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16468
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Discharge summary
|
report
|
Admission Date: [**2143-11-15**] Discharge Date: [**2143-11-28**]
Date of Birth: [**2093-10-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Seizures vs syncopal episodes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50yo woman with breast cancer metastatic to bones, liver, lungs,
and brain, admitted with concern for new seizures.
Ms. [**Known lastname 22552**] was initially diagnosed with left breast cancer (ER
negative, Her2 positive) in 10/[**2135**]. She underwent modified
mastectomy followed by adjuvant AC+T and radiation, completed
8/[**2136**]. In [**1-/2139**] she was diagnosed with metastatic disease to
the liver, bone, and lungs, and then developed brain metastases
in 5/[**2137**]. She underwent resection of these followed by
radiation, repeated at three events. Most recently she has been
treated with Avastin/Herceptin.
Ms. [**Known lastname 22552**] was seen today in clinic where she reported eight
episodes of falls and shortness of breath over the past few
days. She was noted to have brief periods of loss of
consciousness with postictal period during which she also became
transiently hypoxic. A CXR was performed noted a new RLL
consolidation.
In the ED she was evaluated by neurology and treated with Keppra
1g. She also received Ceftriaxone 1g.
ROS:
GEN: no fevers, chills, night sweats
HEENT: no vision changes, tinnitus, loss of hearing, dysphagia
CV: no chest pain
RESP: no cough, +shortness of breath, +orthopnea, no PND
GI: no abdominal pain, nausea, vomiting, diarrhea,
constipation, heartburn, hematochezia, melana
GU: no dysuria, hematuria, hesitancy, or change in frequency or
nocturia
SKIN: no rashes, lesions
NEURO: no weakness, paresthesias, numbness, headaches, dizziness
MUSCULOSKELETAL: no arthralgias, myalgias
Past Medical History:
Her oncological problems began in [**2136-9-25**] when she felt an
egg size mass in her left breast. She underwent an open biopsy
of the left breast that showed infiltrating lobular carcinoma,
ER negative, and Her2/neu positive. She underwent a left
modified radical mastectomy by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 364**], M.D. on [**2136-12-27**]
that showed the same [**Date Range 31255**]. There were 14/16 lymph nodes
positive for tumor. She then received 4 cycles of neoadjuvant
cyclophosphamide and Adriamycin, followed by 4 cycles of
Taxotere. She then completed chest irradiation by Dr. [**Last Name (STitle) 46811**] at
[**Hospital 1474**] Hospital, which she completed on [**2137-8-22**].
Her neurological problems began in mid-[**2138-4-26**] when she
experienced gradually worsening headaches. Head CT and MRI
showed a mass in the left cerebellum. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. performed
a suboccipital craniotomy on [**2138-5-15**]. The [**Date Range 31255**] was
consistent with metastatic breast cancer. She then received
stereotactic radiosurgery to the resection bed on [**2138-6-25**] to
1,500 cGy, followed by another surgical resection of the
previous site on [**2138-10-22**] and another radiation boost to 4,000
cGy from [**2138-11-14**] to [**2138-12-12**]. She then received Cyberknife
radiosurgery to a right cerebellar metastasis (1,800 cGy) and a
right superior cerebellar metastasis (1,600 cGy) on [**2140-6-27**] in
one fraction, followed by a suboccipital craniotomy on [**2141-11-8**]
for removal of right paramedian cerebellar metastasis. Since
[**2142-6-1**], she has been getting bevacizumab (every 2 weeks) and
Herceptin (weekly).
Social History:
Lives with her husband, [**Name (NI) **] tobacco, etoh use
Family History:
Sister died of lung cancerat 43yrs; father died of hymphoma at
63yrs, and
mother of heart attack at 52yrs. Siblings also with CAD.
Physical Exam:
T 96.3 HR 77 BP 144/86 RR 22 96%3L
GEN: alert and oriented, comfortable, no acute distress,
speaking full sentences but somewhat dysarthric and occasional
incorrectly placed word
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes
LYMPH: no anterior/posterior cervical, occipital,
supraclavicular, or axillary adenopathy
CARDIOVASCULAR: PMI nondisplaced, regular rate and rhythm
without murmurs, rubs, or gallops
LUNGS: bilateral crackles
ABDOMEN: soft, nontender, nondistended with normal active bowel
sounds. no masses. no hepatosplenomegaly by percussion or
palpation
EXTREMITIES: no clubbing, cyanosis, or edema
SKIN: no rashes, petechia, lesions, or echymoses
NEURO: cranial nerves II-[**Doctor First Name 81**] intact, with XII tongue deviates to
the left, strength 5/5 BUE, 3+/5 RLE, 4+/5 LLE, sensation intact
BUE/BLE to touch equal and symmetric
Pertinent Results:
Labs on Admission:
9.8
9.3>-----<350
30.9
N:80.8 L:13.0 M:3.6 E:2.4 Bas:0.1
136 99 11
----------- <92
3.7 29 0.4
Ca: 8.3 Mg: 2.1 P: 2.4
Alb: 3.2
PT: 11.9 PTT: 29.2 INR: 1.0
Studies:
EKG ([**11-4**]): Sinus rhythm. Delayed precordial R wave transition.
Compared to the previous tracing of [**2141-11-6**] the rate is
increased. Otherwise, no diagnostic interim change.
CXR ([**2143-11-15**]): 1. New appearance of diffuse multifocal
interstitial and septal thickening in the left upper zone is
concerning for an infiltrative process such as lymphangitic
carcinomatosis.
2. Additional confluent opacity in the right middle lobe is
concerning for
infectious process.
NCHCT ([**2143-11-15**]): 1. No definite acute intracranial abnormality.
2. Grossly unchanged post-surgical changes of the posterior
fossa. Please note that comparison is only made to MRI, a
different modality, which is
suboptimal.
3. Focal small area of calcification adjacent to the left
frontal [**Doctor Last Name 534**]
corresponds to area of enhancement on prior MRI.
4. Mucosal sinus disease and opacification of the right mastoid
air cells,
grossly stable since prior MRI from [**2143-8-30**].
CTA chest ([**2143-11-16**]): 1. No pulmonary embolism. No aortic
dissection.
2. Diffuse ground-glass opacities and septal thickening and
small bilateral effusions. Cardiomegaly. The constellation of
findings is most likely due to pulmonary edema. However,
lymphangitic carcinomatosis cannot be excluded. A followup chest
CT following treatment and resolution of symptoms is
recommended.
3. Focal consolidation of the right middle and left upper lobes
concerning
for superimposed infection.
TTE ([**2143-11-19**]): The left atrium is normal in size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 60-70%). There is no
ventricular septal defect. The right ventricular cavity is
dilated with normal free wall contractility. 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. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: moderate pulmonary hypertension with a dilated right
ventricle and moderate-to-severe tricsupid regurgitation
CT Head ([**2143-11-24**]): No acute intracranial injury. Stable
post-surgical change in the posterior fossa. Fluid in the
mastoid air cells.
CT C-spine ([**2143-11-24**]:
1. No acute cervical fracture or malalignment.
2. Known C4 metastasis. Sclerotic lesion seen on the vertebral
body, also
suspicious for metastasis.
3. Incompletely assessed posterior facets despite stable
post-surgical
appearance.
Chest Xray ([**2143-11-26**]: Severity of the global pulmonary
opacification has worsened since [**11-25**] indicating progression of
a component of pulmonary edema or hemorrhage superimposed on
extensive pulmonary metastatic involvement. Heart size is
slightly larger today. Small pleural effusions are presumed.
Right subclavian infusion port ends in the mid-SVC. No
pneumothorax.
Brief Hospital Course:
50yo woman with breast cancer metastatic to liver, lungs, bone,
and brain admitted with seizures and RLL pneumonia.
#. Hypoxia: As bevacizumab can increase risk of thrombosis, a
CTA was ordered to rule out PE. This did not show evidence of
PE. The CT did however show diffuse ground-glass opacities and
septal thickening and small bilateral effusions, concerning for
possible lymphangitic carcinomatosis. Pulmonology was consulted
who thought that these infiltrates were likely responsible for
her hypoxemia. She underwent speech and swallow evaluation and
was found to have silent aspirations which was likely to
exacerbate her hypoxia. Diuresis was started and the patient
was placed on aspiration precautions. Because of a worsening
respiratory status, she was transferred to the [**Hospital Unit Name 153**] for further
management of hypoxia and respiratory distress. She required a
nonrebreather and initially was maintaining O2 sats in 98-100%.
Urine legionella, and influenza were negative. The patient was
started on IV Decadron for possible lymphagitic spread. She was
also empirically started on treatment with Vancomycin, Cefepime
and Azithromycin. Blood, and urine cultures were negative.
Induced sputum was negative for PCP, [**Name10 (NameIs) **] only grew normal
oropharyngeal flora. PCP treatment was initiated empirically
given recent steroid therapy but did not appear to have any
benefit. TTE showed moderate pulmonary hypertension with a
dilated right ventricle and moderate-to-severe tricsupid
regurgitation. Given the possibility of pulmonary edema
secondary to diastolic dysfunction contributing to respiratory
distress, she was aggressively diuresed. Over the next several
days, the patient had a modest improvement in respiratory status
with sats in high 90's on 60% face mask. Given the patient's
respiratory ditress, and per discussion with the patient and
family, a transbronchial biopsy was not attempted. Nonetheless,
it is believed that the primary cause of respiratory distress
was lymphagitic spread of breast carcinoma. Multiple family
meetings were held to discuss goals of care. Eventually, she
was made comfort-measures only and started on a morphine drip
for comfort and respiratory distress. She died on [**2143-11-28**] at
11:26am. Her neurologist, oncologist and primary care physician
were notified.
Metastatic Breast Cancer: As an ouptatient, she was getting
bevacizumab and Herceptin. She has brain metastasis and
radiation induced necrosis which likely explains her cerebellar
dysfunction.
Seizure: Patient had an EEG which showed no overt electrographic
seizure activity, but suggested a possible focus of cortical
irritability and potential for epileptogenesis as well as
subcortical dysfunction in the left mid to posterior temporal
region. Prolactin levels were within normal limits. Patient
was continued on seizure prophylaxis with keppra. She did not
have any further seizure activity.
Medications on Admission:
Atenolol 25mg po daily
Vicodin Q4 hr prn pain
Neurontin 300mg TID - not taking
Effexor XR 112.5mg daily
Prilosec 20mg daily
Pilocarpine 5mg TID
Claritin prn allergy symptoms
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
respiratory failure
pneumonia
Secondary:
Metastatic Breast Cancer
Seizure
Discharge Condition:
deceased
Followup Instructions:
|
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icd9cm
|
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[
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[] |
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,510
| 102,257
|
5416
|
Discharge summary
|
report
|
Admission Date: [**2149-8-10**] Discharge Date: [**2149-8-11**]
Date of Birth: [**2094-9-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Transfer after cardiac arrest
Major Surgical or Invasive Procedure:
Left Femoral Central Line
Cardioversion
Defibrillation
On transfer from OSH:
Intubation
Right Femoral Arterial Line
Right IJ temporary pacing wire
Left IJ central line/Swam Ganz catheter
foley Catheter
History of Present Illness:
Pt is a 54 F with h/o non-ischemic cardiomyopathy, diastolic CHF
with EF >55%, MR, severe pulm HTN thought [**2-21**] UIP/IPF on
steroids, DM2, HTN, PAF on coumadin, s/p renal Xplant in [**2143**] on
IS, who presents from [**Hospital 21970**] Hospital after asystolic arrest.
Per report, the patient presented to [**Hospital 1474**] hospital on
[**2149-8-2**] after feeling sudden onset of palpitations, chest pain,
and SOB. In the ED, she was treated for her CP but was found to
be in pulm edema and rapid afib. She was admitted to the ICU for
further care, where they aggressively rate controlled her and
diuresed her with lasix. Given her rapid afib, the patient was
started on sotalol on [**8-4**], where she converted to sinus rythm
on [**8-5**]. The patient remained stable until the afternoon of
transfer.
Per report, the patient subsequently went into asystolic arrest
at about 2:30PM on [**8-10**] requiring defibrillation, epi 1mg x4,
atropine 1mg x1, vasopressin 40units x1, lidocaine 100mg x1,
Amiodarone 150mg x1, bicarb, Ca returning her to sinus rythm.
There were no reported shocks. She was intubated during this
event and started on dopamine/neo for sbps in the 80s. In the
ICU, a PA line was placed demonstrating CVP 16, PAP 85/35 and
PCWP 40 with CO 1.4. A R fem A-line was placed, as was a temp
pacing wire for bradycardia. The patient was then switched to
nitro/levophed and given lasix 100mg IV x1. Bedside echo showed
EF 40%. ABG at the time of transfer was 7.35/31/60 on 100% Fi02
and PEEP 5. Due to family request, the patient was transferred
to [**Hospital1 18**] for further care.
On arrival to [**Hospital1 18**], the patient was intubated and sedated with
possible responsiveness. She arrived on nitro/levophed drip. She
was unable to provide history.
Also of note, the patient was recently admitted to [**Hospital1 18**] on
[**2149-6-12**] for increased abd girth and SOB thought [**2-21**] CHF
exacerbation. She was diuresed at that time with
lasix/metolazone. The patient also underwent R heart cath
confirming pulm hypertension(RVEDP = 20 mm Hg, mean PCWP 11 mm
Hg, pulmonary artery pressure 79/59 mm Hg). She underwent lung
biospy and evaluation by pulmonology showing likely UIP/IPF and
was started on high dose prednisone. She was also maintained on
cytoxan for her renal transplant.
ROS: Unable to obtain review of systems due to patient being
intubated/sedated.
Past Medical History:
Non-ischemic cardiomyopathy/CHF: Echo [**2149-6-13**]: EF >55%, 1+ MR,
severe pulm HTN, RV dilation c/w overload
- Pulmonary HTN: R heart cath on [**6-19**] with pulmonary artery
pressure 79/59 mm Hg.
- IPF/UIP--likely from aspiration pneumonitis-Patient has
documented room air saturation of 85%. Diagnosis is Interstitial
pulmonary fibrosis/UIP per thoracotomy and lung biospy
- Paroxysmal Afib with RVR with h/o conversion pauses to sinus.
On coumadin, recently started on sotalol
- ESRD secondary to chronic pyelonephritis, s/p cadaveric
kidney transplant on [**2143-11-12**]
- Diabetes Mellitus Type 2
- Hypertension
- Hyperlipidemia
- Anemia-multifactorial, ACD, ESRD on EPO, Baseline hct 28-35
h/o rhabdomyolysis
- Gout
- Hypothyroidism
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension
Cardiac History: CABG: N/A
Percutaneous coronary intervention, in [**2140-10-21**]:
1. Resting hemodynamics demonstrate mildly elevated right heart
filling pressures. The mean RA pressure was 5mm Hg. The RV
systolic pressure was 42mm Hg. The mean wedge pressure was 12mm
Hg. The pulmonary arterial systolic pressure was 42mm Hg, with
an elevated PVR of 200 dynes-sec/cm2. LVEDP was 12mm Hg. The
cardiac index was 4.5 l/min/m2.
2. Coronary arteriography demontrates no siginifcant disease,
with mild luminal irregularities of the LAD.
3. Left ventriculography demonstrates moderate LV dysfunction
with
global hypokinesis. There was moderate (2+) mitral
regurgitation.
Pacemaker/ICD: N/A
Social History:
Pt. denies smoking, alcohol or illicit drug use. Pt. is
originally from [**Male First Name (un) 1056**], but moved to the US when she was
young and was raised here. She lives with her husband in
[**Name (NI) 1474**].
Family History:
There is history of renal failure and hypertension in the
family.
Physical Exam:
VS: Afebrile, BP 128/90 , HR , RR , O2 % on
Gen: Intubated, sedated female
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with left IJ swan in place. JVP to mandible.
CV: PMI displaced laterally. RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Diffuse
crackles.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No cyanosis/clubbing. Trace b/l edema. No femoral bruits.
Cold, dry extremities.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Ext: left UE fistula w/ bruit
Pertinent Results:
[**2149-8-10**] 08:37PM WBC-12.8*# RBC-3.48* HGB-11.8* HCT-37.0
MCV-106* MCH-34.0* MCHC-32.0 RDW-22.5*PLT COUNT-125*
CALCIUM-10.5* PHOSPHATE-6.6*# MAGNESIUM-2.7* GLUCOSE-129* UREA
N-107* CREAT-2.2* SODIUM-142 POTASSIUM-5.2* CHLORIDE-109* TOTAL
CO2-22 ANION GAP-16 LACTATE-2.6* TYPE-ART PO2-74* PCO2-45
PH-7.32* TOTAL CO2-24 BASE XS--3 freeCa-1.44*
[**2149-8-10**] 08:37PM CK-MB-35* cTropnT-1.40* CK(CPK)-209*
[**2149-8-10**] CXR: Swan-Ganz catheter remains distally positioned with
the tip projecting lateral to the right hilum, likely within a
segmental branch of the right middle or right lower lobe artery.
Other devices remain in standard position except for a right
PICC line, which crosses the midline to terminate at the
junction of the left brachiocephalic and left subclavian veins.
Bilateral combined alveolar and interstitial opacities are again
demonstrated. Alveolar opacities improved on the left but worse
on the right, likely due to rapidly shifting edema, although
superimposed secondary process in the right lung such as
hemorrhage or aspiration is also possible in the appropriate
setting. Small left pleural effusion is unchanged, but
small-to-moderate right pleural effusion has increased.
Position of the PICC line and Swan-Ganz catheter have been
communicated by telephone to Dr. [**Last Name (STitle) 20858**] by telephone on [**2149-8-10**]
[**2149-8-10**] CXR: Swan-Ganz catheter projects distal to the right
hilar contour, likely within a proximal segmental vessel of the
right middle or lower lobe. Right PICC line courses medially
within the left brachiocephalic vein with distal tip at the
junction of the left brachiocephalic vein and left subclavian
vein.
Endotracheal tube tip is not well demonstrated, but has been
better visualized on the subsequent radiograph performed 2215
(dictated under clip [**Clip Number (Radiology) 21971**]). Temporary pacing lead terminates
in right ventricle and nasogastric tube courses below the
diaphragm to terminate in the distal stomach near the junction
with the duodenum.
Cardiac silhouette is enlarged, and pulmonary vascularity is
engorged. Bilateral combined alveolar and interstitial pattern,
worse on the left than the right probably reflects pulmonary
edema. Small pleural effusions are present as well as
preexisting right-sided pleural thickening.
Position of lines and tubes was discussed by telephone on the
morning of [**2149-8-11**], with Dr. [**Last Name (STitle) 21972**].
[**2149-8-10**] ECG:Probable sinus rhythm with sinus arrhythmia and
extensive baseline artifact. Low voltage in the limb leads. ST-T
wave changes anterolaterally consistent with ischemia. Compared
with the prior tracing of [**2149-6-19**] anterolateral ST-T wave
changes are more prominent and QTc interval is shorter.
Brief Hospital Course:
54 F with non-ischemic cardiomyopathy, PAF, severe pulm HTN and
R heart failure, DM2, HTN, s/p renal xplant in [**2143**] presents
from OSH after episode of CP/SOB and cardiac arrest on day of
transfer to [**Hospital1 **]. She was coded with CPR, multiple doses of
epinephrine, atropine, CaCl, vasporession, bicarb, and dopamine
at the outside hopsital. Pressor support with levophed and nitro
on transfer.
Approximately one hour after arrival to the CCU at [**Hospital1 18**], the
patient went into PEA cardiac arrest. She recieved CPR, epi,
atropine, CaCl, vasopressin, and bicarb. Neosynephrine and
levophed were continued for pressor support. Patient had
episodes of maintaining blood pressure after epinephrine but
then would become hypotensive and return to PEA when placed on
ventilator. Patient developed pink, frothy sputum from ET tube.
IV lasix 300mg and bumex x2 failed to create urine output.
Swan showed significantly evelvated PA pressures, at times
higher than SBP. Beside echo with no evidence for tamponade.
CXR without sign of pneumothorax. Patient was not
hypo/hyperthermic. Labs drawn during the code without evidence
of hypo/hyperkalemia. Patient developed one episode of VFib and
was shocked and one episode of atrial fibrillation and she was
cardioverted. Both attempts failed to produce profusing rhythm.
Trial of inhaled NO to get pulm A pressures down failed
secondary to systolic hypotension. Trial of hemodialysis failed
with systolic hypotension. The code was called after 2 hours
and 15mins. Patient's family was at the hospital and notified.
Priest called at the request of the family.
Medications on Admission:
HOME MEDICATIONS:
Metoprolol 50 mg PO BID
Prednisone 60 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Folic Acid 1 mg PO DAILY
Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY
Sevelamer 800 mg PO TID
Aspirin 325 mg PO DAILY
Levothyroxine 25 mcg PO DAILY
Cytoxan 50 mg PO Daily
Furosemide 80 mg PO BID
Insulin NPH 28units daily + sliding scale
Oxycodone 5 mg, 1-2 Tablets PO Q4-6H
Hydromorphone 2-4 mg PO Q3-4H
.
MEDICATIONS ON TRANSFER:
Cytoxan 50mg daily
Aspirin 325mg daily
Nitro 1 tab q5min prn
Tylenol 325-650mg q4-6 prn
Colace 100mg [**Hospital1 **]
RISS
Folic acid 1mg daily
Sevelamer 800mg TIW with meals
Prednisone 60mg daily
CaC03 1g daily
Vit D 800units daily
NPH 28units daily
Bactrim DS 0.5 daily
Levoxyl 50mcg daily
Neurontin 100mg HS
Sotalol 80mg daily
Imdur 60mg Daily
Esomeprazole 40mg [**Hospital1 **]
Morphine
Lasix 40mg daily
Famotidine 20mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulseless Electrical Activity Cardiac Arrest
Pulmonary Hypertension
Idiopathic Pulmonayr Hypertension
status post Ventricular Fibrilation arrest at outside hospital
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
"427.31",
"515",
"427.5",
"V58.65",
"250.00",
"427.41",
"V58.61",
"428.0",
"428.32",
"272.4",
"401.9",
"V42.0",
"416.8",
"424.0",
"425.4",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"99.62",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10971, 10980
|
8396, 10031
|
302, 506
|
11188, 11198
|
5576, 8373
|
11251, 11258
|
4714, 4781
|
10942, 10948
|
11001, 11167
|
10057, 10057
|
11222, 11228
|
4796, 5557
|
10075, 10462
|
233, 264
|
534, 2939
|
10487, 10919
|
2961, 4463
|
4479, 4698
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,472
| 117,593
|
16293
|
Discharge summary
|
report
|
Admission Date: [**2169-1-13**] Discharge Date: [**2169-1-16**]
Date of Birth: [**2095-1-16**] Sex: M
Service: CCU
This is a patient who was initially transfered from [**Hospital 1474**]
Hospital for elective AICD who en route developed respiratory
distress and was initially admitted to the [**Hospital1 346**] MICU status post intubation. He was
then transferred from the MICU to the CCU after AICD and
catheterization.
HISTORY OF PRESENT ILLNESS: This is a 74-year-old male with
a history of dilated cardiomyopathy with an ejection fraction
of 20%, chronic obstructive pulmonary disease, NSVT, atrial
fibrillation who is status post a V fib arrest at [**Hospital 1474**]
Hospital and transferred here for AICD placement.
The patient had a syncopal episode on [**2169-1-8**] and
was found to be in V tach by EMS, but stable. He developed
increased shortness of breath upon arrival to [**Hospital 1474**]
Hospital and was found to have wide complex tachycardia at
195 beats per minute at that time. He was cardioverted and
went into V fib arrest and was defibrillated. He was
intubated at this time for airway protection, loaded with
Amiodarone. Status post his defibrillation, he also spiked a
fever to 101.5 F and was started on antibiotics for a
question of aspiration pneumonia which were later
discontinued when he failed to spike again and failed to have
an increased white blood cell count. He is transferred to
[**Hospital1 69**] for an AICD placement at
this time.
On the ambulance ride over to [**Hospital1 188**], the patient had increasing shortness of breath, chest
tightness and respiratory distress. His pulse went from 78
to 140. In the emergency room at [**Hospital1 190**], he was found to be in atrial fibrillation
with wide complex with his history of old left bundle branch
block. He was thought to be in congestive heart failure and
given Lasix. He continued to develop increasing respiratory
distress and was intubated once again. He was placed on AC
ventilation 12 / 700 / 5 / 100% fio2 and was noted to have
poor air movement on auscultation and an ABG of 7.31 / 53 /
370. At this time, he was thought to have a chronic
obstructive pulmonary disease exacerbation and was given
Solu-Medrol. A chest x-ray done during this period of
respiratory distress showed a right patchy opacity and the
patient was thought to have a question of infection and was
also started on Levaquin.
During the intubation, the patient had a decreased blood
pressure to 60 systolic after being started on Propofol. He
was initially admitted to the MICU Team. The patient had a
cardiac catheterization and AICD placement and then was
transferred to the CCU Team.
PAST MEDICAL HISTORY:
1. Dilated cardiomyopathy times 12 years status post
inferior MI [**2168-11-27**] with an ejection fraction of 20%
with moderate pulmonary hypertension, biventricular
enlargement.
2. Nonsustained ventricular tachycardia previously on
Amiodarone which was discontinued four weeks ago.
3. Chronic obstructive pulmonary disease with a history of
multiple intubations, FEV1 of 1.37.
4. Home oxygen.
5. Question of pulmonary fibrosis.
6. Atrial fibrillation.
7. Hypothyroidism.
8. Patient has a pacemaker.
MEDICATIONS AT HOME:
1. Nitroglycerin.
2. [**Doctor First Name **] 60 b.i.d.
3. Levoxyl 25 mcg q.d.
4. Coumadin three q.o.d. and four q.o.d.
5. Allopurinol.
6. Advair Diskus.
7. Atrovent.
8. Lipitor 40 q.d.
9. Patient recently completed a steroid taper.
MEDICATIONS ON TRANSFER TO [**Hospital1 18**] FROM OUTSIDE HOSPITAL:
1. Flovent b.i.d.
2. Advair Diskus.
3. Lipitor 80 q.d.
4. Synthroid 75 mcg.
5. Allopurinol.
6. Amiodarone.
7. Flagyl 500 t.i.d.
8. Ambien.
9. Coumadin.
MEDICATIONS ON TRANSFER FROM THE MICU TO THE CCU:
1. Vancomycin 500 mg b.i.d. times three days status post
AICD placement.
2. Amiodarone 400 b.i.d.
3. Metoprolol 12.5 b.i.d.
4. Aspirin 325 q.d.
5. Levaquin 500 q.d.
6. Flagyl 500 t.i.d.
7. Albuterol / Ipritroprium inhaler.
8. Protonix 40 q.d.
9. Levothyroxine 75 q.d.
10. Atorvastatin.
11. Heparin drip.
12. Fentanyl.
13. Colace.
14. Senna.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is 150
pack year smoker who quit 15 years ago. Patient quit alcohol
two years ago. Formerly had six beers per day times 50
years.
VITAL SIGNS AFTER TRANSFER: Afebrile, blood pressure 118/60,
MAP 78, pulse 72, saturation 98% on AC vent 12 / 650 / fio2
40%.
PHYSICAL EXAMINATION: In general patient is intubated, awake
and responds to commands. Head, eyes, ears, nose and throat:
Pupils equal and reactive. Anicteric sclerae. ETT in place.
Neck: The patient is lying flat. Chest: He is vented and
clear anterolaterally. Cardiac: Faint heart sounds, no
murmurs. Abdomen: Normoactive bowel sounds, nontender,
nondistended with no organomegaly. Extremities: No bruit at
right groin. Clean, dry and intact cath site. No hematoma.
No cyanosis, clubbing or edema. Dorsalis pedis pulses are 2+
bilaterally. Neuro: The patient moves all four extremities
and follows command. He is pulling at his endotracheal tube.
LABORATORY DATA: White blood count 7.6, hematocrit 34.4,
platelets 298,000. INR 1.7. Sodium 140, potassium 4.9,
chloride 105, bicarbonate 24, BUN 32, creatinine 1.4, glucose
160, calcium 8.1, phosphorus 3.3, magnesium 2.5.
Urinalysis with large blood, positive nitrates, total
protein, no leukocyte esterase, no white blood cells, no
yeasts, 21 to 50 red blood cells. Urine BUN 889, urine
creatinine 125, urine sodium is 66, fractional secretion of
BUN is 31%.
CKs are 319 to 221, MB 9 and 7, troponin less than 0.3 times
two.
Sputum with oropharyngeal flora, greater than 25 polyps,
lactate 1.0.
ABG: 7.45 / 373 / 36 on 100% fio2.
Chest x-ray: Endotracheal tube 7.9 cm above the carina,
hyperinflated lungs, improved interstitial opacities
consistent with congestive heart failure is asymmetric.
Echo: Ejection fraction of less than 15% global, LV
hypokinesis, dilated left atrium, normal valves.
Cardiac catheterization: Hemodynamics show a right atrium of
9, right ventricular of 36/10, PA pressure 36/24, pulmonary
capillary wedge pressure of 17. Cardiac output of 4.8,
cardiac index of 2.2. SVR 1233, PVR 117. SVC saturation
69%. RCA shows 20% stenosis, distal LAD 50% stenosis.
HOSPITAL COURSE: This is a 74-year-old male with severe
nonischemic cardiomyopathy with an ejection fraction of less
than 15%, history of IMI, atrial fibrillation, NSVT formally
on Amiodarone which was discontinued recently for a question
of pulmonary fibrosis, chronic obstructive pulmonary disease
who is transferred from an outside hospital after syncope and
V fib arrest. The patient is also status post intubation
upon arrival to [**Hospital1 69**] for
question of congestive heart failure / chronic obstructive
pulmonary disease exacerbation and respiratory distress.
1. CARDIAC: A. PUMP: Patient has nonischemic
cardiomyopathy as his cardiac catheterization did not show
significant coronary artery disease. For his cardiomyopathy,
he was started on Captopril 6.25 mg p.o. t.i.d. which was
later changed to Lisinopril 2.5 q.d. and this can be
increased as his blood pressure tolerates. He will also be
continued on Toprol XL 25 q.d. Mr. [**Known lastname 24397**] will follow up
with Dr. [**Last Name (STitle) **] in the Heart Failure Clinic.
B. EP: Patient has a history of nonsustained V tach and
recent V tach and V fib arrest now status post AICD
placement. He also has a history of atrial fibrillation and
continued in well rate controlled atrial fibrillation during
this admission. He was continued on a beta blocker. His
Amiodarone was discontinued for his history of question of
pulmonary fibrosis. He was restarted on Coumadin for his
history of atrial fibrillation and cardiomyopathy. His
Coumadin level will be followed by his primary care doctor
and the visiting nurses will draw his INR level. He will
follow up with the Device Clinic in seven days.
C. CORONARY ARTERY DISEASE: The patient had no evidence of
flow limiting lesions on his cardiac catheterization. He
will continue on aspirin 81 mg p.o. q.d. He will also
continue his Atorvastatin 40 p.o. q.d. and his beta blocker.
2. PULMONARY: Patient with history of severe chronic
obstructive pulmonary disease and multiple intubations. He
was extubated on the morning after his admission to the
Coronary Care Unit. He had no other episodes of respiratory
distress after his extubation. His antibiotics were stopped
as there was no evidence of pneumonia on his chest x-ray,
rather it was likely consistent with asymmetric congestive
heart failure. This improved after some mild diuresis. He
will continue on his Advair Diskus and his Combivent inhalers
at home.
3. GENITOURINARY: The patient had evidence of urinary
obstruction after his Foley catheter was discontinued. This
was relieved after he was started on Finasteride 5 mg p.o.
q.d. and continued on this.
4. ENDOCRINE: He was continued on his Levothyroxine for his
history of hypothyroidism.
5. OPHTHALMOLOGIC: He was continued on Gentamycin
ophthalmic drops for his conjunctivitis.
6. RENAL: His creatinine was 1.4 and remained stable status
post cardiac catheterization with no evidence of contrast
nephropathy.
7. HEMATOLOGY: His hematocrit remained stable in the low
30s without any signs of bleeding. He was restarted on his
Coumadin for discharge and will follow up with his primary
care doctor for level monitoring.
DISPOSITION: The patient was discharged home with VNA
Services, home O2 and INR monitoring. Goal INR was 2 to 3.
He will take Coumadin 7.5 once on the day of discharge and
then have it dose as per his levels. He will follow up at
the Device Clinic at [**Hospital1 69**] in
seven days and his PCP within two weeks. He will follow up
with his outpatient cardiologist within two weeks which is
Dr. [**Last Name (STitle) **]. He will also call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3512**] to
follow up with her in Heart Failure Clinic.
DISCHARGE DIAGNOSIS:
1. Tachycardic ventricular fibrillation status post AICD.
2. Atrial fibrillation.
3. Chronic obstructive pulmonary disease.
4. Congestive heart failure.
5. Cardiomyopathy.
6. Hypothyroidism.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Warfarin dose as per INR.
2. Aspirin 81 p.o. q.d.
3. Finasteride 5 mg p.o. q.d.
4. Gentamycin Sulfate ophthalmic drops, two drops OU q. 12
hours for two weeks.
5. Advair Diskus inhaler.
6. Combivent inhaler.
7. Pantoprazole 40 mg p.o. q.d.
8. Levothyroxine 75 mcg p.o. q.d.
9. Atorvastatin 40 mg p.o. q.d.
10. Toprol XL 25 mg p.o. q.d.
11. Lisinopril 2.5 mg p.o. q.d.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 7783**]
MEDQUIST36
D: [**2169-1-18**] 14:01
T: [**2169-1-18**] 16:01
JOB#: [**Job Number 46447**]
|
[
"274.9",
"428.0",
"272.0",
"518.82",
"244.9",
"599.6",
"372.30",
"425.4",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"88.56",
"37.23",
"96.71",
"93.90",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
10152, 10350
|
10410, 11068
|
6391, 10131
|
3258, 4171
|
4523, 6373
|
474, 2705
|
2727, 3237
|
4188, 4500
|
10375, 10384
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,816
| 156,625
|
40060
|
Discharge summary
|
report
|
Admission Date: [**2157-2-1**] Discharge Date: [**2157-3-25**]
Date of Birth: [**2115-6-15**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Chlorhexidine
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Liver failure
Major Surgical or Invasive Procedure:
intubation
paracentesis x4
hemodialysis
History of Present Illness:
41 year old male with history of HCV/cirrhosis and EtOH abuse
(last drink on [**Month (only) 216**]) being transferred fro [**Hospital 40074**]Hospital for liver transplant work-up. He was admitted on
[**2157-1-8**] to RIH with severe pneumonia and intubated in the ED
for acute respiratory distress and transferred to the MICU. He
was treated in broad spectrum abx initially and then narrowed
for Strep pneumoniae in blood and sputum cultures for a total of
18 days. He developed a large right parapneumonic pleural
effusion that was tapped initially. For concerns for this being
an empyema a right chest tube was placed, but then removed
several days after (per notes finally not felt to be an
empyema). He was extubated on [**2157-1-23**], however had to be
reintubated on [**2157-1-27**] for decreased mental status and had an
aspiration event. He was again treated for potential aspiration
pneumonia with vanc/cefepime until [**2157-1-30**], but these were
stopped for no having evidence of fevers or WBC. During the past
2 days has been with progressive renal failure from 2.0 on [**1-29**]
to 3.5 (baseline of 1.3) and has been oliguric, was started on
dopamine for 'potential increase in urine output'. He has
required several blood transfusions, latest had 2U pRBC
yesterday but no signs of bleeding, and his latest Hct is 25.4.
Past Medical History:
DM2
Hepatitis C
grade II esophageal varices
portal hypertensive gastropathy
EtOH abuse (last drink in [**2156-9-12**])
asthma
allergic rhinitis
(no past surgical history)
Social History:
Smokes 1PPD.
EtOH abuse (unclear amounts) until [**2156-9-12**].
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
T 98.6 HR 104 BP 125/67 RR 19 SO2 99%/CMV 100% 500x16 PEEP 10
General: intubated, off sedation.
Neuro: Unresponsive off-sedation. Opens eyes and has some
involuntary movements.
Lungs: Clear to Auscultation bilaterally
Cardiac: Regular rate and rhythm, S1/S2
Abd: Soft, Nontender, distended
Extrem: Warm, well-perfused, palpable distal pulses in all
distal extremities. Slight pitting edema. Has rash in torso and
all extremities with erythema and mild desquamation
Pertinent Results:
ADMISSION LABS
[**2157-2-1**] 10:35PM BLOOD WBC-12.3* RBC-2.83* Hgb-8.9* Hct-28.5*
MCV-101* MCH-31.5 MCHC-31.4 RDW-19.6* Plt Ct-100*
[**2157-2-1**] 10:35PM BLOOD Neuts-78.5* Lymphs-13.4* Monos-3.8
Eos-3.2 Baso-1.1
[**2157-2-1**] 10:35PM BLOOD PT-21.3* PTT-44.6* INR(PT)-2.0*
[**2157-2-1**] 10:35PM BLOOD Fibrino-173
[**2157-2-1**] 10:35PM BLOOD Glucose-130* UreaN-123* Creat-3.7* Na-142
K-6.0* Cl-116* HCO3-16* AnGap-16
[**2157-2-1**] 10:35PM BLOOD ALT-27 AST-47* LD(LDH)-219 AlkPhos-80
Amylase-60 TotBili-1.3
[**2157-2-1**] 10:35PM BLOOD Albumin-2.3* Calcium-7.3* Phos-10.6*
Mg-2.2
[**2157-2-1**] 10:59PM BLOOD Lactate-1.0
PERTINENT LABS
[**2157-2-15**] peak T bili - 3.8*
[**2157-2-2**] 02:21AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-POSITIVE
[**2157-2-14**] 02:43PM BLOOD CEA-3.0 AFP-3.3
[**2157-2-11**] 09:55AM BLOOD HIV Ab-NEGATIVE
[**2157-2-2**] 02:21AM BLOOD HCV Ab-POSITIVE*
DISCHARGE LABS
[**2157-3-25**] 05:45AM BLOOD WBC-7.8 RBC-2.88* Hgb-9.6* Hct-28.2*
MCV-98 MCH-33.5* MCHC-34.1 RDW-18.7* Plt Ct-80*
[**2157-3-25**] 05:45AM BLOOD PT-21.5* INR(PT)-2.0*
[**2157-3-25**] 05:45AM BLOOD Glucose-177* UreaN-30* Creat-3.3*#
Na-132* K-3.2* Cl-96 HCO3-27 AnGap-12
[**2157-3-25**] 05:45AM BLOOD ALT-29 AST-45* AlkPhos-173* TotBili-1.5
[**2157-3-25**] 05:45AM BLOOD Albumin-2.7* Calcium-7.8* Phos-2.6*
Mg-1.9
[**2157-3-22**] 04:11AM BLOOD Type-ART pO2-106* pCO2-42 pH-7.42
calTCO2-28 Base XS-2
[**2157-3-21**] 06:33AM BLOOD Lactate-1.6
PERITONEAL FLUID
[**2157-2-13**] 11:27AM ASCITES WBC-1500* HCT,fl-7.0* Polys-83*
Lymphs-8* Monos-4* Eos-4* Basos-1*
[**2157-2-16**] 03:22PM ASCITES WBC-2750* HCT,fl-7.5* Polys-62*
Lymphs-15* Monos-10* Eos-3* Macroph-10*
[**2157-2-21**] 01:43PM ASCITES WBC-433* HCT,fl-7.0* Polys-48*
Lymphs-12* Monos-0 Eos-2* Macroph-38*
[**2157-3-4**] 04:17PM ASCITES WBC-300* HCT,fl-3.0* Polys-39*
Lymphs-6* Monos-0 Mesothe-2* Macroph-53*
[**2157-3-11**] 02:19PM ASCITES WBC-110* RBC-[**Numeric Identifier **]* Polys-38*
Lymphs-33* Monos-20* Eos-2* NRBC-2* Mesothe-2* Macroph-3*
[**2157-3-20**] 11:53AM ASCITES WBC-270* RBC-[**Numeric Identifier 82693**]* Polys-25* Bands-1*
Lymphs-26* Monos-0 Atyps-3* Metas-1* Mesothe-4* Macroph-40*
PLEURAL FLUID
[**2157-2-3**] 11:02AM PLEURAL WBC-2800* Hct,Fl-3* Polys-48*
Lymphs-15* Monos-0 Eos-16* Atyps-1* Meso-1* Macro-19*
[**2157-2-14**] 03:15PM PLEURAL WBC-2125* Hct,Fl-2.5* Polys-31*
Lymphs-7* Monos-48* Eos-14*
[**2157-2-3**] 11:02AM PLEURAL TotProt-3.3 Glucose-145 LD(LDH)-640
Cholest-21
[**2157-2-14**] 03:15PM PLEURAL TotProt-4.3 Glucose-91 Creat-2.2
LD(LDH)-597 Amylase-43 Albumin-1.9
CHEST (PORTABLE AP) Study Date of [**2157-3-21**] 8:06 AM
FINDINGS: Compared to the study approximately three hours prior,
there is
worsening opacity in the left mid lung. The right basilar
consolidation
continues to become worse, although aeration in the right upper
lobe is
somewhat better. A right-sided central line and esophageal and
gastric
catheter are stable. There is no pneumothorax. Small bilateral
pleural
effusions are present.
IMPRESSION: Worsening right basilar and left mid lung opacities,
which again could be infection, edema, or hemorrhage. Somewhat
improved right upper lobe aeration.
PORTABLE ABDOMEN Study Date of [**2157-3-21**] 8:06 AM
FINDINGS: Post-pyloric NG tube remains in place. There is
generalized
graying of the abdomen consistent with continued ascites. There
is a
nonspecific bowel gas pattern. There is no evidence of free air
or
pneumatosis. Degenerative changes are again noted throughout the
lower lumbar spine as well as the pubic symphysis.
IMPRESSION: Post-pyloric nasogastric tube remains stable. No
evidence of
small bowel obstruction.
--------------------
Radiology Report L-SPINE (AP & LAT) Study Date of [**2157-3-16**] 10:29
AM
IMPRESSION:
1. Degenerative changes of the lumbar spine, worst in the lower
lumbar spine as described above.
2. Findings above concerning for partial small-bowel obstruction
or early
complete small-bowel obstruction. Please see abdominal
radiographs for
further details.
3. Enteric feeding tube.
------------------
MR HEAD W & W/O CONTRAST Study Date of [**2157-2-6**] 2:05 PM
CONCLUSION: Multiple areas of T2 hyperintensity within the
cerebral
hemispheres, described above. These abnormalities could likely
reflect
hepatic encephalopathy, as noted in a recent article (AJNR
10:3174, [**2154**]),
despite the absence of the more typically seen pre-contrast T1
hyperintensity in the globus pallidus. Ischemic or infectious
processes could also be considered. However, if hepatic
encephalopathy is the correct diagnosis, the finding is
potentially reversible, provided the abnormal metabolic state is
addressed and corrected.
MRA BRAIN W/O CONTRAST Study Date of [**2157-2-28**] 7:04 PM
IMPRESSION:
Stable areas of signal abnormality on T2 and FLAIR images within
the white
matter bilaterally. The appearances could represent sequelae of
hepatic
encephalopathy, however, sequelae of old ischemia or prior
inflammation is
also a consideration. Followup may be performed as per clinical
need.
Extensive opacification is seen of the mastoid air cells
bilaterally, though
this has improved since the prior MRI.
Cardiac Cath Study Date of [**2157-2-18**]
COMMENTS:
1. Limited resting hemodynamics revealed normal left and right
sided
filling pressures with an RVEDP of 7mmHg and LVEDP of 8mmHg.
TTE (Congenital, focused views) Done [**2157-3-14**] at 1:50:47 PM
No atrial septal defect, patent foramen ovale, or pulmonary
shunt is seen by 2D, color Doppler or saline contrast with
maneuvers. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (?#) appear structurally normal with good
leaflet excursion. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
IMPRESSION: No intracardiac or intrapulmonary shunt identified.
Portable TTE (Complete) Done [**2157-2-23**] at 4:25:15 PM
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild to moderate
([**2-13**]+) mitral 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 [**2157-2-14**], the
heart rate is faster. There is more mitral regurgitation.
Pulmonary artery pressures could not be determined.
Pulmonary Report SPIROMETRY, DLCO Study Date of [**2157-3-18**] 8:59
AM
SPIROMETRY 8:59 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.15 5.54 39 2.16 39 0
FEV1 1.29 4.14 31 1.47 36 +14
MMF 0.64 4.10 16 0.96 23 +49
FEV1/FVC 60 75 80 68 92 +14
DLCO 8:59 AM
Actual Pred %Pred
DSB 7.19 30.92 23
VA(sb) 3.15 7.80 40
HB 9.40
DSB(HB) 8.83 30.92 29
DL/VA 2.80 3.96 71
Neurophysiology Report EEG Study Date of [**2157-2-3**]
Impression: This telemetry EEG recording showed a slow, low
voltage
encephalopathic background throughout. It did not change
appreciably
over the time of the recording. There were no epileptiform
features or
electrographic seizures recorded.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Mr. [**Known lastname 88075**] is a 41y/o gentleman with alcohol and HCV cirrhosis
who was transferred to [**Hospital1 18**] intubated with hepatic
encephalopathy, for liver transplant evaluation. His course has
been significant for bacterial peritonitis, coagulopathy,
watershed CVA, and acute renal failure requiring initiation of
hemodialysis. His MELD score is 28. He has been listed for
liver transplant as well as kidney transplant. He was
discharged to rehab and will follow up with Hepatology.
.
ACTIVE ISSUES:
.
#. Alcohol and HCV cirrhosis: MELD 28-30 throughout admission,
Blood Type B.
His cirrhosis is complicated by ascites, grade II esophageal
varices, and hepatic encephalopathy. His T bili peaked at 3.8
on [**2157-2-15**] but trended down and was 1.7 at the time of discharge.
His INR was between 1.8 and 2.1. The patient's MELD score is
28, which at this point mostly reflects his dialysis dependence.
Liver transplantation workup was completed; this included a TTE
with elevated right-sided pressures for which he underwent
cardiac cath which showed normal left and right sided filling
pressure. Pulmonary Function Testing was also completed. His
ascites was managed with large volume paracenteses. Hepatic
encephalopathy was managed as described below. He was given
supplemental nutrition via Dobhoff tube, which is to continue
after discharge. For his rectal varices, he was continued on
Nadolol. He will follow up in Liver [**Hospital 1326**] clinic.
.
#. Respiratory Failure: Pneumonia, Atelectasis, and effusions.
The patient was transferred to [**Hospital1 18**] intubated, after being
treated for Strep pneumoniae with effusions (no empyema) as well
as subsequent aspiration pneumonia. Upon arrival, he was put on
Meropenem for empiric coverage for right sided penumonia, and he
received 14 days of antibiotics for this. He had a large left
pleural effusion that underwent a thorcentesis on [**2157-2-3**] for
3400ml of bloody fluid that was not positive for bacterial
growth after cultures. He underwent a bronchoscopy for
difficulty with ventilation and a BAL was sent which eventually
grew yeast for which he was placed on Fluconazole. He underwent
a second bronchoscopy on [**2157-2-8**] when there was difficulty with
ventilation and antother BAL was sent which eventually grew
yeast again. Fluconazole course was completed on [**2157-2-24**]. He
continued to require ventilatory support with daily improvement.
He was extubated on [**2157-2-11**]. On [**2157-2-14**] he underwent a second
thoracentesis for 2000ml with a left-sided pigtail left to
suction, which was discontinued on [**2157-2-17**]. When his respiratory
status was stable, he was transferred to the floor where his O2
sat remained in the low 90s on room air. He has a history of
asthma and did undergo pulmonary function testing for
transplantation workup prior to discharge. He is most
comfortable on supplemental O2 via humidified face tent.
Patient was started on treatment for hospital acquired pneumonia
on [**2156-3-20**] after he was noted to have an increased WBC to 16
and question of left mid and lower lobe opacity, with concern
for aspiration versus atelectasis. Patient was started on
Vancomycin and Piperacillin/Tazobactam, which he tolerated with
no new rashes (despite concern for potential Zosyn allergy
earlier during hospitalization). Patient was transferred to the
SICU briefly in the setting of hypoxia and fluid overload, at
which time he received an extra HD session to remove fluid. At
that time, he was also started on fluconazole on [**2157-3-21**] for
[**Female First Name (un) **] growth in sputum. PICC line was not placed in order to
preserve arm veins in case patient may need HD for a long time
into the future, but antibiotics should be continued through
peripheral IVs until [**3-29**] for a total 10 day course.
Vancomycin is dosed with HD. Fluconazole is also dosed with HD
and will be continued for a total 7day course and may be
discontinued [**2157-3-27**] (patient received last dose just prior to
discharge, so fluconazole no longer needs to be given).
Patient has O2saturation of 92-95% on room air with some
intermittent desaturations to mid 80s% associated with mucus
plugging. Patient does use humidified air with oxygen by face
tent for comfort intermittently. Chest Xrays have also shown
persistent RLL atelectasis associated with pleural effusion,
slightly improved with increased mobilization of patient.
Patient requires regular chest PT and frequent suctioning due to
secretions. [**Month (only) 116**] consider using inhaled Mucomyst with Albuterol
nebulizers prior to chest PT to help with the secretions.
.
#. Hepatic Encephalopathy: Resolved.
He arrived intubated, and in the ICU his mental status waxed
and waned. In the setting of SBP, He had a decompensation in his
mental status on [**2157-2-14**] and was re-intubated. He was extubated
again on [**2157-2-16**]. When he was stabilized and his infections were
treated, he was alert and oriented x3 without asterixis. He
remained on Lactulose and Rifaximin.
.
#. Acute Renal Failure: end-stage renal disease requiring
hemodialysis.
Per Nephrology, his [**Last Name (un) **] was likely due to ATN from his
septicemia. Splanchnic
vasodilitation due to his cirrhosis led to arterial underfilling
and this was a compounding problem. Upon arrival, he was
initiated on dialysis. He was transitioned to CVVH on [**2157-2-9**]
when his blood pressures would no longer tolerate HD, but
subsequently he tolerated HD fine, with 3 sessions per week.
I.R. placed a right IJ tunneled HD line on [**2157-2-25**]. He was put
on Nephrocaps and Sevelamer; Sevelamir was discontinued prior to
discharge because of concern it was causing more malabsorption.
He will continue on hemodialysis and, in addition, he has been
listed for kidney transplant.
.
#. Bacterial peritonitis: Resolved.
He underwent a paracentesis for 2700ml on [**2157-2-13**] which showed
elevated WBCs and polys consistent with SBP. Ceftriaxone was
started. He had a second paracentesis for 3000ml on [**2157-2-16**]
which continued to show signs of SBP with 2700 WBCs and 62%
polys. Ceftriaxone was changed to Zosyn. He underwent a
diagnostic paracentesis on [**2157-2-21**] which showed improvement of
his SBP. He developed a rash, after which he was trasitioned
from Zosyn to Meropenem; the rash continued to worsen, so he was
switched to Levofloxacin and Flagyl. (Of note, he did receive
Zosyn later during hospital course for pneumonia and tolerated
it well with no difficulties.) He received a total of 2 weeks of
antibiotics, and paracentesis on [**2157-3-4**] showed no signs of SBP
so antibiotics were discontinued. Paracentesis on [**3-11**] was
negative for SBP. He will continue on prophylactic
Ciprofloxacin. Ciprofloxacin was held during treatment of
latest pneumonia but SHOULD BE RESTARTED [**2157-3-30**] upon completion
of Vancomycin and Zosyn course. Ciprofloxacin dosing should be
increased to 500mg daily for SBP prophylaxis while on tube feeds
for improved absorption.
.
#. VRE UTI: resolved.
He had positive urine culture for VRE and Linezolid was given
from [**2157-2-13**] until [**2157-2-23**]. Subsequent urine cultures remained
negative.
.
#. Mucosal bleeding: thrombocytopenia, stable.
He was noted to have bleeding from his gums/nose on [**2157-2-21**] and
ENT was consulted. He was found to have left nasal septal
bleeding for which a packing was placed. It was able to be
removed 5 days later. Aminocaproic acid was used for gum
bleeding. Mr. [**Known lastname 88075**] has several reasons to have low platelets;
ESLD, splenomegaly (19.3 cm), critical illness, and multiple
antibiotics that are reversibly myelosuppressive. His bleeding
diathesis is related less to his elevated INR (a completely
unreliable predictor of bleeding in cirrhosis) and more to his
platelet count. His platelet count was as low as 45K (when he
was found to be bleeding) and he required a total of 6 units of
pRBCs. His platelets remained in the 80s-100s with no more
spontaneous bleeding. As part of his twice-weekly labs, CBC
should be checked and he should receive platelet transfusion if
<60.
.
#. Loose stools: negative for C. diff.
PO vanco was empirically started for C.Diff coverage that was
eventually stopped when stool cultures remained negative. His
Lactulose was decreased but he continued to have loose stools,
perhaps in the setting of antibiotic use. He had a flexiseal in
place for several weeks during hospitalization.
.
#. Acute Stroke: watershed CVA.
While he was still in the ICU initially, he continued to have
neurological improvement off sedation until [**2157-2-5**] when he had
a neurological decline with decrease arousability. A CT head
was repeated which showed a hypodensity in right centrum
semiovale likely representing new strokes and an MRI confirmed
the new infarcts. He had no persisting neurologic deficit, and
per Neurology, the infarct should not preclude him from
transplant. He was discharged on Aspirin daily.
.
#. Rash: drug reaction.
Dermatology was consulted regarding a total body rash which was
diagnosed as likely drug reaction to Cefepime he received at the
OSH. His rash also appeared to worsen in the setting of
meropenem use, though it was likely a delayed effect from
cefepime. (He had tolerated meropenem early during hospital
course with no difficulties.) Off antibiotics, his rash
resolved.
.
#. Hoarse voice: vocal cord granuloma.
ENT was cosulted regarding patient's hoarse voice. There was no
evidence of true vocal cord paralysis but he does have a
granuloma at anterior left cord, likely secondary to injury from
prior intubation. This should resolve with time and PPI
treatment. The granuloma may be making vocal cord adduction
more difficult, contributing to his risk of aspiration.
.
#. Decreased functional status: malnutrition and deconditioning.
For most of his stay, the patient remained bedbound with
occasional transfer to chair which was limited due to back pain.
He continued to work with PT and was able to walk a few steps
with assistance prior to discharge. On arrival, albumin was
2.3. Dobhoff feeding tube was placed and he received tube
feeds. In addition, Speech and Swallow therapy was consulted
and video oropharyngeal swallow revealed some aspiration with
thin liquids. He has been approved to have nectar thick liquids
and soft solids, and he may have shakes blended with
nectar-thickened mild (rather than regular milk). He is being
discharged to rehab and it will be important for him to continue
to work with PT.
.
#. Partial Small Bowel Obstruction: He experienced nausea, in
the setting of orthostasis post-dialysis and so a KUB showed
concern for partial SBO. Clinically, his nausea self-improved
amd he was continuing to have bowel movements. Tube feeds were
held for a day and lactulose was stopped briefly. As he did not
clinically appear to have SBO, tube feeds were restarted without
issues.
.
#. Lower Back Pain: chronic.
He has a history of lower back pain, but pain noted to be
worsened somewhat during his admission after hitting his back
against a chair early during admission. He also feels that
lying in bed all day for weeks has made him quite sore and
worsened back pain further. The pain limited his ability to
work with PT initially, though he did make progress during the
last 1.5 weeks of hospitalization. He did have lower back Xrays
which showed DJD but no fracture. The pain is alleviated by PO
Dilaudid.
.
#. Depression and Anxiety
Patient was having some difficulty with depression and anxiety
in the setting of difficult hospital course. He was restarted
on paroxetine at 20mg daily, which can be uptitrated to 30mg
daily. Patient did have occasional episodes of anxiety during
which he felt some shortness of breath during dialysis but did
not have O2 desaturations, improved with 0.25mg po lorazepam.
.
#. Diabetes Mellitus Type 2
Patient was started on tube feeds, so insulin coverage was
switched from home dose of lantus to insulin mix 70/30 7units in
the AM to cover his po meals with sliding scale Humalog insulin.
Patient did have a few hypoglycemic episodes in the setting of
stopping tube feeds with partial small bowel obstruction.
Insulin regimen was later changed to Q6H regular insulin sliding
scale.
.
#. Conjunctivitis: resolved.
Opthalmology was consulted for evaluation of conjunctivitis with
improvement following prescribed treatment with cipro and ciloan
drops. He completed the course and is to continue using
artificial tears.
.
TRANSITIONAL ISSUES:
-Incidental findings that need outpatient follow-up: RML nodule
seen on CT, and lesion in his left glenoid (likely a cyst but
may need MRI).
-Restart Cipro 500mg (dose increased from 250mg to 500mg daily
while on tube feeds containing dairy products due to interaction
with absorption) daily after completion of Vanc/Zosyn course for
pneumonia
Medications on Admission:
Medications at home:
Paxil 30 daily
Ambien prn sleep
vit B12
Folate 1mg daily
Nadolol
Xanax
Flovent
Albuterol
Lantus insulin 47U qpm
.
Meds on transfer:
Octreotide 100 mcg TID
Ascorbic acid 250 daily
chlorhexidine oral rinse
Ciprofloxacin 0.3% eye drops
Combivent inhaler 4 puffs qid;prn
Folic Acid 1 daily
Free Water 340 ml q4h
Heparin SQ
Insulin novolog 70/30 7U q12h
Insulin Humalog SS
Lactulose liq 20 daily
reglan 5mg TID
multivitamin daily
nadolol 10 [**Hospital1 **]
sarna lotion [**Hospital1 **]
thiamine 100 daily
zinc 220 daily
tylenol liq 650 q6:prn
miconazole 2%/nystatin powder qid:prn
artificial tears
petrolatum eye oimt [**Hospital1 **]:prn
oral vancomycin 250 q6h
dopamine gtt
Discharge Medications:
1. fluticasone 100 mcg/Actuation Disk with Device [**Hospital1 **]: One (1)
puff Inhalation twice a day.
2. lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO BID (2
times a day): titrate to [**4-15**] bowel movements daily .
3. rifaximin 550 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2 times a
day).
4. Humalog 100 unit/mL Solution [**Month/Day (3) **]: One (1) injection
Subcutaneous qachs: sliding scale.
5. ciprofloxacin 250 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO Q24H
(every 24 hours): for continuous SBP prophylaxis (PLEASE HOLD
THIS MEDICATION WHILE PT IS STILL ON ZOSYN FOR PNEUMONIA).
6. nadolol 20 mg Tablet [**Month/Day (3) **]: 0.5 Tablet PO BID (2 times a day).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. aminocaproic acid 25 % Solution [**Last Name (STitle) **]: 1.25 gm PO Q1 PRN () as
needed for bleeding gums: if bleeding gums then apply to gums
with soft applicator.
9. trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. folic acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
11. thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. zinc sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
13. B complex-vitamin C-folic acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
14. camphor-menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical
PRN (as needed) as needed for itching.
15. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**2-13**]
Drops Ophthalmic PRN (as needed) as needed for eye irritation.
16. hydromorphone 2 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every four
(4) hours as needed for pain.
17. heparin (porcine) 1,000 unit/mL Solution [**Month/Day (2) **]: One (1) ml
Injection PRN (as needed) as needed for line flush.
18. Artificial Tears Drops [**Month/Day (2) **]: 1-2 drops Ophthalmic four
times a day as needed for dry eyes.
19. glucagon (human recombinant) 1 mg Recon Soln [**Month/Day (2) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol: AS NEEDED FOR HYPOGLYCEMIA.
20. Vancomycin 1000 mg IV HD PROTOCOL
21. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
22. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
23. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP)
Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by
Heparin as above daily and PRN.
24. Heparin Flush (1000 units/mL) 0 UNIT IV PRN Heparin Dwell
Heparin Dwell
25. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
26. Piperacillin-Tazobactam 2.25 g IV Q8H
27. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
28. fluconazole 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QHD (each
hemodialysis) for 2 days: UNTIL [**3-27**] (will not get HD until
[**3-28**], so no further doses of Fluconazole need to be given).
29. paroxetine HCl 10 mg/5 mL Suspension [**Month/Year (2) **]: Thirty (30) PO
DAILY (Daily).
30. midodrine 5 mg Tablet [**Month/Year (2) **]: 1.5 Tablets PO TID (3 times a
day).
31. guaifenesin 100 mg/5 mL Syrup [**Month/Year (2) **]: Ten (10) ML PO Q4H (every
4 hours).
32. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Year (2) **]:
[**2-13**] Adhesive Patch, Medicateds Topical DAILY (Daily) as needed
for back pain.
33. camphor-menthol 0.5-0.5 % Lotion [**Month/Day (2) **]: One (1) Appl Topical
PRN (as needed) as needed for dry or itchy skin.
34. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) unit Inhalation TID (3 times a day).
35. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: One (1) unit
Inhalation TID (3 times a day).
36. insulin regular human 100 unit/mL Solution [**Month/Day (2) **]: per sliding
scale Injection every six (6) hours: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
Cirrhosis from alcohol and hepatitis C
Acute renal failure on hemodialysis
Acute cerebrovascular accident
Pneumonia
Spontaneous bacterial peritonitis
Hepatic encephalopathy
Partial small bowel obstruction
Secondary Diagnosis:
Lower Back Pain
Diabetes Mellitus Type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 88075**],
You were transferred here to be evaluated for transplant due to
your severe liver disease. During this stay you were started on
hemodialysis. The workup has been completed and you are now
listed for liver transplant and kidney transplant.
.
During your stay, you have had pneumonia a couple of times, for
which you were given antibiotics. You have a lot of secretions
in your lungs which intermittently causes your oxygen saturation
to get worse if a mucus plug temporarily blocks one of your
smaller airways. You have also had some small collapse of the
lower parts of your lungs from not breathing deeply for a long
period of time. For these reasons, it is very important for you
to keep up as much physical activity as possible and have some
chest physical therapy as well, which will improve your lungs
and breathing.
.
Most of your medications have been changed since you were
hospitalized and transfered here. Please see the enclosed
medication list for your revised list.
You will be at the rehabilitation facility until you get a liver
transplant.
Followup Instructions:
Please be sure to keep your followup appointment in [**Hospital 1326**]
Clinic, as listed below.
[**2157-4-6**] 02:40p TRANSPLANT [**Hospital **] CLINIC
LM [**Hospital Unit Name **], [**Location (un) **]
TRANSPLANT MEDICINE (NHB
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icd9cm
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[
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icd9pcs
|
[
[
[]
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28353, 28452
|
10256, 10764
|
299, 340
|
28782, 28782
|
2556, 10210
|
30082, 30322
|
2002, 2019
|
23989, 28330
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28473, 28698
|
23271, 23271
|
28958, 30059
|
23292, 23406
|
2034, 2055
|
22900, 23245
|
246, 261
|
10779, 22879
|
368, 1708
|
28719, 28761
|
2069, 2537
|
28797, 28934
|
1730, 1903
|
1919, 1986
|
23424, 23966
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,968
| 126,751
|
18051
|
Discharge summary
|
report
|
Admission Date: [**2161-3-6**] Discharge Date: [**2161-3-19**]
Date of Birth: [**2094-3-14**] Sex: M
Service: Medicine
CHIEF COMPLAINT: Pulmonary embolism found incidentally on a
routine staging CT.
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old male
who was most recently discharged from the hospital on [**2161-3-4**]. He
had been in his usual state of good health until approximately
mid-[**Month (only) 958**] when he began to notice dark colored urine, [**Doctor Last Name 352**]
colored stools and jaundice. Subsequent workup including
abdominal CAT, liver biopsy as well as multiple ERCPs as well as
multiple interventional radiology interventions, concluded the
diagnosis of adenocarcinoma at the head of the pancreas with
liver metastasis as well as biliary obstruction. During the past
hospital admission patient underwent interventional radiology
stenting for a biliary drain and had a routine staging chest CT
prior to discharge. Review of the CT revealed a pulmonary
embolism in a proximal branch of the right pulmonary artery
extending to the right lower lobe. The radiologist communicated
this to the discharge attending and patient was called back to
[**Hospital1 18**]. In the emergency department patient had a CT of the head
done which showed no intra or extra-axial hemorrhage, mass shift,
shift of midline structures or enhancing masses seen. There
was no obvious intracranial hemorrhage or obvious metastasis.
Patient was then started on a heparin drip for anticoagulation
for the pulmonary embolism and admitted to the medicine service.
REVIEW OF SYSTEMS: The patient reports he has had dyspnea
for approximately two weeks which has not changed since his
past admission. He particularly noticed that he is fatigued
while climbing stairs. He denies chest pain, cough, fever,
hemoptysis. He denies nausea, vomiting. He denies diarrhea,
bright red blood per rectum or melena. Stools are normal
color now.
PAST MEDICAL HISTORY: Benign gastric cancer, status post
partial gastrectomy in [**2142**]. Status post right inguinal
hernia repair and left inguinal hernia repair. Denies
coronary artery disease, hypertension or diabetes. Right
Achilles tendon heel rupture, status post repair. Right knee
surgery for a question of cartilage problems, status post
surgery. Recently diagnosed pancreatic cancer with liver
metastasis, status post biliary stent placement and
intervention.
ALLERGIES: No known drug allergies. Adverse reactions:
codeine causes nausea.
SOCIAL HISTORY: The patient smoked one pack per day of
cigarettes times 40 years. He quit approximately two weeks prior
to admission when diagnosed with cancer. He is a social drinker
and drinks a few drinks every week. He is married and lives on
[**Hospital3 **] with his wife. [**Name (NI) **] previously worked in auto repair, but
is now retired.
FAMILY HISTORY: Brother died of pancreatic cancer 1.5 years ago.
PHYSICAL EXAMINATION: Vital signs on admission were
temperature 99, heart rate 107, blood pressure 149/74,
respiratory rate 28, O2 saturation 97% in room air. HEENT
normocephalic, atraumatic. Scleral icterus. Extraocular
motions intact. Pupils equally round and reactive to light.
Neck was supple, there was no lymphadenopathy. Pulmonary
diminished breath sounds bilaterally and poor air movement,
but with good inspiratory effort. Had bibasilar crackles.
Cardiac S1, S2, normal, regular rate and rhythm, no murmurs,
gallops or rubs, no elevated JVD. Abdomen normoactive bowel
sounds, soft, nontender, had a biliary drain intact,
nontender. There was no erythema, rebound, guarding. There
was trace guaiac positive biliary fluid. There was
tenderness in the right upper quadrant and left upper
quadrant. On GU exam trace guaiac positive, but patient had
positive hemorrhoids. Extremities no lower extremity edema.
Dorsalis pedis 2+ pulses bilaterally. Neuro AAO times four.
Cranial nerves II-XII intact. No focal weakness. Good
muscle tone and strength.
LABORATORY DATA: Sodium 138, potassium 4.1, chloride 102,
bicarb 23, BUN 23, creatinine 0.8, glucose 150. White blood
count 18.9, hematocrit 30.1, platelets 431. INR 1.2, PTT
23.9. CEA 547, CA19-9 226,937. CT of the chest inferior
posterior margin of pericardium with a 7 to 8 mm nodular
density. Small hiatal hernia. Atelectasis. A 4 mm
subpleural nodular density along the lateral aspect of the
left lower lobe. There was no effusion. There was a filling
defect of the proximal branch of the right pulmonary artery
extending to the right middle lobe and right lower lobe. The
appearance of this was consistent with pulmonary emboli. The
impression of the CT was that intraluminal filling defects
within the pulmonary artery branches to both the right middle
lobe and right lower lobe were consistent with pulmonary
emboli. CT of the abdomen multiple low attenuation lesions
of the liver, low attenuation of the head of the pancreas.
CT of the head no intracranial or extracranial hemorrhage, no
metastasis. EKG sinus rhythm, rate 90 beats per minute,
normal axis, no ST-T wave changes.
ASSESSMENT: This is a 66 year old white male with a history
of recently diagnosed pancreatic cancer who was called back
to [**Hospital1 18**] for pulmonary embolism which was found incidentally
on a routine staging CT. As there is no contraindication for
anticoagulation (negative head CT, guaiac negative stools),
patient was started on a heparin drip for anticoagulation.
Patient subsequently had a prolonged hospital course and the
hospital course will be dictated by date.
HOSPITAL COURSE: On [**2161-3-6**] patient had a head CT, no metastasis
to the head, no intracranial or extracranial hemorrhage. Patient
was started on a heparin drip for anticoagulation and was then
subsequently changed to Lovenox. Patient as well as his wife
received teaching on Lovenox administration. Oncology consult
(Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/Dr. [**Last Name (STitle) **]. Driver) came and evaluated patient again
and felt that the best anticoagulation therapy would be Lovenox.
They felt that once his bilirubin normalized, treatment options
would include weekly intravenous therapy with gemcitabine or oral
therapy with capecitabine. Due to his high bilirubin and the
potential interactions of Coumadin with capecitabine, the
oncology consult recommended dosing of enoxaparin (Lovenox)
instead of Coumadin as anticoagulation. Patient wished to
receive treatment on [**Location (un) **] and Doctors [**Name5 (PTitle) **]/Driver referred
him to a local oncologist in [**Hospital1 1562**].
Additionally, interventional radiology saw the patient and took
him to the IR suite for evaluation of his stent. This evaluation
revealed a patent common bile duct, however, a new diagnosis of
stenosis proximal to the common bile duct stent was seen. IR
felt that patient needed additional biliary stenting at a later
point in time. On [**2161-3-7**] biliary drainage turned bloody with
some clots in the drainage bag. There was a question of whether
this was secondary to tumor bleeding, possible liver bleeding
with anticoagulation or possible tube track-communication to the
portal branch of one of the vessels. Approximately 20 cc of
bloody clot was found in the bag, but patient was hemodynamically
stable. Interventional radiology was notified and evaluated
patient.
On [**2161-3-8**] the patient began to have abdominal pain, particularly
lower back pain. There were small amounts of bloody drainage in
his biliary bag. Patient began to complain of nausea and
positive vomiting. Abdomen was soft, nontender with no rebound
initially. It appeared that there was no output from the stent
and that the biliary drainage catheter was obstructed. Secondary
to the concern for retroperitoneal bleed/tumor bleeding/any
further bleeding, CT of the abdomen was done stat to evaluate
patient's abdomen. The results of the CT abdomen showed again
liver with numerous hypodense lesions consistent with metastasis,
but there were no signs of intrahepatic ductal dilatation, no
evidence of hemorrhage of the liver lesions and no evidence
of bleeding into the abdomen/retroperitoneal area. In addition,
patient's white blood count increased from 19 to 28 and there was
question of whether this was a stress response versus infection.
Since patient was afebrile, hemodynamically stable and there
began to be minimal output from his biliary drain, it was decided
that patient would be closely watched overnight and if there were
any problems, patient would be started on empiric antibiotic
therapy. In addition, Lovenox was discontinued on [**2161-3-8**] in the
a.m. after patient had episodes of bloody clots in his bag. Over
the night the patient had one to two teaspoons of coffee ground
emesis and his biliary bag became completely occluded. There was
no drainage in the bag whatsoever.
In the early morning of [**2161-3-9**] (2:00 to 4:00 a.m.) the patient
became febrile to 101.7, blood pressure 90/40, heart rate in the
140s, respiratory rate 26, O2 saturation 96% in room air. There
was extreme concern for infection given that his biliary stent
appeared to be occluded. Blood cultures times two were drawn,
patient began to be aggressively hydrated with fluids and patient
was started on empiric ampicillin/levofloxacin/Flagyl for triple
antibiotic coverage. Patient's respiratory rate began to
increase greatly to the upper 30s and an ABG was drawn. This
revealed pH of 7.48, PCO2 26, PO2 39. Lactic acid level was 5.7.
EKG was done which showed sinus tachycardia, no ST-T wave
changes. At this point in time it was felt that patient likely
had ascending cholangitis secondary to undrained biliary fluid
which was leading to sepsis and acidemia. Interventional
radiology was immediately notified and plans were made to take
patient to the interventional suite. Patient was hydrated very
aggressively with 3 to 4 liters of normal saline and still
had decreased urine output. His JVD was flat. In the
interventional radiology suite patient's biliary catheter was
upsized. At this point in time there was no evidence of a blood
clot. IR found his abdomen to be soft, nondistended, nontender.
They found that his biliary catheter was patent and the bile was
brown after upsizing the drain.
Secondary to the patient's
hypertension/tachycardia/sepsis/ascending cholangitis, patient
was taken straight from the interventional radiology suite to the
medical intensive care unit. In the MICU a left subclavian
central axis line as well as an arterial line were placed. He
was hydrated aggressively with IV fluids (normal saline) as he
appeared to be intravascularly depleted with low blood pressure,
tachycardia and decreased urine output. Patient did not require
the use of any pressors in the MICU. Patient's CVP, urine output
were followed and the goal CVP was between 12 and 14. On
admission to the MICU his CVP was between 7 and 8. His
antibiotics were continued (ampicillin/levofloxacin/Flagyl). In
addition, lactate, bicarb, hematocrit, urine output were followed
closely. The impression at this time was that patient had blood
causing a blood clot which subsequently obstructed his biliary
drainage, caused biliary fluid to back up causing ascending
cholangitis and subsequent sepsis. After interventional
radiology had intervened and upsized his biliary drainage tube,
there were no more blood clots and the biliary catheter was
patent with the bile being brown.
The main question at this point in time was what caused the
biliary bleeding. There was a question of whether it was tumor
bleeding, some sort of tract between one of the portal vessels
and the biliary tract, whether there was bleeding of the liver
itself with anticoagulation. On the initial cholangiogram that
was done there was a question of whether there was a biliary
tract fistula with one of the pleural vessels. However, on
cholangiogram done on [**2161-3-9**] any apparent fistulous tracts were
not identified. This was discussed with the interventional
radiology team and they felt that it was safe to anticoagulate
patient for his pulmonary embolism. Therefore, in the MICU
patient's anticoagulation was restarted with a heparin drip. On
[**2161-3-10**] biliary drainage remained patent. Bile was clear and
green. White blood count began to decrease. In the medical
intensive care unit it had risen to 38% and then to 43%.
Subsequently it began to decrease down to the lower 30s and
then to the mid-20s. In addition, on [**2161-3-10**] alkaline
phosphatase/total bilirubin/ALT/AST began decreasing as well.
Blood cultures at this time showed initially a question of
gram positive rods. On [**2161-3-10**] patient was stable to be
transferred to the floor.
On [**2161-3-11**] the patient's biliary catheter drainage tube became
clogged again. Biliary catheter appeared to be obstructed by
a blood clot. Interventional radiology came and examined the
bag and it was flushed, but it still did not drain. Patient's
heparin was discontinued and patient was taken to interventional
radiology for a tube check (cholangiogram) to check for effective
drainage. On [**2161-3-11**] interventional radiology changed the biliary
catheter and additionally identified a fistulous tract. A branch
of the right hepatic artery was embolized. Additionally, blood
cultures that were drawn on [**2161-3-9**] returned as Enterococcus with
sensitivities and identifications still pending. On [**2161-3-12**]
Enterococcus was identified as Enterococcus faecalis with
sensitivities pending. Patient's hematocrit was checked b.i.d.
and remained relatively stable. There was a question of whether
patient may need to have a repeat embolization if he continued to
bleed or if there was another fistulous tract not identified.
Patient's coags were checked and INR was between 1.8 to 2.0, so
he was not started on heparin and not started on Lovenox. There
was hesitancy to anticoagulate this patient to run the risk of
causing rebleeding, reocclusion and reinfection.
On [**2161-3-13**] the biliary stent was patent. Bilirubin continued to
decrease. LFTs continued to decrease. Levofloxacin was
discontinued as the sensitivities from the cultures were back. It
was Enterococcus faecalis sensitive to ampicillin and resistant
to levofloxacin as well as some synergy with streptomycin. Adding
streptomycin in addition to ampicillin as well as Flagyl was
considered, however, it was decided against secondary to the
severe potential toxicity related to streptomycin. Since the
Enterococcus was sensitive to ampicillin, this was the primary
antibiotic.
On [**2161-3-14**] the patient's hematocrit was checked b.i.d. Vital
signs were stable. INR was 1.8. No changes. On [**2161-3-15**] b.i.d.
hematocrit was checked. Vital signs were stable. INR was 1.4.
On [**3-16**] through [**3-17**] patient's biliary drainage was capped by
interventional radiology. A Lovenox trial was initiated, in
treatment of his pulmonary embolism. The Lovenox trial was
initiated to determine whether he would be able to tolerate
anticoagulation. The thought was that if patient rebled on
Lovenox, patient would require an IVC filter for prevention of
future pulmonary emboli. However, if patient did not rebleed
on Lovenox, it would be safe to consider patient tolerates
Lovenox and would be able to take this as an outpatient.
The patient tolerated Lovenox well during the two day trial.
Hematocrit was checked b.i.d. and there was no evidence of
bleeding. In addition, his stools were guaiaced and there was no
evidence of melena or bright red blood per rectum. It appeared
that patient's prior episodes of bleeding while on
heparin/Lovenox were due to the fistulous tract between the
branch of the right hepatic artery with the biliary tract.
Subsequent to his embolization on [**2161-3-11**], there had not been
any apparent episodes of bleeding in his biliary drainage bag
and it appeared that the source of the bleeding had stopped.
On [**2161-3-18**] the patient went to interventional radiology to check
the patency of his stent. Cholangiogram revealed good patency of
the stent and no communication between the biliary ducts and any
vessels. The external tube/drainage was removed. The
intrahepatic tract was embolized. Only the internal stent
remained. Patient tolerated the procedure quite well. On
[**2161-3-19**] patient resumed Lovenox. A PICC line was placed on the
right side for IV antibiotics times 10 days. Patient is to
continue IV antibiotics (ampicillin only) for a 10 day treatment.
He was discharged in good condition on [**2161-3-19**] to home with
services.
Hospital course by issue:
1. Pulmonary embolism. Patient was readmitted to [**Hospital1 18**] for
pulmonary embolism. He was initially started on a heparin
drip and subsequently switched to Lovenox. At various points
throughout the admission patient was either on heparin or
Lovenox, but these were sometimes held, as above. Coumadin was
not recommended as a form of anticoagulation secondary to his
high bilirubin and the potential interactions with Coumadin and
capecitabine, should patient decide to pursue chemotherapy.
Patient's discharge medication is Lovenox 90 mg subcu q.12 hours.
[**Name (NI) **] wife had Lovenox teaching and she administered Lovenox
to patient with ease.
2. Hematology. As above, anticoagulation with Lovenox. In
addition, patient had anemia secondary to acute blood loss
requiring transfusion of packed red blood cells.
3. Prophylaxis. The patient was placed on IV famotidine while
he was not eating well.
4. GI. Biliary obstruction and jaundice, status post
percutaneous drain placement/common bile duct stenting.
Patient had numerous interventional radiology interventions
as dictated above.
5. Ascending cholangitis/sepsis. The patient was
hypotensive (blood pressure 90/50) tachycardiac to 140,
respiratory rate in the 30s, lactate 5.6. It appeared that
patient had ascending cholangitis leading to sepsis. Blood
cultures as well as biliary culture revealed Enterococcus
faecalis sensitive to ampicillin, resistant to levofloxacin.
After patient's final intervention with his common bile duct
stent on Wednesday, [**2161-3-18**], he is to have 10 days of IV
antibiotics (ampicillin).
6. Pancreatitis. The patient's amylase and lipase were
checked serially throughout his admission. They have
fluctuated widely, increasing and decreasing. There are
several causative factors to his pancreatitis with post
procedure pancreatitis being a contribution as well as the
fact that patient has a very large tumor/mass at the head of
the pancreas. There could also be some fluctuation as well
secondary to a question of intermittent/transient obstruction
in the ampulla. Patient did not have any abdominal pain and
denied abdominal tenderness. At this point in time since he
is not symptomatic from the pancreatitis, there will be no
further intervention (no ERCP will be pursued). Patient was
discharged on a regular diet which he tolerated well. While
he was in-house patient was hydrated aggressively with 125 cc
of normal saline per hour while his enzymes were elevated.
7. Neurology. Head CT was without metastasis or hemorrhage.
8. Renal. The patient's creatinine was within normal limits.
9. Fluids, electrolytes and nutrition. The patient had IV
fluids at 125 cc an hour for rehydration purposes while patient
had decreased appetite. Of note, patient does have occasional
nausea and decreased p.o. intake as well as appetite. There was
a question of whether this was secondary to IV Flagyl. IV Flagyl
was discontinued on [**2161-3-19**]. Hopefully, patient will have an
increase in his appetite. It was decided that IV Flagyl was not
necessary and that the primary antibiotic would be ampicillin to
target Enterococcus.
10. Access. The patient had a right PICC line placed for IV
antibiotics times 10 days.
11. Pain. The patient was given morphine IV/subcu p.r.n. for
pain. Patient was discharged with a prescription for p.o.
morphine. Of note, patient does not have severe pain, but does
have occasional back pain when he lays in bed too long.
12. Oncology. The patient has pancreatic cancer
(adenocarcinoma) with liver metastasis. In addition, tumor
burden causes biliary obstruction as well. Patient will
follow up with an oncologist on [**Location (un) **].
13. Communication. The patient's MICU course as well as his
hospital course were communicated to patient's PCP.
[**Name Initial (NameIs) **] PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 49945**]).
DISCHARGE INSTRUCTIONS: If the patient starts having bloody
stools, fever greater than 100.5, fast heart rate greater
than 110, chills/sweating or dizziness with standing/walking,
please go to the nearest emergency department.
CONDITION ON DISCHARGE: Afebrile, hemodynamically stable.
Hematocrit is stable times four days (29 to 30) with two days
on Lovenox. No bloody stools. Tolerating Lovenox well. It
appears that the fistula between the branch of the right hepatic
artery and the biliary tract was the cause of the bleeding while
on anticoagulation. The fistula has since been embolized and
there appears to be no more evidence of bleeding. External
biliary drain has been pulled and patient only has an internal
drain with his common bile duct stent. Since his last
manipulation/intervention was on [**2161-3-18**], he should have 10 days
of IV antibiotics given his past medical history of sepsis with
Enterococcus. He is discharged to home in good condition.
FOLLOWUP: The patient should follow up with his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **],
within the first week after being discharged back to [**Location (un) **].
Patient will follow up with oncology on [**Location (un) **]. This was
conveyed to Dr. [**First Name (STitle) **], who will arrange for this.
PROCEDURES:
1. Status post multiple interventional radiology interventions
on the common bile duct stenting/biliary system.
2. Left subclavian central access line.
3. Arterial line.
DISCHARGE DIAGNOSES:
1. Pulmonary embolism.
2. Pancreatic cancer with liver metastasis.
3. Anemia secondary to blood loss requiring transfusion of
packed red blood cells.
4. Biliary tract fistula to branch of the right hepatic
artery causing acute blood loss, embolized.
5. Sepsis likely secondary to ascending cholangitis. Had a
blood clot in the stent leading to accumulation (no drainage)
of biliary fluid. Recent MICU admission for sepsis. Patient
did not require use of pressors.
6. Pancreatitis, laboratory. Patient had no abdominal pain.
7. Status post multiple interventional radiology
interventions on the biliary system.
8. Status post PICC placement for IV antibiotics.
DISCHARGE MEDICATIONS:
1. Lovenox 90 mg subcu q.12 hours (dose is 1 mg per kg,
patient weighs approximately 95 kg).
2. Ambien 5 to 10 mg p.o. q.h.s. p.r.n. for insomnia.
3. Ativan 0.5 to 1.0 mg p.o. q.six hours as needed for
agitation.
4. Ampicillin 2 gm IV q.four hours times 10 days.
5. Morphine sulfate 10 mg p.o. q.12 hours as needed for
pain.
6. Colace 100 mg p.o. b.i.d. p.r.n.
7. Senna two tabs p.o. b.i.d. p.r.n.
8. Compazine 10 mg p.o. q.four to six hours p.r.n. nausea.
9. Effexor XR 75 mg p.o. q.day. Instructions are to take
one pill every day (75 mg) for five days, then may increase
to two pills every day (150 mg).
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 16787**]
MEDQUIST36
D: [**2161-3-19**] 22:05
T: [**2161-3-20**] 08:40
JOB#: [**Job Number 49946**]
|
[
"038.49",
"577.0",
"447.2",
"157.0",
"576.1",
"576.2",
"197.7",
"285.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"38.93",
"38.91",
"39.79",
"51.98",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
2906, 2956
|
22294, 22967
|
22990, 23854
|
5628, 20776
|
20801, 21005
|
2979, 5610
|
1621, 1973
|
157, 221
|
250, 1601
|
1996, 2533
|
2550, 2889
|
21030, 22273
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,318
| 157,572
|
4258+4259
|
Discharge summary
|
report+report
|
Admission Date: [**2122-12-13**] Discharge Date: [**2122-12-22**]
Date of Birth: [**2047-5-14**] Sex: F
Service: MEDICINE/ICU
CHIEF COMPLAINT: The patient is admitted with
gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: This is a 75 year old woman with
past medical history of hepatocellular carcinoma complicated
by esophageal varices by history, status post radiofrequency
ablation, diabetes mellitus type 2, who was admitted from
[**Hospital3 **] from management of a gastrointestinal
bleed. She recently underwent an open reduction and internal
fixation of an intertrochanteric fracture and was discharged
to rehabilitation on [**2122-12-2**]. While at rehabilitation, she
was placed on Levofloxacin and Flagyl for presumed aspiration
pneumonia. She was complaining of nausea and vomiting on the
day of admission and had hematemesis. In retrospect per her
daughter, the daughter notes days of melena. The patient had
also been treated for Clostridium difficile colitis.
PAST MEDICAL HISTORY:
1. Breast carcinoma, status post lumpectomy treated with
Tamoxifen.
2. Chronic pancreatitis.
3. Status post open reduction and internal fixation left
hip.
4. Spinal stenosis.
5. Hepatocellular carcinoma as described.
6. Diabetes mellitus type 2.
ALLERGIES: She has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Actigall 300 mg p.o. once daily.
2. Albuterol.
3. Atrovent.
4. Aldactone 50 mg once daily.
5. Axid 150 mg twice a day.
6. Doxepin 25 mg three times a day.
7. Iron.
8. Glyburide 5 mg once daily.
9. Synthroid 100.
10. Zofran 8 mg twice a day.
11. Serax 15 mg.
12. Phenobarbital 12 mg twice a day.
13. Os-Cal 500 mg three times a day.
14. Multivitamin.
15. Metformin twice a day.
SOCIAL HISTORY: The patient lived with her husband.
Recently at [**Hospital3 **] post surgery.
FAMILY HISTORY: Sister with breast carcinoma and aunt with
gastric carcinoma.
EMERGENCY DEPARTMENT COURSE: In the Emergency Department,
the patient was intubated for airway protection and
resuscitated aggressively with packed red blood cells and
fresh frozen plasma with good peripheral access and
intravenous fluids. She had a CT of the abdomen. The
patient's lactate was 8.0 and the abdomen was tender and
distended. CT showed ascites, portal venous and superior
mesenteric vein thrombosis and diffuse bowel wall thickening
from hepatic flexure to the rectum. No free air. Surgery
and gastroenterology were consulted. The patient felt not to
be an operative candidate and no acute indication.
Gastroenterology performed nasogastric lavage, remaining
massive amounts of clots and bright red blood before
proceeding to esophagogastroduodenoscopy. The family was
present and confirmed full Code Status of the patient.
PHYSICAL EXAMINATION: On admission to the Medical Intensive
Care Unit, vital signs showed temperature 92.5, pulse 70,
blood pressure 150/77. She was ventilated, assist control
with tidal volume 500, respiratory rate 18, PEEP 5, and FIO2
100%. In general, sedated and intubated. Head, eyes, ears,
nose and throat - blood oozing from nose and mouth. Neck was
supple, no jugular venous distention. Cardiovascular - S1
and S2, tachycardic. Respiratory - coarse breath sounds
bilaterally. Rales at the bases. Abdomen is distended,
decreased bowel sounds, tympanic on the right, dull on the
left. Extremities - no cyanosis, clubbing or edema.
LABORATORY DATA: On admission, partial thromboplastin time
53.0 and INR 2.4. Her baseline INR had been between 2.0 and
10.0. Chem7 showed sodium 134, potassium 4.8, chloride 105,
bicarbonate 16, blood urea nitrogen 41, creatinine 1.2 and
glucose 270. Complete blood count showed white blood cell
count 15.0, hematocrit 33.7 and platelet count 128,000. Her
liver function tests were unremarkable.
HOSPITAL COURSE:
1. Gastrointestinal bleed - The patient was seen by surgery.
Aggressive resuscitation with 10 units of red blood cells and
six units of fresh frozen plasma. Nasogastric lavage removed
several liters of bright red blood and clot.
Esophagogastroduodenoscopy was done and no esophageal varices
were visualized. A cherry red spot was ablated and was
potential for a source of bleed. No active site of bleeding
was visualized. A colonoscopy was performed up to 80
centimeters with no active bleeding and normal appearing
mucosa. The patient was started on an intravenous of
Protonix twice a day, Octreotide, empiric antibiotics for
spontaneous bacterial peritonitis prophylaxis and empiric
coverage for Clostridium difficile and ischemic colitis given
the radiographic and clinical findings which were
subsequently stopped as the patient stabilized. Octreotide
was discontinued after three day course. The patient was
also given Albumin intravenously.
2. Ascites - The patient had abdominal ascites and required
two large volume paracentesis, no evidence of spontaneous
bacterial peritonitis, final cultures were negative.
Spontaneous bacterial peritonitis prophylaxis was stopped as
the patient's condition improved. It was felt to be
secondary to portal vein and superior mesenteric vein
thrombosis in addition to cirrhosis and low albumin.
3. Pulmonary - The patient was intubated for airway
protection. She required increased pressures due to her
severe abdominal distention. After her second paracentesis,
the patient's pressures decreased sufficiently. The patient
was extubated successfully.
4. Hematology - The patient's INR was elevated due to her
liver disease. Chronically she was reversed with fresh
frozen plasma as needed for aggressive resuscitation. She
was given platelets and large volume transfusion as well as
calcium. Goal hematocrit was greater than or equal to 30.0.
5. Endocrine - The patient was started on insulin drip for
tight glucose control. She was not hypotensive. Initially
her Synthroid was converted to intravenous while she was
unable to take p.o.
6. Renal - Her creatinine elevated from baseline on
admission was likely due to her gastrointestinal bleed and
prerenal hypovolemia, improved with adequate volume
replacement.
7. Code Status - The patient was full code on admission.
After discussion with Dr. [**First Name (STitle) 679**], the patient's primary care
physician, [**Name10 (NameIs) **] the family, the family decided on "Do Not
Resuscitate" but no DNI. Subsequently during the course
after discussion with Dr. [**Last Name (STitle) **], the family decided that
they wanted the code status changed back to full code.
8. Hypotension - The patient was initially hypertensive and
became hypotensive when coming to the unit, required Dopamine
drip that was able to wean off as sedation was stopped after
stabilization. Once pressures were stabilized, the patient
was restarted on her outpatient diuretic at the low dose,
titrating up.
9. FEN - The patient was started on tube feeds while
intubated and was able to tolerate p.o. once extubated and
advance diet and tube feeds were discontinued. The patient
was stabilized and called out to the General Medicine Floor
on [**2122-12-18**].
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D.
Dictated By:[**Name8 (MD) 757**]
MEDQUIST36
D: [**2122-12-19**] 12:52
T: [**2122-12-19**] 13:36
JOB#: [**Job Number 18491**]
Admission Date: [**2122-12-18**] Discharge Date: [**2122-12-24**]
Date of Birth: [**2047-5-14**] Sex: F
Service: [**Hospital1 139**] Medicine
HOSPITAL COURSE: Patient was admitted to the [**Hospital6 **]. By transfer, patient's upper GI bleeding had
resolved. Patient continued to have two peripheral IVs.
Hematocrits were monitored without change or drop in
hematocrit. Patient had no hematemesis or melena during the
rest of the hospital course. EGD was performed prior to her
discharge to re-evaluate for varices or sources of upper GI
bleeding. Grade 2 varices was found. Two varices were
banded.
Patient was placed on prednisone for possible adrenal
insufficiency. Patient was tapered off rapidly over the
course of the week off the steroids.
Patient had increasing ascites during her hospital course.
Patient was pain free, able to breathe appropriately.
Paracentesis was performed, which showed no evidence of
infection. Patient was placed on SBP prophylaxis.
Patient had episodes of bradycardia. Patient was placed on
telemetry to monitor. Episodes of bradycardia occurred at
rest while patient was sleeping. Electrolytes were monitored
3x/day. No etiology was determined for the bradycardia,
however, patient was asymptomatic.
Upon initial arrival to the floor, the patient was lethargic
and oriented to time and place. The patient's mental status
continued to improve while she was on the floor. Patient is
alert, oriented, and conversive prior to her discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehab facility.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleeding unknown source.
2. Anemia from blood loss.
3. Cirrhosis.
4. Coagulopathy.
5. Diabetes.
6. Bradycardia.
7. Coagulopathy.
8. Ascites.
DISCHARGE MEDICATIONS:
1. Albuterol inhaler.
2. Ipratropium inhaler.
3. Colace.
4. Levothyroxine 50 mcg p.o. q.d.
5. Protonix 40 mg once a day.
6. Vitamin D.
7. Calcium carbonate.
8. Petroleum cream topical.
9. Pancrelipase capsules three capsules t.i.d. with meals.
10. Ciprofloxacin 500 mg tablets p.o. q.d.
11. Spironolactone 150 mg p.o. q.d.
12. Furosemide 40 mg p.o. q.d.
13. Albumin 25% intravenously b.i.d.
14. Glargine 10 units subcutaneously at bedtime.
15. Humalog sliding scale.
16. Bisacodyl prn.
17. Senna.
FOLLOWUP: Patient was asked to followup with a
gastroenterologist, Dr. [**First Name (STitle) 679**], primary care provider, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 141**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1379**]
Dictated By:[**Name8 (MD) 10402**]
MEDQUIST36
D: [**2122-12-24**] 08:52
T: [**2122-12-24**] 08:56
JOB#: [**Job Number 18492**]
|
[
"571.5",
"285.1",
"276.5",
"557.0",
"518.81",
"789.5",
"456.20",
"785.59",
"507.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.07",
"45.24",
"54.91",
"99.07",
"96.04",
"99.04",
"42.33",
"38.91",
"96.33"
] |
icd9pcs
|
[
[
[]
]
] |
1855, 2766
|
8958, 9120
|
9143, 10092
|
1351, 1741
|
7531, 8864
|
2789, 3816
|
161, 215
|
244, 1004
|
1026, 1325
|
1758, 1838
|
8889, 8937
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,809
| 180,104
|
48888
|
Discharge summary
|
report
|
Admission Date: [**2135-7-3**] Discharge Date: [**2135-7-11**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
Central venous line
Midline
History of Present Illness:
56 YO F with DM1 c/b multiple episodes of DKA, polyneuropathy
and gastroparesis, HCV genotype 1A, [**Doctor Last Name 933**] disease, and
hypertension who presented to the ED due to confusion. Per the
ED resident the patient's daughter reported that the patient had
not been taking her meds for the past couple of days. Her
daughter called her earlier on the day of admission and noted
that she was confused so called EMS who brought the patient into
the ED.
.
Upon arrival to the ED, her VS were: 96.1 115 134/72 42
100%3L. She was triggered upon arrival to the ED due to her poor
mental status. She c/o nausea, SOB and CP with recent flare of
gastroparesis with unknown last BM. Exam was notable for an
irritable female oriented to self. Labs were notable for initial
glucose > than assay, K 7.6; chem 7 revealed glucose 1369, Na
121, K 6.0, bicarb 8, creat 2.2, gap 34. UA was notable for
glucose and ketones. EKG was notable for ST segment elevation in
V1-V2. A Code STEMI was called and the patient was given asa,
plavix 300mg, heparin bolus, integrillin bolus as well as
started on an insulin drip with bolus of 10u and rate of 8u. She
was also given a total of 4.5L NS. A left femormal line was
placed. Of note, placement was complicated by an arterial
puncture. EKG was repeated after insulin drip was started with
improvement in the ST segments. Cardiology therefore felt the
changes were [**2-22**] hyperkalemia in the setting of hyperglycemia
and suggested stopping heparin and integrillin and continuing
treatment of DKA.
.
Repeat labs were notable for glucose 1135, K 4.1, bicarb 5,
creatinine 2.2 and an anion gap of 34.
.
The patient is not able to provide additional history at this
time. She is oriented to place and situation but is quite
somnolent. She c/o abdominal pain but denies ongoing CP or SOB.
.
Of note, she was recently admitted in the end of [**Month (only) 116**] for DKA
found to have an E coli UTI treated with cipro.
Past Medical History:
# DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**].
Several episodes of DKA, managed on 28U Lantus [**Hospital1 **] plus HISS
- Frequent episodes of DKA
- DKA has been complicated by CVA, 3 episodes suspected
(including [**2135-5-14**] episode)
# Diabetic polyneuropathy and gastroparesis
# Hypertension
# Grave's disease s/p RAI [**2129**]
# Reactive airway disease
# Seronegative arthritis, followed in rheumatology
# Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
never been on antiviral therapy, acquired via blood transfusion
during surgery in [**2110**]
# GERD
# Migraines
# Bilateral knee arthroscopy in [**5-24**]
# s/p TAH and pelvic floor surgery with bladder lift
# Depression
# Bone spurs in feet
# Bilateral foot drop requiring wheelchair use
Social History:
Patient lives in an apt building. She has a son, daughter and
another brother who live on another floor. She is a never smoker
and does not use alcohol or drugs. She has not worked for many
years. She uses a wheelchair at baseline.
Family History:
Her mother died of colon cancer. There are multiple family
members with DM.
Physical Exam:
Vitals: T:100.2 Tmax: 101 BP:92/47-148/107 P: 80-99 R: 18 O2:99%
RA
General: Alert, oriented, no acute distress
[**Date Range 4459**]: Sclera anicteric, MMM, oropharyngeal erythema with
multiple shallow ulceration with exudate, Ecchymoses left right
eye.
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
mild tenderness to palpation over epigastrum, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII Intact, Decreased sensation to light touch
bilateral fingers of bilateral upper extremity and feet,
Bilateral foot drop.
Pertinent Results:
Labs on Admission:
[**2135-7-3**] 11:15AM BLOOD WBC-17.4*# RBC-3.41* Hgb-10.0* Hct-35.7*#
MCV-105*# MCH-29.3 MCHC-28.0*# RDW-14.1 Plt Ct-466*
[**2135-7-3**] 11:15AM BLOOD Neuts-84.0* Lymphs-12.2* Monos-3.2
Eos-0.2 Baso-0.3
[**2135-7-3**] 11:15AM BLOOD PT-13.6* PTT-29.5 INR(PT)-1.2*
[**2135-7-3**] 11:15AM BLOOD Glucose-1369* UreaN-39* Creat-2.2*#
Na-121* K-6.0* Cl-80* HCO3-7* AnGap-40*
[**2135-7-3**] 11:15AM BLOOD ALT-17 AST-22 AlkPhos-125* TotBili-0.4
[**2135-7-3**] 11:15AM BLOOD Lipase-61*
[**2135-7-3**] 11:15AM BLOOD cTropnT-<0.01
[**2135-7-3**] 03:15PM BLOOD CK-MB-5
[**2135-7-4**] 09:50AM BLOOD CK-MB-6 cTropnT-<0.01
[**2135-7-3**] 11:15AM BLOOD Calcium-8.2* Phos-7.4*# Mg-2.3
[**2135-7-3**] 05:58PM BLOOD Osmolal-327*
[**2135-7-3**] 05:58PM BLOOD TSH-2.1
[**2135-7-6**] 07:20AM BLOOD HIV Ab-NEGATIVE
[**2135-7-3**] 05:58PM BLOOD ASA-4.2 Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Labs on Discharge:
[**2135-7-11**] 07:10AM BLOOD WBC-4.9 RBC-2.74* Hgb-8.2* Hct-25.8*
MCV-94 MCH-30.1 MCHC-32.0 RDW-15.9* Plt Ct-359
[**2135-7-11**] 07:10AM BLOOD Glucose-490* UreaN-13 Creat-1.1 Na-128*
K-5.1 Cl-95* HCO3-29 AnGap-9
[**2135-7-11**] 07:10AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.7
.
Microbiology:
Urine Cx ([**7-3**]): Final No Growth
Blood Cx ([**7-3**] - 14 - 15): Final No Growth
Catheter Tip:
[**2135-7-4**] 11:17 am CATHETER TIP-IV Source: lft fem.
**FINAL REPORT [**2135-7-6**]**
WOUND CULTURE (Final [**2135-7-6**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
.
Urine Culture ([**7-4**]):
[**2135-7-4**] 4:58 pm URINE Source: Catheter.
**FINAL REPORT [**2135-7-7**]**
URINE CULTURE (Final [**2135-7-7**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Throat Culture:
**FINAL REPORT [**2135-7-8**]**
GRAM STAIN- R/O THRUSH (Final [**2135-7-5**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO [**Doctor Last Name **] ORGANISMS SEEN.
NEGATIVE FOR YEAST.
THROAT - R/O BETA STREP (Final [**2135-7-7**]):
NO BETA STREPTOCOCCUS GROUP A FOUND.
BETA STREPTOCOCCI, NOT GROUP A. RARE GROWTH.
RESPIRATORY CULTURE (Final [**2135-7-8**]):
HEAVY GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
Throat Viral Swab:
Time Taken Not Noted Log-In Date/Time: [**2135-7-5**] 3:11 pm
SWAB
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary):
No Virus isolated so far.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
.
Urine Culture:
[**2135-7-6**] 1:29 pm URINE Source: CVS.
**FINAL REPORT [**2135-7-9**]**
URINE CULTURE (Final [**2135-7-9**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Imaging:
CXR ([**7-3**]): 1. Asymmetric lucent appearance of the left lung is
likely technical in nature.
2. Otherwise, no evidence of acute intrathoracic abnormality.
.
KUB ([**7-3**]): Stool within colon. No evidence of obstruction.
.
CT Head ([**7-3**]): No evidence of acute intracranial abnormality.
In case of
clinical concern for acute infarction, an MRI can be obtained.
.
CXR ([**7-5**]): No evidence of pneumonia.
.
Venous Duplex ([**7-8**]): No evidence of thrombosis of the left
internal jugular or subclavian vein.
Brief Hospital Course:
56 YO F with DM1 c/b multiple episodes of DKA, polyneuropathy
and gastroparesis, HCV genotype 1A, [**Doctor Last Name 933**] disease, and
hypertension presenting with altered mental status found to have
DKA.
.
#. Mental Status Change/DKA: On presentation to ED, exam was
notable for an irritable female oriented to self. Labs were
notable for initial glucose > than assay, K 7.6; chem 7 revealed
glucose 1369, Na 121, K 6.0, bicarb 8, creat 2.2, anion gap 34.
UA was notable for glucose and ketones. Mental status changes
likely secondary to DKA. Unclear if DKA precipitated by
medication non adherence versus infection. CXR clear on
admission. UA negative however reportedly patient was being
treated for UTI as an outpatient. Blood cultures drawn and
negative to date. CT head performed without acute intracranial
pathology. Initially patient given 1/2 NS with potassium and
regular insulin gtt with q1H glucose checks and Q4H
electrolytes. Blood sugar improved and anion gap closed - mental
status improved. Patient transferred to general medical floor.
On the floor course was notable for multiple episodes of
hypoglycemia. [**Last Name (un) **] was consulted and helped manage the
patients blood sugar regimen. Eventually, patient was discharged
with outpatient follow up with the [**Last Name (un) **] Diabetes Center.
Regimen at discharge was Lantus 25U in the morning, 25U in the
evening and humalog insulin sliding scale.
.
#. UTI: Patient was found to have an ESBL Ecoli UTI. Treated
with Nitrofurantoin to complete a 7 day course. Patient remained
afebrile without leukocytosis. At discharge follow up [**Last Name (un) 1988**]
with PCP.
.
#. Pharyngeal Ulceration: During the patient's MICU course
patient endorsed sore throat. Found to have pharyngeal erythema,
exudate, and ulceration concerning for infection. Throat culture
revealed beta strep non group A rate growth. Viral culture was
negative. Patient treated with 5 day course of Azithromycin.
Patient continued to note pain in the posterior pharynx. No
parapharyngeal or retropharyngeal abscess identified. ENT
consulted for potential biopsy of ulcerative lesion. ENT felt
that this lesion likely represents viral infection and
recommended treatment with acyclovir, no biopsy indicated.
Patient improved prior to discharge. Follow up was [**Last Name (un) 1988**] at
discharge and acyclovir was continued to complete a 7 day
course.
.
# EKG changes. On admission EKG was notable for ST segment
elevation in V1-V2. A Code STEMI was called and the patient was
given asa, plavix 300mg, heparin, and integrillin bolus. EKG was
repeated after insulin drip was started with improvement in the
ST segments. Cardiology therefore felt the changes were [**2-22**]
hyperkalemia in the setting of hyperglycemia and suggested
stopping heparin and integrillin and continuing treatment of
DKA. Cardiac enzymes negative. Aspirin 325mg daily, statin, and
beta-blocker continued.
.
# Left femoral hematoma secondary to arterial stick in ED: HCT
and hematoma monitored during admission and stable.
.
# Diabetic polyneuropathy and gastroparesis: Continued reglan,
docusate, senna, hycosamine, amitriptyline, percocet, neurontin.
Symptoms stable during admission.
.
# Hypertension: Initially held antihypertensives in the MICU.
Restarted Losartan on the floor.
.
# Grave's disease; s/p RAI [**2129**]: Continued methimazole.
.
# Reactive airway disease: Continued Advair and Montelukast.
Albuterol and Ipratroprium nebs as needed.
.
# Seronegative arthritis: Continued Sulfasalzine.
.
# Depression: Continued Amitriptyline.
.
# Bilateral foot drop requiring wheelchair use: Consulted PT. At
discharge provided patient with a letter that she should live on
the [**Location (un) 448**] of her apartment building.
.
# Dark skin surrounding right eye: Initially thought to be
bruising. Social work consulted. After discuss discovered that
this has chronically been present and is secondary to a nervous
habit or rubbing the right eye.
Medications on Admission:
-Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
-Albuterol Sulfate inh 2q6h PRN
-Fluticasone-Salmeterol 250-50 mcg/Dose 1inh [**Hospital1 **]
-Aspirin 81 mg Tablet
-Amitriptyline 25 mg Tablet
-Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID
-Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
-Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
-Prilosec 20 mg Tablet, Delayed Release daily
-Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
-Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID
-Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12 hr q8H
-Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
-Oxycodone-Acetaminophen 5-325 mg Tablet q6H PRN
-Diazepam 2 mg Tablet Sig: One (1) Tablet PO q12H PRN
-Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID
-Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-Insulin Glargine 25u qam, 20u q4:30 pm
-Zomig 2.5mg nausea prn
-Miralax 17gm PRN
- hydroxyzine 25mg PO Prn
- on d/c summary but not on current med list
---> Humalog 100 unit/mL Solution QID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every six (6) hours.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12 hr
Sig: One (1) Capsule, Sust. Release 12 hr PO Q 8H (Every 8
Hours).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for Pain.
15. Diazepam 2 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety: do not take medicine and drive a car or
consume alcohol. .
16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
17. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
18. Glargine Insulin
25 units every morning
25 units every evening
19. Humalog Insulin
Sliding Scale Insulin per your home sliding scale.
20. Zomig 2.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for headache.
21. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day
as needed for constipation.
22. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO once a
day as needed for itching.
23. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 4 days.
Disp:*8 Capsule(s)* Refills:*0*
24. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
Primary:
Type One Diabetes
Diabetic Ketoacidosis
Urinary Tract Infection
Pharyngitis
.
Secondary:
Peripheral Neuropathy
Bilateral Foot Drop
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 18741**],
It was a pleasure participating in your care while you were
admitted with diabetic ketoacidosis. During your stay your blood
sugar was controlled. A urinary tract infection was identified
and treated. Further, inflammation of your throat was
appreciated and you were treated with antibiotics and antiviral
medications. Please continue your antibiotics for the full
course even if you start to feel better.
.
Please follow up with your primary care physician and [**Name9 (PRE) **]
diabetes (appointments [**Name9 (PRE) 1988**] below). Please check your blood
sugars prior to eating and at bedtime. Keep a record of your
blood sugars and bring this list to your follow up appointment
with Dr. [**Last Name (STitle) **] on [**7-20**] at [**Last Name (un) **] Diabetes Center.
.
The following changes were made to your medication regimen:
- START: Acyclovir for 4 more days
- START: Macrobid (Nitrofurantoin) for 4 more days
- CHANGE: Lantus Insulin to 25Units in morning and 25 Units in
the evening. Continue your home humalog sliding scale.
.
Again, it was a pleasure participating in your care.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: Wednesday, [**7-20**], 2PM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
.
Please follow up with your primary care doctor, Dr.[**Last Name (STitle) 7537**]
([**Telephone/Fax (1) 7538**]), [**7-20**] at 9:00 AM.
|
[
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"599.0",
"E870.5",
"311",
"493.90",
"715.90",
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"998.12",
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18113, 18167
|
10751, 14734
|
293, 323
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18351, 18398
|
4279, 4284
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19684, 20159
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3381, 3458
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15849, 18090
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18188, 18330
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14760, 15826
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18527, 19661
|
3473, 4260
|
232, 255
|
5208, 10728
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351, 2307
|
4298, 5189
|
18413, 18503
|
2329, 3116
|
3132, 3365
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,827
| 143,123
|
26323
|
Discharge summary
|
report
|
Admission Date: [**2104-11-1**] Discharge Date: [**2104-11-7**]
Date of Birth: [**2025-9-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Upper GI Bleed
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
This is a 79 y.o. gentleman with colon cancer, EtOH Cirrhosis
presenting from an outside hospital with upper GI Bleed and
sepsis. He presented to [**Hospital3 **] on [**2104-10-31**] with sudden
onset of fevers, chills, rectal bleeding and hematemesis. There
he was admitted to the ICU. He was noted to have left LE
cellulitis and 33% bandemia. His SBP was in the 80s and he was
started on dopamine, unasyn, and tequin. His Hct was noted to
drop from 33 to 24. He was transfused 2 units PRBC on [**10-31**]. On
the morning of [**2104-11-1**] he had temp of 103.7, blood cultures +
for GPC, and was started on vancomycin. At 3PM he began
vomiting bright blood (~100 cc). Dr. [**Last Name (STitle) **] was consulted and
recommended Vitamin K, FFP, octreotide gtt and transfer to [**Hospital1 18**]
for variceal banding.
Past Medical History:
1) Colon Cancer, diagnosed in [**2100**] s/p XRT x 3, with resulting
radiation proctitis. He elected not to have surgery because he
did not want a colostomy
2) EtOH Cirrhosis with Portal HTN. Has had esophageal and
gastric varices. He recalls 2 episodes of variceal bleeds
3) Fem-Fem Bypass in [**2102**]
4) Diabetes, diet controlled
Social History:
Former EtOH Abuse. Has not had a drink in over 10 years. No
smoking--quit 18 y.a. Retired tree Surgeon. Involved
daughter. Full code but would not want prolonged intubation.
Family History:
non-contributory
Physical Exam:
Temp:100.0 BP: 140/48 HR:78 RR:14 O2:100 2L
Gen: NAD, A/O x3
HEENT: PEARLA. EOMI.
CV: RR No M/R/C/G. Port-a-cath without erythema
Pulm: CTA b/l
ABD: Soft/NT/ND. No fluid wave or asterixis. No HSM.
Ext: no edema. Marked, dry erythema of left leg from knee to
ankle without bullae or vesicles. 1+ DP b/l. No spider
angiomas
Neuro: Motor [**4-3**] at all flex/ex. Sensation: GI to LT. CN
II-XII GI.
Pertinent Results:
[**2104-11-1**] GLUCOSE-160* UREA N-55* CREAT-1.8* SODIUM-141
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-19* ANION GAP-15
[**2104-11-1**] ALT(SGPT)-122* AST(SGOT)-145* LD(LDH)-289* ALK PHOS-68
AMYLASE-918* TOT BILI-3.7*
[**2104-11-1**] LIPASE-15
[**2104-11-1**] ALBUMIN-2.6* CALCIUM-6.6* PHOSPHATE-4.1 MAGNESIUM-1.7
[**2104-11-1**] WBC-8.9 RBC-2.97* HGB-9.3* HCT-25.7* MCV-86 MCH-31.4
MCHC-36.3* RDW-18.0*
[**2104-11-1**] NEUTS-94.2* LYMPHS-4.0* MONOS-1.6* EOS-0.1 BASOS-0.1
[**2104-11-1**] PLT COUNT-54*
INR:1.8
ECG: NSR at 80 bpm. Nl axis/intervals. QTc=470. Low voltage
CXR: Port-a-cath in good position. Basilar atelectatic change
in left costophrenic angle. No CHF.
EGD: 4 cords of grade II-III varices at lower third of
oesophagus with stigmata of bleeding. 4 bands placed.
Angioectasia in the antrum and second portion of duodenum.
Brief Hospital Course:
The patient is a 79 y.o. gentleman with colon cancer, EtOH
Cirrhosis who presented with upper GI Bleed and ? LE cellulitis
with gram + cocci bacteremia. The patient was admitted to the
ICU where he had an EGD with 4 bands. Blood cultures from the
OSH came back positive for strep group C and the patient was
treated with Unasyn.
1) Upper GI Bleed: Secondary to variceal bleed. He was seen by
GI/liver team on admission and multiple varices were visualized
by EGD, all with stigmata of recent bleeding. He required a
total of 3 U PRBC, and hematocrit remained stable after this
intervention. He was initially on an ocreotide drip which was
stopped after a few days. Twice daily protonix was initiated,
and he was started on nadolol (40mg QD). Hematocrits remained
stable, and he was transferred to the floor. The patients hct
remained stable during the rest of his hospitalization. Dr.
[**First Name (STitle) 437**] (GI) contact[**Name (NI) **] Dr. [**Last Name (STitle) **] (patients outpatient GI) and
scheduled a followup EGD in a few weeks.
2) Cellulitis/Sepsis: He likely has chronic LE venous
insufficiency secondary to his PVD. He likely had an ulcer on
LLE that acted as a portal of entry for infection. Blood
cultures at OSH were growing out 2/4 bottles GPC (not yet
speciated). He was started/continued on Vancomycin and Unasyn
for coverage (to be narrowed based on micro data). He was
transferred also on levofloxacin which was discontinued). He
was initially on dopamine gtt on transfer, transitioned to
levophed on arrival. This was weaned to off, and he remained
hemodynamically stable. At this point OSH records were faxed
over and [**1-4**] cultures were positive for strep group C. ID was
called and recommened d/cing vancomycin as unasyn would be
adequate for strep C. Upon discharge (antibiotic day 7), the
patient was switched to PO augmentin (will complete a 14 day
course). All cultures obtained at [**Hospital1 18**] remained negative. The
patient will need survellence cultures after completion of his
antibiotic course. The patients PCP (Dr. [**Last Name (STitle) **]) will follow
the patient next week.
3) Cirrhosis: likely secondary to EtOH, transplant surgery was
contact[**Name (NI) **] while in-house. He was maintained on aldactone;
portal US of liver showed cirrhotic liver with a very small
amount of perihepatic ascites (not enough to tap or mark).
Hepatitis serologies were sent and are pending. He will follow
up with GI/liver. Lasix was restarted prior to discharge (the
patient had been on bumex prior to admission).
4) Colon Cancer: He has known colon cancer, currently receiving
therapy at [**Hospital3 **]. He has a port-a-cath for access.
5) Hyperamylasemia: Likely secondary to bleeding varices.
Normal lipase. This trended down and abdominal exam remained
benign.
6) PVD: s/p fem-fem bypass. Vascular surgery was consulted
while in-house. Pentoxyfylline was initially held while
in-house but may be restarted as an outpatient. The patient
will need to have further vascular evaluation and likely further
surgery. After speaking with the patients outpatient vascular
surgean (Dr. [**Last Name (STitle) 65145**] it was decided that the patient would be
better served having further surgery at [**Hospital1 18**]. It was also
decided that they patient should finish his course of
antibiotics prior to any intervention so he will be re-admitted
in 1 month. The patient will be following with his PCP next
week and any further pre-op evaluation will be done at that
time. We plan to readmit the patient on [**2104-12-8**] for
further vascular intervention.
7) Low Platelets - The patients platelet count was consistently
low. An outpatient evaluation should be considered with the
patients PCP.
Medications on Admission:
Protonix 40 mg daily
Aldactone 25 [**Hospital1 **]
Trental 400 mg qid
Vicodin 1 tab [**Hospital1 **]
Neurontin 600 mg [**Hospital1 **]
Bumex 1 mg [**Hospital1 **]
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
GI Bleed
Bacteremia
Discharge Condition:
Stable
Discharge Instructions:
--Please return to the ER if you have an signs of bleeding
(spitting up blood, blood in your stool, dizzyness, or
lightheadedness)
--Please followup with all of your appointments. Please take
all medication as we have prescribed.
**We have changed your medications. Please take the medications
as we have prescribed.
******INSTEAD OF BUMEX YOU WILL NOW BE TAKING LASIX
--You will be readmitted to the hospital likely on [**2104-12-8**].
The admitting office will call you to arrange the details.
Followup Instructions:
--You have an appointment with Dr. [**Last Name (STitle) **] on Monday ([**11-10**]) at 2:30.
--Dr [**Last Name (STitle) **] wants to perform your repeat EGD next Thursday.
Please call his office on Monday to get specific instructions
for the procedure. ([**Telephone/Fax (1) 65146**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
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7914, 7920
|
3113, 6888
|
329, 346
|
7984, 7993
|
2242, 3090
|
8541, 8923
|
1775, 1793
|
7101, 7891
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7941, 7963
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6914, 7078
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1808, 2223
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275, 291
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374, 1202
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1224, 1562
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1578, 1759
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,232
| 109,849
|
54346
|
Discharge summary
|
report
|
Admission Date: [**2158-10-16**] Discharge Date: [**2158-10-19**]
Date of Birth: [**2080-6-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
melena, drop in hct
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo male, h/o recently diagnosed metastatic pancreatic cancer,
presenting from rehab with melena and dropping hct. Pt was
recently admitted here at [**Hospital1 18**] with FTT (weight loss 30 lb,
diarrhea, abdominal pain. Work up at this time included CT scan
of the abdomen which showed a 3.5x5.5 cm mass in the head of the
pancreas with erosion into the duodenal wall, with multiple
mesenteric and hepatic metastases. EGD during this
hospitalization showed gastritis, antral erosions, duodenitis,
and metastatic pancreatic cancer encircling the GDA. He
required transfusions at that time to keep his hct>30. He was
discharged to rehabilitation, to follow up with Dr. [**Last Name (STitle) **]
for further oncologic management.
.
Pt has been at [**Hospital3 **] since that time; labs checked
today showed a hematocrit of 24.5 (29.4 on [**10-9**]) and WBC of
16.5. Pt denies melena or BRBPR, but he states that NH staff
found blood in his stool. He reports diarrhea x 1-2 days ([**11-20**]
loose BM per day) and some lightheadedness with standing. He
denies CP/SOB/PND/orthopnea/fever/chills.
Past Medical History:
1. HTN
2. DM 2
3. Hypercholesterolemia
4. Enlarged prostate, elevated PSA (?biopsy)
5. DJD of right hip
6. Large, left, reducible inguinal hernia
7. CRI, baseline 1.1-1.5
8. Metastatic pancreatic cancer, with hepatic and mesenteric
mets, elevated CA [**71**]-9
9. Gastritis on EGD [**2158-9-16**]:
Stenosis of the gastroesophageal junction
Erosion in the stomach
Erythema in the second part of the duodenum and third part
of the duodenum compatible with duodenitis
Stenosis of the second part of the duodenum
On scope withdrawal a hematoma was seen in cervical
esophagus, just below upper esophageal sphincter.
Social History:
Living at [**Hospital3 **] currently, no family in area, remote
smoking ([**12-22**] yrs) but quit 50 yrs ago, no alcohol/drugs, retired
postal worker; never been married, no kids, has cousin living on
west coast. No health care proxy and has no family or friends to
appoint.
Family History:
Mother died in 70s [**12-21**] unknown causes, father died in 70s [**12-21**]
MI, no siblings
Physical Exam:
VS: 98.9 76 99/54 17 100% RA
Gen: elderly male, somewhat disheveled, poor dentition, A&Ox3,
pleasant
HEENT: PERRL, OP clear, poor dentition, MMM; with some asymmetry
of right eyelid/droop
Neck: no LAD, no JVD
Lungs: CTA bilat, no w/r/r
CV: irreg rhythm, nl s1/s2, no m/r/g appreciated
Abd: soft, nt/nd, nabs, no reb/guard
Extr: no c/c/e, PT 1+ bilat
Neuro: CN II-XII intact with lid droop as above, 4+/5 strength
diffusely, toes downgoing bilaterally, MS as above
Skin: multiple nevi diffusely, especially on torso/back, ?SKs
(?sign of [**Last Name (un) **]-Trelat)
Pertinent Results:
Labs:
[**2158-10-16**] 06:58PM WBC-18.2*# RBC-2.77* HGB-8.0* HCT-22.5*
MCV-81* MCH-28.8 MCHC-35.4* RDW-16.0*
[**2158-10-16**] 06:58PM GLUCOSE-354* UREA N-44* CREAT-1.5* SODIUM-133
POTASSIUM-5.3* CHLORIDE-93* TOTAL CO2-27 ANION GAP-18
[**2158-10-16**] 06:58PM CK(CPK)-64
[**2158-10-16**] 06:58PM CK-MB-NotDone cTropnT-0.1*
[**2158-10-16**] 06:58PM PT-13.2 PTT-18.9* INR(PT)-1.2
.
Imaging:
CXR: no infiltrate, perhaps small bilateral effusions
.
CT Abdomen: large pancreatic head mass, slightly larger; still
with encasement of gastroduodenal artery (unchanged); small
filling defect in base of right lung
.
EKG: NSR 68, LAD, ST depr in I, II, AVL, V5, V6; unchanged from
prior
Brief Hospital Course:
1. UGIB: In the ED, he was hemodynamically stable, and his hct
was 22.5. He was transfused 2 U PRBC. A CT abdomen was obtained
and was unchanged except slight in crease in the pancreatic
mass. The pt was monitored overnight in the MICU. He was given
[**Hospital1 **] proton pump inhibitor. He was transfused an additional 1U
and given bicarbonate in his IVF for renal protection. He was
then transfered to the floor.
On the floor the pt continued to have slow blood loss. GI was
consulted but an EGD was deferred because no therapeutic options
were seen and the pt was reluctant to have a procedure done. The
pt was hemodynamically stable. He was thought to have chronic
bleeding most likely from multiple small lesions in the duodenum
and erosive gastritis. He received one more unit of PRBC on the
floor. The pt will probably continue to require transfusions if
the hct continues to fall. Plan was coordinated between Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] at the [**Hospital3 2558**] to have
hematocrits drawn every 4 days as long as he does not have
grossly bloody stools and will be scheduled for regular blood
transfusions through the pheresis unit at [**Hospital1 18**] with scheduling
through [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 46376**].
2. Goals of Care: The pt was addressed regarding the goals of
his care. Palliative care was involved in this discussion. It
seemed that the pt was not able to make a decision for CMO at
this point. He wanted to continue receiving blood transfusions
but opposed chemotherapy.
3. Leukocytosis: The pt initially presented with leukocytosis.
The source was unclear source, and it may originated from a
stress response or might be due to malignancy. The pt did not
have any localizing symtpom. Urine and blood cultures were
negative at time of discharge.
4. Chronic renal insufficiency. The pt was thought to be
slightly volume depleted due to blood loss and resolved after
resuscitation. The pt was given post-CT hydration with sodium
bicarbonate and his creatinine was monitored and remained
stable.
5. NSTEMI: The pt was noted to have an asymptomatic NSTEMI with
elevated cardiac enzymes (0.12->0.15). This likely occurred in
the setting of demand ischemia. Atenolol was stopped initially
but then was restarted at half dose 12.5mg.
6. Communication: Has cousin in [**Name (NI) 36413**]; states does not know
her address or phone number and would not want her contact[**Name (NI) **] in
an emergency/change in status; no HCP designated
Medications on Admission:
Meds on Admission:
Lipitor 40 mg
MVI
Atenolol 50 mg
Prilosec 40 mg
Insulin SS
Mylanta PRN
No known allergies
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO
BID:PRN as needed.
Disp:*30 Capsule(s)* Refills:*0*
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
Disp:*qs * Refills:*2*
6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
Disp:*100 ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Metastatic pancreatic cancer
Upper GI bleeding
NSTEMI
Discharge Condition:
Fair, hematocrit stable for >24 hours
Discharge Instructions:
Please come back to the hospital if you experience any
lightheadedness, chest pain, shortness of breaths or any
concerns. If you develop black or bloody stools you should also
inform your doctors [**First Name (Titles) **] [**Hospital3 **] immediately.
Followup Instructions:
please follow up with Dr. [**Last Name (STitle) **] in the [**Hospital3 **].
|
[
"250.00",
"157.0",
"197.7",
"197.4",
"600.00",
"280.0",
"401.9",
"585.9",
"550.90",
"410.71",
"272.0",
"276.50",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7405, 7475
|
3863, 6468
|
336, 342
|
7572, 7612
|
3152, 3840
|
7913, 7993
|
2447, 2542
|
6628, 7382
|
7496, 7551
|
6494, 6499
|
7636, 7890
|
2557, 3133
|
277, 298
|
370, 1473
|
6513, 6605
|
1495, 2137
|
2153, 2431
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,011
| 108,164
|
53623
|
Discharge summary
|
report
|
Admission Date: [**2198-4-18**] Discharge Date: [**2198-4-23**]
Date of Birth: [**2148-2-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2198-4-19**]
Coronary Artery Bypass x 4 (LIMA-LAD, SVG-PDA, SVG-D1, SVG-D2)
History of Present Illness:
50 year old male with a history of hypertension for 5 years and
a
recent diagnosis of hyperlipidemia and glucose intolerance. One
month ago he began having pressure in his chest along his left
sternum. This would occur when he was under stress and lasts
for
several minutes and then resolve spontaneously. It did not
radiate to his neck, shoulders, arms. It did not occur with
exertion. It was not associated with diaphoresis, shortness of
breath, nausea. He had an exercise tolerance test where he had
chest discomfort which resolved with further exercise but did
have significant ST abnormalities at peak exercise. The ST
segment depression was new from his previous exercise test in
[**2187**]. He was subsequently sent for a cardiac catheterization
which revealed significant two vessel disease not amenable to
percutaneous intervention. He denies shortness of breath,
dyspnea
on exertion, orthopnea, paroxysmal nocturnal dyspnea,
palpitations, dizziness, syncope, and peripheral edema. He has
had left leg discomfort with walking which has been attributed
to
a disc abnormality. Given the severity of his disease, he was
referred on for surgical evaluation.
Past Medical History:
Coronary Artery Disease
post-op AFib
Lumbar disc disease
Hypertension
Hyperlipidemia
Obesity
Glucose intolerance
Social History:
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use: Denies
ETOH: < 1 drink/week [X] [**1-2**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
Father ruptured AAA at 59 Mother < 65 [X] Died of MI at 42
Brother with [**Name2 (NI) **] in his late 30's
Sister with stents in her late 40's
Physical Exam:
Pulse: 67 Resp: 16 O2 sat: 97%
B/P Right: 110/72 Left: 111/68
Height: 5'[**96**]" Weight: 249lbs
General: Well-developed male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema -
Varicosities: None [] superficial spider
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2198-4-19**] Intra-op TEE
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results at the time of
the study.
POST-BYPASS:
The patient is in Sinus Rhythm on low dose phenylephrine
infusion. Biventricular function is maintained. Valves remain
unchanged. The aorta remains intact.
[**2198-4-23**] 04:02AM BLOOD WBC-6.7 RBC-3.55* Hgb-10.3* Hct-31.8*
MCV-90 MCH-29.1 MCHC-32.5 RDW-13.0 Plt Ct-168
[**2198-4-17**] 11:18AM BLOOD Neuts-59.9 Lymphs-31.8 Monos-6.2 Eos-1.4
Baso-0.6
[**2198-4-23**] 04:02AM BLOOD Plt Ct-168
[**2198-4-23**] 04:02AM BLOOD PT-13.3* PTT-27.8 INR(PT)-1.2*
[**2198-4-23**] 04:02AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-29 AnGap-12
[**2198-4-23**] 04:02AM BLOOD Mg-2.0
Brief Hospital Course:
The patient was brought to the Operating Room on [**2198-4-19**] where
he underwent CABG x 4 with Dr. [**Last 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. He was initially on nitro gtt for
hypertension. He was started on lopressor and the nitro gtt was
weaned off. He extubated without difficulty.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. He was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery on POD#1. Chest tubes and
pacing wires were discontinued without complication. He did
develop post-op afib on POD#3 and was started on amiodarone and
coumadin. Lopressor was titrated. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #4 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:
Simvastatin 20 mg Oral Tablet Take 1 tablet every evening
Lisinopril 40 mg Oral Tablet Take 1 tablet daily
Atenolol 100 mg Oral Tablet 1 tablet daily
Hydrochlorothiazide 25 mg Oral Tablet Take 1 tablet daily
ASPIRIN EC TABLET DR 81MG PO 1 tablet orally once a day
Isosorbide mononitrate ER 30mg daily
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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. 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*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Coumadin 2 mg Tablet Sig: as directed Tablet PO once a day:
take 3mg today [**4-23**].
