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Discharge summary
|
report
|
Admission Date: [**2174-4-6**] Discharge Date: [**2174-4-19**]
Date of Birth: [**2125-10-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest tightness, shortness of breath
Major Surgical or Invasive Procedure:
[**2174-4-12**] Five Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending
artery, and saphenous vein grafts to second diagonal, first
obtuse marginal, second obtuse marginal and posterior descending
artery.
[**2174-4-12**] Bronchoscopy with Bronchaveolar Lavage. Excision of
Right Paratracheal Lymph Node.
[**2174-4-7**] Cardiac Catherization
History of Present Illness:
48 year old male with known coronary disease, who presented to
outside hospital with chest tightness and shortness of breath.
He ruled in for an NSTEMI with troponin 8.56. He was started on
intravenous Heparin and Nitroglycerin and urgently transferred
to the [**Hospital1 18**] for further evaluation and treatment.
Past Medical History:
Ischemic Cardiomyopathy
Coronary Artery Disease, prior LAD stent
Hypertension
Dyslipidemia
Diabetes Mellitus Type II
Asthma
Obesity
History of Non-sustained Ventricular Tachycardia
Social History:
Retired paramedic. 20 pack year history of tobacco, quit 4 years
ago. Denies excessive ETOH consumption. Lives alone.
Family History:
Denies premature coronary artery disease.
Physical Exam:
BP 115/85, P 82, RR 16
Ht 75 inches / Wt 140.6 kg
General: obese male in no acute distress
HEENT: oropharynx benign
Neck: supple, no jvd
Chest: few crackles at bases
Heart: regular rate and rhythm, normal s1s2, no murmur or rub
Abd: obese, benign
Ext: warm, trace edema
Neuro: non-focal
Pulses: 1+ distally
Pertinent Results:
[**2174-4-19**] 06:48AM BLOOD WBC-8.8
[**2174-4-18**] 11:00AM BLOOD WBC-11.3* RBC-4.24* Hgb-12.4* Hct-36.8*
MCV-87 MCH-29.2 MCHC-33.7 RDW-13.7 Plt Ct-476*
[**2174-4-6**] 03:55PM BLOOD WBC-10.0 RBC-3.88* Hgb-11.6*# Hct-32.4*#
MCV-84 MCH-29.8 MCHC-35.6* RDW-13.1 Plt Ct-206
[**2174-4-18**] 11:00AM BLOOD Neuts-70.2* Lymphs-19.2 Monos-5.5
Eos-4.4* Baso-0.6
[**2174-4-6**] 03:55PM BLOOD Neuts-73.4* Lymphs-21.4 Monos-4.2 Eos-0.8
Baso-0.3
[**2174-4-18**] 11:00AM BLOOD Plt Ct-476*
[**2174-4-17**] 01:22AM BLOOD PT-15.0* PTT-31.3 INR(PT)-1.3*
[**2174-4-6**] 03:55PM BLOOD Plt Ct-206
[**2174-4-6**] 03:55PM BLOOD PT-17.2* PTT-142.9* INR(PT)-1.6*
[**2174-4-12**] 01:54PM BLOOD Fibrino-470*
[**2174-4-18**] 11:00AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-138
K-4.6 Cl-99 HCO3-29 AnGap-15
[**2174-4-6**] 03:55PM BLOOD UreaN-27* Creat-1.1 Na-134 K-4.4 Cl-102
HCO3-19* AnGap-17
[**2174-4-17**] 01:22AM BLOOD ALT-28 AST-30 AlkPhos-57 TotBili-0.6
[**2174-4-9**] 06:45AM BLOOD proBNP-2083*
[**2174-4-6**] 03:55PM BLOOD cTropnT-2.09*
[**2174-4-18**] 11:00AM BLOOD Phos-2.9 Mg-2.3
[**2174-4-8**] 05:50AM BLOOD %HbA1c-8.4*
[**2174-4-8**] 05:50AM BLOOD Triglyc-153* HDL-17 CHOL/HD-8.4
LDLcalc-95
[**2174-4-14**] 05:52AM BLOOD Vanco-11.1
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 43189**],[**Known firstname **] [**2125-10-12**] 48 Male [**Numeric Identifier 43190**]
[**Numeric Identifier 43191**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**]
SPECIMEN SUBMITTED: immunophenotyping - 4R LN
Procedure date Tissue received Report Date Diagnosed
by
[**2174-4-12**] [**2174-4-13**] [**2174-4-15**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**]/ttl
Previous biopsies: [**Numeric Identifier 43192**] FS R 4 LYMPH NODE.
DIAGNOSIS:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, CD antigens 2, 3, 5, 7, 10, 19, 20, 23, 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells comprise 50% of lymphoid gated events, are polyclonal,
and do not express aberrant antigens.
T cells comprise 39% of lymphoid gated events and express mature
lineage antigens.
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a T- or B-cell
lymphoproliferative disorder are not seen in specimen.
Correlation with clinical findings and morphology (see
S09-[**Numeric Identifier **]) is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas as due to topography, sampling or
artifacts of sample preparation.
Radiology Report CHEST (PA & LAT) Study Date of [**2174-4-18**] 11:38
AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2174-4-18**] 11:38 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 43193**]
Reason: evaluate for effusion
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with s/p cabg mv repair
REASON FOR THIS EXAMINATION:
evaluate for effusion
Final Report
REASON FOR EXAMINATION: Followup of a patient after CABG and
mitral valve
repair.
PA and lateral upright chest radiograph was compared to [**4-15**], [**2174**].
Post-sternotomy wires appear to be intact. Cardiomediastinal
contour is
stable. Left linear opacities consistent with atelectasis, with
overall
slight improvement of the left base aeration. Upper lungs are
clear and there
is no evidence of failure.
IMPRESSION:
Improved aeration of the left paramediastinal opacities
consistent with
improvement of atelectasis.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: MON [**2174-4-18**] 5:49 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 17982**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 43194**] (Complete)
Done [**2174-4-12**] at 9:07:04 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2125-10-12**]
Age (years): 48 M Hgt (in): 74
BP (mm Hg): / Wgt (lb): 300
HR (bpm): BSA (m2): 2.58 m2
Indication: Intra-op TEE for CABG, MV repair
ICD-9 Codes: 428.0, 440.0, 414.8, 424.0
Test Information
Date/Time: [**2174-4-12**] at 09:07 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2009AW05-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.6 cm <= 4.0 cm
Left Ventricle - Diastolic Dimension: *7.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 20% to 25% >= 55%
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 2.2 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec
Mitral Valve - Peak Velocity: 1.1 m/sec
Mitral Valve - Mean [**Last Name (NamePattern5) 21888**]: 1 mm Hg
Mitral Valve - Pressure Half Time: 36 ms
Mitral Valve - MVA (P [**1-28**] T): 6.1 cm2
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 3.33
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Marked LA enlargement. Mild spontaneous echo
contrast in the body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
LAA. Depressed LAA emptying velocity (<0.2m/s)
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Severely dilated LV cavity. Severe
regional LV systolic dysfunction. Severely depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mild mitral annular calcification. No MS.
Eccentric MR jet. Moderate to severe (3+) MR. LV inflow pattern
c/w impaired relaxation.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
1. The left atrium is markedly dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. No
mass/thrombus is seen in the left atrium or left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler.
2. The left ventricular cavity is severely dilated. There is
severe regional left ventricular systolic dysfunction of the
apical, septal and anterolateral segments. Overall left
ventricular systolic function is severely depressed (LVEF= 20-25
%).
3. Right ventricular chamber size is normal. with mild global
free wall hypokinesis.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
6. An eccentric, posterior directed jet of Moderate to severe
(3+) mitral regurgitation is seen. T
7. he left ventricular inflow pattern suggests impaired
relaxation.
8. There is no pericardial effusion.
POST-BYPASS: The patient is A-paced and on infusions of
phenylephrine, epinephrine, and milrinone.
1. Biventricular function is similar to pre-bypass.
2. A PFO is now visualized with color flow doppler.
3. The aorta appears intact post decannulation.
4. A mitral valve annuloplasty ring has been placed. There is no
MR [**First Name (Titles) **] [**Last Name (Titles) **]. [**First Name (Titles) **] [**Last Name (Titles) **] is 3 mmHg at a cardiac output of 7 L/m.
The Swan-Ganz catheter is in the proximal right pulmonary
artery.
5. The remainder of the examination is unchanged.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2174-4-12**] 15:38
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiology service with NSTEMI
troponin 8 setting of known chronic systolic congestive heart
failure. He remained stable on intravenous therapy. The
following day he [**Known lastname 1834**] cardiac catheterization which
revealed severe three vessel coronary artery disease - please
see result section for details. Given that his coronary anatomy
was more suitable for surgical revascularization, cardiac
surgery was consulted and further evaluation was performed. In
anticipation for surgery, Plavix was subseqently held. An
echocardiogram was notable for moderate mitral regurgitation and
an ejection fraction of 20% - see result section for further
details. Carotid ultrasound found normal internal carotid
arteries while vein mapping revealed suitable saphenous vein.
Given chest x-ray findings revealed mediastinal lymphadenopathy,
the pulmonary service was consulted and a chest CT scan was
obtained which showed marked symmetric lymphadenopathy of the
mediastinum and the hila. Lymph node biopsy was recommended
along with bronchoscopy/bronchoaveolar lavage. Preoperative
course was otherwise uneventful, and he remained stable on
intravenous therapy.
On [**4-12**], Mr. [**Known lastname **] [**Last Name (Titles) 1834**] coronary artery bypass
grafting and mitral valve repair, along with excision of
paratracheal lymph node and bronchoscopy with bronchoaveolar
lavage. Please see operative notes for details. Given his
inpatient stay was greater than 24 hours, Vancomycin was given
for perioperative antibiotic coverage. He was transferred in
critical but stable condition to the surgical intensive care
unit, on inotropes and vasoactive medications. A bilateral
alveolar lavage was performed and a subsequent gram stain
revealed gram negative rods and gram positive cocci, which he
was placed on broad spectrum antibiotic coverage until the
culture was finalized. The culture revealed oropharyngeal flora
and antibiotics were discontinued. He was weaned off inotropes
and vasoactive medications, started on lasix for diuresis, and
was extubated on post operative day two. He remained in te
intensive care unit for blood glucose management and [**Last Name (un) 387**] was
consulted. When blood glucose stable he was transferred to the
floor were he received the remainder of his care. Physical
therapy worked with him on strength and mobilty. He was
educated on diabetes and was ready for discharge home on post
operative day seven with services.
Medications on Admission:
Home meds: Lipitor 60 qd, Carvedilol 25 [**Hospital1 **], Lasix 40 prn,
Enalapril 10 am/20 pm, Spironolactone 25 qd, Metformin 850 [**Hospital1 **]
Discharge Medications:
1. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Combivent 18-103 mcg/Actuation Aerosol Sig: 2 puffs
Inhalation four times a day.
Disp:*qs qs* Refills:*0*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*qs qs* Refills:*0*
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
12. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: please see sliding scale .
Disp:*qs qs* Refills:*2*
14. Lantus 100 unit/mL Solution Sig: Fifty Five (55) units
Subcutaneous once a day: please take in morning before breakfast
.
Disp:*qs qs* Refills:*2*
15. Sliding Scale Humalog
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
61-100 mg/dL 12 Units 12 Units 12 Units 0 Units
101-130 mg/dL 15 Units 15 Units 15 Units 0 Units
131-160 mg/dL 17 Units 17 Units 17 Units 0 Units
161-190 mg/dL 19 Units 19 Units 19 Units 3 Units
191-220 mg/dL 21 Units 21 Units 21 Units 6 Units
221-250 mg/dL 23 Units 23 Units 23 Units 8 Units
251-280 mg/dL 25 Units 25 Units 25 Units 10 Units
16. Insulin Needles (Disposable) 29 x [**1-28**] Needle Sig: Five (5)
syringe Miscellaneous per day : for lantus once a day and
humalog four times a day .
Disp:*150 syringes* Refills:*2*
17. Lancets Misc Sig: One (1) lancet Miscellaneous four
times a day.
Disp:*150 lancets* Refills:*2*
18. Blood Glucose Test Strip Sig: One (1) strip In [**Last Name (un) 5153**]
four times a day.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Ischemic Cardiomyopathy
Non ST elevation myocardial infarction
Acute on Chronic Systolic Congestive Heart Failure
Mitral Regurgitation
Coronary Artery Disease, prior LAD stent
Hypertension
Dyslipidemia
Diabetes Mellitus Type II
Mediastinal Lymphadenopathy
Asthma
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
8) Metformin was stopped due to heart failure, this medication
should not be resumed, if any further questions please call
9) Please monitor Blood glucose at least prior to meals and
bedtime, and with symptoms of hypoglycemia, goal BG < 150,
please contact [**Name (NI) **] for questions in relation to blood glucose
management
Followup Instructions:
Please call to schedule appointments
Dr. [**First Name (STitle) **] in 4 week
Dr. [**Last Name (STitle) **], in [**8-5**] days
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3612**] PA in 1 week
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in 3 weeks
Wound Check [**Hospital Ward Name **] 6 - Friday [**4-22**] at 1200 [**Telephone/Fax (1) 3071**]
[**Last Name (un) **] for diabetes management friday [**4-22**] with Dr. [**Last Name (STitle) 978**]
at 1:30pm [**Last Name (un) **] diabetes ([**Telephone/Fax (1) 4847**]
Dr [**Last Name (STitle) **] [**5-12**] at 1:00pm (sleep clinic) [**Hospital Ward Name **] bldg, [**Location (un) **] neurology [**Telephone/Fax (1) 612**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2174-4-19**]
|
[
"428.23",
"427.1",
"410.71",
"785.6",
"414.01",
"424.0",
"493.90",
"500",
"428.0",
"250.60",
"278.00",
"414.8",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.22",
"40.11",
"88.56",
"35.12",
"36.14",
"39.61",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
16699, 16746
|
11235, 13749
|
357, 759
|
17053, 17060
|
1845, 4912
|
18213, 19060
|
1460, 1503
|
13947, 16676
|
4952, 4992
|
16767, 17032
|
13775, 13924
|
17084, 18190
|
9150, 11212
|
1518, 1826
|
281, 319
|
5024, 9101
|
787, 1105
|
1127, 1309
|
1325, 1444
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,288
| 130,410
|
38902
|
Discharge summary
|
report
|
Admission Date: [**2157-4-4**] Discharge Date: [**2157-4-8**]
Date of Birth: [**2135-6-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
21M s/p rollover motor vehicle who was ejected and noted with
left chest deformity and was needle decompressed in the field.
He was transported to [**Hospital1 18**] for further care.
Past Medical History:
PSH: appendectomy
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Temp:AF HR:82 BP:132/P Resp:23 O(2)Sat:93 RA, 99 NRB low
Constitutional: Alert, GCS 15
HEENT: + facial abrasion, + intraoral lac (inside lower
lip), dried blood in nares, no septal hematoma, Pupils
equal, round and reactive to light, Extraocular muscles
intact
C-collar
Chest: Equal breath sounds, L lateral chest wall dressing
(presumably at site of prior decompression), + L clavicular
deformity
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, FAST negative, stable pelvis
Rectal: Normal rectal tone, no gross blood
Extr/Back: + t/l spine ttp, no step-offs, warm,
well-perfused
Skin: Multiple abrasions, including face, L hand, L knee,
low back/L flank, laceration to L hip with exposed subq fat
Neuro: Speech fluent, A&Ox3, CN intact, 5/5 strength
bilaterally, normal sensation to light touch
Pertinent Results:
[**2157-4-4**] 03:41PM GLUCOSE-128* UREA N-13 CREAT-0.9 SODIUM-139
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12
[**2157-4-4**] 03:41PM WBC-14.7* RBC-4.11* HGB-12.4* HCT-36.1*
MCV-88 MCH-30.1 MCHC-34.3 RDW-12.8
[**2157-4-4**] 03:41PM PLT COUNT-263
[**2157-4-4**] 10:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2157-4-4**] 10:25AM WBC-24.2* RBC-4.59* HGB-13.9* HCT-40.4 MCV-88
MCH-30.3 MCHC-34.4 RDW-12.9
[**2157-4-4**] 10:25AM PLT COUNT-292
CT head:
IMPRESSION:
1. Right maxillary air-fluid level, which may represent acute
sinusitis but in the setting of trauma, a subtle facial bone
fracture may be present which is not detected on the current
exam. If clinical suspicion for facial bone fracture remains
high, a dedicated CT of the facial bones is recommended.
3. Left frontal scalp hematoma.
CT torso:
IMPRESSION:
1. Grade 2 splenic injury with associated small perisplenic
hematoma.
2. Bilateral small pneumothoraces without evidence of tension.
3. Bilateral lung contusions.
4. Left distal segmental clavicle fracture.
5. Second through fourth rib fractures on the left side
involving the
costochondral junctions.
6. Left lateral pelvic soft tissue laceration with punctate
densities, for
which correlation for possible foreign bodies are recommended.
CT c-spine:
IMPRESSION:
1. No evidence of fracture or subluxation.
2. Bilateral pneumothoraces and pulmonary contusions.
3. Right maxillary air-fluid level which may indicate a facial
fracture or
may simply signify sinusitis. If there is clinical concern for a
facial
fracture, then a dedicate CT of the facial bones is recommended.
CXR:
IMPRESSION:
1. Heterogeneous parenchymal opacity in the posterior left lower
lobe, has
minimally improved since the earliest CT of [**2157-4-4**]. This likely
represents a resolving contusion, however, superimposed
infection cannot be definitively ruled out.
2. No new parenchymal opacities are identified.
Brief Hospital Course:
He was admitted to the Trauma service and transferred to the
Trauma ICU for close observation. Serial exams and hematocrits
were followed closely and remained stable. He was eventually
transferred to the regular nursing unit. On [**4-5**] he was noted to
be febrile and was cultured; chest xray was done showing new
right pneumonia or aspiration with clearing multifocal lung
contusion. His oxygen saturations remained stable and he was
encouraged to ambulate, cough, deep breathe and use the
incentive spirometer. His fevers defervesced eventually.
He was evaluated by orthopedics for his clavicle fracture; this
was managed non operatively. He is to wear a sling for comfort
and should not bear any weight. He will follow up in 2 weeks in
[**Hospital **] clinic.
His pain was controlled with oral narcotics; he is tolerating a
regular diet and ambulating without difficulty after evaluation
by Physical therapy.
Medications on Admission:
None
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
2. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
over rib fracture site.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Bilateral pneumothoraces
Bilateral pulmonary contusion
Left clavicular fracture, segmental
Left rib fractures 3,4
Left rib dislocation 3/4/5
Grade II splenic laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
IT IS IMPORTANT that if y ou suddenly feel dizzy or light headed
as if you are going to pass out you should return to the nearest
emergency room as this could be a sign that you are having
internal bleeding from your spleen injury.
DO NOT participate in any contact sports of any kind or other
activity that could cause injury to your abdominal region for
the next 6 weeks.
The injuries that you sustained from the motor vehicle crash can
be very painful; it is important that you take your pain
medication as prescribed. Also take a stool softener and
laxative while taking narcotics to prevent constipation.
DO NOT bear any weight on your left arm because of yourfracture;
wear the sling for comfort.
You may use a mild soap to wash your face; take care to gently
wash the areas with the abrasions. It is OK to apply Bacitracin
ointment to your abrasions.
Followup Instructions:
Follow up next week in Trauma clinic with Dr. [**Last Name (STitle) **] for
evaluation of your rib fractures and spleen injury. Call
[**Telephone/Fax (1) 2359**] for an appointment and inform the office that you
will need a standing end expiratory chest xray for this
appointment.
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP for your
clavicle fracture; call [**Telephone/Fax (1) 1228**] for an appointment.
Completed by:[**2157-4-8**]
|
[
"780.60",
"865.03",
"807.03",
"810.03",
"E816.0",
"861.21",
"860.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5174, 5180
|
3556, 4473
|
336, 342
|
5417, 5417
|
1563, 2062
|
6454, 6943
|
612, 629
|
4528, 5151
|
5201, 5396
|
4499, 4505
|
5568, 6431
|
644, 1544
|
273, 298
|
370, 555
|
2071, 3533
|
5432, 5543
|
577, 596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,712
| 178,657
|
10400
|
Discharge summary
|
report
|
Admission Date: [**2110-8-20**] Discharge Date: [**2110-8-26**]
Date of Birth: [**2062-7-3**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Metronidazole
Attending:[**First Name3 (LF) 34452**]
Chief Complaint:
CC - nausea, vomiting, fever, diarrhea x 24 hrs
Major Surgical or Invasive Procedure:
Colonoscopy [**2110-8-25**] with normal results
History of Present Illness:
48 yo man w/ h/o HIV (last CD4 59, recently taken off HAART due
to [**Month/Day/Year 500**] marrow suppression), Hep C, ESLD, and chronic ascites
who presents nausea, vomiting, fever, and diarrhea x 24 hours.
The patient was seen by Dr. [**Last Name (STitle) 497**] in the Liver Center [**8-15**], who
performed a therapeutic paracentesis. On the night prior to
admission, he developed acute onset nausea, non-bloody emesis x
1, fever (100.4 or 104, cannot remember), crampy abdominal pain,
and non-bloody diarrhea. He denied chills, night sweats, SOB,
cough, mental status changes, headache, or rash. Last BM was at
8 am. Reports compliance with all medications; however,
lasix/aldactone were stopped on [**8-15**]. His friend brought him to
the ER for evaluation.
.
In the ED, he was febrile to 102.5, tachy at 119, BP 119/77, RR
28, 97%RA. Then BP subsequently dropped to 94/58. He was given
1.5 liters NS, levofloxacin 500 mg IV x 1, vanco 1 gm IV x 1,
Flagyl 500 mg IV x 1. Lactate was 5.2. He also received 2
units FFP in anticipation of possible paracentesis; however,
abdominal u/s showed no pockets of peritoneal fluid for tap.
Past Medical History:
1. HIV, diagnosed in [**2092**]. Previously on Trizivir, stopped 2
months ago [**2-26**] leukopenia, started on Neupogen. Last CD4 248 on
[**2110-6-16**] off HAART. VL <50 on [**2110-5-5**]. History of + IVDU.
2. Hepatitis C/cirrhosis: Complicated by ascites and varices.
HCV VL 2,660,000 IU/mL on [**2110-5-5**]. Listed for transplant.
3. Chronic back pain and leg pain secondary to spinal stenosis.
4. Peripheral neuropathy
5. History of compression fracture
Social History:
Positive tobacco [**1-26**] ppd X years. No EtOH. Past history of IVDU,
nothing X more than 15 years. He lives alone.
Family History:
Non-contributory
Physical Exam:
100.8 - 104 - 110/52 - 16 - 94% RA
Gen: cachectic man, jaundiced, awake and alert, NAD
HEENT: PERRL, icteric, dry MM, erythematous MM, temporal wasting
Neck: supple, no LAD
Lungs: course bilaterally, +wheezes diffusely, no crackles
Heart: RRR, normal s1s2, no M/R/G
Abd: NABS, distended, TTP RLQ and mid-lower abdomen, no palpable
masses. +caput medusae
Ext: 1+ pitting edema bilaterally, +venous stasis changes
Neuro: A&Ox3, CN II-XII intact; strength grossly intact
bilaterally; +asterixis
Rectal: guaiac negative per ER
.
Brief Hospital Course:
Shortly after admission, the patient became hypotensive and was
transferred to the MICU for pressure management. In the MICU,
the patient was bolused to keep MAP > 60 and empiric Abx
treatment for SBP, PNA/PCP/MAC, and meningitis was started:
Ceftriaxone 2 gm IV Q24H, Levofloxacin 500 mg IV Q24H, Flagyl
500 mg IV Q8h, and Bactrim. 4/4 bottles BCx grew GNR. BP
stabilized overnight, and pt became afebrile. ID consulted,
recommended continuing antibiotic coverage and tailoring after
speciation/sensitivities came back. CMV viral load and extensive
stool studies were sent. Liver service consulted and recommended
lactulose and rifaximin for hepatic encephalopathy, restarting
Lasix/aldactone when hemodynamically stable, and considering
tapping the ascites. Hyponatremia, probably [**2-26**] cirrhosis, was
managed w/ free water restriction. RUQ U/S showed cholelithiasis
but no cholecystitis. Abd CT showed diffuse wall thickening of
ascending and transverse colon likely representing infectious or
inflammatory colitis.
After the patient was stabilized, he was transferred back to the
floor for further management. A colonscopy done showed no
abnormalities. He was continued on Flagyl for a course of 7 days
for the ascending colitis, and on ceftriaxone for E.coli sepsis
2g IV.
At the time of discharge, the patient was no longer having any
diarrhea and asymptomatic. He deferred having a therapeutic
paracentesis multiple times and preferred to wait until his
appointment with Dr. [**Last Name (STitle) 497**] to have the tap done. He was
discharged with a midline to complete his 2-week course of
Ceftriaxone therapy and was to follow with his ID physician for
results of the stool studies, as they were all pending at the
time of discharge.
Medications on Admission:
1. Aldactone 30 mg TID
2. Bactrim 1 tablet daily
3. Lactulose 30 ml TID
4. Lasix 20 mg QID
5. Rifaximin 200 mg TID
6. Truvada 200-300 mg daily
7. MS Contin 240 mg TID
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
3. Rifaximin 200 mg Tablet Sig: 1.5 Tablets PO tid ().
Disp:*135 Tablet(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ceftriaxone Sodium in D5W 40 mg/mL Piggyback Sig: Two (2)
grams Intravenous Q24H (every 24 hours) for 7 days.
Disp:*14 grams* Refills:*0*
7. Morphine 60 mg Tablet Sustained Release Sig: Four (4) Tablet
Sustained Release PO three times a day.
Disp:*168 Tablet Sustained Release(s)* Refills:*0*
8. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary - colitis of unknown etiology
Secondary - HIV/AIDS ([**2092**]), Hep C/cirrhosis/ESLD, chronic
diarrhea, ascites, chronic back pain and leg pain, spinal
stenosis, peripheral neuropathy
Discharge Condition:
Fair
Discharge Instructions:
-continue with medications as prescribed
-please follow-up in clinic as scheduled
-if diarrhea returns or worsens, or any other concerning
symptoms arise, please seek medical attention
-weigh yourself daily
Followup Instructions:
Provider: [**Name10 (NameIs) 454**],SIX DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8
Date/Time:[**2110-8-29**] 12:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2110-9-4**] 11:00
Provider: [**Name10 (NameIs) 454**],SIX DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8
Date/Time:[**2110-8-29**] 12:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2110-9-4**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2110-9-8**] 11:30
Completed by:[**2110-9-1**]
|
[
"V02.59",
"042",
"787.91",
"995.91",
"724.00",
"276.1",
"V09.0",
"355.8",
"682.6",
"574.20",
"558.9",
"038.42",
"518.0",
"287.5",
"707.15",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"38.93",
"99.05",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
5697, 5748
|
2778, 4529
|
332, 382
|
5986, 5992
|
6247, 7075
|
2194, 2212
|
4746, 5674
|
5769, 5965
|
4555, 4723
|
6016, 6224
|
2227, 2755
|
245, 294
|
410, 1558
|
1580, 2042
|
2058, 2178
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,136
| 186,931
|
186
|
Discharge summary
|
report
|
Admission Date: [**2194-5-8**] Discharge Date: [**2194-5-14**]
Service: MEDICINE
Allergies:
Lisinopril / Nsaids / Nesiritide
Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
* interview conducted with the aid of Ms. [**Known lastname 1862**] daughter
.
History of Present Illness: Ms. [**Known lastname **] is an 86 y/o F with
history of nephrotic CRI, renal artery stenosis, and CHF, who
presented with hypertensive emergency and heart failure. The
patient reports that she was in her usual state of health until
3 days prior to admission. At that time, her BP was 220 systolic
@ home and she noticed mild SOB. On the night prior to
admission, she developed increasing SOB. Per the patient's
daughter, she had been taking her medications as prescribed. She
denies chest pain throughout this time. She was brought in by
daughter to [**Name (NI) **] for evaluation and was found to have BP 202/40
with a K of 5.9. She was treated with kayexalate 30, lasix 40
IV, clonidine 0.3 mg PO X 1, and levoflox 750 mg IV x 1.
.
The patient was initially admitted to the floor, where she was
found to have the following vitals: 98.3 226/68 68 90% 5LNC (mid
80s on 2LNC), 96% on face tent, RR > 40. As she was acutely
dyspneic and in acute failure, she was given 100mg IV lasix and
Diuril (on the advice of Renal consultants), w/ good effect->
UOP 350cc in ~1hour. She did not receive any nitrates or
morphine at the time. On MICU evaluation was 99% on shovel mask,
but still RR>40. Appeared comfortable, JVP ~9 cm. At that time,
she denied HA, visual changes, CP, urinary changes, no abd pain,
N/V/D. In the MICU, she was aggressively diuresed and placed on
her usual blood pressure regimen. Overnight [**Date range (1) 1873**], she did
not receive all of her blood pressures meds as her BPs were in
the 110s/120s overnight. She did receive all doses of clonidine
and hydralazine on [**5-9**].
.
Her daughter tells me that her edema is less than usual, but
that her right leg is chronically larger than the left. She has
been using several pillows to sleep at home. She denies PND. She
is not on supplemental O2 at home. Generally BP at home is 170s
(per PCP 160s in office at baseline).
.
Pt was diagnosed with w/ RLL PNA by her PCP and tx [**Name Initial (PRE) **]/
levofloxacin X 10 days about 4 weeks ago. Since that time, the
daughter has been living with the pt X 3 weeks. Her cough has
persisted per the daughter, but the patient did improve greatly
following antibiotics.
.
At the present time, the patient says she is comfortable. She
denies chest pain. She continues to make adequate urine.
Past Medical History:
- Renal artery stenosis: MRI [**2185**] atrophic R kidney, mod
stenosis of R renal artery, L renal artery normal
- CRI/nephrotic range proteinuria, renal artery stenosis,
followed by Dr. [**Last Name (STitle) 1860**] (Nephrology) (recent baseline Cr 7.9-9.1)
- PVD/Claudication
- Congestive heart failure w/ EF 50-55%, known WMA ([**9-1**])
- h/o R cephalic vein DVT ([**7-2**])
- Colon cancer dx [**2-/2192**] s/p resection
- GERD
- Hypertension
- Hyperlipidemia
- h/o Rheumatic Fever
- RBBB
- Anemia baseline Hct low 30s
- Osteoarthritis
- Osteopenia
- Glaucoma
Social History:
Russian-speaking. Living alone independently prior to
hospitalization in 2/[**2192**]. Several children and grandchildren
in the area are involved in her care.
denies alcohol or tobacco use.
Family History:
mother- HTN
Physical Exam:
VS afebrile HR 62 BP 178/46 RR 26 O2 93% 4L NC
GENERAL: NAD, lying @30 degrees and comfortable
HEENT: EOMI, OMMM, pupils small but reactive
NECK: JVP at 8 cm, supple, no LAD, no carotid bruits
CARDIOVASCULAR: S1, S2, reg, II/VI systolic throughout
precordium
LUNGS: crackles halfway up bilaterally, no wheezes, good air
movement
ABDOMEN: Soft, NT, ND, no masses, foley catheter in place
EXTREMITIES: Warm, trace edema bilaterally, right leg slightly
larger than left
NEURO: A/O X3, russian speaking, pleasant, strength 5/5
bilateral grip, biceps, triceps, ankle dorsi- & plantarflexion,
sensation intact bilateral upper & lower extremities
Pertinent Results:
Studies:
[**2194-5-8**] CXR: IMPRESSION: Moderate congestive heart failure,
worse since the exam of one month ago.
.
[**2194-5-8**] ECHO: TTE Conclusions:
The left atrium is moderately dilated. There is moderate
symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF 60%).
.
There is mild aortic valve stenosis (area 1.2-1.9cm2). Moderate
(2+) aortic
regurgitation is seen.
.
There is severe mitral annular calcification. There is a
minimally increased gradient consistent with minimal mitral
stenosis. Mild to moderate ([**1-28**]+) 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
supporting structures of the tricuspid valve are
thickened/fibrotic.
.
There is severe pulmonary artery systolic hypertension. There is
a small pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2193-9-19**], borderline mitral stenosis is now evident.
The mitral regurgitation, which is almost certainly
underestimated on this study, is probably increased.
.
[**2194-5-11**] CXR TWO VIEWS: Comparison with the previous study done
[**2194-5-9**]. There is interval improvement in interstitial pulmonary
edema. The mild pulmonary vascular congestion persists. Streaky
density at the lung bases is consistent with subsegmental
atelectasis. There is a moderate right pleural effusion and
small left pleural effusion. An underlying right basilar
consolidation cannot be excluded. The heart and mediastinal
structures are unchanged.
IMPRESSION: Interval improvement in congestive heart failure.
.
.
Labs:
ProBNP greater than 70,000
.
Cardiac enzymes:
[**2194-5-8**] 12:10PM BLOOD CK(CPK)-24*
[**2194-5-8**] 06:30PM BLOOD CK(CPK)-20*
[**2194-5-9**] 02:50AM BLOOD CK(CPK)-22*
[**2194-5-8**] 04:49AM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2194-5-8**] 12:10PM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2194-5-8**] 06:30PM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2194-5-9**] 02:50AM BLOOD CK-MB-NotDone
[**2194-5-9**] 02:50AM BLOOD cTropnT-0.15*
.
Her lab values remained fairly constant throughout her admission
and her discharge labs are given here.
.
WBC-6.6 RBC-3.46* Hgb-9.5* Hct-29.0* MCV-84 MCH-27.4 MCHC-32.6
RDW-17.7* Plt Ct-211
.
Glucose-89 UreaN-107* Creat-8.6* Na-130* K-5.0 Cl-100 HCO3-17*
Calcium-8.9 Phos-7.1* Mg-2.5
.
.
.
Micro:
[**2194-5-12**] BLOOD CULTURE x2 bottles No growth
[**2194-5-10**] BLOOD CULTURE x4 bottles No growth
[**2194-5-10**] URINE No growth
[**2194-5-10**] BLOOD CULTURE x2 bottles No growth
[**2194-5-8**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE}
EMERGENCY [**Hospital1 **]
[**2194-5-8**] BLOOD CULTURE x2 bottles No growth
Brief Hospital Course:
Ms. [**Known lastname **] is an 86 year old female with probable endstage
renal failure not on HD, who presented with hypertensive
emergency and congestive heart failure. She was admitted to the
medical floor but immediately was sent to the MICU for
respiratory distress. There she was agressively diuresed and
then returned to the medical floor.
.
* Hypertensive Emergency: Her HTN is likely secondary to her
ESRD. The elevated blood pressures caused flash pulmonary edema
and congestive heart failure. She was given blood pressure
medications to help control her BP within the range of 130-160
as she probably is dependent on some hypertension for perfusion.
Her baseline BP is reportedly 160 at home. Ultimately she was
placed on clonidine 0.2 mg TID, hydralazine 100mg TID, norvasc
10mg qday, metoprolol 12.5mg TID, lasix 40mg [**Hospital1 **].
.
* ? SVT: During her initally presentation, she did have some
runs of SVT noted on telemetry. Once she was diuresed no
further episodes were noted. She was continued on metoprolol
12.5 mg TID for given episodes of ? SVT.
.
* Congestive Heart Failure: Likely from worsening renal failure
and hypertensive urgency. She was agressively diuresed in the
MICU with IV furosemide overnight and then with PO furosemide on
the medical floor. She was also continued on hydralazine for
afterload reduction.
.
* Renal Failure: A renal consult was obtained. They felt that
there was no acute needs for dialysis at present although they
have been discussing starting HD with the patient and her family
for a while now. This discussion was continued throughout the
admission and the patient and her family were resistent to
starting. They agreed to meet with Dr. [**Last Name (STitle) 1366**] in the next two
weeks to discuss getting a tunnelled cath and starting HD.
Throughout admission, her electrolytes were monitored closely as
she had boughts of hyperkalemia, hyperphosphatemia and acidosis.
These were controlled with standard measures.
.
* Hyperkalemia: Received Kayexalate in ED. Usually takes
kayexalate twice a week as outpatient, so this was restarted as
an inpatient.
.
* Anemia: Baseline Hct appears to be 29-33 and now 25. Iron 45,
ferritin 149, TIBC 269 in [**3-5**]. Per renal recommendation, she
was transfused 1 unit PRBC on [**2194-5-12**] without complications.
.
* Bacteremia: WBC count 10 on admission and down to 6.4 today.
Has been afebrile but blood cultures showed 2/4 bottles with
staph coag negative- likely contaminant. Before speciation
returned, she was treated with vancomycin dosed by level. Once
it was found to be coag negative staph, the vancomycin was
discontinued. All subsequent surveillence cultures were
negative.
.
* Code status: Full - discussed w/ patient's daughter.
.
* COMM: Dtr [**Name2 (NI) 1874**] [**Telephone/Fax (1) 1875**]; Son [**Name (NI) **] [**Telephone/Fax (1) 1876**]
Medications on Admission:
Albuterol 2 4X/day
Baking soda [**3-30**] tsp
Clonidine 0.3 mg @ AM, 0.2 mg @ Noon, 0.3 mg @ PM
Epogen 10K 2X/week
Hydralazine 75 TID
Imdur 30 once daily
Lasix 20 once daily (daughter states patient taking only 20 at
home)
Lipitor 10 once daily
Toprol 25 once daily
Amlodipine 10 once daily
Phoslo 1334 TID
Renagel 800 TID
Vit D 50K q month
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO every eight
(8) hours.
Disp:*120 Tablet(s)* Refills:*2*
5. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO three times
a day.
Disp:*270 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*270 Capsule(s)* Refills:*2*
8. Baking Soda
[**3-30**] teaspoon by mouth daily
9. Kayexalate Powder Sig: One (1) teaspoon PO Twice a week.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Albuterol Inhalation
12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
13. Epoetin Alfa Injection
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
hypertensive emergency
Diastolic congestive heart failure
stage V chronic kidney disease
Anemia
GERD
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L daily
.
You were admitted with very high blood pressure and fluid
overload in your lungs. You were given medications to help lower
your blood pressure and get the fluid off.
.
Some of your medication doses have been changed. Please see the
medication list for those different doses.
.
As you know, your kidneys do not function very well. It has been
recommended that you start dialysis to help remove the toxins in
your blood which your kidneys can no longer remove. You have
decided to hold off on this for now (despite knowing the risks
of sudden death, fluid overload), but you should follow up with
Dr. [**Last Name (STitle) 1366**] to have this started soon.
.
You should continue to take your medications as prescribed.
.
You should contact your PCP or go to the emergency room if you
have fevers>101, chills, shortness of breath, chest pain, weight
gain more than 3 lbs, or any other symptoms which are concerning
to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2194-5-22**] 5:00PM
.
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule
appointment
.
.
Primary care: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. Date/Time:[**2194-6-17**] 2:30PM
Phone [**Telephone/Fax (1) 250**]
Completed by:[**2194-5-25**]
|
[
"403.01",
"530.81",
"585.5",
"428.30",
"285.9",
"428.0",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11538, 11544
|
7136, 10012
|
260, 267
|
11708, 11717
|
4213, 5952
|
12819, 13321
|
3525, 3538
|
10403, 11515
|
11565, 11565
|
10038, 10380
|
11741, 12796
|
3553, 4194
|
5969, 7113
|
201, 222
|
402, 2711
|
11584, 11687
|
2733, 3298
|
3314, 3509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,337
| 176,555
|
22249
|
Discharge summary
|
report
|
Admission Date: [**2189-2-19**] Discharge Date: [**2189-2-26**]
Date of Birth: [**2134-8-24**] Sex: M
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS:
1. Hepatitis C.
2. Cirrhosis.
3. Grade III esophageal varices.
4. Colonic polyps.
5. History of bradycardia.
6. Status post cholecystectomy.
7. Status post repair of ruptured cervical disc.
8. Status post radiofrequency ablation of hepatoma.
DISCHARGE DIAGNOSIS:
1. Hepatitis C, hepatocellular carcinoma - status post
orthotopic liver transplantation [**2189-2-19**].
2. Insertion of nasal feeding tube.
3. Cirrhosis.
4. Grade III esophageal varices.
5. Colonic polyps.
6. History of bradycardia.
7. Status post cholecystectomy.
8. Status post repair of ruptured cervical disc.
9. Status post radiofrequency ablation of hepatoma.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname **] is a 54-year-old
male who acquired Hepatitis C likely secondary to some
tattoos he had received who's course has been complicated by
cirrhosis and development of hepatocellular carcinoma. His
hepatitis infractory to interferon therapy. He presented
after full workup for liver transplantation as an outpatient
for orthotopic liver transplant on [**2189-2-19**] when a
suitable organ was available for him. At the time of
presentation he had been afebrile and otherwise had no
specific systemic complaints. On examination he was afebrile
and hemodynamically normal. He was not grossly jaundiced
normal and he only had a slight amount of icterus. Otherwise
he had no cervical adenopathy and his lungs were clear. His
heart was regular. His abdomen was soft and distended. He
did have a slight fluid wave and a mild rectus diastasis but
otherwise no hernias. He was guaiac negative. He had no
significant edema in the extremities. In terms of his
admission labs, his preoperative white count was 3.2 with a
hematocrit of 36, platelet count of 150, prothrombin time was
14.2 with an INR of 1.3. BUN and creatinine were 13 and 1.0.
His total bilirubin was 2.4 with an alkaline phosphatase of
315 and his ALT and AST were 110 and 177.
HOSPITAL COURSE: The patient was admitted on [**2189-2-19**] and on
that same day underwent an orthotopic liver transplantation
without note of intraoperative complications. He
specifically had a cadaveric renal transplant with piggyback
technique with portal vein to portal vein anastomosis,
hepatic artery anastomosis and bile duct - bile duct
anastomosis. The patient tolerated the procedure well and
remained intubated and was taken to the intensive care unit
postoperatively for ventilatory support, hemodynamic
monitoring. While in the Post Anesthesia Care Unit he had
nutritional support through tube feedings via intraoperative
replaced nasogastric tube.
His hospital course was relatively unremarkable. He
underwent a hepatic ultrasound on postop day one which did
not show any evidence of hepatic artery thrombosis or
stenosis. He had a good amount of flow. He was extubated on
postop day one and was not requiring any pressors therefore,
by postop day two he was transferred to the floor and
ambulating. The remainder of his hospital course was
essentially for advancement of his diet, monitoring of his
liver function tests which continued to progressively improve
and for immunosuppression. In terms of his immunosuppression
he was given Simulack and Methylprednisolone with CellCept
perioperatively. Postoperatively his CellCept and
Methylprednisolone were continued. He had Cyclosporin added
to this regimen on postop day one and continued to have his
dose adjusted backed on C2 levels which were drawn every
morning. By postop day seven the patient was afebrile,
otherwise hemodynamically normal, he was tolerating regular
diet, not requiring any tube feeds or supplementation.
Otherwise had no respiratory issues and was ambulating
without difficulty therefore, it was felt that he could be
discharged to home in good condition. By the time of his
discharge his liver function tests had greatly improved. His
total bilirubin was 1.7 with alkaline phosphatase phos 237
and an ALT and AST of 205 and 41. His hematocrit was 33.7
and his prothrombin time was 12.4 with an INR of 1.0. He was
discharged to home on the following medications:
1. Bactrim, one tab p.o. once daily.
2. Protonix 40 mg p.o. once daily
3. Fluconazole 400 mg p.o. once daily
4. CellCept [**Pager number **] mg p.o. twice a day.
5. Prednisone 20 mg p.o. once daily.
6. Colace 100 mg p.o. twice a day
7. Acyclovir 900 mg once daily
8. Cyclosporin level was to be adjusted daily.
9. Percocet for pain.
The patient was to have outside laboratory work done twice a
week with laboratory results sent to the Transplant Office.
He was to follow-up with Dr. [**Last Name (STitle) **] in one week.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2189-2-26**] 13:26:55
T: [**2189-2-26**] 14:27:49
Job#: [**Job Number 58020**]
|
[
"456.21",
"070.70",
"155.0",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"00.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
440, 2113
|
2131, 5033
|
175, 419
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,967
| 128,475
|
54648
|
Discharge summary
|
report
|
Admission Date: [**2112-6-27**] Discharge Date: [**2112-7-9**]
Date of Birth: [**2049-8-14**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache/ SAH
Major Surgical or Invasive Procedure:
[**2112-6-27**] Diagnostic cerebral angiogram
[**2112-6-29**] Angiogram with coiling of P-Comm artery aneurysm
History of Present Illness:
Patient is a 62 year old female who has had a week of
headaches focusing on the right side primarily behind the eye
and
ear, as well as in her neck. She presented to an outside
hospital
for evaluation and head CT was done which showed subarachnoid
hemorrhage in the sylvian fissure on the right side. As a result
of these finding she was transferred to [**Hospital1 18**] for further
evaluation. upon arrival neurosurgery was consulted and given
her
imaging we recommended a CTA of the head and neck to better
evaluate her vessels. She c/o headache which has remained
constant in intensity, she denies dizziness, photophobia,
nausea,
vomiting, changes in vision , hearing, or speech, she has no
signs of meningismus.
Past Medical History:
HLD, migraines, choly, tonsilectomy
Social History:
director of counseling at [**University/College **], smokes 15
cigarettes a day, social ETOH
Family History:
mother laryngeal cancer and CAD, father lung cancer
Physical Exam:
On the day of admission: [**2112-6-27**] PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 2 GCS 15
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-23**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-26**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On the day of discharge:
AAO3, perrl, face symmetric, tongue mildline, no pronator drift
motor is [**3-26**] bilaterally, sensory intact, Babinski - flexor
gait is steady
Pertinent Results:
CTA head/ neck [**2112-6-27**]
CONCLUSION:
1. Bilateral subarachnoid hemorrhage.
2. Right posterior communicating artery aneurysm measuring 5 mm
in diameter needs neurosurgical attention.
Preliminary report was generated that read "diffuse subarachnoid
hemorrhage, not increased since the outside CT of [**2112-6-27**] at
11:31 a.m. Right posterior communicating artery aneurysm,
approximately 5 mm in greatest dimension.
CHEST (PORTABLE AP) [**2112-6-27**]
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
ET tube in standard placement. Nasogastric tube ends in the mid
to low
stomach. Supine positioning explains distention of mediastinal
and pulmonary veins. Heart size normal. Lungs clear.
Diagnostic cerebral angiogram [**2112-6-27**]
IMPRESSION: [**Known firstname **] [**Known lastname **] underwent diagnostic cerebral
angiography, and due to the presence of two adjacent aneurysms,
one of which was wide necked and not amenable to coiling,
surgery was recommended.
[**2112-6-28**] ECG:
Sinus rhythm. Early R wave progression. ST-T wave changes in the
precordial leads marred by artifact. Since the previous tracing
of [**2112-6-27**] probably no significant change.
[**2112-6-29**] CXR:
Lungs are fully expanded and clear following tracheal
extubation. Pulmonary vasculature is unremarkable. Heart size
is normal. No pleural abnormality. Nasogastric tube passes
into the stomach and out of view.
Skull xray [**2112-6-30**]:
No movement of coil mass appreciated
[**2112-7-3**] CTA head
IMPRESSION:
1. Improvement in the subarachnoid hemorrhage and
intraventricular hemorrhage compared to the prior head CT dated
[**2112-6-27**].
2. Status post coiling of right PCOM aneurysm.
3. The major intra- intracranial vessels are patent, however,
there is mild hypoattenuation or possible narrowing of the right
posterior communicating artery, possibly representing vasospasm.
[**2112-7-4**] Chest Xray: In comparison with the study of [**6-29**], there
is some mild indistinctness of pulmonary vessels consistent with
some elevated pulmonary venous pressure. Hazy opacification at
the bases raises the possibility of pleural effusions with
compressive atelectasis. However, much of this may be due to
overlying soft tissues and scattered radiation related to the
size of the patient.
[**2112-7-5**] CTA head CONCLUSION:
1. Vessels of anterior and posterior circulation are unchanged
in caliber
compared to prior exams with no evidence of vasospasm.
2. Stable appearance of subarachnoid hemorrhage compared to
prior CT from
[**2112-7-3**].
3. The patient is status post coiling of right PCOM aneurysm.
4. Opthalmic artery aneurysm seen on cerebral angiography is
seen partially obscured by coil artifacts.
[**2112-7-6**] SKull X-rays
Vascular coil again present in the region of the right posterior
communicating artery.
[**2112-7-7**] LENS
No evidence of deep vein thrombosis of either right or left
lower
extremity.
[**2112-7-7**] CT head
Minimal residual subarachnoid hemorrhage with no evidence of new
hemorrhage or infarct.
Brief Hospital Course:
This is a 62 year old female who has had a week of headaches
focusing on the right side primarily behind the eye and ear, as
well as in her neck. She presented to an outside hospital for
evaluation and head CT was done which showed subarachnoid
hemorrhage in the sylvian fissure on the right side. The patient
was transferred to this hospital on [**2112-6-27**] and underwent
further evaluation which included a CTA of the Head and Neck
which was consistent with bilateral subarachnoid hemorrhage and
right posterior communicating artery aneurysm measuring 5 mm in
diameter
needs neurosurgical attention. The patient underwent a cerebral
angiogram which was consistent with a Opthalmic and a pcom
aneurysm.
On [**6-28**], The dilantin level was 2.1 corrected and the patient was
loaded with 1 gm dilantin. Magnesium was repleted. Urine
output this am - 30-35 cc hr for 3 hours and intravenous fluid
was started at 50 cc/hr. The open aneurysm clipping was
cancelled due to OR availability. The patient was electively
extubated. On exam the patient was neurologically intact. At
1700 the patient complained of new onset double vision eye and
intermittent tremor left leg. The patient was requiring
vasopressors to keep SBP < 140. The patient was evaluated by
the team and Dr [**Last Name (STitle) **]. An open clipping was discussed with the
family if coiling was not successful.
On [**6-29**] the patient underwent repeat angiography with successful
coiling of the aneurysm. The patient tolerated the procedure
well. A small part of the coil remained in the parent vessel so
she was kept on a heparin drip overnight.
On [**6-30**] she was neurologically stable. Heparin drip was
discontinued and she was started on a full aspirin. A skull xray
was performed to evaluate the location of the coil mass and
ensure no migration. This remained stable compared to the
angiogram. Family was updated. The patient remained in the ICU
for monitoring. On [**2112-7-1**] TCDs were negative for spasm. On
[**2112-7-3**] a CTA was done which showed improvement in the SAH and
no vasospasm was noted.
On [**7-4**] patient had TCDs in the ICU which did not show any
evidence of vasospasm. She was transferred to the step down unit
for observation. [**7-5**] she underwent CTA that demonstrated
stable SAH and no evidence of vasospasm. She remained on IVF,
maintaining even to positive fluid status. She continued to
have nausea without emesis and Compazine was added to her
medication regimen in addition to Zofran PRN. She also
continued to report [**2110-5-31**] left retro orbital pain with only
minimal relief from narcotics and Fioricet. She remained
neurologically intact and was able to work with physical
therapy.
Due to the change in her HA from right retro-orbital to global,
CT head was done on [**7-7**]. There was interval improvement in SAH.
Her medication was changed from oxycodone to Dilaudid and
Toradol. She mentioned that years ago she had hedaches like the
one she had overnight but does not recall her treatment. Her
PCP's office was contact[**Name (NI) **] and they had no records of this. She
continued to have photo and phonophpbia. Now DOD, she is set
for d/c home and will follow-up accordingly.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Simvastatin 20 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Simvastatin 20 mg PO HS
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Acetaminophen-Caff-Butalbital [**11-23**] TAB PO Q4H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s)
by mouth every four (4) hours Disp #*100 Tablet Refills:*0
4. Diazepam 5 mg PO Q6H:PRN anxiety
hold rr < 12/lethargy
RX *diazepam 5 mg 1 tab by mouth four times a day Disp #*40
Tablet Refills:*0
5. Docusate Sodium 100 mg PO TID
RX *Col-Rite 100 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
6. Famotidine 20 mg PO BID
while on steroids
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Fluocinonide 0.05% Ointment 1 Appl TP 30MINS S/P
BREAKFAST,LUNCH, AND QHS
per [**Hospital1 112**] records; mouth sores
RX *fluocinonide 0.05 % Appl 30MINS S/P BREAKFAST,LUNCH, AND QHS
as indicated Disp #*1 Tube Refills:*0
8. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*1
9. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch daily Disp #*30 Each
Refills:*0
10. Nimodipine 60 mg PO Q4H
RX *nimodipine 30 mg 2 capsule(s) by mouth every four (4) hours
Disp #*360 Capsule Refills:*0
11. PredniSONE 10 mg PO TAPER Duration: 24 Hours
2 tabs po daily x 3 days, 1 tab po daily x 3 days, 1 tab po BID
x 2 days then discontinue
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth as indicated Disp #*14
Tablet Refills:*0
12. Senna 2 TAB PO BID
RX *senna 8.6 mg 1 tab by mouth twice a day Disp #*60 Tablet
Refills:*0
13. Escitalopram Oxalate 20 mg PO DAILY
14. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN headaches
RX *Dilaudid 2 mg 1 tablet(s) by mouth every four (4) hours Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right posterior communicating artery aneurysm
Right ophthalmic artery aneurysm
Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with coil placement
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
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 call [**Telephone/Fax (1) 4296**] to make an appointment to see Dr [**First Name (STitle) **]
in 4 weeks with a MRI/MRA brain ([**Doctor Last Name **] protocol).
Completed by:[**2112-7-9**]
|
[
"442.81",
"430",
"305.1",
"272.4",
"112.0",
"435.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
11564, 11570
|
6186, 9410
|
320, 433
|
11717, 11717
|
3075, 6163
|
13868, 14067
|
1366, 1420
|
9653, 11541
|
11591, 11696
|
9436, 9630
|
11868, 12926
|
12952, 13845
|
1491, 1781
|
267, 282
|
461, 1179
|
2074, 3056
|
11732, 11844
|
1201, 1239
|
1255, 1350
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12
| 112,213
|
50972
|
Discharge summary
|
report
|
Admission Date: [**2104-8-7**] Discharge Date: [**2104-8-20**]
Date of Birth: [**2032-3-24**] Sex: M
Service: Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 363**] is a
72-year-old male with a past medical history significant for
pancreatic cancer, ulcerative colitis, hypertension, status
post endoscopic retrograde cholangiopancreatography, and
status post total abdominal colectomy 20 years ago with an
end-ileostomy.
The patient underwent an endoscopic retrograde
cholangiopancreatography recently, but a stent was unable to
be placed. A computed tomography was performed which
demonstrated a head of the pancreas mass with dilated
intrahepatic duct along with vascular involvement of the
gastroduodenal artery and superior mesenteric vein. He
presented for exploratory laparotomy with possible pancreatic
mass resection.
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Hypertension.
3. Benign prostatic hypertrophy.
PAST SURGICAL HISTORY:
1. Total abdominal colectomy with end-ileostomy.
2. Status post transurethral resection of prostate.
MEDICATIONS ON ADMISSION:
1. Moexipril 15 mg by mouth once per day.
2. Aspirin 81 mg by mouth once per day.
3. Atenolol 25 mg by mouth once per day.
4. Allopurinol 300 mg by mouth once per day.
5. Multivitamin.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: The patient is a thin,
cachectic Caucasian male who was alert and oriented times
three. In no apparent distress. The sclerae were anicteric.
The patient was jaundiced. The oropharynx was clear with
moist mucous membranes. The neck was supple and without
lymphadenopathy. The heart was regular in rate and rhythm.
The lungs were clear to auscultation bilaterally. The
abdomen was soft, nontender, and nondistended. There was a
well-healed midline scar and ileostomy present. The
extremities were warm without cyanosis, clubbing, or edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: His hematocrit
was 43.2. His INR was 1.2. Creatinine was 1.6. Aspartate
aminotransferase was 51, his alanine-aminotransferase was 89,
his alkaline phosphatase was 395, and his total bilirubin was
12.5.
BRIEF SUMMARY OF HOSPITAL COURSE: On the day of admission,
the patient was taken to the operating room where an
exploratory laparotomy was performed. The patient had
evidence of unresectable pancreatic cancer with biliary
obstruction seen intraoperatively. Adhesiolysis was
therefore performed along with a Roux-en-Y
hepaticojejunostomy, and open cholecystectomy, an open
pancreatic biopsy, and a gastrojejunostomy. The estimated
blood loss for the procedure was 250 cc.
The patient was discharged to the regular hospital floor
after being extubated in the Postanesthesia Care Unit in good
condition.
In the evening on postoperative day one, the patient was
taken back to the operating room emergently for likely
mesenteric bleeding. This was controlled with suture
ligation, and the patient was admitted to the Surgical
Intensive Care Unit postoperatively for close monitoring.
The patient remained intubated in the Intensive Care Unit on
pressor support and received total parenteral nutrition until
postoperative day seven. At this time, the patient's mental
status was extremely labile requiring Haldol for agitation.
The patient's hematocrit was stable at 35.8 at this time.
Tube feeds were initiated on postoperative day eight. On
postoperative day nine, the patient was transferred to the
regular hospital floor. At this time, tube feeds were held
for elevated residuals and nausea. He was still receiving
total parenteral nutrition at this time. The patient's
mental status was still not completely improved. A computed
tomography scan was performed on postoperative day ten which
did not demonstrate any intra-abdominal pathology.
The patient was started on sips on postoperative day eleven
and was started on his home medications. At this time, he
was seen by the Physical Therapy Service and was being
screened for rehabilitation placement.
However, on the evening on postoperative day twelve the
patient spiked a temperature to 101.5 degrees Fahrenheit. A
fever workup was done including a chest x-ray and blood
cultures.
Early the next morning, the patient was found unresponsive
without a pulse at approximately 2:45 a.m. At this time, a
code blue was called and advanced cardiac life support
protocol was initiated. However, the patient was asystolic
without any respiratory effort at this time. He did receive
multiple rounds of epinephrine along with attempts at
ventilation. However, the patient never regained electrical
activity and was pronounced deceased at 2:57 a.m. The
patient's wife was notified at this time. However, a
postmortem examination was declined.
CONDITION AT DISCHARGE: The patient expired on [**2105-8-21**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2105-3-16**] 16:05
T: [**2105-3-16**] 18:33
JOB#: [**Job Number 105917**]
|
[
"553.21",
"157.0",
"401.9",
"568.0",
"574.10",
"E878.2",
"998.11",
"997.1",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
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"38.93",
"51.37",
"52.12",
"96.04",
"53.51",
"54.12",
"96.71",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
1134, 2223
|
1004, 1108
|
2252, 4837
|
4852, 5158
|
164, 882
|
904, 981
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,055
| 130,958
|
9171
|
Discharge summary
|
report
|
Admission Date: [**2107-7-24**] Discharge Date: [**2107-8-3**]
Date of Birth: [**2041-4-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
Needle Thoracentesis
Chest Pigtail Catheter Placement and Removal
History of Present Illness:
65 year old man with CAD (s/p multiple DES, see below, last CC
[**4-15**] s/p LCX (Ultra) and OM1 (BMS), CHF EF 40%, severe COPD on
home O2, kidney stones, ETOH abuse presented to ED for
evaluation of bloody loose stools.
.
He notes that over the past 2 days he developed acute onset
loose stools and malaise. He noted on Sat. night that stools
were bloody. He did not have abdominal cramping or pain, no n/v
or anorexia. No melena. No CP. Given that these symptoms
persistent into sunday, he consulted with a physician covering
the PCP, [**Name10 (NameIs) 1023**] suggested he be evaluated in the ED.
.
In the ED, initial vitals were 76 146/74 88% on 6L, s/p Nebs was
94% on 4L. He received combivent x3, 125mg of solumedrol, and
500mg of Azithromycin. Labs were notable for CK 629, MB 29 MBI
4.6 and Troponin of 0.1. Given his "BRBPR" history, pt. was not
stated on heparin gtt. CXR showed unchanged effusion. EKG
notable for TwI II, TwF in III and IVCD with Qw in II, III,
unchanged from prior. He was admitted to cardiology for ROMI and
further evaluation.
.
Of note, patient has had multiple admissions for hypoxemia. This
was felt to be multifactorial (COPD exacerbations vs. effusion
vs. CHF). He had a Right sided pleural effusion chronically,
tapped on [**2107-2-9**], cytology negative, 4+PMN with no growth. Last
fluid total protein 3.5, LDH 130, alb 2.6, PH 7.43. He
apparently had a reaccumulation of the effusion s/p tap. Given
the perisistent hypoxemia during last hospitalization, he was
started on home O2 (ambulatory sat was 83% on room air). He
notes that as he awakens, his Sat is in low 80s and improves to
low 90s after AM inhalers. He uses 2L NC day/night but not
consistently.
.
He endorses DOE and SOB at rest, but only mildly changed over
the past 2 months, states its worse in humid hot weather. He
denies CP, orthopnea, PND or LE edema. Plavix stopped 1 month
ago. per pt. Has had persistent cough, incr. in frequency but
unchanged in sputum character (clear). No recent illnesses. His
wife used to tell him that he snored a good deal and had
episodes of no breathing.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. He denies recent fevers, chills or rigors. All
of the other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY: CAD: s/p PTCA multiple DES in the RCA, LAD
and CRX distribution, last in [**4-14**]: LCX (Ultra) and OM1 (BMS).
-CABG: none, AAA repair
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
CHF - global hypokinesis, EF 40% with diastolic dysfunction,
1+MR.
COPD: Not on home oxygen, does not recall being intubated for
breathing problems
Hypertension
Nephrolithiasis
Chronic back pain
Alcohol abuse: Quit drinking 1-1.5 years ago, drank again for
1-2 weeks recently but has otherwise remained sober
Anxiety
Social History:
divorced - lives alone, unemployed (used to work as a painter
and handyman).
Current smoker, 1 pack every 3 days.
History of alcohol abuse. Reports drinking 1-2 drinks nightly.
Denies drug use.
Family History:
Father with CAD and HTN, no family history of colon cancer but
patient did not know his mother
Physical Exam:
Admission:
97.7 55-71 120-149/75-90 18 94 2LNC weight 107kg
GENERAL: Alert, interactive, obese man in no apparent distress
HEENT: Sclera anicteric. PERRL, EOMI. MMM.
NECK: Supple. JVP 8cm with appropriate decline during
respiration.
CARDIAC: nl S1S2, RR, no m/r/g.
LUNGS: air movement noted bilaterally with no wheezes, +
decrease R base breath sounds and trace crackles.
ABDOMEN: obese, soft, NTND. No HSM or tenderness.
RECTAL: No visible masses or hemorrhoids, no bulges seen on
valsalva. No blood seen on examiner's glove. No stool in
vault.
EXTREMITIES: warm, dry, no edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ radial and DP 2+
Left: Carotid 2+ radial and DP 2+
.
At time of discharge: same as above except:
GENERAL: 90s on 4L NC
LUNGS: bibasilar crackles b/l decreased BS at bases b/l
Discharge weight: 104.3 kg
Pertinent Results:
ADMISSION:
[**2107-7-24**] 08:55PM GLUCOSE-95 UREA N-15 CREAT-0.8 SODIUM-134
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-27 ANION GAP-15
[**2107-7-24**] 08:55PM ALT(SGPT)-19 AST(SGOT)-37 CK(CPK)-628*
[**2107-7-24**] 08:55PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2107-7-24**] 08:55PM WBC-9.3 RBC-5.26 HGB-17.2 HCT-51.3 MCV-98
MCH-32.7* MCHC-33.5 RDW-15.1
[**2107-7-24**] 08:55PM cTropnT-0.10*
[**2107-7-24**] 08:55PM CK-MB-29* MB INDX-4.6
.
CT CHEST [**7-26**]:
1. Chronic moderate non-hemorrhagic right pleural effusion has
grown from
small-to-moderate in volume with attendant progression of
substantial rounded atelectasis in the right middle and lower
lobes. No left pleural effusion, pericardial effusion or ascites
in the upper abdomen.
2. Mild-to-moderate emphysema.
3. Mild-to-moderate cardiomegaly, severe coronary
atherosclerotic
calcification. Probable pulmonary arterial hypertension,
unchanged.
4. Possible thyroiditis and/or hypothyroidism.
.
ECHO with bubble study [**8-2**]:
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers; however cannot definitively exclude particularly
since images were suboptimal. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is probably normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2107-7-26**],
findings are similar.
.
[**8-2**] PCXR:
Moderate to large, non-dependent right pleural effusion has
increased
following removal of right pleural drains. There is no longer a
small
pneumothorax at the base of the right lung. Left lung is clear.
Right lung
is substantially obscured but at least significantly atelectatic
in the lower lobe. Mediastinal widening due to a combination of
lipomatosis and mild adenopathy is unchanged.
.
Lung Biopsy Path:
1. Right pleural tissue, thoracoscopy (A-C):
Dense fibrous tissue with chronic inflammation and reactive
changes.
2. Right visceral pleural rind, thoracoscopy (D):
Fibrovascular tissue with acute and chronic inflammation.
3. Right visceral parietal pleural rind, thoracoscopy (E-G):
Fibroadipose tissue with acute and chronic inflammation.
.
Pleural fluid: 2+ PMNs, no growth on culture (final)
.
DISCHARGE LABS:
[**2107-8-3**] 03:09AM BLOOD WBC-8.7 RBC-4.18* Hgb-13.6* Hct-40.8
MCV-98 MCH-32.6* MCHC-33.5 RDW-14.4 Plt Ct-202
[**2107-8-3**] 03:09AM BLOOD PT-12.5 PTT-26.4 INR(PT)-1.1
[**2107-8-3**] 03:09AM BLOOD Glucose-124* UreaN-21* Creat-0.5 Na-141
K-3.8 Cl-98 HCO3-33* AnGap-14
[**2107-7-27**] 07:55AM BLOOD LD(LDH)-193
[**2107-8-1**] 02:46AM BLOOD proBNP-135
[**2107-8-3**] 03:09AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9
[**2107-7-28**] 06:40AM BLOOD VitB12-306 Folate-8.8
[**2107-7-26**] 09:25PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2107-7-26**] 09:25PM BLOOD RheuFac-<3
[**2107-8-3**] 05:41AM BLOOD Type-[**Last Name (un) **] pO2-151* pCO2-45 pH-7.48*
calTCO2-34* Base XS-9
.
CCP IgG negative
Brief Hospital Course:
66M with longstanding PMH of COPD, R pleural effusion presents
with hypoxia and R sided pleural effusion. S/P diagnostic and
therapeutic thoracentesis, c/b pneumothorax requiring urgent
placement of R pigtail catheter. Following drainage of the Right
pleural effusion he was admitted to the MICU for persistent
hypoxia.
.
# Pleural Effusion/Pneumothorax
A CT chest showed evidence of increase in size of the known R
sided pneumothorax, and Interventional Pulmonology was
consulted. They performed a diagnostic/therapeutic
thoracentesis, unfortunately complicated by formation of a
sizable pneumothorax. He was successfully stabilized and
breathing comfortably after relief of PTX with placement of
pigtail catheter. The pigtail was removed 4 days later, and the
pt is currently stable on 4L NC.
.
# CORONARIES:
DOE was the pt's only symptom, and his EKG unchanged. His ROMI
was indeterminate but was downtrending, with enzymes suggestive
of myocardial strain, which could be from chronic hypoxemia. In
the MICU, continued home aspirin, simvastatin and metoprolol. A
TTE on [**7-26**] showed preserved EF and overall normal systolic
function, and a repeat Echo with bubble study on [**8-2**] also
showed preserved EF and no ASD/PFO.
.
# PUMP:
There is currently little evidence of acute CHF flare, pt's
weight is the same as in [**Month (only) 958**] of this year. He presented with
no pedal edema, and coarse crackles on lung exam in presence of
slightly larger effusion. Pt's measurement of EF 40% was on TEE
performed intraop during AAA repair and aortic cross clamping. A
TTE on [**7-26**] showed preserved EF and overall normal systolic
function, and a repeat Echo with bubble study on [**8-2**] also
showed preserved EF and no ASD/PFO. In the MICU, the pt was
given lasix and the pt was diuresed 1700mL after which his R
pleural effusion on CXR appeared slightly improved. He will
continue torsemide on discharge.
.
# Hypoxemia.
It appears that he is not too far from baseline based on his
report, however did require NRB in the ED. Initially suspected
to be related to either COPD flare (soft call, progressive and
only increasing cough frequency) or due to worsening effusion
(he does tend to desat more when supine and on L side). On
admission he received albuterol nebs Q3H, Ipratraopium Q6H, a
short course of steroids, and Azithromycin for 4days. A PA
lateral was performed which showed R sided effusion.
A Pulm consult obtained, and they recommended IP thoracentesis
with pleural fluid analysis. The etiology of the pleural
effusion was unclear, but the results of studies show an
exudate. The pt has agreed to [**Hospital **] rehab as an outpatient.
Further interventional management may prove difficult if lung
does not re-expand [**3-9**] cortication, may involve thoracic surgery
input for VATS, especially in the setting of his history of
asbestos exposure during construction work in his early youth.
The hypoxemia was not considered to be due to pneumonia and
antibiotics were not started. He will continue torsemide for
continued diureses at rehab.
.
# Bloody loose stools.
The etiology is unclear, and the bloody stools have resolved
currently. The stool was Guaiac neg. He had a colonoscopy which
was negative [**Month (only) 958**] of this year. The Pt has not had any bloody
bowel movements since admission, suggesting that his BRBPR is at
least not severe melena. The pt does state he has a history of
prior hemorrhoids, although none were seen on exam.
.
# ETOH abuse
The pt with extensive ETOh abuse history, and had been on a 1wk
drinking binge prior to admission. He was placed on a CIWA scale
with diazepam Q2hrs as needed for CIWA >10, but in the MICU did
not display and signs or symptoms of EtOH withdrawal. The pt
refused inpatient Etoh detoxification upon discharge.
.
# Thoracic Surgery:
Mr. [**Known lastname **] was taken to the operating room on [**2107-7-29**] for Right
video-assisted thoracoscopic surgical total pulmonary
decortication and parietal pleurectomy. He transfer to the SICU
intubated and extubated the following day. He had high oxygen
requirements initally which decreased with aggressive pulmonary
toilet, nebs ambulation and good pain control. He had 2 right
chest tubes which were removed on [**2107-8-1**] and [**2107-8-2**]. Serial
chest films showed improving right lower lobe effusion.
He continued to make steady progress and was transfer to the
medicine team on [**2107-8-2**]. He will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
.
# Transitional Issues
- continuing torsemide for continued diuresis
- CPAP at night
- wound care for prior pigtail catheters as described
- please check electrolytes on Friday, [**8-5**]. Indication -
diuresis
- f/u appts with specialists as noted above
Medications on Admission:
DIAZEPAM - 5 mg Tablet - 1 Tablet(s) by mouth twice a day this
medication can cause sedation/confusion.
FLUOXETINE - 20 mg Capsule - 4 Capsule(s) by mouth daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inh two times daily
IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth every 8 hours
as
needed for pain. please take with food, 30 mins after aspirin.
if
note dark stool, go to ED.
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once daily
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
daily as needed for as needed in Summer months
PENICILLAMINE [CUPRIMINE] - 250 mg Capsule - 3 Capsule(s) by
mouth twice a day
POTASSIUM CITRATE - 5 mEq (540 mg) Tablet Extended Release - 4
Tablet(s) by mouth three times a day
RANITIDINE HCL - 150 mg Capsule - 1 Capsule(s) by mouth twice
daily
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled daily
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth once a day
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. diazepam 5 mg Tablet Sig: One (1) Tablet PO twice a day: This
medication can cause sedation/confusion.
10. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain: please take with food, 30 mins
after aspirin. if note dark stool, go to ED.
11. penicillamine 250 mg Capsule Sig: Three (3) Capsule PO twice
a day.
12. potassium citrate 5 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO three times a day.
13. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice
a day.
14. trazodone 100 mg Tablet Sig: One (1) Tablet PO once a day.
15. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
COPD
Pleural Effusion
Congestive Heart Failure
Coronary Artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
You were admitted to [**Hospital1 18**] for evaluation of your shortness of
breath and pleural effusion. Your symptoms were likely due to a
combination of your COPD and pleural effusion. You had a
bedside drainage of your effusion, and required a drainage
catheter to help keep the air out of your chest. Once you
recovered you were stable for discharge.
You had fluid removed from your lungs with diuretic medications.
Medications:
New:
torsemide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Changed: none
Stopped: none
Followup Instructions:
You will be seen in the Interventional Pulmonology Clinic next
Wednesday, [**8-3**]. You will be called by the Clinic with a
specific time for this appointment.
You will need to be followed by Dr. [**Last Name (STitle) **], your pulmonary
doctor. His office will contact you once an appointment has been
made for you.
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] [**2107-8-18**]
4:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment.
You should make an appointment with your PCP after leaving
rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"518.83",
"512.1",
"518.0",
"578.1",
"428.0",
"305.1",
"511.89",
"491.21",
"401.9",
"V15.84",
"E879.4",
"305.00",
"278.00",
"V45.82",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.52",
"34.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
15681, 15752
|
8124, 12898
|
337, 405
|
15867, 15867
|
4613, 7395
|
16607, 17426
|
3615, 3711
|
14149, 15658
|
15773, 15846
|
12924, 14126
|
16018, 16584
|
7411, 8101
|
3726, 4594
|
2850, 3037
|
270, 299
|
433, 2770
|
15882, 15994
|
3068, 3387
|
2792, 2830
|
3403, 3599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,025
| 116,670
|
13434
|
Discharge summary
|
report
|
Admission Date: [**2207-6-16**] Discharge Date: [**2207-6-20**]
Date of Birth: [**2141-3-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
found unresponsive
Major Surgical or Invasive Procedure:
s/p catheterization on [**6-19**]
History of Present Illness:
Mr. [**Known lastname 29079**] is a 66 year old male with a history of CAD s/p
multiple interventions, HTN, DM2, hypercholesterolemia who was
transferred from the MICU due to concern of NSTEMI (elevated
cardiac enzymes). He was found to be difficult to arouse by his
wife on [**6-16**] and was transferred to [**Hospital3 3583**]. He was
electively intubated at [**Hospital1 46**] due to altered mental status and
transferred to [**Hospital1 18**]. He was accepted into the ICU and extubated
on [**6-17**]. He was noted to have rising cardiac enzymes and was
transferred to the Cardiology service.
He reports that he has not felt the same since after his last
cath in [**Month (only) 116**]. He states that he has felt weak and that he gets
some chest discomfort when he exerts himself. He reports that
the discomfort only lasts a few minutes and that it resolves
with rest. The day he was found to be unresponsive he does not
recall much of the day. He denied havig any chest pain,
shortness of breath, lightheadedness or palpitations. He only
notes that he had 3 beers that day. As per his wife, she left
him sleeping in the morining and found him still sleeping when
she got home at 3PM. She notes he was making some gurgling
sounds and was difficult to arouse.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
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:
- CAD
NSTEMI (95) s/p PTCA of proximal RCA
PTCA (98) s/p stent proximal LAD
STEMI (03) LAD with severe ISR s/p PTCA/cutting balloon
PCI (09) s/p Cypher stent to LAD, Taxus stent to RCA.
PCI (10)
- HTN
- HL
- DM
- GERD
- Depression
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension
Social History:
Lives w/ wife at home alone. Currently under great financial
stress, as lost much of prior wealth. The patient quit smoking
in [**2181**]. He drinks approximately four to five beers per month.
He is a small business owner.
- Tobacco: quit in [**2181**], 50+pk years.
- Alcohol: [**12-13**] night.
- Illicits: denied by wife.
Family History:
Father died at the age of 58 [**1-13**] CAD, diabetes.
Mother died of old age.
No Hx of strokes, ICH.
Physical Exam:
VS - 98.8 66 114/44 992L
Gen: elderly male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with unremarkable 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: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: MSE: AAOx3
CN: II-XII grossly intact, right eye prosthesis
Strength: [**4-15**] bilaterally for both upper and lower extremitities
Reflexes: 2+ Biceps/Triceps and Patellar bilaterally, Babinski
down going.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+ \
Physical Exam unchanged upon discharge
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
Cardiac Cath [**6-19**]: Cornary angiography showed a R dominant
system. R radial approach was used. Selective angiography of
left system:
LMCA: Normnal
LAD: 50-60% ostial LAD, 70% origin diagonal branch, patent
stents
LCX: patnent stent in LCX, 60% stenoses of continuation of AV
circumflex.
RCA: 70% diffuse distal RCA and 60% at the bifurcation.
ECHO [**6-17**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with focal hypokinesis of the distal left ventricular segments.
The remaining segments contract normally (LVEF = 40-45 %). The
right ventricular size and systolic function are normal. The
aortic root is mildly 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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion
MRI Head [**6-18**]: 1. Multiple foci of restricted diffusion: In the
bilateral basal ganglia, the subcortical left frontal white
matter and the left subependymal region, compatible with focal
infarcts. The distribution is most suggestive of a hypoxic or
hypotensive event. Alternatively, this could represent a
thromboembolic etiology.
2. Minimal irregularity of the right vertebral artery, with
minimal luminal
narrowing. This may be artifactual, or may be related to
atherosclerotic
disease. Overall, the intracranial and neck vasculature is
patent, with no
significant stenosis or occlusion.
3. Chronic small vessel ischemic change.
EEG [**6-17**]: IMPRESSION: Abnormal portable EEG due to the mildly
slow background rhythm. This indicates a widespread
encephalopathy. Medications are likely the most common
explanation of such tracings. Metabolic
disturbances and infection can produce similar tracings. There
were no
areas of prominent focal slowing, but encephalopathies may
obscure focal
findings. There were no epileptiform features.
Brief Hospital Course:
66 yo man w/ CAD (NSTEMI in 95, PTCA and stent to prox LAD [**2194**],
STEMI in [**2199**], LAD/PCA stenting in [**2205**], DES to LCX in [**2206**]),
HTN, HL, DM, GERD, Depression who was found unresponsive by his
wife in the afternoon of [**6-16**] and found to have nSTEMI, ARF,
transaminitis, aspiration pneumonia vs. pneumonitis and
metabolic/resp. acidosis who came to the MICU intubated at OSH.
# NSTEMI: New TwI in lateral leads and elevated Trop, likely
LAD territory and restenosis of prior LAD. Pt was started on a
heparin gtt, goal PTT of 60-90. Continued on ASA, Plavix,
atenolol, statin, isosorbide. Pt was then transferred to CCU
for further management of NSTEMI. Since pt with known OSA, and
perhaps EtOH intake earlier in evening caused increased
myocardial demand -> NSTEMI -> Hypotension -> multiorgan
involvement (see below). Repeat ECHO revealed mild symmetric
left ventricular hypertrophy with normal cavity size, mild left
ventricular systolic dysfunction with focal hypokinesis of the
distal left ventricular segments, LVEF = 40-45 %, normal right
ventricular size and systolic function. Cardiac Cath did not
show disease that needed intervention.
# AMS: Etiology unclear. U and Stox negative, but pt with h/o
EtOH use. Non focal neuro exam, unlikely stroke, though could
not r/o TIA, so ordered MRI/MRA head and neck. Also could not
rule out potential post-ictal somnolence, so ordered 20min EEG
recording to investigate potential epileptiform activity. Also
did infectious work-up, but cx (BCx, UA, Sputum Cx) pending at
time of transfer.
# ARF: Potentially related to hypoperfusion, and ratio of BUN/Cr
suppportive of hypoperfusion. UA positive for blood, ketones,
and protein, but no WBC. Urine electrolytes with FEurea<35%,
which supports prerenal etiology. Gave fluid challenge.
# CAD: See above, NSTEMI.
# Aspiration pneumonitis vs. PNA: Pt initially intubated, but
once in MICU, weaned off ventilator and extubated since not
intubated for respiratory status. Because of aspiration risk,
started Zosyn, though antibx can be discontinued if CXR improves
significantly.
# HTN. Currently normotensive. Continued home meds with holding
parameters.
# Hyperlipidemia: Pt with known CAD, so continued statin. Also
checked fasting lipids, which revealed LDL 49 and HDL 52.
Incidentally, these numbers also support a higher-than-admitted
use of EtOH.
# Metabolic acidosis, metabolic alkalosis, and respiratory
acidosis: Metab. acidosis likely due to renal failure, lactate
is normal (which goes agains a hypoperfusion theory). Trended
electrolytes.
# Transaminitis. Likely [**1-13**] a hypoperfusion episode, could be
due to myocardial injury/muscle leak. Trended LFTs.
# DM: HbA1C = 6.5, continued on half of home-dose humulin and
started on ISS.
Medications on Admission:
ATENOLOL - 25 mg Tablet qpm
CITALOPRAM - 20 mg Tablet morning
CLOPIDOGREL 75 mg morning
CYANOCOBALAMIN - 1,000 mcg/mL Solution - 1 QAM
ESOMEPRAZOLE 40 mg Capsule
GLIPIZIDE - 5 mg Tablet Extended Rel qam
IRBESARTAN 150 mg qam
ISOSORBIDE MONONITRATE SR 60 mg [**Hospital1 **]
LORAZEPAM - 0.5 mg prn
NITROGLYCERIN 0.4 mg prn
PIOGLITAZONE 45 mg qam
ROSUVASTATIN 20 mg qpm
SITAGLIPTIN-METFORMIN [JANUMET] - 50 mg-1000 mg twice a day
ASPIRIN 325 mg am
HCTZ - dose unknown
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
5. Isosorbide Mononitrate 20 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
6. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO PRN as needed
for anxiety.
12. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN as needed for pain.
13. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day.
14. Janumet 50-1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
s/p Unresponsiveness
Secondary Diagnosis:
Type 2 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you had elevated cardiac enzymes in
your blood concerning for a small heart attack. You had a
catheterization to see if you had any blockages. There were no
significant blockages in your artery.
Medications changed upon discharge:
START Ranitidine 150 mg twice a day
STOP ESOMEPRAZOLE
Followup Instructions:
Please make a follow up appointment with your primary care
physician [**Name Initial (PRE) 176**] 2 weeks of discharge.
Please make a follow up appointment with your cardiologist
within 4 weeks of discharge.
|
[
"250.00",
"414.01",
"276.4",
"507.0",
"790.4",
"584.9",
"V45.82",
"272.4",
"412",
"401.9",
"410.71",
"780.97",
"530.81",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"96.71",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
10493, 10499
|
6128, 8929
|
333, 369
|
10621, 10621
|
3947, 6105
|
11108, 11320
|
2776, 2879
|
9445, 10470
|
10520, 10520
|
8955, 9422
|
10772, 11014
|
2894, 3928
|
275, 295
|
11030, 11085
|
397, 2097
|
10582, 10600
|
10539, 10561
|
10636, 10748
|
2119, 2417
|
2433, 2760
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,648
| 118,489
|
35864
|
Discharge summary
|
report
|
Admission Date: [**2135-1-1**] Discharge Date: [**2135-1-2**]
Date of Birth: [**2061-3-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 F w/ pmh of pulmonary fibrosis (not on prednisone) presented
to [**Hospital1 **] w/ 3 days of SOB (per family) and fever (per patient).
Initially 87% on a NRB. Put on CPAP and was much more
comfortable. Febrile to 103. EKG changes initially resolved and
elevated trop. Thought to be at risk for both CHF and pneumonia
so treated with levoflox 500 mg IV, lasix 80 mg IV, prior to tx.
Labs at [**Hospital1 **] w/ BNP of 14,000, Cr of 1.8, and trop of 1.2.
Started on a nitro ggt for SBP of 160s at [**Hospital1 **]. (She receives
most of her care through the [**Hospital1 756**] but no ICU bed available).
Arrived in our ED w/ SBP in the 80s, still on a nitro ggt.
.
In the ED, initial vs were: T 102 P 105-->85 BP 92 --> 85 (Nitro
ggt turned off) SBP now 90/66. R 35 --> 29 O2 sat 99% on 100%
FiO2 on CPAP. Patient was given ASA 600 pr, tylenol 650 pr.
Received 2L IVF here. Has only put out 100 cc urine since
arrival at [**Hospital1 **].
.
On arrival to the ICU, she denies CP. She states her breathing
is much more comfortable. She denies any cough prior to
admission. She denies diarrhea/N/V/abdominal pain. She denies
dysuria. + fever X 2 days. Denies cold symptoms. Has never been
on oral steroids. + LE edema for the last two weeks. Had seen
her PCP on Tuesday who started her on lasix. No sick contacts.
[**Name (NI) **] son and daughter note that she has been spending more and
more time in bed recently.
.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
.
Past Medical History:
Pulmonary fibrosis
? Iron-deficiency anemia
Had recently been started on lasix for LE edema
Social History:
Lives independently w/ her husband and dog. Doesn't drive. Walks
very little (limited by dyspnea). Recently started using a
wheelchair. Drinks 2 glasses of wine per night.
Family History:
NC
Physical Exam:
Vitals: T: 96.6 BP: 93/60 P: 85 R: 26 18 O2: 97% on 60% FiO2/
CPAP.
General: Alert, oriented, appears tired but relatively
comfortable
[**Name (NI) 4459**]: Sclera anicteric, dry MM, crusting around R eye,
esotropia of her RL eyelid, EOMI
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar dry crackles, R diaphragm moves w/ inspiration
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, 1+ radial pulses, dopplerable pedal
pulses, no clubbing, cyanosis. 2+ R LE edema, trace LLE edema
Pertinent Results:
[**2135-1-1**] 03:55PM BLOOD WBC-9.7 RBC-3.89* Hgb-12.9 Hct-36.3
MCV-93 MCH-33.1* MCHC-35.5* RDW-14.5 Plt Ct-47*
[**2135-1-1**] 07:10PM BLOOD WBC-8.6 RBC-4.19* Hgb-14.1 Hct-41.2
MCV-98 MCH-33.6* MCHC-34.2 RDW-14.5 Plt Ct-42*
[**2135-1-1**] 03:55PM BLOOD Neuts-94.6* Lymphs-2.7* Monos-2.1 Eos-0.2
Baso-0.4
[**2135-1-1**] 07:10PM BLOOD Neuts-92.7* Lymphs-4.1* Monos-2.0 Eos-0.2
Baso-1.1
[**2135-1-1**] 03:55PM BLOOD PT-21.6* PTT-44.5* INR(PT)-2.1*
[**2135-1-1**] 11:07PM BLOOD FDP-80-160*
[**2135-1-1**] 03:55PM BLOOD Fibrino-152
[**2135-1-1**] 03:55PM BLOOD Glucose-173* UreaN-29* Creat-2.2* Na-135
K-4.2 Cl-95* HCO3-22 AnGap-22*
[**2135-1-1**] 07:10PM BLOOD Glucose-163* UreaN-32* Creat-2.6* Na-136
K-4.7 Cl-95* HCO3-23 AnGap-23*
[**2135-1-1**] 11:07PM BLOOD Glucose-152* UreaN-35* Creat-2.8* Na-135
K-5.0 Cl-98 HCO3-18* AnGap-24*
[**2135-1-1**] 03:55PM BLOOD ALT-93* AST-365* LD(LDH)-782*
CK(CPK)-409* AlkPhos-78 TotBili-1.3
[**2135-1-1**] 07:10PM BLOOD CK(CPK)-685*
[**2135-1-1**] 03:55PM BLOOD cTropnT-2.00*
[**2135-1-1**] 07:10PM BLOOD CK-MB-11* MB Indx-1.6 cTropnT-2.39*
[**2135-1-1**] 03:55PM BLOOD Albumin-3.2* Calcium-8.1* Phos-5.9*
Mg-1.2*
[**2135-1-1**] 07:10PM BLOOD Calcium-8.2* Phos-6.6* Mg-1.4*
[**2135-1-1**] 09:28PM BLOOD D-Dimer-[**Numeric Identifier **]*
[**2135-1-1**] 03:55PM BLOOD Hapto-154
[**2135-1-1**] 11:20PM BLOOD Type-ART Temp-36.9 pO2-101 pCO2-37
pH-7.32* calTCO2-20* Base XS--6
[**2135-1-1**] 03:55PM BLOOD Lactate-4.1*
[**2135-1-1**] 05:50PM BLOOD Lactate-4.2*
[**2135-1-1**] 11:20PM BLOOD Lactate-4.4*
.
[**1-1**] CXR
UPRIGHT AP VIEW OF THE CHEST: Bibasilar patchy opacities are
demonstrated
with perivascular haziness, findings suggestive of pulmonary
edema. Bibasilar
opacities, left greater than right, are also present, which
could represent
atelectasis, but pneumonia cannot be excluded. Probable left
pleural effusion
is small in size. No pneumothorax. Heart size is difficult to
assess given
the presence of bibasilar opacities, but is likely enlarged. The
aorta is
unfolded. No pneumothorax. Osseous structures are unremarkable.
IMPRESSION:
1. Bibasilar patchy opacities, which could represent pneumonia
or
atelectasis.
2. Probable moderate pulmonary edema with left pleural effusion,
small in
size.
.
[**1-1**]
STUDY: Right lower extremity veins ultrasound.
INDICATION: Respiratory distress and lower extremity discomfort.
FINDINGS: Grayscale, color and pulse Doppler son[**Name (NI) 867**] was
performed on the
right common femoral, superficial femoral and popliteal veins.
Normal flow,
compression, augmentation and waveforms were demonstrated. No
intraluminal
thrombus was detected.
IMPRESSION: No right lower extremity DVT identified.
.
[**1-1**] Abd U/S
STUDY: Liver and gallbladder ultrasound.
INDICATION: Respiratory distress, fever, elevated transaminases.
COMPARISONS: None available.
FINDINGS: Study is incomplete given patient refusal early
through the
examination. Evaluation of the liver is limited given poor
acoustic window.
No large masses identified. The abdominal aorta does not appear
dilated
throughout its course. The neck and body of the pancreas appears
within
normal limits, however, the tail is not well visualized given
overlying bowel
gas. No right upper quadrant ascites is identified.
IMPRESSION: Limited and incomplete examination given poor
acoustic window and
patient compliance. Repeat imaging when feasible is advised.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Assessment and Plan: This is a 73 F w/ pmh of pulmonary
fibrosis, on home O2 p/w fevers, hypoxia, thyrombocytopenia and
renal failure. Overall picture concerning for sepsis with DIC.
The initial problem-based approach is listed below but the
patient rapidly deteriorated from a respiratory standpoint and
became increasingly hypotensive. She could not lie flat for an
IJ or SC line and a femoral line was not possible given her
pannus and the fact that she could not lie flat. The overnight
attending [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 81506**] spoke with the patient and her daughter
and the patient decided that she did not with to persue
agressive measures, including intubation and thus goals of care
were switched to comfort measures only. A morphine drip was
started and she died approximatley 2 hours later. Presumptive
diagnosis was septic shock with DIC. Autopsy was deferred.
.
# Hypoxia/tachypnea: Bibasilar opacities w/ L-shift on CBC and
fevers at home suggesting a PNA although she does not endorse
cough or dyspnea. Given levofloxacin at [**Hospital3 **]. Given
Vancomycin in our ED for MRSA coverage. Has now been weaned off
CPAP. Likely lives w/ a RR in the 30s. Baseline ABG at [**Hospital1 **]
7.36/48/163.
- continue Vanc/Levo for empiric coverage of HAP
- sputum cx if available w/ flu cx
- f/u blood cx
- f/u urine cx
.
# Fevers: Unclear etiology. DDX from PNA (bacterial vs viral).
UA w/o obvious UTI. Abdominal exam totally benign. ? from
thrombophlebitis in RLE. Possibly from PE given swollen RLE and
possible DVT.
- Empiric coverage w/ Vanc/Levo for now
- f/u blood, urine cx
- sputum cx if able
- send for influenza and other respiratory viruses
.
# Borderline hypotension: Concerning for septic shock. Not
tachycardic. Per patient, her pressures usually run w/ SBP in
120s. Currently afebrile. ? from hypovolemia in the setting of
insensible losses.
- fluid boluses to try to increase UOP
.
# Thrombocytopenia/ elevated LDH/ Elevated INR: Concerning for
DIC. Have paged the heme/onc fellow to look at her smear. Will
treat infection as above.
- check FDP, fibrinogen, d-dimer
.
# RLE swelling: concerning for DVT. Was given lovenox at [**Hospital1 **]
but am concerned about giving additional anticoagulation in the
setting of TCP. [**Month (only) 116**] need an IVC filter if anticoagulation is not
possible and has a DVT.
- RLE U/S
.
# Transaminitis: ? from DIC or transient hypotension vs from
alcohol toxicity.
- abdominal U/S
- avoid hepato-toxins
- hepatitis serologies
.
# Acute renal failure: Cr increased from 1.8 at [**Hospital1 **] to 2.6.
Per patient, w/o history of renal disease. ? from ATN from
pre-renal azotemia/septic shock. She was given lasix on Tuesday
but hasn't taken much po. Currently anuric.
- fluid challenge
- urine lytes/eos
- likely renal consult in am
- renally dose meds
- avoid renal toxins
.
# Elevated CE: Elevated trop but w/o elevated MB. ? from demand
in the setting of hypoxia. s/p ASA, lovenox at [**Hospital1 **] for
possible NSTEMI. Currently w/o chest pain and she denies any
chest pain in the past couple of weeks. Cannot given
B-blockers/ACEI in the setting of borderline hypotension.
- trend for now
- EKG
- ECHO in am
Medications on Admission:
lasix (just started)
iron
prilosec
Home O2 (2L NC)
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"584.9",
"790.5",
"486",
"790.4",
"287.5",
"515",
"729.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9975, 9984
|
6616, 9844
|
318, 324
|
10040, 10049
|
3120, 6593
|
10101, 10107
|
2427, 2431
|
9946, 9952
|
10005, 10019
|
9870, 9923
|
10073, 10078
|
2446, 3101
|
271, 280
|
1788, 2106
|
352, 1770
|
2128, 2222
|
2238, 2411
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,192
| 188,914
|
24531
|
Discharge summary
|
report
|
Admission Date: [**2153-8-13**] Discharge Date: [**2153-8-18**]
Date of Birth: [**2075-5-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
Paracentesis X2
History of Present Illness:
78 y/o man w/Rght heart failure, left heart failure, severe TR,
cardiac cirrhosis, ascites requiring frequent paracentesis,
chronic GI bleed [**3-2**] AVMs, and afib admitted after became
hypotensive with labs drawn during routine paracentesis (5L
removed) showed acute renal failure (Cr. 2.2, baseline 1.6)
hyperkalemia (6.8), and Hct 21.
Past Medical History:
-HTN
-CAD: CABG [**2140**], cath [**2151**] with patent lima-lad, occluded
svg-om, near occluded svg-rca
-CHF: TTE [**7-5**] with EF 35%, mild LVH and LV-HK, 2+MR, 4+TR
-Afib
-Cardiac cirrhosis: Requiring repeat sx paracenteses
-Chronic GIB [**3-2**] AVMs
-Colon polyps
-HBV
-CRI: cr 1.5-1.8
-Hypothyroidism
-OA
Social History:
Originally from [**Country 3397**]. Previously living with wife in [**Name (NI) 3146**],
but has been at rehab since recent hospitalization. Quit smoking
15 years ago. Smoked 1 ppd x 40 years. No EtOH. Retired, but
used to work as a machinist. Unable to walk. Needs
wheelchair/walker to get around his house.
Family History:
Mother- HTN, ?died of MI; Father-83 yo and died of "old age"; no
FH of cancer
Physical Exam:
PHYSICAL EXAMINATION:
VS - 95.3 98/60 78 22 94% 2L 850/750 73.6kg
Gen: chronically ill appearing elderly man
HEENT: poor dentition. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
Dry mucosa. No xanthalesma.
Neck: Supple with JVP 10cm, distended external jugular veins,
systolic TR visible in jugular veins with systolic pulse.
CV: Irregularly irregular rhythym, S1, s2, no M/G/R.
Chest: Slightly tachypnic. Lungs with wheezing and rhonchi
bilaterally, crackles @ bases R>L. Decreased BS on left.
Abd: distended, tense. large ubmilical hernia noted
Ext: 1+ pitting edema of LE bilaterally.
Skin: skin changes consistent with stasis dermatits noted
bilaterally. multiple ecchymosis over body.
.
Pulses: Carotid 2+ Radial 2+ DP 2+ bilaterally.
Pertinent Results:
[**2153-8-13**] 08:55AM BLOOD WBC-9.1 RBC-2.38* Hgb-6.5* Hct-21.3*
MCV-89 MCH-27.1 MCHC-30.3* RDW-17.7* Plt Ct-396
[**2153-8-17**] 06:46AM BLOOD WBC-10.0 RBC-3.28* Hgb-8.9* Hct-27.7*
MCV-84 MCH-27.1 MCHC-32.1 RDW-17.7* Plt Ct-302
[**2153-8-13**] 11:15AM BLOOD Hypochr-1+ Anisocy-3+ Poiklo-NORMAL
Macrocy-2+ Microcy-2+ Polychr-2+ Target-1+
[**2153-8-14**] 04:49AM BLOOD PT-13.2* INR(PT)-1.2*
[**2153-8-13**] 08:55AM BLOOD Glucose-95 UreaN-96* Creat-2.1* Na-127*
K-6.8* Cl-96 HCO3-23 AnGap-15
[**2153-8-17**] 06:46AM BLOOD Glucose-101 UreaN-93* Creat-1.9* Na-130*
K-3.3 Cl-93* HCO3-25 AnGap-15
[**2153-8-13**] 11:15AM BLOOD Calcium-7.4* Phos-6.8*# Mg-3.1*
[**2153-8-17**] 06:46AM BLOOD Calcium-6.6* Phos-4.9* Mg-2.7*
[**2153-8-16**] 05:22AM BLOOD TSH-31*
[**2153-8-16**] 05:22AM BLOOD T4-3.3*
[**2153-8-13**] 11:15AM BLOOD Digoxin-0.9
[**2153-8-16**] Echo The left atrium is moderately dilated. The
estimated right atrial pressure is 0-5mmHg. The estimated right
atrial pressure is >20 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is probably mild to moderate global left ventricular hypokinesis
(LVEF = ?40 %; views are technically suboptimal for assessment
of wall motion).[Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is markedly
dilated. There is mild global right ventricular free wall
hypokinesis. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-30**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened and do not
coapt. Moderate to severe [3+] tricuspid regurgitation is seen.
There is no pericardial effusion. There is at least moderate
pulmonary artery systolic hypertension (given elevated high
IVC/RA pressure and measured TR jet velocity).
[**8-14**]/o7 CXR AP PORTABLE UPRIGHT VIEW OF THE CHEST: The
Port-A-Cath device is in stable position. Moderate left pleural
effusion is not significantly changed compared to the study of
seven hours prior. Right lung is grossly clear. There is no
evidence of pneumothorax. The patient is status post CABG.
IMPRESSION: No significant interval change and moderate
left-sided pleural effusion.
Brief Hospital Course:
Patient had brief stay in MICU, was medically managed with
kayexalate, insulin and albuterol, and hyperkalemia resolved.
Was on [**Location **] service with progressive increase in
abdominal girth and pleural effusions. Cardiology was consulted,
decided to hold spironolactone ACEI, BB, and to continue with
Lasix. On night of [**8-15**] had 2 Units PRBCs with total 100mg IV
lasix but developed shortness of breath with slightly increased
oxygen requirment. Put out minimal urine to lasix with continued
dyspnea and oxygen requirment initiating transfer to [**Hospital1 1516**]
service for higher level managment (i.e. lasix drip). Had second
large volume paracentesis [**8-16**] with removal of 4 iters and
administration of 37.5gm [**Month/Year (2) 61990**] for prevention of hepatorenal
syndrome in setting of acute renal failure. Lasix drip 10mg/hr
was begun on [**8-16**]. the following morning the patient was
negative 1.2L. His systolic blood pressure was stable as it
remained in the 100's. He continued on the lasix drip through
[**8-17**], with the goal of keeping him negative another 1-2L. By
[**8-18**] the patient was negative 4.5L. His Lasix was discontinued
and bumetonide 1mg IV BID was added because it has better
absorption from the GI tract. Endocrinology was consulted for
recommendations regarding the patient's hypothyroidism, and they
suggested remeasuring TSH and free T4 next week. Also on [**8-18**],
the patient was demanding to go home, he began to refuse vital
sign checks and medications and threatened to leave AMA. His
placement was complicated by the fact that the [**Hospital1 1501**] he came from
did reserve his bed. The earliest he could have been rescreened
was Monday, but he insisted on being home by Sunday for a family
engagement. Sending him home with services was not an issue
because he has been blacklisted by VNA. The medical team did
not feel it was safe to send him home, and eventually the
patient left against medical advice.
Medications on Admission:
Levothyroxine 150 mcg po daily
Spironolactone 50mg po daily
Furosemide 120mg po bid
Digoxin 125 mcg po q Mo/We/Fr
Albuterol/atrovent nebs
Senna 8.6 mg po bid
Docusate 100mg po bid
acetaminophen 325mg po q4-6 prn
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
9. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten
(10) ML PO Q6H (every 6 hours) as needed.
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours).
12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QMOWEFR
(Monday -Wednesday-Friday).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
16. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime)
as needed.
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
CHF
Anemia
Acute renal failure
Hyperkalemia
Hypocalcemia
Hypothyroidism
Discharge Condition:
fair
Discharge Instructions:
You have decided to discharge yourself from the hospital against
medical advice (AMA). The risks of this, including death, were
explained to you, and you stated that you understood these risks
and still desired to leave the hospital. You signed a legal form
stating your desire to leave as above.
.
Please continue to take all your medicines as directed. If you
experience any symptoms that are disturbing to you, please call
your primary care doctor, or go to the nearest Emergency Room.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L/day
Followup Instructions:
please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your cardiologist, in
[**1-30**] weeks
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"789.5",
"428.23",
"276.7",
"427.31",
"V45.81",
"585.9",
"397.0",
"244.9",
"571.5",
"070.32",
"403.90",
"428.0",
"584.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
8742, 8748
|
5029, 7019
|
327, 345
|
8864, 8871
|
2309, 5006
|
9538, 9767
|
1392, 1471
|
7281, 8719
|
8769, 8843
|
7045, 7258
|
8895, 9515
|
1486, 1486
|
1508, 2290
|
275, 289
|
373, 714
|
736, 1049
|
1065, 1376
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,362
| 135,924
|
48273
|
Discharge summary
|
report
|
Admission Date: [**2146-3-22**] Discharge Date: [**2146-3-29**]
Date of Birth: [**2072-9-7**] Sex: M
Service:
CHIEF COMPLAINT: Hypoxic and hypercarbic respiratory
failure.
HISTORY OF PRESENT ILLNESS: 73-year-old male with a history
of hormone resistant prostate cancer diagnosed in [**2137**],
failed radiation seeds and Lupron therapy presented to he
Emergency [**2146-3-22**] with three weeks of progressive
shortness of breath. The patient stated that over the past
six months he has noted poor exercise tolerance, inability to
lie flat but denied back pain, neurologic compromise, cough
or hemoptysis. The patient's shortness of breath acutely
worsened in the past three days and the patient came to the
Emergency Room. The patient denies fever, chills, sweats or
chest pain. In the Emergency Room the patient was noted to
be hypoxic with paradoxical breaths and he was placed on
pressure support mask, ventilation and had three liters of
grossly bloody fluid drawn off the from the right lung by the
Intensive Care Unit team under supervision of Interventional
Pulmonary. Repeat chest x-ray revealed no pneumothorax and
clear lung fields except two perihilar masses. The patient
was on four liters nasal cannula at that time sating 98% and
seemed symptomatically greatly improved. The patient was
taken to the medical floor for further management but this
morning the patient was noted to be tachypneic, hypoxic with
an arterial blood gases revealing the following numbers 7.31,
60, 78, with O2 sats in the 94% range on two liters nasal
cannula with patient using accessory muscles and the patient
was noted to be quite lethargic and somnolent. Floor team
noticed decreased breath sounds halfway up in the right lung
field and a third of the way up in the left lung field with
dullness to percussion with a respiratory rate at that time
25. A chest CT was performed which revealed numerous
metastatic processes within the lungs and mediastinum with
some constriction of the right pulmonary artery. The patient
was seen once again by the Interventional Pulmonary team who
checked a repeat chest x-ray which revealed rapid
re-accumulation of effusion and at that time the
recommendation was made to consider admission to Intensive
Care Unit secondary to the patient's persistent tachypnea and
relative hypoxia.
The patient was transferred to the Intensive Care Unit team
for further management.
PAST MEDICAL HISTORY:
1. Prostate cancer diagnosed in [**2137**], status post radiation
seeds, Lupron treatment, PSA still climbing despite therapy.
2. Depression.
3. Alcohol use in distant past.
MEDICATIONS ON ADMISSION TO INTENSIVE CARE UNIT:
[**Unit Number **]. Heparin 5000 units subcutaneously q 8.
2. Calcium carbonate 500 mg p.o. four times a day p.r.n.
3. Protonix 40 mg p.o. q 24 hours.
4. Aspirin 162 mg p.o. q day.
5. Elanzepine 2.5 mg p.o. q h.s. p.r.n.
6. Dulcosate 100 mg p.o. twice a day.
7. Tylenol 325 to 650 mg p.o. q 4 to 6 hours p.r.n.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Six pack per day smoking history for
numerous years, no alcohol use.
FAMILY HISTORY: Not obtained.
PHYSICAL EXAMINATION: Upon presentation vitals 128/78, 90,
24 to 26, 96% on two liters, 97.9 axillary. General:
Tachypneic, alert and oriented times three. Pupils are
equal, round, and reactive to light and accommodation.
Mucous membranes moist. Cardiac examination: Normal S1 and
S2. No murmurs, rubs or gallops. Lungs: Decreased breath
sounds on right [**2-15**] of the way up. Decreased breath sounds
up one third of the way up in left lung fields. Positive
paradoxical movements. Abdominal exam: Positive bowel
sounds, soft, nontender, nondistended, no rebound or
guarding. Extremities: 3 second capillary refill. No
edema, no [**Last Name (un) 5813**].
LABS: PSA [**Month (only) 404**] 74.3, [**2145-9-14**] 46.8, [**2146-2-12**] 235,
[**2146-3-15**] 390. White blood cell count 9.7, hematocrit 39.0,
platelets 308, INR 1.0. Sodium 134, potassium 3.9,
bicarbonate 25, chloride 105, BUN 26, creatinine 1.3.
Glucose 95, LDH 270. Calcium 9.4, magnesium 1.7, PSA 393.5.
Pleural fluid analysis gram stain, no organism, no growth, no
Acid fast bacilli. White blood cell count [**Pager number **], red blood
cells [**Pager number **],000. Polys 9, lymphocytes 21, macrocytes 70,
protein 5, glucose 116. LDH 285. Albumin 2.9, cytology
pending. CTA: No PE, enumerable metastatic processes
bilaterally throughout lungs and mediastinum, bulky
lymphadenopathy in the hilar region. Arterial blood gases:
7.39, 60, 78, on four liters nasal cannula, lactate 0.9.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit service for hypoxic and hypercarbic respiratory
failure. Mask ventilation was continued to prevent
respiratory compromise. Cytology revealed the patient had
metastatic prostate cancer and it was thought that this was
the cause of the patient's rapidly re-accumulating pleural
effusions. The patient was also found to have a post
obstructive pneumonia and aggressive chest physical therapy
and bronchoscopy was considered for sputum removal. It was
thought that the patient would not benefit from bronchoscopy
and that his pulmonary function was compromised on numerous
fronts. Ultrasound was performed by Interventional Pulmonary
service to ascertain if he had re-accumulated any pleural
effusion for further thoracentesis and it was found at that
time that the patient's right diaphragm was greatly elevated
which was the cause of his decreased breath sounds on the
right. It was thought that there was probable phrenic nerve
involvement of the metastatic process and this had caused
diaphragmatic compromise on the right. The Interventional
Pulmonary Team felt there would be no benefit in
thoracentesis since pleural effusions were small and probably
not compromising the patient's oxygenation and ventilation
significantly.
It was thought that the patient's metastatic process was
causing the patient's pulmonary compromise. Oncology team
was consulted and they stated that the patient's prognosis
was poor. The attending physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and myself had a
thorough discussion with the family, explained these findings
and given the fact that the patient's pulmonary function was
severely compromised due to metastatic process which could
not be resolved it was thought that intubation and cardiac
resuscitation would not be appropriate. The family
understood the patient's condition and decided after
discussion with the patient himself that [**Last Name (STitle) **] would be the
primary objective.
After lengthy discussions with the palliative care team and
social work the family decided to make Mr. [**Known lastname 7749**] [**Last Name (Titles) **]
measures only and he was placed on a Morphine drip. All
antibiotics and non-essential medications were withdrawn and
the patient was taken off of mask ventilation and succumbed
to respiratory failure in 24 hours.
The family deferred autopsy.
DIAGNOSIS:
1. Respiratory failure secondary to metastatic prostate
cancer.
2. Rapidly re-accumulating malignant effusions.
3. Post obstructive pneumonia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-933
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2146-5-23**] 22:46
T: [**2146-5-23**] 21:22
JOB#: [**Job Number 101695**]
|
[
"198.5",
"788.30",
"196.1",
"447.1",
"519.4",
"336.3",
"486",
"197.2",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"34.91",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
3142, 3157
|
4656, 7459
|
3180, 4638
|
148, 194
|
223, 2433
|
2455, 3038
|
3055, 3125
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,133
| 179,979
|
53499+59533
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-10-11**] Discharge Date: [**2146-10-17**]
Date of Birth: [**2075-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Pravachol / Isosorbide
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Positive stress test
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2146-10-11**]
CABGx3(LIMA-LAD, SVG-OM,SVG-PDA) [**2146-10-12**]
History of Present Illness:
71 year old male with multiple CAD risk factors who has had
"routine" stress tests for several years. A stress-echo in [**Month (only) 547**]
of [**2145**] was markedly positive and he was brought to the cath lab
where it was found that he had severe 3-vessel disease. Patient
was discharged to home to decide on if he wanted surgery or not
and was lost to follow up. His cardiologist finally convinced
him that he needed re-evaluation and he was cathed on [**2146-10-11**]
that showed worsening of his CAD.
Past Medical History:
CAD s/p MI
Diabetes type 2
Hypertension
High cholesterol
Osteoarthritis
Social History:
Patient is a retried electrician. He has only a remote history
of tobacco as a teenager. He has no history of alcohol abuse
but does admit to social alcohol consumption. He is currently
married and lives in [**Location 4288**] with his wife.
Family History:
His father had heart problems in his 50s. His mother died of
CHF in her mid to late 80s.
Physical Exam:
Admission:
145/79 HR 65 Height: 5'4" Weight 164lbs
General: pleasant to speak with. Answers questions appropriately
Chest: Lungs clear to auscultation bilaterally
COR: Nl s1s2. No murmurs, rubs, gallops appreciated.
Abdomen: soft, nontender without rebound or guarding.
Normoactive bowel sounds.
Extremities: warm without edema. 1+ distal pulses
Labs: wbc 4.6, hct 31.5, plts 119. Cr 1.3.
EKG: sinus bradycardia @ 57BPM, RBBB, inverted T waves
II/III/AVF
Pertinent Results:
[**2146-10-11**] 09:15AM WBC-4.6 RBC-3.53* HGB-11.0* HCT-31.5* MCV-89
MCH-31.3 MCHC-35.0 RDW-12.3
[**2146-10-11**] 09:15AM ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-51
AMYLASE-64 TOT BILI-0.2
[**2146-10-11**] 04:00PM ALT(SGPT)-14 AST(SGOT)-15 LD(LDH)-133 ALK
PHOS-62 TOT BILI-0.4
[**2146-10-11**] 04:00PM GLUCOSE-189* UREA N-21* CREAT-1.1 SODIUM-141
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-30 ANION GAP-12
[**2146-10-11**] Cardiac Cath
1. Selective coronary angiography of this right-dominant system
revealed three-vessel coronary artery disease. The LMCA was
without
significant stenoses. The LAD had a 90% stenosis after D1. The
LCX was
totally occluded proximally. A large OM branch and smaller
distal OM
branches were filled from collaterals. The RCA had a long
mid-vessel
90% stenosis with a distal total occlusion before its
bifurcation, with
distal filling of the PDA and PL branches from the LAD.
2. Limited resting hemodynamics revealed normal aortic
pressures
Brief Hospital Course:
Patient was admitted on [**2146-10-11**] for a diagnostic cath that
revealed severe 3-vessel disease (90% LAD, 100% prox LCX with
collaterals filling marginals, 90% mid RCA, distally occluded
RCA with PDA and PLS filling via collaterals). [**10-12**] he was taken
to the OR where he underwent CABG x3 (Lima->LAD, SVG->OM/PDA).
Please refer to Dr[**Last Name (STitle) **] operative report for further
details. He was transferred to the CVICU where he woke up
neurologically intact and was extubated without difficulty. All
lines and drains were discontinued in a timely fashion. He was
transferred to the SDU on POD# 2. He continued to progress and
did well postoperatively. On POD# 3 it was felt he was ready for
discharge to home with VNA. All followup appointments were
discussed with Mr.[**Known lastname **] and he was advised that he might call
[**Hospital Ward Name 121**] 6 anytime with questions or concerns he may have.
Medications on Admission:
Glyburide 5 MG PO daily
Ketorolac 0.4% drops to left eye twice daily
Lisinopril 10MG PO daily
Claritin-D 120/5 daily
Metformin 1000mg PO twice daily
Metoprolol 50 MG PO twice daily
TNG sl 0.3 PRN chest pain
Zocor 40 MG po daily
ASA 81 mg po daily
Multivitamin
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
6. 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*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease
Diabetes
Osteoarthritis
Hypertension
hyperlididemia
Discharge Condition:
Good
Discharge Instructions:
No lifting more than 10 pounds for 10 weeks
No creams, lotions or powders to incisions
Shower daily, no baths or swimming
No driving for 4 weeks and off narcotics
Report any wound drainage/redness or fever more than 101
Take all medications as directed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 3070**]
Date/Time:[**2146-11-22**] 10:15
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) in 4 weeks
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 120**] in [**3-13**] weeks
Completed by:[**2146-10-15**] Name: [**Known lastname **],[**Known firstname 33**] Unit No: [**Numeric Identifier 18045**]
Admission Date: [**2146-10-11**] Discharge Date: [**2146-10-17**]
Date of Birth: [**2075-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Pravachol / Isosorbide
Attending:[**First Name3 (LF) 741**]
Addendum:
Sinus tachycardia developed and he was observed for 48 hours. He
remained in a sinus rhythm susequently and was discharged home
[**Female First Name (un) **] higher dose of lopressor.
Chief Complaint:
CAD
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2146-10-11**]
CABGx3(LIMA-LAD, SVG-OM,SVG-PDA) [**2146-10-12**]
Past Medical History:
CAD s/p MI
Diabetes type 2
Hypertension
High cholesterol
Osteoarthritis
Pertinent Results:
[**2146-10-11**] 04:00PM GLUCOSE-189* UREA N-21* CREAT-1.1 SODIUM-141
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-30 ANION GAP-12
Brief Hospital Course:
On POD #3 ( [**10-15**]) he developed a sinus tachycardia and was kept
in the hospital for another 48 hours. He remained stable and
was discharged on post operative day 5.
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
Disp:*7 7* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
Discharge Diagnosis:
Coronary Artery Disease
Diabetes
Osteoarthritis
Hypertension
hyperlididemia
Discharge Condition:
Good
Discharge Instructions:
No lifting more than 10 pounds for 10 weeks
No creams, lotions or powders to incisions
Shower daily, no baths or swimming
No driving for 4 weeks and off of all narcotics
Report any wound drainage/redness or fever more than 101
Take all medications as directed
report any weight gain of greater than 3 pounds
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 14618**]
Date/Time:[**2146-11-22**] 10:15
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1477**]) in 4 weeks
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2124**] in [**3-13**] weeks
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2146-10-17**]
|
[
"427.89",
"414.01",
"715.90",
"413.9",
"250.00",
"272.4",
"458.29",
"412",
"401.9",
"V17.3",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"99.04",
"36.15",
"39.61",
"88.72",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8654, 8712
|
7419, 7593
|
7063, 7156
|
8832, 8839
|
7270, 7396
|
9195, 9719
|
1325, 1417
|
7616, 8631
|
8733, 8811
|
3870, 4131
|
8863, 9172
|
1432, 1892
|
7020, 7025
|
442, 951
|
7178, 7251
|
1062, 1309
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,907
| 165,566
|
3470
|
Discharge summary
|
report
|
Admission Date: [**2124-11-10**] Discharge Date: [**2124-11-16**]
Date of Birth: [**2076-12-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
altered mental status, question fall
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
HPI 47 y/o with a history of alcohol abuse presents to ED after
found intoxicated. Per ED notes the patient walking up to a gas
station and called for help before throwing him self to the
ground. There are scattered reports of complaints of back pain
or a recent assualt. Noted to smell of alcohol. He was able to
ambulate and was A+Ox3 prior to arrival at the hospital. BG in
the field for 140.
.
Upon arrival to the [**Name (NI) **] pt was 96.8, BP 113/78, HR 84, RR 14, 96%
(on unclear level of oxygen. Pt requested pain medication. He
became increasingly somulent and desated to 86 % on NC.
Saturated improved to 97 % on non-rebreather but the pt became
unresponsive to sternal rub. Received narcan x 2 without
improvement. Serum Etoh 184, tox positive for benzos. He was
intubated for airway protection. ET tube inserted orally after
failed nasal intubation. During intubation pt sat up in bed
requiring propofol gtt for sedation. Received etomidate 20mg,
succinylcholine 100mg, versed 6mg, fentanyl 100mg IV in ED.
.
Upon arrival to floor pt intubated on sedated. Unable to illicit
further history. No contact person.
.
Past Medical History:
PMH: Alcohol abuse with previous withdraw (previous ED note from
[**2119**], no mention of seizures)
Social History:
SH: homeless, history of alcohol abuse. Last drink time unknown.
Family History:
unknown
Physical Exam:
PE: T:96.4 BP:118/86 HR:93 RR:16 O2 100% on CMV 100%/500/14/5
Gen: intubated and aggitated. trying to sit up and pull at
tubes. purposeful movements, no epileptiform movements
HEENT: resisting eye opening. ET tube in place, NG in place
NECK: in hard collar
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, good BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM. small bruising suggestive of
recent SQ heparin on abd.
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
NEURO: intubated and aggitated. CN 2-12 grossly intact. Will not
cooperate for strength or sensation exam. moving all for ext.
Pertinent Results:
[**2124-11-10**] 01:55PM PLT COUNT-330#
[**2124-11-10**] 01:55PM NEUTS-83.6* LYMPHS-12.8* MONOS-1.9* EOS-1.5
BASOS-0.2
[**2124-11-10**] 01:55PM WBC-7.6 RBC-4.44* HGB-14.5 HCT-40.0 MCV-90
MCH-32.6* MCHC-36.3* RDW-13.4
[**2124-11-10**] 01:55PM ASA-NEG ETHANOL-184* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2124-11-10**] 01:55PM CK-MB-2 cTropnT-<0.01
[**2124-11-10**] 01:55PM LIPASE-56
[**2124-11-10**] 01:55PM ALT(SGPT)-23 AST(SGOT)-48* CK(CPK)-110 ALK
PHOS-45 TOT BILI-0.7
[**2124-11-10**] 01:55PM GLUCOSE-105 UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
[**2124-11-10**] 07:47PM PT-14.0* PTT-26.7 INR(PT)-1.2*
.
CT C-SPINE W/O CONTRAST Study Date of [**2124-11-10**] 1:41 PM
FINDINGS: There is no fracture or dislocation detected. The
prevertebral soft tissues are normal. There is multilevel
degenerative changes with no
associated significant central canal stenosis or neural
foraminal narrowing. The visualized outline of the thecal sac
appears unremarkable. CT is not able to provide intrathecal
detail comparable to MRI.
The patient is status post endotracheal tube and orogastric tube
placement. The endotracheal tube balloon demonstrates
overdistention. There is an external catheter that courses
through to the left external jugular vein.
.
CT HEAD W/O CONTRAST Study Date of [**2124-11-10**] 1:41 PM
NON-CONTRAST HEAD CT: There is no hemorrhage, hydrocephalus,
shift of
normally midline structure, or evidence of major vascular
territorial infarct. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. Copious secretions are identified within the
nasopharynx, which is likely related to NG tube/intubation. The
visualized paranasal sinuses and mastoid air cells remain
normally aerated. Old right nasal bone fracture is identified.
IMPRESSION: No hemorrhage.
IMPRESSION:
1. No evidence of fracture or dislocation.
2. Endotracheal tube in place with apparent overdistention of
balloon.
Recommend slight deflation.
3. Catheter visualized in the left external jugular vein. Please
correlate
clinically.
.
CT PELVIS W/CONTRAST Study Date of [**2124-11-10**] 1:42 PM
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases show
mild
dependent atelectasis. NG tube terminates in the stomach. The
liver shows no focal lesion. The gallbladder is normal. The
intra- and extra-hepatic bile ducts are not dilated. Punctate
focus of calcification in the body of the pancreas (2:27) may
relate to parenchymal calcification, however, small stone is not
excluded. There is no pancreatic ductal dilatation or
peripancreatic
stranding.
The spleen and adrenal glands are normal. The kidneys enhance
and excrete
contrast symmetrically. A subcentimeter hypodensity in the lower
pole of the left kidney is incompletely characterized. The
intra- abdominal loops of large and small bowel maintain a
normal caliber without evidence of obstruction. There is no free
air or free fluid. Small peripancreatic lymph nodes are present
measuring up to 7 mm. Aortic atherosclerotic calcification is
moderate. The celiac trunk, SMA, and [**Female First Name (un) 899**] are patent. A
fat-containing umbilical hernia is present.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid
colon,
prostate, and seminal vesicles are unremarkable. The bladder is
collapsed and contains a Foley catheter. There is no
lymphadenopathy or free fluid.
BONE WINDOWS: No suspicious lytic or sclerotic lesion is
identified.
IMPRESSION:
1. No evidence of anterior abdominal parenchymal organ injury.
2. Punctate calcification in the mid body of the pancreas, which
may
represent a focal parenchymal calcification or small stone.
There is no
pancreatic ductal dilatation or peripancreatic inflammatory
change.
3. Mildly prominent peripancreatic lymph nodes, which is a
nonspecific
finding.
.
.
MR CERVICAL SPINE W/O CONTRAST Study Date of [**2124-11-15**] 11:11 AM
FINDINGS: The study is compared with the unenhanced CT of the
cervical spine [**2124-11-10**]. The sagittal STIR sequence is
essentially unremarkable, other than band-like hyperintensity in
the C3 inferior endplate, which demonstrates corresponding
T1-hypointensity, and sclerosis on the CT; this likely
represents a combination of discogenic [**Last Name (un) 13425**] I and III change.
No other focal STIR-signal abnormality is seen to suggest acute
ligamentous or other soft tissue abnormality or spinal cord
injury.
The axial sequence is significantly degraded by motion artifact,
limiting its interpretation, but there are multilevel
degenerative changes, as follows: At C2-C3, a broad-based disc
more than endplate osteophyte effaces the ventral CSF, slightly
indenting the ventral cord.
There is more marked degeneration of the C3-C4 disc with
broad-based
herniation and endplate spondylotic ridge, significantly
flattening the
ventral cord. There is also at least moderately severe right
neural foraminal narrowing, as on the CT. Allowing for
significant artifacts, the sagittal T2- weighted sequence
demonstrates frank compression of the cord at this level, in
part due to ligamentum flavum thickening, dorsally, with
suggestion of central T2-hyperintensity (2:9), which may
represent myelomalacia. There is no evidence of intramedullary
hemorrhage on the GRE sequence.
The C4-C5 disc is better-maintained in height and signal
intensity; however, broad-based endplate spondylotic ridge again
effaces the ventral CSF, flattening that aspect of the cord, and
there is also bilateral neural foraminal narrowing at this
level, as on the CT. At C5-C6 and C6-C7, disc-endplate
osteophyte complex slightly effaces the ventral CSF and flattens
the cord, without intrinsic signal abnormality. The included
upper cervical levels are grossly unremarkable, the
craniocervical junction is within normal limits and the cervical
spinal cord is otherwise normal in caliber and intrinsic signal
intensity. The limited visualized posterior fossa structures are
grossly unremarkable.
IMPRESSION:
1. No definite evidence of acute cervical spine or spinal cord
injury.
2. Multilevel degenerative disc, endplate and uncovertebral
joint disease;
this is most severe at the C3-C4 level where, in combination
with ligamentum flavum thickening, there is frank cord
compression. There is a suggestion of linear T2-hyperintensity
in the central cord substance, which, given the lack of other
evidence of acute injury, more likely represents chronic
myelomalacia rather than edema.
Brief Hospital Course:
Mr [**Known lastname **] is a 47 year old man with a history of alcohol abuse
who presented with altered mental status and a question of
trauma (fall versus assault) and was found to have a serum tox
screen that was positive for alcohol and benzodiazepines.
Intubated for progressive somulence.
.
During this hospitalization the following issues were addressed:
.
# Acute mental status change: On admission the pt was intubated
for airway protection given his progressive somulence. The pt
had a normal serum glucose and no fever or leukocytosis to to
suggest infection. In the emergency room the pt had extensive
imaging including a CT of the head, cervical spine and abdomen
and pelvis to evaluate for traumatic injury. On physical exam
the pt had no focal findings to suggest CVA. On admission to the
ICU the pt remained apneic on arrival secondary to sedation.
Over the course of the first night of admission the pt became
aggitated and in the morning the pt's sedation was weaned and
the pt self-extubated. The pt was then noted to be alert and
oriented to person, place and time and likely at baseline mental
status. The pt's admission somnolence was likely due to alcohol
and benzodiazepine intoxication. The pt did not have any
additional episodes of somnolence or altered mental status
during this admission. On discharge the pt's speech was clear,
linear, regular rate, and he was alert and oriented times three.
.
# Alcohol use: The pt reported a history of alcohol withdraw but
denied a history of seizures with withdrawal. Serum alcohol
level on admission was 184 and the pt was treated with a bannana
bag, thiamine, folate and a CIWA scale was initiated. On day two
of hospitalization the pt was transferred to the medical floor
and was notably agitated, anxious and tremulous. The pt received
one dose of diazepam and over the course of the following 4 days
the pt's CIWA score progressively declined. On discharge the
pt's CIWA score had been in the 0-2 range for 72 hours and he
had not received any diazepam since day 2 of admission. Social
work was asked to evaluate the pt and they recommended a dual
diagnosis inpatient stay, but due to the pt's need for oxycodone
the pt was unable to be placed in a dual diagnosis facility. The
pt reported that he planned to look into outpatient alcohol
cessation programs including one at [**Hospital3 15986**].
.
# Cervical spine tenderness: The pt complained of neck pain
following his extubation on day 2 of admission, so has cervical
collar remained in place. The spine service was asked to
evaluate the pt for purposes of clearing his cervical spine and
they recommended a cervical spine MRI given point tenderness
over the cervical spine. MRI of the cervical spine showed no
definite evidence of acute cervical spine or spinal cord injury
and multilevel degenerative disc, endplate and uncovertebral
joint disease that was most severe at the C3-C4, as well as
evidence of chronic myelomalacia. The spine service recommended
that the pt continue to wear the cervical spine/[**Location (un) 2848**] J collar
for the next few weeks and that he follow up with the spine
service as an outpatient for potential operative or
non-operative treatment.
.
# Hepatitis C: During the pt's admission he was involved in an
employee needle-stick injury. At the time of the injury the pt
was somnolent and his Hep C status was unknown.
Medications on Admission:
oxycodone
nicotine patch
senna
gabapentin
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day) as needed for constipation.
Disp:*QS ML(s)* Refills:*2*
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*39 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol intoxication, Alcohol withdrawal
2. Chronic degenerative cervical spine changes
Discharge Condition:
Stable. Able to breathe comfortably on room air, ambulate
without assistance, attend to all ADLs.
Discharge Instructions:
You were admitted after an assault. Initially you were extremely
somnolent and unable to be aroused and you were intubated for
airway protection. The following morning you removed the
breathing tube. You most likely were somnolent due to
intoxication from alcohol and oxycodone. You were treated during
this admission for alcohol withdrawal and you did not show any
signs of alcohol withdrawal after day 2 of admission.
.
During this admission you also reported some tenderness over the
bones in your neck, so the spine service was asked to consult
about your cervical spine. You had a cervical spine MRI that
showed chronic degenerative changes and now acute injury. The
spine service recommended that you continue to wear your
cervical spine collar until you see them in the office.
.
You have the below follow up appointments with your primary care
providers and the orthopedic surgery spine physician. [**Name10 (NameIs) **] is very
important that you attend your follow up appointments.
.
All of your home medications have been continued. Please take
your medications as directed. During this hospitalization you
were also started on lactulose and senna for constipation and
the vitamins folate and thiamine.
.
Please call your primary care doctor or go to the nearest
emergency room if you develop headaches, nausea, vomiting,
weakness or numbness, are unable to tolerate food or liquids,
fever > 100.4, chills, shortness of breath, chest pain, or any
other concerning symptoms.
.
Followup Instructions:
Primary Care Follow Up:
You have primary care follow up scheduled with your normal PCP
in [**Month (only) 956**]. You also have the following appointment scheduled
with another doctor in the [**Hospital 15987**] Medical Group:
Dr. [**Last Name (STitle) 15988**], Monday, [**2124-11-20**] at 2:00pm.
.
Orthopedic Surgery follow up:
Dr. [**Last Name (STitle) 363**], [**2124-12-13**] at 9:30am. [**Hospital Ward Name 23**] building, [**Location (un) 1385**].
|
[
"V60.0",
"291.81",
"303.01",
"346.90",
"564.00",
"724.2",
"305.1",
"786.03",
"780.09",
"336.8",
"723.1",
"305.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13087, 13093
|
8969, 12353
|
354, 379
|
13228, 13328
|
2448, 3843
|
14863, 14876
|
1759, 1768
|
12446, 13064
|
13114, 13207
|
12379, 12423
|
13352, 14840
|
1783, 2429
|
15194, 15323
|
278, 316
|
407, 1535
|
3852, 8946
|
1557, 1660
|
1676, 1743
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,784
| 128,195
|
1836
|
Discharge summary
|
report
|
Admission Date: [**2116-4-8**] Discharge Date: [**2116-4-15**]
Date of Birth: [**2036-1-27**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol / Aspirin / Lopressor
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
CC: Nausea/Vomitting/Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP w/ sphincterotomy
History of Present Illness:
80yo male w/CAD, DM, and CHF who has a h/o of hepatic
encephalopathy who presented to an OSH w/ N/V/Abd pain that the
day proir to admission. At OSH, he was found to have an amylase
of [**2110**] and an AlkPhos of 700 w/a TotalBili 5.3. He was
transferred to [**Hospital1 18**] for further work-up of his LFT
abnormalities and for mental status changes.
.
In the ED here his LFTs were confirmed and an u/s shared a
mildly dilated CBD without any GB wall thickening or edema. A CT
scan was ordered to evaluate for portal vein thrombosis, which
was subsequently found to be negative. He was stable until 10pm
at which point he became hypotensive with systolic BPs in the
70's. He was bolused with 6 liters NS, but his BPs did not
respond so a central line was placed and pressors were started.
An ERCP was performed revealing multiple stones which were
removed, with post cholangiogram which was free of stones. We
was weaned off pressors, and evaluated by surgery who felt
cholecystectomy is indicated once he is medically stabilized.
.
On tranfer the patient felt well and was without symptoms. He
denied abdominal pain, and had been able to tolerate PO's
without complaint. He noted 2 recent BM's. On ROS, he does
relate ~50 lb weight loss over the past 7 months, which he
relates to his 'water pills.'
Past Medical History:
1. Cryptogenic cirrhosis likely NASH; h/o confusion, with
multiple admissions for suspected hepatic encephalopathy; on
Lasix/Aldactone as an outpatient as well as Lactulose
2. CHF with an EF of 40% [**12/2115**], on Digoxin
3. CAD status post stent x2; cath [**1-/2113**] with 2VD w/ stent of
80% LAD; no other lesion with more than 50% stenosis
4. AFib status post DDD pacer ('[**12**] for symptomatic bradycardia,
intrinsic rhtythm is Afib/flutter); previously on Coumadin,
appears d/c'd after GIB
5. Hypertension.
6. history of CVA.
5. Diabetes Mellitus
6. history of multiple UTIs
7. history of pancytopenia.
8. Eosinophilic syndrome
9. Iron deficiency anemia, known trace pos stools.
10. H/O Upper GI bleed; grade I varices, grade II internal
hemmorroids (cscope [**2110**]), no rectal varices
11. Diverticulosis
12. Chronic renal insufficiency 1.2-1.6 at baseline.
13. s/p Left Total knee replacement
14. history of Gout
15. Liver lesion noted on segment VI [**11/2115**]
Social History:
Denies ETOH, Tobacco, IVDU. Lived w/ wife who died [**3-31**]. Son
involved w/care,
daughter and son-in-law assist them. Worked for the City of
[**Location (un) **]. Was in the Army for 21 years.
Family History:
His father with a MI at age 60. Two brothers with [**Name2 (NI) **] and
diabetes.
Physical Exam:
VITALS: Tm=99.6, Tc=98.1, BP=98/47-141/71, HR=95-124, RR=17-25,
O2=9=100% on RA, CVP=[**9-11**], I/O's= 24 hour +3157, 8 hour +270
GEN: Pt resting comfortably in NAD
HEENT: nonicteric, mucosa slighly dry, +facial telangectasias
CHEST: decreased BS's at bases w/ mild basilar rhales
CV: irreg irregular
ABD: mildly distended, no obvious ascites; no tenderness,
palpable masses
EXT: trace LE bilaterally
NEURO: slighltly slurred speech, but AAOx3; no asterixis;
grossly nonfocal exam
Pertinent Results:
[**2116-4-8**] 08:30PM WBC-4.3 RBC-3.18* HGB-10.3* HCT-29.3* MCV-92
MCH-32.4* MCHC-35.2* RDW-17.5*
[**2116-4-8**] 08:30PM PLT COUNT-147*
[**2116-4-8**] 08:30PM PT-13.7* PTT-25.1 INR(PT)-1.2
[**2116-4-8**] 08:30PM ALBUMIN-3.3*
[**2116-4-8**] 08:30PM ALT(SGPT)-163* AST(SGOT)-218* ALK PHOS-652*
AMYLASE-1005* TOT BILI-5.2* DIR BILI-4.0* INDIR BIL-1.2
[**2116-4-8**] 10:50PM DIGOXIN-0.6*
.
ERCP [**2116-4-9**] - A sphincterotomy was performed in the 12
o'clock position using a sphincterotome over an existing
guidewire; a balloon was used to sweep the duct which expelled
multiple stones and stone fragments. After stone removal a
cholangiogram revealed a duct free of stones
Impression: 1. A bulging of the major papilla suggestive of an
impacted stone. 2. There was a filling defect seen in the distal
biliary tree suggestive of an stone. 3. A sphincterotomy was
performed in the 12 o'clock position using a sphincterotome over
an existing guidewire. 4. A balloon was used to sweep the duct
which expelled multiple stones and stone fragments.
5. After stone removal a cholangiogram revealed a duct free of
stones.
.
CTA ABD W&W/O C - [**2116-4-9**] - IMPRESSION:
1) Mild Pancreatitis, 2) Cholelithiasis, without evidence of
acute cholecystitis, 3) Extensive colonic diverticulosis.
Pericolic fluid is most likely due to underlying liver disease,
4) Lesion in segment VI of liver which has been noted on prior
ultrasounds from [**2115-12-28**], and [**2115-12-24**]. This is
an arterio-portal fistula
with refluxing contrast down the portal vein. The findings are
concerning for a mass in the liver causing this fistula. Because
of this, an MRI is once again recommended to evaluate the
vasculature and in particular, to exclude an underlying liver
malignancy. 5) All intrahepatic arteries, veins and the portal
vein are patent without
intraluminal thrombus. 6) Splenic infarcts.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2116-4-13**] 3:40 PM -
CONCLUSION:
Findings are consistent with cirrhosis and an arteriovenous
fistula. No definite vascularized portal venous tumor thrombus
is identified, and the peripheral RPV thrombus hence appears on
imaging to be bland thrombus. However, although no focal hepatic
mass is identified apart from the AV fistula, the patient's
alpha fetoprotein is noted to be markedly elevated and the
possibility of tumor thrombus cannot definitively be excluded.
As the patient cannot get an MRI and there is no definable
target for biopsy, consideration for a PET-CT study should be
given.
.
UNILAT LOWER EXT VEINS RIGHT [**2116-4-13**] 3:40 PM - IMPRESSION:
Findings suggestive of partial, nonocclusive thrombus in the
right common femoral vein, which may be chronic or acute.
Brief Hospital Course:
80 yo male c/CAD, CHF, DM, CRF and cryptogenic cirrhosis who is
admitted for obstructive pancreatitis and jaundice now s/p ERCP
.
RESOLVING SEPSIS - appears resolved, BP became stable with good
CVP's. Pt was briefly placed on Zosyn, which was then d/c'd with
continued stable BP and negative cultures.
.
GALLSTONE PANCREATITIS - s/p ERCP, and was able to tolerate PO
diet without complaint. His enzymes continued to trend down. Pt
was felt to be a high risk surgery for [**Last Name (LF) 10259**], [**First Name3 (LF) **] no inpatient
surgery was planned. This may be re-addressed as an outpatient.
.
CV: CORONARIES - pt has known CAD, with allergy to ASA (unclear
if true allergy). [**Month (only) 116**] benifit from repeat stress as an
outpatient.
PUMP - pt with known CHF, but continued to have stable O2
sats. He was restarted on his outpt diuretics.
RATE - he was restarted on his outpatient Diltiazem for
Afib, as well as Digoxin. He was temporarily placed on IV
Heparin, but Coumadin was held b/o history of GIB, and well as
fall history. Coumadin was held during previous admission, and
his PCP's office was contact[**Name (NI) **]. It was agreed that we should
continue holding his Coumadin, and this could be further
evaluated as an outpatient.
.
DVT - it was noted by radiology that he may have a possible RUE
dvt on his abdominal CT. Follow-up US confirmed nonocclusive
thrombus. Given previously discussed risks, he was not treated
with Coumadin. These risks were discussed with the patient and
family.
.
ANEMIA - pt w/ h/o GIB, with only grade 1 varices. He was mildly
guiac positive while on Heparin, and recieved 1U of PRBC's with
Hct corrected to baseline. He should have f/u Hct checks.
.
DM - his prevous NPH regimen was held, and was covered with ISS.
He should restart a lower NPH regimen as outpatient, and cover
with ISS.
.
HTN - his ACEi was held, and he was placed back on Diltiazem for
rate control. His BP remained stable without Lisinopril, so this
was not restarted. [**Month (only) 116**] consider change from Diltiazem to
nonselective BB in the future.
.
LIVER - his liver lesion on CT was concerning for HCC, and his
previous AFP was 37.5 on [**2115-3-1**]. Repeated was now 1892. He has
a pacermaker, and could not get MRCP. Will d/w hepatology, and
felt this AFP level was likely diagnostic. A 50lb weight loss
makes this even more concerning. Discussed with IR and ordered
another abd u/s. It was unclear how much the lesion was
infiltrating tumor vs AVM, and given the location and
description he was not a surgical candidate, or a candidiate for
chemoembolization or RFA. He will f/u with Dr [**First Name (STitle) **] as an
outpatient for [**Hospital 10260**] medical therapy. As far as his cirrhosis
goes he does not appear encephalopathic, and was continued on
Lactulose. He was restarted on outpt diuretics.
Medications on Admission:
MEDS ON TRANSFER:
Lactulose 30 ml PO TID
Digoxin 0.125 mg PO DAILY
Lisinopril 10 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Heparin 5000 UNIT SC TID
Piperacillin-Tazobactam Na 4.5 gm IV Q8H
Insulin SS
(at home also on NPH 15U [**Hospital1 **], Aldactone 25 QD, Lasix 20 [**Hospital1 **])
Discharge Medications:
1. Digoxin 125 mcg 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. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Please titrate to [**1-30**] bowel movements per day.
