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67,578
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33541
|
Discharge summary
|
report
|
Admission Date: [**2173-5-4**] Discharge Date: [**2173-6-19**]
Date of Birth: [**2088-6-6**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p motor vehicle collision, multiple rib fractures and sternal
fracture
Major Surgical or Invasive Procedure:
[**2173-5-18**] tracheostomy
[**2173-5-27**] open gastrostomy tube and reduction of paraesophageal
hernia ([**Doctor Last Name **] Procedure)
History of Present Illness:
84 yo F s/p motor vehicle collision in which she was passenger
in car, sideswiped, sustaining multiple fractures to her left
ribs as well as her sternum. She sustained fractures to her left
3rd through 10th rib, with displacement of the 9th rib and
multiple fractures of ribs 6 and 7. She also had a sternal
fracture creating an anterior flail chest.
Past Medical History:
osteoporosis, HTN, DJD, compression fractures of T7, T8, T11 and
L1, L3, L4, and L5, thought to be old and related to her
osteoporosis.
Social History:
Lives with husband, retired.
Family History:
non-contributory
Physical Exam:
on admission:
VS: 97.6 72 152/64 18 95% on 4LNC
gen: A&O x3 GCS 15
pulm: Pt c/o pain in chest but without respiratory
embarrassment, able to maintain own airway
NCAT, CTA B, TTP in left chest, minimal anterior flail segment
without immediately obvious respiratory embarassment
CV: RRR
abdomen: S/NT/ND abd
pelvis stable
moving all extremities
Pertinent Results:
CT Cspine: No acute cervical fracture or malalignment. 3-mm
right upper lobe ground glass nodule for which 12-month follow
up CT is recommended if there are risk factors (smoking or
malignancy history); otherwise no further follow up is needed.
CT head: 1. No acute intracranial injury. 2. Age-related atrophy
and an old lacunar infarct. Minimal microvascular ischemic
disease.
CT torso: 1. No acute vascular injury. No acute solid organ
injury. No CTee air. No pneumoperitoneum. 2. Multilevel
minimally displaced left rib fractures. Multilevel compression
fractures, most severe at T11 and L1. Minimally displaced
manubrial fracture. 3. Small bilateral pleural effusions with
mild bilateral lower lobe atelectasis. Moderate hiatal hernia.
4. Moderate pneumobilia, predominantly in the left hepatic lobe,
secondary to prior sphincterotomy. 5. 7-mm right renal
hypodensity, incompletely assessed. An ultrasound can be
obtained for further evaluation. 6. 2-mm right middle lobe
pulmonary nodule. If the patient has a prior history of
malignancy or smoking, then 1 year CT follow up is recommended;
otherwise no further follow up imaging is needed.
Brief Hospital Course:
Ms. [**Known lastname 77751**] was admitted to the Trauma Surgery service for
pain management and pulmonary toilet. She was placed on her home
medications and given a regular diet. She did fairly well on the
floor initially, but was plagued by pewrsistent left chest pain
despite pain medication. She was therefore seen by anesthesia
for placement of an epidural catheter. On Hospital Day 4
however, the patient was noted to be complaining of dizziness
and sleepiness. A blood pressure was unable to be obtained
although she was mentating appropriately. Her HR was noted to be
38, and O2 saturation 88% on 2LNC. A 'code blue' was called and
the patient was transferred to the Trauma SICU for further care.
Her hospital course can be summarized by systems as follows:
Neuro: her mental status was fully intact at the time of
presentation, but worsened following the aforementioned code and
never really fully resolved thereafter. She remained intubated
and sedated for the vast majority of her hospital stay, and even
after tracheostomy she never fully awoke. She would move all
four extremities without focal neurologic deficits and would
only occasionally open her eyes to commands, but her overall
mental status remained poor and did not improve in any
significant way. In order to improve her oxygenation and
respiratory status, she was placed on paralysis during the week
of [**6-14**] but this was discontinued on [**2173-6-16**].
Respiratory: Due to increased work of breathing as well as her
central flail, the patient was unable to meet her own
respiratory needs. She ultimately underwent elective intubation
on [**2173-5-7**]. Due to inability to wean from the vent, she underwent
tracheostomy on [**2173-5-18**] at the bedside, which was uneventful.
She developed clinically significant bilateral pleural
effusions, for which chest tubes were placed in the OR on
[**2173-5-27**] which were subsequently removed. She underwent R
thoracentesis ast one point and also part of the rationale for
the reduction of her paraesophogeal hernia was the hope it would
improve ventilatory function. Her overall pulmonary status
never improved however and she did not wean from the ventilator.
Specifically, she remained on near full ventilatory support and
never tolerated trach collar trials. She had multiple episodes
of culture-proven pneumonia, including fungal pneumonia and
Klebsiella pneumonia. She was treated with a number of courses
of antibiotics, the last of which was meropenem and linezolid.
CV: For her bradycardia, the patient was placed at various times
on dopamine or epinephrine drips in order to keep her rate up.
She intermittently went from bradycardia to rapid afib requiring
multiple rounds of electrical and chemical cardioversion. During
one of her episodes of bradycardia, she had a brief episode of
asystole requiring compressions with restoration of a rhythm
approximately a minute later. Cardiology and EP had been
consulted and had been following along. Because of the episode
of asystole, the patient ultimately underwent placement of a
temporary pacing wire for suspected tachy-brady/sick sinus
syndrome. She intermittently required pressors for blood
pressure support but was eventually able to be weaned off. Her
external pacemaker was planned to be internalized by the
electrophysiology service, but she never became clinically well
enough for this to happen. She remained paced throughout the
course of her hospital stay, and required intermittent but
ultimately escalating vasopressor support over the week of [**6-14**].
GI: After intubation, the patient was initially receiving tube
feeds via an OG tube. She had a known hiatal hernia and had
intermittent difficulty tolerating tube feeds for this reason.
Discussion was undertaken with the family regarding the need for
nutritional support, and she ultimately underwent open G-tube
placement on [**2173-5-27**] with pull-down of the paraesophageal
hernia. Post-operatively, the patient initially tolerated her
tube feeds at goal without difficulty, but then developed high
residuals from her g-tube and sigificant constipation. After
many aggressive measures to facilitate a bowel movement
including a gastrograffin enema, she did in fact move her bowels
but never really tolerated tube feeds well.
Renal: She was significantly fluid overloaded throughout most of
her hospital stay, requiring aggressive diuresis and a lasix
drip. This improved her volume status significantly, but she
ultimately developed renal failure that was progressive on the
week of [**6-14**]. She became severely oliguric, and her creatinine
continued to rise to a level of > 2.0. It was felt that she
would require hemodialysis for renal replacement, and given her
overall clinical status and prognosis it was decided not to
proceed in this regard.
ID: She developed a number of infections throughout her hospital
stay, including Klebsiella and fungal pneumonia as well as VRE
bacteremia on the week of [**6-14**]. She was treated with
antibiotics directed at these pathogens, and was followed
closely by the infectious disease service.
Overall, she failed to make significant clinical improvement and
her multi-system organ failure worsened. Extensive discussions
were undertaken with her family, who expressed understanding of
her clinical status and decided not to continue heroic measures
to keep her alive.
Medications on Admission:
MVI, Ca, norvasc 5', lisinopril 10', atenolol 25'
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p Motor vehicle collision, rib fractures, respiratory failure,
renal failure
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
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47,800
| 111,942
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35479
|
Discharge summary
|
report
|
Admission Date: [**2107-2-24**] Discharge Date: [**2107-3-1**]
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Intraventricular hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 yo f with history of CVA x 3 (most recent last month) on
coumadin was found down and brought to OSH where she was found
to have a INR of 3.8 and an intraventricular hemorrhage on CT
scan. Patient was then transferred to [**Hospital1 18**] SICU.
Past Medical History:
CVA x 3 with residual right sided weakness
Thyroid disease
Social History:
Unable to attain secondary to mental status.
Family History:
Unable to attain secondary to mental status.
Physical Exam:
VS: T 97.6, BP 146/89, HR 75, RR 20, O2sat 98%4L
Gen: Elderly female in NAD, sleeping but arousable. Not very
cooperative but responds to questions appropriately. Mood,
affect appropriate.
HEENT: NCAT. Conjunctiva pink. No xanthalesma.
Neck: Supple with JVD to angle of jaw, no carotid bruit.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse crackles b/l on
auscultation of anterior lungs.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Neuro: Oriented to name, "hospital" and "[**Month (only) 956**]." Not
cooperative with most of exam but able to follow 1-step
commands. PERRL, EOMI. Face appears symmmetric. Moves all
extremities independently.
Pertinent Results:
[**2-24**]: Head CT: - intraventricular hemorrhage fills and expands
3rd ventricle, extends into right lateral ventricle, small
amount of blood dependently within left occipital [**Doctor Last Name 534**].
ventricular enlargment concerning for hydrocephalus. 2.5cm left
frontal calcified mass - ? meningioma. no surrounding edema
prior CT from OSH not currently available
.
[**2-24**]: Neck CT: no fracture, malalignment or prevertebral
swelling identified
.
[**2-25**] Head CT: No change in intraventricular hemorrhage or
ventricular size. Unchanged calcified left frontal meningioma.
.
[**2-25**] Head MRI: Unchanged left frontal meningioma. Unchanged
right intraventricular hemorrhage. Unchanged ventricular size.
.
[**2-26**] CT Head/Abd/Pelvis: Expected evolution of blood products
within the ventricular system with no new regions of hemorrhage
identified.
no RP bleed. patchy RML, RLL, LLL opacities concerning for pna
or pneumonitis
.
EKG demonstrated TWI in inferior leads and precordial leads with
TWI in V5-V6 new since prior done 12 hours earlier.
.
TELEMETRY demonstrated:NSR
.
2D-ECHOCARDIOGRAM performed on [**2107-2-26**] demonstrated: The left
atrium is mildly dilated. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with inferior akinesis and inferolateral
hypokinesis. The remaining segments contract normally (LVEF =
40-45%). Right ventricular chamber size is normal with mild
global free wall hypokinesis. The ascending aorta is mildly
dilated. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. An eccentric, posteriorly-directed jet of mild to
moderate ([**12-31**]+) mitral regurgitation is seen. There is mild
pulmonary artery systolic HTN. There is no pericardial effusion.
There is an anterior space which most likely represents a fat
pad. IMPRESSION: Mild regional biventricular systolic
dysfunction, c/w CAD (inferoposterior and ?right ventricular
infarction). Mild aortic regurgitation. Mild to moderate mitral
regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
Imaging at the OSH revealed right intraventricular hemorrhage
into the 3rd ventricle and expanding into the 4th ventricle. She
also has a left superior frontal calcified meningioma. She was
transferred to the SICU where she was managed conservatively in
the SICU with serial neurologic exams and head CT which remained
stable.
.
On [**2107-2-25**] she was noted to be hypotensive and bradycardic. EKG
showed ST elevations in the inferior leads and a peak CK of
1063. Given her hemorrhage, patient was managed conservatively
with aspirin 325mg, simvastatin 80 mg daily and low dose beta
blocker (lopressor 2.5mg IV Q6H). TTE performed showed
biventricular hypokinesis. On the day of transfer to the
cardiology floor [**2107-2-27**] she had two bradycardic episodes
associated with nausea and hypertension.
.
On the floor, patient remained somnolent but arousable, able to
answer simple questions and would follow commands. She denied
any chest pain or shortness of breath. Patient was monitored
closely on telemetry. Asymptomatic pauses of 3 seconds were
noted and beta blockers were discontinued. Patient remained
hemodynamically stable without symptoms of chest pain,
hypotension, shortness of breath, or further neurologic
deterioration during the rest of her admission. Cardiology
recommendation was to continue full strength aspirin and high
dose statin with baseline LFTs obtained near normal (ast 74, alt
21). Risk of bradyarrhythmia outweighed the benefit of
beta-blockade, and decision was made to hold this medication
indefinitely. She will follow up with a cardiologist at [**Hospital1 18**]
after she is discharged from rehab to further discuss medical
managament of her coronary artery disease. At the time of
discharge, there was no indication for a coronary intervention
in the future, but this will continue to be discussed on follow
up.
.
Her home thyroid regimen was confirmed prior to discharge. It is
recommended that she continue on ....
.
Patient should continue current medical therapy with aspirin and
simvastatin. Per neurology recommendations patient may restart
her coumadin on [**2107-3-12**]. Coumadin should be started at a low
dose (2.5 mg daily) given patient's supratherapeutic INR on
presentation. Her INR should be closely monitored after
restarting coumadin and her hematocrit should be monitored at
the time of coumadin initation and 1 week later. She should have
a repeat MRI performed to evaluate the status of her bleed and a
follow up appointment with Neurology to review the imaging.
These have been scheduled. Patient should also schedule a follow
up appointment with Dr. [**Last Name (STitle) **] in Cardiology clinic after her
discharge from rehab.
Medications on Admission:
Coumadin 1.25mg/2.5mg alternating days
Atenolol 25mg daily
Levothyroxine 75mcg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please do not start this medication until [**2107-3-12**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Right Intraventricular Hemorrhage
ST Elevation Myocardial Infarction
Atrial Fibrillation
Secondary:
CVA x 3 with residual right sided weakness
Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
You were transferred to [**Hospital1 18**] after you were found to have had
bleeding in your brain after a recent fall. You were admitted
to the ICU where you were closely monitored. During this
admission you had a heart attack. You were started on new
medications for your heart and transferred to the cardiology
floor. You tolerated the medication well without any further
events.
.
The following changes were made to your medications:
1) STOP coumadin can restart [**2107-3-12**] at 2 mg daily
2) START aspirin 325 mg daily
3) START atorvastatin 80 mg daily
4) START pantoprazole 40 mg daily
5) START senna 8.6 mg by mouth twice a day as needed for
constipation
6) START bisocodyl by mouth daily as needed for constipation
7) START docusate 100 mg by mouth twice a day
8) Continue levothyroxine 75mcg daily
.
Please continue all other home medications as previously
directed.
.
Please notify your physician or return to the hospital if you
experience fever, chills, chest pain, shortness of breath, new
neurologic problems or any other symptom that is concerning to
you.
Followup Instructions:
Please call the [**Hospital1 18**] Cardiology Clinic ([**Telephone/Fax (1) 62**]) after
discharge from rehabilitation to arrange a follow up appointment
with Dr. [**Last Name (STitle) **].
.
Please have a repeat MRI of your brain performed on [**4-8**]
at 2:35pm on the fourth floor of the [**Hospital Ward Name 23**] building on the
[**Hospital1 18**] [**Hospital Ward Name 516**]. Please call [**Telephone/Fax (1) 327**] if you need to
reschedule.
.
Please call the [**Hospital 18**] [**Hospital 878**] Clinic ([**Telephone/Fax (1) 2574**]) to confirm
your appointment with Dr. [**Last Name (STitle) **] currently scheduled for [**4-12**].
.
Please have your INR closely monitored after restarting your
coumadin on [**2107-3-12**].
|
[
"244.9",
"V58.61",
"E888.9",
"414.01",
"410.41",
"853.00",
"728.87",
"427.1",
"285.9",
"438.89",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7476, 7573
|
3771, 6475
|
245, 252
|
7776, 7785
|
1612, 1624
|
8911, 9648
|
691, 737
|
6612, 7453
|
7594, 7755
|
6501, 6587
|
7809, 8888
|
752, 1593
|
178, 207
|
280, 530
|
2091, 3748
|
552, 613
|
629, 675
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,555
| 113,264
|
51841
|
Discharge summary
|
report
|
Admission Date: [**2110-6-30**] Discharge Date: [**2110-7-3**]
Date of Birth: [**2061-3-23**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Intubation
Insertion of right-sided internal jugular catheter
History of Present Illness:
49 yo F with h/o DM, CHF, sleep apnea, morbid obesity,
cholelithiasis, DM2, and HTN presented to [**Hospital3 3765**] with
confusion. She noted decreased urine output over the previous 4
days as well as fatigue. Per report, pt had recently started
Klonopin and had decreased PO intake with some nausea and
vomiting. She denied fevers, chills, or pain. At [**Hospital1 **],
patient was found to be in ARF with elevated Cr to 8.0 (from
0.9) and K of 6.8 but no EKG changes. Patient was subsequently
transfered to [**Hospital1 18**] ED where she was given 1 amp of bicarbonate,
70mg of Kayexalate, NS x 1 L, CaCl, insulin 10 units with
dextrose. She also had a RIJ placed. Patient was also found to
have pH of 7.16, pCO2 59 (baseline 50s). HCO3 20. She was
poorly responsive and incoherent. BIPAP was initiated in the
ED. Initial ABG showed improvement in pH.
.
ICU course: On repeat ABG, pH was again 7.16 and pt continued
to be poorly responsive. She was intubated for airway
protection and acidosis management. She was put on IV fluids
with HCO3 for her ARF and acidosis. Her hyperkalemia was
managed with Calcium, Insulin and Dextrose, and Kayexelate, and
her potassium normalized. At the time of transfer to the floor,
the patient had been extubated. Her mental status had improved,
and she was alert and oriented x 3. Her Cr had decreased to 1.4
Past Medical History:
1. Arthritis - on methadone for pain
2. Asthma
3. Diabetes Mellitus - oral antihyperglycemics
4. Obesity - considered too high risk currently for gastric
bypass
5. OSA - supposed to be on CPAP at home
6, ? R sided heart failure from pulm HTN
7. Cholelithiasis - recent bout of cholecystitis, tx w/ abx,
needs ccy
8. Dysfuntional uterine bleeding - refused exam in past
9. Anemia - Hct ranges from 29-34 since [**4-11**], MCV 82, iron 27
10. Anxiety
Social History:
Supportive family. Lives w/ "husband" [**Doctor Last Name **]. Has 3 children, but
not all of them live together. No tob, no EtOH. On disability,
not working.
Family History:
non-contributory
Physical Exam:
97.7 94/45 17 97 [**Telephone/Fax (1) 107364**] getting intubated
General: obese female, opening eyes to voice, following
commands, incoherent,
HEENT: PERRL, anicteric, clear OP
Neck: obese, no JVD visualized
CV: distant HS, rrr
Lungs: CTAB/L anteriorly
ABd: larger protruberant, soft, no fluid wave, non-distended
extremities: mild edema, no cyanosis, no evidence of rash or
cellulitis.
Pertinent Results:
[**2110-6-30**] 06:30PM GLUCOSE-107* UREA N-131* CREAT-7.7*#
SODIUM-131* POTASSIUM-6.0* CHLORIDE-96 TOTAL CO2-20* ANION
GAP-21*
[**2110-6-30**] 06:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2110-6-30**] 06:30PM URINE HOURS-RANDOM UREA N-351 CREAT-217
SODIUM-23 CHLORIDE-17 TOT PROT-61 PROT/CREA-0.3*
[**2110-6-30**] 06:30PM WBC-7.5 RBC-3.82* HGB-10.6* HCT-30.5* MCV-80*
MCH-27.8 MCHC-34.7 RDW-14.8
[**2110-6-30**] 09:28PM TYPE-ART TEMP-36.5 O2-20 PO2-61* PCO2-52*
PH-7.21* TOTAL CO2-22 BASE XS--7 INTUBATED-NOT INTUBA
COMMENTS-O2 DELIVER
Brief Hospital Course:
49 y.o. F with morbid obesity, OSA, DM2 who presented with
mental status changes from ARF with hyperkalemia and acidosis.
.
# ARF - Etiology likely prerenal from dehydration, although
NSAID use may suggest intrinsic component. Cr resolved to 0.8
at time of discharge. Patient was educated re: need to watch
hydration when taking lasix and she was discharged on a low dose
(lasix 40mg po bid) to prevent recurrence of prerenal failure.
In addition, her aldactone and ibuprofen were stopped to prevent
any damage to kidneys until she could be assessed as an
outpatient.
.
# Respiratory distress-- patient was intubated for acidosis that
did not respond to IV bicarb as well as airway protection given
her poor mental status. She was extubated 1 day later. During
her hospitalization, she returned to her baseline oxygen
requirement of 2L nasal cannula at night and intermittently
during the day.
.
# Hyperkalemia--patient was admitted with potassium 6.8. She
did not have EKG changes. She was given Calcium, Insulin and
Dextrose, and Kayexalate. As her kidneys recovered, her
potassium normalized.
.
# Acidosis--was felt to be both metabolic from her renal failure
and respiratory from her baseline hypoventilation/CO2 retention.
- resolved with intubation and recovery of renal function
.
# Chest pain--patient had an episode of chest pressure which she
says was brought on by anxiety.
- Cardiac enzymes negative x 2, no EKG ST segment changes
- pt was given oxygen, morphine, and aspirin while being ruled
out for MI
- pt has no h/o MI, states that she often experiences chest
pressure during episodes of stress
.
# Anxiety
- on Celexa
- started Clonazepam 0.5 mg PO BID PRN--discharged on 1mg
Clonazepam in accordance with OMR record.
.
# Hypernatremia--most likely secondary to post-acute tubular
necrosis diuresis. Patient was given 1/2 NS and her
hypernatremia resolved.
.
# DM2 - RISS; hold metformin until discharge given recent
acidosis.
.
# BP - hypertensive at baseline, but metoprolol and lisinopril
were held during admission to prevent renal damage and b/c her
systolic BP was <120 during her stay.
.
# OSA/obesity hypoventilation - pt was maintained on inhalers
during her stay. She was advised to continue using CPAP on
discharge.
.
# Arthritis--patient takes methadone 10mg [**Hospital1 **] at home--this was
held during hospital stay because of her altered mental status.
Medications on Admission:
Advair 250/50 1 puff [**Hospital1 **]
Aldactone 25mg daily
Ambien 5 qHs
ASA 325mg daily
Celexa 40mg daily
Alb/Atroven INH q6 prn
Lasix 120 PO BID
Ibuprofen 800 prn
Lisinopril 5mg daily
Ativan prn
Metformin 850 [**Hospital1 **]
Metoprolol 50 PO BID
Prilosec 20mg [**Hospital1 **]
Simvastatin 10mg daily
METHADONE 10 MG [**Hospital1 **]
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation twice a day.
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
Primary Diagnosis: Acute Renal Failure
Secondary Diagnoses: Hyperkalemia, Acidosis, Obesity,
Obstructive Sleep Apnea, Diabetes mellitus, Anxiety
Discharge Condition:
Patient was alert and oriented x 3. Her renal failure and
hyperkalemia had resolved at time of discharge. Vital signs
were stable and she was at her baseline oxygen requirement of 2L
nasal cannula. She was assessed by PT, who recommended she go
home with home physical therapy, which was arranged.
Discharge Instructions:
1. Please return to the hospital if you develop increased
shortness of breath, confusion, or any other concerning symptom.