Disp:*30 Tablet(s)* Refills:*2*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): take tab tid x 1 week then 1 tab [**Hospital1 **] x 1 week then 1 tab
daily .
Disp:*90 Tablet(s)* Refills:*2*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: after lasix resume Hctz.
Disp:*14 Tablet(s)* Refills:*0*
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
can increase lisinopril to pre-op dose as BP improves.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] [**Hospital **] Home Health and Hospice
Discharge Diagnosis:
Coronary Artery Disease
post-op AFib
Lumbar disc disease
Hypertension
Hyperlipidemia
Obesity
Glucose intolerance
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
1+ LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, 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 at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2198-5-3**]
10:15
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], [**2198-5-23**] 1:30
Cardiologist Dr.[**Name (NI) 59117**] office will call you to arrange
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) 5147**] C. [**Telephone/Fax (1) 8036**] in [**3-1**] 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
Coumadin for post -op afib
Goal INR
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed
Results to be called to cardiac surgery service [**Telephone/Fax (1) 170**]
until f/u can be arranged with either PCP or cardiologist
Completed by:[**2198-4-23**]
|
[
"722.93",
"427.31",
"790.29",
"997.1",
"V70.7",
"278.00",
"E878.2",
"V17.3",
"414.01",
"411.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7314, 7401
|
4228, 5455
|
322, 403
|
7558, 7726
|
2832, 4205
|
8514, 9476
|
1945, 2093
|
5807, 7291
|
7422, 7537
|
5481, 5784
|
7750, 8491
|
2108, 2813
|
271, 284
|
431, 1597
|
1619, 1734
|
1750, 1929
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,051
| 103,418
|
2654
|
Discharge summary
|
report
|
Admission Date: [**2121-1-27**] Discharge Date: [**2121-2-1**]
Date of Birth: [**2055-3-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Colon tumor
Major Surgical or Invasive Procedure:
s/p Right colectomy, primary anastamosis
History of Present Illness:
Mr. [**Known lastname 8271**] is a 65yo male with a 50yo h/o of cigarette smoking
and h/o CAD, HTN, obesity who underwent a colonoscopy and was
found to have a sessile 50 mm polyp in the hepatic flexure which
could not be removed by colonoscopy and therefore the area was
marked with a tattoo and the patient was referred for surgery.
He was a heavily built man and he had co-morbid conditions of
chronic obstructive pulmonary disease and prior cardiac disease.
His Plavix was stopped 5 days prior to surgery.
Past Medical History:
CAD s/p stent '[**15**], s/p brachytherapy stent, restenosis '[**15**], HTN,
DM, obesity, smoker(50yrs), h/o ETOH abuse-sober 20years
Social History:
Single. Lives alone. Retired engineer from Mass Maritime-[**State 1727**].
Supportive family & friends. H/O ETOH abuse-sober 20 years.
Currently smokes 1-2 packs per day for past 50years. Denies
illicit drug use.
Family History:
Non-contributory
Physical Exam:
PRE-OP
Vitals:T-97.5,HR-76,BP-125/54,RR-20,O2 sat-95% RA
Well-appearing, NAD
Cardiac-RRR, no m/r/g
Lungs-CTAB
ABD obese, soft, NT
Extrem:WWP, no c/c/e
Pertinent Results:
[**2121-1-31**] 06:10AM BLOOD WBC-8.0 RBC-4.73 Hgb-14.5 Hct-42.6 MCV-90
MCH-30.6 MCHC-34.0 RDW-13.7 Plt Ct-120*
[**2121-1-27**] 03:05PM BLOOD WBC-16.0*# RBC-5.10 Hgb-16.0 Hct-46.9
MCV-92 MCH-31.4 MCHC-34.1 RDW-14.8 Plt Ct-169
[**2121-1-31**] 06:10AM BLOOD Plt Ct-120*
[**2121-1-28**] 03:13AM BLOOD PT-15.2* PTT-29.2 INR(PT)-1.3*
[**2121-1-27**] 03:05PM BLOOD PT-17.1* PTT-30.3 INR(PT)-1.5*
[**2121-1-31**] 06:10AM BLOOD Glucose-121* UreaN-15 Creat-0.7 Na-142
K-3.6 Cl-104 HCO3-31 AnGap-11
[**2121-1-27**] 03:05PM BLOOD Glucose-124* UreaN-16 Creat-0.9 Na-142
K-4.9 Cl-108 HCO3-27 AnGap-12
[**2121-1-28**] 03:13AM BLOOD ALT-24 AST-32 LD(LDH)-233 CK(CPK)-466*
AlkPhos-44 Amylase-25 TotBili-1.0
[**2121-1-27**] 03:05PM BLOOD ALT-26 AST-34 LD(LDH)-254* CK(CPK)-234*
AlkPhos-49 Amylase-30 TotBili-1.0
[**2121-1-30**] 11:05AM BLOOD proBNP-1164*
[**2121-1-31**] 06:10AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.0
[**2121-1-27**] 03:05PM BLOOD Albumin-3.9 Calcium-8.4 Phos-2.4* Mg-1.8
.
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2121-1-27**] 5:54 PM:
[**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION
65 year old man with h/o CAD and COPD, s/p hypoxic event
peri-operatively, with increased A-a gradient
IMPRESSION:
1. No evidence of pulmonary embolism in central or segmental
branches. Limited evaluation of the subsegmental branches due to
bolus timing.
2. Bilateral lower lobe airspace consolidation likely
representing atelectasis.
3. Small perihepatic fluid.
4. ETT at the thoracic inlet. Advancement is recommended.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2121-1-27**] 2:25 PM
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with
REASON FOR THIS EXAMINATION:
DESATS IN OR
SINGLE PORTABLE SEMI-UPRIGHT CHEST: Compared to [**2120-6-20**]. A large
portion of the right lung has been excluded from field of view.
Patient is intubated with the tip of the endotracheal tube 8 cm
above the carina at the superior margin of the clavicles. There
has been clearing of the previous left lower lobe consolidation
with some residual opacity in the medial basilar aspect of the
left lower lobe, likely atelectasis. No pneumothorax.
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2121-1-30**] 11:31 AM
REASON FOR THIS EXAMINATION:
Rule out pneumonia, effusions, and changes lung anatomy
IMPRESSION: Persistent low lung volumes with atelectasis at both
bases and small right pleural effusion. Findings discussed with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13289**], nurse practitioner, at the time of dictation.
.
[**2121-1-27**] Pathology Tissue: right colectomy. [**2121-1-27**]
[**Last Name (LF) **],[**First Name3 (LF) **] M. Not Finalized
Brief Hospital Course:
Mr. [**Known lastname 13290**] operative course was complicated by difficult
intubation, decreased oxygen saturations, bradycardia, and
hypotension. He was stabilized with successful intubation, and
IV hydration. His surgery was completed, and he ws transferred
to ICU for further management.
.
POD1-He was extubated in the ICU in the morning, & monitored
closely. He was weaned to 4L of nasal cannula with sats>95%. He
appeared stable, and was transferred to [**Hospital Ward Name **].
.
RESP:He had audible bibasilar crackles post-op. He was diuresed
with IV Lasix, and responded with decreased demand in oxygen via
nasal cannula. He required more time to wean from oxygen. His
sats are currently 92% on RA. Pulmonary Team was consulted who
recommended PFT's on outpatient basis and sleep studies to rule
out sleep apnea. Recommendations also included daily diuresis,
BNP>1200, Spiriva/albuterol/atrovent and aggressive IS
use/CPT/and frequent ambulation. He was taught proper use of
MDI's. Smoker cessation was offered. Patient made it clear he
had no intention of quitting. His [**Last Name (LF) 802**], [**Name (NI) **], will make a
follow-up appointment for PFT's on outpatient basis.
.
ABD:His abdomen is large, soft, NT/ND with active bowel sounds.
His abdominal incision is OTA with staples with a small amount
of erythema along the incision line. He was started on IV
cephazolin, and switched to PO Augmentin due to reports of GI
upset with PO Keflex in the past. He will have the staples
removed at the follow-up appointment with Dr. [**Last Name (STitle) **].
.
NUT:He was NPO post-op. His diet was advanced as his bowel
function resumed. He has been tolerating a regular diet without
complaints of nausea and/or vomiting.
.
ELIM:He had a foley catheter inserted intra-op. The catheter was
removed, and he was able to urinate without difficulty. He
reports passing flatus, but has not had a bowel movement since
surgery.
.
PAIN:His pain was managed with an IV PCA post-op. He was
advanced to oral Percocet once tolerating oral fluids. He
reports her pain 0-2/10 at rest, and increases to [**5-31**] with
activity which is well tolerated. He will be discharged with a 2
week supply of percocet, and colace to prevent constipation.
.
He reports not having a current PCP, [**Name10 (NameIs) **] does not have interest
inestablishing a relationship with a family physician. [**Name10 (NameIs) **] was
encouraged to follow-up with Pulmonology, and to consider
finding a PCP. [**Name10 (NameIs) **] will be discharged home with VNA services for
assessment of respiratory status.
Medications on Admission:
Glyburide/metformin 2.5/500", Avandia 4', Lantus 45Uqhs, Cozaar
50', atenolol 100', Lipitor 10', Plavix 75', testosterone patch.
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Lantus 100 unit/mL Solution Sig: 45 units Subcutaneous at
bedtime.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 Cap(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheeze/SOB.
Disp:*1 * Refills:*1*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
polyp at hepatic flexure
Post-op hypotension
Post-op hypoxemia
.
Secondary:
Smoker
Obese
CAD
HTN
DM2
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* 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 at your follow-up appointment with
Dr. [**Last Name (STitle) **].
-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 make a follow-up appointment with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) **] in [**1-22**] weeks.
2. Make an appointment with Dr. [**First Name8 (NamePattern2) 13291**] [**Last Name (NamePattern1) 4507**] [**Telephone/Fax (1) 13292**] for
Pulmonary Function Tests in [**2-24**] weeks.
3. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**]
Date/Time:[**2121-2-20**] 10:20
4. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2121-7-2**] 11:00
|
[
"V45.82",
"211.3",
"414.01",
"496",
"327.23",
"428.0",
"V10.82",
"997.1",
"250.00",
"278.00",
"518.0",
"552.1",
"427.89",
"401.9",
"458.29",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"53.49",
"99.77"
] |
icd9pcs
|
[
[
[]
]
] |
8055, 8112
|
4232, 6820
|
322, 365
|
8266, 8344
|
1513, 3125
|
9759, 10386
|
1308, 1326
|
7000, 8032
|
3162, 3183
|
8133, 8245
|
6846, 6977
|
8368, 9409
|
9424, 9736
|
1341, 1494
|
271, 284
|
3772, 4209
|
393, 905
|
927, 1062
|
1078, 1292
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,849
| 145,627
|
7478
|
Discharge summary
|
report
|
Admission Date: [**2107-6-30**] Discharge Date: [**2107-7-5**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
male with a past medical history significant for coronary
artery disease, hypertension, hypercholesterolemia, end-stage
renal disease, on hemodialysis, and subdural hematoma
diagnosed in [**2104-6-24**]. The patient was admitted to an
outside hospital for slurred speech and right sided weakness
noted by a health aide following the patient's hemodialysis.
The patient was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] for workup of confusion and fever with his history of
subdural hematoma. The CT scan showed minimal change in the
patient's known subdural hematoma. Chest x-ray, however,
showed bilateral consolidation, with gram positive cocci in
the sputum. The patient was thus dosed with ceftriaxone,
levofloxacin and vancomycin in addition to receiving a one
liter normal saline bolus. The patient was dialyzed 2.5
liters for concern of fluid overload. Following
hemodialysis, the patient became hypotensive to the 70s,
tachypneic and diaphoretic with electrocardiographic changes
showing diffuse ST-T wave changes. The patient was thus
started on Dopamine and given a 750 cc normal saline bolus.
He further required the addition of Neo-Synephrine to support
his blood pressure. His heart rate subsequently increased
and his ST-T wave changes worsened, so his Dopamine was
stopped and these changes resolved. The patient was
subsequently seen by cardiology in the Emergency Room and an
echocardiogram was done, and his ischemia was felt to be
consistent with demand ischemia.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass grafting times four vessels in [**2101**], percutaneous
transluminal coronary angioplasty in [**2097**].
2. Congestive heart failure, left ventricular ejection
fraction 20% to 25%.
3. End-stage renal disease, on hemodialysis.
4. Status post left carotid endarterectomy in [**2100**].
5. Status post bilateral femoral bypass.
6. Status post right below the knee amputation.
7. Subdural hematoma in [**Month (only) 216**] 200, status post drain.
8. Hypertension.
9. Hypercholesterolemia.
10. Peptic ulcer disease.
11. History of Methicillin resistant Staphylococcus aureus.
ALLERGIES: Morphine.
MEDICATIONS ON ADMISSION: Imdur 30 mg p.o.q.d., Aciphex 20
mg p.o.q.d., Phos-Lo 667 mg p.o.t.i.d., Nephrocaps one
p.o.q.d., aspirin 81 mg p.o.q.d., Zoloft 75 mg p.o.q.d.,
Zocor 10 mg p.o.q.d., Ocuvite one p.o.q.d., zinc and B12.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 101.8, heart rate 80 to 110s,
respiratory rate 24 to 28 and oxygen saturation 97% on
nonrebreather. General: Alert, cooperative, tachypneic.
Head, eyes, ears, nose and throat: Extraocular movements
intact, pupils post surgical bilaterally, anicteric sclerae.
Neck: Supple, no lymphadenopathy, no jugular venous
distention. Cardiovascular: Regular rate and rhythm, normal
S1 and S2, II/VI holosystolic murmur at left lower sternal
border, positive S3 which resolved over this admission.
Lungs: Coarse breath sounds throughout. Abdomen: Soft,
nontender, nondistended, no hepatosplenomegaly. Extremities:
Right below the knee amputation, 2+ left posterior tibialis
pulse, cool, no mottling. Neurologic examination: Alert and
oriented times three, strength 4/5 in upper extremities
bilaterally, moved left lower extremity without difficulty.
LABORATORY DATA: Admission white blood cell count 9.2,
hematocrit 37.5, platelet count 177,000, INR 1.5, partial
thromboplastin time 33.3, sodium 136, potassium 4.6, chloride
92, bicarbonate 26, BUN 48, creatinine 6.4, glucose 147, most
recent white blood cell count 8.2. CKs have been trending
down, last CK was 38 on [**2107-7-4**], previous CKs 104,
74, and 72. Vancomycin level from today was 16.1. Sputum
from [**2107-6-29**] showed greater than 25 polymorphonuclear
neutrophils and 2+ gram positive cocci in pairs and clusters.
Blood cultures from [**2107-6-30**] ....... and [**2107-6-29**] show no growth to date. Chest x-ray from [**2107-6-30**]
showed bibasilar consolidation, no congestive heart failure.
The CT scan from [**2107-6-29**] showed a subacute subdural
hematoma, left lateral, slightly increased since [**2104-11-10**] but no herniation and no acute hemorrhage.
Echocardiogram done in the Emergency Room showed inferior,
inferolateral hypokinesis with a left ventricular ejection
fraction of 20% to 25% with 1 to 2+ mitral regurgitation,
systolic pressures of 38.
HOSPITAL COURSE: 1. Sepsis: The patient was admitted with
sepsis presumed secondary to pneumonia. He was continued on
intravenous levofloxacin and vancomycin during his hospital
stay. His white blood cell count has remained stable and he
has remained afebrile. The plan is to continue antibiotics
for a 12 day course of levofloxacin and vancomycin for a
chest x-ray with bibasilar consolidation and a sputum culture
positive for gram positive cocci in pairs in clusters.
2. Hypotension: The patient had an acute blood pressure
drop following hemodialysis in the Emergency Room, requiring
pressor support. He was initially started on Neo-Synephrine
and Dopamine. The Dopamine was stopped for demand ischemia.
The patient was subsequently changed from Neo-Synephrine to
Levophed and Vasopressin for suspected sepsis as the cause of
his low blood pressure. He was maintained on these
medications until successfully weaned off on [**2107-7-4**].
His blood pressure has remained stable over the course of
today in addition to his challenge with hemodialysis today.
3. Cardiac ischemia: The patient had a positive troponin
leak on admission. An echocardiogram done in the Emergency
Room, ischemia thought to be secondary to demand ischemia.
CKs were cycled and were trending down. The patient was
maintained on aspirin and a statin, all chronotropic pressors
were avoided following his diagnosis. The patient was
carefully bolused to maintain his blood pressure due to the
fact that he is at extreme risk for congestive heart failure.
4. Pneumonia: The patient had bibasilar consolidations on
chest x-ray, with sputum culture positive for 2+ gram
positive cocci in pairs and clusters. He is being maintained
on a 12 day course of levofloxacin and vancomycin considering
his history of Methicillin resistant Staphylococcus aureus.
5. End-stage renal disease: The patient was hemodialyzed on
[**7-2**] and 12, [**2106**]. He is regularly dialyzed at Renex
Dialysis Center.
6. Change in mental status: The patient was transferred to
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for a change in mental
status. A neurology consult was obtained and recommendations
were made for an electroencephalogram, which was unrevealing.
There was minimal further improvement in the patient's mental
status following the improvement of his fever. It is the
opinion of the neurology staff that likely metabolic insult
may have explained the patient's acute mental status.
Discussions with the patient's family revealed that he is at
his baseline, and no further management of his mental status
is indicated.
7. Code status: The patient is "Do Not Resuscitate", "Do
Not Intubate".
8. Communication: During the patient's stay in the
Intensive Care Unit, the staff have been communicating with
the patient's son and other family members.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
Sepsis.
Pneumonia.
DISCHARGE MEDICATIONS:
Nephrocaps one p.o.q.d.
Sertraline 50 mg p.o.q.d.
Simvastatin 10 mg p.o.q.d.
Aspirin 81 mg p.o.q.d.
Levofloxacin 250 mg p.o.q.48h. times seven additional days.
Calcium acetate 667 mg p.o.t.i.d. with meals.
Albuterol meter dose inhaler one to two inhalations
q.6h.p.r.n. shortness of breath or wheezing.
Metoprolol 12.5 mg p.o.b.i.d.
Vancomycin 1 mg i.v. dosed for a vancomycin level less than
15 until [**2107-7-12**].
FOLLOW-UP PLANS: The patient is to follow up with his
primary care physician in one to two weeks.
DR [**First Name8 (NamePattern2) **] [**Doctor First Name **] 12.981
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2107-7-5**] 02:25
T: [**2107-7-5**] 14:49
JOB#: [**Job Number 27370**]
cc:[**Hospital 27371**]
|
[
"272.0",
"482.41",
"410.91",
"038.9",
"424.0",
"V45.81",
"428.0",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7663, 7683
|
7706, 8126
|
2451, 2655
|
4699, 6687
|
2678, 3435
|
8144, 8476
|
120, 1734
|
6703, 7608
|
3460, 4681
|
1756, 2424
|
7633, 7642
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,973
| 171,321
|
5208+55646
|
Discharge summary
|
report+addendum
|
Admission Date: [**2189-10-21**] Discharge Date: [**2189-10-28**]
Date of Birth: [**2109-5-7**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
The patient is an 80 yo female with a history of recurrent
substernal postprandial pain attributed to cholelithiasis s/p
ERCP with sphincterotomy and stone removal who was admitted to
[**Hospital1 18**] on [**10-21**] for elective cholecystectomy.
Major Surgical or Invasive Procedure:
s/p Laparoscopic cholecystectomy with intraoperative
cholangiogram
s/p ERCP with stent placement into the cystic duct for
persistent leak
History of Present Illness:
The patient has a history of recurrent postprandial substernal
chest discomfort with known cholelithiasis. She is s/p ERCP in
[**2189-6-21**] but has had persistent symptoms, and so was referred
to Dr. [**Last Name (STitle) **] for an elective cholecystectomy for relief of
her recurrent symptoms.
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Hyperparathyroidism.
4. Osteopenia.
5. Scoliosis.
6. Mild renal insufficiency with mild proteinuria s/p left
partial nephrectomy for congenital aplastic kidney
7. History of hyperplastic colon polyps.
8. Para-ampullary duodenal diverticulum.
9. systolic murmur
10. hx of recurrent cholelithiasis, choledocholithiasis s/p ERCP
[**6-28**] with sphincterotomy and stone removal
Social History:
She has two adult sons. She is a widow. She was employed with
housework. She quit smoking 20 to 30 years ago, but smoked two
packs per day for 20 to 30 years. She drinks one glass of wine
occasionally. She avoids salt in her diet.
Family History:
Mother had HTN.
Physical Exam:
Upon discharge:
A and O NAD
98.2 60 126/70 18 94%
PERRL, anicteric, moist mucus membranes
RRR nl S1,S2 + systolic murmur at apex
CTAB
severe scoliosis
soft, nontender but distended + BS
no c/c slight 1+ edema on R foot
Pertinent Results:
[**2189-10-27**] 05:40AM BLOOD WBC-6.6 RBC-3.59* Hgb-10.9* Hct-31.6*
MCV-88 MCH-30.5 MCHC-34.5 RDW-13.3 Plt Ct-288
[**2189-10-21**] 02:46PM BLOOD WBC-12.0*# RBC-4.41 Hgb-13.3 Hct-38.3
MCV-87 MCH-30.2 MCHC-34.8 RDW-13.3 Plt Ct-270
[**2189-10-27**] 05:40AM BLOOD Plt Ct-288
[**2189-10-21**] 02:46PM BLOOD Plt Ct-270
[**2189-10-27**] 05:40AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-141
K-4.1 Cl-104 HCO3-26 AnGap-15
[**2189-10-22**] 06:20AM BLOOD Glucose-122* UreaN-16 Creat-0.7 Na-136
K-4.0 Cl-98 HCO3-28 AnGap-14
[**2189-10-27**] 05:40AM BLOOD ALT-21 AST-27 AlkPhos-97 TotBili-1.1
[**2189-10-25**] 09:58AM BLOOD CK(CPK)-226*
[**2189-10-23**] 06:40AM BLOOD ALT-37 AST-41* AlkPhos-88 Amylase-56
TotBili-3.3* DirBili-1.6* IndBili-1.7
[**2189-10-21**] 02:46PM BLOOD Amylase-112* TotBili-0.5
[**2189-10-24**] 03:36AM BLOOD Lipase-12
[**2189-10-21**] 02:46PM BLOOD Lipase-25
[**2189-10-25**] 10:00PM BLOOD CK-MB-4
[**2189-10-25**] 03:05PM BLOOD CK-MB-5
[**2189-10-25**] 09:58AM BLOOD CK-MB-4 cTropnT-<0.01
[**2189-10-25**] 06:10AM BLOOD CK-MB-4 cTropnT-<0.0110/07/08 05:40AM
BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
[**2189-10-22**] 06:20AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.4 Mg-1.6
[**2189-10-23**] 09:46PM BLOOD Type-ART pO2-180* pCO2-39 pH-7.44
calTCO2-27 Base XS-2
Pertinent radiology results:
CT scan abdomen [**10-23**]:
1. No evidence of pulmonary embolism.
2. Marked scoliosis, with marked tortuosity of the aorta,
exaggerated by the scoliosis.
3. Bronchus intermedius appears compressed as it courses around
the marked
scoliosis between the spine and the pulmonary artery, likely
contributing to patient's likely chronic right lower lobe
atelectasis.
4. Small bilateral pleural effusions.
5. Nodular appearing liver, perihepatic ascites, incompletely
evaluated on
this study. If clinically indicated, MRI would recommended for
further
evaluation.
6. Small pockets of free air are identified within the abdomen,
correlate with recent surgical history.
7. Emphysematous changes seen at the apices.
[**10-22**] CXR: Increase bibasilar opacities consistent with
increasing
atelectasis and effusion, although infectious pneumonia cannot
be excluded. Pockets of gas on the right side suggest possible
loculation.
[**10-25**]: AXR: Residual contrast is in ascending colon and small
bowel loops in the right hemi abdomen. Fewer contrast has passed
and is in the descending colon. There is mild dilatation of the
colon and some small bowel loops, this is associated with
air-fluid levels.
Severe S-shaped scoliosis is noted. Tubes and catheter
projecting in the
right upper quadrant.
Brief Hospital Course:
OPERATIONS DURING ADMISSION:
Laparoscopic cholecystectomy with intraoperative cholangiogram
PROCEDURES DURING ADMISSION:
ERCP with stent placement
CONSULTATIONS DURING ADMISSION:
Gastroenterology
Cardiology
BRIEF HOSPITAL COURSE:
1. Laparoscopic cholecystectomy with intraoperative
cholangiogram for recurrent choledocholithiasis and
cholelithiasis:
On [**10-21**] the patient was admitted to [**Hospital1 18**] and underwent the
aforementioned procedure. Intraoperative cholangiogram did not
reveal any leak in the cystic duct. The patient tolerated the
procedure well, was extubated, and brought to the PACU.
Postoperatively, she complained immediately of a sharp right
sided pleuritic chest pain, worse with inspiration. A CXR
compared to the pre-op CXR revealed new bibasilar patchy and
linear opacities. She was started on zosyn for broadspectrum
antibiotic coverage.
2. Persistent bile leak through the cystic duct/Possible
aspiration:
On [**10-23**] the patient triggered for increasing oxygen
requirements. She underwent a CTA that revealed no PE, but
effusion R > L, collapsed RLL and LLL atelectasis. An NGT was
placed to prevent aspiration. She underwent a HIDA scan that
confirmed evidence of a bile leak from the cystic duct.
Thus later that day on [**10-23**] the patient went for an ERCP with
placement of a stent into the cystic duct. Post procedure the
patient remained intubated and was admitted to the SICU. For
the question of aspiration she was placed on vancomycin in
addition to zosyn. She was extubated on [**10-24**] and gradually
improved her oxygen saturations. Her oxygen saturations most
likely decreased in the setting of a bile leak rather than frank
aspiration.
Her belly remained distended; she underwent an AXR that revealed
distended loops of bowel consistent with ileus. Her NGT was
kept in until [**10-26**], after she had passed gas and had a bowel
movement.
On [**10-26**] her vancomycin was discontinued. Her zosyn was kept on
until 10/08 per GI. The patient will need a follow up ERCP in 6
weeks.
3. Atypical chest pain: On [**10-25**] the patient had atypical
episodes of chest pain; her ECG revealed nonspecific anterior
ST-T waves changes that were new compared to prior examinations.
Enzymes were negative. Cardiology was consulted, who felt that
the patient ruled out for MI by enzymes, and that her symptoms
were atypical of ACS. They recommended an echocardiogram to
assess for wall motion abnormalities/systolic dysfunction as
well as a follow up stress test. As the patient refused the
echo prior to discharge, they recommended strongly having it
done soon as an outpatient.
The patient was also intermittently placed on ciprofloxacin for
a questionable urinary tract infection.
The remainder of the patient's hospitalization was uneventful.
She progressed
to a regular diet, though her belly still remains slightly
distended. She is maintaining good oxygen saturations on room
air.
As mentioned previously, she should have a follow up appointment
with Dr. [**Last Name (STitle) **], a follow up with Dr. [**Last Name (STitle) **] in 6 weeks for
stent removal, and further evaluation with echocardiogram and
stress test as requested by cardiology.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 a day
ATENOLOL - 25 mg Tablet - 1 a day
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 a day
CALCITRIOL - (Prescribed by Other Provider: [**Name10 (NameIs) 1395**], [**Name11 (NameIs) **]) - 0.25
mcg three times weekly
LISINOPRIL - 10 mg Tablet - 1 (One) Tablet(s) by mouth at night
20 mg orally in AM
ASPIRIN - 81 mg Tablet, Delayed
Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*50 Capsule(s)* Refills:*0*
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
recurrent cholelithiasis and choledocholithiasis s/p
laparoscopic cholecystectomy with intraoperative cholangiogram
cystic duct biliar leak s/p ERCP with stent placement in cystic
duct
Aspiration Pneumonitis in the setting of ERCP
PMx:
Hypertension.
2. Hyperlipidemia.
3. Hyperparathyroidism.
4. Osteopenia.
5. Scoliosis.
6. Mild renal insufficiency with mild proteinuria with s/p left
partial nephrectomy for congenital aplastic kidney
7. History of hyperplastic colon polyps.
8. Para-ampullary duodenal diverticulum.
9. systolic murmur
10. hx of recurrent cholecystitis, cholelithiasis s/p ERCP [**6-28**]
with sphincterotomy and stone removal
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**11-4**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2189-11-13**] 1:00
3. Please call [**Telephone/Fax (1) 21304**] (Dr.[**Name (NI) 12202**] office) to schedule
your appointment in 6 weeks to have your stent removed.
4. Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2190-3-25**] 11:30
5. You need to follow up with Dr [**First Name (STitle) 1395**] as you need a follow up
Echocardiogram and a stress test as an outpatient. You have an
appointment on [**2189-11-5**] at 10:45AM. You may call her
office to change the appointment if that time does not work for
you.
Completed by:[**2189-10-28**] Name: [**Known lastname **],[**Known firstname 3522**] A. Unit No: [**Numeric Identifier 3523**]
Admission Date: [**2189-10-21**] Discharge Date: [**2189-10-28**]
Date of Birth: [**2109-5-7**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3524**]
Addendum:
Addendum to prior discharge summary:
Please disregard the outpatient appointment for MRI (radiology)
as noted on follow up appointments. The patient does not need
this follow up exam, and it has been cancelled.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**]
Completed by:[**2189-10-28**]
|
[
"560.1",
"518.81",
"507.0",
"997.4",
"753.0",
"E878.6",
"574.70",
"599.0",
"272.4",
"733.90",
"492.8",
"403.90",
"737.30",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.23",
"51.87",
"96.71",
"96.04",
"87.53"
] |
icd9pcs
|
[
[
[]
]
] |
12569, 12733
|
4819, 7821
|
529, 669
|
9599, 9608
|
1981, 4563
|
11200, 12546
|
1708, 1725
|
8287, 8871
|
8921, 9578
|
7847, 8264
|
9632, 10831
|
1740, 1740
|
242, 491
|
10843, 11177
|
1756, 1962
|
697, 997
|
1019, 1443
|
1459, 1692
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,721
| 195,065
|
52933
|
Discharge summary
|
report
|
Admission Date: [**2143-10-14**] Discharge Date: [**2143-10-16**]
Date of Birth: [**2074-11-5**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Not being able to say what he wanted to say
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 68 yo right handed man with a history of
atrial fibrillation who presents for evaluation of stroke. The
patient reports the he was feeling well upon waking last Monday
([**2143-10-14**]) and was planning on playing golf during the
afternoon. At approximately 2:45, he stopped by his friend's and
in while speaking to him he suddenly felt strange. His friend
continued to speak and then
asked him if he was feeling ok- the patient was unable to
respond, saying he could not speak a word. His friend told him
to sit down and the patient's symptoms seemed to improve. He
was able to get up and walk outside of the home when he again
was unable to speak. It was at that point that his friend
called
EMS. He was initially brought to [**Hospital1 **] where his NIH Stroke
Scale was 4 (breakdown unavailable, but appears to have had
right arm and leg weakness as well as impaired language which
was worsening during the evaluation). He was evaluated by
telemedicine. CT head was negative and tPA was given at 15:39
(Bolus 7.5mg, then additional 66.3 over 60minutes). The
patient's symptoms showed almost immediate improvement and was
trasferred to [**Hospital1 18**] for further eval.
Here, the patient is able to relay his complete history. He
denies any other symptoms at the time of his event, beyond the
above. He has never had anything like this before. Currently,
the
patient denies headache, loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denied focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denied difficulty with gait.
On general review of systems, the patient denied recent fever or
chills. he has had a runny nose/sinus congestion x 3 days and
was
taking a homeopathic [**Doctor Last Name 360**] for this. Denied 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. He states that he underwent
arthroscopy of the left knee 1.5 weeks ago for a torn meniscus;
he was off his aspirin for this procedure.
Past Medical History:
- Afib x 10 years, s/p cardioversion x 3.
- venous disease of LE, s/p saphenous vein stripping
- Hyperlipidemia
- s/p Left Knee Meniscus surgery [**10-11**]
- s/p right ankle surgery secondary to torn tendons
- s/p left shoulder surgery
- s/p inguinal hernia repair [**2141**]
Social History:
Married, retired. Had multiple jobs, most recently as a Caddy,
but previously a salesman. Avid in sports- has run 46 marathons.
Very remote smoking (as a teenager, quit at age 18). Drinks 15
drinks per week ([**1-3**] glasses of wine in evenings).
Family History:
Mother had stroke in her 80s
Brother with a pacer
Brother s/p MI at age 40
Physical Exam:
At admission:
T 98.9 BP 152/84 HR 76 RR 20 O2% 98 on 2L
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormalities, no scleral icterus
noted, mmm, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm, No murmurs appreciated.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: 2+ radial, DP pulses bilaterally.
Skin: + venous statsis/varicose veins b/l LE, left>right.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read and write without difficulty.
Speech was not dysarthric. The pt. had good knowledge of current
events. There was no evidence of apraxia or neglect,
calculations intact. Registered [**3-4**] and recalled [**2-1**] at 5
minutes, [**3-4**] with catagory cue.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. Visual fields full on bedside
testing. Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Mild right pronator drift.
No rigidity. No adventitious movements, such as tremors, noted.
No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, vibratory sense 8 seconds
on right, 16 on left. Proprioception impaired to fine movements
of the 1rst toe bilaterally. No extinction to double
simultaneous stimuli.
-Deep tendon reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: deferred
At discharge:
T 97.3 BP 150/90 HR 72 RR 18 O2% 100 RA Fingerstick glycemia:
111 mg/dL
No neurological deficit. Gait: normal stance and stride.
Symptoms completely recovered.
Pertinent Results:
Pertinent lab results:
[**2143-10-16**] 04:35AM BLOOD WBC-5.9 RBC-4.65 Hgb-13.8* Hct-39.3*
MCV-85 MCH-29.8 MCHC-35.2* RDW-12.6 Plt Ct-178
[**2143-10-16**] 04:35AM BLOOD Plt Ct-178
[**2143-10-16**] 04:35AM BLOOD PT-12.2 PTT-23.8 INR(PT)-1.0
[**2143-10-16**] 04:35AM BLOOD Glucose-100 UreaN-18 Creat-1.1 Na-141
K-3.9 Cl-107 HCO3-25 AnGap-13
[**2143-10-15**] 03:40AM BLOOD ALT-23 AST-21 LD(LDH)-164 CK(CPK)-86
AlkPhos-82 TotBili-0.9
[**2143-10-15**] 03:40AM BLOOD CK-MB-2 cTropnT-<0.01
[**2143-10-16**] 04:35AM BLOOD Albumin-4.2 Calcium-8.9 Phos-3.2 Mg-2.3
[**2143-10-15**] 03:40AM BLOOD %HbA1c-5.5 eAG-111
[**2143-10-15**] 03:40AM BLOOD Triglyc-138 HDL-56 CHOL/HD-4.0
LDLcalc-140*
Imaging:
MRI/MRA [**2143-10-15**]:
There is a focal, subcentimeter area in the subcortical white
matter of the left temporal lobe with increased signal on
diffusion-weighted and FLAIR sequences with decreased signal on
ADC (10:13). This is compatible
with a small area of ischemia. There is no evidence of large
territorial
ischemia or infarction. There is no evidence of hemorrhage.
There are areas of increased FLAIR signal in the periventricular
and subcortical white matter that likely represent changes from
chronic small vessel ischemic disease. The ventricles and sulci
are prominent consistent with age-related atrophy.
The intracranial vertebral and internal carotid arteries and
their major
branches appear normal without evidence of stenosis, occlusion,
or aneurysm formation.
IMPRESSION: Subcentimeter diffusion abnormality in the
subcortical white
matter of the left temporal lobe compatible with a small area of
ischemia.
Echo [**2143-10-15**]:
The left atrium is elongated. (Transthoracic echocardiography
not adequate to assess for atrial appendage thrombus). No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is mildly
depressed (LVEF= 50-55 %). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
No cardiac source of embolus identified other than atrial
fibrillation.
Brief Hospital Course:
68 year old right handed man with a history of paroxysmal atrial
fibrillation who presents for evaluation following acute speech
arrest. Initial evaluation at [**Hospital1 **] was concerning for
aphasia and right sided weakness. He was given tPA within 1 hour
and had rapid resolution of sx. Transfered to [**Hospital1 18**] where he had
a mild right pronator drift and a brisk patellar reflex, but
otherwise his neurologic exam was normal. CT head was without
evidence of prior infarct or small vessle disease. The patient
reports recently discontinuing his aspirin for a knee surgery.
It is possible that he was acutely hypercoaguable in the setting
of this medication change and recent surgery, this may also be
considered aspirin failure or due to his atrial fibrillatiojn.
Symptoms completely resolved. MRI/MRA showed subcentimeter
diffusion abnormality in the subcortical white matter of the
left temporal lobe compatible with a small area of ischemia and
nil on MRA. Echo showed mildly depressed LC function EF 5-0-55%
and mildly dilated ascending aorta, no source of embolus.
Transferred to floor [**10-15**]. Received physical therapy and was
asymptomatic during his admission.
Cardiologist (Dr. [**Last Name (STitle) 2293**] at [**Hospital1 112**]) was emailed in order to
determine preference of anticoagulation but unfortunately we
were unable to reach him. The patient refused coumadin
regardless so he was started on dabigatran.
Given his altered lipid profile Simvastatin dose was raised to
40 mg qd.
He will continue follow up with Dr. [**Last Name (STitle) **] (Neurology-Stroke).
Medications on Admission:
- Flecanide 75mg [**Hospital1 **]
- ASA 81mg
- Simvastatin 20mg daily
- Atenolol 12.5mg daily
Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. flecainide 50 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours).
4. atenolol 25 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Left temporal subcortical infarct
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: no deficits
Discharge Instructions:
Dear Mr. O' [**Doctor Last Name 10321**],
It was a pleasure to take care of you at the [**Hospital1 18**]. You were
initially admited at [**Hospital1 **] because you had trouble to
express what you wanted to say. There it was noticed you also
had weakness on the right side of your body. A CT scan was
negative for bleeding so you received tPa to disolve the cloat
that was causing your stroke. This was successful since your
symptoms resolved in less than 2 hours. From [**Hospital1 **] you were
transfered to [**Hospital1 18**] to continue follow up. At admission you
still presented slight weakness on your right arm but this
resolved as well as your other symptoms.
Your MRI showed a small infarct (stroke) on the subcortical area
of the left temporal lobe. It is possible that this stroke was
due to your recent medication change and surgery or to your
atrial fibrillation.
You will continue follow up with Dr. [**Last Name (STitle) **] in Neurology-Stroke.
Your antiplatelet medication was modified to start Dabigatran
150mg by mouth twice a day. We attempted to confirm this choice
with your cardiologist prior to your discharge but was unable to
reach him in time. We will contact you if we hear differently
from him.
Your lipid profile is above desirable limits, so your
Simvastatin was increased to 40 mg per day.
If you present a similar event, weakness, sensation deficit or
any other neurological deficit you should consult at the
Emergency Department inmediately.
Followup Instructions:
You have a follow-up appointment with Dr. [**Last Name (STitle) **] on [**11-26**], [**2142**] at 3:30 pm. [**Hospital Ward Name 23**] Building, [**Location (un) **].
Phone:[**Telephone/Fax (1) 657**]
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"V45.88",
"272.4",
"434.91",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10637, 10643
|
8524, 10126
|
351, 358
|
10736, 10736
|
5972, 8501
|
12409, 12728
|
3166, 3243
|
10271, 10614
|
10664, 10715
|
10152, 10248
|
10906, 12386
|
4384, 5775
|
3258, 3831
|
5789, 5953
|
268, 313
|
386, 2584
|
10751, 10882
|
2606, 2884
|
2900, 3150
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,476
| 112,237
|
11155
|
Discharge summary
|
report
|
Admission Date: [**2129-11-3**] Discharge Date: [**2129-11-12**]
Date of Birth: [**2062-6-2**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 66 year old woman who
presented to Dr. [**Last Name (STitle) 468**] approximately a year after an
episode of acute pancreatitis attributed to alcohol abuse.
At the time of that pancreatitis episode, she had a CT scan
which revealed a small pseudo cyst. However, on recent CT
scan, she was found to still have a small cyst, under the
size of one cm, in the head of her pancreas.
Clinically, she remained well over the previous year, without
fevers, chills, nausea, vomiting or other troubles. In
[**2129-9-19**], she developed rapid onset of painless
jaundice. CT scan at this time revealed only dilated extra
hepatic biliary tract. She had a right upper quadrant
ultrasound which showed a dilated common bile duct and
gallbladder but no evidence of common bile duct stones.
Endoscopic retrograde cholangiopancreatography was performed
and a high grade focal stricture of the distal common bile
duct was observed. A stent was placed and she was sent to
Dr. [**Last Name (STitle) 468**] for evaluation.
The patient denies fevers, chills or other symptoms of
cholangitis. She also denies weight loss, history of cancer
or recent exacerbation of alcohol use.
PAST SURGICAL HISTORY: Breast biopsy, appendectomy, a remote
laparoscopy.
PAST MEDICAL HISTORY: Hypercholesterolemia; paroxysmal
atrial fibrillation; mild mitral insufficiency and an alcohol
history of four Manhattans a day.
MEDICATIONS: Lanoxin, Norvasc, Zestril, Zocor, Allopurinol,
Axid, Folic acid and multi-vitamins.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a retired teacher.
PHYSICAL EXAMINATION: On examination, she has jaundice and
has scleral icterus. The rest of her Head, eyes, ears, nose
and throat examination was normal. She had normal carotid
pulses without bruits and no jugular venous distention. Her
chest was clear and her heart was regular rate and rhythm.
She did have grade II out of 6 mid systolic ejection murmur,
heard best at the apex. Her abdomen was soft, nondistended
and nontender. Her gallbladder was not palpable.
HOSPITAL COURSE: She underwent a high contrast CT arterial
study and was then brought into [**Hospital1 188**], where she underwent on [**2129-11-3**], a Whipple
procedure.
Postoperatively, she was placed on prophylactic
benzodiazepine for possible delirium tremens. She was also
placed on subcutaneous heparin, Zantac, Testall and her pain
was controlled with an epidural.
Initially, she was neo-synephrine dependent and she had very
subtle electrocardiogram changes postoperatively. Cardiology
was consulted and a myocardial infarction was ruled out with
negative enzymes. She remained in the Intensive Care Unit
overnight, secondary to the neo drip. However, throughout,
she had excellent urine output.
The evening of postoperative day one, her epidural was
switched to a PCA for better pain control; however, she was
found to be over narcotized and required a Narcan drip to
alleviate this problem.
On postoperative day number two, she was doing well and she
was transferred to the floor. Over the next few days, she
continued to do well. On postoperative day four, she
required some Lasix for mild pulmonary edema on clinical
examination. This resolved with upright positioning and the
diuresis with the Lasix.
On postoperative day number seven, she was noted to have a
large amount of wound drainage and her wound was open for
copious amounts of somewhat enteric looking drainage. She
went for CT scan to rule out fistula or leak. The only
finding was a possible SMB clot. Over this time as well, her
platelets dropped from 325 to 64 and then by postoperative
day number seven, down to nine. Hit antibody was sent. All
heparin was removed from her lines and subcutaneous. Zantac
was stopped. DIC laboratory studies were sent and found to
be unremarkable.
We placed Venodynes on her legs for deep vein thrombosis
prophylaxis and requested a hematology consult. The
hematology consult agreed with our management and
furthermore, advised holding any anticoagulation, secondary
to a risk of bleed, given that her platelet count was only
nine. Her platelet count remained nine over postoperative
day eight. Early in the morning on postoperative day number
nine, she became anuric, hypotensive and her hematocrit was
found to have dropped to 22. She was transferred to the
Intensive Care Unit. Swan-Ganz was placed for fluid
management. She was actively resuscitated with blood
products and fluid. She was taken to the operating room for
exploration of possible abdominal bleed.
Upon opening the abdomen in the operating room, however, the
small bowel was found to be entirely infarcted with
catastrophic abdominal findings. She was reclosed without
any further intervention and brought back to the Intensive
Care Unit. We supported her blood pressure with pressors and
fluids until her family could be fully present. At that
point, she was made comfort measures only. She expired.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 7589**]
MEDQUIST36
D: [**2129-11-12**]
T: [**2129-11-16**] 05:07
JOB#: [**Job Number **]
|
[
"156.9",
"427.31",
"575.11",
"196.2",
"276.2",
"287.4",
"557.0",
"428.0",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"52.7",
"89.64",
"46.39",
"54.11",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
2231, 5383
|
1355, 1407
|
1764, 2213
|
156, 1331
|
1430, 1697
|
1714, 1741
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,668
| 186,952
|
21769
|
Discharge summary
|
report
|
Admission Date: [**2123-3-9**] Discharge Date: [**2123-3-16**]
Date of Birth: [**2075-1-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Mr. [**Known lastname **] is a 48-year-old male with
worsening symptoms related to severe 3-vessel disease.
Major Surgical or Invasive Procedure:
CABG x4 (LIMA-LAD, SVG to [**Last Name (LF) **], [**First Name3 (LF) **], acute marginal) [**3-9**]
History of Present Illness:
Mr. [**Known lastname **] is a 48-year-old male with
worsening symptoms related to severe 3-vessel disease. He is
on hemodialysis with end stage renal disease from diabetes
and its complications. He is presenting for
revascularization.
Past Medical History:
# Insulin-dependent diabetes for 20 years: HgA1c 9.4% on [**2122-6-3**]
# Hypertension
# Hyperlipidemia with markedly elevated TGs
# CKD (mid 2s [**1-16**] to [**3-14**] most recently)
# Pancreatitis; pancreas divisum
# Obesity
# Hyperuricemia
# GERD
Social History:
Patient is married with five children. Patient with disability
due to poor vision from diabetic retinopathy. Wife works at
[**Hospital1 4601**]. Denies tobacco. Rare ETOH.
Family History:
Mother and father with diabetes, no coronary disease, no colon
cancer, no prostate cancer.
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2123-3-15**] 07:00AM 6.9 3.04* 9.2* 28.5* 94 30.4 32.5 16.2*
176
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2123-3-15**] 07:00AM 176
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2123-3-9**] 12:03PM 138*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2123-3-15**] 07:00AM 116* 49* 6.1*# 134 4.7 95* 26 18
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2123-3-12**] 02:54AM Using this1
Source: Line-midline
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2123-3-15**] 07:00AM 6.5* 3.0 2.2
Brief Hospital Course:
Mr. [**Known lastname **] is a 48 yr old man with CAD on HD while awaiting
transplant. He was taken to the OR on [**3-9**] for a CABg x4
(LIMA-LAD, SVG to OM, [**Month/Day (4) **] and acute marginal) [**3-9**]. See
operative note for details. Mr. [**Known lastname 1870**] remained intubated and on
neosynephrine and was transferred to the ICU for ongoing
invasive monitoring. He was weaned from the vent and
successfully extubated on POD#1. He received ongoing
hemodialysis throughout his hospital stay. He was transferred
from the ICU on POD #1. Returned to the ICU on POD#2 for
hyperglycemia. [**Last Name (un) **] was consulted to manage hyperglycemia. Mr.
[**Known lastname **] was transferred from the ICU to the floor again on POD#4
with improved glycemic control. His chest tubes were removed and
CXR was without evidence of pneumothorax. He was given a dose of
betablocker and became bradycardic but remained hemodynamically
stable. Once HR stabilized, his pacing wires were d/c'd. On
POD#5 he was noted to have serosanguinous drainage from the
lower [**12-11**] of his sternal wound. His WBC was normal and remained
afebrile. He was started on keflex. His chest Xray revealed a
moderate left effusion from which he was asymptomatic with room
air oxygen saturations of 97%. He was evaluated by physical
therapy and cleared for discharge to home on POD#7.
Medications on Admission:
Carvedilol 6.25(2),Cinacalcet 30(2),Doxazosin 4(2),Tricor
145(1), Fluoxetine 10(1),Irbesartan 300(1), Omeprazole 20(1),
Novolog 70/30(45 in am and 20 in pm), Pravachol 40(1), Sevelamer
HCL 800(1), Torsemide 2091), Calcium acetate 667(3)w/meals,
Nephrocaps 1(1)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*65 Tablet(s)* Refills:*0*
9. glargine Sig: Seventeen (17) units subcutaneously at
breakfast.
Disp:*1 vial* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous before meals and at bedtime: dose according to
sliding scale.
Disp:*1 vial* Refills:*2*
11. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
coronary artery bypass graft x4(Lima->LAD/SVG->[**Location (un) **]/OM3/Acute
Marginal)-[**2123-3-9**]
-HTN
-hyperLipidemia
-Diabetes
-neuropathy
-retinopathy
-nephropathy,ESRD-Hemodialysis on Monday/wednesday/friday - on
transplant list
- biventricular cardiomyopathy
- Gastritis
- OSA
-Pancreatitis '[**20**]-h/o pancreatic division
-depression
-obesity
Left brachiocephalic AV fistula
s/p angioplasty '[**21**]
s/p thrombectomy '[**21**]
s/p LUE graft placed'[**21**]
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr.[**Last Name (STitle) **] [**Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**Last Name (STitle) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 250**] in 1 week please call for
appointment
Dr [**Last Name (STitle) **],[**First Name3 (LF) **] in [**1-12**] weeks please call for appointment
**Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**]in 4 days, Fri.[**3-19**] : inferior pole serous sternal
drainage/Keflex course
Completed by:[**2123-3-16**]
|
[
"285.21",
"530.81",
"411.1",
"357.2",
"V45.11",
"362.01",
"327.23",
"250.41",
"414.01",
"428.0",
"278.00",
"425.4",
"250.51",
"403.91",
"428.23",
"585.6",
"427.1",
"250.61",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"39.95",
"39.63",
"99.04",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
5068, 5125
|
2058, 3424
|
428, 530
|
5640, 5647
|
1389, 2035
|
6187, 6752
|
1277, 1370
|
3735, 5045
|
5146, 5619
|
3450, 3712
|
5671, 6164
|
281, 390
|
558, 796
|
818, 1071
|
1087, 1261
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,492
| 104,892
|
6413
|
Discharge summary
|
report
|
Admission Date: [**2171-10-18**] Discharge Date: [**2171-10-26**]
Date of Birth: [**2109-4-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
right shoulder - pain- RUL lung tumor for excision s/p
chemotherapy and radiation
Major Surgical or Invasive Procedure:
Right posterior and lateral thoracotomy, right upper
lobectomy with en bloc chest wall resection of ribs 2 and
3.
2. Right cervical incision with scalene fat pad and lymph
node resection as well as mobilization of superior sulcus
tumor off of 1st rib and division of the 2nd rib
anteriorly.
3. Thoracic lymphadenectomy.
4. Flexible bronchoscopy.
History of Present Illness:
62-year-old woman who developed right shoulder pain and was
found to have a large right upper lobe tumor invading into the
2nd and 3rd ribs and abutting up against the 1st rib. She
underwent cervical mediastinoscopy as well as peripheral
metastatic workup. There were no positive lymph nodes and no
metastasis. She underwent induction of chemoradiotherapy to
shrink the tumor away from the subclavian artery and subclavian
vein as well as the brachial plexus. She has been restaged and
was found to have excellent response. We, therefore, took her
forward for a resection of the superior sulcus tumor. Our plan
was to biopsy the scalene fat pad and lymph nodes and if there
is no evidence of tumor to move on to mobilize the superior
sulcus tumor from the cervical incision, including division of
ribs as necessary. We would then move on to a posterolateral
thoracotomy for completion of the procedure.
Past Medical History:
Gastric esophogeal reflux disease, Coronary artery disease,
diabetes type 2, chronic obstructive pulmonary disease, Non
small cell lung cancer s/p chemotherapy and radiation.
Social History:
lives at home, has many family members nearby.
[**Name2 (NI) **] in past
Physical Exam:
General-Elderly female NAD
Resp- Course diminished BS throughout- baseline
Cor-RRR
Abd- Sl distended, NT, + BS,
Ext- no edema
Neuro- fully intact, no R sided deficits
Skin- anterior and posterior thorax incisions. Staples removed,
incision clean and dry.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2171-10-25**] 06:10AM 8.9 3.15* 9.9* 29.0* 92 31.4 34.1 15.4
289
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2171-10-26**] 09:20AM 13.4* 27.9 1.2
INHIBITORS & ANTICOAGULANTS LMWH
[**2171-10-26**] 11:10AM 0.781
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2171-10-25**] 06:10AM 145* 12 0.5 137 4.4 97 311 13
1 NOTE UPDATED REFERENCE RANGE AS OF [**2171-6-21**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2171-10-23**] 04:50PM 128
[**2171-10-23**] 03:48PM 115
[**2171-10-23**] 09:30AM 148*
CPK ISOENZYMES CK-MB cTropnT
[**2171-10-23**] 04:50PM 2
[**2171-10-23**] 03:48PM 1
[**2171-10-23**] 09:30AM 2 <0.011
1 <0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2171-10-25**] 06:10AM 8.4 4.2 2.0
RADIOLOGY Final Report
CHEST (PA & LAT) [**2171-10-24**] 11:29 AM
Reason: eval for PTX
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with lung CA post CT pull
REASON FOR THIS EXAMINATION:
eval for PTX
HISTORY: 62-year-old woman with lung cancer status post surgical
resection. Please evaluate for pneumothorax.
TECHNIQUE: PA and lateral views of the chest were obtained and
compared to [**2171-10-22**].
FINDINGS: There has been interval removal of two right apical
chest tubes. No definite pneumothorax identified. There are
post-surgical changes at the right apex including signs of
volume loss of the right hemithorax with persistent elevation of
the right hemidiaphragm and mediastinal shift to the right.
Again noted are multiple surgical rib defects at the right apex.
The right lung base and the left lung are grossly clear. Heart
size and cardiomediastinal contours are stable given differences
and patient rotation.
IMPRESSION: Interval removal of right apical pleural drains. No
definite pneumothorax. Surgical changes at the right apex with
associated volume loss of the right hemithorax.
Brief Hospital Course:
Pt was admitted on [**2171-10-18**] for ecxision of Pancoast tumor in
RUL. Pain control w/ epidrual is at T6/T7 14/5. She is split
receiving both bupivicaine .1% thru epidural and dilaudid PCA
because she has a wide incision on multiple dermatomes and a
neck incision. She was supported w/ low dose neo while on
epidural. Briefly intubated in ICU and, successfully extubated.
POD#2 AFIB despite IV lopressor. Treated w/ IV amiodarone bolus,
gtt, 2nd bolus and 2 doses of diltiazem. Pain control w/
Epidural- bupivicaine + Dil PCA. 2 chest tubes to suction.
Activity OOB > chair, PT, IS.
POD#3 Transition to po amiodarone w/ recurrent Afib alt w/ NSR.
Re-bolused amiodarone iv and placed back on gtt. Lopressor cont
po. CT 1&2 to water seal w/o ptx. Drainage #1<200cc and d/c w/o
complication, #2 remained to w/s w/ moderate drainage. Incision
anterior and posterior clean and dry, staples intact.
POD#4-Amiod po started, lopressor ^50mgBID. Overnight pt had
episodes of HR 40 SB-150 Afib, treated with IV lopresssor and
Dilt IV with fair rate control. Cardiology consulted.Lopressor
[**Month (only) **]'d 25 [**Hospital1 **].NSR resumed during day. CT #2 d/c w/o complication.
PT, IS, ambulation cont w/ high compliance. BS course, very good
airation. Inhalers cont. Remains on [**12-23**] L O2. Pt R/O'd for MI by
enzymes and EKG.
POD#5- Per Cardiology rec- Amiod 400 BIDpo; Epid d/c, PCA cont.
Lovenox started for anticoagulation in setting of intermittent
Afib post epidural d/c. Evidence of left antecubital
phlebitis(red, swollen, min discomfort) at old IV site present,
Keflex po x10 days started, warm soaks locally w/ small
improvement. Chest tube drainge moderate from CT site. Dressing
changed prn.
POD#6-Remains NSR on Amiod [**Hospital1 **]; PCA weaned, PO Dilaudid started
w/ fair effect. Coumadin 5mg dose #1 @1800. Activity/IS
compliance excellent. Staples removed and steri-strips applied.
Incision- no erythema, small amount serous drainage superior
posterior incision. BS course- good airation, inhalers cont. O2
weaned to off w/ good sat at rest and w/ ambulation- 95%RA.
POD#7- Cont in NSR,Amiod 400BIDpo, lopresor increased to 50 [**Hospital1 **],
restart Imdur 30 mg (1/2 dose), lisinopril 2.5 mg ([**12-25**] daily
dose); Coumadin 5mg dose #2 @1800, lovenox ocnt. Pain med
changed to percocet w/ very good effect. BM- occurred. Plan for
discharge in am POD#8.
Discharge plans arranged for anticoagulation follow-up with: VNA
for blood draw and post op nursing care, Cardiology clinic short
term, then [**Company 191**] coumadin clinic as of [**2171-12-3**]. Follow-up
appointments w/ [**Company 191**] [**10-31**], Cardiology [**11-5**] made. PCP, [**Name10 (NameIs) **]
NP, Cardiology NP and Cardiologist informed of plans.Discharge
instructions, new medication regimen and instructions reviewed
with patient
POD#8-Patient discharged to home in stable condition in company
of family. Discharge instructions given and reviewed w/ patient
and family.
Medications on Admission:
ALBUTEROL 90, ATIVAN 1"PRN, ATROVENT, AZMACORT, ecASA 325',
HUMULIN 70/30 36qam, HUMULIN N 100 20-22qhs, HUMULIN R 100
10-12QDINNER, IMDUR 60', LIPITOR 10', LISINOPRIL 5", METFORMIN
850 TT/T, METOPROLOL 100", SLNG 300 MCG (1/200 GR), PROTONIX
40MG'
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
[**Hospital1 **] (2 times a day).
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)): and 1 pill at bedtime .
Disp:*90 Tablet(s)* Refills:*1*
14. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
16. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
18. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: as
directed.
Disp:*30 Tablet(s)* Refills:*1*
19. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: as
directed.
Disp:*60 Tablet(s)* Refills:*0*
20. hospital bed semi electric
lung cancer s/p chemotherapy, radiation, RUL pancoast tumor
excision.
coronary artery disease, COPD, DM2, GERD
Positioning-pt unable to lie flat while sleeping.
21. overnight pulse oximetry on room air
for oxygenation evaluation at night
22. Enoxaparin 60 mg/0.6mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 4 days.
Disp:*8 syringe* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Gastric esophogeal reflux disease, Coronary artery disease,
diabetes type 2, chronic obstructive pulmonary disease, Non
small cell lung cancer s/p chemotherapy and radiation.
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office for: fever, shortness of breath, chest
pain, redness drainage from incision site.
Take medication as directed on discharge. Your medications and
dosages have changed.
Coumadin dosage Sat [**10-26**] =5mg; Sunday [**10-26**] 2.5mg. No dose on
Monday [**10-28**] until called by Cardiology NP. If she has not called
by 3pm, call her at[**Telephone/Fax (1) 14926**].
Take pain medication as directed. No driving until off narcotic
pain medication.
You will be followed by [**Company **]--[**Telephone/Fax (1) 24704**]-- who
will draw your blood for coumadin level and call/fax result to
Cardiology clinic at [**Hospital1 18**] -[**Telephone/Fax (1) 127**] phone; [**Telephone/Fax (1) 14926**]
fax. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 496**]/ [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nurse Practitioners will be
following you there until you will be followed by [**Hospital 197**]
Clinic in [**Hospital6 733**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24705**] office.
You may shower Sunday [**10-27**], remove dressing and replace with
bandaid as needed after showering.
Followup Instructions:
Call Dr.[**Name (NI) 1816**]/Thoracic office for an appointment in [**12-23**]
weeks- [**Telephone/Fax (1) 170**].[**Hospital Ward Name 23**] Clinical Center [**Location (un) **].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**] [**Hospital Ward Name 23**]
clinical Center 7 th floor Date/Time:[**2171-11-5**] 3:45
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] appointment [**10-31**] at 5pm. You can
call [**Doctor First Name **] to reschedule as needed.
[**Hospital Ward Name 23**] clinical Center [**Location (un) **]
An you have a previously scheduled appointment on [**2171-12-10**]
@10:20am
Completed by:[**2171-10-29**]
|
[
"162.8",
"414.00",
"427.89",
"305.1",
"496",
"250.00",
"V45.81",
"427.31",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.4",
"33.22",
"03.90",
"34.4",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
10084, 10133
|
4367, 7344
|
366, 737
|
10352, 10359
|
2248, 3317
|
11588, 12354
|
7643, 10061
|
3354, 3398
|
10154, 10331
|
7370, 7620
|
10383, 11565
|
1973, 2229
|
245, 328
|
3427, 4344
|
765, 1669
|
1691, 1868
|
1884, 1958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,012
| 140,411
|
32364
|
Discharge summary
|
report
|
Admission Date: [**2150-12-3**] Discharge Date: [**2150-12-4**]
Date of Birth: [**2123-7-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
27F h/o anxiety, depression, and PTSD recent abuse brought by
family to OSH [**2150-12-2**] for ALOC, tremulousness, rigidity. Noted
to start at around 5pm by boyfriend. Not speaking, unable to
stand.
.
At the OSH, vitals were: T 100.8, SBP 88, HR 158. Exam notable
for pupils [**5-14**] OU, diaphoretic, tremulous, "some" rigidity,
moving all extremities. No DTRs documented. She was intubated
for depressed mental status and given ativan repeatedly (15 mg
total), Haldol, and Dilantin 1gm. A CT head was negative. Tox
screens positive only for THC. Seen by neuro there who
recommended EEG. Reported to have narrow complex tachycardia up
to 150s. Transferred to [**Hospital1 18**] for further care.
.
In the ED, labs unremarkable except for WBC 12.0 and CK 298;
repeat tox screens and UHCG were negative. Toxicology was
consulted and recommended continuing supportive care and
following serial CKs.
Past Medical History:
Anxiety
Depression
PTSD
Back surgery
no h/o SI
recent domestic abuse by mother of boyfriend
Social History:
Per report patient does use tobacco and alcohol. Urine tox
positive for marijuana at OSH. Per report, pt victim of recent
physical abuse by the mother of her boyfriend.
Family History:
Unknown
Physical Exam:
T 98.9 HR 89 BP 112/64 RR 16 SaO2 100% on AC 500/14 5 100%
General: WDWN, sedated, intubated
HEENT: pupils pinpoint and sluggish, anicteric sclera,
conjunctivae pink, no ocular clonus, tongue protruberant
Neck: supple, trachea midline
Cardiac: RRR, s1s2 normal, no m/r/g, no JVD
Pulmonary: CTAB
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, no edema
Neuro: sedated, no response to painful stimuli, spontaneous and
inducible clonus, toes equivocal, hyperreflexive
.
Pertinent Results:
<b>Admit Labs:</b>
[**2150-12-2**] 11:50PM WBC-12.0* RBC-3.95* HGB-11.6* HCT-34.1*
MCV-86 MCH-29.2 MCHC-33.9 RDW-13.1
[**2150-12-2**] 11:50PM PLT COUNT-254
[**2150-12-2**] 11:50PM GLUCOSE-116* UREA N-14 CREAT-0.7 SODIUM-142
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-27 ANION GAP-11
[**2150-12-2**] 11:50PM ALT(SGPT)-24 AST(SGOT)-27 CK(CPK)-298* ALK
PHOS-42 AMYLASE-52 TOT BILI-0.3
[**2150-12-2**] 11:50PM LIPASE-14
[**2150-12-2**] 11:50PM CK-MB-5
[**2150-12-2**] 11:50PM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2150-12-2**] 11:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-12-2**] 11:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-12-2**] 11:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2150-12-2**] 11:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
<br>Other Labs:</b>
[**2150-12-3**] 04:44AM BLOOD ALT-20 AST-24 LD(LDH)-172 CK(CPK)-352*
AlkPhos-39 TotBili-0.2
[**2150-12-3**] 04:17PM BLOOD CK(CPK)-542*
[**2150-12-3**] 07:32AM BLOOD Type-ART pO2-176* pCO2-49* pH-7.34*
calTCO2-28 Base XS-0
[**2150-12-3**] 07:32AM BLOOD Lactate-0.9
[**2150-12-3**] 04:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2150-12-3**] 04:20PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2150-12-3**] 04:20PM URINE RBC-11* WBC-8* Bacteri-OCC Yeast-NONE
Epi-<1
[**2150-12-3**] 4:20 pm URINE Source: Catheter.
URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
GRAM POSITIVE BACTERIA. ~4000/ML.
SUGGESTING STAPHYLOCOCCUS SPECIES.
Blood Cx ([**12-3**]) - NGTD
<br>
<b>Discharge Labs:</b>
[**2150-12-4**] 05:02AM BLOOD WBC-9.2 RBC-4.08* Hgb-12.1 Hct-35.8*
MCV-88 MCH-29.7 MCHC-33.9 RDW-12.1 Plt Ct-235
[**2150-12-4**] 05:02AM BLOOD Glucose-98 UreaN-5* Creat-0.5 Na-138
K-3.6 Cl-103 HCO3-27 AnGap-12
[**2150-12-4**] 05:02AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.2
Brief Hospital Course:
This is a 27yo female with a history of depression currently on
an SSRI, PTSD and domestic abuse who presents with
tremulousness, fever and mental status changes. No evidence for
head trauma.
.
# Altered mental status with Likely Serotonin syndrome
On a variety of medication, of note, there is evidence for
interaction between Soma and fluvoxetine, another SSRI. She was
intubated for airway protection and extubated the next day. On
further history after she was extubated, she denied intentional
overdose. However, by pill count, she was missing 22 SOMA and
several paxil. She reported that someone had been taking things
in her house and that that someone may have taken her pills.
CKs initially went up, but then began to decrease. She was seen
by Toxicology service who recommended supportive care and
following CKs. Her symptoms of fever and rigidity had resolved
and her mental status had returned to baseline at the time of
discharge.
.
# Anxiety/depression/PTSD
She was seen by social work and psychiatry. In questioning by
psychiatry, it appears as though patient increased her dose of
medications due to some element of seasonal affective disorder.
This combined with the increased Soma likely led to her
symptoms. The recommendation from psychiatry was to discontinue
all of her psychiatric medications as well as the Soma until she
is seen by her psychiatrist and PCP. [**Name10 (NameIs) **] is to see her
psychiatrist next week.
.
# Back Pain
The Soma which she was previously on was held. She was
continued on oxycodone for her pain. This helped with the
symptoms. On discharge she is to take oxycodone and Motrin for
pain.
Medications on Admission:
Abilify
Paxil
Buproprion
Ritalin
Soma (new) for backpain
Fexofenadine
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for back pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Motrin 800 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for pain: take with meals.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Serotonin Syndrome due to medication interaction
Secondary:
Anxiety
Depression
Post-Traumatic Stress Disorder
Back pain s/p back surgery
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were found to have Serotonin Syndrome due to the combination
of medications you were taking. You should stop taking all of
your psychiatric medications (abilify, paxil, Ritalin,
Bupropion) and your Soma until you are seen by your psychiatrist
and your primary care doctor.
.
Return to the emergency room or call your primary care doctor if
you have increased rigidity, significant fevers, or feel very
depressed.
Followup Instructions:
Primary Care: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 8058**]. Please call for a
follow up appointment in the next 1-2 weeks.
Psychiatry: Please follow up with your psychiatrist as scheduled
next week.
|
[
"E939.7",
"E939.3",
"E938.0",
"333.99",
"E939.0",
"724.2",
"309.81",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6242, 6248
|
4215, 5869
|
293, 319
|
6437, 6468
|
2116, 3066
|
6934, 7188
|
1567, 1576
|
5990, 6219
|
6269, 6416
|
5895, 5967
|
6492, 6911
|
3918, 4192
|
1591, 2097
|
232, 255
|
3727, 3903
|
347, 1249
|
1271, 1365
|
1381, 1551
|
3077, 3692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,576
| 119,543
|
47642
|
Discharge summary
|
report
|
Admission Date: [**2165-3-27**] Discharge Date: [**2165-4-30**]
Date of Birth: [**2078-10-21**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Non healing ulcer of left great hallux
Major Surgical or Invasive Procedure:
[**2165-3-27**]: Left common femoral artery to below the knee popliteal
bypass graft (saphenous vein)
[**2165-4-22**]: PEG
History of Present Illness:
Mrs [**Known lastname 100653**] is an 86-year-old female previously hospitalized
from [**2165-3-9**]- [**2165-3-22**] with persistent ulceration and infection
of the left great toe. An angiogram during that hospitalization
identifying a long occlusion of the left superficial femoral
artery with sole distal runoff constituted by the peroneal
artery which was unable to be open percutaneously. She was
discharge to home on IV antibiotics [**2165-3-22**] and readmitted on
[**2165-3-27**] for a left common femoral to below-knee popliteal artery
bypass graft with nonreverse saphenous vein in hope of
increasing blood flow to the left foot for wound healing.
Past Medical History:
-Peripheral Arterial Disease
-Moderate AS, LVH
-Chronic LE edema
-Chronic diastolic CHF
-s/p PPM for sick sinus syndrome
-IDDM c/b neuropathy, CHF, dysphagia, afib on coumadin, h/o
Sublingual CA
s/p sublingual sx [**2-28**] CA, Dysphagia
cervical/thoracic vertebrae sx for -Spinal stenosis
-On warfarin for afib and PE/DVT [**6-/2164**] for left subclavian DVT
due to PPM wire
-Diabetes
-Laminectomy
-Stage III CKD, baseline 1.4
-RML nodule
Social History:
Lives with husband. [**Name (NI) **] tobacco or etoh use.
Prior smoking history of 1ppd/30 years. Quit 20 years ago.
Pertinent Results:
[**2165-4-30**] 04:35AM BLOOD WBC-11.8* RBC-3.07* Hgb-9.1* Hct-33.5*
MCV-109* MCH-29.8 MCHC-27.3* RDW-20.2* Plt Ct-243
[**2165-4-30**] 04:35AM BLOOD PT-34.4* PTT-38.4* INR(PT)-3.3*
[**2165-4-30**] 04:35AM BLOOD Glucose-175* UreaN-82* Creat-5.1* Na-139
K-5.6* Cl-100 HCO3-28 AnGap-17
Brief Hospital Course:
The patient is an 86-year-old female previously hospitalized
from [**2165-3-9**]- [**2165-3-22**] with persistent ulceration and infection
of the left great toe. An angiogram during the hospitalization
identified a long occlusion of the left superficial femoral
artery with sole distal runoff constituted by the peroneal
artery which was unable to be open percutaneously. She was
discharge to home briefly on IV antibiotics and readmitted on
[**2165-3-27**] for a left common femoral to below-knee popliteal artery
bypass graft with nonreversed saphenous vein in hope of
increasing blood flow to the left foot for wound healing.
1. Peripheral Arterial Disease
Peripheral pulses were dopperable. Feet were warm. Left 1st
toe had dry gangrene.
2. Respiratory Failure
She had a presumed aspiration pneumonia on [**2165-4-12**] requiring ICU
admission and intubation for 2 days, treated with vancomycin and
cefepime. She again required transfer to the ICU on [**2165-4-26**] for
hypercarbia with somnolence requiring BIPAP briefly. She was
maintained on 4L O2 via nasal cannula.
3.Chronic Kidney Disease/Acute Kidney Injury
Baseline creatine was 1.3-1.6 prior to surgery. After surgery,
the patient was oliguric with no response to lasix. She
eventually became anuric secondary to an acute kidney injury and
hemodialysis was starting on [**2165-4-5**].
4.Dysphagia/Aspiration
She had a history of sublingual cancer ~20 years ago and
received oral
resection. Bedside swallowing evaluation showed aspiration. A
Doboff feeding tube was placed and tube feeding were begun. A
PEG tube was placed on [**2165-4-22**].
5. Wounds
Leg thigh incision was opened secondary to nonhealing and packed
with normal saline damp gauze.
6.DVT
Left axillary DVT was found on [**2165-4-20**] felt to be secondary to
PICC which was pulled. She was already fully anticoagulated for
her atrial fibrillation.
7.Goals of Care
After last transfer to ICU for hypercapnia on [**2165-4-26**], the
family met with the medical staff to redefine the goals of care.
Mrs.[**Known lastname 100655**] code status was changed to DNR/DNI and they
decided they did not want to continue dialysis. As arrangements
where being made to transfer to hospice care, Mrs. [**Known lastname 100653**]
cardiac arrested. She died at 8:02PM on [**2165-4-30**].
Discharge Disposition:
Expired
Discharge Diagnosis:
Peripheral Arterial Disease, sp L CFA endarterectomy, L CFA to
BK [**Doctor Last Name **] bypass [**2165-3-27**].
Chronic Kidney Disease, on dialysis
Aortic Stenosis
Dysphagia
Discharge Condition:
Expired
Completed by:[**2165-4-30**]
|
[
"707.15",
"599.0",
"397.0",
"427.31",
"428.32",
"357.2",
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"250.60",
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"428.0",
"V70.7",
"440.4",
"403.90",
"444.21",
"041.3",
"041.7",
"584.5",
"276.1",
"518.81",
"997.32",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.71",
"39.95",
"96.04",
"96.6",
"38.93",
"38.18",
"38.91",
"39.29",
"00.40",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
4427, 4436
|
2084, 4404
|
343, 469
|
4656, 4694
|
1777, 2061
|
4457, 4635
|
265, 305
|
497, 1158
|
1180, 1622
|
1638, 1758
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,123
| 139,238
|
18431+18473
|
Discharge summary
|
report+report
|
Admission Date: [**2188-10-6**] Discharge Date: [**2188-11-3**]
Date of Birth: [**2118-9-19**] Sex: M
Service: BLUMEGART
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
male with a history of type 2 diabetes, coronary artery
disease, status post coronary artery bypass grafting on
[**2178-12-1**], status post aortic valve replacement in
[**2175**], severe peripheral vascular disease, who presented to
the hospital on [**2188-10-6**], for elective femoral to
popliteal bypass in the setting of a chronic nonhealing left
plantar surface foot ulcer.
The patient had the femoral to popliteal bypass on [**2188-10-9**], without complication. This was followed by a left
transmetatarsal amputation on [**10-15**] for persistent
nonhealing ulcer.
The [**Hospital 228**] hospital course was complicated by persistent
hypoxia postprocedure requiring high levels of oxygen until
discharge.
The patient was followed by the Surgical Service with
Cardiology and Pulmonary consult until [**2188-10-23**], when
he was transferred for continued medical management of
persistent hypoxia.
The patient had a baseline function prior to admission,
walking [**1-28**] miles a day with mild shortness of breath, and
this was a drastic change from his baseline.
Prior to transfer to the Medical Service, the patient was
treated with aggressive diuresis for suspected congestive
heart failure, nebulizers for emphysema, and initial
broad-spectrum antibiotics for suspected infected foot ulcer.
The patient does have a heavy smoking history in the past,
approximately 50 to 100 packs/year history and worked as a
welder for approximately 40 years with large asbestos
exposure as well. The patient reported having stopped
smoking approximately 10-15 years ago.
ALLERGIES: PENICILLIN WITH UNKNOWN REACTION.
PAST MEDICAL HISTORY: Type 2 diabetes, coronary artery
disease, status post coronary artery bypass grafting in
[**2178-12-1**], status post aortic valve replacement with
St. Jude valve in [**2175**], severe peripheral vascular disease.
MEDICATIONS ON ADMISSION: Glucovance 5/500 p.o. b.i.d.,
Pravachol 20 mg p.o. q.d., Platol 100 mg b.i.d., Warfarin 2
mg q.d.
PHYSICAL EXAMINATION: Vital signs: Temperature 96.6??????, blood
pressure ..................., pulse 104, respirations 20.
General: The patient was a mildly obese male in no apparent
distress. HEENT: Normocephalic, atraumatic. Moist mucous
membranes. Chest: There was a median sternotomy incision.
Lungs: Clear to auscultation bilaterally. Cardiovascular:
Regular, rate and rhythm. Normal S1. Metallic S2. No
carotid bruits. Abdomen: Soft, nontender, nondistended. No
palpable masses. Extremities: Left leg had a well-healed
vein harvest site. There was a 2 x 3 cm ulcerated mass
behind the left great toe. This did not probe to bone.
Right leg with amputated first digit. Vascular: The patient
had 2+ carotids, 2+ radials, nonpalpable dorsalis pedis
bilaterally.
LABORATORY DATA: On admission white blood cell count was
15.4, hematocrit 38.3; PT 16.9, PTT 28.6, INR 1.9; CHEM7 133,
4.7, 93, 27, 14, 0.8, 187.
HOSPITAL COURSE: This was a 71-year-old male with a past
medical history significant for type 2 diabetes, severe
peripheral vascular disease, coronary artery disease, aortic
valve replacement, originally admitted for an elective
femoral to popliteal bypass in the setting of a left
nonhealing plantar surface foot ulcer for approximately six
months, whose course was complicated by persistent hypoxia
and shortness of breath following the original surgery on
[**2188-10-9**], and a left foot transmetatarsal amputation
on [**2188-10-15**].
1. Hypoxia: The patient had persistent hypoxia postsurgery
requiring high levels of oxygen with nasal oxygen on a 50%
shovel mask for approximately two weeks postprocedure.
The patient was originally treated for what was thought to be
a congestive heart failure exacerbation. An echocardiogram
was performed on [**10-24**] which showed a depressed ejection
fraction and a poor study. Ejection fraction on [**10-9**]
showed an ejection fraction of approximately 48%, normal left
ventricle, with an inferior wall defect.
Consequently the patient was treated with aggressive diuresis
and demonstrated only moderate improvement in his shortness
of breath. The patient also had a long history of smoking
and asbestos exposure. CT exam performed on [**10-7**]
showed isolated pleural plaques with right apical thickening,
central lobar emphysematous change, and multiple ground-glass
opacities suggestive congestive heart failure versus an
infectious process.
On [**2188-10-23**], the patient was transferred to the
Medical Team to further evaluate this hypoxia. At that
particular time, he was reported to have some moderate
improvement over the [**2-26**] proceeding days; however, over the
weekend of [**10-25**], he became markedly hypoxic and
suffered a probable PA arrest and was intubated and
transferred to the Intensive Care Unit.
The patient was extubated without complications. He was
treated with broad-spectrum antibiotics. He was diuresed in
the setting of mild congestive heart failure and treated with
nebulizers for a new diagnosis of chronic obstructive
pulmonary disease.
The patient was transferred back to the floor, continuing his
medical management for his hypoxia. On discharge, his oxygen
requirement had decreased to 1 L, and he was breathing
comfortably on room air with an oxygen saturation of
approximately 96%.
2. Chronic obstructive pulmonary disease: The patient had a
new diagnosis of chronic obstructive pulmonary disease on
this admission in the setting of long-term smoking history
and asbestos exposure. He was treated with Albuterol and
Atrovent nebs, albuterol p.r.n., titrating the oxygen
saturation to greater than 92%. He was given aggressive
chest physical therapy as well.
The patient will be discharged on metered dose inhalers to be
continued as an outpatient with follow-up with his primary
care physician.
3. Congestive heart failure: The patient has evidence of
congestive heart failure during this admission with a
markedly depressed ejection fraction from
[**10-23**]. He was treated with fluid restrictions with
strict I/Os, Lasix 40 mg b.i.d., Lopressor and Lisinopril.
He will continue with these medications as an outpatient.
4. Pneumonia/sepsis: When the patient was transferred into
the Intensive Care Unit, there was a question of whether it
was an infected process. Blood cultures were repeatedly
negative. Bronchial lavage and washings were also negative.
TTE showed no evidence of endocarditis; however, given the
patient's persistent hypoxia, he was continued on a 7-day
course of Ceftazidime. The patient will not be discharged on
antibiotics following discharge.
5. Left femoral to popliteal bypass/left transmetatarsal
amputation: Please seen surgical notes for complete details
and surgical dictation on procedure.
During the patient's stay on the Medical Service, he was
treated with b.i.d. dressing changes, wet-to-dry. There was
no evidence of infection. The patient was not continued on
any antibiotics. The patient will be followed by the
Vascular Team as an outpatient.
6. Transaminitis: The patient had mildly elevated AST and
LSD following admission to the Intensive Care Unit. There
was some question as to whether this was related to "shock
liver" in the setting of hypertension following his PA
arrest. Levels remained mildly elevated on discharge with an
AST of 50 and ALT of 90. This could also be due to his
Pravastatin use. This should be followed as an outpatient.
7. Coronary artery disease/peripheral vascular
disease/aortic valve replacement: The patient was continued
on ACE inhibitor, statin and was anticoagulated with Heparin,
and was subtherapeutic on Coumadin following his surgical
procedure. The patient was discharged with an INR of 1.9 on
Heparin to his nursing care facility on a dose of 5 mg p.o.
q.d.
He will need aggressive follow-up to ensure therapeutic INR
within 2.0-3.0 range. His prior home dose was 2 mg p.o.
q.d.; however, following administration of antibiotics, he
has required additional levels of Coumadin. Please follow
b.i.d. until assurance of appropriate levels.
DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d.,
Pravastatin 20 mg p.o. q.d., Ipratropium Bromide 18
mcg/aerosol 2 puffs q.i.d., Albuterol ..................
solution 1-2 puffs q.6 hours, Albuterol inhalers 1-2 puffs
q.2-4 hours p.r.n. as needed for shortness of breath or
wheezing, Tylenol 325 mg [**12-27**] tab p.o. q.4-6 hours as needed,
Oxycodone 5/325 mg [**12-27**] tab p.o. q.4-6 hours as needed,
Dulcolax [**12-27**] tab p.o. q.d. as needed for constipation,
Aspirin 81 mg p.o. q.d., regular Insulin sliding scale,
Glyburide/Metformin, Glucovance 5/500 1 tab p.o. q.d.,
Lisinopril 10 mg 1 tab p.o. q.d., Lopressor 50 mg 0.5 or 25
mg p.o. b.i.d., Lasix 40 mg p.o. b.i.d., Maalox q.6 hours as
needed for indigestion and reflux, Senna [**12-27**] p.o. b.i.d. as
needed for constipation, Trazodone 25 mg p.o. q.h.s. p.r.n.
as needed for insomnia, Warfarin 5 mg p.o. q.d.
DISCHARGE DIAGNOSIS:
1. Hypoxia, hypoxemia.
2. Heart murmur, unspecified.
3. Congestive heart failure.
4. Valvular anomaly.
5. Arterial sclerosis of extremities, unspecified.
6. Type 2 diabetes, controlled.
7. Abnormal x-ray of lung.
8. Chronic obstructive pulmonary disease exacerbation.
9. Pneumonia.
10. Sepsis.
12. PA arrest.
MAJOR SURGICAL PROCEDURES:
1. Left femoral to popliteal bypass.
2. Left foot transmetatarsal amputation.
3. Left lower extremity angiography.
CONDITION ON DISCHARGE: The patient is stable, breathing
comfortably on room air, tolerating p.o. intake.
DISCHARGE STATUS: The patient will be discharged to an
extended care facility in [**Location (un) 246**].
FOLLOW-UP: 1. Primary care physician for continued medical
management and compliance with medical regimen. 2. The
patient will follow-up with his vascular surgeon for
continued management of his peripheral vascular disease and
wound care.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36
D: [**2188-11-3**] 11:36
T: [**2188-11-3**] 11:36
JOB#: [**Job Number 50726**]
Admission Date: [**2188-10-6**] Discharge Date: [**2188-11-3**]
Date of Birth: [**2117-9-19**] Sex: M
Service:
ADDENDUM:
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. b.i.d.
2. Pravastatin 20 mg p.o. q.d.
3. Ipratropium bromide two puffs q.i.d.
4. Albuterol MDI one puff q.i.d. with Ipratropium.
5. Albuterol 90 microgram inhaler one to two puffs q. two to
four hours as needed for shortness of breath.
6. Propanolol 325 to 650 mg tablets p.o. q. four to six
hours p.r.n. fever or pain.
7. Percocet 5/325 one to two tablets p.o. q. four to six
hours as needed for pain, do not exceed 4 grams of Tylenol
per day.
8. Aspirin.
9. Regular insulin sliding scale.
10. Glyburide/Metformin 5/500 one tablet p.o. b.i.d.
11. Lisinopril 10 mg p.o. q.d.
12. Lopressor 25 mg p.o. b.i.d.
13. Lasix 40 mg p.o. b.i.d.
14. Maalox as needed for indigestion.
15. Senna tablets.
16. Trazodone 25 mg p.o. q.h.s.
17. Warfarin sodium 5 mg one tablet p.o. q.d.
18. Heparin at 1,700 units an hour to use for approximately
48 hours until the patient is therapeutic on Coumadin with an
INR goal of 2.0 to 3.0, goal heparin rate 60-80 PTT.
FOLLOW-UP:
1. The patient is to follow-up with primary care physician
in two weeks for continued medical management.
2. The patient is to contact his vascular surgeon to make a
follow-up appointment as well as continued wound care of his
left transmetatarsal amputation.
3. Please check electrolytes in one to two days to monitor
potassium and creatinine now that he has been started on
Lasix.
4. Please continue aspirin for approximately 48 hours or
until therapeutic on a stable dose of Coumadin, goal INR of
2.0 to 3.0, goal PTT 60-80.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36
D: [**2188-11-3**] 01:56
T: [**2188-11-3**] 17:22
JOB#: [**Job Number 50810**]
|
[
"584.9",
"440.23",
"707.15",
"491.21",
"038.9",
"486",
"428.0",
"996.62",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.71",
"33.24",
"96.6",
"38.93",
"84.12",
"39.29",
"88.48",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8312, 9167
|
9188, 9653
|
10499, 12300
|
2088, 2187
|
3140, 8288
|
2210, 3122
|
171, 1823
|
1846, 2061
|
9678, 10473
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,538
| 187,726
|
8011
|
Discharge summary
|
report
|
Admission Date: [**2166-12-4**] Discharge Date: [**2166-12-10**]
Date of Birth: [**2117-4-21**] Sex: M
Service: SURGERY
Allergies:
Motrin / Lisinopril / Rapamune
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
increasing abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
Interventional radiology - right lateral sacral artery
successfully embolized using Gelfoam, R IJ line placed
hemodialysis
picc placement
History of Present Illness:
49M s/p ECD renal transplant [**7-27**] presents with hct of 16.7 24
hours post liver bx and peritoneal tap by IR. These were
performed because of pt's idiopathic jaundice and recent LFT
elevation. Pt reports diarrhea since the procedure and
increasing abdominal discomfort, nausea and dizziness.
Diagnostic paracentesis was attempted in the ED with return of
frank blood.
Past Medical History:
-End-stage renal disease on HD T/T/S secondary to diabetic
nephropathy-started on dialysis [**2163-7-19**]
-diabetes for at least 20 years with retinopathy and neuropathy
with
footdrop
-coronary artery disease with history of ST elevation MI [**7-24**]
c/b pericardial tamponade requiring pericardiocentesis
-three-vessel disease with stents in the RCA and left circumflex
-hypertension
-depression
-hyperlipidemia
PSH:
[**2166-8-1**] ECD renal transplant with delayed graft function
Social History:
The patient does not smoke and he does not drink alcohol. He
lives with his wife, [**Name (NI) **]. From [**Male First Name (un) 1056**] originally. Has
multiple family members in the area including 4 children, one of
which works in BMT on the [**Hospital Ward Name 516**].
Family History:
Significant for myocardial infarction in his father at the age
of 49. Multiple family members with diabetes.
Physical Exam:
On admission:
97.5 76 117/46 14 96
Gen: Uncomfortable appearing
HEENT: +scleral icterus
Skin: visible jaundice
CV: RRR
Resp: Clear to auscultation
Abd: Distended, +fluid wave, diffuse moderate tenderness, no
rebound or guarding
Pertinent Results:
[**2166-12-10**] 05:27AM BLOOD WBC-6.1 RBC-3.19* Hgb-9.2* Hct-29.3*
MCV-92 MCH-28.9 MCHC-31.5 RDW-16.6* Plt Ct-190
[**2166-12-10**] 05:27AM BLOOD Glucose-99 UreaN-25* Creat-3.5* Na-135
K-3.7 Cl-91* HCO3-33* AnGap-15
[**2166-12-7**] 06:00AM BLOOD ALT-19 AST-31 LD(LDH)-223 AlkPhos-453*
TotBili-1.9*
[**2166-12-10**] 05:27AM BLOOD tacroFK-4.2*
CMV Viral Load (Final [**2166-12-9**]): 17,100 copies/ml
Brief Hospital Course:
The patient was seen in the emergency room and transferred
directly to the interventional radiology suite for embolization.
He was given DDAVP, 6u RBC, and 3 FFP. Following the above
procedure he was transferred to the SICU for continued
monitoring. He resumes his tacrolimus, valcyte, MMF, diet was
NPO, q 6 hour hct, foley catheter in place, 120mg IV lasix x 1.
[**12-5**] transfused two units RBC for drifting hct, RUQ ultrasound
performed demonstrating patent hepatic vasculature with normal
waveforms and flow, no evidence of cholecystitis. Remained NPO.
[**12-6**] Hct stable, diet advanced to a regular diet, continued
tacrolimus, switched to gancicolvir due to CMV viral load, foley
catheter removed, transferred to the floor.
[**12-7**] - albuterol nebs started, continued home medications
[**12-8**] - ECHO performed - left ventricular wall thickness,
systolic function normal. LVEF = 63%, increased left ventricular
filling pressure, aortic valve leaflets are mildly thickened but
aortic stenosis is not present, mitral valve leaflets are mildly
thickened.
[**12-9**] PICC line obtained for gancicolvir, HD performed for 4.5
L, metolazone started, temp to 101.1 overnight, pan cultured
[**12-10**] - UA positive, started on levofloxavin, pulmonary consult
for continued O2 requirement. Their recommendations included
continue to optimize his fluid status and albuterol nebs. He
will follow up in pulm [**Hospital 3782**] clinic. CT chest demonstrated no
airspace opacity or interstitial abnl to suggest pneumonitis.
Discharged home
Medications on Admission:
Norvasc 10', Procrit 10,000 qwk, Lasix 120'', Gabapentin 100',
insulin lantus 6 qam, ISS, Ativan 2mg hs, Lopressor 100'',
Cellcept [**Pager number **]'', Omeprazole 20 prn, Kayexalate prn, Tacro 1'',
Bactrim ss', Valcyte [**Age over 90 **] M/[**Last Name (LF) **], [**First Name3 (LF) **] 325', Benadryl 50 HS
Discharge Medications:
1. Ganciclovir Sodium 500 mg Recon Soln Sig: Ninety (90) mg
Intravenous 3X/WEEK ([**Doctor First Name **],TU,TH): 3x/wk on dialysis days after
dialysis.
Disp:*12 doses* Refills:*1*
2. Outpatient Lab Work
Weekly CMV viral load, ast, alt, alk phos, tbili
fax results to ID [**Telephone/Fax (1) 1419**] attention Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: PICC line
care.
5. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous once a day.
6. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
10. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QOD ().
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze.
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*13 Tablet(s)* Refills:*0*
16. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO once a day:
PM dose.
17. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO once a day:
AM dose.
18. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
19. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
cmv hepatitis
esrd s/p kidney transplant now back on hemodialysis
chronic allograft nephropathy
Discharge Condition:
alert/oriented
ambulating independently, desats to 81% room air
tolerating a regular diet
Discharge Instructions:
Dialysis Schedule:
Thursday [**12-11**] 7:00 AM
[**Month (only) 1017**] [**12-14**] 3:30 PM
Tuesday [**12-16**] 3:30 PM
Thursday [**12-18**] 3:30 PM
[**First Name8 (NamePattern2) 1017**] [**12-21**] 3:30 PM
Wednesday [**12-24**] 3:30 PM
Then Monday, Wednesday Friday at 3:30 PM
.
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, increased shortness of breath, increased abdominal pain,
yellowing of skin or eyes, inability to take food, fluids or
medications
You will be getting the gancyclovir IV medication through the
PICC line following hemodialysis (three times a week)
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-12-15**] 3:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2167-1-19**] 1:20
***Please call transplant clinic for appointment on [**12-15**]
- Outpt PFTs and Pulmonary clinic follow up.
|
[
"311",
"416.8",
"E878.8",
"996.81",
"250.60",
"585.6",
"789.59",
"285.1",
"998.11",
"412",
"357.2",
"078.5",
"568.81",
"736.79",
"403.91",
"573.0",
"599.0",
"573.1",
"250.40",
"428.0",
"272.4",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"39.95",
"54.91",
"88.47",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
6361, 6419
|
2494, 4051
|
337, 476
|
6559, 6651
|
2070, 2471
|
7328, 7722
|
1696, 1806
|
4412, 6338
|
6440, 6538
|
4077, 4389
|
6675, 7305
|
1821, 1821
|
251, 299
|
504, 878
|
1835, 2051
|
900, 1387
|
1403, 1680
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,441
| 183,385
|
39368+58291
|
Discharge summary
|
report+addendum
|
Admission Date: [**2170-10-31**] Discharge Date: [**2170-11-8**]
Date of Birth: [**2115-3-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Coronary artery disease
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x3(LIMA-LAD,SVG-dg,SVG-RCA)
[**2170-10-31**]
History of Present Illness:
This 55 year old white male presented for elective cardiac
catheterization after a positive stress test, done after a
syncopal episode. The catheterization revealed a 70% LAD and
60% RCA lesion and surgical evaluation was requested.
Past Medical History:
hyperlipidemia
noninsulin dependent diabetes
asthma
hypertension
s/p prostate surgery for adhesion secondary to herniorraphy
gastroesophageal reflux
Social History:
Race: Caucasian
Last Dental Exam: 3 weeks ago
Lives with: wife- [**Name (NI) **], and 10 yo daughter
Occupation: stock/inventory clerk at warehouse
Tobacco: denies
ETOH: denies
Family History:
Family History:
Father had diabetes and died in his 60s; His sister and
mother have CAD
Physical Exam:
Pulse: 80 Resp: 14 O2 sat: 98%2L
B/P Right: 104/77 Left:
Height: 6'0" Weight: 99.3kg
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: cath site Left: 1+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2170-11-4**] 04:55AM BLOOD Hct-29.2*
[**2170-11-3**] 05:09AM BLOOD WBC-15.4* RBC-3.57* Hgb-10.2* Hct-30.2*
MCV-84 MCH-28.5 MCHC-33.8 RDW-13.8 Plt Ct-209
[**2170-10-31**] 01:37PM BLOOD WBC-16.4*# RBC-3.15*# Hgb-9.1*#
Hct-26.2*# MCV-83 MCH-29.0 MCHC-34.9 RDW-13.9 Plt Ct-220
[**2170-11-4**] 04:55AM BLOOD UreaN-25* Creat-1.4* Na-141 K-4.2 Cl-97
[**2170-10-31**] 02:52PM BLOOD UreaN-32* Creat-1.6* Na-143 K-4.3 Cl-108
HCO3-26 AnGap-13
The estimated right atrial pressure is 0-5 mmHg. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is moderately
dilated at the sinus level. The ascending aorta is mildly
dilated. Mild (1+) aortic regurgitation is seen.
IMPRESSION: Suboptimal image quality. Normal global left
ventricular systolic function.
Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2170-11-6**] 17:35
Brief Hospital Course:
Following catheterization Mr. [**Known lastname 87027**] was referred for a coronary
artery bypass grafting. On [**11-1**] he went to the operating room
where reveascularization was performed without complication,
please see the operative note for details. He weaned from
bypass on Neo-Synephrine and Propofol infusions. He was stable,
awoke intact, was weaned and extubated.
He was diuresed towards his preoperative weight and beta
blockade begun. After transfer to the step down floor, Physical
Therapy worked with him for strength and mobility. He failed
voiding trial on two occasions and, therefore, an indwelling
catheter was left. Tamsulosin was begun and arrangements were
made for urologic follow up.
He had several episodes of systolic blood pressure in the upper
80s while walking with Physical Therapy. Although he felt okay
while moving, he was slightly lightheaded standing still. While
he did climb stairs it was felt that it was unsafe for him to go
home directly. A short rehabilitation stay was recommended.
Another voiding trial in the day or so after discharge would be
appropriate as he has been on tamsulosin for several days and is
more mobile.
While beta blocker doses were decreased, they were not stopped
as he was slightly tachycardic and his systolic blood pressure
is mostly is in the 110-120s. Wounds are clean and healing well,
labs are stable and he feels well.
Arrangements were made for follow up and medications are as
noted. Plavix was given due to poor bypass targets.
Medications on Admission:
Advair 250/50 [**Hospital1 **]
Glyburide 5mg daily
Simvastatin 80mg daily
Valsartan 80mg daily
Aspirin 81mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
9. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
11. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] house in Westfor Mass.
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
hypertension
hyperlipidemia
noninsulin dependent diabetes mellitus
gastroesophageal reflux
chronic kidney disease
asthma
s/p prostate surgery
urinary retension
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-minimal
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.[**First Name (STitle) **] on [**2170-11-26**] at 1pm ([**Telephone/Fax (1) 170**])
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] ([**Telephone/Fax (1) 11650**]) on [**2170-12-3**] at
10:30am
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2170-11-8**] Name: [**Known lastname 13803**],[**Known firstname **] A. Unit No: [**Numeric Identifier 13804**]
Admission Date: [**2170-10-31**] Discharge Date: [**2170-11-8**]
Date of Birth: [**2115-3-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Mr. [**Known lastname **] was discharged to [**Location (un) 12660**] House in [**Location (un) 12660**],
[**State 1145**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 12660**] house in Westfor Mass.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2170-11-8**]
|
[
"250.00",
"458.9",
"414.01",
"403.90",
"285.1",
"788.20",
"585.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
8233, 8432
|
2960, 4479
|
345, 422
|
6035, 6265
|
1856, 2937
|
7106, 8210
|
1084, 1157
|
4644, 5676
|
5794, 6014
|
4505, 4621
|
6289, 7083
|
1172, 1837
|
282, 307
|
450, 685
|
707, 857
|
873, 1052
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,251
| 199,522
|
25507
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 63721**]
Admission Date: [**2117-10-13**]
Discharge Date: [**2117-11-2**]
Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
status post a fall from 6 stairs due to tripping. There was
no definitive loss of consciousness. She was transferred to
[**Hospital3 51769**] Hospital in hemodynamically stable condition.
There was a report of weakness and cord compression and she
was transferred to the [**Hospital1 18**] for further evaluation.
PAST MEDICAL HISTORY: Hypertension, asthma, coronary artery
disease, urinary tract infections, vaginal prolapse,
pneumonia and thyroid disease.
PAST SURGICAL HISTORY: Thyroidectomy in [**2052**], hysterectomy
in [**2076**], rectal surgery in [**2110**], CABG and valve surgery in
[**2114**].
MEDICATIONS: Advair, lisinopril, verapamil, hydroxyzine,
Prevacid, calcitriol and Ditropan.
PHYSICAL EXAMINATION: Temperature was 96.8, heart rate 72,
blood pressure 130/47, respiratory rate 17, 100% on room air.
On physical examination, she was awake, alert, following
commands. Lungs were clear. Heart was regular. Abdomen was
soft, nontender, nondistended. Her hand grip was diminished
bilaterally at 3/5. Lower extremity strength was [**6-17**]
bilaterally. Her right eye was swollen with gross ecchymosis.
LABORATORY: White blood cell count was 10.8, hematocrit
28.6, platelets 348. Chemistry - sodium was 148, potassium
3.9, chloride 103, bicarbonate 23, BUN 21, creatinine 0.7,
glucose 178. Urine Tox was negative.
HOSPITAL COURSE: The patient was started on steroids at the
outside institution. CT of the head showed a right frontal
contusion. CT of the face showed orbital fracture with
fragment into the orbit, additional contusion and question of
entrapment of the medial rectus, superior oblique. CT of the
spine showed severe degenerative disease. C3-C4 and C4-C5 had
some canal narrowing. The orthopedic spine service was
involved and determined the patient had central cord
syndrome, spinal stenosis. Ophthalmology service was also
involved and they determined that they would not need any
emergent repair of the orbit at that time. The patient was
admitted to the intensive care unit for close neurological
checks. The patient was brought to the operating room and had
a cervical anterior and posterior fixation. This was done on
[**10-17**] for central cord syndrome. The patient was
intubated through the admission and eventually became very
difficult to wean from the ventilator. Tube feeds were
initiated early in the hospital course which were tolerated
well. We attempted several CPAP trials which were tolerated
temporarily, but we would eventually have to switch her back
to assist-control several times. The patient had a
percutaneous tracheostomy and a percutaneous gastrostomy tube
placed by the trauma surgery service. This was done on
[**10-23**]. The patient was started on tube feeds well at
goal. The patient did have some erythema of the trachea for
which vancomycin and Zosyn were started. This erythema
significantly improved. The patient also had MRSA from the
sputum for which vancomycin was again started. She had a
period of diarrhea and the C. diff's were negative, but
Flagyl was started for 6 days empirically and she did well
from that as the diarrhea stopped. The patient had a PICC
line placed on [**10-26**]. The patient will need gradual
wean from the ventilator.
CONDITION ON DISCHARGE: Stable. The patient had a hematocrit
of 23.5 on the day of discharge. It was ranging in the low
range and we elected not to perform a transfusion. Please
check hematocrit at outside institution and if necessary and
feel appropriate, may use blood transfusion. White blood cell
count of the patient was hovering in the 10,000-15,000 range
for approximately 10 days. The patient was afebrile for most
of this time.
DISCHARGE DIAGNOSES: Status post central cord syndrome and
cervical fixation, status post tracheostomy, status post PEG.
DISCHARGE MEDICATIONS: Tylenol 650 mg q.4-6h. p.r.n.,
albuterol nebs p.r.n., Colace 100 mg p.o. b.i.d., iron 325 mg
p.o. daily, fluticasone 110 mcg 2 puffs inhaler b.i.d., folic
acid 1 tablet p.o. daily, heparin subcutaneously 5,000 units
t.i.d., Prevacid 30 mg NG daily, Lopressor 12.5 mg p.o.
t.i.d., oxycodone elixir 5-10 mg p.o. q.4-6h. p.r.n.,
morphine 1-2 mg IV q.3-4h. p.r.n., miconazole powder 2%, one
application q.i.d. p.r.n., Milk of Magnesia 30 mg p.o. q.4-
6h. p.r.n., quetiapine 25 mg p.o. b.i.d. and 25 mg p.o.
b.i.d. p.r.n., senna 1 tablet p.o. b.i.d. p.r.n., sodium
chloride 1 g p.o. b.i.d., vancomycin 1 g q.12h. for 5 more
days, Regular insulin sliding scale. The patient is to
continue on her ProBalance tube feeds.
DISCHARGE INSTRUCTIONS: Please check laboratory values on
the patient including chemistries and CBC at the
rehabilitation facility. The patient will follow up with
Ophthalmology in [**3-18**] weeks as listed on [**Doctor First Name 18169**] 1. The patient
will follow up with Dr. [**Last Name (STitle) 363**] in Orthopedics Spine Clinic in
[**3-18**] weeks. The patient will follow up in __________ in [**3-18**]
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Name8 (MD) 368**]
MEDQUIST36
D: [**2117-11-2**] 11:53:30
T: [**2117-11-2**] 12:32:51
Job#: [**Job Number 63722**]
cc:[**Hospital3 63723**]
|
[
"V09.0",
"787.91",
"584.5",
"V45.81",
"801.21",
"482.41",
"518.81",
"802.0",
"401.9",
"870.8",
"952.08",
"348.4",
"722.4",
"E880.9",
"952.03",
"721.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.03",
"43.11",
"99.04",
"96.72",
"80.51",
"96.6",
"08.61",
"15.7",
"38.93",
"81.02",
"81.63",
"31.1",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3898, 3999
|
4023, 4737
|
1564, 3437
|
4762, 5444
|
692, 912
|
935, 1546
|
177, 522
|
545, 668
|
3462, 3876
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,091
| 139,211
|
24412
|
Discharge summary
|
report
|
Admission Date: [**2195-6-2**] Discharge Date: [**2195-7-3**]
Date of Birth: [**2121-2-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin / Bactrim
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mr. [**Known lastname 61807**] was found to have a 9.5cm ascending aortic aneurysm
and was refered to Dr. [**Last Name (STitle) **] for operative treatement
Major Surgical or Invasive Procedure:
s/p AVR w/23mm homograft and coronary reimplantation [**6-9**]
History of Present Illness:
Mr. [**Known lastname 61807**] was found to have a 9.5 cm ascending aortic
anneurysm on workup for abdominal pain.
Past Medical History:
chronic atrial fibrillation
renal insufficiency
h/o bilat LE cellulitis
chronic anemia
dwarfism
Paget's disease
h/o MI
s/p multiple dental extractions
Social History:
Mr. [**Known lastname 61807**] is retired and lives alone. He denies tobacco and
admits to rare alcohol
Pertinent Results:
[**2195-7-2**] 03:20AM BLOOD WBC-8.9 RBC-2.47* Hgb-7.6* Hct-24.2*
MCV-98 MCH-30.9 MCHC-31.5 RDW-17.2* Plt Ct-118*
[**2195-7-2**] 08:21AM BLOOD Hct-27.8*
[**2195-7-2**] 03:20AM BLOOD Plt Ct-118*
[**2195-7-2**] 03:20AM BLOOD PT-13.3 PTT-47.7* INR(PT)-1.2
[**2195-7-2**] 03:20AM BLOOD Glucose-106* UreaN-22* Creat-1.3* Na-135
K-4.5 Cl-100 HCO3-29 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 61807**] was admitted on [**2195-6-2**] for preoperative evaluation.
He was noted to have an elevated INR at 1.5, which was
consistent with previous data. A hematology consult was obtained
and it was decided that the patient had vitamin K deficiency and
there was no need for further intervention. His INR decreased
to 1.3 and he was taken to the operating room with Dr. [**Last Name (STitle) **]
on [**2195-6-9**] for AVR and replacement of his ascending aorta with
a 23mm aortic valve homograft with coronary reimplantation.
Please see operative note for full details. He was transferred
to the ICU in stable condition. He was slow to awake but was
following commands on POD#1, and was extubated on POD#2. He was
transferred to the regular floor on POD#3. He developed rapid
atrial fibrillation on POD#4. He was found to be hypoxic with
labored breathing. He was transferred back to the ICU and
required reintubation. Bronchoscopy showed copious secretions
which showed oropharyngeal flora. He was extubated on POD#6. A
pulmonary consult was obtained and it was recommended to use
intermittent BiPAP and diuresis. He underwent therapeutic
thoracentesis of the right chest on POD#8, and still required
intermittent BiPAP to maintain adequate ventilation. On POD# 9
he was noted to have a swollen left upper extremity and an
ultrasound showed thrombus in the left internal jugular and left
subclavian. He was started on heparin for anticoagulation. He
underwent thoracentesis of the left chest on POD#10. On POD#12
he was re intubated for worsening respiratory status and
respiratory acidosis with mental status changes. A neurology
consult was obtained and he had a CT scan and MRI which were
negative for any acute process, as well as an EEG which was
negative for any seizure activity, and showed mild diffuse
slowing consistent with encephalopathy. It was thought that the
mental status changes were due to metabolic encephalopathy, he
was started on Coumadin. On POD#15 a pulmonary medicine consult
was again obtained and it was recommended that the patient be
allowed to have a compensatory metabolic alkalosis, and continue
BiPAP and aggressive pulmonary toilet. He was again extubated
and required almost continuous BiPAP to maintain adequate
ventilation. It was determined that the patient would benefit
from a tracheostomy and he was electively re intubated prior to
the procedure and underwent percutaneous tracheostomy on POD#20.
Pulmonary medicine recommended continuing empiric antibiotics
for a presumed ventilator associated pneumonia. He was noted to
have a L inguinal hernia that was un reducible. A general
surgery consult was obtained and and it was decided that no
intervention was needed at this time. He was cleared for
discharge to rehab
Medications on Admission:
digoxin 0.125 qd
oxybutin 10mg qam, 5mg qpm
lasix 40mg [**Hospital1 **]
colace
allopurinol 100mg qd
protonix 40mg qd
lisinopril 2.5mg qd
toprol XL 25mg qd
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p replacement of ascending aortic anneurysm
CRI
anemia
dwarfism
paget's disease
respriatory failure
chronic atrial fibrillation
Discharge Condition:
good
Followup Instructions:
See Dr. [**Last Name (STitle) **] (Cardiac Surgery) in [**3-25**] weeks. ([**Telephone/Fax (1) 1504**]
See Dr. [**First Name (STitle) **] (General Surgery for hernia) in 2 weeks. ([**Telephone/Fax (1) 10248**]
See Dr. [**Last Name (STitle) 5456**] (PCP) within two weeks. [**Telephone/Fax (1) 34605**]
See Dr. [**Last Name (STitle) **] (Cardiology) within two weeks ([**Telephone/Fax (1) 5455**]
Completed by:[**2195-7-3**]
|
[
"997.3",
"428.0",
"486",
"790.92",
"426.4",
"276.2",
"285.29",
"V58.61",
"244.9",
"286.7",
"731.0",
"518.5",
"274.9",
"425.4",
"550.10",
"755.59",
"259.4",
"424.1",
"441.01",
"403.91",
"412",
"427.31",
"518.0",
"525.10",
"414.01",
"707.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"34.91",
"39.61",
"99.04",
"99.05",
"99.06",
"96.05",
"38.45",
"34.04",
"39.64",
"38.93",
"99.07",
"88.72",
"36.99",
"31.1",
"96.71",
"96.04",
"38.91",
"35.21",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
4353, 4424
|
1340, 4147
|
439, 503
|
4597, 4603
|
963, 1317
|
4626, 5053
|
4445, 4576
|
4173, 4330
|
243, 401
|
531, 647
|
669, 822
|
838, 944
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17
| 194,023
|
51782
|
Discharge summary
|
report
|
Admission Date: [**2134-12-27**] Discharge Date: [**2134-12-31**]
Date of Birth: [**2087-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Ampicillin / Remeron
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
History of stroke
Major Surgical or Invasive Procedure:
[**2134-12-27**] Minimally invasive closure of patent foramen ovale
History of Present Illness:
Mrs. [**Known lastname 11679**] is a 47 year old female who suffered a cerebellar
stroke in [**2134-3-9**]. Workup at that time revealed a patent
foramen ovale. She is currently followed by Dr.
[**Last Name (STitle) 1693**](neurologist) from the [**Hospital1 18**]. Full hypercoagulability
workup was unremarkable. Since [**Month (only) 956**], she has had no other
neurological events. In preperation for surgical intervention,
she underwent cardiac catheterization in [**Month (only) **] which showed
normal coronary arteries and normal left ventricular function.
Past Medical History:
Patent foramen ovale; History of Stroke/TIA; Depression;
Anxiety; Borderline Hyperlipidemia; Herniation of Cervical
Discs; Patella-Femoral Syndrome; s/p Bunionectomies
Social History:
Denies tobacco. Admits to occasional ETOH. She is an employee of
the [**Hospital1 18**] in the Neuro-Pysch Department. She is married with two
children. She denies IVDA and recreational drugs.
Family History:
Father underwent CABG at age 72. Cousin died of an MI at age 46.
Physical Exam:
Vitals: BP 114/68, HR 90, RR 14
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, no carotid bruits
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2134-12-31**] 06:15AM BLOOD WBC-6.6# RBC-2.98* Hgb-9.1* Hct-26.1*
MCV-88 MCH-30.6 MCHC-35.0 RDW-13.1 Plt Ct-192
[**2134-12-27**] 06:19PM BLOOD WBC-10.5 RBC-3.42*# Hgb-10.5*# Hct-30.0*
MCV-88 MCH-30.8 MCHC-35.2* RDW-12.6 Plt Ct-138*
[**2134-12-31**] 06:15AM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-140
K-5.1 Cl-106 HCO3-28 AnGap-11
[**2134-12-27**] 07:21PM BLOOD UreaN-11 Creat-0.8 Cl-112* HCO3-23
[**2134-12-31**] 06:15AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
Brief Hospital Course:
Mrs. [**Known lastname 11679**] was admitted and underwent surgical closure of her
patent foramen ovale. The operation was performed minimally
invasive and there were no complications. Following the
procedure, she was brought to the CSRU. She initially remained
hypotensive, requiring volume and Neosynephrine. Within 24
hours, she awoke neurologically intact and was extubated without
difficulty. By postoperative day two, she successfully weaned
from inotropic support. She maintained stable hemodynamics and
transferred to the floor. On telemetry, she remained mostly in a
normal sinus rhythm with brief periods of accelerated junctional
rhythm. She otherwise continued to make clinical improvements
and was cleared for discharge on postoperative day four. She
remained just on Aspirin therapy. Aggrenox was not resumed as
her PFO was surgically repaired. At discharge, her systolic
blood pressures were in the 100's with heart rate of 80-90. Her
room air saturations were 93% and she was ambulating without
difficulty. She had good pain control with Dilaudid and all
wounds were clean, dry and intact.
Medications on Admission:
Bupropion 150 [**Hospital1 **], Aggrenox qd, Centrum, Calcium, Erythromycin
eye gtts
Discharge Medications:
1. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. 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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Patent foramen ovale - s/p surgical closure; History of
Stroke/TIA; Depression; Anxiety; Borderline Hyperlipidemia;
Herniation of Cervical Discs; Patella-Femoral Syndrome; s/p
Bunionectomies
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**5-11**] weeks - call for appt,
[**Telephone/Fax (1) 170**]. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**3-11**] weeks - call for
appt. Local cardiologist, Dr. [**Last Name (STitle) 11255**] in [**3-11**] weeks - call for
appt
Completed by:[**2134-12-31**]
|
[
"V12.59",
"458.29",
"745.5",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.71",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4146, 4204
|
2336, 3443
|
317, 387
|
4439, 4446
|
1851, 2313
|
4765, 5112
|
1399, 1465
|
3578, 4123
|
4225, 4418
|
3469, 3555
|
4470, 4742
|
1480, 1832
|
260, 279
|
415, 982
|
1004, 1173
|
1189, 1383
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,717
| 149,962
|
24324
|
Discharge summary
|
report
|
Admission Date: [**2129-5-21**] Discharge Date: [**2129-5-29**]
Date of Birth: [**2106-6-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Patient status post high speed motor vehicle accident
Major Surgical or Invasive Procedure:
-Left Rib fracture with Pneumothorax s/p Chest Tube 7/2/5
-Splenectomy & right craniotomy for R sided subdural (7/2/5)
History of Present Illness:
21 year old female unrestrained rear seat passanger in a taxi
that was ejected from the vehicle. Asisted by EMS and transfer
to the Emergency Department at the [**Hospital1 1170**].
Past Medical History:
None
Social History:
Swim coach.
Family History:
Patient is one of six children, family very close.
Physical Exam:
Patient was brought to eh ER by EMS after MVA responsive. She
became unresponsive and was placed on Endotracheal Entubation.
Gen: unresponsive.
Neck: cervical collar.
Chest: clear to auscultation bilaterally.
Abdomen: soft, non tender, non distended. FAST ultrasound exam
with fluid in [**Location (un) 6813**] pouch.
Extremeties: good pulses, no deformities.
Pertinent Results:
[**2129-5-21**] 06:26PM HCT-26.8*
[**2129-5-21**] 06:26PM PT-14.8* PTT-30.2 INR(PT)-1.4
[**2129-5-21**] 03:18PM TYPE-ART PO2-208* PCO2-38 PH-7.38 TOTAL
CO2-23 BASE XS--1
[**2129-5-21**] 03:18PM LACTATE-3.9*
[**2129-5-21**] 03:07PM UREA N-11 CREAT-0.7 SODIUM-143 POTASSIUM-4.5
CHLORIDE-114* TOTAL CO2-21* ANION GAP-13
[**2129-5-21**] 03:07PM HCT-30.7*
[**2129-5-21**] 03:07PM PLT COUNT-92*
[**2129-5-21**] 03:07PM PT-14.4* PTT-30.5 INR(PT)-1.4
[**2129-5-21**] 12:25PM TYPE-ART PO2-194* PCO2-35 PH-7.40 TOTAL
CO2-22 BASE XS--1
[**2129-5-21**] 12:25PM GLUCOSE-155* K+-5.7*
[**2129-5-21**] 09:41AM TYPE-ART TIDAL VOL-650 PEEP-10 O2-50 PO2-239*
PCO2-36 PH-7.39 TOTAL CO2-23 BASE XS--2
[**2129-5-21**] 09:41AM LACTATE-4.7*
[**2129-5-21**] 09:30AM PHENYTOIN-11.3
[**2129-5-21**] 09:30AM WBC-12.0* RBC-4.27 HGB-12.9 HCT-37.0 MCV-87
MCH-30.2 MCHC-34.9 RDW-13.9
[**2129-5-21**] 09:30AM PLT COUNT-106*
[**2129-5-21**] 08:27AM LACTATE-4.8* NA+-139 K+-4.3 CL--111
[**2129-5-21**] 08:27AM HGB-12.5 calcHCT-38
[**2129-5-21**] 06:55AM PT-14.0* PTT-25.3 INR(PT)-1.3
[**2129-5-21**] 06:17AM GLUCOSE-145* LACTATE-3.6* NA+-138 K+-4.2
CL--112
[**2129-5-21**] 02:55AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2129-5-21**] 02:55AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2129-5-21**] 02:44AM PLT COUNT-262
Brief Hospital Course:
Patient went to SICU after splenectomy + Craniotomy with good
recovery. Transfer to the floor and follow up with Trauma
Surgery and Neuro Surgery. Had an episode of fever with negative
workout. Her diet was advanced and tolerated. She will be
schedule for Neurosurgery (closure) in two weeks.
Medications on Admission:
None
Discharge Medications:
1. Phenytoin 50 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain for 3 days.
4. Ketorolac Tromethamine 15 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for 3 days.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
-Lef rib fracture
-Slenic laceration (Splenectomy)
-Right Subdural Hematoma (Craniotomy)
-Non operative pelvic/acetabular fracture
Discharge Condition:
Stable, oriented, alert, tolerating diet, walking
Discharge Instructions:
1. Diet as tolerated.
2. Analgesic for pain control
3. Follow up with Neurosurgery Dr [**First Name (STitle) 23161**] [**Telephone/Fax (1) 61628**]
4. Follow up with Trauma Surgery Clinic
Followup Instructions:
1. Follow up with Dr [**Last Name (STitle) **] (Neuro surgery)
2. Follow up with Trauma Surgery Clinic ([**Doctor Last Name **] Splenectomy)
Completed by:[**2129-5-29**]
|
[
"807.01",
"851.81",
"805.6",
"997.3",
"E849.5",
"860.0",
"808.0",
"808.2",
"865.13",
"E812.1",
"518.0",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"01.31",
"02.12",
"96.72",
"38.93",
"34.04",
"41.5",
"01.18"
] |
icd9pcs
|
[
[
[]
]
] |
3606, 3676
|
2680, 2974
|
367, 488
|
3850, 3901
|
1219, 2657
|
4137, 4309
|
772, 824
|
3029, 3583
|
3697, 3829
|
3000, 3006
|
3925, 4114
|
839, 1200
|
274, 329
|
516, 699
|
721, 727
|
743, 756
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,404
| 183,519
|
41464
|
Discharge summary
|
report
|
Admission Date: [**2174-3-10**] Discharge Date: [**2174-3-13**]
Date of Birth: [**2111-9-3**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
L5 excision of mass
post operative anemia requiring transfusion
History of Present Illness:
Mr. [**Known lastname 90212**] is a 62-year-old gentleman with newly diagnosed renal
cell cancer first diagnosed in the [**Location (un) 3156**] (the pathology was
sent to our lab- no official report as of yet). Based on the
son's description, the patient is having probably clear cell
adenocarcinoma with metastasis in L5-S1. He was planning on
going to the NIH for phase I clinical trial with IL-15.
Past Medical History:
Past Oncologic History:
- 2 years ago suffered a mechanical fall and hurt his back and
recovered, then 1.5 years later developed left leg pain in a
similar manner. He saw a chiropractor initially in the [**Location (un) 3156**]
which did not help, so had a CT [**1-14**] which showed a mass at
L5-S1. He then had MRI and biopsy in the [**Location (un) 3156**] and per
records, it was a clear cell adenocarcinoma from this biopsy.
He then decided to travel to the US for a second opinion
.
Other Past Medical History:
None
Social History:
Smokes < 1ppd for 40 years, rare alcohol use. Originally from
the [**Location (un) 3156**], now staying with his son in [**Name (NI) 86**].
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T:98.6 BP: 161/ 82 HR:91 R 16 O2Sats 97% RA
Gen: WD/WN, comfortable, NAD. Conversant, Russian speaking, son
translates questions and directions for exam.
HEENT: Pupils:reactive EOMs intact
Neck: Supple.
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Motor:
IP Q H AT [**Last Name (un) 938**] G
L 5 5 4+ 5 3+ 5
Sensation: decreased sensation of dorsal aspect of left foot
sparing the heal, otherwise intact
Reflexes: Pa Ac
Right 2+ 1
Left 2+ 1
Babinski: Mute
Upon discharge:
Neurolgically intact without deficit
Ambulatory without assistance
Incision clean and dry
xxxxxx
Pertinent Results:
MRI:Large mass around posterior elements of L4/5 invading
spinal canal
CHEST (PORTABLE AP) Study Date of [**2174-3-11**] 4:54 AM
IMPRESSION:
AP chest compared to [**3-10**]:
Lungs clear. Heart size normal. No pleural effusion or evidence
of central
lymph node enlargement. Right jugular line ends centrally.
Mediastinum not
widened.
[**2174-3-13**] 05:25AM BLOOD Hct-26.2*
[**2174-3-12**] 04:40AM BLOOD Plt Ct-117*
[**2174-3-11**] 04:48AM BLOOD Glucose-133* UreaN-22* Creat-1.0 Na-140
K-3.9 Cl-106 HCO3-27 AnGap-11
Brief Hospital Course:
Pt was admitted electively to hospital, went to OR where under
general anesthesia underwent lumbar decompression of L5 mass.
He tolerated the procedure well, was extubated, transferred to
PACU and then floor. Diet and actvity were advanced. Pain
medication was transitioned to PO. He was transfused for
postoperative anemia and his JP drain was removed. He was
voiding without difficulty, ambulating in halls. Incision was
clean dry and intact.
Medications on Admission:
ALLERGIES: NKDA
Medications - Prescription
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s) by
mouth every 6 hours as needed for pain
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by
mouth every 6-8 hours as needed for pain
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain: do not drive hwile on this medication .
Disp:*60 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*2*
4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic renal cell carcinoma to lumbar spine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ remove dressing [**2174-3-12**] / begin daily showers [**2174-3-14**]
?????? If you have steri-strips in place ?????? 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, then increase as tolerated.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN 7 DAYS FOR REMOVAL OF YOUR
STAPLES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2174-3-13**]
|
[
"E878.8",
"336.3",
"198.5",
"998.11",
"729.5",
"305.1",
"199.1",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"80.99"
] |
icd9pcs
|
[
[
[]
]
] |
4200, 4206
|
2864, 3315
|
317, 383
|
4298, 4298
|
2318, 2841
|
5365, 5636
|
1538, 1542
|
3615, 4177
|
4227, 4277
|
3341, 3592
|
4449, 5342
|
1572, 1851
|
268, 279
|
2201, 2299
|
411, 815
|
4313, 4425
|
1356, 1363
|
1379, 1522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,258
| 136,201
|
14110
|
Discharge summary
|
report
|
Admission Date: [**2194-6-6**] Discharge Date: [**2194-6-18**]
Date of Birth: [**2143-3-25**] Sex: M
Service: Neurosurg
HISTORY OF PRESENT ILLNESS: The patient is a 51 year-old
gentleman found unresponsive at home. He was taken to
[**Hospital3 3834**] [**Hospital3 **] admitted to the ER to the ICU with
ETOH level of 380. While in the ICU at [**Hospital3 3834**] he
was being monitored neurologically. In late afternoon his
left pupil became 4mm and fixed, nonreactive. His right pupil
remained reactive. He had an emergency head CT scan which
showed it to be positive for a large left sided acute
subdural hematoma 1 to 2 cm extending along the left
hemisphere with marked midline shift and question of uncal
herniation.
The patient was transferred by [**Location (un) 7622**] to [**Hospital1 346**] and was given . On arrival to [**Hospital1 1444**] he was intubated and
essentially unresponsive to all stimuli except flicker of
withdraw of the left upper extremity to painful stimulation.
His left pupil was 4.5 mm and nonreactive. His right was 3.5
down to 2.5 and reactive. This was an extremely limited exam.
The patient was taken immediately to the operating room for
evacuation of his left subdural hematoma. The scan showed a
left acute subdural hematoma with 2 cm of Mannitol shift and
effacement of the lateral ventricle.
LABORATORY DATA ON ADMISSION: White count 4.4, platelet count
134,000, crit was 48.1. Sodium 136, potassium 3.8, chloride
90, CO2 20, BUN 11, creatinine 1.1, glucose 117.
The patient was taken emergently to the operating room and
have evacuation of the left subdural hematoma. There were no
intraoperative complications in postoperative. The patient
was monitored in the surgical Intensive Care Unit. He
responded to voice by opening his eyes. He followed simple
commands moving all extremities. He had fine tremor of his
right upper extremity. His pupils were 2 mm down to 1.5
bilaterally and reactive. His strength was full antigravity
strength throughout postoperative. He had a repeat head CT
scan the morning after surgery which showed good evacuation
of the subdural hematoma. The patient remained in the
surgical Intensive Care Unit until [**2194-6-13**] secondary to
three episodes of failed extubation secondary to aspiration
pneumonia.
The patient was finally extubated on [**2194-6-12**] and
transferred to the regular floor on [**2194-6-13**] in stable
condition. He was seen by Physical Therapy and Occupational
Therapy and found to require rehabilitation prior to
discharge to home.
Neurologically he was awake, alert and oriented times three.
He was moving all extremities strongly. His gait was still
somewhat unsteady requiring assistance when out of bed
ambulating.
DISCHARGE MEDICATIONS:
1. Zantac 150 mg po bid.
2. Thiamine 100 mg po q day.
3. Folic Acid 1 mg po q day.
4. Metoprolol 25 mg po tid.
5. Miconazole powder 2% topical tid prn.
6. Quinidine patch, one patch to skin change q Sunday.
7. Levofloxacin 500 mg po q 24 hours for his aspiration
pneumonia.
DISCHARGE CONDITION: The patient is in stable condition at
the time of discharge and will follow up with Dr. [**First Name (STitle) **] in one
months time with repeat head CT scan.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2194-6-18**] 10:22
T: [**2194-6-18**] 10:40
JOB#: [**Job Number 42050**]18255w
|
[
"507.0",
"431",
"997.3",
"401.9",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3071, 3516
|
2768, 3050
|
169, 1373
|
1387, 2745
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
639
| 166,626
|
51788
|
Discharge summary
|
report
|
Admission Date: [**2116-9-14**] Discharge Date: [**2116-9-19**]
Date of Birth: [**2063-1-19**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids / Bactrim Ds / Ceclor / Phenobarbital /
Dicloxacillin / Metoprolol / Linezolid / Ativan / Venomil Honey
Bee Venom
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
RLE pain and fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53y/o F w/ HTN, OSA, seizure d/o, and fibromyalgia who was
recently d/c from [**Hospital1 18**] after treatment for LE cellulitis who
was readmitted with complaints of RLE pain and fever. The
patient was d/c on [**9-1**] after a 5d admission for LE cellulitis.
She was d/c on vancomycin and completed a 14d course at home.
Following cessation of the antibiotic, she noted increased
swelling of her legs and worsening pain. She presented to her
PCP after several days and was restarted on vancomycin and then
switched to unasyn. With this regimen, her swelling has
improved but she still has RLE pain. She has also noted fevers
and chills over the past several days but denies any CP, SOB,
abdominal pain, HA, weakness, or paresthesias. She has not had
any cough, dysuria, or recent sick contacts. She denies any
diarrhea or trauma to the RLE. She has had some emesis over the
past several days w/out nausea and has been unable to keep down
her medications as a result. In the context of her recent LE
pain and antibiotic use, she has noticed the eruption of ~5
erythematous papules on her stomach and extremities. She
reports that they initially appeared raised but then broke and
now are scabbing over. They are painful, especially on her
abdomen.
.
In the ED, the patient was afebrile and was started on
vancomycin for a presumed diagnosis of cellulitis. While
waiting for w/u, she was noted to have a convulsive seizure.
Her phenytoin level was noted to be low and she was loaded
orally. Her WBC was flat and LENIs showed no evidence of RLE
DVT. She was given pain meds and admitted for treatment of
cellulitis.
