions, HCT of
22 on admission. She was transfused 2U PRBCs on admission.
.
# Pain: Patient was transitioned from IV pain medications to
fentanyl patch 25 mcg, with dilaudid 2-4 mg po Q3H prn with
instructions for patient to chew medication for quicker onset.
Patient was advised to use dilaudid 20 minutes prior to dressing
changes. Palliative care followed the patient, and felt other
options could include a morphine cream as well as fentanyl
lollipops.
.
# [**Last Name (STitle) **]: Patient was noted to have [**Last Name (LF) 11395**], [**First Name3 (LF) **] she was started
on nystatin and fluconazole. We plan to continue fluconazole for
12 more days, to complete a 14 day course.
Medications on Admission:
CIPROFLOXACIN 250mg [**Hospital1 **] ([**8-29**]-today)
Ducodyl
Fentanyl Patch 12mcg/hour q72h
GABAPENTIN - 300 mg Capsule TID
METOCLOPRAMIDE - 10 mg Tablet - QID prn for nausea
NYSTATIN 5mL swish and swallow
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth 1 hour
before treatment then as needed for every 8 hours
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection Q8H (every 8 hours).
4. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritus.
6. Oral Wound Care Products Gel in Packet Sig: One (1) ML
Mucous membrane TID (3 times a day) as needed for oral
mucositis.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-5**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for [**Month/Day (2) 11395**].
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
10. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 12 days.
11. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nasal congestion.
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain: Please have patient chew pill instead
of directly swallow; please also time dose before dressing
changes and moving patient.
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
14. Haloperidol 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for nausea.
15. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
16. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 10 days.
17. Reglan 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours.
18. Reglan 5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 68723**] [**Hospital **] [**Hospital **] Hospice Home
Discharge Diagnosis:
Abdominal pain, likely due to left flank mass
Acute renal failure, prerenal
Nausea and vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 45419**],
It was a pleasure taking care of you at the [**Hospital1 18**]. You came for
further evaluation of abdominal pain and mass, and decreased
kidney function. Further tests showed that the mass in your
abdomen is related to your ovarian cancer, and surgery would not
be a good option at this time. Your decrease in kidney function
was most likely due to dehydration, and has recovered with
intravenous fluids. It is important that you continue to take
your medications and follow up with your outpatient oncologist.
Followup Instructions:
Department: PAIN MANAGEMENT CENTER
When: MONDAY [**2193-9-23**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
[**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]
|
[
"038.9",
"569.81",
"584.9",
"338.3",
"995.91",
"250.00",
"707.03",
"V44.3",
"V66.7",
"707.23",
"V02.54",
"458.8",
"112.0",
"285.22",
"591",
"719.45",
"V65.3",
"276.52",
"276.2",
"198.89",
"682.2",
"183.0",
"783.0",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11308, 11450
|
6348, 9039
|
361, 367
|
11590, 11590
|
4130, 6325
|
12303, 12725
|
2495, 2573
|
9408, 11285
|
11471, 11569
|
9065, 9385
|
11725, 12280
|
2588, 3200
|
3214, 4111
|
1758, 2075
|
293, 323
|
395, 1739
|
11605, 11701
|
2097, 2371
|
2387, 2479
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,277
| 130,553
|
4835
|
Discharge summary
|
report
|
Admission Date: [**2141-5-11**] Discharge Date: [**2141-5-15**]
Date of Birth: [**2061-2-16**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Haloperidol / Sertraline / Zoloft / Paxil
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
[**2141-5-11**] - Right total hip arthroplasty
History of Present Illness:
Ms. [**Known lastname 1924**] is an 80 year old woman with right hip arthritis that
has failed non-operative treatment. She has elected to undergo
a right total hip arthroplasty.
Past Medical History:
1. CARDIAC RISK FACTORS:: +Dyslipidemia, +HTN, -Diabetes
2. CARDIAC HISTORY:
-CABG:n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: No interventions but 85%
stenosis of RCA and 80-85% stenosis of LAD.
-PACING/ICD:n/a
3. OTHER PAST MEDICAL HISTORY:
PVD
s/p carotid endarterectomy
anxiety/depression
s/p CCY
PVD
TIA
s/p bowel obstruction
Social History:
Lives with her husband in [**Name (NI) 17566**].
-Tobacco history:10cig per day for many years.
-ETOH:denies
-Illicit drugs:denies
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
At the time of discharge:
AVSS
NAD
wound c/d/i without erythema
[**Last Name (un) 938**]/FHL/TA/GS intact
SILT distally
Pertinent Results:
[**2141-5-15**] 06:25AM BLOOD WBC-6.7 RBC-3.62* Hgb-10.9* Hct-30.9*
MCV-85 MCH-30.1 MCHC-35.2* RDW-14.4 Plt Ct-198
[**2141-5-14**] 01:42AM BLOOD WBC-7.1 RBC-3.28*# Hgb-10.1*# Hct-28.2*#
MCV-86 MCH-30.8 MCHC-35.9* RDW-14.1 Plt Ct-143*
[**2141-5-13**] 09:19AM BLOOD WBC-6.4 RBC-2.60*# Hgb-7.9* Hct-22.5*
MCV-86 MCH-30.2 MCHC-35.0 RDW-14.2 Plt Ct-158
[**2141-5-12**] 02:12AM BLOOD WBC-9.1 RBC-3.51* Hgb-10.3* Hct-30.0*
MCV-86 MCH-29.4 MCHC-34.4 RDW-14.2 Plt Ct-194
[**2141-5-11**] 09:16PM BLOOD Hct-31.2*
[**2141-5-15**] 06:25AM BLOOD PT-17.9* PTT-30.2 INR(PT)-1.6*
[**2141-5-14**] 05:55AM BLOOD Plt Ct-140*
[**2141-5-14**] 05:55AM BLOOD PT-17.0* PTT-32.5 INR(PT)-1.5*
[**2141-5-14**] 01:42AM BLOOD Plt Ct-143*
[**2141-5-13**] 01:00PM BLOOD PT-16.2* PTT-33.5 INR(PT)-1.4*
[**2141-5-13**] 09:19AM BLOOD Plt Ct-158
[**2141-5-12**] 02:12AM BLOOD Plt Ct-194
[**2141-5-12**] 02:12AM BLOOD PT-13.9* INR(PT)-1.2*
[**2141-5-11**] 05:58PM BLOOD Plt Ct-206
[**2141-5-15**] 06:25AM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2141-5-14**] 05:55AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-132*
K-4.0 Cl-98 HCO3-26 AnGap-12
[**2141-5-12**] 02:12AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.4*
Brief Hospital Course:
The patient was admitted on [**2141-5-11**] and, later that day, was
taken to the operating room by Dr. [**Last Name (STitle) **] for a right total hip
arthroplasty without complication. Please see operative report
for details. Postoperatively the patient had a planned admission
to the SICU. She remained hemodynamically stable and was
extubated on POD0 without incident. The patient was initially
treated with IV followed by PO pain medications on POD#1. The
patient received IV antibiotics for 24 hours postoperatively, as
well as coumadin for DVT prophylaxis starting on the morning of
POD#1. Because of cardiac necessity, the patient was restarted
on aspirin and plavix on POD1. The drain was noted to have
fallen out overnight on POD0-1. The Foley catheter was removed
without incident. The surgical dressing was removed on POD#2 and
the surgical incision was found to be clean, dry, and intact
without erythema or purulent drainage.
While in the hospital, the patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
stable, and the patient's pain was adequately controlled on a PO
regimen. The operative extremity was neurovascularly intact and
the wound was benign. The patient was discharged to home with
services or rehabilitation in a stable condition. The patient's
weight-bearing status was WBAT with posterior precautions.
Medications on Admission:
Bupropion SR 150 qam and 100 qhs, Clonazepam 0.5mg''', Plavix
75mg', Lisinopril 5mg', Metoprolol 12.5mg'', Seroquel 12.5mg qam
and noon and 25mg qhs, and Seroquel 12.5mg [**Hospital1 **] prn, Simvastatin
80mg', Aspirin 325mg', Calcium + Vit D qday, MVI, fish oil
Discharge Medications:
1. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 3 weeks: Goal INR 2.5-3.0. [**Known firstname **] [**Last Name (NamePattern1) **], NP will follow
the patients INR after discharge.
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day)
as needed for pain.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
16. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO HS (at bedtime).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Constipation.
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
19. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
20. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for pain.
21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Right hip arthritis
Discharge Condition:
Stable
Discharge Instructions:
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain medication. This medication can cause constipation, so
you should drink plenty of water daily and take a stool softener
(e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may get the wound wet or
take a shower starting 5 days after surgery, but no baths or
swimming for at least 4 weeks. No dressing is needed if wound
continues to be non-draining. Any stitches or staples that need
to be removed will be taken out by a visiting nurse at 2 weeks
after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment at 4 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to
prevent deep vein thrombosis (blood clots). After completing
the lovenox, please take Aspirin 325mg twice daily for an
additional three weeks.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after POD#5 but do not take a tub-bath or
submerge your incision until 4 weeks after surgery. Please place
a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by VNA in 2 weeks. If you are going to
rehab, the rehab facility can remove the staples at 2 weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at 2 weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated with posterior
precautions on the operative leg. No strenuous exercise or heavy
lifting until follow up appointment.
13.Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Physical Therapy:
Routine total hip arthroplasty
WBAT w/ posterior precautions
Treatments Frequency:
Wound checks. VNA to remove staples at 2 weeks. INR checks.
Followup Instructions:
Provider: [**Known firstname **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2141-6-16**] 11:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2141-7-5**] 11:10
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-9-26**] 1:40
Completed by:[**2141-5-15**]
|
[
"294.8",
"428.32",
"424.0",
"V45.82",
"715.35",
"285.9",
"428.0",
"414.01",
"401.9",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51"
] |
icd9pcs
|
[
[
[]
]
] |
6358, 6422
|
2548, 4122
|
333, 382
|
6486, 6495
|
1327, 2525
|
9191, 9758
|
1111, 1171
|
4435, 6335
|
6443, 6465
|
4148, 4412
|
6519, 8122
|
1186, 1308
|
9024, 9085
|
9107, 9168
|
691, 825
|
279, 295
|
8134, 9006
|
410, 591
|
857, 946
|
613, 671
|
962, 1095
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,146
| 163,985
|
38278
|
Discharge summary
|
report
|
Admission Date: [**2162-6-17**] Discharge Date: [**2162-6-21**]
Date of Birth: [**2100-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times four (LIMA>LAD, svg>PDA,
svg>RCA, svg>Diag)[**6-17**]
Mediastinal re-exploration and repair of bleeding side branch of
the left internal mammary artery. [**6-17**]
History of Present Illness:
This is a 62 year old male with a history of hypertension,
hyperlipidemia, type 2 diabetes, and polio as a child (with
residual left facial paralysis who presents with dyspnea,
depressed ejection fraction, and an abnormal nuclear stress test
after suffering a cerebral vascular acident in [**Month (only) 116**].
In [**Month (only) 116**] he presented to [**Hospital3 **] with garbled incoherent
speech along with trouble with word finding. He was found to a
non hemorrhagic cerebral vascular accident. His symptoms
resolved within twenty-four hours and he does not have any
residual deficits. He was also found to have a CPK > 5000. His
longstanding Simvastatin was discontinued. He was also told he
had had a myocardial infarction.
Follow up testing revealed an abnormal nuclear stress revealing
and ejection fraction of 39% and a partial, large, severe
perfusion defect involving the entire inferior wall and the mid
and basal walls. A subsequent cardiac catheterization revealed
multi-vessel coronary artery disease and he therefore was
referred for surgical evaluation.
Past Medical History:
Hypertension
Type 2 Diabetes insulin dependent- x 20 years
Hyperlipidemia
CRI- creat 1.6
Polio at age six with right sided facial paralysis
Laser eye surgery (bilaterally)
Tonsillectomy
Chronic systolic heart failure
Social History:
Mr. [**Known lastname 1169**] lives with his daughter. [**Name (NI) **] works full time as
supplier of cleaning chemicals. He smoked 1 pack per day for
seventeen years and quit at age 29. He does not drink alcohol.
Family History:
His grandmother died of a myocardial infarction.
Physical Exam:
Pulse:67 Resp: 18 O2 sat: 97%
B/P Right: 161/87 Left:
Height: 6'2" Weight:210 #'s
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] ** left eye surgery
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: Cath site Left:+2
DP Right:+1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right:+2 Left:+2
Carotid Bruit: None Right: +2 Left:+2
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 85303**] (Complete)
Done [**2162-6-17**] at 11:28:59 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2100-4-25**]
Age (years): 62 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Cerebrovascular event/TIA. Coronary artery disease.
Left ventricular function. Preoperative assessment.
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2162-6-17**] at 11:28 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW3-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: *6.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Annulus: 2.4 cm <= 3.0 cm
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderately dilated LV cavity. Moderate regional
LV systolic dysfunction. Moderately depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root. No atheroma in ascending
aorta. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is moderately dilated. There is moderate
regional left ventricular systolic dysfunction with inferior,
inferolateral and anterolateral hypokinesis.. Overall left
ventricular systolic function is moderately depressed (LVEF=
3--35 %). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. An
epi-aortic scan was performed which showed the ascending aorta
free of atheromatous disease at the clamp and canullation site.
POST BYPASS
There is a small improvement in overall systolic function.
LVEF~40%. There may be improvement of the inferior wall. RV
systolic function remains normal. The study is otherwise
unchanged from the prebypass period.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Brief Hospital Course:
On [**6-17**] Mr. [**Known lastname 1169**] was admitted and underwent Coronary artery
bypass grafting x4, with left internal mammary artery to left
anterior descending coronary artery, reversed saphenous vein
single graft from the aorta to the first diagonal coronary
artery, reversed saphenous vein single graft from the aorta to
the first obtuse marginal coronary artery, and reversed
saphenous vein single graft from the aorta to the posterior
descending coronary artery. Please see the operative note for
details. He was brought to the surgical instensive care unit in
critical but stable condition. However, in the immediate
post-operative period he developed acute respiratory
insufficiency, hypotension, and excessive bleeding from his
chest tubes. He returned to the operating room and underwent a
mediastinal exploration for bleeding. He tolerated this
procedure well. He extubated by the following day and was
weaned from pressors. By post-operative day two he was
transferred to the step-down floor. His chest tubes and wires
were removed per protocol. He was seen by physical therapy.
His insulin was titrated to maintain a glucose below 150.
Despite his rising CK on zocor pre-operatively, lipitor was
started to protect his grafts. An e-mail was sent to Dr. [**Last Name (STitle) **]
that his CK be checked in the near future to assess his
tolerance of this drug. His blood pressure did not allow the
addition of an ACE-inhibitor, but one should be added as his
blood pressure allows in the future secondary to his decreased
ejection fraction and chronic systolic heart failure. By
post-operative day four he was ready for discharge to home.
Follow-up appointments were advised.
Medications on Admission:
carvedilol 3.125 [**Hospital1 **], lantus 30-35 units at bedtime. Novalog 4mg
w/ meals, Lisinopril 40mg daily, Losartan 25mg daily, ASA 81mg
daily.
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. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*2*
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day for 10 days.
Disp:*20 Tablet, ER Particles/Crystals(s)* Refills:*2*
7. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
8. insulin lispro 100 unit/mL Solution Sig: Four (4) units
Subcutaneous with meals.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
1+ LE Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] in [**12-20**] weeks ([**Telephone/Fax (1) 11763**]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 3 weeks
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 110**] [**Last Name (STitle) **] [**3-23**] weeks ([**Telephone/Fax (1) 63087**]
**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:[**2162-6-21**]
|
[
"998.11",
"585.9",
"414.01",
"250.00",
"412",
"403.90",
"458.29",
"518.5",
"138",
"V58.67",
"428.22",
"V12.54",
"V15.82",
"E878.2",
"428.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"33.23",
"36.99",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
9406, 9481
|
6481, 8189
|
317, 521
|
9549, 9767
|
2845, 5211
|
10691, 11291
|
2120, 2170
|
8388, 9383
|
9502, 9528
|
8215, 8365
|
9791, 10668
|
5260, 6458
|
2185, 2826
|
270, 279
|
549, 1629
|
1651, 1870
|
1886, 2104
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,573
| 171,449
|
1119
|
Discharge summary
|
report
|
Admission Date: [**2129-4-6**] Discharge Date: [**2129-4-10**]
Date of Birth: [**2070-7-15**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain, shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 58 yo M with known CAD, diabetes and ESRD who
presents with chest pain. He was resting today and he started
having chest pain. The pain is located in the center of his
chest and associated with shortness of breath. It has been
constant since this morning and started all of a sudden when he
was walking to the kitchen. It is a [**6-5**] in severity. He reports
that he has had nausea and vomited 3 times today with some chest
pain during the vomiting. The vomit has been clear fluid without
blood. He has been feeling weak with what is described as
occasional black vision since but has not had any dizziness,
syncope or headache. Of note, he has recently arrived from
[**Country 7192**] where he was for 10 days. While there he took his
medications every day, but was only able to go to dialysis
twice.
While in the ED initial HR 48 BP 123/102 rr 20 100% FS was 177.
Her atropine 1 mg was given at 1316. Nitro gtt was started at
1336. Also given morphine, glucagon, anzemet. Nitro drip was
increased to 100 mcg/min without relief in chest pain.
Additionally patient received sodium bicarb, calcium gluconate
3amps, magnesium sulfate, and 10 units insulin.
On arrival to the floor the patient still complained of chest
pain and shortness of breath but would intermittently fall
asleep.
Past Medical History:
1. CAD
- s/p CABG [**2-27**] LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1
- [**2127-6-20**] cardiac cath: LMCA 40%, LAD mid 70%, LCx 60%, RCA
previously known proximal 99% occlusion; Patent grafts.
- Stress [**2127-10-10**]: unchanged from [**2127-6-18**]; moderately
reversible inferolateral to inferior walls perfusion defects
with EF 44%
2. Diabetes mellitus: diet controlled
3. Dyslipidemia
4. Hypertension
5. Congestive heart failure: [**2128-9-14**] Echo: EF >55%, severe
[**Month/Day/Year 7216**] dysfunction, estimated EF on Nuclear stress 54%
6. Peripheral [**Month/Day/Year 1106**] disease: s/p stent to bilateral CIAs
(Genesis) and steft to [**Female First Name (un) 7195**]
- s/p POBA and atherectomy of L SFA [**2126-7-17**]
7. End-stage renal disease: [**1-28**] Diabetic Nephropathy - on HD
T/Th/Sat
- currently undergoing evaluation for renal transplant although
considered high risk
8. ? COPD - no PFTs available
9. Tracheomalacia
10. h/o c.diff colitis
11. h/o UGI bleed : EGD showed non-bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
tear, gastropathy, and gastritis
Social History:
Patient is originally from [**Country 7192**]. His wife and family are
still there. Patient currently lives alone, but his brother is
nearby. He is on disability. His sister-in law works @ [**Hospital1 18**] in
housekeeping.
Family History:
Father died of CAD
Mother and brother with [**Name (NI) 7199**]
Physical Exam:
VS: T 94.7 BP 143/49 HR 45 RR 20 O2 99% 4L
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. pupils equal but mildly reactive
to light, EOMI. Conjunctiva were pink, no pallor or cyanosis of
the oral mucosa. No xanthalesma.
Neck: Supple with JVP of [**10-7**] cm.
CV: bradycardic RR, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4, though difficult to auscultate [**1-28**] respiratory
sounds
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. bilateral basilar
crackles with occ wheezes and coarse bs
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. Left fistula without tenderness and with palpable
thrill.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Femoral 2+ Popliteal NP DP 1+ PT 1+
Left: Femoral 2+ Popliteal NP DP 1+ PT 1+
Pertinent Results:
ADMIT LABS:
CBC:
[**2129-4-6**] 01:10PM BLOOD WBC-9.2 RBC-3.25* Hgb-10.9* Hct-32.6*
MCV-101* MCH-33.5* MCHC-33.4# RDW-15.3 Plt Ct-153
[**2129-4-6**] 01:10PM BLOOD Neuts-87.4* Bands-0 Lymphs-6.9* Monos-4.7
Eos-0.8 Baso-0.2
[**2129-4-6**] 01:10PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
COAGS:
[**2129-4-6**] 01:10PM BLOOD PT-15.3* PTT-32.8 INR(PT)-1.4*
CHEMISTRIES:
[**2129-4-6**] 01:10PM BLOOD Glucose-163* UreaN-133* Creat-15.6*#
Na-137 K-8.2* Cl-106 HCO3-14* AnGap-25*
Calcium-6.9* Phos-8.6*# Mg-4.0*
LFTS:
[**2129-4-7**] 04:31AM BLOOD ALT-14 AST-13 LD(LDH)-242 CK(CPK)-85
AlkPhos-122* TotBili-0.5
CARDIAC ENZYMES:
[**2129-4-6**] 01:10PM BLOOD cTropnT-0.20* CK-MB-13* MB Indx-8.4*
[**2129-4-6**] 03:10PM BLOOD CK-MB-12* MB Indx-7.4* cTropnT-0.21*
[**2129-4-6**] 10:00PM BLOOD CK-MB-11* MB Indx-8.0* cTropnT-0.23*
MISC:
[**2129-4-6**] 04:24PM BLOOD VitB12-1238* Folate-GREATER TH
[**2129-4-6**] 01:10PM BLOOD TSH-1.3
EKGs demonstrated evolution in ED from sinus bradycardia to
junctional bradycardia at a rate of 36-40. Complexes were wide
with IVCD and QT prolongation.
CXR ([**2129-4-6**]):
CHF and effusion with slight interval worsening.
ECHO ([**2129-4-7**]):
The left atrium is dilated. The right atrium is moderately
dilated. The
estimated right atrial pressure is 11-15mmHg. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric. There is moderate pulmonary
artery systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is a trivial/physiologic pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2128-9-14**], the mitral regurgitation is somewhat reduced.
No definite vegetations seen. However, if clinically suggested,
the absence of a vegetation by 2D echocardiography does not
necessarily exclude endocarditis.
CAROTID US ([**2129-4-8**]):
60-69% stenosis of the bilateral internal carotid arteries;
however, this estimate of percentage of stenosis may not be
precise due to a generalized increase in systolic velocities in
the bilateral common and internal carotid arteries.
CT CHEST ([**2129-4-9**]):
Interval worsening of right lower lobe opacity, and development
of hazy lingular opacity, likely representing infiltrates, with
adjacent pleural thickening. No intrinsic or extrinsic airway
obstruction is identified.
Atherosclerotic disease of the aorta and coronary arteries.
Stable cardiomegaly.
Brief Hospital Course:
1. Hyperkalemia/ESRD:
Presented with hyperkalemia (>7) in the setting of 2 dialysis
sessions in 10 days. This was urgently treated, given symptoms
(weakness, vomiting) and ECG changes. Follow acute treatment in
ED, was dialyzed daily. Last inpatient dialysis session was on
[**4-9**] with plan for next outpatient session on [**4-12**]. He was
continued on sevelamer and nephrocaps.
2. CAD:
Previously patent grafts on catherization. Presented with chest
pains which were concerning but in the setting of persistent
nontypical pain, this was thought to be likely secondary to
other causes. Did have CK and troponin elevations, but has
chronic troponin elevations. He was continued on his aspirin
and isosorbide mononitrate. His beta-blocker was initially held
in the setting of bradycardia, but this was started after
stabilitization of his rhythm and dialysis.
3. Rhythm:
Presented in sinus bradycardia though briefly had junctional
bradycardia while in the ED. This may have been secondary to
combination of both beta blocker effect (in the absence of
dialysis) as well as severe hyperkalemia. Patient was given
glucagon as well as atropine in the ED with some improvement.
At the time of discharge, was back in sinus rhythm and back on
his beta-blocker.
4. Pneumonia:
Found to have RLL opacity on CXR with leukocytosis and cough.
Treated as a community acquired pneumonia with azithromycin and
ceftriaxone (changed to cefpodoxime upon discharge). A CT was
performed which showed "Interval worsening of right lower lobe
opacity, and development of hazy lingular opacity, likely
representing infiltrates, with adjacent pleural thickening."
Given the chronicity of the process, outpatient pulmonology
follow-up was recommended. Upon discussion with radiology, it
was recommended that an outpatient PET scan be obtained (to
evaluate for possible malignant process).
5. Pump:
Presented with a history of CHF in OMR but normal function on
last echo and nuclear study. Furosemide listed as outpatient
medication on last OMR note, but not taking as outpatient. Did
have volume overload initially, but improved greatly after
dialysis and was euvolemic upon discharge.
6. Chest pain:
Potential causes include angina, esophageal irritation, anxiety
among other causes of atypical chest pains. He was treated
symptomatically with good result.
7. Hyperlipidemia:
Continued atorvastatin.
8. Hypertension:
Initially held beta-blocker, which was restarted later in
admission. ACEI also held initially, given hyperkalemia. This
was restarted before discharge..
9. Diabetes mellitus:
Diet controlled; hypoglycemic on [**4-8**] after getting HS insulin
as part of sliding scale. This was probably seen secondary to
ESRD with poor clearance of insulin. Thereafter, a less
aggressive sliding scale was used.
Medications on Admission:
- B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
- Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
- Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
- Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
- Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
- Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
- Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
- Lyrica 25 mg Qday
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
8. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO qday ().
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
11. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 1 days.
Disp:*1 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Hyperkalemia
2. End-stage renal disease
3. Pneu
Secondary:
1. Coronary artery disease
2. Diabetes mellitus
Discharge Condition:
Hemodynamically stable, saturating well on room air.
Discharge Instructions:
You were admitted after having missed a dialysis session. As
you know, it is essential that you go to dialysis three times
weekly and that you continue to take all the medications, as
prescribed.
You should be sure to follow-up with Dr. [**Last Name (STitle) **] (appointment
below). In addition, you should call Dr.[**Name (NI) 3101**] office on
Tuesday to schedule an appointment for within one week.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 7209**] if your weight
increases by 3 lbs. You should also ddhere to a 2 gram/day
sodium diet.
Followup Instructions:
Please be sure to keep the following appointments:
1. [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2129-4-12**] 2:30
2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2129-4-14**] 9:30
3. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7217**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2129-4-20**] 8:00
In addition to the above, you should call Dr.[**Name (NI) 3101**] office on
Tuesday ([**Telephone/Fax (1) 4022**]) to schedule a follow-up for within the
week.
It will be very important for you to keep all dialysis
appointments. Your next scheduled dialysis is for Tuesday [**4-12**].
|
[
"414.00",
"250.40",
"428.30",
"427.89",
"425.4",
"V15.81",
"276.7",
"433.10",
"285.21",
"V45.81",
"443.9",
"428.0",
"403.91",
"585.6",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11805, 11811
|
7205, 10021
|
300, 308
|
11974, 12029
|
4072, 4731
|
12641, 13374
|
3032, 3097
|
10757, 11782
|
11832, 11953
|
10047, 10734
|
12053, 12618
|
3112, 4053
|
4748, 7182
|
228, 262
|
336, 1639
|
1661, 2773
|
2789, 3016
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,600
| 135,260
|
5545
|
Discharge summary
|
report
|
Admission Date: [**2113-6-14**] Discharge Date: [**2113-6-19**]
Date of Birth: [**2047-10-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
bronchoscopy
bronchial artery embolization
PA catheter placement
esophageal balloon placement
cardioversion
History of Present Illness:
65 y/o M w/CAD s/p CABG, GERD, HTN, PMR on steroids who
presented to [**Hospital 1474**] Hospital on [**2113-6-14**] c/o hemoptysis. For
past 2 days had been coughing up approximately 1-1.5 cups of
blood. At OSH, initial hct was 29.4 CT chest showed severe
centrilobular/preseptal emphysema, bilateral lower lobe
bronchiectasis, bilateral airspace consolidations in LUL, LLL,
RML, and RLL. Bronchoscopy showed main bronchi full of blood,
no no endobronchial lesions. Hct dropped to 23.6, increased to
27 after 2 units prbcs. He was given vitamin K 10 mg SQ and
hydrocortisone 100 mg, and transferred here for further eval.
Past Medical History:
1. GERD
2. HTN
3. Anxiety
4. CAD s/p CABG [**2106**]
5. Hypercholesterolemia
6. Interstitial lung disease
7. PMR on steroids
Social History:
lives with wife. + tobacco. Retired machinist.
Family History:
noncontributory
Physical Exam:
T: 96.8 P: 62 BP: 122/73 97%
Gen: intubated/sedated
HEENT: NCAT, plethoric face
Neck: supple
Lungs: CTA anterior lung fields
CV: RRR, no m/r/g
Abd: soft, nt/nd. +bs.
Ext: no c/c/e
Pertinent Results:
[**2113-6-14**] 07:28PM BLOOD WBC-12.5* RBC-3.18* Hgb-9.1* Hct-26.9*
MCV-85 MCH-28.8 MCHC-34.0 RDW-15.5 Plt Ct-302
[**2113-6-15**] 05:12AM BLOOD WBC-9.1 RBC-3.46* Hgb-9.8* Hct-29.1*
MCV-84 MCH-28.3 MCHC-33.6 RDW-15.1 Plt Ct-203
[**2113-6-19**] 04:55AM BLOOD Neuts-84* Bands-6* Lymphs-3* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-7* NRBC-1*
[**2113-6-19**] 04:55AM BLOOD PT-18.4* PTT-33.2 INR(PT)-2.3
[**2113-6-19**] 08:23AM BLOOD FDP-40-80
[**2113-6-19**] 04:55AM BLOOD Fibrino-524*
[**2113-6-18**] 10:40PM BLOOD Glucose-272* UreaN-38* Creat-2.1*# Na-138
K-4.8 Cl-101 HCO3-25 AnGap-17
[**2113-6-18**] 08:00AM BLOOD Glucose-151* UreaN-24* Creat-1.0 Na-144
K-4.4 Cl-109* HCO3-28 AnGap-11
[**2113-6-18**] 04:15AM BLOOD Glucose-142* UreaN-22* Creat-1.0 Na-146*
K-3.9 Cl-109* HCO3-29 AnGap-12
[**2113-6-17**] 04:05AM BLOOD Glucose-133* UreaN-24* Creat-1.2 Na-145
K-3.7 Cl-108 HCO3-25 AnGap-16
[**2113-6-16**] 03:05AM BLOOD Glucose-114* UreaN-18 Creat-1.1 Na-145
K-4.0 Cl-108 HCO3-28 AnGap-13
[**2113-6-14**] 07:28PM BLOOD CK(CPK)-134
[**2113-6-14**] 07:28PM BLOOD CK-MB-3 cTropnT-0.01
[**2113-6-15**] 05:12AM BLOOD ANCA-POSITIVE
[**2113-6-19**] 10:41AM BLOOD Type-ART Temp-37.1 pO2-50* pCO2-69*
pH-7.19* calHCO3-28 Base XS--3
[**2113-6-19**] 06:19AM BLOOD Type-ART Temp-36.7 Rates-40/ Tidal V-550
PEEP-15 FiO2-100 pO2-49* pCO2-69* pH-7.21* calHCO3-29 Base XS--2
AADO2-603 REQ O2-98 Intubat-INTUBATED
[**2113-6-19**] 05:01AM BLOOD Type-ART Temp-37.1 Rates-46/ Tidal V-550
PEEP-12 FiO2-100 pO2-50* pCO2-64* pH-7.22* calHCO3-28 Base XS--2
AADO2-607 REQ O2-98 -ASSIST/CON Intubat-INTUBATED
[**2113-6-14**] 08:40PM BLOOD Type-ART Temp-36.7 Rates-22/0 Tidal V-700
PEEP-10 FiO2-100 pO2-96 pCO2-44 pH-7.38 calHCO3-27 Base XS-0
AADO2-591 REQ O2-95 -ASSIST/CON Intubat-INTUBATED
[**2113-6-15**] 04:39PM BLOOD Lactate-0.9
[**2113-6-14**] 08:40PM BLOOD Lactate-1.4 K-4.2
[**2113-6-19**] 10:41AM BLOOD Hgb-9.8* calcHCT-29 O2 Sat-77
Chest CTA [**6-15**]: CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS
CONTRAST: There are multiple lymph nodes seen within the
anterior mediastinum, specifically the pretracheal region,
aortopulmonary window, and prevascular spaces. No axillary or
hilar lymphadenopathy is identified. There are bilateral
alveolar air-space opacities located primarily centrally,
however, there are also some dependent areas that are also
opacified. While this patient has a history of pulmonary
hemorrhage, the central distribution and symmetrical pattern of
these opacities is more typical of ARDS or diffuse pneumonia.
There is no focal source of bleeding identified. These airspace
opacities are superimposed on an interstitial lung disease
displaying thickened septae and mild diffuse areas of
bronchiectasis. The airways are patent to the subsegmental
bronchi bilaterally. Coils are seen adjacent to the right main
bronchus, presumably from the patient's recent angiography
procedure. The patient is intubated, and an NG tube is seen
coursing into the stomach, terminating in the gastric antrum.
The visualized lung, spleen, and pancreas are unremarkable. No
dissection within the aorta or pulmonary embolus within the
pulmonary artery is identified.
IMPRESSION:
1. Bilateral, central, primarily symmetrical air-space opacity
with some dependent component which is most likely pulmonary
hemorrhage with a possible ARDS or diffuse pneumonia component.
This process is superimposed on a background of interstitial
lung disease as seen on the prior CT.
2. Coils seen adjacent to the right main bronchus, as patient is
status post pulmonary angiography procedure. No focal source of
bleeding identified on the CT scan
Pulmonary angio:Bronchial artery embolization of second and
third order branches off the right bronchial artery to the right
upper and middle lobes, embolized with coils.
Brief Hospital Course:
He was admitted to the MICU and placed on antibiotics for
pneumonia. It was felt that his hemoptysis was due to his
bronchiectasis and interstitial lung disease. The morning after
admission, he began having spontaneous bleeding into the ETT.
He had a bronchoscopy that demonstrated bleeding from the RUL
and RLL. He was taken to IR and underwent embolization of 2nd
and 3rd order branches of the R bronchial artery. He developed
ARDS. He was paralyzed to minimize the possibility of coughing
episodes that would cause subsequent bleeding. An esophageal
balloon was placed to monitor transpulmonary pressure. He
remained hypoxemic. He underwent 2 subsequent bronchoscopies on
[**6-17**] and [**6-18**] which revealed thick secretions with blood, but no
active bleeding. He then developed afib with RVR and
hypotension. He was cardioverted with transient response to
NSR. Amiodarone was loaded and he was cardioverted again, this
time staying in NSR. He had a PA catheter placed to further
evaluate his hypotension, which revealed RV pressures 49/17, PA
pressures 57/39, and wedge 22. SVR 450, CO 4.5. He developed
SQ air felt secondary to barotrauma, so his PEEP was decreased.
CXR did not demonstrate tension ptx. Because of worsening
hypoxemia, he was proned, with mild improvement. He developed
ARF, creatinine went from 1.0 to 2.3. On [**6-19**], a family meeting
was held regarding goals of care given his overwhelming
respiratory failure. His fiance agreed that he would want to be
kept comfortable. He was made CMO, and died one hour later with
his family by his side.
Medications on Admission:
atenolol
zetia
protonix
prednisone
alprazolam
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
bronchiectasis
ARDS
renal failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"530.81",
"272.0",
"286.9",
"584.9",
"785.59",
"V45.81",
"995.92",
"276.5",
"414.00",
"786.3",
"401.9",
"518.81",
"427.31",
"515",
"280.0",
"V58.65",
"725",
"038.9",
"494.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"33.24",
"89.64",
"88.44",
"96.72",
"00.17",
"39.79",
"99.29",
"99.61",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
7097, 7106
|
5376, 6972
|
325, 434
|
7183, 7192
|
1559, 5353
|
7245, 7252
|
1322, 1339
|
7068, 7074
|
7127, 7162
|
6998, 7045
|
7216, 7222
|
1354, 1540
|
275, 287
|
462, 1092
|
1114, 1240
|
1256, 1306
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,415
| 131,473
|
39344
|
Discharge summary
|
report
|
Admission Date: [**2117-11-22**] Discharge Date: [**2117-12-14**]
Date of Birth: [**2063-1-16**] Sex: F
Service: MEDICINE
Allergies:
Strawberry / Watermelon / [**Location (un) **] Peel Tincture,Sweet / Carrot
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
1. s/p central line placement
2. s/p intubation
3. s/p cardiac arrest, requiring compressions, shock
History of Present Illness:
This is a 54 year-old female with a history of metastatic renal
cell carcinoma who presented for high dose IL-2 biotherapy on
[**2116-11-22**] and transferred to the ICU for hypotension. The patient
was admitted on [**11-23**] and initiated on high dose IL-2. The
patient tolerated the treatment well with some nausea and
vomiting. On day 4 of treatment she developed [**Last Name (un) **] with Cr 1.8,
oliguria and metabolic acidosis that was repleted with IV bicarb
gtt. The patent's IL-2 was stopped on [**2116-11-26**] in the afternoon
(1600) due to fatigue and lethargy. Her renal function
continued to increase to 2.7 the following day. Her blood
pressures ranged SBP 90's during this period of time.
.
On [**2117-11-27**] SBP remained in the 90's, but drifted down to the 70's
by the afternoon. She was given 250cc IVF boluses x2 and
started on dopamine 4mcg/kg/min to maintain SBP in the 90's.
The patient was having frequent PVC and one 9 run beat of V-tach
and so was given an additional 250cc IVF bolus x3. A second
pressor, phenylephrine 1mcg/kg/min, was added to try and
decrease her dopamine to reduce the number of PVC.
Additionally, blood cultures and 1g of vancomycin was hanging at
the time of admission.
.
On arrival the patient denied F/C/N/V/D/abdominal pain or other
complaints.
.
ROS: The patient denies any fevers, chills, weight change,
abdominal pain, diarrhea, constipation, melena, hematochezia,
chest pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
Metastatic RCCA
-- [**2117-7-28**] revealed metastatic RCC clear cell origin
-- CT showed b/l pulmonary nodules
-- Right nephrectomy [**2117-9-6**]
-- right forearm mass resected on [**2117-10-26**]
-- left clavicle soft tissue mass
HTN
Parathyroid Adenoma
Hyperlipidemia
Anxiety
Internal Hemorrhoids
Social History:
Married and lives with her husband in [**Name (NI) **]. She has 2
daughters, 16 and 19yo. No smoking, occasional EtOH. No IVDU
Family History:
non-contributory
Physical Exam:
On Admission:
GEN: ill appearing, somnlent, but easily arousable
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM with dried blood and mucositis
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
CHEST: left clavicle soft tissue mass 5cm, Right SC CVL
COR: RRR, no M/G/R, normal S1 S2
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: awake, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
DISCHARGE PHYSICAL EXAMINATION:
VS: Tm 98.2 Tc 98 BP 98/58 range (83-98)/(53-62) HR 80 range
63-86 RR 18 100%RA Wt 61.2kg (61.38 yest)
8H --/800
24H [**Telephone/Fax (1) 86992**]+ not saved, BMx1 loose brown, guaiac neg
GENERAL: pleasant female, lying down in bed, appears fatigued,
but otherwise NAD
HEENT: dry MM, anicteric, oropharynx clear
NECK: Supple, no appreciable elevation of JVP
CARDIAC: RRR, +S1, S2, soft II/VI systolic murmur appreciated at
LUSB, unable to appreciate radiation
LUNGS: unlabored resp, diminished at bases
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: warm, dry, no edema
SKIN: small abrasion on medial border of left breast, scab now
gone
NEURO: oriented x3
PULSES: 2+ DP bilaterally
Pertinent Results:
ADMISSION LABS:
[**2117-11-22**] 10:08AM WBC-13.5* RBC-3.94* HGB-8.8* HCT-28.9*
MCV-73* MCH-22.2* MCHC-30.4* RDW-16.1*
[**2117-11-22**] 10:08AM PLT COUNT-990*
[**2117-11-22**] 09:00AM GLUCOSE-142* UREA N-18 CREAT-0.9 SODIUM-139
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-28 ANION GAP-17
[**2117-11-22**] 09:00AM ALBUMIN-3.3* CALCIUM-9.3 PHOSPHATE-2.7
MAGNESIUM-2.1
[**2117-11-22**] 09:00AM PT-14.9* PTT-38.8* INR(PT)-1.3*
[**2117-11-22**] 09:00AM ALT(SGPT)-49* AST(SGOT)-40 CK(CPK)-23* TOT
BILI-0.2
.
DISCHARGE LABS:
[**2117-12-14**]:
Na 142 K 4.2 Cl 103 HCO3 28 BUN 20 Cr 1.1 Gluc 89
Mg 1.8
WBC 9.4 Hgb 7.6 Hct 24.6 Plt 620
.
Micro:
MRSA SCREEN (Final [**2117-11-24**]): No MRSA isolated.
.
[**2117-12-1**] 3:14 pm CATHETER TIP-IV Source: TLCL.
**FINAL REPORT [**2117-12-3**]**
WOUND CULTURE (Final [**2117-12-3**]): No significant growth.
.
[**2117-11-28**] 12:53 am URINE Source: Catheter.
**FINAL REPORT [**2117-11-29**]**
URINE CULTURE (Final [**2117-11-29**]): NO GROWTH.
.
[**2117-12-5**] 9:21 am URINE Source: Catheter.
**FINAL REPORT [**2117-12-6**]**
URINE CULTURE (Final [**2117-12-6**]):
YEAST. >100,000 ORGANISMS/ML..
.
Blood Culture, Routine (Final [**2117-12-9**]): NO GROWTH.
.
[**2117-12-6**] 10:44 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2117-12-8**]**
GRAM STAIN (Final [**2117-12-6**]):
[**9-13**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2117-12-8**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
URINE CULTURE [**2117-12-11**]:
[**2117-12-11**] 12:22 pm URINE Source: Catheter.
URINE CULTURE (Preliminary):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
URINE CULTURE [**2117-12-12**]: URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.
.
BLOOD CULTURE [**2117-12-13**]: PENDING
.
ECG: low voltages, sinus rhythm 58 bpm, normal axis, QTc 457,
<1mm ST elevation in III, aVF in the setting of low voltages.
.
TTE: [**12-3**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. At least mild (1+) mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes and low normal left ventricular systolic function.
At least mild mitral regurgitation with normal valve morphology.
.
CHEST (PORTABLE AP)
Final Report
REASON FOR EXAMINATION: Evaluation of the patient after
interleukin treatment due to renal cell cancer with hypotension.
Portable AP chest radiograph was compared to [**2117-11-22**].
Current study demonstrates interval development of bilateral
perihilar
interstitial process consistent with pulmonary edema. Bibasal
opacities are most likely representing part of this process.
Right central venous line tip is at the level of cavoatrial
junction.
Cardiomediastinal silhouette is unremarkable given the low lung
volumes and portable technique, but note is made of the
distension of the azygos vein that might be in part due to
volume overload.
.
TTE [**12-9**]
Left ventricular wall thicknesses and cavity size are normal.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the basal to mid septum and anterior wall.
Right ventricular chamber size is normal with mild global free
wall hypokinesis. The diameters of aorta at the sinus, ascending
and arch levels are normal. The 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. An eccentric, posteriorly directed jet of moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2117-12-3**],
the current study has better image quality and is more complete.
Left ventricular systolic function is probably slightly better.
The right ventricle appears mildly hypokinetic on the current
study (RV not well seen on prior). The degree of mitral
regurgitation has increased.
.
CXR [**12-11**]:
FINDINGS: As compared to the previous radiograph, the right PICC
line is in unchanged position, but the left internal jugular
vein catheter has been removed. There is unchanged opacity with
air bronchograms at both lung bases, right more than left,
associated with minimal pleural effusions. No newly occurred
focal parenchymal opacity. No change in size of the cardiac
silhouette.
Brief Hospital Course:
54 year-old female with a history of metastatic renal cell
carcinoma who presented for high dose IL-2 biotherapy on [**2116-11-22**]
and transferred to the ICU for hypotension.
.
# Hypotension: Likely secondary to IL-2 induced myocarditis as
well as IL-2 therapy itself. Regarding IL-2, treatment was
stopped on [**2116-11-26**] due to lethargy and fatigue. She required
pressor support on night of transfer to [**Hospital Unit Name 153**]. She was initially
placed on dopamine that improved her pressures, however due to
increasing ectopy Neo was added to try and decrease her
dopamine. On night of transfer patient broadly covered with
vanc/cefepime. Infectious work-up was unrevealing and
antibiotics discontinued. An echo was ordered, which was without
sign of pericardial effusion. Hypotension improved shortly after
arrival to [**Hospital Unit Name 153**].
She was transferred to the cardiology service after
stabilization in the ICU. She continued to have hypotension on
day 1 on the floors to systolic 80s, asymptomatic. The
carvedilol started in the ICU for CHF, was discontinued given
continued hypotension. She was bolused with gentle 500cc, and
her hypotension resolved. She was instructed to follow-up with
cardiology further regarding starting beta blockade an an
outpatient. Blood cultures were sent given continued
hypotension, and were pending at the time of discharge. She was
afebrile, and had no other symptoms consistent with SIRS.
.
# IL-2 induced myocarditis/Ventricular Tachycardia: Troponin
peaking to 14.9 on [**11-30**]. Myocarditis treated with supportive
care as unable to give to NSAIDS in setting of [**Last Name (un) **]. Cards
consulted as patient seen to have increasing ectopy as well as
runs of ventricular tachycardia on [**11-29**]. Amio loaded and
infusion started on [**11-29**]. Patient transitioned to PO amio on
[**11-30**]. She was doing well on the [**Hospital1 **] until [**12-3**] when Code Blue
was called whereupon the patient developed unstable VT
(monomorphic with 1 short period of polymorphic), chest
compressions were initiated, shock and 1 mg epinephrine then
rhythm converted to VF, patient was re-shocked and regained
pulse. Patient was conversant and transferred to [**Hospital Unit Name 153**]. On
arrival patient noted to be hypotensive and hypoxic - sterile
femoral line was placed and patient was intubated and started on
phenylephrine. During peri-intubation period, the patient went
in and out of unstable monomorphic VT and required 1 further
shock. Patient was given an IV Amiodarone bolus and started on
an infusion with direction of cardiology. She was aggressively
diuresed while intubated and IV amiodarone infusion was
continued at a low rate. Her post arrest echo showed global left
ventricular systolic function which was more depressed with
similar regional distribution. Patient was transitioned to PO
amiodarone. Patient transferred to cardiology service on [**12-12**].
On the cardiology service, she was continued on Amiodarone 400mg
[**Hospital1 **] per loading. She was discharged to continue Amiodarone 400mg
[**Hospital1 **] for 2 weeks, then 400mg daily for one week, and subsequently
200mg daily thereafter. She was monitored on telemetry without
events. She was completely chest pain free, and without
shortness of breath or palpitations on the day of discharge.
.
# Acute systolic heart failure: As above, she developed a IL-2
induced myocarditis, and subsequent acute systolic heart
failure. TTE on [**12-3**] demonstrated depressed systolic function.
Repeat TTE on [**2117-12-9**] showed slightly improved function. She was
started on carvedilol in the ICU. However, on transfer to the
cardiology service, this was discontinued given hypotension. She
was diuresed in the ICU, and on transfer to cardiology, she
appeared euvolemic. No further diuresis was initiated.
She will need to follow-up with Cardiology, and have repeat TTE
in ~1month to assess for improvement of systolic heart failure.
Beta blockade was not continued on discharge given hypotension.
She will discuss this further with cardiology and PCP. [**Name10 (NameIs) 8213**] was
also considered, but again, this was held given hypotension.
.
#. [**Last Name (un) **]: Began in the ICU, and attributed to IL-2. Her meds
renally doses. Her creatinine steadily improved, and was 1.1 on
discharge.
.
# Metastatic RCC: She initially presented for initiation of IL-2
therapy. However, as above, she had a complicated course. This
was discontinued. She was instructed to follow-up further with
her Oncologist for discussion of further management.
She was evaluated by PT for deconditioning. They recommended
acute rehab for improved functional status.
She will follow-up with oncology as an outpatient for further
management.
.
#. Metabolic Acidosis: Likely secondary to IL-2 treatment and
associated diarrhea. She has been given bicarb and has trended
back to 22. Bicarb trended. Patient received 2amps of HCO3 on
morning of [**11-30**]. This resolved prior to transfer to the
cardiology service.
.
#.Transaminitis: Seen in the ICU. Per the ICU team, did not
appear to be an obstructive picture. Likely IL-2 induced but
likely compounded by hypotension s/p infusion. LFTs downtrended
on transfer to cardiology service. Crestor was held given
transaminitis. She was instructed not to continue this
medication until further discussion with her PCP.
.
#.Coags: On admission to the [**Hospital Unit Name 153**]. INR 1.4. Likely due to IL-2.
Labs negative for DIC. Coags trended, and were normal on
transfer to the cardiology service.
.
# Anemia: Hct 28.9 on admission. She had no signs or symptoms of
bleeding. Iron studies showed elevated ferritin and low TIBC,
suggestive of ACD. Her hematocrit remained stable. Her stools
were guaiac negative. On discharge, she was instructed to have
labs in the next 1-2 days to ensure hematocrit was not falling.
She will need to follow-up as an outpatient for monitoring.
.
# UTI: Urine culture from [**2117-12-12**] grew Klebsiella. She was
started on Ceftriaxone, and discharged on Cefpodoxime, to
continue for 10 day course for complicated UTI. A repeat Urine
culture from [**2117-12-13**] was preliminarily read as gm negative rods,
with final culture pending at the time of discharge.
.
# Elevated TSH: TSH was checked in the ICU, and found to be 13.
Given checked in the setting of acute illness, the importance is
of unclear significance. She should follow-up as an outpatient
with repeat TFT's.
.
# Code Status: Confirmed full with patient and husband during
this admission.
.
STUDIES/LABS PENDING AT TIME OF DISCHARGE:
1. Blood cultures sent [**2117-12-13**]
2. Final Urine culture [**2117-12-13**] (prelim GNR's)
.
FOLLOW-UP NEEDED:
1. Oncology, Dr. [**Last Name (STitle) 1729**]
2. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8671**]
3. Dr.[**Doctor Last Name 3733**]
**Will need repeat TTE in ~1month to assess for improvement of
systolic heart failure
Medications on Admission:
Alprazolam 0.25mg qhs prn
Vit D 50,000U
Crestor 30mg daily
Zoloft 75mg daily
Colace 100mg [**Hospital1 **] prn
Discharge Medications:
1. sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for Insomnia.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. amiodarone 200 mg Tablet Sig: As directed Tablet PO As
directed below: Take Amiodarone 2 tablets 200mg by mouth twice
daily from now until [**2117-12-22**]
Then take Amiodarone 2 tablets 200mg by mouth once daily from
[**Date range (1) 86993**]
Then take Amiodarone 1 tablet 200mg daily from [**2118-1-6**] onward,
indefinitely
.
Disp:*60 Tablet(s)* Refills:*2*
5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
Disp:*1 tube* Refills:*0*
6. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
7. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital
Discharge Diagnosis:
Primary Diagnoses:
1. Metastatic renal cell carcinoma, s/p C1W1 IL-2 therapy
2. Myocarditis, secondary to IL-2 therapy
3. Cardiac arrest
4. Acute renal failure
5. Acute systolic congestive heart failure
6. Hypotension
7. Urinary tract infection
Secondary Diagnoses:
1. Depression
2. Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted for initiation of IL-2 therapy for renal cell
cancer. This admission was complicated by IL-2 toxicity,
resulting in myocarditis. You also had an abnormal heart rhythm,
requiring cardiac resuscitation. Your blood pressure was also
transienttly low. You were started on medication to help control
your heart rate from going into an abnormal rhythm.
The following medications were changed during this admission:
STOP Crestor 30mg by mouth daily
START Cefpodoxime 100mg by mouth twice daily for 7 more days
START Amiodarone per the following schedule:
Take Amiodarone 400mg by mouth twice daily from now until [**2117-12-22**]
Then take Amiodarone 400mg by mouth once daily from
[**Date range (3) 86993**]
Then take Amiodarone 200mg daily from [**2118-1-6**] onward,
indefinitely
**Please discuss with your doctor starting a medication called
Metoprolol. We had you on another medication called Coreg while
you were here. However, given low blood pressure this was
stopped. Metoprolol is a similar medication, and beneficial in
heart failure.
**You should also discuss starting a medication called an ACE
inhibitor. This medication is also beneficial in heart failure.
**Your hematocrit has been low, which means that you have
anemia. You had no signs of bleeding. We think this is largely
due to your renal cancer and inflammation. Please have the
doctors [**Name5 (PTitle) 4169**] this [**Name5 (PTitle) 78297**] at rehabilitation to ensure it
does not drop.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with the following appointments:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8671**] when you leave acute
rehabilitation to schedule an appointment in the next couple of
weeks.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Location: [**Hospital3 **] HEALTHCARE AT [**Hospital1 **]
Address: [**Apartment Address(1) 86994**], [**Hospital1 **],[**Numeric Identifier 26419**]
Phone: [**Telephone/Fax (1) 86995**]
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2118-1-4**] at 3:00 PM
With: [**First Name8 (NamePattern2) 20062**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2118-1-4**] at 3:00 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
***Your oncologist, Dr. [**Last Name (STitle) 1729**], [**First Name3 (LF) **] contact you later this week
to set up an earlier appointment.
Department: CARDIAC SERVICES
When: TUESDAY [**2118-1-18**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Return to [**Hospital 29684**] clinic on [**2118-1-4**] for CT scans and clinic
visit
**You will need a repeat echocardiogram in ~1month to assess for
improvement in your heart failure.
Completed by:[**2117-12-14**]
|
[
"599.0",
"584.9",
"197.0",
"528.00",
"518.0",
"790.4",
"238.71",
"275.2",
"272.4",
"422.93",
"401.9",
"427.1",
"427.31",
"198.89",
"189.0",
"428.21",
"780.52",
"V58.12",
"286.9",
"300.4",
"041.3",
"785.51",
"518.81",
"276.2",
"428.0",
"285.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"96.6",
"96.04",
"38.91",
"00.15"
] |
icd9pcs
|
[
[
[]
]
] |
18118, 18169
|
10006, 16971
|
350, 453
|
18503, 18503
|
4112, 4112
|
20313, 22096
|
2617, 2635
|
17133, 18095
|
18190, 18435
|
16997, 17110
|
18686, 20290
|
4634, 6039
|
2650, 2650
|
18456, 18482
|
3399, 4093
|
299, 312
|
6779, 9983
|
481, 2131
|
4128, 4618
|
2664, 3377
|
18518, 18662
|
2153, 2456
|
2472, 2601
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,815
| 195,297
|
54417
|
Discharge summary
|
report
|
Admission Date: [**2106-6-9**] Discharge Date: [**2106-6-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Mental status changes, UGIB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 83 yo F with a past medical history significant for
critical AS/3VD CAD, CHF, HTN and a recent history of steadily
worsening mental status and confusion in the setting of
underlying dementia, who came to the ED with complaints of
worsening mental status and diarrhea. She was found to be
afebrile, with labs notable for a leukocytosis to 24,000, acute
on chronic renal failure with a creatinine of 2.1 (baseline
1.5-1.7), and hyperkalemia to 6.0. She was also noted to have
guaiac positive stool and a Hct of 25 (baseline low 30's since
[**Month (only) 956**]).
.
Of note, she has had multiple ED visits and admissions since
[**Month (only) 956**] for CHF exacerbations, increasing confusion and once
for GIB.
Her most recent visit to the ED was on [**2106-5-20**] with complaints
of confusion, and was treated empirically based on evidence of
possible RLL infiltrate on CXR for pneumonia with a 7 day course
of levofloxacin. In [**12-30**], her GIB was found to be due to
gastritis and angioectasias in the gastric mucosa, and she was
recommended to start carafate QID and protonix [**Hospital1 **].
.
In the ED, she was hemodynamically stable and remained afebrile.
She was given kayexalate x 1 and calcium gluconate x 1 for her
hyperkalemia, was given a ppi for GIB and NG lavage was negative
x 2. She was also seen by GI consult who recommended likely EGD
in 24 hours. She was given 1 unit of packed red cells for her
Hct of 25, as well as 1 dose of vanco/zosyn for the
leukocytosis, empirically. She was admitted to the [**Hospital Unit Name 153**] for
further management of her GIB.
.
The patient denied chest pain, shortness of breath, and
abdominal pain. She was admitted to the medical floor for
further evaluation.
Past Medical History:
HTN
Hyperlipidemia
Gallstone pancreatitis s/p CCY
s/p appy
CKD 1.5
CHF diastolic dysfx
CAD: Cath last admit with 100% proximal RCA, 20% LMain, 70% mid
LAD, 95%OM1
Last TTE: AS .7 cm2, 2+ MR, TR, AR, E/A 1.13
Social History:
Married with 4 children, Housewife. 10 pack year h/o smoking
(quit several years ago), occ. alcohol, no illicit drugs. Taken
care of by caretakers. Not in contact with children, per night
caretaker present.
Family History:
Non-contributory
Physical Exam:
Vitals: 97 66 114/53 18 100% ra
General: Thin 83 yo F appearing younger than stated age, NAD
HEENT: AT/NC, PERRL, EOMI, anicteric sclerae. OP clear, MM
mildly dry.
Neck: supple, carotid pulse parvus et tardus
Chest: RRR harsh IV/VI SEM radiating to neck and across
precordium
Lungs: CTAB no w/r/r
Abdomen: soft, NT/ND +BS
Ext: warm and well perfused, good distal pulses
Neuro: nonfocal, patient is A&Ox2, intermittently confused
Skin: warm, no jaundice/rashes.
Pertinent Results:
Admission labs:
[**2106-6-8**] 10:30AM WBC-22.2*# RBC-3.39* HGB-8.0* HCT-26.9*
MCV-79* MCH-23.6* MCHC-29.8*# RDW-19.7*
[**2106-6-8**] 10:30AM UREA N-70* CREAT-1.9* SODIUM-138
POTASSIUM-5.5* CHLORIDE-100 TOTAL CO2-20* ANION GAP-24*
[**2106-6-8**] 10:30AM ALT(SGPT)-18 AST(SGOT)-20 CK(CPK)-36
[**2106-6-8**] 10:30AM CALCIUM-9.0 CHOLEST-171
[**2106-6-8**] 10:30AM TRIGLYCER-122 HDL CHOL-41 CHOL/HDL-4.2
LDL(CALC)-106
[**2106-6-9**] 11:50AM WBC-21.9* RBC-3.36* HGB-7.9* HCT-24.9*
MCV-74* MCH-23.6* MCHC-31.9 RDW-19.6*
[**2106-6-9**] 11:50AM NEUTS-34* BANDS-0 LYMPHS-57* MONOS-8 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2106-6-9**] 11:50AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL BURR-OCCASIONAL
[**2106-6-8**] 10:30AM GLUCOSE-115*
[**2106-6-8**] 10:30AM UREA N-70* CREAT-1.9* SODIUM-138
POTASSIUM-5.5* CHLORIDE-100 TOTAL CO2-20* ANION GAP-24*
[**2106-6-8**] 10:30AM ALT(SGPT)-18 AST(SGOT)-20 CK(CPK)-36
[**2106-6-8**] 10:30AM CALCIUM-9.0 CHOLEST-171
Brief Hospital Course:
A/P: 83 yo F with history of critical AS, 3VD CAD, HTN, CHF, GIB
and progressive dementia over several months presents with slow
GIB and leukocytosis.
.
1. GIB: Patient has a history of angioectasias and gastritis
which has caused a hct drop, req. hospitalization in [**Month (only) 956**].
She received 3 units of PRBCs and her HCT remained stable at 34
(admission HCT of 24.9) for 4 consecutive days. She remained
hemodynamically stable with SBP in 110s and her BP regimen was
slowly added back. GI consult service was involved during
admission and given her stablized hematocrit it was felt she
could be discharged with protonix twice daily, sucralfate and
follow up with GI as an outpatient. There was no acute need for
endoscopy during this hospitalization.
.
2. Pleural effusion/pulmonary edema on CXR, [**12-25**] volume
resuscitation with 3 units of PRBCs with h/o severe AS and CHF.
After she was volume resuscitated she was given her home lasix
dose of 40mg po daily and was weaned off of supplemental oxygen.
3. Leukocytosis: Patient had a significant leukocytosis, but no
left shift, and a predominance of lymphs, with an absolute
lymphocyte count of 12,500 on admission. This trended down
throughout the hospitalization and no infectious etiology was
found. Patient remained afebrile and required no antibiotics
during her stay. Urine and blood cultures were negative and she
had one c. diff that was negative as well. The patient
initially presented with diarrhea but had no episodes while
hospitalized. Her caretakers were [**Name2 (NI) 111387**] to call her PCP if
she developed any fevers, cough, or urinary complaints once
discharged.
5. Acute on Chronic Renal Failure: Patient's baseline Cr is
1.5-1.7. She seems to be mildly elevated to 2.1 on admission and
with hydration her Cr returned to 1.3 on the day of discharge.
Meds were initially renally dosed and her electrolytes remained
stable during her stay.
6. Cardiac: Given her initial presentation of low hct with a GI
bleed her ASA was held on admission and she will not be
discharged on this medication. Her caretakers were informed
that she will need to follow up with her PCP in the future. The
beta blocker was initially held given her bleed and was added
back at a lower dose of Toprol xl 50mg po daily. This may need
to be titrated up as an outpatient.
7. Dementia: Patient has underlying history of dementia, with
reports
of worsening over the last several months. Given her mental
status all benadryl and benzo's were held to prevent further
exaccerbation.
Medications on Admission:
Lasix 40mg QD
Lisinopril 10mg QD
Prilosec 40mg QD
Zocor 40mg QD
Aspirin 325mg QD
Toprol XL 100 QD
Colace 200mg Qd
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Name2 (NI) **]:*80 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Name2 (NI) **]:*30 Tablet(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
[**Name2 (NI) **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
acute blood loss, anemia secondary to gastritis
Discharge Condition:
Stable
Discharge Instructions:
Patient to go home with 24 hour caretakers. She should return
to the ER if she develops any lightheadedness, blood in her
stool or fainting.
Followup Instructions:
She will follow up with GI on Monday [**6-21**] at 8AM on [**Hospital Ward Name 452**] 1.
|
[
"585.9",
"584.9",
"414.01",
"428.32",
"424.1",
"535.51",
"285.1",
"272.4",
"276.7",
"403.90",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7730, 7736
|
4130, 6686
|
289, 295
|
7828, 7837
|
3051, 3051
|
8027, 8120
|
2532, 2551
|
6850, 7707
|
7757, 7807
|
6712, 6827
|
7861, 8004
|
2566, 3032
|
222, 251
|
323, 2061
|
3067, 4107
|
2083, 2292
|
2308, 2516
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,996
| 172,521
|
10355
|
Discharge summary
|
report
|
Admission Date: [**2179-2-21**] Discharge Date: [**2179-2-27**]
Date of Birth: [**2093-3-24**] Sex: M
Service: MEDICINE
Allergies:
Bactroban Nasal
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug eluting stent to the obtuse
marginal graft.
History of Present Illness:
Patient is an 85 yo m c CAD s/p CABG (3VD [**2162**]), HTN, HLD, DMII,
aortic aneursym s/o repair, pulmonary fibrosis, asbestosis,
right middle lobectomy, COPD/ asthma, on 2 L at home who
presented to [**Hospital1 1474**] Hosptital with 1 week of increased dyspnea
on exertion, shortness of breath, orthopnea, PND, increased LE
edema. He has some DOE at home but is normally able to walk
around his house with his cane or walker without developing
significant shortness of breath. Last night he states he was
unable to get comfortable. He could not find a position where he
could catch his breath and his wife called an ambulance at 2 am.
He had some pleuritic chest pain associated with the cough and
deep inspiration. He denies dull chest pain or pressure,
palpitations, nausea, vomiting, constipation, diarrhea. He has
also had productive cough over last week as well with
grey-tinged, non-bloody sputum. He has also been feeling very
fatigued. He denies muscle weakness or myalgias.
.
On review of systems, black stools or red stools, palpitations,
syncope or presyncope.
.
At the OSH, his CXR showed bilateral congestion. CT was negative
for PE. His exam was significant for bibasilar crackles and left
sided wheezes. He was treated for CHF and COPD exacerbation with
solumedrol 125 mg iv q8h, lasix iv x2, azithromycin, nebulizer
treatments. He had previously been on prednisone 10 mg po daily
at home for his COPD. His ECG showed new LBBB, high grade av
nodal dissocation, with junctional rhythm in the 60s. His labs
showed, initial trop of 0.12, which increased to 2.12. He was
started on ACS protocol with aspirin 325 mg po daily, metoprolol
5 mg iv q4h. VS on transfer 99.3, SBPs in 120s, RR: 20-30s, P:
109, 99% on 4L NC.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes II , + Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: [**2162**]
-PERCUTANEOUS CORONARY INTERVENTIONS: unknown
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Aortic aneursym s/o AneuRx modular stent graft system repair
[**2169-3-1**]
- Pulmonary fibrosis/ bronchiectasis s/p Right middle lobectomy
in [**2129**]
- Asbestosis
- Glaucoma
- COPD/ asthma, on 2 L at home
- Inguinal hernia repair in [**2137**].
- Hiatal hernia repair in [**2141**].
- Arthroscopy of right knee in [**2142**].
- Arthroscopy of left knee in [**2143**].
- Repair of congenital bladder neck defect in [**2136**].
- Excision of spermatocele in [**2163**].
- Laminectomy at L4 in [**2147**].
- Laminectomy at L5 in [**2148**].
- Appendectomy.
Social History:
-Tobacco history: quit 60 years ago
-ETOH: rare social occasions
-Illicit drugs: denies
Family History:
Mother died of MI
Physical Exam:
Admission:
VS: T=96.8, BP=130/77 HR=107 RR=34 O2 sat= 95% on 4L
GENERAL: elderly, ill appearing male in mild distress, somewhat
confused
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP to earlobe while sitting at 30 degress.
CARDIAC: tachycardic, irregular, difficult to appreciate heart
sounds [**1-20**] respirations
LUNGS: Resp were labored, with accessory muscle use. diffuse
fine crackles c/w fibrosis and decreased BS over RLL
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace edema, dopplerable pulses.
Discharge:
T: 99.0, BP: 124/81, P: 81, RR: 20, 94% on RA
Gen: alert, oriented, sitting in chair.
HEENT: whitish pink lesions on tounge/back of mouth, thrush
appearing
CV: irreg irreg rhythm, distant HS. Not able to appreciate
murmurs.
RESP:Resp unlabored, diffuse fine crackles c/w fibrosis and
Insp/exp wheezes.
ABD: soft, NT, pos BS, no guarding or rebound.
EXTR: warm, no edema
Extremeties: right Groin: small hematoma with no skin
discoloration, no bruit
Pulses:
Right: DP 2+ PT 1+
Left: DP 2+ PT 1+
Skin: skin tear left albow area
Pertinent Results:
Echo: [**2179-2-22**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis with thinning/akinnesis of the
basal inferior wall (LVEF = 25 %). The left ventricle is
visually dyssnchronous. No masses or thrombi are seen in the
left ventricle. The right ventricular cavity is mildly dilated
with moderate global free wall hypokinesis. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with severe global hypokineiss and basal inferior
akinesis/thinning c/w multivessel CAD or other diffuse process.
Pulmonary artery hypertension. Right ventricular cavity
enlargement with free wall hypokinesis. Mild mitral
regurgitation. Mild aortic regurgitation.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2174**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CXR [**2179-2-21**]:
FINDINGS: In comparison with the study of [**3-2**], there is
increased prominence of the diffuse interstitial markings. This
suggests some elevated pulmonary venous pressure, superimposed
on severe chronic pulmonary disease. The possibility of
superimposed infection would have to be considered in the
appropriate clinical setting.
CXR [**2179-2-24**]:
FINDINGS: In comparison with the study of [**2-21**], there is little
overall
change. Again there is diffuse prominence of interstitial
markings that most likely reflect elevated pulmonary venous
pressure superimposed on severe chronic pulmonary disease. The
possibility of supervening pneumonia would have to be considered
in the appropriate clinical setting. Blunting of the
costophrenic angles is consistent with some pleural fluid with
compressive basilar atelectasis.
Hematology:
[**2179-2-27**] 08:25AM BLOOD WBC-17.2* RBC-4.40* Hgb-13.2* Hct-41.5
MCV-94 MCH-30.0 MCHC-31.8 RDW-16.6* Plt Ct-436
[**2179-2-26**] 07:00AM BLOOD WBC-20.1* RBC-4.29* Hgb-12.7* Hct-40.0
MCV-93 MCH-29.6 MCHC-31.8 RDW-16.2* Plt Ct-353
[**2179-2-21**] 09:14PM BLOOD WBC-16.0*# RBC-3.91* Hgb-11.7* Hct-37.1*
MCV-95 MCH-30.0 MCHC-31.6 RDW-16.8* Plt Ct-502*#
[**2179-2-27**] 08:25AM BLOOD PT-14.3* INR(PT)-1.2*
[**2179-2-21**] 09:14PM BLOOD PT-18.8* PTT-69.1* INR(PT)-1.7*
Chemistries:
[**2179-2-26**] 07:00AM BLOOD Glucose-103* UreaN-30* Creat-0.9 Na-139
K-3.7 Cl-94* HCO3-37* AnGap-12
[**2179-2-21**] 09:14PM BLOOD Glucose-427* UreaN-33* Creat-1.1 Na-135
K-4.1 Cl-94* HCO3-27 AnGap-18
LFTS:
[**2179-2-27**] 08:25AM BLOOD ALT-492* AST-188*
[**2179-2-26**] 07:00AM BLOOD ALT-643* AST-223* AlkPhos-107
[**2179-2-25**] 07:05AM BLOOD ALT-872* AST-403* LD(LDH)-388*
AlkPhos-117 TotBili-1.2
[**2179-2-24**] 06:35AM BLOOD ALT-1239* AST-767* LD(LDH)-522*
CK(CPK)-87 AlkPhos-125 TotBili-1.0
[**2179-2-23**] 04:03AM BLOOD ALT-1793* AST-1750* LD(LDH)-849*
CK(CPK)-85 AlkPhos-143* TotBili-0.7
[**2179-2-21**] 09:14PM BLOOD ALT-579* AST-728* LD(LDH)-1396*
CK(CPK)-189 AlkPhos-112 TotBili-0.8
Cardiac Biomarkers:
[**2179-2-23**] 04:03AM BLOOD CK-MB-6 cTropnT-0.35*
[**2179-2-22**] 08:49PM BLOOD CK-MB-7 cTropnT-0.40*
[**2179-2-22**] 12:05PM BLOOD CK-MB-10 MB Indx-6.1* cTropnT-0.50*
[**2179-2-22**] 02:55AM BLOOD CK-MB-12* MB Indx-5.4 cTropnT-0.47*
[**2179-2-21**] 09:14PM BLOOD CK-MB-16* MB Indx-8.5* cTropnT-0.36*
proBNP-[**Numeric Identifier 34360**]*
Other Labs:
[**2179-2-23**] 04:03AM BLOOD calTIBC-216* Ferritn-[**2078**]* TRF-166*
[**2179-2-24**] 06:35AM BLOOD Triglyc-117 HDL-47 CHOL/HD-3.9
LDLcalc-113
[**2179-2-23**] 04:03AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2179-2-23**] 04:03AM BLOOD HCV Ab-NEGATIVE
ABG:
[**2179-2-21**] 08:39PM BLOOD Type-[**Last Name (un) **] pO2-80* pCO2-35 pH-7.48*
calTCO2-27 Base XS-2
[**2179-2-21**] 08:39PM BLOOD Glucose-417* Lactate-4.6* Na-133* K-3.8
Cl-95* calHCO3-25
Brief Hospital Course:
Patient is an 85 yo m c CAD s/p CABG (3VD [**2162**]), HTN, HLD, DMII,
pulmonary fibrosis, asbestosis, s/p right middle lobectomy,
COPD/ asthma (on 2 L at home) who presented to OSH with 1 week
of SOB thought to be secondary to new CHF with an EKG that
showed new LBBB and elevated cardiac enzymes transferred to
[**Hospital1 18**] per patient request for further management.
# CORONARIES: Patient has known CAD s/p CABG for 3VD in [**2162**] who
presented with progressive DOE, new LBBB on EKG and elevated
cardiac enzymes, consistent with acute coronary syndrome. He
initially had some pleuritic chest pain associated with cough,
deep inspiration but denied pain on exertion, palpitations,
chest pressure, SOB. His worsened shortness of breath may be his
angina equivalent. He was initially on a nitro drip which was
discontinued on [**2179-2-22**]. He was started on a heparin drip, given
aspirin 325 mg po daily, clopidigrel 600 mg po x1 and then
continued on 75 mg po daily and started on metoprolol 12.5 mg po
BID. Patient was not initially a good candidate for cardiac
catheterization given his severe CHF and inability to lie flat.