2. Please attend all follow-up appointments as listed below.
3. Please take all medications as prescribed. You will notice
the following changes:
- Please do not take your aldactone, ibuprofen, metoprolol, or
methadone until you see your doctor and get further
instructions.
- Please take lasix 40mg in the morning and 40 mg in the evening
until you see your doctor in the outpatient clinic.
Followup Instructions:
Provider: [**Name10 (NameIs) 14876**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2110-7-8**] 2:50
Provider: [**Name Initial (NameIs) 703**] (C4) TCC RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2110-8-14**] 2:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2110-8-14**]
4:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2110-7-6**]
|
[
"584.9",
"285.9",
"401.9",
"715.96",
"304.91",
"518.82",
"276.0",
"428.0",
"493.90",
"327.23",
"278.01",
"276.2",
"250.00",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.91",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7162, 7229
|
3447, 5846
|
276, 339
|
7418, 7721
|
2837, 3424
|
8285, 8836
|
2396, 2414
|
6231, 7139
|
7250, 7250
|
5872, 6208
|
7745, 8262
|
2429, 2818
|
7310, 7397
|
227, 238
|
367, 1731
|
7269, 7289
|
1753, 2203
|
2219, 2380
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,556
| 102,111
|
45636
|
Discharge summary
|
report
|
Admission Date: [**2159-8-22**] Discharge Date: [**2159-9-8**]
Date of Birth: [**2075-11-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Elective admission for resection of left sided meningioma
Major Surgical or Invasive Procedure:
Left craniotomy for resection of meningioma
History of Present Illness:
83 yo F with known left parasaggital meningioma, followed by Dr.
[**Last Name (STitle) **], who has had progressive right leg weakness and
difficulty walking over the past several months to a year. She
lives independently with her husband and it has become
increasingly difficult to walk. She is altering her gait and
using upper body strenght to walk and climb stairs. Her family
notes that she drags her leg when she walks. No pain, numbness
or tingling.
Work-up of right leg weakness included MRI thoracic and cervical
spine that show only mild degenerative changes and chronic T9
compression fx. She was found to have a left sided meningioma
and he is she is currently scheduled for elective craniotomy.
Past Medical History:
HTN, high cholesterol, oral lichen planus, left sided
parasaggital meningioma (as above), hypothyroid, Irritable bowel
syndrome, GERD, sciatica, aortic/mitral valve insufficiency,
recent PNA 3 weeks ago treated as outpatient.
Social History:
lives independently with husband, cooks and cleans
Family History:
NC
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs Full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 mm to
3 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing decreased to finger rub on right.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-31**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: finger-nose-finger and rapid alternating
movements decreased on right
Handedness Right
Pertinent Results:
[**2159-8-22**] CT Head at 15:00:
The patient is status post left frontal craniotomy approach
resection of a
left parafalcine meningioma as demonstrated on the preoperative
examinations. There is extensive pneumocephalus compatible with
post-surgical change. In addition, high attenuation material
compatible with hemorrhage is demonstrated within the resection
bed with small areas of pneumocephalus. There are low
attenuation areas in the resection bed compatible with edema.
The [**Doctor Last Name 352**]-white matter differentiation is preserved. The
ventricles and sulci are stable in size and configuration. The
visualized portions of the paranasal sinuses and mastoid air
cells are well aerated. There is no shift of normally midline
structures.
IMPRESSION: Status post left frontal craniotomy for resection of
a known left parafalcine meningioma. High-attenuation and low
attenuation regions within the resection bed compatible with
post-surgical hemorrhage and edema.
[**2159-8-22**] CT Head at 19:00:
FINDINGS: Again are noted post-craniotomy changes from a left
frontal
approach with skin staples and a small amount of subcutaneous
emphysema. A
significant amount of bifrontal pneumocephalus is noted, similar
to prior
study with displacement of the frontal lobes and extending into
the middle
cranial fossae. Again is seen in the left frontal resection bed
an
approximately 2 x 1.5 cm focus of intraparenchymal hemorrhage
with surrounding vasogenic edema, which is similar to slightly
decreased compared to prior study. There is no shift of midline
structures. There is no intraventricular hemorrhage or evidence
of hydrocephalus. There is no sign of herniation. The visualized
portion of the paranasal sinuses and mastoid air cells are
clear.
IMPRESSION: Status post left frontal craniotomy for left frontal
mass
resection, with stable appearance of left frontal hemorrhage in
the resection bed. Significant amount of pneummocephalus in the
bifrontal regions with displacement of the frontal lobes; while
this is not significantly changed from prior, correlate
clinically for tension pneumocephalus.
[**2159-8-23**] MR [**Name13 (STitle) **]:
S/post resection of the previously noted left frontal
extra-axial enhancing lesion, likely representing dural-based
lesion such as meningioma. Post-surgical changes are noted,
with presence of blood products at the surgical resection site.
There are also post-surgical changes noted in the adjacent bone
and dura. Small-to-moderate amount of pneumocephalus is noted in
the bifrontal regions. There is moderate amount of surrounding
edema. A few enhancing areas are noted in the surgical resection
site and residual tumor cannot be excluded.
In addition, there is a new moderate sized area of altered
signal intensity in the left parietal lobe, with hypointense
appearance on the T1 and hyperintense on the T2-weighted
sequence with some degree of decreased
diffusion concerning for an infarct in this location. Tiny foci
of negative susceptibility can relate to blood
products/mineralization. There is swelling/thickening of the
cortex with some enhancement on the post-contrast sequences.
There is also enhancement in the sulci in this location. The
appearance can relate to ischemia/infarction, venous
stasis/infarction/inflammatory changes.
There is a small amount of subdural fluid collection noted along
the convexity on both sides. MP-RAGE sequences are limited due
to patient motion-related artifacts. There is likely mild
meningeal enhancement.
The ventricles and extra-axial CSF spaces are otherwise
unremarkable, except for mass effect by the blood products in
the surgical resection site in the left lateral ventricle.
IMPRESSION:
1. Post-surgical changes in the left frontal surgical resection
site at the location of the previously noted meningioma, with
presence of blood products; pneumocephalus and small subdural
fluid collection extra-axially on both sides along with mild
meningeal enhancement.
2. Interval development of a moderate-sized area of altered
signal intensity in the left parietal lobe just posterior to the
surgical resection site, with some degree of decreased
diffusion, cortical swelling concerning for infarction, venous
stasis/infarction/inflammatory changes in this location,
acute-subacute. Followup evaluation to assess interval change
and confirmation of the nature of the abnormality is necessary.
[**2159-8-24**] Head CT at 01:00:
IMPRESSION: Increased intracranial hemorrhage on the left, now
involving the frontal and parietal lobes.
[**2159-8-24**] Head CT at 08:00:
IMPRESSION: Stable intraparenchymal hemorrhage in the left
frontal and left parietal lobes, with associated surrounding
edema and mass effect, unchanged from prior study. Given the
location, especially the left parietal intraparenchymal
hemorrhage as well as the appearance on MR, this raises the
possibility of a hemorrhagic venous infarct.
[**2159-8-24**] Head CT at 14:00:
IMPRESSION: No significant interval change from prior study.
Stable
intraparenchymal hemorrhage in the left frontal and parietal
lobes with
associated surrounding edema and mass effect, unchanged from
prior study.
Given the appearance of MR and the location of the parietal
intraparenchymal hemorrhage, this raises the possibility of
hemorrhagic venous infarct, as mentioned on most recent prior
study.
[**2159-8-25**] ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. 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
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and preserved global biventricular systolic
function. Mild aortic regurgitation. Borderline pulmonary artery
systolic hypertension.
[**2159-8-25**] Head CT:
IMPRESSION: No significant interval change compared to prior
study, with
extensive left frontoparietal multifocal parenchymal hemorrhage,
large region of surrounding edema and degree of mass effect,
unchanged. There is no evidence of uncal or other central
herniation.
[**2159-8-26**] Head CT:
IMPRESSION: No significant interval change in comparison to
prior study from [**2159-8-25**] with extensive left
frontoparietal multifocal parenchymal hemorrhages with a
possibility venous infarction laterally and significant moderate
amount of surrounding edema and stable mass effect.
[**2159-8-26**] CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Mild bilateral pleural effusions. Borderline size of the
cardiac
silhouette with retrocardiac atelectasis. Minimal enlargement of
the
pulmonary vessels, making minimal overhydration likely.
No newly appeared focal parenchymal opacities. Unchanged size of
the cardiac silhouette.
[**2159-8-27**] CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Mild bilateral pleural effusions. Borderline size of the
cardiac
silhouette with retrocardiac atelectasis. Minimal enlargement of
the
pulmonary vessels, making minimal overhydration likely.
No newly appeared focal parenchymal opacities. Unchanged size of
the cardiac silhouette.
[**2159-8-27**] MRI/V Brain
IMPRESSION:
1. New area of acute infarct in right cerebellar hemisphere.
2. Extensive left frontoparietal multifocal parenchymal
hemorrhage which is unchanged from the prior study. This
possibly represents venous infarction. Stable mass effect and
perilesional edema.
3.No evidence of thrombosis in the superior sagittal, transverse
and sigmoid sinuses.
[**2159-8-29**] CXR
IMPRESSION: Right apical opacity is indeterminate but has
reappeared. This likely represents an area of atelectasis. Right
lower lobe collapse has resolved.
[**2159-8-30**] CXR
IMPRESSION: No interval change of small bilateral pleural
effusion with
atelectasis. No evidence of congestive heart failure or
pneumonia.
[**2159-8-31**] Lower Extremity Venous Doppler US
IMPRESSION: Superficial nonocclusive thrombus within the mid
portion of the right basilic vein. No evidence of deep venous
thrombosis.
[**2159-9-6**] LENI's: CONCLUSION: No evidence of DVT in right or
left lower extremity.
Brief Hospital Course:
Pt was admitted to neurosurgery service for elective admission
and underwent a left sided craniotomy. She tolerated this
procedure well with no complications. Post operatively she was
taken to the CT scanner for a CT of the head to evaluate for any
post-operative hemorrhage. the CT showed that she had bled into
the resection cavity. A repeat scan was obtained 3 hours alter
which was improved from the prior. She was subsequently
extubated. She remained stable overnight into the morning of
[**8-23**] when she was examined and rounds and found to have no
movement of her [**Last Name (un) **], minimal TFR to noxious with her RLE and was
grossly full with her left side. She had some word finding
difficulties and was slightly perseverative as well. She
underwent MRI scan of the brain to assess the resection cavity
post-operatively which showed complete resection. On the evening
of [**8-23**] she was noted to have two seizures which was exhibited
by right sided rigidity and left side shaking and hiccuping. She
was started on a second anti seizure [**Doctor Last Name 360**], Keppra, continuous
EEG monitoring was ordered. Serial CT scans showed
intraparenchymal hemorrhage in the left frontal and left
parietal lobes, with associated surrounding edema and mass
effect. Dr [**Last Name (STitle) **] had a meeting with the family and discussed
the seriousness of this bleed.
On [**8-25**] she was reintubated for respiratory distress.
Post-intubation she was bradycardiac to the 20's and Atropine
was given. On [**8-26**], her exam was worse and her SBP was pressed
120-140; there was difficulty in doing this because of her
bradycardia.
On [**8-27**] her exam was stable and she was not following commands.
On [**8-28**] she continued with the EEG which showed some spikes so
her Keppra was increased. On the morning of [**8-29**] on rounds she
was noted to be following commands with the LUE and opening eyes
to voice which was an improvement in exam over the past few
days. Family meeting was scheduled for [**8-30**] and the family
decided to allow for more time for improvement in the patient's
mental status before committing to tracheostomy and PEG.
Right Upper extremity Doppler was performed on [**8-30**] due to
swelling and demonstrated only a superficial thrombus was
discovered, no evidence of occlusive DVT. It was managed with
warm compresses and elevation.
Patient was started on vancomycin on [**8-31**] for pneumonia. EEG
showed seizure activity
and we increased dilantin to 200 tid. The level was 9.1 on [**9-1**].
She was cultured for elevated WBC count to 16 on 8.7. She was
without seizure activity on EEG and her neuro checks were made
Q2 hrs.
Over the next several days she continued to have intermittent
focal seizures and her Keppra dose and dilantin dose were
uptitrated periodically to control seizure at the recommendation
of neurology.
Her neurological exam plateaued. She no longer opens her eyes
to voice and does not follow commands. She continues to move
her left side spontaneously and reflexively. She remains
hemiplegic on the right side. Additional family meetings were
held between the ICU attending and the family on [**9-3**] and between
the Neurosurgery attending (Dr. [**Last Name (STitle) **] and the family on
[**7-25**] to discuss the options of tracheostomy and PEG in the
setting of poor neurological prognosis. On [**9-7**] the patient self
extubated but was unable to maintain an airway. Attempt to
contact the family was made but there was no answer therefore
she was reintubated.
Family meeting was held and given the grim prognosis, goal of
care of changed to comfort measures only and patient was
extubated. Patient died on [**9-8**] and pronounced on [**9-20**]. Family
including husband, Mr. [**First Name8 (NamePattern2) 1312**] [**Known lastname 5066**] was at bedside and
family declined autopsy.
Medications on Admission:
norvasc, atenolol, lipitor, cozaar, levoxyl, MVI, k-dur,
prednisone
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Meningioma
Cerebral edema
Bradycardia
Cerebral venous infarct
Intercerebral parenchymal hemorrhages
seizure
respiratory failure
Discharge Condition:
Died on [**2159-9-8**]
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2159-9-8**]
|
[
"712.36",
"285.9",
"348.5",
"427.89",
"V66.7",
"E849.7",
"E878.8",
"345.50",
"275.49",
"401.9",
"997.02",
"244.9",
"518.81",
"530.81",
"272.4",
"721.1",
"225.2",
"697.0",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"38.91",
"33.24",
"96.6",
"38.93",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
15355, 15364
|
11330, 15208
|
354, 399
|
15535, 15559
|
2723, 8957
|
15612, 15646
|
1475, 1479
|
15326, 15332
|
15385, 15514
|
15234, 15303
|
15583, 15589
|
1494, 1691
|
257, 316
|
427, 1140
|
1943, 2704
|
9261, 11307
|
1706, 1927
|
1162, 1390
|
1406, 1459
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,687
| 129,273
|
7623
|
Discharge summary
|
report
|
Admission Date: [**2155-3-8**] Discharge Date: [**2155-3-11**]
Date of Birth: [**2073-6-5**] Sex: F
Service: MEDICINE
Allergies:
Opioid Analgesics / Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 Y F w/ PMH of HTN, hypercholesterolemia, widely metastatic
breast CA (to bones, lung, pleura, peritoneum, mediastinal and
inguinal lymph nodes), malignant pleural effusion requiring
intermittent drainage, s/p cytoxan, mtx cycle 2, presented to
clinic for a routine PRBC transfusion. While in clinic, she
complained of acute onset RUQ abdominal pain towards the end of
transfusion. She was therefore sent to the ED. While on transit
in the ambulance, she had an episode of nonbillous nonbloody
emesis. She also endorses 3 weeks of worsening shortness of
breath, productive cough with white sputum, fatigue, fevers and
chills and anorexia. In the ED, labs were concerning for new
abnormal LFTs with a predominantly cholestatic picture and CXR
showed BL pleural effusion R>L, and large R lung infiltrate
(with near white out) concerning for pneumonia. USS abdomen
showed ascites, gallstones without e/o acute cholecystitis. CT
abdomen showed GB wall thickening, gallstones, ? liver lesions,
but no e/o pancreatitis. CT chest showed BL pleural effusions, R
lung infiltrate. The patient was given IV vancomycin, flagyl,
zosyn and admitted to OMED for further management.
REVIEW OF SYSTEMS: The patient's son says that she has
deteriorated over the past month, with malaise and anorexia, new
onset jaundice. Prior to this, she was walking on the treadmill.
Recently, she has been in bed most of the day. Also remarkable
for worsening BL LE edema.
Past Medical History:
# Back pain with multilevel osseous metastatic disease in the
thoracic and lumbar spine
# HTN
# Hypercholesterolemia
# Left hip fracture [**2144**], s/p hemiarthroplasty.
MEDICATIONS
Furosemide 20mg daily
Quinapril 20mg daily
Prochloperazine 10mg prn TID nausea
Social History:
She does not smoke or drink. Currently lives with her son. Is
able to ambulate although back pain worse when [**Last Name (un) 27797**] or
walking. Able to cook on own and go to bathroom on own as well.
Family History:
Her father died at age 52 of an MI, her mother at 70 of an MI.
She has one son.
Physical Exam:
Vitals in ED - T:98.4 BP 180/82 HR:97 Sats: 97% 3L
Vitals on floor - T 98, BP 140/80, HR 90, sats 95% 2L
GENERAL: alert and fully oriented. Chronically ill looking but
pleasant and conversant, elderly Armenian female who was not in
acute distress.
SKIN: warm, well perfused
HEENT: scleral icterus. JVP +10, no LAD, MMM, OP without
erythema or exudate
LUNGS: Dull to percussion in the lower 1/3rd. Reduced breath
sounds R base with crackles. No bronchial breath sounds.
CARDIAC: tachycardic S1, S2, no rubs or gallops
ABD: Distended but soft, with fluid wave, mildly tender in RUQ
but [**Doctor Last Name **] negative. No signs of surgical abdomen.
HSM: no organomegaly
EXTR: LE's with 2+ pitting edema up past knees bilaterally, LUE
with lymphedema, no evidence of cellulitis
Pertinent Results:
Basic admission labs:
[**2155-3-7**] 09:30AM WBC-0.9* RBC-3.15* HGB-8.3* HCT-24.7* MCV-79*
MCH-26.5* MCHC-33.8 RDW-18.1*
[**2155-3-7**] 07:26PM GRAN CT-750*
[**2155-3-7**] 07:26PM NEUTS-66 BANDS-0 LYMPHS-34 MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2155-3-7**] 07:26PM GLUCOSE-122* UREA N-32* CREAT-1.2* SODIUM-141
POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
LFTs:
CT Abdomen:
IMPRESSION:
1. Markedly distorted internal anatomy due to severe vertebral
column changes and loss of anterior abdominal wall muscles,
which limits accurate evaluation of some of the visceral organs
such as pancreatic head and uncinate process which was not well
seen.
2. Gallbladder wall edema, generalized anasarca and ascites.
This likely
represents third spacing.
3. Bilateral pleural effusions loculated on the right with right
lower lobe opacity which could reflect post-obstructive
pneumonia with a component of atelectasis.
4. Multiple hepatic hypodensities, could represent simple cysts,
are unchanged.
5. Extensive osseous metastases with further loss of vertebral
body height as described above.
6. Bilateral common femoral vein thrombosis
[**2155-3-10**] CXR
AP chest compared to [**3-7**] through [**2158-3-10**]:19 a.m.
Mild-to-moderate pulmonary edema in the left lung has increased,
moderate left
pleural effusion stable, right lung airless due in large part to
large right
pleural effusion. Heart size is indeterminate. No pneumothorax.
Brief Hospital Course:
Ms. [**Known lastname 27798**] is a 81 year-old woman with metastatic breast
cancer including pulmonary metastases who presents with RUQ
pain, abnormal LFTs, and shortness of breath.
.
# Shortness of breath: Patient was tachypneic to 40, ABG showed
large A-a gradient. Likely contribution from tumor burden in
lungs, pleural effusions, pneumonia, volume overload. She was
given vancomycin and Zosyn to treat the possible pneumonia. She
may also have had one or multiple pulmonary emboli given DVTs
seen on CT, lower extremity edema, and chest pain. Lower
extremity Dopplers confirmed DVTs. Given this, the team felt it
would be appropriate to transfuse platelets to >50k and then
heparinize. However, the patient stated that she did not want
this intervention. She also declined therapeutic thoracentesis.
She was gently diuresed and given supplemental oxygen as neeed.
Late in the evening on [**3-9**] she developed respiratory distress
and was placed on NRB and was satting at 88%. She was
transfered to the ICU and was transiently placed on BiPAP. Her
Chest xray showed white out of the entire right lung as well as
portions of the left lung. It was determined that given her
underlying cancer thoracentesis would be ineffective and likely
would damage the lung further. Per her son she was made DNR/DNI
and then comfort measures only after diuresis did not improve
her oxygenation. She was given PRN morphine and appeared to
remain comfortable. She expired on [**2155-3-11**].
.
# Elevated LFTs and RUQ pain: The cause of this was unclear.
[**Name2 (NI) 1194**] may have been an episode of biliary colic with transient
obstruction causing t bili and alk phos bump. Elevated GGT
confirmed a likely biliary source, and fractionation of
bilirubin demonstrated an elevated conjugated fraction, likely
from the biliary pathology, as well as an elevated unconjugated
fraction, which may have had contributions from both the liver
issues and her recent transfusion. Haptoglobin and reticulocyte
count did not indicate evidence of hemolysis. There was
gallbladder wall inflammation on CT but no cholecystitis by US.
She stated that she would not want surgical evaluation or
consideration of percutaneous drainage. She was initially NPO
but was adamant that she should eat. Thus, her diet was
advanced. The pain did not recur, and her alk phos and t bili
trended down.
.
# Metastatic breast cancer: s/p CMF cycle 2. Likely few further
chemotherapeutic options. Further therapy was deferred to her
primary oncologist.
.
# HTN: She was normotensive. Her ACEl was held in the setting
of contrast load with CT and increase in creatinine
.
# FEN: replete lytes, low salt diet
.
# PPX: bowel prophylaxis, PPI, TEDS
.
# ACCESS: PIV
.
# CODE: DNR/DNI, confirmed with patient [**2155-3-8**]
.
# CONTACT: [**Name (NI) **], [**Name (NI) **], [**Telephone/Fax (1) 27799**]
.
Medications on Admission:
Furosemide 20mg daily
Quinapril 20mg daily
Prochloperazine 10mg prn TID nausea
Zoledronic Acid 4 mg every 3 months given [**2154-12-31**]
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2155-3-12**]
|
[
"196.1",
"197.2",
"E933.1",
"518.81",
"284.1",
"276.0",
"196.5",
"198.5",
"401.9",
"V10.3",
"453.40",
"272.0",
"197.0",
"197.6",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
7815, 7824
|
4720, 7594
|
336, 342
|
7876, 7886
|
3233, 3239
|
7943, 8118
|
2340, 2422
|
7782, 7792
|
7845, 7855
|
7620, 7759
|
7910, 7920
|
2437, 3214
|
1558, 1815
|
258, 298
|
370, 1539
|
3256, 4697
|
1837, 2100
|
2116, 2324
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,952
| 132,792
|
49764
|
Discharge summary
|
report
|
Admission Date: [**2118-10-7**] Discharge Date: [**2118-10-12**]
Service: MEDICINE
Allergies:
Nsaids / Erythromycin Base / Norpace / Atropine
Attending:[**First Name3 (LF) 6578**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
sigmoidoscopy
History of Present Illness:
[**Age over 90 **] year old female with dementia and multiple medical problems
presented from [**Hospital **] rehab with bright red blood per rectum and
clots with dropping hematocrit to 30 (baseline 35) while
anticoagulated with coumadin for mechanical MVR/AVR and A-fib.