Past Medical History:
1. HTN
2. DVT/PE in [**2092**]
3. Hypercholesterolemia
4. OSA
5. Hypothyroidism
6. Seizure d/o
7. Vulvar CA
8. Hx of a myomectomy
9. Fibromyalgia
Social History:
The pt lives by self but brother lives upstairs. She is a former
nurse, but is now on disability. She admitted to a 40 pack-year
smoking history. She denied use of alcohol or illicit drugs.
Family History:
NC
Physical Exam:
98.8, 128/70, 90, 18, 93%RA
Gen: Obese F lying in bed in NAD, pleasant
Heent: PERRLA, MMM, O/P erythematous, no cervical LAD but
habitus limits exam
CV: RRR, 2/6 SEM at the USB w/out radiation to the carotids
Lungs: Basilar crackles that clear w/ deep cough, expiratory
wheezes diffusely and distant breath sounds
Abd: Obese, soft, non-tender, +BS, -HSM, 0.5 cm erythematous
tender papule
Ext: No C/C, bilateral LE pitting edema, tender erythematous
papules on L hand and R 2nd toe, RLE tender from knee to foot,
very mild erythema of the RLE compared to LLE, distal pulses
intact in the RLE
Neuro: CN 2-12 intact, strength intact b/l, RLE strength limited
by pain, desquamation on R foot
Pertinent Results:
[**2116-9-14**] 08:30PM PLT COUNT-234
[**2116-9-14**] 08:30PM NEUTS-77.2* LYMPHS-14.4* MONOS-7.8 EOS-0.3
BASOS-0.1
[**2116-9-14**] 08:30PM WBC-9.1 RBC-4.58 HGB-13.9 HCT-40.7 MCV-89
MCH-30.3 MCHC-34.1 RDW-14.8
[**2116-9-14**] 08:30PM PHENYTOIN-<0.6*
[**2116-9-14**] 08:30PM CALCIUM-10.0 PHOSPHATE-4.3 MAGNESIUM-2.3
[**2116-9-14**] 08:30PM GLUCOSE-110* UREA N-21* CREAT-0.9 SODIUM-139
POTASSIUM-2.5* CHLORIDE-87* TOTAL CO2-36* ANION GAP-19
[**2116-9-14**] 08:50PM URINE RBC-[**1-26**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2116-9-14**] 08:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2116-9-14**] 08:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
discharge labs:
[**2116-9-18**] 04:00AM BLOOD WBC-5.3 RBC-3.59* Hgb-10.7* Hct-34.5*
MCV-96 MCH-29.8 MCHC-31.0 RDW-14.7 Plt Ct-142*
[**2116-9-14**] 08:30PM BLOOD Neuts-77.2* Lymphs-14.4* Monos-7.8
Eos-0.3 Baso-0.1
[**2116-9-17**] 05:55PM BLOOD PT-13.7* PTT-22.8 INR(PT)-1.2*
[**2116-9-18**] 04:00AM BLOOD Glucose-84 UreaN-24* Creat-0.8 Na-140
K-4.2 Cl-107 HCO3-22 AnGap-15
[**2116-9-17**] 05:30AM BLOOD ALT-21 AST-17 LD(LDH)-157 AlkPhos-92
TotBili-0.1
[**2116-9-17**] 05:30AM BLOOD ALT-21 AST-17 LD(LDH)-157 AlkPhos-92
TotBili-0.1
[**2116-9-18**] 04:00AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.3
[**2116-9-17**] 05:55PM BLOOD Phenyto-15.4 Phenyfr-1.3 %Phenyf-8
Brief Hospital Course:
53 HTN/OSA with seizure disorder admitted to medical service
with RLE pain and fever with hospital course complicated by
recurrent seizures and ICU stay for close monitoring.
# RLE pain: Pt with resolving cellulitis. Completed a complete
antibiotic course prior to admission. Exam not consistent with
cellulitis. LENI was without DVT. ABIs obtained which showed
normal lower extremity arterial hemodynamics at rest. pain
improved with elevation and pain medication. Pt maintained on
home narcotic regimen with occasional IV for breakthrough pain.
On time of discharge patient on outpt regimen of PO narcotics.
# Seizures: Convulsive activity in ED (which patient doesn't
recall) in the setting of subtherapeutic phenytoin level [**12-26**]
poor PO and N/V. Pt reloaded with dilantin but had several
breakthrough seizures during hospitalization. One morning had
three seizures within an hour for which Ativan was used to
break. Despite patient's intolerance to Ativan described as
difficulty with agitation and confusion, primary team thought it
was necessary to give in setting of presumed status. Pt
transferred to ICU for closer monitoring. During that period
had one repeat seizure while dilantin level reached therapuetic
range. EEG obtained without focal activity. Pt followed in
conjunction with neurology service who helped in managing
dilantin levels. Subsequent seizures broke with valium. Pt
dishcarged home on pre-admission regimen of dilantin and topamax
with instructions for close monitoring of blood levels and
adherence.
# DVT history: continued on coumadin
# Patient discharged to home from ICU after waiting several days
for a medical bed. She has instructions for close followup with
PCP regarding chronic pain and seizures.
Medications on Admission:
(per [**2116-8-26**] d/c):
1. Phenytoin 700mg qhs
4. Topiramate 100 mg [**Hospital1 **]
5. Ezetimibe 10 mg qd
6. Levothyroxine 50 mcg qd
7. Nexium 40 mg qd
8. Citalopram 20 mg qd
9. Warfarin 7.5 mg qd
10. Nystatin 5mL qid
11. Morphine 30-60mg q3-4h
Discharge Medications:
1. Mupirocin 2 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
[**Hospital1 **]:*1 tube* Refills:*0*
2. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Seven (7)
Capsule PO at bedtime.
[**Hospital1 **]:*210 Capsule(s)* Refills:*2*
4. Morphine 30 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4
Hours) as needed for pain.
[**Hospital1 **]:*48 Tablet(s)* Refills:*0*
5. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*030 Tablet(s)* Refills:*2*
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
check INR on [**9-21**] and have results called to PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2936**]
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Coumadin 2.5 mg Tablet Sig: 3-4 Tablets PO once a day:
alternating 7.5 and 10 mg as directed by your PCP.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2*
12. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
seizures
chronic pain
fibromyalgia
Discharge Condition:
good
Discharge Instructions:
please take all medications as prescribed. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s of your seizure medications. You have been given
prescription for 4 days of morphine. All refills need to be
made with your PCP.
Please call your PCP, [**Name10 (NameIs) **] [**Last Name (STitle) 3707**] with any concerns or CP, SOB,
F/C/S, seizures or worsening pain.
Followup Instructions:
please call Dr [**Last Name (STitle) 3707**] at [**Telephone/Fax (1) 2936**] and make an appointment
to be seen in [**11-25**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"401.9",
"305.1",
"V10.44",
"796.3",
"311",
"244.9",
"709.9",
"729.1",
"276.8",
"682.6",
"V12.51",
"780.57",
"272.4",
"345.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8215, 8253
|
4636, 6399
|
410, 417
|
8332, 8339
|
3197, 3958
|
8776, 9042
|
2469, 2473
|
6698, 8192
|
8274, 8311
|
6425, 6675
|
8363, 8753
|
3975, 4613
|
2488, 3178
|
352, 372
|
445, 2074
|
2096, 2244
|
2260, 2453
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,915
| 175,278
|
27497
|
Discharge summary
|
report
|
Admission Date: [**2159-5-2**] Discharge Date: [**2159-5-30**]
Date of Birth: [**2103-1-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt. is a 56 y/o w/ MMP including cirrhosis, chronic renal
insufficiency, diabetes who p/w mental status changes. History
per EMS report/daughter. Pt. w/ long h/o cirrhosis, unclear
baseline mental status. Recently pt. w/ gait instability. One
day prior to presentation, pt. flew from [**State 8842**] to here for
evaluation by liver transplant team at [**Hospital1 **]. On day of arrival to
MAss., but was talking, but seemed confused. Over the next 24
hours, pt. had nausea/vomiting, but continued to take insulin.
Pt. was unable to answer questions, not talking, seemed weak and
was having difficulty walking. Daughter unable to confirm if pt.
had complaints, but did note rigors in the a.m. and cough. Day
of admission - pt's daughter called EMS and pt. was taken to
[**Hospital3 **].
.
At OSH, pt. was tachycardic, but otherwise VSS. On evaluation,
he was intermittently following commands, not answering
questions. Pt. found to have ammonia for 236. Pt. given
lactulose. Pt. w/ FS at OSH was 66 (given D50). Pt. was also
given 2 L NS, thiamine and kayexalate(45 mg) for hyperkalemia.
Pt. was transferred to [**Hospital1 18**] for further liver evaluation.
.
In [**Name (NI) **], pt w/ mental status changes - oriented to person only.
Pt. was sleepy, but combatative. Concern for encephalopathy
given high ammonia level at OSH. Pt. was in need of infectious
w/u including extensive CT scans. Concern for sedating pt. w/ MS
changes and risking apneic arrest in [**Last Name (LF) **], [**First Name3 (LF) **] decision was made to
intubate patient for airway protection. Per report from ED
attending, pt. was oxygenating well w/ good sats at that point.
In [**Name (NI) **], pt. given vanco/levo/flagyl. Pt. hyperkalemic in ED -
given kayexalate, D50, calcium gluconate. Pt. w/ lactate of 3.0.
Past Medical History:
Cirrhosis - supposed to get liver transplant eval w/ liver at [**Hospital1 **]
Esophageal Varices
Renal Insufficiency(last (Cr 2.9)
Diabetes - insulin dependent
HTN
GERD
Gout
Alcoholism - quit last [**Month (only) **]
Hypercholesterolemia
Social History:
Alcoholism - quit last [**Month (only) **], married - lives in [**State 8842**] w/
daughter in [**Name2 (NI) **], retired fire chief
Family History:
mom - ovarian CA, dad stroke
Physical Exam:
Gen: encephalopathic, open eyes to commands but no other
response
Skin: warm, multiple bruises
HEENT: PERLA, ecchymosis along eye, sclera, anicteric, multiple
petechiae on hard palate
CV: RRR, loud S1/S2
Lungs: upper airway soundss
Abd: umbilical herniation (reducicble), caput medusea,
distended, soft, no rebound/guard, tympanic superiorly, fluid
wave, no HSM appreciated,
Ext: bruises, no c/c/e
Neuro: nl tone,
Pertinent Results:
[**2159-5-26**] 04:35AM BLOOD WBC-13.8* RBC-2.80* Hgb-9.4* Hct-29.8*
MCV-107* MCH-33.5* MCHC-31.5 RDW-24.5* Plt Ct-94*
[**2159-5-26**] 04:35AM BLOOD Plt Ct-94*
[**2159-5-26**] 04:35AM BLOOD PT-14.5* PTT-34.7 INR(PT)-1.3*
[**2159-5-26**] 04:35AM BLOOD Glucose-277* UreaN-54* Creat-4.4* Na-147*
K-3.8 Cl-111* HCO3-21* AnGap-19
[**2159-5-19**] 04:56AM BLOOD LD(LDH)-177 TotBili-2.1*
[**2159-5-19**] 04:56AM BLOOD LD(LDH)-177 TotBili-2.1*
[**2159-5-26**] 04:35AM BLOOD Calcium-9.9 Phos-4.9* Mg-2.1
[**2159-5-21**] 01:40PM BLOOD calTIBC-116* Ferritn-60 TRF-89*
[**2159-5-2**] 10:43PM BLOOD Ammonia-156*
[**2159-5-16**] 02:15AM BLOOD TSH-1.4
[**2159-5-16**] 02:15AM BLOOD Free T4-0.6*
[**2159-5-3**] 02:50PM BLOOD PTH-174*
[**2159-5-4**] 01:02PM BLOOD Cortsol-59.7*
[**2159-5-16**] 02:15AM BLOOD CEA-13* PSA-1.5
[**2159-5-17**] 10:45PM BLOOD Type-ART pO2-89 pCO2-30* pH-7.30*
calHCO3-15* Base XS--9
[**2159-5-16**] 11:56AM BLOOD Glucose-158*
[**2159-5-8**] 03:53AM BLOOD Lactate-1.5
[**2159-5-13**] 11:43AM BLOOD freeCa-1.23
Brief Hospital Course:
# Hepatic encephalopathy: MS changes from Cirrhosis and hepatic
encephalopathy aggravated by pneumonia. Condition became
progressively worse and then he was deemed not be a candidate
for liver transplant.
.
# Renal Failure: complicated w/ hyperkalemia. Most likely from
hepatorenal syndrome. Dialysis was performed intially but then
team decided to stop once it was decided to make him CMO.
.
# Diabetes - pt. w/ insulin dependent diabetes. Pt. w/
hypoglycemia in ED. Will monitor sugars and ISS for now
.
# Code Status: after extensive discussion between Dr.[**Last Name (STitle) 7033**] and
patient's wife and daughter, patient was made DNR/DNI and then
CMO. He passed away in the morning of [**2159-5-30**].
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
Hepatic failure from Cirrhosis
Renal Failure
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2159-5-30**]
|
[
"305.1",
"995.92",
"572.2",
"518.81",
"507.0",
"456.21",
"584.5",
"274.9",
"112.2",
"553.1",
"482.82",
"570",
"572.4",
"482.0",
"038.9",
"403.91",
"303.93",
"571.2",
"781.2",
"117.9",
"276.7",
"572.3",
"428.0",
"V58.67",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.95",
"96.6",
"99.07",
"39.95",
"99.04",
"54.91",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4895, 4904
|
4125, 4840
|
336, 348
|
4992, 5001
|
3082, 4102
|
5057, 5095
|
2602, 2632
|
4863, 4872
|
4925, 4971
|
5025, 5034
|
2647, 3063
|
275, 298
|
376, 2172
|
2194, 2436
|
2452, 2586
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,969
| 107,902
|
54247
|
Discharge summary
|
report
|
Admission Date: [**2121-11-3**] Discharge Date: [**2121-11-17**]
Date of Birth: [**2048-1-11**] Sex: F
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Incarcerated parastomal hernia.
DISCHARGE DIAGNOSES: Incarcerated parastomal hernia.
Status post reduction of hernia, re-siting of colostomy.
Aspiration pneumonia.
ETOH withdrawal.
Respiratory failure.
Status post tracheostomy.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
woman who has a history of parastomal hernias and has had
these hernias repaired times four or five. She now presents
with acute onset of abdominal distention, nausea and
vomiting, as well as a mass in the parastomal region.
PAST MEDICAL HISTORY: ETOH (one bottle of wine per day).
Hypertension.
Gastroesophageal reflux disease.
Hepatitis C.
Anxiety.
Depression.
Etiopathic splenomegaly.
Etiopathic thrombocytopenia.
Heparin induced thrombocytopenia negative.
PAST SURGICAL HISTORY: Status post [**Month (only) **].
Parastomal hernia repair times four or five.
Total abdominal hysterectomy.
Breast biopsy.
Cataract surgery.
MEDICATIONS AT HOME:
1. Aspirin 325 mg once daily.
2. Hydrochlorothiazide 25 mg once daily.
3. Zoloft 50 mg once daily.
4. Lisinopril 10 mg once daily.
5. Ibuprofen 600 mg once daily p.r.n.
6. Serax 15 mg t.i.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission, the patient is afebrile.
Vital signs are stable. Generally, she is in some distress.
Chest is clear to auscultation bilaterally. Cardiovascular is
regular rate and rhythm without murmur, rub or gallop.
Abdomen is soft, mildly distended and tender to palpation.
Tenderness is localized to the lower abdomen and more so in
the parastomal region. There is a large bulge around the
ostomy. Stoma itself is fairly pink and healthy. Extremities
are warm and well perfused with minimal edema.
HOSPITAL COURSE: The patient was admitted for repair of her
incarcerated parastomal hernia. She was taken to the
Operating Room on [**2121-11-3**] for reduction, as well as
colostomy re-siting into the left upper quadrant. For details
of this, please see the previously dictated operative note.
Postoperatively, the patient's course was complicated by what
was thought to be an aspiration event on the evening of
postoperative day number two. She had acute respiratory
distress, as well as change in mental status, which is
different from her baseline. She was maintained with Lasix
diuresis and face mask for approximately 8-12 hours but then
was subsequently intubated and transferred to the Intensive
Care Unit for worsening respiratory status. She was initially
only intubated for about 24 hours and met all criteria for
extubation. Chest x-ray did confirm that she had bilateral
upper zone infiltrates and the patient was empirically
treated with a seven day course of vancomycin and Levaquin.
After the patient met her respiratory extubation criteria,
she was extubated. She continued to do fairly well but had
change in mental status, which could not be attributed to
anything other than alcohol withdrawal. TSH, B-12 and folate
levels were checked, which were normal. CT scan of the head
was obtained on [**2121-11-10**], which did not show any evidence
of acute injury. There was some evidence of old lacunar
infarcts. MR of the head was completed on [**2121-11-12**], which
confirmed the above. In addition, the Neurology service was
consulted for her change in mental status and they felt it
was best attributed also to her alcohol withdrawal, as well
as withdrawal from her Serax. These were restarted per their
recommendations and the patient gradually improved some of
her mental status.
On [**2121-11-10**], the patient was re-intubated (postoperative
day number seven) for worsening respiratory status. She was
maintained and ventilated during this time and had a
bronchoscopy performed on [**2121-11-13**], which proved to be
negative for any significant pluggings or other bronchial
disease. The patient was extubated later that day on
[**2121-11-13**], but then quickly failed her extubation trial
within approximately six hours. She was emergently re-
intubated and there was seen to be a fair amount of tracheal
and laryngeal edema at that time. The decision was then made
to give the patient a surgical airway and percutaneous
tracheostomy was performed on [**2121-11-14**]. This was done in
accordance and consent with her son, who was the healthcare
proxy during her change in mental status.
Ultimately, the patient was discharged on postoperative day
number fourteen to a [**Hospital 4820**] rehabilitation facility for
ventilatory weaning, as well as allowing clearance of her
mental status. The Neurology service had seen the patient on
the day of discharge and agreed with the above and to
continue present management. The patient had a post-pyloric
feeding tube placed in Interventional Radiology on the day of
discharge in order to decrease the risk of aspiration
pneumonia. The patient was tolerating tube feeds adequate and
had good function with occasional tracheostomy mask trials
from the vent.
DISPOSITION: To [**Hospital 4820**] rehabilitation facility.
DIET: Tube feedings: Impact with fiber (or other
immunogenic tube feed formulation) at 75 cc/hr.
DISCHARGE MEDICATIONS:
1. Albuterol nebulizers q 6 hours p.r.n.
2. Lopressor 5 mg intravenously q 6 hours, hold for heart
rate less than 60 or systolic blood pressure of less than
100.
3. Zyprexa 5 mg p.o. or per nasogastric tube daily.
4. Roxicet elixir 5-10 cc p.o. or nasogastric tube q 4 hours
p.r.n. for pain.
5. Serax 15 mg p.o. or per nasogastric tube t.i.d.
6. Heparin 5,000 units subcutaneously t.i.d.
7. Dilaudid 0.5-2.0 mg intravenously or subcutaneously q 4
hours p.r.n. for pain.
8. Insulin sliding scale to cover blood sugars. This should
begin at 120 and advance every 40 points of a blood sugar.
The beginning scale should start at two and increase two
units of insulin per 40 points of blood sugar.
9. Atrovent nebulizers inhaled q 6 hours p.r.n.
10. Ativan 0.5-1.0 mg intravenously q 6 hours p.r.n.
11. Prevacid 30 mg per nasogastric tube q 24 hours.
12. Zoloft 100 mg p.o. or per nasogastric tube daily.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with Dr.
[**Last Name (STitle) **] in four weeks' time. The patient should continue
receiving tube feeds of an immunogenic formula at
approximately 75 cc/hour. The patient should continue all of
her medications as described above. In particular, it is
important to continue the Serax and give Ativan p.r.n. for
withdrawal symptoms. The patient should have ventilatory
weaning with tracheostomy mask trials everyday until the
patient can be weaned off of mechanical ventilation. The
patient should have ostomy care per standard protocol.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1286**], MD [**MD Number(1) 11126**]
Dictated By:[**Last Name (NamePattern1) 23688**]
MEDQUIST36
D: [**2121-11-17**] 14:48:09
T: [**2121-11-17**] 15:25:35
Job#: [**Job Number 111143**]
|
[
"E878.3",
"V45.61",
"292.0",
"303.91",
"070.54",
"304.10",
"V10.06",
"569.69",
"997.3",
"E879.8",
"507.0",
"518.5",
"V55.3",
"E939.4",
"552.8",
"291.0",
"401.9",
"276.3",
"530.81",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"31.1",
"46.42",
"96.71",
"96.6",
"96.04",
"96.72",
"38.93",
"33.24",
"99.15",
"45.79",
"54.59",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
232, 413
|
5309, 6247
|
1906, 5286
|
6272, 7117
|
1133, 1364
|
966, 1112
|
1387, 1888
|
177, 210
|
442, 697
|
720, 942
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,300
| 178,806
|
11169+11170
|
Discharge summary
|
report+report
|
Admission Date: [**2176-12-17**] Discharge Date: [**2176-12-23**]
Date of Birth: [**2125-8-4**] Sex: F
Service: SURGERY
Allergies:
Paxil
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Lt. lower extremity claudication and rest pain
Major Surgical or Invasive Procedure:
[**2176-12-17**]: Left femoral to dorsalis pedis bypass graft with
in-situ greater saphenous vein.
History of Present Illness:
51F admitted on [**2176-12-17**] for left femoral to dorsalis pedis
bypass
graft with in-situ greater saphenous vein.
History of: DM 2, HTN, CVA x 2, asthma, reflux, s/p renal artery
stent placement, s/p SFA stent L.
Past Medical History:
CVA X 2 on coumadin
Asthma
RAS
HTN
myofascial pain syndrome
Social History:
35 pack year smoking history, lives with boyfriend
Family History:
n/c
Physical Exam:
VS: 97.8, 70, 112/56, 16, 95%RA
ABD: soft, n-tender
Lungs: CTA
Incision: CDI
Pulses: graft palp, DP-pulse
Pertinent Results:
[**2176-12-23**] 05:35AM BLOOD WBC-7.4 RBC-3.66* Hgb-10.9* Hct-31.7*
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.5 Plt Ct-334
[**2176-12-23**] 05:35AM BLOOD Plt Ct-334
[**2176-12-23**] 05:35AM BLOOD Glucose-152* UreaN-10 Creat-0.6 Na-140
K-4.2 Cl-103 HCO3-26 AnGap-15
[**2176-12-23**] 05:35AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9
Brief Hospital Course:
[**2176-12-17**]: Admitted for left femoral to dorsalis pedis bypass
graft with in-situ greater saphenous vein. Uneventful
perioperative course. Extubated in the OR, and transferred to
PACU in stable condition.
[**2176-12-18**]: Low grade temp, using IS, palp graft and DP on left,
D/C a-line, advance diet, started heparin gtt for CVA hx.
[**2176-12-19**]: Temp 100, OOB, coumadin restarted. Palp graft and DP,
no hematoma. PCA changed to oral pain meds.
[**2176-12-20**]: Temp 98.1, Heparin gtt continued for ptt goal of 40.
OOB, daily dose of coumadin.
[**2176-12-21**]: afebrile, Heparin gtt adjusted to maintain ptt goal, PT
evaluation today.
[**2176-12-23**]: Stable, cleared by PT for home discharge.
Medications on Admission:
lopressor, glipizide, plavix, coumadin, flexeril, lipitor, asa,
albuterol, flonase, zestril, theophylline
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Theophylline 300 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO DAILY (Daily).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): Continue taking while taking narcotics for pain
relief to prevent constipation. .
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: do not exceed more than
4,000mg of tylenol in a 24 hour period.
Disp:*40 Tablet(s)* Refills:*0*
12. coumadin
Continue pre-hospital dose of coumadin, and follow up with
Primary care physican to adjust dose for a INR goal 2.0-3.0.
13. Coumadin 2 mg Tablet Sig: Three (3) Tablet PO once a day:
Take 3 tablets daily .
Disp:*90 Tablet(s)* Refills:*2*
14. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Flexeril 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
Disp:*14 Tablet(s)* Refills:*0*
16. Outpatient Lab Work
Have INR drawn weekly or as directed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 35967**].
He will continue to manage your anticoagulation.
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower extremity claudication s/p Left femoral to dorsalis
pedis bypass graft with in-situ greater saphenous vein on
[**2176-12-17**]
Discharge Condition:
Stable:
VS: 97.8,70,112/56,16, 95%RA
Labs:
Hct: 31.7
Plt: 152
Cr: 0.6
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Please call Dr.[**Name (NI) 7257**] office at ([**Telephone/Fax (1) 1798**] to schedule a
follow-up appointment in [**11-2**] days.
Completed by:[**2176-12-23**] Admission Date: [**2176-12-23**] Discharge Date: [**2176-12-26**]
Date of Birth: [**2125-8-4**] Sex: F
Service: SURGERY
Allergies:
Paxil
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Wound dehiscence
Major Surgical or Invasive Procedure:
Left fem-DP bypass graft wound closure w/nylon
History of Present Illness:
The patient is a 51 y/o female who is s/p left femoral to DP
bypass with in-situ greater saphenous vein who presents to the
ED with open wound over the bypass graft at the anterior portion
of her ankle. The patient was discharged home today after an
uneventful post-op course during which she was on a heparin drip
in order to bridge her anticoagulation to coumadin. This was
for her history of cerebral vascular accidents. She was
discharged with an INR of 2.2. The patient reports some initial
bleeding from the wound that had stopped by the time of
presentation.
Past Medical History:
Left femoral-DP bypass with in-situ greater saphenous vein
CVA X 2 on coumadin
Asthma
RAS
HTN
myofascial pain syndrome
Social History:
35 pack year smoking history, lives with boyfriend
Family History:
n/c
Physical Exam:
T 97.4 P 80 BP 103/47 R 16 SaO2 98%
Gen - no acute distress
Heent - neck supple, no cervical lymphadenopathy, no carotid
bruits
lungs - clear to auscultation bilaterally
heart - regular rate and rhythm
abd - soft, nontender, nondistended
extrem - R DP/PT 2+
L DP 2+, graft palpable, open wound at anterior aspect of Left
ankle
Pertinent Results:
[**2176-12-23**] 05:35AM BLOOD WBC-7.4 RBC-3.66* Hgb-10.9* Hct-31.7*
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.5 Plt Ct-334
[**2176-12-23**] 05:35AM BLOOD Glucose-152* UreaN-10 Creat-0.6 Na-140
K-4.2 Cl-103 HCO3-26 AnGap-15
[**2176-12-26**] 05:30AM BLOOD Vanco-14.7
Brief Hospital Course:
The patient presented to the ED and was seen in the waiting
area. She was promptly transferred to the OR for washout and
closure for dehiscence of her DP wound which she tolerated well.
She was started on Vancomycin, levaquin, and Flagyl
empirically. Her anticoagulation regimen consisted of aspirin,
plavix, and coumadin. The patient's activity was limited to
bedrest and her left lower extremity was elevated while in bed.
Routine pulse exams were done to ensure patency of the graft.
The wound was monitored for 3 days post-operatively and remained
stable. The patient was then discharged to home with vna
services for wound care in good condition, tolerating a regular
diet and with adequate pain control.
Medications on Admission:
1. Percocet 5/325 1-2 tablets q4-6hr prn pain
2. Metoprolol 50 mg PO BID
3. Lisinopril 30 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Warfarin 2 mg PO HS
7. Lipitor 20mg PO qHS
8. Glipizide 10 mg PO BID
9. Theophylline 300mg q12hr
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*28 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*42 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Theophylline 200 mg Tablet Sustained Release 12HR Sig: Two
(2) Tablet Sustained Release 12HR PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clopidogrel 75 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 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
51F s/p L. fem-DP BPG w/ISGSV for claudication [**12-17**], now
returns w/wound dehiscence s/p closure on this admission
Discharge Condition:
good
Discharge Instructions:
Keep left foot elevated at all times.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in 1 week.
F/u with PCP for dosing of coumadin.
|
[
"E849.8",
"998.32",
"530.81",
"401.9",
"250.00",
"305.1",
"E878.2",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
11537, 11608
|
9047, 9763
|
7520, 7569
|
11773, 11780
|
8766, 9024
|
11866, 11961
|
8395, 8400
|
10277, 11514
|
11629, 11752
|
9789, 10254
|
11804, 11843
|
6665, 7049
|
8415, 8747
|
7464, 7482
|
7597, 8168
|
8190, 8310
|
8326, 8379
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,859
| 144,207
|
38770
|
Discharge summary
|
report
|
Admission Date: [**2130-3-25**] Discharge Date: [**2130-4-28**]
Date of Birth: [**2050-8-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
-valvuloplasty
-intubation
-bronchoscopy
-thoracentesis
-PEG tube placement
-tracheostomy
History of Present Illness:
Mr. [**Name13 (STitle) **] is a 79-year-old male with with critical AS (valve
area <0.8cm2) recently evaluated by CT surgery for his aortic
stenosis and aortic dilatation, found to have a PNA requiring
recent hospitalization when he was treated with levofloxacin,
and subsequently discharged on [**2130-3-23**]. He presents on this
admission with worse dyspnea and weakness. He reports that he
has had stable dyspnea for past month, and on discharge on [**3-23**]
he felt "better." Then, only a day later on [**3-24**] the patient
felt fatigued, had no appetite, and developed a "drowning"
sensation when he couldn't cough up his phlegm. Otherwise he
denies chest pain, pressure, diaphoresis, night sweats, PND,
DOE, and endorses stable two pillow orthopnea. Denies melena,
hematemesis, dysuria, hematuria, nausea or vomiting .
In the ED, initial vs were: 97.8 119/46, 108, 28, 94% sat on 2L.
CXR showed worsening of left-sided pna. Patient was given IV
ceftriaxone, azithromycin, vancomycin and ASA 325mg in ED.
Initial labs were notable for lactate of 3.3, WBC 14, and Na
120. The patient's blood pressure dropped to 84/65 and he got
700 cc IVF (total incl abx) with and improvement in BP to 90/61
with heart rate of 102, RR 28 and oxygen satuations 99%4L. The
patient's case was discussed with CT surgery.
Past Medical History:
aortic stenosis, valve area <0.8cm2
ascending aortic aneurysm
atrial tachycardia
hyperlipidemia
gout
NIDDM (diet-controlled)
BPH
right 5th finger contracture
pernicious anemia
chronic diastolic heart failure
remote left rib fractures [**2-7**] a fall
mild pulmonary fibrosis
bilateral cataract extractions
Social History:
He is a retired attorney who lives with his wife. Independent
with ADLs.
- Tobacco: None.
- Alcohol: 2 drinks/day
- Illicits: None.
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM
Vitals: T: BP: 92/59 P: 96 R: 31 O2: 96% 4L
General: Alert, oriented, no acute distress but coughing
frequently
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 10cm, no cervical LAD
Lungs: Left basilar rales, rhonchi diffusely, right-sided
rhonchi halfway up
CV: Tachycardic, difficult to auscultate heart soudns d/t
coughing, ? II/VI systolic murmur at LUSB, no radiation to
carotids
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ pitting edema to
mid-shin
Neuro: A+Ox3, speech conversant, fluent, EOMI, PERRLA, CNII-XII
intact, strength symmetric, sensation intact, gait assessment
deferred.
Pertinent Results:
ADMISSION LABS:
[**2130-3-25**] 08:45PM LACTATE-2.0
[**2130-3-25**] 08:45PM O2 SAT-74
[**2130-3-25**] 05:22PM GLUCOSE-92 UREA N-41* CREAT-1.5* SODIUM-125*
POTASSIUM-4.6 CHLORIDE-88* TOTAL CO2-27 ANION GAP-15
[**2130-3-25**] 04:31PM LACTATE-2.2*
[**2130-3-25**] 04:31PM O2 SAT-60
[**2130-3-25**] 11:39AM TYPE-[**Last Name (un) **] PO2-36* PCO2-52* PH-7.39 TOTAL
CO2-33* BASE XS-4
[**2130-3-25**] 11:39AM LACTATE-2.3*
[**2130-3-25**] 11:24AM GLUCOSE-137* UREA N-41* CREAT-1.5*
SODIUM-124* POTASSIUM-4.5 CHLORIDE-86* TOTAL CO2-29 ANION GAP-14
[**2130-3-25**] 11:24AM ALT(SGPT)-965* AST(SGOT)-1337* ALK PHOS-175*
TOT BILI-1.0
[**2130-3-25**] 11:24AM ALBUMIN-2.8*
[**2130-3-25**] 09:37AM TYPE-ART PO2-37* PCO2-48* PH-7.40 TOTAL
CO2-31* BASE XS-3 INTUBATED-NOT INTUBA
[**2130-3-25**] 09:37AM LACTATE-3.2*
[**2130-3-25**] 07:12AM URINE HOURS-RANDOM UREA N-1115 CREAT-109
SODIUM-LESS THAN
[**2130-3-25**] 07:12AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2130-3-25**] 07:12AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2130-3-25**] 07:12AM URINE RBC-0-2 WBC-0 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2130-3-25**] 07:12AM URINE HYALINE-[**3-10**]*
[**2130-3-25**] 07:06AM GLUCOSE-224* UREA N-44* CREAT-1.6*
SODIUM-120* POTASSIUM-5.5* CHLORIDE-80* TOTAL CO2-24 ANION
GAP-22*
[**2130-3-25**] 07:06AM CALCIUM-8.4 PHOSPHATE-4.8* MAGNESIUM-2.3
[**2130-3-25**] 07:06AM OSMOLAL-282
[**2130-3-25**] 07:06AM HCT-37.9*
[**2130-3-25**] 05:31AM TYPE-ART PO2-151* PCO2-26* PH-7.54* TOTAL
CO2-23 BASE XS-1
[**2130-3-25**] 05:31AM LACTATE-6.5* NA+-114* K+-5.3
[**2130-3-25**] 01:39AM LACTATE-3.3*
[**2130-3-25**] 01:25AM GLUCOSE-149* UREA N-42* CREAT-1.4*
SODIUM-120* POTASSIUM-5.4* CHLORIDE-82* TOTAL CO2-25 ANION
GAP-18
[**2130-3-25**] 01:25AM CK(CPK)-50
[**2130-3-25**] 01:25AM WBC-14.5* RBC-4.05* HGB-13.1* HCT-39.3*
MCV-97 MCH-32.3* MCHC-33.3 RDW-14.4
[**2130-3-25**] 01:25AM NEUTS-83.2* LYMPHS-9.3* MONOS-6.6 EOS-0.5
BASOS-0.4
[**2130-3-25**] 01:25AM PLT COUNT-287
.
ENDOCRINE LABS:
[**2130-4-13**] 06:54PM BLOOD TSH-2.9
[**2130-4-27**] 04:01AM BLOOD Cortsol-25.6*
.
MICRO:
[**2130-3-25**] Urine Legionella: negative
[**2130-3-25**] Blood cx: negative
[**2130-3-29**] Sputum cx:
GRAM STAIN (Final [**2130-3-29**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2130-3-31**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2130-4-10**] 12:04 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
**FINAL REPORT [**2130-4-24**]**
GRAM STAIN (Final [**2130-4-10**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2130-4-12**]):
Commensal Respiratory Flora Absent.
YEAST. ~[**2120**]/ML.
LEGIONELLA CULTURE (Final [**2130-4-17**]): NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2130-4-10**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2130-4-24**]): YEAST.
.
[**2130-4-14**] 3:54 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2130-4-14**]):
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 [**2130-4-17**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2130-4-20**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
[**2130-4-18**] 6:40 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2130-5-1**]**
GRAM STAIN (Final [**2130-4-18**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2130-4-20**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
LEGIONELLA CULTURE (Final [**2130-4-25**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Final [**2130-5-1**]): YEAST.
.
[**2130-4-24**] 12:32 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2130-4-26**]**
GRAM STAIN (Final [**2130-4-24**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2130-4-26**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
BLOOD CULTURES:
[**4-22**] x 2 negative
[**4-18**] x 2 negative
[**4-17**] x 2 negative
[**4-14**] x 1 negative
[**4-13**] x 2 negative
[**4-11**] x 2 negative
[**4-9**] x 2 negative
[**4-7**] x 1 negative
[**3-25**] x 2 negative
.
[**2130-4-14**] 4:21 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Source:
Line-CVL.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
C.DIFFICILE TESTING:
[**4-2**] - negative
[**4-3**]- negative
[**4-6**] - negative
[**4-17**] - negative
.
PATHOLOGY:
[**2130-3-29**] SPUTUM CYTOLOGY: Atypical
[**2130-4-14**] Pleural Fluid Cytology negative for any malignant cells
.
IMAGING:
[**2130-3-25**] CXR: Progressive opacification of the right lung most
likely due to asymmetric pulmomary edema; however, infection
cannot be excluded. Persistent right lung opacity concerning for
infection.Given the rapid progression of left lung findings,
consider chest CT for further evaluation.
.
[**2130-3-31**] CXR: Extensive consolidation persists in the lower
two-thirds of the left lung. Right upper and lower lobe
opacities are also present. Mild
pulmonary edema and moderate bilateral pleural effusions are
unchanged.
Multiple old left rib fractures are noted. Multifocal
pneumonia, stable vascular congestion.
[**2130-4-7**] CXR:
Extensive consolidation persists in the lower two-thirds of the
left lung. Right upper and lower lobe opacities are slightly
improved. Mild pulmonary edema and small bilateral layering
effusions persist. The cardiomediastinal silhouette is normal.
Multiple old left rib fractures are noted.
.
[**2130-4-18**] CT CHEST/ABD IMPRESSION:
1. Interval worsening of multifocal airspace opacities, most
prominent within the left lung and right middle lobe. No abscess
collection is noted; however, no IV contrast has been
administered.
2. Unchanged moderate-to-severe right and small left pleural
effusion.
3. Unchanged dilated ascending aorta measuring 5 cm.
.
[**2130-4-20**] Dobutamine Stress ECHO /TTE:
IMPRESSION: No significant ST segment changes with appropriate
augmentation of HR.
.
[**4-21**] TTE: There is severe aortic valve stenosis (valve area
0.8-1.0cm2, mean gradient 35 mmHg). Mild to moderate ([**1-7**]+)
aortic regurgitation is seen. Moderate (2+) mitral regurgitation
is seen. Moderate [2+] tricuspid regurgitation is seen. There is
no pericardial effusion. Residual severe aortic stenosis (<1.0
cm2) with a small but significant decrease in mean transvalvular
gradient. Mild to moderate aortic regurgitation. Moderate mitral
and tricuspid regurgitation. Compared with the prior study
(images reviewed) of [**2130-4-21**], aortic stenosis severity has
been reduced slightly.
.
[**2130-4-27**] CXR: As compared to the previous radiograph, there is no
relevant
change. Unchanged monitoring and support devices. Unchanged
massive
bilateral parenchymal opacities and consolidations, largely with
air
bronchograms, unchanged extent of the pre-existing bilateral
pleural
effusions. Decreased volume of the left hemithorax, the visible
parts of the cardiac silhouette are unchanged.
.
[**4-21**] RIGHT SIDED CARDIAC CATH:
COMMENTS:
1. Limited resting hemodynamics revealed critical aortic
stenosis with a
calculated valve area of 0.5mm2. There were elevated left and
right
sided filling pressures with a PCWP of 25 and RVEDP of 15. The
central
aortic pressure was low at 87/57 with a mean of 70mmHg.
2. Successful aortic balloon valvuloplasty using a 22mm x 5cm
and a 23mm
x 6cm Tyshak II and Tyshak X balloon respectively.
3. Following aortic balloon valvuloplasty, the calculated valve
area
improved to 0.91mm2. (see PTCA comments for details)
FINAL DIAGNOSIS:
1. Critical aortic stenosis.
2. Elevated left and right sided filling pressures.
3. Successful aortic balloon valvuloplasty x 3.
LABS FROM [**2130-4-28**]:
[**2130-4-28**] 12:20AM BLOOD WBC-11.7* RBC-2.34* Hgb-8.3* Hct-25.4*
MCV-109* MCH-35.3* MCHC-32.5 RDW-23.2* Plt Ct-80*
[**2130-4-28**] 12:20AM BLOOD Glucose-159* UreaN-41* Creat-0.9 Na-143
K-4.1 Cl-104 HCO3-36* AnGap-7*
[**2130-4-27**] 04:01AM BLOOD ALT-26 AST-86* AlkPhos-71 TotBili-2.4*
.
Brief Hospital Course:
79 year old man with critical aortic stenosis, SVT, congestive
heart failure and questionable HIT who was admitted for hospital
acquired pneumonia complicated by multifactorial respiratory
failure. Patient required prolonged course of intubation and
pressors for septic physiology. Patient was too ill for full AVR
surgery but underwent valvuloplasty. Please see below for brief
hospital course and ICU stay summary prior to patient's death
after being transitioned to CMO status on [**2130-4-28**].
.
# Respiratory failure /Pneumonia: Patient had a prolonged course
on ventilator with inability to wean in the setting of
refractory pneumonia, and fluid overload with refilling
effusions even after thoracentesis. Additionally, patient's
respiratory status was also challenged by his severe hypotension
requiring pressors and his severe aortic stenosis. Chest x-ray,
respiratory distress and leukocytosis were consistent with HAP
early in Mr. [**Name13 (STitle) 31341**] hospital course. Patient completed a 10
day course of Vancomycin/Zosyn for HAP in the ICU. Sputum
cultures, urine legionella, and blood cultures remained
negative. Patient required guaifenesin/codiene for cough
suppression. Later on in ICU admission he required intubation
due to respiratory distress which was felt partially related to
recurrent HAP. Meropenem and Vancomycin were started at this
time and Ciprofloxicin was added for a brief period but then
discontinued. He continued to spike fevers so Flagyl was added
for better anaerobic coverage on [**2130-4-16**]. Notably, radiology
report recommended follow up CT to evaluate for any underlying
lesions to predispose patient to recurrent pneumonia. [**2130-4-18**]
chest CT showed interval worsening of multifocal airspace
opacities, most prominent within the left lung and right middle
lobe. No abscess collections were seen but he continued to have
moderate-to-severe right and small left pleural effusion. Unable
to wean patient to pressure support despite numerous trials over
the last days of his ICU stay. He was given additional small
amounts of morphine and Ativan during several PS trials as he
seemed to be quite agitated but these did not prove to help. He
remained mainly on assist control ventilation over the end of
his ICU course and family decided to officially make patient
CMO on [**4-28**] and he was extubated several minutes before his
death on [**4-28**].
.
# Hypotension: In setting of active infection, etiology was
initially felt to be related to septic physiology. Patient's low
ejection fraction and critical aortic stenosis were also
contibutors to baseline low blood pressures. Patient initially
required levophed and fluids to maintain MAPs > 60. Pressors
were were weaned off. With adequate control of his heart rate
he was able to maintain MAPs >55-60. However, later in ICU
course he was again pressor dependent and tried on both
neosynephrine and levophed at variable times. He remained
pressor dependent up until he was changed to CMO status.
Cortisol levels were tested and were not indicative of
suppressed adrenal response. He often required small IVF boluses
in setting of atrial tachycardia /atrial fibrillation flare-ups
or when lasix diuresis tended to be too aggressive.
.
# Critical aortic stenosis/systolic CHF: The patient has
critical AS by valve area 0.8cm2 and a mean gradient of 23. Most
recent EF 20-25%. CHF was managed with variable amounts of Lasix
based on patient's CVP, urine output measures and blood pressure
fluctuations on pressors. Patient was previously scheduled for
aortic valve replacement for [**2130-4-4**]. Due to PNA and positive
HIT antibody surgery opted to hold off on his procedure. In the
interim, cardiology opted to perform a valvuloplasty which
patient underwent on [**4-21**] with no immediate complications, his
valve area increased two-fold from about .5 to .91cm2 in size.
Ultimately, CT surgery stated that patient would not be an
adequate candidate for AVR until he was no longer ventilator
dependent and it was clear after several weeks, and after
eventual tracheostomy that he could not come off the ventilator
successfully. As above, patient's family decided to make him CMO
and patient was extubated and passed away minutes later on [**4-28**].
.
# Atrial tachycardia: Patient intermittently entered atrial
tachycardia during his ICU admission. Patient's decreased heart
function would not tolerate heart rates greater than 120 and he
would subsequently have flash pulmonary edema neccessitating
additional lasix. Beta blockers were initiated and metoprolol
was titrated up to 37.5 mg po TID for rate control initially. He
had some additional atrial fibrillation with RVR later in ICU
course and he was given amiodarone drip /bolus for better
control which was effective. Beta blocker was decreased in
setting of increased pressor use but reintroduced later in his
ICU stay after amiodarone was stopped due to concerns for
worsening of his pre-existing mild pulmonary fibrosis.
.
# Possible HIT: Platelets were decreased by 50% over first two
weeks of admission. HIT Ab test positive multiple times but SRA
was negative. Hematology-Oncology consulted and recommended
agatroban, which was stopped after 24 hrs due to elevation of
LFTs, followed by lepirudin briefly and this was also stopped.
Later in hospital course he was given large amount of heparin
for valvuloplasty and right sided heart catheterization
procedure and he had a drop again in his platelets and
PT/PTT/INR all spiked as well. This lab pattern seemed
indicative of HIT again so he was briefly started on argatroban
but hematology service felt this was not needed and still
questioned a true HIT diagnosis so argatroban stopped and all
heparin products were held again towards the end of his ICU
course.
.
# Elevated LFTs: Patient had significant elevation in his LFTs
on presentation which was likely due to hypoperfusion given
septic presentation. LFTs were trending down until [**2130-4-4**] when
they began to rise again but again trended down toward end ICU
course.
.
# ARF: Cr 1.5, baseline 1.0, up to 1.2 prior to recent discharge
from the cardiac surgery service. Briefly returned to baseline
during ICU as his hemodynamics improved. Increased creatinine
which fluctuated was likely due to poor forward flow given low
ejection fraction and depressed cardiac output. Over last few
days in ICU he had markedly better renal function with Cr near
baseline at .9-1.0 ranges and adequate urine output on pressors
and lasix.
.
Medications on Admission:
Aspirin 81 mg once a day
Allopurinol 300 mg once a day
Furosemide 20 mg once a day
Levofloxacin 750 mg Daily
Fluticasone 50 mcg/Actuation Disk Once Daily
Metoprolol Tartrate 25 mg Tab Three times daily
Cyanocobalamin 1,000 mcg Daily
Dextromethorphan-Guaifenesin
Discharge Medications:
patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
patient deceased, passed away in ICU on [**4-28**]
Discharge Condition:
patient deceased, passed away in ICU on [**4-28**]
Discharge Instructions:
patient deceased, passed away in ICU on [**4-28**]
Followup Instructions:
patient deceased, passed away in ICU on [**4-28**]
Completed by:[**2130-5-2**]
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22,626
| 159,787
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13676
|
Discharge summary
|
report
|
Admission Date: [**2197-7-29**] Discharge Date: [**2197-8-7**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Chest pain, elevated INR, transfer for concern for tamponade
.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 yo female with history of diastolic CHF, a fib on coumadin,
hypertension, TIA and CVA in [**2192**], chronic kidney disease with
baseline creatinine of 1.3 who is transferred here from [**Hospital1 **]
[**Location (un) 620**] with concern for tamponade.
.
Pt presented initially [**7-28**] to [**Hospital 197**] clinic and was found to
have an INR of 7.1. She reported increasing weakness,
intermittent substernal chest pressure in certain positions and
intermittent shortness of breath so was referred to the
hospital. She denied any associated diaphoresis, no radiation,
no palpitations and stated that only exacerbating factors were
moving in certain positions. She denies any recent fevers,
cough, N/V, no diarrhea or constipation, though she does state
that she has some blood in her stool yesterday. No dysuria or
recent hematuria, no recent falls.
.
At [**Name (NI) 620**], pt was noted to have elevated creatinine to 3.4 from
baseline 1.3. She also had trop increase to 0.048. She had an
elevated BNP to 4752 (though may be her baseline) and there was
concern that she symptoms of DOE were secondary to volume
overload so she was diuresed with lasix 40 mg IV, at least once,
despite BP 87/70. She also received her home dose of clonidine.
Her CXR showed possible worse cardiomegaly. Her creatinine
continued to rise with diuresis to 3.6. Renal and cardiology
were consulted who both felt that her continued increase in
creatinine was likely secondary to over diuresis.
Yesterday evening, pt developed worsening hypotension with SBP
80s for which she received 500 cc NS bolus x 2 with increase in
SBP to 100s transiently, then decreased. With fluid boluses also
came hypoxia requiring 3L oxgyen. She was started on norepi and
a pulsus checked then was reportedly 20 mmHg. She was started
on vanc, ceftriaxone and zosyn as well. At that time, echo was
performed by the ED staff and showed a moderate pericardial
effusion. The patient was then transferred to the [**Hospital1 18**] CCU for
further management. She received vitamin K and FFP prior to
transfer.
.
In the CCU, pt reports chest pain when turning, asymptomatic at
rest, breathing comfortably. She is very tired. Initially she
was confused and thought she was in a parking garage. She
eventually cleared and was able to identify [**Hospital1 **] [**Location (un) 86**].
Past Medical History:
Cardiac Risk Factors: Hypertension with Renal artery stenosis
.
Percutaneous coronary intervention, in [**4-12**] anatomy as follows:
prox LAD 50%, D1 60% on cath
.
Other Past History:
1. CAD (prox LAD 50%, D1 60% on cath [**4-12**])
2. Hypercholesterolemia
3. TIA/CVA [**1-18**] (neg carotid US)
4. GERD
5. esophageal stricture (solid dysphagia) s/p dilation ([**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
at [**Hospital1 18**] [**Location (un) 620**])
6. hypothyroidism
7. post-herpetic neuraligia
8. C4-5 spinal stenosis
9. s/p bilateral RA stenting [**4-12**]
10. s/p TAH-BSO @ 52yo
11. s/p appy @ 16yo
Social History:
Social history is significant for the absence of current or past
tobacco use, though her deceased husband was a heavy smoker.
There is no history of alcohol abuse. She lives with her son who
works for the [**Name (NI) 2318**]. She used to work in quality control. Her
husband passed away 15 years ago.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her mother died of an MI at 67 and her father
died of an MI at an unknown age.
Physical Exam:
VS: T= 98 BP=121/71 HR= 85 RR= 18 O2 sat= 96%
GENERAL: pale appearing woman in NAD. Oriented x2-3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
dry mucous membranes
NECK: Supple with JVP of 10 cm.
CARDIAC: irregularly irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. decreased
breath sounds over L>R base
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/trace edema. 2+ DP pulses
Discharge PE:
Vitals - Tm/Tc:99/98.7 HR:85-91 BP:143-151/82-92 RR:18-20 02
sat: 95% 4L
In/Out:
Last 24H:1200/2155
Last 8H:100/400
Weight: 65.5(66.3)
GENERAL: pale appearing woman in NAD. Oriented x2-3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
dry mucous membranes
NECK: Supple with JVP of 10 cm.
CARDIAC: irregularly irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. Fine b/l
crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/trace edema. 2+ DP pulses
Pertinent Results:
Admission:
[**2197-7-29**] 03:25PM GLUCOSE-83 UREA N-76* CREAT-2.9* SODIUM-136
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16
[**2197-7-29**] 03:25PM CALCIUM-8.2* PHOSPHATE-5.4* MAGNESIUM-2.3
[**2197-7-29**] 03:25PM [**Doctor First Name **]-POSITIVE * TITER-1:40
[**2197-7-29**] 05:23AM URINE RBC->182* WBC-96* BACTERIA-MOD
YEAST-NONE EPI-0
[**2197-7-29**] 04:32AM CK-MB-3 cTropnT-0.03*
.
Discharged Labs:
[**2197-8-7**] 09:00AM BLOOD WBC-9.0 RBC-4.31 Hgb-12.0 Hct-37.7 MCV-87
MCH-27.8 MCHC-31.8 RDW-14.9 Plt Ct-266
[**2197-8-7**] 09:00AM BLOOD PT-21.0* INR(PT)-2.0*
[**2197-8-7**] 09:00AM BLOOD Glucose-90 UreaN-32* Creat-1.5* Na-139
K-4.2 Cl-100 HCO3-30 AnGap-13
[**2197-8-7**] 09:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.3
[**2197-7-29**] 03:25PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40
.
Head CT:FINDINGS: There is no evidence of hemorrhage, edema,
mass effect, or infarction. Prominent ventricles and sulci
suggest age-related atrophy. Periventricular white matter
hypodensities are consistent with chronic small vessel ischemic
disease. There is a small hypodensity in the left occipital
lobe consistent with encephalomalacia from an old infarct. It
is stable from previous exam. The basal cisterns appear patent
and there is preservation of [**Doctor Last Name 352**]-white differentiation.
No fracture is identified. There is fluid in the left sphenoid
sinus. The remaining visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear. The globes are
unremarkable.
CONCLUSION:
No evidence of acute intracranial process.
.
C-Spine:
FINDINGS: There is anterolisthesis of C3 on C4 and
retrolisthesis of C4 on C5 with extensive degenerative changes
at both levels. There is fusion of the left facet joint at
C3-4. These findings suggest that the subluxations are due to
degenerative disk disease. There is mild canal narrowing at C5.
There is no evidence of a fracture. CT is not able to provide
intrathecal detail comparable to MRI, but visualized outline of
the thecal sac appears unremarkable. No lymphadenopathy is
present by CT size criteria. Vascular calcifications are noted
at the aortic arch and in the carotid bifurcations bilaterally.
There are bilateral pleural effusions, larger on the left than
right.
IMPRESSION:
1. No evidence of fracture. Subluxation involving C4 appears
chronic. No
other alignment abnormalities detected.
2. Multilevel degenerative changes of the cervical spine.
3. Bilateral pleural effusions.
TTE: [**2197-8-7**]:
Left ventricular wall thicknesses and cavity size are normal.
There is moderate global left ventricular hypokinesis. The
estimated pulmonary artery systolic pressure is normal. There is
a small to moderate sized circumferential pericardial effusion
which is echo dense, consistent with blood, inflammation or
other cellular elements [**Last Name (un) **] stranding c/w organization. There
are no echocardiographic signs of tamponade or constriction.
.
IMPRESSION: Small to moderate circumferential pericardial
effusion c/w organiziation/blood-inflammation as described
above.
.
Compared with the prior study (images reviewed) of [**2197-7-31**],
the pericardial effusion is smaller and more intense
organization is suggested. Left ventricular systolic function is
more depressed (global).
Brief Hospital Course:
89 yo female with hx of diastolic CHF, CKD with baseline cr 1.3
admitted with supratherapeutic INR, [**Last Name (un) **] and pericardial
effusion.
# Pericardial effusion: Pt was orginally admitted to [**Hospital1 **] [**Location (un) 620**]
and transferred to [**Hospital1 18**] with concern for tamponade physiology.
Bedside TTE on admission showed moderate to large loculated
pericardial effusion with no signs of tamponade. On admission
she was hypotensive (though in the setting of diuresis), was
tachycardia (with atrial fibrillation) with mildl pulsus
paradoxus of 14-16. Loculated nature of effusions suggested
subacute nature. Differential Dx included inflammation from
recent pneumonia, viral pericarditis, drug induced lupus
secondary to hydralazine, but also considered possible uremic
pericarditis in setting of [**Last Name (un) **], though less likely given timing.
Supratherapeutic INR may have exacerbated pericardial effusion.
[**First Name8 (NamePattern2) 6**] [**Doctor First Name **] was (+) but at low titers. Pt continued to remain
hemodynamically stable and pressures improved with IV fluids.
Her home antihypertensives were held and reintroduced bp
returned to baseline (SBP 130-140. Given the loculated nature of
effusion and her hemodynamic stability, pericaridal effusion was
not drained. She had repeat TTE on the day of discharge which
showed the pericardial effusion to be decreasing. She will
follow up with her cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] who will get a
repeat TTE in two weeks to reassess the pericardial effusion.
.
# Atrial fibrillation: Patient has a hx of afib and presented
with a supratheraputic INR to 7.1 and received Vit K and FFP.
Patient was rate controlled with both metoprolol and verapamil
with HR. Patient was considered to ba a poor candidate for
coumdain therefore she was transtioned to rivaroxiban 15mg
daily.
.
# Hypotension: Initially patient presented with hypotension
likely secondary to over diuresis. Had been treated with vanc,
zosyn, ceftriaxone at OSH though no clear indication that she
was infected. Her abx were stopped at [**Hospital1 18**] and she contined to
be afebrile. Her antihypertensives were held on admission and
decision was made to hold [**Last Name (un) **] and hydralazine on discharge as it
is believed hypotension is a greater risk to the patient at this
time. Her blood pressure during rest of admission continued to
be in the 130s systoilics.
.
#Hypoxemia: Patient continued to have sat int he 90s during the
day however at night patient would have drop her sat which would
recover after wakening the patient likely clinically
insignificant.
.
# [**Last Name (un) **]: Creatinine elevated to 3.6 from baseline 1.3 on
admission. Most likely secondary to poor flow secondary over
diuresis. Cr normalized with IVF.
.
# Diastolic CHF: On admission, patient did not have signs of
fluid overload and appeared dry on exam. Diuresis was held for
several days and was restarted when patient had decreased 02
sats and cxr consistent with pulmonary edema. Pt needs daily
weights. She will continue lasix 40mg daily lasix.
.
# HTN: Pt was hypotensive on admission secondary to pericardial
effusion and over diuresis. Metoprolol and verapamil restarted
during admission. [**Last Name (un) **] and hydralazine held on discharge.
.
# Hematuria: Unclear if secondary to elevated INR vs other
underlying process. Resolved on admission. Follow up with outpt
PCP for further evaluation.
Transitions of Care:
1. Pt'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and Hydralzine are being held on discharge over
concern for hypotension
2. Pt's anticoagulation transitioned to rivaroxiban on discharge
3. Pt instructed to report further hematuria to PCP and consider
additional work up if further episodes.
4.Full Code
5. Pt will follow up with cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] who will
get a repeat TTE to assess for pericardial effusion in two
weeks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/CaregiverPharmacy.
1. Atorvastatin 10 mg PO DAILY
2. CloniDINE 0.2 mg PO BID
3. Furosemide 40 mg PO BID
4. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral daily
5. Verapamil SR 240 mg PO Q24H
6. Warfarin 2.5 mg PO DAILY16
alternating with 5mg daily
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Valsartan 160 mg PO BID
10. Vitamin D 1000 UNIT PO BID
11. Divalproex (DELayed Release) 500 mg PO HS
12. OLANZapine 5 mg PO HS
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. OLANZapine 5 mg PO HS
4. Verapamil SR 240 mg PO Q24H
5. Vitamin D 1000 UNIT PO BID
6. Divalproex (DELayed Release) 500 mg PO HS
7. Metoprolol Succinate XL 200 mg PO DAILY
Hold SBP < 100, Hr < 55
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
8. Multivitamins 1 TAB PO DAILY
9. Aspirin 81 mg PO DAILY
10. Rivaroxaban 15 mg PO DAILY
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
11. Furosemide 40 mg PO DAILY
Hold for SBP < 95
RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
Chronic Diastolic CHF
Atrial fibrillation with rapid ventricular response
Hypertension
Acute on Chronic Kidney Injury
Hypercoagulopathy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure taking care of you during your [**Hospital1 18**]
admission. You were transferred from [**Hospital1 **] [**Location (un) 620**] because you had
a collection of fluid around your heart and low blood pressure.
An ultrasound of your heart showed that the fluid likely had
been there for some time and it was not drained. Your heart
function was initially poor because of the fluid but has
improved considerably. Your kidney function had worsened because
your lasix dose was too high for you. Your lasix dose was
decreased and you kidney function is now back to baseline. Your
INR or warfarin level was very high therefore we have switched
you to a different medication called rivaroxiban. On the day of
discharge you were feeling better wihout any chest pain or SOB.
A repeat ultrasound of your heart showed the fluid around your
heart to be decreeasing. You should follow up with your
cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] for further managment.
Followup Instructions:
Name: [**Last Name (LF) 4135**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: BIDH-[**Location (un) **] CARDIOLOGY
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 4105**]
Appointment: Tuesday [**2197-8-22**] 11:40am
Completed by:[**2197-8-7**]
|
[
"530.81",
"790.92",
"428.0",
"V12.54",
"428.33",
"458.29",
"584.9",
"423.9",
"E934.2",
"V58.61",
"244.9",
"585.9",
"272.0",
"427.31",
"599.70",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13748, 13825
|
8416, 11938
|
292, 298
|
14005, 14005
|
5081, 5898
|
15260, 15633
|
3653, 3814
|
13066, 13725
|
13846, 13984
|
12497, 13043
|
14189, 15237
|
3829, 4403
|
4417, 5062
|
190, 254
|
326, 2668
|
5906, 8393
|
14020, 14165
|
11959, 12471
|
2690, 3316
|
3332, 3637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,566
| 192,573
|
17572
|
Discharge summary
|
report
|
Admission Date: [**2130-3-20**] Discharge Date: [**2130-3-29**]
Date of Birth: [**2084-7-8**] Sex: F
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
female who is a donor for a liver transplant patient here at
the [**Hospital1 69**]. She has otherwise
been healthy and is a church member at the patient's church.
She went to the operating room on the date of admission where
she underwent a right donor hepatectomy of segments five,
six, seven, and eight.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Early osteoporosis.
PAST SURGICAL HISTORY:
1. Hysterectomy and oophorectomy.
2. Umbilical hernia repair.
3. Appendectomy.
4. Tonsillectomy.
5. Previous eye surgery.
MEDICATIONS:
1. E-Vista.
2. Tylenol prn.
ALLERGIES: Erythromycin, tetracycline, and codeine.
SOCIAL HISTORY: She smokes about one pack of cigarettes per
week and drinks 2-3 alcoholic drinks per week.
PHYSICAL EXAMINATION: On examination, the patient is
afebrile, vital signs are stable. Heart is regular. Lungs
are clear. Abdomen is soft. There are well-healed scars.
No extremity edema.
HOSPITAL COURSE: The patient underwent procedure without
incident. There was intraoperatively 7,000 cc of crystalloid
given, 1 liter of cell [**Doctor Last Name 10105**]. There was 1500 cc in and 1300
cc of urine output. She was not extubated, taken to the
Intensive Care Unit for close monitoring. Then in the
Intensive Care Unit, the patient was found to be hypotensive
with a decreased urine output and hematocrit of 21. She is
transfused 2 units and taken back to the operating room for
exploratory laparotomy.
There she remained stable and on further exploration, all
bleeding seemed to have stopped. The wound was closed and
she was taken back to the Intensive Care Unit intubated and
there overnight she remained stable. Total she had received
5 units of packed red blood cells and 4 units of fresh-frozen
plasma. She had urine output of 5 liters.
On postoperative day #1 she remained stable and was extubated
without incident. Following this course, she remained
otherwise stable, remained in the Intensive Care Unit with a
hematocrit of 29 with good pulmonary and cardiovascular
status. She was transferred to the floor on postoperative
day #3. From there, she continued to improve. Diet was
advanced on postoperative day #5, the patient reported bowel
function.
The patient continued to have issues of pain control, which
was managed by changing her pain medications, Dilaudid and
starting Vioxx, which seemed to help. She does have
occasional episodes of nausea which is helped by Compazine.
Patient had a JP remaining on postoperative day #8. The JP
bilirubin was 8.1. She had a mild bile leak. It was decided
that the JP would remain after discharge, and she can receive
VNA care for this JP drain. She has remained stable, and on
postoperative day #9, patient's LFTs demonstrated a slight
elevation, ALT was 118, AST 90, alkaline phosphatase 196, and
total bilirubin 0.8. The patient was going to undergo an
ultrasound to look for intrahepatic biliary ductal
dilatation. If this all looks normal, this will be
discharged as planned.
Patient has otherwise been hemodynamically stable, tolerating
diet and ambulating.
DISCHARGE DIAGNOSES:
1. Status post liver hepatectomy for donor and a liver
transplant.
2. Take back for bleeding.
3. Elevated transaminases investigating with ultrasound,
question of biliary stricture.
DISCHARGE MEDICATIONS:
1. Dilaudid [**1-31**] po q4h prn.
2. Compazine 10 mg po q6h prn.
3. Vioxx 12.5 mg po q day.
4. The patient will go back on her home doses of E-Vista,
Nexium.
FOLLOW-UP INSTRUCTIONS: The patient will follow up on Friday
for a repeat LFTs, amylase, and lipase. and staples will be
discontinued upon discharge. JP will remain in place, and be
followed up in the office for removal. She will be seen by Dr.
[**Last Name (STitle) **] in his office next Wednesday.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2130-3-29**] 11:35
T: [**2130-3-31**] 09:08
JOB#: [**Job Number 49000**]
|
[
"285.1",
"305.1",
"E878.6",
"V59.6",
"997.4",
"998.11",
"530.81",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"54.12",
"87.53",
"50.3"
] |
icd9pcs
|
[
[
[]
]
] |
3316, 3499
|
3522, 3682
|
1158, 3295
|
618, 837
|
969, 1140
|
175, 513
|
3707, 4253
|
535, 595
|
854, 946
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,208
| 167,918
|
30923
|
Discharge summary
|
report
|
Admission Date: [**2193-7-5**] Discharge Date: [**2193-7-11**]
Date of Birth: [**2137-8-27**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
s/p ? Fall
Major Surgical or Invasive Procedure:
open reduction and internal fixation of leforte I maxillary
fracture
History of Present Illness:
55 yo male found down, was taken to an area hospital with
multiple facial trauma; found to have multiple facial fractures
and was then transferred to [**Hospital1 18**] for further care.
Past Medical History:
MI, s/p CABG
Family History:
Noncontributory
Physical Exam:
WD WN man intubated, sedated, vented, on stretcher.
propofol gtt, no commands
130/90 90 18 100% vent
face with diffuse midfacial swelling.
upper face stable/atraumatic
pupils minimally reactive bilaterally, eyelids swollen shut
bilaterally, + spectacle sign on L, no proptosis, free movement
on forced duction bilaterally. prolene stitch present in L
lower
eyelid.
R EAM with blood and ? R tympanic rupture. L TM intact. B
diffuse ear swelling without hematoma L > R
midface grossly unstable with crepitance
dental plate upper jaw (bad condition), poor mandibular
dentition
with mult missing teeth although no apparant acute dental
trauma/loss. mandible stable, able to reach concentric relation
bilaterally of TMJ.
zygoma stable
nasopharynx packed, nasal pyramid grossly stable.
Pertinent Results:
[**2193-7-5**] 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2193-7-5**] 02:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2193-7-5**] 02:00AM FIBRINOGE-318
[**2193-7-5**] 02:00AM PT-11.8 PTT-20.8* INR(PT)-1.0
[**2193-7-5**] 02:00AM PLT COUNT-131*
[**2193-7-5**] 05:22AM LACTATE-0.9
[**2193-7-5**] 05:22AM TYPE-ART TIDAL VOL-600 PEEP-5 O2-60 PO2-124*
PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 -ASSIST/CON
INTUBATED-INTUBATED
Brief Hospital Course:
He was admitted to the Trauma Service. Plastic Surgery,
Ophthalmology and ENT were consulted given his multiple facial
fractures. Nasal packing was performed by ENT.
There were no acute Ophthalmology issues identified. He was
taken to the operating room on [**7-10**] by Plastics (followin
cardiology consultation regarding his operative hisk, given his
CAD) for repair of his facial fractures. ORIF of his Leforte I
fractures was performed on [**7-10**], and the surgery was tolerated
without complications.
Occupational therapy was consulted for cognitive evaluation
given his extensive facial trauma. Social work was also
consulted because of substance abuse history.
On POD1 pt was toelrating a soft diet, his pain was
well-controlled, and and he was discharged home with his wife on
a soft diet, on clinda and peridex mouthwashes, to follow-up
with Dr. [**First Name (STitle) **].
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QID (4 times a day).
Disp:*QS QS* Refills:*2*
2. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
4. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for prn pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
13. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane QID (4 times a day) for 7 days.
Disp:*420 ML(s)* Refills:*0*
14. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO three
times a day for 7 days.
Disp:*42 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
leforte I facial fracture
nasal bone Fx
Discharge Condition:
stable
Discharge Instructions:
the following: chest pain, shortness of breath, severe headache,
increased redness or drainage from your incisions, vision
changes, fever greater than 101F, or any other concerning
symptoms.
You should sleep on at least 3 pillows to reduce swelling.
You should eat only SOFT FOODS - no solid food for 1 month.
You shoudl take all medication as prescribed.
You should rinse you mouth with the peridex mouthwash as
prescribed.
Followup Instructions:
follow-up with Dr. [**First Name (STitle) **] in [**2-5**] weeks - call ([**Telephone/Fax (1) 23796**] for
appt
Completed by:[**2193-7-11**]
|
[
"272.4",
"802.0",
"E968.9",
"401.9",
"V45.81",
"410.00",
"412",
"V43.65",
"802.6",
"802.4",
"802.8",
"715.96",
"305.61",
"V45.82",
"801.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"76.74",
"96.71",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
4416, 4422
|
2056, 2946
|
324, 395
|
4506, 4515
|
1500, 2033
|
4988, 5131
|
663, 680
|
2969, 4393
|
4443, 4485
|
4539, 4965
|
695, 1481
|
274, 286
|
423, 611
|
633, 647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,268
| 140,384
|
44309
|
Discharge summary
|
report
|
Admission Date: [**2138-2-7**] Discharge Date: [**2138-2-13**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Drop in HCT at rehab, Guiaic positive stools
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Briefly, patient is an 87 year-old gentleman with a history of
multiple myeloma, essential thrombocytosis, diabetes mellitus
(presumed Type II), who was recently started on [**First Name3 (LF) **] for his
essential thrombocytosis who presented from [**Hospital3 2558**] with
decreased Hct (27 --> 23). Stool was noted to be guiaic positive
on admission. He denied abdominal pain, nausea, vomiting, or
diaphoresis. No symptoms of anemia including lightheadedness,
dizziness, shortness of breath, or chest pain were experienced.
In the ED, he was hemodynamically stable but was noted to have
maroon stools and clots per rectum. NG lavage was negative. GI
was consulted, tagged red cell scan was done as part of w/u,
which was negative. Patient was transfused total of 3 units, and
Hct has subsequently remained stable. Plan is for colonoscopy on
Monday. While in MICU, patient had large hematuria; he was
evaluated by GU, and hematuria was thought to be secondary to
both UTI and foley trauma with underlying BPH. After drainage,
urine clarity has improved, and Hct has remained stable. Patient
will need cystoscopy as outpatient.
.
Patient also noted to be hyperkalemic on [**2138-2-7**], EKG had
questionable T-wave peaking, and he was given Ca Gluconate, D50
and insulin, kayexelate.
Past Medical History:
1. CAD - large reversible defect per MIBI [**11-9**], for medical
management
2. CHF - LVEF of 45% by echo [**2137-6-21**].
3. Atrial fib - Pt was anticoagulated in the past on coumadin
but this was discontinued in [**4-/2137**] following a GI bleed.
4. Essential thrombocytosis - This was diagnosed in [**2129**]. The pt
is followed by Dr. [**First Name (STitle) **]. Previously treated with hydroxyurea
which was discontinued in [**12/2137**] when pt developed pancytopenia
and low Hct requiring multiple transfusions.
5. IgA multiple myeloma - This was diagnosed in 10/[**2137**]. Pt is
followed by Dr. [**First Name (STitle) **].
6. HTN
7. Type 2 diabetes mellitus
8. H/O Dieulafoy's lesion and UGIB requiring ICU stay [**6-/2137**]
9. Hypercholesterolemia
10. PVD s/p L fem-[**Doctor Last Name **] bypass surgery [**2137-12-19**]
Social History:
Pt lives at [**Hospital3 2558**] ([**Telephone/Fax (1) 7233**]) on [**Location (un) **]. Served
in [**Country 2559**] and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 480**] during WWII. Following this, he worked as
a touring tap dancer for over 30 years. Pt is a former smoker
who quit 1 year ago.
Family History:
Non-contributory.
Physical Exam:
VS T 97.0; BP 121/40; HR 63; RR 12; O2 Sat 100% RA
GEN: NAD, comfortable, slightly impaired speech
HEENT: MMM. PERRL. EOMI. anicteric sclerae
CV: S1S2 RRR with occasional ectopy. No appreciable M/R/G
LUNGS: Basilar crackles, otherwise CTA
ABD: soft, NT/ND. +BS. No organomegaly
EXT: Diminished DPs, LLE dressing C/D/I. Extremities warm
Pertinent Results:
[**2138-2-7**] 11:00PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.012
[**2138-2-7**] 11:00PM URINE BLOOD-LGE NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-MOD
[**2138-2-7**] 11:00PM URINE RBC- WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2138-2-7**] 07:45PM GLUCOSE-129* UREA N-71* CREAT-1.8* SODIUM-135
POTASSIUM-6.6* CHLORIDE-102 TOTAL CO2-21* ANION GAP-19
[**2138-2-7**] 07:45PM WBC-13.0* HCT-25.0*
[**2138-2-7**] 07:45PM NEUTS-72* BANDS-1 LYMPHS-20 MONOS-3 EOS-2
BASOS-0 ATYPS-2* METAS-0 MYELOS-0 NUC RBCS-1*
[**2138-2-7**] 07:45PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
FRAGMENT-OCCASIONAL
[**2138-2-7**] 07:45PM PLT SMR-VERY HIGH PLT COUNT-1436*
[**2138-2-7**] 07:45PM PT-14.4* PTT-31.9 INR(PT)-1.3*.
.
[**2138-2-7**]: GI Bleeding Study
IMPRESSION: No active gastrointestinal bleeding at the time of
study.
.
[**2138-2-10**]: L Foot AP/LAT/Oblique
IMPRESSION: Minimally displaced fracture of the first distal
phylangeal tuft of indeterminate age.
.
[**2138-2-10**]: Arterial Duplex Studies Left
IMPRESSION: Patent left femoral to peroneal artery bypass graft
without any evidence of stenosis. However, based on metatarsal
PVRs, there appears to be significant distal tibial disease with
severe flow deficit to the forefoot.
.
[**2138-2-11**] Colonoscopy
Diverticulosis of the hepatic flexure and sigmoid colon
Grade 3 internal hemorrhoids
Polyp in the proximal ascending colon
Stool in the cecum
.
[**2138-2-13**] 05:45AM BLOOD Hct-29.3*
[**2138-2-12**] 06:35AM BLOOD WBC-10.0 RBC-3.39* Hgb-9.8* Hct-28.6*
MCV-84 MCH-29.0 MCHC-34.5 RDW-18.4* Plt Ct-979*
[**2138-2-11**] 05:40AM BLOOD Hct-29.7*
[**2138-2-10**] 06:30AM BLOOD WBC-9.8 RBC-3.65* Hgb-10.2* Hct-29.6*
MCV-81* MCH-28.0 MCHC-34.5 RDW-18.2* Plt Ct-1035*
[**2138-2-9**] 07:45PM BLOOD Hct-31.4*
[**2138-2-12**] 06:35AM BLOOD Plt Smr-VERY HIGH Plt Ct-979*
[**2138-2-10**] 06:30AM BLOOD Plt Smr-VERY HIGH Plt Ct-1035*
Brief Hospital Course:
Patient is an 87 year-old gentleman with Multiple Myeloma,
Essential Thrombocytosis, Atrial Flutter/Fibrillation who
presented witha 4 point Hct drop at [**Hospital3 2558**] in setting of
guiaic positive stools. The following issues were addressed
during his hospital stay:
.
1. LOWER GI BLEED
Patient with guiaic positive stools with blood noted on rectal
examination here. Tagged red cell scan was negative for source
of bleed. Patient was admitted to the MICU and received 3 units
PRBCs with appropriate increase in Hct. Antihypertensives,
aspirin, and Heparin were held; IV Protonix was administered
[**Hospital1 **]. When stabilized, patient was transferred to the floor. He
had one additional episode of bleeding per rectum and was
tranfused 4th unit PRBCs. Following adequate bowel preparation,
colonoscopy was performed, which was negative for active
bleeding or culprit lesion (see full report above) -- drop in
Hct was attributed to bleeding diverticulum that had
self-resolved. Hct remained stable in the 28-29 range
thereafter. No further bleeding episodes or change in stool
color were noted. Incidental polyps were noted on colonoscopy,
patient to have follow-up study in 6 months per PCP [**Name Initial (PRE) 8469**].
2A. HEMATURIA
Following foley placement, patient with notable bleeding into
foley bag, including passage of clots. [**Name Initial (PRE) 159**] was consulted,
and 3-way foley was placed with irrigation. Bleeding was
attributed to underlying UTI given positive UA and to trauma
from foley in setting of underlying BPH. Patient's urine cleared
following foley irrigation, and no further blood was noted in
the urine. Patient to follow-up with [**Name Initial (PRE) **] for cystoscopy as
outpatient, appointment time/date noted in discharge planning.
.
2B. UTI
Patient with positive UA on admission, which was treated with 5
days Ciprofloxacin. Patient likely with some urinary retention
secondary to BPH. To be further managed by [**Name Initial (PRE) **] as
outpatient, work-up including cystoscopy.
.
2C. BPH
Once hemodynamically stable, outpatient Tamsulosin was
restarted.
3. ACUTE RENAL FAILURE
Patient with Cr 1.8 on admission, improved with fluids and
PRBCs. Pre-renal etiology secondary to volume loss. Cr 0.7 on
discharge.
.
4. ATRIAL FIBRILLATION/CAD
Anticoagulation was held in setting of GI Bleed. Patient was not
on Coumadin therapy given multiple GI Bleeds. Aspirin was also
held - patient had been on [**Name Initial (PRE) **] as therapy for thrombocytosis,
will hold off on medication per discussion with PCP. [**Name10 (NameIs) **]
treatment re: therapy pending discussions between PCP and
[**Name9 (PRE) **].
.
5. ESSENTIAL THROMBOCYTOSIS
Aspirin held secondary to GI Bleed. Patient to follow-up with
Heme-Onc as outpatient regarding re-starting therapy vs.
substitute therapy. Hydroxyurea discontinued in past due to
pancytopenia. Patient with significantly elevated platelets to
1000 on this admission. Appointment scheduled for him.
.
6. HTN
Antihypertensives were held initially due to lower GI Bleed.
They were re-started cautiously as tolerated, and PCP will
increase dosages as tolerated as outpatient. Patient had been on
Toprol XL 100, Lasix 80, Tamsulosin 0.4, Spironolactone 50,
Lisinopril 5. At time of discharge, patient had received
Lopresor 50 mg AM dose, Tamsulosin 0.5, Lisinopril 5, and
Spironolactone 25.
Medications on Admission:
1. Atorvastatin 40
2. Folic Acid 1
3. Pantoprazole 40 mg
4. Docusate Sodium 100 mg [**Hospital1 **]
5. Bisacodyl [**Hospital1 **]
6. Tamsulosin 0.4mg qhs
7. Heparin 5000 SC TID
8. Aspirin 325 mg
9. Acetaminophen 1000 TID
10. MVI
11. Lisinopril 5 mg
12. Ferrous Sulfate 325
13. Spironolactone 50 mg
14. Metoprolol Succinate 100 mg PO qd
15. Senna 8.6 mg [**Hospital1 **]
16. Lasix 80 mg Tablet PO qd
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Cap(s)
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Injection TID (3 times a day).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please have your electrolytes monitored by Dr. [**Last Name (STitle) 5351**]
while on this medication. Medication to be titrated up to 50mg
PO qd (outpatient regimen) as tolerated.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Can be switched to Toprol XL 100 at Dr. [**Name (NI) 93775**] discretion.
11. Lasix Oral
12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary
1. Lower GI Bleed
2. LLE ulcer s/p Left femoral-peroneal bypass [**12-9**]
Secondary
1. Multiple Myeloma
2. Essential Thrombocytosis
3. Atrial Fibrillation
4. HTN
5. CAD
Discharge Condition:
feeling well, Hct stable, without fever or dyspnea
Discharge Instructions:
1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
2. Please take all medications as prescribed
3. Please make all follow-up appointments
4. If you develop any further episodes of bleeding, or develop
chest pain, shortness of breath, fevers, chills, or other
concerning symptoms, please contact your PCP [**Name Initial (PRE) **]/or report to
the Emergency Department
Followup Instructions:
Your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5351**] will follow-up with you at [**Hospital3 2558**].
.
You have follow-up scheduled with your [**Hospital3 1106**] surgeon Dr.
[**Last Name (STitle) 1391**] on [**2142-2-26**]:00 AM. [**Hospital **] Medical Office
Building, [**Location (un) 442**].
.
You have an appointment scheduled with your
hematologist-oncologist:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2138-2-28**] 10:00. Please discuss with her re: further
management of your thrombocytosis.
.
You have a [**Month/Day/Year **] follow-up appointment scheduled for [**3-5**]
at 10:00 AM, [**Location (un) 470**] [**Hospital Ward Name 23**] Clinical Center, Provider:
[**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2138-3-5**] 10:00
Completed by:[**2138-2-13**]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,232
| 107,911
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30537
|
Discharge summary
|
report
|
Admission Date: [**2168-5-9**] Discharge Date: [**2168-5-20**]
Date of Birth: [**2119-2-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Compazine / Erythromycin Base
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
resp failure
Major Surgical or Invasive Procedure:
Arterial line
PICC line
Tracheostomy
History of Present Illness:
HPI: 49 y/o female with HTN, COPD/Emphysema, and CHF who has had
two admissions (first to B&W hospital and most recently to
[**Hospital 16843**] Hospital, where she was discharged from last week) in
the last month for COPD/PNA requiring intubation. She was doing
well after her discharge last week, but her daughter had a cold,
and the patient began to develop cough with sputum leading to
fevers, chills, and eventually lethargy on the morning of
admission, prompting her daughter to call EMS. Per her daughter,
she was not having chest pain, but was having increased leg
swelling, and orthopnea/dyspnea causing her to be unable to move
about the house and requiring her to sleep sitting up at the
kitchen table.
.
Arrived at [**Hospital 16843**] Hospital at 4AM [**2168-5-9**], Temp 99.5, Tachy
to
154 (MAT vs. ST with ectopy), RR 28 with sat 98% on nebulizer.
Intubated at 5AM with 8.0 tube after being given 6mg versed, 4mg
ativan, 140mg succinyl choline, 20 mg norcuron. Treated with 250
mg solumedrol (6AM), 2g Ceftriaxone (7AM), and 500mg Levaquin.
Blood pressure stable throughout with a low SBP of 115. Labs
showed WBC 19.8, HCT 36.7, Plt 356, CHem 10 with K 3.3,Hco3 of
36.6, BUN 10, Cr 0.6, CK13 with trop I 0.10 (0.00-0.40 normal
range). BNP 49. U/A showed tr blood, 300 prot, and 100 glucose.
No evidence of urinary tract infection. Digoxin level 0.15.
Past Medical History:
Obesity
HTN
COPD/Emphysema- on home O2 at 2 liters constantly and on
prednisone after hospitalizations. Two previous intubations in
the last month, but for the two years prior had not required
intubation. Would like trach if needed.
Pulmonary Hypertension
Question of CHF/Right Sided Failure
Presumed Sleep Apnea- on home BIPAP
Depression
h/o Afib
Social History:
Lives with her two daughters. Smoking history
unclear. Recently in and out of hospitals over the last several
months for PNA and COPD with intubations.
Family History:
NC
Physical Exam:
On admission:
Obese female, lying in bed, intubated with Foley in place.
Responds to basic commands. Moving all four extremities.
T 96.4 BP 131/113 HR 130 RR 29 SAT 95%
on AC 470x16 FIO2 .50 PEEP 5
HEENT: Pupils 2mm and reactive to light bilaterally. Sclera
anicteric. Moist mucous membranes.
NECK: No LAD. No thyromegaly or nodules.
CHEST: Lung sounds faint but audible bilaterally. No rales or
wheezes.
HEART: Tachycardic. No audible murmurs.
ABD: Obese, soft, NT, ND. No masses or palpable organomegaly.
EXT: Left leg mildly larger than right leg, with pitting edema
to
shin. Bilateral chronic venous stasis changes bilaterally with
poor foot care.
NEURO: Responds with head nods. Moves hands and feet bilaterally
to command.
Pertinent Results:
Labs on admission:
[**2168-5-9**] 11:28AM TYPE-ART PO2-84* PCO2-86* PH-7.22* TOTAL
CO2-37* [**2168-5-9**] 11:28AM LACTATE-1.0
[**2168-5-9**] 11:11AM GLUCOSE-347* UREA N-14 CREAT-0.5 SODIUM-143
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-33* ANION GAP-15
[**2168-5-9**] 11:11AM ALT(SGPT)-53* AST(SGOT)-30 LD(LDH)-307*
CK(CPK)-34 ALK PHOS-94 AMYLASE-20 TOT BILI-0.3
[**2168-5-9**] 11:11AM CK-MB-3 cTropnT-<0.01
[**2168-5-9**] 11:11AM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-6.1*
MAGNESIUM-1.7
[**2168-5-9**] 11:11AM WBC-27.7* RBC-4.58 HGB-11.6* HCT-38.1 MCV-83
MCH-25.3* MCHC-30.4* RDW-14.6
[**2168-5-9**] 11:11AM PLT COUNT-414
[**2168-5-9**] 11:11AM PT-11.2 PTT-23.1 INR(PT)-0.9
[**2168-5-9**] 12:18PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Labs on discharge:
[**2168-5-18**] 04:21AM BLOOD WBC-14.9* RBC-4.34 Hgb-10.8* Hct-33.7*
MCV-78* MCH-24.8* MCHC-31.9 RDW-15.5 Plt Ct-227
[**2168-5-18**] 04:21AM BLOOD Glucose-125* UreaN-36* Creat-0.9 Na-139
K-3.9 Cl-93* HCO3-38* AnGap-12
[**2168-5-18**] 04:21AM BLOOD Calcium-9.4 Phos-4.8* Mg-2.1
[**2168-5-18**] 08:29AM BLOOD Type-ART Temp-36.2 PEEP-8 FiO2-40 pO2-82*
pCO2-58* pH-7.45 calTCO2-42* INTUBATED Comment-PSV 12/8
[**2168-5-17**] 03:33AM BLOOD ALPHA-1-ANTITRYPSIN-PND
Echo ([**2168-5-10**]): The left atrium is normal in size. The estimated
right atrial pressure is 16-20 mmHg. 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 normal (LVEF 70%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a fat
pad.
BILATERAL LOWER EXTREMITY ULTRASOUNDS ([**2168-5-10**]): No evidence of
bilateral lower extremity DVT.
CXR on admission ([**2168-5-9**]): Mild upper lobe vascular
re-distribution and possible small bilateral pleural effusions
likely representing mild CHF.
CXR prior to discharge ([**2168-5-19**]): The tip of the nasogastric
tube does appear to lie below the diaphragm. The lung fields
appear clear.
Micro: (note - no positive growth at time of discharge)
[**2168-5-19**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2168-5-19**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2168-5-19**] URINE URINE CULTURE-PENDING INPATIENT
[**2168-5-19**] URINE URINE CULTURE-PENDING INPATIENT
[**2168-5-9**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2168-5-9**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2168-5-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2168-5-9**] URINE URINE CULTURE-FINAL
Brief Hospital Course:
The patient was admitted to the [**Hospital Unit Name 153**] on [**5-9**]. By problem:
# Hypercarbic Respiratory Failure: Etiology of CO2 retention
likely multifactorial--COPD flare in setting of bronchitis,
obstructive sleep apnea, with possible contribution of pulmonary
edema. She was treated with combivent nebulizers,
corticosteroids, and 10d course of levofloxacin for presumed
bronchitis. Despite positive d-dimer, PE was deemed unlikely
given clinical picture and negative LENIs, but her body habitus
precluded CT angiogram. Given 3 intubations within past six
weeks and OSA component, thoracic surgery was consulted and a
7mm [**Last Name (un) 295**] trach was placed on [**2168-5-11**] in the OR. Weaning pt from
the vent proved difficult; pt initially did not tolerate trials
of pressure support ventilation (she would become agitated and
anxious, and blood pressure would increase). With diuresis and
decrease of airway resistance with abx/steroids, she was finally
able to tolerate pressure support ventilation on [**2168-5-18**]. On
[**5-19**] she was able to transition off the vent for up to 2 hours
at a time. A Passey-Muir valve was attempted but tracheal
pressures were too high (20) and so it was not continued.
Eventually the trach can be replaced with a smaller trach for
re-attempt of PMV. She should remain on 20 mg predisone until
follow up with pulmonary after dischartge from rehab.
.
# CHF: An echocardiogram was performed which showed LVEF 70%,
mild symmetric LVH, moderate pulmonary hypertension, and R
atrial pressures of 16-20mm Hg. Admission cxr showed bl pleural
effusions and prominent pulmonary vasculature; pt was diuresed
with Lasix with good effect on pulmonary function and LE edema.
She was maintained on Digoxin 0.125mcg daily and lasix was
restarted at 80 po daily on discharge, which can be increased to
120 po daily (her home dose) if maintaining a positive fluid
balance and her electrolytes are stable.
.
# HTN: Pt was initially very hypertensive (SBPs as high as 210)
while intubated despite being given home meds (Diovan and
Cartia, her doses were initially unknown, therefore they were
titrated up). Hypertension was observed to worsen when pt was
anxious or agitated. She was started on atenolol for further
control. At one point, during an episode of extreme anxiety and
agitation, she briefly was placed on labetalol drip, which was
stopped after BPs came under control. Toward the end of her
course, her blood pressure was actually over-controlled and so
BP meds were down-titrated and lasix was held. This brief
episode of hypotension was due to mild volume depletion but
mostly due to the inaccurate BP cuff readings on her arm
(NOTE:calf measurements much more reliable). He blood pressure
was stable for 24 hours prior to discharge.
.
# Elevated WBC count: Initial WBC count of 27.7 rapidly came
down to mid teen's after starting antibiotics. WBC count
remained at 14-16 throughout course, most likely secondary to
corticosteroids. Pt was afebrile throughout course, with
negative cultures (blood, urine, negative. Pt was treated with
10 days of levofloxacin for presumed bronchitis.
.
# Hyperglycemia: Pt carried a diagnosis of steroid-induced DM
prior to admission. Blood sugars were initially very high,
brought under control with insulin drip which was then
transitioned to long-acting insulin regimen (lantus 20U) with
sliding scale coverage qAC and qhs. Finger sticks were stable
on this regimen.
.
# Depression: Pt was intermittently anxious and tearful during
her course, as was having trouble dealing with tracheostomy
(unable to talk, uncomfortable sensation). She was continued on
her home regimen of Zoloft, Lorazepam, and Seroquel. Trazodone
was held while in house as we did not want her too sedated.
Social work was consulted to help pt deal with feelings of
helplessness/anxiety s/p trach placement. NOTE: She became VERY
tearful s/p failure of passey-muir valve as she considers it
essential to regain speech. This will be a priority in
optimizing her care.
.
# Prophylaxis: Pt was maintained on subQ heparin, pneumoboots,
and a proton pump inhibitor.
# Diet: Pt received Promote w/ fiber tube feeds through an NG
tube.
# Access: Right radial arterial line and Picc line (placed as
she has very poor IV access).
# Code: FULL
# Contact: daughter [**Name (NI) 72523**] [**Telephone/Fax (1) 72524**]
Medications on Admission:
(meds obtained thru d/c summary from [**Hospital **] hospital)
Prednisone 20mg daily
Home Oxygen 2L Day and Night
BIPAP
Albuterol nebulizer
Cartia XT 120mg daily
Lipitor 20mg qhs
Trazodone 50mg qhs
Digoxin 0.125 mcg daily alternating with 0.250mcg daily
Lasix 80mg po daily
Lorazepam 1mg po tid
Advair 500/50 1 puff twice a day
Zoloft 150mg daily
Singulair 10mg daily
Diovan 80mg daily
Seroquel 50mg daily
Protonix 40mg daily
Spiriva, unknown dose
Glyburide 5mg daily (started on [**2168-4-30**], unclear if was taking
prior to admission [**2168-5-9**])
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
5. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back pain.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
13. Insulin Glargine Subcutaneous
14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
15. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating/gas pain.
16. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID
(2 times a day).
17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
19. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
21. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
22. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
23. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
24. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**]
Discharge Diagnosis:
Hypercarbic Respiratory Failure, likley chronic obstructive
pulmonary exacerbation
Congestive heart failure
.
Obesity
HTN
Pulmonary Hypertension
Sleep Apnea- on home BIPAP- however no confirmative sleep study
Depression
h/o Afib
Discharge Condition:
BP 150/70 by arm/leg cuff, breathing comfortably on PS 12/5 with
trach in place.
Discharge Instructions:
You were admitted for difficulty breathing and underwent
placement of a tracheostomy.
Please follow the instructions below and ensure follow up for
the patient.
Followup Instructions:
Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for follow up in pulmonary clinic
afer discharge from rehab - call [**Telephone/Fax (1) 612**] for an
appointment.
.
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week following discharge
from rehab.
|
[
"785.0",
"416.8",
"V46.2",
"428.0",
"276.2",
"327.23",
"427.31",
"278.01",
"E932.0",
"518.81",
"491.21",
"311",
"401.9",
"251.8",
"276.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.72",
"38.91",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13341, 13393
|
6308, 10697
|
315, 353
|
13665, 13747
|
3077, 3082
|
13957, 14256
|
2308, 2312
|
11301, 13318
|
13414, 13644
|
10723, 11278
|
13771, 13934
|
2327, 2327
|
263, 277
|
3910, 6285
|
381, 1750
|
3096, 3891
|
1772, 2122
|
2138, 2292
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,753
| 102,793
|
34405
|
Discharge summary
|
report
|
Admission Date: [**2186-6-30**] Discharge Date: [**2186-7-14**]
Date of Birth: [**2142-11-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Dizziness, lethargy, transfer from SICU
Major Surgical or Invasive Procedure:
Intubation, Brain Biopsy
History of Present Illness:
Pt. is a 43 yo F being transferred to the floor from the SICU
after resolution of acute cerebral edema. The patient reported
that 4 days prior to admission she developed the onset of
slurred speech, dysarthria, and dizziness upon standing. The
patient presented to her PCP one day prior to her admission but
no interventions were done at that time. The symptoms continued,
so the patient presented to an outside hospital ([**Hospital1 2436**]) on
[**6-29**] where a CT scan of brain revealed B/L basal ganglial masses
with B/L vasogenic edema and mild mass effect with mild
subfalcine herniation. The patient was referred to [**Hospital1 18**] for
further neurosurgery evaluation.
Upon arriving to the ED, the patient actutely decompensated with
GCS from 15 to 9. The patient was summarily placed on decadron
and dilantin with the endgoal of intubation. A CT scan showed
progression of mass effect and she was admitted to the SICU. A
subsequent MRI showed multifocal ring enhancing lesions strongly
suggestive for Toxoplasmosis. She also received acyclovir,
ampicillin and vancomycin in the ED. Tmax in the ED was 100.8.
In the SICU the was intubated and sedated on propofol. The
patient was subsequently given mannitol in the SICU, and started
on empiric pyrimethamine, sulfadiazine, and leucovorin for toxo,
and a brain biopsy was done showing bradyzoites (confirming toxo
infection). The patient also had a CD4 count sent with 2, and a
subsequent positive [**Doctor First Name **] HIV test with pending western blot.
Pt. began to recompensate with less edema, was extubated on
[**7-1**], and was stable enough to be transferred to the floor 4
days later.
Past Medical History:
-S/P fibroid resection
Social History:
Lives by herself, sexually active with one person, no smoking
hx, social drinker, no IVDU, has a brother who is actively
involved in her care.
Family History:
HTN
Physical Exam:
Vitals: Afebrile, to come
Gen: Patient in NAD cooperative and responsive
HEENT: EOMI, PERRLA, scar from biopsy on L. parietal area of
head, no LAD, no bruits B/L, no JVD
Lungs: CTA B/L
CV: RRR, nl S1/S2, no m/r/g
Abd: Midline surgical scar below navel, s/nt/nd/hypoactive BS
Extremities: No cyanosis, clubbing, edema, R/DP pulses 2+ B/L
Neuro: AAO x 3, R. nasolabial fold flattened, R. facial droop,
R. shrug droop, CN II-XII otherwise intact, strength and grip in
all upper extremities [**4-17**], strength in lower extremities [**4-17**],
motor, sensory (vibration, pinprick intact globally), mild
dysdiadichokinesis with R. hand, gait mildly ataxic, mild
pronator drift of R. hand. MMSE > 25.
Psych: Anxious
Pertinent Results:
Toxo IgG by EIA 232 IU/mL; IgM negative
CMV IgG, IgM negative
Cryptococcal Ag negative
EBV IgG Positive; IgM negative
CMV viral load negative
RPR non reactive
[**2186-6-30**] 03:16AM WBC-3.5* RBC-4.59 HGB-11.1* HCT-34.8* MCV-76*
MCH-24.3* MCHC-32.0 RDW-12.7
Pathology Report - Brain Biopsy ([**2186-6-30**]): Moderately
hypercellular brain with mixed inflammatory cells and organisms
most consistent with toxoplasma bradyzoites.
MRI Head w/wo Contrast ([**2186-6-30**]): Thin walled ring enhancing
lesions within the basal ganglia and right parietal lobe with
vasogenic edema resulting in mild rightward subfalcine
herniation. Findings are suggestive of toxoplasmosis with a
differential of lymphoma and metastasis. Thallium SPECT scan can
be performed for further evaluation if clinically warranted.
CT Chest ([**2186-7-6**]): 1. Moderate improvement in lingular
consolidation, which can be followed to resolution by chest
radiograph.
2. Resolution of right upper lobe infectious process and
pulmonary nodules.
3. Resolution of bibasilar atelectasis and tiny effusions.
4. Stable 2.7-cm left thyroid nodule for which thyroid
ultrasound is
recommended.
Rectal Swab ([**2186-7-6**]): MRSA positive
BCx 1 of 2 bottles ([**2186-7-5**]): Gram + cocci in clusters
CMV IgG positive ([**2186-7-7**])
Cryptococcal Antigen negative ([**2186-7-7**])
Brief Hospital Course:
Upon arriving to the ED, the patient actutely decompensated with
GCS from 15 to 9. The patient was summarily placed on decadron
and dilantin with the endgoal of intubation. A CT scan showed
progression of mass effect and she was admitted to the SICU. A
subsequent MRI showed multifocal ring enhancing lesions strongly
suggestive for Toxoplasmosis. She also received acyclovir,
ampicillin and vancomycin in the ED. Tmax in the ED was 100.8.
In the SICU the was intubated and sedated on propofol. The
patient was subsequently given mannitol in the SICU, and started
on empiric pyrimethamine, sulfadiazine, and leucovorin for toxo,
and a brain biopsy was done showing bradyzoites (confirming toxo
infection). The patient also had a CD4 count sent with 2, and a
subsequent positive [**Doctor First Name **] HIV test with pending western blot.
Pt. began to recompensate with less edema, was extubated on
[**7-1**], and was stable enough to be transferred to the floor 4
days later.
1. Toxoplasmosis: Patient was continued on Pyrimethamine,
sulfadiazine, and leucovorin.
2. HIV: Patient was informed of HIV status with the help of
Infectious Disease and HIV Social worker.
She was also started on azithromycin for prophylaxis against
[**Doctor First Name **].
She was receiving fluconazole for oral candidiasis. However she
developed a transaminitis, likely secondary to the fluconazole.
Fluconazole was discontinued, and transaminitis slowly resolved.
RUQ US was unremarkable.
3. Cerebral Edema: Patient was on Dexamethasone, and tapered off
of it during her hospital stay. She was also on prophylactic
Dilantin, and then switched to Keppra prior to discharge.
Patient had no seizures, headaches, or vision changes during
hospital stay. She was able to walk around the floor with the
help of PT, and gait, strength, and balance were much improved.
4. Thyroid nodule: First noticed on chest CT scan to evaluate
her lungs. She subsequently received a thyroid US which showed
Dominant large left thyroid nodule with no internal worrisome
features. FNA should be considered. Patient was asymptomatic,
and had never noticed this before.
Medications on Admission:
None at home. On transfer to the floor:
Phenytoin 100 mg PO TID
Famotidine 20 mg PO Q12H
SulfADIAzine 1500 mg PO Q6H
Dexamethasone 4 mg IV Q6H
Pyrimethamine 75 mg PO DAILY
Heparin 5000 UNIT SC TID
HYDROmorphone (Dilaudid) 2-4 mg PO/NG Q4H:PRN
Leucovorin Calcium 10 mg PO DAILY
Discharge Medications:
1. Leucovorin Calcium 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Pyrimethamine 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
3. Sulfadiazine 500 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*0*
4. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QWEEKLY ()
as needed for MAC prophylaxis.
Disp:*12 Tablet(s)* Refills:*0*
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Toxoplasmosis
HIV
Cerebral Edema
Thyroid nodule
Discharge Condition:
Stable
Discharge Instructions:
You were in the hospital for an infection in your brain called
Toxoplasmosis. Because of the infection, you've had some
swelling in your brain. You were placed on steroids to reduce
the swelling, and you were intubated as you could not breathe on
your own. You had a brain biopsy done, that confirmed that you
had an infection called Toxoplasmosis. You were started on
antibiotics called Pyramethamine and Sulfadiazine for your
infection.
Because of the swelling of your brain, you were kept on steroids
during your stay in the hospital and anti-seizure meds.
Your brother consented for an HIV test while you were intubated,
which turned out to be positive. Your CD4 count is 2. You were
placed on another antibiotic called Azithromycin, to avoid
getting another infection.
Please call your primary doctor or go to the emergency room if
you have any seizures, difficulty seeing, bad headaches,
weakness in your arms or legs, or fevers.
Followup Instructions:
Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2186-7-27**]
3:30
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2186-8-17**] 10:00
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2186-8-24**] 4:00
Please follow up in [**Hospital 6091**] clinic on Thursday [**7-20**] 8am
Dr. [**First Name (STitle) **]
[**Telephone/Fax (1) 61238**]
Please follow up with your primary care doctor as soon as
possible
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2186-7-14**]
|
[
"198.3",
"162.8",
"573.3",
"130.7",
"042",
"112.0",
"348.5",
"241.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.13",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7476, 7531
|
4431, 6570
|
355, 381
|
7623, 7632
|
3054, 4408
|
8621, 9399
|
2292, 2297
|
6899, 7453
|
7552, 7602
|
6596, 6876
|
7656, 8598
|
2312, 3035
|
276, 317
|
409, 2069
|
2091, 2116
|
2132, 2276
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,788
| 156,664
|
26516
|
Discharge summary
|
report
|
Admission Date: [**2174-6-14**] Discharge Date: [**2174-6-16**]
Date of Birth: [**2098-6-16**] Sex: F
Service: MEDICINE
Allergies:
Prednisone / Plaquenil / Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 yo female with hx of lung adenoCA s/p lobectomy, CAD s/p CABG
and LAD stent, carotid stenosis, afib, PE who presents with
hypotension after bronchoscopy with lymph node biopsy. She was
in her usual state of health until presentation to the hospital
yest for elective bronchoscopy with lymph node FNA. During the
procedure she was given a total of 3mg of versed and 100mg of
Fentanyl and had mild hypotension with SBP's in the 90s so was
given 250cc bolus of NS periprocedure. While in recovery the
patient was mildy dizzy and felt the urge to defacate. As she
was getting up to go to the bathroom she felt presyncopal and
nauseas and layed down. Symptoms improved when laying down, and
she denied any CP, CT, palpitations but did feel diaphoretic.
She was given an aspirin and vital signs revealed HR 58-64 and
SBP 78-95. She was given another 500cc bolus with no improvement
in SBP so she was sent to the ED for further evaluation. Prior
to admisssion she reports some baseline DOE since her lobectomy
but was otherwise feeling well. She had been admitted to an OSH
6 weeks ago for PNA and developed diarrhea from the antibiotics
without black or bloody stool but this all resolved 3 weeks ago.
.
In the ED she was persistently hypotensive and was administered
2L NS and ECG revealed new TWI in V2-4. CXR revealed no CHF,
infiltrate, or pneumothorax. Due to persistent hypotension with
no clear source she was admitted to the ICU for further
monitoring.
Past Medical History:
-LLL adenocarcinoma s/p VATS and LLL lobectomy [**8-/2173**] (poorly
differentiated, nodes negative)
-HTN
-Hypercholesterolemia
-CAD s/p 3v-CABG [**2168**], LIMA-LAD stent [**1-22**]
-Carotid stenosis
-Prior TIA's
-GIB [**2-/2173**], found to have gastritis and duodenitis
-Diverticulosis
-SLE(cutaneous only)
-Raynaud's
-s/p PE and IVC filter
-CHF with preserved EF
-afib not anticoagulated (given GIB h/o)
.
PSH:
-LLL lobectomy [**8-22**]
-TAH 40 yrs ago
-Appendectomy
-Breast lumpectomy x2
-tonsillectomy
-cataract repair
Social History:
Married, lives with husband. Smoked 40-pack yrs, quit [**2165**].
Drinks [**1-18**] glasses wine daily. Used to work as a tour guide
Family History:
Mother died of complications of dementia at 79, father died of
MI at 57, granddaughter died of glioblastoma.
Physical Exam:
T 96.5 HR 82 BP 133/75 RR 16 O2sat 99% [**Female First Name (un) **]
Gen-sitting up in bed in NAD
HEENT-PERRL, no elev JVP, MMM, bilat carotid bruits
Hrt-irreg irreg rhythm, nS1S2 [**3-22**] HSM at LUSB
Lungs-CTA bilat
Abd-soft, midline scar, NT, ND, no HSM
Extrem-2+ rad and dp pulses, no LE edema, warm and well perfused
Neuro-A and O x3, CNII-XII intact, [**5-21**] UE and LE strength
Pertinent Results:
[**2174-6-14**] 01:40PM WBC-8.4 RBC-3.80*# HGB-12.7# HCT-38.4#
MCV-101* MCH-33.4* MCHC-33.0 RDW-14.8
[**2174-6-14**] 01:40PM NEUTS-84.5* BANDS-0 LYMPHS-9.2* MONOS-4.8
EOS-1.1 BASOS-0.4
[**2174-6-14**] 01:40PM CK-MB-3 cTropnT-<0.01
[**2174-6-14**] 05:22PM LACTATE-1.8
[**2174-6-14**] 01:40PM BLOOD Glucose-149* UreaN-9 Creat-0.7 Na-132*
K-5.0 Cl-98 HCO3-24 AnGap-15
.
ECG afib at 60, nl axis, new TWI in V1-v4, biphasic T in III no
other ST or T changes
Brief Hospital Course:
In the ICU, she was observed and her anti-hypertensives were
held yesterday. Her BPs ranged in the 120-150s, and her HR
remained 70s-110s. Her metoprolol was restarted and she was
called out to the floor. On the floor, she was initially put on
short-acting diltiazem which was then switched back to her home
regimen of sustained-release diltiazem. She was monitored on
telemetry and was rate-controlled with HR 60s-80s by the time of
discharge. She was noted to be hyponatremic, but this was at
baseline. She was initially thought to have a hematocrit drop,
but this was confirmed to be a lab anomaly. She will follow up
with Dr. [**Last Name (STitle) 952**] next week.
Medications on Admission:
-Aciphex 10mg daily
-Lisinopril 5mg daily
-ASA 81mg daily
-Clopidogrel 75mg daily
-Metoprolol 25mg [**Hospital1 **]
-Diltiazem SR 240mg daily
-Zetia 10mg daily
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: 0.5 Tablet,
Delayed Release (E.C.) PO once a day.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
hypotension
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with a low blood pressure
following your bronchoscopy. Blood tests showed no evidence of
any infection or heart attack. It is likely that this low blood
pressure was from the sedation you had for the bronchoscopy. No
changes were made to any of your home medications.
.
Please attend all followup appointments. Please take all
medications as prescribed.
.
If you experience high fevers, chest pain, difficulty breathing,
loss of consciousness, or other concerning symptoms, then you
need to seek medical attention.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**0-0-**] Date/Time:[**2174-6-21**]
11:00
.
Please follow up with your primary care physician as previously
scheduled.
|
[
"V10.11",
"458.29",
"E879.8",
"V45.82",
"710.0",
"V45.81",
"428.0",
"253.6",
"E849.7",
"511.9",
"562.10",
"414.00",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
"88.79",
"33.27",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
4911, 4917
|
3538, 4215
|
309, 315
|
4972, 4980
|
3053, 3515
|
5581, 5789
|
2518, 2628
|
4425, 4888
|
4938, 4951
|
4241, 4402
|
5004, 5558
|
2643, 3034
|
258, 271
|
343, 1803
|
1825, 2352
|
2368, 2502
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,707
| 156,381
|
7337
|
Discharge summary
|
report
|
Admission Date: [**2128-5-25**] Discharge Date: [**2128-5-30**]
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Aspirin / Plavix
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion, recent CHF admission
Major Surgical or Invasive Procedure:
[**5-25**] 1. Aortic valve replacement with a size 19
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue valve. 2. Coronary artery bypass
graft x3, left internal mammary artery to left anterior
descending artery and saphenous vein grafts to diagonal and
obtuse marginal arteries.
Past Medical History:
Severe aortic stenosis s/p Aortic valve replacement
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Chronic systolic congestive heart failure
Atrial fibrillation
Hypertension
Hyperlipidemia
Moderate mitral regurgitation
Gout
Ischemic colitis with LGIB x 3-4 times, last one month ago
Diverticulosis
Plasmacytoma vs lymphoproliferative disorder
Duodenal angioectasia
Bladder cancer ??????currently undergoing treatment with BCG
injection once weekly
Newly discovered EF 40%
2l Oxygen at night
hernia repair
tonsillectomy and uvulectomy
left cataract surgery
Social History:
Home:Lives with a lot of family in a 13 bedroom home.
Occupation: retired [**Company 2676**] worker. She has worked both in
electronic assembly and in the office, although she denies
either radiation or toxin exposure.
EtOH: Denies
Drugs: Denies
Tobacco: 5- or 8-pack-year history of smoking
Family History:
Mother - died of [**Name (NI) 2481**] disease
Father - died of unknown form of cancer
Brother - melanoma
Brother - died of a myocardial infarction.
Physical Exam:
Pulse: 59 SB Resp: 16 O2 sat: 99%RA
B/P Right: 156/52 Left:
Height: 5' Weight: 128lb
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [] left pupil fixed ~4mm, right round and
reactive to light
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur x 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] well healed scar of ventral hernia repair, ventral hernia
present
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] no edema or varicosities
Neuro: Grossly intact x
Pulses:
Femoral Right: cath site Left: 1+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: radiation of cardiac murmur
Pertinent Results:
Echo [**2128-5-25**]: 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. There is mild symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is low
normal (LVEF 50-55%). with normal free wall contractility. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Mild to moderate ([**2-7**]+) mitral regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
Brief Hospital Course:
Ms. [**Known lastname **] is a same day admission after undergoing all
pre-operative work-up during her recent hospitalization. Upon
admission she was brought directly to the operating room where
she underwent a aortic valve replacement and coronary artery
bypass graft x 3. Please see operative report for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours she was
weaned from sedation awoke neurologically intact and extubated.
Beta blockers and diuretics were initiated and she was diuresed
towards he pre-op weight. On post-op day one she was transferred
to the telemetry floor for further care. Chest tubes and
epicardial pacing wires were removed per protocol.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility.
By the time of discharge on POD #5 Mrs. [**Known lastname **] was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to her [**Known lastname 802**]'s home in
good condition with appropriate follow up instructions and VNA
services.
Medications on Admission:
ALLOPURINOL - (Dose adjustment - no new Rx) - 300 mg Tablet -
0.5 (One half) Tablet(s) by mouth once a day
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 40 mg Tablet - 0.5 (One half) Tablet(s) by mouth every
other day
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
Medications - OTC
CALCIUM-VITAMIN D3-VITAMIN K [VIACTIV] - (Prescribed by Other
Provider) - Dosage uncertain
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
three times a day as needed for constipation Take this
medication
while taking narcotic pain medications.
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 400 unit
Capsule - 1 capsule by mouth twice a day
FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 2 Tablet(s) by
mouth once per day as needed for take with [**Location (un) 2452**] juice or
vitamin c
PSYLLIUM [METAMUCIL] - (Prescribed by Other Provider) - 0.52
gram Capsule - 1 Capsule(s) by mouth once a day
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for PAIN/FEVER.
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
10. 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*
11. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day: after
7 days decrease dose to 1 tablet every other day.
Disp:*60 Tablet(s)* Refills:*2*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day: take
two tablets for 7days then 1 tablet every other day with lasix
pill.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Severe aortic stenosis s/p Aortic valve replacement
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Chronic systolic congestive heart failure
Atrial fibrillation
Hypertension
Hyperlipidemia
Moderate mitral regurgitation
Gout
Ischemic colitis with LGIB x 3-4 times, last one month ago
Diverticulosis
Plasmacytoma vs lymphoproliferative disorder
Duodenal angioectasia
Bladder cancer ??????currently undergoing treatment with BCG
injection once weekly
Newly discovered EF 40%
2l Oxygen at night
hernia repair
tonsillectomy and uvulectomy
left cataract surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics prn
Sternal incision clean and dry
left leg harvest incision healing
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**] in [**2-7**] weeks
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2128-6-28**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2128-6-7**] 9:20
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2128-5-30**]
|
[
"537.82",
"188.9",
"272.4",
"V45.61",
"424.0",
"428.22",
"285.9",
"401.9",
"428.0",
"414.01",
"427.31",
"274.9",
"562.10",
"424.1",
"E942.0",
"V45.89",
"794.31",
"426.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7153, 7210
|
3401, 4545
|
284, 577
|
7845, 8013
|
2505, 3378
|
8637, 9181
|
1518, 1667
|
5704, 7130
|
7231, 7344
|
4571, 5681
|
8037, 8614
|
1682, 2486
|
203, 246
|
7366, 7824
|
1208, 1502
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,914
| 135,433
|
43998
|
Discharge summary
|
report
|
Admission Date: [**2105-6-11**] Discharge Date: [**2105-6-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy [**2105-6-12**]
Colonoscopy [**2105-6-12**]
History of Present Illness:
Mr. [**Known lastname 94500**] is an 83 year-old male with a history of atrial
fibrillation on Coumadin therapy, CAD status post angioplasty in
[**2094**]/[**2095**], HTN and DM type 2, with a prior 4-unit GI bleed in
[**2102**] while on Coumadin with work-up remarkable for antral
polyps, [**Last Name (un) 865**] esophagus, C-scope with colonic polyps without
bleeding, and negative capsule endoscopy, who now returns with a
1-day history of "black stools". Of note, he was transfused 1
unit of PRBCs in [**3-/2105**] at the time of his CEA for Hct 23.4,
and was transfused an additional 2 units of PRBCs last week at
[**Hospital 4068**] hospital, Hct unclear.
He reports some constipation over the past few days. He moved
his bowels yesterday morning, brown stools, with some straining.
He subsequently had one loose BM with dark stools on the toilet
paper, and another BM with black stools with some bright blood
in the toilet. He then decided to seek medical attention. He
describes transient lightheadedness last night, resolved. No
chest pain (he never had chest pain, prior cardiac presentations
with dizziness), no shortness of breath. No N/V. No abdominal
pain. No fever or chills at home. No history of EtOH. No NSAIDs.
He remains on ASA and Coumadin daily. ROS negative for weight
loss.
In ED, T 98.9, HR 98, BP 99/52, RR 18. Sat 99% on RA. An NG
lavage was performed, which was negative (no return of bile).
DRE with maroon-colored stools. INR returned at 1.9, and he was
given Vitamin K 5 mg SC X1, and FFP X2 units. His hematocrit
also returned at 26.5, and he was transfused 2 units of PRBCs,
without improvement and with further drop in Hct to 23. 2
additional units were given (ongoing at time of transfer). GI
was consulted. While in the ED, he had a large loose BM with
[**Last Name (un) 30212**] stools. He remained hemodynamically stable. He is being
admitted to the ICU for further management.
Past Medical History:
1. Atrial fibrillation on Coumadin therapy
2. Hypertension
3. DM type 2, last HbA1c on file 7.7 in [**5-/2104**]
4. CAD status post angioplasty to LAD and D1 in [**2094**], status
post angioplasty to LAD and D2 in [**2095**]. Persantine MIBI in
[**2-/2105**] with reversible, small, mild perfusion defect involving
the LAD territory and transient cavity dilation.
5. Carotid stenosis status post left carotid endarterectomy with
Dacron patch angioplasty on [**2105-4-6**].
6. Prostate cancer about 11 years ago, status post resection.
7. History of GI bleed in [**2102**], 4 units of PRBCs. EGD with
antral polyps, [**Last Name (un) 865**] esophagus, C-scope with colonic polyps
without bleeding, negative capsule endoscopy. No clear source of
bleeding found.
8. Chronic iron deficiency anemia
9. Hyperlipidemia
10. Barrett's esophagus as noted above, colonic adenoma in [**2102**].
11. Asthma
Social History:
He lives with his wife at home. They have 3 grown children, and
7 grandchildren. He does not smoke, no EtOH X 3 years
Family History:
Non-contributory.
Physical Exam:
VITALS: Afebrile, BP 136/64, HR 88, RR 17, Sat 100% on RA.
GEN: In NAD.
HEENT: Slightly dry MM, anicteric.
NECK: JVP flat.
RESP: Distant heart sounds, no murmur appreciated.
CVS: CTAB, without adventitious sounds.
GI: Obese abdomen, soft and non-tender.
DRE (repeated in ICU): Maroon stools.
EXT: Palpable pedal pulses. Warm extremities, no pedal edema.
Pertinent Results:
Relevant laboratory data on admission:
CBC:
[**2105-6-10**] 03:19PM WBC-4.7 RBC-3.22* HGB-8.7* HCT-26.5* MCV-83
MCH-27.1 MCHC-32.8 RDW-15.6* PLT COUNT-197
NEUTS-81.5* LYMPHS-13.3* MONOS-4.4 EOS-0.4 BASOS-0.4
Chemistry:
GLUCOSE-217* UREA N-51* CREAT-1.5* SODIUM-139 POTASSIUM-5.2*
CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
Coagulation:
PT-19.8* PTT-34.4 INR(PT)-1.9*
Cardiac enzymes:
[**2105-6-10**] 03:19PM [**2105-6-10**] 03:19PM CK(CPK)-53
[**2105-6-10**] 03:19PM CK-MB-NotDone cTropnT-<0.01
[**2105-6-11**] 08:41AM CK(CPK)-63
[**2105-6-11**] 08:41AM CK-MB-2 cTropnT-<0.01
EKG in ED: Atrial fibrillation, rate 114 bpm, LAD, old LAFB and
RBBB, Qs II, III, aVF, poor R wave progresion, old TWI in V1-4.
No change versus prior.
Relevant imaging data:
[**2105-6-11**] Colonoscopy: Normal mucosa in the whole colon.
Otherwise normal colonoscopy to cecum.
[**2105-6-11**] SMALL BOWEL ENTEROSCOPY: A small size hiatal hernia was
seen. A salmon colored mucosa distributed in a localized
pattern, suggestive of Barrett's Esophagus was found. Many
polyps of benign appearance were found in the stomach body and
antrum. One polyp in the body was ulcerated with stigmata of
recent bleeding. Duodenum: Protruding lesions. A single
pedunculated polyp with stigmata of recent bleeding was found in
the proximal bulb. It was observed prolapsing into the stomach
through the pylorus. Jejunum: Normal jejunum. There was no blood
seen to mid jejunum.
Brief Hospital Course:
Mr. [**Known lastname 94500**] is an 83 year-old male with atrial fibrillation on
Coumadin with INR 1.9, CAD on ASA, DM type 2, with prior GI
bleeding without a clear source identified, admitted to the ICU
with a 1-day history of maroon stools with Hct drop. His
hospital course will be reviewed by problems.
1) GI bleed: As noted above, an NG lavage performed in the ED
was negative for blood, but limited by lack of bilious return.
His hematocrit nadir was 24, and he was admitted to the ICU for
further care. He was transfused a total of 7 units of PRBCs
during his hospital stay, and 3 units of FFP for emergent
reversal of Warfarin. Vitamin K was also administered. His ASA
and coumadin were held on admission. GI was consulted, and a
push enteroscopy was performed on [**2105-6-11**], remarkable for
Barrett's esophagus, and polyps in the antrum and stomach body,
one of which was ulcerated with stigmata of recent bleeding. A
duodenal polyp was also seen prolapsing through the pylorus,
also with stigmata of recent bleeding. A colonoscopy was
unremarkable. It is likely that the ulcerated polyps accounted
for his GI bleeding, although the presentation with
maroon-colored stools and BRBPR with lack of hemodynamic
instability is somewhat unusual. While in the ICU, his bloody
bowel movements resolved (last during bowel prep on [**2105-6-11**] in
AM).
Recommendation was made to proceed with a repeat upper endoscopy
on [**6-16**] (with Dr. [**Last Name (STitle) 172**] for polypectomy. His ASA and Coumadin
will remain on hold until that time. We will leave it to Dr.
[**Last Name (STitle) 172**] to decide upon timing to resume
anticoagulation/antiplatelet therapy. His hematocrit at
discharge was 30.2. He was discharged home from the ICU.
2) CAD: His EKG in the ED was at baseline, and he was ruled out
with serial cardiac biomarkers. His antihypertensives were held
on admission (Enalapril and Diltiazem), as well as ASA. He was
continued on Lipitor. There were no issues during his hospital
stay. Enalapril and Diltiazem were both resumed prior to
discharge.
3) Atrial fibrillation: As noted above, Coumadin was held at the
time of admission. He remained in atrial fibrillation, with
occasional rapid ventricular response to the 110s. His
Diltiazem, which was transiently held, was resumed prior to
discharge. His Coumadin remains on hold at the time of discharge
pending repeat upper endoscopy. The decision to resume
anticoagulation will be left to his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 172**].
4) DM type 2: He was placed on a regular insulin sliding scale
in the ICU for glycemic control. His Avandia was resumed prior
to discharge.
5) Acute on chronic renal insufficiency: His creatinine on
admission was 1.5, up from a baseline of 1.2 in 04/[**2104**]. His
creatinine improved with volume expansion, ultimately attributed
to pre-renal azotemia.
Medications on Admission:
Albuterol 1-2 puffs [**Hospital1 **]
Flovent 110 mcg [**Hospital1 **]
Warfarin 5 mg PO QD
Lipitor 20 mg PO QD
Enalapril 5 mg PO QD
Avandia 8 mg PO QD
Omeprazole 20 mg PO QD
Diltazem 240 mg PO QD
ASA 325 mg PO QD
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
Atrial fibrillation
Discharge Condition:
Patient discharged home in stable condition. Hematocrit at
discharge 30.2.
Discharge Instructions:
Please call your PCP or return to the hospital if you develop
recurrent bleeding from your rectum, or if you develop shortness
of breath, or chest pain.
You are scheduled for a repeat endoscopy on Tuesday [**2105-6-16**]
with Dr. [**Last Name (STitle) 172**]. DO NOT TAKE ASPIRIN, DO NOT TAKE COUMADIN until
advised otherwise by Dr. [**Last Name (STitle) 172**].
Please note that we have started a new medication called
Protonix. Please take 1 tablet twice daily. Take it instead of
Omeprazole. If you have difficulties with filling the
prescription, then you can take Omeprazole twice daily.
Followup Instructions:
1. You are scheduled for a repeat endoscopy on Tuesday [**6-16**]
with Dr. [**Last Name (STitle) 172**]. It is crucial that you go to this appointment.
Please contact his office on [**Name (NI) 766**] ([**Telephone/Fax (1) 133**]) to ask for
any specific preparation prior to Tuesday.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2105-6-13**]
|
[
"211.1",
"427.31",
"530.85",
"414.01",
"V10.46",
"493.90",
"584.9",
"578.1",
"V45.82",
"280.9",
"272.4",
"403.91",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"96.33",
"99.07",
"45.16",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9146, 9152
|
5269, 8167
|
297, 370
|
9231, 9308
|
3796, 3821
|
9951, 10403
|
3387, 3406
|
8429, 9123
|
9173, 9210
|
8193, 8406
|
9332, 9928
|
3421, 3777
|
4181, 5246
|
230, 259
|
398, 2318
|
3835, 4164
|
2340, 3236
|
3252, 3371
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,062
| 160,576
|
39376+58292+58297
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2148-1-2**] Discharge Date: [**2148-1-19**]
Date of Birth: [**2068-11-10**] Sex: M
Service: SURGERY
Allergies:
sulfasalazine
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Crohn's disease, parastomal hernia, and prolapsing stoma.
Major Surgical or Invasive Procedure:
Left colectomy with takedown of splenic flexure; complete
proctectomy; appendectomy; repair of parastomal hernia; revision
of the colostomy.
History of Present Illness:
The patient is a 79-year-old male with severe Crohn's disease,
mostly in the rectosigmoid. He had a loop colostomy which was
eventually converted to an end colostomy. He had severe disease
in the rectum and was unable to be examined with a large
parastomal hernia and prolapse interfering with stoma function.
The patient presented to [**Hospital1 18**] for elective surgical managment
of these issues.
Past Medical History:
Chron's disease
Afib
HTN
HL
DM2
asthma
BPH
arthritis
depression
OSA: pnt has CPAP at home but does not use it.
.
PSH: anal stricturoplasty x 2, loop descending colostomy [**3-17**],
colostomy revision to end colostomy [**6-16**] ([**Hospital3 **]), open
CCY '[**41**], R inguinal hernia x2, L5 sacral fusion
Social History:
2ppd x 58yrs, rare EtOH (once monthly). Lives
with wife. ADL independent. Has 5 children and 42 grandchildren
and great-grand children.
.
Family History:
N/C
Physical Exam:
On ICU admission:
Vitals: T: 98.1 BP: 150/49 HR: 97 RR: 25 O2Sat: 88% on RA 94% on
40% FiO2
GEN: A+Ox3, appears weak, tachypnic but not dyspneic
HEENT: pallor, no Jaundice, EOMI, PERRLA, sclera anicteric, dry
MM
NECK: No JVD, trachea midline
COR: [**Last Name (un) **], no M/G/R, radial pulses +2
PULM: reduced air entry over lower lung fields with bibasilar
insp crackles.
ABD: Distended, diffuse tenderness w/o r/g,+BS, stapled surgical
wounds vertical mid lower abdomen and horizontal left lower
abdomem appear well healed with minimal surrounding erythema w/o
discharge, drain in place c/c/e, colostomy with propapse 3-4 cm,
pink edematous looking mucosa, brown liquid output in bag.