A cardiac catheterization was performed on [**2179-2-23**] and showed
that his native vessels were 100% occluded. SVG-RCA 100%
occluded. SVG-OM successfully stended with DES. LIMA-LAD patent,
diffuse distal LAD disease. He will need to remain on
clopidigrel 75 mg po daily and aspirin 325 mg po daily for at
least one year.
# PUMP: Patient had no history of CHF and his last echo in [**7-28**]
was normal with EF >55% but he been on lasix as an outpatient.
His elevated JVP, LE edema, crackles and pulm congestion seen on
CXR were consistent with acute CHF as well as his BNP elevated
to 30,000. His echo showed severe global hypokinesis and focal
apical hypokinesis with an EF of 25-30%. New/ worsened CHF may
have been [**1-20**] ACS. He was initially treated with boluses of
lasix 80 mg iv and then with boluses of lasix 120 iv. His
respiratory status improved with diuresis. He was discharged on
lasix 40 mg po daily.
# RHYTHM: Patient was in sinus tachy with PACS on EKG. He also
had av dissociation with junctional rhythm on EKG at OSH. He was
monitored on telemetry and his rhythm was sinus with
intermittent MAT.
#Pulmonary: Patient has several underlying comorbid lung
problems including pulmonary fibrosis, asbestosis,
bronchiectasis, COPD/ asthma and uses 2 L NC at home. He
normally sleeps on 2 pillows and has some DOE at baseline,
though now much worse. His clinical picture was most consistent
with CHF complicated by his underlying pulmonary pathology. He
was continued on azithromycin, albuterol, ipratroprium, and
mucomyst nebs.
#DMII: Patient is on glargine and humalog sliding scale at home.
His was initially given a 10 units of glargine for his bedtime
dose and this was increased back to his home dose of 14 units
when he was no longer NPO. However, he continued to have low
blood sugars and his glargine dose was decreased back to 10
units.
#Elevated LFTs: Patient had elevated AST/ALT on admission which
more than doubled by hospital day 2. This was thought most
likely to atorvastatin as he has had lab abnormalities with
rousuvastatin in the past. Atovastatin was discontinued and his
LFTs trended down.
# Leukocytosis: Was thought secondary to solumedrol and
prednisone though infectious etiology also possible. There was
no sign of pna on CXR and all cultures were negative.
Medications on Admission:
Brovana, pulmicort and acetylcysteine vials together in neb [**Hospital1 **]
Lumigan eye drops daily
Ambien 5 mg at HS
Fosamax 70 mg q week
Alphagan eye drops TID
Pulmicort 2 puffs daily
Vitamin C 500 mg po daily
Vitamin D3 1000 units daily
vitamin B6 25 mg daily
Aspirin 81 mg po daily
Spiriva 18 mcg inhaled daily
Potassium- 20 meq daily
Lasix 40 mg po BID four days a week, 60 mg po BID three times a
week
Omeprazole 40 mg po qAM and 20 mg po qPM
Mucinex 600 mg po BID
Ibuprofen 200 mg po QID prn pain
Tussionex prn
Prilosec 20 mg [**Hospital1 **]
Lantus 14 units at bedtime
Humalog 10 units with breakfast, sliding scale at lunch, 6 units
at dinner
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
3. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous [**Hospital1 **] (2 times a day).
4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
5. zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
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. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
9. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
10. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
11. Vitamin B-6 25 mg Tablet Sig: One (1) Tablet PO once a day.
12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
13. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
17. insulin lispro 100 unit/mL Solution Sig: 0-14 units
Subcutaneous four times a day: per sliding scale.
18. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day as needed for cough.
19. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
20. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for oral thrush for 7 days.
Disp:*150 ML(s)* Refills:*0*
21. Lumigan 0.03 % Drops Sig: One (1) drop both eyes Ophthalmic
once a day.
22. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
HOLD for SBP <100. Tablet(s)
23. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: Hold for SBP< 100, HR <60.
24. Outpatient Lab Work
Please check weekly electrolytes: Na, K, Cl, HCO3, BUN,
Creatinine.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34165**] - [**Location (un) 2498**]
Discharge Diagnosis:
Coronary artery disease/Non ST Elevation Myocardial Infarction
Diabetes Mellitus Type 2
Pulmonary fibrosis/COPD
Acute Systolic congestive Heart Failure
Transaminitis related to Statin Allergy
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:
Mr. [**Known lastname 1662**], you were short of breath and had swelling in your
legs and were found to have a heart attack. A cardiac
catheterization was performed on [**2-23**] which showed a blockage in
one of your bypass grafts that was opened and stented with a
drug eluting stent. You will need to take aspirin and plavix
every day for at least one year. This it to prevent the stents
from clotting off and causing another heart attack. Do not stop
taking Plavix or aspirin unless Dr. [**Last Name (STitle) 11679**] tells you to.
You were treated for a pneumonia with antibiotics. A cholesterol
medicine called Atorvastatin was started after your heart attack
but your liver function deteriorated and we stopped the medicine
because we think it caused the liver issues. You will need to
avoid any cholesterol medicines that are in the "statin" family.
You will be started on a medicine called Niaspan once your liver
function is back to normal.
You heart function is now weaker because of the heart attack.
You will need to take all of your medicines and eat a diet that
is low in salt (sodium). This will prevent fluid from building
up in your lungs. Weigh yourself every morning, call Dr. [**Last Name (STitle) 11679**]
if weight goes up more than 3 lbs in 1 day or 5 pounds in 3
days.
.
We made the following changes to your medicines:
1. Start taking Advair instead of Brovana and pulmocort
2. Decrease your long acting insulin to 10 units daily at night
3. Decrease Ambien to 2.5 mg to prevent oversedation
4. Increase aspirin to 325 mg daily
5. Start Plavix 75 mg daily to prevent the stent from clotting
off
6. Decrease Furosemide to 40 mg daily
7. Change omeprazole to pantoprazole daily
8. Start heparin injections to prevent a blood clot
9. Stop ibuprofen and Tussinex
10. Start Citalopram to help control your anxiety
11. Stopped prilosec
12. Stopped potassium supplementation- your dose will be
determined by daily labs
13. Started metoprolol 12.5 mg twice a day
14. Started lisinopril 2.5 mg once a day
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 26860**]
When: Tuesday, [**2179-3-9**]:15AM
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1105**]/PULMONARY
Address: [**Last Name (NamePattern1) 34361**], [**Hospital1 1474**], [**Numeric Identifier 34362**]
Phone: [**Telephone/Fax (1) 34363**]
When: Thursday, [**3-11**], 2:30PM
Department: VASCULAR SURGERY
When: MONDAY [**2179-5-3**] at 9:40 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2179-5-3**] at 9:00 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"790.4",
"486",
"493.20",
"414.01",
"288.60",
"494.0",
"410.71",
"416.8",
"V49.86",
"794.8",
"501",
"401.9",
"112.0",
"E942.2",
"428.0",
"428.21",
"250.00",
"V46.2",
"414.02",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"00.66",
"00.40",
"37.23",
"00.45",
"89.64",
"88.56",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
15010, 15089
|
8692, 12146
|
296, 376
|
15325, 15325
|
4247, 5387
|
17549, 18749
|
3050, 3070
|
12849, 14987
|
15110, 15304
|
12172, 12826
|
15501, 17526
|
3085, 4228
|
2252, 2335
|
5410, 8208
|
237, 258
|
404, 2139
|
15340, 15477
|
2366, 2927
|
2161, 2232
|
2943, 3034
|
8220, 8669
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,274
| 188,360
|
53060
|
Discharge summary
|
report
|
Admission Date: [**2165-8-2**] Discharge Date: [**2165-8-8**]
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
Cardiac Arrest
Major Surgical or Invasive Procedure:
Pacemaker Lead revision and ICD change: pt is pacer dependent.
Intubation s/p arrest on admission and during lead revision
History of Present Illness:
Mr. [**Known lastname 93843**] is a 84 yo male with a h/o CHF who is transferred
from [**Hospital **] Hospital after a witnessed cardiac arrest at home.
Per his family, he had just gone to dinner and was in his usual
state of health. His wife heard him fall to the ground and
found him minimally responsive. EMS was called. At the time of
EMS arrival, he was unresponsive, pulseless, with a HR 40. CPR
was initiated and he was paced externally. At one point, he had
a 90-second asystolic arrest. CPR was continued. He received
atropine and was intubated.
.
He arrived to the [**Hospital **] Hospital ER with a perfusing rhythm.
When EMS's leads were removed from the patient's chest, the
patient again became pulseless and bradycardic with a HR 20's.
His internal pacemaker did not initiate a rhythm. CPR was
reinitiated, and he received atropine 1 mg. External pacing
leads were reapplied and a perfusing rhythm was obained. BP was
100's/70's. Patient was noted to be agitated and moving all
extremities. He was later transiently hypotensive and was
briefly on a norepinephrine drip.
.
Cardiology consult was obtained in the [**Hospital **] Hospital ED and
his pacemaker was interrogated. It was concluded that the
pacemaker lead was fractured, which had lead to pacemaker
malfunction. He is being transferred to [**Hospital1 18**] for further
management.
.
On review of symptoms, patient's wife denies that he has any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She is
unaware of any recent fevers, chills or rigors, exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
1. Diabetes Type II, diet-controlled
2. CAD s/p 3 stents to the RCA [**2154**], stent to prox RCA, rPL in
[**2160**]
3. 2V CABG [**12-22**] with mitral valve repair (at OSH in [**State 108**])
4. Pacemaker placement [**2160**] for complete heart block
5. Pacemaker upgrade to biventricular ICD [**2162**] (in [**State 108**])
6. Hyperlipidemia
7. HTN
8. Prostate cancer s/p prostatectomy '[**44**] with complication
requring colostomy, reversed 3 months later
9. CHF w/ EF 20%
10. CRI, baseline Cr 1.6
11. Afib on coumadin
Social History:
Married, 3 children, lives in [**Location **], MA with wife and oldest
daughter. [**Name (NI) 3106**] veteran. Remote tob use, quit in [**2116**] or
[**2126**], previously 2 pks/wk x 30 yrs
Soc EtOH, no IVDA.
Family History:
Father who died of pancreatic CA at age 60
MOther with heart dz, passed away at 76
Brother with CAD, s/p PTCA in his 70s
Physical Exam:
VS: T 97, BP 127/75, HR 80, RR , O2 % on
Gen: frail elderly male, intubated or sedated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis.
Intubated, resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi. Decreased breath sounds at right
lung base.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: Trace non-pitting lower extremity edema. No femoral
bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
ADMISSION LABS:
[**2165-8-2**] 12:42PM BLOOD WBC-7.7# RBC-3.82* Hgb-11.1* Hct-33.9*
MCV-89 MCH-29.1 MCHC-32.8 RDW-16.1* Plt Ct-209
[**2165-8-2**] 12:42PM BLOOD PT-26.9* PTT-46.5* INR(PT)-2.7*
[**2165-8-2**] 12:42PM BLOOD Plt Ct-209
[**2165-8-2**] 12:42PM BLOOD Glucose-102 UreaN-41* Creat-2.3*# Na-140
K-4.1 Cl-104 HCO3-25 AnGap-15
[**2165-8-2**] 12:42PM BLOOD Calcium-8.1* Phos-4.1# Mg-2.2
[**2165-8-2**] 12:42PM BLOOD TSH-8.5*
[**2165-8-2**] 12:42PM BLOOD T3-83 Free T4-1.1
[**2165-8-2**] 12:42PM BLOOD Digoxin-3.8*
[**2165-8-2**] 03:08PM BLOOD Type-ART pO2-147* pCO2-40 pH-7.42
calTCO2-27 Base XS-1
.
.
PERTINENT LABS/STUDIES:
Hct: Ranged from 30-33 on this admission (which is his baseline)
Cr: 2.3 ([**8-2**]) -> 2.9 -> 3.1 -> 2.6 -> 2.1 -> 1.8 -> 1.8 ([**8-8**])
Fe: 40
TIBC: 338, Ferritin 124, TRF 260
TSH: 8.5
T3: 83
Dig 3.8 -> 2.7 -> 1.3
CXR ([**8-2**]): 1. Endotracheal tube and nasogastric tube in the
standard positions. 2. Bilateral right greater than left
effusions and densities, which may reflect combination of
atelectasis, infection or aspiration.
3. Findings consistent with overhydration.
CXR ([**8-4**]): Increased retrocardiac density, increased pleural
fluid. Atelectasis or pneumonia is possible. No overt worsening
of fluid status. Positioning may be contributory.
CXR ([**8-5**]): Bilateral pleural effusions, right greater than
left, slightly decreased when compared to prior exam. Increased
retrocardiac opacity may represent atelectasis or early
infection, unchanged.
CXR ([**8-7**]): Large right and small-to-moderate left pleural
effusion unchanged. No pneumothorax or mediastinal widening.
Large cardiac silhouette partially obscured by right pleural
effusion. Bibasilar atelectasis, unchanged. Transvenous right
atrial and left ventricular pacer leads and right ventricular
pacer defibrillator leads are unchanged in standard placements.
.
.
DISCHARGE LABS
U/A: Small blood, trace protein, trace leukocytes, few bacteria,
positive eosinophils
[**2165-8-8**] 07:22AM BLOOD WBC-6.2 RBC-3.41* Hgb-9.9* Hct-30.4*
MCV-89 MCH-29.1 MCHC-32.6 RDW-15.8* Plt Ct-212
[**2165-8-8**] 07:22AM BLOOD Plt Ct-212
[**2165-8-8**] 07:22AM BLOOD PT-17.2* PTT-39.2* INR(PT)-1.6*
[**2165-8-8**] 07:22AM BLOOD Glucose-87 UreaN-49* Creat-1.8* Na-140
K-4.0 Cl-104 HCO3-27 AnGap-13
[**2165-8-8**] 07:22AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8
[**2165-8-5**] 06:45AM BLOOD calTIBC-338 Ferritn-124 TRF-260
[**2165-8-8**] 07:22AM BLOOD Digoxin-1.3
Brief Hospital Course:
Mr. [**Known lastname 93843**] is an 84 yo man with a h/o ischemic cardiomyopathy,
complete heart block with pacer/ICD presenting following cardiac
arrest in the setting of inappropriate ICD firing and pacer
failure.
.
# Pacer Malfunction: Patient has a history of CHB with ICD
device who presented with cardiac arrest due to pacer/ICD
malfunction leading to inappropriate shocks x 6 and pacing
failure. The patient's baseline rhythm, as documented during
recent EP visit, is currently atrially sensed/atrially
paced/ventricularly paced at a rate of 75 beats per minute. That
patient's coumadin was held on admission, and his ICD was
replaced after his was <2. The patient was continued on
Amiodarone and Coreg during this admission and he had no acute
events during this stay.
.
# Systolic Congestive Heart Failure: The patient has an EF ~20%,
which is secondary to ischemic cardiomyopathy. On admission,
the patient had a CXR which showed evidence of volume overload,
secondary to aggressive fluid diuresis in the setting of cardiac
arrest. The patient was diuresed during this hospital stay, and
his CXR and clinical symptoms returned to baseline.
.
# Coronary Artery Disease: Patient has a history of Coronary
Artery Disease. The patient was continued on his home dose of
ASA, Zetia, Imdur, and Coreg. He did not have any acute events
during this hospital admission.
.
# Respiratory failure: Patient was intubated in the field during
CPR for presumed cardiac event. There is evidence of volume
overload but no other indications of an acute respiratory
process. The patient was diuresed on admission, and he was
extubated on hospital day #1.
.
# Acute renal failure: The patient presented with a creatinine
of 2.3, up from baseline of 1.6. The patient's acute on chronic
renal failure was most likely due to renal hypoperfusion in the
setting of poor forward flow. The patient was diuresed in the
setting of congestive heart failure, and his creatinine
improved.
.
# Diabetes Mellitus Type 2: The patient has a history of Type 2
Diabetes. He was continued on a sliding scale insulin during
this admission, and he did not have any acute events.
.
Medications on Admission:
ASA 81 mg daily
Zetia 10 mg daily
Imdur 15 mg daily
Digoxin 0.125 mg daily
Coreg 40 mg daily
Amiodarone 200 mg daily
Lasix 40 mg daily
KCl 20 meq daily
MVI
Coumadin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for PM implantation for 7 days: end on
[**2165-8-13**].
Disp:*12 Capsule(s)* Refills:*0*
5. Outpatient Lab Work
Please check INR, HCT, BUN, Creatinine on Friday [**8-9**] and
call results to Dr. [**Last Name (STitle) 1270**] at [**0-0-**]
6. Coreg CR 40 mg Cap, Multiphasic Release 24 hr Sig: One (1)
Cap, Multiphasic Release 24 hr PO once a day.
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please check INR on [**8-9**].
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
10. Imdur 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet
Sustained Release 24 hr PO at bedtime.
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Pacer lead fracture resulting in cardiac arrest.
Chronic Systolic LV dysfunction.
Acute renal failure
Blood loss Anemia
Discharge Condition:
Consider: ACEI pending renal function, and follow-up of guaiac+
stools.
stable
BP=104/63
HR=80
O2 sat=94%
left pacer site without hematoma or erythema: CXR confirmed
placement
INR 1.4
hct 29.7
BUN =49 creat =1.8
Discharge Instructions:
You had a malfunction with one of your pacemaker leads and
needed to have the lead replaced and new ICD implanted. There
were no complications with the procedure and your ICD/pacer
seems to be working properly. You are scheduled for an
evaluation of your new pacemaker on [**8-13**].
Avoid any sudden or large movements with your left arm such as
reaching for an object or tucking your shirt in. Do not lift
more than 5 pounds for one week. You have an appt at the Device
clinic next Wednesday and they will tell you what activity is OK
after this appt. You should not swim or take showers that might
get the pacer site wet for 1 week. Call the device clinic if you
notice any increased redness, discharge or pain around the pacer
site. Take your antibiotic for 6 days to prevent a pacer site
infection.
.
New or changed medicines:
Cephalexin: antibiotic for 6 days
Digoxin: 0.125 mg EVERY OTHER day
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
.
Please adhere to 2 gm sodium diet. Information was given to you
about this on discharge.
Fluid Restriction:1.5 liters (about 6 cups per day)
Followup Instructions:
Primary Care:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1270**], MD
Phone: [**0-0-**]
Date/Time: Wednesday [**8-14**] at 2:30pm.
(Consider: ACEI pending renal function, and follow-up of guaiac+
stools.)
.
Device clinic:
Provider: [**Name10 (NameIs) 676**] CLINIC
Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2165-8-13**] 11:30
.
Provider: [**Name10 (NameIs) **],
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2165-8-26**] 10:00
.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2165-9-2**] 9:00
.
Provider: [**Name10 (NameIs) 676**] CLINIC
Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2165-10-24**] 8:30
.
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2165-10-24**] 9:00
.
Completed by:[**2165-8-29**]
|
[
"V45.81",
"412",
"427.5",
"414.8",
"E944.3",
"584.9",
"V58.61",
"280.9",
"427.31",
"792.1",
"414.00",
"E879.8",
"428.20",
"424.0",
"996.04",
"428.0",
"403.90",
"585.9",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
10073, 10144
|
6581, 8740
|
227, 352
|
10308, 10523
|
4102, 4102
|
11722, 12703
|
3102, 3224
|
8956, 10050
|
10165, 10287
|
8766, 8933
|
10547, 11699
|
3239, 4083
|
173, 189
|
380, 2310
|
4119, 6558
|
2332, 2857
|
2873, 3086
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,956
| 178,395
|
23934
|
Discharge summary
|
report
|
Admission Date: [**2126-5-23**] Discharge Date: [**2126-5-28**]
Date of Birth: [**2064-7-28**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 61-year-old gentleman
with a known history of coronary artery disease who was
admitted preoperatively for a CABG. He had no complaints of
chest pain, shortness of breath, nausea, vomiting, or fever.
He had been cathed prior to admission on [**Month (only) 547**] which showed a
RCA 60% lesion, a left main 60% lesion, diagonal one 70%, OM
40%, and an ejection fraction of 35%. When he had his episode
of crushing chest pain he went up to the emergency room at
his local hospital and was transferred to [**Hospital1 18**] for emergent
catheterization.
HISTORY OF PRESENT ILLNESS: Includes herniated disc and an
elevated cholesterol as well as a history of bradycardia. The
patient also was a previous smoker who is status post an ST-
elevation MI.
PREOPERATIVE LABORATORY DATA: White count of 9.2, hematocrit
of 40.9, platelet count of 122,000. PT of 13.4, PTT of 28.8,
INR of 1.1. Repeat platelet count the following day was
142,000. Urinalysis showed some hematuria, but no urinary
tract infection. Sodium of 141, K of 3.8, chloride of 108,
bicarbonate of 28, BUN of 13, creatinine of 1.0, with a blood
sugar of 97. Anion gap of 9. CK of 358. ALT of 52, AST of
174, alkaline phosphatase of 53, total bilirubin of 0.4,
lipase of 21. Troponin T also preoperatively was 2.69 two
weeks prior to admission. Additional preoperative
laboratories revealed an albumin of 3.7, calcium of 8.7,
phosphorous of 2.9, magnesium of 1.9, cholesterol of 173,
HbA1C of 6.4%, triglycerides of 97.
PREOPERATIVE RADIOLOGIC STUDIES: EKG showed sinus
bradycardia with PAC's at a rate of 53 with a possible acute
IMI. Please refer to the official report dated [**2126-5-10**].
A preoperative echocardiogram status post his myocardial
infarction showed a moderately dilated RA, mild LA
enlargement, no LV mass or thrombus, moderate regional LV
systolic dysfunction, normal ascending, transverse, and
descending thoracic aorta, no AS, no AI, 1 to 2+ MR, and
trivial TR. Please refer to the official report dated [**2126-5-10**].
PHYSICAL EXAMINATION ON ADMISSION: He was in sinus rhythm at
66 with a blood pressure of 132/72 on the left and 149/68 on
the right. He appeared well. His heart was regular in rate
and rhythm. The lungs were clear bilaterally. His abdomen was
soft. He had 2+ bilateral femoral pulses without any
extremity edema.
HOSPITAL COURSE: He was also seen by Dr. [**Last Name (STitle) **] in
consultation, and on the 14th he underwent a CABG with a LIMA
of the LAD, a vein graft to the diagonal, a vein graft to the
OM. He was transferred to the cardiothoracic ICU in stable
condition on a Neo-Synephrine drip at 0.1 mcg/kg/min and a
propofol drip at 30 mcg/kg/min. He was extubated later that
afternoon.
On postoperative day 1, he was hemodynamically stable with a
blood pressure of 106/45. His creatinine was stable at 1.0
with a hematocrit of 25.9. He was doing very well. He was
started on beta blockade. He was weaned off his Neo-
Synephrine. He began Lasix diuresis, and his Swan was
discontinued. Later that afternoon he was transferred out to
[**Hospital Ward Name 121**] Two. He began his aspirin and Plavix therapy. His
Hemovac drain was removed, his chest tubes were removed, and
her epicardial pacing wires were removed. He was alert and
oriented with a nonfocal exam. His lungs were clear. His
heart was regular in rate and rhythm. His incisions were
clean, dry, and intact. He began to work with the nurses and
physical therapy on increasing his ambulation and his
stamina. He also had a drug-eluting stent to his mid RCA and
then was transferred post catheterization on an Integrilin
drip for evaluation for surgery. The initial preoperative
evaluation was done on [**2126-5-10**].
On postoperative day 3, his last chest tube was removed. He
was doing very well. His Lopressor was increased. He
continued to be out of bed and working with a physical
therapist and continued to make excellent progress. He was
switched over to p.o. Percocet for pain control.
On postoperative day 4, he remained in a sinus rhythm and was
hemodynamically stable. His Lasix was decreased to 20 daily.
His sternum was stable, and the incisions looked good. His
hematocrit dropped slightly from 25 to 24.5. He was up
approximately 4 kilograms from his preoperative weight. He
continued with diuresis. On the 19th he did a level 5 with
the physical therapist and plans were made to discharge him
home. His hematocrit remained stable at 25, and cleared a
level 5.
DISCHARGE STATUS: He was discharged on the 19th in stable
condition to home with VNA services. On the day of discharge,
his exam was unremarkable. The sternum was stable. The
incisions looked good. His blood pressure was 130/68. In
sinus rhythm at 75. Saturating 96% on room air.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x 3.
2. Status post right coronary artery drug-eluting stent.
3. Status post myocardial infarction.
4. Elevated cholesterol.
5. Herniated disc.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Enteric coated aspirin 81 mg p.o. once a day.
3. Percocet 5/325 1 to 2 tablets p.o. q.[**5-15**].h. p.r.n. (for
pain).
4. Plavix 75 mg p.o. once a day.
5. Thiamin 100 mg p.o. once daily.
6. Folic acid 1 mg p.o. daily.
7. Lipitor 10 mg p.o. daily.
8. Metoprolol 25 mg p.o. twice a day.
9. Lasix 20 mg p.o. daily (x 7 days).
10. Potassium chloride 20 mEq p.o. once a day (for 7
days).
11. Iron complex 150 mg p.o. once a day.
12. Vitamin C 500 mg p.o. twice a day.
DISCHARGE FOLLOWUP: The patient was instructed to follow up
in our [**Hospital 409**] Clinic in 2 weeks post discharge. To see his
primary care physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26225**] - in 3 to 4 weeks post
discharge and to make an appointment with Dr. [**Last Name (STitle) **] to see
him for his postoperative surgical visit in the office in 4
weeks.
CONDITION ON DISCHARGE: The patient was discharged to home
in stable condition on [**2126-5-28**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2126-6-26**] 13:53:23
T: [**2126-6-27**] 15:43:20
Job#: [**Job Number 60996**]
|
[
"401.9",
"790.92",
"305.00",
"272.0",
"410.82",
"414.01",
"724.2",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15",
"88.72",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
4942, 5135
|
5161, 5685
|
2519, 4921
|
5706, 6100
|
756, 2207
|
2222, 2501
|
6125, 6468
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,904
| 169,475
|
33819
|
Discharge summary
|
report
|
Admission Date: [**2188-5-17**] Discharge Date: [**2188-5-22**]
Date of Birth: [**2121-12-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Central line placement
Upper endoscopy
History of Present Illness:
Ms. [**Known lastname 11924**] is a 66 yo female with h/o HCV cirrhosis, DM2, CAD
s/p recent [**Known lastname **] who was dc'd from [**Hospital1 **] on [**5-15**] and now presents
from NH with hypotension and ? hct drop. Pt denies any fevers,
chills, lightheadedness, chest pain, shortness of breath,
dysuria or cough. She states she was woken up at the nursing
facility and told that she needed to come in. Per ER report this
was due to low SBP. Per patient care referral from, she was
being admitted for hct of 24 (last hct on [**5-15**] was 25.9).
.
Upon arrival to the ER her VS were: T 97.4 HR 84 BP 62/24 and O2
sat 97%. She was A&O x3, and SBPs ranged in the 70s-80. She was
treated with 3 L IVF and vancomycin and zosyn to cover for
sepsis. A RIJ was placed and she was started on levophed with
improvement in SBPs to low 100s.
.
In the ICU her only complaint was that she was tired. She was
started on levophed and was started on Ceftriaxone for SBP
treatment. She was followed by the liver service. 4/5 days of
her treatment course was completed. She was found to have acute
renal failure which was thought to be due to hypotension and
ATN. She received albumin for the renal failure and had flash
pulmonary edema on [**5-19**] which was treated with diuretics.
.
ROS: Denies fevers, chills, chest pain, shortness of breath,
abdominal pain, hematochezia, dysuria, hematuria, anorexia or
decreased PO intake.
States she has diarrhea all the time d/t lactulose. Also states
she fell yesterday after losing her balance, but did not have
dizziness or chest pain at the time.
Past Medical History:
1. HCV cirrhosis currently undergoing transplant work-up, had
SBP in [**5-6**]
2. Diabetes mellitus type 2: Per old records, pt had diagnosis
of diet controlled type 2 diabetes.
3. Umbilical hernia
4. [**Date Range **] in [**5-6**]: EKG c/w anteroseptal MI with new ST elevations
in V2-3. Elevated troponins but not cath candidate. Echo
confirmed anteroseptal WMA and pt was medicallly managed.
5. diastolic CHF
6. CKD
Social History:
From [**Location (un) 5354**], lived alone there and now moved in with her
brother here in [**Name (NI) 86**]. Presented to the ED directly from the
airport upon arrival in [**Location (un) 86**] several weeks ago for possible
liver txplnt. Former smoker, 20 pack-years, quit 10 years ago.
Former moderate EtOH consumption. Denies current EtOH use.
Denies illicit drug use/IVDU.
Family History:
Father died of MI at age 62, brother had MI at age 60, brother
also has DM.
Physical Exam:
PE: T: 96.8 BP:101/46 HR: 86 RR: 12 O2 sat: 99% on 4L NC
Gen: pale, well appearing, NAD
HEENT: anicteric sclera, dry MM
Cardio: RRR, nl S1 S2, 2/6 systolic murmur, loudest at apex
Lungs: CTAB anteriorly
Abd: soft, mildly distended, + hyperactive BS, NT, reducible
umbilical hernia
Ext: 2+ pitting edema in ble, 2+ DP pulses b/l
Neuro: awake, mentating appropriately, no asterixis
Skin: pale skin, bruises on arms
Pertinent Results:
Admission labs:
[**2188-5-17**] 08:15PM WBC-6.2 RBC-2.67* HGB-8.9* HCT-26.5* MCV-100*
MCH-33.5* MCHC-33.7 RDW-18.6*
[**2188-5-17**] 08:15PM NEUTS-66 BANDS-5 LYMPHS-10* MONOS-16* EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2188-5-17**] 08:15PM PLT SMR-LOW PLT COUNT-105*
[**2188-5-17**] 08:15PM GLUCOSE-191* UREA N-58* CREAT-2.9*#
SODIUM-129* POTASSIUM-6.2* CHLORIDE-96 TOTAL CO2-25 ANION GAP-14
[**2188-5-17**] 08:15PM ALBUMIN-2.2* CALCIUM-7.5* PHOSPHATE-4.1
MAGNESIUM-2.1
[**2188-5-17**] 08:15PM ALT(SGPT)-26 AST(SGOT)-78* CK(CPK)-72 ALK
PHOS-144* TOT BILI-2.0*
[**2188-5-17**] 08:15PM LIPASE-65*
[**2188-5-17**] 08:15PM cTropnT-0.14*
[**2188-5-17**] 08:12PM LACTATE-2.7* K+-5.4*
[**2188-5-17**] 08:35PM AMMONIA-<6
.
Discharge labs:
[**2188-5-22**] 05:45AM [**Month/Day/Year 3143**] WBC-4.6 RBC-2.98* Hgb-9.4* Hct-28.3*
MCV-95 MCH-31.6 MCHC-33.3 RDW-18.6* Plt Ct-78*
[**2188-5-22**] 05:45AM [**Month/Day/Year 3143**] Glucose-173* UreaN-34* Creat-1.2* Na-140
K-3.7 Cl-99 HCO3-35* AnGap-10
[**2188-5-22**] 05:45AM [**Month/Day/Year 3143**] Calcium-8.1* Phos-2.7 Mg-2.0
[**2188-5-22**] 05:45AM [**Month/Day/Year 3143**] ALT-25 AST-42* AlkPhos-134* TotBili-2.7*
[**2188-5-19**] 04:35AM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-0.15*
[**2188-5-18**] 01:26PM [**Month/Day/Year 3143**] Lactate-1.7
.
Studies:
CHEST (PORTABLE AP) [**2188-5-17**]
Right IJ central venous catheter has been pulled back, tip now
situated in the lower portion of the SVC. There is no
pneumothorax. Appearance of the chest is otherwise unchanged,
with findings most consistent with mild CHF and small bilateral
pleural effusions, and pulmonary vascular congestion.
.
ECG Study Date of [**2188-5-17**]
Rate PR QRS QT/QTc P QRS T
61 182 82 446/447 47 -22 33
Sinus rhythm. Borderline low QRS voltage. Delayed R wave
progression with
late precordial QRS transition. Non-specific precordial
lead/anterior T wave abnormalities. Findings are non-specific
but clinical correlation is
suggested. Since the previous tracing of [**2188-5-6**] precordial lead
T wave changes appear slightly more prominent.
.
CHEST (PORTABLE AP) [**2188-5-19**]
Single portable radiograph of the chest demonstrates persistent
increased airspace opacity involving both lungs. There are
persistent bilateral pleural effusions. Right internal jugular
central venous catheter is again seen with its tip in the SVC.
No pneumothorax. Cardiomediastinal contours are normal. Trachea
is midline.
.
TTE (Complete) Done [**2188-5-21**]
The left atrium is mildly dilated. The left atrial volume is
increased. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is mild regional left ventricular
systolic dysfunction with mild hypokinesis of the mid to distal
anterior septum and anterior wall.. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Diastolic dysfunction. Moderate pulmonary artery systolic
hypertension. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2188-5-5**], the
estimated pulmonary artery systolic pressure is slightly higher.
The other findings are similar.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2188-5-20**]
FINDINGS: Duplex and color Doppler demonstrate no lower
extremity DVT bilaterally.
.
[**2188-5-22**] - EGD report
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Granularity and erythema of the mucosa were noted in
the stomach body. These findings are compatible with mild portal
hypertensive gastropathy.
Protruding Lesions A few small gastric nodules were seen in the
fundus.
Duodenum: Normal duodenum.
Other
findings: No evidence of varices.
Impression: Granularity and erythema in the stomach body
compatible with mild portal hypertensive gastropathy
Nodules in the fundus
No evidence of varices.
Brief Hospital Course:
66 yo female with h/o HCV cirrhosis, DM2, CAD s/p recent [**Year (4 digits) **]
admitted to MICU for hypotension which was thought to be due to
SBP/fluid depletion. Hypotension resolved w/empiric SBP
treatment and IVFs/albumin. She was then transferred to the
floor in stable condition but with persistent oxygen requirement
after having had episode of flash pulmonary edema 2 days prior.
.
# Hypotension: Pt's baseline SBP are in the 90s given her
underlying ESLD. Pt required levophed in the MICU and is now
stable off levophed. The hypotension was likely due to
hypovolemia and/or sepsis. She was treated with IVFs/albumin
for concern of hypovolemia d/t diuresis and diarrhea and
ceftriaxone empirically for SBP with concern of sepsis. U/A was
also noted to be dirty and urosepsis was considered. CXR
appeared clear on admission. This was unlikely hemorrhagic shock
as Hct was stable. There was concern for cardiogenic shock as
the pt has h/o CAD with recent [**Year (4 digits) **]; however, troponins were
overall trending down. Pt completed 5 day course of ceftriaxone
for possible SBP, and then returned to SBP ppx with
ciprofloxacin. [**Year (4 digits) **] cultures remained no growth to date. She
was restarted on low dose metoprol 12.5 [**Hospital1 **] instead of her
nadolol as she had no esophageal varices seen on EGD. Her ACE-I
was not restarted. She will follow up with her PCP.
.
# Acute on chronic diastolic CHF: Pt with baseline EF of 55%
with recent [**Hospital1 **] and anteroseptal hypokinesis. Pt had
increased O2 requirement after IVF resuscitation, and CXR was
c/w pulmonary edema. She was then diuresed successfully with
lasix and spironolactone. She was discharged on Lasix 40 mg and
spironolactone 100 mg. She was also restarted on low-dose
metoprolol. Her ACE-I was not restarted. She will follow up
with her PCP.
.
# HCV Cirrhosis: Pt was recently diagnosed with SBP and treated
with 5 day course of ceftriaxone and discharged on ciprofloxacin
for SBP ppx. LFTs are at baseline. She was continued on
lactulose. Nadolol was held on admission given her hypotension
and was not restarted as EGD on [**5-22**] showed no varices but
portal hypertensive gastropathy. Prior to discharge, she was
restarted on Lasix and spironolactone.
.
# ARF: Cr on admission was 2.9, increased from 1.6 on [**5-15**].
Recent baseline has been 1.5-1.6. ARF was likely [**3-1**]
hypovolemia/hypotension. Creatinine seemed to have improved to
quickly for ATN. Creatinine at discharge was 1.2. Diruetics
were restarted at a lower dose: Lasix 40 mg and spironolactone
100 mg.
.
# CAD: Pt had a small [**Month/Day (2) **] on prior admission. EKG appeared
similar to previous and troponins lower than previously. She
was continued on ASA. BB, ACEI was held on admission given her
hypotension. BB was restarted as above. ACEI was held as
above.
.
# DM: Pt was continued on ISS.
.
# Anemia: Recent baseline has been 25-30. Previus w/u
demonstrated nl iron, low TIBC and nl B12, folate, possibly c/w
ACD. She does have a history of guaiac positive stool. She was
transfused a total of 2 units of PRBCs during her stay. EGD on
[**5-20**] showed no varices but did show portal hypertensive
gastropathy. Given stable HCT, colonoscopy was deferred for
outpatient.
.
# FEN: Diabetic/Cardiac, low salt diet.
.
# PPx: PPI, bowel regimen, pneumoboots
.
# Code status: Full Code
.
# Communication: Next of [**Doctor First Name **]: [**Known lastname **],[**Name (NI) **] (brother), Phone:
[**Telephone/Fax (1) 78190**]
Medications on Admission:
1. Ciprofloxacin 250 mg q24 hours.
2. Nadolol 20 mg daily
3. Lactulose 30 ml TID
4. Lisinopril 5 mg daily
5. Aspirin 325 mg daily
6. Pantoprazole 20 mg q12 hours
7. Insulin Lispro SS
8. Hexavitamin 1 cap daily
9. Folic Acid 1 mg daily
10. Oxycodone 5 mg q4 hours prn
11. Albuterol Sulfate neb q6 hours prn
12. Ipratropium Bromide q6 hours
13. Dulcolax 10 mg qday prn
14. Spironolactone 200 mg daily
15. Furosemide 80 mg PO BID
16. MOM prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Primary:
Hypotension
.
Secondary:
Acute on chronic diastolic dysfunction
Hepatitis C virus cirrhosis
Coronary artery disease
Acute on chronic renal failure
Discharge Condition:
Stable, SBP in 90s (baseline)
Discharge Instructions:
You were admitted with low [**Hospital **] pressure. You were treated
with intravenous fluids and albumin as well as antibiotics for
possible infection in your abdomen. Your [**Hospital **] pressure has
improved.
.
You were noted to have small amounts of [**Hospital **] in your stool.
You had an upper endscopy, which was a procedure involving a
camera looking into your stomach. There was no active bleeding.
You will need an outpatient colonoscopy.
.
Please take your medications as directed.
.
Please keep your follow up appointments.
.
If you develop nausea/vomiting, abdominal pain, [**Hospital **] in the
stool, shortness of breath, chest discomfort,
lightheadedness/dizziness, or any other concerning symptoms,
please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2422**].
Followup Instructions:
Please keep the following appointments:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2188-6-10**] 3:15
.
You also have an outpatient colonoscopy scheduled for [**2188-6-2**] at 8AM. The clinic will contact you with more information.
.
Please also make an appointment with a primary care provider
[**Name Initial (PRE) 176**] 3 weeks. You may call Heathcare Associates, which is
part of [**Hospital1 69**], for one. The
clinic number is [**Telephone/Fax (1) 250**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"537.89",
"428.33",
"585.9",
"428.0",
"250.00",
"280.0",
"567.23",
"070.54",
"276.52",
"410.12",
"571.5",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11686, 11738
|
7656, 11196
|
334, 374
|
11938, 11970
|
3368, 3368
|
12816, 13499
|
2842, 2919
|
11759, 11917
|
11222, 11663
|
11994, 12793
|
4120, 7633
|
2934, 3349
|
283, 296
|
402, 1986
|
3384, 4104
|
2008, 2429
|
2445, 2826
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,222
| 156,134
|
4125
|
Discharge summary
|
report
|
Admission Date: [**2200-5-13**] Discharge Date: [**2200-5-17**]
Service: MEDICINE
Allergies:
Morphine Sulfate / Ciprofloxacin / Demerol
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
88 year old man with hx of internal hemorrhoids, A. fib on
coumadin, MDS w/ chronic anemia and thrombocytopenia presents w/
BRBPR and worsening Hct.
Major Surgical or Invasive Procedure:
Colonscopy
History of Present Illness:
Mr. [**Known lastname 18064**] is an 88 year old man with a history of interal
hemorrhoids, myelodysplasia with chronic anemia and
thrombocytpenia, and A fib. on coumadin who presents after
being sent to ED by PCP to be transfused for Hct of 25 on
routine weekly INR checks. Pt recalls "feeling tired" over the
past week and noticing bright red blood on this toilet paper
after bowel mov'ts for the past wk. Admits to constipation,
straining, ? tenesmus over past wk. Denies abdominal pain,
diarrhea, change in color of stools?, melena, chest pain, SOB.
Last colonscopy was 3 yrs ago, polyps on past studies. Has
reported occasional BRBPR in the past, guiaics by PCP all
negative per daughter's report. Hx of internal hemorrhoids dx 4
yrs ago.
In [**Name (NI) **], pt's vitals: HR 70, BP 124/62--> 84/26 (asx?) O2sat 97%
4L NC 86% RA. Exam notable for pale conjunctivae, irregular HR,
grossly bloody rectum, no external hemorrhoids, anoscope:
internal hemorrhoids, not actively bleeding. Gastric lavage was
negative. Received 1 unit of packed RBCs, Vit 5mg po, 5mg sc, 1
unit of FFP. Labs remarkable for Cr 2.0, Hct 26.9, PT 22.1, INR
3.1, Plt 90. EKG 64 atrial fibrillation nl axis ST depressions
(1mm) V3-V6, TWI V4-V6, prolonged QTc. Compared to prior EKG, ST
depressions in same leads slight more depressed on this more
current EKG.
Past Medical History:
PMH
Myelodysplasia - dx'd 2 [**2-9**] yrs ago
Atrial fibrillation
CAD s/p CABG/quadruple '[**89**], CHF-EF 40% in [**2198**]
AI s/p valvuloplasty
Aortic stenosis
Melanoma or basal cell ca? - face, dx in '70s s/p radiation
Acute pancreatitis -
Cholelithiasis
"Mild Parkinson's"
Internal Hemorrhoids
GERD
Dyplastic polyps on colonscopy
Social History:
Lives in the same house as his adult daugher who appears
supportive and actively involved in this care. He occupies the
apt below hers and uses a baby [**Name (NI) **]-[**Name2 (NI) 18065**] to stay in constant
communication with him. Uses a walker to ambulate at home.
Family History:
Family Hx: Daughter, Crohn's Disease
Physical Exam:
VS BP 112/66 HR 61 RR 16 SaO2 99% 4L NC
General: elderly male, conversant, engaging
HEENT: actinic skin changes, conj. b/l red, appears irritated,
purulent discharge in right eye, no JVD, nl JVP, MMM
Chest: Lungs clear, no crackles, wheezes, good chest expansion
Cardiac: irregular rhythm, III/VI crescendo-descr. systolic
murmur best heard at the 2nd intercostal space radiated to
clavicles, ? II/VI diastolic murmur at LSB
Abd: soft obese nontender no HSM normal bowel sounds, no masses
palpated
Ext: warm well-perfused, 2+ DPs, trace pedal edema
Neuro: alert, oriented x 3, grossly intact
Pertinent Results:
[**2200-5-13**] 07:20PM WBC-6.1 RBC-2.67* HGB-8.6* HCT-26.9*
MCV-101*# MCH-32.3*# MCHC-32.0 RDW-18.7*
[**2200-5-13**] 07:20PM CK(CPK)-44
[**2200-5-13**] 07:20PM CK-MB-2 cTropnT-0.10*
[**2200-5-13**] 07:20PM PLT SMR-LOW PLT COUNT-90* LPLT-2+
[**2200-5-13**] 07:20PM PT-22.1* PTT-41.1* INR(PT)-3.1
[**2200-5-14**] 04:00AM BLOOD WBC-6.0 RBC-2.58* Hgb-8.5* Hct-25.5*
MCV-99* MCH-33.0* MCHC-33.3 RDW-19.6* Plt Ct-67*
[**2200-5-14**] 10:00AM BLOOD Hct-27.6*
[**2200-5-14**] 05:40PM BLOOD Hct-29.7*
[**2200-5-15**] 05:26AM BLOOD WBC-5.4 RBC-2.95* Hgb-9.5* Hct-28.3*
MCV-96 MCH-32.2* MCHC-33.6 RDW-19.9* Plt Ct-69*
[**2200-5-13**] 07:20PM BLOOD Plt Smr-LOW Plt Ct-90* LPlt-2+
[**2200-5-14**] 04:00AM BLOOD Plt Ct-67* LPlt-2+
[**2200-5-15**] 05:26AM BLOOD Plt Smr-VERY LOW Plt Ct-69* LPlt-1+
[**2200-5-13**] 07:20PM BLOOD CK-MB-2 cTropnT-0.10*
[**2200-5-14**] 04:00AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2200-5-14**] 10:00AM BLOOD CK-MB-2 cTropnT-0.12*
[**2200-5-15**] 05:26AM BLOOD CK-MB-2 cTropnT-0.13*
Brief Hospital Course:
1. [**Name (NI) 18066**]
Pt remained hemodynamically stable while on the floor with no
signs of active bleeding. He received an additional unit of
PRBC. His Hct bumped appropriately and remained stable in the
high 20s. Colonscopy performed on [**5-15**] demonstrated grade 1
non-bleeding internal hemorrhoids w/ anal tage, non-bleeding
diverticulosis of the sigmoid colon, small polyp in sigmoid
colon o/w normal. Likely source of bleed thought to be internal
hemorrhoids.
2. Anemia
As above, Hct increased with additional unit of PRBC, remaining
stable. Hemolysis and Fe studies were WNL. Likely an acute on
chronic picture with [**Month/Day (4) 18066**] worsening baseline anemia from MDS.
Now back to baseline crit which hovers around 30.
3. ST depressions on EKG
Present on EKG from a yr ago. Likely not ischemia as they have
persisted.
4. Elevated troponins
Pt presented w/ increased troponins which continued to be high
on serial enzymes. At baseline troponins have been elevated in
the past, so likely [**3-12**] to chronic renal insuff. and not demand
ischemia
5. CHF
Pt with no overt signs of volume overload on exam while in unit.
Lasix dose reduced to 40mg qd vs [**Hospital1 **] while in unit.
6. A. fib
Coumadin held during MICU stay in setting of [**Hospital1 18066**], then
restarted.
7. CRI
Pt with Cr of 2.0 on admission, which then improved
8. Thrombocytopenia
Plts remain in the 60s, at baseline plts have hovered in this
range and higher. [**3-12**] to MDS
9. DISPO - pt was evaluated by physical therapy, and was felt to
benifit from Rehab placment
Medications on Admission:
MEDS
Epogen 20,000/ml 1 ml SQ qwk
Sinemet 25/100 1 tab [**Hospital1 **]
Lasix 40mg 2 tabs qd
Aldactone 25mg 1 tab qd
Toprol XL 50mg tab qd
Protonix 40mg 1 tab qd
Lipitor 10mg 1 tab qd
Paxil CR 12.5 mg qd
Pepcid AC 10mg 2 tabs qd
Coumadin 1.0 mg qd
Alphagan 10ml one drop to left eye [**Hospital1 **]
Xalatan 0.005% one frop to left eye qhs
IC Erythromycin ointment tid prn
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily) as needed
for CHF, HTN, A fib.
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for anemia.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Lower GI Bleeding
Myelodysplasia - dx'd 2 [**2-9**] yrs ago
Atrial fibrillation
CAD s/p CABG/quadruple '[**89**], CHF-EF 40% in [**2198**]
AI s/p valvuloplasty
Aortic stenosis
Melanoma or basal cell ca? - face, dx in '70s s/p radiation
Cholelithiasis
"Mild Parkinson's"
Internal Hemorrhoids
GERD
Dyplastic polyps on colonscopy
Discharge Condition:
Stable
Discharge Instructions:
Please continue all medications as prescribed, and monitor for
any further episodes of bleeding. Please continue to work with
physical therapy. If you you have any chest pain, further
bleeding, shortness of breath, or any other concerning symptoms
please seek further medical attention.
Followup Instructions:
Please make a follow-up appointment within 1 week of discharge
with your PCP Dr [**Last Name (STitle) **]. [**Telephone/Fax (1) 18067**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2200-6-3**] 10:45
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"424.1",
"414.00",
"V45.81",
"V58.61",
"285.9",
"238.7",
"428.0",
"427.31",
"455.2",
"496",
"287.5",
"272.0",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
7343, 7421
|
4141, 5720
|
398, 410
|
7791, 7799
|
3110, 4118
|
8134, 8565
|
2441, 2479
|
6144, 7320
|
7442, 7770
|
5746, 6121
|
7823, 8111
|
2494, 3091
|
210, 360
|
438, 1779
|
1801, 2137
|
2153, 2425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,751
| 182,352
|
38650+58230
|
Discharge summary
|
report+addendum
|
Admission Date: [**2115-1-9**] Discharge Date: [**2115-1-23**]
Date of Birth: [**2043-12-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Aortic Valve Replacement
History of Present Illness:
71 year old patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 29117**] (PCP) and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
(neurology) with a progressive decline in activity tolerance,
dyspnea on exertion and severe aortic regurgitation referred for
right and
left heart catheterization prior to AVR.
Regarding his AI, in [**2110**] he was quite active and had very
little DOE. Over the past two years, he has noticed a
significant decline in his exercise tolerance along with
fatigue. Four years ago he was able to walk a mile, lately he
has not been able to walk 20 feet due to sob. He was recently
started on lasix 1-2 weeks prior and he was able to walk from
the garage to the hospital without difficulty, approximatley 50
feet. Thus has improved his symptoms but not has resolved it.
Has noticed worsening LE edema in past 2-3 months. Gained 90
pounds over past 12 months per his wife. Also has 2 pillow
orthopnea and +PND. Denies syncope, presyncope, palpitations,
cp.
Echo in [**2110**] showed [**12-8**] + AI with preserved EF and normal LV
size. However recent echo shows severe AI.
In cath today, his coronary arteries were found to be normal. He
was found to be in heart failure when found to have a RVSP: 82
(nml < 35) and PCWP of 40 (nml < 12). He received 40 mg of IV
lasix in cath lab with 1400 cc output. He was also started on a
nitro gtt due to elevated BPs. Noted to have oozing from site as
well. CT surgery was consulted in cath lab and are planning for
AVR Monday.
.
On the floor patient feels well. He denies complaints at this
time.
Past Medical History:
Hypertension
Hyperlipidemia
Morbid Obesity, BMI: 43.62
Moderate to severe AI ([**2114-12-26**] echo: LVEF 45-50%, Dilation of
the aortic root and descending aorta to 4.0cm. 1+ MR, mild AS)
Morbid Obesity
Prostate cancer s/p prostatectomy approximately 15 years ago,
currently undergoing hormone treatment for a rising PSA
(occasional urinary incontinence)
Sleep apnea (does not use CPAP)
Hard of hearing
Social History:
Patient is married with three grown children. He is
retired from the fire department. ETOH: seldom. Tobacco: quit
over 14 years ago
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Ht: 5 feet 8 inches Wt: 309 pounds
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
VS: HR: BP: 189/90 HR: 72 RR: 20, 99% 2L
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 15 cm.
CV: PMI soft at midclavicular line. RR, normal S1, S2. [**1-10**]
diastolic murmur heard best at base radiating to apex. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, obese, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
[**2115-1-9**] 09:10AM PT-14.1* PTT-28.8 INR(PT)-1.2*
[**2115-1-10**] 06:10AM BLOOD WBC-7.6 RBC-4.31* Hgb-11.1* Hct-36.4*
MCV-85 MCH-25.8* MCHC-30.6* RDW-15.5 Plt Ct-246
[**2115-1-9**] 09:10AM BLOOD PT-14.1* PTT-28.8 INR(PT)-1.2*
[**2115-1-10**] 06:10AM BLOOD Glucose-102* UreaN-15 Creat-0.9 Na-143
K-3.9 Cl-103 HCO3-32 AnGap-12
[**2115-1-10**] 06:10AM BLOOD ALT-15 AST-19 AlkPhos-50 TotBili-0.6
[**2115-1-10**] 06:10AM BLOOD %HbA1c-6.1* eAG-128*
[**2115-1-21**] 05:30AM BLOOD WBC-10.3 RBC-3.71* Hgb-9.8* Hct-31.6*
MCV-85 MCH-26.3* MCHC-30.9* RDW-14.8 Plt Ct-303
[**2115-1-21**] 05:30AM BLOOD Plt Ct-303
[**2115-1-22**] 06:05AM BLOOD Glucose-92 UreaN-13 Creat-1.0 Na-142
K-3.9 Cl-102 HCO3-28 AnGap-16
[**2115-1-22**] 06:05AM BLOOD Mg-2.1
Radiology Report CHEST (PA & LAT) Study Date of [**2115-1-21**] 8:32 PM
Clip # [**Clip Number (Radiology) 85871**]
Final Report
HISTORY: Left effusion, to evaluate for change.
FINDINGS: In comparison with the study of [**1-18**], the central
catheter has been removed. Substantial enlargement of the
cardiac silhouette persists without definite vascular
congestion. The elevated pleural line seen previously is not
definitely appreciated on the current study.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *2.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.2 cm <= 5.6 cm
Left Ventricle - Stroke Volume: 23 ml/beat
Aorta - Sinus Level: 2.5 cm <= 3.6 cm
Aorta - Ascending: 2.5 cm <= 3.4 cm
Aorta - Arch: 2.4 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *2.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 18 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 5 mm Hg
Aortic Valve - LVOT VTI: 5
Aortic Valve - LVOT diam: 2.4 cm
Aortic Valve - Valve Area: 5.3 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Severely dilated LV cavity. Normal
regional LV systolic function. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in aortic arch. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Aortic leaflet
prolapse. AR vena contracta is >0.6cm. Severe (4+) AR. Eccentric
AR jet directed toward the anterior mitral leaflet.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Image quality was
suboptimald - poor esophageal contact.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
A patent foramen ovale is present. The left ventricular cavity
is severely dilated. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 45%). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. Aortic leaflet
prolapse is present. The aortic regurgitation vena contracta is
>0.6cm. Severe (4+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric.
Post bypass
The patient is on a levophed drip at .1mcg/kg/min
A 29 Bioprosthetic valve has been placed.
The mean gradient across the valve is 9.
There is no AI/Paravalvular leaks
There is Inferoseptal dyskinesis with Inferior wall akinesis,the
rest of the LV function is preserved
RV function is preserved
Dr [**Last Name (STitle) 914**] informed of the above findings and discussed with
Radiology Report CAROTID SERIES COMPLETE Study Date of [**2115-1-10**]
9:09 AM
Final Report
Standard Report Carotid US
Study: Carotid Series Complete
Reason: pre op Aortic Valve replacement
Findings: Duplex evaluation was performed of bilateral carotid
arteries.
Minimal plaque is noticed.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 52/9, 54/9, 89/15
cm/sec. CCA peak systolic velocity is 140 cm/sec. ECA peak
systolic velocity is 81 cm/sec. The ICA/CCA ratio is .64. These
findings are consistent with < 40 stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 69/13, 50/10, 71/9 cm/sec. CCA peak
systolic velocity is 83 cm/sec. ECA peak systolic velocity is
177 cm/sec. The ICA/CCA ratio is .83. These findings are
consistent with with < 40 stenosis.
Right vertebral antegrade artery flow.
Left vertebral antegrade artery flow.
Impression: Bilateral < 40% stenosis
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Brief Hospital Course:
71 year old Male with severe aortic insufficiency initially
presented with acute on chronic CHF exacerbation found in
pre-operative cardiac cath [**1-9**]. He was diuresed on in the
cardiology floor and prepped for aortic valve replacement. He
was taken to surgery [**2115-1-15**], please see operative report for
details. In summary had aortic valve replacement with a 29-mm
[**Company 1543**] Mosaic aortic valve bioprosthesis, his
CARDIOPULMONARY BYPASS TIME was: 90 minutes wiith a CROSSCLAMP
TIME: 67 minutes. He tolerated the operation well and was
transferred from the operating room to cardiac surgery ICU in
stable condition on propofol, amiodarone, and levophed
infusions. Remained hemodynamically stable, awoke neurologically
intact and extubated the evening of surgery. He was transferred
to the floor on POD #2 to begin increasing his activity level.
All tubes, lines, drains and pacing wires removed per protocol.
He had a scant amount of sternal drainage after transfer to the
floor that resolved with IV Ancef. He was discharged on PO
keflex for further management. He was noted to be hypertensive
and his medications were titrated up for better blood pressure
control. The remainder of his hospital stay was uneventful. He
was cleared by physical therapy for home and was discharged home
on POD8. Follow up with Dr [**Last Name (STitle) 914**] in 4 weeks.
Medications on Admission:
albuterol sulfate 2 puffs QID prn
atenolol 25 mg daily
advair diskus 1 puff [**Hospital1 **]
lasix 20 mg daily
combivent 1 puff [**Hospital1 **]
latanoprost 0.005% drops-one drop OU QHS
losartan 25 mg daily
simvastatin 20 mg daily
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
Disp:*2 bottles* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg daily [**Date range (1) 1396**]; then 200 mg daily for 2 weeks
per cardiologist.
Disp:*60 Tablet(s)* Refills:*0*
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation QID (4 times a day) as needed for wheezing.
Disp:*2 MDI* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days: 40mg Qd x10 days then resume preop schedule for Lasix.
Disp:*10 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 10 days.
Disp:*20 Tablet Sustained Release(s)* Refills:*0*
13. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
Discharge Diagnosis:
Severe Aortic Insufficiency s/p AVR
Acute on Chronic Systolic Congestive Heart Failure
HTN
hyperlipidemia
prostate CA s/p prostatectomy; now with hormone rx for rising
PSA
occ.urinary incontinence
sleep apnea
hard of hearing
recently diagnosed asthma
postop A Fib
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Sternal wound: healing well, no drainage or erythema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) 914**] Tuesday [**2-19**] @ 1:00 PM [**Telephone/Fax (1) 170**]
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) 3172**] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2115-3-13**] 11:20
[**2115-2-13**] 8:50 PM Sleep Health Center [**Location (un) 83510**]
[**Location (un) 583**], [**Numeric Identifier 85872**]
Please call to schedule appointments
Dr. [**Last Name (STitle) 3748**] (urology) 1 week [**Telephone/Fax (1) 3752**]
Primary Care Dr. [**Last Name (STitle) 29117**] in [**12-8**] weeks
Cardiologist Dr. [**First Name (STitle) **] in [**12-8**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule before discharge
Completed by:[**2115-1-23**] Name: [**Known lastname 13610**],[**Known firstname **] Unit No: [**Numeric Identifier 13611**]
Admission Date: [**2115-1-9**] Discharge Date: [**2115-1-23**]
Date of Birth: [**2043-12-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1543**]
Addendum:
Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 1481**] was mistakenly identified as Mr [**First Name (Titles) 13612**] [**Last Name (Titles) 13613**]
on previous discharge summary. It should indicate that he is the
patients Cardiologist.
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2115-1-28**]
|
[
"V85.4",
"424.1",
"788.30",
"278.01",
"272.4",
"780.57",
"493.90",
"428.23",
"523.5",
"427.31",
"401.9",
"428.0",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"35.21",
"39.61",
"88.72",
"23.19",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
14419, 14626
|
8490, 9866
|
296, 323
|
12287, 12287
|
3441, 6291
|
13002, 14396
|
2545, 2627
|
10148, 11908
|
12000, 12266
|
9892, 10125
|
12485, 12979
|
6335, 8467
|
2642, 3422
|
237, 258
|
351, 1953
|
12301, 12461
|
1975, 2380
|
2396, 2529
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,723
| 194,934
|
53829
|
Discharge summary
|
report
|
Admission Date: [**2105-11-21**] Discharge Date: [**2105-12-4**]
Date of Birth: [**2044-10-21**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
Thoracic fusion
History of Present Illness:
HPI: 61 year old male construction worker fell 25 feet off a
bridge tonight while working and landed on his feet. He was
brought directly to [**Hospital1 18**] from the scene. The patient reports no
sensation from just above the nipples down to his feet. He is
unable to move his legs. The patient is being seen by the trauma
team and his injuries include a nasal fx, right clavicular fx,
right rib fx, T3, T4 comminuted fx with anterolisthesis of T3 on
T4. He also has an endplate fx of L1. The patient also has
hypotension and is being given fluids currently.
Past Medical History:
PMHx: seizure disorder
Social History:
Social Hx: is a construction worker
Family History:
Family Hx: non-contributory
Physical Exam:
PHYSICAL EXAM:
T:97.1 BP:95/48 HR:80 RR:16 O2Sats:100%
non-rebreather
Gen: Is lying on backboard, is sleepy, but cooperative with
exam.
HEENT: Head - large left parietal/occipial superfical laceration
Ears/Nose: no rhinorrhea, otorrhea; no blood in ears or nose
Pupils: PERRL EOMs-intact
Neck: In cervical collar, no point tenderness.
Spine: + point tenderness around T3, T4/ infrascapular region
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
B T Grip IP Q AT [**Last Name (un) 938**] G
R 5 4 5 0 0 0 0 0
L 5 4- 5 0 0 0 0 0
Sensation: Intact to light touch in upper extremities
bilaterally. No sensation from just above the nipples down to
his
feet.
Propioception - not intact
Toes mute bilaterally
Rectal exam - no anal sphincter tone, no sensation
Pertinent Results:
CT head: **preliminary report**
1. No intracranial hemorrhage or edema.
2. Nasal bone comminuted fractures.
3. Opacification of the right maxillary sinus, which is
incompletely evaluated. If there is concern for a facial
fracture, consider dedicated facial bone CT.
CT c-spine: **preliminary report**
FINDINGS: A highly comminuted fracture of the posterior mid and
anterior elements of T3 is partially imaged and better evaluated
on a subsequent CT torso. The cervical spine appears well
aligned and demonstrates no evidence of acute fracture. The
atlanto-axial and atlanto-occipital articulations are
maintained.
Prevertebral swelling and hematoma in the vicinity of the T3
fracture is also partially imaged.
There is multilevel cervical spondylosis with disc height
narrowing most prominent from C5-6 through C6-7. Anterior and
posterior osteophytes are noted at these levels as well.
A minimally displaced fracture of the right clavicle is noted as
well as fractures second rib bilaterally and left third rib near
its articulation. The mastoid air cells are well aerated. The
right maxillary sinus is completely opacified, but incompletely
evaluated. Mucosal thickening within the left mastoid sinus is
noted.
The lung apices demonstrate subpleural bleb again and possibly a
small amount of pleural air at the right apex.
IMPRESSION:
1. Complex _____ T3 fracture, partially imaged. No evidence of
a cervical spine fracture or acute alignment abnormality.
2. Possible small right apical pleural pneumothorax.
3. Right clavicle and bilateral rib fractures as described,
partially imaged.
CT chest, abdomen:
Preliminary Report !! Wet Read !!
High comminuted unstable fracture T3 and T4 with Grade I
anterolisthesis of T3 on T4 and angulation of spinal canal at
this level. No definite bony protrusion into canal however
evaluation for epidural hematoma is limited and MRI would be
better for evaluation. Extensive posterior medisatinal hematoma
likelt stems from spinal injury. No definite aortic injury.
Correlate clinically. Fracture of superior endplate of L1 with
slight retropulsion of fragment into canal. Right clavice
fracture. 2nd ribs fractured posteriorly bilaterally. Tiny right
pneumothorax. Manubrial fracture.
MRI: pending
Labs:
Tox screen positive for benzos, negative for everything else
Na 141 Cl 106 BUN 19 Glu 119 AGap=14
K 4.0 CO2 25 Cr 1.6
WBC 9.7 Hgb 14.0 Hct 38.0 Plts 184
N:80.6 L:13.7 M:3.6 E:1.9 Bas:0.2
PT: 13.7 PTT: 26.9 INR: 1.2
Brief Hospital Course:
The patient is a 61-year-old male who fell 25 feet from a
bridge. He was found to have a complete spinal cord injury,
being a T5 [**Last Name (un) **], associated with a fracture-dislocation of his
thoracic spine with severe bony injuries to all three columns of
T3 and T4 with severe kyphosis and anterolisthesis. He was
admitted to the trauma service and monitored in the trauma icu
he required chest tubes for pneumothorax. He had no movement of
his legs from admission and no sensation from just above the
nipples down to his feet.
He was stable hemodynamically on [**11-27**] so he was taken to the
operating room for reduction of his traumatic deformity and
stabilization as well as fusion. He had a
1. Thoracic laminectomy T4, T3 and T2.
2. Iliac crest autograft harvest.
3. Posterior instrumentation, segmental, T1 to T8.
4. Posterolateral arthrodesis T1 to T8.
5. Open reduction of thoracic fracture-dislocation.
6. Autograft for spinal surgery
During this procedure he also had an IVC filter placed.
He was monitored for 48 hours for hypotension and respiratory
distress in PACU and TSICU. He was transferred to the surgical
floor and on [**12-1**] he developed fevers to 102. He had full work
up including chest xray, blood cultures and c-diff which were
all negative. His fevers late on the [**4-1**] and he has
been afebrile. He had one episode of desaturation that improved
with position and chest PT. He continues to be paralegic in his
legs. His incision is well healed and staples should be removed
on the 26th.
Medications on Admission:
All: NKDA, has pollen allergy
Medications prior to admission: Diazepam
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-13**]
Drops Ophthalmic Q AC/HS ().
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Multiple trauma
S/P Fall with T3-T4 transection of spinal cord
Discharge Condition:
Paraplegic
Discharge Instructions:
?????? Do not smoke
?????? Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
?????? Have a family member check your incision daily for signs of
infection
?????? If you are required to wear one, wear cervical collar or back
brace as instructed
?????? You may shower briefly without the collar / back brace unless
instructed otherwise
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
FOLLOW-UP WITH DR. [**Last Name (STitle) 1960**] (ORTHO) THIS WEEK FOR R CLAVICULAR
FX, PHONE NUMBER: [**Telephone/Fax (1) 1228**]
Have staples removed at rehab on [**12-7**]
Follow up with Dr [**Last Name (STitle) 548**] in 6 weeks call [**Telephone/Fax (1) 1669**]
Completed by:[**2105-12-4**]
|
[
"802.0",
"806.21",
"E884.9",
"E849.5",
"807.02",
"511.9",
"806.26",
"860.4",
"518.0",
"810.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.7",
"38.93",
"77.79",
"03.53",
"81.05",
"81.63",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7478, 7548
|
4704, 6245
|
326, 343
|
7655, 7668
|
2172, 2172
|
8980, 9278
|
1052, 1082
|
6368, 7455
|
7569, 7634
|
6271, 6302
|
7692, 8957
|
1112, 1616
|
6334, 6345
|
282, 288
|
371, 935
|
2181, 4681
|
1631, 2153
|
957, 982
|
998, 1036
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,180
| 199,001
|
44833
|
Discharge summary
|
report
|
Admission Date: [**2109-2-4**] Discharge Date: [**2109-2-10**]
Date of Birth: [**2051-12-17**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Codeine / Meperidine
Attending:[**First Name3 (LF) 1242**]
Chief Complaint:
melena/BRBP ostomy/abd pain
Major Surgical or Invasive Procedure:
EGD [**2109-2-4**]: single cratered bleeding duodenal bulb ulcer. Tx
with epi and electrocautery.
History of Present Illness:
The patient is a 57 year old female with a history of peptic
ulcer disease, colonic inertia s/p total colectomy with
ileostomy [**3-15**], and GERD who noticed "black motor oil" coming
from her ostomy 6 days prior to admission ([**2109-1-29**]). She stayed
in bed thinking it would go away. She had been experiencing
intermittent abdominal pain that was exacerbated by food,
radiating to her back and was aggressively worked up as an
outpatient. On the day of admission ([**2109-2-3**]) the patient
developed lightheadedness/dizziness/and headache and worsening
shortness of breath. She suddenly noticed bright red blood
draining into her ostomy bag (approx 2 cups). After instruction
from [**Company 191**] on call to go to ED, her husband drove her to [**Hospital1 18**] ED
from [**Location (un) 3844**].
In the ED, the patient received 1 unit PRBCs. NG lavage was
negative.
Past Medical History:
colonic intertia dx [**7-/2101**]
-s/p colectomy [**2101**]
-s/p ostomy redo [**3-15**]
PUD
esophageal dysmotility
biliary sphincterotomy [**4-9**]
hypercalcemia s/p parathyroidectomy x 4
hyperthyroidism
PTSD
S/P TAH [**9-/2097**]
urinary incontinence
h/o microscopic hematuria
Osteoporosis
Carpal tunnel
headaches
arthralgias
Social History:
Denies smoking/Etoh/drugsMarried on disability
Family History:
FH of breast CA, ovarian CA, and colon CA
Physical Exam:
VS: AF 87 107/56 21 100% RA
Genl: well appearing NAD
HEENT: EOMI, PERRL, dry mm, o/p clear of lesions
Neck: supple, no [**Doctor First Name **]
CV: rr no m
PULM: CTAB
ABD: s, mild ttp over epigastrium, nd, pos bs, no organomegaly.
ostomy
EXT: no edema, palp pulses
NEUR: CN II-XII intact, 5/5 strength, no sensory deficits
Pertinent Results:
[**2109-2-5**] 03:12AM BLOOD WBC-5.7 RBC-3.31* Hgb-10.2* Hct-29.3*
MCV-88 MCH-30.8 MCHC-34.8 RDW-14.2 Plt Ct-230
[**2109-2-4**] 09:00PM BLOOD Hct-30.1*
[**2109-2-4**] 01:10PM BLOOD Hct-27.9*
[**2109-2-4**] 05:00AM BLOOD Hct-28.5*
[**2109-2-4**] 04:40AM BLOOD WBC-5.7 RBC-2.77* Hgb-8.6* Hct-25.2*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.1 Plt Ct-244
[**2109-2-3**] 10:15PM BLOOD WBC-7.8 RBC-3.04*# Hgb-9.1*# Hct-27.0*#
MCV-89 MCH-30.0 MCHC-33.7 RDW-12.5 Plt Ct-320#
[**2109-2-3**] 10:15PM BLOOD Neuts-77.7* Lymphs-19.2 Monos-2.1 Eos-0.8
Baso-0.3
[**2109-2-5**] 03:12AM BLOOD Plt Ct-230
[**2109-2-4**] 04:40AM BLOOD PT-12.9 PTT-23.9 INR(PT)-1.1
[**2109-2-5**] 03:12AM BLOOD Glucose-79 UreaN-15 Creat-0.6 Na-140
K-3.5 Cl-111* HCO3-24 AnGap-9
[**2109-2-3**] 10:15PM BLOOD ALT-20 AST-23 AlkPhos-56 Amylase-124*
TotBili-0.2
[**2109-2-3**] 10:15PM BLOOD Lipase-57
[**2109-2-5**] 03:12AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.0
[**2109-2-3**] 10:15PM BLOOD Albumin-4.0
[**2109-2-4**] 04:40AM BLOOD TSH-3.7
[**2109-2-5**] 03:12AM BLOOD Gastrin-PND
EGD [**2109-2-4**]: single cratered bleeding duodenal bulb ulcer. Tx
with epi and electrocautery.
ECG Study Date of [**2109-2-3**] 10:54:54 PM
Sinus rhythm
Normal ECG
Since previous tracing of [**2108-7-26**], no significant change
ABDOMEN (SUPINE & ERECT) [**2109-2-5**] 10:32 AM
IMPRESSION: No evidence for free intraperitoneal gas or
intestinal obstruction. Probable mild postop ileus.
CHEST (PORTABLE AP) [**2109-2-6**] 5:12 PM
IMPRESSION: Interval placement of right-sided chest tube, with
significant decrease in the size of the right-sided
pneumothorax.
CHEST (PA & LAT) [**2109-2-9**] 9:41 AM
FINDINGS:
Compared to the film from the prior day, there has been no
significant interval change in the right subclavian line with
tip in the right atrium, or small right apical pneumothorax.
There continues to be linear atelectasis in the left mid lung
and small left pleural effusion.
IMPRESSION:
No significant change.
Brief Hospital Course:
57 year old female with history of total colectomy secondary to
colonic inertia, s/p ileostomy, peptic ulcer disease, GERD, s/p
parathyroidectomy [**3-13**] hypercalcemia admitted for
gastrointestinal bleed secondary to a bleeding duodenal ulcer.