Disp:*qs 1 months' supply* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Gallstone Pancreatitis
Liver Mass
CHF
CAD
AFib status post DDD pacer
Hypertension.
H/O CVA.
Diabetes Mellitus
DVT
Discharge Condition:
Stable
Discharge Instructions:
Please continue to take all medications as prescribed. Please
continue your diuretics, and be sure to weigh yourself every
morning. Please lower your NPH regimen to 5U twice a day, and
cover with an insulin sliding scale. If you develop any
nausea/vomiting, bleeding from your rectum, chest pain,
shortness of breath, or any other concerning symptoms please
seek immediate medical attention.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT
MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**],
[**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2116-5-6**] 4:00
Please make an appointment with Dr [**First Name (STitle) **] to make an appointment
about your liver lesion. Please call ([**Telephone/Fax (1) 10261**].
Completed by:[**2116-4-15**]
|
[
"280.0",
"574.90",
"V45.82",
"785.52",
"250.00",
"428.0",
"V45.01",
"401.9",
"995.92",
"155.0",
"571.5",
"038.9",
"577.0",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"00.17",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
10233, 10291
|
6263, 9122
|
328, 353
|
10448, 10456
|
3517, 6240
|
10896, 11385
|
2916, 3000
|
9457, 10210
|
10312, 10427
|
9148, 9148
|
10480, 10873
|
3015, 3498
|
253, 290
|
381, 1686
|
1708, 2687
|
2703, 2900
|
9166, 9434
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,441
| 138,437
|
39571
|
Discharge summary
|
report
|
Admission Date: [**2122-8-4**] Discharge Date: [**2122-8-12**]
Date of Birth: [**2062-2-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillin G
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2122-8-7**] Coronary artery bypass graft x2 with the left internal
mammary artery to the left anterior descending artery and
reverse saphenous vein graft to the right coronary artery.
Bentall procedure using a 28 mm Gelweave graft for the distal
aorta and a [**Company 1543**] Freestyle aortic root/heart valve size 29
mm for the proximal aorta.
[**2122-8-6**] Colonscopy
[**2122-8-4**] Cardiac catheterization
History of Present Illness:
60 year old male with no significant cardiac history who
presented to OSH on [**2122-7-30**] with chest pain at rest and new onset
atrial fibrillation with RVR. The patient states that he has had
6 months of worsening shortness of breath, chest
discomfort, and new palpitations. Trop I peaked at 0.86 ruled in
for NSTEMI. His hematocrit was noted to be 25.8, but stools were
guaiac negative. He is now s/p 2 units RBCs at OSH. He was
transferred directly to [**Hospital1 18**] catheterization lab
Past Medical History:
Atrial Fibrillation- diagnoses [**2122-7-30**]
Thoracic/Descending aortic aneurysm 5.8cm at aortic root
Renal Cortical Cyst
Right renal Calculus
Anemia
Diverticulosis
h/o rectal bleed and GI bleed with negative colonoscopies [**2115**],
[**2118**]; bleeding resolved spontaneously
Left inguinal hernia
s/p ventral hernia repair
s/p tonsillectomy
Social History:
Lives with:Alone
Occupation:Farmer, self-employed
Tobacco:remote hx, not heavy
ETOH:2 beers/day x 10 years
Family History:
Mother with DM, died of HF age 75, Father with [**Name2 (NI) 499**] CA
Physical Exam:
Pulse:95 Resp:22 O2 sat:100%
B/P Right:140/101 Left:130/94
Height: 6'4" Weight:258 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
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: dressing Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2122-8-12**] 09:15AM BLOOD WBC-10.5 RBC-4.05* Hgb-9.4* Hct-30.1*
MCV-74* MCH-23.1* MCHC-31.1 RDW-21.5* Plt Ct-264
[**2122-8-4**] 03:10PM BLOOD WBC-6.6 RBC-4.44* Hgb-8.8* Hct-29.5*
MCV-66* MCH-19.9* MCHC-29.9* RDW-21.4* Plt Ct-266
[**2122-8-12**] 09:15AM BLOOD Plt Ct-264
[**2122-8-8**] 01:26AM BLOOD PT-14.4* PTT-28.7 INR(PT)-1.2*
[**2122-8-4**] 03:10PM BLOOD PT-13.6* PTT-25.8 INR(PT)-1.2*
[**2122-8-4**] 12:00PM BLOOD PT-13.6* INR(PT)-1.2*
[**2122-8-4**] 12:00PM BLOOD PT-13.6* INR(PT)-1.2*
[**2122-8-8**] 01:26AM BLOOD Fibrino-224
[**2122-8-12**] 09:15AM BLOOD Glucose-181* UreaN-21* Creat-1.1 Na-141
K-4.1 Cl-105 HCO3-26 AnGap-14
[**2122-8-4**] 03:10PM BLOOD Glucose-100 UreaN-17 Creat-1.0 Na-137
K-4.5 Cl-105 HCO3-23 AnGap-14
[**2122-8-10**] 02:18AM BLOOD ALT-19 AST-30 LD(LDH)-226 AlkPhos-46
TotBili-1.3
[**2122-8-4**] 03:10PM BLOOD ALT-22 AST-19 CK(CPK)-46* AlkPhos-58
Amylase-40 TotBili-1.2 DirBili-0.3 IndBili-0.9
[**2122-8-4**] 03:10PM BLOOD CK-MB-2 cTropnT-0.03*
[**2122-8-12**] 09:15AM BLOOD Mg-2.3
[**2122-8-4**] 03:10PM BLOOD Albumin-4.0 Cholest-114
[**2122-8-4**] 03:10PM BLOOD VitB12-236*
[**2122-8-5**] 12:00AM BLOOD %HbA1c-5.9 eAG-123
[**2122-8-5**] 12:00AM BLOOD Triglyc-82 HDL-29 CHOL/HD-4.0 LDLcalc-72
[**2122-8-5**] 11:15AM BLOOD TSH-2.9
[**2122-8-5**] 12:00AM BLOOD Triglyc-82 HDL-29 CHOL/HD-4.0 LDLcalc-72
Final Report
CHEST RADIOGRAPH
INDICATION: Evaluation for pleural effusion.
COMPARISON: [**2122-8-10**].
FINDINGS: The right-sided central venous insertion sheath has
been removed.
Unchanged alignment of sternal wires and cardiac clips. Minimal
left pleural
effusion with retrocardiac atelectasis and right basal
atelectasis. No
pulmonary edema. No evidence of pneumonia. Known healed right
rib fracture.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: TUE [**2122-8-11**] 11:44 AM
Brief Hospital Course:
Transferred in from outside hospital for cardiac evaluation
after ruling in for myocardial infarction. He was referred to
cardiac surgery after found to have coronary artery disease and
dilated aorta. He underwent preoperative workup including
colonscopy due to history of bleeding and decreased hematocrit,
and was found to have severe colonic diverticulosis none of
which appeared to be bleeding. He was brought to the operating
room on [**2122-8-7**] where the patient underwent coronary artery
bypass graft and bentall. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. He was
tranfused multiple products post operatively for high chest tube
output and this had slowed by post operative day 1 with no signs
of tamponade. Epinephrine was weaned off POD 2 and he remained
hemodynamically stable with PA catheter removed. He was
extubated, alert and oriented and breathing comfortably on post
operative day 2. The patient remained neurologically intact and
hemodynamically stable on no inotropic or vasopressor support
and was transferred to the step down unit on POD 3. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD five he was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. He was discharged home with services with
plan for cousin to stay with him.
He was not placed on coumadin for atrial fibrillation due to
risk of bleeding.
Medications on Admission:
aspirin 325mg daily
simvastatin 80mg daily
Coreg 3.125 [**Hospital1 **]
lisinopril 5mg daily
SL NTG prn
morphine prn
Plavix 75mg daily, 600mg on [**2122-8-2**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
please take twice daily for 7 days then decrease to once a day
until follow up with cardiologist .
Disp:*37 Tablet(s)* Refills:*0*
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Ascending aortic aneurysm s/p Bentall
NSTEMI at OSH troponin 0.86
Atrial Fibrillation diagnoses [**2122-7-30**]
Renal Cortical Cyst
Right renal Calculus
Anemia
Diverticulosis
h/o rectal bleed and GI bleed with negative colonoscopies [**2115**],
[**2118**]; bleeding resolved spontaneously
Left inguinal hernia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Right Left - healing well, no erythema or drainage. trace 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
Surgeon: Dr [**Last Name (STitle) **] Wed [**9-9**] at 1:00PM
Cardiologist: Dr [**Last Name (STitle) **] [**9-16**] @ 1pm [**Last Name (NamePattern4) 87349**].
Name: [**Doctor Last Name **]-[**Last Name (LF) **],[**First Name3 (LF) **] Z.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**]
Phone: [**Telephone/Fax (1) 6699**]
Appt: [**8-17**] at 11:30am
**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:[**2122-8-12**]
|
[
"414.01",
"537.1",
"424.1",
"441.2",
"531.90",
"280.9",
"410.71",
"427.31",
"550.90",
"562.10",
"424.0",
"593.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"88.56",
"38.45",
"37.22",
"35.21",
"45.16",
"36.15",
"45.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7479, 7534
|
4360, 6103
|
289, 707
|
7921, 8143
|
2480, 4337
|
8983, 9674
|
1745, 1818
|
6314, 7456
|
7555, 7900
|
6129, 6291
|
8167, 8960
|
1833, 2461
|
238, 251
|
735, 1234
|
1256, 1604
|
1620, 1729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,073
| 196,783
|
29859
|
Discharge summary
|
report
|
Admission Date: [**2198-3-12**] Discharge Date: [**2198-3-17**]
Date of Birth: [**2128-12-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
MVR/cabg x3 [**2198-3-12**] ( 29 mm [**Company 1543**] Mosaic Porcine valve,
LIMA to LAD, SVG to ramus, SVG to OM)
History of Present Illness:
69 yo male with abnormal ETT despite being asymptomatic. Echo on
[**11-3**] showed EF 60-65% , moderate MR, and mild TR. Cath
performed [**2-4**] revealed severe CAD with EF 65%, 90% LAD, 50%
Diag 1, 80% CX, 70% OM 2, 50% ostial RCA. Referred for surgery
to Dr. [**Last Name (STitle) 1290**].
Past Medical History:
HTN
PUD/GERD/hiatal hernia
fibromyalgia
mild COPD by CXR
elev. lipids
Lyme dz.
cerv. spine [**Doctor First Name **] [**2188**]
cataract surgery
bil. ing. herniorrhaphies
? glaucoma
Social History:
retired analyst
smoked pipe during college
2 glasses of wine per day
lives with wife
Family History:
no premature CAD
Physical Exam:
HR 98 RR 20 right 150/84 left 150/80
6' 175#
anxious-appearing
skin/ HEENT unremarkable
neck supple with slightly decreased ROM, no bruits
CTAB
RRR, no murmur
soft, NT, ND, + BS
warm, well-perfused, no peripheral edema or varicosities noted
neuro grossly intact
2+ bil. fem/DP/ PT/ radials
Discharge
Vitals 97.7 SR 88 125/80 20 RA sat 96% wt 83.4kg
Neuro a/o x3 nonfocal
Pulm CTA bilat
Card rrr no m/r/g
Abd soft, nt nd + BS bm [**3-16**]
Ext warm pulses palpable
Inc sternal no drainage/erythema sternum stable steris
Left leg EVH steris healing no drainage/erythema
Pertinent Results:
[**2198-3-17**] 10:00AM BLOOD WBC-12.7* RBC-2.90* Hgb-9.0* Hct-25.8*
MCV-89 MCH-31.2 MCHC-35.0 RDW-14.0 Plt Ct-164
[**2198-3-12**] 02:30PM BLOOD WBC-17.2*# RBC-3.26*# Hgb-9.9*#
Hct-28.8*# MCV-89 MCH-30.3 MCHC-34.3 RDW-13.5 Plt Ct-117*#
[**2198-3-17**] 10:00AM BLOOD Plt Ct-164
[**2198-3-12**] 02:30PM BLOOD PT-17.8* PTT-31.8 INR(PT)-1.7*
[**2198-3-14**] 03:11AM BLOOD PT-12.6 PTT-27.8 INR(PT)-1.1
[**2198-3-17**] 10:00AM BLOOD UreaN-25* Creat-1.3* K-3.7
[**2198-3-16**] 07:40AM BLOOD Glucose-104 UreaN-31* Creat-1.3* Na-138
K-4.2 Cl-104 HCO3-27 AnGap-11
[**2198-3-12**] 03:44PM BLOOD UreaN-13 Creat-0.8 Cl-114* HCO3-23
[**2198-3-13**] 02:01AM BLOOD Glucose-122* UreaN-15 Creat-1.3* Na-137
K-4.7 Cl-109* HCO3-23 AnGap-10
[**3-16**] CXR
[**Hospital 93**] MEDICAL CONDITION:
69 year old man s/p CABG/MVR
REASON FOR THIS EXAMINATION:
eval post op
AP CHEST, 8:44 A.M., [**3-16**]
HISTORY: Status post CABG.
IMPRESSION: PA and lateral chest compared to [**3-12**] and 14:
Lung volumes have improved since [**3-14**]. Small bilateral
dependent pleural effusions remain. Mild enlargement of the
postoperative cardiac silhouette could be due to mediastinal
fluid retention, some of which is demonstrated by an air-fluid
level seen on the lateral view at the level of the sternal
angle. Aside from mild basal atelectasis, lungs are clear. There
is no pulmonary edema. No pneumothorax.
Echo [**3-12**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.18 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 40% to 55% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in
the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Mildly depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending
aorta. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
thickening of
mitral valve chordae. Torn mitral chordae. No MS. Mild to
moderate ([**1-30**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate
[[**1-30**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. The patient was
under general
anesthesia throughout the procedure.
Conclusions:
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular
systolic function is mildly depressed. Right ventricular chamber
size and free
wall motion are normal. The ascending aorta is mildly dilated.
There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets
are mildly thickened. Torn mitral chordae are present. Mild to
moderate ([**1-30**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly
thickened. There is no pericardial effusion.
POST BYPASS:
Preserved biventricular systolic function.
Bioprosthesis seen in the mitral position. Well seated and
mechanically
stable, with good leaflet esxcursionand trace valvular mitral
regurgitation.
No signoficant gradient across the mitral valve, and MVA by PHtT
> 2 cm2. The
peak gradient across the LVOT was calculated to be 30 mm HG,
with uniform flow
with color flow Doppler and no evidence of turbulence.
No other change.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Admitted [**2198-3-12**] and underwent CABG x 3/MVR with Dr. [**Last Name (STitle) 1290**].
Transferred to the CSRU in stable condition on propofol and
phenyleprine drips. Extubated that evening, and transferred to
the floor on POD #2 to begin increasing his activity level.
Chest tubes and pacing wires removed without incident. Beta
blockade titrated and cleared for discharge to home with
services on post operative day 5.
Medications on Admission:
altace 5 mg daily
atacand 8 mg daily
nexium 40 mg daily
lipitor 40 mga daily
celexa 60 mg daily
xalatan 0.005% one drop right eye QHS
vitamins daily
L-arginine
ASA 81 mg daily
xanax 0.25 mg prn
Co-Q 10
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 10 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*1*
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
Disp:*2 vials* Refills:*0*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
s/p MVR/cabg x3
mild COPD
HTN
elev. chol.
PUD
Lyme Dz.
fibromyalgia
GERD/Hiatal hernia
? glaucoma
Discharge Condition:
good
Discharge Instructions:
may shower over incisions and pat dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
follow up with Dr. [**First Name (STitle) **] in [**1-30**] weeks
follow up with Dr. [**Last Name (STitle) 1295**] in [**3-3**] weeks
follow up with Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
[**Hospital Ward Name 121**] 2 wound check
Completed by:[**2198-3-17**]
|
[
"729.1",
"272.4",
"424.0",
"553.3",
"443.9",
"414.01",
"272.0",
"401.9",
"496",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8962, 9024
|
6807, 7234
|
336, 454
|
9165, 9171
|
1727, 2463
|
9432, 9729
|
1098, 1116
|
7486, 8939
|
2500, 2529
|
9045, 9144
|
7260, 7463
|
9195, 9409
|
1131, 1708
|
283, 298
|
2558, 6747
|
482, 776
|
6784, 6784
|
798, 980
|
996, 1082
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,931
| 120,710
|
31426
|
Discharge summary
|
report
|
Admission Date: [**2106-9-23**] Discharge Date: [**2106-9-29**]
Service: CARDIOTHORACIC
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
sternal wound drainage
Major Surgical or Invasive Procedure:
sternal wound debridment
History of Present Illness:
84 yoM s/p CABG [**8-13**], Trach&PEG [**8-31**], transferred to rehab [**9-15**]
returned [**9-23**] w/sternal drainage from lower third of sternal
wound. No associated fever or elevated WBC while at
rehabilitation. Wound opened at bedside on day of admission and
following day pt brought to operating room for local
debridemnet. Vac placed after wound debridement.
Past Medical History:
s/p CABGx5 [**8-13**], s/p trach & PEG [**8-31**]
MI [**2071**], CHF, Afib (currently NSR), lipids, HTN, BLE vein
surgery [**2041**], bilat knee surgery.
Social History:
retired
lives with wife at [**Name (NI) 74005**] Place
quit tobacco 15 years ago, 30 pack year history
occasional etoh
Family History:
NC
Physical Exam:
Admission:
VS T 96 HR 87 BP 112/48 RR 23 02sat 97% CPAP 50/15/5
Gen: NAD, lying in bed
Neuro: Awake, responds to voice, MAE, does not consistantly
follow commands
CV: Irreg, sternum stable. Sternal incision w 3x1cm open area in
lower third of wound. Minimal surrounding erythema.
Pulm: Rhonchi throughout, diminished BS bilat bases
Abdm: soft, NT/+BS. PEG site CDI
Ext: warm, no edema. Bilat vein harvest sites w steri strips
Skin: Groin w/ macular rash
TLD: foley-gravity, PEG, Trach
Discharge
VS T 97 HR 91 BP 103/57 RR 22 02sat 96% CPAP 50/8/5
Gen NAD
Resp Diminished bases L>R
CV irreg irreg. Sternum stable , wound w/VAC dsg
Abdm soft/NT/+BS. PEG site CDI
Ext warm 1+ edema
TLD PICC, Trach, PEG
Pertinent Results:
[**2106-9-23**] 05:38PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2106-9-23**] 03:28PM GLUCOSE-160* UREA N-90* CREAT-1.4*
SODIUM-153* POTASSIUM-3.3 CHLORIDE-113* TOTAL CO2-32 ANION
GAP-11
[**2106-9-23**] 03:28PM ALT(SGPT)-137* AST(SGOT)-56* ALK PHOS-277*
AMYLASE-49 TOT BILI-1.7*
[**2106-9-23**] 03:28PM ALBUMIN-2.5* CALCIUM-6.5* MAGNESIUM-3.2*
[**2106-9-23**] 03:28PM WBC-16.1*# RBC-3.57* HGB-11.4* HCT-35.7*
MCV-100* MCH-31.8 MCHC-31.8 RDW-19.2*
[**2106-9-23**] 03:28PM PLT COUNT-94*
[**2106-9-23**] 03:28PM PT-26.3* INR(PT)-2.7*
[**2106-9-28**] 02:45AM BLOOD WBC-8.6 RBC-2.89* Hgb-9.3* Hct-28.6*
MCV-99* MCH-32.2* MCHC-32.5 RDW-18.3* Plt Ct-105*
[**2106-9-28**] 02:45AM BLOOD Plt Ct-105*
[**2106-9-28**] 02:45AM BLOOD PT-21.4* PTT-44.1* INR(PT)-2.1*
[**2106-9-28**] 02:45AM BLOOD Glucose-161* UreaN-94* Creat-1.5* Na-147*
K-2.7* Cl-107 HCO3-30 AnGap-13
[**2106-9-23**] 3:28 pm BLOOD CULTURE Source: Line-r subclavian.
**FINAL REPORT [**2106-9-26**]**
AEROBIC BOTTLE (Final [**2106-9-26**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 74007**] [**2106-9-24**] 9:15AM.
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CIPROFLOXACIN--------- =>8 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC BOTTLE (Final [**2106-9-26**]):
STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM
AEROBIC BOTTLE.
Brief Hospital Course:
Pt admitted on [**9-23**], wound debrided at bedside, central line
placed.
Brought to operating room on [**9-24**], see OR report for details,
wound debrided and VAC dressing applied. Tissue sample to micro
for culture.
Pt tx initially with Vancomycin and Levaquin then switched to
Nafcillin once sensitivities obtained.
PICC line placed [**9-28**] for long term atibx.
Left thoracentesis for 1800cc's on [**9-28**]
Receiving Coumadin for AFib, INR 3.3 on day of discharge, would
hold Coumadin until INR < 2.0, then resume very low dose.
Transferred to rehab [**2106-9-29**].
Medications on Admission:
Lantus 10', RISS, Lopressor 75''', Prevacid 30', Lipitor 10',
KCL 20', ASA 325', Coumadin 1', Zantac 150', Sertraline 50',
Lasix 40", Zaroxyln 5", Colace 100", MVI, Lactulose 15",
Prednisone 15", Lisinopril 2.5'
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
11. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
Two (2) Inhalation [**Hospital1 **] (2 times a day).
13. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150)
mg PO DAILY (Daily).
14. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous once a day.
15. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
Q4H (every 4 hours) as needed.
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams
Intravenous Q6H (every 6 hours) for 6 weeks: start date [**9-27**].
19. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
20. Warfarin 0.5 mg Tablet Sig: as directed Tablet PO once a
day: target INR 1.5-2.0. DO NOT RESUME UNTIL INR LESS THAN 2.0
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
s/p superficial sternal wound debridement
PMH:s/p CABG ([**8-13**]), s/p trach/PEG ([**8-31**]), Afib, ^chol, HTN, BLE
vein surgery, B knee [**Doctor First Name **]
Discharge Condition:
good
Discharge Instructions:
keep wound clean and dry.
change VAC sressing Q3-4 days
take all medications as prescribed
Followup Instructions:
Dr. [**First Name (STitle) **] in 3 weeks
With PCP upon discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2106-9-29**]
|
[
"428.0",
"427.31",
"401.9",
"V44.0",
"998.59",
"V45.81",
"414.00",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"77.61",
"96.6",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
6046, 6120
|
3640, 4218
|
252, 279
|
6329, 6336
|
1753, 3617
|
6475, 6674
|
1006, 1010
|
4480, 6023
|
6141, 6308
|
4244, 4457
|
6360, 6452
|
1025, 1734
|
190, 214
|
307, 676
|
698, 853
|
869, 990
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,878
| 176,165
|
37288
|
Discharge summary
|
report
|
Admission Date: [**2185-11-21**] Discharge Date: [**2185-12-3**]
Date of Birth: [**2130-3-13**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Penicillins / Cephalosporins
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
recurrent UGIB in cirrhotic patient
Major Surgical or Invasive Procedure:
EGD with banding of varicies.
History of Present Illness:
55M with EtOH and Hep C cirrhosis, admitted [**2185-11-12**] to OSH with
rectal bleeding and abdominal pain, now transferred to [**Hospital1 18**]
with continued UGIB for TIPS evaluation.
.
He was admitted after presenting with (per the notes) 2 days of
RUQ/epigastric pain and 2 episodes of large volume hematochezia.
Patient recalls not much abdominal pain but does report 6 hours
of BRBPR as well as some hematemesis. At admission HR 128 with
BP 133/83 and Hct 34.9. Total bili 1.7 and INR 1.1 with
platelets 49. At OSH, he subsequently developed hematemesis with
Hct drop to 28.3. Emergent EGD showed bleeding grade III
varices, which were sclerosed. He was treated also with protonix
gtt and octreotide gtt. Received 4 units PRBCs and one unit
platelets. Nadolol was started. He continued to have melena but
was hemodynamically stable and was transferred to the floor. On
[**11-17**] he again developed hematemesis (400 cc bright red blood).
He went back to the MICU with hypotension to the 80s. Received 4
more units and fluids (Hct low 24.3). EGD at that time did not
suggest bleeding of his varices but did show gastritis with
hemorrhage. He received 2 more units PRBCs on [**11-19**] and [**11-20**]. On
[**11-20**] he had 2 episodes of BRBPR with 6 point hematocrit drop.
Colonoscopy was done today without evidence of a source.
Following this, he "coughed up" 20 cc blood (patient does not
recall this). He received one more unit PRBCs. Last hematocrit
31.2 at noon today (got one more unit after this).
During his admission he was also treated with 5 days ertapenem
for ?colitis on CT. No other major events during his hospital
course.
.
Currently denies abdominal pain or nausea. Endorses mild
lightheadedness. Does recall watery diarrhea from prep overnight
but none recent. No noted jaundice or scleral icterus. Does
endorse LE edema that he noted today as well as abdominal
distension. Also notes he developed cough, mildly productive,
since going outside for transfer today.
.
Review of systems:
(+) Per HPI
(-) Denies fever (though did have a 100.4 at hospital
admission), chills, recent weight loss or gain (unsure of this).
Denies headache. Denies shortness of breath, wheezing. Denies
chest pain, chest pressure, palpitations. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- ESLD due to EtOH and HCV
- EtOH abuse with history of DTs.
- Hepatitis C
- GERD
- Cervical disc degeneration s/p surgical procedure
Social History:
- Tobacco: Current smoker of 1.5 PPD x 40 years.
- Alcohol: 12-18 beers per day; occasionally hard alcohol.
Family History:
Mother died of throat cancer. Father died of MVA
Physical Exam:
ON ADMISSION:
General: Chronically ill appearing. Alert, oriented, no acute
distress
HEENT: Sclera anicteric, PERRL (3->2), EOMs intact with few
beats horizontal nystagmus, MM slightly dry, oropharynx clear.
Neck: supple, JVD flat, no LAD
Lungs: + bibasilar crackles R>L, clear almost entirely with
cough. Few wheezes when coughing.
CV: Regular rate and rhythm, normal S1 + S2, soft SM at apex.
Abdomen: soft, non-tender, mild to moderate distension,
hyperactive bowel sounds present, no rebound tenderness or
guarding. mostly tympanic with some peripheral ?shifting
dullness.
Ext: warm, well perfused, 2+ LE edema.
Neuro: alerted and oriented x 3, CN II-XII intact, strength 5/5
in distal UEs and LEs, no asterixis.
ON DISCHARGE:
Pertinent Results:
On Admission:
[**2185-11-21**] 05:12PM BLOOD WBC-10.2 RBC-3.43* Hgb-10.7* Hct-31.7*
MCV-93 MCH-31.2 MCHC-33.7 RDW-17.3*
[**2185-11-22**] 12:03AM BLOOD WBC-28.8*# RBC-3.71* Hgb-12.1* Hct-34.0*
MCV-92 MCH-32.5* MCHC-35.5* RDW-17.8* Plt Ct-83*
[**2185-11-21**] 05:12PM BLOOD Glucose-110* UreaN-15 Creat-0.7 Na-138
K-3.9 Cl-110* HCO3-22 AnGap-10
[**2185-11-21**] 05:12PM BLOOD ALT-35 AST-40 LD(LDH)-185 AlkPhos-43
TotBili-2.6*
CXR:
FINDINGS: No prior comparisons films. Heart size is normal,
although patient rotation limits evaluation of the right heart
border. There is a large opacity/consolidation in the left mid
and lower lung fields. Differential includes aspiration as well
as infectious processes. No definite adenopathy is seen. Right
lung is clear. NG tube tip lies well below the diaphragm, its
distal end is not included on the film. No pneumothorax.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Mr [**Known lastname **] was initially transferred to the ICU for management
of his hematemesis. Hepatology was consulted and performed an
EGD in the ICU which revealed bleeding varicies which were
banded. IR was made aware in case he re-bled, the plan would be
for urgent/emergent TIPS. He was started on Ciprofloxacin for
SBP prophylaxis. He was continued on a PPI and octreotide drip
in the ICU. He was then transferred to the floor but had
recurrent episodes of bleeding and was sent back to the ICU
where an emergent TIPS was eventually performed by IR. Patients
hematocrit remained stable back on the floor. Lasix, Nadolol was
restarted, and Mr [**Known lastname 1226**] bleeding did not recur. He did
have an abnormal respiratory exam; a chest x-ray revealed a
large consolidation while he was in the ICU and he completed a
course of vancomycin and meropenem while in the unit; on the
floor his respiratory status improved and was breathing normally
on room air. He was not encephalopathic during his
hospitalization. His end-stage liver disease was felt secondary
to his hepatitis C history and alcohol history. He was not
considered a transplant candidate since does have active
drinking. Social work was consulted for his alcohol history. A
nicotine patch was started for smoking cessation. He was
discharged with liver follow up.
Medications on Admission:
Medications at home:
None
Medications at transfer:
Octreotide 50 mcg/hr IV
Protonix 8 mg/hr IV
Trazodone 100 mg HS and 25 mg daily prn insomnia
Nicotine patch 21mg daily
Morphine 2 mg IV q3H prn pain (4 doses yest, one today)
zofran 4 mg IV q4H prn nausea
Magnesium 2 gram x 1 today
Potassium phosphate 15 mmol x1 today
Golytely yesterday
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 3 bowel movements daily.
Disp:*2700 ML(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
7. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed secondary to varices
HCV and alcoholic cirrhosis
Alcohol abuse
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Patient has been hemodynamically
Discharge Instructions:
You were transferred to [**Hospital1 18**] because of bleeding from your
esophagus and to be evaluated for further treatments. While at
[**Hospital1 18**] you had an endoscopy which showed continued bleeding and
some blood vessels were banded (tied off to stop the bleeding).
You then had repeat bleeding and required a procedure to
decompress your varices (TIPS). This should prevent bleeding
from these swollen vessels in the future. You also developed a
pneumonia that required IV antibiotics. This has resolved. You
have not had any other signs of infection while you were here.
You underwent a paracentesis which did not show any infection in
the fluid in your abdomen. You had fluid in your abdomen
(ascites) which was removed as well for comfort.
You were also incidentally found to have a very small clot in
one of the vessels in your abdomen (superior mesenteric vein).
This should be followed by your outpatient doctor; however,
nothing needs to be done at this time.
You have been started on a number of new medications for your
liver disease as noted below. Please take all of these
medications as prescribed:
1. Spironolactone (for your ascites and swelling in your legs) -
150 mg daily
2. Lasix (also for swelling and ascites) - 60 mg daily
3. Protonix (for ulcer prevention) - 40 mg daily
4. Lactulose (to prevent confusion given your liver disease) -
take 30 mL three times daily. You should titrate this (either
take less or more) so that you are having 3 bowel movements
every day
5. Rifaximin (to prevent confusion given your liver disease) -
400 mg three times daily
6. Multivitamin - you should take this to give you the vitamins
and minerals you need daily
7. Nicotine patch - use this as needed to stop smoking
You have been given a walker as you are a bit unsteady on your
feet for now, likely from deconditioning since you have been in
the hospital. Please use this to prevent falls.
Followup Instructions:
It is very important that you follow up with your primary care
doctor as well as hepatology (Dr. [**First Name8 (NamePattern2) 2943**] [**Name (STitle) 696**]). Since it
is the weekend, we cannot make an appointment for you, but we
will have Dr.[**Name (NI) 8653**] office contact you next week with a
follow up appointment. If you do not hear from his office by
the middle of the week, please call to arrange an appointment.
The number is [**Telephone/Fax (1) 673**].
In addition, it is very important that you continue to get
alcohol relapse prevention and/or attend AA meetings.
|
[
"557.1",
"288.60",
"518.5",
"303.90",
"789.59",
"070.44",
"305.1",
"567.23",
"507.0",
"571.2",
"786.3",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"54.91",
"33.24",
"38.93",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
7424, 7430
|
4820, 6174
|
340, 371
|
7552, 7552
|
3868, 3868
|
9707, 10295
|
3051, 3101
|
6564, 7401
|
7451, 7531
|
6200, 6200
|
7762, 9684
|
6221, 6541
|
3116, 3116
|
3849, 3849
|
2412, 2751
|
265, 302
|
399, 2393
|
3882, 4797
|
7566, 7738
|
2773, 2909
|
2925, 3035
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,914
| 103,537
|
24713+57416
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-11-18**] Discharge Date: [**2142-12-27**]
Date of Birth: [**2112-9-20**] Sex: F
Service: SURGERY
Allergies:
Vancocin Hcl
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
30 F s/p multiple gun shot wounds brought in by EMS in pulseless
electrical activity.
Major Surgical or Invasive Procedure:
1. Aortic arch and selective innominate, left carotid and left
subclavian arteriograms, inferior vena cava filter placement.
2. Median sternotomy and cervical incision for
exposure of upper thoracic and lower cervical spine.
Total vertebrectomy of C7 and T1.
3. Fusion C6-T2.
4. Anterior cage placement.
5. Repair of dural defect.
6. Autograft.
7. Flexible bronchoscopy and aspiration and lavage.
8. Percutaneous tracheostomy tube placement.
9. Percutaneous endoscopic gastrostomy tube placement.
History of Present Illness:
30 F who answered a knock on her door when she received multiple
gun shot wound including left leg, left clavicle, right
posterior trapezius. Found down in PEA, intubated in the field,
and sent to [**Hospital1 1474**] hosptial. Subsequently med-flighted to
[**Hospital1 18**] for further evaluuation. Hematocrit at outside hospital
=15, received 5 units PRBC on arrival to [**Hospital1 18**]. Initially no
dopplerable pedal pulses, decreased rectal tone, guiac postive.
Bilateral pulmonary contusions, C6-T1 burst fractures
Past Medical History:
No significant past medical history
Social History:
African american female with excellent family support.
No history of alcohol, tobacco, or drug abuse
Family History:
non-contributory
Physical Exam:
Neuro:Alert and oriented. Communicates when cuff down with
interrupted speach. Lip talks well.
Cardiac:RRR
Respiratory:Lungs clear bilaterally. Incision on neck and chest
clean and dry
Abdomen:soft nontender, obese, non-distended. G tube site clean.
Extremities:Moves right upper extremity only.
Pertinent Results:
Laboratories on Discharge
wbc:8.3
Hct: 28.9
Plts: 265
Sodium: 136
Potassium:3.7
Bun:21
Creatinine:0.3
Brief Hospital Course:
Ms [**Known lastname 12330**] was admitted to the trauma service after multiple
gunshot wounds. The one with consequence entered left neck and
exited right posterior neck causing spinal cord injury at
approximately c6 level leaving her quadraplegic with some
movement of right arm. Studies included arteriogram of neck
showing left vertebral disruption. Procedures included cervical
and superior thoracic spine fixation by anterior and posterior
approach, tracheostomy tube, gastrostomy tube, and ivc filter.
She is completely neurologically intact but has had little
improvement with her paralysis. Majority of her hospital course
has been due to fevers that go as high as 103. complete
infectios disease workup including CT of chest and abdomen,
wound checks, lumbar puncture have been negative. She has fevers
despite normal white count off antibiotics. Infectious disease
consultants have cleared her and she is being discharged to
rehabilitation alert and oriented, tolerating tube feeds,
comfortable, speaking with cuff down for short periods of time,
still with occasional fevers, and hemodynamically stable.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection TID (3 times a day).
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
5. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) 300 mg PO Q8H
(every 8 hours) as needed.
6. Gabapentin 250 mg/5 mL Solution Sig: One (1) 300 mg PO TID (3
times a day).
7. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) 150 mg PO BID (2
times a day).
8. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): 25 mcg/hr. wean as tolerated.
9. Lorazepam 0.5 mg Tablet Sig: One (1) 0.5 mg PO TID (3 times a
day): wean as tolerated.
10. Lorazepam 1 mg Tablet Sig: One (1) 1 mg PO HS (at bedtime):
wean as tolerated.
11. Mirtazapine 15 mg Tablet Sig: One (1) 15 mg PO HS (at
bedtime).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED): Insulin regular
sliding scale.
13. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
15. Acetaminophen 160 mg/5 mL Solution Sig: One (1) 325 mg PO
Q4-6H (every 4 to 6 hours) as needed.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
17. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
18. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
19. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
20. [**Location (un) **] Oil Oil Sig: One (1) Miscell. prn (): patient
taking own med. ([**Location (un) 2452**] oil).
21. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Multiple gun shot wounds
C6 spinal cord injury
Quadraplegia (with some movement of right arm)
Respiratory failure
Status post cervical spine fixation
Status post tracheostomy
Status post gastrostomy tube
Status post inferior vena cava filter placement
Discharge Condition:
Good.
Discharge Instructions:
Neuro: pain meds and ativan as required
Cardiac: Stable
Respiratory: Wean vent as tolerated. Routine trach care (#7
fenestrated cuffed)
GI: Goal tube feeds
ID: No antibiotics. Has fevers without source of infection. WBC
stable off antibiotics.
Renal: Foley. wean as tolerated
Prophylaxis: Ivc filter, heparin sq, tube feeds
Followup Instructions:
Trauma clinic 2-3 weeks at [**Hospital1 18**]. [**Numeric Identifier 50514**]
Completed by:[**0-0-0**] Name: [**Known lastname 10227**],[**Known firstname **] Unit No: [**Numeric Identifier 11207**]
Admission Date: [**2142-11-18**] Discharge Date: [**2142-12-27**]
Date of Birth: [**2112-9-20**] Sex: F
Service: SURGERY
Allergies:
Vancocin Hcl
Attending:[**First Name3 (LF) 813**]
Addendum:
Ms [**Known lastname **] returned to T-SICU on [**12-24**], as there were no rehab
beds available. Over last 3 days, she was monitored in the
[**Hospital1 8**] trauma SICU with minimal change in her condition. Of
note, however, her temperature curve and her WBC count both
improved to normal ranges. Her medication regimen was
simplified (please refer to page 1 for med list). Her current
clinical status is listed below in organ system based fashion.
Neuro: Alert, interactive. Moves only RUE minimally. Requires
standing ativan & sleeping medications, as well as prn pain
meds.
CV: stable
RESP: still vented on CPAP with PEEP.
FEN: TF at goal. Check nutrition labs q1-2 weeks. Requires
straight cath q6.
GI: H2 blocker prophylaxis.
HEME: s/p IVC filter, on SQ heparin
ID: intermittent fevers s/p negative micro workup. improving
over last few days
ENDO: sliding scale q6
Chief Complaint:
s/p multiple GSW
Major Surgical or Invasive Procedure:
Anterior and Posterior fixation of cervical vertebrae
Tracheostomy
Gastrostomy tube
IVC filter placement
Past Medical History:
No significant past medical history
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection TID (3 times a day).
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
4. Gabapentin 250 mg/5 mL Solution Sig: One (1) 300 mg PO TID (3
times a day).
5. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) 150 mg PO BID (2
times a day).
6. Lorazepam 0.5 mg Tablet Sig: One (1) 0.5 mg PO TID (3 times a
day): wean as tolerated.
7. Lorazepam 1 mg Tablet Sig: One (1) 1 mg PO HS (at bedtime):
wean as tolerated.
8. Mirtazapine 15 mg Tablet Sig: One (1) 15 mg PO HS (at
bedtime).
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection four times a day: Administer per
attached sliding scale.
Disp:*100 dose* Refills:*2*
10. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
14. Lorazepam 0.5-1 mg IV Q6H:PRN anxiety
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
Disp:*1 inhaler* Refills:*5*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Diagnosis:
Multiple gun shot wounds
C6 spinal cord injury
Quadriplegia (with some movement of right arm)
Respiratory failure
Status post cervical spine fixation
Status post tracheostomy
Status post gastrostomy tube
Status post inferior vena cava filter placement
Discharge Condition:
Good
Discharge Instructions:
Neuro: pain meds and ativan as required
Cardiac: stable
Respiratory: Wean vent as tolerated (current settings on page
2). Routine trach care (#7 fenestrated cuffed trach)
GI: Goal tube feeds via PEG
ID: No antibiotics. Has fevers without source of infection. WBC
stable off antibiotics.
Renal: Straight cath q6.
Prophylaxis: IVC filter, heparin sq, H2 blocker
Followup Instructions:
Trauma clinic 2-3 weeks at [**Hospital1 8**]. [**Telephone/Fax (1) 3594**]
[**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 815**] MD [**MD Number(2) 816**]
Completed by:[**2142-12-27**]
|
[
"900.89",
"427.89",
"780.6",
"E965.4",
"861.31",
"518.0",
"285.1",
"806.16",
"806.31",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"84.51",
"88.42",
"03.53",
"81.04",
"31.1",
"01.18",
"81.63",
"43.11",
"33.24",
"81.02",
"03.59",
"96.6",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
9135, 9205
|
2080, 3199
|
7470, 7577
|
9501, 9508
|
1954, 2057
|
9916, 10152
|
1605, 1623
|
7659, 9112
|
9226, 9480
|
3225, 3231
|
9532, 9893
|
1638, 1935
|
7414, 7432
|
887, 1412
|
7599, 7636
|
1487, 1589
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,825
| 162,803
|
21568
|
Discharge summary
|
report
|
Admission Date: [**2141-8-28**] Discharge Date: [**2141-9-18**]
Date of Birth: [**2083-4-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
congestive heart failure
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x5
(LIMA-LAD,SVG-mg,SVG-OM1,SVG-OM2,SVG-PDA)[**2141-9-1**]
Placement of intra-aortic balloon [**2141-9-4**]
closed thoracostomy -left [**2141-9-11**]
fiberoptic bronchoscopy [**2141-9-5**]
History of Present Illness:
58 year old male with a history of Type II DM, HTN,
hyperlipdiemia, and ischemic heart disease (EF 20%,
medicallymanaged)recently admitted with NYHA class III symptoms.
The patient was wintering in [**State 108**] and developed
chest pain and R/I for NSTEMI. Per the patient's report, he was
admitted to the ICU for observation given his presenting
asymptomatic SBP in the 70s mmHg; he did not require IABP or
assist device. TTE showed severely depressed LVEF 15-20%,
consistent with admission TTE on [**2141-8-18**]. LHC was performed
during this admission, with mild progression of his CAD with LAD
80%,D1 95%, D2 70% OM1/OM2 70/90%, chronic total occlusion RCA.
The patient was counseled on ICD placement by his providers in
[**State 108**] but declined at that time. He had been medically managed
for systolic left heart failure with Diovan, Coreg, and Lasix
since that time. He reports progressive DOE, weight gain, and
worsening LE edema over the past month. He denied chest pain,
orthopnea, PND, pre-syncope/syncope. He presented to [**Hospital1 18**] with
LE edema and has been managed with diuretics, beta blockade, and
[**Last Name (un) **]. Since admission, the patient notes improvement in his LE
edema. Csurg was consulted for evaluation for CABG
Past Medical History:
Multivessel CAD, medically managed
Prior MI w/ systolic HF of 40%
Mild MR
HTN
Hyperlipidemia
DM2 w/ complications
Social History:
Worked as a firefighter and EMT but now on disability.
Former heavy smoker (>25 pack years)quit back in [**2135**].
ETOH: very heavily (over a case a week)in past, no alcohol in
over a year.
Declines any history of drug use.
Lives alone. Has a 26 year old son.
Family History:
Father is a diabetic. Mother with CAD with stent in her 70s. He
has 5 brothers and 1 sister. His sister died from a "staph
infection." His brother died from CAD and cocaine use.
Physical Exam:
Admission:
VS - 98.8 97/68 87 20 100RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of jaw line.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NT, slightly distended, no shifting dullness. No HSM
or tenderness. Abd aorta not enlarged by palpation. No
abdominial bruits.
Ext: 1+ pretibial edema to knee. No c/c. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission:
[**2141-8-28**] 12:00PM BLOOD WBC-6.5 RBC-3.61* Hgb-9.0* Hct-29.1*
MCV-81* MCH-25.0* MCHC-31.1 RDW-21.0* Plt Ct-317
[**2141-8-28**] 12:00PM BLOOD Glucose-187* UreaN-17 Creat-1.1 Na-134
K-4.3 Cl-101 HCO3-24 AnGap-13
[**2141-8-29**] 06:10AM BLOOD ALT-20 AST-24 CK(CPK)-48 AlkPhos-87
TotBili-2.2* DirBili-1.2* IndBili-1.0
[**2141-9-14**] 02:54AM BLOOD ALT-39 AST-76* LD(LDH)-265* AlkPhos-116
TotBili-19.9*
[**2141-8-28**] 12:00PM BLOOD proBNP-8511*
[**2141-8-28**] 12:00PM BLOOD cTropnT-0.02*
Discharge:
[**2141-9-18**] 06:45AM BLOOD WBC-12.5* RBC-3.18* Hgb-9.2* Hct-28.8*
MCV-91 MCH-28.8 MCHC-31.8 RDW-25.7* Plt Ct-420
[**2141-9-18**] 06:45AM BLOOD Plt Ct-420
[**2141-9-13**] 03:51AM BLOOD PT-18.5* PTT-30.3 INR(PT)-1.7*
[**2141-9-18**] 06:45AM BLOOD Glucose-90 UreaN-24* Creat-1.0 Na-140
K-4.0 Cl-108 HCO3-23 AnGap-13
[**2141-9-18**] 06:45AM BLOOD ALT-53* AST-89* AlkPhos-117 TotBili-12.2*
[**2141-9-13**] 03:51AM BLOOD ALT-33 AST-68* LD(LDH)-241 AlkPhos-82
Amylase-15 TotBili-19.7*
[**2141-9-13**] 03:51AM BLOOD Lipase-146*
Radiology Report CHEST (PA & LAT) Study Date of [**2141-9-15**] 1:41 PM
Final Report CHEST RADIOGRAPH: INDICATION: Status post CABG.
COMPARISON: [**2141-9-13**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The pre-existing right IG line has been removed. The
nasogastric
tube and the left PICC line are in unchanged position. The left
chest tube
has also been removed. Moderate cardiomegaly. No evidence of
pneumothorax.
No pulmonary edema. Presence of a minimal left pleural effusion
cannot be
excluded.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 56817**], [**Known firstname 1775**] [**Hospital1 18**] [**Numeric Identifier 56819**] Done [**2141-9-1**] at
10:28:05
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 20% to 25% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Arch: 2.2 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.1 cm
Tricuspid Valve - Peak Velocity: 0.3 m/sec
Findings
LEFT ATRIUM: Mild LA enlargement. Mild spontaneous echo contrast
in the body of the LA. Mild spontaneous echo contrast in the
LAA. Depressed LAA emptying velocity (<0.2m/s)
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Severe global LV hypokinesis. Severely depressed LVEF.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**2-4**]+) MR.
TRICUSPID VALVE: Mild to moderate [[**2-4**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The patient appears to be in sinus rhythm.
Emergency study. Results were personally reviewed with the MD
caring for the patient. See Conclusions for post-bypass data The
post-bypass study was performed while the patient was receiving
vasoactive infusions (see Conclusions for listing of
medications).
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS:
The left atrium is mildly dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium and in the left
atrial appendage. No atrial septal defect is seen by 2D or [**Last Name (un) **].
The left atrial appendage emptying velocity is depressed
(<0.2m/s).
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is septal
akinesis; the remaining left ventricular segments are
hypokinetic. Overall left ventricular systolic function is
severely depressed (LVEF= 20%).
RV with moderate global free wall hypokinesis.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
Mild to moderate ([**2-4**]+) mitral regurgitation is seen The jet is
eccentric.
Mild to moderate ([**2-4**]+) tricuspid regurgitation is seen.
Bilateral pleural effusions.
POSTBYPASS:
The patient is on infusions of milrinone, vasopressin, and
norepinephrine.
Left ventricular function is slightly improved with an LVEF of
30%.
RV remains mildly depressed.
The mitral regurgitation is moderate (2+) with eccentricity.
(toward the posterior leaflet; obvious with the inotrope use?)
No aortic regurgitation is seen.
Aortic contours remain normal.
Dr. [**Last Name (STitle) **] and the surgical team were notified in person of the
results.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2141-9-4**] 09:32
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] for sysptoms consistent with heart
failure. Following initial assessment and diuresis cardiac
surgery was consulted to assess for bypass grafting. On [**9-1**] he
went to the Operating Room for coronary artery bypass grafting.
Please see operative report for details in summary he had:
Coronary artery bypass grafting x5 with the left internal
mammary artery to the left anterior descending
artery and reverse sequential saphenous vein graft to the right
acute marginal artery and the posterior descending artery, and
reverse saphenous vein graft to the first and second obtuse
marginal artery. His bypass TIME was 97 minutes, with a
CROSSCLAMP TIME of 80 minutes. He weaned from bypass on
Milrinone, Levophed and Vasopressin. Following the operation he
was transferred to the cardiac surgery ICU on inotropic and
pressor support. The patient self extubated on POD1 following
which he suffered a VT arrest requiring chest compressions.
Epinephrine was added to his inotropic support, however, he
remained unstable and oliguric and an inta-aortic balloon was
placed. Following IABP placement he stabilized and improved.
The balloon was removed on [**9-6**] and pressors gradually weaned.
His post-op course was further compromised by hypoxia, a
bronchoscopy was unrevealing but CXR showed a large effusion. A
CT was placed on [**9-11**] with improvement. He was extubated on
POD8, initially very confused, gradually cleared.
It should also be noted that following his arrest the patient
had an elevated bilirubin and was seen by Hepatology. An
abdominal ultrasound was done and showed no evidence of
cholecystitis or biliary dilatation, moderate ascites and
periodic reversal of flow in the portal vein which can be seen
with right heart failure or tricuspid regurgitation. The
bilirubin peaked at 19 and gradually resolved w/o treatment.
Due to lethargy the patient had difficulty meeting his caloric
needs orally and tube feeding were utilized for nutrition
support transiently until oral intake was felt to be adequate.
All tubes, lines and drains were removed according to cardiac
surgery protocols.
The patient remained in the cardiac ICU for close monitoring
until POD13 when he was transferred to the stepdown floor. Once
on the floor he continue to make progress with his activity and
the remainder of his hospital course was uneventful.
On POD17 he was transferred to rehabilitation at Newbridge on
the [**Doctor Last Name **] in [**Location (un) 1411**]
Medications on Admission:
-1. Aspirin 325 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY (Daily).
-2. Atorvastatin 80 mg daily
- 3. Spironolactone 25 mg daily
4. Valsartan 80 mg daily
-5. Gabapentin 300 mg [**Hospital1 **] prn leg pain
-6. Carvedilol 6.25 mg [**Hospital1 **]
-7. Furosemide 20 mg daily
-8. Glipizide 5 mg [**Hospital1 **]
-9. Nitroglycerin 0.3 mg prn
Discharge Medications:
1. Spironolactone 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day) as needed for leg pain.
4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Glipizide 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO every [**7-11**]
hours as needed for pain.
10. Bisacodyl 10 mg Suppository [**Month/Day (3) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Carvedilol 12.5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2
times a day).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Glipizide 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
14. Atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
15. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
[**Last Name (STitle) **]: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
17. Diovan 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x5
postoperative VT arrest
noninsulin dependent diabetes mellitus
hypertension
hyperlipidemia
ischemic cardiomyopathy
h/o gastrointestinal bleed
post-operative hyperbilirubinemia-unknown etiology
Discharge Condition:
Alert and oriented x3 ,nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions: Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: 1+ edema bilat
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 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**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**10-18**] @ 1PM
Please call to schedule appointments with:
Primary Care: Dr. [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) **] in [**2-4**] weeks
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] in [**2-4**] 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:[**2141-9-18**]
|
[
"403.90",
"788.5",
"782.4",
"250.00",
"412",
"518.5",
"997.39",
"585.2",
"997.1",
"414.01",
"424.0",
"272.4",
"397.0",
"414.8",
"511.9",
"V15.82",
"414.2",
"E878.2",
"785.51",
"427.5",
"427.1",
"428.0",
"410.72",
"519.19",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"96.6",
"36.14",
"36.15",
"96.72",
"37.61",
"33.24",
"38.93",
"99.60",
"96.05",
"96.04",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
13812, 13906
|
9084, 11594
|
301, 522
|
14204, 14442
|
3373, 7365
|
15197, 15787
|
2247, 2426
|
11997, 13789
|
13927, 14183
|
11620, 11974
|
14466, 15174
|
7409, 9061
|
2441, 3354
|
237, 263
|
550, 1815
|
1837, 1952
|
1968, 2231
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,734
| 177,496
|
44330
|
Discharge summary
|
report
|
Admission Date: [**2106-9-11**] Discharge Date: [**2106-9-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
PCP: [**Name Initial (NameIs) **]
.
CHIEF COMPLAINT: GIB
REASON FOR MICU ADMISSION: Hemodynamic monitoring.
Major Surgical or Invasive Procedure:
colonoscopy
EGD
History of Present Illness:
83 y/oF with pAF, valvular disease AVR/MVR, HTN, h/o colon ca
s/p colectomy in [**2099**] transferred from [**Hospital1 **] with GIB. She was
recently hospitalized with a right hip fracture and underwent
ORIF. During that hospitalization, she required 3 units of pRBC.
She has been having progressive fatigue at rehab coinciding with
more loose, dark stools concerning for GIB. Her hematocrit
returned at 23 from 26.6. She has had no increase in SOB nor has
she had any chest pain. Her last BM was yesterday, but
reportedly more normal.
Her review of systemis is also notable for dysuria and
suprapubic pain, and she has recently started cefpodoxime (1 day
ago). Otherwise her ROS is negative.
In the ED, initial VS: 98.5 64 150/30 16 100% on 3L. She was
transfused 2 units. She refused NG lavage, was reportedly guaiac
positive from rectal exam, and was given 40mg IV pantoprazole.
Currently, she feels much improved with one unit transfusion.
Past Medical History:
1. Colon cancer status post right colectomy ([**9-4**])
2. Hypertension
3. Paroxysmal atrial fibrillation requiring cardioversion in the
past
4. S/p AVR/MVR [**2093**] secondary to rheumatic fever
5. Diastolic Heart Failure
6. GERD
7. S/P TAH-BSO
8. Hypothyroidism
9. Depression
Social History:
Home: Lives alone. Very active with physical therapy twice
weekly for right shoulder pain, exercise at least twice weekly.
Has a helper at home once and sometimes twice weekly who does
her grocery shopping. Has two children, four grandchildren.
EtOH: Denies
Drugs: Denies
Tobacco: Denies
Family History:
Mother - possibly heart disease although she is unsure of the
specifics
Father - rectal surgery and colostomy although for unclear
reasons
Physical Exam:
VSS
GENERAL: Well appearing, well groomed elderly female.
HEENT: PERRL. Anicteric. neck supple.
CARDIAC: Mechanical heart sounds, II/VI SM Left sternal border,
lat radiation
LUNG: grossly clear bilaterally
ABDOMEN: NT ND nl BS
EXT: 1+ LE Edema
NEURO: CN II-XII grossly intact. D/WE/IP/TE [**4-6**] b/l.
DERM: No appreciable rashes.
Pertinent Results:
Labs at admission:
[**2106-9-11**] 04:30PM BLOOD WBC-9.5 RBC-2.40* Hgb-8.1* Hct-24.1*
MCV-100* MCH-33.6* MCHC-33.5 RDW-17.3* Plt Ct-311#
[**2106-9-11**] 04:30PM BLOOD Neuts-85.7* Lymphs-8.5* Monos-3.7 Eos-1.8
Baso-0.2
[**2106-9-11**] 04:30PM BLOOD PT-27.3* PTT-29.9 INR(PT)-2.7*
[**2106-9-11**] 04:30PM BLOOD Glucose-117* UreaN-31* Creat-1.2* Na-138
K-3.6 Cl-100 HCO3-30 AnGap-12
[**2106-9-16**] 07:20PM BLOOD ALT-8 AST-24 AlkPhos-58 TotBili-1.4
[**2106-9-12**] 02:37AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
[**2106-9-11**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}
[**2106-9-11**] 04:30PM URINE RBC-0-2 WBC->50 Bacteri-MOD Yeast-NONE
Epi-<1 RenalEp-<1
[**2106-9-11**] 04:30PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-LG
[**2106-9-11**] 04:30PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-<1.005
Labs at discharge:
[**2106-9-19**] 05:45AM BLOOD WBC-4.8 RBC-2.91* Hgb-9.0* Hct-28.8*
MCV-99* MCH-31.0 MCHC-31.3 RDW-17.8* Plt Ct-221
[**2106-9-17**] 05:20AM BLOOD Neuts-75.1* Lymphs-13.5* Monos-6.6
Eos-4.4* Baso-0.5
[**2106-9-20**] 08:40AM BLOOD PTT-60.2*
[**2106-9-20**] 05:40AM BLOOD PT-26.3* PTT-79.9* INR(PT)-2.6*
[**2106-9-20**] 05:40AM BLOOD Glucose-99 UreaN-20 Creat-1.2* Na-141
K-3.4 Cl-102 HCO3-30 AnGap-12
[**2106-9-20**] 05:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6
PERTINENT IMAGING STUDIES
PORTABLE CHEST, [**2106-9-12**]
FINDINGS:
Since the prior study, there is mildly increased prominence of
the central
pulmonary vasculature consistent with mild congestive failure.
There has also been development of small bilateral pleural
effusions and mild bibasilar atelectasis. Valvular prosthesis is
present. Heart is mildly enlarged. Aorta is calcified.
[**2106-9-16**] COLONOSCOPY
Impression: Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
[**2106-9-16**] EGD:
Impression: Varices at the lower third of the esophagus
Otherwise normal EGD to third part of the duodenum
[**2106-9-17**] ABDOMINAL U/S
IMPRESSION:
1. Stable appearing hepatic hemangiomas with no new focal liver
lesion
identified.
2. No varices identified.
3. Patent hepatic vasculature.
Brief Hospital Course:
MICU COURSE [**9-11**] - [**2106-9-12**]:
==============================
1. Acute Blood Loss Anemia: [**Month (only) 116**] be upper GI bleed from gastritis
or PUD, suggested by dark stools, or lower source such as
diverticular bleeding, though she has never had this before on
prior colonoscopies. Refused NG lavage, though likely not brisk
upper GI bleed given overall stability. Transfused 2 pRBCs with
appropriate bump in Hct. 2 PIVs. GI consulted and plan for
EGD/Colonoscopy for Tuesday. Pt currently on clear liquid diet.
Hemodynamically stable during ICU stay.
2. Paroxysmal Atrial Fibrillation: Sinus rhythm on admission.
Continued amiodarone. Held coumadin given likely EGD/[**Last Name (un) **].
3. Valvular Disease: Given her slow bleed and s/p MVR/AVR, she
merits anticoagulation between 2.5-3.5. Coumadin held on
admission. Monitored INR. Once INR < 2.5, will need heparin gtt
until EGD/colonscopy.
3. Urinary Tract Infection: Pt was on cefpodoxime at rehab x 3
days. Urine culture from NH pending. UCx here pending. Changed
to IV ceftriaxone with plan for 4 more days. Started pyridium
for bladder spasm.
4. Hypoxia: Pt desaturates off of nasal canula, but promptly
improves with 1-2 L to 100%. [**Month (only) 116**] be related to volume overload,
amiodarone (has been on over 10 years). CXR did not show
effusions, but ? infiltrate in RML. Did not start abx given no
fever, leukocytosis, cough.
5. Hip Fracture: Continue PT as tolerates
6. Chronic Diastolic CHF (EF>60%): Held standing lasix given
GIB, though may need additional lasix between transfusions if
she becomes more hypoxic. Continued carvedilol.
7. Hypothyroidism: Continued LT4
# DISPO: To Medicine Floor on [**2106-9-12**]
MEDICINE FLOOR COURSE: [**9-12**] to [**2106-9-20**]
HOSPITAL COURSE:
89 y/o female with recent hip surgery, mechanical valves and PAF
on warfarin with guaiac positive stools and acute blood loss
anemia. Was transferred from the ICU to the Medicine floor on
[**2106-9-12**]. A brief description of her hospital course is
organized according to problems below.
.
# UGIB / Acute Blood Loss Anemia. Was difficult to tell if the
melena/ +guaiac in the setting of anemia was an upper GI bleed
from gastritis or PUD (suggested by dark stools) or a lower
source such as diverticular bleeding (though she has never had
this before on prior colonoscopies). She refused NG lavage. On
HD6, her INR was decreased to <2.0 and she had upper and lower
endoscopies to further evaluate the bleeding source yesterday.
She was found to have Grade I-II esophageal varices which GI did
not believe to be the cause of her bleeding. No other possible
causes were found. She had not required further PRBC
transfusions and her Hct was stable, so GI believed she could
have further work-up as an outpatient. They recommended
considering a capsule study and will discuss this with her at an
outpatient appointment that has been made.
.
# Esophageal varices: GI found Grade I-II esophageal varices on
EGD. She had an abdominal U/S to look for a cause. U/S found
stable hemangiomas of the liver and no blockage of splenic vein.
No further management or imaging was deemed necessary. She had
LFTs tested and these were found to be normal as well.
.
# pAF on Warfarin: Patient presented in sinus and was
anticoagulated on warfarin at home. Her amiodarone was
continued. See below for a description of her anticoagulation
course. Her INR was 2.6 on day of discharge.
.
# Valvular Disease: Patient s/p MVR/AVR and merits
anticoagulation between 2.5-3.5. She needed to be below 2.0 for
the colonoscopy and EGD studies. She was taken off her coumadin
and when her INR reached 2.5 she was started on a heparin gtt.
Her heparin gtt was stopped 6 hours before her colonoscopy and
EGD and restarted immediately after because no biopsies were
taken. Her coumadin was restarted and when her INR was >2.5,
her heparin gtt was stopped. She was discharged home after a
therapeutic INR was achieved (2.6 day of discharge).
.
# Urinary Tract Infection. She started cefpodoxime at rehab. A
urine culture taken her day of admission grew pseudomonas
sensitive to cipro. She was started on Cipro and a repeat U/A
and culture were done the day before d/c and were found to be
clear. She will continue the Cipro for one more week.
.
# Hypoxia
Pt desaturated when she came to the floor, but improved with
1-2 L to 100%. This was probably related to volume overload,
amiodarone (has been on over 10 years). CXR confirmed volume
overload and CHF. Home lasix started with improvement of her
sats. Now >94% on RA.
.
# Hip Fracture: An A/P and Lateral Xray of the hip was taken and
patient was evaluated by orthopaedics while in house. She is
FWB and does not need surgical intervention at this time. An
appointment has been made for discussion of future treatments.
.
# Chronic Diastolic CHF (EF>60%): Continued carvedilol,
restarted lasix, and monitored her fluid status.
.
# Hypothyroidism: continued levothyroxine. Si/Sx of
hypothyroidism were monitored.
.
# FEN: Patient was NPO for procedures, but tolerating normal
diet the remainder of the stay and was tolerating oral diet and
medications the day of discharge.
.
# PPX: PPI, therapeutic warfarin, holding dose today, bowel
regimen on hold
.
# ACCESS: PIV
.
# CODE: FULL
.
# CONTACT: daughter
.
# DISPO: back to facility on HD 10
Medications on Admission:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO Q M W F SAT
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
4. Clonazepam 0.5 mg Tablet Sig: 0.5 (half) Tablet PO QHS (once
a day (at bedtime)) as needed for insomnia, anxiety.
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID
7. Pantoprazole 40 mg Tablet PO daily
8. Atorvastatin 20 mg Tablet PO daily
9. Furosemide 20 mg Tablet [**Hospital1 **]
10. Multivitamin Daily
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO tu-th-sa-[**Doctor First Name **].
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO m-w-f.
13. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H PRN Pan
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
15. Docusate Sodium 100 mg [**Hospital1 **]
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for apply to hip for pain.
17. Acetaminophen 500 mg 2 tabs q6h prn pain
18. Atorvastatin 20 mg daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO EVERY MON,
WED, FRI, SAT ().
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Atorvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Adhesive Patch, Medicated(s)
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: 1 Tablet(s) by mouth tu-th-sa-[**Doctor First Name **]; 2 tabs mo-we-fr .
Disp:*60 Tablet(s)* Refills:*5*
19. Phenergan 25 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
GI bleed
Discharge Condition:
stable, tolerating oral diet and medications
Discharge Instructions:
You were hospitalized because of blood found in your stool that
was causing you to become anemic. While in the hospital, you
received studies to look for bleed in your stomach, esophagus,
colon, and some of your small bowel. No cause of the bleed was
found. This could be because the cause has resolved or because
the cause falls in the area of your small bowel that was not
visualized.
Since, you are no longer losing, blood, we believe the best
thing is to return and home and monitor your symptoms and bowel
movements. If the bleeding returns, you can return for a study
called a "capsule study" that looks at your small bowel that
could not be seen by colonoscopy and endoscopy.
Ways of knowing that you are bleeding are dark/black stools,
bloody stools, feeling weak or light-headed. Please call your
doctor if you have those symptoms.
You will need to be seen at the [**Hospital 191**] clinic for monitoring of
your INR. I will send them an email regarding your discharge.
Please return to the ER or call your doctor if you spike a fever
>101, have chest pain, or shortness of breath as well.
You have the following appointment to discuss future treatment
of your hip fracture. At this time, no treatment is needed.
[**2106-10-26**] 09:30a [**Last Name (LF) **],[**First Name3 (LF) **] K.
[**Hospital6 29**], [**Location (un) **]
[**Hospital **] CLINIC (SB)
This image should be obtained before your hip appointment:
[**2106-10-26**] 09:10a X-RAY ORTHO SCC2
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
X-RAY ORTHO SCC2
You have the following appointment to make sure your GI bleed is
managed:
[**2106-10-5**] 02:00p [**Last Name (LF) **],[**First Name3 (LF) 1948**] S.
RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
GI FACULTY (SB)
Please your PCP at the following appointment in order to assure
that you are doing all right after your discharge from the
hospital.
[**2106-10-1**] 09:50a [**Company 191**] POST [**Hospital 894**] CLINIC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
Followup Instructions:
You have the following appointment to discuss future treatment
of your hip fracture. At this time, no treatment is needed.
[**2106-10-26**] 09:30a [**Last Name (LF) **],[**First Name3 (LF) **] K.
[**Hospital6 29**], [**Location (un) **]
[**Hospital **] CLINIC (SB)
This image should be obtained before your hip appointment:
[**2106-10-26**] 09:10a X-RAY ORTHO SCC2
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
X-RAY ORTHO SCC2
You have the following appointment to make sure your GI bleed is
managed:
[**2106-10-5**] 02:00p [**Last Name (LF) **],[**First Name3 (LF) 1948**] S.
RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
GI FACULTY (SB)
Please your PCP at the following appointment in order to assure
that you are doing all right after your discharge from the
hospital.
[**2106-10-1**] 09:50a [**Company 191**] POST [**Hospital 894**] CLINIC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
Completed by:[**2106-9-20**]
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65,056
| 124,292
|
33506
|
Discharge summary
|
report
|
Admission Date: [**2177-11-29**] Discharge Date: [**2177-12-16**]
Date of Birth: [**2111-3-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
open cholecystectomy
History of Present Illness:
Mr. [**Known lastname 77690**] is a 65-year-old gentleman who is referred to me at
the Thoracic [**Hospital 32535**] Clinic by Dr. [**Last Name (STitle) **] [**Name (STitle) 47851**] for
evaluation of a right upper lobe nodule. Mr. [**Known lastname 77690**] recently
had a COPD flare and was admitted to [**Hospital6 8283**]
and a CT scan revealed this nodule. He denies any hemoptysis or
purulent sputum production. He denies any fevers, chills, or
sweats. He has stable shortness of breath. He can walk about
50 feet with crutches. He denies any weight loss. He denies
any new back or bony pain or neurological
symptoms. He denies any abdominal pain.
Past Medical History:
COPD, which requires steroids and antibiotics about four times a
year for flares, MI in [**2172**] and [**2173**], pacemaker,
non-insulin-dependent diabetes, GERD, obstructive sleep apnea,
osteoarthritis, and obesity.
Social History:
80-pack-year smoker, discontinued in [**2172**]. Occupation, taxi
driver, lives alone. He is divorced with two children and
denies alcohol use or exposure history.
Family History:
Mother had [**Name (NI) 2481**], father had an aneurysm. He has a sister
with hypertension and another sister with renal disease.
Physical Exam:
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 92, blood pressure 128/73,
respiratory rate 18, oxygen saturation 93% on room air, height
73
inches, weight 323.8 pounds.
GENERAL: Obese, well-developed gentleman sitting in a
wheelchair
in no apparent distress, alert and oriented x3.
HEENT: NC/AT. EOMI. PERRL. Sclerae are anicteric.
Oropharynx
and nasopharynx free of mucosal abnormality. Tongue is midline.
Palate elevates symmetrically. Trachea is midline.
NECK: Supple and nontender without mass. Thyroid is of normal
size and contour.
RESPIRATORY: Distant breath sounds bilaterally. There is no
dullness to percussion. Chest excursion is symmetric and good.
There is no tactile fremitus or egophony.
BACK: There is no spine or CVA tenderness.
CARDIOVASCULAR: Regular rate and rhythm without murmur, rub, or
gallop. There is no JVD. Peripheral pulses intact. PMI is in
normal position.
EXTREMITIES: There is a 3+ lower extremity edema on the left,
trace on the right.
ABDOMEN: There is no abdominal bruit or carotid bruit.
GASTROINTESTINAL: Abdomen soft, nontender, nondistended,
without
mass or hepatosplenomegaly. There is no hernia.
SKIN: No rashes, lesions, ulcers, induration, nodular,
tightening other than an ecchymosis on the left hand.
NEUROLOGIC: Strength and sensation intact and symmetric.
Reflexes are normal. There is no facial asymmetry. Cognition
is
intact. Cranial nerves are intact.
LYMPH NODES: No cervical, supraclavicular, or axillary
adenopathy.
MUSCULOSKELETAL: There is no clubbing or cyanosis. Gait is not
assayed, as he is sitting in a wheelchair. There is no
tenderness to palpation. There is normal tone and alignment.
Range of motion is normal. Palpation of nails is normal.
PSYCHIATRIC: There is normal judgment, insight, memory, mood,
and affect.
Pertinent Results:
[**2177-11-29**] 04:00PM GLUCOSE-130* UREA N-20 CREAT-1.1 SODIUM-139
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-30 ANION GAP-11
[**2177-11-29**] 04:00PM ALT(SGPT)-7 AST(SGOT)-14 CK(CPK)-49 ALK
PHOS-85 TOT BILI-0.6
[**2177-11-29**] 04:00PM LIPASE-13
[**2177-11-29**] 04:00PM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-1.6
[**2177-11-29**] 04:00PM WBC-7.3 RBC-3.23* HGB-9.6* HCT-29.7* MCV-92
MCH-29.9 MCHC-32.5 RDW-19.9*
[**2177-11-29**] 04:00PM NEUTS-76.1* LYMPHS-16.2* MONOS-4.8 EOS-2.5
BASOS-0.4
[**2177-11-29**] 04:00PM PLT COUNT-239
[**2177-12-14**] 07:15AM BLOOD WBC-5.7 RBC-3.51* Hgb-9.8* Hct-32.4*
MCV-92 MCH-28.0 MCHC-30.4* RDW-18.3* Plt Ct-297
[**2177-12-12**] 04:46AM BLOOD Neuts-68.6 Lymphs-22.4 Monos-6.9 Eos-1.9
Baso-0.2
[**2177-12-14**] 07:15AM BLOOD Plt Ct-297
[**2177-12-12**] 04:46AM BLOOD PT-15.0* PTT-28.2 INR(PT)-1.3*
[**2177-12-16**] 05:05AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-139
K-4.1 Cl-98 HCO3-33* AnGap-12
[**2177-12-5**] 07:40AM BLOOD ALT-13 AST-17 AlkPhos-87 TotBili-0.6
[**2177-12-16**] 05:05AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8
.
[**2177-11-29**] US: Gallbladder wall edema, cholelithiasis and
equivocal [**Doctor Last Name 515**]
sign. In appropriate clinical setting findings may be due to
acute
cholecystitis. Clinical correlation recommended. HIDA scan can
be obtained
for confirmation if clinically warranted.
.
MRSA SCREEN (Final [**2177-12-12**]): No MRSA isolated.
.
URINE CULTURE (Final [**2177-12-1**]): NO GROWTH
Brief Hospital Course:
Mr [**Known lastname 77690**] was admitted to Dr.[**Name (NI) 10946**] general surgery
service for his acute on chronic cholecystitis. He was kept NPO
with IVF and given IV cipro and flagyl. He was seen by
cardiology for consultation given his prior cardiac history.
They recommended continuing therapy with b-blocker, ACE-I, and
high dose statin, continuing ASA but holding Plavix, obtain TTE
and prior cardiac records. A repeat RUQ ultrasound on HD4 was
unchanged. Subjectively he felt decreased pain and was started
on a clear diet.
A HIDA scan was done on HD 5 indicating gallbladder not filling;
likely acute cholecystitis. The patient was pre-op'd and
consented and taken to the OR for a lap converted to open CCY.
He was transferred to the ICU post-op secondary to failed
spontaneous breathing trial, had desat to 80s in early
afternoon, felt to be [**3-3**] autopeep, hypotension to SBP 80s-90s,
also thought to be related to autopeep, changed to AC
ventillation. He was successfully extubated on POD 1 and
transferred to the floor.
He was maintained as NPO with PCA/Foley/O2 to maintain O2 sats
between 90-93. Pt is on home O2 2Liters via NC with baseline
sats in the low 90's. He was diuresed with IV lasix.
With the return of bowel function and flatus his diet was slowly
advanced as tolerated. Chest pt was done every 1-2 hrs, the pt
will need aggressive respitory care at rehab.
Medications on Admission:
ASA 81mg qday, lipitor 80mg qday, lasix 60mg qday, Carvedilol
6.25mg [**Hospital1 **], Lisinopril 5mg qday, Protonix 40mg qday, FA 1mg [**Hospital1 **],
Ezetimibe 10mg qday, Tiotropium Bromide 18 mcg daily, plavix
75mg daily, Pulmicort Flexhaler 90 mcg/Inhalation Aerosol 1 puff
[**Hospital1 **], Xopenex HFA 45 mcg/Actuation HFA Aerosol
Inhaler 1 puff [**Hospital1 **] prn, glargine 30 units every evening at
bedtime.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Lisinopril 5 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Pulmicort Flexhaler 90 mcg/Inhalation Aerosol Powdr Breath
Activated Sig: One (1) Inhalation twice a day.
12. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation twice a day as needed for shortness of breath or
wheezing.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 2 weeks.
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 2
weeks: 12 hours on, 12 hours off .
15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
16. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day: 30 units at bedtime.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation for 1 months: take
with pain meds.
18. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain for 2 weeks.
19. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 2 weeks.
20. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
21. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**]
Discharge Diagnosis:
acute on chronic cholecystitis
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.
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 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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed on [**12-30**] and steri strips will be
applied.
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after application.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Followup Instructions:
1. Please call Dr.[**Name (NI) 10946**] office, [**Telephone/Fax (1) 9**], to make a
follow up appointment in [**1-31**] weeks.
Completed by:[**2177-12-26**]
|
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"412",
"518.84",
"V46.2",
"V85.4",
"285.9",
"414.01",
"V87.41",
"278.01",
"574.10",
"518.0",
"V64.41",
"574.00",
"428.23",
"327.23",
"428.0",
"250.00",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
8990, 9042
|
4977, 6375
|
335, 358
|
9117, 9196
|
3486, 4954
|
10808, 10968
|
1491, 1623
|
6845, 8967
|
9063, 9096
|
6401, 6822
|
9220, 10362
|
10377, 10785
|
1638, 1638
|
1660, 3467
|
274, 297
|
386, 1049
|
1071, 1291
|
1307, 1475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,755
| 138,568
|
21277
|
Discharge summary
|
report
|
Admission Date: [**2183-3-8**] Discharge Date: [**2183-3-13**]
Date of Birth: [**2122-10-27**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Ultrasound-guided imaging for [**First Name3 (LF) 1106**] access, contralateral
third order arteriography through a brachial puncture, abdominal
aortogram and unilateral extremity runoff, stent of common iliac
artery and stent of external iliac artery, AngioJet thrombectomy
of iliac artery.
History of Present Illness:
60F well known to our service. She has undergone bilateral
common iliac stenting, right external iliac stenting, and
bilateral femoropopliteal bypass grafts, and has a known
occlusion of her right femoropopliteal graft. She
presents to the ER today with worsening, crampy pain in her
right leg. She does have some claudication at baseline but
reports that this is worse than her usual pain. Pain is now
occuring at rest. She reports numbness on her right foot and
her medial right leg, although this has been chronic. Of note
she has been having a lower GI bleed for approximately one month
and she has been intermittently off her coumadin for 2 days at a
time twice in the past month for endoscopy procedures. Her last
dose of coumadin was Thursday night, and her INR yesterday was
3.4.
She otherwise denies nausea, vomiting, chest pain, shortness of
breath, or abdominal pain.
Past Medical History:
PMH: PVD, benign breast tumors, TIAs/R-hemispheric embolic CVA
in
[**2178**], GI bleed as above
PSH: R-CFA-akPop w PTFE 6mm ('[**77**]--failed), L-CFA:akPop with
NRGSV ([**2178-6-3**]),s/p R-CIA/EIA stenting on [**2179-11-4**], R SFA patch
angioplasty & femoral thrombectomy [**2181-3-29**]
Social History:
Lives with her husband.works at [**Name (NI) 10936**] Brothers.occasional EtOH.
15 pack years smoking
Family History:
non-contributory
Physical Exam:
PE: Temp: 97.8F, HR 80, BP 124/70, RR 12, O2 sat 100%
Gen: NAD
HEENT: PERRL, EOMI b/l
Neck: no LAD, no masses
CV: RRR
Pulm: CTA b/l
Abd: soft, NT, ND
Ext: RLE with slow cap [**Name (NI) **], min ttp in calf, decreased
sensation in foot and over medial right leg
Pulses:
Fem DP PT
R D -- --
L P D --
Pertinent Results:
[**2183-3-8**] 09:57AM BLOOD WBC-8.4 RBC-3.63* Hgb-8.4* Hct-26.4*
MCV-73*# MCH-23.0*# MCHC-31.6 RDW-22.6* Plt Ct-369#
[**2183-3-8**] 04:40PM BLOOD WBC-8.9 RBC-3.59* Hgb-8.6* Hct-26.4*
MCV-74* MCH-24.0* MCHC-32.5 RDW-21.6* Plt Ct-310
[**2183-3-9**] 04:16AM BLOOD WBC-9.3 RBC-3.48* Hgb-8.3* Hct-24.9*
MCV-72* MCH-23.9* MCHC-33.3 RDW-21.1* Plt Ct-317
[**2183-3-9**] 11:18PM BLOOD WBC-10.8 RBC-4.37# Hgb-11.0*# Hct-32.2*#
MCV-74* MCH-25.1* MCHC-34.1 RDW-20.6* Plt Ct-323
[**2183-3-11**] 06:20AM BLOOD WBC-10.7 RBC-4.32 Hgb-10.5* Hct-32.3*
MCV-75* MCH-24.4* MCHC-32.7 RDW-20.4* Plt Ct-346
[**2183-3-13**] 05:45AM BLOOD PT-19.6* PTT-78.2* INR(PT)-1.8*
[**2183-3-8**] 09:57AM BLOOD Glucose-86 UreaN-13 Creat-0.7 Na-140
K-3.8 Cl-106 HCO3-25 AnGap-13
[**2183-3-11**] 06:20AM BLOOD Glucose-112* UreaN-12 Creat-0.6 Na-144
K-4.0 Cl-108 HCO3-25 AnGap-15
[**2183-3-8**] 09:57AM BLOOD CK(CPK)-158*
[**2183-3-8**] 09:20PM BLOOD CK(CPK)-362*
[**2183-3-9**] 11:18PM BLOOD CK(CPK)-214*
[**2183-3-11**] Upper extremity ultrasound
1. AV fistula between the brachial artery and both adjacent deep
and
superficial brachial veins.
2. There is flow in a tract communicating with the antebrachial
vessels
without pseudoaneurysm identified.
[**2183-3-13**] Ultrasound: Left brachial artery and both brachial vein
fistula. Pulsatile flow to left brachial vein. No brachial
artery pseudoaneurysm.
Brief Hospital Course:
Patient admitted to Dr.[**Name (NI) 1720**] [**Name (NI) 1106**] surgical service on
[**2183-3-8**]. She was taken emergently to the operating room for a
AngioJet thrombectomy of occluded iliac stents, successful
stenting of the right common and external iliac artery between
the 2 stent grafts. With history of recent GI bleed and need for
anticoagulation, patient extubated and taken directly to the
intensive care unit for monitoring. She was transferred to the
VICU and surgical floor POD3.
Her hospital course could be summarized by the following:
Neuro: Patient initially presented with decreased sensation to
her right limb and over medial right leg due to her ischemia.
After her operation, patient regained and maintained motor and
sensory function throughout hospital stay. She was also able to
ambulate without any difficulty.
Ativan and morphine for anxiety and pain control, respectively.
After brachial sheath removed, patient had no sensory or motor
loss to left arm.
Resp: Patient with no respiratory issues.
Cardio: She was kept on telemetry monitoring. No cardiac issues.
She was transfused 2u pRBC (Hct 25) with FFP for sheath removal
on POD1. Post-transfusion Hct was 32. She remained
hemodynamically stable throughout hospital course.
[**Date Range **]: On presentation, patient with no right foot pulses.
After procedure, signals were dopplerable to PT and DP. Patient
maintained on heparin drip. Brachial sheath removed POD1 (ACT
175) with good hemostasis. Some bleeding from puncture site and
an Ace bandage applied to her left arm. We prevented left arm
from blood pressures and blood draws. Ultrasound on left arm
concerns for fistula. Study repeated POD5 with same findings.
Patient started on Coumadin POD3 and kept on heparin for
therapeutic bridging. She will be discharged on home dose of
Coumadin (4mg/3mg alternating doses). Discharge INR was 1.8.
Plan for follow up with PCP
for further INR/Coumadin dosing and adjustments. Patient will
follow up with Dr. [**Last Name (STitle) **] next month with ultrasound studies to
evaluate her left arm and iliacs.
Signals to lower extremities remained dopplerable on discharge.
GI/Renal/FEN: Patient tolerated regular diet with return normal
bowel function. No active issues. She does have a recent history
of GI bleeding. Dr. [**Last Name (STitle) 56292**] (outpatient GI)contact[**Name (NI) **] and
informed to not do any further procedures until clearance from
[**Name (NI) 1106**] clinic. She did not have any hematochezia.
Heme: Started on heparin drip and titrated to match PTT goal
60-80. Started on Plavix regimen. Aspirin not given due to
history of GI bleeding. Coumadin started and plan as stated
above.
Endo: Patient with sliding scale for glycemic control.
I/D: During pre-operative workup in the ED, urinalysis results
concerning for uncomplicated UTI. Given 3 day treatment of
ciprofloxacin. Patient was afebrile without any urinary
symptoms.
Dispo: She was cleared by PT to be discharged home. Follow up
appointments with PCP and Dr. [**Last Name (STitle) **] arranged.
Medications on Admission:
Gabapentin 300mg qDay, Tramadol 100mg TID, Atorvastatin 80mg
qDay Coumadin 3mg and 4mg alternating days, Protonix 40mg qDay
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed: No alcohol or driving while on
medication. Do not exceed 12 tabs in 24 hrs. .
Disp:*45 Tablet(s)* Refills:*0*
10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY
(Every Other Day).
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER
DAY (Every Other Day).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral [**Last Name (STitle) **] Disease
Ischemic lower extremity limb
Left arm arteriovenous fistula
Discharge Condition:
stable
INR 1.8
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-If you have staples, they will be removed during at your follow
up appointment.
.
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.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**9-4**] lbs) until your follow up appointment.
NO BLOOD DRAWS or BLOOD PRESSURES to left arm until follow up
appointment.
Please see PCP tomorrow to have blood drawn for INR/couamdin
dosing.
Followup Instructions:
Follow up with PCP [**2183-3-14**] Dr.[**Name (NI) 45872**] office. Please arrive
between 0900am-1230pm to have blood drawn for INR and coumadin
dosing.
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2183-6-17**]
9:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2183-6-17**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2183-6-17**] 10:30
|
[
"599.0",
"E878.8",
"440.22",
"998.11",
"996.62",
"447.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"00.42",
"00.46",
"88.48",
"88.42",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
8286, 8292
|
3758, 6835
|
329, 623
|
8442, 8459
|
2364, 3735
|
10413, 10930
|
1991, 2009
|
7010, 8263
|
8313, 8421
|
6861, 6987
|
8483, 8483
|
8499, 10390
|
2024, 2345
|
275, 291
|
651, 1540
|
1562, 1855
|
1871, 1975
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,541
| 198,352
|
27705
|
Discharge summary
|
report
|
Admission Date: [**2142-6-20**] Discharge Date: [**2142-6-26**]
Date of Birth: [**2066-7-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2142-6-20**]
1. Coronary bypass grafting times 5. The left internal
mammary artery to the left anterior descending coronary
artery; reverse saphenous vein, double sequential graft
from the aorta to the acute marginal coronary artery and
the posterior descending coronary artery
2. Reverse saphenous vein single graft from the aorta to
the first obtuse marginal coronary artery; as well as
reverse saphenous vein graft from aorta to the first
diagonal coronary artery
History of Present Illness:
75 year old male has a history of
hypertension, hyperlipidemia, diabetes and rheumatoid arthritis.
Prior stress testing from [**2140**] had revealed evidence of a
possible silent inferior MI with a small area of peri-infarct
ischemia/LVEF 45%. At the time of that test, he was completely
asymptomatic and medical management was continued. Several days
ago the patient noticed significant shortness of breath after
pulling a garden hose in his yard, requiring him to sit down to
catch his breath. It was not accompanied by any chest discomfort
or other symptoms. He has also noticed increased fatigue over
the
past weeks. Because of these symptoms, he underwent nuclear
stress testing on [**2142-6-11**]. This was notable for inferolateral ST
depression but no chest pain. There was a dilated LV cavity at
stress consistent with exercise associated LV dysfunction. There
was a moderate reversible inferior wall defect. He was referred
for left heart catheterization to further evaluate. He was found
to have three vessel disease upon cardiac catheterization. He is
now referred to cardiac surgery for evaluation of
revascularization.
Past Medical History:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Possible prior silent MI
Diabetes Type 2
Rheumatoid arthritis
s/p recent skin cancer resection
Gout
Past Surgical History:
s/p Left Knee replacement
s/p Right Cataract extraction
Social History:
Lives with:Wife
Occupation:
[**Name2 (NI) 1139**]:denies
ETOH:Occasional beer on weekend
Family History:
Mother died in her late 50's from heart disease.
Father died from CABG in his 60's.
Physical Exam:
Pulse:52 Resp:18 O2 sat: 99/RA
B/P Right:194/77 Left: 206/73
Height:5'[**41**].5" Weight:204 lbs
General:
Skin: Dry [x] intact [x- skin cancer excised from abd earlier
this month-healing well]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left:+2
DP Right:+1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right:Cath site Left:+2
Carotid Bruit None Right:+2 Left:+2
Pertinent Results:
[**2142-6-26**] 04:10AM BLOOD WBC-5.2 RBC-3.35* Hgb-10.4* Hct-30.8*
MCV-92 MCH-31.2 MCHC-33.9 RDW-14.8 Plt Ct-168
[**2142-6-24**] 06:00AM BLOOD WBC-7.3 RBC-2.97* Hgb-9.7* Hct-27.5*
MCV-93 MCH-32.5* MCHC-35.1* RDW-14.7 Plt Ct-130*
[**2142-6-26**] 04:10AM BLOOD Glucose-150* UreaN-29* Creat-1.1 Na-139
K-4.3 Cl-99 HCO3-32 AnGap-12
[**2142-6-24**] 06:00AM BLOOD Glucose-147* UreaN-37* Creat-1.1 Na-137
K-4.5 Cl-98 HCO3-31 AnGap-13
[**2142-6-20**]
Conclusions
The left atrium is normal in size. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a trivial/physiologic pericardial effusion. LV >55%
with no RWMA
Post bypass
The patient is s/p CABG
The patient is on a neosynephrine drip @0/5 mcg/kg/min
LV function is preserved @>55%
The aorta is intact post decannulation
Brief Hospital Course:
The patient was brought to the Operating Room on [**2142-6-20**] where
the patient underwent CABG x 5 with Dr. [**Last Name (STitle) 914**]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. He became
hypotensive requiring volume and remained in the unit one extra
night. On POD 2 the patient was transferred to the telemetry
floor for further recovery. Chest tubes and pacing wires were
discontinued without complication. He had a brief burst of
atrial fibrillation which resolved and beta blocker was
increased. Lisinopril was added for hypertension. Metformin
was resumed. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 6 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home in good condition with
appropriate follow up instructions.
Medications on Admission:
ALLOPURINOL 30mmg daily
DILTIAZEM HCL [DILTZAC ER] 240mg daily
GEMFIBROZIL 600 mg [**Hospital1 **] (pt. unclear if he is taking)
HYDROCHLOROTHIAZIDE 25mg daily
LISINOPRIL 40mg daily
METFORMIN 500mg every morning
PRAVASTATIN 40mg daily
SULFASALAZINE 1000 mg Tablet [**Hospital1 **] with meals
TERAZOSIN 5 mg once a day
Medications - OTC
ASPIRIN [ASPIR-81] - (OTC) - 81 mg Tablet, Delayed Release
(E.C.) - Tablet(s) by mouth
FISH OIL-DHA-EPA [FISH OIL] - (OTC) - 1,200 mg-144 mg Capsule -
1 Capsule(s) by mouth once a day
FOLIC ACID - (OTC) - 1 mg Tablet - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
[**2142-6-20**] CABGx5(LIMA-LAD,SVG-Diag,SVG-OM,SVG-AM-PDA)
PMH: HTN, hyperlipidemia, DM, RA, s/p recent skin ca resec,
Gout, s/p Left Knee replacement, s/p Right Cataract extraction
Discharge Condition:
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+lower extremity 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:
Recommended Follow-up:
You are scheduled for the following appointments
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2142-7-3**] 11:00 in
the [**Hospital **] medical office building [**Hospital Unit Name **]
surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2142-7-24**] 1:00
in the [**Hospital **] medical office building [**Hospital Unit Name **]
cardiologist: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
date/Time:[**2142-9-13**] 10:30
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17025**] in [**3-27**] weeks [**Telephone/Fax (1) 6699**]
**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:[**2142-6-26**]
|
[
"458.29",
"V43.65",
"414.01",
"714.0",
"412",
"V10.83",
"401.9",
"274.9",
"V45.61",
"250.00",
"V17.3",
"272.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7864, 7919
|
4221, 5535
|
329, 829
|
8167, 8418
|
3192, 4198
|
9261, 10287
|
2370, 2456
|
6180, 7841
|
7940, 8125
|
5561, 6157
|
8442, 9238
|
2189, 2247
|
2471, 3173
|
269, 291
|
857, 1992
|
2014, 2166
|
2263, 2354
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,103
| 175,513
|
34123
|
Discharge summary
|
report
|
Admission Date: [**2115-4-2**] Discharge Date: [**2115-4-8**]
Date of Birth: [**2086-11-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Pericardiocentesis and drain placement
History of Present Illness:
Ms. [**Known lastname 1968**] is a 28y/o woman with a h/o untreated SLE (dx [**2109**])
presenting with one day of syncopal episodes on [**2115-3-31**] and a
6wk h/o worsening fatigue. On the morning of [**3-31**], she awoke to
go to the bathroom, urinated, and began feeling dizzy upon
rising from the toilet. She walked a few steps and then
experienced a "blackout" with loss of sensation. She hit her
head on the way down, but reports no pain at site of trauma.
Since she didn't have insurance, she arranged to see a new PCP
on [**Name9 (PRE) 766**], who referred her to OSH, where she was found to have
hypotension, tachycardia, pancyptopenia w/ bandemia,
cardiomyopathy, and have a pericardial effusion. She was
transferred to [**Hospital1 18**], and a TTE revealed tamponade. A
pericardiocentesis was performed, and 340cc serous fluid was
drained from the pericardium.
.
She reports [**8-30**] joint pain with activity and had 40lb weight
loss since the birth of her daughter in summer of [**2113**]. Her
symptoms worsened during the winter of [**2114**], and then even more
in the last 6wks. She reports trying to control her lupus with
diet and holistic therapy. She also notes severe dry mouth
beginning on [**2115-3-29**], which she claims often portends worsening
lupus symptoms.
.
She reports polyuria, nocturia, night sweats, anorexia, early
satiety, 40lb weight loss, hair loss, joint pain, general aches,
extreme fatigue, dry mouth, and vaginal dryness. Unable to gain
weight with effort. No menses for 1yr. Reports scalp lesions and
tingling with sun exposure. FH significant for father with h/o
RA. Reports feeling of always being cold. Reports more confusion
and memory difficulty in last year. Reports oral ulcers approx.
once per month. Denied melana, diarrhea, constipation.
Past Medical History:
# Lupus- diagnosed in [**2109**]. untreated. sought consultation b/c
hairloss, fatigue, weight loss, dry mouth. Attempted to control
with diet and holistics. Recent symptoms include flairs in
shoulder joint and rash on eyelid with sun exposure.
#Amenorrhea - one year. Not on any form of medical
contraception.
#Lock Jaw- uses guard at home
Social History:
Denies smoking, EtOH, drugs. Has 4 children (all full term).
Recently under greater stress b/c move from [**State **] to MA and
breakup with former boyfriend. N.B. Decided not to treat lupus
because her brother told her "it was all in her head" and so
began holistic therapy. Family from Barbados and [**Country 3594**].
Family History:
Father w/ [**Name2 (NI) **], DM, "englarged heart"
Physical Exam:
GEN: Young woman looking somnelent but comfortable lying in bed
talking to family.
VS Tm 95.9 HR 100 BP 90/64, 95% RA RR 14
HEENT: NC,AT. Sclera anicteric, VFFTC, PERLLA, EOMI. Clear OP,
MMM.
Neck: Supple. Trachea midline. Thyroid not palpable. Shoddy LAD
bilaterally in anterior cervical chain.
Lungs and Thorax: Decreased breath sounds. Decreased
respirations. Respirations unlabored.
CV: Tachycardic. S3 gallop. Radial, Pedal Pulses 1+ bilaterally.
Abdomen: + Bowel sounds. NTND. No bruits. No HSM appreciated.
Skin: Cool. Dry texture. No jaundice.
Extremities: No clubbing, cyanosis, or edema. Bruising on distal
fingers. Swollen, warm L ankle. Toes and ankles tender to touch
bilaterally.
Neuro:
Mental Status-A&Ox3. No dysarrthria.
Pertinent Results:
[**2115-4-1**] 11:45PM BLOOD WBC-1.9* RBC-2.65* Hgb-7.1* Hct-22.1*
MCV-84 MCH-26.8* MCHC-32.1 RDW-16.0* Plt Ct-119*
[**2115-4-1**] 11:45PM BLOOD Neuts-37* Bands-0 Lymphs-51* Monos-11
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2115-4-2**] 04:04AM BLOOD ESR-150* Gran Ct-520*
[**2115-4-2**] 04:04AM BLOOD ALT-105* AST-196* LD(LDH)-422* AlkPhos-96
Amylase-109* TotBili-0.3
[**2115-4-2**] 04:04AM BLOOD C3-23* C4-LESS THAN
[**2115-4-2**] 04:04AM BLOOD calTIBC-153* VitB12-1120* Folate-15.1
Hapto-30 Ferritn-719* TRF-118*
[**2115-4-3**] 04:23AM BLOOD PT-12.5 PTT-86.1* INR(PT)-1.1
[**2115-4-3**] 03:00PM BLOOD Cryoglb-POSITIVE
[**2115-4-3**] 03:00PM BLOOD RheuFac-29*
[**2115-4-3**] 03:00PM BLOOD PEP-POLYCLONAL IgG-2231* IgA-352 IgM-349*
IFE-NO MONOCLO
[**2115-4-3**] 03:00PM BLOOD GRANULOCYTE ANTIBODIES-
[**2115-4-3**] 03:00PM BLOOD SM ANTIBODY-Test
[**2115-4-3**] 03:00PM BLOOD RO & [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]
[**2115-4-3**] 03:00PM BLOOD RNP ANTIBODY-Test
[**2115-4-3**] 03:00PM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG &
IGM)-Test
[**2115-4-3**] 03:00PM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-Test
[**2115-4-4**] 06:15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL Fragmen-OCCASIONAL Ellipto-1+
[**2115-4-4**] 05:50PM BLOOD Thrombn-60.2*
[**2115-4-4**] 05:50PM BLOOD ACA IgG-11.4 ACA IgM-45.4*
[**2115-4-5**] 06:50AM BLOOD Thrombn-31.7*#
[**2115-4-7**] 06:58AM BLOOD Calcium-7.6* Phos-3.2 Mg-1.7
[**2115-4-8**] 09:05AM BLOOD WBC-3.6* RBC-2.93* Hgb-8.0* Hct-25.0*
MCV-85 MCH-27.3 MCHC-32.0 RDW-17.4* Plt Ct-179
[**2115-4-8**] 09:05AM BLOOD ALT-167* AST-141* AlkPhos-87 TotBili-0.3
Brief Hospital Course:
Ms. [**Known lastname 1968**] is a 28 year old female with PMH of SLE, diagnosed in
[**2109**] but untreated, who was transferred from OSH with fever,
hypotension, tachycardia and pericardial effusion with evidence
of early tamponade on admission ECHO. She presented to an OSH
after several syncopal episodes and was transferred to [**Hospital1 18**]
when echocardiogram suggested pericardial effusion and
tamponade. At [**Hospital1 **], TTE confirmed early pericardail tamponade and
a pericardiocentesis was performed wit drainage of 340cc of
serous pericardial fluid. Her pericardial effusion was
exudative and was determined to be likely [**12-22**] her SLE. She was
started on prednisone and hydroxychloroquine for suspected SLE
and autoimmune panel was ordered. Her pericardial drain was
removed the day after placement and she did well with no
evidence of recurrance of her effusion. She was initially
treated with azithromycin and cefepime however these were
discontinued on transfer to the floor as infectious workup was
negative and fevers and leukocytosis were more likely associated
was SLE flare and systemic inflammation.
.
1)Pericardial effusion/early tamoponade: s/p percardiocestesis
with removal of 340cc yellow fluid removed, exudative on
analysis. She tolerated removal of drain well with no
hemodynamically consequent recurrance of her effusion. She was
treated with prednisone and hydroxychloroquine and slowly
improved throughout her admission. She had a repeat ECHO on [**4-4**]
prior to discharge which did not show any evidence of repeat
effusion. She was discharged with follow up with Dr. [**Last Name (STitle) **] in
cardiology clinic.
2)Cardiomyopathy: On echocardiogram she was noted to have global
LV hypokinesis and systolic dysfunction with EF of 35% most
likely due to lupus cardiomyopathy. She was followed by
rheumatology consultants who felt that her cardiomyopathy would
likely resovle with treatment of her SLE as above. She was
treated with afterload reduction in the meantime with
lisinopril. She will follow up in cardiology clinic.
3)SLE: The patient reports receiving a dx of SLE in [**2109**], which
she claims to have controlled with diet. On presention, her
symptoms and labs were c/w an acute SLE flare and included
amenorrhea, unintentional weight loss, fevers, fatigue,
alopecia, sun sensitivity, xerostomia, sicca, and vaginal
dryness. She also reports frequent "lumps" under her chin,
indicating possible enlarged salivary glands. These symptoms
are consistent with Sjogren's Syndrome, which is most frequently
associated with RA but can also underlie other autoimmune
conditions such as SLE. She had comprehensive lab work up that
was consistent with a diagnosis of SLE including diminished C3,
positive SSA, positive [**Doctor First Name **], pancytopenia, positive
antigranulocyte antibodies, positive antiRNP antibodies,
elevated IgG, IgM, and elevated RF. She was treated with
prednisone and hydroxychloroquine and will follow up in one week
of discharge in lupus clinic.
4)Pancytopenia: Most likley [**12-22**] to her diagnosis of acute SLE
flare. She was followed by hematology during her admission.
Blood titers for CMV, EBV, and parvovirus were negative. She
was treated with high dose folate.
5) Proteinuria: She was evaluted by nephrology team due to
concern for possible lupus nephritis given that she had
proteinuria. Her urine sediment was reviewed with no evidence
of lupus nephritis. Given her increased risk she will follow up
in nephrology clinic for close monitoring of her renal function.
Medications on Admission:
MVI
White Oak Bark
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Calcium Carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID with meals .
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Pericardial Effusion with early tamponade
Lupus
Discharge Condition:
fair
Discharge Instructions:
You were transferred to the [**Hospital3 **] because you were having
shortness of breath and passed out and you were found to have
fluid around your heart. You were seen by the cardiologists and
the fluid was drained. This was most likely caused by lupus.
You were followed by the rheumatologists and you were started on
prednisone and plaquenil. It is very important that you
continue to take these medications and that you follow up with
the rheumatology doctors as [**Name5 (PTitle) **] outpatient to prevent further
serious complications of untreated lupus. You will also need to
follow up with the kidney doctors to be sure that you are not
sustaining kidney damage from the lupus.
Medications:
1) You were started on prednisone 60mg daily which you will need
to continue until instructed to decrease or change the
medication by the rheumatologists.
2) You were started on Plaquenil which you should also take for
your Lupus
3) You were started on lisinopril which you will take to protect
your heart.
4)You should take calcium and vitamin D to protect your bones
while you are on prednisone.
5)You were started on prilosec which you should take to protect
your stomach while you are on prednisone.
6)You were started on folic acid for your anemia.
7)You were started on Bactrim which you should take daily to
prevent infections in your lungs while you are on prednisone.
Please follow up as below.
Please call your doctor or return to the hospital if you
experience any concerning symptoms including chest pain,
difficulty breathing, lightheadedness, fainting, fevers or any
other worrisome symptoms.
Followup Instructions:
1)The [**Hospital **] Clinic will contact you about making an appointment.
If they don't contact you within two days of discharge, please
call them at [**Telephone/Fax (1) 2226**]. You should have an appointment within
two weeks of discharge. While in the hospital, you saw Dr. [**First Name (STitle) 1075**].
2)You have a followup appointment at the nephrology clinic with
Dr. [**Last Name (STitle) 4883**] on Monday [**4-22**] at 3:00pm in the [**Hospital Ward Name 23**] Building
of the [**Hospital Ward Name **] of the [**Hospital1 18**]. Please come to the appointment
with a full bladder. The nephrology clinic's phone number is
[**Telephone/Fax (1) 60**]. This is important to be sure that there is not any
ongoing damage to your kidneys from the Lupus.
3)You have a follow up appointment at the cardiology clinic with
Dr. [**Last Name (STitle) **] on Monday [**4-29**] at 8:40am. The phone number of the
clinic is ([**Telephone/Fax (1) 7437**].
4)You have scheduled an apponintment with your primary care
doctor, Dr. [**Last Name (STitle) **] at [**Hospital1 **], on [**4-23**] at 1:30.
([**Telephone/Fax (1) 78671**]
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"423.3",
"425.8",
"284.1",
"710.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
10072, 10147
|
5461, 9049
|
320, 361
|
10239, 10246
|
3732, 5438
|
11908, 13171
|
2906, 2958
|
9118, 10049
|
10168, 10218
|
9075, 9095
|
10270, 11885
|
2973, 3713
|
273, 282
|
389, 2187
|
2209, 2552
|
2568, 2890
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,740
| 154,934
|
51055
|
Discharge summary
|
report
|
Admission Date: [**2175-12-5**] Discharge Date: [**2175-12-9**]
Date of Birth: [**2119-2-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
acute renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 year old female with history of bipolar disorder, chronic
renal insufficiency (baseline Cr [**2-17**]) initially presented to PCP
c/o cough x 3 weeks (non-productive) and malaise. No fevers,
chills, headache, neck stiffness, nausea, vomiting, abdominal
pain, dysuria, hematuria, increased urinary frequency/urgency,
diarrhea. She noted decreased UOP over the 24 hrs prior to
seeing her PCP. [**Name10 (NameIs) **] did not decreased PO intake, which she
attributed to decreased appetite from resperidone and codeine.
At her PCPs office, she was noted to be hypotensive bp 70s/30s
and tachycardic 115. She was transferred to [**Hospital1 18**] ED for further
evaluation, where Cr noted to be 9.5. In the ED, she received 2
L NS, followed by D5 1/2 NS w/ 2 amps HCO3 @ 200 cc/hr with
improvement in sbp to 110s-120s. She is admitted to the MICU for
further management.
Past Medical History:
1) CRI: baseline Cr [**2-17**]
2) osteoarthritis
3) bipolar disorder
4) h/o pancreatitis [**9-20**]
5) Pancreatic divisim
6) Hypertension
7) h/o nephrogenic diabetes insipidus secondary to lithium
Social History:
Lives alone in [**Location (un) 577**]. No toacco use. Rare EtOH. No other drug
use.
Family History:
NC
Physical Exam:
PE: Tc 98.1, HR 110bp 122/57, resp 15, 96% RA
Gen: Middle-aged female, alert and oriented to person and place,
NAD
HEENT: anicteric, pale conjunctiva, OM dry, OP clear, neck
supple, no JVD
Cardiac: tachycardic, regular, II/VI SM at apex
Pulm: CTA bilaterally
Abd: Mildly distended, NABS, soft, mild LLQ tenderness without
rebound or guarding
Ext: No C/C/E, warm with good cap refill.
Neuro: CN II-XII grossly intact and symmetric bilaterally, [**4-20**]
strength throughout, no tremor/asterixis noted.
Pertinent Results:
CXR: minimal linear opacity at left [**Known lastname **] base, c/w atelectasis
.
Abd CT: Minimal fluid within the pelvis and in the left
pericolic gutter, with haziness of the mesenteric fat, without
any definite inflammatory stranding or bowel wall thickening. A
5.7 x 5.2 cm dermoid arising off the left ovary. Cholelithiasis.
Two hypodensities are seen within the liver, one of which
represents a cyst, and the other which is too small to
characterize. <5 mm focal nodule seen in the right lower [**Known lastname **]
(f/u in 1 yr)
.
EKG: ST @ 114 bpm, nl axis, nl intervals, Q II, III, avF, TWI
III (old) upsloping ST segment in V1 (new); c/t [**2174-1-5**]
Brief Hospital Course:
A/P: 56 y.o. woman with bipolar disorder and HTN who presents
with ARF on CRI and hypotension, responsive to fluid
resuscitation.
.
1) ARF on CRI: unclear precipitant, likely pre-renal in setting
of decreased PO intake/diabetes insipidis. No evidence of
hydronephrosis on Abd CT to suggest obstruction. Renal sevice
was consulted who followed the patient and did not see any
indication for emergent dialysis initially. Lytes were checked
daily and pt was able to maintain good PO intake. Also
continued bicitra tid. Pt has slow improvement in creatinine.
There was concern for uremia contributing to her delirium,
nausea and vomiting. Her symptoms improved as well as renal
function slightly. Transplant surgery was consulted who will
setup for AV fistula placement after discharge.
.
2) Hypotension: likely hypovolemia, possibly exacerbated by
acidemia in setting of ARF. Responsive to fluid resuscitation
and was not an issue afterwards.
.
3) Diabetes insipidus: nephrogenic DI secondary to lithium. Pt
able to maintain enough PO intake.
.
4) Anemia: HCT 22.7 (from baseline 26-27). Likely represents
hemodilution superimposed on ACD (iron studies [**9-20**] not c/w Fe
def anemia, nl/high vit B12/folate). Pt received 1 unit PRBC in
the MICU. hct remained stable aftewards. She was started on
IRon and epogen per renal recs.
5) Positive serum tox: pt reports taking codeine for cough,
denies other opiate use.
.
6) Bipolar disorder: Per psych her initial hypotension was
probably contributed mainly from uremia and not overmedication
with Risperidone. Continued home resperidone dose initially.
Patient was seen by psych who recommended increasing the dose.
She was slowly increased from 1 mg qd to 3 mg qhs.
.
7) HTN: Initially losartan and atenelol were held given
hypotension and [**Doctor First Name **]. She was restarted on metoprolol, which
should be continued after discharge instead or ateneolol given
her renal insufficeincy.
Medications on Admission:
1) Nephrocaps 1 cap PO daily
2) Risperidone 1 mg PO daily
3) Losartan 50 mg PO daily
4) Sodium citrate 30 mg PO BID
5) atenolol
6) calcitriol 0.5 mg PO daily
Discharge Medications:
1. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO BID (2 times a day).
Disp:*1 month supply* Refills:*2*
4. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic renal failure
Uremia
Hypotension
Dehydration
Bipolar disorder
Diabetes insipidus
Discharge Condition:
Stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) 1007**] or return to ER for any: nausea, vomiting,
itching, confusion or ANY other unusual or concernign symptoms.
Please follow-up with all appontments as scheduled
Take all medications as prescribed
Followup Instructions:
1) Dr. [**Last Name (STitle) 1007**]: Wednesday [**2175-12-13**] at 3 pm for lab draw
2) Renal:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2175-12-14**]
11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
Completed by:[**2176-1-15**]
|
[
"296.7",
"276.2",
"584.9",
"588.1",
"E939.8",
"585.9",
"276.52",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5690, 5696
|
2811, 4762
|
336, 343
|
5838, 5847
|
2123, 2788
|
6129, 6543
|
1581, 1585
|
4970, 5667
|
5717, 5817
|
4788, 4947
|
5871, 6106
|
1600, 2104
|
277, 298
|
371, 1242
|
1264, 1462
|
1478, 1565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,204
| 147,321
|
31367
|
Discharge summary
|
report
|
Admission Date: [**2114-12-28**] Discharge Date: [**2115-1-5**]
Date of Birth: [**2046-12-4**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
The patient presents for resection of a known duodenal mass
Major Surgical or Invasive Procedure:
1. Pylorus-preserving pancreaticoduodenectomy (Whipple's
procedure).
2. Open cholecystectomy.
History of Present Illness:
Mr. [**Known lastname **] is a delightful, 68-year-old gentleman who had a
duodenal
adenocarcinoma identified by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on endoscopy.
This was biopsy proven. The patient had also suffered a
myocardial ischemic insult in late [**2113**] and has been placed on
anticoagulants, following successful deployment of a
coronary artery stent.
Past Medical History:
CAD
- s/p POBA of LAD '[**12**]
- s/p [**Year (2 digits) **] (Taxus) to mid LAD [**2114-10-26**]
- s/p re-look angiography [**2114-11-5**]
Asthma
COPD
HTN
Remote history of a fractured ankle
S/P hernia repair
S/P appendectomy
H/O kidney stones s/p lithotripsy
Sleep apnea
RBBB
H/O Beryllium exposure in [**2065**]
Social History:
Lives w/wife, quit smoking 30 years ago drinks 4x/week ([**11-24**]
drinks).
.
CARDIAC RISK FACTORS:: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
Social History:
Lives w/wife, quit smoking 30 years ago drinks 4x/week ([**11-24**]
drinks).
Family History:
Non-contributory.
Physical Exam:
On day of admission:
Gen: alert and oriented
CVS: RRR
Pulm: CTA b/l
Abd: s/nt/nd/no masses palpable
Ext: no peripheral edema
Pertinent Results:
[**2114-12-28**] 05:46PM GLUCOSE-159* UREA N-15 CREAT-1.1 SODIUM-141
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12
[**2114-12-28**] 05:46PM CALCIUM-8.5 PHOSPHATE-3.8 MAGNESIUM-1.4*
[**2114-12-28**] 05:46PM WBC-7.8 RBC-3.71* HGB-9.7* HCT-29.0* MCV-78*
MCH-26.3*# MCHC-33.6 RDW-18.8*
[**2114-12-28**] 05:46PM PLT COUNT-218
[**2114-12-28**] 05:46PM PT-14.1* INR(PT)-1.2*
[**2114-12-28**] 05:45PM TYPE-ART PO2-133* PCO2-40 PH-7.40 TOTAL
CO2-26 BASE XS-0
[**2114-12-28**] 05:45PM freeCa-1.20
.
Cardiology Report ECG Study Date of [**2114-12-30**] 8:11:58 PM
Sinus rhythm. Right bundle-branch block. Compared to the
previous tracing
there is no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 150 148 390/433 36 -5 64
Pathology pending
Brief Hospital Course:
The patient underwent the above procedure and tolerated it well.
He remained intubated following the procedure and was
transferred to the the ICU. He had IVF for hydration, NGT and
foley catheter in place, with prn sedation.
[**12-29**] - the patient was successfully extubated, remained NPO with
IVF for hydration, PCA for pain control, NGT and foley in place,
transferred to the surgical floor for continued monitoring,
started on ASA per rectum and hep gtt at 500
[**12-30**] - continued hep gtt, NGT removed. Experienced mild nausea.
pain controlled.
[**12-31**] - diet advanced to sips, peripheral line placed, central
line removed, foley catheter removed at midnight, started
plavix, discontinued heparin drip. Single, brief episode of (L)
sided chest pain without radiation, dizziness, lightheadedness.
AVSS. EKG NSR w/o changes. CK 194, MB1, Troponin <0.1, HCT 28.9,
PTT 30.6. Sx resolved with Zofran. No further episodes of Chest
pain.
[**1-1**] - CVL discontinued, PIV placed. Diet advanced to clears
with c/o mild bloating, gassiness, relieved with stool
softeners. Pain remained well controlled. JP contined putting
out >400cc. JP amylase on [**1-2**] was 87.
[**1-3**] - Diet advanced to regular with good tolerability. (+)
flatus, but no bowel movement. Bowel regimen started. Pain
remained well controlled. Ambulating without assist. JP output
>350.
[**1-4**] - Patient experienced crampy abdominal pain in the morning,
but improved when patient got back on more routine schedule with
pain medication. Tolerated diet w/o N/V. Ambulating with steady
gait. Improved activity tolerance.
[**1-5**] - 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. JP remained indwelling due to output >300.
Patient to go home with VNA services to manage and teach JP
care. During hospitalization, patient required regular sliding
scale insulin coverage for blood sugars in the 150-250 range.
Patient received insulin administration and glucose monitoring
teaching with good understanding. VNA will reinforce and monitor
insulin management as an outpatient.
Medications on Admission:
Plavix 75', ASA 325', quinapril 40', HCTZ 25', Lasix 40',
amlodipine 5', Singulair 10', Zocor 20', albuterol 90 q4prn,
advair 250-50", ativan 0.5 prn, simvastatin 20', iron 325'
Discharge Medications:
1. Plavix 75 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Quinapril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhlation Inhalation [**Hospital1 **] (2 times a day).
12. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
14. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
16. One Touch Ultra System Kit Kit Sig: One (1) kit
Miscellaneous n/a.
Disp:*1 kit* Refills:*0*
17. One Touch UltraSoft Lancets Misc Sig: n/a Miscellaneous
n/a.
Disp:*1 box* Refills:*2*
18. One Touch Ultra Test Strip Sig: n/a In [**Last Name (un) 5153**] Test as
directed ACHS.
Disp:*100 test strips* Refills:*2*
19. Insulin Syringe-Needle U-100 [**11-23**] mL 29 x [**11-23**] Syringe Sig:
n/a Miscellaneous n/a: As directed for insulin injections.
Disp:*1 box* Refills:*0*
20. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ACHS PRN: Administer subcutaneously as directed per
insulin sliding scale.
Disp:*1 vial* Refills:*1*
21. Regular Insulin Sliding Scale
Fingerstick ACHS Regular Insulin SC Sliding Scale:
Glucose Insulin Dose
0-60 mg/dL ***[**Name8 (MD) **] M.D. immediately***
Breakfast Lunch Dinner Bedtime
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-150 mg/dL 2 Units 2 Units 2 Units 0 Units
151-180 mg/dL 4 Units 4 Units 4 Units 4 Units
181-210 mg/dL 6 Units 6 Units 6 Units 6 Units
211-240 mg/dL 10 Units 10 Units 10 Units 8 Units
241-280 mg/dL 12 Units 12 Units 12 Units 10 Units
> 280 mg/dL ***Notify M.D.immediately***
Discharge Disposition:
Home With Service
Facility:
Bayoda VNA
Discharge Diagnosis:
1. Duodenal cancer.
2. Gastrointestinal bleeding with recurrent anemia.
3. Myocardial ischemia, status post coronary artery stent.
4. Severe obesity.
5. Sleep apnea.
6. Asthma
7. Hypertension
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 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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
JP Tube Monitoring/Care:
*Monitor for redness, increased drainage, bleeding, pus,
swelling, or pain at insertion site; if occurs, notify your VNA
nurse or call your doctor immediately.
*Keep area clean and dry. [**Month (only) 116**] place a gauze dressing over area
if some drainage continues. Your VNA nurse [**First Name (Titles) **] [**Last Name (Titles) 8146**] you on
specific care.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) 468**] to arrange a follow up
appointment in 2 weeks at [**Telephone/Fax (1) 2835**]
|
[
"285.9",
"V58.61",
"578.9",
"V45.82",
"152.0",
"278.01",
"493.20",
"575.11",
"414.01",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.7",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
7555, 7597
|
2458, 4677
|
339, 438
|
7833, 7840
|
1659, 2435
|
9762, 9902
|
1480, 1499
|
4906, 7532
|
7618, 7812
|
4703, 4883
|
7864, 9010
|
9025, 9739
|
1514, 1640
|
240, 301
|
466, 865
|
887, 1202
|
1384, 1464
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63
| 195,961
|
24347
|
Discharge summary
|
report
|
Admission Date: [**2169-1-7**] Discharge Date: [**2169-1-7**]
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
right hip pain, fall
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
This is a 88 year-old man with dementia, COPD, CHF,
osteoarthritis s/p L hip replacement and h/o TIA who presented
to the ED after a fall. In the ED, he was initially stable, but
he began to become increasingly agitated and aggressive. He
received haloperidol and ativan, but remained combative. His O2
sats never dipped below 90% but he became even more agitated,
diaphoretic and, after discussion with the pt's daughter, the
decision was made to intubate him so a w/u of his fall could be
undertaken.
There was some concern about O2 sats in the low 90s, and after a
d-dimer returned at 1000, a CTPA was done. It was negative. A
head CT revealed no acute change. Hip films revealed.
He was admitted to the ICU intubated.
Past Medical History:
Dementia
COPD
CHF (EF unknown)
Osteoarthritis s/p L hip replacement
h/o TIA
Social History:
Lives at dementia [**Hospital3 **] facility
Family History:
non-contributory
Physical Exam:
VS: Temp: afebrile BP: 140/52 HR: 60 RR: 12 O2sat 93%
general: sedated, intubated
HEENT: PERLL, anicteric, MMM
Lungs: CTA anteriorly
Heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
Abdomen: nd, +b/s, soft, no masses or hepatosplenomegaly
Extremities: no cyanosis, clubbing or edema
Pertinent Results:
[**2169-1-6**] 08:45PM BLOOD WBC-12.9* RBC-4.94 Hgb-15.6 Hct-44.5
MCV-90 MCH-31.5 MCHC-35.0 RDW-13.7 Plt Ct-195
[**2169-1-6**] 08:45PM BLOOD D-Dimer-1009*
[**2169-1-6**] 08:45PM BLOOD Glucose-129* UreaN-19 Creat-1.2 Na-140
K-4.2 Cl-100 HCO3-28 AnGap-16
[**2169-1-6**] 08:45PM BLOOD CK(CPK)-101
[**2169-1-6**] 08:45PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-72
[**2169-1-7**] 12:05AM BLOOD Type-ART pO2-524* pCO2-36 pH-7.44
calTCO2-25 Base XS-1
CT head:
1. No hemorrhage or mass effect.
2. The temporal horns are prominent but there is no
hydrocephalus.
3. Paranasal sinus mucosal disease.
CTA chest:
1. No pulmonary embolus.
2. Mild CHF.
3. Gallstones.
Hip films: No acute fracture or dislocation of right hip.
Consider MRI if symptoms persist.
Brief Hospital Course:
This is a 88 year-old man with history of dementia, COPD and CHF
(EF unknown) who presented from his nursing home after falling
and having some right-sided weakness. In the ED, he became
agitated and combative and was intubated for workup.
## Agitation, intubation: CTA revealed no avute pathology. He
was extubated without difficulty.
## s/p fall: Hip films and CT head were unremarkable. Likely
mechanical fall. No events on telemetry.
## COPD: Extent of COPD unknown. Takes no meds at baseline.
Reason for intubation was not hypoxia.
## Cardiomyopathy: presumed ischemic in nature. Unknown EF, but
BNP <100 suggested no significant volume overload. He was
continued on atorvastatin 10.
Medications on Admission:
Furosemide 40 gm PO qd
Atorvastatin 10 mg PO qd
Quetiapine 25 mg PO qd
Sertraline 100 mg PO qd
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Springhouse
Discharge Diagnosis:
Primary:
Fall
Secondary:
Dementia
COPD
CHF (EF unknown)
Osteoarthritis s/p L hip replacement
h/o TIA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of a fall. You did not fracture any
bones.
Please take all of your medications as prescribed.
Please follow-up with your primary care doctor.
Followup Instructions:
Please follow up with your primary care doctor.
|
[
"496",
"E849.8",
"574.20",
"780.8",
"428.0",
"307.9",
"414.8",
"719.45",
"E888.9",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3460, 3498
|
2334, 3028
|
263, 276
|
3644, 3653
|
1561, 2001
|
3871, 3922
|
1207, 1225
|
3174, 3437
|
3519, 3623
|
3054, 3151
|
3677, 3848
|
1240, 1542
|
203, 225
|
304, 1030
|
2010, 2311
|
1052, 1130
|
1146, 1191
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,390
| 137,142
|
28642
|
Discharge summary
|
report
|
Admission Date: [**2130-12-1**] Discharge Date: [**2130-12-14**]
Service: MEDICINE
Allergies:
Vancomycin / Percocet
Attending:[**First Name3 (LF) 11348**]
Chief Complaint:
Left Hip fracture s/p fall
Major Surgical or Invasive Procedure:
Left Hip ORIF
History of Present Illness:
85 y/o M with PMHx on CHF, CAD, PVD, HTN, DM and CKD presented
today from his NH with a L Intertrochanteric hip fx. Per son, pt
was attempting to ambulate around a chair, caught his foot and
fell. There was no LOC, fall was witnessed. Pt was seen by ortho
in the ED and will need surgical repair, it has been discussed
with Pt's PCP ([**Doctor Last Name 1266**]) and Ortho attending [**Doctor Last Name 1005**].
Pt arrived to floor after receiving Morphine in the ER, he was
denying CP/SOB/Cough/N/V/Abd pain. He has some Left hip pain but
it is significantly improved since receiving the morphine. He is
oriented to place, person, not time.
Past Medical History:
- CHF([**2-9**]) EF 30-35%, inf/post hypokinesis
- CAD s/p CABG x 4 [**2115**]
- PVD s/p multiple amputations, h/o dry gangrene s/p LLE bypass
- DM on insulin c/w nephropathy
- CKD Cr baseline 3.8
- Ischemic colitis [**11-10**], colonoscopy w/polyp removal, but
limited to sigmoid b/c of stricture at 40cm above anus; virtual
colonoscopy was unable to be performed [**3-10**] patient not
tolerating bowel preparation.
- Anemia (blood loss, GIB)
- h/o A.fib not on anticoagulation
Social History:
Lives at [**Hospital **] Healthcare Center NH, speaks Toisanese, some
english, used to be in Navy. No h/o etoh, tob, drugs.
Family History:
+CAD, son deceased from cholangiocarcinoma
Physical Exam:
GEN: NAD, slight upper extremity tremor (baseline per son)
[**Name (NI) 4459**]: eyes closed, opens to name, NCAT, EOMI, no
lymphadenopathy
CV: RRR no m/r/g
Resp: Crackles noted bilaterally at bases (ant & post) otherwise
clear
Abd: soft, NT/ND, NABS
Extr: warm, trace edema bilaterally, e/o vascular surgical
scars, s/p toe amputations bilaterally, Left shin ulcer and
Right foot ulcer with some active drainage.
Left lower extremity- externally rotated and shortened, TTP
Pertinent Results:
[**2130-12-1**] 11:40AM PT-13.9* PTT-28.5 INR(PT)-1.2*
[**2130-12-1**] 11:40AM WBC-9.4 RBC-3.76*# HGB-12.4*# HCT-37.7*#
MCV-100* MCH-32.9* MCHC-32.9 RDW-15.0
[**2130-12-1**] 11:40AM NEUTS-92.2* BANDS-0 LYMPHS-4.8* MONOS-1.9*
EOS-1.0 BASOS-0.1
[**2130-12-1**] 11:40AM CALCIUM-9.4 PHOSPHATE-2.4* MAGNESIUM-2.1
[**2130-12-1**] 11:40AM CK-MB-4
[**2130-12-1**] 11:40AM cTropnT-0.04*
[**2130-12-1**] 11:40AM CK(CPK)-112
[**2130-12-1**] 11:40AM GLUCOSE-313* UREA N-50* CREAT-2.9* SODIUM-137
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17
[**2130-12-1**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2130-12-1**] 11:57PM LACTATE-8.9*
[**2130-12-14**]
Na 141 / K 3.8 / Cl 103 / CO2 23 / BUN 36 / Xe 2.1 / BG 146 /
Calcium 8 / Mg 1.8 / Phos 3.2
WBC 8.3 / Hct 31.4 / Plt 164
[**2130-12-1**] Left Femur XR - Intertrochanteric fracture
[**2130-12-1**] CXR
1. Evidence of mild congestive heart failure, with greater
cephalization than before.
2. Persistent retrocardiac opacity without definite evidence for
superimposed pneumonia.
[**2130-12-1**] Left Hip XR - Comminuted intertrochanteric fracture
with mild valgus angulation. These results were posted to the ED
dashboard at approximately 1:45 p.m. on the day of the study.
[**2130-12-2**] Head CT -
1. No evidence of acute intracranial abnormality on the
non-contrast study.
2. Cerebral atrophy.
3. Findings consistent with chronic microvascular infarcts.
[**2130-12-4**] Echo
Regional left ventricular systolic dysfunction c/w multivessel
CAD. Moderate mitral regurgitation. Pulmonary artery systolic
hypertension. Right ventricular free wall hypokinesis. Compared
with the prior study (images reviewed) of [**2129-8-24**], the
severity of mitral regurgitation is increased and pulmonary
artery systolic hypertension with right ventricular free wall
hypokinesis are now seen.
Brief Hospital Course:
85 yo with multiple medical problems including congestive heart
failure with an EF of 35%, coronary artery disease s/p MI in
[**2115**], Atrial Fibrillation, diabetes mellitus, hypertension, and
peripheral vascular disease was admitted to [**Hospital1 18**] after left hip
fracture.
.
1. Left Hip Fracture.
Patient was admitted with left hip fracture. His pre-op course
was complicated by respiratory distress and aspiration
pneumonia. However he underwent his left hip ORIF on [**2130-12-12**]
without complication. Pain control has been with scheduled
tylenol dosing and 2.5mg oxycodone prn for breakthrough. Further
narcotics have been avoided given patient's apneic episodes in
the setting of narcotics use. DVT prophylaxis has included
lovenox 30 SC daily to be taken for four weeks after surgery.
.
2. Respiratory Distress
Shortly after admission, patient had respiratory apnea x 2,
necessitating code blue and bag mask ventilation. During both
episodes, patient improved with bag ventilation alone and was
monitored in the MICU. Neurology was consulted and his apnea was
thought likely secondary to [**Last Name (un) **] [**Doctor Last Name 6056**] respirations that were
further depressed with narcotics use. Shortly after these apneic
episodes, patient developed a fever and was noted to have
increased crackles with a productive cough. CXR was notable for
a left sided infiltrate. He was started on ceftriaxone and
flagyl for presumed aspiration pneumonia and is to complete a
fourteen day course with PO ceftin and PO flagyl. He has
continued to improve clinically with chest PT, increased
mobility, nebulizer treatments, and antibiotics.
.
3. Sparse growth of Aspergillus
During the work-up for patient's respiratory distress, sputum
cultures were sent. Sparse growth of aspergillus was noted.
Unclear if sparse aspergillus growth represents an actual
infection or contaminant. To further evaluate aspergillus,
patient would need either a bronchoscopy/BAL and/or chest CT
with contrast. Given patient's chronic renal insufficiency,
chest CT was not recommended. Given patient's improving clinical
appearance, decision was made with patient and family to not
pursue any further invasive testing at this time, including BAL.
Would recommend continuing to follow closely. Galactomannan and
beta glucan tests are pending.
.
4. Candiduria
As part of fever work-up, urine cultur was sent and grew yeast.
Thought to be likely colonization and no further treatment was
continued.
.
5. Gout
Patient has a history of gout in both knees. Duringt his
admission, he was found to have minimal erythema and swelling.
Uric Acid was slightly elevated at 9.5 and ESR was also elevated
at 95. Rheumatology was consulted and performed a tap of his
knee which was notable for gout crystals. Joint fluid cx was
negative.
.
6. Coronary Artery Disease
Patient has a history of CAD s/p CABG in [**2115**]. He remained on
his outpatient regimen of metoprolol, imdur, and statin. Unclear
why patient is not on an ACEI. Would consider adding to his
regimen in the future.
.
7. Congestive Heart Failure
Patient has a known EF of 30-35%. His lasix was initially held
and he became slightly overloaded. His volume status improved
with restarting of his home dose of lasix. He was otherwise
maintained on his metoprolol, imdur.
.
8. Atrial Fibrillation
Patient was maintained with rate control with metoprolol 25mg
PO bid. Patient is not on anticoagulation due to a history of GI
bleed.
.
9. Peripheral Vascular Disease
Patient has a history of peripheral vascular disease with a
previous revascularization. During this admission, he was found
to have a right foot infected ulcer with exposed necrotic bone.
WOund culture was notable for polymicrobial growth. He was
evaluated by wound care and podiatry who debrided the wound and
recommend sulfasalazine and further outpatient follow-up.
.
10. Acute on CRI
Patient has chronic renal insufficiency thought likely secondary
to diabetes mellitus and hypertension. His baseline creatinine
was 2.5 and increased to 3.3 for a short time but improved
initially with IV hydration.
.
11. Diabetes Mellitus
Patient was maintained on an insulin sliding scale.
.
Code: DNR/DNI confirmed with son [**Name (NI) 3094**] [**Name (NI) 724**] [**Telephone/Fax (1) 69309**]. HCP
is daughter [**Name (NI) 1743**] [**Name (NI) **] [**Telephone/Fax (1) 69310**]
Medications on Admission:
Furosemide 100 mg PO DAILY
Multivitamins 1 CAP PO DAILY
Ferrous Sulfate
Isosorbide Mononitrate 30 mg PO DAILY
Pantoprazole 40 mg PO
Atorvastatin 10 mg PO DAILY
Insulin Sliding Scale
Mirtazapine 7.5 mg PO QHS
Acetaminophen 650 mg PO Q6H:PRN pain
Metoprolol 25 mg PO BID
Docusate Sodium 100 mg PO BID
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN congestion, sob
Bisacodyl 10 mg PR HS:PRN
Senna prn
Fleets Enema prn
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
4. Atorvastatin 10 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. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
12. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical
DAILY (Daily).
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
15. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for congestion, sob.
16. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
18. Ceftin 500 mg Tablet Sig: One (1) Tablet PO twice a day for
4 days.
19. Humalog 100 unit/mL Cartridge Sig: One (1) Subcutaneous
four times a day: Please administer insulin according to the
following sliding scale: FS 151-200 give 2 units, FS 201-250,
give 4 units, FS 251-300, give 6 units; FS 301-350, give 8 units
.
20. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours) for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Left Hip Fracture
2. Aspiration Pneumonia
3. Apnea secondary to [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations and narcotics
.
SECONDARY DIAGNOSIS:
1) CHF, last echo in [**11-12**] with EF 35% with inferoseptal and
inferoapical hypokinesis.
2) CAD s/p CABG x 4 in [**2115**]. P-MIBI in [**9-11**] without reversible
defects: Multiple fixed myocardial perfusion defects in all
three major coronary artery territories, including severe fixed
defects of the apex and inferolateral walls and moderate defects
of the distal anterior wall, the anteroseptal wall, inferoseptal
wall and inferior wall. Enlarged left ventricular cavity. Global
hypokinesis with calculated LVEF 29%.
3) Atrial fibrillation, not on anticoagulation [**3-10**] chronic GI
bleeding. s/p pacemaker placement, appears to be abandoned on
CXRs
4) PVD status post multiple amputations. History of dry gangrene
status post LLE bypass.
5) DM on insulin, complicated by nephropathy.
6) Chronic renal insufficiency, baseline creatinine appears to
be around 2.5.
7) Ischemic colitis [**11-10**], colonoscopy with polyp removal, but
limited to sigmoid because of stricture at 40cm above anus;
virtual colonoscopy was unable to be performed [**3-10**] patient not
tolerating bowel preparation.
8) Anemia (blood loss, GIB)
Discharge Condition:
Stable. Patient is tolerating oral intake, ambulating with
assistance, and is stable for discharge to rehab.
Discharge Instructions:
You were admitted to the hospital with left hip pain and were
found to have a left hip fracture. You had your left hip
fracture repair on [**2130-12-12**] without any major complications. Your
pain has been under good control with tylenol and oxycodone.
.
While you were in the hospital, you were also found to have a
likely pneumonia and have been started on two antibiotics. You
should take these antibiotics through [**2130-12-18**]. In
evaluating your shortness of breath, your cultures also grew out
very small amounts of a fungus called aspergillus. It is unclear
if this represents an actual infection or was a contaminant. To
further evaluate this, you might need more invasive studies,
which we discussed with your daughter. As we discussed with you
and your daughter, your primary care doctor is aware and will
continue to follow you closely. If you develop any worsening
shortness of breath or sputum production, please seek immediate
medical attention.
.
You were also in the intensive care unit for a short time due to
difficulty breathing. We think that your breathing became very
slow in the setting of receiving pain medication. In the future,
you and your doctors should be very careful in giving you
narcotics for pain control and you will need to be monitored
very closely.
.
Please continue to take your medications as prescribed.
.
If you develop any new symptoms of fevers, chills, difficulty
breathing, worsening cough, shortness of breath, abdominal pain,
or leg swelling, please seek immediate medical attention.
Followup Instructions:
Please continue to follow-up with your primary care doctor Dr.
[**First Name8 (NamePattern2) 6923**] [**Name (STitle) 6924**] while you are at rehab. Her phone number is
[**Telephone/Fax (1) 608**].
.
Please also follow-up with your orthopedic surgeon Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**2131-1-4**]. You have an Xray of your hip scheduled for
8:20am and and your appointment with Dr. [**Last Name (STitle) **] at 8:40am. If
you need to reschedule, please call his office at [**Telephone/Fax (1) 1228**].
.
Please also follow-up with podiatry. We have scheduled an
appointment for you with podiatry on [**2131-1-26**] 2:30. If you need
to reschedule, please call their office at [**Telephone/Fax (1) 543**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 11352**]
|
[
"E888.9",
"820.21",
"799.1",
"584.9",
"427.31",
"280.0",
"585.9",
"933.1",
"440.23",
"428.0",
"507.0",
"V45.01",
"V12.79",
"V45.81",
"V17.3",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
10932, 11002
|
4104, 8479
|
258, 275
|
12363, 12474
|
2164, 4081
|
14060, 14921
|
1610, 1654
|
8941, 10909
|
11023, 11023
|
8505, 8918
|
12498, 14037
|
1669, 2145
|
192, 220
|
304, 948
|
11209, 12342
|
11042, 11188
|
970, 1452
|
1468, 1594
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,233
| 144,344
|
35482
|
Discharge summary
|
report
|
Admission Date: [**2194-8-25**] Discharge Date: [**2194-9-3**]
Date of Birth: [**2148-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2194-8-26**] cardiac catheterization
[**2194-8-29**] 1. Coronary bypass grafting x4: Left internal mammary
artery to left anterior descending coronary; reverse
saphenous vein single graft from aorta to first diagonal
coronary artery; reverse saphenous vein single graft
from aorta to the first obtuse marginal coronary artery;
reverse saphenous vein single graft from aorta to
posterior descending coronary artery.
2. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
On [**8-25**] this 46 year old male, who has no significant past
medical history, remote tobacco history,and hasn't been seen by
[**Name8 (MD) **] MD in >10 years presented to
[**Hospital1 18**] ED complaining of CP. He awoke with sudden, sharp chest,
lateral neck, and back pain. Denies sob/nausea or diaphoresis.
Admitted to Cardiology for further workup.
Past Medical History:
denies
Social History:
Pt works as VP of a management company.
Tobacco history: 15 pack year history, quit in [**2183**]
ETOH: 6 drinks about once a month
Illicit drugs: none
Family History:
Maternal grandfather with MI in his 60s. Older brother with CAD.
Physical Exam:
Pulse: 70 Resp: O2 sat:
B/P
Height: 70" Weight:237LB
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [], well-perfused [] Edema Varicosities: None
[]cool extremities/cyanotic nail beds (B) post cath. Doppler
pulses (B)DP/PT palp (B)
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: Left:
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit None Right:2+ Left:2+
Pertinent Results:
[**2194-8-31**] 06:24AM BLOOD WBC-9.4 RBC-4.02* Hgb-11.6* Hct-33.8*
MCV-84 MCH-28.8 MCHC-34.4 RDW-13.7 Plt Ct-225
[**2194-8-31**] 06:24AM BLOOD Glucose-102* UreaN-11 Creat-1.0 Na-137
K-3.9 Cl-104 HCO3-28 AnGap-9
Intra-op TEE [**2194-8-29**]
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular 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.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation.
There is no mitral valve prolapse. No mitral regurgitation is
seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**Known firstname 1158**]
[**Known lastname **] before surgical icnsion.
Post Bypass:
Preserved biventricular sysotlic function.
LVEF 55%.
Intact thoracic aorta.
Trivial MR..
[**2194-9-3**] 04:55AM BLOOD WBC-6.4 RBC-3.78* Hgb-10.9* Hct-31.1*
MCV-82 MCH-28.9 MCHC-35.0 RDW-13.9 Plt Ct-319
[**2194-8-25**] 11:45AM BLOOD WBC-8.2 RBC-5.47 Hgb-15.6 Hct-45.5 MCV-83
MCH-28.6 MCHC-34.4 RDW-14.0 Plt Ct-299
[**2194-8-25**] 11:45AM BLOOD Neuts-74.8* Lymphs-19.6 Monos-3.7 Eos-1.0
Baso-1.0
[**2194-9-3**] 04:55AM BLOOD Plt Ct-319
[**2194-8-25**] 11:45AM BLOOD Plt Ct-299
[**2194-8-25**] 11:45AM BLOOD PT-12.0 PTT-22.0 INR(PT)-1.0
[**2194-9-3**] 04:55AM BLOOD Glucose-104* UreaN-15 Creat-1.1 Na-140
K-4.0 Cl-104 HCO3-29 AnGap-11
[**2194-8-29**] 07:49AM BLOOD Glucose-106* UreaN-16 Creat-1.1 Na-140
K-4.1 Cl-102 HCO3-30 AnGap-12
[**2194-8-25**] 11:45AM BLOOD Glucose-127* UreaN-15 Creat-1.0 Na-138
K-4.0 Cl-104 HCO3-25 AnGap-13
[**2194-8-26**] 05:45PM BLOOD ALT-73* AST-35 CK(CPK)-77 AlkPhos-69
Amylase-44 TotBili-1.0 DirBili-0.2 IndBili-0.8
[**2194-8-26**] 08:05AM BLOOD CK-MB-4 cTropnT-0.08*
[**2194-9-3**] 04:55AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.2
[**2194-8-26**] 05:45PM BLOOD %HbA1c-5.8 eAG-120
[**2194-8-26**] 08:05AM BLOOD Triglyc-187* HDL-36 CHOL/HD-6.8
LDLcalc-171*
INDICATION: 46-year-old man status post CABG postop day 3,
please evaluate
for effusion.
TECHNIQUE: Chest PA and lateral radiograph obtained.
COMPARISON: Comparison is made to portable chest radiograph
obtained
[**2194-8-31**].