EXT: No C/C/E, normal peripheral pulses
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: no rash
On Discharge:
Pertinent Results:
[**2148-1-19**] 06:09AM BLOOD WBC-15.0* RBC-2.99* Hgb-8.6* Hct-26.7*
MCV-89 MCH-28.8 MCHC-32.3 RDW-14.1 Plt Ct-UNABLE TO
[**2148-1-18**] 05:09AM BLOOD WBC-16.0* RBC-3.14* Hgb-9.3* Hct-28.3*
MCV-90 MCH-29.5 MCHC-32.7 RDW-14.2 Plt Ct-144*
[**2148-1-17**] 05:28AM BLOOD WBC-16.3* RBC-3.14* Hgb-9.2* Hct-27.2*
MCV-87# MCH-29.3 MCHC-33.9 RDW-13.8 Plt Ct-UNABLE TO
[**2148-1-16**] 05:55AM BLOOD WBC-15.4* RBC-3.16* Hgb-9.8* Hct-30.8*
MCV-98# MCH-30.9 MCHC-31.6 RDW-13.7 Plt Ct-UNABLE TO
[**2148-1-15**] 05:30AM BLOOD WBC-16.4* RBC-3.43* Hgb-9.9* Hct-30.2*
MCV-88 MCH-28.9 MCHC-32.8 RDW-13.7 Plt Ct-171
[**2148-1-13**] 04:58AM BLOOD WBC-19.3* RBC-3.35* Hgb-10.0* Hct-29.4*
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.6 Plt Ct-UNABLE TO
[**2148-1-12**] 05:07AM BLOOD WBC-16.8* RBC-3.27* Hgb-9.7* Hct-28.6*
MCV-88 MCH-29.7 MCHC-33.9 RDW-13.3 Plt Ct-164
[**2148-1-11**] 05:25AM BLOOD WBC-14.9* RBC-3.44* Hgb-9.7* Hct-29.8*
MCV-87 MCH-28.3 MCHC-32.7 RDW-13.5 Plt Ct-UNABLE TO
[**2148-1-11**] 05:25AM BLOOD WBC-14.2* RBC-3.17* Hgb-9.3* Hct-28.8*
MCV-91 MCH-29.2 MCHC-32.2 RDW-13.5
[**2148-1-10**] 04:07AM BLOOD WBC-11.9* RBC-3.37* Hgb-9.9* Hct-30.2*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.3 Plt Ct-UNABLE TO
[**2148-1-9**] 02:34AM BLOOD WBC-14.9* RBC-3.31* Hgb-10.1* Hct-29.1*
MCV-88 MCH-30.6 MCHC-34.9 RDW-13.4 Plt Ct-UNABLE TO
[**2148-1-7**] 08:55AM BLOOD WBC-11.4* RBC-3.76* Hgb-11.1* Hct-33.3*
MCV-89 MCH-29.6 MCHC-33.3 RDW-13.2 Plt Ct-UNABLE
[**2148-1-6**] 10:35AM BLOOD WBC-12.1* RBC-3.85* Hgb-11.3* Hct-33.1*
MCV-86 MCH-29.3 MCHC-34.1 RDW-13.1 Plt Ct-UNABLE
[**2148-1-5**] 06:30AM BLOOD WBC-10.8 RBC-3.61* Hgb-10.7* Hct-31.7*
MCV-88 MCH-29.6 MCHC-33.7 RDW-13.4 Plt Ct-ERROR
[**2148-1-4**] 06:20AM BLOOD WBC-12.8* RBC-3.51* Hgb-10.5* Hct-31.4*
MCV-89 MCH-29.9 MCHC-33.5 RDW-13.5 Plt Ct-UNABLE TO
[**2148-1-3**] 09:30AM BLOOD WBC-17.6* RBC-3.80* Hgb-11.1* Hct-34.2*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.5
[**2148-1-3**] 06:30AM BLOOD WBC-16.9*# RBC-3.91* Hgb-11.4* Hct-35.1*
MCV-90 MCH-29.2 MCHC-32.5 RDW-13.7 Plt Ct-UNABLE TO
[**2148-1-2**] 02:32PM BLOOD Hct-36.4*
[**2148-1-16**] 05:55AM BLOOD Neuts-92* Bands-0 Lymphs-3* Monos-3 Eos-1
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2148-1-13**] 04:58AM BLOOD Neuts-87.5* Lymphs-5.3* Monos-5.9 Eos-0.8
Baso-0.5
[**2148-1-10**] 04:07AM BLOOD Neuts-87* Bands-0 Lymphs-5* Monos-7 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2148-1-16**] 05:55AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2148-1-10**] 04:07AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL
[**2148-1-19**] 06:09AM BLOOD Plt Smr-UNABLE TO Plt Ct-UNABLE TO
[**2148-1-19**] 06:09AM BLOOD PT-17.5* INR(PT)-1.6*
[**2148-1-18**] 11:34AM BLOOD PT-15.1* PTT-35.1* INR(PT)-1.3*
[**2148-1-18**] 05:09AM BLOOD Plt Ct-144*
[**2148-1-17**] 05:28AM BLOOD Plt Ct-UNABLE TO
[**2148-1-17**] 05:28AM BLOOD PT-14.5* PTT-32.3 INR(PT)-1.3*
[**2148-1-16**] 05:55AM BLOOD Plt Smr-UNABLE TO Plt Ct-UNABLE TO
[**2148-1-15**] 05:30AM BLOOD Plt Ct-171
[**2148-1-10**] 04:07AM BLOOD PT-15.3* PTT-33.4 INR(PT)-1.3*
[**2148-1-9**] 02:34AM BLOOD PT-15.2* PTT-31.7 INR(PT)-1.3*
[**2148-1-8**] 06:53PM BLOOD PT-14.9* PTT-31.4 INR(PT)-1.3*
[**2148-1-17**] 05:28AM BLOOD Glucose-144* UreaN-15 Creat-0.9 Na-139
K-4.2 Cl-106 HCO3-29 AnGap-8
[**2148-1-16**] 08:20AM BLOOD Glucose-142* UreaN-14 Creat-0.8 Na-142
K-3.8 Cl-106 HCO3-30 AnGap-10
[**2148-1-16**] 05:55AM BLOOD Glucose-1233* UreaN-12 Creat-1.0 Na-130*
K-8.2* Cl-103 HCO3-26 AnGap-9
[**2148-1-15**] 05:30AM BLOOD Glucose-127* UreaN-14 Creat-0.7 Na-143
K-3.8 Cl-106 HCO3-32 AnGap-9
[**2148-1-14**] 04:55AM BLOOD Glucose-125* UreaN-13 Creat-0.7 Na-140
K-3.6 Cl-103 HCO3-33* AnGap-8
[**2148-1-13**] 04:58AM BLOOD Glucose-200* UreaN-11 Creat-0.8 Na-139
K-3.2* Cl-101 HCO3-33* AnGap-8
[**2148-1-12**] 05:07AM BLOOD Glucose-149* UreaN-8 Creat-0.8 Na-140
K-3.4 Cl-104 HCO3-32 AnGap-7*
[**2148-1-11**] 05:25AM BLOOD Glucose-163* UreaN-8 Creat-0.8 Na-139
K-3.2* Cl-103 HCO3-28 AnGap-11
[**2148-1-11**] 05:25AM BLOOD Glucose-704* UreaN-8 Creat-0.8 Na-134
K-4.5 Cl-100 HCO3-27 AnGap-12
[**2148-1-10**] 04:07AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-139
K-3.9 Cl-107 HCO3-26 AnGap-10
[**2148-1-9**] 12:45PM BLOOD UreaN-12 Creat-0.8 Na-137 K-3.8 Cl-105
HCO3-29 AnGap-7*
[**2148-1-9**] 02:34AM BLOOD Glucose-128* UreaN-16 Creat-1.0 Na-136
K-5.5* Cl-105 HCO3-27 AnGap-10
[**2148-1-8**] 06:53PM BLOOD Glucose-165* UreaN-16 Creat-0.9 Na-138
K-4.0 Cl-105 HCO3-24 AnGap-13
[**2148-1-8**] 06:50AM BLOOD Glucose-104* UreaN-12 Creat-0.8 Na-139
K-3.6 Cl-104 HCO3-27 AnGap-12
[**2148-1-7**] 08:55AM BLOOD Glucose-133* UreaN-12 Creat-0.8 Na-139
K-3.6 Cl-105 HCO3-28 AnGap-10
[**2148-1-6**] 10:35AM BLOOD Glucose-151* UreaN-14 Creat-0.9 Na-137
K-4.0 Cl-101 HCO3-29 AnGap-11
[**2148-1-4**] 06:20AM BLOOD Glucose-147* UreaN-24* Creat-1.2 Na-138
K-4.2 Cl-104 HCO3-28 AnGap-10
[**2148-1-3**] 09:30AM BLOOD Glucose-114* UreaN-22* Creat-1.0 Na-137
K-4.5 Cl-105 HCO3-29 AnGap-8
[**2148-1-3**] 06:30AM BLOOD Glucose-128* UreaN-20 Creat-1.0 Na-138
K-7.0* Cl-105 HCO3-28 AnGap-12
[**2148-1-2**] 02:32PM BLOOD Na-140 K-3.8 Cl-107
[**2148-1-10**] 04:07AM BLOOD ALT-11 AST-15 LD(LDH)-197 AlkPhos-116
TotBili-0.4
[**2148-1-9**] 02:34AM BLOOD ALT-13 AST-29 LD(LDH)-420* AlkPhos-131*
TotBili-0.4
[**2148-1-8**] 06:53PM BLOOD ALT-16 AST-19 LD(LDH)-215 AlkPhos-135*
TotBili-0.6
[**2148-1-7**] 06:20AM BLOOD CK(CPK)-41*
[**2148-1-7**] 12:40AM BLOOD CK(CPK)-44*
[**2148-1-17**] 05:28AM BLOOD Calcium-7.7* Phos-3.7 Mg-1.9
[**2148-1-16**] 08:20AM BLOOD Calcium-8.1* Phos-3.3# Mg-2.0
[**2148-1-16**] 05:55AM BLOOD Calcium-8.5 Phos-8.3*# Mg-2.7*
[**2148-1-15**] 05:30AM BLOOD Calcium-7.8* Phos-3.5 Mg-1.9
[**2148-1-14**] 04:55AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.9
[**2148-1-13**] 04:58AM BLOOD Calcium-7.6* Phos-3.2 Mg-1.9
[**2148-1-12**] 05:07AM BLOOD Calcium-7.5* Phos-3.5 Mg-2.0
[**2148-1-11**] 05:25AM BLOOD Calcium-7.5* Phos-3.3 Mg-1.8
[**2148-1-10**] 04:07AM BLOOD Calcium-7.3* Phos-2.8 Mg-1.9
[**2148-1-9**] 12:45PM BLOOD Calcium-7.6* Phos-2.6* Mg-1.9
[**2148-1-9**] 02:34AM BLOOD Albumin-2.7* Calcium-7.3* Phos-3.6 Mg-2.0
[**2148-1-8**] 06:53PM BLOOD Albumin-3.0* Calcium-7.8* Phos-3.7 Mg-2.1
[**2148-1-7**] 08:55AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.9
[**2148-1-18**] 08:14AM BLOOD Vanco-23.6*
[**2148-1-16**] 06:03PM BLOOD Vanco-21.3*
[**2148-1-12**] 09:27PM BLOOD Vanco-12.5
[**2148-1-11**] 05:25AM BLOOD Vanco-12.8
[**2148-1-10**] 04:07AM BLOOD Vanco-11.2
[**2148-1-13**] 04:58AM BLOOD Digoxin-0.8*
[**2148-1-10**] 04:07AM BLOOD Digoxin-1.5
[**2148-1-9**] 02:34AM BLOOD Digoxin-2.1*
[**2148-1-4**] 06:20AM BLOOD Digoxin-1.2
[**2148-1-10**] 04:26AM BLOOD Type-[**Last Name (un) **] Temp-39.1 pO2-44* pCO2-56*
pH-7.35 calTCO2-32* Base XS-3 Comment-AXILLARY
[**2148-1-10**] 04:26AM BLOOD Lactate-0.8
[**2148-1-8**] 07:03PM BLOOD Lactate-1.1
CT ABD & PELVIS W/O CONTRAST Study Date of [**2148-1-8**] 10:55 PM
IMPRESSION:
1. Small-bowel obstruction with transition point at the mid
ilium adjacent to (but not related to) the transverse end
colostomy. The stomach is not
decompressed despite the presence of a nasogastric tube.
2. Large volume pneumoperitoneum, likely secondary to recent
laparotomy.
3. Moderately large bilateral pleural effusions with associated
compressive
atelectasis and moderately large non-hemorrhagic pericardial
effusion.
CT ABD/Chest & PELVIS WITH CONTRAST Study Date of [**2148-1-12**] 1:28
PM
IMPRESSION:
1. Enlarging bilateral pleural effusions which do not have
appearance
suspicious for empyema are accompanied by new septal thickening,
the overall appearances in addition to an enlarging pericardial
effusion suggest congestive heart failure.
2. Decompression of distended small bowel since [**2148-1-8**].
3. Interval decrease in volume of free intra-abdominal air after
laparotomy.
4. No evidence of abscess.
CHEST (PA & LAT) Study Date of [**2148-1-13**] 2:59 PM
IMPRESSION: AP chest compared to [**1-9**] through 3:
Moderate enlargement of the cardiac silhouette has improved and
small
bilateral pleural effusions, left greater than right, have
decreased.
Bibasilar atelectasis is relatively mild. Upper lungs are clear
and there is no pulmonary vascular engorgement or edema.
Mediastinal veins are not
dilated. Right PIC line passes at least as far as the upper
right atrium,
approximately 2 cm beyond the estimated location of the superior
cavoatrial junction, but the tip is not distinct.
Residual pneumoperitoneum is small. Nasogastric tube ends in the
upper
stomach. No pneumothorax.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2148-1-15**]
8:13 AM
IMPRESSION:
No evidence of deep venous thrombosis.
CHEST (PA & LAT) Study Date of [**2148-1-17**] 9:08 AM
1. Improved aeration of the left lung.
2. Stable small bilateral pleural effusions.
ABDOMEN (SUPINE & ERECT) Study Date of [**2148-1-17**] 9:58 AM
IMPRESSION: Nonspecific bowel gas pattern with no evidence of
obstruction.
Brief Hospital Course:
The patient was admitted to the inpatient unit status-post Left
colectomy with takedown of splenic flexure; complete
proctectomy; appendectomy; repair of parastomal
hernia; revision of the colostomy. The patient was stable on the
floor, he was monitored closely on telemetry for atrial
fibrillation, hydrated with intravenous fluids, and pain was
controlled with intravenous pain medications. On post-operative
day one he remained NPO with IV hydration because of his
extensive surgical procedure. On post-operative day two, the
patient was started on a clear liquid diet and hydration
continued. The patient complained of a small amount of nausea
and splinting and his diet was decreased to sips of clear
liquids. The appearance of the stoma was monitored closely and
it was noted to be slightly edematous which prompted the
surgical team to closely monitor his volume status. On
post-operative day [**2-9**] the patient was continued on sips of
clear liquids and had increasing abdominal distension. The PCA
remained for pain control and the patient continued get out of
bed. Geriatrics was consulted to assist in the medical
management of the patients complicated medical issues. On the
evening of post-operative day six the patient was noted to have
increased abdominal pain and distension. The patient was
transferred to the intensive care unit and a CT scan of the
abdomen and pelvis was obtained which showed small bowel
obstruction, distended stomach, small amount of ascites, small
amount of pneumoperitoneum, and small bilateral pleural
effusions. A nasogastric tube was placed. The details of the
patients ICU admission follow:
79 yo gentleman with med history including AF, HTN, DM2, HLD,
asthma, Crohn's disease s/p proctectomy + parastomal hernia
repair + revised colostomy [**1-2**] who was transferred to the [**Hospital Unit Name 153**]
from the surgery floor on [**1-8**] to worsening abdominal pain and
distention, hypoxia and oliguria and was found to have SBO.
# SBO: this was most likely [**1-10**] to adhesions after numerous
surgeries, CT also demonstrated pneumoporitoneum which likely
residual from surgery w/o evidence of perforation or
intraabdominal abscess, stomach was markedly distended. NG tube
was placed with output of upto 2L daily of bilious content. IV
metoclopramide was given for nausea. Abx coverage was started
with Vanco + Zocyn (day 1 [**1-8**]). Abdominal distension
subsequently markedly improved with improvement in pain and
resolution of patients nausea. Patient was transferred to the
surgery floor for further management.
.
#. SOB, desaturation, productive cough: Likely caused by
combination of underlying COPD, atelectasis d/t splinting from
pain and pleural effusions + difficult breathing d/t abdominal
distention. There was no evidence of pneumonia and no clinical
signs of CHF. PE could not be completely ruled out, but was
thought unlikely in the presence of another more likely
diagnosis and the absence of sign of DVT. Patient was treated
with incentive spirometry, nebs, pain control with improvement
in his SOB and hypoxia.
.
# Oliguria: was oliguric on ICU admission [**1-10**] to hypovolemia
from NG losses and third spacing, FeNA was 0.07%. UOP improved
with IVF and oliguria resolved. renal functions remained stable
throughout his ICU course.
.
#Anasarca with ascitis, pleural effusions and pericardial
effusions: [**1-10**] to hypoalbuminemia, no signs of tamponade
physiology/ no pulsus. TPN was started.
.
# Bacteriuria: associated with indwelling urethral catheter. UA
was moderately positive for WBC and RBC. Gram neg rods grew in
urine with speciation and sensitivities still pending at ICU
discharge. Patient was generally afebrile throughout course
except for one spike to 100.3. Pnt was under IV abx as above
(see SBO) which was considered adequate empirical coverage in
case of hospital acquired acquired UTI.
#. Chronic Afib: On diltiazem, digoxin and Coumadin at home. Had
some AF/RVR events post surgery which improved with adjustment
of PO Diltiazem and dig dosage on surgery floor. In the ICU
patient was made NPO, rate controlled was achieved by IV
metoprolol 10mg QID. Digoxin was initially held d/t
supratheraputic serum levels. Then started on day of ICU
discharge at IV equivalent of home dose (0.2mg). Patient has
CHADS2 score 3, home Coumadin was held and no antiplatelet [**Doctor Last Name 360**]
was given due to high risk for abdominal bleed per surgery team.
.
# Normocytic anemia: baseline Hct 39, stable at around 31 on
this admission since post op. Likely has mild anemia of chronic
disease now worsened d/t blood loss during surgery
.
# Unmeasurable platelets: PLT reported as ??????clumping?????? on all CBCs
since admission. PLT count in yellow tube 138.
.
# Depression: Saw geriatrics consult on Surgery floor which
recommended increasing citalopram dose to 30mg qday. In the ICU
citalopram was held as patient was NPO.
.
# PPx: SQ heparin 5000 TID, IV Pantoprazole 40mg QD
On post-operative day seven, a PICC line was placed and the
patient was started on TPN. On post-operative day eight, the
patient appears to be stabilizing and was transferred back to
the inpatient [**Hospital1 **] with the nasogastric tube in place. The
patient continued on intravenous antibiotics for treatment of
moderate amounts of erythema noted around the old stoma site and
vertical abdominal incision which drained a small amount of
drainage process and klebsiella urinary tract infection. He
received intravenous vancomycin and Zosyn to treat this
erythema. Unfortunately, the perianal incision line was noted to
be separating and this was seen by the wound/ostomy nursing team
also following the stoma and they recommended treatment with
Aquacel Ag and dry absorbent dressings. The patient's condition
continued to improve. The abdominal distension had improved and
on post-operative day 12 the nasogastric tube was removed after
an improved KUB and decreasing white blood cell count. The
patient began to sip clear liquids, the erythema around the
surgical sites improved, his Foley catheter was removed, and he
was able to void on his own. Because of a white blood cell count
of 21, the patient was pan cultured on post-operative day 12
which showed a negative urine culture, improved chest Xray, and
the patient's stool was negative for Cdiff. The patient was
closely monitored for this white blood cell count, and during
this time he remained afebrile and on discharge his white blood
cell count was 15.0 which was an improvement. LENI's were also
obtained to rule out an additional cause for this unexplained
white blood cell count which was negative for DVT. The patient
had moderate ostomy output and was advanced to a regular diet on
post-operative day fourteen. Until this time, the patients heart
rate and blood pressure had been controlled by intravenous
medications. His diltiazem was restarted however, the patient
was noted to be tachycardic to the 140's requiring intravenous
diltiazem and additional PO doses. Geriatrics recommended
discontinuing the extended release diltiazem 180 mg daily and
initiating 10mg of immediate release Diltiazem every 6 hours for
discharge to rehabilitation with the in assumption that this
will be titrated to an appropriate dose of sustained release
Diltiazem. The patients Digoxin was restarted at .25mg daily and
will need a Digoxin level checked on [**2148-1-21**]. The patient's
Coumadin was restarted at his home dose of 5mg daily and his INR
continues to respond with an INR of 1.6 at discharge. His goal
is [**1-11**] and this can be titrated at the rehabilitation hospital.
The patient participated in physical therapy throughout his time
on the inpatient [**Hospital1 **] and made great progress. After tapering
froom TPN he continued to eat a regular diet and has appropriate
return of bowel function after a dose of miralax. The erythema
noted on his abdomen continues to resolve and he will continue
Augmentin therapy for the prescribed duration. All surgical
drains and the PICC line were removed at the time of discharge.
The patient was stable with a resting heart rate in the
60's-70's at the time of discharge on post-operative day
seventeen. The patient was also seen by hematology as his
platelets continued to clump when sampled and this was not
worrisome. Please consider increasing citalopram dose as
recommended by geriatrics on an outpatient basis. Tolerating
20mg of Citalopram at this time.
Medications on Admission:
Home:
albuterol sulfate 90 mcg HFA prn
digoxin 0.25mgQD
diltiazem SR 180mg QD
zocor 10mg QD
cortifoam enema
terazosin 5mg QD
celexa 20mg QD
coumadin 5mg QD
transfer meds:
IV piperacillin - Tazobactam 4.5g q 8h (started [**1-8**] 17:00)
IV vancomycine 1000mg q 12h (started [**1-8**] 17:00)
SQ Heparin 5000 TID
ISS
IV metoclopramide 10 mg Q6h
Albuterol nebs 1 [**Doctor First Name **] Q6H
Ipratropium bromide nebs 1 neb Q 6H
Nicotine patch 14mg TD QD
IV Pantoprazole 40mg Q24h
IV hyromorphone 0.5-1mg Q3H: prn pain
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day): per facility policy.
2. insulin regular human 100 unit/mL Solution Sig: please see
insluin sliding scale Injection ASDIR (AS DIRECTED): Please see
insulin sliding scale.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
4. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for very dry skin.
5. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours). neb
6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Last INR am of [**2148-1-19**]= 1.6.
10. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
12. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for apply to ostomy site with pouch
changes: Please apply to small area of fungal infection around
ostomy site with ostomy pouch changes.
14. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q 12H (Every 12 Hours) for 10 days: Last dose should
be on [**2148-1-28**].
Disp:*17 Tablet(s)* Refills:*0*
15. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): Please monitor closely, patient take long acting at
baseline and needs to be titrated up in his usual dose. .
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain for 7 days.
18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
19. Miralax 17 gram Powder in Packet Sig: One (1) Dose PO daily
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Lifecare Center of [**Hospital3 **]
Discharge Diagnosis:
Prolapsed Colostomy, Perianal Crohn's 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 to the hospital for surgical managment of your
prolapsed colostomy and perianal disease related to crohn's
disease. You because very sick after your surgery with an illeus
which is slowing of your intestines and you were admitted to the
intensive care unit. You have recovered well from this and you
are now ready to be discharged to a rehabilitation facility. It
is important that you continue to participate in physical
therapy and contiue to take your medications as given by the
facility.
You have staples in your abdomen that will be removed at your
follow-up appointment. We have removed all of the drains from
your abdomen and this is stable. You may shower 24 hours after
this drain has been removed. Please cover the site with a dry
sterile dressing. The incision line where your peri-rectal
incision was has been opened and should be monitored very
closely. You will continue to have aquacel AG dressings applied
daily to this area. Please monitor all of the incisions on your
abdomen and perianal area for signs of infection including:
increasing redness, green/white/yellow/ foul smelling drainage,
fever, or increased warmth around the area.
Please continue to care for your ostomy as you have been
instructed by the wound ostomy nurses. Please monitor the
appearance of the ostomy, it should be beefy red/pink in color,
if the stoma becomes dark bluish in color or purple please call
the office. If the stoma becomes very swollen please call the
office. Please monitor the skin around the stoma for signs of
infection listed above and follow-up closely with the
wound/ostomy team. The care of your stoma will be assisted by
the nurses at the rehabilitation hospital.
You have had some urinary symptoms of frequency and urgency, you
had a UTI during your hospital stay, it is important that you
are monitored closely for additional urinary tract symptoms and
evaluated by the medical team at the rehabilitation facility.
You will continue taking your current pain medication regimen of
oxycodone and tylenol by mouth. Please do not drink slcohol
while taking these medications and do not drive a car if taking
narcotic poain [**Name2 (NI) 87044**]. Do not take more than 4000mg of
Tylenol daily.
Followup Instructions:
Please make a follow-up appointment to see Dr. [**Last Name (STitle) **] in 7 days,
please call the office to make this appointment [**Telephone/Fax (1) 17489**].
Completed by:[**2148-1-19**] Name: [**Known lastname 13369**],[**Known firstname **] Unit No: [**Numeric Identifier 13805**]
Admission Date: [**2148-1-2**] Discharge Date: [**2148-1-19**]
Date of Birth: [**2068-11-10**] Sex: M
Service: SURGERY
Allergies:
sulfasalazine
Attending:[**First Name3 (LF) 94**]
Addendum:
Patient was seen by geritricets during this admission and
verbalized possibly wanting to become DNR/DNI, this was never
offically filed after discussion with the surgical attending as
this admission was surrounding a surgery. These wishes should be
adressed in the future. He was counciled on this issue by the
geriatrics team and Dr. [**Last Name (STitle) **].
Major Surgical or Invasive Procedure:
Left colectomy with takedown of splenic flexure; complete
proctectomy; appendectomy; repair of parastomal hernia; revision
of the colostomy.
Discharge Disposition:
Extended Care
Facility:
Lifecare Center of [**Hospital3 **]
[**Name6 (MD) **] [**Last Name (NamePattern4) 97**] MD [**MD Number(2) 98**]
Completed by:[**2148-1-19**] Name: [**Known lastname 13369**],[**Known firstname **] Unit No: [**Numeric Identifier 13805**]
Admission Date: [**2148-1-2**] Discharge Date: [**2148-1-19**]
Date of Birth: [**2068-11-10**] Sex: M
Service: SURGERY
Allergies:
sulfasalazine
Attending:[**First Name3 (LF) 94**]
Addendum:
Discharge PE
Physical Exam:
Discharge Physical Exam:
General: No issues, Stayed overnight for heart rate control. No
apparent distess.
VS: Tmas 99.2, T: 98.6, HR: 70 BP: 113/50, RR: 20, O2 93 RA
Neuro: A&OX3
Cardiac: afib, HR 94 at discharge.
Lungs: CTA Bil
Abd: soft, nontender, nondistended, soft stool in ostomy bag.
Wound: C/D/I, incision closed with staples with mild errythema
which is resolving. JP drain from right lower quadrant removed
at discharge.
Discharge Disposition:
Extended Care
Facility:
Lifecare Center of [**Hospital3 **]
[**Name6 (MD) **] [**Last Name (NamePattern4) 97**] MD [**MD Number(2) 98**]
Completed by:[**2148-1-19**]
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"47.19"
] |
icd9pcs
|
[
[
[]
]
] |
27216, 27413
|
11239, 19699
|
26024, 26167
|
22647, 22647
|
2319, 11216
|
25085, 25986
|
1411, 1416
|
20265, 22473
|
22579, 22626
|
19725, 20242
|
22830, 25062
|
26760, 26760
|
2300, 2300
|
233, 293
|
502, 907
|
22662, 22806
|
929, 1239
|
1255, 1395
|
26785, 27193
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,881
| 121,109
|
32438
|
Discharge summary
|
report
|
Admission Date: [**2128-10-20**] Discharge Date: [**2128-10-29**]
Date of Birth: [**2071-3-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
left chest pain and right buttock pain
Major Surgical or Invasive Procedure:
Insertion of left tube thoracostomy.
1. Closed reduction right hip dislocation with
manipulation.
2. Closed treatment right proximal femoral head fracture
with manipulation.
History of Present Illness:
Mr. [**Known lastname 3460**] is a 57 year old male who was hit head on in a 5 car
accident on [**2128-10-20**]. He was the restrained driver and was
taken to [**Hospital3 **], stablized, scanned and transferred to
[**Hospital1 18**] for further management
Past Medical History:
Hypertension
Type II Diabetes
Social History:
Occ ETOH, No tobacco, No IVDA
Lives alone, works PT in OR at [**Hospital1 18**]
2 supportive children
Family History:
non contributory
Physical Exam:
Temp 97.2 HR 107 BP 188/116 O2sat 98 on 100% O2
HEENT NCAT PERRLA conjunctiva pink sclera anicteric
Neck supple No JVD No thyromegly
Chest crackles at bases,tender to palpation over left chest
COR RRR
Abd soft non tender
Ext Right leg shortened and internally rotated, right hip tender
and ecchymotic
Pulses 2+ DP/PT bilat
Pertinent Results:
[**2128-10-20**] 02:22PM GLUCOSE-119* LACTATE-2.9* NA+-141 K+-4.1
CL--97* TCO2-26
[**2128-10-20**] 02:16PM UREA N-17 CREAT-1.2
[**2128-10-20**] 02:16PM WBC-11.6* RBC-4.98 HGB-13.8* HCT-43.1 MCV-87
MCH-27.6 MCHC-31.9 RDW-14.4
[**2128-10-20**] 02:16PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-10-20**] 02:16PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
(/16/09 Chest Xray :1. Left-sided rib fractures, with associated
subcutaneous emphysema, and left
pneumothorax, better assessed on CT performed at [**Hospital1 **].
2. Patchy opacification within the lungs bilaterally,
particularly in the
upper lobes, which could reflect areas of contusion and/or
atelectasis.
(/16/09 CT of abdomen and pelvis :
1. Multiple left rib fractures as described above, involving
left 4th-10th ribs. Associated extensive left lateral chest wall
subcutaneous emphysema, extending to the posterior chest wall
and also left hemidiaphragm.
2. Small left pneumothorax.
3. Right upper and lower lobe partial collapse.
4. Partially collapsed left lower lobe with likely underlying
consolidation
and small left pleural effusion. Right upper lobe ground glass
opacity;
findings may be secondary to contusion.
5. Supero-posterior dislocation of the right hip. Comminuted
right acetabular
and right femoral head fractures. Bone fragment in the
acetabular fossa with
lipohemarthrosis.
6. Subtle hazy mesentery, cannot exclude mesenteric injury.
7. Sliver of lucency in the left anterior abdominal cavity,
difficult to
discern whether within bowel or extra-luminal. Small amount of
pneumoperitoneum not excluded.
8. Inflated Foley balloon in the urethra. Recommend
repositioning.
[**2128-10-21**] CT Pelvis/Ortho :
1. Status post reduction of the fracture dislocation of the
right femoral
head. Comminuted fracture of the posterior wall and column of
the acetabulum
and the anterior part of right femoral head are noted. The
femoral head
fragment is displaced anteriorly and inferiorly but not between
the articular
surfaces.
[**2128-10-22**] CT C spine:
No evidence of fracture in the C-spine. Multilevel
degenerative
changes in the C-spine. Small pneumothorax at the left lung
apex, with a chest
tube in place.
[**2128-10-23**] Cardiac Echo :
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: No pericardial effusion or regional wall motion
abnormalities to suggest cardiac contusion. No
clinically-significant valvular disease seen.
[**2128-10-25**] Bilat Lower Extremity Venous studies : Somewhat limited
evaluation of the right popliteal vein, though no evidence of
DVT in the legs bilaterally \
[**2128-10-27**] CTA Chest : No filling defects in the central or
segmental pulmonary arteries to suggest pulmonary embolus.
Evaluation of the subsegmental pulmonary arteries is limited by
timing of contrast bolus and respiratory motion, particularly in
the lower lobes.
Brief Hospital Course:
Mr. [**Known lastname 3460**] was admitted to the hospital and immediately evaluated
by the Trauma service to assess and stabilize injuries. He
immediately taken to the Operating Room for left chest tube
placement secondary to his hemopneumothorax and replacement of
Foley catheter. Following stablilty of his vital signs his
orthopedic problems were addressed and he initially underwent
closed reduction of his right hip dislocation and right femoral
head fracture. His symptoms were manifested by a right sciatic
nerve palsey.
He tolerated the procedure well and returned to the ICU in
stable condition. His pain was controlled with a Dilaudid PCA.
On [**2128-10-22**] he returned to the Operating Room and underwent ORIF
of his acetabular fracture. Again this was well tolerated.
Following transfer out of the ICU on [**2128-10-23**] he continued to
make good progress.
He was tolerating a diabetic diet and his blood sugars were
controlled on NPH 10 units [**Hospital1 **] with occasional sliding scale
coverage. He will follow up with his own Endocrinologist at
[**University/College **] Health.
He was placed on his pre op lisinopril for blood pressure
control and lopressor was eventually added for persistent sinus
tachycardia. Despite his euvolemic state and his adequate pain
control his heart rate remained in the 96-110 range. Lopressor
was titrated up to 50 mg PO TID with no significant impact. This
prompted a CTA of the chest to R/O PE. He had no other symptoms
and his scan was negative. He did admit to a history of anxiety
and low dose Ativan was added to see if his tachycardia was
relieved. Curently his heart rate is about 100 bpm.
He was working well with the Physical Therapist and his gait was
gradually getting steadier. From a surgical standpoint his
wounds were healing well without drainage or erythema and he
continued to use his incentive spirometer to remain free of any
pulmonary complications. He did have some temperature spikes
>100.5 and was cultured on multiple occasions. To date all
blood cultures are negative.
Following manipulation of his catheter the Urology
recommendation was to leave the catheter in place for 2 weeks
post op ([**2128-11-4**]) then begin a voiding trial. Should he have
any problems with voiding he can follow up with our Urology
service.
Mr. [**Known lastname 3460**] was transferred to rehab on [**2128-10-29**] for further
progression in his efforts to return home.
Medications on Admission:
Lisinopril 20 mg PO DAILY
70/30 Insulin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
4. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO four
times a day: Hold for SBP < 100 HR < 60.
7. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 0.5 ml Subcutaneous
DAILY (Daily).
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous twice a day.
9. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale units per sliding scale Injection pre meal and hs.
10. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day): Hold for sedation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
S/P MVA with hemopneumothorax and flail chest, right femoral
head fracture dislocation of hip and right posterior wall
acetabular fracture. hematuria secondary to foley catheter
inflation in prostatic urethra.
Discharge Condition:
Stable hemodynamics, tolerating a regular diet, progressing with
physical therapy.
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 [**6-13**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] for a follow up appointment on [**2128-11-10**]
([**Telephone/Fax (1) 2359**]).
Call the [**Hospital **] Clinic for an appointment 2 weeks after your
staples are removed ([**Telephone/Fax (1) 1228**]) Staples can be removed on
[**2128-11-4**]
Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 75714**] (PCP) for a follow up appointment 2 weeks
after your discharge from rehab.
Completed by:[**2128-10-29**]
|
[
"820.09",
"250.00",
"E812.0",
"808.0",
"518.0",
"997.1",
"860.4",
"401.9",
"958.7",
"807.09",
"835.00",
"511.9",
"807.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.39",
"79.75",
"34.09",
"79.05"
] |
icd9pcs
|
[
[
[]
]
] |
8351, 8421
|
4872, 7323
|
353, 537
|
8675, 8760
|
1389, 4849
|
10774, 11241
|
1013, 1031
|
7413, 8328
|
8442, 8654
|
7349, 7390
|
8784, 10242
|
10258, 10751
|
1046, 1370
|
275, 315
|
565, 825
|
847, 878
|
894, 997
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,527
| 185,892
|
2180
|
Discharge summary
|
report
|
Admission Date: [**2133-3-1**] Discharge Date: [**2133-3-3**]
Date of Birth: [**2083-2-21**] Sex: F
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
endoscopy with clipping of bleeding vessel
History of Present Illness:
50 y.o. female presenting with weakness for 3 days. 3 days ago
had episode nausea followed closely by "bright red" emesis, but
she did not think this was blood. Since then, has been having
black stool and diarrhea and feeling progressively weak and
nauseated. This morning she gagged on her toothbrush and had
another episode of emesis that had blood specks in it so she
came to the ED. Denies any NSAID use, no history of GI bleed or
ulcer, no ETOH, no recent abdominal pain, nausea or retching.
.
She was managed medically for UGIbleed and underwent an EGD in
the ICU. EGD revealed
On arrival to the ICU, patient reports feeling more SOB and
having a lot of discomfort with the NG tube. She denies
abdominal pain, nausea or more emesis or diarrhea. She has had
no new medications recently.
.
Past Medical History:
eczematous dermatitis (previously thought to be psoriasis, but
biopsy on [**1-17**] showed subacute eczematous dermatitis)
Heart Murmur
Social History:
Divorced, works as an office professional.
- Tobacco: 30pack year history
- Alcohol:denies
- Illicits:denies
Family History:
father with PUD, brother with GERD
Physical Exam:
Vitals: T: BP: 145/90 P:121-105 R:26 18 O2:100% on RA
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, NG tube in place
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachy, regular and rhythm, 2/6 systolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds
hyperactive, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Mild scaling over left elbow.
Pertinent Results:
Endoscopy report not accessible
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2133-3-3**] 07:13AM 6.6 3.87* 11.7* 34.4* 89 30.2
34.0 15.9* 148*
[**2133-3-2**] 04:15PM 32.9*
[**2133-3-2**] 06:07AM 31.4*
[**2133-3-2**] 01:58AM 7.1 3.36* 10.8* 30.1* 89 32.0 35.8*
16.0* 144*1
[**2133-3-1**] 08:14PM 31.2*#
RECEIVED AT 2234
[**2133-3-1**] 05:41PM 5.7 2.70* 8.7* 24.6* 91 32.1* 35.2*
14.1 202
[**2133-3-1**] 01:30PM 7.4# 3.36* 10.5*# 30.5* 91 31.3
34.5 14.1 248
Brief Hospital Course:
#Acute Blood loss anemia due to upper GI bleed: Patient denies
NSAIDs, ETOH use, prednisone use, history of GI bleed, also
denies any recent GI symptoms. Only true risk factor for ulcers
is H.Pylori +. Bleeding was addressed with endoscopy and
clipping. HCT remained stable for 36 hours. She was transitioned
from IV PPI to Oral PPI. She was discharged on H. Pylori
eradication.
.
#Eczematous Dermatitis: Patient currently without flare, only
using clobetasol on her left elbow PRN.
-continue clobetasol
Medications on Admission:
clobetasol cream
Discharge Medications:
1. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
Disp:*30 Lozenge(s)* Refills:*5*
4. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 11 days.
Disp:*88 Capsule(s)* Refills:*0*
5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 11 days.
Disp:*44 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 11 days.
Disp:*22 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Gastric Ulcer
Upper GI bleed
Dieulafoy's lesion
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to the MICU with GI bleeding. You required
blood transfusion, you underwent endoscopy which revealed mild
gastritis, H.pylori infection, and a bleeding ulcer. This ulcer
was clipped by the gastroenterologist.
.
The follwing changes were made to your medications:
Sucralfate 1 gram Tablet by mouth 4 times per day for the next
11 days
Amoxicillin 250 mg Capsule Sig: Four (4) Capsule by mouth twice
per day (every 12 hours) for 11 days.
Clarithromycin 250 mg Two (2) Tablet by mouth every 12 hours for
11 days.
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) by mouth twice a day for the next
11 days.
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, per day after the above finishes
.
YOU MUST STOP SMOKING. You are interested in the patches, which
are over the counter. Please start with 14mg per day for 2
weeks, then 7mg per day for two weeks. You can call
1-800-trytostop to attempt to get these supplies for free.
Followup Instructions:
Please call Dr.[**Name (NI) 4279**] office at [**Telephone/Fax (1) 7976**] for follow-up
within the next week.
Completed by:[**2133-5-16**]
|
[
"537.84",
"535.50",
"531.40",
"285.1",
"041.86",
"692.9",
"530.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
4217, 4223
|
2679, 3186
|
272, 317
|
4314, 4314
|
2046, 2656
|
5496, 5638
|
1442, 1478
|
3253, 4194
|
4244, 4293
|
3212, 3230
|
4462, 5473
|
1493, 2027
|
224, 234
|
345, 1140
|
4329, 4438
|
1162, 1299
|
1315, 1425
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,708
| 143,683
|
36466
|
Discharge summary
|
report
|
Admission Date: [**2155-6-6**] Discharge Date: [**2155-6-10**]
Date of Birth: [**2075-8-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2155-6-6**] Coronary Artery Bypas Graft x 3 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
obtuse marginal, Saphenous vein graft to posterior descending
artery)
History of Present Illness:
79 year old with known coronary artery disease and prior
myocardial infarction who presents with increased dyspnea on
exertion over last year. Recent stress test was positive and
cardiac cath revealed severe three vessel coronary artery
disease.
Past Medical History:
Coronary Artery Disease, history of Myocardial Infarction [**2124**]
Hypertension
Hyperlipidemia
Chronic renal insufficiency
Reactive airway disease
Osteoarthritis
Carotid Disease
Benign Prosatic Hypertrophy
Head Injury secondary to Motor vehicle accident
Social History:
Retired. 40 pack year smoking history. Denies alcohol use.
Family History:
Non-contributory
Physical Exam:
Vitals: 80 16 131/71
General: Elderly male in no acute distress
Skin: Warm, dry, +Vitiligo
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear to auscultation bilaterally
Heart: Regular rate and rhythm with no murmurs
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, -edema
Neuro: Grossly intact
Pertinent Results:
UreaN Creat K
[**2155-6-10**] 05:45AM 31* 1.7* 4.9
[**6-6**] Echo: PRE-BYPASS: 1. No mass/thrombus is seen in the left
atrium or left atrial appendage. 2. No atrial septal defect is
seen by 2D or color Doppler. 3. There is mild regional
anteroseptal, septal, inferoseptal, and apical wall hypokinesis,
in the presence of global left ventricular hypokinesis (LVEF =
40-45 %). 4. Right ventricular chamber size and free wall motion
are normal. 5. The diameters of aorta at the sinus, ascending
and arch levels are normal. 6. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta. 7. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
There is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**2-14**]+) mitral regurgitation
is seen. POST-BYPASS: 1. For the post-bypass study, the patient
was receiving vasoactive infusions including phenylephrine. AV
pacing initially. 2. Preserved biventricular systolic function
from pre cpb. Inferior hypokinesis. LVEF is now 45%. 3. Aortic
contour is normal post decannulation.
Brief Hospital Course:
Mr. [**Known lastname **]. [**Known lastname 17862**] was a same day admit after undergoing
preoperative work-up prior to admission. On [**6-6**] he was brought
to the operating room where he underwent a coronary artery
bypass graft x 3. Please see operative report for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
On post-operative day one he was transferred to the telemetry
floor for further care. He had a short run of atrial
fibrillation which converted to sinus rhythm with beta blockers.
Chest tubes and epicardial pacing wires were removed per
protocol. He continued to slowly improve and worked with
physical therapy for strength and mobility. Mr. [**Known lastname **]. [**Known lastname 17862**] did
c/o difficulty swallowing- a speech and swallow consult and
video swallow was done and no abnormality was detected. He had
no further complaints of swallowing difficulty. On
post-operative day #4 he was discharged to home with VNA.
Medications on Admission:
Simvastatin 40mg daily, Benicar 20mg daily, Aspirin 81mg daily,
Metoprolol 25mg daily, Avodart 0.5mg daily, Advair 250/50mg [**Hospital1 **],
Methotrexate 10 every sunday, Alendronate 70 every wekk,
Calcium, Folate
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily ().
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
start on [**2155-6-18**].
Disp:*30 Tablet(s)* Refills:*2*
13. methotrexate
Discharge Disposition:
Home With Service
Facility:
Home Health and Hospice [**Location (un) 8117**], NH
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Chronic renal insufficiency
Reactive airway disease
Osteoarthritis
Carotid Disease
Benign Prosatic Hypertrophy
Head Injury secondary to Motor vehicle accident
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 2 weeks
Dr. [**Last Name (STitle) 31087**] in [**2-14**] weeks
Dr. [**Last Name (STitle) 82599**] in 2 weeks
Completed by:[**2155-6-10**]
|
[
"411.1",
"424.0",
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icd9cm
|
[
[
[]
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[
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icd9pcs
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339, 540
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4232, 5572
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5699, 5911
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3993, 4209
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5962, 6454
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1219, 1561
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280, 301
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568, 815
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837, 1094
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1110, 1170
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
110
| 154,943
|
25359
|
Discharge summary
|
report
|
Admission Date: [**2110-6-2**] Discharge Date: [**2110-6-5**]
Date of Birth: [**2110-5-29**] Sex: M
Service: NB
ID: [**First Name5 (NamePattern1) **] [**Known lastname 63430**] is a 6 day old term infant with presumed
viral sepsis being discharged from the [**Hospital1 18**] NICU.
HISTORY: [**First Name5 (NamePattern1) **] [**Known lastname 63430**] is a 3545 gram product of a term
gestation sent to the newborn intensive care unit for
evaluation of sepsis risk manifested by postnatal fever.
[**Doctor Last Name **] was born on [**5-29**] to a 35 y.o. G3 P0-1 mother whose
pregnancy was apparently uncomplicated. The mother is a
healthy woman with unremarkable prenatal screens, including
blood type 0 positive, antibody negative, hepatitis B surface
antigen negative, RPR non reactive, rubella immune, group B
strep status negative. The infant was delivered via cesarean
section for failure to progress. No sepsis risks factors.
Apgar scores were 9 at 1 minute and 9 at 5 minutes of age.
The infant was sent to the newborn nursery shortly after
delivery. The infant did well in the nursery until the
morning of [**6-2**], when the infant was noted to have a
temperature of 101.2. He had otherwise been doing well in the
newborn nursery. His weight loss at that time was [**8-2**]
percent. There was no history of maternal herpes simplex
virus or other illness.
PHYSICAL EXAMINATION ON ADMISSION: Infant pink on exam. He
was sleepy but easily awakened. Oxygen saturations were in
the low 90s in room air. A fine maculopapular rash was noted
about the face and the trunk. Initially his perfusion was
decreased, with acrocyanosis, but gradually improved over the
morning. No vesicles were noted with the rash. Head, ears,
eyes, nose and throat were normal. Heart had normal S1 and S2
without murmurs. Lungs clear to auscultation bilaterally.
Abdomen benign. No hepatosplenomegaly. Normal male genitalia.
Circumcised. Neurologic nonfocal and age appropriate. Hips
normal. Infant moving all extremities.
HOSPITAL COURSE:
1. RESPIRATORY. [**Doctor Last Name **] has been in room air throughout his
hospitalization and has not required any supplemental
oxygen. He has had a comfortable respiratory pattern
throughout.
2. [**Doctor Last Name **] blood pressure has been stable throughout his
hospitalization. He did receive one normal saline bolus after
admission to the NICU for decreased perfusion with
improvement. No murmurs have been heard.
3. FLUID, ELECTROLYTES AND NUTRITION. [**Doctor Last Name **] has been ad lib
demand feeding throughout his hospital course without
difficulty. His weight at time of discharge was 3405
grams. Electrolytes upon admission to the newborn
intensive care unit showed a sodium of 146, potassium 4.8,
chloride 106 and bicarbonate of 21. He has been voiding
and stooling without difficulty.
4. GASTROINTESTINAL. A bilirubin was drawn on day of life 4,
with a total bili of 4.8 and a direct bili of 0.4. He has
not required any phototherapy during his hospitalization.
5. HEMATOLOGY. [**Doctor Last Name **] hematocrit upon admission to the
newborn intensive care unit was 58.9, with a platelet
count of 118. His platelet count dropped over the course
of the next 48 hours, with a low of 52,000 on [**6-3**]. His
platelet count subsequently has risen, with a platelet
count of 67 on day of life 5 and a platelet count of 80 on
day of life 6, then finally a platelet count of 115 on day
of life 7. He did not require any platelets or other blood
products throughout his hospitalization. Coagulation studies
were measured on day of life 5, with a PT of 17.3 and a
PTT of 29, a fibrinogen of 336, and elevated d-dimers of
6631. Overall it was thought the thrombocytopenia was most
consistent with viral sepis.
6. INFECTIOUS DISEASE. Upon admission to the newborn
intensive care unit, a CBC with differential and blood
cultures were drawn. The CBC showed a white count of 5.3,
hematocrit of 58.9, platelet count 118, with 60 percent polys
and 3 percent bands. There were toxic granulations in the
sample. Lumbar puncture was performed, with CSF analysis
without pleocytosis. At that time, ampicillin, gentamicin and
acyclovir were initiated. Repeat CBC on day of life 4 showed a
white count of 10.7, hematocrit of 58.1, platelet count of 73,
with 48 percent polys and 1 percent bands. He received a
48 hour course of ampicillin and gentamicin. CSF HSV PCR was
sent shortly after admission to the NICU and was found to
be negative on day of life 7. The acyclovir was
discontinued at that time. Blood cultures sent upon
admission to the NICU also were negative. The rash noted upon
admission to the NICU increased over the next 24 hours,
becoming a diffuse whole-body maculopapular rash, without
petechiae or vesicles. The rash was thought to be most
consistent with enteroviral infection. Enteroviral
surface cultures and CSF PCR were sent, and these are pending
at the time of discharge. Secondary to the thrombocytopenia,
two urine samples were sent for CMV culture; these are
negative at the time of discharge. Of note, as the most
likely diagnosis was thought to be viral sepsis, liver
function tests were measured twice, and were within normal
limits.
7. NEUROLOGY. Neurologic examination remained within normal
limits throughout hospitalization. CSF analysis was benign.
8. SENSORY. A hearing screen was performed with automated
auditory brainstem responses. The infant passed in both
ears. Ophthalmology - Eye exam not indicated for this full
term infant.
9. PSYCHOSOCIAL. [**Hospital1 69**] social
worker has been involved with the family. The contact
social worker can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: The infant is stable in room air.
Signs of infection have resolved. The infant is clinically
well.
DISPOSITION: To home with parents.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital 1411**] Pediatrics,
phone [**Telephone/Fax (1) 63431**].
CARE RECOMMENDATIONS:
1. Feeds at discharge are ad lib, demand bottle or breast
feeding.
2. Medications - None.
3. Car seat position screening not indicated.
4. State newborn screening status - State newborn screen was
sent on [**6-1**], and no abnormal results have been
reported.
5. Immunizations received - [**Doctor Last Name **] received his first
hepatitis B vaccine on [**6-1**].
6. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following three criteria: 1)
Born at less than 32 weeks. 2) Born between 32-35 weeks
with two of the following: day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings. 3) With chronic lung
disease. Influenza immunization is recommended annually in
the fall for all infants once they reach six months of
age. Before this age, and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
A followup appointment with Dr. [**Last Name (STitle) **] has been scheduled for
[**6-6**]. Followup platelet count is recommended at that time.
DISCHARGE DIAGNOSES:
1. Rule out sepsis.
2. Viral sepsis, likely enteroviral.
3. Thrombocytopenia, resolving..
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2110-6-5**] 16:04:30
T: [**2110-6-5**] 16:40:10
Job#: [**Job Number 63432**]
|
[
"771.81",
"V30.01",
"778.8",
"776.1",
"782.1",
"V05.3",
"V72.1",
"079.89",
"V50.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55",
"03.31",
"64.0"
] |
icd9pcs
|
[
[
[]
]
] |
7483, 7822
|
2046, 5852
|
6198, 6578
|
6606, 7462
|
1425, 2029
|
5877, 6176
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,899
| 115,232
|
22298
|
Discharge summary
|
report
|
Admission Date: [**2106-2-10**] Discharge Date: [**2106-2-23**]
Date of Birth: [**2044-3-28**] Sex: M
Service: SURGERY
Allergies:
Demerol / Ativan
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Severe ischemia of lower extremities/ s/p R. ilio-femoral and
femoral-femoral bypass graft.
Major Surgical or Invasive Procedure:
Thrombectomy of right iliofemoral graft, femoral-femoral graft,
patch angioplasty of right femoral artery and left femoral
artery with saphenous vein.
History of Present Illness:
The patient is a 60M with history of right sided stage III
laryngeal cancer diagnosed in [**2099**] and treated with chemotherapy
(adjuvant taxol and cisplatin followed by taxol, cisplatin and
etoposide for three total cycles) and radiation (62g to right
neck and vocal cords). He was last admitted to [**Hospital1 18**] [**2105-6-29**]
with disabling claudication and rest pain in his bilateral lower
extremities. For this, right common iliac artery to common
femoral artery bypass and femoral-femoral cross-over graft were
performed.
Past Medical History:
Hyperlipidemia
laryngeal CA
basal cell ca
peptic ulcer dz
hx. of esophageal stricture
ETOH abuse
Known aortic dissection
Iliac stent with fem - fem graft
Social History:
Pos alcohol
pos smoker
Family History:
non contributary
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
Groins dressed so femoral nodes not assessed
Fem pulses present b/l
Bil LE warm; + pulses by doppler
Pertinent Results:
CHEST (PORTABLE AP) [**2106-2-15**] 9:06 AM
CHEST: AP portable semi-upright view. The nasogastric tube and
the left internal jugular central venous catheter remain in good
positions. There is interval worsening of bilateral perihilar
and basilar opacities, consistent with increasing congestive
heart failure. There are persistent opacities in the right and
left upper lobe, consistent with pneumonia or aspiration.
Multiple surgical clips are again seen in the upper mid abdomen
and just above the gastroesophageal junction.
IMPRESSION:
1. Worsening congestive heart failure.
2. Unchanged right and left upper lobe pneumonia versus
aspiration.
CT CHEST W/CONTRAST [**2106-2-15**] 4:20 PM
CHEST CT WITH INTRAVENOUS CONTRAST: Emphysema is again noted,
with multiple bullae in the middle and upper lobes. There are
confluent ground-glass opacities as well as interlobular septal
thickening in both upper lobes, right middle lobe, lingula, and
the superior and anterior portions of the lower lobes. The
opacities are most dense in the upper lobes. Small peripheral
centrilobular ground-glass opacities are present throughout both
lower lobes, similar in appearance to [**2104-7-16**]. While the
centrilobular and confluent ground glass opacities are
consistent with aspiration or pneumonia, presence of
interstitial septal thickening also suggest pulmonary edema.
While there is some nodularity within the opacities, nodular
opacities that were seen in the left upper and right lower lobes
on [**2105-7-16**] are no longer present. There is no evidence of an
abscess.
The trachea, right and left main stem bronchi are mildly
dilated. Mild-to- moderate bronchiectasis is noted in the upper
lobes, right middle lobe and lingula. Dependent secretions are
noted in the trachea.
There are numerous enlarged mediastinal lymph nodes, increased
in number and size compared to [**2104-7-16**]. The largest right
superior mediastinal node measures 12 mm in short axis diameter.
The largest upper right paratracheal node measures 11 mm. The
largest lower right paratracheal node measures 9 mm. The largest
right para-aortic node measures 12 mm. The largest subcarinal
node measures 15 mm. The largest right para-esophageal node
measures 13 mm. Numerous subcentimeter nodes are present in both
hila.
There are small bilateral pleural effusions. There is no
pericardial effusion. Scattered atherosclerotic calcifications
are present in the thoracic aorta. Mural thrombus is noted in
the proximal abdominal aorta.
There is an unchanged ill-defined hypodensity in the right lobe
of the thyroid gland, measuring approximately 2 x 1 cm.
There is an approximately 4 cm hypodense lesion in the lower
pole of the spleen, unchanged compared to the [**2106-2-13**] abdominal
CT, which may represent a splenic infarction. Scattered
calcified granulomas are again noted in the liver. Stones are
again seen in the gallbladder. Surgical clips are again noted in
the porta hepatis and in the region of the gastroesophageal
junction. The imaged portions of the pancreas, adrenal glands,
and kidneys appear unremarkable. The imaged bones appear
unremarkable.
IMPRESSION:
1. Diffuse bilateral pulmonary opacities, confluent in the upper
and middle lobes, consistent with aspiration or pneumonia.
Recurrent interlobular septal thickening is consistent with
superimposed pulmonary edema. Given foci of nodularity,
follow-up is recommended after treatment. No evidence of an
abscess.
2. Small bilateral pleural effusions.
3. Mild central tracheal dilatation. Diffuse mild-to-moderate
bronchiectasis in the upper and middle lobes.
4. Increased number and size of mediastinal and bilateral hilar
lymph nodes, which may be reactive. However, metastatic disease
cannot be excluded, and follow-up after treatment is
recommended.
5. Hypodense splenic lesion, unchanged since [**2106-2-13**], compatible
with an infarct.
6. Cholelithiasis.
7. Unchanged hypodense lesion in the right lobe of the thyroid.
[**2106-2-13**] 11:08:22 PM
EKG
Sinus tachycardia. Right bundle-branch block. Compared to
tracing #1, no
diagnostic change.
[**2106-2-13**] 3:20 PM
CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST
CT ABDOMEN WITHOUT AND WITH IV CONTRAST:
Hazy nodular opacities about the airways within the lower lungs
have increased since the prior study consistent with small
airways disease. There is mild hazy opacity within the lung
bases which could represent normal lung at expiration, however
mild ground glass airspace disease cannot be excluded.
There is a hepatic granuloma within the dome of the liver. No
concerning hepatic lesions. There are multiple small gallstones
dependently within the gallbladder. No gallbladder wall
thickening. No biliary ductal dilatation or choledocholithiasis
evident. There is a choledochojejunostomy, which is normal in
appearance.
Within the inferior aspect of the spleen, there is a large
hypodense lesion, without enhancement measuring 4.4 x 4.3 x 3.9
cm that has significantly increased since the [**5-7**] study. There
is an adjacent smaller similar- appearing lesion lateral to this
larger lesion. These are nonspecific but considerations would
include a splenic infarct. There is no stranding around these
lesions, however infection of the lesions cannot be excluded.
Small splenic hemangioma is also again noted unchanged.
The pancreas is normal in appearance. The patient has undergone
gastric bypass with a gastrojejunostomy. Adrenal glands are
normal in appearance. No bowel wall thickening. No evidence of
bowel wall thickening or bowel obstruction. The appendix
contains contrast within it and gas, possibly from prior CT
scan. No evidence for appendicitis. Small amount of fluid within
the right lower quadrant is nonspecific.
The kidneys show heterogeneous hypoenhancement symmetrically in
a patchy geographic pattern in some locations. These areas have
heterogeneous enhancement still on nephrographic phase. There is
no persistent staining on the delayed images, nor is there
contrast within the kidneys on the pre- contrast CT remaining
from [**2106-2-11**] angiogram. These findings are nonspecific but
considerations would include embolic phenomenon such as
cholesterol or other emboli. Of note, there is a large calcified
plaque within the right renal artery just beyond its origin with
at least moderate narrowing of the right renal artery. There is
also moderate narrowing of the left renal artery at its origin.
There are multiple cysts within the kidneys bilaterally. There
are multiple hypoattenuating lesions which are too small to
characterize but likely cysts.
No lymphadenopathy or ascites.
CT PELVIS WITHOUT AND WITH IV CONTRAST:
The urinary bladder has a Foley catheter within it and is
incompletely distended. No definite urinary bladder abnormality.
There is a small amount of free fluid within the pelvis. Bowel
within the pelvis is within normal limits. There is a rectal
tube with balloon inflated within the rectum. Subsequent
administration of rectal contrast shows no leakage of contrast
and no other abnormality. No lymphadenopathy.
CT ARTERIOGRAM WITH IV CONTRAST:
There is diffuse atherosclerotic plaque within the aorta with a
large amount of plaque within the infrarenal aorta. There is an
ulcerated plaque within the infrarenal aorta with a small neck.
This does not extend beyond the normal contour of the aorta. The
left common iliac artery is occluded, as before. There is
reconstitution of the left external iliac artery from retrograde
flow and there is minimal flow within the left internal iliac
artery. The right common iliac artery is patent at its origin
and then there is a bypass graft from the right common iliac
artery to the right common femoral artery. Native right common
iliac artery distally and the external iliac artery is occluded
with an old stent in place. The iliac-femoral graft is widely
patent. Just distal to its insertion within the right common
femoral artery, there is a right to left femoral-femoral bypass
graft which is widely patent. This is just superior to an
excluded partially thrombosed old femoral- femoral bypass graft
which contains gas within it, likely from recent surgery.
Bilateral superficial femoral arteries are patent proximally
though diminutive. There are small fluid collections about
bilateral common femoral arteries near the graft
origin/insertions, both of which contain small amounts of gas,
likely related to recent surgery. Just distal to the insertion
site of the femoral-femoral bypass graft on the left is a round
fluid collection that on pre-contrast images is heterogeneous in
density and post-contrast images shows a small amount of
contrast outside the lumen of the adjacent arteries with
progressive increased density dependently within the collection
seen, making this highly suspicious for a pseudoaneurysm. This
is best demonstrated on series 2, 3, and 4, images 90-94 and
series 6 B, images 186-189. The arteries distal to the graft
sites are patent within the visualized portions.
SMA, [**Female First Name (un) 899**], and celiac artery are all patent and without evidence
of proximal stenoses. As mentioned above, the right renal artery
has a large calcified plaque just beyond its origin with at
least moderate stenosis. The left renal artery has moderate
stenosis at its origin.
BONE WINDOWS: There is multilevel lumbar disc degeneration. No
suspicious bone lesions.
IMPRESSION:
1. Aortic atherosclerosis with ulcerated plaque in the
infrarenal aorta. Occluded left common iliac artery with
external iliac artery reconstitution from retrograde flow from
fem-fem bypass graft. Patent right common iliac- femoral bypass
graft and right to left femoral-femoral bypass graft with patent
superficial femoral artery distal to the bypass grafts in the
visualized portions.
2. Just distal to the left insertion of the fem-fem bypass graft
with findings are highly suspicious for a pseudoaneurysm.
[**Female First Name (un) **] ultrasound of this area is recommended to further
evaluate.
3. Gas and fluid about the bilateral femoral [**Female First Name (un) 1106**] operative
sites and gas within the old thrombosed fem-fem bypass graft
likely related to surgery.
4. Increased size of hypodense splenic lesions that could
represent infarcts. No secondary signs of infection, however
this cannot be excluded.
5. Patent SMA and [**Female First Name (un) 899**] without evidence of bowel abnormality.
6. Bilateral patchy heterogeneous perfusion abnormalities within
the kidneys suggesting recent bilateral renal insult, possibly
from embolic phenomenon such as cholesterol emboli. There is
also bilateral renal artery stenosis, slightly worse on the
right than the left, at least a moderate degree.
7. Bilateral pulmonary small airways disease, worse in the bases
than in [**2105-5-3**]. If clinically indicated, high resolution chest
CT could be performed.
[**2106-2-23**] 04:30AM
COMPLETE BLOOD COUNT
White Blood Cells 8.3
Red Blood Cells 3.76*
Hemoglobin 11.2* g/dL
MCV 89
MCH 29.9
MCHC 33.7
RDW 16.4*
Platelet Count 298 K/uL 150 - 440
[**2106-2-23**] 12:01PM
PT 15.8*
PTT 34.2
INR(PT) 1.4*
[**2106-2-20**] 06:00AM
RENAL & GLUCOSE
Glucose 86 mg/dL
Urea Nitrogen 14 mg/dL
Creatinine 0.7 mg/dL
Sodium 137 mEq/L
Potassium 3.9 mEq/L
Chloride 104 mEq/L
Bicarbonate 24 mEq/L
Anion Gap 13
CHEMISTRY
Calcium, Total 7.8*
Phosphate 2.5*
Magnesium 2.1
GENERAL URINE INFORMATION
Urine Color Amber
Urine Appearance Cloudy
Specific Gravity 1.049* 1.001 - 1.035
DIPSTICK URINALYSIS
Blood LG
Nitrite NEG
Protein 30 mg/dL
Glucose NEG mg/dL
Ketone NEG mg/dL
Bilirubin NEG EU/dL
Urobilinogen NEG mg/
pH 6.5
Leukocytes NEG
MICROSCOPIC URINE EXAMINATION
RBC >50
WBC 1 #
Bacteria MOD
Yeast NONE
Epithelial Cells 0 #/hpf
Transitional Epithelial Cells 1 #/hpf
Granular Casts 0-2 #/lpf 0 - 0
Amorphous Crystals FEW
[**2106-2-15**]
SWAB
No VRE isolated.
Brief Hospital Course:
Patient was admitted and started on anti-coagulation secondary
to LE graft coagulopathy. Patient was started on a heparin gtt
with goal of 60-80. Patients Coumadin was initially held.
Patient had groin exploration/angiogram. Patient was given an
epidural. Patient tolerated procedure and in PACU area it was
noticed that Hct levels had come down. Patient was transfused 2
units. Patient's anticoags were held while he got his
transfusion and then was re-started. Heme was consulted for
this and suggested HIT. Patient most-likely was sub-therapeutic
on lovenox. Typical dosing for Lovenox is 1mg/kg [**Hospital1 **] and he was
only on 30mg/day. Patient was admitted to SICU. Patient was
continued on broad spctrum
antibiotics(Vanco/Clinda/Ceftaz/Flagyl). Patient's groin
dressings were continually monitored during this time while in
the unit where it was noticed to be draining. Patient was
screened for HIT and started on Argatroban. Patients Argatroban
was started/stopped [**Hospital 58097**] hospital stay. Patients
epidural and NG-tube were DC's post-op day 4 and Clinda was DC'd
as per IS requests. Patient transferred to VICU and Argatroban
and Coumadin were re-started. Through-out the patients entire
hospital stay the goal was to acquire a therapeutic state
between (2.0-3.0) Patient was started on Lovenox sq on final
hospital day and it was explained to patient that when he get's
discharged from hospital he won't be able to check his lovenox
levels. It was suggested to patient that he stay in the
hospital until his PT becomes therapeutic but the patient
requested he leave and go home on Lovenox sub-q. Patient was
instructed to f/u w/ PCP(Dr. [**Last Name (STitle) 5456**] qod for coag checks.
Patient wwas also Dc'd on Coumadin 3mg hs, ASA 81mg qd. Patient
was also given Abx- (Levo/Flagyl).
Medications on Admission:
Coumadin,
asa,
percocet
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*4 inhalers* Refills:*2*
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*4 inhalers* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 ML(s)* Refills:*0*
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous twice
a day for 4 days.
Disp:*8 Lovenox (Subcutaneous) 60 mg/0.6 mL Syringe* Refills:*1*
9. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*6*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 weeks.
Disp:*63 Tablet(s)* Refills:*0*
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
South Eastern [**State 350**] VNA
Discharge Diagnosis:
Thrombosed femoral-femoral graft and iliofemoral graft with
bilateral extremity ischemia.
Hypercoagulable state.
Discharge Condition:
Stable
Discharge Instructions:
Please restart your home medications. You may shower regularly,
but no tub baths. Pat your incisions dry. If there continues
to be drainage from your incision, place dry gauze over it.
Call a physician or go to the emergency room if you experience
fever >101.4F, pain unrelieved by medication, or foul-smelling
drainage coming from your incision.
Discharge Instructions:
You are to be discharged on coumadin. You must have your INR
followed. This measures the level of coumadin in the blood. This
level must be between [**2-5**]. Your PCP [**Name9 (PRE) **] been [**Name (NI) 653**]. [**Name2 (NI) **] will
follow your INR.
You are also on Lovenox this is again a blood thinner, You must
give yourself shots twice a day. You are to take Lovenox untill
the Coumadin (INR ) is between [**2-5**]. When your coumadin level is
appropriate. You may stop the Lovenox.
WOUND CARE:
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your wound(s).
New pain, numbness or discoloration of your lower or upper
extremities (notably on the side of the incision).
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
OTHER INFORMATION:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re wound / incision site and this should
be left in place for three (3) days. Remove it after this time
and wash your incision(s) gently with soap and water. You will
have sutures, which are usually removed in 4 weeks. This will be
done by the Surgeon on your follow-up appointment.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for
removal.).
When the sutures / staples are removed the doctor may or may not
place pieces of tape called steri-strips over the incision.
These will stay on about a week and you may shower with them on.
If these do not fall off after 10 days, you may peel them off
with warm water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
two weeks after surgery.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re wound / incision site and this should
be left in place for three (3) days. Remove it after this time
and wash your incision(s) gently with soap and water. You may
have staples and or sutures, which are usually removed in 4
weeks. This will be done by the Surgeon on your follow-up
appointment.
Limit strenuous activity and or heavy lifting until the wound
is well healed. Activity may prevent the wound from healing.
Do not drive a car unless cleared by your Surgeon.
Try to keep your affected limb elevated when not in use, This
decreases swelling to the affected wound and helps in the
healing process.
You may have an ace wrap around the affected limb with the
wound. This helps prevent swelling to the area. You may take
this off at night. But when you are doing activity the ace wrap
should be worn.
ANTIBIOTICS:
You may have a prescription for antibiotics. Take as directed.
Be sure you take the full course even if the wound looks well
healed. Failure to do so may lead to infection.
Followup Instructions:
Call Dr.[**Name (NI) 1720**] clinic at [**Telephone/Fax (1) 1241**] to schedule a follow-up
appointment in [**2-5**] weeks.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB)
Date/Time:[**2106-4-15**] 10:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2106-4-15**] 10:30
Test for consideration post-discharge: Activated Protein C
Follow - up with Dr [**Last Name (STitle) 5456**] for your INR. VNA will moniter your
INR. Dr [**Last Name (STitle) 5456**] will adjust your coumadin accordingly. VNA will
fax the results to Dr [**Last Name (STitle) 5456**] office at [**Telephone/Fax (1) 32161**].
Completed by:[**2106-2-23**]
|
[
"287.4",
"428.0",
"996.74",
"507.0",
"492.8",
"V10.21",
"285.1",
"272.4",
"E934.2",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"99.07",
"39.49",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
17345, 17409
|
13795, 15629
|
368, 521
|
17567, 17576
|
1842, 13772
|
20956, 21789
|
1320, 1338
|
15703, 17322
|
17430, 17546
|
15655, 15680
|
17976, 18469
|
1353, 1823
|
237, 330
|
18482, 20933
|
549, 1086
|
1108, 1263
|
1279, 1304
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,422
| 192,960
|
12571
|
Discharge summary
|
report
|
Admission Date: [**2194-12-1**] Discharge Date: [**2194-12-8**]
Date of Birth: [**2155-8-3**] Sex: F
Service:ORTHO
DISCHARGE DIAGNOSIS: Progressive kyphoscoliosis.
PROCEDURE PERFORMED: Revision of posterior spinal fusion
T3-S1.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant
39-year-old white female with a history of multiple previous
spinal operations for scoliosis. She subsequently developed
an infection postoperatively in the past requiring hardware
removal. Despite adequate fusion both in the upper thoracic
and lower lumbar spines, she developed a pseudarthrosis in
the region of a previous osteotomy in the upper lumbar spine
resulting in progressive kyphoscoliosis. She presents
electively for planned revision posterior spinal fusion from
T3 to S1.
For further details of the history and physical, please see
chart.
HOSPITAL COURSE: Patient was admitted to the hospital on
[**2194-12-1**] after undergoing the aforementioned procedure.
She tolerated the procedure well with no apparent
intraoperative or postoperative complications. She received
1 unit of packed red blood cells intraoperatively, an
additional 2 units of packed red blood cells while at
recovery room. She spent the first postoperative night in
the recovery room, where she was slowly extubated and
monitored closely. She was subsequently sent to the
Orthopedic floor in stable condition.
Postoperative course was essentially unremarkable. She was
seen by the Anesthesia Pain service throughout her
hospitalization due to chronic pain issues and need for
expertise in managing her pain issues. She received
perioperative antibiotics. She was placed in TEDS stockings
and SCDs for DVT prophylaxis. Hematocrit remained stable
throughout the remainder of her hospitalization with no need
for additional blood transfusions. She was slowly
transitioned from IV to oral narcotic analgesics.
She was seen by Physical Therapy on a daily basis, and a new
TLSO brace was made during this hospitalization. She was
ambulating independently prior to her discharge home.
Patient was tolerating a general diet without restriction,
had full return of bowel and bladder function, and was felt
to be medically stable for discharge home with home health
nursing services on postoperative day #7.
DISCHARGE INSTRUCTIONS: Patient will follow up Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 363**] in two weeks for wound check. She will follow up
sooner should she experience fevers, chills, worsening pain,
wound drainage, neurologic changes, or other concerns.
DISCHARGE DIET: General without restriction.
DISCHARGE ACTIVITY: The patient may be up as tolerated in
her TLSO brace. She is to refrain from any bending, lifting,
pushing, or pulling activities.
DISCHARGE MEDICATIONS:
1. Morphine sulfate 60 mg p.o. q.8h.
2. Morphine sulfate 15 mg tablet [**2-6**] p.o. q.3-4h. prn for
breakthrough pain.
3. Ferrous sulfate one p.o. b.i.d.
DISCHARGE INSTRUCTIONS: Patient will have arrangements for
home VNA services for wound checks and dressing changes. She
will additionally have a home Physical Therapy evaluation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**]
Dictated By:[**Last Name (NamePattern4) 38908**]
MEDQUIST36
D: [**2194-12-7**] 15:21
T: [**2194-12-8**] 14:37
JOB#: [**Job Number 38909**]
|
[
"998.89",
"737.39",
"E878.2",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.39",
"81.64",
"81.35"
] |
icd9pcs
|
[
[
[]
]
] |
2814, 2970
|
153, 248
|
879, 2302
|
2995, 3426
|
277, 861
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,085
| 150,876
|
33265
|
Discharge summary
|
report
|
Admission Date: [**2200-3-20**] Discharge Date: [**2200-3-23**]
Date of Birth: [**2137-11-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
1. Ascending aortic aneurysm and bicuspid aortic valve.
2. Severe aortic insufficiency as well as aortic stenosis.
Major Surgical or Invasive Procedure:
AVR (27mm mosaic), Asc Aorta replacement
History of Present Illness:
This is a 62-year-old male who had
been evaluated approximately 4 years ago for new onset of
chest pain and upon that workup, it was noted the patient
had a dilated ascending aorta and some aortic stenosis.
Several followup echocardiograms were performed during this 4-
year period. Now presents with increase in aortic size up to
5 cm as well as significant aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of
0.7 and a peak gradient of 95. His ejection fraction was
60%. He also underwent a CAT scan preoperatively which showed
once again ascending aorta of approximately 4.9-5 cm. Based
on these findings, the patient was recommended to undergo
aortic valve replacement as well as ascending aortic
replacement. The patient understood the risks and benefits of
the procedure which included but were not limited to
bleeding, infection, myocardial infarction, stroke, death,
renal and pulmonary insufficiency as well as the possibility
of blood transfusions and future revascularization
procedures. In spite of this, the patient agreed to proceed.
Past Medical History:
PMH: AS [**12-21**] bicuspid valve, hyperlipidemia, migraines, GERD,
OSA, sig alcohol history
PSH: anppy, tonsillectomy, schatzki ring dilation, colon
polypectomy
Social History:
SOCIAL HISTORY: () Single (+) Married () Divorced
Has two children.
Lives with: wife in [**Name (NI) 86**]
Occupation: [**Name (NI) 75297**]. Currently doing consulting
ETOH: Several alcoholic drinks a day
Contact person upon discharge: [**Name (NI) **] [**Name (NI) **] (wife):
[**Telephone/Fax (1) 77243**]
Family History:
FH: Father had either an MI or stroke in his early 60??????s.
Paternal
grandfather died of cardiac disease at age 62
Physical Exam:
On physical examination, his pulse was 72 and respirations were
14. Blood pressure was 126/74. His height was 71" and he
weighed 190 lbs. Overall, he appeared to be a well developed
and well-nourished male in no acute distress. His skin was
warm, dry, and intact. His extraocular movements were intact.
His pupils were equal, round, and react to light. His neck was
supple with full range of motion without any JVD. There were no
carotid bruits noted. His lungs were clear to auscultation.
Sternal Incision is clean, dry and inatct. Cardiac examination
revealed regular rate and rhythm His abdomen was soft,
nontender, and nondistended with positive bowel sounds.
Extremities are warm and well perfused without any edema or
varicosities. Neurologically, he was alert and oriented x3.
Moving all extremities and nonfocal examination.
Pertinent Results:
[**2200-3-22**] 08:17AM BLOOD
WBC-10.1 RBC-2.99* Hgb-9.7* Hct-27.0* MCV-91 MCH-32.4*
MCHC-35.8* RDW-13.4 Plt Ct-106*
[**2200-3-22**] 08:17AM BLOOD
Plt Ct-106*
[**2200-3-21**] 01:54AM BLOOD
PT-13.4 PTT-41.1* INR(PT)-1.2*
[**2200-3-22**] 08:17AM BLOOD
Glucose-108* UreaN-15 Creat-0.8 Na-134 K-4.1 Cl-101 HCO3-26
AnGap-11
[**2200-3-21**] 09:00AM
freeCa-1.04*
[**2200-3-20**] 07:40AM BLOOD
Hgb-14.3 calcHCT-43
[**2200-3-22**] 1:37 PM
CHEST (PORTABLE AP)
Tubes and lines have been removed. Aside from linear basal left
lower atelectasis the lungs are clear. Cardiac size is top
normal, accentuated by the projection. There is no pneumothorax
or sizable pleural effusion. Fluid overload has resolved.
Mediastinal wires are aligned.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Aorta - Annulus: 2.8 cm <= 3.0 cm
Aorta - Sinus Level: *4.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.4 cm <= 3.0 cm
Aorta - Ascending: *4.6 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *33 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 18 mm Hg
Aortic Valve - LVOT pk vel: 1.39 m/sec
Aortic Valve - LVOT diam: 2.5 cm
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Normal LA size.
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: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Moderately dilated
ascending aorta. Normal descending aorta diameter.
AORTIC VALVE: Bicuspid aortic valve. Moderate AS (AoVA
1.0-1.2cm2) Significant AR, but cannot be quantified. Eccentric
AR jet directed toward the anterior mitral leaflet.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: PVR not well seen. Physiologic
(normal) PR. No Doppler evidence for PDA
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).
Conclusions
PRE-BYPASS:
1. The left atrium is normal in size.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated.
6. The aortic valve is bicuspid. There is moderate aortic valve
stenosis (area 1.0-1.2cm2). Significant aortic regurgitation is
present, but cannot be quantified. The aortic regurgitation jet
is eccentric, directed toward the anterior mitral leaflet.
7. The mitral valve appears structurally normal with trivial
mitral regurgitation.
8. The pulmonic valve prosthesis is not well seen.
9. There is no pericardial effusion.
POST-BYPASS:
For the post-bypass study, the patient was receiving vasoactive
infusions including phenylephrine and was in SR.
1. A well-seated bioprosthetic valve is seen in the aortic
position with normal leaflet motion and gradients (mean gradient
= 10 mmHg) with a cardiac output of 6L/min. Trivial aortic
regurgitation is seen.
2. Regional and global left ventricular systolic function are
normal.
3. Aortic contours are intact post-decannulation.
Brief Hospital Course:
[**3-20**]
PROCEDURE PERFORMED:
1. Ascending aortic replacement with a number 26 Gelweave graft.
2. Aortic valve replacement with a #27 Mosaic porcine valve.
No complications. tolerated the proceure well. Transfered to the
CVICU in stable condition.
Extubated POD # 1 / diureses throughout the hospital course / to
be continued on DC.
Foley DC - pt urinating on DC. Diet advanced. Tolerating PO's
CT out POD # 2, post cxr no sequele from chest tubes
Pacing wires out POD # 3. No sequele
PT consult
Cleared for home with VNA
Medications on Admission:
[**Last Name (un) 1724**]: zocor 60', aspirin 81'
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*6*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
PREOPERATIVE DIAGNOSIS:
1. Constrictive pericarditis.
2. Severe two-vessel coronary artery disease.
3. Status post previous myocardial infarction.
Discharge Condition:
Good
Discharge Instructions:
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
shower daily, no swimming or bathing for 1 month
no driving for 1 month
Followup Instructions:
PCP: [**Name10 (NameIs) 8505**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 8506**] - call and make an
appointmnent upon leavig the hospital. You should see your PCP
in one week.
Call Dr [**Last Name (STitle) 35849**] office and schedule an appointment for 2 weeks
Completed by:[**2200-3-23**]
|
[
"530.81",
"746.4",
"E878.2",
"272.4",
"788.5",
"997.5",
"424.1",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9394, 9428
|
7443, 7977
|
437, 480
|
9619, 9626
|
3117, 7420
|
9824, 10150
|
2123, 2241
|
8077, 9371
|
9449, 9598
|
8003, 8054
|
9650, 9801
|
2256, 3098
|
282, 399
|
2034, 2107
|
508, 1589
|
1611, 1776
|
1809, 2018
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,898
| 104,850
|
44584
|
Discharge summary
|
report
|
Admission Date: [**2174-2-19**] Discharge Date: [**2174-3-16**]
Date of Birth: [**2122-12-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
R internal jugular central line
History of Present Illness:
51 yo male with AIDs (dx [**2158**], on HAART, VL undetectable, CD4 90
[**1-3**], h/o thrush and esophagitis) admitted with back pain/flank
pain and fevers. He was in hus USOH until [**2174-1-27**] when he went
to his PCP's with R sided pleurtic chest pain. He also had a
resurangence of fevers to 102 - 105 and night sweats which he
had had for 13 years, then stopped 2 years prior when he started
HAART. CXR on [**2174-1-27**] showed infiltrate within the left upper
lobe and an opacityl at the right heart border. He was started
on Levaquin at that time. Then on [**2174-2-3**], he went to [**Hospital1 **]
[**Location (un) 620**] with L calf pain. He was admitted with a DVT and
multiple PEs. Chest CT at that time also showed multiple
bilateral segments and subsegmental pulmonary emboli,
consolidation vs. infarct in the posterior left upper lobe and
anterior right lower lobe, multiple bilateral pulmonary nodules,
and mediastinal lymphadenopathy. MDs there were also concerned
that he could have TB as he had weight loss, fevers, and pulm
nodules. He underwent bronch on [**2174-2-7**] which was "normal".
Cytology showedd atypical flora. Cultures/labs from there showed
negative crypto ag, oral flora from the bronch, AFB smear
negative, culture pending. He was started on coumadin and
heparin and a second of levofloxacin. During this stay, he had
no pulmonary symptoms.
.
On discharge from [**Location (un) 620**], he noticed his Right leg now was
tender, where it had not been before. He then was switched to a
course of Doxy on [**2-11**] my his PCP. [**Name10 (NameIs) **] was not doing well at home
since he was having extreem pain in both his legs. The swelling
in the LLE diminished, but the right increased. He had no
pulmonary symptoms until the afternoon on [**2-18**] when he began to
become SOB. He came to the ED.
.
In ED, initial vitals were 103.6, HR 145, BP 78/62, RR 18, 98%
-> 100% on 2L .He was complaiing of worsening SOB and pleurtic
right chest pain. Code sepsis called, RIJ placed. Initial CVP
was 7. he was boluesd 8 L NS in the ED. Of note, his O2 sat on
arrival was 98% RA, then 100% 2l in the ED,94% on 4L NC on
arrival to MICU. he was started on Dopamine and levophed. He was
given 1 gram of vancomycin, 1 gram of CTX, and a DS bactrim.
Blood cultures and urine cultures were sent. A ct chest revealed
a left upper lobe opacity, subsegmental PE's, multiple B pulm
nodules.
.
Currently, he is SOB and c/o pleurtic right sided and posterior
chest pain and bilateral calf pain. He has been having fevers to
102 - 105 daily with night sweats. Denies large weight gain (he
has had touble with weight loss since his MAC). No HA. No neck
pain. No nausea. No vomiting. Has one loose BM daily [**3-3**] HAART.
Denies missing any of his medicine. Quit smoking 2 eeks agi. No
recent PPD. No TB contacts. [**Name (NI) **] Rashes. No recent travel.
Past Medical History:
AIDS on HAART c/b thrush
H/O MAC infection of unknown site
DVT left leg- [**2174-2-3**]
COPD- bullous changes
intermittent diplopia
asymptomatic UTI
Moderate cervical spondylosis with moderate spinal canal
stenosis
and multilevel bilateral neural foraminal narrowing seen on MR
cervical spine- [**2170**]
Epidermal inclusion cyst- right thigh
Social History:
+tobacco ([**1-31**] pack a day) x35 years and quit 2 weeks ago, no
ETOH. no illict drugs, lives alone. Works part-time with
caterers.
Family History:
Mother- breast cancer, stomach cancer Father: CVA, heart disease
Physical Exam:
wt: 62kg, 97.9 po, p123, 108/75 (dopamine 9, levophed .2), r28,
96% on 4l nc (ED 8liter in and 1500cc out)
General: mild resp distress, talkitave. Able to relate history
well.
HEENT: NC/AT, PERRLA. dentures in, no thrush seen. no scleral
icterus noted, MMM.
Neck: Supple, JVP normal
Pulmonary: Anterior reveals a three componet pulmonary rub.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: diffusly tender with voluntary guarding. normoactive
bowel sounds, no masses or organomegaly noted. extreme right
CVAT
Extremities: 1+ pitting edema bilaterally on calf. VERY tender
gastroc. 2+ radial, DP and PT pulses b/l.
Neurologic: A and O x3; srength grossly normal.
Brief Hospital Course:
Assessment: 51 yo m with AIDS, recent diagnosis of PE, pulmonary
nodules, fevers, and shock. His shock is most likely due to
sepsis given his increasing WBC and low CVP making right heart
strain from PE unlikley.
.
Plan:
# Septic shock: He seems to be in distributive shock. Most
likely this is sepsis, given that he is immunocompromised with
fevers and respiratory distress. However, Adrenal insufficiency
unlikely given normal [**Last Name (un) 104**] stim test. Given his
immunocomprimised state, he has many potential sources for
sepsis including bactreial, fungal, and viral. Infectious
disease was consulted who recommended continue treatment with
caspofungin, azithromycin, imipenem-cilastin. Continue
antiretrovirals and bactrim ppx. Unclear source at this point.
So far all cultures NGTD, cryptococcus, CMV, and histo
serologies negative, AFB x3, PCP stain, [**Name9 (PRE) 20613**] ag, negative. Pt
was placed on Sepsis protocol. With frequent NS fluid bolus for
CVP >12 and pressors. He had episode of NSVT on arrival while
on dopamine and was changed over to levophed, which he required
for several days of his addmision to keep MAP>65. Given
persistent hypotension concern for neurogenic shock secondary to
autonomic dysfunction, Neuro consult was obtained who did not
think that patient has autonomic dysfunction on initial
assessement.
.
# Respiratory distress - as above, most likely secondary to
pulmonary infection complicated by pulmonary emboli. Required
significant oxygen supplementation initially but this was
reduced by 6 days of hospitalization from NRB to 40% by
facemask.
.
# PE/DVT: Hx of DVT and PE on recent hospitalization. RL LENI
shows DVT this admission. Given likely coumadin failure IVC
filter was placed. Pt was started on heparin initially and then
changed over to lovenox 1mcg/kg [**Hospital1 **]. [**2-27**] AM with RUE swelling
as well, with DVT. Heme onc consulted, started on heparin as
developing DVTs through lovenox.
- Given recurrent dvt and ?pulmonary nodules and enlarged
lymphnode concern for malignancy in setting of hypercoguble
state high.
- Currently morphine prn.
.
#. hemoptysis - likely secondary to underlying pulmonary
processes. Consider bronchoscopy only if this worsens (currently
stable).
.
#Polyuria - Unclear etiology. Continues to urinate to the point
of hypotension despite IVF being stopped. [**Month (only) 116**] have neprogenic DI
[**3-3**] ambisome. [**Month (only) 116**] also not be able to concentrate urine to
excrete all the salt he has gotten on the sepsis portocol
causing an solute diuresis. Gave dose of ddAVP to see if can
concentrate urine. Ambisome switched to caspofungin.
- Renal was consulted given concern for DI. They did not think
that the pt has diabetes insipidus given that the patient has
had normal Uosm and Una. More likely, this is consistent with a
solute diuresis from the large amounts of fluid the patient has
received during this hospitalization. It is unclear whether he
is intravascularly depleted or overloaded, and his weight is up
approx 6kg. If he is making appropriate urine to previous IVF
administration, would expect his urine now to more accurately
match his input. With restriction on NS IVF, pt's urine output
has improved.
.
# Infection - unclear etiology most likely source of infectionis
pulmonary, but differential in this immunocompromised patient is
very broad. ID following. So far all cultures NGTD,
cryptococcus, CMV, and histo serologies negative
- on retrovirals, azithro/bactrim
- imipenem dc'd- continuing with vanco
.
## Neuro - pt with c/o diplopia this morning which is new. Also
with nystagmus on exam concerning for brainstem process.
- per discussion with neuro attg, given pt's likely
hypercoaguble state need to rule out stroke.
- MRI/MRA -small L cerebellar stroke, w/ sluggish basilar artery
flow, CTA also showed no thrombus but decreased basilar artery
flow. Per Neuro ordered TTE w/ bubble, no ASD or PFO
- Daily CT showed no change (needs daily CTx7 day to assess no
hemorrhagic development
.
#Hemoptysis - likel secodary to PE and PNA. Stable in amount and
frequency. Is small amounts at this time. If decompensates of
hemoptysis progresses beyond tsp amounts will need bronchoscopy
and possible surgical consult.
.
## Neuro - pt with c/o diplopia this morning which is new. Also
with nystagmus on exam concerning for brainstem process.
- per discussion with neuro attg, given pt's likely
hypercoaguble state need to rule out stroke.
- MRI/MRA to eval for stroke.
.
# AIDS: Initially held HAART therapy. Restarted on [**2173-2-24**].
#. pulm nodules - concern for malignancy given fevers, LAD. o/w
infection as above. with LUL mass, discuss timing of biopsy as
differential includes lymphoma vs lung neoplasm, will need to
discuss holding anticoagulation.
.
PPx: PPI, no pneumoboots, lovenox, increase bowel regimen given
constipation, no bowel movement since admission per pt
FEN: po diet as resp status stable
Access: RIJ, R art line, PIV
Communication: sister [**Name (NI) **]
Dispo: ICU until HD stable
# Code Status: Full, discussed extensively with paitent and HCP,
[**Name (NI) **], his sister. [**Name (NI) **] is very nervous about intubation, but
agrees that he may benefit from it in the short term.
# Dispo: ICU for now given hypotension.
# Contact: [**Name (NI) **], sister ...
The patient had a prolonged intensive care unit stay. He
developed further progressive thromboses. An IVC filter was
placed to prevent further pulmonary emboli. He developed
ischemic bowel with thrombosis of celiac and mesenteric
arteries. After extensive discussion with patient and his
sister [**Name (NI) **], the patient was made care and comfort measures
only. He was treated with IV morphine and expired peacefully on
[**2174-3-16**].
Medications on Admission:
Truvada
Reyataz 150'
Norvir 100'
Bactrim DS'
Azithromycin twice weekly
Ambien prn
Doxycycline 100 mg [**Hospital1 **] since [**2-11**]
Vicodin 5/725 prn for leg pain
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Acquired immune deficiency syndrome
adenocarcinoma of lung
pulmonary emboli
mesenteric ischemia
Discharge Condition:
Deceased
Discharge Instructions:
Remains released to funeral home
Followup Instructions:
None
|
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icd9cm
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[
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icd9pcs
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[
[
[]
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10614, 10623
|
4568, 10368
|
327, 360
|
10763, 10773
|
10854, 10861
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3799, 3865
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10394, 10562
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10797, 10831
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276, 289
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388, 3264
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3286, 3631
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3647, 3783
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,087
| 127,171
|
41159
|
Discharge summary
|
report
|
Admission Date: [**2109-5-25**] Discharge Date: [**2109-6-7**]
Date of Birth: [**2051-3-23**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
External Ventricular Drain
Endotracheal Intubation
History of Present Illness:
Patient (supposed real name [**Known lastname 33754**], [**Known firstname 429**]) is a 58 year old
male with history of hypertension (reportedly noncompliant),
CABG, who reportedly presented to an OSH for chest pain. This
history was taken from the outside hospital as no family could
be
contact[**Name (NI) **]. [**Name2 (NI) **] preortedly called an ambulance, after he had been
drinking beer and complained of chest pain. He looked to
bystanders like he was going to pass out. Presenting BP was
209/130. EKG at OSH sinus rhythm with LVH, diffuse ST and T wave
changes. Labs were significant for a WBC of 10.7, Hct of 50.9,
negative cardiac enzymes, and an EtOH of 66. INR was 1.0. A
nitroglycerine drip was initiated to control the blood pressure
which reportedly regularly runs greater than 100 diastolic, 200
systolic. Following this he reportedly became less responsive,
responding to pain only. No further speech. At this point
patient was intubaged for airway protection. He was given
fentanyl initially and then succinyl coline and etomidate. He
was given an additional 20 mg of labetalol and a nitroprusside
gtt was started. Head CT demonstrated a left thalamic
hemorrhage
with intraventricular extension. His BP was in the 150s prior
to
transfer to [**Hospital1 18**]. At some point at the OSH BP reportedly
"dropped" and he was given dopamine and IV fluids and fentanyl
to
help with aggitation. Upon transfer to [**Hospital1 18**] Neurology was
called for further management. With his poorly declining status
we contact[**Name (NI) **] Neurosurgery to emergently place an EVD. The
opening pressure was 18.
ROS - unable to preform secondary to mental status
Past Medical History:
CABG performed 2 to 3 years ago. .
HTN - reportedly does not take his medication.
Social History:
Smokes tobacco, Reportedly a "heavy" drinker
Family History:
Unknown
Physical Exam:
Vitals: 73 96/66 11 97% on CMV@100% 480x17 PEEP@5
Gen: Intubated, sedated, weaning off paralyctics
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: warm and well perfused.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: will open eyes briefly to deep sternal rub
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 nonreactive BL. Does not blink to threat in any
field. No gaze deviation.
III, IV, VI: +vestibuloccular reflex.
V/VII: + Corneals Bilaterally. Mild left sided facial droop.
IX, X: + gag
-Motor/Sensory: briskly withdraws in bilateral lower
extremities.
Localizes with left upper extremity. extensor postures in the
right upper extremity to noxious.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor extensor.
-Gait: not tested
ON DISCHARGE
MS: alert, not oriented to location or date. Unable to retain
any words or have memory of prior days events. Language is
intact - fluent, w/ normal comprehension, and repetition.
CN: pupils symmetric and reactive; EOMI no nystagmus, skew
resolved
Motor: full strength in upper and lower extremities
Gait: able to walk with assistance of a walker
Reflexes: symmtric/normal, toes down
Pertinent Results:
CT: [**2109-5-25**]
Large left thalamic hemorrhage extending into the ventricles
with
associated mild obstructive hydrocephalus.
CT: [**2109-6-1**]
1. Evolving left thalamic hemorrhage with intraventricular
extension and
surrounding edema and mass effect, stable since the prior study.
2. Interval removal of a right frontal ventriculostomy catheter,
with minimal pneumocephalus. No significant change in the
ventricular size.
3. Extensive small vessel ischemic disease.
TTE: [**2109-5-27**]
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Dilated
ascendting aorta. Left atrial enlargement. No valvular pathology
or pathologic flow identified.
These findings are c/w hypertensive heart.
Renal U/S
Bilateral renal blood flow with morphologically normal
waveforms.
There is no difference in peak systolic velocities given the
limitations in technique. There is no definitive evidence of
renal artery stenosis. Mildly elevated resistive indices may be
related to medical renal disease.
CTA
1. Mild atheromatous disease. Hypoplastic left vertebral artery
is not
visualized at its origin, but reconstitutes distally. No
evidence of
vasculitis.
2. Evolving left thalamic hemorrhage, with intraventricular
extension.
3. Right frontal ventriculostomy catheter in position, with
stable
ventricular size and decreased intraventricular blood products.
4. Severe small vessel ischemic disease.
HgA1c 6.3
FLP LDL 71 HDL 64 Chol 151 Tg 82
Brief Hospital Course:
Left Thalamic Hemorrhage
[**Known firstname 429**] [**Known lastname 33754**] was admitted to the neuro-ICU after he had onset
of chest pain and headache and a deterioration in his level of
consciousness. He was intubated in the ED and transferred to the
ICU. On examination he had significant eye movement
abnormalities in the right eye in which it was deviated out, but
improved during his hospital course. He had an EVD placed and
received intraventricular tPA for concern of obstructive
hydrocephalus. On extubation he was found to have a profound
anterograde amnesia. It was unknown whether some of this was
preexisting due to excessive alcohol use or a result of the
thalmaic hemorrhage and connections with the hippocampus. His
exam improved significantly in areas of motor and gait, but he
continued to require a walker to get around. His blood pressure
was controlled with an increased regimen of antihypertensive and
he was normotensive on discharge. He should continue to remain
normotensive and will follow-up with Dr. [**Last Name (STitle) 1693**], but he needs to
call registration prior to his appointment.
Medications on Admission:
None
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
4. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
Crotchette Mountain
Discharge Diagnosis:
Left thalamic hemorrhage with intraventricular extension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the neurology service in the ICU after you
had a depressed level of consciousness. You were intubated and
taken to the ICU. Your exam was notable for depressed
consciousness and extensor posturing, however on discharge your
motor exam had improved and your deficits were mostly in
concentration, orientation and memory. You had a CT that showed
a left thalamic hemorrhage with intraventricular extension. You
had an EVD placed by neurosurgery and received intraventricular
tPA. You were transferred out of the ICU and maintained on an
antihypertensive regimen. You will be discharged to an acute
rehab in [**Location (un) 3844**]. A follow-up appointment was made with
Dr. [**Last Name (STitle) 1693**]. Call registration prior to your appointment
[**Telephone/Fax (1) 10676**] as you may need to be self-pay.
1. F/U with Dr. [**Last Name (STitle) 1693**] in 3 months
2. Continue on current antihypertensive
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**]
Date/Time:[**2109-9-17**] 11:30
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2109-6-7**]
|
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icd9cm
|
[
[
[]
]
] |
[
"99.10",
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icd9pcs
|
[
[
[]
]
] |
7137, 7183
|
5309, 6433
|
313, 366
|
7284, 7284
|
3787, 5286
|
8387, 8718
|
2268, 2278
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|
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|
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|
265, 275
|
394, 2082
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|
2104, 2189
|
2205, 2252
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
927
| 116,557
|
23388
|
Discharge summary
|
report
|
Admission Date: [**2107-1-25**] Discharge Date: [**2107-1-29**]
Date of Birth: [**2030-5-5**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 76 year old male with
a known history of coronary artery disease, who reports some
episodes of chest pain with radiation to his jaw, right ear,
and right arm. He also reported progressive shortness of
breath, all occurring a few times over the past couple of
months. He said he also had one episode on [**1-14**] while
at rest. He had a stress test on [**12-29**] which showed
inferior, posterior and lateral infarct, inferoapical lateral
hypokinesis and ejection fraction of 47 percent. He denied
any nausea, vomiting or diaphoresis. His cardiac
catheterization showed ejection fraction of 51 percent, LAD
90 percent lesion, circumflex 90 percent lesion, OM1 80
percent lesion and the RCA 70 percent lesion. His past
medical history includes being hard of hearing,
hypothyroidism, no tendons in his right foot and hepatitis in
[**2052**]. Past surgical history includes appendectomy,
tonsillectomy and left ear surgery at age 6 months. He had
no known drug allergies. Medications preop were
levothyroxine, 100 mcg po daily and ibuprofen, 800 mg po prn.
He is married and lived in [**Hospital1 **]. He is retired. He had no
tobacco history and no use of alcohol.
Preop chest x-ray showed no active lung disease, but
tortuosity of thoracic aorta with calcification. Please
refer to the official report dated [**2107-1-20**]. Preop EKG on
[**2107-1-20**] showed sinus rhythm at 93 with some low amplitude
T waves and LVH. Please refer to the official report dated
[**2107-1-20**].
On exam he is 5 feet 8 inches tall, 152 pounds, in sinus
rhythm at 86 with a blood pressure of 162/97, respiratory
rate 16, sating 98 percent on room air. He was lying flat in
bed in no apparent distress. He was alert and oriented times
three and appropriate. Moving all extremities. His lungs
were clear bilaterally. His heart was regular rate and
rhythm with S1 and S2 tones and a grade 2/6 systolic ejection
murmur. His abdomen was soft, flat, nontender, nondistended
with positive bowel sounds. Extremities warm, dry and well
perfused with no edema or varicosities noted. He had 2 plus
bilateral radial and DP pulses and 1 plus bilateral PT
pulses.
Preop labs are as follows. White count 4.9, hematocrit 30.1,
platelet count 161,000. Sodium 139, potassium 3.3, chloride
108, bicarb 28, BUN 38, creatinine 0.8 with a blood sugar of
158. PT 13.0, PTT 31.2, INR 1.1. AST 13, ALT 15, alkaline
phosphatase 68, total bilirubin 0.5, albumin 3.5. Urinalysis
preop was negative for UTI, but had trace hematuria.
Additional labs as follows: albumin 3.5, cholesterol 142,
anion gap 10, triglycerides 70, HDL 36, cholesterol to HD
ratio 3.9, calculated LDL 92.
The patient went home over the weekend and came back for
surgery on [**1-25**], the day of admission, and underwent
coronary artery bypass grafting times four with LIMA to the
LAD, vein graft to the OM, vein graft to PL and vein graft to
the RCA by Dr. [**Last Name (STitle) **]. He was transferred to the
cardiothoracic ICU in stable condition on a Neo-Synephrine
drip at 0.3 mcg per kg per minute and a propofol drip at 30
mcg per kg per minute. On postoperative day one, the patient
was stable hemodynamically with a blood pressure 106/50 in
sinus rhythm at 97. He remained ventilated with CPAP early
that morning with a white count of 8.1, hematocrit 32.8.
Potassium 4.4, BUN 20, creatinine 0.9. PA pressures of 38/16
with an index of 3.35 and a mixed venous of 80 percent. He
was also evaluated by case management. Later that evening he
was extubated, overnight had some wheezes and got some
racemic epinephrine therapy, kept in the unit on
postoperative day one just to keep an eye on his respiratory
status.
He was evaluated by case management on postoperative day two.
His creatinine remained stable at 0.9. He was
hemodynamically stable with a blood pressure of 136/66 in
sinus rhythm in the 90s. Beta blockade was begun. He was
transferred out to the floor. A swallow study was ordered as
there was some question of some aspiration risk and was to be
re-evaluated during the day. If a swallow study was needed,
it would be ordered for him at that time. His beta blockade
was increased on postoperative day two on the floor. He was
evaluated by physical therapy and was encouraged to increase
his activity level and ambulate with the physical therapist
and the nurses. On [**1-27**] his chest tubes were
discontinued and his wires were discontinued. On
postoperative day three he was alert and oriented. He had
nonfocal exam. His lungs were clear. His heart was regular
rate and rhythm. He remained on Lasix, 20 mg twice a day.
Lopressor was increased to 75. Pacing wires were
discontinued. He was sating 93 percent on 4 liters nasal
cannula. His Foley was removed and he voided successfully.
He had evaluation by orthopedics given the fact that he had
no tendons in his right foot and had a long-standing old
remote injury. He complained of some pain on ambulation.
They recommended possible strength training exercises,
elevating his foot and ankle, only weightbearing as tolerated
and giving him ibuprofen for prn pain control. He was alert
and oriented and steady on his feet. His diet was advanced.
On postoperative day three his creatinine remained stable at
1.0 with hematocrit of 32.8 and white count of 11.5. He was
independently ambulating. Was denying any pain. He appeared
to be sleeping well. He had a T-max of 100.3 on
postoperative day three, but then rapidly became afebrile.
He was ambulating a level 5 and moving all extremities and
doing extremely well.
On the day of discharge his blood pressure was 156/76, sating
97 percent on room air. Heart rate 80. His lungs were clear
bilaterally. His heart was regular rate and rhythm. He was
alert and oriented. His abdomen was soft, nontender,
nondistended. He had some trace bilateral lower extremity
edema. He was doing very well and was discharged to home
with VNA services on [**2107-1-29**] with the following discharge
instructions. He was instructed to see Dr. [**Last Name (STitle) **] in the
office approximately four weeks postop and to see his primary
care physician in approximately two weeks post discharge.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times four.
2. Hard of hearing.
3. Hypothyroidism.
4. Status post right foot injury with absence of tendons.
5. Remote hepatitis in [**2052**].
DISCHARGE MEDICATIONS:
1. Colace, 100 mg po twice a day.
2. Enteric coated aspirin, 81 mg po once a day.
3. Percocet 5/325, 1 to 2 tablets po prn q4 hours for pain.
4. Levothyroxine sodium, 100 mcg po once daily.
5. Metoprolol, 75 mg po twice a day.
6. Lasix, 20 mg po once a day for 7 days.
The patient was discharged to home on [**2107-1-29**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2107-3-17**] 09:35:56
T: [**2107-3-17**] 12:27:40
Job#: [**Job Number 60022**]
|
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"413.9",
"786.1",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6392, 6585
|
6608, 7201
|
164, 6371
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,985
| 151,653
|
8332
|
Discharge summary
|
report
|
Admission Date: [**2194-6-19**] Discharge Date: [**2194-6-23**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 84F w/PMHx of longstanging DM, HTN, and
hyperlipidemia and colon cancer who presents with a right sided
SDH. The patient was getting a haircut on the day of admisison,
when she turned quickly to speak with someone and fell on the
right side of her head. She was brought to an OSH where head CT
showed a small right occipital SDH. She was then transferred to
[**Hospital1 18**] for definitive NSURG care.
Past Medical History:
DMx20yrs w/retinopathy, neuropathy, HTN, hyperlipidemia,
bilateral cataract surgery, multiple eye surgeries, colon CA s/p
right hemicolectomy, s/p CCY, s/p tonsillectomy
Social History:
Russian Speaking only, denies smoking/ETOH
Family History:
non-contributory
Physical Exam:
On Discharge:
Patient is alert, oriented and following commands.
Pertinent Results:
Labs on Admission:
[**2194-6-20**] 03:00AM BLOOD WBC-12.1* RBC-3.90* Hgb-9.7* Hct-30.1*
MCV-77* MCH-24.9* MCHC-32.2 RDW-15.1 Plt Ct-276
[**2194-6-20**] 03:00AM BLOOD PT-12.9 PTT-23.0 INR(PT)-1.1
[**2194-6-20**] 03:00AM BLOOD Glucose-166* UreaN-26* Creat-1.2* Na-142
K-4.2 Cl-105 HCO3-27 AnGap-14
[**2194-6-20**] 03:00AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.1
[**2194-6-20**] 03:00AM BLOOD Phenyto-9.7*
Labs on Discharge:
[**2194-6-23**] 05:15AM BLOOD WBC-10.7 RBC-3.73* Hgb-9.3* Hct-29.2*
MCV-78* MCH-25.0* MCHC-31.9 RDW-15.1 Plt Ct-310
[**2194-6-23**] 05:15AM BLOOD PT-11.7 PTT-21.9* INR(PT)-1.0
[**2194-6-23**] 05:15AM BLOOD Glucose-102 UreaN-24* Creat-1.2* Na-144
K-4.3 Cl-102 HCO3-31 AnGap-15
[**2194-6-23**] 05:15AM BLOOD Calcium-9.5 Phos-2.8 Mg-1.9
Imaging:
Head CT [**6-19**]:
FINDINGS: A non-contrast CT of the head was performed. There has
been marked interval enlargement of a right hemispheric subdural
hematoma with both acute and hyper-acute blood identified
measuring approximately 1.2 cm in greatest diameter. There is
approximately 6 mm of right to left midline shift. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. There are
periventricular white matter hypodensities which are most likely
attributed to chronic ischemic microvascular disease. There is
diffuse parenchymal atrophy which is age appropriate. Mass
effect from the subdural on the right hemisphere is causing
early uncal herniation as evident by widening of the ipsilateral
prepontine cistern. There is a soft tissue hematoma within the
right posterior temporo- occipital region. The calvarium is
intact. The visualized paranasal sinuses are normally aerated.
IMPRESSION:
Significant interval increase in size of right hemispheric
hyperacute on acute subdural hematoma causing approximately 6 mm
of right to left midline shift and early uncal herniation.
Head CT [**6-22**]:
NON-CONTRAST HEAD CT.
Comparison is made to [**6-20**] and [**6-21**] examinations. The size
of the right subdural hematoma along the right cerebral
convexity with components along the posterior falx and tentorium
is stable, with no new foci of intracranial hemorrhage
identified. The appearance of the brain parenchyma is stable
compared to prior exams, with unchanged sequelae of chronic
small vessel disease. Atherosclerotic disease is also unchanged.
No soft tissue abnormalities are identified. Osseous structures
remain stable.
IMPRESSION:
Unchanged examination with stable right-sided subdural hematoma.
No new
intracranial hemorrhage identified.
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] NSURG service on [**6-19**], after
suffering a fall earlier in the day with resulting right sided
subdural hematoma. She was admitted to the ICU overnight for
continuous monitoring. On [**6-20**] in the morning, she had a repeated
non-contrast head CT, which demonstrated stability, and she was
subsequently transferred out of the ICU to the neuro stepdown
unit. She was then transferred to floor status on [**6-22**], with a
head CT which showed a stable ICH. She was seen and evaluated by
PT and OT who determined she would be safe for home discharge
with outpatient PT/OT. She was discharged with said
arrangements on [**6-23**].
Medications on Admission:
Metformin
Glipizide XL
Actos
Januvia
Lipitor
Lisinopril/HCTZ
Ca Citrate w/D
Mag-Ox
Vitamin D
Cymbalta
ASA
MVI
Vitamin C
Colace
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: [**1-17**] PO BID (2 times a
day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Glipizide 2.5 mg Tablet Extended Rel 24 hr (2) Sig: One (1)
Tablet Extended Rel 24 hr (2) PO DAILY (Daily).
9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Januvia 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Right Subdural Hematoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 26803**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2194-6-23**]
|
[
"250.50",
"401.9",
"362.01",
"357.2",
"852.21",
"V10.05",
"272.4",
"E885.9",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5610, 5685
|
3677, 4355
|
275, 282
|
5753, 5777
|
1118, 1123
|
7039, 7500
|
1000, 1018
|
4532, 5587
|
5706, 5732
|
4381, 4509
|
5801, 7016
|
1033, 1033
|
1047, 1099
|
227, 237
|
1535, 3654
|
310, 731
|
1137, 1516
|
753, 924
|
940, 984
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,084
| 114,044
|
42256
|
Discharge summary
|
report
|
Admission Date: [**2101-9-6**] Discharge Date: [**2101-9-13**]
Date of Birth: [**2055-6-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
hypotension and ascites
Major Surgical or Invasive Procedure:
Abdominal Paracentesis (8.8 and 8.11)
History of Present Illness:
Mr. [**Known lastname 59304**] is a 46-year-old male with metastatic renal cell
carcinoma now on axitinib therapy for ~5 weeks, admitted
[**Date range (1) 91600**] with anemia, malignant ascites and treated with
3L therapeutic paracentesis 2 wks ago and noted to have disease
progression on CT. Patient presented from cliic with hypotension
(SBP 70s). He had acutely worsening sharp diffuse abdominal pain
that is worse with movement the night prior to admission. The
morning of admission he felt weak and dizzy. He had two episoes
of vomiting; one prior to admission which was bilious and one
while in the ED that had small amount of blood. He also reports
decreased PO intake over the past several days secondary to
feeling consipated and bloated. His last bowel movement was two
days prior to admission. He denies any fever, cough, dyspnea,
chest pain, rash.
Of note, has also been on steroid taper (previously on dex 1 mg
qdaily, now tapered to 0.5mg every other day).
In the ED, initial VS were: 97.7 104 94/54 17 97%RA.
Examination was notable for a distended, tender, non-rigid
abdomen with guarding. Got 100 hydrocortisone, 2L NS, and
Albumin 5% (12.5g / 250mL) x1. Dilaudid 1mg x3 given for pain
control. Bladder scan showed > 800 cc and patient unable to
void; foley placed with 35 cc UOP, likely that bladder saw
ascites not urine. Foley placement verified by ultrasound.
Diagnostic paracentesis performed. Patient was started on
ceftriaxone 1g, vancomycin 1g, azithromycin 500mg and blood,
urine, ascites cx sent.
On transfer, VS were:
97.2 103 87/57 20 99% 4L
On arrival to the MICU, patient's VS. 98.1, 100, 96/59, 18, 98%
RA
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies diarrhea, dark or bloody stools. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Oncologic History:
Mr. [**Known lastname 59304**] presented to his PCP in [**2100-10-30**] for routine
physical exam and reported he had some left lower quadrant
abdominal discomfort. He was referred to a surgeon for
questionable hernia with CT scan on [**2100-11-18**] revealing a left
kidney mass measuring 9 x 7.5 cm, with a larger exophytic
component measuring approximately 12 cm abutting the abdominal
wall. He also had periaortic lymphadenopathy and pulmonary
nodules. He was referred here for further management. Plain film
of the left femur was done due to pain, revealing a lytic
lesion. He was referred to Dr. [**First Name (STitle) 4223**] in orthopedics with plan
for left femur surgery in the future. She obtained plain films
of the right wrist due to pain and another lytic lesion was
noted in the distal ulna. Bone scan on [**2100-12-6**] revealed
widespread bony disease. Zometa was initiated on [**2100-12-7**]. He
underwent open radical left nephrectomy on [**2100-12-17**] by Dr.
[**Last Name (STitle) 3748**]. At the time of surgery, there was significant
progression of disease with extension of tumor into the colon
and mesentery, requiring left colectomy and small bowel
resection. Pathology confirmed renal cell carcinoma, clear cell
histology, [**Last Name (un) 19076**] grade 2 with lymphovascular invasion and 4
positive lymph nodes. He underwent excision and curettage of
left distal femur lesion and prophylactic fixation with a
combination of cement, plate, and screws on [**2101-1-5**] by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**]. He developed increased right wrist pain and was found
to have a pathologic fracture of the distal ulna on [**2101-1-17**]. He
underwent radiation therapy to the right wrist, left shoulder
and left femur at the [**Location (un) **] [**Hospital 5028**] Cancer Center.
Right heel MRI on [**2101-2-28**] demonstrated a metastatic bony lesion
and he received radiation to that site, completing on [**2101-3-18**].
He also had radiation to the left tibia and L3 region. He
developed a pathologic fracture of the left
proximal humerus on [**2101-4-25**], managed with splinting. He was
admitted [**Date range (3) 91600**] with anemia, ascites and disease
progression noted on CT including lung/liver/peritoneam
metastases.
1. RCC - as above
2. Hypertension.
3. Hypercholesterolemia.
4. Anxiety -- has prior history of panic attacks.
5. Migraines.
6. Seasonal allergies.
7. s/p XRT to L3 lesion
8. Right humerus pathologic fracture
Social History:
Divorced and lives in [**Location **]. He has two daughters ages 8 and 11. He
works as a firefighter and EMT. No smoking. He drinks alcohol
socially. Denies illicit drug use. Brother [**Name (NI) **] is HCP.
Family History:
No history of renal cell carcinoma or other cancers. His mother
died of a cardiac arrest with no significant cardiac history at
age 66. Grandmother died of a stroke and coronary artery
disease in her 80s. He has a brother who is alive and well.
His biological father died when he was age 12 and he does not
know his medical history.
Physical Exam:
ADMITTING EXAM
97.2 103 87/57 20 99% 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: distended, flank dullness to percusion, bowel sounds
present, diffusely tender to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, gait deferred, no asterixis
Pertinent Results:
ADMITTING LABS
[**2101-9-6**] 02:10PM UREA N-44* CREAT-2.9*# SODIUM-132*
POTASSIUM-5.8* CHLORIDE-91* TOTAL CO2-24 ANION GAP-23*
[**2101-9-6**] 02:10PM ALT(SGPT)-17 AST(SGOT)-19 LD(LDH)-205 ALK
PHOS-162* TOT BILI-0.3
[**2101-9-6**] 02:10PM LIPASE-7
[**2101-9-6**] 02:10PM ALBUMIN-2.5* CALCIUM-9.0 PHOSPHATE-5.4*#
MAGNESIUM-2.1
[**2101-9-6**] 02:10PM TSH-6.8*
[**2101-9-6**] 02:10PM WBC-10.2# RBC-4.90# HGB-13.2*# HCT-42.5#
MCV-87 MCH-27.0 MCHC-31.1 RDW-17.0*
[**2101-9-6**] 02:10PM NEUTS-78* BANDS-0 LYMPHS-18 MONOS-3 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
PERTINENT LABS
[**2101-9-12**] 04:08AM BLOOD Glucose-146* UreaN-61* Creat-3.4* Na-137
K-4.8 Cl-103 HCO3-14* AnGap-25*
[**2101-9-12**] 04:08AM BLOOD Calcium-8.5 Phos-5.8* Mg-2.4
[**2101-9-12**] 01:25AM BLOOD Type-ART pO2-87 pCO2-31* pH-7.26*
calTCO2-15* Base XS--11 Intubat-NOT INTUBA
[**2101-9-12**] 11:11AM BLOOD Lactate-3.7*
MICRO
[**2101-9-10**] 1:36 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2101-9-10**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
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 (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2101-9-7**] 2:23 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2101-9-7**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
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 [**2101-9-10**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING
.
Radiology Report RENAL U.S. Study Date of [**2101-9-7**] 9:30 AM
IMPRESSION:
1. Prior left nephrectomy. No evidence of hydronephrosis or
renal vascular
occlusion involving the right kidney to explain the patient's
acute renal
failure.
2. Large amount of ascites with diffuse intraperitoneal
metastatic disease.
.
ECHO [**2101-9-8**] at 9:30:00 AM
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF =
75%) M-mode analysis of the aortic valve suggests premature
systolic closure. A left ventricular outflow tract obstruction
cannot be excluded with certainty due to the technically
suboptimal nature of this study. Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg). The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. 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 mild posterior leaflet mitral valve prolapse. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
ECHO Portable TTE (Complete) Done [**2101-9-12**] at 2:20:00 PM
FINAL
Poor image quality.The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are probably normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. Tricuspid regurgitation is
present but cannot be quantified. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
CXR 8.9
As compared to the previous radiograph, there is a newly
appeared
moderate left pleural effusion. There is unchanged evidence of
low lung
volumes and known nodular opacities in both lungs. No evidence
of pulmonary edema. Unchanged appearance of the cardiac
silhouette.
Brief Hospital Course:
# Shock: The patient presented with hypotension with systolics
in the 70s-80s compared to his baseline of 120s-130s in the
outpatient setting. His pressures did not respond adequately to
fluid boluses. A PICC line was placed and he was started on
dopamine initially. Dopamine was switched to vasopressin given
concern for his recurrent ascites. His shock was thought to be
due to a combination of sepsis and intravascular volume
depletion [**3-3**] recurrent malignant ascites. A definitive
infectious source was never identified, though SBP was excluded
with 2 large volume paracenteses. The patient was placed on
vancomycin, cefepime, and flagyl. He was also given stress dose
steroids. Fluid resuscitation was performed with crystalloid and
colloid without success. The patient continued to rapidly
reaccumulate fluid in his abdomen. The patient remained oliguric
to anuric during his admission. Norepinephrine was added on the
day of intubation added without improvement in urine output.
After a family meeting, the patient was made CMO and vasoactive
medications were discontinued. The patient expired shortly
thereafter.
# Respiratory failure: The patient developed tachypnea and
increased work of breathing on the morning of his expiration
while undergoing a CT head. He was intubated for respiratory
distress, self-extubated, and was reintubated for continuing
respiratory distress. Versed, fentanyl, and propofol were used
for sedation. A CXR did not show any acute intrapulmonary
process. Bilateral LENIs were negative for DVTs. An ECHO did
not show any RV strain. Most likely etiology was worsening lung
function in the setting of extensive RCC lung metastases and
worsening metabolic acidoses due to renal failure. A family
meeting was held in the afternoon and the decision was made to
make him CMO given his poor prognosis. The patient was
terminally extubated on the afternoon of [**9-12**] and expired
shortly thereafter.
# Acute renal failure: The patient was oliguric on presentation.
A renal ultrasound did not show impaired renal flow. Bladder
pressures were consistently below 20. Etiology was likely
secondary to intraarterial volume depletion due to massive 3rd
spacing of fluids secondary to ascites. Urine output did not
improve after large volume paracentesis or after fluid
resuscitation with crystalloid or colloid. Patient became
increasingly acidemic. Dialysis was discussed and not
considered appropriate given his poor prognosis.
# Metastatic renal cell carcinoma: The patient required 2 large
volume paracenteses to manage his malignant ascites. His pain
was managed with a dilaudid PCA. Patient's outpatient
oncologist was contact[**Name (NI) **] and informed of worsening status and
the decision was made to not be aggressive with interventions
given his worsening prognosis and lack of tumor response to
multiple biologic therapies.
# Comfort care: Patient's Oncologist was contact[**Name (NI) **] regarding
transitioning to comfort care. As noted above, his prognosis
was poor given his lack of response to biologic therapies.
Palliative care service was consulted. Patient's family was
called on the day of intubation and arrived in the afternoon.
Discussion was had with the family as well as Oncologist NP and
Palliative care and decision was made to terminally extubate.
Patient expired peacefully in the evening.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Dexamethasone 0.5 mg PO EVERY OTHER DAY
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO DAILY PRN SBP>110
4. HYDROmorphone (Dilaudid) 2-6 mg PO Q3H:PRN pain
hold for sedation, RR<10
5. Oxycodone SR (OxyconTIN) 60 mg PO Q8H
6. Sertraline 50 mg PO DAILY
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic renal cell carcinoma
Malignant ascites
Respiratory failure
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
Completed by:[**2101-9-13**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"54.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14430, 14439
|
10602, 13976
|
326, 365
|
14553, 14564
|
6210, 7459
|
14621, 14661
|
5254, 5591
|
14398, 14407
|
14460, 14532
|
14002, 14375
|
14588, 14598
|
5606, 6191
|
2064, 2455
|
263, 288
|
393, 2045
|
7983, 10579
|
2477, 5008
|
5024, 5238
|
7491, 7506
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68,949
| 148,762
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36992
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Discharge summary
|
report
|
Admission Date: [**2140-9-9**] Discharge Date: [**2140-11-4**]
Date of Birth: [**2093-8-5**] Sex: F
Service: MEDICINE
Allergies:
Benzocaine / Vancomycin / Ranitidine
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
abdominal distention
Major Surgical or Invasive Procedure:
paracentesis
endotracheal intubation
History of Present Illness:
47 yo F with HCV and DM2, large refractory ascites and failed
TIPS in [**Month (only) 205**] admitted from clinic today with tense ascites and
ARF. Please see [**Hospital1 **] A admission note for full HPI, PMH,
home meds, SH, FH. Briefly, she had been getting roughly weekly
therapeutic [**Doctor First Name 4397**] at [**Hospital6 17183**], last 10 days ago. She
feels that these paracentesis have not been particularly
effective from a comfort standpoint. Her Cr was noted to be 2.0
in [**Last Name (LF) 205**], [**First Name3 (LF) **] when she presented to clinic today, Dr. [**Last Name (STitle) 497**] felt
admission for workup of her ARF and possible large volume para
with albumin would be appropriate. She is also complaining of
worsening LE edema.
.
Other than tense abdomen and LE edema, she has no symptoms. She
denies F/C/NS, N/V/D, CP, SOB, BRBPR, melena. She reports taking
her diuretics at home though admits to a high salt diet.
.
She was initially admitted to [**Wardname 836**] because of a bed shortage on
[**Wardname 13487**]. There, her diuretics were held, an infectious workup was
started including a diagnostic paracentesis which was (-) for
SBP, and she was given albumin in HRS treatment doses.
.
Currently on [**Wardname 13487**] she states she feels well, her abdomen is
tense and she has slight discomfort but not enough to need an
urgent therapeutic paracentesis in the setting of renal disease.
She states that her legs are more swollen than before and that
her legs hurt when she walks, which is atributed to her edema.
.
Pt was transferred to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service and today to MICU.
Reason for transfer is Pt's worsening respiratory status. At
time of transfer Pt is maintaining 02 sats in 90s on
non-rebreather. Earlier Pt had episodes of hypoxia to 80s on
while on 3l NC in setting of receiving methadone dose this
morning. Pt also still w/ [**Last Name (un) **] to 2.0 due to hepatorenal
syndrome.
Please see [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] and [**Hospital1 **] A admission notes for full
HPI, PMH, home meds, SH, FH.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea. Denied cough, shortness of breath.
Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-chronic hepatitis C infection with cirrhosis c/b refractory
ascites
-diabetes mellitus type 2
-h/o IV drug use with relapse four years ago
-h/o EtOH abuse with relapse four years ago
-thrombocytopenia
-chronic back pain
-peripheral neuropathy
-deviated septum s/p repair
-s/p CCY
-s/p carpal tunnel repair
-s/p hemorrhoidectomy
-s/p C-sections
Social History:
she currently is not working. She lives with the father of one
of her children. She has 3 children. She smokes approximately 1
pack per day. She denies alcohol or IV drug use.
Family History:
non-contributory
Physical Exam:
Vitals: T:98.8 BP:141/70 P:98 R: 30 18 O2:93% non-rebreather
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRLA, pupils dilated and symmetric,
MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles to apices bilaterally, no wheezes, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no asterixis. Peritoneal drain
in place, draining clear yellow fluid, no erythema or
tenderness, at drain site
Ext: warm, well perfused, 2+ pulses, 2+ edema, no clubbing,
cyanosis. Venous stasis changes on shins bilaterally
Pertinent Results:
===========================
Labs on admission [**2140-9-9**]:
===========================
-13.5* PTT-28.3 INR(PT)-1.2* PLT COUNT-160
NEUTS-79.1* LYMPHS-13.7* MONOS-5.5 EOS-1.1 BASOS-0.6
WBC-7.7 RBC-4.20 HGB-12.4 HCT-38.4 MCV-92 MCH-29.6 MCHC-32.3
RDW-14.8
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
ALBUMIN-2.9* CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-2.0
ALT(SGPT)-15 AST(SGOT)-20 LD(LDH)-141 ALK PHOS-118* TOT BILI-0.3
estGFR-Using this
GLUCOSE-118* UREA N-39* CREAT-2.7* SODIUM-136 POTASSIUM-TOTAL
CO2-28 ANION GAP-13
ASCITES WBC-85* RBC-90* POLYS-2* LYMPHS-26* MONOS-72*
ASCITES ALBUMIN-0.8
.
.
==================
Labs on Discharge [**2140-11-4**]
==================
CBC--------------------WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2140-11-4**] 04:30AM 7.4 3.25* 9.5* 29.0* 89 29.2 32.8 15.7*
166
Ca 9.5, Phos 3.7, Mg 2.4
PT/INR 14.2/1.2
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2140-11-4**] 04:30AM 165* 47* 3.9*#1 137 4.5 99 30 13
ALT/AST 53/59
T Bili 0.4
.
.
==================
Peritoneal fluid:
==================
ASCITES ANALYSIS WBC RBC PMNs Lymphs Monos Mesothe Macroph
Other
[**2140-11-4**] Pending
[**2140-10-31**] 08:29AM 70* 73* 3* 40* 12* 1* 44*
PERITONEAL FLUID
[**2140-10-21**] 03:16PM 24* 70* 4* 25* 0 1* 68*1 2*2
PERITONEAL FLUID
[**2140-10-8**] 02:51PM 55* 118* 6* 33* 34* 2* 24* 1*3
PERITONEAL FLUID
[**2140-10-6**] 11:11AM 65* 28* 8* 31* 20* 41*
[**2140-9-15**] 11:12PM 105* 69* 7* 10* 3* 80*
[**2140-9-13**] 03:13PM 128* 36* 12* 17* 0 71*
PERITONEAL FLUID
[**2140-9-9**] 03:35PM 85* 90* 2* 26* 72*
.
.
==================
MICROBIOLOGY
==================
C Diff neg [**2140-10-22**]
Blood Cx x2 [**2140-11-2**] Pending
Blood Cx [**2140-11-4**] Pending
[**2140-10-31**] 6:00 am SWAB
**FINAL REPORT [**2140-11-4**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2140-11-3**]):
ENTEROCOCCUS SP.. Sensitivity testing performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ >256 R
Carbapenase Resistant Enterobacteriaceae Screen (Final
[**2140-11-2**]):
No Carbapenem-Resistant or Carbapenemase-Producing
Enterobacteriaceae
Isolated.
.
Swab from HD tunnelled cath [**2140-11-4**], Gram stain and Culture
PENDING
.
==================
Transplant Workup
==================
lipids:T Chol 55, HDL 17, LDL 26, TG 58
Vit D <4 (low)
AMA neg
[**Doctor First Name **] neg
IgG/IgM/IgA in normal range
CEA 7.6 (elevated)
Ca19-9 19
AFP 10.2 ([**2140-9-11**])
Fe 123 ([**7-21**]), Ferritin 57, TIBC 216
Tox screen neg
HCV pos
HBsAg neg, HBsAb pos, HBcAb IgG pos, HBcAb IgM neg
HIV neg
EBV: VCA IgG Ab +, EBNA IgG Ab+, VCA IgM Ab neg
CMV IgG neg
Rubella Ab +
RPR NR
VZV IgG +
HCV genotype 4, Viral load 241,000
Abd CT: [**10-12**]
Echo [**9-21**]: Normal global and regional biventricular systolic
function. Moderate pulmonary hypertension.
PFTs [**2140-10-12**]: FEV1/FVC 108%, Moderate restrictive ventilatory
defect with a moderate gas exchange defect.
[**Last Name (un) **] normal
Pap [**2140-11-4**] PENDING
Stress Mibi normal perfusion and wall motion, EF 72%, stress
with no CP or ECG changes
TTE [**2140-10-19**]: There is borderline pulmonary artery systolic
hypertension (although tricuspid regurgitation jets were
technically suboptimal for quantitation).
Right Heart Cath [**2140-10-31**]:
1. Mild left ventricular diastolic dysfunction.
2. Preserved cardiac index.
3. Mild pulmonary hypertension. (and slightly elevated PCWP,
mean 17)
.
==================
Imaging
==================
.
Abdominal ultrasound [**2140-9-10**]: Patent main portal vein and
hepatic venous vasculature. Redemonstration of ascites.
.
TTE [**2140-9-16**]:
IMPRESSION: Normal global and regional biventricular systolic
function. Moderate pulmonary hypertension.
.
Renal ultrasound [**2140-9-20**]: 1. Normal renal ultrasound. 2.
Cirrhosis, moderate to large ascites, and splenomegaly,
suggestive of portal hypertension.
.
CT abd/pelvis w/C [**2140-10-12**]:
1. Cirrhosis with large volume ascites as detailed above.
2. Splenomegaly.
3. Non-obstructive left nephrolithiasis
.
TTE [**2140-10-19**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. The tricuspid valve leaflets are
mildly thickened. There is borderline pulmonary artery systolic
hypertension (although tricuspid regurgitation jets were
technically suboptimal for quantitation). There is a small
pericardial effusion.
Compared with the prior study (images reviewed) of [**2140-9-16**],
estimated pulmonary artery systolic pressure is now probably
lower. However, tricuspid regurgitation jets were technically
suboptimal in the current study.
.
Mammogram [**2140-10-20**] No evidence of malignancy
.
[**2140-10-21**] Fluoroscopy: Successful post-pyloric feeding tube
placement. (nasointestinal tube placed).
.
[**2140-10-28**] Fluoroscopy: 1. Successful placement of left internal
jugular hemodialysis catheter with tip terminating in the low
right atrium. The line is ready to use.