The bleeding started after receiving a fleets enema on [**10-6**]. Her
INR at presentation was 2.3. She has a history of possible
ischemic colitis ([**5-6**]). On arrival to the ED she was
hemodynamically stable with HR 70's, BP 100's-120's over 50's to
70's. Her son reported that she had increased confusion. She was
given 1u FFP, 1mg Vit K and 1 L IVF in ED. Hematc rit was 27.2
and she continued to pass clots with bright red blood per
rectum. Gastric lavage via NG tube was negative. She was
transferred to the ICU. She could open eyes to voice and
remained noncommunicative in the ICU. Flex sigmoidoscopy by GI
to 30 cm showed colitis they considered consistent with ischemic
colitis in rectosigmoid junction (up to 15 cm). In the ICU, she
was treated with supportive care with PRBC transfusions and IVF.
At transfer to the floor, her hematocrit was stable at 27 and
she was eating a pureed diet at her baseline mental status. The
history is from the patient's chart, rehab home, and son.
Past Medical History:
CVA '[**08**]- persistant L neglect/hemipelegia
Dementia
AVR/MVR for rheumatic disease
A-fib
Aspiration History
CAD - MI '[**07**]
CHF
C.difficile
DM type II
Depression
Hearing Loss
Partially Blind
Urinary Incontinance
s/p CCY
GERD
Basal Cell Ca
Social History:
Lives in [**Hospital 100**] Rehab dementia unit. Eats pureed diet. Son is a
physician and active in her care planning.
Family History:
noncommunicative
Physical Exam:
Tc 97.8 Tm 98.9 P 78 BP 138/50 R 20 O2 95% on RA
Gen - Partially Blind, Hard of hearing, resting comfortably in
NAD
HEENT - PERRL, MMMI, malar rash, oropharynx clear
Cor- irreg rate, loud S2, III/VI SEM
Chest- CTA B
Abd - soft/NT/ND, no reaction to palpation, +BS
Ext - no c/c/e, decub on both heels
Neuro - hemipelegia and contracted on left side
In ED - Rectal - guaiac +, decreased tone, blood in vault
Pertinent Results:
Labs at discharge:
[**2118-10-12**] 07:10AM BLOOD WBC-8.4 RBC-3.41* Hgb-10.8* Hct-31.1*
MCV-91 MCH-31.6 MCHC-34.7 RDW-14.7 Plt Ct-183
[**2118-10-12**] 07:10AM BLOOD PT-15.3* PTT-32.3 INR(PT)-1.5
[**2118-10-12**] 07:10AM BLOOD Glucose-218* UreaN-21* Creat-0.9 Na-141
K-3.6 Cl-106 HCO3-27
[**2118-10-12**] 07:10AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0
.
Admission labs:
[**2118-10-7**] 06:00PM WBC-11.1* RBC-3.45* HGB-10.4* HCT-30.8*
MCV-89 MCH-30.3 MCHC-33.9 RDW-13.7 NEUTS-78.9* LYMPHS-14.3*
MONOS-5.0 EOS-1.5 BASOS-0.3
[**2118-10-7**] 06:00PM PT-18.9* PTT-40.5* INR(PT)-2.3
[**2118-10-7**] 06:00PM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-2.2
[**2118-10-7**] 06:00PM CK-MB-2 cTropnT-<0.01
[**2118-10-9**] 12:00AM BLOOD CK-MB-3 cTropnT-0.02*
[**2118-10-8**] 06:32PM BLOOD CK-MB-3 cTropnT-0.01
[**2118-10-7**] 06:00PM ALT(SGPT)-14 AST(SGOT)-12 LD(LDH)-224
CK(CPK)-115 ALK PHOS-95 AMYLASE-38 TOT BILI-0.6 LIPASE-32
[**2118-10-7**] 06:00PM GLUCOSE-216* UREA N-26* CREAT-1.2* SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
[**2118-10-7**] 06:18PM LACTATE-1.6
[**2118-10-7**] 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2118-10-7**] 11:45PM HGB-9.4* HCT-27.2*
[**2118-10-7**] 11:45PM PT-16.7* PTT-37.5* INR(PT)-1.8
.
CXR [**2118-10-7**]: Stable cardiomegaly with mild CHF. Left lower lobe
effusion. Atelectasis/consolidation in the left lower lobe.
CXR [**2118-10-10**]: 1) Significant interval improvement in bilateral
perihilar interstitial opacities consistent with improved
pulmonary edema. 2) Persistent left lower lobe atelectasis with
effusion.
.
Abd CT [**2118-10-7**]: no stranding, no thickening of bowel wall
except in rectum (no change), no free fluid
.
EKG - a fib with vent rate of 60-90bpm,, nl QRS, nl QT, ST dep
in V4-6.
Brief Hospital Course:
This is a [**Age over 90 **]-year-old demented female from [**Hospital3 **]
with history of diabetes, status post mitral valve and aortic
valve repair, coronary artery disease, status post
cerebrovascular accident, in atrial fibrillation admitted with
gastrointestinal bleed passing bright red blood and clots per
rectum.
.
Bright red blood per rectum: The patient presented with history
of prior episodes of small amount of bright red blood per rectum
and concern for ischemic colitis. She had been anticoagulated on
coumadin for mechanical heart valves and atrial fibrillation.
Before this admission, she had begun bleeding per rectum after a
fleets enema. In the ED, her anticoagulation was reversed with
vitamin K and FFP and she was transferred to the ICU for
supportive care. Since the NG lavage was negative and the blood
was bright red, lower GI bleed was suspected. Etiologies may
include ischemic bowel, hemorrhoids, or diverticular disease.
While the sigmoidoscopy was showed colitis possibly consistent
with ischemic colitis, her serum lactate was normal and she
lacked persistant fever. She was supported with IV hydration and
blood transfusions. She received 2 units PRBCs on [**10-8**] and the 1
unit on [**10-10**]. Since transfusion, the patient's hematocrit
remained relatively stable around 30. The abdominal CT showed no
evidence of mesenteric ischemia or obstruction. There was mild
thickening of the rectum, which was nonspecific in nature and
unchanged from the prior study. She is currently at her
baseline functioning and tolerating a pureed diet. The patient
had been noted to pass loose stools. Stool cultures were sent
however C. difficile toxin testing; however, due to copiouis
blood and mucous, the sample was sent to an outside laboratory
for toxin B testing and results are pending. Her hematocrit has
remained stable despite reinitiation of anti-coagulation with
warfarin. While heparin per IV had been initiated, it was
discontinued due to concern for rebleeding and patient
discomfort with serial phlebotomy. The patient's son, [**Name (NI) **]
[**Name (NI) 111**], was involved in discussions regarding the patient's
goals of care including endoscopy and anticoagulation. She was
discharged to rehab in stable condition with hematocrit near 30
and no evidence of further bleeding. She will need labs to
assess the extent of anticoagulation on warfarin and to monitor
her hematocrit.
.
Cardiovascular: Coronary artery disease. The patient was not
given aspirin considering her history of allergy to aspirin in
the context of a gastrointestinal bleed. Her Ace inhibitor has
been held for low blood pressure and it may be re-started once
she demonstrates a stable hematocrit and INR on warfarin. Adding
a beta-blocker to her medication regimen may be considered as
this has been shown to decrease mortality. We have deferred
doing so while in the hospital due to the potential for masking
a compensatory tachycardia in the context of her current
bleeding.
.
Congestive heart failure. The patient received a total of three
units packed red blood cells along with IV lasix as needed to
prevent volume overload. Her lung exam was clear at discharge.
Chest xray showed significant interval improvement in bilateral
perihilar interstitial opacities consistent with improved
pulmonary edema. She's also had persistent left lower lobe
atelectasis with effusion. If her blood pressure remains stable
without no further gastrointestinal bleeding, restarting her
home dose of Lasix should be considered.
.
Rhythm. The patient currently in atrial fibrillation. Her INR
was initially reversed with p.o. Vitamin K and FFP in the
context of acute gastrointestinal bleed. She briefly received a
Heparin drip that has since been discontinued due ot concern for
rebleeding and patient comfort. She had received Coumadin to
anticoagulate for history of atrial fibrillation with artificial
aortic and mitral valve. The therapeutic INR goal is INR 2 to 3
with daily monitoring.
.
Diabetes mellitus. The patient was maintained on one half of
her home dose of NPH while NPO. While eating, she received
standing NPH insulin as well as subcutaneous regular insulin per
sliding scale.
.
Hearing Loss. On [**10-11**], she started debrox 5 drops [**Hospital1 **] x 5 days
for moderate ear wax.
.
She is DNR/DNI per her health care proxy, her son, Dr. [**First Name4 (NamePattern1) 1399**]
[**Known lastname 29919**].
(h) [**Telephone/Fax (1) 104027**] (beeper) [**Telephone/Fax (1) 104028**] (w) [**Telephone/Fax (1) 104029**].
Medications on Admission:
Folic Acid qam
Coumadin (INR 2.5-3.5)
Lasix 120 qam
zoloft 30 qday
NPH 12u [**Hospital1 **]
Lansoprazole 30 qday
Lisinopril 2.5 qday
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Insulin Regular Human Injection
5. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Debrox 6.5 % Drops Sig: Five (5) Drop Otic [**Hospital1 **] (2 times a
day) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Ischemic colitis
Gastrointestinal bleeding
secondary:
Diabetes mellitus.
Status post aortic and mitral valve replacement secondary to
rheumatic heart disease.
Atrial fibrillation.
Coronary artery disease.
Cerebrovascular accident with residual left hemiplegia.
Urinary incontinence.
Gastroesophageal reflux disease.
Dementia.
Hemorrhoids.
Severe hearing loss.
Status post CCY.
Discharge Condition:
Good. No further bleeding per rectum and stable hematocrit.
Tolerating pureed diet.
Discharge Instructions:
Please take all medications as prescribed. Please monitor
coagulation laboratory tests and titrate coumadin dose for INR
goal of [**1-4**] unless the patient is actively bleeding. For bright
red blood per rectum, please check hematocrit and give blood
transfusion if the hematocrit has dropped.
Followup Instructions:
Patient is to be discharged to [**Hospital3 **] and be
followed by her physician at [**Name9 (PRE) 5595**].
|
[
"414.00",
"V43.3",
"412",
"427.89",
"250.00",
"578.1",
"V58.83",
"438.20",
"427.31",
"398.91",
"557.9",
"285.9",
"380.4",
"V58.61",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
9730, 9795
|
4416, 8970
|
284, 300
|
10216, 10302
|
2485, 2485
|
10645, 10756
|
2023, 2041
|
9154, 9707
|
9816, 10195
|
8996, 9131
|
10326, 10622
|
2056, 2466
|
217, 246
|
2504, 2833
|
328, 1599
|
2849, 4393
|
1621, 1869
|
1885, 2007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,456
| 180,122
|
26162
|
Discharge summary
|
report
|
Admission Date: [**2120-12-3**] Discharge Date: [**2120-12-8**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Salicylates
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Transferred to CCU with pericardial effusion/tamponade s/p VT
ablation.
Major Surgical or Invasive Procedure:
VT ablation (unsuccessful), PA line placement,
pericardiocentesis.
History of Present Illness:
88yoF with nonischemic dilated CM (EF 30%), 4+ AI, and history
of VT s/p [**First Name3 (LF) 3941**], PAF on coumadin and amiodarone, who presented to
cardiologist ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45945**], [**Hospital3 **]) on [**11-22**] with
persistent slow VT. Plan was made for VT ablation in early
[**Month (only) 404**]; on [**12-2**], Pt. became acutely SOB, worsening during night,
with increased orthopnea, presented to OSH on [**12-3**] in am. Pt.
also noted increased LE edema, DOE, but denied
palpitations/cp/pressure/PND. Pt. was found to be in slow VT
alternating with NSR.
.
Pt. was transferred to [**Hospital1 18**] for VT ablation. LV mapping was
limited, and a large apical scar was identified. SBP went from
140s to 100s and an intra-procedure echo showed a pericardial
effusion, which may have resulted from a small myocardial
perforation. Lidocaine 50mg was given to try to break VT; Pt.
became hypotensive and bradycardic, given atropine, and paced
out of VT. 375cc of bloody fluid was removed from the
pericardial space with marked improvement in systolic blood
pressure. The pericardial pressure decreased to 3mmHg after
removal of fluid. The cardiac index markedly improved to 3.1
L/min/m2 (from 1.6) after removal of fluid. For recurrent VT, a
second dose of lidocaine 50mg was given. The [**Hospital1 3941**] leads were
reprogrammed for AV-pacing at 100bpm to suppress VT. A
pericardial drain was left in place and the patient was
transferred in stable clinic to the CCU.
Past Medical History:
1. idiopathic hypertrophic cardiomyopathy/nonischemic.
2. h/o VT, with [**Company **] [**Last Name (un) **] DR [**Last Name (STitle) 3941**], last generator change
[**2-2**].
3. AS, 4+ AI, PAF, EF preserved on past records but recently
reported as 30%.
4. CHF with systolic and diastolic failure.
5. apical aneurysm with nonobstructive CAD on cath.
6. hypothyroidism.
7. CRI (Cr 1.6-2.0 as of [**2-2**]).
8. GERD.
9. chronic anemia, on epogen.
Social History:
Widowed, lives with son and daughter in law, independent of most
ADLs, ambulates with walker and cane, remote h/o occassional
tobacco use 60yrs ago, no EtOH or illicits.
Family History:
Non-contributory.
Physical Exam:
PE: VS: 97.0 | 97/35 | 100 | 26 | 97% on 4L NC | pulsus < 10
gen: NAD, pleasant and cooperative.
HEENT: no JVD, PERRL and EOM intact.
neck: supple, no masses, no LAD, R carotid artery bounding
pulse, no carotid bruits.
CV: tachycardic, regular rhythm, nl s1s2, iii/vi sem at LUSB
radiating to RUSB and LLSB.
chest: CTA b/l, no crackles or wheezes; pericardiocentesis tube
draining 150cc serosanguinous fluid.
abd: soft, nt/nd, +bs, no organomegaly.
extr: warm, well perfused, no cyanosis, clubbing. 2+ LE pitting
edema, 1+ dp pulses b/l. ankle erythema b/l.
neuro: a&ox3, cn ii-xii intact; motor, sensory, coordination,
and language grossly normal.
Pertinent Results:
ECG [**2120-12-4**]: AV-paced at 100bpm.
.
Cardiac Catheterization [**2120-12-4**]: Severe pericardial tamponade. 2.
Hemodynamic improvement with drainage of pericardial fluid.
COMMENTS: 1. Resting hemodynamics revealed elevated right- and
left-sided filling pressures (mean RA 13 mmHg, mean PCW 20mmHg).
PA pressure was mildly elevated at 38/15. The cardiac index was
moderately depressed at 1.6 L/min/m2. 2. Pericardial pressure
was elevated at 14mmHg and equal to right atrial pressure. 375cc
of bloody fluid was removed from the pericardial space with
marked improvement in systolic blood pressure. The pericardial
pressure decreased to 3mmHg after removal of fluid. The cardiac
index markedly improved to 3.1 L/min/m2 after removal of fluid.
3. The pericardial drain was left in place and the patient was
transferred in stable clinic to the CCU.
.
Echo [**2120-12-4**] (#1): There is a moderate sized circumferential
pericardial effusion that measures 2 cm anterior to the right
ventricle and slightly increases in size during the course of
the study with corresponding decrease in right ventricular
cavity size/compression/tamponade physiology. A large left
ventricular apical aneurysm is identified.
.
Echo [**2120-12-4**] (#2): There is a large (6cm) apical left
ventricular aneurysm. There is a moderate to large sized (2.5cm
anterior to the right ventricle) circumferential pericardial
effusion with evidence of right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology. Compared
with the prior study (images reviewed) of earlier in the day),
the findings are similar.
.
Echo [**2120-12-4**] (#3): There is a trivial/physiologic pericardial
effusion. Compared with the prior study (tape reviewed) of
[**2120-12-4**], the pericardial effusion has resolved and the right
ventricular cavity is expanded.
.
TTE [**2120-12-5**]: There is a large left ventricular apical aneurysm.
There may be thrombus in the aneurysm. Right ventricular chamber
size is small. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. The tricuspid valve leaflets are
mildly thickened. There is a small pericardial effusion. There
is a somewhat echodense pericardial region, particularly
posteriorly which may present residual organized effusion and/or
thickening. There are no echocardiographic signs of tamponade.
.
CXR [**2120-12-5**]: [**Year/Month/Day 3941**] device seen in place without evidence of
pneumothorax. Enlarged cardiac silhouette with pericardial
drains seen overlying the heart. Bilateral pleural effusions are
seen, without evidence of focal consolidations.
.
[**2120-12-8**] 06:50AM BLOOD WBC-2.7* RBC-3.37* Hgb-10.2* Hct-30.8*
MCV-91 MCH-30.2 MCHC-33.1 RDW-17.9* Plt Ct-155
[**2120-12-4**] 05:20AM BLOOD WBC-3.8* RBC-3.24* Hgb-10.2* Hct-30.0*
MCV-93 MCH-31.5 MCHC-33.9 RDW-18.1* Plt Ct-178
[**2120-12-4**] 05:20AM BLOOD PT-12.5 PTT-20.4* INR(PT)-1.0
[**2120-12-8**] 06:50AM BLOOD Plt Ct-155
[**2120-12-4**] 05:20AM BLOOD Glucose-92 UreaN-87* Creat-2.7* Na-143
K-4.9 Cl-99 HCO3-36* AnGap-13
[**2120-12-8**] 06:50AM BLOOD Glucose-88 UreaN-70* Creat-2.3* Na-145
K-4.0 Cl-103 HCO3-35* AnGap-11
[**2120-12-8**] 06:50AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3
[**2120-12-5**] 02:40AM BLOOD TSH-2.3
[**2120-12-5**] 02:40AM BLOOD T4-6.4
[**2120-12-5**] 04:08AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2120-12-5**] 04:08AM URINE RBC-0 WBC-18* Bacteri-MOD Yeast-NONE
Epi-0
[**2120-12-5**] 04:08AM URINE Hours-RANDOM Creat-80 Na-45
[**2120-12-5**] 04:08AM URINE Osmolal-361
Brief Hospital Course:
A/P: 88yoF with pericardial effusion/tamponade s/p VT ablation.
.
Pt. was transferred to CCU following an attempt at VT-ablation
for persistent slow VT, which was complicated by a small
myocardial perforation, which led to a pericardial
effusion/tamponade. The Pt. underwent pericardiocentesis in the
cath lab, and approximately 375cc of serosanguinous fluid was
drained. A drain was left in place, and was removed after 12
hours of no drainage, which occurred on day 2 following
catheterization. Pulsus, jugular venous distension and blood
pressure were followed closely.
.
After catheterization, the Pt. was treated with mexilitine (a
Class 1b antiarrhythmic), and amiodarone, and was initially
AV-paced at 100bpm. The Pt. was paced at a rate greater than
her usual VT-rate (90bpm) in order to decrease the probability
of conversion to VT. The Pt. remained in normal rhythm, and
after two days of mexilitine treatment, AV-pacing was switched
to 80bpm. The Pt. tolerated this well, and there were no
episodes of VT on continuous telemetry monitoring. The Pt. was
also continued on metoprolol.
.
The Pt. was initially volume overloaded on exam, with symptoms
of heart failure including shortness of breath, lower extremity
edema, dyspnea on exertion, and recently increased orthopnea.
These symptoms were likely secondary to poor forward flow
related to slow VT. A CXR showed no signs of cardiopulmonary
edema. The Pt. responded well to diuresis with lasix.
.
TTE revealed a large left ventricular apical aneurysm, which was
felt to be likely old/organized. The Pt. was treated with
heparin and transitioned to coumadin for Ppx against
thromboembolism/embolic stroke. The Pt. also has a history of
paroxysmal atrial fibrillation (PAF) and had previously been on
coumadin. Since the Pt. has a risk of re-bleed and re-effusion,
INR goal in the short term is conservative, at 1.5-2.0. This
goal can be increased in the future by PCP.
.
The Pt's hypoxia was initially worsened from her baseline of 2L
O2 via NC at home. The Pt. reported that her O2 had been
initiated several years ago due to her "heart problems". The
Pt. did maintain sats in the low-mid 90s on room air, but with
exertion/ambulation, she de-sat'ed to 80s. By the time of d/c,
she was stable on 2L NC. She was discharged on lasix 20mg QD;
this dose may be adjusted in the future based on volume status
and renal function.
.
On admission, the Pt. had a Cr of 2.7, which is elevated above
Pt's baseline of 1.6-2.0. It was thought that this may have
resulted from poor forward flow in the setting of slow-VT. With
diuresis and AV-pacing/rhythm control, Cr was trending toward
baseline at the time of discharge.
.
Regarding code status, the Pt. remains DNI, but patient did want
shocks if needed, and has an [**Year/Month/Day 3941**] in place.
.
Patient was evaluated by physical therapy during this admission.
Medications on Admission:
(list per pt, not sure of all doses)
1. lasix 40/20mg, QOD
2. coumadin for PAF
3. amiodarone 200mg daily
4. calcium and vitamin D
5. MVI
6. colace
7. metamucil
8. toprol 50mg QD
9. levoxyl 150/137mcg QOD
10. protonix 40mg [**Hospital1 **]
11. oxygen 2L at home
12. xanax 0.25mg [**Hospital1 **], 0.5mg QHS
13. epogen
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
3. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY ().
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for s/p vt abl.
Disp:*90 Capsule(s)* Refills:*3*
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal infection in abd folds.
Disp:*QS QS* Refills:*1*
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): dose per coumadin clinic, goal INR 1.5 - 2.0 .
Disp:*60 Tablet(s)* Refills:*2*
12. Epogen 10,000 unit/mL Solution Sig: One (1) Injection Q
tuesday.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
15. Lasix 40 mg Tablet Sig: 0.5 Tablet PO once a day: take one
half pill daily.
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Ventricular tachycardia
S/P perforation of ventricle resulting in pericardial
effusion/tamponade
Nonischemic cardiomyopathy with apical aneurysm
CHF
Hypothyroidism
CKD
GERD
Chronic anemia
Discharge Condition:
Fair, stable.