1. GIB:
The patient has a long standing history of gastric ulcers and
duodenal erosions that never healed. She was originally admitted
to the MICU for monitoring overnight. She received a total of 5
units PRBCs and IV hydration throughout her stay. She underwent
an EGD on [**2109-2-4**] which showed an ulcer in the distal and
posterior bulbs of the duodenum. Her epigastric pain persisted.
She was maintained on IV protonix 40mg [**Hospital1 **]. Gastroenterology
recommended checking gastrin levels (though have been normal in
the past to assess for possible MEN syndrome given her history
of hyperparathyroidism) which are still pending.
The patient had a complication from a central line that delayed
a repeat EGD and she was transfused as needed with serial Hcts.
Ultimately, her black stool ceased and her Hct remained stable
around 33-34. She advanced to clears without difficulty and
ultimately a house diet. She still had mild epigastric
tenderness. It was thus decided that she did not need an urgent
inpatient endoscopy and could follow up as an outpatient with
Dr. [**Last Name (STitle) 10689**] from GI for repeat endoscopy in 8 weeks.
2. Pneumothorax:
Initially, a repeat EGD was planned given her need for repeat
transfusions but delayed as the patient did not have IV access
which has been a problem in the past. As a result, a central
line was placed on [**2-6**] which resulted in a right-sided 15%
pneumothorax. The patient complained of right-sided chest pain
and chest pain with deep inspiration. As a result, her EGD was
delayed and thoracic surgery was called and inserted a chest
tube on the right side. Her vital signs were stable and she
sat'd well with 97-100% on room air. Her chest tube was
ultimately discontinued on [**2109-2-8**] and the patient had a
persistent small apical pneumothorax on the right side that
remained stable and the patient had stable vital signs without
any complaints after a short trial of 100% O2 on a
non-rebreather mask. Her central line was pulled on [**2109-2-10**]
without difficulty.
2. Abdominal pain: This represented an ongoing problem for
months to years. She recently had a negative gastric emptying
study. She has also had CT and MRCP, showing no abnormalities.
Her most recent endoscopy in [**9-/2108**] showed persistent small
gastric ulcers and duodenal erosions. She had a KUB on this
admission showing no evidence of SBO or perforation. However, an
EGD on [**2109-2-4**] confirmed a duodenal ulcer which explains her
symptoms. She was originally given vicodin and morphine for her
pain, especially after the chest tube placement, but she did not
tolerate these well. She experienced severe nausea and vomiting.
NSAIDs were not used given her active GI bleed. After the chest
tube was discontinued, the patient's pain was well-controlled
with tylenol and Ativan.
3. History of hypercalcemia:
Her hypercalcemia was not believed to be due to
hyperparathyroidism but rather to a calcium sensor defect in her
kidney that was successfully treated with a parathyroidectomy.
Her calcium had been normal as an outpatient, with the exception
of a few isolated low readings. She did develop a low corrected
calcium level in-house and was thus treated with calcium
carbonate supplements in hospital.
Medications on Admission:
atenolol 50gm once a day which she stopped taking while sick.
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer and resulting gastrointestinal bleed.
Right-sided 15% pneumothorax, resolved after chest tube
placement.
Discharge Condition:
Stable.
Discharge Instructions:
Please return to the ER or call your primary care physician if
you experience any bloody stool, lightheadedness, dizziness,
abdominal pain or shortness of breath.
You should follow up with Dr. [**Last Name (STitle) **], your primary care physician
[**Last Name (NamePattern4) **] [**2-10**] weeks and have your hematocrit rechecked.
Avoid the use of non-steroidal anti-inflammatory medications
such as ibuprofen given your duodenal ulcer as this may worsen
your symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], OD Where: [**Hospital6 29**]
Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2109-2-19**] 9:30
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2109-3-18**]
12:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2109-4-30**] 9:30
Please call ([**Telephone/Fax (1) 8622**] to schedule an appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10689**], your gastroenterologist, for evaluation and
endoscopy in 8 weeks.
|
[
"244.9",
"532.40",
"V44.2",
"789.06",
"512.1",
"532.90",
"285.1",
"530.81",
"786.52",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.33",
"99.04",
"38.93",
"34.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
8122, 8128
|
4173, 7691
|
337, 436
|
8292, 8301
|
2186, 4150
|
8823, 9603
|
1781, 1824
|
7803, 8099
|
8149, 8271
|
7717, 7780
|
8325, 8800
|
1839, 2167
|
270, 299
|
464, 1343
|
1365, 1701
|
1717, 1765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,183
| 133,706
|
28843
|
Discharge summary
|
report
|
Admission Date: [**2142-9-10**] Discharge Date: [**2142-9-14**]
Date of Birth: [**2124-11-20**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Pedestrian struck by auto
Major Surgical or Invasive Procedure:
[**2142-9-11**] Open reduction and internal fixation of right tib/fib
fractures
History of Present Illness:
17 yo male pedestrian who was struck by auto at unknown speed;
+LOC. He was medflighted to [**Hospital1 18**] for ongoing trauma care. Upon
arrival GCS 15, alert and oriented x3.
Past Medical History:
Attention deficit disorder (diagnosed @14yrs of age)
Social History:
High school student
Resides with parents and siblings
Family History:
Noncontributory
Pertinent Results:
[**2142-9-10**] 08:48PM GLUCOSE-101 LACTATE-2.9* NA+-142 K+-3.6
CL--102 TCO2-26
[**2142-9-10**] 08:34PM UREA N-12 CREAT-1.0
[**2142-9-10**] 08:34PM AMYLASE-44
[**2142-9-10**] 08:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2142-9-10**] 08:34PM WBC-16.0* RBC-4.89 HGB-14.5 HCT-40.4 MCV-83
MCH-29.7 MCHC-35.9* RDW-13.4
[**2142-9-10**] 08:34PM PLT COUNT-247
[**2142-9-10**] 08:34PM PT-12.7 PTT-23.8 INR(PT)-1.1
CT HEAD W/O CONTRAST
Reason: STUCK BY AUTO
[**Hospital 93**] MEDICAL CONDITION:
56 year old man s/p struck by auto
REASON FOR THIS EXAMINATION:
eval for bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Struck by car.
COMPARISONS: None.
TECHNIQUE: Axial MDCT images of the brain without IV contrast.
FINDINGS: There is a linear nondepressed right temporal
calvarial fracture extending into the mastoid process. There is
a small subdural hematoma with components of pneumocephalus
tracking from the mastoid air cells. There is no shift of
normally midline structures. There is also a left occipital
scalp contusion but no associated skull fracture. Prominent
sutures in this young patient, the right calvarial suture
extending into the right temporal bones appears more prominent
than its counterpart on the left, however, [**Known lastname **]s not appear to
represent an acute fracture. No other acute fractures are
appreciated. There is small amount of mucosal thickening in the
sphenoid sinuses. No air-fluid levels to suggest occult facial
fractures. Orbits are unremarkable.
IMPRESSION: Linear right temporal calvarial fracture extending
into the mastoid process with small associated right posterior
convexity subdural hematoma and pneumocephalus. Discussed with
trauma team during the study.
CT C-SPINE W/O CONTRAST
Reason: STUCK BY AUTO
[**Hospital 93**] MEDICAL CONDITION:
56 year old man s/p struck by auto
REASON FOR THIS EXAMINATION:
eval for fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 18-year-old hit by car. Head injury to the occiput.
COMPARISONS: None.
TECHNIQUE: Axial MDCT images of the cervical spine with coronal
and sagittal reformats without IV contrast.
FINDINGS: C1 through T1 are well visualized. There is normal
alignment of the cervical vertebral bodies without acute
fracture or traumatic malalignment. The posterior elements are
intact. There is no significant prevertebral soft tissue
swelling. The C1-C2 relationship is within normal limits. The
dens is intact. The lung apices are clear without pneumothorax.
The upper ribs are intact. There is a linear right temporal
calvarial fracture extending into the right temporal bones. This
appears to stop short of the carotid canal. Multiple posterior
right-sided mastoid air cells are opacified with blood.
IMPRESSION:
1) No acute cervical spine fracture.
2) Linear right temporal calvarial fracture extending into the
mastoid with a small right posterior convexity subdural hematoma
and pneumocephalus; see head CT report.
CHEST (PA & LAT)
Reason: Please r/o acute process.
[**Hospital 93**] MEDICAL CONDITION:
17 year old man with post-op fever.
REASON FOR THIS EXAMINATION:
Please r/o acute process.
INDICATION: Postoperative fever.
COMPARISONS: Comparison is made to [**2142-9-11**].
TECHNIQUE: PA and lateral views of the chest.
FINDINGS: The heart is of normal size. Mediastinal and hilar
contours are within normal limits. The lung fields are clear.
There are no pleural effusions or focal consolidations. There is
no evidence of CHF.
IMPRESSION: No evidence of significant abnormality.
TIB/FIB (AP & LAT) SOFT TISSUE
Reason: eval for alignment, post op changes
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with open RLE fx now s/p fixation
REASON FOR THIS EXAMINATION:
eval for alignment, post op changes
INDICATION: Fracture. Assess for alignment.
RIGHT TIBIA/FIBULA, AP AND LATERAL VIEWS: An intramedullary rod
is seen fixating a proximal diaphyseal comminuted tibial
fracture with six proximal and two distal screws. Additionally,
a side plate is seen medially fixating the fracture. There is a
non-displaced comminuted fracture of the proximal fibular
diaphysis. There is surrounding soft tissue swelling. Os
trigonum is visualized.
IMPRESSION: Comminuted proximal tibiofibular fractures status
post ORIF of the tibia with an intramedullary rod and side
plate. No evidence of immediate hardware complication.
CT HEAD W/O CONTRAST
Reason: follow up ct
[**Hospital 93**] MEDICAL CONDITION:
17 year old man with pneumocephalus s/p ped v. mvc
REASON FOR THIS EXAMINATION:
follow up ct
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: History of pneumocephalus status post
pedestrian versus motor vehicle collision. Follow up CT scan.
COMPARISON: Non-contrast head CT from [**2142-9-11**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: The previously noted subdural hemorrhage in the right
posterior fossa appears less conspicuous. The pneumocephalus
adjacent to the linear skull fracture appears to have decreased
in size. There are persistent bifrontal and right parietal
hemorrhagic contusions with surrounding edema and possible small
left frontal subarachnoid hemorrhage (adjacent to falx) which
are largely unchanged. There is no shift of normally midline
structures or hydrocephalus. The ventricles, cisterns and sulci
are normal. The air- fluid level in the right sphenoid sinus and
bilateral opacification of the mastoid air cells are unchanged.
IMPRESSION:
1. Decreased size of right posterior subdural hemorrhage.
2. Multifocal hemorrhagic contusions and surrounding edema are
largely unchanged.
Brief Hospital Course:
He was admitted to the trauma service. Orthopedics and
Neurosurgery were consulted because of his injuries. His
Neurosurgical issues were nonoperative; he was loaded with
Dilantin; serial head CT scans were performed and were stable.
He will need to follow up with Dr. [**Last Name (STitle) **] in 4 weeks for repeat
head imaging and continue with Dilantin for one month.
His right tib/fib fracture was repaired by Orthopedics on [**9-11**];
postoperatively there were no complications. Weight bearing
status was increased to weight bearing as tolerated. He was
fitted with a hinged [**Doctor Last Name **] brace for his LLE. He will need to
continue on Lovenox injections for at least 4-6 weeks.
He was transfused with 3 u packed cells for a hematocrit of 21,
post transfusion HCT was 26.1; there was a questionable
transfusion reaction at the end of his first unit of packed
cells; he did subsequently receive the remaining 2 units without
any further reaction.
Physical and Occupational therapy were consulted and have
recommended home with services.
Medications on Admission:
None
Allergic to PCN and Sulfa
Discharge Medications:
1. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO three times a day for 1 months.
Disp:*180 Tablet, Chewable(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. Lovenox 40 mg/0.4 mL Syringe Sig: 0.4 ML's Subcutaneous once
a day for 30 days.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
s/p Pedestrian Struck by Auto
Subdural hematoma
Skull fracture
Right comminuted tibia/fibula fracture
Discharge Condition:
Good
Discharge Instructions:
Return to the emergency room if you develop fevers, chills,
severe headaches, visual disturbances, nause, vomiting and/or
any other symptoms that are concerning to you.
You will need to conrtinue with your Lovenox injections for at
least 4-6 weeks as instructed by Orthopedics
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 7376**], Orthopaedics in [**9-29**] days, call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up with Dr. [**Last Name (STitle) **], Neurosurgery in 4 weeks; call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat head CT scan for this appointment.
Completed by:[**2142-9-18**]
|
[
"805.4",
"305.1",
"780.6",
"803.20",
"999.8",
"823.92",
"E814.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.33",
"99.04",
"79.36"
] |
icd9pcs
|
[
[
[]
]
] |
8194, 8245
|
6463, 7521
|
325, 407
|
8391, 8398
|
814, 1319
|
8724, 9099
|
778, 795
|
7603, 8171
|
5310, 5361
|
8266, 8370
|
7547, 7580
|
8422, 8701
|
256, 287
|
5390, 6440
|
435, 615
|
637, 691
|
707, 762
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,369
| 186,547
|
22267
|
Discharge summary
|
report
|
Admission Date: [**2180-9-5**] Discharge Date: [**2180-11-15**]
Date of Birth: [**2109-11-8**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Sub-sternal chest pain
Major Surgical or Invasive Procedure:
s/p cath and stent placement to LCX and LAD
s/p tracheostomy
History of Present Illness:
70y/o M w/ DM2, Hypercholesterolemia, obesity, and tobacco use.
Woken up at 4am by substernal non radiating chest pain, went to
bathroom and came back, chest pain worsened [**10-22**], severely
diaphoretic, wife noticed patient was very pale. No sob, no
LH/dizzyness, called EMS they arrived at ~6am. Transported to
[**Hospital 58045**] hospital, en route received NTG x3, asa, oxygen, pain
decreased to [**5-22**]. At GSM EKG initially showed STE in leads
II,III,AVF with STD in V1-V4. Pt repeat EKGs then showed STE in
II,III,AVF as well as V5-V6 with coupling. Patient received
heparin bolus and gtt, integrellin gtt, morphin sulfate 2mg x 3,
lopressor 5mg x 2, and transferred to [**Hospital1 18**] for PCI. Cath
revealed: Right Dominant; 3vd+LM; RCA-TO distal; LMCA-small with
mild dampining; LAD-80% proximal/mid; LCx-90% thrombotic
proximal lesion. HD: RA 13; RV 58/16; PAP 58/30; PCWP 31; CO
4.0; CI 2.2; SVR 1665; PASat 72% Cypher stent was placed in the
LCx. Pt had IABP placed due to high filling pressures, bridge to
possible CABG, and because of LM disease. Pt CI was around 1.6
so pt [**Name (NI) 8213**] was increased with no improvement so low dose
dopamine was started.
Past Medical History:
DM2, hypercholesterolemia, h/o DVT (2 clots in left leg) treated
medically 2 years ago, h/o ruptured disk s/p surgery [**01**]-30yrs
ago, colonic polyps (non malignant per patient), urinary
incontinence, obesity.
Social History:
h/o tobacco use, no etoh, no ivdu,
Family History:
CAD, DM, Cancer; Father died 75 from MI, Brother 62 from MI,
sister 60's from MI.
Physical Exam:
VS: afebrile, BP 125/72, HR 64, RR13
Pertinent Results:
Brief Hospital Course:
70 yo M with DM2 who p/w STEMI with PCI's to LCx and LAD, c/b
pericardial effusion/pericarditis, ARF, liver failure, PNA, CHF,
HIT, AFib. Brief course by system.
1. CARDIOVASCULAR
-A. Coronaries/CAD: Severe 3vd + LM by cath report with initial
PCI placed in LCx. Pt was continued on Asa, plavix, metoprolol,
Lipitor, and an [**Year (2 digits) **]. CT [**Doctor First Name **] consulted and pt received a stress
test to assess if CAD significant enough for CABG but the MIBI
showed an irreversible defect and so it was felt that a CABG
would not be beneficial. Following this, however, pt developed
SSCP again that was unable to be controlled with a nitro gtt and
multiple other medications. ECG showed slight ST depressions in
V2-V5 and pt was taken emergently back to Cath where it was seen
that the LCx was still patent. At this time 3 stents were placed
in the LAD, however after the procedure the pt was still c/o CP.
BP was slightly low after the cath and an echo showed a
pericardial effusion without tamponade - managed as below. Pt
was continually managed on ASA, plavix, Metoprolol, and
Atorvastatin. Captopril was held while pt had ARF. Several times
during admission, low dose captopril was added to the medical
regimen, however Pt suffered from short episodes of hypotension
where on one occasion required brief pressor support. After
discharge, Patient should be restarted on ace inhibitor once Pt
stable and volume status maximized.
*
-B. Pump/CHF: ECHO showed EF 30-40%. Pt had IABP initially
placed after cath then removed since it was determined that it
was not helping pt. Pt eventually weaned of Dopamine and
improved. He was felt to be in CHF and was diuresed gently until
the pericardial effusion was discovered - likely Dressler's
syndrome. No evidence of tamponade. Pt was given some fluids and
watched carefully. He remained hemodynamically stable and the
effusion was followed with serial echo's and was seen to be
resolving. At no point did the pt have hemodynamic compromise or
pulsus.
Pt's O2 sats were low, however, and he was felt to be wet based
on lung exam and peripheral edema. Cr bumped to 4.6 following
the second cath (likely ATN) and UOP dropped. He was given
hemodialysis and O2 sats and lung exam gradually improved. Once
kidney fxn improved with time he was diuresed with lasix. He
received dye loads with imaging of his LE's and Cr bumped again
so diuresis was slowed but eventually he was successfully
diuresed with Lasix. Overall Pt volume overloaded but stable.
Needs continued gentle diuresis with lasix. Pt has responded to
Lasix quite well while hospitalized and should continue to be
diuresed gentle adjusting the Lasix dose as necessary.
*
-C. Rhythm/A fib: When pt was initially admitted he was in NSR.
On [**9-7**] he went into AFib and was started on a heparin gtt.
Cardioversion was attempted on [**9-8**] but was unsuccessful and so
pt was started on Amiodarone. Initially his HR was difficult to
control (120's-130's) and was refractory to max doses of
metoprolol. He was started on digoxin for one day, however, then
he started c/o nausea and it was felt that digoxin would not
likely be a good drug for him. At this point he had the
recurrent CP and was taken back to cath. After cath and the
development of the pericardial effusion, his HR remained in the
70-80's even without metoprolol. He was maintained on the
amiodarone only. Heparin was stopped when HIT was discovered,
and then amio was stopped when liver enzymes became extremely
elevated. Pt remained in AFib and rates were well controlled
with metoprolol that was again titrated up to 100 po tid.
However, during hospital stay suffered from hypotension at times
requiring cessation of beta blockade. Pt was restarted on short
acting carvediol and tolerated dose of 3.125 mg po qd. On
discharge, patient a fib seems too be well rate controlled on
his current coreg dose. He will need to be cardioverted as an
outpatient after 4 weeks therapeutic INR. In regards to
anti-coagulation, Pt's coumadin briefly held secondary to GI
bleed and restarted one week prior to discharge. INR
supratherapeutic on 5mg po qhd and will be sent home on 3mg po
qhs. INR will require multiple checks in the upcoming weeks.
*
-D. Peripheral vasculature: Pt was found to be HIT-Ab+ and was
started on argatroban right away. He was ruled out for PE's with
an MRI and hepatic vein thrombosis with abdominal ultrasound. He
did develop ischemic necrosis of his R foot which was felt to be
due to HIT as well as possible cholesterol emboli. He underwent
angioplasty of R Posterior Tibial artery with increased
perfusion. Since patient has diffuse dry gangrene vascular
surgery recommends that he return for follow up in [**2-15**] weeks to
determine if amputation will be necessary. At time of discharge
vascular surgery would consider bypass grafting for which he
needs to follow up after discharge from rehab. This is no
indication for amputation at this point. Patient should also
follow up with HEME.
*
2. Pulm: Pt was felt to be hypoxic during this hospitalization
mostly due to pulmonary edema. ABG's remained stable and O2 was
titrated to keep O2sats above 93%. O2sats improved and oxygen
requirements decreased as pt was diuresed. He was felt to have a
possible pneumonia in the middle of his hopitalization that was
treated with ceftriaxone x 10 days. Pt was ventilated for a
prolonged period requiring tracheostomy. At time of dischage
patient over ventilator support for 5 days requiring on oxygen
by face mask.
*
3. Renal: Pt came in with a Cr of 1.3. His kidney function
remained relatively good until the 2nd cardiac catheterization,
afterwhich the pt was felt to suffer from dye-induced ATN. Cr
bumped to 4.6 and UOP dropped. He was given hemodialysis for
several days in order to keep his fluid status stable. His
kidneys then recovered and UOP rose. Cr trended down. After this
pt was treated with mucomyst before and after all of his dye
related proceudures but Cr bumped up slightly again after
catheterization of R foot occurred. At discharge Pt Cr stable at
1.6, slightly elevated from his baseline.
*
4. GI: Pt had hematemesis episode [**9-5**]. EGD showed gastritis
only and pt was started on Protonix 40 [**Hospital1 **]. He later had a 2 day
episode of nausea and vomiting which was guiac negative in the
middle of the hospitalization of which etiology was not
determined. Symptoms resolved with PR compazine. Later he also
had guiac positive stools, but Hct remained stable. Recommend pt
obtain further workup for GIB as outpt with colonoscopy. Pt also
had an episode of tongue swelling after his foot angioplasty
which was felt to be an allergy to the dye. He was given
benadryl, solumedrol, and famotidine and symptoms resolved. Pt
to be discharged on prilosec daily.
*
5. HEME: Coagulopathy/thrombocytopenia: HIT + causing
microangiopathic ischemic feet, on argatroban [**9-18**]. This was
titrated carefully to avoid supratherapeutic levels (PTT target
60-75). After all surgical procedures were completed, pt was
transitioned to coumadin, which he will need to be on for
approximately 3-6 months due to HIT.
*
6. ENDOCRINE: DM2 was stable and pt was followed by [**Last Name (un) **].
*
7. Neuro: During the fourth week of his hospitalization the pt
began to have episodes of confusion most consistent with
sundowning. He was calmed and reoriented easily. Started zyprexa
2.5 mg po qhs.
On the day patient was to be discharged to [**Hospital 1474**] rehab with
the aforementioned hospital course, he began having BRBPR with
BP to 88/54. Patient was stabilized and given 2 units of RBC and
4 units of FFP to reverse high INR. Tagged red cell study was
performed which showed delayed bleeding on sigmoid area. During
this time period HCTs were- 33.1 (prior to bleed)--30.5--30.8
(after transfusion crit want to 33.7)and INR became 1.4. Patient
was transferred back to unit. INR on [**10-11**] was 1.7 so patient was
given 2 more units if FFP and he had more bleeding from the
rectum with and hct fell to 27.8. Patient was then given 2 more
units of RBCs and hct was then 40. Patient was preped for
colonoscopy. On the morning of [**10-12**] patient became acutely
hypoxic and agitated, and the question of PE arose. Patient also
was given diltiazem for afib with RVR. ABG at that time as
7.31/75/70 and chest x-ray indicated worsening failure so
patient was given lasix. On exam it seemed patient was not
moving much air, so he was given nebs and bipap. Simultaneously
patient began bleeding form rectum. Patient was placed on 100%
non-rebreather and blood gas was then 7.28/81/116. Thereforem
decision to intubate and obtain CT to rule out PE. Post
intubtaion, patient systolic bp dropped to 50. Sats in the 80's.
R IJ cortis was placed and NS bolus was given. 1 unit FFP given
and Levophed given. Bp increased to 200/100. Patient heart rate
increased to 140's and he was given lopressor. There was no
evidence of PE on CT. In addition, nurse [**First Name (Titles) 23491**] [**Last Name (Titles) **] that
patient was inadvertently given heparin -- slight amount in
flush. heme was then consulted. Once stable, patient had repeat
tagged red cell scan and was prepped for colonoscopy.
Colonoscopy revealed a rectal ulcer.
A narrative of the hospital course following this sentinel
event:
The bleeding slowly resolved on argatroban but he remained
intubated with difficulty weaning from the ventilator. As his
fluid overloaded state with pulmonary edema was thought to be
contributing to this, multiple attempts were made to diurese
extra fluid using dopamine/vasopressin as needed for
hypotension, natrecor, lasix, with only moderate success. A PA
catheter was inserted for tighter control of volume status on
[**2180-10-19**]. Eventually diuresis was achieved with 1-2 liters out
per day. Potassium had to be repleted extremely aggressively
during this period, and he was able to achieve negative fluid
balance of minus 1-2 liters per day. The ACE and beta blocker
were held due to low blood pressures.
He also had multiple runs of syptomatic NSVT starting [**10-15**]. For
these he was continued on metoprolol and loaded on amiodarone.
Additionally, it was felt that this lack of diuresis and poor
pressures were due to the A. fib. A TEE revealed no thrombus on
[**2180-10-20**], so he was loaded with amiodarone and he was
cardioverted multiple times, cardioverted [**10-20**]-> back in Afib
[**10-22**]-> reattempt cardioversion [**10-22**]-> back in Afib in minutes
- reattempt cardioversion [**10-25**] - back in 2 days. As these were
unsuccessful, the amiodarone was decreased to QD dosing for VT
prevention. Anticoagulation with argatroban changing over to
coumadin is planned.
A third reason it was believed that it was difficult to extubate
him during the original intubation is that he had a persistent
metabolic alkalosis. This was believed to be a result of
respiratory compensation leading to apnea. After failing diamox
he was given arginine 60 g iv for two days which corrected the
bicarbonate and his apnea.
He also developed hypernatremia during hospitalization and was
maintained on free water boluses to keep his sodium less than
145.
He was extubated [**2180-10-27**] successfully following a 3 day period
of sinus rhythm, then 3 days later had to be reintubated for
respiratory distress and hypotension later discovered to be a
recurrent MSSA pneumonia. The swan was reinserted which showed a
picture consistent with sepsis superimposed on CHF. He was
treated with vasopressin. oxacillin and then trached due to the
difficulties of weaning from the ventilator. He was weaned with
pressure support and trach collar as tolerated.
While on the argatroban, he began to again have BRBPR/melena on
[**11-1**]. GI was reconsulted and an EGD showed gastritis without
active bleed. Since he had a known rectal ulcer, this was
thought to be the cause and supportive care was maintained and
the argatroban was held. He was transfused to keep above 30.
Vascular surgery signed off during the hospitalization and he
may choose to have lower leg amputations as an outpatient.
His blood sugars were controlled with insulin drip transitioned
to ISS.
Pt started on empiric Zosyn upon suffering from hypotension. Pt
without obvious source of infection. At time of discharge Pt
was treated for 10 out 14 days of Zosyn. Pt to continue Zosyn
6.25 q6hr times 5 days upon discharge.
Medications on Admission:
Glucophage, MVI, ASA, lipitor, ?one other DM med
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 300 days.
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day) as needed.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
9. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO QD ().
12. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO QD ().
13. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD ().
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
15. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
16. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
17. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q3-6H () as needed.
18. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for insomnia, anxiety.
19. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
20. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
21. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): titrate as needed for goal INR [**2-15**].
22. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): titrate for volume status.
23. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 5 days.
24. Insulin sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
status post st wave elevation MI
CHF
Heparin Induced thrombocytopenia
AFib
GI bleed secondary to gastritis and antral ulcer
necrotic toe with dry gangrene
diabetes
s/p traceostomy
Discharge Condition:
stable
Discharge Instructions:
please follow up with the appointments listed below,
continue to monitor your daily weights and call your doctor
immediately if there is a significant weight change.
call your doctor/ or go to ER if you develop chest pain, SOB,
fainting.
Followup Instructions:
Please follow up with your primary care physician, [**Name10 (NameIs) **],[**Name11 (NameIs) 569**]
[**Name Initial (NameIs) **]. [**Telephone/Fax (1) 36098**], within 1 week after discharge from rehab.
please call for follow up with Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 4022**]. Pt
will need to be started on ace inhibitor after CR is stable and
BP stable.
please calll and make a follow up appointmnet with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 284**] (EP) ([**Telephone/Fax (1) 5862**]. Patient will need cardioversion
after 4 weeks of anticoagulation secondary to A. fib.
please make a follow up appointmnet with Dr. [**Last Name (STitle) 1391**] in
vascular surgery to evaluate AV fistula and perfusion of feet,
question amputation verse bypass.
Please call and reschedule your follow up appointmnet with
Hematology for heparing induced thrombocytopenia: Provider:
[**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
[
"287.4",
"E934.2",
"570",
"427.31",
"411.0",
"410.71",
"428.0",
"440.24",
"995.92",
"535.01",
"038.9",
"584.5",
"442.3",
"785.59",
"482.41",
"518.81",
"997.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.07",
"99.20",
"39.95",
"31.1",
"39.90",
"36.07",
"37.22",
"43.11",
"89.64",
"00.13",
"45.13",
"96.6",
"99.62",
"00.17",
"39.50",
"88.72",
"45.23",
"37.61",
"99.04",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
16835, 16907
|
2082, 14516
|
318, 381
|
17131, 17139
|
2059, 2059
|
17425, 18594
|
1903, 1986
|
14615, 16812
|
16928, 17110
|
14542, 14592
|
17163, 17402
|
2001, 2039
|
256, 280
|
409, 1599
|
1621, 1835
|
1851, 1887
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,267
| 166,355
|
53767
|
Discharge summary
|
report
|
Admission Date: [**2171-3-9**] Discharge Date: [**2171-3-22**]
Date of Birth: [**2128-4-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
Trauma: s/p MVC
Major Surgical or Invasive Procedure:
[**2171-3-9**] - exploratory laparotomy, left nephrectomy
[**2171-3-9**] - left posterior auricular advancement flap
[**2171-3-10**] - anterior odontoid ORIF
History of Present Illness:
42M unrestrained driver, ejected in high-speed MVC. Presented
with hypovolemic shock in setting of shattered L kidney, as well
as type 2 odontoid fracture and multiple other spine fractures.
Brought to OR for exploratory laparotomy and left nephrectomy.
Past Medical History:
PMH: none
PSH: none
Social History:
Drinks 1 case of beer/night.
Family History:
N/C
Physical Exam:
PHYSICAL EXAMINATION: upon admission: [**2171-3-9**]
HR: 112 BP: 94/66 Resp: 19 O(2)Sat: 100 Normal
Constitutional: intubated, sedated
HEENT: Pupils equal, round and reactive to light, abrasions
to scalp
ETT in place
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended
GU/Flank: no evidence of trauma
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: intubated, no movement of ext's
Psych: unresponsive
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Physical examination upon discharge: [**2171-3-22**]:
Vital signs: 97.7, hr=95, bp 128/85, resp. rate 18, oxygen sat
95% room air
General: Resting comfortably in bed, NAD
CV: Ns1, s2, -s3, -s4
LUNGS: Decreased breath sounds bases bil.
ABDOMEN: soft, non-tender
EXT: + dp bil., no pedal edema bil.
NEURO: Oriented to name, disoriented to time and place, random
movement of upper ext., wiggles toes randomly
SKIN: head laceration clean and dry, right ear lacertion clean,
no ulcerations coccyx
Pertinent Results:
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2171-3-22**] 11:05 66*1 25* 1.3* 128* 5.3* 89* 26 18
[**2171-3-22**] 05:09 991 22* 1.1 129* 5.2* 92* 25 17
[**2171-3-18**] 06:02AM BLOOD WBC-12.1* RBC-3.84* Hgb-11.3* Hct-34.7*
MCV-91 MCH-29.3 MCHC-32.4 RDW-14.7 Plt Ct-456*
[**2171-3-17**] 05:45AM BLOOD WBC-9.1 RBC-3.52* Hgb-10.6* Hct-31.9*
MCV-91 MCH-30.0 MCHC-33.1 RDW-14.5 Plt Ct-388
[**2171-3-9**] 10:23AM BLOOD Neuts-84.7* Lymphs-10.9* Monos-3.8
Eos-0.4 Baso-0.3
[**2171-3-18**] 06:02AM BLOOD Plt Ct-456*
[**2171-3-17**] 05:45AM BLOOD Plt Ct-388
[**2171-3-10**] 01:27PM BLOOD PT-11.3 PTT-25.8 INR(PT)-1.0
[**2171-3-10**] 12:51AM BLOOD PT-11.4 PTT-25.2 INR(PT)-1.1
[**2171-3-9**] 06:40AM BLOOD PT-12.9* PTT-26.7 INR(PT)-1.2*
[**2171-3-9**] 10:23AM BLOOD Fibrino-252#
[**2171-3-9**] 06:40AM BLOOD Fibrino-123*
[**2171-3-18**] 06:02AM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-136
K-3.5 Cl-101 HCO3-24 AnGap-15
[**2171-3-17**] 05:45AM BLOOD Glucose-99 UreaN-16 Creat-1.0 Na-139
K-3.8 Cl-101 HCO3-25 AnGap-17
[**2171-3-16**] 08:00AM BLOOD Glucose-84 UreaN-20 Creat-1.0 Na-143
K-4.0 Cl-105 HCO3-27 AnGap-15
[**2171-3-18**] 06:02AM BLOOD ALT-32 AST-31 AlkPhos-82 TotBili-2.0*
[**2171-3-17**] 05:45AM BLOOD ALT-35 AST-46* AlkPhos-75 Amylase-135*
TotBili-2.9*
[**2171-3-18**] 06:02AM BLOOD Lipase-184*
[**2171-3-17**] 05:45AM BLOOD Lipase-235*
[**2171-3-18**] 06:02AM BLOOD Albumin-3.4* Calcium-8.9 Phos-2.9 Mg-1.9
[**2171-3-17**] 05:45AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
[**2171-3-9**] 03:43AM BLOOD ASA-NEG Ethanol-230* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2171-3-13**] 09:09AM BLOOD Lactate-0.9
[**2171-3-10**] 01:42PM BLOOD Glucose-102 Lactate-1.2
[**2171-3-13**] 09:09AM BLOOD freeCa-1.02*
[**2171-3-10**] 01:42PM BLOOD freeCa-1.04*
[**2171-3-9**]: cat scan of the c-spine:
IMPRESSION: Odontoid fracture extending into the articulating
surface of the
left lateral mass (type 2 odontoid fracture) as well as
additionalfracture of the lateral mass extending down into the
transverse process. Left C3 and C4 and possibly C5 transverse
foramen fractures. Pre-vertebral soft tissue swelling evident.
These injuries are concerning for injury to the left vertebral
artery, particularly in patient with GCS of 3 and no obvious
intracranial hemorrhage. Recommend evaluation with CTA.
Ligamentous injury also likely. Additional possible anterior
inferior endplate fracture at C5 No pre-vertebral soft tissue
swelling evident at this level.
[**2171-3-8**]: head cat scan:
IMPRESSION: No intracranial process. No evidence of edema. Large
right-sided subgaleal hematoma
[**2171-3-9**]: cat scan of abdomen and pelvis:
IMPRESSION:
1. Shattered left kidney (Grade V injury) with devascularied
lower and
interpolar regions. Vascularized fragment in the upper pole has
a laceration extending to renal pelvis. Right kidney is
uninjured.
2. Splenic hematoma/laceration extending towards but not
definitively
involving the hilum.
3. Large retroperitoneal hematoma extending down the left
iliopsoas to the
level of the femoral head.
4. Multiple fractures of the spine and pelvis as described
above.
[**2171-3-9**]: CTA neck:
IMPRESSION: The left vertebral artery is hypoplastic as
apparent from this smaller transverse foramen on the left side.
The left vertebral arteries opacified from the origin in the
subclavian to the region of left posterior inferior cerebellar
artery. There is no evidence of flap visualized of the vertebral
arteries to indicate dissection. There is no compression seen in
the region of fracture. No other vascular abnormalities are
seen. No extravasation of contrast to indicate vascular tear
identified. An endotracheal tube tip is in the glottic region.
[**2171-3-10**]: MR cervical spine:
IMPRESSION:
Fracture of the odontoid process identified without significant
edema or
displacement. Small amount of fluid is seen within the left
atlantoaxial
joint. Prevertebral soft tissue swelling is identified
indicating small
hematoma extending from C2-C5. Posterior ligamentous signal
changes are seen indicating trauma without evidence of
ligamentous disruption. No evidence of intraspinal hematoma or
spinal cord compression seen.
[**2171-3-11**]: cat scan of sinus and mandible:
1. Loculated fluid within right frontal, bilateral ethmoid, and
bilateral
maxillary sinuses. Mucosal thickening of the sphenoid sinuses.
2. Status post screw fixation of an odontoid fracture. Fractures
of C2 left lateral mass and left transverse foramen are similar
to the prior study.
[**2171-3-13**]: cat scan of abdomen and pelvis:
1. Status post left nephrectomy. Multiple splenic lacerations,
similar to
the prior study.
2. No new interval bleed within the abdomen and pelvis. Small
amount of
ascites in the perihepatic region, right paracolic gutter and
pelvis.
3. Mild ileus. No evidence of bowel obstruction.
4. Multiple lumbar spine and right iliac [**Doctor First Name 362**] fractures.
[**2171-3-13**]: cat scan of the head:
Several new small [**Doctor Last Name 352**]-white junction hypodensities, one of
which is
associated with a small amount of blood product, concerning for
diffuse axonal injury. MRI may be obtained for further
evaluation.
2. Bifrontal subdural spaces have increased, compatible with
small subdural effusion. No ventriculomegaly.
[**2171-3-14**]: chest x-ray:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The monitoring and support devices are constant.
Borderline size of the cardiac silhouette, bilateral pleural
effusions that might have slightly increased. Subsequent areas
of atelectasis bilaterally. No newly appeared focal parenchymal
opacities. No pneumothorax.
[**2171-3-15**]: chest x-ray:
FINDINGS: Interval extubation and removal of nasogastric tube.
Heart size is upper limits of normal. Worsening pulmonary
vascular congestion with
accompanying mild-to-moderate edema. Moderate bilateral
effusions are again demonstrated with associated lower lobe
atelectasis.
[**2171-3-17**] 8:49 am SWAB Source: right piv site.
WOUND CULTURE (Preliminary): RESULTS PENDING.
[**2171-3-21**]; cat scan of the chest:
IMPRESSION:
1. No fluid collection or infectious process to explain rising
WBCs and fever.
2. Decreased small left pleural effusion.
3. Splenic lacerations
4. Nearly completely resorbed retroperitoneal hematoma
5. Multiple fractures of the right iliac [**Doctor First Name 362**], T5, T11, and L4
spinous
processes and L2,3,4,5 right transverse processes.
6. Right hilar adenopathy and small left hilar and mediastinal
lymph nodes
stable from [**2171-3-9**]. This can ce seen in sarcoidosis. Follow-up
chest CT in 3 months is recommended to evaluate for resolution.
Brief Hospital Course:
The patient was admitted to the trauma service after being
involved in a motor vehicle accident. He was intubated at the
scene with a GCS of 3. The emergency room course was
complicated by hemodynamic instability with FAST and then cat
scan demonstrating left renal grade 4 injury. The patient was
taken to the operating room for emergent exploratory laparotomy
necessiating a left nephrectomy. In the operating room he
received 6uPRBS, 5uFFP, 2u Cryo, and 5 liters of crystalloid
with a [**2-17**] liter blood loss. His hematocrit post-op was 33. He
was monitored in the intensive care unit after the procedure.
Course of events while in the intensive care unit:
Neuro: He was unresponsive upon arrival to the ED.
Post-operatively his mental status improved and he was able to
be extubated. He was found on head cat scan to have a large
right-sided subgaleal hematoma. No intervention was recommended
by neurology.
Post-extubation he remained lethargic, but was alert and
oriented, and followed commands. He admitted to a significant
alcohol history, and was started on a CIWA protocol. He had an
unstable C2 fracture, which was repaired by ortho spine. He is
to stay in his [**Location (un) 2848**] J brace until follow-up with ortho spine.
He also has multiple cervical, lumbar and thoracic spine
fractures.
CV: Post-operatively he remained hemodynamically stable. He was
tachycardic and hypertensive, which was treated with
beta-blockers and pain medication. After discovering his
alcohol history and starting the CIWA protocol, his hypertension
and tachycardia improved with the addition of beta-blockers.
Resp: He was extubated on POD 1 and was stable. He vomited and
aspirated on [**2171-3-13**], which progressed to respiratory distress
and required intubation. A bronchoscopy performed that morning
showed bilious fluid in the lungs.
GI: A small serosal tear of the 4th portion of the duodenum was
noted intra-operatively, and primarily repaired. He was kept
NPO with intravenous fluids. He had increasing emesis [**3-12**] into
[**3-13**], associated with abdominal distention. An oral gastric
tube was placed after intubation, and a significant amount of
bilious fluid was removed. A cat scan was performed to
evaluate for ileus, obstruction, or worsening of duodenal
injury. No new bleed was identified.
GU: He underwent emergent left nephrectomy for a shattered
kidney and hemodynamic instability. His foley was kept to
gravity post-operatively, and his hematuria slowly cleared.
When acceptable to urology, his foley catheter was removed and
he was able to void without difficulty. His creatinine peaked
at 1.3, and then trended down to 1.1.
Heme: He required multiple transfusions immediately after
presentation and while in the operating room. He received a
total of 4u cryoprecipitate, 6u FFP, and 8u PRBC. His
hematocrit stabilized immediately post-operatively, and he did
not require any further transfusion. His hematocrit is currently
stable at 38.
ID: He received appropriate peri-operative antibiotics. He had
a complex left posterior auricular laceration, which was
repaired by plastic surgery. He was kept on cipro x5 days after
repair.
MSK: Right iliac fracture was reported on imaging. Orthopedics
was consulted and recommended closed treatment with weight
bearing as tolerated bilateral lower extremities. Splints were
applied to his lower extremities.
Social services have been involved in his care providing support
to the family. His vital signs have remained stable with the
addition of beta-blockers. His white blood cell count is
decreasing to 14.6 form 16.6. He underwent a cat scan of the
abdomen on [**3-22**] and no abdominal collections were noted. He is
tolerating a regular diet with supervision and voiding without
difficulty.
He is preparing for discharge to an extended care facility where
he can further regain his strength and mobility.
Of note: hilar and mediastinal lymph nodes reported stable on
cat scan, but follow-up cat scan recommended in 3 months per
radiology
Of note: electrolytes repeated prior to discharge: Na= 128,
K=5.3, creat 1.3. Rehabilitation facilty informed of results
and results faxed. Informed of need to repeat electrolytes in
morning.
Medications on Admission:
none
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
4. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: hold for increased sedation, resp. rate <12.
9. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for systolic blood pressure <120, hr <60.
10. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
11. hydralazine 50 mg Tablet Sig: One (1) Tablet PO every six
(6) hours: hold for systolic blood pressure <120, hr <60.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Trauma:
Type 2 odontoid fracture
Left C3, C4 transverse foramen fracture
Right subgaleal hematoma
Shattered left kidney (grade [**3-21**])
Splenic hematoma/laceration
T5, T11, L4 spinous process fracture
Right L1, L2, L5 transverse process fracture
Comminuted right iliac fracture
Right posterior ear laceration
Discharge Condition:
Mental Status: oriented to name, answeres questions, follows
commands
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after you were involved in a
car accident. You sustained injuries to your neck, head, back
and pelvis as well as a laceration to your spleen and an injury
to your left kidney. Because of the extent of your injuries, you
were seen by Neurology, orthopedics, and the plastic service
and you were monitored in the intensive care unit. You were
taken to the operating room where you had your left kidney
removed and a tear in your intestine repaired. You returned
to the operating room for stabilization of your neck and repair
of a right ear laceration. Your vital signs have stabilized and
you were discharged from the intensive care unit to the surgical
floor. You have been evaulated by physical therapy. Your white
blood cell count is slowly coming down. Your vital signs are
stable and you are preparing for discharge to an extended care
facility where you can further regain your strength and
mobility.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2171-4-9**] at 2:30 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**] in ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2171-4-24**] at 10:25 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SPINE CENTER
When: WEDNESDAY [**2171-4-24**] at 10:45 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 8603**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2171-3-26**]
|
[
"873.49",
"E812.0",
"787.22",
"958.4",
"518.52",
"780.97",
"872.01",
"852.24",
"920",
"401.9",
"907.0",
"808.41",
"805.4",
"276.2",
"805.02",
"303.01",
"785.6",
"866.03",
"507.0",
"427.89",
"863.21",
"865.01",
"805.03",
"868.04",
"285.1",
"805.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62",
"03.53",
"46.71",
"18.79",
"96.72",
"78.59",
"54.0",
"55.51",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14212, 14309
|
8765, 13019
|
320, 479
|
14666, 14666
|
1993, 8072
|
15849, 16862
|
868, 873
|
13074, 14189
|
14330, 14645
|
13045, 13051
|
14877, 15826
|
888, 888
|
911, 913
|
264, 282
|
8104, 8742
|
1508, 1974
|
507, 763
|
928, 1492
|
14681, 14853
|
785, 806
|
822, 852
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,816
| 198,968
|
54902
|
Discharge summary
|
report
|
Admission Date: [**2127-6-26**] Discharge Date: [**2127-7-1**]
Date of Birth: [**2057-4-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain and Dyspnea on exertion
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x2 with the left
internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the obtuse
marginal artery.
History of Present Illness:
70 year old male with history of coronary artery disease with
previous myocardial infarction with DES to LAD. He had been
complaining of chest tightness and dyspnea with minimal
activity, last episode of chest pain last
night, resolved with 1 SL nitroglycerin
Past Medical History:
Coronary artery disease
Anterior myocardial infarction with LAD stenting
Hypertension
Dyslipidemia
Social History:
Lives with: son
Contact: Phone #
Occupation:
Cigarettes: Smoked no [] yes [x] last cigarette >10 years ago
Hx:50 pky
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-25**] drinks/week [] >8 drinks/week [x]
Illicit drug use-drinks 1-2 beers most nights
Family History:
Father CVA deceased at 60
Mother Tuberculosis deceased
Sister deceased brain tumor
Physical Exam:
Physical Exam
Pulse:62 Resp: O2 sat: 96%
B/P Right: 119/63 Left:
Height: 64 in Weight: 145 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade _2/6 systolic
_____
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] No Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact x[]
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+-felt at AT Left:2+
PT [**Name (NI) 167**]:1+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Intra-op TEE [**2127-6-27**]
PREBYPASS: The left atrium is normal in size. The right atrium
is dilated. The left ventricular cavity is dilated. There is
severe regional left ventricular systolic dysfunction with
akinesis in the LAD distribution; LVEF = 20-25%.. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is a trivial/physiologic
pericardial effusion. Mild descending thoracic aortic
atherosclerosis. Intact IAS. No clot seen in LAA. Normal
coronary sinus.
POSTBYPASS: Improved LV systolic function. Improved wall motion
in area of LAD distribution. Otherwise uncanged. No dissection
seen after cannula removed.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2127-6-27**] 15:54
?????? [**2118**] CareGroup IS. All rights reserved.
.
[**2127-7-1**] 04:46AM BLOOD WBC-14.5* RBC-3.44* Hgb-11.1* Hct-33.2*
MCV-96 MCH-32.2* MCHC-33.4 RDW-13.3 Plt Ct-166
[**2127-6-30**] 04:55AM BLOOD WBC-15.7* RBC-3.45* Hgb-11.0* Hct-33.5*
MCV-97 MCH-32.0 MCHC-32.9 RDW-13.2 Plt Ct-113*
[**2127-7-1**] 04:46AM BLOOD Glucose-148* UreaN-21* Creat-1.2 Na-134
K-4.5 Cl-96 HCO3-32 AnGap-11
[**2127-6-30**] 04:55AM BLOOD Glucose-171* UreaN-19 Creat-0.9 Na-132*
K-4.3 Cl-97 HCO3-29 AnGap-10
[**2127-7-1**] 04:46AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.3
Brief Hospital Course:
[**2127-6-27**] Mr.[**Known lastname **] was taken to the operating room and underwent
Coronary artery bypass grafting x2 (left internal mammary artery
to the left anterior descending artery and reverse saphenous
vein graft to the obtuse marginal artery) with Dr.[**Last Name (STitle) **].
CROSS-CLAMP TIME: 54 minutes.PUMP TIME: 66 minutes. Please see
operative report for further surgical details. He tolerated the
procedure well and was transferred to the CVICU in stable but
critical condition. He awoke neurologically intact and was
weaned to extubation. He weaned off pressor support and was
started on beta-blocker, Statin, aspirin and diuresis. All lines
and drains were discontinued per protocol. CXR post chest tube
removal revealed right moderate pneumothorax. Serial CXRs showed
resolution of the right pneumothorax. POD#1 he was transferred
to the step down unit for further monitoring and recovery.
Physical Therapy was consulted for evaluation of strength and
mobility. Postoperatively his rhythm went into rapid atrial
fibrillation requiring Amiodarone drip. He converted to normal
sinus rhythm. The remainder of his postoperative course was
uneventful. By POD4 he was cleared for discharge to home with
VNA services. All follow up appointments were advised.
Medications on Admission:
Aspirin 325 mg po daily
HCTZ 12.5 mg po daily
Simvastatin 20 mg daily
Toprol XL 50 mg po daily
Lisinopril 10 mg po daily
NTG 0.4 mg prn
Discharge Medications:
1. Amiodarone 200 mg PO BID
400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then 200mg daily
RX *amiodarone 200 mg twice a day Disp #*100 Capsule Refills:*0
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Ibuprofen 400 mg PO Q8H:PRN pain
5. Lisinopril 10 mg PO DAILY
hold for SBP<95 and notify HO if held
6. Metoprolol Tartrate 25 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg three times a day Disp #*90
Capsule Refills:*0
7. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *Dilaudid 2 mg q3h prn Disp #*60 Capsule Refills:*0
8. Hydrochlorothiazide 12.5 mg PO DAILY
RX *hydrochlorothiazide 12.5 mg daily Disp #*30 Capsule
Refills:*0
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease
Secondary:
Anterior myocardial infarction with LAD stenting
Hypertension
Dyslipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
Edema - none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
The Cardiac Surgery office will call you with the following
appointments:
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 29070**]
Wound Check at cardiac surgery office: [**Telephone/Fax (1) 170**]
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 82128**] in [**1-20**] 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:[**2127-7-1**]
|
[
"512.1",
"428.0",
"V15.82",
"427.31",
"997.1",
"285.9",
"272.4",
"411.1",
"E878.2",
"412",
"414.01",
"414.8",
"V45.82",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5988, 6063
|
3750, 5029
|
327, 505
|
6217, 6439
|
2031, 3727
|
7363, 7977
|
1226, 1311
|
5216, 5965
|
6084, 6196
|
5055, 5193
|
6463, 7340
|
1326, 2012
|
252, 289
|
533, 796
|
818, 919
|
935, 1210
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,262
| 153,496
|
13334
|
Discharge summary
|
report
|
Admission Date: [**2104-5-24**] Discharge Date: [**2104-6-5**]
Date of Birth: [**2079-5-9**] Sex: M
Service: TRAUMA S.
AGE: 25-YEAR-OLD MALE.
HISTORY OF THE PRESENT ILLNESS: The patient is a 25-year-old
gentleman, who was involved in a motor vehicle accident
sustaining multiple trauma. He was transferred to an outside
hospital to [**Hospital3 **]. He was helmeted and initially
triaged to [**Hospital 1474**] Hospital, where he had a traumatic
amputation of his distal left thumb. There was also an
obvious open fracture and deformity of the left femur, which
they were unable to put in traction. Vital signs remained
stable throughout. The patient was evaluated and
transported to [**Hospital3 **]. [**Location (un) 2611**] Coma Scale was 15
throughout, but the patient did report loss of consciousness
from the accident. Upon arrival to [**Hospital3 **] he was
conversant and appropriate. He was complaining of left leg
pain, but no other abnormalities. He was electively
intubated in the trauma bay for reduction of his femur and
facilitate movement and CAT scan evaluations.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Examination revealed the following:
temperature 100.8, heart rate 111, blood pressure 150/70,
saturation 98% on room air. GENERAL: [**Location (un) 2611**] Coma Scale 15.
HEENT: Pupils equal, round, and reactive to light
3- mm to 2-mm bilaterally. There were no facial deformities.
Trachea midline. No broken teeth. Tympanic membranes were
clear bilaterally. NECK: No soft tissue deformities.
C-collar on, no pain or deformity. LUNGS: Clear to
auscultation bilaterally. ABDOMEN: Soft, nontender,
nondistended. Pelvis: Stable, nontender, guaiac negative,
normal tone, normal prostate with Foley in place.
EXTREMITIES: Left arm: Degloving injury over the medial
forearm. Left thumb: Degloving injury and amputation injury
at the metacarpophalangeal joint and degloving to the thenar
eminence.
RADIOLOGIC: CT of the head: No hemorrhage. CT of the neck:
No fracture. CT of the chest: Vessels intact, no
pneumothorax, no contusions, no effusions. CT of the abdomen
and pelvis: No injuries to the intra-abdominal organs, no
pelvic fracture. Plain films of the extremities: Left thumb
has amputation at the metacarpophalangeal joint; left femur
revealed a transverse shaft fracture.
HOSPITAL COURSE: The patient remained hemodynamically
stable, throughout the stay. Studies were obtained. The
patient was seen by both the Orthopedic Department and
Plastic Surgery Department for extremity injuries. The
patient was taken to the operating room, where the Department
of Plastic Surgery repaired the left thumb with repair of his
tendon and arterial injuries. For full detail of this
procedure, please see the operative note. The patient had a
traction pin placed to the distal femur in preparation for
repair of the femur fracture. The patient was transferred to
the Surgical Intensive Care Unit for postoperative care. The
patient remained hemodynamically stable, but had to return to
the operating room twice for repeat surgeries of his left
thumb due to loss of capillary refill and loss of vascular
perfusion. He also underwent plating of the left femur
fracture. There was concern for compartment syndrome of the
left femur and left calf, so, he underwent upper and lower
left lower leg fasciotomies with good effect. The distal
extremities were made perfused with pulses intact and no
evidence of ischemia or neurological dysfunction. The
patient did have a brief period of hypotension and the
patient's hematocrit dropped to 15 in the operating room
during his repeat operation. The patient was transfused with
packed red blood cells and intraoperative DPL was performed
with negative gross aspiration findings to one liter of
normal saline the cell counts for the DPL were both
considered negative for intra-abdominal injury. The patient
recovered well from this procedure. The patient had VAC
dressings placed to his fasciotomy sites on the upper and
lower left legs. He was monitored in the Surgical Intensive
Care Unit postoperatively and did extremely well. The
hematocrit continued to trend after this. The pain was well
controlled on PCA pump. The patient was transfused red cells
as needed postoperatively to maintain the hematocrit. The
thumb remained warm and with good capillary refill to the
fingers, although no sensation was noted postoperatively
after the second re-exploration. He was noted to have some
right wrist tenderness and hand tenderness. X-rays of this
area revealed a fractured base of his fifth metacarpal with
slight ambulation. He had a splint placed initially with a
plan for return to the operating room for surgical repair.
The patient has remained hemodynamically stable. The patient
was transferred out of the Surgical Intensive Care Unit on
hospital day #4. He was maintained on IV antibiotics with
Kefzol for his multiple open fractures and he remained
afebrile. The patient returned to the operating room on
hospital day #5 for closure of the fasciotomy and left lower
extremities. This was performed successfully without any
difficulties. The patient was able to tolerate diet after
this and the pain control was adequate with initially PCA and
then oral pain medications. On hospital day #8, the patient
returned to the operating room. The patient had hand surgery
with repair of his 5th metacarpal fracture on his right hand.
He did well with this injury. The patient was placed in an
ulnar-gutter splint on that side and remained in a
thumb-spica splint on the left hand. The patient was
undergoing physical therapy for both ambulation and
strengthening of the upper extremities. He is able to fully
weightbearing on his right leg. He was touch down
weightbearing on the left leg because of his fasciotomy
repair and plating of the left femur fracture.
On hospital day #9, the patient was tolerating oral pain
medications, full diet. The pain was well controlled. He
remained with intact neurovascular status of the left thumb,
except for poor sensation, as well as the left lower
extremities and the right upper extremity. The patient did
develop, on hospital day #12, hematoma underneath the
degloving injury site of the left medial forearm. Plastic
Surgery evaluated this wound, which they had closed and found
that he should go back to the operating room to have this
area explored. Upon exploration, they found a bleeding
perforating artery, which was ligated with good success. The
wound was reclosed successfully. Postoperatively, the wound
remained clean, dry, and intact. There was no evidence of
further bleeding underneath the incision. The patient's diet
was again advanced to full diet. Pain was well controlled
with Dilaudid orally. Physical therapy evaluation showed
that he was doing extremely well. He was transferred to
inpatient rehabilitation to assist with his deconditioning.
He was full weightbearing on the right lower leg, but
touchdown weightbearing on the left lower leg. In addition,
there was to be no movement of his left wrist or thumb, but
to follow neurovascular status closely on that thumb. The
right hand should be in an ulnar-gutter splint
postoperatively until reevaluation by hand surgery. The
patient was felt be stable for discharge.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The patient was discharged to [**Hospital 38**]
Rehabilitation Facility.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o.q.d.
2. Dilaudid 4 mg p.o.q.4h.p.r.n.
3. Ferrous Sulfate 325 mg p.o.t.i.d.
4. Colace 100 mg p.o.b.i.d.
5. Since the patient was regaining full strength, decision
was pending at to whether he should continue Lovenox given
his prior bleeding difficulties.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 32895**]
MEDQUIST36
D: [**2104-6-5**] 09:24
T: [**2104-6-5**] 10:22
JOB#: [**Job Number **]
|
[
"881.00",
"E812.2",
"997.2",
"821.11",
"885.1",
"998.12",
"815.02",
"958.8",
"903.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.65",
"83.14",
"79.33",
"78.55",
"39.31",
"84.21",
"39.32",
"79.35",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
7631, 8181
|
1203, 1264
|
2510, 7481
|
1169, 1176
|
1287, 2492
|
1138, 1145
|
7506, 7608
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,992
| 188,911
|
2812
|
Discharge summary
|
report
|
Admission Date: [**2154-10-7**] Discharge Date: [**2154-10-25**]
Date of Birth: [**2074-11-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
chest pain, dyspnea on exertion
Major Surgical or Invasive Procedure:
chest tube placement
History of Present Illness:
79 yo w/GIST, diastolic CHF, Afib presents with dyspnea on
exertion and chest pain. Pt reports sx began 7-10 days ago.
Exertional only, resolved with rest. Also with LH upon standing.
No rectal bleeding, no hematemesis or hematuria. Last BM
yesterday.
In ED found to have drop in Hct from 32 to 22. ECG without ST
changes.
Vitals: 97.5 130/67 79 18 90%
On arrival to floor pt reports feeling better after blood
transfusion. Denies CP, SOB, abd pain.
10 point ROS: otherwise negative
.
Past Medical History:
- RIGHT MEDIAL THIGH WOUND: Developed after developing severe
cellulitis in late [**2153**] and underwent a biopsy of the area
[**2153-11-22**]. Did not heal due to DM and chemo. Sunitinib put on
hold to allow further healing, but has since restarted low dose.
Measurement of wound was 8 x 0.5cm. The first 4 cm on the right
was still open with hypergranulation tissue present on [**2153-12-25**].
- GIST: Diagnosed in [**2143**], treated with surgery and multiple
intermittant courses of gleevac, complicated by side effects.
She had partial gastrectomy and GIST resection in [**2143**], and a
GIST omental metastasis resection in 03/[**2153**]. Noted to have GIB
in [**Month (only) 205**] and [**2153-8-13**] due to enlarging GIST lesions. Started
on Sutent since [**2153-10-1**]. Currently on low dose Sutent
following poor wound healing as above.
- ANEMIA, iron deficiency
- Paroxysmal ATRIAL FIBRILLATION, not on AC due to multiple RP
bleeds
- CONGESTIVE HEART FAILURE, Diastolic, ef >70%.
- DIABETES MELLITUS
- Chronic DYSPNEA, exertional
- HYPERTENSION
- HYPOTHYROIDISM
- CVA in [**2136**], Residual R hemiparesis and intermittent aphasia,
- TIA in [**2148**]
- Status post knee surgery in [**2137**].
Social History:
Lives alone. Has 2 daughters. Moved from [**Country **] in [**2137**]. Has
grandchildren who visit her.
-Tobacco history: negative
-ETOH: negative
-Illicit drugs: negative
Family History:
No family history of cancer, lung disease or heart disease.
+ for DM.
Physical Exam:
ADMISSION EXAM:
VS: 97.4 154/91 70 28 98% on 2.5L
Gen: nad
Heent: op clear
Chest: wheezing in RUE, distant breath sounds
CV: irreg, irreg, normal rate, no m/r/g
Abd: distended, soft, nabs, nt/nd
Ext: no e/c/c
Neuro: alert, follows commands
.
Discharge exam
-patient passed away, Dr. [**First Name (STitle) **] pronounced patient
Pertinent Results:
[**2154-10-7**] 11:00AM WBC-7.1 RBC-2.33*# HGB-6.2*# HCT-22.0*#
MCV-95# MCH-26.6* MCHC-28.1* RDW-22.6*
[**2154-10-7**] 11:00AM PLT SMR-NORMAL PLT COUNT-391#
[**2154-10-7**] 12:57PM PT-12.2 PTT-29.1 INR(PT)-1.1
[**2154-10-7**] 11:00AM cTropnT-<0.01
[**2154-10-7**] 11:00AM GLUCOSE-109* UREA N-32* CREAT-1.5* SODIUM-141
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-16
[**2154-10-7**] 11:00AM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-2.5
[**2154-10-7**] CXR (PA/lat)
IMPRESSION: Increased opacity at the right lung base, likely a
combination of effusion and atelectasis, though underlying
pneumonia difficult to exclude.
.
[**2154-10-8**] CXR (portable)
IMPRESSION: AP chest compared to [**10-7**]:
There is greater consolidation at the right lung base today,
which could be atelectasis worsening in the setting of
persistent moderate right pleural effusion or worsening
pneumonia. Improvement in perihilar opacification in the left
mid lung may be a function of difference in radiographic
technique.
The area is not clear, whether it is edema or a second focus of
pneumonia, is radiographically indeterminate. Moderate
enlargement of the cardiac silhouette is longstanding.
.
[**2154-10-10**] CT Abd/Pelvis (with contrast)
IMPRESSION:
1. Large-volume hemoperitoneum concerning for bleeding from
diffuse
peritoneal metastases, though there is no active extravasation.
.
2. Increased right pleural effusion with possibly hemorrhagic
contents,
raising the question of thoracoabdominal communication through a
diaphragmatic rent.
.
3. Volume overload.
.
[**2154-10-15**] CT Abd/Pelvis (non-contrast)
IMPRESSION:
1. Mild interval increase in the complex abdominal fluid,
likely
hemoperitoneum, compared to [**2154-10-10**]. Multiple stable
peritoneal and
mesenteric metastasis.
.
2. Mild interval increase in the hemorrhagic moderate-to-large
right pleural effusion.
.
[**2154-10-15**] CT Abd/Pelvis (non-contrast)
IMPRESSION:
1. Stable intra-abdominal and pelvic hemoperitoneum, overall
unchanged since CT from 9 hours prior.
2. Foci of hyperdensity within the anterior aspect of the left
side of the hemoperitoneum may represent residual contrast
within bowel. Overall, no significant change in attenuation of
the hemoperitoneum to suggest accumulating acute blood product.
3. Stable moderate right basilar high density pleural effusion
and basilar atelectasis.
4. Completely decompressed urinary bladder with Foley catheter
in place and no residual urine noted within the bladder. Large
amount of pelvic
hemoperitoneum overlies the urinary bladder superiorly. No
evidence of
hydronephrosis. On review of the prior CT, no distended bladder
is identified
- it is possible that the post void residual seen was due to
above loculated hemoperitoneum given the extent of fluid as
described.
.
[**2154-10-17**] CT Chest (non-contrast)
IMPRESSION:
1. Complete drainage of right pleural fluid collection after
placement of right basal pleural catheter. Bibasilar opacities
are more likely atelectasis than aspiration. Status of the
effusion can be monitored with serial radiographs if clinically
relevant.
.
2. Intervally enlarged epicardial lymph node with possibly
enlarging right hilar lymph nodes are not fully assessed on this
non-contrast study. These findings should be reassessed in [**3-19**]
weeks (or per continuing surveillance plans for intraabdominal
malignancy) with a contrast CT study.
.
3. Complex ascites and other findings of known intra-abdominal
malignancy are incompletely assessed on this study.
.
.
[**2154-10-20**] CT AP
IMPRESSION:
1. Mild interval increase in high density ascites along the
left paracolic
gutter, representing mild progression of hemoperitoneum compared
to [**2154-10-15**].
2. Interval drainage of right pleural effusion with pleural
catheter in place
and hydropneumothorax.
3. Redemonstration of the diffuse omental and peritoneal
metastases.
4. No evidence of renal vein compression in particular (as
queried) given the
limitations of this non-contrast study.
.
Brief Hospital Course:
79 yo w/GIST, diastolic CHF, Afib presents with dyspnea on
exertion and chest pain, found to have dropping Hgb likely
source was hemoperitoneum and hemothorax
.
# Symptomatic Acute Blood Loss Anemia: [**2-14**] GIST tumor bleeding
pt received a total of 3 units pRBC with improvement in her
symptoms. CT abd/pelvis to look for recurrent RP bleed, was
delayed due to [**Last Name (un) **] as the study required contrast. On hosptial
day 3 pt had CT scan which showed hemoperitoneum without any
active bleeding. She initially remained stable, however, her
Hct after a period of stability, began to downtrend again,
suggesting recurrent bleed. She received 2 additional units of
PRBC's, with appropriate response. Repeat non-contrast CT's
showed relatively stable hemoperitoneum, but did suggest
expanding pleural effusion, suggesting potential blood loss into
the thorax. She underwent chest tube placement by IP at the
bedside (see below). She was also seen by Surgery Consult for
possible surgical intervention, however, given the metastatic
disease, she is a poor surgical candidate. Furthermore, pt and
her family did not want to pursue surgery as an option. Her
case was discussed with IR and they could not see a localized
source of bleeding on the CT scans and suggested a tagged RBC
scan to further eval for bleeding. However, b/c of [**Last Name (un) **], even if
a tagged RBC scan could localize bleeding, angiography and
intervention would come at high risk for worsening [**Last Name (un) **] given
contrast load and risk of contrast-induced nephropathy. As
such, given that pt was clinically stable after the 2nd
transfusion, held off a tagged RBC scan.
.
# GIST Tumor: Was potentially a risk factor for her bleeding, as
such, Sorafenib was held. This was d/w her primary oncologist,
Dr. [**Last Name (STitle) **]. Of note, pt was found to have her brought to
the hospital her own pill bottles from home of sorafenib, and
had to be instructed multiple times not to take her own pills.
Her care was further d/w Dr. [**Last Name (STitle) **], and there are no chemo
options at this time that will provided acute resolution of her
bleed. In terms of long term management of her GIST, there were
still some potential options for chemotherapy, but after a goals
of care discussion was had, the patient was made CMO.
.
# Distolic Heart Failure: Home lasix was held on admission due
to [**Last Name (un) **]. Pt then developed volume overload with hydration. IV
lasix was started and a Foley was placed. She initially
responded well with good UOP and improvement in her Cr and
respiratory status, suggesting successful diuresis. However,
her Hct then dropped and she developed [**Last Name (LF) **], [**First Name3 (LF) **] her diuresis had
to be stopped. Her medications were then discontinued when the
family decided to shift the concentration of the patients care
towards comfort.
.
# Worsening Pleural Effusion
Initially felt to be possibly due to [**Last Name (LF) 9215**], [**First Name3 (LF) **] she was diuresed,
with improvement in her respiratory status. CT scan however,
showed significantly larger right-sided pleural effusion. IP
was consulted for a thoracentesis and a chest tube was placed,
which drained significantly bloody effusion. The effusion was
consistent with exudative effusion and hemothorax, as it had a
Hct of 39. The pt continued to have bloody drainage, suggesting
possible connection between the abdominal cavity and
hemoperitoneum with the thoracic cavity and pleural space.
.
# Acute Kidney Injury / Acute Renal Failure
Presented with [**Last Name (un) **] with elevated Creatinine to 1.6 (baseline 1)
in the setting of anemia. Improved after transfusion of PRBC's
as well as IV diuresis for presumed volume overload with acute
on chronic [**Last Name (un) 9215**]. [**Last Name (un) **] then recurred, in the setting of
intravascular volume depletion with acute blood loss anemia and
aggressive IV diuresis. Urine lytes c/w pre-renal etiology,
Foley catheter placement and abdominal imaging ruled out
post-renal obstruction. Was seen by Renal Consult service due
to oliguria, sediment showed non-specific granular casts, but no
overt evidence of ATN. Urine with only rare urine eos.
Creatinine and UOP improved with additional PRBC transfusion.
.
# ICU course:
Patient transferred to ICU on [**10-19**] due to concern for
hemoperitoneum, oliguric renal failure, and compartment
syndrome. Per daughter/HCP, do not want to proceed with surgery
and paracentesis not an option given increased risk of bleeding.
CT abdomen was obtained which showed mild interval increase of
bleeding in the peritoneum cavity and diffuse omental and
peritoneal metastases. There was no evidence of renal vein
compression, but image was limited as it was non-contrast. Her
hematocrit came down to 23 and she was transfused 1 unit of pRBC
on [**10-20**] with appropriate bump in hematocrit to 26.1
post-transfusion. Her urine output decreased and was bolused
with 500cc but without much response. Her urine output continues
to be 10-20 cc/hr. Patient had a period of resp distress with
spo2 in low 80s and appeared cyanotic, but improved with sitting
up on chair and morphine. A family meeting with [**Name (NI) 13762**]
(HCP/daughter), ICU team, palliative care, and social work
occurred on [**10-21**] with decision to move to comfort care. Patient
was also placed DNR/DNI. Her insulin sliding scale and
ceftriaxone were discontinued. She was started on dilaudid IV
0.3-0.6mg q1h:PRN for shortness of breath and pain. The
Palliative Care team followed the patient when transfered to the
floor. Her symptoms were agressviely managed and support was
offered to the family. The patient passed away comfortably on
[**2154-10-25**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. ammonium lactate *NF* 12 % Topical daily
2. clotrimazole-betamethasone *NF* 1-0.05 % Topical [**Hospital1 **]
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Lorazepam 0.5-1 mg PO HS:PRN insomnia/muscle aches
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
9. Sorafenib 400 mg PO BID
10. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
11. Zolpidem Tartrate 10 mg PO HS:PRN insmonia
12. Acetaminophen 325-650 mg PO Q8H:PRN pain
13. Aspirin 81 mg PO DAILY
14. camphor-menthol *NF* 230-70 mg Topical QID prn itching
15. diphenhydramine-zinc acetate *NF* 2-0.1 % Topical QID prn
itching
16. Docusate Sodium 100 mg PO BID
17. Senna 1 TAB PO BID:PRN constipation
18. urea *NF* 10 % Topical QID
hands and feet
Discharge Medications:
None-patient passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute Blood Loss Anemia
Bleeding GIST Tumor
Acute on chronic diastolic heart failure
pleural effusion
.
Patient passed away
Discharge Condition:
patient passed away
Discharge Instructions:
patient passed away
Followup Instructions:
patient passed away
|
[
"428.33",
"V66.7",
"511.9",
"428.0",
"584.9",
"171.5",
"V12.54",
"427.31",
"401.1",
"698.9",
"511.89",
"568.81",
"244.9",
"285.1",
"V49.86",
"276.1",
"293.0",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
13635, 13644
|
6818, 12592
|
338, 360
|
13811, 13832
|
2756, 6795
|
13900, 13922
|
2317, 2388
|
13586, 13612
|
13665, 13790
|
12618, 13563
|
13856, 13877
|
2403, 2737
|
267, 300
|
388, 876
|
898, 2109
|
2125, 2301
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,026
| 133,176
|
2979
|
Discharge summary
|
report
|
Admission Date: [**2150-12-1**] Discharge Date: [**2150-12-11**]
Date of Birth: [**2083-5-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Infected Fem-Fem graft
Major Surgical or Invasive Procedure:
[**2150-12-8**]
PROCEDURE: Removal of femoral-femoral graft and vein patch
repair of right common femoral artery.
[**2150-12-2**]
PROCEDURE: Left iliofemoral arteriogram; debridement of left
femoral artery with vein patch repair using saphenous vein;
removal of the left half of the femoral-femoral bypass and
angioplasty and covered stenting of left external, common and
proximal superficial femoral arteries via a superficial
femoral artery cutdown.