2. Successful removal of tunneled right hemodialysis catheter
with Gelfoam
slurry/thrombin injection into the tract to prevent oozing (see
separate
report).
.
CXR Portable [**2140-11-2**]:
FINDINGS: Feeding tube is in place, with the tip out of view
that passes
beyond the second portion of the duodenum. A left internal
jugular
hemodialysis catheter is in the right atrium. The
cardiomediastinal
silhouette is stable. The right hemidiaphragm remains elevated,
atelectasis at the right base has improved. There is no focal
consolidation, pleural effusion or pneumothorax. Pulmonary
vascularity is normal.
IMPRESSION: No radiographic evidence of pneumonia.
Brief Hospital Course:
47 yo woman with a history of chronic Hepatitis C cirrhosis
complicated by portal HTN and refractory ascites, DM, s/p failed
TIPS procedure, who initially presented with abdominal ascites,
bilateral leg edema, and ARF. She had a long hospital course
including respiratory failure requiring transfer to the ICU and
intubation, as well as progressive renal failure thought to be
secondary to hepatorenal syndrome, now initiated on hemodialysis
and on transplant list for liver/kidney. Below is a problem
based summary of hospitalization.
.
# HCV Cirrhosis: The patient initially presented with
decompensated liver disease, including worsening ascites and
encephalopathy. Additionally, she is s/p failed TIPS [**7-20**],
which could not be revised due to anatomy. She has known Grade
1 varices and congestive gastropathy. Her ascites have required
frequent therapeutic paracentesis (1-2x weekly) during the
hospitalization, and peritoneal fluid has been negative for SBP
throughout admission. Last paracentesis was performed on
[**2140-11-4**], and 6.5 L of fluid was removed, with cell count
pending. Also has elevated AFP at 10.2. During this
hospitalization, a transplant evaluation was completed and the
patient was listed for a combined liver and kidney transplant.
The patient was treated with rifaximin throughout the admission,
but only intermittently with lactulose because of ongoing
diarrhea and a stable mental status.
.
.
# Acute renal failure: At admission, the patient was found to
have a creatinine of 2.7, which is elevated from baseline 1.2 in
early [**2140-7-13**]. She was given albumin challenge, with little
improvement and was started on octreotide/midridone/albumin for
treatment of HRS. Renal function initially improved based on
decline in creatinine, however after 5 days of treatment, renal
function worsen again. At this point, she was transferred to
the ICU for respiratory failure due to possible oversedation vs.
pulmonary edema vs ARDS. Renal was consulted in the ICU. Urine
sediment showed fine granular casts, crystals (possibly sulfa
crystals). Pt was continued on octreotide and midodrine per
Hepatology, however she was not consistently given albumin
during the MICU course. Additionally, she recieved IV lasix
during her initial ICU course. Creatine began slowly
downtrending during MICU course. Diuretics were restarted while
continuing the octreotide and midrodine. The patient was then
transferred back to the floor with renal function at baseline.
Diuretics were discontinued after 2 days on the floor due to
worsening renal function. Midodrine and Octreotide were
titrated to maximum dose with little improvement in renal
function. Her creatinine then acutely worsened over the next
several days in the context of two small volume paracenteses,
with albumin repletion. Thereafter, her renal function
continued to decline despite optimal treatment with albumin,
octreotide and midodrine. Another renal consult was obtained,
and the patient was felt to have type 1 Hepatorenal syndrome,
and was initiated on hemodialysis. Last hemodialysis was on
[**2140-11-3**], and 1.3 L of fluid was removed. The patient is
planned for next hemodialysis on [**2140-11-5**], and should continue
on a Tues/Thurs/Sat schedule thereafter if possible;
additionally, she should continue to receive Epogen with
dialysis. She has a left IJ tunnelled HD line in place.
Additionally, on HD days, she would receive midodrine in the
morning, and metoprolol should be held to allow for optimal
ultrafiltration. At discharge, the patient complained of slight
discomfort at the site of her HD tunnelled line; the area was
then swabbed for cell count and culture, and redressed with
triple antibiotic ointment. The swab was pending at the time of
discharge.
.
.
# Respiratory distress: Patient developed acute hypoxic event
approxamately one week into admission. Prior to MICU transfer,
patient required increasing oxygen demand after walking around
then vomiting while in bed. There was concern for aspiration,
however CXR did not support this. Instead, hypoxia was thought
likely due to decreasing respiratory drive from methadone in
setting of increased pulmonary edema. The patient was
transferred to the MICU and required mechanical ventilation
after failing NIPPV. In the MICU, patient was intubated for
hypoxemic respiratory failure, tolerated ARDSnet protocol well
with improved pulmonary exam and oxygenation. She completed an 8
day course of antibiotics for presumed aspiration pneumonia.
The differential for her respiratory failure included pulmonary
edema secondary to HRS versus ARDS. Bronchoscopy was performed
on [**9-23**] with RLL secretions, BAL was sent but showed no evidence
of infection. U/S at bedside showed likely fluid with lung
collapse on R side. She had a PS trial with 7.37/42/94 with
RSBI 24 on [**9-25**]. Extubated successfully on [**9-26**]. She was
restarted on lasix and spironolactone on [**9-25**] per hepatology.
Patient did not experience any further episodes of SOB during
admission.
.
.
# Diabetes: Patient was on insulin sliding scale when admitted
due to history of diabetes. Due to poor nutrition, patient was
put on tube feeds while intubated. Insulin sliding scale and
glargine were continued during this time. On transfer to the
floor, patient had continued poor PO intake and had a dobhoff
placed for nutrition. Lantus and humalog insulin have been
titrated to keep glucose as controlled as possible, but patient
has continues to be intermittently hyperglycemic when tube feeds
are at full strength; insulin should be titrated as appropriate.
.
.
# Nutrition: Patient with poor PO intake and had dobhoff to
improve nutritional status. The patient has been maintained on
Novasource Renal Full strength with added Beneprotein. Tube
feeds should continue at the current rate at discharge.
Additionally, as part of her transplant workup, the patient was
found to have a low vitamin D level, most likely from a
nutritional deficiency. She was started on Vitamin D 50,000
units weekly. This should be continued for another six weeks,
and switched to 1000 units of vitamin D3 daily thereafter.
.
.
# Narcotic Withdrawal: On methadone as outpatient. She required
large amounts of fentanyl while intubated. Given high doses for
prolonged time, concern for withdrawal. On [**9-25**], pt
hypertensive. She was given fentanyl bolus with good effect.
Fentanyl patch was started and continued throughout admission.
One attempt was made to titrate down dosage of fentanyl patch,
with resultant nausea, vomiting and hypertension. Fentanyl was
subsequently increased to prior dosage of 75mcg q72 hours, and
continued for the remainder of her hospitalization.
.
.
# Hypertension: The patient has labile blood pressure, with one
episode of hypertensive urgency in the context of decreasing
fentanyl, as described above. She was started on a beta
blocker, with good effect. She should continue on low dose
metoprolol, which should be held on the morning of dialysis days
to allow for optimal ultrafiltration.
.
.
# Depression/flat affect: The patient has been maintained on
home dose of citalopram 60mg daily. She was also one methadone
as an outpatient, and transitioned to fentanyl while inpatient
as above.
.
.
# Bleeding from HD tunnelled line: Prior lines on right (2
separate lines were placed) bled persistently and had to be
replaced; unclear cause of bleeding as patient's INR and PTT
were only mildly elevated. She received DDAVP and thrombin
injection and thrombin gel dressings to lines. Eventually felt
to have a mechanical problem with the line, possibly due to
issues with anatomy on the right side. Now s/p removal of right
sided lines with new line placed using the left IJ.
.
.
# Leukocytosis: Transiently elevated WBC on [**9-15**] and again on
[**10-21**], felt to be related to underlying infectious processes.
Urine Cx on [**2140-9-15**] grew klebsiella. Pt completed 7 day course
of Cipro, which ended on [**2140-9-21**]. Infectious source on [**9-21**] was
felt to be HD line, which had been manipulated several times
because of persistent oozing. HD line was pulled, and patient
treated with ceftriaxone from [**Date range (1) 83429**], with resolution of
leukocytosis.
.
.
# Anemia, likely due to a variety of factors, chiefly chronic
HCV. Has been receiving PRBCs prn, transfused numerous times
during the hospitalization for a Hct <22. She also began
receiving Epogen with hemodialysis 3x/week.
.
.
# Thrombocytopenia: Platelets 160 on admission, down to 47 on
[**9-22**], now back to baseline. HIT antibody was negative, and
thrombocytopenia felt to be most likely due to vancomycin (given
for empiric treatment of aspiration pneumonia while in MICU),
because it resolved once Vancomycin was stopped.
Medications on Admission:
- Citalopram 60mg daily
- Lasix 40mg Tab [**Hospital1 **]
- Spirinolaactone 100mg Tab [**Hospital1 **]
- Insulin 46cc (70/30) [**Hospital1 **]
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
3. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Midodrine 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA): If HD days change, please dose only on HD days in
the morning prior to HD.
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for confusion: titrate to [**3-16**] bowel
movements daily. Patient may refuse if no confusion.
9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (SA).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for sbp < 90, HR <60 Hold in AM on dialysis
days and give dose after dialysis.
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
discomfort.
14. Prochlorperazine Edisylate 5 mg/mL Solution Sig: [**1-15**]
Injection Q6H (every 6 hours) as needed for nausea.
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for to affected areas.
17. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
18. Insulin Glargine 100 unit/mL Solution Sig: Forty Six (46)
Subcutaneous at bedtime.
19. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: Please see sliding scale
included.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
Primary Diagnoses:
HCV Cirrhosis
Hepatorenal Syndrome requiring hemodialysis
Diabetes Mellitus
Discharge Condition:
Good; afebrile, hemodynamically stable and improved.
Discharge Instructions:
You have a diagnosis of Cirrhosis and Hepatorenal Syndrome
causing you to need dialysis. You have had a very long hospital
course, which included initiation of dialysis and a thorough
workup in order to determine if you would be a good candidate
for liver transplantation. Prior to discharge, you were placed
on the transplant list for a liver and kidney transplant.
.
Please see the medication list for a complete list of your
medications. We made many changes to your outpatient regimen,
including:
STOP diuretics
START Rifaximin
START METOPROLOL
START MIDODRINE on hemodialysis days
START Ergocalciferol (vitamin D)
STOP Methadone and START Fentanyl
Insulin was changed as well; please see sliding scale for
specific dosages.
START Lactulose. Our goal is for you to have [**3-16**] bowel movements
daily while taking this medication. If you become confused,
please increase the amount of lactulose you are taking. If you
have diarrhea, please decrease the amount of lactulose you are
taking.
.
If you experience any fever, chills, abdominal pain, dizziness,
rectal bleeding, black tarry stools or vomiting of blood please
return to the hospital immediately.
Followup Instructions:
Appointment at the Liver Transplant Center on Wednesday, [**11-9**] at 3pm. This office is located in the [**Hospital Unit Name **], [**Location (un) **]. Phone:[**Telephone/Fax (1) 673**]
|
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21590, 21651
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,227
| 125,069
|
48709
|
Discharge summary
|
report
|
Admission Date: [**2154-12-9**] Discharge Date: [**2154-12-28**]
Date of Birth: [**2080-7-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
Recurrent left lower quadrant pain,
Major Surgical or Invasive Procedure:
Exploratory laparoscopy, low anterior resection, extended left
colectomy
History of Present Illness:
74-year-old female with a recurrent left lower quadrant pain,
status post recent hospitalization for a recurrent
diverticulitis. For the last three years, she has had increasing
left lower quadrant pain. It all started on a
trip to [**Location (un) 5354**] where she presented with fevers, chills and
was diagnosed with ischemic colitis of unclear etiology. She
does have a history of CREST syndrome. In the last year,
however, she has had two hospitalizations for high fevers
associated with left lower quadrant pain, anorexia, and fatigue.
In the last two months she has lost 30 pounds because of lack of
appetite. She underwent a recent colonoscopy by Dr. [**Last Name (STitle) 1940**],
which revealed a very redundant sigmoid, as well as a very
thickened sigmoid, which she was unable to completely traverse.
Biopsies there were negative for malignancy. A CT scan at that
time revealed a thickened colon with multiple diverticuli.
A CT scan, as well as story, all confirmed recurrent
diverticular disease that is now recalcitrant to medical
therapy. For this reason, surgery was indicated, sigmoid
colectomy for diverticulitis.
Past Medical History:
Sleep apnea (uses CPAP at night), gastroesophageal reflux
disease, Barrett's esophagus,
CREST syndrome, hypertension. She had an open cholecystectomy in
[**2121**] and an open hysterectomy in [**2131**]. She has also had cataract
surgery.
.
[**Last Name (un) 1724**]: ASA 81 qd, omeprazole qd, norvasc 5 qd, lisinopril 60 qd,
atenolol 50 qd, zyrtec prn, evista.
.
ALL: NKDA
Social History:
Denies tobacco, drugs; occ EtOH. Recieves family support from
Daughter, [**Known firstname 1787**] and son, [**Name (NI) **]. She is married, from [**Country 5976**], has
three children, and denies tobacco use. She is currently
retired.
Family History:
Family history is notable for diabetes mellitus and cervical
cancer.
Physical Exam:
T 98.2 HR 81 BP 146/58 RR 18 SaO2 95%room air
CTAB
RRR
Open wound with retention sutures, wet-dry dressings,
appropriately tender. Ostomy w/brown stool.
Trace peripheral edema
Pertinent Results:
[**2154-12-9**] WBC-6.8 RBC-3.25* HGB-11.2* HCT-31.7* MCV-98 MCH-34.6*
MCHC-35.4* RDW-14.8
Brief Hospital Course:
The patient was admitted to the Platinum surgery service (Dr.
[**First Name8 (NamePattern2) 102407**] [**Last Name (NamePattern1) 6633**]) on [**2154-12-9**] and underwent an open left
hemicolectomy. Two days post op, she developed atrial
fibrillation, was transferred to the ICU, and treated with
Amiodarone with conversion to normal sinus rhythm. She developed
a fever and wound infection, with cultures growing out E coli
and Enterococcus for which she was placed on Vancomycin and
Zosyn per the Infectious Disease team. Ultimately, she was taken
back to the operating room on [**2154-12-15**] for an exploratory
laparotomy after wound dehiscence and repair of posterior
anastomotic breakdown of colorectal anastomosis. She was
resuscitated in the ICU postoperatively, and extubated on
[**2154-12-23**]. Enteral feeding was initiated. She was transferred to
the floor on [**2154-12-26**]. By [**12-27**], she was able to tolerate thin
liquids and soft solids by a formal swallow evaluation. She had
an echocardiogram which revealed no atrial thrombus. She
completed her 2-week course of antibiotics. She was seen by
physical therapy and deemed fit for discharge to a
rehabilitation facility on [**2154-12-28**].
Medications on Admission:
Lisinopril 40, Norvasc 10, Atenolol 50, Evista 60, Zyrtec 10,
Omeprazole 10, HCTZ 25
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Date Range **]: One (1) inj
Injection TID (3 times a day).
2. Insulin Regular Human 100 unit/mL Solution [**Date Range **]: One (1) inj
Injection ASDIR (AS DIRECTED): per protocol sliding scale.
3. Albuterol Sulfate 0.083 % Solution [**Date Range **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
6. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
7. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Hexavitamin Tablet [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily).
9. Amlodipine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily):
hold for SBP<100.
10. Lisinopril 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): hold for SBP<100.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Good
Discharge Instructions:
Call or return if you have a fever >101.5, persistent
nausea/vomiting, inability to pass gas or stool into the ostomy,
severe pain, worsening redness, swelling, or foul drainage from
wounds, or any other concerns. Do not lift anything heavier than
10 pounds for 6 weeks. Resume your home medications.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) 102407**] [**Last Name (NamePattern1) 6633**]' office at [**Telephone/Fax (1) 36613**] to
schedule a follow-up appointment in 1 week.
|
[
"562.11",
"530.85",
"599.0",
"710.1",
"401.9",
"998.59",
"041.04",
"250.00",
"518.5",
"998.31",
"997.4",
"327.23",
"557.1",
"427.31",
"041.4",
"567.29",
"530.81",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.15",
"96.6",
"00.17",
"99.04",
"48.62",
"93.90",
"38.93",
"45.75",
"48.23"
] |
icd9pcs
|
[
[
[]
]
] |
5167, 5237
|
2659, 3876
|
351, 425
|
5296, 5303
|
2543, 2636
|
5652, 5835
|
2257, 2328
|
4011, 5144
|
5258, 5275
|
3902, 3988
|
5327, 5629
|
2343, 2524
|
276, 313
|
453, 1587
|
1609, 1987
|
2003, 2241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,782
| 179,196
|
24442
|
Discharge summary
|
report
|
Admission Date: [**2125-6-19**] Discharge Date: [**2125-6-22**]
Date of Birth: [**2041-5-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Strawberry / Dicloxacillin
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 year-old woman with a history of CVA was found unresponsive
and reported to be pulseless at her nursing home. CPR was
initiated briefly until her DNR/DNI status was discovered.
Patient states that she was aware of the chest compressions. En
route to ED she had 4 episodes of non-bloody, non-bilious
emesis.
In ED patient, was on a non-rebreather. Labs notable for
positive urinalysis with WBC 57 and positive leukocyte esterase
and nitrates. Lactate 1.9, CXR without pneumonia. CT
ABDOMEN/PELVIS initially concerning for intermittent cecal
volvulus, but on review with radiologist there is contrast past
cecum so unlikely to have obstruction. Ceftriaxone given for
UTI and 3 liters of IV fluids given. Patient had transient
decrease in SBP to 75, but spontaneously increased to > 100 upon
awakening. Admitted to ICU for monitoring.
ICU course: Patient did not have any hypotension in the ICU.
Review of Systems:
(+) Per HPI and has urinary incontinence at basline and has
paranoid delusions. Denies dysuria, fever, chills, chest pain,
syncope, headache, vision changes, shortness of breath,
palpitations, neck stiffness, abdominal pain, diarrhea, or
constipation.
(-) Denies night sweats, weight change, visual changes, oral
ulcers, bleeding nose or gums, orthopnea, PND, lower extremity
edema, cough, hemoptysis, melena, BRBPR, dysuria, hematuria,
easy bruising, skin rash, myalgias, joint pain, back pain,
numbness, weakness, dizziness, vertigo, headache, confusion, or
depression. All other review of systems negative.
Past Medical History:
- GERD
- Post herpetic neuralgia - Chronic pain began in [**11/2118**]
following an episode of herpes zoster.
- Polymyositis diagnosed in [**2113**].
- Hypothyroidism status post thyroidectomy 12 years ago for
goiter.
- Stress fracture, left thigh (femur).
- Spinal stenosis.
- Basal cell carcinoma.
- Recurrent falls.
- Paranoid schizophrenia, last hospitalization two years ago.
- Depression.
- Cholecystectomy
- 3 episodes of sepsis in [**2119**] requring MICU stay and
intubation. Last in [**4-20**]. Methortrexate stopped after last MICU
stay.
Social History:
Living in [**Hospital 100**] Rehab currently. No history of smoking,
alcohol, or recreational drug use. Walks with a walker.
Independent in some activities of daily living, like toileting,
feeding, walking, using telephone, etc. Needs assistance or is
dependent on rest. Has 3 involved daughters.
Family History:
Mother with asthma. Father died of old age.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 99.4 BP: 111/41 P: 74 R: 14 O2: 94% on 4L
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, moist mucous membrane, oropharynx
clear, no thrush
Neck: supple, JVP not elevated, no LAD
Lungs: trace crackle at right lung base, otherwise CTAB with no
wheeze or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, 1/6 systolic murmur
at LUSB, no rub or gallops
Abdomen: soft, non-tender, +BS, minimal distension, no HSM, no
rebound or gaurding, tympanic to percussion over epigastric
area.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: alert, oriented to year, place and person. CN II-XII
grossly intact. spontaneously moves all 4 extremities.
sensation intact throughout.
Skin: no rashes noted.
TRANSFER TO FLOOR EXAM [**2125-6-20**]:
VS: 98.9, 130/80, 78, 20, 97% on room air
Pain: None
GEN: NAD
HEENT: EOMI, MMM, no oral lesions
NECK: Supple, JVP flat
CHEST: Right basilar mild rales
CV: RRR, normal S1 and S2
ABD: Soft, nontender, nondistended, bowel sounds present
EXT: No lower extremity edema
SKIN: No rash
GU: Foley in place
NEURO: Alert, oriented x3, CN 2-12 intact, sensory intact
throughout, strength 5/5 BUE/BLE, fluent speech, normal
coordination
PSYCH: Calm
Pertinent Results:
[**2125-6-20**] 04:07AM BLOOD WBC-5.7 RBC-3.01* Hgb-9.6* Hct-29.0*
MCV-96 MCH-32.0 MCHC-33.3 RDW-12.6 Plt Ct-183
[**2125-6-18**] 11:10PM BLOOD WBC-4.5 RBC-3.87* Hgb-11.9* Hct-36.4
MCV-94 MCH-30.7 MCHC-32.7 RDW-13.1 Plt Ct-211
[**2125-6-20**] 04:07AM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-140
K-4.0 Cl-106 HCO3-29 AnGap-9
[**2125-6-18**] 11:10PM BLOOD Glucose-137* UreaN-22* Creat-0.7 Na-138
K-4.2 Cl-101 HCO3-29 AnGap-12
ECG [**2125-6-18**]: Sinus tachy, rate 116, normal axis, 1st degree AV
conduction delay, incomplete RBBB, poor R-wave progression
ECG [**2125-6-19**]: Sinus rhythm, rate 71, normal axis, 1st degree AV
conduction delay, incomplete RBBB, poor R-wave progression
Microbiology:
Urine culture [**2125-6-19**]: E. coli >100,000
URINE CULTURE (Final [**2125-6-21**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Feces negative for C.difficile toxin A & B by EIA
Blood culture [**2125-6-18**] and [**2125-6-19**]: No growth to date
Radiology:
CXR [**2125-6-18**]: Mild cardiomegaly, but no acute cardiopulmonary
process.
CXR [**2125-6-19**]: Findings concerning for early heart failure.
CT ABDOMEN AND PELVIS [**2125-6-19**]:
1. Findings compatible with cecal bascule.
2. Mild intra- and moderate extra-hepatic biliary dilatation.
While these findings might be seen in post-cholecystectomy
patients of this age, ultrasound may be considered to assess for
an obstructing stone or lesion.
Brief Hospital Course:
84 year-old woman with history of CVA found to be unresponsive
at nursing home likely [**1-17**] urinary tract infection. Patient had
transient hypotension for which he was observed in the ICU. This
may have due to a sepsis syndrome or due to hypovolemia from
several days of diarrhea reporteddly before admission.
Problem [**Name (NI) **]:
# E. Coli UTI: Initially received three days of IV Ceftriaxone.
When the sensitivities of the E.Coli in the urine came back, she
was switched to oral Cipro x 5 more days (total of 8 days of
Abx)
# Hypotension - Monitored in ICU without further hypotension.
Responded to fluids and antibiotics. See above. Did not recur.
# Schizophernia: Chronic. Pt with active paranoid delusions
both with family and staff. Geriatrics, in the ICU, recommended
holding QHS doses and using zyprexa only PRN if agitated for now
to see if she continues with apnea/hypotension at night.
Restarting home risperidone slowly to make sure blood pressure
tolerates. Started on risperidone 1mg [**Hospital1 **] (normally 1mg Qam,
2mg Qpm). On this regimen, she did well from a psychiatric point
of view for the few days she was here.
# Hypothyroidism s/p thyroidectomy: Continue Levothyroxine
# Post-Herpetic Neuralgia: Continue Gabapentin and Oxycodone prn
# DVT prophylaxis: Subcutaneous heparin
# Communication: Patient/HCP [**Name (NI) **],[**First Name3 (LF) **] (DAUGHTER)
Phone: [**Telephone/Fax (1) 61842**] Other Phone: [**Telephone/Fax (1) 61843**]
# Code: DNR/DNI, pressors okay if not primary pulmonary
issue(discussed with HCP)
Medications on Admission:
Oxycodone 2.5mg [**Hospital1 **]
Oxycodone 2.5 mg q4h prn breakthrough pain
Seroquel 100 mg qpm
Vitamin D2 5000 unit
Risperidone 1 mg qam
Risperidone 2 mg q1900
Levothyroxine 50 mcg daily
Magnesium Hydroxide (Milk of Magnesia) 30 mL daily
Gabapentin 100 mg q1200, 200 mg q1600
Tylenol 650 mg q6h prn fever/pain
Senna 1 tab qhs
Cadexomer apply daily to affected area
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. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
6. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
9. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for agitation.
10. risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 100**] Senior Life - [**Location (un) 2312**]; [**Location (un) 550**] versus Long-Term Care
Discharge Diagnosis:
Sepsis syndrome
Urinary tract infection
Fecal impaction
Hypovolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for low blood pressure and difficulty
awakening felt to be due to dehydration from diarrhea and
urinary tract infection. You improved with antibiotics and IV
fluids. Other than severe constipation no significant other
abnormalities were identified.
Followup Instructions:
Your primary care physician and your psychiatrist will see you
at the [**Hospital1 100**] Senir Life Rehabilitation and Long Term Care
Center upon your arrival there.
|
[
"560.32",
"710.4",
"995.91",
"053.19",
"244.0",
"038.42",
"295.30",
"276.52",
"V49.86",
"599.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9357, 9489
|
6264, 7834
|
314, 321
|
9601, 9601
|
4137, 6241
|
10043, 10213
|
2788, 2833
|
8250, 9334
|
9510, 9580
|
7860, 8227
|
9752, 10020
|
2848, 4118
|
1273, 1886
|
262, 276
|
349, 1254
|
9616, 9728
|
1908, 2458
|
2474, 2772
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,507
| 185,859
|
25779
|
Discharge summary
|
report
|
Admission Date: [**2160-6-16**] Discharge Date: [**2160-6-19**]
Date of Birth: [**2089-5-18**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Chlorhexidine Gluconate/Brush
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Bloody stool and drop in hct s/p peripheral angiography and
revascularization
Major Surgical or Invasive Procedure:
Periperhal Angiopgraphy and revascularization
Colonoscopy
History of Present Illness:
71-year-old female patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5292**] and with a history
of pseduoxanthoma elasticum , peripheral vascular disease s/p
left SFA stent in [**1-/2159**] and right atherectomy with right SFA
stent on [**2159-3-15**], and recurrent claudication referred for
peripheral angiography and possible revascularization. She was
seen in vascular with Dr. [**First Name (STitle) **] on [**2160-6-12**] where she complained
of new onset claudication symptoms. She was admitted for cath
with possible revascularization.
In cath lab on [**6-16**] stents found to be clotted. SFA treated with
one stent, laser, angiojet with TPA, angiosealed. Next day Pt
had decrease in Hct, hypokalemia and rapid a-fib (RAF). She was
triggered for RAF into 160s, she was rate controlled with
atenolol. Later Pt had episode of BRBPR and episode of melena.
Pt asypmtomatic, BP was 90/58 with HR of 88. Pt transfered to
CCU.
Past Medical History:
PXE, diagnosed at age 42 c/b retinal hemorrhage OU, legally
blind
PVD, s/p bilateral SFA stenting
Hypertension
Hyperlipidemia (patient denies)
Diastolic heart failure
Mitral regurgitation, MVP
Atrial fibrillation
Polymalgia rheumatica
Endometrial cancer, s/p TAHBSO
Left carpal tunnel release
Eczema
Osteoporosis
S/P fungal infection of right toes
.
Cardiac History:
CABG: none
Percutaneous coronary intervention: none
Pacemaker/ICD placed: none
.
PMH:
1. PXE (pseudoxanthoma elasticum) a rare hereditary connective
tissue disorder: legally blind
2. A fib (has been holding Coumadin for ~1 month starting with
colonoscopy)
3. Eczema
-Last mammogram [**7-25**]: normal
-Colonoscopy [**2-24**]: normal
OB/GYN HISTORY: She has had NSVD x2. She reports regular
menstrual cycles until her ? early 50s. She denies history of
abnormal Pap smears, STDs, cysts, or fibroids.
Social History:
She is married with two adult children. She does not smoke or
drink alcohol. She is a homemaker.
Family History:
No family history of CAD.
Physical Exam:
Vitals: Vital signs stable, afebrile
GEN: NAD
HEENT: PERRL, MMM
NECK: No JVD
CV: S1 S2, irregularly irregular rhythm. No Murmurs
CHEST: Rhales at bases B/L
ABD: Soft, NT, ND +BS
EX: +1 pitting edema B/L, distal pulses intact.
Pertinent Results:
Blood:
[**2160-6-19**] 05:50AM BLOOD WBC-9.7 RBC-2.98* Hgb-9.7* Hct-29.4*
MCV-99* MCH-32.6* MCHC-33.1 RDW-17.5* Plt Ct-204
[**2160-6-18**] 09:46PM BLOOD Hct-31.6*
[**2160-6-18**] 08:25AM BLOOD WBC-13.6* RBC-3.48* Hgb-11.3* Hct-34.1*
MCV-98 MCH-32.6* MCHC-33.3 RDW-17.7* Plt Ct-268
[**2160-6-18**] 12:53AM BLOOD Hct-29.4*
[**2160-6-17**] 05:50AM BLOOD Hct-25.6* Plt Ct-217
Electrolytes:
[**2160-6-19**] 05:50AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-138
K-4.8 Cl-104 HCO3-28 AnGap-11
[**2160-6-19**] 05:50AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.3
Lipid:
[**2160-6-18**] 08:25AM BLOOD Triglyc-183* HDL-77 CHOL/HD-2.8
LDLcalc-101
Brief Hospital Course:
71 yo female with PXE, PVD s/p L and R SFA stent who underwent
revascularization by atherectomy and local tpa and replacement
of right stent on [**6-16**]. Post-op she was noticed to have a
decrease in her hematocrit from 32 to 25. She also went into
A-fib with rapid ventricular respose at which point she was rate
controlled with Atenolol. A repeat hematocrit was 28. She then
had en episode of BRBPR and melena. Her vitals were stable.
She was transered to the CCU. She was transfused one unit of
blood overnight and her hematocrit increased to 34. She
continued to have some blood mixed in with her stool. GI was
consulted and she went for a colonoscopy the next day ([**2160-6-18**])
which showed no active bleeding but there was a friable lesion
that was biopsed. Biopsy results were pending at time of
discharge. She remained stable and was transfered to [**Hospital Ward Name 121**] 3 for
observation. Patient remained in A-fib. Her hematocrit
decreased to 29.4, but she remained asymptomatic. She was
discharged from the hospital on Ausust 1. She will have her INR
and her hematocrit checked on [**6-22**]. She has follow up
appointments with her cardiologist, PCP and [**Name Initial (PRE) **] general sugeon for
possible rescection of bowel lesion.
.
Problems:
.
# CAD/Ischemia: Pt without Hx of CAD, but does have PVD s/p left
SFA stent in [**1-/2159**] and right atherectomy with right SFA stent
on [**2159-3-15**] and stent, thrombectomy and tpa on [**2160-6-16**] of R SFA.
- Primary prevention for CAD includes ASA, BB, ACEi.
- Plavix and ASA for stent placement.
.
# Heart Failure: Pt with Hx of diastolic heart failure. No
record of Echo. Pt with crackles on exam and B/L LE edema.
- Continue lasix
.
# Rhythm: Pt with Hx of a-fib and has been having episodes Rapid
A-fib. She is rate controlled with atenolol.
- Continue atenolol for rate control.
- Coumadin stopped for revascularization. Coumadin was
restarted after her colonoscopy.
.
# HTN: Hx of Hypertension. Patient was not hypertensive durring
her hospital stay. She remained on her blood pressure
medication.
- C/w BP meds.
.
# GI BLEED: Pt. with BRBPR and melena after procedure. Pt. has
been on coumadin, ASA and plavix for long time. There was a
concern that some of the tpa that became systemic durring her
procedure had caused her GI bleed, however a friable lesion was
found on biopsy that was the most likely cause of the bleeding.
Her hematocrit initially dropped from 32 to 28 and increased to
34 with one unit of blood. On discharge her hematocrit was
29.4. She remained without symptoms, and her vitals were stable.
No further signs of bleeding. Colonoscopy done showing a
friable lesion in the ascending colon.
- Biopsies pending on discharge
- Continue with protonix
- Follow up with GI as out pt
.
Medications on Admission:
Coumadin 5 mg 1 tab M,W,F and ?????? tab the other days LD [**2160-6-12**]
Diovan/HCTZ 320/12.5 mg ?????? tab daily
Iron 325 mg 1 tab [**Hospital1 **]
Fosamax 70 mg 1 tab weekly
Lasix 80 mg 1 tab daily
Caltrate 1 tab daily
Lorazepam 0.5 mg prn
ASA 81 mg 1 tab daily
Atenolol 25 mg 1 tab daily
Prednisone 4 mg 1 tab in am and 5 mg in hs titrating downward
Discharge Medications:
1. Diovan HCT 160-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Caltrate Plus 600-400 mg-unit Tablet Sig: One (1) Tablet PO
once a day.
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. 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*
11. Outpatient Lab Work
Please check CBC and INR on Saturday [**6-21**] and call results
to Dr. [**Last Name (STitle) 5292**] at [**Telephone/Fax (1) 5294**]
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
taper as per outpt instructions.
13. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily): taper as per outpatient instructions.
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Take on Friday and check your INR on Saturday. Dr. [**Last Name (STitle) 5292**]
will tell you how much coumadin to take over the weekend. .
15. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*3*
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral vascular disease
Acute on chronic Diastolic Congestive Heart Failure
Gastro-intestinal Bleed
Discharge Condition:
VS: Stable, afebrile
Right groin: stable
Labs: hct 29.4, plt 204, BUN 12, Creat 0.7, INR 1.1
Discharge Instructions:
Per post stent instructions.
Please follow a 2 gram sodium diet. Please weigh yourself every
day in the morning when you first get up before breakfast. Call
Dr. [**Last Name (STitle) 5292**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] if you gain more than 3 pounds in 1 day
or 6 pounds in 3 days. Also call if you notice more swelling in
your hands or feet.
Medications:
Plavix x 1 month, decrease aspirin to 81 mg daily.
Atenolol increased to twice a day to control your heart rate.
Continue coumadin at usual dose, please check INR on Saturday,
[**6-21**] with results to Dr. [**Last Name (STitle) 5292**].
Please do not do any strenuous activity such as gardening or
lifting objects heavier than 10 pounds, you may walk and do
light activity.
.
You had a colonoscopy that showed a thickening in the first part
of your colon with some swollen lymph nodes. A biopsy was taken
and results are pending. You have an appt to see a surgeon next
week to discuss this. Please let Dr. [**Last Name (STitle) 5292**] know if you have any
more blood in your stool or if you get more tired or have
trouble breathing. you will have your blood count checked on
Saturday to make sure it's stable.
.
Please call Dr. [**Last Name (STitle) 5292**] for any pain in your groin, chest, trouble
breathing or abdominal discomfort.
Followup Instructions:
Primary Care:
Follow up with Dr. [**Last Name (STitle) 5292**] Phone: [**Telephone/Fax (1) 5294**]
Cardiology:
Follow up with Dr. [**First Name (STitle) **]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3100**], [**MD Number(3) 1240**]: [**Telephone/Fax (1) 62**]
Date/Time [**2160-7-3**] at 1:30pm
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2160-6-30**] 1:15
Surgery:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2160-6-23**]
10:15
|
[
"401.9",
"V58.61",
"369.4",
"276.8",
"427.31",
"996.74",
"V10.42",
"578.9",
"153.6",
"725",
"428.33",
"440.21",
"455.0",
"285.1",
"428.0",
"E934.2",
"424.0",
"578.1",
"272.4",
"757.39",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"00.40",
"00.45",
"88.48",
"99.04",
"45.25",
"39.90",
"99.10",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8395, 8401
|
3389, 6199
|
378, 437
|
8549, 8644
|
2741, 3366
|
10028, 10641
|
2452, 2479
|
6605, 8372
|
8422, 8528
|
6225, 6582
|
8668, 10005
|
2494, 2722
|
261, 340
|
465, 1424
|
1446, 2322
|
2338, 2436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,073
| 123,509
|
41391
|
Discharge summary
|
report
|
Admission Date: [**2174-2-17**] Discharge Date: [**2174-2-28**]
Date of Birth: [**2102-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Type A Dissection
Major Surgical or Invasive Procedure:
[**2174-2-17**] -
1. Emergency repair of type A aortic dissection with a size
28-mm Gelweave interposition graft replacing the ascending aorta
and hemiarch. 2. Aortic valve resuspension. 3. Right axillary
artery cannulation done by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] with Dr.
[**Last Name (STitle) **], and the surgeon for the right axillary artery
cannulation was Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
History of Present Illness:
71 year old male with complaint of sudden onset chest pain since
this morning. Rates severity of [**6-7**] with pain radiating front
to back and associated with
nausea. Had similar episode 2 days ago which spubsided with
rest. Presented to [**Hospital **] [**Hospital3 **] and underwent
non-contrast chest CT which showed possible Type A dissection.
Transferred to [**Hospital1 18**] for surgical management.
Past Medical History:
Type A Dissection
Diabetes Mellitus
Hypertension
Hyperlipidemia
Social History:
Lives with:
Occupation:
Tobacco: Quit smoking 10 yrs ago
ETOH: Socially
Family History:
non-contributory
Physical Exam:
Vitals: within normal limits
General: NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
[X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2174-2-17**] ECHO
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated.
A mobile density is seen in the ascending aorta, arch,
descending thoracic aorta consistent with an intimal flap/aortic
dissection. The Flap was seen close to the RCA origin RV
systolic function was intact.
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. Trivial mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results on Mr.
[**Known lastname **] before surgical incision..
POST-BYPASS:
Preserved biventricular systolic function.
LVEF 55%.
Trivial MR.
Mild AI.
The ascending aorta and arch are intact.
[**2174-2-17**] CTA
1. Type A aortic dissection extending from the aortic root
distally into the proximal right external iliac artery.
Dissection also extends into the left subclavian artery.
2. Right renal artery arises from the false lumen with poor
enhancement of
the right kidney, concerning for hypoperfusion.
3. 3.9-cm rounded area in the interpolar region of the right
kidney
(Se300;Im33) which while may represent a very prominent column
of Bertin, a renal mass may be present, not well evaluated on
this study. Further
evaluation is recommended with ultrasound when the patient is
clinically
stable.
These findings were discussed with Dr. [**Last Name (STitle) **] by Dr.
[**Last Name (STitle) **] in person at 11:40 a.m. on [**2174-2-17**]. Updated findings
and recommendation under #3, regarding right renal findings,
were submitted to the radiology critical findings dashboard on
[**2174-2-17**].
[**2174-2-18**] Renal U/S
1. No evidence in the main renal artery within the hilum of the
kidney
bilaterally to suggest renal artery stenosis. Ultrasound is
unable to
visualize the renal artery from the origin to the hilum of the
kidney. The
artery is only visible within the renal hilum.
2. Solid right renal mass which could represent an
angiomyolipoma vs
hyperechoic renal cell carcinoma. Further characterization is
suggested.
[**2174-2-26**] 05:59AM BLOOD WBC-11.1* RBC-3.38* Hgb-9.8* Hct-28.0*
MCV-83 MCH-29.0 MCHC-35.0 RDW-14.2 Plt Ct-259
[**2174-2-26**] 05:59AM BLOOD Glucose-111* UreaN-91* Creat-3.2* Na-142
K-3.7 Cl-103 HCO3-29 AnGap-14
[**2174-2-18**] 02:40AM BLOOD ALT-15 AST-28 AlkPhos-35* TotBili-0.6
[**2174-2-23**] 04:30AM BLOOD Mg-2.7*
[**2174-2-28**] 04:32AM BLOOD WBC-14.1* RBC-3.69* Hgb-10.4* Hct-30.3*
MCV-82 MCH-28.2 MCHC-34.4 RDW-13.7 Plt Ct-363
[**2174-2-27**] 04:33AM BLOOD WBC-15.9* RBC-3.74* Hgb-10.7* Hct-30.7*
MCV-82 MCH-28.6 MCHC-34.8 RDW-13.9 Plt Ct-357
[**2174-2-28**] 04:32AM BLOOD UreaN-77* Creat-2.8*
[**2174-2-27**] 04:33AM BLOOD UreaN-83* Creat-3.0* Na-142 K-3.7 Cl-101
[**2174-2-26**] 05:59AM BLOOD Glucose-111* UreaN-91* Creat-3.2* Na-142
K-3.7 Cl-103 HCO3-29 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2174-2-17**] for surgical
management of his type A dissection. He was taken directly to
the operating room where he underwent repair of his type A
dissection. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. He was transfused with blood and blood products for
postoperative bleeding and anemia. As his right kidney was
perfused by the false lumen and no flow was noted, the urology
service was consulted. Chest tubes and pacing wires removed per
protocol.His creatinine was noted to elevate and he was seen by
renal service and will follow up with them as an outpt. Further
eval revealed a right renal mass that requires evaluation by an
outpt. urologist. He went into A Fib and was treated with
amiodarone with conversion to SR. He continued to make good
progress and was cleared for discharge to [**Hospital3 **] in
[**Location (un) **] on POD #11. All f/u appts were advised.
**Requires further w/u of renal mass by a urologist as an outpt.
Medications on Admission:
Lisinopril 10mg daily
Metformin 850 mg [**Hospital1 **]
Aspirin 81mg daily
Crestor 120mg daily
Januvia 100mg daily
Glyburide 5mg daily
Gemfibrozil 600mg daily
Metoprolol 25 mg [**Hospital1 **]
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): through [**2-28**].
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: [**3-1**] through [**3-7**].
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
starting [**3-8**] ongoing.
10. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
13. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
16. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
17. insulin glargine 100 unit/mL Solution Sig: Forty (40)
Subcutaneous Breakfast.
18. insulin lispro 100 unit/mL Solution Sig: 0-12 Subcutaneous
four times a day: Humalog Sliding Scale per attached.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Type A dissection s/p aortic valve resuspension/repl. ascending
aorta
acute renal failure
postop A Fib
right renal mass
Diabetes Mellitus
Hypertension
Hyperlipidemia
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 1+
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. [**First Name (STitle) **] on [**3-14**] at 2:15pm
Cardiologist:Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] - please contact her office for
appt in [**3-3**] weeks [**Telephone/Fax (1) 62**]
Nephrologist: Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] [**Telephone/Fax (1) 90088**] - please call for
appt in 3 weeks
Please call to schedule appointments with your :
Primary Care Dr.[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **] in [**5-3**] weeks
**Please arrange appoointment with your urologist in [**3-3**] weeks
for f/u of right kidney mass
**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:[**2174-2-28**]
|
[
"593.9",
"285.1",
"443.29",
"272.4",
"V15.82",
"997.1",
"V10.46",
"427.31",
"584.5",
"441.03",
"403.90",
"585.3",
"E849.7",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.11",
"96.71",
"39.61",
"38.45",
"39.31",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8352, 8426
|
5372, 6451
|
327, 778
|
8636, 8810
|
2017, 5349
|
9699, 10662
|
1411, 1430
|
6695, 8329
|
8447, 8615
|
6477, 6672
|
8834, 9676
|
1445, 1998
|
270, 289
|
806, 1217
|
1239, 1305
|
1321, 1395
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,166
| 123,110
|
23360
|
Discharge summary
|
report
|
Admission Date: [**2188-11-20**] Discharge Date: [**2188-12-11**]
Date of Birth: [**2126-2-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Motrin
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
transfer from OSH with TV endocarditis
Major Surgical or Invasive Procedure:
[**11-26**] Dobhoff placement
[**12-1**] PICC placement
History of Present Illness:
62 yof A-fib (s/p ablation) h/o IVDA, remote tricuspid valvue
replacement x 3 who is transffered from [**Hospital3 **] for TV
endocarditis.
.
.
She had history of TV replacement X 3 in the past most recently
at [**Hospital1 18**] in [**2184**]. Also h/o Afib/fibrilation - s/p ablation at
[**Hospital1 **]; also h/o SSS - currently with pacer wires w/o battery.
Has prior history of candidemia and klebsiella bacteremia, as
well as in [**2184**] endocarditis with MSSA + VRE bacteremia. Per ID
notes at the time did not finish recommended Abx course.
.
Presented to [**Hospital 26580**] Hospital on [**11-18**] with cough, dyspnea x [**2-19**]
days. She denied IVDU. No further history was obtainable. In the
OSH ED was found to be hypotensive and in respiratory distress
Hypotension, leukocytosis, lactate 6.8 cortisol of 22, multiple
lung infiltrates, nodules and cavitations by chest CT consistent
with septic emboli, echocardiogram demonstrated TV vegetations.
.
Patient was intubated, levophed for BP (initially via femoral
central line, now with new left IJ), agressive iv fluid
ressucitation to CVP of 17. Blood cultures revealed yeast (1
bottle) and GPC's, as well yeast in urine and GPC in sputum -->
started on vancomycin, levofloxicin, ceftazidime, micfungin.
.
Other features of hospitalization: right groin hematoma
(multiple central line attempts in ER), renal failure initiallt
with poor UOP which improved with fluid resucitation and after
IV lasix 20mg yesterday, thrombocytopenia to 14,000 on
presentation (normal base-line), coagulopathy (INR = 2.6),
evidence for cocaine, BZ, oxycodone on admission tox screen,
also had abnormal LFT's on presentation with total bili of 2.0,
elevated AST, ALKP and ALT which subsequently trended down. RUQ
US revelaled fatty liver and ascitis as well as "prominent
gallbladder and hepatic ducts". Albumin = 2.0, pre-albumin = 5.
Patient recieved FFP X2 + PLT X 2 + PRBC X2. Lactate trended
down to 2.3 prior to transfer.
.
On day of transfer in the AM patient self extubated, she got
reintubated prior to transfer for hypoxia and tachypnea
TVR reportedly last performed at [**Hospital1 18**] [**2184**]. Also with h/o SSS
--> pacer wires in place but reportedly with no battery pack.
Reportedly has indwelling hardware in spine (?plate) from prior
surgery.
.
Self extubated this AM, with marginal respiratory status -->
plan to reintubate prior to transfer. Requested copies of all
images on CD.
.
In the ED, initial VS were:
.
On arrival to the MICU,
.
Review of systems: unobtainable.
Past Medical History:
1. s/p TV repair '[**59**], s/p TVR/PFO closure '[**69**], s/p Redo
tricuspid valve replacement with a St. [**Male First Name (un) 1525**] tissue valve and
placement of epicardial permanent pacing leads
([**2185-2-19**])arrest
2. Breast CA s/p left lumpectomy + axial node
dissection/Chemo/XRT '[**78**]
3. sepsis related to Portacath
4. Afib/fibrilation - s/p ablation at [**Hospital1 **]; also h/o SSS -
currently with pacer wires w/o battery.
5. multiple spinal surgeries, h/o
spinal stimulators-?removal
6. COPD
7. Left ing hernia repair.
8. BCC X3.
9. Cerebrovascular accident ([**2169**]).
Social History:
Lives with partner of 30 years([**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 17926**]) who has not been
in contact during this admission. Talked to patient's brother
[**Name (NI) **] [**Name (NI) 59954**] (home: [**Telephone/Fax (1) 59955**], cell: [**Telephone/Fax (1) 59956**]), he
is patient's HCP and will send paperwork to that effect. Lives
in Fort-[**First Name9 (NamePattern2) 59957**] [**State 108**] and will travel here within the next
few days. There are two more brothers in the [**Name (NI) 59958**] Area who have
been visiting. Patient's daughter lives in area.
.
Per HCP patient is active IVDU. Has + tobacco - about [**11-17**] ppd
Family History:
Mother- Diabetes/HTN
Physical Exam:
On ICU admission:
.
General: Patient is alert, appears uncomfortable, opens eyes to
command but otherwise not cooperative, intubated, ventilated, on
IV fentanyl + IV levophed
HEENT: Sclera anicteric, MMM, thrush on tongue, Pupils sluggish
and unequal, R 4mm, L 2mm
Neck: supple, JVP at jaw angle, no LAD, left IJ in place with
some hematoma around site.
CV: IRRegular rate and rhythm, minimal systolic murmur [**11-21**] at
LLSB, no rubs, gallops. Wires are palpable in right anterior
chest subcutaneously.
Lungs: bil air entery other Clear to auscultation bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Back: bony protrusion at midline @ ~ T10 level, no tenderness or
erythema, surgical scars along spine.
Ext: clubbing of fingers, large subcutaneous hematoma over left
groin and thigh, femoral pulses palpable bilaterally, warm, well
perfused, DP's + radials thready and symetrical, faint, no
cyanosis, bil tibial edema right > left, no calf tenderness.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Skin: No stigmata of endocarditis seen. Multiple echymosis,
Stage 3 decub ulcer on left elbow.
On discharge: T 98.5 BP 90s-100s/40-60s P 70s-140s RR mid 20s
96% on 4L O2
HEENT: WNL
LUNGS: CTA B/L
CARDS: irregularly irregular. no m/r/g. hyperdynamic
precordium with diffuse PMI.
Abdomen: Soft and non-tender. No HSM
Extremities: R>L swelling. 3+ R, 2+ L.
Back: No active signs of infection of back wound. No drainage.
Pertinent Results:
[**2188-11-20**] 08:35PM TYPE-CENTRAL VE TEMP-37.5
[**2188-11-20**] 08:35PM O2 SAT-72
[**2188-11-20**] 08:27PM TYPE-ART TEMP-37.5 RATES-16/4 TIDAL VOL-520
PEEP-8 O2-40 PO2-71* PCO2-38 PH-7.33* TOTAL CO2-21 BASE XS--5
-ASSIST/CON INTUBATED-INTUBATED
[**2188-11-20**] 08:27PM O2 SAT-92
[**2188-11-20**] 07:08PM TYPE-[**Last Name (un) **] PO2-177* PCO2-47* PH-7.22* TOTAL
CO2-20* BASE XS--8
[**2188-11-20**] 07:08PM LACTATE-3.0*
[**2188-11-20**] 06:46PM GLUCOSE-100 UREA N-23* CREAT-1.1 SODIUM-136
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-20* ANION GAP-13
[**2188-11-20**] 06:46PM estGFR-Using this
[**2188-11-20**] 06:46PM ALT(SGPT)-31 AST(SGOT)-64* LD(LDH)-490* ALK
PHOS-204* TOT BILI-2.1*
[**2188-11-20**] 06:46PM ALBUMIN-2.4* CALCIUM-7.8* PHOSPHATE-3.6
MAGNESIUM-2.1
[**2188-11-20**] 06:46PM HAPTOGLOB-<5*
[**2188-11-20**] 06:46PM TRIGLYCER-125
[**2188-11-20**] 06:46PM WBC-12.7* RBC-3.07* HGB-9.1* HCT-28.3* MCV-92
MCH-29.5 MCHC-32.0 RDW-22.2*
[**2188-11-20**] 06:46PM NEUTS-89.7* BANDS-0 LYMPHS-8.0* MONOS-2.1
EOS-0.2 BASOS-0.1
[**2188-11-20**] 06:46PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL
[**2188-11-20**] 06:46PM PLT SMR-VERY LOW PLT COUNT-39*#
[**2188-11-20**] 06:46PM PT-18.2* PTT-41.1* INR(PT)-1.7*
Relevant Labs:
[**2188-12-6**] 05:05AM BLOOD Fibrino-273
[**2188-12-6**] 05:05AM BLOOD FDP-10-40*
[**2188-12-5**] 04:43AM BLOOD ESR-98*
[**2188-12-9**] 04:09AM BLOOD Ret Aut-3.3*
[**2188-12-10**] 05:28AM BLOOD AlkPhos-466*
[**2188-12-3**] 09:49AM BLOOD GGT-78*
[**2188-12-9**] 04:09AM BLOOD calTIBC-182* Ferritn-472* TRF-140*
[**2188-11-29**] 06:23AM BLOOD Lactate-0.9
[**2188-12-8**] 02:08PM BLOOD B-GLUCAN-Test: Positive. has been
persistently positive.
Galactomannin negative
[**2188-11-22**] 03:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
Discharge Labs:
[**2188-12-10**] 05:28AM BLOOD WBC-5.6 RBC-2.51* Hgb-7.7* Hct-24.3*
MCV-97 MCH-30.5 MCHC-31.6 RDW-19.5* Plt Ct-73*
[**2188-12-10**] 05:28AM BLOOD Glucose-132* UreaN-31* Creat-1.0 Na-132*
K-4.2 Cl-100 HCO3-30 AnGap-6*
[**2188-12-10**] 05:28AM BLOOD AlkPhos-466*
[**2188-12-10**] 05:28AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7
Micro: Last positive blood culture drawn on [**2188-11-28**].
Blood Culture, Routine (Final [**2188-12-6**]):
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **].
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVE TO Fluconazole.
sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
This test has not been FDA approved but has been
verified
following Clinical and Laboratory Standards Institute
guidelines
by [**Hospital1 69**] Clinical
Microbiology
Laboratory..
Aerobic Bottle Gram Stain (Final [**2188-12-3**]):
BUDDING YEAST.
Reported to and read back by DR. [**Last Name (STitle) **] [**2188-12-3**] 08:23AM.
All blood cultures since have been negative.
Urine cultures negative
Negative C diff
Imaging:
[**2188-11-23**]: CT L and T spine
1. Increased sclerosis and collapse of vertebral bodies in the
lower lumbar spine at L2 through the lumbosacral junction. No
focal fluid collection or evidence of abscess formation. These
findings could represent chronic osteomyelitis, less likely
neoplasm.
2. Diffuse anasarca and abdominal ascites. Decreased delineation
of
paraspinal muscles in the lumbar spine could represent edema or
muscle
atrophy.
3. Previously placed spinal stimulator lead within the spinal
canal with lead extending to the subcutaneous tissues. As
compared to the prior examination, a portion of the lead has
been removed.
4. Right renal hydronephrosis.
5. Bilateral pleural effusions and atelectasis within the
partially imaged
portion of the lungs.
[**11-21**] Echo:
The coronary sinus is dilated (diameter >15mm), likely as a
result of high right atrial pressures. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-50%). The right ventricular cavity is
markedly dilated with severe global free wall hypokinesis. There
is abnormal diastolic septal motion/position consistent with
right ventricular volume overload. The aortic valve leaflets are
mildly thickened (?#). No masses or vegetations are seen on the
aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. A bioprosthetic tricuspid valve is
present. There is a moderate vegetation on the tricuspid valve.
No vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: Endocarditis of the bioprosthetic tricuspid valve
with at least mild to moderate regurgitation. Dilated right
ventricle with severe systolic dysfunction.
Compared with the prior study (images reviewed) of [**2185-3-18**],
there is a new vegetation on the tricuspid bioprosthesis. Right
ventricle is more dilated and hypokinetic and LV function is not
as vigorous.
.
[**12-4**] Echo:
The estimated right atrial pressure is 5-10 mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size is normal. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
Trace aortic regurgitation is seen. Trivial mitral regurgitation
is seen. A bioprosthetic tricuspid valve is present. There is a
large (1.8 x 1.1 cm) vegetation on the tricuspid valve. There is
mild functional tricuspid stenosis. Severe [4+] tricuspid
regurgitation is seen. There is mild 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.] There is no pericardial effusion.
IMPRESSION: Prosthetic tricuspid valve endocarditis with severe
regurgitation. Moderately dilated right ventricle with moderate
global systolic dysfunction. Normal global and regional left
ventricular systolic function.
Compared with the prior study (images reviewed) of [**2188-11-21**],
right ventricle is smaller and biventricular systolic function
has slightly improved. Severe tricuspid regurgitation is seen.
.
[**12-6**] US Lower back:
FINDINGS: [**Doctor Last Name **]-scale and color son[**Name (NI) 1417**] of the region of
fluctuance in the patient's lower back were performed. There is
a small strip of essentially anechoic material suggesting fluid
without internal vascularity in the subcutaneous tissues,
maximally measuring 4 mm AP. No substantial or drainable fluid
collection is identified.
IMPRESSION: Trace superficial fluid at the area of fluctuance on
the
patient's lower back, only 4 mm in width, along the subcutaneous
fat.
The study and the report were reviewed by the staff radiologist.
.
[**12-10**] CXRay:
Moderate pulmonary edema has improved. Multifocal nodular
opacities with
cavitation in the right upper lobe are consistent with known
septic emboli. Left PICC tip is in the lower SVC. NG tube tip
is out of view below the diaphragm. Cardiomegaly is stable.
Bibasilar consolidations larger on the right have improved from
the left. There is no pneumothorax.
.
ECG:
Sinus tachycardia with premature atrial and ventricular
complexes. Rightward axis. Incomplete right bundle-branch block.
Borderline left atrial abnormality. Non-specific ST segment
changes in the inferolateral leads. Compared to the previous
tracing of [**2188-11-25**] the findings are similar.
Brief Hospital Course:
62 yof A-fib (s/p ablation) h/o IVDA, tricuspid valve
replacement x 3 who was transferred from [**Hospital3 **] [**11-20**] for
management of septic shock, respiratory failure, and TV
endocarditis with septic pulmonary emboli.
.
# Candidemia: Source is candidal endocarditis complicating IVDU.
Severe sepsis on admission now resolved. Last positive Bcx was
[**11-28**]. Continued ambisome (day 1 = [**11-18**]) + Micafungin (day 1 =
[**11-29**]) added by ID due to ongoing fungimia. Per ID plan is to
continue this course for minimum of 14 days from first day of
neg cultures ([**11-28**]) before considering switching to oral
fluconazole which may have to be continued for life if no
Surgery.
- No surgery teams will intervene for removal of hardware
(epicardial leads, spinal stimulator) at this time given
comorbidities, history of repeated drug use.
- Last day of ambisome on [**12-12**].
- Continue micafungin for at least 3 more months.
.
#Respiratory status: Extubated [**11-23**], most likely due to
involvement of lungs with septic emboli + fluid overload. O2
requirement weaned with diuresis. Stable now. Current deficits
are most likely [**12-18**] to underlying lung involvement with septic
emboli and some amount of right ventricular overload from
pulmonary hypertension. Her furosemide dose is a moving target,
and we've been using 20-40mg daily. Her pulmonary edema has
improved, but we're cautious of overdiuresing given her soft
pressures.
- continue weaning O2 as possible.
.
#Tricuspid valve endocarditis: CT surgery: not surgical
candidate at this time
- retinoscopy negative for [**Female First Name (un) 564**] x2 (last retinal exam on
[**12-5**])
.
#Cavitary Pulmonary Lesions: Most likely septic emboli.
Continued anti-fungals as above.
.
# abnormal LFT??????s: HBV/HCV serology neg. Initially thought to
have some cholesatsis [**12-18**] to liver congestion. RUQ US on [**12-1**]
was non-concerning. AST/ALT/Bili have normalized but Alk phos
rising. Most likely this is from ambisome which will be stopped
shortly
- continue to trend LFT??????s QOD
.
#DIC/Thrombocytopenia: consumptive process evidenced by low
fibrinogen, elevated INR, low platelets, pos hemolysis labs. [**Month (only) 116**]
also have element of shearing from vegetations + BM suppression
given her illness + sequestartion from minimally enlarged spleen
(13.5cm per US [**12-1**]) likely [**12-18**] to right heart failure and
congestion. Over time with resolution of infection, her
numbers have improved. Her platelets are steadily climbing.
Her fibrinogen is normal. Her FDP has improved.
.
# right LE edema: LENI [**12-1**] was negative. [**Month (only) 116**] have some venous
stasis complicating large right groin hematoma due to multiple
attempts at femoral access in OSH. She has heart failure and
hasn't been up around and moving which is causing the bilateral
edema. It is worse on right though.
.
# right renal hydronephrosis: renal function is normal. Right
hydronephrosis is stable.
.
#Fluctuance over t/l spine in the area of the spinal stimulator:
spinal abscess was ruled out by imaging. No hardware removal at
this time.
.
# Acute on chronic systolic and diastolic heart failure: LVEF
now 55% with some degree of right ventricular interdependence.
- started lisinopril 2.5mg. Uptitrate as pressures tolerate.
- Lasix 20mg daily.
.
# Social: brother [**Name (NI) **] who lives in [**Name (NI) 108**] is HCP, has not
seen patient during entire hospital course. Patient??????s two other
brothers live in [**Name (NI) 86**]. Her partner of 30 years has not visited
or called during this admission. Her son lives in [**State **].
- get HCP paperwork from Brother [**Name (NI) **] (all contact numbers in
team census).
.
# Nutrition:
- continued tube feeds still needs Dobhoff.
- continued advancing PO diet to regular - with soft solids for
dysphagia and thin liquids.
- continued thiamine and MVI and zinc for healing
.
.
# FEN: no IVF, replete electrolytes as needed,
# Prophylaxis: Pneumoboots for now , no heparin while active DIC
# access: PICC planned for today, will d/c art line.
# Communication:
[**First Name8 (NamePattern2) 6303**] [**Known lastname **] (daughter currently using her friend's phone):
[**Telephone/Fax (1) 59959**]
[**Name (NI) **] (son from Ca) [**Telephone/Fax (1) 59960**]
[**Doctor First Name 1453**] daughter [**Telephone/Fax (1) 59961**]
three brothers [**Name (NI) **], [**Name (NI) 53228**] and [**First Name5 (NamePattern1) **] [**Name (NI) 59962**]: [**Doctor First Name 53228**] used to
work for [**Location (un) **] Trap Company
Partner is [**First Name5 (NamePattern1) 4049**] [**Last Name (NamePattern1) 59963**] and pts home number [**Serial Number 59964**] is where
he stays--gets home from work 7pm
brother in [**Name (NI) 108**] and HCP [**Name (NI) **] [**Name (NI) 59954**] (home:
[**Telephone/Fax (1) 59955**], cell: [**Telephone/Fax (1) 59956**]),
.
# Code: DNR/DNI. Pt with capacity. Understands her illness.
Able to describe what happened to her heart. The necessity of
antifungals. The danger of IV drugs. The inability to
surgically intervene on her heart and back at this time.
.
Transitional: One more day of ambisome on [**12-12**]. Continue
micafungin. Monitor nutrition. Dobhoff placed on [**11-26**]. Will
need to be taken out per [**Hospital1 **]. Needs rehab.
Medications on Admission:
Medications Home:
Albuterol nebs
Fentanyl patch PRN
Oxycodone PRN
Robaxin (methocarbamol = muscle relaxant) 500 QID
Allergies: Aspirin, Motrins, Penicillins - per chart
.
Transfer meds:
Ceftazidime, Levofloxacin, Vanco, Micfungin\
Norepinephrin drip
Fentanyl drip
Midazolam PRN
Ondasternon PRN
Senna PRN
Pantoprazole
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day) as needed for constipation.
4. ascorbic acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
5. zinc sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing .
7. thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. trazodone 50 mg Tablet [**Hospital1 **]: 0.25 Tablet PO HS (at bedtime) as
needed for insomnia.
9. lisinopril 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
10. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3
times a day).
11. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours).
12. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
13. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
14. methocarbamol 500 mg Tablet [**Hospital1 **]: 1.5 Tablets PO TID (3 times
a day).
15. oxycodone 20 mg Tablet Extended Release 12 hr [**Hospital1 **]: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
16. oxycodone 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for back pain.
17. furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
18. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
19. benzonatate 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3
times a day).
20. Ambisome 400 mg IV Q24H
Please space by 2 hours from platelet transfusions.
21. Ondansetron 4 mg IV Q8H:PRN n/v
22. Micafungin 100 mg IV Q24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Tricuspid valve endocarditis with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**],
Cavitary pulmonary nodules thought [**12-18**] to septic emboli,
Multifocal atrial tachycardia, Acute on chronic systoilc and
diastolic heart failure
Secondary: Elevated alk phos, Thrombocytopenia, Right renal
hydronephrosis, malnutrition
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 **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted with an infection of your heart valve with a fungus.
You are being treated with two antifungals. You have a spinal
stimulator in your back and a pressure ulcer there as well. The
neurosurgeons and plastics team came to evaluate this wound and
did not feel that surgery was an option at this point. The
cardiothoracic surgery team also evaluted you for possible
intervention on your tricuspid valve and removal of the
pacemaker, but also felt that this was not an option now.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: MONDAY [**2188-12-29**] at 9:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2188-12-11**]
|
[
"591",
"995.92",
"112.0",
"287.5",
"V12.54",
"305.50",
"707.23",
"707.03",
"428.0",
"305.60",
"496",
"584.5",
"415.12",
"785.52",
"428.43",
"E930.1",
"293.0",
"263.1",
"350.1",
"112.81",
"V49.86",
"286.6",
"416.8",
"790.4",
"996.61",
"518.81",
"V10.3",
"789.59",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.6",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
21542, 21613
|
13751, 19111
|
332, 390
|
22012, 22012
|
5935, 7777
|
22809, 23173
|
4290, 4312
|
19480, 21519
|
21634, 21991
|
19137, 19457
|
22195, 22786
|
7793, 13728
|
4327, 5587
|
5601, 5916
|
2948, 2964
|
254, 294
|
418, 2929
|
22027, 22171
|
2986, 3588
|
3604, 4274
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,742
| 180,497
|
32418
|
Discharge summary
|
report
|
Admission Date: [**2126-11-21**] Discharge Date: [**2126-11-23**]
Date of Birth: [**2053-11-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Exploratory Laparotomy
History of Present Illness:
~40yrs) who presented to an OSH with chest pain and neck pain x2
days. Pt states that he developed the acute onset of substernal
chest pressure, "like someone was sitting on my chest", one
morning earlier this week (can't remember which day). It woke
him from sleep and was associated with cold sweats and nausea.
He vomited x1 with resolution of the chest pain but he then
developed neck "throbbing" and an aching sensation in his R
forearm. He notes that the symptoms were constant throughout the
day. He was unable to eat and unable to sleep, so at 4am, he
decided to go to the hospital. Sx were not associated with SOB,
dyspnea on exertion, cough, palpitations. + cold sweats,
nausea/anorexia, and LH.
In the [**Location (un) **] ER, his initial VS were HR 220, BP 150/78, RR 28,
sats of 96% on RA. EKG revealed rapid afib w/ ST elevations in
V2-V6. His labs revealed WBC 14.7, Hct 35.2, plt 234, Na 130, K
4.0, glu 311, Cr 1.8, albumin 3.3, AST 81, ALT 61, AP 92, CK
202, CKMB 8.4, MBI 4.2, trop I 16.91. He was given ASA 325mg,
lopresor 5mg IV x2, ativan 1mg IV x1, SL ntg, 500cc NS bolus,
plavix 600mg PO x1 and heparin gtt (w/ bolus). He was
med-flighted to [**Hospital1 18**] for intervention. At [**Hospital1 **], he went right to
the cath lab. An EKG confirmed ST elevations in an anterior
distribution. In the cath lab, the LAD was found to be occluded,
wire was able to be passed and a balloon was inflated, but there
was no restoration of flow. However, the patient was agitated
and unable to stay still so no further interventions were
attempted.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the
*** Cardiac review of systems is notable for absence of chest
pain (currently), dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope. He denies any angina preceding this event.
.
Past Medical History:
No known PMHx
Social History:
[**Name (NI) 1094**] father had CABG x5, paternal uncle and brother both had MI.
Mother died of breast cancer. Pt is a retired carpenter (retired
at age 62). He denies any tobacco or EtOH use (used to smoke
1ppd but quit when he retired). Lives w/ his wife.
Physical Exam:
VS: T 98.1, BP 91/55, HR 64, RR 33, O2 100% on 3L nc
Gen: WDWN middle aged male, restless, agitated, but AAOx3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, no elevated JVP.
CV: RR, with III/VI holosystolic murmur heard throughout the
precordium, radiates to axilla, not to carotids.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Thin, soft, NTND, no HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. Bulge in L groin, soft, tender
to palpation. Arterial puncture site in R groin.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 1+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
EKG demonstrated sinus tachycardia, rate of 104, leftward axis,
normal intervals, biphasic P waves in V1 and V2, Q waves in
V1-V4, I and [**Last Name (LF) **], [**First Name3 (LF) **] elevations V2-V6 as well as I and [**First Name3 (LF) **].
CARDIAC CATH performed on [**2126-11-21**] demonstrated:
R dominant system
LMCA normal
LAD occluded after large S1 and D1
LCx moderate mid disease to 50-70%
RCA diffuse <50% disease
"Initial arterial pressure 75/53, neo gtt started with SBP
90-100, change for 6 French XBLAD 3.5 guide, LAD occlusion
crossed w/ wire and dilated w/ 2.0 balloon w/o restoration of
flow. Distal injection through the balloon showed diffusely
diseased vessel w/ cutoff before apex. Because of this, late
presentation after MI and pt's inability to cooperate, procedure
terminated w/ plan for medical therapy."
HEMODYNAMICS [**2126-11-21**]:
Ao mean 25
RA mean 20, A wave 26, V wave 26
RV 43/14, end 21
PCW 23, A wave 22, V wave 27
PA 43/22, mean 30
ECHO [**11-21**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears moderately-to-severely
depressed (ejection fraction approximately 30 percent) secondary
to akinesis of the anterior septum, anterior free wall, and
apex. There is no ventricular septal defect. Right ventricular
chamber size is normal. Right ventricular systolic function
appears depressed. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Impression: extensive anteroseptal-apical myocardial infarct;
moderate-to-severe tricuspid regurgitation; moderate pulmonary
hypertension; hypokinetic right ventricle
ECHO [**11-23**]: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the mid anterior septum and anterior walls,
akinesis of the distal third of the ventricle, and mild
dyskinesis/aneurysm of the apex. The remaining segments contract
normally (LVEF = 30-35%). No masses or thrombi are seen in the
left ventricle. The estimated cardiac index is borderline low
(2.0-2.5L/min/m2). Right ventricular chamber size is normal with
moderate global free wall hypokinesis. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2126-11-21**],
the findings are similar.
ECHO [**11-23**]: There is a post infarction distal ventricular septal
defect (VSD) with a 1cm defect seen on 2D imaging and prominent
left-to-right flow on color Doppler. Right ventricular systolic
function appears depressed. Regional left ventricular systolic
dysfunction is similar to the prior studies (proximal/mid-LAD
distribution).
Compared with the prior study of earlier in the day, a large
ventricular septal defect is now identified. The area was not
interrogated with 2D or color Doppler on the prior study of
earlier in the day. Thus the finding may not reflect a true
interim change.
CT ABDOMEN: 1. Focal moderate inflammation involving the
descending and third/fourth
portions of the duodenum with adjacent stranding and fluid which
tracks along
the anterior pararenal fascia to the right paracolic gutter.
This is likely
representative of duodenitis, peptic ulcer disease or less
likely
pancreatitis.
2. Bibasilar pleural effusions, cardiomegaly, coronary artery
calcifications
and anemia.
3. 5.1-cm infrarenal AAA without discrete evidence of leak.
4. Left inguinal fat-containing hernia.
CXR [**11-21**]: AP single view of the chest obtained with patient in
sitting
upright position demonstrates no significant cardiac
enlargement. No
pulmonary congestion, edema or acute infiltrates. Observe,
however, that the portable film does not cover the entire right
chest base.
[**2126-11-21**] 05:17PM GLUCOSE-203* UREA N-50* CREAT-2.2* SODIUM-137
POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-21* ANION GAP-18
[**2126-11-21**] 05:17PM CK(CPK)-296*
[**2126-11-21**] 05:17PM CK-MB-7 cTropnT-4.24*
[**2126-11-21**] 05:17PM CALCIUM-7.9* PHOSPHATE-3.1 MAGNESIUM-2.4
[**2126-11-21**] 05:17PM TSH-3.2
[**2126-11-21**] 05:17PM HCT-30.6*
[**2126-11-21**] 05:17PM PT-16.8* PTT-44.3* INR(PT)-1.5*
[**2126-11-21**] 11:23AM GLUCOSE-259* UREA N-42* CREAT-1.9* SODIUM-137
POTASSIUM-5.3* CHLORIDE-103 TOTAL CO2-18* ANION GAP-21
[**2126-11-21**] 11:23AM estGFR-Using this
[**2126-11-21**] 11:23AM ALT(SGPT)-425* AST(SGOT)-445* LD(LDH)-1461*
CK(CPK)-242* ALK PHOS-97 TOT BILI-0.7
[**2126-11-21**] 11:23AM CK-MB-7 cTropnT-3.61*
[**2126-11-21**] 11:23AM CALCIUM-7.7* PHOSPHATE-3.2 MAGNESIUM-2.3
CHOLEST-133
[**2126-11-21**] 11:23AM %HbA1c-7.0*
[**2126-11-21**] 11:23AM TRIGLYCER-95 HDL CHOL-38 CHOL/HDL-3.5
LDL(CALC)-76
[**2126-11-21**] 11:23AM HBsAg-NEGATIVE HBs Ab-NEGATIVE IgM
HBc-NEGATIVE
[**2126-11-21**] 11:23AM ACETMNPHN-NEG
[**2126-11-21**] 11:23AM HCV Ab-NEGATIVE
[**2126-11-21**] 11:23AM URINE HOURS-RANDOM UREA N-419 CREAT-260
SODIUM-LESS THAN
[**2126-11-21**] 11:23AM URINE OSMOLAL-614
[**2126-11-21**] 11:23AM WBC-13.1* RBC-3.64* HGB-10.9* HCT-32.8*
MCV-90 MCH-29.8 MCHC-33.1 RDW-13.6
[**2126-11-21**] 11:23AM NEUTS-80.1* LYMPHS-14.6* MONOS-5.2 EOS-0
BASOS-0.1
[**2126-11-21**] 11:23AM PLT COUNT-211
[**2126-11-21**] 11:23AM PT-15.8* PTT-44.7* INR(PT)-1.4*
[**2126-11-21**] 11:23AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2126-11-21**] 11:23AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-5.0
LEUK-NEG
[**2126-11-21**] 11:23AM URINE RBC-[**2-18**]* WBC-0 BACTERIA-MOD YEAST-NONE
EPI-0-2 TRANS EPI-[**2-18**]
[**2126-11-21**] 10:45AM HCT-31.4*
[**2126-11-21**] 09:06AM PLT COUNT-268
[**2126-11-21**] 05:50AM TYPE-ART PO2-100 PCO2-33* PH-7.44 TOTAL
CO2-23 BASE XS-0
[**2126-11-21**] 05:50AM GLUCOSE-250* LACTATE-1.6 K+-4.6
[**2126-11-21**] 05:50AM HGB-15.7 calcHCT-47 O2 SAT-97
[**2126-11-21**] 05:50AM freeCa-1.03*
Brief Hospital Course:
CARDIAC- patient arrived to [**Hospital1 18**] s/p an LAD STEMI and underwent
cardiac catheterization with a culprit lesion found in the LAD
but no reflow. POBA was not able to restore blood flow.
Patient was transferred to the CCU for medical management of his
STEMI. The patient was relatively stable initially; however
over the ensuing 24-48 hours he became hypotensive. The patient
made it known that his chest pain actually began 72 hours
earlier but he told [**Last Name (un) 15025**] and remained at home with the pain. He
was started on pressors and on labs was noted to have a rising
lactate and rising LFTs in the setting of a leukocytosis. It
was unclear if the leukocytosis was related to his MI or bowel
ischemia/infarction so broad spectrum antibiotics were started
while cultures were pending. His lactate continued to rise and
his LFTs were elevated to the thousands. His ECHO earlier had
showed no VSD but significant TR- the patient had a loud
holosystolic murmur on exam. The patient continued to
decompensate and was taken to the OR for an ex-lap as his
lactate continued to rise in the setting of hypotension; the
thought was that he likely had ischemic bowel. His bowel was
run and was determined to be normal. Of note he was found to
have a large firm liver. The patient continued to be
hypotensive and require additional pressors and had another
Echocardiogram which revealed a cardiac index < 2.0; compared to
cardiac indicies of roughly [**3-21**] calculated by the FICK method
with the patient's swan ganz catheter. A third echo was
obtained, to specifically look for a shunt; a ventricular septal
perforation was noted on this echocardiogram. The patient at
this point was on 3 different pressor agents and despite this
remained hypotensive. Cardiac Surgery was contact[**Name (NI) **] immediately
for the possibility of surgical closure of a VSD. Given the
patient's overall clinical picture the decision was made not to
surgically intervene or place an IABP as he had progressed to an
inoperable state. The patient's family was made aware of the
situation and the fact that he would very likely not survive a
cardiac surgical operation. The patient expired.
Medications on Admission:
none
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"789.00",
"286.9",
"593.9",
"300.00",
"416.8",
"584.9",
"285.9",
"496",
"V15.82",
"785.51",
"570",
"414.01",
"790.29",
"787.3",
"276.2",
"573.3",
"288.60",
"410.11",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.11",
"99.07",
"88.56",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
12742, 12751
|
10450, 12655
|
323, 371
|
12802, 12811
|
3733, 10427
|
12867, 12877
|
12710, 12719
|
12772, 12781
|
12681, 12687
|
12835, 12844
|
2840, 3714
|
278, 285
|
399, 2513
|
2535, 2550
|
2566, 2825
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,080
| 187,059
|
34034
|
Discharge summary
|
report
|
Admission Date: [**2165-6-7**] Discharge Date: [**2165-6-17**]
Date of Birth: [**2111-1-2**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Central venous catheter placement, intubation, PICC line, lumbar
puncture
History of Present Illness:
54 yo F with h/o HTN, hyperlipidemia transferred to [**Hospital1 18**] after
OSH head CT was concerning for acute infarct. She reports she
has been feeling unwell over the past week with headache,
nausea/vomiting, myalgias and arthralgias. She also endorses
fevers/chills over this time period. She reports she was seen
by her PCP and was diagnosed with the "flu" and was treated with
amoxicillin. She and family report that over the past week she
has also experienced 2 episodes of slumping to the ground
without clear LOC. She has been confused following these
episodes per both patient and family. At her family's urging,
she presented to [**Hospital6 3105**] for further
evaluation. There, she underwent head CT which demonstrated a
right temporal lobe lesion concerning for acute infarct. Thus,
she was transferred to [**Hospital1 18**] for further evaluation and
management.
.
In the ED, initial vitals were T: 102.2 BP: 117/72 HR: 113 RR:
16 O2 sat: 94% RA. On exam she was noted to have a "petechial
rash" per verbal s/o (not on our exam) and developed vesicular
lesions on her palms while in the ED. UA was negative for
infection and CXR from OSH was reviewed by ED and radiology and
reportedly negative for infiltrate/acute cardiopulmonary
process. CT head from OSH was reviwed with radiology and
neurology and there was concern for infarct, abscess or mass.
Neurology was consulted and recommended MR for further
evaluation, LP, and coverage with ctx/vanco/acyclovir. They
additionally recommended EEG to r/o seizure activity given these
"drop" episodes followed by increased confusion. MRI/MRA was
performed which demonstrated marked temporal lobe edema.
Because of the edema, LP was deferred and she received empiric
rx with 2g IV ceftriaxone, 1g IV vancomycin, and 800mg IV
acyclovir. She received 4.5 L IVFs.
.
ROS: As above. Denies photophobia, Further denies CP/SOB. No
abdominal pain, no diarrhea, no blood in stool. No
dysuria/hematuria.
Past Medical History:
HTN
Hyperlipidemia (familial)
s/p hysterectomy
s/p tonsillectomy
Social History:
Lives with husband at home. Retired high school teacher. Taught
business and accounting and retired 2 years ago. Denies tobacco
and alcohol use.
Family History:
Hypercholesterolemia (paternal grandparents, daughter)
Physical Exam:
VS: T- 98.6, BP - 159/51, HR - 101, RR - 19, O2 - 100% 2 L NC
GEN: Confused, lethargic
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
NEURO: CN II-XII grossly intact, 4/5 strength in UEs. Pt. unable
to cooperate with strength testing in LEs. Brisk reflexes in
biceps, brachioradialis and patella. Downgoing toes bilaterally.
No sensory deficits to light touch appreciated.
SKIN: Discrete vesicles on hands and eczematous skin on soles,
otherwise no lesions
Pertinent Results:
[**2165-6-7**] MRA Brain w/o Contrast: (1) Extensive FLAIR signal
abnormality and mild enhancement predominantly involving the
medial temporal lobe in addition to right insula and a small
focus of the right frontal lobe. Given clinical history findings
are more likely due to herpes encephalitis. However, followup
imaging after resolution of clinical symptoms is recommended to
exclude the possibility of infiltrative glioma. (2)Multiple foci
of hyperintense FLAIR signal abnormality of white matter of both
cerebral hemispheres, with morphology and distribution more
characteristic of demyelinating disease, but given history of
hyperlipidemia and hypertension, could reflect chronic small
vessel infarction.
.
TIME-OF-FLIGHT MR ANGIOGRAPHY OF THE HEAD INCLUDING CIRCLE OF
[**Location (un) **]: The anterior and posterior circulations including circle
of [**Location (un) 431**] are patent without evidence of aneurysm, stenosis,
occlusion, dissection or vascular malformation.
.
[**2165-6-7**] CT head w/o contrast: (1) Extent of cortical and white
matter abnormality consistent with presumed herpes encephalitis
is not significantly changed in extent. However, evidence of
increased cerebral edema is noted by increased sulcal effacement
of the right parietal and right temporal lobes. (2) Comparison
difficult given difference in modality. However, mild increase
in effacement of the right perimesencephalic cistern is
concerning for developing transtentorial/uncal herniation.
.
[**2165-6-7**] EEG: Abnormal portable EEG due to the abnormal
background consisting of disorganized, low voltage fast
activity. This likely reflects medication effects from recent
benzodiazepine or barbiturate administration. There were no
areas of prominent focal slowing. There were no epileptiform
features and no electrographic seizure activity was noted. .
[**2165-6-11**] CT head w/o contrast: No interval change
.
[**2165-6-11**] CXR Portable: (1) Malpositioned right subclavian PICC
line with tip in the right atrium that needs to be retracted by
at least 7-8 cm. (2) The patient is status post extubation.
.
[**2165-6-14**] CT head w/o contrast: (1) No acute intracranial
hemorrhage. (2) No change in the large hypodense area, noted
involving the right temporal,
right inferior frontal, basal ganglia and thalamus, with mild
mass effect on the right lateral ventricle better evaluated on
prior MR study.
.
[**2165-6-15**] MRI head w/ and w/o contrast: Overall there has been no
significant change in the mass effect as well as the T2 signal
abnormalities involving the right temporal lobe, right inferior
frontal lobe and superior frontal lobe laterally as well as
subtle abnormality in the left subinsular region. On the current
examination, there appears to be slightly more distinct
enhancement visualized in the right medial temporal lobe.
However, it is unclear whether this is due to differences in
technique as only axial T1 images could be compared and the
sagittal post-gadolinium images on the current study are limited
by motion. Further followup recommended.
.
[**2165-6-15**] EEG:
Brief Hospital Course:
54 y.o. female with recent history of "drop attacks" presenting
with fever, altered mental status and temporal lobe edema on
head MRI, treated for viral (likely HSV) encephalitis
.
# Viral (likely HSV) encephalitis: Initial head imaging revealed
right temporal lobe edema and given prodromal viral syndrome
concern was for HSV meningoencephalitis. She was covered
empirically with ceftriaxone/vancomycin/acyclovir. She was
loaded with phenytoin and placed on maintenance dose. Given
edema and mass effect on initial imaging, LP was deferred in
this setting. Upon arrival to the ICU, mental status continued
to decline and she was intubated for airway protection. EEG was
performed on arrival to the ICU which revealed low voltage fast
activity which likely reflects medication effects from recent
benzodiazepine or propofol. There was otherwise no clear
epileptiform activity. Neurosurgery was consulted and
recommended mannitol which she was continued on; since having
been titrated down. Serial head CTs have been stable. ID was
also consulted and recommended continuation of acyclovir;
ceftriaxone and vancomycin were discontinued. She was extubated
successfully on [**2165-6-11**]. The patient was given Acyclovir on the
floor.
.
# Altered mental status: Most likely in the setting of HSV
meningoencephalitis. EEG without clear epileptiform activity
however has been loaded with and remains on standing dilantin
given high risk of seizures. The patient resolved her altered
mental status after dilantin and acyclovir use.
.
# Rash: Unclear etiology as it is not petechial in nature which
might be seen in a bacterial meningitis. Rash is mostly
isolated to the palms of hands and is somewhat vesicular in
nature. Viral DFA and cultures were sent and are pending.
.
# HTN: Briefly hypotensive following intubation and transiently
on neosynephrine. Neo was then restarted with goals to maintain
MAPs >60 for cerebral perfusion. She has since been weaned off
neo successfully. Antihypertensive medications have been held
in this setting.
.
Medications on Admission:
Amoxacillin 500mg PO tid
Promethazine 25mg [**Hospital1 **] prn
Atenolol 50mg PO daily
Lipitor 40mg daily
Zetia
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acyclovir Sodium 500 mg Recon Soln Sig: 1.6 Recon Solns
Intravenous Q8H (every 8 hours) for 34 doses.
Disp:*68 Recon Soln(s)* Refills:*0*
4. Heparin Flush 10 unit/mL Kit Sig: Two (2) 2mL Intravenous
every eight (8) hours: flush each port of picc line per protocol
after each use.
Disp:*QS * Refills:*2*
5. Outpatient Lab Work
Please have phenytoin level drawn first thing in the morning
prior to usual dose on Monday [**6-24**] and have this result faxed
to Dr. [**First Name4 (NamePattern1) 714**] [**Last Name (NamePattern1) 78553**] at [**Telephone/Fax (1) 891**]
6. Dilantin Kapseal 100 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary
1. Viral encephalitis (likely secondary to HSV)
Secondary
1. Hypercholesterolemia
2. Hypertension
Discharge Condition:
Hemodynamicaly stable, ambulatory
Patient to work with physical therapy as an outpatient.
Discharge Instructions:
You were admitted to an outside hospital for fevers, myalgias,
and two fainting episodes and transferred to [**Hospital1 18**] for concern
of a CT scan. Imaging and laboratory studies here indicated that
you suffered a viral encephalitis, most likely due to HSV. You
were admitted to the MICU and had a breath tube placed to
protect your airway. Your primary care team worked with teams of
neurologists and infectious disease experts to best direct your
care. You were treated for your infection, in addition to being
given medicines to prevent seizures and to lower the pressure in
your head.
Your medication regimen has changed from when you came into the
hospital. Please review you medicines carefully and take as
directed - this is very important. We also recommend that you
continue to have physical therapy as an outpatient.
Please seek immediate medical attention for the following:
fevers, headache, vision changes, extreme tiredness, fainting
spells, or for any other concerns.
Followup Instructions:
1.) ID - ID mentioned that they would set up an [**Hospital1 648**] and
time. Call ([**Telephone/Fax (1) 4170**]
2.) Neuro - Follow up [**Telephone/Fax (1) 648**] scheduled for Wednesday, [**7-17**] at 5pm on the [**Location (un) **] of the [**Hospital Ward Name 23**] building in Dr. [**Name (NI) 78554**] and Dr.[**Hospital 78555**] clinic.
3.) Primary Care Physician [**Name Initial (PRE) **] [**Name10 (NameIs) **] with Dr. [**Last Name (STitle) **]
scheduled for Monday, [**6-24**] at 10:30 AM. Location of
[**Month (only) 648**] is now at 500 [**Location (un) **] in [**Hospital1 487**], Exit 44 from
495. Please have Dilantin Level drawn before or at that
[**Hospital1 648**] before taking morning Dilantin dose (if drawing
level at [**Hospital1 648**], bring prescription sheet).
Completed by:[**2165-6-24**]
|
[
"424.0",
"518.81",
"401.9",
"348.5",
"054.3",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.04",
"96.6",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9597, 9680
|
6541, 7796
|
288, 363
|
9830, 9922
|
3428, 6518
|
10960, 11782
|
2634, 2690
|
8763, 9574
|
9701, 9809
|
8627, 8740
|
9946, 10937
|
2705, 3409
|
227, 250
|
391, 2368
|
7812, 8601
|
2390, 2456
|
2472, 2618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,505
| 148,384
|
37786
|
Discharge summary
|
report
|
Admission Date: [**2187-9-25**] Discharge Date: [**2187-10-17**]
Date of Birth: [**2114-9-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Hematemesis and hypotension
Major Surgical or Invasive Procedure:
EGD with banding
Endotracheal intubation
CVL
History of Present Illness:
73 year old gentleman with a PMH significant for MELD 21 EtOH
cirrhosis complicated by encephalopathy and varices, EtOH abuse,
HTN, and recent MVA admitted for hematemesis now transferred to
the MICU for hypotension, ARF, and leukocytosis. The patient
initially presented to an OSH after developing a large amount of
hematemesis (>1L per report) described as dark red blood with a
hct of 19. The patient intubated for airway protection and then
transferred to [**Hospital1 18**] on [**2187-9-25**]. In the ED, he was noted to have
a positive FAST exam in the RUQ with an initial hct of 21.7. Of
note, the patient was initially admitted to the T/SICU on the
trauma service as had an MVA 1 week ago and signed out AMA. He
was rescucitated with 4 units of PRBC and 2 units FFP and was
started on an octreotide gtt, protonix gtt, and ciprofloxacin
for SBP prophylaxis. He underwent upper endoscopy yesterday that
demonstrated 3 cords of grade 3 varices that were banded and a
small non-bleeding duodenal ulcer. His hematocrit has since
remained stable at 28-31. His hospital course has been
complicated by hypotension (80s/40s) requiring vasopressors with
norepinephrine and phenylephrine, a rising leukocytosis to 30.2
with a left shift, and acute renal failure with a peak
creatinine of 2.5.
.
ROS: Unable to obtain as patient is intubated.
Past Medical History:
ETOH cirrhosis with encephalopathy and continued ETOH abuse as
per PCP, [**Name10 (NameIs) **] has refused EGD in the past, no awareness of
hematemesis in the past
HTN
Hyperglycemia
Hyperlipidemia
Gout
GERD
Hiatal hernia
Cholelithiasis
Hx of traumatic fx of nose
BPH
Hx of facial erysipelas
Social History:
Unable to obtain
Family History:
Unable to obtain
Physical Exam:
98.5 94 97/45 25 100% AC 500x16,5,0.5
Gen: Intubated
HEENT: Scleral icterus, PERRL, ETT in place
CV: Nl S1+S2, II/VI systolic murmur at base.
Pulm: Bilateral rales (L>R) anteriorly
Abd: Distended, umbilical hernia, +bs. -fluid wave
Ext: 2+ pitting edema bilaterally
Neuro: Unresponsive. PERRL
Pertinent Results:
EGD [**2187-9-25**]: Varices at the middle third of the esophagus, lower
third of the esophagus and gastroesophageal junction (ligation)
Blood in the stomach body and antrum
Hiatal hernia seen
Ulcer in the first part of the duodenum
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
73M with cirrhosis, admitted with hematemesis secondary to
esophageal varices. After a prolonged MICU stay, he was
transferred to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service for further management.
.
Hematemesis/anemia: Patient found to have grade 3 varices and
duodenol ulcers [**9-25**] with banding. He was maintained on PPI,
with stable hematocrit. On [**10-1**] patient had bloody respiratory
secretions, for which he was given vitamin K (since poor
nutritional status). Bronch showed only small abrasions as
source for bleeding, likely [**3-5**] suctioning. Hematocrit,
platelets, and INR remained stable during hospital course. On
[**10-16**], patient underwent relook endoscopy which showed
improvement to grade 1 varices and no intervention was done.
Plan upon discharge was for repeat scope in 3months.
.
Liver disease/Hepatic Encephalopathy: On admission,
transaminases were mildly elevated, with elevated INR and low
albumin and worsening hyperbilirubinemia that resolved. He had
an abdominal ultrasound with dopplers on [**2187-9-26**], which showed
patent hepatic flow and minimal ascites. OGT was placed by
hepatology and he was maintained on lactulose and rifaximin
starting on [**2187-9-30**]. On transfer to floors patient had poor
mentation and was A&Ox2 and had an episode of aspiration. A
dobhoff was placed and patient was pan-cultured given
deterioration in mental status. Initial blood cultures grew out
gram positive cocci, CXR with bibasilar consolidations, echo neg
for vegetations, and patient was started on broad spec
antibiotics. Final blood cultures showed only contaminants with
coag neg staph and so antibiotics were discontinued. Patient
was agitated [**Date range (1) 84597**] and pulled out dobhoff three times,
which had to be placed ultimately by IR. Patient's mentation
improved with lactulose.
.
Hypotension: Initially patient was hypotensive likely secondary
to hypovolemia from hematemesis (large grade 3 varices of the
esophagus). On admission, patient was 1 week s/p MVA and had
positive FAST exam, but negative for acute trauma on CTA. An
echo on [**9-26**] showed preserved LVEF. Also on admission, there
was a concern for SIRS in the setting of leukocytosis and
vasopressor requirement. He was pancultured, with negative
results to date, but given a 7 day course for HAP vs SBP
(vancomycin, zosyn, and cipro from [**2187-10-2**] to [**2187-10-9**]) after
having fevers, rigors, increased sputum production and potential
aspiration pneumonia on CXR. He was maintained on MAP>65,
UOP>30 cc/hr, CVP>12, ScVO2>70 with IVF bolus, colloid/blood
products, and norepinephrine as necessary to maintain
hemodynamic goals. He was weaned off pressors on [**2187-9-28**]. Upon
transfer to the floors, hypotension resolved.
.
Respiratory Failure: Patient intubated for airway protection at
OSH. This likely was [**3-5**] fluid overload originally, but with
questionable pneumonia superimposed. He improved after diuresis
and antibiotics and was extubated on [**2187-10-7**] without difficulty.
While in the MICU his goal diuresis was 1.5-2L daily, which was
initially achieved with lasix drip. Lasix drip was discontinued
on [**2187-10-8**], as patient was making good UOP with metolazone and
spironolactone alone. Upon transfer diuretics were held given
hypernatremia (see below). Patient also had episode of
aspiration in the MICU and on the floor and was placed on
aspiration precaution. As mentation improved patient was
cleared by speech and swallow.
.
Acute renal failure: Creatinine has trended down from peak of
2.5 on admission to 1.4-1.5 during later part of stay in MICU.
He had been started on midodrine, octreotide, and albumin for
possible HRS, but these were discontinued on [**2187-9-29**]. Upon
transfer to the floors, metolazone was held. The patient's
creatine trended down to 1.1 on discharge.
.
CV: Patient with ECG on admission without acute ST-T wave
changes suggestive of ischemia. Cardiac biomarkers during
admission with elevated CK in 400s with flat MB (CK 578 on
[**1-8**]) but with rising TnT 0.08->0.19 suggesting demand ischemia
and/or impaired clearance in setting of ARF. TnT did trend down
and ECG's normalized.
.
Hypokalemia, Hypernatremia: Patient was persistently hypokalemic
towards end of MICU stay, likely secondary to lasix drip. He was
requiring IV and PO potassium repletion daily. Upon transfer,
his lasix drip had been stopped and potassium levels remained
within normal limits. Upon transfer patient had hypernatremia
secondary to aggressive diuresis while in the ICU. Lasix and
metolazone were not restarted, and patient was corrected with
free water fluids.
.
Nutrition: OGT was placed by hepatology and he was maintained on
lactulose and rifaximin starting on [**2187-9-30**]. Upon transfer
patient had episode of witnessed aspiration, put on aspiration
precaution and dobhoff was placed. Dobhoff was pulled by
patient as he was agitated and had to be replaced by IR twice.
On discharge patient passed speech and swallow and was able to
take in POs.
.
Thrombocytopenia: Likely secondary to sequestration in setting
of liver disease and portal hypertension. Platelets remained
stable during her stay.
.
Medications on Admission:
Medications (home): obtained from family
Lactulose - dose unknown
Omeprazole 20 mg
Allopurinol 300 mg
Tramadol 50 g
Metolazone 2.5 mg
Ferrous Sulfate 325 mg
Celebrex 200 mg
Spironolactone 25 mg
Bumetanide 2 mg
Benicar 20 mg
Potassium 20 mEq
.
Medications (on transfer):
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Ciprofloxacin 400 mg IV Q12H
Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION
Insulin SC
Calcium Gluconate IV Sliding Scale
Magnesium Sulfate IV Sliding Scale
Midazolam 2-4 mg IV Q2H:PRN anxiety
Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP > 60
Octreotide Acetate 50 mcg/hr IV DRIP INFUSION
Pantoprazole 8 mg/hr IV INFUSION
Potassium Chloride IV Sliding Scale
Potassium Phosphate IV Sliding Scale
Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation
.
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID (4 times
a day): Please titrate to 3 bowel movements daily.
2. Pantoprazole 40 mg Recon Soln Sig: One (1) dose unit
Intravenous twice a day.
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] hospital
Discharge Diagnosis:
1. Esophageal variceal bleed
2. Cirrhosis
Discharge Condition:
Stable vital signs: Afebrile, normotensive, breathing
comfortably on RA
~600cc stool/day via flexiseal
Euvolemic to slightly negative fluid balance
Mental status: alert and oriented x3, at his best when his
family is at the bedside, at his worst at night. Some daytime
somnolence.
Portuguese speaking only
Discharge Instructions:
You were admitted with bleeding from your esophagus, from
varicose veins. We placed "bands" around these bleeding veins
to prevent further bleeding, and this improved your condition.
You will need to have another endoscopy in three months
re-evaluate these veins, and ensure that they continue to do
well.
.
We made the following changes in your medications:
1. You should increase your omeprazole from 20mg once daily to
40mg twice daily when you leave rehab
2. We have stopped your tramadol and celebrex
3. We are holding your metolazone, bumex, and lasix. The lasix
may be restarted in rehab
4. We stopped your iron pills, as these may cause constipation
5. We stopped your benecar, as you blood pressure was normal
6. We stopped your potassium supplement.
7. We started a medication called rifaximin, which will help
with your cirrhosis
8. We started a medication called nadolol, which will help
prevent your varices from bleeding again
9. We started vitamins called folic acid.
.
Please follow up as indicated below.
.
If you develop further bleeding with vomiting, black or bloody
stools, dizziness, abdominal pain, confusion, or any other
concerning symptoms, please return to the emergency room to be
evaluated.
Followup Instructions:
When you complete your rehabilitation, please call our
hepatology clinic and make an appointment to see one of our
hepatologists regarding your diagnosis of cirrhosis, the phone
number here is [**Telephone/Fax (1) 84598**]
You have an appointment to have a repeat endoscopy on Wednesday
[**1-16**] at 12:30PM. Their phone number is [**Telephone/Fax (1) 463**]
Completed by:[**2187-11-2**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
494
| 146,035
|
43465
|
Discharge summary
|
report
|
Admission Date: [**2171-12-19**] Discharge Date: [**2171-12-25**]
Date of Birth: [**2109-12-22**] Sex: F
Service: MEDICINE
Allergies:
Captopril / Vancomycin / Dapsone
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Lightheadedness/Dizziness, SOB on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 year-old woman with diabetes mellitus type I, ESRD s/p kidney
and pancreas transplant in [**2159**], HTN, CAD p/w lightheadedness x
one and a half weeks after a normal colonoscopy and endoscopy
s/p biopsy [**12-9**]. Vague historian. She states that over the past
3 days her lightheadedness has worsened. Specifically, when she
stands from a seated position, she feels weak and lightheaded.
She denies feeling like this before and admits to it starting in
the setting of her bowel prep last week. She noted that she
"lost a lot of fluid". Also notes SOB on walking 25yrds -
previously could walk100yrds (1 block) without having to stop
due to SOB. Recently changed from Bactrim to Dapsone [**12-3**] by
ID.
In the ED, initial VS: 98.8 88 169/70 18 93% RA. Desaturating to
low 90s on room air at rest. Came up with oxygen. Initial trop
negative. EKG unchanged. D-dimer negative. CXR with no
consolidation. Has a new anemia with Hct 27.5 (prior Hct [**7-30**]
34.0). She was guaiac negative.
Vitals prior to transfer: 82 149/80 18 92% 2L.
Currently, patient continues to be hypoxic at 89% on RA. Denies
feeling SOB. Denies cough/fever. [**Last Name (un) 25177**] noted painful R shoulder
with restricted elevation past 2 months.
ROS: Denies fever, chills, night sweats, 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:
- Diabetes mellitus type I
- ESRD
- S/p pancreas/kidney transplant in [**2159**]
- CAD - cath [**5-22**] - LAD - distal 60% stenosis distally before
the apex, LCx - 50% stenosis in one branch, RCA - dominant
vessel with mild diffuse disease, PDA - 70% mid-vessel stenosis
- ECHO [**11-23**] LVEF > 55%, PFO present
- History of obstructive cardiomyopathy (LV outflow tract with a
41 mm Hg gradient at rest)
- HTN
- Hypercholesterolemia
- Previous PCA stroke
- SCCA vulva s/p vulvectomy
- Anemia
- Vit D deficiency
- Hx of spetic knee in [**10-23**] - asp grew strep viridans
- Chronic UTIs - hx of MRSA UTI, on supressive therapy
- Acute neutrophilic esophagitis awaiting fungal cultures seen
on recent endoscopy [**12-9**]
Social History:
Pt was a pediatrician in Russian, came to US many years ago.
Lives alone in [**Location (un) **]; she has a male partner.
She has never smoked and does not drink.
No reecnt foreign travel.
Pets - 1 cat well
Family History:
Mother and father bot died of old age at 86
2 sisters - well
Physical Exam:
Admission:
VS - Temp 99.2 F, BP149/80 , HR80 , R21 , O2-sat 93% % 5L
GENERAL - Sallow complexion, comfortable, appropriate
HEENT - NC/AT, Bilat irregular and fixed pupils [**2-19**] cataract
ops, EOMI, sclerae anicteric, MMM, OP clear. Bilat partial
ptosis
NECK - supple, no thyromegaly, no JVD, no carotid bruits Bilat
ant cervical LAD
LUNGS - Decreased BS at bases with slight R pleural friction rub
HEART - PMI non-displaced, RRR, ?ESM radiating into carotids
with PSM radiating into axilla, nl S1-S2. Prominent jugular
venous pulsation
ABDOMEN - NABS, soft/NT/ND, no HSM, no rebound/guarding.
Bilateral IF scars from transplants [**Last Name (un) **] bruit over transplanted
kidney in LIF.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII normal - no apparent worsening
ptosis on prolonged upgaze, muscle strength 5/5 throughout in LL
but marked proximal weakness in UL with restricted R shoulder
elevation and [**4-22**] in s abduction both sides, sensation grossly
intact throughout, DTRs 2+ and symmetric, cerebellar exam
normal, gait not assessed
Pertinent Results:
Admission labs
[**2171-12-19**] 12:30PM BLOOD WBC-4.7 RBC-3.02* Hgb-9.0* Hct-27.5*
MCV-91 MCH-29.8 MCHC-32.8 RDW-13.9 Plt Ct-162
[**2171-12-19**] 12:30PM BLOOD Neuts-76.6* Lymphs-16.8* Monos-5.8
Eos-0.1 Baso-0.6
[**2171-12-19**] 12:30PM BLOOD PT-12.5 PTT-25.8 INR(PT)-1.1
[**2171-12-19**] 12:30PM BLOOD Glucose-104* UreaN-29* Creat-1.0 Na-144
K-4.3 Cl-107 HCO3-28 AnGap-13
[**2171-12-19**] 12:30PM BLOOD ALT-12 AST-16 AlkPhos-76 TotBili-0.8
[**2171-12-19**] 12:30PM BLOOD Lipase-99*
[**2171-12-19**] 12:30PM BLOOD cTropnT-<0.01
[**2171-12-19**] 02:43PM BLOOD D-Dimer-245
ABGs
[**2171-12-19**] 08:30PM BLOOD Type-ART pO2-87 pCO2-36 pH-7.48*
calTCO2-28 Base XS-3 Intubat-NOT INTUBA
[**2171-12-19**] 10:12PM BLOOD Type-ART Temp-37 pO2-73* pCO2-40 pH-7.46*
calTCO2-29 Base XS-4 Intubat-NOT INTUBA
[**2171-12-19**] 08:30PM BLOOD Lactate-1.00
[**2171-12-19**] 10:12PM BLOOD O2 Sat-79
[**2171-12-20**] 12:34AM BLOOD Type-ART Temp-36.7 pO2-67* pCO2-41
pH-7.45 calTCO2-29 Base XS-3 Intubat-NOT INTUBA
[**2171-12-20**] 12:34AM BLOOD O2 Sat-79 COHgb-2 MetHgb-13*
[**2171-12-21**] 01:09AM BLOOD O2 Sat-87 COHgb-2.8 MetHgb-8.9*
Other labs
[**2171-12-20**] 07:20AM BLOOD Albumin-3.4* Calcium-8.1* Phos-3.9
Mg-1.5* Iron-177*
[**2171-12-20**] 07:20AM BLOOD calTIBC-220* Hapto-27* Ferritn-210*
TRF-169*
[**2171-12-19**] 02:43PM BLOOD D-Dimer-245
[**2171-12-20**] 07:20AM BLOOD Ret Aut-2.7
[**2171-12-24**] 07:15AM BLOOD Cyclspr-75*
[**2171-12-21**] 12:58AM BLOOD VitB12-278 Folate-9.2 Hapto-7*
[**2171-12-22**] 06:20AM BLOOD METHYLMALONIC ACID- 368 H
Urine
[**2171-12-19**] 03:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2171-12-19**] 03:45PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
[**2171-12-19**] 03:45PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2171-12-19**] 03:45PM URINE Mucous-MANY
Radiology
XR CHEST (PA & LAT) [**2171-12-19**]:
IMPRESSION: No acute cardiopulmonary abnormality. Chronic
blunting of the
right costophrenic angle.
XR SHOULDER [**2-20**] VIEWS NON TRAUMA RIGHT [**2171-12-20**]:
IMPRESSION: Mild degenerative disease and possible loose body in
the
glenohumeral joint.
Cardiology
TTE (Congenital, complete) Done [**2171-12-20**] at 10:20:00 AM
The left atrium is elongated. A patent foramen ovale is present.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Patent foramen ovale with mild right-to-left
shunting. Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
mitral regurgitation.
Compared with the prior study (images reviewed) of [**2171-2-22**], PFO
is identified. The other findings are similar.
PFTS [**2171-12-20**]: REPORT PENDING
[**2171-12-25**] 10:55AM BLOOD WBC-5.9# RBC-3.93*# Hgb-11.7*# Hct-35.0*#
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.0 Plt Ct-177
[**2171-12-23**] 01:30PM BLOOD I-HOS-EAST
Brief Hospital Course:
61 yo F h/o DMT1 s/p kidney/renal transplant, CAD, HTN p/w one
and a half weeks of lightheadedness and new onset hypoxia felt
to be methemoglobinemia. Pulmonary Medicine was consulted and
it was suspected that this was due to recent dapsone therapy, so
dapsone was discontinued. She was transferred with the
anticipation of treating with methylene blue, however this was
withheld as her concentration was <20%. She did not receive
methylene blue during this admission. Her hypoxia was noted to
gradually improve and she was satting 96% RA at the time of
discharge. Vitamin C therapy initiated as it has been shown to
have some benefit in methemoglobinemia.
Due to the discontinuation of Dapsone, Atovaquone was started
for PCP [**Name Initial (PRE) 1102**].
Additional considerations regarding her hypoxia were as follows:
1) cardiac - PFO - echo [**12-20**] showed mild right-to-left shunt
2) Pulmonary - previous restrictive lung disease - PFT RESULTS
PENDING
3) Methemogobinemia - Dark blood despite relatively preserved
pO2 and low O2 sat on ABG - MetHb 13% on ABG and pulmonary felt
this in setting of anemia is the likely diagnosis. ABG on air
[**12-19**] pH 7.46 pCO2 40 pO2 73 HCO3 29 BaseXS 4 - Low sO2 79 on air
with pO2 73. Rpt ABG on RA - pH 7.45 pCO2 41 pO2 67 HCO3 29
BaseXS 3 COHb: 2 MetHb: 13 O2Sat: 79.
The methemoglobinemia was considered to be the most likely
etiology of her hypoxia, despite the above considerations.
# Hypertension / Orthostatic hypotension:
Pt was noted to have ongoing symptoms of orthostasis, with
significant dizziness with standing, despite continuing her home
florinef dose. Her orthostasis did not adequately respond to
IVF boluses. Her metoprolol dose was decreased from 25 mg po
BID to 12.5 mg po BID, and her amlodipine was discontinued, but
she continued to feel lightheaded. Hematology was consulted for
anemia, (see below), and her lightheadedness resolved with
transfusion of 2 units PRBC.
.
# Anemia, multifactorial
Pt was noted to have progressive anemia, with noted low
haptoglobin, and mildly elevated LDH. The remaining labs were
unimpressive for hemolysis, so Hematology was consulted for
further evaluation. After full evaluation, including review of
peripheral smear, it does NOT appear that she had any
significant hemolysis. She had a low normal B12 level, but her
methylmalonic acid was elevated, suggestive of b12 deficiency.
She was started on oral B12 replacement, which she will continue
as an outpatient. Her iron and folate levels were normal.
.
# Chronic UTIs (hx MRSA UTIs):
Pt has a history of chronic UTI's, for which she is on
Methenamine as an outpatient. Her prophylactic antibiotics were
held during the admission, as it is non-formulary, and there was
not a reasonable substitute. She will resume her home
Methenamine at discharge.
.
# History of renal and pancreas transplant:
Pt was followed by the Renal Transplant service through the
hospitalization. She was continued on her home cellcept,
Prednisone, and cyclosprine. Her Sensipar was discontinued per
Renal. She continued bicarbonate.
Her cyclosporine level was 75; which is appropriate. This was
confirmed with Renal Transplant, and she will continue her
current dose.
.
# Diabetes mellitus type 1 s/p pancreas transplant [**2159**]
- glucose remained well controlled without insulin.
.
# # Acute neutrophilic esophagitis -
Pt was noted to have had a recent EGD with biopsy which showed
neutrophilic esophagitis. Note that the PAS plus diastase stain
was negative for fungal infection. She will continue PPI and
sucralfate for esophagitis.
.
# Coronary artery disease: Continued Aspirin, Plavix,
Pravastatin, and her Metoprolol dose was decreased due to
orthostasis.
.
# Chronic SOB: Known restrictive ventilatory deficit. Pt had
PFT's performed, although the report is currently unavailable.
Her breathing was stable at the time of discharge, and was
satting well on room air.
.
# History of obstructive cardiomyopathy (LV outflow tract with a
41 mm Hg gradient at rest)
Note that her metoprolol dose was decreased during the admission
due to orthostasis, which seemed to improve with blood
transfusion. Due to her LV outflow tract limitation, she may
benefit from uptitration of her metoprolol back to her home dose
as an outpatient.
.
# Vit D deficiency:
- continue Weekly vitamin D per PCP.
.
# Full code
# [**Year (4 digits) **]: discharged to home
Medications on Admission:
Medications - Prescription
AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth once a day
CINACALCET [SENSIPAR] - (Dose adjustment - no new Rx) - 30 mg
Tablet - 1 Tablet(s) by mouth twice a day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth daily
CYCLOSPORINE MODIFIED [GENGRAF] - 25 mg Capsule - 3 Capsule(s)
by
mouth twice per day
DAPSONE - 100 mg Tablet - 1 Tablet(s) by mouth daily replaces
Bactrim (trimethoprim/sulfamethoxazole)
ECONAZOLE - 1 % Cream - apply to fingers twice daily
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - 50,000 unit Capsule - 1 Capsule(s) by mouth weekly
FLUDROCORTISONE - 0.1 mg Tablet - 2 Tablet(s) by mouth once a
day
METHENAMINE HIPPURATE - 1 gram Tablet - 1 Tablet(s) by mouth
daily
METOPROLOL TARTRATE - (Dose adjustment - no new Rx) - 25 mg
Tablet - 1 Tablet(s) by mouth two times daily
MYCOPHENOLATE MOFETIL - 500 mg Tablet - 1 Tablet(s) by mouth
twice a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth before diarrhea
PRAVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 1 mg Tablet - 4 Tablet(s) by mouth every day
SUCRALFATE - (Not Taking as Prescribed: 10mL TID) - 1 gram/10 mL
Suspension - 20 mL(s) by mouth twice a day as needed for as
needed for pain Take 15 min before breakfast and dinner
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet - 1 Tablet(s) by mouth daiily
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH TEST] - Strip - qid qid as
directed box of 100 strips for "one touch 2"
CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - 315 mg-200 unit
Tablet - 2 Tablet(s) by mouth twice a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day
SODIUM BICARBONATE - (Dose adjustment - no new Rx) - 650 mg
Tablet - 8 Tablet(s) by mouth three times a day
Discharge Medications:
1. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. cyclosporine modified 25 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours).
4. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
[**Year (4 digits) **]:*QS 1 month* Refills:*0*
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Year (4 digits) **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
8. sucralfate 100 mg/mL Suspension Sig: Twenty (20) mL PO twice
a day as needed for pain.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. sodium bicarbonate 650 mg Tablet Sig: Eight (8) Tablet PO
TID (3 times a day).
12. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO
once a day.
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*0*
14. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
twice a day.
15. pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Vitamin C 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO twice a day for 1 weeks: You may purchase over the
counter.
17. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily): Take 2 tabs po q day x 6 days, then 2
tabs po q Week until instructed to stop by PCP.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Methemoglobinemia
- Anemia, multifactorial
SECONDARY DIAGNOSES:
- Diabetes mellitus type I s/p pancreas transplant
- End stage renal disease s/p renal transplant
- Recurrent urinary tract infection
- Coronary artery disease
- Chronic shortness of breath
- Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were diagnosed with methemoglobinemia, a condition likely
caused by the medication called Dapsone. Dapsone was stopped
and vitamin C was started, a treatment for that condition. You
were evaluated for treatment with methylene blue, but you did
not require this. You were aslo found to be anemic, and you
received a blood transfusion and were started on B12. Your
immunosuppresants put you at risk for recurrent infections. In
place of Dapsone, the medicine called Atovaquone was started to
protect you from infections, and you will resume your
methenamine as an outpatient.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2172-1-9**] at 11:40 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"285.9",
"745.5",
"E931.8",
"414.01",
"268.9",
"289.7",
"V42.0",
"V10.44",
"530.12",
"425.4",
"401.9",
"V42.83"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15550, 15556
|
7494, 11909
|
339, 345
|
15899, 15899
|
4121, 7471
|
16656, 16993
|
2845, 2907
|
13792, 15527
|
15577, 15642
|
11935, 13769
|
16050, 16633
|
2922, 4102
|
15663, 15878
|
257, 301
|
373, 1858
|
15914, 16026
|
1880, 2605
|
2621, 2829
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,622
| 135,960
|
37494
|
Discharge summary
|
report
|
Admission Date: [**2179-2-9**] Discharge Date: [**2179-2-18**]
Date of Birth: [**2128-7-17**] Sex: M
Service: MEDICINE
Allergies:
Ketorolac / Codeine
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Variceal Bleed
Major Surgical or Invasive Procedure:
TIPS
Intubation
[**Last Name (un) **] Placement
History of Present Illness:
This is a 50 year old male with history of cirrhosis secondary
to alcohol and hep C who was admitted to [**Hospital 8641**] Hospital 2 [**1-30**]
weeks ago for a variceal bleed. He underwent an EGD on that day
and underwent banding. He had some further bleeding on the day
of admit and underwent another EGD and had some more banding.
He was eventually intubated for alcohol withdraw. On [**2179-2-8**]
durring the day it was noticed that his hb was dropping (9.3
from 10). He was started on an octreotide drip and his hb
continued to drop to 7.3. He was Tx 2U PRBC and at approx 2am
had an episoide of bright red bloody emesis. He was taken for
an emergent EGD which showed no active bleeding but ulcers in
the EG junction where his prior banding was. There was some
venous blood seen that was not bleeding. An attempt was made to
sclerose blood at which point the venous blood started activly
bleeding. It was unable to be controlled endoscopically. A
[**State **] was placed in the operating room. A cordis was
placed. Patient recieved 7U PRBC and 4 U FFP. He recieved 1g
Anfec in the ED. He was paralized with Vec for the Minessota
tube placement. He was then transferred to [**Hospital1 18**] for further
management of his bleeding and anticipated TIPS placement.
Past Medical History:
Past Medical History:
- Cirrhosis (alcoholic/HCV)
- Hepatitis C virus
- Type II diabetes mellitus
- Alcohol abuse
Social History:
Patient is not married but has a girlfriend who works as a
nurse. He has a 13-year old daughter of whom he has sole custody
(her mother is about to go to prison); she is currently staying
with his 80-year old mother. [**Name (NI) **] is an active drinker of alcohol
with a history of abuse.
Family History:
Non-contributory.
Physical Exam:
General: sedated.
HEENT: Intubated. [**State **] tube in place. Sclera anicteric,
MMM.
Neck: supple, difficult to assess JVP.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Dullness to percussion b/l on flanks consistent with ascities.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs On Admission:
[**2179-2-9**] 07:08AM FIBRINOGE-210
[**2179-2-9**] 07:08AM PT-16.1* PTT-35.8* INR(PT)-1.4*
[**2179-2-9**] 07:08AM PLT COUNT-150
[**2179-2-9**] 07:08AM WBC-18.6* RBC-3.07* HGB-9.5* HCT-26.8* MCV-87
MCH-30.8 MCHC-35.2* RDW-15.7*
[**2179-2-9**] 07:08AM ALBUMIN-2.3* CALCIUM-7.4* PHOSPHATE-5.1*
MAGNESIUM-1.8
[**2179-2-9**] 07:08AM ALT(SGPT)-36 AST(SGOT)-63* LD(LDH)-289* ALK
PHOS-121 TOT BILI-4.1*
[**2179-2-9**] 07:08AM estGFR-Using this
[**2179-2-9**] 07:08AM GLUCOSE-170* UREA N-23* CREAT-1.1 SODIUM-141
POTASSIUM-5.3* CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
[**2179-2-9**] 07:50AM freeCa-0.96*
[**2179-2-9**] 07:50AM TYPE-[**Last Name (un) **] TEMP-37.4 PH-7.37 COMMENTS-GREEN TOP
[**2179-2-9**] 10:00AM URINE MUCOUS-FEW
[**2179-2-9**] 10:00AM URINE HYALINE-107*
[**2179-2-9**] 10:00AM URINE RBC-9* WBC-11* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-1
[**2179-2-9**] 10:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-2* PH-5.5
LEUK-NEG
[**2179-2-9**] 10:00AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2179-2-9**] 10:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2179-2-9**] 10:00AM URINE GR HOLD-HOLD
[**2179-2-9**] 10:00AM URINE HOURS-RANDOM
[**2179-2-9**] 10:00AM URINE HOURS-RANDOM
Labs On Discharge:
[**2179-2-18**] 05:50AM BLOOD WBC-9.3 RBC-3.02* Hgb-9.1* Hct-27.2*
MCV-90 MCH-30.1 MCHC-33.4 RDW-18.1* Plt Ct-162
[**2179-2-18**] 05:50AM BLOOD PT-19.3* PTT-42.4* INR(PT)-1.8*
[**2179-2-18**] 05:50AM BLOOD Glucose-128* UreaN-16 Creat-1.0 Na-137
K-3.9 Cl-105 HCO3-25 AnGap-11
[**2179-2-18**] 05:50AM BLOOD ALT-48* AST-71* AlkPhos-143* TotBili-6.9*
[**2179-2-18**] 05:50AM BLOOD Calcium-7.0* Phos-2.6* Mg-1.8
Studies:
ECG [**2179-2-9**]: Sinus tachycardia with delayed R wave transition.
Low limb lead voltage. No previous tracing available for
comparison.
CXR [**2179-2-9**]: FINDINGS: AP single view of the chest has been
obtained with patient in supine position. Right caliber special
tube has been introduced, reaching far below the diaphragm and
terminating out of the caudal border of the image. Moderately
inflated balloon surrounds the tube at the level of the hiatus,
occupying the upper portion of the stomach fundus. The patient
is intubated, the ETT terminating in the trachea some 5 cm above
the level of the carina. No pneumothorax is identified.
Pulmonary vasculature not congested. Heart size is moderately
enlarged with a marked prominence of left ventricular contour,
as well as that of the ascending aorta. Pleural effusion.
IMPRESSION: Moderate inflation of balloon of gastric tube
occupying the hiatal area.
ABDOMINAL US with Doppler [**2179-2-9**]:
IMPRESSION:
1. Patent hepatic vasculature.
2. Splenomegaly.
3. Large amount of ascites.
4. No liver lesion identified and no biliary dilatation.
TIPS [**2179-2-9**]:
Successful placement of TIPS; paracentesis with 3 L removed.
Post-TIPS
portosystemic gradient of 15 mmHg; however, minimal inflow of
varices on
post-TIPS portal venogram.
Paracentesis [**2179-2-9**]:
IMPRESSION:
1. Successful TIPS placement using 7+2, 10mm Viatorr stent
angioplasty to 10 mm.
2. Post-TIPS transhepatic portography with hemodynamics
demonstrating final portosystemic gradient of 15 mmHg (pre-TIPS
portosystemic gradient of 17 mmHg).
3. Placement of triple-lumen central venous line via the right
internal jugular access.
4. Portogram showing brisk flow up stent and substantial
reduction in flow to the coronary vein varix post-TIPS
placement.
5. Paracentesis with removal of 3 liters of clear yellow ascites
fluid.
Abdominal US with Doppler [**2179-2-14**]:
IMPRESSION:
1. Patent TIPS with appropriate directionality and flow in the
portal venous vasculature.
2. Cirrhosis, ascites.
3. Gallbladder wall edema and distention without cholelithiasis.
Findings
are nondiagnostic for acute cholecystitis given underlying
hepatic dysfunction can explain gallbladder wall changes due to
third spacing and distension may be due to a fasting state.
Clinical correlation or HIDA san as necessary is recommended.
Diagnostic paracentesis (US guided) [**2179-2-17**]:
IMPRESSION: Uncomplicated diagnostic and therapeutic
ultrasound-guided paracentesis with removal of 1250 mL of clear
yellow fluid.
Chest X-ray [**2179-2-17**]:
FINDINGS: In comparison with study of [**2-10**], there is continued
enlargement of the cardiac silhouette with left ventricular
prominence. The [**Last Name (un) **] tube has been removed. Some
atelectatic changes are seen at both bases. On the lateral view,
there are substantial pleural effusions bilaterally. No evidence
of acute focal pneumonia.
Microbiology:
Blood cx 1/4 bottles positive for enteroccous faecium
(sensitive) on [**2-9**]
Blood cx negative or NGTD from [**2-9**], [**2-10**], [**2-11**], [**2-13**], [**2-17**]
MRSA screen negative
Urine cx negative [**2-17**]
Peritoneal gram stain negative for organisms/PMNs [**2-17**] (cx
pending)
Brief Hospital Course:
50 yo M ELSD secondary to EtOH abuse admitted to OSH with
variceal bleed s/p EGD with banding x2 and subsequent alcohol
withdrawal transferred to [**Hospital1 18**] for management of recurrent
refractory UGIB s/p [**State **] tube placement and subsequent
removal one day later. TIPS performed although with modest drop
in gradient s/p procedure. Hct stable. Found to have AMS,
generating concern for benzo withdrawal vs. hepatic
encephalopathy. The following problems were addressed at this
admission:
# UGIB: Source was seen on endoscopy at OSH which was venous
blood that was attempted to be sclerosed, bu then opened up. GE
ulcers also seen on previous banding sites that were
non-bleeding. Patient had banding x2 at OSH. He received 7U
pRBCs and 4 FFP at OSH, and then was transferred here for
further management after a [**State **] tube was placed. He
received 2 more units of pRBC here and underwent TIPS.
Hematocrit remained stable the rest of patient's MICU stay, and
he remained hemodynamically stable. TIPS was performed [**2-9**],
[**State **] tube removed [**2-10**]. We continued PO PPI [**Hospital1 **] and treated
GIB with ceftriaxone. Patient continued to remain stable.
Ultrasound to evaluate TIPS patency on [**2-14**] showed patent TIPS.
Patient was transferred to the floor on [**2-15**]. He had stable Hct
and no further evidence of bleed.
# AMS: Patient had AMS s/p extubation. It was classic for
delirium; he had been picking at sheets, inattentive and showed
fluctuating mental status. Thus, was encephalopathic but without
asterixis and less likely due to hepatic dysfunction.
Respiratory status and renal function are also good. Given
alcohol history, also considered Korsakoff. We had obtained B12,
TSH. We continued Lactulose, Rifaximin, thiamine and PO Ativan
CIWA. On the floor, his mental status improved and he was
attentive and responding to questions appropriately. He was
oriented to person and place but was unable to correctly state
date and still displayed occasional word-finding difficulties
(e.g. In response to "What month is this?" he would answer "The
first one.").
# Positive blood culture. Patient had 1/4 bottles positive for
enterococcus faecium on [**2-9**]. All other cultures were negative.
This was felt to be possibly a contaminant. He was treated with
a 6-day course of vancomycin.
# Volume overload. Patient has ascites (1200 cc removed [**2-17**])
and peripheral edema, which may have been exacerbated by
pRBC/FFP/fluid rescusitation during his bleed. He will be
discharged on Lasix 40 mg PO daily and spironolactone 50 mg PO
daily with plan to monitor electrolytes, renal function and
increase as needed. Most recently, patient's weight is down 0.5
kg on this regimen over past 24 hours.
# Respiratory status: It was unclear whether the patient was
intubated for EtOH withdrawal or for EGD. Patient had received
paralysis for EGD and [**Location (un) **]. He was extubated successfully
and has had [**Last Name **] problem with oxygenation and no subjective SOB.
He received a 5 day course of ceftriaxone for ? infiltrate
(stopped on [**2-15**]).
# Cirrhosis: Secondary to alcohol and hepatitis C. Unclear if
patient listed on transplant list. As he has been an active
drinker, he is not currently a transplant candidate but this may
be considered if he is able to successfully quit drinking
alcohol in the future.
# EtOH withdrawal: The patient had a high benzodiazepine
requirement at the OSH. He required intubation and multiple
drips. Here, he was continued on thiamine, folate, and CIWA
scale; at the time of discharge he was still mildly confused but
otherwise not showing signs of active withdrawal.
# Hepatitis C virus: Likely contributing to cirrhosis. Unclear
if he has been treated in the past.
# Diabetes mellitus: The patient was placed on an insulin
sliding scale for the duration of his stay.
Medications on Admission:
Flexeril
Neurontin
Insulin
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO TID
(3 times a day).
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Insulin Lispro 100 unit/mL Solution Sig: According to sliding
scale Subcutaneous ASDIR (AS DIRECTED).
7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY:
- Esophageal variceal bleed
- Hepatic encephalopathy
- Alcoholic/HCV cirrhosis
SECONDARY:
- Alcoholism
- Diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes (has not been able to state
date correctly, but oriented to person/place)
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - PT consult has recommended walking
with supervision until discharged home to prevent falls
Discharge Instructions:
You were transferred to the medical intensive care unit at [**Hospital1 1535**] after efforts to stop massive
bleeding from esophageal varices were unsuccessful at [**Hospital 8641**]
hospital. You underwent a procedure called TIPS placement which
allowed the bleeding to stop. You received transfusion of two
units of red blood cells while you were here, and your blood
levels stabilized. Your breathing tube was removed the
following day. After one week, you were transferred out of the
ICU to the liver service [**Hospital1 **]. Initially, you were very sleepy
and confused, but you steadily became more clear-headed.
At your request, we have arranged for you to be transferred back
to [**Location (un) 3844**].
Please note that it is extremely important that you stop
drinking alcohol. Even a small amount will be very dangerous to
your liver. As our social workers have discussed, there are many
resources to support you in your decision to stop drinking
alcohol. Please ask any of your health care providers for
additional hellp if you feel that you need it.
Followup Instructions:
Please follow up as directed following your discharge from
[**Hospital 8641**] Hospital.
Completed by:[**2179-2-18**]
|
[
"250.00",
"456.20",
"070.54",
"789.59",
"571.2",
"572.2",
"303.90",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.1",
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12398, 12413
|
7730, 11612
|
294, 343
|
12590, 12590
|
2706, 2711
|
13985, 14105
|
2117, 2136
|
11689, 12375
|
12434, 12569
|
11638, 11666
|
12893, 13962
|
2151, 2687
|
240, 256
|
4068, 7707
|
371, 1656
|
2725, 4049
|
12605, 12869
|
1700, 1793
|
1809, 2101
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,562
| 177,344
|
51899
|
Discharge summary
|
report
|
Admission Date: [**2133-5-29**] Discharge Date: [**2133-6-3**]
Date of Birth: [**2067-7-20**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Iodine; Iodine Containing / Tetracyclines /
Macrodantin / Flexeril / Keflex
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
fatigue and bradycardia
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
The patient is a 65 year old woman with multiple medical
problems most notably CHF (EF 40-45%), DM2, seizure disorder,
multiple admissions for bradycardia presenting with bradycardia.
She was just discharged from [**Hospital1 18**] on [**2133-5-4**] at which time she
presented with bradycardia and weakness. At that time the
bradycardia was junctional escape and self resolved during the
hospital stay. Per discharge notes, the bradycardia was
attributed to Zoloft which was held on admission and removed
from her medication list. The patient states that she has not
taken any of the Zoloft or her prior metoprolol which had been
discontinued in [**1-24**] after being admitted with bradycardia.