FINDINGS: Stable right internal jugular venous catheter with tip
in the lower
SVC. Stable low lung volumes. Unchanged bibasilar and
retrocardiac
atelectasis. Slight decrease in small left pleural effusion.
Sternotomy
sutures are midline and intact. Surgical clips are seen
projecting over the
heart. No pneumothorax.
IMPRESSION:
Unchanged bibasilar atelectasis. Slight decrease in small left
pleural
effusion.
Brief Hospital Course:
Presented to the emergency department and was admitted with non
ST elevation myocardial infarction. On [**2194-8-26**] he underwent
cardiac catheterization that revealed coronaruy artery diseae
and was referred for surgical evaluation. He underwent
preoperative workup and on [**2194-8-29**] was brought to the operating
room and underwent coronary artery bypass graft surgery. See
operative report for futher details. Vancomycin was used for
surgical antibiotic prophylaxis, given the pre-operative stay of
greater than 24 hours. In was brought to the intensive care
unit postoperatively for management. In the first twenty four
hours he was weaned from sedation, awoke neurologically intact
and was extubated without complications. On postoperative day
one he was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. He
had small amout of erythema and was started on antibiotics with
improvement and was afebrile and normal WBC. It continued to
improve and he was switched to oral antibiotics and discharged
home with services on post operative day five with follow up
wound check [**9-9**] in clinic. He was unable to be started on ace
inhibitor due to hypotension and should be consider in follow
clinic visits.
Medications on Admission:
occasional Prilosec
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Pepcid 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): 75 mg three times a day .
Disp:*135 Tablet(s)* Refills:*0*
12. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 10 days: for wound erythema .
Disp:*40 Capsule(s)* Refills:*0*
13. ACE inhibitor
Unable to start ace inhibitor due to hypotension - consider
starting as outpatient
14. Outpatient Lab Work
Labs in 1 month - LFT due to starting statin - please discuss
with Dr [**Last Name (STitle) 31888**] at office visit at [**Hospital1 **] heart center
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
Non ST elevation myocardial infarction
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with dilaudid, motrin and tylenol
Sternal Incision - healing well, drainage, mild erythema distal
incision
Left leg EVH - ecchymosis thigh, no drainage no erythema
Edema 1+ bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound check Dr [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] - [**2194-9-9**] 1:00 pm
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] - [**2194-9-23**] 1:00 pm
Cardiologist Dr. [**Last Name (STitle) 31888**] [**Telephone/Fax (1) 6256**] heart center of [**Hospital1 **] -
[**2194-9-19**] at 9:30 am
**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:[**2194-9-3**]
|
[
"V70.7",
"272.4",
"278.00",
"410.71",
"414.01",
"458.29",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.13",
"88.53",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8431, 8494
|
5187, 6591
|
329, 827
|
8610, 8873
|
2187, 5164
|
9661, 10235
|
1429, 1496
|
6661, 8408
|
8515, 8589
|
6617, 6638
|
8897, 9638
|
1511, 2168
|
279, 291
|
855, 1214
|
1236, 1244
|
1260, 1413
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,521
| 157,194
|
21598+57250
|
Discharge summary
|
report+addendum
|
Admission Date: [**2124-9-12**] Discharge Date: [**2124-9-26**]
Date of Birth: [**2042-4-3**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Fever of unknown origin, pancytopenia, acute hypoxemic
respiratory failure, myelodysplasia
Major Surgical or Invasive Procedure:
BAL
placement of PICC
elective intubation
History of Present Illness:
[**Location 56870**] ATTENDING ADMISSION NOTE
Date: [**2124-9-20**]
Time: 22:45
The patient is an 82-year-old Spanish-speaking female with hx of
ulcerative colitis in remission s/p colectomy who was
transferred from OSH for hypoxemic respiratory failure in the
setting of a new diagnosis of myelodysplasia and pancytopenia.
The history was collected with assistance from daughter (HCP)
who lives with the patient. Per daughter, patient was in her
usual state of health until early [**Month (only) **] when she had back
pain after making her bed. An x-ray of her back was taken and
she was told she had a "pinched nerve" for which she was treated
with one week of a prednisone taper and vicodin with good
improvement. Subsequently, on the week of [**2124-8-21**], she began
to complain of abdominal pain and general malaise. The following
week, on [**2124-8-28**], she had a fever at home as well as rash on
her arms and legs, which was raised and painful to touch. She
was seen by her PCP Dr [**Last Name (STitle) **] on [**2124-8-30**]; CXR and blood tests
were performed. Per her daughter, she was feeling extremely weak
and had poor po intake during these days. Based on the results
of the blood tests, she was referred to oncology. She was seen
by Dr [**Last Name (STitle) 56871**] on [**2124-9-1**] for her pancytopenia and admitted
directly to the hospital as she appeared tachypneic and unwell.
During her hospital admission, bone marrow biopsy was performed
that showed 18% blasts concerning for high grade myelodysplastic
syndrome as well as granulomas concerning for fungal infections.
Heme/onc was consulted who felt that initiating treatment for
myelodysplasia was not warranted. ID was also consulted as she
had persistent fevers to 102-103, ANC ranged 1000-1400. She was
transferred to the ICU for hypotension with intermittent fluid
boluses to maintain BPs. ID was concerned for strep pharyngitis
and recommended ceftriaxone (discouraged vanc/cefepime as these
could worsen pancytopenia). Infectious work-up included TTE, CT
abdomen/pelvis, BCxs and stool studies that were unremarkable.
Urine was weakly positive for histoplasmosis. She was given a
dose of amphotericin that caused rigors and tachycardia. She was
then placed on trial of IV solumedrol 80mg TID and fevers
defervesced. On day of transfer to [**Hospital1 18**], she had worsening
hypoxemia with increasing FiO2 requirement. CXR showed diffuse
bilateral pulmonary infiltrate, predominantely perihilar in
distribution, and b/l pleural effusions. ID had recommended that
steroids be discontinued on transfer and amphotericin resumed
(150mg daily). She was also given a dose of lasix for volume
overload prior to transfer.
On the floor, she reports that she is comfortable. She reports
that her breathing has improved. She denies pain anywhere,
including abdominal pain. She reports her diarrhea has resolved
with immodium. + dry mouth, but was able to tollerate po in the
ICU.
Review of Systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
visual changes, headache, dizziness, sinus tenderness, neck
stiffness, rhinorrhea, congestion, sore throat or dysphagia.
Denies chest pain, palpitations, orthopnea, dyspnea on exertion.
Denies shortness of breath, cough or wheezes. Denies nausea,
vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or
abdominal pain. No dysuria, urinary frequency. Denies
arthralgias or myalgias. Denies rashes. No increasing lower
extremity swelling. No numbness/tingling or muscle weakness in
extremities. No feelings of depression or anxiety. All other
review of systems negative.
Past Medical History:
Ulcerative colitis s/p total colectomy with ileoanal anastomosis
Recurrent small bowel obstructions s/p adhesiolysis [**2121**], [**12/2123**]
GERD
Hyperlipidemia
Osteoporosis
Social History:
Originally from [**Country 13622**] Republic; has been living in US for
27years. Has 3 daughters. Lives with oldest daughter [**Name (NI) **].
- [**Name2 (NI) 1139**]: Hx of social smoking. Quit in the [**2092**]
- Alcohol: Social EtOH, glass of wine occasionally.
- Illicits: None
Family History:
Mother: MI (60s)
Brother: CV disease
Brother: emphysema
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 Ax, 129/66 110 22 96%2L; pain 0/10
GEN: No apparent distress
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-tender, non-distended; no guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**4-6**] motor function globally
DERM: dark circular plaques over upper and lower extremities
b/l, no longer raised or painful
DISCHARGE PHYSICAL EXAM:
VS:
GEN:
HEENT:
CV:
PULM:
EXT:
NEURO:
SKIN:
Pertinent Results:
On admission to OSH:
WBC 1.9, Hgb 10.2, Hct 32, MCV 77, Plts 80K. Polys 50%, bands
40%, lymphs 8%, monos 2%, ESR 105, Alk Phos 237
Prior to transfer:
WBC 1.8, Hgb 9.6, Hct 29, Plts 71K, Alk Phos 254
ABG [**2124-9-9**] pH 7.49, bicarb 19.6, PCO2 26, PO2 56, Oxygen sat
89%5L
On admission:
[**2124-9-12**] 10:55PM GLUCOSE-141* UREA N-33* CREAT-0.9 SODIUM-143
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13
[**2124-9-12**] 10:55PM ALT(SGPT)-29 AST(SGOT)-36 LD(LDH)-307* ALK
PHOS-237* TOT BILI-0.7
[**2124-9-12**] 10:55PM ALBUMIN-2.6* CALCIUM-8.1* PHOSPHATE-3.3
MAGNESIUM-2.4 IRON-74
[**2124-9-12**] 10:55PM calTIBC-202* HAPTOGLOB-300* FERRITIN-1283*
TRF-155*
[**2124-9-12**] 10:55PM WBC-2.2* RBC-3.80* HGB-10.0* HCT-30.5*
MCV-80* MCH-26.3* MCHC-32.8 RDW-21.7*
[**2124-9-12**] 10:55PM NEUTS-79* BANDS-2 LYMPHS-10* MONOS-2 EOS-1
BASOS-0 ATYPS-1* METAS-2* MYELOS-2* NUC RBCS-2* PLASMA-1*
[**2124-9-12**] 10:55PM PT-14.0* PTT-22.8 INR(PT)-1.2*
[**2124-9-12**] 10:55PM FIBRINOGE-305
Pertinent Labs:
[**2124-9-13**] 05:35AM BLOOD WBC-1.9* RBC-3.65* Hgb-9.7* Hct-30.3*
MCV-83 MCH-26.6* MCHC-32.1 RDW-21.2* Plt Ct-38*
[**2124-9-14**] 04:34AM BLOOD WBC-3.0* RBC-4.26 Hgb-11.6* Hct-34.9*
MCV-82 MCH-27.1 MCHC-33.1 RDW-20.8* Plt Ct-41*
[**2124-9-16**] 04:37AM BLOOD WBC-3.1* RBC-3.29* Hgb-8.8* Hct-26.7*
MCV-81* MCH-26.7* MCHC-32.9 RDW-20.6* Plt Ct-24*
[**2124-9-14**] 04:34AM BLOOD PT-12.8 PTT-20.3* INR(PT)-1.1
[**2124-9-16**] 04:37AM BLOOD PT-13.6* PTT-26.1 INR(PT)-1.2*
[**2124-9-13**] 11:21AM BLOOD FDP-80-160*
[**2124-9-15**] 04:57AM BLOOD FDP-40-80*
[**2124-9-16**] 04:37AM BLOOD FDP-80-160*
[**2124-9-13**] 05:35AM BLOOD Gran Ct-1653*
[**2124-9-13**] 05:35AM BLOOD Glucose-131* UreaN-36* Creat-0.7 Na-140
K-3.9 Cl-107 HCO3-24 AnGap-13
[**2124-9-14**] 04:34AM BLOOD Glucose-153* UreaN-36* Creat-0.8 Na-140
K-3.9 Cl-104 HCO3-23 AnGap-17
[**2124-9-16**] 04:37AM BLOOD Glucose-98 UreaN-28* Creat-0.6 Na-140
K-2.6* Cl-108 HCO3-25 AnGap-10
[**2124-9-17**] 12:35AM BLOOD Na-136 K-3.2* Cl-106
[**2124-9-12**] 10:55PM BLOOD ALT-29 AST-36 LD(LDH)-307* AlkPhos-237*
TotBili-0.7
[**2124-9-14**] 04:34AM BLOOD Albumin-3.0* Calcium-8.0* Phos-3.4 Mg-2.2
[**2124-9-13**] 05:35AM BLOOD TSH-0.41
[**2124-9-14**] 04:34AM BLOOD ANCA-NEGATIVE B
[**2124-9-14**] 04:34AM BLOOD dsDNA-NEGATIVE
[**2124-9-14**] 04:34AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-PND
[**2124-9-16**] 07:23AM BLOOD Vanco-6.4*
BGlucan 62
Galactomannan 0.1
Urine
[**2124-9-14**] 08:34PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2124-9-14**] 08:34PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2124-9-14**] 08:34PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
TransE-<1
[**2124-9-12**] 11:21PM URINE CastHy-57*
studies:
Histoplasmosa antibody neg
Anti GBM neg
Anti Histone neg
Histoplasma urine antigen neg
BAL Cell differential
[**2124-9-13**] 05:24PM OTHER BODY FLUID Polys-13* Lymphs-14* Monos-0
Eos-2* Macro-71*
IMAGES:
Echo [**2124-9-19**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
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. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CXR [**2124-9-22**]
IMPRESSION: AP chest compared to [**9-13**] through 18:
Radiographically, there has been no change since [**9-18**] in
large areas of perihilar consolidation, left greater than right.
In the interim, moderate bilateral pleural effusions have
decreased. Heart size is exaggerated by large hiatus hernia.
Much of the perihilar consolidation is probably pulmonary edema
given the
waxing and [**Doctor Last Name 688**] in the severity of at least the left upper
lobe component
between [**9-14**] and [**9-17**].
Right PICC line ends in the SVC. No pneumothorax.
[**2124-9-16**] Radiology CT TORSO W/CONTRAST
1. Slight decrease in diffuse alveolar ground-glass opacities
with a
perihilar and lower lung predominance, likely secondary to
either infection,
drug reaction, or pulmonary edema.
2. Moderate bilateral pleural effusions, right greater than
left, not
significantly changed in size compared to prior CT from [**9-13**], [**2123**].
3. Fluid within the endometrial cavity without other definite
uterine
abnormalities. Followup of the uterus and endometrium should be
performed
with short-term ultrasound on a non-emergent basis.
[**2124-9-15**] Radiology UNILAT UP EXT VEINS US
Nonocclusive thrombus in the left brachial vein containing the
peripheral
catheter. Images were obtained ~5 inches proximal to the
antecubital fossa
[**2124-9-15**] Radiology CHEST (PORTABLE AP)
Cardiomegaly is stable. Increase opacities in the lower lobes
bilaterally
greater on the right are a combination of atelectasis and large
pleural
effusions; part of the change is due to difference in position
of the patient.
Cardiomegaly is stable. Otherwise, perihilar opacities are
unchanged. There
is no evidence of pneumothorax. ET tube is no longer present.
[**2124-9-14**] Radiology CHEST (PORTABLE AP)
1. New endotracheal tube terminating 2.5 cm above the carina.
2. Bilateral pulmonary edema is essentially unchanged. Lateral
portion of
the left hemithorax is excluded from the film.
[**2124-9-14**] Pathology Tissue: Slides referred for [**2124-9-14**]
Skin, left thigh, punch biopsy (consult from [**Hospital **] Hospital
S-[**Numeric Identifier 14526**]-11, [**2124-9-5**], 1 H&E, 1 AFB, 1 GMS, 4 immunostains with
neg controls):
Mild superficial to mid-dermal perivascular lymphocytic
inflammation with focal mixed cell inflammation in the
superficial subcutis.
Note: An underlying panniculitis is possible, however, the
limited sampling of the subcutis precludes further
classification of the inflammation within the panniculus. GMS
and AFB stains are negative. C-kit stains a few mast cells and
CD34 stains vessels. No leukemic infiltrate is identified.
[**2124-9-13**] Radiology CT CHEST W/O CONTRAST
1. Predominantly central perihilar opacities, in the setting of
bilateral
pleural effusions and mildly enlarged heart, these findings are
most
suggestive of pulmonary edema. No definite findings to suggest
infection.
2. Moderate-to-large hiatal hernia.
3. Tip of the central catheter is at the junction of the
brachiocephalic vein and the superior vena cava.
[**2124-9-13**] Radiology CHEST (PORTABLE AP)
Patient is not intubated, heart is mildly to moderately enlarged
and small
bilateral pleural effusions are present. The very symmetric
perihilar
pulmonary consolidation in both lungs could therefore be
pulmonary edema
rather than pneumonia. Prior chest radiograph should be obtained
to make a
more knowledgeable assessment
[**2124-9-13**] Cardiology ECG [**2124-9-14**] [**Last Name (LF) 2437**],[**First Name3 (LF) **]
Normal sinus rhythm. Right bundle-branch block. No previous
tracing available for comparison.
OSH STUDIES:
Bone marrow flow cytometery: bone marrow shows 18% blasts,
blasts expressing CD34, CD 117, and various myeloid antigens
Pathology report shows hypercellular bone marrow for age wtih
trilineage dysopoiesis, increased blasts and granulomatous
inflammation
Fungal cultures from bone marrow: no yeast or fungus
AFB bone marrow: AFB stain showed no acid fast bacillus
Skin punch biopsy [**2124-9-6**] shows superficial and deep dermal
perivascular inflammation extending into the superficial subcut
Skin biopsy: no growth seen, no neutrophils, no organisms
CT abdomen/Pelvis [**2124-9-1**]
No acute inflammatory process, normal small bowel within right
lower quadrant. No evidence of closed loop bowel or inflammation
Chest CT scan [**2124-9-6**]:
bilateral central perihilar patchy ground glass infiltrates and
small bilateral pleural effusions.
.
TTE [**2124-9-9**]:
The left ventricle is normal in size. There is normal left
ventricular wall thickness. Left ventricular systolic function
is normal. Ejection fraction 55-60%. There is mild mitral
annular calcification. The mitral valve leaflets appear
thickened, but open well. Mild to moderate mitral regurgitation.
Mild tricuspid regurgitation. Mild aortic regurgitation. No
definitive valvular vegetation could be identified on this
study. If there is future concern regarding possible
endocarditis, consider TEE.
EKG [**2124-9-1**]:
Sinus rhythm. Incomplete RBBB.
MICROBIOLOGY
[**2124-9-19**] Bcx: Pending x 2
[**2124-9-19**] Bcx: NO GROWTH
[**2124-9-19**] Ucx: NO GROWTH
[**2124-9-17**] 12:22 pm BONE MARROW PRECAUTION FOR
HISTIPLASMOSIS.
FLUID CULTURE (Preliminary): NO GROWTH.
BRUCELLA CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2124-9-16**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG
AB-Postive; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-Positive;
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB-NegativeINPATIENT
[**2124-9-16**] Blood (CMV AB) CMV IgG ANTIBODY-Positive;
CMV IgM ANTIBODY-Negative INPATIENT
[**2124-9-16**] SEROLOGY/BLOOD VARICELLA-ZOSTER IgG
SEROLOGY-POSITIVE INPATIENT
[**2124-9-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative FINAL INPATIENT
[**2124-9-15**] STOOL OVA + PARASITES-negative INPATIENT
[**2124-9-15**] SPUTUM ACID FAST SMEAR-PRELIMINARY; ACID
FAST CULTURE-negative INPATIENT
[**2124-9-15**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2124-9-14**] BLOOD CULTURE Blood Culture, Routine-NO
GROWTH. INPATIENT
[**2124-9-14**] URINE URINE CULTURE-NO GROWTH. FINAL
INPATIENT
[**2124-9-14**] STOOL OVA + PARASITES-negative FINAL
INPATIENT
[**2124-9-14**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-
negative INPATIENT
[**2124-9-14**] Resp BAL cx: NEGATIVE for Pneumocystis jirovecii
[**2124-9-13**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL; Immunoflourescent test for
Pneumocystis jirovecii (carinii)-FINAL; FUNGAL
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY INPATIENT
[**2124-9-13**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture- NO GROWTH, <1000 CFU/ml; Respiratory
Viral Antigen Screen-FINAL INPATIENT
[**2124-9-13**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL; POTASSIUM HYDROXIDE
PREPARATION-FINAL; Immunoflourescent test for Pneumocystis
jirovecii (carinii)-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT
[**2124-9-13**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-negative
INPATIENT
[**2124-9-13**] BLOOD CULTURE Blood Culture,
Routine-negative INPATIENT
[**2124-9-13**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-negative FINAL; OVA + PARASITES-FINAL negative; FECAL
CULTURE - R/O VIBRIO-FINAL negative; FECAL CULTURE - R/O
YERSINIA-FINAL negative; FECAL CULTURE - R/O E.COLI
0157:H7-FINAL negative; MICROSPORIDIA STAIN-FINAL negative;
CYCLOSPORA STAIN-FINAL negative; Cryptosporidium/Giardia
(DFA)-FINAL negative; CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT:
Feces negative for C.difficile toxin A & B by EIA.
[**2124-9-13**] SEROLOGY/BLOOD CRYPTOCOCCAL
ANTIGEN-CRYPTOCOCCAL ANTIGEN NOT DETECTED. FINAL INPATIENT
[**2124-9-12**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2124-9-12**] BLOOD CULTURE Blood Culture, Routine-NO
GROWTH.
INPATIENT
[**2124-9-12**] MRSA screen: No MRSA isolated.
[**2124-9-12**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.}
INPATIENT
Brief Hospital Course:
82-year-old Spanish-speaking female with hx of ulcerative
colitis in remission s/p colectomy being transferred from OSH
for hypoxemic respiratory failure in setting of new diagnosis of
myelodysplasia and pancytopenia.
# Hypoxemic respiratory distress: Stable. She was transferred
from OSH with worsening respiratory distress satting mid 90's on
NRB. CXR showed diffuse b/l pulmonary infiltrates and small
pleural effusions. She was treated empirically for HCAP with
vancomycin, cefepime, and azithromycin. Also continued on
ambisome per ID recs due to reports of positive histoplasmosis
antigen from OSH. She was diuresed with IV lasix approximately
4L prior to transfer to the floor. She was electively intubated
for bronchoscopy on [**9-13**], and was successfull extubated the
following day. As below, the BAL returned bloody fluid. On
[**9-18**], the again began to experience respiratory distress
associated with borderline BP and a 10 point decrease in her
hematocrit. She was again transferred to the ICU for further
monitoring. Her blood pressures remained fluid responsive to
both IVF and PRBCs (1 unit). It was felt that the etiology of
her hypoxia and hypotension was possible due to additional
alveolar hemorrhage. Her respiratory status and blood pressures
improved during her ICU stay and were stable prior to transfer
back to the general medical floor. On the floor, she continued
to do better. On one occasion on the night of [**9-22**], the patient
spiked a fever after 48 hours of afebrile condition. A chest
x-ray showed possible LUL pneumonia, which was treated
emperically with vanco/zosyn. On day of discharge, the patient's
respiratory status was stable, requiring supplemental oxygen
after exertion.
# Fever: She had persistent fevers at OSH despite being on
ceftriaxone and then amphotericin/itraconazole. Work up at OSH
included CT abdomen, CT chest, TTE, BCx, and stool studies which
were been unremarkable. Urine was weakly positive for
histoplasma antigen at OSH, and she was started on amphotericin.
Urine culture on admission grew 10-100K VSE and BAL returned
bloody fluid. Otherwise blood, urine, and BAL cultures were
unremarkable, including repeat urine culture. She continued to
spike fevers, and CT a/p showed no source of infection, although
did mention fluid in the endometrial cavity. She was ruled out
x3 for TB. Histoplasma and autoimmune serologies are negative.
After transfer to the floor, patient was afebrile for 48 hours.
Spiked spontaneously on one evening, and initially the chest
x-ray was concerning for LUL pneumonia, and the patient was
started on vancomycin/zosyn for treatment of ventilator acquired
PNA. In the interim, the patinet's urine culture grew out VRE,
only susceptible to linezolid. The patient was discharged on the
remainder of a 3 day course of levaquin and voriconazole which
she was to continue until final results of the histo PCR were
complete.
# Pancytopenia: Bone marrow biopsy from OSH reportedly showed
18% blasts with myelodysplasia concerning for new diagnosis of
AML. Also with reported granulomas. Heme/onc was consulted who
reviewed outside smear, and recommended repeating smear with
cultures performed. Platelets continually dropped during stay in
MICU and patient received 1 unit of platelets. Patient also
received a unit of RBCs while on the floor and also while in the
unit (2 units total). Repeat bone marrow biopsy was consistent
with MDS as opposed to AML. The patient's white blood cell count
continued to drop through the admission, and she did become
neutropenic; her neutropenia was attributed to her underlying
MDS. The patient will need follow-up on an outpatient basis for
monitoring, transufions of blood products as well as for
treatment of underlying MDS. Transfusions goals are 1 unit for a
hematocrit of less than 24 or platelets less than 30.
# Rash: Initial presentation concerning for erythema nodosum.
Per OSH records, biopsy was sent to [**Last Name (un) **] Life Sciences for
outside consultation. Biopsy slides were arranged to be sent to
our pathology department. Pathology report also consistent with
erythema nodosum.
# Diarrhea: She has chronic diarrhea, and arrived from OSH with
flexiseal in place. C. Diff and stool cutlures were negative.
She was treated symptomatcially with loperamide with good
effect. During this hospitalization, C. diff antigen x 2 and PCR
were all negative. Flexiseal was discontinued during the
admission. Continue home loperamide as needed for diarrhea upon
discharge from the hospital.
# Left UE DVT: Left arm noted to be swollen during [**Hospital Unit Name 153**] stay.
UENI showed clot in left arm associated with PICC line. Line was
pulled, and there was resolution of the erythema associated with
the left upper extremity DVT. The patient was not started on
anticoagulation given her thrombocytopenia.
TRANSITIONAL ISSUES:
1. Continue on Voriconazole as ordered until we receive final
results of the histoplasmosis PCR, which we expect will be by
Wednesday, [**9-27**]. If the results are negative we will
stop the voriconazole. If the results are positive we will
continue the voriconazole and schedule her for a follow up
appointment with the infectious disease clinic at [**Hospital1 **].
2. Continue the levofloxacin for one more day, to end on
Wednesday, [**9-27**].
3. Follow up appointment with Dr. [**Last Name (STitle) 3759**] for further evaluation
and management of her myelodysplastic syndrome.
4. Check chem 10 and CBC on Friday [**9-29**] and follow up as needed
including electrolyte repletions and blood and platelet
transfusions if needed (for a hematocrit < 25 or platelets <
30).
Medications on Admission:
Simvastatin 20mg daily
Alendronate 70mg weekly
Os-Cal 2 tablets daily
Folic acid 400mg daily
B12 500mg daily
Vitamin D 800 IU daily
Loperamide 2mg daily prn
Temazepam 15mg qhs prn
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day) as needed for diarrhea.
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
7. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
8. Other
Home oxygen
9. alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
10. voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a
day: Continue to take until directed to stop by your physician.
11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Discharge Disposition:
Extended Care
Facility:
The [**Hospital **] Rehab
Discharge Diagnosis:
Histoplasmosis (pending confirmation)
MDS
pulmonary alveolar hemorrhage
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 56872**],
It was a pleasure taking care of your during your
hospitalization at [**Hospital1 18**]. You presented to us with shortness of
breath and fevers. While with us, we determined that you likely
suffered the fevers from an infection infection. Your shortness
of breath was attributed to bleeding in your lungs, which
stopped during your hospital [**Last Name (un) 10128**]. We also determined that you
likely have myelodysplastic syndrome, which will require further
workup and treatment as an outpatient.
The following changes were made to your medication:
ADDED:
- Combivent inhaler 1-2 puffs as needed for shortness of
breath/wheezing every 4 to 6 hours
- Levaquin which you should take for 3 days
- Voriconazole, which you should continue until we have final
results of your test for histoplasmosis. We expect to have these
results within the next week.
You had a skin biopsy while you were here. You need to have your
sutures removed two weeks after the biopsy which was [**9-18**], so
the sutures should be removed on or around [**10-1**]. One of your
physicians at the facility you are going to can remove them.
Until then the dressing on the wound from your biopsy should be
changed daily and the wound treated with vaseline.
Followup Instructions:
Department: HEMATOLOGY/BMT
When: TUESDAY [**2124-10-3**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2124-10-3**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Name: [**Known lastname 10609**],[**Known firstname 10610**] Unit No: [**Numeric Identifier 10611**]
Admission Date: [**2124-9-12**] Discharge Date: [**2124-9-26**]
Date of Birth: [**2042-4-3**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7042**]
Addendum:
UW Micro Labs called this evening ([**10-5**]) and all results of the
cultures/PCRs are now finalized negative. Told Ms. [**Known lastname 10612**]
daughter she can stop the voriconazole. She is also following up
with Dr. [**Last Name (STitle) 25**] from ID tomorrow.
Discharge Disposition:
Extended Care
Facility:
The [**Hospital **] Rehab
[**Name6 (MD) 2292**] [**Name8 (MD) **] MD, [**MD Number(3) 7043**]
Completed by:[**2124-10-5**]
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|
5378, 5423
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,210
| 158,605
|
21211
|
Discharge summary
|
report
|
Admission Date: [**2104-7-27**] Discharge Date: [**2104-8-1**]
Date of Birth: [**2046-2-9**] Sex: M
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Unrestrained driver ejected from rollover MVA
Major Surgical or Invasive Procedure:
Closed Reduction, external fixation of pelvic fracture [**2104-7-28**]
History of Present Illness:
55 year old Vietnamese only speaking male was the unrestrained
driver in a MVA. Patient was ejected from rollover MVA. Patient
may have had LOC at the scene. Patient was stable during
[**Location (un) **], but patient's systolic blood pressure fell to 70s in
Emergency Department. Patient was given fluid resuscitation and
when the pelvis was sheeted, the blood pressure improved.
Patient was taken to the Operating room on [**7-28**] for a closed
reduction and external fixation of the Pelvic fracture.
Past Medical History:
unremarkable
Social History:
Stopped smoking cigarettes 2 years ago
Alcohol on weekends
Lives at home with Wife [**Name (NI) **] [**Name (NI) **] and their four children
Family History:
Non-contributory
Physical Exam:
General: Well appearing male in NAD
Neuro: Alert, orientied to person place and time.
HEENT: Pupils equal round and reactive to light. Oropharynx
clear. No cervical Lymphadenopathy
Cardiac: regular rate and rhythm, no murmurs rubs or gallops
Lungs: clear to auscultation bilaterally
Abdomen: Soft, nontender and non distended. 1cm wound covered
by steri-strip at previous diagnostic peritoneal lavage site.
Extremities: No clubbing, cyanosis or edema. Bilateral
external fixators in place. Pin sites clean, dry and intact
without erythema or discharge
Skeletal: Full and symmetric strength bilaterally distally with
symmetric sensation bilaterally.
Pertinent Results:
[**2104-7-27**]- PELVIS, TWO VIEWS, [**7-27**]: There is marked diastasis
of the symphysis pubis and slight diastasis of the right
sacroiliac joint. No definite fractures.
[**2104-7-27**]-RIGHT SHOULDER: There is a fracture of the scapula that
extends into the
glenoid. No dislocation and the acromioclavicular and
glenohumeral joints are
intact.
[**2104-7-27**]-CT Chest/Abdomen/Pelvis: Multiple fractures of the right
scapula, ribs and transverse processes of the lumbar vertebrae.
Additionally diastasis of the right SI joint and pubic symphysis
also noted with small amount of surrounding hemorrhage.
No intraabdominal visceral injury identified. The thoracic
vertebrae are
normally aligned and there is no evidence of vertebral fracture
or
dislocation. There is a fracture of the right sixth rib and the
left twelfth
rib. There are fractures of the left L1, L2, L3, and L4
transverse processes.
The vertebrae are normally aligned, without evidence of
spondylylisthesis.
There is slight increased sclerosis along the anterior superior
endplate of
L3, which is likely chronic in nature. There is no loss of
vertebral body
height. Widening of the right SI joint is present.
[**2104-7-27**]-CT head: No mass effect or hemorrhage.
[**2104-7-27**]-LUMBAR SPINE CT: There is a fracture of the left
twelfth rib. There are left transverse fractures of L1, L2, L3,
and L4. The fractured processes are
minimally displaced. Degenerative changes with anterior
osteophyte formation
are present at L1-2, L2-3, and L3-4. There is superior
end-plate sclerosis at
L3. There is no loss of vertebral body height and no loss of
disc herniation.
The vertebral body heights are preserved. There is no
spondylolisthesis.
The posterior facets are normally aligned. There is a
non-displaced fracture through the left iliac bone, immediately
adjacent to the left sacroiliac joint. There is widening of the
right sacroiliac joint. Soft-tissue stranding and fluid are
present within the subcutaneous tissues of the back and upper
pelvis.
[**2104-7-28**]-CT Pelvis and Abdomen: New 7 x 9.7cm pelvic
extraperitoneal hematoma. No evidence of active extravasation.
Mass effect from the hematoma displacing the bladder leftward.
Brief Hospital Course:
When patient arrived in the Emergency department, he became
hypotensive while the pelvis was examined and was given 2 units
of packed red blood cells and Lactated ringers. The pelvis was
sheeted at that time and the blood pressure elevated. Injuries
include a pelvic fracture, multiple rib fractures, Left
transverse process fractures of L2, L3, L4, a right scapular
fracture. Patient admitted to the hospital and underwent closed
reduction and external fixation of his pelvic fracture in the
operating room on [**7-28**]. The patients hematocrit dropped to 25
on [**7-28**] and he received 2 more units of packed red blood cells.
He responded well and his hematocrit remained stable for the
remainder of his stay. He responded well to physical therapy
and his diet was advanced and he was able to be discharged to
home with home physical therapy.
Medications on Admission:
None
Discharge Medications:
1. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
Disp:*1 1 tube* Refills:*2*
2. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours) for 4 weeks.
Disp:*60 syringe* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] [**Doctor First Name **]
Discharge Diagnosis:
Right scapula fracture
Pelvic fractures
Pelvic Hematoma
Lumbar transverse process fracture of lumbar vertebrae 1, 2, 3
and 4
Fracture of Left twelth rib and right sixth rib
Discharge Condition:
Good
Discharge Instructions:
-Touchdown weightbearing RLE, WBAT LLE, ambulate with home
physical therapy help
-Lovenox for four weeks
-Pin care twice a day, with home of home nurse aid training
-wear sling on right upper extremity for comfort
Followup Instructions:
Please follow up in Trauma clinic in 2 weeks [**Telephone/Fax (1) 2359**]
Please follow up with Dr [**First Name (STitle) 1022**] (orthopedic surgery)in 2 weeks
[**Telephone/Fax (1) 4301**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"811.03",
"E816.0",
"458.9",
"780.09",
"868.03",
"808.9",
"807.02",
"805.4",
"790.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"79.19"
] |
icd9pcs
|
[
[
[]
]
] |
5579, 5655
|
4152, 5006
|
372, 444
|
5871, 5877
|
1904, 3105
|
6139, 6460
|
1190, 1208
|
5061, 5556
|
5676, 5850
|
5032, 5038
|
5901, 6116
|
1223, 1885
|
287, 334
|
472, 980
|
3115, 4129
|
1002, 1016
|
1032, 1174
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,201
| 167,242
|
5192
|
Discharge summary
|
report
|
Admission Date: [**2187-8-17**] Discharge Date: [**2187-8-28**]
Date of Birth: [**2119-12-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
[**8-19**]: Gastrointestinal arteriogram and embolization of
metastatic pancreatic tumor feeding arteries with no immediate
complications.
[**8-17**] IMPRESSION: Positive GI bleeding study at 60 minutes with
findings highly suggestive of small bowel bleeding, likely
related to known midline duodenal/pancreatic metastasis. The
transverse colon is noted to positioned more superior (on prior
CT's) then site of bleeding on current study.
History of Present Illness:
67 y.o.m. with metastatic renal cell carcinoma with metastasis
to the pancreas and liver as well as known duodenal/ampullary
mass presents with BRBPR x 2 days. Of note, the patient was
recently started on sutent. Pt states that he first noticed
bloody bowel movement yesterday am. He called his oncologist who
recommended bowel prep in anticipation of colonoscopy today
given known side effect of bleeding with sutent. Pt has
colonoscopy this am that showed blood in colon but no
identifiable source. Pt was referred to the ED for tagged RBC
scan and labs.
Here, a tagged RBC scan was positive at 60 min, and pt was taken
to angiography. There, they couldn't find any obvious source of
bleed, but was consistent with a small bowel source.
HCT noted to drop further to 21 and patient was then referred
for MICU admission.
On admission, he denies fast heart rate, lightheadedness,
dizziness, chest or abdominal pain, tenesmus. He feels
generally well, though a little anxious.
Past Medical History:
# GIB [**2184**], EGD revealed duodenal ulcer c/w malignancy
# Hypertension.
# No cardiac problems, diabetes, or cholesterol.
# Traumatic fracture of the right fibula which require open
reduction.
# RCC in [**2167**], treated with IL 2/LAK and was disease free until
[**2181**], now with metastatic disease to pancreas and likely liver.
.
ONCOLOGIC HISTORY :
1. Status post left nephrectomy followed by high-dose IL-2
[**2166**].
2. LAK therapy in [**2167**].
3. st. post resection of residual renal bed mass in [**2168**]
4. Recurrence in the left renal fossa and pancreas in [**4-/2182**]
5. Low-dose interleukin-2 in 12/[**2181**].
6. Atrasentan medication trial 11/[**2181**].
7. initiated on Nexavar 400 mg twice daily, dose reduced on
10/1005 in the setting of hypertension. His course has been
complicated by a GI bleed with possible small bowel obstruction,
and an admission to [**Hospital3 **] in [**8-/2185**] for anemia
and acute renal failure while on full dose Nexavar 400 mg given
twice daily.
8. Nexavar dose reduced to 400 mg q.a.m., 200 mg q.p.m.
9. Nexavar dose increased to 400 mg b.i.d. following CT in
[**9-/2186**], which showed progression of pancreatic metastases.
10. Enrolled in perifosine trial 06-408 on [**2187-2-28**].
11. Perifosine held since [**2187-6-13**] due to GI bleed.
12. ERCP on [**2187-6-20**] showed a malignant appearing mass in
duodenum, pathology consistent with metastatic renal cell Ca.
13. Perifosine restarted [**2187-6-27**] for one week, held on [**7-4**] due
to
SBO requiring hospital admission in [**Hospital3 2783**], and
restarted again on [**7-11**].
14. Perifosine held due to elevated LFTs on [**2187-7-25**].
15. ERCP on [**2187-8-3**] - biliary stent placed to proximal CBD.
.
Social History:
He is married and has two children. He is retired from GM. He is
a part-time smoker and drinks alcohol socially.
Family History:
.
FAMILY HISTORY: Non-contributory
Physical Exam:
PHYSICAL EXAMINATION:
VITALS: HR 89 BP 145/92 RR 15 Sat 99 (intubated)
GENERAL: Well-appearing in NAD
HEENT: NC/AT
CARD: RRR, nl s1 s2, no m/r/g
RESP: CTAB
ABD: Soft, Non-tender, Non-distended, with scattered nodules.
RECTAL: Deferred
BACK: Mild winging of right scapula. No CVA tenderness.
EXT: WWP, 2+ PT, DP pulses, No C/C/E
Pertinent Results:
[**2187-8-17**] 12:00PM BLOOD WBC-5.9 RBC-3.88* Hgb-9.0* Hct-29.0*
MCV-75* MCH-23.3* MCHC-31.2 RDW-20.6* Plt Ct-149*
[**2187-8-17**] 05:50PM BLOOD WBC-4.1 RBC-2.73*# Hgb-6.5*# Hct-20.6*#
MCV-75* MCH-23.7* MCHC-31.6 RDW-19.5* Plt Ct-103*
[**2187-8-18**] 12:04PM BLOOD WBC-7.2 RBC-3.88* Hgb-10.0* Hct-29.3*
MCV-76* MCH-25.7* MCHC-34.0 RDW-19.3* Plt Ct-116*
[**2187-8-19**] 05:45PM BLOOD WBC-7.5# RBC-3.77* Hgb-10.5* Hct-30.2*
MCV-80* MCH-27.8 MCHC-34.8 RDW-18.1* Plt Ct-103*
[**2187-8-20**] 12:18PM BLOOD Hct-31.0*
[**2187-8-20**] 02:07AM BLOOD Glucose-120* UreaN-10 Creat-0.9 Na-137
K-4.5 Cl-110* HCO3-18* AnGap-14
[**2187-8-21**] 12:49PM BLOOD Hct-30.1*
[**2187-8-21**] 09:28PM BLOOD Hct-30.4*
[**2187-8-22**] 10:09AM BLOOD WBC-9.2 RBC-4.25* Hgb-12.1* Hct-34.4*
MCV-81* MCH-28.5 MCHC-35.1* RDW-19.0* Plt Ct-112*
Blood cx [**8-22**] NGTD x 2
.
[**8-17**] Bleeding study: Positive GI bleeding study at 60 minutes
with findings highly suggestive of small bowel bleeding, likely
related to known midline duodenal/pancreatic metastasis. The
transverse colon is noted to positioned more superior (on prior
CT's) then site of bleeding on current study.
.
[**8-17**] Arteriogram: Arteriogram of celiac trunk and superior
mesenteric artery with no extravasation.
.
[**8-19**] Bleeding Study: Intermittent brisk bleeding. Origin of the
bleeding appears to be just to the left of midline in the
epigastrium.
.
[**8-19**] IR study: Gastrointestinal arteriogram and embolization of
metastatic pancreatic tumor feeding arteries with no immediate
complications.
.
[**8-20**] Femoral ultrasound: No evidence of pseudoaneurysm.
.
[**8-22**] CXR: Low lung volumes. Left lower lobe retrocardiac opacity
is most likely atelectasis.
.
[**8-24**] Knee X-ray: Mild patellofemoral compartment osteoarthritis.
.
[**8-24**] Ultrasound: Examination limited by extensive bowel gas,
which may represent the source of the patient's distention. Mild
ascites. Mild interval increase in size of a right hepatic mass,
allowing for differences in technique.
.
[**8-25**] CT Abd/Pelvis: 1. Bilateral pleural effusions, left greater
than right. Interval increase in intra-abdominal and intrapelvic
ascites. Small pericardial effusion. 2. Cholelithiasis. 3.
Diverticulosis. Mild edema of the colonic wall could reflect a
mild portal colopathy. 4. No significant change in multiple
areas of metastatic disease, including multiple large masses of
the pancreas. Status post left nephrectomy. 5. Patent biliary
stent. 6. Portal vein thrombosis with innumerable coallaterals.
7. Left inguinal hematoma. 8. No evidence of bowel obstruction.
9. Suboptimal evaluation of the spleen; while the appearance may
reflect heterogeneous enhancement due to the phase of contrast,
the possibility of infarcts should be considered. Attention to
this area on follow-up imaging is
advised.
.
[**8-27**] Abd Ultrasound for diagnostic paracentesis: Very small
amount of ascites adjacent to the liver dome. Given the small
amount of fluid and resolution of patient's symptoms, no
paracentesis was performed at this time.
Brief Hospital Course:
Mr. [**Known lastname 21223**] is a 67yM with metastatic RCC, h/o GIB c malignant
ulcer, p/w BRBPR for 2 days and admitted to MICU for careful
hemodynamic monitoring.
1. GI Bleed: Likely related to a metastatic lesion, complicated
by starting Sutent. Patient has a history of bleeding GI masses,
and had been temporarily stopped in Atrasentan trial for anemia.
EGD showed no bleeding from duodenal/ampullary mass or
hematobilia. He thus likely has a lower GI source, which is
consistent with colonoscopy with blood throughout. Pt had RBC
scan w/ bleeding at 60min and nothing on angio, then had more
BRBPR in the MICU, was re-RBC scanned w/ bleeding at 7 min, and
was re-angioed this am, where they embolized feeding arteries
around tumor, but did not see any large bleeds. The following
day ([**8-21**]) the patient was hemodynamically stable and had a Hct
of 31 in the AM, yet her afternoon HCT was found to be 24 and
confirmed on repeat. The patient was transfused 2 units and
responded appropriately. The patient was continued on a PPI [**Hospital1 **],
and had two IVs kept in place. His hematocrit remained stable 24
hours after. However, he was transferred to [**Hospital Unit Name 153**] given continued
repeated drops in HCT. GI and surgery consulted but did not
recommend further interventions at time of transfer. Once
transferred to the floor, his hematocrit remained stable. He
received a total of 12 units of pRBC's during this admission.
#. Gout. He developed a gout flare during admission (despite
being on allopurinol), confirmed by arthrocentesis. He was
started on a steroid taper, which he will complete as an
outpatient.
#. Abdominal distention. His abdomen was noted to be distended,
although nontender. An ultrasound identified mild ascites and
increased bowel gas, and a CT abd/pelvis was performed,
demonstrating pleural effusions and mild ascites. A diagnostic
paracentesis was attempted but could not be safely performed
given the small amount of fluid.
#. Hypertension. His outpatient regimen was initially held in
the setting of lower GI bleed. His nodal blocking agents were
slowly added back (diltiazem first), and he was discharged to
continue all of his home blood pressure medications.
#. Fever. He had low grade temperatures for several days during
the admission but no sources were identified. Cultures were
negative at the time of discharge and should be followed up as
an outpatient.
#. Renal Cell cancer: He will complete his course of XRT at
discharge and will follow up with Dr. [**Last Name (STitle) **] afterward.
Medications on Admission:
Allopurinol 200 mg daily
Atenolol 50 mg daily
Diltiazem 360 mg daily
Nexium 40 mg daily
Lisinopril 40 mg daily
Iron 325 daily
Acetaminophen prn
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Gas-X 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
every eight (8) hours as needed for gas.
7. Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
10. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day
for 6 days: [**Date range (1) 21224**] take 3 tablets; [**Date range (1) 21225**] take 2
tablets; [**Date range (1) 21226**] take 1 tablet, then stop.
Disp:*12 Tablet(s)* Refills:*0*
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Renal Cell Carcinoma
Gastrointestinal Bleed
Discharge Condition:
The patient was hemodynamicall stable, afebrile and without
pain.
Discharge Instructions:
You were admitted for gastrointestinal bleeding which required
ICU care. Your bleeding was determined to be caused by a mass
in your intestine. You underwent endoscopy and blood vessels in
your tumor were treated. You received several blood
transfusions but have had not evidence of bleeding for several
days.
.
In addition, you developed a gout flare of your right knee. You
should continue taking the prednisone as prescribed.
.
Take all of your medications as prescribed. You should resume
taking all of the pills you were taking prior to this admission
(EXCEPT for Sutent; this will be discussed with Dr. [**Last Name (STitle) **] at
your next visit).
.
If you develop any concerning symptoms, such as more bleeding
from your rectum, vomiting any blood, increasing abdominal
fullness or abdominal pain, dizziness, numbness, chest pain,
shortness of breath, or other concerning symptoms, please seek
medical attention immediately.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] after your radiation is finished;
his office will contact you for an appointment.
.
Continue going to radiation until you complete the course; they
will give you a time for daily visits.
|
[
"197.8",
"285.22",
"452",
"401.1",
"574.20",
"V10.52",
"211.3",
"578.9",
"197.7",
"535.50",
"197.4",
"562.10",
"274.0",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.29",
"45.13",
"81.91",
"88.47",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11148, 11154
|
7207, 9774
|
341, 782
|
11253, 11321
|
4122, 7184
|
12306, 12541
|
3728, 3747
|
9969, 11125
|
11175, 11232
|
9800, 9946
|
11345, 12283
|
3762, 3762
|
3784, 4103
|
274, 303
|
810, 1788
|
1810, 3562
|
3578, 3693
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,242
| 156,277
|
54458
|
Discharge summary
|
report
|
Admission Date: [**2141-7-5**] Discharge Date: [**2141-7-11**]
Service: NEUROSURGERY
Allergies:
Bactrim / Ciprofloxacin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
R hand clumsiness, difficulty speaking
Major Surgical or Invasive Procedure:
[**2141-7-7**] B/L burr holes and evacuation of SDH
History of Present Illness:
History of Present Illness:
[**Known firstname 622**] is a 86 yo right handed woman with a history of HL and
previous subdural hematoma 6 weeks ago who presents today with
acute onset of right hand clumsiness and word finding
difficulty.
She was last seen well during dinner with her daughter at 6:30pm
when [**Known firstname 622**] noticed that she had clumsiness in her right hand.
Her right wrist felt numb without tingling. She did not notice
any obvious weakness but had trouble holding a glass of water
and
dropped the glass. There was no facial assymetry. Her daughter
noticed that she had word finding difficulty possibly with some
paraphrasic errors although they can't think of any examples.
She was frequently pausing and her speech was mildly dysarthric.
They moved into the living room to relax thinking it was becase
she was just overwhelmed. [**Known firstname 622**] remembers everything and
felt
that her thinking was clear but could not make her mouth say the
words that she was thinking. When the symptoms didn't resolve,
she came by ambulance.
In the ambulance by 8:40pm the symptoms resolved. Upon arrival
the ED, a code stroke was called.
Review of symptoms: She has had unsteady gait since the
previous
subdural hematoma. There are no known falls. She had several
episodes at the rehab center of emesis.
Negative for: diplopia, vertigo/lightheadedness; dysphagia,
weakness, bowel or bladder incontinence, HA, seizure, LOC.
Also negative for fever/chills/night sweats, CP, SOB,
palpitations, abd pain, URI sx, wt changes, cough, UTI sx, back
pain, neck pain.
Time Code Stroke called: 8:45pm
Time Neurology at bedside for evaluation: 8:50pm
Time (and date) the patient was last known well: 6:30pm
NIH Stroke Scale Score: 0
t-[**MD Number(3) 6360**]: NO
Reason t-PA was not given or considered: CT scan showed subdural
hematoma
Past Medical History:
- Hypertension
- Hypothyroidism
- Atrophic vagnitits
- Recurrent UTI
- Anxiety
- Previous history of subdural hematoma after a suspected head
trauma-
Social History:
Mass native, high school graduate, three
children, housewife who worked parttime as a cashier. She
enjoys
household activities. She does not drink alcohol or smoke
tobacco. Recent stressor is that her husband had to leave their
home to go to a nursing home facility.
She uses a rolling walker even indoors since the prior subdural
hematoma. She was discharged yesterday from acute rehab. They
had arranged for visiting nurses, PT, OT, and home health aide.
Family History:
- Mother: Died of COPD/CHF at 82
- Father: Died at 84 after complication from gall bladder
surgery
There is no history of seizures or dementia or
cardiac arrest. Several family members are hard of hearing.
She has three daughters who are healthy. She has a brother with
AAA.
Physical Exam:
Physical Exam on Admission:
Physical Examination:
Gen:
HEENT: Sclera anicteric. Oropharynx benign. Mucous membranes
moist.
Neck: No carotid bruits. Supple. No LAD.
Cor: RRR, nl S1, S2. No m/r/g appreciated.
Chest: CTAB.
Abdomen: Soft, NTND.
Back: No spinous process tenderness. No CVA tenderness.
Ext: Warm, no edema.
Neuro:
MS:
Gen: Alert, appropriately interactive, normal affect.
Orientation: Full.
Attention: Names days of week backwards correctly. She could
not
do more than one step in series seven
Speech/[**Doctor Last Name **]: Fluent w/o paraphasic errors; Follows simple and
complex commands without L/R confusion. Repetition, [**Location (un) 1131**]
intact. She had difficulty with low frequency objects
occasionally.
Memory: [**1-19**] at registration and [**11-21**] at 5 minutes despite
prommpting. When asked again at 15minutes she still maintains
[**11-21**]. (she kept saying one of the words from Dr.[**Name (NI) 66745**]
testing the day before) She had difficulty related current
events. When asked what was going on recently in Afganistan she
simply said war but could not elaborate.
Calculations: Intact (9 quarters = $2.25).
Praxis: Able to pantomime brushing hair and teeth.
CN:
II: Visual fields full to confrontation. Pupils equally round &
reactive to light 4 mm to 2 mm. No relative afferent pupillary
defect. Optic discs and retina normal.
III,IV,VI: EOMI w/o nystagmus (or diplopia). Mild left ptosis
(family reports is baseline)
V: Sensation intact to light touch. Bite strength equal
bilaterally.
VII: Face symmetric without weakness.
VIII: difficulty hearing and needed loud speaking.
IX,X: Voice normal. Palate elevates symmetrically.
[**Doctor First Name 81**]: SCM and trapezii full.
XII: Tongue protrudes midline.
Motor:
Normal bulk and tone; no tremor, rigidity, or bradykinesia. No
pronator drift. Finger tapping more difficult on right even
though dominant hand side.
Full strength in bilateral deltoids, elbow flexion and
extension,
wrist and finger flexion and extension, APB, FDI, ADM, hip
flexors, knee flexion and extension, ankle dorsi- and
plantarflexion, [**Last Name (un) 938**].
Coord: Rapid alternating and finger-to-nose-finger movements
intact. No truncal ataxia.
Reflex: Normal and symmetric (2+) in bilat biceps, triceps,
brachioradialis, patella. Ankles are absent. Toes downgoing
bilat.
[**Last Name (un) **]: LT and temperature intact. Joint position intact.
Vibration mildly diminished. No evidence of extinction.
Gait: She was able to lift herself out of bed and stand up
without assistance. She seems unsteady while standing in place
which was made worse with rhomberg testing. Did not attempt
pull
testing because suspect patient would just fall. Did not
further
test gait at this time.
Physical Exam on Discharge:
Pt was seen and examined this am and her exam is reported as
She is slightly lethargic but oriented. Does not want to fully
participate with the exam this am. Her speech is clear without
paraphrasic errors. Her upper extremity motor exam is full.
Pertinent Results:
[**2141-7-5**] 04:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2141-7-5**] 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2141-7-5**] 04:30PM URINE RBC-1 WBC-6* BACTERIA-FEW YEAST-NONE
EPI-1
[**2141-7-5**] 04:30PM URINE MUCOUS-RARE
[**2141-7-4**] 11:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2141-7-4**] 11:30PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.005
[**2141-7-4**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2141-7-4**] 09:00PM GLUCOSE-114* UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-30 ANION GAP-10
[**2141-7-4**] 09:00PM estGFR-Using this
[**2141-7-4**] 09:00PM VIT B12-860
[**2141-7-4**] 09:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2141-7-4**] 09:00PM WBC-6.9 RBC-3.62* HGB-11.8* HCT-32.9* MCV-91
MCH-32.7* MCHC-35.9* RDW-12.9
[**2141-7-4**] 09:00PM PT-11.6 PTT-24.1 INR(PT)-1.0
[**2141-7-4**] 09:00PM PLT COUNT-211
CT head [**7-4**]:
bilateral subacute isodense SDH left greater than right with
effacement of both hemispheres. Left 16mm and right 10mm. No
hydrocephalus or evidence of uncal herniation.
CT Head [**7-7**]:
1. Postoperative changes with pneumocephalus and residual fluid
are seen
along the right and left frontotemporal parietal convexities, as
expected.
2. No change in mass effect or midline shift compared to prior
study.
3. No new areas of hemorrhage.
MRI C spine [**7-6**]:
There is no evidence of abnormality in the visualized spinal
cord.
There is no evidence of compression or subluxation. Degenerative
changes are noted in the cervical spine.
repeat MRI MRA of the c-spine is pending final results at this
time of discharge
Brief Hospital Course:
86 yo right handed female with HL, hypothyroidism, and history
of right sided subdural hematoma 6 weeks ago who presents with
sudden onset of right wrist numbness and clumsiness with word
finding difficulty lasting about 2 hours that self resolved.
NIHSS was 0. Initial neuro exam was significant for mild
cognitive deficits, mild right hand clumsiness, and positive
romberg sign.
CT scan revealed significant bilateral L> R subacute subdural
hematomas. Started on Keppra for seizure prophylaxis. She
continued to have some mild short term memory deficits and
findings consistent with cervical myelopathy but her neurologic
exam was otherwise intact and an MRI C spine proved negative.
She was seen by neurosurgery and went to OR for bilateral SDH
evacuation on [**2141-7-7**]. Post operatively she was transferred to
the ICU for further care including SBP control and q1 neuro
checks. A post op head CT showed good evacuation of B/L SDH. Her
exam remained intact. She was transferred to the floor on [**7-8**]
in stable condition. She was able to void on her own and was
tolerating a PO diet. She was seen by the physical therapy team
and was found to need a short term of [**Hospital 98**] rehabilitation. She
was discharged to [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) 479**] Rehab.
Medications on Admission:
ESTRADIOL [ESTRACE] - 0.01 % Cream - apply as directed weekly
LEVOTHYROXINE - 50 mcg Tablet - 1 (One) Tablet(s) by mouth once
a
day
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg
Capsule
- 2 Capsule(s) by mouth qAM
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1
(One) Tablet(s) by mouth once a day
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO once a
day.
4. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain or fever.
13. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety for 2 doses.
14. HydrALAzine 10 mg IV Q6H:PRN for SBP > 140
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. travoprost 0.004 % Drops Sig: One (1) Ophthalmic qhs () as
needed for glaucoma.
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
20. Morphine Sulfate 1 mg IV Q4H:PRN breakthrough pain
hold rr < 12
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
- you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
*** PLEASE REMOVE STAPLES ON [**2141-7-19**]******
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Please call to schedule a follow up appointment with the
neurology team to be seen in [**12-23**] weeks to review the findings of
your brain MRI.
Completed by:[**2141-7-11**]
|
[
"V70.7",
"344.1",
"244.9",
"294.9",
"401.9",
"784.3",
"721.1",
"300.00",
"E888.9",
"272.4",
"852.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
11478, 11613
|
8164, 9477
|
271, 325
|
11675, 11675
|
6260, 8141
|
13461, 13918
|
2892, 3171
|
9854, 11455
|
11634, 11654
|
9503, 9831
|
11826, 13438
|
3186, 3200
|
3237, 5962
|
5990, 6241
|
193, 233
|
381, 2221
|
3214, 3214
|
11690, 11802
|
2243, 2395
|
2411, 2876
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,781
| 146,687
|
25258
|
Discharge summary
|
report
|
Admission Date: [**2102-12-4**] Discharge Date: [**2103-1-1**]
Date of Birth: [**2030-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
72yM w/history of gastric stromal tumor s/p partial
gastrectomy/pancreatectomy/splenectomy presents for elective
gastrectomy secondary to recurrent strictures and esophagitis.
Major Surgical or Invasive Procedure:
gastrectomy, partial esophagectomy, roux-en-Y
esophagojejunostomy, [**2102-12-6**]
History of Present Illness:
Pt is a 72yo man who in [**2102-7-21**] was diagnosed with a bleeding
ulcer and subsequently a gastric mass found to be a rare gastric
stromal tumor. He underwent a subtotal gastrectomy,
pancreatectomy, splenectomy and J tube placement at that time.
His course has been complicated by [**Female First Name (un) **] esophagitis and
stenosis of the anastamotic site and pylorus. Pt has continued
dysphagia despite balloon dilation. He presents for elective
completion gastrectomy, distal esophagectomy and roux en Y
esophagojejunostomy. On presentation, there is no evidence of
metastatic spread or recurrence of his stromal tumor, however,
he does have a small 5mm R lung lesion too small to
characterize.
Past Medical History:
s/p partial gastrectomy, splenectomy, j tube placement [**7-25**]
gastric stromal tumor s/p
gastrectomy/pancreatectomy/splenectomy- [**2102-12-6**]
Insulin Dependent diabetes Mellitus
Hypertension
hyperlipidemia
Gatric esophogeal reflux disease
Social History:
lives alone in [**Last Name (un) 28523**] home in [**Location (un) 7740**], MA. Drives, works
full-time for City ofBoston. has been out of work for 4 months
on short ter disability.
Was trasferred from [**Hospital1 **] at [**Hospital3 417**].
contacts- Brother [**Name2 (NI) 63231**] [**Telephone/Fax (1) 63232**], dtr- [**Female First Name (un) 63233**]
[**Telephone/Fax (1) 63234**] or [**Telephone/Fax (1) 63235**].
Physical Exam:
General-
HEENT-neg sclera interus, no JVD, no tracheal deviation,
REsp- CTA bilat
Cor-RRR
Abd- NT, ND, + BS, j-tube- no erythema or tenderness, midline
scar; abd incision- medial- vac dressing in place, lateral- W> D
dsg, change TID. JP drain -in duodenal stump
Ext- warm, no edema.
Skin- dry, good tone. sores
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2103-1-1**] 10:00AM 11.3* 3.67* 10.4* 32.7* 89 28.4 32.0
16.1* 619*
RECEIVED AT 11:05AM
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2103-1-1**] 10:00AM 619*
RECEIVED AT 11:05AM
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2103-1-1**] 10:00AM PND PND PND PND PND PND PND
RECEIVED AT 11:05AM
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2102-12-15**] 04:48AM 280*
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2102-12-7**] 09:47PM 8 0.011
1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2102-12-24**] 10:39 AM
Reason: rule out gastric dilatation
[**Hospital 93**] MEDICAL CONDITION:
72 year old man s/p completion gastrectomy, Roux-en-Y
esophagojejunostomy w/ fluroscopic NGT placement on [**12-20**] for
vomiting now s/p accidental removal of NGT
REASON FOR THIS EXAMINATION:
rule out gastric dilatation
PORTABLE CHEST
INDICATION: Check for gastric dilatation after inadvertent
removal of NGT.
COMPARISON: [**2102-12-23**].
FINDINGS:
Compared to the prior study, there is no evidence of progressive
distention of the visualized bowel loops. No abnormal gastric
dilatation. A shallow level of inspiration is demonstrated, but
there are no significant interval changes versus prior.
RADIOLOGY Final Report
Reason: please place NGT into esophogas under fleuro (per
picture)
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with POD#14 s/pcomplete gastrectomy, distal
esophagectomy, roux-en-y esophajejunostomy for reflux and
dysphagia; now w/ vommitting. Last study eval J-tube to rectum
w/ no obstruction.
REASON FOR THIS EXAMINATION:
please place NGT into esophogas under fleuro (per picture) and
eval to J-tube.
INDICATION: The patient is postop day 14 status post complete
gastrectomy, distal esophagectomy and Roux-en-Y
esophagojejunostomy. Patient now with vomiting. Previous
evaluation of bowel from level of the J-tube to the rectum
demonstrates no obstruction. Please place a nasogastric tube
into the esophagus under fluoroscopic guidance and evaluate for
proximal obstruction.
[**Last Name (un) **]-INTESTINAL TUBE PLACEMENT: Patient was placed in the seated
position. Hurricaine Spray was used to anesthetize the pharynx
and lidocaine jelly was used to anesthetize the right naris. A
[**Hospital1 3597**] sump tube was advanced through the right naris into the
proximal esophagus. The patient was then placed in the supine
position, and a small amount of water-soluble contrast was
injected. The water-soluble contrast opacified the dilated
portion of the esophagus, and a small amount of reflux was
noted. After a couple of minutes, contrast passed through the
esophagojejunal anastomosis, and the jejunal loop was
decompressed at the level of the anastomosis. Using the
contrast- opacified gut lumen as the guide, the [**Last Name (un) **]-intestinal
tube was advanced. The tip was advanced to the level of the
esophagojejunal anastomosis, and could not be advanced further.
Contrast and bilious material was then aspirated via the sump at
the conclusion of the procedure.
IMPRESSION:
1. Holdup of contrast at the level of the esophagojejunal
anastomosis, with dilated esophagus proximally and decompressed
jejunum distally. The findings suggest postoperative edema of
the esophagojejunal anastomosis.
2. [**Hospital1 3597**] sump placement, with the tip at the level of the
esophagojejunal anastomosis.
Brief Hospital Course:
Patient was admitted and a CT scan of his chest and abdomen was
performed. It revealed his anatomy consistent with his previous
surgery as well as multiple small right sided pulmonary nodules
and bilateral renal cysts. A bowel prep was performed using
Golytely. Pre-op for [**Doctor First Name **] in am [**12-6**].
Patient tolerated extensive surgery (~8hrs) well. The patient
was then transferred to the cardiothoracic intensive care unit
in satisfactory condition. Blood loss for
the procedure approached 4 liters, and the patient received
8units of blood and 2 units of FFP during the operation. He
remained hemodynamically stable. His double-lumen endotracheal
tube was exchanged for a single-lumen endotracheal tube at the
end of the operation. Patient trasferred to ICU post-op for
close respiratory and hemodynamic monitoring. Pt w/ weaned and
extubated POD#1; hemodynamically stable -gently diuresis w/
LAsix gtt. Pain control w/ Demerol epidural- followed by APS.
REsp-98%- 2lNC POD#4-; Right chest tube d/c w/o complication-
POD#4.
Hemo/ Dyn- Initial use of Neo and levo- weaned on POD#2; lasix
for diuresis POD1-5then d/c; Beta blocker for rate control, NSR.
GI- TPN and octreotide IV started POD#1; NPO; 2 bulb drains -
bile.
Activity- OOB to chair POD#1 and ambulation POD#2-Physical
therapy following pt for entire hospitalization- progressed to
Independent w/ ambulation w/ assist for tube feedings and vac
dressing machine assistance.
Patient transferred to floor on POD#5-11/21/05.
POD#7 NGT d/c'ed. TPN cont w/ close FS monitoring w/ RISS. Close
I/O. POD #8 epidural discontinued and patient started on a
dilaudid PCA with adequate control of pain. Wound noted to
express small amount of purulent fluid, opened and I&D'ed at
bedside revealing small pocket of pus. Patient started on
empiric vancomycin and levoflox at this time for a suspected
wound infection. Cultures returned positive for both Klebsiella
and Pseudomonas, both pansensitive to patient's antibiotic
regimen. Patient's abdominal wound initially managed with wet to
dry dressings but eventually changed to a VAC dressing. At this
time, patient's chest tube was removed with no complication. POD
#10 patient underwent an interventional pulm R chest tap of
300cc of fluid. Diuresis was continued with iv lasix. POD #12
patient's antibiotic regimen changed to fluconazole/zosyn.
Patient febrile overnight, CT torso performed which revealed
small fluid collection in the left abdomen. Patient defervesced
but developed nausea and vomiting. On POD #14 a nasogastric tube
was placed with fluoroscopic guidance and contrast was instilled
revealing postoperative edema of the esophagojejunal anastamosis
site with slowing of contrast through this area. The NGT was
kept in place for decompression.
Over the next few days, patient remained afebrile and stable
with the NGT in place. He was continued on TPN. On POD #18, his
NGT was removed. His abdominal JP drain output slowly decreased
to <50cc per day. He had persistent spitting up of both clear
and bilious material throughout the day as well as intermittent
episodes of emesis. He remained stable, however, and on POD #20,
he did have a small bowel movement. He was started on minimal
tube feeds and tolerated them well. Over the next few days,
patient was able to be advanced on his tube feeds, and his TPN
was slowly weaned off. His episodes of emesis also resolved
although he continued to spit moderate amounts of saliva mixed
with bilious material throughout the day. He was able to walk
liberally around the floor, with +BM's. He was continued on
fluc/zosyn with three times weekly VAC changes. His wound
continued to improve with each dressing change. His tube feeds
were advanced to goal on POD #24 which the patient tolerated
well. Neurologically his pain was controlled with dilaudid iv
prn. His blood pressure and heart rate remained stable on low
dose metoprolol. GI he remained NPO with tube feeds at goal. ID
he remained afebrile and his antibiotics were discontinued prior
to discharge. Heme his Hct was stable with no evidence of
bleeding. Endocrine his blood sugars were well controlled prior
to discharge running <150. GU he had adequate urine output with
no diuretics.
On POD #26, his central line was discontinued and a peripheral
iv was placed. On POD #27 a barium swallow was performed which
demonstrated a patent esophagojejunostomy anastamosis site with
no evidence of leak.
The patient was discharged to rehab with an abdominal JP in
place as well as a VAC dressing. He was instructed to follow up
with Dr. [**Last Name (STitle) **] in two weeks.
Medications on Admission:
lopressor 75", NPH [**6-19**], RISS, nexium ?, folate 500', advair,
provigil 100', paxil 20', scopalomine TD Q72hrs, KCl 40', colace
100", hydramine 25 QHS, senna 2QHS, tylenol PRN
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
2. Octreotide Acetate 500 mcg/mL Solution Sig: Two Hundred (200)
mcg Injection Q8H (every 8 hours).
3. Insulin Regular Human 100 unit/mL Solution Sig: as needed
sliding scale units Injection ASDIR (AS DIRECTED).
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO QID
(4 times a day).
5. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
6. Hydromorphone 1-4 mg IV Q4-6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
gastric stromal tumor s/p gastrectomy/pancreatectomy/splenectomy
Insulin Dependent diabetes Mellitus
Hypertension
hyperlipidemia
Gatric esophogeal reflux disease
Discharge Condition:
stable
Discharge Instructions:
Please call Dr[**Name (NI) **]/ Thoracic Surgery office at ([**Telephone/Fax (1) 4044**] for:fever, chest pain, nausea/vomiting, inability to
take your tube feedings, dizziness/weakness, or shortness of
[**Last Name (LF) 1440**], [**First Name3 (LF) 691**] bleeding, redness, oozing or persistent pain at your
surgical sites.
Take medications as directed.
Followup Instructions:
Please call for appointment with Dr. [**Last Name (STitle) **] in [**11-3**]
days.[**Telephone/Fax (1) 170**].
Completed by:[**2103-1-1**]
|
[
"V58.67",
"511.8",
"568.0",
"998.59",
"250.00",
"V45.79",
"997.4",
"560.1",
"V10.04",
"530.81",
"787.2",
"239.1",
"530.19",
"272.4",
"401.9",
"041.85",
"530.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"42.54",
"42.41",
"99.07",
"93.56",
"86.04",
"96.6",
"99.04",
"99.15",
"46.39",
"38.93",
"96.07",
"34.91",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
11332, 11404
|
5945, 10552
|
496, 581
|
11610, 11619
|
2369, 3141
|
12023, 12165
|
10784, 11309
|
3907, 4107
|
11425, 11589
|
10579, 10761
|
11643, 12000
|
2037, 2350
|
280, 457
|
4136, 5922
|
609, 1317
|
1339, 1585
|
1601, 2022
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19,815
| 139,461
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22227
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Discharge summary
|
report
|
Admission Date: [**2137-9-8**] Discharge Date: [**2137-10-2**]
Date of Birth: [**2063-1-4**] Sex: F
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Diabetic ketoacidosis, non ST segment myocardial infarction
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
tracheostomy
PEG tube placement
transfusions
History of Present Illness:
Ms. [**Known lastname 57980**] is a 74 year old female with a past medical history
of Diabetes Melitis type 2, now insulin dependent, hyperlipid,
[**Last Name (un) 32665**]-[**Doctor Last Name 122**] disease, and dementia who presented to an out
side hospital with uncontrolled finger stick glucoses (500s
despite sliding scale insulin at home), lethargy, mental status
changes, and nausea and emesis (1 day prior). She was found to
be in diabetic ketoacidosis, with a urinalysis positive for
infection, ECG with diffuse t wave inversions, CK 700, MB 129,
and TropI 33. She was given aspirin, subcutaneous lovenox,
integrilin, levofloxacin, subcutaneous insulin and transfered to
[**Hospital1 18**] for further management & consideration of cardiac
catheterization.
Past Medical History:
DM2 on insulin
Hypercholesterolemia
Dementia/[**Doctor Last Name 122**] disease (an inherited spinocerebellar ataxia:
progressive neurological disorder of ataxia, peripheral
neuropathy)
(No known HTN)
Social History:
Prior to admission the patient was living at home with her
daughter. The patient was bedridden and very dependent on family
members to care for her. She has a significant smoking history
of 50 pack years, though she quit smoking 10 years ago. Denies
EtOH or other drugs.
Family History:
[**Last Name (un) 32665**]-[**Doctor Last Name 11042**] disease.
Physical Exam:
T: 98.5 HR: 89 BP: 129/50 RR: 21 O2sat 100% 1L NC
Gen: cachectic female.
HEENT: MM dry. no sceral icterus. EOMI.
Neck: supple, no lymphadenopathy. No JVD.
Chest: pectus carinarum
CV: RRR, II/VI systolic murmur heard best at LLSB.
Lungs: Course breath sounds bilaterally.
Abd: thin, S/NT/ND. +BS. No HSM
Ext: no c/c/e. Pulses 2+ femoral, 1+ bilaterally DP/PT.
Neuro: Oriented to person. Non-focal. strength 5/5 throughout.
MAEW - alternating contracting muscles in legs and pulling them
up to chest.
Pertinent Results:
Head CT ([**2137-9-12**]):
Limited study secondary to motion artifact with severely limited
examination/ of the infratentorial structures and the middle
cranial fossa. Within the limits of this study, there was no
evidence of major vascular territorial infarction or acute
intracranial hemorrhage.
*
EEG ([**2137-9-13**]):
Markedly abnormal EEG due to the low voltage slow
background with occasional surpressive bursts and with runs of
uniformly
distributed alpha frequencies throughout. Overall, the tracing
indicates a widespread and moderately severe encephalopathy.
This can
come from anoxia or severe metabolic derangements, but the
widespread
alpha frequency suggests medication effect. There were no
epileptiform
features.
[**2137-9-8**] 11:56PM CK(CPK)-1453*
[**2137-9-8**] 11:56PM CK-MB-129* MB INDX-8.9* cTropnT-3.77*
[**2137-9-8**] 11:56PM WBC-20.3* RBC-3.82* HGB-11.5* HCT-34.4*
MCV-90 MCH-30.2 MCHC-33.5 RDW-14.0
[**2137-9-8**] 11:56PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2137-9-8**] 11:56PM URINE RBC-62* WBC-20* BACTERIA-OCC YEAST-NONE
EPI-2
[**2137-9-26**] 9:04 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2137-9-28**]**
GRAM STAIN (Final [**2137-9-26**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2137-9-28**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
Brief Hospital Course:
Overall it was hypothesized that the patient developed an
infection (i.e., urinary tract infection) leading to DKA & had a
non ST elevation myocardial infarction in this setting of acute
infection & metabolic abnormalities.
1. Cardiovascular:
A. CAD: NSTEMI - ECG changes and + cardiac enzymes; CK peaked at
1450 and then trended down. CK did rise again later after pt was
intubated, but MB and troponin continued to trend down. Because
the patient was not felt to be a good candidate for
catheterization, she was managed medically. She was started on
ASA, Plavix, and her statin was increased to 20 per day. She was
initially started on Metoprolol to control heart rate and blood
pressure, and when her blood pressure allowed she was given
captopril. She was given Lovenox for 48 hours but no integrillin
since she was not going to catheterization. The aspirin and
plavix were held during periods when concerns for intracranial
bleeding were present, but then restarted when this was felt to
be less likely.
Later, Ms. [**Known lastname 57980**] pulled out her NG tube repeatedly and it was
not possible to maintain her on plavix since it cannot be
administered otherwise. Her aspirin was continued rectally and
other medications were administered intravenously until her PEG
tube was placed. Of note, she had sufficient bleeding around her
tracheostomy site that her surgeon had to return to stitch it
down. It was thought that hemostasis was difficult to achieve
since she was on aspirin and plavix. Once her PEG was placed, it
was decided not to continue her plavix in the interest of
preserving hemodynamic stability.
B. Pump: EF 30-35%; Pt initially received aggressive intravenous
fluids for diabetic ketoacidosis, and then was diuresed since
oxygen saturations dropped and the patient was having more
labored breathing. The patient's blood pressures were initially
high and would go even higher with agitation. She was maintained
on a labetolol gtt for a short time to control these BP's. Her
labored breathing eventually led to intubation, followed by
extubation during a period where her hemodynamics had
stablilized, and then re-intubation since pt's breathing was
extremely labored on the shovel mask. For the second intubation
the patient was given propofol for sedation and her BP dropped
acutely. She required 3 pressors (Dopamine, Neo, Levophed) with
MAPs in 70s, SBP in 110s. Bedside Echo showed no changes after
these events. Her hemodynamics were gradually stablized and BP
eventually became high again. Throughout her hospitalization the
pt had extremely labile BP's that seemed to be affected by her
position and level of agitation. These changes were of unclear
etiology and thought to be possibly related to her underlying
[**Doctor Last Name 11042**] disease vs. pain. Her blood pressure medications were
titrated aggressively since she developed flash pulmonary edema
nearly each time she became hypertensive, tachycardic, and
tachypneic. Upon discharge, she was stable and normotensive.
C. Rhythm: Pt was in NSR for most of her hospitalizaton. During
the time she was maintained on Dopamine, however, EKG's showed a
junctional rhythm which resolved when the Dopa was weaned. She
remained in sinus throughout the remainder of her intensive care
unit stay.
2. Pulmonary: As discussed above, the pt was intubated on [**9-12**]
for primary respiratory acidosis with hypercarbic failure.
Extubated to face mask later on the same day but persistently
tachypneic to 30s. Tried BIPAP to no avail. Off BIPAP patient
continued to breathe at 30 and breathing looked extremely
labored. It was felt that it would be unlikely that the patient
would be able to leave the hospital without some kind of
respiratory support and so it was collectively decided with the
family that a temporary tracheostomy might help her improve yet
be more comfortable than the breathing tube. On [**9-13**] she was
electively intubated (as bridge to PEG and TRACH) with
subsequent hypotension requiring 3 pressors as described above.
She was stabilized from this and eventually had a tracheostomy
placed with a minor bleeding complication due to administration
of aspirin and plavix. Ms. [**Known lastname 57980**] also suffered a small
pneumothorax as a consequence of an attempted right subclavian
line. This was followed with serial chest x rays and did not
require a chest tube to be placed. It resolved within 2 days.
She then developed a methicillin sensitive staph aureus
ventilator associated pneumonia. She was started on levofloxacin
for a total course of 8 days.
3. Endocrine: The patient was admitted in diabetic ketoacidosis
with blood glucose 559, ketones & an anion gap of 20 at an
outside hospital and only covered with sliding scale insulin
there. Her anion gap was 15 on arrival. The precipitant was
likely infection (urinary tract) and the patient was managed on
insulin drip until [**9-9**], after which she was covered with NPH
[**Hospital1 **] and HSS. She initially had presented with hypernatremia (Na
was 150) which was corrected wwith [**1-11**] normal saline and
normalized. Throughout her stay, her blood sugars were very
labile and difficult to control although she was on an insulin
drip. She was stabilized on glargine 35 units QPM and covered
with a regular insulin sliding scale.
4. ID: The patient presented with elevated white blood cell
count and neutrophilia. Her urinalysis was positive at the
outside (although with some epithelial cells so it may have been
contaminated). She was started on Levofloxacin for the urinary
tract infection and was treated for 7 days. Her chest x ray was
initially clear, but then developed a questionable left upper
lobe infiltrate. Any possible pneumonia would likely have been
covered by the Levaquin, however, then the patient's blood
pressures dropped following intubation and there was a concern
that she may have been septic. Thus, she was started on
Ceftazidime, vancomycin, and flagyl to cover wider for the
possible pneumonia as well as any line infection with
methicillin resistant staph aureus. However, no cultures ever
grew out any organism. The patient spiked a few fevers while on
these antibiotics, however, then the fevers resolved on their
own and all antibiotics were discontinued since no organisms
were ever identified. Later in her course, Ms. [**Known lastname 57980**] developed
increasing secretions and clinical decompensation. Although she
never became febrile and her chest x ray was unchanged, she was
started on vancomycin. Her sputum was sent for culture and it
was determined that she had heavy growth of methicillin
sensitive staph aureus. She was de-escalated to levoquin and
will finish her 8 day course at the outside rehabilitation
facility. Following the second day of treatment the patient's
mental status and tone improved.
5. Neuro: History of [**Last Name (un) 32665**] [**Doctor Last Name 11042**] disease; per family,
initially lethargic at outside hospital (Head CT neg there),
near baseline on admission to [**Hospital1 18**]. After extubation, however,
pt was more lethargic. She followed some commands but was too
drowsy to swallow. Her mental status declined until eventually,
she did not even respond to noxious stimuli applied to her
nailbeds or sternum.
Her head CT was repeated with no changes seen (no intracranial
hemorrhage). She was evaluated by neurology who felt that she
may have been having a seizure since she had symptoms concerning
for myoclonus and posturing. The EEG was abnormal in that it
showed encephalopathy but did not show seizure activity.
However, the patient was started on phenytoin since she had been
given Ativan before the EEG was taken and it thus seizure was
able to be completely ruled out. After several days without
evidence of seizure activity, the team decided to stop the
phenytoin as it was thought that the medication might contribute
to the patient's decreased mental status. She slowly became more
alert during her course, but would wax and wane continually.
Eventually she would respond to commands and was occasionally
alert and oriented to person and place. It was thought that the
etiology to her obtundation was toxic metabolic.
6. Lines: The patient was initially managed with peripheral
IV's, however, as her condition worsened central access was
attempted at the right internal jugular and right subclavian
without success. See above pulmonary section for complications.
She was thus managed with a right femoral line for several days
which was changed to a left femoral line until a PICC was
placed.
*
6. FEN: Speech/swallow had evaluated the patient before her
intubation and had recommended prethickened liquids. However,
after her intubation for the second time it was felt that the
patient was not able to handle her secretions well and would
likely need a PEG placed for nutrition as well as for safety
reasons. Her tracheostomy placement was complicated with some
difficulty attaining hemostasis. Her PEG tube was placed without
complications and she was fed through it during the remainder of
her hospitalization. Upon speech and swallow evaluation of her
after placement of the tracheostomy, it was decided that she was
not ready for any oral feeds since she appeared to be aspirating
her secretions. It was thought that once she was weaned from the
ventilator, she could be evaluated again. She should not be
given anything by mouth because she is a serious aspiration
risk.
7. Communication: Full code. The family was heavily involved in
making decisions about the patient's care and all along
expressed wishes for aggressive care.
Medications on Admission:
Synthyroid 88 mcg once a day
Lipitor 10 mg once a day
70/30 insulin 24 units qam, 24 units qpm
Discharge Medications:
1. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
6. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day).
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
13. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
14. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
15. Insulin Glargine 100 unit/mL Solution Sig: 35 units QPM
Subcutaneous once a day.
16. sliding scale insulin
please see attached sliding scale for regular insulin
17. Outpatient Lab Work
Please check electrolytes within 3 days
18. Outpatient Speech/Swallowing Therapy
Can be evaluated for swallowing when ventilator is weaned and is
tolerating passey muir valve
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
non ST segment MI
[**Last Name (un) 32665**]-[**Doctor Last Name 11042**] Disease
Respiratory failure, requiring intubation
cardiogenic shock
Anemia
Congestive heart failure with EF of 35%
Diabetes type 2, now insulin dependent
ventilator associated pneumonia
Discharge Condition:
fair
Discharge Instructions:
Vent settings: PS 10, PEEP 5, FiO2 of 40%.
Titrate blood pressure meds closely. The patient has a tendency
to flash pulmonary edema if she becomes hypertensive. Keep her
ins and outs even and check her potassium in the next day since
her captopril was recently increased.
Titrate glargine and sliding scale insulin carefully. The
patient is a brittle diabetic with a tendency to both hypo and
hyperglycemia. Check blood sugars frequently. Do not allow her
to eat since she has failed her speech swallow evaluation. She
was fitted for a Passey Muir valve and can use it once her
respiratory status becomes stable.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] on Monday [**10-7**] at 9:45 PM
([**Telephone/Fax (1) 33330**]) on [**Street Address(2) 14531**] in [**Hospital1 1474**], [**Location (un) 10043**].
If there are problems with the tracheostomy or the PEG tube,
call Dr. [**Last Name (STitle) **]. He is located at [**Hospital Unit Name 57981**], [**Location (un) 86**], [**Numeric Identifier 718**], Phone: [**Telephone/Fax (1) 2981**] Fax: [**Telephone/Fax (1) 57982**]
|
[
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"428.0",
"518.81",
"599.0",
"250.12",
"785.51",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
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"96.04",
"38.93",
"96.72",
"99.15",
"43.11",
"96.71"
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icd9pcs
|
[
[
[]
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15680, 15752
|
4349, 13967
|
325, 410
|
16055, 16061
|
2336, 4326
|
16723, 17188
|
1735, 1801
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14113, 15657
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15773, 16034
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13993, 14090
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16085, 16700
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1816, 2317
|
226, 287
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438, 1206
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1228, 1431
|
1447, 1719
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69,341
| 168,984
|
38159
|
Discharge summary
|
report
|
Admission Date: [**2193-8-9**] Discharge Date: [**2193-8-14**]
Date of Birth: [**2123-8-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Found unresponsive, seizing.
Major Surgical or Invasive Procedure:
Extubation
Lumbar Puncture
History of Present Illness:
Mr. [**Known lastname 16968**] is a 70 year old man with hx of Left MCA stroke, s/p
L CEA, PVD, HTN, DM, EtOH abuse and no previous hx of seizures
was reportedly found down on the floor, having GTC seizure at
9:30am.
He was last seen awake and alert yesterday evening while at his
son's birthday gathering. Of note, in AM of that day, c/o of CP
and pressure to the family, which improved in the afternoon. The
evening prior to the event, while at dinner, had been feeling
"heartburn" and was noted to be diaphoretic. He was found to be
unsteady on his gait later in the evening and had some "mouth
twitching movements" while at dinner, but was awake, alert and
able to interact with family. Of note, he reported increasing
DOE over the past month.
This morning, his son found him on the floor of his bathroom,
with movements felt to be a GTC seizure (arms and legs shaking
synchronously, unresponsive). He was noted to have an injury of
his left foot and on his head. There is a mention of someone
hearing a sound at 7am when he likely fell down. EMS was called,
he was found to have GTCS. At OSH, he was taken to OSH where he
was febrile to 104.4F, tachycardiac to 160's with SBP 140's. He
was given adenosine for his tachycardia. EKG showed ST elevation
V1-V4 as well as II, III, AVF. Troponin was 0.4. He was started
on heparin gtt. Patient also received 6mg ativan IV and unknown
amount of valium (at least 10mg en route to [**Hospital1 18**]).
It is not clear from the records when pt. actually stopped
seizing.
At OSH, he was then intubated with for airway protection
(propofol and succinylcholine used for this purpose). His head
CT was reportedly normal and he was transferred to [**Hospital1 18**] for
further care.
.
On arrival to [**Hospital1 18**], initial (5pm) VS were [**Age over 90 **]F HR 123 BP 156/90
RR28 100% on ventilator (unknown settings). He was noticed by
staff to have bilateral rhythmic twitching of LEs and received
2mg of ativan. He was started empirically on IV ceftriaxone 2g,
vancomycin 1g, ampicillin 2g, acyclovir 900mg. He was loaded
with dilantin, 1500mg and midazolam/fentanyl for sedation. In
addition, EKG showed ST elevations in V1-V4 (1mm in V1,4 and 3mm
in V2-3). He now received aspirin 600mg in addition to the
heparin gtt. By 1900, he was noted to be hypotensive to low 80s
systolic and had received a 500cc NS bolus with increase of BP
to 100s. In on the way to the floor while at CT, BP was 79/51,
HR 116, received 500cc NS bolus and SBP improved to low 100s.
.
Neurology and cardiology were consulted in ED. Per neurology,
the etiology of sz was unclear, and ddx included "anoxic from an
MI and brain hypoperfusion; infection is a suspicion given T104;
alcohol withdrawal given recent heavy drinking per family; a
brain ischemic process is also a possibility but no clear
evidence on exam."
Per cardiology, it was felt that he could be having an MI, but
in setting of a seizure and possible stroke they felt this was
the latter were the more likely explanations. Patient was
admitted to MICU for further management.
.
Of note, family suspects that patient had been drinking heavily
last week.
On the floor, VS were 98.4F, 102/62, 89, 15, on 90%FiO2, Tv 500.
He was unresponsive to verbal or tactile stimuli.
.
He had here positive stool and no lavage but coffee ground
emesis in the ED.
Past Medical History:
-previous LMCA stroke 10 years ago perioperatively s/p L
endarterectomy
-hx of EtOH abuse
-HTN
-DM
-PVD
-[**Country **] occlusion
Social History:
Former Cook. Cuurently retired. Lives in N. [**Location (un) 8545**], in senior
comm. living. Widowed and divorced.
- Tobacco: quit 10 yrs ago. 50+ ppy hx.
- Alcohol: currently using, unknown amount.
- Illicits: marijuana in the past.
Family History:
Non-contributory
Physical Exam:
VS T:98.4F BP:102/62 P:89 RR:15 90%FiO2, Tv 500
General: intubated, sedated. no response to vocal or tactile
stimuli
HEENT: Sclera anicteric, dMM, oropharynx clear, Right edematous
ear, w/ external bleeding, unable to visualize TM.
Neck: supple, no JVD, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate, normal S1 + S2, no murmurs, gallops
Abdomen: soft, non-tender, non-distended, no hepatomegaly.
Ext: warm, trace pulses in b/l LEs, no clubbing or edema.
Abrasion on LEFT.
NEURO: eyes closed, does not respond to commands, grimaces to
noxious. PERRL, corneal, oculocephalic and gag intact, withdraws
RUE flexor, LUE EXTENSOR, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] flextion bilaterally. Has a
mild RIGH facial. Toe UP on LEFT, equivocal on right. No clonus.
Increased tone in RUE and RLE. DTRs symmetrically [**Name2 (NI) 19912**] in UEs
and LEs.
Pertinent Results:
[**2193-8-9**] 05:45PM BLOOD WBC-15.8* RBC-4.83 Hgb-16.3 Hct-46.6
MCV-96 MCH-33.6* MCHC-34.9 RDW-13.4 Plt Ct-191
[**2193-8-9**] 09:18PM BLOOD WBC-15.5* RBC-4.61 Hgb-15.7 Hct-45.5
MCV-99* MCH-34.0* MCHC-34.5 RDW-13.5 Plt Ct-200
[**2193-8-11**] 03:13AM BLOOD WBC-17.3* RBC-4.27* Hgb-14.5 Hct-41.5
MCV-97 MCH-34.0* MCHC-35.0 RDW-13.5 Plt Ct-198
[**2193-8-11**] 02:39PM BLOOD WBC-10.8 RBC-3.85* Hgb-13.2* Hct-37.6*
MCV-98 MCH-34.2* MCHC-35.0 RDW-13.6 Plt Ct-166
[**2193-8-12**] 03:28AM BLOOD WBC-14.1* RBC-4.17* Hgb-14.2 Hct-40.7
MCV-98 MCH-34.0* MCHC-34.8 RDW-13.4 Plt Ct-210
.
.
[**2193-8-9**] 05:45PM BLOOD Glucose-215* UreaN-15 Creat-0.8 Na-136
K-3.2* Cl-98 HCO3-18* AnGap-23*
[**2193-8-9**] 09:18PM BLOOD Glucose-248* UreaN-15 Creat-1.1 Na-136
K-4.0 Cl-102 HCO3-17* AnGap-21*
[**2193-8-10**] 04:43AM BLOOD Glucose-264* UreaN-17 Creat-1.0 Na-136
K-3.6 Cl-104 HCO3-20* AnGap-16
[**2193-8-10**] 11:37AM BLOOD Glucose-173* UreaN-17 Creat-0.9 Na-137
K-3.4 Cl-104 HCO3-16* AnGap-20
[**2193-8-10**] 05:53PM BLOOD Glucose-171* UreaN-17 Creat-1.0 Na-139
K-4.1 Cl-105 HCO3-18* AnGap-20
[**2193-8-11**] 03:13AM BLOOD Glucose-208* UreaN-17 Creat-1.0 Na-142
K-3.9 Cl-106 HCO3-19* AnGap-21*
[**2193-8-11**] 02:39PM BLOOD Glucose-259* UreaN-18 Creat-0.9 Na-140
K-3.4 Cl-110* HCO3-21* AnGap-12
[**2193-8-12**] 03:28AM BLOOD Glucose-251* UreaN-19 Creat-0.9 Na-141
K-4.3 Cl-108 HCO3-23 AnGap-14
.
.
[**2193-8-9**] 05:45PM BLOOD ALT-160* AST-199* CK(CPK)-[**2087**]*
AlkPhos-72 TotBili-0.8
[**2193-8-9**] 09:18PM BLOOD ALT-153* AST-207* CK(CPK)-1760*
AlkPhos-63 Amylase-24
[**2193-8-10**] 04:43AM BLOOD ALT-151* AST-195* CK(CPK)-1508*
[**2193-8-11**] 03:13AM BLOOD ALT-177* AST-194* AlkPhos-64 TotBili-0.8
[**2193-8-12**] 03:28AM BLOOD ALT-203* AST-152* AlkPhos-145*
TotBili-0.7
.
.
[**2193-8-9**] 05:45PM BLOOD cTropnT-1.01*
[**2193-8-9**] 09:18PM BLOOD CK-MB-45* MB Indx-2.6 cTropnT-1.02*
[**2193-8-9**] 10:38PM BLOOD CK-MB-47* MB Indx-2.7 cTropnT-0.81*
[**2193-8-10**] 04:43AM BLOOD CK-MB-50* MB Indx-3.3 cTropnT-0.72*
[**2193-8-10**] 11:37AM BLOOD CK-MB-43* MB Indx-3.2 cTropnT-0.60*
[**2193-8-11**] 03:13AM BLOOD CK-MB-29* cTropnT-0.55*
.
.
Brief Hospital Course:
Patient was a 70 year old man with hx of Left MCA stroke, s/p L
CEA, HTN, DM, PVD, EtOH abuse and no previous hx of seizures who
deveoped CP, indigestion symptoms, diaphoresis and chest
pressure, and was found the next morning with GTC seizure, of
unclear duration. He was intubated at an OSH and had STe at V1-4
with reciprocal changes in II, III, AVf.
.
# Status Epilepticus. He was found to be in status epilepticus.
He had a known LMCA infarct, thus reduced sz threshold, however,
in setting of fever to 104, must r/o encephalitis and
meningitis. In addition, it was possible that he is withdrawing
from EtOH (athough had "only a glass" of wine yesterday). In
addition, there was concern for a stroke (mechanism would be a
stump embolus if actually has complete occlusion). Utox and Stox
negative. Given the patients seizures, likely stroke, fever and
leukocytosis, hypoxia, and overall grim outlook the family
elected to institute comfort measures only for Mr. [**Known lastname 16968**]. Mr.
[**Known lastname 16968**] was made comfortable and given morphine for pain control.
He expired on [**2193-8-14**].
Medications on Admission:
family thinks he takes multivitamins only
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"443.9",
"438.20",
"578.9",
"434.11",
"458.9",
"518.81",
"345.3",
"305.00",
"348.5",
"276.2",
"250.00",
"V66.7",
"380.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6",
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8455, 8464
|
7214, 8330
|
306, 334
|
8515, 8524
|
5062, 7191
|
8580, 8726
|
4123, 4141
|
8423, 8432
|
8485, 8494
|
8356, 8400
|
8548, 8557
|
4156, 5043
|
238, 268
|
362, 3700
|
3722, 3854
|
3870, 4107
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,917
| 133,450
|
3372
|
Discharge summary
|
report
|
Admission Date: [**2125-11-15**] Discharge Date: [**2125-11-23**]
Date of Birth: [**2046-3-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Senna / Iodine / Optiray 350
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
abdominal pain and hypotension
Major Surgical or Invasive Procedure:
s/p l chest pigtail catheter
History of Present Illness:
The patient is a 79 yo woman well known to our service as she
redo sternotomy/bentall with Freestyle graft/CABGx1 with Dr.
[**Last Name (STitle) 914**] on [**2125-10-22**]. Her post-op course was complicated by
pericardial effusion and tamponade requiring return to the OR
for mediastinal exploration. She did develop dysrhythmias,
including rapid a-fib, for which she was unsuccessfully
cardioverted. EP was
consulted. Medications were adjusted and seh did convert to SR
prior to discharge. Coumadin was not resumed post-operatively
due to post-op bleeding and sinus rhythm at the time of
discharge. She did require CVVH post-operatively for volume
overload and was transitioned to HD, then weaned from HD. She
also developed Serratia bacteremia which was treated with cipro,
and blood cultures were clear prior to discharge. Urinalysis
was positive on discharge, and the patient was maintained on
cipro pending culture and sensitivity.
She returns to the ED today c/o vague abdominal pain and is
found to be hypotensive with SBP in the 60s in the ED. Central
line is placed, levophed is started and CT Abdomen is pending.
Initial bedside echo does not reveal evidence of pericardial
effusion.
Past Medical History:
1. Aortic stenosis s/p Aortic valve replacement with [**Company 1543**]
mosaic valve, 19mm([**2118**])-Dr [**Last Name (STitle) **]
2. Acute Congestive Heart Failure with numerous hospitalizations
3. CAD - CABG x 1 with SVG to PDA in [**2118**], PCI to LAD [**2119**]
4. HTN
5. DM2
6. DDD-Pacemaker for complete heart block-[**2118**]
7. History of left atrial appendage thrombus on coumadin
8. Schwanomma T11 to T12 s/p resection ([**2-16**]).
9. Anemia.
10. PVD with bilateral subclavian stenosis.
11. History of subdural hemorrhage after motor vehicle accident.
12. Depression
13. renal failure
14. chronic abdominal pain
Past Surgical History:
- s/p redo sternotomy/Bentall w/ freestyle/CABGx1 [**2125-10-22**]
- s/p AVR #19 Porcine/CABG x1(SVG-PDA)[**2118**]
- s/p Schwannoma s/p resection [**2119**]
Social History:
Lives with Husband. Adult [**Name2 (NI) **] Care.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
Brother MI [**79**]
Father/Mother HTN
Physical Exam:
Pulse: 80 V-paced Resp: 26 O2 sat: 100%4Lnc
B/P Right: 95/61 Left:
Height: Weight:
General: lethargic, tachypneic
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI []
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- trace Varicosities: None []
Neuro: Grossly intact x
Pulses:
Femoral Right: Left:
DP Right: NP Left: NP
PT [**Name (NI) 167**]: NP Left: NP (awaiting Doppler)
Radial Right: Left:
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2125-11-23**] 09:00AM BLOOD WBC-5.2 RBC-3.49* Hgb-10.1* Hct-30.5*
MCV-88 MCH-29.0 MCHC-33.1 RDW-16.4* Plt Ct-223
[**2125-11-16**] 04:26AM BLOOD PT-12.8 PTT-29.1 INR(PT)-1.1
[**2125-11-23**] 09:00AM BLOOD Glucose-165* UreaN-60* Creat-2.6* Na-140
K-3.3 Cl-99 HCO3-29 AnGap-15
[**2125-11-18**] 04:00AM BLOOD ALT-26 AST-23 LD(LDH)-273* AlkPhos-86
Amylase-61 TotBili-1.2
[**Known lastname **],[**Known firstname **] [**Medical Record Number 15634**] F 79 [**2046-3-14**]
Radiology Report CHEST (PA & LAT) Study Date of [**2125-11-22**] 3:55 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2125-11-22**] 3:55 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 15635**]
Reason: eval for effusion
[**Hospital 93**] MEDICAL CONDITION:
79 year old woman s/p bentall
REASON FOR THIS EXAMINATION:
eval for effusion
Final Report
HISTORY: Status post cardiac surgery, to assess for change.
FINDINGS:
In comparison with the study of [**11-21**], the monitoring and support
devices
remain in place. There is a small reaccumulation of left pleural
fluid,
without definite pneumothorax. The effusion and atelectasis at
the right base
are less prominent. The degree of pulmonary vascular congestion
has
decreased. Moderate cardiomegaly is longstanding and the
extensive heavy
mitral annulus calcification is again seen.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 15636**]Portable TTE
(Complete) Done [**2125-11-16**] at 12:41:12 PM 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: [**2046-3-14**]
Age (years): 79 F Hgt (in): 62
BP (mm Hg): 109/50 Wgt (lb): 160
HR (bpm): 80 BSA (m2): 1.74 m2
Indication: Pericardial effusion.
ICD-9 Codes: 402.90, V43.3, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2125-11-16**] at 12:41 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 15637**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West CCU
Contrast: None Tech Quality: Adequate
Tape #: 2010W000-0:00 Machine: Vivid q-2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 2.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 75% >= 55%
Left Ventricle - Stroke Volume: 57 ml/beat
Left Ventricle - Cardiac Output: 4.52 L/min
Left Ventricle - Cardiac Index: 2.60 >= 2.0 L/min/M2
Left Ventricle - Peak Resting LVOT gradient: 5 mm Hg <= 10 mm
Hg
Left Ventricle - Lateral Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *29 < 15
Aorta - Sinus Level: 2.3 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 13 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 7 mm Hg
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - Peak Velocity: 1.3 m/sec
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - E Wave deceleration time: 246 ms 140-250 ms
TR Gradient (+ RA = PASP): *27 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2125-10-24**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal
regional LV systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Calcified tips of
papillary muscles. No MS. Mild to moderate ([**12-16**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. A composite bioprosthetic aortic valve /aortic root
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet motion and transvalvular gradients.
The mitral valve leaflets are moderately thickened. Mild to
moderate ([**12-16**]+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a trivial
echodense pericardial effusion.
IMPRESSION: No clinically-significant pericardial effusion seen.
Normally-functioning composite aortic root/aortic valve
prosthesis. Small and hypertrophied LV with normal biventricular
systolic function.
Compared with the prior study (images reviewed) of [**2125-10-24**],
the findings are similar.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-11-16**] 13:44
Brief Hospital Course:
The patient was admitted to the CVICU and was briefly on
levophed and neo. She had benign abdominal studies and had a
swallowing evaluation which she passed successfully. She was
transferred to the floor on HD#1 and was aggressively diuresed.
Her foley was discontinued and she had urinary retention and it
was replaced. She grew yeast from her urine and was treated
with vaginal miconazole cream. She was followed by physical
therapy. Her son told us that she always complains of abdominal
pain and it is related to when she has gas. She was started on
simethicone PRN.
Her hypotension recurred and her blood pressure in her right arm
was much higher than her left arm. She was mentating well
during what we thought we hypotensive episodes.
She had a large left pleural effusion and interventional
pulmonology placed a pigtail catheter and obtained 400 cc and it
drained another liter of fluid overnight. She continued to
improve and was discharged to [**Location (un) 583**] House rehab on HD# 9 in
stable condition.
Medications on Admission:
1. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/t>101.
12. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day for 7 days: Stop [**11-19**].
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) for 2 weeks.
16. insulin glargine 100 unit/mL Solution Sig: One (1) 40 Units
Subcutaneous Q Breakfast.
17. insulin lispro 100 unit/mL Solution Sig: One (1) Sliding
Scale Subcutaneous four times a day: Sliding Scale. Check FS QID
0-70 - Hypoglycemic protocol
BS 71-110 - O units.
BS 111-140 - Breakfast 2 units, Lunch 2 units, Dinner 2 units,
Bedtime 0 units.
BS 141-180 Breakfast 4 units, Lunch 4 units, Dinner 4 units,
Bedtime 2 units.
BS 181-220 Breakfast 6 units, Lunch 6 units, Dinner 6 units,
Bedtime 4 units.
BS 221-260 Breakfast 8 units, Lunch 8 units, Dinner 8 units,
Bedtime 6 units.
BS >260 - [**Name8 (MD) 138**] MD.
18. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
19. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
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 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed for fever, pain.
13. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
14. insulin lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous four times a day: sliding scale.
15. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day). Tablet(s)
16. miconazole nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 3 days.
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
18. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas discomfort.
19. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
20. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
21. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
22. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed for anxiety.
23. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day): to right groin.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House Rehab & Nursing Center
Discharge Diagnosis:
1. Aortic stenosis s/p Aortic valve replacement with [**Company 1543**]
mosaic valve, 19mm([**2118**])-Dr [**Last Name (STitle) **]
2. Acute Congestive Heart Failure with numerous hospitalizations
3. CAD - CABG x 1 with SVG to PDA in [**2118**], PCI to LAD [**2119**]
4. HTN
5. DM2
6. DDD-Pacemaker for complete heart block-[**2118**]
7. History of left atrial appendage thrombus on coumadin
8. Schwanomma T11 to T12 s/p resection ([**2-16**]).
9. Anemia.
10. PVD with bilateral subclavian stenosis.
11. History of subdural hemorrhage after motor vehicle accident.
12. Depression
13. chronic abdominal pain
14. renal failure
15. s/p AVR #19 Porcine/CABG x1(SVG-PDA)[**2118**]
16. s/p Schwannoma s/p resection [**2119**]
17. s/p redo sternotomy/Bentall (21 Freestyle
tissue)/CABGx1(SVG->PDA) [**2125-10-22**]
Discharge Condition:
Alert and oriented x2 nonfocal
Ambulating with 2 assists
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
R groin: errythema with small opening being treated with
betadine and daily dsd
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: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2125-11-27**] 1:45
Cardiologist: Dr. [**Last Name (STitle) 3357**]:
Dr. [**Last Name (STitle) **]:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2125-11-26**] 1:00
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2126-1-4**]
3:40
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
We will make appointments with Drs. [**Last Name (STitle) 3357**] and [**Name5 (PTitle) **] and
[**Location (un) 15638**] House with the appointment information.
Completed by:[**2125-11-23**]
|
[
"V42.2",
"427.31",
"788.20",
"428.0",
"414.00",
"112.2",
"789.00",
"458.9",
"285.9",
"401.9",
"V45.81",
"511.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
14843, 14922
|
9443, 10471
|
327, 358
|
15775, 16073
|
3293, 4083
|
16998, 17894
|
2564, 2603
|
12677, 14820
|
4123, 4153
|
14943, 15754
|
10497, 12654
|
16097, 16975
|
2262, 2422
|
2618, 3274
|
257, 289
|
4185, 9420
|
386, 1591
|
1613, 2239
|
2438, 2548
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,821
| 182,983
|
48773
|
Discharge summary
|
report
|
Admission Date: [**2160-8-6**] Discharge Date: [**2160-9-6**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
5 months of SOB, fatigue, fevers to 102, night sweats, weight
fluctuations
Major Surgical or Invasive Procedure:
- [**2160-8-6**]: Endobronchial ultrasound with ultrasound-guided
transbronchial needle aspiration (EBUS-TBNA) by Thoracic Surgery
- [**2160-8-8**]: Right cervical lymph node biopsy
- [**2160-8-9**]: Bone marrow biopsy by Heme/Onc
- [**2160-8-19**]: Renal biopsy by Nephrology
- [**2160-8-25**]: Right video-assisted thoracoscopic (VATS) lung
biopsy, limited thoracotomy and mediastinal lymph node biopsy by
Thoracic Surgery
History of Present Illness:
Patient is a 55yoF with a h/o hodgkin's lymphoma dx in [**2148**]
treated with 6 cycles of chemotherapy [**2149**]-[**2150**] (no radiation),
and asthma who presents with 5 months of B-symptoms (afternoon
fevers to 102, chills, night sweats, progressive shortness of
breath, easy bruising). She notes these are the same exact
symptoms she had when she was first diagnosed with lymphoma in
[**2148**].
She was first evaluated for these symptoms in [**Month (only) 116**] at [**Hospital1 2177**], where
a CT scan showed mediastinal lymphadenopathy. Approximately 1
month ago, she underwent a bone marrow biopsy and
mediastinoscopy with subcarinal node biopsy that were, per the
patient's report, unrevealing. She established care here at
[**Hospital1 18**] with Dr. [**Last Name (STitle) 410**] shortly after these studies, and underwent
rigid bronchoscopy [**2160-8-6**] for lymph node biopsy (around the
RLL). The day of her procedure she was NPO all day, and only
received 700cc fluid in the OR. She did well immediately
post-op, but in the PACU developed tachycardia to the 140s,
tachypnia to the high 30s, hypotensive to the high 80s systolic
and febrile to 102, concerning for a SIRS response. She
complained of chest tightness and so an ekg, chest xray, and
labs were sent she was monitored. The ekg showed sinus
tachycardia and the first trop was negative. She was given
demerol and tylenol for rigors, started on vanc and zosyn, then
sent to the MICU. There, she was continued on the vancomycin
(lymph node gram stain showed GPCs) and rehydrated with mulitple
liters of fluid. In the MICU she was noted to be coughing up
blood tinged sputum, was given nebulizers, and required O2 only
when asleep. When her tachycardia resolved and her blood
pressure stabilized, she was sent to the floor.
As for recent infections, she was treated at [**Hospital1 2177**] for PNA in
[**5-8**], and was treated with a z-pack without resolution of
symptoms. She went to [**Hospital1 112**] with persistent symptoms, and was
diagnosed with EBV. It was during this hospitalization that she
had a CT chest/abd/pelvis showing mediastinal and abdominal LAD,
prompting the above work up.
ROS: Reports fluctuations in weight over the last few months,
chronic constipation, and recent HA which she describes as
throbbing, are focal and can occur anywhere in her head, happen
any time of the day, have associated white spots in her visual
fields, and are relieved by 2 tablets of Alieve. Patient also
has a baseline cough of clear sputum [**1-30**] cup/day. Denies sinus
tenderness, rhinorrhea, congestion, nausea, vomiting, diarrhea,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes.
**Of note, she has port in place from [**Location (un) 745**] [**Location (un) 3678**] from [**2149**],
which has not been accessed since her chemotherapy treatments
finished. It has been accessed here by [**Doctor First Name 8817**] and works and can
be used. But [**First Name8 (NamePattern2) **] [**Doctor First Name 8817**], we need records from NWH with
information about the port (we know it's not a power port, but
need lot number, refrence number, type of port). Currently
these records are in storage; NWH is in the process of
collecting these records, and will fax them to the MICU and to
[**Doctor First Name 8817**] directly.
Past Medical History:
Past Medical History:
1. Lymphocyte Depleted Hodgkins Lymphoma s/p 6 cycles of ABVD in
[**2148**]
2. asthma
3. pulmonary fibrosis
4. chronic history of mild anemia - sickle cell trait +/-
thalassemia per oncology records
5. depression
Past Surgical History:
1. hysterectomy due to uterine fibroids in [**2138**].
Social History:
She quit smoking a few weeks ago after smoking pack per day for
30 years. She does not drink alcohol. She has two daughters and
a son. She is single and lives with her son. She formally
worked as a school bus dispatcher, but says that she is now too
weak to continue to work.
Family History:
Mother died from ovarian cancer. Father is living. She had
nine siblings, three of which have passed away, one from
hepatitis, one for murder and one from unclear causes. She has
two other siblings with diabetes and a son with sarcoid. She
knows of no other cancers or blood diseases within the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 102 BP: 112/70 P: 122 R: 31 18 O2: 98
General: Alert, oriented, no acute distress very pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles at the bases
Abdomen: soft, non-tender, non-distended, bowel sounds present
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
DISCAHRGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
[**2160-8-6**] 05:09PM URINE COLOR-DkAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2160-8-6**] 05:09PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300
GLUCOSE-TR KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-6.0 LEUK-NEG
[**2160-8-6**] 05:09PM URINE RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-2
[**2160-8-6**] 05:09PM URINE HYALINE-15*
[**2160-8-6**] 05:09PM URINE MUCOUS-RARE
[**2160-8-6**] 03:35PM GLUCOSE-100 UREA N-30* CREAT-1.5* SODIUM-136
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-10
[**2160-8-6**] 03:35PM CK(CPK)-101
[**2160-8-6**] 03:35PM CK-MB-2 cTropnT-<0.01
[**2160-8-6**] 03:35PM CALCIUM-7.5* PHOSPHATE-3.7 MAGNESIUM-2.1
[**2160-8-6**] 03:35PM WBC-3.5* RBC-4.19* HGB-10.4* HCT-33.1*
MCV-79* MCH-24.8* MCHC-31.4 RDW-16.1*
[**2160-8-6**] 03:35PM PLT SMR-VERY LOW PLT COUNT-40*
[**2160-8-7**] 04:31AM BLOOD ALT-65* AST-222* LD(LDH)-1520*
AlkPhos-429* TotBili-1.6*
[**2160-8-7**] 04:31AM BLOOD Albumin-1.7* Calcium-6.6* Phos-3.4 Mg-2.0
UricAcd-5.1
DISCHARGE LABS:
[**2160-9-6**] 12:10AM BLOOD WBC-6.9 RBC-3.02* Hgb-7.9* Hct-24.7*
MCV-82 MCH-26.0* MCHC-31.8 RDW-20.3* Plt Ct-93*
[**2160-9-6**] 12:10AM BLOOD Neuts-42* Bands-0 Lymphs-51* Monos-5
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2160-9-6**] 12:10AM BLOOD PT-10.9 PTT-38.6* INR(PT)-1.0
[**2160-9-6**] 12:10AM BLOOD Glucose-107* UreaN-25* Creat-1.3* Na-129*
K-3.8 Cl-100 HCO3-23 AnGap-10
[**2160-9-6**] 12:10AM BLOOD ALT-57* AST-203* LD(LDH)-514*
AlkPhos-490* TotBili-1.5
[**2160-9-6**] 12:10AM BLOOD Albumin-1.5* Calcium-6.8* Phos-3.1 Mg-2.0
[**2160-9-3**] 12:00AM BLOOD Ferritn-5119*
[**2160-8-14**] 12:00AM BLOOD PEP-NO SPECIFI IgG-772 IgA-24* IgM-7*
IFE-NO MONOCLO
PATHOLOGY:
[**2160-8-6**] Pathology Tissue: Right Lower Lobe.
FLOW CYTOMETRY REPORT
INTERPRETATION: Non-specific T cell dominant lymphoid profile;
diagnostic immunophenotypic features of involvement by lymphoma
are not seen in specimen. Correlation with clinical findings and
concurrent morphology (see cytology report) is recommended. Flow
cytometry immunophenotyping may not detect all lymphomas as due
to topography, sampling or artifacts of sample preparation.
[**2160-8-6**] Cytology EBUS TBNA LEVEL 7 Lymph node (Level 7),
EBUS-TBNA:
NEGATIVE FOR MALIGNANT CELLS.Bronchial epithelial cells and
polymorphous lymphocytes consistent with lymph node sampling
(see note).
[**2160-8-8**] Pathology Tissue: right cervical lymph node
SPECIMEN: RIGHT CERVICAL LYMPH NODE, BIOPSY.
DIAGNOSIS:
TISSUE WITH EXTENSIVE HEMORRHAGE AND NECROSIS, INFILTRATION BY
MACROPHAGES AND SPARSE LYMPHOID INFILTRATE. SEE NOTE.
Note: The findings are concerning for infections, particularly
mycobacterial or fungal. Alternatively, the findings may
represent ??????steroid-treated?????? lymphoma. Special stains for
mycobacterial ([**Last Name (un) 18566**] and AFB), AND fungal (PAS, Mucicarmine and
GMS) organisms are negative.
Microscopic description: Slides reveal fibrous tissue with a
vaguely nodular cellular infiltrate comprised of histiocytes and
lymphocytes. Few giant cells are present. There is extensive
hemorrhage and liquefactive necrosis between the histiocytic
nodules. Focal fibrosis is also present. The pattern of necrosis
overall is suggestive of therapy effect or infection, rather
than tumor necrosis. Vessels are focally prominent. The sparse
lymphoid infiltrate is made up of small and mature appearing
lymphocytes, with rare intermixed immunoblasts, and many
interspersed foamy histiocytes.
By immunohistochemistry, the lymphoid component is predominantly
composed of CD3 and CD5 positive T cells. Only rare cells
exhibit immunoreactivity for CD20, BCL6, MUM1, or CD30. CD10
highlights stromal elements. CD45 and CD68 highlight histiocyte
groups and clusters, including some in the nonviable areas.
CD15 is negative. MIB1 stains only scattered cells.
[**2160-8-9**] Pathology Tissue: BONE MARROW CORE BIOPSY
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:CELLULAR BONE MARROW WITH MATURING TRILINEAGE
HEMATOPOIESIS AND NO MORPHOLOGIC EVIDENCE OF INVOLVEMENT BY
LYMPHOMA, SEE NOTE.
Note: The findings of increased macrophages with ingestion of
cells and debris, as well as an increased cytotoxic T cell
infiltrate with concurrent markedly elevated ferritin level,
raise the possibility of a primary, or more likely secondary,
macrophage activation syndrome. Nevertheless, lymphoma remains a
strong consideration and procurement of adequate tissue from the
PET avid mediastinal mass may represent the best chance for a
definitive diagnosis. Of note, recently EBV viremia has [**Doctor First Name **]
documented. EBV viremia increases the risk of both macrophage
activation syndrome and B cell lymphoma.
IMAGING:
EKG [**2160-8-6**]: Sinus tachycardia @128 nl axis, pr 150, qrs 98,
Qtc413
no stemi, no st dep, good r-r progression, no q waves
IMAGING STUDIES:
CXR [**2160-8-6**] - No previous radiographs available. No evidence of
pneumothorax following surgery. Cardiac silhouette is within
normal limits. Bibasilar opacification most likely reflects a
combination of atelectasis and effusion. In the appropriate
clinical setting, pneumonia would have to be considered.
Central catheter probably extends to the upper portion of the
right atrium.
[**2160-8-8**] Cardiovascular ECHO
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The 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 mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild pulmonary hypertension.
[**2160-8-8**] Radiology ABDOMEN U.S.
FINDINGS: Evaluation was limited due to poor acoustic
penetration. The liver is mildly echogenic consistent with
fatty infiltration. The portal vein is patent with hepatopetal
flow. No intra or extrahepatic biliary duct dilatation. The
common bile duct measures 4 mm and is normal. The gallbladder
is collapsed with a mildly thickened wall, but no son[**Name (NI) 493**]
[**Name2 (NI) 515**] was present. No cholelithiasis noted. There is a
small right pleural effusion. The right kidney measures 10.4 cm
and no stones or hydronephrosis is noted. The left kidney
measures 11.6 cm and is normal. The spleen measures 11.5 cm but
was not completely imaged. The visualized IVC is unremarkable.
The aorta and pancreas were not adequately imaged due to body
habitus. A prominent portal lymph node
is noted measuring 9 mm.
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease or more advanced liver disease cannot be
excluded.
2. Prominent 9-mm portal venous lymph node is non-specific and
may relate to underlying lymphoma or liver disease.
[**2160-8-9**] Radiology CHEST
FINDINGS: As compared to previous radiograph, there is no
relevant change. Likely small bilateral pleural effusions,
reactive bilateral basal areas of atelectasis, but no newly
appeared parenchymal opacity suggesting pneumonia. Moderate
cardiomegaly, known right-sided Port-A-Cath.
[**2160-8-12**] Pulmonary SPIROMETRY, LUNG VOLUMES, DLCO
Mechanics: The FVC is moderately reduced. The FEV1 is mildly
reduced. The
FEV1/FVC ratio is elevated.
Flow-Volume Loop: Moderate restrictive pattern with an abrupt
and early
termination of exhalation and a starting hesitation.
Lung Volumes: The TLC is mildly to moderately reduced. The FRC
and RV are moderately reduced. The RV/TLC ratio is normal.
DLCO: The Diffusing Capacity corrected for hemoglobin is
moderately reduced.
Impression:
Mild to moderate restrictive ventilatory defect with a
moderate gas
exchange defect. The DLCO is reduced out of proportion to the
reduction in TLC which is consistent with an interstitial
process. The FVC is likely underestimated due to an early
termination of exhalation. There are no prior studies available
for comparison.
[**2160-8-16**] Radiology UNILAT LOWER EXT VEINS
FINDINGS: Evaluation is limited due to patient body habitus and
overlying edema. Grayscale and Doppler son[**Name (NI) 1417**] of bilateral
common femoral, right superficial femoral, and right popliteal
veins were performed. There is normal compressibility, flow,
and augmentation. The right calf veins were not visualized due
to edema in the calf. Please note several of the images were
mislabelled as to the side being evaluated.
IMPRESSION: Limited study demonstrates edema with no evidence
of right lower extremity DVT. Right calf veins were not clearly
visualized.
[**2160-8-22**] Radiology CT CHEST W/CONTRAST
IMPRESSION:
1. Multiple enlarged mediastinal lymph nodes in the
paratracheal, precarinal, subcarinal, and right hilar stations,
unchanged from the prior study.
2. Diffuse interstitial lung abnormality with traction
bronchiectasis and fibrosis which is may be due to NSIP is
similar compared to the prior study except for new bilateral
pulmonary nodules. These nodules are most likely infectious
given the rapid development, however could also be due to
lymphoma and less likely other neoplasms.
3. New right pleural effusion.
4. Spleen with multiple hypodense lesions is slightly smaller
compared to the prior, although this is incompletely imaged.
5. Enlarged main pulmonary artery suggestive of pulmonary
artery
hypertension.
[**2160-8-25**]: Right middle lobe biopsy PATHOLOGY report
The poor viability and presence of extensive necrosis and
histiocytic infiltrate makes assessment difficult. Given the
extensive necrosis, presence of immunoblasts and scattered large
LMP-1 immunoreactive cells, a diagnostic consideration is an
infectious lymphadenitis, such as due to persistent EBV
infection ([**Last Name (un) **] pending). However, in patients with a known
prior history of Hodgkin lymphoma, the presence of a scattered
large cells also raises the concern for possible lymphoma with
histological appearance modified by intercurrent therapy
(steroids, etc); the strong CD20 immunoreactivity in a majority,
albeit rare, large cells, and the absence of convincing
CD30-immunoreactivity in the RS-like cells precludes an
unequivocal diagnosis of lymphoma. The findings are similar to
those present on a previous biopsy of a right cervical lymph
node (S12-31209A).
Brief Hospital Course:
Patient is a 55yoF with a h/o Hodgkin's lymphoma diagnosed in
[**2148**], treated with 6 cycles of chemotherapy [**2149**]-[**2150**] (no
radiation), and asthma who presents with 5 months of B-symptoms
(afternoon fevers to 102, chills, night sweats, progressive
shortness of breath, easy bruising); admitted after developing
tachycardia, hypotension, and fever in the PACU status post
rigid bronchoscopy for mediastinal LN biopsy. Following
extensive work up, patient was found to have
hypogammaglobulinemia and prolonged EBV viremia, possibly
resulting in her abnormal LFTs, nephrotic syndrome, and
macrophage activation syndrome.
Active Diagnoses:
# Macrophage activating syndrome: Cellular debris within
macrophages on bone marrow biopsy, admission ferritin 11k.
Etiology is unclear, possibly due to lymphoma or EBV infection.
Extensive W/U including multiple lymph node biopsies all
inconclusive. Bone marrow showed cellular bone marrow with
maturing trilineage hematopoiesis and no morphological evidence
of lymphoma, but with evidence of MAS. Ferritin down - trend EBV
PCR on Mondays
# Malignancy work up: History of lymphoma, presented with
B-symptoms and lymphadenopathy on CT torso concerning for
underlying malignant process. However, extensive work up as
detailed below did not yield clear diagnosis. Mediastinal lymph
node biopsy was inconclusive, for lymphoma vs infectious
lymphadenitis (EBV). Cervical node biopsy results were similarly
inconclusive. SPEP, UPEP, free light chains were negative. Bone
marrow biopsy showed cellular debris in macrophages consistent
with macrophage activation syndrome but no evidence of
malignancy.
-Patient had persistent pleural effusion following
video-assisted thoracoscopic surgery. Chest tube was removed
[**2160-8-27**] for decreased drainage, but drainage persisted for [**3-30**]
days after but had resolved by time of discharge. Surgical
inscisions were healing well without signs of infection as well.
Post-surgical effusion was slow to resorb due to underlying
nephrotic syndrome causing hypoalbuminemia.
-Patient has an appointment with thoracic surgery for follow up
and suture removal.
# EBV viremia: VL was obtained given prolonged fevers and liver
abnormalities. EBV VL noted to be initialy [**2171**] but weekly
titers showed persistent viremia at >1k copies. ID followed,
CMV, histoplasma, aspergillus, Beta glucan, gallactomannan and
quantTB were all negative, blood cultures were negative
throughout hospital course, hepatitis panel, HIVAb, HIV viral
load were all negative as well.
- Weekly EBV viral load as outpatient (last was [**2160-9-1**], VL 1469)
# Nephrotic syndrome: Focal segmental glomerular sclerosis on
biopsy, likely related to EBV viremia vs macrophage activation
syndrome. Patient with [**Last Name (un) **] on admission (Cr 1.5), developed
extensive anasarca with 24 hr urine protein 8 grams and
hypoalbuminemia. She was not anticoagulated for the increased
risk of thrombosis associated with nephrotic syndrome because of
concurrent thrombocytopenia. She did have one isolated episode
of leg pain, ultrasound with doppler did not show DVT, leg edema
remained symmetric. ANCA, [**Doctor First Name **], dsDNA, C3, C4 were all negative.
Renal was consulted, advised treatment with lasix and
lisinopril.
- Continue lisinopril 5mg, hold for SBP <100
- Continue diuresis with 40 PO lasix [**Hospital1 **], hold for SBP <90
- Elevate legs, wrap as needed
- Follow up with nephrology as scheduled [**2160-10-8**]
# Hypogammaglobulinemia: Acquired vs. inherited, possible common
variable immune deficiency (CVID). Normal IgG, low IgA and IgM,
no response to pneumococcal vaccine given [**5-21**]. H flu immune,
meningococcal IgG consistent with pre-vaccination reference
ranges. Immunology was consulted, agreed with trial of monthly
IVIG infusion with goal of eradicating EBV viremia. Had two
infusions of IVIG, 15mg each on [**9-3**] and [**2160-9-4**].
- Monthly IVIG to be determined by outpatient heme/onc
# Abnormal LFTs - Most likley EBV-induced vs macrophage
activating syndrom vs NASH, other infections, malignancy, or
drug reactions, autoimmune less likley following extensive work
up. Patient presented with transaminitis and hyperbilirubinemia,
abnormalities dating back at least to [**Month (only) 547**] or [**2160-5-27**] upon
presentation to [**Hospital1 112**]. RUQ ultrasound remarkable for fatty liver
infiltration and splenomegaly, hepatitis serologies were
negative.
- Patient should avoid hepatotoxic medications and alcohol
# Pancytopenia: Most likely related to EBV or macrophage
activation syndrome.
CBC was trended, she required transfusion of platelets only on
one occasion and transfusion of pRBC on two occasions. Discharge
CBC as listed in dedicated discharge summary section.
Chronic issues:
#Asthma: Patient was treated with albuterol and ipratroprium
nebs. She was treated with supplimental O2 as needed. O2
requirement had resolved at time of discharge.
# Pulmonary fibrosis s/p bleomycin: Pulmonary function testing
was performed which showed mild to moderate restrictive
ventilatory defect with a moderate gas exchange defect. The DLCO
was reduced out of proportion to the reduction in TLC,
consistent with an interstitial process, likely due to bleomycin
toxicity. Confirmation of fibrosis on biopsy this admission.
Transitional Issues:
# Outpatient follow up with Dr. [**Last Name (STitle) 410**] to discuss possible
initiation of steroids
# Will have outpatient follow up with renal
# Monthly IVIG infusion at heme/onc clinic
# Access: Hickman catheter in place- 10 years per hx
# Patient has been spiking low grade temps likely related to her
underlying disease process, please call Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **]
office at [**Telephone/Fax (1) 3760**] if temperature above 101F or change in
clinical status.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
5. Vitamin D 1000 UNIT PO DAILY
6. Naproxen 500 mg PO Q8H:PRN pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
2. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
3. Vitamin D 1000 UNIT PO DAILY
4. Furosemide 40 mg PO BID
Hold for SBP <90
5. Lisinopril 5 mg PO DAILY
hold for SBP<100
6. Guaifenesin [**6-5**] mL PO Q6H:PRN cough
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 1 TAB PO BID:PRN constipation
9. Simethicone 40-80 mg PO QID:PRN gas
10. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Hold for somnolence or RR <10
11. Morphine Sulfate 2-4 mg IV Q2H:PRN pain
for severe surgical site pain. please hold for somnolence or RR
<10
12. Docusate Sodium 100 mg PO BID
Hold for loose stools
13. OxycoDONE (Immediate Release) 5-10 mg PO Q3H:PRN pain
Please hold for somnolence or RR<10
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: [**Doctor Last Name 3271**]-[**Doctor Last Name **] Viremia, macrophage activation
syndrome
Secondary diagnosis:
Abnormal liver function test
Nephrotic syndrome
Hypogammaglobulinemia
Asthma
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 Mrs. [**Known lastname **],
It was a pleasure taking part in your care during your
hospitalization at [**Hospital1 18**]. You presented with fevers, sweats and
shortness of breath along with enlarged lymph nodes on CT scan
of your chest and abdomen. You had a procedure called a
bronchoscopy to obtain a biopsy of your enlarged lymph nodes,
following which you had low blood pressures and difficulty
breathing, for which you required a brief stay in the intensive
care unit. To further investigate the cause of your symptoms you
underwent biopsies of your bone marrow, kidney and lymph nodes
in your lung and neck. You were found to be suffering from an
immune deficiency (low antibodies) that may have allowed an
infection with [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus to affect your blood cells,
liver, and kidneys. You were treated with a medicine called IVIg
to give you extra antibodies, and were stable to be discharged
to a rehabilitation facility to improve your strength. Please
use caution and do not take any substances that may further harm
your kidneys or liver, such as alcohol, tylenol, or NSAIDS (like
ibuprofen or Advil). You should continue to take the lisinopril
and lasix as directed in your medication list to decrease the
swelling in your legs, and follow up with the kidney doctors [**First Name (Titles) **] [**Name5 (PTitle) **].
Your surgeons have advised you to do the following:
* Monitor your surgical incision carefully and call your
surgeon, Dr. [**Last Name (STitle) 7343**], if you see increasing redness, pus, or
separation of the incision
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Followup Instructions:
Please follow up with your oncologist, Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] within
the next week. Someone from his office will call you to notify
you of the time and date of your appointment. If you do not hear
from someone by Tuesday ([**9-9**]), please call ([**Telephone/Fax (1) 16336**].
Department: THORACIC SURGERY
When: THURSDAY [**2160-9-11**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15855**], MD [**Telephone/Fax (1) 2348**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
For concerns related to your lung biopsy surgery, please call
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 2348**].
Department: NEPHROLOGY - WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2160-10-8**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2160-9-6**]
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"41.31",
"32.20",
"40.11",
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
23510, 23516
|
16433, 17066
|
376, 803
|
23769, 23769
|
5790, 5790
|
25829, 27251
|
4878, 5185
|
22744, 23487
|
23537, 23537
|
22344, 22721
|
23952, 25806
|
6797, 10620
|
4508, 4565
|
5771, 5771
|
21800, 22318
|
262, 338
|
831, 4227
|
23669, 23748
|
5806, 6781
|
23556, 23648
|
23784, 23928
|
21246, 21779
|
17085, 21230
|
4271, 4485
|
4581, 4862
|
10637, 16410
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,289
| 118,784
|
13804
|
Discharge summary
|
report
|
Admission Date: [**2153-12-30**] Discharge Date: [**2154-1-6**]
Date of Birth: [**2081-10-15**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname 41485**] is a 72 year old
female with a history of hypertension who presented to an
outside Emergency Department after she experienced the sudden
onset of low back pain. She had associated symptoms
including abdominal pain which was a band-like pain and
constant, diaphoresis, and nausea and vomiting. There was no
chest pain, no shortness of breath, no lightheadedness.
There were no paresthesias or weakness. She has never had
any such pain before in her life.
At the outside hospital, an abdominal ultrasound was
performed which revealed aortic dissection. The patient was
transferred to [**Hospital1 69**] for
further management.
Blood pressure upon arrival to the Emergency Department was
190/79.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Osteoarthritis.
3. Glaucoma.
4. Polymyalgia rheumatica.
5. Status post cholecystectomy.
6. Status post removal of part of the pancreas, right
nephrectomy and splenectomy due to a pancreatic cyst which
was later found to be benign.
ALLERGIES: Plaquenil.
CURRENT MEDICATIONS AT HOME:
1. Lotensin 20 mg p.o. q. day.
2. Vioxx.
3. Pepcid.
SOCIAL HISTORY: Thirty to forty pack year smoking history
and she drinks two drinks per day.
PHYSICAL EXAMINATION: On admission, temperature of 96.0 F.;
blood pressure of 146/50 while on Nipride and Esmolol drip.
Heart rate of 61. Physical examination is notable for
regular rate and rhythm, with no evidence of aortic
insufficiency murmur. There are no carotid bruits. There is
no abdominal bruit. Abdominal examination is benign.
Neurological examination obtained in the Emergency Department
shows cranial nerves II through XII to be intact. Dorsalis
pedis and posterior tibialis pulses are present bilaterally.
LABORATORY: EKG shows normal sinus rhythm at a rate of 61.
There are no ST segment elevations or Q waves.
Labs are remarkable for an elevated white blood cell count of
17.1 but the remainder of her labs are unremarkable.
CT scan of the chest, abdomen and pelvis showed an aortic
dissection extending from the level of the pulmonary vein
beyond the left subclavian and into the celiac artery but not
including the celiac artery. There was no evidence of
contract extravasation. There is no ascending aortic
involvement. There is no aortic arch involvement.
HOSPITAL COURSE:
1. AORTIC DISSECTION: The patient was admitted with a Type
B aortic dissection. She was initially placed on a Nipride
and Esmolol drip to maintain her systolic blood pressures
between 100 and 120. She was noted to have a very labile
systolic blood pressure. She was noted to become easily
agitated which would cause her blood pressures to rise up to
the 160s.
In the Coronary Care Unit, she was slowly transitioned to
p.o. medication and off Nipride and esmolol. Eventually, she
was able to be weaned off drip. In the Emergency Department,
a Vascular Surgery consultation had been obtained. Vascular
Surgery followed her for the remainder of the
hospitalization.
They recommended continuing medical management as they did
not feel that there was indication for surgical intervention.
At the time of discharge, the patient was requiring
amlodipine 10 mg p.o. q. day, labetalol 800 mg p.o. twice a
day and Lisinopril 40 mg p.o. q. day, to maintain her
systolic blood pressure in the one-teens to 120 range. The
patient was also counseled about smoking cessation, which she
agreed to. She was also asked to limit alcohol intake to a
maximum of one to two drinks per day.
During the course of the hospitalization, the patient
complained of left flank pain which was positional. A repeat
chest, abdomen and pelvic CT angiogram was performed. It
showed no extension of the aortic dissection.
2. CEREBROVASCULAR ACCIDENT: On admission, the patient had
no focal neurological findings. CT angiogram on admission
showed no involvement of the aortic arch to suspect extension
of the dissection up into the carotids. On approximately
hospital day number four, the patient was noted to have
difficulty using her right hand to lift up a drinking cup.
The patient was examined and was found to have no appreciable
weakness on examination.
Her blood pressure was being tightly controlled with a goal
systolic blood pressure between 100 and 120 due to her Type B
aortic dissection. At one point, she was noted to have very
labile blood pressures and became briefly hypotensive but she
quickly returned to baseline after Nipride drip was turned
off. The patient again complained of weakness in the right
leg greater than the right arm. Again, neurological
examination showed some mild right upper extremity weakness
with four out of five strength proximally but no pronator
drift on examination. She was also noted to have give-way
weakness of the right lower extremity.
A repeat chest CT angiogram was performed which showed no
involvement of the aortic arch to suggest dissection to the
carotids. An MRI / MRA of the brain was obtained which
showed possible narrowing of the left posterior cerebral
artery and inferior division of the left middle cerebral
artery origin, but the study was severely limited by motion.
It also showed a left sided subcortical subacute watershed
infarction of the posterior frontal lobe and extending into
the parietal lobe and toward the posterior portion of the
lateral ventricle.
A Neurology consultation was obtained to recommend further
management given the patient's aortic dissection. Neurology
recommended aiming for the highest systolic blood pressure
possible in the goal range for aortic dissection, which is
120. They also recommended doing studies of her carotids.
The patient was started on aspirin 325 mg p.o. q. day as well
as Lipitor.
At the time of discharge, the patient's neurologic findings
were resolving but her walking was still limited by the right
lower extremity weakness.
3. RHEUMATOLOGY: On admission, the patient was noted to
have arthritic changes of the hand. There was concern that
possibly the patient may have a vascular disease which may be
effecting her aorta and thus leading to her aortic
dissection. A Rheumatology consultation was obtained.
Work-up included as follows: Plain x-rays of the hand showed
findings most consistent with osteoarthritis. ESR was
negative. [**Doctor First Name **] was negative and rheumatoid factor was
negative. Rheumatology noted that given the patient's past
medical history of polymyalgia rheumatica that giant cell
arteritis is associated with aortic dissection. However, the
patient had no jaw claudication or temporal tenderness on
examination. Her ESR was also 15. Based on these, were not
consistent with giant cell arteritis.
They felt that her physical examination findings were most
consistent with osteoarthritis and recommended continuing
Vioxx. Rheumatology also noted that renal artery stenosis
can be associated with certain arthritides. Abdomen CT
angiogram showed no evidence of renal artery stenosis in her
one remaining renal artery.
4. URINARY INCONTINENCE: On admission, a Foley catheter was
placed to monitor input and output. During the hospital
stay, the Foley was removed, however, the patient had
difficulty holding her urine and difficulty getting up out of
bed to go to the urinal. She decided to have the Foley put
back in. The patient states that she has a history of
urinary incontinence at home.
CONDITION ON DISCHARGE: Condition on discharge was stable.
A Foley catheter was in place due to urinary incontinence
which is an old medical problem. She is chest pain and back
pain free with no evidence of continuing dissection. The
patient continues to have difficulty ambulating due to her
right lower extremity weakness but has good use of the right
upper extremity, and no evidence of cranial nerve involvement
or sensory deficit.
DISCHARGE STATUS: The patient is discharged to
Rehabilitation for Physical [**Hospital **] rehabilitation as well as
[**Hospital 4038**] rehabilitation.
DISCHARGE DIAGNOSES:
1. Type B aortic dissection, thoraco-abdominal.
2. Hypertension.
3. Ischemic stroke (watershed infarction of the left middle
cerebral artery territory).
4. Anxiety.
5. Urinary incontinence.
DISCHARGE MEDICATIONS:
1. Vitamin D 400 units p.o. q. day.
2. Calcium carbonate 500 mg p.o. three times a day.
3. Senna p.o. twice a day p.r.n.
4. Docusate 100 mg p.o. twice a day.
5. Ambien 5 mg p.o. q. h.s. p.r.n.
6. Famotidine at 20 mg p.o. twice a day.
7. Amlodipine 10 mg p.o. q. day.
8. Diazepam 5 mg p.o. q. six hours p.r.n.
9. Vioxx 12.5 mg p.o. q. day.
10. Labetalol 800 mg p.o. twice a day.
11. Lisinopril 40 mg p.o. q. day.
12. Lipitor 10 mg p.o. q. day.
13. Enteric-coated aspirin 325 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient is asked to follow-up with her primary care
physician for strict control of her blood pressure. The
patient will schedule an appointment with her primary care
physician.
2. The patient is discharged to an extended care facility,
[**Hospital6 1293**] in [**Location (un) **].
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 41486**]
MEDQUIST36
D: [**2154-1-5**] 17:04
T: [**2154-1-5**] 17:42
JOB#: [**Job Number 41487**]
|
[
"441.03",
"434.91",
"342.90",
"305.1",
"300.00",
"365.9",
"788.30",
"715.34",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8206, 8402
|
8425, 8925
|
2523, 7588
|
8949, 9509
|
1262, 1318
|
1438, 2506
|
167, 928
|
950, 1241
|
1336, 1414
|
7614, 8185
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,697
| 116,664
|
31375
|
Discharge summary
|
report
|
Admission Date: [**2168-7-7**] Discharge Date: [**2168-7-11**]
Date of Birth: [**2120-9-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Methadone
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
left sided neglect, right sided weakness, dysarthria
Major Surgical or Invasive Procedure:
[**2168-7-7**] L frontal craniotomy & tumor resection
History of Present Illness:
Patient is a 47 year old woman with a history of metastatic
melanoma with mets to the abdomen, brain, right tibia initially
found via a shoulder lesion which was excised. She underwent
craniotomies for resection of Brain lesions with Dr [**Last Name (STitle) **] in
[**2164**] and [**2165**], as well as cyberknife 3 times in [**2164**] and [**2165**]
following her resections and then again in [**2166**]. She was seen by
Dr [**Last Name (STitle) 724**] in clinic on [**6-23**] after an MRI on [**6-22**] showed worsening
of her left frontal and left cerebellar lesions in the interval
from her last MRI which was done in [**2166-12-24**]. She
reported 3 days of progressive left sided weakness prior to that
visit. Plan following that visit was for her to be discussed in
brain [**Hospital 341**] Clinic on [**6-27**] with neuro-onc, rad-onc, and
neurosurgery. On [**6-24**] she developed what was described by OSH
reports as expressive aphasia and left facial droop which were
not noted in Dr [**Last Name (STitle) 73943**] note from [**6-23**]. She was subsequently
transferred to [**Hospital1 18**] for further management given these
findings.