Discharge Instructions:
Take all medications as prescribed. Your coumadin dose has been
lowered. You should take 2.5 mg each night, with a new goal INR
1.5-2.0 for the next month while your heart heals. You should
have your INR check on [**2119-12-12**].
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 16072**] within 1-2 weeks
.
Have INR check on or before [**2119-12-12**].
.
Please Call Cardiology Clinic for a follow up appointment with
Dr [**Last Name (STitle) 23651**] within 1 week ([**Telephone/Fax (1) 9410**].
Completed by:[**2120-12-10**]
|
[
"425.1",
"585.9",
"584.9",
"427.31",
"V53.32",
"424.1",
"997.1",
"998.2",
"244.9",
"428.0",
"E878.8",
"V58.61",
"285.9",
"427.1",
"428.43",
"420.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"88.55",
"89.64",
"37.27",
"99.04",
"37.21",
"37.34",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
11855, 11906
|
6995, 9886
|
315, 383
|
12137, 12153
|
3325, 6972
|
12432, 12723
|
2621, 2640
|
10253, 11832
|
11927, 12116
|
9912, 10230
|
12177, 12409
|
2655, 3306
|
203, 277
|
411, 1951
|
1973, 2418
|
2434, 2605
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,355
| 195,690
|
47258
|
Discharge summary
|
report
|
Admission Date: [**2104-2-4**] Discharge Date: [**2104-2-7**]
Date of Birth: [**2049-8-29**] Sex: F
Service: MEDICINE
Allergies:
Toprol Xl
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
hemodialysis
Intubation
History of Present Illness:
54F with hx of ESRD on HD, HIV, asthma, HTN, brca presenting
with 28lb wt gain, increased LE swelling x 1 week, SOB. Pt was
due for HD today, but presented to ED instead.
.
In ED. Hyperkalemic with peaked T waves, treated with bicarb,
kayexelate and calcium for K 6.3. Initially clinically
stabilized then developed acute SOB, unable to obtain 02 sat was
emergently intubated. Became hypertensive to SBP 260s, on nitro
gtt. Repeat K 7, received more ca, insulin, D50 prior to ICU
admit.
Past Medical History:
HIV--dx [**2086**]. No opportunistic infections. Last CD4 ([**2100-12-17**]):
110. Last viral load ([**2100-12-17**]): 33,600. Has not been taking all
her medications, and her ID doctor and she are discussing a
"clean start"
ESRD--on HD since [**10-3**]. She has a permacath in the left side,
but this week has started using her R upper arm fistula.
h/o aseptic meningitis
h/o Bell's palsy
HTN
Asthma
Carpel tunnel
Panic d/o - reportedly takes 3-5mg klonapin daily
Nephrotic syndrome
Social History:
Social History: No smoking, history of cocaine use (positive tox
screen when requesting escalating narcotics)
Family History:
Mother, throat ca, colon cancer
Father, cad, dm
Physical Exam:
General Appearance: NAD, speaking in full sentences
Tmax-101 175/74, 98, RR 17-30, sat 98% on 3L/M
Tc 98.9
HEENT: [**Last Name (LF) 12476**], [**First Name3 (LF) **] facies
Neck: No JVD, supple
Cor: tachycardic, with unchanged flow murmur.
Lung: Decreased BS R > L
abd: bsx4, snt/nd, no ascites
Extremities: 1+ edema
Neuro: AxOx3
Pertinent Results:
[**2104-2-4**] 11:50PM COMMENTS-GREEN TOP
[**2104-2-4**] 11:50PM LACTATE-1.2
[**2104-2-4**] 11:33PM GLUCOSE-134* UREA N-93* CREAT-12.4*
SODIUM-139 POTASSIUM-7.1* CHLORIDE-96 TOTAL CO2-19* ANION
GAP-31*
[**2104-2-4**] 11:33PM CK(CPK)-451*
[**2104-2-4**] 11:33PM cTropnT-0.11*
[**2104-2-4**] 11:33PM CK-MB-10 MB INDX-2.2
[**2104-2-4**] 11:33PM WBC-10.2 RBC-3.39* HGB-11.2* HCT-34.0*
MCV-101* MCH-33.0* MCHC-32.8 RDW-16.8*
[**2104-2-4**] 11:33PM NEUTS-58.5 LYMPHS-31.1 MONOS-4.9 EOS-4.8*
BASOS-0.6
[**2104-2-4**] 11:33PM PLT COUNT-232
[**2104-2-4**] 11:33PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2104-2-4**] 11:26PM URINE HOURS-RANDOM
[**2104-2-4**] 11:26PM URINE GR HOLD-HOLD
[**2104-2-4**] 11:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2104-2-4**] 11:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2104-2-4**] 11:15PM URINE RBC-[**11-20**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-[**6-10**]
[**2104-2-4**] 08:42PM URINE HOURS-RANDOM
[**2104-2-4**] 08:42PM URINE GR HOLD-HOLD
[**2104-2-4**] 08:42PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2104-2-4**] 08:42PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2104-2-4**] 08:42PM URINE RBC-<1 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**6-10**]
[**2104-2-4**] 06:50PM GLUCOSE-103 UREA N-92* CREAT-12.5*#
SODIUM-140 POTASSIUM-6.3* CHLORIDE-98 TOTAL CO2-23 ANION GAP-25*
[**2104-2-4**] 06:50PM estGFR-Using this
[**2104-2-4**] 06:50PM CK(CPK)-414*
[**2104-2-4**] 06:50PM CK-MB-10 MB INDX-2.4 cTropnT-0.12*
[**2104-2-4**] 06:50PM WBC-7.6# RBC-2.92* HGB-9.9* HCT-29.4*
MCV-101* MCH-34.0* MCHC-33.8 RDW-17.6*
[**2104-2-4**] 06:50PM NEUTS-65.2 LYMPHS-22.8 MONOS-5.2 EOS-6.3*
BASOS-0.6
[**2104-2-4**] 06:50PM PLT COUNT-194
Brief Hospital Course:
#Respiratory failure. Potentially multifactorial, predominantly
in setting of fluid overload from under-dialyzing. In the
emergency room, patient became acutely short of breath. He was
intubated and transfered to the ICU. Pt had dialysis on first
and second day of admission. After first session, pt tolerated
spontaneous breathing trial and was extubated. Had HD on day 1
with 4.6 kg removed. Pt had HD with 5 kg removed on day 2.
Repeat CXR demonstrated marked improvement in overload and she
was transfered to the medical floor. On the medical floor, she
seemed back to baseline respiratory status. She was able to
ambulate without dropping her sats.
.
#Hyperkalemia. Peak K 7.1, peaked T waves on ECG. K decreased
with medical management. Pt's K stabilized with HD and was 4.0
at the time of discharge.
.
#HTN. Has history of HTN. Hypertensive urgency/emergency in ED
with SBP to 260s. Possibly multifactorial given history of panic
attacks/anxiety, ? med compliance, possible volume overload. BP
decreased with HD but rebounded to systolics of 200 with HR
around 100 in the unit. Nitro gtt d/c'd after initiation of HD
but then restarted initially before being dc'd again. Pt with
known hx of cocaine use, however tox sceens here were negative.
Pt was initially started on labetalol at 50 PO BID with
inadequate HTN control and then BP was controlled effectively
with labetalol 100 PO BID. She was restarted on her home meds
on the medical floor and her pressure was well controlled at the
time of discharge.
.
#ESRD on HD. Per OMR notes likely due to hypertensive
nephropathy. Typically gets HD in [**Location (un) **] MWF. Per dialysis
clinic pt frequently misses sessions or shows up late for
sessions. She recieved dialysis in house with success. Her
calcium acetate was increased because of increased phosphate.
She will resume her regular dialysis schedule as an outpatient.
.
#Asthma. Continued home meds: fluticasone, ipratropium,
albuterol
.
#HIV -under control per last ID note, Continued ARVs
.
#Anxiety/Depression continued clonazepam, fluoxetine
.
#BRCA: continued arimidex. Timing of surgery should be
discussed with her PCP and surgeon
.
#Anemia. Recent baseline HCT low to mid 30s, 29 and stable at
time of discharge. Her HCT should be followed by her PCP
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for SOB/ Wheeze.
2. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
3. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily): take with norvir.
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Betamethasone Dipropionate 0.05 % Ointment Sig: One (1)
application Topical twice a day as needed for itching.
6. Calcium Acetate 667 mg Tablet Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times
daily, also 2 tabs at bedtime.
8. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
12. Hydrocortisone 1 % Cream Sig: One (1) application Topical
twice a day as needed for rash: to face.
13. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Lamivudine 150 mg Tablet Sig: 0.5 Tablet PO once a day.
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
17. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
18. Serevent 21mcg Aerosol
2 puffs twice daily
19. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO ONCE WEEKLY ON SATURDAY ().
20. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO daily ().
21. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
22. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
End Stage Renal Disease
Acute Pulmonary Edema
Asthma
Hypertension
Discharge Condition:
stable, comfortable on room air, ambulating without desaturation
Discharge Instructions:
You were seen in the hospital for treatment of volume overload
and acute shortness of breath. Your shortness of breath
required a brief period of mechanical ventilation. You were
dialyized in the hospital and fluid was removed.
.
Your labetalol was increased to 100mg [**Hospital1 **]
We also increased your PhosLo to 2 tabs three times dailys with
meals.
.
Please resume your regular dialysis schedule as an outpatient.
.
We noted two small masses under your skin while in the hospital.
The ultrasound is consistent with benign reactions to the
heparin. Please ask your primary care physician to follow these
by examination.
.
Either return to the emergency room of call your primary care
physician if you have any chest pain, shortness of breath,
notice increased swelling in your legs, gain more than 3lbs or
any other symptoms of concern to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2104-2-13**] 3:30
.
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2104-2-12**] 7:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2104-2-12**] 8:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-2-22**]
11:30
Completed by:[**2104-2-8**]
|
[
"493.90",
"518.81",
"233.0",
"585.6",
"276.6",
"276.7",
"285.21",
"042",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7955, 7961
|
3798, 6096
|
288, 313
|
8071, 8138
|
1898, 3775
|
9040, 9548
|
1481, 1530
|
6119, 7932
|
7982, 8050
|
8162, 9017
|
1545, 1879
|
229, 250
|
341, 831
|
853, 1338
|
1370, 1465
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,938
| 168,826
|
13217
|
Discharge summary
|
report
|
Admission Date: [**2180-4-3**] Discharge Date: [**2180-4-6**]
Date of Birth: Sex: M
Service: CCU
CHIEF COMPLAINT: Status post syncope.
HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old
male with a history of coronary artery disease status post
myocardial infarction seven years ago, status post three
vessel coronary artery bypass graft seven years ago with
saphenous vein graft to left anterior descending coronary
artery, saphenous vein graft to posterior descending coronary
artery, saphenous vein graft to obtuse marginal one who has
been asymptomatic since who was in his usual state of health
this evening when he developed lightheadedness followed by
syncope and loss of bowel control while sitting in a chair
watching TV. His wife called EMS. He was found to have a
heart rate in the 20s to 30s with a systolic in the 100s to
110s. The patient was given Atropine without effect.
Systolic pressures dropped into the 70s and the patient was
transcutaneously paced on route to the hospital. At the
outside hospital the patient's potassium was found to be 8.0
and a creatinine of 2.5. He was treated aggressively with 1
amp of D50, 10 units of regular insulin, 1 amp of calcium
chloride. He was also given Digibind 5 vials for a Digoxin
level of 1.0. He was given Kayexalate and a temporary
transvenous pacer was placed and the patient was transferred
to [**Hospital1 69**].
The patient denies any history of chest pain, shortness of
breath, palpitations prior to this syncope. Currently he is
again without any chest pain or lightheadedness.
REVIEW OF SYSTEMS: He admits to increasing pruritus over his
entire body for the past two to three weeks. He also notes
decreased urine stream and decreased urine output over the
last few days. He also notes decreased appetite and
decreased po intake over the past few days. He denies any
orthopnea, paroxysmal nocturnal dyspnea, lower extremity
edema. Also of note he has been taking Aldactone for the
last two months along with potassium supplements and eating
bananas with breakfast. He has also been taking indomethacin
for the last week for a gouty attach of his right big toe.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post myocardial infarction/three vessel coronary artery
bypass graft in [**2173**]. 2. Gout. 3. Chronic renal
insufficiency per wife. 4. Cataracts status post surgery of
the left cataract.
MEDICATIONS ON ADMISSION: Aspirin 81 q.d., Aldactone 25
q.d., beta paced 80 b.i.d., Lanoxin .125 q.d., Lasix 40 q.d.,
Lipitor 40 q.d., Lopressor 25 b.i.d., Zestril 5 q.d., Indocin
prn. Loratadine prn. Xanax .5 q.h.s. prn, Xydone 325 prn,
Doryx 100, Medrol 4 prn.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is
married. No alcohol. No active tobacco. He smoked twenty
years ago times one pack a day.
PHYSICAL EXAMINATION: Temperature 97.3. Blood pressure
104/50. Pulse 67. Respiratory rate 21. Sating 98% on 2
liters nasal cannula. In general, the patient is alert and
oriented times three, pleasant and conversant. HEENT pupils
are equal, round and reactive to light. Extraocular
movements intact. No scleral icterus. Dry mucous membranes.
Oropharynx clear. Neck supple. He has a right IJ [**Last Name (un) 14097**] in
place with a temporary pacer wire. Lungs, there is scattered
crackles at the bases right greater then left. Heart
examination. Regular rate. S1 and S2. No murmur noted.
Abdomen soft, nontender. Positive bowel sounds.
Extremities, there is trace lower extremity edema
bilaterally. Skin examination the patient has warm, dry skin
with a slightly raised pink macular papular rash over his
abdomen and some linear petechia on his lower extremities
bilaterally. Genitourinary, the patient with mild swelling
of the foreskin at the ureteral meatus. No evidence of
balanitis. No erythema or discharge.
LABORATORIES AT THE OUTSIDE HOSPITAL: White blood cell count
13.6, hematocrit 35.6, platelets 371, potassium 8.0, BUN 53,
creatinine 2.8, glucose 201. On arrival at the [**Hospital1 346**] the patient's white count 9.2, 72%
polys, 15% lymphocytes, hematocrit 31.7, platelets 301,
potassium 6.2, BUN 49, creatinine 2.6, coags normal. First
CK 46, calcium 9.4, phos 5.0, magnesium 2.7, potassium 6.4.
Chest x-ray revealed pulmonary edema. Pacer wire in
position. Arterial blood gas 7.39, 33, 64 on 2 liters nasal
cannula.
HOSPITAL COURSE: 1. Ischemia: The patient with a history
of coronary artery disease status post three vessel coronary
artery bypass graft in [**2173**] given new onset of complete heart
block, although the patient had no electrocardiogram changes
consistent with ischemia. The patient was ruled out with
three sets of negative enzymes. The patient was continued on
aspirin. He will need an outpatient stress test at some
point to determine if there is any new inducible ischemia
after his previous coronary artery bypass graft.
2. Pump: The patient is hypotensive on arrival. He was on
Dopamine at the outside hospital, however, did not require
pressor support during this stay. The patient was bolused
with normal saline, 250 cc during the first two days of
hospitalization with good improvement in his urine and his
blood pressure and urine output. The patient was then
restarted on his Lopressor and eventually was restarted on
his Cozaar and Betapace as well. Zestril was held. The
patient's blood pressure remained stable throughout. Repeat
echocardiogram revealed an EF of 20%, multiple regional wall
motion abnormalities. No significant change since
echocardiogram in [**Month (only) 958**] at outside hospital. The patient
continues Cozaar for afterload reduction. Digoxin was
discontinued.
3. EP: The patient was admitted with complete heart block
secondary to hyperkalemia. The patient's potassium and
creatinine corrected. The patient regained his normal sinus
rhythm. Temporary pacing wire was pulled after 48 hours and
the patient was restarted on his Betapace. Again Digoxin was
held. The patient did have one rune of twelve beats of
nonsustained ventricular tachycardia in the setting of a low
magnesium. The patient's magnesium was repleted and the
patient had no further ectopy. Cardiologist was notified and
the patient may need EP study ICD in the near future.
4. Renal: The patient with acute renal failure. Baseline
creatinine unknown, but per wife was abnormal. On obtaining
further records the patient's creatinine was 1.2 in [**Month (only) 205**] and
then increased to 1.9 early this year. The patient was
admitted with a creatinine of 2.8. The patient was hydrated.
Renal toxic medications such as Indocin, Aldactone, Zestril
and Digoxin were held. The patient's creatinine continued to
improve from 2.6 down to 2, eventually down to 1.4 and then
upon discharge the patient's creatinine was 1.0. The patient
also had a renal ultrasound, which was negative for
obstruction, however, revealed a question of an echogenic
mass in the left upper pole. The patient will need an MRI of
his kidney to further elucidate what this is, although likely
represents a duplication of the collecting system. Given the
patient's anxiety and claustrophia he denied an MRI. The
patient will need to follow up with his primary care
physician. [**Name10 (NameIs) **] primary care physician was notified prior to
discharge. The patient's urinalysis and urine cultures were
negative. Phena was less then .3 indicating a prerenal
picture again with cessation of renal toxin medications and
gentle fluids, the patient's creatinine improved to baseline
at 1.0.
5. FEN: Patient was admitted with a potassium of 8.0 likely
secondary to recently starting Aldactone, using Indocin for
gout and worsening renal function. Also the patient was
supplementing with po potassium in the presence of an ace
inhibitor. The patient's potassium, Zestril, Aldactone and
Indocin were held as the creatinine improved. The patient's
potassium also improved. The patient was given an additional
D50 and 10 units of insulin along with Kayexalate and 2 amps
of calcium chloride. The patient's potassium was 6.4 in the
[**Hospital1 69**] Emergency Room, which
decreased down to 5.7 and eventually down to 4.9 and upon
discharge the patient's potassium was 4.2. The patient was
restarted on standing Lasix as well. The patient's Foley was
discontinued with good urine output and continued decrease in
his creatinine.
6. Psychiatric: Patient with a history of anxiety. Per
some family members the patient was deemed unsafe to return
home, however, after psychiatric consultation was obtained
and further discussion with the family all parties felt that
it was safe for the patient to go home on his prn Xanax to
follow up as an outpatient for further neurocognitive testing
to workup the diagnosis of question of dementia.
DISCHARGE DIAGNOSES:
1. Hyperkalemia.
2. Acute renal failure.
3. Complete heart block.
4. Gout.
5. Coronary artery disease status post myocardial infarction
and three vessel coronary artery bypass graft in [**2173**].
DISCHARGE MEDICATIONS: Aspirin 81 mg q.d., Lipitor 40 mg
q.d., Lopresor 25 b.i.d., Betapace 80 b.i.d., Cozaar 25 q.d.,
Lasix 40 q.d., Xanax .5 q.h.s. prn, Medrol .4 prn. The
patient is to stop taking Digoxin, K-Dur, Zestril and
Aldactone.
DISCHARGE CONDITION: Stable.
DISCHARGE FOLLOW UP: The patient is to follow up with his
primary care physician regarding further neuropsychiatric
testing and MRI of his head and workup of left upper pole
renal mass with MRI versus CT of the abdomen and kidneys.
The patient needs his potassium and creatinine checked in one
week or the patient needs an electrocardiogram in one week
for evidence of heart block/bradycardia. The patient is to
be counseled for the use of non-steroidal anti-inflammatory
drugs for gout. The patient is also to follow up with his
cardiologist for management of his cardiac medications,
future exercise stress testing and a possible
electrophysiology study and internal cardiac defibrillator.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2180-4-6**] 15:56
T: [**2180-4-7**] 07:04
JOB#: [**Job Number 40300**]
|
[
"426.3",
"427.89",
"593.9",
"276.7",
"293.0",
"275.2",
"428.0",
"782.1",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9377, 9396
|
8910, 9113
|
9137, 9355
|
2465, 2705
|
4451, 8889
|
9408, 10346
|
2892, 4433
|
1615, 2185
|
143, 165
|
194, 1595
|
2208, 2438
|
2722, 2869
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,471
| 108,658
|
8563
|
Discharge summary
|
report
|
Admission Date: [**2127-7-14**] Discharge Date: [**2127-7-19**]
Date of Birth: [**2089-12-13**] Sex: F
Service: CSU
CHIEF COMPLAINT: Atrial mass.
HISTORY OF PRESENT ILLNESS: The patient is a 37-year old
female with a right atrial mass that was found on
echocardiogram. The patient was hospitalized in [**Month (only) 958**] of
this year for an asthma exacerbation. The patient underwent
an echocardiogram to follow up for a high-dose steroid use.
The echocardiogram revealed a right atrial mass. The patient
had reported six to seven weeks of a low-grade fever with a
temperature of 99 to 100. The patient was placed on Ceftin
for a positive urinary tract infection, and since then she
has had no fevers. The patient reportedly had received 125
mg of Solu-Medrol two days prior to admission for an asthma
exacerbation. The patient's Perm-A-Cath (through which she
was receiving gamma globulin) was discontinued under local
anesthetic on Friday - three days prior to admission. She
complained of no pain since that time.
The patient had an echocardiogram in [**Month (only) 958**] of this year with
an ejection fraction of 65 percent and a right atrial mass of
2 cm x 2 cm.
PAST MEDICAL HISTORY: The patient has a significant history
of asthma, chronic obstructive pulmonary disease,
hypertension, morbid obesity, degenerative disc disease,
systemic lupus erythematosus, sleep apnea, hypoglycemia, skin
cancer, renal calculi, steroid-induced myopathy of the spine,
and rheumatoid arthritis.
PAST SURGICAL HISTORY: The patient is status post
laparoscopic cholecystectomy, bilateral temporal artery
biopsy, and right subclavian Port-A-Cath placement.
ALLERGIES: She is allergic to BETADINE, ERYTHROMYCIN, SULFA,
AMOXICILLIN, AUGMENTIN, CIPROFLOXACIN, VASOTEC, BIAXIN,
TETRACYCLINE, XOLAIR, OXYCONTIN, ETODOLAC, PSEUDOEPHEDRINE,
and GUAIFENESIN.
MEDICATIONS AT HOME:
1. Albuterol nebulizer twice per day.
2. Atacand 8 mg by mouth once per day.
3. Celexa 10 mg by mouth once per day.
4. Pulmicort nebulizers three times per day.
5. Zantac 150 mg by mouth twice per day.
6. Singulair 10 mg by mouth once per day.
7. Gamma globulin infusion 84 grams every three weeks.
8. Ambien 2.5 mg by mouth as needed.
9. Nasonex 2 squirts as needed.
10. Verapamil 280 mg by mouth once per day.
11. Topamax 50 mg by mouth once per day.
12. Uniphyl 400 mg by mouth twice per day.
13. Weekly intramuscular allergy injections.
14. Ceftin 500 mg by mouth twice per day (for the past
two weeks).