When returning home from breakfast she noted progressive
weakness. She also had sudde onset of shortness of breath and
right sided chest pain. The pain happened both at rest and with
exertion. The pain was worse with deep breathing. The pain
radiated to her neck and both shoulders. The pain was a
tightness. She noted that she was so weak that she could only
take a nap. When her boyfriend found her she was too weak to
transfer to her wheelchair, so EMS was called. She states that
she takes all of her medications daily with the help of a nurse
who lays them out for her in medication boxes. She denies
getting confused and taking extra doses of medication. She
states that she took her blood sugar this morning but does not
remember the value.
.
Initial vital signs in the ED were [**Age over 90 **]F 36 117/61 12 99%RA. An
EKG showed junctional bradycardia @30-40 with no ischemic
changes seen.
A head CT was unremarkable.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, black stools or red stools. She denies recent
fevers, chills or rigors. She has no dysuria or abdominal pain.
She denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, syncope or presyncope.
Past Medical History:
# skin cancer s/p resection to right temple ([**5-26**])
# bradycardia
# CHF ([**2129**]: EF 40-50%)
# HTN
# Asthma
# DM2 with peripheral neuropathy
# Grand mal seizures [**12-20**] MVA [**2103**]
# Depression
# B total knee replacement ([**2120**])
# L4-L5 lumbar laminectomy, L4-L5 diskectomy, and foraminotomy
(L5-S1) [**12-20**] lumbar spinal stenosis
# Hip pinning
# L2 compression fracture [**12-20**] fall from height ([**10/2131**])
# LBKA [**12-20**] train accident ([**1-/2132**])
# Barrett's esophagus
# Diverticulosis, diverticulitis
# Lower GI bleed ([**2130**])
# Appendectomy (remote)
# Laparascopic cholecystectomy (remote)
# Peptic ulcer disease
# Kidney trauma [**12-20**] MVA requiring surgeries, unclear procedures
# Bladder reconstruction (remote)
# Total abdominal hysterectomy, unilateral oophorectomy (remote)
.
Cardiac Risk Factors: +Diabetes, Dyslipidemia, +Hypertension
Social History:
Lives alone in apartment. Receives VNA services and home visits
from [**Hospital3 **]. Per previous d/c summary--She has never been
employed and has received welfare. The patient denies EtOH or
smoking history but per past d/c summary has a history of [**11-19**]
ppd x 20y, quit [**2094**] and alcohol abuse x 20y, quit [**2104**],
recreational drugs (multisubstance and IVDU in [**2094**]). patient
had 5 children all died by age 13.
Family History:
N/C
Physical Exam:
VS: T 98.4 , BP 121/49, HR 33, RR 21, O2 97-100% on RA
Gen: obese middle aged female in NAD, resp or otherwise.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: well healing surgical scar on right forehead. Sclera
anicteric. left anisocoria, bilateral reactive pupils, left
cataract, EOMI. lid droop on right. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. edentulous
Neck: Supple with JVP flat
CV: PMI located in 5th intercostal space, midclavicular line.
bradycardic, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: well healed surgical scars. Obese, soft, NTND, No HSM or
tenderness. No abdominal bruits.
Ext: No c/c/e. No femoral bruits. s/p left BKA w/o stump
erythema
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit
Neuro:
MS - alert and oriented x3, coherent response to interview
CN: II-XII intact except for anisocoria
Motor: normal tone and bulk. [**3-23**] bicep/tricep/hip flex bilat
[**Last Name (un) **]: light touch intact to face/hands/right foot w/o extinction
Coord: FTN intact and rapid
Brief Hospital Course:
65 year old woman with MMP and prior hx of bradycardia
previously attributed to medications who presented with
symptomatic junctional bradycardia (HR 35 bpm) on no AV nodal
agents.
.
# Rhythm:
Pt was admitted with a junctional bradycardia that spontaneously
converted to sinus bradycardia. After multiple admissions for
symptomatic bradycardia attributed to medications (Zoloft,
metoprolol), on this admission it was determined that pt likely
had sick sinus syndrome due tointrinsic SA nodal failure. An
ischemic trigger was ruled out by negative cardiac enzymes and a
recent TSH was normal. The patient was monitored on telemetry
and received a dual-chamber pacemaker on [**6-2**]. The patient did
not experience any episodes of bradycardia or arrhythmia
following pacemaker placement. The patient was discharged with a
short course of clindamycin following pacemaker placement.
.
# UTI:
Pt developed urinary retention on day 1 of admission and the
urine culture grew gram negative rods. The patient was treated
with aztreonam empirically due to multiple drug allergies, and
when sensitivities were available it was confirmed by telephone
with the clinical lab that the pt's E. coli UTI was sensitive to
aztreonam. The patient completed a 3-day course of aztreonam.
.
# CHF/Pump:
2D-ECHOCARDIOGRAM performed on [**2130-9-8**] calculated LVEF 35%. The
patient remained euvolemic during admission.
.
# CAD:
EKG from admission demonstrated no significant ST changes
compared with prior dated [**2133-5-1**]. Cardiac enzymes were
negative. The patient was continued on aspirin.
.
# Hypertension:
HCTZ and lisinopril were started and the patient's blood
pressure tolerated the medications.
.
# DM2:
The patient was continued on her home dose of insulin.
.
# Seizure Disorder:
The patient was continued on her home Tegretol for her history
of seizure disorder. The patient did not experience any seizure
activity during the hospitalization.
.
# FEN:
The patient followed a diabetic, heart-healthy diet.
.
# Code: full
Medications on Admission:
1. Insulin NPH 30 units in the morning and 12 units at night.
2. Gabapentin 300 mg QAM
3. Trazodone 100 mg HS prn
4. Hydrochlorothiazide 25 mg daily
5. Mirtazapine 30 mg qhs
6. Gabapentin 1200 mg qhs.
7. Carbamazepine 200 mg HS
8. Albuterol 90 mcg INH q6prn
9. Lisinopril 20 mg daily
10. Aspirin 81 mg daily
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
7. Gabapentin 600 mg Tablet Sig: Two (2) Tablet PO at bedtime.
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
10. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous once a day.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous at bedtime.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
14. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO
three times a day for 2 days.
Disp:*18 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Bradycardia s/p pacemaker
Urinary Tract Infection
.
Secondary:
seizure disorder
hypertension
Discharge Condition:
Stable. Transfers from bed to wheelchair without assist.
Discharge Instructions:
You were admitted with generalized weakness and a slow heart
rate. You were also found to have a urinary tract infection.
You had a pacemaker placed on [**2133-6-2**]. You will need to follow
up with device clinic as shown below. You also had a urinary
tract infection that was treated with antibiotics.
.
We have started you on an antibiotic called Clindamycin 450mg
three times a day for the next 2 days to prevent infection
around the new pacemaker. Otherwise, we have not made any
changes to your medications.
.
If you develop any chest pain, shortness of breath, weakness,
loss of consciousness or any other general worsening of
condition, please call your PCP or come directly to the ED.
Followup Instructions:
Primary Care Doctor: Dr. [**Last Name (STitle) 1266**] knows that you are home and
will make sure your home visits resume. Please call [**Telephone/Fax (1) 608**]
with questions.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2133-6-10**]
1:30
Neurology:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2133-6-9**] 6:00
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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310, 335
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423, 2507
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2529, 3430
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3446, 3883
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,337
| 104,624
|
42377
|
Discharge summary
|
report
|
Admission Date: [**2159-2-14**] Discharge Date: [**2159-2-21**]
Date of Birth: [**2100-12-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
cardiac catheterisation
History of Present Illness:
58M hx CAD s/p 2 stents 9 years prior to unknown artery, hep C,
HTN, HLP who presented to OSH today for elective L hip ORIF. He
was off his plavix and aspirin since [**2-5**] in preparation for
the procedure. Arrived to PACU @ 12:56pm today c/o chest
pressure with lateral ST elevations & HR in the 120s 127/80. He
received Plavix 600mg, [**Year (2 digits) **] 325 mg, IV ntg @ 20 mcg, heparin @
1300 units/hr no [**Year (2 digits) 1868**], lipitor 80mg, IV lopressor 5mg x2. HR
down to 72, BP 107/78 with 6/10 chest pressure. He was
transferred to [**Hospital1 18**] for urgent cath.
.
In cath lab, he underwent thrombectomy and DES to the LAD. He
underwent the procedure without complication, suffering only
some nausea. On transfer to the floor, he was hemodynamically
stable, awake and alert without complaints.
.
During the first few hours of his CCU course, he experienced an
episode of nausea with loss of conciousness and was found to be
pulseless. CPR was begun and stopped quickly after patient
regained conciousness. IO and central line access were obtained
as was epinephrine given during the code, with dopa and neo
afterward. Labs showed HCT of 24 from 32 at OSH prior to ORIF.
2L IVF were given and he was stabilized.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: ?MI in past, s/p multiple stents 9 years
prior
3. OTHER PAST MEDICAL HISTORY:
Hep C
HTN
HLP
Social History:
- Tobacco history: Quit 15yrs prior
- ETOH: 1-2 drinks per day
- Illicit drugs: none
Family History:
- Brother with cardiac disease, sister "on LVAD"
Physical Exam:
On admission: VS: Pulse 97 BP 108/56 100%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVD unable to be appreciated due to habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, heart sounds distant.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. IO line in place on
the right tibial tuberosity.
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+
At discharge: 98.9, 125/78, 90, 20 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Central
line in place.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVD unable to be appreciated due to habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, heart sounds distant.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Left hip bandaged,
taut, tender to palpation.
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:
[**2159-2-14**] 05:32PM BLOOD WBC-10.7 RBC-2.76* Hgb-7.8* Hct-23.9*
MCV-87 MCH-28.4 MCHC-32.8 RDW-13.1 Plt Ct-188
[**2159-2-14**] 09:53PM BLOOD Hct-30.8*# Plt Ct-152
[**2159-2-15**] 01:37AM BLOOD Hct-30.2*
[**2159-2-15**] 06:13AM BLOOD WBC-9.2 RBC-3.38* Hgb-9.8*# Hct-28.8*
MCV-85 MCH-29.0 MCHC-34.0 RDW-13.9 Plt Ct-172
[**2159-2-15**] 11:03AM BLOOD Hct-26.4*
[**2159-2-15**] 04:01PM BLOOD Hct-23.1*
[**2159-2-15**] 11:28PM BLOOD Hct-25.7*
[**2159-2-16**] 03:15AM BLOOD WBC-8.4 RBC-2.94* Hgb-8.6* Hct-24.7*
MCV-84 MCH-29.3 MCHC-34.9 RDW-13.5 Plt Ct-138*
[**2159-2-16**] 08:43AM BLOOD Hct-23.8* Plt Ct-142*
[**2159-2-16**] 03:20PM BLOOD Hct-25.9*
[**2159-2-16**] 09:08PM BLOOD Hct-22.6*
[**2159-2-17**] 06:21AM BLOOD WBC-9.7 RBC-2.98* Hgb-8.8* Hct-24.8*
MCV-83 MCH-29.7 MCHC-35.6* RDW-13.7 Plt Ct-138*
[**2159-2-17**] 05:30PM BLOOD Hct-26.4*
[**2159-2-17**] 11:28PM BLOOD Hct-25.0*
[**2159-2-18**] 05:34AM BLOOD WBC-10.5 RBC-2.94* Hgb-8.6* Hct-24.6*
MCV-84 MCH-29.2 MCHC-34.9 RDW-13.1 Plt Ct-179
[**2159-2-18**] 03:00PM BLOOD Hct-24.1*
[**2159-2-19**] 03:59AM BLOOD WBC-11.4* RBC-2.86* Hgb-8.2* Hct-24.0*
MCV-84 MCH-28.9 MCHC-34.4 RDW-13.3 Plt Ct-230
[**2159-2-20**] 05:10AM BLOOD WBC-12.2* RBC-2.98* Hgb-8.6* Hct-25.4*
MCV-85 MCH-28.7 MCHC-33.6 RDW-12.9 Plt Ct-313
[**2159-2-20**] 05:10AM BLOOD Neuts-68.7 Lymphs-15.1* Monos-10.5
Eos-5.3* Baso-0.4
[**2159-2-14**] 05:32PM BLOOD Plt Ct-188
[**2159-2-14**] 05:32PM BLOOD PT-16.7* PTT-46.9* INR(PT)-1.6*
[**2159-2-14**] 09:53PM BLOOD Plt Ct-152
[**2159-2-15**] 06:13AM BLOOD Plt Ct-172
[**2159-2-16**] 03:15AM BLOOD PT-14.4* PTT-28.3 INR(PT)-1.3*
[**2159-2-16**] 03:15AM BLOOD Plt Ct-138*
[**2159-2-16**] 08:43AM BLOOD Plt Ct-142*
[**2159-2-17**] 06:21AM BLOOD PT-14.1* PTT-29.0 INR(PT)-1.3*
[**2159-2-14**] 05:32PM BLOOD Glucose-208* UreaN-19 Creat-0.9 Na-140
K-3.6 Cl-111* HCO3-18* AnGap-15
[**2159-2-14**] 09:53PM BLOOD Na-137 K-4.4 Cl-108
[**2159-2-15**] 06:13AM BLOOD Glucose-162* UreaN-25* Creat-1.2 Na-138
K-4.8 Cl-108 HCO3-24 AnGap-11
[**2159-2-16**] 03:15AM BLOOD Glucose-126* UreaN-17 Creat-0.7 Na-135
K-3.8 Cl-106 HCO3-23 AnGap-10
[**2159-2-16**] 03:20PM BLOOD Glucose-139* Na-135 K-4.3 Cl-103 HCO3-23
AnGap-13
[**2159-2-17**] 06:21AM BLOOD Glucose-121* UreaN-10 Creat-0.8 Na-137
K-3.7 Cl-104 HCO3-27 AnGap-10
[**2159-2-17**] 05:30PM BLOOD Na-136 K-3.9 Cl-102
[**2159-2-18**] 05:34AM BLOOD Glucose-116* UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-103 HCO3-26 AnGap-12
[**2159-2-18**] 03:00PM BLOOD Na-135 K-4.3 Cl-101
[**2159-2-19**] 03:59AM BLOOD Glucose-127* UreaN-16 Creat-0.8 Na-137
K-4.1 Cl-103 HCO3-26 AnGap-12
[**2159-2-20**] 05:10AM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-138
K-4.4 Cl-103 HCO3-23 AnGap-16
[**2159-2-14**] 05:32PM BLOOD CK(CPK)-1709*
[**2159-2-15**] 01:37AM BLOOD CK(CPK)-1718*
[**2159-2-15**] 06:13AM BLOOD CK(CPK)-1279*
[**2159-2-15**] 11:03AM BLOOD CK(CPK)-924*
[**2159-2-14**] 05:32PM BLOOD CK-MB-174* MB Indx-10.2* cTropnT-3.94*
[**2159-2-14**] 09:53PM BLOOD CK-MB-241*
[**2159-2-15**] 01:37AM BLOOD CK-MB-191* MB Indx-11.1* cTropnT-6.80*
[**2159-2-15**] 06:13AM BLOOD CK-MB-129* MB Indx-10.1* cTropnT-6.77*
[**2159-2-15**] 11:03AM BLOOD CK-MB-85* MB Indx-9.2* cTropnT-5.64*
[**2159-2-14**] 05:32PM BLOOD Calcium-6.8* Phos-3.4 Mg-1.4*
[**2159-2-15**] 06:13AM BLOOD Calcium-7.8* Phos-3.9 Mg-2.3
[**2159-2-16**] 03:15AM BLOOD Calcium-7.7* Phos-1.5*# Mg-2.0
[**2159-2-16**] 03:20PM BLOOD Calcium-8.0* Phos-3.1# Mg-2.0
[**2159-2-17**] 05:30PM BLOOD Calcium-8.1* Mg-1.8
[**2159-2-18**] 05:34AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9
[**2159-2-18**] 03:00PM BLOOD Mg-2.2
[**2159-2-19**] 03:59AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
[**2159-2-20**] 05:10AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2
.
Discharge labs:
[**2159-2-21**] 19 122 AGap=14
4.8 25 0.8
Ca: 8.5 Mg: 2.0 P: 3.8
13.6>8.2/24.5<353
PT: 13.9 PTT: 29.9 INR: 1.3
.
[**2159-2-14**] CARDIAC CATHETERISATION
1. Selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel CAD. The LMCA had no significant
stenosis.
The mid LAD had a large occlusive thrombus in the prior stent.
The LCX
had 60% stenosis at the origin. A large OM1 branch had 60%
stenosis. The
dominant RCA had 80% stenosis in the mid RPDA branch.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures with a measure central aortic pressure of 114/80/83.
3. Left ventriculography was deferred.
4. Very late stent thrombosis in the LAD (previous stent
deployed in
[**2149**]) with acute antero-lateral MI.
5. LAD stenosis successfully treated by aspiration thrombectomy
and
deployment of a 3.0 x 12 mm Promus drug-eluting stent.
.
FINAL DIAGNOSIS:
1. Acute anterior [**Year (4 digits) **].
2. 3 vessel CAD.
3. Very late stent thrombosis in the LAD treated successfully
with
aspiration thrombectomy and deployment of a 3.0 x 12 mm Promus
drug-eluting stent.
4. [**Year (4 digits) **] 325mg/day; plavix 75mg/day for minimum 1 year.
.
[**2159-2-14**] HIP XRAY WITH PELVIS
Left total hip arthroplasty in satisfactory alignment with no
evidence of immediate post-surgical complications.
.
[**2159-2-15**] ECHOCARDIOGRAPHY
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with moderate anterior septal hypokinesis and mild
inferior septal hypokinesis. 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. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits). The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
IMPRESSION: Moderate hypokinesis of the anterior septum, mild
hypokinesis of the inferior septum. No significant valvular
abnormality seen.
.
[**2159-2-16**] CT Abdomen/Pelvis without contrast
1. No retroperitoneal hematoma.
2. Expected soft tissue edema and subcutaneous air, consistent
with
post-surgical changes from left total hip arthroplasty.
3. Bilateral fat-containing inguinal hernias.
.
[**2158-2-19**] CXR
No evidence of pneumonia.
Brief Hospital Course:
58M hx CAD with LAD and ?other stents 9 years prior, hep C, HTN,
HLP who presented to OSH for elective L hip ORIF. In PACU,
developed substernal chest pressure, was found to have ST
elevations in V2-V4 and transferred for cath.
.
# CAD: Unclear history of cardiac disease, has had at least one
stent to the LAD ~9 years prior. Post-operatively had ST
elevations in the precordial leads. Was plavix loaded, put on
hep gtt without [**Last Name (LF) 1868**], [**First Name3 (LF) **] 325, atorva 80, was on a nitro gtt
for hypertension and received lopressor 5 IV x2. Cath showed
large LAD thrombus in the old stent, s/p thrombectomy with [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 5175**]. EKG after stent showed resolution of ST elevations.
He will continue on aspirin, plavix, atorvastatin, metoprolol
and lisinopril following discharge.
.
# PEA: On [**2158-2-14**], patient experienced a PEA arrest. Likely
vagal episode (nausea prior to event) versus hypovolemia (blood
loss into RP versus into hip). Stabilized after short course of
CPR and epinephrine, transiently on dopamine/neo. s/p 2L IVF.
HCT 24 from 32 at OSH. Currently stable. No further PEA
episodes.
.
# L hip ORIF: s/p elective surgery. Possible site of bleeding
for PEA etiology. Unfortunately due to [**Date Range **] and DES, will
require [**Date Range **]/plavix. ongoing bleeding, likely into left hip.
Ortho was not concerned for compartment syndrome currently.
Hematocrit was currently stable. CT [**Last Name (un) 103**]/pelvis was not
concerning for RP bleed. He received a total of 6 units PRBCS
and 1 unit FFP. His hemotcrit subsequently stabilised and was
trending up at the time of discharge. He will continue lovenox
for DVT prophylaxis for a total of 4 weeks.
.
# Leukocytosis: WBCs up to 12.2 currently from 8.4 on [**2158-2-16**].
Etiology unclear. [**Name2 (NI) **] localizing symptoms. LIkely [**3-15**]
inflammation from recent hip surgery and cardiac manipulation.
cx ngtd. UA and CXR were negative for infection.
.
# CHF: No history of CHF. Appears hemodynamically stable
without evidence of pulmonary congestion. In setting of volume
resuscitation/blood and anterior [**Last Name (LF) **], [**First Name3 (LF) **] monitor fluid
status and oxygenation. We restarted ACE inhibitor and he will
followup with cardiology as an outpatient.
.
# HTN: Restarted home lisniopril one Hct was stable.
.
# HLD: increased atorvastatin to 80 daily.
Medications on Admission:
Toprol XL 50
Atorvastatin 40
Plavix 75 (held on [**2-5**] for procedure)
Lisinopril 10
Aspirin 81 (held on [**2-5**] for procedure)
MVI
Discharge Medications:
1. 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*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 24 days.
Disp:*48 * Refills:*0*
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours:
please hold for sedation, do not take if you are drowsy or are
having difficulty breathing. Please do not drive while you are
taking this medication.
.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Primary: ST Elevation Myocardial Infarction, PEA Arrest
Secondary: s/p Open Reduction Internal Fixation, Acute Blood
Loss
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:
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with a heart attack
following your hip surgery. We performed a cardiac
catheterisation and found some blockage to the blood flow to
your heart, which we repaired by placing a stent.
During your stay in our intensive care unti, you transiently
lost your pulse. We performed CPR and were able to rapidly
restore your pulse. This episode was probably due to some blood
loss during your surgery, and you had no further episodes during
your hospitalization. We monitored your hematocrit (a measure
of your blood levels) and found that it was dropping, probably
due to slow ongoing bleeding into your left hip. We gave you
blood transfusions and your hematocrit level was stable by the
time of discharge.
We made the following changes to your medications.
-INCREASED Metoprolol XL to 200 mg daily
-INCREASED Atorvastatin to 80 mg daily
-INCREASED Lisinopril to 20 mg daily
-INCREASED Aspirin to 325 mg daily
-STARTED Enoxaparin
-STARTED Percocet
Please continue taking your other medications as usual.
Please followup with your doctors, see below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] T.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appointment: TUESDAY [**2-27**] AT 2:45PM
Department: CARDIAC SERVICES
When: MONDAY [**2159-3-26**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You will also need to followup with your orthopedic surgeon at
[**Hospital3 **]. Please call his office to make a followup
appointment regarding your hip.
Completed by:[**2159-2-21**]
|
[
"E878.1",
"V45.82",
"996.72",
"070.70",
"412",
"285.1",
"401.9",
"V43.64",
"427.5",
"410.01",
"V54.81",
"414.01",
"272.4",
"V15.82",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"88.56",
"00.45",
"17.55",
"00.66",
"37.22",
"00.40",
"36.07",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13705, 13764
|
10038, 12490
|
320, 345
|
13930, 13930
|
3795, 7455
|
15271, 16089
|
1924, 1974
|
12676, 13682
|
13785, 13909
|
12516, 12653
|
8387, 10015
|
14113, 15248
|
7471, 8370
|
1989, 1989
|
1709, 1756
|
2888, 3776
|
266, 282
|
373, 1614
|
2003, 2874
|
13945, 14089
|
1787, 1803
|
1636, 1688
|
1819, 1908
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,483
| 126,391
|
54141
|
Discharge summary
|
report
|
Admission Date: [**2177-9-27**] Discharge Date: [**2177-10-6**]
Date of Birth: [**2113-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Weakness, fatigue
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
63 year-old male with follicular lymphoma who was recently
discharged one week ago after being treated for L3 thecal sac
compression who now presents with generalized weakness for one
day prior to admission. He had been well at rehab until he
began to feel a generalized fatigue and weakness. Initially,
this resolved on its own, but then returned the following day.
At the time, he denied any fever, chills, lightheadedness, chest
pain, cough, shortness of breath, nausea or vomiting. He was
then transfered to the [**Hospital1 18**]. However, during transport, he
became hypontensive to the 80's systolic, tachycardic to the
140's, and hypoxemic to the 70's. He was diverted to [**Hospital1 3793**] and was found to have pneumonia on chest x-ray. He was
given one dose of ceftriaxone and received 2L of normal saline
with improvement in vital signs. He was transfered to [**Hospital1 18**].
In the Emergency Department, he was normotensive, afebrile, and
his oxygen saturations were in the mid-90's on 4L nasal cannula.
He also had an elevated lactate. He was given vancomycin and
azithromycin. He was transfered to the Intensive care unit for
further care given that he appeared septic since he was
initially hypotensive with an elevated lactate.
Past Medical History:
Past oncology history: He was diagnosed with low-grade
follicular lymphoma in [**2168**] when he presented with a large right
neck mass. He was treated with 6 cycles of CHOP chemotherapy
followed by 4 cycles of Rituxan. He had a good initial resonse
to chemotherapy; however, his disease recurred in [**2172**]. He
underwent 2 more cycles of CHOP followed by CEPP. He was
subsequently treated with Bexxar radiolabeled antibody and
attained a complete remission for about 3 years. In [**Month (only) 956**]
[**2176**], he noted the gradual increase of his right neck mass,
which showed follicular lymphoma on biopsy. He underwent [**3-5**]
cycles of R-CEPP responded well. This chemotherapy was
itnerupted secondart to a hip fracture. He was notd to have
cervical spine involvement of imaging and was place in a soft
cervical collar. He underwent 2 cycles of [**Hospital1 **] salvage
chemotherapy in [**7-4**] and [**8-4**]. He recently was admitted thecal
sac compression at the L3 level for which he received 10 doses
of radiation therapy.
.
Past Medical History:
1. Follicular lymphoma as above
2. Status post cholecystectomy
3. Neuropathy secondary to chemotherapy
4. Status post left hip fracture [**5-/2177**]
Social History:
The patient is married and lives at home with his wife in
[**Name (NI) 43018**]. He has three children, none of whom live at home. His
wife has [**Name (NI) 2481**] dementia and receives a lot of care from
her children. The patient's daughter died at age 20 from
lymphoma (He thinks ALL). He previously worked for NSTAR
switching lines. He denies any tobacco or drug use. He reports
occasional alchohol with about 1 beer per week.
Family History:
His daughter died at age 20 of lymphoma (he believes ALL). He
has an Aunt with melanoma.
Physical Exam:
Vitals: Temperature:98.4 Pulse:100 Blood Pressure:125/70
Respiratory Rate:20 Oxygen Saturation:96% on 15L Non-rebreather.
General:pleasant elderly gentleman wearing soft c-spine collar
in no acute distress.
HEENT: Pupils equal and reactive, extraoccular movements intact,
anicteric sclera, oropharynx clear, moist mucous membranes.
Cardiac: Regular rate and rhythm without murmurs, rubs, or
gallops.
Pulmonary: Coarse breath sounds throughout with rhonchi at the
bases, with left greater than right.
Abdomen: Normoactive bowel sounds, soft, nontender,
nondistended, no hepatosplenomegaly.
extremities: Warm and well perfused without cyanosis, trace
edema at ankles.
Neuro: Alert and oriented x3, cranial nerves [**1-11**] grossly
intact, 5/5 strength bilaterally in deltoids, triceps, biceps,
grip, hip flexor, hip extensors, quadriceps, hamstrings,
dorsiflexion, plantarflexion. Sensation symmetric to light
touch bilaterally.
Pertinent Results:
12.4>28.6<147
N:97.5 L:0.9 Bands:0 Monos:1.1 Eos:0.2 Basos:0.1
.
[**Age over 90 **]|96|24/230
4.3|21|1.1\
Ca:8.2 Mg:1.7 P:2.9
.
PT:12.6 PTT:32.9 INR:1.1
.
Lactate:2.4
.
Iron:63 CaTIBC:114 Ferritin:>[**2171**] TRF:88
B12:755 Folate:3.9
.
Sputum (induced) 4+ yeast with pseudohypae
Blood Culture ([**9-27**]) no growth
Urine Culture ([**9-27**]) no growth
.
Urinalysis:small blood, trace protein, trace ketones, 0-2 RBC,
0-2 WBC, few bacteria, [**2-1**] epithelial cells.
.
CXR: Multifocal new patchy opacities. While this might all
represent
atelectasis, differential diagnosis includes aspiration and
infiltrate.
.
CTA: No PE. Bibasilar dependent consolidation. RUL dependent
consolidation.
Brief Hospital Course:
63 year-old male with recurrent follicular cell lymphoma with
recent chemotherapy and radiation to L3 who was admitted for
pneumonia and sepsis.
.
1. Pneumonia: On chest x-ray, he had evidence of pneumonia.
Given that he has recently been hospitalized, he was initially
covered for both pseudomonas and MRSA with ceftazidime and
vancomycin. On hospital day 3, his oxygen requirement increased
and he spiked a temperature; therefore, his antibiotic coverage
was broadened to include Flagyl, Caspofungin, and Bactrim. He
improved on that regimen and his oxygen requirement decreased.
An induced sputum showed budding yeast and was negative for PCP.
[**Name10 (NameIs) **] that time, the Flagyl and the treatment dose Bactrim was
stopped. His oxygen requirement decreased throughout his
hospital course. On discharge, he had completed 11 days of
vancomycin and ceftazidime and 9 days of caspofungin. He was
discharged to complete 14 days of antibiotics with levofloxacin.
.
2. Sepsis: The source of his sepsis was likely the pneumonia.
He was adequately volume resuscitated in the emergency
department. He was initially monitored in the intensive care
unit. His lactate trended down with fluids and he remained
normotensive.
.
3. Lymphoma: He recently underwent a cycle of [**Hospital1 **] chemotherapy
2 weeks prior to admission. He has just completed a 10-day
course of radiation therapy for his L3 thecal sac compression.
He was admitted on a prednisone taper from his recent admission.
When he was tapered from 40 to 20 mg of prednisone, he had
increased pain and lower extremity weakness. Until a cervical,
thoracic, and lumbar spine MRI was negative for compression, he
was maintained on high dose dexamethasone. He was then maintain
on 40 mg prednisone daily. He also has C-3 disease for which he
should continue to wear his soft c-spine collar. During this
admission, he had an increase in size of his right neck mass.
He will need his third cycle of [**Hospital1 **] chemotherapy once he has
recovered from his pneumonia. He was maintain on his
allopurinol and prophylactic Bactrim.
.
4. Anion gap acidosis: He initially had an anion gap acidosis
that was likely secondary to lactate. His anion gap acidosis
resolved with fluid resuscitation.
.
5. Acute renal failure: On admission, his BUN and creatinine
were elevated. This was attributed to a pre-renal etiology in
the setting of decreased perfusion from sepsis. His creatinine
returned to baseline with fluid resuscitation.
.
6. Anemia: On admission, his hematocrit was near baseline of
27-30. His iron studies were consistent with anemia of chronic
disease and his B12 and folate were normal. His hematocrit
dropped to 18 on hospital day 1, which was likely secondary to
dilution from fluid resuscitation. He received 1 U packed red
cell transfusion with an appropriate increase in his hematocrit.
He hematocrit remained stable above 25 throughout the remainder
of the admission.
.
7. Hyperglycemia: He has no history of diabetes. His elevated
glucose was likely secondary to steroids. He was covered with
an insulin sliding scale.
.
8. FEN: He was maintained on a regular diet. Initially, he
received IV fluid resuscitation for low blood pressure as above.
His electrolytes were repleted.
.
9. Prophylaxis: Subcutaneous heparin, PPI, bowel regimen.
.
10. Access: Left Port-a-cath and peripheral IV.
.
11. Code: DNR/DNI
.
12. Dispo: He was discharged to rehab once his respiratory
status had improved. He will follow-up with his oncologist to
discuss when to start cycle 3 of [**Hospital1 **].
Medications on Admission:
Medications on Admission:
Prednisone taper
SC Heparin
Pantoprazole 40 mg Tablet PO Q24H
Gabapentin 800 mg PO Q8H
Oxycodone 5 mg 1-2 Tablets PO Q2-4HR prn
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg 1 Tablet PO BID
Oxycodone 40 mg Tablet Sustained Release 12HR
Trimethoprim-Sulfamethoxazole 160-800 mg 1 Tablet PO 3X/WEEK
(MO,WE,FR)
Allopurinol 300 mg DAILY
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
6. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
9. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
10. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
11. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale Subcutaneous four times a day: Check QID fingersticks and
use sliding scale as follows:
150-199:2Units
200-249:4Units
250-299:6Units
300-349:8Units
350-300:10Units.
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Discharge Disposition:
Extended Care
Facility:
ArberJonice
Discharge Diagnosis:
Pneumonia
Lymphoma
Acute renal failure
Anion gap metabolic acidosis
Discharge Condition:
Stable. His oxygen requirement has decreased.
Discharge Instructions:
Please take all medications as prescribed. You will finish a 14
day course of antibiotics with levofloxacin for your pneumonia.
Followup Instructions:
You have the following appointment with Dr. [**First Name (STitle) 1557**]:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2177-10-9**] 2:30
Completed by:[**2177-10-6**]
|
[
"202.01",
"E933.1",
"584.9",
"285.29",
"791.9",
"995.92",
"286.9",
"038.9",
"V15.3",
"112.0",
"276.2",
"486",
"355.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10420, 10458
|
5113, 8697
|
333, 340
|
10570, 10619
|
4397, 5090
|
10797, 11060
|
3343, 3433
|
9114, 10397
|
10479, 10549
|
8749, 9091
|
10643, 10774
|
3448, 4378
|
276, 295
|
368, 1630
|
2724, 2875
|
2891, 3327
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,104
| 150,510
|
44054+44055
|
Discharge summary
|
report+report
|
Admission Date: [**2192-8-29**] Discharge Date: [**2192-9-8**]
Date of Birth: [**2148-11-12**] Sex: M
Service: MEDICINE
Allergies:
Indomethacin
Attending:[**Last Name (un) 11220**]
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43M with h/o chronic pancreatitis, HTN, HLD, DM type 1, diabetic
nephropathy presents with chest pain, abdominal pain, nausea,
and vomiting. Nausea w/ nb/nb emesis began 1 week ago. Pt.
states he has been vomiting multiple times per day and has been
unable to keep down any significant amount of food. Abdominal
pain started 3 days ago. It is located in the RUQ with radiation
to the back. No obvious exacerbating factors. [**6-29**] pain at it's
worst. Describes it as very similar to pain he has had with
multiple prior pancreatitis flares. This morning began to
experience chest tightness, which lasted for 2-3 minutes on and
off throughout the morning. Not associated with exertion. No
radiation of chest pain. Was recently admitted for anasarca and
was discharged on [**8-23**] on increased dose of lasix (80qAM/40qPM).
He has been taking this and notes significant decrease in edema.
In the ED, initial vitals 98.4 79 123/80 16 96%
Labs: notable for lipase 405, Lytes notable for Na 140, K 5.4,
Bicarb 33, Cr 3.5 (baseline 3-3.2), troponin 0.08 with flat Ck
and MB, D dimer 380. UA notale for 300 protein, 100 glucose, tr
blood. AST ALT and AP and [**Female First Name (un) 7925**] wnl.
Given asa 81mg, zofran 2mg IV x 2, omeprazole 20mg, aluminum
magnesium, simethicone, dilaudid 1mg. Received total of 1L NS
Vitals prior to transfer: 98.6 87 115/56 16 99%
Past Medical History:
1. Diabetes mellitus Type 1: diagnosed 28 years ago
2. Asthma
3. Hypertension
4. Hyperlipidemia
5. Chronic kidney disease (baseline Cr 3-3.2) secondary to
diabetic nephropathy
6. Question of PE in [**2186**]: VQ scan suggestive but not conclusive
of PE in
[**2187-2-18**]; non-compliant with coumadin
7. Obstructive sleep apnea on CPAP
8. Obesity
9. S/p appendectomy
10. Pancreatitis
10. Recurrent pancreatitis w/ several admissions for this in the
past
Social History:
Lives in [**Location 686**] alone. Separated from his with wife and 11
y.o. son, 2 step sons. [**Name (NI) 1403**] at hardware store. Former 1.5 ppy
smoker x 28 years, now smokes [**11-21**] cigarettes every other day.
Drinks occasionally. Denies illicit or recreational drug use.
Family History:
- Father DM, died ESRD
- Mother, grandmother DM
- Denies history CAD, blood clots, lung disease
Physical Exam:
Upon Admission:
================================
VS - 97.9 169/81 93 20 100%/2L nc
GENERAL - Well-appearing 43 yo M who appears comfortable,
appropriate and in NAD
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - distant heart sounds, regular rate and rhythm, no
audible m/r/g
ABDOMEN - NABS, soft, obese, non-distended, Mild tenderness to
palpation in RUQ, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Very mild b/l LE edema to mid-shin level
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-24**] throughout, sensation grossly intact throughout
Upon Discharge:
===================================
VS 98 179/84 81 18 97RA FS 265
GEN: Awake, alert and oriented. No acute distress
HEENT: Sclera anicteric, MMM, Nares has blood at opening.
NECK: Supple, no JVD, no lymphadenopathy
PULM: Good aeration, CTAB, without w/r/r.
CV: RRR. distant heart sounds. normal S1/S2, no mrg
ABD: Soft, obese, non-distended, mild tenderness to palpation in
RUQ, no rebound or guarding.
EXT: WWP 2+ pulses palpable bilaterally, trace pitting edema b/l
lower extremities
SKIN: no ulcers or lesions
Pertinent Results:
Upon Admission:
================================
[**2192-8-29**] 11:15AM BLOOD WBC-14.2* RBC-4.87 Hgb-13.5* Hct-40.0
MCV-82 MCH-27.7 MCHC-33.7 RDW-13.4 Plt Ct-285
[**2192-8-29**] 11:15AM BLOOD Neuts-83.7* Lymphs-10.7* Monos-4.2
Eos-1.0 Baso-0.3
[**2192-8-29**] 11:15AM BLOOD Glucose-241* UreaN-64* Creat-3.5* Na-140
K-5.4* Cl-99 HCO3-33* AnGap-13
[**2192-8-29**] 11:15AM BLOOD Lipase-405*
[**2192-8-29**] 11:15AM BLOOD CK-MB-4 cTropnT-0.08*
[**2192-8-30**] 07:50AM BLOOD CK-MB-10 MB Indx-5.6 cTropnT-0.30*
[**2192-8-29**] 11:15AM BLOOD D-Dimer-384
[**2192-8-30**] 07:50AM BLOOD Triglyc-265*
Upon Discharge:
================================
1.0/20/12 07:15AM BLOOD WBC-6.1 RBC-4.14* Hgb-11.7* Hct-34.5*
MCV-83 MCH-28.4 MCHC-34.0 RDW-13.1 Plt Ct-279
[**2192-9-8**] 07:15AM BLOOD Glucose-286* UreaN-28* Creat-2.5* Na-138
K-4.9 Cl-100 HCO3-34* AnGap-9
.
Microbio:
================================
NONE
.
Imaging:
================================
[**2192-8-29**] CXR: possible atelectasis
.
[**2192-9-3**] CT abdomen without contrast: Mild peripancreatic fat
stranding around the head, distal body/tail, consistent with the
known history of acute pancreatitis. No peripancreatic fluid
collections are seen.
.
[**2192-3-1**] RUQ US:Mild fatty deposition in the liver. No biliary
duct dilation. Status post cholecystectomy.
.
[**1-30**] MRI abdomen:Mild fatty deposition in the liver. No biliary
duct dilation. Status post cholecystectomy.
Brief Hospital Course:
43M with history of DM1, hypertension, asthma, CKD [**1-22**] [**12-22**]
diabetic nephropathy, obesity, chronic pancreatitis presenting
with chest pain/nausea/vomiting consistent with his prior
episodes of pancreatitis.
Active Problems:
===============================
# Acute on Chronic Pancreatitis: The patient has previously
admitted with pancreatitis that clinically presented the same on
this admission. His lipase was elevated at 405 and patient's
abdominal pain, nausea/vomiting was consistent with a diagnosis
of pancreatitis. The precipitating event is unclear. [**Name2 (NI) **] is s/p
cholecystectomy and had MRCP [**1-30**] that did not show biliary duct
dilation or stones in duct. Also had [**3-1**] RUQ US that did not
show biliary duct dilation to consider gallstones as the cause
of his pancreatitis. Triglycerides were not elevated
significantly enough to consider that as a cause of
pancreatitis. He denies any EtOH use. HCTZ was discontinued
during last admission for thought that it was the precipitant.
His furosemide was thought to be contributing factor so it was
discontinued during this admission. He was gently given IVF
given his underlying nephrotic syndrome. His pain was initially
controlled with dilaudid, but it was making him nauseated so he
was started on morphine. Zofran was used to control his nausea.
As patient was having difficulty to advancing his diet, so [**9-3**]
CT abdomen without contrast showed fat stranding without fluid
collection. Eventually his pain improved, his diet was advanced
and his pain was controlled with po narcotics.
.
#Epistaxis
He had a self-limited episode of epistaxis during the hospital
stay, which was initially concerning for hematemesis. It was
felt to be due to a dry nasal mucosa from nasal oxygen. Efforts
were made to humidify his mucosa. It did not recur and his Hct
remained stable.
.
#Chest pain/tightness: Patient had chest pain and tightness that
occurred when he was nauseated and vomiting. The presentation
was not typical for cardiac chest pain, though patient with
multiple risk factors for CAD including HTN, HLD, and DM. EKG
did not have ischemic changes. Troponin was mildly elevated
which thought to be secondary to his secondary to his CKD as
CK-MB not elevated.
.
#Leukocytosis: Patient developed leukocytosis to 17 that then
returned to [**Location 213**]. The etiology was unclear, but thought
secondary to pancreatitis.
# Chronic CKD with nephrotic syndrome: Cr 3.5, baseline is
between 3.0-3.2. Pt has history of diabetic nephropathy. His
urine protein/creatine ratio on recent admission was 5.8. This
slight elevation in his Cr may represent a mild pre-renal
azotemia. Patient received 1L NS and his Cr downtrended during
this admission. His furosemide was held as it was thought to
contribute to his pancreatitis. He was started on torsemide 40mg
[**Hospital1 **] upon discharge.
.
Chronic Problems:
==================================
# DM1: A1C 8.2 checked recently few weeks ago. Complicated with
diabetic nephropathy. Home insulin regimen of Lantus 62units qAM
and 32 units qPM. Pt. has not been taking insulin for past week
because of persistent nausea/vomiting. States FSGs have been low
70s-90s at home. The amount of lantus he received during the
admission was dependent on his caloric intake.
# HTN: He was continued on home diltiazem and minoxidil. His
lisinopril was briedfly held with slight elevation in Cr. It was
restarted upon discharge.
# OSA: He was continued on his home CPAP.
#Asthma:He was continued on albuterol as needed.
Transitional Issues:
===============================
#CODE STATUS: Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
4. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
5. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO BID:PRN pain
6. Glargine 62 Units Breakfast
Glargine 32 Units Bedtime
Insulin SC Sliding Scale using UNK Insulin
7. Lisinopril 5 mg PO DAILY
8. Minoxidil 2.5 mg PO DAILY
9. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h PRN
10. sildenafil *NF* 50 mg Oral daily PRN erectile dysfunction
11. Ursodiol 1000 mg PO BID
12. Furosemide 80 mg PO QAM
13. Furosemide 40 mg PO QPM
Discharge Medications:
1. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h PRN
2. Atorvastatin 40 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Minoxidil 2.5 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
7. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO BID:PRN pain
8. Lisinopril 5 mg PO DAILY
9. sildenafil *NF* 50 mg Oral daily PRN erectile dysfunction
10. Ursodiol 1000 mg PO BID
11. Torsemide 40 mg PO QHS
RX *torsemide 20 mg 4 tablet(s) by mouth qAM Disp #*90 Tablet
Refills:*0
12. Glargine 50 Units Breakfast
Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Torsemide 80 mg PO QAM
RX *torsemide 20 mg 2 tablet(s) by mouth at bedtime Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
-pancreatitis
Secondary Diagnosis:
Chronic Kidney Disease
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you while here at [**Hospital1 771**].
You were admitted to the hospital because you were found to have
inflammation around your pancreatitis. You have had this
previously, but this time you had a harder time recovering
because it was difficult for you to eat without becoming
nauseous. While here, you had a CT scan of your abdomen that did
not show any complication of pancreatitis. We treated your pain
and gave you intravenous fluids and you got better.
The following changes were made to your medications:
STOP taking furosemide this may have contributed to your
pancreatitis
take torsemide 80mg in the morning and 40mg at night
-Please decrease your insulin to:
50 units Lantus in morning
25 units Lantus at night
Followup Instructions:
Please call [**Last Name (un) **] at ([**Telephone/Fax (1) 4847**] to schedule an appointment
soon (within 1 week)
Department: PULMONARY FUNCTION [**Telephone/Fax (1) **]
When: THURSDAY [**2192-9-27**] at 2:40 PM
With: PULMONARY FUNCTION [**Year (4 digits) **] [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2192-9-27**] at 3:00 PM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2192-9-27**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
Admission Date: [**2192-9-13**] Discharge Date: [**2192-9-15**]
Date of Birth: [**2148-11-12**] Sex: M
Service: MEDICINE
Allergies:
Indomethacin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43M h/o chronic pancreatitis, HTN, HLD, DM type 1, diabetic
nephropathy presents with dizziness and hypotension. He reports
that this morning he felt lightheaded, nauseous, and vomited one
time. Yesterday he reports three episodes of diarreha. He denies
any recent sick contacts. [**Name (NI) **] states that he has recently had
decrased PO intake, because he had been afraid of eating in the
setting of his recent pancreatitis bout. Additionally, over the
course of his last hospitalization, his diuretics were adjusted,
and he was discharged on torsemide rather than the lasix that he
was previously taking. Today he was driving on the highway when
he became acutely lightheaded and nauseous, he also reported
some abdominal pain. He took vicodin and zofran while driving,
without improvement in his symptoms. His wife then took control
of the car. He went to his PCP's office after his meeting for
assessment of persistent lightheadedness. In the PCP's office he
was found to have SBP of 90. He was sent from the PCP's office
to the ED for further treatment.
In the ED, initial VS were: 97.0, 82, 89/53, 20, 100% 4LNC.
Additionally, he was found to have elevated creatinine of 5.2
and lipase 256. He was given a total of 4L NS bolus, and IV
dilaudid for abdominal pain. His blood pressure recovered to
systolics of the 110-120's.
On arrival to the MICU, he reported persistent lightheadedness
and nausea. He denied any abdominal pain.
Past Medical History:
1. Diabetes mellitus Type 1: diagnosed 28 years ago
2. Asthma
3. Hypertension
4. Hyperlipidemia
5. Chronic kidney disease (baseline Cr 3-3.2) secondary to
diabetic nephropathy
6. Question of PE in [**2186**]: VQ scan suggestive but not conclusive
of PE in
[**2187-2-18**]; non-compliant with coumadin
7. Obstructive sleep apnea on CPAP
8. Obesity
9. S/p appendectomy
10. Pancreatitis
10. Recurrent pancreatitis w/ several admissions for this in the
past
Social History:
Lives in [**Location 686**] alone. Separated from his with wife and 11
y.o. son, 2 step sons. [**Name (NI) 1403**] at hardware store. Former 1.5 ppy
smoker x 28 years, now smokes [**11-21**] cigarettes every other day.
Drinks occasionally. Denies illicit or recreational drug use.
Family History:
- Father DM, died ESRD
- Mother, grandmother DM
- Denies history CAD, blood clots, lung disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.2 BP: 139/78 P: 102 R:15 O2: 96%RA
General: Alert, no acute distress
HEENT: Sclera anicteric, mucus membranes dry, oropharynx clear
Neck: supple, JVP difficult to assess given body habitus
CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, non-tender, non-distended, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
DISCHARGE PHYSICAL EXAM:
VS 98.5 150/80 83 20 95% ra UOP 1050 (after mn)
GEN Alert, oriented, no acute distress, breathing comfortably
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, mild diffuse wheezes
CV RRR normal S1/S2, no mrg
ABD soft, obese, mildly ttp RUQ, normoactive bowel sounds, no
r/g
EXT WWP 2+ pulses palpable bilaterally, +2 bilateral LE pitting
edema
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS:
[**2192-9-13**] 08:20PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2192-9-13**] 08:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2192-9-13**] 05:20PM PT-10.4 PTT-36.8* INR(PT)-1.0
[**2192-9-13**] 05:17PM LACTATE-1.1
[**2192-9-13**] 05:00PM GLUCOSE-160* UREA N-52* CREAT-5.2*#
SODIUM-133 POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-27 ANION GAP-17
[**2192-9-13**] 05:00PM ALT(SGPT)-28 AST(SGOT)-19 ALK PHOS-237* TOT
BILI-0.3
[**2192-9-13**] 05:00PM LIPASE-256*
[**2192-9-13**] 05:00PM ALBUMIN-3.5 CALCIUM-8.9 PHOSPHATE-6.2*#
MAGNESIUM-1.8
[**2192-9-13**] 05:00PM WBC-9.1 RBC-4.46* HGB-12.6* HCT-37.1* MCV-83
MCH-28.2 MCHC-33.9 RDW-13.8
[**2192-9-13**] 05:00PM NEUTS-65.7 LYMPHS-26.1 MONOS-4.8 EOS-2.7
BASOS-0.6
IMAGING:
- CXR ([**2192-9-13**]): IMPRESSION: No acute cardiopulmonary process.
DISCHARGE LABS:
[**2192-9-15**] 11:50AM BLOOD WBC-5.8 RBC-4.48* Hgb-12.6* Hct-37.3*
MCV-83 MCH-28.2 MCHC-33.8 RDW-13.6 Plt Ct-372
[**2192-9-15**] 11:50AM BLOOD Plt Ct-372
[**2192-9-15**] 11:50AM BLOOD Glucose-145* UreaN-38* Creat-3.4* Na-141
K-4.6 Cl-104 HCO3-29 AnGap-13
[**2192-9-15**] 11:50AM BLOOD Calcium-9.0 Phos-4.6* Mg-1.9
Brief Hospital Course:
43M with history of DM1, hypertension, asthma, CKD [**1-22**] [**12-22**]
diabetic nephropathy, obesity, chronic pancreatitis presenting
with poor PO intake and hypotension.
# Hypotension: Likely secondary to recent poor PO intake and
dehydration. Also likely contribution from recent changes made
to diuretics. In looking at his discharge summary from [**2192-9-8**],
it appears that his diuretic dose was doubled when converting
from lasix to torsemide, adjusting for strength of dosing.
Following NS IVF boluses in the ED his blood pressure returned
to the normal range, but again became soft shortly after he was
settled into the ED. While in the MICU he was fluid
resuscitated, and his diuretics and antihypertensives were held.
His blood pressure returned to the normal range, and he was safe
for transfer to the floor. His Torosemide was restarted while on
the floor. He remained normotensive and became mildly
hypertensive. He was considered safe for discharge.
# Acute-on-chronic kidney disease: His baseline creatinine is
approximately 2.5, but was elevated to 5.2 on presentation to
the ED. Additionally, he reports decreased urine output. Most
likely pre-renal given poor PO intake and excess diuretics.
While in the MICU his creatinine trended down with IVF
resuscitaiton. As above, his antihypertensive medications and
diuretics were held until the day of discharge when he was noted
to be hemodynamically appropriate in setting of receiving
diuretics.
CHRONIC ISSUES:
# Type 1 DM: No acive issues while in the MICU. He was
maintained on his home insulin dosing with lantus and HISS.
# OSA: While in the MICU he refused to use CPAP, but reported
that his wife would bring his home machine in the following day.
Overnight he was given supplemental oxygen via a nasal cannula.
#Asthma: No active issues. He was given albuterol nebs as
needed.
TRANSITIONAL ISSUES:
- Patient carefully instructed on dosage of diuretics at home.
He was also given strict instructions to weigh himself daily and
call his nephrologist immediately if he notes a weight gain.
- His antihypertensives were restarted upon discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h PRN
2. Atorvastatin 40 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Minoxidil 2.5 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
7. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO BID:PRN pain
8. Lisinopril 5 mg PO DAILY
9. sildenafil *NF* 50 mg Oral daily PRN erectile dysfunction
10. Ursodiol 1000 mg PO BID
11. Torsemide 40 mg PO QHS
12. Glargine 50 Units Breakfast
Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Torsemide 80 mg PO QAM
Discharge Medications:
1. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h PRN
2. Atorvastatin 40 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
4. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
5. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO BID:PRN pain
6. Glargine 50 Units Breakfast
Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Torsemide 40 mg PO QHS
8. Ursodiol 1000 mg PO BID
9. Minoxidil 2.5 mg PO DAILY
10. sildenafil *NF* 50 mg Oral daily PRN erectile dysfunction
11. Diltiazem Extended-Release 240 mg PO DAILY
12. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure caring for you while you were in the hospital.
You were admitted because your blood pressures became very low
at home. This is likely because of too much diuresis. You spent
one night in the ICU where you monitored carefully. Your blood
pressure returned to [**Location 213**] with IV fluids.
Dr. [**Last Name (STitle) 4920**] saw you in the hospital and feels that you can take
Torsemide 40mg a day. However, it is EXTREMELY important that
you weigh yourself daily. If your weight increases, please call
Dr. [**Last Name (STitle) 4920**] to have your medications redosed.
Followup Instructions:
Please schedule an appointment with your primary care doctor,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94576**] for this week. This is a very important visit
and we would strongly recommend that you call his office at
[**Telephone/Fax (1) 2010**] on Monday morning.
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2192-9-27**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
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20940, 20946
|
17461, 18931
|
12800, 12807
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21002, 21002
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16209, 16209
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3976, 4552
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18947, 19322
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14770, 15053
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15721, 16190
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,611
| 122,449
|
2387
|
Discharge summary
|
report
|
Admission Date: [**2131-6-27**] Discharge Date: [**2131-7-3**]
Date of Birth: [**2066-10-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
cc:[**CC Contact Info 12362**]
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Pt is a 64 y/o male with prostate ca s/p brachytx, hrt, and xrt,
alcohol abuse, gi diverticulosis and avm in [**2125**] and dementia of
unknown etiology presents with brbpr, malaise, and weakness x
three days in setting of [**12-28**] weeks of increasing abdominal girth
and jaundice. His partner states that he has been having small
amount of brbpr for 2 months now, but that it seems to have been
small amounts and that on the day of admission he had a large
amount of brbpr. He denies f/c, cough, abdominal pain, n/v/d,
dysuria/hematuria (though he has had urinary incontinence over
the past few months). Last drink 2 days ago.
In ED, given 3 L NS, RUQ US with minimal ascites, no biliary
dilatation. Given Ceftriaxone, Levofloxacin.
Past Medical History:
1. Chronic obstructive pulmonary disease; emphysema with no
home oxygen use; followed by Dr. [**Last Name (STitle) **]. Last pulmonary
function test in [**7-/2129**] with FVC of 82%, FEV1 of 47%, FEV1
to FVC ratio 57%.
2. Prostate cancer status post hormonal therapy and status
post brachy therapy and radiation therapy.
3. History of gastrointestinal bleed in [**2125**].
4. Cataract surgery.
5. Glaucoma.
6. History of retinal detachment.
7. Alcohol abuse; no history of delirium tremens or
withdrawal.
8. History of incontinence of both bowel and bladder.
9. Recent short term memory loss.
10. s/p hip fracture/repair
Social History:
Continues EtOH 4-5 drinks/day, quit smoking 2 yrs ago (100
pk-yrs history). Lives with partner at home. Retired,
previously worked in advertising.
Family History:
non-contributory
Physical Exam:
PE: 102 (Rectal) 116--> 105 95-110/50-61 18-20 97% RA
Gen: cachectic, chronically ill appearing, pursed lips
HEENT: icteric, dry mm
CV: reg, S1, S2, no M/R/G
lungs: crackles at L base
Abd: NABS, + distended, NT. no rebound/guarding
Ext: warm, no edema
Neuro: alert, mildly confused, + asterixis
Rectal: frank blood, clots per ED.
Pertinent Results:
Admission laboratories:
CBC with differential
[**2131-6-27**] 10:45AM BLOOD WBC-9.0 RBC-2.78* Hgb-10.7* Hct-31.9*
MCV-115*# MCH-38.7* MCHC-33.6 RDW-14.0 Plt Ct-135*#
[**2131-6-27**] 10:45AM BLOOD Neuts-86.4* Lymphs-8.2* Monos-4.9 Eos-0.5
Baso-0
Chemistry panel
[**2131-6-27**] 10:45AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-126*
K-4.1 Cl-92* HCO3-21* AnGap-17
[**2131-6-27**] 10:45AM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.0 Mg-1.6
Coagulation
[**2131-6-27**] 10:45AM BLOOD PT-18.3* PTT-53.8* INR(PT)-2.2
Liver Enzymes
[**2131-6-27**] 10:45AM BLOOD ALT-70* AST-293* LD(LDH)-491*
AlkPhos-318* Amylase-25 TotBili-16.9* DirBili-12.0* IndBili-4.9
Other
[**2131-6-27**] 10:45AM BLOOD Lipase-38
[**2131-6-27**] 10:45AM BLOOD Hapto-23*
[**2131-6-27**] 12:30PM BLOOD Ammonia-85*
[**2131-6-28**] 02:10AM BLOOD TSH-1.2
Tox screen
[**2131-6-27**] 10:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.7
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-6-27**] 10:53AM BLOOD Lactate-3.5*
[**2131-6-28**] 10:55PM BLOOD Hct-26.1*
[**2131-6-29**] 05:12AM BLOOD PT-19.5* PTT-54.3* INR(PT)-2.5
Peak of liver enzymes on [**2131-6-30**]
[**2131-6-30**] 04:44AM BLOOD ALT-69* AST-173* AlkPhos-277* Amylase-26
TotBili-24.6*
[**2131-6-30**] 04:44AM BLOOD Glucose-124* UreaN-8 Creat-0.7 Na-141
K-4.0 Cl-111* HCO3-18* AnGap-16
[**2131-6-30**] 04:44AM BLOOD Calcium-8.9 Phos-2.2* Mg-2.4
[**2131-6-30**] 07:13AM BLOOD Type-ART Temp-35.8 pO2-82* pCO2-33*
pH-7.35 calHCO3-19* Base XS--6 Intubat-NOT INTUBA
[**2131-6-30**] 11:30PM BLOOD Type-ART FiO2-50 pO2-88 pCO2-37 pH-7.41
calHCO3-24 Base XS-0
Final blood gas
[**2131-7-3**] 02:56AM BLOOD Type-ART Temp-36.7 Rates-/32 Tidal V-100
O2 Flow-6 pO2-63* pCO2-59* pH-7.26* calHCO3-28 Base XS--1
Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NASAL [**Last Name (un) 154**]
[**2131-7-2**] 12:11AM BLOOD Lactate-2.3*
Final chemistries
[**2131-7-3**] 05:41AM BLOOD Glucose-128* UreaN-16 Creat-0.9 Na-152*
K-3.6 Cl-120* HCO3-24 AnGap-12
Final CBC
[**2131-7-3**] 05:41AM BLOOD WBC-8.5 RBC-2.61* Hgb-10.1* Hct-31.9*
MCV-122* MCH-38.8* MCHC-31.8 RDW-18.6* Plt Ct-82*
[**2131-7-3**] 05:41AM BLOOD PT-16.1* PTT-43.4* INR(PT)-1.7
[**2131-7-3**] 05:41AM BLOOD Plt Smr-LOW Plt Ct-82* LPlt-1+
PORTABLE AP CHEST AT 2:30 AM, [**2131-7-3**]: Comparison is made to
[**2131-7-1**]. NG tube tip remains within the stomach. The left
PICC tip is in the distal SVC. There is evidence of volume loss
in the left hemithorax with herniation of the right lung across
the midline and leftward displacement of the anterior junctional
line. There is no pneumothorax. The volume loss is likely in the
left lower lobe as there is evolving retrocardiac opacity. Also
noted on this study, which does not persist on subsequent
studies, is mild tracheal narrowing at the level of the aortic
arch. There is slight worsening opacity in the left upper lobe,
which could be due to aspiration or asymmetrical edema, or
pneumonia.
Brief Hospital Course:
This 64 year-old gentleman with a history of alcoholic
cirrhosis, prostate CA s/p brachytherapy and radiation therapy,
COPD, and dementia was admitted to the ICU for a 2 to 3 week
history of increasing abdominal girth, bright red blood per
rectum, and malaise that had been worsening [**12-28**] d PTA. In [**Name (NI) **] pt
found to be hypotensive and tachycardic P in 100's BP at 95/50,
BP improved with 3 L NS but tachycardia persisted. On exam pt
was jaundiced with tense abdominal ascites. Some bright red
blood per rectum. Neurologically the pt had a tremor.
Creatinine was normal. Liver enzymes found to be markedly
elevated. Ceftriaxone started empirically for the possibility
of subacute bacterial peritonitis. Hepatology service
consulted, recommended commencing pentoxifylline for prevention
of development of HRS.
Pt was transferred to MICU for concern for hypotension which
could have been secondary to one or all of the following
possibilities 1) sepsis 2) liver failure 3) acute blood loss.
In addition, given his history of alcohol abuse and the presence
of tachycardia and tremor concern was also raised for alcohol
withdrawal syndrome progressing to delirium tremens and CIWA
protocol was started.
On transfer to MICU pt went into respiratory distress, this
resolved adequately with inhaler therapy and continuous positive
airway pressure support. Throughout his hospital course, the
patients hemodynamic status was tenuous, frequently having
elevated respiratory rates along with low normal blood pressure
and frequent tachycardia. Per his partner, it was established
on HD 2 that he wished to be DNR/DNI from a living will he had
earlier wrote. Other major events of his hospital course
included a paracentesis on HD 4 that removed 2 L and resulted in
some symptomatic improvement. Analysis of this fluid was
remarkable only for serum ascites albumin gradient consistent
with portal hypertension. Pt was generally afebrile and, until
HD 6 did not appear septic. His BRBPR resolved and hematocrit
remained generally stable throughout his course.
In early morning of HD 7, pt was found to be in respiratory
distress with oxygen saturations falling to 80-90 range and
respiratory rate ranging from 30-40. Serial chest x-ray
demonstrated rapidly evolvling L lung field infiltrates,
consolidation and collapse consistent with aspiration pneumonia.
Levofloxacin and flagyl were started along with continuous
positive airway pressure support. In spite of these measures
the patient rapidly deteriorated into respiratory failure. No
further interventions could be performed in the patient as his
code status was DNR/DNI. The patient expired on 1:30 PM on
[**2131-7-3**].
Medications on Admission:
fludrocortisone 0.1, protonix 40, xalatan gtt, trusopt gtt,
combivent, aspirin
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver failure secondary to alcoholic cirrhosis.
Aspiration pneumonia resulting in respiratory failure and death.
Discharge Condition:
Expired.
Followup Instructions:
Autopsy declined by health care proxy.
|
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"571.2",
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"567.2",
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"276.1",
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icd9cm
|
[
[
[]
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] |
[
"99.07",
"38.93",
"54.91",
"96.6",
"93.90",
"45.13",
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icd9pcs
|
[
[
[]
]
] |
8104, 8113
|
5265, 7975
|
344, 349
|
8269, 8279
|
2347, 5242
|
8302, 8343
|
1958, 1977
|
8134, 8248
|
8001, 8081
|
1992, 2328
|
275, 306
|
377, 1121
|
1143, 1776
|
1792, 1942
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32,658
| 123,485
|
32809
|
Discharge summary
|
report
|
Admission Date: [**2143-4-5**] Discharge Date: [**2143-4-9**]
Date of Birth: [**2095-1-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 2234**]
Chief Complaint:
GI bleed and Hypotension
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy
Sigmoidoscopy
History of Present Illness:
This is a 48 year-old male with a history of ESLD and variceal
bleed who is transferred from OSH with GI bleed and hypotension.
.
OSH course: Per pt history and partial OSH record (full records
not available on admission) the patient was admitted on [**4-1**]
with melana and syncope. An EGD was performed in OSH ED
revealing grade 1 distal esophageal varices, portal gastropathy,
fresh heme in the stomach without active bleed. He remained
stable until the day of transfer.
.
On the day of transfer, a 3 L paracentesis was performed. Sortly
thereafter he was noted to be hypotensive with an SBP in the
60s. He was transferred to the ICU. He had several episodes of
large volume melanotic BMs. Labs revealed Hct of 17 (was 33
earlier that day).
A TLC femoral line was placed. He was transfused 3 units PRBCs,
2 units FFP, 2 units platelets. He was started on levophed 12
mcg/min, protonix gtt and octreotide gtt at 50 ml/hr.
[**Name8 (MD) **] RN report, he also spiked to [**Age over 90 **]F today, and was therefore
given a dose of ceftriaxone 2g/vanco 1g/flagyl 500. he was
transferred to [**Hospital1 18**] via [**Location (un) **] for further evaluation and
management.
.
On arrival to the ICU: He immediatly passed >300 cc's of
melanotic/bloody liquid BM. SBP 90 (on levophed), HR 60s. He
complained of mild epigastric pain, +chronic low back pain,
unchanged from baseline. No nausea/vomiting/sob/chest
pain/lightheadedness. He denies cough, urinary frequency,
urgency, dysuria, focal weakness, vision changes, headache, rash
or skin changes.
.
He was continued on levophed, given a NS bolus and transfused 2
units emergency release PRBCs. The liver team was consulted for
? emergent EGD.
Past Medical History:
-Cirrhosis: from HCV infection. Complicated by variceal bleed
([**2138**]) w/p EGD and banding last in [**11-24**], ascites on diuretics,
hyponatremia, and hepatic encephalopathy. Had been listed for
[**Date Range **] at [**Hospital1 2025**], but removed after psychiatric hospitalization
for SI/HI. Last colonoscopy in [**11-24**]. Reported baseline
coagulopathy, with INR
between [**1-20**].
-Hypertension
-Pancytopenia
-Depression, Anxiety, Psychosis: s/p admissions (most recently
[**2-23**]) for homicidal ideation
-GERD
-Chronic lower back pain
Social History:
Married with 1 adult daughter, smokes 1.5 ppd. + h/o etoh (sober
X 3 years) and drugs (h/o intranasal cocaine, IVDA), but
apparently quit in [**2138**]. On disability.
Family History:
Denies liver disease in family.
Physical Exam:
Vitals: T: 97.6 BP:96/55 (on levo) HR:61 RR: 13 O2Sat:100% 4L NC
GEN: ill appearing, pale, lethargic.
HEENT: jaundiced. EOMI, sclera anicteric, no epistaxis or
rhinorrhea, MM dry , OP Clear
NECK: Neck veins flat, carotid pulses brisk, no bruits, no
cervical lymphadenopathy, trachea midline
COR: RRR, [**2-21**] HSM normal S1 S2, radial pulses +2
PULM: Lungs CTAB, but diminished BS b/l bases
ABD: Distended but soft, +fluid wave, +umbilical hernia, mild
epigastric tenderness
EXT: No C/C/E, 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, +multiple spider angiomas. ecchymosis over R
ant chest wall.
Pertinent Results:
Admission labs:
[**2143-4-5**] 11:52PM WBC-11.9*# RBC-2.67* HGB-8.3* HCT-23.3*#
MCV-88# MCH-31.2 MCHC-35.7* RDW-17.8*
[**2143-4-5**] 11:52PM NEUTS-89* BANDS-6* LYMPHS-1* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2143-4-5**] 11:52PM PLT SMR-LOW PLT COUNT-147*#
[**2143-4-5**] 11:52PM GLUCOSE-166* UREA N-15 CREAT-1.1 SODIUM-134
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
[**2143-4-5**] 11:52PM ALBUMIN-2.5* CALCIUM-7.2* PHOSPHATE-3.2
MAGNESIUM-1.6
[**2143-4-5**] 11:52PM ALT(SGPT)-25 ALK PHOS-63 TOT BILI-4.1*
[**2143-4-5**] 11:52PM PT-19.7* PTT-45.2* INR(PT)-1.8*
.
Discharge labs:
[**2143-4-9**] 06:25AM BLOOD WBC-4.4 RBC-3.53* Hgb-10.8* Hct-31.6*
MCV-90 MCH-30.7 MCHC-34.3 RDW-17.5* Plt Ct-42*
[**2143-4-9**] 06:25AM BLOOD PT-20.3* PTT-44.1* INR(PT)-1.9*
[**2143-4-9**] 06:25AM BLOOD Glucose-61* UreaN-14 Creat-0.6 Na-131*
K-4.0 Cl-98 HCO3-29 AnGap-8
[**2143-4-8**] 12:27AM BLOOD Calcium-8.2* Phos-1.9* Mg-1.9
[**2143-4-9**] 06:25AM BLOOD ALT-42* AST-117* AlkPhos-70 TotBili-5.5*
.
Studies:
GI BLEEDING STUDY [**2143-4-6**]
IMPRESSION: Negative GI bleed scan.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2143-4-6**]
IMPRESSION:
1. Stigmata of longstanding liver disease including cirrhosis,
large amount of ascites, and splenomegaly.
2. Sludge within the gallbladder, however no evidence of
cholecystitis.
.
EGD, [**4-6**]
Findings: Esophagus:
Protruding Lesions 3 cords of grade I varices were seen in the
esophagus. The varices were not bleeding.
Stomach:
Mucosa: Granularity and mosaic appearance of the mucosa were
noted in the whole stomach. These findings are compatible with
portal hypertensive gastropathy.
Duodenum:
Mucosa: Granularity and friability of the mucosa with no
bleeding were noted in the duodenal bulb compatible with portal
hypertensive duodenopathy.
Other
findings: No evidence of upper GI bleed.
Impression: Esophageal varices
Granularity and mosaic appearance in the whole stomach
compatible with portal hypertensive gastropathy
Granularity and friability in the duodenal bulb compatible with
portal hypertensive duodenopathy
No evidence of upper GI bleed.
Otherwise normal EGD to proximal jejunum
Recommendations: 1) Proceed with flexible sigmoidoscopy
.
Sigmoidoscopy, [**4-6**]
Findings:
Contents: Clotted blood was seen in the rectum, sigmoid colon
and distal descending colon. It was not possible to get above
the blood. The site of bleeding was not identified.
Impression: Blood in the rectum, sigmoid colon and distal
descending colon
Otherwise normal sigmoidoscopy to descending colon
Recommendations: 1) Transfuse 2u PRBCs.
2) Correct coagulopathy/ thrombocytopenia.
3) Needs mesenteric angiography +/- embolization.
.
Colonoscopy, [**4-7**]
Impression: Ulceration, friability and abnormal vascularity in
the proximal ascending colon compatible with Ischemic bowel
(biopsy)
Otherwise normal colonoscopy to cecum
Recommendations: 1) Avoid hypotension.
2) Continue antibiotics.
3) Transfuse as required.
4) Follow histology.
.
SPECIMEN SUBMITTED: PROXIMAL ASCENDING COLON...1 JAR.
Procedure date [**2143-4-7**]
DIAGNOSIS:
Colon, ascending, mucosal biopsy:
A. Necrotic mucosa. See note.
B. Fibrinopurulent exudate with bacterial colonies.
Note: The findings are consistent with (the endoscopic finding
of) ischemia.
Brief Hospital Course:
48 year-old man with a history of ESLD and prior variceal bleed
who presents to OSH with GI bleed and hypotension, transferred
to [**Hospital1 18**] for further treatment.
.
Plan:
#GI Bleed/Ischemic colitis: Pt had sig. melanotic stool
concerning for upper GI bleed, esp. given his history of
variceal bleed. He was initially started on an octreotide gtt
as well as protonix IV BID. However, EGD did not reveal a
bleeding source; sigmoidoscopy could not locate the source due
to the extent of blood in the colon. Initial bleeding scan was
also unrevealing. The following day, a colonoscopy was
performed and findings suggested ischemia, as did the colon
biopsy. He was transfused a total of 7 units of PRBCs, 3 units
of FFP, and 4 units of platelets. His HCT stabilized at 31, and
he had no further episodes of sig. bleeding. He was discharged
on protonix.
.
#Acute blood loss anemia: As above.
.
#Hemorrhagic/Hypovolemic Hypotension: This was likely
hemorrhagic in the setting of GIB. On arrival, he required
levophed for 1 day in the MICU. His SBP returned to baseline of
90s with aggressive IVF resuscitation and transfusion of blood
products as above. Sepsis was also considered. He received
vanc, ceftraixone, and flagyl at the OSH prior to transfer. Pt
was continued on ceftriaxone given high risk of SBP (no
paracentesis was performed prior to initiation of abx) and
discharged on cipro for ppx. Pt was pancultured without any
growth.
.
#Hepatitis C virus cirrhosis. After pt was stabilized, he was
restarted on lactulose, rifaxamin, nadolol, lasix,
spironolactone. He was continued on ceftriaxone given high risk
of SBP though no paracentesis was performed prior to initiation
of abx)
.
#h/o psychosis, depression: Pt was continued on citalopram and
risperdone.
.
#Chronic back pain: Pt was cont on home regimen of oxycontin.
.
# Code: FULL
Medications on Admission:
Meds on transfer:
Levophed gtt
Octreotide gtt
Flagyl day 1
Vanco day 1
ceftriaxone day 1
albumin 50 g x1
lasix 40 mg/day
protonix
propranolol 10 mg daily
oxycontin 20 mg
risperidone 2 g [**Hospital1 **]
citalopram 20
spironolactone 25
lactulose tid
ondansetron prn
.
Meds at home: (per [**3-13**] discharge summary)
Rifaximin 400 mg TID
Pantoprazole 40 mg
Citalopram 20 mg
Oxycontin 20 mg [**Hospital1 **]
Nadolol 20 mg qHS
Furosemide 40 mg
Spironolactone 100 mg
Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H PRN
Lactulose 45 ml q4 titrate to 4 bm/day
Risperidone 2 mg [**Hospital1 **]
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO TID
(3 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Risperidone 2 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
10. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO twice a
day: Please take 2 tablets (500 mg) twice a day for 2 more days.
Then take 1 tablet (250 mg) once a day for 1 month.
Disp:*40 Tablet(s)* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain: Please do not take more
than 2 gm per day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastrointestinal bleed, upper and lower
Ischemic colitis
Acute blood loss anemia
Hypovolemic shock
.
Secondary:
Hepatitis C virus cirrhosis
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for bleeding from your gastrointestinal tract.
You required several blood transfusions. Upper endoscopy
looking into your stomach showed no signs of bleeding. There
was, however, bleeding noted in your colon. The bleeding seems
to have resolved. Your blood counts have been stable.
.
Please continue to take your medications as needed. For a
possible infection in your abdomen, you were started on
antibiotics. Please continue to the antibiotic ciprofloxacin
500 mg twice a day for 2 more days. Then you need to take
ciprofloxacin 250 mg once a day for at least a month to prevent
return of the infection. You should follow up with Dr. [**Last Name (STitle) 497**] to
see if you should continue ciprofloxacin longer than that.
Please avoid ibuprofen or naproxen. You may take acetaminophen
(tylenol) up to 2 grams per day.
.
If you develop a fever, worsening abdominal pain,
nausea/vomiting, blood in the stool or vomitus,
lightheadedness/dizziness, or any other concerning symptoms,
please call Dr. [**Last Name (STitle) 497**] at [**Telephone/Fax (1) 673**].
Followup Instructions:
Please keep the following appointments:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-4-10**] 2:00
|
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,269
| 140,783
|
1830
|
Discharge summary
|
report
|
Admission Date: [**2158-1-8**] Discharge Date: [**2158-1-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Intubation
Central Line
History of Present Illness:
HPI: Ms [**Known lastname **] is a [**Age over 90 **] yo female with h/o CHF (diastolic
dysfunction), CAD, CKD, PAFib, COPD/asthma who presents with
tachypnea and hypoxia. Pt was brought in by EMS. Per EMS she
was feeling lousy over past few days with progressive SOB and
cough starting 1 day prior to presentation.
.
In the ED she was found to be tachypneic to 40s with sats as low
as 80%. She denied CP. Her code status was confirmed as full.
She was intubated and placed on Midazolam gtt and Fentanyl
boluses. ABG 7.27/50/172/24 intubated on 100% FiO2. Of note
she was last intubated for respiratory failure in [**2157-4-9**]
thought to be secondary to PNA, COPD exacerbation, and CHF.
.
She was initially placed on a nitro gtt. Her lactate was
elevated at 3.8 and a code sepsis was called. IJ placed with
checklist preformed. She was given CTX 1 gm and Azithromycin
IV. The nitro gtt was stopped. Her SBP then dropped to the
70's and she was started on Neosynephrine with little effect,
changed to levophed. CVP ranged from [**8-19**]. SVO2 72%. She
received Aspirin, Furosemide 100mg, and Dexamethasone 4MG.
First set of cardiac enzymes were negative. Blood and urine
cultures were sent. UA with occ bacteria, 500 protein, o/w
negative. Creat noted to be 2.0. CXR with vascular congestion
and patchy LLL infiltrate.
.
Currently she is intubated and sedated. Opens eyes and responds
to verbal commands. Denies pain.
Past Medical History:
-CHF- ECHO [**6-14**] EF >55% with mild MR [**First Name (Titles) **] [**Last Name (Titles) 10225**]
-Coronary Artery Disease, LAD stent [**5-13**]
-Paroxysmal Atrial Fibrillation not on coumadin
-Asthma
-hypothyroidism
-Diverticulitis
-Hypercholesterolemia
-Right Hip Fracture
-History of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears
-Chronic Kidney Disease (baseline Creat1.9-2.0)
-h/o MRSA PNA
-h/o hypertensive urgency
-pseudogout
Social History:
Lives in apartment with 24 hour home care. Able to ambulate
with walker at home, but uses wheelchair when leaving the house.
Daughter is main caregiver and helps with administering
medications. Smoked in her teens but none since. Rare EtOH
use.
Family History:
Non-contributory
Physical Exam:
Admission physical exam:
PHYSICAL EXAM:
VS: Tc 98.6, BP 146/68, HR 70, RR 17, O2 sat 98%
Vent: AC, Vt 550, RR 17, FiO2 60%, PEEP 5
Drips: Levophed 0.1 mcg/kg/min
Gen: intubated, sedated, appears comfortable, NGT in place
HEENT: MMM, anicteric
Neck: unable to assess JVD
CV: RRR, nl S1S2
Pulm: Ant: bronchial breath sounds, rhonchi throughout, no
wheezing
Abd: soft, NT/ND, pos BS
Ext: no edema, strong DP/PT pulses, moving all extremities
spontaneously, feet cool with bluish discoloration, good cap
refill
Brief Hospital Course:
.
A/P: [**Age over 90 **] yo female with h/o CHF (diastolic dysfunction), CAD,
CKD, Pafib, COPD/asthma who presents with tachypnea and hypoxia
requiring intubation.
.
# Respiratory failure: Likely multifactorial including LLL PNA,
COPD exacerbation, and CHF. Intubated; succesfully extubated
[**2157-1-16**] after made DNR/DNI
- Consulted neurology for ?myopathy vs. neuropathy in effort to
understand inability to wean. Neurology service does not
believe exam consistent with myositis/nerve process/myasthenia
but cannot exclude steroid myopathy. Successfully extubated
[**2157-1-16**]
- Continue prednisone taper for COPD; patient failed attempt to
wean from 40 mg to 5 mg (fast taper preferred in setting of
concern re steroid myopathy), becoming hypotensive. Currenttly
on 30mg qd. Will be discharged on slow taper to goal of 10mg qd
- initially treated w/ CTX and Azithro for CAP, continue
vancomycin for sputum +MRSA for a total of 14d course. Last day
[**2158-1-22**]
-diuresed well with lasix 40 mg IV qAM, transitioned to 40mg po
qAM on discharge
.
# Sepsis likely secondary to PNA. Received 4 liters of NS in
ED.
- Received 4 liters of NS in ED.
- transiently hypotensive when titrating steroids quickly, but
has been normotensive on slow taper
- continued vancomycin as above, dosed per level given her
improving renal function
.
# CKD. Creat improved to better than baseline during admission.
attempted low dose linsinopril dose, but failed [**2-10**] Cr bump
(see below)
.
# CAD/CHF: s/p stent [**5-13**]. initially held statin as may have
contributed to myopathy/weakness, but CK wnl, so we restarted
it. We continued ASA, B- blocker and started ACE-I at low dose
2d prior to discharge, but her Cr bumped from 1.4 to 1.8, so it
was discontinued
.
# PAF: not coumadin candidate given h/o falls and diverticular
bleeds. Currently in sinus. Continue ASA. Was in sinus during
her stay here. She was discharged on the same metorprolol dose
she was on prior to admission
.
# Hypothyroidism:
-TSH on [**2158-1-10**] low at 0.055, initially levothyroxine was
decreased from 88 mcg daily to 50 mcg daily. However, this was
in context acute illness and other labs c/w sick euthyroid, so
thyroid replacement was returned to standard dose prior to
discharge
.
# FEN:
-speech and swallow evaluation, initially failed [**2-10**] somnolence
and cough s/p extubation, but was reevaluated and was cleared to
take regular foods and thin liquids with as tolerated.
.
# CODE: Had multiple discussions with patient and family s/p
extubation and everyone agreed that at this time pt. an family
would not want intubation, resuscitative measures in the future.
This is noted in POE by a DNR/DNI status
Medications on Admission:
1. Prilosec 20 mg PO once a day.
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk [**Hospital1 **]
3. Bisacodyl 10 mg PO DAILY as needed
4. Docusate Sodium 100 mg PO BID
5. Prednisone 10 mg PO once a day.
7. Aspirin 325 mg PO DAILY
8. Levothyroxine 88 mcg et PO DAILY
9. Albuterol Neb [**Hospital1 **]
10. Ipratropium Inhalation every six hours prn.
11. Colchicine 0.6 mg PO daily.
12. Ferrous Sulfate 325 PO DAILY
13. Furosemide 80 mg PO DAILY
14. Multivitamins PO DAILY
15. Atorvastatin 20 mg PO HS
16. Metoprolol Tartrate 50 mg PO three times a day.
23. Senna 187 mg PO twice a day as needed
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
units Injection Q8H (every 8 hours).
3. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Cap PO DAILY
(Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
8. Cepacol 2 mg Lozenge [**Hospital1 **]: One (1) Lozenge Mucous membrane PRN
(as needed).
9. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
10. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
11. Benzonatate 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3
times a day) as needed for cough.
12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
13. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
14. Lisinopril 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
15. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
16. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Hospital1 **]: 1000 (1000)
mg Intravenous Q 24H (Every 24 Hours) for 3 days.
17. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO qd () for 3
doses.
18. Prednisone 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO qd () for 7
doses: Start after 30mg dose is finished.
19. Prednisone 5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO qd () for 7
doses: Start after 20mg dose is finished.
20. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO qd (): Start
after 15mg dose is finished.
21. Levothyroxine 88 mcg Tablet [**Hospital1 **]: One (1) Tablet PO once a
day.
22. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO
three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Community acquired MRSA PNA
COPD
Diastolic CHF
Asthma
_______________________
Atrial Fibrillation
Ahronic Kidney Disease
CAD
Hypercholesterolemia
Discharge Condition:
good, tolerating pos, sitting up without assistance, satting 95%
on 1-2L.
Discharge Instructions:
Please seek medical attention should you develop increased
shortness of breath, chest pain, nausea, fever, chills. Please
also return if you should develop abodminal pain, GI bleeding,
urinary symptoms, increased swelling or any other concerning
symptoms.
Please take all your medications exactly as prescribed and
follow up with your PCP as below
Followup Instructions:
Your PCP will follow up with you within a week of leaving rehab.
You should call to make an appointment with him at [**Telephone/Fax (1) 10238**]
should he not contact you during that time. He should check
your creatinine as we have initiated lisinopril as well as
adjust your lasix dose per your symptoms. He should also check
your thyroid function tests as your TSH was low in the hospital,
though that was in the context of your being quite ill.
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
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] |
icd9pcs
|
[
[
[]
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] |
8789, 8868
|
3117, 5827
|
281, 306
|
9058, 9134
|
9532, 9987
|
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,502
| 155,976
|
5679
|
Discharge summary
|
report
|
Admission Date: [**2114-11-26**] [**Month/Day/Year **] Date: [**2114-12-3**]
Date of Birth: [**2079-7-7**] Sex: M
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
35 y/o male with SLE/Myositis overlap, dCHF, HTN, CKD who
presents with diffuse arthralgias, blurry vision, N/V and CP
reproducible with palpation. These symptoms have been waxing and
[**Doctor Last Name 688**] for 2 weeks. The pt took Prednisone 50 mg last night per
his PCP although has been off home prednisone since [**Month (only) **]. LE
edema is roughly at baseline, as is L ankle tenderness.
Patient's HbA1c was 7 in [**Month (only) **] and has not had a previous
admission w/ hyperglycemia and does not have a formal diagnosis
of DM.
.
In the ED, initial VS were HR 77, BP 145/82, RR 22, Sat 98% RA,
BG critically high
.
ROS notable for + cough, muscle aches, blurry vision, HA. Neg
for SOB, CP at rest. Labs were notable for glucose of 1065, chem
of 118* 6.2* 71* 27 45* 2.5. Urine however was negative for
ketones. EKG showed SR@93 NA/NI inf-ant STD c/w prior. Bedside
US of heart - no effusion. CXR was unremarkable for any new
consolidation, or infectious process.
.
Pt was given 3L NS, morphine 4mg X 2 and was started on insulin
10 meq/hr gtt in the ED.
Per his PCP, [**Name10 (NameIs) **] [**Last Name (STitle) **], who talked to him over the phone
yesterday, "We had deferred steroids given side effect profile,
but probably cannot do that anymore. See my telephone note from
last night; has some serositis, fatigue. If this is not renal
failure and indeed a flare of his myositis/serositis, we may
have to give him pulse methylprednisolone, would consult with
[**Doctor First Name **] [**Doctor Last Name 1667**] his outpatient rheumatologist. His outpt therapy is
hydroxychloroqine and myfortic (though myfortic he has not been
able to tolerate b/c of GI sx, may be related to current flare).
He also gets rituxan.".
On arrival to the MICU, the patient was well oriented and
vitally stable.
.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight gain. Denies
sinus tenderness, rhinorrhea or congestion. Denies shortness of
breath, or wheezing. Denies palpitations, or weakness. Denies
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies rashes or
skin changes.
Past Medical History:
1. Hypertension.
2. Left ventricular hypertrophy secondary to hypertensive heart
disease.
3. Rare PAF.
4. Stage IV chronic kidney disease (baseline between 1.5-2.5).
5. Probable diastolic heart failure.
6. Hypertensive nephropathy.
7. Lupus.
8. Venous stasis and lymphedema with chronic lower extremity
edema.
9. Morbid obesity.
10. Non-ST elevation MI x2.
11. Gout.
12. GERD, status post ventral hernia repair in [**2110**].
13. Impaired glucose intolerance.
14. Hyperlipidemia.
15. Polymyositis.
Social History:
Lives with his girlfriend and they have one
child together, recently engaged, currently on disability,
worked
in corrections facility for 15 years. Nonsmoker, rare ETOH, no
IV drug use.
Family History:
Includes hypertension, heart disease, thyroid
problems, diabetes, and osteoarthritis.
Physical Exam:
Vitals: T: 97.5 BP:137/98 P: 95 R: 23 O2: 98 on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Edema unchanged from baseline
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Brief Hospital Course:
37m k/c of SLE, CKD, HTN, s/p MI X 2, and impaired glucose
intolerance presenting with hyperglycemia.
#Hyperosmotic hyperglycemic state + IDDM:
On presentation was hypovolemic with anion gap acidosis and
grossly elevated glucose but no urine ketones indicating HHS,
not DKA. After starting insulin gtt, his gap closed and
metabolic derrangements improved. Although he did not have
previous dx of DM, has numerous risk factors for diabetes and
was recently on prednisone, which likely contributed to acute
exacerbation. In [**2114-4-20**], pt's A1C was 7.1 and on admission
it was >14 indicating that he has been diabetic for at least
three months. Pt required very large doses of insulin to
control blood glucose and he was eventually stabilized on
humalog and lantus regimen. Pt understood how to administer
insulin and how to use humalog sliding scale. He was taught how
to use his home glucometer and will follow up in [**Hospital **] clinic
in two weeks time. At time of [**Hospital **] islet cell antibody was
pending. Glutamic acid decarboxylase was checked and was normal.
.
#SLE flare:
Pt was worked up for SLE flare at time of admission. His CK
elevated and ESR, CRP and C4 were mildly elevated. Rheumatology
was consulted and it was determined that he was not having an
SLE flare. He was continued on his home chloroquine and
prednisone was discharged in setting of hyperglycemia.
.
#CKD: Patient's baseline Cr is 1.5-2.5. On admission Cr was at
baseline and remained at baseline until his diuretics were
restarted. He diuresed 4 liters in 1 day and creatinine rose to
3.3. Diuretics were temporarily stopped due to [**Last Name (un) **] and his
creatinine improved to baseline at time of [**Last Name (un) **].
Metolazone was discontinued and he was restarted on
spironolactone 100mg [**Hospital1 **] and his torsemide was decreased to 60mg
daily at time of [**Hospital1 **].
.
#Gout: Pt's colchicine was held in setting of [**Last Name (un) **]. Febuxostat
was continued at time of [**Last Name (un) **].
.
#CAD: Patient continued to recieve aspririn, isosorbide
dinatrate, and carvedilol.
.
FULL CODE
.
Transitional Care:
- follow up islet cell antibodies
- follow up with PCP, [**Name10 (NameIs) **], Rheumatology and Cardiology.
Medications on Admission:
AMMONIUM LACTATE - (Prescribed by Other Provider) - 12 % Lotion
- 1 Lotion(s) three times a day
CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
COLCHICINE [COLCRYS] - 0.6 mg Tablet - one Tablet by mouth up to
twice a day only as needed for gout pain; stop taking if
diarrhea
occurs
FEBUXOSTAT [ULORIC] - 40 mg Tablet - one Tablet(s) by mouth once
a day
HYDROXYCHLOROQUINE - 200 mg Tablet - 2 Tablet(s) by mouth once a
day
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth DAILY
METOLAZONE - 5 mg Tablet - 2 Tablet(s) by mouth twice a day, 60
minutes prior to each torsemide dose
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
POTASSIUM CHLORIDE - (taking 160meq total not 180meq) - 20 mEq
Tablet, ER Particles/Crystals - 3 Tablet(s) by mouth three times
a day with meals
SEVELAMER CARBONATE [RENVELA] - (Prescribed by Other Provider;
NOT TAKING) - 800 mg Tablet - 1 Tablet(s) by mouth three times a
day
SPIRONOLACTONE - 100 mg Tablet - 1 Tablet(s) by mouth TWICE a
day
TORSEMIDE - (Dose adjustment - no new Rx) - 100 mg Tablet - 1
Tablet(s) by mouth twice a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider: [**Name10 (NameIs) **] med) - 325
mg
Tablet - 1 Tablet(s) by mouth daily
CALCIUM CARBONATE [CALTRATE 600] - 600 mg (1,500 mg) Tablet - 1
Tablet(s) by mouth twice a day
CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] - (Prescribed by Other
Provider) - 400 unit Tablet - 2 Tablet(s) by mouth DAILY (Daily)
[**Name10 (NameIs) **] Medications:
1. ammonium lactate 12 % Lotion Sig: One (1) application Topical
TID (3 times a day).
2. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. febuxostat 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Three (3) Tablet, ER Particles/Crystals PO three times a day:
taking 160 total mEq not 180.
8. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. insulin glargine 100 unit/mL Solution Sig: 70-80 Units
Subcutaneous twice a day: take 80 units at breakfast and 70
units at bedtime .
Disp:*42 mL* Refills:*2*
14. insulin lispro 100 unit/mL Solution Sig: 40-55 units
Subcutaneous three times a day: take 55 units at breakfast, 40
units at lunch and 50 units at dinner .
Disp:*40 mL* Refills:*2*
15. insulin lispro 100 unit/mL Solution Sig: 4-26 units
Subcutaneous per sliding scale: refer to sliding scale for
dosing.
16. insulin syringes (disposable) 1 mL Syringe Sig: [**1-21**]
syringe Miscellaneous four times a day: use a new syringe for
each injection of insulin .
Disp:*180 syringes* Refills:*2*
17. torsemide 20 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
18. blood glucose test strips
Freestyle Lyte test strips
use one strip four times daily
#120
19. lancets
lancets for blood glucose monitoring
one lancet to test blood glucose levels 4 times daily
#120
[**Month/Day (2) **] Disposition:
Home
[**Month/Day (2) **] Diagnosis:
hyperosmotic hyperglycemic state
insulin dependent diabetes
acute on chronic kidney failure
[**Month/Day (2) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Month/Day (2) **] Instructions:
Dear Mr. [**Known lastname 22702**],
It was a pleasure taking care of you. You were admitted to the
hospital for a condition called hyperglycemic hyperosmotic
state, which is caused by very high blood sugars in people with
diabetes. We treated you with IV fluids and insulin in the ICU
until your blood sugars were under control. When your sugars
stabilized, we started you on insulin injections and we now
believe we have you on a good regimen. It is important to
follow up at [**Last Name (un) **] in two weeks for additional teaching about
lifestyle modifications and management of your diabetes.
.
During your hospitalization we restarted your home diuretics and
your kidney function declined. We decreased your torsemide and
stopped metolazone and your kidney function improved to your
baseline.
.
We have made the following changes to your medications:
START insulin glargine intramuscular injection 80 units at
breakfast and 70 units at bedtime
START insulin humalog intramuscular injection 55 units at
breakfast, 40 units at lunch and 50 units at dinner.
ADDITIONALLY, use humalog for insulin sliding scale
CHANGE Torsemide from 100mg twice daily to 60 mg twice daily
STOP metolazone
.
Please continue all the rest of your home medications.
We have arranged follow up appointments for you, the details are
outlined below.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2114-12-6**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Follow up with [**Hospital **] Clinic in two weeks. They have provided
you with the follow up information.
.
Department: RHEUMATOLOGY
When: TUESDAY [**2114-12-25**] at 8:30 AM
With: [**Name6 (MD) 3712**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2115-2-6**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
- Dr. [**Last Name (STitle) 4883**] would like to see you earlier than this. His
office will be calling you within the next day to schedule an
appointment within the next week. If you do not hear from him,
please call the number above.
Department: CARDIAC SERVICES
When: MONDAY [**2115-3-4**] at 11:40 AM
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
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4050, 6312
|
292, 299
|
11820, 13462
|
3256, 3344
|
6338, 10206
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,031
| 179,732
|
32476
|
Discharge summary
|
report
|
Admission Date: [**2118-2-17**] Discharge Date: [**2118-3-25**]
Date of Birth: [**2052-10-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Abdominal Pain and Vomiting
Major Surgical or Invasive Procedure:
EGD [**2-18**]
ERCP [**2-22**], 2/19
[**2118-3-15**]: Extensive lysis of adhesions, gastrojejunostomy.
History of Present Illness:
65 year old male with hx of CBD stricture s/p Common bile duct
excision, cholecystectomy, Roux-en-Y hepaticojejunostomy
transferred from OSH with abdominal pain, nausea/vomiting and
WBC. Patient states he was admitted to OSH last week for
pancreatitis after having some abd pain and lipase checked by
PCP, [**Name10 (NameIs) 21299**] slowly to full liquid diet and discharged home on
Tuesday, [**2118-2-15**]. Then night of [**2118-2-16**] after a low fat meal, he
developed severe epigastric pain, nausea/vomiting which lasted
for 36 hours and presented again to OSH ED. CT scan from workup
from previous admission ([**2-9**]) to OSH shows pancreatic head mass,
gastritis with possible GOO and evidence of portal venous HTN
w/possible varices. He was given zosyn and then transfered for
further evaluation. On arrival to our ED, his vitals were
stable, he was given zofran, morphine, valium. KUB was done
which showed a nonspecific gas pattern. ERCP was called who
recommended an U/S guided biopsy.
.
On admission to the floor, he was vomiting dark black coffee
ground material and reported melenotic stool x1 days. He reports
vomiting all day. NG lavage was performed. A total of 400 cc of
water was flushed with dark black emesis for return. Emesis
continued to return without flush and a total of 5.5 L of black
(non-red) emesis was drained. NG tube was left on low
intermittent suction. GI was consulted with plan for EGD this
morning. Pt was type/crossed and ordered for 2U prbcs.
.
Patients Hct on arrival to the ED 35 -->32->30->29 this AM.
Patient was given some fluids 150cc/hr. Pts BP initially stable
but trended down to Systolics of 90s and he was bolus'd 1Liter
with improvement 110s. Given he could not obtain blood
transfusion during an EGD down in the endoscopsy suite; he was
transferred to the MICU for closer monitoring.
.
He currently reports he has [**1-16**] abdominal pain. Denies CP;/SOB.
He reports no nausea, + vomiting overnight.
Past Medical History:
CBD stricture s/p Common bile duct excision, cholecystectomy,
Roux-en-Y hepaticojejunostomy performed in [**2115**] at [**Hospital1 18**] (Dr.
[**Last Name (STitle) **]
--->no malignancy identified on path however CBD pathology had
areas of both low and high grade dysplasia
- depression
- s/p tonsillectomy
- s/p elbow surgery
- Carpal tunnel syndrome
Social History:
Patient denies smoking, alcohol, lives with wife
Family History:
noncontributory
Physical Exam:
General: Alert, slight discomfort with NGT in place
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm no murmurs
ABDOMEN: soft, Tender to palpation mildly in epigastric/RUQ
region, right lateral abdominal wall hernia; non
tender/reducible
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No jaundice, no spider angiomata
Pertinent Results:
CT Abdomen
1. Extensively infiltrating mass in the region of the porta
hepatis, with
vascular encasement, may be of pancreatic origin or represent an
extrahepatic
cholangiocarcinoma, as previously suggested.
2. Thrombus within the portal vein as well as encasement and
occlusion of the
splenic vein/SMV confluence.
3. Multiple hypodense liver lesions, unchanged.
4. Multiple lymph nodes within the mesentery and along the
portocaval,
celiac, and superior mesenteric regions.
5. Right lateral abdominal wall hernia containing nonobstructed
loops of
bowel.
6. Interval increase in small amount of free fluid within the
paracolic
gutters and the perihepatic space.
7. Interval increase in small bilateral pleural effusions.
8. Extensive varices, unchanged.
Pathology:
[**2-22**] duodenal biopsy:
Duodenum, biopsy:
Duodenal mucosa with chronic and active inflammation.
[**2-22**] porta hepatis mass:
ATYPICAL.
A few groups of atypical glandular cells, can not exclude
dysplasia.
[**2-25**]: ascitic fluid, perigastric area
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, histiocytes, scant lymphocytes, and
benign-appearing squamous cells.
[**2-25**] celiac node FNA by EUS
NEGATIVE FOR MALIGNANT CELLS.
Scattered small mature lymphocytes; no definite evidence of
lymph node sampling.
A few groups of glandular epithelial cells and
benign-appearing squamous cells, consistent with
gastrointestinal contamination.
.
EGD [**2-18**]:
Esophagitis
Blood in the stomach
Duodenal ulcer
Duodenal stenosis
Otherwise normal EGD to second part of the duodenum
.
EGD/EUS [**2-22**]:
Circumferential non-bleeding mass of malignant appearance was
found at the distal bulb, D1/D2 junction.
The mass caused a partial obstruction.
Appearances suggestive of extrinsic infiltrating malignant
process.
Relatively easy passage of scope raises possibilty of
paraneoplastic Gastroparesis as main cause of nausea as opposed
to mechanical obstruction
EUS examination
Normal diameter pancreatic duct seen in grossly abnormal
pancreatic parenchyma
Hypoechoic septated parenchyma seen from stomach.
Unable to pass obstruction with EUS probe, no clear view of
pancreatic head.
5x5 cm lesion noted from duodenal bulb extending towards porta
hepatis
Heterogenous appearance with areas suggestive of necrosis,
malignant phenotype.
Unable to identify CBD.
Portal vein clearly seen, flow absent.
Flow seen in distal SMV.
Complete replacement of portal confluence by mass noted.
Multiple pathological perigastric nodes noted.
Periduodenal, perigastric ascites noted.
Coeliac axis examined carefully, there was no lymphadenopathy
Cytology samples were obtained
Cold forceps biopsies were taken from involved mucosa at the
level of the infiltrating duodenal mass.
.
Labs at discharge: [**2118-3-25**]
WBC-10.2 RBC-3.39* Hgb-9.8* Hct-30.1* MCV-89 MCH-28.8 MCHC-32.4
RDW-15.0 Plt Ct-157
Glucose-111* UreaN-16 Creat-0.6 Na-133 K-4.1 Cl-104 HCO3-22
AnGap-11
ALT-61* AST-39 AlkPhos-159* TotBili-0.8
Calcium-7.7* Phos-3.2 Mg-2.0 Triglyc-121
[**2118-2-24**] CEA-<1.0 AFP-1.1
[**2118-2-25**] CA [**27**]-9 -343
Brief Hospital Course:
65 yo man admitted with UGIB, found to have gastric outlet
obstruction due to portahepatis mass, awaiting EUS for
diagnosis.
# Upper GI bleed, with duodenal ulcer, and acute blood loss
anemia: Patient presented with large volume black emesis now
draining >5L. He was admitted to the ICU and an EGD on arrival
to ICU: showed ulcer in duodenal bulb, evidence of Gastric
outlet obstruction with concern for mass going into the lumen.
He was transfused 2U prbcs. He subsequently underwent a CT
Abdomen which showed a hypodense mass in the region of the porta
hepatis which remained hypodense suggestive of
cholangiocarcinoma. He was started on protonix IV and
sucralfate, and had stable Hct after transfusion.
.
# Portahepatis Mass: He was found to have a porta hepatis mass.
ERCP was consulted for evaluation, and he underwent EUS for
diagnostic purposes twice, with no clear diagnosis yet obtained.
He is now awaiting repeat EUS. He was also seen by Dr. [**Last Name (STitle) **]
of hepatobiliary surgery, who knows Mr. [**Known lastname 1557**] from his prior
surgery. His final recommendations are awaiting results of
biopsy, but if the mass is found to be malignant, as expected,
it would be unresectable. CEA and AFP were negative. CA [**27**]-9
was 343 (high). Biopsy with atypical cells, too few to
characterize. Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] agreed that next step
should be gastrojejunostomy and biopsy. Dr. [**Last Name (STitle) **] and his
service took over care and he underwent Extensive lysis of
adhesions, and gastrojejunostomy on [**2118-3-15**]. He tolerated the
procedure and was kept NPO with the NGT in place for a week post
operatively. His nutrition was maintained on TPN which he
received via a PICC line. On [**3-20**] a gastrografin swallow was
performed and demonstrated no evidence of extraluminal leak.
Once the NG tube was removed following the study, he was started
slowly on clears and was then advanced to regular diet with no
nausea, vomiting or increased abdominal pain. The TPN was
continued until the day of discharge and the PICC was pulled
prior to discharge. ...
.
# Duodenal obstruction: On initial EGD, he was found to have
possible duodenal obstruction. NG tube was placed and he was
made NPO. Subsequent EGD showed evidence of possible
gastroparesis, with food in the stomach, despite NPO status for
several days prior. He was started on reglan, and on a diet
slowly, and had no evidence of obstruction, without nausea or
vomiting. His NGT was removed and he was able to tolerate a
clear liquid diet. He soon developed worsening abdominal
distension and nausea and had his NGT replaced. He had >3L dark
coffee ground output. GI was reconsulted and felt urgent EGD
was not needed. He was transfused another 2 units of PRBC
overnight. With placement of the NGT, his nausea and distension
resolved.
.
# Depression: Restarted lexapro and will be continued with home
dose and outpatient followup with his psychiatrist.
.
By day of discharge the patient was tolerating regular diet
(although small amounts and was encouraged to use supplements at
home). He had return of bowel funcion. He was ambulating without
assist.
Medications on Admission:
Admission medications:
Lexapro 10 mg daily
MVI daily
Nadolol 20 mg daily - was prescribed [**2118-2-14**] and he only took 1
dose 3 days ago
Chondroitin-glucosamine 1 tab daily
Calcium 2 tabs daily
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q 8H (Every 8 Hours).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. Glucosamine-Chondroitin 500-400 mg Capsule Sig: One (1)
Capsule PO twice a day.
6. Calcium 500 with Vitamin D 500 mg(1,250mg) -200 unit Tablet
Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Interim VNA
Discharge Diagnosis:
Upper GI bleed/ resolved
Acute blood loss anemia
Duodenal obstruction, now s/p gastrojejunostomy
Discharge Condition:
Stable/Good
A+OX3
Ambulatory
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills,
nausea, vomiting, diarrhea, increased abdominal pain, increased
drainage or bleeding from the abdominal incision, inability to
take or keep down food, fluids or medications.
Monitor the incision for redness, increased drainage or
bleeding. Change the dressing twice daily
No heavy lifting (nothing heavier than a gallon of milk)
No driving if taking narcotic pain medication
Drink enough fluids to keep urine light yellow in color
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2118-3-30**]
2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2118-3-25**]
|
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"276.8",
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"486",
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"535.61",
"564.00",
"532.41",
"577.9",
"568.0",
"E879.8",
"537.0",
"576.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"88.74",
"99.15",
"46.41",
"54.59",
"45.16",
"38.93",
"51.12",
"97.49",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
10607, 10649
|
6532, 9740
|
342, 447
|
10790, 10821
|
3426, 6171
|
11402, 11721
|
2895, 2912
|
9988, 10584
|
10670, 10769
|
9766, 9766
|
10845, 11379
|
9789, 9965
|
2927, 3407
|
275, 304
|
6190, 6509
|
475, 2435
|
2457, 2812
|
2828, 2879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,701
| 154,678
|
34454
|
Discharge summary
|
report
|
Admission Date: [**2189-7-27**] Discharge Date: [**2189-8-6**]
Date of Birth: [**2123-3-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Lightheadness, coffee grounds emesis
Major Surgical or Invasive Procedure:
EGD, blood transfusions
History of Present Illness:
This is a 66 year-old female with a history of who presents with
left PICA artery aneurysm s/p coiling [**3-16**], PVD s/p SMA
stenting, HTN, hyperlipidemia presents with light-headedness.
The patient reports that she was discharged from [**Hospital **] [**Hospital 4117**]
Rehab 2 weeks ago. She states that over the weekend she was
walking down the stairs and felt light-headed. She states that
she "blacked out" for several seconds. She continued to feel
dizzy and light-headed. The following day she states she was
too weak to get out of bed and spent most of her time in bed.
She continued to feel dizzy and weak this AM. She reports
vomiting coffee ground/black emesis x1. She also reports
chronic black stools since she was started on Fe supplements
several months previously. Has been taking ASA 325mg, no other
NSAIDS. She denied any hematochezia. She was seen by the VNA
today and advised to go to the ED.
.
She also reports chronic baseline cough. However, she reports
that she has had increasing cough and sputum production. No
fevers or chills. She does report that her grandchilden have
been sick recently.
.
In the ED, VS 98.1, 123, 129/58, 18, 96%RA. Patient labs were
remarkable for a Hct of 17.7 (baseline low-mid 20's, severely Fe
deficient with ferritin of 6). On exam she was occult blood
positive, but no gross blood was seen. She was transfused 1U
pRBC, 2 PIV, and given 40mg IV protonix. She was also given 3L
IVF. GI was consulted and aware. WBC was 11.0, lactate 2.7. CXR
showed possible early RUL pna and given 750mg levofloxacin.
The patient states the she had a EGD and colonscopy 1 month
prior at [**Hospital3 **] that was reportly normal. Per prior d/c
summary she underwent EGD and colonscopy on [**6-15**] at an OSH
which showed only ischemic colonic ulcer.
Past Medical History:
Left proximal PICA aneurysm w/mass effect on brainstem s/p
coiling
Emphysema
Hypertension
Hyperlipidemia
Cholecystectomy
Peripheral vascular disease, mild celiac stenosis and
moderate-to-severe SMA stenosis s/p stent [**8-15**] with known [**Female First Name (un) 899**]
occlusion.
S/P left ankle fracture
Tobacco abuse
Appendectomy
Depression
Social History:
She is married with four living children. Tobacco - quit in
[**8-15**](prior 1 pack per day x 56 years. No EtOH or other drugs.
She works as bookkeeper for her husband [**Name (NI) **]
Family History:
Her mother ovarian ca, father with unknown ca
Physical Exam:
Vitals: T:97.0 BP:148/63 HR:109 RR:15 O2Sat:98%RA
GEN: Elderly female in no acute distress, appears fatigued
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: no JVP no bruits, no cervical lymphadenopathy
COR: RRR, no M/G/R, normal S1 S2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact, except mild facial droop on left. Moves all 4
extremities. Strength 5/5 in upper and lower extremities on
right, but [**4-12**] on left. Patellar DTR +1. Plantar reflex
downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2189-7-27**] 11:52PM WBC-10.3 RBC-2.32* HGB-6.8* HCT-20.8* MCV-89
MCH-29.4 MCHC-32.9 RDW-16.7*
[**2189-7-27**] 11:52PM PLT COUNT-412
[**2189-7-27**] 03:55PM GLUCOSE-111* UREA N-36* CREAT-0.7 SODIUM-140
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
[**2189-7-27**] 03:55PM estGFR-Using this
[**2189-7-27**] 03:55PM ALT(SGPT)-8 AST(SGOT)-8 ALK PHOS-82 TOT
BILI-0.1
[**2189-7-27**] 03:55PM LIPASE-25
[**2189-7-27**] 03:55PM WBC-11.0 RBC-1.87*# HGB-5.7* HCT-17.7*
MCV-95# MCH-30.8# MCHC-32.4 RDW-14.3
[**2189-7-27**] 03:55PM NEUTS-77.7* LYMPHS-18.7 MONOS-3.1 EOS-0.4
BASOS-0.2
[**2189-7-27**] 03:55PM PLT COUNT-498*
[**2189-7-27**] 03:55PM PT-12.3 PTT-24.3 INR(PT)-1.0
[**2189-7-27**] 03:12PM LACTATE-2.7*
Most recent labs:
Na 139, K 4.4, Cl 100, HCO3 30, BUN 10, Cr 0.6, Gglu 99
WBC 12.7, Hct 27.1, plts 618
.
Imaging:
Chest xray: Admission [**7-27**]
IMPRESSION: Right upper lung airspace opacity worrisome for an
early
pneumonia.
Most recent [**8-5**]:
1. A new right PICC line terminates in the mid SVC without
complications.
2. Stable right pulmonary nodule warrants further investigation.
PA and
lateral chest radiographs are recommended for better
visualization of this abnormality. In addition, a right lateral
decubitus view would be helpful to evaluate the right lower lung
abnormality.
Chest CT [**8-6**]:
1. New right upper lobe well-defined homogenous opacity is most
likely an
abscess, although a necrotic soft tissue tumor is also in the
differential.
Recommend 3-4 weeks of antibiotic treatment and follow up with
chest x-ray to assess any change in size of this nodule and
possible biopsy or PET scan at that stage if the mass remains
unchanged. appearances.
Right lower and middle lobe collapse with persistent minor
atelectasis with a smaller right pleural effusion. Slight
increase in the central lymph nodes as described athough these
are not pathological by CT size criteria.
Stable right renal cyst and left adrenal adenoma.
Brief Hospital Course:
66F h/o L PICA artery aneurysm s/p coiling [**3-16**], dysphagia, p/w
coffee grounds emesis and acute blood loss anemia.
1. Acute blood loss/anemia: On arrival to the [**Hospital Unit Name 153**], Mrs. [**Known lastname 79194**] vital signs were stable and she was anemic to 17.7
(baseline Hct mid 20s secondary to Fe deficiency). Presumptive
diagnosis was upper GI source due to h/o coffee grounds emesis.
Melena hard to interpret due to Fe therapy. She received 1 units
PRBCs in the ED and 2 units in the [**Hospital Unit Name 153**] with appropriate Hct
bumps. On hospital day 2 her Hct was stable in the low 30s
without transfusions over the past 24 hours. She has not had
further coffee grounds emesis. She was started on an IV PPI, put
on maintenance IVF, and was made NPO for planned EGD on hospital
day 2. She underwent EGD, without obvious source. Hct remained
stable in the high 20s for the last several days, with most
recent value 27.1. She will need small bowel capsule study as
an outpatient.
.
2. Pneumonia: CXR at admission showed new infiltrate in RUL,
likely a pneumonia. WBC was 11 on day 1, up to 18.8 on day 2
(75% PMNs, no bands), but she remained afebrile. Initial lactate
was 2.7. Patient remained stable and did not complain of dyspnea
or cough. She was started on levofloxacin for CAP, with plans to
broaden coverage if clinical picture worsened given recent stay
at rehab. She was treated with levofloxacin, without clinical
improvement. She then developed a rising O2 requirement, as
well as worsening leukocytosis. CXR showed evolution of the
right middle lobe infiltrate, and then after a trigger for
hypoxia on [**8-4**], a new infiltrate on the right base. This was
attributed to aspiration. Her antibiotics were broadened to
cefepime, vancomycin and flagyl. With this combination, her
oxygen requirement improved and her leukocytosis improved. She
will complete a 3 week day course of cefepime and flagyl. SHE
WILL NEED REPEAT CHEST XRAY IN 3 week VERIFY RESOLUTION, GIVEN
ROUNDED APPEARANCE OF PNEUMONIA IN RIGHT MID LUNG, AS WELL AS
DEVELOPMENT AT RIGHT BASE. This was also evaluated on CT, and
appears consistent with pnemumonia, but could also reflect an
early abscess, not amenable to drainage. Given clinical
improvement, she will be discharged on prolonged antibiotics
with repeat imaging before the course is over.
.
3. Left proximal PICA aneurysm w/mass effect on brainstem s/p
coiling: she was seen by neurosurgery, who recommended
outpatient follow up. She had chronic dizziness treated by
meclizine. Florinef was restarted.
.
4. Dysphagia: She has had chronic dysphagia since her aneurysm
coiling. Post EGD, her swallowing was worse, but then improved
as her discomfort improved. She was back to her baseline at
discharge, with aspiration precautions, with nectar thick
liquids and ground solids.
.
5. Hyperlipidemia: Simvastatin restarted at discharge.
.
6. Depression/ Anxiety: She is extremely anxious, and was
treated with ativan as needed.
.
Medications on Admission:
Nexium 40mg [**Hospital1 **]
Calcium w/ Vit D
Simvastatin 40mg daily
Effexor 50mg daily
Meclizine 25mg prn
Tizanidine 2mg prn
ASA 325mg daily
Senna
Ferrous Sulfate 300mg [**Hospital1 **]
Florinef 0.1mg daily
Docusate 100mg [**Hospital1 **]
Tiotropium inhaler
Milk of Mag
Xanaz 0.5mg prn
Bisacodyl 10mg daily
Tylenol 650mg
Miconazole powder [**Hospital1 **]
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
2. Alprazolam 0.25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
3. Fludrocortisone 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
6. Tizanidine 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day) as needed.
7. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO BID (2 times a day).
10. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H
(every 8 hours) for 3 weeks.
11. Heparin, Porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Hospital1 **]: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath, wheezing.
14. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
15. Acetaminophen 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO every [**4-13**]
hours as needed for fever.
16. Nexium 40 mg Capsule, Delayed Release(E.C.) [**Month/Day (3) **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
17. Meclizine 25 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO twice a day as
needed for dizziness.
18. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet [**Month/Day (3) **]: One
(1) Tablet PO once a day.
19. chest xray
1 week, to assess right lower lobe and mid lobe
20. Outpatient Lab Work
CBC [**2189-8-8**]
21. Cefepime 2 gram Recon Soln [**Month/Day/Year **]: Two (2) g Intravenous twice
a day for 3 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8971**] Rehab ans [**Hospital **] Care Center
Discharge Diagnosis:
1) Upper GI bleed with acute blood loss anemia
2) Pneumonia
3) Anemia-acute on chronic
4) Chronic dizziness
5) PICA aneurysm, s/p coiling.
6) Anxiety
7) Dysphagia
Discharge Condition:
Stable; Stable Hct 27.1., platelets 612. O2 98% on 2L
Discharge Instructions:
You were admitted with a GI bleed, anemia, and pneumonia. No
source was identified. You will need further testing in the
outpatient setting to identify a source of bleeding. Your ASA
was held. Your pneumonia worsened and we had to give you
stronger antibiotics. You have been doing well for the past 2
days, with improved oxygen.
.
Medication changes:
Your aspirin was discontinued. It will need to be restarted at
81 mg after her small bowel study.
.
You will need a repeat chest xray as there is a possible nodule
on your chest xray - in 1 week, and probably a chest CT
.
Return to the ER with recurrent bleeding, high fevers, trouble
breathing, chest pain, palpitations.
Followup Instructions:
CHEST XRAY IN 1 WEEK TO ASSESS RIGHT BASE AND RIGHT MID LUNG -
CT IF NO IMPROVEMENT
1)Please call for an appointment for the GI doctors:
Gastroenterology Office Visits East
Department: Department of Medicine
Operating Unit: [**Hospital1 18**] Location: [**Hospital Ward Name 452**]-Rose 101/East
Office Phone: ([**Telephone/Fax (1) 2233**] Office Fax: ([**Telephone/Fax (1) 79195**]
Departmental Pager:
2) Neurology
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2189-8-19**] 1:00
Operating Unit: [**Hospital1 18**] Location: E/TCC/8
3) You expressed an interest in having a sleep study you can
speak to your primary care doctor about a referral for a sleep
study.
4) Please follow-up with your primary care doctor within the
next 2 weeks.
|
[
"486",
"300.00",
"578.9",
"787.20",
"285.1",
"507.0",
"311",
"V15.82",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11128, 11212
|
5546, 8558
|
350, 375
|
11418, 11473
|
3535, 5523
|
12199, 13071
|
2793, 2840
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11497, 11831
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2855, 3516
|
11851, 12176
|
274, 312
|
403, 2205
|
2227, 2574
|
2590, 2777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,932
| 143,924
|
5378
|
Discharge summary
|
report
|
Admission Date: [**2175-6-26**] Discharge Date: [**2175-7-7**]
Date of Birth: [**2115-6-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2175-6-26**] Three Vessel Coronary Artery Bypass Grafting utilizing a
left internal mammary artery to left anterior descending artery,
with vein grafts to diagonal artery and obtuse marginal.
History of Present Illness:
Mr. [**Known lastname 21860**] is a 60 year old male with multiple cardiac risk
factors. He had complaints of worsening dyspnea on exertion
which prompted a stress test which was positive for ischemia.
Echocardiogram in [**2175-5-9**] showed no valvular pathology and an
LVEF of 60%. Subsequent cardiac catheterization in [**2175-5-9**] was
notable for severe two vessel coronary artery disease. Coronary
angiography revealed a right dominant system with normal right
coronary artery. The LAD had a 99% stenosis, with 70% lesion in
the first diagonal, and 90% stenosis in the circumflex system.
Based upon the above results, he was referred for cardiac
surgical intervention.
Past Medical History:
Diabetes Mellitus Type I
Chronic Renal Insufficiency
Hypertension
Hypercholesterolemia
Peripheral Neuropathy
Diabetic Retinopathy
Bilateral Cataract Surgery
Bilateral Vitrectomy
Prior Right Foot Surgery
Social History:
Quit tobacco in [**2151**]. Admits to only social ETOH. He is married,
wife works as an registered nurse. He is employed as a real
estate [**Doctor Last Name 360**].
Family History:
Denies premature coronary artery disease.
Physical Exam:
Pre Admit
Vitals: BP 180/100, HR 72, RR 14
General: well developed male in no acute distress, appears older
than stated age
Skin: vitilgo pathces noted
HEENT: oropharynx benign,
Neck: supple, no JVD, soft carotid bruits noted
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: obese, soft, nontender, normoactive bowel sounds
Ext: warm, 3+ pedal edema, no varicosities
Pulses: 1+ distally
Neuro: nonfocal
Pertinent Results:
[**2175-7-7**] 08:30AM BLOOD WBC-6.6 RBC-2.77* Hgb-8.6* Hct-24.6*
MCV-89 MCH-31.0 MCHC-35.0 RDW-13.9 Plt Ct-400
[**2175-7-7**] 08:30AM BLOOD Glucose-230* UreaN-71* Creat-4.3* Na-132*
K-4.9 Cl-100 HCO3-25 AnGap-12
[**2175-7-6**] 09:55AM BLOOD Glucose-136* UreaN-76* Creat-4.3* Na-136
K-4.9 Cl-101 HCO3-26 AnGap-14
[**2175-7-6**] 09:55AM BLOOD ALT-15 AST-23 LD(LDH)-296* AlkPhos-77
Amylase-44 TotBili-0.4
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Left ventricular function.
Mitral valve disease. Valvular heart disease.
Status: Inpatient
Date/Time: [**2175-6-26**] at 09:44
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW000-0:0
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
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. Normal LV wall thicknesses and cavity size.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild thickening of mitral valve chordae. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
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. Suboptimal image quality -
poor echo
windows.
Conclusions:
PRE-BYPASS: The left atrium is normal in size. 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 and cavity size are normal. Right ventricular
chamber size and
free wall motion are normal. 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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
POST-BYPASS: Preserved [**Hospital1 **]-ventricular systolic function is
normal. Normal
valvular function.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2175-6-26**] 11:23.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr. [**Known lastname 21860**] was admitted and underwent coronary artery bypass
grafting by Dr. [**Last Name (STitle) **]. For surgical details, please see
seperate dictated operative note. Following the operation, he
was brought to the CSRU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated without
incident. Given his chronic renal failure, the renal service was
consulted to assist in postoperative management while all
medications were titrated accordingly. On postoperative day two,
he developed atrial fibrillation which was successfully treated
with Amiodarone and beta blockade. His CSRU course was otherwise
uneventful and he transferred to the SDU on postoperative day
four. For the remainder of his hospital stay, no further
episodes of atrial fibrillation were noted. He remained in a
normal sinus rhythm and beta blockade was slowly advanced as
tolerated. He did experience a further decline in renal function
as his creatinine peaked to 4.4. This was attributed to acute
tubular necrosis. He however, did not become oliguric and
dialysis was not indicated. Diuretics were titrated and by
discharge, his renal function has stabilized, with a creatinine
of 4.3 for the past 2 days (4.4 prior to that). The remainder of
his hospital course was uneventful and he was medically cleared
for discharge to home on [**2175-7-7**].
Medications on Admission:
Atenolol 50 qd, Lasix 80 qd, Novalog SQ, Lantus SQ, Levoxyl 125
mcg qd, Lipitor 10 qd, Terazosin 5 qhs, Alphagen eye gtts,
Cosopt eye gtts, Florinef 0.1 qd, Aspirin 81 qd
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. Protonix 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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: then decrease to 200 mg (1 tab) daily until
discontinued by cardiologist.
Disp:*40 Tablet(s)* Refills:*1*
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 vial* Refills:*2*
5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*1 vial* Refills:*2*
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. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22)
Units Subcutaneous Q HS.
Disp:*1 vial* Refills:*2*
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Postoperative Atrial Fibrillation
Diabetes Mellitus Type I
Chronic Renal Insufficiency
Hypertension
Hypercholesterolemia
Peripheral Neuropathy
Diabetic Retinopathy
Discharge Condition:
Stable
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**4-13**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**2-11**] weeks, call for appt
Dr. [**Last Name (STitle) **] or [**Doctor Last Name 5762**] in [**2-11**] weeks, call for appt
Dr.[**Name (NI) 4849**] in 2weeks, call for appt.
Completed by:[**2175-7-7**]
|
[
"414.01",
"427.31",
"357.2",
"585.9",
"250.61",
"250.51",
"997.1",
"272.0",
"362.01",
"403.90",
"250.41",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
9168, 9219
|
5931, 7310
|
296, 493
|
9462, 9471
|
2142, 2546
|
9855, 10161
|
1624, 1667
|
7531, 9145
|
9240, 9441
|
7336, 7508
|
9495, 9831
|
2572, 5868
|
1682, 2123
|
237, 258
|
521, 1198
|
5908, 5908
|
1220, 1425
|
1441, 1608
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,993
| 129,776
|
37607
|
Discharge summary
|
report
|
Admission Date: [**2156-9-20**] Discharge Date: [**2156-9-25**]
Date of Birth: [**2089-7-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mitral regurgitation
Major Surgical or Invasive Procedure:
[**2156-9-20**] right and left heart catherization, coronary
angiography,left ventriculogram
[**2156-9-21**] Mitral Valve repair (32mm CG future ring)
History of Present Illness:
This 67 year old white male has a long history of a heart
murmur. An echocardiogram recently revealed severe mitral
regurgitation and prolapse. he was refered for surgical
evaluation and a catheterization was performed as a part of that
workup.
Past Medical History:
hypertension
glaucoma
vasectomy
Social History:
lives with his wife, works a a launch pilot at a yacht club
never smoked
occasional beer
Family History:
both parents died at "a young age" of unknown causes
Physical Exam:
Admission:
Pulse:56 Resp:18 O2 sat:98% RA
B/P Right:134/66 Left:
Height: 73" Weight:82.5 lbs
General: WDWN male in NAD
Skin: Dry [X] intact [X], Warm, No C/C/E
HEENT: NCAT, PERRLA, EOMI, OP benign, Teeth in good repair, one
intact crown
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR [X], +S1-S2, IV/VI holosystolic murmur best heard at
left MSB radiating to apex.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema No right
groin
hematoma at cath site
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right/Left: Transmitted vs. Bruit
Pertinent Results:
[**2156-9-24**] 06:00AM BLOOD WBC-9.8 RBC-3.26* Hgb-9.7* Hct-28.3*
MCV-87 MCH-29.6 MCHC-34.2 RDW-13.5 Plt Ct-105*
[**2156-9-23**] 05:55AM BLOOD WBC-9.9 RBC-3.38* Hgb-10.3* Hct-29.6*
MCV-88 MCH-30.3 MCHC-34.7 RDW-13.3 Plt Ct-88*
[**2156-9-24**] 06:00AM BLOOD Glucose-93 UreaN-15 Creat-0.8 Na-134
K-4.1 Cl-99 HCO3-29 AnGap-10
[**2156-9-23**] 05:55AM BLOOD Glucose-88 UreaN-15 Creat-0.9 Na-131*
K-4.4 Cl-101 HCO3-24 AnGap-10
Brief Hospital Course:
Following catheterization which revealed 4+ mitral regurgitation
and prolapse,intact LV (50%) and nonobstructive coronary
disease, preoperative workup was completed. There was <50%
carotid disease, dental clearance was obtained and labs were
completed and reviewed.
On [**9-21**] he went to the Operating Room where mitral repair was
effected. See operative note for details. He weaned from
bypass on Propofol and low dose pressor. He awakened intact,
was weaned and extubated without incident. Atrial fibrillation
developed on POD 1 and Amiodarone was started. This recurred
the following day and Lopressor was started with rate control
but persisitent atrial fibrillation. Coumadin was begun for
this dysrhythmia. Diuresis towards baseline weight was
undertaken and CTS and temporary pacing wires were removed
according to protocol.
Physical Therapy worked with him for strengthening and mobility.
He was ready for discharge on [**9-25**]
Medications, followup and precautions were discussed with him
prior to discharge. Arrangments were made for Coumadin dosing
to be monitored by his cardiologis as directed on the pg 1 with
a target INR of [**12-29**].5.
Pt to be discharged on 4 mg coumadin. Has follow up 11/2. His
INR on DC is 1.o
Medications on Admission:
Lumigan 0.03% 1gtt OU QD
Istalol 0.5% 1gtt OU [**Hospital1 **]
Cozaar 25mg/D
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:*50 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400 mg twice a day until [**9-30**] - then
decrease to 400 mg once a day until [**10-7**] - then decrease to 200
mg daily and follow up with Dr [**Last Name (STitle) 41632**] .
Disp:*70 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
Cardiologist Dr [**Last Name (STitle) 41632**] ([**Telephone/Fax (1) 19666**]). tO FOLLOW
.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Mitral Regurgitation
s/p mitral valve repair
Post operative atrial fibrillation
Hypertension
Glaucoma
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming
Monitor wounds for infection and report any redness, warmth,
swelling, tenderness or drainage
Please take temperature each evening and Report any fever 100.5
or greater
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments with:
Surgeon Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Primary Care Dr [**Last Name (STitle) 84384**] in [**11-28**] weeks
Cardiologist Dr [**Last Name (STitle) 41632**] in [**11-28**] weeks ([**Telephone/Fax (1) 19666**])
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
PT/INR for coumadin dosing - Atrial fibrillation with goal INR
2.0-2.5 first draw [**9-27**] with results to coumadin clinic at Dr
[**Last Name (STitle) 41632**] office.
Completed by:[**2156-9-25**]
|
[
"429.5",
"997.1",
"427.31",
"365.9",
"414.01",
"E878.8",
"428.0",
"401.9",
"397.0",
"424.0",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.23",
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
4893, 4966
|
2301, 3555
|
341, 495
|
5112, 5119
|
1855, 2278
|
5748, 6357
|
948, 1002
|
3682, 4870
|
4987, 5091
|
3581, 3659
|
5143, 5725
|
1017, 1836
|
281, 303
|
523, 770
|
792, 825
|
841, 932
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,458
| 129,898
|
25852
|
Discharge summary
|
report
|
Admission Date: [**2159-8-29**] Discharge Date: [**2159-9-4**]
Date of Birth: [**2108-10-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
s/p Coronary Artery Bypass Graft x 3 on [**2159-8-31**]
s/p Cardiac Catheterization on [**2159-8-29**]
History of Present Illness:
50 y/o male with no known CAD who presented to OSH ER w/ acute
onset chest pain. Thought to be from his rotator cuff injury. On
day of admission, pain was substernal with no related n/v or
diaphoresis, SOB. Pt. transferred from [**Hospital1 **] ER to [**Hospital1 18**] for
cardiac cath and further management.