Of note at the OSH she was found to have a hematocrit of 15 a
hemoglobin of 4.3, a WBC of 31.9, and a platelet count of 920.
She was given Decadron 10mg IV x 1, as well as 2 units of RBCs
and transferred here. On arrival she was evaluated by the ED who
found that she also had a guaiac positive rectal exam.
Past Medical History:
PAST ONCOLOGIC HISTORY: (from OMR)
- [**1-26**] 0.47-mm thick, [**Doctor Last Name 10834**] level II melanoma resected from
right shoulder lesion during her second pregnancy, then observed
- [**2162**] developed a forehead nodule and a biopsy in [**2163-8-24**]
revealing melanoma. PET/CT scan revealed uptake in the right
frontal bone, a 2 cm soft tissue mass near the ascending colon
and in the right tibia
- Cyberknife radiosurgery to the skull lesion on [**2163-10-11**],
followed by
high-dose IL-2 therapy that was started on [**2163-11-14**]. A follow
up PET/CT at week 11 revealed interval increase in size of the
right
tibial lesion, but no FDG avidity in the right frontal bone or
ascending colon soft tissue mass.
- XRT to the right tibia over 5 fractions completed on [**2164-3-15**].
Follow up tibial MRI showed increased enhancement while PET scan
was stable in that area.
- right tibial metastasis resected by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**], M.D. on
[**2164-12-26**]. She took Chinese herbal medication until [**2165-3-5**].
She then received ipilimumab treatment from [**2165-3-6**] to [**2165-5-22**]
in a phase II protocol.
- [**9-/2164**], she developed forgetfulness and frontal headaches.
Outpatient head MRI on [**2164-10-18**] showed a large right frontal
heterogeneously enhancing mass suggestive of a metastasis.
- resection by [**Name8 (MD) **], M.D. on [**2164-10-18**], and the pathology was
metastatic melanoma.
- Cyberknife radiosurgery to the resection cavity from [**2164-11-6**]
to [**2164-11-8**] to 2,400 cGy (800 cGy x 3 fractions). She later had
more Cyberknife radiosurgery procedure to a left parietal brain
metastasis on [**2165-9-27**] to 2,000 cGy at 78% isodose line. She
then had a left parietal craniotomy for resection of hemorrhagic
tumor by Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] on [**2165-12-23**], followed by more Cyberknife radisurgery to a
left cerebellar to 2200 cGy at 79% isodose line on [**2165-12-25**], and
another Cyberknife radiosurgery to a left medial frontal
metastasis on [**2166-4-15**] to 2,200 cGy at 75% isodose line.
- One month F/U brain MRI was stable. PET scan on [**2166-5-19**]
revealed increased FDG avidity in the right tibia and in the
posterior stomach felt c/w recurrent disease.
- She began compassionate-use ipilimumab on [**2166-6-25**] with
worsening right LE pain noted. She received radiation, 10
fractions over two weeks, to the RLE, completed on [**2166-11-19**].
- underwent resection of the right proximal tibia and
reconstruction with an oncologic hinged proximal tibia
replacement prosthesis on [**2167-2-4**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**].
- status post EGD with biopsy on [**2167-7-16**] showing melanoma,
and
- received PD-1 antibody treatment from [**2168-1-27**] to [**2168-4-20**].
- Left occipital craniotomy resection of brain mass [**2168-7-7**]
Social History:
No tobacco, alcohol or drug use. Lives with her husband who is
her HCP. Brother is very involved in care as well. On Hospice
Family History:
Mother had pancreatic cancer and diabetes at 63. Her
grandmother's brother died of melanoma and her great grandmother
died of colon cancer.
Physical Exam:
Gen: cachetic, tired, comfortable, NAD.
HEENT: Pupils: PERRL EOMs left gaze neglect but crosses
midline with prompting
Neck: Supple.
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, flat
affect.
Orientation: Oriented to person, place, and date.
Language: some dysarthria, pt says her speech feels garbled, she
has good comprehension and repetition. Naming intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
3mm bilaterally. Visual fields are difficult to assess given
patient cooperation
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus when prompted, has a left gaze neglect.
V, VII: Left facial droop sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue deviates to left without fasciculations.
Motor: decreased bulk and tone bilaterally. No abnormal
movements
or tremors. LUE 4+, RUE grip 5-, [**Hospital1 **] and tri [**3-28**], LLE 4+
throughout, RLE IP 4, Q/H/Gas/AT/[**Last Name (un) 938**] [**3-28**], No pronator drift.
Left
sided exam likely secondary to neglect as patient verbalizes
knowledge she is moving right when asked to move left. With much
prompting and discussion moves left side well
Sensation: Decreased on left upper and lower extremities likely
secondary to neglect. On right side is Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger with right upper
extremity, does not complete on left side
Discharge exam:
Gen; pleasant and cooperative
neuro: AOX3 PERRL, EOM intact, face symmetric, motor [**5-28**] except
for LLE secondary to known osteosarcoma, sensory intact to light
tough, no clonus
skin: incision intact, clean and dry with absorbable monocryl
sutures in place.
Pertinent Results:
MRI Brain [**6-22**]
1. Marked interval increase in size of the left frontal
contrast-enhancing lesion, with an even larger interval increase
in surrounding vasogenic edema in the bilateral frontal lobes,
which now causes subfalcine herniation with 9-mm rightward shift
of midline structures, as well as further effacement of
the frontal [**Doctor Last Name 534**] of the left lateral ventricle.
2. Minimal increase in size and comparatively larger interval
increase in surrounding vasogenic edema seen at the left
cerebellar enhancing lesion.
3. Stable contrast enhancement adjacent to the right frontal
lobe resection cavity.
4. No new lesions detected.
MRI Brain [**2168-7-7**]
No significant changes are identified since the most recent
examination, unchanged left frontal heterogeneous enhancing
lesion, similar pattern of enhancement surrounding the right
frontal surgical cavity with ex
vacuo dilatation of the ventricular frontal [**Doctor Last Name 534**]. Fiducial
markers are in
place. Stable left cerebellar enhancing lesion. No new lesions
are
identified since the most recent exam.
CT Head [**2168-7-7**]
Expected post craniotomy appearance.
MRI Brain [**2168-7-8**]
1. Small amount of residual circumferential nodular enhancement
around the left frontal surgical bed. Continued attention to
this area should be paid on followup exams.
2. Expected postoperative findings of pneumocephalus, a small
amount of blood products, and cytotoxic edema is present.
3. Stable appearance of prior resections in the left parietal
and right
frontal lobes. A stable pattern of enhancement is present
adjacent to the
right frontal lobe resection.
4. Tiny regions of nodular dural thickening with mild
enhancement. Attention to these lesions should be paid in
followup exams.
Brief Hospital Course:
47 y/o F with L frontal metastatic lesion with L neglect, R arm
weakness and dysarthria presents for elective tumor resection.
She was taken to the OR on [**7-7**] with no complications. She was
transferred to the ICU post surgery.
On [**7-9**], the patient was started on iron for a hematocrit of 24.
Her dose of Dexamethasone was weaned, and her Foley was
discontinued. (**Concern for tongue deviation on [**7-9**] exam??**)
The following day, her hematocrit decreased to 23 and she was
transfused 2 units of pRBCs. He post transfusion hematocrit was
31%. She was evaluated by PT and was deemed stable for
discharge with outpatient physical therapy.
Medications on Admission:
citalopram, dexamethasone, keppra,
lidocaine patch, ativan, ritalin, omeprazole, oxycodone
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp/ha
max 4g/24hrs
2. Citalopram 20 mg PO DAILY
3. Dexamethasone 2 mg po bid Duration: 30 Days
RX *dexamethasone 2 mg twice a day Disp #*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg twice a day Disp #*60 Capsule Refills:*0
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluconazole 200 mg PO Q24H Duration: 4 Days
RX *Diflucan 200 mg daily Disp #*4 Tablet Refills:*0
7. Lorazepam 0.5 mg PO Q8H:PRN nausea, anxiety
8. MethylPHENIDATE (Ritalin) 5 mg PO QAM
9. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg twice a day Disp #*60 Capsule Refills:*0
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg every four (4) hours Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice
Discharge Diagnosis:
L frontal metastatic lesion
pterygium
post operative anemia
constipation
oral candidiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? **You have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You will need an appointment in 2 weeks at the Brain [**Hospital 341**]
Clinic and please call. Their phone number is [**Telephone/Fax (1) 1844**]. The
Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in
the [**Hospital Ward Name 23**] Building, [**Location (un) **].
- Please follow up with Ophthomolgy in [**7-1**] weeks for your
Pterygium for evaluation and treatment.
Completed by:[**2168-7-11**]
|
[
"285.9",
"780.39",
"V12.54",
"V16.0",
"372.40",
"V10.82",
"784.51",
"729.89",
"112.0",
"300.00",
"781.94",
"198.3",
"781.8",
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] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
10558, 10612
|
9000, 9658
|
340, 395
|
10745, 10745
|
7182, 8977
|
12386, 12886
|
5035, 5178
|
9800, 10535
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10633, 10724
|
9684, 9777
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10896, 12363
|
5193, 5437
|
6899, 7163
|
247, 302
|
423, 1882
|
5691, 6883
|
10760, 10872
|
1904, 4873
|
4889, 5019
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,914
| 145,788
|
22927
|
Discharge summary
|
report
|
Admission Date: [**2141-1-30**] Discharge Date: [**2141-3-18**]
Date of Birth: [**2070-7-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
N/V and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70 y/o male with PMHx of DM II, HTN, prostate adenocarcinoma s/p
prostatectomy presented to [**Hospital3 **] with sudden onset
N/V/abdominal pain that began [**1-28**] in the am after breakfast.
Per patient's family, patient had abrupt onset of nausea and
violent non-bloody emesis, accompanied by diaphoresis. He had
apparently been complaining of vague stomach pain for several
days prior. + constipation. Had another episode of emesis, and
presented to [**Hospital1 **]. Very rare EtOH use.
On [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] admission, was afebrile. WBC 20,000 with 18 bands,
HCT 44.7. ALT 170, AST 311, Tbili 2.9, alk 188 lipase >[**2136**],
amylase >4000. CT abdomen showed enlarged pancreas with
peripancreatic stranding, but no definite abscess, phlegmon or
pseudocyst. Multiple GB stones, though no GB distension.
Was started on hydration, pain controled with dilaudid. T bili
subsequently decreased to 1.5, alk to 79, alt 67, ast 114 [**1-29**].
Developed worsening respiratory failure and hypotension:
ABG [**1-29**] 7.34/23/69
ABG [**1-29**] 7.30/29/71
ABG [**1-30**] am 7.28/33/73
ABG [**1-30**] am 7.23/35/69 6L NC
Chest film [**1-30**] showed R basilar atelectasis vs infiltrate.
Became incrasingly tachypnic with RR> 40, tachy > 140, was
intubated [**1-30**] am for hypoxic RF and acidemia. Also started on
empiric imipenem/vancomycin [**1-30**].
Calcium was 4.1 [**1-30**], IV repletion begun. Developed ARF, with
Cr 1.0 -> 1.6, continued on IVF (1-2L/day). Cultures from [**Hospital1 **]
no growth to date. On ambulance transfer, patient became
hypotensive to the 40s in the setting of increased sedation and
paralysis, and received an additional 1L of saline.
ROS: (per records and family) prior to [**Hospital1 **]: no fever, chills,
HA, SOB, chest pain, myalgia or arthralgia. No recent changes
in medications (has been on same lipitor dose for over a year).
Past Medical History:
prostate adenoca, s/p radical prostatectomy [**2-7**]
DM II, on glyburide/metformin
hyperlipidemia
HTN
Syncope [**2137**], underwent Echo and ETT, reportedly unremarkable.
No known h/o gallstones.
Social History:
married, lives with wife. Retired, press operator x 24 yrs.
No ETOH.
Family History:
non-contributory
Physical Exam:
Tc: 100.1 P 120 BP 95/32 (on levophed 0.1) RR 24
patient found lying flat in bed, intubated, sedated.
anicteric, conj uninjected, pupils 2mm and reactive bilaterally,
mm dry.
no cervical adenopathy
Regular tachy rhythm, nl s1 s2, no m/r/g
CTA anterolaterally
abdomen distended, no involuntary guarding
no rashes or purpura
trace pedal edema
hyperkeratottic nails
somnolent, sedated, not arousable to voice or painful stimuli,
not moving spontaneously
Pertinent Results:
[**2141-1-30**] 08:21PM WBC-12.6* RBC-3.43* HGB-10.5* HCT-32.7*
MCV-95 MCH-30.7 MCHC-32.2 RDW-14.2
[**2141-1-30**] 08:21PM PLT COUNT-153
[**2141-1-30**] 08:21PM NEUTS-65 BANDS-24* LYMPHS-7* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2141-1-30**] 08:21PM PT-16.0* PTT-33.8 INR(PT)-1.6
.
[**2141-1-30**] 08:21PM GLUCOSE-166* UREA N-39* CREAT-2.7*
SODIUM-150* POTASSIUM-4.2 CHLORIDE-126* TOTAL CO2-15* ANION
GAP-13
[**2141-1-30**] 08:21PM ALBUMIN-2.2* CALCIUM-4.0* PHOSPHATE-2.8
MAGNESIUM-1.3*
[**2141-1-30**] 08:21PM ALT(SGPT)-37 AST(SGOT)-130* LD(LDH)-1317*
CK(CPK)-4258* ALK PHOS-59 AMYLASE-1069* TOT BILI-0.9
[**2141-1-30**] 08:21PM LIPASE-442*
.
[**2141-1-30**] 08:21PM CK-MB-21* MB INDX-0.5 cTropnT-<0.01
.
ECG on admission: sinus tachycardia, nl axis, PR, QRS intervals.
Low voltages. TWF aVL.
.
Brief Hospital Course:
A/P: 70 yo M with DM II, HTN, hyperlipidemia admitted with acute
pancreatitis( by amylase, lipase, CT scan) felt secondary to
choledocholithiasis. Course was complicated by shock,
respiratory failure, persistent fevers, and other issues as
stated below:
.
1. Pancreatitis - Followed closely for necrotizing pancreatitis,
phlegmon, pseudocyst development given elevated HCT on
presentation, high [**Last Name (un) 5063**] score, and low calcium suggestive of
saponification. However multiple CT abdomens with no evidence of
abscess/ phlegmon/ or pseudocyst and only small amount of fluid.
Some areas of decreased enhancement in pancreas which could be
necrotic changes, no change over time. Initially covered
empirically with meropenem, vancomycin which were discontinued
[**2-8**] given no evidence of infection. Pt has significant third
spacing. Bladder pressures were followed, and initially >20 but
then decreased to within normal range. Repeat abd CT on [**3-10**]
showed extensive peripancreatic fluid.
.
2. Ileus: Pt developed intermittent abdominal distension
concerning for ileus and had his NGT to suction w/TF thru
postpyloric, some concern for illeus. TF were intermittently
held.
.
3. Fevers: Pt had persistent fevers for greater than 1 month of
unclear etiology. The known sources were C diff positive (was on
flagyl and vanco), pancreatitis (without evidence of pseudocyst/
abscess on numerous abdominal CT scans). On [**2-12**] bcx grew [**2-7**]
coag (-) staph (from LSC). On [**2-13**] LSC line was pulled, with the
cx tip(+) fo coag neg staph. Pt was given 7 day course of vanco
from removal of line
Pt continued to have diarrhea but had numerous negative C. diff
(negative [**2-13**], [**2-12**], [**2-3**], [**2-2**]). Treated with flagyl. On
[**2-20**], pt had diagnostic paracentesis with cultures that grew out
[**2-7**] lactobacillus, [**3-10**] grew out Bacteroides fragilis. Pt had
persistent fevers off abx and hypotension, c/w septic
physiology. On [**2-24**], started on vanco/levo/flagyl started [**2-24**].
Pt treated like he was septic. On [**2-28**], CT head showed sinuses
with left maxillary sinus thickening. On [**3-1**] found to be C.
diff (+); po vanco started in addition to IV flagyl. On [**3-2**]
bronch done; given mucus plugging and concern for VAP, added
ceftazidime. Pt found to have DVT.
.
# Hypotension: Pt has been intermittently hypotensive.
Throughout, responded well to colloid (albumin/ blood). He was
on and off levophed. Appropriate [**Last Name (un) 104**] stim test.
.
# Atrial Fib vs AT: Had new Afib vs Aflutter. Initially on
heparin gtt. Spontaneously converted to NSR; heparin gtt
discontinued.
.
# Hypocalcemia, resolved: [**3-8**] pancreatitis. Initially on Ca
Gluconate drip but switched to PRN repletion.
.
# ?Seizure activity: Pt presented with intermittent generalized
body shaking; not typical seizure activity. Felt sz activity vs
myoclonus. Increased Versed and checked head CT which had no
acute change. Neuro consulted, not felt to be seizures.
.
# ICU neuropathy: Pt found to be flaccid around [**2-28**]. Had normal
CK. EMG performed on [**3-1**] was c/w ICU neuropathy. MRI of c-spine
found no acute pathology. Pt was given PT.
.
# Resp Failure: Pt developed respir failure in setting of
sepsis. Had failure to wean and is s/p tracheostomy [**2-22**] by IP.
Tolerated PSV well. On [**3-2**] desated to 80%; had CXR w/ sig LLL
collapse. Bronch removed large mucus plugs, sats improved.
Continued to have intermittent episodes of desat's likely [**3-8**]
intermittent mucous plugging.
.
# Volume overload: Pt remained volume overloaded throughout
hospitalization. Is most likely intravascularly dry with
extensive third spacing.
.
# ARF: Cr peaked 4.8 almost certainly ATN from
hypotension/shock. Following aggressive hydration for goal MAP
>60, creat trended down by [**2-19**] to Cr 0.9.
.
# DVT: Found to have DVT. Started on heparin drip.
.
# CK leak: [**3-8**] pressors vs myositis vs rhabdo. This resolved
.
# Anemia - Followed serial HCT and Tx for HCT < 28.
.
# DM - Remained on insulin drip, holding oral agents.
.
# hyperlipidemia - Lipitor held [**3-8**] increased CK/ pancreatitis.
.
# Scrotal swelling, resolved: [**2-3**] scrotum-->swollen, dusky,
and cold. urology consulted --> rec'd elevation and improved
.
# Hypernatremia: [**3-8**] to lasix drip (now off), got free water
boluses, D5W. Resolved.
.
# psych: started on zoloft
.
# FEN: On/off TF
.
# Mental status: For the last couple weeks of pt's ICU stay, he
became increasingly minimally responsive to stimuli. Unable to
follow commands, answer questions, or interact with family
members.
.
# [**Month/Day (2) 3225**]: Pt was unable to be weaned from vent. He continued to
have septic physiology; on and off pressors. He developed almost
every possible ICU complication, as stated above. After several
weeks of no clinical improvement, decision was made to make pt
[**Name (NI) 3225**].
Medications on Admission:
Meds on [**Hospital1 **] admission: lisinopril 10, glyburide 2.5,
metformin 500
lipitor 40
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
pancreatitis, sepsis, respiratory failure, ICU neuropathy, DVT
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
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icd9cm
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9094, 9103
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,254
| 197,167
|
34058
|
Discharge summary
|
report
|
Admission Date: [**2105-8-19**] Discharge Date: [**2105-8-24**]
Date of Birth: [**2026-12-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
right foot pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
78 yo M with IDDM, AF on coumadin, CAD, dCHF presenting with
right foot pain. Patient reports that his right foot has been
red for some time, but in the last 2 days it has become painful,
and he is unable to ambulate. He fell out of bed several days
ago, banging his right knee and the right toes, with worsening
redness, however it was red before that event. He has had
chills, but did not take his temperature at home. He reports
urinary frequency but denies dysuria. He also reports shortness
of breath but no chest pain, no worsening LE edema.
In the ED, initial vital signs were 97.3 120 136/74 18 96%. Exam
was consistent for LE cellulitis, and xray of the foot showed no
evidence of subcutaneous air or fracture. Labs were notable for
WBC of 14.1 with left shift, Cr 1.8 (baseline), and positive
urinalysis. Patient received 1g IV vancomycin, 1 L NS and 5mg IV
morphine and was transferred to the floor for further
management.
On arrival to the floor, initial vital signs were 97.5 110/60 97
20 99% 2LNC. Patient reports pain in the right toe and mild
shortness of breath.
Past Medical History:
- hypertension
- hyperlipidemia
- DMII- on insulin
- Chronic kidney disease
- Chronic atrial fibrillation- on coumadin
- Ostium secundum ASD s/p repair [**2089**]
- Functional TR s/p annuloplasty ring [**2089**]
- Multivessel CAD- noted on cath [**7-/2103**], no h/o interventions
- diastolic CHF- last echo [**2105-1-28**]- EF 65%, LVH and RVH
Social History:
Lives alone, wife passed away. Retired engineer. Independent in
ADLs. Son and granddaughter live in NY.
Family History:
There is no family history of premature coronary disease,
unexplained heart failure, or sudden death.
Physical Exam:
Admission Physical Exam
VS 97.5 110/60 97 20 99% 2LNC
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD
PULM CTA bilaterally, no crackles, no wheezes
CV well healed midline incision scar. irregularly irregular
rhythm, normal rate, normal S1/S2, no mrg
ABD +BS, distended but soft and nontender
EXT WWP 2+DP/PT pulses palpable bilaterally.
On the dorsal aspect of the right foot, there is an area of
erythema and warmth extending from below the 1st MTP. There is
tenderness to palpation of the foot and pain with passive/active
ROM of 1st MTP.
NEURO CNs2-12 intact, motor function grossly normal
SKIN hyperpigmentation of b/l LE, no rashes or lesions
DISCHARGE:
98.2 114/76 87 20 95 2l
GEN Alert, oriented, russian speaking male in no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM CTAB, no rales/ronchi
CV irregularly irregular normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT 1+ pitting edema up to knees. Right MCP area without
erythema in circumscribed region, mild tender to palpation
compared to the left, slightly warm, no swelling. WWP 2+ pulses
palpable bilaterally,
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Admission labs:
[**2105-8-18**] 11:00PM BLOOD WBC-14.1*# RBC-4.89 Hgb-15.9 Hct-47.3
MCV-97 MCH-32.5* MCHC-33.6 RDW-14.7 Plt Ct-133*
[**2105-8-18**] 11:00PM BLOOD Neuts-88.7* Lymphs-6.1* Monos-5.0 Eos-0.1
Baso-0.2
[**2105-8-19**] 05:27AM BLOOD PT-24.8* PTT-33.4 INR(PT)-2.4*
[**2105-8-18**] 11:00PM BLOOD Glucose-122* UreaN-28* Creat-1.8* Na-138
K-4.2 Cl-100 HCO3-25 AnGap-17
[**2105-8-18**] 11:00PM BLOOD ALT-20 AST-27 AlkPhos-89 TotBili-1.2
[**2105-8-18**] 11:00PM BLOOD cTropnT-<0.01
[**2105-8-19**] 05:27AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.4
[**2105-8-18**] 11:00PM BLOOD Albumin-4.2
[**2105-8-19**] 07:09AM BLOOD Type-[**Last Name (un) **] Temp-39.4 Rates-/24 FiO2-100
pO2-53* pCO2-44 pH-7.39 calTCO2-28 Base XS-0 AADO2-619 REQ
O2-100 Intubat-NOT INTUBA Comment-NON-REBREA
[**2105-8-19**] 07:09AM BLOOD Lactate-3.2*
[**2105-8-19**] 01:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2105-8-19**] 01:00AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2105-8-19**] 01:00AM URINE RBC-5* WBC-76* Bacteri-MOD Yeast-NONE
Epi-0
DISCHARGE:
[**2105-8-24**] 06:45AM BLOOD WBC-6.8 RBC-5.01 Hgb-16.2 Hct-48.3 MCV-96
MCH-32.3* MCHC-33.5 RDW-14.7 Plt Ct-157
[**2105-8-24**] 06:45AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.5
[**2105-8-24**] 06:45AM BLOOD PT-33.8* INR(PT)-3.3*
Micro:
Blood culture [**8-18**] and [**8-19**]- PENDING
Urine culture [**8-19**]- PENDING
[**2105-8-19**] 7:38 am URINE Source: Catheter.
**FINAL REPORT [**2105-8-22**]**
URINE CULTURE (Final [**2105-8-22**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. 2ND MORPHOLOGY.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S 8 S
AMPICILLIN/SULBACTAM-- <=2 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Imaging:
CXR [**2105-8-18**]: In comparison with the study of [**2103-7-11**], there is
continued enlargement of the cardiac silhouette in a patient
with intact midline sternal wires. No definite vascular
congestion. There is increased opacification at the right base
medially. This could represent merely crowding of vessels
combined with atelectasis. However, in the appropriate clinical
setting, supervening pneumonia would have to be considered. The
left hemidiaphragm is relatively well seen, though there may
well be some atelectatic change involving the left lower lobe.
Brief Hospital Course:
78 yo M with h/o IDDM, dCHF, afib on coumadin presenting with
right foot pain, found to have cellulitis who was transferred to
the ICU on the night of his admission for dyspnea. Was treated
with abx for e coli UTI and cardiac meds were titrated. Pt was
stable and dc-ed to rehab.
#Reason for MICU transfer: on arrival to the floor, the
patient's temperature increased to 103 and he was tachycardic
with rates in the 160-170s and tachypneic and wheezy who met
SIRs criteria and was admitted to the ICU. While in the ICU, EKG
showed ST depressions in lateral precordial leads. Cardiology
was consulted and EKGs showed resolution of these changes with
administration of IV metoprolol, therefore likely demand
ischemia. His cardiac enzymes were cycled and normal.
#SEPSIS from urinary tract infection: Pt. met criteria for
severe sepsis given his tachycardia, fever, and leukocytosis on
admission with elevated lactate. On admission his UA was
positive. He was febrile to 103 with altered mental status. In
the ED he received vancomycin. ON arrival tot he floor he
recieved ciprofloxacin and ceftriaxone. While in the MICU, his
lactate did not respond greatly to fluid resuscitation, his WBC
increased, and his MAP were between 55-65, so he was broadened
to vanc/cefepime with improvement in his clinical status. His
urine grew out pansensitive E Coli and cefepime was swithced to
cipro and was dsicharged on a total 5 day course.
#Right foot pain- his right foot had increased redness and on
arrival to the ED there was concern that this could signify
cellulitis. He was given vancomycin in the ED. He was evaluate
by rheumatology for concern of possible crystal arthropathy,
however rheumatology felt that there was not an adequate amount
of fluid in the joint to tap. Furthermore, patient has had toe
pain for nearly one year. Given that patient has likely UTI and
doesn't complain of pain, it is unlikely that he has cellulitis.
he was treated empirically with
Ceftriaxone/Vancomycin/Ciprofloxacin but only cipro for uti at
time of dc. His uric acid level was 9.1 However, decision
regarding starting allopurinol was deferred as pt asymptomatic
and recent flare.
#Dyspnea- patient was sating 100% on 2L on arrival to the
medical floor. Over the night he developed worsening dyspnea.
CXR did not show any pulmonary edema but did show an opacity in
the RLL. This could have signified an aspiration pnuemonia
however he notably has had a RLL opacification on prior CXR in
[**2101**] making aspiration event less likey. He likely had flash
pulmonary edema in the setting of a-fib with RVR. He had no
further episodes of severe dyspnea during his MICU and floor
stay. Was dc-ed on home dose of torsemide.
#Atrial Fibrillation- in the setting of an infeciton, he
developed afib with RVR. His CHADS2 score is [**3-8**] who is on
coumadin at home and rate controlled at home, on arrival he was
therapeutic on his coumadin. His metoprolol was uptitrated to
100mg [**Hospital1 **] at time of dc. HR ranged in the 80s and 90s.
#diastolic heart failure-patient has history of diastolic
dysfunction which likely contributed to flash pulmonary edema.
Patient received a TTE which showed EF 55%, however was unable
to comment on diastolic function. No further management changes
were made for his chronic condition. He was diuresed with IV
lasix in ICU and was on home torsemide on med floor and did
well.
TRANSITIONAL ISSUES:
1. NEEDS PCP [**Name Initial (PRE) **].
2. [**Month (only) **] NEED MORE STRICT RATE CONTROL AS HR IN 80S-90S EVEN ON
100 [**Hospital1 **] OF METOPROLOL
3. HAD ELEVATED URIC ACID LEVEL. ALLOPRURINOL WASNT STARTED AS
RECENT FLARE BUT [**Month (only) **] CONSIDER AS OUTPATIENT BY PCP
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Atorvastatin 10 mg PO DAILY
2. Torsemide 40 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
please hold for SBP<100
4. glimepiride *NF* 4 mg Oral [**Hospital1 **]
5. sitaGLIPtin *NF* 50 mg Oral daily
6. Metoprolol Tartrate 75 mg PO BID
please hold for SBP<100, HR<60
7. Nitroglycerin SL 0.3 mg SL PRN CP
8. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >
9. Warfarin 4 mg PO DAILY16
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
please hold for SBP<100
3. Metoprolol Tartrate 100 mg PO Q12H
hold for HR<60 or SBP<90
4. Nitroglycerin SL 0.3 mg SL PRN CP
5. Torsemide 40 mg PO DAILY
6. Warfarin 3 mg PO DAILY16
7. Aspirin 81 mg PO DAILY
8. glimepiride *NF* 4 mg ORAL [**Hospital1 **]
9. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >
10. sitaGLIPtin *NF* 50 mg Oral daily
11. Ciprofloxacin HCl 500 mg PO Q12H
PLEASE CONTINUE THROUGH [**2105-8-26**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
severe SEPSIS due to bacterial UTI
ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RATE
ACUTE ON CHRONIC CONGESTIVE HEART FAILURE
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:
Mr [**Known lastname 78603**],
You were admitted to [**Hospital1 18**] after you developed an infection. You
developed shortness of breath and were transferred to the ICU.
You were started on antibiotics and got treatment to optimize
your heart rate and congestive heart failure. You tolerated the
treatments well and were discharged to rehab for further
managment.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2105-9-9**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2106-2-10**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
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[
[]
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1462, 1809
|
1825, 1930
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,927
| 103,192
|
48235
|
Discharge summary
|
report
|
Admission Date: [**2159-6-2**] Discharge Date: [**2159-6-5**]
Date of Birth: [**2082-10-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77-year-old male with diabetes mellitus type 2,
hypercholesterolemia, hypertension, status post porcine mitral
valve replacement in [**2137**],
diabetic nephropathy and retinopathy who presents w/ ? of
altered mental status. In [**2137**] patient had developed bacterial
endocarditis, having received a six week course of antibiotics
prior to mitral valve replacement. For the patient two years,
the patient has noted an increased symptom burden from heart
failure, with worsened dyspnea on exersion, 4 pillow orthopnea,
lower extremity edema. At present pt describes dyspnea with
minimal exertion (dressing himself, or toileting). The patient
has had ongoing conversations with his outpatinet cardiologist
regarding the necessity of valve replacement. Over the last
month the patient has an even more progression of his symptoms.
The patient was discharged from BIDNH 2 days prior to
presentation after a MVA [**3-3**] to a syncopal episode. The patient
reports prior synocopal epsides while standing from sleep. The
etiology of his LOC was attributed to hypotension in the setting
of increased BP meds in the setting of MS. The patient was
discharged with plans for cardiology follow up to plan for valve
replacement.
.....On the morning of presentation, the patient was awakening
from sleep, and for the first 1-2 minutes he was confused,
thinking he was in [**Country 9819**]. The patients family reports
recurrent episodes of acute, short-duration confusion while
awakening for the last few months. The patients family does not
feel that he is confused during day to day activities, but does
note that he is somnlanent throughout the day. In review of
systoms, the patient endoreses an englarging abdomen over the
last 2-4 weeks. He denies abdominal pain, blood in stool,
change in stool quality. He has no history of liver disease.
.....With this ? of altered mental status, the patinet was
brought into the ED for further evaluation. while there his BP
was 90/53, HR 70, 89% 2L, 97% on 3L. He was given an aspirin,
and admitted for further manegment.
Past Medical History:
1. Diabetes mellitus-2.
2. Hypercholesterolemia.
3. Hypertension.
4. Strangulated hernia, status post surgery in [**2158-10-30**].
5. Mitral valve replacement, porcine, [**2137**].
6. Diabetic retinopathy.
7. Diabetic nephropathy.
8. Gout.
9. Severe mitral regurgitation with chronic systolic heart
failure.
Social History:
The patient lives at home with his wife. Former computer
programer. No alcohol, tobacco or drugs.
Family History:
noncontributory.
Physical Exam:
Gen: WDWN middle aged male tachypnic slouched forward. Oriented
x3. Mood, affect appropriate. + RLS
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Difficultly
keeping eyes open.
Neck: Supple with [**Doctor Last Name **] V waves JVP at mandible.
CV: RRR, S1,S2, III/VI holosystolic murmur heard best at base.
+ S3
Chest: Wet crackles b/l heard 1/2 up lung fields
Abd: Soft, NT. + abdominal distension w/ + FW. No HSM or
tenderness. Surigcal vental scar noted.
Ext: 1+ - 2+ LE edema. 2+ dp/pt. No femoral bruits.
Pertinent Results:
[**2159-6-2**] 09:50AM BLOOD WBC-8.0 RBC-3.64* Hgb-12.0* Hct-36.0*
MCV-99* MCH-33.0* MCHC-33.4 RDW-18.5* Plt Ct-128*
[**2159-6-2**] 09:50AM BLOOD Neuts-83.1* Lymphs-9.4* Monos-5.0 Eos-2.1
Baso-0.4
[**2159-6-2**] 09:50AM BLOOD Glucose-217* UreaN-70* Creat-2.2* Na-144
K-3.9 Cl-106 HCO3-29 AnGap-13
[**2159-6-2**] 09:50AM BLOOD CK-MB-4 proBNP-[**Numeric Identifier **]*
[**2159-6-2**] 09:50AM BLOOD cTropnT-0.17*
[**2159-6-2**] 09:50AM BLOOD CK(CPK)-141
[**2159-6-2**] 11:31AM BLOOD Lactate-1.5
[**2159-6-2**] 09:50AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.8*
NCHCT: [**2159-6-2**]
1. No acute intracranial process.
2. Slight prominence of the right MCA, most likely represents
slight tortuosity. However, a small aneurysm cannot be excluded.
.
CXR ([**2159-6-2**]):
IMPRESSION: Subtle reticulonodular pattern in the lower lobes
bilaterally. In the absence of a prior chest radiograph this
could represents an atypical pneumonia or chronic changes. If
clinical suspicion for infection is high consider chest CT.
TTE ([**2159-5-30**]):
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-15mmHg. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). The right
ventricular cavity is mildly dilated There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The prosthetic mitral valve leaflets are
thickened. Motion of the prosthetic mitral valve leaflets/poppet
is abnormal. There is a question of flail leaflet motion There
is moderate valvular mitral stenosis (area 1.0-1.5cm2). Severe
(4+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension.
Brief Hospital Course:
Patient is a 76 year old male with history of MVR ('[**37**]), DM,
CRI, w/ known severe mitral regurgitation who presents with ?
AMS, found to be in acute heart failure.
On initial exam, there was clear evidence of volume overload,
with Lower Extremity edema, hypoxia, pulmonary edema, and
abdominal ascietes. No evidence of LV systolic dysfunction on
TTE. Patient's complaints of fatigue and SOB/DOE were thought
to be due to mitral valvular dysfunction, and patinet was
considered for MVR. CT surgery was consulted. On the afteroon
of [**2159-6-4**], the patient was sent for cardiac catheterization for
pre-operative evaluation. In the holding area the patient
became increasingly altered, hypotensive, and Short of breath.
Due to his worsened status, he was transferred to the CCU for
concern of sepis. Broad spectrum antibiotics were started prior
to transfer, he was placed on Vancomycin, Levofloxacin and
Meropenem. His respiratory and mental status continued to
decline and he was intubated. He became hypotensive and
required pressors. The family was notified and the wife decided
to make no further interventions, he was DNR/DNI. Pressors were
increased due to continued hypotension. Blood cultures came
back positive for gram + cocci. The patient went into cardiac
arrest and expired on the morning of [**2159-6-5**].
Medications on Admission:
1. Allopurinol 100 mg daily.
2. Iron 325 t.i.d.
3. Klor-Con at least 40 daily.
4. Procrit weekly.
5. Bumex 4 mg twice daily.
6. Avapro 75 mg daily.
7. Folic acid 1 mg daily.
8. Zetia 10 mg daily.
9. Januvia 50 mg daily.
10. Crestor 10 mg daily.
11. Glimepiride 2 mg daily.
12. Insulin 70/30 ten units in the morning.
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"995.92",
"038.9",
"780.6",
"585.9",
"584.9",
"403.90",
"250.50",
"789.59",
"458.9",
"571.5",
"274.9",
"250.40",
"V42.2",
"272.0",
"362.01",
"599.7",
"424.0",
"583.81",
"428.23",
"782.4",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7169, 7178
|
5416, 6758
|
275, 281
|
7229, 7238
|
3488, 5393
|
7294, 7304
|
2858, 2877
|
7137, 7146
|
7199, 7208
|
6784, 7114
|
7262, 7271
|
2892, 3469
|
232, 237
|
309, 2383
|
2405, 2724
|
2740, 2842
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,957
| 194,008
|
21528+21529
|
Discharge summary
|
report+report
|
Admission Date: [**2200-4-23**] Discharge Date: [**2200-5-16**]
Date of Birth: [**2129-3-10**] Sex: F
Service: VSU
CHIEF COMPLAINT: Abdominal and back pain.
HISTORY OF PRESENT ILLNESS: The patient was initially
evaluated in the emergency room and admitted to the vascular
service for continued care. She is a 71 year-old who has
known thoracoabdominal aneurysm measuring 6.6 cm in diameter
who has not been compliant with her medications, now presents
with two weeks of abdominal pain. Initially it was described
as epigastric but now is more flank pain than any other type
of pain. The patient reports emesis x2 a week ago. Also
episodes of slurred speech and problems ambulating two weeks
prior to admission. Now these symptoms have subsided. She
denies any constitutional symptoms.
PAST MEDICAL HISTORY: Erythromycin and codeine allergies.
Medications include atenolol 50 mg b.i.d., Lisinopril 40 mg
daily, Paxil 40 mg daily, hydrochlorothiazide and Lescol 80
mg daily. Illnesses include thoraco-abdominal aneurysm 6.6 cm
in size, hypertension, hypercholesterolemia, depression. Past
surgical history includes cholecystectomy, appendectomy,
hysterectomy and a history of chronic renal insufficiency.
SOCIAL HISTORY: She denies alcohol use but is a [**2-2**] pack per
day, previously was 1 1/2 packs per day times many years.
PHYSICAL EXAMINATION: Vital signs are 97.3, 80, 65, 80s,
respiratory rate 18, oxygen saturation 97% on room air, blood
pressure 110/65. General appearance: This is an alert,
cooperative white female in no acute distress. No focal
neurological deficits noted. No carotid bruits. Heart is
regular rate and rhythm. Lungs are clear to auscultation.
Abdominal examination is nontender, nondistended with
bilateral flank tenderness on palpitation with a palpable
pulse in the mid abdomen. Pulse examination shows palpable
radials, femorals, popliteals bilaterally 2+. The right
dorsalis pedis is 1+ with a monophasic signal posterior
tibialis. On the left the dorsalis pedis is biphasic signal
and the posterior tibialis is monophasic signal. No spinal
tenderness.
HOSPITAL COURSE: The patient was initially evaluated in the
emergency room. She was given Vicodin and Dilaudid for pain.
Lopressor and hydralazine were instituted for hypertension
control. The vascular service was consulted and the patient
was admitted to the vascular service for further evaluation
and treatment. She was seen by the cardiology department. Her
BNP was negative and they felt the patient from a cardiac
standpoint asymptomatic. No other cardiac evaluation was
required prior to surgery. The patient underwent on [**2200-4-23**] a transthoracoabdominal type three aneurysm repair with
an aorto-renal artery bypass with Dacron graft. The patient
tolerated the procedure well and was transferred to the
Thoracic Surgical Intensive Care Unit for continued
postoperative care. Postoperative day one the patient
required transfusion, required a Swan catheter placement for
monitoring of hemodynamics. Neo-Synephrine was required for
hypotensive blood pressure support. She required multiple
transfusions. Postoperative day #2 her hematocrit was 30.6,
post transfusion drifted to 26. Her creatinine bumped to 2.1
from 1.6. She was continued to be transfused, intubated on
vasopressor support. Postoperative day #3 she remained in the
thoracic Intensive Care Unit. Her hematocrit was 31 to 28.
Her BUN was 24. Her creatinine was 2.3. Renal ultrasounds
were obtained. There was no obstructive disease noted. The
thoracotomy chest tube was discontinued and the left internal
jugular was discontinued. The patient's Levophed was weaned
and the transfused to hematocrit of 28 and extubated.
Postoperative day #4 patient required diuresis with
intravenous Lasix 20 x2 doses. Her white count climbed to
24.8, hematocrit 27, requiring a transfusion. Her spinal
catheter was removed. She remained n.p.o. The nasogastric
tube was discontinued. Stools were sent for C difficile for
her profuse diarrhea and p.o. Flagyl was instituted. The
patient's Swan was converted to a triple lumen catheter.
Postoperative day #5 patient's white count improved to 20.7,
hematocrit was still low at 26.2 requiring transfusion. Her
creatinine continued to climb to 2.5. She was tolerating
clears. Her diet was advanced as tolerated.
Postoperative day #6 the patient was extubated and
transferred to the Vascular Intensive Care Unit for continued
monitoring and care. She continued to require transfusions
for a low hematocrit of 22.9, white count improved to 14.7.
Creatinine peaked at 2.5. Postoperative day #7 the white
continued to show a downward trend with the stabilization of
her hematocrit to 30.2 with continued improvement in her
creatinine to 2.3. Postoperative day 8 patient was ambulated.
Total parenteral nutrition was instituted for nutritional
support. The white count continued to show improvement. The
hematocrit was 25 down from 29.2 post transfusion requiring
transfusion. Her creatinine returned to baseline from 2.0 to
1.7. Postoperative #10 the total parenteral nutrition was
discontinued. PO's were instituted. The patient passed
flatus. Postoperative day #11 she tolerated the PO's and diet
was advanced as tolerated. Postoperative day #12 the patient
had episode of atrial fibrillation requiring Lopressor to
convert to normal sinus rhythm. Her white count was
normalized to 7.6. Her creatinine was at baseline 1.6 and her
hematocrit remained stable at 32.9. Chronic pain service saw
the patient and made recommendations regarding analgesic
control. Cardiology saw the patient because of her atrial
fibrillation. She was diuresed for congestive heart failure.
They recommended starting Coumadin and Diltiazem 60 mg daily
The patient continued to have persistent diarrhea. She was
continued on Flagyl.
On postoperative #13 the patient converted to normal sinus
rhythm. Hematocrit was stable at 33, creatinine was 1.7.
Physical therapy evaluated the patient and recommended
rehabilitation prior to being discharged to home when
medically stable. On postoperative day #14 orthopedics was
consulted secondary to findings of an L2 compression fracture
on her CT scan. On postoperative day #16 the patient
complained of back pain. The pain service saw her and
nonsteroidals were instituted. Orthopedics was consulted for
considerations for vertebroplasty. Recommendations were that
Dr. [**Last Name (STitle) **] would review to see if the patient was a candidate
for a vertebroplasty. Cardiology recommended to start
Coumadin and the patient to follow up with the cardiologist
in one to four weeks. The patient continued to progress and
was discharged to rehabilitation in stable condition.
DISCHARGE MEDICATIONS: Include aspirin 325 mg daily,
albuterol 0.083% solution q 6 hours as needed, improprium
bromide 0.02% solution inhalation q 6 hours as needed,
psyllium 1.7 gram wafer daily, metoprolol 75 mg b.i.d.,
ibuprofen 600 mg q 8 hours, miconazole nitrate powder to
areas t.i.d., acetaminophen 325 mg tablets 2 q 6 hours, Paxil
40 mg daily, Protonix 40 mg daily, tramadol 50 mg 1 tablet q
4 to 6 hours p.r.n. for pain. A decision regarding
anticoagulation will be made prior to the patient's discharge
and an addendum will be dictated to the Discharge Summary.
DISCHARGE DIAGNOSIS:
1. Lower abdominal aortic aneurysm x3, status post repair
with a right aortorenal bypass graft.
2. Blood loss anemia, postoperative transfused, corrected.
3. Postoperative acute renal failure, resolved.
4. Postoperative atrial fibrillation converted.
5. L2 compression fracture.
DISCHARGE INSTRUCTIONS: The patient should of follow up with
Dr. [**Last Name (STitle) **] in three to four weeks post discharge. She should
also follow up with the cardiology department, Dr. [**Last Name (STitle) **] in
one to four weeks post discharge. She should call for an
appointment. The patient is discharged on Coumadin. INRs
should be monitored on a daily basis and the goal INR is 2.0
to 3.0.
[**Last Name (LF) **],[**First Name3 (LF) **] W. M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2200-5-12**] 14:37:02
T: [**2200-5-12**] 15:42:55
Job#: [**Job Number 56754**]
Admission Date: [**2200-4-23**] Discharge Date: [**2200-5-24**]
Date of Birth: [**2129-3-10**] Sex: F
Service: VSU
This is a 71 year old patient admitted on [**2200-4-23**].
Discharge date anticipated [**2200-5-16**] was cancelled. This
is a continuation of the hospital course from the discharge
summary, document #[**Numeric Identifier 56754**].
HOSPITAL COURSE, CONTINUED: The patient's discharge was
delayed. Dr. [**Last Name (STitle) **] of the interventional radiology service
saw the patient regarding vertebroplasty for her lumbar
compression fracture. An MRI was obtained, which demonstrated
a compression fracture of the anterior aspect of the L2
vertebral body, with minimal associated T2 and STIR signal
abnormalities. The remaining vertebral bodies were normal in
height, signal and alignment. There were no epidural
collections seen. The conus medullaris ends at L1-L2, and
there was no spinal cord narrowing. Also noted on the scan
was a large left retroperitoneal hematoma in a patient who is
status post thoraco-abdominal aortic aneurysm repair. There
was some edema in the muscular soft tissues posterior to the
lumbar spine at the levels of L2 to L4. These findings could
reflect dependent changes related to the patient's
longstanding supine positioning. At this point, a
vertebroplasty was deferred.
The patient in the next 24 hours developed onset of abdominal
pain and diarrhea. Abdominal CT was obtained. This CT of the
abdomen and pelvis did not show any evidence of thoraco-
aortic dissection. There was a persisting small bowel
obstruction, which had partially decompressed, and the left
abdominal wall had a surgical site seroma. The thoraco-
abdominal aneurysm repair was stable in appearance. The
appearance of the stenosis of the origin of the SMA, celiac
and right renal arteries was stable. The patient then
proceeded to surgery on [**2200-5-16**], and underwent
abdominal aortogram with selective celiac angiogram,
angioplasty, and stenting of the celiac artery through a left
brachial artery access. The patient tolerated the procedure
well and was transferred to the post anesthesia care unit in
stable condition, and returned to the VICU for continued
monitoring and care. The patient's postoperative day 1 from
her angioplasty and stenting of the celiac artery was
hemodynamically stable. White count was 13.4, hematocrit
31.5, BUN 30, creatinine 1.0. Physical examination was
remarkable for a soft, nontender abdomen with bowel sounds.
The nasogastric tube was removed and the diet was advanced as
tolerated. Ambulation was continued. The patient was
continued on TPN.
Over the next 24 hours, the patient tolerated liquids. The
TPN was continued. Physical therapy continued to work with
the patient. Psychiatry was requested to see the patient
because of a history of depression. The patient's head CT
scan was remarkable for periventricular white matter changes
and an old right insular infarct. Psychiatric felt that the
patient's [**Last Name 16423**] problem was delirium, which was mild and
which was related to surgery and all the perioperative events
in an older woman with underlying structurally abnormal
brain. There was no evidence of anxiety present.
Recommendations were to discontinue the Ativan, give the
patient Haldol 0.5 - 1 mg IV every 4-6 hours p.r.n. for
anxiety or confusion, minimize the use of Dilaudid, or
replace with a non narcotic analgesic. The patient did
experience episodes of somnolence with Ativan and narcotics.
The narcotics were withdrawn, and the Ativan was tapered
accordingly, with improvement in the patient's somnolence.
The patient continued to show improvement, and was
transferred to the regular nursing floor on [**2200-5-22**]. The TPN
was weaned, and she was continued on diet advanced as
tolerated. Case Management was requested to begin screening
for rehab. The finalization of the [**Hospital 228**] hospital course
will be dictated at the time of discharge to rehab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17755**], [**MD Number(1) 17756**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2200-5-23**] 13:34:03
T: [**2200-5-23**] 14:28:22
Job#: [**Job Number 56755**]
|
[
"557.0",
"285.1",
"486",
"998.12",
"427.5",
"293.0",
"518.81",
"427.31",
"401.9",
"428.0",
"584.9",
"787.91",
"441.7",
"276.5",
"E928.9",
"805.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"99.04",
"38.44",
"99.07",
"88.72",
"99.05",
"39.24",
"99.15",
"39.50",
"89.64",
"38.45",
"96.72",
"39.59",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
6742, 7294
|
7315, 7599
|
2136, 6718
|
7624, 12516
|
1380, 2118
|
154, 180
|
209, 810
|
833, 1230
|
1247, 1357
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,648
| 179,869
|
13966
|
Discharge summary
|
report
|
Admission Date: [**2175-2-16**] Discharge Date: [**2175-2-22**]
Date of Birth: [**2094-9-11**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Heparin Agents
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Transferred from an OSH ([**Hospital **] hospital) for hemoptysis and at
the request of the patient's family.
Major Surgical or Invasive Procedure:
BiPap
History of Present Illness:
The patient is an 80 y.o. male with remote h/o MI, htn, pvd, s/p
AAA repair and aortobypass in [**2163**] p/w acute onset of sob and
hemoptysis at an OSH one day prior to admission to [**Hospital1 18**]. He
reported throat tightness and half a glass of hemoptysis - thin
watery but red vs blood tinged mucous which began after taking
his medications. He then developed acute shortness of breath.
He denied CP. No palpitations. No leg swelling. No f/c. No
rigors or recent travel.
Of note he has a h/o hemoptysis 4 years ago for which he
underwent a bronchoscopy which was c/w pulmonary asbestos at
[**Hospital **] [**Hospital 1459**] hospital.
In the ED at OSH, afebrile but hypoxic sating 74% on NRB with RR
= 38. BP = 170/97. He was started on bipap with improvement in
his O2 sat. His Xray was thought to be c/w pulmonary edema. He
was started on a nitro gtt with good effect. ECG with ? STE in
[**First Name9 (NamePattern2) 41738**] [**Last Name (un) 41739**] and bigeminy. He was then transferred to
the CCU. His troponin on admission was 16 with CK of 138 with ,
MB fraction = 25.8, His troponin then rose to 22.56. His sob
improved with "diuretics" and he is now sating 97% on 2-3L NC.
During hospitalization he had 6 bts WCT NOS on [**2175-2-16**].
At baseline he is able to walk only a [**12-22**] mile before he
develops leg pain. He is also limited in this way when climbing
the stairs. He had a recent stress/echo [**1-21**] which he was unable
to complete [**1-20**] leg pain but his EF was 40%. Recent admission
for CHF see PMH below.
Past Medical History:
CAD s/p MI in [**2143**]
s/p aortobifemoral bypass in [**2163**]
anxiety disorder
HTN
AAA s/p repair in [**2172**]
Asbestosis- worked in construction cutting marble
COPD diagnosed 2 years ago after "breathing tests" and started
on spiriva and advair. He is followed by pulmonologist Dr.
[**Last Name (STitle) 41740**] at [**Hospital3 7362**].
H/o hemoptysis attributed to asbestosis
CHF with EF =40% diagnosed 4 years ago with recent visit to
hospital for CHF exacerbation 3 weeks ago after which his lasix
dose was doubled.
H/o GIB 4 years ago s/p EGD and started on protonix. Pt cannot
remember what EGD showed.
Social History:
Lives alone, independent, drives takes himself shopping, manages
his own finances. 80 pk year smoking h/o. Quit 11 years ago. No
ETOH. No illicits. No TB exposures. No recent travel.
Family History:
nc
Physical Exam:
VS T = 97.6, P = 74-78 BP = 111/58 RR = 18-20 O2Sat = 96% on 3L
GENERAL: Pleasant ederly male laying almost flat, nad
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, dry MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Prolonged expirtory phase, decreased breath sounds,
crackles at both bases b/l.
Cardiac: RRR, nl. S1S2, [**2-21**] holosystolic murmur with radiation
to the axilla.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Well healed midline scar appreciated. Guiac
negative.
Extremities: No C/C/E bilaterally, 2+ radial. No DPP
appreciated.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
Pertinent Results:
At [**Hospital1 **]:
Cr = 1.6, Glucose = 217, BUN = 31, WBC = 9.2, HCT = 45.1, Hgb =
15.1, MCV = 107.7, Trop = 16.10. LFTs Tbili = 2.0, direct bili =
0.3, indirect bili = 1.7, INR = 1.47, trop = 16.1, BNP = 562, CK
= 138, AST = 62 (0-43). CKMB = 2.8, %MB = 2.0
Admission labs:
[**2175-2-16**] 09:16PM BLOOD WBC-7.1 RBC-3.43* Hgb-12.3* Hct-37.2*
MCV-109* MCH-35.9* MCHC-33.1 RDW-20.2* Plt Ct-71*
[**2175-2-16**] 09:16PM BLOOD PT-16.8* PTT-74.4* INR(PT)-1.6*
[**2175-2-16**] 09:16PM BLOOD Glucose-104 UreaN-35* Creat-1.4* Na-140
K-4.3 Cl-104 HCO3-26 AnGap-14
[**2175-2-16**] 09:16PM BLOOD ALT-18 AST-53* CK(CPK)-162 AlkPhos-41
TotBili-2.6*
[**2175-2-16**] 09:16PM BLOOD CK-MB-19* MB Indx-11.7* cTropnT-1.31*
proBNP-[**Numeric Identifier 41741**]*
[**2175-2-16**] 09:16PM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.4 Mg-2.2
Other Labs:
[**2175-2-16**] 09:16PM BLOOD CK-MB-19* MB Indx-11.7* cTropnT-1.31*
CK(CPK)-162
[**2175-2-17**] 02:51AM BLOOD CK-MB-12* MB Indx-8.9* cTropnT-1.04*
CK(CPK)-135
[**2175-2-18**] 05:21AM BLOOD CK-MB-NotDone cTropnT-0.78* CK(CPK)-83
[**2175-2-19**] 05:07AM BLOOD VitB12-647 Folate-GREATER TH Hapto-155
[**2175-2-20**] 05:00AM BLOOD Hapto-148
Discharge Labs:
[**2175-2-22**] 05:25AM BLOOD WBC-4.5 RBC-3.03* Hgb-10.9* Hct-33.5*
MCV-110* MCH-36.0* MCHC-32.6 RDW-19.6* Plt Ct-72
[**2175-2-22**] 05:25AM BLOOD PT-15.5* PTT-32.1 INR(PT)-1.4*
[**2175-2-22**] 05:25AM BLOOD Glucose-109* UreaN-23* Creat-1.2 Na-143
K-4.2 Cl-105 HCO3-31 AnGap-11
[**2175-2-22**] 05:25AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
Microbiology:
Blood cx [**2175-2-17**] - ngtd
ECG:
Rate = 100s, Bigeminy, Q in III, aF,
ECG on admission to [**Hospital1 18**]: NSR at 70 bpm, TWI in V4-V6, , Q in
III.
CXR ([**2175-2-17**])
IMPRESSION:
1) Right perihilar opacification may be due to pneumonia or
right
hilar mass.
2) Abnormal descending aorta, could be aneurysmal or dissected.
3) Mild pulmonary edema.
4) Extensive, asbestos-related pleural plaque and
calcification.
Recommend dedicated chest CTA to evaluate for aortic aneurysm
and lung algorithm to further assess pleural disease and right
hilar abnmormality.
.
CT of chest w/o contrast ([**2175-2-18**])
IMPRESSION:
1. Multifocal consolidative and ground-glass opacities in both
lungs is concerning for multifocal pneumonia. There are
associated moderate right and small left-sided pleural
effusions.
2. More nodular opacities particularly in the left lower lobe
and lingula are also seen ranging between 5 and 7 mm. Followup
imaging after resolution of the acute process is recommended to
evaluate for resolution of these regions.
3. Extensive pleural plaques consistent with prior asbestos
exposure.
4. Coronary artery and aortic valvular calcifications.
5. Simple-appearing cyst in the left kidney.
.
Echo ([**2175-2-17**])
Conclusions: EF 35-40%
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is mild to moderate global left
ventricular hypokinesis. The inferior wall apeear akinetic.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] There
is no ventricular septal defect. Right ventricular systolic
function is borderline normal. The aortic root is mildly dilated
at the sinus level. The number of aortic valve leaflets cannot
be determined. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is no mitral valve
prolapse. Severe ([**2-19**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Severe mitral regurgitation with depressed LVEF.
Brief Hospital Course:
The patient is a 80 y.o. M with COPD, asbestosis, CAD, [**Hospital 15134**]
transferred from OSH with NSTEMI and hemoptysis and b/l
infiltrates RLL>LUL and RML. His hospital course during this
admission is as follows:
1 Hemoptysis and SOB and alveolar infiltrates:
Because his hypoxia 74% on NRB during initial presentation on
[**2175-2-16**], he was initially admitted to the MICU, and improved
rapidly with Bipap. He was called to the floor on [**2175-2-19**] after
clinical stabilization and O2 sat 96% on 2L by the time he
reached the floor. Differential includes PE, TB, PNA,
bronchietasis, CHF. It is unclear what is the precipitatin event
? PNA vs NSTEMI. Our thinking is a combination of CHF/cardiac
ischemia, CAP and was worsened by his heparin gtt. He had a
chest CT with contrast which was negative for malignancy or
aorto-esophageal fistula, but showed multifocal pneumonia.
Levoquin was started for his pneumonia on [**2175-2-16**] and needs to be
continued for a 14 day course (day 1 [**2175-2-16**]). Pulmonary was
consulted at the MICU, and no urgent need for bronch given
decreased hemoptysis and overall clinical stability. His Hct
and pulmonary status remained stable on the floor and he was to
follow up with his pulmonologist Dr. [**Last Name (STitle) 41740**] at [**Hospital3 7362**]
upon d/c.
2 NSTEMI/CAD: This may be demand in the setting of his PNA and
hypoxemia on admission. We followed his CES, which trended down.
Initially he was put on heparin gtt, but was quickly d/c'ed due
to thrombocytopenia. ASA was also initially d/c'ed at the MICU
aafter TCP, and was resumed on [**2175-2-19**] after his platelets
stabilized for cardiac protection. cardiology was consulted and
recommended no urgent indication for cath given medical
comorbidities, and continue medical management with lopressor,
ACEI, aldactone, Imdur and statin. He was monitored on tele
throughout this hospital stay, and remained CP free, and no
further episodes of ischemia once on the floor.
3 CHF: Echo at the OSH showed EF = 25% on [**2-16**], but repeat
Echo at the [**Hospital1 **] showed 35-40% here with severe MR with 1-2+ TR
here on admission. BNP = 30K on admission.
Patient has no clear signs of fluid overload upon admission and
his O2 sat has remained stable on 3-4L NC dramatically improved
from 74% on NRB at the OSH.
We continue lopressor and titrate up to HR = 60 and SBP = 110.
Continued ACEI and titrate to SBP = 110, and started
spironolactone. He remained clinically stable without evidence
of fluid overload during this admission.
4 Rhythym: Bigeminy at OSH. now in sinus rhtym with non-specific
changes. We kept his K >4.0 and Mg >2.0; continued lopressor for
rate control
5 HTN: continued b-b/ACEI/Imdur/aldactone; well controlled at
the time of discharge.
6 TCP: Ddx includes consumption,sequestration or decreased
production. We d/c'ed heparin (no heparin products); send HIT
antibody (pending) at the time of dishcarge. Initially hold ASA
and PPI, H2 blocker in the MICU. negative for DIC. His
platelets remained stable on the floor, and baby ASA and PPI
were restarted on [**2-19**] and [**2-20**], respectively.
7 COPD/asbestosis: continued spiriva and advair; alb nebs prn
8 PVD: ASA initially held in the unit after pt developed TCP,
and baby ASA was restarted once platelet was stable on the floor
9 AAA: stable
10 macrocytic anemia: ho of GI bleed, but pt was guiac negative;
folate and vit B12 was nl; DIC panel negative; he was initially
on protonix, but briefly d/c'ed for 1 day due to TCP in the
MICU, and we resumed his protonix once he was called out to the
floor and his platelets and hct remained stable.
11 Psycho: pt appear anxious and rude at times to nurses, case
manager and HO; ho of anxiety disorder, continued Xanax qhs prn
(pt's outpt med)
12 Prophylaxis: SCDs, bowel regimen, PPI (briefly held); PT
evaluated pt and recommended rehab
13 FEN: cardiac heart healthy diet, p.o. diet as tolerated;
Speech and swallow evaluation cleared pt for thin liquids and
regular solids.
14 Code Status: Full, discussed with patient and son.
Medications on Admission:
Transfer Medications from OSH
Spiriva one puff daily
Advair 500/50 one puff [**Hospital1 **]
duoneb
albuterol and atrovent q 2 hrs
lasix 40 mg IV q 12
heparin gtt
zocor 40 mg po qd
atenolol 25 qd
Outpatient Medications
Spiriva
Advair
Lasix 20 mg T [**Hospital1 **]
Atenolol 25 mg qd
Imdur 30 mg qd
Xanax 0.5 mg 2T qhs- pt unsure of this dose
protonix 40 mg po qd
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
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. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: end on [**2175-3-1**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
NSTEMI/CAD
pneumonia
Thrombocytopenia
hemoptysis
Secondary diagnosis:
s/p aortobifemoral bypass in [**2163**]
Anxiety disorder
HTN
AAA s/p repair in [**2172**]
Asbestosis- worked in construction cutting marble
COPD diagnosed 2 years ago
H/o hemoptysis attributed to asbestosis
CHF with EF =40%
H/o GIB 4 years ago s/p EGD and started on protonix
Discharge Condition:
stable, afebrile, VSS, tolerating POs, ambulating
Discharge Instructions:
You were admitted for hemotysis and SOB and alveolar
infiltrates. You were found to have pneumonia which you were
treated with antibiotics. You need to continue on levofloxacin
(antibiotic) for 7 more days after discharge for a total of 14
day course. We are currently thinking that it is a combination
of CHF/cardiac ischemia, pneumonia in the setting of heparin.
You should not have any heparin products from now on. You
symptoms have improved since then, and your blood counts and
your platelet counts have been stable. You need to follow up
with your PCP regarding whether you have developed heparin
dependent antibody which is still pending at the time of your
discharge.
.
You also had a myocardial infarction during this admission, our
cardiology team evaluated you; Given multiple risk factors
thrombocytopenia and no heparin products), it was decided
medical management for your cardiac disease. Please make sure
you continue taking low dose Aspirin, betablocker, ACE
inhibitor, aldactone, Imdur, statin.
.
Please take all your medications as prescribed.
.
Please follow up all of your appointments.
.
If you experience any chest pain, SOB, fever, chill, dizziness,
palpitation or any symptoms concerning to you, please call your
PCP or call 911 immediately.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and your
cardiologists within 2 weeks of discharge from rehab.
Please follow up with your pulmonologist Dr. [**Last Name (STitle) 41740**] at [**Hospital1 **] after discharge from rehab.
Completed by:[**2175-2-22**]
|
[
"397.0",
"799.02",
"443.9",
"786.3",
"287.5",
"412",
"441.4",
"401.9",
"584.9",
"496",
"501",
"428.0",
"428.23",
"410.71",
"424.0",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13412, 13485
|
7542, 11645
|
394, 402
|
13895, 13947
|
3655, 3917
|
15271, 15620
|
2839, 2843
|
12060, 13389
|
13506, 13506
|
11671, 12037
|
13971, 15248
|
4840, 7519
|
2858, 3556
|
245, 356
|
430, 1985
|
13596, 13874
|
3933, 4472
|
13525, 13575
|
3571, 3636
|
2007, 2622
|
2638, 2823
|
4484, 4823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,509
| 157,834
|
37818
|
Discharge summary
|
report
|
Admission Date: [**2135-3-3**] Discharge Date: [**2135-3-5**]
Date of Birth: [**2077-12-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 57 year-old male with a history of metastatic
esophageal cancer who presents with anemia. He was recently
admitted [**2-22**] to [**2135-2-23**] after presenting with jaundice and
tbili of 31. He underwent ERCP with stent placement for a lower
CBD extrinsic compression with dilated upper CBD and
intrahepatic ducts. After the procedure he was briefly
hypotensive and was d/ced on Levo and flagyl for 8 days. He also
had a LUL cavitary lesion felt to be a necrotic met vs. abcess
for which the abx were also intended. He was seen by pallative
care last admission.
.
After discharge, his strength continued to worsen and he was
unable to stand intermittently. He also has fallen without a
head strike. He cut his elbow a few days ago and has also been
intermittently bleeding from the site large quantities. Last
evening he started to have "old blood" poor from his mouth. He
feels as it is coming from his stomach "at the site of the old
stent". he described the blood loss via mouth as 1 oz. He has
chronic abd discomfort which is not signficantly worse. He has
constipation but was incontinent of loose brown stool last
evening. Denies F/C/S, dizziness.
.
He presented to [**Hospital6 28728**] Center. There he was
hypotensive to 70s but not tachycardic. His HCT was 19.8 down
from 24.5 on discharge [**2135-2-23**]. WBC was 50. He was given 500 CC
IVF and protonix. 2 PIV were placed and he was transferred to
[**Hospital1 18**].
.
In the ED, inital VS 97.7, HR 75, BP 74/50, 26, 99% RA. He
remained with HR in the 70s, but BP droped to 61/38. HCT on
arrival was 14. He was given fluids, 1 unit RBC (2nd started on
the way up). He was given octreotide gtt, protonix gtt,
vancomycin and zosyn. He got 20mEQ in the ED and 10mEQ on route
from [**Hospital1 3597**]. VS prior to transfer 76/48, 74, 19, 100% 4L
.
On the floor, he is fatigued but without pain.
.
ROS: + LE edema. The patient denies any fevers, chills,
diarrhea, chest pain, shortness of breath, orthopnea, PND,
cough, urinary frequency, urgency, dysuria, lightheadedness,
focal weakness, vision changes, headache, rash or skin changes.
.
Past Medical History:
h/o ETOH abuse and polysubstance abuse
history of PE (noted incidentally on a CT)
Metastatic poorly differentiated adenocarcinoma of the
esophagus, diagnosed [**10-7**], metastatic to liver and lung
Social History:
h/o ETOH abuse and polysubstance abuse (opiates / heroin) denies
IVDU, 60pk yr history of smoking
Family History:
- Brother with GERD
- Denies any FH of cancer or heart disease
- Extensive family history of EtOH abuse
Physical Exam:
Vitals: T: 96.2 BP: 82/51, HR: 74 RR: 22 O2Sat: 100%2L
GEN:cachetic, jaundice, chronically ill appearing in NAD
HEENT: EOMI, PERRL, sclera icteric, dried blood at nares, Dry
MM, OP thrush
NECK: No JVD, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: + fluid wave, diffuse submucosal nodularity. Soft, mild
diffuse tenderness, ND, +BS, no HSM, no masses
EXT: 4+ BL LE edema, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities.
SKIN: jaundice, diffuse ecchymoses. right elbow in bandage.
.
Pertinent Results:
Labs during admission:
.
[**2135-3-3**] 10:20AM BLOOD WBC-31.7*# RBC-1.63*# Hgb-5.0*#
Hct-14.4*# MCV-88 MCH-30.9 MCHC-35.1* RDW-29.1* Plt Ct-135*
[**2135-3-4**] 05:30AM BLOOD WBC-45.8* RBC-3.29*# Hgb-9.9*# Hct-26.4*
MCV-80*# MCH-30.1 MCHC-37.5* RDW-23.8* Plt Ct-74*
.
[**2135-3-3**] 10:20AM BLOOD PT-36.9* PTT-67.3* INR(PT)-3.8*
[**2135-3-4**] 05:30AM BLOOD PT-29.1* PTT-50.5* INR(PT)-2.9*
.
[**2135-3-3**] 02:15PM BLOOD Fibrino-403*
[**2135-3-3**] 02:15PM BLOOD FDP-10-40*
[**2135-3-3**] 10:20AM BLOOD Hapto-<5*
.
[**2135-3-3**] 10:20AM BLOOD Glucose-91 UreaN-54* Creat-2.1*# Na-138
K-2.5* Cl-100 HCO3-14* AnGap-27*
[**2135-3-4**] 05:30AM BLOOD Glucose-71 UreaN-58* Creat-2.4* Na-142
K-2.8* Cl-104 HCO3-19* AnGap-22*
.
[**2135-3-3**] 10:20AM BLOOD ALT-32 AST-96* LD(LDH)-661* AlkPhos-977*
TotBili-32.9* DirBili-26.1* IndBili-6.8
[**2135-3-4**] 05:30AM BLOOD ALT-31 AST-145* LD(LDH)-1178*
AlkPhos-1032* TotBili-47.8*
.
[**2135-3-3**] 10:20AM BLOOD Albumin-1.7* Calcium-6.3* Phos-5.1*
Mg-2.8*
[**2135-3-4**] 05:30AM BLOOD Albumin-2.5* Calcium-6.3* Phos-5.6*
Mg-3.0*
.
[**2135-3-3**] 10:20AM BLOOD Lactate-9.8*
[**2135-3-4**] 05:46AM BLOOD Lactate-5.1*
.
MICRO:
Blood and urine cx - NGTD
.
IMAGING:
CT chest/abd/pelvis w/o contrast (wet read):
chest:
1. small bilateral pleural effusions, right greater than left.
right has
slightly increased in size since [**2135-2-23**].
2. again, multifocal consolidation and developing abscesses with
enlarging
left upper lobe pneumatocele. however, consolidations appear
slightly smaller in size than before. no new areas.
3. esophageal stent remains unchanged in position. significant
amount of
fluid/debris within stent; measures low density and unlikely
acute hemorrhage.
.
Abd/pelvis:
1. gastric stent has migrated even further distally and now
within body and antrum of stomach. punctate foci of high density
material at the GE junction and fundus of stomach are likely
broken off pieces of the stent stuck within the wall of the
stomach.
2. diffuse hepatic metastases appear to have worsened since the
recent chest CT.
3. metallic CBD stent appears unchanged in position and
appearance.
4. large amount of ascites measuring simple fluid density.
5. no evidence of hematoma or areas of high density fluid to
suggest bleeding on this noncontrast study.
6. high density material within the bowel could reflect acute
bleeding within the colon and distal small bowel. alternatively,
could reflect ingested material/medication. please correlate
clinically.
7. tiny nonobstructing right renal stones.
.
CXR:
IMPRESSION:
Interval decrease in size and extent of right middle and lower
lobe nodules, and decreased surrounding opacity about a left
upper lobe probable pneumatocele. Findings suggest improvement
of a multifocal infectious process.
Brief Hospital Course:
This is a 57 year-old male with a history of metastatic
esophogeal adenocarcinoma who presents with severe anemia, GI
bleed, and increased lethargy.
.
# Adenocarcinoma of esophagus with metastases of liver and lungs
with multi-organ failure: While he was still pursing pallative
chemo with his oncologist at [**Hospital3 3765**], it became clear
during this hospitalization that he was too sick undergo any
further chemotherapy. Due to his end-stage and deteriorating
condition, the family decided, in accordance with the patient
wishes, to withdraw all care (including antibiotics, blood
transfusion, and laboratory data/vital signs monitoring) and
transition him to CMO. His pain was controlled with ativan,
fentanyl gtt, and a morphine gtt. With his family by his side,
he became progressively bradycardic and passed away quickly
thereafter in the early evening on [**2135-3-5**].
The following issues were addressed during his brief
hospitalization:
# Acute anemia: Possible etiologies of blood loss included GI
bleeding from the tumor at the esophageal stent or hemobilia
with recent stent placement are both highly possible, especially
in the setting of his coagulopathy and recent lovenox
administration. The initial description of bleed seemed more
consistent with epistaxis and ENT was consulted for an exam but
did not find any suspicious source of bleeding. GI and ERCP
were consulted and wanted to hold off on evaluating the biliary
stent and possible biliary tree investigation due to continued
coagulopathy and risk of bleeding. He was given a total of 4
units pRBCs during this hospitalization with Hct resolving to
26. He was given vitamin K and FFP for elevated INR and DIC
labs were checked. His labs did show evidence of hemolysis with
elevated bilirubin, low haptoglobin and elevated LDH. He was
started on an octreotide and protonix gtt's for GI bleeding
prophylaxis.
.
#Lactic acidosis: 9.8 on admission. Likely combination of
hypotension and loss of liver function. With elevated WBC and
biliary obstruction, cholangitis was considered a likely cause,
despite the lack of RUQ pain and fevers. There was also
increased concern about his previous lung abscess which could be
causing severe infection. He was continued on broad coverage
with vanco, cefepime and flagyl for suspected cholangitis and
respiratory coverage. Blood and urine cultures did not grow any
organisms.
.
# Hypotension: SBP in 70s, but given liver pathology and lack of
tachycardic compensation, this is likely not far from baseline.
Likely further exacerbated with acute blood loss. Since he was
not responsive to IVF boluses and 5% albumin, he was started on
Levophed due to persistent hypotension.
.
# ARF: Cr 2.1 from baseline of 0.9 on discharge. Likely prerenal
given blood loss and poor oncotic pressure with albumin < 2.0.
He was volume resuscitated, but his kidney function continued to
worsen, likely secondary to intrinsic renal dysfunction from ATN
and sustained hypotension.
.
Medications on Admission:
1. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for anxiety or nausea: do not take if driving or drinking
alcohol.
3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
6. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO every 6-8 hours as
needed for pain.
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. multivitamin Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
10. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: last day [**2135-2-28**], for pneumonia.
Disp:*7 Tablet(s)* Refills:*0*
11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
12. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous once
a day: continue taking your dose at before the hospitalization.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnoses:
Metastatic esophageal adenocarcinoma
Acute cholangitis (obstructive)
Secondary diagnoses:
Liver failure secondary to metastases
Lung abscess/pneumonia
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"197.7",
"305.1",
"197.0",
"285.22",
"486",
"576.1",
"572.8",
"578.0",
"576.2",
"458.9",
"584.9",
"513.0",
"V58.61",
"V12.51",
"578.9",
"276.8",
"150.8",
"511.9",
"564.00",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10780, 10789
|
6423, 9420
|
311, 317
|
11004, 11014
|
3619, 6400
|
11066, 11072
|
2817, 2922
|
10752, 10757
|
10810, 10899
|
9446, 10729
|
11038, 11043
|
2937, 3600
|
10920, 10983
|
263, 273
|
345, 2462
|
2484, 2685
|
2701, 2801
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,820
| 182,099
|
46200
|
Discharge summary
|
report
|
Admission Date: [**2205-7-29**] Discharge Date: [**2205-8-9**]
Date of Birth: [**2129-3-14**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Ceftin / Bactrim / Zocor / Lopressor / Rezulin
Attending:[**First Name3 (LF) 8928**]
Chief Complaint:
Hip pain and drainage from prior surgical site
Major Surgical or Invasive Procedure:
Abscess drainage, washout, hardware removal, and antibiotic
spacer placement in the OR in the left hip.
History of Present Illness:
Patient is a 76yoF with multiple medical problems including CAD
s/p CABG, DM2, AS s/p bovine AVR, HTN, HLD and a left hip
hemiarthroplasty s/p infection/abx/washout/suppressive abx over
the last year, who was admitted [**7-29**] with a several week history
of left hip pain, which evolved to include edema, pain, and
finally mucopurulent drainage from her previous surgical
incision site. She underwent abscess drainage, washout, hardware
removal, and antibiotic spacer placement in the OR late on [**7-30**],
complicated by an intraoperative blood loss estimated at 1000cc.
She received 2 units PRBC. Tissue culture is having sparse coagu
negaitve sptaph. Last year tissue culture grew a coag negative
staph lugdunensis. Wound vac and drain were placed in the site.
ID is seeing her and has her on vancomycin 750mg Q12.
.
Post-operatively, she developed a dense delirium last night,
accusing staff of trying to kill her, pulling at IV lines and
her wound vac. Took a few swings at staff. Received IV haldol
0.5mg x 2 with good effect. QTC at 410. She has suffered post-op
delirium in previous surgeries, tends to wane in 2 days.
.
She has numerous metabolic derangements: hyperglycemic with AM
glucose 576 (though FSG shortly thereafter was 300 without any
interval insulin administered). Hyperkalemic with K=5.7 (no EKG
change). Hypomagnesemic. Tachycardic and dry-appearing with HCT
25ish. Complaining of some left hip pain.
Past Medical History:
- Coronary artery disease s/p 4 vessel CABG [**2190**]: LIMA to LAD,
reverse saphenous vein graft from aorta separately to ramus
intermedius, obtuse marginal, and posterolateral branch of RCA.
- Re-do sternotomy for AVR ([**1-6**]) for critical symptomatic
critical aortic stenosis with bovine AVR
- Carcinoid tumor of right middle lung lobe s/p resection.
- Diabetes mellitus, type 2
- Hypertension
- Hyperlipidemia
- Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped
Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC
filter, [**2197**] reports being off of coumadin now
- Oxygen dependent since lung surgery and for obstructive sleep
apnea, uses 2L nasal cannula 02 only at night at home. No Bpap
for obstructive sleep apnea.
- Restrictive lung disease
- carpel tunnel syndrome b/l, [**2179**] s/p decompression
- Chronic Diastolic heart failure (left atrium is mildly
dilated.
LVEF 67%/[**2199**])
- Anemia of Chronic disease, baseline Hct=26-31.0
Social History:
Patient is originally from [**Country 5881**]. Moved to U.S long time ago.
Currently live with husband and son in [**Name (NI) 77913**] plane. Denies any
tobacco, alcohol and drugs.
Family History:
Denies any family history of blood clot. REports vague family
history o heart attacks.
Her mother was diagnosed with diabetes.
Physical Exam:
Physical Exam on Tranfer to Medicine Team
Vitals: T: 100.1 99.1 96/53 85 16 97%RA
General: Alert able to converse, lying flat on bed.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
pupils reactive to light bilaterally, EOMI. Right pupil
slightly elongated
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally in the anterioc hest
wall, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**3-4**]
crescendo-decresedo murmur at LUSB radiating to carotids.
Abdomen: soft, non-tender, distended, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Surgical site appears clean without erythema. Tender to
touch. Wound wac in place. Poor skin turgor.
Neuro: Alert and oreinted x2 (name and place). Able to have
conversation. CNII-XII intack.
.
Discharged Physical Exam
97.9 96/54 64 18 100% on 2L
Gen: NAD
CV: RRR with systolic murmur ([**3-4**]) radiating to carotids
Resp: CTAB no w/r/r
Abd: mild distention, withough ttp or guarding, improved from
prior
Extr: bandaged ulcer on left heel, left hip wound bandage c/d/i
with ttp but no visible erythema, induration, or hematoma
Neuro: A&Ox2, appropriate, grossly nonfocal
Pertinent Results:
Admission
[**2205-7-29**] 01:08PM BLOOD WBC-6.0 RBC-3.21* Hgb-8.9* Hct-27.5*
MCV-86 MCH-27.6 MCHC-32.2 RDW-15.8* Plt Ct-274
[**2205-7-29**] 01:08PM BLOOD Neuts-75.4* Lymphs-17.7* Monos-5.4
Eos-1.2 Baso-0.2
[**2205-7-29**] 01:08PM BLOOD Glucose-197* UreaN-43* Creat-1.1 Na-138
K-4.5 Cl-101 HCO3-27 AnGap-15
[**2205-8-1**] 06:40AM BLOOD ALT-9 AST-11 AlkPhos-61 TotBili-0.4
[**2205-7-30**] 05:10AM BLOOD Calcium-8.9 Mg-1.5*
[**2205-7-29**] 01:07PM BLOOD Lactate-0.7
Blood Culture, Routine (Final [**2205-8-4**]): NO GROWTH.
Pertinent
[**2205-8-5**] 05:53AM BLOOD Glucose-45* UreaN-43* Creat-1.9* Na-130*
K-5.0 Cl-100 HCO3-23 AnGap-12
[**2205-8-2**] 10:18PM BLOOD CK-MB-2 cTropnT-<0.01
[**2205-8-3**] 03:22AM BLOOD CK-MB-4 cTropnT-0.12*
[**2205-8-3**] 01:11PM BLOOD CK-MB-4 cTropnT-0.06*
[**2205-8-5**] 12:13PM BLOOD cTropnT-0.04*
[**2205-8-5**] 04:44PM BLOOD CK-MB-3 cTropnT-0.04*
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2205-8-7**]):
POSITIVE BY EIA.
Blood Culture, Routine (Final [**2205-8-9**]): NO GROWTH.
GRAM STAIN (Final [**2205-7-31**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2205-8-4**]):
STAPHYLOCOCCUS LUGDUNENSIS. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
350-0974S
[**2205-7-31**].
STAPHYLOCOCCUS LUGDUNENSIS. RARE GROWTH. SECOND
MORPHOLOGY.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
350-0974S
[**2205-7-31**].
Discharge
[**2205-8-9**] 04:48AM BLOOD WBC-7.0 RBC-2.66* Hgb-7.9* Hct-24.3*
MCV-91 MCH-29.8 MCHC-32.7 RDW-16.0* Plt Ct-296
[**2205-8-9**] 04:48AM BLOOD Glucose-71 UreaN-27* Creat-1.1 Na-136
K-4.4 Cl-103 HCO3-26 AnGap-11
[**2205-8-9**] 04:48AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9
[**2205-8-9**] 04:48AM BLOOD Vanco-22.9* (not true trough as dose was
given at 8pm night prior)
[**2205-7-29**] 01:08PM BLOOD WBC-6.0 RBC-3.21* Hgb-8.9* Hct-27.5*
MCV-86 MCH-27.6 MCHC-32.2 RDW-15.8* Plt Ct-274
[**2205-8-3**] 03:22AM BLOOD WBC-10.3 RBC-3.01* Hgb-9.1* Hct-26.8*
MCV-89 MCH-30.2 MCHC-33.8 RDW-15.3 Plt Ct-173
[**2205-8-3**] 03:22AM BLOOD Neuts-88.0* Lymphs-5.9* Monos-4.7 Eos-1.1
Baso-0.3
[**2205-8-3**] 03:22AM BLOOD PT-12.7* PTT-27.5 INR(PT)-1.2*
[**2205-7-30**] 05:10AM BLOOD ESR-84*
[**2205-7-29**] 01:08PM BLOOD Glucose-197* UreaN-43* Creat-1.1 Na-138
K-4.5 Cl-101 HCO3-27 AnGap-15
[**2205-8-3**] 03:22AM BLOOD Glucose-119* UreaN-24* Creat-1.0 Na-132*
K-4.9 Cl-103 HCO3-21* AnGap-13
[**2205-8-2**] 10:18PM BLOOD CK-MB-2 cTropnT-<0.01
[**2205-8-3**] 03:22AM BLOOD CK-MB-4 cTropnT-0.12*
[**2205-8-3**] 03:22AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.8
.
Pelvis and dedicated left Hip X-Ray: [**2205-7-29**]
FINDINGS: AP view of the pelvis and three dedicated views of the
left hip obtained. Long stem left hip bipolar hemiarthroplasty,
cerclage wire, and greater trochanter hook device are in similar
position to prior. Lucencies surrounding the cement-bone
interfaces of the intertrochanteric region and proximal femur
are similar to prior, accounting for positioning. No evidence of
new osseous fracture. Diffuse demineralization is again seen.
Vascular calcifications and radiopaque pills in the right lower
quadrant are similar to prior. Numerous metallic clips over the
medial thigh soft tissues.
IMPRESSION: Stable position of left femoral hardware with
cement-bone.Preliminary Reportinterface lucencies similar to
prior.
.
CXR: [**2205-7-29**]
FINDINGS: The patient is status post aortic valve replacement
and probably coronary artery bypass graft surgery as well as
placement of fixation plates along the sternum. The cardiac,
mediastinal and hilar contours appear unchanged. There is no
pleural effusion or pneumothorax. A mild background interstitial
abnormality appears unchanged. The bones appear demineralized.
Mild superior endplate compression deformity along an upper
thoracic vertebral body with sclerosis is also unchanged.
IMPRESSION: No evidence of acute cardiopulmonary disease.
.
Left Pelvis X-ray: [**2205-7-31**]
FINDINGS: Since the previous study, there has been removal of
the hemiarthroplasty on the left side. There has been placement
of an antibiotic spacer within the hip joint as well as within
the femoral shaft. Lateral surgical skin staples are seen.
There is soft tissue swelling and gas consistent with the recent
surgery. Some generalized demineralization.
.
Echo [**2205-8-3**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal to mid septal hypokinesis (the anterior
wall is not well seen). The aortic root is mildly dilated at the
sinus level. A bioprosthetic aortic valve prosthesis is present.
The aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is severe mitral annular calcification. There
is mild functional mitral stenosis (mean gradient 7 mmHg) due to
mitral annular calcification. Mild to moderate ([**1-28**]+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
CTA chest [**2205-8-2**]
1. No pulmonary embolus.
2. Enlarged main pulmonary artery, suggesting pulmonary
arterial
hypertension.
3. Cardiomegaly, unchanged.Chronic small bilateral
non-hemorrhagic pleural
effusions with loculated components, with only very mild
component of
pulmonary edema.
Brief Hospital Course:
76yoF with CAD s/p 4v CABG, DM2, AS s/p bovine valve, HTN, HLD
and a left hip hemiarthroplasty with recurrent prosthetic joint
infection s/p washout, abscess drainage, hardware removal, and
antibiotic spacer placment on [**7-30**] with post-op delirium and
cultures which coagu negative staph.
# Prostethic Joint Infection: Patient presented with hip pain
and found to have mucopurulent drainage from her previous
surgical incision site. She underwent abscess drainage, washout,
hardware removal, and antibiotic spacer placement in the OR on
[**7-30**], complicated by an intraoperative blood loss estimated at
1000cc. She received 3 units PRBC with stablization of her
hematocrit. Tissue culture grew coagulase negative staph,
staphylococcus Lugdunesis, the same organism found in her prior
hip infections. She remained afebfile without any signs of
sepsis. She was started on IV vancomycin and had PICC line
placed. Her vancomycin dose was adjusted in the setting of her
acute renal failure but has been now established by ID to be 750
q 24 hrs. She continues to experience pain which is well
controoled with PO oxycodone 2.5. She will need to follow up
with orthopedics next week for staple removal and infectious
disease and further management.
# Post-operative respiratory distress: Post-op, was noted to
have be hypoxemic, which was rapidly weaned back to nasal
cannula with SpO2 in high 90s. Unclear etiology. Transferred to
ICU. CTA negative for PE. Troponin was elevated to 0.12 but
decreased to 0.06 there after. EKG was unchanged. [**Month (only) 116**] have
been [**2-28**] to narcotic effects in setting of OSA. Should obtain
sleep study given questionable history of OSA.
# Systolic CHF/CAD: s/p 4V CABG [**2190**]. Noted on echo which was
obtained because of episode of hypoxia and chest pain. EF 45%
with presumed ischemic cardiomyopathy. Newly diagnosed.
Carvedilol was increased to 6.25 [**Hospital1 **]. ASA 81 continued. Unable
to add ACEI because it was not tolerated due to hypotension.
F/U with cardiology.
# Post Operative delirium: Patient was at high risk for delirium
given her history of previous post-op delirium, pain, immobility
and anesthesia. She was given haldol 0.5mgx2 with good effect.
She was transferred to the ICU very delirious in the setting of
hypoxia and was given additional doses of Haldol IV. Within 8
hours of transfer to ICU, patient's delirium had cleared. On
transfer to medicine team, patient was awake, alert and oriented
and did not have any further episodes of delirium. She remained
A&Ox2 for the remainder of her stay.
# Anemia: Patient has history of iron deficiency anemia with
baseline HCT 25-30. Colonoscopy from [**2198**] showed diverticulosis
of the colon and grade 3 internal hemorrhoids. During her
orthopedic surgery this admission, she lost aproximately 1000cc
of blood and recieved eunits of blood transfusions. She denied
hemoptysis, hematamesis and hemmatochezia. Her hematocrit
remained stable around 25% after procedure. Patient will need
to follow up with PCP for further evaluation/management of her
anemia.
# GI bleed: Pt had questionable episode of coffee ground emesis.
She was started in IV pantoprazole [**Hospital1 **]. HCT and pressures were
stable during this event and during the remainder of her stay.
Her enoxaparin was initially held but then restarted in setting
of hemodynamic instability. She was transitioned to
pantoprazole PO BID. GI was consulted and did not recommend
EGD but will see her as outpatient. H Pylori antibody was
positive and she was started on metronidazole and clarithromycin
for a course of 10 days of treatment. She will need to follow
up with gastorenterology to have stool antigen testing or urea
breath test to confirm erridication.
# Constipation: pt was profoundly constipated in the post
operative period with evidence of dilated loops of bowel on abd
xray. An aggressive bowel regimen was instituted with
combinations of senna, docusate, miralax, milk of mag,
lactulose, and pr bisacodyl. She ultimated had several large
bowel movements and improvement was noted in abdominal
distention on exam and on bowel dilation on xray. She is now on
senna and docusate and miralax with bisacodyl prn.
# [**Last Name (un) **]: Pt creatinine rose from baseline of 1->1.9 in the
postoperative/post CTA period. It was initially unresponsive to
NS bolus. Renal US was normal. Prior to discharge, her
creatine downtrended to 1.1. Etiology, while unclear was likely
secondary to prerenal azotemia.
# Hx of recurrent DVT: Patient is s/p IVC filter. She was kept
on lovenox given she is at risk for DVT/PE from orthopedic
surgery and immnobilization. She will continue lovenox for 19
more days after d/c for a total of 4 weeks.
Chronic
# Hypertension: Blood pressure was well controlled during this
admission. Uptitrated Carvedilol. Unable to add ACEI because of
soft pressures.
# Diabetes Type 2: Patient was kept on 10NPH in the morning and
8NPH at dinner consistent with home dose. ISS was added as
well. Metformin was held while in house. She was discharged on
her home NPH dose and her home metformin.
# Hyperlipdiema: Continued atorvastain.
TRANSITIONAL ISSUES:
# Unable to start ACEI because it was not tolerated by blood
pressure->should be considered in setting of systolic CHF
# Would likely benefit from outpatient sleep study to further
define severity of OSA and need for nocturnal O2
# Will need vancomycin trough on sunday with goal between 15-20.
Results to be faxed to the Infectious Disease R.N.s at [**Hospital1 18**] fax
([**Telephone/Fax (1) 4591**]
# She will need weekly CBC, Creatinine, LFTs checked weekly and
faxed to the Infectious Disease R.N.s at [**Hospital1 18**] fax ([**Telephone/Fax (1) 4591**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Atorvastatin 40 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Senna 1 TAB PO DAILY:PRN Constipation
5. Docusate Sodium 100 mg PO DAILY Contipation
6. Multivitamins 1 TAB PO DAILY
7. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral Twice daily
8. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN Pain
9. Aspirin 81 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. NPH 10 Units Breakfast
NPH 8 Units Dinner
12. Bromday *NF* (bromfenac) 0.09 % OU daily
13. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Senna 1 TAB PO DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO DAILY Contipation
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral Twice daily
7. Bromday *NF* (bromfenac) 0.09 % OU daily
8. Atorvastatin 40 mg PO DAILY
9. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN Pain
10. Carvedilol 6.25 mg PO BID
Hold for BP<90 or HR<60.
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Bisacodyl 10 mg PR HS:PRN Constipation
13. Clarithromycin 500 mg PO Q12H Duration: 9 Days
14. Enoxaparin Sodium 40 mg SC DAILY Duration: 19 Days
15. MetRONIDAZOLE (FLagyl) 500 mg PO BID Duration: 9 Days
16. Ondansetron 4 mg IV Q8H:PRN nausea
17. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
Hold for excessive sedation.
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth q6hrs Disp
#*30 Capsule Refills:*0
18. Pantoprazole 40 mg PO Q12H
19. Vancomycin 750 mg IV Q 24H
20. NPH 10 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary Diagnosis: Prostethic Joint Infection
Secondary Diagnosis: Delirium, Type II Diabetes, systolic heart
failure, acute kidney injury, constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair due to
surgical pain.
Discharge Instructions:
Dear Mrs. [**Known lastname 32737**], it was a pleasure taking care of you during
your hospitalization at [**Hospital1 18**]. You were admitted because you
had left hip pain which was draining pus from previous surgical
incision site. You were taken to the operating room where you
had drainage of the pus, removal of the hardware in the hip, and
antibiotic placement in your hip. Tissue culture from your hip
grew bacteria similar to your past joint infections. Infectious
disease specialist were also involved in your care who started
you on intravenous antibtioics. In order to treat your
infection outside the hospital you had a PICC line placed for
antibiotic adminstration in your rehab/home. You also had some
shortness of breath and chest pain during your stay. However,
it was determined that you did not have a heart attack. It was
noted that your heart did not squeeze as hard as it should and
we have started some new medications to treat this problem. we
recommend that you see a cardiologist to help manage this
problem.
You will need follow up with gastroenterology, cardiology,
infectious disease, and orthopedic doctors
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2205-8-14**] at 10:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2205-8-15**] at 3:00 PM
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: TUESDAY [**2205-8-20**] at 10:40 AM
With: [**Year (4 digits) **] XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2205-8-20**] at 11:00 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
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Department: Cardiology
Location: [**Hospital **] HOSPITAL
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 38978**]
Phone: [**Telephone/Fax (1) 77385**]
Appointment: Thursday [**2205-8-22**] 11:30am
Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2205-8-29**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**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
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8931**]
|
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"564.00"
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icd9cm
|
[
[
[]
]
] |
[
"38.97",
"84.56",
"80.85",
"78.65"
] |
icd9pcs
|
[
[
[]
]
] |
18166, 18260
|
10462, 15660
|
366, 472
|
18459, 18459
|
4596, 10439
|
19811, 21695
|
3161, 3291
|
17028, 18143
|
18281, 18281
|
16272, 17005
|
18642, 19788
|
3306, 4577
|
15681, 16246
|
280, 328
|
500, 1930
|
18350, 18438
|
18301, 18329
|
18474, 18618
|
1952, 2943
|
2959, 3145
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,916
| 132,667
|
44267+58696
|
Discharge summary
|
report+addendum
|
Admission Date: [**2139-9-15**] Discharge Date: [**2139-10-7**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Urinary incontinence
Major Surgical or Invasive Procedure:
L3 mass excision with L1-5 posterior fusion with
instrumentation.
History of Present Illness:
86 M w/ PMH locally advanced prostate cancer responsive to
hormone therapy, MGUS, and presumed plasmacytoma of L3 region
who presented to the ED with a 1 day history of urinary
incontinence.
As per the pt's family, he has been having worsened anxiety and
aggitation. His daughter-in-law feels that he has difficulty
expressing himself and this manifests as worsened back pain, as
well as N/V. As a result, he has received increased doses of
narcotics, up to 4mg of Dilaudid Q2H. He also was started on
Ativan 0.5mg TID on [**9-11**]. Yesterday he had at least one
episode of urinary incontinence.
.
In the ED, he had an MRI of the Lspine notable for stable cord
compression due to L3 lesion. Spine and Rad onc were consulted
and felt the images were stable from [**9-4**].
.
The morning after admission, the patient was confused and did
not answer questions with the interpreter present. As per
chart, he had denied weakness and numbness, as well as
fever/chills. At one point he tried to stand up, and appeared
to be in pain. By the time the RN returned to give him pain
medications, he had fallen back asleep.
Past Medical History:
1. Coronary artery disease with a positive stress test in [**2127**]
and a negative stress test in [**2135**]. EF was 60-70% in [**1-5**].
2. Hypertension.
3. Prostate cancer - First dx in [**12-4**]. PSA ~73 at that time. He
underwent transurethral biopsy by Dr. [**Last Name (STitle) **] on [**2138-1-10**] which
revealed a very aggressive prostate adenocarcinoma with a
[**Doctor Last Name **]
score of 8 involving 13 of 20 cores with at least 30%-80% of
each
of the cores. He was treated with Lupron in the [**1-/2138**] and had
a a good response within about 6 weeks with a PSA that was 0.9.
He had repeat shots in 4 and [**6-3**] and in [**7-/2138**], he had an
undetectable PSA. He did not f/u until [**6-4**], when his PSA was
3.2. He had a Lupron shot on [**2139-6-24**]. PSA on [**2139-9-3**] was 0.4.
4. Polymyalgia rheumatica on steroids in the past
5. MGUS - followed by Dr. [**Last Name (STitle) **] - IgG-kappa monoclonal
gammopathy c/b
with anemia and mild chronic renal failure
6. Anemia - baseline 28-32
7. Chronic renal insufficiency with baseline creatinine 1.2-1.5
8. Presumed plasmacytoma of L3 - noted on spine xray in setting
of chronic low back pain. On [**2139-7-16**], CT Lspine showed expansion
and further destruction of L3 lytic lesion with soft tissue
extension on the left side. MRI on [**2139-8-21**] was notable for
metastasis to L3 vertebral body with compression and left
paraspinal mass with 75% narrowing of the spinal canal at L3
level due to retropulsion and epidural mass. He completed [**9-8**]
sessions of XRT to the spinal mass in addition to steroid
therapy. He refuses a bx for definitive dx.
9. H/O adenomatous polyps resected in [**2131**]
10. Mass on left lower abdominal wall resected [**2134**],
subsequently found to be a schwannoma
Social History:
He is Russian speaking. He lives with his wife. [**Name (NI) **] does not
smoke or drink alcohol. His son is the HCP. His dtr-in-law,
[**Name (NI) 33933**] [**Name (NI) 94935**], translated for him. Her # is [**Telephone/Fax (1) 94936**] cell,
[**Telephone/Fax (1) 94937**] home.
Family History:
Non-contributory
Physical Exam:
Vitals: T 96.5, BP 125/71, HR 69, RR 20, Sat 97% on RA
General: asleep, nad, restraints in place
HEENT: EOMI, no nystagmus, sclera anicteric, MMM, OP clear
Neck: supple, no LAD
Cardiac: RRR, nl S1S2. III/VI early systolic murmur best at RUSB
Lungs: CTAB, no w/c/r
Abdomen: NABS, ND/NT, no rebound or guarding, no appreciable HSM
Extremities: no edema, 1+ B/L pulses
Rectal: good tone
Back: no spinal tenderness
Skin: No rashes rashes.
Neuro: 5/5 strength - hip f/e/ab/ad, knee f/e, df/pf (trying
actively to kick me away)
2+ patellar reflexes b/l; toes downgoing
--unable to assess sensation; kicks to pain
Pertinent Results:
[**2139-9-14**] 07:10PM PLT COUNT-160
[**2139-9-14**] 07:10PM NEUTS-79.2* LYMPHS-15.2* MONOS-4.4 EOS-1.2
BASOS-0
[**2139-9-14**] 07:10PM WBC-2.3* RBC-3.48* HGB-11.1* HCT-31.3* MCV-90
MCH-32.0 MCHC-35.7* RDW-14.2
[**2139-9-14**] 07:10PM ALBUMIN-3.9 CALCIUM-9.3 PHOSPHATE-3.6
MAGNESIUM-2.1
[**2139-9-14**] 07:10PM LIPASE-35
[**2139-9-14**] 07:10PM ALT(SGPT)-60* AST(SGOT)-41* LD(LDH)-155 ALK
PHOS-50 AMYLASE-48 TOT BILI-0.4
[**2139-9-14**] 07:10PM GLUCOSE-105 UREA N-17 CREAT-1.1 SODIUM-135
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-31 ANION GAP-12
[**2139-9-14**] 08:05PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2139-9-14**] 08:05PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2139-9-14**] 08:05PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2139-9-15**] 10:30AM GRAN CT-1110*
.
CT head [**9-14**]- No acute intracranial hemorrhage or mass effect
.
[**9-14**] MRI L-spine w/gadolinium- Large mass at L3 with features
as discussed above. There is severe canal stenosis. There is no
definite change from prior study
Brief Hospital Course:
A/P: 86yo man with h/o prostate CA, presumed plasmacytoma of L3
vert, admitted for urinary incontinence with stable MRI with
cord compression and N/V with normal head CT.
.
# Urinary incontinence - known spinal cord compression on exam
but stable since last imaging, pt without new weakness or saddle
anesthesia and good rectal tone so may be related to prostate
pathology instead; UA neg for infxn
- have d/c'd decadron
- bladder scan showed 750cc urine
- need to place foley
.
# N/V- CT head neg, could be [**1-1**] increased narcotic use and
anxiety
- d/c dilaudid
- LFTs slightly [**Last Name (LF) **], [**First Name3 (LF) **]/lipase wnl
- reglan w/meals
- anzemet IV or compazine PO PRN
- monitor symptom
.
# Pain mgmt- difficult b/c pt appears in pain at times, but as
per family he is anxious and cannot easily express this. Also
he appears to be having narcotic toxicity
- increase fentanyl patch to 50mcg
- d/c dilaudid as may be cause of confusion and nausea
- oxycodone for BT
- Ativan PRN for anxiety
.
# Prostate CA
- concern for disease progression as as pt with urinary
retention
- urology consult
.
# Plasmacytoma - concern for spinal cord compression, but MRI
does not show change from prior
- Ortho Spine performed decompression of L3 lesion with
posterior stabilization from L1-5. Incisions were clean and dry
upon discharge. Follow up will occur in two weeks in the ortho
Spine clinic. Call [**Telephone/Fax (1) 11061**] for an appointment.
- mgmt per Dr. [**Last Name (STitle) 363**]
.
# CAD- cont ASA 81mg and placed pt on metoprolol in place of
atenolol. Will hold on lipitor.
.
# B12 deficiency- pt no longer deficient, will d/c
supplementation
.
# CKD - at baseline creatinine
.
# FEN- cardiac diet as tolerated, replete lytes prn, no need for
IVFs for now
.
# PPx- SC heparin, bowel reg, PPI
.
#Code: Full
.
#Contact: daughter in law [**Female First Name (un) 94938**] [**Telephone/Fax (1) 94936**] cell,
[**Telephone/Fax (1) 94937**] home
Medications on Admission:
Medications on Admission:
1. Aspirin 81 mg Tablet daily
2. Simethicone 80 mg Tablet qid prn
3. Docusate Sodium 100 mg [**Hospital1 **]
4. Miralax
5. Ativan PRN
6. Neurontin 300 mg qhs
7. Decadron ? dose
8. Fentanyl 25 mcg/hr One (1) Patch 72HR
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-5**]
10. Metoclopramide 10 mg PO QIDACHS
11. Tamulosin 0.4mg daily
12. Lipitor 20mg daily
13. Atenolol 25mg daily
Discharge Medications:
1. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
2. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Please do not give with Percocet.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
L3 lesion with spinal canal compromise.
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic if you
experience fevers above 101.7 or for any additional concerns.
Physical Therapy:
Activity: Ambulate
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
Please follow up in the Orthopedic Spine clinic in two weeks.
Please call [**Telephone/Fax (1) 11061**] to schedule an appoinement.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2139-9-24**] 10:00
Provider: [**Name10 (NameIs) 8848**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2139-10-8**] 11:30
Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2139-10-8**] 11:30
Completed by:[**2139-9-22**] Name: [**Known lastname 15013**],[**Known firstname **] Unit No: [**Numeric Identifier 15014**]
Admission Date: [**2139-9-15**] Discharge Date: [**2139-10-7**]
Date of Birth: [**2053-5-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2389**]
Addendum:
Pt admitted to Orthopedics service for decompression of L3
lesion with posterior stabilization from L1-5, transferred to
Medicine after developing atrial fibrillation post surgery.
Chief Complaint:
transfer from Ortho service for atrial fibrillation
Major Surgical or Invasive Procedure:
L3 mass excision with L1-5 posterior fusion with
instrumentation.
History of Present Illness:
86 M w/ PMH locally advanced prostate cancer responsive to
hormone therapy, MGUS, and presumed plasmacytoma of L3 region,
hx of tachyarrhythmias, trasfered care to medicine team for
atrial fibrillation.
Pt initially presented to the ED on [**9-15**] with a 1 day history
of urinary incontinence, severe low back pain, altered mental
status concerning for spinal cord compression, but with MRI
demonstrating compression due to L3 lesion. Spine and Rad onc
were consulted and felt the images were stable from [**9-4**].
Admitted to OMED. Of note patient has hx of atrial fibrillation
occuring prior to a colonoscopy. Pt on atenolol as outpatient.
Pt admitted to OMED, but atenolol was not started at that time.
Ortho consulted and in discussion with oncology felt surgical
intervention best for treatment of severe symptoms. Spine
performed decompression of L3 lesion with posterior
stabilization from L1-5 on [**9-18**]. Pt stable until today when HR
noted to be in 130's to 140's. In atrial fibrillation.
Lopressior 5 mg x 3 given, with no relief. Diltiazem 10 mg IV
once given with rate to 70's to 80's. Of note patient not on his
beta blocker for one week, and 3 units PRBC's given, though
chest x-ray with no strong evidence of failure. On seeing
patient, agitated in A-fibb but not in acute distress.
Past Medical History:
1. Coronary artery disease with a positive stress test in [**2127**]
and a negative stress test in [**2135**]. EF was 60-70% in [**1-5**].
History of atrial fibrillation prior to colonoscopy. Hx of
tachyarr.
2. Hypertension.
3. Prostate cancer - First dx in [**12-4**]. PSA ~73 at that time. He
underwent transurethral biopsy by Dr. [**Last Name (STitle) **] on [**2138-1-10**] which
revealed a very aggressive prostate adenocarcinoma with a
[**Doctor Last Name **] score of 8 involving 13 of 20 cores with at least
30%-80% of
each of the cores. He was treated with Lupron in the [**1-/2138**] and
had
a a good response within about 6 weeks with a PSA that was 0.9.
He had repeat shots in 4 and [**6-3**] and in [**7-/2138**], he had an
undetectable PSA. He did not f/u until [**6-4**], when his PSA was
3.2. He had a Lupron shot on [**2139-6-24**]. PSA on [**2139-9-3**] was 0.4.
4. Polymyalgia rheumatica on steroids in the past
5. MGUS - followed by Dr. [**Last Name (STitle) 343**] - IgG-kappa monoclonal
gammopathy c/b
with anemia and mild chronic renal failure
6. Anemia - baseline 28-32
7. Chronic renal insufficiency with baseline creatinine 1.2-1.5
8. Presumed plasmacytoma of L3 - noted on spine xray in setting
of chronic low back pain. On [**2139-7-16**], CT Lspine showed expansion
and further destruction of L3 lytic lesion with soft tissue
extension on the left side. MRI on [**2139-8-21**] was notable for
metastasis to L3 vertebral body with compression and left
paraspinal mass with 75% narrowing of the spinal canal at L3
level due to retropulsion and epidural mass. He completed [**9-8**]
sessions of XRT to the spinal mass in addition to steroid
therapy. He refuses a bx for definitive dx.
9. H/O adenomatous polyps resected in [**2131**]
10. Mass on left lower abdominal wall resected [**2134**],
subsequently found to be a schwannoma
Social History:
He is Russian speaking. He lives with his wife. [**Name (NI) **] does not
smoke or drink alcohol. His son is the HCP. His dtr-in-law,
[**Name (NI) **] [**Name (NI) **], translated for him. Her # is [**Telephone/Fax (1) 15015**] cell,
[**Telephone/Fax (1) 15016**] home.
Social History:
He is Russian speaking. He lives with his wife. [**Name (NI) **] does not
smoke or drink alcohol. His son is the HCP. His dtr-in-law,
[**Name (NI) **] [**Name (NI) **], translated for him. Her # is [**Telephone/Fax (1) 15015**] cell,
[**Telephone/Fax (1) 15016**] home.
Family History:
Non-contributory
Physical Exam:
Vitals: 98.0, HR 128, range 68-148, BP 105/75, 96-159/59-100, on
repeat SBP 130's. 99 2L. 97% RA
General: agitated non cooperative with exam.
HEENT: PERRL, sclera anicteric, MMM, OP clear
Neck: supple, no LAD
Cardiac: Irregularly irregular, rate in 120's.
Lungs: bibasilar crackles
Abdomen: NABS, ND/[**Name (NI) **], pt grimacing, no appreciable HSM
though difficult exam given combative nature.
Extremities: no edema, 1+ B/L pulses.
Back: spinal tenderness, patient grimacing, but difficult to
ascertain given agitation.
Skin: No rashes
Neuro: Not answering questions, agitated, grabbing my arm.
Pertinent Results:
LABS-
CK: 241 MB: 3 Trop-*T*: 0.01
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Crit 30.3
[**9-21**]
9.3
3.0 121
26.1
EKG atrial fibrillation RVR, rate 124, PVC's. Inferior and
anterior T wave changes.
.
Images-
CT head [**9-14**]- No acute intracranial hemorrhage or mass effect
.
[**9-14**] MRI L-spine w/gadolinium- Large mass at L3 with features
as discussed above. There is severe canal stenosis. There is no
definite change from prior study
.
CXR portable [**9-22**]-
A small radiopaque band is seen just above the left costophrenic
angle, likely representing focal atelectasis. Otherwise, the of
the lung fields is symmetric.
.
CT L-SPINE W/O CONTRAST [**2139-9-27**] 8:16 PM
soft tissue mass at the L3 level with associated osseous
destruction of the L3 vertebral body. The patient has undergone
interval placement of posterior fusion hardware from L1-5. There
is no evidence of spondylolisthesis.
.
CT C-SPINE W/O CONTRAST [**2139-9-27**] 8:16 PM
1. Extensive degenerative changes are seen, as described above.
2. There is no fracture.
3. There is a 3 mm grade I anterolisthesis of C4 on C5 with
focal kyphotic angulation. There is no associated prevertebral
soft tissue abnormality. While this is possibly degenerative,
the kyphosis appears more prominent in comparison to the prior
C-spine radiographs from [**2135-12-19**], and an underlying ligamentous
injury is not excluded. Clinical correlation is recommended, and
further evaluation with an MRI could be obtained if indicated.
I agree that there is more subluxation and kyphosis now than on
the prior study.
.
CT T-SPINE W/O CONTRAST [**2139-9-27**] 8:16 PM
1. No fracture or subluxation of the thoracic spine is
identified.
2. Bilateral pleural effusions and adjacent atelectasis.
3. Slightly increased density of the liver parenchyma is noted,
and may reflect changes related to prior treatment or
transfusion.
.
CT HEAD W/O CONTRAST [**2139-9-27**] 7:29 PM
No intracranial hemorrhage is identified. The ventricles are
symmetric, and there is no shift of normally midline structures.
The [**Doctor Last Name **]-white matter differentiation is preserved. Again seen
are areas of low attenuation within the periventricular and
subcortical white matter, consistent with change from chronic
microvascular angiopathy. Soft tissue and osseous structures are
stable in appearance. The visualized portions of the paranasal
sinuses are well aerated.
No hemorrhage is identified.
.
MRA BRAIN W/O CONTRAST [**2139-9-30**] 1:05 PM
1. No evidence of acute intracranial process; specifically,
there is no evidence of acute infarction.
2. Moderate generalized atrophy and chronic micro-ischemic
change in subcortical and periventricular white matter.
3. Unremarkable cranial MRA. .
.
CHEST (PORTABLE AP) [**2139-10-4**] 3:29 PM
1. No consolidation. No effusion.
2. Nodular opacity projecting over the left lung base is not
evident on the chest radiograph of [**2139-10-1**]. The finding may
simply represent nipple shadow. It clinically indicated, repeat
chest radiograph with nipple marker in place could be performed
to exclude pulmonary nodule.
.
PORTABLE ABDOMEN [**2139-10-4**] 3:20 PM
Limited study secondary to patient motion. Normal bowel gas
pattern..
.
L-SPINE (AP & LAT) [**2139-10-5**] 10:43 AM
1. Laminectomy and spinal stabilization procedure, in nominal
alignment, with osseous destruction of L3. Degenerative
narrowing at multiple disc levels noted.
2. Lytic lesion in right iliac bone, not fully evaluated. Is
this the site of previous surgical intervention?.
.
Brief Hospital Course:
86yo man with h/o prostate CA, presumed plasmacytoma of L3 vert,
admitted for back pain, altered mental status, urinary
incontinence s/p decompression of L3 lesion with posterior
stabilization from L1-5 with subsequent episode of atrial
fibrillation and worsening altered mental status.
.
#Altered mental status- Present post dilaudid and Ativan for low
back pain as outpatient. In house felt likely due to narcotics.
In house had been on dilaudid and ativan, then fentanyl 50 mcg,
which was cut to 25 mcg and then stopped. No improvement in
mental status though difficult to assess given language barrier.
Pt agitated at night requiring Haldol, with episodes of
somnolence. Pt would communicate with wife, but not alert to
person, place, or time for several days into admission. Pt had
fall on [**9-27**] with no evidence of bleed on CT head. [**9-28**] Neuro
consulted given worsening mental status. Neuro felt possible
left hemisphere pathology causing receptive aphasia with right
sided weakness. Broad differential for this post-operative
delirium included cerebral hypoxia, endocrine or electrolyte
imbalance, postoperative pain, full bladder, hyper or
hypoglycemia, drug intoxication or withdrawl,
language/communication barriers, UTI, drug-intoxication (e.g.
opioids), cerebral hypoxia, sleep deprivation. Considered
L-sided stroke [**1-1**] atrial fibrillation consistent with
right-sided motor signs and possible aphasia. MRI/MRA stroke
protocol to be performed negative for acute bleed or stroke
pathology. EEG with no seizure focus. No evidence of UTI,
metabolic derrangement or neurological pathology. [**9-30**] patient
began to improve, not necessitating haldol at night, taking
PO's, decreased somnolence throughout the day. [**10-4**] bradycardic
to 38, somnolent, neuro felt unresponsiveness related to
bradycardia, though BP stable. At time of discharge mental
status improving alert and oriented x 1, afebrile, ambulating
with aid, not requiring Haldol, to be discharged to
rehabilitation hospital.
.
#Atrial fibrillation- On episode previously pre colonoscopy
[**1-5**], occured post surgery. Of note patient was on atenolol as
an outpatient and had been taken off the beta blocker x 1 +
weeks, prior to episode. Diltiazem 10 mg IV, 5 mg IV lopressor
given. Pt restarted on metoprolol 25 TID. Within two days
reverted to sinus with ectopy. With elevated BP to 170's on
captopril and 25 TID BB, increased metoprolol to 37.5 TID.
Episode of bradycardia two days later associated with episode of
unresponsiveness. Beta Blocker DC'd and within one day patient
reverted to A-fibb with rate 150's. Dilt 10 mg IV once,
lopressor IV 5 mg once and metoprolol 25 [**Hospital1 **] started, with rate
control to 70's within several hours. Converted to sinus. EP
consulted concern for tachy/brady, sick sinus syndrome. EP
reported likely medication adjustment related, and to continue
metoprolol 25 [**Hospital1 **], captopril for BP control with addition of CC
blocker if needed. In terms of atrial fibrillation, considered
elderly male with CAD, htn, setting of stressor, surgical
intervention in addition to possible increased fluid load all
exacerbating factors, but appears discontinuation of beta
blocker with rebound tachyarrhythmia likely culprit. Enzymes
sent and did not appear to be from MI, pulmonic process or PE,
or CHF by XCR.
Pt not anticoagulated given falls in hospital and risk. As per
EP, as mental status improves if continues to have episodes of
tachy/brady symptomatic may likely need permanent pacemaker.
.
#hyponatremia- Pt to 128 lowest. Urine OSM's suggestive of
SIADH, but pt appeared hypovolemic on admission with very poor
PO intake. NS given with return to 135. Sodium fluctuated
throughout admission. Pt not on any medications that would
classicaly lead to SIADH picture. 130 on discharge.
.
# Urinary incontinence - Known spinal cord compression on exam ,
but stable since last imaging, pt without new weakness or
saddle, anesthesia, good rectal tone. Felt likely related to
prostate pathology. Prostate Ca, [**Doctor Last Name **] score 8.
Considered retention with overflow incontinence. Bladder scan on
transfer with 100+ cc residual. Tamsulosin continued.
Incontinent of urine and bowel, but throughout course of
admission, fair urine output. Discharge with good urine output,
no foley catheter, incontinent of urine.
.
# Pain mgmt- Delirium likely result of pain medications, ativan
and dilaudid. Dilaudid Discontinued and fentanyl patch started
and discontinued on [**9-25**]. Toradol given for pain. Pt reported
to interpreter no pain, and tylenol continued. Comfortable in no
acute distress or pain, with tylenol for relief.
.
# Chordoma-Ortho Spine performing decompression of L3 lesion
with posterior stabilization from L1-5. Chordoma identifies,
locally invasive bone tumor, rarely metastatic, results
discussed with oncologist Dr. [**Last Name (STitle) 15017**] who assessed patient and
will see as outpatient. Radiation x 10 treatments given prior to
admission therefore will likely just follow.
.
# CAD- Metoprolol 25 [**Hospital1 **], captopril 25 TID, aspirin held given
surgery. On statin.
.
# CKD -Remained ay baseline creatinine during course of
admission.
.
#Contact: daughter in law [**Female First Name (un) 15018**] [**Telephone/Fax (1) 15015**] cell,
[**Telephone/Fax (1) 15016**] home.
.
Pt discharged to rehabilitation hospital with follow up with Dr.
[**Last Name (STitle) **], Dr. [**Last Name (STitle) 15017**], Dr [**Last Name (STitle) 6733**].
Medications on Admission:
Medications on admission to hospital-
1. Aspirin 81 mg Tablet daily
2. Simethicone 80 mg Tablet qid prn
3. Docusate Sodium 100 mg [**Hospital1 **]
4. Miralax
5. Ativan PRN
6. Neurontin 300 mg qhs
7. Decadron ? dose
8. Fentanyl 25 mcg/hr One (1) Patch 72HR
9. Hydromorphone 2 mg Tablet [**Hospital1 1649**]: 1-2 Tablets PO every [**3-5**]
10. Metoclopramide 10 mg PO QIDACHS
11. Tamulosin 0.4mg daily
12. Lipitor 20mg daily
13. Atenolol 25mg daily
.
medications on transfer-
hold for SBP<100, HR<55
Heparin 5000 UNIT SC TID
Bisacodyl 10 mg PO/PR DAILY:PRN
Morphine Sulfate 2-4 mg IV Q4H:PRN
Acetaminophen 325-650 mg PO/PR Q4-6H:PRN
Pantoprazole 40 mg IV Q24H
Atorvastatin 20 mg PO HS
Tamsulosin HCl 0.4 mg PO DAILY
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Fentanyl Patch 50 mcg/hr TP Q72H
Prochlorperazine 10 mg PO/IV Q6H:PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule [**Month/Day (3) 1649**]: One (1) Capsule PO BID (2
times a day) as needed for constipation: as needed.
2. Senna 8.6 mg Tablet [**Month/Day (3) 1649**]: One (1) Tablet PO BID (2 times a
day) as needed for constipation: as needed for constipation.
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Month/Day (3) 1649**]: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet [**Month/Day (3) 1649**]: Two (2) Tablet PO HS (at
bedtime).
5. Acetaminophen 325 mg Tablet [**Month/Day (3) 1649**]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Please do not give with Percocet.
6. Prednisone 5 mg Tablet [**Month/Day (3) 1649**]: One (1) Tablet PO DAILY (Daily).
7. Haloperidol Lactate 5 mg/mL Solution [**Month/Day (3) 1649**]: 0.5 mg [**Month/Day (3) 15019**]
[**Hospital1 **] (2 times a day) as needed for excessive agitation.
8. Captopril 25 mg Tablet [**Hospital1 1649**]: One (1) Tablet PO TID (3 times a
day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) 1649**]: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO BID
(2 times a day).
12. Metoclopramide 10 mg Tablet [**Last Name (STitle) 1649**]: One (1) Tablet PO QIDACHS.
13. Neurontin 300 mg Capsule [**Last Name (STitle) 1649**]: One (1) Capsule PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
Primary:
L3 chordoma
altered mental status
atrial fibrillation
hyponatremia
bradycardia
.
Secondary:
Prostate Ca
MGUS
Anemia
Discharge Condition:
mental status improving, sinus, denies pain, tolerating PO.
Discharge Instructions:
Youe were admitted for resection of a L3 mass. You developed
atrial fibrillation, but are now not in atrial fibrillation. You
experienced a change in mental status likely related to
narcotics, which is slowly improving.
-Please take all medications as prescribed to you.
-Please hold all narcotics if possible
-Please return to the hospital if you are experiencing change in
mental status above baseline in hospital, fever, shortness of
breath, abdominal or severe back pain, or any other symptoms
concerning to you or you caregivers.
Followup Instructions:
Please follow up in the Orthopedic Spine clinic Wednesday
[**10-21**] at 3:00 PM. [**Hospital Ward Name **] 2, ortho, [**Hospital Ward Name **].
[**Telephone/Fax (1) 1742**]
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 657**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 1578**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15020**], MD Phone:[**Telephone/Fax (1) 1578**], Appointment at
11:30 PM [**2139-10-15**]
.
Dr. [**Last Name (STitle) 15021**] office will arrange for follow up. Please call
with any questions Phone:[**Telephone/Fax (1) 23**]
.
Provider: [**Name Initial (NameIs) **]/UROLOGY UROLOGY CC3 (NHB) Phone:[**Telephone/Fax (1) 5721**]
Date/Time:[**2139-10-28**] 11:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2365**] MD, [**MD Number(3) 2390**]
Completed by:[**2139-10-11**]
|
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] |
icd9cm
|
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[
[]
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[
"77.79",
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"03.59"
] |
icd9pcs
|
[
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[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,026
| 183,906
|
38631
|
Discharge summary
|
report
|
Admission Date: [**2189-1-26**] Discharge Date: [**2189-2-21**]
Date of Birth: [**2113-12-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
-Endoscopic Retrograde Cholangiopancreatography x 3
-Percutaneous transhepatic cholangiography
-Biliary drain placement and removal
-Hemodialysis
-Interventional radiology tunneled line hemodialysis line in the
right internal jugular vein
-Interventional radiology placement of peripherally inserted
central catheter (PICC) line
-Mechanical ventilation
History of Present Illness:
Patient is a 71 y/o female with COPD, DM type II, PUD s/p
Gastro-jejunostomy, mild dementia, and schizophrenia who was
admitted to [**Hospital 16843**] Hospital on [**1-22**] with fever to 101 at her
nursing home, decompensated heart failure with hypoxia to 85% on
RA, and MAT. She was complaining of SOB, dysuria, abdominal
pain, diarrhea, weakness, and fatigue. In the ED, she was
bolused and started on diltiazem gtt for MAT and diuresed with
IV Lasix for her CHF. She was started on levaquin for +U/A. Upon
admission, she then became hypotensive to systolic of 70s, so
her dilt gtt was d/c'ed and she was bolused with saline. She was
on neo and vasopressin gtts until [**2189-1-25**] AM. Her abx were
expanded to Vanc/Zosyn/Levaquin and hydrocortisone, currently
weaned to 50 q8 (despite [**Last Name (un) 104**] stim of 50.7->73->67.3). She was
subsequently found to have GNRs in her blood and urine cultures,
as well as group B strep in urine. Her course was complicated by
demand ischemia with Trop I peak of 0.85 and ARF with creatinine
peak of 2.08.
.
She was doing well until 48 hours ago. She was found to have
increasing LFTs with TB of 2.6, DB 2.1, alk phos 600 though no
abdominal pain. INR went from 2.1 to 6.5 on [**1-25**], which is now
down to 1.35 after vitamin K. She had a RUQ ultrasound that
showed gallbladder and CBD sludge v. stone v. mass and
associated intra- and extrahepatic biliary tree dilatation.
"This has worsened significantly since [**2188-2-15**]." Pt was
transferred here for GI evaluation and possible ERCP given
complicated anatomy.
Past Medical History:
1. CHF
2. Hyperlipidemia
3. COPD
4. HTN
5. DM2
6. Anemia
7. Gastritis/PUD
8. Schizophrenia
9. Dementia
10. Dysphagia
11. Urinary incontinence
12. h/o LE cellulitis
13. h/o Klebsiella UTI
14. chronic sinusitis
15. h/o acute cholecystitis
Social History:
Patient lives at a nursing home. She was widowed. She quit
smoking 2 years ago. She denies any ETOH, IVDU.
Family History:
Unable to obtain
Physical Exam:
Admission physical exam:
General Appearance: No acute distress, Overweight / Obese,
Diaphoretic
Eyes / Conjunctiva: PERRL, sluggish
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), tachy
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Breath Sounds: Crackles : coarse
bilaterally)
Abdominal: Soft, Bowel sounds present, Tender: inconsistent
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, venous stasis changes
Skin: Warm
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Verbal stimuli, Oriented (to): [**Known firstname 2411**], [**Location (un) 86**],
[**2-20**]--, Movement: Not assessed, Tone: Not assessed
.
Discharge physical exam:
GEN: Elderly female lying in bed in NAD. Mental status: able to
count 10 to 1 backwards. Can respond to questions appropriately.
Very alert. Alert to year and person. Breathing comfortably.
NECK: Rt IJ dialysis catheter in place without erythema. Clean,
dry and intact dressing at site.
HEENT: PEERL, sclera anicteric, OP clear
CV: Tachycardic. Regular rhythm. Normal rate, no MRG
PULM: Coarse breath sounds. Clear to auscultation bilatearlly.
No ronchi, wheezing or crackles.
ABD: +BS, obese, soft. Distended with umbilical hernia. Mild
tenderness in abdomen.
LIMBS: 2+ edema present in right arm, Legs with trace edema
bilaterally improving.
NEURO: Alert to person, place, not time. Can interact and answer
simple questions. Poor concentration. Able to follow simple
commands. Can count back from 10 to 1.
Pertinent Results:
Admission labs:
[**2189-1-26**] 10:40PM WBC-16.3* RBC-3.52* HGB-9.4* HCT-30.1* MCV-85
MCH-26.7* MCHC-31.3 RDW-17.1*
[**2189-1-26**] 10:40PM NEUTS-87* BANDS-5 LYMPHS-3* MONOS-3 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2189-1-26**] 10:40PM PLT SMR-NORMAL PLT COUNT-200
[**2189-1-26**] 10:40PM GLUCOSE-131* UREA N-34* CREAT-1.3* SODIUM-139
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-20* ANION GAP-13
[**2189-1-26**] 10:40PM CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-2.3
[**2189-1-26**] 10:40PM ALT(SGPT)-34 AST(SGOT)-42* ALK PHOS-479* TOT
BILI-3.4*
[**2189-1-26**] 11:27PM LACTATE-1.7
[**2189-1-26**] 10:40PM PT-12.8 PTT-32.4 INR(PT)-1.1
[**2189-1-26**] 11:27PM TYPE-ART PO2-71* PCO2-35 PH-7.38 TOTAL CO2-22
BASE XS--3
----------------
[**1-28**]: RUQ ultrasound
IMPRESSION:
1. Intra- and extra-hepatic biliary dilatation with common duct
measuring up to 2.8 cm.
2. Pneumobilia, compatible with recent history of ERCP.
3. Multiple stones, air and gallbladder wall thickening, with
pericholecystic fluid. Changes may be secondary to ERCP,
however, CT is recommended for further assessment.
4. Marked splenomegaly.
5. Moderate ascites.
.
[**1-29**] CT abd/pelvis
IMPRESSION:
1. Markedly dilated biliary tree, with the CBD measuring up to
2.2 cm, with a large impacted stone. An underlying infectious
process such as cholangitis cannot be excluded, and is the most
likely septic source.
2. The biliary stent has migrated into the duodenum or proximal
jejunum.
3. Moderate ascites.
4. Nondilated gallbladder with air and sludge and/or old
contrast.
5. No evidence of bowel obstruction or perforation.
6. Right inferior and superior minimally-displaced rami
fractures of unknown chronicity, with evidence of healing.
.
[**2-2**] Echocardiogram:
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Mild to moderate
([**1-3**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: No vegetation or abscess seen (cannot exclude). Mild
symmetric left ventricular hypertrophy with preserved global
biventricular systolic function. A focal wall motion abnormality
cannot be excluded. Mild to moderate mitral regurgitation, trace
aortic regurgitation.
[**2-8**], CT of the chest/abdomen/pelvis
IMPRESSION:
1. Improved biliary dilatation with residual hyupodense areas in
the left lobe which are not well defined or delineated. If
clinically indicated, ultrasound could be considered since these
could represent small fluid collections in the left lobe.
2. Focal pulmonary opacities suggesting multifocal pneumonia.
3. Increased ascites.
4. Prior pelvic fractures.
Abdominal ultrasound, [**2-12**]:
1. No evidence of hepatic abscess.
2. Gallbladder stones and sludge with CBD stent and mild
extrahepatic biliary dilatation; no intrahepatic biliary
dilatation.
3. Ascites.
Brief Hospital Course:
*** see attending d/c letter for attending note:
following is by Dr. [**Last Name (STitle) 18582**]
A/P: Pt is a 75 yo female with history of CHF, COPD, DM2,
schizophrenia who presented with E. coli sepsis, requiring
vasopressors initially, transfered to [**Hospital1 18**] for ERCP given
increasing total bilirubin.
.
# Severe septic shock from VRE cholangitis/bacteremia: The
source of the vancomycin enterococcus bacteremia was likely
biliary. Pt had an ERCP on [**2189-1-27**] to work-up the common bile
duct obstruction seen on the RUQ ultrasound from the OSH. ERCP
showed multiple stones, ranging in size from 8 mm to 15 mm, that
were causing partial obstruction of the common bile duct. There
was also post-obstructive dilation with the CBD measuring 20mm
and dilation of the intrahepatic biliary tree; the stone was not
extracted on this occasion. A 7cm by 7FR Cotton [**Doctor Last Name **] biliary
stent was placed successfully to establish effective biliary
drainage, which later become dislodaged and was removed. After
her ERCP, she was become septic again, requiring levophed (which
was switched to neo given SVT), and abx were broadened to vanc
and meropenam. Blood cultures from [**2189-1-29**] later grew VRE, and
she was switched from vanc to linezolid. CT abdomen suggested
cholangitis. Surgery was consulted. She went to IR for PTC
drain on [**2189-1-29**], which was later switched for a larger drain,
10 french, given her thick bile. The drain needed to be revised
multiple times for biliary sludging. She needed at 50 cc/day of
biliary draining and climbed to 400 cc/day, likely representing
obstruction of the drain. Since the biliary drain was not a
longterm option, she underwent ERCP on [**2-19**] for stone
extraction, sphincteroplasty, and sphincteromy. She tolerated
the procedure well and her biliary drain was removed.
Post-procedure, the patient had mild abdominal pain to palpation
with a normal lipase. She was able to tolerate a regular diet.
She will be continued on Cipro/Flagy post-procedure for 1 day
after discharge. She does not need ERCP followup.
.
# Acute renal failure leading to end-stage renal disease: Pt
developed anuric acute kidney injury, likely from acute tubular
necrosis during hypotensive episodes due to sepsis. The patient
was started on CVVH in the intensive care unit and then switched
to ultrafiltration on the medicine floor to remove volume. She
converted over to hemodialysis while on the floor. Overall, her
volume status has greatly improved. There were initially signs
of renal recovery, however, the patient still needs dialysis.
Furosemide 160 mg [**Hospital1 **] was tried to remove fluid on non-dialysis
days, however, it was unsuccessful. She was continued on
dialysis on a schedule of Monday, Wednesday, and Friday.
.
# Anasarca: The patient developed anasarca due to fluid boluses,
acute exacerbation of diastolic heart failure, and poor PO
intake. She underwent dialysis for fluid removal. Her PO intake
increased and her albumin has beeen improving. She had
significant LE edema which has resolved. She continues to have
upper extremity edema bilaterally. She underwent an ultrasound
of her right arm which was negative for DVT (she remained
anticoagulated on heparin SC during her hospitalization)
.
# Diabetes Mellitus Type II: Pt was moderately controlled on
insulin SS. Her home glyburide was held. Her glucose has been
ranging from 150-200. As she increases her PO intake, she might
need Lantus at night. In addition, can also consider starting on
oral medications.
.
# Normocytic anemia: The patient developed a normocytic anemia
while in the hospital. She presented with a hematocrit of 30.1
which trended down to 23.0. She was pan-scanned to rule out any
bleed and it showed no evidence of bleeding. Her labs did not
show any hemolysis. Her anemia was likely related to iron
deficiency and bone marrow suppression in the face of multiple
medical issues. She required 2 units of blood to be transfused
during her hospitalization. On the last week before discharge,
the patient's hematocrit remained stable and she did not need
any transfusions.
.
# Severe septic shock from E. coli urinary tract
infection/bacteremia: Pt was found to be in septic shock at OSH
with E. coli in blood and urine. At the OSH, pt was treated
wtih Vanc/zoysn, which was transitioned to CTX on arrival here.
She was later switched to linezolid and meropenem and cleared
her blood cultures.
.
# Diarrhea: The patient developed diarrhea while in the
hospital. Multiple C diff tests and stool cultures were
negative. Her diarrhea most likely relates to medication side
effect vs. bacterial overgrowth. If she continues to have
massive amounts of diarrhea, requiring a rectal tube, she should
be further evaluated. She was started on Loperamide on [**2-20**] to
slow its progression. The patient had a flexiseal placed on
[**2189-2-2**].
.
# Atrial fibrillation/flutter: The patient was noted to have an
episode of tachyarrhthmia on the morning of [**2189-1-29**] to 200s,
which broke with carotid massage. Levophed was changed to Neo
In the evening, she had recurrent SVT initially to 200s, which
came down to 150s with carotid massage. At the time, adenosine
showed underlying atrial flutter. She remained hemodynamically
stable during these tachycardic events. She received dilt x 2
without change and was thus started on amoidarone. She was
loaded with amiodarone and continued on a maintainence dose of
200 mg daily. She remains on aspirin for anticoagulation. She
would benefit from Coumadin, though this decision will be
deferred to outpatient where she will be more stable. Aspirin
was stopped after her ERCP procedure and should be started on
[**2189-2-26**].
.
# Hypoactive delirium: The patient developed a hypoactive
delirium while in the intensive care unit. The initial
etiologies were due to toxic/metabolic effects, use of sedatives
during intubation and renal/hepatic failure. A head CT was
negative for intracranial bleed. She was started on CVVH in the
ICU. Her increased transaminases were likely due to
cholangitis/liver congestion. She was initially on rifaxamin and
lactulose for treatment of hepatic encephalopaty (had elevated
ammonia), but it was stopped. With treatment of her underlying
disease processes and orientation, the patient became more
alert. She was able to count from 10 to 1 backwards and alert to
person and place. She was interactive, though does not realize
the full extent of her disease. Her home Celexa, Trazodone and
trifluphenazine were held since they can alter mental status.
.
# Multifocal pneumonia: The patient was found to have a
multifocal pneumonia with stable hemodynamics. She completed a
ten day course of vancomycin and zosyn.
.
# Chronic obstructive pulmonary disease: The patient was on high
dose steroids during her stay in the ICU. The patient was
transferred to the floor and developed increasing respiratory
distress on [**2-8**]. She was transferred to the ICU and started on
high dose steroids and nebulizers for treatment of COPD
exacerbation. She was quickly tapered off of her steroids and
her last day was [**2-15**]. She was continued on
albuterol/ipratropium nebulizers and had no signs of respiratory
distress.
.
# Hypoxic and hypercapneic respiratory failure: Pt was
electively intubated for ERCP and remained intubated afterwards
for somnolence. She was extubated and did not need further
intubation. She developed acute respiratory distress on [**2-8**]
while on the medical floor. She was transferred to the ICU where
she was diuresed, started on treatment for COPD, and started on
antibiotics for hospital acquired pneumonia. She was transferred
back to the floors without any respiratory distress. She
continues to be fluid overloaded, which likely causes increased
shortness of breath. At rest, she does not need oxygen.
.
#Pancytopenia: While on linezolid, the patient developed anemia,
thrombocytopenia, and leukopenia. The pancytopenia was likely
multifactorial and related to linezolid, other medications and
infection. As the patient became more stable, her
thrombocytopenia and leukopenia resolved. She still has an
anemia.
.
# Schizophrenia: Abilify was initially held for her altered
mental status and started once the patient's mental status
became clear. Her home trifluphenazine and celexa were held on
discharge. If warranted, she can start these medications as an
outpatient.
.
# Stage II sacral ulcer: Patient has a sacral ulcer. Wound care
was provided to the area.
.
# Vaginal/inguinal candiasis: The patient developed candiasis
while on antibiotics. She received one dose of fluconazole on
[**2-10**] and it improved. She was continued on topical antifungals
.
# Gastritis/peptic ulcer disease: On lansoprazole. No signs of
active bleeding or gastritis.
.
Contact: Daughter [**Name (NI) **] (HCP) [**Telephone/Fax (1) 85846**] (work) [**Telephone/Fax (3) 85847**]
(home)
Outpatient followup:
1. As an outpatient, might need anticoagulation with Coumadin
for atrial fibrillation
2. Diabetes: Will likely need lantus based on insulin needs
3. Diarrhea: Consider further workup. Flexiseal placed on [**2189-2-2**]
4. Aspirin: 81 mg daily should be started on [**2189-2-26**]
5. Antibiotics: the patient will need IV antibiotics for one day
after discharge
Medications on Admission:
Home Medications:
Captopril 50 mg q8
glyburide 10 mg daily
Neurontin 300 mg q8
Trifluoperazine 5 mg daily
Abilify 20 mg daily
Celexa 30 mg daily
Trazodone 100 mg qhs
omeprazole 20 mg daily
Zantac 300 mg daily
Beclomethasone diproprionate HFA 40 mcg inh daily
Zyrtec 10 mg daily
Spiriva 18 mcg inh daily
Advair 100/50 mcg [**Hospital1 **]
ferrous sulfate 325 mg daily
vitamin D 50,000 units q Friday
.
Transfer Medications:
Zosyn 2.25 gm IV q6 (day 5)
Vancomycin 250 mg IV q24 hr (day 5)
Levaquin 750 mg q48 hr (day 5)
Hydrocortisone 50 mg q8
Protonix 40 mg daily IV
Abilify 20 mg daily
Stelazine 5 mg daily
Neurontin 300 q8 mg
Celexa 20 mg daily
Tylneol 650 mg daily
Zyrtec 10 mg daily
Becloven 1 puff daily
Advair 100/50 1 puff [**Hospital1 **]
Detrol LA 4 mg qhs
Vitamin K 10 mg daily
Iron 325 mg daily
Humalog ISS
Spiriva 18 mcg daily
Discharge Medications:
1. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL
Injection TID (3 times a day).
3. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed for Rash.
4. Aripiprazole 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
5. Beclomethasone Dipropionate 40 mcg/Actuation Aerosol [**Hospital1 **]: One
(1) spray Inhalation once a day.
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Nystatin 100,000 unit/g Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for yeast infection.
8. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) nebulizer
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) nebulizer Inhalation every 4-6 hours
as needed for shortness of breath or wheezing: mix with
ipratropium.
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
12. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
[**Last Name (STitle) **]: One (1) inhaler Inhalation once a day.
14. Vitamin D 50,000 unit Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a
week.
15. Loperamide 2 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID:PRN as
needed for constipation.
16. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: see sliding scale
Subcutaneous ASDIR (AS DIRECTED).
17. Ciprofloxacin in D5W 400 mg/200 mL Piggyback [**Last Name (STitle) **]: Four
Hundred (400) mg Intravenous Q24H (every 24 hours) for 1 days.
18. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [**Last Name (STitle) **]:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 4
doses.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
-Choledocolithiasis complicated by cholangitis
-Sepsis due to E. coli and vancomycin resistant enterococcus
bacteremia
-Acute oliguric renal failure needing dialysis
-Hypoactive delirium
-Respiratory failure requiring intubation and mechanical
ventilation
.
Secondary
-Type II diabetes mellitus
-Hypertension
-Schizophrenia
-Normocytic anemia
-diarrhea
Discharge Condition:
Mental Status:Clear and coherent (poor attention span, can count
from 10 to 1 backwards)
Level of Consciousness:Alert and interactive
Activity Status:Bedbound
Discharge Instructions:
Dear Mrs. [**Known lastname 85848**],
.
You were had fevers and you were transferred here for an ERCP.
You had an infection in your bile ducts. One gallstone was too
large to be removed and an external drain was placed to drain
the bile. It was later removed. You were very sick and had to be
in the intensive care unit with breathing help from a ventilator
and medicines to maintain your blood pressure and dialysis.
Fortunately, you improved on antibiotics.
.
You developed multiple problems while in the hospital. You had
infectious complications of pneumonia and sepsis. Your kidneys
failed during your low blood pressure states and you continue to
need dialysis. You became confused which seemed to clear.
.
Your medications have changed:
-stop captopril
-stop glyburide
-stop neurontin
-stop trifluoperazine
-stop celexa
-stop trazodone
-stop zantac
-start albuterol and ipratropium nebulizers
-start cipro and flagyl (antibiotics)
-start antifungal creams and powders
-start lansoprazole
-start nephrocaps
Followup Instructions:
You do not need followup with the ERCP team.
You should followup with your primary care doctor after rehab.
|
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icd9cm
|
[
[
[]
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[
"39.95",
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icd9pcs
|
[
[
[]
]
] |
20457, 20532
|
8007, 17339
|
323, 678
|
20938, 20938
|
4428, 4428
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22160, 22272
|
2680, 2698
|
18227, 20434
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20553, 20917
|
17365, 17365
|
21123, 22137
|
2738, 3575
|
17383, 17766
|
277, 285
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17788, 18204
|
706, 2280
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4445, 7984
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20952, 21099
|
2302, 2540
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2556, 2664
|
3600, 3641
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,910
| 143,290
|
55175
|
Discharge summary
|
report
|
Admission Date: [**2186-10-12**] Discharge Date: [**2186-11-14**]
Date of Birth: [**2103-6-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2186-10-13**]
Urgent coronary artery bypass graft x4 with Left internal
mammary artery to left anterior descending artery, and saphenous
vein grafts to diagonal and saphenous vein sequential graft to
obtuse marginal and distal circumflex.
[**2186-11-2**]
Open tracheostomy tube and percutaneous endoscopic gastrostomy
tube.
History of Present Illness:
83 year old female presented to [**Hospital 1474**] Hospital emergency room
with chest pain at rest. Labs were drawn and troponin was 3.5
she was brought to the cardiac catheterization lab and was found
to have three vessle disease. She was transferred to [**Hospital1 18**] for
revascularization.
Past Medical History:
Coronary artery disease s/p Coronary artery bypass graft x 4
Post operative CVA-Left sided deficits
respiratory failure s/p open tracheostomy tube and percutaneous
endoscopic gastrostomy tube.
Acute kidney injury-now resolved
HIT positive
PMH:
Hypertension
Diabetis Mellutis
Gastritis
Hiatal Hernia
Lipoma R thigh
Urinary incontinence
Inguinal hernia repair
Gall bladder removal
Hysterectomy
Social History:
Lives with: widowed, lives in senior housing in [**Location (un) 5165**]
Contact: [**Name (NI) 122**] [**Name (NI) **] (son-in-law) Phone #[**0-0-**]
or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter) ([**Telephone/Fax (1) 112541**]
Occupation: retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-28**] drinks/week [] >8 drinks/week []
No Illicit drug use
Family History:
No Premature coronary artery disease
Physical Exam:
Pulse:70 Resp: 18 O2 sat: 98%RA
B/P 145/68 mmHg
Height:66" Weight:99.8 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade II/VI SEM
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 []tremors
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:1+ Left:1+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2186-10-13**] Echo: PREBYPASS: Preserved LV systolic function with
LVEF > 55% with no segmental wall motion abnormalities. The left
atrium is normal in size. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the ascending aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. Mild to moderate ([**1-23**]+) mitral regurgitation is
seen. MR is worse with high systolic BP and appears to be
central due to mild restriction of the mitral valve leaflets. No
systolic flow reversal observed in either the right or left
pulmonary veins. There is a trivial/physiologic pericardial
effusion. Mild TR. Mild PI. Normal coronary sinus. No Clot in
LAA Findings discussed with Dr [**Last Name (STitle) **].
POSTBYPASS:
The left ventricular chamber size is small, consistent with
hypovolemic state. The LV systolic function is preserved,
estimated EF>55%. Right ventricular systolic function remains
normal. The calculated cardiac output is 3.9L/min.
The MR remains mild to moderate. Other valvular function remain
unchanged.
.
[**2186-10-13**] Carotid U/S: There is 40-59% stenosis in the right
internal carotid artery. There is less than 40% stenosis within
the left internal carotid artery.
.
[**2186-10-16**] Echo: 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. Mild (1+) mitral regurgitation is
seen. There is a small posterior pericardial effusion. There are
no echocardiographic signs of tamponade.
Neurophysiology Report EEG Study Date of [**2186-11-6**]
OBJECT: 83-YEAR-OLD WOMAN WITH ACUTE MI, S/P CARDIAC ARREST.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
FINDINGS:
ABNORMALITY #1: There is a marked interhemispheric asymmetry
with the left
overall lower in amplitude and slower than the right. Rhythms
over the right
were generally of moderate to, at times, moderately high voltage
and in the
delta and less frequently theta range. Those over the left were
of lower
amplitude and largely in the delta range. The interhemispheric
differences
were more prominent in the parasagittal regions than in the
temporals.
BACKGROUND: The background activity is disorganized and
consisted of mixed
frequencies of polymorphic delta/theta with some alpha
activities.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No clear change in state was seen.
CARDIAC MONITOR: Was not recorded.
IMPRESSION: This is an abnormal EEG due to marked overall
slowing in the
context of an interhemispheric asymmetry with the left
hemisphere more
severely affected. This would suggest a moderately severe
diffuse
encephalopathy affecting leftsided structures more than right.
No discharging
features were seen.
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2186-10-29**]
9:15 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2186-10-29**] 9:15 AM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; -59 DISTINCT
PROCEDURAL SERVIC Clip # [**Clip Number (Radiology) 112542**]
Reason: worsening of stroke
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman s/p CABG with post-op lMCA stroke
REASON FOR THIS EXAMINATION:
worsening of stroke
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
TECHNIQUE: MRI of the brain without and with gad. MRA of the
circle of
[**Location (un) 431**] using 3D time-of-flight.
HISTORY: Status post CABG, MCA stroke.
COMPARISON: CT head [**2186-10-27**].
FINDINGS: There is a large evolving left MCA territory
infarction involving
both the cortical masses and the basal ganglion. Small amount
of blood
products are seen in the left putamen andin the left temporal
lobe. A few
acute infarcts in the left cerebellum are also identified.
There are
scattered small vessel ischemic changes in the white matter.
MRA of the circle of [**Location (un) 431**] demonstrates at least moderate
grade narrowing in
the MCA bifurcation. There is a questionable 1-2 mm aneurysm of
the left
cavernous ICA. There is a relative paucity of the left superior
division MCA
branches. Basilar artery is patent.
IMPRESSION: Evolving acute infarcts in the left MCA territory
with mass
effect on the left lateral ventricle and minimal 1-2 mm of
midline shift.
There is evidence of blood products in the left putamen and in
the left
temporal lobe.A few acute infarcts in the left cerebellum are
also identified.
.
[**2186-11-14**] 05:41AM BLOOD WBC-7.5 RBC-3.46* Hgb-9.9* Hct-32.7*
MCV-95 MCH-28.8 MCHC-30.4* RDW-16.5* Plt Ct-181
[**2186-11-13**] 03:14AM BLOOD WBC-7.5 RBC-3.48* Hgb-9.9* Hct-33.0*
MCV-95 MCH-28.5 MCHC-30.1* RDW-16.3* Plt Ct-188
[**2186-11-12**] 02:45AM BLOOD WBC-6.7 RBC-3.33* Hgb-9.9* Hct-31.4*
MCV-94 MCH-29.6 MCHC-31.4 RDW-16.3* Plt Ct-191
[**2186-11-14**] 05:41AM BLOOD PT-21.9* PTT-32.0 INR(PT)-2.0*
[**2186-11-13**] 03:14AM BLOOD PT-26.4* PTT-34.4 INR(PT)-2.4*
[**2186-11-12**] 02:45AM BLOOD PT-24.7* PTT-32.2 INR(PT)-2.3*
[**2186-11-11**] 03:46AM BLOOD PT-23.2* PTT-32.4 INR(PT)-2.1*
[**2186-11-10**] 02:43AM BLOOD PT-22.1* PTT-33.8 INR(PT)-2.0*
[**2186-11-9**] 02:20AM BLOOD PT-20.3* PTT-21.1* INR(PT)-1.9*
[**2186-11-8**] 02:13AM BLOOD PT-21.1* PTT-31.8 INR(PT)-1.9*
[**2186-11-14**] 05:41AM BLOOD Glucose-189* UreaN-60* Creat-1.1 Na-152*
K-3.8 Cl-106 HCO3-40* AnGap-10
[**2186-11-13**] 02:38PM BLOOD Na-151* K-4.4 Cl-107
[**2186-11-13**] 03:14AM BLOOD Glucose-134* UreaN-60* Creat-1.2* Na-148*
K-3.9 Cl-105 HCO3-36* AnGap-11
[**2186-11-12**] 04:27PM BLOOD Na-153* K-4.0 Cl-107
[**2186-10-26**] 08:11PM BLOOD ACA IgG-31.3* ACA IgM-5.0
[**2186-11-4**] 10:32AM BLOOD ALT-72* AST-56* LD(LDH)-385* AlkPhos-93
Amylase-55 TotBili-0.9
[**2186-11-3**] 09:28PM BLOOD ALT-33 AST-18 AlkPhos-23* Amylase-12
TotBili-0.9
[**2186-10-27**] 02:46AM BLOOD ALT-143* AST-130* AlkPhos-82 Amylase-96
TotBili-1.6*
[**2186-11-4**] 10:32AM BLOOD Lipase-66*
[**2186-11-13**] 02:38PM BLOOD Mg-3.0*
[**2186-11-13**] 03:14AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4
Brief Hospital Course:
The patient was brought to the Operating Room on [**2186-10-13**] where
the patient underwent CABG x 3 with Dr. [**First Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. She remained intubated on POD 1, was weaned
from Neo and diuresed. By POD 2, she was extubated, alert and
oriented and breathing comfortably. She was transfused one unit
of PRBC for post-op anemia with a hematocrit 23%. Platelets
decreased to 52,000 and Heparin Antibody test was sent, which
would return negative. Platelet count would subsequently
improve. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
She developed rapid atrial fibrillation with rates into the 180s
on POD 4. She did not tolerate this well, becoming hypotensive
and diaphoretic. She was transferred to the CVICU for further
management. She was chemically cardioverted with IV amiodarone
and IV Lopressor.
She improved and converted to sinus rhythm and was transferred
back to the floor. She went back into AF and was evaluated by
EP. She was on Amiodorone, Lopressor, and Diltiazem. On POD#8
she became unresponsive and was found to have a large left MCA
infarct. She was intubated and transferred back to the CVICU.
She remained in the ICU and had prolonged intubation. Eventually
she had a trach and PEG on POD#20 and has been on trach collar
since. She was less responsive at one point and she had an EEG
which showed a question of seizure activity. She was started on
Keppra. She has been more responsive for the last 5 days. She
has been anticoagulated with coumadin for atrial fibrillation
and HIT. She was found to have HIT and was first anticoagulated
with argatroban and was transitioned to coumadin. She has some
necrotic toes and has been followed by the vascular service.
She will continue to be followed by vascular and may need a
procedure in the future. She also had hypernatremia which
responded well to free water in her PEG. She continued to
progress and was discharged to [**Hospital1 **], [**Location (un) 86**] in stable
condition on POD#32.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 320 mg PO DAILY
2. Propranolol 120 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Albuterol-Ipratropium [**1-23**] PUFF IH Q6H:PRN wheezes
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. LeVETiracetam 750 mg PO BID
8. Nystatin Cream 1 Appl TP Q12H:PRN rash
9. Warfarin 3 mg PO DAILY16
10. Furosemide 80 mg PO BID
11. Glargine 50 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
12. Potassium Chloride 60 mEq PO BID
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
14. Warfarin MD to order daily dose PO DAILY
15. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Post operative CVA-Left sided deficits
respiratory failure s/p open tracheostomy tube and percutaneous
endoscopic gastrostomy tube.
Acute kidney injury-now resolved
HIT positive
PMH:
Hypertension
Diabetis Mellutis
Gastritis
Hiatal Hernia
Lipoma R thigh
Urinary incontinence
Inguinal hernia repair
Gall bladder removal
Hysterectomy
Discharge Condition:
Neuro: awake, moves left upper extremity spontaneously and to
command-rt sided paresis
nods appropriately to simple questions/inconsistently
Activity: OOB chair w/full assist
Incisional pain managed with: tylenol
Incisions: Sternal - healing well, no erythema or drainage
Trach and G-tube sites-CDI
Extrem: bilat necrotic toes. Edema: 2+ bilat
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. [**First Name (STitle) **] on [**2186-11-21**] at 2:15PM
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2186-12-4**] at 11:45a
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 2631**] [**Name (STitle) **] after discharge from rehabilitation.
**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:[**2186-11-14**]
|
[
"E879.8",
"584.9",
"745.5",
"599.0",
"997.31",
"427.31",
"E878.2",
"788.30",
"041.49",
"453.42",
"997.1",
"518.4",
"348.30",
"401.9",
"240.9",
"285.1",
"250.00",
"414.01",
"289.84",
"570",
"434.11",
"997.2",
"431",
"458.9",
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"276.0",
"444.22",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"39.61",
"43.11",
"34.91",
"33.24",
"88.72",
"96.6",
"31.1",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
12074, 12145
|
8817, 11158
|
293, 623
|
12581, 12927
|
2530, 5899
|
13850, 14518
|
1822, 1860
|
11395, 12051
|
5939, 5991
|
12166, 12560
|
11184, 11372
|
12951, 13827
|
1875, 2511
|
243, 255
|
6023, 8794
|
651, 950
|
972, 1366
|
1382, 1806
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,971
| 128,344
|
40749
|
Discharge summary
|
report
|
Admission Date: [**2137-5-29**] Discharge Date: [**2137-6-13**]
Date of Birth: [**2094-10-1**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Tylenol and alcohol overdose
Major Surgical or Invasive Procedure:
Paracentesis - performed three times.
History of Present Illness:
Ms. [**Known lastname **] is a 42 year old female with a history of alcohol,
opiate, and acetaminophen abuse who presents with
encephalopathy, acute hepatitis and coffee ground emesis. She is
a poor historian, and much of the history was taken from the
medical record. She has been feeling ill for about 5 days. She
endorses vomiting and belly pain, but she is not able to
describe the nature of the pain. She does endorse taking either
percocet or vicodin in unknown quantities, and she drinks 5-10
"nips" of vodka daily. She does not remember how or why she went
to the hospital. Per the ED record, she had been taking [**3-17**]
percocet daily for body aches, and had started to vomit coffee
ground material yesterday and was noticed to be jaundiced today.
.
She was reportedly brought to the OSH by her boyfriend or
fiance, after he noticed that she was ill and vomiting; the
circumstances of this are unclear. At the OSH on [**2137-5-29**], her
initial vitals vitals were BP 98/56, HR 87, RR 20, Sat 100%
4LNC. Her laboratory values are reviewed below, notable for
severe transaminemia, high lipase, hyponatremia, hypokalemia,
hypocalcemia, and anemia. Acetaminophen and salicylate levels
were normal. Loading dose of 150mg/kg for total 7500mg of NAC
given at 1300, second dose of 50mg/kg for total 2500mg given at
1420. Also given zofran, morphine, protonix 40mg iv, vit k 5mg
sc abd, and MMR.
.
In the ED, initial vs were: T P BP R O2 sat. Patient was given
vitamin k 10mg iv, ffp 4 units (2 there, 2 in MICU), protonix
40mg iv then 8mg/hr gtt, octreotide 50mcg iv then 50mcg/hr, 4g
ca gluconate iv, potassium 40meq iv, NAC 5g over 16hrs
(312.5mg/hr), vancomycin 1g iv, zosyn 4.5mg iv.
.
On the floor, she complained of abdominal pain; she could not
describe the pain. She was confused.
.
Review of systems:
(+) Per HPI
(-) Denies dysuria and urinary frequency. Other than this,
review of systems was difficult to obtain.
Past Medical History:
anxiety
depression
arthritis
ovarian cyst
anorexia
polysubstance abuse: etoh, opiates, tylenol, marijuana
Surgical History:
tubal ligation
right oopherectomy
L ovarian cyst removal
Social History:
Social History: Lives with her fiance and 5 cats.
- Tobacco: yes, unknown amount
- Alcohol: yes [**4-16**] "nips" of liquor daily
- Illicits: marijuana, percocet and/or vicodin abuse
Family History:
Mother had pancreatic cancer.
Physical Exam:
ADMISSION
Tmax: 36.7 ??????C (98.1 ??????F), 98 (97 - 101), 18 (9 - 19) insp/min,
96%RA
General Appearance: Anxious
Eyes / Conjunctiva: Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic, Poor dentition, NG tube
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Bowel sounds present, Tender: especially RUQ,
without rebound/guarding, non-distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed, no spider angiomata
Neurologic: Responds to: Not assessed, Oriented (to): person,
day of the week, not year/place, Movement: Purposeful, Tone: Not
assessed, moving all extremities, positive asterixis
DISCHARGE
VS: 99.3, 121/70, 112, 18, 99%RA
Physical Exam:
GEN: Jaundiced, thin.
HEENT: MMM. no appreciable JVD. Neck supple. Jaudiced
conjunctiva.
Cards: RR nl. S1/S2, no murmurs/gallops/rubs.
Pulm: CTABL.
Abd: BS+, Distended, striae, tender to palpation throughout.
Extremities: wwp, no edema, + DPs. No asterixis.
Skin: Jaundiced. Bilateral bruising on back.
Neuro: Pt was AOx3 this AM. 5/5 strength. Sensation intact to
LT.
Pertinent Results:
Blood Counts
[**2137-5-29**] 04:13PM BLOOD WBC-7.2 RBC-3.03* Hgb-11.7* Hct-31.5*
MCV-104* MCH-38.6* MCHC-37.1* RDW-13.9 Plt Ct-61*
[**2137-6-2**] 03:25PM BLOOD WBC-16.7* RBC-3.21* Hgb-11.5* Hct-32.7*
MCV-102* MCH-35.8* MCHC-35.1* RDW-20.2* Plt Ct-66*
[**2137-6-8**] 07:00AM BLOOD WBC-16.2* RBC-2.62* Hgb-9.7* Hct-28.9*
MCV-111* MCH-36.9* MCHC-33.4 RDW-20.0* Plt Ct-218
[**2137-6-11**] 12:23PM BLOOD WBC-12.5* RBC-2.59* Hgb-9.9* Hct-29.1*
MCV-112* MCH-38.0* MCHC-33.9 RDW-20.2* Plt Ct-241
[**2137-6-13**] 07:04AM BLOOD WBC-10.5 RBC-2.35* Hgb-8.7* Hct-26.5*
MCV-113* MCH-37.0* MCHC-32.7 RDW-20.1* Plt Ct-222
Coags
[**2137-5-29**] 02:30PM BLOOD PT-39.0* PTT-36.1* INR(PT)-4.0*
[**2137-5-29**] 08:45PM BLOOD PT-28.5* PTT-33.0 INR(PT)-2.8*
[**2137-5-31**] 02:25PM BLOOD PT-20.6* PTT-27.8 INR(PT)-1.9*
[**2137-6-5**] 01:34AM BLOOD PT-18.0* PTT-30.6 INR(PT)-1.6*
[**2137-6-13**] 07:04AM BLOOD PT-15.8* PTT-25.9 INR(PT)-1.4*
Chemistry
[**2137-5-29**] 04:13PM BLOOD Glucose-133* UreaN-61* Creat-4.3* Na-118*
K-2.6* Cl-62* HCO3-27 AnGap-32*
[**2137-5-29**] 08:45PM BLOOD Glucose-171* UreaN-56* Creat-3.7* Na-125*
K-3.2* Cl-73* HCO3-30 AnGap-25*
[**2137-5-31**] 11:00PM BLOOD Glucose-164* UreaN-15 Creat-0.4 Na-134
K-3.4 Cl-97 HCO3-29 AnGap-11
[**2137-6-13**] 07:04AM BLOOD Glucose-94 UreaN-8 Creat-0.2* Na-137
K-3.6 Cl-104 HCO3-30 AnGap-7*
Liver
[**2137-5-29**] 04:13PM BLOOD ALT-1522* AST-5648* AlkPhos-99
TotBili-10.7*
[**2137-5-31**] 02:24AM BLOOD ALT-595* AST-566* AlkPhos-69
TotBili-12.7*
[**2137-6-5**] 01:34AM BLOOD ALT-182* AST-100* LD(LDH)-471*
AlkPhos-126* Amylase-309* TotBili-21.1*
[**2137-6-9**] 06:10AM BLOOD ALT-90* AST-67* AlkPhos-128*
TotBili-21.4*
[**2137-6-11**] 06:00AM BLOOD ALT-69* AST-59* AlkPhos-126*
TotBili-14.4*
[**2137-6-12**] 05:55AM BLOOD ALT-59* AST-48* AlkPhos-135*
TotBili-11.7*
[**2137-6-13**] 07:04AM BLOOD ALT-55* AST-47* AlkPhos-126*
TotBili-10.1*
[**2137-5-29**] 08:45PM BLOOD HCV Ab-NEGATIVE
[**2137-6-4**] 07:40PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2137-6-4**] 07:40PM BLOOD Smooth-NEGATIVE
[**2137-5-29**] 08:45PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE
[**2137-6-7**] Liver, transjugular, needle core biopsy:
1. Focal necrosis of zone [**1-10**] involving approximately 50% of
the tissue examined (reticulin stain evaluated).
2. Predominantly macrovesicular steatosis with associated
neutrophils.
3. Bile duct proliferation with associated neutrophils.
4. No viral cytopathic effect seen.
5. Trichrome stain has been evaluated. Given the presence of
necrosis, it is difficult to assess the stage of fibrosis.
6. Iron stain shows mild iron deposition in Kupffer cells and
hepatocytes.
7. Immunostains for herpes simplex virus and CMV are negative.
Brief Hospital Course:
Hospital Course
This is a 42yo F PMHx EtOH and opiate abuse presenting with
alterred mental status, hepatitis, pancreatitis in the setting
of recent heavy alcohol and tylenol usage, complicated by
gastrointestinal bleed, now w liver enzymes trending downward,
hemodynamically stable, discharged to rehab
ACTIVE
#Liver failure due to acetaminophen toxicity and alcoholic
hepatitis: Pt admitted w marked transaminitis (ALT 1500, AST
5600), rising bilirubin from uncertain baseline. Bilirubin
continued to rise despite initiation of NAC and pentoxyphyline,
prompting biopsy which demonstrated severe necrosis. Patient
started on steroid taper w subsequent improvement in LFTs. At
discharge bili 10.1, INR 1.4. Other pertinent w/u included
negative HepB, Hep C, and [**Last Name (un) **] serologies. Course was
complicated by recurrent ascites, likely representative of acute
hepatitis vs worsening chronic cirrhosis (see below). At
discharge plan to continue pentoxifylline for 16 additional
days, prednisone for 22 days (after which she will need a taper,
to be supervised by Liver service).
#Gastrointestinal Bleed with acute blood loss anemia: Pt
initially w coffee ground emesis, Hct drop from 31 to 23. Pt
received 2 units pRBCs and underwent EGD that demonstrated
severe gastritis. Patient started on pantoprozole and
sucralfate and remained hemodynamically stable. Patient will
need outpatient follow-up EGD to be arranged by liver service.
#Acute Pancreatitis: At admission pt w lipase 1333 in setting of
reported recent alcohol binge. Thought to most likely be [**1-9**]
etoh given recent history. Trended down with conservative
therapy. Post-pyloric feeding tube placed to help w nutrition w
subseuqent clinical improvement.
#Polysubstance Abuse: Pt w history of opiate and alcohol abuse.
Seen by social work, but declining inpatient treatment. Per
social work patient will be followed-up in community for
outpatient treatment for abuse.
# Recurrent Ascites: Course was complicated by recurrent
ascites, likely representative of acute hepatitis vs worsening
chronic cirrhosis (unable to differentiate between in acute
setting). Patient was treated w therapeutic paracentesis w/o
evidence of SBP/bleeding.
# Pain: Pain from pancreatitis and hepatitis treated w morphine
sulfate IR w plan to wean off w resolution of symptoms.
TRANSITIONAL
1. Transfer of Care: Patient discharged to [**Hospital 5503**] Rehab
with copy of discharge summary. Patient to be followed up in
Liver Clinic w Dr. [**First Name (STitle) **].
2. Pending: No labs were pending at time of discharge.
Medications on Admission:
- omeprazole
- colace
- nicotine patch
- senna
- milk of magnesia prn
- ultram 50mg q 12 hrs
Discharge Medications:
1. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. pentoxifylline 400 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO TID (3 times a day) for 16 days.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
8. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours)
as needed for pain.
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q12H (every 12 hours).
12. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 22 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary:
- Acute hepatitis secondary to acetaminophen overdose
- Acute pancreatitis
Secondary:
- Chronic alcoholic hepatitis
- Anorexia
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:
Ms. [**Known lastname **],
It was a pleasure to look after you as a patient at the [**Hospital1 1535**]. You were admitted with a
serious acute hepatitis and pancreatitis after an overdose of
tylenol and alcohol. You were evaluated by medicine doctors.
You were found to have bleeding in your stomach, which was
stopped. You were treated with medications to control the
inflammation in your liver. Your blood tests and symptoms
improved.
During this hospitalization, the following changes were made to
your medications:
- STARTED Sucralfate
- STARTED Pantoprazole
- STARTED Prednisone (to be continue until [**2137-7-5**])
- STARTED Pentoxifylline (to be continued until [**2137-6-28**])
- STARTED Ursodiol
- STARTED Ondansetron
- STARTED Morphine sulphate as needed
- STARTED Multivitamins
- STARTED Folic acid
- STARTED Thiamine
- STARTED Nystatin
- STOPPED Zoloft
- STOPPED Vicodin
- STOPPED Ultram
- STOPPED Omeprazole
Followup Instructions:
Department: LIVER CENTER
When: THURSDAY [**2137-6-20**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2137-6-13**]
|
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icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6",
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"45.13",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10684, 10782
|
6894, 9494
|
321, 361
|
10963, 10963
|
4141, 6871
|
12102, 12442
|
2745, 2777
|
9637, 10661
|
10803, 10942
|
9520, 9614
|
11146, 12079
|
3752, 4122
|
2205, 2321
|
252, 283
|
389, 2186
|
10978, 11122
|
2343, 2527
|
2560, 2729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,133
| 115,598
|
21717
|
Discharge summary
|
report
|
Admission Date: [**2168-8-19**] Discharge Date:
Date of Birth: [**2112-3-3**] Sex: M
Service: ORT
DIAGNOSIS: Cervical spinal cord injury with C5 burst
fracture.
PROCEDURES PERFORMED: Anterior and posterior spinal fusion,
cervical, tracheostomy, PEG placement, posterior spinal
decompressive laminectomy and debridement, central line and
then eventual PICC line placement.
HOSPITAL COURSE: His 56 year old male was admitted to the
Trauma Service on the [**2168-8-19**] after sustained
a cervical spine injury during an intoxication event. The C5
burst fracture was associated with a central cord spinal cord
syndrome. He was medically stabilized and underwent cervical
spine stabilization procedure on the [**8-21**]. A C5
vertebrectomy and fusion was performed on the [**2168-8-20**]. In addition, a posterior spinous process
wiring stabilization was also performed. The immediate
postoperative course was unremarkable with extubation
proceeding on the 29th. Due to difficulties with secretions,
percutaneous tracheostomy was placed on [**2168-9-1**]. The
anterior and posterior fixation was performed on [**8-22**]. On the [**7-30**], decreased movement to the lower
extremities was noted and the MRI scan confirmed compression
of the cervical spinal cord and emergent posterior
decompression with removal of the hardware and laminectomy
from levels C3 to C7 was performed. Findings at the time of
surgery included hematoma in the epidural space and also
purulent material in the subcutaneous space adjacent to the
hardware and bone graft fixation. Eventually, this culture
from intraoperatively grew out an Enterobacter species and he
has been treated with piperacillin and ceftazidime
intravenously. Perioperative cefazolin was the initial
antibiotic coverage. Only low grade temperatures were
documented. The antibiotics recommended included vancomycin,
piperacillin and ceftazidime. MRSA screen was negative and on
[**8-24**], Clostridium difficile toxin screen was negative. The
culture from the [**7-30**] grew out the Enterobacter
species. Zosyn was initiated along with vancomycin from the
time of surgery and ciprofloxacin was also added for the
acute perioperative coverage. The Zosyn, Cipro and vanco were
continued until [**9-1**] where he received four days of Zosyn
and two days of ciprofloxacin. The vancomycin was
discontinued on the [**8-3**] and Cipro and Zosyn were
also continued. Ciprofloxacin was changed to levofloxacin on
the [**8-3**] and Zosyn was continued.
He tolerated the trach procedure. The anterior wound healed
and the suture was removed on postoperative day 10.
Eventually, the posterior incision healed well and the
staples were removed on postoperative day 10 after the
posterior procedure. No signs of active wound sepsis
occurred. Repeated transfusion for asymptomatic anemia were
performed and multiple replacements of magnesium have been
performed during his hospitalization.
CURRENT MEDICATIONS: Current medications are metoprolol 100
mg po tid, lorazepam 1 mg IV tid, Atrovent MDI two puffs q6h,
famotidine 20 mg IV q12h, olanzapine 5 mg po Q.D., Zosyn 4.5
g IV q8h and levofloxacin 500 mg IV q24h and now
metronidazole 500 mg IV q8h. The metronidazole should be
continued as long as the other antibiotics are continuing.
The duration of antibiotics from the time of discharge is an
additional four weeks of therapy via the PICC line. Tube
feedings have been initiated for the last 48 hours. Diarrhea
occurred and this was felt to be due to the strength of the
tube feedings and they were cut in half and free water was
added. However, in light of the C. difficile toxin positive
screen, the tube feedings may be advanced per his nutritional
requirements and tolerance up to the goal of 70 cc per hour
with a 300 cc water flush every 12 hours.
DISCHARGE INSTRUCTIONS: The care needs include trach care
and this has been attended by the General Surgery team prior
to his transfer, fitting a size 7 cuffed tube which they felt
could be inflated or not inflated. Also, the PEG is the
source of nutrition and for PO medications. A PICC line in
the left brachium was inserted by the radiology
interventionists and verified to be in position and has been
successfully used for installation of intravenous medications
and this will be continued for the four week duration of
antibiotics.
The cervical collar should be also used for an additional
four weeks. After three to four weeks, follow-up with
Infectious Disease should be performed with follow-up of CBC,
sed. rate, C-reactive protein. Orthopedic follow-up with Dr.
[**Last Name (STitle) 363**] will be performed in four weeks with AP and lateral x-
ray of the cervical spine to assess healing. The cervical
collar should remain in place full-time until this follow-up
is completed.
Mobility is important for pulmonary toilet and he has
successfully been mobilized to the seated position out of the
chair.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
Dictated By:[**Last Name (NamePattern1) 3193**]
MEDQUIST36
D: [**2168-9-12**] 13:23:08
T: [**2168-9-12**] 14:00:15
Job#: [**Job Number 45658**]
cc:[**Name8 (MD) 57092**]
|
[
"909.4",
"996.67",
"530.10",
"305.1",
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"041.85",
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"291.0",
"008.45",
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"998.12",
"303.90",
"496",
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"787.2",
"E888.9",
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icd9cm
|
[
[
[]
]
] |
[
"81.63",
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"99.15",
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"81.03",
"77.79",
"38.93",
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"99.04",
"84.51",
"96.04",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
415, 2947
|
3844, 5232
|
2969, 3819
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,649
| 118,641
|
54921
|
Discharge summary
|
report
|
Admission Date: [**2182-9-22**] Discharge Date: [**2182-9-27**]
Date of Birth: [**2095-11-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 15397**]
Chief Complaint:
cholecystitis, transfer from [**Hospital 8641**] Hospital MICU for ERCP
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
86M with CAD s/p DES to LAD x 4 in [**1-/2180**], TIA s/p CEA in [**2179**],
and h/o failed laparascopic cholecystectomy [**2178**] with
nonvisualization of gallbladder on [**9-20**] abdominal [**Hospital 4338**]
transferred from [**Hospital 8641**] Hospital on [**9-22**] after failed ERCP on
[**9-21**] for cholangitis complicated by gram-negative bacteremia.
Briefly, the patient present to [**Hospital 8641**] Hospital on [**9-20**] with
severe abdominal pain worsened by inspiration and was found to
be febrile to 102.7, tachycardic to HR 130s, and have
significant LFT abnormalities (lipase 6391, T.bili 1.7, D. bili
1.3, AST 281, ALT 134, AP 285). He was initially placed on BiPap
and received Lasix 100mg IV in the ED for his respiratory
distress; Bipap was quickly discontinued and the patient
received Zosyn, IVF, and pain medication (morphine 2mg IV x 1)
with significant improvement in his abdominal pain. He was
transferred to the [**Location (un) 8641**] MICU for further management. He had
some hypotension to SBP 90s on the night of admission, however
he never required pressor support. [**9-21**] Blood cultures revealed
GNRs in 4 of 4 bottles; spec/[**Last Name (un) 36**] are pending. The patient had
an attempted ERCP [**9-21**] which was aborted as the ERCP scope was
unable to be passed into the second part of the duodenum
secondary to a significant stricture of the duodenal bulb, just
before the D1/D2 junction. Also noted were a medium-sized hiatal
hernia, as well as an oozing superficial duodenal ulcer in the
bulb with no stigmata of recent bleeding. Given that the patient
is on Plavix (last dose 8/24 AM), it was decided to hold off on
dilating the stricture and transfer him to [**Hospital1 18**] for further
management of his cholangitis. Patient reportedly tolerated the
procedure well, but had some post-procedure wheezing that was
treated with bronchodilators. On transfer, the patient's BPs had
improved to 120s/50s-60s. Labs on discharge were lipase 1313,
T.bili 3.6, D.bili 3.0, AST 161, ALT 126, AP 210, LDH 262. Blood
cultures growing GNRs (prelim) were still pending.
Of note, the patient's gallbladder was not visualized on either
abdominal ultrasound or MRCP on [**9-20**]. He had an attempted
laparascopic cholecystectomy in [**2178**] which was aborted due to
extensive adhesions, but he and his family are certain that he
has not had his gallbladder removed. GI consult at [**Location (un) 8641**]
suggested that he might have a congenital atrophic gallbladder
or he might have had recurrent attacks of acute cholecystitis
causing him to have significant fibrosis and shrinking of the
gallbladder. There are no clips in the gallbladder fossa to
suggest prior cholecystectomy.
On arrival to the [**Hospital Unit Name 153**], VS were: T 98.1, 151/71, HR 76, SpO2
96%RA, RR 15. The patient appears jaundiced but comfortable and
denies any abdominal pain.
Past Medical History:
- CAD s/p DES (Xience) to LAD x 4 in [**2180**] (reportedly performed
at [**Hospital3 **], EF 45%)
- TIA [**8-/2179**] s/p right carotid endarterectomy [**10/2179**]: no
significant residual deficits. Most recently had an episode of
amaurosis fugax in spring [**2182**] & saw his neurologist, Dr. [**First Name (STitle) 6692**],
who did carotid dopplers on [**2182-5-30**] that showed severe bilateral
ICA disease >70% bilaterally. Patient has been managed medically
with Plavix.
- H/o cholecystitis s/p failed laparascopic cholecystectomy in
[**2178**]. Reportedly surgeon was unable to perform procedure because
of [**Last Name (un) **] adhesions around the gallbladder; unclear why procedure
was not converted to open.
- Hypertension
- Hyperlipidemia
- S/p right inguinal herniorhapy x 3 with 3rd operation
requiring removal of his right testicle ([**2140**])
- Meniere's disease with recent complaints of refractory
dizziness earlier this summer [**2182**]
- Tinnitus (likely related to Meniere's)
- Hearing loss in left ear
- Seizure disorder on low-dose Tegretol (did not tolerate switch
to Keppra; high-dose Tegretol has been associated with cognitive
slowing). EEG showed L temporal seizure activity. Most recent
"spell" of transient confusion (attributed to seizure activity)
occured in [**2182-4-28**].
- GERD
- BPH
- Asthma
Social History:
Denies any tobacco or illicit drug use. Drank more heavily
previously, but has not had alcohol for the past 5 years.
Widowed. Previously worked for GE. Lives full-time in an
[**Hospital3 **] facility (where his daughter [**Name (NI) **] [**Name (NI) **] works).
Walks with a cane.
Family History:
Father with CAD.
Physical Exam:
ADMISSION EXAM
Vitals: T 98.1, 151/71, HR 76, SpO2 96%RA, RR 15
General: Alert, oriented, no acute distress
HEENT: Sclerae icteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, no focal neuro deficit
Discharge exam: Unchanged. No foley.
Pertinent Results:
[**Hospital 8641**] Hospital labs [**9-20**]
WBC 9.9, Hgb 13.5, Plt 303, Na 136, K 4.1, Cl 98, bicarb 27, BUN
8, Cr 1, glucose 168, lactate 1.8, Tbili 1.7, Dbili 1.3, AST
281, ALT 134, AP 285, Lipase 6391, Troponin <0.04, BNP 39.
Microbiology:
[**9-21**] [**Hospital 8641**] Hospital blood cultures (PRELIM): 4 of 4 bottles
growing GNRs - Klebsiella pneumoniae sensitive to augmentin.
[**2182-9-22**] 10:23AM BLOOD WBC-7.2 RBC-3.57* Hgb-11.1* Hct-32.7*
MCV-92 MCH-31.2 MCHC-34.1 RDW-12.9 Plt Ct-205
[**2182-9-22**] 10:23AM BLOOD Glucose-88 UreaN-20 Creat-1.5* Na-140
K-3.3 Cl-101 HCO3-27 AnGap-15
[**2182-9-22**] 10:23AM BLOOD ALT-62* AST-64* AlkPhos-156* TotBili-4.9*
[**2182-9-22**] 10:23AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.8 Mg-2.2
IMAGING
CT ABD/PELV WITH CONT
1. Atypical appearance of the gallbladder and extrahepatic bile
ducts. An atrophic and severely collapsed gallbladder may be
present versus a markedly thick walled cystic duct remnant. The
point of convergence of the cystic duct and CHD is difficule to
ascertain but the segment of duct presumed to represent the CBD
is diffusely and markedly thick walled and heterogeneous. This
may relate to chronic inflammatory change, cholangitis or
neoplasm (i.e. cholangiocarcinoma). No intrahepatic biliary
ductal dilatation. Recommend further evaluation with ERCP and
brushings.
2. Second portion of duodenum appears markedly collapsed or
atrophic, but no mass identified in this region.
3. Hiatal hernia containing GE junction and transdiaphragmatic
herniation of hepatic dome which appears to be exerting a degree
of mass effect on the
cephalad IVC.
4. Atrophic pancreas without surrounding inflammatory change.
No pancreatic mass or pancreatic duct dilatation identified. No
focal or free fluid identified within the abdomen.
5. Mild-to-moderate atherosclerotic narrowing of the ostia of
the celiac and superior mesenteric arteries.
6. Mild compression deformity of the superior endplate of T11.
7. Trace bilateral pleural effusions.
ERCP:
A medium size hiatal hernia was seen, displacing the Z-line to
35 cm from the incisors, with hiatal narrowing at 40 cm from the
incisors.
A salmon colored mucosa distributed in a segmental pattern,
suggestive of short segment Barrett's Esophagus was found. The
Z-line was at 35 cm from the incisors and the upper end of the
gastric folds started at 38 cm from the incisors. Cold forceps
biopsies were performed for histology.
Exam of the stomach was normal.
A benign intrinsic stricture was found in the distal bulb.
The forward viewing scope scope traversed the stricture. Mild
resistance was noted to passage of the scope.
The stricture was dilated gradually from 12mm to15mm using a CRE
balloon. Duodenum distal to the stricture is normal. Cold
biopsies were performed for histology from the duodenal
stricture.
Evidence of a previous sphincterotomy was noted in the major
papilla. The sphincterotomy was adequate.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique. Contrast medium was
injected resulting in complete opacification.
A mild diffuse dilation was seen at the main duct with the CBD
measuring 8 mm.
No filling defects were noted.
The left intra hepatic ductal system was noted to be normal.
The right intra hepatic ducts were noted to be thin. Cystic duct
is not visualized.
There is collection of contrast in the right lobe of the liver
suggestive of intrahepatic gallbladder.
Balloon sweep was performed. No sludge or stones noted.
MRCP: 1. Cholangitis involving the extra-hepatic, gallbladder,
and central left lobe biliary system. Chronic atrophy of the
left hepatic lobe may be secondary to prior biliary pathology;
there is not evidence for a current obstruction of the left
ducts. 2. New small right hepatic subcapsular bile collection
compared to CT, which correlates with bile collection seen on
ERCP. 3. Diminutive gallbladder may be from congenital atrophy
as there is no evidence of surgical resection. No evidence of
intrahepatic gallbladder. 4. Resolved pancreatitis. 5.
Moderate stenosis of the SMA over medium length segment from
atherosclerosis. 6 Moderate hiatal hernia.
[**2182-9-26**] 06:15AM BLOOD WBC-5.4 RBC-3.41* Hgb-10.4* Hct-32.2*
MCV-94 MCH-30.6 MCHC-32.5 RDW-14.1 Plt Ct-231
[**2182-9-26**] 06:15AM BLOOD Glucose-91 UreaN-12 Creat-1.1 Na-138
K-3.5 Cl-104 HCO3-23 AnGap-15
[**2182-9-27**] 06:20AM BLOOD ALT-71* AST-83* AlkPhos-317* TotBili-1.6*
[**2182-9-26**] 06:15AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.2
Brief Hospital Course:
86M with CAD s/p DES to LAD x 4 in [**1-/2180**], TIA s/p CEA in [**2179**],
and h/o failed laparoscopic cholecystectomy [**2178**] with
nonvisualization of gallbladder on [**9-20**] abdominal [**Hospital 4338**]
transferred from [**Hospital 8641**] Hospital who spontaneously passed stone
and was treated for cholangitis and bacteremia.
# Cholangitis: Patient presented with evidence of biliary
obstruction that was unable to be relieved during ERCP at [**Hospital 8641**]
Hospital on [**9-21**] secondary to duodenal stricture. In the context
of the patient also being on Plavix and concern for bleeding
during dilation or possible sphincterotomy, it was decided to
transfer him to [**Hospital1 18**] for further management and repeat attempt
at ERCP. On arrival to the ICU, patient was given maintenance
LR to maintain UOP > 45cc/h. Zosyn was continued. A CT abdomen
was done which revealed a potentially atrophic vs. collapsed
gallbladder and signs concerning for cholangitis. He underwent
an ERCP (described in results section) without complications. He
had evidence of prior sphincterotomy and likely passed stones
prior to procedure. He remained afebrile, with good hemodynamics
and down trending labs after the procedure. He was continued on
antibiotics and will need 9 more days of antibiotics as an
outpatient. He should follow up with his primary care physician
for further evaluation of his symptoms. He had an MRCP to
further characterize his anatomy which did show some continued
infection/inflammation (see pertinent results). No evidence of
any masses appreciated.
# Pancreatitis: Patient presented to [**Hospital 8641**] Hospital with
elevated lipase; thought to be secondary to gallstone
pancreatitis in the setting of biliary obstruction/cholangitis.
MRCP did not show evidence of pancreatitis. CT abdomen in house
showed atrophic pancreas with no signs of inflammation. Patient
was nevertheless maintained on generous IVF, written for Zosyn.
He denied any symptoms and his lipase trended to normal.
# Acute Kidney Injury: Patient presented with a Cr of 1.5. This
was most likely prerenal in the context of hypotension from
sepsis and volume depletion. FENa 0.8% even after being volume
resuscitated. No reason to suspect intrinsic renal or post-renal
etiology. He was maintained on generous IVF with goal UOP >45
cc/h. His creatinine came down nicely. It was confirmed with
his PCP that his baseline creatinine is around 1.1 (in [**Month (only) 116**],
[**2182**]). At the time of discharge his creatinine had returned to
baseline.
# H/o TIA/CAD : Patient takes Plavix both for h/o TIA/medical
management of cerebrovascular disease, as well as CAD s/p 4 DES
to LAD in [**2180-1-28**]. Given need for stricture dilatation and
possible sphincterotomy, will hold Plavix for now to reduce risk
of bleeding. After the ERCP the plavix was restarted and he
should continue to take this medication.
# Hyperlipidemia: Held Zocor in the context of transaminitis.
This should be discussed with his primary care physician at the
follow up appointment.
# QTc prolongation: Patient had an EKG that showed prolonged QTc
(>550msec) while at [**Hospital 8641**] Hospital. A repeat EKG showed a QTc
of 429. Electrolytes were monitored and replaced as needed.
# Seizure disorder: Continued Tegretol 50mg [**Hospital1 **].
# GERD: Maintained on home medications at discharge.
# Asthma/COPD: Patient had some wheezing after his ERCP at
[**Hospital 8641**] Hospital on [**9-21**] that was relieved with bronchodilators.
Occasionally uses albuterol inhaler at home. He was started on
Advair at [**Hospital 8641**] Hospital. PCP was [**Name (NI) 653**] who informed us
that he has had no PFTs in the past and likely has only been
diagnosed with mild intermittent asthma. He notes that his
wheezing is chronic and at his baseline. This should be
evaluated further with his PCP as an outpatient.
# BPH: Continued finasteride.
# Code: DNR/DNI (confirmed)
Transitional issues:
- repeat LFTs to ensure resolution - to be done at PCPs office
- finish 9 days of antibiotics for infection
- evaluation of wheezing by PCP
Medications on Admission:
Tylenol 1000 mg q8 hrs prn
Albuterol 2 puffs QID prn
Maalox 30 ml QID prn
Calcium plus Vitamin D 600/400 1 tab at bedtmie
Tegretol 50 mg [**Hospital1 **]
Plavix 75 mg Qdaily
Senokot 1 tablet [**Hospital1 **]
Colace 100 mg Qdaily prn
Proscar 5 mg QHS
Robitussin DM QID prn
Lisinopril 10 mg Qdaily
Imodium prn
Milk of magnesia 30 ml Qdaily prn
Multivitamin Qdaily
Ocuvite [**Hospital1 **]
Sublingual nitroglycerin prn
Prilosec 20 mg Qdaily
Metamucil Qdaily prn
Zocor 80 mg QHS
Advair 250/50 1 puff inh [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Carbamazepine 50 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
6. Senna 1 TAB PO BID:PRN Constipation
7. Finasteride 5 mg PO HS
8. Multivitamins 1 TAB PO DAILY
9. Amoxicillin-Clavulanic Acid 875 mg PO Q12H Duration: 9 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
twice per day Disp #*18 Tablet Refills:*0
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
puff inhaled twice per day Disp #*1 Inhaler Refills:*0
11. Simvastatin 80 mg PO DAILY
please hold this medication until you speak with your primary
care physician
12. Psyllium 1 PKT PO DAILY:PRN constipation
13. Omeprazole 20 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
call doctor if you use
15. Ocuvite *NF* (vit A,C & E-lutein-minerals;<br>vit C-vit
E-lutein-min-om-3) 1,000-60-2 unit-unit-mg Oral [**Hospital1 **]
as previously prescribed
16. Milk of Magnesia 30 mL PO Q12H:PRN constipation
17. Imodium A-D *NF* (loperamide) 2 mg Oral [**Hospital1 **]:PRN diarrhea
18. Lisinopril 10 mg PO DAILY
19. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
20. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral qHS
21. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN GERD
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
cholangitis
bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted from another hospital with cholangitis
(infection) and stones in your bile duct. You were treated with
IVF, antibiotics, bowel rest with improvement of your labs. You
underwent an ERCP procedure which showed a previously
cholecystectomy. The procedure went well.
You will need more antibiotics at home. Please take the complete
course of antibiotics, even though you are feeling better.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) 60843**]
When: Friday [**2182-10-4**] at 4:00 PM
Location: [**Location (un) **] FAMILY PRACTICE
Address: [**Apartment Address(1) 84408**], STRATHAM,[**Numeric Identifier 89468**]
Phone: [**Telephone/Fax (1) 84410**]
|
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24,938
| 165,840
|
23503
|
Discharge summary
|
report
|
Admission Date: [**2149-3-1**] Discharge Date: [**2149-4-30**]
Date of Birth: [**2108-1-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
abdominal pain with diverticulosis
Major Surgical or Invasive Procedure:
Exploratory laparotomy with ventral hernia repair and drainage
of pelvic abscess
History of Present Illness:
pt has hx of diverticulitis s/p sigmoid resection. Pt noted
severe pain over right side beginnign around 3 pm [**2149-2-28**].
Denies fever,chills or vomitting. He did haev nausea. Admits to
PO intake.
Past Medical History:
- HTN
- hypercholesterolemia
- angina
- diverticulitis s/p sigmoid colectomy in [**9-/2147**]
- appendectomy in [**10/2147**]
- cecectomy in [**1-/2148**]
Social History:
Pt denies EtOH, tobacco, and recreational drug use
Family History:
NC
Physical Exam:
nad
rrr
ctab
soft, obese, distended. mIld diffuse tenderness over right side
Pertinent Results:
[**2149-2-28**] 07:48PM BLOOD WBC-17.8*# RBC-5.09 Hgb-15.9 Hct-44.6
MCV-88 MCH-31.3 MCHC-35.8* RDW-13.8 Plt Ct-248
[**2149-3-1**] 07:15AM BLOOD WBC-14.5* RBC-4.56* Hgb-14.4 Hct-39.7*
MCV-87 MCH-31.6 MCHC-36.2* RDW-13.8 Plt Ct-235
[**2149-3-2**] 04:38AM BLOOD WBC-24.3*# RBC-4.77 Hgb-15.5 Hct-41.9
MCV-88 MCH-32.5* MCHC-37.0* RDW-13.8 Plt Ct-313
[**2149-3-3**] 05:36AM BLOOD WBC-16.8* RBC-3.91* Hgb-12.1*# Hct-33.5*
MCV-86 MCH-30.9 MCHC-36.1* RDW-13.6 Plt Ct-213
[**2149-3-4**] 05:09AM BLOOD WBC-12.2* RBC-3.83* Hgb-11.9* Hct-32.9*
MCV-86 MCH-31.2 MCHC-36.3* RDW-13.4 Plt Ct-207
[**2149-3-5**] 04:55AM BLOOD WBC-10.4 RBC-3.72* Hgb-11.5* Hct-33.2*
MCV-89 MCH-31.0 MCHC-34.8 RDW-13.3 Plt Ct-247
[**2149-3-6**] 04:42AM BLOOD WBC-9.3 RBC-3.64* Hgb-11.1* Hct-32.3*
MCV-89 MCH-30.6 MCHC-34.4 RDW-13.4 Plt Ct-276
[**2149-3-8**] 05:08AM BLOOD WBC-10.5 RBC-3.55* Hgb-11.2* Hct-31.2*
MCV-88 MCH-31.5 MCHC-35.8* RDW-13.4 Plt Ct-260
[**2149-3-11**] 09:12AM BLOOD WBC-19.1*# RBC-3.97* Hgb-12.1* Hct-35.2*
MCV-89 MCH-30.5 MCHC-34.5 RDW-13.5 Plt Ct-415#
[**2149-3-12**] 06:37AM BLOOD WBC-20.1* RBC-4.08* Hgb-12.3* Hct-35.6*
MCV-87 MCH-30.2 MCHC-34.6 RDW-13.6 Plt Ct-420
[**2149-3-15**] 01:26AM BLOOD WBC-10.6 RBC-3.41* Hgb-10.4* Hct-30.1*
MCV-88 MCH-30.5 MCHC-34.5 RDW-13.6 Plt Ct-383
[**2149-3-15**] 03:04PM BLOOD WBC-9.2 RBC-3.48* Hgb-10.5* Hct-30.4*
MCV-87 MCH-30.1 MCHC-34.4 RDW-13.5 Plt Ct-397
[**2149-3-16**] 03:00AM BLOOD WBC-11.6* RBC-3.47* Hgb-10.5* Hct-30.5*
MCV-88 MCH-30.1 MCHC-34.3 RDW-13.3 Plt Ct-411
[**2149-3-17**] 05:33AM BLOOD WBC-12.1* RBC-3.41* Hgb-10.5* Hct-29.9*
MCV-88 MCH-30.7 MCHC-35.0 RDW-13.5 Plt Ct-412
[**2149-2-28**] 07:48PM BLOOD Neuts-83.3* Bands-0 Lymphs-12.0*
Monos-3.5 Eos-0.9 Baso-0.2
[**2149-3-1**] 07:15AM BLOOD Neuts-82.9* Bands-0 Lymphs-11.9*
Monos-4.2 Eos-0.8 Baso-0.1
[**2149-2-28**] 07:48PM BLOOD Glucose-140* UreaN-12 Creat-0.9 Na-142
K-4.0 Cl-100 HCO3-29 AnGap-17
[**2149-3-1**] 06:50AM BLOOD Glucose-176* UreaN-9 Creat-0.7 Na-139
K-3.6 Cl-101 HCO3-26 AnGap-16
[**2149-3-2**] 04:38AM BLOOD Glucose-235* UreaN-12 Creat-0.8 Na-136
K-4.1 Cl-102 HCO3-24 AnGap-14
[**2149-3-3**] 05:36AM BLOOD Glucose-173* UreaN-13 Creat-0.9 Na-139
K-4.3 Cl-104 HCO3-26 AnGap-13
[**2149-3-4**] 05:09AM BLOOD Glucose-163* UreaN-10 Creat-0.7 Na-137
K-3.7 Cl-101 HCO3-29 AnGap-11
[**2149-3-5**] 04:55AM BLOOD K-3.7
[**2149-3-6**] 04:42AM BLOOD K-4.0
[**2149-3-7**] 04:08AM BLOOD K-4.0
[**2149-3-8**] 05:08AM BLOOD Glucose-129* UreaN-7 Creat-0.8 Na-136
K-3.7 Cl-102 HCO3-26 AnGap-12
[**2149-3-9**] 06:02AM BLOOD K-3.9
[**2149-3-10**] 09:30AM BLOOD K-3.7
[**2149-3-11**] 04:39AM BLOOD Glucose-128* UreaN-14 Creat-1.0 Na-136
K-4.6 Cl-101 HCO3-24 AnGap-16
[**2149-3-12**] 06:37AM BLOOD Glucose-129* UreaN-15 Creat-1.0 Na-133
K-4.1 Cl-97 HCO3-22 AnGap-18
[**2149-3-12**] 10:57PM BLOOD K-4.1
[**2149-3-13**] 04:01AM BLOOD Glucose-125* UreaN-13 Creat-0.9 Na-135
K-4.3 Cl-101 HCO3-21* AnGap-17
[**2149-3-14**] 01:41AM BLOOD Glucose-146* UreaN-10 Creat-0.7 Na-136
K-4.0 Cl-101 HCO3-24 AnGap-15
[**2149-3-15**] 01:26AM BLOOD Glucose-144* UreaN-8 Creat-0.7 Na-139
K-4.1 Cl-103 HCO3-27 AnGap-13
[**2149-3-15**] 03:04PM BLOOD Glucose-143* UreaN-9 Creat-0.6 Na-139
K-4.1 Cl-101 HCO3-26 AnGap-16
[**2149-3-1**] 06:50AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.3*
[**2149-3-2**] 04:38AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8
[**2149-3-3**] 05:36AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.8
[**2149-3-4**] 05:09AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.8
[**2149-3-6**] 04:42AM BLOOD Mg-1.9
[**2149-3-7**] 04:08AM BLOOD Mg-1.9
[**2149-3-8**] 05:08AM BLOOD Calcium-8.4 Phos-4.6*# Mg-1.6
[**2149-3-11**] 04:39AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8
[**2149-3-12**] 06:37AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.7
[**2149-3-12**] 10:57PM BLOOD Calcium-8.4 Mg-1.7
[**2149-3-14**] 01:41AM BLOOD Albumin-2.9* Calcium-8.6 Phos-4.6* Mg-1.7
[**2149-3-1**] 08:56AM BLOOD Type-[**Last Name (un) **] Rates-/10 Tidal V-800 FiO2-50
pO2-44* pCO2-52* pH-7.34* calHCO3-29 Base XS-0 Intubat-INTUBATED
Vent-CONTROLLED Comment-ETT
[**2149-3-2**] 01:22PM BLOOD Type-ART O2 Flow-2 pO2-76* pCO2-41
pH-7.44 calHCO3-29 Base XS-3 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2149-3-14**] 12:55PM BLOOD Type-ART pO2-95 pCO2-39 pH-7.41
calHCO3-26 Base XS-0
CT PELVIS W/CONTRAST [**2149-2-28**]
Incarcerated ventral wall hernia with dilated loops of small
bowel and pneumoperitoneum., Fatty liver.,Cholelithiasis., Right
renal cyst.
CHEST (PA & LAT) [**2149-3-11**]
Aside from an irregular 1 cm wide nodular opacity projecting
over the right second rib, which could be a lung nodule seen on
prior chest CT, [**2148-7-11**], lungs are clear. There is no
evidence of pneumonia. Heart is normal in size. There is no
pleural effusion. Depending upon clinical circumstances,
followup evaluation with chest CT scanning should be considered.
CT 150CC NONIONIC CONTRAST [**2149-3-12**]
IMPRESSION:
Large ventral fluid collection just deep to the surgical skin
staples, with high density. Given the air-fluid level, there is
suspicion for infection. However, a complex hematoma may also be
considered. There is no definite evidence of oral contrast
extravasation, although the fluid within this collection is
slightly higher density than muscle.
Several small and focal ground-glass opacities seen within the
right lower lobe remain present, when compared to earlier
examinations including [**2148-7-11**].
[**2149-3-11**] PERITONEAL FLUID
STAPHYLOCOCCUS, COAGULASE NEGATIVE, CORYNEBACTERIUM
SPECIES
UNILAT LOWER EXT VEINS LEFT [**2149-3-20**] 6:37 PM
IMPRESSION: Occlusive thrombus extending from the proximal
superficial femoral vein to the popliteal vein and even more
distally to the posterior tibial veins in the calf that
represents a deep venous thrombosis.
Brief Hospital Course:
On [**2149-3-1**] Mr. [**Known lastname 656**] was admitted to the surgery service under
the care of Dr. [**Last Name (STitle) **]. He was taken to the OR for an
exploratory laparotomy and repair of a large ventral hernia and
perforated diverticulitis. For details of the procedure, please
see Dr.[**Name (NI) 22019**] operative report. Postoperatively he was
placed on a 10 day course of IV antibiotics, his diet was
advanced, and he was ambulating well. On POD 11, when he was
transitioned to po antibiotics, Mr. [**Known lastname 656**] began experiencing
increasing abdominal discomfort and fevers. A CT of his abdomen
revealed a large collection under his previous incision. He was
taken back to the OR and found to have an enterocutaneous
fistula. Four sump drains were placed over the fistulas and set
to suction postoperatively. He remained intubated until POD 2.
On POD 3, TPN was started. He was transferred to the floor on
POD 4. The next day he was diagnosed with a LLE DVT after
experiencing some left calf pain and was started on IV heparin
with a goal PTT of 60-80. Dr. [**Last Name (STitle) 957**] was consulted for help
regarding the EC fistula. On HD 25, 3 of the 4 sumps were
removed and the most active one was left to suction. On HD 28,
VAC dressing placed on wound site. Pt begun on Coumadin therapy.
Pt started on 5mg and advanced to 12.5 mg of Coumadin. On HD 30,
VAC was removed and a feeding tube was placed within the fistula
site going distally. Tube feeds were started at 20/hr. Heparin
ggt was continued for treatment of the left DVT with daily
monitoring of PTT level. On [**3-31**], as per patient request social
work was consutled to discuss financial matters regarding the
extended hospital stay. On [**4-1**], adjustments were made in
patients TPN to adjust dose according to pateints actual weight
and with AA 225g. Tube feeds continued to be advanced to a goal
of 50cc/hr. Various adjustements were made in the sump set up to
allow the most efficient network. On HD38, heparin was d/c'd as
patients INR was 2.2. Coumadin was continued.
The sump drain at this point was continuously becoming clogged
and not properly functioning and a vac dressing was placed for
better drainage and wound contraction. Tube feeds were
discontinued at this point. The vac dressing remained in place
working well with daily changes. Wound was noted to be
contracting well and was draining.
On POD 50/39, his VAC was changed. On POD 58/47 ([**2149-4-28**]), his
VAC was changed. Nutrition labs were drawn. Dr. [**Last Name (STitle) 957**]
decided that he was fit to go to a rehabillitation center,
provided that he could continue his TPN, VAC to continuous
suction, and frequent blood draws. Plans were made for him to
go to rehab and he was happy with this idea. His fistula output
was changed to replacement with 1/2 cc per cc of D5NS with 20
mEq/L KCL instead of cc:cc replacements. This was done beacuse
his fistula output continued to be 1500-1800 cc/day. On POD
60/49, his VAC had to be changed again for leakage. On POD
61/50, the patient was dischagred to rehab. Please see page 1
report for a copy of his treatments and frequencies. In breif,
he will require every third day VAC changes and blood draws,
with careful monitoring of his BUN and createnine. He will also
require 1/2 cc per cc replacement of his fistula output. He was
discharged in good condition.
Medications on Admission:
ASA
Atenolol 100'
Isosorbide 60'
Cozaar 100
HCTZ 25
Folate 400
Caudet(norvasc/lipitor)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Atorvastatin 20 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 Q24H (every 24 hours).
4. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
5. Insulin Regular Human Subcutaneous
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
Fifteen (15) ML PO Q4H (every 4 hours).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day).
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-6**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
12. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
13. Warfarin 2.5 mg Tablet Sig: Five (5) Tablet PO QOD ():
alternate 12.5mg with 10.5mg.
14. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO QOD ():
alternate 12.5mg with 10.5mg.
15. Metoclopramide 10 mg IV Q6H
16. Hydromorphone 2 mg/mL Syringe Sig: [**1-6**] Injection Q2H (every
2 hours) as needed for pain.
17. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed.
18. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Perforated diverticulitis
Ventral hernia
enterocutaneous fistula
SFA-[**Doctor Last Name **] DVT
Discharge Condition:
Good
Discharge Instructions:
Call your doctor or go to the ER if you experience any of the
following: high fevers >101.5, severe pain, increasing
nausea/emesis, or pus draining from his wound. If fistula output
changed significantly please call. Call with any questions
reguarding coumadin dosing or elextrolyte imbalances.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - call for an appointment [**Telephone/Fax (1) 10533**] in
[**2-7**] weeks
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2149-4-22**] 9:15
Please call the officeof Dr. [**Last Name (STitle) 957**] to schedule an appointment
in [**2-7**] weeks at ([**Telephone/Fax (1) 57851**]
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2149-4-30**]
|
[
"276.51",
"278.01",
"569.5",
"569.81",
"567.21",
"401.9",
"997.2",
"V58.61",
"552.21",
"562.11",
"414.01",
"453.41",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.61",
"96.6",
"99.15",
"93.59",
"38.93",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
11924, 11996
|
6794, 10202
|
349, 432
|
12137, 12144
|
1042, 6771
|
12488, 13054
|
926, 930
|
10339, 11901
|
12017, 12116
|
10228, 10316
|
12168, 12465
|
945, 1023
|
275, 311
|
460, 663
|
685, 841
|
857, 910
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,850
| 104,490
|
27735
|
Discharge summary
|
report
|
Admission Date: [**2118-3-20**] Discharge Date: [**2118-3-26**]
Date of Birth: [**2063-8-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Abdominal port placement [**2118-3-21**]
History of Present Illness:
54 y/o woman with metastatic ovarian cancer complicated by
ascites requiring frequent paracentesis who is admitted to the
[**Hospital Ward Name 332**] ICU after presenting to the emergency department with
dyspnea.
.
Her ascites has been a [**Last Name 12785**] problem of late, and has required 2
paracentesis last week alone. She was in fact scheduled to have
IR place a peritoneal port on [**2118-3-21**]. She underwent her last
recieved chemo on [**2118-3-15**]; and was transfused 2U PRBC for HCT 26
that day. She last underwent paracentesis on [**2118-3-18**].
.
She awoke on the day of admission (Sunday [**2118-3-20**]) feeling short
of breath, and with abdominal distension, and noted that this
was similar to how she feels prior to paracentesis. She has not
had any acute abdominal pain, but notes a bloating and a
tightness sensation. She vomited once last night after eating
and has had poor PO intake at baseline. She also reports feeling
increasingly weak. She has had no chest pain.
.
In the ED, she was afebrile 99.5, with BP 110/60, HR 120, 18, O2
sat 98% on RA. She was found to have a Hct of 16 (down from 26
on [**2118-3-16**]) and WBC of 1.0. A CT torso was performed in the ED
which demonstrated no PE/dissection, but progression of
omental/peritoneal disease with pockets of hyperdense ascites in
LUQ and mid line lower abdomen which likley represent
intraperitoneal hemmorhage mixed with ascites. Surgery was
consulted and felt that there was no need for surgical
intervention. She was admitted to the [**Hospital Unit Name 153**] for further
monitoring.
Past Medical History:
1. Ovarian Cancer
Diagnosed with Stage I in [**2115-7-11**] with good surgical
resection. Ascites has been positive. Received adjuvant with
carboplatin and taxol with avastin Received 6 cycles. Had
recurrent disease in [**2116-10-10**] and had gemcitabine, 7
cycles taxol, 4 cycles doxil, and started Alimta on [**2118-2-23**].
2. Anxiety disorder followed by a psychiatrist
3. Hypertension after treatment with Avastin
4. DVT and bilateral subsegmental PE diagnosed [**2-17**]
Social History:
Worked as a schoolteacher. Does not smoke or drink.
Family History:
She has one uncle who had prostate cancer. Both her sister and
brother have had basal cell carcinoma of the nose.
There is no history of any breast, ovarian, uterine, or
colorectal cancer.
Physical Exam:
VS 98.5 76 118/80 28 99%4L
GEN: NAD
HEENT: ATNC, HEENT, EOMI
HEART: RRR, no m/r/g
LUNGS: CTAB, no r/r/w
ABD: Distended, soft, nt, nd
EXTREM: No c/c/e
Neuro: nonfocal
Pertinent Results:
On Admission:
[**2118-3-20**] 10:35AM GLUCOSE-126* UREA N-26* CREAT-0.5 SODIUM-130*
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-24 ANION GAP-12
[**2118-3-20**] 10:35AM ALT(SGPT)-13 AST(SGOT)-21 CK(CPK)-12* TOT
BILI-0.2
[**2118-3-20**] 10:35AM cTropnT-<0.01
[**2118-3-20**] 10:35AM CK-MB-NotDone
[**2118-3-20**] 10:35AM TOT PROT-4.0* CALCIUM-7.1* PHOSPHATE-3.2
MAGNESIUM-1.9
[**2118-3-20**] 10:35AM WBC-1.0*# RBC-1.76*# HGB-5.5*# HCT-16.0*#
MCV-91 MCH-30.9 MCHC-34.1# RDW-18.6*
[**2118-3-20**] 10:35AM NEUTS-30* BANDS-0 LYMPHS-70* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-6*
.
Imaging:
CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST [**2118-3-20**]:
1. No evidence of aortic dissection or pulmonary embolism.
2. Interval disease progression involving the peritoneum and
omentum within the abdomen and pelvis with increased ascites.
Pockets of ascites appear to display hyperdense components
within it, noted within the left upper quadrant and lower
midline abdomen which are suggestive of regions of
intraperitoneal hemorrhage. No findings of active extravasation.
3. Unchanged intrathoracic and abdomen/pelvic lymphadenopathy.
4. Slightly prominent air- and fluid-filled loops of transverse
colon without any secondary signs to suggest bowel obstruction.
.
CT Abdomen [**2118-3-23**]:
1. No evidence of active extravasation.
2. Stable appearance of known extensive metastatic disease with
ascites,
peritoneal and omental implants. Stable appearance of high
attenuation
components in left upper quadrant within the ascites suggestive
of regions of intraperitoneal hemorrhage.
3. Interval development of small-to-moderate right pleural
effusion.
4. Dilated loops up to 7 cm of air and fecal material filled
transverse and
ascending colon, and cecum that is compatible with ileus.
Brief Hospital Course:
[**Hospital Unit Name 153**] and Oncology course according to problem list.
.
# Anemia: Patient presented with a hematocrit of 16 in the
setting of recent chemotherapy and no clear source of acute
bleeding. An abdominal CT was performed and demonstrated
ascitic fluid consistent with focal areas of hemorrahage from
metastatic disease. This was thought to be the etiology of the
patient's acute anemia and she was admitted to the [**Hospital Unit Name 153**] for
close monitoring. She was transfused a total of four units of
blood and had a post-transfusion Hct of 34, suggesting that her
initial Hct of 16 was erroneous. Lovenox, which she takes
because of a history of DVT/PE, was held. Her Hct remained
stable and she was subsequently transferred to the medical floor
for further management. On the floor patient had 1 L of fluid
drained from abdominal port for comfort - the next day she had >
15 pt HCT drop (30.4 -> 15.7). Hemodynamics were stable. CTA was
performed which demonstrated no active source of bleeding from
vessels. However, abdominal port was draining frank blood.
Patient was transfused 2 units, and HCT increased to 28.6. Again
it was felt 15 HCT was erroneous and perhaps due to dilution
(port draw). Regardless patient is suffering from
intraperitoneal bleeding demonstrated by frank blood (drained
from abdominal port). CTA ruled out treatable vascular source,
most likely bleeding is from metastatic peritoneal disease.
There is some concern that removing fluid for comfort increases
peritoneal bleeding due to decreased pressure/tamponade.
HOwever, prior to discharge 500 cc X 2 was drained with no
significant drop in HCT or change in hemodynamics. Plan is to
discontinue lovenox, transfuse based on symptoms only and drain
ascities for comfort.
.
# Ascities: The patient has significant ascites and has
undergone multiple therapeutic paracentesis to relieve dyspnea
and abdominal discomfort. IR placed guided port on [**2118-3-21**].
Abdominal port is currently draining frank blood (see above),
but does provide significant comfort. Patient was briefly
started on antibiotics (Vanc, Ceftrioxone) for possible
intrapertineal infection based on PMN 249 ([**2118-3-22**]), however
culture returned negative and antibiotics were discontinued.
- Drain prn for comfort
.
# History of DVT/PE: Lovenox discontinued in setting of
intraperitoneal hemorrhage.
# Metastatic ovarian cancer: Patient discharged home with
hospice.
- Morphine prn
- Paracentesis via port for comfort
- Transfusions based on symptoms
# FEN: Encourage po intake
# CODE: DNR/DNI
Medications on Admission:
1. Lovenox 100mg sq daily (of note did not take AM of sunday
[**2118-3-20**])
2. senna 8.6mg daily
3. Reglan 5mg po q6hrs prn nausea
4. clonazepam 0.5mg [**Hospital1 **] prn anxiety
5. proAir HFA 90mcg 1-2puffs q6-8 hrs prn cough
6. dexamethasone 8mg [**Hospital1 **] the day before, of and day after chemo
7. famotidine 40mg [**Hospital1 **] prn
8. vitamin B-12
9. colace 100mg [**Hospital1 **]
10. desipramine 50mg daily
11. folic acid 1mg daily
12. zofran 8mg TID prn nausea
13. Alimta q3 weeks, last dose [**2118-3-15**].
Discharge Medications:
1. [**Doctor Last Name **] needles 4p/week 19 gauge, 1 inch
For abdominal port access
2. Port a cath access kits
Please provide 3 kits/week
3. Saline and Heparin flush
Use PRN with abdominal port
4. 3 way stop cock
Please provide 3 per week
5. 30 cc syringe - [**Last Name (un) **] lock
Please provide 3 per week
6. ETOH wipes, dressing materials, and needle bucket
Please provide enough for one month supply
Indication: abdominal port
7. Nephrostomy drainage bag
Please provide 6 bags per month
8. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO q1hr
as needed for pain.
Disp:*30 ml* Refills:*0*
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for nausea.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
13. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
17. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
18. Desipramine 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
19. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
Disp:*30 suppository* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Ovarian cancer
Refractory ascites
Intraperitoneal hemorrhage
Discharge Condition:
Good, pain well controlled.
Discharge Instructions:
You were admitted for low blood counts. You stabilized with
blood transfusions. Your lovenox was discontinued. An abdominal
port was placed to allow frequent paracentesis.
.
Attend all your follow-up appointments. You will have an
appointment with Dr. [**Last Name (STitle) 4149**] and [**Doctor Last Name **] [**0-0-**] on Friday (not
tuesday).
.
Follow your medication list, we have changed some of your
medications.
.
Call your doctor if you experience dizziness, chest pain, fever,
chills, nausea, vomiting, pain or any other concerning symptoms.
Followup Instructions:
You will have an appointment with Dr. [**Last Name (STitle) 4149**] and Dr. [**Last Name (STitle) **]
[**0-0-**] on Friday Febuary 20th. They will call you with the
time. Your appointment on Tuesday [**3-29**] has been cancelled.
Completed by:[**2118-3-25**]
|
[
"401.9",
"288.03",
"789.51",
"V10.43",
"197.6",
"284.89",
"300.00",
"E933.1",
"276.1",
"276.50",
"568.81",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.93"
] |
icd9pcs
|
[
[
[]
]
] |
9827, 9905
|
4789, 7372
|
322, 365
|
10010, 10040
|
2957, 2957
|
10640, 10902
|
2566, 2756
|
7950, 9804
|
9926, 9989
|
7398, 7927
|
10064, 10617
|
2771, 2938
|
275, 284
|
393, 1978
|
2971, 4766
|
2000, 2479
|
2495, 2550
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,371
| 102,519
|
42324
|
Discharge summary
|
report
|
Admission Date: [**2119-8-21**] Discharge Date: [**2119-8-24**]
Service: MEDICINE
Allergies:
Tylenol
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Balloon Aortic Valvuloplasty [**2119-8-22**] -- Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
History of Present Illness:
Ms. [**Known lastname **] is an 88yoF with a h/o severe AS, Afib on coumadin,
HTN, HLD who was transferred from OSH with acute pulmonary edema
requiring intubation and hypotension requiring pressors.
Patient is unable to provide a history at this time so details
obtained by family and note by Dr. [**Last Name (STitle) **] in OMR. Pt recently
saw Dr. [**Last Name (STitle) **] in clinic on [**2119-8-16**] for evaluation for AVR. Per
his note, she had a syncopal episode approximately 5 mos ago.
She also c/o occasional SOB but this had recently improved. Her
most recent echocardiogram of [**2119-7-19**] showed severe AS ([**Location (un) 109**]
0.47cm2, mn 37) with normal systolic function (LVEF 60%). She
was scheduled for elective AVR on [**2119-9-21**] with anticipated
pre-admission for IV heparin and routine PATs.
.
Per the family, on the day of admission she developed acute SOB
at home and called her neighbor, who is a nurse. Her daughter
had visited her only 30 minutes prior, and states that she did
not appear SOB at that time. Her neighbor called EMS and the pt
was brought to [**Hospital6 33**]. There she was intubated for
poor responsiveness and started on dopamine gtt for BP 70/40.
She was transferred to [**Hospital1 18**] for further management.
.
On transfer to ED, she was intubated and on dopamine gtt.
Vitals afebrile with HR 140, BP 97/64, RR 22 O2sat 95%. BP
decreased to 71/57, started on levophed and neosynephrine gtt
and BP stabilized 90s/60s. Received IV lasix 40mg x1. Dopamine
gtt was d/c'd. EKG showed Afibb with RVR. LIJ and arterial line
placed. (RIJ attempted but c/b blood clot.) DCCV attempted but
she remained in afib. She was admitted to CCU for respiratory
and pressure support.
.
ROS: Unable to obtain
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension +Hyperlipidemia
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Severe Aortic stenosis: [**Location (un) 109**] 0.47cm2, mn 37
- Atrial fibrillation (per family, diagnosed [**5-19**] mos ago;
cardioversion discussed but not attempted, now on coumadin)
3. OTHER PAST MEDICAL/SURGICAL HISTORY:
- S/p Bilateral Total Knee Replacements
- S/p Right Thumb surgery
- S/p Appendectomy
- Left Cataract
Social History:
Lives alone in [**Location (un) 3493**], several adult children who live nearby.
Per family, she is still extremely active and independent in
all ADLs. She continues to drive and works part time in her
son's restaurant. Never smoked, rare ETOH.
Family History:
NC
Physical Exam:
Admission Exam
Vitals: T 96 HR 102 BP 85/54 RR 16 O2 96% on vent
GENERAL: Sedated, intubated
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: Supple, JVP flat.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachy, Irregularly irregular rhythm, normal S1, S2. IV/VI
systolic murmur, loudest at RUS border, radiating to carotids.
No S3 or S4.
LUNGS: Intubated, bibasilar crackles, no wheezes/rhonchi.
ABDOMEN: Soft, ND. No HSM. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Pertinent Results:
CBC:
[**2119-8-21**] 10:05PM WBC-15.6* RBC-5.28 HGB-15.9 HCT-49.3* MCV-93
MCH-30.1 MCHC-32.2 RDW-14.8
[**2119-8-21**] 10:05PM NEUTS-79.1* LYMPHS-17.7* MONOS-2.2 EOS-0.2
BASOS-0.9
[**2119-8-21**] 10:05PM PLT COUNT-328
BMP:
[**2119-8-21**] 10:05PM GLUCOSE-287* UREA N-28* CREAT-1.5* SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-20* ANION GAP-19
[**2119-8-23**] 02:24PM BLOOD Glucose-143* UreaN-61* Creat-4.2* Na-134
K-5.8* Cl-103 HCO3-15* AnGap-22*
LFTs:
[**2119-8-21**] 10:05PM ALT(SGPT)-14 AST(SGOT)-26 CK(CPK)-103 ALK
PHOS-90 TOT BILI-0.9
Cardiac Enzymes:
[**2119-8-21**] 10:05PM CK-MB-8
[**2119-8-21**] 10:05PM cTropnT-0.08*
[**2119-8-23**] 04:06AM BLOOD CK-MB-14* MB Indx-5.3
ABG:
[**2119-8-21**] 10:50PM TYPE-ART O2-100 PO2-93 PCO2-50* PH-7.21*
TOTAL CO2-21 BASE XS--8 AADO2-575 REQ O2-94 -ASSIST/CON
INTUBATED-INTUBATED COMMENTS-GREEN TOP
[**2119-8-23**] 07:25PM BLOOD Type-ART pO2-64* pCO2-29* pH-7.30*
calTCO2-15* Base XS--10
UA:
[**2119-8-22**] 10:57AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2119-8-22**] 10:57AM URINE RBC->182* WBC-90* Bacteri-MOD Yeast-MANY
Epi-0
[**2119-8-22**] 10:57AM URINE CastHy-19*
Microbiology:
[**2119-8-22**] 10:52 am BLOOD CULTURE Source: Line-aline.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2119-8-23**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2119-8-23**] 2:45PM.
Imaging:
CXR [**2119-8-21**]: New left internal jugular line terminates in the
proximal
SVC. Endotracheal tube has been retracted, and now terminates 3
cm above the carina. Nasogastric tube has also been retracted,
with side port just beyond the gastroesophageal junction, and
tip in the stomach. There is no
pneumothorax. Severe cardiomegaly and/or pericardial effusion is
unchanged, vascular congestion and moderated pulmonary edema are
worse.
CXR [**2119-8-23**]:
1. Progressive asymmetric focal opacification in the right lower
lobe raises concern for infection.
2. Endotracheal tube 1.8 cm above the carina.
[**2119-8-21**] TTE: The left atrium is elongated. The estimated right
atrial pressure is 5-10 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional wall motion is normal. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size is normal. with mild global free wall hypokinesis. The
ascending aorta is mildly dilated. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
partial posterior mitral leaflet flail. Moderate to severe (3+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade. Echocardiographic signs of
tamponade may be absent in the presence of elevated right sided
pressures.
[**2119-8-23**] TTE: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global left ventricular
hypokinesis. Severe aortic stenosis. Moderate, eccentric mitral
regurgitation. Small posterior pericardial effusion. Compared
with the prior study (images reviewed) of [**2119-8-22**], aortic valve
gradient is lower. The severity of mitral regurgitation is
reduced, although image quality is technically limited. The
heart rate is slower. The severity of tricuspid regurgitation is
reduced. The estimated pulmonary artery pressures are lower.
[**2119-8-22**] Cardiac Catheterization:
Patient was brought to the cath lab on ventilator and
inotropic support. Vascular access was secured through the right
femoral
artery and vein. Selective coronary angiography was performed
using 4 Fr
JL 4 and JR 4 diagnostic catheters. A 5 Fr Pigtail catheter on a
straight 0.035 wire was used to cross the aortic valve.
Hemodynamic
parameters were measured and an Amplatz 260 cm Extra stiff wire
with
floppy 7 cm tip shaped like a pigtail to avoid injuring the
ventricle
was delivered to the left ventricle through the pigtail
catheter. The
pigtail was withdrawn. A temporary pacing catheter was advanced
in
to the RV apex and tested for capture. Then a Tyshak 20 mm x 6
cm
valvuloplasty balloon was railed in over the amplatz wire and
situated
across the aortic valve. The balloon was rapidly inflated and
deflated 2
times for valvuloplasty while patient was underwent rapid RV
pacing with
drop in SBP<60-70 mm Hg. FOllowing valvuloplasty right heart
catheterization was performed using a Swan-Ganz catheter which
was
left in place and covered with sterile sheath. The arterial
puncture
site was closed with an 8Fr Angioseal device. Of note, in she
was
electrically cardioverted after loading with amiodarone IV.
FINAL DIAGNOSIS:
1. Non-obstructive CAD
2. Severe aortic stenosis status post palliative balloon aortic
valvuloplasty
3. Severe acute MR due to a flail posterior leaflet.
Brief Hospital Course:
Primary Reason for Hospitalization:
88yoF with h/o severe AS, afib on coumadin, HTN, HLD who is
transferred from [**Hospital6 33**] for acute pulmonary edema
and hypotension requiring intubation and pressors.
Brief Hospital Course:
On admission pt required levophedrine and phenylephrine pressors
to maintain blood pressure with MAP > 60. On HD#2 TTE showed
severe mitral regurgitation with flail valve, and severe aortic
stenosis. She was cardioverted and started on amiodarone drip,
and reverted to sinus rhythm. She had an aortic balloon
valvuloplasty in hopes of improving flow through the stenotic
valve. Unfortunately her blood pressure continued to decrease
and she developed renal failure and anuria. She also developed
fever with leukocytosis (WBC 21), and CXR showed e/o RLL
pneumonia. She was started on vanc/cefepime for broad coverage.
Swann-Ganz catheter showed cardiac output of 3.1L/min and
cardiac index of 1.9. On [**2119-8-23**] renal service was consulted
and a trial of CVVH was started in hopes of correcting her
electrolyte abnormalities. Unfortunately her blood pressure
continued to decrease to 70s/40s despite pressors. A family
meeting was held, and the family decided to change goals of care
to comfort measures only. CVVH and pressors were stopped. At
00:45 on [**2119-8-24**] she passed away with family at bedside. Family
declined autopsy. Primary care physician and attending
notified.
Medications on Admission:
Medications - Prescription
DILTIAZEM HCL [CARTIA XT] - (Prescribed by Other Provider) -
240
mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth
.
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a
day
NIACIN - (Prescribed by Other Provider) - 500 mg Capsule,
Extended Release - 1 Capsule(s) by mouth once a day
Discharge Disposition:
Expired
Discharge Diagnosis:
Mitral valve regurgitation
Aortic valve stenosis
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"427.1",
"401.9",
"396.8",
"427.31",
"V66.7",
"272.4",
"276.4",
"288.60",
"414.01",
"486",
"785.51",
"788.5",
"424.1",
"780.60",
"584.9",
"V49.86",
"428.1",
"V43.65",
"424.0",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"96.71",
"38.95",
"38.97",
"35.96",
"38.91",
"37.23",
"99.62",
"99.69"
] |
icd9pcs
|
[
[
[]
]
] |
11093, 11102
|
9248, 10448
|
235, 354
|
11194, 11205
|
3647, 4203
|
11257, 11264
|
2930, 2934
|
11123, 11173
|
10474, 11070
|
8836, 8992
|
11229, 11234
|
2949, 3628
|
2238, 2649
|
4978, 8819
|
4220, 4934
|
176, 197
|
382, 2140
|
2162, 2218
|
2665, 2914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,138
| 199,775
|
53477
|
Discharge summary
|
report
|
Admission Date: [**2145-2-17**] Discharge Date: [**2145-2-27**]
Date of Birth: [**2082-8-18**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
male with increasing chest pain over the past six months
which occurs with any activity like shoveling snow, walking
to the mailbox etcetera. Not after meals. Not at rest.
The pain is associated with indigestion and shortness of
breath. The pain is relieved by rest and Mylanta.
REVIEW OF SYSTEMS: On review of systems, the patient denies
hypertension, diabetes, cerebrovascular accident, transient
ischemic attack, pulmonary disease, constitutional symptoms,
claudication, gastrointestinal bleed, and bleeding disorders.
PAST MEDICAL HISTORY:
1. Non-Hodgkin lymphoma.
2. Right hernia repair.
3. Appendectomy.
4. Tonsillectomy.
MEDICATIONS ON ADMISSION: (Home medications on admission
included)
1. Propanolol 20 mg p.o. twice per day.
2. Protonix 40 mg p.o. once per day.
3. Benefiber one teaspoon p.o. once per day.
ALLERGIES: ASPIRIN (which causes hives).
SOCIAL HISTORY: No tobacco. No alcohol. The patient is
married and lives with his wife.
PHYSICAL EXAMINATION ON PRESENTATION: On general physical
examination the patient was a healthy-appearing male. Alert
and oriented times three. He moved all extremities. He
followed commands. Head, eyes, ears, nose, and throat
examination revealed pupils were equal, round, and reactive
to light. Extraocular movements were intact. Sclerae were
anicteric. Mucous membranes were moist. The oropharynx was
without erythema or exudate. The neck was supple. No
jugular venous distention. No lymphadenopathy. No bruits.
The lungs were clear to auscultation bilaterally.
Cardiovascular examination revealed a regular rate and
rhythm. No murmurs, rubs, or gallops. The abdomen was
soft, nontender, and nondistended. Normal active bowel
sounds. No hepatosplenomegaly. A well-healed scar in the
right lower quadrant. Extremities were warm and well
perfused. No clubbing, cyanosis, or edema. Pulses were 2+
in bilateral carotids, femoral, radial, and dorsalis pedis
arteries.
HOSPITAL COURSE: The patient was admitted on [**2145-2-17**]
and initially cared for by the medical team.
On [**2145-2-19**], the patient was taken to the operating room
where a coronary artery bypass graft and aortic valve
replacement with a 23-mm CarboMedics mechanical valve was
performed. The patient tolerated the procedure quite well.
He initially had chest tubes and pacing wires in place. He
required a drip of Neo-Synephrine briefly.
The patient did well in the Intensive Care Unit and was
transferred on postoperative day one to the regular
cardiothoracic surgical floor. His chest tube and pacing
wires were removed at the appropriate times. He was advanced
on a regular diet, which he tolerated well.
On postoperative day two, the patient experienced an episode
of rapid atrial fibrillation which improved with intravenous
Lopressor. He was started on amiodarone as prophylaxis. He
was also started on heparin and Coumadin loading for
prophylaxis due to his mechanical valve.
Over the next several days, the patient did very well. He
was seen by Physical Therapy. His strength came back
quickly. He continued to have periodic episodes of atrial
fibrillation; as a general rule, rate controlled and usually
spontaneously breaking.
Also over the course of the next several days, the patient's
INR level was monitored; such that his Coumadin became
therapeutic. The patient briefly received Flagyl for empiric
Clostridium difficile treatment; although, the Clostridium
difficile test was negative, and the Flagyl was stopped.
CONDITION AT DISCHARGE: On [**2145-2-27**], and the patient
was in good condition. His INR peaked at 2.5 yesterday, and
his heparin was stopped.
DISCHARGE DISPOSITION: He was to be discharged today (on
[**2145-2-27**]).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 838**] in
one to two weeks.
2. The patient was also to follow up with Cardiology in two
to three weeks.
3. The patient was to follow up with Dr. [**Known firstname **] [**Last Name (NamePattern1) 70**] in
six weeks.
4. Dr. [**Last Name (STitle) 838**] has agreed to monitor the patient's INR for
continued Coumadin dosing.
5. The patient was to observe a heart-healthy diet.
6. The patient should take showers rather than bathes.
7. The patient was to avoid strenuous activity.
MEDICATIONS ON DISCHARGE:
1. Coumadin 5 mg p.o. once per day.
2. Protonix 40 mg p.o. once per day.
3. Amiodarone 200 mg p.o. twice per day.
4. Lopressor 50 mg p.o. twice per day.
5. Dilaudid 2 mg to 8 mg p.o. q.4-6h. as needed.
6. Lasix 20 mg p.o. twice per day (times seven days).
7. Potassium chloride 20 mEq p.o. twice per day (times seven
days).
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1332**]
MEDQUIST36
D: [**2145-2-27**] 10:13
T: [**2145-2-27**] 10:33
JOB#: [**Job Number 109952**]
|
[
"V70.7",
"V10.79",
"427.31",
"427.89",
"414.01",
"424.1",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"36.12",
"36.15",
"88.53",
"35.21",
"88.72",
"39.61",
"39.63"
] |
icd9pcs
|
[
[
[]
]
] |
3872, 3925
|
4573, 5198
|
856, 1066
|
2166, 3710
|
3958, 4547
|
3725, 3848
|
493, 718
|
160, 472
|
740, 829
|
1083, 2147
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,528
| 139,494
|
48957
|
Discharge summary
|
report
|
Admission Date: [**2145-1-22**] Discharge Date: [**2145-1-28**]
Date of Birth: [**2079-8-23**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Cortisporin / Bactrim / Levofloxacin /
Sertraline / Ceftriaxone / Adhesive Tape / Keflex / Bee Sting
Kit / Sarna
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
R Leg Pain
Major Surgical or Invasive Procedure:
arterial cannulization
History of Present Illness:
PCP: [**Name10 (NameIs) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]- confirmed with patient, last saw
PCP in [**2144-12-18**].
.
Admission Date/Time: [**2145-1-23**] 1:00 am
65 yo female with history of COPD, morbid obesity, DM h/o DVT/PE
on coumadin with INR = 1.8 who presents with RLE pain and SOB x
1 day and cough x 3/4 weeks. She first develop URI sx 4 weeks
ago which manifested itself as sore throat. She then developed a
dry cough. No f/c. A LE US was a limited study but it was
negative for DVT. She then reported SOB and a CXR and ECG. [**9-26**]
pain in the back of calf x 5 days which is worsened when
transfering from her wheelchair to the BR. + SOB with exertion
and coughing but no SOB at rest.
A limited CXR demonstrated a LL infiltrate. She was tachpneic in
low 20s and she was 88% on RA. She received levoquin and
azithromycin. She says that she has an [**Month/Year (2) **] to levofloxacin
which resulted in emesis. She received percocet for her chronic
back pain which resulted in pruritis for which she received
benadryl. her HR increases to 170 when she stands up. Her HR
improved to 130 with IVF. She also received zofran 4 mg IV xT.
In ER: (Triage Vitals: ) 10 97.5 98 137/72 24 96%
VS on 98.1, 134, 129/74, 27, 95% on 2L NC.
Given a total of 3100 cc NS in the ED. UOP = 380 cc.
.
ROS:
-Constitutional: []WNL []Weight loss [+]Fatigue/Malaise [-]Fever
[-]Chills/Rigors []Nightweats [-]Anorexia
-Eyes: [X]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: []WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain [+]Sore throat
-Cardiac: []WNL [+]Chest pain with coughing []Palpitations []LE
edema []Orthopnea/PND [+]DOE
-Respiratory: []WNL [-]SOB [-]Pleuritic pain []Hemoptysis
[+]Cough- non productive
-Gastrointestinal: []WNL [+]Nausea & Vomiting post percocet and
levaqun bu tow resolved [-]Abdominal pain []Abdominal Swelling
[]Diarrhea [+]Constipation- last BM yesterday [-]Hematemesis
[]Hematochezia []Melena
-Heme/Lymph: [X]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: [X]WNL []Incontinence/Retention []Dysuria []Hematuria
[]Discharge []Menorrhagia
-Skin: [X]WNL [][**Month/Year (2) **] []Pruritus
-Endocrine: [X]WNL []Change in skin/hair []Loss of energy
[]Heat/Cold intolerance
-Musculoskeletal: []WNL []Myalgias [+]RLE Arthralgias []Back
pain
-Neurological: [ ]WNL []Numbness of extremities []Weakness of
extremities []Parasthesias [-]Dizziness/Lightheaded [-]Vertigo
[]Confusion [-]Headache
-Psychiatric: [-]WNL []Depression []Suicidal Ideation
-[**Month/Year (2) 9039**]/Immunological: [X] WNL []Seasonal Allergies
All other ROS negative
Past Medical History:
1. Morbid obesity making her wheelchair bound
2. Chronic pain [**1-19**] osteoarthritis of bilateral knees and
shoulders
3. PE for which she is anticoagulated
4. Type 2 diabetes
- previously on insulin, currently diet controlled, but per pt
on regular diet when admitted to hospital
5. Obstructive sleep apnea - on BiPAP, 4L O2 at night
6. Hyperlipidemia
7. Hypothyroidism
8. Hypertension
9. Recurrent UTIs
- followed by ID and urogynecology, has estrogen ring/pessary in
place. Urinary pathogens have included pseudomonas, Klebsiella,
Proteus, and E. coli (which has been highly resistant in the
past).
10. h/o panniculitis
- Previous episode [**7-22**] with infected hematoma and complications
resulting in ICU stay afterwards.
11. Anxiety
12. h/o Anemia
- hemolytic anemia after Keflex
13. COPD
14. Gout - managed with daily allopurinol
15. Atrial fibrillation- followed by Dr. [**Last Name (STitle) 73**]
Social History:
Home: single, lives at home on disability; perform her ADLs,
goes shopping, and gets around in her wheelchair. Has a weekly
housemaker who helps w/ laundry/shopping/cleaning.
PCA comes 2x week and gives her sponge baths.
Occupation: on disability; previously employed as an
administrative assistant at School of Nursing at
[**Hospital3 1196**]
EtOH: Rare
Drugs: Denies
Tobacco: quit smoking > 40 years ago
Family History:
Father - deceased - MI in his 40s, died in his 60s.
Mother - deceased at age 65 - diabetes mellitus, leukemia
Physical Exam:
VS: T = 98.1 P = 98 BP 88/56 -> 98/55 RR = 24 O2Sat = 95% 2L
GENERAL: Obese female sitting up in bed
Nourishment: OK
Grooming: well groomed
Mentation: alert, speaking in full sentences
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Lungs CTA bilaterally without R/R/W but poor exam
due to body habitus
Cardiovascular: RRR, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
Enlarged pannus with erythematous [**Hospital3 **]
Genitourinary:defferred
Skin: rashes as stated above
Extremities: 2+ edema b/l, 2+ DP pulses b/l, R leg with
increased erythema, and warmth compared with right.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or
inguinal lymphadenopathy 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.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric: somewhat limited but with occasional appropriate
brightening.
Pertinent Results:
[**2145-1-22**] 09:45PM WBC-8.6 RBC-3.75* HGB-12.5 HCT-39.7 MCV-106*
MCH-33.2* MCHC-31.4 RDW-14.7
[**2145-1-22**] 09:45PM NEUTS-69.7 LYMPHS-20.8 MONOS-5.5 EOS-3.5
BASOS-0.5
[**2145-1-22**] 09:45PM PLT COUNT-271
[**2145-1-22**] 06:28PM PT-19.4* PTT-28.6 INR(PT)-1.8*
Admission LE US:
[**Last Name (un) **] DVT
CXR [**2145-1-23**]:
FINDINGS: There are low lung volumes, which accentuate
cardiomegaly.
Cardiomediastinal silhouette is otherwise unremarkable.
Pulmonary vascularity is normal. Lungs are clear, without
consolidation, pleural effusion or pneumothorax. Degenerative
changes involving the left shoulder is noted.
IMPRESSION: No acute cardiopulmonary abnormality.
Admission ECG;
ST at 116 bpm without acute changes.
Subsequent ECGs: atrial fibrillation
CT [**2145-1-24**]
IMPRESSION:
1. No acute intrathoracic process. Small bibasilar opacities,
left greater
than right, likely atelectasis.
2. Coronary and valvular calcifications.
3. Stable pulmonary nodules measuring less than 4 mm.
4. Unchanged pulmonary arterial enlargement may reflect
underlying pulmonary hypertension.
ECHO [**2145-1-26**]
The left atrium is mildly dilated. Premature contrast is not
seen in the left heart after intravenous injection of saline
(suboptimal views). There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size is normal. The aortic valve leaflets are mildly
thickened (?#). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Suboptimal technical quality. Mild symmetric left
ventricular hypertrophy with preserved globabl systolic
function. No definite evidence for intracardiac shunt
identified. Trace aortic regurgitation.
Discharge labs:
[**2145-1-28**] 03:34AM BLOOD WBC-12.2* RBC-3.15* Hgb-10.9* Hct-32.9*
MCV-104* MCH-34.7* MCHC-33.3 RDW-14.2 Plt Ct-283
[**2145-1-28**] 03:34AM BLOOD PT-36.1* PTT-58.7* INR(PT)-3.7*
[**2145-1-28**] 03:34AM BLOOD Glucose-154* UreaN-23* Creat-1.1 Na-142
K-4.2 Cl-96 HCO3-34* AnGap-16
[**2145-1-28**] 03:34AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.1
[**2145-1-27**] 03:00PM BLOOD Type-ART O2 Flow-4 pO2-83* pCO2-53*
pH-7.41 calTCO2-35* Base XS-6 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2145-1-22**] 06:28PM BLOOD proBNP-685*
[**2145-1-25**] 09:05AM BLOOD CK-MB-5 cTropnT-0.01 proBNP-5977*
[**2145-1-25**] 08:23PM BLOOD CK-MB-4 cTropnT-0.02*
[**2145-1-26**] 05:04AM BLOOD CK-MB-4 cTropnT-0.02*
Brief Hospital Course:
The patient is a 65 year old female with MMP including morbid
obesity, hypothyroidism, DM, pulmonary embolism on
anticoagulation who presents with RLE pain and shortness of
breath. Her intial shorntess of breath was likely multifactorial
in etiology: COPD, reactive airway disease, bronchitis, CHF,
OSA, obesity, hypoventilation syndrome and possible PNA. She had
RLE edema but US was negative for DVT and CTA was negative for
PE. She completed a course of treatment for CAP with 5 days of
azithro. She was transferred to the MICU for hypercarbic
respiratory failure. At this time, she was noted to have an
elevated BNP. She was also in atrial fibrillation with
ventricular rates to the 140s. She improved over several days
with a combination of BIPAP, rate control and diuresis.
For her [**Female First Name (un) **] of the pannus, she was continue nystatin powder.
Her statin was continued for her hyperlipidemia, her synthroid
was continued for her hypothyroidism. She was treated with her
home dose of cymbalta and prn ativan for her depression and
anxiety. Her diabetes was managed with NPH and sliding scale.
Her allopurinol was continued for her gout. Her coumadin was
continued and then held for several days for supratherapeutic
INR. Continued morphine SR for pain. Did not require percocet.
prn for DJD/chronic back pain. For GERD, continued PPI. Macrobid
for recurrent UTI was stopped. Ursodiol was stopped.
PENDING ISSUES/FOLLOW-UP:
1. DIURESIS: still actively diuresing with furosemide 80mg
daily. Monitor lytes and creatinine and weights. Will need dose
adjusted when at dry weight. Diuresed 11L during ICU stay.
Replete lytes.
2. COUMADIN: Anticoagulated for history of PEs. Coumadin now
being held for supratherapeutic INR. Will need to restart.
3. RESPIRATORY STATUS / OSA: She requires BIPAP at night. If she
takes the mask off she will drop her sats.
4. BICARB: Our hypothesis is that her goal bicarb should be
28-36 (compensation for chronic CO2 retention.
Her code status was full.
Medications on Admission:
--------------- --------------- --------------- ---------------
Active Medication list as of [**2145-1-22**]:
Medications - Prescription
ALBUTEROL SULFATE - (Dose adjustment - no new Rx; medication
reconciliation) - 2.5 mg/0.5 mL Solution for Nebulization - 1
solution via nebulizer every 4-6 hours as needed
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2 puffs(s) by mouth every four (4) to six (6) hours as needed
for cough/wheezing
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 [**12-19**] po Tablet(s) by
mouth qd (30mg)
DULOXETINE [CYMBALTA] - 20 mg Capsule, Delayed Release(E.C.) - 2
Capsule(s) by mouth every morning
EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1:1,000) Pen Injector -
use in case of severe reaction and call 911 (use only once)
EXTRA LARGE ADULT DIAPERS - - AS DIRECTED. TWICE A DAY AND AS
NEEDED. DX:URINARY INCONTINENCE
FESOTERODINE [TOVIAZ] - 8 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - 500 mcg-50 mcg/Dose Disk with Device - twice a day
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth prn le edema
HOSPITAL BED MATTRESS - - use as directed daily Diagnosis:
327.2 Sleep apnea 493.9 Asthma 278.01
morbid obesity
INHALATIONAL SPACING DEVICE [AEROCHAMBER WITH FLOWSIGNAL] -
Inhaler - as directed with inhalers twice a day
LEVOTHYROXINE - 125 mcg Tablet - 1 (One) Tablet(s) by mouth once
a day
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - 1 Tablet(s) by mouth twice
a day
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth in the morning
and 2 tablets in the evening.- is currently taking but will hold
given CKD.
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth twice
a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
MORPHINE - 30 mg Tablet Sustained Release - 1 Tablet Sustained
Release(s) by mouth twice a day
NITROFURANTOIN MACROCRYSTAL - 100 mg Capsule - 1 Capsule(s) by
mouth twice a day
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**12-19**] Tablet(s) by
mouth every four (4) hours max 8 tabs per day
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth twice a day
RANITIDINE HCL - 300 mg Capsule - 1 Capsule(s) by mouth at
bedtime
SOLIFENACIN [VESICARE] - 10 mg Tablet - 2 Tablet(s) by mouth at
bedtime
TRAZODONE - 100 mg Tablet - 1 to 3 Tablet(s) by mouth at bedtime
as needed for insomnia
URSODIOL [[**Last Name (un) 390**] 250] - 250 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
WARFARIN - 5 mg Tablet - 1-T Q T/Thurs/Sat
WARFARIN - 2.5 mg Tablet - -- Tablet(s) by mouth once a day Take
as directed by [**Hospital 197**] Clinic [**Telephone/Fax (1) 10844**].
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet
- [**12-19**] Tablet(s) by mouth every six (6) hours as needed
ASCORBIC ACID [VITAMIN C] - 1,000 mg Tablet - 1 Tablet(s) by
mouth twice a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - USE
THREE TIMES PER DAY TO TEST BLOOD SUGARS. DX CODE 250.0
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (OTC; ) -
Dosage uncertain
CYANOCOBALAMIN [VITAMIN B-12] - (OTC; ) - Dosage uncertain
DIPHENHYDRAMINE HCL [BENADRYL] - (OTC; medication
reconciliation) - 25 mg Capsule - 1 Capsule(s) by mouth once a
day
FERROUS SULFATE - (OTC; Dose adjustment - no new Rx; per pt,
medication reconciliation) - 325 mg (65 mg) Tablet - take one
tablet by mouth once a day
LORATADINE - 10 mg Tablet - take one Tablet(s) by mouth once a
day
MAGNESIUM OXIDE - 400 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC;
medication reconciliation) - Tablet - 1 Tablet(s) by mouth
once a day
Caclcium
Iron
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
13. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for dry skin, itch.
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath.
16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. Zofran 4 mg Tablet Sig: 1-2 Tablets PO three times a day as
needed for nausea.
19. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for anxiety.
20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
21. Insulin Aspart 100 unit/mL Solution Sig: sliding scale
Subcutaneous QACHS: Sliding Scale
101-150 mg/dL: 2 Units; 151-200 mg/dL 4 Units; 201-250 mg/dL 6
Units; 251-300 8 Units; 301-350 10 Units; 351-400 12 Units
.
22. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Five
(5) units Subcutaneous twice a day.
23. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
HOLD UNTIL INR < 3.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: congestive heart failure with preserved systolic
function, obstructive sleep apnea, obesity, atrial fibrillation
Secondary: diabetes mellitus, history of pulmonary emboli, gout,
hypertension, hypothyroidism
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted to the hospital with difficulty breathing. You
had an abnormal heart rate that likely led to fluid building up
in your lungs. We used a medicine to make you urinate and your
breathing improved. You urinated more than 10 liters. We also
increased your metoprolol which helped your heart rate from
going too fast.
Medication changes:
Increase metoprolol to 50 mg three times daily
Increase furosemide to 80 mg daily
Stop ursodiol
Stop percocet (you havent needed it here)
Stop macrobid
You will need to restart your coumadin
Followup Instructions:
Provider: [**Name10 (NameIs) **] NURSE Phone:[**Telephone/Fax (1) 9316**] Date/Time:[**2145-2-2**]
7:55
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2145-2-5**] 8:20
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 9141**] Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2145-2-12**]
9:20
|
[
"274.9",
"V12.51",
"428.0",
"338.29",
"244.9",
"V46.3",
"V58.61",
"721.90",
"278.01",
"272.4",
"466.0",
"327.23",
"300.4",
"V58.67",
"428.33",
"250.40",
"729.39",
"715.91",
"403.90",
"585.3",
"715.96",
"276.2",
"427.31",
"493.20",
"278.8",
"530.81",
"584.9",
"518.81",
"112.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17010, 17081
|
8820, 10832
|
400, 425
|
17343, 17343
|
5940, 8074
|
18117, 18572
|
4504, 4615
|
14731, 16987
|
17102, 17322
|
10858, 14708
|
17515, 17880
|
8091, 8797
|
5625, 5921
|
4630, 5529
|
17900, 18094
|
350, 362
|
453, 3130
|
17357, 17491
|
3152, 4063
|
4079, 4488
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,519
| 189,828
|
43107+58586
|
Discharge summary
|
report+addendum
|
Admission Date: [**2188-6-15**] Discharge Date: [**2188-8-1**]
Date of Birth: [**2127-3-20**] Sex: F
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old
female with a history of diabetic type 1, hypertension,
hyperlipidemia, status post renal transplant in [**2185**] with a
negative Persantine MIBI in [**2188-1-19**] presenting with ten
hours of chest pain. The patient had positive cardiac
enzymes with a troponin of 7.8, non ST elevation myocardial
infarction, catheterized on [**2188-6-15**] showed severe left main
disease 70 to 80%, right coronary artery disease 99% and left
circumflex diffuse disease and diffuse mid disease in left
anterior descending coronary artery.
PAST MEDICAL HISTORY: As above. Type 1 diabetes mellitus,
end stage renal disease status post living related donor
transplant in [**2186-2-19**], hypertension, left pontine
cerebrovascular accident in [**2184**], hyperlipidemia,
gastroesophageal reflux disease, palpitations and septicemia.
ALLERGIES: Codeine and tetracycline and intravenous
contrast.
MEDICATIONS:
1. Lopressor 25 b.i.d.
2. Lipitor 10 q day.
3. Lisinopril 2.5 q day.
4. _____________two b.i.d.
5. CellCept [**Pager number **] b.i.d.
6. Prilosec 20 q day.
7. Bactrim swish and swallow.
8. Lantus.
9. Aspirin 325 mg q.d.
10. Ambien 10 q.h.s.
HOSPITAL COURSE: The patient underwent a coronary artery
bypass graft times three, left internal mammary coronary
artery to the left anterior descending coronary artery,
saphenous vein graft to posterior descending coronary artery
and saphenous vein graft to obtuse marginal and she tolerated
the procedure well. She was reintubated on [**2188-6-20**] for
respiratory distress. Echocardiogram showed hypokinesis at
the apex right ventricle. The patient was recatheterized and
showed saphenous vein graft down times two and the stents
were placed in the LM and RCA. The patient suffered acute
renal failure on [**6-21**] secondary to hemodynamic instability and
dye load from the catheterization. Creatinine bumped to 3.7.
The patient was started on CVVH per the renal teams request.
The patient was bradycardic and developed some polymorphic
ventricular tachycardia. Electrophysiology and Department of
Cardiology was consulted and recommended starting Lidocaine.
The patient had numerous episodes of CVA clotting off and
being restarted. The patient continued to have episodes of
ventricular tachycardia being bolused with Lidocaine. On
[**2188-6-25**] the patient was taken for a relook catheterization.
LMCA stent was patent. Circumflex left anterior descending
coronary artery showed no changes. Left anterior descending
coronary artery had okay flow. Left circumflex showed stent
to be patent and right coronary artery stent was patent.
[**2188-6-26**] the patient had another episode of ventricular
tachycardia, but spontaneously converted and the patient had
polymorphic ventricular tachycardia, ventricular fibrillation
and was shocked and restarted on Lidocaine and Mexiletine.
The patient continued to have episodes of ventricular
tachycardia and the patient had a continued white count with
an infectious disease consult following. The patient was on
broad antibiotic coverage with no noted source. The patient
had failed extubation on [**2188-7-7**] and was percutaneously
trached on [**2188-7-11**]. The patient had cardiac echocardiogram
on [**7-17**], which was normal. The patient underwent an ablation
on [**7-18**] and AICD placement on [**2188-7-24**]. The patient had
another episode of ventricular tachycardia after the AICD
placement, which had converted spontaneously without the AICD
needing to fire. The patient then underwent a bedside PEG
placement on [**2188-7-30**] and was at goal tube feeds on [**2188-8-1**]
with mostly physical therapy issues as far as deconditioning.
The patient was continued to be afebrile with vital signs
stable, sating at 99% on trach at FI02 of 35%. White blood
cell count was within normal limits and hematocrit was
relatively stable in the low 30 range. The patient was being
rehab screened for placement in the near future.
This is the first portion of a discharge dictation. Addendum
to be completed at the time of discharge.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (STitle) 92944**]
MEDQUIST36
D: [**2188-8-1**] 09:06
T: [**2188-8-1**] 09:21
JOB#: [**Job Number 92945**]
Name: [**Known lastname 14630**], [**Known firstname 14631**] Unit No: [**Numeric Identifier 14632**]
Admission Date: [**2188-6-15**] Discharge Date: [**2188-8-5**]
Date of Birth: [**2127-3-20**] Sex: F
Service:
ADDENDUM TO DISCHARGE SUMMARY: On postoperative day 44 the
patient was started on tube feeds and advanced. She was
continued on Kefzol prophylaxis. The patient's AICD was
interrogated on [**2188-8-1**]. The patient was deemed okay for
hospital discharge for the Electrophysiology Department of
Cardiology. From their standpoint the patient would have a
follow up evaluation in one month and test in two months.
The patient continues to improve from the renal standpoint
and creatinine got better and urine output moved slowly. The
patient was felt ready for discharge on postoperative day
number 48. No events. Vital signs stable. The patient is
to be discharged to a rehabilitation facility.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To a rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft times three with
left internal mammary coronary artery to left anterior
descending coronary artery, saphenous vein graft to posterior
descending coronary artery, saphenous vein graft to the
obtuse marginal.
2. Diabetes type 1.
3. Hypertension.
4. Hyperlipidemia.
5. End stage renal disease.
6. Gastroesophageal reflux disease.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg po q day.
2. Mycophenolate mofetil 500 mg po b.i.d.
3. Albuterol four puffs q 6 hours.
4. Ipratropium bromide MDI two puffs q 6 hours.
5. Colace 100 mg po b.i.d.
6. Aspirin 325 mg po q day.
7. Dilaudid .5 mg q 6 subq prn.
8. Synthroid 50 micrograms q day.
9. Amiodarone 400 mg po q day.
10. Tylenol 650 mg po q 4 hours prn.
11. Percocet elixir 5 to 10 ml po q 4 to 6 hours prn.
12. Epogen 6000 units subq twice a week on Monday and
Thursday.
13. Miconazole powder 2% topical prn.
14. Ativan .5 mg intravenous q 8 hours prn.
15. Tacrolimus 1.5 mg po b.i.d.
16. Ambien 5 mg po q.h.s.
17. Lopressor 12.5 mg po b.i.d.
18. Regular insulin sliding scale plus 24 units of Glargine
at bedtime.
FOLLOW UP: The patient is scheduled for follow up with Dr.
[**Last Name (STitle) **] and follow up with his primary care physician in one to
two weeks, his cardiologist in two to three weeks and Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one month after discharge or upon discharge
from rehabilitation facility.
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Name8 (MD) 2182**]
MEDQUIST36
D: [**2188-8-4**] 01:25
T: [**2188-8-4**] 13:43
JOB#: [**Job Number 14633**]
cc:[**Last Name (NamePattern1) 14634**]
|
[
"414.02",
"414.01",
"996.81",
"427.1",
"518.5",
"250.61",
"486",
"293.0",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"36.07",
"36.12",
"31.1",
"54.98",
"37.94",
"36.05",
"36.15",
"39.61",
"43.11",
"37.22",
"88.72",
"37.61",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
5601, 5979
|
6002, 6723
|
1373, 5496
|
6735, 7373
|
174, 731
|
754, 1355
|
5521, 5580
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,866
| 178,651
|
47494
|
Discharge summary
|
report
|
Admission Date: [**2138-9-8**] Discharge Date: [**2138-9-26**]
Date of Birth: [**2057-5-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Codeine / Darvocet-N
100 / Vancomycin / Lactose / Ciprofloxacin / Sulfa (Sulfonamide
Antibiotics) / Levofloxacin / Prilosec
Attending:[**First Name3 (LF) 14689**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Left hip total arthroplasty [**2138-9-18**]
History of Present Illness:
81-year-old woman with history of colon cancer and CML presents
with worsening abdominal pain for the past several weeks.
Patient complains of epigastric and RLQ abdominal pain that had
been intermittent, usually exacerbated after eating, until the
day prior to admission when the pain became almost constant. The
pain is sharp, not associated with nausea, vomiting, or changes
in bowel habits. Denies fevers or chills. She has experienced
poor appetite and reports losing 5 lbs in the past few months.
.
In the ED, T 98.2, HR 93, BP 138/73, RR 16, 100%RA. Her exam
reportedly revealed mild tenderness at RUQ and RLQ without any
rebound tenderness. She underwent an abdominal/pelv CT, with PO
contrast but without IV contrast due allergy, which showed
increased masses throughout her abdomen. She was administered
morphine 15 mg PO x 1 and a total of 8 mg of morphine IV for her
pain. She was then admitted to OMED for further management. On
arrival to the floor, she was pain free. Of note, Ms. [**Known lastname 100416**] was
recently admitted from [**2138-8-18**] to [**2138-8-22**] at [**Hospital1 18**] for a UTI and
pneumonia, treated with cefpodoxime adn
azithromycin, as well as worsening hip pain, treated with
increased amounts of narcotics and a plan for orthopedics
follow-up. She saw Dr. [**Last Name (STitle) **] on [**2138-8-25**], who planned to schedule
a total hip replacement as soon as possible. For her colon
cancer, she underwent right hemicolectomy with primary
reanastomosis in 09/[**2135**]. She was treated for a short time with
capecitabine, but due to side effects treatment was stopped
after after two and a half cycles. PET scan on [**2135-7-30**] showed
new FDG uptake in retroperitoneal lymph nodes in the left
abdomen area with elevated CEA concerning for progression of her
metastatic colon cancer. Was planning to follow up with Dr.
[**Last Name (STitle) **]. She saw Dr. [**Last Name (STitle) **] and NP[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
[**2138-9-4**], for her CML. Her BRC-ABL level was re-checked, and a
bone marrow biopsy was done. Dr. [**Last Name (STitle) **] plans to switch her
imatinib to dasatinib once insurance coverage for the medication
is assured.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations. Denies cough, shortness of breath, or
wheezes. Denies vomiting, diarrhea, constipation. No recent
change in bowel or bladder habits. Denies arthralgias or
myalgias. Denies rashes or skin breakdown. No numbness/tingling
in extremities. All other review of systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
# Stage III colon cancer: status post right hemicolectomy with
primary reanastomosis in 09/[**2135**]. She was treated for a short
time with capecitabine, but due to side effects treatment was
stopped after after two and a half cycles. PET scan on
[**2135-7-30**]
showed new FDG uptake in retroperitoneal lymph nodes in the left
abdomen area with elevated CEA concerning for progression of her
metastatic colon cancer. Planning to follow up with Dr.
[**Last Name (STitle) **].
# CML: on imatinib since [**3-/2131**]
# Lymphoma. (Diagnosed in early [**2098**]; in remission)
# Bladder cancer related to cyclophosphamide; s/p cystectomy and
left nephrectomy, with ileal loop reconstruction
OTHER MEDICAL HISTORY:
# Pulmonary fibrosis secondary to bleomycin
# Recurrent UTIs
# Chronic anemia
# S/p left knee replacement in [**3-23**]
# Hypothyroidism
# GERD
Social History:
Home: Married; lives with her husband in apartment in the [**Location (un) 100419**]
Occupation: previously employed as an actress, producer, and
director - primarily worked in theater but also worked in
television and film
EtOH: ~ 1 glass of wine per night
Drugs: Denies
Tobacco: ~20-30 PPY smoking history ([**1-18**] PPD x30-40 yrs); quit >
20 yrs ago
Family History:
Sister - died of lung cancer
Mother - coronary artery disease, stroke
Father - coronary artery disease, diabetes mellitus, stroke
Physical Exam:
Vitals: T 98.2, BP 142/74, HR 82, RR 19, 97%RA
Gen: elderly woman, oriented x 3, pleasant, in no acute distress
HEENT: extraocular movements intact, conjunctivae clear, sclerae
anicteric, oropharynx moist and without lesion
Neck: supple, no LAD
CV: no jugular venous distention, normal rate, regular rhythm,
normal S1/S2, no murmur
Lungs: clear to ascultation bilaterally, no crackles or wheezes
Abd: soft, nontender, nondistended, bowel sounds present, no
hepatosplenomegaly, surgical scars well-healed, urostomy bag in
place
Back: no CVA tenderness bilaterally
Ext: warm, well-perfused, no cyanosis or edema
Neuro: oriented x 3, answering all questions appropriately
Pertinent Results:
Admission Labs:
[**2138-9-8**] 04:24PM BLOOD WBC-15.9* RBC-3.29* Hgb-9.4* Hct-30.7*
MCV-93 MCH-28.5 MCHC-30.6* RDW-16.7* Plt Ct-672*
[**2138-9-8**] 04:24PM BLOOD Neuts-90.6* Lymphs-4.6* Monos-3.0 Eos-1.0
Baso-0.9
[**2138-9-8**] 09:43PM BLOOD PT-12.7 PTT-35.9* INR(PT)-1.1
[**2138-9-8**] 04:24PM BLOOD Glucose-101* UreaN-11 Creat-1.0 Na-136
K-4.0 Cl-101 HCO3-26 AnGap-13
[**2138-9-8**] 04:24PM BLOOD ALT-11 AST-21 LD(LDH)-361* AlkPhos-114*
TotBili-0.4
[**2138-9-8**] 04:24PM BLOOD Lipase-41
[**2138-9-8**] 04:24PM BLOOD Albumin-3.1* Calcium-8.5
[**2138-9-8**] 04:24PM BLOOD CEA-425*
.
WBC Trend:
[**2138-9-8**] WBC-15.9, [**2138-9-11**] WBC-12.5, [**2138-9-12**] WBC-11.3,
[**2138-9-13**] WBC-10.8
[**2138-9-13**] WBC-38.9, [**2138-9-14**] WBC-48.4, [**2138-9-15**] WBC-25.2,
[**2138-9-16**] WBC-15.5, [**2138-9-17**] WBC-11.3, [**2138-9-18**] WBC-12.5,
[**2138-9-19**] WBC-12.5, [**2138-9-20**] WBC-16.2, [**2138-9-21**] WBC-21.1,
[**2138-9-22**] WBC-24.7, [**2138-9-23**] WBC-24.1, [**2138-9-24**] WBC-27.6,
[**2138-9-25**] WBC-39.8, [**2138-9-26**] WBC-33.7
.
Discharge Labs:
[**2138-9-26**] 08:00AM BLOOD WBC-33.7* RBC-3.14* Hgb-9.2* Hct-28.8*
MCV-92 MCH-29.2 MCHC-31.9 RDW-16.7* Plt Ct-515*
[**2138-9-26**] 08:00AM BLOOD Neuts-56 Bands-6* Lymphs-3* Monos-3 Eos-1
Baso-3* Atyps-0 Metas-15* Myelos-12* Promyel-1*
[**2138-9-26**] 08:00AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Burr-OCCASIONAL Bite-1+
[**2138-9-26**] 08:00AM BLOOD Glucose-78 UreaN-18 Creat-0.8 Na-137
K-4.0 Cl-105 HCO3-24 AnGap-12
[**2138-9-26**] 08:00AM BLOOD Calcium-7.6* Phos-3.3 Mg-1.7
.
CT Abd/Pelvis [**2138-9-8**]:
1. Interval increase in size and number of intraperitoneal
metastases. New
small amount of pelvic fluid and mesenteric stranding,
suspicious for
malignant involvement. Recommend followup CT with intravenous
contrast (with premedication) or MRI to assess patency of
abdominal vasculature and better assess tumor burden.
2. Increase in paraaortic lymphadenopathy, also consistent with
disease
progression.
3. Right ileal conduit, with unchanged parastomal hernia.
4. Severe osseous degenerative changes.
.
Bone Scan [**2138-9-11**]:
1. Increased uptake in the left femoral head and acetabulum is
consistent with avascular necrosis. No definite evidence of
metastatic disease.
2. New asymmetric increased uptake in the right shoulder. Would
recommend
correlative radiographs for further evaluation.
3. Focal increased uptake in the right knee consistent with
degenerative
changes seen on prior radiograph.
.
CXR [**2138-9-13**]: In comparison with study of [**8-19**], there is
extensive patchy
opacification involving much of the left lung, consistent with
the clinical diagnosis of widespread pneumonia. The right lung
remains essentially clear.
.
Left Hip X-Ray [**2138-9-18**]: Limited examination due to body
habitus. Multiple surgical clips project over the pelvis. Right
lower quadrant ostomy projects over the right greater
trochanter. Degenerative changes of the pubic symphysis. The
right hip is not well visualized due to overlying soft tissue
structures. Status post left total hip arthroplasty. The
hardware appears intact. No definite fracture or dislocation on
this single AP view. Subcutaneous emphysema and edema,
post-surgical. Skin staples present. IMPRESSION: Status post
left total hip arthroplasty, as above.
.
CXR [**2138-9-22**]: There has been interval partial clearing of the
infiltrate in the left mid lung. However, there continues to be
dense retrocardiac opacity consistent with a combination of both
volume loss and consolidation.
.
CXR [**2138-9-25**]: official read pending at time of discharge
.
Bilateral lower ext vein ultrasound [**2138-9-26**]: prelim read at
time of discharge - no evidence of DVT in bilateral lower ext
veins
Brief Hospital Course:
81yo female with history of colon cancer and CML who presented
with worsening abdominal pain for the past several weeks.
#. Abdominal pain: Pain likely secondary to worsening tumor
burden from known colon cancer that had been seen imaging
studies prior to admission. CT on admission confirmed interval
increase in size and number of intraperitoneal metastases, as
well as increase in paraaortic lymphadenopathy, consistent with
disease progression. Her pain was controlled with narcotic pain
medications during the admission. She will follow-up with Dr.
[**Last Name (STitle) **] after discharge from rehab.
.
#. Pneumonia: During the [**Hospital 228**] hospital course, she
developed acute hypoxia, and was transferred to the ICU. CXR
showed a left-sided infiltrate, and the patient was started on
broad coverage for hospital-acquired PNA vs. aspiration
pneumonia. She was thought to have possibly aspirated in setting
of increased sedation while receiving pain control via dilaudid
PCA. She was started on vancomycin, aztreonam, and
ciprofloxacin. Her oxygen was weaned, and the patient was
transferred back to the floor in stable condition. Her PCA
dosing was adjusted accordingly. She completed a 9-day course of
antibiotics for her pneumonia. At time of discharge, she was
afebrile, without chest pain, SOB, or cough, and CXR showed
improvement in left lobe consolidation.
.
# Colon cancer: CT abdomen showed increased size and number of
intraperitoneal metastases, as well as increase in paraaortic
lymphadenopathy masses throughout abdomen. CEA noted to be
increasing as well. Her abdominal pain, likely due to to
increasing tumor burden, was well controlled at time of
discharge. She will follow-up with Dr. [**Last Name (STitle) **].
.
# CML: The patient has been followed by Dr. [**Last Name (STitle) **] as an
outpatient, and was on imatinib at time of admission. Per notes,
her WBC was 15.9 at baseline. She was initially continued on
imatinib, then switched to dasatinib once she had insurance
approval. Her dasatinib was held in setting of pneumonia and hip
surgery, and restarted on [**2138-9-24**] at 70mg daily. Her WBC had
previously peaked at 48.4 in setting of her pneumonia, then
trended down to as low as 11.3 on [**2138-9-17**]. However, WBC was
noted to rise again, peaking at 39.8 on [**2138-9-25**]. She did have a
left shift/bandemia, but no infectious source was indentified.
There was no evidence of infection at her surgical site, no
clinical evidence of pneumonia, blood cultures were negative,
and the patient remained afebrile. Her stool tested negative for
C. diff x2. She had a decrease in WBC on the day of discharge,
from 39.8 to 33.7, in setting of starting dasatinib. She will
follow-up with Dr. [**Last Name (STitle) **] following discharge.
#. Left hip pain: Pain was secondary to avascular necrosis of
the hip, and the patient underwent a left total hip arthroplasty
on [**2138-9-18**]. She tolerated the procedure well. Pain control was
difficult, as the patient required high doses of narcotics to
control her pain, but was very susceptible to respiratory
depression and lethargy in setting of increased narcotic dosing.
Ultimately, her pain was brought under control after a 3-day
course of toradol in addition to methadone 2.5mg TID, with
oxycodone for breakthrough pain. Her pain also steadily
improved following her hip replacement surgery. She will be
discharged on a pain regimen of acetaminophen 1000mg PO TID,
gabapentin 400mg [**Hospital1 **], methadone 2.5mg PO TID, naproxen 375mg [**Hospital1 **]
(to be continued through [**2138-10-1**]), with oxycodone 15-30mg Q3 prn
breakthrough pain. After [**2138-10-1**], she should only receive
naproxen as needed for pain. Her renal function should be
closely monitored in setting of NSAID use. Regarding her hip
surgery, she should have staples removed on [**2138-10-10**] with
steri-strips placed, and will follow-up with ortho on [**2138-10-17**].
.
#. Diarrhea: The patient did develop some loose stools during
her hospital stay. Given her rising white count and antibiotic
use, she was tested for C. diff infection, but testing was
negative x2. Her diarrhea may be secondary to the dasatanib.
Her symptoms improved with Lomotil.
.
#. Hypothyroidism: The patient was continued on her home dose of
levothyroxine 125 mcg daily.
.
#. Insomnia: The patient was given zolpidem 5 mg QHS prn
insomnia.
.
#. Anxiety: The patient was seen by palliative care during the
admission, and per their recommendations was started on
olanzapine for increased anxiety.
Medications on Admission:
docusate sodium 100 mg [**Hospital1 **]
gabapentin 400 mg [**Hospital1 **]
mirtazapine 30 mg qhs
omeprazole ER 20 mg [**Hospital1 **]
levothyroxine 125 mcg daily
imatinib 400 mg daily
zolpidem 10 mg qhs prn insomnia
oxycodone SR 30 mg q12h
acetaminophen 1000 mg tid
diphenoxylate-atropine 2.5-0.025 mg q6h prn diarrhea
oxycodone 15 mg q4-6h prn
senna prn
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for dry skin.
4. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS PRN () as
needed for insomnia.
5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
7. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily).
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
11. Methadone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Naproxen 375 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
14. Dasatinib 70 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
15. Oxycodone 15 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for breakthrough pain.
16. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for diarrhea.
17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
18. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
19. Outpatient Lab Work
Please check twice weekly CBC with diff, chemistries (Na, K, Cl,
HCO3, BUN, Cr, Ca, Mag, Phos)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Colon cancer
CML
Pneumonia
Left hip replacement surgery [**2138-9-18**]
Diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with worsening abdominal pain,
which is likely due to your colon cancer. Your pain was better
controlled after we increased your pain medications.
You developed some shortness of breath and low oxygen levels,
and were found to have a pneumonia. You were briefly treated in
the ICU, but then were stable to be transferred back to the
general oncology floor. We treated you with antibiotics, and
your pneumonia resolved.
You had left hip replacement surgery on [**2138-9-18**]. You tolerated
this procedure well. Your staples should be removed in 2 weeks,
and you will follow-up with the orthopedics team on [**2138-10-17**].
It was difficult to control your pain during your hospital stay.
You tried many different narcotic medications, including
morphine, oxycodone, and dilaudid. A medication called toradol
was very effective, but you can only take this medication for 3
days at a time. You will be discharged on a medication called
naproxen, which is in the same family as toradol. You can take
this medication for one week, and you can also continue to take
the oxycodone as needed for pain.
While you were here, you stopped taking imatinib and were
started on a medication called dasatinib. This medication was
held while you were treated for the pneumonia and surgery. We
noticed your white blood cell count was increasing again after
the surgery, and we re-started the dasatinbib.
Followup Instructions:
Department: HEMATOLOGY/BMT
When: THURSDAY [**2138-10-16**] at 11:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Last Name (NamePattern1) 280**] [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2138-10-16**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: FRIDAY [**2138-10-17**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], PA [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You should also follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
You should follow-up with your primary care doctor, Dr. [**First Name (STitle) **]
[**First Name8 (NamePattern2) **] [**Doctor Last Name **]. The clinic number is [**Telephone/Fax (1) 133**].
[**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
]
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15856, 15926
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9147, 13714
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440, 486
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16051, 16051
|
5330, 5330
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,891
| 103,942
|
22277
|
Discharge summary
|
report
|
Admission Date: [**2106-11-3**] Discharge Date: [**2106-11-6**]
Date of Birth: [**2030-2-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD on [**2106-11-3**]
History of Present Illness:
This is a 76 yo M with ETOH cirrhosis, HCC, grade III varicies
who presented to the ED with 5-6 episodes of BRBPR followed by
black stools. Denied n/v. Denied abdominal pain. Had mild
lightheadedness with the stools but none after that.
.
In the ED, vital signs were intially T 98, BP 120/44, HR 59; RR
18; O2sat 100% RA. 2 large bore PIVs were placed and he was
given 1L IVF, IV pantoprazole. GI consult suggested octreotide
bolus and then gtt. No NG lavage given varicies.
.
He continues to deny pain, CP, SOB, abdominal pain, headache,
nausea or vomiting, weakness, lightheadedness, headache, vision
changes.
.
Past Medical History:
-ETOH cirrhosis- quit drinking in [**2106-4-4**]
-HCC s/p radiofrequency ablation
-grade III varicies
-portal vein thrombosis - occlusive; not on anticoagulation
given high grade varicies
-DM2
Social History:
Married and lives with son. Denies smoking, alcohol or drug use.
States last alcohol was in [**Month (only) 547**] of this year.
Family History:
No family history of liver disease
Physical Exam:
Vitals: BP 122/35, HR 85, RR 19, O2sat 100% RA
General: elderly male in NAD sitting up in bed
HEENT: pale conjunctiva, anicteric sclera, MMM, no JVD
CV: RRR, 2/6 systolic murmur
Lungs: crackles at left base; otherwise clear
Abdomen: +BS, soft, NT, distended with mild ascites, well healed
laproscopic incisions, occasional healing bruises across abdomen
Extremities: venous stasis changes to BLE; DP 1+ symmetric; no
edema; no asterixis
Pertinent Results:
Admission Labs:
[**2106-11-3**] 10:30AM PLT COUNT-210
[**2106-11-3**] 10:30AM NEUTS-57.8 LYMPHS-32.5 MONOS-6.6 EOS-2.1
BASOS-1.0
[**2106-11-3**] 10:30AM WBC-7.8 RBC-2.39* HGB-7.9* HCT-24.5* MCV-102*
MCH-33.0* MCHC-32.2 RDW-17.4*
[**2106-11-3**] 10:30AM ALBUMIN-3.3*
[**2106-11-3**] 10:30AM LIPASE-105*
[**2106-11-3**] 10:30AM ALT(SGPT)-42* AST(SGOT)-44* LD(LDH)-273* ALK
PHOS-167* AMYLASE-80 TOT BILI-0.7
[**2106-11-3**] 10:30AM estGFR-Using this
[**2106-11-3**] 10:30AM GLUCOSE-118* UREA N-47* CREAT-1.5* SODIUM-140
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2106-11-3**] 10:34AM HGB-8.2* calcHCT-25
[**2106-11-3**] 10:57AM PT-14.1* PTT-29.9 INR(PT)-1.3*
[**2106-11-3**] 02:28PM HGB-8.3* calcHCT-25
[**2106-11-3**] 05:06PM PT-13.6* PTT-31.2 INR(PT)-1.2*
[**2106-11-3**] 05:06PM PLT COUNT-130*
[**2106-11-3**] 05:06PM WBC-3.8*# RBC-2.04* HGB-6.6* HCT-20.8*
MCV-102* MCH-32.5* MCHC-31.9 RDW-17.3*
[**2106-11-3**] 05:06PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.0
[**2106-11-3**] 05:06PM GLUCOSE-102 UREA N-39* CREAT-1.3* SODIUM-143
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-20* ANION GAP-16
[**2106-11-3**] 10:29PM HCT-29.0*#
.
EGD: Findings: Esophagus:
Protruding Lesions 4 cords of grade III varices were seen
starting at 25 cm from the incisors in the lower third of the
esophagus and middle third of the esophagus. There were stigmata
of recent bleeding.
Stomach: Normal stomach.
Duodenum:
Excavated Lesions A single acute superficial non-bleeding 7mm
ulcer was found in the first part of the duodenum. Cold forceps
surveillance biopsy samples were retrieved from the stomach
Other procedures: 6 bands were successfully placed in the lower
third of the esophagus.
.
Liver US [**2106-11-3**]: IMPRESSION: Limited evaluation of cirrhotic
liver with partially occlusive thrombus of the main portal vein
redemonstrated. Evidence of portal hypertension including
splenomegaly and ascites.
.
CT Ab/Pelvis: IMPRESSION:
1. No evidence of enhancement in the region of patient's
previously seen left-sided hepatic mass lesion to suggest
residual tumor. No definite new enhancing lesions identified.
Atrophy of the left lobe of the liver distal to site of
radiofrequency ablation again seen.
2. Progression of patient's portal venous, splenic, and SMV
thrombosis. Interval increase in amount of free abdominal and
pelvic free fluid.
.
Discharge Labs:
[**2106-11-6**] 12:35PM BLOOD WBC-5.0 RBC-3.03* Hgb-9.7* Hct-29.0*
MCV-96 MCH-32.0 MCHC-33.4 RDW-18.9* Plt Ct-143*
[**2106-11-6**] 12:35PM BLOOD Glucose-175* UreaN-20 Creat-1.3* Na-135
K-3.7 Cl-103 HCO3-21* AnGap-15
[**2106-11-5**] 06:35AM BLOOD ALT-28 AST-27 LD(LDH)-209 AlkPhos-116
TotBili-1.2
[**2106-11-6**] 12:35PM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1
[**2106-11-5**] 06:35AM BLOOD ALT-28 AST-27 LD(LDH)-209 AlkPhos-116
TotBili-1.2
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2106-11-5**]): POSITIVE BY
EIA.
Brief Hospital Course:
# GI bleeding: Patient was transferred from the ED to the MICU.
At that time he was transfused 2 units PRBC in total. Patient
received an EGD [**2106-11-3**] showing 4 cords of grade III varices
with three bands placed in lower third of esophagus. There was a
duodenal ulcer noted without biopsies taken. Patient had one
melanotic stool the day of transfer and one guaiac positive
without frank blood but remained hemodynamically stable. Patient
was placed on an octreotide gtt. Patient was kept at a goal HCT
of 25-27 to avoid increasing his portal pressures. He will
receive a total of 7 days ciprofloxacin for SBP prophylaxis. He
was restarted on nadolol on the day of transfer to medicine
floor. VS on transfer T 99 HR 61 BP 118/56 RR 19 O2sat 100%RA.
On day of discharge, patient was found to be H. pylori positive.
He is discharged with 2 weeks of antibiotics for treatment of
his infection. Prior to discharge, he was restarted on his
diuretics and remained hemodynamically stable.
.
# ETOH cirrhosis/Hepatocellular carcinoma: Known 3-4cm lesion
s/p radioablation in [**9-10**]. LFTs remained at baseline. CT of
abdomen demonstrating no new lesions or evidence of residual
tumor. Continued on diuretics and nadolol as above.
.
# Acute renal failure: Creatinine initially up to 1.5 on
admission with baseline around 1. Likely prerenal given bleeding
with elevated BUN as well. Improved to 1.3 at time of discharge.
.
# DM2: On ISS as inpatient. Restarted on outpatient glipizide
at time of discharge.
.
# Code: Full
.
# Communication: Son [**Name (NI) **] [**Telephone/Fax (1) 58057**]
Medications on Admission:
GLIPIZIDE 5 mg--1 tab(s) by mouth daily
LISINOPRIL 5 mg--2 tablet(s) by mouth daily
NADOLOL 20 mg--1 tablet(s) by mouth daily
PRILOSEC 20 mg--1 capsule(s) by mouth once a day
SPIRONOLACTONE 100 mg--1 tablet(s) by mouth daily
LASIX 20 mg--1 tablet (s) by mouth daily
Discharge Medications:
1. 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:*0*
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 26 doses.
Disp:*52 Tablet(s)* Refills:*0*
6. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 26 doses.
Disp:*104 Capsule(s)* Refills:*0*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 3 bowel movements daily.
Disp:*2700 ML(s)* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: GI bleed
Secondary diagnoses: Alcoholic cirrhosis, Hepatocellular
carcinoma, grade III esophageal varices, portal venous
thrombosis, type II diabetes mellitus
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after several episodes of bright red blood in
your stools. While you were here, you had an EGD that showed
severe varices and these were banded. In addition, you had an
ulcer in your duodenum. You were found to be positive for the
bacteria H. Pylori, and you are being treated for 2 weeks for
this infection.
If you develop any more bright red blood in your stools, dark
tarry stools, dizziness or lightheadedness, chest pain,
shortness of breath, vomiting blood, or any other symptom that
concerns you, please go to the nearest Emergency Department or
call your doctor as soon as possible.
Please take your medications as directed.