History of Present Illness:
67 M with known Child's A cirrhosis, obesity. he recently
underwent a left common iliac artery angioplasty and stent.
Followed Right to Left femoral bypass to improve his severe
disabling claudication on [**2150-8-25**]. Since the he has been treated
for UTI and a Right Lobe PNA. He presented to his PCP with [**Name9 (PRE) **]
cellulitis with possible infected Fem to Fem BPG. He was
transfered to the ER. Then admitted to are service for further
evaluation.
To note he has had fevers to 103. He is afebrile now. He had
Blood cultures at the time of his PNA. They are presumed
negative.
Past Medical History:
PMH: Diabetes, PVD, HTN, Obesity, Liver disease, PUD
PSH: cholecystectomy in [**2114**]
Social History:
Pos ETOH. Past smoker, stopped >1year ago
retired computer facilitator
lives with family
Family History:
n/c
Physical Exam:
VS:
99.3 HR: 75 BP: 183/88 RR: 18 Spo2: 98%
Gen: Alert and oriented x 3
Neuro: CN II-XII
Cardiac: RRR
Lungs: CTA B
Abd: soft, NT, ND, obese + ascities
Incisions:
Bilateral groin incisions intact with staples/sutures intact. No
hematoma and no bleeding.
PICC line intact and patent
Pulses: Fem Dp Pt
[**Name (NI) 2325**] palp palp dop
Right palp palp dop
Pertinent Results:
[**2150-12-11**] 05:10AM BLOOD Hct-26.0*
[**2150-12-10**] 05:19AM BLOOD WBC-2.7* RBC-3.15* Hgb-9.5* Hct-27.9*
MCV-88 MCH-30.3 MCHC-34.2 RDW-18.0* Plt Ct-140*
[**2150-12-7**] 04:14AM BLOOD Neuts-66.4 Lymphs-25.9 Monos-7.4 Eos-0.2
Baso-0.1
[**2150-12-1**] 06:56PM BLOOD Neuts-77* Bands-4 Lymphs-7* Monos-11
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2150-12-1**] 06:56PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+
Target-OCCASIONAL
[**2150-12-10**] 05:19AM BLOOD Plt Ct-140*
[**2150-12-8**] 05:13AM BLOOD PT-17.6* PTT-37.4* INR(PT)-1.6*
[**2150-12-11**] 05:10AM BLOOD UreaN-16 Creat-1.6* K-3.1*
[**2150-12-10**] 05:19AM BLOOD UreaN-16 Creat-1.6* Na-138 K-3.4 Cl-103
HCO3-26 AnGap-12
[**2150-12-10**] 05:19AM BLOOD ALT-10 AST-34 AlkPhos-107 TotBili-3.0*
[**2150-12-5**] 03:54AM BLOOD ALT-15 AST-34 AlkPhos-141* TotBili-5.2*
[**2150-12-8**] 05:13AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1
[**2150-12-7**] 04:14AM BLOOD TotProt-5.9* Albumin-2.7* Globuln-3.2
Calcium-8.1* Phos-4.2 Mg-1.9
[**2150-12-8**] 02:48PM BLOOD Type-ART FiO2-50 pO2-178* pCO2-40 pH-7.45
calTCO2-29 Base XS-4 Intubat-INTUBATED
[**2150-12-8**] 02:48PM BLOOD Glucose-99 Lactate-1.0 Na-136 K-3.5
Cl-103
[**2150-12-8**] 02:48PM BLOOD Hgb-11.0* calcHCT-33 O2 Sat-98
[**2150-12-8**] 02:48PM BLOOD freeCa-1.09*
[**2150-12-2**] 05:30AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.047*
[**2150-12-2**] 05:30AM URINE Blood-MOD Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2150-12-2**] 05:30AM URINE RBC-0-2 WBC-0 Bacteri-OCC Yeast-NONE
Epi-0
[**2150-12-7**] 05:51PM URINE Eos-NEGATIVE
[**2150-12-5**] 05:15PM URINE Hours-RANDOM Creat-35 Na-53
Time Taken Not Noted Log-In Date/Time: [**2150-12-8**] 9:15 pm
TISSUE PERIGRAFT.
GRAM STAIN (Final [**2150-12-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
[**2150-12-1**]
Patient was transferred from an outside hospital for + fevers,
leg pain and questionable staph infection. Patient was found to
have a left groin pseudoaneurysm which was suspected to be
infected. He was admitted to the Vascular Surgery service.
Started on Cipro and Vancomycin for septicemia.
[**2150-12-2**]
Patient was taken to the OR for repair of pseudoaneurysm and
clean out of infected graft. He was intubated and sedated
overnight and recovered in the ICU. He received 8 units of PRBC,
3 units of FFP and 1 units of platelets for acute anemia related
to blood loss during surgery. IVF overnight for marginal urine
output. On Neo overnight for BP control. Two JP drains to the
left thigh draining serosanguinous fluid.
[**2150-12-3**]
ICU status. Pain control. Fevers max 101.2. Vent attempted to be
weaned. Flagyl added to IV therapy. Blood cultures from OSH +
for GPC in pairs and clusters.
[**2150-12-4**]
Patient was extubated. Received 2 more units of PRBC. Hepatology
and Hematology consulted for elevated Bili and decreased WBC
which were thought to be related to infectious process.
[**Date range (3) 14240**]
Stale VS- afebrile. Hct stable at 30.5 after one more unit of
blood. Pain management. PT/OT following. Anticipating another
surgery [**12-8**] to remove the rest of the infected graft.
[**2150-12-8**]
Hypertension overnight which required IV hydralazine. Labs
stable. Taken to the OR for removal of graft. Transferred to the
VICU for monitoring. On Nitro gtt. Palpable pulses bilaterally.
Bedrest.
[**Date range (3) 14241**]
Stable post-op/ OOB with PT. Labs stable. DC planning. Growing
MSSA in blood. PICC placed for 6 weeks of IV antibiotics.
[**2150-12-11**]
Stable. Discharge home with VNA and 6 weeks of Naficillin.
Medications on Admission:
Norvasc 10, Nadolol, Nexium 40', Glipizide 5', HCTZ 25',
Ranitidine 300', Simvastatin 80', Valsartan 160', Ascorbic Acid
500', Calcium 500', Ergocalciferol, MVI, Omega-3 [**2140**], Vitamin E
400U
Discharge Medications:
1. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q6H (every 6 hours) for 6 weeks/42 days: from
[**2150-12-8**]- [**2151-1-19**].
Disp:*qs grams* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*6*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain: prn.
Disp:*40 Tablet(s)* Refills:*0*
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. PICC
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a
day.
13. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
14. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
once a day.
15. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO twice a
day.
16. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.
17. Vitamin E-400 400 unit Capsule Sig: One (1) Capsule PO once
a day.
18. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Home solutions; infusion therapy
Discharge Diagnosis:
Infected femoral-femoral bypass with left femoral artery
infected false aneurysm.
Childs A alcoholic cirrhosis s/p elective
Portal hypertension
Progressive leukopenia.
DM, PVD, HTN, obesity, PUD
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Overview
Your doctor has placed sutures (stitches) to keep the incision
closed for proper wound healing.
Please try to keep the incision line clean and dry. You can
shower and gently wash the incision line with soap and water.
Dry the incision area and keep the incision line open to air.
It is not necessary to apply antibiotic ointment, alcohol,
hydrogen peroxide, or a new bandage to the incision line. If
your sutures get caught on your clothing or there is a small
amount of drainage from the incision, you may want to cover it
with small gauze for your own comfort. If so, please use as
little tape as possible to hold the gauze in place as tape can
irritate the skin.
A small amount of drainage from the incision in the first few
days after surgery is not unusual and it will probably resolve
on its own. However, if you should notice bleeding from the
surgical site, apply firm direct pressure for ten minutes. If
the bleeding persists, reapply firm direct pressure for an
additional ten minutes. If the bleeding does not stop after 20
minutes, call our contact phone numbers or go to the nearest
emergency room for assistance.
What to Avoid
Please avoid the following
Do not submerge the incision line under water for a prolonged
period of time with activities like taking a bath, swimming, or
sitting in a hot tub.
Do not participate in any vigorous activities or exercises that
may put stress on the incision.
Do not apply perfumes or scented lotions to the sutures as this
may cause irritation.
When to Call the Doctor
Please contact us immediately if you develop:
Fevers, chills, or night sweats
Increasing redness, pain, or pus at the incision
Bleeding that does not stop with firm pressure
Followup Care
If your sutures need to be removed, this is usually done [**12-27**]
weeks after surgery. Even if your sutures will dissolve, the
doctor usually likes to examine the incision while it is
healing. Therefore, you should have been scheduled for a
follow-up appointment in clinic at the time of your discharge
from surgery. As this appointment is very important, please
contact the clinic if you do not have one scheduled or you need
to change the date and/or time.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2150-12-21**] 11:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2150-12-22**] 11:30
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-5-7**] 9:00
Completed by:[**2150-12-11**]
|
[
"996.62",
"286.9",
"442.3",
"571.2",
"038.11",
"285.1",
"288.50",
"584.9",
"V15.82",
"789.59",
"250.00",
"443.9",
"682.6",
"572.3",
"278.00",
"E878.2",
"303.93",
"998.11",
"414.01",
"289.4",
"456.21",
"533.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50",
"39.49",
"88.48",
"00.40",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
7822, 7885
|
4201, 5972
|
338, 795
|
8125, 8125
|
2154, 4129
|
10491, 10935
|
1652, 1657
|
6219, 7799
|
7906, 8104
|
5998, 6196
|
8270, 10468
|
1672, 2135
|
276, 300
|
823, 1417
|
4165, 4178
|
8139, 8246
|
1439, 1529
|
1545, 1636
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,648
| 113,922
|
42613
|
Discharge summary
|
report
|
Admission Date: [**2130-3-24**] Discharge Date: [**2130-4-4**]
Date of Birth: [**2067-10-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
auditory hallucinations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 yo female with history of PUD, memory deficits, history of
auditory hallucinations who presents after hearing voices
telling her to kill herself. Per report, patient has had AH
intermittently in since [**2124**] and had previously been on
medications which patient states helped her. Hallucinations are
described as a woman's voice telling her to fall down her
stairs. Patient also states that she believes snakes are inside
of her and that she sees snakes. The snakes tell her to hurt
herself. Per report, the patient has long-standing memory
difficulties (leaves gas stove on). The patient went to [**Hospital1 112**]
yesterday for auditory hallucinations where she was found to
have a negative head CT. Infectious workup for delerium
revealed a UTI and the patient was started on a course of
macrobid.
.
Patient currently complains of epigastric pain, which worsens
with spicy food and is improved with maalox. She also complains
of left flank pain. She denies currently hearing voices, but
states that she hears them frequently.
Past Medical History:
-- History of Auditory Hallucinations since [**2124**] after the birth
of her son. Was treated with seroquel and zoloft at that time
per the records with good response.
-- Depression
-- Peptic Ulcer Disease
-- Diverticulosis
-- Tension Headache
-- Memory Deficits
Social History:
Lives with son [**Name (NI) **]. Not currently working. Prior history of
smoking, no tobacco now. No drugs or alcohol.
Family History:
Older sister with memory deficits. Mother with [**Name2 (NI) **] (died
at 81). No psychiatric family history.
Physical Exam:
Admission physical exam:
VS - Temp 98.3, BP 125/73, HR 82, R 18, O2-sat 98 % RA
GENERAL - well-appearing in NAD, comfortable, well groomed
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, mildly enlarged thyroid with tenderness on
palpation, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, mild epigastric tenderness on
palpation, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - scars from burns on the thighs bilaterally
NEURO - awake, A&Ox3, attention good with days of the week
backwards (mixed up monday and tuesday), CNs II-XII intact,
muscle strength 5/5 deltoids/triceps/biceps, illiopsoas,
sensation grossly intact throughout, cerebellar exam intact,
steady gait
.
Discharge physical exam:
VS - 98.6 122/84 92 18, 96% RA
GENERAL - pleasant woman laying comfortably in bed
NECK - supple, mildly enlarged thyroid with tenderness on
palpation, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/non-tender/non-distended, no masses or HSM,
no rebound/guarding
BACK - area of lumbar puncture non-erythematous
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - scars from burns on the thighs bilaterally; no lesions on
hands or feet
NEURO: CN II-XII intact; pupils equal, round and reactive to
light; strength 5/5; romberg negative
PSYCH: endorses pleasant voices telling her to walk around,
denies SI/HI
Pertinent Results:
Admission labs:
[**2130-3-24**] 05:50PM BLOOD WBC-8.1 RBC-4.68 Hgb-12.9 Hct-39.5 MCV-84
MCH-27.5 MCHC-32.7 RDW-12.5 Plt Ct-294
[**2130-3-24**] 05:50PM BLOOD Glucose-122* UreaN-16 Creat-0.8 Na-142
K-4.0 Cl-105 HCO3-27 AnGap-14
[**2130-3-24**] 05:50PM BLOOD ALT-14 AST-19 AlkPhos-82 TotBili-0.1
[**2130-3-24**] 05:50PM BLOOD Lipase-74*
[**2130-3-24**] 05:50PM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2
[**2130-3-24**] 05:50PM BLOOD VitB12-877 Folate-11.1
[**2130-3-24**] 05:50PM BLOOD TSH-3.6
[**2130-3-24**] 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
CSF analysis:
[**2130-3-28**] 12:33PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
Lymphs-67 Monos-33
[**2130-3-28**] 12:33PM CEREBROSPINAL FLUID (CSF) TotProt-55*
Glucose-72
[**2130-3-28**] 12:33PM Syphilis (VDRL) (CSF) Non-Reactive (-)
[**2130-3-28**] 12:33PM Herpes Simplex Virus PCR (CSF) Negative
.
Discharge labs:
[**2130-3-31**] 07:03AM BLOOD WBC-6.4 RBC-4.70 Hgb-13.2 Hct-40.1 MCV-85
MCH-28.0 MCHC-32.8 RDW-12.8 Plt Ct-294
[**2130-3-31**] 07:03AM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-136
K-5.3* Cl-101 HCO3-27 AnGap-13
[**2130-3-31**] 07:03AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.3
[**2130-3-31**] 07:03AM BLOOD HIV Ab-NEGATIVE
.
CXR [**2130-3-24**]: Frontal and lateral views of the chest were
obtained. In the left upper to mid lung, there is a 0.5 cm
calcified nodule most likely representing a calcified granuloma.
No focal consolidation, pleural effusion, or evidence of
pneumothorax is seen. The cardiac and mediastinal silhouettes
are unremarkable. No overt pulmonary edema is seen.
Brief Hospital Course:
62 year old woman with history of PUD, dementia of unclear
etiology, and auditory hallucinations who presents after hearing
voices telling her to harm herself.
#. Hallucinations/SI: The patient has a history of auditory
hallucinations and subacute memory decline since [**2124**]. The
patient was seen by psychiatry for hallucinations, who
recommended Risperdal [**Hospital1 **] for symptoms. RPR, TSH, HIV, and B12
were negative on admission. However, the patient was noted to
have positive RPR and anti-treponemal antibody at an OSH in
[**2128**], untreated per records and discussion with PCP.
[**Name10 (NameIs) 92169**] antibody had been repeated at the OSH just prior
to the patient's admission to [**Hospital1 18**], and again returned positive
during her hospital stay. Positive anti-treponemal antibody
with subacute memory decline and vivid visual and auditory
hallucinations concerning for neuro-syphilis as source of
symptoms. The patient underwent lumbar puncture that showed 1
WBC and elevated protein to 55 that may be consistent with late
neuro-syphilis. CSF-VDRL and HSV PCR negative, anti-treponemal
antibody pending. As the patient was noted to have a penicillin
allergy, she was transferred to the ICU for penicillin
desensitization. She then was started on a 10 day course of
penicillin G to be completed night of [**2130-4-7**]. Given the
patient underwent desensitization, she may not miss a dose of
medication, as it may result in serious side effects. The
patient should follow up with her PCP on discharge regarding her
symptoms, and for referral to cognitive neurology. She should
undergo neuropsychiatric testing as an outpatient. Under the
guidance of psychiatry, she was started on risperidone. She had
marked improvement in her hallucinations on this medication.
#. Abdominal pain: On admission, the patient complained of mild
abdominal pain that by history was consistent with GERD. She
was also found to have a mildly elevated lipase to 74.
Abdominal pain may also be a manifestation of the hallucinations
i.e. snakes in stomach. She was started on ranitidine and Maalox
for symptoms. With improvement in her symptoms, she was
transitioned to pantoprazole. She should follow up with her PCP
if symptoms recur.
#. Vulvovaginitis: Patient reported whitish vaginal discharge
and pruritis after starting penicillin. Pelvic exam revealed
erythema, and the patient was given fluconazole 150mg PO x1.
# CODE: FULL CODE
# CONTACT: HCP: [**Name (NI) **] (son)-[**Telephone/Fax (1) 92170**]
===============================================================
TRANSITIONAL ISSUES
# Patient should complete 10-day penicillin course night of
[**4-7**]. She may not miss a dose, as she has a PCN allergy and is
s/p desensitization.
# Patient needs follow up with cognitive neurology. Must make
appointment through PCP for insurance purposes.
Medications on Admission:
Nitrofurantoin 100mg [**Hospital1 **] x 5 days (started [**2130-3-23**])
Ranitidine 150mg [**Hospital1 **]
Meclizine unknown dose
Discharge Medications:
1. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for GERD.
2. risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. penicillin G potassium 20 million unit Recon Soln Sig: 4
million units Injection Q4H (every 4 hours) for 4 days: Patient
may not miss dose due to hypersensitivity, last dose 2/24 PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Auditory hallucinations, depression,
syphilis
SECONDARY DIAGNOSIS: urinary tract infection, GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital for hearing voices that were
telling you to hurt yourself. Prior to your admission, you were
also discovered to have a urinary tract infection. You were
continued on 3 days of ciprofloxacin for your urinary tract
infection. For the voices you were hearing, you were evaluated
by psychiatry, who recommended medication to help resolve the
voices. You were also noted to have tests indicative of a
chronic syphilis infection that we think may be causing the
voices. The voices improved over the course of your
hospitalization. Because you have had a penicillin allergy in
the past, you were transferred to the ICU during your admission
to start you on a course of penicillin. You had a special IV
placed, and will complete a 10 day course of penicillin for your
syphilis. It is important that you do not miss a dose of
penicillin. On discharge, please follow up with your primary
care physician for [**Name Initial (PRE) **] referral to a cognitive neurologist.
.
Medications changed this admission:
START risperidol 1 mg every morning and 2 mg every evening
START Penicillin G Potassium 4 Million Units IV Q4H (LAST DAY
[**2130-4-8**])
START Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO/NG 4
times daily as needed for heartburn
START pantoprazole 40 mg daily. Discuss stopping this
medication with your primary care physician on discharge.
STOP nitrofurantoin
STOP ranitidine
Followup Instructions:
Please call your primary care physician for [**Name Initial (PRE) **] follow up
appointment on discharge:
Name: [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 38279**], NP
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3530**]
You should follow up with cognitive neurology. Your primary
care physician will set up this appointment for you on
follow-up.
|
[
"530.81",
"V12.71",
"599.0",
"493.90",
"094.9",
"E930.0",
"368.16",
"112.1",
"V62.84",
"462",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8873, 8937
|
5227, 8109
|
295, 302
|
9099, 9099
|
3619, 3619
|
10729, 10821
|
1814, 1926
|
8289, 8850
|
8958, 8958
|
8135, 8266
|
9252, 10706
|
4525, 5204
|
1966, 2820
|
10836, 11199
|
232, 257
|
330, 1374
|
9046, 9078
|
3635, 4509
|
8978, 9024
|
9114, 9228
|
1396, 1661
|
1677, 1798
|
2845, 3600
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,412
| 178,005
|
31856
|
Discharge summary
|
report
|
Admission Date: [**2129-9-11**] Discharge Date: [**2129-9-26**]
Service: VSU
CHIEF COMPLAINT: Ischemic left lower extremity.
HISTORY OF PRESENT ILLNESS: This is an 85-year-old female
who is transferred from [**Hospital3 417**] Hospital who is a
resident at [**Hospital1 **] Rehab with an ischemic left
foot. The patient recently underwent revascularization of the
left lower extremity in [**Month (only) 216**] of this year and was
hospitalized because of the ischemic extremity on [**2129-9-5**]. The patient was referred here for further evaluation
and treatment.
PAST MEDICAL HISTORY: Illnesses - peripheral vascular
disease, status post left fem-[**Doctor Last Name **] in [**2129-7-6**] with
thrombectomy, history of stroke x2 - ischemic stroke and
hemorrhagic stroke with residual dysphagia and aspiration;
asymptomatic abdominal aortic aneurysm 4.3 cm in size; type 2
diabetes, controlled; history of hypertension;
ALLERGIES: Haldol allergy new.
MEDICATIONS ON TRANSFER: Nexium 40 mg daily; Lopressor 25 mg
b.i.d.; Arimidex 1 mg daily; nitro patch 0.4 mg daily;
Remeron 15 mg at bedtime; ferrous sulfate 300 mg twice a day;
Tylenol 650 mg q.4h. p.r.n.; aspirin 325 mg daily; bacitracin
ointment to left breast b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Negative for tobacco use and negative for
alcohol use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM: Vital signs - 98.3, 88, 16, O2 sat 96% on
room air, blood 133/66. General appearance - is an elderly
female in no acute distress. HEENT exam is unremarkable. Lung
sounds are diminished at the bases bilaterally. Heart has a
regular rate and rhythm without murmur, gallop, or rub.
Abdominal exam is benign except for PEG tube placement site
clean without erythema. Lower extremities with coolness of
temperature to the distal lower left extremity, diminished
capillary refill with mild mottling. Motor and sensory are
unassessable. Pulse exam shows palpable femorals bilaterally
with Dopplerable popliteal, DT and PT on the right and absent
DP and PT on the left.
HOSPITAL COURSE: The patient was initially admitted through
the emergency room and evaluated. IV heparinization was
continued to maintain a PTT between 60 and 80. The patient
underwent on [**2129-9-12**], a diagnostic angio of the
abdominopelvic vessels with left leg runoff via the right
femoral artery. The patient tolerated the procedure well.
Nutrition was consulted on admission for recommendations for
tube feeds. The patient is dependent at baseline on her tube
feeds. Current regimen is Probalance at 45 cc per hour which
gives the patient 1296 kilocalories and 58 gm of protein.
Residuals are checked q.4h. and held for residual greater
than 150 cc and the tube is flushed every 4 hours with 50 cc
of fluid. Speech and swallow evaluation was requested on
[**2129-9-13**]. In summary, the patient does not appear to
aspirate nectar-thick liquid and ground p.o. However, the
patient's oral phase and left buccal pocketing is a safety
issue. Also due to the patient's coughing (a sign of
aspiration) at the completion of the assessment a video
swallow was recommended. Recommendations were the patient
could have thickened liquids only for comfort. A video
swallow was obtained the following day on [**9-14**].
Recommendations were there were no signs of aspiration but
the patient's oropharyngeal phase was discoordinated and PEG
feedings were to be continued and thickened liquids for
pleasure only.
The patient had an episode of agitation and confusion which
resolved with Haldol IV. Geriatrics was consulted for
management of this complicated patient. They felt the
delirium was secondary to multifactorial reasons and would
recommend that we take her off narcotic and give her Tylenol
1 gm t.i.d. standing and to simply her opiate treatment to
oxycodone 5 mg q.4-6h. p.r.n. for break through pain. The
Haldol was discontinued and Zyprexa 2.5 mg nightly was
instituted and 2.5 mg of Zyprexa for agitation as required.
Recommendations were to avoid any type of restraints and to
re-orient the patient and avoid any unnecessary interruption
of sleep/wake cycle. Recommendations were to also make sure
that the patient was up in a chair and that physical therapy
and OT saw the patient. On [**2129-9-15**], the patient's
Zyprexa was converted to Seroquel 50 mg at bedtime which
could be repeated x1. The patient was continued to be
followed both by speech and swallow and the geriatric service
during her hospitalization.
Heparin was continued. The patient underwent on [**2129-9-18**], a left axillofemoral bypass and a left femoral-to-
distal bypass. The patient tolerated the procedure. She
required 2 units of packed cells intraoperatively. She was
transferred to the PACU in stable condition and then to the
SICU for continued monitoring and care postoperatively.
Postoperative day one the patient was continued on vancomycin
and ciprofloxacin. She did require a total of four 250-fluid
boluses for mild postoperative hypotension which was resolved
with fluid resuscitation. Her heparin was continued and
coumadinization was begun on [**2129-9-20**].
The patient did require several units of packed red blood
cells postoperatively for hematocrit that drifted from 30.2
to 24. Reticulocyte count was 2.1, ferritin was 271, TIBC was
203, B12 and folate were normal. GI was consulted for the
patient's persistent anemia postoperatively and dark stool.
GI felt that the source was either upper or lower GI; this
could not be fully evaluated given the patient's need for
continuous anticoagulation but this should be evaluated on an
outpatient basis when the patient has recovered from current
surgery, but the patient would be monitored on a clinical
basis, and if required at some point prior to discharge,
would consider endoscopies to evaluate for active bleeding.
On [**2129-9-22**], the patient's Swan was converted to a
central line and her IV fluids were Hep-Locked. PT was
consulted and rehab screening was requested. The patient's
heparin was discontinued on [**2129-9-23**], and her INR was
4.1 and anticoagulation was held and the INR was serially
monitored. This will be restarted when her INR is less than
3. Physical therapy would assess the patient in anticipation
for discharge planning. The patient will be discharged to
rehab when medically stable.
DISCHARGE MEDICATIONS: Mirtazapine 15 mg at bedtime;
nitroglycerin 0.4 mg per hour patch q.24h., on 12, off 12;
bacitracin ointment to the left breast area b.i.d.; ferrous
sulfate 300 mg b.i.d.; aspirin 325 mg daily; acetaminophen
1000 mg t.i.d.; oxycodone 5 mg q.4h. p.r.n. for break through
pain; cortisone 1% cream to the affected areas t.i.d.;
quetiapine 50 mg at bedtime; __________ 30 mg b.i.d.;
cyanocobalamin 100 mcg [**12-7**] tablet daily; ascorbic acid 500 mg
b.i.d.; folic acid 1 mg daily; oxycodone 5-mg solution in 5
cc, 2.5 mg b.i.d. for pain, warfarin 5 mg daily, goal INR 2.0
to 3.0; heparin flush to PICC line (of importance - the PICC
has had to have irrigation with alteplase 1 mg on 3 separate
occasions; the most recently was [**2129-9-23**]); regular
insulin q.4h., see sliding scale.
DISCHARGE DIAGNOSES:
1. Left leg ischemia.
2. Peripheral vascular disease, status post left fem-[**Doctor Last Name **] in
[**2129-7-6**] with thrombectomy.
3. History of cerebrovascular accident x2, ischemic and
hemorrhagic strokes with residual dysphagia and
aspiration.
4. Asymptomatic abdominal aortic aneurysm of 4.3 cm.
5. History of type 2 diabetes, controlled.
6. History of hypertension, controlled.
7. Haldol allergy new.
8. Preoperative delirium, multifactorial, resolved.
9. Preoperative anemia, transfused x2.
10.PICC line thrombus x3, treated.
11.Postoperative blood loss anemia, transfused.
DISCHARGE INSTRUCTIONS: Aspiration precautions - the head of
the bed should be elevated upright position when the patient
is taking orals. The oropharyngeal cavity should be suctioned
prior to reclining the head of the bed. No bed trapeze.
Please call if she develops fever greater than 101.5 or if
the axillary or groin wounds or leg wound develop swelling,
redness, or drainage. Skin clips remain in place until seen
in followup with Dr. [**Last Name (STitle) 1391**].
MAJOR SURGICAL AND INVASIVE PROCEDURES: Diagnostic
arteriogram with left leg runoff via the right femoral artery
access on [**9-12**]. Left axillary-femoral bypass with a left
femoral to distal bypass on [**2129-9-18**].
FOLLOWUP: The patient should follow up with Dr. [**Last Name (STitle) 1391**] in
2 weeks' time. Call for an appointment at [**Telephone/Fax (1) 1393**].
DISCHARGE MEDICATIONS: As previously dictated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2129-9-23**] 11:10:21
T: [**2129-9-24**] 00:40:59
Job#: [**Job Number 74709**]
|
[
"458.29",
"V44.1",
"338.19",
"440.22",
"425.4",
"437.0",
"174.9",
"250.00",
"441.4",
"290.41",
"401.9",
"285.1",
"787.22",
"578.9",
"693.0",
"438.82",
"444.89",
"E939.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"88.48",
"99.04",
"96.6",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
1374, 1392
|
7184, 7782
|
8657, 8953
|
2089, 6353
|
7807, 8633
|
1408, 2071
|
107, 139
|
168, 582
|
999, 1284
|
605, 973
|
1301, 1357
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,842
| 163,738
|
54060
|
Discharge summary
|
report
|
Admission Date: [**2156-2-27**] Discharge Date: [**2156-3-3**]
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
dyspnea.
Major Surgical or Invasive Procedure:
endotracheal intubation [**2-27**], extubation [**2-28**].
History of Present Illness:
A [**Age over 90 **]yo Russian-speaking F presented from [**Hospital 100**] Rehab on [**2-27**]
with worsening dyspnea x 1 day, found to have BNP=[**Numeric Identifier 56841**],
crackles and rales on exam, hypertension, and a CXR consistent
with volume overload. Unclear trigger of CHF exacerbation, ?
med or diet non-compliance, but daughter reports that she had
visited Pt. earlier in the evening of admission, and that she
was asymptomatic. Upon arrival in [**Name (NI) **], Pt. was found to be in
acute respiratory distress. ABG in ED: 7.12/67/83/23. Pt. was
given IV lasix and a nitro gtt was started. ABG following
intubation was 7.35/39/219/22 (on A/C 550x14, 100% FiO2 + 5
PEEP). In MICU, Pt. had episode of hypotension while on nitro
gtt, this was stopped and bp quickly recovered. Pt. was
diuresed with IV lasix boluses, now on 20mg PO QD. Extubated on
[**2-28**], currently on 2LNC; Pt. is not on home O2.
Past Medical History:
1. CAD: 3VD s/p multiple MIs and PCIs
2. Diastolic CHF (EF=45%)
3. A-V pacer placed in [**2145-10-20**] for sick sinus syndrome
4. h/o atrial fibrillation
5. HTN
6. hypercholesterolemia
7. GERD
8. CRI: Pt's baseline creatinine is 2.2.
9. anemia secondary to chronic kidney disease
10. constipation
11. hypothyroidism
12. gout
13. h/o colon adenocarcinoma s/p resection
14. h/o C.diff colitis diagnosed on last admission in [**Month (only) 404**]
[**2155**]
Social History:
The patient previously lived alone but has been at [**Hospital1 100**] Senior
Life for 1yr. Her daughter is involved with her care. Denies
EtOH, tobacco, and drugs.
Family History:
Non-contributory.
Physical Exam:
PE: VS: 98.3 | 135/64 | 80 | 28 | 97% on 2L O2NC
gen: alert, pleasant, elderly female in NAD, oriented x 3
[**Hospital1 4459**]: NC/AT, PERRL and A, EOM intact, OP clear, MMM.
neck: supple, no LAD, no thyromegaly, no LAD, no JVD.
CV: regular, nl. s1s2, no M/R/G.
chest: crackles at bases b/l, no wheezes.
abd: +bs, soft, nt/nd, no rebound, no guarding, no organomegaly.
extr: no LE edema, no cyanosis, 2+ dp pulses b/l.
neuro: awake, alert; cn ii-xii intact, RLE 4/5 strength,
otherwise 5/5 strength; sensory, coordination, and language
grossly normal.
Pertinent Results:
[**2156-2-27**] 08:50AM BLOOD WBC-16.8*# RBC-3.84* Hgb-12.1 Hct-38.3
MCV-100*# MCH-31.6 MCHC-31.7 RDW-18.9* Plt Ct-347
[**2156-2-27**] 08:50AM BLOOD Neuts-49.9* Lymphs-43.6* Monos-2.7
Eos-2.8 Baso-1.1
[**2156-2-27**] 08:50AM BLOOD PT-16.8* PTT-24.0 INR(PT)-1.6*
[**2156-2-27**] 08:50AM BLOOD Plt Ct-347
[**2156-2-27**] 08:50AM BLOOD Glucose-322* UreaN-26* Creat-1.9* Na-143
K-3.7 Cl-109* HCO3-18* AnGap-20
[**2156-2-27**] 08:50AM BLOOD CK(CPK)-35, 40, 37, 31
[**2156-2-27**] 08:50AM BLOOD CK-MB-NotDone
[**2156-2-27**] 08:50AM BLOOD cTropnT-0.03, 0.06, 0.06, 0.05
[**2156-2-27**] 08:50AM BLOOD Calcium-9.0 Phos-5.7*# Mg-2.2
[**2156-2-27**] 11:01AM BLOOD Lactate-1.9
[**2156-2-27**] 08:50AM BLOOD proBNP-[**Numeric Identifier 56841**]*
.
ECG: AV-paced.
.
CXR [**2156-2-28**]: Persistent congestive heart failure with
redistributing, possibly decreasing pulmonary edema, and new
bilateral pleural effusions.
.
TTE [**2156-3-2**]: LVEF=25-30%. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed. Resting regional wall motion abnormalities include
inferior/inferolateral akinesis, apical akinesis/dyskinesis and
septal akinesis/hypokinesis. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is no pericardial
effusion.
.
TTE [**9-23**]: LVEF=45%. Left ventricular cavity size is normal.
Overall left ventricular systolic function is mildly depressed.
Resting regional wall motion abnormalities include inferior
akinesis, inferoseptal akinesis/hypokinesis, and inferolateral
hypokinesis. The apical lateral and apical septal segments also
appear hypokinetic. The right ventricular cavity may be mildly
dilated; free wall motion is not fully visualized. The aortic
valve is not well seen; leaflets appear mildly to moderately
thickened (gradient not assessed). No aortic regurgitation is
seen in focused views. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen in focused
views. There is no pericardial effusion.
.
Cath [**9-23**]: 1. 3VD. 2. Elevated systemic pressures. 3.
Successful stenting of the acutely occluded RCA.
Brief Hospital Course:
[**Age over 90 **]yoF with 3VD and CHF, Afib, SSS with AV-PM, p/w 1d dyspnea
likely [**1-22**] CHF exacerbation, s/p intubation.
.
# CHF: CXR consistent with volume overload and BNP very
elevated, likely [**1-22**] diastolic dysfunction (EF 25-30%) and
possible med/diet non-compliance. TTE results indicate diffuse
myocardial dysfuction, possibly secondary to LAD closure leading
to anterior/apical akinesis/dyskinesis. Pt. is already on
coumadin. Treatment options were discussed with family
(including intervention for revascularization), and decision was
made for medical management. Therefore, toprol XL dose and
lasix dose were increased, and spironolactone was initiated to
optimize cardiac function. Her [**Last Name (un) **] was also continued, and the
dose of this can be increased in the future, if her bp will
tolerate.
.
# CAD: was ruled out for MI upon admission, but TTE consistent
with ? new WMAs (akinesis/dyskinesis). Continued on ASA,
plavix, statin, BB, [**Last Name (un) **].
.
# Afib: AV-paced, on BB and amiodarone, and coumadin (goal
INR>2.0), currently in NSR.
.
# CRI: baseline Cr elevation (high 1s - low 2s), currently at
baseline. urine output and Is/Os were monitored.
Low-Na/cardiac diet was encouraged.
.
# anemia: [**1-22**] renal dx, tends to run in low 30s. will monitor
and tranfuse (with extra diuresis given CHF) for goal Hct>30
given CAD. Hct stable. Pt. on epogen at home, will resume at
ECF.
.
# hypothyroidism: continue synthroid.
.
# ID: blood cx NGTD. u/a negative.
.
# FEN: low-Na diet, monitor and replete electrolytes, MVI.
.
# Ppx: PPI, coumadin for Afib, heparin SC, bowel reg.
.
# Comm: with Pt. and daughter (Home [**Telephone/Fax (1) 110810**]; Work
[**Telephone/Fax (1) 110811**]; Cell [**Telephone/Fax (1) 110812**]).
.
# Code: Full code.
Medications on Admission:
amiodarone 200 mg QD
ASA EC 325 mg QD
plavix 75mg QD
epogen 40 mcg Qweek
colace 100 mg [**Hospital1 **]
senna 2 tabs QHS
dulcolax 5 mg PRN
lasix 20 mg QOD
levothyroxine 25 mcg QD
toprol XL 25 mg QD
MVI QD
protonix 40 mg QD
zocor 80 mg QD
trazodone 25 mg QHS
coumadin 1 mg QHS
tylenol PRN
albuterol/atrovent nebs PRN
ativan 0.5 mg PRN anxiety
milk of mag 30 mL PRN
nitrostat 0.4 mg PRN chest pain
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Amiodarone 200 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. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
14. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Tablet(s)
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Epogen, please resume 3x/week.
18. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
1. congestive heart failure
2. coronary artery disease
3. atrial fibrillation
4. chronic renal insufficiency
5. reflux disease
6. hypercholesterolemia
7. hypothyroidism
8. hypertension
Discharge Condition:
Fair, stable.
Discharge Instructions:
* Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
* Adhere to 2 gm sodium diet
* Fluid Restriction: 1.0-1.5 L per day.
.
Please continue to take all your medications exactly as
prescribed. If you experience shortness of breath, chest pain,
or any other concerning symptoms, call your PCP or return to the
hospital.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 5376**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2156-3-16**]
1:00
.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Date/Time:[**2156-3-18**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2156-3-3**]
|
[
"401.9",
"428.0",
"518.81",
"V45.01",
"274.9",
"585.9",
"412",
"428.33",
"285.21",
"244.9",
"427.31",
"530.81",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8930, 9015
|
5003, 6803
|
232, 292
|
9243, 9258
|
2533, 4980
|
9647, 10091
|
1925, 1944
|
7249, 8907
|
9036, 9222
|
6829, 7226
|
9282, 9624
|
1959, 2514
|
184, 194
|
320, 1245
|
1267, 1726
|
1742, 1909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,233
| 156,253
|
6192
|
Discharge summary
|
report
|
Admission Date: [**2121-9-13**] Discharge Date: [**2121-9-18**]
Date of Birth: [**2056-9-4**] Sex: F
Service: MEDICINE
Allergies:
Latex / Vancomycin / Sudafed / IVIG
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
hypotension, cough
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] is a 65 year-old woman with h/o metastatic breast
cancer (mets to brain and bone, currently receiving radiation tx
with radiosensitizing platinum and trastuzumab, received dose of
cisplatin yesterday), hypogammaglobulinemia (on prophylactic
doxy), h/o recurrent aspiration pneumonia, HTN, HLD, transferred
to [**Hospital1 18**] from OSH for pneumonia. Yesterday patient had
chemotherapy (low dose cisplatin). She was complaining of
productive cough and low grade fevers (99) over the past several
days. Last night she called her daughter at 1:30 AM and was
asking for help. Her daughter could not make sense of what she
was saying and she seemed confused. When her daughter saw her
she was rigoring, coughing up pink/red-tinged sputm and was
vomiting. Her temperature was 101.9. Her daughter gave her 1
gram tylenol, zofran, and compazine and called 911. Patietn
became increasingly confused when EMS arrived. Patient was
initially seen at [**Hospital 11066**] Hospital where initial vitals were
102.7, 141/79, 117, 18, 82% on RA. She was found to have a
pneumonia on CXR. OSH labs were significant for a Na of 149,
creatinine of 0.9, lactate of 1.6. She received one zosyn 3.375
mg x1, 4 mg zofran, 500 cc NS bolus, and 8 mg morphine. She was
transferred to [**Hospital1 18**] for continuity of care. En route, patient
became hypotensive with systolic blood pressures ranging 70s -
90s.
Of note, patient was admitted from [**2121-8-16**] - [**2121-8-19**] for fever,
which was thought to be secondary to cellulitis. Per discharge
summary patient was treated with vancomycin IV and was then
transitioned to bactrim at discharge.
In the ED, initial vital signs were 98.6 100 75/? 24 92% 2L.
Exam was significant for hypoxia, hypotension, and lethargy.
CXR showed LLL pneumonia. She had a bedside ultrasound showing
IVC with > 50% collapse, FAST negative. Patient received 2L of
IVF and her blood pressure improved to systolics in the 90s.
Patient received clindamycin 600 mg IV x1 to cover for MRSA
pneumonia as she has a vancomycin allergy. As per ED, patient
initially looked like she may need intubation, but she improved
while in the ED and did not need intubation. Vitals on transfer
94/55 92 18 100% on non-rebreather.
On arrival to the MICU, patient's blood pressure is 89/58, HR
93, RR 22, O2 Sat 100% on NRB. Patient is lethargic and cannot
participate in history or ROS.
Review of systems:
Patient is lethargic and cannot participate in ROS.
Past Medical History:
Metastatic breast cancer - diagnosed in [**2106**] at stage IV with
mets to lymph nodes and liver; initially treated with
doxorubicin, a bone marrow transplant, and a partial mastectomy.
Had recurrence in [**2108**]. Developed brain mets and bone mets
[**2114**]-[**2116**] - multiple surgeries and chemotherapeutic regimens
since that time. Currently receiving radiation treatments and
hyperthermia with a dose of radiosensitizing platinum.
weekly here
- Recurrent aspiration pneumonia, hospitalized in [**2121-3-2**] for
this
- HTN
- Dyslipidemia
- GERD
- RLS
- Depression
- Insomnia
- Chronic pain
- Hypercoagulability/SVC thrombus: possible borderline protein
C/S deficiency; on enoxaparin
- Hypogammaglobulinemia: previous reaction to IVIG, now on Doxy
ppx since [**2-9**]
Social History:
She was married. Her husband died suddenly in [**Name (NI) **] which was
very distressing for her. She lives with her daughter who is a
RN and grandchildren. She smoked 1ppd for a few years, but quit
~30 years ago. She use to drink alcohol (about 2 drinks per
month) but has not been drinking recently. No illicit drug use.
Family History:
Her daughter had breast cancer at 29, and had a recurrence. Her
neice also had breast cancer. Her brother had lung cancer. She
denies any other family history of lung cancer.
Physical Exam:
Admission Physical:
Vitals: 94/55 92 18 100% on non-rebreather
General: Lethargic, but opens eyes to voice
HEENT: NC/AT, Sclera anicteric, PERRL, non-rebreather in place
Neck: supple, JVP not elevated
CV: Tachy, S1, S2, no murmurs appreciated
Lungs: Diffuse coarse rhonchi b/l, no wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis,
trace edema, left thigh with surgical wound wrapped in ace
bandage, slight erythema extending above ace bandage.
DISCHARGE:
Vitals: 98.0 108/64 69 18 93%RA
General: Patient awake and alert in NAD
HEENT: NC/AT, Sclera anicteric, PERRL, nasal canula in place
Neck: supple, JVP not elevated
CV: Tachy, S1, S2, no murmurs appreciated. Port in place without
surrounding erythema or induration
Lungs: Continued improvement with basilar crackles b/l but no
longer rhoncherous, L > R. no wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis,
trace edema. left thigh with surgical wound wrapped in ace
bandage, slight erythema extending above ace bandage. Multiple
crusted-over circular 1cm lesions with 1-2mm surrounding
erythema. warm and tender to palpation but without clear
evidence of cellulitic process, slight improvement from [**9-17**].
Pertinent Results:
Admission Labs:
[**2121-9-12**] 11:25AM BLOOD WBC-5.3 RBC-4.25 Hgb-11.5* Hct-34.6*
MCV-81* MCH-27.1 MCHC-33.3 RDW-18.1* Plt Ct-88*
[**2121-9-12**] 11:25AM BLOOD Gran Ct-4080
[**2121-9-12**] 12:10PM BLOOD UreaN-10 Creat-0.8
[**2121-9-12**] 12:10PM BLOOD ALT-12 AST-22 AlkPhos-72 TotBili-0.3
[**2121-9-12**] 12:10PM BLOOD Albumin-3.8 Calcium-9.5
[**2121-9-12**] 12:10PM BLOOD CEA-76* CA27.29-1418*
Discharge Labs:
[**2121-9-18**] 05:22AM BLOOD WBC-4.3 RBC-3.39* Hgb-9.1* Hct-28.0*
MCV-83 MCH-26.8* MCHC-32.5 RDW-17.6* Plt Ct-118*
[**2121-9-18**] 05:22AM BLOOD Glucose-110* UreaN-7 Creat-0.6 Na-138
K-4.1 Cl-103 HCO3-28 AnGap-11
[**2121-9-18**] 05:22AM BLOOD Calcium-7.5* Phos-3.5 Mg-1.8
OTHER RELEVANT:
[**2121-9-13**] 07:05AM BLOOD WBC-4.0 RBC-3.94* Hgb-10.4* Hct-32.3*
MCV-82 MCH-26.3* MCHC-32.1 RDW-17.4* Plt Ct-81*
[**2121-9-14**] 03:30AM BLOOD WBC-3.6* RBC-3.17* Hgb-8.4* Hct-26.3*
MCV-83 MCH-26.7* MCHC-32.1 RDW-17.6* Plt Ct-51*
[**2121-9-15**] 06:00AM BLOOD WBC-5.1 RBC-3.23* Hgb-8.6* Hct-26.8*
MCV-83 MCH-26.8* MCHC-32.3 RDW-18.2* Plt Ct-72*
[**2121-9-16**] 06:00AM BLOOD WBC-4.1 RBC-3.37* Hgb-8.9* Hct-27.8*
MCV-82 MCH-26.4* MCHC-32.0 RDW-18.2* Plt Ct-90*
[**2121-9-17**] 05:44AM BLOOD WBC-3.6* RBC-3.57* Hgb-9.6* Hct-29.1*
MCV-82 MCH-27.0 MCHC-33.1 RDW-17.5* Plt Ct-114*
[**2121-9-14**] 03:30AM BLOOD Neuts-83.2* Lymphs-7.0* Monos-5.9 Eos-3.4
Baso-0.5
[**2121-9-15**] 06:00AM BLOOD Neuts-80.7* Lymphs-7.8* Monos-5.9
Eos-4.9* Baso-0.6
[**2121-9-12**] 11:25AM BLOOD Gran Ct-4080
[**2121-9-13**] 07:05AM BLOOD Glucose-121* UreaN-14 Creat-1.0 Na-138
K-3.0* Cl-100 HCO3-26 AnGap-15
[**2121-9-13**] 08:32PM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-138
K-7.7* Cl-112* HCO3-22 AnGap-12
[**2121-9-14**] 03:30AM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-138
K-3.2* Cl-108 HCO3-22 AnGap-11
[**2121-9-13**] 07:05AM BLOOD ALT-8 AST-15 AlkPhos-58 TotBili-0.4
[**2121-9-13**] 08:32PM BLOOD Calcium-6.4* Phos-3.0 Mg-1.2*
[**2121-9-14**] 03:30AM BLOOD Calcium-6.7* Phos-2.8 Mg-2.3
[**2121-9-15**] 06:00AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.9
[**2121-9-16**] 06:00AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.7
[**2121-9-17**] 05:44AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.6
Micro:
Blood culture [**2121-9-13**]: negative
Urine culture [**2121-9-13**]: negative
Sputum culture [**2121-9-13**]: contaminated
Imaging:
CXR [**2121-9-13**]:
IMPRESSION:
Left lower lung and possibly right lower lung pneumonia. Tip of
right-sided central venous catheter obscured but seen as far as
cavoatrial junction
Brief Hospital Course:
Ms. [**Known lastname **] is a 65 year-old woman with h/o metastatic breast
cancer, recurrent aspiration pneumonia, transferred from OSH for
pneumonia, now also with hypotension and hypoxia.
ACTIVE ISSUES:
# SEPSIS: Patient transferred for fever, tachycardia,
tachypnea, and known source of pneumonia. Pneumonia is [**Location (un) **]
care associated as patient was discharged from hospital < 1
month ago. She is also immunosupressed given current
chemotherapy and hypogammaglobulenemia. No evidence of
bleeding/hemorrhagic shock, no history of recent steroid
use/adrenal insufficiency. Cefepime/vancomycin 8-day course
through [**9-20**] to cover for HCAP and cellulitis, vancomycin
allergy is red mans and pt received vancomycin during last
admission. Tolerated well during this admission by giving slowly
and with IV benadryl.
# Left thigh wound: Chronic wound, overall significantly
improved per Dr. [**First Name (STitle) **]. Currently without clear evidence of
cellulitis given lack of erythema in areas of tenderness. The
warmth and significant tenderness on exam considered secondary
to recent radiation and chemotherapy changes. Small superficial
skin infection considered, but improved by discharge and patient
already receiving IV vancomycin course for her pneumonia.
# Altered mental status: Patient was lethargic on admission,
likely in the setting of infection and sepsis. No focal
abnormalities noted on neurologic exam, but completely resolved
by the time of transfer to the floor.
# Acute renal failure, mild: Pre-renal in setting of sepsis.
Resolved with IV fluids.
CHRONIC ISSUES:
# SVC thrombus: Pt with h/o thrombotic disease causing known
right-to-left (PFO), RV dilation and pulmonary hypertension.
Continued on lovenox 80 mg SC BID
# Metastatic breast cancer: Patient with mets to brain, liver,
and bone. Currently receiving radiation with sensitizing
platinum. Wound care was consulted for left thigh wound due to
metastatic lesions. Based on assessment by Dr. [**First Name (STitle) **], there has
been significant improvement in this thigh lesion. Further
management of her malignancy and thigh lesion as an outpatient.
# Depression: Restart home medications (bupropion, sertraline)
when mental status improved.
# Hypogammaglobulinemia: Patient previously on IVIG, but was on
prophylactic doxy prior to her current pneumonia. Doxycycline
held given treatment with cefepime and vancomycin.
# Chronic pain: Managed at the [**Location (un) **] pain center.
# GERD: Continue home protonix 40 [**Hospital1 **] and ranitidine 300 qHS
TRANSITIONAL:
# Metastatic breast cancer and thigh lesion: Thigh wound
remained slightly tender on exam though stable and non-infected
appearing.
# Pneumonia: To continue on cefepime and vancomycin IV through
[**9-20**].
# SVC Thrombus: To continue on lovenox.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 100 mg PO DAILY
2. Diazepam 5 mg PO Q12H:PRN muscle spasm
3. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea
4. Doxycycline Hyclate 100 mg PO Q12H
5. Enoxaparin Sodium 80 mg SC Q12H
6. Gabapentin 600 mg PO TID
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) 15 mg PO Q4-6H:PRN pain
9. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
10. Pantoprazole 40 mg PO Q12H
11. pramipexole *NF* 0.25-0.5 Oral QHS:PRN
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
13. Ranitidine 300 mg PO HS
14. Sertraline 200 mg PO DAILY
15. Trastuzumab Dose is Unknown IV Frequency is Unknown
Duration: 1 Doses
16. Vitamin D [**2108**] UNIT PO DAILY
Discharge Medications:
1. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1gram every twelve (12) hours Disp #*7
Gram Refills:*0
2. CefePIME 2 g IV Q8H
RX *cefepime 2 gram 2gm every eight (8) hours Disp #*20 Gram
Refills:*0
3. DiphenhydrAMINE 12.5 mg IV BID
RX *diphenhydramine HCl 50 mg/mL 12.5mg twice a day Disp #*87.5
Gram Refills:*0
4. BuPROPion 100 mg PO DAILY
5. Enoxaparin Sodium 80 mg SC Q12H
6. Gabapentin 600 mg PO TID
7. OxycoDONE (Immediate Release) 15 mg PO Q4-6H:PRN pain
8. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
9. Pantoprazole 40 mg PO Q12H
10. Ranitidine 300 mg PO HS
11. Sertraline 200 mg PO DAILY
12. Diazepam 5 mg PO Q12H:PRN muscle spasm
13. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea
14. Doxycycline Hyclate 100 mg PO Q12H
15. Ondansetron 8 mg PO Q8H:PRN nausea
16. pramipexole *NF* 0.25-0.5 Oral QHS:PRN
17. Prochlorperazine 10 mg PO Q6H:PRN nausea
18. Vitamin D [**2108**] UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Secondary Diagnosis:
Acute renal failure, mild
Metastatic breast cancer
Left lower extremity wound, chronic
Known SVC thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure to care for you during your hospitalization.
You were admitted on [**2121-9-13**] for pneumonia and required
temporary admission to the Intensive Care Unit due to low blood
pressures. Your pneumonia has been resolving and your symptoms
of cough, breathing, and fevers have all improved after starting
IV antibiotics. You are now improved and stable enough to be
discharged home with home nursing services.
Please be sure to keep your appointments listed below. Please
also be sure to complete the prescribed IV antibiotic course as
well as your regular medications listed below.
Followup Instructions:
Department: OSTOMY/[**Hospital **] CLINIC
When: THURSDAY [**2121-9-25**] at 11:30 AM
With: WOUND/OSTOMY NURSE [**Telephone/Fax (1) 23664**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**2121-9-26**] 10:15a CLINIC VISIT HEM ONC,CC9
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEM [**Hospital **] CLINIC
[**2121-9-26**] 11:00a [**Location (un) **]-[**Last Name (LF) **],[**First Name3 (LF) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] [**Location (un) **]/ONCOLOGY-SC
[**2121-10-3**] 10:45a CLINIC VISIT HEM ONC,CC9
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEM [**Hospital **] CLINIC VISIT
[**2121-10-3**] 11:30a [**Last Name (LF) **],[**First Name3 (LF) **] R.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] [**Location (un) **]/ONCOLOGY-SC
[**2121-10-3**] 12:00p [**Location (un) **]-[**Last Name (LF) **],[**First Name3 (LF) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] [**Location (un) **]/ONCOLOGY-SC
[**2121-9-26**] 01:00p WOUND/OSTOMY NURSE-CC3 [**Doctor First Name 147**] SPEC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] OSTOMY/WOUND
|
[
"584.9",
"V45.71",
"333.94",
"284.19",
"198.3",
"453.77",
"V10.3",
"530.81",
"785.52",
"198.5",
"272.4",
"V15.82",
"799.02",
"V42.81",
"401.9",
"682.6",
"198.89",
"279.00",
"338.29",
"486",
"V16.1",
"V16.3",
"995.92",
"311",
"V58.69",
"780.52",
"197.7",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
12712, 12786
|
8179, 8371
|
315, 322
|
12988, 12988
|
5682, 5682
|
13793, 15095
|
4014, 4191
|
11787, 12689
|
12807, 12807
|
11048, 11764
|
13138, 13770
|
6095, 8156
|
4206, 5663
|
2797, 2851
|
257, 277
|
8387, 9476
|
350, 2778
|
12858, 12967
|
5698, 6079
|
12826, 12837
|
13003, 13114
|
9791, 11022
|
2874, 3655
|
3671, 3998
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,445
| 113,005
|
30935+57727
|
Discharge summary
|
report+addendum
|
Admission Date: [**2134-7-15**] Discharge Date: [**2134-7-31**]
Date of Birth: [**2059-4-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
endotracheal intubation at outside hospital ER
AVR(#19 CE perimount Magna) [**7-22**]
History of Present Illness:
75 yo F hx DM II, presented to OSH ([**Hospital1 46**]) by EMS (7:30PM) for
worsening dyspnea. Pt had been treated for pneumonia with resp
sx's x2 weeks. On arrival, the patient was noted to have a LBBB.
CE's significant for Trop T 1.91, CK 106. She was initially
afebrile at 98.5, HR 100s, BP 90/, O2 sat 90% on RA. The patient
was intubated for respiratory distress, ABG post 7.28/48/210,
started on nitro drip, given IV lasix 40mg, lopressor, IV
lovenox 90mg, ASA 324mg, plavix, and transferred to [**Hospital1 18**] for
further care.
On arrival, pt had low grade temp 100.2, HR 105, BP 94/64.
Evaluated by cardiology fellow, felt that pt has LAFB with rate
related QRS prolongation, cardiac enzymes flat. Given 80mg lasix
IV, plavix 600mg, admitted to CCU for further care.
Past Medical History:
DM2
HTN
PNA
Giant Cell Arteritis
Rt Hip replacement
Rt knee replacement
CCY
Rt carpal tunnel release
Social History:
Lives alone. Denies tobacco and ETOH
Family History:
noncontributory
Physical Exam:
Admission
VS: T 99.1 BP 113/74 HR 103 RR 18 O2 100% on PS 8/5, 50% FiO2
Gen: elderly female, intubated, sedated, well appearing, NAD
HEENT: NCAT. Sclera anicteric. PERRL.
Neck: thick neck, unable to see JVP.
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: Resp were unlabored, no accessory muscle use. bibasilar
crackles with good air entry b/l, no wheezes.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Pulses:Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2134-7-15**] 08:23PM TYPE-ART PO2-113* PCO2-40 PH-7.44 TOTAL
CO2-28 BASE XS-3
[**2134-7-15**] 08:19PM HGB-11.8* calcHCT-35 O2 SAT-70
[**2134-7-15**] 08:03PM PT-13.0 PTT-29.3 INR(PT)-1.1
[**2134-7-15**] 07:50PM GLUCOSE-209* UREA N-17 CREAT-0.7 SODIUM-139
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
[**2134-7-15**] 07:50PM CK(CPK)-1158*
[**2134-7-15**] 07:50PM WBC-13.7* RBC-4.27 HGB-13.6 HCT-40.2 MCV-94
MCH-31.9 MCHC-33.9 RDW-13.2
[**2134-7-15**] 05:00AM GLUCOSE-214* UREA N-20 CREAT-0.9 SODIUM-137
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13
[**2134-7-14**] 11:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2134-7-14**] 10:50PM ALT(SGPT)-31 AST(SGOT)-46* LD(LDH)-354*
CK(CPK)-121 ALK PHOS-85 TOT BILI-0.6
[**2134-7-14**] 10:50PM ALBUMIN-3.9 CALCIUM-8.7 PHOSPHATE-5.6*
MAGNESIUM-2.5
[**2134-7-29**] 07:20AM BLOOD WBC-11.7* RBC-3.63* Hgb-11.1* Hct-33.5*
MCV-92 MCH-30.6 MCHC-33.1 RDW-14.3 Plt Ct-286
[**2134-7-29**] 07:20AM BLOOD Plt Ct-286
[**2134-7-29**] 07:20AM BLOOD Glucose-106* UreaN-16 Creat-0.7 Na-141
K-4.6 Cl-101 HCO3-33* AnGap-12
RADIOLOGY Final Report
CHEST (PA & LAT) [**2134-7-28**] 8:37 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman s/p VR.
REASON FOR THIS EXAMINATION:
evaluate effusion
STUDY: PA and lateral chest [**2134-7-28**].
HISTORY: 75-year-old woman status post MVR. Patient with pleural
effusion.
FINDINGS: The Swan-Ganz catheter has been removed. Median
sternotomy wires are seen. There is again seen a left
retrocardiac opacity and a left-sided pleural effusion. There is
some atelectasis at the right base and a small right-sided
pleural effusion. There are no signs for overt pulmonary edema.
Overall, the findings are stable.
Cardiology Report ECHO Study Date of [**2134-7-22**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for AVR, ?MVR
Status: Inpatient
Date/Time: [**2134-7-22**] at 13:28
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW4-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 20% (nl >=55%)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.1 cm (nl <= 2.5 cm)
Aortic Valve - Peak Gradient: 64 mm Hg
Aortic Valve - LVOT Diam: 1.9 cm
Aortic Valve - Valve Area: *0.4 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Mild symmetric LVH. Normal LV cavity size. Severely
depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Focal calcifications
in ascending aorta. Simple atheroma in aortic arch. Simple
atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral
annular calcification. Moderate to severe (3+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was
under general anesthesia throughout the procedure. The patient
appears to be in sinus rhythm. Emergency study. Results were
Conclusions:
PRE CPB The pre-bypass study was limited by the fact that the
patient became unstable and was quickly and urgently placed on
bypass.
The left atrium is moderately dilated. The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is severely, globally depressed.
There maybe worse function of the septum. Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen. The posterior
leafllet of the mitral valve is moderately to severely thickened
and moderately immobilized. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is a trivial/physiologic pericardial effusion.
Post-CPB The patient is receiving norepinephrine, epinephrine,
and milrinone by infusion. There is normal right ventricular
systolic function. Left ventricular systolic function is
markedly improved. The ejection fraction is in the range of
40%. Poor acoustic windows prevent the exclusion of a regional
wall motion abnormality. There is a bioprosthesis in the aortic
position. It appears well seated. The leaflets are only very
poorly seen and their function can not be commented on. The
effective orifice area (EOA) is about 1.2 cm2 and the maximum
gradient is about 38 mm Hg with a cardiac output near 6 l/m.
These numbers indicate an EOA slightly less than expected.
There is very trace valvular AI. A perivalvular jet is not
obvious but poor windows prevent complete exclusion. The
thoracic aorta appears intacy.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2134-7-22**] 17:11.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 73141**])
RADIOLOGY Final Report
CAROTID SERIES COMPLETE [**2134-7-19**] 9:09 AM
CAROTID SERIES COMPLETE
Reason: Pre-op Eval for aortic valve repair
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with Aortic Stenosis
REASON FOR THIS EXAMINATION:
Pre-op Eval for aortic valve repair
Carotid duplex series in a 75-year-old woman with aortic
stenosis. Preop evaluation of the carotids.
FINDINGS: Duplex evaluation was performed on the bilateral
carotid arteries. On the right, peak systolic velocities in
cm/sec are as follows: 48/14 in the proximal ICA, 51/15 in the
mid ICA and 66/22 in the distal ICA, 51/15 in the CCA and 57 in
the ECA. The ICA/CCA ratio is 1.29 and this is consistent with a
widely patent right ICA.
On the left, the peak systolic velocities are as follows: 52/14
in the proximal ICA, 35/10 in the mid ICA and 48/12 in the
distal ICA. There is a velocity of 66/18 in the CCA and 59 in
the ECA. The ICA/CCA ratio is 0.78 and this is consistent with a
widely patent left ICA.
There is antegrade flow in both vertebral arteries.
IMPRESSION: There is a widely patent right ICA and a widely
patent left ICA with antegrade flow in both vertebral arteries.
This is a normal carotid duplex exam.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2134-7-20**] 12:02 PM
Brief Hospital Course:
Mr [**Known lastname **] is a 75yoW who presented to the ER at an outside
hospital complaining of increasing dyspnea after having been tx
for 2 weeks for pneumonia. In the ER she was intubated and found
at that time to have EKG chaanges(new LBBB) andelevated
TropT(1.91). She was then transferred to [**Hospital1 18**] for further
evaluation and care. At [**Hospital1 **] patient had cardiac cath that showed
no sig CAD, sevAS [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 109**] 0.38cm2. A f/u echo showed sev AS and
mod MR w/EF 20-25%. The patient extubated after studies
completed.
She was seen and accepted by CT surgery for AVR. On [**7-22**] she had
an AVR(#19 CE perimount pericardial), please see OR note for
full details. She tolerated the operation well and was
transferred to the cardiac surgery ICU in stable condition on
Milrinone Epinepherine and Propofol infusions. During that
evening her epinephrine infusion was weaned to off. On POD 1 she
was sucessfully extubated and her Milrinone infusion was weaned.
On POD2 she experienced multipple episode of atrial fibrillation
and was started on Beta blockade and Amiodarone and converted to
sinus rhythm. On POD3 the Milrinone wean was completed and her
PA catheter was removed. On POD5 she was transferred to the step
down floor. Over the next several days she made slow progress in
her activity and strenghth recovery and it was decided she would
benefit from a short stay in a rehabilitation center. On post
operative day seven she was discharged to [**Location (un) 169**] Rehab of
[**Location (un) 3320**].
Medications on Admission:
Glyburide 5mg [**Hospital1 **]
Prednisone-stopped at latest on [**6-28**] but PCP is unsure
Percocet PRN for pain
Actonel
CaCarbonate
neurontin 300mg [**Hospital1 **]
Keflex - 10 days
.
Allx Sulfa
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg QD x 7days then 200mg QD.
Disp:*35 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**] of [**Location (un) 3320**]
Discharge Diagnosis:
s/p AVR(#19 CE perimount Magna)[**7-22**]
PMH:DM2,HTN,PNA,Giant cell arteritis,Rt hip replacement,Rt knee
replacement, CCY,Rt Carpal tunnel release
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medication as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks
PCP/Cardiologist in [**3-28**] weeks
Completed by:[**2134-7-29**] Name: [**Known lastname 12178**],[**Known firstname **] Unit No: [**Numeric Identifier 12179**]
Admission Date: [**2134-7-15**] Discharge Date: [**2134-7-31**]
Date of Birth: [**2059-4-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 741**]
Addendum:
patient remained at [**Hospital1 8**] due to availability of rehab bed and
patient and family request for location of rehab. She has
remained stable, and is being transferred to a rehab facility
today, [**2134-7-31**], on POD # 9.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1353**] of [**Location (un) 1541**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2134-7-31**]
|
[
"410.71",
"V43.65",
"398.91",
"997.3",
"272.4",
"518.0",
"401.9",
"V43.64",
"486",
"250.00",
"514",
"518.81",
"427.31",
"426.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"99.04",
"38.91",
"89.68",
"39.61",
"99.20",
"88.56",
"34.04",
"37.23",
"96.71",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
13978, 14180
|
9709, 11299
|
295, 383
|
13010, 13017
|
2074, 3333
|
13218, 13955
|
1385, 1402
|
11546, 12717
|
8512, 8551
|
12839, 12989
|
11325, 11523
|
13041, 13195
|
3977, 8267
|
1417, 2055
|
248, 257
|
8580, 9686
|
411, 1191
|
8299, 8475
|
1213, 1315
|
1331, 1369
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,965
| 152,716
|
6182
|
Discharge summary
|
report
|
Admission Date: [**2136-6-13**] Discharge Date: [**2136-6-24**]
Date of Birth: [**2059-11-21**] Sex: M
Service: CCU
CHIEF COMPLAINT: Fever.
HISTORY OF PRESENT ILLNESS: This is a 74-year-old male with
a history of coronary artery disease status post coronary
artery bypass graft in [**2121**], status post ICD placement in
[**2131**] for V-fib arrest. Patient was doing well until two days
prior to admission when he noted fevers up to 101.5
associated with chills and rigors. He noted a dry cough.
There was no chest pain, blurry vision, headache, abdominal
pain. He did have some nausea and vomiting x1, nonbloody,
nonbilious. Patient denies any sick contacts, travel,
camping, new foods, or raw foods.
Patient had an appointment with Dr. [**Last Name (STitle) **]. In the office
he was found to be febrile with systolic blood pressure at
90. Laboratories were drawn. The patient was sent to the
Emergency Department and admission. In the Emergency
Department the patient was noted to be afebrile with blood
pressure of 76/46, pulse of 84, O2 saturation of 99% on room
air. The patient received 500 cc of normal saline and his
blood pressure rebounded to 115/60.
The patient was admitted to the Medicine floor. Two days
after being admitted, the patient was still febrile up to
101.1. He was in the bathroom when he started feeling dizzy
and faint. Telemetry showed that the patient was tachycardic
up to about 180 beats per minute. Patient noted respiratory
distress, but no chest pain. His ICD fired four times.
Patient's blood pressure remained stable during this episode
as well as his oxygen saturation. Patient was transferred to
the Intensive Care Unit for further workup.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post IMI and coronary
artery bypass graft in [**2121**].
2. Status post V-fib arrest and ICD placement in [**2131**].
3. History of ulcerative colitis diagnosed in [**2128**], last
scoped in [**2136-2-4**].
4. Cellulitis from [**2136-2-4**], initially received Keflex,
then readmitted and treated with IV Ancef and then
dicloxacillin.
5. Recurrent DVT bilaterally from the year [**2133**].
6. Hypertension.
7. Hypercholesterolemia.
8. History of TB, status post thoracotomy in [**2088**] with wedge
resection.
9. Status post right inguinal hernia repair.
10. Postphlebitic syndrome.
MEDICATIONS:
1. Lipitor 40 mg po q hs.
2. Asacol 1200 mg po q [**Hospital1 **].
3. Coumadin 3 mg po q hs.
4. Hydrochlorothiazide 25 mg po q hs.
5. Atenolol 25 mg po q am.
ALLERGIES: No known drug allergies, although reportedly
Morphine causes nausea and question of rash.
SOCIAL HISTORY: Patient worked in "management". The patient
is married with two children, lives with his wife at home.
He denies any current or past alcohol or tobacco use.
FAMILY HISTORY: Father had a "leaky valve." The patient's
mother had hypertension.
PHYSICAL EXAM IN THE CCU: Temperature 97.8, T max 101.2,
pulse 85-130, blood pressure 112/42-151/78, respiratory rate
23-45, O2 saturation 97-98% on 4 liters. In general, the
patient is in no apparent distress. HEENT: Mucous membranes
moist. Pupils are equal, round, and reactive to light and
accommodation. Lungs: Inspiratory crackles halfway up the
base. Cardiovascular: Regular, rate, and rhythm, no murmur,
gallop, or rubs. Abdomen is soft, nontender, nondistended,
normoactive bowel sounds. Extremities: No clubbing,
cyanosis, or edema.
LABORATORIES: White count 3.9, hematocrit 39.9, platelets
106. PT 24.9, PTT 38.5, INR 4.1. Sodium 132, potassium 4.4,
chloride 99, bicarb 19, BUN 24, creatinine 1.6, glucose 142,
calcium 8.5, magnesium 2.1, phosphorus 1.4. CK 789, MB 5,
troponin 4.4.
Electrocardiogram: Sinus tachycardia, left bundle branch
block, prolonged P-R, no change from prior.
HOSPITAL COURSE: In short, this is a 74-year-old male with a
history of coronary artery disease, status post IMI in [**2121**]
with CABG, status post AICD placement in [**2131**] for V-fib,
admitted for fever workup initially. Two days into his
admission, patient noted to be tachycardic up to 170-180
beats per minute, hemodynamically stable, AICD shocked x4.
Patient admitted to CCU for further observation.
1. Rhythm: When patient was admitted to the CCU, pacer was
interrogated. It appears that the patient actually received
six shocks. Most of the shocks actually for a
supraventricular tachycardia. It appears that the patient
had at least one episode of actual ventricular tachycardia.
It was likely induced by a supraventricular tachycardia.
This supraventricular tachycardia was likely a flutter given
the rate of 150. Because the patient's amiodarone had been
discontinued due to ophthalmic side-effects, he was started
on dofetilide. The patient was started at 500 mg po bid,
checking Q-T intervals before each dose. After several
doses, the patient was noted to have a prolonged Q-T interval
up to 700 milliseconds. Patient also was having frequent
polymorphic V-tach on the monitor, but not frequent enough to
initiate a shock from AICD.
On [**2136-6-19**], the patient also was noted to have lost his
pulse in the context of a bradyarrhythmia. This was
transient lasting only several seconds. Patient's one lead
VVI pacer kicked in at a rate of 40. Patient otherwise
remained hemodynamically stable. Patient's dofetilide dose
was held.
On [**2136-6-21**], the patient went for EP study. A small focus of
A-flutter was located and was ablated. It was unclear how
clinically significant this was. Because the patient was not
having anymore tachyarrhythmias off of the dofetilide, there
was no further interventional procedures. No atrial lead
placement occurred as it would require a new pacer generator
and would likely be done in conjunction with the placement of
a [**Hospital1 **]-V pacer in the near future.
Following the ablation, the patient was visited by his
ophthalmologist. He commented it was probably safe to
restart amiodarone given that the patient's loss of vision in
one eye was likely ischemic in nature and not secondary to
amiodarone. Patient was started on amiodarone 200 mg po tid.
Toward the latter end of his admission, patient was noted to
be slightly bradycardic and V paced at 50 beats per minute.
For this reason, the amiodarone was decreased to 200 mg po
bid. Patient will follow up with Dr. [**Last Name (STitle) 73**].
2. Coronary artery disease: Patient has known coronary
artery disease. He did have a troponin leak, but his CK
peaked at 790 and his MB index remained flat. His troponin
leak was likely secondary to receiving AICD shocks. It was
important to rule out that the patient's tachyarrhythmia was
not secondary to ischemia. The patient received a Persantine
MIBI. This showed no reversible perfusion defects. There
was a severe fixed perfusion defect involving the basilar
portion of the lateral wall and the basilar portion of the
inferior wall in addition to a mild fixed perfusion defect at
the apex. The LV ejection fraction was calculated at 18%.
Patient was kept on beta blocker, ACE inhibitor, in addition
to aspirin and Lipitor.