Past Medical History:
Acute Myocardial Infarction
Hypertension
Gastroesophageal Reflux Disease
s/p Bilat Hernia repair
L Rotator Cuff injury
Social History:
Does not smoke, drinks socially but drinks three 12 packs per
week in the summer, no IVDA, works as a maintenance man and says
he walks about 10 miles/day at his job; used to exercise more
before he began having knee pain
Family History:
Father had MI at 45 and bypass at age 65, no other family
members with CAD
Physical Exam:
VS: 97.8 78SR 115/65 18 93% 2L 5'[**64**]" 99.8kg
General: Lying in bed in NAD
Neuro: A&O x 3, MAE, following commands, non-focal
HEENT: PERRLA w/ EOMI, anicteric, non-injected. MMM, -lesions
Neck: Supple, -JVD, -Bruits
Cardio: RRR, +s1 s2, -c/r/m/g
Pulm: CTAB -w/r/r
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -c/c/e, -varicosities, 2+ pulses
throughout
Pertinent Results:
Cardiac Catheterization [**8-29**]:
FINAL DIAGNOSIS:
1.Three vessel coronary artery disease.
2. Mildy elevated left sided pressures.
3. Acute anterior myocardial infarction, managed by acute ptca.
PTCA of
the diagonal 1.
Echo ([**2159-8-29**]):
EF 35%, no pericardial effusion. Left ventricular wall
thicknesses and cavity size are normal. Resting regional wall
motion abnormalities include near akinesis of the distal half of
the anterior septum and anterior wall, basal inferior wall, and
apex. The aortic valve leaflets appear structurally normal with
good leaflet excursion. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
[**2159-8-29**] 04:25PM BLOOD WBC-12.8* RBC-5.32 Hgb-15.9 Hct-42.5
MCV-80* MCH-30.0 MCHC-37.5* RDW-12.6 Plt Ct-199
[**2159-9-4**] 05:40AM BLOOD WBC-8.9 RBC-3.35* Hgb-9.7* Hct-28.1*
MCV-84 MCH-29.0 MCHC-34.5 RDW-13.2 Plt Ct-326
[**2159-8-29**] 04:25PM BLOOD PT-12.9 PTT-22.6 INR(PT)-1.1
[**2159-9-4**] 05:40AM BLOOD PT-12.9 INR(PT)-1.1
[**2159-8-29**] 04:25PM BLOOD Glucose-110* UreaN-17 Creat-0.9 Na-138
K-3.9 Cl-105 HCO3-23 AnGap-14
[**2159-9-4**] 05:40AM BLOOD Glucose-96 UreaN-16 Creat-0.8 Na-140
K-4.4 Cl-103 HCO3-30 AnGap-11
[**2159-8-29**] 04:25PM BLOOD Calcium-9.4 Phos-3.1 Mg-2.1
[**2159-8-30**] 04:27PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2159-8-30**] 04:27PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-8.0 Leuks-NEG
Brief Hospital Course:
As mentioned in the HPI, pt transferred from OSH for cath.
Cardiac cath revealed 3 vessel disease. Diagonal branch was
stented and pt was then referred for CABG for coronary
revascularization. On HD #3, pt was brought to the OR, where he
underwent Coronary Artery Bypass graft x 3. Please see op note
for details. Pt tolerated the procedure well and was transferred
to the CSRU in stable condition being titrated on Neo and
Propofol. Later on op day, pt was weaned from mechanical
ventilation and propofol and was extubated. By POD #1 he was
weaned from Neo and started on Lasix and b-blockers per
protocol. Also on POD #1 his chest tubes and Swan-Ganz catheter
were removed. On POD #3 pt had his epicardial pacing wires
removed and was transferred to telemetry floor. Pt. appeared to
be recovering well and had no post-op complications. PT was
seeing the pt during his post-op period and on POD #4 felt pt
was at level 5. His PE was unremarkable, labs were stable and pt
was d/c'd on POD #4 with VNA services and the appropriate f/u's.
Medications on Admission:
Nexium 40 po qd
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
Disp:*20 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 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary [**Last Name (un) 64346**] Disease s/p Coronary Artery Bypass Graft x 3
Myocardial Infarction
Hypertension
Gastroesophageal Reflux Disease
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with water and gentle soap.
Gently pat dry. Do not take bath or swim.
Do not apply lotions, creams, ointments, or powders to
incisions.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 2 months.
Make/Keep all follow-up appointments.
Take all prescribed meds.
If you notice any drainage from incisions, redness, or fever,
please contact office.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks.
Follow-up with PCP (Dr. [**Last Name (STitle) 18323**] in 2 weeks.
Follow-up with Cardiologist in 2 weeks.
Completed by:[**2159-9-4**]
|
[
"410.01",
"458.29",
"427.89",
"530.81",
"305.00",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"37.23",
"88.72",
"39.61",
"99.20",
"36.15",
"88.56",
"99.05",
"36.12",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
5678, 5729
|
3123, 4162
|
332, 436
|
5920, 5926
|
1644, 1680
|
6366, 6559
|
1173, 1249
|
4228, 5655
|
5750, 5899
|
4188, 4205
|
1697, 3100
|
5950, 6343
|
1264, 1625
|
282, 294
|
464, 776
|
798, 918
|
934, 1157
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,613
| 163,881
|
3839
|
Discharge summary
|
report
|
Admission Date: [**2196-8-24**] Discharge Date: [**2196-8-31**]
Date of Birth: [**2161-10-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Codeine / Tape / Sulfa
(Sulfonamides) / Dipentum
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
found on floor by husband at home, unresponsive, breathing
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
34 year old woman with DM1 on an insulin pump at baseline who
was recently admitted here [**Date range (1) **] for foot cellulitis (MRSA
with osteo, s/p partial amputation of the lt. foot) and again
[**Date range (1) 17232**] in the ICU with DKA who was found Tuesday Morning at
approximately 10:30 pm, lying on the floor, moaning and
combative, by her husband. She had last been seen by him at 7:30
pm. She had apparently fallen out of her wheelchair, and was on
the kitchen floor, bleeding from a head lac. The dog food bowl
was broken. He checked her blood glucose which was critically
high. He disconnected her insulin pump. He contact[**Name (NI) **] EMS. The
first to arrive on the scene were the police, who felt that the
pt. may have been seizing, but this subsided by the arrival of
EMS (seizure-like activity not described in the record).
.
She was initially transported to [**Hospital 5871**] Hospital, where her
FSBG was found to be 910 - Gap of 20, pH 7.26, serum acetone
positive. She was given insulin 10 U X 1 and then 10 U per hour,
then decreased to 5 U per hour when sugar was down to 400. She
was febrile to 101.5 on admission there. Blood cultures were
drawn and IV CTX was administered. A head CT and C/S CT were
both negative. She recieved a total of 5 litres of normal saline
there. She was transferred to [**Hospital1 **] at the request of her family at
5:20 am Wednesday, while still getting NS at 200/hr and insulin
gtt still at 5 U per hour.
.
In the ED here, she was found to be minimally responsive to
sternal rub, but she was breathing, had sbp of 154, HR 119, Sat
96%. She was noted to be febrile to 104. Blood cultures obtained
and Vanc and Zosyn administered. Her initial BG was 103 - her
fluid was switched to D5 W at 150 per hour, in addition, she was
given 2 more litres of NS, and her insulin gtt was turned off.
Past Medical History:
1. Type 1 diabetes mellitus- diagnosed at 9 months old. Has
neuropathy, nephropathy, and retinopathy. She is followed by Dr.
[**Last Name (STitle) 10086**] at the [**Last Name (un) **]. On insulin pump. Last A1c 7.4% on [**2196-6-15**]
2. Peripheral diabetic neuropathy with left foot cellulitis, s/p
recent hospitalization as above, resulting in partial amp lt.
foot; readmitted [**8-7**] in DKA to ICU (as outlined above).
3. Autonomic dysfunction
4. Hypercholesterolemia
5. Iron deficiency anemia- Pt was first diagnosed with iron
deficiency anemia in [**2180**] and is followed for this by Dr. [**Last Name (STitle) 410**]
in heme onc. It is felt to be due to her ulcerative collitis. Pt
receives parenteral iron as needed. Reports a port-a-cath was
placed 14 years ago for IV iron and she has had it since then.
6. [**Name (NI) 4545**] Pt reports that she was diagnosed with
hypothyroidism at age 8. She was taken off all thyroid
medications at age 29 and her TFTs have been normal since that
time.
7. Ulcerative collitis- Pt was diagnosed with ulcerative
collitis
in [**2180**] and underwent a pouch ileostomy in [**2181**].
Social History:
Lives with husband in [**Name (NI) **], MA. No tobacco, EtOH, or
illicits. Works in marketing department at a nursing home;
currently not working while she has foot infection but plans on
returning.
Family History:
numerous family members with type 2 DM
Physical Exam:
76 kg 99.8 Ax 115 157/60 Sat 97 % on 2 L nc
Somnolent, responding to pain only
warm/hot skin throughout
Mult visible small lacerations to head/face, non bleeding
No visible eye deviation, pupils equal and minimally reactive
(per mother her baseline is "sluggish" pupillary reaction)
Unable to visualize tongue, but no buccal lacs
Trachea midline
Tachy, reg, no MRG
CTA t/o, Rt sided POC cath in place, no visible purulence or
erythema
Abdomen soft, diminished bowel sounds, midline scar, seems to
respond with facial grimmace to bilateral lower quadrant
pressure
Foley in place draining clear, dilute-appearing urine
No edema
Lt. foot dressed in dry guaze, TMA with erythema, minimal
purulence at incision site. Nothing could be expressed from the
wound.
Pertinent Results:
[**2196-8-24**] 06:20AM BLOOD WBC-11.8*# RBC-2.86* Hgb-8.5*
Hct-NOTIFIED C MCV-82 MCH-29.7 MCHC-36.1* RDW-14.7 Plt Ct-271
[**2196-8-24**] 06:20AM BLOOD Neuts-88.6* Lymphs-7.0* Monos-4.2 Eos-0.1
Baso-0.1
[**2196-8-24**] 06:20AM BLOOD PT-12.5 PTT-38.9* INR(PT)-1.1
[**2196-8-24**] 06:20AM BLOOD Glucose-71 UreaN-32* Creat-1.5* Na-145
K-3.6 Cl-112* HCO3-22 AnGap-15
[**2196-8-27**] 03:00AM BLOOD Glucose-88 UreaN-10 Creat-0.9 Na-140
K-3.7 Cl-109* HCO3-26 AnGap-9
[**2196-8-24**] 12:25PM BLOOD ALT-13 AST-18 AlkPhos-68 Amylase-75
TotBili-0.3
[**2196-8-24**] 06:20AM BLOOD Calcium-8.0* Phos-1.4*# Mg-2.2
[**2196-8-27**] 03:00AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9
[**2196-8-24**] 12:25PM BLOOD TSH-1.4
[**2196-8-24**] 12:25PM BLOOD Free T4-1.0
[**2196-8-25**] 12:09PM BLOOD Vanco-16.9*
[**2196-8-24**] 12:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-8-24**] 06:54AM BLOOD pO2-55* pCO2-42 pH-7.34* calTCO2-24 Base
XS--2 Comment-GREEN TOP
[**2196-8-24**] 09:12PM BLOOD Lactate-1.6
.
[**2196-8-24**] 06:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2196-8-24**] 06:20AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-1000 Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2196-8-24**] 06:20AM URINE RBC-[**6-11**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2196-8-24**] 06:20AM URINE CastGr-[**3-6**]* CastHy-0-2
[**2196-8-24**] 12:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
amphetm-NEG
[**2196-8-24**] 06:20AM URINE UCG-NEGATIVE
.
[**2196-8-24**] 02:20PM CEREBROSPINAL FLUID (CSF) WBC-52 RBC-1120*
Polys-96 Lymphs-2 Monos-2
[**2196-8-24**] 02:20PM CEREBROSPINAL FLUID (CSF) WBC-52 RBC-2*
Polys-98 Lymphs-0 Monos-2
[**2196-8-24**] 02:20PM CEREBROSPINAL FLUID (CSF) TotProt-46*
Glucose-67
[**2196-8-24**] 02:20PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
.
[**2196-8-24**] 6:20 am URINE CULTURE: NO GROWTH.
.
[**2196-8-24**] 2:20 pm CSF;SPINAL FLUID
GRAM STAIN (Final [**2196-8-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final): NO GROWTH.
VIRAL CULTURE: Pending
.
[**2196-8-24**] BLOOD CULTURE: Pending
.
[**2196-8-26**] STOOL VIRAL CULTURE: Pending
.
Left foot (3 views): There is no change in the appearance of the
transmetatarsal amputation. The resection sites have well
marginated bone without evidence of focal lysis to suggest
osteomyelitis. There is no subcutaneous gas. Bones remain
diffusely demineralized secondary to disuse. Surgical clips are
again noted adjacent to the distal tibia posteriorly. As
before, there are extensive [**Month/Day/Year 1106**] calcifications.
.
CXR (single veiw): AP BEDSIDE CHEST: The heart is borderline
enlarged. There is slight [**Month/Day/Year 1106**] plethora. Tip of right
subclavian line is at junction of SVC and right atrium. Slight
prominence of the lung markings in the lower lobe behind the
heart is probably normal allowing for relatively elevated
diaphragms and remainder lungs clear. No PTX or effusion on
this semi-erect film. Since exam [**2196-8-8**], the slight
[**Month (only) 1106**] congestion has developed (I doubt this reflects higher
diaphragms). IMPRESSION: Pneumonia cannot be entirely excluded
in the left lower lobe. Probable [**Month (only) 1106**] congestion.
.
ABDOMEN (single view): Paucity of gas within the abdomen likely
represents fluid filled loops of small bowel and is consistent
with ileus.
.
CXR (portable): Right jugular CV line is in region of cavoatrial
junction. No pneumothorax. heart size is difficult to evaluate
on this portable supine film. There could be slight
cardiomegaly and some pulmonary [**Month (only) 1106**] engorgement consistent
with CHF, increased since the prior study of [**2196-8-24**].
Mild atelectasis is present at the left base. No pneumothorax.
.
Brief Hospital Course:
# DKA: The patient's anion gap closed rapidly on an insulin drip
with IV D5W infusion during her stay in the MICU. Her mental
status cleared. Prior to transfer to the floor she was
transitioned to her home insulin pump regimen. Her blood glucose
levels remained stable between 70-200. She was seen by [**Last Name (un) **]
consult regarding her insulin regimen. Electrolytes were
monitored daily and repleted as needed. She was discharged to
home on insulin pump with [**Last Name (un) **] follow-up with Dr. [**Last Name (STitle) 10088**].
.
# Meningitis: The patient was sent to the MICU. She was
breathing spontaneously but only responsive to painful stimuli
with fevers to 104F. On LP, the patient was discovered to have
meningitis (CSF with 60 WBC - 96% PMNs, 2 RBC, protein 46,
glucose 67; gram stain and bacterial culture negative, viral
culture pending). ID team was consulted and the patient was
started on vancomycin, ceftriaxone, meropenem (for Listeria
coverage as she has a bactrim/PCN allergy), and acyclovir. Over
a period of two days, the patient's mental status cleared and
her fever and photophobia resolved. Although she continued to
have a lingering headache, it responded well to pain
medications. Based on the LP results, her meningititis was
believed to be likely early viral (enterovirus, HSV, other), and
CSF viral cultures as well as HSV pcr and West [**Doctor First Name **] studies were
sent and are pending. In addition, stool viral cultures were
obtained and are pending. However, despite the low absolute WBC
count, the neutrophilic predominance and slightly decreased
glucose could indicate bacterial source. While the gram stain
and culture were negative, she had been on vanco/levo/flagyl x 6
weeks at home and only finished this course 2 days PTA. Repeat
LP was attempted but unsuccessful. Acyclovir was discontinued
after PCR was negative for HSV. Meropenem and vancomycin were
discontinued after the bacterial CSF cultures were negative.
However, she received ceftriaxone before the LP was done so she
will be discharged on a 3 week course with VNA service. She
remained afebrile with stable hemodynamics until discharge.
.
# Blurry vision: Patient reports having significantly more
blurry vision since pre-admission. She has a known right
cataract and diabetic retinopathy. Ophthalmology was consulted.
Patient will follow up with Dr. [**Last Name (STitle) 17233**] at the [**Last Name (un) **] Center.
She might need ultrasound of the right eye give her fall, and
she will need laser treatment of her left eye for presence of
small amounts of intraocular blood.
.
# Partial left foot amputation: on admission, patient has pus
draining from her partial amputatation. Plastic surgery and
[**Last Name (un) 1106**] were consulted and she was managed with dressing
changes TID. Her drainage stopped at time of discharge. She
will f/u with plastic surgery as an outpatient.
.
# HTN: While in the MICU, the patient's antihypertensives were
held. At transfer to the floor, her BP's were eleveated into the
170/110 range and she was restarted on metoprolol and
lisinopril.
.
# Low back pain: likely secondary to LP. She was given vicodin,
which she takes at home as needed for pain, with good effect and
morphine for breakthrough. She was discharged on her home dose
of vicodin.
.
# Chronic iron-deficiency anemia: Her Hct remained near
baseline. She was guaiac negative. She receives parenteral iron
as an outpatient and follows with Dr. [**Last Name (STitle) 410**]. The patient will
require continued outpatient follow-up of her chronic anemia.
.
# FEN: [**Doctor First Name **] diet, monitored electrolytes daily and repleted as
needed
.
# PPX: heparin sc tid
.
# Code: Full
.
# Contact: [**Name (NI) 2174**] [**Name (NI) 17234**] ([**Telephone/Fax (1) 17235**] (Husband); Proxy is
Mother: [**Name (NI) 17236**] [**Name (NI) 17237**] ([**Telephone/Fax (1) 17238**]
Medications on Admission:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
2. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
5. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
7. Fludrocortisone 0.1 mg Tablet Sig: Five (5) Tablet PO DAILY
8. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lyrica 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Vicodin 5-500mg 1-2 tabs po bid prn pain
13. Insulin Pump - per regimen: this is actively being titrated
by [**Last Name (un) **] - most recently per record approx 1.3 to 1.5 U per
hour, with boluses of 1 U per 10 grams of carbs at meals.
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fludrocortisone 0.1 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
5. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every twelve (12) hours as needed for pain.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical DAILY (Daily).
9. Neomycin-Bacitracin-Polymyxin Ointment Sig: One (1) Appl
Topical DAILY (Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lyrica 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Tablet(s)
13. Insulin pump
Insulin Pump, use [**First Name8 (NamePattern2) **] [**Hospital **] Clinic protocol
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
16. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous Q12H (every 12 hours): last doses on
[**2196-9-2**].
Disp:*10 grams* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis:
1) Diabetic ketoacidosis
2) Aseptic meningitis
.
Past medical history:
1. Type 1 diabetes mellitus c/b neuropathy, nephropathy, and
retinopathy
2. Peripheral diabetic neuropathy with left foot osteomyelitis
s/p partial amputation of left foot
3. Autonomic dysfunction
4. Hypercholesterolemia
5. Iron deficiency anemia
6. Hypothyroidism
7. Ulcerative collitis s/p colectomy with pouch ileostomy.
8. Cataracts
Discharge Condition:
hemodynamically stable, afebrile
Discharge Instructions:
Please take all medications as advised. Keep all appointments
listed below.
.
A visiting nurse will give you antibiotics for the next two
weeks. Please complete the course of cetriaxone.
.
Please follow up with Dr. [**Last Name (STitle) 17233**] at the [**Hospital **] Clinic about your
vision changes.
.
Continue to monitor your blood glucose levels as prescribed.
Call your doctor if you have any questions.
.
If you experience fever, chills, nausea, vomiting, abdominal
pain, weakness, numbness, tingling, visual changes, stiff neck,
or other concerning symptoms please call your doctor immediately
or return to the Emergency Department for evaluation.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the appropriate provider with any questions or if you need to
reschedule.
.
PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **], [**Telephone/Fax (1) 250**]. [**9-9**], Friday at
1:30pm. Please note that Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] has left [**Hospital1 18**]. Dr.
[**First Name (STitle) **] will take over your care for Dr. [**Last Name (STitle) **]. Please call
[**Hospital3 **] at your earliest convenience so they can
send you more information [**Telephone/Fax (1) 250**].
.
Ophthalmology: Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17233**], ([**Telephone/Fax (1) 17239**]. [**8-31**]
(today) at 2pm. [**Hospital **] Clinic, first floow.
.
Endocrinology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10088**], ([**Telephone/Fax (1) 17240**]. [**9-15**] at 1:30pm. At the [**Hospital **] clinic.
.
Infectious disease: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone: [**Telephone/Fax (1) 457**]
Date/Time:[**2196-9-19**] 2:30
.
Plastic surgery: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2647**], MD. ([**Telephone/Fax (1) 10419**]. Friday
[**9-2**], at 1pm.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2196-8-31**]
|
[
"280.9",
"250.13",
"250.53",
"362.01",
"250.83",
"250.63",
"047.9",
"583.81",
"401.9",
"556.9",
"731.8",
"730.17",
"337.1",
"357.2",
"250.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
14561, 14610
|
8389, 12299
|
402, 420
|
15081, 15116
|
4519, 8366
|
15822, 17334
|
3689, 3729
|
13123, 14538
|
14631, 14631
|
12325, 13100
|
15140, 15799
|
3744, 4500
|
304, 364
|
448, 2300
|
14650, 14699
|
14721, 15060
|
3473, 3673
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,579
| 108,941
|
6929
|
Discharge summary
|
report
|
Admission Date: [**2121-12-23**] Discharge Date: [**2121-12-28**]
Date of Birth: [**2056-5-19**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: 65-year-old male with left upper
lobe lung cancer. He developed hemoptysis, and chest x-ray
revealed a mass. He underwent mediastinoscopy/Chamberlain
and negative nodes. Follow-up CT [**12-1**] revealed 3 and 5 cm
left upper lobe masses. Now presents for left upper
lobectomy.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post catheterization on
[**2121-10-29**]; [**11-5**] echocardiogram shows an ejection fraction of
greater than 55%; catheterization showed two vessel disease,
six stents to right coronary artery/mid-right coronary artery
dissection. Myocardial infarction [**11-27**] with troponin-i at
12.3.
2. Peripheral vascular disease status post aortobifemoral,
[**2-/2118**] by Dr. [**Last Name (STitle) **]; right femoral-popliteal in [**2111**]; toe
amputations; renal artery graft during aortobifemoral
3. Type 2 diabetes
4. Hypertension
5. Gastroesophageal reflux disease
6. Hypercholesterolemia
7. FEV-1 of 3.26, which is 96% of normal
LABORATORY DATA: Hematocrit 31.3, INR 1.2, creatinine 1.
Liver function tests negative.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.7, pulse
69, respiratory rate 16, blood pressure 150/60, oxygen
saturation 100% on room air. Cardiovascular: Regular rate
and rhythm. Pulmonary: Clear to auscultation. Abdomen:
Soft, nontender, nondistended. Extremities: Warm, with
palpable femoral pulses bilaterally.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2121-12-23**], at which time a left upper lobectomy and
mediastinal lymphadenectomy was performed. The patient
postoperative had complaints of vague chest pain, at which
time an electrocardiogram was checked and was found to be
normal, unchanged from baseline.
On early postoperative day one, the patient was found to have
decreased urine output, which did not respond to 250 cc
normal saline bolus. The patient dropped his blood pressure,
at which time the epidural was stopped. The patient
subsequently received one unit of blood for a hematocrit of
23, and a liter of crystalloid, and a dopamine infusion of 2
mcg/kg/minute was started. An electrocardiogram at that time
revealed non-ST elevation myocardial infarction. Enzymes
were cycled, which showed an increase in the CK/MB as well as
the troponin-i.
The patient was transferred to the Intensive Care Unit, where
he continued to do well enough so that the dobutamine drip
was weaned off. The patient was transfused with another unit
of packed red blood cells. A Cardiology consult was
obtained, which suggested Plavix for one year, as well as
agreeing with the current management.
The patient continued to do well in the Intensive Care Unit,
and was subsequently transferred in stable condition with a
stable blood pressure of 140, heart rate of 72, and oxygen
saturation of 92%, the patient was transferred to the
Surgical floor.
On the Surgical floor, intense pulmonary toilet was
continued, as well as good pain control. On postoperative
day four, the patient continued to do well, and subsequently
the following day, the patient was discharged to home on
[**2121-12-28**].
CONDITION AT DISCHARGE: Good
DISCHARGE STATUS: To home
DISCHARGE DIAGNOSIS:
1. Lung cancer in the left upper lobe
2. Non-ST elevation myocardial infarction
FOLLOW-UP PLANS: Follow up with cardiologist in one week.
Follow up with Dr. [**Last Name (STitle) 175**] in two weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 100 mg twice a day
2. Zestril 40 mg once daily
3. Hydrochlorothiazide 25 mg once daily
4. Norvasc 2.5 mg twice a day
5. Protonix 40 mg by mouth once daily
6. Lipitor 40 mg by mouth once daily
7. Plavix 75 mg by mouth once daily
8. Dilaudid 4 to 8 mg by mouth every four to six hours as
needed for pain
9. Colace 100 mg by mouth twice a day
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern1) 8455**]
MEDQUIST36
D: [**2121-12-28**] 21:33
T: [**2121-12-29**] 00:36
JOB#: [**Job Number 26073**]
|
[
"410.92",
"401.9",
"V45.82",
"997.1",
"410.91",
"272.0",
"530.81",
"162.3",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.4",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
3607, 4252
|
3379, 3462
|
1601, 3309
|
1277, 1583
|
3324, 3358
|
3480, 3584
|
186, 468
|
490, 1254
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,130
| 107,506
|
54814
|
Discharge summary
|
report
|
Admission Date: [**2102-6-29**] Discharge Date: [**2102-7-13**]
Date of Birth: [**2050-2-22**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2102-6-30**] ORIF Left SI joint and anterior ring pelvis-Krod
[**2102-7-5**] POSTERIOR INSTRUMENTATION FUSION T11-T12, L1, L2, L3
[**2102-7-10**] Revision pelvic fixation with additional sacroiliac
[**Last Name (LF) 112030**], [**First Name3 (LF) **] Additional symphysial plate and reinforcement with
anterior external fixator frame.
History of Present Illness:
52 year old gentleman who is s/p fall off of a ladder today
while working on a tree. He fell 25 feet striking the left side
of his body. he was taken to an OSH for evaluation and imaging
there showed an L1 burst fx with retropulsion of fragments, L5
transverse process fx, as well as an open book pelvic fracture.
He was transferred to [**Hospital1 18**] for further care and evaluated as a
trauma upon arrival. Per report he had no bulbocavernous reflex
and decreased rectal tone. given this Spine was emergently
consulted and we evaluated the patient. He denies sensory
deficit
or perceived weakness.
Other injuries include open book pelvic fx, L1 burst, L5 TP fx.
Past Medical History:
PMH: HTN, HLD
PSH: R hand tendon surgery @ 18yo
Family History:
NC
Physical Exam:
At admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: hard C-Collar in place Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: abrasions along left side of torso. Soft, NT, BS+
Extrem: abrasions to left LLE as well as ecchymosis along left
lateral thigh and anterior foot. Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Proprioception intact
Toes downgoing bilaterally
Rectal exam slightly decreased
At discharge:
afebrile, VSS
NAD
A&Ox3
Ex-fix pin sites without erythema or drainage
LLE: WWP, +DP pulse
+TA [**Last Name (un) 938**] G/S
SILT saph sural DPN SPN plantar nerves
Pertinent Results:
[**2102-6-29**] 11:54PM GLUCOSE-138* UREA N-17 CREAT-0.9 SODIUM-140
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
[**2102-6-29**] 11:54PM CALCIUM-7.9* PHOSPHATE-3.9 MAGNESIUM-1.8
[**2102-6-29**] 11:54PM WBC-9.3 RBC-3.65* HGB-11.8* HCT-34.8* MCV-96
MCH-32.3* MCHC-33.8 RDW-14.1
[**2102-6-29**] 11:54PM PLT COUNT-184
[**2102-6-29**] 06:10PM URINE HOURS-RANDOM
[**2102-6-29**] 06:10PM URINE GR HOLD-HOLD
[**2102-6-29**] 06:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2102-6-29**] 06:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2102-6-29**] 06:10PM URINE RBC-98* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0
[**2102-6-29**] 06:10PM URINE HYALINE-1*
[**2102-6-29**] 06:02PM COMMENTS-GREEN TOP
[**2102-6-29**] 06:02PM GLUCOSE-155* LACTATE-1.7 NA+-140 K+-3.6
CL--101 TCO2-25
[**2102-6-29**] 06:02PM HGB-14.4 calcHCT-43
[**2102-6-29**] 05:55PM UREA N-16 CREAT-1.1
[**2102-6-29**] 05:55PM estGFR-Using this
[**2102-6-29**] 05:55PM LIPASE-55
[**2102-6-29**] 05:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2102-6-29**] 05:55PM WBC-18.5* RBC-4.32* HGB-13.8* HCT-42.0 MCV-97
MCH-32.0 MCHC-33.0 RDW-14.2
[**2102-6-29**] 05:55PM PLT COUNT-225
[**2102-6-29**] 05:55PM PT-10.9 PTT-22.7* INR(PT)-1.0
[**2102-6-29**] 05:55PM FIBRINOGE-175*
IMAGING:
[**6-29**] CT C/A/P - L1 Burst fracture. Displaced fracture of superior
portion of left hemisacrum with widening of left sacroiliac
joint. Fracture of L5 transverse process. Diastasis of the pubic
symphisis. 6cm x 4cm left retroperitoneal hematoma.
[**6-29**] LLE Xrays:
IMPRESSION: No evidence of left lower extremity fracture.
[**6-29**] Pelvis Xray:
IMPRESSION: Pubic symphysis and left sacroiliac joint
diastasis. An external fixation device has been placed in the
distal lower extremity. To evaluate for fracture, consider CT.
[**7-6**] CT T and L spine:
IMPRESSION:
1. No evidence of hardware complications. The lumbar fusion
hardware is
better evaluated on the concurrent lumbar spine CT. There is no
evidence of postoperative hematoma or fluid collection.
2. Stable burst fracture of L1 with persistent retropulsion of
the fragment fractures and associated mild-to-moderate spinal
canal narrowing.
3. Bilateral small pleural effusions and dependent atelectasis.
[**7-7**] CXR 2 view:
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Mr. [**Known lastname **] was initially admitted to the Trauma SICU on [**6-29**] for
further management of his spinal and pelvic fractures. His
initial toxicology screen was negative. He required 4 units of
pRBCs. On [**6-30**], he was taken to OR with the Orthopaedic Surgery
service for ORIF pelvic fracture. He tolerated the procedure
well and was taken to the PACU and then the floor in stable
condition.
He remained stable during his floor course. On [**2102-7-5**], he was
transferred to the Neurosurgery service and underwent the above
stated procedure. Post-operatively, he was transferred to the
ICU for acute anemia as well as pain management. He was fitted
for a TLSO brace to be worn while out of bed. Hemovac drain was
removed on [**7-7**]. On [**7-8**], he was started on Aspirin and his
TLSO brace was re-fitted due to discomfort. He was seen by the
Orthopaedic Surgery service on [**7-9**] due to complaints of
"clicking" in his hips as well as pelvic pain. An x-ray of the
pelvis was performed that showed loss of reduction wo he went
back to the OR for revision ORIF and ex-fix placement. The
patient tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with PT.
The patient received peri-operative antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
asa, lipitor, fish oil
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H
5. Bisacodyl 10 mg PO/PR DAILY
6. Diazepam 2-5 mg PO Q8H:PRN spasm
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 40 mg SC DAILY
9. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
hold for excess sedation or RR < 12. Pls use IV as breakthrough
RX *Dilaudid 2 mg every four (4) hours Disp #*80 Tablet
Refills:*0
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Senna 1 TAB PO QHS
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
- Left sacroiliac joint dissociation and symphysial disruption
with vertical shear pelvic fracture - s/p ORIF anterior ring
with plating and s/p ORIF left sacroiliac joint with sacroiliac
[**Hospital3 112030**].
- L1 burst fracture s/p Posterior approach for open reduction,
instrumented fusion T10, T11, T12, L1, L2-L3, L4 using bilateral
pedicle [**Hospital3 112030**], posterior rods, cross-links, global system;
autologous autograft using right sided iliac crest; Allograft
(morselized bone); Open reduction.
Back pain
post operative anemia
constipation
scrotal edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: as above
Discharge Instructions:
NEUROSURGERY INSTRUCTIONS:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? Dressing may be removed on Day 2 after surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Wear the TLSO brace any time you are out of bed or
chair.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
ORTHOPEDIC SURGERY INSTRUCTIONS:
******SIGNS OF INFECTION**********
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
Strict non-weight bearing in left lower extremity. Touch down to
full weight bearing in right lower extremity for transfers to
chair or commode only. It is ok to go to cahir or commode, but
no other activity.
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink 8-8oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on Fridays.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
Physical Therapy:
Strict non-weight bearing in left lower extremity. Touch down to
full weight bearing in right lower extremity for transfers to
chair or commode only. It is ok to go to cahir or commode, but
no other activity.
Treatments Frequency:
physical therapy
wound care
nursing
Followup Instructions:
Follow Up Instructions/Appointments for Neurosurgery:
??????Please return to the office in [**8-1**] days (from date of surgery)
for removal of your staples/sutures and/or a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 8 weeks.
??????You will need CT-scan of the lumbar spine prior to your
appointment. This can be scheduled at the same time as your
appointment.
Orthopedic Surgery Follow-up:
******FOLLOW-UP**********
Please have your sutures/staples removed at your rehabilitation
facility at post-operative day 14.
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**11-5**] days
post-operation for evaluation. Call [**Telephone/Fax (1) 1228**] to schedule
appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,877
| 104,201
|
3014+55434
|
Discharge summary
|
report+addendum
|
Admission Date: [**2196-7-28**] Discharge Date: [**2196-8-6**]
Date of Birth: [**2135-11-11**] Sex: F
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 60-year-old
African-American female with a history of end-stage renal
disease on hemodialysis, hypertension, peripheral vascular
disease, status post bilateral AKAs, diabetes type 2, CVA,
coronary artery disease, status post CABG and mitral valve
repair, history of DVT and PE, COPD, who presents from
outpatient hemodialysis with increasing lethargy. At
baseline, the patient is responsive and interactive verbally.
On admission, the patient was only responsive to sternal rub.
At hemodialysis, the temperature was 99.8, pulse 130-140, 02
saturation 85% on room air which went up to 100% on a
nonrebreather; 2 kilograms of fluid were removed at
hemodialysis over two hours and then the patient was sent to
the Emergency Room.
The initial vital signs were a temperature of 99.8, blood
pressure 100/53, heart rate 120, respirations 30, saturating
99% on a nonrebreather. The initial physical examination was
positive for abdominal tenderness. The patient was sent for
an abdominal CT which showed extensive atherosclerotic
changes involving all of the abdominal vasculature and
possible thickening of the small bowel walls. Mesenteric
ischemic could be excluded. No evidence of obstruction. No
perforation or abscess.
General Surgery were consulted but no operative intervention
was deemed necessary at that time. The patient continued to
have a blood pressure systolic 80s to 100s, responsive to 2
liters of normal saline. The patient's chest x-ray also
showed evolving bilateral opacities and the patient was
treated with vancomycin, ceftriaxone, and Flagyl.
The patient was weaned off the nonrebreather to 4 liters
nasal cannula. CTA was done to rule out PE given the
patient's hypoxia, hypertension, and tachycardia. The study
was negative for PE but did show new ground glass opacities
at the right lung base suspicious for aspiration pneumonitis.
There was also chronic consolidation of the left lung base
and radiation changes of the right hemithorax which were
stable.
The patient was transferred initially to the Medical
Intensive Care Unit for further management.
REVIEW OF SYSTEMS: The patient had diarrhea for the past
week. No nausea, vomiting, no change in her chronic
abdominal pain. No change in her chronic cough. No fevers,
chills, dysphagia. The patient is anuric at baseline.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis every Tuesday,
Thursday, and Saturday.
2. Coronary artery disease, status post CABG.
3. CVA.
4. COPD.
5. Diabetes type 2.
6. History of PE and DVT.
7. History of hypertrophic obstructive cardiomyopathy with a
LV outflow tract gradient of 50 mmHg, EF 65-75%.
8. Peripheral vascular disease, status post bilateral AKA in
[**5-1**].
9. Breast cancer, status post right mastectomy and XRT in
[**2185**].
10. Status post mitral valve repair.
11. Hypertension, baseline systolic blood pressure in the
160s to 200s.
12. History of pseudoseizures.
13. History of MRSA line infection.
14. Status post appendectomy.
15. Status post TAH/BSO.
16. Status post cataract surgery.
ALLERGIES: The patient is allergic to penicillin, aspirin,
Oxycodone, cephalosporins, and benzodiazepines.
HOME MEDICATIONS:
1. Toprol XL 25.
2. Lactulose 3 mg p.o. q.d.
3. Lisinopril 80 mg p.o. q.d.
4. Nephrocaps 1 mg one tablet p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Renagel 1,600 mg p.o. t.i.d.
7. Combivent inhaler.
8. Celexa 20 mg p.o. q.d.
9. Prevacid 30 mg p.o. q.d.
10. Senna one tablet p.o. q.d.
11. Diltiazem 180 mg p.o. q.d.
12. Nifedipine 10 mg p.o. on hemodialysis days.
SOCIAL HISTORY: The patient is a Jehovah's witness and does
not accept blood products. She has a 60 pack year smoking
history. No history of alcohol. She lives with her son in a
handicapped apartment.
FAMILY HISTORY: Positive for hypertension and diabetes.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
99.8, heart rate 88, blood pressure 86/42, respirations 19,
saturating 100% on 4 liters nasal cannula. General: The
patient is somnolent and arousable to sternal rub, unable to
follow commands. More verbal when family is around. No
clear communication. HEENT: The patient is anicteric. The
oropharynx is dry. Cardiovascular: Regular rate and rhythm.
No murmurs. Lungs: Diffuse rhonchi bilaterally. Decreased
breath sounds, left greater than right base. Abdomen: Soft,
nontender, nondistended, normoactive bowel sounds, Guaiac
negative. Extremities: Status post bilateral AKA right
upper extremity, slightly more edematous than her left upper
extremity, 1+ pitting edema.
LABORATORY/RADIOLOGIC DATA: Head CT showed multiple old
infarct including occipital infarct bilaterally as well as
lacunar infarct in the right thalamus and left putamen which
appear unchanged compared to [**2196-3-1**]. There is a new
infarct in the left side of the pons, unable to comment on
exact timing. No mass affect. No hemorrhage.
CT of the abdomen showed question of possible small bowel
thickening, mesenteric ischemia could not be excluded. No
obstruction, no perforation, no abscess.
CT angiogram showed no PE, new ground glass patchy opacities
at the right lung base suspicious for aspiration pneumonitis,
chronic left lung base consolidation and radiation treatments
to the right hemithorax.
Right upper quadrant ultrasound showed no intra or
extrahepatic biliary ductal dilatation, small amount of
pericholecystic fluid but no gallbladder wall edema, several
small gallstones. No biliary obstruction.
Cardiac echocardiogram showed mild left atrial dilation,
symmetric LVH, moderate global LV hypokinesis, moderate
global right ventricular free wall hypokinesis, 1+ MR, 2+ TR,
mild pulmonary artery systolic hypertension, significant
pulmonary regurgitation, trivial pericardial effusions.
Ejection fraction of 30%, TR gradient 34.
HOSPITAL COURSE: 1. The patient was found to have
gram-negative rod bacteremia with Stenotrophomonas and
Enterobacter, likely from gut translocation from her acute on
chronic mesenteric ischemia. The patient also had evidence
of an aspiration pneumonia. The patient was treated with
Levaquin and Flagyl, a total course of 14 days as well as an
initial five day course of gentamicin. During this time, the
patient's right-sided Hickman was kept in place per renal.
The patient subsequently had 48 hours worth of negative blood
cultures.
2. HYPOTENSION: Secondary to sepsis from gram-negative rod
bacteremia, plus/minus pneumonia. The patient was treated
with normal saline boluses as well as transient use of
dopamine. The patient's blood pressure eventually stabilized
to the 120s systolic; however, her antihypertensives were
never reintroduced secondary to hypotension after
hemodialysis. As of discharge, the patient is still not on
home antihypertensive medications.
3. HYPOXIA: Secondary to sepsis and aspiration pneumonia.
The patient was treated with antibiotics for the above and
quickly weaned off her 02 requirement.
4. MIXED ACID BASE DISORDER: Initially, the patient came in
with nongap metabolic alkalosis as well as respiratory
alkalosis. These all resolved as the patient's sepsis
improved.
5. NEUROLOGIC STATUS: The patient's mental status improved
with treatment of sepsis.
6. END-STAGE RENAL DISEASE: The patient continued to
receive dialysis through her right subclavian Hickman. This
was never removed despite the patient's bacteremia. The
patient's most recent dialysis before discharge was on
[**2196-8-5**]. She was able to tolerate ultrafiltration; however,
no fluid was able to be removed secondary to hypotension down
to the 80s-90s systolic.
7. GASTROINTESTINAL: The patient is known to have bad
diffuse atherosclerosis, likely has chronic mesenteric
ischemia. MRA of the abdomen was unable to be performed
since the patient did not have any access to receive the MRI
contrast dye. Given the low likelihood that any surgical or
angioplastic interventions would be likely in this patient
given all of her comorbidities, MRA was deferred at this
time. The patient's abdominal pain had improved by the time
of discharge and she was tolerating a full cardiac and renal
diet.
8. HEMATOLOGY: The patient is a Jehovah's witness and does
not accept any blood transfusion products. She initially had
a low crit likely from hemodilution which eventually
stabilized. She also came in with thrombocytopenia. Workup
was negative for HIT antibody as well as DIC. The patient
gets Epogen at hemodialysis.
9. CODE STATUS: After a family meeting, it was decided that
the patient would be do not intubate (DNI); however, CPR and
resuscitation were still desired.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharge the patient to rehabilitation.
DISCHARGE DIAGNOSIS:
1. Stenotrophomonas and Enterobacter bacteremia and sepsis.
2. Acute on chronic mesenteric ischemia.
3. End-stage renal disease, on hemodialysis.
4. Peripheral vascular disease, status post bilateral AKAs
and impossible venous access.
5. Delirium from sepsis.
6. Aspiration pneumonia.
7. Anemia of chronic disease.
DISCHARGE MEDICATIONS:
1. Flagyl 500 mg p.o. b.i.d. until [**2196-8-10**] to complete a 14
day course.
2. Regular insulin sliding scale.
3. Levofloxacin 200 mg p.o. q. 48 hours until [**2196-8-10**] to
complete a 14 day course.
4. Protonix 40 mg p.o. q. 24 hours.
5. Atrovent two puffs q. six hours.
6. Albuterol two puffs q. six hours p.r.n.
7. Tylenol 325 mg p.o. q. four to six hours p.r.n.
FOLLOW-UP: The patient is to follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], in [**9-13**] days.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 7112**]
MEDQUIST36
D: [**2196-8-6**] 01:12
T: [**2196-8-6**] 13:52
JOB#: [**Job Number 14374**]
Name: [**Known lastname 2251**], [**Known firstname 1647**] Unit No: [**Numeric Identifier 2252**]
Admission Date: [**2196-7-28**] Discharge Date: [**2196-8-11**]
Date of Birth: [**2135-11-11**] Sex: F
Service: [**Hospital1 **]
ADDENDUM: This is a discharge Addendum to the Discharge
Summary done on [**2196-8-6**].
HOSPITAL COURSE BY ISSUE/SYSTEM CONTINUED: (From [**2196-8-6**] until the day of discharge of [**2196-8-11**])
1. BACTEREMIA ISSUES: The patient continued to be
asymptomatic during the course of her stay. The patient also
continued to have negative blood cultures prior to her
discharge. Cultures from [**8-8**], [**8-9**], and
[**8-10**] were pending. These blood culture results will
be followed up upon.
2. HYPOTENSION ISSUES: The patient continued to have low
blood pressures and abdominal pain while at dialysis
requiring a decrease in the amount of the fluid that could be
removed. This led to less than optimal dialysis results.
The likely etiology was thought to be due to low-flow
ischemia given her chronic vascular disease as well as past
abdominal computed tomography scans revealing diffuse
atherosclerotic lesions in her abdominal vasculature.
3. HYPOXIA ISSUES: The patient's oxygen saturations
remained in the high 90s on room air. The patient was
asymptomatic without shortness of breath throughout the
course and on through discharge.
4. END-STAGE RENAL DISEASE ISSUES: The patient was
continued on dialysis three times per week. However, the
patient continued to have abdominal pain and hypotension that
led to a decrease in the amount of the fluid that could be
taken off.
Given this chronicity, and the potential to interfere with
dialysis, a magnetic resonance angiography was ordered.
Access was difficult for magnetic resonance angiography;
however, it was eventually done through a hemodialysis line.
The magnetic resonance angiography revealed a mild 40%
stenosis of the mid superior mesenteric artery as well as an
atherosclerotic plaque on the abdominal aorta at the level of
the celiac artery. Otherwise, the magnetic resonance
angiography was unremarkable with the exception of a
consistent picture of hemosiderosis. No surgical
intervention or angioplastic intervention was sought after
following these results. The patient was to continue
dialysis three times per week as an outpatient.
5. HEMATOLOGIC ISSUES: A low hematocrit is chronic and
likely attributable to anemia of chronic disease. The
patient was receiving Epogen during dialysis, and the patient
was to continue to have Epogen during dialysis three times
per week.
6. CODE STATUS ISSUES: The patient is do not intubate and
is allowing cardiopulmonary resuscitation and pressor
support.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was to be discharged to home
with visiting nurse services.
DISCHARGE DIAGNOSES:
1. Bacteremia.
2. Sepsis.
3. Aspiration pneumonia.
4. End-stage renal disease (on hemodialysis).
5. Abdominal pain.
MEDICATIONS ON DISCHARGE:
1. Ipratropium bromide 2 puffs inhaled q.6h.
2. Albuterol 2 puffs inhaled q.6h. as needed.
3. Pantoprazole 40 mg by mouth once per day.
4. Acetaminophen 325 mg to 650 mg by mouth q.4-6h. as
needed.
5. Regular insulin sliding-scale.
6. Nephrocaps 1-mg capsules one capsule by mouth every day.
7. Colace 100 mg by mouth twice per day.
8. Celexa 20 mg by mouth once per day.
9. Timolol 0.25% ophthalmologic drops 1 to 2 drops once per
day in the left eye.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] (telephone number [**Telephone/Fax (1) 2253**]) in two to four
weeks.
2. The patient has expressed a willingness and ability to
participate in 24-hour care for the patient. The patient was
to have maximum assistance at home.
3. The patient's blood pressure medications were to be held
at this point given her low blood pressure at dialysis;
further decisions to be made by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1385**], M.D. [**MD Number(1) 2254**]
Dictated By:[**Last Name (NamePattern1) 2255**]
MEDQUIST36
D: [**2196-8-18**] 17:29
T: [**2196-8-18**] 18:59
JOB#: [**Job Number 2256**]
|
[
"403.91",
"038.49",
"425.1",
"507.0",
"287.5",
"263.9",
"496",
"785.59",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.93",
"38.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
3964, 4026
|
13036, 13158
|
9291, 12873
|
8945, 9268
|
13184, 13647
|
6031, 8829
|
13680, 14523
|
3369, 3741
|
12888, 13015
|
2294, 2502
|
4041, 6013
|
2524, 3351
|
3758, 3947
|
8854, 8924
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,811
| 115,771
|
38911
|
Discharge summary
|
report
|
Admission Date: [**2129-12-29**] Discharge Date: [**2130-1-3**]
Date of Birth: [**2085-7-9**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
OSH transfer for alcoholic pancreatitis
Major Surgical or Invasive Procedure:
PICC placement
NGT placement post pyloric by floroscopy
History of Present Illness:
Mr. [**Known lastname 12130**] is a 44 year old man with ETOH abuse and Crohns'
disease initially admitted to OSH [**12-23**] with abdominal pain
radiating to back, nausea and vomiting x 1 week, which became
progressively worse over 24 hours PTA found to have acute
pancreatitis with initial amylase>3000 and CT with evidence of
necrotizing pancreatitis. At OSH, he was treated with bowel
rest, IVF and started on primaxin. Course was complicated by
ETOH withdrawal and DTs so he was transferred to ICU there and
started on an ativan drip which was uptitrated to 15mg/hr. He is
being transferred to [**Hospital Unit Name 153**] for further management, ? need for
surgical intervention. Course also c/b fevers to 101 and
positive blood cx with GPCs in clusters on [**2129-12-28**] (2 bottles of
coag neg staph, sensitive to cefazolin, CTX, cipro/levo, clinda,
azithro, oxacillin, bactrim, tetra, and vanc). He reportedly had
been started on TPN day prior to transfer via PICC.
.
VS prior to transfer: T:101 rectal HR: 110s BP:120-130/70-80
RR:30s O2 sat: 99-100%2L
.
Upon arrival to the ICU a complete ROS could not be obtained.
Prior to transfer to the medical floor the patient was able to
state that he did not have CP, SOB, dysuria, headache,
neurologic changes, visual changes prior to presentation. He had
pain in his abdomen with defecation which is consistent with his
Crohn's disease.
.
Per discussion with family, patient had denied any other
complaints prior to admission other than right shoulder pain
which was attributed to rotator cuff tear and was recently being
worked up with MRI. He had approximately 1 episode of emesis per
week for 3 weeks PTA and had multiple episodes nonbloody bilious
emesis on day of admission with epigastric abdominal pain as
above. Had denied fevers, chills, diarrhea, joint pains,
headache or any other complaints. Denies recent weight loss or
gain.
.
While in the [**Hospital Unit Name 153**] a rectal tube placed for frequent stooling.
Two cidffs have been negative. A post pyloric feeding tube
placed and he started tube feeds. His PICCL was d/c'ed and
cultured. On [**2129-12-31**] he developed thrush and was started on
nystatin. While in the ICU his mental status slowly cleared.
.
ROS:
Currently reports [**12-28**] pain in his R shoulder c/w rotator cuff
tear. He does not have any abdominal pain. No cp/sob/n/v. +
Diarrhea. He is unclear if it is worse than his usual Crohn's
but his family does. [**2130-1-26**] back pain. He reports decreased
dexterity of his fingers in that he keeps dropping things. No
slurred speech or other focal weakness.
All other ROS negative.
Past Medical History:
Crohn's Disease
ETOH abuse
Marijuana abuse
Right shoulder pain/rotator cuff tear
Social History:
Lives with girlfriend. Divorced. [**Name2 (NI) **] 3 children (2 sons, one 10
year old daughter). Per friends and [**Name2 (NI) 40764**], drinks 1 pint of
vodka/hard liquor per day and 2 glasses-1 bottle of wine daily.
No prior h/o withdrawal. Also reprots daily marijuana use. No
other drug use. Occ cigarettes. No regular tobacco abuse. He
works as an electrician.
Family History:
Father died of a cerebral anneurysm. Mother is good health. MGF
had DM. His second cousin has [**Name (NI) 4522**] disease. No family h/o
pancreatitis.
.
Physical Exam:
Vitals: Tm=101, Tc=99.2 HRm = 91-105: BP: Pc =105 : R: 18 O2:
100% RA
Fluid balance: I/O = [**Telephone/Fax (1) 86327**] LOS = + 3.4 L
.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, moist MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, decreased bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: + foley draining clear yellow urine
Rectal: rectal tube draining dark liquid stool.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
R shoulder without erythema or wamth. No pain with active and
passive ROM.
Neuro: A & O x3. Able to DOW backwards. 5/5 strength in upper
and lower extremities b/l. 2+ biceps and patella DTRs.
**************
at discharge:
patient awake, alert, mental status clear. still generally weak
and walking with a walker. NGT in place. Not tremulous or with
any s/s of etoh w/d. abd tender in epigastrim with some
firmness, but no r/g.
Pertinent Results:
OSH Labs: WBC 15.2 HCT 50.4 Lipase>3000, AST 2 ALT 249 T Bili
1.4
Na 145 K 3.4 BUN 5 Cr 0.8 Phos 1.9 ca 7.8 WBC 30.6 HGB 12.8 PLT
168.
LDL 42 TG 202
Micro: OSH: Blood cx as above. Blood cultures at [**Hospital1 18**] are
pending.
ADMISSION LABS:
[**2129-12-29**] 04:57PM BLOOD WBC-16.8* RBC-4.43* Hgb-13.6* Hct-38.8*
MCV-88 MCH-30.7 MCHC-35.0 RDW-13.1 Plt Ct-283
[**2129-12-29**] 04:57PM BLOOD Neuts-88.5* Lymphs-6.0* Monos-3.3 Eos-2.0
Baso-0.2
[**2129-12-29**] 04:57PM BLOOD PT-14.0* PTT-30.5 INR(PT)-1.2*
[**2129-12-29**] 04:57PM BLOOD Glucose-144* UreaN-9 Creat-0.7 Na-139
K-4.4 Cl-106 HCO3-19* AnGap-18
[**2129-12-29**] 04:57PM BLOOD ALT-35 AST-31 LD(LDH)-480* AlkPhos-97
TotBili-0.8
[**2129-12-29**] 04:57PM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-2.2
[**2129-12-29**] 04:57PM BLOOD Osmolal-293
[**2129-12-29**] 04:57PM BLOOD Vanco-4.6*
[**2129-12-29**] 05:42PM BLOOD Type-[**Last Name (un) **] pO2-64* pCO2-30* pH-7.47*
calTCO2-22 Base XS-0
[**2129-12-29**] 05:42PM BLOOD Lactate-1.6
REPORTS:
CXR [**2129-12-29**]:
Lung volumes are extremely low exaggerating vascular congestion
in the lungs and mediastinum though there may be volume
overload. Discrete opacification at the left lung base is
probably atelectasis. Pleural effusions are small if any.
Cardiac silhouette is largely obscured by the high diaphragm but
not grossly dilated. No pneumothorax. Left PIC catheter passes
at least as far as the upper right atrium, obscured beyond that
by overlying EKG leads.
CXR [**2130-1-1**]:
FINDINGS: Radiodense tip of feeding tube is visualized in the
upper to mid
cervical region as communicated by telephone to Dr. [**Last Name (STitle) **].
Exam is
otherwise similar to recent radiograph of two days earlier.
CT head [**2130-1-1**]:
FINDINGS: There is no intracranial hemorrhage, edema, mass
effect, shift of normally midline structures, or acute major
vascular territorial infarction. The ventricles and sulci are
prominent, likely reflective of atrophy. Minimal mucosal
thickening of the ethmoid air cells are noted bilaterally.
Osseous structures reveal no evidence of fracture.
IMPRESSION: No acute intracranial process.
CXR PA/LAT [**2130-1-1**]:
IMPRESSION:
Small left pleural effusion with adjacent opacity favoring
atelectasis over infectious pneumonia.
[**2129-12-29**] ECG
Baseline artifact. The rhythm is most likely sinus tachycardia.
Non-specific ST-T wave changes. Repeat tracing is recommended.
No previous tracing available for comparison.
Brief Hospital Course:
Assessment and Plan: 44 year old man with ETOH abuse transferred
from OSH with necrotizing pancreatitis, ETOH withdrawal and DTs,
fever and GPC bacteremia.
.
#. Necrotizing Pancreatitis: Patient initially presented with
abdominal pain and nausea and vomiting with lipase>3000 and
evidence of pancreatic 20-30% necrosis on CT scan. US without
stones. Surgery evaluated him and elected for conservative
management. With high fever and level of necrosis, meropenim was
started at the OSH. A 7 day course of this was completed. His
abd pain is now mostly resolved. He has developed an appetite,
but given the level of necrosis seen on the CT scan the mild DM
that he has developed it was recommended by surgery that he get
jejunal tube feedings for at least another week. After that
time, clears should be introduced and diet advanced, and if not
tolerated, TF resumed. He is followed by gastroenterology, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2523**] MD [**Telephone/Fax (1) 86328**] for his crohn's disease and she
will follow him for his pancreatitis as well. Of note, at the
time of discharge his LFT's had returned to [**Location 213**] and his WBC's
had come down to 14 from a high of 22.
.
# ETOH Withdrawal/abuse: Patient reportedly agitated at OSH
secondary to ETOH withdrawal and has reported heavy daily ETOH
intake. No prior h/o withdrawal but has been in active
withdrawal there on ativan drip and also getting haldol for
agitation. Last ETOH [**12-22**] or [**12-23**]. Pt arrived to the ICU with
significance somnolence, minimally responsive but protecting his
airway. We d/c'd ativan drip and changed to valium PO as
tolerated. Pt's mental status significantly improved and patient
became more coherent. CT head without acute changes. Continued
MVI, thiamine, folic acid. Strongly encouraged ETOH cessation.
At the time of discharge he was AAO x 3, awake, alert, and w/o
any s/s of withdrawal.
.
# GPC bacteremia: Most likely sources include catheter related
bloodstream infection given PICC line given TPN. Treated with
vanco and [**Last Name (un) 2830**] for now while awaiting speciation and
sensitivities, that returned as pansensative coag neg staph. He
was given ceftriaxone to complete a 2 week course to end [**1-10**]. A
midline was placed for this which should be removed after abx
therapy is complete.
.
# Fever/leukocytosis: Likely multifactorial secondary to
pancreatitis and bacteremia. last check 14.
.
#B12 deficiency: The patient arrived to our institution on daily
B12 injections, presumably from a newly diagnosed B12
deficiency. he received 1 week of daily injections, planning for
1 month of qweek followed by qmonth afterwards.
.
#Diarrhea:while on zosyn, the patient had severe diarrhea.
infectious w/u neg. diarrhea stopped.
.
#crohn's disease:No issues. His mesalamine was held while sick,
but was restarted.
.
#Fe deficiency anemia:was also noticed to have low Tsat with fe
17 TIBC 190. Ferritin high from inflammation. did not start on
iron tabs given GI issues, but when stable should resume this.
Guaic was negative.
.
#diabetes:likely pancreatitis related. q6 FS while on TF with
insulin SS. Hopefully with not require DM therapy after
discharge.
Medications on Admission:
Home medications:
Lialda 1.2g 2 tablets daily
Percocet prn
Medications prior to Transfer:
Clonidine patch 0.3mg transdermal q week
TPN with fat emulsion
Heparin 5000 units SQ TID
Primaxin 500mg IV q day
Ativan drip at 15mg/hr
Lopressor 5mg IV q6 hours
Protonix 40mg IV BID
Vanco 1g IV q12 day 1 [**2129-12-28**]
B12 1000mcg IM q24 hours
tylenol, benadryl, haldol, dilaudid, ativan, reglan, zofran prn
Discharge Medications:
1. Lialda 1.2 g Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day.
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
3. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) dose
Injection once a week for 4 weeks: then 1 q month.
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
regular insulin SS q6 while on Tube feedings Injection every six
(6) hours.
5. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) GM Intravenous Q24H (every 24 hours) for 7 days.
6. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
7. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25-0.5 mg Injection
Q3H (every 3 hours) as needed for pain: (patient has not
required this medication in>48hrs).
8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: patient was taking prior to admission
to shoulder injury.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Discharge Worksheet-Discharge Diagnosis-Finalized:[**Last Name (LF) **],[**Name8 (MD) **],
MD on [**2130-1-3**] @ 1351
Primary Diagnosis: 577.0 PANCREATITIS, ACUTE
Secondary Diagnosis: 291.81 DRUG WITHDRAWAL, ALCOHOL
Secondary Diagnosis: 303.90 DRUG USE/DEPENDENCE, ALCOHOL
Secondary Diagnosis: 555.9 CROHN'S DISEASE
Secondary Diagnosis: 790.7 BACTEREMIA
Secondary Diagnosis: 787.91 DIARRHEA, NOS
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Patient being transferred to a facility for tube feedings and to
complete antibiotic course.
Followup Instructions:
with PCP at the time of discharge from rehab
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Location (un) 35619**], [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 23661**]
Phone: [**Telephone/Fax (1) 35614**]
Fax: [**Telephone/Fax (1) 35625**]
*
Also needs f/u with his gastroenterologist. We believe he should
be seen within next 2-4 weeks, but she had no appts during that
time. She was not availible for contact today, but will be in
the office tomorrow to schedule f/u. please call their office
tomorrow.
MD: Dr [**Last Name (STitle) **] [**Name (STitle) 2523**]
Specialty: Gastroenterology
Phone number: [**Telephone/Fax (1) 86328**]
|
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"266.2",
"303.91",
"E939.4",
"555.9",
"280.9",
"999.31",
"790.7",
"305.21",
"292.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
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"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12053, 12127
|
7347, 10567
|
308, 366
|
12568, 12568
|
4839, 5071
|
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|
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|
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|
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394, 3021
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12524, 12547
|
5088, 7324
|
12286, 12312
|
12582, 12689
|
3043, 3126
|
3142, 3510
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,935
| 180,232
|
24590
|
Discharge summary
|
report
|
Admission Date: [**2104-6-1**] Discharge Date: [**2104-6-9**]
Service: MEDICINE
Allergies:
Lipitor / Codeine / Procardia / Iodine / Pepcid / Catapres
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
NSTEMI - being transferred for cath
Major Surgical or Invasive Procedure:
cardiac cath
History of Present Illness:
87 yo female with history of hypertension who presented to
[**Hospital1 **] with chest pain for 2 days and found to have a NSTEMI
as per cardiac enzymes. Peak Trop I was 0.96 although CKs have
remained flat as per outside hospital. Patient continued to have
episodes of chest pain that were being treated with SL NTG with
improvement. Denies any other associated symptoms including
nausea, vomiting, diaphoresis. However, did note that the pain
radiated to both of her arms. Patient went into mild heart
failure yesterday after getting IVF but seems to be improving
with IV Lasix. Was seen by Cardiology this morning, and was
started on Lipitor, Heparin gtt and Integrillin gtt and
requested to be transferred here for cath. She refused Lipitor
because she is allergic to it. Being transferred here for cath
and further management.
Past Medical History:
1. Hypertension
2. Hypothyroidism
3. Atrial Fibrillation
4. Sick Sinus Syndrome s/p pacemaker
5. Hyperlipidemia
6. Congestive Heart Failure
7. Myocardial Infarction x 2 prior episodes (as per patient)
8. chronic mesenteric ischemia - followed by a
gastroenterologist
Social History:
Patient lives with her elder son who was recently diagnosed with
lng cancer; patient denies any tobacco, EtOH of recreational
drug use
Family History:
Non contributory
Physical Exam:
VS: Temp 98.9, Pulse 64, BP 145/55, RR 18, O2 sat 97% on 2
liters
GEN: comfortable, NAD
HEENT: OP clear, EOMI, PERRLA
NECK: no JVD noted, supple
LUNGS: CTA bilateral
HEART: S1, S2, RRR, no murmurs, rubs, gallops
ABD: soft, ND, NT, no HSM, + bowel sounds
EXTREM: no edema, cyanosis, clubbing
NEURO: AAO x3, CN II-XII tested and grossly intact
Pertinent Results:
[**2104-6-1**] 03:58PM GLUCOSE-128* UREA N-26* CREAT-1.3* SODIUM-140
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17
[**2104-6-1**] 03:58PM CK(CPK)-31
[**2104-6-1**] 03:58PM CK-MB-NotDone cTropnT-0.29*
[**2104-6-1**] 03:58PM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-1.4*
[**2104-6-1**] 03:58PM WBC-5.3 RBC-3.00* HGB-10.5* HCT-32.4*
MCV-108* MCH-34.9* MCHC-32.3 RDW-16.8*
[**2104-6-1**] 03:58PM PLT COUNT-471*
[**2104-6-1**] 03:58PM PT-14.4* PTT-28.7 INR(PT)-1.3
EKG: a-v paced with a rate around 65, LBBB
CHEST (PORTABLE AP)
Reason: please assess interval change
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with NSTEMI, new onset shortness of breath now
s/p diuresis
REASON FOR THIS EXAMINATION:
please assess interval change
INDICATION: 87-year-old with congestive heart failure.
Portable upright frontal radiograph. Comparison is made to one
day earlier and study performed 6 hours earlier.
FINDINGS:
Compared to the study of 6 hours earlier, there has been an
improvement in the congestive heart failure pattern with
decreased upper zone redistribution. There is stable
cardiomegaly. Clips are seen in the right upper quadrant, likely
from prior cholecystectomy. The aorta is calcified, and
calcifications are also seen in the splenic artery.
IMPRESSION:
Improving congestive heart failure.
1. Coronary angiography of this right dominant system revealed
three
vessel coronary artery disease. The left main coronary artery
had a 20%
stenosis. The LAD had a 90% stenosis at the origin. The LCX
had a 60%
stenosis of the OM1. The RCA was totally occluded.
2. Resting hemodynamics revealed mildly elevated right sided
filling
pressures (mean RA pressure was 9 mm Hg and RVEDP was 10 mm Hg).
Pulmonary artery pressures were mildly elevated (PA pressure was
47/18
mm Hg). Left sided filling pressures were moderately elevated
(mean PCW
pressure was 21 mm Hg). Central arterial pressure was mildy
elevated
(aortic pressure was 150/63 mm Hg). Cardiac index was low (at
2.2
L/min/m2).
3. Successful PTCA/stenting of the proximal LAD with a 3.0x13mm
Cypher
DES. Final angiography revealed no residual stenosis, no
dissection and
TIMI-3 flow (see PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderately elevated left sided filling pressures.
3. PCI of the LAD.
ECHO
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.7 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: *<= 30% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.7 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A Ratio: 0.64
Mitral Valve - E Wave Deceleration Time: 455 msec
TR Gradient (+ RA = PASP): *30 to 36 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Severely depressed
LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Moderate (2+) MR. LV inflow pattern c/w impaired
relaxation.
TRICUSPID VALVE: Mild PA systolic hypertension.
PERICARDIUM: Small pericardial effusion.
Conclusions:
1. The left atrium is moderately dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Overall left ventricular systolic
function is severely
depressed. Anterior, septal, apical, distal inferior, and distal
lateral
severe hypokinesis to akinesis is present.
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened. Moderate
mitral
regurgitation is present.
5. There is mild pulmonary artery systolic hypertension.
6. There is a small pericardial effusion.
Brief Hospital Course:
# CHF - The arrived slightly fluid overloaded then had flash
pulmonary edema in the setting of hypertension and fluid
administration on the floor. She was transferred to the ICU for
[**Last Name (un) 62089**] monitoring but did not require intubation. Her echo showed
an EF of less than 30%, 2+ MR, overall left ventricular systolic
function was severely
depressed. Anterior, septal, apical, distal inferior, and distal
lateral
severe hypokinesis to akinesis was present. She diuresed well
and became euvolemic with a base weight of 49.8kg. She will be
discharged on only Lasix 20mg.
.
# CAD- The patient was transferred here from [**Hospital1 **] for an
NSTEMI. Her cath showed 20% LMCA, 90% LAD which was stented, and
a 60% OM1 lesion. Her RCA was totally occluded. Her peak
troponin 1.07 and peak CK of 354. She was continued on a ASA
B-blocker, and ACEi. She was given Crestor because she said she
was allergic to Lipitor and tolerated this well. If her diarrhea
persists, consider stopping Crestor. She should remain on Plavix
for at least 6-9 months.
.
# LBBB. AV paced. The paitent had a 16 beat run of VT on the
tele monitor here. She was asymotpaitc. She should be evaulated
by her cardiologist for a Biv/ICD pacer if nnecessary.
.
# Acute renal failure- The patient had an increase in her Cr
here thought to be due to contrast. Peak was 1.5 and began to
decrease before discharge. Recheck in [**2-10**] weeks.
.
# Anemia and thrombocytosis: She takes hydrea for essential
thrombocytosis. Also takes procrit as outpt to counteract
hydrea. Initially her Plavix was doubles to 150 since she has
thrombocytosis, but then she had an episode of blood-streaked
stool therefore her Plavix was reduced to 75. Her HCT decreased
to 26 ans she was transfused 1 unit to a HCT of 32.
.
# Abdominal Pain: The paitent had abdominal pain, nausea, and
vomiting daily at home and this continued here. She is under tha
care of a gastroenterologist as an outpaitent and should make an
appointment as soon as possible. In addition, she had one stool
that was streaked with blood here in the setting of 150 of
Plavix. She then sunsequently had Guiac neg stools. She should
have a colonoscopy as an outpaitent and a HCT checked in 1 week.
Medications on Admission:
1. Aspirin 81mg po daily
2. Synthroid 25mcg po daily
3. Enalapril 20mg po daily
4. Lopressor 100mg po bid
5. Protonix 40mg po daily
6. Methyldopa 750mg po tid
7. Lasix 20mg po daily
8. Hydrea 500mg po bid
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Rosuvastatin Calcium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Methyldopa 250 mg Tablet Sig: Three (3) Tablet PO Q8H (every
8 hours).
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Continue until the patient is
walking at least TID.
11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily):
Hold for SBP < 100 and HR < 50 .
13. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO every
other day as needed for diarrhea.
14. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): Do not stop the medication unless you speak with
your cardiologist.
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
16. Epogen 20,000 unit/2 mL Solution Sig: One (1) mL Injection
qMOWEFR: 10,000U qMOWEFR.
17. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal [**Hospital1 **] (2 times a day) as needed.
18. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
congestive heart failure
NSTEMI
acute renal failure
diarrhea
sick sinus syndrome
Discharge Condition:
good
Discharge Instructions:
You should weigh yourself daily. Call your PCP if you have a
increase in your weight by more than 3 lbs.
Maintain a 2 L fluid restriction
DO NOT STOP YOUR PLAVIX under any circumstances before speaking
with your cardiologist in the next 9 months.
Followup Instructions:
You have an appointment with Dr. [**First Name (STitle) **], your cardiologist, on
3Pm [**7-4**]. The phone number is ([**Telephone/Fax (1) 20259**].
You should follow up with your gastroenterologist as soon as
possible.
|
[
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"414.01",
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"427.31",
"428.0",
"412",
"401.9",
"427.81",
"V45.01",
"426.3",
"E947.8",
"584.9",
"787.01",
"428.20",
"272.0",
"244.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"99.04",
"36.07",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10783, 10798
|
6407, 8638
|
299, 313
|
10923, 10929
|
2029, 2610
|
11224, 11449
|
1634, 1652
|
8893, 10760
|
2647, 2725
|
10819, 10902
|
8664, 8870
|
4245, 6384
|
10953, 11201
|
1667, 2010
|
224, 261
|
2754, 4228
|
341, 1175
|
1197, 1465
|
1481, 1618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,202
| 152,698
|
33838
|
Discharge summary
|
report
|
Admission Date: [**2125-5-22**] Discharge Date: [**2125-6-1**]
Date of Birth: [**2050-5-9**] Sex: M
Service: VSU
CHIEF COMPLAINT: Arterial insufficiency with right foot
pain.
HISTORY OF PRESENT ILLNESS: This is a 75-year-old gentleman
with a significant past medical history with coronary artery
disease status post stenting, chronic obstructive pulmonary
disease, syndrome of inappropriate antidiuretic hormone and
peripheral vascular disease. He presented to Caritas [**Hospital6 40383**] two to three weeks prior to transfer here for
right foot pain. The patient states that his pain became
progressively progressed to the point he was unable to walk.
This was associated with swelling. Therefore, he was
evaluated on [**2125-5-21**], at [**Hospital3 **] Caritas. He was
found to have a normal white count of 9.4 and was afebrile.
He was also found to have urinary retention. He was started
on vancomycin and Zosyn and was transferred to our
institution for further workup and possible vascular
intervention. The patient was known peripheral vascular
disease. He was to have an elective leg re-vascularization
by Dr. [**Last Name (STitle) **] and this was cancelled due to the patient's
significant history of chronic obstructive pulmonary disease.
The patient denies any constitutional symptoms, shortness of
breath, chest pain, nausea, vomiting or bowel habit changes.
He was treated at Caritas [**Hospital3 **] for right lower lobe
pneumonia as well as chronic obstructive pulmonary disease
exacerbation.
PAST MEDICAL HISTORY: Illnesses: Chronic obstructive
pulmonary disease, coronary artery disease, paroxysmal atrial
fibrillation anticoagulated, peripheral vascular disease,
history of alcohol abuse, history of SIADH.
PAST SURGICAL HISTORY: Coronary artery stenting, vessels
unknown.
MEDICATIONS: Medications at home include nitroglycerin
sublingual, Atrovent, Procardia 240 mg ER, Ecotrin 81 mg
daily, Lasix 40 mg twice a day, pravastatin 40 mg twice a
day, Pulmicort, Spiriva, vitamin B12, Xopenex 0.4 mg four
times a day p.r.n.
Transfer medications were vancomycin 1 gram every 12 hours,
Zosyn 3.375 grams every 8 hours, omeprazole, acetaminophen,
morphine, Lovenox 30 mg, Diltiazem 240 mg, Ecotrin 81 mg,
simvastatin 20 mg, vitamin B12 500 mg and Spiriva.
SOCIAL HISTORY: The patient can ambulate and take care of
himself before it became too painful to walk. He has a
heavy smoking history of one to two packs per day for
approximately 60 years. He quit three months ago. He does
have a history of alcohol excess and admits to drinking one
12-ounce beer per night.
PHYSICAL EXAMINATION: Vital signs: 98.4, 86, 18, O2
saturation 955 on 2 liters, blood pressure 133/67. General
appearance: Alert and oriented x3, appears somewhat
uncomfortable with movement of the foot. HEENT examination
is unremarkable. Neck is supple. Carotid pulses are
symmetrical. There are no carotid bruits. Heart is a
regular rate and rhythm with a 2/6 systolic ejection murmur.
Lungs increased AP diameter and sounds are distant globally.
Abdominal examination is unremarkable. There are no intra-
abdominal bruits. A Foley is in place. Extremity
examination shows 3+ edema right greater than left. The
right foot is with blanching erythema extending to just
proximal to the ankle and diffuse erythema of the leg to the
hip. It is more pronounced on the dorsal leg. There are
multiple scars and superficial erosions on the anterior
tibia. Toes two, three and four with violaceous ischemic
appearance. Capillary refill is greater than 3 seconds.
There are small ulcers in the web spaces in the interdiginous
areas between the toes with fibrinous purulent exudate. The
fourth toenail is separating. Overall, foot is somewhat cool
to touch with toes being most pronounced compared to the
contralateral side. Overall, poor foot hygiene. Left foot
is warm with adequate perfusion. Pulse examinations:
Carotids 2+, radials 2+, femoral faintly palpable on the left
and 1+ on the right. On the left, the popliteal is palpable.
The dorsalis pedis and posterior tibial are monophasic
[**Hospital3 **] signals. On the right, the popliteal, dorsalis
pedis are absent. The posterior tibial is a monophasic
signal.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service. He was continued on his antibiotics. Podiatry was
consulted. They felt at this time there was no surgical
indication to treat the foot or leg lesions. They
recommended to continue antibiotics, daily wound care with
Betadine to the lesions and the patient could ambulate full
weightbear with a healing sandal. Outside, a CT of the
abdomen and aorta with runoffs falling. There is complete
occlusion of the left external iliac artery, occlusion of the
proximal superficial femoral artery with reconstitution of
the distal superficial femoral artery with large deep femoral
artery with three-vessel runoff. On the right side, there
was stenosis in the proximal common iliac and external iliac
arteries with a high-grade stenosis of the deep femoral
artery, poor collateral flow distally, some reconstitution of
the right popliteal artery and two-vessel runoff on the right
ankle with dominant vessel being posterior tibial. There was
severe atherosclerotic and mesenteric and renal artery
changes.
The patient underwent arteriogram on [**2125-5-25**], without
complication. He was recommended that he could be
revascularized. Outside cultures grew methicillin-sensitive
Staphylococcus aureus, methicillin-resistant Staphylococcus
aureus. The patient was continued on vancomycin, Cipro and
Flagyl. The patient underwent on [**2125-5-25**], a right
femoral endarterectomy with a right superficial femoral
artery posterior tibial bypass with non-reverse saphenous
vein graft, angioscopy and valve lysis. The patient required
2 units of packed red blood cells intraoperatively. The
patient tolerated the procedure well and was transferred to
the postanesthesia care unit in stable condition.
Postoperatively, he remained hemodynamically stable. He was
transfused 2 units of packed red blood cells. He continued
to do well and was transferred to the VICU for continued
monitoring and care. On postoperative day one, there were no
overnight events. T-max was 100.4 to 99. His blood gases
were 7.34, 43, 76, 24, -2. Hematocrit was 31.3. BUN 5,
creatinine of 0.6. Pulse examination on the right side
showed a [**Name (NI) **] PT signal. Foot was warm. The patient
remained in the VICU. Intravenous fluids were Hep-Lock'd.
Diet was advanced.
Postoperative day two, the patient continued to do well. The
right second toe remained ischemic in appearance. The Swan
was discontinued. He required diuresis. He was allowed to
ambulate to a chair. His T-max was 100.2 to 99.6. He
remained in the VICU. Most of the time he was noted to be
hyponatremic with a sodium of 122. Fluid restriction of 1000
cubic centimeters per 24 hours was instituted along with salt
tablets 1 gram twice a day. Hematocrit remained stable at
29.5. Antibiotics were continued. Diuresis continued and
the patient remained on a CIWA scale for his history of
alcohol use. The patient did demonstrate some mild confusion
which we felt was secondary to his hyponatremia.
Postoperative day three, there were no overnight events. He
was continued in the VICU. He was de-lined. Chair
ambulation was continued. Physical Therapy was prescribed to
see the patient and he was transferred to the regular nursing
floor for continued care. The patient underwent a right
second toe amputation on [**2125-5-31**]. He tolerated the
procedure well. He was reevaluated by Physical Therapy who
felt he would require rehabilitation prior to being
discharged to home.
Postoperative day five and one, the patient continued to do
well. Intravenous antibiotics were discontinued. Bactrim
was instituted. Coumadinization was reinstituted for his
history of fibrillation. He was given 5 mg. Sodium was
continued to be monitored. Sodium continued to show
improvement. He continued with the fluid restriction and
salt tablets. On postoperative day number six, the patient
continued to do well. Sodium was 128. He was afebrile. His
amputation site wound looked clean, dry and intact.
Ambulation essential distances full weightbearing with
healing sandal was instituted. He was screened by Physical
Therapy and Rehab. He will be transferred to Rehab for
continued postoperative care in stable condition.
DISCHARGE INSTRUCTIONS: The patient may shower but no tub
baths. He may ambulate essential distances with healing
sandal. If he develops any fevers, wound changes consisting
of redness, drainage or groin swelling or drainage, please
notify Dr.[**Name (NI) 1392**] office. His antibiotics should be
continued until seen in follow up. His INR should be
monitored on a daily basis for goal INR of 2.0 to 3.0.
Coumadin should be adjusted as needed. The patient is on
Bactrim which interacts with Coumadin and may elevated the
INR. The sodium should also be monitored. His current
sodium is 128 on a fluid-restriction of 1200 cubic
centimeters per 24 hours and 2 grams of sodium tablets twice
a day. The patient should follow up with Dr. [**Last Name (STitle) 1391**] in two
to three weeks.
DISCHARGE DIAGNOSIS: Arterial insufficiency with ischemic
right foot pain, history of ischemic heart disease status
post percutaneous coronary intervention, history of chronic
obstructive pulmonary disease, history of paroxysmal atrial
fibrillation anticoagulated, history of syndrome of
inappropriate antidiuretic hormone, history of alcohol abuse,
status postop hyponatremia treated, postoperative blood loss
anemia transfused.
MAJOR SURGICAL AND INTERVENTION PROCEDURES: Diagnostic
arteriogram via right femoral access on [**5-25**]; a right
femoral endarterectomy with a right fem PT bypass with non-
reversed greater saphenous vein on [**2125-5-25**]; a right
second to amputation on [**5-31**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2125-6-1**] 12:47:53
T: [**2125-6-1**] 14:48:45
Job#: [**Job Number 78210**]
|
[
"427.31",
"496",
"276.1",
"682.7",
"V45.82",
"440.24",
"285.1",
"414.01",
"730.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"88.42",
"38.18",
"39.29",
"00.40",
"84.11"
] |
icd9pcs
|
[
[
[]
]
] |
9341, 10293
|
4281, 8523
|
8548, 9319
|
1788, 2311
|
2649, 4263
|
152, 198
|
227, 1544
|
1567, 1764
|
2328, 2626
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,217
| 124,545
|
31973
|
Discharge summary
|
report
|
Admission Date: [**2116-10-20**] Discharge Date: [**2116-11-3**]
Date of Birth: [**2039-3-8**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Transferred from OSH w/ anemia and cardiac ischemia
Major Surgical or Invasive Procedure:
-Intubation
-EGD with cauterization
-reduction of nasal septum
-suturing of facial lacerations
-placement of radial a-line
-placement of left IJ trauma line
-intubation
History of Present Illness:
77 yo male w/ hx of a fib on coumadin, CABG (20 yrs ago), PVD -
s/p femoral bypass (? graft) and CEA x 2 who presetned to OSH on
evening of [**10-19**] after a fall. Per patient and daughter, patient
fell at home and landed on his face, however the patient cannot
recall the events surrounding the fall.
Patient's daugher reports that he had grown progressively
fatigued for several days PTA. On the day of his admission to
[**Hospital1 2436**] he was extremely fatigued and she noticed he was
dyspneic with minimal exertion. He had not been complaining of
shortness of breath of chest pain. No fevers/chills, abd pain,
vomiting, hematemesis, BRBPR, or melena. Cicumstances
surrounding fall are unclear; neither patient nor family able to
provide clear history. Of note, patient recently lost "some
weight" and six weks ago underwent a screening colonscopy to
look for malignancy. Daughter also reports that patient seemed
to have some trouble swallowing his food and was frequently
coughing/choking.
For several days prior to the fall patient had been complaining
of extreme fatigue and the daughter noted him to have
significant dyspnea on exertion. He had also been complianing of
back pain and had been taking vicodin sevreal days prior to
admission.
Presented to [**Hospital3 2783**] w/ a hct of 16, INR of 22-
given 2uPRBC and 1uFFP and 10 sc vit K x 1. Had facial fx on
head CT w/o ICH. Found to have a trop of 1.59 (n < 0.4). Tx to
[**Hospital1 18**]. In [**Hospital1 **] ER found to be borderline hypotensive SBP 90-110,
and HR in 90s sating 100% on 4L and afebrile- showed ST dep
1-2mm in V4-V6 and STE of 1mm in V1/V2. Found to have LLL
infiltrate and R sided pleural effusion. Given levofloxacin.
Noted to have guiac + stools, no gross blood. Admitted to ICU-
hypotensive to SBP of 70 but alert and answering questions
appropriately. HR 91, hypothermic to 91F axillary. Became
acutely unresponsive w/ labored breathing and HR in 20-30
(palpable) and SBP down to 50, patient rec'd atropine and
pressors. Given 4 uPRBC, 2uFFP. Bedside echo showed EF of 30%
and anteroseptal WMA. Pressors weaned. EGD performed revealing
duodenal bulb ulcer w/ visible vessel for which bicap/epi was
applied, ? ischemic changes of gastric mucosa. Normal
colonoscopy 6 weeks prior to admission so colonoscopy deferred.
Per ICU team- pt also had 15 beat run of NSVT w/o hemodyamic
compromise and "resolving delerium."
Past Medical History:
-CAD - s/p CABG in [**2097**] (for anatomy see outside records in
chart), per PCP free of angina symptoms since then
-A fib - dx in [**4-1**], on coumadin since then, INR on [**10-13**] was 2.5
-valvular heart disease - ECHO at [**Hospital1 2436**] in [**4-1**] w/ EF
50-555%, mild AS, mod AR, mod MR, mod TR - has been asymptomatic
-PVD - s/p r fem-[**Doctor Last Name **] bypass (? graft) years ago, had revision in
'[**14**]
-hypercholesterolemia
Social History:
Retired in '[**97**] after his CABG. Lives with his daughter. [**Name (NI) **]
smoked since he was a teenager, formerly a moderate drink but no
etoh x several years.
Family History:
Noncontributory
Physical Exam:
T 98.6, BP 114/62, HR 94, RR 18, sat 93% RA
HEENT: PERRL, EOMI, MMM, poor dentition
Lungs: LLL ronchi, decreased breath sounds at the R base
Cards: irregularly irregular, diastolic and systolic murmur,
unable to characterize
Abd: + bs, soft, mildly distended abdomen
Ext: 1+ lower ext edema bilat, pulses PT 1+ bilaterally.
Neuro: ambulates with assist, AOx1-2, interactive, follows
commands, speech appropriate, EOMI, PERRL, CN2-12 normal, normal
stregnth in all 4 extremities.
Pertinent Results:
EGD: ulcer w/ visible vessel in the proximal bulb. Mottled
red/purple appearing mucosa in the stomach body/fundus
compatible with ischemic changes.
[**10-20**] head CT: Study is limited by motion. No evidence of
intracranial hemorrhage identified. Multiple facial fractures,
as detailed above, however, incompletely visualized.
Encephalomalacia in the right frontal and right temporal regions
suggest prior hemorrhage, contusion or infarct.
[**2116-10-28**] repeat Head CT: No significant change since [**2116-10-20**] with
no intracranial hemorrhages.
ECHO [**10-20**]: EF 30%
Repeat Echo [**10-28**]: EF 45-50%. mildly dilated LV, intrinsic LV
systolic function likely depressed given the severity of
valvular regurg. no effusion. 2+MR, 1+TR, 1+AR, mild AS..
admission labs [**10-20**]: hct 19, INR 3.6, WBC 19.1.
discharge labs [**11-3**]: BUN 17, Cr 0.7, WBC 11.7, hct 30.4, Plt
181, INR 1.3
C diff negative x 1
[**10-20**] TnT 0.27, peak [**10-27**] 1.36
[**10-20**] CK 334, peak [**10-21**] 847, [**10-30**] 47
u/a [**10-29**]: Lg blood, > 50 RBC, otherwise negative
Ucx negative
H. Pylori antibody +
[**10-27**] sputum: respiratory / OP flora
[**10-20**], [**10-23**] blood cx negative
CTA chest [**10-20**]
1. No evidence of traumatic aortic injury or retroperitoneal
hematoma.
2. Patchy opacity in the left lung base, likely aspiration,
with developing pneumonia.
3. Moderate right-sided simple pleural effusion.
4. Extensive paraseptal emphysema.
5. Extensive atherosclerotic disease involving the coronary
arteries, aorta, and its major branches.
6. Cystic structure associated with the left hip joint, which
could be a
synovial cyst or fluid within a bursa, other joint pathology
cannot be
excluded and an MRI could be of value
Brief Hospital Course:
GI bleed: in setting of INR 22 (on [**10-19**], although 6 days earlier
was reportedly 2.5). Hct initially 16, found to have ulcer w/
visible vessel. Given high risk of re-bleed patient was
monitored closely and responded to blood transfusions and
clinically improved. Hemodynamically stable for > 72 hours upon
discharge with a stable hct. Patient will be discharged on a
regimen including flagyl/clarithromycin for H. pylori treatment.
Also, he should be on a PPI [**Hospital1 **] x 2-3 weeks, this can then be
changed to daily.
NSTEMI: In the setting of severe anemia and hypovolemia the
patient had an elevated troponin, ST depressions in the
antero-lateral leads and a CK that peaked in the 800s. His EF
dropped to 30% and recovered to 40-45% upon repeat Echo. He was
started on an ACEi and was diuresed for mild volume overload.
He was started on lasix 20mg po daily upon discharge, this
should be titrated to a goal diuresis of net negative 500cc
daily, please titrate his diuretic based upon his volume status
and renal function. He has cardiology follow up and a repeat
ECHO scheduled. He would benefit from an outpatient stress
test, will defer to outpatient cardiology to plan this if
indicated. Per GI patient should not restart coumadin or
aspirin. If patient must restart ASA 81mg daily in the future
per cardiology would not restart until re-evaluated by GI and
ulcer has resolved on repeat endoscopy.
Leukocytosis: peaked at 18, normal diff, this trended downward
with no clear source of infection. Cultures negative, C diff
negative x 1.
CHF: previously no documented history of CHF but in acute NSTEMI
EF was 30%, increased to 40-45% upon re-ECHO. Has cardiology
follow up set and a repeat ECHO, continue ACEi and Lasix.
A-FIB: given absolute severity of illness due to
supratherapeutic INR (INR 22) would hold coumadin. Unclear as
to why it was so high, possibly due to patient taking excessive
medication or to sensitivity to coumadin; however, these are
speculations at this time.
Medications on Admission:
atenolol
atorvastatin
coumadin
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: as directed PO TID (3
times a day): 200mg po tid.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for Constipation.
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
take 40mg po bid until [**2116-11-26**] then tke 40mg po daily.
6. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 10 days.
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
9. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
#. GI bleed secondary to duodenal Ulcer
#. Ischemic Gastritis
#. NSTEMI
#. Acute systolic CHF with depressed EF 45%
#. Delerium
.
Secondary:
#. Coronary Artery Disease - s/p CABG in [**2097**]
#. Afib
#. Moderate MR, Moderate TR
#. Peripheral Vascular Disease
#. Hyperlipidemia
Discharge Condition:
stable, sating well on RA, hemodynamically stable
Discharge Instructions:
1. Please take all medications as prescribed
.
2. Please keep all outpatient appointments.
.
3. Please follow the care of the Physicians at [**Hospital **] Rehab
.
4. Please return to the hospital for any symptoms of chest pain,
shortness of breath, fevers, chills, nausea/vomiting or any
other concerning symptoms.
Followup Instructions:
Friday [**11-13**] at 1:00 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 23**] building [**Location (un) 470**] on
the [**Hospital Ward Name 516**] of [**Hospital1 18**].
.
2. You will also need to follow up with cardiology on discharge.
You have an ECHOCARDIOGRAM on [**2116-12-21**] at 9:00 am. Please call
[**Telephone/Fax (1) 128**] with questions.
.
You have a caridiology follow-up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 171**] on [**2116-12-21**] 11:20 in the [**Hospital Ward Name 23**] building on the [**Location (un) **]. The phone number is [**Telephone/Fax (1) 1989**]. Please cal with any
questions or scheduling concerns.
.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25699**], after
discharge from the rehab facility. Please contact his office at
[**Telephone/Fax (1) 47432**]
|
[
"518.81",
"E888.9",
"285.1",
"276.52",
"802.0",
"693.0",
"785.51",
"802.8",
"424.0",
"397.0",
"507.0",
"802.4",
"427.31",
"276.2",
"427.1",
"287.5",
"532.00",
"V58.61",
"410.71",
"428.0",
"443.9",
"E930.0",
"V45.81",
"584.5",
"428.21",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93",
"99.04",
"21.71",
"44.43",
"99.07",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9110, 9189
|
5925, 7945
|
317, 487
|
9530, 9582
|
4143, 4305
|
9946, 10882
|
3612, 3629
|
8026, 9087
|
9210, 9210
|
7971, 8003
|
9606, 9923
|
3644, 4124
|
226, 279
|
515, 2940
|
4621, 5902
|
9229, 9509
|
2962, 3413
|
3429, 3596
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,463
| 135,787
|
30289
|
Discharge summary
|
report
|
Admission Date: [**2181-10-25**] Discharge Date: [**2181-11-15**]
Date of Birth: [**2124-3-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
[**10-25**] upper endoscopy
[**10-29**] upper endoscopy
[**11-6**] upper endoscopy
[**11-6**] colonoscopy
[**11-7**] upper endoscopy w/ variceal banding
History of Present Illness:
57 yo F with hx of polysubstance abuse, alcoholic cirrhosis,
active NSAID use, transferred from [**Hospital 8**] Hospital to [**Hospital1 18**]
for possible angiography and intervention of upper GI bleed. At
6am on [**10-23**], pt had approximately 1 quart of bloody emesis
associated with weakness. On initial arrival to OSH ED, HR~115,
with systolic 60s to 70s. She was started on protonix and
octreotide drips at that point with 2L IVF and 4 U pRBC. EGD
done in their ED revealed a large clot with bleeding in the
gastic cardia. No varices were seen & Epinephrine was injected.
.
Summary of transfusion and Hcts:
- [**10-23**]: Hct 25 in ED --> 2L IVF, 4U pRBC --> 36.3
- [**10-24**]: 31 --> 25 --> 4 U pRBC + 2FFP -->31 -->39
- [**10-24**], 9PM: 39 --> 30 --> 2U pRBC + 2-3 units in transport
.
A total of 4.25 L of bloody contents were suctioned from her
stomach after EGD and she had extensive melanotic/bloody BMs.
.
CT of the abdomen showed showed cirrhosis, chronic pancreatitis,
ascites and diffuse colonic wall thickening. There was also a
finding in the LLL concerning for PNA for which she received
amikacin, cefepime, and vancomycin. WBC trended from 16 to 20
prior to transfer. Initial blood gas at OSH showed ph of 7.07 in
setting of ETOH level of 200, corrected fairly rapidly to 7.32.
.
ROS: unable to assess
Past Medical History:
ETOH cirrhosis MELD 8
opiod depenence
OA
idiopathic peripheral neuropathy
gastritis/duodenitis
GERD
endoscopy [**2175**] w 'watermelon stomach'
no varices
Social History:
Lives alone in [**Hospital1 8**] with 6 cats including her favourite, a
Siamese named [**Name (NI) 72105**]. She denied ETOH at OSH but level on
admission ~200; 20 pack-year hx of smoking. As per her
[**Last Name (LF) 72106**], [**First Name3 (LF) **] and [**Last Name (LF) **], [**Known firstname **] has been a closet alcoholic and
hid her addiction from them for many years. She drank vodka
every day since she was young and told others it was a "hormone
drink" as she mixed it with juice. They are unaware of any drug
use. She has not tried detox or AA in the past but reportedly
had previous episodes of (? variceal, ?ulcer) "bleeding out"- as
per [**Known firstname 72106**] [**11-11**] [**Last Name (NamePattern4) 72107**]
Family History:
patient does not recall her family history, but as per her good
friends [**Known firstname **] father was an alcoholic and died from alcoholic
cirrhosis. Her mother was a heavy drinker and also died from
alcohol-related complications.
Physical Exam:
DISCHARGE EXAM/ VITALS
VS: T 98.9 BP 120/70 HR 77 RR 20 SaO2 99 RA
GEN: thin, ill and anxious-appearing woman appearing older than
her stated age sitting up in a chair in no apparant distress
HEENT: anicteric sclerae, EOMI, PERRLA, poor dentition
CV: Regular rate and rhythm, no murmurs appreciated
LUNGS: clear to auscultation b/l no wheeze appreciated, good air
movement b/l
ABD: NABS, soft, slightly distended with fluid present,
non-tender to palpation, liver edge palpated 2cm below
costophrenic angle
EXT: no edema B/L LE, 2+ DP and PT pulses B/L
SKIN: multiple scattered ecchymoses/ healed scab on left side of
chest just lateral to sternum
MUSC: diffuse muscular atrophy B/L UE and LE
Pertinent Results:
[**10-25**] EGD: Varices at the gastroesophageal junction and lower
third of the esophagus Congestion and granularity in the whole
stomach compatible with diffuse moderate nonbleeding portal
gastropathy. Blood in the fundus and cardia this obstructed
vision of these areas. The body, antrum, duodenal bulb and D2,
D3 had no bleeding sites. Otherwise normal EGD to third part of
the duodenum
[**10-29**] EGD: Varices at the lower third of the esophagus and
gastroesophageal junction Varices at the lower third of the
esophagus and gastroesophageal junction 4-5 mm adherent clot
overlying potential ulcer without active bleeding in fundus.
Clot adherent despite numerous flushes.
Erythema, congestion, mosaic appearance and abnormal vascularity
in the whole stomach compatible with portal hypertensive
gastropathy Otherwise normal EGD to second part of the duodenum
[**2181-10-25**] 04:20AM BLOOD WBC-16.9*# RBC-5.71*# Hgb-16.4*#
Hct-47.6# MCV-83# MCH-28.8# MCHC-34.6 RDW-17.0* Plt Ct-57*#
[**2181-10-25**] 04:20AM BLOOD Neuts-87.3* Lymphs-6.6* Monos-5.1 Eos-0.2
Baso-0.7
[**2181-10-25**] 04:20AM BLOOD PT-14.5* PTT-29.4 INR(PT)-1.3*
[**2181-10-25**] 04:20AM BLOOD Glucose-175* UreaN-21* Creat-0.7 Na-143
K-3.6 Cl-117* HCO3-17* AnGap-13
[**2181-10-25**] 04:20AM BLOOD ALT-24 AST-66* LD(LDH)-268* AlkPhos-127*
Amylase-59 TotBili-1.9*
[**2181-10-25**] 04:20AM BLOOD Albumin-2.8* Calcium-7.6* Phos-4.3 Mg-2.1
[**2181-11-7**] EGD:
4 cords of grade II-III varices were seen in the lower third of
the esophagus. The varices were not bleeding. 2 bands were
successfully placed.
Brief Hospital Course:
57 year-old female w/ polysubstance abuse, active alcoholism,
EtOH cirrhosis, previously with UGIB at OSH s/p EGD on admission
showing grades I & II varices and clot overlying peptic ulcer
with BRBPR. Due to prolonged hospital course, discharge summary
is in chronological order:
First MICU Course: ([**Date range (1) 72108**])
GI Bleed: Urgent EGD was done on admission [**10-25**], it showed
grades I & II varices, and clot overlying peptic ulcer but did
not show any actively bleeding varicies. She was suspected to
have a symptomatic ulcer and underwent repeat EGD on [**10-29**] to
evaluate the need for TIPS. Given insignificant varicies,
hepatology service recommended against TIPS. A potential
culprit ulcer was found, covered by clot overlying the fundus.
An intervention was not indicated and patient was continued on
PPI and sucralfate.
.
Respiratory failure: OSH chest CT showed bilateral lower lobe
consolidations, possibly from aspiration and patient required
significant ventilatory support. Patient was started on
Vanc/ceftriaxon on [**10-25**] and brodened to Vanc/Zosyn on [**10-26**].
She was ventilated with low-tidal volume ventilation. She
completed an 8 day course of antibiotics. She was extubated on
presodex on [**10-31**] and her oxygen requirement continued to
decrease.
.
Leukocytosis: Patient had a leukocytosis of unclear etiology.
Cultures, paracentesis and C. diff assay were unrevealing. This
was trending down prior to transfer.
[**Doctor Last Name **]-[**Doctor Last Name **] COURSE: ([**Date range (1) 69839**])
Ms. [**Known lastname **] was transferred to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service on [**11-4**]
on 4 L NC oxygen which was quickly weaned to 2 L then to room
air, which she tolerated. Her leukocytosis was thought to be
secondary to an inflammatory process rather than an infectious
one, as her hypoxia improved and she was afebrile. For her
mental status, she was treated for PSE with lactulose and
rifaxamin. Her mental status improved dramatically over her
course on the floor and she was being screened for rehab, having
done well with PT/OT but had a large bloody bowel movement
consisting of fresh red blood and clot on [**11-6**], which caused her
to be readmitted to the ICU for further hemodynamic monitoring.
Second MICU Course: ([**Date range (1) 9395**])
Returned to MICU with BRBPR concerning for fast upper versus
lower GI bleed. HCT was stable. Vital signs were stable.
Regardless, was started on octreotride drip and pantoprazole
drip. Seen by GI for colonoscopy and EGD. Copious blood seen in
colon, but no site of bleeding found. At repeat EGD received
banding of 2 varices. Given prophylactic levofloxacin. Continue
to have altered mental status. Most likely etiology was hepatic
encephalopathy. Held lactulose in context of bleed, but
continued rifaximin. Given stability of vital signs and
hematocrit, was called back to the floor for further management.
[**Doctor Last Name **]-[**Doctor Last Name **] COURSE: ([**Date range (1) 72109**])
She remained hemodynamically stable on the floor but still had
altered mental status and was less clear than she had been
during her first stay on the floors. She was treated with
lactulose and rifaxamin with some mild improvement. Her altered
mental status is more likely due to alcoholic encephalopathy
(Wernicke-Korsakoff's type picture) and less likely hepatic
encephalopathy as she confabulates, circumvents questioning and
has tangible speech. She had been alert and oriented and
asterixis was never present on exam on the floors. She was
screened for rehab again with physical and occupational therapy,
and was seen by social work regarding her alcohol abuse. She was
cleared medically but stayed in house for several extra days due
to issues with discharge as patient refused acute rehab. She
remained at her baseline mental status and was discharged home
with services on [**2181-11-15**].
Medications on Admission:
Amitryptyline
Naproxen
Prilsoc 20 daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*1*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Disp:*180 Tablet(s)* Refills:*2*
9. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO
three times a day: titrate to [**1-31**] loose BM's per day.
Disp:*1 bottle* Refills:*2*
11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Ensure High Protein Liquid Sig: One (1) can PO three
times a day: take w meals breakfast, lunch, dinner.
Disp:*90 cans* Refills:*2*
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 doses.
Disp:*3 Tablet(s)* Refills:*0*
14. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: Start on [**2181-11-16**] when you finish the twice a day dosing.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY:
1. Decompensated Alcoholic Cirrhosis complicated by
encephalopathy, esophageal varices and ascites
2. Upper GI bleed.
SECONDARY:
1. Hypertension
Discharge Condition:
Vitals stable, ambulating without difficulty, alert and oriented
to person, place, time and purpose.
Discharge Instructions:
It was a pleasure being involved in your care, Ms. [**Known lastname **]. You
were admitted to the hospital with a large upper GI bleed for
which you had several blood transfusions and upper endoscopies
which showed esophageal varices and a peptic ulcer that may have
been bleeding. You were intubated for the procedure and may have
had an aspiration pneumonia. You were treated with antibiotics
and were stable enough to come to the liver service. You were
initially confused so were treated with lactulose.
You had blood in your stool, and so you were sent to the ICU for
investigation and close monitoring.
Your medications have CHANGED as follows:
1. We ADDED Nadolol 20mg twice per day. This is important to
take to prevent further bleeding.
2. We ADDED Sucralfate and Pantoprazole for your ulcer.
3. We ADDED Lactulose and Rifaxamin to help keep your thinking
clear.
4. We added Amlodipine for blood pressure control. We
DISCONTINUED captopril during your last hospitalization.
5. We added FOLATE, THIAMINE and MULTIVITAMINS which you should
take daily for good nutrition.
6. We ADDED Ciprofloxacin to prevent infection in your abdomen.
You need to take this TWICE A DAY until [**11-16**] and then take it
once a day from then on. Your cefpodoxime was stopped.
It is extremely important to stop drinking alcohol as drinking
alcohol is the cause of your bleeding. You were seen by social
work and were given resources to stop drinking.
Please call your doctor or 911 if you experience crushing chest
pain, difficulty breathing, fevers/ chills intractable nausea or
vomiting, blood in your urine vomit or stool or any other
concerning medical problem.
Followup Instructions:
Please call your primary care doctor, Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 57762**] to
schedule a post-hospitalization follow-up.
GASTROENTEROLOGY:
For repeat Endoscopy:
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2181-12-18**] 10:00.
Please arrive at 9am for this appointment.
Dr.[**Name (NI) 37751**] office will call you to schedule you for a clinic
appointment.
Completed by:[**2181-11-15**]
|
[
"276.2",
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"356.9",
"518.81",
"291.81",
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"401.9",
"305.1",
"303.91",
"789.59",
"456.21",
"478.5",
"530.81",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"96.6",
"96.72",
"96.04",
"45.13",
"38.91",
"45.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11028, 11086
|
5354, 9308
|
332, 486
|
11285, 11388
|
3757, 5331
|
13106, 13582
|
2790, 3026
|
9398, 11005
|
11107, 11264
|
9334, 9375
|
11412, 13083
|
3041, 3738
|
277, 294
|
514, 1847
|
1869, 2027
|
2043, 2774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,223
| 130,044
|
41781
|
Discharge summary
|
report
|
Admission Date: [**2148-11-6**] Discharge Date: [**2148-11-15**]
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / Nafcillin
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Bedside wound debridement
History of Present Illness:
[**Age over 90 **] yo woman with CHF (baseline EF 30%), CAD, MR, who was
admitted with syncope/pre-syncope. The patient is a poor
historian, but per my history she more had fatigue and malaise
and was found to have large (10cm) leg wound/ulcer leading to
transfer to OSH. During [**Location (un) 620**] admission, found to have acute
on chronic renal failure (now back to baseline with iv fluids),
elevated troponin (seen by cards who felt no active issue at
this time, no cath), repeat ECHO showed EF 10%. Also evaluated
by ID, who rec'ed Vanc/Zosyn for leg, also empiric treatment for
scabies (given) for a diffuse skin rash, though they felt that
this was unlikely, no scrapings done. Did have ABIs attempted
limited by calcified vessels and large leg ulcer. Of note, no
osteo seen on xray of leg. Transferred to [**Hospital1 18**] for vascular
surgery eval. Vitals on floor: 98.2 108/58 /84 18 99RA
.
Currently feels well. On ros denies fever, chills, night sweats,
headache, vision changes, rhinorrhea, congestion, sore throat,
cough, shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria. All other systems negative.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
1. Chronic venous stasis leading to edema.
2. Varicose veins.
3. Hypertension.
4. Hyperlipidemia.
5. Gouty arthritis.
6. Rheumatoid arthritis.
7. Hypothyroidism.
8. Cervical cancer status post surgery.
9. MI at the age of 58.
10. Thyroid cancer, status post surgery .
Social History:
Lives at home by herself. Mostly independent of ADLs. Denies
smoking, alcohol or drugs.
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM:
VS: 98.2 108/58 /84 18 99RA
GENERAL: Well-appearing female in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM,
NECK: Supple,
LUNGS: CTA bilat, with crackles at left lower base. good air
movement, resp unlabored.
HEART: RRR, III/VI SEM
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: Malodorous ulcer on left lower extremity with dried
eschar. Down to muscle.
SKIN: Patient with prurigo nodularis on bilateral arms.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact.
.
DISCHARGE EXAM:
VS: T 97-98 BP 95-110/45-61 HR 70s-80s RR 18 O2 Sat 100% RA
GEN: Elderly woman in NAD
HEENT: EOMI, NCAT, MMM.
NECK: Supple, JVP 10cm above the RA
CV: RRR, normal s1/s2, II/VI systolic murmur heard most
prominently at the RUSB and apex. There is an S4. PMI laterally
displaced at the 5th intercostal space, mid-axillary line.
PULM: Bibasilar crackles, L>R. No wheezes or rhonchi, no
increased WOB
ABD: NTND, NABS, no rigidity, rebound or guarding.
EXT: L shin with a recently changed dry dressing. Pulses not
palpable. 1+ pitting edema to the mid shin.
NEURO: A/Ox3, CN II-XII intact, non focal.
Pertinent Results:
Admission Labs:
[**2148-11-7**] 07:44AM BLOOD Neuts-74.4* Lymphs-19.1 Monos-4.7 Eos-1.4
Baso-0.3
[**2148-11-7**] 07:44AM BLOOD ESR-116*
[**2148-11-14**] 06:55AM BLOOD Ret Aut-3.0
[**2148-11-7**] 07:44AM BLOOD Glucose-124* UreaN-46* Creat-1.4* Na-139
K-3.8 Cl-100 HCO3-26 AnGap-17
[**2148-11-7**] 07:44AM BLOOD CK(CPK)-386*
[**2148-11-8**] 07:44AM BLOOD CK(CPK)-179
[**2148-11-9**] 07:09AM BLOOD ALT-70* AST-90* LD(LDH)-437* AlkPhos-114*
TotBili-0.7
[**2148-11-7**] 07:44AM BLOOD CK-MB-7 cTropnT-2.56*
[**2148-11-8**] 07:44AM BLOOD CK-MB-5
[**2148-11-11**] 05:55AM BLOOD CK-MB-2 cTropnT-2.63*
[**2148-11-11**] 01:50PM BLOOD CK-MB-2 cTropnT-2.29*
[**2148-11-11**] 09:01PM BLOOD CK-MB-2 cTropnT-2.08*
[**2148-11-7**] 07:44AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7 Cholest-124
[**2148-11-14**] 06:55AM BLOOD calTIBC-276 VitB12-592 Folate-20.0
Hapto-229* TRF-212
[**2148-11-7**] 07:44AM BLOOD Triglyc-101 HDL-62 CHOL/HD-2.0 LDLcalc-42
LDLmeas-50
[**2148-11-7**] 07:44AM BLOOD CRP-76.7*
.
Discharge Labs:
[**2148-11-15**] 06:30AM BLOOD WBC-13.2* RBC-3.62* Hgb-10.3* Hct-31.4*#
MCV-87 MCH-28.5 MCHC-32.9 RDW-17.8* Plt Ct-333
[**2148-11-15**] 06:30AM BLOOD Neuts-71.4* Lymphs-14.1* Monos-4.3
Eos-10.0* Baso-0.2
[**2148-11-13**] 02:08AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Acantho-1+
[**2148-11-15**] 06:30AM BLOOD Glucose-94 UreaN-45* Creat-2.0* Na-139
K-4.0 Cl-99 HCO3-28 AnGap-16
[**2148-11-15**] 06:30AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9
Persantine Mibi ([**2148-11-12**]): [**Age over 90 **] year old female with
hypertension, hyperlipidemia, cad, infarct-related
cardiomyopathy, referred for evaluation. The patient was infused
with 0.142mg/kg/min of dipyridamole over 4 minutes as per
protocol. The patient did not complain of chest, back, neck or
arm pain during the infusion or recovery. The rhythm was sinus
throughout the procedure with rare, isolated APbs and rare,
isolated VPBs during the infusion and recovery. There were no
significant ischemic ST segment changes. The hemodynamic
response to the infusion was appropriate. 125 mg of
aminophylline IV was given at the end of the infusion, as per
protocol.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
.
The image quality is adequate.
Left ventricular cavity size is 267 mL.
Rest and stress perfusion images reveal a moderate fixed defect
of the septum, apex and anteroseptal walls and a severe fixed
defect of the inferolateral wall.
Gated images reveal global hypokinesis.
The calculated left ventricular ejection fraction is 15%.
IMPRESSION: 1. No reversible defects.
2. Moderate fixed defect of the septum, apex and anteroseptal
walls. Severe fixed defect of the inferolateral wall, all
consistent with multivessel disease.
3. Enlarged left ventricle with global hypokinesis. LVEF 15%.
Brief Hospital Course:
Primary Reason for Admission: [**Age over 90 **]F with multiple medical
problems, found to have [**Name (NI) **] in conjunction with a large
non-healing tibial ulcer.
.
Active Problems:
.
# [**Name (NI) **]: Unclear when occurred, EKG @OSH on [**11-5**] with STE
III/AVF in setting of previous q-waves documented without STE
prior. Also had MB elevations at OSH, seen by cards there and
felt to be a non-issue. Asymptomatic from this event. At [**Hospital1 18**],
had enzyme elevation suggesting an actual infarct; as she was
>24 hours out, no indication for intervention so was medically
managed. She was placed on a BB, high dose atorvastatin,
aspirin. Heparin gtt was not given as it was felt that her
infarct was complete. She remained chest pain free throughout
the admission. On [**11-11**], developed an irregular SVT with rates
to ~200 that degenerted into VT with rates ~220+. Was
symptomatic ("felt like passing out and felt warm") but not
shocked as she spontaneously converted to a rhythm at ~160 with
full conciousness. Was given 75mg lidocaine bolus and 5mg
metoprolol IV, started on Lidocaine gtt with conversion to a
stable sinus rhythm and good perfusion pressure and transferred
to the CCU. The lidocaine drip was discontinued and she was
started on IV loading dose of amiodarone over 18 hours and then
converted to PO amiodarone 400mg daily x 1 week to be dosed at
200mg daily thereafter. She had one very brief run of NSVT on
tele during her first night in the CCU (asymptomatic) and had
occasional PVC's without symptoms. She has a MIBI which showed
moderate fixed defect of the septum, apex and anteroseptal
walls. Severe fixed defect of the inferolateral wall, all
consistent with multivessel disease as well as an LVEF of 15%.
She was restarted on lisinopril and started on low-dose
spironolactone for medical management as MIBI revealed all fixed
defects. She was then transferred back to the floor, where
Lisinopril was d/c'ed [**1-24**] [**Last Name (un) **] in the setting of recently
restarted Lisinopril. She continued to have asymptomatic runs of
NSVT, which is being treated medically with Amiodarone.
.
TRANSITIONAL ISSUES: She was discharged to rehab with
instructions to follow up with Dr. [**Last Name (STitle) **] in clinic in [**12-24**]
weeks. She should be evaluated for ICD placement and
consideration should be given to restarting her Lisinopril
pending resolution of [**Last Name (un) **].
.
# sCHF: Previous ECHO with EF ~30%, repeat ECHO at OSH on [**11-5**]
with EF 10-15% and severe wall motion abnormalities likely in
the setting of a missed [**Month/Year (2) **] (see above). On exam on admission
was very volume overloaded as she received volume resuscitation
at OSH for [**Last Name (un) **] (see below), and was restarted on her home lasix
with IV boluses with imprvement in volume status. Initially, she
was not started on an ACE as her BPs were too tenuous and her Cr
continued to rise with diuresis. However, her Cr later improved
at she was euvolemic by [**2148-11-11**] and continued on her home
Lasix. For the remainder of her course, she remained euvolemic,
comfortable on RA.
.
TRANSITIONAL ISSUES: She should follow up with Dr. [**Last Name (STitle) **] for
ICD eval given her reduced EF. Her Lisinopril could be restarted
with resolution of [**Last Name (LF) **], [**First Name3 (LF) **] defer to outpatient Cardiologist.
.
# LLE Ulcer: In context of peripheral vascular disease. ESR/CRP
elevated. Xray of leg at [**Location (un) 620**] without evidence of osteo. Her
BIDN wound culture grew pseudomonas, serratia, and MSSA. ID was
consulted and recommended Nafcillin/Cipro based on sensitivity
data. She developed a drug rash, and Nafcillin was d/c'ed and
Vancomycin was started. Per ID, she should recieve a 4 week
course of Vanc/Cipro ([**Date range (2) 90751**]). PICC was placed on
[**2148-11-15**]. Vascular was also consulted and felt that this was
likely a venous ulcer in the setting of poor arterial perfusion
(and hence poor healing). Now s/p multiple superficial bedside
debridements with vascular. A wet to dry dressing was placed on
the day of d/c and she will need a black sponge wound vac placed
once she arrives at rehab. She should follow up Dr [**First Name (STitle) 1022**] of
Plastic Surgery in 5 days. She will likely need angiography to
eval for perfusion, at which point revascularization vs wound
flap vs BKA can be considered. Plastics will coordinate ongoing
management of ulcer with Vascular as an outpatient.
.
TRANSITIONAL ISSUES: She will need a black sponge wound vac
placed to her L leg ulcer at rehab. She should f/u with Plastics
as an outpatient. She will need Vanc levels checked before each
Vanc dose given fluctuating renal funciton, goal 15-20.
.
# [**Last Name (un) **]/CKD: On admission to found to have acute on chronic renal
failure. Her renal failure was felt to be [**1-24**] decreased forward
flow in the setting of recent MI and reduced EF and volume
overload. Her Cr eventually improved with diuresis. On [**2148-11-14**]
her Cr increased from 1.5->2.0. Given her Lisinopril had
recently been restarted, her [**Last Name (un) **] was felt to be ACEI mediated
and her Lisinopril was held. Urine Eos were negative on
admission. Her elevated Cr could also be [**1-24**] AIN in the setting
of Nafcillin drug reaction; her Nafcillin has been stopped.
.
# L Foot Pain: While working with PT on [**2148-11-15**] pt noted
moderate L foot pain with ambulation. L foot films showed
changes consistent with gout but no fracture. ABI/PVR were
pending at the time of discharge. She has taken Colchicine in
the past - will hold on Colchicine for now given [**Last Name (un) **]. If her
pain worsens, should consider restarting Colchicine if renal
function improves.
.
# HCT Drop: Pt the evening of [**2148-11-15**], pt had a HCT drop 28->25
in the setting of BRBPR. She has no h/o GIB. Stools have been
black appearing since starting Fe supplementation. She was
transfused 1U pRBCs with response 25->28. She had a BM the
morning of discharge without BRB. Given her stable HCT and
negative h/o GIB, we felt she was safe for d/c with follow up.
She should have HCT checked the mornnig of [**2148-11-18**] to ensure it
is stable.
.
Chronic Problems:
.
# Anemia: Patient with HCT of 24.7 prior to transfer, currently
30. Likely ACD.
- Continue iron supplementation
- Folate/B12/Fe/TIBC/Hapto normal
.
# Hypothyroidism:
- Cont home Levothyroxine
.
Transitional Issues: Pt should follow up with Cardiology in [**12-24**]
weeks and Plastic Surgery IN FIVE DAYS. Please call Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] (Plastics) office at [**Telephone/Fax (1) 90752**] to schedule an
appointment. Please also call Dr.[**Name (NI) 90753**] office to schedule
the cardiology appointment for the patient. She will need a
black sponge wound vac placed on arrival to the rehab facility
and not removed until the appointment with Dr. [**First Name (STitle) 1022**].
Medications on Admission:
1. Lipitor 10 mg p.o. q.h.s.
2. Levoxyl 88 mcg p.o. daily.
3. Atenolol 50 mg p.o. daily.
4. Lisinopril 40 mg p.o. daily.
5. Lasix 40 mg p.o. daily.
6. Calcium with vitamin D 2 tablets p.o. q.h.s.
7. Kcl 10 mEq p.o. daily.
8. Aspirin 81 mg p.o. daily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 14 days.
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
11. Vancomycin 1000 mg IV Q48H
12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
13. collagenase clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day).
14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
15. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
16. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) for 10 days.
17. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 1 days.
18. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
19. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
20. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for pruritis.
21. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
Myocardial Infarction
Secondary:
Ventricular Tachycardia
Leg Ulcer
HTN
Gout
HLD
sCHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms [**Known lastname **],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for a fall. While you were in
the hospital, we found that you likely had a heart attack. For
this, we placed you on medications to help your heart function.
You also had an irregular heart rhythm while you were here that
required you to spend a few days in the CCU. We treated this
arrhythmia with medications to control your heart rate.
For your leg ulcer, we had the vascular and plastic surgeons
evaluate you. The vascular surgeons cleaned the wound; at rehab
you will need a special device placed to help the wound heal.
You will need to follow up with the vascular and plastic
surgeons in 5 days for ongoing management of this problem. [**Name (NI) **]
will also need to be on IV antibiotics for 4 weeks
([**Date range (2) 90751**]).
Please note the following changes to your medications:
INCREASED Atorvaststin to 80mg by mouth once a day
INCREASED Aspirin to 325mg by mouth once a day
STOPPED Atenolol 50mg by mouth once a day
STARTED Amiodarone 400mg by mouth once a day x1 day, then 200mg
by mouth once a day thereafter
HELD Lisinopril 40mg by mouth daily for elevated Cr
STARTED Metoprolol Tartrate 25mg by mouth twice a day
STARTED Ciprofloxacin 750mg by mouth once a day x14 days
STARTED Vancomycin 1000mg IV every 48 hours x14 days
STARTED Ferrous Sulfate 325mg by mouth once a day
STARTED Spironolactone 12.5mg by mouth twice a day
STARTED Simethicone 80mg by mouth 4 times a day for gas pain
STARTED Collagenase 1 application twice a day for ulcer
STARTED Latanoprost 0.005% 1 drop to L eye at night
STARTED Timlol 0.5% 1 drop to both eyes daily
STARTED Triamcinolone 0.1% to rash twice a day x10 days
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Thank you for allowing us to participate in your
care.
Followup Instructions:
Please call [**Telephone/Fax (1) 62**] to schedule an appointment with Dr.
[**Last Name (STitle) **] within 1-2 weeks of discharge.
Please call [**Telephone/Fax (1) 31444**] to schedule an appointment with Dr. [**First Name (STitle) 1022**]
in 5 days for have your wound vac checked.
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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15075, 15158
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6059, 8197
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283, 311
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15296, 15296
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3219, 3219
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,718
| 152,847
|
42473
|
Discharge summary
|
report
|
Admission Date: [**2193-4-8**] Discharge Date: [**2193-4-13**]
Date of Birth: [**2116-5-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
lisinopril / Ampicillin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion, fatigue
Major Surgical or Invasive Procedure:
[**2193-4-9**] Aortic Valve Replacement(21mm St. [**Male First Name (un) 923**] Epic Porcine)
History of Present Illness:
This is a 76 year old female with aortic stenosis has been
experiencing progressive symptoms of exertional chest pressure
that occurs when walking up an incline and overall activity
intolerance. She also notes dysnea when climbing stairs. She
does report having dizzy spells back in [**Month (only) **] and was started
on Meclizine by her PCP with improvement. She denies any recent
syncope but did have syncope in [**2188**] prior to her pacemaker
being placed. Her most recent echo which was done in [**Month (only) **]
demonstrates severe aortic stenosis. She was recently seen by
Dr. [**Last Name (STitle) **] who referred her for cardiac catheterization. She
underwent cardiac cath on [**2193-3-26**] which revealed clean
coronaries. She was cleared to proceed with surgery and admitted
to cardiac surgery for an aortic valve replacement. Prior to
surgery, Coumadin was stopped five days prior and she was
admitted the day before for intravenous Heparin.
Past Medical History:
Severe aortic stenosis
Hypertension
Retinal tear without detachment
Hammer toe
Atrial fibrillation - on Coumadin
Diabetes type I diagnosed at age 32
History of syncope last episode [**2188**]
Pacemaker [**2188-8-10**] - [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) 10550**]:5826 / Serial:[**Numeric Identifier 91939**]
s/p right knee replacement surgery
s/p right hip replacement surgery
s/p right foot surgery
s/p bilateral Vein stripping
s/p right Tennis elbow surgery
Social History:
Last Dental Exam: 1 month ago, dentist gave verbal clearance,
general written clearance in chart
Lives with: Daughter
Contact: [**Name (NI) 14552**] (daughter) Phone #[**Telephone/Fax (1) 91940**]
Occupation: retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use: denies
ETOH: < 1 drink/week [] [**3-19**] drinks/week [x] >8 drinks/week []
Illicit drug use: denies
Family History:
Denies premature coronary artery disease. Father had an MI in
his 70s.
Physical Exam:
PREOP EXAM - Height:5'8" Weight:170 lbs
Vitals: Pulse:59 Resp:20 O2 sat:100% RA BP Right:141/60
Left:142/60
General: awake, alert, no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade _III_
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] 2+ edema in
R lower extremity 1+ Left lower extremity edema Varicosities:
None [x] (s/p BLE vein stripping)
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: trace Left: trace
PT [**Name (NI) 167**]: trace Left: trace
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2193-4-12**] 06:25AM BLOOD WBC-8.9 RBC-3.24* Hgb-9.5* Hct-28.4*
MCV-88 MCH-29.5 MCHC-33.6 RDW-13.9 Plt Ct-105*
[**2193-4-13**] 05:55AM BLOOD PT-26.9* INR(PT)-2.6*
[**2193-4-12**] 06:25AM BLOOD Glucose-141* UreaN-21* Creat-0.8 Na-136
K-3.9 Cl-100 HCO3-28 AnGap-12
[**2193-4-12**] 06:25AM BLOOD Mg-2.0
[**4-12**] PCXR:
IMPRESSION: AP chest compared to [**4-9**]:
Previous mild pulmonary edema has almost entirely cleared.
Bibasilar
atelectasis, moderate on the left, unchanged, moderate on the
right, increased
slightly, accompanied by new small right pleural effusion.
Postoperative
cardiomediastinal silhouette is unremarkable and unchanged.
Small right
pneumothorax is new. There is no pneumothorax on the left.
Transvenous right
atrial and right ventricular pacer leads in standard placement.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2193-4-12**] 4:07 PM
[**4-9**] TEE:
PRE-BYPASS: The left atrial appendage emptying velocity is
depressed (<0.2m/s). A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. The left ventricle is not well seen. Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve is bicuspid. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to
moderate ([**2-11**]+) aortic regurgitation is seen. The mitral valve
leaflets are severely thickened/deformed. There is severe mitral
annular calcification. There is moderate valvular mitral
stenosis (area 1.0-1.5cm2). No mitral regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results at time of surgery.
POST-BYPASS:
There is a bioprosthetic valve in the aortic position. The valve
appears well seated with normally mobile leaflets. No
paravalvular leaks are seen. There is no AI.
The left ventricular systolic function appears normal, estimated
EF=55%. The right ventricular systolic function appears normal.
There is no evidence of dissection.
Brief Hospital Course:
Mrs. [**Known lastname 91941**] was admitted for intravenous Heparin and routine
preadmission testing. Workup was uneventful and she was cleared
for surgery. The following day, she underwent an aortic valve
replacement by Dr. [**Last Name (STitle) **] [**Name (STitle) 91942**] a 21mm St. [**Male First Name (un) 923**] porcine
valve. For surgical details, please see operative note. Given
her severe penicillin allergy, Vancomycin was used for
perioperative antibiotic coverage. Following the operation, she
was brought to the CVICU for invasive monitoring. Within 24
hours, she awoke neurologically intact and was extubated without
incident. Initially hypotensive, she required Phenylephrine
drip. She was also transfused with PRBC for a postoperative
anemia, and EP increased her pacemaker rate to 70 bpm. Over
several days, her hemodynamics improved. She transiently
required Insulin drip for adequate glucose control. On
postoperative day two, she transferred to the SDU. Warfarin was
resumed and dosed for a goal INR between 2.5 to 3.0. On the
floor she continued to progress well. Pacing wires and CT were
discontinued without incident. She was hyperglycemic at times
and insulin was adjusted. Her post-operative CXR revealed small
right pneumo that was stable and unchanged on her discharge CXR.
All patients questions and concerns addressed. Follow up appts
made. She was discharged to [**Hospital 1514**] health Care rehab on POD #4.
Medications on Admission:
ATENOLOL 100 mg [**Hospital1 **]
ATORVASTATIN 10 mg daily
INSULIN LISPRO [HUMALOG] 100 unit/mL Solution - sliding scale
with meals
LOSARTAN 100 mg daily
POTASSIUM CHLORIDE 10 mEq daily
TRIAMTERENE-HYDROCHLOROTHIAZID 37.5 mg/25 mg Capsule - 1 Capsule
daily
WARFARIN 1 mg Tablet - 1-2 Tablets by mouth 1mg M/F, 2mg all
other days Last dose WED [**3-20**]
MAGNESIUM OXIDE 400 mg daily
NPH INSULIN HUMAN RECOMB [HUMULIN N] 100 unit/mL Suspension - 42
units in the am
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 10
days: then reevaluate. Tablet Extended Release(s)
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain/fever: prn for pain. Tablet(s)
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. furosemide 10 mg/mL Solution Sig: Two (2) ml Injection Q12H
(every 12 hours) for 10 days: then reevaluate.
12. NPH insulin human recomb 100 unit/mL Suspension Sig: Forty
Two (42) units Subcutaneous once a day: give in AM.
13. Novolog 100 unit/mL Solution Sig: ACHS units Subcutaneous
sliding scale: see sliding scale attached.
14. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1514**] Health Care Center - [**Location (un) 1514**]
Discharge Diagnosis:
aortic stenosis
s/p aortic valve replacement( tissue)
paroxysmal atrial fibrillation
s/p Permanent pacemaker implant (St. [**Male First Name (un) 923**] 5826 in [**2188**])
hypertension
s/p bilateral vein strippings
insulin dependent diabetes mellitus
postop anemia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with assist
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema +2 right lower, +1 left lower
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr.[**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2193-5-15**] at 1;15pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] no 3/19/12/at11;10am
Please call to schedule appointments:
Primary Care: Dr.[**First Name (STitle) 9054**] [**Name (STitle) 91689**] ([**Telephone/Fax (1) 91943**]in [**5-16**] weeks
INR goal 2.5-3.0 for a-fib coumadin to be managed by her PCP
[**Location (un) 1514**] [**Location (un) **]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hour
Completed by:[**2193-4-13**]
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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317, 412
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|
2355, 2428
|
7484, 8874
|
9010, 9278
|
6996, 7461
|
9505, 10382
|
2443, 3250
|
249, 279
|
440, 1401
|
1423, 1949
|
1965, 2339
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,200
| 111,701
|
30510
|
Discharge summary
|
report
|
Admission Date: [**2128-1-13**] Discharge Date: [**2128-1-21**]
Date of Birth: [**2087-7-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
EGD with banding
paracentesis X2
History of Present Illness:
40yo woman with history of ETOH Abuse presented to the ED with
hematemesis. She has a history of ETOH abuse, and reportedly
went on a binge recently. In that setting, she had about 400cc
in hematemesis. She presented to an OSH where her Hct was 12.