FAMILY HISTORY: Mother is alive at the age of 67. Father
died at the age of 51 - killed in a motor vehicle accident.
SOCIAL HISTORY: The patient denies smoking or the use of
alcohol. The patient is disabled and lives with her husband.
The denies the use of cocaine or marijuana.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's
temperature was 99.3, her pulse was 86, her blood pressure
was 138/78, respiratory rate was 18, and she was saturating
96 percent on room air. The patient was generally obese,
alert, and oriented. The patient had no obvious lesions on
the skin. The patient's pupils equal, round and reactive to
light. The extraocular movements were intact. The sclerae
were anicteric. The eyes were not injected. There were no
bruits heard. There was no jugular venous distention on the
neck. There was no lymphadenopathy. The patient's lungs
were clear to auscultation bilaterally. The patient had a
well-healed right Port-A-Cath site. Cardiovascular
examination revealed first heart sounds and second heart
sounds heard. A regular rate and rhythm. There were no
murmurs. The patient's abdomen was obese and healed. The
extremities were warm and well perfused. There was no
clubbing, cyanosis, or edema. The patient's neurologic
examination was grossly intact. The patient had good 2 plus
dorsalis pedis pulses bilaterally and 1 plus posterior tibial
pulses bilaterally.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
hospital and underwent a repeat urinalysis and complete blood
count.
The patient was admitted to the Cardiac Surgery Service and
an evaluation for low-grade fever prior to her surgery. The
patient had a repeat urinalysis and straight catheter
urinalysis recommended by Infectious Disease. We obtained a
consultation from them, who felt that the patient did not
have a urinary tract infection and that there was no need for
her to continue antibiotic coverage. Thus, from that
standpoint, was able to go to the operating room. The repeat
urinalysis was negative with the straight catheterization.
The patient's white blood cell count was 13.5 preoperatively;
however, the patient had Solu-Medrol three days prior. Thus,
this was not a concern. Infectious Disease recommended that
the patient may go to the operating room without antibiotics.
The patient underwent a right atrial removal. On
postoperative day one, the patient was extubated. She
remained neurologically intact and remained in a sinus rhythm
with good pressure without any clips. The patient was
saturating 97 percent on 2 liters. She was able to take
clears without any difficulties. She had a low-grade
temperature of 100.1, but this temperature defervesced. The
patient's creatinine was 0.6. Otherwise, she was doing well.
The patient's chest tubes were removed due to low chest tube
output, and she was advanced to a cardiac diet.
On postoperative day two, the patient was doing well. The
patient was on the floor. She was afebrile with stable vital
signs. The patient was put on Toradol for pain management.
There were no major issues.
On postoperative day three, the patient remained afebrile
with stable vital signs. The patient was put back on her
home medication and was given Dilaudid and Motrin for pain
management and was discharged home.
MEDICATIONS ON DISCHARGE:
1. Verapamil 280 mg by mouth once per day.
2. Celexa 10 mg by mouth once per day.
3. Zantac 150 mg by mouth twice per day.
4. Theophylline 400 mg by mouth twice per day.
5. Atacand 8 mg by mouth once per day.
6. Pulmicort nebulizer three times per day.
7. Colace 100 mg by mouth twice per day.
8. Dilaudid 2 mg to 4 mg by mouth once per day.
9. Motrin 600 mg by mouth three times per day (for three
days).
10. Tylenol as needed.
11. Albuterol as needed.
DISCHARGE FOLLOWUP: The patient was instructed to follow up
with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in four weeks.
The patient was instructed to follow up with Dr. [**First Name (STitle) **] in
one to two weeks.
DISCHARGE STATUS: Discharged home with Visiting Nurses
Association.
CONDITION ON DISCHARGE: Good.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Doctor Last Name 6052**]
MEDQUIST36
D: [**2127-7-19**] 12:21:58
T: [**2127-7-19**] 14:06:55
Job#: [**Job Number **]
|
[
"496",
"714.0",
"710.0",
"278.01",
"E932.0",
"212.7",
"359.4",
"715.90",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"89.61",
"39.61",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
2557, 2660
|
5878, 6347
|
1902, 2540
|
1549, 1881
|
3983, 5852
|
155, 169
|
6368, 6656
|
198, 1206
|
1229, 1525
|
2677, 3954
|
6681, 6931
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,850
| 126,087
|
7023
|
Discharge summary
|
report
|
Admission Date: [**2157-11-13**] Discharge Date: [**2157-11-15**]
Date of Birth: [**2122-9-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Seizures, recurrent
Major Surgical or Invasive Procedure:
None
History of Present Illness:
35F with ETOH abuse, h/o seizures, and Hepatitis C s/p recent
fall out of bed at home and possible head bleed on prophylactic
antiepileptics presenting with witnessed seizures x 3 today. Per
patient's fiance, patient was noted to be tremulous this am and
then had witnessed seizure so he called 911. Per fiance, she was
tremulous this morning stating she needed a drink then had
bilateral upper and lower extremity shaking then fell from
standing position hitting the bridge of her nose and was
unresponsive for approximately 1 minute. Fiance called 911 and
she subsequently had second seizure when ambulance arrived with
tongue biting. Per fiance, she typically drinks 1L vodka daily
and yesterday drank 1 pint of vodka, couple cups of brandy and
several beers. She does not recall any events surrounding her
seizure and is unable to relate recent history of ETOH intake.
Of note, she was recently admitted [**2157-9-20**] for ETOH detox but
left AMA and also was admitted to [**Hospital1 756**] recently for seizures
and possible head bleed.
En route, patient had 2 witnessed seizures in ambulance and
received 6mg ativan IV but was protecting her airway. In the ED,
initial vs were: 98.6 HR 150 BP 146/90 RR 26 95%RA. Exam was
notable for being slightly confused and presumably post-ictal.
CT head was unremarkable and negative for bleed. She received
55mg IV valium for s/s ETOH withdrawal. She initially was
tachycardic to 160s but HR improved to 120s with valium and 3.5L
NS.
On the floor, she reports tremulousness, subjective fevers,
chills, dry cough. Denies palpitations, CP, objective fever,
SOB, dysuria.
Past Medical History:
- Alcohol abuse
- Hepatitis C
- h/o pancreatitis
- ETOH pancreatitis
- h/o IVDU (quit 5 yrs ago)
- G2P1
- h/o domestic violence (prior partner, not current)
- h/o ETOH related falls
Social History:
- Tobacco: 1 ppd
- etOH: 1L vodka daily (active)
- Illicits: marijuana intermittently, h/o IVDU stopped 5yr ago
- lives w/ fiance (he is non-drinker), engaged x 1 yr, has known
him for 12 yr.
- unemployed x 7yr, on disability for "liver failure, heart
failure, cardiac arrest, and depression....I don't know my
father filled out the papers."
- former fiance physically abused her
Family History:
Fa - DM2
Mo - Diverticulitis
Sis - Asthma
Aunt had breast Ca in her 60's as well as lung Ca
Grandmother had lung Ca
Physical Exam:
Initial Examination
General: Alert, oriented, no acute distress, somnolent but
arousable, slightly tremulous and diaphoretic
HEENT: Sclera anicteric, MM dry, oropharynx clear, ecchymoses L
infraorbital region, slightly tender. No nystagmus. EOMI and
fulla lthough at rest, L pupil slightly more inwardly directed
and disconjugate from R.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Tachycardic. Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, + mild epigastric tenderness, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No e/o track marks. No splinter hemorrhages
Skin: No rash
Neuro: CN 2-12 intact. Tremor as above. Sensation grossly
intact. Unable to assess strength or gait.
Pertinent Results:
[**2157-11-13**] 08:32PM TYPE-[**Last Name (un) **] TEMP-37.8 O2-20 PO2-123* PCO2-29*
PH-7.57* TOTAL CO2-27 BASE XS-5 INTUBATED-NOT INTUBA
[**2157-11-13**] 08:32PM LACTATE-2.0
[**2157-11-13**] 05:32PM freeCa-1.04*
[**2157-11-13**] 04:43PM CK(CPK)-345*
[**2157-11-13**] 11:06AM GLUCOSE-191* UREA N-10 CREAT-0.9 SODIUM-140
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-13* ANION GAP-33*
[**2157-11-13**] 11:06AM ALT(SGPT)-25 AST(SGOT)-34 CK(CPK)-267* ALK
PHOS-78 TOT BILI-0.3
[**2157-11-13**] 11:06AM LIPASE-23
[**2157-11-13**] 11:06AM OSMOLAL-299
[**2157-11-13**] 11:06AM HCG-<5
[**2157-11-13**] 11:06AM WBC-16.3*# RBC-3.97* HGB-12.3 HCT-37.0 MCV-93
MCH-30.8 MCHC-33.1 RDW-15.5
[**2157-11-13**] 11:06AM NEUTS-88.2* LYMPHS-8.5* MONOS-2.3 EOS-0.2
BASOS-0.8
[**2157-11-13**] 11:06AM PLT COUNT-469*
[**2157-11-13**] 11:06AM PT-12.4 PTT-25.8 INR(PT)-1.0
[**2157-11-13**] 04:43PM VIT B12-288
[**2157-11-13**] 04:43PM TSH-1.6
[**2157-11-13**] 11:40AM URINE UCG-NEGATIVE
[**2157-11-13**] 11:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Brief Hospital Course:
Pt is a 35 year old woman who presents with acute seizures,
repeatedly on the day of admission, including after EMS arrival.
She reports active drinking, once she was able to provide
history. She also notes not taking her Keppra for the week or
more prior to admission due to losing it. She was initially
transferred to the ICU, and later to the medical service, and
had no further seizures.
She did develop alcohol withdrawl symptoms, without evidence of
delirium tremens. She was maintained on a CIWA scale during her
ICU stay and received over 50mg of valium in the first 24 hours.
She was improving, and only required several doses after
admission to the floor.
The patient requested to leave AMA after one night on the
medical service. She was extensively evaluated by psychiatry and
the medicine attending, due to concerns that she was still on
valium for alcohol withdrawl symptoms. She was felt to have
capacity to make her medical decision to leave AMA, with her
current boyfriend at the bedside. She was seen by social work,
and deferred all alcohol treatment options.
The patient was provided plans to take two doses of valium the
evening after discharge, which would be provided to her by her
partner [**Name (NI) 26247**], and a further dose the following morning. Her
partner agreed to control these medications, and would be
staying with her for those hours to observe her condition. They
were instructed to return to seek medical attention if her
condition worsened.
Medications on Admission:
Keppra 500mg [**Hospital1 **]
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks.
Disp:*60 Tablet(s)* Refills:*0*
2. diazepam 10 mg Tablet Sig: One (1) Tablet PO twice a day for
2 days: Please take two tablets (10mg each) at 10pm [**2157-11-15**].
Please take one tablet (10mg) at 8am on [**2157-11-16**]. Disp:*3
Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute seizures
Alcohol withdrawl
Alcohol addiction with abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Known lastname 26248**],
It was a pleasure to take care of you during your admission. As
you know, you were admitted first to the ICU and then the
medicine service for seizures in the setting of not taking your
Keppra and continuing to drink alcohol.
You stopped having seizures in the ICU, but were still
withdrawing from alcohol while you were here. You wanted to
leave while you were still having some alcohol withdrawl
symptoms, and we felt that you have the ability to make that
decision right now. We asked that your boyfriend [**Male First Name (un) 26247**] help you
control the temporary medication you are being given, and give
you the doses at the appropriate times.
You should stop drinking alcohol, and we have asked your PCP to
speak with you further about this. Please note that even if you
are drinking, it is still better to take the Keppra than to skip
it.
Please note that although you are leaving before we would want
you to, and therefore against our advice at this time, we want
you to seek medical attention if you have any further withdrawl
symptoms or seizures.
Followup Instructions:
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment
to discuss alcohol cessation and smoking cessation, as well as
your seizure disorder within the next week.
[**Last Name (LF) **],[**First Name3 (LF) **] R
[**Location (un) 26249**], [**Location (un) **],[**Numeric Identifier 6086**]
[**Telephone/Fax (1) 26250**]
Please call Dr [**First Name (STitle) **] at [**Hospital1 112**] to [**Hospital1 **] an appointment for followup
of your seizure disorder.
We have given you a prescription for your Keppra for 30days and
you must see your doctor in the meantime, to get further
prescriptions for this medication.
We are giving you three tablets of valium (diazepam) that your
boyfriend [**Name (NI) 26247**] should give you over the next 24 hours. You
should take two tablets tonight at 10pm, and the remaining one
tablet tomorrow morning at 8am. Please note that you should
return to seek treatment at an Emergency Room if you have any
tremors or seizures.
|
[
"345.90",
"V15.88",
"291.81",
"305.22",
"577.1",
"303.91",
"305.1",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6731, 6737
|
4796, 6283
|
337, 344
|
6843, 6843
|
3680, 4773
|
8115, 9131
|
2612, 2729
|
6363, 6708
|
6758, 6822
|
6309, 6340
|
6994, 8092
|
2744, 3661
|
278, 299
|
372, 1993
|
6858, 6970
|
2015, 2198
|
2214, 2596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,697
| 170,023
|
51439
|
Discharge summary
|
report
|
Admission Date: [**2151-6-9**] Discharge Date: [**2151-6-18**]
Date of Birth: [**2092-12-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
mitral prolapse
Major Surgical or Invasive Procedure:
[**2151-6-9**] Mitral valve repair(32mm Ring) & closure of patent
foramen ovale
History of Present Illness:
This 58 year old white male has known mitral prolapse. The
regurgitation has increased on serial echocardiograms and he is
admitted for repair v. replacement.
Past Medical History:
hypertension
hypercholesterolemia
obesity
h/o thyroid cancer
s/p neck exploration and thyroidectomy
degenerative joint disease
bilateral pulmonary nodules
Social History:
lives with "significant other"
dental [**12-20**]
employment:food broker
nonsmoker
[**2-11**] drinks /week
caucasian
Family History:
father s/p strke/valve surgery
Physical Exam:
admission:
68" 85kg
128/77 lt arm pulse reg at 64 RR 16 RA O2 99%
4/6 SEM precordium to neck
Cor-RSR
Ext: no CCE. 2+ pulses
Pertinent Results:
[**2151-6-9**] Intraop TEE:
Pre-bypass: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 %). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. There is
no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric, directed toward
the anterior mitral leaflet. The mitral valve leaflets are
myxomatous. An eccentric, anteriorly directed jet of Moderate to
severe (3+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is a trivial/physiologic
pericardial effusion.
Post-bypass: The patient is not receiving inotropic support
post-CPB. There is a well-seated mitral annuloplasty ring. There
is no mitral regurgitation. There is a transvalvular mean
gradient of 3 mm Hg at a cardiac output of 5.8 L/min.
Biventricular systolic function is preserved and all findings
are consistent with pre-bypass findings. The aorta is intact
post-decannulation. All findings were discussed with the surgeon
intraoperatively.
[**2151-6-17**] BLOOD WBC-11.3* RBC-3.74* Hgb-11.4* Hct-31.4* Plt
Ct-365
[**2151-6-16**] WBC-11.3* RBC-3.66* Hgb-10.9* Hct-30.5* Plt Ct-367
[**2151-6-15**] WBC-10.8 RBC-4.37* Hgb-13.3*# Hct-37.1* Plt Ct-403#
[**2151-6-14**] WBC-10.0 RBC-3.59* Hgb-10.6* Hct-30.7* Plt Ct-268
[**2151-6-13**] WBC-10.6 RBC-3.58* Hgb-10.8* Hct-31.1* Plt Ct-233
[**2151-6-12**] WBC-13.7* RBC-3.99* Hgb-11.7* Hct-34.2* Plt Ct-211#
[**2151-6-11**] WBC-14.0* RBC-3.53* Hgb-10.8* Hct-30.6* Ct-137*
[**2151-6-10**] WBC-16.4* RBC-3.42* Hgb-10.3* Hct-29.4* Plt Ct-166
[**2151-6-18**] PT-14.0* INR(PT)-1.2*
[**2151-6-17**] PT-12.5 INR(PT)-1.1
[**2151-6-15**] PT-12.0 PTT-28.0 INR(PT)-1.0
[**2151-6-17**] Glucose-92 UreaN-20 Creat-1.0 Na-137 K-4.2 Cl-101
HCO3-25 AnGap-15
[**2151-6-16**] Glucose-104* UreaN-22* Creat-1.1 Na-136 K-4.4 Cl-102
HCO3-25
[**2151-6-15**] Glucose-108* UreaN-16 Creat-1.1 Na-136 K-4.5 Cl-98
HCO3-27
[**2151-6-14**] Glucose-110* UreaN-11 Creat-1.0 Na-136 K-4.5 Cl-104
HCO3-25
[**2151-6-13**] Glucose-112* UreaN-17 Creat-0.9 Na-136 K-4.0 Cl-98
HCO3-28
[**2151-6-12**] Glucose-109* UreaN-19 Creat-0.9 Na-139 K-3.7 Cl-100
HCO3-28
[**2151-6-11**] Glucose-140* UreaN-19 Creat-1.0 Na-136 K-4.0 Cl-101
HCO3-26
[**2151-6-17**] Mg-2.2
Brief Hospital Course:
On [**2151-6-9**], Dr. [**Last Name (STitle) 914**] performed a mitral valve repair and
closure of a patent foramen ovale. See operative note for
details. Following surgery, he was transferred to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and extubated without incident. Chest tubes were removed
per protocol and low dose beta blockade was initiated. He went
on to develop complete heart block, requiring temporary pacing.
Beta blockade was subsequently stopped. EP service was consulted
and attributed AV block to AV nodal edema. His rhythm was
observed for several days and his AV block resolved. He went on
to develop first degree AV block with conversion to persistent
atrial fibrillation/flutter. He remained asymptomatic and pacing
wires were eventually removed on postoperative day nine.
Warfarin was eventually started and dosed for a goal INR between
2.0 and 3.0. All nodal agents continued to be withheld and EP
service felt pacemaker was not indicated at this time. Mr.
[**Known lastname 14893**] will followup with EP/cardiology as an outpatient. At
time of discharge, INR was subtherapeutic but will be followed
closely by [**Hospital1 **] Cardiology Clinic. The remainder of
his postoperative course was routine and he was cleared for
discharge to home on postoperative day nine.
Medications on Admission:
amlodipine 10mg daily
levoxyl 250mcg daily
Hctz 25 mg daily
Simvastatin 20 mg daily
Trazadone prn
fish oil, vitamins
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*11*
2. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: Take for 7 days then stop. Please take with KCL.
Disp:*7 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7
days: Please take with Lasix. Stop after 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO qpm: Take as
directed by MD. Daily dose may vary according to INR. Goal INR
between 2.0 - 3.0.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
mitral regurgitation/prolapse
patent foramen ovale
transient AV block(postop)
atrial fibrillation/flutter(postop)
obesity
hypertension
hypercholesterolemia
degenerative joint disease
s/p thyroidectomy
h/o thyroid cancer
s/p neck exploration
s/p tonsillectomy
pulmonary nodules- bilateral
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- none
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on Tuesday, [**7-20**] at 1pm
Please call to [**Month/Year (2) **] appointments with:
Primary Care: Dr. [**Last Name (STitle) **] [**Name (STitle) 1022**] ([**Telephone/Fax (1) 56757**]) in [**12-12**] weeks
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**12-12**] weeks
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks, your nurse [**First Name (Titles) **] [**Last Name (Titles) **]
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Labs: PT/INR for Coumadin ?????? indication MV repair, atrial
fibrillation/atrial flutter
Goal INR: 2.0 - 3.0
First draw: [**2151-6-21**]
Results to: [**Hospital1 **] Cardiology Clinic
phone: [**Telephone/Fax (1) 2258**]
fax: [**Telephone/Fax (1) 79385**]
**VNA to call or fax results to [**Hospital1 **]**
Completed by:[**2151-6-18**]
|
[
"E878.8",
"745.5",
"429.5",
"278.00",
"272.0",
"424.0",
"427.32",
"401.9",
"427.31",
"715.90",
"244.0",
"997.1",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"35.71",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6747, 6802
|
3928, 5265
|
336, 418
|
7134, 7317
|
1127, 3905
|
8069, 9132
|
935, 967
|
5432, 6724
|
6823, 7113
|
5291, 5409
|
7341, 8046
|
982, 1108
|
281, 298
|
446, 606
|
628, 784
|
800, 919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,717
| 181,935
|
8033
|
Discharge summary
|
report
|
Admission Date: [**2144-11-24**] Discharge Date: [**2144-11-28**]
Date of Birth: [**2094-10-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
n/v and altered mental status
Major Surgical or Invasive Procedure:
LP [**2144-11-24**]
History of Present Illness:
50 yo F with PMH of DM1, ESRD not on HD, gastroparesis, HTN who
presents with vomiting and altered mental status. Her husband
reports that their two sons have been sick this week with a
viral gastroenteritis (vomiting and diarrhea). The patient has
not been feeling very well for the last couple of days. When he
left for work this morning, she was "ok." But he called to check
in on her and found that she had been vomiting. He came home and
brought her to the ED. He reports that she has been speaking
without making sense and he can't understand what she is saying.
He reports that she "gets like this" when her sugars are very
high or if she has high temperatures. She has been hospitalized
several times for hypotension, infections in her toes or hypo or
hyperglycemia. He denies that she had fevers at home. She did
not complain of CP, SOB, f/c, abdominal pain, headache or change
in vision at home.
.
In the ED, her BP in initially was 212/137, HR 110, O2sat 99%
and T 96.8. Her BS was 436 on arrival. She vomited coffee ground
emesis and received zofram, regular insulin 10 units,
hydralazine 10mg IV, protonix 40mg IV. NG lavage was attempted
several times without success. GI was notified and decided to
hold on scoping her until she was more stable unless her HCT
dropped. Her BS decreased to 318 with a AG of 16. She was given
more insulin and IVF. Her temperature spiked to 104 axillary.
BCx and UCx and LP were performed. She was also given levo,
flagyl, ceftriaxone. She was admitted to the MICU for futher
care.
Past Medical History:
1. Poorly controlled DM type 1, diagnosed in [**2117**]. Followed at
the [**Last Name (un) **] (Dr. [**Last Name (STitle) 14116**]. Last HbA1c 11.2 in [**10-16**] from [**Last Name (un) **]
notes
2. Severe gastroparesis
3. Diabetic neuropathy, with Charcot joints
4. Chronic renal insufficiency baseline Cr ~4
5. Hypertension
6. Non-healing left foot ulcer with several foot surgeries
7. Hx. of MRSA
Social History:
She lives with her husband and two adult sons. She is a social
drinker but does not smoke currently.