3. Pump: Initially, the patient was noted to be in slight
congestive heart failure. He received 40 mg of IV Lasix with
good diuresis. He had no further active failure. As already
noted, the patient had an ejection fraction of 18% per his
stress test. Patient received a metabolic stress test to
determine his qualification for [**Hospital1 **]-V pacer. Patient at this
time does not meet the qualification for a [**Hospital1 **]-V pacer given
his oxygen consumption that was calculated.
Patient was seen by the Heart Failure team. [**Hospital **]
medical regimen was optimized for his congestive heart
failure. Patient was started on ACE inhibitor and his
lisinopril was titrated up to 20 mg po q day. He was also
started on digoxin with an initial digoxin load. The patient
was also started on aldactone 12.5 mg po q day. Finally, the
patient's beta blocker was titrated up. He was changed from
atenolol to Toprol given its proven efficacy in congestive
heart failure patient. As already noted, the patient became
bradycardic towards the end of his stay likely secondary to
the addition of amiodarone and digoxin onto his regimen that
already included a beta blocker. For this reason, the
patient's Toprol dose was decreased to 50 mg po q day and his
amiodarone dose was decreased to 200 mg po bid. Patient will
likely require [**Hospital1 **]-V pacer in the near future.
4. ID: Patient was initially admitted for fever workup.
Patient's cultures remained negative. It is possible that
fever was a result of the mesalamine that he is taking for
his ulcerative colitis which is not active at this time.
Patient has been on the mesalamine for several years, but
there have been cases where fever has developed in response
to this drug even after chronic use. The mesalamine was
discontinued. Patient's fevers stopped. He never had an
elevated white blood cell count or impressive left shift.
5. Chronic DVT: The patient was kept on Heparin while
in-house. His INR was initially reversed with vitamin K.
Because the patient was not therapeutic on discharge with an
INR of 1.4, he was started on Lovenox as a bridge.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Lipitor 40 mg po q hs.
2. Tylenol prn.
3. Lisinopril 20 mg po q pm.
4. Toprol XL 50 mg po q am.
5. Lovenox 80 mg subQ [**Hospital1 **], until INR within goal of [**2-6**].
6. Aldactone 12.5 mg po q day.
7. Aspirin 81 mg po q day.
8. Coumadin 3 mg po q hs.
9. Digoxin 0.125 mg po q day.
10. Amiodarone 200 mg po bid.
DISCHARGE INSTRUCTIONS: Patient was instructed to see a
doctor if he developed any chest pain, shortness of breath,
nausea, vomiting, excessive sweating, dizziness, or
lightheadedness. Patient will need to have his INR checked
on Tuesday, [**6-26**]. Once the INR is between [**2-6**], he may
discontinue the Lovenox. Patient also needs to make a
follow-up appointment with Dr. [**Last Name (STitle) 73**] at the [**Hospital 19721**] Clinic,
number to call is [**Telephone/Fax (1) **]. He will also need to have a
digoxin level drawn. Patient also needs to followup with his
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within two weeks.
DISCHARGE DIAGNOSES:
1. Supraventricular tachycardia.
2. Ventricular tachycardia.
3. Status post EP study with atrial flutter focus ablation.
4. Ejection fraction of 18%.
5. Fevers of unknown cause, possibly secondary to mesalamine.
6. Hypertension.
7. Hypercholesterolemia.
8. Status post myocardial infarction.
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2136-6-24**] 16:37
T: [**2136-7-3**] 06:48
JOB#: [**Job Number 24117**]
|
[
"584.9",
"V45.81",
"780.6",
"414.00",
"428.0",
"413.9",
"276.5",
"427.1",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
2828, 3811
|
10338, 10871
|
9333, 9653
|
3829, 9278
|
9678, 10317
|
151, 159
|
188, 1719
|
1741, 2635
|
2652, 2811
|
9303, 9310
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,372
| 141,158
|
44674
|
Discharge summary
|
report
|
Admission Date: [**2192-3-20**] Discharge Date: [**2192-3-30**]
Date of Birth: [**2118-4-12**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This 73-year-old white male
had a CABG times two, AVR, [**Last Name (un) 3843**]-[**Doctor Last Name **], in [**2178**]. He
was admitted to an outside hospital with acute onset of
shortness of breath and found to be in CHF. He ruled out for
an MI. He had a cardiac catheterization at the [**Hospital1 **] on
[**2192-3-20**] which revealed an 80% left main, 50% mid LAD lesion
and 70% proximal left circumflex lesion. He had an
echocardiogram in [**1-22**] which revealed an EF greater than 55%
with moderate AI and AS. He is now admitted for redo CABG
and AVR.
PAST MEDICAL HISTORY:
1. Status post CABG times two with saphenous vein graft to
the OM and RCA and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3843**]-[**Doctor Last Name **] AVR in [**2178**].
2. Status post left carotid endarterectomy in [**2190**].
3. History of macular degeneration.
4. History of hypertension.
5. History of bilateral iliac aneurysms which were noted on
the cardiac catheterization and a calcified aorta.
ADMISSION MEDICATIONS:
1. Synthroid 0.1 mg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He is a former smoker, quit in [**2178**]. Does
not drink alcohol. The patient lives with his wife.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient is
a well-developed, elderly white male in no apparent distress.
Vital signs: Stable, afebrile. HEENT: Normocephalic,
atraumatic. The extraocular movements were intact. The
oropharynx was benign. Neck: Supple, full range of motion.
No lymphadenopathy or thyromegaly. Carotids had question of
bilateral bruits versus radiating murmur. Lungs: Clear to
auscultation and percussion. Cardiovascular: There was a
III/VI systolic ejection murmur. Regular rate and rhythm.
Abdomen: Soft, nontender, with positive bowel sounds. No
masses or hepatosplenomegaly. Extremities: Without
clubbing, cyanosis or edema. Neurologic: Nonfocal.
HOSPITAL COURSE: The patient had a CTA to evaluate his
ascending aortic arch and Dr. [**Last Name (STitle) 1537**] was consulted. He had
carotid ultrasounds which revealed mild to moderate plaque,
right greater than left with narrowing of the right of 60-69%
and left 40-59% narrowing.
On [**2192-3-22**], he underwent a redo AVR with LIMA to the LAD,
reverse saphenous vein graft to the OM2, and the distal RCA.
He had a redo AVR with a #21 CE pericardial valve. The cross
clamp time was 157 minutes. The total bypass time was 193
minutes. He was transferred to the CRSU in stable condition
on propofol, epinephrine, Neo-Synephrine. He had some lactic
acidosis on the night of surgery which resolved with fluid
resuscitation.
He was weaned and extubated on postoperative day number one.
On postoperative day number two, he remained on milrinone.
He did have some confusion. He was treated with Haldol. He
continued to have some agitation but was easily reoriented.
He had his chest tubes discontinued on postoperative day
number four. His Swan was discontinued on postoperative day
number four. On postoperative day number six, he was
transferred to the floor in stable condition. He continued
to have some altered mental status but this slowly improved.
On postoperative day number eight, he was discharged to home
in stable condition.
Laboratories on discharge revealed a hematocrit of 31.6,
white count 13,800, platelets 320,000. Sodium 139, potassium
4, chloride 105, C02 26, BUN 27, creatinine 1.3, blood sugar
90.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. q.d. times seven days.
3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q.d. times seven days.
4. Colace 100 mg p.o. b.i.d.
5. Ecotrin 325 mg p.o. q.d.
6. Plavix 75 mg p.o. q.d.
7. Captopril 12.5 mg p.o. t.i.d.
8. Levoxyl 100 micrograms p.o. q.d.
9. Lopressor 25 mg p.o. b.i.d.
FOLLOW-UP: The patient will be followed by Dr. [**Last Name (STitle) **] in one
to two weeks, Dr. [**Last Name (STitle) 95597**] in two to three weeks and Dr.
[**Last Name (STitle) 1537**] in four weeks.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Aortic stenosis.
3. Hypothyroidism.
4. Hypertension.
5. Postoperative delirium.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 275**] 02-248
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2192-3-30**] 05:20
T: [**2192-3-30**] 20:13
JOB#: [**Job Number 95598**]
|
[
"401.9",
"244.9",
"293.9",
"414.01",
"414.02",
"276.2",
"424.1",
"E878.0",
"996.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"36.15",
"36.12",
"35.21",
"99.07",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
1455, 1470
|
3766, 4350
|
4371, 4726
|
2223, 3743
|
1203, 1318
|
1490, 1526
|
1541, 2205
|
753, 1180
|
1335, 1438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,596
| 101,706
|
55053
|
Discharge summary
|
report
|
Admission Date: [**2128-7-14**] Discharge Date: [**2128-7-19**]
Date of Birth: [**2046-11-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
basic trauma for MVC
Major Surgical or Invasive Procedure:
[**2128-7-16**]- ORIF left femur fracture
History of Present Illness:
This patient is a 81 year old male with a history of atrial
fibrillation (on coumadin) and hypertension who was transferred
from [**Hospital 11560**] [**Hospital3 **] with a distal left femur
fracture involving his previous total knee replacement. He was
an unrestrained driver going approximately 30 MPH when he had a
left headlight to left headlight MVC with moderate vehicle
damage. He was brought to [**Hospital 11560**] [**Hospital3 **] complaining
only of left knee pain. He had a head and C-spine CT which were
negative. He had a distal left femur fracture. His INR was 1.7.
His systolic blood pressure varied at the OSH, but remained in
the 80s prior to transfer. En route, his systolic blood pressure
dropped to the 70s. He received 50 of fentanyl and 4 of morphine
prior to transfer, and currently complains only of left knee
pain. He did not have an abdominal CT scan prior to transfer to
[**Hospital1 18**].
Past Medical History:
- Afib on Coumadin
- previous back injury
- HYPERthyroidism
- s/p L TKA
Social History:
lives alone in [**Location (un) 3844**] during the week and works as a
private carpenter and handyman; goes to stay w/dtr and her
family on weekends in [**Location (un) 1475**], MA
Family History:
non-contributory
Physical Exam:
Discharge Physcial Exam:
VS: 98.3 109 116/66 19 997%4L
Gen: alert, occasionally confused but easily orients. NAD
CV: RRR
Pulm: Easy WOB CTAB
Abd: Soft NT ND
Ext: LLE in ACE and knee immobilizer, DP palp bilat
Pertinent Results:
[**7-14**] CT abd/pelvis
IMPRESSION:
1. Multilevel bilateral rib fractures without pneumothorax.
These include at least right anterior second through fifth ribs
and left posterior third through fifth ribs. Probable small
right upper lung pulmonary contusion.
2. No solid organ injury.
3. Angulated mildly impacted left basicervical femoral
fracture.
4. 2.3-cm right thyroid nodule/cyst, to be further assessed by
ultrasound.
5. Chronic interstitial changes in the right lung and mild
bronchiectasis. Bilateral nodular opacities including a 12-mm
nodular opacity in the left upper lobe (2, 32), which could be
correlated with prior CT and if needed, follow up in six months
to one year is recommended.
6. Trace right pleural effusion.
7. Hypodensities in the liver, spleen, kidneys, most of which
too small to fully characterize.
8. Subcentimeter hyperdense lesion in the left hepatic lobe (2,
72), which could represent a small flash-filling hemangioma.
9. Ectatic ascending aorta to 4.5 cm without frank aneurysm.
Diffuse
atherosclerotic disease. No acute vascular injury.
Brief Hospital Course:
Mr. [**Known lastname 112367**] was initially admitted to the trauma ICU for
neurological checks given concern for delayed head bleed. He
remained in the ICU throughout his course, which is summarized
by systems below. In brief, he was taken to the OR for ORIF of
the left femur fracture; did well postoperatively, and is
discharged to rehab on HD 6.
Neuro: He did have some episodes of ICU delirium which were
managed with PRN haldol and seroqeul. Otherwise pain was well
controlled with IV medication that was transitioned to orals as
he began to tolerate PO. His confusion improved during the day
and with reorientation by family.
CV: He was initially hypotensive to the 60's in the ED;
hypotension responsed to IVF initially, and then 2u pRBC. He had
a bedside echo and was started on a phenylephrine drip. He is on
coumadin at baseline for afib; this was held for concern for
head bleed. His INR was reversed with 3u FFP on [**7-15**] in
anticipation of going to the OR for repair of his femur
fracture. He did require pressors immediately postop but these
were weaned off on POD1 and at time of discharge he is
cardiovascuarly stable.
Pulm: He was intubated to go to the operating room for his femur
fracture and remained intubated overnight. He also had a
bronchoscopy during the OR procedure. He was diuresed
postoperatively with albumin and lasix drip. The lasix drip was
transitioned to intermittent lasix and his respiratory status
improved; he was weaned to room air and remained stable.
GI: He was kept NPO until he went to the operating room.
Postoperatively diet was advanced and he tolerated well with no
issues.
GU: A foley catheter was placed in the ED and remained in place
until POD2; at this time it was discontinued and he voided
without difficulty.
Heme: Pt recieved 2u pRBC upon admission. INR was elevated due
to home coumadin; 3u FFP to reverse prior to OR. Postop his Hct
decreased to 21 and he recieved 2u pRBC; his Hct bumped
appropriately to 26 and remained stable throughout the remainder
of his course. Coumadin was restarted on [**2128-7-18**].
MSK: Injuries included bilateral rib fractures (L ribs [**12-25**] and R
ribs [**2-24**]) and fracture of the left femur. Ortho was consulted in
the ED and followed throughout the patient's course. He was
taken to the OR with ortho for ORIF of the femur fracture on
[**7-16**]; for full details please see the dictated operative report.
At discharge he is non-weight bearing on the left lower
extremity with an unlocked [**Doctor Last Name **] brace. Physical therapy did
see him inpt and recommended rehab.
Medications on Admission:
Methimazole 2.5mg PO q48
Coumadin 5mg PO daily
Sotalol 80mg PO AM
Sotalol 40mg PO QPM
Digoxin 0.25mg PO daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever/pain
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Digoxin 0.25 mg PO DAILY
Please draw digoxin level before 2nd dose
4. Docusate Sodium 100 mg PO BID
5. Methimazole 2.5 mg PO Q48H
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
7. Senna 1 TAB PO BID:PRN constipaiton
8. Sotalol 80 mg PO QAM
9. Sotalol 40 mg PO QPM
10. Warfarin 5 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA)
home rx
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
bilateral rib fractures
L distal femur fracture
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 ACS service after your trauma.
You may continue to eat a regular diet. You should exercise as
much as possible and continue to ambulate. However, you should
not bear any weight on your L left. You may take tylenol for
pain and narcotic medication as directed. You should also resume
your coumadin.
Followup Instructions:
Follow-up with Orthopedic surgery by [**7-30**] w/ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Please call to make an appointment: [**Telephone/Fax (1) 1228**]
You should follow up with ACS in [**12-22**] weeks after discharge. Call
to make an appointment: [**Telephone/Fax (1) 600**]
Completed by:[**2128-7-19**]
|
[
"E812.0",
"242.90",
"E915",
"996.44",
"518.0",
"293.0",
"427.31",
"933.1",
"820.09",
"807.08",
"891.0",
"V58.61",
"458.9",
"V43.65",
"276.69",
"V15.82",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"33.23",
"81.52",
"83.45",
"38.91",
"83.65",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6232, 6329
|
3004, 5598
|
325, 368
|
6421, 6421
|
1895, 2981
|
6952, 7292
|
1629, 1647
|
5759, 6209
|
6350, 6400
|
5624, 5736
|
6604, 6929
|
1662, 1876
|
265, 287
|
396, 1318
|
6436, 6580
|
1340, 1414
|
1430, 1613
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,280
| 188,905
|
19753
|
Discharge summary
|
report
|
Admission Date: [**2170-4-24**] Discharge Date: [**2170-4-28**]
Date of Birth: [**2127-8-6**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 42-year-old woman with
metastatic melanoma to the brain, breast and abdomen who
presented to the oncology service at [**Hospital1 **]
hospital on [**2170-4-24**] with hypotension, dehydration and
anemia. She proceeded to develop peritonitis and was brought
emergently to the operating room on [**2170-4-25**] where she
underwent ex-lap, drainage of abdominal and pelvic abscess
and jejunal-ileal small bowel bypass.
The patient survived her operation, however, postoperatively
was found to be profoundly acidotic with a pH of 7.08. A
discussion was held with her family regarding her poor
prognosis, not only at the current time, but giving
consideration to her widely metastatic melanoma. The
decision was made to make her "comfort measures only".
Propofol and morphine were administered for comfort and the
patient passed away on [**2170-4-28**].
PAST MEDICAL HISTORY: Her past medical history included
metastatic melanoma originating on her right arm, anemia,
excision of variant cyst, and right axillary dissection.
[**Name6 (MD) **] [**Name8 (MD) **] m.d. [**MD Number(1) 845**]
Dictated By:[**Last Name (NamePattern4) 53391**]
MEDQUIST36
D: [**2170-5-3**] 05:52:52
T: [**2170-5-3**] 19:43:16
Job#: [**Job Number 53392**]
|
[
"285.9",
"276.5",
"198.3",
"197.4",
"995.91",
"198.89",
"198.81",
"197.6",
"567.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.91",
"99.04",
"54.19",
"93.59",
"92.39"
] |
icd9pcs
|
[
[
[]
]
] |
182, 1047
|
1070, 1457
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,124
| 110,763
|
49792
|
Discharge summary
|
report
|
Admission Date: [**2193-11-18**] Discharge Date: [**2193-11-21**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Altered Mental Status, Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, this is a 60 yoM with ESRD on peritoneal dialysis, DM2,
HTN, diastolic CHF, anemia, wheelchair-bound state who presented
from home with agitation and dyspnea after his wife was unable
to successfully complete his PD sessions at home. The catheter
had been flipped up into his abdomen and was not successfully
pulling back. He also became dyspneic at home - likely from
volume overload with inability to remove the dwelling fluid. The
catheter has since been fixed and he has had successful dialysis
while here. Importantly, the patient also had a recent admission
for C.diff diarrhea (+ by PCR) and is to complete a PO Vanc
course until [**2193-11-25**]. On initial presentation the patient was
extremely agitated, K was 6.9, lactate 0.8. CXR was performed
and pneumonia could not be excluded, thus patient was given 750
mg IV levofloxacin, also got doses of vanco and flagyl.
Kayexelate, insulin were given and K improved to 4.7 today.
.
Currently, the patient's VS are 99.8 80 138/67 18 99% on RA. He
is conversant and appropriate. He states that he feels well and
wants to go home. He denies SOB though his lungs have diffused
rhonchi and crackles. He abdomen is non-tender. He reports that
he was having [**1-5**] bowel movements at home. He currently has a
flexiseal in place.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-7**], then PD since
[**9-9**]
2. HTN
3. Chronic low back pain [**2-5**] herniated discs
4. diastiolic CHF- TTE [**12-9**] EF 75%, LVH
5. Peripheral neuropathy
6. Anemia
7. h/o nephrolithiasis
8. s/p cervical laminectomy; ?osteo in past
9. h/o depression
10. h/o MSSA bacteremia ([**3-9**]-infected HD catheter), E. coli
bacteremia
11. s/p L AV graft: [**7-7**]
12. h/o [**12-7**] of L4-5 diskitis, osteo, epidural abscess
13. MRSA cath tip infection
14. MSSA peritonitis [**6-10**]
15. thyroid nodule on u/s [**6-10**], recommended f/u 1 yr
16. wheelchair bound due to knee/muscle contraction since had a
PNA and ICU admission in [**2187**]
17. h/o IJ clot
18. Right third digit abscess through the entire finger
including flexor sheath s/p amputation 9/[**2193**].
Social History:
Lives in [**Location 2268**] with wife, who takes care of him at home, she
also takes care of his peritoneal dialysis. He uses a wheel
chair to move around at home which has been more difficult for
him and wife has had difficulties with transfers. Has two sons.
One of his sons lives in [**Name (NI) 3908**] and the other lives in [**Location 86**].
TOBACCO: 1-2 packs per day for the past 40 years.
ETOH: Last drinking 8 years ago
ILLICITS: Denies
Family History:
No family history of high blood pressure or heart attack. Two of
his grandparents, his aunt, and his father had diabetes, but he
is not sure which type. Both his father and mother passed away
from lung cancer. No fam hx of renal disease.
Physical Exam:
On admission:
VS: 99.8 80 138/67 18 99% on RA
GEN: alert and oriented, appropriate, lying on back in NAD
HEENT: PERRL, EOMI, red eyes and mildly icteric sclerae
NECK: Supple, no LAD, distended neck vein
PULM: Bilateral rhonchi and expiratory wheezing, patient with
abdominally augmented expiration, crackles heard throughout
CARD: RR, 2/6 systolic murmur at RUSB, nl S2, no R/G
ABD: BS+, soft, NT, ND, PD catheter site without tenderness or
erythema, no exudates
EXT: WWP, diminished peripheral pulses
NEURO: sensation intact; CNII-XII intact, Full strength in bil
UE/LE, able to lift both legs off bed
.
On discharge:
pulmonary exam had improved with only scattered crackles heard
and with transmitted upper airway noises
Pertinent Results:
Labs/Studies:
.
CBC:
[**2193-11-18**] 03:00AM BLOOD WBC-10.4# RBC-2.57* Hgb-7.5* Hct-24.2*
MCV-94 MCH-29.2 MCHC-31.0 RDW-21.3* Plt Ct-429
[**2193-11-21**] 05:37AM BLOOD WBC-8.0 RBC-2.93* Hgb-8.8* Hct-27.5*
MCV-94 MCH-29.9 MCHC-31.8 RDW-20.0* Plt Ct-383
.
[**2193-11-18**] 03:00AM BLOOD Glucose-77 UreaN-46* Creat-9.9*# Na-135
K-6.9* Cl-106 HCO3-20* AnGap-16
[**2193-11-21**] 05:37AM BLOOD Glucose-102* UreaN-36* Creat-9.9* Na-142
K-3.8 Cl-104 HCO3-25 AnGap-17
[**2193-11-18**] 10:54AM BLOOD ALT-53* AST-40 LD(LDH)-291* CK(CPK)-374*
AlkPhos-111 TotBili-0.1
.
[**2193-11-18**] 05:02PM BLOOD CK-MB-15* MB Indx-4.6 cTropnT-0.73*
[**2193-11-19**] 12:43AM BLOOD CK-MB-11* MB Indx-4.0 cTropnT-0.81*
[**2193-11-19**] 04:40AM BLOOD CK-MB-11* MB Indx-3.8
.
[**11-20**] CXR:
Cardiomediastinal silhouette is unchanged, slightly shifted
towards the left
side. Bibasilar consolidations have improved on the right side
due to
improvement of the component of atelectasis. Vascular congestion
has markedly
improved. There is pneumothorax or large pleural effusions.
Spinal hardware
is present.
.
AbXrays: initially showed peritoneal dialysis catheter flipped
into upper quadrant (wrong location) and then showed resolution
with catheter coiled in RLQ
.
11/5 Blood and peritoneal fluid cultures: NGTD
Brief Hospital Course:
60 yo M with ESRD on peritoneal dialysis, presented from home
with altered mental status and dyspnea in setting of receiving
no peritoneal dialysis since recent discharge from [**Hospital1 18**] on
[**2193-11-14**]. In ED, was combative and refusing treatment, had
hyperkalemia on laboratory evaluation.
.
#. Altered Mental Status:
Patient with single day of confusion and agitation. AMS most
likely secondary to metabolic derangements (hyperkalemia) given
recent limitations in dialysis. Pt was alert and oriented x 3
at the time of discharge. Blood cultures were negative at the
time of discharge. Restarted home mirtazapine and paroxetine at
home doses.
.
#. ESRD / Hyperkalemia:
Likely due to insufficient peritoneal dialysis in last 4 days
due to shift in location of dialysis catheter and in setting of
patient being discharged from hospital newly on lisinopril and
with instructions to take 20 mEq supplemental potassium daily.
(Patient was recently started on potassium supplements and
lisinopril because of chronically low K). The catheter shifted
back into proper location and multiple rounds of successful
peritoneal dialysis were performed. The patient was discharged
to have labs drawn the following week in case his potassium
again became low. Continued calcitriol and nephrocaps.
.
#. Dyspnea:
Likely due to volume overload from ineffective dialysis. He was
initially covered with antibiotics, however these were stopped
when the patient's dyspnea improved with successful dialysis. He
did have crackles on pulmonary exam at the time of discharge,
however, CXR was improved and he did not have fevers. He did
have URI symptoms but broad-spectrum antibiotics were not
continued as the patient was breathing comfortably on room air.
.
#. Diarrhea:
Presumably related to c diff colitis as evidenced by +PCR during
prior admission.
Continued oral Vancomycin for until [**2193-11-25**] as previously
planned. Restarted loperamide and Diphenoxylate-Atropine and
uptitrated medications to help slow the diarrhea. The patient
was to have GI follow-up the following week. He had no
tenderness on abdominal exam.
.
#. Troponin elevation:
Likely slightly elevated in setting of ineffective dialysis.
CK-MB values were flat. Continued aspirin and simvastatin.
.
#. Hypertension:
BP elevated to 170s systolic at presentation, no periods of
relative hypotension in [**Name (NI) **]. Continued home metoprolol and
nifedipine. Held lisinopril though this may need restarted as an
outpatient if potassium again becomes low.
.
#Anemia: Hct stable but low at 23; likely [**2-5**] renal disease.
Transfused 1 unit PRBCs with adequate response.
.
Access: The patient had a R femoral line during admission.
.
# DVT prophylaxis was with subQ heparin. The patient remained
full code during this admission. Communication was with [**Name (NI) 3408**]
[**Name (NI) 103960**] (Wife and HCP) - (h)[**Telephone/Fax (1) 103965**] , (c)[**Telephone/Fax (1) 104066**].
Medications on Admission:
1) Omeprazole 20 mg PO DAILY
2) Paroxetine HCl 20 mg PO DAILY
3) Mirtazapine 30 mg PO HS
4) Nifedipine 60 mg PO DAILY
5) Simvastatin 20 mg PO DAILY
6) Aspirin 325 mg PO DAILY
7) Calcitriol 0.25 mcg PO DAILY
8) Metoprolol tartrate 12.5 mg PO BID
9) Gabapentin 600 mg PO HS
10) Gabapentin 300 mg PO AM
11) Epoetin alfa 10,000 unit/mL MWF
12) Potassium chloride 20 mEq PO once a day
13) Oxycodone 5 mg PO Q6H:PRN pain
14) Nephrocaps 1 mg DAILY
15) Loperamide 4 mg PO TID
16) Diphenoxylate-atropine 2.5-0.025 mg PO BID:PRN loose stools
17) Vancomycin 125 mg PO Q6H until [**2193-11-25**]
18) Lisinopril 5 mg PO HS
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO at bedtime.
10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a
day.
11. Epogen 10,000 unit/mL Solution Sig: One (1) injection
Injection qMon,Wed,Fri.
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
13. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) puff Inhalation every six (6) hours as
needed for dyspnea or wheezing.
16. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) as needed for diarrhea.
17. loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day) as needed for diarrhea.
18. Outpatient Lab Work
Please have bloodwork checked next Tuesday [**2193-11-26**]. Check
Chem10 panel. Please fax results to Dr. [**Last Name (STitle) 1366**] at [**Telephone/Fax (1) 721**].
19. Outpatient Lab Work
Please have bloodwork checked on Friday, [**2193-11-22**]. Check Chem10
panel. Please fax results to Dr. [**Last Name (STitle) 1366**] at [**Telephone/Fax (1) 721**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Hyperkalemia
C. difficile diarrhea
Pulmonary edema
Anemia of chronic disease
.
Secondary:
ESRD on peritoneal dialysis
Hypertension
Chronic lower back pain
Diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 103960**],
You were admitted to the hospital because you were short of
breath and you were agitated. These symptoms were from
inadequate dialysis at home as your dialysis catheter was in the
wrong location - your potassium was very high as a result. This
problem resolved on its own and you have had successful dialysis
during this admission. You have also had problems with diarrhea
- you will need to complete a course of vancomycin and you
should continue to take loperamide and lomotil to help slow down
the diarrhea. You will see a GI physician next Tuesday who will
address your diarrhea if it has not slowed down. Your shortness
of breath improved your chest x-ray looked much better before
discharge. We believe that the mass on your L hip is a lipoma
-this is not a concerning finding but can be surgically excised
if you have pain or discomfort at the site.
.
We made the following changes to your medications:
We STOPPED potassium supplemention
We STOPPED lisinopril
We stopped these agents because they can increase your
potassium. Depending on your values next week. They may be
restarted if your potassium again becomes low.
You should continue dialysis per your home regimen.
.
Your follow-up appointments are listed below.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2193-11-22**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2193-11-26**] at 2:30 PM
With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"428.32",
"285.21",
"582.1",
"780.97",
"428.0",
"585.6",
"E879.1",
"403.91",
"799.02",
"356.9",
"V12.04",
"276.69",
"724.2",
"V46.3",
"276.7",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
10794, 10851
|
5305, 5622
|
346, 353
|
11073, 11073
|
3997, 5282
|
12539, 13317
|
3000, 3239
|
8922, 10771
|
10872, 11052
|
8287, 8899
|
11249, 12168
|
3254, 3254
|
3873, 3978
|
12197, 12516
|
276, 308
|
381, 1673
|
3268, 3859
|
11088, 11225
|
1695, 2517
|
2533, 2984
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,081
| 175,144
|
15148
|
Discharge summary
|
report
|
Admission Date: [**2186-10-20**] Discharge Date: [**2186-10-22**]
Date of Birth: [**2160-4-26**] Sex: M
Service: TRAUMA
CHIEF COMPLAINT: Motor vehicle crash.
HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old man
who was an unrestrained driver in an SUV that hit the median
at moderate speed. The patient's airbag deployed and the
patient was ambulating at the scene. EMS transported the
patient to the [**Hospital1 69**] Trauma
Bay in stable condition.
PAST MEDICAL HISTORY: None.
MEDICATIONS: Questionable.
ALLERGIES: Unknown.
PHYSICAL EXAMINATION: Pupils 2-3 mm and reactive.
Cardiovascular: Regular rate and rhythm. Respiratory: Clear
to auscultation bilaterally. No jugular venous distention.
Rectal: Normal tone. Extremities: Good pulses bilaterally.
LABORATORIES: White blood cell count 10.7, hematocrit 42.7,
platelets 341,000. Chem-7 was sodium 144, potassium 3.8,
chloride 99, bicarbonate 27, BUN 12, creatinine .9 and a
glucose of 94. PT 13.1, PTT 25.6, INR 1.2. Fibrinogen is
219. Amylase is 36.
In the CT scan, the patient had an episode of decreased
saturations to 80%. The patient was intubated and
transferred to the Intensive Care Unit. After intubation,
the patient's 02 saturation normalized.
HOSPITAL COURSE: During the hospital stay, the patient's
course was fairly uneventful. The patient was stabilized and
then extubated. The patient was noted to have a grade 4
liver laceration. For that the patient had serial
hematocrits, which remained stable. The patient was
transferred out to the floor without complications or
incident. The patient had his hematocrit continually
monitored and on hospital day four, the patient was
discharged in stable condition.
DISCHARGE PHYSICAL EXAMINATION: Temperature 98.6, 97.8,
104/60, 84, 18 and 96% on room air. Cardiovascular: Regular
rate and rhythm. Respiratory: Clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended with
mild right upper quadrant tenderness, positive bowel sounds.
DISCHARGE CONDITION: Good and stable to home.
DISCHARGE DIAGNOSIS: Status post motor vehicle crash,
unrestrained driver with Grade 4 liver laceration.
DISCHARGE PLAN: Patient will be discharged home and will
follow-up in Trauma Clinic in roughly one week. Patient to
return to the Emergency Department or call the hospital with
any concerns.
DISCHARGE MEDICATIONS:
1. Zantac.
2. Wellbutrin.
3. Prozac.
4. Trazodone.
5. Depakote.
6. Percocet.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2186-10-29**] 16:40
T: [**2186-11-3**] 20:35
JOB#: [**Job Number 44154**]
|
[
"864.05",
"780.09",
"305.00",
"E816.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2055, 2081
|
2405, 2768
|
2103, 2188
|
1282, 1748
|
1771, 2033
|
155, 177
|
206, 483
|
2205, 2382
|
506, 564
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,689
| 176,728
|
26810
|
Discharge summary
|
report
|
Admission Date: [**2126-7-8**] Discharge Date: [**2126-7-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
dyspnea and peripheral edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 66000**] is an 84 year old male with PMH of CAD and
biventricular congestive heart failure who presented to his PCP
with [**Name Initial (PRE) **] chief complaint of increasing edema and fatigue. The
patient was admitted to [**Location (un) **] and found to have a HR up to
120; he received IV lopressor with a drop in his blood pressure.
Echocardiogram demonstrated EF 10% (down from prior 20-25%) as
well as a thickened septum thought to be consistent with
amyloid. He was placed on renally-dosed dopamine and BP meds
were held. Dr. [**Last Name (STitle) 1911**] evaluated the patient on [**7-7**] and on
interrogation of his AICD found him to be in atrial tachycardia
at a rate 130. He was placed on IV heparin for atrial
fibrillation. Dopamine was continued but as his blood pressures
improved, he was started back on a beta blocker and aldactone.
The decision was made for transfer to [**Hospital1 18**] for further
treatment.
At the time of transfer, the patient was still on dopamine at a
rate of 7.5. He stated that his breathing is "not too good," but
only woke up briefly to relate this. He denied chest pain.
ROS: Endorses urinary frequency. Not able to obtain other ROS
due to mental status.
EKG demonstrated an atrial rate of ~ 100, ventricular rate 70.
At times appeared V paced but not consistently. No ST/T wave
changes.
Past Medical History:
PMHx:
Biventricular heart failure:CHF: Dilated biventricular
cardiomyopathy EF 20-25%. Mild MR, Pulm HTN
Atrial tachycardia/atrial fibrillation (at OSH); prior history
of atrial fibrillation but taken off of amiodarone,
Pacemaker/ICD [**2125-3-7**]
2V CAD
Hypertension
DM type 2, insulin dependent
CRI (baseline creatinine 2.6)
Dementia
Arthritis
History of hernia repair
GI bleed
Cardiac studies:
Cardiac cath [**3-/2125**]:
Right dominant system. Two vessel CAD - 60% lesion in distal
portion of the RPDA. LCx 90% distal stenosis. Elevated right and
left pressures (RVEDP = 24 mm Hg; PCWP mean = 32 mm Hg). Severe
pulmonary HTN.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe systolic ventricular dysfunction.
3. Severe pulmonary hypertension.
.
Echo: EF 25-30%.
The left atrium is mildly dilated. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal with severe global hypokinesis and inferior wall
akinesis. Tissue velocity imaging E/e' is elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal with
moderate global free wall hypokinesis. The aortic root is
moderately dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Prominent symmetric left ventricular hypertrophy
with global and regional systolic dysfunction c/w multivessel
CAD or other diffuse process. Right ventricular free wall
hypokinesis. Dilated aortic root.
Social History:
The patient lives in [**Hospital3 **] with his daughter and
son-in-law who are essentially his 24 hour/day caregivers.
Retired. [**Name2 (NI) **] previously smoked but quit several years ago. He
does not drink alcohol.
Family History:
Not obtainable from patient.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 96.1 BP 96/66 HR 72 RR 14 O2 97% on 4 L NC Wt 100 kg
Gen: Obese male in mild distress. Oriented to self. Using
accessory muscles to breath. Drowsy but arousable.
HEENT: Conjunctiva injected bilaterally. PERRL, EOMI. No pallor
or cyanosis of the oral mucosa. Wearing glasses.
Neck: JVP at angle of the mandible.
CV: RR and rhythm. normal S1, S2. No thrills, lifts. No S3 or
S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were slightly labored with use of accessory muscle use. Crackles
with rhonchi bilaterally throughout lung fields.
Abd: Obese but nontender. Normoactive bowel sounds. No HSM or
tenderness. Abd aorta not palpated. No abdominial bruits.
Ext: total body anasarca. R UE swelling more pronounced than L
UE swelling.
Skin: Scattered ecchymoses.
Pulses:
Right: Carotid 1+ DP 1+ PT 1+
Left: Carotid 1+ DP 1+ PT 1+
Pertinent Results:
LABORATORY DATA (from OSH):
potassium 5.6, BUN 61, creatinine 2.8
WBC 6.6, Hct 47, plt 133
BNP 866 (normal 0-100)
CK 111 --> 107
Troponin 0.22 --> 0.24 --> 0.22
LAB RESULTS (at [**Hospital1 18**]):
[**2126-7-8**] WBC-5.6 RBC-4.20* Hgb-14.4 Hct-44.1 MCV-105* MCH-34.2*
MCHC-32.5 RDW-15.3 Plt Ct-118*
[**2126-7-13**] WBC-5.8 RBC-3.44* Hgb-12.3* Hct-34.5* MCV-100*
MCH-35.7* MCHC-35.7* RDW-16.0* Plt Ct-178
[**2126-7-8**] Glucose-60* UreaN-54* Creat-2.2* Na-131* K-4.5 Cl-95*
HCO3-29
[**2126-7-12**] Glucose-175* UreaN-51* Creat-2.2* Na-129* K-4.1
[**2126-7-13**] Calcium-9.4 Phos-2.7 Mg-2.3
[**2126-7-8**] ALT-21 AST-26 LD(LDH)-293* AlkPhos-175* TotBili-2.2*
[**2126-7-8**] Albumin-3.4 Calcium-8.8 Phos-3.1 Mg-2.8*
EKG from [**2126-7-8**] demonstrated v-paced (inconsistent) with atrial
rate ~ 100. No ST/T wave changes
IMAGING:
2D-ECHOCARDIOGRAM performed on [**7-7**] at [**Location (un) **] demonstrated (by
report): LV not dilated; moderate biatrial enlargement. Marked
septal thickening (2.2). LV walls considerably more thickened
compared to [**2125-3-7**]. Elevated CVP 20 mmHg. Elevated PA
systolic pressure (50 mmHg). EF ~ 10%. RV is dilated. Septal
flattening consistent with volume overload. No significant
valvular disease. Does have restrictive mitral inflow pattern.
TTE performed on [**7-8**]: The left atrium is markedly dilated. The
right atrium is markedly dilated. The estimated right atrial
pressure is >20 mmHg. There is severe symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
severely depressed (ejection fraction 20 percent) secondary to
akinesis of the inferior and posterior walls and severe
hypokinesis of the inferior septum and lateral wall. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
The right ventricular cavity is dilated. There is severe global
right ventricular free wall hypokinesis. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade. No right atrial or
right ventricular diastolic collapse is seen. The mitral inflow
is consistent with a restrictive filling pattern, a marker of
severe diastolic and/or systolic dysfunction. Compared with the
findings of the prior study (images reviewed) of [**2125-3-26**],
the left ventricular ejection fraction is further depressed;
right ventricular contractile function is now severely
depressed.
R upper extremity ultrasound performed on [**7-7**] at [**Location (un) **] was
negative for DVT
R upper extremity ultrasound on [**7-11**] demonstrated: No evidence of
DVT in the right upper extremity.
KUB on [**7-7**] at [**Location (un) **]: large amount of stool, mildly dilated
small bowel loops which are nonspecific and probably due to
ileus
CXR (from [**Location (un) **], [**7-7**]): limited study with possible tiny
pleural effusions or pleural thickening
CXR [**7-8**] demonstrated: The heart is enlarged. Considerable
tortuosity of the aorta is present. The position of the multiple
pacemaker leads is unchanged since the prior chest x-ray of
[**3-12**]. No significant failure is present. Costophrenic angles
appear clear. IMPRESSION: Cardiomegaly, no gross failure.
CXR [**7-12**]: There is prominence of the indistinctness of pulmonary
vessels with fullness of the hila, to a greater extent than
before. There are no pleural effusions or
pneumothorax.IMPRESSION: New mild congestive heart failure.
Brief Hospital Course:
Pt is an 84 year old male with history of nonischemic
cardiomyopathy, biventricular dysfunction, CAD, atrial
fibrillation with pacemaker, DM2 and HTN admitted for
decompensated heart failure.
.
CAD. Patient had catheterization in [**3-12**] which demonstrated 2
vessel coronary disease (90% distal LCx stenosis, 60% distal
RPDA stenosis). No intervention was performed at that time. His
current presentation did not appear consistent with ischemia. He
had elevated cardiac enzymes that peaked, but were likely not
significant given his renal insufficiency.
.
Atrial fibrillation. Patient has a history of afib and was
thought to have an underlying atrial rhythm, so EP was consulted
and his AICD/pacer was interrogated which showed Atach/Afib with
multiple mode switches. Patient was continued on a heparin drip.
Given patient's restrictive left ventricular dysfunction it was
felt that rhythm control would not provide much benefit as the
atrial kick would not contribute significantly to filling. Rate
control was targeted with IV lopressor which was titrated up as
his blood pressure tolerated, to achieve a HR 70-90bpm, and he
was eventually switched to po metoprolol 25mg po TID. He was
weaned off the dobutamine drip. Metoprolol was switched to
Toprol XL prior to discharge. Patient was sent home on Coumadin
2.5 mg po qday and the heparin drip was discontinued. INR to be
monitored every week by hospice services and faxed to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 12982**] at [**Telephone/Fax (1) 15181**]. INR goal is 2.0. Pacemaker ICD
function was turned off prior to discharge.
.
Pump. The patient had an EF of 10% at OSH and 20% on echo done
here, and was grossly volume overloaded with total body
anasarca. Patient was determined to be in decompensated heart
failure and was maintained on a milrinone drip, which was
titrated up to 0.5 mcg/kg/hr and a lasix drip which was titrated
up to 15mg/hr. 250mg IV Diuril was added daily to assist in
diuresis, with good effect. We slowly attempted to change him to
po meds, starting first by taking him off the lasix drip and
giving bolus doses of IV lasix after po metolazone (thiazide
diuretic). Patient remained hemodynamically stable and improved
clinically with slowly decreasing edema and decreasing JVP.
Eventually milrinone was d/c'd and Lasix was switched to po
dosing with stable hemodynamics. Patient was sent home on Lasix
100 mg PO BID and metolazone 5 mg PO BID, 30 minutes prior to
lasix. If patient becomes more symptomatic with increased
shortness of breath, please titrate home oxygen therapy to
comfort and administer roxanol prn.
.
R upper extremity edema. Though patient was grossly edematous,
patient had persistent R>L upper extremity edema, which was
concerning for DVT. A repeat doppler of the RUE on [**7-11**] was
negative for DVT (as above). Care was made to avoid placement
of BP cuff and RUE and the edema appeared to decrease with
overall diuresis.
.
Hyperlipidemia. Not on treatment with statin.
.
DM: On lantus with sliding scale insulin with fingersticks QID.
Oral diabetic meds were held while in the hospital. Patient to
continue on sliding scale with Lantus 20 units QHS.
.
Depression. On celexa.
.
Anemia: Patient on home iron. His HCT was 47 at the OSH but
dropped
gradually to 34.5 during admission. HCT was monitored daily.
.
CRI: Patient's BL Cr is 2.6. During the course of the
hospitalization the Cr remained stable at 2.1-2.5, in spite of
aggressive diuresis.
.
FEN: Cardiac, diabetic diet. After heavy diuresis the patient
became slightly hyponatremic. Electrolytes were monitored
regularly and repleted as necessary.
.
Dispo. Patient returned to [**Hospital3 **] with hospice.
.
Code. DNI/DNR per HCP (daughter) [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 66001**]. Palliative care was consulted to discuss long-term
goals of care with family. A meeting was held with Dr. [**First Name (STitle) 437**] in
which the family expressed a desire for no escalation in care,
with continuing to manage medically to d/c to [**Hospital3 **]
with hospice care. If he deteriorates clinically while at
home(i.e. worsening renal status, hyponatremia, worsening heart
failure) he will be made CMO and there will be no further
escalation of care.
Medications on Admission:
MEDICATIONS (on transfer):
heparin gtt (not on upon arrival)
glucotrol XL 15 mg daily
humalog sliding scale
celexa 20 mg daily
namenda 10 mg [**Hospital1 **]
iron 325 daily
centrum daily
glucosamine/chondroitin 500/400 1 tab QAM, 2 tabs QHS
toprol XL 25 mg daily
lasix 40 mg IV
aldactone 25 mg QAM
prilosec 20 mg daily
lantus 25 U QHS
midodrine 10 mg TID
dopamine drip (at 7.5)
MEDS at home:
glucotrol 5 mg, lasix 80QAM 40Qnoon and 40 QPM, aldactone 25 mg
daily, prilosec 20 mg daily, celexa 20 mg daily, iron, aspirin
325 mg daily, namenda 10 mg [**Hospital1 **]
Discharge Medications:
1. Roxanol Concentrate 20 mg/mL Solution Sig: One (1) 5-20 mg PO
q1hour as needed for pain.
Disp:*60 mg* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for consipation.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-8**]
Drops Ophthalmic PRN (as needed).
7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
10. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Congestive heart failure
Discharge Condition:
Patient is saturating well on room air, with minimal extremity
edema.
Discharge Instructions:
You have been treated for your end-stage congestive heart
failure with intravenous diuretics.
It is recommended that you adhere to 2 gm sodium diet.
.
You will be continued on your coumadin. Please have your INR
checked every week. This will be performed by your visiting
hospice nurses. Dr. [**Last Name (STitle) 12982**] will be monitoring this level and
adjusting your coumadin dosage as needed. Please fax INR level
to Dr. [**Last Name (STitle) 12982**] at [**Telephone/Fax (1) 15181**]
.
If you experience any shortness of breath please use home oxygen
and take Roxanol as needed to relieve your shortness of breath.
Followup Instructions:
Please call Dr.[**Name (NI) 66002**] office at [**Telephone/Fax (1) 62842**] to schedule a
follow-up appointment in [**4-12**] weeks.
|
[
"311",
"294.8",
"427.31",
"V66.7",
"403.90",
"428.42",
"V45.02",
"585.9",
"272.4",
"428.0",
"425.4",
"V15.82",
"V58.67",
"414.01",
"250.00",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14730, 14798
|
8580, 12870
|
298, 305
|
14867, 14939
|
4636, 8557
|
15614, 15751
|
3698, 3728
|
13485, 14707
|
14819, 14846
|
12896, 13462
|
2367, 3446
|
14963, 15591
|
3743, 3743
|
3765, 4617
|
230, 260
|
333, 1696
|
1718, 2350
|
3462, 3682
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,076
| 147,491
|
54330
|
Discharge summary
|
report
|
Admission Date: [**2119-9-2**] Discharge Date: [**2119-9-8**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
[**Age over 90 **] F s/p mechanical fall frp, standing, no LOC, found by
daughter c/o L hip pain, GCS=15
Major Surgical or Invasive Procedure:
Open reduction internal fixation left three-part
intertrochanteric femur fracture with Synthes 135 degree
four-hole side plate, trochanteric stabilization plate and
screws, allograft cancellus chips.
History of Present Illness:
[**Age over 90 **] F presenting to [**Hospital1 18**] s/p unwitnessed fall onto left hip.
Found after 1.5 hours by her daughter c/o L hip pain.
Past Medical History:
1. Coronary artery disease, remote inferior myocardial
infarction, status post right coronary artery stenting in
[**2106**].
2. Congestive heart failure, diastolic, ejection fraction of
55 to 60%, 2 to 3+ mitral regurgitation.
3. Hypertension.
4. Bilateral renal artery stenosis, post bilateral stenting
in [**2113**].
5. Transient ischemic attack, [**2111**].
6. Peripheral vascular disease.
7. Atrial fibrillation.
8. Iron deficiency anemia.
Social History:
former seamstress,no hx tobacco, occ EtOH
previously, now none; Greek descent. Performs ADLs & IADLs
Family History:
n-c
Physical Exam:
On Arrival to [**Hospital1 18**] per inpatient record:
" 97.2 193/64 (112) 67 97% RA A&O
PERL [**Last Name (LF) 3899**], [**First Name3 (LF) 2995**] x4 x L hip [**1-18**] pain
GCS 15, NC TM's clear
Irreg Irreg; chest stable
decrease BS but clear
soft NT ND
+ TTP L hip
2+ edema, warm;
guiac negative normal tone"
Pertinent Results:
[**2119-9-8**] 06:50AM BLOOD WBC-12.5* RBC-4.11* Hgb-10.4* Hct-31.9*
MCV-78* MCH-25.2* MCHC-32.5 RDW-19.4* Plt Ct-245
[**2119-9-7**] 12:43AM BLOOD WBC-13.8* RBC-4.42 Hgb-11.2* Hct-34.0*
MCV-77* MCH-25.3* MCHC-33.0 RDW-18.9* Plt Ct-239
[**2119-9-6**] 01:44PM BLOOD Hct-33.0*
[**2119-9-6**] 02:12AM BLOOD WBC-15.7*# RBC-3.94* Hgb-9.8* Hct-30.0*
MCV-76* MCH-25.0* MCHC-32.8 RDW-18.5* Plt Ct-220
[**2119-9-5**] 09:29PM BLOOD Hct-29.8*
[**2119-9-5**] 10:41AM BLOOD Hct-29.9*
[**2119-9-5**] 02:00AM BLOOD WBC-10.1 RBC-3.51* Hgb-8.6* Hct-27.3*
MCV-78* MCH-24.6* MCHC-31.6 RDW-18.2* Plt Ct-180
[**2119-9-4**] 10:33AM BLOOD Hct-27.8*
[**2119-9-4**] 02:01AM BLOOD WBC-11.6* RBC-3.47* Hgb-8.6* Hct-26.8*
MCV-77* MCH-24.9* MCHC-32.2 RDW-17.4* Plt Ct-191
[**2119-9-3**] 09:58PM BLOOD Hct-26.3*
[**2119-9-3**] 04:14PM BLOOD Hct-27.2*
[**2119-9-3**] 10:55AM BLOOD Hct-26.7*
[**2119-9-3**] 04:37AM BLOOD Hct-23.8*
[**2119-9-3**] 03:07AM BLOOD WBC-9.8 RBC-3.36* Hgb-7.7* Hct-24.1*
MCV-72* MCH-23.0* MCHC-32.1 RDW-17.0* Plt Ct-230
[**2119-9-2**] 04:35PM BLOOD WBC-9.2# RBC-4.36 Hgb-10.2* Hct-32.0*
MCV-73* MCH-23.5* MCHC-32.0 RDW-17.1* Plt Ct-256
[**2119-9-2**] 04:35PM BLOOD Neuts-76.1* Lymphs-16.0* Monos-4.7
Eos-2.9 Baso-0.2
[**2119-9-8**] 06:50AM BLOOD Plt Ct-245
[**2119-9-7**] 12:43AM BLOOD Plt Ct-239
[**2119-9-6**] 02:12AM BLOOD Plt Ct-220
[**2119-9-5**] 02:00AM BLOOD Plt Ct-180
[**2119-9-5**] 02:00AM BLOOD PT-14.3* PTT-26.1 INR(PT)-1.4
[**2119-9-4**] 02:01AM BLOOD Plt Ct-191
[**2119-9-3**] 03:07AM BLOOD Plt Ct-230
[**2119-9-3**] 03:07AM BLOOD PT-14.1* PTT-24.3 INR(PT)-1.3
[**2119-9-2**] 04:35PM BLOOD Plt Ct-256
[**2119-9-2**] 04:35PM BLOOD PT-13.3 PTT-24.3 INR(PT)-1.2
[**2119-9-8**] 05:30PM BLOOD Glucose-219* UreaN-62* Creat-1.7* Na-155*
K-4.1 Cl-114* HCO3-29 AnGap-16
[**2119-9-8**] 12:40PM BLOOD Glucose-214* UreaN-60* Creat-1.7* Na-153*
K-4.1 Cl-112* HCO3-27 AnGap-18
[**2119-9-8**] 06:50AM BLOOD Glucose-110* UreaN-55* Creat-1.7* Na-154*
K-4.2 Cl-113* HCO3-29 AnGap-16
[**2119-9-7**] 11:54AM BLOOD K-3.6
[**2119-9-7**] 12:43AM BLOOD Glucose-119* UreaN-30* Creat-1.1 Na-149*
K-2.8* Cl-106 HCO3-29 AnGap-17
[**2119-9-6**] 01:44PM BLOOD Glucose-146* UreaN-32* Creat-1.0 Na-148*
K-2.9* Cl-109* HCO3-27 AnGap-15
[**2119-9-6**] 02:12AM BLOOD Glucose-114* UreaN-33* Creat-1.1 Na-147*
K-3.2* Cl-111* HCO3-25 AnGap-14
[**2119-9-5**] 10:41AM BLOOD Glucose-137*
[**2119-9-5**] 02:00AM BLOOD Glucose-113* UreaN-23* Creat-1.1 Na-143
K-4.3 Cl-110* HCO3-22 AnGap-15
[**2119-9-4**] 02:01AM BLOOD Glucose-154* UreaN-20 Creat-1.1 Na-141
K-4.2 Cl-108 HCO3-22 AnGap-15
[**2119-9-3**] 04:09PM BLOOD Glucose-83 K-3.9
[**2119-9-3**] 01:15AM BLOOD K-3.8
[**2119-9-2**] 04:35PM BLOOD Glucose-162* UreaN-18 Creat-1.2* Na-138
K-2.8* Cl-98 HCO3-25 AnGap-18
Cardiac enzymes negatve x 3
Brief Hospital Course:
[**Age over 90 **] yo F w/ h/o CAD, CHF, HTN presents to the ED s/p unwitnessed
mechanical fall found after 1.5hours by her daughter. On arrival
to [**Hospital1 18**] she was c/o L hip pain. Pt noted to have 3 part
transverse intertrochantieric left hip fracture on plain
radiograph in the ED. CT scan of the head showed right subdural
hematoma. Orthopaedics and neurosurgery services were consulted.
Patient was admitted to the ICU for frequent neuro checks. SBP
was kept < 140 by nipride drip given her history of hypertension
and the HOB was elevated >30 degrees. Aspirin was held. She was
administered dilantin for anti-seizure prophylaxis.
Interval CT scan on [**2119-9-3**] showed no interval [**Doctor Last Name **] of her SDH
with no shift of midline structures or edema. Neurosurgery
recommended a 10 day course of dilantin and signed off. She was
occasionally confused on exam, followed commands.
On [**2119-9-5**] she was taken to the operating room by orthopaedics
for open reduction internal fixation of her left hip. On POD#1
she was maintained on dilaudid for pain. Her neuro status
remained sleepy and she was kept on dilantin. Cardiovascularly
she was continued on lopressor, enalapril, amlodipine, and
nipride. Pulmonary she was stable on trach mask w/ pulmonary
edema. She was diuresed with 20 of Lasix IV. She was given
peri-operative ancef and her hematocrit remained stable.
On POD#2, she remained delirious in the ICU, her dressings were
clear and her L foot was well perfused.
On [**2119-9-8**] she was lethargic. At 18:35 she was found with
increasing tachypnea and ronchorous sounds in the throat. She
then desat'd to the 70's and was placed on a non-rebreather
which brought her into the 80's. Family wished for her to be
DNR/DNI and she was made comfort measures only with morphine. At
19:35 patient was found lying prone, no moving, with family
around the bed making no respiratory effort. Pupils were fixed
and dilated and unresponsive to light. After 1 minute of
listening at the apex, no heart sounds were heard. Skin was
jaundiced. Patient was pronounced deceased at 19:21.
**Note: the above hospital course, exam, and notes were dictated
from the inpatient record without contact with the patient.
Medications on Admission:
1. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1)
Transdermal once a week.
2. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
13. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO
three times a day.
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Amlodipine Besylate 10 mg Tablet Sig: 1.5 Tablets PO once a
day: (15 mg total)
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
-SDH
-L hip fracture
-Coronary artery disease, remote inferior myocardial
infarction, status post right coronary artery stenting in
[**2106**].
-Congestive heart failure, diastolic, ejection fraction of
55 to 60%, 2 to 3+ mitral regurgitation.
-Hypertension.
-Bilateral renal artery stenosis, post bilateral stenting
in [**2113**].
-Transient ischemic attack, [**2111**].
-Peripheral vascular disease.
-Atrial fibrillation.
-Iron deficiency anemia.
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2119-12-4**]
|
[
"820.09",
"427.31",
"285.1",
"584.9",
"401.9",
"427.5",
"E885.9",
"428.0",
"293.0",
"852.01",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"79.35",
"38.93",
"96.6",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
8180, 8189
|
4481, 6718
|
364, 566
|
8682, 8692
|
1696, 4458
|
8745, 8780
|
1342, 1347
|
8151, 8157
|
8210, 8661
|
6744, 8128
|
8716, 8722
|
1362, 1677
|
220, 326
|
594, 739
|
761, 1207
|
1223, 1326
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,112
| 192,293
|
17284+17285
|
Discharge summary
|
report+report
|
Admission Date: [**2161-8-15**] Discharge Date: [**2161-8-22**]
Date of Birth: [**2087-2-26**] Sex: M
Service: ORTHO
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2988**]
Chief Complaint:
Neck pain s/p fall from wheelchair
Major Surgical or Invasive Procedure:
C3-4 abcess removal
History of Present Illness:
74 yo male presents in ED on [**2161-8-18**] s/p fall from wheelchair at
[**Hospital1 11851**] Home. Complained of mile neck pain. Pt taken to OSH
where MRI of C-spine revealed suspicious area at C3-C4.
Question of epidural abcess. No weakness or parasthesias were
demonstrated.
Pt transfered to [**Hospital1 18**] for further eval. Ed started pt on
Vancomycin and Unasyn for antibiotic coverage.
Past Medical History:
Hep B/C
Syphylis
HTN
Foot ulcer
Peripheral neuropathy
Family History:
NA
Physical Exam:
100.0 149/61 60 20
A&O answering questions appropriately
Hard collar
RRR
CTA B
BUE [**3-25**]
Brief Hospital Course:
Seen by neurology and orthopedics/spine in ED.
MRI showed C3-5 osteomyelitis, discitis, w/ concern for epidural
abscess. Initially placed on vancomycin, but by [**8-16**], blood
cultures grew [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 48411**]. ID was consulted and
ambisome was added. Taken to OR for C3/4
discectomy/vertebrectomy [**2161-8-17**] w/ Dr. [**First Name (STitle) 1022**]. Infectious disease
was consulted and recommended multiple tests including to pull
PICC line, obtain ophthalmology evaluation to r/o fungal
retinitis, HIV, TTE, and EKG.
While in the hospital, the patient exhibited waxing/[**Doctor Last Name 688**]
mental status and paranoid ideation. He claimed the medical
staff were "performing experiments" on him and didn't believe
that the fungemia was real. Pt's delerium was evaluated w/
repeat head CT, UA/Cx, LFTs/ammonia, CXR. No obvious source of
delirium besides infection itself. Seen by psych and
recommended haldol [**Hospital1 **].
EKG showed wandering atrial pacemaker. Cardiology and medicine
recommended low dose beta blockers, but patient refused. Pt did
appear to improve, but continued to refuse multiple tests,
including optho evaluation, HIV, and TTE. PICC line replaced.
Per ID, ambisome was changed to amphotericin qd preceeded by 500
cc IVF bolus. They recommended 8 weeks of ampho and vanc.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
C-spine abcess
Discharge Condition:
good
Discharge Instructions:
Activity as toloerated. C-collar X 4 weeks. Amphoteracin/Vanco
IV X 8 weeks. Please bolus 500cc NS prior to each amphoteracin
dosage. Please check weekly CBC, LFTs, lytes and creatinine
while on abx and fax to Dr. [**Last Name (STitle) 11382**] [**Telephone/Fax (1) 1353**].
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 1022**] in [**9-3**] days. [**Telephone/Fax (1) 46169**]
Please follow up with Dr. [**Last Name (STitle) 11382**] in [**Hospital **] clinic [**Telephone/Fax (1) 48412**] and
check weekly CBC, LFTs, lytes and creatinine while on abx and
fax to Dr. [**Last Name (STitle) 11382**] [**Telephone/Fax (1) 1353**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 2991**]
Admission Date: [**2161-8-22**] Discharge Date: [**2161-9-2**]
Date of Birth: [**2087-2-26**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Inability of extended care facility to administer meds
Major Surgical or Invasive Procedure:
Gastrografin swallow evaluation
Video esophageal evalaution
CT guided aspiration of prevertebral fluid collection
History of Present Illness:
This is a 74 year-old man with history of hepatits B and C,
syphylis, hypertension who suffered a fall from wheelchair at
[**Hospital1 11851**] Home on [**8-13**], MRI at OSH revealed C3-C4 area
suspicious for osteomyletis, sent to [**Hospital1 18**]. C-spine and x-ray at
that time showed no pathology.
He was recently discharged from [**Hospital1 18**] ([**8-22**]) to rehab after
findings here including C3-C5 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]/ ?staph
osteomyletitis, discitis, para-verterbral abcess s/p
discectomy/vertebrectomy on [**8-17**]. He was discharged on
amphotericin and vancomycin. Rehab was unable to administer
amphotericin and so he returned on [**2161-8-22**]. Since that time, he
has been followed by ortho as primary as well as ID, medicine
consult. He is now found to have ARF during this admission in
addition to his previous medical issues. On last admit, HIV,
TTE, optho eval for endoopthalmitis/retinitis were all negative.
When seen on transfer the patient reports dysphagia and sore
throat. Denies odynophagia. Has trouble swallowing pills and
solids particularly, but fluids as well. No nausea, vomiting,
diarrhea or constipation. Has decreased PO intake. No bowel or
bladder incontinence and no sensory changes.
He reports some continued neck pain, as well as pain in his
shin. Has not been feeling feverish and denies chills.
Denies chest pain, shortness of breath, abdominal pain.
Past Medical History:
Hep B/C
Syphylis
HTN
left lower extremity ulcer w/ psuedomonas
Peripheral neuropathy
s/p total knee replacement
s/p triple a repair
Family History:
NA
Physical Exam:
VS: 130-138/70's HR 74-77 RR: 20 98Tmax 98%rm air
gen: NAD, pleasant man appearing his stated age, with collar in
place, became tearful during exam
HEENT: collar in place, NCAT, MMM, neck has some edema under
chin, non-tender, no lymphadenopathy, masses, thyromegaly or
thyroid nodules appreciated.
PERLLA. no JVD, no canon A waves, no radiation of pulse to
carotids.
lung: decreased breath sounds on the left, especially at base,
right-CTA.
heart: irregular, S1 and S2 wnl, no murmurs, rubs or gallops
abd: +b/s, soft, nt, nd
extr: LLE-bandage in place, no discharge. no edema, clubbing or
tenderness
neuro: A and oriented x3.
Pertinent Results:
Admit labs:
[**2161-8-21**] 05:14AM WBC-5.2 RBC-3.89* HGB-10.5* HCT-32.3* MCV-83
MCH-27.1 MCHC-32.7 RDW-14.3
[**2161-8-21**] 05:14AM PLT COUNT-251
[**2161-8-21**] 05:14AM GLUCOSE-120* UREA N-9 CREAT-1.1 SODIUM-142
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-26 ANION GAP-17
[**2161-8-21**] 05:14AM CALCIUM-9.8 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2161-8-21**] 12:50AM VANCO-20.5*
Rule out MI labs:
[**2161-8-22**] 08:47PM CK(CPK)-32*
[**2161-8-22**] 08:47PM CK-MB-NotDone cTropnT-0.01
[**2161-8-23**] 04:26AM BLOOD CK(CPK)-35*
[**2161-8-23**] 04:26AM BLOOD CK-MB-NotDone
[**2161-8-23**] 01:06PM BLOOD CK(CPK)-36*
[**2161-8-23**] 01:06PM BLOOD CK-MB-NotDone
[**2161-8-24**] 04:15AM BLOOD CK(CPK)-30*
[**2161-8-24**] 04:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
cervical spine series w/ flexion/extension [**2161-8-31**]: There is
bony destruction involving the anterior portions of the bodies
of _CV3 and CV4 as previously demonstrated. No evidence of
instability on lateral flexion and extension films. There is
narrowing of the C5-6 and C6-7 discs as previously demonstrated.
There is slight widening of the prevertebral soft tissues at the
C3-4 level.
[**2161-8-28**] VIDEO OROPHARYNGEAL SWALLOW: The study was performed in
conjunction with the speech therapist. Various consistencies of
barium were administered. There is no evidence of aspiration.
Penetration was noted with thin liquids and nectar. The barium
tablet passed freely into the stomach. IMPRESSION: No evidence
of aspiration.
Brief Hospital Course:
The patient was transferred to the MICU for management of his
airway secondary to his dysphagia and for his acute renal
failure.
Hospital course, by problem:
1. prevertebral fluid collection - seroma vs hematoma vs abcess.
Has been imaged by CT w/o contrast, MRI, and x-ray. ENT scope
showed posterior pharyngeal edema between the glottis and
epiglotis w/ mild degree of airway narrowing. On broad spectrum
antibiotics. Ent rescoped and found no perforation, after which
he was transferred to the floor for further management. He
underwent a ct guided aspiration of the prevertebral collection.
This was limited to only 0.5 cc of aspirate which was negative
for growth on culture. Subsequent to these results, his
meropenem and vancomycin were discontinued. He then underwent a
cspine series with flexion and extension radiographs and was
determined to have no cervical instability. His cervical collar
was removed without any complications.
2. fungemia - blood growing [**Female First Name (un) **] para. from line ([**Date range (1) 31561**]).
Surveilance blood cx negative. Was on ampho but secondary to
acute renal failure was switched to fluconazole. Subsequent to
these results, his meropenem and vancomycin were discontinued.
TTE was negative. He refused ophthalmologic examination.
3. acute renal failure - cr up to 2.2 from baseline of 1.0.
Likely secondary to pre-renal hypovolemia and vanc/ampho. He
was hydrated and switched to fluconazole from amphotericin and
his creatinine stabilized around 1.5
4. anemia - hct 27.5 down from 31-34 (baseline). MCV microcytic.
He had no evidence of acute bleeding and his iron studies were
consistent with anemia of chronic disease. He did receive 2
units of PRBCs while on the floor as the Hct drifted to below
25. He will need an outpatient colonoscopy.
5. ekg consistent w/ wandering atrial pacemaker. echo consistent
w/ lvh. Couple runs of NSVT, asymptomatic. Ruled out for
myocardial infarction. He heart rate was maintained on
lopressor.
6. Hypertension-he was given iv lopressor while he was npo and
this was switched to po after he was able to swallow. Once he
tolerated po, his nifedipine was switched to amlodipine as his
heart rate did go into the 40s with lopressor.
7. dysphagia - secondary to prevertebral mass. He initially
failed speech and swallow study while in the MICU and was made
npo, but after being ruled out for esophageal perforation and
transfer to the floor, subsequently had no difficulties passing
a reevaluation. He was advanced to soft solids and thin liquids
and then to regular diet without difficulty.
Medications on Admission:
vancomycin, amphotericin, metoprolol, nifedipine, protonix,
haldol
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 8 weeks.
Disp:*112 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
8. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
9. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
12. Morphine Sulfate 2 mg IV Q4H:PRN
13. Ondansetron 2 mg IV Q6H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
PRimary Diagnoses:
1) C3-C5 [**Female First Name (un) **] [**Female First Name (un) 48411**], osteomyelitis and disciitis
2) prevertebral abscess
3) acute renal failure
Secondary diagnoses:
status post discectomy/vertebrectomy
HyperTension
wandering atrial pacemaker
anemia
Hepatitis B
Hepatitis C
Syphillis
Peripheral neuropathy
Left lower extremity ulcer
Discharge Condition:
Stable and improved. His airway was patent and he had no
dysphagia. He passed speech and swallow study and was
tolerating a regular diet with continued strict aspiration
precautions while eating. His creatinine trended now and
settled at what is likely his new baseline of 1.5-1.6.
Discharge Instructions:
Call your doctor or return to the emergency room immediately if
you experience fever greater than 100.4, shaking chills,
shortness of breath, difficulty swallowing, chest pain,
worsening neck pain or sudden numbness/tingling, or weakness in
your arms or legs, or loss of bowel or bladder control.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13076**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2161-9-15**] 10:30
2. Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], OD Where: [**Hospital6 29**]
Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2161-9-21**] 9:00
3. Follow up with your orthopedist, Dr. [**First Name (STitle) 1022**] in one to two weeks.
Call [**Telephone/Fax (1) 7807**] to make an appointment.
4. Follow up with your Primary Care doctor, Dr. [**First Name (STitle) **] [**Name (STitle) **] in
2 weeks.
|
[
"285.29",
"730.28",
"276.0",
"112.5",
"070.70",
"707.10",
"356.9",
"584.9",
"722.91",
"427.31",
"070.30",
"401.9",
"427.1",
"276.5",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"86.01"
] |
icd9pcs
|
[
[
[]
]
] |
11667, 11751
|
7707, 10306
|
3741, 3857
|
12153, 12439
|
6186, 7684
|
12784, 13404
|
5516, 5520
|
10423, 11644
|
11772, 11942
|
10332, 10400
|
12463, 12761
|
5535, 6167
|
11963, 12132
|
3647, 3703
|
3885, 5344
|
5366, 5500
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,163
| 158,480
|
10681
|
Discharge summary
|
report
|
Admission Date: [**2116-10-28**] Discharge Date: [**2116-12-6**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male with
hypertension, prostate cancer (status post radiation
therapy), status post coronary artery bypass graft times four
in [**2116-7-15**] following a positive exercise tolerance
test and a catheterization which showed a 90% left main and
3-vessel disease.
During his hospitalization for his coronary artery bypass
graft, the patient developed new atrial fibrillation and
aspiration pneumonia, a left pleural effusion, and he also
received a right iliac stent during his catheterization. He
was discharged to rehabilitation and then to home.
On [**2116-10-27**], the patient's visiting nurse noted that
the patient had a melanic stool. The patient was then
admitted to [**Hospital 4199**] Hospital where he was noted to have an
infected sternal wound. He was then transferred to [**Hospital1 1444**] for further care.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Non-insulin-dependent diabetes mellitus.
4. Prostate cancer, status post radiation therapy in [**2112**].
5. Glaucoma.
6. Right inguinal hernia repair.
7. Atrial fibrillation (new onset in [**2116-7-15**]).
8. Colon polyps.
9. Carotid stenosis.
10. History of transient ischemic attack.
11. Coronary artery bypass graft times four.
12. Peripheral vascular disease, status post stent to the
iliac artery in [**2116-7-15**].
MEDICATIONS ON ADMISSION: Medications on admission included
multivitamin, Lopressor 50 mg p.o. b.i.d., aspirin 81 mg p.o.
q.d., Ambien, Humulin, captopril, amiodarone, Pravachol,
Cosopt, Alphagan, iron sulfate, Coumadin (held), Protonix.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife at home with
[**Hospital6 407**].
PHYSICAL EXAMINATION ON PRESENTATION: Temperature of 99.9,
pulse of 100, blood pressure of 162/62, oxygen saturation of
97% on 2 liters. In general, the patient was in no acute
distress. His head, eyes, ears, nose, and throat were
unremarkable. He had no icterus. His neck was supple with
jugular venous distention. He did have bilateral carotid
bruits. His lungs were clear bilaterally. His heart was
regular in rate and rhythm without murmur, rubs or gallops.
His abdomen was soft, nontender, and nondistended, with good
bowel sounds. His extremities had no edema. His right foot
had a healing ulcer on the bottom of his heel and over the
lateral malleolus. His sternum incision showed erythema and
purulent and sanguinous fluid staining the dressing with a
small opening at the inferior portion of the incision. The
sternum was not stable. The rectal examination was
guaiac-positive.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories from
outside hospital revealed a white blood cell count of 17.4,
hematocrit of 32.8, platelets of 368 (85% polys, 6%
lymphocytes, 9% monocytes). Sodium of 138, potassium of 4.1,
chloride of 96, bicarbonate of 28, blood urea nitrogen of 26,
creatinine of 0.9, glucose of 385. INR of 7.4. Urinalysis
was unremarkable.
HOSPITAL COURSE: The patient was initially admitted the
Surgical Service. On [**10-30**], the patient underwent
debridement and partial resection of his sternum. The
sternum wires were removed. There was evidence of sternal
dehiscence. OR cultures and blood cultures grew out
methicillin-resistant Staphylococcus aureus, and the patient
was placed on vancomycin.
He underwent an omental flap on [**11-11**]. This procedure
was delayed secondary to sepsis and hypotension requiring
pressors. The patient was temporarily paralyzed and
intubated. Following the flap reconstruction, the patient
remained intubated and developed a ventilatory-requiring
pneumonia. A bronchoscopy on [**2116-11-19**] revealed a
pseudomass infection which was resistant to ceftazidime and
imipenem but sensitive to cefepime.