She received 2 units PRBC and 2U FFP there. She was then
transferred here to [**Hospital1 18**]. No further episodes of hematemesis
here.
.
In the ED, she was hemodynamically stable. Initial vitals were:
101.1, 106, 132/66, 19, 99% RA. She was found to have a Hct of
17.6. Her labs were otherwise notable for platelets of 45 and
INR of 1.4. Her chemistry was otherwise normal with normal renal
function and an anion gap of 11. She had a mild transaminitis
with AST/ALT ratio of > 2:1. While in the ED, she had two Lg
bore peripheral IV's placed and was transfused in total 2 units
of PRBC as well as platelets. She was started on Protonix and
Octreotide drips. Got 1L banana bag, followed by > 1L NS.
.
Of note, she has a history of ETOH abuse. No documented history
of cirrhosis or esophageal varices. On interview, she confirms
the above history of ETOH binge with resultant episode of
hematemesis. Otherwise, she reports mild subjective fever,
abdominal fullness, and tenderness. Otherwise, ROS negative. No
CP, SOB, cough, dysuria, meningeal symptoms, or any other focal
complaints. She does report that she has been feeling
increasingly depressed resulting in her most recent ETOH binge.
.
Past Medical History:
1. ETOH abuse
2. cocaine abuse
3. depression
Social History:
Pt married, in long-standing abusive marriage and had recently
gotten
a restraining order on husband (3 months ago), but rescinded it
this past w/e to join him on [**Hospital3 4298**] where they were
drinking/using drugs. Pt lives in [**Location (un) 72459**] with 15yo
daughter. Pt has not worked inmany years. Pt is one of 5
siblings who live in the [**Location (un) 86**] area. both parents still living
although father has not been involved in many years and has hx
of etoh abuse. Currently, pt. adamant about stopping ETOH. She
states she has long history of drinking, mostly weekend binge
drinking of 2 pints/day on weekends. Interested in rehab from
home but cannot pay [**1-2**] insurance
Family History:
ETOH abuse in father
Physical Exam:
vs: 100.4, 92, 114/71, 20, 100% on 2L nc
.
gen a/o, nad
heent anicteric, mmm
neck supple, no meningeal signs, no JVD
cv rrr, no m/r/g
resp CTA bilaterally
abd mildly distended, soft, mild diffuse tenderness; no
peritoneal signs
extr warm, well perfused; no c/c/e
neuro + mild asterixis
Pertinent Results:
[**2128-1-12**] 10:55PM PT-15.8* PTT-30.2 INR(PT)-1.4*
[**2128-1-12**] 10:55PM PLT SMR-VERY LOW PLT COUNT-45*
[**2128-1-12**] 10:55PM NEUTS-80.7* BANDS-0 LYMPHS-13.5* MONOS-5.3
EOS-0.1 BASOS-0.4
[**2128-1-12**] 10:55PM WBC-9.9 RBC-1.98* HGB-6.0* HCT-17.6* MCV-89
MCH-30.4 MCHC-34.3 RDW-18.3*
[**2128-1-12**] 10:55PM ALBUMIN-3.2*
[**2128-1-12**] 10:55PM LIPASE-31
[**2128-1-12**] 10:55PM ALT(SGPT)-19 AST(SGOT)-73* LD(LDH)-169 ALK
PHOS-262* AMYLASE-37 TOT BILI-1.6*
[**2128-1-12**] 10:55PM GLUCOSE-99 UREA N-17 CREAT-0.5 SODIUM-141
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
CHEST (PA & LAT) [**2128-1-17**] 3:42 PM
There is patchy opacity in the right cardiophrenic region,
similar to that seen on the portable film from earlier the same
day. This most likely lies in the anterior segment of the right
lower lobe. There is a small-to-moderate right and small left
pleural effusion. Both the patchy opacity and the right effusion
are new compared with [**2128-1-13**].
IMPRESSION:
1. Bilateral right greater than left effusions.
2. Patchy opacity, right base, suggestive of a pneumonic
infiltrate.
ABDOMEN U.S. (COMPLETE STUDY) [**2128-1-13**] 8:06 AM
There are no prior studies for comparison. The liver is
intensely echogenic and heterogeneous compatible with fatty
infiltration. No discrete masses are identified. There is
massive ascites, and an appropriate spot was marked in the right
lower quadrant for paracentesis by the clinical team.
Liver Doppler shows fully patent portal veins with forward flow
and normal respiratory variations. There is evidence of portal
hypertension as manifested by a patent umbilical vein. The
hepatic veins, inferior vena cava, and hepatic arteries are all
fully patent. The pancreas and retroperitoneum are not well seen
and the splenic and superior mesenteric veins are also not well
visualized.
There is a small gallstone in the neck of the gallbladder, but
no signs of acute cholecystitis. There is no bile duct
dilatation. The right kidney measures 9.3 cm in length and the
left kidney 11.5 cm. Both kidneys are normal in appearance. The
spleen is upper normal in size at 12.3 cm.
CONCLUSION: Fatty heterogeneous liver with signs of portal
hypertension including a patent umbilical vein. The degree of
heterogeneity in the liver makes exclusion of small lesions
difficult and consideration of further imaging with MRI is
recommended.
Massive ascites with the spot marked in the right lower quadrant
for paracentesis by the clinical team.
Gallstone.
Brief Hospital Course:
In ICU, had elective intubation for EGD which showed grade III
varices which were banded. She also had nl. portal flow and RUQ
U/S with fatty liver and e/o portal hypertension including
patent umbilical vein and massive ascites. Extubated without
event. Had 4L paracentesis, no e/o SBP. On cipro ppx for 5 days
given recent bleed. Was also on CIWA scale with little diazepam
requirements.
Further management on the floor:
# GI bleed- s/p banding of variceal ulcer twice, 4U pRBCs; EGD
[**2128-1-13**] showed stage III varices. HCT stable since admit.
Hepatology following. [**2128-1-20**] had EGD with banding and no repeat
bleeding. Did have some post procedure pain, but improved with
pain meds and sucralfate. Will need follow up with GI [**2-12**]
for repeat EGD and then with Dr. [**Last Name (STitle) **] [**2-9**].
Discharged on PPI [**Hospital1 **], sucralfate qid. Propranolol [**Hospital1 **]
.
# Cirrhosis- [**1-2**] ETOH abuse w/LFT's elevated and AST/ALT>[**1-1**].
alk phos, tbili, transaminases trending down. Likely had
alcoholic hepatitis that is improving. Patient as tested for
hep C negative, hep B S-Ab positive, other hepB serologies
negative. Was also started on diuretics of lasix 40 mg,
sprinolactone 100mg per hepatology recommendations. [**Month (only) 116**] need
staging bx. as outpt. Should be maintained on low salt diet as
an outpatient.
.
# h/o ETOH abuse Currently with no signs and symptoms of
withdrawal. Was on CIWA but had minimal diazepam requirment.
Patient has been accepted at AD care treatment center.
.
# fever- positive UA with >100,000 e coli, treated with
ceftriaxone for 3 days, asymptomatic now and afebrile for
several days prior to discharge.
.
# thrombocytopenia: stable. likely [**1-2**] chronic liver dz.
Medications on Admission:
none
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*14 caps* Refills:*0*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*14 Tablet(s)* Refills:*0*
4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*14 Tablet(s)* Refills:*0*
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*56 Tablet(s)* Refills:*2*
7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
8. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours:
no more than 2 grams/day (6 tablets).
9. Propranolol 10 mg Tablet Sig: One (1) Tablet PO twice a day:
hold for dizziness or light headedness.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12671**] Hospital - [**Hospital1 1559**]
Discharge Diagnosis:
Grade III esophageal varices
Blood loss anemia
ETOH abuse
ETOH cirrhosis
depression
Discharge Condition:
good, tolerating pos, ambulating without assistance, satting
>95% on room air
Discharge Instructions:
As you know you were admitted with a bleed from large veins in
the esophagus, called varices. These veins are large and prone
to bleeding because of your liver disease, called cirrhosis,
which is from alcohol use. We strongly advise you to remain
abstinent from all alcohol.
You should limit your salt and fluid intake as you have been
instructed by nutritional services here.
You need to take all medications exactly as prescribed,
especially spironolactone (for fluid, a diuretic), lasix (for
fluid, a diuretic), pantoprazole (to prevent acide in the
stomach), and propranolol (to keep BP low and prevent bleeding
in your esophagus). These medicines are very important to
prevent reaccumulation of your ascites, infection, and
rebleeding.
Follow up as below.
..........
DIET: you should only have clear liquids for 6 hours after EGD
today and then soft foods for the next 24 hours (as you had
bands placed today and you have to eat soft foods to allow them
to heal).
Followup Instructions:
Make an appointment to follow up with your primary care
provider's office within 1 week.
You will also need a follow up EGD as below. It is essential
that you attend this appointment
Provider: [**Name10 (NameIs) **] WEST,ROOM TWO GI ROOMS Date/Time:[**2128-2-12**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 33499**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2128-2-12**] 9:30
|
[
"041.4",
"303.91",
"456.20",
"287.5",
"291.81",
"571.2",
"572.3",
"276.51",
"789.5",
"280.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8407, 8486
|
5527, 7292
|
326, 360
|
8613, 8692
|
2974, 5504
|
9715, 10143
|
2631, 2653
|
7347, 8384
|
8507, 8592
|
7318, 7324
|
8716, 9692
|
2668, 2955
|
275, 288
|
388, 1833
|
1855, 1901
|
1917, 2615
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,143
| 189,152
|
12775
|
Discharge summary
|
report
|
Admission Date: [**2120-12-4**] Discharge Date: [**2120-12-8**]
Date of Birth: [**2055-5-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cefazolin
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Aspirin overdose
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central Venous Line Placement
HD line placement
Hemodialysis *3
History of Present Illness:
This is a 65-year-old man with history of diabetes type II,
hypercholeseterolemia, osteoarthritis, and remote history of
lymphoma s/p autologous transplant (~20 years ago), alcoholism,
and depression who was transferred from [**Hospital3 **] after a
suicide attempt with aspirin and wrist-cutting. Apparently, the
patient called his estranged wife saying he wanted to harm
himself by overdosing on his medications and cutting his left
wrist. His wife called the group home where he was staying and
911, and EMS found him altered in bed with two empty bottles of
ASA next to him. Also had a deep laceration of his left wrist.
Other coingestions are not known but patient reportedly takes
iron, insulin, simvastatin, gabapentin, ranitidine, glyburide,
pioglitazone, valsartan, hctz, and fluvoxamine.
Pt was taken to [**Hospital3 3583**] initially where his VS were
99.9, 102/47, 81, 99% RA. He was reported as "lethargic" and
"very drowsy," though he was answering questions appropriately
with slurred speech. He was tachypneic to 36 breaths per minute,
and was noted to have a horizontal laceration on his left wrist.
Labs were notable for WBC 16.6, Hct 26, anion gap 13, ASA level
58.8. ABG was 7.49/27/86/21. ECG showed NSR with no ectopy or
QTc prolongation.He was started on 100 mEq NaHCO3 in 1 liter D5W
@ 200 cc/hr. Aspirin level was 58. He was transferred to [**Hospital1 18**]
for further management.
In the [**Hospital1 18**] ED, initial vital signs included were BP 90/42, HR
74, RR 32, O2 97% RA. No temperature is recorded, until a 3:00
am measurement of 103.2 F rectally. he had guaiac positive brown
stool. Aspirin level was 66.8, and urine/serum toxicology were
otherwise negative. He was reportedly alert and agitated on
arrival, unable to answer questions at triage. He became
alternatingly lethargic and combative, and was intubated with
etomidate and rocuronium for airway protection. He became
hypotensive and norepinephrine was started through a peripheral
IV. He was given gastric lavage with 25 g charcoal. Renal was
consulted, and a R IJ HD line was placed, along with an arterial
line and a left triple-lumen CVL. EKG showed normal sinus rhythm
with normal intervals. Labs were notable for acute renal failure
with creatinine of 1.9 (up from 1.0 several years ago), bicarb
of 19, and potassium of 5.2. Anion gap was 17. Other labs
notable for anemia of 25.9 with MCV 79, white count of 14.8 with
89% polys, and platelets of 401. An ABG drawn in the ED showed a
respiratory alkalosis: 7.58/21/92. Patient was started on
bicarbonate drip and admitted to medical ICU for further
management.
Past Medical History:
Diabetes Mellitus Type 2
Hypercholeseterolemia
Osteoarthritis
Lymphoma s/p autologous transplant (~20 years ago)
Severe depression
Alcohol Abuse
Implanted spinal stimulator (at [**Hospital3 3583**])
Social History:
Patient had been living in group home in [**Hospital1 14211**] since early
[**Month (only) 359**]. Prior to that he had been given a restraining order
against his wife and imprisoned for weeks to months of
agitation, bizarre behavior such as running around naked
outdoors, alcohol abuse, ultimately threatening to kill his
wife. [**Name (NI) **] has a longstanding history of alcohol abuse, with a
period of abstinence leading to his relapse 4-5 years ago.
Despite the restraining order his wife is extremely concerned
about his well being and was critical to having him discovered.
Turbulent history of sexual abuse and exposure to alcoholism in
childhood per report. Aside from known alcohol abuse other
substance abuse was unknown. One estranged son.
Family History:
Alcoholism in multiple relatives. His brother is schizophrenic.
Physical Exam:
VS: Temp:104 BP: 153/65 HR:92 RR:28 O2sat:100%
Assist control 700 x 26, PEEP 5, FiO2 100%
GEN: Intubated, sedated
HEENT: PERRL, EOMI, anicteric, MMM, OP without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTAB, with good air movement throughout
CV: RR, S1/S2 wnl, no m/r/g
ABD: Forceful expiration with contraction of abdominal muscles,
nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e. + transverse laceration 2-3 cm deep in left
wrist, with visible tendons
SKIN: no rashes/no jaundice/no splinters
NEURO: Sedated and paralyzed. PERRL.
RECTAL: Reportedly guaiac positive in ED.
Pertinent Results:
===================
LABORATORY RESULTS
===================
Admission Labs:
WBC-14.8*# RBC-3.26* Hgb-8.6*# Hct-25.9*# MCV-79*# RDW-15.7* Plt
Ct-401
---Neuts-88.9* Lymphs-6.8* Monos-3.6 Eos-0.5 Baso-0.1
PT-12.4 PTT-23.5 INR(PT)-1.0
Glucose-283* UreaN-26* Creat-1.9* Na-136 K-5.2* Cl-100 HCO3-19*
ALT-23 AST-33 AlkPhos-88 TotBili-0.1
Calcium-8.6 Phos-5.8*# Mg-2.5
BLOOD ASA-66.8* Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
ABG:7.58/21/92
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 Blood-TR
Nitrite-NEG Protein-25 Glucose-TR Ketone-TR Bilirub-NEG
Urobiln-NEG pH-5.0 Leuks-NEG
RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0
Labs Prior to Death:
WBC-14.6* RBC-2.82* Hgb-7.4* Hct-22.8* MCV-81* RDW-15.9* Plt
Ct-371
PT-16.0* PTT-33.5 INR(PT)-1.4*
Glucose-92 UreaN-46* Creat-3.2*# Na-136 K-5.5* Cl-103 HCO3-18*
ALT-1707* AST-3222* LD(LDH)-2860* CK(CPK)-209 AlkPhos-137*
TotBili-0.2
Calcium-7.5* Phos-4.7*# Mg-2.3
ABG: 7.35/36/106
Serial Aspirin Levels:
[**2120-12-4**] 04:19AM BLOOD ASA-82.4*
[**2120-12-4**] 10:51AM BLOOD ASA-32.2*
[**2120-12-4**] 01:20PM BLOOD ASA-33*
[**2120-12-4**] 05:49PM BLOOD ASA-17.8
[**2120-12-5**] 04:12AM BLOOD ASA-14.7
[**2120-12-5**] 04:48PM BLOOD ASA-8.3
==============
MICROBIOLOGY
==============
Blood Cultures:
[**2120-12-5**]:
lood Culture, Routine (Final [**2120-12-10**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN-----------<=0.25 S R
ERYTHROMYCIN----------<=0.25 S =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 4 R =>8 R
OXACILLIN-------------<=0.25 S 1 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S =>16 R
VANCOMYCIN------------ 1 S <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2120-12-6**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2120-12-6**] 11AM.
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2120-12-7**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**2120-12-6**]:
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
Additional 1/2 blood cultures from [**12-5**] and [**12-6**] are no growth
to date
Blood Cx *2 from [**12-4**] and [**12-7**]: No Growth to Date
All Other Urine and Sputum Cultures Negative
================
OTHER STUDIES
================
ECG [**2120-12-4**]:
Sinus rhythm. Non-diagnostic inferior Q waves. Wandering
baseline. No previous
tracing available for comparison.
Transthoracic Echocardiogram [**2120-12-4**]:
Conclusions
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%). No
resting LVOT gradient is identified. The estimated cardiac index
is high (>4.0L/min/m2). 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. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness with normal
regional and hyperdynamic global systolic function.
Chest Radiograph [**2120-12-4**]:
IMPRESSION:
Possible bilateral pleural effusions.
CT Head [**2120-12-5**]:
IMPRESSION: No acute intracranial abnormality. No evidence of
hemorrhage,
masses, or mass effect that may explain the patient's new
physical finding.
Mucosal thickening and possibly fluid within the sinuses which
is consistent
with the history of intubation.
CT Chest, Abdomen, and Pelvis W/O Contrast [**2120-12-7**]:
IMPRESSION:
Bibasilar atelectasis and consolidation.
CT Sinus/Maxillofacial W/O Contrast [**2120-12-7**]:
IMPRESSION:
1. Small amount of fluid and mild mucosal thickening in the
paranasal sinuses
as described above. No bony erosion or thickening.
2. Mastoid air cells are clear.
3. No acute facial bone fracture.
Brief Hospital Course:
This was a 65 year old male with alcoholism, depression, and a
history of bizarre behavior presenting after a suicide attempt
by slitting his wrist and taking large doses of aspirin.
1) Aspirin Overdose: The patient presented with an aspirin
level>50, which increased to 84. He also had a respiratory
alkalosis, which is consistent with aspirin overdose, and
attempts were initially made to avoid intubation as this tends
to lead to worse outcomes. Unfortunately, due to the patient's
persistent agitation and encephalopathy he was intubated to
protect his airway. Aspirin levels were initially extremely
high and given dose ingested toxicology predicted a quite grave
prognosis. Nephrology was consulted and emergently placed an HD
line and initiated HD with the goal of rapid removal of
salicylate to help prevent neurotoxicity. The patient underwent
HD sessions *3 with rapid reduction in his salicylate level to
17.8 within 24 hours of admission. In the interim an effort was
made to keep the patient alkalotic so as to minimize CNS
absorption of salicylates and alkalinize the urine to promote
excretion. With hyperventilation and bicarbonate drip and/or
alkalotic dialysate the team attempted to maintain a pH of
7.45-7.55 during those first 24 hours, which was generally
maintained except for some periods of over-alkalinization with
pH's in the 7.6 range. Patient also received 2 doses of
activated charcoal to decrease toxin absorptions. Despite these
efforts persistent encephalopathy and fever (see further
discussion below) raised concern of severe neurological injury
due to his toxic ingestion.
2) Fevers: The patient remained persistently febrile throughout
his hospitalizaton. Initial cultures remained negative,
however, and suspicion was fevers were most likely due to
overdose and central mechanisms. Nevertheless, despite
relatively benign chest radiograph aspiration was considered
consistent with injury so the patient was started on
levofloxacin at presentation for possible aspiration
pneumonia/pneumonitis. The patient also initially received
vancomycin on presentation for empiric coverage though this was
narrowed to TMP/Sulfa the following day for skin coverage
(including CA-MRSA) given his wrist laceration. When blood
cultures from [**12-5**] returned positive for GPC's on [**12-6**]
TMP/Sulfa was switched to vancomycin, which was continued.
Given persistent fevers on antibiotics primary concerns were for
another source of infection and inadequate coverage particularly
of gram negative organisms vs decoupling of oxidative
phosphorylation and central fever due to profound neurological
injury due to salicylate poisoning. On [**12-6**] the patient
underwent a failed LP given persistent encephalopathy and fever
and on [**12-7**] he underwent CT of chest/abdomen/and pelvis, which
except for small consolidations failed to reveal a clear source
of infection. Due to prolonged fevers and overall clinical
deterioration cefepime was started very early in the AM on [**12-8**]
for empiric broader gram negative coverage. Cultures have
remained negative except for coag negative staph on [**2-10**] blood
cultures on two consecutive days prior to initiation of
vancomycin therapy.
3) Acute Kidney Injury: The patient's last recorded (though some
time ago) Cr was 1.0 and thus suspicion he was suffering from
acute kidney injury, likely due to direct salicylate toxicity.
Despite this he was not initially anuric or hyperkalemic and
underwent dialysis purely to speed salicylate clearance. Cr
continued to worsen over the course of his hospitalization and
reached 3.2 on the morning of withdrawal of care and his demise.
4) Transaminitis: The patient developed a significant
transamnitis on the morning of his demise. The etiology of this
is unclear as no singificant work-up was managed prior to his
passing.
5) Hypotension: The patient intermittently required pressors
throughout his hospitalization and pressures were supported with
norepinephrine. Presumed etiology was cardiogenic shock from
diminished EF in the face of electrolyte abnormalities vs
neurogenic shock in the context of hypothalamic toxicity. He
was off pressors much of the day on [**12-7**] though required
multiple fluid boluses and was restarted on norepinephrine just
prior to his wife's decision to make him CMO.
6) Respiratory Failure: Attempts to wean the patient's
ventilatory support were persistently thwarted by tachypnea even
after the salicylate and metabolic acidosis had resolved.
Unclear what the primary mechanism was though suspicion of
central hyperventilation was high given minimal lung disease /
involvement.
7) IDDM: patient was maintained on an insulin sliding scale for
his DM.
8) Ileus: Patient was noted to have minimal lower GI output and
persistently had charcoal sucked out of orogastric tube even
days after doses. Likely paralytic ileus in the context of ?
underlying autonomic neuropathy from DM and addition of opiates.
CT showed dilated loops but no air fluid levels or signs of
obstruction.
9) Encephalopathy: The patient remained persistently
encephalopathic and went from early agitated delirium to
obtundation. At the time of his demise sedation had been
stopped for two days without any purposeful movements being
noted or signs of awakening. Plan was underway for EEG and
repeat head imaging (limited by spinal stimulator) prior to
decompensation and withdrawal of care.
10) Ethics / Decision-Making: Discussion was had with legal
regarding appropriateness of the patient's wife as his
substitute decision maker due to their estrangement. Legal
department thought if wife seemed to be acting in best interest
of patient that this was appropriate, and throughout our
interaction the patient's wife seemed very concerned with his
welfare, sad about his condition, and hopeful, though realistic
about his chances for improvement. Code status was initially
Full Code in hopes of full recovery but given persistently
without signs of awaking his wife mentioned that he would not
want and she would not put him through prolonged artificial
support. Very early in the AM of [**12-8**] his wife was informed of
his deterioration and very concerning lab values and elected to
make him DNR/DNI. With the onset of pressor-requiring
hypotension she was alerted once again and given seeming lack of
progress and persistent encephalopathy with likely permanent
deficits even with survival she elected to have care withdrawn
and make the patient CMO. Patient was terminally extubated and
cares withdrawn and he expired less than an hour later on the
morning of [**12-8**]. Given death was a result of a suicide attempt
the case was accepted by the medical examiner who will perform
an autopsy.
Medications on Admission:
Ferrous sulfate 324 mg PO daily
Simvastatin 20 mg PO daily
Gabapentin 1200 mg PO TID
Ranitidine 150 mg PO daily
Glyburide 10 mg PO BID
Actos 30 mg PO daily
Diovan 160 mg PO daily
HCTZ 12.5 mg PO daily
Fluvoxamine 200 mg PO daily
Combigan eye drops, 1 drop into left eye [**Hospital1 **]
Cymbalta 90 mg PO daily
Lantus 12 units SC QAM
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspirin Overdose
Acute Kidney Injury
Discharge Condition:
Expired
Discharge Instructions:
Pt Expired
Followup Instructions:
Pt Expired
|
[
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"518.81",
"584.9",
"881.02",
"V10.79",
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"276.3",
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icd9cm
|
[
[
[]
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] |
[
"38.91",
"86.59",
"38.93",
"96.72",
"96.04",
"03.31",
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icd9pcs
|
[
[
[]
]
] |
18128, 18137
|
10947, 17709
|
302, 391
|
18218, 18227
|
4775, 4834
|
18286, 18299
|
4050, 4117
|
18093, 18105
|
18158, 18197
|
17735, 18070
|
18251, 18263
|
4132, 4756
|
7869, 10924
|
246, 264
|
419, 3038
|
4850, 7825
|
3060, 3260
|
3276, 4034
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,432
| 172,262
|
46684
|
Discharge summary
|
report
|
Admission Date: [**2176-12-1**] Discharge Date: [**2176-12-13**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
male with a past medical history of benign gastrointestinal
polyps, status post left hemicolectomy, coronary artery
disease, status post coronary artery bypass graft, mitral
valve replacement on chronic anticoagulation, who presents
with bright red blood per rectum times one day. The patient
was in his usual state of health when he developed abdominal
cramping with bloody stools one day ago. The patient took
Imodium with relief. On the evening of admission, the
patient developed bloody stools times one. He came to the
Emergency Department, felt dizzy, had a large bright red
blood per rectum with syncope, systolic blood pressure in the
90s. His blood pressure improved with hydration. The
patient had three large bore intravenouses placed. He was
typed and crossed with two units of packed red blood cells
and transfused and given one bag of fresh frozen plasma. At
that time, he was transferred to the Medical Intensive Care
Unit. The patient denied any chest pain, shortness of
breath, nausea, vomiting, heartburn, acid taste in his mouth,
denies feeling dizzy while supine but had increased
diaphoresis when upright with cramping abdominal pain and
rectal pressure. The patient takes Enteric Coated Aspirin
every day, Celebrex two times a week, and he denies any
ethanol use.
PHYSICAL EXAMINATION: On physical examination, temperature
was 97.6, blood pressure 119/20, heart rate 70, oxygen
saturation 99% in room air In general, the patient is an
elderly pleasant male, uncomfortable at times. Head, eyes,
ears, nose and throat examination - no conjunctival
injection. The pupils are equal, round, and reactive to
light and accommodation. No scleral icterus. Mucous
membranes are moist. The chest is clear to auscultation
bilaterally. No crackles, wheezes or rhonchi. The heart is
regular rate and rhythm, positive murmur. The abdomen is
soft, tender diffusely, no rebound, positive bowel sounds.
Extremities no edema. Dorsalis pedis pulses are 2+.
Neurologically, the patient is alert and oriented.
LABORATORY DATA: The patient had a hematocrit of 37.0 down
from 46.9 on [**2176-11-17**]. He also had a blood urea nitrogen of
32 from 22 and a creatinine of 1.5, up from 1.2. Urinalysis
was negative.
Electrocardiogram showed normal sinus rhythm at 70 beats per
minute. No signs of ischemia.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit posttransfusion and fresh frozen plasma
infusion in the Emergency Department. He was made NPO and
given intravenous hydration for hypovolemia. He was also
given Vitamin K to reverse his anticoagulation. His Coumadin
and Aspirin were both stopped. The patient was seen by
Internal Medicine and Gastroenterology. Gastroenterology
recommended reversal of his anticoagulation as had been done
as well as holding his hypertension medications as well as a
bleeding scan to localize his gastrointestinal bleeding and
angiography if he continued to bleed. The patient was also
seen by pulmonary medicine who agreed with the current plan.
The bleeding scan was performed which localized bleeding to
the area of the cecum and proximal ascending color. The
patient was taken to angiography and an attempt to embolize
his bleeding vessels was made, although secondary to the
tortuousity of these vessels, embolization was unsuccessful.
The patient continued to have bleeding showing hematocrit
drop from 37.0 to 28.0 and then to 21.0 despite eight units
of blood and four units of fresh frozen plasma infusion by
[**2176-12-2**]. Due to his unstable condition, the patient was
taken to the operating room the morning of [**2176-12-2**]. Right
colectomy was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The
patient received an additional unit of packed red blood cells
and an additional unit of fresh frozen plasma coming to a
grand total of 11 units of packed red blood cells and seven
units of fresh frozen plasma and one unit of platelets given
by this time. He tolerated the procedure well without
complications. The patient was transferred back to the
Medical Intensive Care Unit intubated.
Postoperatively, the patient did well in the Medical
Intensive Care Unit with no continued bleeding apparent. The
patient was given postoperative antibiotics for prophylaxis
against infection of his mitral valve. He was quickly
extubated once taken to the Medical Intensive Care Unit and
given pulmonary toilet. He was left NPO and on intravenous
fluids. The patient was seen by cardiology on [**2176-12-4**], who
noted good cardiac function and no damage secondary to his
hypovolemia. They also recommended that a Heparin drip be
started as soon as possible which was also started on that
day. There was some difficulty in regulating the Heparin
drip to achieve the desired partial thromboplastin time
although the attempt was eventually successful. On [**2176-12-5**],
the patient was restarted on his Coumadin. The patient was
evaluated on [**2176-12-6**], by physical therapy who continued to
work with him.
The patient was transferred to the floor on [**2176-12-7**], in
stable condition. He indicated that he had started to pass
flatus and his diet was advanced on a diabetic diet. He was
changed to oral medications. He was, however, complaining of
progressive watery bowel movements. For this reason, he was
given Imodium and Metamucil wafers to decrease his stool
output. This being successful the patient was left only with
the need for appropriate coumadinization which took a
considerable amount of time. Per cardiology, he was
coumadinized to an INR of 2.5 which was finally achieved on
[**2176-12-13**]. The patient is being discharged today in stable
condition and he will follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
approximately one week. His staples were removed from his
incision.
MEDICATIONS ON DISCHARGE::
1. Lipitor 20 mg one p.o. once daily.
2. Coumadin 3 mg one p.o. q.p.m.
3. Moduretic [**5-/2124**] one p.o. once daily.
4. Protonix 40 mg one p.o. once daily.
5. Captopril 6.25 mg one p.o. twice a day and two p.o.
q.h.s.
6. Lantus 24 units q.h.s.
7. Tylenol #3 one to two p.o. q4hours p.r.n. pain.
8. Atenolol 50 mg one p.o. once daily.
9. Humalog subcutaneous insulin 3 units q.a.m. and 5 units
at lunch and 11 units q.h.s.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**]
Dictated By:[**Last Name (NamePattern4) 8358**]
MEDQUIST36
D: [**2176-12-13**] 10:17
T: [**2176-12-15**] 14:51
JOB#: [**Job Number **]
|
[
"V43.3",
"250.00",
"276.5",
"V45.81",
"427.31",
"285.9",
"401.9",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
6075, 6782
|
2491, 6049
|
1462, 2473
|
112, 1439
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,731
| 138,291
|
41903
|
Discharge summary
|
report
|
Admission Date: [**2131-9-14**] Discharge Date: [**2131-10-6**]
Date of Birth: [**2080-3-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8810**]
Chief Complaint:
New diagnosis ALL
Major Surgical or Invasive Procedure:
Plasmaphersis line placement
PICC placement
Bone Marrow Biopsy
Lumbar Puncture
History of Present Illness:
HPI: 51M with HTN, CAD s/p stenting [**2123**], HTN who presented with
shortness of breath and new leukocytosis to 199k with 88%
blasts. He was in his USOH until 2weeks ago when he began to
develop increased DOE and worsening exercise tolerance with
occassional chest pressure. He continued to work and today he
developed near syncopal symptoms while raking at work. EMS was
called and he was taken to [**Hospital1 34**] where he was found to have new
WBC to 199k, HCT 28.5, PLT 33k with reported 2% polys and 85%
blasts. Fibrinogen was 354, INR 1.4, Cr 1.4. Cardiac biomarkers
were negative and his EKG was unchanged from prior. He was seen
by Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **] from [**Doctor Last Name **] hematology and started in hydroxyurea
2gm and allopurinol. He was transferred to [**Hospital1 18**] for further
management.
.
In the ED inital vitals were, 98.1 139/79 62 98 RA. He had a
pheresis line and picc placed. On admission, he was fatigued but
otherwise well. No SOB/DOE or chest pressure at rest. No HA,
N/V or dizziness. He denies easy bruising or bleeding and
specifically denies dark tarry stools, gum bleeding, hematuria.
No fevers, chills or night sweats. Sent to IR for pheresis
catheter and PICC placement.
.
Patient was transferred to the [**Hospital Unit Name 153**] overnight where he received
high volume IVFs, plasmapheresis, rasburicase 6mg IV for a uric
acid of 11 and 1 unit of PRBCs for a hct of 21.4. AM labs showed
Hct 23.1, platelet count of 18, WBC 88.5, K+ 3.7, Ca+ 8.2, Phos
4.4, uric acid 4.4, BUN 18, Cr 0.8.
.
This morning in the [**Hospital Unit Name 153**], patient had a bone marrow biopsy and a
TTE showing an EF>55%. He received hydroxyurea 3000mg PO,
dexamethasone 20mg PO, 1 unit of platelets. Patient received a
total of 3L of fluid going at 200ml/hr. Repeat plts 43, hct
25.1, WBC 109.7, uric acid 3.2.
.
On transfer to the floor, the patient is stable. VS are T 98.6,
BP 120/60, HR 52, RR 20, Satting 97% RA. No complaints.
Past Medical History:
1. NIDDM2 on Metformin/Glyburide
2. HTN
3. Hyperlipidemia
4. Hypothyroidism
5. Cervical DJD/OA
6. CAD s/p stenting x1 in [**2123**] by Dr. [**First Name4 (NamePattern1) **] [**Known firstname 8467**]. The patient
had followed with him but not in the past several years. The
patient's last exercise treadmill test was in [**2127**] and it was
non-diagnostic.
7. S/P CCK in [**2127**]
8. Psoriasis controlled with topicals in past, had tried PUVA in
past several years ago
Social History:
Living/Support: He is married and lives with his wife, they have
2 children ages 19 (daughter in nursing school) and son 14
Work/Income: He runs the park/rec dept in [**Last Name (un) 33487**], MA and
works part time at [**Company **].
EtOH: Very rare
Tobacco: Never
Illicits: denies, no h/o IVDU
Diet/Exercise: No regular exercise, tries to follow
cardiac/diabetic diet
Hobbies: Family
Travel: NONE
Pets: 1 cat
Family History:
No known hematologic malignancies, +HTN
Physical Exam:
ADMISSION EXAM:
GEN: well appearing white male
HEENT: Pupils equal round and reactive, extraocular movements
intact, oropharynx clear w/o lesions or petechiae, good
dentition
NECK: JVP flat
CV: nl s1s2, regular rate and rhythm, no murmur/rubs/gallops
PULM: clear to auscultation bilaterally w/good air movement, no
crackles/wheezes
ABD: obese, soft, non-tender, non-distended, +Bowel sounds, no
fluid wave or bulging flanks, no CVAT, no hepatosplenomgaly
LYMPH: no cervical, axillary or inguinal LAD
EXT: warm, well perfused, no cyanosis/clubbing/edema, no open
lesions
SKIN: multiple large psoriatic plaques on trunk as well as
confluent on much of his bilateral lower extremities, no
evidence
of superficial infection.
NEURO: AOx3, CN2-12 intact, 5/5 strength in all extremities,
grossly normal sensation, gait not assessed.
LINES: PICC line and pheresis line are c/d/i without bleeding or
drainage
DISCHARGE EXAM:
Pertinent Results:
OSH labs
[**2131-9-14**] 12:34
White Blood Count 199.1 K/mm3
Hemoglobin 9.5 g/dL
Hematocrit 28.5 %
Platelet Count 33 K/mm3
Neutrophils % (Manual) 2 %
Lymphocytes % (Manual) 9 %
Monocytes % (Manual) 4 %
Blastocytes % 85 %
INR 1.4
Fibrinogen 354 mg/dL
Sodium Level 140 mEq/L
Potassium Level 4.9 mEq/L
Chloride Level 102 mEq/L
Carbon Dioxide Level 26 mEq/L
Blood Urea Nitrogen 16 mg/dL
Creatinine 1.4 mg/dL
Glucose Level 100 mg/dL
Calcium Level 9.3 mg/dL
Total Bilirubin 0.7 mg/dL
Aspartate Amino Transf 29 U/L
Alanine Aminotransferase 25 U/L
Alkaline Phosphatase 95 U/L
Total Creatine Kinase 136 U/L
Creatine Kinase MB 3.5 ng/ml
Troponin T < 0.01 ng/ml
Total Protein 6.6 g/dL
Albumin 3.9 g/dL
Admission labs:
[**2131-9-14**] 06:00PM BLOOD WBC-203.3* RBC-2.74* Hgb-8.5* Hct-24.4*
MCV-89 MCH-30.9 MCHC-34.7 RDW-16.6* Plt Ct-36*
[**2131-9-14**] 11:49PM BLOOD WBC-179.6* RBC-2.52* Hgb-8.1* Hct-21.5*
MCV-85 MCH-32.2* MCHC-37.7* RDW-16.5* Plt Ct-29*
[**2131-9-15**] 01:35AM BLOOD WBC-105.1* RBC-2.48* Hgb-7.7* Hct-21.3*
MCV-86 MCH-31.1 MCHC-36.3* RDW-15.9* Plt Ct-22*
[**2131-9-15**] 03:45AM BLOOD WBC-84.4* RBC-2.53* Hgb-8.2* Hct-21.4*
MCV-85 MCH-32.4* MCHC-38.3* RDW-15.6* Plt Ct-17*
[**2131-9-15**] 05:15AM BLOOD WBC-88.5* RBC-2.74* Hgb-8.8* Hct-23.1*
MCV-84 MCH-32.1* MCHC-38.1* RDW-15.6* Plt Ct-18*
[**2131-9-14**] 06:00PM BLOOD Neuts-1* Bands-0 Lymphs-9* Monos-0 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-1* Other-88*
[**2131-9-14**] 11:49PM BLOOD Neuts-1* Bands-0 Lymphs-8* Monos-1* Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Other-90*
[**2131-9-14**] 06:00PM BLOOD PT-16.2* PTT-23.6 INR(PT)-1.4*
[**2131-9-14**] 06:00PM BLOOD Glucose-72 UreaN-16 Creat-1.3* Na-142
K-4.1 Cl-104 HCO3-27 AnGap-15
[**2131-9-14**] 11:49PM BLOOD Glucose-69* UreaN-16 Creat-1.2 Na-143
K-3.7 Cl-107 HCO3-24 AnGap-16
[**2131-9-15**] 05:15AM BLOOD Glucose-82 UreaN-18 Creat-0.8 Na-138
K-3.7 Cl-101 HCO3-28 AnGap-13
[**2131-9-14**] 06:00PM BLOOD ALT-25 AST-26 LD(LDH)-699* AlkPhos-83
TotBili-0.8
[**2131-9-14**] 11:49PM BLOOD LD(LDH)-618* CK(CPK)-59
[**2131-9-15**] 05:15AM BLOOD LD(LDH)-474* CK(CPK)-PND
[**2131-9-14**] 11:49PM BLOOD CK-MB-2 cTropnT-<0.01
[**2131-9-14**] 06:00PM BLOOD TotProt-6.0* Albumin-4.0 Globuln-2.0
Calcium-9.0 Phos-5.6* Mg-2.1 UricAcd-11.6*
[**2131-9-14**] 11:49PM BLOOD Calcium-8.8 Phos-4.9* Mg-2.0
UricAcd-11.1*
[**2131-9-15**] 05:15AM BLOOD Calcium-8.2* Phos-4.4 Mg-2.6 UricAcd-5.5
DISCHARGE
[**2131-10-6**] 12:00AM BLOOD WBC-8.4# RBC-3.19* Hgb-10.1* Hct-28.1*
MCV-88 MCH-31.6 MCHC-35.9* RDW-15.5 Plt Ct-102*#
[**2131-10-6**] 12:00AM BLOOD Neuts-85* Bands-3 Lymphs-5* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-1* Promyel-1*
[**2131-10-6**] 10:51AM BLOOD PT-15.2* PTT-26.3 INR(PT)-1.3*
[**2131-10-6**] 10:51AM BLOOD FDP-0-10
[**2131-10-6**] 10:51AM BLOOD Fibrino-474*#
[**2131-10-6**] 12:00AM BLOOD Glucose-128* UreaN-15 Creat-1.0 Na-139
K-3.8 Cl-102 HCO3-31 AnGap-10
[**2131-10-6**] 12:00AM BLOOD ALT-22 AST-15 LD(LDH)-215 AlkPhos-82
TotBili-0.6
[**2131-10-6**] 12:00AM BLOOD Albumin-3.3* Calcium-8.2* Phos-3.5 Mg-1.9
UricAcd-4.3 Iron-83
[**2131-10-6**] 10:51AM BLOOD D-Dimer-2417*
[**2131-10-6**] 12:00AM BLOOD Ferritn-2346*
Micro:
[**9-26**] c. diff positive
[**9-26**] blood culture negative
Imaging:
[**2131-9-14**] ECG: rate 58. Sinus bradycardia. Otherwise, normal
tracing. No previous tracing available for comparison.
[**2131-9-15**] Echo: The left atrium is elongated. The estimated right
atrial pressure is 0-5 mmHg. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated with normal free wall contractility.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
[**2131-9-15**] CXR: No acute pathology
[**2131-9-19**] 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 [**2131-9-15**],
the findings are similar.
[**2131-9-20**] CXR: Comparison is made to prior study from [**9-15**].
Cardiomediastinal contours are normal. Right central catheters
are in stable standard position. The tip is in the mid SVC.
There is no pneumothorax or pleural effusion. Bibasilar
opacities greater on the left base have increased. They are
likely atelectasis but superimposed infection on the left cannot
be totally excluded and followup is recommended. There is no
pneumothorax or pleural effusion.
[**2131-9-29**] CXR:AP chest compared to [**2131-9-20**]: The lungs
are fully expanded and clear. There is no pulmonary edema or
pleural effusion. Cardiomediastinal and hilar silhouettes and
pleural surfaces are normal. A right PIC line ends in the mid
SVC. There is no pneumothorax or atelectasis. Heart size is
normal.
Pathology:
[**2131-9-14**] Bone Marrow: Immunophenotypic findings consistent with
involvement by acute B-cell lymphoblastic leukemia (pre-B ALL)
with expression of CD34, HLA-DR, CD10 (partial, dim), CD19, CD20
(partial dim), TDT and CD13 (small subset). The review of the
peripheral blood smear reveals a population of variably sized
blasts with large nuclei with smooth chromatin, high nuclear to
cytoplasmic ratio and scant amount of basophilic cytoplasm.
Correlate with cytogenetic, molecular findings (see separate
report) and clinical findings. Dr. [**Last Name (STitle) **] was notified of
the results on [**2131-9-15**].
The combined morphologic and immunophenotypic findings (see
S11-42160C) are consistent with the diagnosis of acute precursor
B-lymphoblastic leukemia. Immunophenotypically, cells exhibit a
typical pre-B cell phenotype, but are only partly (small subset)
positive for CD10.
Cytogenetics: karyotype:
54,XY,+X,+2,+4,+6,t(9;22)(q34.1;q11.2),+14,+21,
+[**Doctor Last Name **](22)t(9;22),+[**Month (only) **][cp13]
Only thirteen metaphases were available for chromosome analysis.
All metaphases showed the same abnormal clone. All cells were
hyperdiploid with a 9;22 translocation and an extra [**Location (un) 5622**]
chromosome. This karyotype is most consistent with ALL.
[**2131-9-23**] CSF: no evidence of CSF involvement ->Diagnostic
immunophenotypic features of involvement by leukemia are not
seen in specimen on a limited panel. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation. Review
of corresponding cytospin showed a paucicellular specimen with
small mature lymphocytes and monocytes. Correlation with
clinical findings is recommended.
Brief Hospital Course:
Primary Reason for Admission: 51M with HTN, DM2, CAD s/p
stenting in [**2123**] who presents with new ALL, started treatment
with HyperCVAD and Gleevec, C1D1: [**2131-9-16**].
.
# ALL: Patient presented with SOB and a WBC of 199, as well as
some evidence of spontaneous lysis. The patient was transferred
directly from an OSH to the ICU given concern for need for
urgent plasmapheresis. Pheresis and BMT were consulted, line was
placed, and he was pheresed on admission, with improvement in
WBC from 203K to 80K. He was also given 1 dose hydroxyurea. Uric
acid was elevated and he was given rasburicase x1 given concern
for tumor lysis syndrome with improvement in uric acid level.
Bone marrow biopsy was performed on morning after admission and
flow cytometry was rushed. BMT felt this was more likely ALL so
hydroxyurea was stopped and he was given dexamethasone 20mg x1.
TTE was suboptimal study but showed normal LVEF. Good urine
output was maintained with IVF. Troponin trended up from <.01 to
0.03, next pending at time of transfer. He was deemed stable to
be transferred to the BMT unit. Flow cytometry confirmed ALL,
cytogenetics positive for [**Location (un) **] chromosome. Patient
started on HyperCVAD and Gleevec, initially requiring frequent
transfusions of cyroprecipitate for low fibrinogen. Echo
suggests intact cardiac function, EF >55%. LP does not show
signs of CNS disease, flow cytometry negative. Got IT cytarabine
after LP. Patient tolerating chemo well. Kept on IVFs. Initially
on acyclovir, bactrim, fluconazole, and levofloxacin for ppx,
however levo was d/c'd [**1-10**] prolonged Qtc. Hct kept >26, given
cardiac history and plts kept>10.
continued on ppx: acyclovir, bactrim, fluconazole.
.
# Febrile Neutropenia: Patient developed a fever to 101.0F about
10 days into treatment. Had some diarrhea, found to be C. diff
positive. Afebrile with decreased diarrhea on IV flagyl, PO
vanc, and cefepime. Also, with chronic dry cough from 2 weeks
prior to admission. No other signs of infection. IV Antibiotics
eventually discontinued, patient given short course of neupogen,
and remained afebrile for remainder of hospital course.
.
# C. diff: [**9-27**] C. diff positive. Treated with flagyl 500mg IV
Q8h and PO vanc 125mg QID(started [**9-27**]). Increased oral
vancomycin to 500mg on [**10-2**] with some improvement, and
discontinued metronidazole at time of discharge.
.
# Eye floaters: Patient initially complained of red and blue
floating spots over field of vision in both eyes. No diplopia.
Ophtho consult r/o leukemic changes in eyes. One hemosiderin
spot on right retina that could be the cause of his symptoms.
Nothing to do. Hct and plts kept above 26 and 10 respectively.
.
# Cough: Patient with persistent dry cough for the past couple
weeks.Had been on ACEI prior to admission, so could be lingering
ACEI cough. Improved somewhat with Guaifenesin, Benzonatate,
Cepacol, Sodium Chloride Nasal [**12-10**] SPRY as well ad famotidine
20mg PO BID. CXR WNL. Cough improved gradually.
.
# CAD: Echo suggests intact cardiac function, EF >55%.Statin and
ASA held during admission due to interaction with chemo and
thrombocytopenia.
.
# DM: on Metformin and glyburide at home. FS not well controlled
in house, especially while on steroids. Patient was kept on ISS
and NPH, with frequent adjustments depending on whether he was
receiving dexamethasone or not, [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations.
Prior to discharge, patient was not requiring any insulin and
thus was discharged on no medications for treatment of DM. He
was instructed to monitor his fingersticks regularly and call
his physician if he noted his BG to be continually elevated.
.
# Hypothyroidism: Continued home levothyroxine
.
# HTN: Patient has been normotensive off ACEI. Held lisinopril,
as patient has not needed it over admission.
.
# Hyperlipidemia: Held simvastatin due to drug interactions.
.
# Psoriasis: Per patient, controlled with topicals in past. Had
tried PUVA several years ago. Does not bother patient.
Dermatology was consulted and recommended aquaphor and
triamcinolone. Patient additionally getting methotrexate as part
of chemo regimen, which treated psoriasis. Will need biopsy of
nevi on back in the next 1-2 months when patient is more stable.
Transition Issues:
Patient needs f/u with derm for biopsy of lesion on his back
when plt count is sufficient (within 1-2months)
.
Medications on Admission:
Metformin, 1000 g in the morning and 500 mg in the evening
glyburide 5 mg b.i.d.
simvastatin 20 mg daily
enteric-coated aspirin 325 mg daily
lisinopril 10 mg daily
levothyroxine 0.1 mg one tablet MTWTh, 2 tablets FSaSu
Discharge Medications:
1. Gleevec 100 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*1*
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK
(MO,TU,WE,TH): 2 tablets by mouth 3X/WEEK ([**Doctor First Name **],FR,SA) .
Disp:*144 Tablet(s)* Refills:*2*
3. benzocaine-menthol-cetylpyrid 15-2 mg Lozenge Sig: One (1)
Mucous membrane every 4-6 hours as needed for sore throat.
Disp:*30 * Refills:*0*
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
5. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
Disp:*30 ML(s)* Refills:*0*
6. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal
QID (4 times a day) as needed for cough.
Disp:*1 * Refills:*0*
7. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea/anxiety/insomnia.
Disp:*10 Tablet(s)* Refills:*0*
9. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for psoriasis.
Disp:*qs * Refills:*0*
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*qs * Refills:*2*
12. medical equipment
[**Hospital 485**] hospital bed
Diagnosis Acute Lymphocytic Leukemia
ICD9: 204
Ht 71in
Wt 247lbs
13. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
15. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
16. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours).
Disp:*240 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis: New diagnosis ALL
Secondary Diagnosis:
-Clostridium Diff. Colitis
- DM Type II
- HTN
-Hypothyroidism
- Psoriasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 90972**],
It was a pleasure taking care of you in the hospital. You were
admitted with a new diagnosis of acute lymphocytic leukemia.
Because your white blood cell count was so high you spent one
night in the intensive care unit and your blood was filtered.
You began chemotherapy treatment which you tolerated well. Your
course was complicated by a diarrheal infection called C. diff,
and you are still being treated with oral and intravenous
antibiotics for this.
Your diabetes has also been well controlled off of insulin. Do
not restart your diabetes medications for now. Please check your
blood sugars one-two times a day, and call your doctor if your
BG is more than 200.
Please START taking the following medications:
- Vancomycin
- Trimethoprim-Sulfamethoxazole
- Metoprolol
- Fluconazole
- Acyclovir
Please STOP:
-Aspirin
-Metformin
-Glyburide
-Lisinopril
-simvastatin
Please continue your:
-Levothyroxine
Followup Instructions:
Patient to return to [**Hospital1 18**] BMT unit on [**Hospital Ward Name 1826**] 11 at 1200 on
[**2131-10-9**].
|
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48,946
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53213
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Discharge summary
|
report
|
Admission Date: [**2119-3-2**] Discharge Date: [**2119-3-6**]
Date of Birth: [**2040-12-5**] Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
s/p fall, unresponsive, hypotensive
Major Surgical or Invasive Procedure:
Scalp laceration repair at the [**Hospital3 **]
Intubation and mechanical ventilation
PICC line placement
History of Present Illness:
78 yo Cantonese speaking M w/ h/o prostate ca on radiation, G6PD
deficiency, anemia, myelodysplastic syndrome, hypothyroidism s/p
thyroidectomy, and hypertension who presents from OSH,
transferred with concern for T1 fracture.
.
Was seen in clinic today in routine follow up where VS were wnl-
at that time BP 100/58 mmHg Pulse 71 Temp 97.4 ??????F SpO2 100 %.
Per report, was subsequently running errands when had a
mechanical slip and fell. Was transported to [**Hospital3 **]. In
OSH ED, alert and hemodynamicaly stable w/ VS: T 97.0, BP
105/46, HR 53, RR 16, O2 sat 99% on RA. Labs were notable for
hyponatremia to 128, hyperkalemia to 6.4, creatinine of 4.5 and
bicarb of 18. Lipase was 105. He received bacitracin, lidocaine,
tetanus, calcium gluconate 1 g, dextrose, insulin 10 units, 1 L
NS, 50 mEq NaHCO3. He underwent CT head and C spine- negative
for acute bleed, but showed concern for fracture at T1 involving
R pedicle. His forehead laceration was cleaned and repaired w/
sutures and he was transferred to [**Hospital1 18**] for further management.
.
In the ED, initial VS were: T 96.5 BP 110/57 HR 66 RR 18 O2 sat
94% on RA. On arrival here, he was arousable only to vigerous
sternal rub, w/ some spontaneous movements of all 4 extremities.
Pupils were midsize equal and reactive. He quickly became
hypotensive to 70s systolic. Fast exam negative, no pericardial
effusion on bedside ultrasound. Normal rectal tone, guaiac
negative. Son was notified and reported pt is full code so was
intubated w/ 7.5 endotracheal tube w/ 20 mg etomidate, 60 mg
rocuronium, lidocaine 100 mg, and was started on a propofol gtt
running at 10. He received 2 L NS w/ response in BP and was
started on levophed. He was able to be weaned off this within
one hour. He received an additional liter of NS, vancomycin and
zosyn for broad coverage. A triple lumen femoral line was placed
under sterile conditions. UA remarkable for >182 WBCs, + LE, but
no nitrites or bacteria. UCx, and blood culture were sent. He
underwent pan CT scan of head, C-spine, and torso which in
prelim showed no fractures, but some fluid/stranding at the
pancreas. Surgery was consulted who remarked that CT abd
findings were unlikely to be related to trauma, and that the pt
may have some pancreatitis- they recommended repeat CT Abd w/ PO
contrast. Pt was admitted to MICU7 for further management- VS on
transfer were: HR 67 BP 119/63 RR 16 O2 sat 100% on 500 x 16
PEEP 5 FIO2 50%.
.
On arrival to the MICU, patient was intubated and sedated and
unresponsive to verbal stimuli. Mild response to sternal rub,
and was moving all extremities spontaneously.
Past Medical History:
Prostate cancer (Gleasons 4+3 adenocarcinoma s/p zoladex, XRT)
Hypertension
CKD stage 3
Hyperparathyroidism [**2-2**] CKD
G6PD
Anemia- Macrocytic (early MDS, G6PD, [**Last Name (un) **] neg [**2114**])
Myelodysplastic syndrome
Osteoporosis
H. pylori w/ chronic gastritis (on EGD [**2111**])
Hypothyroidism s/p thyroidectomy
HLD
Trigeminal neuralgia
Gout
Social History:
Lives alone in a senior housing complex in [**Hospital1 392**]. Widower. Has
two children- son (here in MA) and daughter (in [**Name (NI) 6847**]).
Widower. Formerly worked at [**Hospital1 18**] in food services. No tobacco,
EtOH, or illicits.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 92.3 (rectal) BP: 165/63 P: 65 R: 15 O2: 100%
General: Intubated, sedated, arouses faintly to sternal rub
HEENT: Sclera anicteric, dry MM, OG and ETT in place, PERRL
Neck: cervical collar in place, unable to assess JVP
CV: Bradycardic rate and rhythm, normal S1 + S2, diastolic
murmur, no rubs, gallops
Lungs: Coarse BS b/l anteriorly, no wheezes, rales, ronchi
Abdomen: soft, distended, bowel sounds present
GU: Foley
Ext: cool, 2+ radials, DPs, PTs; no clubbing, cyanosis or edema
Neuro: sedated, but arouses to sternal rub w/ eye opening,
PERRL, moves all four extremities spontaneously
DISCHARGE EXAM:
Vitals: Tm 99.4 Tc 97.7 130-140s/60-70s 58 18 96RA
General: NAD, alert, awake, interactive.
HEENT: Front scalp laceration s/p repair at OSH dressing
covered, partially stained with dry serous drainage. No e/o
active drainage. non-tender. No surrounding erythema. No warmth.
Sclera anicteric, MMM, EOMI
Ear: External exam: no erythema or edema. No tenderness with
pulling the auricles. No tenderness to palpation over the
mastoid. No discharges.
Neck: Neck supple
CV: RRR, Normal S1, S2, III/VI SEM heard best at the LUSB, not
radiating, no rubs, gallops
Lungs: CTAB
Abdomen: soft, mildly distended, non-tender, no organomegaly,
bowel sounds present. No CVA or suprapubic tenderness.
Ext: Warm, no edema 2+ DPs, 2+ radial
Neuro: CNII-XII grossly intact. No focal deficits.
Skin: Marked improvement with leg rash now only involving the L
outer thigh. Blanching. Confluent coalescing small erythematous
macules
Pertinent Results:
ADMISSION LABS:
[**2119-3-2**] 10:54PM LACTATE-1.5
[**2119-3-2**] 10:30PM GLUCOSE-179* UREA N-65* CREAT-3.5* SODIUM-133
POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-11* ANION GAP-18
[**2119-3-2**] 10:30PM LD(LDH)-254* CK(CPK)-290
[**2119-3-2**] 10:30PM CK-MB-7 cTropnT-0.01
[**2119-3-2**] 10:30PM CALCIUM-7.6* PHOSPHATE-4.5 MAGNESIUM-2.3
[**2119-3-2**] 10:30PM FREE T4-1.1
[**2119-3-2**] 10:30PM CORTISOL-14.2
[**2119-3-2**] 10:30PM WBC-6.7# RBC-2.53* HGB-8.7* HCT-25.8*
MCV-102* MCH-34.5* MCHC-33.8 RDW-15.5
[**2119-3-2**] 07:40PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008
[**2119-3-2**] 07:40PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2119-3-2**] 07:40PM URINE RBC-2 WBC->182* Bacteri-NONE Yeast-NONE
Epi-0
[**2119-3-2**] 07:40PM URINE Hours-RANDOM UreaN-365 Creat-44 Na-47
K-21 Cl-35
[**2119-3-2**] 07:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2119-3-2**] 07:40PM URINE Osmolal-282
OTHER LABS:
[**2119-3-2**] 10:54PM BLOOD Lactate-1.5
[**2119-3-2**] 04:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2119-3-3**] 07:41AM BLOOD Vanco-15.7
[**2119-3-2**] 10:30PM BLOOD Cortsol-14.2
[**2119-3-2**] 10:30PM BLOOD Free T4-1.1
[**2119-3-2**] 04:55PM BLOOD TSH-5.4*
[**2119-3-3**] 02:32AM BLOOD Osmolal-302
[**2119-3-4**] 02:30AM BLOOD Albumin-2.6* Calcium-7.9* Phos-5.3*
Mg-1.9
[**2119-3-2**] 04:55PM BLOOD cTropnT-<0.01
[**2119-3-2**] 10:30PM BLOOD CK-MB-7 cTropnT-0.01
[**2119-3-2**] 04:55PM BLOOD Lipase-96*
[**2119-3-4**] 02:30AM BLOOD Lipase-45
[**2119-3-2**] 04:55PM BLOOD ALT-12 AST-20 AlkPhos-41 Amylase-108*
TotBili-0.1
[**2119-3-4**] 02:30AM BLOOD ALT-18 AST-42* LD(LDH)-328* AlkPhos-42
Amylase-115* TotBili-0.7
DISCHARGE LABS:
[**2119-3-5**] 05:49AM BLOOD ALT-17 AST-30 AlkPhos-39* TotBili-0.5
[**2119-3-5**] 05:51AM BLOOD PT-12.1 PTT-70.5* INR(PT)-1.1
[**2119-3-6**] 05:09AM BLOOD WBC-5.5 RBC-2.72* Hgb-9.0* Hct-25.1*
MCV-92 MCH-33.0* MCHC-35.7* RDW-17.2* Plt Ct-178
[**2119-3-6**] 05:09AM BLOOD Glucose-103* UreaN-44* Creat-2.6* Na-141
K-4.3 Cl-111* HCO3-21* AnGap-13
MICROBIOLOGY:
Blood cultures 3/1: pending, no growth to date at time of
discharge
Urine culture [**3-2**]: negative
Blood cultures [**3-3**]: pending, no growth to date at time of
discharge
Sputum culture [**3-3**]: sparse growth commensal respiratory flora,
rare growth GNRs
Urine culture [**3-3**]: YEAST ~[**2107**]/ML.
Urine legionella antigen [**3-3**]: negative
Stool [**3-3**]: negative for C. diff
Stool [**3-4**]: negative for C. diff
IMAGING:
[**3-2**] CT head: No acute intracranial process or fractures.
[**3-2**] CT C-spine:
1. No acute fracture or malalignment.
2. Small amount of fluid superior to the endotracheal tube
balloon.
[**3-2**] CT torso:
1. Peripancreatic fluid - could be related to pancreatic injury
or acute pancreatitis. Clinical correlation is recommended,
correlate with serum pancreatic enzyme levels.
2. Thick urinary bladder wall - correlate clinically for
underlying infection.
3. Bilateral dependent opacities in the lungs likely atelectasis
and/or aspiration.
[**3-3**] ECHO:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF 75%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is borderline/mild posterior leaflet mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**3-3**] CT abd/pelvis w/oral contrast:
1. Mild stranding and free fluid in the upper abdomen. Based on
prior CT, early pancreatitis is favored, with gastritis and
duodenal injury less likely.
2. Increasingly distended gallbladder, with possible
sludge/stones. Consider ultrasound if there is clinical concern
for acute cholecystitis.
3. Thickwalled bladder, suggesting outlet obstruction versus
infection/inflammation.
4. Mild volume overload with pleural/pericardial effusions,
ascites, and anasarca.
5. Infrarenal aortic ectasia.
[**3-3**] LENIs:
IMPRESSION: Non-occlusive peripheral deep vein thrombosis of the
proximal femoral vein with central flow within it. This is
consistent with an old recanalized deep vein thrombosis. No
acute DVT.
[**3-3**] CXR: Tip of the endotracheal tube has been partially
withdrawn, now no less than 3 cm from the carina. Nasogastric
tube loops in the stomach ending in the fundus. Mild-to-moderate
cardiomegaly and mild pulmonary vascular congestion have both
improved, and there is no pulmonary edema. Greater opacification
at the base of the left lung is probably a combination of
persistent atelectasis and increasing small left pleural
effusion. No pneumothorax.
[**3-6**] CXR:
Continued decrease in central pulmonary vascular prominence. No
edema. Small bilateral pleural effusions, with interval
improvement on the left. Improved bibasilar atelectasis,
particularly at the left base.
Brief Hospital Course:
78M with past medical history notable for prostate
adenocarcinoma on XRT, CKD stage III, MDS, G6PD deficiency,
hypothyroidism and recent UTI on treatment transferred from OSH
after a mechanical fall with concern for T1 fracture, with
course c/b hypotension and hypothermia presumably secondary to
septic shock, initially requiring intubation, mechanical
ventilation, aggressive IVF, pressors, and broad spectrum
antibiotics. Was ultimately felt shock was due to sepsis, from
urinary source.
# FALL AND HEAD INJURY:
Fall mechanical in nature. Was initially concern for T1
fracture based on OSH imaging, though imaging at [**Hospital1 18**] did not
show evidence of a fracture. Additionally, no acute
intracranial process was seen on imaging. Patient did not have
any focal neurologic deficits on exam. He did sustain a scalp
laceration that was sutured at [**Hospital3 **] prior to
transfer. There was no evidence of infection involving the
scalp laceration. Patient will need suture removal [**2119-3-9**] if
scalp laceration appears healed. Will need PT at rehab.
# SHOCK
Patient suddenly became hypotensive with SBP to 70s in the ED.
FAST was negative. There was no pericardial effusion on bedside
echo. He was guaic negative. He was intubated and sedated
given altered mental status (as below). Received 2L NS with BP
response and was put on levophed. BP improved quickly and he
came off pressors within hours. UA was notable for many WBCs and
+ LE, but no nitrates or bacteria. He was admitted to MICU. In
the MICU, he again required pressors, but briefly and in setting
of being on sedation. He continued to have aggressive fluid
resuscitation. He received broad spectrum antibiotics,
including vancomycin, zosyn, cefepime, levofloxacin, azithro,
flagyl. Antibiotics eventually narrowed to levofloxacin for
presumed UTI, given known history of urinary retention,
prostate cancer currently on radiation treatment, prior UTIs,
and dirty UA on presentation. UCx and BCx were negative (though
in setting of recent outpatient antibiotics). Sputum Cx revealed
GN rods, but CXR revealed no e/o infective process. Patient was
also found to have purulent discharge from both ears, consistent
with bilateral otitis media. There was no leukocytosis, but he
has MDS. He was extubated without difficulty on [**3-3**], and
transferred to medicine floor on [**3-4**]. He remained
hemodynamically off pressors and continued to do well on
throughout the remaining hospital course. It was thought that
septic shock from urinary source was the most likely explanation
for his hypotensive episode. Of note, patient had a
peri-pancreatic inflammatory picture and gallbladder distention
on CT, with no clinical correlation (unremarkable LFTs, only
slightly elevated lipase that trended down to normal, and no
abdominal pain). Other causes of shock, such as cardiogenic
shock, deemed less likely in the setting of normal LV function
on echo and negative cardiac enzymes. History of poor PO intake
suggested possible hypovolemic status, but there was no evidence
suggesting large volume loss on imaging studies or lab tests.
Adrenal insufficiency unlikely given normal cortisol level. He
was discharged with plan to complete 10d course of levofloxacin
(last day [**2119-3-11**]) which will cover both UTI and otitis media.
# HYPOTHERMIA:
Likely secondary to septic shock. TSH slightly elevated but free
T4 normal, and cortisol WNL. Temperature improved quickly with
antibiotic therapy and Bair hugger.
# RESPIRATORY FAILURE:
He was intubated due to an unresponsive state and failure to
protect his airway, but there was no clear h/o any hypoxia.
ABGs while on mechanical ventilation suggested that he was
oxygenating relatively well. Did however have A-a gradient and
some opacities in bases, likely atelectasis, which gradually
improved. He was extubated on [**2119-3-3**] without incident prior to
transfer to the floor. He was diuresed with lasix 10mg IV prior
to transfer. Did not require supplemental O2 on the floor.
Repeat CXR [**3-6**] did not show any edema, bilateral effusions had
improved, and atalectasis had improved. Should have repeat CXR
in several weeks to confirm that there are not any persistent
abnormalities.
# UNRESPONSIVENESS
He had sudden onset on unresponsiveness w/o any known prodrome.
Given hypotension on presentation, possibly related to
hypoperfusion. No evidence of other toxins on serum/urine tox
screen. No historical clues to suggest meningitis, but likely
that infection played a large role given degree of hypotension
and hypothermia. Neuro exam was non focal. CT head negative for
any acute pathology. Mental status improved after abx and IVF
resuscitation. He remained alert, awake and interactive
throughout the remaining hospital course.
# OTITIS MEDIA:
Per patient, he had purulent discharge from both ears starting
two days before the admission. He continued to have purulent
discharge L > R. The ear cannals appeared erythematous and
injected. Patient remained asymptomatic without significant
change in hearing difficulty (hard of hearing at baseline).
Discharge gradually subsided throughout the remaining hospital
course. He was discharged with the plan to complete total 10d
course of levofloxacin as above (last day [**3-11**]).
.
# [**Last Name (un) **] on CKD:
He had elevated Cr at 4.5 at OSH prior to transfer from baseline
of 1.3. Urine chemistry and clinical history was most consistent
with ischemic ATN superimposed upon his CKD. He briefly required
lasix in the MICU. He otherwise maintained good UOP on the
floor. Cr continued to improve (2.6 on the day of discharge)
with improved hemodynamic state and aggressive fluid
resuscitation. He remained hemodynamically stable, asymptomatic.
Enalapril was held, but can likely be restarted in outpt setting
once renal function improves back to baseline. Medications were
renally dosed when appropriate.
.
# DIARRHEA
He developed frequent loose stools after transfer to the floor.
This was thought to be related to recent multiple abx
administration, and possibly related to his recent radiation
treatments. C diff testing was negative x2. Given no abdominal
pain, leukocytosis or fever, had low clinical suspicion for C.
diff. Abdominal exam was benign. Patient received continued
fluids.
.
# ANEMIA:
He presented with a Hct that 6 points lower than his recent Hct
on [**2-27**]. Baseline Hct appears to be 29-30. He was transfused 2
units with an appropriate bump in Hct. Has had extensive w/u
including negative EGD and colonoscopy outpatient. Anemia
currently attributed primarily to early myelodysplastic
syndrome. Patient also has h/o G6PD. No evidence of hemolysis
during the admission. Patient was guiac neg in ED, and did not
have any evidence of bleeding on imaging. Hct was trended daily
and ranged 23-27 on the floor.
.
# RASH
He developed confluent coalescing blanching erythematous macules
covering the entire lower extremities, sparing a few ovoid
patches over the shins and back in the setting of multiple abx
administration. Rash improved after most of the antibiotics were
discontinued (including vancomycin; as above) to near resolution
prior to discharge.
.
# NON-OCCLUSIVE CHRONIC DVT
He was started on a heparin drip after he was noted to have R
DVT on lower extremity ultrasound. However, final report of
ultrasound suggested a non-occlusive peripheral deep vein
thrombosis of the proximal femoral vein with central flow within
it, consistent with an old re-canalized deep vein thrombosis. He
was asymptomatic, and could not recall a history of DVT/PE. As
DVT not felt to be acute, heparin gtt d/c'd.
.
# PERIPANCREATIC FLUID COLLECTION ON CT:
There were CT findings concerning for pancreatitis, but there
was no clinical correlation. Patient did not have any nausea,
vomiting, or abdominal pain and had and unremarkable abdominal
exam. Amylase and lipase only mildly elevated. No intervention
other than fluid resuscitation and serial abdominal exams.
.
# HYPOTHYROIDISM:
s/p thyroidectomy. TSH was slightly elevated, and free T4 was
normal. His home levothyroxine was continued. Should have
repeat TFTs in outpatient setting once acute issues resolve.
.
#. HTN:
His home atenolol and enalapril were initially held in setting
of hypotension and [**Last Name (un) **]. Atenolol restarted prior to discharge.
Enalapril was held given [**Last Name (un) **], but can likely be restarted in
outpatient setting once renal function improves.
.
# Osteoporosis: Calcium, vitamin D. Receives alendronate every
2 weeks.
.
#. Chronic gastritis: Continued PPI.
.
# Hyperlipidemia: Continued statin.
.
# Trigeminal neuralgia: Continued gabapentin, renally dosed.
.
# Gout: Continued allopurinol, renally dosed.
# Prostate cancer: Patient currently getting XRT and per his son
he only has a few sessions left. He is having difficulty with
excessive urination at home and per report has not been drinking
as much as a result. He also reportedly had hypotension on
Flomax which was recently stopped and has led to an exacerbation
of his symptoms. He would likely benefit from re-initiation of
Flomax if BP remains stable at rehab. He is scheduled to return
to XRT [**3-7**].
TRANSITIONAL ISSUES:
-Needs removal of sutures from the scalp laceration repair on
[**2119-3-9**]
-Should continue levofloxacin for 5 additional days (last day
[**2119-3-11**]) to treat UTI, otitis media
-PICC line should be removed prior to discharge home from rehab
-Please monitor renal function (check chem7 on [**2119-3-8**] and at
least 3 times per week at rehab) to ensure renal function
trending back to baseline (Cr 1.3-1.5)
-Please re-dose meds for renal function (including levofloxacin,
allopurinol, gabapentin)
-Restart home enalapril once kidney function back at baseline.
-Repeat thyroid function tests once acute illness resolved
-Home safety evaluation for elderly fall risk
-Patient's code status was confirmed as full code this admission
-Contact is patient's son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 109554**]
Medications on Admission:
Enalapril Maleate 10 mg Oral Tablet 1 po bid
Gabapentin 300 mg TID
Allopurinol 200 mg daily
Tamsulosin 0.4 mg ER PO daily
Finasteride 5 mg PO daily
Simvastatin 40 mg PO daily
Docusate Sodium 100 mg PRN
Levothyroxine 100 mcg Oral (TAKE 1 TABLET four times per week
and [**1-2**] of a tablet three times per week.)
Alendronate 70 mg q2weeks
Atenolol 12.5 mg PO daily
Omeprazole 20 mg daily
Triamcinolone Acetonide 0.1 % Dental Paste TID PRN
CALCIUM-CHOLECALCIFEROL (D3) 600 MG (1,500 MG)-400 UNIT CAP
(CALCIUM CARBONATE/VITAMIN D3) daily
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day): four times per week.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day): three times per week.
7. alendronate 70 mg Tablet Sig: One (1) Tablet PO q2wks.
8. atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. triamcinolone acetonide 0.1 % Paste Sig: One (1) application
Dental three times a day as needed.
11. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
13. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: last day [**2119-3-11**].
14. PICC Line Flush
Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin
dependent: Flush with 10mL Normal Saline followed by Heparin as
above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care Center
Discharge Diagnosis:
Primary Diagnoses:
Mechanical fall
Scalp laceration
Shock
Acute toxic metabolic encephalopathy
Urinary tract infection
Otitis media
Acute kidney injury
Anemia
Drug Rash
Secondary Diagnoses:
Prostate cancer
Hypertension
Hyperlipidemia
Gout
Hypothyroidism
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 Mr. [**Known lastname **],
You were transferred to [**Hospital1 18**] after falling and hitting your
head on [**2119-3-2**]. You were initially brought to [**Hospital3 **],
where there was concern for a fracture in your back. However,
our scans here did not show any evidence of a fracture.
While you were in the emergency department, your temperature and
blood pressure dropped suddenly and you became unresponsive.
You needed a breathing tube to help protect your airway, and
fluids and medications to help raise your blood pressure. You
stayed in the intensive care unit briefly. You were treated
with various antibiotics for your ongoing urinary tract
infection and ear infection. You improved rapidly. You stayed
free of fever and had no pain anywhere. Your ear infection
improved. Your kidney function also started to improve. You
should finish your prescribed antibiotics course (last dose
[**2119-3-11**]) for your urinary tract infection and ear infection.
Your scalp laceration was repaired at the [**Hospital3 **]. You
should get the stitches removed after [**2119-3-9**] if the laceration
on your head is well healed. Your PCP or doctors at the rehab
will help arrange this.
You developed rash on your legs which may have been caused by
one of the antibiotics you received (vancomycin). The rash
improved when we stopped this medication.
You developed diarrhea. We think this is related to antibiotics.
We tested you for an infectious cause of diarrhea called C.
difficile, but this test was negative. Your diarrhea should
improve on its own shortly. Please make sure to drink plenty of
water (at least 6 glasses of water daily) when you go home.
We have made the following changes to your medications:
- STOPPED enalapril (you can restart this when your kidney
function returns to normal, please discuss with your doctors)
- STOPPED docusate sodium (Colace) while you are having diarrhea
- DECREASED gabapentin to 300 mg daily
- DECREASED allopurinol to 100 mg every other day
- ADDED levofloxacin 250 mg daily (for urinary tract and ear
infections), last day will be [**2119-3-11**]
- ADDED sarna cream as needed for itching
We have continued all your other medications and adjusted some
of their doses for your decreased kidney function.
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**First Name9 (NamePattern2) 109555**]
[**Name (STitle) 61187**], following your discharge from rehab. The number to
schedule an appointment is [**Telephone/Fax (1) 68410**].
Ongoing radiation treatment at the [**Location (un) **] Atrius Cancer
Center
[**Telephone/Fax (1) 109556**]
Drs. [**Last Name (STitle) 89344**] and [**Name5 (PTitle) **]
Next appointment [**2119-3-7**] at 14:15
Dr. [**First Name (STitle) 38748**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Hospital1 392**] Nephrology
[**2119-3-30**] 10:30 AM Appointment
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27,374
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45104
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Discharge summary
|
report
|
Admission Date: [**2107-10-20**] Discharge Date: [**2107-10-25**]
Date of Birth: [**2042-6-25**] Sex: F
Service: MEDICINE
Allergies:
Mevacor / Bactrim / Dilantin / Naprosyn / Clindamycin / Percocet
/ Quinine / Levofloxacin / Penicillins / Vicodin / Latex Gloves
/ Morphine
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
S/p fall with hip fracture
Major Surgical or Invasive Procedure:
L Hip ORIF
History of Present Illness:
65 year old female with COPD on home 3L O2, CAD s/p stent, CHF
with EF 50%, T2DM, ESRD on HD, Afib, HTN, OSA who was admitted 2
days ago with a pelvic fracture s/p repair yesterday. She is now
being transferred to the MICU with hypotension and hypoxia at
her HD session.
She reports that two days ago she was walking without her walker
and lost her balance trying to step up to the curb. Her left hip
hit the concrete and she was unable to get up and called 911.
She denies any preceding CP, palpitations, dizziness. Also
denies LOC or head trauma.
In the ED, intial vitals were 97.7 64 119/42 18 94%RA (although
wears 3L at all times at home). She was found to have a left
subtrochanteric hip fracture. She was given vitamin K for an INR
of 3.1 and transferred to the medicine floor.
She underwent left ORIF yesterday after an HD session. She had
2.5L taken off at HD yestserday and was given 1.5L during the
OR. This morning her vitals prior to dialysis were "99.1 109/89
63 18 95%RA" per review of records. Since admission her BP's
have ranged 101/53-112/45 and O2 sats have ranged from 86%RA to
86%3L. This morning she went to HD and was found to have a BP of
70's/40's with O2 Sat in the 70's on room air. She was given 1L
NS and BP was responsive to 91/44. She was then transferred to
the MICU.
Currently reports not feeling well. Reports not hearing well
this morning and having mild nausea. Also reports not eating in
2 days. Denies any dizziness or chest pain, but does feel that
her breathing is more labored. Also c/o worsened back pain, and
sore, dry throat. Has a baseline cough but not coughing anything
up.
Past Medical History:
Cardiac:
1. CAD s/p Taxus stent to mid RCA in [**2101**], 2 Cypher stents to
mid LAD and proximal RCA in [**2102**]; 2 Taxus stents to mid and
distal LAD (99% in-stent restenosis of mid LAD stent); NSTEMI in
[**8-1**]
2. CHF, EF 50-55% on echo in [**7-/2105**] Systolic and diastolic heart
failure with mild mitral regurgitation and tricuspid
regurgitation.
3. PVD s/p bilateral fem-[**Doctor Last Name **] in [**2093**] (right), [**2100**] (left)
4. Hypertension
5. Atrial fibrillation noted on admission in [**9-2**]
6. Dyslipidemia
7. Syncope/Presyncopal episodes - This was evaluated as an
inpaitent in [**9-2**] and as an opt with a KOH. No etiology has been
found as of yet. One thought was that these episodes are her
falling asleep since she has a h/o of OSA. She has had no tele
changes in the past when she has had these episodes.
.
Pulm:
1. Severe Pulmonary Disease
2. Asthma
3. Severe COPD on home O2 3L
4. OSA- CPAP at home 14 cm of water and 4 liters of oxygen
5. Restrictive lung disease
.
Other:
1. Morbid obesity (BMI 54)
2. Type 2 DM on insulin
3. ESRD on HD since [**2107-2-28**] - 4x weekly dialysis
Tues/Thurs/Fri/Sat 9R 2 lumen tunnelled line
4. Crohn's disease - not currently treated, not active dx [**2093**]
5. Depression
6. Gout
7. Hypothyroidism
8. GERD
9. Chronic Anemia
10. Restless Leg Syndrome
11. Back pain/leg pain from degenerative disk disease of lower L
spine, trochanteric bursitis, sciatica
.
PSHx:
s/p L brachiocephalic fistula formation [**2107-4-28**]
S/P fem-popliteal bypass -'[**93**], '[**00**]
S/P Hernia repair
S/P open cholecystectomy, appendectomy
S/P burn closure
Social History:
Lives on the [**Location (un) 448**] of a 3 family house with [**Age over 90 **] year old
aunt and multiple cousins in Mission [**Doctor Last Name **]. Can walk 10 yards
with walker and is limited by leg pain and SOB. Quit smoking 5
years ago, smoked 2.5ppd x 40 years (100py history). Infrequent
EtOH use (1drink/6 months), denies other drug use. Retired from
electronics plant.
Family History:
Per medicine admission note: Sister: CAD s/p cath with 4 stents
MI, DM, Brother: CAD s/p CABG x 4, MI, DM, ther: died at age 79
of an MI, multiple prior, DM, Father: [**Name (NI) 96395**] MI at 60
Physical Exam:
MICU ADMISSION PHYSICAL
VS: 99.0 104/66 69 20 96% on 3L
General: Alert, oriented, no acute distress. Morbidly obese.
Right HD line, left UE fistula.
HEENT: Sclera anicteric, MM slightly dry with oropharynx clear.
PERRLA, EOMI.
Neck: Supple, JVP not elevated, no LAD, no palpable thyromegaly
Lungs: Grossly clear to auscultation bilaterally anteriorly and
with mild rhonchi bilaterally at bases, no wheezing
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Midline surgical scar with large right sided reducible.
Soft, not tender or distended, +BS
Ext: Warm, well perfused, 2+ pulses palpable DPs bilaterally, no
clubbing, cyanosis. Mild pitting edema to shins. Tender to
palpation over legs to thighs bilaterally.
Neuro: A+Ox3. Moving all 4 limbs. Left hip with clean, dry,
intact dressings. Sensation intact.
DISCHARGE PHYSICAL:
General: Alert, oriented, no acute distress. Right HD line, left
UE fistula.
HEENT: MMM with oropharynx clear. PERRLA, EOMI.
Neck: Supple, JVP not elevated, no LAD, no palpable thyromegaly
Lungs: Grossly clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Midline surgical scar with large right sided reducible.
Soft, not tender or distended, +BS
Ext: Warm, well perfused, 2+ pulses palpable DPs bilaterally, no
clubbing, cyanosis. Mild pitting edema to shins. Tender to
palpation over legs to thighs bilaterally.
Neuro: A+Ox3. Moving all 4 limbs. Left hip with clean, dry,
intact dressings.
Pertinent Results:
Hip xray [**10-22**]:
IMPRESSION:
1. Left femoral neck fracture.
2. Bilateral osteoarthritis of the hips and lumbosacral spine.
Admission labs:
[**2107-10-20**] 11:30AM GLUCOSE-154* UREA N-93* CREAT-8.2*#
SODIUM-132* POTASSIUM-5.8* CHLORIDE-89* TOTAL CO2-25 ANION
GAP-24*
[**2107-10-20**] 11:30AM WBC-8.0 RBC-3.65* HGB-11.7* HCT-36.0 MCV-99*
MCH-32.0 MCHC-32.5 RDW-16.3*
[**2107-10-20**] 11:30AM NEUTS-84.7* LYMPHS-8.7* MONOS-3.8 EOS-2.0
BASOS-0.7
[**2107-10-20**] 11:30AM PLT COUNT-262
Discharge labs:
[**2107-10-25**] 08:30AM BLOOD Glucose-175* UreaN-55* Creat-6.1*#
Na-126* K-4.5 Cl-85* HCO3-27 AnGap-19
[**2107-10-25**] 08:30AM BLOOD WBC-6.4 RBC-2.73* Hgb-8.8* Hct-26.9*
MCV-99* MCH-32.2* MCHC-32.7 RDW-15.6* Plt Ct-276
[**2107-10-22**] 11:48PM BLOOD Neuts-82.8* Lymphs-8.5* Monos-5.2 Eos-2.1
Baso-1.4
[**2107-10-25**] 08:30AM BLOOD PT-14.8* PTT-97.7* INR(PT)-1.3*
Brief Hospital Course:
65F with COPD on home 3L O2, CAD s/p stent, CHF with EF 50%,
DM2, ESRD on HD, Afib on warfarin, HTN, OSA, who underwent
successful repair of left hip fracture. [**Hospital 72030**]
transferred to MICU for hypotension and hypoxia at dialysis.
.
# Hypotension: Patient was transferred to the MICU after an
episode of hypotension at HD. Her BP was 70's/40's and
responsive to 1L IVF. Subsequently her blood pressure remained
stable and her metoprolol was restarted. CXR was consistent
with pulmonary edema and further fluids were minimized. Her O2
sats remained at her home level. She was called out to the
general medical service on hospital day 3. Her pressures
remained stable on the floor.
.
# Hypoxia: Likely [**3-1**] lack of home oxygen in dialysis. Placed on
3L home requirement and saturated well.
.
# ESRD: No dialysis on [**10-22**] as she was hypotensive prior to
connecting to machine. Received dialysis on [**10-24**]. Continued
sevelamer, low phos diet. She was given a three day course of
aluminum hydroxide for elevated phosphorus levels.
.
# Hyponatremia: Na in low 120s, likely [**3-1**] free water intake.
She was placed on fluid restriction. Na improved to 126 prior
to discharge. This will need to be repeated on [**10-26**] at dialysis
and discussed with MD.
.
# Pain control s/p hip fx repair: Initially on IV dilaudid,
then switched to oral dilaudid. Fentanyl patch added on the day
prior to discharge. Incision site clean, dry, and intact.
.
#. AF: She was started on a heparin drip for a bridge to
[**Month/Year (2) **] for anticoagulation following her procedure. Goal INR
[**3-2**]. Discharged with continued bridge.
.
# CAD: Episode of hypoxia in dialysis, most likely [**3-1**] lack of
home oxygen, no EKG changes. Troponin elevation attributed to
CKD.
.
#. OSA: stable on home 3L. Continued home CPAP at night.
.
#. DM2 on insulin: Last HbA1c 8.0 this year. Continued home
Lantus 17 units qam and 12 units qpm. Continued ISS and diabetic
diet.
.
Medications on Admission:
Allopurinol 200mg po daily
B Complex-Vitamin C-Folic Acid 1mg po daily
Gabapentin 200mg po qam, 400mg po qpm
Levothyroxine 175 mcg po daily
Calcitriol 0.25mcg po daily
Metolazone 2.5mg po daily
Omeprazole 20mg po daily
Paroxetine HCl 40mg po daily
Polyethylene Glycol 3350 17 gram/dose po daily
Sevelamer HCl 2400 mg po tid with meals (Pt not taking)
Aspirin 81mg po daily
Simvastatin 80mg po daily
Albuterol Sulfate 90mcg/Actuation HFA Aerosol Inhaler 1-2 Puffs
Inhalation Q4H prn SOB, wheezing
Diltiazem HCl SR 120mg po daily
Fluticasone 110mcg/Actuation 2 puffs inhaled [**Hospital1 **]
Fluticasone 50 mcg/Actuation Spray 2 spray nasal daily
Metoprolol Succinate 75 mg po daily, dose confirmed
Warfarin 6mg po daily
Ipratropium Bromide 0.02 % Solution q6h prn SOB/wheeze
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inh Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
14. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
15. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
16. IV heparin drip
Please continue heparin gtt at 1600 units/h and titrate to PTT
60-100. PTT 96 on discharge. Please discontinue when INR >2
17. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
20. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for breakthrough pain.
21. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
22. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
23. insulin
Please give 17 units of insulin glargine each morning and 12
units of insulin glargine each evening.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis: Status-post Left hip fracture repair
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear. Ms. [**Known lastname 1968**],
You were admitted to the hospital for repair of your hip
fracture. You tolerated the procedure well. Following the
procedure, you underwent dialysis, and during this session you
were found to have a low oxygen level in your blood and a low
blood pressure. Both of these issues resolved during your
hospital stay. You were given medication for pain in your hip
and leg.
During your stay, you were found to have a low [**Known lastname 197**] level.
You were started on an additional blood thinner, heparin,
because of this.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up at the following time/place:
.
Department: TRANSPLANT CENTER
When: [**Name8 (MD) **] [**2107-10-28**] at 2:40 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
When: [**Hospital Ward Name **] [**2107-11-11**] at 9:20 AM
With: DR. [**First Name (STitle) **] / DR. [**First Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PODIATRY
When: [**Hospital Ward Name **] [**2107-11-25**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"285.9",
"427.31",
"274.9",
"276.7",
"424.0",
"416.8",
"428.32",
"276.1",
"397.0",
"327.23",
"458.9",
"820.22",
"250.92",
"412",
"403.91",
"414.01",
"E849.9",
"V85.4",
"275.3",
"719.43",
"428.0",
"278.01",
"E880.1",
"585.6",
"799.02",
"493.20",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"79.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11898, 11964
|
6808, 8797
|
429, 441
|
12064, 12064
|
5903, 6033
|
12916, 14046
|
4151, 4350
|
9622, 11875
|
11985, 11985
|
8823, 9599
|
12240, 12893
|
6418, 6785
|
4365, 5884
|
363, 391
|
469, 2097
|
6050, 6402
|
12004, 12043
|
12079, 12216
|
2119, 3737
|
3753, 4135
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,873
| 134,114
|
2303
|
Discharge summary
|
report
|
Admission Date: [**2172-6-2**] Discharge Date: [**2172-6-8**]
Date of Birth: [**2108-5-17**] Sex: F
Service: SURGERY
Allergies:
Dyazide / Prozac / Nsaids / Inderal / Cefazolin
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
AV graft placement needed for dialysis
Major Surgical or Invasive Procedure:
placement of left upper extremity graft for dialysis
History of Present Illness:
Ms. [**Known lastname 12067**] is a 68 year-old woman with end stage renal disease
who has a failed kidney transplant. She had multiple procedures
on her upper
extremities and currently has a right sided PermaCath. There is
a subclavian stenosis on the right side and so this side was not
thought to be usable. Venogram on the left side revealed 2 good
quality veins. However, these were up at almost the level of the
chest wall and given her previous grafts on the left side we
felt that a high left upper extremity graft would be her best
option. She understood the risks and benefits and wished to
proceed.
Past Medical History:
Past Medical History:
1. ESRD s/p cadaveric renal transplant in [**2168**] back on HD at
[**Location (un) 4265**] [**Location (un) **] (M,W,F)
2. DM2 last HbA1c [**11-29**] is 10.6% - w/ retinopathy, nephropathy
and peripheral neuropathy
3. Hyperlipidemia
4. s/p CVA
5. CHF [**12-26**] diastolic dysfunction- last echo [**2-26**]- mild LVHF, nl
systolic function. 2+MR. [**11-25**]+ MR. [**First Name8 (NamePattern2) **] [**Last Name (Titles) 6879**]
6. CAD s/p cath [**2-26**]- LAD 50% stenosis, RCA 60% and mild
diastolic dysfunction.
7.s/p right cataract removal
8. s/p hysterectomy
9. PNA-trtd at [**Hospital6 **] in the beginning of [**Month (only) 404**]
this year.
Social History:
Pt is from [**Country **], raised 2 daughters on her own, now has 3
grandchildren
Lives in [**Location 686**] with her daughter. Was a nurses aide at the
[**Hospital **] hospital but stopped [**12-26**] illness.
No EtOH, tobacco, drugs.
Family History:
Father w/ DM and mother w/ HTN.
Physical Exam:
VITALS: Her blood pressure is 100/58, afebrile, pulse 72,
respiratory rate 16, and 72.9 kilograms.
Gen: tired and has discomfort from lower back pain.
HEENT: Her oropharynx is clear. She has dentures. She is
anicteric.
LUNGS: Her lungs are clear.
CV: Heart is regular. She has a systolic murmur.
ABD: Her abdomen is soft, obese, and nontender. The kidney
transplant is
nontender and palpable in the right lower quadrant.
EXT: She has no pedal edema or suspicious skin lesions.
Pertinent Results:
[**2172-6-2**] 10:49PM GLUCOSE-185* UREA N-44* CREAT-5.9* SODIUM-141
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-23*
[**2172-6-2**] 10:49PM CALCIUM-9.8 PHOSPHATE-5.3* MAGNESIUM-1.9
[**2172-6-2**] 10:49PM WBC-18.5*# RBC-3.96* HGB-11.0* HCT-33.4*
MCV-84 MCH-27.7 MCHC-32.9 RDW-16.2*
[**2172-6-2**] 10:49PM PLT COUNT-295
[**2172-6-2**] 09:16PM TYPE-ART PO2-141* PCO2-30* PH-7.48* TOTAL
CO2-23 BASE XS-0
[**2172-6-2**] 07:47PM CK-MB-4 cTropnT-0.20*
[**2172-6-2**] 04:34PM TYPE-ART RATES-/12 TIDAL VOL-100 PEEP-5
PO2-314* PCO2-42 PH-7.38 TOTAL CO2-26 BASE XS-0
INTUBATED-INTUBATED VENT-IMV
[**2172-6-2**] 03:30PM TYPE-ART PO2-176* PCO2-67* PH-7.25* TOTAL
CO2-31* BASE XS-0
[**2172-6-2**] 03:30PM GLUCOSE-208* LACTATE-1.6 NA+-139 K+-4.8
CL--101
[**2172-6-2**] 03:30PM HGB-11.7* calcHCT-35
[**2172-6-2**] 11:56AM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF
[**2172-6-2**] 11:56AM GLUCOSE-91 K+-4.4
[**2172-6-2**] 7:47P TROP 0.20*
[**6-3**] 0443 am TROP 0.33
[**6-3**] 1107 am TROP 0.37
ELECTROCARDIOGRAM PERFORMED ON: [**2172-6-2**] 16:17:18
Sinus rhythm.
Vertical axis
Consider right ventricular hypertrophy
Inferior T wave changes are probably due to ventricular
hypertrophy
rsr' in lead V1
Early R wave progression
QT interval prolonged for rate
Since previous tracing, axis more vertical, inferior T wave
abnormalities less
Clinical correlation is suggested
ELECTROCARDIOGRAM PERFORMED ON: [**2172-6-2**] 21:12:48
Sinus tachycardia
Possible right ventricular hypertrophy
Vertical axis
rsr' in lead V1
Since previous tracing, heart rate increased, QT interval
decreased, T wave
abnormalities more marked
Clinical correlation is suggested
ELECTROCARDIOGRAM PERFORMED ON: [**2172-6-4**] 07:33:36
Sinus rhythm
Atrial premature complex
S1, Q3, T3 pattern
Nonspecific ST-T abnormalities
Findings are nonspecific but clinical correlation is suggested
for possible in
part RV overload
Since previous tracing of [**2172-6-2**], further precordial leads ST-T
wave changes present.
AP CHEST FROM 11:09 P.M. [**6-2**]
HISTORY: End-stage renal disease and respiratory distress. Check
ET tube
placement.
IMPRESSION: AP chest compared to 3:00 and 4:30 p.m. today:
With the chin down, the tip of the endotracheal tube is at the
upper margin of
the clavicles at least 5 cm from the carina, 2-3 cm above
optimal placement.
Consolidation in the infrahilar right lung has improved since
3:00 p.m.
indicating this is likely atelectasis. Severe cardiac silhouette
enlargement
is unchanged. Left lung is clear. Nasogastric tube passes into
the stomach
and out of view. The tips of a dual channel supraclavicular
right central
venous catheter project over the SVC and superior cavoatrial
junction
respectively. No pneumothorax.
FINAL REPORT
PROCEDURE: Single AP portable view of the chest.
REASON FOR EXAM: Assess for aspiration, 64-year-old woman with
ESRD with
respiratory distress.
Comparison is made with prior study performed the day before.
FINDINGS: There is retrocardiac left base opacity concerning for
aspirative
consolidation new from prior study. Stable small bilateral
pleural effusions.
Stable enlarged cardiomediastinal contour. A right subclavian
venous access
catheter tip remains in the right atrium. Right infrahilar
opacity is
unchanged.
IMPRESSION:
Left retrocardiac consolidation consistent with an aspirative
process
Findings were discussed with Dr [**Last Name (STitle) **] at the mom[**Name (NI) **] of the
interpretation
of the study.
HISTORY: Question aspiration _____ surgery yesterday, question
pneumonia.
CHEST, TWO VIEWS.
Compared with [**2172-6-4**], there has been some interval clearing at
the left lung
base, with improvement and only minimal residual retrocardiac
patchy density.
No CHF or other evidence of consolidation or effusion. Minimal
subsegmental
atelectasis at the right base. A right IJ central line is
present, tip
overlying uppermost right atrium.
FINAL REPORT
INDICATION: 64-year-old woman, status post left AV graft, now
with swelling
of the right forearm. Evaluate the right arm for DVT.
COMPARISON: Ultrasound from [**2169-4-4**].
UNILATERAL UPPER EXTREMITY ULTRASOUND: [**Doctor Last Name **]-scale and color
Doppler
son[**Name (NI) 867**] was performed of the right internal jugular,
subclavian, axillary,
basilic, brachial, and cephalic veins and the left subclavian
vein. Normal
flow, waveforms, compressibility, and augmentation are
demonstrated. No
intraluminal thrombus is identified.
IMPRESSION: No right upper extremity DVT.
Brief Hospital Course:
Patient was taken to the OR where she had Left AV upper arm
graft placed for HD access secondary to ESRD. Patient
technically had fine placement of Left AV graft; however, during
procedure patient had respiratory compromise/airway edema and
was intubated. Patient noted to have elevated troponinsX3 as
above s/p airway management. Patient stayed overnight in PACU
with anesthesia monitoring patient. Patient had facial swelling
and renal was initially consulted on [**6-2**] postop. They
concurred with surgeon's evaluation that patient had become
hypercarbic and tachypnic during OR and thought the angioedema
was most likely to drug allergic reaction secondary to no
pulmonary edema on CXR. The patient did vomit and aspirated in
PACU and developed retrocardiac infiltrates concerning for
aspiration pneumonia. Patient was extubated on [**2172-6-3**]. The
patient was treated with Zosyn in hospital then Augmentin po x
6days postdischarge. Patient was transferred to floor but noted
to be hypersomnolent and subsequently had low oxygen saturation
secondary to suspected ativan/oxycodone even on
100%nonrebreather mask. These medications were discontinued and
patient improved mentally after several doses of flumazenil and
narcan; however, patient was transferred to T/SICU for HD and
observation on [**2172-6-4**]. Pt transferred back to floor ([**Hospital Ward Name **] 7)
on [**2172-6-5**] and patient improved gradually, was hemodialyzed per
renal recommendations, her diet was advanced as tolerated, and
eventually was discharged on home meds as above with diabetes
management [**First Name8 (NamePattern2) **] [**Last Name (un) **] consult recommendations which were the
same as her prehospital insulin.
Medications on Admission:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
4. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Forty
Eight (48) units Subcutaneous q am before breakfast.
5. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Eighteen
(18) units Subcutaneous evening dose.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day. Tablet, Chewable(s)
7. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Two (2) Tablet Sustained Release 24HR PO once a day.
10. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day.
11. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
13. Gabapentin 100 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Paxil 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
6. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Forty
Eight (48) units Subcutaneous q am before breakfast.
7. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Eighteen
(18) units Subcutaneous evening dose.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day. Tablet, Chewable(s)
9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO once a day.
12. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day.
13. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
15. Gabapentin 100 mg Tablet Sig: One (1) Tablet PO once a day.
16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
17. Paxil 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
end stage renal disease, diabetes mellitus, hyperlipidemia,
congestive heart failure, coronary artery disease, NSTEMI
Discharge Condition:
stable
Discharge Instructions:
Take medications as directed and follow your dialysis schedule
as directed. [**Name8 (MD) **] MD or come to Er if having worsening pains,
fevers, chills, nausea, vomiting or if there are any questions
or concerns.
Resume your regular insuling dosing that you had been taking
before. Resume all home medications.
Followup Instructions:
Scheduled Appointments :
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2172-6-30**] 9:00
Call for [**Last Name (un) **] consult/appointment as needed with Dr [**Last Name (STitle) 3617**].
[**Telephone/Fax (1) 12068**]
Completed by:[**2172-6-9**]
|
[
"585.6",
"403.91",
"250.40",
"428.0",
"518.5",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.27",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11475, 11532
|
7116, 8840
|
344, 399
|
11694, 11703
|
2561, 7093
|
12065, 12386
|
2007, 2040
|
10070, 11452
|
11553, 11673
|
8866, 10047
|
11727, 12042
|
2055, 2542
|
266, 306
|
427, 1040
|
1084, 1736
|
1752, 1991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,706
| 167,507
|
42657
|
Discharge summary
|
report
|
Admission Date: [**2106-2-1**] Discharge Date: [**2106-2-6**]
Date of Birth: [**2080-6-23**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 371**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
25 yo M on methadone maintenance, unrestrained driver in head-on
collision at approx. 40 mph, +airbag, steering wheel collapsed,
with +LOC, however EMS foudn pt w/ GCS 15 and hemodynamically
stable. In ED remained stable, found to have multiple abrasions
and abdominal pain. Preliminary head CT and spine CT negative,
abdominal CT shows liver contusion and hemoperitoneum.
Past Medical History:
PMH: IVDU
PSH: none
Social History:
History of IVDU, currently on methadone maintenance.
Family History:
N/C
Physical Exam:
On Discharge:
Gen: no acute distresss
CV: RRR, nl S1 and S2
Pulm: CTAB, respiratory effort improved from admission, pulling
1250cc on IS machine
Abd: soft, NT, ND, no rebound/guarding
Ext: bilateral edema
Pertinent Results:
Hct: 33.1-35.1-35.3-31.5-30.2-28.1-27-26.6
WBC: 21.7-18.1-12.4
CT Head [**2106-2-2**]: No acute process. Material within the right
external auditory canal likely represents cerumen, less likely
blood; correlate with clinical examination.
CT abd /pelvis [**2106-2-2**]: 1. Liver contusion and lacerations with
considerable hemorrhagic ascites, although without evidence for
active extravasation of contrast. 2. At least three right-sided
rib fractures involving displaced fifth, sixth and minimally
displaced seventh right rib fractures, and left anterior 3rd rib
fracture.
3. Non-displaced fracture of the manubrium
CT C-spine [**2106-2-2**]: No evidence of fracture or dislocation.
Brief Hospital Course:
Mr. [**Known lastname 92233**] was evaluated in the [**Hospital1 18**] ED as part of a trauma
activation, which revealed the following injuries, Rib Fractures
[**3-22**] on the right, Liver contusion,
with hemoperitoneum. He was admitted to the TICU for further
evaluation and monitoring.
In the TICU he had GCS 15 throughout and had his C-collar
cleared. He had some desaturations initially related to pain
that slowly resolved with IS use and ambulation. He was also
noted to be tachycardic in the TICU initially, to 110-120 but
this was also thought to be in the setting of pain.
On HD 3 he was transferred to the floor. He was tranistioned
from IV to PO methadone and was started on a clear diet, which
he tolerated. He did complain of reflux and was started on
Pepcid and Tums, which he takes when needed at home. He was
still requiring oxygen but this was improving. His pain was
adequately controlled on his home methadone and oxycodone. On HD
4 he was restarted on heparin after his hematocrits had been
stable for over 24 hours. He continued to have his hematocrit
checked, which remained stable. He was weaned off oxygen and
physical therapy continued to work with him.
At time of discharge he was tolerating a regular diet, was
afebrile, had adeqaute pain control, and was able to ambulate.
He was using his IS well.
Medications on Admission:
methadone 80'
Discharge Medications:
1. methadone 10 mg Tablet Sig: Eight (8) Tablet PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 5 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Rib fractures
Liver contusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the taruma service after a motor vehicle
accident and suffered multiple injuries, including right rib
fractures and liver contusion. Your labs and overall clinical
picture were mointored to make sure you were stable throughout
this hospitalization. Because of your liver contusion you should
avoid any heavy physical contact to your abdomen for 6 weeks.
Please take all your home medications and all prescriptions as
prescribed. Please remember that you should not drive or operate
heavy machinery when taking narcotic pain medications. You
should not take more than 4000mg of Tylenol in 24 hours period.
Also, you have been prescribed stool softeners as narctotic pain
medication can make you constipated.
Please continue to use your incentive spirometer as you have
been doing in the hospital.
Followup Instructions:
Please follow up in the ACUTE CARE SURGERY CLINIC
Phone:[**Telephone/Fax (1) 600**] Date/Time:[**2106-2-23**] 2:00. The office is
located in the [**Hospital **] Medical Office Building in [**Hospital Unit Name **] on the
[**Location (un) 10043**].
Completed by:[**2106-2-6**]
|
[
"868.03",
"E812.0",
"304.00",
"807.03",
"785.0",
"864.01",
"787.01",
"850.11"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3657, 3663
|
1802, 3136
|
307, 313
|
3737, 3737
|
1091, 1779
|
4731, 5009
|
844, 849
|
3200, 3634
|
3684, 3716
|
3162, 3177
|
3888, 4708
|
864, 864
|
879, 1072
|
260, 269
|
341, 715
|
3752, 3864
|
737, 758
|
774, 828
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,991
| 171,092
|
37634
|
Discharge summary
|
report
|
Admission Date: [**2164-8-8**] Discharge Date: [**2164-8-11**]
Date of Birth: [**2083-7-29**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
R sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 81 yo RHM with hx of HTN, CAD and
hypercholesterolemia on Plavix here with L thalamic hemorrhage
seen from head CT at [**Hospital3 1280**] Hospital today. Per patient and
wife who is at bedside, they worked on their garden for a few
hours this morning around 11am. He appeared very tired and pale
hence wife recommended for him to lay down while she prepared
lunch. He got up about an hour later around noon and
subsequently had soup for lunch. He had no trouble drinking and
eating. They did not converse much and watched news on
television which he had no trouble comprehending. He still felt
diffusely weak and tired despite the meal and when he stood up,
he realized that his R side was weak and he could not ambulate
steadily. He did not fall but had to sit himself down hence EMS
was called and he was taken to [**Hospital3 1280**] where his head CT
showed L thalamic hemorrhage hence he was transferred here for
further care.
Patient denies any HA, trauma/fall, numbness or visual change.
He does report that he felt that he was having trouble
expressing
himself although he understood perfectly and he knew what he
wanted to say but could not find the words. There was no
slurring of speech. Also, no report of any facial asymmetry.
ROS completely negative for any CP, palpitation, fever/chills,
dysuria, N/V/D or sick contact. There has been no recent
medication changes and he has never had similar symptoms in the
past. He is legally blind at baseline but able to do all ADLs
including independent ambulation without assistance.
Past Medical History:
PMH:
1. CAD s/p stents x3 (Seen by Dr. [**Last Name (STitle) 656**] who is his PCP and
primary care)
2. HTN
3. hx of C.diff
4. hx of abdominal surgery x2 - partial colectomy from
obstruction then another surgery for adhesions in mid [**2134**]'s.
5. Hypercholesterolemia
6. Legally blind
7. Macular degeneration - treated with laser therapy
8. Arthritis
MEDS:
1. Plavix 75mg daily
2. Metoprolol XL 25mg daily
3. Lipitor - dose unsure
4. Tylenol PRN
Social History:
Lives at home with wife - has 4 grown children. Retired IRS
[**Doctor Last Name 360**]. Quit smoking in [**2114**] and rare EtOH. HCP is daughter,
[**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 84415**] but never discussed code status.
Family History:
Not obtained
Physical Exam:
T 97.6 BP 132/82 HR 62 RR 14 O2Sat 100% RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No carotid or vertebral bruit
CV: Very faint heart sounds but sounds regular - possible
murmur.
Lung: Clear
Abd: +BS, soft, nontender
Ext: No edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is intermittently fluent with normal
comprehension and repetition; mild dysnomia with low frequency
words. No dysarthria. No right left confusion. No evidence of
apraxia or neglect.
Cranial Nerves:
II: Pupils slightly irregular but symmetric and reactive to
light, 3 to 2 mm bilaterally.
III, IV & VI: Extraocular movements intact bilaterally, no
nystagmus.
V: Sensation intact to LT and PP.
VII: Facial movement symmetric.
VIII: Hearing intact to finger rub bilaterally.
X: Palate elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline, movements intact
Motor:
Normal bulk and tone bilaterally. No observed myoclonus or
tremor. No asterixis but R pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 *5- 5 5 5 5 5
L ham appears to have giveway weakness from pain/arthritis
Sensation: Intact to light touch, pinprick, and cold but
decreased JPS on R and mildly decresaed vibratory sensation on
both toes.
Reflexes:
+2 and symm for UEs but 3 for L patellar and 2+ for R patellar
and none for both Achilles. Toes downgoing bilaterally
Coordination: FTN, FTF and [**Doctor First Name **]/HTSs normal.
Gait: Leans to the R when standing - unsteady.
Pertinent Results:
ADMISSION LABS:
[**2164-8-8**] 04:55PM GLUCOSE-83 K+-4.0
[**2164-8-8**] 04:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2164-8-8**] 04:56PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2164-8-8**] 04:56PM PT-12.3 PTT-24.0 INR(PT)-1.0
[**2164-8-8**] 04:56PM PLT COUNT-176
[**2164-8-8**] 04:56PM NEUTS-63.8 LYMPHS-28.4 MONOS-5.2 EOS-2.1
BASOS-0.4
[**2164-8-8**] 04:56PM WBC-6.8 RBC-3.67* HGB-12.1* HCT-36.9*
MCV-101* MCH-33.0* MCHC-32.9 RDW-13.1
[**2164-8-8**] 04:56PM URINE GR HOLD-HOLD
[**2164-8-8**] 04:56PM URINE HOURS-RANDOM
[**2164-8-8**] 04:56PM estGFR-Using this
[**2164-8-8**] 04:56PM GLUCOSE-87 UREA N-19 CREAT-1.0 SODIUM-142
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-26 ANION GAP-14
DISCHARGE LABS:
[**2164-8-11**] 06:30AM BLOOD WBC-8.6 RBC-3.72* Hgb-12.7* Hct-37.4*
MCV-101* MCH-34.2* MCHC-34.0 RDW-12.9 Plt Ct-189
[**2164-8-8**] 04:56PM BLOOD Neuts-63.8 Lymphs-28.4 Monos-5.2 Eos-2.1
Baso-0.4
[**2164-8-11**] 06:30AM BLOOD Plt Ct-189
[**2164-8-8**] 04:56PM BLOOD PT-12.3 PTT-24.0 INR(PT)-1.0
[**2164-8-11**] 06:30AM BLOOD Glucose-94 UreaN-22* Creat-0.9 Na-137
K-4.2 Cl-101 HCO3-27 AnGap-13
[**2164-8-11**] 06:30AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.2
[**2164-8-10**] 08:13AM BLOOD %HbA1c-5.9
[**2164-8-10**] 04:50AM BLOOD Triglyc-67 HDL-47 CHOL/HD-2.7 LDLcalc-67
IMAGING:
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2164-8-8**]
4:20 PM
HEAD CT WITHOUT IV CONTRAST: There is an acute hemorrhage of the
left
thalamus which measures 2.3 x 2.5 cm. There is hyperdense blood
in the left
occipital [**Doctor Last Name 534**] (2:16) consistent with intraventricular extension
of the left
thalamic hemorrhage. There is edema surrounding the parenchymal
hemorrhage
but no shift of normally midline structures or hydrocephalus.
Basilar cisterns
are patent. There is mild prominence of ventricle and sulci
consistent with
age- related parenchymal involutional change. Periventricular
white matter
hypodensity is consistent with chronic microvascular ischemic
change. The
visualized paranasal sinuses and soft tissues appear
unremarkable. Soft
tissues are otherwise unremarkable.
IMPRESSION: Left thalamic hemorrhage with extension into the
left lateral
ventricle. Findings posted to ED dashboard.
Brief Hospital Course:
Mr. [**Known lastname 84416**] is an 81yo RHM with HTN, CAD and
hypercholesterolemia who felt extremely weak but worse on R and
had trouble expressing himself this mid-morning then found to
have L thalamic hemorrhage most likely hypertensive in etiology.
1. Left thalamic hemorrhage. Mr. [**Known lastname 84416**] was found to have a
left thalamic hemorrhage. This is often associated with severe
hypertension, however his blood pressure was not significantly
elevated on admission. His lipids were measured, and his LDL was
found to be 67. His statin dose was decreased from 80mg/day to
40mg/day. His blood pressure remained well controlled. He was
evaluated by PT, who found him to be safe for discharge with
home PT and safety evaluations. Exam on discharge was notable
for slight right pronator drift, and baseline poor vision.
Medications on Admission:
1. Plavix 75mg daily
2. Metoprolol XL 25mg daily
3. Lipitor - 80mg daily
4. Tylenol PRN
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Left Thalamic Hemorrhage
Discharge Condition:
The patient was hemodynamically stable. His neurologic exam was
notable a slight right side pronator drift and baseline poor
vision. Otherwise unremarkable.
Discharge Instructions:
You were admitted for evaluation of weakness. You were found to
have a bleed in your brain which was possibly due to high blood
pressure.
Because of your hemorrhage, you were seen by physical therapists
who have recommended a home therapy evaluation.
We have decreased your dose of Lipitor to 40mg (you reported
taking 80mg at home).
You should follow up with your primary care doctor in the next 2
weeks to discuss this hospitalization. You have been scheduled
for follow-up in the Neurology [**Hospital 4038**] Clinic with Dr. [**First Name (STitle) **] on
[**9-11**].
Please call your doctor or seek immediate medical attention if
you develop any worsening of symptoms of weakness, confusion,
headache, changes in vision or any other symptom of concern.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD
Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2164-9-11**] 11:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"348.5",
"414.01",
"V45.82",
"272.0",
"362.50",
"401.9",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8103, 8162
|
6849, 7691
|
309, 315
|
8231, 8392
|
4507, 4507
|
9202, 9455
|
2667, 2681
|
7830, 8080
|
8183, 8210
|
7717, 7807
|
8416, 9179
|
5325, 6826
|
2696, 2949
|
253, 271
|
343, 1911
|
3344, 4488
|
4524, 5308
|
2988, 3328
|
2973, 2973
|
1933, 2386
|
2402, 2651
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,157
| 109,176
|
41216
|
Discharge summary
|
report
|
Admission Date: [**2124-3-14**] Discharge Date: [**2124-3-27**]
Date of Birth: [**2094-3-2**] Sex: F
Service: MEDICINE
Allergies:
Unasyn
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
neck swelling
Major Surgical or Invasive Procedure:
left neck exploration and drain placement
intubation and mechanical ventilation
History of Present Illness:
30F with a history of [**Doctor Last Name 9376**] disease and chronic
pancytopenia/neutropenia who is re-admitted with reaccumulation
of fluid following initial drainage of posterior/parapharyngeal
abscess on [**2124-2-23**].
She initially presented ~3 weeks ago with neck/swallowing pain
and was found to have the above abscess on CT imaging, which was
drained and cultures ultimately grew beta streptococcus group A
and propionobacterium acnes. She was treated with meropenem for
this (changed to ertapenem upon discharge). Her initial
hospitalization ([**Date range (1) 61436**]) was complicated by intubation for
airway protection x several days, neutropenia (WBC nadir 0.6
with 67% neutrophils on [**2-26**]), anemia to Hct < 21 (received 2
units pRBCs). She also developed left IJ nearly-occlusive clot,
which was not felt to be septic in origin. After multispecialist
discussion, the decision was made not to anticoagulate as risks
were felt to outweigh benefits. She was seen by hematology
during that admission and started on Neupogen, which was stopped
when WBC count came > 3500. She had planned follow up as an
outpatient for ? BMBx in early [**Month (only) 116**].
After returning home, she initially stabilized and felt she was
beginning to improve; however, her husband noticed after several
days that she was developing increased swelling at the surgical
site as well as increased drainage. She also had increased pain
and developed nightsweats, though temps were in 99s (no true
fever). She came back to ED where CT scan showed re-accumulation
of fluid, and she was taken back to OR [**2124-3-14**] by ENT for
drainage. She spent the night in SICU for observation, where she
has done well from a surgical perspective (3 drains in place, no
airway compromise).
Currently she has minimal complaints of neck pain well
controlled with dilaudid PCA. Has no difficulty swallowing,
breathing or speaking.
Past Medical History:
#Neutropenia of unknown etiology - diagnosed 2 years ago,
baseline WBC 1.8, had serial blood tests in [**Location (un) 18317**] for 8 weeks
and as WBC stayed stable no treatment was initiated, had MRI at
the time but no bone marrow, has been told she has splenomegaly,
no history of prior serious infections or hospitalizations aside
from her pregnency though per husband she does take longer to
recover from minor infections
#[**Doctor Last Name 9376**] disease - diagnosed 2 years ago
#Fe deficiency anemia - not currently on iron supplementation
#Hx of Mononucleosis infection
#Warts on feet - on ranitidine, followed by dermatology
#Ovarian cystectomy
Social History:
Born in New [**Country 6679**] but has lived in MA for six years. Married
with no children (had child with hypoplastic left heart syndrome
who died at age of 2 days in [**2116**]). Works as Jet Blue flight
attendant. Non-smoker. [**1-23**] drinks/month. No drugs.
Family History:
Father with [**Doctor Last Name 9376**] syndrome, history of mono
Mother died of lupus in [**2116**]
Aunt with severe MS
Grandfather had cancer
No history of immune disorders, clotting or bleeding disorders
Physical Exam:
PHYSICAL EXAM: on transfer
VS - 99.9/99.2 122/70 86-89 18-20 97% RA
General: lying in bed, NAD,
EENT: pressure dressing around left side of neck, erythema and
swelling in the anterior neck
CV: RRR, normal S1, S2, -mrg
Pul: CTAB on anterior exam
GI: + bowel sounds, soft, non-distended, no hepatosplenomegaly
MSK: no joint swelling or erythema, non-tender to palpation over
her knees and upper leg with full ROM
Extremities: warm and well perfused, no edema
SKIN: no lesions or skin breakdown
NEURO: alert and oriented x3, CN 2-12 grossly intact with
decreased sensation over the ear and lower [**11-23**] of the left face
PSYCH: non-anxious, normal affect
Physical exam on discharge:
Vitals: tm 99.1, tc 98.6. 105-117/65-80, 72-93, 20, 99% RA
GEN: pale young woman w/ neck dressing in no acute distress
HEENT: left lateral neck incision with mild tenderness
CV: RRR normal s1/s2, no m/r/g
LUNGS: CTAB
Ab: normal bowel sounds, no masses, non-tender
Ext: 2+ pulses radial and dp
Skin: no rash evident
Neuro: alert and oriented x3, CN 2-12 grossly intact with
decreased sensation over the ear and lower [**11-23**] of the left face
Pertinent Results:
Admission labs:
[**2124-3-14**] 04:55PM BLOOD WBC-5.0 RBC-3.59* Hgb-10.1* Hct-31.5*
MCV-88 MCH-28.2 MCHC-32.2 RDW-14.0 Plt Ct-458*
[**2124-3-14**] 04:55PM BLOOD Neuts-72.8* Lymphs-22.2 Monos-0.4*
Eos-3.2 Baso-1.4
[**2124-3-14**] 04:55PM BLOOD Glucose-118* UreaN-15 Creat-0.4 Na-133
K-4.0 Cl-97 HCO3-28 AnGap-12
[**2124-3-15**] 01:20AM BLOOD ALT-16 AST-14 LD(LDH)-133 AlkPhos-110*
TotBili-0.5
[**2124-3-15**] 01:20AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.7 Mg-1.7
[**2124-3-14**] 05:04PM BLOOD Lactate-0.9
[**2124-3-14**] 08:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2124-3-14**] 08:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2124-3-14**] 08:30PM URINE UCG-NEGATIVE
.
Discharge labs:
[**2124-3-27**] 07:04AM BLOOD WBC-3.7* RBC-3.49* Hgb-9.6* Hct-30.1*
MCV-87 MCH-27.5 MCHC-31.8 RDW-14.6 Plt Ct-405
[**2124-3-25**] 06:36AM BLOOD Neuts-54.0 Lymphs-39.5 Monos-0.5*
Eos-5.1* Baso-1.0
[**2124-3-27**] 07:04AM BLOOD PT-12.4 PTT-37.6* INR(PT)-1.1
[**2124-3-27**] 07:04AM BLOOD Glucose-98 UreaN-9 Creat-0.4 Na-138 K-4.0
Cl-100 HCO3-30 AnGap-12
[**2124-3-26**] 06:53AM BLOOD ALT-351* AST-228* LD(LDH)-173 CK(CPK)-8*
AlkPhos-667* TotBili-0.7
[**2124-3-27**] 07:04AM BLOOD ALT-244* AST-72* CK(CPK)-9* AlkPhos-590*
TotBili-0.8
[**2124-3-27**] 07:04AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.8
.
Micro:
[**2124-3-14**] blood cultures x 2 - no growth final
[**2124-3-15**] blood cultures x 2 - no growth final
[**2124-3-14**] urine culture - < 10k colonies
[**2124-3-15**] L neck wound cultures x 2 - gram stain negative, no
bacterial growth final, no fungal growth prelim
[**2124-3-15**] MRSA screen negative
[**2124-3-18**] R PICC line catheter tip - no growth final
Imaging:
[**2124-3-14**] Radiology CT NECK W/CONTRAST:
TECHNIQUE: MDCT-acquired 2.5 mm axial images of the neck were
obtained following the uneventful administration of 70 cc of
Omnipaque intravenous contrast. Coronal, sagittal reformations
were performed at 2 mm slice thickness. FINDINGS: Extensive soft
tissue swelling throughout the superficial and deep spaces of
the left neck and abnormal thickening and enhancement of the
left sternocleidomastoid and posterior cervical muscles are
again seen (2:29). There is increased rim thickening and
enhancement of an organizing fluid collection along the left
neck extending posteriorly (2:33) since [**2124-2-28**], with a
dominant collection measuring 34 x 7 mm (2:28). Previously noted
drains have been removed with subcutaneous gas likely reflecting
packing material within a lateral incision (2:54). No bony
erosions are detected. There is improved retropharyngeal
swelling with decreased mass effect on the neighboring airway,
including slight restoration of the left piriform sinus and
decreased swelling of the left aryepiglottic fold and
epiglottis. The airway remains patent. No new fluid collections
are seen. There is no subcutaneous emphysema. Neighboring great
vessels remain patent, although there is continued marked
narrowing of the left internal jugular vein (2:34) as it passes
through the area of inflammation in the left neck. Included
views of the lung apices demonstrates minimal paraseptal
emphysema (301b:68). The thyroid is normal. IMPRESSION: 1.
Organizing rim-enhancing fluid collection concerning for an
abscess tracking along the left lateral and posterior neck,
overall slightly worsened since [**2124-2-28**], with increased
size of a dominant posterior collection measuring up to 8 mm,
and increased thickeness of an enhancing rind. 2. Improved
retropharyngeal swelling with decreased mass effect on the
neighboring airway, including slight restoration of the left
piriform sinus and decreased swelling of the left aryepiglottic
fold and epiglottis. 3. Removal of surgical drains with
subcutaneous gas in the left neck possibly reflecting packing
material within the surgical incision. 4. Continued severe focal
narrowing the left internal jugular vein as it courses through
the area of inflammation in the left neck.
[**3-25**] Liver U/S: Normal liver echotexture. No intra- or
extra-hepatic bile duct dilation. The gallbladder is collapsed.
Brief Hospital Course:
30F hx [**Doctor Last Name **] and idiopathic neutropenic who was recently d/c
s/p neck I&D of an infected abscess, now readmitted with
increased drain output and night sweats. Found with
reaccumulated fluid collection and s/p I&D/washout on [**3-14**].
#Neck abscess: Pt presented to the ED after having previously
undergone a left neck incision for a posterior parapharyngeal
abscess on [**2124-3-4**]. She was treated with IV antibiotics and
discharged with a PICC line and continued ertapenem. She
re-presented on [**2124-3-14**] to the emergency room noting several
days of increasing swelling around the surgical site with
increasing drainage and pain, as well as night sweats and
fevers. CT scan of the neck showed reaccumulation of fluid in
her left cervical region concerning for worsening infection, and
patient was taken emergently to OR by ENT for L neck exploration
and incision and drainage. Procedure was well-tolerated and
proceeded without issue; 3 penrose drains were placed. No
fevers/chills while in house and no signs of sepsis. Was able to
protect airway, breath/swallow comfortably post-op. Per ID, it
was not felt that this episode was antibiotic failure, so she
was continued on meropenem. She continued to spike temps >101
for the first few days post-op and eventually her fever curve
downtrended. The penrose drains were removed every 1-2 days
until the final drain was removed on [**2124-3-24**]. Her wound and blood
cultures did not grow any organisms. Pt was treated with
meropenem while hospitalized with initial plan to switch to
ertapenem 2 days prior to discharge. However, LFTs were found to
be elevated on [**2124-3-24**] and [**2124-3-25**], which ID felt may be due to
ertapenem. Pt was then switched to daptomycin with improvement
of her LFTs. She was discharged on daptomycin for an indefinite
treatment course as will be defined by her infectious disease
doctors.
# [**Month/Day/Year **]: LFTs were elevated on [**2124-3-24**] w/ AST 192, AST
184, AP 310, and normal T bili 0.7. Pt's LFTs were also elevated
during prior admission when she was on meropenem and
hydromorphone for pain control. She has also received several
grams of acetaminophen daily during this hospitalization.
Suspect that this is due to a drug effect. Acetaminophen was
stopped and hydromorphone reduced, but LFTs continued ot
increase. Abdominal exam completely benign. RUQ ultrasound also
showed no obvious pathology. ID felt that ertapenem may be
contributing to [**Last Name (LF) **], [**First Name3 (LF) **] this was switched for
daptomycin on [**2124-3-26**] with prompt resolution.
#Neutropenia of unknown cause: Baseline WBC per report ~1.8,
unclear etiology for her leukopenia. Had follow-up with
heme/onc for a ? of WHIM syndrome, was planned for a bone marrow
biopsy as an outpatient. ANCs were trended throughout without
requiring neupogen administration. She will follow-up in
outpatient hematology with Dr. [**Last Name (STitle) 6944**] in mid [**Month (only) **].
Transitional Issues:
-needs close monitoring while on daptomycin for resolution of
infection and myositis (with weekly CK)
-monitor LFTs for resolution of [**Month (only) **]
-needs continued workup for neutropenia
Medications on Admission:
3. bismuth subsalicylate 262 mg/15 mL Suspension Sig: Thirty
(30) ML PO QID (4 times a day) as needed for diarrhea.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*21 Tablet(s)* Refills:*0*
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*21 Tablet(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
8. ertapenem 1 gram Recon Soln Sig: One (1) Grams Intravenous
once a day.
Disp:*30 doses* Refills:*0*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*50 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Outpatient [**Name (NI) **] Work
Pt will need weekly CBC, Na, K, Cl, HCO3, BUN, Cr, Glucose, AST,
ALT, Total bilirubin, Alkaline phosphatase and have the results
faxed to [**Hospital **] clinic at [**Numeric Identifier 89785**], attention Dr. [**First Name (STitle) **].
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 2 weeks: Do not operate machinery or
drive on this medication. Do not mix with alcohol.
Disp:*50 Tablet(s)* Refills:*0*
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO once a day as needed for constipation for 2 weeks: use
daily for constipation while taking hydromorphone (Dilaudid).
Disp:*30 packets* Refills:*2*
7. daptomycin 500 mg Recon Soln Sig: 350 mg Recon Solns
Intravenous Q24H (every 24 hours).
Disp:*30 Recon Soln(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Neck abscess/infected fluid collection
Idiopathic neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You came to the hospital for worsening neck swelling and
drainage after your prior neck surgery. You had a scan, which
showed increased fluid in the previously drained areas of your
neck. Our ENT surgeons re-explored your neck and placed several
drains. You were seen by our infectious disease specialists, who
felt that your symptoms were due to incomplete drainage after
your first procedure. You were continued on antibiotics and your
wound and blood cultures did not grow any bacteria. Your ENT
surgeons slowly removed your neck wound drains and removed your
stitches. You will need to continue IV antibiotics for several
weeks to months. The exact duration will depend on your clinical
progress and the assessments of your ENT and infectious disease
doctors.
We have made the following changes to your medications:
START prochlorperazine maleate (Compazine) 10mg tablets, 1 tab
by mouth every 6 hours as needed for nausea
START docusate sodium 100mg capsules, 1 cap by mouth twice daily
START hydromorphone (Dilaudid) 2 mg tablets, 1-2 tabs by mouth
every 4-6 hours as needed for severe pain. Do not operate
machinery or drive on this medication. Do not mix with alcohol.
START polyethylene glycol (Miralax) 17g powder in packet, 1
packet dissolved in water by mouth daily as needed for
constipation
START daptomycin 350mg IV daily until instructed to stop by your
infectious disease specialist, Dr. [**First Name (STitle) **]
Please continue to take your other medications as previously
prescribed. We have made several appointments for you (see
below). We have also arranged for a nurse to come to your home
to administer your medication and to draw your blood labs.
Followup Instructions:
Department: OTOLARYNGOLOGY (ENT)
When: TUESDAY [**2124-3-28**] at 3:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: Primary Care
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **] for Dr. [**First Name8 (NamePattern2) 781**] [**Last Name (NamePattern1) 797**]
When: Thursday [**2124-3-30**] at 3:20 PM
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2124-4-5**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/BMT
When: WEDNESDAY [**2124-5-3**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD [**Telephone/Fax (1) 3241**]
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(1) 4236**]
|
[
"277.4",
"E878.8",
"E930.8",
"453.81",
"782.1",
"682.1",
"288.09",
"728.89",
"280.9",
"478.24",
"728.86",
"794.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"06.02",
"38.97",
"83.02"
] |
icd9pcs
|
[
[
[]
]
] |
14155, 14200
|
8870, 11872
|
281, 363
|
14306, 14306
|
4667, 4667
|
16191, 17619
|
3289, 3498
|
12988, 14132
|
14221, 14285
|
12114, 12965
|
14457, 15278
|
5449, 8847
|
3528, 4172
|
4200, 4648
|
11893, 12088
|
15308, 16168
|
227, 243
|
391, 2312
|
4684, 5433
|
14321, 14433
|
2334, 2991
|
3007, 3273
|
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