.
Family History:
Positive to DM2.
Physical Exam:
vitals: T 102.4 BP 200/98 HR 98 RR 10, O2sat 98% RA
General: moderate distress, warm
HEENT: pupils 3-4mm and minimally reactive to light. Dry MM
CV: borderline tachy, no murmur/r/g appreciated
Lungs: decreased BS bilaterally but clear. No wheezing
Abdomen: +BS, soft NTND
Rectal in ED was guiac positive
Extremities: DP 2+ symmetric. Surgical changes feet
Neuro: given altered mental status, difficult to assess. Answers
often not appropriate to questions. Speech is non-sensical but
other times clear "I want to go home." Othertimes says things
like "sub 2" out of nowhere.
Cranial nerves: EOMI, pupils minimally reactive to light. tongue
midline. Difficult to assess other cranial nerves. Facial
muscles seem normal and symmetric.
Motor: cogwheel rigidity vs her not relaxing muscles
Sensation: can not assess.
Reflexes: could not elicit given her rigidity
Pertinent Results:
[**2144-11-24**] 12:45PM BLOOD Neuts-82.9* Lymphs-13.5* Monos-2.0
Eos-1.2 Baso-0.4
[**2144-11-24**] 12:45PM BLOOD Glucose-397* UreaN-42* Creat-4.3* Na-138
K-4.0 Cl-97 HCO3-25 AnGap-20
[**2144-11-24**] 05:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-53*
GLUCOSE-148 LD(LDH)-21
[**2144-11-24**] 05:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-4*
POLYS-36 LYMPHS-41 MONOS-23
[**2144-11-24**] 03:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2144-11-24**] 03:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2144-11-24**] 03:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2144-11-24**] 03:41PM LACTATE-3.2*
[**2144-11-24**] 12:45PM TSH-1.9
[**2144-11-24**] 12:45PM VIT B12-1082* FOLATE-10.5
[**2144-11-24**] 10:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2144-11-24**] 08:40PM TYPE-ART TEMP-38.8 PO2-102 PCO2-36 PH-7.43
TOTAL CO2-25 BASE XS-0 INTUBATED-NOT INTUBA
Brief Hospital Course:
50 yo F with DM1, ESRD not on HD with hyperglycemia, n/v and
altered mental status in the setting of fevers to 104. She
initially was brought to the MICU for care for hypertenisve
urgency.
.
# altered mental status: The initially ddx included infection,
toxic metabolic, ingestion, hypertensive encephalopathy. Her
CSF was clear and her cultures (blood, urine and CSF) were all
negative. Her toxic metabolic work up was negative including
RPR, TSH, B12, folate. Her mental status cleared the next day
after controlling her blood pressure, so the likely diagnosis
was hypertensive encephalopathy. Her mental status throughout
the rest of her hospitalization was oriented times three and at
baseline.
.
# Fever/N/V/D: She had very high fevers on the first day of
admission up to 104 and was placed on a cooling blanket. She was
initially placed on vanco/zosyn for 48hrs until her cultures
were negative. The antibiotics were discontinued. She likely had
a viral illness similar to her family members. Once transferred
to the medical floor she remained afebrile, tolerated a po diet
well.
.
# UGI bleeding: She had coffee ground emesis in ED and once in
the MICU on arrival. NG lavage could not be done (attempted
several times). Likely etiology was [**Doctor First Name **]-[**Last Name (un) 28726**] tear from
vomiting. GI was aware and given her other conditions, she was
not initially scoped. Her HCT remained stable and she was
continued on a PPI. She should f/u with GI as an outpatient.
.
# hypertensive urgency: She was initially treated with a
labetolol gtt to control her blood pressures which were intially
over 200/100. She was then tappered off and onto her home
medications of metoprolol and amlodipine. Her furosemide was
held given her rising Cr. She will be discharged with
instructions of not to use her lasix until instructed by her
PCP.
.
# DM1: elevated BS in ED. Started on insulin gtt for concern for
mild DKA in setting of N/V/D. Mild ketoacids on labs. She was
transitioned to lantus and humalog with the help of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
diabetes consult. Her glargine was increased to 35, as was her
home sliding scale. She will be discharged with glargin 35 and
her regular home sliding scale/
.
# ESRD: Patient's renal attending, Dr, [**Name (NI) **] saw patient rather
than renal consult and asked for renal c/s given slightly elev
Cr and potential need for HD soon. No acute need for HD (lytes
stable, euvolemic). Her urine output was satisfactory on being
transferred to the floor.
.
# HTN: Patient off Labetolol gtt, and currently has been started
on Norvasc, Metoprolol and lasix. Pt will be discharged on
Metoprolol and Norvasc at higher doses than her previous home
doses.
.
# FEN: [**Doctor First Name **], renal diet; monitor lytes
# PPX: MRSA precautions; PPI; pneumoboots; bowel reg
# access: 2 PIVs
# Code: full; discussed with husband, HCP
# Dispo: home
Medications on Admission:
lantus 32 units at bedtime
humalog pen
amitriptyline 50mg at bedtime
furosemide 20mg once daily
lipitor 40mg at bedtime
metoprolol 25mg once daily
norvasc 5mg once daily
reglan 10mg twice a day
ferrous gluconate daily
asa 81mg daily
pro-crit 20,000 unit vial injection 1cc syringe once weekly
Discharge Medications:
1. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Five (35)
units Subcutaneous at bedtime.
2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Reglan 10 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Ferrous Gluconate 225 (27) mg Tablet Sig: One (1) Tablet PO
once a day.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. Folic Acid 1 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 Q24H (every 24 hours).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Insulin Lispro 100 unit/mL Insulin Pen Sig: as directed
Subcutaneous four times a day: as directed on sliding scale.
14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive encephalopathy
hyperglycemia
UGI bleed likely secondary to [**Doctor First Name **]-[**Doctor Last Name **] tear
poorly controlled DMI
severe gastroparesis
diabetic neuropathy with charcot joints
chronic renal insufficiency (baseline Cr 4)
hypertension
non-healing ulcer of the left foot s/p several foot surgeries
history of MRSA
Discharge Condition:
stable, afebrile, good po intake
Discharge Instructions:
You were admitted with high blood sugar, high blood pressure,
fever, and altered mental status. You were admitted to the
medical ICU and treated with medications to improve your blood
pressure. You had a spinal tap which was normal. You had some
upper GI bleeding that was self resolving. You were followed by
[**Last Name (un) **] for your blood sugars.
We have added new medications for your blood pressure, these are
Metoprolol 25mg three times a day and Norvasc 10mg once a day.
You should continue taking your medications as prescribed.
Please follow up as instructed below.
Call your doctor for any headache, dizzyness, nausea, vomiting,
abdominal pain, any bleeding, chest pain, shortness of breath or
any other concerning symptoms.
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6431**], and make an appointment within
the next week
Please follow up with Dr. [**Last Name (STitle) 14116**] within two weeks
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2144-12-14**] 8:30
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-1-15**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2145-1-15**] 11:00
Completed by:[**2144-12-4**]
|
[
"250.13",
"357.2",
"536.3",
"437.2",
"585.6",
"403.91",
"250.63",
"530.7",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
8935, 8941
|
4441, 4642
|
347, 368
|
9329, 9364
|
3400, 4418
|
10156, 10787
|
2487, 2505
|
7727, 8912
|
8962, 9308
|
7409, 7704
|
9388, 10133
|
2520, 3095
|
278, 309
|
396, 1926
|
3111, 3381
|
4657, 7383
|
1948, 2350
|
2366, 2471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,979
| 158,349
|
36178
|
Discharge summary
|
report
|
Admission Date: [**2129-2-3**] Discharge Date: [**2129-3-2**]
Date of Birth: [**2056-10-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 72M w/ pmh CHF, a-fib on warfarin, ckd baseline Cr
2.2, presenting with two days of fatigue. He reports waking
yesterday morning, and when he got out of bed he syncopized. He
is unsure how long he was unconscious for. He reports his wife
found him from the floor and called an ambulance. Prior to the
ambulance arriving his temperature was measured at home and
found to be 104. He was brought to [**Hospital **] hospital where he
was complaining of fatigue, poor appetite, and left sided
shoulder, and chest pain, worse with movement of his arm. He was
hypotensive with sbp in the 80's. he had a white count which was
20, and an abdominal US which showed intraabdominal fluid and
mildly thickened gallbladder. He was given 3L of NS, and started
on vancomycin and zosyn.
.
He was transferred to [**Hospital1 18**] for further management, where his
vitals were: 97.8 100/45 70 99% 3L. He was given 2 more liters
of NS and decadron 10mg IV X1.
He was recently hospitalized from [**2129-1-19**] through [**2129-1-29**] for
treatment of acute renal failure, congestive heart failure,
hyponatremia, upper GI bleeding, and amiodarone induced
thyrotoxicosis. During this hospitalization, he was started on
theophylline for his heart failure, underwent cauterization for
his upper GI bleeding, and was started on prednisone and
methimazole for his amiodarone induced hyperthyroidism. He
reports feeling well since his discharge on [**1-29**]. However, he
reports visiting his endocrionologist on [**2-2**], during which his
theophylline and methimazole were stopped, and he reports his
symptoms began after these medications were discontinued.
.
On ROS, he reports chest congestion, and occasional vomiting
over the past month. He denied dysuria or diahrrea. He denied
shortness of breath, orthopnea, or PND.
Past Medical History:
Chronic CHF
Atrial fibrillation on coumadin
CHB s/p PPM/AICD
Type II Diabetes mellitus
Chronic Kidney Disease (baseline creatinine 2.2)
Chronic anemia (had been on procrit but this was d/c'd ~1 year
ago)
Degenerative disc disease
s/p L inguinal repair
Colonoscopy [**2125**] showed diverticulosis and hemorrhoids
Social History:
The patient is married, lives with his life [**Doctor First Name 46250**] and 2 dogs He
owns a construction and transportation business which he still
runs. He has 7 children all of whom live in the area.
Tobbaco: The patient is a life-long non-smoker
Ethanol: He denies any history of alcohol abuse.
There is no family history of premature coronary artery disease
or sudden death.
Family History:
Father died of pancreatic cancer
Mother died of old age.
Physical Exam:
Vitals: 97.8 100/53 70 17 100% RA,
General: Awake, alert, NAD.
HEENT: hyperpigmented purple nodule on forhead. EOMI without
nystagmus, no scleral icterus noted, MM dry,
Neck: JVP to angle of jaw
Pulmonary: crackles at left base
Cardiac: RRR, nl. S1S2, 2/6 systolic murmur at LLSB
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 3+ edema b/l
Skin: spider angiomata over chest
Pertinent Results:
[**2129-2-3**] 08:00PM URINE HOURS-RANDOM
[**2129-2-3**] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2129-2-3**] 08:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2129-2-3**] 08:00PM URINE RBC-0-2 WBC-[**2-17**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2129-2-3**] 06:38PM LACTATE-1.5
[**2129-2-3**] 06:30PM GLUCOSE-130* UREA N-109* CREAT-3.3*#
SODIUM-129* POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-23 ANION GAP-16
[**2129-2-3**] 06:30PM ALT(SGPT)-51* AST(SGOT)-49* CK(CPK)-240* ALK
PHOS-80 TOT BILI-1.6*
[**2129-2-3**] 06:30PM LIPASE-42
[**2129-2-3**] 06:30PM cTropnT-0.07*
[**2129-2-3**] 06:30PM CK-MB-5
[**2129-2-3**] 06:30PM DIGOXIN-1.5
Radiology:
[**2129-2-3**] CT ABD/Pelvis:
IMPRESSION:
1. Moderate ascites of unclear etiology, though liver disease
should be
considered in the setting of gynecomastia.
2. Small bilateral pleural effusions and atelectasis.
3. Small metallic density in the proximal stomach is of unknown
etiology. Correlation is needed.
.
CXR [**2129-2-3**]
IMPRESSION: Cardiomegaly without focal lung consolidation or
overt edema.
CT Head [**2129-2-3**] :
IMPRESSION:
1. No intracranial hemorrhage or fracture.
2. Small metal density in the subcutaneous soft tissues below
the right orbit of unclear etiology. Correlate with direct
visual inspection.
[**2129-2-4**] US ABD LIMIT, SINGLE OR
FINDINGS: Limited abdominal ultrasound. There is moderate
ascites in all four quadrants of the abdomen. However, the
patient has significantly elevated INR of 3.2 in the morning of
the study. Paracentesis was not performed.
[**2129-2-5**] Radiology UNILAT UP EXT VEINS US
IMPRESSION: No evidence of DVT in the left upper extremity
Micro:
[**2129-2-5**] BLOOD CULTURE Blood Culture, Routine-NGTD
[**2129-2-5**] BLOOD CULTURE Blood Culture, Routine-NGTD
[**2129-2-4**] URINE URINE CULTURE-FINAL NEGATIVE
[**2129-2-3**] Blood Culture, Routine (Pending):
OSH:
[**2129-2-3**] Blood Culture: 2/2 Bottles +MSSA
TTE [**2129-2-8**]:
Conclusions
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is
10-20mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 70%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
The right ventricular cavity is dilated with depressed free wall
contractility. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2129-1-20**], right heart volume overload is increased.
TTE [**2129-2-17**]:
Conclusions
The left atrial volume is markedly increased (>32ml/m2). The
left atrium is dilated. The right atrium is markedly dilated.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Dilated, hypokinetic right ventricle with moderate
to severe tricuspid regurgitation and moderate pulmonary
hypertension. No evidence of endocarditis (cannot exclude).
Severe biatrial enlargement.
[**2129-2-8**] CT upper extremity:
Final Report
EXAMINATION: CT left shoulder.
TECHNIQUE: Axial CT images of the left shoulder were obtained
with selective sagittal and coronal reformats. No priors for
comparison.
HISTORY: MSSA Bacteremia, evaluate for septic arthritis.
FINDINGS:
There is degenerative spurring at the glenoid. In addition,
there is
degenerative cartilage loss and subchondral cyst formation at
the
acromioclavicular joint. However, there are no erosive changes
identified.
There is no gross effusion on this limited soft tissue windows
of the CT.
There is a focal calcific density adjacent to the greater
tuberosity
consistent with an area of calcific tendinitis.
There is no fracture or dislocation identified.
Small left-sided pleural effusion and subjacent dependent
atelectasis is
noted.
Cardiac pacer device is identified.
IMPRESSION:
1. No gross glenohumeral joint effusion or bony erosive changes
to
suggestive CT evidence of septic arthritis.
2. Degenerative changes compatible with osteoarthritis in the
acromioclavicular and glenohumeral joints.
3. Small left-sided pleural effusion with subjacent atelectasis.
[**2129-2-7**]:
RIGHT UPPER QUADRANT ULTRASOUND
INDICATION: 72-year-old man with MSSA bacteremia.
COMPARISON: CT abdomen dated [**2129-2-3**].
FINDINGS: The liver is normal in size, echogenicity and
architecture. There is no focal liver lesion. There is small
amount of perihepatic ascites. The gallbladder is nondistended,
the wall is thickened, which can be seen in the setting of
ascites. No gall stones. There is no cholecystic fluid or
gallbladder wall edema or distention to suggest acute
cholecystitis. The common duct measures 3 mm at the porta
hepatis. Hepatopetal flow is demonstrated in the main portal
vein, biphasic nature of the waveform could be related to
congestive heart failure.
IMPRESSION:
1. No evidence of acute cholecystitis or biliary ductal
dilatation.
2. Abdominal ascites.
[**2129-2-26**] 6:59 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2129-2-27**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-2-27**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 0542 ON [**2129-2-27**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
Brief Hospital Course:
72 year old male with PMH of right-sided heart failure, CHB s/p
PPM/AICD, atrial fibrillation on coumadin, CKD, upper GI
bleeding w/ recent cauterization, amiodarone-induced
thyrotoxicosis, anemia who presented from OSH with MSSA
bacteremia (per OSH blood cultures).
During the [**Hospital 228**] hospital course at [**Hospital1 18**], decision was made
to treat presumptively with 6 weeks of vancomycin for the
patient's MSSA bacteremia. Due to the high co-morbidities of
removing the biventricular pacer, the pacer was not removed. If
after 6 weeks of IV antibiotics, the patient has fevers and
evidence of bacteremia, then the reconsideration of pacemaker
removal will be discussed by the patient and his cardiologist
Dr. [**Last Name (STitle) **]. During the patient's hospitalization, he developed
severe right-sided heart failure that was unresponsive to high
dose IV diuretics and theophylline. The patient subsequently
developed acute renal failure requiring dialysis. The patient
was aggressively dialyzed with removal of large volumes of fluid
so that he went from a top weight of 216 lbs to a weight of
approx. 190 lbs on day of discharge. Goal weight is approx. 180
lbs.
# MSSA Bacteremia: After extensive discussions with the
patient's cardiologist and the ID service, the plan was made to
treat the patient with 6 weeks of IV antibiotics. If the
patient subsequently, developed recurrent bacteremia, then the
pacer would have to be removed. Given the patient's prior
history, his concomittant severe right-sided heart failure, and
the adverse remodelling effects of removing the biventricular
pacer and temporarily pacing only a single ventricle, his
cardiologist believed this was the best approach. The patient
was initially treated with nafcillin but due to his renal
failure this was changed to vancomycin to rule out any
possibility of AIN (although repeat urine analysis never was
consistent with this) and also to decrease the volume he was
being given due to the difference in dosing between the two
agents. The patient will complete a 6 week total course of
antibiotics on [**2129-3-17**].
-Continue vancomycin until [**3-17**]. Check levels at diaysis and
dose accordingly (see below).
-Obtain surveillance blood cultures for any fevers,
leukocytosis.
-If patient spikes temperature and/or has significant
leukocytosis after antibiotics are stopped, obtain immediate
blood cultures and contact his cardiologist and PCP.
.
# Acute Renal Failure: The patient has CKD at baseline and
developed worsening acute renal failure in the setting of his
severe right heart failure and diuresis. There was no evidenece
of AIN due to nafcillin. The patient was closely followed by
renal throughout his admission and both cardiology and renal
monitored his diuresis in the setting of his ARF. Due to
non-responsive right heart failure to both high dose diuretics
and theophylline, the decision was made after repeated
discussion with the patient to continue aggressive diuresis,
realizing that this may lead to dialysis. The patient's renal
function evetually worsened to the stage where a tunnel line was
placed and dialysis was initiated on Friday [**2-18**]. The renal
team was able to remove a large amount of fluid through repeated
aggressive dialysis sessions where the patient went from a high
weight of 216 lbs to a discharge weight of approx 190 lbs. Goal
weight is approximately 180 lbs. HD and UF should be continued
(see below).
.
#Marked right-sided CHF: The patient developed severe
right-sided heart failure as described above. His TTEs
demonstrated severe right ventricular volume overload. The hope
is that with removal of significant volume through
ultrafiltration that his right ventricular function will
improve.
.
#Amiodarone induced thyrotoxicosis, most likely type 2,which is
a destructive thyroiditis: The patient was very closely
followed by the endocrinology service during his admission. His
PTU was changed briefly to methimazole due to increasing
isolated hyperbilirubinemia, but was shortly therafter changed
back to PTU. The patient was not treated with steroids given
his MSSA bacteremia and clostridial colitis.
-The patient should have weekly TFTS checked with results
communicated to his endocrinologist as well as to consulting
endocrinologist at the LTAC/rehab facility, with adjustment of
his PTU accordingly.
.
#Atrial Fibrillation: Cardiology was contact[**Name (NI) **] regarding
whether amiodarone continuation was reasonable in the setting of
thyrotoxicosis and agreed that it was, and that this had
previously been clarified between the patient's attending
cardiologist and endocrinologist - see below for further
instruction. The patient was therapeutic on coumadin at time of
discharge.
.
#Supratheraputic INR: On [**2-15**], the patient was noted to
have bleeding in his mouth, his [**2-16**] am INR was >21 from an
INR of 2 on [**2-11**]. This dramatic rapid elevation in the
patient's INR was believed secondary to decreased warfarin
metabolism from his theophylline, diarrhea, right heart failure
and cessation of nafcillin. Of note, the patient was on his
normal daily dose of warfarin 5 mg po qd. The patient was
rapidly reversed. Warfarin dose should be titrated to target
INR of 2.0 to 3.0.
.
#Diarrhea: The patient had several episodes of diarrhea, found
to be c. difficile toxin positive. Pt did not have abdominal
pain, and diarrhea was minimal. This is therefore felt to
represent mild colitis, 10 day course of oral metronidazole
prescribed.
.
#Anemia: Likely from CKD, with recent studies c/w ACD.
-Treatment with epoetin and PRBC transfusions with HD prn.
.
#Barrett's esophagus s/p recent GI bleed from gastric antral
vascular ectasia: PPI [**Hospital1 **].
.
#Hyponatremia: Evaluation consistent with CHF-induced
hyponatremia that resolved with aggressive dialysis volume
removal.
.
#Depression: Seen repeatedly by social work.
.
#Diabetes: Insulin regimen [**First Name8 (NamePattern2) **] [**Last Name (un) **]/endocrine. Adjusted with
control.
Medications on Admission:
Warfarin 5 mg Tablet PO daily
Spironolactone 25 mg Tablet PO BID
Avapro 150 mg Tablet PO daily
Digoxin 125 mcg Tablet PO QOD
Prednisone 20 mg Tablet PO BID
Torsemide 20 mg Tablet PO BID
Pantoprazole 40 mg Tablet, Delayed Release PO BID
Insulin NPH 14 units qam
Humalog Pen 100 unit/mL per sliding scale
Amiodarone 200 mg Tablet PO daily
Discharge Medications:
1. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mL PO QID (4 times a
day) as needed.
2. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
3. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO Every other
day.
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QMON, THURS
().
11. Epoetin Alfa 10,000 unit/mL Solution Sig: as per renal
recommendation units, epogen Injection ASDIR (AS DIRECTED):
renal MD to consider initiation of epogen.
12. Propylthiouracil 50 mg Tablet Sig: Four (4) Tablet PO Q8H
(every 8 hours): Needs weekly TFTs drawn on this therapy and
interpreted/medication titrated by an Endocrinologist.
13. Insulin Glargine 100 unit/mL Solution Sig: see attached
dosing regimen of glargine and humalog insulin units, insulin
Subcutaneous QACHS: see attached regimen of glargine and humalog
sliding scale insulin.
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): titrate warfarin dose to target INR 2.0 to 3.0.