In terms of his gastrointestinal bleeding, an upper endoscopy
was performed on [**11-17**] which showed normal mucosa to the
duodenum. The patient continued to have gastrointestinal
bleeding, however, and on [**11-27**] underwent a colonoscopy
showing angiectasia of the rectum and radiation proctitis;
however, this was not actively bleeding.
Other events of significance during his hospitalization
included direct current cardioversion on [**11-14**] for
atrial flutter. The patient also had episodes of gross
hematuria. Urology was consulted and recommended outpatient
followup. The patient also developed a clot in the right
internal jugular that was identified by Doppler. The patient
also developed bilateral pleural effusions. The patient also
developed a splenic infarct while on pressors.
On [**11-30**], the patient was transferred from the Surgical
Service to the Medical Intensive Care Unit. It was felt that
his surgical issues had resolved. However, the patient had
multiple medical problems at that time including failure to
wean from the ventilator, ongoing pneumonia, and pleural
effusions.
As far as his cardiac status at that time, he was noted to be
in some congestive heart failure secondary to diastolic
function. He was placed on captopril at that time.
As far as his renal function, he had developed acute tubular
necrosis in the setting of hypotension from sepsis, and this
was slowly resolving. He was grossly fluid overloaded,
however.
In terms of his neurologic status, he had generalizes
weakness and also had profound mental status changes. He was
alert but not responsive and would not follow commands.
In terms of his gastrointestinal status, the patient was on
Protonix for his history of upper gastrointestinal bleed.
His hematocrit was stable at the time of his transfer to the
Medical Intensive Care Unit. As far as his hematuria, he
continued to have intermittent hematuria attributed to Foley
trauma.
The remainder of the [**Hospital 228**] hospital course was
significant for his failure to wean off the ventilator and
for his change in mental status.
As far as his failure to wean, he was repeatedly attempted to
wean. Despite adequate treatment of his pneumonia, the
patient would become extremely agitated and tachypneic on
trials of pressor support.
As far as his cardiac function, a repeat echocardiogram
showed moderately depressed systolic function, and the
patient was continued on amiodarone, Lopressor, and an ACE
inhibitor.
The patient was evaluated by the Neurology Service who felt
that his delta mental status was most likely multifactorial
in the setting of his medical problems. [**Name (NI) 6**] magnetic
resonance imaging of the head showed no acute stroke or bleed
but had an old left cerebellar stroke and mild atrophy with
diffuse microvasculature ischemic changes and bilateral
mastoid air cell disease.
As the patient's condition did not improve despite aggressive
treatment, and given his multiple medical problems and his
overall poor prognosis, after an extensive discussion with
the patient's wife and her nieces, it was decided to withdraw
aggressive care and make the patient comfort measures only.
In this setting, the patient expired secondary to respiratory
failure and cardiac asystole on [**12-6**] at 5:43 p.m.
DIAGNOSES AT DEATH:
1. Status post sternal debridement.
2. Status post omental flap reconstruction of the sternum.
3. Congestive heart failure.
4. Ventilator-requiring pneumonia.
5. Respiratory failure.
6. Acute tubular necrosis.
7. Acute renal failure.
8. Insulin-dependent diabetes.
9. Change in mental status.
10. Upper gastrointestinal bleed.
11. Radiation proctitis.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2117-4-2**] 10:44
T: [**2117-4-3**] 06:15
JOB#: [**Job Number 35009**]
|
[
"038.19",
"453.8",
"996.67",
"730.28",
"E878.1",
"584.5",
"578.1",
"518.5",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"77.61",
"86.74",
"83.82",
"96.04",
"77.81",
"96.72",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
1512, 1763
|
3144, 7914
|
122, 973
|
996, 1485
|
1780, 3126
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,671
| 157,438
|
32589
|
Discharge summary
|
report
|
Admission Date: [**2152-4-23**] Discharge Date: [**2152-4-30**]
Date of Birth: [**2093-3-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central venous catheter insertion and removal.
History of Present Illness:
59 year old male with recurrent squamous cell lung cancer, now
C1D10 of gemcitabine, last dose on [**2152-4-20**] who p/w fever and
dizziness. He called the oncology fellow tonight w/ temp to
102.3. Onc fellow recommended he come to ER for counts to r/o
febrile neutropenia. He reports that he had fever and rigors
with chemotherapy 3 days ago, was told to take tylenol. The
following day hie was afebrile. The day of admission, he felt
weak, went to sleepi nthe afternoon and t hen awoke with fever
102.3., no chills or rigors. He states that he has been pushing
fluids and has had nl urine output, btu has had [**Month (only) **] appetitie.
He denies any change in cough or sputum production ?????? only basein
occaisonal thin white sputum- Sob at baseline, no V/D, no abd
pain, no dysuria, no rashes, no oral ulcers.
In the ED: He was initially stable with SBP 116/76 but then
developed tachycardiac to 120's and eventually hypotension to
SBP 70's. He was given a central line -which had to be replaced
3 times due to curling of the line. He also was given 6liters NS
with improvement of HR to 100's but SBP remained 85/40. Neo was
started. CVP was 10 and UOP 1870. He was mentating well. He was
also given Vancomycin and Cefepime. In addition, no lateral ST
depressions were noted in V4-V6; cardiac enzymes negative in the
ED.
Intial vitals 116/76 88 76 22 100%2L then 101 130 75/51
Of Note, he was discharged from the CCU one month ago after
being admitted for aflutter with RVR. The resolved spontaneously
and his medications were not changed.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
ONC: squamous cell lung cancer T3, N2 s/p L pneumonectomy [**2-/2151**]
after chemo and XRT; bronchoscopy on [**12-22**] revealed erythema and
abnormal appearance in the L bronchial stump suggesting
recurrent disease. Recent PET shows some FDG avidity along the
pneumonectomy suture line with a comment about a foci of avidity
in the AP window area. There is also circumferential uptake
around the pneumonectomy cavity. There is also a note of poor
anatomic delineation without a contrast CT. There was also FDG
avidity between the right atrial appendage and the left
ventricular outflow track without anatomic correlate. No
definite bony lesions, no subdiaphragmatic lesions. He is being
considered for radiation therapy
- He started weekly Taxotere on [**2152-2-3**], and completed
two
cycles.
- C1D10 of gemcitabine, last dose on [**2152-4-20**]
.
PAST MEDICAL HISTORY:
====================
- a-flutter s/p ablation in [**11/2151**]; not anticoagulated [**1-17**]
bleeding problems while on coumadin for PE in the past
- PE [**11-20**]
- multiple PNAs, most recently in [**12-24**] (as above)
- + PPD, treated with INH x8 months (completed in [**4-21**])
- COPD: FEV1 of 1.55 liters or 48% of predicted, an FVC of 2.38
liters or 53% of predicted, and an FEV1/FVC ratio of 55%
- Pulmonary embolism [**11/2150**]
- L frozen shoulder
Social History:
Patient is divorced and lives with his two daughters. [**Name (NI) **] son as
well. Only rare alcohol use and prior tobacco use (roughly 70
pack years); he quit smoking approximately a year ago just prior
to be diagnosed with lung cancer. He was born in [**Country 5881**] and came
to the U.S. roughly forty years ago.
Family History:
Father died of laryngeal cancer. Does not know what his mother
died from.
Physical Exam:
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: no JVD, no LAD, no oral ulcers or lesions
CARDIAC: RRR, S1/S2, no mrg
LUNG: bilateral high picked end expiratory wheeze
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
ADMISSION LABS:
[**2152-4-22**] 10:25PM WBC-7.2 RBC-4.06* HGB-11.1* HCT-32.7* MCV-81*
MCH-27.4 MCHC-34.0 RDW-16.7*
[**2152-4-22**] 10:25PM NEUTS-89.7* LYMPHS-7.9* MONOS-0.6* EOS-1.5
BASOS-0.4
[**2152-4-22**] 10:25PM PLT COUNT-181
[**2152-4-22**] 10:25PM PT-15.1* PTT-31.2 INR(PT)-1.3*
[**2152-4-22**] 10:25PM GLUCOSE-134* UREA N-14 CREAT-0.9 SODIUM-136
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
[**2152-4-22**] 10:30PM LACTATE-2.9* K+-3.1*
ADMISSION CXR ([**2152-4-22**]):
1. Stable post left pneumonectomy changes.
2. Patchy nodular densities within the right lower lung, likely
reflect
residual infection, as seen on chest CT [**2152-4-7**].
3. Emphysema.
CTA CHEST ([**2152-4-24**]):
1. No evidence of pulmonary embolism.
2. Increased peribronchial and diffuse right lung opacities,
superimposed
upon emphysema. The diffuse abnormalities may be due to
pulmonary edema,
especially given a new small right pleural effusion, but diffuse
infection is also possible. Right middle lobe and other
peribronchial opacities slightly increased, likely infectious,
but attention to this region should be paid on subsequent
followups.
3. Persistent soft tissue lateral to the hilar pneumonectomy
stump, very
worrisome for local recurrence. Unchanged left basilar pleural
nodules,
suggestive of pleural metastases.
4. Signs of anemia.
5. Stable old left humeral bone infarct or enchondroma.
CXR ([**2152-4-26**]):
Patient is status post pneumonectomy on the left side. A
left-sided central
line is identified in situ. There is evidence of widespread
patchy change in the right lung, which is nonspecific, but as
mentioned before could reflect toxic drug damage ,edema or
infection. The appearances are certainly not changed from prior
day, but when compared to multiple prior radiographs have
demonstrated probable progressive change. The nodular pattern
may be misleading given the widespread emphysematous change
present. Osseous structures are grossly unremarkable.
Brief Hospital Course:
59 yo male with pmh of recurrent squamous cell lung carcinoma
s/p left pneumonectomy in [**2-20**] now s/p cycle one of gemcitabine
(last on [**2152-4-20**]) who presented on [**4-23**] with fevers and
hypotension possibly be secondary to Gemcitabine-related
inflammatory lung disease.
# Sepsis/Hypoxia: Felt to be most likely related to
gemcitabine-related inflammatory lung disease. He was initially
started on both high-dose steroids and broad spectrum
antibiotics (added to home Levaquin). After culture data
returned negative, antibiotics were stopped and steroids were
continued. He was maintained on [**4-19**] L of supplemental oxygen
throughout his hospitalization and was discharged home on this
amount. His steroids were tapered after he began to improve: 60
mg prednisone [**Hospital1 **] x 2 days, then 60 mg daily x 2 days, then 40
mg daily x 2 days, then 20 mg daily x 2 days, then 10 mg daily x
2 days, then 5 mg daily x 2 days. He will follow up with
pulmonary as an outpatient.
# Atrial fibrillation: During this hospitalization he was in
sinus rhythm. He was continued on flecainide and aspirin; after
blood pressure improved, diltiazem was restarted. He is not
systemically anticoagulated due to problems with bleeding in the
past.
# COPD: Continued on his home regimen of Advair, albuterol, and
spiriva.
# Anemia: Likely from bone marrow suppression from
chemotherapy. His Hct remained in the low 30's during his
hospitalization and his baseline is in the mid-30's. He had no
clinical evidence of bleeding.
# Squamous cell carcinoma: Patient is s/p neoadjuvant cisplatin
and etoposide with concomitant radiation completed [**2151-1-13**] for
squamous cell lung cancer s/p left pneumonectomy on [**2151-3-4**]
and s/p first dose of palliative Taxotere on [**2-3**]. Most
recently s/p one cycle of gemcitabine as above. He was
continued on the Levaquin which is given prophylactically while
on chemo.
# CODE: Full code
# COMM: Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 75970**] ([**Telephone/Fax (1) 75971**]; HCP is son
[**Name (NI) **],[**Name (NI) **] Phone number: [**Telephone/Fax (1) 75972**]
Medications on Admission:
Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H Aspirin 325
mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Diltiazem HCl 60 mg Capsule, Sust. Release 12 hr
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
2. Flecainide 100 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every six (6) hours as needed for SOB.
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia.
8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
9. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
10. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times
a day.
11. Diltiazem HCl 60 mg Capsule, Sust. Release 12 hr Sig: One
(1) Capsule, Sust. Release 12 hr PO once a day.
12. Prednisone 5 mg Tablet Sig: taper as directed below Tablet
PO once a day for 10 days: Taper:
1. Take 60 mg of prednisone daily x 2 days.
2. Then take 40 mg of prednisone daily x 2 days.
3. Then take 20 mg of prednisone daily x 2 days.
4. Then take 10 mg of prednisone daily x 2 days.
5. Then take 5 mg of prednisone daily x 2 days.
Disp:*54 Tablet(s)* Refills:*0*
13. Patient requires oxygen at 5-6 L due to hypoxia.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary -
Hypotension
Fevers
Hypoxia
Possible gemcitabine-related inflammatory lung disease
Secondary -
Squamous cell lung cancer
History of atrial flutter
Chronic obstructive pulmonary disease
Discharge Condition:
Stable, satting 93 % with ambulation on 6 L of NC. Satting in
the mid90's on 6L of NC at rest.
Discharge Instructions:
You were admitted to the hospital due to fevers and low blood
pressure. You were thought to have developed a reaction to
gemcitabine which caused your symptoms. Due to involvement of
your lungs you now require supplemental oxygen to maintain
adequate oxygen saturation.
Medication changes:
1. You will need to complete a prednisone taper:
1. Take 60 mg of prednisone daily x 2 days.
2. Then take 40 mg of prednisone daily x 2 days.
3. Then take 20 mg of prednisone daily x 2 days.
4. Then take 10 mg of prednisone daily x 2 days.
5. Then take 5 mg of prednisone daily x 2 days.
Call your primary doctor, or go to the emergency room if you
experience fevers, chills, dizziness, worsening shortness of
breath, return of your original symptoms, or other worrisome
symptoms.
Followup Instructions:
Please call the Pulmonary Clinic ([**Telephone/Fax (1) 612**]) and schedule a
follow up appointment with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], or
[**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] in 1 month.
Please keep your previously scheduled appointment:
Please call Dr.[**Name (NI) 3279**] office tomorrow ([**0-0-**]) to be
seen later this week. Your previously schedule appointment is
below. Please try to move the appointment to this week.
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2152-5-11**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2152-5-11**] 9:30
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2152-5-11**] 10:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2152-5-2**]
|
[
"276.2",
"V12.51",
"162.8",
"496",
"780.60",
"511.9",
"995.93",
"515",
"V15.82",
"196.9",
"284.89",
"V46.2",
"416.8",
"427.31",
"E933.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10817, 10823
|
6286, 8455
|
321, 370
|
11062, 11160
|
4275, 4275
|
11993, 13148
|
3712, 3787
|
9363, 10794
|
10844, 11041
|
8481, 9340
|
11184, 11457
|
3802, 4256
|
11477, 11970
|
276, 283
|
398, 1953
|
4292, 6263
|
2896, 3360
|
3376, 3696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,176
| 143,412
|
7044
|
Discharge summary
|
report
|
Admission Date: [**2127-3-22**] Discharge Date: [**2127-3-28**]
Date of Birth: [**2052-9-4**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
worsening dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74yo F PMHx lung ca, and laryngeal ca s/p laryngectomy, lots of
radiation who presents from [**Hospital3 537**], who states pt has had
progressive worsening of her shortness of breath. The patient
states that she has been feeling poorly for the past four days.
She has had worsening shortness of breath and trouble catching
breath. Reportedly pt had O2 saturations in mid-80s at [**Hospital 5346**] with 2L NC. She had nebs at [**Hospital3 537**] which partially
improved symptoms. The patient denies any fevers but does state
that she has a mild cough, occasionally productive of sputum.
Also she does have bilateral lower extremity swelling
chronically.
.
Pt states that has had more trouble recently with coughing while
eating/drinking. She also has pleuritic chest pain that started
a few days ago. Denies palpitations.
.
There is a tracheostomy tube in place, capped. She lives at
rehab ([**Hospital3 537**]). Pt is on 2-3L NC at home at [**Hospital **]. Pt denies diarrhea. Pt endorses some chronic back pain.
.
In the ED inital vitals were, 100 120 126/82 24 99% neb.
On exam, pt was wheezy at RLB, 1+ pitting edema b/l. Pt received
duonebs in the ED. got nebulizer. CXR w infiltrates, t100.0 -->
pt received vanc+levoflox+zosyn. Fever spiked to 102.4, and
patient received tylenol. Blood cultures were sent in the ED.
HR in the 110s. Vitals on transfer are: t102.4 HR116 18-20
105/56 96%4L. Access: 20 gauge R antecubital.
.
On arrival to the ICU, 99.8 104 94/47 99% 3L. Patient unable
to give a thorough history secondary to fatigue and difficulty
speaking. Breathing unlabored and patient comfortable.
.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Endorses congestion. 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:
-Lung cancer - Initially diagnosed with left lung cancer in
[**2116**], which was treated with wedge excision. Recurrent squamous
cell cancer in the left upper lobe in [**2121**], which was treated
with a left thoracotomy with left upper lobectomy in 05/[**2121**].
She is followed by Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 4507**].
-Laryngeal cancer - The patient is status post laryngectomy,
radiation therapy, and chemotherapy. She has a tracheostomy. She
is followed by Dr. [**First Name (STitle) **]
[**Name (STitle) 26283**] apnea
-DVT - The patient has had multiple DVTs in the past and is on
chronic anticoagulation with Coumadin. Her goal INR is [**2-28**].
-Asthma
-Chronic back pain
-Hypothyroidism
-Obesity
-Gastroesophageal reflux disease
-Subretinal hemorrhage nasal to the optic nerve and inferior to
the macula in the left eye associated with vitreous
hemorrhage
Social History:
The patient lives in a nursing home, previously lived alone in
subsidized housing in [**Location (un) **]. She has one daughter who lives in
[**Name (NI) 8**]. Patient quit smoking in [**2120**] per notes, though she
states no tobacco x32 years. Reports former EtOH abuse, goes to
AA, no use x32 years. H/o cocaine and heroin use, none for past
32 years.
Family History:
Daughter has diabetes. Granddaughter with lupus.
Physical Exam:
ADMISSION PHYSICAL EXAM:
99.8 104 94/47 99% 3L
GENERAL - comfortable with eyes closed, in NAD
HEENT - NC/AT, EOMI, sclerae anicteric, MM mildly dry, OP clear
NECK - supple, trach in place and capped, with trach collar, JVP
difficult to assess secondary to trach collar
LUNGS - scarce crackles b/l, moderate air movement b/l, no
wheeze appreciated
HEART - RRR, no MRG, nl S1-S2, no tenderness to palpation of
chest wall
BACK - no midline spinal tenderness, no CVA tenderness
ABDOMEN - NABS, obese, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ lower extremity edema to knee b/l, 2+ DP pulses
SKIN - unremarkable
NEURO - sleepy but arousable, CNs II-XII grossly intact, muscle
strength 5/5 throughout
Discharge Exam:
VS: AFebrile 70-80s 120-130s/60-80s 20-22 96% 40% TM
GENERAL: appears generally comfortably, tracheostomy in place,
smiling, obese
HEENT: anicteric
NECK: tracheostomy stoma c/d/i. Healing pressure ulcer around
trach.
HEART: RRR. nl s1s2. No mrg.
LUNGS: scattered rhonchi continuing to improve. comfortable.
talking audibly and clearly with finger covering trach
ABDOMEN: Soft/NT/ND
EXTREMITIES: warm, wearing pneumatic boots, mild nonpitting
edema in bilateral LEs. Swollen left arm without tenderness to
palpation or pitting. Full ROM. No erythema.
NEURO: Awake, alert, interactive (closes trach when wanting to
speak),
Pertinent Results:
Admission Labs:
[**2127-3-22**] 07:27PM BLOOD WBC-9.3# RBC-3.57* Hgb-11.2* Hct-34.4*
MCV-96 MCH-31.4 MCHC-32.6 RDW-13.8 Plt Ct-95*
[**2127-3-22**] 07:27PM BLOOD Neuts-85.5* Bands-0 Lymphs-9.5* Monos-4.5
Eos-0.2 Baso-0.3
[**2127-3-22**] 09:13PM BLOOD PT-27.4* PTT-32.0 INR(PT)-2.6*
[**2127-3-22**] 08:00PM BLOOD Glucose-117* UreaN-26* Creat-1.6* Na-144
K-4.2 Cl-101 HCO3-28 AnGap-19
[**2127-3-22**] 08:00PM BLOOD cTropnT-<0.01 proBNP-1374*
[**2127-3-22**] 08:00PM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8
[**2127-3-22**] 07:46PM BLOOD Type-ART Temp-37 pO2-64* pCO2-51* pH-7.40
calTCO2-33* Base XS-4 Intubat-NOT INTUBA
[**2127-3-22**] 07:24PM BLOOD Glucose-105 Lactate-2.1* Na-143 K-4.0
Cl-99
[**2127-3-22**] 08:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2127-3-22**] 08:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
MICRO:
blood cultures 2/25: no growth to date
urine legionella antigen [**3-22**]: negative
sputum culture [**3-23**]:
[**2127-3-23**] 9:37 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2127-3-27**]**
GRAM STAIN (Final [**2127-3-23**]):
[**11-20**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2127-3-27**]):
SPARSE GROWTH Commensal Respiratory Flora.
PROTEUS MIRABILIS. SPARSE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
MORPHOLOGY CONSISTENT WITH ISOLATE #1.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| STAPH AUREUS COAG +
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 0.5 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R <=0.5 S
VANCOMYCIN------------ 1 S
blood culture [**3-24**]: no growth to date
IMAGING:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2127-3-22**] 7:13
PM
IMPRESSION: Right basilar opacity silhouetting the
hemidiaphragm, possibly
due to any combination of effusion, atelectasis or
consolidation. Clinical
correlation recommended. Two-view chest x-ray may also offer
additional
detail.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2127-3-23**] 7:42 PM
IMPRESSION: AP chest compared to [**3-22**]:
Tip of the new left PIC line projects over the low SVC.
Opacification at the lung bases is more pronounced on the left
today, stable on the right compared to [**3-22**]. Left-sided
changes are particularly suggestive of pneumonia due to recent
aspiration since right lower lobe atelectasis has been present
since [**2-5**]. Azygous distention indicates volume
overload. Bulbous contour of the left hilus is stable and better
evaluated by CT scanning. Heart size top normal, no change.
Small bilateral pleural effusions are presumed. No pneumothorax.
The study and the report were reviewed by the staff
radiologist.
Videoswallowing: IMPRESSION: Gross aspiration of thins,
nectar-thicks, and ground solids.
LUE Venous Duplex:
IMPRESSION: No evidence of DVT.
Discharge/Notable Labs:
[**2127-3-28**] 06:00AM BLOOD WBC-3.5* RBC-3.32* Hgb-9.9* Hct-30.3*
MCV-91 MCH-29.8 MCHC-32.6 RDW-13.7 Plt Ct-116*
[**2127-3-28**] 06:00AM BLOOD PT-35.2* INR(PT)-3.4*
[**2127-3-28**] 06:00AM BLOOD Glucose-73 UreaN-13 Creat-1.0 Na-144
K-3.2* Cl-104 HCO3-33* AnGap-10
Studies pending at discharge:
None
Brief Hospital Course:
74 yo F with history of laryngeal squamous cell carcinoma s/p
supraglottic laryngectomy, non-small cell lung cancer s/p left
upper lobectomy with subsequent chemotherapy and neck
irradiation with chronic tracheostomy admitted with multifocal
pneumonia felt to be due to aspiration.
#Pneumonia due to Proteus and Methicillin resistant staph
aureus:
Patient was admitted with hypoxia above 2-3L home needs and was
found to have right basilar opacification on CXR and CT showed
RLL heterogenous consolidation and RUL ill defined opacification
with trace right sided effusion. She was initially treated with
Vancomycin, Cefepime, Levaquin, and Azithromycin and was
narrowed to Vancomycin and Cefepime and then to Vancomycin and
Ceftriaxone based on sputum culture sensitivities. She was
discharged to complete an 8 day course of antibiotics to end
[**2127-3-29**]. Her oxygen requirement decreased to 40% FiO2 via 10L/min
TM satting in the high 90s. Given that patient was satting well
on 40% FiO2 she can likely have her oxygen weaned further at
rehab.
#Aspiration:
Patient is known to aspirate when eating, but has not had
history of recurrent aspiration pneumonias. It is unclear why
the patient aspirated resulting in pneumonia this admission, but
it may have been related to an underlying viral URI as
subglottic edema was seen on evaluation laryngoscopy with ENT.
The patient had a videoswallowing study that was similar to
previous. She was allowed to eat a soft diet with thinned
liquids and all crushed pills and tolerated this without
significant desaturations. She should continue on this diet on
discharge.
#Chronic deep venous thrombosis:
Patient had a supratherapeutic INR during admission and Coumadin
was held. Coumadin can be restarted when INR drops to <3. INR
continued to be >3 on the day of discharge.
.
#Left Uppe extremity swelling:
Patient was noted to have left upper extremity swelling related
to the RUE without pitting edema, change in temparature or skin
changes of the limb, reduced ROM, or pain. INR was >3 entire
admission and LUEUS showed no DVT. Given that the patient had a
PICC in that arm, it was felt that this swelling related to
reduced venous outflow from PICC. Since the patient had one more
day left of IV abx, the PICC was left with instructions to the
rehab to pull PICC as soon as last dose of antibiotics on the
day after discharge.
#THROMBOCYTOPENIA: This was stable between 90-120 during
admission and improved with treatment of infection.
#Anemia: Hematocrit dropped from 34 to 27 but remained stable in
the high 20s thereafter. This should be followed on discharge to
make sure it remains stable. There was low suspicion for blood
loss.
.
#Hypothyroidism: Patient was continued on home levoxyl.
#Chronic back pain: Continued on prn dilaudid and standing
Tylenol. To help keep pain controlled would consider assessing
pain every 3-4 hours and giving dilaudid po every 4 hours to
keep control of the pain.
#Depression: Continued on citalopram
#Pressure ulcer: Patient has healing ulcer under trach which has
been treated with Xeroform guaze.
#GERD: continued on PPI
#Access: PICC Line - placed [**2127-3-23**] 07:30 PM. Should be
removed after completion of IV antibiotics (last doses [**2127-3-29**]).
#Prophylaxis: INR>2
#Contact: [**Name (NI) 9496**] (HCP, not related), [**Telephone/Fax (1) 26284**]; [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
(daughter) [**Telephone/Fax (1) 26285**]
#CODE: DNR
#Disposition: Patient was discharged to rehab to continue abx
for pneumonia until [**2127-3-29**] and for continued monitoring of
aspiration and respiratory status improvement. She may require
occasional deep suctioning if she has desaturation and should
eat with trach button, but otherwise should not have the trach
button in per ENT recs. She should have PCP and ENT follow up
arranged in [**1-27**] weeks (PCP) and 2-4 weeks (ENT) by rehab
facility.
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Date Range **]: One (1) Inhalation 2-3 times daily as needed
for SOB or wheezing.
2. citalopram 20 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
3. gabapentin 100 mg Capsule [**Date Range **]: One (1) Capsule PO Q12H (every
12 hours).
4. levothyroxine 100 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Date Range **]:
One (1) Cap Inhalation DAILY (Daily).
7. acetaminophen 325 mg Tablet [**Date Range **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
8. calcium-vitamin D3-vitamin K 500-200-40 mg-unit-mcg Tablet,
Chewable [**Date Range **]: One (1) Tablet, Chewable PO three times a day.
9. docusate sodium 100 mg Capsule [**Date Range **]: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. hydromorphone 2 mg Tablet [**Date Range **]: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler [**Date Range **]: Two (2)
Inhalation four times a day as needed for shortness of breath
or wheezing.
13. zolpidem 5 mg Tablet [**Date Range **]: One (1) Tablet PO at bedtime as
needed for insomnia.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): hold for [**Last Name (un) 940**]
stools.
15. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (un) **]: One (1)
PO DAILY (Daily) as needed for constipation.
16. warfarin 2.5 mg qd
17. furosemide 20 mg Tablet
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (un) **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
2. citalopram 20 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily).
3. levothyroxine 50 mcg Tablet [**Last Name (un) **]: Two (2) Tablet PO DAILY
(Daily).
4. gabapentin 250 mg/5 mL Solution [**Last Name (un) **]: Two (2) mL PO Q12H
(every 12 hours): please crush all pills.
5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours).
7. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Thirty (30) mL PO
three times a day.
8. calcium-vitamin D3-vitamin K 500-200-40 mg-unit-mcg Tablet,
Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO three times a day:
crush pills.
9. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation: crush pills.
11. hydromorphone 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every four
(4) hours as needed for pain: crush pills.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. Ambien 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia: crush pills.
16. Miralax 17 gram/dose Powder [**Last Name (STitle) **]: One (1) dose PO once a day
as needed for constipation.
17. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: crush
pills.
18. vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) gram Intravenous
every twelve (12) hours for 1 days: Last dose 3/3. Please pull
PICC line after last dose to reduce LUE swelling.
19. ceftriaxone 1 gram Piggyback [**Last Name (STitle) **]: Two (2) grams Intravenous
every twenty-four(24) hours for 1 days: Last dosse [**2127-3-29**].
Please remove PICC line after last dose of antibiotics to reduce
LUE swelling.
Discharge Disposition:
Extended Care
Facility:
The [**Hospital3 537**]
Discharge Diagnosis:
Primary:
Aspiration pneumonia due to Proteus and MRSA
Secondary:
Chronic deep venous thrombosis
Hypothyroidism
GERD
Back pain
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 for aspiration pneumonia and treated with
antibiotics. You were also seen by the ENT sevice (Dr. [**Last Name (STitle) 26286**]
and had your tracheosomy examined. You improved on antibiotics
and were able to eat well without significant pulmonary
complications prior to discharge.
At rehab, you should continue to have your airway suctioned if
you have obstruction. It is also very important that you not
wear your tracheostomy plug except when you are eating until you
have your follow up appointment with ENT (Dr. [**Last Name (STitle) 26286**].
Also, your Coumadin was held because your INR was >3, but this
should be restarted when your INR drops below 3.
Please call your doctor if you experience worsening breathing or
have increased trouble swallowing properly.
Followup Instructions:
1) Please have your rehab call Dr.[**Name (NI) 26287**] office to set up a
follow up appointment in [**3-30**] weeks
2) Please have your rehab call Dr.[**Name (NI) 25674**] office to schedule a
follow up appointment in the next 1-2 weeks.
|
[
"707.20",
"V49.86",
"V10.21",
"724.5",
"244.9",
"707.09",
"V10.11",
"V44.0",
"287.5",
"278.00",
"493.90",
"285.9",
"453.72",
"V58.61",
"780.57",
"530.81",
"482.42",
"482.1",
"507.0",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
17932, 17982
|
9593, 13530
|
320, 326
|
18153, 18153
|
5053, 5053
|
19150, 19393
|
3603, 3654
|
15395, 17909
|
18003, 18132
|
13556, 15372
|
18336, 19127
|
3694, 4395
|
4411, 5034
|
9563, 9570
|
1999, 2290
|
263, 282
|
354, 1980
|
5069, 9549
|
18168, 18312
|
2312, 3214
|
3230, 3587
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,874
| 145,109
|
2858
|
Discharge summary
|
report
|
Admission Date: [**2156-6-7**] Discharge Date: [**2156-6-16**]
Service: MEDICINE
Allergies:
Penicillins / Keflex / Capoten / Calan
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Diagnostic coronary angiography
Coronary angiography and stent placement
History of Present Illness:
The patient is an 85 year old female with hypertension and
diabetes who presented to ED with atypical CP. The patient began
to experience chest pressure at 5:30 AM on [**2156-6-7**] after eating
breakfast. It was located in the left side of her chest and
radiated to her shoulder and to her back. It was not associated
with nausea, vomiting, diaphoresis, lightheadedness,
palpitaions, or any other symptoms. Her husband called EMS.
She received one dose of sublingual nitroglycerine and it
resolved. She was brought to the BIMDC ED.
.
In the ED she was noted to be afrebrile with a heart rate of 70
and a blood pressure of 240/120. Her hypertension was
controlled with 5 mg IV lopressor. She also received 20 mg
lasix. While in the ED she had two sets of negative cardiac
enzymes. EKG with non-specific inferior T-wave changes. A
persantine MIBI was performed with equivocal EKG changes but
nuclear imaging showed a reversible anterior/apical defects and
TID. The patient did experience one episode of chest pain of
similar quality while in the ED on the evening of presentation.
It resolved by itself.
.
On review of symptoms she denies fevers, chills, cough,
shortness of breath. She denies lightheadedness or dizziness.
She denies prior episodes of chest pain or palpitations. She
denies nausea, vomiting, diarrhea, constipation, melena, BRBPR.
She denies PND, orthopnea, nocturia. She does have peripheral
edema at baseline and this is unchanged.
Past Medical History:
1. Hypertension
2. NIDDM
3. Retinal vasculitis/uveitis: dx [**2137**]. Treated in past with
prednisone but stopped due to hyperglycemia and HKNA.
Methotrexate, but this was infeffective. Cellcept for years, but
lost efficacy.
Now cytoxan. Dr. [**Last Name (STitle) 6426**], rheum attg. Dr. [**First Name (STitle) 4702**], optho.
4. Gallstone pancreatitis s/p cholecystectomy
5. Left lower extremity vein striping.
6. Bilateral cataract surgery.
7. Colonoscopy for rectal bleed, with the finding of a
benign polyp.
Social History:
Lives in [**Location **] with her husband. [**Name (NI) **] smoking, etoh, drug use.
Family History:
Father and brother w/ diabetes, mother lived until age [**Age over 90 **].
Physical Exam:
Vitals: T: 98.1 BP: 156/73 P: 69 R: 18 O2: 96% RA
.
General: Well nourished, in no acute distress
HEENT: pupils reactive, EOMI, oropharynx clear
Neck: supple, no LAD
Lungs: crackles at bases bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no HSM
Ext: warm, 2+ edema to mid-calf bilaterally, unable to palpate
DP/PT pulses bilaterally.
Pertinent Results:
Admission Labs:
[**2156-6-7**] 08:00AM GLUCOSE-244* UREA N-24* CREAT-0.9 SODIUM-138
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-29 ANION GAP-13
[**2156-6-7**] 08:00AM WBC-7.1# RBC-4.09* HGB-12.3 HCT-35.6* MCV-87#
MCH-30.2 MCHC-34.7 RDW-14.9
[**2156-6-7**] 08:00AM NEUTS-78.8* LYMPHS-15.1* MONOS-3.5 EOS-2.1
BASOS-0.6
[**2156-6-7**] 08:00AM PLT COUNT-193
[**2156-6-7**] 08:00AM PT-12.5 PTT-26.4 INR(PT)-1.1
[**2156-6-7**] 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
Cardiac Enzymes:
[**2156-6-7**] 02:00PM CK(CPK)-91 CK-MB-NotDone cTropnT-<0.01
[**2156-6-7**] 08:00AM CK(CPK)-84 CK-MB-NotDone cTropnT-<0.01
[**2156-6-8**] 09:57PM CK(CPK)-101 CK-MB-5 cTropnT-0.02
---
.
Other results:
[**2156-6-9**] 04:20PM BLOOD ALT-13 AST-16 CK(CPK)-93 AlkPhos-77
Amylase-38 TotBili-0.4 DirBili-0.1 IndBili-0.3
[**2156-6-9**] 11:23AM BLOOD %HbA1c-6.9*
[**2156-6-9**] 06:00AM BLOOD Triglyc-153* HDL-46 CHOL/HD-4.5
LDLcalc-129
.
Images:
CXR: PA and lateral upright chest radiograph compared to [**2155-4-17**].
The heart size is top normal. The aorta is mildly elongated with
aortic arch calcifications. There is mild bronchial wall
thickening and Kerley B lines are seen bilaterally in the lower
lobes. There is no pleural effusion or pneumothorax. There are
no focal lung infiltrates or masses.
The patient is after cholecystectomy.
IMPRESSION: CHF with mild interstitial edema.
.
EKG: NSR, borderline first degree AV block, LAD, RBBB with left
anterior fascicular block, inferior T wave changes that are
non-specific.
.
Exercise Stress:
IMPRESSION: Equivocal EKG changes in the absence of anginal
symptoms.
.
Persantine MIBI:
IMPRESSION: 1. Abnormal myocardial perfusion study
demonstrating a severe, predominantly reversible defect in the
distal anterior wall and apex consistent with a lesion in the
mid to distal LAD. 2. Transient cavitary dilatation is
present. 3. Apical hypokinesis (LVEF @ 53%)
.
Cardiac Cathterization [**2156-6-9**]
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
40% LMCA lesion and severe three vessel disease (diffuse). The
LAD had a long segnemt of proxinmal and mid vessel lesion with
most severe lesion being 99%. There was an ostial D1 lesion. The
LCX had an 80% ostial lesion and was diffusely diseased. The RCA
had a 90% ostial lesion with
mild diffuse disease throughout.
2. Left ventriculography was deferred.
3. Limited hemodynamic assessment showed markedly elevated
systemic aortic pressures.
FINAL DIAGNOSIS:
1. Severe three vessel coronary artery disease.
2. Normal ventricular function.
.
C.CATH Study Date of [**2156-6-11**]
*** Not Signed Out ***
COMMENTS:
1) Dissection of the left main with guide engagement resulting
in
successful stenting of the left main with a 3.0x18 mm Cypher
stent
postdilated to 4.0 mm.
2) Successful PTCA and stenting of the proximal and mid LAD with
a
3.0x23mm Cypher, 2.5x18mm Cypher stent, and a 2.5x13mm Cypher
stent.
3) Successful stenting of the proximal and mid CX with a
3.0x33mm Cypher
stent and a 3.0x18mm Cypher stent both postdilated to 3.5mm.
4) Final angiography revealed 0% residual stenosis, no
angiographically
apparent dissection, and TIMI 3 flow in the LM, LAD, and CX.
(see PTCA
comments)
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the left main after dissection
3. Successful stenting of the LAD and CX
.
ECHO ([**6-11**])
Conclusions:
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
ejection fraction is normal (LVEF 60%); there is a significant
area of apical hypokinesis. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
.
C. Cath ([**6-14**])
COMMENTS:
1) Initial coronary angiography revealed a 95% ostial RCA lesion
and
widely patent left main, LAD, and Cx stents with mild diffuse
disease.
2) Renal angiography revealed an 80% proximal left renal artery
lesion
and a 30% right renal artery lesion.
3) Successful PTCA and stenting of the ostial RCA with a 3.5x18
mm
Cypher Rx stent which was post-dilated to 4.0 mm. Final
angiography
revealed a 10% residual lesion, no dissection, and TIMI 3 flow.
(see
PTCA comments)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Left 80% renal artery stenosis.
3. Successful PTCA and stenting of the ostial RCA
Brief Hospital Course:
The patient is an 85 year old female with hypertension and
diabetes who presented to emergency room following one episode
of atypical CP.
.
Coronary Artery Disease: In the emergency department the patient
had three sets of negative cardiac enzymes and no EKG changes.
She underwent a PMIBI which showed a reversible defect in the
territory of the mid LAD. She was started on a heparin drip and
received aspirin and metoprolol. On [**2156-6-9**] she underwent
diagnostic cardiac catheterization which revealed severe three
vessel coronary disease with normal ventricular function. No
interventions were taken at the time of initial catheterization.
The patient was presented with the option of undergoing CABG or
high risk percutaneous coronary intervention. The patient and
her family were not interested in pursuing a surgical option.
She underwent high risk catheterization on [**2156-6-11**]. During
this catheterization, her left main coronary artery was
dissected and subsequently stented (7 stents) to restore flow.
Her left circumflex was also stented. Her occluded RCA was not
stented during this intervention. Following the procedure, she
developed a groin hematoma and required transfusion of 1uPRBC.
She remained hemodynamically stable and recovered well after the
procedure, but did have a rise in her cardiac enzymes that was
likely due to poor perfusion with the dissection of left main.
Recommendations were made for her to have a "re-look" agiogram
in 3months to assess the patency of the LAD given the multiple
stents placed & the high risk for restonsis--this was
communicated to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] via email on [**6-12**], as Dr.
[**First Name (STitle) **] will likely be following up with her care. On [**2156-6-14**] she
had a repeat catheterization to address the right coronary
artery. Her RCA was stented with a Cypher drug eluting stent,
resulting in TIMI 3 flow. Separately, she was found to have an
80% left renal artery stenosis and 30% right renal artery
stenosis, which were not intervened on. For her coronary artery
disease, she was discharged on a full dose of aspirin and on
plavix 75 qd. It is imperative that she remain on plavix for at
least nine months because of her drug eluting stent.
.
Diabetes: The patient's blood sugars were controlled during this
hospitalization with an insulin sliding scale. Her hemoglobin
A1C was measured at 6.9. She was discharged on her normal home
glucose control regimen.
.
Hypertension: Stable, though following repeat cath her BP was
elevated & her home BP regmimen was adjusted. Her outpatient
dose of metoprolol was increased from 50 mg [**Hospital1 **] to 75mg [**Hospital1 **] and
amlodipine was increased from 5 mg to 10mg daily. Her
lisinopril was increased from 20 mg daily to 40 mg daily. On
discharge, she was transitioned from 75 mg [**Hospital1 **] metoprolol to 75
mg QD atenolol for easier dosing. In addition, she was
transitioned from her previous diuretic, lasix 40 qd, to
hydrochlorothiazide 25 qd.
.
Hyperlipidemia: The patient's cholesterol panel on this
admission revealed a total cholesterol of 206, triglycerides of
153, HDL of 46 and LDL 129. LFTs were within normal limits.
She was started on high dose lipitor 80 mg daily.
.
Anemia: The patient presented with a normocytic anemia with a
hematocrit of 35.6. Following repeat cath, her HCT dropped to
27, presumably due to groin hematoma. She was transfused for
this.
Medications on Admission:
Lopressor 50 mg [**Hospital1 **]
Norvasc 5 mg QAM
Lisinopril 20 mg daily
Folic Acid 1 mg daily
Lasix 40 mg daily
Fluoprofen eye drops 4x daily
Glypizide 10 mg daily
Aspirin 81 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Fluorometholone 0.1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
Disp:*1 bottle* Refills:*2*
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Unstable angina
Coronary Artery Disease
Secondary:
Diabetes
Hypercholesterolemia
Hypertension
Uveitis
Discharge Condition:
Stable. Good O2 sats on room air. Able to ambulate with cane.
Discharge Instructions:
You were found to have blockages in your heart arteries, which
were stented (Left circumflex artery, right coronary artery).
Your cardiac catheterization was complicated by dissection of
your left main artery, which was stented.
Your were started on Plavix and regular dose aspirin. You MUST
take both of these medications every day without missing a dose,
or else you will be at risk of your stents closing off and
causing a heart attack.
Your medication regimen was changed as follows:
1. Your aspirin dose was increased to 325mg daily.
2. Your Lopressor has been discontinued and replaced by
Atenolol, which is a once a day medication.
3. Your Amlodipine dose was increased
4. Your Lisinopril dose was increased
5. You were started on a cholesterol lowering medication
(Lipitor)
6. Your Lasix dose was discontinued.
7. You were started on Hydrochlorithiazide for blood pressure
control
Your Lasix was discontinued because you didn't have excess fluid
in your body. Please continue to weigh yourself daily. If your
weight increases by more than 3 lbs, call your primary care
doctor or your cardiologist.
You will need to have a repeat cardiac catheterization in 3
months to make sure that your left main artery is still open and
working well. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for this
procedure.
Followup Instructions:
Please follow up with your primary care [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**]
within 2 weeks of discharge. Call [**Telephone/Fax (1) 133**] to schedule an
appointment.
Please follow up with your new cardiologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 2
weeks of discharge. Call ([**Telephone/Fax (1) 9490**] to schedule an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2156-6-16**]
|
[
"272.0",
"440.1",
"443.9",
"411.1",
"401.9",
"250.00",
"724.3",
"428.0",
"364.3",
"427.89",
"285.1",
"998.12",
"998.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.48",
"99.04",
"00.42",
"00.40",
"00.45",
"37.22",
"99.20",
"88.45",
"00.66",
"88.56",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
12344, 12415
|
7706, 11185
|
257, 331
|
12570, 12634
|
3037, 3037
|
14043, 14639
|
2481, 2558
|
11421, 12321
|
12436, 12549
|
11211, 11398
|
7557, 7683
|
12658, 14020
|
2573, 3018
|
3597, 5579
|
206, 219
|
359, 1824
|
3053, 3580
|
1846, 2362
|
2378, 2465
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
135
| 192,180
|
17455
|
Discharge summary
|
report
|
Admission Date: [**2173-5-18**] Discharge Date: [**2173-5-26**]
Date of Birth: [**2123-6-9**] Sex: M
Service: Neurology
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 48749**] is a 49-year-old
man diagnosed with neurosarcoid in a previous neurologic
admission who was recently discharged to rehabilitation on
[**5-11**] after extensive workup for neurosarcoid. In
rehabilitation he was doing well and was ambulating with and
without a walker. On [**2173-5-15**], he was prematurely
changed from IV steroids to po Medrol. Since then, he has
been deteriorating rapidly to the point that he awoke on the
day of admission, and was not able to move his legs at all.
He had breakthrough pain in his lower back and exacerbation
of this allodynia in his feet and legs. When he was
initially seen in the Emergency Room, he was tearful with
feelings of hopelessness, very upset about his condition.
PHYSICAL EXAM ON ADMISSION: His vital signs were stable. He
is alert, awake, oriented and tearful. Normal name and
repetition, comprehension was intact. Months of the year
backwards and forwards were normal. Cranial nerves were
intact. Extraocular movements were full. Face is symmetric.
Tongue was midline. Palate elevates symmetrically. Shoulder
shrug was normal. He had decreased strength in his lower
extremities, 0/5 and full [**5-24**] in his upper extremities. His
sensory: Decreased sensation to C6-T1 pin prick in his upper
extremities and deep tendon reflexes were 0/4 in the upper
extremities, trace brachioradialis. Proprioception was
decreased in his fingers, wrist, and elbow at the level of
the shoulders. In his lower extremities, he had severe
decrease in sensation, decreased pin prick, light touch,
vibratory, and cold from T7 down, worse on the left side.
He was seen and admitted for acute worsening of his lower
extremity weakness. He decided to order a MRI of the spine
which is unchanged from before, and we changed the steroids
to 1 gram IV q day, Solu-Medrol x5 days, and had Rheumatology
consult to discuss these use of other immunomodulatory
agents. He had severe pain and at first we increased his
methadone and Neurontin, and started a Morphine PCA pump. We
had him on pantoprazole GI prophylaxis, and watched him
closely on the neurologic service.
Over the coming days with his movement and pain was somewhat
better controlled, Rheumatology saw him and agreed with
Solu-Medrol, and then felt that he would also benefit from
steroids after that as well. He was watched closely on the
Neurologic service, and PCA pump was working well to control
his pain.
On [**5-20**], he was found by the Neurology Service to be
minimally responsive. He was given naloxone with much
benefit. He continued to be less responsive and was not
following commands. We transferred him to the Intensive Care
Unit for further observation on [**5-20**] as well as a STAT
electroencephalogram was performed. This
electroencephalogram showed a mild encephalopathy, but was
negative for seizures. He was monitored and his respiratory
distress was watched closely. Initially, his respirations
were [**6-27**], however, in the coming hours, he improved and was
able to breathe in regular rate 12-15 breathes/minute, and
his neurologic status improved. It was felt that his acute
change in mental status was attributed to his increased pain
medications especially his PCA pump.
He was transferred back to the floor the following day. IV
steroids and Solu-Medrol were continued, and a full course
was given in five days. Again Rheumatology recommended to
continue Imuran 50 mg q day as well as continue 1.2 mg of
Medrol IV divided in [**Hospital1 **] dosages. They also recommended that
infliximab may be used 5 mg/kg IV x1, and after the IV
steroids were completed, and then two weeks later as well as
six weeks after that. I discussed this with the entire
Neurology team as well as other consulting services.
We also discussed the issue of a positive PPD with Infectious
Disease and given that we were giving him infliximab and high
dosed steroids, we may need to be more aggressive with his
anti-TB prophylactic treatment. They felt that INH was
sufficient and he would just have to be monitored closely.
He was also given a bowel regimen of Senna, Dulcolax, and
Colace, and he was able to control his bowels as well.
He was found to have a urinary tract infection with some
blood in his urine, and he was started on Levaquin 500 mg po
q day. He will continue this as an outpatient as well. His
pain was controlled on his gabapentin, nortriptyline,
Percocet, and methadone and his leg shaking was controlled on
increasing doses of primidone tapered up to 225 mg po tid.
Over the few days before his discharge, he had increasing leg
strength, and was able to abduct his legs for the first time
since admission. He remains clinically stable. We
discontinued the Foley the day prior to admission, and he
urinated nine hours later 500 cc. He continued to have
hyperesthesia in his bilateral lower extremities and his
strength was returning slowly. He was deemed stable for
discharge to rehabilitation on [**5-26**] with followup in the
[**Hospital 878**] Clinic as well as followup in the Pheresis Unit at
[**Hospital3 **] Hospital for his infliximab treatment. He was
seen and followed up with Psychiatry and his mood was better.
He stated he was hanging in there and doing well. They felt
that we should continue with Celexa 40 mg and consider using
Seroquel 25-50 mg q hs for sleep instead of Ambien.
On discharge, he was much improved. Social Work as well as
other services met with him. Social Work helped him with
[**Social Security Number 48750**]social security disability benefit forms, and relayed
information. Physical Therapy and Occupational Therapy were
.................... for rehabilitation.
DISCHARGE STATUS: Improved.
DISCHARGE DIAGNOSES:
1. Neurosarcoid.
2. Urinary tract infection.
DISCHARGE MEDICATIONS:
1. Primidone 225 mg po tid.
2. Alprazolam 0.5 mg po q am prn and 1 mg po q hs prn
anxiety.
3. Celexa 60 mg po q day.
4. Colace 100 mg po tid.
5. Seroquel 25/250 mg po q hs prn insomnia, please offer q
hs.
6. Calcium carbonate 1,000 mg po bid.
7. Methylprednisolone sodium succinate 65 mg IV bid.
8. Pantoprazole 40 mg po q24h.
9. Levaquin 500 mg po q24h x7 days.
10. Methadone 10 mg po bid.
11. Trileptal 600 mg po bid.
12. Percocet 1-2 tablets po q4-6h prn pain.
13. Atorvastatin 10 mg po q day.
14. Baclofen 5 mg po tid.
15. Bisacodyl 10 mg po/pr q day prn.
16. Vitamin D 400 units po q day.
17. Nortriptyline 75 mg po q hs.
18. Folic acid 1 mg po q day.
19. Senna two tablets po bid.
20. MVI one cap po q day.
21. Thiamine 100 mg po q day.
22. Gabapentin 1200 mg po tid.
23. Metoprolol 50 mg po bid.
24. Isoniazid 300 mg po q day.
DISCHARGE FOLLOWUP: He is to followup with Dr. [**Last Name (STitle) **] and
Dr. [**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 48750**] in the [**Hospital 878**] Clinic
at [**Hospital1 **] Hospital on [**6-3**] at 2:30 pm for
a previously scheduled appointment. He will also followup
the following weak in the Plasmapheresis Unit at [**Hospital1 346**] and plans for his followup will be
conveyed to him on [**6-3**]. He will need ambulance
transport for both of these visits. He will then need
another dose of infliximab at the Pheresis Unit six weeks
after his second treatment.
[**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 11278**], M.D.
[**MD Number(1) 11279**]
Dictated By:[**Last Name (NamePattern1) 7813**]
MEDQUIST36
D: [**2173-5-26**] 11:52
T: [**2173-5-26**] 11:54
JOB#: [**Job Number 48751**]
|
[
"E935.2",
"599.0",
"349.82",
"311",
"135"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5927, 5973
|
5996, 6831
|
6852, 7748
|
170, 934
|
949, 5906
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,548
| 159,650
|
40389
|
Discharge summary
|
report
|
Admission Date: [**2109-11-7**] Discharge Date: [**2109-11-19**]
Date of Birth: [**2067-12-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
intracerebral hemorrhage
Major Surgical or Invasive Procedure:
[**2109-11-8**] Cerebral Angiogram and Coiling
[**2109-11-12**] Cerebral Angiogram
[**2109-11-18**] Cerebral Angiogram
History of Present Illness:
Ms. [**Known lastname **] is a 41 yo Right
handed woman with an unclear past medical history and current
illness course. It is known that she has a history of IVDU and
is
taking methadone. She was last seen well 8 days ago. Apparently
she was found today by a neighbor. Tragically, it seems that she
was lying in bed with a deceased 10 month old infant. She was
taken to [**Hospital **] hospital. There she seemed disheveled, babbling
and requesting methadone. Patient was noted to have "delusions"
and was transferred here. There, a head CT showed an
approximately 4.5 cm midline frontal mass. I reviewed this
image.
There is a well circumscribed hyperdense lesion arising from the
suprasellar cistern and involving the septum pellucidum. It does
not appear to be a menigioma, neither does it seem to be a pure
hemorrhage.
Past Medical History:
IVDA on methadone x 10 months
Social History:
english speaking, single. Mother and brother are deceased. Has
an estranged daughter in her 20's, a 3 yo that is in [**Doctor Last Name **] care
with plans to be adopted by that family, 10mo old that was found
deceased the day of admission. History of IVDA but clean for
past 18months.
Family History:
non-contributory
Physical Exam:
On Admission:
When interviewed, the patient is sleepy but FULLY arousable. She
is very uncooperative and irritable. She will not comply with
the
majority of my examination. I was able to get her to say her
name
and that she was in "[**Hospital 88551**] hospital." She stated her age as
27 and the year as [**2100**]. She was able to say that [**Last Name (un) 2753**] was the
president. Pupils are equal and reactive. She does seem to have
full EOM and no facial asymmetry. She has no drift and is
grossly
full strength in all extremities.
Upon Discharge:
AOx3, speech is clear, follows commands, MAE [**5-8**], no pronator
Brief Hospital Course:
Pt admitted to neurosurgery service and the ICU on [**2109-11-8**]. Her
intial imaging appeared to be consistent with a interventricular
mass that had hemorrhaged. She had no hydrocephalus and did not
require an emergent procedure. An MRI/MRA of the head was
obtained to evaluate this mass and showed it to be suggestive of
an ACOMM aneurysm. For further evaluation, a diagnostic cerebral
angiogram was performed and this confirmed the presecnce of a
large thrombosed ACOMM aneurysm. After her anerusym was
confirmed she was intubated with anesthesia and she underwent an
umcomplicated coiling of this aneurysm. She did remain intubated
overnight and was kept flat bed rest for 6 hours. On post op
exam she did not follow commands but she moved all extremities
purposefully and her pupils remained equal and reactive. She had
no signs of groin hematoma and she had good distal pulses.
She was extubated on the morning of [**11-9**] without difficulty.
Her exam improved and she was opening eyes intermittently to
voice, following commands and moving all extremities with good
strength. Her groin site remained clean and dry with no signs of
hematoma and she had good distal pulses.
Psychiatry was consulted and recommended given her altered
mental status they recommended an EEG which showed an abnormal
EEG due to the presence of a slower
than average background. This finding may could be seen in the
context of a
mild to moderate encephalopathy of toxic, metabolic, or anoxic
etiology. They recommened restarting her Methadone in case she
was withdrawing causing her altered mental status. Haldol was
also started.
On [**11-12**] she underwent an angiogram which showed Acomm artery
coiling with no residual filling. On [**11-13**] she was transferred
to the Step Down Unit were she remained stable and she was
transferred to the floor on [**11-14**]. Her methadone was increased
to 30mg on [**11-16**]. Social Work continued to provide support to
the patient.
On [**11-18**] her Methadone was increased to 40mg. On [**11-18**] she was
scheduled for a cerebral angio but was cancelled because patient
was unable to tolerate. She underwent an angiogram on [**11-19**]
which was stable.
She was discharged to [**Hospital3 **] on [**11-19**].
Medications on Admission:
Celexa
Methadone 70mg daily
Topamax
Discharge Medications:
1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
2. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/headache.
6. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-5**]
Tablets PO Q6H (every 6 hours) as needed for headaches.
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO DAILY (Daily).
12. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
14. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
ACOMM Aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with coiling
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? 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 Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks with a Head
CTA.
Please call Takeisha to make this appointment [**Telephone/Fax (1) 4296**]
Completed by:[**2109-11-19**]
|
[
"276.0",
"288.60",
"349.82",
"293.0",
"331.4",
"310.0",
"430",
"304.01",
"292.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
6011, 6081
|
2373, 4623
|
344, 465
|
6140, 6140
|
8225, 8441
|
1691, 1709
|
4709, 5988
|
6102, 6119
|
4649, 4686
|
6291, 7283
|
7309, 8202
|
1724, 1724
|
280, 306
|
2281, 2350
|
493, 1319
|
1738, 2265
|
6155, 6267
|
1341, 1372
|
1388, 1675
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,070
| 171,863
|
11620
|
Discharge summary
|
report
|
Admission Date: [**2199-3-12**] Discharge Date: [**2199-3-20**]
Date of Birth: [**2127-11-30**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
cough, sob.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 M h/o mental retardation, OSA, asthma on 2L home O2, CVA,
parkinsonism, living in group hospice, who is referred to [**Hospital1 18**]
for 5d cough, SOB.
.
Pt is somewhat poor historian, but per discussion with group
home staff ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 36884**]), pt notes ~5d productive cough
(yellow) and SOB. His PCP was called on [**3-8**] and started pt on
augmentin over the phone, without subsequent improvement. Pt
was brought back to PCP [**Last Name (NamePattern4) **] [**3-12**] for persistent cough, SOB,
malaise, and new diarrhea (x2/day per group home staff).
.
Per PCP visit note, pt with RR 33, O2 Sat 69% on O2 HR 113,
"pale, dyspneic, O2 sat up to 91% with rest, lungs coarse,"
concern for COPD flare, thus pt was sent to [**Hospital1 18**], though he was
to remain DNR/DNI.
.
Upon arrival to ED, VS=99.3 113 159/80 25 85% on 5L. CXR
with ?RLL effusion (?chronic right elevated hemidiaphragm). Pt
treated with solumedrol 80 x 1, levaquin 750 x 1, azithro 500 x
1, combivent nebs, with initial improvement to 97%4L RR 36, then
down to 90% so started NRB with sats 94%->88% RR 25->29, so
received 10mg iv lasix, and started on BiPaP with sats 98% RR
25.
Past Medical History:
-DM2
-Hypercholesterolemia
-CVA with residual left-sided weakness
-Mental retardation
-Parkinsonism
-Mood disorder
-OSA on home CPAP
-Asthma, on 2L home O2 at rest, 4L with activity
-s/p right lobectomy for empyema at young age
-OA - knee pain
Social History:
Lives in group home in [**Hospital1 3494**], dependent on aides for ADLs.
Per [**Hospital1 **], lifetime non-smoker, no h/o heavy etoh use.
Family History:
Family history of Parkinson's, SL, RA, heart attacks
Physical Exam:
VS: T 98.5 111 147/88 18 99%BiPaP
GEN: Pleasant male, breathing comfortably, sitting in bed in NAD
[**Hospital1 4459**]: PERRL, EOMI, MMM, JVP <8cm @ 90 degrees.
CV: rrr, s1s2, no m/r/g
PULM: No acc muscle use, roncherous breath sounds bilaterally,
R>L, faint expiratory wheezing. good airmovement throughout, no
egophany, no dullness to percussion.
ABD: NABS, soft, nt, nd
EXTR: No c/c, wwp, trace-1+ b LE edema.
NEURO: A&O x 1 (first name only, not to place, date).
Pertinent Results:
STUDIES:
[**2199-3-12**] EKG: showed nsr, nl axis, nl intervals, no ste/std, twi,
poor baseline in v2.
.
[**2199-3-12**] CXR:
Persistent elevation of the right hemidiaphragm with right-sided
pleural thickening, unchanged from [**2194**]. No definite focal
consolidation.
.
[**2199-3-15**] CXR:FINDINGS: In comparison with study of [**3-14**], the
patient has taken a poor inspiration. Persistent elevation of
the right hemidiaphragmatic contour with some enlargement of the
cardiac silhouette and evidence of increased pulmonary venous
pressure.
.
IMPRESSION: Little change.
.
[**2199-3-12**] 07:02PM BLOOD WBC-10.7# RBC-3.73* Hgb-11.1* Hct-34.3*
MCV-92 MCH-29.7 MCHC-32.3 RDW-13.1 Plt Ct-246
[**2199-3-13**] 04:58AM BLOOD WBC-7.7 RBC-3.57* Hgb-10.9* Hct-33.2*
MCV-93 MCH-30.4 MCHC-32.8 RDW-12.6 Plt Ct-240
[**2199-3-12**] 05:31PM BLOOD Glucose-147* UreaN-17 Creat-0.8 Na-137
K-7.0* Cl-98 HCO3-33* AnGap-13
[**2199-3-13**] 04:58AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.7
[**2199-3-13**] 04:58AM BLOOD %HbA1c-6.3*
[**2199-3-12**] 06:15PM BLOOD Type-ART Rates-/38 O2 Flow-5 pO2-68*
pCO2-73* pH-7.33* calTCO2-40* Base XS-8 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2199-3-13**] 01:09AM BLOOD Type-ART pO2-71* pCO2-72* pH-7.37
calTCO2-43* Base XS-12 Intubat-NOT INTUBA
[**2199-3-13**] 03:13PM BLOOD Type-ART pO2-58* pCO2-69* pH-7.39
calTCO2-43* Base XS-12
[**2199-3-15**] 05:34AM BLOOD WBC-10.8 RBC-3.91* Hgb-11.5* Hct-35.7*
MCV-91 MCH-29.4 MCHC-32.2 RDW-12.3 Plt Ct-325
[**2199-3-15**] 05:34AM BLOOD Glucose-248* UreaN-22* Creat-0.9 Na-141
K-4.6 Cl-98 HCO3-37* AnGap-11
Brief Hospital Course:
71 M with PMHx of asthma, multiple recurrent bronchitis & PNA
over past year, now admitted with 5days of cough & SOB.
.
# HYPOXIA: Pt with h/o asthma/COPD, chronic CO2 retention (PCO2
baseline 60s, HCO3 30s-40s), s/p right lobectomy for empyema.
Patient admitted to ICU on [**3-12**]. 6L oxygen requiremnt, bipap at
night. Started on iv solumedrol, levoquin, received q4 nebs,
advair, flovent. Influenza/Legionella returned negative.
Gradually improved. To floor on night of 2/29. Continued to
improve on floor with steroids, levoquin, q4 nebs. Oxygen
requirement gradually decreased to baseline of 2 liters.
Patient to continue on steroid taper per discharge medication
list.
.
# Diarrhea ?????? Pt presented c/o new diarrhea in setting of recent
Augmentin. However, no further diarrhea in house.
.
# OSA - Pt continued to have significant apneic episodes
overnight despite home biPAP settings, likely c/w baseline.
BIPAP continued as possible.
.
# CVA - residual left-sided weakness
- continued home regimen of aspirin daily
.
# Parkinsonism - continued home regimen of Benztropine.
.
# Mood disorder/Psychosis - continued home Paxil & Risperidone.
.
# OA - prn motrin for knee pain.
.
# DM2- held oral hypoglycemics in house
- coverage with ISS and BS QIDACHS
- Hgb A1c 6.3
# h/o PE - Bilateral PEs diagnosed in 05. Per review of [**Name (NI) **], pt
not managed on Coumadin due to h/o falls. No CTA on this admit
given improvement of resp status with treatment of
asthma/COPD/pneumonia.
DNR/DNI throughout
Medications on Admission:
augmentin 875-125 1 tablet po bid [**Date range (1) 36885**]/08
loperamide 204mg qid prn (start [**3-11**])
duoneb q6hr
multivitamin qdaily
pantoprazole 40mg po qdaily
metformin 1000mg po bid
aveeno cream prn
aspirin 325mg po qdaily
paxil 30mg po qdaily
finasteride 5mg po qdaily
advair 250/50 1puff [**Hospital1 **]
MOM 30ml 2x week (mon, thurs)
benztropine 0.5mg po qdaily
senna 2 tabs qhs
ibuprofen 400mg po bid (for knee pain)
colace 100mg [**Hospital1 **]
risperdone 2mg po qhs
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for knee pain.
6. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Colloidal Oatmeal 100 % Packet Sig: One (1) Packet Topical
[**Hospital1 **] (2 times a day) as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*30 [**Hospital1 4319**]* Refills:*3*
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed.
Disp:*30 [**Hospital1 4319**]* Refills:*3*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
15. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days: Then 20mg po daily for 7 days, then one-half tablet
daily for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
16. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
17. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation every six (6) hours: Okay to let sleep.
Disp:*qs for one month qs* Refills:*2*
18. Regular Insulin Sliding Scale
Please resume RISS with FS four times daily. Sliding scale
attached.
19. oxygen
supplemental oxygen via NC at 2L (to keep sats greater than 92%)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] hospice
Discharge Diagnosis:
1. Acute respiratory failure
2. Astham with acute exacerbation
3. COPD
4. Hypoxemia
Secondary:
1. CVA late with residual effect
2. Osteoarthritis
3. Type II DM, controlled without complications
4. Mental Retardation
Discharge Condition:
Stable, tolerating good PO, respiratory status back to
baseline-2L oxygen requirement
Discharge Instructions:
All medications as prescribed.
Follow up as below.
If you have fevers, chills, increasing shortness of breath,
chest pain or any other new concerning symptoms, contact your
doctor or go to the emergency room.
Followup Instructions:
Follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] in [**1-16**] weeks. Please
call [**Telephone/Fax (1) 608**] for an appointment.
|
[
"332.0",
"V46.2",
"327.23",
"296.90",
"319",
"250.00",
"V12.51",
"715.90",
"787.91",
"272.0",
"493.22",
"438.89",
"780.79",
"518.81",
"V58.66"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8273, 8330
|
4143, 5665
|
279, 286
|
8590, 8678
|
2536, 4120
|
8937, 9150
|
1973, 2027
|
6198, 8250
|
8351, 8569
|
5691, 6175
|
8702, 8914
|
2042, 2517
|
228, 241
|
314, 1533
|
1555, 1800
|
1816, 1957
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,847
| 193,505
|
14015
|
Discharge summary
|
report
|
Admission Date: [**2141-6-25**] Discharge Date: [**2141-7-1**]
Date of Birth: [**2061-2-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Nephrostomy tube
History of Present Illness:
80 yo male with history of Parkinson's disease, dementia, CAD,
and CHF with EF 25% who presented for altered mental status. He
was last at his baseline yesterday at 10am. Last night, his
careworkers reported that he was refusing medications and
hallucinating. Over the past few days he has had his eyes
closed more and has had a decreased appetite. Last night, he
was diaphoretic and uncovering himself in bed. He was very
restless and pointing to his abdomen. This morning, patient
remained altered and had one episode of emesis. His finger
sticks were also higher than they were normall, elevated at 280
from 100. At baseline, pt speaks few words in Greek and is
bed-bound, but is responsive and recognizes familiar faces.
In the ED, initial vitals were: HR85, BP 132/89, RR 16, 02 97%
RA, rectal temp 101.2. He was responsive only to pain.
-UA was grossly positive
-He was given ceftriaxone
-He was tachy with abd pain? CT abdomen performed and revealed
8-mm obstructing right mid ureteric stone with upstream
hydronephroureter.
-Urology deferred to IR
-IR to put in perc neph tube tonight
-Initial lactate 4.1 w/ markedly abnl UA suggestive of
infection. Pt received rectal tylenol, 2L NS. Pt also given
Zofran for nausea after several episodes of gagging.
-CXR nonacute. CT head negative for intracranial hemorrhage.
-access 2PIV
Most recent vitals prior to transfer:
He went to IR for perc neph tube placement where he was on
pressors during the procedure. An 8F catheter was placed on the
right side draining to vac.
On arrival to the MICU, he will not respond to voice or noxious
stimuli. Family reports this is at his baseline at times.
Review of systems: Unable to report.
Past Medical History:
1. Parkinson's Disease, severe, with dementia
2. CAD s/p STEMI [**2136**] with PCI/stenting of LAD
3. CHF with EF 25% in '[**36**]
4. Hypertension
5. Hyperlipidemia
6. DM on glypizide
7. Chronic bilateral shoulder pain
8. Appendectomy
9. DVT on chronic LMWH
Social History:
Lives with wife at home, and full-time caretaker. Cannot walk
with walker anymore, bed-bound. Few Greek words on occasion.
Cannot perform any ADLs. No tob/EtOH/illicits.
Family History:
non-contributory to current presentation
Physical Exam:
Admission exam:
VITALS: Tm 100.6 Tc 99.8 HR 72 BP 141/39 RR 17 SpO2 95/RA
GENERAL: awake and alert, makes eye contact, appears comfortable
HEENT: PERRL, EOMI, dry MMM
NECK: no carotid bruits, JVP not elevated
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
BACK: No CVA tenderness appreciated, nephrostomy drain in place
on right
GU: Foley in place
EXTREMITIES: Trace LE edema, 1+ DP pulses bilat
NEUROLOGIC: A&Ox0, tries to communicate, follows simple commands
by miming, moving all extremities, unable to cooperate with full
neuro exam. Fasked face with ridigity in upper extremities.
Discharge Exam:
VITALS: T 98, HR 54 BP 130/60 RR 20 SpO2 97% RA
GENERAL: asleep, but easily arousable
HEENT: PERRL, EOMI, moist MMM
NECK: no carotid bruits, JVP not elevated
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
BACK: No CVA tenderness appreciated, nephrostomy drain in place
on right
GU: Condom catheter in place.
EXTREMITIES: No LE edema
NEUROLOGIC: Sleeping, and slightly snoring
Pertinent Results:
Admission labs:
[**2141-6-25**] 01:45PM BLOOD WBC-7.2 RBC-4.00* Hgb-11.1* Hct-35.0*
MCV-88 MCH-27.6 MCHC-31.6 RDW-14.3 Plt Ct-158
[**2141-6-25**] 01:45PM BLOOD Neuts-95.6* Lymphs-3.2* Monos-0.9*
Eos-0.3 Baso-0.1
[**2141-6-25**] 01:45PM BLOOD PT-11.6 PTT-32.0 INR(PT)-1.1
[**2141-6-25**] 01:45PM BLOOD Glucose-256* UreaN-32* Creat-1.4* Na-139
K-4.3 Cl-104 HCO3-24 AnGap-15
[**2141-6-25**] 01:45PM BLOOD ALT-17 AST-15 AlkPhos-45 TotBili-0.8
[**2141-6-25**] 01:45PM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.4* Mg-1.8
LACTATE TREND:
[**2141-6-25**] 02:00PM BLOOD Lactate-4.1*
[**2141-6-25**] 05:17PM BLOOD Lactate-3.5*
[**2141-6-26**] 04:38AM BLOOD Lactate-1.9
DISCHARGE LABS:
[**2141-7-1**] 06:40AM BLOOD WBC-6.7 RBC-3.74* Hgb-10.4* Hct-31.9*
MCV-85 MCH-27.7 MCHC-32.5 RDW-14.2 Plt Ct-170
[**2141-7-1**] 06:40AM BLOOD Glucose-185* UreaN-18 Creat-0.6 Na-140
K-4.0 Cl-104 HCO3-28 AnGap-12
[**2141-7-1**] 06:40AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.7
Microbiology:
[**2141-6-25**] 1:45 pm BLOOD CULTURE
**FINAL REPORT [**2141-6-28**]**
Blood Culture, Routine (Final [**2141-6-28**]):
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2141-6-25**] 2:10 pm URINE
**FINAL REPORT [**2141-6-27**]**
URINE CULTURE (Final [**2141-6-27**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Imaging:
# CHEST (PORTABLE AP) Study Date of [**2141-6-25**]
FINDINGS: Single AP upright radiograph of the chest was
obtained. The lungs are slightly lower in volume but clear.
There is no pleural effusion or pneumothorax. Heart is top
normal in size with normal cardiomediastinal contours.
# CT HEAD W/O CONTRAST Study Date of [**2141-6-25**]
FINDINGS: There is no intracranial hemorrhage, mass effect,
edema, or shift of normally midline structures. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. There is extensive
periventricular and subcortical white matter hypoattenuation,
compatible with a small vessel ischemic disease. Ventricles and
sulci are prominent, compatible with age-related involution.
Suprasellar and basilar cisterns are patent.
Paranasal sinuses and mastoid air cells are well aerated.
Vascular
calcifications are seen in the cavernous carotid arteries. The
middle ear structures are symmetric. Soft tissue density in
bilateral external auditory canals likely represents cerumen.
Globes are intact with bilateral lens replacement.
IMPRESSION:
1. No acute intracranial process.
2. Extensive age-related involution and small vessel ischemic
disease.
3. If there is persistent clinical concern for ischemia,
consider MRI if not contraindicated.