Followup Instructions:
It is very important that you keep the following appointments:
Provider: [**Name10 (NameIs) **] WEST,ROOM TWO GI ROOMS Date/Time:[**2106-11-11**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2106-11-11**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2106-11-17**]
11:20
|
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[
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|
7764, 7895
|
274, 284
|
374, 990
|
1895, 4248
|
7734, 7743
|
1012, 1207
|
1223, 1353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,332
| 142,867
|
34122
|
Discharge summary
|
report
|
Admission Date: [**2200-4-28**] Discharge Date: [**2200-5-14**]
Date of Birth: [**2131-11-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
off pump CABG X 4 ([**5-2**])
History of Present Illness:
68 yo F with 3 weeks of angina, cath today with 3VD. Transferred
for surgical evaluation.
Past Medical History:
ESRD on HD, anemia, ?myelodysplasia, lipids, HTN, afib, lupus
anticoagulant with abn. ptt.
Social History:
retired
no tobacco
no etoh
Family History:
NC
Physical Exam:
HR 50 RR 14 BP 175/63
NAD
Lungs CTAB
Heart RRR
Abdomen benign
slihgt oozing from right groin s/p cath
left arm AV fistula + bruit
Pertinent Results:
[**2200-5-14**] 05:35AM BLOOD WBC-4.2 RBC-2.60* Hgb-8.2* Hct-24.1*
MCV-93 MCH-31.6 MCHC-34.1 RDW-16.3* Plt Ct-260
[**2200-5-12**] 08:00AM BLOOD WBC-5.8 RBC-2.96* Hgb-8.8* Hct-26.9*
MCV-91 MCH-29.7 MCHC-32.7 RDW-16.6* Plt Ct-188
[**2200-5-10**] 07:09AM BLOOD WBC-6.3 RBC-2.79* Hgb-8.4* Hct-25.7*
MCV-92 MCH-30.0 MCHC-32.5 RDW-16.9* Plt Ct-152
[**2200-5-14**] 05:35AM BLOOD PT-28.0* INR(PT)-2.8*
[**2200-5-13**] 07:00AM BLOOD PT-37.2* INR(PT)-4.0*
[**2200-5-12**] 05:20AM BLOOD PT-37.6* INR(PT)-4.0*
[**2200-5-11**] 05:53PM BLOOD PT-50.0* INR(PT)-5.7*
[**2200-5-11**] 06:06AM BLOOD PT-40.7* INR(PT)-4.4*
[**2200-5-10**] 07:09AM BLOOD PT-26.1* PTT-55.8* INR(PT)-2.6*
[**2200-5-9**] 02:53PM BLOOD PT-17.3* PTT-53.3* INR(PT)-1.6*
[**2200-5-6**] 05:00AM BLOOD PT-14.8* PTT-63.3* INR(PT)-1.3*
[**2200-5-5**] 02:40AM BLOOD PT-18.0* PTT-63.6* INR(PT)-1.6*
[**2200-5-4**] 03:05AM BLOOD PT-20.3* PTT-76.0* INR(PT)-1.9*
[**2200-5-3**] 04:06AM BLOOD PT-16.8* PTT-59.3* INR(PT)-1.5*
[**2200-5-2**] 10:20PM BLOOD PT-17.0* PTT-94.0* INR(PT)-1.5*
[**2200-5-14**] 05:35AM BLOOD UreaN-34* Creat-5.0* K-4.4
[**2200-4-28**] 05:34PM BLOOD Glucose-81 UreaN-47* Creat-8.8* Na-136
K-5.7* Cl-96 HCO3-30 AnGap-16
CHEST (PA & LAT) [**2200-5-13**] 10:00 AM
CHEST (PA & LAT)
Reason: assess for infiltrates/effusions
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman s/p cabg
REASON FOR THIS EXAMINATION:
assess for infiltrates/effusions
HISTORY: Status post CABG.
FINDINGS: In comparison with study of [**5-7**], there has been some
decrease in the right pleural effusion. However, at the left
base, there is poor definition of the hemidiaphragm suggesting
some increasing pleural effusion on this side. The central
catheters remain in place.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 78669**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78670**] (Complete)
Done [**2200-5-2**] at 1:48:45 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2131-11-4**]
Age (years): 68 F Hgt (in): 64
BP (mm Hg): 100/60 Wgt (lb): 150
HR (bpm): 60 BSA (m2): 1.73 m2
Indication: Intraoperative TEE for CABG--off pump
ICD-9 Codes: 786.05, 786.51, 440.0, 424.1
Test Information
Date/Time: [**2200-5-2**] at 13:48 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: B2100
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: *4.0 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 9 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 4 mm Hg
Aortic Valve - Valve Area: *1.7 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 94 ms
Mitral Valve - MVA (P [**12-18**] T): 2.3 cm2
Findings
LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Moderately
dilated ascending aorta. Simple atheroma in aortic arch. Mildly
dilated descending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Physiologic MR (within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Pre-revascularization:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly to moderately dilated. There
are simple atheroma in the aortic arch. The descending thoracic
aorta is mildly dilated. There are simple atheroma in the
descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits).
Post-revascularization:
Pt in normal sinus rhytm on phenylephrine infusion.
1. Biventricular function is preserved.
2. No new regional wall abnormalities.
Brief Hospital Course:
She was admitted to the ICU. She was started on a nitro drip and
was subsequently chest pain free. She continued on hemodialysis.
She remained stable and was transferred to the floor. SHe was
seen by hematology for her history of myelodysplasia as well as
lupus anticoagulant. She remained stable and was cleared for
surgery by hematology.
She was taken to the operating room on [**5-2**] where she underwent
an off pump CABG x 4. She was transferred to the ICU in stable
condition. A temporary dialysis line was placed as her AV
fistula clotted. She will need outpatient follow up for
permenant dialysis access. She was extubated on POD #1. HCT
dropped to 19, CT scan showed no RP bleed, and she was
transfused. She developed RUQ pain and RUQ ultrasound was
negative, LFTs were elevated. She was transferred to the floor
on POD #3. She underwent tunneled catheter placement in IR on
POD #4. She was seen by general surgery and an NGT was placed.
She was started on amiodarone and coumadin for atrial
fibrillation. Her abdomen improved and her NGT was removed and
diet advanced. Her INR became supratherapeutic, her coumadin was
held and she remained in the hospital awaiting stable
therapeutic INR. Spoke to [**Doctor First Name **] at the [**Hospital1 **] Heart Center
[**Hospital 197**] clinic who has agreed to follow her coumadin. She last
received coumadin on [**5-10**] when she received 1 mg. Prior doses
were [**5-9**] 2mg, [**5-8**] 3mg.
Last HD was [**5-12**].
She was ready for discharge home on POD #12.
Medications on Admission:
Coreg 3.125'', lisinopril 20', clonidine 0.2', phoslo, zocor
20', imdur 30'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 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:*0*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: then 1 tablet (200 mg) daily ongoing.
Disp:*37 Tablet(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Coumadin 1 mg Tablet Sig: 0.5 Tablet PO at bedtime for 1
doses: check INR [**5-15**] with results to Dr. [**Last Name (STitle) 3659**].
Disp:*60 Tablet(s)* Refills:*0*
10. Outpatient [**Name (NI) **] Work
PT/INR [**5-15**] with results called to Heart Center [**Hospital 197**] Clinic
[**Telephone/Fax (1) 6256**]. Further [**Telephone/Fax (1) **] draws per [**Hospital 197**] Clinic.
Discharge Disposition:
Home
Discharge Diagnosis:
CAD now s/p CABG
ESRD on HD, anemia, ?myelodysplasia, lipids, HTN, afib, lupus
anticoagulant with abn. ptt.
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Coumadin for atrial fibrillation - Have INR checked [**5-15**] with
results to Dr. [**Last Name (STitle) 3659**]/coumadin clinic [**Telephone/Fax (1) 6256**], goal INR
[**1-19**].
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 24107**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3659**] 2 weeks
Dr. [**Last Name (STitle) 816**] or local surgeon for new permenant dialysis access.
Have INR checked [**5-29**] have blood drawn at Cancer Care
Center [**Last Name (NamePattern1) 51148**], [**Location (un) **], [**Location (un) 47**] or at [**Hospital1 **].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2200-5-14**]
|
[
"585.6",
"411.1",
"238.75",
"403.91",
"414.01",
"997.1",
"285.9",
"997.4",
"289.81",
"560.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
9549, 9555
|
6554, 8073
|
288, 320
|
9707, 9715
|
784, 2075
|
10208, 10810
|
614, 618
|
8199, 9526
|
2112, 2139
|
9576, 9686
|
8099, 8176
|
9739, 10185
|
633, 765
|
238, 250
|
2168, 6531
|
348, 439
|
461, 553
|
569, 598
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,001
| 132,506
|
10636
|
Discharge summary
|
report
|
Admission Date: [**2150-8-23**] Discharge Date: [**2150-9-1**]
Date of Birth: [**2122-6-5**] Sex: M
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: This is a 29-year-old man who
was a restrained driver of a car hit by a bus prolonged
extraction, conscious when extracted. He complained of
difficulty breathing and back pain. Hemodynamically, the
patient was stable on transfer to the [**Hospital6 649**]. On arrival to the Trauma Bay, he continued
to complain of difficulty breathing and back pain.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs: Heart rate 104. Blood
pressure 120/palp. Saturating 98% on room air. He was
alert, he responded to verbal communication, motor response
intact. Pupils equal and reactive to light, size 2 mm. GCS
was 15 prior to intubation. Head exam revealed no
ecchymosis, no Battle sign. Tympanic membranes were intact
bilaterally. Trachea was midline. Clear entry bilaterally.
Patient had crepitus over both anterior chest wall fields.
Abdomen was positive guarding, tender. Pelvis was stable,
nontender. No blood at the meatus of his urethra. Rectal:
Normal tone. Spine: No step-offs or bruises. Patient had
hematuria when the Foley was inserted.
HOSPITAL COURSE: He was intubated in the Trauma Bay for
respiratory distress and the drugs they used to intubate by
anesthesia were etomidate and succinylcholine. His head was
maintained in inline traction. A left chest tube was
inserted into the fourth intercostal space. Patient was sent
to CAT scan and was shown to have a small right-sided frontal
[**Doctor Last Name 534**] temporal subarachnoid, left temporal contusion, rib
fractures posteriorly [**1-19**] in thorax on the left, left
pneumothorax, pulmonary contusions and Grade 1 liver
laceration. A cystogram was done to rule out a bladder
injury. There was no extravasation of contrast material.
Bronchoscopy was done and there was blood in the left lower
lung orifice secondary to this pulmonary contusion. There
was no tracheal bronchial injury. Bronchoscopy was repeated
the following day with improvement. Thoracic Surgery was
consulted regarding this chest tube and blood in the
bronchial system, and it was thought to be in agreement with
our hypothesis, that this was secondary to pulmonary
contusion. Neurosurgical consult for this question of
subarachnoid hemorrhoid at the frontal horns.
Recommendations were to obtain a follow-up CT scan of the
head the next day. There were no acute neurosurgical issues
at the time. Patient was admitted to the Surgical Intensive
Care Unit.
Orthopedics was consulted as well, for the findings of a
scapular fracture on the left side. He was also found to
have a transverse process fracture at T6 and Ortho was
covering spine during his hospitalization. Their findings on
review of the following films: The trauma series which
showed frontal rib fractures and pneumothorax,
hemopneumothorax and a cervical spine where T1 was not well
visualized. CT of his thorax: Rib fractures,
hemopneumothorax, and T6 transverse process fracture, a
scapula body fracture. Their recommendations for the left
scapula was pain control, comfort measures for sling, and
repeat a neurological exam. For the T6 transverse process
fracture, no intervention needed at the time. They will
reexamine the spine and a hard collar to be continued with
Ortho spine following. Urology was consulted as well. He
underwent a retrograde urethrogram, a urogram, and showed
bladder fill with contrast, no leakage in urethra or bladder,
no contrast in the pelvis cavity. After a void, there was no
residual contrast, no leaking. They did not find any signs
of trauma on their exam of the genitourinary system. He did
have a positive stool and normal rectal tone. They did not
find any genitourinary surgical intervention necessary. They
thought that the hematuria on the Foley was most likely
secondary to insertion trauma. They suggested repeat
cystogram and urethrogram after the Foley was removed and
patient was placed on Ciprofloxacin in the Surgical Intensive
Care Unit for prophylaxis given his indwelling catheter.
Patient's hematocrit was steadily trending down from 35.5
initially, to 31 to 29.7, to 28. Chest tube was kept in
place. Repeat CT scan of the head followed by Neurosurgery,
they advised no neurosurgical issues and essentially signed
off the case. C spine, CT scan was done. Spine x-rays were
done. He was taken off logroll precaution. His hematocrit
continued to decline down to 25.1 but he was receiving fluids
at the time. Despite his decreasing hematocrit, platelets
and coags remained stable. CT C spine did not result in any
change of management. The patient was placed on vancomycin
for gram positive cocci in a blood culture from his arterial
line and for gram positive cocci in the sputum sample. He
was febrile to 102.6. Patient was gradually weaned off the
vent. This was proceeded slowly given his pulmonary
contusions. His hematocrit continued to decrease to 23.8 but
gradually was coming up. Gram positive cocci came back as
pansensitive. Patient was on Levaquin.
Patient was rebronched on the 16th with small amount of light
mucus secretions. No blood seen in the left bronchial tree
despite some grossly visible blood in the tracheal secretions
done in suctioning by the nurse in the Surgical Intensive
Care Unit. Patient was extubated on the 17th. She tolerated
this well. Peripheral IVs were placed. His white blood cell
count was 13. His hematocrit was 25.2. Hematocrits were
checked less frequently given that they were stable and
increasing. His diet was advanced. Pulmonary toilet. He was
transferred out of the Surgical Intensive Care Unit to the
regular floor. Patient was seen by Physical Therapy. Ortho
spine final recommendations were to continue hard collar for
two more weeks and to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**].
Patient was given an appointment. Patient was to follow-up
with regular Orthopedics which was done with Dr. [**First Name (STitle) **] in two
weeks. Patient was changed to oxacillin and gradually
changed to oral form dicloxacillin. Pain control was an
issue and was finally under control with oral Dilaudid. A
sling and swath was applied and patient was given an
appointment with Trauma Clinic which he is to come in the
first week of [**Month (only) **] as was his other appointments.
Patient had a spontaneous bowel movement, tolerating a
regular diet, ambulating around the hallway. He has all his
follow-up appointments set up for him. He will be discharged
to home today with his cervical collar for two more weeks.
DISCHARGE DIAGNOSES:
1. Status post a motor vehicle accident.
2. Grade 1 liver laceration.
3. Multiple rib fractures.
4. Left scapular fracture.
5. Small subarachnoid hemorrhage.
6. First rib disruption.
7. Pulmonary contusion.
8. Hematuria.
DISCHARGE MEDICATIONS:
1. Dilaudid [**2-15**] q. [**4-17**] prn.
2. Tylenol 650 around the clock for five days.
3. Clindamycin times five days 300 q.i.d.
4. Colace 100 mg po b.i.d.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2150-9-5**] 09:50
T: [**2150-9-5**] 09:50
JOB#: [**Job Number 34917**]
|
[
"861.21",
"851.80",
"852.00",
"860.4",
"E812.1",
"958.7",
"864.05",
"807.07",
"805.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"33.23",
"96.04",
"38.91",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6782, 7012
|
7035, 7467
|
1311, 6761
|
629, 1293
|
162, 517
|
540, 606
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,249
| 180,253
|
48754
|
Discharge summary
|
report
|
Admission Date: [**2130-10-12**] Discharge Date: [**2130-10-22**]
Date of Birth: [**2054-4-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Shortness of breath, Fever and Cough
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
76-year-old W with DM2, CRI (last GFR 23), Obesity, HTN, and IBS
who presents to ED after ~ 7d of cough, fever, nasal congestion,
worsening SOB in setting of 1.5yrs of DOE, fatigue, and black
stools.
.
Pt. reports 1.5 yrs of worsening fatigue/lack of energy since a
RT at that time. Since the infection, she reports she has never
recovered. She has noted progressively worsening DOE and nasal
congestion, productive of green purulent sputum with fevers
Q2-3months and blood tinged sputum. These would resolve on
their own, however, would recur regularly.
.
[**Known firstname **] was in USOH (as above) until ~ 7d ago, when she noted
worsening nasal congestion, subjective fever, anorexia and NP[**MD Number(3) 23674**]. Her DOE worsened to the point where she was unable to
ambulate from living room to kitchen and noted severe HAs along
with sinus tenderness. In addition, describes central CP with
exertion, w/o diaphoresis/n/v or radiation. Her fatigue cough
have gotten worse to the pt. that she did not take anything PO x
3-4 days. Objective temp maxed out at 103F, w/ chills. She has
been taking up to 650mg QID for fevere and pain. Her sister
made her go to the [**Name (NI) **].
.
Over the past year she has noted black stools w/o wt. loss,
abdominal discomfort with food intake, progressively worsening
exercise tolerance, recurrent skin rashes and recently oral
ulcers. She reported recurrent orthopne and PND.
.
Per Admission note, "upon arrival to [**Hospital1 18**], vitals were: T 97,
BP 183/52, HR 103, RR 18, SaO2 74% RA. The patient was triggered
for hypoxemia. Her SaO2 responded to 6L FM and her breathing
became more comfortable. She had a chest x-ray which the EW
reported as early pneumonia. She was given IVFs, ceftriaxone 1g
IV and azithromycin 500mg PO. Her oxygen status continued to
improve and she is comfortable on 4L NC. She was admitted to
medicine for further evaluation and management."
.
At time of interview, she reported feeling much improved, but
cont. to have SOB. She did not have other active complaints w/
exeption of fatigue.
.
Review of systems:
(+) Per HPI
(-) Denies palpitations, diarrhea, constipation, change in bowel
or bladder habits, dysuria, arthralgias or myalgias
Past Medical History:
1. Diabetes, Type II, insulin, c/b renal insufficiency, A1C
[**6-/2130**] was 7.6
2. Renal insufficiency, baseline unclear, [**Name2 (NI) 28645**] recently
1.7-1.9
3. Obesity
4. Hypertension
5. Back pain
6. Thyroid nodule, biopsy was benign
7. Breast lumps, atypical ductal hyperplasia in [**2124**]
8. Irritable bowel syndrome, not active
9. Bilateral cataract one in [**2127**] and one in [**2128**]
10. Status post hysterectomy in [**2094**] for benign tumors. There is
one ovary remaining
11. Removal of two benign breast lumps
12. Cholecystectomy
[**32**]. Iron deficiency anemia - etiology unclear.
14. Dyspnea: the patient states she has had dyspnea for the last
3-5 years which has been progressive. This mostly worsens with
exertion
Social History:
Lives in [**Location **] alone, former librarian, still volunteers.
has sister visiting with her now.
EtOH: rare
Smoking: quit 25yrs ago, history of 20 years x 2 ppd
Illicits: none
Family History:
No early CAD/MI.
Mother died of cervical cancer at age 62.
Father died of cancer of the stomach.
Older brother had a stroke.
[**Name (NI) **] brother - CM, died at 30yo.
Sister - lupus.
Physical Exam:
Vitals: T: 97.3, BP: 127/56, P: 83 R: 20, SaO2: 93% 4LNC
General: Obese female, pleasant, somewhat psychomotor slowed.
HEENT: Sclera anicteric, dMM, oropharynx without lesions. TTP at
b/l sinuses.
Neck: supple, unable to assess JVP as pt. sitting in chair.
Lungs: R base crackles, no decr. breath sounds, L crackles [**11-26**]
up the L lung, none anteriorly. No accessory muscle usage
CV: RR no murmurs appreciated
Abdomen: obese, soft, non-tender, non-distended
Ext: Warm, well perfused, no edema
Neuro: Alert, oriented to time/place/person. Attentive to DOWb,
[**Last Name (un) **] language, no apraxia. VFF confrontation, EOMi, reactive to
light symmetrically, face symmetric. UEs grossly full. Deferred
the rest of exam per patient preference.
Pertinent Results:
[**2130-10-11**] 08:10PM BLOOD WBC-13.5*# RBC-4.11* Hgb-11.8* Hct-34.9*
MCV-85 MCH-28.7 MCHC-33.9 RDW-13.5 Plt Ct-296
[**2130-10-13**] 05:35AM BLOOD WBC-9.5 RBC-3.28* Hgb-9.2* Hct-28.2*
MCV-86 MCH-28.1 MCHC-32.7 RDW-13.7 Plt Ct-256
[**2130-10-16**] 08:55AM BLOOD WBC-8.3 RBC-3.37* Hgb-9.5* Hct-29.2*
MCV-87 MCH-28.2 MCHC-32.5 RDW-13.9 Plt Ct-333
[**2130-10-11**] 08:10PM BLOOD Neuts-86.3* Lymphs-8.1* Monos-4.8 Eos-0.5
Baso-0.3
[**2130-10-11**] 08:10PM BLOOD PT-14.1* PTT-27.5 INR(PT)-1.2*
[**2130-10-16**] 08:55AM BLOOD PTT-55.0*
[**2130-10-11**] 08:10PM BLOOD Glucose-302* UreaN-40* Creat-2.4* Na-135
K-5.1 Cl-98 HCO3-23 AnGap-19
[**2130-10-16**] 06:15AM BLOOD Glucose-238* UreaN-81* Creat-2.7* Na-138
K-5.9* Cl-99 HCO3-27 AnGap-18
[**2130-10-16**] 06:15AM BLOOD ALT-10 AST-17 LD(LDH)-191 CK(CPK)-45
AlkPhos-97 TotBili-0.1
[**2130-10-11**] 08:10PM BLOOD cTropnT-<0.01
[**2130-10-12**] 11:30AM BLOOD cTropnT-<0.01
[**2130-10-13**] 05:35AM BLOOD CK-MB-4 cTropnT-<0.01
[**2130-10-12**] 11:30AM BLOOD Mg-2.3
[**2130-10-16**] 06:15AM BLOOD Albumin-3.0* Calcium-PND Mg-2.4
[**2130-10-13**] 05:35AM BLOOD calTIBC-233* Ferritn-130 TRF-179*
[**2130-10-12**] 11:30AM BLOOD VitB12-766 Folate-6.5
[**2130-10-12**] 11:30AM BLOOD Free T4-1.2
[**2130-10-11**] 08:10PM BLOOD TSH-0.20*
[**2130-10-16**] 08:55AM BLOOD HIV Ab-NEGATIVE
.
Imaging/Studies:
.
ECHO:
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. Left
ventricular systolic function is hyperdynamic (EF>75%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The right ventricular cavity is
moderately dilated with depressed free wall contractility. 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. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
IMPRESSION: Hyperdynamic left ventricular systolic function.
Abnormal LVOT systolic flow contour without frank obstruction.
Diastolic dysfunction. No significant valvular abnormality.
Moderate pulmonary artery systolic hypertension.
.
CXR on admission:
IMPRESSION: Subtle nodular opacities in the left mid lung, for
which CT is
recommended to more clearly assess. Vague increased opacities in
the lower
lungs bilaterally which could reflect crowding of
bronchovasculature though early pneumonia cannot be entirely
excluded. Recommend repeat with more optimized technique with a
dedicated PA and lateral view.
.
VQ scan: [**10-13**]
.
IMPRESSION: 1. Triple matched (ventilation, perfusion, and chest
radiograph) abnormality in the left upper lung of unclear
significance. Correlation with chest CT is recommended. 2.
Central clumping and decreased peripheral distribution of tracer
on ventilation images, consistent with airways disease. 3. Low
likelihood ratio for pulmonary embolism.
.
CT chest:
IMPRESSION:
1. Multifocal peribronchovascular consolidative foci.
Differential includes bacterial infection, though atypical
organisms could also cause this appearance. Nocardia is a
possibility. Septic emboli are not excluded, but the
ill-marginated appearance and air-bronchograms make this less
likely. Multifocal bronchoalveolar neoplasm is not excluded, so
radiographic follow-up to assess for resolution following
treatment is recommended
2. Basal atelectasis and mild-to-moderate effusions.
3. No evidence for emphysema.
4. Mild fluid overload versus congestive heart failure in the
right clincial circumstance.
Brief Hospital Course:
Mrs. [**Known lastname 102483**] was a 76 year-old woman with DM2, dCHF, CKD,
Obesity and HTN admitted for hypoxia and felt to have pneumonia.
.
# Pneumonia: Initially felt to be due to atypical CAP that was
multifocal. Cultures were negative. Patient underwent
treatment of 3 days of CFTX/Azithro without improvement. Her
hypoxemia actually worsened on HD2. Although initially she
appeared hypovolemic and her lasix was held x 24 hours, she was
subsequently felt to be mildly volume overloaded, and was
diuresed (~ 1.5L). ECHO showed diastolic dysfunction, RV
dilatation and PAH. Her hypoxemia worsened and was out of
proportion to her CXR. V/Q scan showed no PE but LUL abnormality
that was further investigated via CT. She was broadened to
Vanco/Cefepime/Azithro on [**10-14**] given concern for possible viral
PNA with superinfection. She completed an 8 day course for HAP.
CT showed multifocal PNA with peribronchial opacities, but the
differential diagnosis also included cryptogenic organizing
pneumonia as well as interstitial lung disease. She was
transferred to the ICU for further monitoring. She was never
intubated, nor did she receive bronchoscopy. HIV and ANCA were
negative. She slowly improved after completing her Abx course
for HAP and atypical pneumonia. She was slowly weaned from her
oxygen; however, did desaturate to the low 80s and qualified for
2-4L supplemental oxygen. She is being discharged with
supplemental oxygen, was felt to be slowly improving with regard
to her exam and hypoxia, and will be discharged on 2-4L NC. She
has close PCP and pulmonary [**Name9 (PRE) 702**], and it is expected that
she should continue to be able to wean from her supplemental
oxygen.
.
# Atrial fibrilaltion and atrial flutter: Converted with
metoprolol PO. She has DM/HTN/CHF, thus high risk for stroke
(8.5% annual risk of stroke). Her current afib/flutter was felt
to be likely due to infection. She was started on heparin gtt
and was started on coumadin. On discharge, her coumadin dose is
5 mg and INR is at 1.5. She will be set up with coumadin clinic
on discharge. She will receive metoprolol succinate 150 mg
daily as a new medication for rate control.
.
# DOE/CHF: Multifactorial, see above. Also with evidence of CHF
w/RV failure and PAH on TTE. She was felt to be euvolemic on
discharge at lasix 40 mg daily.
.
# Anemia: acute on chronic, normocytic. HCT stable throughout
hospitalization. Fe low, otherwise Fe studies nl. She was
started on iron sulfate. She may need conoloscopy given guaiac
positive stools.
.
# Diabetes: Held glipizide. Maintained on glargine and HISS. On
discharge will resume her home medications.
.
# Hypertension: she will stop her losartan given hyperkalemia.
This can be re-addressed by her PCP. [**Name10 (NameIs) **] has a new medication,
metoprolol succinate, 150 mg daily, for rate control. Her lasix
dose will be 40 mg daily to maintain euvolemia.
.
# F/U: with PCP and pulmonary. Being discharged to home with
services, physical therapy, and supplemental oxygen. Is being
set up with coumadin clinic.
Medications on Admission:
amlodipine 10 mg PO daily
clonidine 0.2 mg/24 hour Patch Weekly
furosemide 40 mg PO BID
gemfibrozil 600 mg PO daily
glipizide 10 mg PO BID
insulin glargine 28 units SC daily
losartan 100 mg PO BID
aspirin 81 mg PO daily - not taking regularly.
warfarin 5mg daily
metoprolol succinate 150mg daily
Discharge Medications:
1. Supplemental Oxygen
2-4L continuous, pulsed dose for portability
Pulmonary Hypertension, Congestive Heart Failure and s/p
Pneumonia.
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
7. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous once a day.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
10. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) inhalation Inhalation every six (6) hours as needed
for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pneumonia
Atrial Fibrillation
Pulmonary Hypertension
Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for fever, shortness of breath
and cough. You were evaluated and treated by the medicine
service. You were found to have pneumonia and were started on
appropriate antibiotics. Your pneumonia made it difficult for
you to breathe and you required supplemental oxygen and
treatment in the intensive care unit. You breathing improved
with the appropriate therapy and you were transfered back to the
general medicine floor where you continued to improve. You will
be provided with supplemental oxygen (2-4 liters as needed) for
home use while your breathing completely recovers and should
continue with home physical therapy. You will have close
follow-up with Dr. [**Last Name (STitle) **] and the lung doctors.
The following changes have been made to your medications:
1. You have been STARTED on Iron supplementation (ferrous
sulfate 325 mg) daily
2. You have been STARTED on coumadin at 5 mg daily (this will be
titrated to INR [**12-28**])
3. You have been STARTED on metoprolol succinate 150 mg daily
4. You have been STARTED on supplemental oxygen for use outside
of the hospital until your respiratory function recovers
5. You have been STARTED on ipratropium nebulizers as needed for
shortness of breath
6. Please STOP losartan until discussed with your primary care
doctor, as you had high potassium levels
7. Your furosemide dose has been CHANGED to 40 mg daily
Please take your medications as prescribed and keep your
outpatient appointments.
Followup Instructions:
Department: GERONTOLOGY
When: MONDAY [**2130-10-23**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2130-10-31**] at 10:00 AM
With: DR. [**First Name (STitle) **]/DR. [**Last Name (STitle) 3172**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You will need to follow-up with the pulmonary lung doctors
[**Name5 (PTitle) 176**] 1 week of discharge. Please call [**Telephone/Fax (1) 612**] so we can
help set up an appointment.
Completed by:[**2130-10-22**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,668
| 160,603
|
51553
|
Discharge summary
|
report
|
Admission Date: [**2187-3-8**] Discharge Date: [**2187-3-23**]
Date of Birth: [**2112-5-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Fever, hypoxia
Major Surgical or Invasive Procedure:
PRBC transfusion
History of Present Illness:
The patient is a 74 year-old female with PMH significant for PNH
c/b pancytopenia, who presented to clinic for routine C5
inhibitor treatment with eculizumab, and was found to have a
fever to 102.4 and hypoxia to 82%RA. The patient reports a dry
cough ongoing x 1 week without F/C or other symptoms. She notes
"feeling warm" this am with sx of SOB. She was able to perform
her daily morning activities independently, but proceeded slowly
[**1-20**] SOB. She also experienced sudden onset vomiting x 1 (mucous
only) with no c/o nausea, abd pain, or diarrhea before or after
this. She presentated to clinic for routine C5 administration,
where she was noted to be febrile and hypoxic, as above.
.
Of note, she reports + sick contacts at her nursing facility -
"everyone has the flu". + flu vaccine earlier this season. She
denies prior fevers, no chills/ rigors, abd pain, nausea,
diarrhea, constipation, dysuria, myalgias, rhinorrhea. She
currently feels "warm" but otherwise well without complaints.
SOB resolved with O2 by nasal cannula.
Past Medical History:
PNH- Dx approx 25 yrs ago; treated with Danazol, prednisone,
IVIG in the past; recently started on trial of cyclosporine
Type II DM
HTN
Social History:
SOC HX: Lives with daughter: nonsmoker, occasional ETOH, no
illicits
Family History:
NC
Physical Exam:
VS: T 97.8 HR 65 RR 18 BP 138/53 O2sat 99%3L
GEN: WN, WD elderly female in NAD
HEENT: NCAT, EOMI, partially blind in L eye [**1-20**] ?retinal
hemorrhages - L pupil ~4mm. OP clear, MMM, no e/o mucosal or
gingival bleeding
CV: RRR, I/VI SEM > LSB, nml S1 and S2
CHEST: nml respiratory effort, + rales diffusely throughout
ABD: + BS, soft, NT, ND, no HSM
EXT: nml muscle bulk and tone, 2+ distal pulses, 3+ LE edema to
knees b/l
NEURO: CN III-XII intact b/l (blind in L eye), spontaneously
moving all four ext
SKIN: Diffuse ecchymoses on the arms, chest, and abdomen with
petechiae present on the legs bilaterally and back.
Pertinent Results:
[**2187-3-8**] 10:30AM BLOOD WBC-1.5*# RBC-2.29* Hgb-7.0* Hct-19.9*
MCV-87 MCH-30.5 MCHC-35.0 RDW-21.9* Plt Ct-11*
[**2187-3-8**] 10:30AM BLOOD Plt Ct-11*
[**2187-3-8**] 10:30AM BLOOD Gran Ct-990*
[**2187-3-8**] 10:30AM BLOOD Glucose-163* UreaN-33* Creat-1.8* Na-137
K-4.1 Cl-102 HCO3-26 AnGap-13
[**2187-3-8**] 10:30AM BLOOD ALT-75* AST-67* LD(LDH)-513* AlkPhos-114
TotBili-2.4* DirBili-1.7* IndBili-0.7
[**2187-3-9**] 07:40AM BLOOD proBNP-1531*
[**2187-3-9**] 10:23AM BLOOD Type-ART Temp-37 O2 Flow-4 pO2-78*
pCO2-34* pH-7.51* calTCO2-28 Base XS-3 Intubat-NOT INTUBA
Comment-NC
.
Studies:
[**2187-3-8**] CXR: IMPRESSION: Right perihilar increased interstitial
markings consistent with interstitial pneumonia given the
clinical history.
.
[**2187-3-9**] CXR (AP port): FINDINGS: In comparison with study of
[**3-8**], there is persistent enlargement of the cardiac silhouette
with further increase in the interstitial pulmonary markings.
More coalescent areas are seen in the upper lung zones, raising
the
possibility of focal areas of pneumonia.
.
MICRO:
[**2187-3-8**] BCX: GPC in pairs and chains
[**2187-3-8**] UCX: GNR > 100K, presumptive E. coli
[**2187-3-9**] sputum: influenza neg.
[**2187-3-9**] BCX: NGTD
[**2187-3-10**] BCX: NGTD
[**2187-3-11**] UCX: legionella urinary Ag neg, cx P
[**2187-3-11**] BCX: NGTD
[**2187-3-11**] UCX: P
Brief Hospital Course:
Mrs. [**Known lastname **] is a 74 yo W with PNH complicated by persistent
pancytopenia who initially presented with fevers and hypoxia,
strep viridans positive blood cultures, Klebsiella UTI and chest
imaging concerning for atypical/interstitial pulmonary
infection. Her course was complicated by worsening respiratory
distress following bronchoscopy and platelet transfusion, with
likely transfusion reaction.
1)Neutropenia, fever, dyspnea, hypoxia: She had persistant
fevers throughout the first week of her admission concerning for
infectious process most likely from a pulmonary source.
History, exam, and imaging consistent with atypical/interstitial
pulmonary process. Her blood cultures from admission had one
set positive for strep viridans and her urine culture was
growing Klebsiella > 100K(pansensitive except for
nitrofurantoin). All blood and urine cultures since starting
antibiotics were negative. She had bronchoscopy to attempt to
obtain a culture diagnosis and to evaluate for tuberculosis.
Bacterial cultures from BAL were negative, AFB culture still
pending however the smear was negative so TB precautions were
discontinued. Post bronchoscopy she had exacerbation of her
reactive ariways with incrased oxygen requirement and poor air
movement. She was treated with a oxygen by NRB and albuterol
and ipratropium nebulizers. In addition, she developed
respiratory distress following platelet transfusion consistent
with acute tranfsuion reaction and was transferred to the
intensive care unit. Her respiratory status slowly improved
over the next several day with diuresis and she returned to the
floor and remained stable from a respiratory standpoint
throughout the rest of her hospitalization. She was discharged
to a nursing facility to complete a 14 day course of cefepime,
azithromycin, and vancomycin given neutropenia, last day of
antibiotics should be [**3-28**]. At the time of discharge she was
breathing comfortably, still with oxygen requirement of 3L by
nasal cannula.
2)Paroxysmal Nocturnal Hemoglobinuria: Eculizumab held
throughout admission and on discharge in light of fevers. She
became progressively pancytopenic during her admission most
likely due to acute illness vs. MDS transformation of her bone
marrow. Her granulocyte count reached a low point of 50 during
her admission and trended back up to 580 prior to discharge.
She was transfused a total of 4 units of PRBC to maintain a
hematocrit >18 and 2 units of platelets for platelet count <10.
Her second PLT transfusion was complicated by likely an acute
transfusion reaction characterized by acute respiratory
distress, rigors and fever requiring MICU transfer. By the time
of discharge her granulocytes were slowly trending up, and were
580 on last check. After extensive conversation with Mrs.
[**Known lastname **] she decided that she no longer wished to have
transfusions given that she most likely would be transfusion
dependent. She understood and accepted the risks of not being
transfused PRBC and Platelets and opted to no longer have
routine lab draws. As she was competent and understood the
risks and options, this was respected and labs draws were
stopped. She was continued on danazol, folic acid and
cyanocobalamin on discharge. She will follow up with Dr. [**Last Name (STitle) **]
and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**] in oncology clinic two weeks after discharge.
She should not have routine blood work at her nursing facility.
3) HTN: Stable throughout her admission. She was continued on
her outpatient regimen of norvasc and lasix.
4)Diabetes mellitus: She has a history of brittle diabetes,
complicated by retinopathy and nephropathy. She had been having
symptomatic hypoglycemic episodes in the early morning so her PM
dose of 70/30 was decreased from 15 to 10 units. Her morning
dose was continued at 10 units. She may require up titration of
her evening insulin dose as she recovers from her acute illness
and her appetite improves. She was also treated with humalog
sliding scale.
5)CRF: creatinine at baseline of 1.9-2.0. Her medications were
renally-dosed.
6) PPX: thrombocytopenia - no SQH or pneumoboots, defer PPI
given risk of BM suppression, bowel reg.
7)FEN: reg diet, monitor lytes
8)Code: DNR/DNI, she no longer wants transfusions or routine
blood draws
Medications on Admission:
1. Norvasc 10 mg daily.
2. Cholestyramine 4 grams daily.
3. Danazol 200 mg b.i.d.
4. Flovent two puffs b.i.d.
5. Folic acid 5 mg daily.
6. Lasix 40 mg daily.
7. Calcium citrate 500 mg b.i.d.
8. Vitamin B12 [**2178**] mcg daily.
9. Colace 100 mg b.i.d.
10. Vitamin D 400 units b.i.d.
11. Insulin 70/30 25 units q.a.m., 15 units q.p.m.
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Danazol 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
3. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
4. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed.
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-20**] Sprays Nasal
QID (4 times a day) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Neb Inhalation Q6H (every 6 hours).
16. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
18. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
19. Insulin Asp Prt-Insulin Aspart 100 unit/mL (70-30) Solution
Sig: as directed Subcutaneous twice a day: inject 27 units qam
and 10 units qpm.
20. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous four times a day: inject as directed according to
sliding scale.
21. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days: last day of antibiotics is [**2187-3-28**].
22. Cefepime 1 gram Recon Soln Sig: One (1) g Injection Q24H
(every 24 hours) for 5 days: last day of antibiotics is [**2187-3-28**].
23. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: 1000
(1000) mg Intravenous Q 24H (Every 24 Hours) for 5 days: last
day of antibiotics is [**2187-3-28**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 7168**]
Discharge Diagnosis:
Primary:
- GPC bacteremia
- UTI
- febrile neutropenia
- pancytopenia
.
Secondary:
- PNH
- Type 2 diabetes mellitus.
- Hypertension.
- Hypercholesterolemia.
- Diabetic retinopathy.
- Chronic kidney disease.
Discharge Condition:
fair
HCT on discharge 17.8, patient does not want further
transfusions, is aware of risks
satting 100% on 3L NC at rest
legally blind
petechial rash on buttocks
Discharge Instructions:
You were admitted with fevers, shortness of breath, and low
oxygen saturations that were thought to be caused by a viral
infection versus a pneumonia. You were also put on several
antibiotics to cover for bacteria in the blood as well as a
urinary tract infection. During the admission your blood counts
were also found to be low, likely due to a combination of your
infection and due to progression of your PNH and possible effect
on your bone marrow.
You were admitted to the intensive care unit during your
admission due to a reaction that you had to platelets that you
were given. You were treated with high flow oxygen and steroids
and you slowly improved.
You decided during your admission that you no longer wanted
blood transfusions even though your blood count was low.
Please continue to take all of your medications as prescribed.
Please attend all of your follow-up appointments.
.
If you experience any fevers > 100.5, chills, shortness of
breath, palpitations, bleeding, chest pain, swelling, or any
other concerning symptoms please contact your PCP or go to the
ER for further evaluation.
Followup Instructions:
You have the following appointments scheduled to follow up:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-4-5**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-4-5**] 2:30
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2187-4-30**] 1:10
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2187-4-30**] 1:30
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
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icd9cm
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,448
| 127,957
|
18601
|
Discharge summary
|
report
|
Admission Date: [**2185-1-24**] Discharge Date: [**2185-2-1**]
Date of Birth: [**2122-7-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
found unresponsive
Major Surgical or Invasive Procedure:
endotracheal intubation, NG tube placement
History of Present Illness:
HPI:62 y/o ESRD s/p renal transplant, CAD s/p CABG, and DM s/p
multiple episodes of "diabetic coma," who is transferred from an
OSH, where he initially presented after being found unresponsive
at home. His wife last saw pt well 6am--hours prior to
presentation. She called home at 9:30am, & pt reported to be
feeling well and was going for a drive. His sister stopped by
at noon, became worried to see his car in the driveway and
called police. The Pt was found unresponsive in chair in front
of the TV snoring loudly. There was a Klonipin bottle close by
the patient. BG in field normal. Pt was responsive to only
sternal from. There is an ill-defined report of arm shaking.
.
Pt first presented to [**Hospital3 2568**] hosptial, where he was intubated
for airway protection. Blood cultures taken. Got Etomidate,
Pavulon, succinylcholine, versed 2.5, solumedrol 60 IV,
ceftriaxone 2 gm. Dilatin 500mg IV, BG on arrival 181.
Intubated. Critcal care consult suggested loading with dilantin
and transfer to [**Hospital1 **] for EEG. Question of shaking activity on
verbal sign out, no documentation of this in record sent with
patient.
.
Since [**Holiday 1451**], the patient has had [**Hospital 51081**] medical
problems. During the week prior to [**Holiday 1451**] the patient was
found outside of [**Location (un) 8985**] mall in hypoglycemic coma (his 4th
episode in the last year) after taking insulin and hospitalized
in [**Hospital3 **]. He was dischanged 3 days later. He represented
days later to [**Hospital3 2568**] with a PNA and UTI. Per family pt has
been slowly regaining his strength since that hospitalization.
He was discharged on Augmentin and switched to amoxiciilin after
developing diarrhea over the last 2 weeks. At worst, he was
having [**8-19**] BM daily, [**2-11**] on day PTA.
.
In the days PTA, pt was oriented x3 but often fatigued and
falling asleep. Family reporst chills worsening over the last
few days but no fever. Positive HA. No known CP, SOB< cought,
abd pain, N/V. No focal weakness.
.
On arrival to [**Hospital1 18**] ED, T 97, BP 179/69, HR 58, R 14, 100% on
RA. Received Vanco 1gm, ceftriaxone 2g IV, hydral 10 IV
Past Medical History:
PMHx:
Chronic renal failure due to diabetic nephropathy s/p Kidney
transplant [**4-/2180**]
Brittle DM on insulin w/ multiple episodes of hypoglycemia
CAD s/p CABG [**2173**]
- stress [**2184-12-29**] without evidence of ischemia by report
PUD
htn
hyperlipidemia
B aortoilliac bybass
ex lap and AKA amputation during [**Country 3992**] after gunshot with
phantom limb pain
osteomylitis of L hip
h/o kidney stone
MVA s/p splenectomy [**6-/2181**]
diabetic retinopathy
bilateral carotid stenosis
s/p cervical fusion
anxiety with PTSD
h/o colitis in [**2183**] s/p colonoscopy w/ ileitis/colitis, ? crohns
vs microscopic colitis
Social History:
Lives in house with wife and son. Retired veteran counselor.
Able to do ADLS without dificulty. Distant 15-20 pack/yr smoking
hitory. No alcohol use. No illicit drug use. Per wife, pt would
only take 0.5 to 1 klonopin pill infrequently, was not on pain
meds. Takes tylenol once every feww days.
Family History:
FH: Mother ovarian can, father, brain ca, DM in brothers.
Physical Exam:
PE: T:94.2 BP:120/59 HR:59 RR:17 O2 100% on CMV 40%/600/12/5
Gen: intubated and sedated, withdrawing to painful stimuli (R >
L)
HEENT: No conjunctival pallor. PERRLA, No icterus. MMM. OP
clear.
NECK: Supple, No JVD.
CV: RRR. nl S1, S2. 2/6 SEM, no rubs or [**Last Name (un) 549**]. well healed
CABG
LUNGS: CTAB, good BS BL, No W/R/C
ABD: Soft well healed large midline abd scar, NT, ND. NL BS. No
HSM
EXT: WWP, NO CCE. AKA amb on left. Large scar over left hip
2+ DP on R
SKIN: fungal rash in left groin
genital: tight but distentable R inguinal hernia.
NEURO: Unresponsive to voice, withdraws to pain R > L. 2+
reflexes, equal BL. tone normal
Pertinent Results:
[**2185-1-24**] 06:50PM WBC-8.0# RBC-3.50* HGB-11.7* HCT-35.1*#
MCV-100* MCH-33.4* MCHC-33.4 RDW-16.5*
[**2185-1-24**] 06:50PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2185-1-24**] 06:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-46.9*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-1-24**] 06:50PM tacroFK-5.6
[**2185-1-24**] 06:50PM cTropnT-0.03*
[**2185-1-24**] 06:50PM LIPASE-55
[**2185-1-24**] 06:50PM ALT(SGPT)-28 AST(SGOT)-44* ALK PHOS-153* TOT
BILI-0.8
[**2185-1-24**] 06:50PM GLUCOSE-180* UREA N-42* CREAT-2.0* SODIUM-135
POTASSIUM-5.3* CHLORIDE-100 TOTAL CO2-25 ANION GAP-15
[**2185-1-24**] 07:36PM TYPE-ART PO2-501* PCO2-34* PH-7.46* TOTAL
CO2-25
[**2185-1-24**] 09:11PM LACTATE-1.1
[**2185-1-25**] 1:17 am CSF;SPINAL FLUID Source: LP.
GRAM STAIN:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS
SEEN.
FLUID CULTURE: NO GROWTH.
[**2185-1-25**] 01:17AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-22* Polys-2
Lymphs-49 Monos-49
[**2185-1-25**] 01:17AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1011*
Polys-80 Lymphs-9 Monos-11 TotProt-77* Glucose-117
Discharge labs:
[**2185-1-31**] 11:38AM BLOOD WBC-7.3 RBC-3.57* Hgb-12.2* Hct-35.0*
MCV-98 MCH-34.2* MCHC-34.9 RDW-16.5* Plt Ct-348
[**2185-1-31**] 06:35AM BLOOD Glucose-123* UreaN-40* Creat-1.8* Na-136
K-4.7 Cl-101 HCO3-26 AnGap-14
[**2185-1-31**] 06:35AM BLOOD ALT-52* AST-45* LD(LDH)-486* AlkPhos-219*
TotBili-0.5
[**2185-1-31**] 06:35AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
[**2185-1-26**] 05:07AM BLOOD CEA-2.0 AFP-<1.0
[**2185-1-31**] 06:35AM BLOOD tacroFK-5.2
.
.
[**1-25**] Echo: The left atrium is markedly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). However, the interventricular
septum was suboptimally visualized - hypokinesis of this wall
cannot be excluded with certainty. 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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
MRI/MRA: 1. Small focus of abnoraml diffusion signal intensity
in the subcortical white matter of the left cerebral hemisphere
lateral to the body of the corpus callosum without corresponding
signal abnormality in the ADC map. These findings may represent
a subacute or late ischemic vent.
2. Two-third stenosis involving the proximal right internal
carotid artery. The severity of the stenosis is not constant and
was measured using the best plane possible, however, it may be
underestimated. If clinically indicated, a CTA may be helpful
for further characterization.
3. Small air-fluid level in the right maxillary sinus.
.
CT abd/pelvis:
1. Large hypoattenuating liver mass and two smaller
hypoattenuating liver
lesions are incompletely characterized on this non-contrast
study. For
further evaluation in this patient with rising creatinine and
renal
transplant, ultrasound is recommended for further evaluation.
2. Soft tissue mass seen anterior to the calcified splenic
artery is
continuous with the pancreatic tail and the gastric wall.
Findings are
concerning for either a gastric mass or a pancreatic mass with
extension into the stomach wall.
3. Status post right pelvic renal transplantation.
4. Extensive vascular calcifications. Vascular stent in the
right external iliac artery, the patency of which cannot be
evaluated on this non-enhanced study.
5. Small bilateral pleural effusions with dependent atelectasis.
6. Status post CABG.
.
US abd: : Multiple nonspecific hypoechoic liver lesions
concerning for
malignant process. Pancreatic lesion not imaged due to overlying
bowel gas.
Brief Hospital Course:
This is a 62 y/o with multiple prior episodes of altered MS due
to hypoglycemia, CAD, ESRD s/p transplant who presents with
unexplained, acute change in mental status.
.
# Altered Mental Status: Etiology unclear, pt found at home
unresponsive. At the time, his FSBS was within normal limits.
Broad workup undertaken. There was no clear evidence for
infection: CXR was clear, neg UA, blood cultures were without
growth. CSF negative, cultures negative, as well as crypto
antigen in CSF, HSV PCR and JCV PCR.
Toxic-metabolic evaluation notable for tox screen positive for
opiates and tylenol (level in 40s). Pt treated with NAC for
possible tylenol OD, though LFTs were never significantly
elevated. Despite report of Klonipin bottle at patient's side
when he was found down, there were no benzos in his tox screen.
Once MS cleared, pt reported having no clear recollection of the
events prior to his LOC. However, he denied suicidal thoughts
and feelings of depression.
Neurologic evaluation for his mental status changes included an
MRI/ MRA, which showed no obvious CVA, though there was a small
focus of abnormal diffusion signal intensity in the subcortical
white matter. Neurology was consulted and did not believe these
findings to be causing encephalopathy. Imaging also showed ICA
& verterbral stenosis, both of which were thought to be unlikely
related to his presentation. There was a question of the
patient having seizure activity at the OSH, and thus he was
dilantin loaded there. As above, his LP was negative, cultures
no growth. EEG at [**Hospital1 18**] showed encephalopathy but no seizure
activity.
The patient's mental status gradually cleared, and eventually
returned to baseline. No clear cause for his MS changes was
ever found.
.
# Fever: New onset [**1-26**] CXR showed possible retrocardiac
opacity and now on vent for > 48 hrs. UA negative. Blood and
urine cult drawn, remain negative. Sputum cult growing only OP
flora. Was cover for VAP with vanc and cefepime, however d/ced
on [**1-28**].
.
# Liver masses: The patient was found to have 3 masses in the
liver and one contiguous w/ panc tail and gastric wall on an
abdominal CT done as part of evaluation of mental status
changes. Concern for lymphoma given LDH and renal transplant on
immunosuppressive. IR was consulted for biopsy of the
lesion(s). They requested that the patient be off of ASA for a
full 5 days. The patient was scheduled for an outpatient biopsy
on [**2185-2-2**].
.
#DM: history of 4 hypoglycemic episodes leading to "coma"
according to family. BG ok on all hosptial records. Possible
having prolonged MS change in setting of hypoglycemia. However
BG elevated on presentation. BG now stable on current dosing
regimen. No documented hypoglycemia.
.
#ESRD s/p transplant: Cr 2.0 at baseline. Continued prograf,
azthioprin, prednisone.
.
#CAD: S/p CABG, per family recent cath at [**Hospital3 **]. Statin held
due in setting of possible Tylenol OD/slightly elevated LFTs.
[**1-25**] EKG showed improved conduction delay compared to EKG on
admission pointing towards ingestion.
.
# HTN: continue clonidine, lasix. Increased coreg to 25 [**Hospital1 **]
Medications on Admission:
aspirin 81 mg daily
lasix 20 mg daily
carvedilol 12.5 mg [**Hospital1 **]
prograf 0.5 mg [**Hospital1 **]
azathioprine 50 mg daily
protonix 40 mg daily
prednisone 2.5 mg daily
lipitor 40 mg qhs
bactrim ds three times per week
clonidine 0.1 mg [**Hospital1 **]
lyrica 75 mg tid
lantus 24 u qhs
novolog sliding scale 61-100 no units, 101-150 4 units, 151-200
6 units, 201-250 8 u, 251-300 10 u, 301-350 12 u, 351-400 14 u,
> 400 16 u
clonazepam 1 mg prn anxiety
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): A.K.A Prograf.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin rash: Apply to groin as
needed for rash. .
Disp:*1 tube* Refills:*0*
10. Insulin
Lantus 24 units every evening.
Novolog sliding scale
71-200 mg/dL 0 Units
201-250 mg/dL 2 Units
251-300 mg/dL 4 Units
301-350 mg/dL 6 Units
351-400 mg/dL 8 Units
11. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day:
Hold if feeling light-headed.
Disp:*60 Tablet(s)* Refills:*1*
12. Novolog 100 unit/mL Solution Sig: Per Sliding Scale
Subcutaneous With Meals and at bedtime: See sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Altered Mental Status - unknown etiology
Liver biopsy
Diabetes
End-stage renal disease s/p transplant
CAD
Discharge Condition:
Good, ambulating, stable vitals.
Discharge Instructions:
You were admitted for altered mental status of unclear source.
You had a CT abdomen which demonstrated liver masses which will
be biopsed on Wednesday [**2-2**]. It is very important you
attend this appointment, see instructions below.
.
We have made the following changes to your medication:
1) Increased Carvedilol to 25 mg twice a day
2) Stopped your Lipitor, please have your liver function tested
before re-starting this medication
3) Started Nystatin cream for your groin skin infection.
Continue to use this until the rash resolves.
4) Decreased your Novolog sliding scale - follow the sliding
scale on your medication list print out.
5) Your aspirin was stopped for the liver biopsy. The doctors
who [**Name5 (PTitle) **] the procedure will tell you when you can restart this.
.
Please attend the following appointments:
1) Liver biopsy: [**2185-2-2**] 10:15a [**Telephone/Fax (1) 327**] [**Telephone/Fax (1) 703**] WEST
INTERVENTIONAL/PROSTATE US CC CLINICAL CENTER, [**Location (un) **] [**Hospital Ward Name 12837**]. Arrive at 8:45 am DayCare Unit, [**Hospital1 **] 1, [**Hospital Ward Name 121**]
Building - ask for directions at entrance. Nothing per mouth at
midnight the night before. No Aspirin, Tylenol, Ibuprofen before
hand.
2) [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:01/27/0 8:20
3) [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2185-4-29**]
9:10
.
Return to the ER or call your doctor if you experience fever,
chills, dizziness, nausea, vomiting or any other concerning
symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 703**] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2185-2-2**] 10:15
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2185-3-8**] 8:20
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2185-4-29**] 9:10
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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|
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|
332, 376
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,040
| 186,401
|
5864
|
Discharge summary
|
report
|
Admission Date: [**2165-5-31**] Discharge Date: [**2165-6-10**]
Date of Birth: [**2085-1-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
7.7cm AAA
Major Surgical or Invasive Procedure:
[**6-3**] endovascular AAA repair
History of Present Illness:
80 y.o male presented to [**Hospital3 **] with w/ 1 day h/o L
buttock/groin pain; worked up w/ abd CT which revealed
non-ruptured 7.7 cm infrarenal AAA. Transfered to [**Hospital1 18**] SICU for
monitoring and BP control. Surgery tomorrow.
Past Medical History:
PMH: HTN, COPD, Open Chole, Colon CA- sp Colectomy
Social History:
Lives in [**Location 13588**] with daughter, son-in-law and grandson
Wife is deceased.
Retired
Quit tobacco [**2143**]
Occasional ETOH (3 beers/per week)
Family History:
Brother has resting tremor/Possible Parkinsons
Physical Exam:
S:
Patient reports that he is feeling great today. Denies any
concerns. Denies CP and abdominal pain. Reports that his
breathing is at baseline. Appetite good.
.
O:
98.0 Tm- 99.0 148/80 n(145-[**Medical Record Number 23209**]) 86 22 94% 2L NC
Gen- Pleasant elderly man sitting up in bed. Cooperative.
Attentive with questions. NAD.
Cardiac- Distant heart sounds. RRR. S1 S2. No m,r,g.
Pulm- Improved air movement compared to last week. CTAB.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e. Left thigh very atrophied. 1+ DP pulses
bilaterally.
Neuro- Much more attentive and focused than last week. Answering
questions appropriately. Oriented to self and [**Hospital1 **] in [**Location (un) 86**]. Not
oriented to the date.
Pertinent Results:
[**2165-6-7**] 05:50AM BLOOD WBC-7.8 RBC-3.46* Hgb-9.7* Hct-29.8*
MCV-86 MCH-28.2 MCHC-32.7 RDW-16.0* Plt Ct-277
[**2165-6-7**] 05:50AM BLOOD Plt Ct-277
[**2165-6-7**] 05:50AM BLOOD Glucose-85 UreaN-24* Creat-0.5 Na-141
K-3.8 Cl-100 HCO3-36* AnGap-9
[**2165-6-7**] 05:50AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.1
Brief Hospital Course:
[**2165-5-30**]: 80 y.o male presented to [**Hospital3 **] with w/ 1 day
h/o L buttock/groin pain: worked up w/ abd CT which revealed
non-ruptured 7.7 cm infrarenal AAA. Transferred to [**Hospital1 18**] SICU
for monitoring and BP control. HCT stable.
[**2165-5-31**] Dr. [**Last Name (STitle) **]/Cardiology consult obtained. Given size of AAA,
did not recommend PMIBI or Echo to delay surgery. Betablocker
continued..
Blood pressure controlled with home meds and nicardipine gtt.
Preop confusion noted. Surgery scheduled for [**2165-6-3**].
[**2165-6-3**] Underwent Percutaneous Endovascular abdominal aortic
aneurysm
repair using Zenith 28-125 graft. Extubated in PACU. Doing well,
following commands, transferred to VICU.
[**2165-6-4**]: No acute events. VSS. Hemodynamically stable.OOB to
chair. B/L DP/PT dopplerable.
[**2165-6-5**]: No acute events. VSS. Physical therapy requesting
rehab. Continue pulmonary toilet and ambulation. Tolerating
regular diet. Podiatry consulted for toenails. Nails reduced and
palliative care q13weeks recommended.
[**2165-6-6**]: VSS. 90%RA. ASA restarted. patient more confused,
requiring O2-Primary care MD [**Name (NI) 653**]. Geriatrics consult
obtained. Neurology consult obtained per family request, patient
with history of hand tremors. Chest x-ray showing mild pulmonary
edema.
Neurology Consult:
Reason for Consult: Tremors, question of Parkinson's
HPI: The patient is a 80 year-old RH man who is POD3 from a AAA
repair and referred for tremors and question of Parkinson's
disease per family request. With regard to present hospital
stay, he presented on [**5-30**] with L buttock pain and found to have
a 7.7 cm infrarenal AAA, which was repaired on [**6-3**].
Post-operative course is significant for O2 rqmt due to COPD and
leg weakness working with PT. Plan for discharge to rehab for
further PT.
At baseline, the patient is high functioning, able to perform
ADL's with some assistance for fine motor tasks. Daughter
reports he walks with occ use of cane but really should use a
walker due to leg weakness. He reports a tremor in his R hand
only for past 2 years (daughter has observed in both hands).
The
tremor has become more "annoying," but he denies increased
frequency or significant interference with ADLs. The tremor
does
not occur at rest and is only noticeable when he is using his
right hand, for example to pour water into a cup. The tremor
does not involve upper arms, LE, or lips/jaw. He denied any
difficulties with speech or swallowing, slowed motor activity,
visual or hearing changes (baseline glaucoma), focal weakness,
numbness, paraesthesia, bowel or bladder incontinence. He
denies
any falls.
Neurologic:
-Mental Status: Alert, oriented month - [**Month (only) **], date -
initially stated 19- something, self corrected [**2165**], hospital _
[**Hospital1 **]. Attention moderate with some distractibility, able to name
[**Doctor Last Name 1841**] backwards accurately in 3 m with some pausing. Able to
relate history, though with some confusion (believed surgery on
13th and thought he had been in hospital for over 1 wk). Encode
[**4-13**], Registration [**2-13**], Recall 0/3 - 0/3 w/ prompting.
Difficulty naming low frequency object (hammock). + L/R
confusion - likely attention related. Language is fluent with
intact repetition and comprehension. Speech was not dysarthric.
[**Location (un) **] intact. Writing illegible due to tremor.
-Cranial Nerves: Olfaction not tested. PERRL 4 to 3mm. There
is
no ptosis bilaterally. EOMI without nystagmus. Facial sensation
intact to pinprick. No facial droop, facial musculature
symmetric. Hearing intact to finger-rub bilaterally. Palate
elevates symmetrically. 5/5 strength in trapezii and SCM
bilaterally. Tongue protrudes in midline.
-Motor: Diffuse atrophy most prominent in L thigh. Paratonia UE,
normal tone LE. No pronator drift bilaterally, UE and LE
postural tremor noted bilateral R>L , 5 Hz, low amplitude.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc [**First Name9 (NamePattern2) **] [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 4 3 3 4+ 5 0 0
R 5 5 5 5 5 5 5 4 5 4+ 4+ 5 0 0
-Sensory: Moderately decreased (~50%) vibration in stocking
distribution bilat LE. UE vibration intact. No deficits to
light touch, pinprick throughout.
-Coordination: Worsened tremor bilaterally with FNF. Heel-shin
without difficulty bilaterally. Finger tapping mildly slowed,
poor accuracy and missing target. No rebound or overshoot in UE.
Writing elicits tremor and signature is illegible.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
-Gait: Deferred
Laboratory Data:
K: 4.3 Ca: 8.0 Mg: 2.0 P: 2.5
86
9.6 \ 10.0 / 220
30.0
CXR [**6-3**]: Heart size and aortic calcification remain stable.
Hyperinflation of the lung fields consistent with emphysema is
again noted. Irregular and indistinct contours of the lung
bases
and medial portions of the hemidiaphragms is noted, suggesting
new pleural effusions and adjacent opacities (atelectasis versus
infection).
Assessment and Plan: The pt is a 80 year-old man h/o HTN, COPD,
and recent AAA repair, with bilat extremity tremor and L leg
weakness. His neuro exam was significant for mild postural and
moderate-severe intention tremor, L leg weakness, and mildly
decreased vibratory sensation in stocking distribution.
In terms of his tremor, we would not classify it as
Parkinsonian as it does not occur at rest. More likely, it is
an
essential tremor (positive family history, action/postural).
Albuterol may worsen his tremor due to sympathetic effect, and
therefore tremor may be exacerbated by worsened lung function.
Stress/anxiety of hospitalization may also contribute.
Treatment
for essential tremor would be beta-blocker, and he is already on
metoprolol for BP control. However given acute medical issues,
we would consider treatment only after recovery from acute
illness. Recommended the daughter plan follow-up with an
outpatient neurologist.
His attention and cognitive function also appears worse than
baseline (usu reads paper, takes care of bills). He has some
CO2
retention and compensatory metabolic alkalosis from COPD, but is
likely chronic. No signs of infection that could contribute to
metabolic encephalopathy. Both ativan and narcotics for pain
could worsen confusion in hospital setting, would minimize use
if
possible.
His leg weakness is significant due to large resection of L
thigh for tumor. He also has generalize muscle atrophy.
Further
work with PT should benefit him. For his safety, patient should
use walker for assistance (discussed with daughter who agrees).
His peripheral neuropathy is moderate but due to his already
unstable gait may be advisable to check vitamin B12, thiamine,
TSH levels.
- F/u outpatient neurologist
- Check TSH, vitamin B12, thiamine
- PT and use of walker
[**2165-6-7**]: VSS, confused. 92% 1L. Geriatrics, physical therapy
following.
[**2165-6-8**]: VSS, 91% on 1L. Confusion clearing. Continue OOB with
nursing/ PT. Aggressive pulmonary toilet.
[**2165-6-9**]: VSS, 92%1L. Dopplerable DP/PT. Lopressor increased.
Groins without evidence of erythema or infection.
[**2165-6-10**]: No overnight events. VSS. 95% on 1Liter NC
Delirium/Confusion greatly improved. Plan discharge to rehab.
Will require continued oxygen until O2 at RA is 91-93%. To
follow up with Dr. [**Last Name (STitle) **], Poditary and Neurology.
Geriatric MD saw patient prior to discharge:
Geriatric Fellow Consult Note
.
Vascular surgery requested consult for confusion and increased
oxygen requirement
.
S:
Patient reports that he is feeling great today. Denies any
concerns. Denies CP and abdominal pain. Reports that his
breathing is at baseline. Appetite good.
.
Urine culture ([**6-6**])- neg
Blood culture ([**6-2**])- neg
.
A/P:
80 y/o M with PMH significant for HTN, COPD, and glaucoma
admitted to the vascular surgery service on [**5-31**] for a AAA
repair. Consult requested for assistance with confusion and
increased oxygen requirement.
.
1. Mental status- Patient continues to show some evidence of
delirium at this time but overall much improved--- nursing note
does report some confusion earlier this morning. Much more
attentive. No aggitation. Delirium in this man is most likely
multifactorial due to surgery, medical issues, age, and possible
infection. ETOH as a cause is also very concerning given his
history of drinking and hallucinations.
- Must consider respiratory status as possible cause of the
patient's delirium. Has a history of COPD with baseline SOB with
exertion. Oxygen as needed to maintain saturation of 91-93%.
Would not want higher saturation given COPD history. Started on
steroid inhaler [**6-6**] with improvement.
- Medications are frequent contributors to delirium in the
elderly. If pain med needed, would utilize tylenol. Would not
start on scheduled at this time as he denies any pain.
- Patient reports that he drinks three beers per week. Despite
this report, concern that he could be having some withdrawal.
Continue on folic acid 1 mg daily and thiamine 1 mg daily.
- Nonpharmacologic management is the mainstay of delirium
treatment. Please provide frequent reorientation for the
patient. He should be out of bed as much as possible during the
day. Continue with PT consulting. Monitor closely off the
sitter. Family should be encouraged to be at the bedside as much
as possible.
- Sensory input is very important in delirium. Patient has
glaucoma so please provide visual orientation as needed.
- Pharmacologic treatments for delirium should only be used if
the patient is a risk to himself or others. In that case, could
use haldol 0.5 mg up to TID PRN or olanzapine 2.5 mg TID PRN.
Would be inclined to uses olanzapine instead of haldol even
though tremor appears to be essential tremor. Has not required
these for over three days.
- Do not use physical restraints. They do not prevent falls or
pulling out lines. They worsen delirium and can lead to
injuries.
.
Pulm- Patient with increased oxygen requirement since admission
but overall respiratory status appears much more comfortable.
Still has some varying oxygen requirement which is most likely
due to his COPD. Started on steroid inhaler [**6-6**]. Improved air
movement at this time. Continue to monitor closely. Oxygen as
needed to maintain saturation of 91-93%.
.
Dispo- DC to rehab.
.
Medications on Admission:
lisinopril 40mg', HCTZ 12.5', atenolol 100mg', felodipine 5',
albuterol,terazosin 2', lovastatin 20', asa 325
Discharge Medications:
1. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
2. Atorvastatin 20 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 Q24H (every 24 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Felodipine 5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily): hold for SBP <
100 mmHg and HR < 60/ min .
7. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic HS (at
bedtime) as needed for glaucoma: OD HS glaucoma .
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Until ambulatory.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): HOLD HR<55 SBP<100 .
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. Regular Insulin Sliding Scale
Prior to meals
0-60 mg/dL 1 amp D50
61-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
351-400 mg/dL 10 Units
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
8cm AAA, now repaired
PMH: HTN, COPD, Open Chole, Colon CA- sp Colectomy
Discharge Condition:
Good. VSS.
Confusion improving
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**3-16**]
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 [**5-17**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) 1111**],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3121**] Call to schedule
appointment
Call [**Hospital **] Clinic to schedule follow up ([**Telephone/Fax (1) 4335**].
Recommend f/u every 12 weeks unless toenails addressed at rehab.
Call Neurology to schedule follow up of Tremors/Parkinson's
evaluation at([**Telephone/Fax (1) 2528**]. Inital evaluation was performed
while inpt at [**Hospital1 18**]. The Attending neurologist that saw you
while in patient was Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] phone ([**Telephone/Fax (1) 23210**]
Completed by:[**2165-6-10**]
|
[
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icd9cm
|
[
[
[]
]
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[
"39.71"
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icd9pcs
|
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[
[]
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324, 360
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46,551
| 165,054
|
54505
|
Discharge summary
|
report
|
Admission Date: [**2111-9-24**] Discharge Date: [**2111-9-28**]
Date of Birth: [**2056-6-6**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Mercaptopurine / Canasa / Clindamycin Hcl
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2111-9-24**]
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Small-bowel resection.
4. Repair of internal hernia.
5. Primary anastomosis.
History of Present Illness:
55F with hx of Crohn's disease s/p total abdominal colectomy
with ileorectal anastomosis in [**2107**] presents with severe
abdominal pain for 1.5 days. Patient experienced sudden onset of
abdominal pain after dinner on [**2111-9-22**] and several episodes of
vomiting. She has not been passing flatus or having bowel
movements for at least 2 days. She has never had symptoms like
this before. Since her colectomy, her UC has not been active and
she has been completely off steroids.
On arrival in the ED around 1 pm (per patient), patient was
tachycardic to 120s and complaining of RLQ pain. Her HR came
down
to low 100s with 2L of fluid. Her pain worsened while in the ED
over a period of 10 hours. Surgery was consulted at 10:45 pm for
CT findings of SBO with a transition point. An NGT was placed at
that time with 400 cc of CT contrast effluent. A foley was
placed
with clear, yellow, urine. On exam, she complained of severe RLQ
pain, though her nausea had largely resolved. Stat repeat labs
were sent.
Past Medical History:
UC, osteoporosis (2 steroids), knee OA, kyphosis and compression
fractures, ovarian cysts, Notalgia paraesthetica on back, HTN,
hyperlipid, GERD, anxiety/depression, CBP
Social History:
Lives in group home due to mental illness, denies tobacco,
alcohol, and illicit drug use
Family History:
non contributory
Physical Exam:
Temp 98.8 HR 120 BP 143/98 RR 18 RA O2 sat 99%
Gen: Appears uncomfortable, distressed
CV:RRR
Resp: CTAB
Abd: distended, very tender in RLQ to percussion and palpation.
+rebound and guarding. Umbilical hernia palpable.
Ext: Warm, well perfused
Pertinent Results:
[**2111-9-23**] 01:50PM WBC-22.5*# RBC-5.14 HGB-15.4 HCT-47.0 MCV-92
MCH-29.9 MCHC-32.7 RDW-12.5
[**2111-9-23**] 01:50PM NEUTS-86.6* LYMPHS-8.8* MONOS-3.5 EOS-0.9
BASOS-0.3
[**2111-9-23**] 01:50PM PLT COUNT-391
[**2111-9-23**] 01:50PM ALT(SGPT)-27 AST(SGOT)-52* ALK PHOS-73 TOT
BILI-0.5
[**2111-9-23**] 01:50PM LIPASE-28
[**2111-9-23**] 01:50PM GLUCOSE-110* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-27 ANION GAP-21*
[**2111-9-23**] 07:35PM LACTATE-1.7
[**2111-9-23**] CT Abd/pelvis ;
1. Status post total colectomy. Abnormal fecalized loop of small
bowel in
the right lower quadrant with adjacent fluid and fat stranding
raising concern for a small bowel obstruction, with closed loop
obstruction not excluded. A repeat study of the pelvis after
oral contrast administration could better evaluate this finding.
2. 3 cm left adnexal cyst can be further evaluated on nonurgent
pelvic
ultrasound.
3. Stable spinal degenerative changes.
4. Stable ventral hernias containing a small amount of fat and a
small loop of nonobstructed bowel.
[**2111-9-23**] CT pelvis :
Small bowel obstruction with a mildly dilated small bowel loop
in
the right lower quadrant with fecalized material and a
transition point.
Adjacent fat stranding and a small amount of fluid.
[**2111-9-28**] PA & Lat CXR :
There is severe scoliosis with wedge-shaped thoracic vertebra,
leading to extreme asymmetry of the thoracic rib cage and wall.
In addition, irregular rib margins and inhomogeneous bony
structures are seen bilaterally. There is moderate-to-severe
cardiomegaly with signs of mild pulmonary edema.
In addition, moderate bilateral pleural effusions with areas of
subsequent
atelectasis are seen. No evidence of pneumonia in the well
ventilated lung
areas. No pneumothorax.
Brief Hospital Course:
The patient was taken to the OR on [**9-24**] for emergent exlap. She
was found to have some ischemic small bowel which was resected
and primary anastomosis was performed. Please see operative
report for further details. Postoperatively, the patient was
managed in the ICU. Her pain was well controlled with Dilaudid
PCA. She was kept NPO/IVF with NGT in place. She had persistent
tachycardia on PO D1, but BP was stable and urine output was
strong. She did receive additional fluid boluses and IV
Lopressor was started, which helped control her tachycardia. On
[**9-25**], the patient's NGT was removed because output was minimal.
The patient was overall doing well and she was transferred to
the floor.
Following transfer to the Surgical floor she continued to do
well. Her tachycardia resolved after full fluid resuscitation
and her Lopressor was discontinued. Her diet was slowly
advanced after full bowel function was attained and she
tolerated it well without nausea or vomiting. Her abdominal
incision had some mild erythema which resolved on its own and
was healing well. Her oxygen saturations were in the low 90% on
room air. A chest xray was done which showed bilateral small
effusions and atelectasis. She also has severe kyphosis which
contributes to her pulmonary deficits. She is able to cough and
deep breath along with use her incentive spirometer.
Prior to discharge, electrolytes were checked and she was found
to have a potassium of 2.8 and a phosphorus of 1.0. She
received 40 meq of Potassium Chloride and 1 packet of
Neutra-Phos prior to leaving and she will continue Neutra-Phos
TID for 3 days as well as take an additional dose of Potassium
40 meq tonight. After an uneventful recovery she was discharged
to home on [**2111-9-28**] and will follow up in the [**Hospital 2536**] Clinic in 2
weeks for staple removal.
Medications on Admission:
Calcium-Vit D, pantoprazole 40', reclast 5 yearly, simvastatin
10', immodium, sucralfate 1', MV, folic acid 1, flonase prn
Discharge Medications:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal once a day as needed for allergy symptoms.
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once: take with dinner.
Disp:*2 Tablet, ER Particles/Crystals(s)* Refills:*2*
10. medication
Nutra-Phos
sig 1 packet PO TID for three days
Dispense 10 packets
No refills
Discharge Disposition:
Home
Discharge Diagnosis:
1. Intestinal obstruction.
2. Internal hernia.
3. Intestinal necrosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 [**4-14**] 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.
*Your staples will be removed at your follow-up appointment.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 weeks for staple removal
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2111-10-8**] 12:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33176**], M.D. Phone:[**Telephone/Fax (1) 96976**]
Date/Time:[**2111-11-11**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time:[**2111-12-22**] 10:10
Completed by:[**2111-9-28**]
|
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"54.59",
"45.62",
"53.9"
] |
icd9pcs
|
[
[
[]
]
] |
6997, 7003
|
3966, 5817
|
335, 483
|
7118, 7118
|
2144, 3943
|
9125, 9725
|
1839, 1857
|
5991, 6974
|
7024, 7097
|
5843, 5968
|
7269, 8727
|
8743, 9102
|
1872, 2125
|
281, 297
|
511, 1523
|
7133, 7245
|
1545, 1716
|
1732, 1823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,930
| 184,037
|
24036
|
Discharge summary
|
report
|
Admission Date: [**2121-5-12**] Discharge Date: [**2121-5-16**]
Date of Birth: [**2047-1-17**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
History of hematuria, left renal tumor on CT with left hilar and
lung mets, presented for debrieding nephrectomy
Major Surgical or Invasive Procedure:
Left radical nephrectomy
Thrombectomy
chest tube placement
nasogastric tube placement
central line (internal jugular vein) placement
arterial line placement
Foley catheter placement
History of Present Illness:
Mr. [**Known lastname **] is a 74-year-old
gentleman with a chief complaint of metastatic left renal cell
carcinoma. He had an episode of gross hematuria
approximately one year ago that spontaneously resolved. He had a
repeat episode of gross hematuria in [**2120-12-17**]. This was
followed up by a CT scan of the abdomen and pelvis, which
demonstrated a large 10-12 cm left upper-to-mid pole renal mass
and some metastatic foci have been identified in the pleura and
the hilar region. He also had a cystoscopy by his local
urologist that showed no evidence of abnormality in the bladder.
He presents for a left debrieding nephrectomy.
Past Medical History:
Diabetes (diet controlled)
Hypertension
Bilateral cataract surgery
Circumcision
Social History:
He is a retired machinist and he had a
25-pack-year history of smoking and he smoked approximately [**2-18**]
cigarettes per day presently. He drinks 2 caffeinated products
per day and no alcoholic beverages.
Has very supportive wife and extended family
Family History:
No evidence of kidney cancer in the family.
Physical Exam:
Temp: 97.9 HR 74 BP: 138/70 RR:18 95% on room air
Alert and oriented. Sclerae non-icteric. Puppils round and
reactive to light.
Regular rate and rhythm. Normal S1 and S2 with nor murrmurs,
rubs appreciated
Lungs clear to auscultation. Decreased breath sounds on R > L at
bases
Thorax: Left lateral incision withwout drainage. Staples and
sutures intact. Mild erythema at lateral margin of wound,
improved from evening of [**2121-5-15**]. Erythema is less pronounced
but more diffuse/larger in area.
Abdomen soft, non-tender, non-distended. Obese abdomen. Tatoo on
lower abdomen.
GU: Foley in place. No blood at meatus. Circumcised. Normal
male anatomy.
Ext: warm and well perfused. No cyanosis, clubbing, or edema.
Pertinent Results:
[**2121-5-12**] 10:41PM WBC-7.6 RBC-2.92* HGB-8.7* HCT-24.2* MCV-83
MCH-29.8 MCHC-36.0* RDW-15.0
[**2121-5-12**] 10:05PM TYPE-ART PO2-190* PCO2-39 PH-7.38 TOTAL
CO2-24 BASE XS--1
[**2121-5-12**] 10:05PM TYPE-ART PO2-190* PCO2-39 PH-7.38 TOTAL
CO2-24 BASE XS--1
[**2121-5-12**] 09:47PM GLUCOSE-160* UREA N-17 CREAT-1.0 SODIUM-139
POTASSIUM-4.5 CHLORIDE-112* TOTAL CO2-21* ANION GAP-11
[**2121-5-12**] 02:04PM CK-MB-4 cTropnT-<0.01
[**2121-5-12**] 02:04PM CK(CPK)-203*
[**2121-5-12**] 11:13AM TYPE-ART PO2-175* PCO2-39 PH-7.37 TOTAL
CO2-23 BASE XS--2
[**2121-5-12**] 10:41AM TYPE-ART PO2-113* PCO2-34* PH-7.46* TOTAL
CO2-25 BASE XS-0 INTUBATED-INTUBATED
[**2121-5-12**] 08:29AM TYPE-ART PO2-365* PCO2-39 PH-7.44 TOTAL
CO2-27 BASE XS-2
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2121-5-13**] 3:49 PM
CHEST (PORTABLE AP)
Reason: s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
74 year old man s/p left debulking nephrectomy
REASON FOR THIS EXAMINATION:
s/p chest tube removal
HISTORY: Status post left nephrectomy. Chest tube has been
removed.
COMPARISON: Five hours prior on [**2121-5-13**].
FINDINGS: AP upright portable view. The endotracheal and
nasogastric tubes, as well as the left chest tube, have been
removed. The right internal jugular venous catheter remains in
unchanged position, terminating in the upper SVC. There is no
pneumothorax. Intra-abdominal free air is again under the
diaphragm. Lung volumes are low. Bibasilar atelectasis is
present. The large left lateral pleural-based mass is again
seen. There is fluid or thickening in the right minor fissure.
IMPRESSION:
1. No pneumothorax.
2. Left pleural mass.
3. Postoperative intra-abdominal free air.
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a left renal debulking nephrectomy in
preparation for dendritic cell vaccine. Intraoperatively, the
tremendous vascularization of the tumor led to excessive blood
loss prompting infusion of 8 units of packed red blood cells as
well as 10 L of crystaloid. The patient experienced a brief
hypotensice episode but recovered quickly. After surgery
patient was transfered to intensive care unit in light of large
fluid load. He briefly required pressors but was weened by
[**2121-5-13**]. He was extubated, nasogastric tube, chest tube, were
discontinued and patient was transferred to the floor in good
condition. His condition continued to improve. Diet was
cautiously advanced and he tolerated POs on day 3 without nausea
or vomitting, and patient was able to tolerated full house died
by evening of [**2121-5-15**]. Epidural catheter was removed on [**5-15**] and
patient was converted to PO dilaudid with very good pain control
and no nause or vomiting. Patient remained hemodynamicaly
stable. Thoraco-abdominal wound developed mild cellulitis at
posterior margin and patient was begun on seven day course of
Keflex. Patient was discharged to home in good condition with
strict follow-up instructions.
Medications on Admission:
Lisinopril 20 mg once a day, atenolol 50 mg once
per day, hydrochlorothiazide 25 mg once per day, Pravachol 10 mg
p.o. once daily
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Continue as directed by your primary care provider.
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Continue as directed by your primary care provider.
3. Pravastatin Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Continue as directed by your primary care provider.
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2-3H as needed
for pain: Take as needed. [**Month (only) 116**] cause constipation.
Disp:*50 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q2-3h as needed
for pain: Take for pain. [**Month (only) 116**] cause constipation.
Disp:*50 Tablet(s)* Refills:*0*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for anemia: This medication may
contribute or cause constipation.
Disp:*60 Tablet(s)* Refills:*0*
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take as directed by your primary care physician.
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for wound cellulitis for 6 days: Please
continue for a total of one week.
Disp:*26 Capsule(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: Please take for
constipation. .
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Renal cell tumor.
Discharge Condition:
Good
Discharge Instructions:
having worsening pains, fevers, chills, nausea, vomiting,
shortness of breath, chest pain, worsening redness or drainage
about the wounds, or if there are any questions or concerns.
Patient to take antibiotics and other medications as directed.
Please continue to take medications you normally take at home.
Patient not to drive or operate heavy machinery while on any
narcotic pain medication such as percocet as it can be sedating.
It is advised that you do not drive a car for the first three
weeks after your surgery unless you are specifically cleard by
your surgeon. Patient to take colace to soften the stool as
needed for constipation as narcotic pain medication can cause
this issue.
Patient to avoid strenuous activity or lifting heavy objects for
the first 2-3 weeks after surgery.
Followup Instructions:
Please confirm your appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 61158**]
([**Telephone/Fax (1) 61159**]) to remove your staples and sutures. Your
appointment is scheduled for Thursday, [**2121-5-22**] at 1:00 PM.
Please call [**Telephone/Fax (1) 10941**] to confirm your appointment with Dr.
[**Last Name (STitle) 4229**] which is scheduled for Thursday, [**2121-5-29**] at 11:30
AM.
Please call to confirm your appointment in the
Hematology/[**Hospital **] clinic which is scheduled for [**2121-6-4**]. [**Hospital Ward Name **] CENTER HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2121-6-4**] 2:30
Please be aware that Dr.[**Name (NI) 13919**] office may contact you to
change your appointments so that there is better coordination
between the two appointments.
Completed by:[**2121-5-16**]
|
[
"197.0",
"227.0",
"682.2",
"401.9",
"453.3",
"998.59",
"250.00",
"189.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"38.91",
"38.07",
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
7041, 7047
|
4209, 5474
|
427, 611
|
7109, 7115
|
2474, 3349
|
7957, 8816
|
1671, 1718
|
5655, 7018
|
3386, 3433
|
7068, 7088
|
5500, 5632
|
7139, 7934
|
1733, 2455
|
275, 389
|
3462, 4186
|
639, 1279
|
1301, 1382
|
1398, 1655
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,786
| 142,903
|
52057
|
Discharge summary
|
report
|
Admission Date: [**2112-5-23**] Discharge Date: [**2112-6-3**]
Date of Birth: [**2034-6-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 yo M with DM type I, CKD (baseline Cr 1.4), history of CVA,
subacute R. foot ulcer, recent pneumonia, presented to [**Hospital1 **] ED with worsening mental status, transferred to [**Hospital1 18**]
for further management.
.
Per daughter, patient was in his normal state of health until
[**2112-5-17**], when he fainted in the bathroom. He was found by wife
in the bathtub, but had no signs of trauma or brusing. EMS
evaluated the patient and all vital signs were normal thus he
was not admitted to the hospital. On [**2112-5-20**], patient was noted
to be unsteady on his feet, lethargic, and had severe diarrhea.
Presented to [**Hospital3 **] ED on [**2112-5-21**] where he was
diagnosed with LLL pneumonia and treated with IV antbiotics. CT
head at the time showed old infarct but no acute lesions. He
clinically improved and was discharged on [**2112-5-22**] and as doing
well. At 3 AM on the day of admission, patient got up to go to
bathroom. Wife called out to him and patient reported that he
was doing well. However, by 8 AM the same morning, there were
major changes in his mental status. Patient was confused,
lethargic, weak and unable to stand. He represented to [**Hospital1 **] on [**2112-5-23**].
.
There, VS were T:99.2 BP:160/80, HR 92, O2 sat 97% 2L and
patient was noted to be rigoring. ABG 7.53/ 24/134/20 with blood
sugar of 208. Blood pressure remained stable. Repeat CXR was
unremarkable. CT head showed old left watershed infarct of
indeterminate age consistent with history of 2 prior strokes.
Mild cerebral atrophy with chronic white matter ischemic
changes. No MRI was performed. Neurologic exam was notable for
occasional aphasia but no other deficits. KUB showed stools but
no obstruction. He was transferred to [**Hospital1 18**] for further
management.
.
In the [**Hospital1 18**] ED, initial vs were: T(oral): 99.4, T(rectal): 102,
HR:100 BP:155/87 RR:16 O2sat:100% 3L NC. He proceed to desatted
to the 69% on RA, which improved to 80% on 2L NC, then 100% on
FM. His mental status was noted to be very altered. Neural exam
notable for intact gaze, reactive pupils (blind on right eye),
questionable hyperreflexia, and was moving extremities but not
following commands. Lumbar punction was performed which showed
clear CSF, WBC of 13 and 19 in tubes 1 and 4, respectively, and
RBC of 77 and 31 respectively. Protein elevated at 86, and
decreased glucose 77 (90% of serum). CSF cultures were sent.
Patient treated with 2 grams of vancomycin.
.
Of note, patient's baseline functional status is high. He is
always alert and oriented x3, and despite being hard of hearing
with residual aphasia from his stroke, he is able to hold
conversations and be independent for his ADLs. His presenting
state is thus a market departure from norm
.
On the floor, patient was arousable to voice and intermittently
follows commands. Occasionally answers yes/no questions with
slurring. He was initally tachycardic and hypertensive to the
190 systolic. ABG was 7.45/31/242/22 on facemask. Two hours
after arrival, patient was noted to have right down-looking
gaze. He then proceeded to have a violent tonic-clonic seizure.
His respiratory status decompensated acutely and he was
intubated. An a-line was placed.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Type I DM
- Hypertension
- Two strokes in [**2-8**] (second one more severe, with
aphasia)
- Benign prostatic hypertrophy
- Chronic kidney disease (baseline Cr=1.4)
- GERD (mild)
- Recent right diabetic foot infection since [**3-4**]. Amputation in
the past right third toe in [**6-2**].
- Tore right rotator cuff, no surgical intervention
- Blind in right eye since birth (from forceps trauma)
Social History:
Lives with wife in own house. Six kids all involved. Smoke:
never. Alcohol: never. Illicits: never.
Family History:
Father kidney failure. Mother of old age.
Physical Exam:
EXAM ON ADMISSION:
Vitals: T: 99.7 BP:198/100 P:128 R:11 O2:99% FM
General: arousable, minimally responsive, NAD
HEENT: Sclera anicteric, L pupil 3 mm, R pupil 4 mm. Left pupil
reactive to light. Afferent pupillary defect on the right side.
Mild esotropia. Responds to confrontation. Oropharynx clear
Neck: supple, difficult to observe JVP, no LAD
Lungs: Anterior exam, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, soft bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Skin: multiple corns on both arms, chest, no obvious rash, no
vescicles
GU: Foley in place, draining clear urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro exam: Arousable, answers "yes and no" at times, squeezes
both hands and wiggles right toes. Grimace to repositioning. Neg
Babinski. Unable to elicit reflexes. Upper extremities rigidity
with cogwheeling.
Pertinent Results:
1. Labs on admission:
[**2112-5-23**] 04:45PM BLOOD WBC-9.4 RBC-4.49* Hgb-13.6* Hct-37.6*
MCV-84 MCH-30.2 MCHC-36.1* RDW-14.1 Plt Ct-229
[**2112-5-24**] 01:05AM BLOOD PT-13.8* PTT-26.1 INR(PT)-1.2*
[**2112-5-23**] 04:45PM BLOOD Glucose-85 UreaN-20 Creat-1.5* Na-137
K-3.6 Cl-106 HCO3-19* AnGap-16
[**2112-5-23**] 04:45PM BLOOD ALT-21 AST-24 LD(LDH)-187 CK(CPK)-147
AlkPhos-63 TotBili-1.0
[**2112-5-23**] 04:45PM BLOOD cTropnT-0.02*
[**2112-5-24**] 01:05AM BLOOD CK-MB-5 cTropnT-0.02*
[**2112-5-24**] 09:17AM BLOOD CK-MB-6 cTropnT-0.03*
[**2112-5-24**] 01:05AM BLOOD Albumin-3.0* Calcium-7.3* Phos-2.1*
Mg-1.9
[**2112-5-24**] 09:17AM BLOOD Triglyc-77
[**2112-5-23**] 04:45PM BLOOD TSH-0.53
[**2112-5-23**] 04:45PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2112-5-24**] 02:23AM BLOOD freeCa-1.11*
[**2112-5-23**] 04:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2112-5-23**] 04:45PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-100 Ketone-15 Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
[**2112-5-23**] 04:45PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2112-5-23**] 04:45PM URINE Hours-RANDOM UreaN-965 Creat-149 Na-112
K-52 Cl-129
[**2112-5-23**] 04:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
2. Labs on discharge:
.
3. Imaging/diagnostics:
- CXR ([**2112-5-23**]): No acute cardiopulmonary process.
.
- MRI HEAD ([**2112-5-24**]):
1. Extensive confluent T2/FLAIR hyperintensity involving the
left frontal,
parietal, and occipital lobes with associated cortical thinning
and
destruction, particularly in the left frontal lobe, are most
consistent with encephalomalacia secondary to prior infarction.
MRA may provide further insight into the etiology of these
signal abnormalities.
2. Increased T2/FLAIR signal in the left cerebellar hemisphere
with
associated volume loss is consistent with prior infarction.
3. No hydrocephalus to indicate increased intracranial pressure.
4. No evidence of acute infarction or intracranial hemorrhage.
.
- MRI HEAD ([**2112-5-29**]): No new abnormality of the brain is seen.
Other findings discussed above.
.
- EEG ([**2112-5-24**]): This is an abnormal video EEG due to the
presence of a low voltage, slow, and disorganized background
which represents a severe
encephalopathy. There were no areas of persistent focal slowing
although occasionally, severe encephalopathy can obscure focal
findings.
There were no clear epileptiform discharges or electrographic
seizures.
.
- Renal ultrasound ([**2112-5-27**]): 1. No evidence of obstruction,
hydronephrosis, or stones. 2. Simple cyst in the upper pole of
the right kidney. 3. Decompressed bladder with Foley catheter.
.
4. Microbiology:
- Blood cultures ([**2112-5-23**]): negative
.
- Urine cultures: ([**2112-5-24**], [**2112-5-28**]): negative
.
- Sputum cultures:
GRAM STAIN (Final [**2112-5-28**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2112-5-30**]):
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
.
- CSF cultures:
GRAM STAIN (Final [**2112-5-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2112-5-29**]): NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
.
- CSF serologies:
[**2112-5-23**] 11:06PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test - negative
[**2112-5-26**] 06:09PM CEREBROSPINAL FLUID (CSF) EBV-PCR-Test Name
negative
[**2112-5-26**] 06:09PM CEREBROSPINAL FLUID (CSF) ENTEROVIRUS PCR-Test
Name
negative
[**2112-5-26**] 06:09PM CEREBROSPINAL FLUID (CSF) STATE/CDC LAB
TEST-PND
pending
[**2112-5-26**] 08:18AM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS -
PCR-Test
negative
[**2112-5-26**] 08:18AM CEREBROSPINAL FLUID (CSF) VARICELLA DNA
(PCR)-Test
negative
Brief Hospital Course:
77 yo M with DM type I, CKD (baseline Cr 1.4), history of CVA,
subacute R. foot ulcer, recent pneumonia, transferred to [**Hospital1 18**]
for altered mental status.
.
# Altered mental status: Etiologies considered include toxic
metabolic, vasular insult, or infectious. Serum/urine toxocology
screens negative and electrolytes within normal limits.
Infectious causes considered include UTI (UA negative),
pneumonia (CXR no acute process), infected foot ulcer (well
healed on exam), and skin (no obvious lesions), and finally
intracranial. Lumbar puncture result showed lymphocytic
predominance suggestive of viral encephalitis. HSV PCR, Lyme,
RPR, Enterovirus, EBV, VZV were all negative. EEE and West [**Doctor First Name **]
and CDC panel were sent and pending. Patient emperically treated
with acyclovir and vancomycin/ceftriaxone/ampicillin for
bacterial meningitis. Shortly after arrival in the ICU patient
witnessed to have tonic-clonic seizure and was urgently
intubated for airway protection. Infectious disease and
neurology consulted. Two MRIs were performed which showed
chronic changes from prior strokes but no acute findings. Two
EEGs were which showed signs of severe encephalopathy but no
seizure focus. At the request of the family, patient was
extubated and made CMO. He finally expired on [**2112-6-3**] at 945
AM.
.
# Volatile blood pressure: Blood pressure was fairly volatile
initially, with sBP in the 80s shortly after intubation and then
up in the 180s while agitated. Aggressively fluid resuscitated.
Ventilatory settings were adjusted accordingly and Labetalol up
titrated to 1200 mg PO/NG Q8H. All antihypertensives were
stopped after patient made CMO.
.
# Acute on chronic kidney disease: Per report, baseline Cr 1.4.
Initially worsened and Cr peaked 3.2. Renal was consulted and
thought etiology most likely ATN. All medications were renally
dosed and ACE-I held. Renal ultrasound showed simple cysts but
no hydronephrosis. Renal function improved and Cr was 1.8 prior
to being made CMO. Patient was able to maintain urine output
throughout.
.
# GI bleed: Patient had occult positive NGT aspiration as well
as stool on HOD #7 most likely from gastritis. Patient placed on
[**Hospital1 **] PPI.
.
# Right foot ulcer: Continued routine wound care.
.
# Type I Diabetes mellitus: Controlled with insulin sliding
scale.
Medications on Admission:
- Lantus 100 units qAM
- Simvastatin 20 mg po qAM
- Plavix 75 mg qAM
- Verapamil ([**12-27**] of 120 mg ? E.R. pill) 60 mg qAM
- Lisinopril 10 mg qAM
- Prilosec 20 mg aPM
- Lexapro (Escitalopram) 10 mg po qnoon
- Onglyza (saxagliptin) 5 mg qPM
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"348.30",
"047.9",
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"600.00",
"V66.7",
"V49.86",
"707.15",
"438.11",
"995.92",
"V58.67",
"780.39",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"03.31",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12395, 12404
|
9754, 9932
|
326, 332
|
12455, 12464
|
5590, 5598
|
12520, 12530
|
4531, 4575
|
12425, 12434
|
12127, 12372
|
12488, 12497
|
4590, 4595
|
264, 288
|
6902, 9731
|
3608, 3978
|
360, 3590
|
5612, 6883
|
9947, 12101
|
4000, 4398
|
4414, 4515
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,926
| 134,891
|
5297+5298
|
Discharge summary
|
report+report
|
Admission Date: [**2187-5-21**] Discharge Date: [**2187-5-24**]
Date of Birth: [**2128-9-25**] Sex: M
Service: MEDICINE
Allergies:
sulfites / [**Doctor Last Name 5942**] Juice, Lime Juice, Sauerkraut
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Mr. [**Known lastname 1557**] is a pleasant 58yo gentleman with multiple myeloma
day +20 s/p auto transplant who was recently dischared [**2187-5-17**].
His hospital course was complicated by typhlitis, and he was
discharged home to complete a course of Flagyl when symptoms
improved. He was seen in clinic the day after discharge. He
complained of nausea with the Flagyl tablets, so given clinical
resolution of typhlitis, Flagyl was d/c'ed. He reports poor
appetite at home. He and his wife went on a trip to [**Hospital3 635**]
yesterday to visit his mother and he reported feeling nausea at
the dinner, not being able to eat much. Reports diarrhea x1 day.
Highest temperature the day prior to admission was 100.2, so
they waited at home over night and came in the morning. The
fever had gone down to 99 this morning. Feeling anxious.
Past Medical History:
Past Oncologic History:
The patient developed anemia in [**2174**] which was treated with iron
for 3 years without satisfactory improvement. A more extensive
workup of his anemia revealed an IgG lambda monoclonal component
on his SPEP and UPEP. A bone marrow biopsy in [**10/2178**] showed 8%
plasma cells and his skeletal survey was negative. He was
followed for MGUS and remained relatively stable.
.
In late [**2186-7-19**] he developed skin lesions on his arms,
legs, and back and continued to have fatigue. Re-evaluation by
his PCP at that time revealed worsened anemia and new mild renal
insufficiency. SPEP in late [**2186-9-18**] revealed a significant
increase of IgG lambda to greater than 6 grams.
.
He was first seen in the oncology clinic in late [**2186-10-18**]
and was shortly after diagnosed with multiple myeloma, IgG
lambda, with plasma cells = 80% of marrow cellularity on
[**2186-11-13**]. A skeletal survey was negative, and cytogenetics were
notable for a deletion at 13q14.3.
.
[**2186-12-22**] = C1D1 bortezomib 1.3 mg/m2 d1,4,8,11 + dexamethasone
20mg d1,2,4,5,8,9,11,12 of 21 days cycle. Complicated by
vomiting and d11 bortezomib was held. Zometa 3.3mg q4wks
started.
.
[**2187-1-12**]: C2D1, no complications.
.
[**2187-2-2**]: C3D1, Zometa increased to 4mg.
.
[**2187-2-23**]: C4D1. Monoclonal IgG decreased by >90% (still detectable
in blood and urine), and bone marrow biopsy with <5% plasma
cells, indicating VGPR. Plan was made to proceed withautologous
stem cell transplant followed by PD-1 treatment, as part of
clinical trial 09-061.
.
[**2187-4-5**]: Admit for high dose cytoxan stem cell mobilization.
[**2187-4-15**]: Admit for fever [**12-20**] neupogen tx
.
Other Past Medical History:
- Sleep apnea - [**2175**]
- Hemorrhoids - [**2151**]
- Anemia - [**2174**]
- Fainting at high altitudes - since childhood
- Asthma - since childhood
- Seasonal allergies - since childhood
- Low Back pain - [**2176**] - resolved with acupuncture in [**3-/2185**]
- Gout - [**2161**]
- Kidney stones - [**2161**]
- Eczema - since childhood
- MGUS - [**10/2178**], now Multiple Myeloma [**2185**]
Surgical Hx:
- Cholecystectomy [**2180**]
Social History:
(from OMR, patient)
- Lives at home with wife, [**Name (NI) **]. They just rented a new
apartment near the hospital in [**Location (un) **]. Used to split his time
between an apartment in [**Location (un) 7349**] and [**Location (un) 86**] when he started a new job
6 mo ago working for lower [**Location (un) 21601**] Arts Council
- Married for 28 years
- Has 2 sons age 21 and 24
- Never smoker
- Has about 1 alcoholic drink per week
- Very distant history of drug use
- Has some dietary restrictions since cholecystectomy
Family History:
(from OMR)
- Mother alive at 80, no family history of cancer, hypothyroid,
aortic aneurism
- Father died at 86 from lung cancer
- 3 brothers, one died from drug overdose, other two alive and
well
Physical Exam:
Physical Exam at Admission:
VS: T 99.6, BP 110/76, HR 108, RR 22, 98% RA
GEN: AOx3, in mild distress, lying on his side on bed
HEENT: PERRLA. MM dry, OP clear. no LAD. no JVD. neck supple. No
cervical, supraclavicular, or axillary LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: BS+, soft, distended, not firm; NT, no rebound/guarding, no
HSM, no [**Doctor Last Name 515**] sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities.
sensation intact to LT, cerebellar fxn intact (FTN, HTS).
.
Physical Exam at Discharge:
VS: T 96.6, BP 108/68, HR 90, RR 20, 94% RA
GEN: AOx3, lying in bed
HEENT: PERRLA. MM dry, OP clear. no LAD. no JVD. neck supple. No
cervical, supraclavicular, or axillary LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB, mild bibasilar crackles, no wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities.
sensation intact to LT, cerebellar fxn intact (FTN, HTS).
.
Pertinent Results:
[**2187-5-21**] 06:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2187-5-21**] 03:30PM GLUCOSE-101* UREA N-8 CREAT-1.0 SODIUM-136
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-21* ANION GAP-13
[**2187-5-21**] 03:30PM ALBUMIN-3.2* CALCIUM-7.4* PHOSPHATE-2.5*
MAGNESIUM-1.8
[**2187-5-21**] 03:30PM WBC-3.3* RBC-3.57* HGB-11.1* HCT-30.9* MCV-86
MCH-30.9 MCHC-35.8* RDW-16.4*
[**2187-5-21**] 03:30PM NEUTS-65 BANDS-0 LYMPHS-9* MONOS-14* EOS-0
BASOS-0 ATYPS-4* METAS-4* MYELOS-4*
[**2187-5-21**] 03:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+
[**2187-5-21**] 03:30PM PLT SMR-NORMAL PLT COUNT-168
[**2187-5-21**] 03:30PM PT-13.5* PTT-26.8 INR(PT)-1.2*
[**2187-5-21**] 03:30PM GRAN CT-2090*
.
[**2187-5-24**]:
141 113 10
------------- 111
4.0 21 0.9
Ca: 7.8 Mg: 2.2 P: 2.5
ALT: 10 AP: 42 Tbili: 0.2 Alb: 3.0
AST: 13 LDH: 265
9.7
6.9 ---- 152
26.6
N:80.6 L:12.4 M:6.5 E:0.4 Bas:0.1
PT: 12.6 PTT: 22.9 INR: 1.1
=============================================
Imaging
CXR ([**2187-5-21**]): IMPRESSION: Minimal patchy opacity at both bases
could represent early infiltrates. Differential diagnosis
includes areas of aspiration. These findings appear new compared
with a chest CT dated [**2187-5-9**]. Findings in right cardiophrenic
region are also new compared with [**2187-5-8**] chest x-ray.
Abdominal X-Ray ([**2187-5-21**]): Increased density in the colon is
consistent with residual oral contrast. Gas is seen through
level of the sigmoid colon. No air-filled dilated loops of small
bowel to suggest obstruction are identified. No free air is
detected. Allowing for limitations of technique, no mural
thickening is identified in the ascending or transverse colon.
Focal narrowing in the descending colon is seen only on one view
and may represent a transient finding.
EGD ([**2187-5-23**]): normal appearing stomach and duodenum.
Brief Hospital Course:
Nausea: Nausea was improved with scheduled IV compazine and prn
IV zofran and ativan. He also received 10 mg of dexamethasone
for 2 days. GI was consulted and EGD was done, which showed
normal stomach and duodenum. For better control of his nausea,
reglan and zyprexa tablet were added (patient had tried zyprexa
ODT in the past without relief of nausea) and patient's nausea
resolved. He was able to tolerate food and po medications.
.
Dehydration: Pt was started on NS 100 cc/hr for poor PO fluid
intake and felt improvement. He was kept on maintenance IVF of
NS 100 cc/hr until the day of discharge when his labs showed
slight hyperchloremic acidosis, likely from the NS. The patient
was switched to LR and did well.
.
Low grade fevers: Patient and his wife reported having low grade
fevers to 100.2F at home. Given his recent autologous stem cell
rescue status, he was started on flagyl to cover his recent
typhlitis, cefepime to cover for gram negative bacteria and
fluconazole for fungal coverage. In the hospital, he did not
have any fever, and the antibiotics were discontinued on the day
of his discharge.
Medications on Admission:
acyclovir 400 mg Tablet, One (1) Tablet by mouth three times a
day.
loratadine 10 mg Tablet, One (1) Tablet by mouth once a day as
needed for allergy symptoms.
metronidazole 500 mg Tablet, One (1) Tablet by mouth every eight
(8) hours for 8 days.
montelukast 10 mg Tablet, One (1) Tablet by mouth DAILY (Daily).
salmeterol 50 mcg/dose Disk with Device One (1) Disk with Device
Inhalation every twelve (12) hours.
ondansetron 4 mg Tablet, Rapid Dissolve One (1) Tablet, Rapid
Dissolve by mouth every eight (8) hours as needed for nausea.
lorazepam 1 mg Tablet, One (1) Tablet by mouth every six (6)
hours as needed for nausea.
ranitidine HCl 75 mg Tablet, One (1) Tablet by mouth once a day
as needed for heartburn.
Discharge Medications:
1. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): to prevent infection in your lung.
Disp:*30 Tablet(s)* Refills:*2*
3. olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Take this twice daily for nausea.
Disp:*60 Tablet(s)* Refills:*0*
4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours: to prevent viral infection. Tablet(s)
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Disp:*120 Tablet(s)* Refills:*0*
6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for nausea.
7. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
9. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day as needed for heartburn.
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1557**],
.
It was a pleasure to take care of you during this
hospitalization. You came into the hospital with increased
nausea, inability to tolerate food/drinks, some diarrhea, and
low grade fevers to 100.2F. In the hospital, we started
intravenous medications for your nausea, fluids for dehydration,
and antibiotics for your fevers. Gastroenterologists were
consulted and they did a procedure called EGD (upper endoscopy)
to look in your stomach and duodenum. The EGD was normal.
.
You were started on new medication called Zyprexa for nausea.
Because you did not have fevers in the hospital and your white
cell count was good, the intravenous antibiotics were stopped.
You tolerated eating food and taking pills by mouth without
nausea.
.
We have made following changes to your medications:
- STARTED Zyprexa (Olanzapine) 5 mg by mouth, twice daily, for
your nausea
- STARTED Compazine (prochlorperazine maleate) 10 mg, one tablet
by mouth every 6 hours as needed for nausea
- STARTED Bactrim SS (sulfamethoxazole-trimethoprim 400-80mg)
one tablet by mouth, daily, to prevent infection of your lung
.
- CHANGED Zofran (Ondansetron) ODT to 8 mg by mouth every 8
hours as needed for nausea
- CHANGED Ativan (Lorazepam) to 1 mg by mouth every 4 to 6 hours
as needed for nausea
.
Followup Instructions:
Friday [**2187-5-25**] at [**Hospital Ward Name 1826**] 7 Clinic at 2PM
Saturday [**2187-5-26**] at [**Hospital Ward Name 1826**] 7 Clinic at 830 AM
.
At Friday's appointment in the clinic, they will give you a
follow up appointment with Dr. [**Last Name (STitle) **] for [**2187-5-28**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Admission Date: [**2187-5-25**] Discharge Date: [**2187-5-31**]
Date of Birth: [**2128-9-25**] Sex: M
Service: MEDICINE
Allergies:
sulfites / [**Doctor Last Name 5942**] Juice, Lime Juice, Sauerkraut
Attending:[**First Name3 (LF) 11754**]
Chief Complaint:
Chest pain, sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58 y/o M with multiple myeloma s/p chemo and auto SCT [**4-27**]
presenting with acute onset of CP. Pt was discharged from the
oncology service yesterday, when he noticed onset of severe
pleuritic chest pain. Stated this started in the setting of a
new medication for nausea started by his oncologist earlier
today (Zyprexa). Also c/o difficulty catching his breath. Says
pain doesn't radiate anywhere. Has chronic trouble with
nausea/vomiting. No cough, dysuria, oliguria. He states he has
never had easy bleeding or bruising and denies history of GI
bleeding other than small amounts due to hemhorroids. To his
knowledge, never had brain involvement of his MM.
.
In the ED, initial vs were: T 99.3P 109BP 123/75 R O2 sat. Had
CTA showing PE predominantly in L main PA w/ a small
non-occlusive strand in the R main PA, and extension into LLL,
LUL, and lingular branches. 2. smaller PE in the RML and RUL
branches. 3. flattening of ventricular septum but no bowing into
the LV to suggest R heart strain. Patient was given a dose of
cefepime, morphine for pain, and started on a heparin gtt.
.
Past Medical History:
OSA, hemorrhoids, anemia, asthma, allergies, distant h/o gout,
eczema, s/p chole [**2180**], Multiple myeloma s/p chemo and ASCT
[**4-/2187**], hospital course c/b typhilitis and thrush which
resolved, h/o gout with elevated uric acid on previous adm.
He was first seen in the oncology clinic in late [**2186-10-18**]
and was shortly after diagnosed with multiple myeloma, IgG
lambda, with plasma cells = 80% of marrow cellularity on
[**2186-11-13**]. A skeletal survey was negative, and cytogenetics were
notable for a deletion at 13q14.3.
[**2186-12-22**] = C1D1 bortezomib 1.3 mg/m2 d1,4,8,11 + dexamethasone
20mg
d1,2,4,5,8,9,11,12 of 21 days cycle. Complicated by vomiting and
d11 bortezomib was held. Zometa 3.3mg q4wks started.
[**2187-1-12**]: C2D1, no complications.
[**2187-2-2**]: C3D1, Zometa increased to 4mg.
[**2187-2-23**]: C4D1. Monoclonal IgG decreased by >90% (still detectable
in blood and urine), and bone marrow biopsy with <5% plasma
cells, indicating VGPR. Plan was made to proceed withautologous
stem cell transplant followed by PD-1 treatment, as part of
clinical trial 09-061.
[**2187-4-5**]: Admit for high dose cytoxan stem cell mobilization.
[**2187-4-15**]: Admit for fever [**12-20**] Neupogen tx
[**2187-5-1**]: melphalan auto SCT, post-transplant course complicated
by typhlitis
Social History:
(from OMR, patient)
- Lives at home with wife, [**Name (NI) **]. They just rented a new
apartment near the hospital in [**Location (un) **]. Used to split his time
between an apartment in [**Location (un) 7349**] and [**Location (un) 86**] when he started a new job
6 mo ago working for lower [**Location (un) 21601**] Arts Council
- Married for 28 years
- Has 2 sons age 21 and 24
- Never smoker
- Has about 1 alcoholic drink per week
- Very distant history of drug use
- Has some dietary restrictions since cholecystectomy
Family History:
(from OMR)
- Mother alive at 80, no family history of cancer, hypothyroid,
aortic aneurism
- Father died at 86 from lung cancer
- 3 brothers, one died from drug overdose, other two alive and
well
Father died from lung cancer, pt thinks he had h/o PE. No other
history of clotting in family.
Physical Exam:
Adm PE:
Vitals: T: 97.9 BP: 111/76 P:103 R: 22 O2: 94% 4L
General: Alert, oriented, in pain but 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: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge PE:
Vitals: 98.4 130/70 86 18 94$ RA
Gen: alert, oriented, no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, no LAD
CV: normal S1S2, no murmurs rubs or gallops
Resp: CTAB
Abd: soft, non-tender, non-distended, + BS
Ext: warm, well perfused, no edema or cyanosis
Pertinent Results:
Adm labs:
[**2187-5-24**] 11:35PM BLOOD PT-12.8 PTT-23.2 INR(PT)-1.1
[**2187-5-24**] 11:35PM BLOOD CK(CPK)-26*
[**2187-5-24**] 11:35PM BLOOD cTropnT-<0.01
[**2187-5-24**] 11:46PM BLOOD Lactate-1.7
.
Micro:
Blood cultures ([**5-24**], 8, 10): no growth to date
Urine culture ([**5-27**]): no growth to date
.
Imaging:
[**5-24**] ECG: Sinus tachycardia with non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2187-4-27**]
non-diagnostic repolarization abnormalities are now present.
.
[**5-24**] CTA: The visualized portion of the thyroid appears
unremarkable. There
is no axillary, hilar, or mediastinal lymphadenopathy. The aorta
is of normal caliber along its course with no intramural
hematoma or dissection. The heart shows no pericardial effusion.
There is no pleural effusion. Mild bibasilar atelectasis is
demonstrated.
A large filling defect is seen in the left main pulmonary
artery with a
smaller contiguous component crossing over into the proximal
right main
pulmonary artery (3; 55). The left main pulmonary arterial
embolus extends
into the lower lobe, lingula, and upper lobe branches.
Additionally,
pulmonary emboli are seen in the right middle lobe, right upper
lobe and right lower lobe branches. The heart shows no bowing of
the intraventricular septum in the left ventricle to suggest
heart strain. Additionally, the main pulmonary artery is of a
normal caliber. The visualized portion of the upper abdomen
shows no gross abnormality. No aggressive appearing lytic or
sclerotic lesions are seen.
.
[**5-25**] CXR: Small left pleural effusion.
.
[**5-25**] Echo: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No valvular
pathology or pathologic flow identified. Compared with the prior
study (images reviewed) of [**2187-3-26**], the echocardiographic
findings are similar (heart rate is now tachycardic).
.
D/C labs:
[**2187-5-31**] 05:55AM BLOOD WBC-5.8 RBC-3.83* Hgb-11.8* Hct-33.3*
MCV-87 MCH-30.9 MCHC-35.5* RDW-16.5* Plt Ct-326
[**2187-5-29**] 05:55AM BLOOD Neuts-59 Bands-0 Lymphs-9* Monos-23*
Eos-8* Baso-1 Atyps-0 Metas-0 Myelos-0
[**2187-5-31**] 05:55AM BLOOD Plt Ct-326
[**2187-5-31**] 05:55AM BLOOD PT-50.3* PTT-46.6* INR(PT)-5.3*
[**2187-5-31**] 05:55AM BLOOD Glucose-96 UreaN-5* Creat-0.9 Na-138
K-3.9 Cl-106 HCO3-22 AnGap-14
[**2187-5-30**] 04:40AM BLOOD ALT-33 AST-36 LD(LDH)-279* AlkPhos-252*
TotBili-0.2
[**2187-5-31**] 05:55AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.9
Brief Hospital Course:
MICU course:
.
58 y/o M with multiple myeloma s/p chemo and auto SCT [**4-27**]
presenting with acute onset of CP found to have a PE on CTA.
#PE - likely related to underlying hypercoaguable state due to
malignancy, though olanzipine was held given that it was only
recently started. Per CTA pt with large clot burden.
Hemodynamically stable throughout course, only with tachycardia
upon arrival to the floor to 130s. Echo shows no right heart
strain. Started on hep gtt and coumadin bridge begun, still on
hep gtt at time of transfer. Mainly, pt experiences intense L
chest pain that is pleuritic in nature, which causes him to
become very tachycardic and tachypneic (fast and shallow breaths
to avoid the pain). He doesn't experience much SOB from the PE
other than when the pain becomes too much. He was started on a
dilaudid PCA after multiple tries with IV morphine, which
eventually controlled his pain. On transfer, he is on PO
oxycodone with good pain management, less tachycardic to the
110s and satting 96% on RA. Incentive spirometry was encouraged
.
#Anemia: mild crit drop on [**5-27**] am labs to slightly below his
baseline. He had no signs of acute bleed, and his vitals were
stable.
.
#Fever: Low grade temperature felt most likely to be a result
of clot burden, but may also be an infectious etiology. A CXR
and CTA were without infiltrate. No infectious signs or symptoms
on exam. Blood cultures were negative at the time of transfer
to the floor.
.
#Nausea/vomiting: has had severe n/v that has been recalcitrant
to many therapies, and required recent addition of olanzipine.
EGD [**5-23**] showed normal mucosa.
.
Transferred from ICU to floor on [**5-25**]:
#PE: Transferred from heparin gtt --> Lovenox for total 5 days
heparin therapy. Coumadin was started [**5-28**] and rapidly
achieved therapeutic INR. Lovenox was d/c [**5-30**]. The
patient's pleuritic chest pain largely resolved, with some
residual constant chest pain. CXR showed no additional effusion
or consolidation.
.
#nausea: Zofran, compazine, Ativan, scopolamine patch, Reglan
attempted with poor control. In review of records and
discussion with outpatient oncologist, it was determined that
these had not previously been effective. The risk of restarting
Zyprexa was determined to be low, as there is little evidence of
a correlation to coagulation. As the patient's INR was
therapeutic (3.6), the Zyprexa was restarted to good effect.
.
#Anemia: On the evening of [**5-29**], Hct drop of 6 points was
suspected. 2 units PRBCs were transfused and possible origins
of bleeding investigated. Tests were negative, vital signs were
stable, and in response to the PRBCs the Hct rose 11 points. It
is possible this was an erroneous lab result. No signs of
bleeding.
.
Full Code
Medications on Admission:
Acyclovir, montelukast, lorazepam 1mg q6 prn, salmeterol,
loratadine, ranitidine 150, zofran 8mg qhs prn, compezine 10mg
q6 PRN, and olanzipine 5mg [**Hospital1 **], bactrim 400-80 daily
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
3. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
5. olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for heartburn.
9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Take as directed by Dr. [**Last Name (STitle) **]/[**Doctor Last Name **]. .
Disp:*30 Tablet(s)* Refills:*0*
11. salmeterol 50 mcg/dose Disk with Device Sig: One (1)
ihalation Inhalation every twelve (12) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
multiple myeloma post stem cell transplant
pulmonary embolism (clot in the lungs)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 1557**],
It was a pleasure taking care of you during your stay at [**Hospital1 1535**].
.
You were hospitalized because of chest pain, which began shortly
after your discharge from a long hospital stay. This was
determined to be due to a blood clot in the vessels in your
lungs. You were treated with heparin, a blood thinner, and
transitioned to coumadin, a long-term anti-clotting therapy.
Currently, your coumadin level is, so you should not take any
coumadin tonight. You will come to the 7 [**Hospital Ward Name 1826**] outpatient
area tomorrow to have the level checked again.
.
During your stay, you experienced nausea, which has been a
[**Last Name 4820**] problem for you since your stem cell transplant.
Zyprexa, a medication which had been helpful to you, was stopped
due to a concern that it might contribute to clotting. This
medicine was restarted once testing revealed your anti-clotting
medication had taken effect.
.
Please make the following changes to your medication regimen:
- We are going to give you a prescription for Coumadin
(warfarin), but do NOT start taking this until directed by the
clinic.
.
Please keep all follow-up appointments.
Followup Instructions:
Department: BMT/ONCOLOGY UNIT
When: FRIDAY [**2187-6-1**] at 8:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2187-6-4**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2187-6-4**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10565**], NP [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"493.90",
"203.00",
"787.01",
"V42.82",
"285.9",
"780.61",
"511.9",
"327.23",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
23503, 23509
|
19374, 22166
|
12673, 12679
|
23635, 23635
|
16858, 19351
|
24999, 25879
|
15706, 16003
|
22403, 23480
|
23530, 23614
|
22192, 22380
|
23786, 24976
|
16018, 16544
|
4811, 5357
|
11432, 11919
|
16558, 16839
|
12618, 12635
|
12707, 13810
|
23650, 23762
|
13832, 15147
|
15163, 15690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,292
| 127,659
|
7190
|
Discharge summary
|
report
|
Admission Date: [**2166-6-21**] Discharge Date: [**2166-6-30**]
Date of Birth: [**2098-4-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Keflex / Paper Tape
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Cereberal angiography
History of Present Illness:
Pt with left frontal and prepontine cisternal hemorrhages (new
onset headache,neurologically intact). S/P left ICA stent
placemtn at an outside hospital. Transferred to [**Hospital1 18**] for
further treatment.
Past Medical History:
R leg sciatica
hypothyroid
Parkinson's
TAH/BSO
GERD
CAD
60-69% L ICA stenosis
CABGx4
S/P Appendectomy
Social History:
Lives with husband
Present tobacco use
Family History:
Noncontributory
Physical Exam:
VSS per Medical record. Afebrile, B/P 136/60. Headaches are
controlled on present therapies. No VA changes. Neurologically
intact. No nausea or vomiting. Tolerating all p.o. food and
fluids well.
Pertinent Results:
CBC ([**2166-6-30**])-11.4* 4.18* 10.2* 32.7* 78* 24.5* 31.3 18.7* 411
Brief Hospital Course:
Pt underwent cerebral angiography by Dr. [**First Name (STitle) **] on [**2166-6-21**].No
post procedure complications. Progressing as expected in the
immediate post procedure phase. Tolerating all p.o. food and
fluids well. No nausea or vomiting. Headaches controlled on
present regimen.
Medications on Admission:
albuterol inhaler and nebulizers twice a day prn,
atorvastatin 20 mg daily,
carbidopa-levodopa 50/200 twice daily,
Plavix 75 mg daily,
diltiazem 240 mg daily,
Advair 100/50 twice daily,
omeprazole 40 mg twice daily,
glyburide 5 mg twice daily,
HCTZ 12.5 mg daily,
lisinopril 10 mg daily,
metoprolol 100 mg twice daily,
Effexor 150 mg daily,
oxycodone 5 mg qid prn,
ASA 325 mg daily.
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
13. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4hrs; prn as
needed.
Disp:*81 Tablet(s)* Refills:*0*
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*28 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Subarachnoid hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
Angiogram
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? 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 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 call Dr.[**Initials (NamePattern4) 935**] [**Last Name (NamePattern4) 26680**] for appointment. He would like
to see you next week. [**Telephone/Fax (1) 1669**].
Completed by:[**2166-6-30**]
|
[
"414.01",
"332.0",
"V15.82",
"530.81",
"430",
"599.0",
"250.00",
"244.9",
"V45.81",
"496",
"443.9",
"729.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
3372, 3469
|
1095, 1386
|
291, 314
|
3536, 3544
|
1000, 1072
|
5531, 5730
|
751, 768
|
1820, 3349
|
3490, 3515
|
1412, 1797
|
3568, 4590
|
4616, 5508
|
783, 981
|
243, 253
|
342, 554
|
576, 679
|
695, 735
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,102
| 146,559
|
38462+58220
|
Discharge summary
|
report+addendum
|
Admission Date: [**2191-6-26**] Discharge Date: [**2191-7-19**]
Date of Birth: [**2121-3-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fish Oil / Iodine
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
RUQ abdominal pain, fever
Major Surgical or Invasive Procedure:
ERCP [**6-27**]
[**Name (NI) 48373**] PTC placement [**6-29**]
ERCP [**6-30**]
History of Present Illness:
This is a 70 y/o female with a history of CAD s/p CABG 1 year
ago (no stents), HTN, s/p CCY [**12-22**] requiring placement of a
drain, who presented to [**Hospital **] hospital with RUQ pain, nausea,
and vomiting of bilious material x 2 days. In addition she had
a fever to 101 at home. At [**Hospital1 **], labs were significant for
WBC 5.9, Bili 5 (Indirect 0.6), AP 602, lipase 47. CT scan
demonstrated CBD dilitation of 1.5 cm, intra- and extra-hepatic
dilitation, and ?round densities in the CBD (?stone). She was
given zofran, morphine, and meropenem; transferred to [**Hospital1 18**] for
surgical and ERCP evaluation.
In the ED: VS: 98.9 69 122/56 16 98% on RA. Surgery and ERCP
were consulted. RUQ u/s confirmed similar findings.
Currently, the patient reports intermittent RUQ pain. No
current f/c/s. No nausea or vomiting. Bowels normal, no
urinary difficulties.
10-point ROS otherwise negative in detail.
ROS: 10 point review of systems negative except as noted above.
Past Medical History:
CAD s/p CABG 1 year ago
COPD
HL
HTN
osteoporosis
GERD
OA
CCY [**12-22**], complicated by drain placement
s/p hysterectomy
gastroduodensotomy [**2157**] for PUD
right ovarian cystectomy
hiatal hernia repair
Social History:
She lives at home by herself with her daughter close by. She
has a 50+ pack-year history of smoking, currently smoking 4
cigarettes/day. No alcohol or illicit drug use. She is active
at baseline and uses a cane occasionally.
Family History:
Mother died from emphysema. History of CAD and unknown
malignancies in her mother's family. No history of GI
malignancies.
Physical Exam:
VS: Tc 97.7, BP 154/75, HR 74, RR 20, SaO2 97%/RA
General: Pleasant, well-appearing female in NAD, AO x 3
HEENT: NC/AT, PERRL, EOMI. +minimal scleral icterus. MM
slightly dry, OP clear
Neck: supple, no LAD
Chest: CTA-B, no w/r/r
CV: RRR, s1 s2 normal, no m/g/r
Abd: soft, with marked TTP in the RUQ, minimal rebound and
guarding. Negative [**Doctor Last Name 515**] sign.
Ext: no c/c/e, wwp
Neuro: AO x 3, non-focal exam
Skin: warm, dry, no rashes, slightly jaundiced
Pertinent Results:
CBC: WBC-5.8 HCT-33.9* PLT COUNT-135*; diff: NEUTS-86.7*
LYMPHS-6.6* MONOS-5.8 EOS-0.2 BASOS-0.7
ALBUMIN-3.3* LIPASE-17 ALT(SGPT)-169* AST(SGOT)-156* ALK
PHOS-570* TOT BILI-4.9* DIR BILI-4.3* INDIR BIL-0.6
BMP: GLUCOSE-138* UREA N-9 CREAT-0.8 SODIUM-135 POTASSIUM-3.5
CHLORIDE-101 TOTAL CO2-26
UA: BLOOD-LGE NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15
BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-NEG; RBC-[**6-23**]* WBC-0
BACTERIA-FEW YEAST-NONE EPI-1
Coags: PT-23.1* PTT-27.2 INR(PT)-2.2*
Urine cx, blood cx pending [**6-26**]
RUQ US [**6-26**]: Intra- and extra-hepatic bile duct dilatation with
CBD 1.5 cm. No choledocholithiasis identified. Ascending
cholangitis not excluded. Consider MRCP or ERCP for further
evaluation.
[**Hospital **] Hospital:
WBC 5.9
Bili 5 (Indirect 0.6)
AP 602
lipase 47
CT showed CBD dilation, stone
Brief Hospital Course:
This is a 70 year old woman with coronary disease s/p CABG (no
stents) on aspirin and coumadin who presented with cholangitis.
A CT and RUQ ultrasound on admission showed CBD dilitation and
stones. She received ciprofloxacin and flagyl with improvement
in her fever, liver function tests, and all of her symptoms. She
underwent an unsuccessful ERCP on [**6-27**] (inability to visualize
the papilla). She underwent an MRCP that same day, which
demonstrated 2 large stones in the CBD with intra and
extra-hepatic dilitation. She underwent an [**Name (NI) 48373**] PTC
placement on [**6-29**] after 1 day of being pre-medicated due to a
contrast allergy (hives). The ERCP team attempted a rendezvous
procedure on [**6-30**] using the PTC, however, they were unable to
access the ampulla. The patient had a complicated anatomy from
gastric bypass in the [**2151**]. She underwent an IR guided
procedure for stone extraction on [**7-4**] which was successful but
was complicated with hypoxia and respiratory distress. She was
then admitted to MICU ([**7-5**]). She was initially placed on BiPap
but was weaned latter to 2 L nasal cannula. Hypoxic respiratory
distress was from decompensated CHF and flash pulmonary edema as
well as her COPD/asthma exacerbation and improved with diuresis
and bronchodilators. TTE showed no systolic failure but she may
had diastolic heart failure. She also received diltiazem for
several episodes of atrial fibrillation and rapid ventricular
rate and her beta blocker dose was increased. However,
Metoprolol was inadequate to treat her atrial fibrillation.
Digoxin was added with excellent contol (HR of 65-70) and
avoidance of excessive hypotension. Coumadin was held due to
procedures but she was started on lovenox 70 mg SC BID since
will need a repeat outpatient IR procedure (PTC) soon
(appointment was scheduled). Despite significant GI improvement,
she developed progressive right pleural effusion. She underwent
thoracentesis for diagnostic purpuses to rule out parapneumonic
effusion and effusion related to subdiaphragm process. She was
finally discharged to LTAC as her fluid analysis showed no
infection.........Before discharge, she was started on Augmentin
to treat mild infection of biliary drain exit site......
.
Instructions for LTAC: Please hold Lovenox on the day of
radiology appointment with IR as they may take the drain out.
She had an appointment for outpatient IR already. The external
drain was capped on [**7-9**] with no recurrence of her symptoms
despite eating a normal diet.
Medications on Admission:
metoprolol 25 mg [**Hospital1 **]
simvastatin 40 mg daily
singulair 10 mg daily
advair 500/50 mcg [**Hospital1 **]
prilosec 40 mg [**Hospital1 **]
lasxi 40 mg daily
coumadin 2 mg daily, 8 mg qMon
KCl 20 Meq daily
reglan 10 mg QIDACHS
caltrate-D
MVI
ativan 0.5 mg [**Hospital1 **], qHS
spiriva
neurontin 300 mg tid
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] [**Location (un) 85598**] [**Location (un) **] [**Doctor First Name **]
Discharge Diagnosis:
Cholangitis
Choledocholithiasis
Atrial Fibrillation
Acute Diastolic Heart Failure
COPD with acute exacerbation
Coronary Artery Disease
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 bile duct obstruction and infection.
There were several unsuccessful attempts to remove the
obstruction but finally on [**7-5**] radiology removed the stones and
inserted a biliary catheter for drainage. This was capped on
[**2191-7-9**]. Radiology will perform another study of your biliary
tract during your next appointment.
Followup Instructions:
Department: DAYCARE UNIT
When: FRIDAY [**2191-7-22**] at 8:30 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: FRIDAY [**2191-7-22**] at 10:00 AM [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Known lastname **],[**Known firstname 194**] Unit No: [**Numeric Identifier 13574**]
Admission Date: [**2191-6-26**] Discharge Date: [**2191-7-19**]
Date of Birth: [**2121-3-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fish Oil / Iodine
Attending:[**First Name3 (LF) 3046**]
Addendum:
No addendum necessary.
Chief Complaint:
RUQ abdominal pain, fever
Major Surgical or Invasive Procedure:
ERCP
Percuatenous Transhepatic Cholangiogram
Thoracentesis
History of Present Illness:
This is a 70 y/o female with a history of CAD s/p CABG 1 year
ago (no stents), HTN, s/p CCY [**12-22**] requiring placement of a
drain, who presented to [**Hospital 1263**] hospital with RUQ pain, nausea,
and vomiting of bilious material x 2 days. In addition she had
a fever to 101 at home. At [**Hospital1 1263**], labs were significant for
WBC 5.9, Bili 5 (Indirect 0.6), AP 602, lipase 47. CT scan
demonstrated CBD dilitation of 1.5 cm, intra- and extra-hepatic
dilitation, and ?round densities in the CBD (?stone). She was
given zofran, morphine, and meropenem; transferred to [**Hospital1 8**] for
surgical and ERCP evaluation.
In the ED: VS: 98.9 69 122/56 16 98% on RA. Surgery and ERCP
were consulted. RUQ u/s confirmed similar findings.
Currently, the patient reports intermittent RUQ pain. No
current f/c/s. No nausea or vomiting. Bowels normal, no
urinary difficulties.
10-point ROS otherwise negative in detail.
Past Medical History:
1. Coronary artery disease s/p CABG ([**2190**])
2. COPD
3. Hypertension
4. Hyperlipidemia
5. Atrial fibrillation
6. Osteoporosis
7. GERD
8. Osteoarthritis
9. CCY [**12-22**], complicated by drain placement
10. s/p hysterectomy
11. Gastroduodensotomy [**2157**] for PUD
12. Right ovarian cystectomy
13. Hiatal hernia repair
Social History:
She lives at home by herself with her daughter close by. She
has a 50+ pack-year history of smoking, currently smoking 4
cigarettes/day. No alcohol or illicit drug use. She is active
at baseline and uses a cane occasionally.
Family History:
Mother died from emphysema. History of CAD and unknown
malignancies in her mother's family. No history of GI
malignancies.
Physical Exam:
On discharge:
T 99.2, BP 117/66, HR 66, RR 20, 99% on 2 liters
General - appears well, sitting on comode able to speak in
complete sentences
CV - irregular; no audible murmurs
PULM - dull at the right base
ABD - soft; mildly tender in RUQ near site of drain; no
tenderness elsewhere; drain site itself has mild purulent
discharge
EXT - warm; no edema
Neuro - awake, alert, conversent
Pertinent Results:
Discharge Labs:
138 102 15
------------87
4.0 30 1.1
Ca: 7.7 Mg: 2.4 P: 3.7
WBC: 4.1
HCT: 26.1
Most recent LFTs ([**2191-7-9**]):
ALT: 8
AST: 14
AP: 83
Bili: 0.5
CXR ([**2191-7-19**]) showed persistent right-sided pleural effusion
Brief Hospital Course:
This is a 70 year old woman with coronary disease s/p CABG (no
stents) on aspirin and coumadin who presented with cholangitis.
A CT and RUQ ultrasound on admission showed CBD dilitation and
stones. She received ciprofloxacin and flagyl with improvement
in her fever, liver function tests, and all of her symptoms. She
underwent an unsuccessful ERCP on [**6-27**] (inability to visualize
the papilla). She underwent an MRCP that same day, which
demonstrated 2 large stones in the CBD with intra and
extra-hepatic dilitation. She underwent an [**Name (NI) 13575**] PTC
placement on [**6-29**] after 1 day of being pre-medicated due to a
contrast allergy (hives). The ERCP team attempted a rendezvous
procedure on [**6-30**] using the PTC, however, they were unable to
access the ampulla. The patient had a complicated anatomy from
gastric bypass in the [**2151**].
She underwent an IR guided procedure for stone extraction on
[**7-4**] which was successful but was complicated with hypoxia and
respiratory distress. She was
then admitted to MICU ([**7-5**]). She was initially placed on BiPap
but was weaned latter to 2 L nasal cannula. Hypoxic respiratory
distress was from decompensated CHF and flash pulmonary edema as
well as her COPD/asthma exacerbation and improved with diuresis
and bronchodilators. TTE showed no systolic failure but she may
had diastolic heart failure.
She also received diltiazem for several episodes of atrial
fibrillation and rapid ventricular rate and her beta blocker
dose was increased. She remains on metoprolol, which should
continue to be titrated.
Coumadin was held due to procedures but she was started on
lovenox 70 mg SC BID since will need a repeat outpatient IR
procedure on [**8-11**].
Despite significant GI improvement, she developed progressive
right pleural effusion. She underwent thoracentesis for
diagnostic purpuses to rule out parapneumonic effusion and
effusion related to subdiaphragm process.
She was treated for 5 days for a cellulitis at the drain site;
at the time of discharge there continued to be mild discharge
around the area.
Medications on Admission:
Metoprolol 25 mg [**Hospital1 **]
Furosemide 40 mg daily
Simvastatin 40 mg daily
Coumadin 2 mg daily, 8 mg qMon
Singulair 10 mg daily
Advair 500/50 mcg [**Hospital1 **]
Prilosec 40 mg [**Hospital1 **]
KCl 20 Meq daily
Reglan 10 mg QIDACHS
Caltrate-D
MVI
Ativan 0.5 mg [**Hospital1 **], qHS
Spiriva
Neurontin 300 mg tid
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. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Enoxaparin 80 mg/0.8 mL Syringe Sig: 70 MG Subcutaneous Q12H
(every 12 hours): please continue until she is back on Coumadin
(once the biliary drain is out). Please hold one dose prior to
her outpatient Radiology appointment as the drain may get
removed.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB/wheezing.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) as needed for nicotine cravings.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] - [**Location (un) 95**] - [**Location (un) 4534**]
Discharge Diagnosis:
Atrial Fibrillation with rapid ventricular rate
Acute Diastolic Heart Failure
Acute Renal Failure
Cholangitis
Choledocholithiasis
COPD with acute exacerbation
Coronary Artery Disease, s/p CABG
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 bile duct obstruction and infection.
There were several unsuccessful attempts to remove the
obstruction but finally on [**7-5**] radiology removed the stones and
inserted a biliary catheter for drainage. This was capped on
[**2191-7-9**], and restudied on [**2191-7-15**]. An ampullary stricture was
seen, and a procedure to open this stricture is needed before
the drain can be removed.
It is essential that you follow-up with the interventional
radiologists for drain removal. Your appointment information is
listed below.
Followup Instructions:
Interventional Radiology Follow-up
[**2191-8-11**]
9:00
[**Hospital Ward Name **] Building, [**Hospital Ward Name 3621**] [**Location (un) 457**]
Phone [**Telephone/Fax (1) 13576**]
Department: RADIOLOGY
When: FRIDAY [**2191-7-22**] at 10:00 AM [**Telephone/Fax (1) 13577**]
Building: CC CLINICAL CENTER [**Location (un) 1826**]
Campus: WEST Best Parking: [**Street Address(1) 1827**] Garage
[**First Name11 (Name Pattern1) 394**] [**Last Name (NamePattern4) 3047**] MD [**MD Number(2) 3048**]
Completed by:[**2191-7-19**]
|
[
"305.1",
"427.31",
"576.1",
"574.51",
"V45.86",
"414.00",
"584.9",
"428.31",
"V45.81",
"786.09",
"V58.61",
"401.9",
"511.9",
"530.81",
"428.0",
"272.4",
"493.22",
"733.00",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"51.98",
"51.10",
"34.91",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
14575, 14674
|
10539, 12634
|
8096, 8157
|
14911, 14911
|
10276, 10276
|
15669, 16228
|
9730, 9856
|
13004, 14552
|
14695, 14890
|
12660, 12981
|
15094, 15646
|
10292, 10516
|
9871, 9871
|
9886, 10257
|
8030, 8058
|
8185, 9120
|
14926, 15070
|
9142, 9468
|
9484, 9714
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,233
| 119,308
|
7671
|
Discharge summary
|
report
|
Admission Date: [**2139-12-24**] Discharge Date: [**2140-1-4**]
Date of Birth: [**2087-3-27**] Sex: M
Service: NEUROSURGERY
Allergies:
Percocet / Labetalol / Felodipine
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Scapular pain
Major Surgical or Invasive Procedure:
1. T5 partial vertebrectomy.
2. Transpedicular decompression of the thecal sac.
3. T2-T8 posterior instrumentation segmental (Globus
[**Location (un) 3146**]), bone marrow aspirate right posterior-superior
iliac crest, posterolateral arthrodesis T2-T8 and local
autograft.
History of Present Illness:
This 52-year-old gentleman had a known history of pancreatic
carcinoma status post resection. Developed right-sided radicular
symptoms in the region of the scapula. Imaging demonstrated a
lesion compressing the spinal cord
with involvement of the T5 vertebral body. He is admitted for an
operative decompression and reconstruction.
Past Medical History:
Oncologic History: Intraductal papillary mucinous neoplasm
diagnosed [**1-/2136**], s/p total pancreatectomy [**6-/2136**], solitary
recurrence in liver [**10/2137**], s/p 1st RFA [**11-19**], s/p rt
hemihepatectomy, s/p 2nd RFA [**2139-6-24**]
Recent enterococcal bacteremia in [**6-21**]
Coronary artery disease
Hypertension
Hyperlipidimia
Insulin dependent diabetes
Polycythemia [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] stones
GERD
Pseudohyperkalemia caused by myeloproliferative syndrome with
thrombocythemia
Bacteremia s/p splenectomy
PAST SURGICAL HISTORY
1. elbow surgery [**2125**]
2. basal cell ca surgery [**2131**]
3. total pancreatectomy [**2137**]
4. Vental hernia surgery [**2137**]
5. right hemihepatectomy [**2138**]
6. VATS [**2138**]
7. T5 partial corpectomy, T2-8 posterior fusion with bone marrow
aspirate
Social History:
Married. Works as a contractor. No EtOH since pancreatectomy.
Smoked 2 packs per day, quit 13 years ago. No history of IV
drug use, marijuana use, tattoos, hepatitis, or piercing.