Tablet(s)
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
Q HD per HD protocol: dosing at dialysis. Target trough of 20.
Weekly safety labs as described below.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
17. line care Sig: One (1) line care once a day: HD access and
PICC line care per routine.
18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
1)MSSA bacteremia
2)Severe Right-sided Heart Failure
3)Acute Renal Failure requiring dialysis.
4)Supratherapeutic INR with bleeding.
5)Amiodarone induced thyrotoxicosis
6)Clostridial colitis
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium, cardiac diabetic renal diet.
Fluid Restriction: 1 liter per day.
You had MSSA bacteremia for which you will complete a total 6
week course of antibiotics. You had severe right-sided heart
failure which contributed to renal failure leading to
hemodialysis.
You have previously diagnosed amiodarone-induced thyrotoxicoisis
for which you are being treated and monitered.
You have c. diff colitis for which you have been prescribed an
oral antibiotic
Followup Instructions:
Patient's family to schedule f/u with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
[**Telephone/Fax (1) 82054**].
Patient to f/u with his cardiologist Dr. [**Last Name (STitle) **] of [**Hospital1 18**] - Dr.
[**Last Name (STitle) **] will discuss with family or they can call him (has
known pt. for over 25 years).
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2129-3-7**]
11:00
Provider: [**Name10 (NameIs) **],DIALYSIS SCHEDULE HEMODIALYSIS UNIT
Date/Time:[**2129-2-28**] 7:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-3-11**] 9:00
|
[
"V45.01",
"242.80",
"428.0",
"E942.0",
"286.9",
"V58.67",
"276.1",
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"250.00",
"427.31",
"530.85",
"427.1",
"403.90",
"285.21",
"585.9",
"038.11",
"426.0",
"428.23",
"008.45",
"789.59",
"311",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
19125, 19168
|
10613, 16672
|
321, 327
|
19402, 19422
|
3435, 5375
|
20017, 20782
|
2920, 2978
|
17060, 19102
|
19189, 19381
|
16698, 17037
|
19446, 19994
|
2993, 3416
|
5410, 10590
|
274, 283
|
355, 2167
|
2189, 2504
|
2520, 2904
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,411
| 196,741
|
54373
|
Discharge summary
|
report
|
Admission Date: [**2199-1-2**] Discharge Date: [**2199-1-15**]
Date of Birth: [**2130-3-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
[**2199-1-4**] - Bilateral sphenopalatine and left descending palatine
artery embolization by Interventional Radiology
[**2199-1-2**] to [**2199-1-5**] - Intubation and mechanical ventilation
[**2199-1-5**] - Bronchoscopy
[**2199-1-11**] - Direct current electrical cardioversion
History of Present Illness:
This is a 68-year old Male with a PMH significant coronary
artery disease (s/p PCI with stenting of LAD, [**4-/2195**]), alcoholic
vs. infarct-related dilated cardiomyoatphy (EF 20-25%), s/p
biventricular [**Year (4 digits) 3941**] placement in [**6-/2195**], persistent atrial
fibrillation (s/p multiple cardioversions), h/o embolic renal
infarct ([**2-/2195**]) with prior left atrial appendage thrombus,
alcohol abuse who presented to [**Hospital1 18**] [**Location (un) 620**] with uncontrolled
left-sided posterior epistaxis and coagulopathy with INR of 5.2
requiring ENT consultation and Epistat packing. The bleeding
progressed to bilateral involvement and he was not clearing the
brisk [**Last Name (LF) **], [**First Name3 (LF) **] he was intubated for airway protection and a
right Epistat was placed by ENT. He received 2 units of FFP, but
had a stable HCT at the time. He was transferred to [**Hospital1 18**] for
further management; vent settings 500/16/5/100%.
.
While in the MICU, patient received 1 unit of PRBCs (HCT nadir
of 24.8%), 4 units of FFP total (INR peak 5.2) and was continued
on Augmentin given packing placement. ENT evaluated the patient
and agreed with iniatial management with packing for 5-days. On
[**1-4**], the patient underwent IR-guided successful embolization
of the right sphenopalatine artery and embolization of the left
sphenopalatine artery and left desecending palatine artery
utilizing coils. OG lavage following the procedure was
reassuring. Bronchoscopy in the MICU showed minimal clot burden
and was otherwise normal. The patient did receive intermittent
IV Lasix (20 mg IV x 2) given some volume overload concerns
while in the MICU (net negative 1L for [**1-5**] prior to transfer,
but positive LOS fluid balance of 3L). He was extubated on [**1-5**]
without issue. He did have some ICU-delirium concerns requiring
Haldol IV. Patient was transferred to the Medicine-SIRS team at
that time.
.
While on the Medicine floor, the patient was noted to have
substantial hypoxia to the 80% on room air with evidence of an
A-a gradient and persistent cough concerns. He was dosed Lasix
60 mg IV, received Albtuerol nebs and his CXR showed stable
frank pulmonary congestion with minimal bilateral effusions and
no evidence of consoldiation. Of note, a positive sputum culture
from [**1-4**] showed sparse coagulase positive Staphylococccus.
Given his worsening acute hypoxic failure (ABG 7.43/27/55 on
facemask) and concern for acute congestive heart failure
decompensation, he was transferred to the CCU. Prior to transfer
from Medicine floor, 98.6 60-80 102/60 35 92-94% FM.
.
On arrival to the CCU, the patient is speaking in short
sentences on a Venturi mask.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or pre-syncope.
.
ROS: The patient denies a history of prior stroke/TIA, deep
venous thrombosis or pulmonary embolus. Denies headaches or
vision changes. Denies chest pain, dizziness or lightheadedness;
no palpitations. No nausea or vomiting, denies abdominal pain.
No dysuria or hematuria. No change in bowel movements or bloody
stools. Denies muscle weakness, myalgias or neurologic
complaints. No exertional buttock or calf pain.
Past Medical History:
CARDIAC HISTORY: Coronary artery disease, Hypertension
.
- infarct-related vs. alcoholic dilated cardiomyopathy (EF
20-25% in [**4-/2198**])
- [**4-/2195**] - PCI stenting of proximal-LAD with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 1 after
diagnostic cardiac catheterization (LMCA modest calcification,
LAD 80-90% stenosis proximally, LCx 60% mid-segment lesion in
the AV-groove), dominant RCA
- [**8-/2195**] - direct-current cardioversion for atrial fibrillation
- [**10/2195**] - successful pericardiocentesis via the subcostal
approach with removal of 400 cc serousanguinous fluid for
moderate-severe pericardial effusion with dyspnea in the setting
of anticoagulation
.
* CABG: None
* PERCUTANEOUS CORONARY INTERVENTIONS:
- [**4-/2195**] - PCI stenting of proximal-LAD with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 1 after
diagnostic cardiac catheterization
* PACING/[**Last Name (Prefixes) 3941**]: biventricular [**Last Name (Prefixes) 3941**] placement, [**2195**] (last
interrogation in [**10/2198**])
.
PAST MEDICAL & SURGICAL HISTORY:
1. Coronary artery disease
2. Infarct-related dilated cardiomyopathy
3. Hypertension
4. Persistent atrial fibrillation
5. history of right-sided embolic renal infarct ([**2-/2195**]) with
left atrial appendage thrombus identified at that time
6. Alcohol abuse history
7. (?) Thalamic infarct
8. Benign prostatic hypertrophy
9. s/p ear malformation reconstructive surgeries
Social History:
Patient lives at home, and is a widower. He is a financial
consultant. Denies tobacco use, but consumes 2-glasses of wine a
few days a week and on weekends (former heavy alcohol use); no
recreational substance use.
Family History:
Notable family history of early MI (mother age 55, father age
65); but denies arrhythmia, cardiomyopathies, or sudden cardiac
death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAM (on CCU admission):
.
VITALS: see Metavision printout
GENERAL: Appears in mild, acute distress. Alert and speaking in
short sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. No xanthalesma.
NECK: supple without lymphadenopathy. JVD markedly elevated to
mid-neck at 30-degrees.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal. No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Decreased
breath sounds bilaterally. No wheezin or rhonchi; mild
inspiratory crackles at bases. Stable inspiratory effort, but
appearing mildly fatigued.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; [**1-21**]+ peripheral edema to mid-thigh
and on lower back, 2+ peripheral pulses
DERM: No stasis dermatitis, ulcers, scars, or xanthomas. Some
bright-red macules with some excoriation over back surface.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Sensation grossly intact. Gait deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
.
[**2199-1-2**] 09:31PM [**Month/Day/Year 3143**] WBC-12.2*# RBC-3.31* Hgb-10.7* Hct-32.7*
MCV-99* MCH-32.3* MCHC-32.7 RDW-15.0 Plt Ct-295#
[**2199-1-2**] 09:31PM [**Month/Day/Year 3143**] Neuts-88.1* Lymphs-7.3* Monos-3.8 Eos-0.5
Baso-0.3
[**2199-1-2**] 09:31PM [**Month/Day/Year 3143**] PT-52.6* PTT-41.3* INR(PT)-5.2*
[**2199-1-2**] 09:31PM [**Month/Day/Year 3143**] Glucose-124* UreaN-24* Creat-0.8 Na-137
K-4.4 Cl-107 HCO3-23 AnGap-11
[**2199-1-7**] 11:00AM [**Month/Day/Year 3143**] ALT-4790* AST-6854* LD(LDH)-6230*
CK(CPK)-973* AlkPhos-161* TotBili-5.1*
[**2199-1-7**] 11:00AM [**Month/Day/Year 3143**] CK-MB-7 cTropnT-0.02* proBNP-[**Numeric Identifier **]*
[**2199-1-3**] 02:20AM [**Month/Day/Year 3143**] Calcium-7.3* Phos-2.7 Mg-1.8
[**2199-1-7**] 01:15PM [**Month/Day/Year 3143**] calTIBC-295 Ferritn-1891* TRF-227
[**2199-1-3**] 03:17AM [**Month/Day/Year 3143**] Lactate-1.4
.
PERTINENT LABS:
.
[**2199-1-7**] 09:00PM [**Month/Day/Year 3143**] WBC-18.9* RBC-3.17* Hgb-9.9* Hct-31.1*
MCV-98 MCH-31.3 MCHC-31.9 RDW-16.8* Plt Ct-156
[**2199-1-10**] 04:23AM [**Month/Day/Year 3143**] PT-29.7* PTT-31.5 INR(PT)-2.9*
[**2199-1-8**] 03:00AM [**Month/Day/Year 3143**] Glucose-117* UreaN-61* Creat-1.9* Na-147*
K-4.1 Cl-107 HCO3-25 AnGap-19
[**2199-1-8**] 03:00AM [**Month/Day/Year 3143**] ALT-6240* AST-6855* LD(LDH)-4476*
CK(CPK)-1899* AlkPhos-192* TotBili-5.4*
[**2199-1-9**] 04:39AM [**Month/Day/Year 3143**] ALT-4770* AST-2699* AlkPhos-191*
TotBili-5.7*
[**2199-1-10**] 04:23AM [**Month/Day/Year 3143**] ALT-3306* AST-976* AlkPhos-167*
TotBili-6.0*
.
[**2199-1-7**] 11:00AM [**Month/Day/Year 3143**] CK-MB-7 cTropnT-0.02* proBNP-[**Numeric Identifier **]*
[**2199-1-7**] 09:00PM [**Month/Day/Year 3143**] CK-MB-11* cTropnT-0.02*
[**2199-1-8**] 03:00AM [**Month/Day/Year 3143**] CK-MB-9 cTropnT-0.01
[**2199-1-10**] 04:23AM [**Month/Day/Year 3143**] Albumin-2.6* Calcium-7.9* Phos-2.2*
Mg-2.9*
.
[**2199-1-7**] 01:15PM [**Month/Day/Year 3143**] HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE HAV Ab-POSITIVE
[**2199-1-7**] 01:15PM [**Month/Day/Year 3143**] HCV Ab-NEGATIVE
.
[**2199-1-7**] 07:48AM [**Month/Day/Year 3143**] Lactate-7.0*
[**2199-1-7**] 04:04PM [**Month/Day/Year 3143**] Lactate-6.3*
[**2199-1-8**] 03:52AM [**Month/Day/Year 3143**] Lactate-4.4*
[**2199-1-8**] 06:44PM [**Month/Day/Year 3143**] Lactate-3.1*
[**2199-1-9**] 06:14PM [**Month/Day/Year 3143**] Lactate-1.9
.
MICROBIOLOGIC DATA:
[**2199-1-3**] [**Month/Day/Year **] culture - negative
[**2199-1-3**] [**Month/Day/Year **] culture - negative
[**2199-1-3**] Urine culture - negative
[**2199-1-3**] MRSA screen - negative
[**2199-1-4**] Sputum culture - sparse coagulase positive
Staphylococcus aureus (MSSA)
[**2199-1-7**] Urine culture - negative
[**2199-1-7**] [**Month/Day/Year **] culture - pending
[**2199-1-7**] [**Month/Day/Year **] culture - pending.
.
IMAGING STUDIES:
[**2199-1-4**] CAROTID/CERVICAL EMBOLIZATION - Successful embolization
of the right sphenopalatine artery (3rd order branch) using
Vortex coils. Successful embolization of the left sphenopalatine
artery (3rd order branch) and left desecending palatine artery
(3rd order branch) using PVA particles and coils.
.
[**2199-1-5**] CHEST (PORTABLE AP) - The ET tube tip, the NG tube, the
pacemaker leads, the cardiomegaly, and mediastinal silhouettes
are unchanged. Widespread consolidations within the lungs are
unchanged as well with no definitive evidence radiologically of
deterioration. Bilateral pleural effusion is unchanged. No
evidence of pneumothorax is seen.
.
[**2199-1-7**] 2D-ECHO - The left atrium is mildly dilated. The right
atrium is markedly dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is severe global left ventricular hypokinesis with
inferior akinesis (LVEF = 25 %). No masses or thrombi are seen
in the left ventricle. The right ventricular cavity is dilated
with moderate global free wall hypokinesis. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild to
moderate ([**1-21**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Marked left ventricular cavity enlargement
with severe global systolic dysfunction c/w multivessel CAD or
other diffuse process. Right ventricular cavity enlargement with
free wall hypokinesis. Mild-moderate mitral regurgitation.
Pulmonary artery hypertension. Compared with the prior study
(images reviewed) of [**2198-4-30**], the left ventricular cavity is
larger and the severity of mitral regurgitation and the
estimated PA systolic pressure have increased.
.
[**2199-1-10**] FOCUSED 2D-ECHO - LVOT VTI during biventricular paced
beats = 11 cm. LVOT VTI during native conduction = 13 cm.
Conclusion: left vemtricular stroke volume is approximately 18%
higher during native conduction compared to biventricular
pacing.
.
[**2199-1-15**] ECHO: The left atrium is mildly dilated. The right
atrium is markedly dilated. A 4-6mm mobile echodensity is seen
in the right atrium (clip [**Clip Number (Radiology) **]) in close association with RV
pacing lead and c/w a thrombus (cannot exclude vegetation if
clinically suggested). No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is at least
15 mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is mild-moderate
regional dysfunction with thinning/near akinesis of the basal
half of the inferolateral wall and inferior walls. The remaining
segments are mildly hypokineti (LVEF =30-35 %). No
intraventricular thrombi are identified. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild-moderate (1=2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. CONCLUSION: Dilated left ventricular cavity with
regional and global systolic dysfunction c/w multivessel CAD or
other diffuse process. Pulmonary aretry hypertension.
Mild-moderate mitral regurgitation. Moderate tricuspid
regurgitation. Mobile right atrial echodensity associated with
the pacing wire as described above most c/w thrombus. Increased
PCWP. Compared with the prior study (images reviewed) of
[**2199-1-7**] a mobile echodensity on the atrial pacing wire is now
seen. The heart rate is now slower. Other findings are similar.
Brief Hospital Course:
IMPRESSION: 68M with a PMH significant for coronary artery
disease (s/p PCI with stenting of LAD, [**4-/2195**]), alcoholic vs.
infarct-related dilated cardiomyoatphy (EF 20-25%), s/p
biventricular [**Year (4 digits) 3941**] placement in [**6-/2195**], persistent atrial
fibrillation (s/p multiple cardioversions), h/o embolic renal
infarct ([**2-/2195**]) with prior left atrial appendage thrombus,
alcohol abuse who presented with severe epistaxis and
coagulopathy requiring intubation for airway protection who was
stabilized and subsequently extubated, now with worsening acute
hypoxic respiratory failure, leukocytosis with AG-metabolic
acidosis and acute renal insufficiency.
.
PLAN:
# ACUTE HYPOXIC RESPIRATORY FAILURE - The patient initially
presented with epistaxis requiring intubation for airway
protection and was weaned from ventillation on [**1-5**] without
issues. Since floor transfer, the patient had developed
worsening acute hypoxic respiratory failure with oxygen
desaturations to the 80s on facemask with exam showing elevated
JVP, inspiratory crackles and peripheral edema; CXR with
evidence of pulmonary congestion with bilateral pleural
effusions concerning for overt overload. On admission, the
etiologies we considered were congestive heart failure
exacerbation (most likely) vs. pulmonary embolism vs. ARDS vs.
TRALI or late-transfusion related reaction vs. reactive airway
disease vs. infection or pneumonia (coagulase positive
Staphylococcus aureus [MSSA] in sputum culture from [**2199-1-4**]).
His clinical exam and imaging suggested that an acute systolic
failure exacerbation was most likely and we performed aggressive
diuresis. He diuresed 3L and appeared euvolemic with weaning to
only nasal cannula supplementation prior to discharge. ON
discharge, he was breathing comfortably on room air. We deferred
antibiotic treatment for his sputum culture, given that his
leukocytosis improved and he remained afebrile.
.
# ACUTE ON CHRONIC SYSTOLIC DYSFUNCTION - The patient had a
prior 2D-Echo from [**4-/2198**] showing LVEF of 20-25% with LV cavity
that was moderately dilated with some severe regional LV
systolic dysfunction with basal to mid inferior/inferolateral
akinesis and basal inferoseptal akinesis with anterior and
anterolateral hypokinesis elsewhere. 3+ TR and 1+ MR at that
time was noted, with mild pulmonary artery HTN and no
pericardial effusion. This admission, he presented with
coagulopathy and epistaxis requiring 4 units FFP and 1 unit
PRBCs (net positive 3L for LOS on CCU transfer) with clinical
exam suggestive of over volume overload. Etiologies or triggers
for acute decompensation would include: ACS/MI vs. infectious
etiology (positive sputum culture) vs. volume overload in the
setting of [**Year (4 digits) **] product administration vs. worsening valvular
disease. Based on our assessment, he appeared volume overloaded
in the setting of product administration. We aggressively
diuresed roughly 3L of fluid utilizing a Lasix gtt, without
issues. We had initially turned his pacing rate up to
accommodate aggressive diuresis. We then titrated back his home
heart failure regimen, which included Lisinopril, beta-blocker
(Carvedilol) and felt his Digoxin therapy had limited benefit so
this was discontinued. We also removed his LV pacing and a
repeat 2D-Echo showed 18% improvement in his stroke volume
without the pacing of the left ventricle, so this remained off.
On discharge, his home lasix was resumed.
.
# ACUTE RENAL INSUFFICIENCY, METABOLIC DERRANGEMENTS - The
patient presented with a baseline creatinine of 0.7-0.9 with
evidence of acute renal insufficiency to 1.2 trending to 1.7.
Patient also had an anion-gap metabolic acidosis with
compensatory respiratory component (and primary respiratory
alkalosis given work of breathing) with a lactate of [**6-26**],
leukocytosis trending from 13 to 18 (afebrile) which was
suggestive of poor forward flow and impaired perfuson of
peripheral tissues in the setting of decompensated heart failure
with or without an infectious source. Upon admission, we
performed aggressive diuresis and his creatinine improved to
baseline. We adjusted his pacer function to increase his
diuretic response. We renally dosed all medications and avoided
nephrotoxins. Creatinine was 0.8 on the day of discharge, so
lisinopril was increased to home dose.
.
# ACUTE LIVER INJURY, TRANSAMINITIS ?????? The patient presented with
no prior known liver dysfunction or evidence of liver failure on
exam with mild transaminitis in the past attributed to
Amiodarone use?; acute liver injury with moderate-severe
transaminitis noted on admission with AST 6854 and ALT 4790 with
hyperbilirubinemia to 5.1 and mild jaundice. INR 5.1 to 6.0 on
admission (on Coumadin). Albumin 3.2 (from 3.7 baseline).
Etiologies that we considered: congestive hepatopathy vs.
ischemic hepatopathy (recent hypotension) or shock liver vs.
acute viral hepatitis vs. toxin-mediated or medication-induced
(Amiodarone) vs. alcoholic liver disease vs. metabolic. No prior
ultrasounds or imaging was noted in our system. No sequelae of
chronic liver disease and no evidence of ascites was noted.
Evidence of natural immunity to hepatitis B and prior hepatitis
A exposure was noted based on hepatitis serologies. We employed
supportive management given his evidence of transaminitis with
coagulopathy and hyperbilirubinemia with hypoalbuminemia. His
iron studies: iron 30, TIBC 295, ferritin 1891 were reassuring.
Hepatitis serologies (HbsAg negative, HbsAb positive, HbcAb
positive, HCV-Ab negative, HAV-Ab positive) were consistent with
prior hepatitis A exposure and immunity due to natural infection
of hepatitis B. We avoided hepatotoxic medications (discontinued
Amiodarone) and monitored serial LFTs with overall marked
improvement.
.
# LEUKOCYTOSIS - the patient presented without initial
leukocytosis; but had coagulase positive Staphylococcus aureus
sputum culture, MSSA ([**1-4**]) with WBC trend from 13 to 18 (94%
neutrophilia) this admission; but he remained afebrile.
Infectious work-up in the setting of acute decompensated failure
was reassuring and
we deferred antibiotic therapy. He steadily improved, with
normalizing WBC and he remained afebrile this admission. His
urinalysis and urine/[**Month/Year (2) **] cultures were all unrevealing. His
CXR showed some concern for consolidation, but this was
conservatively monitored and not treated.
.
# CORONARIES - Coronary angiography last performed in [**4-/2195**]
showed a right dominant system with an LMCA with modest
calcification, the LAD had a hazy 80-90% stenosis in its
proximal portion and was stented. The LCx was a non-dominant
vessel with a 60% mid-segment lesion in the AV groove. The RCA
was a dominant vessel with mild luminal irregularities. Patient
had no complaints of chest pain this admission, but he did have
notable bleeding concerns on admission. His EKG was reassuring,
but AV-paced.