# CT ABD & PELVIS WITH CONTRAST Study Date of [**2141-6-25**]
CT ABDOMEN: There is trace bibasilar dependent atelectasis.
The heart is normal in size without pericardial effusion.
Multivessel coronary arterial calcifications are noted, with
concurrent aortic valve calcification.
The liver demonstrates no focal lesion. The gallbladder,
spleen, and adrenal glands appear unremarkable. The pancreas is
diffusely atrophic and demonstrates a 9-mm cyst in the head.
There is no pancreatic ductal
dilatation.
The nephrograms are symmetric. There is moderate right
hydronephroureter
upstream of an 8-mm mid ureteric stone (2, 51). There is also a
suggestion of urothelial hyperenhancement upstream of the stone,
suggestive of pyelitis. There is no left-sided renal
obstruction. No additional stone is seen. Moderate stranding
and free fluid is seen around the right kidney. Small and large
bowel loops are normal in caliber. Trace free fluid is seen
subjacent to the cecal tip. There is no intra-abdominal
lymphadenopathy. Great vessels are patent. Moderate
atherosclerotic disease is present throughout the descending
aorta extending into branching vessels.
There are bilateral renal cysts, some of which too small to
fully
characterize.
CT PELVIS: The bladder is partially distended, but demonstrates
urothelial hyperemia and mural thickening, likely reflecting
presence of cystitis. There is nondependent air and a Foley
catheter in place, possibly related to recent instrumentation.
The prostate gland appears enlarged to 5.9 cm. There is
significant fecal impaction within the rectum. No inguinal or
pelvic sidewall adenopathy.
No focal concerning lesion. Multilevel lower thoracic
spondylosis is present.
IMPRESSION:
1. 8-mm right mid ureteric obstructing stone with moderate
upstream
hydronephroureter, as well as urothelial hyperenhancement
suggestive of
pyelitis. Consider percutaneous nephrostomy placement.
2. Bladder thickening and urothelial hyperenhancement
suggestive of
concurrent cystitis.
3. Bilateral renal cysts.
4. 9-mm pancreatic head cyst, statistically most likely to
represent side branch IPMN, which could be followed by MRCP.
# PORTABLE ABDOMEN Study Date of [**2141-6-27**]
FINDINGS: There is an 8-mm main ureteral stone seen on the
right which
appears to be similar in location as seen on the CT exam. Right
percutaneous nephrostomy tube catheter is in place. There is a
nonspecific bowel gas pattern with air in both the colon and
small bowel. There is no evidence of obstruction, ileus, or
large amount of free air. There are degenerative changes in the
lower lumbar spine.
IMPRESSION: 8-mm right mid ureteral stone in similar position
as prior CT.
Brief Hospital Course:
80 yo male with history of Parkinson's disease, dementia, CAD,
and CHF with EF 25% who presented for altered mental status
found to have a UTI and an obstructing right mid ureteric stone
with upstream hydronephroureter. His mental status improved with
ceftriaxone treatment.
ACTIVE ISSUES:
# Urosepsis: Patient presented with fever, hypotension, and left
shift with positive UA as the source. Pt was found to have a UTI
with upstream hydronephroureter and acute kidney injury
secondary to obstructing right mid ureteral stone. Patient
underwent urgent decompression of the right collecting system
with percutaneous nephrostomy tube in IR. He was transiently
hypotensive during the procedure requiring pressors, which the
patient was quickly weaned from. He was initially placed on
ceftriaxone, but then broadened to cefepime when blood cultures
returned positive for gram negative bacteremia. However, he was
narrowed back to ceftriaxone once speciation and sensitivities
returned. His lactate was elevated on presentation, which
normalized with IVFs. Anti-hypertensives were held on admission.
Mental status improved after two days of antibiotics and blood
cultures were negative for 48 hours before he was discharged.
Antibiotics will be continued for a total of 2 weeks, until
[**7-9**]. Patient has a MIDLINE for antibiotic administration in his
rehab facility.
# [**Last Name (un) **]: Pt's creatinine noted to be doubled compared to patient's
baseline on admission, likely secondary to obstruction from
nephrolithiasis and prerenal state secondary to poor PO intake
and febrile illness. His creatinine trended down with
resolution of obstruction and IVF. His serum creatinine
improved with IVFs and correction of obstruction and are now to
his baseline of 0.8.
# Altered mental status: This was attributed to fevers, UTI, and
dehydration from febrile illness. Family reports he is now back
to his baseline.
CHRONIC ISSUES:
# Normocytic anemia: Likely secondary to anemia of chronic
disease. Pt was guaiac negative in ED. His HCT remained stable
in ICU and on medical unit.
# DVT: Pt was on sub therapeutic dosing of Lovenox on admission.
This was increased to 1.5 mg/kg/day prior to discharge.
# CHF: last EF reported 25%. Pt was hypovolemic on admission and
was fluid resuscitated. He appeared euvolemic on discharge and
was satting well on room air.
# CAD/HTN: Pt was continued on his aspirin. His lisinopril and
metoprolol were initially held for hypotension but these were
resumed without problem on the medical unit.
# HL: Continued atorvastatin.
# Parkinson's: Continued carbidopa-levodopa. Initially his home
Seroquel was held given AMS, but then tolerated it well once
mental status improved.
# DM: Pt's glipizide was held while in house, but resumed on
discharge.
# Constipation: Continued MiraLax. Also added Colace, senna and
bisacodyl.
# Urinary Retention: Patient required Foley placement. Started
on Flomax.
#Transitional issues:
Pt will be discharge to rehab for IV antibiotic treatment.
He will need to follow up with urology on [**7-5**] for continued
treatment planning of his obstructing kidney stone. They will
also determine whether his Foley can be discontinued at that
time.
Medications on Admission:
1. Atorvastatin 80 mg PO DAILY
2. Carbidopa-Levodopa (25-100) 0.5 TAB PO TID
3. GlipiZIDE 10 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Quetiapine Fumarate 12.5 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. Enoxaparin Sodium 60 mg SC DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carbidopa-Levodopa (25-100) 0.5 TAB PO TID
4. Polyethylene Glycol 17 g PO DAILY
5. GlipiZIDE 10 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Enoxaparin Sodium 100 mg SC DAILY
9. Quetiapine Fumarate 12.5 mg PO BID
Hold for sedation or RR<10.
10. CeftriaXONE 1 gm IV Q24H
11. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
13. Senna 1 TAB PO BID:PRN constipation
14. Outpatient Lab Work
Please have labs checked at your urology appointment on [**2141-7-5**]:
CBC, Chem 10, AST, ALT, alk phos, total bili
Have results faxed to Dr. [**Last Name (STitle) **] Phone: [**0-0-**]
Fax: [**Telephone/Fax (1) 8474**]
ICD 9:995.91
15. IV care
Please discontinue MIDLINE once antibiotic course is complete.
16. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY:
Urosepsis
right obstructing kidney stone
Urinary retention
SECONDARY:
Diabetes
hypertension
coronary artery disease
parkinson's
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 41838**],
It was a pleasure taking care of you. You were admitted to the
hospital for altered mental status and were found to have a
urinary tract infection that had spread to your blood stream,
likely a result of blockage of your right urinary tract from a
kidney stone in your right kidney. You were treated with
intravenous antibiotics which you must continue taking to make
sure that infection resolves.
You have an appointment scheduled with urology on [**2141-7-5**] for
follow up of your kidney stone.
Please make the following changes to your medications:
# START ceftriaxone 1 gram every 24 hours, last dose 7/15
# START Flomax 0.4mg QHS for urinary retention
Continue all other medications as prescribed.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2141-7-5**] at 9:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2141-7-2**]
|
[
"285.29",
"584.9",
"592.1",
"414.01",
"038.40",
"401.9",
"276.51",
"599.0",
"V45.82",
"564.00",
"412",
"294.10",
"428.0",
"V49.86",
"788.29",
"428.22",
"719.41",
"425.4",
"250.00",
"272.4",
"V12.51",
"331.82",
"995.91",
"593.5",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.03",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
15058, 15124
|
10444, 10720
|
307, 326
|
15306, 15306
|
3675, 3675
|
16215, 16508
|
2539, 2582
|
14029, 15035
|
15145, 15285
|
13692, 14006
|
15445, 16010
|
4346, 10421
|
2597, 3224
|
3240, 3656
|
13410, 13666
|
16039, 16192
|
2035, 2054
|
264, 269
|
10735, 12226
|
354, 2015
|
3691, 4330
|
15321, 15421
|
12380, 13389
|
2076, 2335
|
2351, 2523
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,968
| 121,273
|
40467
|
Discharge summary
|
report
|
Admission Date: [**2171-4-13**] Discharge Date: [**2171-4-17**]
Date of Birth: [**2126-2-22**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
The pt is a 45-year-old man who presents with first-time
seizure. He was last seen well at 9: 40 pm on [**2171-4-12**] before
going to bed. Early this morning at 3:30 am, his wife observed
that he had full body shaking which lasted for about 5 minutes.
She describes that his lips were blue, and he was making strange
noises. There was no urinary incontinence. EMS was called.
When they arrived, he was no longer seizing but was very
agitated
and combative, requiring many men to hold him down. He was
taken
to [**Hospital1 18**] [**Location (un) 620**]. There, upon arrival, he appeared post-ictal
initially. Then he was able to accurately say his name, his
wife's name, and address. Then, he became increasingly
combative
and agitated, and therefore, he was intubated. It was unsure
whether his combativeness could be seizure. He received 4 mg of
Ativan, 10 mg of Haldol, and received etomidate and rocuronium.
He was placed on propofol and versed drips. He was loaded with
Dilantin 1000 mg x 1. Head CT was done which reportedly did not
show an acute intracranial process, but this was not available
at
time of presentation to review. He was afebrile. Blood
cultures
were obtained, and he was empirically started on vancomycin,
ceftriaxone, and acyclovir for meningitis coverage. He
received
magnesium 2 g IV or mildly prolonged QT interval. Of note, a
petecchial rash was noted to appear on both arms and chest which
seemed to develop either at [**Location (un) 620**] or during transport. He was
transferred to [**Hospital1 18**] [**Location (un) 86**] for further management. Lumbar
puncture was done upon arrival.
On neuro [**Last Name (LF) **], [**First Name3 (LF) **] his wife, he does not have history of
headaches. Yesterday, he was interacting normally with normal
speech and gait. Within the past year, he had minor head trauma
without loss of consciousness described as falling and hitting
his head on a brick wall.
On general review of systems, per his wife, he has not had
fever. He has not had recent vomiting, diarrhea, or abdominal
pain. No recent change in bowel or bladder habits.
Past Medical History:
His wife describes an episode of waking up with
confusion/short-term memory loss which occurred 6-8 months ago.
His wife denies history of hypertension, diabetes, or high
cholesterol.
He has never had a seizure before.
No history of febrile seizures or learning disabilities.
He has no prior hospitalizations or surgeries.
Social History:
He is married with two children.
Family History:
His wife is not aware of any family history of seizure or
stroke. His grandmother has [**Name (NI) 2481**].
Physical Exam:
ON ADMISSION
Vitals: T: 97.4 P: 69 R: 16 BP: 121/85 SaO2: 100% FiO2 98 %
PEEP 5
General: intubated
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: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: + petecchial rash on shoulders, arms, chest
Neurologic:
-Mental Status: intubated. When examined off propofol, he is not
responsive to voice or noxious stimuli.
-Cranial Nerves:
Pupils 3 and sluggishly reactive. No blink to threat. No
horizonatal or vertical oculocephalics present. No facial droop,
facial musculature symmetric.
No corneals bilaterally. No gag reflex.
-Motor: Flexor posturing of both arms. Extensor posturing of
both legs. Does not withdraw to noxious stimuli.
-Sensory: Does not withdraw to noxious stimuli.
-DTRs: Unable to elicit reflexes throughout. Toes mute
-Coordination: Unable to test.
-Gait: Unable to test.
ON DISCHARGE
GEN: red sclera on the right eye with some periorbital bruising
MS: intact, minimal memory of the event
CN: intact
Strength: full throughout
Reflexes: symmetric b/l, with toes flexion
Coordination intact
Gait normal stride and gait
Pertinent Results:
MRI:
1. No acute infarction. Allowing for the pulsation artifacts, no
areas of
altered signal intensity on the FLAIR sequence. However, a few
scattered T1 hyperintense foci, may relate to pulsation
artifacts/slow flow in the venous structures. These are not
identifiable on the other sequences. Hence, the significance of
these findings is uncertain. A followup study, along with MRV
can be considered for better assessment if there is continued
concern.
2. In the coronal sequences, the hippocampi are grossly
symmetric in size;
slightly increased T2 signal in the left hippocampus, which is
equivocal
significance. To correlate with EEG and follwo up as clinically
indicated.
3. Paranasal sinus disease as described above.
CTA
No acute abnormality is seen. Subtle infarcts maybe occult on CT
perfusion
and if there is continued clinical concern, MRI would be more
sensitive.
CK on discharge: [**Numeric Identifier 88658**]
Brief Hospital Course:
Seizure
[**Known firstname **] [**Known lastname 8320**] was admitted after he had a witnessed GTC seizure
at home. He required multiple agents post-ictally as he was
combative and ended up being intubated. There was initial
concern for an infarct given absent cranial nerves on exam,
however it was later thought that this could be secondary to
paralytics. His MRI showed FLAIR abnormalities in the right
temporal lobe consitent with a recent seizure. His EEG was
pending on discharge but showed no evidence of seizure activity.
He was started on Keppra 1500 [**Hospital1 **] and discharged on this
medication. He was ordered for an MRI with contrast one week
after his discharge.
Rhabdomyolisis
His CK was climbing on HD 3 to a max of [**Numeric Identifier 88659**]. Renbal was
consulted and he was put on bicarb drip. His creatinine improved
during the hospitalization. He was told to get his CK and
creatinine checked in 2 days after his hospitalization.
Medications on Admission:
Fish Oil
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. omega-3 fatty acids Capsule Sig: 1000 (1000) Capsules PO
BID (2 times a day).
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. Outpatient Lab Work
BUN/Creatinine
CK
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Acute Kidney Injury
Rhabdomyolisis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the neurology service after you had a
seizure while waking up that was described as a generalized
tonic-clonic seizure. Your wife felt that it lasted at least 5
minutes. Following the seizure you were confused and combative
and were intubated. A CTA was done that showed no evidence of a
stroke and an MRI showed no evidence of stroke or mass. You were
transferred out of the ICU, but had elevations in your CK. We
kept you on fluids and renal was consulted and felt you would
benefit from a bicarb drip. You will need to stay on Keppra and
will need an MRI with contrast of your head which was not done
given the acute kidney injury. An EEG was done which showed no
evidence of seizure activity.
1. Continue on Keppra 1500 mg twice daily
2. You will need an MRI w/ contrast done in 1 week - this has
been scheduled. Radiology will call you to make an appointment
3. Please come in to get your CK and Creatinine checked in 2
days
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2171-5-15**] 4:00
Completed by:[**2171-4-18**]
|
[
"584.9",
"728.88",
"780.39",
"782.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"03.31",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6795, 6801
|
5392, 6355
|
313, 339
|
6888, 6888
|
4438, 5322
|
8014, 8204
|
2912, 3023
|
6414, 6772
|
6822, 6867
|
6381, 6391
|
7039, 7991
|
3702, 4419
|
3038, 3580
|
5336, 5369
|
266, 275
|
367, 2499
|
6903, 7015
|
2521, 2846
|
2862, 2896
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,727
| 191,117
|
51926
|
Discharge summary
|
report
|
Admission Date: [**2156-2-3**] Discharge Date: [**2156-2-13**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
hypotension, septic shock
Major Surgical or Invasive Procedure:
intubation
central venous line placement
History of Present Illness:
59M with MMP inlcuding CAD s/p MI, chronic systolic CHF (EF
30-35%), DM2 on insulin, HTN, and ESRD on HD, who was brought to
the ED on [**2-3**] after being found lethargic at home by partner.
[**Name (NI) **] his partners report, he had been progressively "sicker" over
the last day, with more general malaise, weakness, and lethargy.
He was dialyzed on Monday and was fine there, but complained of
foot pain. He went out with his son-in-law today, but when he
returned, he felt ill and was too weak to walk back in the house
by himself. Took FSG, was 241. He had N/V x 2. His partner
eventually called EMS for a change in mental status, decreased
responsiveness. On EMS arrival he was noted to hypotensive and
altered. By his partners report, no fevers but + shaking chills
and weak, with diaphoresis. Did complain of being cold and some
SOB but no CP or abdominal pain. Had a new cough productive of
phlegm. Had diarrhea x 1. No sick contacts.
.
In ED, patient arrived in extremis, VS 97.1 88 50/palp 18 100%
NRB. Was immediately intubated for altered mental status and
airway protection. A CVL was placed in the RIJ, and vasopressors
were started (dopamine and levophed). He received 2L IVF, and
dopa was gradually weaned down, but remained on levophed at 0.12
mcg/min. Initial labs revealed venous lactate of 8.2 and
non-hemolyzed K of 6.7. EKG was without peaked T waves, but pt
received calcium and insulin. There were no acute ischemic EKG
changes (has RBBB, old inferior Q waves). 1st set of CE's
revealed flat CKs with baseline elevated troponin. CXR showed ?
development of bilateral early infiltrates. He is anuric so no
urine studies were able to be obtained. Serum tox was negative.
Blood cultures were drawn and he was empirically covered broadly
with vanco/zosyn/flagyl. CT head showed no ICH, and CT abdomen
showed no acute intraabdominal process, but revealed LLL
atelectasis vs PNA. He was then admitted to the ICU.
.
On arrival to the ICU the patient is intubated and sedated. Full
ROS is unable to be obtained at this time
Past Medical History:
#. Type II diabetes mellitus - on insulin
#. CAD s/p MI - cath in [**9-21**] with non-flow-limiting CAD
#. CHF with EF 30-35%
#. history of multiple admissions for chest pain with negative
work up. Past chest pain syndromes have been in the setting of
crack/ cocaine use. Most recently admitted [**Date range (1) 32600**] for the
same.
#. Hypertension
#. Dyslipidemia
#. h/o atrial tachycardia s/p EPS [**9-21**] and ablation x 2 for left
sided, triggered (not re-entrant) Atachs
#. Hisrory of gastrointestinal bleed: multiple previous workups
have included at least six endoscopies, three colonoscopies, one
enteroscopy, and a capsule camera study, and all have been
negative, except for small AVM's in the duodenum s/p thermal
therapy
#. Chronic pancreatitis
#. Hepatitis C
#. GERD
#. ESRD on [**Month/Year (2) 13241**] (Tues/Thurs/Sat, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis,
[**Location 1268**], [**Telephone/Fax (1) 69669**])
#. Gout, s/p arthroscopy with medial meniscectomy [**5-/2149**]
#. Depression, s/p multiple hospitalizations due to SI
#. Polysubstance abuse: crack cocaine, EtOH, tobacco
#. Erectile dysfunction, s/p inflatable penile prosthesis [**5-/2148**]
Social History:
He lives with a female partner in [**Location (un) 686**], MA. 42 pack-year
smoking history, recently up to 6 cigarettes per day. He has a
history of alcohol abuse, with DTs and detoxification, with last
drink on [**Holiday 1451**]. History of crack cocaine use.
Family History:
Father with alcoholism. Mother with type 2 diabetes, renal
failure, died at age 58. Son with diabetes. Cousin with [**Name2 (NI) 14165**]
cell disease.
Physical Exam:
Vitals - 95.0 74 124/63 20 100% on AC 500/14/5/100%
GENERAL: intubated, sedated, does not respond to voice
HEENT: AT/NC, EOMI, PERRLA(surgical pupil on L), muddy sclera,
MMM NECK: RIJ in place, JVP not grossly elevated
CARDIAC: RRR, no murmur/r/g.
LUNG: anteriorly rhonchorous, clear posteriorly and at bases. No
crackles
ABDOMEN: soft, no rebound/guarding, + hepatomegaly 7cm below
costal margin, no obvious fluid wave
EXT: cool extremities, no cyanosis, clubbing or edema
SKIN: no excoriations, no rashes. LLE with superficial knee
abrasion
Pertinent Results:
[**2156-2-3**] 05:00PM BLOOD WBC-6.1 RBC-3.45* Hgb-10.3* Hct-31.9*
MCV-92 MCH-29.9 MCHC-32.4 RDW-14.7 Plt Ct-155
[**2156-2-4**] 02:55AM BLOOD WBC-10.7# RBC-3.61* Hgb-10.8* Hct-32.3*
MCV-90 MCH-29.9 MCHC-33.5 RDW-15.2 Plt Ct-229
[**2156-2-3**] 05:00PM BLOOD PT-16.5* PTT-33.3 INR(PT)-1.5*
[**2156-2-3**] 05:00PM BLOOD Neuts-66.8 Lymphs-25.4 Monos-5.6 Eos-1.8
Baso-0.4
[**2156-2-3**] 05:00PM BLOOD Glucose-350* UreaN-32* Creat-5.0* Na-133
K-6.5* Cl-92* HCO3-26 AnGap-22*
[**2156-2-4**] 02:55AM BLOOD Glucose-55* UreaN-37* Creat-5.2* Na-135
K-6.4* Cl-98 HCO3-28 AnGap-15
[**2156-2-3**] 05:00PM BLOOD ALT-27 AST-32 CK(CPK)-118 AlkPhos-222*
TotBili-0.9
[**2156-2-3**] 05:00PM BLOOD CK-MB-7
[**2156-2-3**] 05:00PM BLOOD cTropnT-0.28*
[**2156-2-3**] 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2156-2-4**] 06:49AM BLOOD Type-ART pO2-121* pCO2-49* pH-7.36
calTCO2-29 Base XS-1 Comment-ADD ON K @
[**2156-2-4**] 10:11AM BLOOD Type-ART Temp-36.4 Rates-0/18 Tidal V-470
PEEP-5 FiO2-40 pO2-99 pCO2-52* pH-7.38 calTCO2-32* Base XS-3
Intubat-INTUBATED
[**2156-2-3**] 04:52PM BLOOD Glucose-310* Lactate-8.2* Na-137 K-6.7*
Cl-94* calHCO3-22
[**2156-2-3**] 05:30PM BLOOD Glucose-316* Lactate-5.4* Na-136 K-6.0*
Cl-97* calHCO3-24
[**2156-2-4**] 06:49AM BLOOD Lactate-1.2 K-5.8*
[**2156-2-4**] 10:11AM BLOOD Lactate-1.1 K-5.9*
.
GI Bleed study: 1. No definite evidence of gastrointestinal
bleeding during the period of imaging. 2. Enlarged liver.
.
CT ABD/PEL: 1. Left lower lobe pneumonia. 2. Moderate sized
right pleural effusion and right lower lobe atelectasis. 3.
Moderate amount of ascites. 4. 1-cm hypodense lesion in the
pancreatic body remains concerning for IPMN or pancreatic
pseudocyst and was better evaluated on MRI performed [**2154-7-21**].
Brief Hospital Course:
MICU COURSE: Patient arrived intubated and sedated with evidence
of severe sepsis. His lactate peaked in the ED of 8.2, and
improved with IV fluids. He had [**Month/Day/Year 13241**] on [**2-4**] and [**2-5**].
On [**2-4**] he was also extubated and weaned off pressores. On
[**2-5**], he was hypertensive to the 200s. He was restarted on his
oral antihypertensive medications and has been stably in the
120s-130s since.
On [**2-5**], he was noted have melanotic stools. On [**2-6**] he had 300
cc BRBPR. His hematocrits have been stable and his stools have
been brown recently. He continues to have loose stools that were
C.diff negative.
He had evidence of altered mental status in the ICU that was
likely [**2-16**] hypoxemia. He was monitored initially on CIWA scales,
but was not requireing benzodiazepines.
59M with CAD, CHF, DM, ESRD on HD, who presented with severe
sepsis possibly from line infection or pneumonia, called out
from MICU, also with GI bleed.
.
SEPSIS: On presentation, patient had hypotension to 50/palp with
evidence of initial hypoperfusion with lactate in ED of 8.2, but
improved to 5.4 with fluids in ED. Based on time course, patient
most likely became bacteremic in [**Month/Day (2) 13241**]. A primary
pulmonary source is also possible. He has remained afebrile. CXR
with improving pulm edema but no clear evidence of pneumonia.
Endotracheal sputum showed sparse OP flora that was likely a
contaminant. Following discharge from ICU, patient had normal
oxygen saturation on room air. Presuming a skin flora source,
he was treated with Vanc for a 14 day course ([**2-3**] ?????? [**2-17**]).
.
HEART BLOCK: Patient reported 1 hour of sharp left sided chest
pain, improved with rest. Known CAD, but low prob for ACS. EKG
with new CHB. No ischemic changes. Likely [**2-16**] excess nodal
agents. Cardiac enzymes remained at baseline. He was restarted
on a lower dose of diltizam.
.
GI Bleed: Patient has long history of GI bleeding with multiple
AVMs s/p thermal ablation in the past. He recieved 2 U PRBC in
HD for falling Hct on [**2-10**]. He continues to maintin stable blood
pressures and heart rate. EGD and colonscopy ([**2-9**]) was
negative. Tagged RBC scan showed no evidence of
gastrointestinal bleeding on [**2-10**]. His bleeding tapered off and
his hematocrit remained stable.
.
ITCHING: Patient with puritis since initiating HD. No skin
abnormalities on exam. PTH is very high consistent with renal
associated hyperparathyroidism. Ne sevelamer per renal team. He
was treated Sarna lotion, hydralizine and benadryl PRN.
.
ESRD on HD: Dry weight 66 kg per OMR, with volume overload in
ICU from IV fluids. He was diuresed in HD to dry weight.
.
CONGESTIVE HEART FAILURE and CORONARY ARTERY DISEASE: chronic
systolic CHF - EF 30%. He continued medical management with
statin, betablocker, ACE inhibitor. ASA was held given
recurrant GI bleeding.
.
PANCREATIC LESION: Possible IPMN.
- Consider outpatient imaging.
.
HISTORY OF ATRIAL TACHYCARDIA - not on Coumadin [**2-16**] GI bleeds.
He continued amiodarone, labetalol, dilt.
.
DIABETES: on RISS and standing NPH, but reportedly with poor
compliance. Last HgB A1c 7.4%. He was conutinued on insulin and
neurontin for diabetic neuropathic pain.
.
DEPRESSION: continued sertraline 100mg daily
.
CODE STATUS: FULL
.
COMM:
- wife [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 107505**] (doesn't live with him)
- female partner [**Name (NI) 5464**] [**Telephone/Fax (1) 107506**]
Medications on Admission:
#. Labetalol 100 mg PO TID
#. Amiodarone 200 PO DAILY
#. Lisinopril 10 mg PO DAILY
#. Atorvastatin 20 mg PO DAILY
#. Cinacalcet 30 mg PO DAILY
#. Pantoprazole 40 mg PO Q24H
#. Sertraline 100 mg PO DAILY
#. Multivitamin PO DAILY
#. Gabapentin 300 mg PO Q48H
#. DILT-XR 180 mg PO once a day.
#. Dextromethorphan-Guaifenesin 5ML PO Q6H prn cough.
#. Diphenhydramine HCl 25 mg PO Q6H.
#. Insulin NPH: 15 units Subcutaneous [**Telephone/Fax (1) **], 10 units Subcutaneous
qpm.
#. Insulin Lispro sliding scale.
#. Acetaminophen 325-650 mg Tablet PO Q4H
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Cinacalcet 30 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. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
10. Diphenhydramine HCl 25 mg Capsule Sig: [**1-16**] Capsules PO Q6H
(every 6 hours) as needed.
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: [**10-28**]
units Subcutaneous twice a day: 15 units SQ in the morning and
10 using SQ in the evening.
12. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous QAC: sliding scale.
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
14. Vancomycin 500 mg Recon Soln Sig: One (1) dose Intravenous
HD PROTOCOL (HD Protochol) for 4 days: with HD, last dose 2/3.
15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
16. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
[**Month/Year (2) **]:*30 Cap(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
Primary:
SEPSIS
UPPER GASTROINTESTINAL BLEED
HEART BLOCK
ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE
Secondary:
PURITIS
END-STAGE RENAL DISEASE ON [**Hospital **]
CONGESTIVE HEART FAILURE
CORONARY ARTERY DISEASE
PANCREATIC LESION
DIABETES
DEPRESSION
Discharge Condition:
Stable vital signs and Hct.
Discharge Instructions:
You were admited because you have a severe infection. This
infection was likely in your blood and caused you to have a low
blood pressure. We gave you fluids and blood pressure raising
drugs to keep you alive. You were started on antibiotics, and
should complete a two week course of these antibiotics, which
can be given at [**Hospital 13241**].
You were found to have a significant amout of rectal bleeding.
The gastroenterologists did studies to determine the source of
this bleeding.
For your heart failure, you should weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: 2L per day
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2156-2-18**] 11:30
You have an appointment with podietry schedule for [**2156-3-3**] at
3:50 with Dr. [**Last Name (STitle) **]. Phone: [**Telephone/Fax (1) 3828**]
Please resume your regularly [**Telephone/Fax (1) 1988**] dialysis tomorrow.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Completed by:[**2156-3-1**]
|
[
"038.9",
"427.31",
"577.9",
"250.00",
"426.9",
"785.52",
"995.92",
"578.9",
"518.81",
"414.01",
"428.0",
"585.6",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.6",
"96.71",
"38.93",
"45.13",
"96.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
12090, 12159
|
6485, 9976
|
293, 335
|
12461, 12491
|
4681, 6462
|
13198, 13724
|
3949, 4103
|
10573, 12067
|
12180, 12440
|
10002, 10550
|
12515, 13175
|
4118, 4662
|
228, 255
|
363, 2409
|
2431, 3651
|
3667, 3933
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,248
| 177,240
|
8234
|
Discharge summary
|
report
|
Admission Date: [**2144-6-27**] Discharge Date: [**2144-7-8**]
Date of Birth: [**2088-4-18**] Sex: M
Service: MEDICINE
Allergies:
Coreg
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
RLE stump wound infection, urinary tract infection and altered
mental status
Major Surgical or Invasive Procedure:
[**2144-7-6**] debridement, primary closure R BKA
[**2144-7-1**] debridement right BK stump
failed lumbar puncture times three
History of Present Illness:
Mr. [**Known lastname **] is a 56 year-old man with a history of kidney
transplant x 2, DM, bilateral BKA with RLE non-healing ulcer
(right BKA in [**2144-5-21**]), who presents from rehab with AMS. Of
note, he was recently discharged on [**2144-6-13**] after being admitted
with a CHF exacerbation; at that time, he also had a wound VAC
placed on his right stump and was treated with two weeks of
vancomycin for an enterococcus wound infection. He was doing
well at his nursing home until the day prior to admission when
he was noted to have worsening mental status. He was also found
to have a UTI and was started on imipenem. On the day of
admission, he was found standing next to his bed on his stumps
and was combative and noncooperative with nursing home staff,
pulling out both his PICC and foley. He was then transferred to
the ED for further evaulation.
.
In the ED, initial vs were: T 99.2 P 51 BP 141/83 R 18 O2 97%ra
sat. He was given vancomycin and zosyn, later spiked a
temperature to 102.9 rectal which resolved with PR tylenol, and
was placed in wrist restraints for combativeness. His right BKA
was draining purulent material and vascular was consulted, with
a recommendation to start broad spectrum antibiotics. He was
also noted to have diarrhea and an abdominal CT was performed to
rule out colitis or an abdominal process, with an initial read
that was negative. Because of his history of VRE, he was also
given linezolid and then ceftriaxone 2g/acyclovir 50 mg x 1 to
cover for meningitis. An LP was attempted (3 passes) but was
unsuccessful. He was admitted to the MICU because of his severe
agitation and concern that he would fail management on the
floor.
.
On the floor, he was agitated but intermittently cooperative
with interview and exam.
Past Medical History:
- CHF with Known EF 25-35%
- PVDF with a right foot nonhealing ulcer s/p right SFA-to-DP
bypass graft, a nonreverse saphenous vein in [**2134**], a left BKA
in [**2133**], R BKA [**2144-5-21**]
- ESRD secondary to his diabetes s/p failed LLRT in [**2116**], second
LRRT in [**2135**] (stable)
- CAD s/p myocardial infarction, s/p angioplasty with stent
placement
- HTN
- CVA [**2131**]
- type 1 insulin dependent diabetes with triopathy
- GERD
- Hyperlipidemia on a statin
- left AVF fistula
- Chronic diarrhea [**3-9**] to ? diabetic autnomic neuropathy
- Recent [**First Name9 (NamePattern2) **] [**Doctor Last Name **]. Enterococcus stump infection, on [**Doctor Last Name **]
Social History:
Lives alone, recently in a rehab facility. Has an intermittent
smoking history of approximately 20-30 packyears. Smoked 1
cigarette today. Denies EtOH or other drug use.
Family History:
M: Colon Ca
F: Prostate Ca
Physical Exam:
Vitals: T: 98 BP: 128/70 P: 80 R: 18 O2: 97%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
Ext: 2+ RLE edemma, no edema LLE. R BKA stump with erythema, s/p
vac dressing removal, 3 cm ulcerated wound on anterior stump,
base of stump also with ulcertation, erythema, and purulent vs
fibrinous appearing material.
Pertinent Results:
[**2144-6-27**] 06:00PM URINE COMMENT-SPERM SEEN
[**2144-6-27**] 06:00PM URINE RBC-0-2 WBC-[**12-25**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2144-6-27**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2144-6-27**] 06:00PM NEUTS-80.2* LYMPHS-14.2* MONOS-4.8 EOS-0.7
BASOS-0
[**2144-6-27**] 06:00PM WBC-7.2 RBC-3.44* HGB-10.0* HCT-30.9* MCV-90
MCH-29.0 MCHC-32.3 RDW-14.9
[**2144-6-27**] 06:00PM CK-MB-NotDone
[**2144-6-27**] 06:00PM cTropnT-0.14*
[**2144-6-27**] 06:00PM LIPASE-7
[**2144-6-27**] 06:00PM ALT(SGPT)-11 AST(SGOT)-24 CK(CPK)-83 ALK
PHOS-263* TOT BILI-0.4
CT HEAD [**2144-6-27**]:
IMPRESSION: No acute intracranial pathology including no
hemorrhage.
CT ABDOMEN PELVIS [**2144-6-28**]:
1. Cardiomegaly, small pericardial effusion and small bilateral
pleural
effusions, body wall edema. Findings likely secondary to volume
overload.
2. Small amount of gas in bladder, mild bladder wall thickening
and
perivesical stranding may be seen in the setting of infection.
Recommend
clinicalcorrelation.
3. Bilateral atrophic native kidneys are in place. Transplanted
kidney is
noted within the right lower quadrant area.
4. Cholelithiasis with no evidence of cholecystitis.
5. Extensive atherosclerosis with prior right SFA stenting.
KNEE XRAY [**2144-6-29**]:
The patient is status post right-sided below-the-knee
amputation. There is
soft tissue gas in an ulcer adjacent to the distal tibial stump.
However, the
cortical margins are unchanged and preserved since the previous
study.
Underlying osteomyelitis is likely given the development of the
ulcer
extending to exposed bone (best seen on the lateral view). There
is increase
in the soft tissue swelling since the prior study. Vascular
calcifications
are identified.
OPERATIVE REPORT [**2144-7-1**] DEBRIDEMENT:
PREOPERATIVE DIAGNOSIS: Nonhealing right BKA stump
POSTOPERATIVE DIAGNOSIS: Nonhealing right BKA stump
ASSISTANT: [**First Name8 (NamePattern2) 5045**] [**Last Name (NamePattern1) 29242**], M.D.
REASON FOR PROCEDURE: Mr. [**Known lastname **] is a 56-year-old male who
underwent right below-the-knee amputation a bout a month ago.
He
was found standing next to his bed on his BKA stumps at rehab,
confused and combative and was admitted to [**Hospital1 18**] for stump
infection and MS changes. The decision was made to debide the
stump back to viable bone and soft tissue. The procedure was
discussed in detail and the patient signed an informed consent
prior to the procedure.
OPERATIVE NOTE: The patient was taken to the operating room
and the right leg was prepped and draped in the usual sterile
fashion. A spinal block was performed and level was confirmed.
A
ronjour was then used to trim the tibia to healthy, bleeding
bone
which only required removal of about 1cm of distal tibia. Skin
and soft tissue was also debrided to healthy tissue. There was
a
pocket between the anterior and posterior compartments that
contained a 20cc fluid collection. This fluid was sent for
aerobic and anaerobic cultures. Hemostasis was achived and a
occlusive negative pressure dressing was placed with continuous
suction at 100mmHg.
The patient's indwelling foley catheter was removed at the
request of the primary team.
The patient awoke from MAC sedation, tolerated the procedure
well, and was taken to the PACU uneventfully.
The estimated blood loss of the procedure minimal.
Complications: none
Brief Hospital Course:
Patient is a 56 year old male s/p kidney transplant x 2, DM1,
bilateral BKA with RLE stump who presented with AMS secondary to
sepsis from UTI and osteomyleitis from stump site infection.
Patient is s/p multiple debridements and primary closure done by
vascular surgery currently on tobramycin.
.
# Right BKA stump infection / Osteomyelitis - S/p BKA procedure
in [**5-14**] by vascular surgeon, Dr. [**Last Name (STitle) 1391**]. On previous admission
[**2144-6-13**], pt had a wound VAC placed on his right stump and was
treated with two weeks of vancomycin for an (VSE) enterococcus
wound infection. Previously this infection cultured out VRE and
required treatment with linezolid, but ID not recommending any
antibiotics at this time. Initially presented with overlying
cellulitis, responded well to 5 days of CTX that was given for
UTI. Contributed to altered mental status on initial
presentation. Was found to have osteo in the stump and underwent
surgical debridement on [**7-1**]. Wound vac was changed on [**7-3**].
Went to OR today for primary clousure. Patient is to continue
[**Hospital1 **] wet to dry dressings. Patient had wound vac placed by
vascular surgery and to have outpatient follow up. Patient is
having tobramycin given at 240mg IV, first day on [**2144-7-3**],
initially dosed Q48H but will be dosed per through levels, <1.0.
Pain medication regimen adjusted, percocet PO and dilaudid PO
for breakthru pain. ID will assist in medication dosing.
.
# Resolved Altered mental status: On intial exam and at time of
admission to unit and at time of my initial exam on the floor,
patient had altered mental status. At ECF, patient was agitated
and pulling out lines. Patient is calm at this time. AMS was
thought to be in the setting of infection from UTI vs wound
infection. Other causes were considered including, Meningitis
less likely given absence of nuchal rigidity and photobia. Had
failed LP x3, was placed on meningitis ppx with
linezolid/ctx/acyclovir until cleared by neuro with exam with no
focal deficits. Head CT negative. Agiation initially required
physical and pharmacological restriants. Currently, alert and
oriented times three and full insight but has waxing and [**Doctor Last Name 688**].
Patient may benefit from outpatient psych.
.
# Resolved Urinary tract infection - [**6-24**] from rehab had
pan-sensitive E coli UTI that was being treated with imipeniem
for unclear reasons. Had foley placed in ED. Patient's repeat UA
on [**6-29**] was clean, IV ceftriaxone was stopped after 5d course.
.
# Stage 2 sacral decubti - stable, not superinfected
.
# Chronic diarrhea - has been worked up throughly by GI in the
past. C diff negative again on this admission. Symptomatic
treatment with loperamide
.
# Kidney Transplant/Acute renal failure: Status post failed LLRT
in [**2116**], second LRRT in [**2135**], and on prednisone, tacrolimus and
sirolimus as outpatient. Had tacrolimus dose decreased from 4 mg
to 2 mg po bid during last admission. Transplant team following.
Cr above baseline of 1.4. Function progressively improving.
Continued tacrolimus and prednisone. Renal transplant to follow
up as outpatient to determine restarting serolimus.
.
# chronic sCHF/CAD, EF 25%: Had troponin leak on this
presentation, but setting of ARF. Completed ROMI. Echo from
[**2144-6-5**] shows severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild mitral regurgitation.
Moderate pulmonary hypertension. Had CHF AE admission on [**2144-6-13**].
CAD s/p myocardial infarction, s/p angioplasty with PCI.
Continue aspirin 81, metoprolol, atorvastatin.
.
# Diabetes mellitus, type 1, moderately controlled: continue
ISS. [**Last Name (un) **] assisting but not formally consulting since he is
dictating his own insulin dosages.
.
# ? hx of skin ca - unclear diagnosis. Patient should have
outpatient derm for hx of skin cancers and now off serolimus.
.
# HTN - well controlled on diruetics and metoprolol
.
# CVA in [**2131**] - cont ASA 81
.
# GERD - on pantoprazole 40mg PO daily
.
# Code: DNI/DNR, discussed with patient
Medications on Admission:
Loperamide 2 mg PO q8hr
Flomax 0.4mg PO qHS
Atorvastatin 20mg PO Daily
Finasteride 5mg PO Daily
Sirolimus 1mg PO Daily
Aspirin 81mg PO Daily
Metoprolol 12.5 mg PO BID
Isosorbide mononitrate 60mg PO Daily
Pantoprazole 40mg PO Daily
Furosemide 80mg IV Daily
Furosemide 40mg PO Daily
Tacrolimus 2mg PO BID
Morphine 4-8mg IV prn pain
Prednisone 4mg PO Daily
KCl 20 mEq PO Daily
Alprazolam 0.5mg PO TID
Percocet q6hr prn
Glargine 8u SQ Daily
Lispro ISS
Pacrelipase 1cap PO w/ meals and qHS
Imipenem 500mg IV q8hr
Haldol 5mg PO q4hr prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for anxiety.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for breakthru pain.
17. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20)
units Subcutaneous at bedtime.
18. Humalog 100 unit/mL Cartridge Sig: per sliding scale units
Subcutaneous four times a day.
19. Sodium Polystyrene Sulfonate 15 g/60 mL Suspension Sig: Two
(2) mg PO ONCE (Once) for 1 doses.
20. Tobramycin Sulfate 40 mg/mL Solution Sig: One [**Age over 90 11578**]y
(180) mg Injection Q48H (every 48 hours) for 6 weeks: course
finishes on [**2144-8-17**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] health care east region
Discharge Diagnosis:
Primary:
R BKA stump infection with osteomyelitis and closure
resolved urinary tract infection
resolved altered mental status
.
Secondary:
Stage 2 sacral decubti
chronic sCHF EF 25%
Chronic diarrhea
s/p renal transplant
Diabetes mellitus, type 1, moderately controlled
Discharge Condition:
stable, on antibiotics
Discharge Instructions:
You were admitted for an infection of your right BKA stump and
the underlying bone and a urinary tract infection causing
altered mental status. You initially were treated in the
intensive care unit for your mental status and were given
ceftriaxone antibiotic for you urinary tract infection for five
days. You underwent two surgical procedures, on [**2144-7-1**]
debridement right BK stump and [**2144-7-6**] debridement, primary
closure R BKA. You had a wound vac placed to improve wound
healing. Your blood sugars were better controlled as your
insulin regimen was increased. You are to continue Tobramyicin
as your antibiotic for six weeks for the treatment of your bone
infection.
.
Please take all medications as prescribed and go to all
scheduled follow up appointments. Your dosage of tobramycin will
be adjusted based on trough levels. Sirolimus was stopped.
.
Please return to the hospital if you develop altered mental
status, fevers, or another infection at your stump site. Please
be compliant with your diabetic diet and take your insulin as
per your sliding scale.
.
Follow up:
Dr. [**Last Name (STitle) 1391**] - Vascular surgery on [**2144-8-12**] at 1:00pm at [**Last Name (NamePattern1) **]. Suite 5C in [**Hospital Unit Name **].
.
Renal transplant:Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2144-7-30**] 9:20
.
Dermatology:Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2144-9-8**] 1:15
.
Infectious Disease: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2144-8-14**] 9:30
Followup Instructions:
Dr. [**Last Name (STitle) 1391**] - Vascular surgery on [**2144-8-12**] at 1:00pm at [**Last Name (NamePattern1) **]. Suite 5C in [**Hospital Unit Name **].
.
Renal transplant:Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2144-7-30**] 9:20
.
Dermatology:Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2144-9-8**] 1:15
.
Infectious Disease: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2144-8-14**] 9:30
Completed by:[**2144-7-8**]
|
[
"V58.67",
"250.63",
"272.4",
"707.19",
"362.01",
"995.92",
"996.81",
"599.0",
"416.8",
"428.22",
"038.9",
"414.01",
"250.53",
"787.91",
"530.81",
"357.2",
"730.26",
"997.62",
"V45.82",
"584.9",
"707.03",
"428.0",
"440.20",
"V12.54",
"682.6",
"585.9",
"412",
"041.4",
"707.22",
"V49.75"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.56",
"84.3"
] |
icd9pcs
|
[
[
[]
]
] |
13945, 14011
|
7383, 8876
|
342, 471
|
14324, 14349
|
3892, 7360
|
16109, 16753
|
3177, 3206
|
12046, 13922
|
14032, 14303
|
11491, 12023
|
14374, 15455
|
3221, 3873
|
15466, 16086
|
226, 304
|
499, 2269
|
8891, 11465
|
2291, 2973
|
2989, 3161
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,478
| 143,019
|
17559
|
Discharge summary
|
report
|
Admission Date: [**2183-4-1**] Discharge Date: [**2183-4-8**]
Date of Birth: [**2108-1-11**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 25067**] is a 75-year-old man
with known coronary artery disease status post coronary
artery bypass grafting x 3 in [**2173**]. The patient underwent
percutaneous transluminal coronary angioplasty of the left
anterior descending coronary artery last month due to
recurrent angina. The patient presented on [**2183-3-30**] to an
outside hospital with increased chest pain. Cardiac
catheterization showed tortuous but patent left internal
mammary artery graft to the left anterior descending coronary
artery. An attempt to stent the left anterior descending
coronary artery was unsuccessful due to restenosis. The
patient at that time had 3/10 chest pain on IV heparin and
nitroglycerin drip. The patient had increased ST segment
elevation in V2 and V3. The patient had a left ventricular
ejection fraction of 50%.
PAST MEDICAL HISTORY: 1. Coronary artery bypass grafting x 3
in [**2173**]. 2. Noninsulin dependent diabetes mellitus. 3.
Hypercholesterolemia. 4. Status post prostate surgery. 5.
Status post hernia repair.
SOCIAL HISTORY: No tobacco or alcohol history.
MEDICATIONS AT HOME: 1. Glucotrol 10 mg b.i.d. 2.
Glucophage 1,000 mg b.i.d. 3. Enteric-coated aspirin 325 mg
q.d. 4. Cozaar 50 mg q.d. 5. Imdur 60 mg q.d. 6. Plavix 75
mg q.d. which was received on the morning of admission at the
outside hospital. 7. Nitroglycerin paste 1 inch q. 4. 8.
Regular Insulin sliding scale. 9. Pepcid 10 mg b.i.d. 10.
Lopressor 50 mg b.i.d. 11. Heparin drip.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Neurological: Awake, alert. Neck:
No carotid bruits noted. Lungs: Clear to auscultation
bilaterally. Cardiac: Regular rate and rhythm, normal S1
and S2, no murmurs noted. Abdomen: Benign. Extremities:
Warm, no edema, no varicosities. Previous saphenous vein
harvest per the right leg visible.
HOSPITAL COURSE: The patient was admitted on [**2183-4-1**] with a
diagnosis of a small myocardial infarct. On [**2183-4-4**] the
patient was taken to the operating room where a redo coronary
artery bypass grafting was performed within left internal
mammary artery to left anterior descending coronary artery,
saphenous vein graft to obtuse marginal and saphenous vein
graft to posterior descending coronary artery.
Postoperatively the patient required a propofol drip. He was
transferred to the cardiothoracic surgical intensive care
unit in good condition. He had chest tubes and pacing wires
in place. Postoperatively the patient was started on beta
blockers, Imdur and Plavix, as well as Losartan, isosorbide
and Lasix. At the appropriate times the patient's chest
tubes and pacing wires were removed.
In the intensive care unit the patient experienced a
short-lived increase in creatinine. Otherwise his stay in
the intensive care unit was relatively uneventful. The
patient was transferred to the regular cardiothoracic floor
where he continued to do well. He was visited by physical
therapy who over the course of the patient's stay here were
pleased with his progress and cleared him to be discharged
home.
It is now [**2183-4-8**]. It is anticipated that the patient will
be discharged today provided that he voids post Foley
catheter removal. If so the patient will be discharged in
good condition.
FOLLOW UP: He was to follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in
four weeks, Dr. [**Last Name (STitle) 48970**] [**Name (STitle) 7659**] in one to two weeks, and
Dr. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] in two to three weeks.
DISCHARGE INSTRUCTIONS: The patient may shower but may not
take baths. The patient should not drive while on pain
medications. The patient should avoid strenuous activity.
The patient may observe a heart healthy diabetic diet.
DISCHARGE MEDICATIONS:
1. Metformin 1,000 mg p.o. b.i.d.
2. Insulin sliding scale.
3. Flomax 0.4 mg p.o. q.h.s.
4. Percocet 1-2 tablets p.o. q. 4 p.r.n. pain.
5. Glipizide 10 mg p.o. q.d.
6. Enteric-coated aspirin 325 mg p.o. q.d.
7. Ranitidine 150 mg p.o. b.i.d.
8. Losartan 50 mg p.o. q.d.
9. Docusate sodium 100 mg p.o. b.i.d. p.r.n.
10. Potassium 20 mEq p.o. q. 12 for seven days.
11. Lasix 20 mg p.o. q. 12 for seven days.
12. Plavix 75 mg p.o. q.d.
13. Isosorbide mononitrate 60 mg p.o. q.d.
14. Lopressor 50 mg p.o. b.i.d.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1332**]
MEDQUIST36
D: [**2183-4-8**] 10:58
T: [**2183-4-8**] 11:13
JOB#: [**Job Number 48971**]
|
[
"V45.81",
"410.91",
"250.00",
"414.01",
"V64.1",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.12",
"39.61",
"36.15",
"88.72",
"37.22",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
4042, 4813
|
2085, 3490
|
3813, 4019
|
1309, 1740
|
3502, 3788
|
1763, 2067
|
182, 1025
|
1048, 1238
|
1255, 1287
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,721
| 139,628
|
9664+56055
|
Discharge summary
|
report+addendum
|
Admission Date: [**2136-6-11**] Discharge Date: [**2136-6-20**]
Date of Birth: [**2078-3-24**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Recurrent abdominal pain.
Major Surgical or Invasive Procedure:
Cholecystectomy with common bile duct exploration and
choledochotomy and choledochoenterostomy [**2136-6-12**].
History of Present Illness:
The patient is a 58year old male with longstanding HIV/AIDS and
Hepatitis C Co-infection complicated by a history of
non-adherence with HAART. He had been admitted in the hospital
in [**Month (only) 958**] initially with cholangitis at which time he underwent
an ERCP with sphincterotomy and stent placement. He failed to
follow up as scheduled and repeat ERCP was ultimately done with
a stent change for continued stones throughout the external
hepatic duct and again, a stent was placed. After that, he was
referred for cholecystectomy. Given the extent of stone disease,
stone burden would likely to be difficult to clear again with
ERCP and common bile duct exploration, therefore, indicated.
Again, because of his history of noncompliance, it would be
difficult to place a T-tube in
this patient, expect him to follow up and, therefore, likely a
biliary bypass is anticipated.
Past Medical History:
PMHx: HIV/AIDS diagnosed in [**2109**], Chronic Hepatitis C,
choledocholithiasis, cholelithiasis, polysubstance abuse
(heroin, cocaine, phenergan, benzodiazepine)on methadone
maintenance, pyschiatric problems.
PSHx: s/p ERCP with sphincterotomy and stent placement.
Social History:
Lives alone, divorced, 27 year old daughter, father died [**2-27**],
mother died 3 years ago, last worked in [**2107**]. Now on SSI
disability due to HIV/AIDS. History of heavy alcohol abuse, but
none for years. Heroin abuse, currently on Methadone
maintenance. Remote occassional cocaine use. Tobacco [**1-20**] PPD x
30years. History of multiple male and female sexual partners.
Family History:
Father died of Alzheimer's at age 87. Mother died of multiorgan
failure and DM
Physical Exam:
AVSS/afebrile.
GEN: NAD
HEENT: AT/NC, EOMI, neck supple, trachea midline, no scleral
icterus
CV: RRR
RESP: CTAB
ABD: S/ND, mild tenderness to palpation peri-umbilical; small
1-2cm midportion of wound open; packing
EXT: no C/C/E
PSYCH: A+Ox3; affect appropriate.
Pertinent Results:
[**2136-6-11**] 09:15PM WBC-4.8 LYMPH-19 ABS LYMPH-912 CD3-79 ABS
CD3-722 CD4-5 ABS CD4-50* CD8-72 ABS CD8-658 CD4/CD8-0.08*
[**2136-6-11**] 03:33PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2136-6-11**] 03:33PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-[**6-27**]
[**2136-6-11**] 03:30PM GLUCOSE-89 UREA N-34* CREAT-1.6* SODIUM-137
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14
[**2136-6-11**] 03:30PM ALT(SGPT)-40 AST(SGOT)-48* ALK PHOS-211*
AMYLASE-98 TOT BILI-0.5
[**2136-6-11**] 03:30PM LIPASE-28
[**2136-6-11**] 03:30PM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-2.1
[**2136-6-11**] 03:30PM WBC-4.8 RBC-3.69* HGB-12.1* HCT-34.8* MCV-94
MCH-32.9* MCHC-34.8 RDW-15.3
[**2136-6-11**] 03:30PM PLT COUNT-227
[**2136-6-11**] 03:30PM PT-12.1 PTT-24.4 INR(PT)-1.0
.
[**2136-6-11**] Radiology Report CHEST (PRE-OP PA & LAT):
Cardiomediastinal contours are normal. There is no evidence of
pneumonia, CHF, pleural effusion or pneumothorax.
.
[**2136-6-12**] PATHOLOGY:
SPECIMEN SUBMITTED: GALLBLADDER STONES, gallbladder.
DIAGNOSIS:
I. Gallbladder:
1. Acute and chronic cholecystitis.
2. Cholelithiasis, cholesterol type.
II. Gallbladder stones: Calculi, gross examination only.
Clinical: Cholelithiasis.
Gross:
The specimen is received fresh in two parts, each labeled with
the patient's name, "[**Known firstname **] [**Known lastname 4711**]", and the medical record
number.
Part 1 is additionally labeled "gallbladder". It consists of a
gallbladder specimen which measures 8 cm x 5 x 2 cm. The surface
of the gallbladder is smooth and erythematous. The cystic duct
is identified and is probe patent. No cystic duct lymph node is
identified. The specimen is opened to reveal approximately 10 cc
of bile and small cholesterol type stones measuring in aggregate
3 x 3 x 2 cm. The mucosa is hemorrhagic and granular. The
gallbladder wall measures up to 0.6 cm in thickness.
Representative sections are submitted as follows: A=cystic duct,
B= gallbladder neck, body and fundus.
Part 2 is additionally labeled "gallbladder stones". It consists
of multiple cholesterol type stones measuring in aggregate 3 x
1.2 x 1 cm. The specimen is for gross diagnosis only.
Brief Hospital Course:
The patient was admitted on [**2136-6-11**] to the General Surgical
Service for evaluation and treatment of the aforementioned
problem. [**Name (NI) **] underwent pre-operative screening and initial Acute
Pain Service consult, given outpatient methadone maintenance.
Made NPO after midnight. On [**2136-6-12**], the patient underwent
cholecystectomy with common bile duct exploration and
choledochotomy and choledochoenterostomy, which went well
without complication (reader referred to the Operative Notes for
details). After a brief, uneventful stay in the PACU, the
patient was transferred tothe ICU given the patient's
post-operative pain control needs NPO with a NG tube in place,
on IV fluids, IV Cipro and Flagyl, and a foley catheter. For
pain post-operatively, the patient received a Ketamine IV drip,
Dialudid PCA, a clonidine patch, and was started on low-dose IV
Methadone for pain control. The patient was hemodynamically
stable.
[**2136-6-13**]: Due to inadequate pain control, the patient was brought
to the PACU, where a Bupivacaine epidural was placed. Dilaudid
PCA, IV Methadone, clonidine patch, and IV Ketamine infusuion
were also continued with improved pain control. Lorazepam was
given PRN for agitation. The patient did require upper extremity
limb restraints due to heavy sedation to prevent the patient
from pulling at tubes and drains. Acute Pain Service continued
to follow the patient until transferredto the Chronic Pain
Service; their recommendations were appreciated and followed.
[**2136-6-14**]: The NG tube was discontinued. The patient was restarted
back on PO medications, including HAART. IV fluids reduced to
maintenance. IV Ketamine and IV Methadone discontined; Dilaudid
PCA, Bupivacaine epidural, and Clonidine patch continued with
Methadone PO and Tizanidine started with good pain control. The
patient no longer required Ativan or restraints for agitation
and sedation. He remained hemodynamically stable, and was
transferred to the floor.
[**2136-6-15**]: Started on sips with good tolerability. Started on a
bowel regimen. Dilaudid PCA discontined; changed to Dilaudid PO
PRN. Pain remained well controlled. Ambulated.
[**2136-6-16**]: Diet advanced to clears with good tolerability.
Bupivacaine epidural discontinued. Foley discontinued six hours
after epidural out; patient voided without problem.
[**2136-6-17**]: Diet advanced to clear liquids. IV saline locked for
good PO intake. Chronic Pain Service consulted; recommendations
appreciated and followed. Due to increased pain with
discontinuation of epidural and PCA, Methadone PO dose increased
to 50mg TID, and Gabapentin and Ketamine IV PRN added with good
effect. Psychiatry in for initial consult given patient's
history of chronic psychiatric issues, and anticipated need for
psychiatric care post-discharge. Social Work continues to
follow.
[**2136-6-18**]: Diet advanced to regular with good tolerability. Chronic
Pain Service in for follow-up consult to plan for post-discharge
pain control; patient tapered Dilaudid use. Tolerating a regular
diet. Ambulating frequently. Social Work and Psychiatry continue
to follow.
[**6-19**]: Pt medically cleared for discharge, does not need any
further inpatient medical/surgical care. He is tolerating a
regular diet, does not require IV abx or medications, is
ambulating without assistance and his pain is controlled with
oral medications. His only medical requirement are dressing
changes to his surgical wound with moist gauze twice daily.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
CITALOPRAM - 10 mg Tablet - 1(One) Tablet(s) by mouth once a day
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1
(One) Tablet(s) by mouth once a day
LOPINAVIR-RITONAVIR [KALETRA] - 200 mg-50 mg Tablet - 2 (Two)
Tablet(s) by mouth twice a day
METHADONE - (Prescribed by Other Provider) - 10 mg Tablet - 14
Tablet(s) by mouth once a day
TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM] - 1 tab PO daily for PCP
Prophylaxis
MULTIVITAMIN [MULTIPLE VITAMIN] - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
2. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QWEEK ON
FRIDAYS ().
Disp:*10 Tablet(s)* Refills:*2*
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary:
Cholelithiasis and choledocholithiasis.
Secondary:
1. HIV/AIDS
2. Acute on chronic pain
3. Mood Disorder
4. HIV Dementia
Discharge Condition:
Stable.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-27**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call ([**Telephone/Fax (1) 32682**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 32683**] (PCP) in 2 weeks.
Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment
with Dr. [**First Name (STitle) **] (Surgery) in 2 weeks.
Completed by:[**2136-6-20**] Name: [**Known lastname 5672**],[**Known firstname **] Unit No: [**Numeric Identifier 5673**]
Admission Date: [**2136-6-11**] Discharge Date: [**2136-6-20**]
Date of Birth: [**2078-3-24**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3149**]
Addendum:
The patient was accepted at the [**Location (un) 5674**] Psychiatric Unit at
[**Hospital 1263**] Hospital. Again, he will have saline moist-to-dry
packing applied to a small incisional wound at the lower aspect
of the midline incision twice daily until resolved. Incision
care otherwise as documented. Staples will be removed at the
patient's follow-up appointment with Dr. [**First Name (STitle) **] (Surgery), which
will need to be scheduled in one week. Discharge summary as
amended herein, otherwise unchanged.
Discharge Medications:
1. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
2. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QWEEK ON
FRIDAYS ().
Disp:*10 Tablet(s)* Refills:*2*
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Methadone 10 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
13. Tizanidine 4 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for muscle spasm.
14. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTUES (every Tuesday) as needed for Pain.
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Cholelithiasis and choledocholithiasis.
Secondary:
1. HIV/AIDS
2. Acute on chronic pain
3. Depression with paranoia
4. Cognitive disorder
5. Small incisional wound
Discharge Condition:
Stable.
Followup Instructions:
Please call ([**Telephone/Fax (1) 5675**] to schedule a follow-up appointment
with Dr. [**First Name (STitle) **] (Surgery) in 1 week. Staples will be removed at
this appointment.
Please call ([**Telephone/Fax (1) 5676**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 5677**] (PCP) in 2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 3151**]
Completed by:[**2136-6-20**]
|
[
"296.90",
"294.10",
"042",
"304.01",
"338.18",
"305.1",
"305.60",
"574.70",
"297.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.36",
"51.22",
"97.55",
"51.41"
] |
icd9pcs
|
[
[
[]
]
] |
14816, 14831
|
4690, 8528
|
297, 411
|
15049, 15059
|
2409, 4667
|
15082, 15557
|
2031, 2112
|
13327, 14793
|
14852, 15028
|
8554, 9047
|
10157, 11612
|
11628, 12118
|
2127, 2390
|
232, 259
|
439, 1325
|
1347, 1616
|
1632, 2015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,126
| 115,476
|
15386
|
Discharge summary
|
report
|
Admission Date: [**2165-3-2**] Discharge Date: [**2165-3-4**]
Date of Birth: [**2131-12-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
33 year old man with a history of HIV (last CD4 1003 [**2-4**]) and
polysubstance abuse, presents with apnea, cyanosis, and hypoxia
after doing "poppers" (amyl nitrate) with friends. Apparently,
the patient was at a party with a large supply of amyl nitrate.
He mistakenly ingested the amyl nitrate; was also drinking
alcohol and smoking cocaine during this time. His friends
noticed he became altered and called EMS, who brought him to the
ED.
.
In the ED, initial vs were: 97 122 123/75 86%NRB. Patient had 2
PIVs 18G placed. He was apneic and lethargic and given 2.4mg of
narcan with minimal response. He desated to the 85-89% on NRB
and was given etom and succ and intubated easily with 8.0. He
was given fentanyl and versed ( 200mcg and 7 mg) for sedation
and 10mg vecuronium IV ONCE. Patient was found to have evidence
of methemoglobinemia on labs. He was seen by toxicology who
recommended methylene blue 1mg/kg. Patient was given 4L NS and
neosynephrine transiently for hypotension to the 70s, but this
was stopped after pressures normalized. Last set of vitals: 125,
128/48 no pressors, 98% on AC 500, 18, peep 5.
.
On the floor, the patient remains intubated and sedated but
responsive and denies pain. His methemoglobinemia was still
noted to be elevated at 5, and therefore was given a second dose
of methylene blue at 1mg/kg.
.
Review of systems:
Unable to obtain. Per family no complaints. He is a very private
person.
Past Medical History:
1) HIV, last CD4 count 1,003 [**2-4**] - on Atripla, last VL unknown
2) Alcohol abuse - multiple ED admissions for intoxication
3) Marijuana abuse
4) Chronic back pain, seen by pain clinic
5) h/o klonopin abuse
6) Tobacco abuse (14 pack year)
7) Depression
8) s/p ex-lap [**2155**] after stabbing incident
Social History:
MSM. Patient currently on disability for back pain. Has smoked
1 PPD for past 14 years. Has 15-20 beers per day vs. 5 half
pints of vodka per day. Has history of marijuana use, recent
cocaine use. Denies IVDU.
Family History:
Diabetes. No history of TB.
Physical Exam:
PE on admission to MICU:
General: Intubated, sedated, responsive young man in NAD
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
Discharge Exam:
VS: 98.9 132/78 98 20 96% RA
GENERAL: resting in bed, pleasant, NAD
HEENT: NCAT, sclera anicteric, MMM
NECK: supple, no cervical LAD
CARDIAC: RRR, no r/m/g
LUNGS: CTAB, no wheezes, crackles, rhonchi
ABDOMEN: bowel sounds present, soft, NT, ND, no
hepatosplenomegaly, well-healed vertical incision scar, RUQ
incision scar
EXTREMITIES: warm, DT/PT/radial pulses 2+ bilaterally, no edema
NEURO: AAOx3, moving all four extremities
SKIN: excoriations on upper back, no other rashes noted
Pertinent Results:
ADMISSION LABS:
[**2165-3-2**] 05:33AM WBC-17.5* LYMPH-17* ABS LYMPH-2975 CD3-56
ABS CD3-1668 CD4-46 ABS CD4-1379* CD8-9 ABS CD8-270 CD4/CD8-5.1*
[**2165-3-2**] 05:31AM LACTATE-5.6*
[**2165-3-2**] 05:31AM HGB-15.3 calcHCT-46 O2 SAT-43 CARBOXYHB-6*
MET HGB-43*
[**2165-3-2**] 05:33AM FIBRINOGE-272
[**2165-3-2**] 05:33AM PLT COUNT-340
[**2165-3-2**] 05:33AM PT-12.4 PTT-19.3* INR(PT)-1.0
[**2165-3-2**] 05:33AM ASA-NEG ETHANOL-250* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-3-2**] 05:33AM ALBUMIN-4.8 CALCIUM-8.7 PHOSPHATE-5.0*
MAGNESIUM-2.5
[**2165-3-2**] 05:33AM CK-MB-3 cTropnT-<0.01
[**2165-3-2**] 05:33AM LIPASE-31
[**2165-3-2**] 05:33AM ALT(SGPT)-45* AST(SGOT)-48* CK(CPK)-303 ALK
PHOS-57 TOT BILI-0.2
[**2165-3-2**] 05:33AM GLUCOSE-186* UREA N-16 CREAT-1.6*
[**2165-3-2**] 05:45AM URINE HYALINE-[**12-15**]*
[**2165-3-2**] 05:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-1
[**2165-3-2**] 05:45AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
DISCHARGE LABS:
[**2165-3-4**] 06:25AM BLOOD WBC-8.2 RBC-4.35* Hgb-13.7* Hct-39.0*
MCV-90 MCH-31.5 MCHC-35.1* RDW-13.1 Plt Ct-293
[**2165-3-4**] 06:25AM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-140
K-4.1 Cl-106 HCO3-23 AnGap-15
IMAGING:
[**2165-3-2**] EKG: Sinus tachycardia. Baseline artifact. Poor R wave
progression. Non-specific
ST-T wave changes. Compared to the previous tracing of [**2157-5-6**]
baseline artifact is more pronounced.
[**2165-3-2**] CXR:
1. Low lung volumes.
2. Retrocardiac opacity concerning for aspiration.
3. Endotracheal tube in appropriate position.
4. NG tube with tip below GE junction, not clearly visualized
probably
projecting at the stomach.
[**2165-3-3**] CXR: Pulmonary vascular engorgement has resolved. Heart
size is normal. There is
no focal pulmonary abnormality or pleural effusion.
Brief Hospital Course:
33yo male with history of HIV and polysubstance abuse, admitted
with apnea and hypoxia in setting of methemoglobinemia after
ingestion of amyl nitrate.
#) Methemoglobinemia: Almost certainly secondary to amyl nitrate
toxicity. A level of 43 was moderately severe, and toxicology
was consulted. Amyl nitrate is a well known hemoglobin oxidizer
per toxicology, and explains the patients hypoxemia and altered
mental status. Received two treatments of methylene blue
(1mg/kg) and methemoglobin levels trended down to within normal
limits. Patient was initially intubated secondary to his altered
mental status, apnea, and hypoventilatory hypoxia, but was
improved rapidly after treatment and was extubated on [**2165-3-2**].
He was stable for transfer to medicine floor on [**2165-3-3**], and
respiratory status remained stable for remainder of his hospital
course.
.
#) Lactic acidosis: Most likely secondary to reduced O2
delivery, secondary to methemoglobinemia. Resolved with
correction with methylene blue.
.
#) Leukocytosis: WBC elevated at 17.5 on presentation. Given
finding of retrocardiac opacity on CXR with air bronchograms,
was concern for an aspiration pneumonitis or aspiration PNA.
Ceftriaxone 1gm IV Q24H and Azithromycin 500mg PO Q24H were
started. However, subsequent CXR showed that areas of
atelectasis had improved, and antibiotics were discontinued
[**2165-3-3**]. Patient's WBC continued to trend down, and was within
normal limits on day of discharge.
.
#) Depression/History of Suicidal Ideation: Patient with history
of depression and polysubstance abuse. He recently told mother
his back pain was so severe that he wanted to kill himself.
Initially, it was unclear if this incident was secondary to
lapse in judgement or a suicidal attempt. Psychiatry consulted
on [**2165-3-3**], and did not feel patient had suicidal or homicidal
ideation. Per psych recs, patient restarted on zoloft 25mg
daily at time of discharge. He will follow-up with his PCP, [**Name10 (NameIs) 1023**]
will likely be able to coordinate outpatient pysch follow-up at
[**Hospital6 **] Center.
.
#) [**Last Name (un) **]: Patient's Cr elevated at 1.6 on presentation. Was most
likely prerenal, and [**Last Name (un) **] promptly resolved with fluids.
.
#) HIV: Last known CD4 was 1003 in 1/[**2164**]. Patient had not been
taking Atripla as directed, and of note his family was unaware
of his diagnosis. His CD4 count, viral load, and HIV genotype
were checked, with results still pending at time of discharge.
Patient discharged on Atripla, and will follow-up with PCP next
week.
.
#) Transaminitis: Chronic. Most likely secondary to alcoholism,
although, ALT/AST ratio not consistent. Patient had hepatitis
serologies sent, which were still pending at time of discharge.
Will follow-up with PCP.
.
#) Alcoholism: Patient has history of heavy alcohol abuse, and
reports having up to 15-20 beers per day. Last drink was just
prior to admission. He received a banana bag on admission, and
was continued on thiamine, folic acid, and MVI. He was
monitored per CIWA protocol, and did receive diazepam in setting
of mild anxiety, restlessness, and tachycardia. No evidence of
severe withdrawal including DT. Social work was consulted, and
patient was also seen by substance abuse nurse. He was strongly
encouraged to seek to treatment, but declined any inpatient
treatment/detox programs at this time. Was given information
about potential programs and hotlines.
.
#) Cocaine abuse: Patient endorsed use of crack cocaine the
night before admission, and tox screen positive for cocaine.
Social work and substance abuse RN consulted as above.
LABS PENDING AT TIME OF DISCHARGE:
-HIV viral load
-CD4 count
-Hepatitis B, C serologies
-HIV genotype
TRANSITIONAL ISSUES:
-Patient was a full code during this admission
-Patient was counseled about polysubstance abuse as above, will
need outpatient follow-up with PCP, [**Name10 (NameIs) **] work, psych
Medications on Admission:
1) Atripla 1 tab PO daily
Discharge Medications:
1. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
2. Zoloft 25 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Methemoglobinemia secondary to amyl nitrate
ingestion
Secondary Diagnoses: Polysubstance abuse, HIV, depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
You were admitted to the hospital after you ingested amyl
nitrate (Poppers) at a party, which caused your oxygen levels to
drop dangerously low and also caused you to stop breathing for
periods of time. You were diagnosed with a condition called
methemoglobinemia, in which your blood is unable to carry enough
oxygen to the rest of your body. You were treated with a
substance called methylene blue, which helps to reverse this
condition. You initially had to be admitted to the ICU because
you required a breathing tube, but we were able the take this
tube out later that night. Your breathing significantly
improved, and your oxygen levels returned to [**Location 213**].
We are very concerned about your tobacco, alcohol, and drug use,
and strongly urge you to seek treatment with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 27299**] after you leave the hospital. You were
seen by the psychiatry team, and also the substance abuse nurse,
while you were in the hospital.
They gave you information about the LARK program at the [**Hospital1 **]
(an inpatient 3 month program for people with HIV and
addiction), and also spoke with you about other resources at the
[**Hospital 778**] Health Center. They gave you a Self Help Fact Sheet with
a 24 hour hot line number to call if you need to. It is very
important that you follow-up with your doctor for treatment, in
order to prevent another life-threatening event.
While you were here, we made the following changes to your
medications:
1. STARTED Zoloft
2. CONTINUED Atripla
Please follow-up with Dr. [**Last Name (STitle) **] in clinic.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] C.
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within 1 week. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.
You also have an appointment scheduled with him for [**2165-3-19**].