Family History:
Father died of metastatic carcinoma to the liver, age 59.
Mother had a GI tumor removed early in her life, but lived for
many years afterwards.
Grandfather thought to have stomach cancer.
Physical Exam:
VSS: Gen: WD/WN, comfortable, NAD.
MS: A&O X 3
HEENT: Pupils: 3MM bilaterlly and reactive EOMs intact
Neck: Supple. No JVD
Extrem: Warm and well-perfused. No edema
Neuro: Mental status: Awake and alert, cooperative with exam,
normal
affect.EOM's full. Conjugate gaze. No nystagmus Facial symmetry
even. Tongue
protrudes midline. Speech is clear. Stream of thoughts fluid.
No stuttering or paraphrasic errors. Good historian of pertinent
medical events and treatments.
Oriented x3.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
Sensation: Intact to light touch bilaterally
Propioception intact
Toes downgoing bilaterally
Wound: Mid line incision high thoracic area, Suture closure,
good approximation.
Slightly tender to touch. Steristrips to prior drain site
are intact and covered with a dsd and tegaderm. Will remain in
place for 72 hours.
Pertinent Results:
[**2139-12-29**] 05:22AM BLOOD WBC-PND RBC-3.57* Hgb-9.3* Hct-27.8*
MCV-78* MCH-26.0* MCHC-33.3 RDW-16.4* Plt Ct-PND
[**2139-12-28**] 05:40AM BLOOD Plt Ct-669*
[**2139-12-29**] 05:22AM BLOOD Glucose-202* UreaN-18 Creat-1.0 Na-132*
K-5.5* Cl-92* HCO3-32 AnGap-14
[**2139-12-29**] 05:22AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.7
X-RAY T SPINE:
There are bilateral spinal rods in place extending from the
upper through mid
thoracic spine. Hardware alignment is nominal on this view. Note
is made of
a large abnormal soft tissue density in the right upper
paraspinal or
paratracheal region, similar to [**2139-12-27**].
Brief Hospital Course:
Mr [**Known lastname 27908**] was admitted electively for a T5 partial
vertebrectomy. Post operatively he recovered well with
significant pain issues he was treated with MS Contin 30mg tid
with good effect. Neurologically he had no deficits. His
incision was without redness and drained serosanguous drainage
for approx 3 days then stopped. His BP in his first 2 post
operative days remained elevated so he received a medicine
consult who recommended increasing his Verapamil in the next 24
hours if his BP continued to be elevated.On POD #2 he had a
fever and was pan cultered his CXR showed bilateral alectasis
and right sided effusion, he was encouraged to use his IS and
moblize.
Mr. [**Known lastname 27909**] hospitalization and post- operative course was
complicated by a gradual wound leak of serosanguonus drainage
that progressively got worse. on POD #6 he went back to the or
where the wound was opened and a liquidified hematoma was
drained, a JP was placed.
The morning of discharge the JP was pulled without incident and
the pt. went home on a two week course of Cipro and
_____________.He will follow up with Dr. [**Last Name (STitle) 548**] in ten days for a
wound check with suture removal and again in one month to
re-evaluate. Physical and occupational therapy have evaluated
pt and feel he is now cleared for d/c to home. He has progressed
well to this point and is eager to return home.
Medications on Admission:
Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. Anagrelide 0.5 mg Capsule Sig: Eight (8) Capsule PO BID (2
times a day).
3. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: [**6-20**] Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
5. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
8. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for stomach discomfort.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
11. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Five (35)
U Subcutaneous QAM.
Disp:*20 Capsule(s)* Refills:*0*
13. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for 3 days.
Disp:*1 qs* Refills:*0*
14. Insulin Lispro Subcutaneous
Discharge Medications:
1. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
2. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: [**5-19**] Capsule, Delayed Release(E.C.)s
PO with each meal (): Pt. doses med.
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Last dose to be completed on [**2140-1-18**].
Disp:*28 Tablet(s)* Refills:*0*
7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6hrs; PRN
as needed.
10. Anagrelide 0.5 mg Capsule Sig: Eight (8) Capsule PO twice a
day.
Disp:*480 Capsule(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 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.
13. Baclofen 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*1*
14. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4HR; PRN
as needed for pain: For breakthrough pain only.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
T5 metastatic lesion
T2-T8 fusion
Post Op hematoma formation and wound drainage
Diabetes Mellitus
Chronic pain
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke or use tobacco. It can impair wound and
fusion healing.
?????? Keep wound clean. Please avoid tub baths or pools until
seen in follow up by your surgeon. Remove dressing,begin daily
showers
?????? You have steri-strips in place over your prior drain
insertion site. ?????? keep dry x 72 hours. Do not pull them off.
They will fall off on their own or be taken off in the office
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection or separation. Any drainage or weeping should
be reported to the surgeons office immediately.
?????? 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
CALL THE SURGEONS OFFICE FOR AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO
HAVE YOUR SUTURES REMOVED AND WOUND CHECKED IN 10 DAYS
[**Telephone/Fax (1) 1669**].
IN ADDITION, PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT
WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU [**Month (only) **] NEED ADDITIONAL
IMAGING DONE PRIOR TO THIS APPOINTMENT WHICH WILL BE ARRANGED
FOR YOU.
Followup Instructions:
CALL THE SURGEONS OFFICE FOR AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO
HAVE YOUR SUTURES REMOVED AND WOUND CHECKED IN 10 DAYS
[**Telephone/Fax (1) 1669**].
IN ADDITION, PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT
WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU [**Month (only) **] NEED ADDITIONAL
IMAGING DONE PRIOR TO THIS APPOINTMENT WHICH WILL BE ARRANGED
FOR YOU.
Completed by:[**2140-1-4**]
|
[
"401.9",
"414.01",
"238.4",
"250.01",
"E849.7",
"998.12",
"198.5",
"V10.09",
"197.7",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"03.02",
"81.63",
"77.79",
"81.05",
"80.99"
] |
icd9pcs
|
[
[
[]
]
] |
8167, 8173
|
3778, 5190
|
312, 587
|
8328, 8337
|
3141, 3755
|
10544, 10988
|
2044, 2233
|
6489, 8144
|
8194, 8307
|
5216, 6466
|
8361, 10521
|
2248, 2419
|
259, 274
|
615, 949
|
2434, 3122
|
971, 1827
|
1843, 2028
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,038
| 145,615
|
6534
|
Discharge summary
|
report
|
Admission Date: [**2103-11-1**] Discharge Date: [**2103-11-12**]
Date of Birth: [**2043-8-20**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 8840**] is a 60-year-old
woman with past medical history significant for hypertension,
hypercholesterolemia, two episodes of acute pancreatitis,
secondary to alcohol abuse, gastroesophageal reflux disease
with hiatal hernia and an appendectomy in the remote past who
presented to the Emergency Room on [**10-31**] with a chief
complaint of three days of nausea, vomiting, and anorexia in
the absence of abdominal pain. Initial evaluation in the
Emergency Department revealed a serum bicarbonate level of 5
and an anion gap of 45. There were ketones in the urine but
a normal serum glucose level. Serum tox screen was negative.
In the Emergency Department, the patient became acutely short
of breath and subsequently intubated for hypoxic respiratory
failure. She was admitted to the Medical Intensive Care Unit
for management of her severe azotemia.
PHYSICAL EXAMINATION: On examination, she was tachycardic
and tachypneic. Her heart and lung exam were within normal
limits at the time of the examination and her abdominal exam
was benign.
ADMISSION LABORATORY VALUES: Notable for serum bicarbonate
5, anion gap of 45, potassium 2.7, negative serum tox screen
for ethanol and a normal white count. A chest x-ray taken in
the Emergency Department revealed possible bilateral lower
lobe infiltrates.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit with the presumptive diagnosis of septic shock,
secondary to an unknown source. Subsequent laboratory values
showed an elevated GGT and a right upper quadrant ultrasound
revealed evidence of acute cholecystitis. A percutaneous
drain was placed into the gallbladder. Cultures drawn from
the vile of blood and urine were all negative. Her pulmonary
status evolved into a picture of adult respiratory distress
syndrome requiring prolonged intubation with ..........
inverse-ratio ventilation and pressure-controlled
ventilation. She remained on pressors throughout the
duration of her hospital course. She had a persistent lactic
acidosis from an unknown source throughout the duration of
her Intensive Care Unit stay. After a prolonged period of
mechanical ventilation, blood pressure support with pressors,
shock liver, and no improvement in clinical status,
discussions were held with the family members regarding the
patient's wishes. On [**11-12**], the focus of care was
shifted to providing comfort measures. The patient expired
on the evening of [**11-12**].
DISCHARGE DIAGNOSIS: Septic shock, question secondary to
biliary sepsis.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 7787**]
MEDQUIST36
D: [**2103-11-13**] 18:48
T: [**2103-11-13**] 18:48
JOB#: [**Job Number 25057**]
|
[
"038.9",
"785.59",
"303.90",
"281.9",
"593.9",
"575.0",
"518.81",
"276.2",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"38.91",
"87.54",
"96.72",
"89.64",
"38.93",
"51.01"
] |
icd9pcs
|
[
[
[]
]
] |
2662, 2989
|
1514, 2640
|
1065, 1496
|
163, 1042
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,439
| 112,353
|
50613
|
Discharge summary
|
report
|
Admission Date: [**2136-8-31**] Discharge Date: [**2136-9-7**]
Date of Birth: [**2064-3-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
N/V/diarrhea
Major Surgical or Invasive Procedure:
intubation, placement of femoral line
History of Present Illness:
72 yoF with h/o HIV(CD4 312, VL <50 [**2136-8-23**]),CHF(EF 10%), h/o
endocarditis, who p/w N/V and diarrhea for two days. Diarrhea is
watery, nonbloody. Vomitus is non-bloody. Also reports abdominal
pain.
In ED, patient reported fevers at home to 103. Denied recent
travel, dietary changes, chest pain. Did note mild HA.
.
In the ED, T 96.7, SBP in 80s. Patient's abdomen diffusely
tender and distended. Laboratory studies showed lactate 6.8,
transaminitis with INR 9.1, pancreatitis, acute on chronic renal
failure with hyperkalemia and hyperphosphatemia. Patient
received vancomycin 1 gram, levo 750 mg, and falgyl 500 mg, as
well as 10 mg of vitamin K, 15 grams of kayexalate, 1 amp of
biarb, and calcium gluconate with insulin. She had a femoral CVL
placed and was volume resuscitated but rapidly developed SOB. By
report from ED resident, long discussion with patient held and
patient voiced desire to be DNR but would like to be intubated
and dialyzed. Patient was then intubated and volume
resuscitation continued. Was also briefly placed on levophed for
hypotension which was quickly weaned off. She received a CT of
the abdomen/pelvis which showed some concern for ischemic
changes. Surgery evaluated patient and did not feel there was
any acute indication for surgery. Renal was also consulted and
felt that she did not need emergent dialysis.
.
Of note, recent admit [**Date range (1) 105349**] after presenting with
bradycardia and treated for digoxin and amiodarone toxicity,
acute on CRI, and CHF. Amiodarone stopped (had been started
during prior hospitalization due to runs of Vtach. Also started
on coumadin given severely depressed EF. [**Date range (1) 2775**] therapy was also
discontinued which was verified with her PCP.
Past Medical History:
1. HIV- Diagnosed in [**2116**], has taken [**Year (4 digits) 2775**] therapy
intermittently. Stopped taking her pills three months ago
because stated she had foamy vomit every time she took them. CD4
274, VL<50 in [**12-10**]
2. CHF- EF 10% 7/07 followed by Dr. [**First Name (STitle) 437**]
3. HCV- VL >700K in [**12-9**], not a good candidate for interferon
therapy or liver biopsy per gi note in 04.
4. mild COPD- PFTs [**7-/2129**] showed a normal study
5. IVDU--last abuse heroin several days ago, skin popping
6. Arthritis
7. chronic pancreatitis
8. ventricular tachycardia
Social History:
Has 20 grandchildren, tobacco: [**4-8**] cig/day, 40 py
Heavy EtOH in past. States that last used heroin in the past few
days (skin popping) and also used cocaine in the last month.
Family History:
NC
Physical Exam:
PE: T: 96.2 BP: 83/60 HR: 53 Vent: AC 450x12, PEEP 5, FiO2 1
Gen: intubated, sedated
HEENT: No icterus. Dry MMs. ET tube in place
NECK: Supple, No LAD. JVP ~14 cm H2O.
CV: RRR. nl S1, S2. II/VI holosystolic murmur. +S3.
LUNGS: crackles at bases
ABD: NABS. moderately distended. Soft. Left femoral CVL in place
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: Diffuse scarring from skin popping on lower extremities.
Scarring from presumed IVDU in anticubital fossas
NEURO: pupils equal, dilated, minimally reactive
Pertinent Results:
[**2136-8-30**] 05:59PM HGB-9.4* calcHCT-28
[**2136-8-30**] 05:59PM GLUCOSE-37* LACTATE-6.8* NA+-134* K+-6.1*
CL--101 TCO2-16*
[**2136-8-30**] 06:35PM PT-70.8* PTT-50.9* INR(PT)-9.1*
[**2136-8-30**] 06:35PM PLT SMR-NORMAL PLT COUNT-247
[**2136-8-30**] 06:35PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ BURR-1+
[**2136-8-30**] 06:35PM NEUTS-85* BANDS-0 LYMPHS-10* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2136-8-30**] 06:35PM WBC-7.3 RBC-3.21* HGB-9.4* HCT-29.2* MCV-91
MCH-29.3 MCHC-32.2 RDW-15.4
[**2136-8-30**] 06:35PM CALCIUM-8.8 PHOSPHATE-8.8*# MAGNESIUM-2.9*
[**2136-8-30**] 06:35PM CK-MB-NotDone
[**2136-8-30**] 06:35PM cTropnT-0.04*
[**2136-8-30**] 06:35PM LIPASE-111*
[**2136-8-30**] 06:35PM ALT(SGPT)-345* AST(SGOT)-777* CK(CPK)-91 ALK
PHOS-123* AMYLASE-173* TOT BILI-1.1
[**2136-8-30**] 06:35PM GLUCOSE-168* UREA N-88* CREAT-5.1*#
SODIUM-129* POTASSIUM-6.0* CHLORIDE-92* TOTAL CO2-14* ANION
GAP-29*
[**2136-8-30**] 06:48PM GLUCOSE-165* LACTATE-5.9* K+-5.9*
[**2136-8-30**] 08:19PM PO2-32* PCO2-43 PH-7.30* TOTAL CO2-22 BASE
XS--5 INTUBATED-INTUBATED
[**2136-8-30**] 09:30PM PT-76.8* PTT-68.8* INR(PT)-10.0*
[**2136-8-30**] 09:30PM PLT COUNT-185
[**2136-8-30**] 09:30PM NEUTS-87.1* LYMPHS-8.3* MONOS-4.3 EOS-0.3
BASOS-0
[**2136-8-31**] 03:17AM URINE MUCOUS-FEW
[**2136-8-31**] 03:17AM URINE RBC-21-50* WBC-[**7-15**]* BACTERIA-FEW
YEAST-NONE EPI-<1
[**2136-8-31**] 03:17AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2136-8-31**] 03:17AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2136-8-31**] 03:17AM FIBRINOGE-234 D-DIMER-1335*
[**2136-8-31**] 03:17AM FDP-0-10
[**2136-8-31**] 03:17AM PT-84.2* PTT-52.8* INR(PT)-11.2*
[**2136-8-31**] 03:17AM PLT COUNT-206
[**2136-8-31**] 03:17AM WBC-8.7 RBC-3.30* HGB-9.3* HCT-29.5* MCV-90
MCH-28.4 MCHC-31.6 RDW-15.1
[**2136-8-31**] 03:17AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-POS
[**2136-8-31**] 03:17AM URINE HOURS-RANDOM
[**2136-8-31**] 03:17AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2136-8-31**] 03:17AM CORTISOL-39.6*
[**2136-8-31**] 03:17AM HAPTOGLOB-123
[**2136-8-31**] 03:17AM CALCIUM-8.2* PHOSPHATE-8.7* MAGNESIUM-2.7*
[**2136-8-31**] 03:17AM CK-MB-6 cTropnT-0.03*
[**2136-8-31**] 03:17AM CK(CPK)-68
[**2136-8-31**] 03:17AM GLUCOSE-72 UREA N-84* CREAT-4.9* SODIUM-134
POTASSIUM-6.5* CHLORIDE-99 TOTAL CO2-17* ANION GAP-25*
[**2136-8-31**] 04:35AM CORTISOL-42.2*
[**2136-8-31**] 04:43AM TYPE-ART TEMP-36.1 RATES-12/ TIDAL VOL-450
PEEP-5 O2-100 PO2-348* PCO2-36 PH-7.25* TOTAL CO2-17* BASE
XS--10 AADO2-335 REQ O2-61 -ASSIST/CON INTUBATED-INTUBATED
[**2136-8-31**] 05:43AM CORTISOL-38.6*
[**2136-8-31**] 05:52AM POTASSIUM-5.3*
[**2136-8-31**] 06:06AM O2 SAT-95
[**2136-8-31**] 06:06AM TYPE-[**Last Name (un) **]
[**2136-8-31**] 11:38AM PT-36.2* PTT-49.4* INR(PT)-4.0*
[**2136-8-31**] 11:38AM DIGOXIN-0.5*
[**2136-8-31**] 11:38AM VANCO-<1.7
[**2136-8-31**] 11:38AM POTASSIUM-5.0
[**2136-8-31**] 02:28PM K+-4.1
[**2136-8-31**] 02:28PM TYPE-ART TEMP-35.9 RATES-14/4 TIDAL VOL-450
PEEP-5 O2-50 PO2-91 PCO2-41 PH-7.43 TOTAL CO2-28 BASE XS-2
-ASSIST/CON INTUBATED-INTUBATED
[**2136-8-31**] 06:45PM estGFR-Using this
[**2136-8-31**] 06:45PM GLUCOSE-88 UREA N-84* CREAT-4.3* SODIUM-137
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17
.
CT ABDOMEN W/O CONTRAST [**2136-8-30**] 9:32 PM
1. Linear focus of air within the left renal vein. Approximate
volume is 0.7 cubic centimeters. This is of unclear clinical
significance, but likely relates to injected air from IV
placement or medication administration.
2. Diffuse stranding of the mesentery and abdominal ascites.
Please note, lack of intravenous contrast administration limits
detailed evaluation of the intra-abdominal and pelvic organs.
3. Non-obstructive left upper pole renal calculus.
4. Nasogastric tube should be advanced at least 5 cm for optimal
placement.
.
CT HEAD W/O CONTRAST [**2136-8-31**] 12:41 AM
IMPRESSION: Limited examination secondary to patient motion. No
acute intracranial hemorrhage.
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2136-8-3**].
LEFT ATRIUM: Marked LA enlargement. LA volume markedly
increased.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. The
patient is
mechanically ventilated. Cannot assess RA pressure.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Severe
global LV hypokinesis. No LV mass/thrombus. No resting LVOT
gradient.
RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV
free wall
hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
thickening of
mitral valve chordae. Moderate (2+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate to severe
[3+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Significant
PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Ascites.
Conclusions:
The left and right atria are markedly dilated. The left atrial
volume is
markedly increased. Left ventricular wall thicknesses are
normal. The left ventricular cavity is severely dilated with
severe global hypokinesis (LVEF <20%). No masses or thrombi are
seen in the left ventricle. The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is moderate
thickening of the mitral valve chordae. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2136-8-3**],
the severity of tricuspid regurgitation has progressed.
Biventricular systolic function is similar.
Brief Hospital Course:
Shock:
In the MICU, pt had evidence of multisystem organ dysfunction.
Ddx included septic vs. cardiogenic. There was initial concern
for septic shock given reported high fever, symptoms of GI
infection, and hypotension. However, after volume resuscitation,
pt was extubated, off all pressors and mounting excellent BP for
her EF. It was thought that her hypotension was likely due to
cardiogenic shock in the setting of dehydration from diarrhea
and preload dependence. No source for infection was isolated
during her hospital stay. Mrs [**Known lastname **] was treated with a full 7
day course of levofloxacin and flagyl for presumed
gastroenteritis in immunocompromised patient. Stool cultures,
blood cultures, urine cx remained negative throughout stay.
Was ruled out for MI with serial cardiac enzymes.
CHF: An ECHO was completed on [**2136-8-31**] that revealed marked
dilatation of the left and right atria, normal left ventricular
wall thicknesses. The left
ventricular cavity was severely dilated with severe global
hypokinesis (LVEF
<20%). No masses or thrombi were noted. The right ventricle was
moderately dilated with severe hypokinesis. Moderate (2+)
mitral regurgitation and moderate to severe [3+] tricuspid
regurgitation was seen. There was moderate pulmonary artery
systolic hypertension with significant pulmonic regurgitation.
Patient has been treated with anticoagulation with goal INR [**3-10**]
in setting of her global hypokinesis and poor EF. At the time of
discharge her INR was 1.7 on Coumadin 2mg.
Throughout her hospital course, Mrs. [**Known lastname **] felt short of
breath, was unable to lie flat secondary to orthopnea, and had
cough. CXR on [**2136-9-4**] demonstrated small bilateral pleural
effusion, left greater than right, and left atelectasis vs.
consolidation. She was treated with diuresis, oxygen via nasal
cannula and incentive spirometry. It was felt that her symptoms
were likely secondary to her severe CHF and pulmonary edema.
Patients sats remained good. By the time of discharge she was
comfortable, experienced no SOB but remained on 4L via nasal
cannula for symptomaitc relief. She would have labored breathing
if that aws not administered.
Chronic renal failure- Patients baseline Cr is 1.5-2. Her peak
cr during hospitalization was 4.3 and had returned to baseline
(1.8) by the time of discharge.
Renal failure was thought to be prerenal.
HIV/AIDS
Mrs [**Known lastname **] [**Last Name (NamePattern1) **] most recent labs revealed CD4 count of 312, Viral
load less than 50 on [**2136-8-23**]. She was not started on
antiretrovirals or during her hospital course. Patient was on
PCP prophylaxis with bactrim.
# CODE STATUS: lengthy discussion with pt. and grandson by
primary and CHF teams and pt. made decision that she would like
to seek hospice with focus on comfort and would not want to be
intubated or resuscitated in the future and would like to avoid
future hospitalizations. Her code status was changed and
palliative care consult was called to aid in placement and
delineation of goals. She was screened for hospice.
Medications on Admission:
Methadone 90 mg PO DAILY
Lansoprazole 30 mg PO DAILY
Trimethoprim-Sulfamethoxazole 160-800 mg PO DAILY
Furosemide 100 mg PO BID
Digoxin 125 mcg PO every other day
Coumadin 5 mg PO once a day
Discharge Medications:
1. Warfarin 2 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
2. Ipratropium Bromide 0.02 % Solution [**Year (4 digits) **]: One (1) Inhalation
Q4-6H (every 4 to 6 hours).
3. Digoxin 125 mcg Tablet [**Year (4 digits) **]: Half tablet Tablet PO QMOWEFR
(Monday -Wednesday-Friday).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Year (4 digits) **]: One (1)
Inhalation Q4H (every 4 hours).
5. Furosemide 40 mg Tablet [**Year (4 digits) **]: 2.5 Tablets PO BID (2 times a
day).
6. Methadone 10 mg/mL Concentrate [**Year (4 digits) **]: Three (3) PO TID (3
times a day).
7. Morphine 10 mg/5 mL Solution [**Year (4 digits) **]: One (1) PO Q3H (every 3
hours) as needed for pain or Shortness of breath.
8. Lorazepam 0.5 mg Tablet [**Year (4 digits) **]: [**2-7**] to 1 tablet Tablet PO Q4H
(every 4 hours) as needed for anxiety.
9. Aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11729**] Home - [**Location (un) 686**]
Discharge Diagnosis:
HIV/AIDS (CD4 312, VL< 50 on [**2136-8-23**])
CHF (EF 10%)
Chronic hepatitis C
Discharge Condition:
Stabe
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"042",
"070.54",
"428.0",
"496",
"785.52",
"397.0",
"424.0",
"570",
"785.51",
"577.0",
"584.9",
"425.9",
"276.7",
"038.9",
"585.9",
"995.92",
"305.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14168, 14251
|
9875, 12968
|
283, 322
|
14374, 14504
|
3464, 9852
|
2917, 2921
|
13210, 14145
|
14272, 14353
|
12994, 13187
|
2936, 3445
|
231, 245
|
350, 2096
|
2118, 2701
|
2717, 2901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,266
| 173,804
|
28610
|
Discharge summary
|
report
|
Admission Date: [**2142-6-5**] Discharge Date: [**2142-6-9**]
Date of Birth: [**2083-11-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
hypotension, anemia.
Major Surgical or Invasive Procedure:
EGD [**6-7**], colonoscopy [**6-8**].
History of Present Illness:
58 year old man with widely metastic prostate cancer (calverium,
spine, ribs, pelvis, and proximal humeri and femurs) presented
with profound weakness, n/v/d after initiating chemotherapy for
prostate cancer one week ago. He was admitted to the ICU with
hct 16 (baseline 25). He notes 1 week PTA initiating taxotere.
Additionally in that week he had difficulty with ambulation and
a fall and difficulty getting up. He notes urinary incontinence
that he says is due to inability to get to the bathroom but also
diarrhea with incontinence. This appears relatively new for him
but he notes he is able to control his sphincter function and
incontinence is in the setting of decreased ability to ambulate.
He had notes diarrhea that is watery with with brown/black
specks in that look like 'licorice' but denies BRBPR. He notes
increased productive cough (yellow sputum) for 3+ days PTA which
is not normal per him, but denies episodes of coughing or
choking on foods.
.
In the ED, patient initially had Temp 99.4, SBP in the 60s,
which improved to 90s with 3L NS, which is according to
oncologist at his baseline. He was also noted to have a hct of
16 and ANC of roughhly 1000. He received vancomycin in the ED.
He was tranferred to the ICU where he received 2 uPRBC's and was
continued on vanco/zosyn for pneumonia (by CT scan). Hct
improved to 28.2.
.
He denies fevers, chills (but is always cold), head ache,
abdominal pain, nausea, vomitting, or rashes. He states today he
feels much better than he has with much improved pain.
Past Medical History:
Oncologic history:
-presented [**12-19**] with diffuse bony pain (cervical, lumbar, lower
exremity) and weight loss (25-30 lbs). CT--diffuse mottled
appearance of the bones concerning for diffuse metastases, C6
and C7 spinous process fx. PSA = 30.4.
-Prostate biopsy=[**Doctor Last Name **] 5+4 prostatic adenocarcinoma
-Bone marrow biopsy=metastatic poorly differentiated carcinoma
associated with extensive fibrosis.
-s/p orchiectomy
-[**10-20**] started on ketoconazole/hydrocortisone, ordered stopped
[**3-21**] as disease progressive (but appears from outpatient
medication list that he continued taking it).
-[**2142-5-10**]: Symptoms from disease progression: worsening bilateral
pelvic bone pain and left shoulder pain.
-[**2142-5-29**]: palliative chemotherapy with taxotere/prednisone (but
appears that he has not had any prednisone as an outpatient).
.
PMH:
1. Chronic pancreatitis.
2. Malnutrition.
3. Anemia.
4. s/p abdominal gun wound many years prior with surgical
repair.
Social History:
Lives in [**Hospital3 **] vs. NH-[**Street Address(1) **]
Family History:
Unknown.
Physical Exam:
Vitals: T 98.6, P 101, BP 93/58, RR 16, O2 sat 100% on 2L
Gen: Cachectic, comfortable, speaking slowly in full sentences
LN:
HEENT: MMM, PERRL, EOMI
CV: RRR, no m/r/g
Chest: coarse crackles on right posteriorly
Abd: soft, nt, +bs
Ext: no c/c/e
Neuro: grossly intact, AAOx3
Guiac +
Pertinent Results:
Admission labs:
139 109 25
------------<100
4.5 20 1.0
estGFR: >75 (click for details)
Ca: 7.4 Mg: 1.4 P: 2.5
.
PT: 15.1 PTT: 30.8 INR: 1.4
.
CK: 28 MB: Notdone Trop-T: <0.01
Ca: 8.2 Mg: 1.4 P: 2.5
ALT: 12 AP: 155 Tbili: 0.8 Alb: 2.5
AST: 20 LDH: 236
[**Doctor First Name **]: 27 Lip: 12
Iron: 19
calTIBC: 90
Hapto: 473
Ferritn: >[**2135**]
TRF: 69
.
5.3
2.4>---<444
16.4---------->improved to 27.8 after 2 uPRBC's and remained
stable
N:25 Band:16 L:45 M:8 E:1 Bas:0 Atyps: 4 Metas: 1 Nrbc: 9
Neuts: TOXIC GRANULATIONS
Hypochr: 1+ Anisocy: 1+ Poiklo: OCCASIONAL Macrocy: 2+ Polychr:
OCCASIONAL Acantho: OCCASIONAL
Ret-Aut: 0.9
Lactate:1.3
.
Micro:
UA: negative, legionella antigen negative
Blood Cultures: No Growth
C. diff toxin A negative x2
.
Imaging:
Imaging:
CXR [**6-5**]:
1) Increased opacity in the right lower lobe is consistent with
a pneumonic consolidation.
2) Diffuse sclerotic osseous metastasis.
.
Abd Film [**6-5**]: 1) Nonspecific prominent loop of small bowel is
noted, which is likely unchanged in configuration in comparison
to the prior study. No other dilated loops of bowel.
2) Diffuse osseous sclerotic metastases.
3) Coarse calcification in the epigastric region from chronic
pancreatitis
.
Bone scan: Widespread metastatic bony disease.
.
CT Abd [**5-16**]:
1. Scattered small diffuse retroperitoneal adenopathy and right
iliac adenopathy. No regions meet criteria to be considered
target lesions.
2. Diffuse bony metastatic disease primarily sclerotic in
origin. However, with a single lytic area within the right iliac
bone andthat within the left iliac bone showing extension into
the adjacent musculature.
3. Findings consistent with chronic pancreatitis and a probable
simple pancreatic pseudocyst involving the pancreatic head.
Attention to this area on followup to ensure that this cyst
which appears simple, remains stable.
.
CXR [**2142-6-6**]: Multilobar pneumonia in the right lower lung has
improved since [**6-5**]. Left lung grossly clear. Heart size
normal. Pleural effusion if any is minimal, on the right.
Extensive blastic metastatic prostate carcinoma is seen in the
chest cage.
Brief Hospital Course:
A/P: 58 yo man with diffusely metastatic prostate cancer
presenting with anemia, hypotension, and pneumonia.
.
1 Hypotension: Resolved. Likely secondary to hypovolemia with
acute anemia, improved with IVF/transfussion, though in clinic
notes documented baseline 83-116 SBP. Not likely to be adrenal
insufficiency given response to treatment. BP remained stable
after initial volume resuscitation SBP: 95-120.
.
2 Anemia: Megaloblastic. Not clearly related to recent chemo,
hemolysis labs negative (high hapto, LDH normal, t.bili normal).
Retic inappropriately low, not surprising given his known
fibrosis of bone marrow with metastatic prostate CA. Iron
studies suggest AOCD, vitamin B12/folate replete. Stopped iron
supplement. Coags mildly elevated PT/INR. H/O melena and guaiac
positive in the icu (despite being negative in ED) suggests GIB
contributing to acute change. If on prednisone as outpatient
(unclear) could predispose him to GIB. Had negative EGD [**6-7**],
negative colonoscopy [**6-8**], hct stable since admit transfussion.
.
3 Pneumonia: CXR consistent with pneumonia, likely aspiration
given distribution but as living in long-term care facility
warrants treatment as HAP. Not currently neutropenic. Speech and
swallow cleared him (no observed aspiration risk). Urine
legionella ag negative. He was transitioned to levofloxacin for
po treatment and discharged to complete a 10 day course.
.
4 Metastatic Prostate cancer: s/p taxotere recently, held
prednisone given potential GIB but restarted [**6-8**] since hct
stable, continue morphine sulfate slow release and vicodin prn
for pain as outpatient pain regimen. Further treatment as an
outpatient. Will continue on prednisone 5mg [**Hospital1 **].
.
5 Diarrhea: Unclear etiology, may be related to GIB (blood is
cathartic in GI tract,) c.diff unlikely negative x2. Improved
during his admission.
.
6 Oropharyngeal [**Female First Name (un) **]: Noted on exam, improved with nystatin
swish and swallow qid.
.
7 Proph: [**Hospital1 **] pantoprazole, bowel regimen-held for diarrhea,
heparin sc tid.
.
8 Code status: DNR/DNI per discussion with patient-of note pcp
documents this as not c/w previously stated wishes, but verified
DNR/DNI on [**2142-6-9**].
Medications on Admission:
Iron sulfate 325 mg p.o. daily
folic acid 1 mg p.o. daily
multivitamin one tablet p.o. daily
thiamine 100 mg p.o. daily
MS contin 30 mg p.o. b.i.d.
nicotine 11 mg patch daily
colace 100 mg p.o. b.i.d.
ensure as needed,
prilosec 20 mg p.o. b.i.d.
Genasyme 80 mg p.o. b.i.d.
Vicodin as needed for pain.
Prednisone 5 mg **not sure if patient is taking, he can not
recall, can not name his pharmacy though notes it is [**Street Address(1) 69238**]
Discharge Medications:
1. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. Levofloxacin 250 mg Tablet Sig: Five (5) Tablet PO Q24H
(every 24 hours) for 5 days: starting [**2142-6-10**].
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
Metastatic prostate cancer, anemia, pneumonia.
.
Chronic pancreatitis.
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow-up appointments. Please notify your primary care doctor
or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] if you experience fevers, chills, nausea,
vomitting, worsening cough, shortness of breath, chest pain,
black or tarry stools, dizziness, lightheadedness or any
symptoms that concern you.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on [**2142-6-21**]
at 9:00am. Please call [**Telephone/Fax (1) 22**] if questions.
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
|
[
"112.0",
"507.0",
"276.52",
"577.1",
"185",
"285.22",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9243, 9296
|
5530, 7759
|
335, 375
|
9411, 9421
|
3364, 3364
|
9851, 10149
|
3037, 3047
|
8254, 9220
|
9317, 9390
|
7785, 8231
|
9445, 9828
|
3062, 3345
|
275, 297
|
403, 1933
|
3380, 5507
|
1955, 2945
|
2962, 3021
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,631
| 181,402
|
12564
|
Discharge summary
|
report
|
Admission Date: [**2152-2-28**] Discharge Date: [**2152-3-5**]
Date of Birth: [**2089-8-8**] Sex: M
Service: GEN [**Doctor First Name 147**]-PURPLE
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old
male in his usual state of health who became nauseated and
within 30 minutes vomited blood and passed melanotic stool.
The patient presented to an outside hospital where he
received packed red blood cells, hematocrit had gone down to
23. He also received platelets at the outside hospital. The
patient had a bleeding scan which showed bleeding in the
second part of the duodenum. He also had an
esophagogastroduodenoscopy which showed duodenal diverticula
with active bleeding. No intervention could be done.
At [**Hospital1 69**], a repeat EGD with
ongoing bleeding without intervention and he was sent to
Interventional Radiology and no source could be demonstrated.
The patient received five units of packed red blood cells at
[**Hospital1 69**] since the second day of
admission. The patient in the Intensive Care Unit was
hemodynamically stable without complaints. No nausea or
vomiting, no hematemesis since his first episode at the
outside hospital. Since arriving at [**Hospital1 190**], hematocrit had gone from 30 to 24 and up to
27 with one unit transfusion.
PAST MEDICAL HISTORY:
1. Coronary artery disease with stent placement.
2. Hypertension.
3. High cholesterol.
4. Gastroesophageal reflux disease.
5. Osteoarthritis of the left knee.
PAST SURGICAL HISTORY: No past surgeries.
The patient denies any previous episodes of GI bleeding.
MEDICATIONS:
1. Aspirin.
ALLERGIES: The patient has an allergy to penicillin.
SOCIAL HISTORY: The patient quit smoking 40 years previous.
HOSPITAL COURSE: The patient was consulted to Surgery. On
hospital day number three, the patient was found to be
afebrile with vital signs stable. Abdomen was soft,
nontender, nondistended. Rectal: There was scant blood
noted on the glove with dark tarry stool. The patient's
white count was 8.0. Hematocrit was 29; potassium was 2.3;
other electrolytes were within normal limits as were the
liver function tests. Esophagogastroduodenoscopy and
angiograms as noted above.
On hospital day number four, the patient passed melena times
two and with decreased blood pressure. The patient was
bolused and received two units of packed red blood cells.
The patient was afebrile with vital signs stable after that.
The patient was stable otherwise besides the drop in blood
pressure with the passage of the melena in large amount.
Interventional Radiology was contact[**Name (NI) **] regarding angiogram
procedures and try to coil bleeding. The patient underwent
an exploratory laparotomy and duodenal diverticulectomy.
Postoperative day one, the patient continued to have falling
resuscitation. PCA was discontinued. Given one unit of
packed red blood cells postoperatively by the Intensive Care
Unit team and received a liter of fluid boluses. The patient
was afebrile. Vital signs were stable. The patient had a
few crackles and decreased breath sounds. Abdomen was soft,
nondistended, nontender, and the incision was clean, dry and
intact. The patient had a white count of 18, hematocrit
30.6, platelets 137. Other electrolytes were within normal
limits.
The patient was transferred to the Floor. On postoperative
day two, the patient had no complaint, no nausea, vomiting,
fevers or chills. He was ambulating well. He was afebrile
and vital signs were stable. He continued to be soft,
nontender, nondistended. The incision was clean, dry and
intact. The patient's diet was advanced. The medications
were made p.o. and discharge planning was begun. The patient
had a hematocrit of 23.6; vital signs stable; alert and
oriented. Continuing to pass some stools with clot and was
felt to be tolerating diet, ambulating well, pain controlled.
He was felt to be stable to go home with follow-up with Dr.
[**Last Name (STitle) **].
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Status post exploratory laparotomy, duodenal
diverticulectomy.
2. Hypertension.
3. Dyslipidemia.
4. Gastroesophageal reflux disease.
5. Osteoarthritis of the left knee.
6. Coronary artery disease.
DISCHARGE MEDICATIONS:
1. Darvocet for pain.
Restart on his previous medications.
DISCHARGE INSTRUCTIONS:
1. To follow-up with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2152-9-14**] 10:30
T: [**2152-9-14**] 10:54
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern4) 38892**]
|
[
"562.02",
"285.1",
"530.81",
"272.0",
"V45.82",
"414.01",
"715.96",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.31",
"45.13",
"54.11",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
4078, 4285
|
4308, 4369
|
1759, 4003
|
4393, 4749
|
1518, 1679
|
4019, 4057
|
198, 1307
|
1329, 1494
|
1696, 1741
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,545
| 197,390
|
16898
|
Discharge summary
|
report
|
Admission Date: [**2183-12-3**] Discharge Date: [**2183-12-4**]
Date of Birth: [**2132-4-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tape
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
mechanical ventilation
arterial cannulation
central venous cannulation
History of Present Illness:
51 year old man with acute promyelocytic leukemia status post
allogeneic bone marrow transplant two years ago, complicated by
extensive moderate graft vs. host disease (extending to his
skin, eyes, lungs, and GI tract), resistant stenotrophomonas in
his sputum, and bronchiolitis obliterans (FVC 2.31 and FEV1
0.75), transferred from [**Hospital3 **] emergency department to
[**Hospital1 18**] for respiratory failure and hypotension. He was recently
discharged from [**Hospital1 18**] after a hospitalization for exacerbation
of his pulmonary GVHD. He had a 12[**Hospital 15386**] hospital stay, ending
[**11-19**]. He uses home oxygen and his oxygen saturation had been
95% on 2 liters.
He was noted to have increasing weakness over the past several
days, as well as progressive respiratory distress and change in
mental status. On the day of admission, he had increased work of
breathing and significant confusion. His family noted he was
saying things that were coherent but inappropriate, such as
saying he was handing his daughter [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 47606**], or talking about
seeing a skunk. His wife thought he may have been having visual
hallucinations while in the outside hospital.
Initially, he was sent in an ambulance to [**Hospital1 18**], but due to his
increasing respiratory distress, he was sent to [**Hospital1 498**] first.
There, he initially presented with T 97.3, BP 152/97, HR 60, RR
20, SaO2 93%/3L. He was given albuterol nebs, seemingly without
significant improvement. An arterial blood gas was 7.19/71/79
and he was intubated. He was given a dose of meropenem. Around
the same time as intubation and treatment, he became
hypotensive. He was started on a dopamine gtt.
When he arrived at [**Hospital1 18**], he was hypotensive with SBPs 60-70,
and was started on levophed, vasopressin and dopamine. He was
also given 3L fluid bolus.
Past Medical History:
1. Acute promyelocytic leukemia - s/p ATRA and arsenic therapy,
allogeneic BMT, complicated by GVHD.
- bronchiolitis obliterans - FVC 2.31; FEV1 0.75; FEV1/FVC 32,
with chronic cough
- s/p corneal transplant L eye [**6-2**] and s/p cataract removal R
eye [**10-3**]
- pruritic rash
- h/o diarrhea; gallbladder sludge - on ursodiol; lost about
130lbs after BMT
2. history of resistant stenotrophomonas growing from sputum
3. history of Pseudomonas pneumonia
4. chronic kidney disease - unclear etiology, thought to be
[**Name (NI) 47605**]; recent baseline 0.9-1.0
5. hypertension
6. history of childhood asthma - hospitalized but not intubated
7. chronic C. difficile
Social History:
Married with two children. Not able to work currently secondary
to his illness but previously he worked as an administrator for
the VNA service in [**Hospital1 1559**], a tax accountant, and an ICU
nurse. Distant tobacco (pipe, quit 20 years ago), no cigarettes,
ETOH or illicit drug use.
Family History:
No family history of leukemia/lymphoma.
Mother with renal disease, on HD.
Father died suddenly at 63, presumed to be secondary to MI.
Physical Exam:
HR 75, RR 16, BP 65/39, O2Sat 92% CMV 600x16 PEEP 5 FiO2 100%
Gen: Patient sedated, not responsive
Heent: Right eye sewn shut. Intubated with OG tube in place
Lungs: Diffuse tubular sounds ant/lat
Cardiac: Decreased heart sounds, no murmurs
Abdomen: Soft, distended, decreased BS
Ext: anasraca, +2 pitting edema in UE and LE b/l
Neuro: sedated
Pertinent Results:
Admission labs:
CBC: WBC-0.4*# RBC-3.52* Hgb-13.5* Hct-42.8 Plt Ct-60*# Gran
Ct-30*
Coags: PT-12.2 PTT-33.8 INR(PT)-1.0
Chem 10: Glucose-142* UreaN-44* Creat-0.6 Na-145 K-3.0* Cl-112*
HCO3-27 Calcium-7.6* Phos-2.3*# Mg-1.3* freeCa-1.14
Enzs: ALT-35 AST-32 LD(LDH)-306* AlkPhos-609* Amylase-137*
TotBili-1.3 Lipase-96* Albumin-1.9*
Cards: CK(CPK)-36* CK-MB-6 cTropnT-0.02*
Lactate-2.0 -> 2.6 - 3.2 - 3.8
ABG: 7.25/53/88 -> 7.21/45/76
Abdominal u/s: 1. Gallbladder wall thickening and gallstones
seen in the neck of the gallbladder consistent with
cholecystitis. Given lack of distention, other possible
etiologies include CHF, ascites, and hypoproteinemia should be
considered.
2. Ascites
3. Right pleural effusion.
KUB: No diagnostic abnormality.
CXR: 1. Symmetric bilateral opacities in the mid lungs
suggestive of moderate pulmonary edema, less likely hemorrhage.
These areas could also possibly represent an aspiration
pneumonia.
2. No evidence of pneumothorax.
ECHO:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV cavity size. Cannot assess LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
TRICUSPID VALVE: Normal tricuspid valve leaflets.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: No pericardial effusion.
Brief Hospital Course:
Assessment: 51yo man with acute promyelocytic leukemia s/p bone
marrow transplant complicated by extensive graft vs. host
disease including bronchiolitis obliterans, history of
pseudomonas PNA, sputum growing resistant stenotrophomonas, and
aspergillus colonization, who was admitted to the ICU with
respiratory failure and found to be hypotensive as well.
Hospital course is discussed below by problem:
1. Respiratory failure - The most likely etiology of the
respiratory failure was a pneumonia on the background of
significant pulmonary disease (bronchiolitis obliterans with
severely depressed FEV1 and FVC). Given his severe
immunocompromise, he was covered for infection by bacteria
(including pseudomonas and resistant stenotrophomonas), fungus,
or PCP. [**Name10 (NameIs) 227**] his penicillin allergy, he was treated with
vancomycin, ciprofloxacin, aztreonam (changed from tobramycin),
IV flagyl, voriconazole, and IV bactrim. Colistin was
considered, but given its significant toxicity, it was not
started and was awaiting stenotrophomonas sensitivities. He had
cultures drawn, a BAL was considered. He was thought to likely
have ARDS secondary to sepsis, and the ARDS protocol for
ventilator settings was attempted, but he did not tolerate these
settings and became hypoxemic and acidemic. He was thus
ventilated with larger volumes. He was additionally treated with
albuterol, atrovent, and flovent. He required escalating FiO2,
evantually at 100%, and remained with persistent acidosis.
2. Hypotension - On arrival to the ICU, the patient was found to
be hypotensive. The first BP read was 150/120, but then he was
found to have a kinked blood pressure cuff. The more accurate
[**Location (un) 1131**] was in the 70s/30s. While placing an arterial line, his
blood pressure began to fall. He had been switched from dopamine
to levophed, vasopressin was added, and the dopamine restarted.
He was given over 5 liters of fluid with eventual stabilization
of his blood pressure with MAPs in the 50s. Most likely, the
hypotension was secondary to septic shock. Other possibilities
include tamponade, which was not evidenced by ECHO. Pulmonary
embolus was considered, but was less likely given his CXR. He
was likely adrenally insufficient, given his outpatient regimen
including prednisone, so he was started on stress-dose steroids.
3. Acidosis - He was found to have a significant acidosis. This
was thought to be secondary to lactic acidosis, nongap acidosis
from normal saline boluses, and respiratory abnormalities. His
ventilator was set to attempt to correct the acidosis, but his
blood pressure and hypoxia were confounding factors.
4. Acute promyelocytic leukemia with graft vs. host disease - He
was continued on acyclovir, IV voriconazole, ursodiol,
ophthalmic ointment. He was given stress dose steroids and
started on GCSF. The bone marrow transplant team followed
throughout his hospital course.
5. Abdominal pain - He was found to have abdominal pain the
morning after admission. An x-ray and ultrasound were performed
for evaluation, as the patient was too sick to go for CT. He was
found to have likely cholecystitis.
6. C diff - He was treated with IV metronidazole.
7. Glucose control - His blood glucose was controlled with an
insulin drip.
Despite maximal medical management in the MICU, the patient
developed progressive organ dysfunction, in the context of
advanced GVHD and progressive bronchiolitis obliterans lung
disease. Following several multidisciplinary meetings with
numberous family members (including wife) and discussions with
the patient's primary Oncologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]), the decision
was made not to resuscitate the patient in the event of a
cardiac arrest. On the second hospital/MICU day, the patient
expired following an asystolic arrest. Family members were at
his bedside.
Medications on Admission:
Atrovent nebs every 6 hours p.r.n.
albuterol every 6 hours p.r.n.
Advair Diskus 250/50 mg 1 inhalation b.i.d.
budesonide 3 mg capsule p.o. b.i.d.
Protonix 40 mg p.o. once daily
ursodiol 300 mg p.o. b.i.d
acyclovir 400 mg p.o. b.i.d
Bactrim-DS 1 p.o. 3 times per week
metoprolol 50 mg 2 tablets p.o. b.i.d
clotrimazole 10 mg p.o. b.i.d
lorazepam 1 mg one to two tablets p.o. q.h.s. p.r.n.
folic acid 1 mg p.o. once daily,
sulfacetamide ophthalmic ointment apply OU b.i.d.
fluticasone 100 mcg inhalation b.i.d.
Flagyl 500 mg p.o. 1 t.i.d.
voriconazole 200 mg p.o. b.i.d.
prednisone 20 mg p.o. qam, prednisone 10 mg p.o. qpm.,
losartan 25 mg p.o. daily
loperamide 2 mg capsule p.o. q.i.d.
Lasix 60mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute promyelocytic leukemia
Graft vs. host disease
Septic shock
Pneumonia
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"205.00",
"995.92",
"518.81",
"008.45",
"486",
"585.9",
"255.4",
"575.10",
"785.52",
"V42.5",
"401.9",
"276.2",
"038.9",
"996.85",
"516.8",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"38.91",
"00.17",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9934, 9943
|
5252, 9152
|
298, 370
|
10062, 10071
|
3831, 3831
|
10123, 10255
|
3317, 3452
|
9906, 9911
|
9964, 10041
|
9178, 9883
|
10095, 10100
|
3467, 3812
|
239, 260
|
398, 2301
|
3847, 5229
|
2323, 2993
|
3009, 3301
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,321
| 198,614
|
5942
|
Discharge summary
|
report
|
Admission Date: [**2154-9-28**] Discharge Date: [**2154-9-30**]
Date of Birth: [**2080-8-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
During Code:
Intubation
Femoral Central Line
Transvenous pacing
Arterial Line
History of Present Illness:
74 yo diabetic male with metastatic renal cancer involving the
lung and liver on avastin, prostate cancer, a history of PE, and
no known heart disease, presenting to [**Hospital1 18**] with 1 day of
non-specific fatigue and malaise subsequently found to have an
I-STEMI, and who now presents to the CCU s/p 2 BM stents to
ostial and distal RCA stensoses and intra-catheterization
vagally induced hypotension in the setting of acute kidney
injury.
.
He has felt unwell with fatigue and malaise since he underwent
CT-scan last Monday. Notes that he felt particularly unwell
Wednesday and that on Friday, the day prior to admission, he had
a presyncopal event, which he describes as feeling weak in the
legs while he was walking to the bathroom in his home; he lost
his balance and hit his forehead against the wall but did not
lose consciousness. He retired to bed, where he remained for the
rest of the day and awoke the day of admission with fatigue and
malaise. He went to church despite these symptoms, where he saw
the [**Doctor Last Name 23432**] nurse, who advised him to present to the ED. During
the interval between when he was presyncopal to when he
presented to the ED, he had no chest tightness or heaviness,
shortness of breath, palpitations, nausea, vomiting. He also
denies orthopnea, PND, or dependent edema. At baseline he can
climb 2 flights of stairs to his apartment without significant
exertional dyspnea.
.
In the ED, vitals were Temp:97.6 HR:74 BP:127/64 Resp:16
O(2)Sat:100 on RA. EKG showed [**Street Address(2) 4793**] elevation in leads III and
AVF. Mild reciprocal ST depression in aVL and V3 Acute since
prior EKG. He was given ASA and loaded with Plavix, code STEMI
was called, and he was taken to the catheterization lab for
intervention.
.
In the lab, stenoses were appreciated in the viscinity of the
ostium of the RCA and in the distal RCA. A bare metal stent was
successfully deployed in each of the lesions; DES were deferred
in the setting of the patient's metastatic cancer and potential
bleeding risk on longterm anticoagulation. The procedure was
complicated by an episode of fluid responsive hypotension due to
vagal stimulation.
.
On the floor, vitals were Temp:98.3 HR:73 BP:172/55 Resp:24
O(2)Sat:100 RA. He continued on a renally dosed integrilin gtt
for 6 hours post cath and was started on medical management for
acute coronary syndrome with ASA 325, plavix 75, metoprolol 12.5
[**Hospital1 **], and atorvastatin 80. Afterload reduction was deferred given
his recent hypotension. Sheaths were pulled.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. S/he denies recent fevers, chills or rigors. S/he denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Past Medical History:
Renal Cell Ca clear cell histology, metastatic to lung, dx [**2146**]
in eval for elevated PSA
Prostate adenocarcinoma, diagnosed in [**6-/2147**], Followed by Dr.
[**First Name (STitle) 2856**] at [**Hospital1 882**]
.
Treatment Hx:
Status post left radical nephrectomy, [**2147-7-13**].
Status post left pulmonary wedge resection, [**2147-7-13**], path
showed clear cell RCC.
Interleukin-2 low-dose completed in [**1-/2148**] for RCC
Lupron Q 3 mos for prostate ca
.
Other PMHx:
Hypercholesterolemia
Diabetes II
Hypertension
Social History:
From Barbados, moved to US in [**2121**], has 5 grown children, lives
alone, has niece and friend who help take him to doctor's appt,
able to do ADL's on own, no ETOH currently, +tob 15 pack yr
history, quit 32 years ago, no drugs
Family History:
DM
Physical Exam:
Admission Exam:
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. JVP not elevated.
CARDIAC: Non-displaced PMI. Quiet heart sounds. RR, normal S1,
S2. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Right Groin: No bruits
Pertinent Results:
STUDIES:
[**9-28**] Cardiac Catheterization:
1. Selective coronary angiography in this right dominant system
demonstrates two vessel disease. The right coronary artery has a
proximal 70 % stenosis, as well as a 99% lesion in the distal
RCA just
after the PDA bifurcation. The circumflex artery has a 60%
lesion
distally. The left main coronary artery and LAD are free of
angiographically apparent flow limiting disease.
2. Limited hemodynamics demonstrated mild hypotension that
responded to
one liter fluid bolus.
3. Successful PTCA and stenting of distal RCA subtotal occlusion
with
2.0x18mm Mini Vision bare metal stent.
4. Successful direct stenting of proximal RCA lesion with
3.0x18mm
Vision bare metal stent postdilated to 3.25mm.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Systemic hypotension during the case, that responded to
intravenous
fluid bolus.
3. Acute inferior/posterior STE myocardial infarction.
4. Successful PCI of distal RCA subtotal occlusion with BMS.
5. Successful PCI of proximal RCA stenosis with BMS.
[**9-29**] Renal U/S: No acute renal pathology. No hydronephrosis.
[**9-30**] TEE at bedside:
A thrombus is suggested in the body of the right atrium. Left
ventricular wall thicknesses and cavity size are normal. There
is severe global left ventricular hypokinesis (LVEF = <20 %).
The right ventricular cavity is markedly dilated with severe
global free wall hypokinesis/akinesis. There is a
trivial/physiologic pericardial effusion.
Post-TPA infusion, there is no change.
These findings are suggetive of a primary pulmonary process
(e.g. pulmonary embolism), or a primary right ventricular
ischemia/infarction.
Brief Hospital Course:
Inferior STEMI: 74 yo diabetic male with metastatic renal cancer
involving the lung and liver on avastin, prostate cancer, a
history of PE, and no known heart disease, presenting to [**Hospital1 18**]
with 1 day of non-specific fatigue and malaise subsequently
found to have an I-STEMI. He presented to the CCU s/p 2 BM
stents to ostial and distal RCA stensoses and
intra-catheterization vagally induced hypotension in the setting
of acute kidney injury. Presented with essentially no specific
symptomatology, noting instead to have 1 week of vague malaise
and fatigue punctuated by an episode of presyncope the day prior
to admission. CK/MB and Troponins were positive in the setting
of STE changes in the inferior leads with reciprocal changes
across the precordium; CKMB peaked the day of admission and was
low in comparison to the Troponins in absolute value, suggesting
that the STEMI was missed and may have occurred a week ago. The
etiology of the STEMI is thought to be a thromboembolic event
due to Avastin, which is known to put patients at risk for these
phenomena.
[**Last Name (un) **]: Pt found to have [**Last Name (un) **], which is likely multifactorial - due
to pre-renal (FeNA<1%), post-renal, and intra-renal
pathophysiology; responded well to an empiric fluid challenge
and bladder scan was revealing of bladder outflow obstruction,
prompting placement of a foley; UA showed casts concerning for
contrast nephropathy after a heavy dye load recently (a CT for
re-staging of his cancer) and catheterization. Pt responded to
fluid challenge.
Likely PE: Pt's condition acutely deteriorated on [**2154-9-20**]. A
code was called after he suddenly syncopized. CPR was initiated
immediately. Bedside emergent echo revealed thrombus in right
atrium suggestive of possible large PE. TPA was administered. Pt
continued to decline despite aggressive resusitation. He passed
away in the morning on [**2154-9-30**].
Medications on Admission:
AMLODIPINE 5 mg daily
DOXAZOSIN 4 mg daily
GLIPIZIDE 10 mg daily
METFORMIN 850 mg TID
LISINOPRIL 40 mg daily
LEUPROLIDE 1 mg/0.2 mL Solution - 22.5mg IM q3months
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
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"788.29",
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"414.01",
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"458.29",
"426.12",
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"E879.0",
"197.7",
"410.31",
"584.9",
"250.00",
"596.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.46",
"36.06",
"96.04",
"99.60",
"00.66",
"37.78"
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icd9pcs
|
[
[
[]
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] |
8871, 8880
|
6701, 8629
|
320, 399
|
8932, 8942
|
5012, 5753
|
8999, 9010
|
4130, 4135
|
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8901, 8911
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8655, 8819
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5770, 6678
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8966, 8976
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4150, 4993
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275, 282
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427, 3315
|
3337, 3866
|
3882, 4114
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,088
| 183,275
|
42285
|
Discharge summary
|
report
|
Admission Date: [**2129-2-4**] Discharge Date: [**2129-2-10**]
Date of Birth: [**2057-1-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
septic shock
Major Surgical or Invasive Procedure:
percutaneous cholecystostomy tube placement
History of Present Illness:
This is a 72 year old male who initially presented 4 days prior
to admission with right upper quadrant pain. On the night prior
to admission, he developed fevers to 100, then on the morning of
admission, fevers progressed to near 101 accompanied by shaking
chills. His family took him to [**Hospital3 **], where a right
upper quadrant ultrasound revealed gallstones and fluid around
the gallbladder. He was treated initially with ceftriaxone,
ciprofloxacin, and flagyl. He became hypotensive to the 70s and
80s at the OSH and was started on norepinephrine. Given
persistent hypotension, he was also started on phenylephrine.
Mr [**Known lastname 91641**] was then transferred to [**Hospital1 18**] for further management.
In the ED at [**Hospital1 18**], he was febrile with temperatures to 101;
LFTs were also noted to be elevated with ALT of 152 and AST of
178 with normal alkaline phosphatase. CT abdomen was obtained
which revealed stones in the gallbladder with mild gallbladder
stranding but no cystic duct or CDB ductal dilation. No obvious
signs of cholecystis or cholangitis on imaging. Upon arrival to
the MICU, he had no active complaints; he denied abdominal pain,
nausea, vomiting, or feeling feverish. He did state he has not
moved his bowels in several days.
Past Medical History:
1. depression
2. hyperlipidemia
3. type II DM
4. HTN
5. hyperlipidemia
6. tobacco abuse
7. cardiomyopathy s/p ICD / pacer
8. ulcerative colitis
9. diverticulosis
10. GERD
11. BPH
12. COPD
13. CKD
Social History:
Lives in [**Location 7661**] with his wife. Retired, used to be mechanic.
No smoking history, remote drinking history.
Family History:
Has 2 brothers and 2 sisters. [**Name (NI) 6419**] brothers and one sister have
insulin-dependent diabetes. Brother also has hypertension.
Mother had heart disease and died at age 78. Father died of
leukemia.
Physical Exam:
ICU EXAM:
VS: His vitals show a regular rhythm with a heart rate of 75-80.
His blood pressure is 105 systolic on 2 pressor agents. His
oxygenation is at 96% on 2 L oxygen via nasal cannula.
Respiratory rate of 12. He is afebrile in the MICU.
Gen: Caucasian male, pleasant, in no apparent distress
Cardiac: Nl s1/S2, RRR, no murmurs appreciable
Pulm: clear in anterior lung fields
Abd: mild tenderness in right upper quadrant, no [**Doctor Last Name 515**] sign,
tympanic, distended
Ext: 1+ lower extremity edema
DISCHARGE EXAM:
Tm 98.9 Tc 98.6 HR 76 BP 133/79 O2 94%/RA
GEN AOX3, well-appearing well-nourished male NAD sitting up in
bed
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 3+costal angle, no LAD
PULM: faint lung sounds, no r/r/w
COR: distant heart sounds, nl S1 S2 no audible murmur
ADB: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly; perc chole tube
RUQ in place w/dressing c/d/i, no surrounding tenderness,
draining clear bilious liquid
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: speech fluent, CN intact, strength 5/5 throughout,
spontaneously moves all extremities, reflexes/gait not assessed
Pertinent Results:
ADMISSION LABS:
[**2129-2-4**] 07:20PM BLOOD WBC-15.6*# RBC-3.61* Hgb-10.6* Hct-31.5*
MCV-87 MCH-29.3 MCHC-33.6 RDW-13.2 Plt Ct-92*
[**2129-2-4**] 07:20PM BLOOD Neuts-81* Bands-7* Lymphs-4* Monos-3
Eos-1 Baso-0 Atyps-0 Metas-3* Myelos-1*
[**2129-2-4**] 07:20PM BLOOD PT-14.2* PTT-28.7 INR(PT)-1.3*
[**2129-2-4**] 07:20PM BLOOD Glucose-193* UreaN-26* Creat-2.3*# Na-137
K-4.0 Cl-103 HCO3-20* AnGap-18
[**2129-2-4**] 07:20PM BLOOD ALT-152* AST-178* AlkPhos-41 TotBili-1.0
[**2129-2-4**] 07:20PM BLOOD Albumin-3.3* Calcium-7.6* Phos-2.4*
Mg-0.8*
[**2129-2-4**] 07:31PM BLOOD Lactate-1.7
[**2129-2-5**] 02:35AM BLOOD Lactate-1.1
.
DISCHARGE LABS:
[**2129-2-10**] 05:25AM BLOOD WBC-8.8 RBC-3.73* Hgb-10.7* Hct-31.6*
MCV-85 MCH-28.7 MCHC-33.8 RDW-13.5 Plt Ct-187#
[**2129-2-10**] 05:25AM BLOOD Plt Ct-187#
[**2129-2-10**] 05:25AM BLOOD Glucose-216* UreaN-20 Creat-0.8 Na-141
K-3.8 Cl-104 HCO3-30 AnGap-11
[**2129-2-10**] 05:25AM BLOOD ALT-29 AST-19 LD(LDH)-200 AlkPhos-38*
TotBili-0.4
[**2129-2-10**] 05:25AM BLOOD Albumin-3.2* Calcium-9.1 Phos-4.7*
Mg-1.4*
.
MICROBIOLOGY
[**2129-2-5**] 10:30 am BILE
**FINAL REPORT [**2129-2-11**]**
GRAM STAIN (Final [**2129-2-5**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final [**2129-2-11**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
[**First Name8 (NamePattern2) 15571**] [**Last Name (NamePattern1) 15572**] REQUESTED IDENTIFICATIONS AND SENSITIVITIES
ON ALL
ORGANISMS [**9-/3909**] [**2129-2-8**].
PRESUMPTIVE STREPTOCOCCUS BOVIS. MODERATE GROWTH.
Sensitivity testing performed by Sensititre.
SENSITIVE TO CLINDAMYCIN MIC <=0.12 MCG.
ENTEROCOCCUS SP.. SPARSE GROWTH.
ENTEROBACTER AEROGENES. SPARSE 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.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PRESUMPTIVE STREPTOCOCCUS BOVIS
| ENTEROCOCCUS SP.
| | ENTEROBACTER
AEROGENES
| | |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
PENICILLIN G---------- 0.25 I 2 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ <=1 S 1 S
ANAEROBIC CULTURE (Final [**2129-2-9**]): NO ANAEROBES ISOLATED.
.
[**2129-2-5**] 4:00 pm BLOOD CULTURE Source: Line-aline.
**FINAL REPORT [**2129-2-11**]**
Blood Culture, Routine (Final [**2129-2-11**]): NO GROWTH.
.
IMAGING
.
CXR [**2129-2-4**]
No signs of CHF, pneumonia, or effusion. Right IJ central venous
catheter with tip at the cavoatrial junction.
.
CT ABD/PELVIS [**2129-2-4**]
1. Cholelithiasis with thickened gallbladder wall, without
hydropic
gallbladder distension. No pericholecystic fluid or evidence of
perforation. Overall, these findings are nonspecific and a HIDA
may be performed if strong clinical concern for acute
cholecystitis.
2. Diverticulosis without diverticulitis.
.
TTE 2/4/123
IMPRESSION: Normal global and regional biventricular systolic
function.
.
RUQ U/S [**2129-2-5**]
TARGETED RIGHT UPPER QUADRANT ULTRASOUND: There is mild diffuse
echogenicity of the liver, findings consistent with fatty
infiltration. The main portal vein is patent with hepatopetal
flow. Evaluation of the gallbladder is somewhat limited on this
examination. The gallbladder is filled with multiple stones and
appears distended. Though, there is no clear wall edema or
pericholecystic fluid on these limited images, findings from
prior imaging suggest acute cholecystitis. There is no abdominal
free fluid. No intra- or extra-hepatic biliary ductal dilatation
is identified. The common bile duct measures 4 mm and is not
dilated.
IMPRESSION:
1. Distended stone filled gallbladder; though wall edema is less
well
depicted on this examination than on the prior ultrasound due to
technical
factors, findings are concerning for acute cholecystitis.
2. No intra- or extrahepatic biliary ductal dilatation.
3. Probable diffuse fatty infiltration of the liver. More severe
forms of
liver disease including hepatic fibrosis/cirrhosis cannot be
excluded.
Brief Hospital Course:
72M admitted for fever and hypotension, found to have biliary
sepsis [**2-3**] acute cholecystitis.
.
# Biliary Sepsis [**2-3**] Acute Cholecystitis
Patient initially presented with pressor-dependent hypotension
and fever with signs of acute cholecystitis on imaging but
relatively benign exam. OSH blood cultures grew Strep Bovis and
Enterobacter, which later also grew in bile fluid cultures here
(plus Enterococcus). Perc chole drain was placed by IR [**2-5**] for
direct decompression of inflammed GB. At time of MICU transfer
he was afebrile and normotensive off pressors. He had received
3d vanc/zosyn/flagyl which had been narrowed to Cftx given known
susceptibilities from OSH blood Cx; on the floor, this was
broadened to cefepime/flagyl given likelihood of polymicrobial
infection from biliary source. Plan was for 14d course
cefepime/flagyl, day 1=[**2-9**]. By discharge, leukocytosis (from max
WBC 23) had resolved, he was still normotensive & back on home
BP meds, afebrile and well-appearing. Plan (confirmed with ACS
surgery residents) was for 2-week follow-up during which they
will discuss plans for CCY & clamp and possibly remove perc
chole drain (or make arrangements for drain removal in the
future). VNA was arranged for twice-daily cefepime
administration, drainage of perc chole bag. Primary team
communicated verbally with PCP's office regarding need to
re-draw blood cultures in 2 weeks, remove PICC if negative, and
arrange for follow-up colonoscopy (given possible colonic source
of Strep bovis)
.
# COPD
Intermittent cough/wheeze during this admission. On home advair,
flonase, and additional nebulizers q4h PRN. By time of
discharge, his cough and wheeze had resolved, and he was
comfortable lying flat and walking around w/O2 sat 95/RA.
Discharged on home COPD meds.
.
# Hx HTN
MICU had been holding home antihypertensives in the setting of
sepsis on admission. Home lisinopril 20 QD and carvedilol
gradually added-back prior to discharge - he maintained normal
BPs thereafter.
.
# Hx Type II DM
On metformin at home. BS running 200-300 here on ISS. Consider
transitioning from metformin to insulin as an outpatient.
.
#Hx Cardiomyopathy
Thought [**2-3**] to alcoholic use. TTE on admission showed systolic &
diastolic function wnl and LVEF >55%. Has ICD and is followed
regularly by outpatient cardiologist. Continued aspirin. Needs
follow-up echo to re-assess pacer leads after antibiotic course
completes.
.
# ARF
Noted on admission; Cr resolved to 0.9 w/treatment of sepsis as
above.
.
# hx Hyperlipidemia
Continued lipitor
.
# Hx GERD
Continued omeprazole [**Hospital1 **]
.
# R leg sciatica
Unclear chronicity. Continued home ultram 50 [**Hospital1 **] w/good effect.
.
# Depression
Continued paxil.
.
TRANSITIONAL ISSUES
1. BILIARY SEPSIS/PERC CHOLE DRAIN
Plan post-discharge:
- VNA to visit [**Hospital1 **] to administer cefepime q12h, drain perc chole
tube PRN
- ACS general surgery follow-up in 2 weeks for
----A) discussion of cholecystectomy and
----B) perc chole tube clamping, possible drain pull (if deemed
clinically ready).
- PCP [**Name9 (PRE) 702**] for repeat blood cultures in 2 weeks
- PCP [**Name9 (PRE) 702**] for PICC pull after 2 weeks antibiotics received
& BCx negative
- PCP [**Name9 (PRE) 702**] to arrange colonoscopy given Strep bovis in
blood/bile cultures
.
2. DIABETES
Blood sugars consistently >200 on insulin sliding scale. On oral
hypoglycemics at home; these may need to be adjusted and/or
transitioned to insulin in follow-up.
Medications on Admission:
1. lipitor 20 mg daily
2. lisinopril 20 mg daily
3. carvedilol 25 mg [**Hospital1 **]
4. metformin 1000 mg [**Hospital1 **]
5. aspirin 81 mg daily
6. omeprazole 20 mg [**Hospital1 **]
7. paxil 20 mg
8. advair 500-50 mcg/dose
9. flonase 50 mcg - 2 sprays per nose
10. butrans 20 mcg/hr
11. tramadol 50 mg [**Hospital1 **]
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation once a day.
9. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
twice a day for 12 days: 8 AM and 6 PM.
Disp:*24 Recon Soln(s)* Refills:*0*
12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 12 days.
Disp:*48 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home I nfusions
Discharge Diagnosis:
Primary Diagnoses
BILIARY SEPSIS
ACUTE CHOLECYSTITIS
.
Secondary Diagnoses
HYPERTENSION
TYPE II DIABETES
CHRONIC CARDIOMYOPATHY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a sepsis, a systemic
infection with bacteria from your gallbladder.
You were in the intensive care unit for antibiotics and pressors
(medications to keep your blood pressure in safe range). You
also had a drain placed to allow free flow of infected bile from
your gallbladder. Surgeons who saw you thought you needed your
gallbladder out, which they will discuss with you at a follow-up
appointment.
We made the following changes to your medications:
1. STARTED CEFEPIME (INTRAVENOUS ANTIBIOTICS), A VISITING NURSE
WILL INFUSE 1 BAG AT 8 AM AND 6 PM DAILY FOR 2 WEEKS TOTAL, LAST
DOSE [**2-22**].
2. STARTED FLAGYL (METRONIDAZOLE, ANOTHER ANTIBIOTIC), TAKE 1
500-MG TAB EVERY 6 HOURS FOR 2 WEEKS TOTAL, LAST DOSE [**2-22**].
Please review the medication list with your doctor at your next
appointment.
Followup Instructions:
Name: [**Doctor Last Name **],SAYEEDA
Specialty: INTERNAL MEDICINE
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Street Address(2) **], [**Location **],[**Numeric Identifier 21771**]
Phone: [**Telephone/Fax (1) 82227**]
Appointment: MONDAY [**2-14**] AT 2:30PM
**You will be seeing a Nurse Practitioner at this appointment.**
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2129-3-1**] at 1:45 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in the ACUTE CARE CLINIC
Phone: [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"250.00",
"403.90",
"425.4",
"575.0",
"584.9",
"287.5",
"038.9",
"311",
"496",
"V58.67",
"585.9",
"600.00",
"530.81",
"V45.02",
"556.9",
"995.92",
"785.52",
"576.1",
"272.4",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.01",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14045, 14115
|
9092, 12594
|
316, 361
|
14287, 14287
|
3530, 3530
|
15306, 16038
|
2047, 2257
|
12966, 14022
|
14136, 14266
|
12620, 12943
|
14438, 14901
|
4173, 9069
|
2272, 2788
|
2804, 3511
|
14930, 15283
|
264, 278
|
389, 1673
|
3546, 4157
|
14302, 14414
|
1695, 1893
|
1909, 2031
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,523
| 110,260
|
20564
|
Discharge summary
|
report
|
Admission Date: [**2186-2-25**] Discharge Date: [**2186-4-1**]
Date of Birth: [**2128-4-19**] Sex: M
Service: MED
DATE OF EXPIRATION: [**2186-4-1**]
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
male with past medical history of coronary artery disease,
status post 4-vessel CABG in [**5-4**], status post pacemaker
placement who was admitted for evaluation of elevated white
blood cell count. In [**2-2**], he noticed fatigue, decreased
energy, diffuse body aches, swollen gums, and swollen glands.
He did not note any gum bleeding. He experienced extreme
dyspnea on exertion, initially only while walking uphill or
exerting himself, but progressively increasing to the point
that he was having dyspnea with walking on level ground for
distances greater than [**9-20**] feet. The fatigue came
gradually and unexpectedly and was progressing. He went to
the outpatient primary care physician on the day prior to
admission for routine blood work. CBC there showed white
blood cell count of approximately 128,000. He was advised to
go to the hospital. He first went to an outside hospital and
was transferred to [**Hospital1 69**] on
[**2186-2-25**] for full workup.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
Coronary artery disease, status post CABG times 4 vessels in
[**5-4**]. No history of myocardial infarction.
Basal cell carcinoma, status post excision.
Nephrolithiasis, status post surgical removal.
Status post pacemaker placement in [**5-4**], recently
interrogated.
ALLERGIES: THE PATIENT REPORTS ALLERGIES TO AMOXICILLIN
RESULTING IN SENSATION OF SWELLING WITHIN HIS MOUTH AND
FINGERS.
MEDICATIONS PRIOR TO ADMISSION:
1. Amiodarone.
2. Lisinopril.
3. Toprol XL.
4. Lipitor.
5. Aspirin.
SOCIAL HISTORY: The patient works for an insurance company.
He denies any tobacco use, but reports occasional alcohol
use.
FAMILY HISTORY: The patient's father was deceased from
[**Name (NI) 4278**] lymphoma and diabetes mellitus 2, mother deceased
from a colon cancer, and sister with cervical cancer.
PHYSICAL EXAMINATION UPON ADMISSION: Vital signs -
temperature 101.3 degrees, heart rate 86, blood pressure
119/63, and respiratory rate 20. Generally, this is a well-
developed, thin, chronically ill-appearing male, no acute
distress. Head and neck exam had pupils equal, round, and
reactive to light. No scleral injection or icterus. There
was positive lymphadenopathy at the right and left
submandibular, soft, mobile lymph nodes approximately 1 cm in
diameter and matted lymph nodes in the anterior cervical neck
chain. Cardiovascular exam, was regular rate and rhythm with
normal S1 and S2 heart sounds and crescendo/decrescendo
murmur at the right upper sternal border. Lungs were clear
to auscultation bilaterally. Abdomen was soft, nontender,
nondistended with no hepatosplenomegaly. There was a
surgical scar noted from his kidney surgery. Extremities
were warm and well perfused without clubbing, cyanosis or
edema. Neurologically, he was alert and oriented times 3.
Cranial nerves II through XII intact. Strength 5/5
throughout and sensation grossly intact to light touch.
PERTINENT LABORATORY, X-RAY, OTHER STUDIES: Complete blood
cell count on admission was 128,000 white blood cells, 32.8
hematocrit, platelets of 76. Chemistry was remarkable for
sodium 138, potassium 2.7, BUN 20, creatinine 1.3, and
glucose 61.
BRIEF SUMMARY OF HOSPITAL COURSE: Leukemia: The patient
underwent bone marrow biopsy, result consistent with acute
myelogenous leukemia. He started induction chemotherapy with
7 plus 3. His post chemotherapy course was complicated by
multiple events. Notably, on admission, he had febrile
neutropenia with an ANC less than 500. For this, he was
started on broad spectrum antibiotics. Status post
subclavian line placement for chemotherapy, he had increased
bleeding and oozing from line site on [**2186-2-27**] and was found
on laboratories to be in acute DIC. He had a prolonged
period of neutropenia from [**2186-3-2**] to [**2186-3-24**]. He was
supported with blood products including platelets and serial
blood transfusions to keep platelet count greater than 10 and
hematocrit greater than 25. However, he had a transfusion-
dependent anemia and low platelets that was concerning for
antiplatelets antibodies. Additionally, towards the end of
his hospital course, a peripheral smear started to reveal
presence of immature cells. This was concerning for
recurrence of his disease.
Dyspnea/hypoxia: Starting on [**2186-3-6**], the patient became
more dyspneic with increasing oxygen requirement. CT scan of
the chest at that time demonstrated right upper lobe ground
glass opacities concerning for infection versus hemorrhage.
He underwent bronchoscopy on [**2186-3-7**] with grossly bloody
lavage fluid concerning for diffuse alveolar hemorrhage. For
this, he was treated with 1 g of IV Solu-Medrol times 3 days.
As part of the workup for his dyspnea, he also underwent
echocardiogram, which showed a depression of his ejection
fraction to 40 percent. The patient's dyspnea remained with
very minimal improvement. In light of this, repeat CT scan
was performed on [**2186-3-20**], which demonstrated persistent
bilateral diffuse interstitial opacities concerning for
atypical versus fungal infection versus cryptogenic
organizing pneumonia. He underwent repeat bronchoscopy on
[**2186-3-21**] with cultures growing budding yeast, which was
speciated as [**Female First Name (un) 564**] albicans. He had already been on
prophylactic doses of ampicillin at that time, but ampicillin
was increased to treatment dose of 5 mg/kg. During this
period of time, the patient was profoundly neutropenic.
However, as his counts came back up, he had an increasing
oxygen requirement concerning for engraftment syndrome.
Therefore, he was treated with Solu-Medrol 60 mg IV times 2
on [**2186-3-25**] and [**2186-3-26**] for engraftment. He continued to be
treated on cefepime, ampicillin, and Flagyl. There was a
concern whether he had some evidence of aspiration versus
hospital acquired pneumonia as serial chest x-rays
demonstrated left lower lobe and lingular opacities. He
continued to have increasing oxygen requirement and had an
episode of acute respiratory distress on [**2186-3-28**],
necessitating transfer to the Medical Intensive Care Unit.
After transfer to the Medical Intensive Care Unit, he
underwent a CT angiogram of the chest. This was felt to be a
limited study secondary to consolidation, atelectasis, and
due to patient movement. It showed a slight decrease in
previously noted bilateral pleural effusions. There was
patchy consolidation bilateral diffusely mostly in the
peripheral lung zones. There was increasing atelectasis at
the right greater than the left bases. There are bilateral
lower lobe opacities with question of airway collapse. There
were no filling defects concerning for a pulmonary embolus
noted. The patient's pre and subcarinal lymph nodes remained
prominent in spite of his recent courses of chemotherapy.
The patient continued to be in profound respiratory distress
and was managed in the Intensive Care Unit with noninvasive
ventilation mode. There was some concern that perhaps some
of his respiratory compensation was due to amiodarone
toxicity, as he had been on amiodarone in the past. He was
continued on oxygen, chest physical therapy, aggressive
pulmonary toilet. He was also evaluated for a possible VATS
procedure. He continued to have episodes of hypoxia and
desaturation, which responded to repositioning, anxiolytics,
and noninvasive ventilation. VATS was planned for [**2186-3-31**].
The patient was intubated prior to the procedure. However,
post intubation, he became unstable from the hemodynamic
standpoint. Therefore, VATS was postponed. His degree of
hypotension ultimately necessitated initiation of pressors.
On [**2186-3-31**], a discussion including the Medical Intensive
Care Unit team, the Oncology Service, and the patient's
family was held. At this time, it was felt that the
patient's prognosis was very poor given his increased need
for hemodynamic support via pressors in his prolonged
persistent hypoxia unresponsive to ventilation techniques,
and broad spectrum antibiotics for possible pulmonary
process. At that time, it was decided that VATS could not be
performed due to the patient's instability as well as due to
his overall prognosis. At that time, additionally, the
family decided to withdraw aggressive care and focus instead
on comfort measures only. The patient was made DNR/DNI. He
expired on [**2186-4-1**].
Congestive heart failure: On admission, the patient's EKG
showed a paced rhythm. He had a cardiac history consisting
of status post coronary artery bypass grafting times 4 grafts
in [**5-4**]. As part of the workup for his dyspnea, cardiac
components were evaluated as well. Echocardiogram showed an
EF of 40 percent with inferolateral hypokinesis and
anteroseptal hypokinesis, which was a new finding.
Therefore, the patient was started on management for
congestive heart failure. Review of his weight and volume
status during this admission noted that he had gained over 20
pounds status post initiation of the chemotherapy from early
[**Month (only) 547**] to mid [**Month (only) 547**]. Therefore, he was diuresed aggressively
with Lasix. He was also started on metoprolol and
lisinopril. He was diuresed to close to his dry weight.
However, diuresis was complicated by development of a drug
reaction, which was felt to be due to Lasix. Therefore,
Lasix was discontinued. During the diuresis period, the
patient's dyspnea was much improved. However, around this
time, his white blood cell counts returned. As noted, in the
management of his dyspnea, return of his white blood cell
count was felt to result in some element of engraftment
syndrome, which necessitated treatment with steroids. At
this standpoint, [**2186-3-25**] and [**2186-3-26**], the majority of his
dyspnea was felt to be related to pulmonary issues and not to
heart failure issues. He was managed as such.
Question of disseminated candidiasis: On bronchoscopy, the
patient's bronchoalveolar lavage fluids grew [**Female First Name (un) 564**]. It was
unclear whether this was a colonizer or an actual infectious
organism. He was on prophylactic doses of AmBisome at that
time and had AmBisome increased to 5 mg/kg for treatment
doses. This resulted in elevations in his liver
transaminases concerning for drug reaction versus hepatic
involvement of the [**Female First Name (un) 564**]. An ultrasound was done to assess
the hepatobiliary system and there was no evidence of hepatic
involvement. Throughout his hospital course, he was
continued on antifungal therapy.
Status post treatment with Lasix, the patient developed a
diffuse maculopapular rash. He was seen by Dermatology, who
felt that several of his medications could be the culprit.
He was continued on his antibiotics due to his profound
neutropenia and immunocompromised state. Lasix was held,
however; and with discontinuation of Lasix, his rash
improved. At no time was there any mucosal involvement,
blistering, or bullae formation.
Hypophosphatemia: On serial electrolyte studies, the patient
was found to be profoundly hypophosphatemic. Urinary
electrolytes were evaluated and felt to be consistent with
Fanconi's syndrome. His phosphorus loss was exacerbated by
diarrhea as well as respiratory alkalosis. Therefore, he was
aggressively repleted. Evaluation of his parathyroid hormone
found it to be markedly elevated. He was followed by
Endocrine Service, who recommended checking vitamin D. His
vitamin D was low. He was started on calcitriol.
Disposition: The patient was initially full code. However,
due to multiple complicating events status post initiation of
chemotherapy for his AML, including worsening cardiopulmonary
status and need for higher level of care in the Medical
Intensive Care Unit, code status was re-addressed to his
family on [**2186-3-31**]. At that time, it was felt that his
prognosis was poor and family wished to focus on comfort
measures only. At that time, the patient was made
DNR/DNI/comfort measures only. Intravenous pressors, which
were being used for hemodynamic support were slowly weaned.
He remained intubated, but had morphine added to his
medication regimen for respiratory distress. He ultimately
expired on [**2186-4-1**]. The patient's family was at bedside;
attending was notified appropriately.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**]
Dictated By:[**Last Name (NamePattern1) 14378**]
MEDQUIST36
D: [**2186-5-22**] 15:40:35
T: [**2186-5-23**] 03:27:25
Job#: [**Job Number 55000**]
cc:[**Last Name (NamePattern4) **]
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], MD
|
[
"284.8",
"786.3",
"205.00",
"518.81",
"528.0",
"428.0",
"268.9",
"275.3",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24",
"96.71",
"99.04",
"96.04",
"41.31",
"99.25",
"96.6",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
1909, 2097
|
3453, 12979
|
1697, 1767
|
201, 1207
|
2112, 3424
|
1230, 1665
|
1784, 1892
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,592
| 104,329
|
3171
|
Discharge summary
|
report
|
Admission Date: [**2166-11-9**] Discharge Date: [**2166-11-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation
Left subclavian central line
History of Present Illness:
81 yo man with hx sig for CVA with residual seizure d/o and
hemiparesis presents with apparent sepsis, hypernatremia and
altered mental status from rehab. Per discussion with the ED
and [**Hospital 100**] rehab staff, the patient had [**Doctor Last Name 688**] mental status and
poor po intake over the past few days. He was empirically
startd on levofloxacin yesterday for ? PNA and ?UTI with labs
pending. He complained of feeling ill today but went out with
his wife, drinking only coffee. He was found later, obtunded,
with chicken in his mouth and hypoxic and hypotensive. Per
report, his heart rate was in the 80s in the field and BP was
60/40. O2 sat was 88% on RA. He received 250 cc NS in the
ambulance en route with improvement in BP to 80/39; this quickly
came up to 140s systolic with IVF.
In the ED, the pt was intubated for airway protection. Code
sepsis was called. He had a central line placed, and received
just less than 7 L of NS. Temperature was 100.1. Initial labs
showed high lactate and low Hct; repeat labs after hydration
showed CBC likely erroneous and lactate much improved. CXR
showed b/l PNA, head CT negative for bleed. The patient received
ceftriaxone, vanc and azithromycin for CAP and ? nosocomial PNA.
"Brown chunky secretions" in moderate amount were suctioned
from the ETT in the ED.
Past Medical History:
1. Hypertension.
2. Status post right frontal cerebrovascular accident with
residual left hemiparesis.
3. Status post left basal ganglionic hemorrhage with
residual right hemiparesis.
4. Status post generalized tonic/clonic seizures , most recent
here in ED [**5-6**].
5. Status post bilateral hip replacement.
6. Osteoarthritis
7. BPH s/p TURP
8. Hx RBBB
9. Depression
10. Mild Cognitive Impairment
11. Remote appendectomy
12. Lipoma excision
13. Achilles tendon repair
14. CRI (1.2)
15. Behavior d/o (aggressive)
Social History:
He is a retired mechanical engineer. No alcohol or tobacco use.
He is living at [**Hospital 100**] Rehab due to mobility issues at home.
He is married, he wife still lives at home.
Family History:
NC
Physical Exam:
Vitals: 97.4F, 72, 153/73, CVP 8, O2 100% on ventilator
Gen: Elderely man, sedated and intubated
HEENT: no icterus, dry mm, slowly reactive pupils
Neck: JVP approx 4
Heart: rr, no m/g/r
Lungs: coarse breath sounds with scattered rhonchi
Abd: s/nt/mildly distended, +BS, no hsm
Ext: thin, hairless, no c/c/e, 1+ dps
Psych: sedated and intubated
Skin: no decubs per rns
Pertinent Results:
Studies:
EKG: SR with RBBB, rate 88, no actue ST changes, similar to [**5-6**]
CXR [**2166-11-9**]: 1) ETT 5.5 cm above the carina, more optimally
positioned if advanced 1-2 cm. 2) Unchanged right upper and
lower lobe pneumonia.
Head CT [**2166-11-9**]: There is no hemorrhage, mass effect, shift of
normally midline structures, or hydrocephalus. There is
unchanged prominence of the ventricles and sulci, consistent
with involutional change. There are multiple lacunar infarcts,
specifically within the basal ganglia bilaterally, unchanged
from the prior study. There is stable periventricular
subcortical white matter low attenuation, which is consistent
with chronic microvascular ischemic changes. The surrounding
osseous and soft tissue structures are unremarkable.
CXR [**2166-11-14**]: Right upper lobe consolidation has substantially
cleared. Heart size top normal. Mediastinal widening suggests
vascular engorgement. No large pleural effusion and no
pneumothorax.
Admission Labs:
URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.025
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-0-2 WBC-0
BACTERIA-FEW YEAST-NONE EPI-0-2
WBC-8.6 RBC-2.27*# HGB-7.3*# HCT-22.8*# MCV-100*# MCH-32.3*
MCHC-32.2 RDW-13.6 NEUTS-79.3* BANDS-0 LYMPHS-16.7* MONOS-3.2
EOS-0.7 BASOS-0.1
PLT COUNT-114*#
PT-17.1* PTT-47.3* INR(PT)-2.0
GLUCOSE-170* UREA N-70* CREAT-2.8*# SODIUM-163* POTASSIUM-3.5
CHLORIDE-129* TOTAL CO2-22 CALCIUM-7.4* PHOSPHATE-2.0*
MAGNESIUM-2.3
1) CK(CPK)-297* cTropnT-0.05* CK-MB-10 MB INDX-3.4
2) CK(CPK)-400* CK-MB-14* MB INDX-3.5 cTropnT-0.10*
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-POS mthdone-NEG
LACTATE-4.4*
TYPE-ART PO2-176* PCO2-38 PH-7.40 TOTAL CO2-24 BASE XS-0
Brief Hospital Course:
81 y/o man with h/o cva and residual left hemiparesis presents
with PNA and sepsis.
1) PNA likely secondary to aspiriation requiring intubation.
Initial CXR showed RUL and RLL infiltrates. Started initially
on ctx, azithro, vanc and flagyl. On [**11-11**] his ABX was narrowed
to ctx and azithro. He tolerated cpap trial on [**11-11**] and was
successfully extubated on [**11-12**]. His respiratory status has been
stable since extubation. He finished a 5 day course of azithro
on [**11-14**]. He will be discharged to the acute care unit at
[**Hospital 100**] Rehab with an IJ central line to complete a 7 day course
of CTX (to end [**2166-11-16**]).
2) Sepsis. Pt volume resuscitated with 7 L of fluid in the ED.
He was monitored with frequent checks of lactate and
chemistries; lactate quickly normalized. Although he was
hypotensive in the field, he was hemodynamically stable and
never required pressors. He also rec'd 1u prbcs for likely
spurious hematocrit result. A random cortisol was normal.
3) AMS: Pt ws unresonsive per EMS and withdrew only to pain in
ED. Head CT was negative. The differential diagnosis for his
altered mental status includes post-ictal state (known sz
disorder), infection, hypernatremia, or new CVA not yet seen on
CT. His baseline mental status is unclear however he was alert
and answering questions appropriately prior to discharge. He
was continued on lamictal for sz and his infection and
hypernatremia were treated.
4) Hypernatremia (initial Na of 167): etiology thought to be
volume depletion, as suggested by elevated BUN/Cr and poor PO
intake as per NH staff. He was agressively rehydrated with NS
for intravascular depletion and his free water deficit of 5.1
liters was corrected with 200 cc /hr of D51/2 NS and free water
boluses through his NG tube. His Na normalized by [**11-13**].
5) Acute renal failure: Pt with longstanding mild CRI (1.2),
exacerbation likely [**2-5**] prerenal etiology and ATN. He was
rehydrated as above and his creatinine improved. His ACE
inhibitor was initially held given sepsis and ARF.
6) Hypertension: Initially held ACEI for renal failure. He was
started on a nitro drip on [**11-12**] prior to extubation. It was
discontinued on [**11-14**] and he was restarted on Lisinopril 40 mg
daily. His BP continued to be elevated in the 160's however no
additional changes were made to his medical regimen. Consider
starting a B-B as an outpatient.
7) Anemia: Pt's initial hct was 22 down from 40 in [**9-8**]. This
was likley a spurious result as repeat Hct after aggressive
hydration was 32. He received 1u prbcs. He hct remained stable
in the high 20's/low 30's during his hospital stay. He was
guaiac negative in the ED. The etiology of his anemia is
unclear.
8) Troponin leak: Likely in setting of ARF and demand ischemia;
enzymes negative by MB index.
9) FEN: He received Tube Feeds while intubated. Once extubated
he refused a formal speech and swallow evalution, however, his
nurse feels he is able to eat small amount of soft foods. He
should be continued on aspiration precautions.
11) Access: left IJ
Medications on Admission:
Zoloft 150 mg po qam
Lamictal 225 mg po qhs
Lisinopril 40 mg po qam
MVI liquid
Levaquin 250 mg po qd
Seroquel 25 mg po qhs
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
5. Lamotrigine 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): total dose of 225 qpm. Tablet(s)
6. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO at bedtime:
total of 225 at night.
7. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Ceftriaxone 1 g Recon Soln Sig: One (1) Intravenous once a
day for 2 days.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Aspiration Pneumonia requiring Intubation
Discharge Condition:
Fair
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience worsening shortness of breath,
confusion, chest pain, fever, or have any other concerns.
Please continue IV Ceftriaxone through central line to end
[**2166-11-16**].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 14943**]) in one to two
weeks.
|
[
"518.81",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
9085, 9158
|
4748, 7870
|
283, 337
|
9244, 9251
|
2861, 3838
|
9550, 9658
|
2453, 2457
|
8043, 9062
|
9179, 9223
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7896, 8020
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9275, 9527
|
2472, 2842
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222, 245
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365, 1699
|
3854, 4725
|
1721, 2237
|
2253, 2437
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,709
| 182,203
|
6596+6597+55769
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2186-6-21**] Discharge Date: [**2186-6-25**]
Date of Birth: [**2108-7-20**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: This is a 77 year old Caucasian
male patient with a history of peripheral vascular disease,
carotid artery stenosis, status post a right carotid
endarterectomy in [**2183**], complicated by cerebrovascular
accident, and diverticulosis, who was admitted to an outside
hospital on [**2186-6-18**], with a several day history of black and
bloody stools in addition to a six to twelve month history of
lightheadedness and shortness of breath. On admission to the
outside hospital, the patient denied chest pain or pressure,
jaw or arm pain, paroxysmal nocturnal dyspnea, back pain,
abdominal pain or orthopnea. He described shortness of
breath as progressive dyspnea on exertion over the last six
to twelve months prior to admission. In the outside hospital
Emergency Department, the patient was noted to have a
hematocrit of 23.0 with a troponin I of 8.55. He was
profoundly orthostatic and was transfused with seven units of
packed red blood cells. The patient was admitted to the
outside hospital Intensive Care Unit and seen by
gastroenterology and cardiology. A diagnostic cardiac
catheterization showed severe three vessel coronary artery
disease and the patient was transferred to [**Hospital1 346**] for evaluation. On transfer to [**Hospital1 1444**], the patient denies chest
pain, paroxysmal nocturnal dyspnea, orthopnea, edema,
palpitations, syncope, but does report mild chronic shortness
of breath and lightheadedness on standing.
PAST MEDICAL HISTORY: Carotid artery stenosis, status post
right carotid endarterectomy in [**2183**].
Cerebrovascular accident as a complication of his right
carotid endarterectomy in [**2183**], manifested as dysarthria and
ataxia.
Diverticulosis.
Raynaud's.
Depression.
Peripheral vascular disease.
Duodenal ulcer.
Status post a fall in [**2185-7-19**], resulting in a broken
shoulder, status post a second fall several days later
resulting in a broken hip, status post pin placement.
ALLERGIES: SSRIs.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o. once daily.
2. Klonopin 0.5 mg twice a day.
3. Zyprexa 2.5 mg q.h.s.
4. Remeron 30 mg two tablets q.p.m.
5. Vitamin E.
6. Vitamin C.
7. Flomax 0.4 mg.
8. Pamelor which is Nortriptyline 25 mg four tablets q.p.m.
SOCIAL HISTORY: The patient is currently retired and lives
with his wife. [**Name (NI) **] quit smoking tobacco approximately fifty
years ago and quit drinking alcohol fourteen years ago.
PHYSICAL EXAMINATION: Blood pressure is 111/66, heart rate
88, respiratory rate 20, oxygen saturation 97 percent on two
liters. In general, a well appearing elderly man, mildly
confused in no acute distress. Head, eyes, ears, nose and
throat examination - The pupils are equal, round and reactive
to light and accommodation. Extraocular movements are
intact. The patient has moist mucous membranes. His
oropharynx is clear. Neck - jugular venous pressure is
estimated at approximately ten centimeters. There are no
audible carotid bruits bilaterally. Lungs - bibasilar
crackles but otherwise clear to auscultation bilaterally.
Cardiovascular is regular rate and rhythm with multiple
ectopic beats, normal S1 and S2, I/VI holosystolic murmur
appreciated over the apex. The patient has two plus femoral
dorsalis pedis pulses bilaterally and one plus posterior
tibial pulses bilaterally. There is no evidence of edema.
The abdomen shows normoactive bowel sounds, soft, nontender,
nondistended. Extremities - no evidence of cyanosis,
clubbing or edema. Neurologically, the patient is
dysarthric. He is alert and oriented times three. His
cranial nerves II through XII are intact aside from
dysarthria, hypophonia and a mild left sided facial droop.
The patient's motor examination is significant for [**5-24**] muscle
strength throughout all muscle groups except for five minus
out of five strength in the left triceps, left hip flexors
with mildly increased tone on the left. Sensation is intact
to light touch in all four extremities. The patient's deep
tendon reflexes are symmetric though mildly decreased on the
right.
LABORATORY DATA: White blood cell count was 12.8, hematocrit
31.2, platelet count 202,000. INR 1.4. Sodium 144,
potassium 4.5, chloride 107, bicarbonate 25, blood urea
nitrogen 31, creatinine 1.1, glucose 92. CK 44, troponin
3.44. ALT 24, AST 31, alkaline phosphatase 51, total
bilirubin 1.3.
HOSPITAL COURSE: Coronary artery disease - The patient was
transferred from an outside hospital with three vessel
coronary artery disease as demonstrated on a diagnostic
cardiac catheterization performed prior to transfer. The
cardiac surgery consult service was consulted for possible
coronary artery bypass graft and a preoperative workup was
initiated. The patient was continued on Aspirin, beta blocker
and a statin was added for hypercholesterolemia. The patient
had no complaints of chest pain, shortness of breath
throughout his hospitalization and his beta blocker and ace
inhibitor were titrated up as tolerated by his heart rate and
blood pressure. The patient was evaluated with a viability
study prior to discharge, the results of which are pending at
the time of dictation.
Congestive heart failure - The patient was evaluated with an
echocardiogram on admission which demonstrated an ejection
fraction of less than 20 percent, moderately dilated left
ventricular cavity with severe global left ventricular
hypokinesis. The patient had no signs or symptoms of volume
overload on physical examination. He was continued on the
beta blocker and ace inhibitor, the doses of which were
titrated up as tolerated by his blood pressure and heart
rate. The patient required no additional doses of Lasix
throughout his hospitalization. As noted previously, the
patient was evaluated with a viability study prior to
discharge, the results of which are pending at the time of
dictation.
Rhythm - The patient was monitored on telemetry throughout
his hospitalization. He had occasional episodes of premature
ventricular contractions that were asymptomatic.
Gastrointestinal bleed - The patient was transferred from an
outside hospital with a history of melena and hematocrit of
23.0 on initial presentation to the outside hospital. The
gastroenterology consult service was consulted and performed
an esophagogastroduodenoscopy on [**2186-6-22**], that was
significant for patchy superficial erythema in the fundus but
an otherwise normal esophagogastroduodenoscopy to the third
part of the duodenum. There was no source of bleeding
identified. The patient was maintained on Pantoprazole 40 mg
p.o. twice a day which he will receive for a total of
fourteen days after which he will be switched to Pantoprazole
40 mg p.o. once daily. Given a positive serum H. Pylori
antibody test, the gastroenterology consult service
recommended treatment with Metronidazole, Amoxicillin and
Pantoprazole.
Neurology - The neurology consult service was consulted for
preoperative stroke clearance given the patient's history of
a cerebrovascular accident. A urine culture, TSH,Vitamin
B12, folate and RPR were checked and noted to be normal. The
patient also had a MRI/MRA which showed no acute ischemic
changes and was only significant for chronic small vessel
disease with old lacunar infarcts. At the time of dictation,
the neurology consult service has not specifically commented
on the patient's stroke risk for a potential upcoming
coronary artery bypass graft.
Psychiatry - The patient was admitted with a history of
depression and possible dementia. He was continued on his
previous doses of Nortriptyline and Olanzapine. His Klonopin
was changed to p.r.n. Throughout his hospitalization, the
patient was noted to become mildly confused at night
consistent with potential sundowning. As noted previously,
his neurologic workup was negative.
Hematology - The patient's INR was noted to be elevated to
1.7 of an unclear etiology. Liver function tests were
checked and noted to be largely normal. The etiology of the
patient's elevated INR is considered potentially related to a
poor nutritional state. The patient's albumin was 3.3. He
was given a dose of Vitamin K.
The remainder of the [**Hospital 228**] hospital course, his discharge
medications, diagnoses and follow-up instructions will be
dictated at the time of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 4958**]
Dictated By:[**Last Name (NamePattern1) 12325**]
MEDQUIST36
D: [**2186-6-25**] 12:08:31
T: [**2186-6-25**] 13:47:02
Job#: [**Job Number 25207**]
Admission Date: [**2186-6-21**] Discharge Date: [**2186-6-28**]
Date of Birth: [**2108-7-20**] Sex: M
Service: CME
ADDENDUM: Since the previous dictation:
SUMMARY OF HOSPITAL COURSE CONTINUED:
CORONARY ARTERY DISEASE ISSUES: As noted previously, the
patient was transferred from an outside hospital with three
vessel coronary artery disease as noted on a diagnostic
cardiac catheterization. The patient underwent a
preoperative workup for potential coronary artery bypass
grafting. He was continued on aspirin. His beta blocker and
ACE inhibitor doses were titrated up as tolerated by his
blood pressure and heart rate. These medications were
switched to a every day regimen prior to discharge. The
patient was also continued on a statin for
hypercholesterolemia.
As noted in the previous dictation, the patient was evaluated
with a cardiac viability study. The patient had a cardiac
magnetic resonance imaging which demonstrated an ejection
fraction of less than 20 percent with some inferior scarring,
likely representing nonviable myocardium. However, most of
the patient's heart - including the anterior and lateral
walls - appeared viable. The cardiac surgeons recommended
discharging the patient to a rehabilitation facility with
followup in their office as an outpatient. During this
follow-up appointment, the surgeons will meet with the
patient and his family members to discuss the risks and
benefits of coronary artery bypass grafting and whether or
not to proceed with the operation.
CONGESTIVE HEART FAILURE ISSUES: As noted previously, the
patient was continued on a beta blocker and ACE inhibitor
which were titrated up as tolerated by his heart rate and
blood pressure. His cardiac magnetic resonance imaging was
significant for a severely depressed left ventricular
systolic function with an ejection fraction of less than 20
percent.
RHYTHM ISSUES: The patient was monitored on telemetry
throughout his hospitalization and had occasional episodes of
premature ventricular contractions that were asymptomatic.
GASTROINTESTINAL BLEED ISSUES: The patient's hematocrit
remained stable throughout the remainder of his
hospitalization. On discharge, he was to be treated with
metronidazole, amoxicillin, and pantoprazole for a positive
serum Helicobacter pylori antibody test.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient was to be discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSES: Three vessel coronary artery disease.
Congestive heart failure.
Gastrointestinal bleed.
Status post cerebrovascular accident.
Depression.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Toprol-XL 200 mg by mouth once per day.
3. Lisinopril 40 mg by mouth once per day.
4. Atorvastatin 40 mg by mouth once per day.
5. Pantoprazole 40 mg by mouth twice per day (times two
weeks).
6. Amoxicillin 1000 mg by mouth twice per day (times two
weeks).
7. Metronidazole 500 mg by mouth twice per day (times two
weeks).
8. Mirtazapine 50 mg by mouth at hour of sleep.
9. Olanzapine 2.5 mg by mouth at hour of sleep.
10. Nortriptyline 100 mg by mouth at hour of sleep.
11. Clonazepam 0.5 mg by mouth three times per day as
needed.
12. Pantoprazole 40 mg by mouth once per day (after the
patient finishes his twice per day dose for two weeks).
DISCHARGE INSTRUCTIONS-FOLLOWUP: The patient will be
followed by the physicians at the rehabilitation facility.
He was encouraged to contact his primary care physician to
schedule [**Name Initial (PRE) **] follow-up appointment within one week after
discharge. The patient will also be scheduled to follow up
in the Cardiac Surgery outpatient clinic to discuss a
potential coronary artery bypass grafting at a later date.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 4958**]
Dictated By:[**Last Name (NamePattern1) 12325**]
MEDQUIST36
D: [**2186-6-28**] 10:59:02
T: [**2186-6-28**] 12:27:10
Job#: [**Job Number 25208**]
Name: [**Known lastname 4292**], [**Known firstname 651**] F. Unit No: [**Numeric Identifier 4293**]
Admission Date: [**2186-6-21**] Discharge Date: [**2186-6-29**]
Date of Birth: [**2108-7-20**] Sex: M
Service: CME
HOSPITAL COURSE: Since the previous dictation:
Fever: The patient had a fever to 102.5 on the day prior to
discharge with an elevation in his white blood cell count.
The patient reported feeling well and denied symptoms
localizing an infection. He denied shortness of breath,
cough, chest pain, diarrhea, dysuria, urinary frequency,
rhinorrhea and sinus headaches. The patient had blood
cultures drawn. A urinalysis did not suggest infection. A
chest x-ray showed no infiltrate. The patient was noted to
have a warm, erythematous, edematous area of his right upper
extremity at the site of a previous IV with a palpable core.
Given concern for thrombus, the patient was evaluated with an
ultrasound, which showed no deep venous thrombosis. Given his
fevers and elevated white blood cell count, the patient was
started on Keflex for treatment of a superficial
thrombophlebitis. He was afebrile prior to transfer and
remained asymptomatic.
Cardiac: The patient was continued on his previous
medications for coronary artery disease and congestive heart
failure and remained hemodynamically stable and asymptomatic.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSES: Three-vessel coronary artery disease.
Congestive heart failure.
Gastrointestinal bleed.
Status post cerebrovascular accident.
Depression.
Helicobacter pylori positive.
Superficial thrombophlebitis.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q day.
2. Toprol-XL 200 mg p.o. q day.
3. Lisinopril 40 mg p.o. q day.
4. Atorvastatin 40 mg p.o. q day.
5. Pantoprazole 40 mg p.o. b.i.d.
6. Keflex 500 mg p.o. q six hours times one week.
7. Mirtazapine 50 mg p.o. q h.s.
8. Olanzapine 2.5 mg p.o. q h.s.
9. Nortriptyline 100 mg p.o. q h.s.
10. Clonazepam 0.5 mg p.o. t.i.d. p.r.n.
FOLLOW UP: The patient will be followed by the physicians at
the rehabilitation facility. He has a follow-up appointment
scheduled with cardiac [**Last Name (LF) 4294**], [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D., on
[**2186-7-12**] at 4:00 p.m. He is instructed to contact his
primary care physician to schedule [**Name Initial (PRE) **] follow-up appointment
within 1-2 weeks after discharge. As the patient has been
started on a cholesterol lowering medication during this
hospitalization, he will need a blood test in [**1-21**] months to
look for possible muscle or liver side effects. He is also
encouraged to discuss treatment for his Helicobacter pylori.
The Gastrointestinal Consult service recommended two weeks of
amoxicillin, metronidazole and pantoprazole b.i.d. This
treatment should be considered after the patient finishes his
treatment for superficial thrombophlebitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 4295**]
Dictated By:[**Last Name (NamePattern1) 4296**]
MEDQUIST36
D: [**2186-6-29**] 09:52:09
T: [**2186-6-29**] 10:17:56
Job#: [**Job Number 4297**]
|
[
"428.0",
"451.82",
"578.9",
"414.01",
"410.91",
"311",
"443.9",
"041.86",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
14290, 14495
|
14518, 14880
|
11378, 13042
|
2157, 2392
|
13060, 14160
|
14892, 16067
|
2606, 4519
|
165, 1614
|
1637, 2131
|
2409, 2583
|
14185, 14268
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,253
| 107,741
|
48771
|
Discharge summary
|
report
|
Admission Date: [**2136-10-4**] Discharge Date: [**2136-10-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
foley change
Major Surgical or Invasive Procedure:
G tube replacement
Right SC line placement
History of Present Illness:
85M w/PMHx sx for C5/C6 subluxation s/p fixation, HTN, dementia
(vascular vs. Alzheimer's), h/o CVA, and prostate cancer who
initially admitted [**2136-10-4**] for a Foley change. At [**Hospital 100**] rehab,
he was being treated with vanco/flagyl for suspected aspiration
pneumonia. He maintained sbps >1001/3 bottles (+) for GPC in
chains and pairs for which he was started on linezolid (given
concern for VRE). He was transufsed 1u PRBC for HCT 22At rehab
on day of admit, his chronic foley was removed for scheduled
changed and could not be replaced (although reportedly pus was
expressed). He was sent to ED, where frank blood was noted at
his urethral meatus. Urology placed a foley with 300 cc pink UOP
and then irrigated the bladder. He was noted to have fever of
102 with tachypnea (RR high 20s). ABG 7.27/38/56 on RA with
lactate 4.6 and HCO3 15. He became hypotensive with sbp 80s. CXR
showed RLL opacity. A central line was placed and he was covered
with vanco/flagyl/cipro and amditted to the [**Hospital Unit Name 153**]. Following
fluid resuscitation, his blood pressure stabilized. His bcx grew
GPC in pairs and chains and linezolid was added given concern
for VRE. He is now being transferred to the floor for further
management
Past Medical History:
1) HTN
2) hyperchol
3) Dementia: vascular vs Alzheimer's
4) s/p CEA b/l [**2118**]/[**2125**]
5) R stroke [**3-19**] with residual left hand weakness
6) h/o prostate CA s/p prostatectomy
7) UGIB
8) C spine subdural hematoma
9) pseudoaneurysm aortic arch
10) Mass in hepatic flexure of colon: Noted on [**4-19**] Abd CT,
concerning for colonic adenocarcinoma. Has not had additional
work-up since that time.
11) Right SFV thrombosis s/p placement of IVC filter.
12) C5/C6 neck fracture s/p reduction anterior/posterior fusion
13) s/p G-tube placement
14) Type II DM
15) Hypothyroidism
16) CRI: baseline Cr 1.4-1.6
Social History:
[**Hospital 100**] rehab resident. No tobacco, alcohol, or other drug use.
Son very involved
Family History:
Noncontributory
Physical Exam:
Tc 97.6, pc 77, bpc 110/60, resp 20, 97% RA
Gen: elderly male, lying in bed, alert but not following
commands or vocalizing. NAD
HEENT: anicteric, pale conjunctiva, OMM slightly dry, OP clear,
neck supple, no JVD, LAD, or thyromegaly noted
Cardiac: RRR, II/VI SM at apex
Pulm: Crackles at bases bilaterally with occasionally ronchi.
Abd: NABS, soft, mildly distended, non-tender, G tube in place
Ext: [**12-18**]+ LE and UE edema, lower extremities warm with good cap
refill.
Neuro: moves all extremities in response to noxious stimuli, 1+
DTR throughout, toes mute bilaterally.
GU: Foley draining grossly bloody urine, small clots with
flushing.
Skin: 7 X 6 cm sacral ulcer with central necrotic area. Mild
skin breakdown at heels bilaterally.
Pertinent Results:
[**2136-10-4**]
PT-14.0 PTT-31.2 INR(PT)-1.3
GLUCOSE-126 UREA N-53 CREAT-0.9 SODIUM-142 POTASSIUM-4.3
CHLORIDE-118 TOTAL CO2-14
CALCIUM-7.9 PHOSPHATE-2.6 MAGNESIUM-1.6 IRON-16
WBC-8.6 RBC-2.42 HGB-6.8 HCT-22.4 MCV-92 MCH-28.1 MCHC-30.5
RDW-17.1
PLT COUNT-357
LACTATE-2.6*
EKG [**10-4**]: ST at 113 bpm, RBBB, no [**Month/Year (2) 65**] change from prior
.
Radiology:
[**10-5**] CXR: increased patchy opacities in left middle and lower
lung fields and right abses
Brief Hospital Course:
85 year old male w/ h/o dementia/CVA presents with sepsis, found
to have VRE bacteremia, multifocal pneumonia, C. diff colitis.
.
P:
1) Sepsis: The patient was initially admitted to the intensive
care unit for fluid resuscitation. He was covered broadly with
antibiotics to treat presumed pneumonia (multifocal opacities on
CXR) and urinary tract infection with
vancomycin/ciprofloxacin/metronidazole and pan-cultured.
Following volume resucitation, he became hemodynamically stable.
Blood cultures from [**10-4**] grew [**1-22**] VRE, which presumably came
from a urinary source, although urine culture only grew ~1000
GNR. He was also found on [**2136-10-5**] to be C. diff (+). His
antibiotics were changed to linezolid/levofloxacin/metronidazole
to treat C. difficile colitis, VRE bactremia, and multifocal
aspiration pneumonia. He will complete 14 day courses of
linezolid (to complete [**2136-10-18**]) and levofloxacin (to complete
[**2136-10-17**]). He will continue metronidazole until 14 days after the
completion of his other antibiotics (to complete [**2136-11-1**]).
Echocardiogram was obtained, which is pending at time of
discharge.
2) Sacral decubitus ulcer: Wound care and plastic consults were
obtained for assistance with wound care.
3) Hematuria: The patient's gross hematuria on admission was
likely secondary to traumatic foley insertion. Urology was
consulted, who recommended monitoring and flushes as needed to
remove clots. By the time of discharge, the patient's urine had
cleared. His urine output will need to be monitored as an
outpatient and the foley flushed as needed.
4) NAG acidosis: During his admission, the patient was noted to
have a non-AG acidosis, most likely secondary to a combination
of diarrhea and aggressive saline resusication. However, RTA is
also possible, given baseline HCO3 has been in the high 10s for
the last year. Hopefully, his diarrhea will gradually improve
with treatment of C. diff. He will continue sodium bicarbonate
at his home dose.
5) Anemia: The patient received a total of 2 units of PRBC (last
[**2136-10-6**]) given drop in HCT 24 to from 31.3 on admit (baseline
30-35). His anemia likely represents hemodilution in the setting
of chronic fluid resuscitation superimposed on ACD (based on
iron studies). His vit B12 and folate were normal. He will
continue on darbopoietin as an outpatient. His hematocrit at
discharge was 27.9.
6) HTN: Given hypotension on admission, his metoprolol initially
held and then gradually titrated up. At time of discharge, he
was tolerating metoprolol 50 mg PO TID, which can be titrate up
as tolerated as an outpatient to his prior dose of 75 mg PO TID.
7) Type II DM: The patient was continued on his home NPH/RISS
regimen with adequate glucose control.
8) FEN: His G-tube became occluded on [**2136-10-7**] and required
revision by interventional radiology on [**2136-10-8**].
9) Code -- DNR/DNI
Medications on Admission:
Na bicarb [**2080**] TID
Zn sulfate 220 mg [**Hospital1 **]
Metoprolol 75 mg TID
Vancomycin 1000 mg
Lactobacillus 2 tabs G tube QID
Levothyroxine 25 mcg daily
Flagyl 500 mg TID
Ipratropium neb
Fluconazole 50 mg daily
NPH
Insulin 6 U QAM, 4U QPM
Cholestyramine 1 scoop tube [**Hospital1 **]
Nexium 40 [**Hospital1 **]
Darebpoietin 100 mcg SC Wed
Docusate 100 [**Hospital1 **]
MOM
Discharge Medications:
1. Sodium Bicarbonate 650 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
(3 times a day).
2. Zinc Sulfate 220 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
4. Lactobacillus Acidophilus Tablet [**Hospital1 **]: Two (2) Tablet PO
once a day.
5. Levothyroxine Sodium 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
7. Fluconazole 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours).
8. Insulin NPH Human Recomb 100 unit/mL Suspension [**Hospital1 **]: Six (6)
units Subcutaneous qAM: and 4 units qPM.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Cholestyramine (Bulk) Powder [**Last Name (STitle) **]: One (1) packet
Miscell. twice a day: Please dose separate from other
medications.
11. Darbepoetin Alfa-Albumin 100 mcg/mL Solution [**Last Name (STitle) **]: One
Hundred (100) mcg Injection once a week.
12. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
13. Ascorbic Acid 500 mg/5 mL Syrup [**Last Name (STitle) **]: Five Hundred (500) mg
PO DAILY (Daily).
14. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: sliding
scale Injection qAC and qHS: If FS <150 give 0 units, if
151-200 give 2 units, if 201-250 give 4 units, if 251-300 give 6
units, if 301-350 give 8 units, if 351-400 give 10 units, if
>400 [**Name8 (MD) 138**] MD.
15. Linezolid 600 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO Q12H (every
12 hours) for 10 days: to complete [**2136-10-18**].
16. Levofloxacin 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q24H
(every 24 hours) for 9 days: to complete [**2136-10-17**].
17. Metronidazole 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3
times a day) for 24 days: to complete [**2136-11-1**] (14 days after
completion of linezolid/levofloxacin course).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] CENTER
Discharge Diagnosis:
Primary: sepsis
Secondary: Aspiration pneumonia, VRE bacteremia, C. diff
colitis, dementia, hypertension, hyperlipidemia
Discharge Condition:
Good. The patient is at his baseline in terms of mental status.
Discharge Instructions:
Please follow-up or come to the emergency room if you develop
shortness of breath, persistent/worsening diarrhea, nausea,
vomiting.
Followup Instructions:
Please follow-up with primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**]
([**Telephone/Fax (1) 142**]) within 2 weeks following discharge
Completed by:[**2136-10-22**]
|
[
"244.9",
"276.7",
"V12.51",
"707.03",
"276.52",
"729.89",
"401.9",
"599.0",
"038.9",
"584.9",
"294.10",
"271.3",
"507.0",
"V10.46",
"272.4",
"438.89",
"331.0",
"867.0",
"458.9",
"599.7",
"E879.6",
"536.42",
"585.9",
"V45.4",
"995.91",
"276.2",
"008.45",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.02",
"57.95",
"96.6",
"00.14",
"38.93",
"99.04",
"96.48"
] |
icd9pcs
|
[
[
[]
]
] |
9157, 9207
|
3643, 6553
|
275, 320
|
9372, 9438
|
3155, 3620
|
9618, 9865
|
2358, 2375
|
6982, 9134
|
9228, 9351
|
6579, 6959
|
9462, 9595
|
2390, 3136
|
223, 237
|
348, 1595
|
1617, 2232
|
2248, 2342
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,506
| 161,088
|
40710
|
Discharge summary
|
report
|
Admission Date: [**2111-7-20**] Discharge Date: [**2111-8-1**]
Date of Birth: [**2060-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
aortic stenosis
Major Surgical or Invasive Procedure:
[**2111-7-20**] Aortic valve replacement (25mm On-X mechanical valve,
serial number [**Serial Number 89021**]),Pericardial reconstruction using the
CorMatrix
History of Present Illness:
This 50 year old male has known bicuspid aortic stenosis first
diagnosed in [**2106**], has been followed with serial echocardiograms
since that time. Recently he has been symptomatic with
exertional shortness of breath, fatigue. He also had an episode
of syncope which occurred in the setting of starting diuretic
therapy and an episode of nocturnal diarrhea. He was seen in
the ER and
had a head CT that was negative. His diuretic was stopped. His
most recent echo shows progression of his aortic stenosis with a
valve area of 0.8cm2. Given the progression of his disease, he
underwent cardiac catheterization in anticpiation of surgery.
Moderate aortic stenosis was noted with normal coronariy
arteries. He is now admitted for surgical management.
Past Medical History:
Hypertension
Elevated cholesterol/triglycerides
Hard of hearing
Giardia [**2089**]
Social History:
Last Dental Exam: Every 6 months. Needs a scaling completed.
Lives with: Alone in [**Location (un) 5176**]
Contact: Phone #
Occupation: Works as a computer programmer at Mathworks. Lives
alone in [**Location (un) 5176**].
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: < 1 drink/week [X] [**1-12**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
Family History:Premature coronary artery disease. Father had
CABG at age 65. has 6 siblings, one of whom has bicuspid aortic
valve.
Physical Exam:
Pulse: 72 SR Resp: 18 O2 sat: 98%
B/P Right: 148/80 Left: 142/80
Height: 70 Weight: 260
General: WDWN in NAD.
Skin: Warm, dry and intact. Left wrist with macular patches of
scar tissue/erythema for past insect bit. The tissue blanches.
HEENT: Functionally deaf however communicates excellently NCAT,
PERRLA [X] EOMI [X] Sclera anicteric, OP benign. Teeth in good
repair.
Neck: Supple [X] Full ROM [X] Non JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, III/VI Systolic murmur
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:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Transmitted vs. bruit
Pertinent Results:
[**2111-7-20**] ECHO
PRE-BYPASS:
The left atrium is mildly dilated. 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.
There is severe symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level.
The ascending aorta is mildly dilated. There are simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta.
The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Mild to moderate ([**12-7**]+) aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is a very small pericardial
effusion.
POST-BYPASS:
There is a well-seated, well-functioning mechanical prosthetic
valve in the aortic position. New valve area 2.4 cm2 with
residual mean gradient of 10 mm of Hg.
No aortic regurgitation is seen. No aortic stenosis is seen.
The ascending aorta, aortic arch, and descending aorta are
intact.
[**2111-7-20**] 10:58AM BLOOD WBC-11.3*# RBC-3.37*# Hgb-10.4*#
Hct-28.4*# MCV-84 MCH-31.0 MCHC-36.7* RDW-14.0 Plt Ct-139*
[**2111-7-20**] 12:17PM BLOOD UreaN-20 Creat-1.2 Na-140 K-5.5* Cl-111*
HCO3-25 AnGap-10
[**2111-8-1**] 07:20AM BLOOD WBC-8.5 RBC-3.54* Hgb-10.7* Hct-29.7*
MCV-84 MCH-30.3 MCHC-36.2* RDW-13.5 Plt Ct-249
[**2111-8-1**] 07:20AM BLOOD PT-23.8* PTT-98.1* INR(PT)-2.2*
[**2111-8-1**] 07:20AM BLOOD Glucose-104* UreaN-27* Creat-1.3* Na-134
K-4.4 Cl-99 HCO3-27 AnGap-12
[**2111-8-1**] 07:20AM BLOOD Mg-2.5
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2111-7-20**] for surgical
management of his aortic valve disease. He was taken directly to
the Operating Room where he underwent aortic valve replacement
using a 25mm On-X valve. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next several hours, he awoke neurologically
intact and was extubated. He developed complete heart block and
was seen by EP service who recommended watch and wait period. He
remained paced and hemodynacically stable. His creatinine peaked
at 1.8 he was gently diuresed and his creatinine returned to
baseline over time. At discharge it was 1.3. He transferred to
the floor on POD#3, he remained to CHB and was paced 100% of the
time. He remained on Heparin for anticoagulation and eventually
had a PPM placed on POD#9. His coumadin was started on POD#9 and
he was ready for discharge for home on POD# 12. Follow-up
appointments advised. Target INR 2.5-3.0 for mechanical aortic
valve. INR / coumadin f/u with Atrius anti-coag. clinic. First
INR check [**8-2**].
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
Disp:*360 Tablet(s)* Refills:*2*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Indication:Mech AVR Dose based on INR
Goal INR 2.5-3.0.
Disp:*30 Tablet(s)* Refills:*2*
12. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for prophylaxis s/p PPM for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
13. Outpatient Lab Work
INR check daily until stable then 3x times weekly then as
directed by Atrius cardiology
Number [**Telephone/Fax (1) 82719**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Aortic stenosis
s/p aortic valve replacement
Hypertension
Elevated cholesterol/triglycerides
Hard of hearing
s/p tonsillectomy
Giardia [**2089**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2111-8-25**] at 1:00pm [**Hospital Unit Name 3269**] [**Last Name (NamePattern1) **]
Wound check in the cardiac surgery office the week of [**2111-8-3**]-
please call and schedule [**Telephone/Fax (1) 170**]
Pacer appointment [**2111-8-7**] (plaese call for time of appointment)
in device clinic at [**Location (un) **] [**Hospital1 **] with Dr. [**First Name (STitle) **]
Cardiologist:Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7756**] on [**2111-8-6**] at 1:30pm
Please call to schedule appointments with:
Primary Care Dr. [**First Name (STitle) 2530**] [**Name (STitle) **] ([**Telephone/Fax (1) 71053**]in [**3-10**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Aortic mechanical valve
Goal INR 2.5-3.0
First draw [**2111-8-2**]
Results to: [**Hospital1 **] main anticoag line phone:
[**Telephone/Fax (1) 89022**] fax: [**Telephone/Fax (1) 89023**]
Completed by:[**2111-8-2**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,009
| 182,233
|
35488
|
Discharge summary
|
report
|
Admission Date: [**2170-5-13**] Discharge Date: [**2170-6-5**]
Date of Birth: [**2115-9-23**] Sex: F
Service: MEDICINE
Allergies:
Atorvastatin / Ibuprofen / Levofloxacin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
fevers, headache, abd pain, shortness of breath
.
Major Surgical or Invasive Procedure:
endotracheal intubation
tracheostomy
arterial line
central venous catheter
.
History of Present Illness:
This is a 54 yo F with h/o STEMI [**1-8**], DM type 2, HTN,
headaches, and depression who presents with fevers, cough,
headache, and n/v/d. Pt was feeling in USOH until this past
Tuesday when she began to develop worsening of her usual
headaches, subjective fevers, dry cough, and shortness of
breath. She also began to feel nauseous, vomited several times a
day, and has been unable to take her medications or tolerate
pos. Symptoms progressed to include diffuse myalgias, neck pain,
some photophobia, fevers to 101, chills, diffuse abdominal pain
but worse in the epigastric area, and diarrhea with 1 episode
associated with blood after wiping with toilet paper. She has
also had worsening temporal-occipital headaches not associated
with chest pain or focal numbness or weakness. Denies recent
travel. Has had contact with her grandson who recently had a
"cold." She saw her PCP [**Last Name (NamePattern4) **] [**5-10**] and was reportedly ruled out for
influenza, told her she likely had a "viral infection," and
recommended taking tylenol. However, she progressively felt
worse and went to the ED for evaluation this am.
.
In the ED, Tm 99.7, BP 132/75, HR 91, RR 18-22, O2 sat initially
mid 83 on RA and up to 96% 3L NC. Labs significant for WBC 4.9,
BUN 36, Cr 1.8, HCO3 19 with AG 18, AST 51, ALT 62, lactate 1.4.
CXR with multi-focal PNA predominanatly in the bases. Due to
diffuse abdominal tenderness on exam, CT abd/pelvis obtained
that was negative for acute intrabdominal processes. Given
levofloxacin that resulted in hives, requiring benadryl. Then
given vancomycin, ceftazidime, azithromycin, tylenol, 3L IVFs,
60 mEQ KCl and admitted to the [**Hospital Unit Name 153**] for further care.
.
ROS as above. Currently, she is in [**9-8**] pain and mostly
complains of her headache, which she describes as the worst
headache of her life. She reports she was taking an unknown
antibiotic for 1 week approximately 2 weeks ago for an oral
infection after a tooth was pulled.
Past Medical History:
s/p STEMI [**1-8**], cath with clean coronaries
HTN
DM type 2
Depression
Anxiety
h/o diverticulitis
Headaches
s/p hysterectomy
s/p appy
s/p chole
s/p hernia repair x 2 with mesh
Social History:
Moved to [**Location (un) 86**] from [**State 2690**] (6 months ago) to live with her
daughter. Previously worked in a restaurant, not currently
employed. Has 2 kids. Former smoker quit 14 years ago. No
alcohol or drugs.
Family History:
Has 9 siblings. one younger brother had first MI at age 46.
father died of MI at 66, first was in mid-50s. mother died of
stroke also had DM2, PVD s/p leg amputation
Physical Exam:
[**Hospital Unit Name 153**] Admission exam:
PE: T 98.3 BP 118/69 HR 82 RR 22 O2 sat 94% 4L NC
Gen - in moderate distress [**1-1**] pain, visible tachypnea. No
accessory muscle use noted. Speaks in slightly shortened
sentences due to shortness of breath.
HEENT - scleare anicteric, dry MM, OP with mild erythema but no
exudates, no cervical, preauricalar, submandibular LAD
CV - RRR, distant heart sounds, no m/r/g appreciated
Lungs - anterior crackles heard b/l, diffuse crackles, rhonchi
throughout with some end expiratory wheezes and sqeaks
Abd - Soft, large midline scar, diffusely tender to palpation,
mild guarding, neg rebound, normoactive to hyperactive BS, no
masses appreciated
Ext - no LE edema, WWP
Neuro - AAO X 3, slightly tearful during exam. Follows commands.
Decreased sensation to light touch entire left side including
facial area. Motor: [**3-4**] upper extremity bilateral and [**4-3**] lower
extremity bilateral. Reflexes: Patella 3+, negative babinski's.
Negative Kernigs, Brudzinskis. Able to rotate head side to side
without difficulty but does have some increased occipital head
and neck pain with touching chin to chest. Negative photophobia.
Skin - no rashes appreciated
Pertinent Results:
[**Hospital Unit Name 153**] Labs:
LABS ON ADMISSION:
[**2170-5-13**] 09:13AM BLOOD WBC-4.9 RBC-5.08 Hgb-14.2 Hct-41.3
MCV-81* MCH-27.9 MCHC-34.3 RDW-13.9 Plt Ct-243
[**2170-5-13**] 09:13AM BLOOD Neuts-79.3* Lymphs-18.6 Monos-1.6*
Eos-0.1 Baso-0.5
[**2170-5-13**] 06:40PM BLOOD PT-12.5 INR(PT)-1.1
[**2170-5-13**] 09:13AM BLOOD Glucose-154* UreaN-36* Creat-1.8*# Na-138
K-3.1* Cl-100 HCO3-19* AnGap-22*
[**2170-5-13**] 09:13AM BLOOD ALT-62* AST-51* CK(CPK)-36 AlkPhos-177*
TotBili-0.2
[**2170-5-13**] 09:13AM BLOOD Lipase-51
[**2170-5-13**] 09:13AM BLOOD Albumin-4.2 Calcium-8.4 Phos-4.7*# Mg-2.3
.
CARDIAC:
[**2170-5-13**] 09:13AM BLOOD cTropnT-<0.01
[**2170-5-13**] 06:40PM BLOOD CK-MB-2 cTropnT-<0.01
[**2170-5-14**] 02:46AM BLOOD CK-MB-2 cTropnT-<0.01
[**2170-5-13**] 09:13AM BLOOD CK(CPK)-36
[**2170-5-13**] 06:40PM BLOOD CK(CPK)-32
[**2170-5-14**] 02:46AM BLOOD CK(CPK)-41
.
URINE:
[**2170-5-13**] 10:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2170-5-13**] 10:10AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2170-5-13**] 10:10AM URINE RBC-[**2-1**]* WBC-[**10-19**]* Bacteri-RARE
Yeast-NONE Epi-0-2
[**2170-5-13**] 10:10AM URINE CastHy-[**2-1**]*
[**2170-5-14**] 03:32PM URINE Streptococcus pneumoniae Antigen
Detection-PND
.
RADIOLOGY:
CT Head [**5-13**]: IMPRESSION: Normal study
.
CT A/P [**5-13**]:
1. No acute intra-abdominal process identified. No evidence for
colitis.
2. Multifocal airspace consolidation partially imaged,
concerning for
multifocal pneumonia.
3. Fatty liver.
.
CXR [**2170-5-13**]: Multifocal airspace consolidations, most
compatible with
multifocal pneumonia. Conversley, this may represent principally
a left lower lobe pneumonia with scattered atelectasis
elsewhere. Follow up after therapy recommended to document
resolution.
.
[**5-20**] UPPER EXTREMITY US
No evidence of upper extremity DVT.
Please note that ultrasound cannot assess for more central
venous narrowing
such as SVC syndrome.
.
US LIVER/GALLBLADDER [**5-23**]
1) Apparent surgical absence of the gallbladder. Please refer to
CT torso
performed on the same day.
2) Echogenic liver consistent with fatty infiltration. Other
forms of liver
disease and more advanced liver disease including significant
hepatic
fibrosis/cirrhosis cannot be excluded on this study.
.
CT Chest [**5-23**]
IMPRESSION:
1. Multifocal bilateral airspace opacities with air bronchograms
consistent
with patient's known diagnosis of multifocal pneumonia. There
are no pleural
effusions. There is no pneumothorax.
2. No abnormal collections in the abdomen or pelvis to suggest
additional
sites of infection.
3. Air in the nondependent portion of the bladder likely due to
Foley
instrumentation.
4. Tip of left-sided central line terminates at the
SVC/brachiocephalic
junction and should be advanced further for optimal positioning.
5. Minimal dilation of the CBD in a patient status post
cholecystectomy.
6. Unchanged dystrophic calcifications in the liver.
.
CT ABD/PELVIS [**5-23**]
IMPRESSION:
1. Multifocal bilateral airspace opacities with air bronchograms
consistent
with patient's known diagnosis of multifocal pneumonia. There
are no pleural
effusions. There is no pneumothorax.
2. No abnormal collections in the abdomen or pelvis to suggest
additional
sites of infection.
3. Air in the nondependent portion of the bladder likely due to
Foley
instrumentation.
4. Tip of left-sided central line terminates at the
SVC/brachiocephalic
junction and should be advanced further for optimal positioning.
5. Minimal dilation of the CBD in a patient status post
cholecystectomy.
6. Unchanged dystrophic calcifications in the liver.
.
[**5-23**] CT SINUS
1. Pan-sinus mucosal disease, with hyperdense inspissated as
well as
aerosolized secretions. There are also extensive retained
secretions in the
posterior nasopharynx. Though these findings may be secondary to
intubation
and supine positioning, a component of acute sinusitis cannot be
excluded.
2. Osseous defect in the alveolar ridge of the left maxilla,
with adjacent
soft tissue stranding. Given history of recent dental work, this
could be
post-surgical. However, correlation with a detailed procedure
note and
thorough dental exam is recommended.
.
CXR [**2170-5-31**]
AP single view of the chest has been obtained with patient in
semi-upright position. Analysis is performed in direct
comparison with a
preceding similar study obtained seven hours earlier during the
same day.
During the interval, a tracheostomy has been performed. The
previous ETT has been removed and a metallic cannula has been
placed, seen to terminate in the trachea at the level of the
clavicles. No pneumothorax has developed. Previously existing
NG tube has been replaced with a Dobbhoff tube, the tip of which
reaches the first portion of the duodenum. Previously described
bilateral patchy confronting parenchymal densities are still
present. There appears a mild improvement of the densities, but
this can also be related to some better aeration at the time of
the examination.
.
CARDIOLOGY:
TTE: The left atrium and right atrium are normal in cavity size.
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with focal hypokinesis of the distal inferior wall (clip [**Clip Number (Radiology) **]). The
remaining segments contract normally (LVEF = 55%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION: Mild
regional left ventricular systolic dysfunction c/w CAD.
Borderline pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2170-4-18**], the
area of the regional wall motion abnormality was not as well
visualized on the prior study.
.
Micro Data:
BAL:
[**Date Range **] STAIN (Final [**2170-5-19**]): 4+ (>10 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary): Negative, aspirgillus
galactomannan negative, beta-glucan negative
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): negative
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2170-5-19**]): NEGATIVE for Pneumocystis jirovecii (carinii).
CDIFF negative x 4 (most recent [**2161-5-31**])
Mycoplasma IGM negative
Coccidiodes antibody negative
Chlamydia pneumonia antibody negative
Babesia antibody negative
Mycoplasma pneumonia negative
Erlichia antibody negative
HIV negative
Negative respiratory viral screen
Blood cx [**5-21**] coag negative staph (thought to be contaminant)
.
Infectious work-up pending: LYMPHOCYTIC CHORIOMENINGITIS
.
Brief Hospital Course:
[**Hospital Unit Name 153**] Course ([**Date range (2) 80832**]):
54 year old F with h/o DM II, HTN, NSTEMI who presented with
fevers, cough, myalgias, n/v/d and found to have hypoxia and
multi-focal infiltrates on CXR eventually required intubation
for respiratory distress. An extensive infectious workup was
undertaken, however, no causitive organism was identified during
the hospitalization. The patient was treated with multiple
antibiotics from [**5-13**] - [**5-29**] and experienced one serious
angioedema reaction on [**5-21**] thought most likely to be Linezolid.
Patient defervesced approximately 2 weeks into the hospital
course and was gradually weaned off the vent, but required a
tracheostomy on [**5-31**] due to the prolonged intubation and slow
weaning. Mechanical ventilation was ultimately discontinued 2
days s/p tracheostomy and the patient was transferred to a rehab
facility for continued OT/PT.
.
# Respiratory distress: Required intubation and intermittent
paralytics. Secondary to multi-focal pneumonia on admission and
then subsequent pulmonary edema. See treatment of PNA below.
Patient developed pulmonary edema secondary to fluid repletion
and mild regional left ventricular systolic dysfunction.
Diuresis was attempted with goal -500 to 1 L a day. Despite
decreasing oxygen requirements, the patient remained intubated
for 15 days. She repeatedly failed spontaneous breathing trials
secondary to tachypnea and low tidal volumes. This was felt to
be multifactorial from muscle weakness due to prolonged
intubation, anxiety and decreased lung compliance. The patient
received a tracheostomy on [**5-31**] without complication. The
patient was continued on CMV after tracheostomy and was switched
over to PSV and weaned off mechanical ventilation on [**6-2**].
Patient was continued on oxygen by trach mask until discharge.
On transfer to the rehab facility her O2 saturation was >92% on
trach mask and patient was in no acute respiratory distress and
had no signs of active infection. She is scheduled to follow-up
with Dr. [**First Name (STitle) **] (Thoracic surgeon who placed trach) on [**6-19**] for
follow-up and suture removal.
.
# Multi-focal PNA: Differential on admission included staph,
pneumococal, atypicals (Mycoplasma, Chlamyadia), legionella and
aspiration PNA. Patient continued to have high temperatures on
broad spectrum antibiotics and consequently ID was consulted.
Infectious work-up involved: negative BAL (pcp, [**Name10 (NameIs) **] stain,
legionella), influenza, rapid respiratory viral screen, HIV
serology and viral load, EHRLICHIA, BABESIA, CHLAMYDOPHILA
PNEUMONIAE, M. PNEUMONIAE, COCCIDIOIDES, LYMPHOCYTIC
CHORIOMENINGITIS, HISTOPLASMA ANTIGEN, Streptococcus pneumoniae
Antigen, repeat urine cultures (postive for yeast only) and
blood cultures. Autoimmune workup negative ([**Doctor First Name **]/ANCA). Patient
was treated with the following antibiotic regimen: ceftriaxone
([**Date range (1) 17333**]), cefepime ([**Date range (1) 47946**]), vanco ([**Date range (1) 80833**]),
oseltamivir ([**5-17**] ?????? [**5-19**]), Doxycycline ([**Date range (1) **]). Due to
concern of drug fevers patient was switched to Meropenum
([**Date range (1) 80834**]), Linezolid ([**Date range (1) 80835**]) and Azithromycin ([**2170-5-18**]).
Linezolid was stopped on [**5-21**] due to concern of angioedema (see
below) and the patient was restarted on an eight day course of
vanco ([**Date range (1) 80836**]). The patient's clinical status improved with
decreasing oxygen requirements. At time of discharge from the
[**Hospital Unit Name 153**], the CXR showed little improvement with persistent
widespread bilateral parenchymal opacities.
.
# Face and tongue swelling: Developed [**2170-5-19**]. Unclear etiology
?????? differential included volume overload (dependent edema) vs
angioedema from drug rxn (see above) vs possible clot. For
possible drug reaction patient was started on benadryl and
famotidine, linezolid and cefepime were discontinued (switched
to meropenum and vancomycin). Bilateral upper extremity
ultrasound demonstrated no evidence for upper extremity of
narrowing of SVC. For volume overload placed in reverse
trendelenburg and diuresised. The patient's symptoms resolved
with the above interventions.
.
# N/V/D: Resolved on admission. Unclear etiology, most likely
secondary to viral/bacterial cause of PNA (see above). Negative
for urine legionella, however this does not test all serotypes
and patient was continued on Azithromycin for empiric treatment.
C. Diff negative and no colitis on CT. CT on admission no
abnormalities other than fatty liver.
.