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
|
[
"305.60",
"584.9",
"311",
"305.20",
"305.1",
"288.60",
"289.7",
"458.9",
"338.29",
"972.4",
"303.01",
"V08",
"E858.3",
"518.81",
"724.5",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9660, 9666
|
5382, 9136
|
326, 351
|
9842, 9842
|
3464, 3464
|
11674, 12342
|
2392, 2421
|
9417, 9637
|
9687, 9687
|
9366, 9394
|
9993, 11651
|
4546, 5359
|
2436, 2940
|
9782, 9821
|
2956, 3445
|
9157, 9340
|
1740, 1814
|
265, 288
|
379, 1721
|
3480, 4530
|
9706, 9761
|
9857, 9969
|
1836, 2144
|
2160, 2376
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,829
| 170,154
|
54363
|
Discharge summary
|
report
|
Admission Date: [**2120-8-25**] Discharge Date: [**2120-9-10**]
Service: SURGERY
Allergies:
Levofloxacin / Azithromycin / Amlodipine / Clobetasol
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Extended Right colectomy
History of Present Illness:
HPI: [**Age over 90 **] yo F w/ recent [**Hospital Unit Name 196**] amdit for fall, thigh hematoma,
supratherapeutic INR. GIB during admission, got ACS/NSTEMI. Now
7lbs lighter w/ dyspnea increased work of breathing. Was doing
ok at home but still not very mobile, last night got suddent
onset SOB, no CP, no cough while drinking Mgcitrate for prep.
Also endorses orthopnea, nocturia. Trop trending down, BNP up to
16k. EKG showed STD's deeper than prior, d-dimer 3100. Got CTA
in ED for ? PE as she has been off warfarin which was negative.
.
In [**Name (NI) **] pt. was noted to have crackles to apices bilaterally and
hypertensive to SBP 180s so she was given 1L IVF and admitted w/
CHF exacerbation.
.
On the floor her TWI/STD's appear to have decreased
.
In the ED, VS: 89, 181/110, 24, 99%2L
.
Currently, she complains of shortness of breath.
Past Medical History:
1. Atrial fibrillation, s/p cardioversion [**11-8**]
2. Congestive heart failure, EF 55%
3. Stroke [**9-/2098**]
4. Hypertension
5. Sciatica [**6-/2114**]
6. Aortic insufficiency [**6-/2113**]
7. Status post partial thyroidectomy [**2089**]
8. Stress incontinence
9. Hyperlipidemia
10. Osteoporosis
11. hypothyroidism
12. Glaucoma
Social History:
Lives with granddaughter, still driving and doing own shopping.
Occasional EtOH
Quit tobacco 30 years ago, smoked for 5 yrs in her late 60s.
Family History:
Non-contributory.
Physical Exam:
Vitals - T: 95.8 BP: 183/92 HR: 81 RR: 20 02 sat: 98%2L
GENERAL: Pleasant, well appearing woman in NAD, appears to be
somewhat labored breathing.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP at angle of the jaw.
LUNGS: Crackles to apices bilaterally
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Trace LE edema 2+ dorsalis pedis pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate.
Pertinent Results:
[**2120-8-25**] 07:15PM BLOOD WBC-11.2* RBC-4.11* Hgb-12.0 Hct-35.9*
MCV-87 MCH-29.2 MCHC-33.4 RDW-13.6 Plt Ct-405
[**2120-8-25**] 07:15PM BLOOD Neuts-87.7* Lymphs-6.8* Monos-4.3 Eos-0.6
Baso-0.6
[**2120-8-25**] 07:15PM BLOOD PT-12.4 PTT-22.2 INR(PT)-1.0
[**2120-8-25**] 07:15PM BLOOD Glucose-129* UreaN-15 Creat-0.8 Na-133
K-3.1* Cl-92* HCO3-32 AnGap-12
[**2120-8-26**] 07:50AM BLOOD Glucose-128* UreaN-14 Creat-0.8 Na-137
K-3.9 Cl-96 HCO3-30 AnGap-15
[**2120-8-25**] 07:15PM BLOOD CK(CPK)-38
[**2120-8-26**] 07:50AM BLOOD CK(CPK)-41
[**2120-8-25**] 07:15PM BLOOD cTropnT-0.03*
[**2120-8-26**] 07:50AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2120-8-25**] 07:15PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2120-8-26**] 07:50AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.7*
[**2120-8-25**] 09:38PM BLOOD D-Dimer-3136*
CHEST RADIOGRAPH PERFORMED ON [**2120-8-25**].
Comparison is made with a prior chest radiograph from [**2120-8-14**] as
well as a
prior CTA chest from [**2120-8-15**].
CLINICAL HISTORY: Shortness of breath. Question pneumonia.
FINDINGS: PA and lateral views of the chest are obtained.
Patient is rotated
to her right, which limits evaluation. Coarsened interstitial
markings are
again noted and may reflect underlying scarring, better assessed
on prior CT.
Areas of traction bronchiectasis in the right middle lobe likely
accounts for
the increased opacity seen in the right medial cardiophrenic
recess. Lungs
are hyperinflated. There is no definite evidence of pneumonia or
overt CHF.
No large pleural effusions are seen. Calcification of the
tracheobronchial
tree is noted. Cardiomediastinal silhouette is stable. There is
no
pneumothorax. Bones are diffusely demineralized. Degenerative
changes are
noted in the thoracic spine with kyphosis.
IMPRESSION: No definite evidence of pneumonia. Chronic changes
as described.
[**2120-8-25**] Wet read CT of chest: No PE, dissection or aneurysm.
Small bilateral pleural effusions.
Brief Hospital Course:
Patient is a [**Age over 90 **] year old woman with acute on chronic diastolic
heart failure. She presented to the emergency department with an
episode of shortness of breath after taking an entire bottle of
mag-citrate. During her admission she was diuresed with IV
lasix. Her shortness of breath improved to her baseline. She was
found on CT to have a stricture in the ascending colon. She is
scheduled for surgery on [**8-31**].
.
#CAD: Patient has a history of CHF. She had an NSTEMI/demand
ischemia event a few weeks ago in the setting of a GI bleed and
bowel prep. During the hospitalization she was continued on
aspirin, atorvastatin, and a beta-blocker. She had a slightly
elevated troponin which was likely residual from her previous
event.
.
#CHF: Patient was volume overloaded in the ED. We diuresed her
with several doses of IV furosemide. Her breathing and clinical
exam greatly improved. Patient was able to ambulate in the halls
without oxygen. We continued lisinopril throughout the hospital
stay. An echocardiogram showed an EF of > 55% with severe
pulmonary artery systolic hypertension.
.
#HTN: She presented to the ED hypertensive and was noted to have
labile blood pressure per clinic records. We switched her from
metoprolol to labetalol which was her previous home medication.
This resulted in improved BP control.
.
#AF: She had a history of atrial fibrillation. When she
presented, she was in sinus. During the hospitalization, her
rate became irregular with bigeminy and rapid ventricular
response. She was not anticoagulated given her recent episode of
bleeding. We continued her beta-blocker and amiodarone.
.
# GI: During the patient's recent hospitalization she was unable
to complete the bowel prep because of her NSTEMI/demand
ischemia. Her abdominal symptoms of bloating, cramping,
distention, and constipation worsened throughout this hospital
stay cosistent with a high grade partial obstruction. A CT scan
of the abdomen and pelvis showed a stricture in the ascending
colon. Both GI and surgery were asked to consult. She was
scheduled for surgery on [**8-30**].
______________________________
Ms. [**Name13 (STitle) 16490**] was taken to surgery on [**2120-8-31**] and underwent an
extended R colectomy. The operation itself went well.
Postoperatively, she was oliguric and hypotensive. She was
evaluated for MI and her EKGs and cardiac enzymes were
reassuring. On exam, she had no signs of heart failure and did
respond to IV fluids. On POD#1, her urine output increased but
her blood pressure remained low. She was transferred to the
VICU, and then to the SICU for close monitoring for her
asymptomatic hypotension and rapid heart rate requoring
medications and fluids. Her diet was advanced to clears and then
to regular diet after resumption of bowel function and after her
abdominal exam was reassuring. Pathology returned
adenocarcinoma T3 N1 M0 with 1/16 nodes involved.
She remained in the ICU until POD#4. She was transferred to the
floor. On POD#5, she started having small amounts of
hematochezia. She had tachycardia to 110-120s. Her Hct dropped
to 25. INR was elevated to 3.5 despite holding coumadin. This
was corrected with vit K and FFP. Over the next 2 days, the
bleeding continued, but at a slower rate, and she was given a
total of 4 units of blood. She was started on PPI and her ASA
was reduced from 325mg to 81mg. The bleeding stopped eventually,
and she had 6 stable Hcts above 30.
She had lower extremity edema which is quite a bit better at the
time of discharge.
She is discharged home with services and PT. She is tolerating a
regular diet though her appetite is somewhat depressed. She will
follow up in office with Dr. [**Last Name (STitle) **], her primary care doctor
and with Dr. [**Last Name (STitle) **] for check-up and skin clip removal.
Consideration for adjuvant chemotherapy will be addressed at GI
Oncology Conference, but it is unlikely that this will be
recommended, given her comorbidities.
Medications on Admission:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
9. Tylenol Arthritis 650 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO at bedtime.
10. Glucosamine-Chondroitin Complx 500-400 mg Capsule Sig: One
(1) Capsule PO once a day.
11. Synthroid 75 mcg Tablet Sig: One (1) Tablet PO once a day.
12. Ecotrin Low Strength 81 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*
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a
day.
Disp:*90 Tablet(s)* Refills:*2*
14. trazodone 25 mg po qhs prn insomnia; Disp: 30, Refills: 1
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 160 mg/5 mL Solution Sig: [**1-5**] PO Q6H (every 6
hours).
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for home regimen.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day: Take while taking narcotic pain medication to prevent
constipation.
Disp:*20 Tablet(s)* Refills:*0*
9. Amiodarone 100 mg Tablet Sig: [**1-5**] Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis: Carcinoma of the colon with obstruction
Secondary Diagnosis:
Acute on Chronic diastolic heart failure
Atrial fibrillation with rapid ventricular response
Post operative hypovolemia
Post operative blood loss anemia requiring transfusion
Coagulopathy
Hypertension
Dyslipidemia
Discharge Condition:
Stable
Discharge Instructions:
You may resume all your prehospital medications.
You may shower - pat wound dry afterward. No swimming or soaking
in a tub for 4 weeks after your surgery.
Call Dr.[**Name (NI) 1482**] office or come to the Emergency Room if you
have:
* fever above 101.5F
* nausea, vomiting or diarrhea that doesn't stop
* chest pain or difficulty breathing
* opening up or drainage from your wound
* any other concerning symptoms
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 mL
Followup Instructions:
In [**1-5**] weeks with Dr [**Last Name (STitle) **], please call [**Doctor First Name 1785**] at
[**Telephone/Fax (1) 2981**] to
schedule this appointment.
The following appointments have been made for you:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2120-9-10**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2120-9-10**] 1:30
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2120-9-11**] 7:40
Completed by:[**2120-9-9**]
|
[
"416.8",
"424.1",
"428.33",
"285.1",
"153.1",
"428.0",
"733.00",
"397.0",
"410.72",
"560.89",
"401.9",
"196.2",
"244.9",
"427.31",
"578.9",
"788.5",
"V12.54",
"276.52",
"272.4",
"458.29",
"782.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
10474, 10523
|
4348, 8328
|
280, 306
|
10862, 10870
|
2377, 4325
|
11464, 12079
|
1716, 1735
|
9578, 10451
|
10544, 10544
|
8354, 9555
|
10894, 11441
|
1750, 2358
|
221, 242
|
334, 1187
|
10625, 10841
|
10563, 10604
|
1209, 1541
|
1557, 1700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,183
| 146,306
|
20074
|
Discharge summary
|
report
|
Admission Date: [**2114-11-21**] Discharge Date: [**2114-12-12**]
Date of Birth: [**2048-7-14**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 66-year-old
Asian male who has a history of hypertension and was doing
yard work and had a syncopal event. He was admitted to
[**Hospital3 **] on [**2114-11-20**] and had an EKG which was
suspicious for an MI. He was started on Lopressor and
transferred to [**Hospital1 18**] for cardiac catheterization. He
underwent cardiac catheterization on [**2114-11-21**] which
revealed an ejection fraction of about 30% with 1-2+ MR,
anterior basal hypokinesis, anterolateral hypokinesis, apical
dyskinesis, and inferior and posterior basal hypokinesis.
His left main coronary artery showed 40-50% stenosis. His
left anterior descending artery had ostial and proximal
severe diffuse disease and was totally occluded after the
first diagonal. His left circumflex showed major OM with 40%
ostial lesion and a 70% distal stenosis. His right coronary
artery is dominant with a mid tubular 60% stenosis and a
distal 70% stenosis. He also had an echocardiogram which
revealed an EF of 50% and moderate to severe mitral
regurgitation. He was then referred for cardiac surgery.
PAST MEDICAL HISTORY:
1. History of hypertension.
2. History of pneumonia.
SOCIAL HISTORY: He lives at home with his wife. [**Name (NI) **] does not
smoke. He does not drink alcohol.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS: He did not taken any medications at
home but on transfer was taking Lopressor 25 mg p.o. b.i.d.
and aspirin 325 mg.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
a well-developed, well-nourished Asian male in no apparent
distress. The vital signs were stable. HEENT: PERRL, EOMI,
oropharynx benign with good dentition. His neck was supple
with a full range of motion. He had no lymphadenopathy or
thyromegaly. His carotids were 2+ and equal bilaterally
without bruits. His lungs were clear to auscultation
bilaterally. His heart revealed a regular rate and rhythm
without rub or gallop. There is a III/VI holosystolic
ejection murmur from the apex to the axilla. Abdomen:
Positive bowel sounds, soft, nontender, without masses or
hepatosplenomegaly. Extremities: Without clubbing, cyanosis
or edema. He had 2+ pulses bilaterally throughout.
Neurologic: Nonfocal.
LABORATORY/RADIOLOGIC DATA: On admission, white count 6.2,
hematocrit 41.3%, platelet count 539,000. Potassium 3.8, BUN
16, creatinine 1.2.
The EKG showed sinus rhythm in the 60s with ST elevations in
the inferior leads, ST elevations in V2, V3, and V6.
HOSPITAL COURSE: While awaiting surgery, he was seen by the
Electrophysiology staff in regards to his syncopal episode.
They did feel that his syncopal episode was consistent with a
possible vagal episode but they felt that they would rather
do EP studies following his CABG and at that point may or may
not place an AICD.
On [**2114-11-23**], he underwent coronary artery bypass
grafting times three with left internal mammary artery to
left anterior descending artery, saphenous vein graft to the
OM, and saphenous vein graft to the PDA. He also had a
mitral valve replacement with a #31 Carbomedics mechanical
valve and intra-aortic balloon pump placed intraoperatively.
This surgery was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], nurse practitioner as the assistant. The surgery
was performed under general endotracheal anesthesia with the
cardiopulmonary bypass time of 175 minutes and a cross-clamp
time of 154 minutes.
The patient was transferred to the Cardiac Surgery Recovery
Unit on epinephrine, milrinone, nitroglycerin, and propofol
in normal sinus rhythm, two atrial and two ventricular pacing
wires and two mediastinal and one left pleural chest tube.
In the immediate postoperative period the patient was noted
to have a nosebleed and increased chest tube drainage. He
was given Protamine, 1 unit of FFP, 4 units of packed cells,
and one dose of cryoprecipitate. He was noted to have
profound hypotension and underwent TEE which revealed
hypokinetic anterior wall but was actually better than the
immediate postoperative TEE.
On postoperative day number one, he remained sedated and
intubated. He continued on the milrinone drip and the
epinephrine drip was weaned to 0.01 micrograms. His
epinephrine drip was eventually weaned and discontinued
during that day. By postoperative day number two, his
milrinone was decreased and he was started on Lasix for
diuresis.
Also on postoperative day number two, his sedation was
lightened. He was able to move everything to commands but
became hypotensive and was eventually placed back on the
propofol drip.
By postoperative day number three, he was continued to be
hemodynamically stable after epinephrine with the milrinone
weaned down slightly. His intra-aortic balloon pump was
discontinued without incident. He continued to be sedated
and the ventilator was weaned. Also, on this day he was
noted to be in atrial flutter and an Amiodarone bolus was
given. He was almost cardioverted but converted to normal
sinus rhythm on his own. Also, his propofol was weaned to
off on this day.
Off the propofol, he was very slow to wake and remained
lethargic the following postoperative day but did follow
commands and move all extremities.
By postoperative day number four, the ventilator continued to
be very slowly weaned and his milrinone was decreased to
0.25. Later that day, he had paroxysmal atrial fibrillation
from which he converted to normal sinus rhythm and then a
junctional rhythm. He continued on Amiodarone and had
started on heparin.
On postoperative day number five, he had his chest tube
discontinued and he had a new left subclavian Cordis and Swan
placed. His chest x-ray did show a left-sided pneumothorax
and he did have a new chest tube inserted on that side which
showed reinflation of the left lung.
By postoperative day number six, his milrinone was
discontinued and he continued to have good cardiac function.
He was also extubated on postoperative day number six and
tolerated that well.
By postoperative day number seven, he was started on heparin
for anticoagulation for his atrial fibrillation and his
mechanical mitral valve. He was also transferred to the
surgical floor on this day and began more aggressive physical
therapy.
By postoperative day number eight, it was decided that his
Coumadin should be held in case the plan for EP study and
insertion of a ICD would be done this admission. He
continued to be treated with heparin and have his Coumadin
held while the Electrophysiology Service sorted out his
echocardiogram and decided when would be the best time to do
his studies. He did have a rise in his white blood cell
count on postoperative day number nine and cultures were
sent. His chest x-ray did show a left lower lobe
consolidation and he was started on levofloxacin.
On postoperative day number 11, he was complaining of throat
pain. He was noted to have a purulent exudate around his
uvula and he was started on Rocephin for that and his
Levaquin was discontinued. His Coumadin continued to be held
because his INR had bumped high and were waiting for it to
decreased to remove his pacing wires.
During that time, it was felt that he would not need to have
EP studies during this admission and the plan was for him to
return after discharge to see Dr. [**Last Name (STitle) 284**] for further
electrophysiology workup.
By postoperative day number 12, his INR had drifted down to
1.9 and his pacing wires were discontinued without incident.
He was restarted on his Coumadin and was awaiting elevation
of his INR to be discharged home.
Over the next week, he did receive doses of anywhere from 1-3
mg of Coumadin each time his INR would bump into the range of
5. The remainder of his hospital course was uncomplicated.
By the second attempt at anticoagulation, his INR drifted
down to 2.6 and he was started on 1 mg of Coumadin and was
discharged on this dose.
DISCHARGE EXAMINATION: Vital signs: Heart rate 74, blood
pressure 115/64, respirations 18, 02 saturation 98% on room
air. Lungs: Clear to auscultation bilaterally. Heart:
Regular rate and rhythm. Abdomen: Positive bowel sounds,
soft, nontender, nondistended. Extremities: Without edema.
Neurologic: Alert and oriented times two, moving all
extremities. His incisions were clean, dry, and intact. His
sternum was stable.
DISCHARGE LABORATORY DATA: White count 11.3, hematocrit
40.6%, platelet count 334,000. Sodium 137, potassium 4.6,
chloride 103, C02 25, BUN 20, creatinine 1.1, blood glucose
96. PT 20, with an INR of 2.6.
Discharge chest x-ray showed his lungs to be clear with a
very small left apical pneumothorax.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 81 mg p.o. q.d.
2. Captopril 12.5 mg p.o. t.i.d.
3. Amiodarone 200 mg p.o. q.d.
4. Atenolol 25 mg p.o. q.d.
5. Coumadin 1 mg p.o. on the night of discharge and then as
needed to maintain an INR of 2.5 to 3.5.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting times three
with a left internal mammary artery to left anterior
descending artery, saphenous vein graft to obtuse marginal,
and saphenous vein graft to posterior descending artery with
a #31 Carbomedics mechanical mitral valve replacement on
[**2114-11-23**].
2. Postoperative atrial fibrillation.
FOLLOW-UP: The patient should follow-up with Dr.
.................... in one week, with Dr. [**Last Name (STitle) 284**] in two
weeks, and with Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 54036**]
MEDQUIST36
D: [**2114-12-12**] 05:58
T: [**2114-12-12**] 18:02
JOB#: [**Job Number 54037**]
|
[
"486",
"427.31",
"458.29",
"427.32",
"401.9",
"424.0",
"428.0",
"512.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"37.22",
"88.56",
"36.15",
"34.04",
"36.12",
"96.72",
"35.24",
"89.68",
"89.64",
"99.04",
"39.61",
"88.53",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
9014, 9255
|
9308, 10136
|
2750, 8991
|
1544, 1661
|
1681, 1717
|
1732, 2732
|
1298, 1354
|
1371, 1520
|
9280, 9287
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,026
| 151,552
|
1554
|
Discharge summary
|
report
|
Admission Date: [**2128-5-19**] Discharge Date: [**2128-5-21**]
Date of Birth: [**2068-7-23**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Amoxicillin / Azithromycin / Iodine; Iodine
Containing
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
allergic reaction
Major Surgical or Invasive Procedure:
Mesenteric angiogram
History of Present Illness:
59 y/o female with PMH significant for hypothyroidism, s/p
bioprosthetic MVR [**1-30**] papillary muscle infarction due to MI
[**12-2**], recently admitted to [**Hospital1 18**] [**0-0-0**] with the
possible diagnosis of Churg-[**Doctor Last Name 3532**] vasculitis, who now presents
with an allergic reaction s/p angiogram today. Per report, she
underwent a mesenteric angiogram w/contrast by IR yesterday
morning and finished around 11 am. Approximately 1-2 hours
later, the patient felt very flushed, itchy, hot. She spiked a
temp to 101. No SOB or dyspnea. She was given benadryl and
transferred to the ED. In the ED, she became hypotensive to the
70's systolic and was given 5 L NS, famotidine, benadryl,
solumedrol, epinephrine, and started on dopamine. BP improved
slightly and she was transferred to the MICU for further
observation given the hypotension. Patient had no respiratory
symptoms or compromise during this time. Per patient, no other
symptoms.
.
She had initially been admitted on [**2128-4-13**] due to severe CNS
symptoms including cognitive deficit as well as falls and was
found to have multiple cerebral infarcts, evidence of
myocarditis, and persistent eosinophilia. She was discharged to
rehab in improved and stable condition on steroids and close
follow-up with multiple specialities, including Allergy, ID,
Neurology, Rheumatology, and Cardiology. She has been having
non-specific GI c/o including diarrhea, which is thought to be
part ofher vasculitis. The angiogram was done to evaluate the
SMA and [**Female First Name (un) 899**] for changes c/w vasculitis as no other tissue has
been available to biopsy.
Past Medical History:
- s/p recent admission for ?Churg-[**Doctor Last Name 3532**]
- erythroderma
- hypothyroidism ([**1-30**] Grave's disease s/p RAI ablation)
- history of cholestasis
- overactive bladder
- deep venous thrombosis (arm; when line in place); coumadin
discontinued end of [**3-3**]
- s/p MVR (bio) [**12-2**]; rupture of papillary muscle and MI
(course included chest CT, which showed infiltrates atypical in
distribution for aspiration pneumonia)
- cardiac cath [**12-2**]: normal coronary arteries.
- h/o allergic rhinitis in the spring
- h/o eosinophilia
Social History:
Lives at home with her husband, recently discharged from
[**Hospital3 **]. Ambulating at baseline. No tobacco, rare EtOH,
no illicits.
Family History:
- DM in her grandfather.
- bullous pemphigoid
- skin cancer, CAD, multiple strokes in her father
Physical Exam:
General: Pleasant female in NAD, AO x 3
HEENT: NC/AT, PERRL, EOMI. MM dry, OP clear
Neck: supple, no LAD or TMG
Chest: CTA-B, no w/r/r
CV: RR tachy, s1 s2 normal, +click
Abd: soft, NT/ND, NABS
Ext: no c/c/e, wwp
Neuro: AO x 3, CN II-XII intact grossly, MS [**5-1**] on right, [**4-1**] on
left, sensation intact
Skin: flushed, blanching erythema of anterior chest, cheeks and
upper back; no raised lesions or hives; no other rashes seen
Pertinent Results:
[**2128-5-19**] 09:48PM GLUCOSE-174* UREA N-15 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-21* ANION GAP-14
[**2128-5-19**] 09:48PM estGFR-Using this
[**2128-5-19**] 09:48PM ALT(SGPT)-13 AST(SGOT)-19 ALK PHOS-57
AMYLASE-63 TOT BILI-0.3
[**2128-5-19**] 09:48PM LIPASE-39
[**2128-5-19**] 09:48PM CALCIUM-7.5* PHOSPHATE-2.6*# MAGNESIUM-1.6
[**2128-5-19**] 09:48PM WBC-17.3* RBC-3.33* HGB-10.3* HCT-29.6*
MCV-89 MCH-31.0 MCHC-34.9 RDW-15.5
[**2128-5-19**] 09:48PM WBC-17.3* RBC-3.33* HGB-10.3* HCT-29.6*
MCV-89 MCH-31.0 MCHC-34.9 RDW-15.5
[**2128-5-19**] 09:48PM NEUTS-97.2* BANDS-0 LYMPHS-1.9* MONOS-0.6*
EOS-0.3 BASOS-0
[**2128-5-19**] 09:48PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2128-5-19**] 09:48PM PLT SMR-NORMAL PLT COUNT-255
[**2128-5-19**] 09:48PM PT-12.4 PTT-25.0 INR(PT)-1.1
[**2128-5-19**] 07:18AM PT-10.9 INR(PT)-0.9
[**2128-5-18**] 11:40AM LD(LDH)-316*
[**2128-5-18**] 11:40AM VIT B12-373 FERRITIN-59
[**2128-5-18**] 11:40AM TSH-2.9
[**2128-5-18**] 11:40AM ANCA-NEGATIVE B
[**2128-5-18**] 11:40AM [**Doctor First Name **]-NEGATIVE
[**2128-5-18**] 11:40AM CRP-1.7
[**2128-5-18**] 11:40AM IgG-714 IgA-128 IgM-216
[**2128-5-18**] 11:40AM C3-139 C4-27
[**2128-5-18**] 11:40AM WBC-16.5* RBC-3.94* HGB-12.4 HCT-36.6 MCV-93
MCH-31.5 MCHC-34.0 RDW-14.9
[**2128-5-18**] 11:40AM NEUTS-90.5* BANDS-0 LYMPHS-7.0* MONOS-2.0
EOS-0.2 BASOS-0.2
[**2128-5-18**] 11:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2128-5-18**] 11:40AM PLT SMR-NORMAL PLT COUNT-327
[**2128-5-18**] 11:40AM SED RATE-21*
[**2128-5-18**] 11:40AM CD5-D CD23-D CD45-D HLA-DR[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7736**]7-D KAPPA-D
CD2-D CD7-D CD10-D CD19-D CD20-D LAMBDA-D CD16/56-D
[**2128-5-18**] 11:40AM CD3-D CD4-D CD8-D
[**2128-5-18**] 11:40AM IPT-D
Brief Hospital Course:
# Hypotension/flushing - Initially admitted to the ICU. Most c/w
allergic/anaphylaxis reaction to contrast or antibiotic without
respiratory compromise. Received solumedrol, then switched to
prednisone 60 mg to be tapered to 10 mg/day. She was briefly on
dopamine but was quickly weaned off pressor. She remained very
stable on the floor, on prednisone and H1 H2 blockers.
- Allergies added to medical record and patient instructed to
warn health care providers in the future.
.
# ?Churg-[**Doctor Last Name 3532**]
- Patient needs to follow up with several specialties as an
outpatient. Rheumatology, Allergy and Hematology. Workup for
hypercoagulable state was begun in house a few hours prior to
discharge, results pending at time of discharge. She had no
eosinophilia this admission.
.
# Hypothyroidism (s/p radioablation for [**Doctor Last Name 933**]) - continued
synthroid
.
# F/E/N - cardiac diet
.
# PPx - pneumoboots
.
# Access - PIVs
.
# Code - full
Medications on Admission:
Prednisone 10 mg daily (on a taper)
Syntrhoid 100 mcg daily
Zantac 150 mg [**Hospital1 **]
Ditropan 5 mg daily
[**Doctor First Name **] 60 mg daily prn
ASA 81 mg daily
MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 1 days: [**5-22**].
Disp:*3 Tablet(s)* Refills:*0*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Outpatient Physical Therapy
8. Outpatient Occupational Therapy
9. Outpatient Speech/Swallowing Therapy
10. Please continue your prednisone taper
Take 60 mg of prednisone on [**5-22**] and starting on [**5-23**] continue
the taper as previously prescribed.
Discharge Disposition:
Home
Discharge Diagnosis:
Allergy reaction to iodinated contrast and/or azithromycin
Discharge Condition:
Good. No shortness of breath. Ambulatory.
Discharge Instructions:
You were admitted to the hospital for observation because you
developed a severe allergic reaction to iodinated contrast
and/or the antibiotic azithromycin. Please avoid these products
in the future. They have been added to your list of allergies in
our records.
You were also evaluated by the surgery service for the
possibility of a sural nerve biopsy in the future. You will need
to see Neurosurgery for this as an outpatient. Blood tests for
the coagulation of your blood were also taken, and you will need
to follow up on these results with your allergy doctor.
Please return to the ED if you experience any concerning
symptoms.
Followup Instructions:
Dr [**Last Name (STitle) **]: please call to make an appointment.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 6405**] [**Name (STitle) 6406**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2128-5-26**] 8:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2128-5-31**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2128-6-11**] 10:30
|
[
"E947.8",
"447.6",
"V12.51",
"E930.3",
"244.1",
"V43.3",
"995.0",
"V10.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
7331, 7337
|
5325, 6288
|
349, 372
|
7440, 7484
|
3361, 5302
|
8171, 8695
|
2789, 2888
|
6511, 7308
|
7358, 7419
|
6314, 6488
|
7508, 8148
|
2903, 3342
|
292, 311
|
400, 2042
|
2064, 2620
|
2636, 2772
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,033
| 160,591
|
31994
|
Discharge summary
|
report
|
Admission Date: [**2103-6-23**] Discharge Date: [**2103-7-8**]
Date of Birth: [**2035-8-7**] Sex: M
Service: MEDICINE
Allergies:
AZILECT
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Intubation, trach, PEG
History of Present Illness:
67yoM with Parkinson's disease, Bipolar disorder, HTN,
dyslipidemia, right vertebral artery aneurysm who presents for
hypoxia.
.
Per ED report and per the patient's sister's report (who spoke
directly to the nurses who were taking care of the patient
today), the patient was in his usual state of health at [**Hospital 100**]
Rehab and had just eaten breakfast and was waiting to be wheeled
to his room for his routine nap. The nurse turned away to finish
feeding another patient and turned back to see the patient with
emesis coming out of his nose and mouth. The patient was
unresponsive during this episode and was rapidly suctioned.
However, he was hypoxic and EMS was called who found the patient
to be hypoxic en route to the ED and bag masked and ventilated
for initial apnea, per report. He was lethargic en route and
transferred to the [**Hospital1 18**] ED for further evaluation. There was no
reports of fevers or symptoms preceeding the event, but the
sister states that the patient does not typically complain of
symptoms even when he feels unwell. The patient's sister reports
the patient has never had difficulties with swallowing or
eating, and has never had an aspiration episode in the past.
.
In the ED, initial VS: 99.6 (rectal) 67 132/94 91% NRB
The patient was reportedly not responsive to commands and had
coarse rales diffusely. He was given Vanc/Levofloxacin/Flagyl in
the ED and intubated for hypoxia. EKG showed sinus rhythm at
62bpm without evidence of acute ischemia. CXR was obtained which
showed possible RML infiltrate. CTA chest was obtained to r/o PE
which instead showed evidence of aspiration pneumonia. CT head
showed enlargement of the patient's known right vertebral artery
aneurysm, and Neurology and Neurosurgery were consulted out of
concern that the intracranial aneurysm could be contributing to
his symptoms. Neurosurgery recommended MRI head/neck and
Neurology planned to have the stroke consult see him in the AM
pending MRI/MRA results. He was transferred to the MICU for
further management. Transfer vitals were: 84 109/68 19 100% TV
500 PEEP 8 RR 20 FiO2 100
.
On arrival to the MICU, the patient was minimally responsive to
pain off sedation after having received paralytics. He went to
for the MRI/MRA during which time his respiratory rate increased
and sedation was initiated with Propofol boluses, then a low
dose gtt. He became fully responsive to commands and his
respiratory rate and blood pressures increased on CMV/AC.
Past Medical History:
- HTN
- Hyperlipidemia
- Bipolar disorder
- Parkinson's disease (PET in [**2094**] consistant with diagnosis)
- Gastropathy
- Unruptured right vertebral artery aneurysm (CTA from an
outside facility was reviewed; right vertebral artery aneurysm,
longest dimension 9-10 mm located intradurally in the region of
the right vertebral artery. He could not becertain whether the
aneurysm involved the PICA origin, but most likely it seemed to
be separate from it.)
- Depression
- Degenerative arthritis/multilevel spondylosis
- Knee OA, s/p TKA
Social History:
- Tobacco: Denies
- EtOH: Denies
- Illicit Drugs: Denies
Non-ambulatory at baseline. Lives at nursing home, [**Hospital 100**] Rehab
since [**2099**]. Retired Ph.D. psychologist.
Family History:
Father with "ataxia" and prostate cancer. Mother with breast
cancer. Pt denies family cardiac history.
Physical Exam:
VS: 100.1 80 130/75 100% on CMV FIO2 100% TV 6000 PEEP 5
GEN: Intubated, not following commands, no acute distress
HEENT: PERRL, sclera anicteric, MMM
CV: Soft heart sounds, RRR, normal S1/S2, no m/r/g
RESP: Equal BS b/l, rhonchi and coarse crackles at RLB, no
wheezes
ABD: Soft, NT/ND, +BS, no masses or hepatosplenomegaly
EXT: WWP, no c/c/e, 2+ DP pulses b/l
SKIN: No rashes/no jaundice/no splinters
NEURO: Corneal reflexes b/l, rare spontaneous non-purposeful
movements of right finger.
Pertinent Results:
[**2103-6-23**] 10:55AM BLOOD WBC-10.6 RBC-4.82 Hgb-14.5 Hct-40.5
MCV-84 MCH-30.2 MCHC-35.9* RDW-13.5 Plt Ct-213
[**2103-6-23**] 10:40PM BLOOD Neuts-39* Bands-39* Lymphs-5* Monos-2
Eos-1 Baso-0 Atyps-3* Metas-11* Myelos-0
[**2103-6-23**] 10:55AM BLOOD PT-13.0 PTT-22.9 INR(PT)-1.1
[**2103-6-23**] 10:55AM BLOOD Fibrino-334
[**2103-6-23**] 10:55AM BLOOD Glucose-119* UreaN-24* Creat-1.1 Na-140
K-5.7* Cl-104 HCO3-20* AnGap-22*
[**2103-6-23**] 10:40PM BLOOD ALT-12 AST-15 CK(CPK)-111 AlkPhos-38*
TotBili-0.5
[**2103-6-23**] 10:55AM BLOOD Lipase-37
[**2103-6-23**] 10:55AM BLOOD cTropnT-<0.01
[**2103-6-23**] 10:40PM BLOOD CK-MB-4 cTropnT-<0.01
[**2103-6-24**] 04:14AM BLOOD CK-MB-4 cTropnT-<0.01
[**2103-6-23**] 10:55AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.5
[**2103-6-23**] 10:55AM BLOOD Triglyc-136
[**2103-6-28**] 06:20AM BLOOD Vanco-13.6
[**2103-6-23**] 10:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-6-23**] 12:12PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-8
FiO2-100 pO2-436* pCO2-56* pH-7.27* calTCO2-27 Base XS--1
AADO2-233 REQ O2-46 -ASSIST/CON Intubat-INTUBATED
[**2103-6-23**] 11:41AM BLOOD Lactate-2.9*
[**2103-6-23**] 11:48PM BLOOD Lactate-2.3*
[**2103-6-24**] 04:34AM BLOOD Lactate-2.7*
[**2103-6-24**] 03:23PM BLOOD Lactate-1.6
[**2103-7-4**] 04:49PM BLOOD Lactate-1.4
[**2103-6-24**] 03:23PM BLOOD freeCa-1.14
REPORTS:
CXR AP [**2103-6-23**]
IMPRESSION:
1. Standard position of endotracheal tube.
2. Nasogastric tube extends below level of diaphragm, but
inferior aspect not well seen. Consider repeat if desire to
confirm that it terminates in the stomach.
3. Low lung volumes with mild bibasilar atelectasis.
CT Head [**2103-6-23**]
1. Interval increased size of a right-sided vertebral artery
aneurysm with
increased mass effect upon the brainstem. CTA should be
considered for
further evaluation.
2. Parenchymal atrophy and small vessel ischemic disease. No
other acute
findings.
CTA Chest [**2103-6-23**]
1. Bibasilar, and perihilar opacities with peribronchial
thickening may
reflect aspiration pneumonia. Hilar lymph nodes may be reactive.
2. No pulmonary embolism.
3. NG tube tip at the GE junction and should be further advanced
to achieve gastric positioning.
MRA Head/Neck [**2103-6-23**]
IMPRESSION: Right vertebral artery aneurysm at the V3 segment,
apparently
partially thrombosed, the carotid bifurcations and the left
vertebral artery are grossly normal.
CTA Head w and w/o contrast [**2103-7-7**] (prelim read!) - (Final
report dictation confirms preliminary findings.)
1. Right vertebral artery aneurysm measuring smaller on CTA than
routine head CT - likely secondary to differences in technique.
Difficult to measure on non-contrast images due to artifact.
Continues to demonstrate compression on the brainstem.
Reconstructions pending at this time.
2. No evidence for other aneurysm, vascular malformation or
proximal large
arterial occlusion.
3. New fluid in mastoid air cells bilaterally, may be secondary
to recent
intubation and supine positioning. Clinical correlation
recommended.
MICRO
[**2103-7-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY INPATIENT
[**2103-7-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2103-7-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2103-7-4**] URINE URINE CULTURE-FINAL INPATIENT
[**2103-7-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT - NEGATIVE
[**2103-7-2**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL INPATIENT
[**2103-7-2**] BRONCHIAL WASHINGS GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL {STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA, GRAM NEGATIVE ROD #2, YEAST}; Immunoflourescent
test for Pneumocystis jirovecii
(carinii)-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST} INPATIENT
+
GRAM STAIN (Final [**2103-7-2**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2103-7-4**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
324-8468N
([**2103-6-27**]).
GRAM NEGATIVE ROD #2. RARE GROWTH.
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2103-7-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT - NEGATIVE
[**2103-7-1**] URINE URINE CULTURE-FINAL INPATIENT
[**2103-6-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2103-6-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA,
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION} INPATIENT
GRAM STAIN (Final [**2103-6-30**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2103-7-3**]):
Commensal Respiratory Flora Absent.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
324-8468N
([**2103-6-27**]).
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE
GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # 324-8468N
([**2103-6-27**]).
[**2103-6-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2103-6-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2103-6-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA,
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION} INPATIENT
[**2103-6-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2103-6-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2103-6-27**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA,
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION, SERRATIA SPECIES}
INPATIENT
[**2103-6-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2103-6-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST} INPATIENT
[**2103-6-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2103-6-23**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2103-6-23**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2103-6-23**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2103-6-23**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2103-6-23**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
DISCHARGE LABS:
Na 143
K 4.3
Cl 108
BUN 26
BUN 9
Cr 0.5
Gluc 94
Ca 8.5
Mg 2
Phos 3.7
WBC 5.5
HCT 31 (stable)
PLT 243
Brief Hospital Course:
67yoM with Parkinsonism & cognitive impairment with known R
vertebral aneurysm (prior eval by [**Doctor Last Name **] in [**2099**]). Pt admitted
after syncopal episode after which he was unresponive, apneic.
#. Hypoxic Respiratory Distress: Per report, the patient's
episode of coughing while eating, hypoxia, and subsequent loss
of consciousness is consistent with aspiration pneumonia. He was
intubated for his hypoxemic respiratory failure. His chest
imaging, and purulent sputum from endotracheal tube all confirm
this diagnosis. Patient was treated with an 8 day course of
vanc/cefepime/flagyl from [**2103-6-23**] until [**2103-7-1**] for
health-care-associated pneumonia. Given that he had
stenotrophamonas growing in his sputum sensitive to bactrim, he
was started on bactrim 40 mL PO/NG QID d1=[**6-29**] for a long 2-week
course, last dose to be given on [**2103-7-13**]. Given his baseline
Parkinson's disease, likely ICU myopathy, and generalized
weakness, the patient was unable to be weaned from the
ventilator successfully. He was extubated on [**2103-7-2**] but had to
be emergently reextubated the same day for acute respiratory
failure. A trach and PEG was placed on [**2103-7-6**] without
complication and he was successfully weaned off of the
ventilator on [**2103-7-8**], currently satting in the mid-high 90s on
50% FiO2 trach mask. He would benefit from continued antibiotics
and pulmonary rehabilitation/chest PT. Blood and repeat sputum
cultures remained negative.
#. Loss of Consciousness: Given the limited history, it is
unclear whether the patient had loss of consciousness following
or preceeding the emesis and aspiration event. cardiac enzymes
negative x2. Neurologic work up revealed slightly larger known
vertebral artery aneurysm (more on this below) thought not to be
related to his current presentation per neurology and
neurosurgery consultation. This was thought to be related to his
hypoxic respiratory failure per above. The patient remained
sedated throughout the admission and on day of discharge.
#. Vertebral Artery Aneurysm: Patient with known right vertebral
artery aneurysm, currently 14x12mm as compated to 11x9mm in
[**2101-8-6**]. Neurosurgery was consulted and did not recommend
acute treatment of the aneurysm, but recommended MRI brain, MRA
head and neck. Neurology stroke consult was also recommended
given the as stroke is a possibility given this limited history
and exam. Repeat CTA head/neck revealed a slightly smaller
aneurysm. These findings were discussed with neurosurgery on day
of discharge and a follow up appointment with neurosurgery
should be arranged [**Telephone/Fax (1) 1669**] within 4-8 weeks.
#. Fever: Patient persisted to have multiple low grade fevers
for several days all thoughout his ICU course (tmax in 24 hours
100.5 last evening [**2103-7-7**]) and 100 this morning [**2103-7-8**]. A large
number of blood, urine, stool, and sputum cultures were drawn
and only positive for STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA
per above and negative for c diff x 2 over the course of [**7-15**]
days. Yeast grew in the sputum as well that was thought to be
nonpathologic. The patient developed an acne-like rash on his
backside thought to be secondary to diaphoresis, however,
drug-hypersensitivity secondary to bactrim was considered but
felt to be unlikely. Eosinophil count remained normal on day of
discharge. His PICC line was also pulled as a potential source
of infection on day of discharge. His fever was therefore
thought to be secondary to stenotrophomonas infection of the
lungs. Monitoring of the rash by [**Hospital 100**] Rehab staff would be
appropriate as well.
#. Elevated Lactate: Patient with lactate of 2.9 on initial
presentation, likely secondary to volume depletion and
hypovolemia. This cleared after IVF.
#. Parkinson's Disease: Continued home Sinemet 25/100mg 0.5 tab
at 5pm, 8pm, 1.5 tabs at 8am, 12pm, 2pm
#. Bipolar Disorder: Stable. Continued home Seroquel 50mg [**Hospital1 **],
Hold Seroquel 25mg q6h prn given patient is intubated, Continued
Neurontin 100mg daily, Continued Valproic acid 250mg tid with no
adverse events.
#. Hypertension: BP stable, no evidence of shock or hypotension.
Held lisinopril , Metoprolol 25mg [**Hospital1 **], Held Klonipin 0.5mg tid
as patient sedated and intubated, can be restarted at rehab.
#. Dyslipidemia: Continued Simvastatin 20mg qhs
#. Depression: Continued Cymbalta 40mg [**Hospital1 **] per home regimen
#. Prophylaxis: patient continued on heparin subcutaneous 5,000
units TID. PPI and chlorhexadine were discontinued upon
discharge as he became vent independent today.
Lidoderm patch for chronic pain was continued.
Senna/Colace/Miralax. PPI.
#. Contact: Sister [**Name (NI) **] - [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 74952**] (home),
[**Telephone/Fax (1) 74953**] (cell). Sister [**Name (NI) 382**], POA) - [**Name (NI) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 74954**] (home), [**Telephone/Fax (1) 74955**] (cell).
#. Code status: After extensive family meetings, patient was
deemed DNR but not DNI. Ambulance services refused to accept DNR
order, despite MD signature, demanded HCP signature,
unfortunately, she was not available for signature, therefore
she remained full code for transport. He would return to DNR
status upon arrival to [**Hospital 100**] Rehab.
Medications on Admission:
- Lisinopril 40mg qhs
- Lopressor 25mg [**Hospital1 **]
- Simvastatin 20mg qhs
- Seroquel 25mg q6h prn
- Seroquel 50mg [**Hospital1 **]
- Sinemet 25/100mg 0.5 tab at 5pm, 8pm, 1.5 tabs at 8am, 12pm,
2pm
- Valproic acid 250mg tid
- Lidoderm patch
- Tylenol 1gm q8h prn pain
- Vitamin D 1000 units daily
- Klonipin 0.5mg tid
- Cymbalta 40mg [**Hospital1 **]
- Neurontin 100mg daily
- Nitro TP 0.2mcg/day
- Miralax 17g [**Hospital1 **]
- Dulcolax 5mg qday prn
.
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
5. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
6. carbidopa-levodopa 25-100 mg Tablet Sig: 0.5 Tablet PO Q 5PM,
8PM ().
7. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: Five
(5) mL (250 mg) PO Q8H (every 8 hours).
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain, fever.
10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. gabapentin 250 mg/5 mL Solution Sig: 100 mg (2 mL) PO DAILY
(Daily).
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Ok to hold if pt is able to
ambulate TID.
15. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-7**]
Drops Ophthalmic PRN (as needed) as needed for dry, red eyes.
16. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension Sig:
Forty (40) ML PO QID (4 times a day) for 5 days: Take through
[**7-13**].
17. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic [**Hospital1 **] (2 times a day) for 2 days.
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing, shortness of breath.
19. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
QID (4 times a day) as needed for wheezing, shortness of breath.
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
21. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
22. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
23. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Aspiration pneumonia, respiratory failure, altered
mental status
.
Secondary: conjunctivitis, parkinson's, bipolar, loss of
conciousness, verterbral artery anuerysm
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital for hypoxic respiratory
distress thought to be due to aspiration pneumonia. You were
treated with antibiotics and you improved, however you were
unable to be weaned from the ventilator, therefore a
tracheostomy was performed and a PEG tube was placed for
nutrition. Additionally while in the hospital you were treated
for conjunctivitis and followed for your vertebral artery
anuerysm which was stable. Your home psychiatric and
parkinson's medications were continued.
.
The following changes were made to your medications:
-START Bactrim, continue taking through [**7-13**]
-STOP lisinopril and nitroglycerin pathc, this can be restarted
if you are hypertensive, however it was discontinued during the
admission because your pressures were well controlled
-START SC heparin for DVT prophylaxis
-START erythromycin eye ointment and moisturizing eye drops
-START albuterol and ipratroprium nebs as needed for shortness
of breath
-START senna and docusate for constipation
Followup Instructions:
Please follow up with your rehab physician. [**Name10 (NameIs) 357**] schedule
follow up with neurosurgery in [**4-13**] weeks by calling:
[**Telephone/Fax (1) 1669**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2103-7-8**]
|
[
"995.92",
"518.81",
"V49.86",
"437.3",
"372.30",
"693.0",
"584.5",
"332.0",
"038.9",
"296.50",
"272.4",
"401.9",
"482.83",
"507.0",
"E931.0",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.72",
"31.1",
"96.6",
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
19388, 19454
|
11110, 16481
|
274, 298
|
19672, 19672
|
4214, 10968
|
20840, 21132
|
3583, 3688
|
16991, 19365
|
19475, 19651
|
16507, 16968
|
19808, 20817
|
10984, 11087
|
3703, 4195
|
227, 236
|
326, 2807
|
19687, 19784
|
2829, 3370
|
3386, 3567
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,799
| 122,970
|
14036
|
Discharge summary
|
report
|
Admission Date: [**2155-8-18**] Discharge Date: [**2155-8-23**]
Date of Birth: [**2101-8-30**] Sex: M
Service: MEDICINE
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
L knee pain
Major Surgical or Invasive Procedure:
Left Total Knee Replacement (Dr. [**First Name (STitle) **]- [**2155-8-18**]
History of Present Illness:
53M with HCV Cirrhosis, OSA on Bipap that was admitted for an
elective left total knee replacements. Pt with hx of devastating
knee dislocation. He is ligamentously stable now but has
advancing osteoarthritis, tricompartmental. He has significant
discomfort and pain. His operation was cleared through workmen's
comp.
Past Medical History:
-Hep C cirrhosis with sustained virologic response, 1 cord of
grade 1 varices
-Thyroid cancer, status post thyroidectomy
-Silent myocardial infarction in [**2142**] (per OMR, patient denies)
with normal cardiac cath [**9-/2145**]
-Nephrolithiasis
-OSA on BiPAP
-H/o MVA with chest and abdominal trauma
-Deviated septum repair
-Inguinal hernia repair as infant
- ?COPD Pulmonologist: Dr. [**First Name8 (NamePattern2) 4580**] [**Last Name (NamePattern1) 41892**], [**Location (un) 8545**], MA
Social History:
Quit smoking ~8/[**2153**]. History of [**2-9**]-1ppd since [**2130**]. Denies
EtOH, has remote h/o drug use (cocaine), but no current use, no
h/o IVDU. Works as an EMT. He can walk [**Age over 90 **] yds or climb one
flight of stairs with groceries before getting SOB. As an EMT,
he regularly lifts patients and stretchers. He also performs
yard work, including stacking wood. He has no CP at rest or on
exertion. Does have chronic ankle edema.
Family History:
Mother died of congestive heart failure at the age of 51 and
maternal grandfather died of a myocardial infarction at age 42.
Two brothers with hypertension and increased cholesterol.
Physical Exam:
Admission Exam:
Exam today demonstrates well-healed incisions.
He is stable to varus and valgus stress and full extension. At
about 20-30 degrees of flexion, he has mild opening medially.
.
Discharge Exam:
Afebrile
NAD, AOx3
Resp: Bibasilar dullness otherwise good airmovement without
focal rales or rhonchi.
Card: S1S2 No MRG
Abd: Soft Obese NT ND BS+
Extr.....
Pertinent Results:
Labs upon admission:
[**2155-8-19**] 02:39AM BLOOD WBC-14.6*# RBC-4.97 Hgb-14.5 Hct-42.3
MCV-85 MCH-29.2 MCHC-34.3 RDW-13.0 Plt Ct-174
[**2155-8-19**] 02:39AM BLOOD Neuts-85.7* Lymphs-6.8* Monos-7.1 Eos-0.2
Baso-0.2
[**2155-8-19**] 02:39AM BLOOD PT-13.4 PTT-25.1 INR(PT)-1.1
[**2155-8-19**] 02:39AM BLOOD Glucose-142* UreaN-18 Creat-0.7 Na-141
K-4.8 Cl-103 HCO3-31 AnGap-12
[**2155-8-19**] 02:39AM BLOOD ALT-19 AST-16 LD(LDH)-202 AlkPhos-86
TotBili-0.7
[**2155-8-19**] 02:39AM BLOOD Albumin-4.0 Calcium-8.9 Phos-3.8 Mg-2.2
[**2155-8-19**] 02:56AM BLOOD Type-[**Last Name (un) **] pO2-55* pCO2-66* pH-7.31*
calTCO2-35* Base XS-3
Labs prior to discharge:
Micro:
[**8-21**] blood culture pending
[**8-20**] urine culture pending
[**8-20**] blood culture pending
Imaging:
[**8-18**] left knee xray: Skin staples are present. Subcutaneous
edema and emphysema, post-surgical. Gas is seen within the
joint, post-surgical. A surgical drain is seen within the joint.
Status post left total knee arthroplasty. Normal alignment.
Prior ACL reconstruction. The hardware is intact and unchanged
in position. Posttraumatic deformity of the proximal fibula.
IMPRESSION: Post-surgical changes of the left knee as above.
[**8-19**] CXR: Vascular engorgement predominantly in the left lung
and interval increase in mild-to-moderate cardiomegaly all
suggest cardiac decompensation, perhaps due to volume overload.
No pneumothorax.
[**8-20**] CXR: Increased caliber to the upper mediastinum suggests
volume overload but there is no pulmonary edema. Left infrahilar
opacification is probably atelectasis, unchanged. Heart size top
normal. Small right pleural effusion may be present. No
pneumothorax.
Brief Hospital Course:
53M with Hx of HCC Cirrhosis, OSA admitted for left TKR
complicated by respiratory distress and fever.
# Left BKA: The patient was admitted to the orthopaedic surgery
service and was taken to the operating room for L knee surgery
as described above. Please see separately dictated operative
report for details. The surgery was uncomplicated and the
patient tolerated the procedure well. Patient received
perioperative IV antibiotics.
The patient was transferred to the ICU for post-operative
somnolence and hypoxemia. Initial VBG at time of ICU transfer
was 7.31/66/55. Treated with autoset CPAP and nasal trumpet for
respiratory acidosis. He was awake and alert at time of transfer
back to the floor on POD#1. While in the ICU, he did experience
knee pain, especially during mobilization; his IV morphine pain
regimen was transitioned to PO narcotics. Pain was initially
controlled with IV morphine. At time of transfer to the floor,
the patient was controlled on oxycodone 5-10 mg PO q4H PRN.
Upon the patient's first transfer from the ICU, the patient was
written for PO oxycodone as well as IV morphine for pain
control. On the othro floor, the patient received 12mg po
Dilaudid. In the evening he was found to be somnolent and
unresponsive with a blood gas shoing hypoxemia and hyprecarbia,
so he given narcan and transferred back to the ICU. He responded
well to narcan: no longer somnolent, O2 saturation improved.
Pain medications were reduced: IV morphine stopped and oxycodone
decreased to 5-10 mg q6H PRN. Of note, the patient does have a
chronic need for CPAP/BiPAP. Of note, patient is concerned that
he became somnolent because he responds poorly to supplemental
O2 given his suspected COPD. He does not have an outpatient
pulmonologist and will need to be setup with outpatient
pulmology followup at time of discharge.
The patient received lovenox for DVT prophylaxis starting on the
morning of POD#1; this was later increased to 40 mg [**Hospital1 **] (weight
based dosing). The foley was removed on POD#2 and the patient
was voiding independently thereafter.
The surgical dressing was changed on POD#2 and the surgical
incision was found to be clean and intact without erythema or
abnormal drainage. The patient was seen daily by physical
therapy.
Per the [**Hospital1 **] service, the operative extremity was
neurovascularly intact and the wound was benign. The patient's
weight-bearing status is weight bearing as tolerated on the
operative extremity.
Labs were checked throughout the hospital course and repleted
accordingly. The patient was afebrile with stable vital signs.
The patient's hematocrit was stable and pain was adequately
controlled on an oral regimen.
The patient was transferred in and out the [**Hospital Unit Name 153**] on POD#3
requiring a narcan gtt in the setting of somulence. He was
subsequently called out to the Hospital Medicine Service.
On POD#4 the pt was noted to have erythema of the left knee in
the setting of fever, discharge was subsequently delayed and the
pt was given a dose of Vancomycin.
On POD#5 the patient had significant improvement in his erythema
and no more episodes of fever. He did not complain of any other
localizing symptoms and had a normal WBC count. He was also
evaluated by Orthopedics as well, who felt that his erythema was
not consistent with cellulitis, and more likely due to a small
hematoma. Nonetheless, they recommended a prophylactic course
of antibiotics. Given that pt has had a history of positive
MRSA screen in the recent past, he will be discharged on a
regimen of Bactrim for prophylaxis.
Of note, pt still has several sets of blood cultures that are
still pending at time of discharge.
Medications on Admission:
furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
trazodone 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for Insomnia.
zolpidem 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at
bedtime)) as needed for Insomnia.
Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1) Cap PO
DAILY (Daily).
levothyroxine 137 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
citalopram 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 3 weeks.
Disp:*21 syringes* Refills:*0*
3. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice
a day for 3 weeks: starting after lovenox completed.
Disp:*42 Tablet(s)* Refills:*0*
4. furosemide 40 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. trazodone 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for Insomnia.
7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for Insomnia.
8. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1) Cap
PO DAILY (Daily).
9. levothyroxine 137 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. citalopram 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
12. morphine 15 mg Tablet Sig: 7.5 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
13. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for Wheeze.
15. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
16. BiPAP
BiPAP at night while sleeping
Settings: 14/6 at 2 L/min with spontaneous rate
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Left knee osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out at your follow-up visit in three (3)
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in three (3) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for three (3)
weeks to help prevent deep vein thrombosis (blood clots). After
completing the lovenox, please take Aspirin 325mg TWICE daily
for three weeks. [**Male First Name (un) **] STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
visit in three (3) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, and wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. CPM/ROM as tolerated. No strenuous exercise
or heavy lifting until follow up appointment.
Physical Therapy:
WBAT LLE
CPM as tolerated, increase flexion as able
Treatments Frequency:
DSD to incision daily as needed
Remove staples on POD#14
Elevate LLE when sitting or in bed
Ice to wound as needed
TEDS for 6 weeks
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2155-9-2**] 2:00
|
[
"E929.9",
"571.5",
"278.03",
"V15.82",
"496",
"070.70",
"276.2",
"300.4",
"456.1",
"715.96",
"V10.87",
"518.0",
"414.01",
"327.23",
"518.81",
"E878.1",
"905.6",
"780.60",
"E937.9",
"412",
"780.09",
"998.12",
"244.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.54"
] |
icd9pcs
|
[
[
[]
]
] |
9980, 10094
|
4001, 7698
|
284, 363
|
10163, 10163
|
2293, 2300
|
13459, 13654
|
1709, 1893
|
8342, 9957
|
10115, 10142
|
7724, 8319
|
10346, 12491
|
1908, 2099
|
13229, 13281
|
13303, 13436
|
2115, 2274
|
233, 246
|
12503, 13211
|
391, 713
|
2314, 3978
|
10178, 10322
|
735, 1229
|
1245, 1693
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,282
| 122,678
|
29518
|
Discharge summary
|
report
|
Admission Date: [**2190-2-16**] Discharge Date: [**2190-2-24**]
Date of Birth: [**2131-1-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt woke up this morning with R sided pleuritic chest pain that
awoke her from sleep. She said it felt sharp, worse with
inspiration. No SOB but tried not to take deep breaths [**2-26**]
pain. Has had recent cough about 2 weeks ago, given
azithromycin with resolution of cough, no production. No recent
prolonged travel - longest car ride was about 1 1/2 hours. Pt
denies swelling in legs. Pt denies fevers at home. Has not had
any miscarriages in the past. Pt's last [**Last Name (un) 3907**] was last year -
did have a breast biopsy 2-3 years ago but was not malignant.
Had a colonoscopy 6-8 months ago, negative, no h/o blood in
stool.
.
At the OSH, CT chest noted 11mm lung nodule, 14mm thyroid
nodule, and saddle pulmonary embolus. Pt was started on a
heparin gtt and was transferred here. At [**Hospital1 18**], her vital signs
were stable - 98, 77, 121/80, 16, 98% 2L. She was guaiac
negative. CXR was performed. Bedside echocardiogram showed no
RV collapse.
Past Medical History:
multiple sclerosis
hyperlipidemia
Social History:
Lives with her husband. Used to work at a jeweler's and at a
bank, stopped in [**2171**] [**2-26**] MS. Pt is ambulatory at home and gets
around by herself. Has been smoking 1/2ppd for about 40 years.
Occasional social EtOH, h/o cocaine use in [**2163**], none recently.
Family History:
no h/o known clots or miscarriages
Physical Exam:
VS: 98.0 109/64 81 14 100% 3L NC
Gen: slightly anxious, otherwise NAD, no respiratory distress
HEENT: PERRL, EOMI, MM dry, OP clear
Neck: no JVD, no cervical LAD, no thyroid nodules palpated
CV: RRR, nl S1, loud P2, no m/r/g
Pulm: crackles at bases L > R, no wheezes
Abd: soft, obese, NT/ND, - masses
Ext: 1+ pitting edema, RLE with more erythema and warmth than
LLE, no tenderness to palpation of calves, no palpable cords
Pertinent Results:
Chest CT (OSH read): PE involving both main pulmonary artery
bifurcations and branches, 11mm nodular density in LUL;
atelectasis at both bases; 14mm low attenuation nodule in L lobe
of thyroid
.
CXR: Linear opacity in L lung base, atelectasis vs early PNA,
cannot r/o small L pleural effusion; cardiomegaly
.
EKG: 59bpm, nl axis, nl intervals, deep Q in III but no S1 or
T3, poor R wave progression
Brief Hospital Course:
59 yoF with history of multiple sclerosis transferred from OSH
with saddle pulmonary embolism and left lung nodule.
.
# Pulmonary embolus: Patient transferred to [**Hospital1 18**] for management
of saddle pulmonary embolus. Pt did not have any risk factors
for thrombus, although LUL nodule in setting of tobacco use is
concerning for underlying malignancy. Patient remained
hemodynamically stable without evidence of right heart strain on
echo and no RAD on EKG. The magnitude of PE and hemodynamic
stability may suggest a chronicity of her process. Patient had
large RLE DVT and a pulomonary/interventional pulmonary consults
were placed. An IVC filter was not deemed an appopriate option.
CT head had been concerning for embolus/PFO showing possible
infarction; MRI head without these findings, however, showed
changes consistent with multiple sclerosis.
- Coumadin - lovenox bridge started [**2-23**], to have PT/INR checked
[**2-26**] by PCP, [**Name10 (NameIs) 151**] [**Name11 (NameIs) 702**] by him, Dr. [**Last Name (STitle) 36552**]. Plan for
coumadin 5mg x 2days, [**2-24**] and [**2-25**], with INR check [**2-26**] -
further assessment of coumadin dose as above.
- coagulation studies/panel will need to be undertaken as an
outpatient.
- [**Month (only) 116**] need 6-9 months of anti-coagulation, possibly lifelong if
this is indeed secondary to malignancy
- PULM CONSULT RECS:
1. Chest CT (non-contrast in 6 weeks). She will need follow-up
which can be local, but alternatively she may follow up here.
2. Continue anticoagulation, as above
3. No role for IVC filter in this hemodynamically stable patient
who is tolerating anticoagulation.
4. Usual hypercoagulation workup (Protein C, S; ATIII; lupus
anticoagulant; cardiolipin antibodies; prothrombin gene mutation
[**Numeric Identifier 23885**]; homocysteine). Also age appropriate cancer screenings as
outpatient.
.
# Lung mass: 11 mm nodule seen in LUL on OSH CT chest. PE raises
suspicion of pulmonary malignancy.
- Biopsy deferred due to size of mass. Needs CT follow-up in
[**4-30**] weeks, scheduled follow-up with [**Hospital1 **] pulmonologist in [**Month (only) 547**],
as above.
.
# Thyroid nodule: 14 mm nodule seen on OSH CT chest. PE raises
suspicion of malignancy.
- Will need reassessment of this nodule, perhaps biopsy as
deemed indicated by Dr. [**Last Name (STitle) 36552**], as well as thryoid function
tests repeated.
.
# Multiple sclerosis: Patient functional at baseline;
ambulatory. No acute issues.
- Continue topamax
- Patient would optimally benefit from seeing a neurologist on
an outpatient basis.
.
# FEN/GI - Low cholesterol diet
.
# Code status - Full
.
# Dispo - Home
Medications on Admission:
lipitor 10mg daily
topamax 200mg daily
detrol 4mg daily
MVI
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Topiramate 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Lovenox 100 mg/mL Syringe Sig: One (1) 90 Subcutaneous twice
a day for 10 doses: DOSE IS 90 units. Start evening of [**2-24**], to
last through AM of [**3-1**], or as instructed by your primary care
physician.
[**Name Initial (NameIs) **]:*10 10* Refills:*0*
5. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO every twelve
(12) hours as needed for pain.
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2
doses: Take in PM on [**2-24**] and [**2-25**]. You will then have your
PT/INR checked - Dr. [**Last Name (STitle) 36552**] will instruct on how much to take
thereafter.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Pulmonary embolus
2. Lung nodule
3. Thyroid nodule.
.
Secondary:
1. Multiple sclerosis
2. Hyperlipidemia
Discharge Condition:
Afebrile, stable vital signs. On room air.
Discharge Instructions:
You were hospitalized with a pulmonary embolus.
Take all of your medications as prescribed.
Keep your appointments, namely your PT/INR check on Friday.
Please verify your follow-up appt when you are having your blood
drawn this Friday, [**2-26**].
If you acquire chest pain, shortness of breath, nausea,
vomiting, or any other concern, please seek immediate medical
attention.
Followup Instructions:
I have spoken with Dr.[**Name (NI) 70816**] clinic and Dr. [**Last Name (STitle) 36552**] is
willing to follow your PT/INR levels as an outpatient. You are
to go to his clinic on Friday and have your PT/PTT/INR levels
drawn, with the results given to Dr. [**Last Name (STitle) 36552**] (the goal INR is
between [**2-27**]). Stop the lovenox shots once Dr. [**Last Name (STitle) 36552**] instructs
you to do otherwise..Patient discharged with coumadin 5mg on
[**2-24**] and [**2-25**], also given script for coumadin in 2mg tablets,
with dose to be determined by Dr. [**Last Name (STitle) 36552**]. Script for 10
lovenox shots given, to be discontinued at discretion of Dr.
[**Last Name (STitle) 36552**].
.
Given your pulmonary embolus and the findings on the CT scan of
a nodule in your thyroid and in your lung, you should have a
repeat CT scan within 4-6 weeks to address both of these issues.
.
Pulmonary Referral - [**Hospital1 **] - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
(please acquire CT scan prior to this appointment): [**5-3**],
Monday 1:40 please arrive 30 minutes prior to appointment. [**Location (un) 1385**] of [**Location (un) 8661**] building for breathing test, then doctor appt
is on [**Location (un) 436**] of [**Hospital Ward Name 23**] building.
.
Also, you should speak with Dr. [**Last Name (STitle) 36552**] about seeing a
neurologist for your multiple sclerosis.
.
Dr.[**Name (NI) 70816**] Clinic - [**3-9**], 2:00pm - for follow-up.
|
[
"276.52",
"340",
"453.40",
"272.4",
"415.19",
"518.89",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6301, 6307
|
2628, 5308
|
325, 332
|
6468, 6513
|
2204, 2605
|
6938, 8438
|
1704, 1740
|
5418, 6278
|
6328, 6447
|
5334, 5395
|
6537, 6915
|
1755, 2185
|
275, 287
|
360, 1340
|
1362, 1397
|
1413, 1688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,185
| 111,278
|
23766
|
Discharge summary
|
report
|
Admission Date: [**2162-2-11**] Discharge Date: [**2162-2-13**]
Date of Birth: [**2117-4-13**] Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old
male with a history a seizure disorder who presented to
Northeast [**Hospital 3914**] [**Hospital 12018**] Hospital on [**2162-2-9**], with
several days of vomiting and vague abdominal pain. The
patient was found to have an increase in LFTs with an AST of
11,700; an ALT of 11,800. Coagulopathic INR of 14.8. The
patient was lethargic. Alert and oriented x 3 without
encephalopathy. Positive asterixis. The patient also
complained of right upper quadrant pain. Denies a history of
excessive EtOH. Denies a large amount of Tylenol ingestion.
Denies IV drug abuse, or blood transfusions, or recent
travel. The patient's Dilantin, Tegretol, and valproic acid
were all in a therapeutic range. The patient was transfused 4
units of FFP and vitamin K for an increased INR. The patient
was also noted to have hematemesis. Serial hematocrits were
obtained and monitored. The patient was intubated for
increased lethargy and agitation and transferred to [**Hospital1 18**] via
medical flight. He had positive epistaxis per report, and
there was an atraumatic intubation.
PAST MEDICAL HISTORY: Includes seizure disorder, GERD,
hypertension, and self gunshot wound to groin as a suicide
attempt in [**2157-12-5**].
PAST SURGICAL HISTORY: None.
MEDICATIONS AT HOME: Depakote 500 t.i.d., Tegretol 300
b.i.d., Dilantin 300 b.i.d., Nexium 40 daily, lisinopril 10
daily.
ALLERGIES: Vioxx, rash.
SOCIAL HISTORY: No tobacco. No ethanol. No IV drug abuse. On
Dilantin due to a seizure disorder.
PHYSICAL EXAMINATION ON ADMISSION: Vital's on admission were
95.9, 130/86, 82, 14, 100%. He was intubated on assist
control of 60%, respiratory rate 14 with a PEEP of 5. The
patient was intubated, sedated, and paralyzed. His heart was
regular in rate and rhythm without murmurs, rubs, or gallops.
The lungs were clear to auscultation bilaterally. The abdomen
was soft, and no palpable liver edge. Positive edema. Mild
distention on abdominal exam.
IMAGING: Imaging at the outside hospital showed an abdominal
ultrasound with gallbladder small. No gallstones. Chest x-ray
was unremarkable. KUB was unremarkable.
LABORATORY DATA: The patient had an ammonia of 202.
Admission labs with a white count of 8.9, hematocrit of 35,
platelets pending on admission. Coagulation studies of 23.5,
34.7, 3.5. Fibrinogen of 109. AST of 280, ALT 669, amylase
55, lipase of 105, LDH of 923, alkaline phosphatase of 127,
total bilirubin of 9.2, albumin of 3.3. Phenytoin was 7.6,
valproic acid of 4.5, carbamazepine of 7.6, and acetaminophen
was 5.8. Calcium of 7.5, magnesium of 2.0. Sodium of 150,
potassium of 4.1, chloride of 116, bicarbonate of 24, BUN of
49, creatinine of 3.5, with a glucose of 115. The patient had
a blood gas of 7.40, 38, 259, 25 and 0.
HOSPITAL COURSE: On hospital day 1 neurology was consulted.
On hospital days 0 and 1 neurology was consulted and
suggested checking levels of antiepileptic medications.
Suggested an EEG. Neurology also suggested on hospital day 2
start Versed for seizure control and overnight the patient
had 3 seizures requiring large doses of Ativan. A head CT
showed no evidence of acute intracranial pathology with sinus
opacification. Abdominal CT the same day showed ascites with
no focal collection, edematous appearing kidneys with no
evidence of hydronephrosis or hydroureter. The distal ureters
were not imaged. Somewhat large edematous appearing liver
with no focal lesion, parenchyma suggestive fatty
replacement. Gallbladder containing dense material consistent
with sludge may represent biliary excretion, contrast from
previous CT scan. Bilateral pleural effusion, bilateral
atelectasis. A liver ultrasound on hospital day 3 showed
patent hepatic artery, veins small, small amount of ascites,
with gallbladder sludge. The patient continued to receive
large amounts of transfusions of blood products throughout
hospital course, and by hospital day 3 had ALT of 3802 and
AST of 1300 with an INR of 2.75. Because the patient was in
status epilepticus, he currently was not transplantable and
was clinically comatose by [**2162-2-12**]. Progressively
deteriorated by [**2162-2-13**]. Over the course of the
evening and early morning and became progressively acidotic,
worsening lactate, progressive coagulopathy; unresponsive to
sodium bicarbonate infusion, IV fluids resuscitation, and
blood product infusion. On [**2162-2-13**], was on Levophed
0.5 mcg per kg per minute and Neo-Synephrine at 7.0 mcg per
kg per minute with the most recent ABG of 7.09/27/127/9/and -
20. He was on full life support measures at that time but was
appearing to be futile. The patient was made CMO at the
request of his wife.
The patient died at 4:15 a.m. on [**2162-2-13**], was
asystolic on telemetry. Organ bank was notified, and autopsy
report showed submassive hepatic necrosis with bowel stasis
most concentrated around zones 2 and 3 of the liver, soft
density mild vascular congestion, mild interval thickening of
the right coronary artery.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 3762**]
Dictated By:[**Doctor Last Name 9174**]
MEDQUIST36
D: [**2162-5-10**] 11:52:11
T: [**2162-5-11**] 15:39:36
Job#: [**Job Number 60689**]
|
[
"401.9",
"570",
"530.81",
"780.39",
"584.9",
"780.01",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2941, 5413
|
1445, 1573
|
1416, 1423
|
156, 1248
|
1708, 2923
|
1271, 1392
|
1590, 1693
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.