# Headache: On admission patient described severe headache. CT
scan negative for acute process such as SAH or SDH. Also on
differential was meningitis given her complaints of photophobia
and neck pain. However, her exam did not clearly support a
diagnosis of meningitis and doubted bacterial cause for this as
pt would likely be sicker by now as has had 5 days of symptoms.
Neurologic exam non-localizing other than decreased sensation on
left, which appears to be a long standing issue in OMR. Patient
has chronic headahces, and most likely she had worsened of her
baseline HAs in setting of infection/dehydration. Prior to
admission head MRI/MRA unremarkable. Headache was responsive to
percocet.
.
# ARF: On admission, patient's chemistry showed elevated
creatinine of 1.8 that was thought to be due to hypovolemia. Pt
was treated with IV fluids and creatinine normalized overnight.
Renal function was normal for duration of [**Hospital Unit Name 153**] stay.
.
# Tranaminitis: Trended down. Slight elevation in
AST/ALT/alkphos but TBili wnl. Final CT abd/pelivs fatty liver
only. On [**5-28**], pt had elevated LFTs found on routine
labwork, U/S abdomen showed dilated CBD at the upper range of
normal, but acalculous cholecystitis was ruled out due to hx of
cholecystectomy in this patient.
.
# HTN ?????? History of hypertension, meds held during [**Hospital Unit Name 153**] stay due
to hypotension initially. Blood pressure soon normalized.
Outpatient Metoprolol started on [**6-3**] in preparation for transfer
to the rehab facility.
.
# s/p NSTEMI ?????? On review of prior records and EKG appears to
have been NSTEMI not STEMI. Continued ASA and Statin.
.
# Depression/anxiety: Continue sertraline. Patient was extremely
anxious as sedation was weaned and required Ativan prn. Once pt
recieved tracheostomy, anxiety decreased, however, supportive
psychotherapy provided by both nursing staff and physicians.
.
# DM: Patient was placed on sliding scale insulin and glargine
while in ICU for tighter control of glucose levels.
.
Full Code throughout stay.
Medications on Admission:
ASA 81 mg daily
Pravastatin 40 mg qhs
Metoprolol 50 mg [**Hospital1 **]
Metformin XR 500 mg daily
Sertraline 100 mg daily
Tramadol 50 mg prn for HA
Trazodone 50-150 mg qhs prn for insomnia
Melatonin 1-4 mg qhs
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day): Please hold for SBP <100, HR <60.
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed for headache.
8. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary: Community acquired pneumonia
Secondary: CAD s/p STEMI with clean cath, hypertension, DM type
II, Anxiety
Discharge Condition:
vitals stable, satting well on 40% trach collar
Discharge Instructions:
You were admitted for pneumonia and required endotracheal
intubation for respiratory distress. A tracheostomy collar was
placed for additional respiratory suppor. You were treated with
antibiotics and showed significant improvement. We are
discharging you to rehab to help improve your strength and
nutrition.
We have not made any changes to your medications.
Please call your doctor or return to the emergency room if you
develop any of the follow:
-increased difficulty breathing or shortness of breath
-chest pain
-fevers >100.4
-difficulty with your trach collar
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2170-6-19**] 10:30
Provider: [**Name10 (NameIs) 4678**],[**Name11 (NameIs) 4677**] NEUROLOGY UNIT CC8 (SB)
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2170-6-19**] 4:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2170-7-5**] 10:20
|
[
"412",
"276.52",
"401.9",
"250.00",
"784.0",
"300.4",
"285.9",
"518.81",
"995.1",
"584.9",
"276.2",
"276.6",
"486",
"E930.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"38.93",
"96.6",
"33.24",
"31.1",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
19217, 19260
|
11435, 18159
|
349, 428
|
19418, 19468
|
4304, 4344
|
20088, 20504
|
2900, 3067
|
18420, 19194
|
19281, 19397
|
18185, 18397
|
19492, 20065
|
3082, 4285
|
10753, 11412
|
10637, 10723
|
260, 311
|
456, 2443
|
4358, 10599
|
2465, 2645
|
2661, 2884
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,055
| 173,825
|
20103
|
Discharge summary
|
report
|
Admission Date: [**2161-3-2**] Discharge Date: [**2161-3-4**]
Service: MEDICINE
Allergies:
Percocet / Dilaudid (PF)
Attending:[**Attending Info 11308**]
Chief Complaint:
altered mental status, unresponsiveness
Major Surgical or Invasive Procedure:
Right ventricular lead revision
History of Present Illness:
[**Age over 90 **]-year-old white female with a recent PPM for CHB, history of
CAD, hyperlipidemia, hypertension and arthritis who presented to
[**Hospital6 33**] with altered mental status and failure of
RV capture.
.
Per ED report, the patient had a syncopal episode at her nursing
facility today. The patient just had a pacemaker placed on
[**2161-2-17**] at [**Hospital3 **] after prolonged episodes of complete
heart block with asystole and no escape rhythm. The patient's
family subsequently reports that the patient had been
complaining of some discomfort in the left lower chest/ left
upper abdomen over the past 2 days. They report this is worse
when the patient takes a deep breath.
.
EMS reports that the patient's pacemaker did not appear to be
functioning adequately as they found the patient's heart rate to
be between the 30's and 70's. EMS was not able to obtan IV
access and an IO was placed. There are no reports of any recent
chest pain, shortness of breath, abdominal pain, new back pain,
or trauma. The patient was not able to answer review of systems
questions or identify exacerbating or alleviating factors. The
patient did have some eccymosis about the left side of her head.
.
In the [**Hospital3 **], the patient was successfully intubated with
versed, fentanyl, and succinylcholine out of concerns that she
could not protect her airway and hypotension. A temporary pacing
wire was placed via the right IJ. The patient was bradycardic
and a CXR demonstrated a displaced right ventricular pacer wire.
After consultation with the family, the patient was transferred
to [**Hospital1 18**] for further evaluation and management.
.
At [**Hospital1 18**], we noted complete loss of capture of the pacemaker RV
lead, and intermittent or absent capture of the temporary pacing
wire. During periods of her complete paroxysmal heart block,
she was completely pacer dependent. Given the tenuous
situation, she was taken to the OR emergently. On Echo, there
was concern for RV lead displacement but no evidence of
tamponade or effusion. She was taken to the OR and had the RV
lead repositioned to the RVOT. She was intubated and sedated
and on dopamine. A repeat ECHO demonstrated no effusion or
complication of lead placement. Access is PIV, femoral 7-french
central line.
.
ROS: unable to obtain due to intubation/sedation.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, diabetes
mellitus
2. CARDIAC HISTORY: CAD. s/p inferior microinfarction
- PACING/ICD: complete heart block s/p pacemaker placement in
[**1-/2161**]
3. OTHER PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Colon cancer.
3. Insulin dependent-diabetes mellitus.
4. History of duodenal ulcer.
5. COPD.
6. Asthma.
7. History of cataracts.
8. Osteoarthritis.
9. History of ventral hernia.
10. History of abdominal wall abscess.
11. Depression.
12. History of colocutaneous fistula.
13. History of diverticulitis.
14. Hyperlipidemia
15. CAD. s/p inferior microinfarction
16. Pulmonary edema, diastolic dysfunction
17. complete heart block.
.
PAST SURGICAL HISTORY:
1. Right colectomy for colon cancer.
2. Ventral hernia repair with mesh.
3. Bilateral hip replacements.
4. Antrectomy and vagotomy with [**Doctor First Name 892**]-[**Doctor Last Name **] II reconstruction with
splenectomy and partial pancreatectomy for duodenal ulcer.
5. Duodenostomy tube.
6. Feeding jejunostomy.
7. Exploration of abdominal abscess.
Social History:
- Tobacco history: ex-smoker
- ETOH: no
- Illicit drugs: no
Family History:
NC
Physical Exam:
VITAL SIGNS: 95.1 60 111/53 100% CMV assist control 400/14
PEEP 5
GENERAL: Intubated w/ RASS of -5.
HEENT: Conjunctiva were pale. Pupils reactive to light. No
xanthalesma.
NECK: Supple with JVP flat
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Pt
intubated CTAB, no crackles, wheezes or rhonchi on anterior lung
exam.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: Intubated with RASS of -5, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Discharge:
VITAL SIGNS: 98.8 71 110/38 26 99%2L
GENERAL: NAD, AxOx1, agitated.
HEENT: Conjunctiva were pale. Pupils reactive to light. No
xanthalesma.
NECK: Supple with JVP flat
CARDIAC: irregular RR, normal S1, S2. 1/6 systolic flow murmur .
LUNGS: No chest wall deformities, scoliosis or kyphosis. Pt
intubated CTAB, no crackles, wheezes or rhonchi on anterior lung
exam.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
LABS ON ADMISSION:
[**2161-3-2**] 04:30PM BLOOD WBC-15.7* RBC-3.39* Hgb-10.1* Hct-30.8*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.1 Plt Ct-232
[**2161-3-2**] 04:30PM BLOOD Neuts-83.7* Lymphs-11.3* Monos-3.7
Eos-0.9 Baso-0.4
[**2161-3-2**] 04:30PM BLOOD Plt Ct-232
[**2161-3-2**] 04:30PM BLOOD Glucose-103* UreaN-49* Creat-1.7* Na-145
K-5.3* Cl-117* HCO3-22 AnGap-11
[**2161-3-2**] 04:30PM BLOOD CK(CPK)-89
[**2161-3-3**] 04:38AM BLOOD Calcium-8.1* Phos-5.3* Mg-1.8
[**2161-3-2**] 04:21PM BLOOD Type-ART Rates-16/ Tidal V-400 PEEP-5
FiO2-100 pO2-472* pCO2-35 pH-7.36 calTCO2-21 Base XS--4
AADO2-206 REQ O2-43 Intubat-INTUBATED Vent-CONTROLLED
.
LABS ON DISCHARGE:
[**2161-3-4**] 04:22AM BLOOD WBC-12.3* RBC-2.88* Hgb-8.8* Hct-26.3*
MCV-92 MCH-30.6 MCHC-33.5 RDW-14.5 Plt Ct-191
[**2161-3-4**] 04:22AM BLOOD Plt Ct-191
[**2161-3-4**] 04:22AM BLOOD Glucose-93 UreaN-41* Creat-1.6* Na-145
K-4.3 Cl-116* HCO3-22 AnGap-11
[**2161-3-4**] 04:22AM BLOOD Calcium-7.8* Phos-4.2 Mg-2.9*
[**2161-3-3**] 01:25AM BLOOD Lactate-1.1
[**2161-3-3**] 01:25AM BLOOD O2 Sat-98
[**2161-3-3**] 01:25AM BLOOD freeCa-1.14
.
[**2161-3-3**]
pCXR
IMPRESSION:
1. ETT approximately 1.7cm above the carina and should be
repositioned.
2. New right ventricular lead projects medial to the ventricular
apex, however it's exact position cannot be completely assessed
without a lateral view.
.
[**2161-3-2**]
pCXR
FINDINGS: In comparison with the study of [**3-2**], the new right
ventricular lead appears to be in good position, substantially
less peripheral than on the previous study. Endotracheal tube
tip lies approximately 2 cm above the carina. Small layering
pleural effusion persists on the left and there is mild
bilateral basilar atelectasis.
.
ECHO [**2161-3-2**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The right ventricular pacing lead is identified in the right
ventricular cavity. It does not appear to extend beyond the free
wall (but images are focused). There is a trivial pericardial
effusion with no echocardiographic signs of tamponade.
.
Compared with the prior study of earlier in the day, the right
ventricular pacing lead no longer appears to extend beyond the
free wall (though views are focused).
.
ECHO [**2161-3-1**]
Normal right ventricular cavity size and free wall motino. In
some views (clips [**4-7**]), the right ventricular pacing lead
appears to extend beyond the right ventricular free wall. There
is no pericardial effusion.
.
MICROBIOLOGY:
[**2161-3-2**] 4:30 pm URINE Site: NOT SPECIFIED HEM# 1646E
[**3-2**].
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
.
3/6/012
[**2161-3-3**] 2:43 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2161-3-3**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2161-3-3**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
[**Age over 90 **]-year-old white female with a history of CAD, hyperlipidemia,
hypertension, DM, and arthritis with recent PPM placement at
[**Hospital1 **] on [**2-18**] for complete heart block (?paroxysmal av block)
and syncope who presented to [**Hospital6 33**] with altered
mental status and a displaced RV pacerlead with bradycardia now
s/p pacer lead revision.
.
# COMPLETE HEART BLOCK/RV LEAD DISPLACEMENT: The patient had a
DDD pacemaker placed at [**Hospital1 **] on approximately [**2161-2-22**] for
symptomatic (syncope) bradycardia. She was transferred to [**Hospital1 18**]
today after being found unresponsive; it was found that her RV
pacer lead had perforated her RV apex. A temporary pacing wire
was placed [**2161-3-2**] at [**Hospital3 **] without complication and she
was transferred to [**Hospital1 18**]. An echo here demonstrated no
pericardial effusion, but showed clear perforation of the RV
lead. She underwent RV lead revision, with post-operative echo
showing no complication. Repeat Echo demonstrates only minimal
pericardial fluid, but no evidence of tamponade. Patient was
monitored on telemetry and with serial EKG without additional
complication. She received a one time dose of vancomycin, and
then on discharge, will continue keflex, renally dosed, for a
total of 7 day of Abx coverage for lead revision. She will have
follow-up at device clinic on Tuesday, [**2161-3-10**].
.
# CHF: diastolic dysfunction. Patient was continued on her home
BB, ASA.
.
# [**Last Name (un) **]: Pt's Cr baseline appears to be near 1.2 as per discharge
from [**Hospital1 **] on [**2161-2-22**]. Cr was 1.7 on admission. DDx included
prerenal vs intrinsic. Cr remained stable during admission, and
on discharge was 1.6.
.
# COPD - known history of COPD. She was continued on albuterol
and ipratropium, and discharged on her home fluticasone and
salmeterol.
.
# E. Coli UTI - UA suggestive of urinary tract infection.
Culture grew > 100k E.coli with sensitivities pending. She
received a dose of ceftriaxone, and then was changed to
ciprofloxacin x 5 days on discharge. She remained afebrile, with
resolving wbc. She denied urinary symptoms while here. If
sensitivities are cephalosporin positive, ciprofloxacin could be
discontinued, as she is on keflex x 5 days for lead revision.
.
# Diarrhea: resolved. Cdiff was checked and negative.
.
# Code: DNR/DNI, confirmed with HCP
.
# Transitions:
- E.coli sensitivities from urine culture pending
- spoke with PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 15532**] at [**Hospital1 **] and updated on patient's
admission.
Medications on Admission:
HOME MEDICATIONS: From D/C summary from [**Hospital1 **] on [**2161-2-22**];
unable to confirm as pt intubated and sedated
Lactobacillus 1 tab [**Hospital1 **]
Metoprolol Tartrate 25 mg [**Hospital1 **]
Aspirin 325 mg DAILY
Enoxaparin Sodium 30 mg DAILY
Fluticasone [**Hospital1 **]
Salmeterol INH
Acetaminophen 650mg Q4H PRN
Oxycodone 1 tab Q4H PRN
Magnesium Hydroxide
Nitroglycerin 0.4 mg Q5M PRN
Discharge Medications:
1. lactobacillus acidophilus Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous once a day.
5. fluticasone 110 mcg/actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
6. salmeterol 50 mcg/dose Disk with Device Sig: One (1) puff
Inhalation once a day.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for constipation.
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain: Can take 3 in 15
minutes.
12. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] HealthCare Center at [**Location (un) 38**]
Discharge Diagnosis:
Primary:
1. Right ventricular lead revision
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
.
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted for malfunction and displacement of your pacer lead.
This was fixed with good results. You had an echocardiogram
which showed no complication.
.
You were noted to have a urinary tract infection. You will take
antibiotics for this, and also for the pacer lead revision.
.
MEDICATION CHANGES:
- START keflex 500 mg every 8 hours for 5 more days
.
Please seek medical attention for any concerns. Please attend
your follow-up appointments below.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2161-3-10**] at 10:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 163**] MD [**MD Number(2) 11313**]
Completed by:[**2161-3-4**]
|
[
"414.01",
"715.90",
"428.0",
"996.01",
"V49.86",
"V10.05",
"V43.64",
"E878.1",
"530.81",
"599.0",
"041.49",
"250.00",
"401.9",
"787.91",
"426.0",
"272.4",
"493.20",
"428.30",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"37.75",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12567, 12657
|
8426, 11028
|
269, 303
|
12745, 12745
|
5371, 5376
|
13509, 13895
|
3879, 3883
|
11477, 12544
|
12678, 12724
|
11054, 11054
|
12930, 13314
|
3432, 3786
|
3898, 5352
|
2799, 2909
|
11072, 11454
|
13334, 13486
|
190, 231
|
6025, 7979
|
8014, 8403
|
331, 2685
|
5390, 6006
|
12760, 12906
|
2940, 3409
|
2707, 2779
|
3802, 3863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,081
| 180,381
|
8990
|
Discharge summary
|
report
|
Admission Date: [**2120-2-6**] Discharge Date: [**2120-2-13**]
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old
female who reports left frontal pain, left eye double vision
and ptosis of the left eye since [**2119-2-20**]. The patient
was diagnosed with a wide-necked left cavernous carotid aneurysm
and is status post diagnostic angiography done two weeks prior to
this admission. The patient has a past medical history of
valvular heart disease, hypertension, dyspnea with two flights,
breast cancer times three on both sides, also TMJ and thyroid
nodules.
PHYSICAL EXAMINATION: On physical examination she is in no
acute distress, awake, alert and oriented times three.
Cardiovascular regular rate and rhythm with a II/VI systolic
murmur, radiating to the left and right carotids. Lungs were
clear to auscultation. Abdomen was soft, nontender,
nondistended. Positive bowel sounds. Extremities: No
cyanosis, clubbing or edema. She has a left eye ptosis. Her
pupils are 2.5 mm and equally reactive. Extraocular
movements are full. She has no nystagmus, smile is
symmetric. No sensory loss. Her strength is [**4-25**] in all
muscle groups. Her visual fields are full.
HOSPITAL COURSE: Mrs. [**Known lastname 31174**] was admitted and underwent a
cerebral angiogram with a balloon test occlusion (BTO) of the
left internal carotid artery with the assistance of anesthesia.
She tolerated the temporary occlusion for 25 minutes without
neurological deficit. This included a hypotensive challenge via
intravenous nitroglycerin during which her systolic pressure was
decreased below 100mmHg. After successful BTO, the wide-necked
aneurysm was coiled loosely using Matrix platinum coils to form a
scaffold and to prevent distal embolization of proximal embolic
materials that would be subsequently used to occlude the parent
vessel proximally. The left ICA was then occluded from an
endovascular approach. Post-operatively, she was admitted to
the ICU for close neurological monitoring. Her vital signs
were stable. She was afebrile. She continued with the left
eye ptosis. The lungs were clear. Neurologically, awake,
alert and oriented times three, following commands. Speech
was fluent. Continues with strength 5/5 in all muscle groups
with no drift. She was continued to be monitored in the
Intensive Care Unit. She was kept with strict blood pressure
control to 130 to 160 range at all times, flat bedrest until
the sheath was removed and she was an aspirin
postoperatively.
On postoperative day Number 1, she was oriented times three
moving all extremities, following commands. Speech intact.
The groin had no hematoma. She had positive pedal pulses.
She was out of bed, ambulating in the afternoon on
postoperative day Number 1. She was transferred to the
regular floor, to Stepdown on postoperative day Number 2.
She remained neurologically stable. She did have a couple of
episodes of hypotension down to the 90s. She did have her
Foley catheter discontinued on [**2120-12-8**], but was
unable to void. The new Foley catheter was replaced. She
did have blood-tinged urine thought to be traumatic and had
problems with hyponatremia and was started on salt tabs 3
grams p.o. t.i.d. for a sodium level of 133. On [**2120-2-11**], the patient complained of mild erythema, sore throat.
A throat culture was sent and is negative to date. The
patient has a history of first degree atrioventricular block.
PR interval was elongated. Blood pressure was running in the
90s to 150s. Her antihypertensive medication was stopped.
Her intravenous fluids stopped on [**2120-2-12**], and her
blood pressure has been in the normal range 130 to 160.
Vital signs have remained stable. She has been afebrile.
DISCHARGE MEDICATIONS: Medications at the time of discharge
include heparin 5000 units subcutaneously b.i.d., Neutra-Phos
2 packages p.o. b.i.d., Colace 100 mg p.o. b.i.d., Famotidine
20 mg p.o. once day, aspirin 325 p.o. q. day. Currently on
salt tablets 3 grams p.o. t.i.d. to wean off when sodium
normalizes.
CONDITION ON DISCHARGE: The patient's condition was stable
at the time of discharge.
FOLLOW UP: She will follow up with Dr. [**Last Name (STitle) 1132**] in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2120-2-12**] 14:39:59
T: [**2120-2-12**] 15:54:01
Job#: [**Job Number 31175**]
|
[
"998.12",
"401.9",
"599.7",
"276.1",
"V10.3",
"462",
"458.29",
"437.3",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
3811, 4102
|
1253, 3787
|
4201, 4523
|
635, 1235
|
117, 612
|
4127, 4189
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,337
| 124,908
|
31794
|
Discharge summary
|
report
|
Admission Date: [**2127-7-22**] Discharge Date: [**2127-8-7**]
Date of Birth: [**2056-1-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Milk / Egg / Sulfa (Sulfonamides) /
Penicillins / Ciprofloxacin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Patient transferred for coronary catherization
Major Surgical or Invasive Procedure:
coronary catherization
heart balloon pump placement
[**2127-7-31**] Off-Pump Coronary Artery Bypass Graft x 2 (LIMA to LAD,
SVG to Diag)
History of Present Illness:
71 yo female with history of a-fib, diabetes, CVA who was
initially transferred to [**Hospital1 18**] from [**Hospital3 **] on [**2127-7-22**]
for catheterization following a positive P-MIBI. Cardiac cath
demonstrated significant 3VD including LMCA with mild plaquing,
LAD heavily calcified throughout with TIMI [**11-26**] flow; mid-LAD
with 80% stenosis at the bifurcation with D2, and the mid-LAD
with 95% stenosis well after S2 and D3 with diffuse plaquing
beyond. The patient was evaluated by CT surgery, and decision
was made to plan for CABG. Today the patient developed chest
pain and triggered for hypotension to systolic BP in the 70's.
She was given 1 liter IVF with improvement of her BP to systolic
of 90's. Her chest pain resolved with oxygen. She was taken to
cath today IABP and PA cath placed, and she was transferred to
the CCU for further monitoring.
.
On review of symptoms, she denies any prior history of venous
thrombosis, pulmonary embolism, excessive bleeding, cough,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. She does complain of chronic back pain and right leg pain
which is unchanged from prior.
.
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.Brittle DM
2.Atrial fibrillation, sick sinus syndrome
3.Polymyalgia Rheumatica
4.COPD
5.Asthma
6.s/p thalamic infarction
7.Hypertension
8.Gout
9.h/o urosepsis
10.s/p pacemaker placement
11.GERD w/ esophageal stricture
12.Severe back pain s/p prior surgery
[**32**].Hypothyroidism
14.Hypercholesterolemia
15.Hypertension
Social History:
Married, no children, lives with husband, used to work for
telephone company, now retired. No current tobacco use, no
history of alcohol abuse. Family history significant for mother
deceased at 73 from "massive" MI, brother s/p CABG at age 79
Family History:
No family history of premature coronary artery disease or sudden
death. Sister also has congenital ankle deformity.
Physical Exam:
VS - 98.5, 103/62, 68, 16, 97% RA
Gen: NAD, lying in bed. Obese.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, JVD could not be assessed [**12-27**] body habitus.
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
.
Pertinent Results:
EKG demonstrated LAD, A-sensed, V-paced, with no significant
change compared with prior dated [**2127-7-26**].
.
2D-ECHOCARDIOGRAM performed on [**2127-7-23**]: The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is 16-20 mmHg.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is top normal/borderline dilated. No
masses or thrombi are seen in the left
ventricle. Overall left ventricular systolic function is
severely depressed (LVEF= 25 %) with global hypokinesis and
akinesis of the
inferior/infero-lateral walls, distal LV and apex. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
Right ventricular chamber size is normal. There is mild global
right ventricular free wall hypokinesis. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**11-26**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
P-MIBI performed on [**2127-7-21**] at OSH demonstrated: LV dilated at
stress and at rest. Large aneteroapical infarct with mild
periinfarct ischemia. Marked diffuse hypokinesis of the left
ventricle, stress LV EF reduced at 23%.
.
CARDIAC CATH performed on [**7-22**] demonstrated: 1. Coronary
angiography in this left-dominant system demonstrated
three-vessel disease:
--The LMCA had mild plaquing.
--The LAD was heavily calcified throughout with TIMI [**11-26**] flow;
the
mid-LAD had an 80% stenosis at the bifurcation with D2, and the
mid-LAD had a 95% stenosis well after S2 and D3 with diffuse
plaquing beyond. The distal LAD wraps around the apex. There
are septal collaterals to the distal RCA system. There is
disease in the origin of S2.
--The LCx had a 20% proximal stenosis with diffuse luminal
irregularities. There is a small OM1. OM2 is a modest vessel
with mild proximal plaquing. There is a large LPL branch.
There is an 80% stenosis in the distal LCx at the origin of the
LPDA.
--The RCA is a small, non-dominant vessel with proximal
occlusion after atrial and conus branches.
2. Angiography of the left subclavian artery reveals a patent
left
subclavian artery supplying the in-situ LIMA. No gradient
across aortic valve.
.
CARDIAC CATH performed on [**2127-7-29**] demonstrated:
.
HEMODYNAMICS:
Resting hemodynamics revealed elevated right- and left-sided
filling
pressures with RVEDP of 12 mmHg and LVEDP of 18 mmHg. The
cardiac index was depressed at 2.2 L/min/m2. There was mild
pulmonary arterial hypertension with PA systolic pressure of 38
mmHg. Pulmonary vascular resistance was mildly elevated at 164
dynes-sec/cm5. Systemic vascular resistance was normal at 1005
dynes-sec/cm5. Systemic systolic arterial pressures were
low-normal.
.
CAROTID US [**2127-7-23**]: There is no stenosis within bilateral
internal carotid arteries
Brief Hospital Course:
She was found to have significant 3VD on cath, and later was
transferred to CCU for hypotension and IABP. Preoperative
workup continued. She was seen by GI and underwent endoscopy on
[**7-25**] which was normal. She was treated for a UTI. On [**7-31**] she
was taken to the operating room where she underwent a CABG x 2.
She was transferred to the ICU in critical but stable condition.
Her IABP was dc'd on POD #1. She was extubated on POD #2. She
was followed by [**Last Name (un) **] for her diabetes. She was restarted on
coumadin for atrial fibrillation. She became somnolent and her
nuerontin and ultram were dc'd. She improved and was ready for
discharge to rehab on POD #7.
Medications on Admission:
1.Digoxin 0.25 Daily
2.[**Doctor First Name **] 60mg [**Hospital1 **]
3.Neurontin 300mg [**Hospital1 **]
4.Remeron 15 QD
5.Protonix 40 QD
6.Paxil 30 QD
7.K-dur 10 [**Hospital1 **]
8.Seroquel 25 QHS
9.Singulair 10 QD
10.Synthroid 0.1mg QD
11.Theophylline ER 200mg QD
12.Cozaar 50mg QD
13.Wellbutrin SR 150mg QD
14.ASA 81 QD
15.Lantus 84 QD
16.Cardizem 60mg Daily
17.Januvia100mg daily
18.Lipitor 80mg daily
19.Toprol XL 25mg
20.Warfarin 2mg QD
21.Glucophage 1000mg [**Hospital1 **]
22.Vicodin PRN
23.Tylenol PRN
24.Plavix 600
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO DAILY (Daily).
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Tablet, Delayed Release (E.C.)(s)
14. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
1 days.
15. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day.
17. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
18. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease s/p Off Pump Coronary Artery Disease
PMH: Hypertension, Diabetes Mellitus, Atrial Fibrillation, Sick
Sinus Syndrome s/p pacemaker, h/o Stroke [**2125**], Asthma,
Polymyalgia Rheumatica, Anxiety/depression, Esophageal
stricture, Gout, Gastroesophageal reflux disease ,
Hypothyroidism, Congenital ankle deformity, Chronic low back
pain, fractured hip as child, s/p hysterectomy, s/p
cholecystectomy, s/p appendectomy, s/p back surgery, s/p hernia
repair, s/p right knee athroscopy, s/p d & c
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 10543**] in [**12-28**] weeks
Dr. [**Last Name (STitle) 18323**] in 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2127-8-7**]
|
[
"357.2",
"V12.59",
"530.81",
"414.01",
"584.9",
"725",
"311",
"274.9",
"272.0",
"401.9",
"410.71",
"V58.61",
"300.00",
"276.51",
"599.0",
"244.9",
"427.81",
"427.31",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.53",
"36.15",
"99.04",
"45.13",
"37.21",
"88.56",
"36.11",
"88.72",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
9523, 9620
|
6638, 7322
|
403, 542
|
10178, 10185
|
3418, 6615
|
10927, 11192
|
2588, 2706
|
7897, 9500
|
9641, 10157
|
7348, 7874
|
10209, 10904
|
2721, 3399
|
317, 365
|
570, 1966
|
1988, 2311
|
2327, 2572
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,240
| 143,820
|
29820
|
Discharge summary
|
report
|
Admission Date: [**2179-5-5**] Discharge Date: [**2179-5-13**]
Date of Birth: [**2101-1-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Sternal drainage
Major Surgical or Invasive Procedure:
[**2179-5-5**] - Sternal Derbridement
[**2179-5-7**] - Sternal Plating and Bilateral Pectoralis Flap Closure
History of Present Illness:
The patient is a 78-year-old gentleman who underwent coronary
artery bypass grafting almost 4 weeks ago. He was doing well at
home when it was noted that he had some erythema involving his
wound. He was placed on antibiotics by
his primary cardiologist. He was at home last night and his
wound opened up and pus began draining from the wound. This was
cultured and he was placed on antibiotics. The patient appeared
to be nontoxic with a stable sternum initially. However, upon
inspection this morning on morning rounds, it was noted that his
sternum was unstable. It was felt that he needed to proceed with
sternal debridement.
Past Medical History:
s/p appy
prostate procedure
Ischemic cardiomyopathy
Glaucoma
AF
s/p CABGx5 [**2179-4-8**]
HTN
Hyperlipidemia
Social History:
Retired plumber
Plays hockey 3x week
Currently non-etoh; however previous history of heavy drinking
quit 25 years ago
No drugs
No tobacco
Family History:
Father had MI (died) age 67
Mother died of TB
All children healthy
Physical Exam:
Admission
HR62 SR RR 12 BP 128/58
GEN: elderly male in NAD
HEENT: Unremarkable
NECK: FROM, supple. No carotid bruits.
LUNGS: Clear
HEART: RRR
STERNUM: 1 cm opening with pus draining, Sternum unstable with
cough.
ABD: Benign
EXTR 2+ Pulses, no edema
NEURO: Nonfocal
Discharge
VS T96.3 HR 73SR BP108/60 RR 18 O2sat 100%RA
Gen NAD
Neuro A&O, nonfocal exam
Pulm CTAB
CV RRR S1-S2. Sternum stable
Abdm soft, NT/ND/+BS
Ext warm well perfused. no edema. Left arm PICC line no erythema
Pertinent Results:
[**2179-5-5**] 01:30AM WBC-12.3* RBC-3.53* HGB-10.9* HCT-32.0*
MCV-91 MCH-30.8 MCHC-34.0 RDW-15.2
[**2179-5-5**] 01:30AM GLUCOSE-119* UREA N-22* CREAT-0.9 SODIUM-133
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-27 ANION GAP-14
[**2179-5-5**] 01:30AM PT-13.1 PTT-28.9 INR(PT)-1.1
[**2179-5-7**] ECHO05/03/07 05:04AM BLOOD WBC-13.3* RBC-3.33* Hgb-10.1*
Hct-29.2* MCV-88 MCH-30.2 MCHC-34.4 RDW-15.1 Plt Ct-405
[**2179-5-13**] 05:04AM BLOOD Plt Ct-405
[**2179-5-13**] 05:04AM BLOOD Glucose-91 UreaN-12 Creat-0.8 Na-135
K-3.8 Cl-97 HCO3-30 AnGap-12
[**2179-5-11**] 10:23PM BLOOD ALT-45* AST-46* AlkPhos-118* Amylase-43
TotBili-0.3
[**2179-5-11**] 10:23PM BLOOD Albumin-2.6*
Echo
Conclusions:
No atrial septal defect is seen by 2D or color Doppler. Overall
left
ventricular systolic function appears depressed. There are
complex (>4mm)
atheroma in the aortic arch. There are three aortic valve
leaflets. There is a small (2 x 3 mm) vegetation on the
noncoronary cusp of the aortic valve with trace aortic
regurgitation. There is no aortic ring abscess. The mitral valve
appears structurally normal with trivial mitral regurgitation.
No mass or vegetation is seen on the mitral valve. No
vegetation/mass is seen on the pulmonic valve or tricuspid
valve.
IMPRESSION: Small vegetation on the noncoronary cusp of the
aortic valve,
without associated abscess or fistula seen. Trace aortic
regurgitation.
[**2179-5-10**] CXR
Single upright radiograph of the chest, comparison [**2179-5-5**], demonstrates a right central venous catheter terminating
in the cavoatrial junction. A small right apical pneumothorax is
present. Left chest tube appears to be in unchanged position on
single view. Lungs are clear, and increased opacity at right
lower lung has resolved.
There has been interval placement of flexible plates with
fixation screws overlying the chest wall. Radioopaque catheter
overlying right mediastinum may represent a mediastinal drain.
Significant degenerative change is evident within right shoulder
Brief Hospital Course:
Mr. [**Known lastname 1137**] was admitted to the [**Hospital1 18**] on [**2179-5-5**] for further
management of his sternal wound infection. Vancomycin and
levofloxacin were started. As he had some sternal instability,
he was taken to the operating room where he underwent a
debridement on [**2179-5-5**]. Cultures were sent which revealed Staph
Aureus. His chest was left open with the plan for the plastic
surgery service to close him in the next day or two. They were
consulted intraoperatively and agreed to the plan.
Postoperatively he was taken to the intensive care unit for
monitoring. As the echocardiogram showed a aortic valve
vegetation, the cardiologys service was consulted. Tube feeds
were started for nutritional support. A repeat echocardiogram
showed a small vegetation on the noncoronary cusp of the aortic
valve with trace regurgitation. No associated abscess or fistual
was seen. On [**2179-5-7**], Mr. [**Known lastname 1137**] returned to the operating room
with the plastic surgery service where he underwent a sternal
debridement and closure with sternal plating and bilateral
pectoralis flap coverage. Postoperatively he was returned to the
intensive care unit for monitoring. On postoperative day one,
Mr. [**Known lastname 1137**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. His
cultures ultimately grew out MRSA and vancomycin was continued
and the levofloxacin was stopped. The infectious disease service
was consulted and followed him throughout his hospital course.
The physical therapy service was consulted for assistance with
his postoperative strength and mobility. A swallowing evaluation
was performed by the speech and swallow service as he had some
coughing with oral intake. No signs of aspiration were found and
he was cleared to eat a regular diet. On postoperative day
three, he was transferred to the step down unit for further
recovery. The infectious disease service recommended 6 weeks of
vancomycin. Over the next several days the patient did well and
on POD6 it was decided he was ready for discharge to
rehabilitation at [**Hospital 21892**] Rehab/[**Location (un) 21892**], MA.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks: please take twice a day for 7 days and then
decrease to once daily and follow up with your cardiologist
within 2 weeks.
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
prn as needed for constipation.
9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
12. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours): continue through [**6-14**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 21892**] Healthcare Center
Discharge Diagnosis:
Sternal wound infection/Instability
Bacteremia
s/p CABGx5 [**2179-4-8**]
Ischemic Cardiomyopathy
Atrial Fibrillation
Appy
Glaucoma
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 11493**] in [**2-13**] weeks.
Follow-up with Dr. [**Last Name (STitle) **] in [**2-13**] weeks. [**Telephone/Fax (1) 35783**]
Follow-up with Dr. [**First Name (STitle) **] on [**2179-5-20**] at 3PM. Phone [**Telephone/Fax (1) 1429**]
Call all providers for appointments. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2179-6-14**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] CARDIAC SURGERY LMOB 2A Date/Time:[**2179-5-26**]
2:15
Completed by:[**2179-5-13**]
|
[
"790.7",
"V09.0",
"V10.46",
"998.59",
"V45.81",
"272.4",
"421.0",
"041.11",
"365.9",
"401.9",
"414.8",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"37.49",
"88.72",
"77.61",
"86.74",
"38.93",
"78.51"
] |
icd9pcs
|
[
[
[]
]
] |
8354, 8419
|
4010, 6169
|
316, 427
|
8594, 8603
|
1981, 3987
|
9115, 9743
|
1389, 1457
|
6988, 8331
|
8440, 8573
|
6195, 6965
|
8627, 9092
|
1472, 1962
|
260, 278
|
455, 1085
|
1107, 1217
|
1233, 1373
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,501
| 121,916
|
23040
|
Discharge summary
|
report
|
Admission Date: [**2119-5-26**] Discharge Date: [**2119-6-5**]
Date of Birth: [**2036-7-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
PICC line placement
History of Present Illness:
82f with HTN, DM2, cva from bleeding aneurysm x 2 s/p clipping,
COPD on 2L home o2, and a recent admit at [**Hospital1 112**] for what sounds
like urosepsis presented to the ED with bloating and dyspnea.
After her admit, she's been at [**Hospital1 599**] NH, where for the past few
days she's had worsening dyspnea and has felt bloated. Her
daughter is concerned they weren't keeping up with her
medication regimen, and this is why she became overloaded.
.
In the ED, she required 4L to keep o2 in mid-90's. She was felt
to be significantly overloaded, with plans to admit to the
medical floor for diuresis, but while in the ED, she became
increasingly lethargic, demonstrated poor respiratory effort;
ABG returned 7.13/151, and she was intubated. There was
question of post-intubation seizure activity, but her daughter
(who was with her for the majority of the time and is intimately
familiar with her health history) does not feel that she had a
seizure.
.
She's had some intermittent fevers since her admit to [**Hospital1 112**].
Cough and phlegm for about two weeks. No other major sx,
without c/s, chest pain, abd pain, n/v/d/c, dysuria, hematuria,
rash.
Past Medical History:
-HTN
-DM2
-CVA: bleeding aneurysm x 2, s/p clipping
-CHF: diastolic ([**Hospital1 112**]: ef 75%)
-COPD: FEV1 0.46, 27%; FVC 0.48, 20%
-seizure d/o (further details unknown)
-AS
Social History:
Lives with daughter. Smoked 1ppd x 30-40 years, quit [**2105**].
Family History:
NC
Physical Exam:
per MICU team
97.5, 132/93, 80, 22, 98%
A/C 360/22/8/80%, PIP 30, minute ventl 7.6
Intubated, sedated
Regular
Fair air movement, decreased at bases
Soft abd
1+ leg edema
Responds to nox stimuli; left pupil > right (daughter says has
been so, doesn't see well out of left eye)
Pertinent Results:
[**2119-5-26**] 04:15PM BNP-1835*
.
Admission [**2119-5-26**] CXR:
Cardiomegaly, bilateral pleural effusions, and pulmonary
vascular congestion are consistent with congestive heart
failure. The bony thorax is unremarkable.
IMPRESSION: Findings consistent with congestive heart failure
.
admission ABG: 7.13/151/99
Admit labs:
Glu:114
Lactate:0.7
Trop-T: <0.01
146 100 22
----------------< 115
6.2 47 0.7
K: Hemolysis Falsely Elevates K
CK: 32 MB: Notdone
Ca: 8.4 Mg: 2.5 P: 3.9
Phenytoin: 1.2
.
WBC: 6.6
HCT: 28
PLT: 317
.
PT: 11.7 PTT: 23.8 INR: 1.0
.
Trends:
HCT: 20 on [**5-26**] on [**6-2**] on [**6-5**]
Dispo Lytes:
Gluc 167, BUN 15, Cr 0.9
.
MICRO:
Sputum: MRSA
.
Urine: ESBL E Coli:
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
82 woman with AS, htn, dm2, diastolic chf, cva x 2, seizure d/o,
severe copd here with hypercarbic resp failure in setting of
volume overload. Hosp course by problem:
.
# Hypercarbic respiratory failure: Patient is with known COPD
and chronically elevated bicarb suggestive of CO2 retention,
however acute precipitant of decompensation in the ED not
entirely clear (preintubation gas 7.13/151/53). CXR revealed
volume overload. Sounds as if has been progressively overloaded
and this may have been primary insult, though atypical for
overload to cause a primary hypercarbia. Perhaps overload
caused increased work of breathing and she tired. She was
intubated in the ED and treated in the MICU. Treatment included
abx for PNA, steroids and nebs for COPD, and lasix gtt for dCHF
exacerbation. See below for details. Respiratory status
improved with treatment of COPD exacerbation, fluid overload and
MRSA pneumonia. She was extubated on [**5-31**] without issue and
transferred to floor in stable condition on [**6-1**].
.
# MRSA pneumonia: Growing MRSA from sputum culture. Treated with
8 day course of vancomycin. This was completed prior to
discharge. No infiltrate grew on CXR so not entirely clear that
this was primary issue.
.
# COPD exacerbation. Chronic C02 retention. Baseline CO2 around
80. Treated with prednisone taper, nebs, home inhalers with
improvement. On room air at time of discharge. Please continue
atrovent, albuterol, and steroid taper as per med list.
.
# Congestive heart failure: Diastolic etiology. Treated with
lasix gtt followed by boluses for preload reduction. Discharged
on lasix 20mg PO daily. ON ACE-I for afterload reduction and
betablocker. Euvolemic at time of d/c. Please recheck lytes in
[**2-15**] days and adjust ACE-i and lasix as needed.
.
# Anemia: Normocytic with normal RDW. Baseline low 30's at [**Hospital1 112**].
Stable but profoundly below baseline. Brown, guaiac + stools.
EGD/[**Last Name (un) **] [**2114**] at [**Hospital1 112**] showed non-errosive gastritis with negative
antral biopsy, colonic polyp: hyperplastic adenoma. Treated with
IV PPI [**Hospital1 **] initially. HCT nadir at 20 so received 1u in MICU.
HCT stable therafter. We gave an additional 2u on day prior to
discharge and her hct was 31. Switched to PO PPI daily, iron
supplements and will likely need outpatient colonoscopy.
Consider repeat HCT in [**2-15**] days to ensure stability.
.
# Decreased mental status: In part hypercarbia and in part
phenoytoin load and lorazepam in ED. Improving with decreased
sedating meds. Likely component of delirium as well given
infection and hospital stay. Delirium improved and patient was
without sitter for >24h prior to d/c.
.
# ? seizure activity: Possible seizure after intubation.
Unclear if actually was a seizure. She has some seizure history
per [**Hospital1 112**] records but unclear details, may have been placed on
phenytoin for prophylaxis given prior intracerebral hemorrhage.
Level on arrival low but s/p load in ED. No clear seizure
activity during her stay. Treated with phenytoin per home dose.
.
# UTI: ESBL E. coli. Initially treated with bactrim but ESBL.
Patient's foley removed and repeat UA/urine culture checked.
Pending upon discharge. Completed 3 day course of bactrim. Not
clear that she had a UTI. Instead may just be colonized with
ESBL.
.
# Lung nodule: Per [**2119-5-29**] CXR read: "Left mid lung nodule,
which remains indeterminate, however, may contain calcified
component. Repeat chest radiograph recommended in three months
for further evaluation."
- will need repeat imaging to follow as outpatient.
.
# Diabetes melitus, type 2: BG moderately controlled with RISS,
uses NPH at home: 6u qam, 12u qpm; Started back on home reigmen
adn couvered with sliding scale.
.
# Hypernatremia: Improved with 500cc D5W. Sodium subsequently
normalized.
.
# Access: PICC placed and remained at discharge. Since abx
finished, we pulled PICC prior to transport.
.
# Full code.
.
# Communication: Daughter [**Name (NI) 59413**] [**Name2 (NI) **] [**Telephone/Fax (3) 59414**]
.
# OUTPATIENT FOLLOW UP APPT: [**6-29**] @ 10am, [**Hospital1 112**] Center for
Chest Diseases, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6754**]
Medications on Admission:
-Metoprolol XL 100mg daily
-CA/VitD 600/200
-Omeprazole 20mg daily
-Phenytoin 100mg tid
-Pravastatin 40mg daily
-Salmeterol 50mcg daily
-Tiotropium 18mcg daily
-Trazadone 25mg daily
-Fe 325mg daily
-Ipratropium 4x/day
-Lisinopril 10mg daily
-Metformin 500mg [**Hospital1 **]
-NPH 6 units AM, 12 units PM
-RISS
-lidoderm patch R knee
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO TID (3
times a day).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAILY (): Please take
off for 12 hours each day.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime): hold for bowel movement.
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
2 days: Give dose on Monday [**6-5**] and Tuesday [**6-6**].
18. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as
directed Subcutaneous twice a day: Give 6 units qAM and 12
units qPM.
19. Insulin sliding scale
Please see attached sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
COPD exacerbation
MRSA Pneumonia
Diastolic Heart failure
Iron deficiency anemia
Secondary:
Diabetes Mellitus Type II
Discharge Condition:
VSS, O2 sat 90% on 2L, comfortable
Discharge Instructions:
You were admitted to the hospital with respiratory distress. You
were treated for a pneumonia, fluid overload and a COPD
exacerbation.
You finished a course of antibiotics.
We started a new medication called lasix to minimize excess
fluid. Please take this medication as directed.
.
Please contact your doctor or return to the emergency room if
you develop any worrisome symptoms such as fevers, chills,
shortness of breath, chest pain.
Followup Instructions:
Lung nodule: Per [**2119-5-29**] CXR read: 'Left mid lung nodule, which
remains indeterminate, however, may contain calcified component.
Repeat chest radiograph recommended in three months for further
evaluation.'
- will need repeat imaging to follow
.
Iron deficiency anemia with guaiac positive stool
- will need outpatient colonoscopy
.
F/u with PCP [**Last Name (NamePattern4) **] [**12-14**] weeks
|
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"276.3",
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"491.21",
"428.0",
"V12.72",
"041.4",
"518.89",
"276.2",
"518.81",
"780.39",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9919, 9991
|
3356, 5794
|
321, 354
|
10161, 10198
|
2166, 3333
|
10684, 11091
|
1850, 1854
|
7994, 9896
|
10012, 10140
|
7636, 7971
|
10222, 10661
|
1869, 2147
|
274, 283
|
382, 1550
|
5809, 7610
|
1572, 1752
|
1768, 1834
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,206
| 195,693
|
53008
|
Discharge summary
|
report
|
Admission Date: [**2201-6-3**] Discharge Date: [**2201-6-22**]
Date of Birth: [**2135-5-28**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
lethargy, nausea/vomiting, abdominal pain
Major Surgical or Invasive Procedure:
1. intubation x2
2. exploratory laparotomy
3. placement of R internal jugular venous catheter
4. placement of femoral line
5. placement of PICC line
History of Present Illness:
Pt was brought to the ED with mental status changes/lethargy,
nausea/vomiting, and abdominal pain. He was unable to give much
of a history given his mental status. He had been vomiting and
unable to keep food down for the past several days, but cannot
give more specific details.
In the ED, he was found to have a BP of 50/40, with a lactate of
8.1, with guaiac positive stool and acute renal failure
(baseline Cr 0.4, Cr on admission 3.9). In addition, his WBC
count was 12.9. The MUST protocol was initiated, and pt was
intubated. As there was concern for intraabdominal infection as
source of sepsis, pt was taken for an exploratory laparotomy.
Past Medical History:
1. pituitary tumor, now panhypopit
2. seizure disorder
3. hypothyroidism
4. GERD
5. hypercholesterolemia
6. legally blind
Social History:
He is single, smokes 1.5 to 2ppd, and abstains, after previous
problems with alcoholism 11 years ago. He is a housing manager.
Family History:
F died of CVA
M - TB
Physical Exam:
Initial PE:
PE on transfer to floor:
VS: Tm 98.7 Tc 97.3 155/69 69 18 95% 3L NC
Gen: appears stated age, somewhat hoarse voice, NAD, appears
fatigued
HEENT: PERRL, EOMI, MMM, OP clear
Neck: no cervical LAD
Pulm: mainly clear bilaterally, good air movement, trace
bibasilar crackles, dullness to percussion at R base
CV: RRR, nl S1/S2, no murmurs
Abd: soft, NT/ND, +BS, no masses; midline wound with staples -
minimally tender at superior edge; wound intact without drainage
Ext: 2+ distal pulses, trace edema
Pertinent Results:
Admission labs:
CBC: WBC-12.9*# RBC-5.84# HGB-16.5# HCT-50.5# MCV-87 MCH-28.3
MCHC-32.8 RDW-14.3
NEUTS-80.6* BANDS-0 LYMPHS-15.0* MONOS-3.5 EOS-0.7 BASOS-0.2
PLT SMR-NORMAL PLT COUNT-169
coags: PT-15.9* PTT-35.3* INR(PT)-1.6
electrolytes: GLUCOSE-117* UREA N-21* CREAT-3.9*# SODIUM-147*
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-20* ANION GAP-25*
ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-5.2*# MAGNESIUM-1.7
[**2201-6-3**] 10:09AM LACTATE-8.1*
[**2201-6-3**] 12:11PM LACTATE-3.1*
[**2201-6-3**] 02:55PM LACTATE-2.0
CT abdomen/pelvis [**6-3**]:
IMPRESSION: 1) No evidence of an acute pathologic process in the
abdomen or pelvis on extremely limited examination without oral
or intravenous contrast. Evaluation of the bowel for ischemia or
other pathologic process is particularly limited.
2) Dilatation of the proximal small bowel with normal-caliber
distal small bowel and colon. This appearance is nonspecific but
may be seen in early ileus.
3) Ectatic infrarenal aorta with maximal AP diameter of 2.5 cm.
4) Diverticulosis.
5) Probable left renal cyst. If there are no outside prior
studies to document stability, further evaluation may be
performed by ultrasound.
echo [**6-4**]:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). The right ventricular
cavity is mildly dilated. Right ventricular systolic function is
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
[**2201-6-10**] CXR: Worsening bibasilar atelectasis/consolidation and
right pleural effusion.
[**2201-6-11**] CXR: IMPRESSION: NG tube terminating in right upper
quadrant. Increasing opacity in the left lower lobe, which may
represent atelectasis, however, pneumonia cannot be totally
excluded.
[**2201-6-15**] CXR: Bibasilar pulmonary opacities, which could be
secondary to effusion or atelectasis. Stable appearance of mild
prominence of the central pulmonary vasculature.
Labs on transfer to floor:
CBC: WBC-7.5 RBC-3.78* Hgb-10.6* Hct-30.3* MCV-80* MCH-28.1
MCHC-35.0 RDW-14.0 Plt Ct-274
electrolytes: Glucose-96 UreaN-4* Creat-0.4* Na-128* K-4.1
Cl-94* HCO3-31* AnGap-7* Calcium-8.1* Phos-2.5* Mg-1.7
Micro data:
multiple blood/urine cultures negative
sputum cultures: [**6-6**] 1+ GPCs in pairs/clusters on gram stain
[**6-12**], [**6-13**] c/w contamination
[**6-14**]: MRSA in sputum
Brief Hospital Course:
Note: Hospital course written by floor resident, with
information gleaned from chart regarding SICU and MICU stay but
without the benefit of input from caretakers from these units.
1. sepsis - Pt initially presented with fatigue/mental status
changes, hypotension, acidosis, acute renal failure, and a
lactate of 8.1. In the ED, the MUST protocol was initiated, and
the pt was intubated and transiently placed on levophed.
Lactate decreased over 4 hours to 2. Broad spectrum antibiotics
were given - levo/flagyl/vanco. Concern was for peritonitis,
and pt was emergently taken to OR on [**6-3**] for an exploratory
laparotomy. No source of peritonitis was found; there was some
purulent peritoneal fluid, which did not grow any
microorganisms, and dusky-appearing, but viable, bowel; the
duskiness was thought to be due to hypoperfusion in setting of
sepsis. Pt was taken to the SICU and followed. He was
extubated on [**6-4**], then reintubated on [**6-5**] due to mental status
decline and hypoxia, as below. He was transferred to the MICU.
For the remainder of pt's hospitalization, he was
hemodynamically stable and did not display further septic
physiology.
2. respiratory failure - Extubation was attempted a couple of
times, which failed. Sputum cultures were unrevealing. Pt
continued a course of vanc/levo/flagyl, and then
vanc/ceftaz/flagyl. Vanco was ultimately continued for 17 days,
levo for about 10 days, and flagyl for about 12 days.
Ceftazidime was on board for 5 days. Pt was noted to have RLL
collapse on CXR, and areas of consolidation vs atelectasis on
CXR. However, no microorganisms were isolated in sputum (save
for MRSA, 2+ on [**6-14**] sputum, thought perhaps to be a colonizer).
Concern for increased secretions prompted consideration of trach
placement, but pt was able to be extubated successfully. He was
given an incentive spirometer, and pt was placed on nebs. Since
extubation, pt has been doing quite well from a respiratory
standpoint, sats in 96-97% on room air.
3. hyponatremia - Pt was noted to develop hyponatremic around
[**2201-6-12**]. Initially it was thought that he was hypovolemic, but
with fluids, sodium did not correct. Endocrine was consulted,
particularly as pt has h/o panhypopituitarism. Urine and serum
osms were sent, the results of which were consistent with SIADH.
Pt was free water restricted, and sodium was monitored. His
mental status remained stable after transfer to the floor. On
discharge, his sodium had improved to 129. Pt should continue
on fluid restriction to 1L while he is at rehab.
4. seizure disorder - Pt was placed on IV dilantin starting on
[**6-18**]. This was switched to po dilantin. Levels were checked
and were found to be low. However, steady state takes about
7-10 days to reach; therefore, pt is currently on 100mg po tid,
and levels should be checked again on [**6-25**] to determine whether
an increased dose is needed (goal level: [**11-26**]). He will
continue on Dilantin 100 mg PO TID.
5. anemia - Pt's Hct remained stable without evidence of GI
bleed or other source of bleed. Workup revealed that this was
most consistent with anemia of chronic disease. Hct was
monitored, and remained stable.
6. panhypopituitarism - pt was maintained on low dose
prednisone, per outpatient regimen, of 5mg po bid. Also was
continued on synthroid. Of note, TSH has been <0.02, but this
was checked in the setting of acute illness. Pt had repeat TSH
checked just prior to discharge but this was still pending; this
level will need to be followed up while pt is at rehab.
7. acute renal failure - Pt's Cr on admission was 3.9. His
baseline is 0.5. Creatinine trended towards normal with IVF.
ARF thought most likely to be due to prerenal azotemia in the
setting of shock and hypoperfusion, and it corrected easily with
IVF.
8. s/p exploratory laparatomy - as mentioned in HPI, pt had ex
lap for concern of intraabdominal infection which was
unrevealing except for some evidence of small bowel ischemia
which was thought to be in the context of hypoperfusion due to
sepsis. Pt has had no further abdominal symptoms. His staples
were removed just prior to discharge. He will follow-up with
surgery Dr. [**Last Name (STitle) **] in 2 weeks.
Medications on Admission:
lipitor
protonix
ranitidine
prednisone
fexofenadine
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day) as needed for thrush.
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): may discontinue if pt
walking consistently.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed.
4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
1. septic shock
2. acute renal failure, due to prerenal azotemia
3. respiratory failure
4. syndrome of inappropriate antidiuretic hormone
5. panhypopituitarism
6. seizure disorder
Discharge Condition:
stable, tolerating po
Discharge Instructions:
Please tell the staff if you experience chest pain, shortness of
breath, abdominal pain, or any other concerning symptom.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Where: LM [**Hospital Unit Name 40**] (ENT) Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2201-7-8**] 10:30
Please call ([**Telephone/Fax (1) 8417**] to make an appointment with Dr.
[**Last Name (STitle) 1266**].
Follow-up with surgery for post-op check:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: LM [**Hospital Unit Name 3665**]
ASSOCIATES Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2201-7-7**] 3:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
Completed by:[**2201-6-22**]
|
[
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"567.2",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"00.17",
"54.11",
"96.71",
"96.04",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10067, 10137
|
4699, 8963
|
327, 482
|
10367, 10390
|
2055, 2055
|
10560, 11276
|
1477, 1499
|
9065, 10044
|
10158, 10346
|
8989, 9042
|
10414, 10537
|
1514, 2036
|
246, 289
|
510, 1165
|
2072, 4676
|
1187, 1316
|
1332, 1461
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,888
| 199,641
|
22600
|
Discharge summary
|
report
|
Admission Date: [**2104-7-6**] Discharge Date: [**2104-7-12**]
Date of Birth: [**2026-2-19**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
fever, nausea, vomiting
Major Surgical or Invasive Procedure:
ERCP [**2104-7-5**]
ERCP [**2104-7-6**]
gatroduodenal artery embolization [**2104-7-7**]
History of Present Illness:
78 year old woman with a history of HTN, hypercholesterolemia
presented as transfer from [**Hospital3 3583**] for acute
cholangitis. She initially presented on [**2104-7-5**] to [**Hospital1 3325**] bilious vomiting, fevers, and malaise for two days
where a RUQ ultrasound revealed cholelithiasis, CBD=10mm, and
blood cultures were positive for Klebsiella. She was
transferred to [**Hospital1 18**] where she underwent an ERCP that day which
revealed CBD dilitation, acute suppurative cholangitis, and
multiple gallstones which were removed. Also, a sphincerotomy
was performed with subsequent bleeding at sphincter site
requiring epinephrine injections x3. On [**2104-7-6**] she had
continued n/v, and noticed melena and syncope x2. She
represented to [**Hospital3 3583**] and was again transferred to
[**Hospital1 18**] and underwent a repeat ERCP [**2104-7-6**] which revealed further
sphincter bleeding requiring epinephrine x6, also noted was a
non-bleeding gastric ulcer. Post-procedure she continued to
have hematochezia and dropping HCT and emergently had a
gastroduodenal artery embolization [**2104-7-7**] with resultant
stablization of her HCT. She was admitted to the ICU for close
monitoring, and the following day was transferred to the
medicine service. On transfer she feels well, denies n/v/f/c,
and notes continued hematochezia.
Past Medical History:
1. Hypertension - controlled on Timolol
2. Hypercholesterolemia - controlled on Lipitor
3. Cholelithiasis
4. Diverticulitis
5. s/p ruptured appy
Social History:
The patient is a non-smoker, lives with her husband, and has two
grown daughters in the area. She has approximately four glasses
of wine per week, denies IVDU.
Family History:
non-contributory
Physical Exam:
Vitals on transfer: T 98.1 BP 132/68 P112 RR12 98%3L I/O:
1590/2070
Gen: pleasant, conversant, NAD
HEENT: EOMI, PERRL, OP clear, MMM
Neck: supple, no LAD
CV: tachy, regular
Lungs: decreased air movement at bases bilaterally, ?crackles at
left base
Abd: soft, NT/ND, +bs
Ext: w/wp, 2+ DP pulses, strength 5/5, sensation grossly intact
to light touch
Neuro: AOx3, CN 2-12 grossly intact, gait not tested
Pertinent Results:
CBC:
[**2104-7-6**] 11:45PM WBC-15.8*# RBC-3.02* HGB-9.1* HCT-26.2*
MCV-87 MCH-30.3 MCHC-34.8 RDW-14.0
[**2104-7-8**] 01:51PM BLOOD Hct-26.2* (transfused 2 units with
appropriate response)
[**2104-7-9**] 12:50AM BLOOD Hct-33.0*#
[**2104-7-9**] 05:37AM BLOOD WBC-13.4* RBC-3.93* Hgb-12.0 Hct-33.1*
MCV-84 MCH-30.7 MCHC-36.4* RDW-13.9 Plt Ct-120*
[**2104-7-9**] 11:06AM BLOOD Hct-33.9*
[**2104-7-11**] 04:58AM BLOOD WBC-10.2 RBC-3.83* Hgb-11.7* Hct-33.1*
MCV-86 MCH-30.5 MCHC-35.3* RDW-14.0 Plt Ct-233
LFTs:
[**2104-7-6**] 08:09PM ALT(SGPT)-37 AST(SGOT)-40 LD(LDH)-173 ALK
PHOS-224* AMYLASE-1588* TOT BILI-4.7*
[**2104-7-6**] 08:09PM LIPASE-5034*
[**2104-7-7**] 03:35AM BLOOD ALT-26 AST-29 AlkPhos-170* Amylase-770*
TotBili-2.3*
[**2104-7-9**] 05:37AM BLOOD ALT-20 AST-30 LD(LDH)-161 AlkPhos-121*
TotBili-1.5
[**2104-7-10**] 06:15AM BLOOD ALT-18 AST-26 LD(LDH)-173 AlkPhos-120*
Amylase-102* TotBili-1.4
[**2104-7-11**] 04:58AM BLOOD ALT-18 AST-26 AlkPhos-125* TotBili-1.1
[**2104-7-10**] 06:15AM BLOOD Lipase-199*
Coags:
[**2104-7-6**] 08:09PM PT-13.6 PTT-25.4 INR(PT)-1.2
TFTs:
[**2104-7-10**] 09:04PM BLOOD TSH-4.4*
[**2104-7-10**] 09:04PM BLOOD Free T4-1.3
ERCP ([**7-6**]):
Impressions: Active bleeding from the sphincterotomy site.
Hemostasis was achieved with local epinephrine injection.
Ulcer in the stomach body without evidence of hemorrhage.
Diverticulum in the near the area of the papilla.
Blood in the whole duodenum
Otherwise normal limited EGD to the third part of the duodenum.
IR Embolization ([**7-7**]):
IMPRESSION: No site of active bleeding was detected with
selective catheterization of the celiac trunk and SMA.
Prophylactic embolization of the GDA was performed with Gelfoam.
U/A ([**7-11**]):
[**2104-7-11**] 08:53AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2104-7-11**] 08:53AM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2104-7-11**] 08:53AM URINE RBC-89* WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
UCx ([**7-11**]): no growth
Brief Hospital Course:
1) GI Bleed - The patient was initially medflighted to the [**Hospital1 18**]
the day after ERCP/sphincterotomy with a hematocrit of 30.9 up
from 28.8 after two units of PRBCs, clots on NG lavage and a
hypotensive episode on arrival (90/palp). She was, in total
given 6 units of PRBCs at [**Hospital1 18**] but continued to have GI
bleeding. She underwent another ERCP with a second attempt to
contol bleeding with 6 epinephrine injections, and subsequently
underwent a gastroduodenal artery embolization. After this
procedure her hematocrit stabilized and remained approximately
33 for the rest of her hospitalization. On transfer to the
floor, she continued to get HCT check [**Hospital1 **] all of which were
stable, and her stool continued to test + for occult blood, but
the BRBPR had ceased. She required no further transfusions, and
had a stable HCT for >48 hours on discharge.
2) Tachycardia - On transfer to floor the patient was
tachycardic between 110s-120s. An EKG was done ([**7-9**]) which
showed sinus tachycardia. Initially thought to be due to
intravascular volume depletion vs. infection/cytokine release.
She was bolused 500cc NS several times over that night without
heart rate response. TFTs were sent to r/o hyperthyroidism and
showed mildly elevated TSH at 4.4 but normal free T4. The
following day, she mentioned that she is normally on Timolol at
home. Her tachycardia and slightly elevated BP could have been
[**12-24**] stopping Tomolol during hospitalization. Therefore,
metoprolol 12.5mg [**Hospital1 **] was started (timolol is non formulary) and
was increased to 25bid the following day. Her heart rate and
blood pressure responded well to this. She also underwent an
ECHO [**7-11**] to evaluate LV function and RV strain and it showed an
EF >55% and normal [**Doctor Last Name 1754**], with mild TR and AR. She was
discharged home with instructions to continue the Metoprolol 25
[**Hospital1 **] and to stop her timolol until she followed up with her
primary physician.
3) Infection - The patient was admitted w/h/o acute suppurative
cholangitis and klebsiella bacteremia at [**Hospital3 3583**]. She
had been placed on a 10 day course of amp/levo/flagyl (started
[**7-6**]). On [**7-10**], her dose of flagyl was increased to 500mg from
250mg. She had been afebrile since transfer to the floor, but
on [**7-11**] she ran a low grade temperature (99s). U/A and UCx were
sent and her foley was dc'd. The U/A was negative and the UCx
was negative on discharge. The patient also has mental status
changes that day, and her mental status was assessed serial by
exam and she had no focal neurological findings. That day the
sensitivities of the klebsiella were obtained from [**Hospital1 3325**]; the organism was sensitive to all antibiotics tested
EXCEPT for ampicillin. Therefore the ampicillin and flagyl were
discontinued and Levofloxacin (which the organism was sensitive
to) was continued. The patient was discharged at her baseline
mental status.
4) Increased oxygen requirement - On transfer to the floor the
patient was on 3L NC of oxygen. Her CXRs ([**7-7**] and [**7-10**]) did
not show signs of CHF or PNA and she was weaned off oxygen
without difficulty. Incentive spirometry was encouraged.
5) Gastric ulcer - The patient was maintained on a proton pump
inhibitor during her hospitalization.
6) FEN - The patient was kept NPO and hydrated with IVF while in
the intensive care unit. Her diet was advanced slowly and she
was tolerating an oral diet on discharge. Her LFTs and
amylase/lipase trended down. Her elecrolytes K, Mg, Phos were
repleted as needed.
7) Prophylaxis - The patient was kept on a ppi and pneumoboots
while hospitalized. SQ heparin was not given since the patient
had had a bleed. She was ambulatory with assist. PT evaluated
her, and felt that there was no acute need for PT.
8) Dispo - The patient will follow-up with Dr. [**Last Name (STitle) 58604**] for
elective cholecystectomy. Follow-up with Dr. [**Last Name (STitle) **] as needed.
Medications on Admission:
Lipitor 10mg daily
Sulindac
Klorkon
Metolaz
Timolol
MVI
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Suppurative cholangitis s/p ERCP, sphincterotomy
2) GI bleed s/p epinephrine injections and s/p gastroduodenal
artery embolism
3) Hypertension
4) Mental status changes
Discharge Condition:
Stable, tolerating an oral diet, ambulatory, alert and oriented
x3.
Discharge Instructions:
Please take your full course of antibiotics. Please do NOT
resume your Timolol and instead take the Metoprolol twice a day.
Resume your other medications. Please call your physician or
return to the emergency department if you notice and fevers,
chills, nausea, vomiting, blood in your stool, worsening
confusion, abdominal pain, or any other symptoms concerning to
you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] within one week of discharge
([**Telephone/Fax (1) 58605**]).
Please follow-up with Dr. [**Last Name (STitle) 58604**] or another general surgeon
to have your gallbladder removed.
|
[
"272.0",
"E878.8",
"531.90",
"401.9",
"276.5",
"790.7",
"576.1",
"998.11",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"99.04",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
9270, 9276
|
4701, 8742
|
333, 423
|
9491, 9560
|
2629, 4678
|
9982, 10217
|
2169, 2187
|
8848, 9247
|
9297, 9470
|
8768, 8825
|
9584, 9959
|
2202, 2610
|
270, 295
|
451, 1807
|
1829, 1975
|
1991, 2153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,189
| 102,766
|
51822
|
Discharge summary
|
report
|
Admission Date: [**2205-4-30**] Discharge Date: [**2205-5-16**]
Date of Birth: [**2158-6-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
elective admit for gyn procedure, transfered for acute renal
failure from gyn service, volume assessment
Major Surgical or Invasive Procedure:
- elective operative ablation of vulvar and anal dysplastic
lesions on [**4-30**]
- continuous renal replacement therapy
- paracentesis
History of Present Illness:
46 year old woman with CVID, h/o lymphoma s/p CHOP,
granulomatous hepatitis with portal hypertension, primary
pulmonary hypertension and
refractory HPV related vulvo-/anal disease admitted to the
hospital for elective operative ablation of vulvar and anal
dysplastic lesions on [**4-30**]. She maintained a baseline Creatinine
baseline in the range of 0.7-1.1 until very recently.
.
Her postoperative Creatinine was noted to be increased to 2.2
and
peaked at 3.5 on [**5-2**]. Her potassium levels have also
intermittently increased to 6.0, but are currently down after
Kayexalate.
.
The Surgery itself was uncomplicated and was conducted under
general anesthesia. She remained hemodynamically stable and
other than a single blood pressure drop to 70's systolic and few
readings in the 90's systolic, there were no major hypotensive
events. She received about 300 ml LR and no colloids or blood
products. The EBL was 3 ml. She received e-Aminocaproic acid
before the case as a prophylaxis for her bleeding disorder,
while her Lasix, Spironolactone and Nadolol were held.
.
She has been transfered to the West ICU team due to concern of
renal failure and difficult to monitor fluid status in the
setting of pulmonary HTN. On day of transfer she had a
therapeutic paracentesis of 1L. She received 200cc of 25%
albumin.
.
On [**5-2**], UOP was 20-45 cc/hr, on 1-2L oxygen, BPs 90-106/60-76.
This morning, UOP was 0-40 cc/hr for 233 UOP in 11 hours. She
has had 30 cc/2hr of UOP after arival on the floor.
.
Patient states she states that she had one problem with renal
failure in the past but it resolved on its own (in the setting
of pneumonia). She denied CP but reports some mild dyspnea which
had been worsening since her surgery on [**4-30**]. She stated that her
abdomen was much distended from baseline but better than it was
before the paracentesis the morning of MICU transfer.
Past Medical History:
Past Medical History (per ID note):
1. Common variable immunodeficiency complicated by:
-E. coli bacteremia [**11-1**] treated with 3 days IV cefepime
switched to oral cipro for 14-day course, presumed source was GI
-recurrent CMV disease (adenopathy, [**Month/Year (2) 15482**] suppression, colitis)
requiring IV foscarnet, now on valganciclovir suppression
-HPV related vulvo-anal and vocal cord disease s/p laser
fulguration
-[**Doctor First Name **] adenitis and recurrence with [**Doctor First Name **] enteritis on
[**Doctor First Name 107290**] for secondary PPX due to intolerance/failure of
azithromycin
-granulomatous hepatitis with cholangitic overlay presumed to
be from CVID, and clinical cirrhosis
-pulmonary disease with some fibrosis s/p wedge resection [**6-25**]
with chronic interstitial pneumonitis with mild-moderate
inflammatory component interstitial fibrosis, patchy acute
organizing pneumonitis
-intermittent recurrent diarrhea
2. Bleeding disorder - possible PAI-1 deficiency
3. S/p splenectomy for symptomatic hypersplenism and refractory
ITP; incidentally found large B cell lymphoma with splenectomy
-s/p 6 cycles of CHOP [**10-27**] - [**2-26**]
4. Chronic LE lymphedema
5. Bilateral arthropathy
Past Surgical history:
1. hysterectomy [**3-/2198**] for intractable HPV cervical disease
2. Splenectomy [**9-/2198**] for ITP
3. Multiple colposcopies/laser cervical operations and partial
vulvectomy
4. Exploratory laparotomy for small bowel obstruction on [**12-3**]
[**2202**]
Social History:
Married and living with husband. Previously employed as a
paralegal, but now on disability secondary to multiple medical
conditions. Has VNA assistance for medication management. Denies
tobacco or alcohol.
Family History:
Common variable immune deficiency in twin sister who passed from
metastatic anal carcinoma and in older brother. [**Name (NI) **] brother
is healthy without immunodeficiecny. [**Name (NI) 1094**] mother died of
lymphoma at 52 and had similar symptoms, but was never diagnosed
with CVID. Father with hypertension.
Physical Exam:
Admission Exam:
Vitals: 97.7 67 105/66 24 94/3L 60.1 kg
General: Alert, oriented, no acute distress, breathing
comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to mandible
Lungs: Clear to auscultation except for decreased at lung bases
R>L
CV: Regular rate and rhythm, normal S1 + S2, occassional S3, no
murmurs, rubs, gallops
Abdomen: + ascites, not tense, nontender, +BS
GU: foley in place
Ext: warm, well perfused, 2+ pulses,+ clubbing, blue tinge of
hands and feet b/l
Pertinent Results:
[**2205-5-7**] 02:37AM BLOOD WBC-7.3 RBC-4.03* Hgb-11.6* Hct-36.0
MCV-89 MCH-28.8 MCHC-32.2 RDW-19.7* Plt Ct-126*
[**2205-5-7**] 02:37AM BLOOD Plt Ct-126*
[**2205-5-7**] 02:37AM BLOOD Glucose-106* UreaN-17 Creat-0.8 Na-136
K-3.6 Cl-97 HCO3-26 AnGap-17
[**2205-5-6**] 02:01AM BLOOD ALT-27 AST-58* LD(LDH)-251* AlkPhos-218*
TotBili-1.5
[**2205-5-7**] 02:37AM BLOOD Calcium-10.9* Phos-2.3* Mg-1.7
[**2205-5-7**] 02:55AM BLOOD Type-ART pO2-103 pCO2-34* pH-7.51*
calTCO2-28 Base XS-4
[**2205-5-7**] 02:55AM BLOOD Glucose-101 K-3.4*
[**2205-5-7**] 02:55AM BLOOD O2 Sat-97
.
Micro:
[**2205-5-4**] 12:01 am BLOOD CULTURE Source: Line-tlc.
Blood Culture, Routine (Preliminary):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2205-5-4**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 83961**]).
.
[**2205-5-11**] 1:53 pm Immunology (CMV) Source: Line-VIP HD line
.
**FINAL REPORT [**2205-5-14**]**
CMV Viral Load (Final [**2205-5-14**]):
CMV DNA not detected.
.
[**2205-5-11**] 5:29 pm URINE Source: CVS.
**FINAL REPORT [**2205-5-14**]**
URINE CULTURE (Final [**2205-5-14**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 324-5996F
[**2205-5-10**].
This was not treated b/c concern this was likely contaminant and
pt not having symptoms.
.
Imaging:
CHEST (PA & LAT) Study Date of [**2205-5-13**] 8:42 PM
FINDINGS: In comparison with study of [**5-4**], the monitoring and
support
devices have been removed. Blunting of the left costophrenic
angle
posteriorly could reflect pleural effusion or pleural scarring.
Low lung
volumes most likely account for the prominence of the transverse
diameter of the heart. No acute focal pneumonia or vascular
congestion.
.
MRI of head limited study -52 REDUCED SERVICES Study Date of
[**2205-5-11**] 5:51 PM
FINDINGS: This is a non-diagnostic and incomplete examination,
the axial
images demonstrate significant motion, however high-signal
intensity is
visualized in both basal ganglia, suggesting changes due to
hepatic
encephalopathy. A trace of high signal intensity is demonstrated
on FLAIR on the right insular region (image 12, 13, 14, series
#7), suggesting possible proteinaceous material versus
subarachnoid hemorrhage, please consider repeat examination
under conscious sedation. Bilateral opacities are demonstrated
in the maxillary sinuses and left mastoid air cells.
IMPRESSION: Non-diagnostic examination due to patient motion.
Questionable high signal intensity demonstrated on the right
insular region, suggesting proteinaceous material versus
subarachnoid hemorrhage. High-signal intensity visualized in the
basal ganglia, these type of findings have been described in
patients with hepatic encephalopathy.
.
CT HEAD W/O CONTRAST Study Date of [**2205-5-10**] 5:30 PM
There is no intracranial hemorrhage, and no parenchymal edema or
mass effect. The [**Doctor Last Name 352**] and white matter are normal in
attenuation, without evidence of territorial infarct on CT.
There are no abnormal extra-axial fluid collections. There is no
shift of midline structures, and the basal cisterns remain
patent. Ventricles and sulci are normal in size and
configuration. There are no lytic or sclerotic osseous lesions
identified concerning for malignancy. There is partial
opacification of the mastoid air cells, without osseous
destruction. There is complete opacification of the visualized
left and right maxillary sinuses. The sphenoid sinuses and
ethmoid air cells are clear. The frontal sinuses are
underpneumatized.
IMPRESSION:
1. No hemorrhage, edema, mass effect, or other acute
intracranial process.
2. Complete opacification of the right and left maxillary
sinuses, progressed from [**2203-11-25**]. Clinically correlate to
exclude acute sinusitis.
3. Partial left and right mastoid air cell opacification.
CXR [**5-3**]
FINDINGS: In comparison with study of [**4-15**], there is continued
enlargement of
the cardiac silhouette. Prominence of interstitial markings is
consistent
with elevated pulmonary venous pressure and renal failure. More
coalescent
area of opacification at the right base medially could represent
a supervening
pneumonia in the appropriate clinical setting. Patchy area of
opacification
in the left mid zone could also represent atelectasis or
possible supervening
pneumonia.
.
US abd [**5-3**]
of note, discussed with rads and no evidence for hepatic vein
obstruction.
FINDINGS: The liver demonstrates coarsened heterogeneous
echotexture,
consistent with known cirrhosis. The main portal vein is patent
with
hepatopetal flow; of note, evaluation is slightly suboptimal
given patient's
difficulty holding breath. The gallbladder wall is edematous,
likely
secondary to third spacing. There is a large amount of ascites.
The pancreas
is not well seen due to overlying bowel gas. The common duct is
not dilated.
IMPRESSION:
1. Coarse heterogeneous hepatic echotexture, consistent with
known cirrhosis.
2. Gallbladder wall edema likely secondary to third spacing.
3. Ascites. At the time of the study paracentesis is scheduled.
.
[**5-3**] LE U/S right
FINDINGS: The right common femoral, superficial femoral, and
popliteal veins
demonstrate normal flow and compressibility. The right
superficial femoral
and popliteal veins demonstrate normal augmentation. The right
peroneal and
posterior tibial veins demonstrate normal flow.
IMPRESSION: No evidence for DVT.
.
[**5-2**] TTE
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is markedly
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets fail to fully coapt. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension.
IMPRESSION: At least moderate (and probably severe) pulmonary
hypertension with right ventricular dilation, systolic
dysfunction and pressure/volume overload. Moderate to severe
functional tricuspid regurgitation. Normal global and regional
left ventricular systolic function.
.
Renal U/S [**5-1**]
FINDINGS: The right kidney measures 10.1 cm. The left kidney
measures 11.9
cm. Neither kidney demonstrates hydronephrosis, stones, or large
masses. The
bladder is grossly unremarkable. Ascites is noted.
IMPRESSION: Ascites, without evidence for renal abnormality.
[**2205-5-1**] 06:30AM BLOOD Glucose-147* UreaN-57* Creat-2.2* Na-128*
K-6.0* Cl-101 HCO3-19* AnGap-14
[**2205-5-2**] 04:10AM BLOOD Glucose-125* UreaN-69* Creat-3.5* Na-132*
K-4.9 Cl-102 HCO3-17* AnGap-18
[**2205-5-4**] 01:10AM BLOOD Glucose-142* UreaN-85* Creat-3.8* Na-128*
K-4.6 Cl-97 HCO3-12* AnGap-24*
[**2205-5-5**] 08:18PM BLOOD UreaN-25* Creat-1.3*
[**2205-5-6**] 02:37PM BLOOD Glucose-88 UreaN-18 Creat-1.0 Na-136
K-4.0 Cl-99 HCO3-23 AnGap-18
[**2205-5-8**] 06:06AM BLOOD Glucose-78 UreaN-21* Creat-0.8 Na-133
K-3.5 Cl-96 HCO3-29 AnGap-12
[**2205-5-14**] 07:50AM BLOOD Glucose-73 UreaN-38* Creat-1.2* Na-138
K-4.0 Cl-108 HCO3-19* AnGap-15
[**2205-5-16**] 06:10AM BLOOD Glucose-81 UreaN-35* Creat-1.0 Na-134
K-4.1 Cl-107 HCO3-19* AnGap-12
[**2205-5-6**] 02:01AM BLOOD WBC-7.3 RBC-3.78* Hgb-11.4* Hct-34.0*
MCV-90 MCH-30.1 MCHC-33.4 RDW-19.4* Plt Ct-123*
[**2205-5-4**] 04:46AM BLOOD ALT-34 AST-82* AlkPhos-254* TotBili-2.6*
[**2205-5-5**] 04:00AM BLOOD ALT-34 AST-77* AlkPhos-243* TotBili-1.9*
[**2205-5-14**] 07:50AM BLOOD ALT-13 AST-49* AlkPhos-231* TotBili-1.1
[**2205-5-1**] 06:30AM BLOOD PT-13.3 PTT-26.5 INR(PT)-1.1
[**2205-5-3**] 06:25AM BLOOD PT-14.9* PTT-30.2 INR(PT)-1.3*
[**2205-5-4**] 04:18PM BLOOD PT-18.2* PTT-34.0 INR(PT)-1.6*
[**2205-5-15**] 06:10AM BLOOD PT-14.2* PTT-30.1 INR(PT)-1.2*
Brief Hospital Course:
46 year old woman with Common Variable Immuno Deficiency, h/o
lymphoma s/p CHOP, granulomatous hepatitis with portal
hypertension, primary pulmonary hypertension and refractory HPV
related vulvo anal disease admitted initially for elective
operative ablation of vulvar and anal dysplastic lesions on [**4-30**],
course complicated by pseudomonas bacteremia, acute renal
failure resulting in temporary CVVH, delirium, and fluid
overload secondary to underlying cirrhosis.
.
# Acute Renal Failure:
Acute renal failure, likely secondary to ATN, had resolved by
time of discharge. ATN may have been secondary to hypotensive
episode in the OR during surgery. CVVH was initiated in the
MICU, and patient was temporarily on pressors to maintain blood
pressures with renal replacement therapy. She was transitioned
to midodrine to maintain blood pressures. Patient was
transfered to floor after CVVH was weaned off, and renal
function continued to improve. Diuretic regimen was uptitrated
slowly to 60mg lasix + 100mg spironalactone, which she tolerated
well.
# Pseudomonas Bacteremia:
Blood cultures from [**5-4**] grew pan-sensitive pseudomonas. She
was initially treated with vancomycin, cefepime, flagyl with
concern for possible polymicrobial infection, but vancomycin and
flagyl were tapered off after 5 days of persistently negative
cultures. Cefepime was transitioned to po ciprofloxacin 750mg
[**Hospital1 **] on [**2205-5-15**], and patient was discharged with plan for total
antibiotic course at least 14 days. She will follow up with
Infectious Disease specialist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in clinic next week,
at which point he will decide how much longer to continue
antibiotic course (day #1 antibiotics [**2205-5-5**]). Day# 14
antibiotics would be [**5-19**], though total course is yet to be
determined.
.
# Delirium -
On [**5-10**], pt became increasingly agitated and emotional,
reportedly unable to sleep at all. There was concern that
perhaps this was a manic episode in the setting of taking
citalopram for depression as this medication had apparently only
been started several months back. Pt's mental status continued
to worsen over the next 24-36 hours. Psychiatry was consulted
and recommended haldol for agitation and to help w/sleep,
minimizing interruptions. Delirium work was initiated,
including Head CT, blood and urine cultures, as well as chest
Xray. Head CT showed no acute process. [**Name (NI) **] pt was agitated
and had risk of bleeding due to bleeding diathesis, decision was
made not to LP pt or do paracentesis (no fever or WBC elevation
at that time, and she was covered with cefepime for
pseudomonas). One dose Haldol had improved agitation and pt was
marginally able to partially tolerate a brain MRI but this was
relatively unrevealing showing possible enhancement of basal
ganglia often seen w/hepatic encephalopathy; however, pt's labs
had generally shown improvement since leaving the ICU she did
not have asterixis on exam. ID, Liver, Renal consults were
heavily involved. Concern for infection was high given pt's
immuno compromised state. Concern for possible medication
effects was also high as pt had past hx of medication
sensitivty. Efforts were made to minimize medications and the
following medications were stopped: voriconazole, citalopram,
sildenafil, midodrine. Pt improved in setting of getting more
sleep after haldol dose. Infectious work-up was unrevealing.
Lactulose was briefly given but stopped given pt's return to
baseline mental status, though she was continued on rifaximin.
Etiology of acute decompensation is still unclear but may have
been multifactorial.
.
# Cirrhosis ??????
Concern for mild encephalopathy. Treated with rifaximin 550mg
[**Hospital1 **] and ursodiol. Lactulose was held given anal surgery.
Hepatology continued to follow. In setting of delirium (see
above) lactulose was restarted. After delirium resolved,
lactulose was stopped. Pt remained stable w/out evidence of
acute or worsening encephalopathy. Pt was able to be titrated up
to 60mg of lasix + 100mg spironalactone to help w/diuresis and
improvement of ascites.
.
# Hypoxia: Pleural effusions improved with diuresis. NC was
weaned. Maintained sat >96%. Continued empirical antibiotics as
above with NC prn.
.
# Hypotension:
Hypotension likely multifactorial, secondary to decompensated
cirrhosis, intravascular volume depletion, sepsis. Goal SBPs >
110 to maintain renal perfusion, requiring levophed for two days
in MICU, then transitioned to midodrine, which was titrated off
on the floor. BPs continued to improve and remain stable on the
floor.
.
# Severe pulmonary hypertension:
Chronic ongoing problem which would preclude liver
transplantation. Patient's home sildenafil was held in MICU and
restarted on floor at home dose 10mg [**Hospital1 **]; however, in the
setting of delirium and ?facial swelling (which pt had had in
the past w/this medication), decision was made to stop sildenfil
(see above). Dr. [**Last Name (NamePattern1) 11031**]following.
# HPV:
Patient was admitted for elective operative ablation of vulvar
and anal dysplastic lesions on [**4-30**]. Path came back showing
vulvar cancer which Dr. [**Last Name (STitle) 107309**] discussed w/pt. Plan for f/u
with Dr. [**Last Name (STitle) 2028**] and Dr. [**Last Name (STitle) **] 2 weeks ([**Telephone/Fax (1) 107310**]) or once
pt out of hospital.
.
# Bleeding diathesis:
Patient with long standing bleeding diathesis followed by Dr.
[**Last Name (STitle) 3060**]. Temporarily on Amicar while in MICU. No evidence of
bleeding. [**Month (only) 116**] need reinstitution of Amicar if going for any
procedure with risk of bleed.
.
# CVID: long hx of infections. Pt was continued
hydroxychloroquine, valgancyclovir. Voriconazole was stopped as
above but may need to be restarted as outpt pending fungal
markers. Pt got IVIG as inpt as on [**2205-5-13**] as she was due for
her regular dose. She will continue to receive her regular IVIG
doses at home.
Prophylactic valgancyclovir dose continues at 900mg daily. Abx
as described above. Pt has planned outpt visit w/ID attending
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] for further follow-up.
.
# h/o high fungal markers: repeat beta glucan and galactomannan
markers were sent and will be followed up by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
Patient was initially continued on voriconazole which was later
discontinued in setting of delirium. Voriconazole may need to
be restarted by Dr. [**Last Name (STitle) 724**] as outpt pending fungal markers.
.
# depression:
Citalopram was held after episode of delirium for concern of
mania, but it will be restarted at 10mg daily on discharge, to
be uptitrated to 20mg daily after a few days.
.
Transitional issues:
- f/up fungal markers
- planned outpt visit w/ID attending Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] for further
follow-up to determine total antibiotic course for pseudomonas
bacteremia and to follow up fungal markers
- Plan for f/u with Dr. [**Last Name (STitle) 107309**] and Dr. [**Last Name (STitle) **] 2 weeks ([**Telephone/Fax (1) 107311**]) or once pt out of hospital
Medications on Admission:
MEDICATIONS (at home, confirmed with patient):
Omeprazole 20 mg PO DAILY
Acetaminophen 500 mg PO/NG Q6H:PRN pain
Creon 12 [**12-30**] CAP PO TID W/MEALS
Sildenafil 10 mg PO BID
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Citalopram 30 mg PO/NG DAILY
Ursodiol 600 mg PO DAILY
Hydroxychloroquine Sulfate 200 mg PO/NG [**Hospital1 **]
Voriconazole 200 mg PO/NG Q12H
Vitamin D 400 UNIT PO/NG DAILY
Lorazepam 0.5 mg PO/NG Q6H:PRN anxiety
ValGANCIclovir 450 mg PO EVERY OTHER DAY
Lasix 20mg daily
Spironolactone 100mg daily
.
On transfer:
Bisacodyl prn
Creon 12 [**12-30**] cap PO TID with meals
Chlorhexidine 0.12% oral rinse 15mL [**Hospital1 **]
Citalopram 30mg daily
Docusate [**Hospital1 **]
Hydroxychloroquine 200mg [**Hospital1 **]
Omeprazole 20mg daily
Senna [**Hospital1 **] prn
Sildenafil 10 mg PO BID
Ursodiol 600mg daily
Voriconazole 200mg [**Hospital1 **]
Vitamin D 400 U daily
Valgancyclovir 450mg every other day
Discharge Medications:
x
Discharge Disposition:
Home
Discharge Diagnosis:
x
Discharge Condition:
x
Discharge Instructions:
x
Followup Instructions:
x
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
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icd9cm
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[
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22745, 22748
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277, 384
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588, 2482
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4031, 4239
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41,156
| 124,557
|
20740
|
Discharge summary
|
report
|
Admission Date: [**2139-8-25**] Discharge Date: [**2139-8-28**]
Date of Birth: [**2069-12-11**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6736**]
Chief Complaint:
BPH, Hematuria
Major Surgical or Invasive Procedure:
PROCEDURE: Transurethral recess resection of the prostate.
History of Present Illness:
Mr. [**Known lastname **] is known to Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] with a history of previous laser
photo vaporization of the prostate many years ago who has had
regrowth of the prostate. He presented with gross hematuria and
and for transurethral
resection.
Past Medical History:
Elevaed PSA s/p muliple negative biopsies
h/o HG dysplasia on c-scopy polypectomy
BPH s/p TURP
Recent admission for hematuria
HTN
onychomycosis
Hyperglycemia
CKD stage II
Social History:
Married and lives with wife. [**Name (NI) **] [**Name2 (NI) **], does not smoke, use
alcohol, or other drug use.
Family History:
(per [**Name2 (NI) **]): His mother and father both had high
blood pressure, both deceased. No family history of any coronary
artery disease or strokes, diabetes, bleeding disorder.
Pertinent Results:
[**2139-8-28**] 06:52AM BLOOD WBC-9.1 RBC-4.05* Hgb-11.8* Hct-34.4*
MCV-85 MCH-29.1 MCHC-34.3 RDW-15.0 Plt Ct-199
[**2139-8-26**] 04:33AM BLOOD WBC-11.3* RBC-3.69* Hgb-10.9* Hct-31.3*
MCV-85 MCH-29.6 MCHC-35.0 RDW-14.2 Plt Ct-163
[**2139-8-25**] 05:04PM BLOOD WBC-15.2*# RBC-4.00* Hgb-11.6* Hct-33.7*
MCV-84 MCH-29.1 MCHC-34.4 RDW-13.7 Plt Ct-193
[**2139-8-28**] 06:52AM BLOOD Glucose-99 UreaN-16 Creat-1.2 Na-138
K-4.3 Cl-104 HCO3-23 AnGap-15
[**2139-8-27**] 08:01AM BLOOD Glucose-98 UreaN-19 Creat-1.3* Na-139
K-4.0 Cl-107 HCO3-26 AnGap-10
[**2139-8-26**] 12:49PM BLOOD Glucose-124* UreaN-24* Creat-1.2 Na-137
K-4.2 Cl-105 HCO3-25 AnGap-11
[**2139-8-28**] 06:52AM BLOOD Calcium-9.3 Mg-2.0
[**2139-8-27**] 08:01AM BLOOD Calcium-8.5 Mg-2.1
Brief Hospital Course:
69 y/o with HTN, CKD Stage II, Hyperglycemia, BPH present
[**2139-8-25**] a TURP. Mr. [**Known lastname **] was admitted to Dr[**Last Name (STitle) **] Urology
service after TURP of the prostate. No concerning intraoperative
events occurred; please see dictated operative note for details.
The patient received peri-operative antibiotic prophylaxis with
gentamycin and kefzol. Patient's postoperative course was
complicated by TUR syndrome due to the bladder irrigation. He
remained afebrile throughout his hospital stay. While in the
PACU Mr. [**Known lastname **] developed a dysrythmia, remained confused confusion
and experienced some visual acuity changes and vertical
nystagmus. He described mild dizziness and nausea. He developed
bradycardia believed to be sinus arrest with junction escape
rhythm which has since resolved. HTN up to SBP 200 also occured
in the PACU. Electrolytes were obtained demonstrating
hyperkalemia and hyponatremia and given the questions of mental
status changes and visual changes/vertical nystagmus "stat"
cardiology, ICU, nephrology and opthalmology consults were
obtained. Mr. [**Known lastname **] was managed for TUR syndrome with electrolyte
correction and monitored with serial labs, EKGs and was also
sent for imaging to rule out brain infarct, bleed, increased
pressure. Final results: 1. No acute intracranial pathology.
Note, limited sensitivity of CT towards central pontine
myelinolysis for which MR is a better modality.
2. Mild sinus disease with air-fluid level in the right
maxillary sinus, in
the correct clinical setting could represent an acute sinusitis.
3. Mild prominence of R>L prefrontal extraxial spaces could
represent atrophy
related changes or small subdural collections.
Mr. [**Known lastname **] was kept in ICU overnight and on POD2 was transferred to
the general surgical urology floor. His electrolytes corrected
as did his EKG and his clarity returned. On POD2 he passed his
trial of voiding and began physical therapy. He endorsed feeling
well and voiding without difficulty despite PVRs x 2 around
300cc. By POD3, [**2139-8-28**] Mr.[**Known lastname **] was doing very well, tolerating
a regular diet and PO pain medications and denying any new
complaints. He endorsed being ready for discharge home and his
wife will be retrieving him later this evening. After formal
evaluation with PT and their recommendations, Mr. [**Known lastname **] was
discharged home with services for physical therapy.
He was discharged with explicit instructions to follow-up with
his own opthalmologist and to follow up with nephrology,
urology, cardiology and his Primary care clinician. All his
questions were answered.
Medications on Admission:
Atenolol
Proscar
HCTZ
Lisinopril
Flomax
ASA
NKDA
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime): PLEASE CONTINUE
UNTIL YOUR F/U WITH DR. [**Last Name (STitle) 163**].
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please continue until your f/u with Dr. [**Last Name (STitle) **].
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: DO NOT drive, consume ETOH or operate
machinery/dangerous equipment if using. .
Disp:*25 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PREOPERATIVE DIAGNOSES: Benign prostatic hypertrophy,
hematuria.
POSTOPERATIVE DIAGNOSES: Benign prostatic hypertrophy,
hematuria.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequecy over the next month.
-You may shower and bathe normally.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily
Tylenol dose is 4gm, note that narcotic pain medication also
contains Tylenol (acetaminophen)
-Do not drive or drink alcohol while taking narcotics. Do not
operate heavy machinery/dangerous equipment while taking
narcotics
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops.
-Resume your home medications, except hold NSAID (aspirin, and
ibuprofen containing products such as advil & motrin,) until you
see your urologist in follow-up
DO NOT RESUME LISINOPRIL OR HYDROCHLOROTHIAZIDE until advised by
cardiology or nephrology in follow-up.
-Call Dr.[**Name (NI) 10529**] office ([**Telephone/Fax (1) 921**]) for follow-up AND if you
have any questions (page Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Telephone/Fax (1) 2756**]).
The operation you have experienced is a "scraping" operation.
Bleeding was controlled with electrocautery which has produced a
"scab" in the channel through which the urine passes (the
urethra). About 1-2 weeks after the operation, pieces of the
scab will fall off and come out with the urine. As this occurs,
bleeding may be noted which is normal. You should not worry
about this. Simply lie down and increase your fluid intake for a
few hours. In most cases, the urine will clear. If bleeding
occurs or persists for more than 12 hours or if clots appear
impairing your stream, call your surgeon. Because of the
potential for bleeding, aspirin (or Advil) should be avoided for
the first 3 weeks after surgery. You will be given a
prescription for antibiotics to be taken for a few days after
surgery. This is to help prevent infection. If you develop a
fever over 101??????, chills, or pain in the testicles, call your
surgeon. Although not common, this may indicate infection that
has developed beyond the control of the antibiotics that you
have taken. It will take 6 weeks from the date of surgery to
fully recovery from your operation. This can be divided into two
parts -- the first 2 weeks and the last 4 weeks. During the
first 2 weeks from the date of your surgery, it is important to
be "a person of leisure". You should avoid lifting and
straining, which also means that you should avoid constipation.
This can be done by any of 3 ways: 1) modify your diet, 2) use
stool softeners which have been prescribed for you, and 3) use
gentle laxatives such as Milk of Magnesia which can be purchased
at your local drug store.
Remember that the prostate is near the rectum, and therefore, it
is important for you to be mindful of the way you sit. For
example, sitting directly upright on a hard surface, such as an
exercise bicycle [**Last Name (LF) 10530**], [**First Name3 (LF) **] cause bleeding. Reclining on a soft
sea, or sitting on a "donut", is best. Walking (not jogging) is
okay. You should avoid sexual activity during this time. Also,
avoid driving an automobile. This is important, not because you
are physically incapable of driving, but rather if you have an
urge to urinate, it is important that you void and not let your
bladder "stretch" too much, otherwise bleeding may occur.
Therefore, it is OK for you to be a passenger in an automobile
(or even to drive for very short distances). During the second
[**2-13**] week period of your recovery, you may begin regular
activity, but only on a graduated basis. For example, you may
feel well enough to return to work, but you may find it easier
to begin on a half-day basis. It is common to become quite tired
in the afternoon, and if such occurs, it is best to take a nap!
If you are a golfer, you may begin to swing a golf club at this
time. Sexual activity may be resumed during the second 3 week
period, but only on a limited basis. Remember that the ejaculate
may be directed back into the bladder (rather than out),
producing a "dry" orgasm which is a normal consequence of the
operation. This should not change the quality of sex.
In general, your overall activity may be escalated to normal as
you progress through this second time period, such that by [**5-19**]
weeks following the date of surgery, you should be back to
normal activity. Remember that your operation was a "scraping"
operation and not all of the prostate was removed. Therefore,
you should still be monitored for prostate cancer (assuming age
and general medical conditions dictate such).
Followup Instructions:
Please follow up with Urology, Cardiology, Nephrology and
Opthalmolgy.
[**2139-9-10**] 03:00p Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]
DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **]
RENAL DIV-WSC (SB)
[**2139-9-7**] 10:30a [**Last Name (LF) 163**],[**First Name3 (LF) 161**] K.
[**Hospital6 29**], [**Location (un) **]
UROLOGY CC3 (NHB)
Name: [**Name8 (MD) **], MD, FACS, [**Doctor First Name **] K. Pager: [**Numeric Identifier 55344**] Office Phone: ([**Telephone/Fax (1) 14702**] Office Location: [**Location (un) **];Rabb440: [**Hospital Ward Name 23**]
3:[**Location (un) 86**] [**Numeric Identifier **] Division: Urology
Name: [**Last Name (LF) 4090**], [**First Name3 (LF) 4102**] Pager: [**Numeric Identifier 55345**] Office Phone: ([**Telephone/Fax (1) 817**]
Office Location: One [**Last Name (un) **] Place [**Location (un) 86**] [**Numeric Identifier **] Division:
Nephrology
PLEASE CALL BY MONDAY, [**8-31**], TO SCHEDULE AN APPOINTMENT WITHIN
[**6-11**]- DAYS OF DISCHARGE.
[**Last Name (LF) 73**], [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Division:Cardiology
Office Location:[**Street Address(2) **]. - W/ [**Hospital Ward Name **] 4
Phone:([**Telephone/Fax (1) 2037**] Fax:([**Telephone/Fax (1) 16763**] Pager:[**Numeric Identifier 55346**]
Completed by:[**2139-8-28**]
|
[
"403.90",
"276.1",
"285.1",
"600.00",
"276.7",
"585.2",
"599.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"60.29"
] |
icd9pcs
|
[
[
[]
]
] |
5745, 5802
|
2016, 4697
|
330, 392
|
5979, 5979
|
1252, 1993
|
10927, 12343
|
1049, 1233
|
4797, 5722
|
5823, 5958
|
4723, 4774
|
6130, 10904
|
276, 292
|
420, 707
|
5994, 6106
|
729, 901
|
917, 1033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,118
| 139,333
|
40686
|
Discharge summary
|
report
|
Admission Date: [**2126-7-29**] Discharge Date: [**2126-8-20**]
Date of Birth: [**2057-6-9**] Sex: M
Service: MEDICINE
Allergies:
Potassium Aminobenzoate / lisinopril
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Thoracentesis
Tube thoracostomy
Esophagogastroduodenoscopy
Colonoscopy
History of Present Illness:
69yo M PMhx afib on coumadin, psuedomonal pneumonia c/b
intubation for hypoxic respiratory failure c/b difficult weaning
requiring tracheostomy placement complicated by tracheostomy
bleeding, also w recurrent bilateral pulmonary effusions s/p
bilateral chest tubes,
now p/w progressive SOB x1d found to have Hct 18 at OSH, CXR w
R-sided pleural effusion. Patient reports that during week prior
to admission, he experienced progressive dyspnea on exertion; he
denied chest pain, dizziness, HA, motor/sensory deficits during
this time. He did report mild epistaxis, but denied hematuria,
hematemesis, melena, hematochezia. Patient was transfused 1 unit
pRBCs and transferred to [**Hospital1 18**] for further management.
.
On arrival to [**Hospital1 18**], initial vital signs were 98.6, BP 107/67,
HR 81-86, RR 16-17, SpO2 95-100% on 3L (baseline). Exam was
recorded as signifcant for decreased R sided breath sounds; no
rectal exam or guaiac was performed. Labs were significant for
WBC 12.3, Hct 20.6, Cr 0.3. CXR demonstrated R sided pleural
effusions, as well as potential bilateral infiltrates. EKG w/o
ST elevations. Patient was given vancomycin, azithromycin, and
zosyn for HCAP coverage and wasa admitted to medicine service
for further evaluation and management.
Vital signs prior to transfer were 97.7 82 102/67 100%4LNC.
.
On arrival to the floor, vital signs were 97.2 125/76 92 22
93%3L. Patient comfortable and without complaints. Reported mild
epistaxis and some blood streaked sputum. Denied fevers,
nightsweats, chills, increased cough. Review of systems
otherwise negative for headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- Afib on coumadin
- GERD
- PNA c/b b/l pleural effusions, tracheostomy [**5-/2126**]
Social History:
SOCIAL HISTORY:
Currently lives at rehab facility, previously lived alone in
[**Location (un) **], h/o extensive ETOH use (1pint/day)
Family History:
FAMILY HISTORY:
No h/o GI bleeds.
Physical Exam:
Admission Exam:
VS: Tmax 97.2 Tc 96 BP 120/82 (101-136/72-82) HR 77 (62-92) RR
20 (20-22) 97% 3L
GEN: AOx3
HEENT: Bilatreal conjunctival pallor, tracheostomy covered
Cards: irreg irreg 2/6 SEM radiating to the apex (patient has
history of MR)
Pulm: Decreased BS at RLL otherwise Clear and moving air,
Abd: S/NT/ND/NBS, without hepato-splenomegaly, PEG site is
C/D/I, with only mild erythema
Extremities: LLE cool to the touch, difficult to palpate DP/PT
on the R, bounding popliteral pulses bilaterally
Rectal: rectal irritation without any evidence of hemmoroids,
guiaic positive tarry stool
Pertinent Results:
[**2126-7-29**] 04:00PM PT-32.2* PTT-28.8 INR(PT)-3.2*
[**2126-7-29**] 04:00PM PLT COUNT-286
[**2126-7-29**] 04:00PM WBC-12.3*# RBC-2.31* HGB-6.7*# HCT-20.6*#
MCV-89# MCH-29.0# MCHC-32.6 RDW-18.3*
[**2126-7-29**] 04:00PM NEUTS-65.6 LYMPHS-26.3 MONOS-6.9 EOS-0.7
BASOS-0.4
[**2126-7-29**] 04:00PM HAPTOGLOB-252*
[**2126-7-29**] 04:00PM ALT(SGPT)-20 AST(SGOT)-26 LD(LDH)-206 ALK
PHOS-103 TOT BILI-0.4
[**2126-7-29**] 07:25PM LACTATE-1.1
[**2126-7-29**] 04:00PM GLUCOSE-97 UREA N-23* CREAT-0.3* SODIUM-140
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-36* ANION GAP-9
.
SPUTUM Culture:
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- =>16 R
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
CXR [**2126-7-29**]
1. Bilateral pleural effusions, increased since the prior study,
and likely at least partially loculated.
2. Ovoid right base opacity, while could represent loculated
fluid,
consolidated mass is not excluded. Additional bibasilar
opacities are seen, while could represent combination of
effusion and atelectasis, additional consolidations not
excluded. Ill-defined right upper lung opacification has
decreased since the prior study, with some mild residua
remaining. There is also patchy opacity at the left mid to lower
lung.
.
CT Chest [**2126-7-30**]
Overall decrease in extent of the bilateral pleural effusions,
the effusions, however, are now loculated but without evidence
of focal
pleural thickening or focal hyperenhancement.
Adjacent areas of atelectasis. Most of the pre-existing
additional
parenchymal opacities have either cleared or substantially
decreased in
extent.
Emphysema, mucus in both the larger and smaller airways.
Moderate enlargement of the pulmonary artery. Coronary
calcifications.
Healed rib fractures, vertebral wedge deformity, all unchanged
since the
previous CT.
.
[**2126-8-2**] Video Swallow
Evidence of aspiration with thin liquids. For full details,
please refer to the speech and swallow note in the OMR.
Brief Hospital Course:
69yo M PMhx of ETOH abuse, afib on Coumadin, COPD, CHF, Recent
pneumonia c/b intubation requiring tracheostomy [**1-30**] difficulty
weaning, H/o DVT and PE, also w recurrent bilateral pulmonary
effusions s/p bilateral chest tubes, who presented with acute
anemia and possible R-sided consolidation.
.
#Hypoxia: Pt was found to have bilateral pleural effusion at the
time of his admission and possible R sided consolidation. He
was started on zosyn, ciprofloxacin, and vancomycin and
completed an 8 day course of treatment for HAP, completed on
[**2126-8-5**]. He underwent diagnostic thoracentesis on [**2126-7-31**] of the
right pleural effusion and then chest tube was placed to
suction. The patient experienced an hypoxic episode 2 hours
after chest tube placement, two CXRs confirmed correct tube
placement and the absence of a pneumothorax. The patient
stabilized after NT suction. Effusion was noted to be exudative
from CHF. In the mean time, echocardiogram was obtained showing
moderate to severe heart failure and aggressive medical
management of heart failure was recommended. Pt was
aggressively diuresed which improved hypoxia, but no improvement
in chest tube output. He began to develop difficulty with thick
secretions on [**2126-8-7**] for which regimen frequent suctioning,
chest PT, and deep suctioning was started. Chest tube remained
in place draining 100-300cc daily until decided to d/c chest
tube on [**2126-8-9**] to avoid further complication.
.
On [**2126-8-9**] Mr. [**Known lastname 36803**] became unresponsive, hypoxic, and
hypotensive, and a code blue was called. He was intubated and
transferred to the ICU. He required intermittent pressors for
several days thought to be secondary to sepsis. Pneumonia vs.
aspiration were thought to be the cause of his respiratory
failure, and he was started on Tobramycin/Vancomycin/Zosyn for
coverage of his known bugs and empirically. He was also
diuresed aggressively. The MICU team noted difficulty weaning
the vent secondary to secretions. On [**2126-8-15**] he self-extubated,
was transitioned from a bag mask (immediately after extubation)
to a NRB and was weaned to a face mask. He tolerated the
extubation and change to face mask well. He was transferred to
the floor on [**8-16**].
.
On the medical floor, he developed intermittent hyoxia with O2
sats dropping to the mid 70s on RA/ 80s on face mask. Pt had a
difficult time keeping the face mask and nasal cannula due to
worsening delirium. Hypoxic episodes were believed to be due to
mucus plugging and patient has a weak cough. Pt was thought to
be clinically dry on exam, with metabolic alkylosis. He
continued to have frequent plugging and had an episode of
desaturation to 50% which resolved with nasotracheal suctioning.
Pt was started on a more aggressive regimen of deep and
superficial suctioning, nebulizers, humidified air. Was unable
to tolerate chest PT on the floor due to desaturation with
position changes and hip pain. Most recent CXR shows bilateral
pulmonary effusion, pulmonary edema, but without any acute
change from baseline. Pt was tranferred back to MICU on [**8-19**] due
to high nursing needs and closer monitoring. At time of tranfer
he was satting 92% on 5L NC
.
#Anemia: Pt was noted to have a hematocrit of 20 on admission
with guiac positive stools from 30 at time of discharge. He was
remained on a heparin gtt while evaluated for GIB. EGD and
colonoscopy performed [**2126-8-5**] showed diverticulosis, but no sign
of active bleed. His hematocrit continued to decline very lowly
thought to be from a very slow GIB in the setting of
anticoagulation and poor marrow response. Stool guiac
documented negative [**8-16**], and brown stools. Hematocrit remained
subsequently stable until [**8-17**]. At that time his hematocrit
dropped from 25 --> 23 --> 18 and he was transfused 3 units on
[**8-18**] with a 7 point increase in Hct. Concerning sources of
bleed include oropharyngeal blood loss, pt has been noted to
have hemoptysis (thought to be [**1-30**] to trauma from nasopharyngeal
suctioning) and nurses have been suctioning up to 50 cc blood
since AM of [**8-19**]. He needs, stools (guiac <neagative [**8-19**]),
hemolytic anemia associated with transfusion (though coombs test
negative), hemothroax (CXR stable with bilat effusions), or
possibly a hematoma in the left hip as he reports pain in this
area since [**8-17**] and there is increased emema of the L hip
compared to the right. Imaging of the hip has been delayed due
to concern over the patient's respiratory status.
.
#Leukocytosis:
On [**2126-8-19**], pt was noted to develop a leukocytosis to 21. At
the time he was already on broad spectrum antibiotics with
Vancomycin, Zosyn, and Tobramycin for MDR psuedomonas and MRSA
pneumonia. Repeat CXR showed no new consolidation, UA and Stool
culture for Cdiff were sent. (UA not obtained as of yet)
.
# History of DVT/PE: Pt remained on anticoagulation throughout
his hospitalization in various forms, always bridged when
subtherapeutic. At the time of transfer, coumadin was held,
concern for . MICU may decide to resume.
.
#Psych - The patient experienced multiple episode of
confusion/agitation. These episodes occured more often during
the evening hours. The etiology is likely multifactorial.
Citalopram and quetiapine at home doses were continued during
the admission. Later in his hospitalization he was found to
have waxing and [**Doctor Last Name 688**] orientation and he was started on 0.5mg
haldol [**Hospital1 **], as his delirium was an impairment to keeping his
oxygen delivery devices to his face.
.
#Atrial fibrilation - The patient had multiple episodes of
atrial fibrillation with RVR with rates in the 130s that were
controlled with diltiazem. Otherwise the patient was treated
with home doses of digoxin and sotolol, with good heart rate
control. In the ICU his nodal agents were held due to
hypotension but they were uptitrated to home doses when he
returned to the flor. He was noted to have worsening afib with
RVR when volume depleted on [**8-17**] which improved with
discontinuation of lasix.
.
# CAD - Pt was noted to have new wall motion abnormalities on a
poor quality echocardiogram. However, this was highly
suggestive of a relatively recent episode of ACS. Pt had no
chest pain during admission, and EKG remained stable through
out. ASA was held initially in the setting of acute bleeding
risk, but was resumed after HCT stabilized. His statin dose was
increased.
.
#Hypothyroidism - TSH: 8.5, Free T4 1.1. Patient was never
symptomatic. Synthroid was continued at the patient's home dose.
.
#Goals of care - Pt was Full code at the start of this admission
which was confirmed on the day of his respiratory code [**8-9**]. On
[**8-16**], code status was readdressed, pt was less confident of his
decision but decided to remain full code. On [**8-17**] after pt was
triggered for afib with RVR and hypoxia, code status was
readdressed and pt stated he would not want to be intubated or
resuscitated or go back to the ICU. This was confirmed on [**8-19**]
again after trigger for hypoxia to 50% due to secretions.
Unfortunately, due to high monitoring, suctioning, and other
medical needs, patient was unable to be managed on the floor.
He was in agreement with ICU tranfer for this reason. In the
ICU, it was noted that he had bloodly secretions, presumably
from nasopharyngeal trauma of agressive suctioning. The famiyl
was updated, and confirmed the DNR/DNI goals of care.
Unfortunately, the morning of [**2126-8-20**], he became acutely
bradycardic to the 20s and unresponsive. There was a faint
femoral pulse. A few minutes later, the patient became
pulseless. He was pronounced dead at 0715 that morning. Family
declined an autopsy.
Medications on Admission:
- aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
- citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
- tiotropium daily
- advair 1 puff [**Hospital1 **]
- lasix 30mg daily
- floranex 2 tabs [**Hospital1 **]
- lansoprazole 30mg [**Hospital1 **]
- sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
- albuterol q6hrs
- vicodin prn pain
- dulcolax prn constipation
- warfarin 6.5 mg daily
- synthroid 25mcg daily
Discharge Medications:
patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
patient deceased
Discharge Condition:
patient deceased
Discharge Instructions:
patient deceased
Followup Instructions:
patient deceased
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,347
| 135,808
|
32306+32307+32308
|
Discharge summary
|
report+report+report
|
Admission Date: [**2200-11-25**] [**Month/Day/Year **] Date: [**2200-11-27**]
Date of Birth: [**2141-8-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Erythromycin Base / Tetracycline /
Prednisone / Vancomycin
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo F w/ pmxh of depression, L hip fx complicated by wound
infection on vancomycin developed a rash. Her vancomycin used
dates to [**10-28**] for a soft tissue infxn, for a conservative 4
week course to end [**11-25**] given recent hardware. She developed
rash on thursday, noted on chest, pruritic, spoke with ID and
dc'd vanco started benadryl 1-2 tabs every six hrs, the rash
initially improved until sunday, where she developed a more
diffuse rash now on torso, legs, also had generalized malaise,
decreased Po intake, nauseas, no vomitting. diarrhea, and also
fevers as high as 102.7 yesterday.
Past Medical History:
Depression
Social History:
Lives with husband
[**Name2 (NI) 17923**]
Retired
Family History:
n/a
Physical Exam:
97.4 104/60 78 24 98RA
Gen: NAD, pleasant speaking in full sentences
HEENT: PERRL, EOMI, MMM
Neck: supples, no LAD, OP clear, no stridoe
CV: RRR no mrg
Resp: CTA b/l no w/r/r
Abd: +BS nt/nd
Ext: no c/c/e well healed L incision wound from ORFI
Neuro: AAOx3 nonfocal
Skin: macular papular blanching diffuse rash with areas of
coalescence on torso, upper thighs
Pertinent Results:
[**2200-11-26**] 06:05AM BLOOD WBC-11.9* RBC-3.98* Hgb-11.8* Hct-34.6*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.5 Plt Ct-222
[**2200-11-26**] 06:05AM BLOOD Neuts-72* Bands-8* Lymphs-11* Monos-0
Eos-4 Baso-0 Atyps-4* Metas-1* Myelos-0
[**2200-11-26**] 06:05AM BLOOD Glucose-155* UreaN-12 Creat-0.7 Na-143
K-4.0 Cl-106 HCO3-25 AnGap-16
[**2200-11-26**] 06:05AM BLOOD CRP-181.5*
[**2200-11-26**] 06:05AM BLOOD ESR-25*
.
MICRO:
[**11-26**]: c.dif (-). urine/blood cx NGTD
Brief Hospital Course:
59 W with pmhx of L ORIF with complicated by soft tissue
infection on vancomycin with rash.
.
# Pruritis/Rash
Appeared to be a drug rash, given its nature, and the temporal
relationship with her 3 week course of Vancomycin. However,
given her atypical lymphs on her dif, along with her recent 2d
of diarrhea and sore throat, it was unclear whether this
represented a viral exanthem. She was admitted and placed on IV
SoluMedrol, Benadryl, and Pepcid for histamine control.
Dermatology was consulted who agreed that this was likely a drug
reaction to vancomycin, but could rule out this being a viral
exanthem. They recommended d/c'ing her with Triamcinolone
cream, and oral anti-histamine meds. On morning of [**Month/Year (2) **],
she complained of "dry, scratchy throat" which she attributed to
recently receiving benadryl. She had no sob, OP exam and neck
wnl. [**Month/Year (2) **] was held until end of day for monitoring, with
no worsening of throat complaints.
She was discharged with PCP f/u and instructed that her rash may
represent a vanco allergy and she should not take this
medication unless permitted by a doctor.
Medications on Admission:
Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Sertraline 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
[**Month/Year (2) **] Medications:
1. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours.
2. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
Disp:*1 tube* Refills:*2*
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
Disp:*30 Tablet(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
4 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
[**Hospital1 **] Disposition:
Home
[**Hospital1 **] Diagnosis:
Rash due to Drug reaction vs viral exanthem
[**Hospital1 **] Condition:
Stable to be discharged home.
[**Hospital1 **] Instructions:
You developed an allergic reaction to vancomycin and you were
treated with IV prednisone and benadryl. Please continue to use
the triamcinolone cream as needed to relieve your symptoms.
.
Continue to take your other medications as you have been doing.
.
If you develop worsening fevers, oral ulcers, worsening malaise,
or any other concerning symptoms, please call your doctor or
report to the nearest ER.
Followup Instructions:
Please your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] to be seen 1
week after [**Last Name (Titles) **] to monitor your improvement. If you would
like to schedule with a primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 34374**] [**Hospital 3038**], call ([**Telephone/Fax (1) 1300**] to find an available PCP.
.
You can call the dermatology office at ([**Telephone/Fax (1) 8132**] to
schedule an urgent visit or a visit in 3 weeks to follow up on
your progress.
.
YOUR PREVIOUSLY SCHEDULED APPOINTMENTS:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2200-12-18**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2200-12-18**] 10:50
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2200-11-27**] Admission Date: [**2200-11-28**] [**Month/Day/Year **] Date: [**2200-12-2**]
Date of Birth: [**2141-8-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Erythromycin Base / Tetracycline /
Prednisone / Vancomycin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
facial swelling, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 59 year old woman with history of cellulitis
complicating a hip fracture repair s/p extended abx course who
now presents with facial swelling and fever.
.
She was initially admitted on [**2200-10-15**] for repair of a left hip
fracture that was sustained following getting injured by a
horse. She underwent an ORIF w/o initial complication. She was
later readmitted 2 weeks later for an overlying cellulitis
around her hip repair wound. She was treated with 3 weeks of IV
vancomycin and discharged home.
Of note, she was admitted [**Date range (3) 75504**] for rash She
completed a 4 week course of IV vancomycin with initial plan to
complete on [**2200-11-25**]. Several days prior to this completion
date, she reportedly developed a truncal rash. She was
instructed by ID to discontinue vancomycin at that time and
began benadryl q6h at that time with initial improvement in her
rash. 4 days later, just prior to her recent admission, she
developed worsening rash expanding to torso, legs. Her rash was
associated with generalized malaise, decreased PO intake,
nausea, no vomiting. She also had diarrhea and fevers to 102.7
prior to that admission.
.
During [**Date range (1) 75505**] admission, she was noted to have atypical
lymphs on her dif, along with her recent 2d of diarrhea and sore
throat so, although it seemed more likely a drug rash, it was
unclear whether this represented a viral exanthem. During her
hospital stay, she received IV SoluMedrol, Benadryl, and Pepcid
for histamine control. Dermatology was consulted who agreed that
this was likely a drug reaction to vancomycin, but could rule
out this being a viral exanthem. She was discharged home on
[**2200-11-27**] with Triamcinolone cream and oral anti-histamine meds.
This morning when she woke up she noticed face swelling, mild
shortness of breath, trouble swallowing, and worsening of her
full body rash.
.
In the ED today, initial vitals were 99.7 98 100/58 18 100%RA.
She received epi sc, benadryl 50mg IV, famotidine 40 mg IV,
solumedrol 125mg x1. ID was consulted who recommended holding
off on abx for now unless worsening hemodynamically stability.
PIV were placed.
Past Medical History:
# Depression
# Left hip fx s/p Left ORIF [**10/2200**]; complicated by MRSA wound
infection
# lumbar spinal fusion in [**2185**]
Social History:
lives with husband. 2 grown children. quit smoking >30yrs ago.
no EtOH in >3 years
Family History:
sister with [**Name (NI) **]
father with hypertension
Physical Exam:
VS: Temp: 98.9 BP: 114/58 HR: 82 RR: 19 O2sat: 97%2L
GEN: pleasant, comfortable, NAD
HEENT: notable diffuse facial edema and erythema. MMM. no tongue
swelling. oropharynx clear.
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTA b/l with good 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, warm, good pulses
SKIN: no jaundice. diffuse confluent papules on erythematous
base over trunk, legs, face, arms, palms, no soles. no pustules.
no oral lesions
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
[**2200-11-28**] 05:05PM PLT SMR-NORMAL PLT COUNT-262
[**2200-11-28**] 05:05PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+
[**2200-11-28**] 05:05PM NEUTS-31* BANDS-8* LYMPHS-21 MONOS-4 EOS-8*
BASOS-0 ATYPS-26* METAS-1* MYELOS-1*
[**2200-11-28**] 05:05PM WBC-31.1*# RBC-4.46 HGB-13.2 HCT-38.4 MCV-86
MCH-29.6 MCHC-34.4 RDW-14.3
[**2200-11-28**] 05:05PM ALT(SGPT)-109* AST(SGOT)-100* ALK PHOS-197*
TOT BILI-0.3
[**2200-11-28**] 05:05PM GLUCOSE-114* UREA N-14 CREAT-0.9 SODIUM-137
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
[**2200-11-28**] 07:05PM URINE HYALINE-[**2-4**]*
[**2200-11-28**] 07:05PM URINE RBC-[**2-4**]* WBC-[**5-12**]* BACTERIA-FEW
YEAST-NONE EPI-[**2-4**]
[**2200-11-28**] 07:05PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
.
CXR pa/l [**11-29**]:
FINDINGS: Lung volumes are mildly diminished. There is no
consolidation or superimposed edema. The mediastinum is
unremarkable. The cardiac silhouette is within normal limits for
size. No effusion or pneumothorax is evident. A mid-thoracic
compression fracture is again demonstrated and stable.
Otherwise, the osseous structures are unremarkable.
IMPRESSION: No acute pulmonary process.
.
EKG: sinus @80. normal axis and intervals. no ST-T changes.
.
CMV IgG ANTIBODY (Final [**2200-12-1**]):
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2200-12-1**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2200-12-1**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2200-12-1**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Preliminary):
PENDING.
Brief Hospital Course:
59 year old woman with history of hip fracture s/p ORIF c/b
cellulitis now presenting with facial rash and edema.
.
# Facial Swelling: She receieved subQ epinephrine in the
emergency department and was initially admitted to the ICU for
observation. She did not have airway compromise and thus was
never intubated. Her symptoms were felt to be likely related to
previous seen drug eruption now leading to worsening edema and
progression of erythema. She was treated with solumedrol
(tapering course), H2 blocker, benadryl/hydroxyzine for itch.
ID was consulted and recommended no antibiotics as likely to be
drug reaction. She was seen by dermatology and allergy who felt
allergy to vancomycin was most likely and she should not take
this in future. She was transferred to the medicine floor and
treated with an additional day of IV methylprednisolone which
she tolerated and then per allergy recommendations was started
on an oral methylprednisolone taper starting at 64mg daily and
to be tapered as an outpatient over 14 days. Her facial swelling
completely resolved and she had no further symptoms of
difficulty breathing or airway swelling. Her pruritis did
improve slightly and she was discharged on
benadryl/hydroxyzine/zantac as well as triamcinolone and sarna
lotion.
.
# Transaminitis: The patient's transaminitis, fever, and
diarrhea were thought to be secondary to a drug reaction (DRESS
syndrome - drug rash with eosinophilia and systemic symptoms).
Her enzymes were trended and overall were stable or trended
down. Viral Hepatitis serologies were sent and positive for EBV
IgG (IgM pending) and negative for CMV.
.
# Thrombocytopenia: Drop in platelets [**11-30**], then returned to
baseline by the following day. Possible lab/sampling error or
involvement of DRESS syndrome. HIT ab sent and negative.
Medications on Admission:
1. Benadryl 25 mg PO q8hours
2. Alendronate 5 mg PO daily
3. Sertraline 150 mg daily
4. Triamcinolone Acetonide 0.1 % Ointment apply [**Hospital1 **]
5. Hydroxyzine HCl 25 mg PO Q6hours prn
6. Prednisone 40 mg x 4 days (to complete [**2200-12-1**])
7. Ativan 1 mg PO bid prn anxiety
[**Month/Day/Year **] Medications:
1. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injector
Intramuscular As needed: As needed for severe allergic symptoms,
including difficulty breathing. After use call an ambulance or
go to the nearest emergency department.
Disp:*1 injection* Refills:*3*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): for itching.
Disp:*60 Tablet(s)* Refills:*2*
3. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed for itching for 1 months:
avoid use on face.
Disp:*1 month supply* Refills:*0*
4. Diphenhydramine HCl 25 mg Capsule Sig: [**12-3**] Capsules PO Q8H
(every 8 hours) as needed for itching for 2 months.
Disp:*60 Capsule(s)* Refills:*0*
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 large bottle* Refills:*0*
6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching for 2 months.
Disp:*60 Tablet(s)* Refills:*0*
7. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO once a day.
8. Alendronate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Methylprednisolone 16 mg Tablet Sig: 0.5-4 Tablets PO once a
day for 14 days: Take 4 pills (64mg) for 3 days, then 3 pills
(48mg) for 3 days, then 2 pills (32mg) for 3 days, then 1 pill
for 3 days (16mg), then [**12-3**] pill for 2 days then stop.
Disp:*31 Tablet(s)* Refills:*0*
12. Lorazepam 0.5mg po qhs prn sleep for two weeks
[**Month/Day (2) **] Disposition:
Home
[**Month/Day (2) **] Diagnosis:
Primary:
1.) Drug hypersensitivity reaction
2.) Anaphylaxis-like reaction with facial swelling, not
requiring intubation
.
Secondary:
3.) s/p MRSA cellulitis
[**Month/Day (2) **] Condition:
afebrile, displaying normal vital signs without symptoms of
difficulty breathing or facial swelling, ambulating with
crutches and tolerating a regular diet.
[**Month/Day (2) **] Instructions:
You were admitted to the hospital because of facial swelling and
difficulty breathing. You received a dose of epinephrine in the
emergency department and were then observed briefly in the
intensive care unit. While you were in the hospital you were
evaluated by the infectious disease, allergy and dermatology
consult teams and it was felt that your rash and facial swelling
were due to a hypersensivity reaction most likely to vancomycin.
.
You were also treated with intravenous steroids while you were
in the hospital to help reduce the inflammation. It is very
important that you take the methylprednisolone pills when you
leave the hospital and complete the 14 day course even if you
are feeling better. Other medications have also been prescribed
that should help with the itch. The triamcinolone is a steroid
cream and should not be used on your face. Finally, you have
been prescribed an EpiPen to use in case of emergencies (facial
swelling, throat closing symptoms) - fill this prescription as
soon as you leave the hospital.
.
If you experience any symptoms at all of difficulty breathing,
facial swelling, or trouble swallowing you should use the EpiPen
as directed and immediately call 911 or go to the closest
emergency department. If you have fever, chills, worsening rash,
abdominal pain or diarrhea, or if you feel worse in any way,
seek immediate medical attention.
Followup Instructions:
You must call to make a follow-up appointment in the infectious
disease clinic within the next 7-10 days at [**Telephone/Fax (1) 457**], you
may ask to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] if available.
.
Also, please follow-up with Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] in [**Hospital 9039**] Clinic
at ([**Telephone/Fax (1) 14583**] in the next 1-2 weeks.
.
You also have the following previously scheduled appointments
for Dr. [**Last Name (STitle) **] on [**12-18**].
.
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2200-12-18**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2200-12-18**] 10:50
Admission Date: [**2200-12-8**] [**Year/Month/Day **] Date: [**2200-12-12**]
Date of Birth: [**2141-8-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Erythromycin Base / Tetracycline /
Prednisone / Vancomycin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
thigh lesions
Major Surgical or Invasive Procedure:
Incision and drainage of thigh abscesses x 2
History of Present Illness:
59 year old female s/p L femur fx [**10-9**] & complicated post-op
course, including severe delayed rxn to vanco including full
body rash and facial swelling. Currently p/w purplish
sores/blister-like lesions on inner thighs started 2 days
ago--one lesion on L inner thigh & two on R. Very painful.
Low-grade fevers at home. Surrounding redness. H/o MRSA
cellulitis. Followed by ID. Pt was maintained on
methylprednisolone taper, currently taking: 32mg/day.
Her recent hx can be summarized as follows.
-she had an ORIF with intramedulary rod placement for left sided
fractured femur [**10-16**] which was complicated by the development
of a superficial proximal wound infection.
--treated with a course of IV Vancomycin through [**2200-11-25**].
--developed fever and rash on [**11-18**] and ultimately,
the decision was made to stop IV vancomycin on [**11-20**], having
completed three weeks of IV antibiotics
--instructed to take benadryl for pruruitis and noted initial
improvement over the ensuing several days but subsequently had a
worsening of her rash.
--rash progressed and she was admitted [**Date range (1) 75505**] with a drug
reaction during which time she was seen by dermatology, treated
with antihistamines and topical steroids.
--dc'd on [**11-28**] with antihistamines, topical and systemic
steroids and had worsening of facial rash and progression of the
rash on her trunk and extremities prompting an urgent care
dermatology evaluation
on [**11-29**].
--She was noted to have somewhat improved rash overall at
that visit, but there was concern for airway involvement so she
was sent to the ER.
--ER [**11-29**], she had low grade temperature, confluent rash
and papular rash on her trunk and extremities and tachycardia
with boderline hypotension.
--severe drug rxn, SIRS syndrome were entertained, in the end,
she was
thought to have DRESS, in reaction to vancomycin and during her
hospitalization from [**Date range (1) 75506**], she was treated with systemic
steroids, H1 and H2 blockers after initial treatement with
epinephrine in the ER. She noted an improvement in her rash.
--Over the ensuing days since [**Date range (1) **], she has done well from
the
standpoint of her rash, but has developed sores on the inside of
her thighs which are painful and growing. Sores started out as
pimple type things that she thought were ingrown hairs, but they
have grown in size, degree of pain and over the past day, she
has developed a slight degree of surrounding redness and
tenderness with firmness underlying the lesions. + slight
fatigue and decreased appetite.
.
In ED, t 100.7, HR 90s, BP initialy 80s systolic in triage, up
to 100s w/o intervention on arrival to room. BP then fluctuating
b/t 90s-100s (baseline syst 100-110s, though occas 90s when sick
per pt). Lesion exam revealed [**2-3**] purplish b/l inner thigh
lesions (some w/ scabs--not necrotic per surgery) able to
squeeze out small amount of sanguinuous fluid--non-purulent
appearing. No clear abscess. Bedside u/s showwed minimal if any
fluid w/ larger L thigh lesion, none seen w/ other lesions. Pain
meds were given and abscesses were drained in the ED by surgery,
fluid sent for cx and gram stain. Pt was given 10mg
dexamethasone given initial low BP & h/o recent steroid use (for
vanc rxn). By the end of I&D, pt looked better (rash less
erythematous) after fluids, abx, steroids.
.
.
Review of Systems: No CP, no SOB, no dizziness, no LH, no
headaches. No abd pain, no dysuria. +pain and pruritis as
described above.
Past Medical History:
PMH:
# Depression
# Left hip fx s/p Left ORIF [**10/2200**]; complicated by MRSA wound
infection (s/p vanc tx x 3 wks, c/b eisinophilic DRESS
syndrome), including near anaphylasix and facial swelling
requiring MICU stay.
# persistent delayed rxn to vancomycin
# Lumbar spinal fusion in [**2185**]
Social History:
lives with husband. 2 grown children. quit smoking >30yrs ago.
no EtOH in >3 years
Family History:
sister with [**Name (NI) **]
father with hypertension
Physical Exam:
Tm 100.7; Tc 98.1 R18 BP: 98/58. 99%ra
General:Alert, conversant, Appears uncomfortable
HEENT: No oropharyngeal lesions, no other blistering lesions or
other concerning lesions
Neck: Supple, no lymphadenopathy
Cardiovascular: S1 and S2 only, without murmurs rubs nor gallops
Respiratory: Clear bilaterally
Gastrointestinal: Soft, NT, ND, normal active bowel sounds
Musculoskeletal: No joint swelling
Skin: Papular rash on extremities.
Extremities: Warm, well perfused, her lateral thigh wounds are
dressed with clean dressings after I and D.
.
Per Dr.[**Name (NI) 75507**] note, earlier exam showing: Warm, well perfused,
her lateral thigh wounds are without tenderness, redness,
[**Name (NI) **] or drainage. Her medial
thighs have two lesions on the inside of her medial thigh with a
small necrotic appearing eschar overlying an area of purplish
induration with underlying induration, tenderness with
surrounding erythema on skin. Left thigh with area of necrosis,
escar and induration with warmth and tenderness.
Pertinent Results:
WBC 11.7 (56N, 29L, 11E, 4M)
Hct 32.8, plt 105
BUN 22, creatinine 1.2, bicarb 26, lactate 2.4
U/A tr protein only; 3-5 wbcs, 0-2 rbcs
.
[**Date range (1) 75508**]:
PT-14.6* PTT-25.7 INR(PT)-1.3*
ALT-382* AST-173* LD(LDH)-346* AlkPhos-129* TotBili-0.3
.
Micro: swab with + MRSA
Brief Hospital Course:
59 year old female h/o recent femoral ORIF post op MRSA soft
tissue infection, previous hardware placement, s/p vanc tx c/b
DRESS syndrome, presenting with lesions of the medial thigh,
possibly related to skin excoriation with recent topical steroid
use, s/p I and D of thigh lesions in the ED. Culture with MRSA.
.
# Thigh lesions: Sent in from the [**Hospital **] clinic. s/p I and D in the
ED, cultures growing MRSA. Patient's ID fellow recommended Levo
and Dapto empirically for skin organism coverage, and this was
started. Surgery continued to follow her and performed a second
I&D on a third lesion that had begun to progress similar to the
others. With the start of daptomycin and levofloxacin, there
was initially concern of rash progression; however, this soon
improved without intervention. However, LFTs were noted to be
elevated (382/173). ID was formally consulted, and the risks
and benefits of continued antibiotic therapy were discussed.
Antibiotics ultimately stopped [**12-10**], with plan for close
monitoring and surgical drainage alone if possible. She
continued hot packs and short [**Last Name (un) **] baths per surgery recs. She
remained afebrile without leukocytosis for greater than 24 hours
without antibiotics. Blood cultures remained negative and she
had no evidence of cellulitis or more widespread infection. She
was discharged and will have rapid followup with her ID fellow
Dr. [**Last Name (STitle) 7443**] on Monday. Warning signs were repeatedly discussed
and she will return if her lesions progress.
.
# Rash: Since end of vanco therapy as HPI. T-cell mediated rash
on previous bx. Very pruritic. She had been on steroids for
this, and these were continued in house with taper as previously
scheduled (though she did get additional dose of steroids in the
ED). Has been overall improved since onset, but then with ? of
worsening erythema following admission. There was initially
some concern of this being due to daptomycin or other new
exposure, but erythema subsequently improved without
intervention. Her usual regimen of benadryl, pepcid, and
topical treatments were continued. Steroid taper continued as
above. Peripheral eosinophilia varied from 4 to 11% without
particular pattern. Dr. [**Last Name (STitle) 2603**], who had previously seen her
regarding DRESS, was consulted during this admission. He felt
further reaction to new antibiotics was unlikely; okay to retry
with dapto or levofloxacin in the future. Of note, vancomycin
should never be retried in the future.
.
# Peripheral eosinophilia: likely residual from [**Month (only) 404**] DRESS
syndrome. Patient with patent airway, no wheezing, SOB or
stridor. Steroid taper continued as above. Allergy consulted
as above.
.
# Hypotension: in ED, reported SBP in 80s. Improved with IVFs.
Anaphylaxis unlikely. There was no further hypotension or signs
of SIRS.
.
# Acute renal failure: likely due to dehydration. not on any
renal-toxic meds at the present time. Improved with IV fluid
hydration.
.
# Thrombocytopenia. Drop from 223->105 at admission. Perhaps [**1-3**]
the same inflamm process. HIT negative in the past. Likely
related to infection; steady improvement seen once treatment
begun. Fibrinogen normal to elevated.
.
# Abnormal LFTs: Possibly daptomycin related. Trended down, and
should further improve with d/c of dapto. ID/allergy/PCP to
follow as outpatient.
.
# Depression: euthymic, though slightly anxious regarding
infection. Continued sertraline, support and reassurance.
.
# Full code
Medications on Admission:
1. Benadryl 25 mg PO q8hours
2. Alendronate 10 mg PO daily
3. Sertraline 150 mg daily
4. Triamcinolone Acetonide 0.1 % Ointment apply [**Hospital1 **]
5. Hydroxyzine HCl 25 mg PO Q6hours prn
6. Ativan 1 mg PO bid prn anxiety
7. Imitrex PRN migraines
8. Methylprednisone taper
[**Hospital1 **] Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Alendronate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Methylprednisolone 8 mg Tablet Sig: 1-2 Tablets PO DAILY
(Daily): take 2 pills [**12-13**] and [**12-14**]; then decrease to 1 pill
daily starting [**2200-12-15**].
5. Diphenhydramine HCl 25 mg Tablet Sig: One (1) Capsule PO
every eight (8) hours as needed for priuritis.
6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for prurutis.
10. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical TID (3 times a day).
11. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for anxiety.
[**Month/Day/Year **] Disposition:
Home With Service
Facility:
Greater [**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**]
[**Last Name (NamePattern1) **] Diagnosis:
MRSA abscess of thigh, s/p incision and drainage.
DRESS (drug rash with eosinophilia and systemic symptoms)
Depression
[**Last Name (NamePattern1) **] Condition:
Stable
[**Last Name (NamePattern1) **] Instructions:
You were admitted with new abscesses in your thighs. The
surgeons performed incision and drainage of three of these
abscesses. We initially started you on antibiotics; however, we
have discontinued these, and they are improving following
surgical treatment alone.
.
Please return to the hospital or call your doctor if you
experience fever (temp >100.5); worsening swelling or redness
around the thighs; worsening of your rash, breathing, or facial
swelling; or any new symptoms that you are concerned about.
.
Please keep all of your appointments with your doctors,
including your appointment on Monday with Dr. [**Last Name (STitle) 7443**]. Take all
medications as prescribed. Since you have been here, we have
continued your steroid taper; please take 16 mg
methylprednisolone tomorrow and Sunday; then decrease to 8 mg
daily as previously directed starting on Monday. Be sure that
you are also taking calcium and vitamin D.
Followup Instructions:
Please remember to keep your appointment with Dr. [**Last Name (STitle) 7443**] on
Monday: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-12-15**]
9:30
.
You also have the following upcoming appointments at [**Hospital1 18**]:
[**Hospital1 **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-12-18**] 10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-12-18**] 10:50
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (allergy), MD Phone:[**Telephone/Fax (1) 9316**]
Date/Time:[**2200-12-18**] 1:00
.
You should have your CBC and liver function tests checked within
one week (will be arranged at followup ID appointment).
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
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"584.9",
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"041.11",
"288.3",
"311",
"682.6",
"573.3",
"784.2",
"V09.0",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
23573, 27109
|
18131, 18178
|
23272, 23550
|
29849, 30825
|
22162, 22217
|
27135, 27413
|
22232, 23253
|
21607, 21723
|
18078, 18093
|
4048, 4054
|
27443, 29826
|
18206, 21588
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4082, 4186
|
21745, 22044
|
22060, 22146
|
4217, 4625
|
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