His cardiac biomarkers were reassuring. We did not initiate
statin treatment give his initial acute liver injury. We
restarted his daily Aspirin 5-days following his embolization
for epistaxis.
.
# ATRIAL FIBRILLATION, RHYTHM - The patient had placement of a
biventricular pacing device-[**Year (4 digits) 3941**] with OptiVol in [**2195**] with last
interrogation in [**10/2198**] that was reassuring; patient is
atrially paced with biventricular pacing. Interrogated on [**1-7**]
(this admission) which showed no arrhythmia events. 98%
[**Hospital1 **]-ventricularly pacing. History of persistent atrial
fibrillation s/p multiple cardioversions (last in [**2195**]) and on
chronic Amiodarone therapy. We opted to perform electrical
cardioversion this admission, with good result. His Coumadin was
resumed on [**1-10**] when his coagulopathy had resolved and he had
no further bleeding concerns.
.
# SEVERE EPISTAXIS, S/P IR-GUIDED EMBOLIZATION - The patient
presented with left-sided posterior epistaxis and coagulopathy
with INR of 5.2 requiring ENT consultation and Epistat packing
bilaterally. The bleeding progressed and required IR-guided
successful embolization of the right sphenopalatine artery and
embolization of the left sphenopalatine artery and left
desecending palatine artery utilizing coils ([**1-4**]) without
further bleeding concerns. Posterior packing removed by ENT
service on [**1-6**]. He had no further bleeding concerns and his
epistaxis improved. His coagulopathy resolved and he was
re-anticoagulated. He was antibiosed with Augmentin 875 mg PO
Q12H for 10-days for TSS prophylaxis (started [**1-2**]).
.
# HYPERTENSION - Home regimen includes ACEI, beta-blocker, loop
diuretic; we restarted his agents as clinically indicated given
acute CHF decompensation.
.
# ALCOHOL ABUSE HISTORY - He appears to have a history of
chronic alcohol abuse with current moderate-social alcohol
intake; monitored for withdrawal this admission, and he had no
evidence of withdrawal.
.
TRANSITION OF CARE ISSUES:
1. Lidocaine level sent (patient transiently on Lidocaine gtt
given his ventricular tachycardia) and should be followed-up by
Cardiology. He had episodic somnolence while being dosed this
medication.
2. Decreased Carvedilol from 25 to 12.5 mg PO BID. Consider
titrating back to home dosing prior to admission.
3. Started Aldactone 25 mg PO daily given his heart failure
symptoms and heart failure class.
4. Has scheduled follow-up with his primary care physician, [**Name10 (NameIs) **]
Dr. [**Last Name (STitle) **] from Cardiology. This appointment was made instead
of follow up with Drs. [**First Name (STitle) 437**] and [**Name5 (PTitle) **] [**Name5 (PTitle) **] patient
insistence.
5. Patient remains on anticoagulation for atrial fibrillation.
Will continue his Coumadin dosing of 1.5 mg PO 5 days a week, as
previous. Will need serial INR monitoring for goal INR [**2-22**].
6. Patient is going to Short Term Rehab.
Medications on Admission:
Amiodarone 200 mg a day
Coreg 25 mg twice per day
Digoxin 125 mcg daily
Lasix 40 mg in the morning if needed
Lisinopril 30 mg a day,
warfarin 1.5 mg 5 days a week Monday through Friday
Aspirin 162 mg a day
Magnesium 250 mg daily
Vitamin B complex daily
Calcium carbonate with D daily.
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
4. warfarin 1 mg Tablet Sig: 1.5 Tablets PO 5X/WEEK
(MO,TU,WE,TH,FR).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. magnesium oxide 250 mg Tablet Sig: One (1) Tablet PO once a
day.
7. B complex vitamins Tablet Sig: One (1) Tablet PO once a
day.
8. calcium carbonate-vitamin D3 Oral
9. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Center
Discharge Diagnosis:
Primary Diagnoses:
1. Acute hypoxic respiratory failure
2. Infarct-related cardiomyopathy with acute decompensated
systolic dysfunction
3. Incessant ventricular tachycardia
4. Epistaxis requiring embolization
.
Secondary Diagnoses:
1. Coronary artery disease
2. Infarct-related dilated cardiomyopathy
3. Hypertension
4. Persistent atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 10840**],
.
You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 regarding management of your
heart failure and your acute respiratory issues. When you were
admitted, you required IV medications to help remove extra
fluid, which improved your breathing. You also developed some
ventricular arryhthmia concerns which required IV
anti-arrhythmic medications and adjustments in your
[**Hospital Ward Name 3941**]/pacemaker. Your breathing and arrhythmia improved and were
discharged to rehab in stable condition.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 [**Hospital Ward Name **] or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have [**Hospital Ward Name **] in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
The following changes were made to your medications:
.
DISCONTINUE: Digoxin
DISCONTINUE: Amiodarone
.
CHANGE: Carvedilol from 25 to 12.5 mg by mouth twice daily
.
START: Spironolactone 25 mg by mouth daily
.
Please resume all other medications as you were previously
taking them.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2199-1-22**] at 2:30 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2199-1-28**] at 4:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OTOLARYNGOLOGY (ENT)
When: WEDNESDAY [**2199-1-30**] at 9:45 AM
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
|
[
"518.7",
"518.81",
"401.9",
"305.00",
"V53.32",
"428.23",
"276.4",
"593.9",
"427.31",
"293.0",
"416.8",
"286.7",
"V45.82",
"427.89",
"E934.7",
"412",
"425.4",
"600.00",
"570",
"784.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"39.75",
"96.71",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
25057, 25116
|
14157, 24043
|
314, 596
|
25511, 25511
|
7081, 7081
|
27546, 28496
|
5618, 5780
|
24379, 25034
|
25137, 25348
|
24069, 24356
|
25696, 27523
|
5795, 7062
|
25369, 25490
|
265, 276
|
624, 3892
|
7097, 7989
|
25526, 25672
|
8005, 9941
|
3914, 5370
|
5386, 5602
|
9958, 14134
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,901
| 193,073
|
46167
|
Discharge summary
|
report
|
Admission Date: [**2176-7-27**] Discharge Date: [**2176-8-4**]
Date of Birth: [**2109-11-23**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin Hcl / Penicillins / Bactrim / Cephalexin /
Nitrofurantoin / Dilantin / Tegretol / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
dizziness, nausea, vomiting, diarrhea, abdominal pain, LH
Major Surgical or Invasive Procedure:
1. Central line placement.
History of Present Illness:
66 y/o woman with hx. CRT [**2166**] who was recently admitted here
[**6-30**] for ARF c/b SVT requiring version, NSTEMI who presents
today from home c/o diarrhea, nausea, lightheadedness, vomiting,
generalized weakness, diminished po intake for 4-5 days. In the
ED, found to be AF, yet profoundly hypotense (47/32). She was
placed in trendelenburg, a rt. EJ was placed, and NS bolused. A
Rt. IJ cordis was placed and 2 units blood given as a small
amount of BRBPR noted, 4 litres of NS given. She was noted to
desaturate at this time to 88% on 6l nc, so NRB placed, and
fluids put to KVO, and levophed gtt started. BP to 203/175 on
levophed, then 119/56 on 0.4 ucg/kg/min. Sent for abd CT then
to MICU for sepsis.
Past Medical History:
1. Renal transplant in [**2166**] secondary to chronic reflux
nephropathy.
2. Status post craniotomy for an intracranial aneurysm.
3. Osteopenia.
4. Status post cholecystecomy
5. Status post appendectomy
6. Osteonecrosis of feet c/b osteomyelitis now on IV Vanco
7. Hx of c.dif
8. Hx of MRSA
9. NSTEMI - [**6-30**] - Catheterization did not result in
intervention.
Social History:
She is divorced and lives alone. She quit smoking 20 years ago.
She occasionally drinks alcohol.
Family History:
Non-contributory
Physical Exam:
VS: 98.6 67 104/45 15 100% on 6 L via NC
HEENT Pale, EOMI, PERRL
COR: Distant heart sounds, no MRG, RRR
PULM: Clear anteriorly
ABD: obese, soft, min llq ttp
EXT: 1+ edema, diffuse ecchymoses
NEURO: Fully alert and oriented, moves all four.
Pertinent Results:
RADIOLOGY:
==========
CT abdomen without contrast:
.
IMPRESSION:
1. No evidence of retroperitoneal hematoma or hemorrhage
collection within the abdomen or pelvis.
2. Interim development of [**Doctor First Name 9189**] mesentery, a nonspecific
finding. This could be related to edema in this patient.
Attention on followup scans is recommended. The stranding does
not appear to be localized around any particular abdominal or
pelvic structure.
3. Small amount of free fluid adjacent to the liver.
4. Pneumobilia unchanged.
5. Diffuse diverticulosis, without evidence of diverticulitis.
6. Trace right pleural effusion.
.
Portable chest after Rt. IJ cordis placement:
IMPRESSION: Interval widening of the mediastinum status post
right internal jugular line placement. Given this patient's
symptom of hypotension, further evaluation with a chest CT may
be warranted if clinically indicated. These findings were
discussed with the Emergency Department physician caring for the
patient, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8026**] at 9:00 p.m. on [**2176-7-27**].
.
Renal U/S [**2176-7-28**]: IMPRESSION: No significant change in
appearance of the transplanted kidney. No hydronephrosis. Patent
renal transplant vasculature with normal resistive indices.
Acute renal failure of a transplanted kidney with good blood
flow and normal arterial resistive indices is more commonly seen
with cyclosporine toxicity than rejection
.
ECHO [**2176-7-30**]: Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The inferior vena cava is
dilated (>2.5 cm). Left
ventricular wall thicknesses are normal. 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 low normal (LVEF 50%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated. Right
ventricular systolic function is borderline 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. There is no mitral valve prolapse. Mild to
moderate ([**11-27**]+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion
.
Compared with the findings of the prior study (images reviewed)
of [**2176-7-3**], the right ventricle is now significantly
dilated and hypocontractile; the left ventricular ejection
fraction is markedly increased. These findings raise the
suspicion for an acute pulmonary embolus
.
Lung Scan:INTERPRETATION:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views
demonstrate diffusely heterogeneous tracer activity without
focal defect. Perfusion images in the same 8 views show
heterogeneous tracer activity in a
pattern that matches the ventilation study. The ventilation and
perfusion images are similar to the prior study of [**2175-12-31**].
IMPRESSION: Low likelihood ratio for recent pulmonary embolus.
.
Portable Chest on [**2176-8-3**] after rales detected on lung exam.
IMPRESSION: Increased bilateral pleural effusions.
.
Admit Labs:
=========
* Urine Studies: URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.021
URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD RBC-[**5-4**]* WBC-21-50*
BACTERIA-MANY
* LACTATE-1.2
* CHEM 7: GLUCOSE-100 UREA N-57* CREAT-4.3*# SODIUM-131*
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-12* ANION GAP-23*
* CE's: CK(CPK)-147 CK-MB-3 cTropnT-0.08*
* CBC/DIFF: WBC-20.6*# RBC-4.06* HGB-11.0* HCT-32.8* MCV-81*
MCH-27.1 MCHC-33.6 RDW-16.7* NEUTS-86* BANDS-3 LYMPHS-6* MONOS-5
EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0
* COAGS: PT-12.5 PTT-27.6 INR(PT)-1.1
URINE CULTURE (Final [**2176-7-30**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 32 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
This is a 66 y/o woman with hx. CRT in [**2166**] with recent
admission at [**Hospital1 18**] for ARF attributed to N/V and HCTZ who
presents from home c/o LH, nausea, vomiting, diarrhea She was
found to be profoundly hypotense requiring volume and pressors,
WBC of 21 with bandemia. She was admitted to MICU for sepsis of
unclear etiology. She was started on broad spectrum antibiotics
including meropenem, levofloxacin, flagyl, and vancomycin. In
addition, her MMF was held out of concern that this was causing
diarrhea. Her hypotension resolved by day 4 and pressors were
weaned off. Her leukocytosis also resolved. She remained
otherwise hemodynamically stable.
.
Her urine culture returned as Kleb pneumonia sensitive to
levofloxacin and a number of other drugs. Meropenem was
discontinued as was vancomycin. Levofloxacin was continued to
complete fourteen day course. C. diff returned negative and
flagyl was therefore discontinued. The patient had stopped
having diarrhea by this time for three days.
.
Of note, an echocardiogram revealed RV dilatation with wide open
TR. She did not have signs of R heart failure. Cardiology was
notified they felt no assessment or intervention was necessary
on their part and recommended outpatient follow up.
.
With regard to her renal function, her creatinine was noted to
improve with volume resusciation. Renal transplant service was
consulted and they recommended continuation of all
immunosuppressive agents except MMF.
.
GI was consulted regarding her diarrhea. They suggested
obtaining microsporidia stain cyclospora stain, fecal cultures,
salmonella and shigella cultues, and campylobacter culture. A
CMV viral load was also ordered. These were all negative.
.
The patient was noted to be wheezing on physical exam, despite
feeling subjectively asymptomatic with respect to her breathing.
CXR reveal bilateral effusions. As these were not imparing the
patients functional capacity and were likely due to recovering
myocardium, volume overload, and prolonged hospitalization, the
patient was prepared for discharge.
.
Medications on Admission:
1. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Calcitriol 0.25 mcg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
5. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*11*
6. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Mycophenolate Mofetil 250 mg Capsule [**Hospital1 **]: One (1) Capsule PO
[**Hospital1 **] (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED) as needed for for
SOB/chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: 1-2 puffs
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
13. Lisinopril 20 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
14. Sirolimus 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Rapamycin check [**Hospital1 **]: One (1) rapamycin (sirolimus) check
Monday, [**2176-7-15**] for 1 days: Please fax results to:
[**Telephone/Fax (1) 3382**].
Disp:*1 check* Refills:*5*
Discharge Medications:
1. Prednisone 5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
2. Levofloxacin 250 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
4. Calcitriol 0.25 mcg Capsule [**Telephone/Fax (1) **]: Two (2) Capsule PO DAILY
(Daily).
5. Aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Amiodarone 200 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Nitroglycerin 0.3 mg Tablet, Sublingual [**Telephone/Fax (1) **]: One (1)
Sublingual As Directed.: Take one for chest pain. Wait 5
minutes. If you still have chest pain take a second. Wait
another 5 minutes. If you still have chest pain take a thrid
pill. If this still doesn't work, call 911 or EMS.
Disp:*1 bottle* Refills:*2*
9. Sirolimus 1 mg Tablet [**Telephone/Fax (1) **]: see below Tablet PO DAILY (Daily):
take 2 tablets M,W,F
take 1 tablet all other days.
10. Ipratropium Bromide 0.02 % Solution [**Telephone/Fax (1) **]: 1-2 puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
11. Acyclovir 200 mg Capsule [**Telephone/Fax (1) **]: Two (2) Capsule PO Q 24H
(Every 24 Hours).
12. Loperamide 2 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO QID (4 times
a day) as needed.
Disp:*120 Capsule(s)* Refills:*2*
13. Prilosec 20 mg Capsule, Delayed Release(E.C.) [**Telephone/Fax (1) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
15. Blood Work [**Telephone/Fax (1) **]: One (1) test once for 1 doses: Please
check: CBC, Chem 10, LFT's, Rapamune Level. Report to Dr
[**First Name (STitle) 10083**] ([**Telephone/Fax (1) 817**].
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
-Urosepsis
-Right ventricular dilation and high grade tricuspid
regurgitaion on echocardiogram
-Diarrhea
Discharge Condition:
Afebrile, vital signs stable. Ambulating well.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight changes more
than 3 pounds. Adhere to 2 gm sodium diet
Fluid Restriction:
Please do not drink more than 1 liter of fluid per day. This is
about the same volume as three cans of soda.
Please take all medications and make all appointments as listed
in the discharge paperwork. You are being discharged on
antibiotics please finish the entire course even if you feel
better.
If you have any fever, chills, chest pain, shortness of breath,
pain with urination or other concerning symptoms please call
your doctor or come to the emergency room.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], on [**8-13**] at 11:20AM. She will then refer you
to a cardiologist and to get an ECHO cardiogram.
.
Have your blood work checked next tuesday or wednesday at [**Hospital1 18**].
Call Dr. [**First Name (STitle) 10083**] [**Telephone/Fax (1) 3637**] the next day to check the
results.
.
Please set up follow up with nephrology with in the next [**11-27**]
weeks (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10083**]) ([**Telephone/Fax (1) 817**].
.
Other appointments:
Provider: [**Name10 (NameIs) 9977**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2176-9-11**]
10:20
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2176-8-5**]
|
[
"427.31",
"397.0",
"733.90",
"424.0",
"599.0",
"996.81",
"041.3",
"511.9",
"E878.0",
"412",
"995.92",
"038.9",
"584.9",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13317, 13375
|
7021, 9109
|
441, 471
|
13524, 13574
|
2038, 6998
|
14232, 15136
|
1742, 1760
|
11216, 13294
|
13396, 13503
|
9135, 11193
|
13598, 14209
|
1775, 2019
|
343, 403
|
499, 1222
|
1244, 1610
|
1626, 1726
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,341
| 150,751
|
5035
|
Discharge summary
|
report
|
Admission Date: [**2146-9-20**] Discharge Date: [**2146-9-26**]
Date of Birth: [**2077-11-3**] Sex: M
Service: SURGERY
Allergies:
lisinopril
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Infected Right Fem-[**Doctor Last Name **] bypass graft
Major Surgical or Invasive Procedure:
PROCEDURE [**2146-9-20**]: Removal of infected right graft, and
replacement with right common femoral to below-knee popliteal
artery bypass with non-reversed left greater saphenous vein and
angioscopy
History of Present Illness:
This a 68-year-old gentleman who had a right femoral above-knee
popliteal artery bypass performed with a prosthetic graft on
[**2145-12-6**]. The graft required a stent placement
postoperatively. Ultimately, he developed an open
wound at the level of the popliteal exposure, a graft infection
with severe Staphylococcus bacteremia, and nearly died as result
of multisystem organ failure of sepsis. He subsequently
recovered from that; but has still had a
nonhealing wound in his groin, and a draining sinus at his
popliteal space. A CT angiogram showed that his graft was
nearly eroding through the skin, and that there was a stent in
it, making it somewhat rigid. It was also very redundant, and
there was a large inflammatory mass around it. An
arteriogram showed that his the below-knee popliteal artery was
a suitable target with anterior tibial and posterior tibial
runoff distally. His right saphenous vein had previously been
partially harvested.
Past Medical History:
PMH: MI s/p CABG (used right leg vein and his right
radial artery), pacer, MRSA infection
PSH: [**2145-12-6**] right femoral above-knee to popliteal bypass with
a PTFE graft (Dr. [**Last Name (STitle) 20793**]- complicated by wound infection and
sepsis
Social History:
Lives with wife
Retired
Former tobacco use, stopped more than 1 year ago
Alcohol: [**4-15**] drinks/week
Denies recreational drug use
Family History:
n/c
Physical Exam:
Discharge Physical Exam:
Tmax 991, HR 75, BP 124/48, RR 18, O2 sat 96% RA
General: A&Ox3, NAD
Neuro: CN II-XII grossly intact
Lungs: CTA bilat, no resp distress
Heart: RRR, nl S1/S2, no MRG appreciated
Abd: NBS, soft, nt, nd, no rebound/guarding
Wounds: CDI, no erythema/induration
Extremities: no CCE
LE Pulses:
Left palp fem, dop DP, dop PT
[**Name (NI) 167**] palp fem, dop DP, dop PT
Pertinent Results:
[**2146-9-20**] 02:15PM BLOOD WBC-8.6 RBC-3.54* Hgb-11.6* Hct-30.7*
MCV-87 MCH-32.6* MCHC-37.7* RDW-14.8 Plt Ct-178
[**2146-9-20**] 09:09PM BLOOD WBC-8.6 RBC-3.46* Hgb-10.6* Hct-30.3*
MCV-88 MCH-30.7 MCHC-34.9 RDW-14.5 Plt Ct-145*
[**2146-9-21**] 04:30AM BLOOD WBC-9.5 RBC-3.26* Hgb-9.9* Hct-27.9*
MCV-85 MCH-30.3 MCHC-35.5* RDW-14.4 Plt Ct-132*
[**2146-9-22**] 02:06AM BLOOD WBC-8.8 RBC-3.00* Hgb-9.0* Hct-26.5*
MCV-88 MCH-30.1 MCHC-34.0 RDW-14.3 Plt Ct-157
[**2146-9-22**] 11:47AM BLOOD WBC-12.2* RBC-3.18* Hgb-9.6* Hct-28.5*
MCV-89 MCH-30.1 MCHC-33.7 RDW-14.2 Plt Ct-180
[**2146-9-23**] 06:27AM BLOOD WBC-6.7 RBC-2.57* Hgb-7.9* Hct-21.9*
MCV-85 MCH-30.9 MCHC-36.2* RDW-14.0 Plt Ct-122*
[**2146-9-23**] 09:52AM BLOOD WBC-7.4 RBC-2.63* Hgb-8.2* Hct-23.1*
MCV-88 MCH-31.1 MCHC-35.4* RDW-14.0 Plt Ct-144*
[**2146-9-23**] 11:45AM BLOOD WBC-7.8 RBC-2.65* Hgb-8.2* Hct-23.4*
MCV-88 MCH-31.0 MCHC-35.2* RDW-14.1 Plt Ct-154
[**2146-9-23**] 10:00PM BLOOD WBC-7.2 RBC-2.96* Hgb-9.4* Hct-25.9*
MCV-87 MCH-31.6 MCHC-36.2* RDW-14.1 Plt Ct-144*
[**2146-9-24**] 08:00AM BLOOD Hct-27.8*
[**2146-9-25**] 05:40AM BLOOD WBC-8.0 RBC-3.04* Hgb-9.4* Hct-26.9*
MCV-89 MCH-30.8 MCHC-34.8 RDW-14.7 Plt Ct-173
[**2146-9-26**] 05:08AM BLOOD WBC-8.6 RBC-3.08* Hgb-9.5* Hct-27.3*
MCV-89 MCH-30.7 MCHC-34.7 RDW-14.9 Plt Ct-215
[**2146-9-20**] 02:15PM BLOOD PT-13.5* INR(PT)-1.1
[**2146-9-20**] 02:15PM BLOOD Plt Ct-178
[**2146-9-21**] 04:30AM BLOOD PT-13.6* PTT-28.2 INR(PT)-1.2*
[**2146-9-21**] 04:30AM BLOOD Plt Ct-132*
[**2146-9-26**] 05:08AM BLOOD Plt Ct-215
[**2146-9-20**] 02:15PM BLOOD Fibrino-343
[**2146-9-20**] 02:15PM BLOOD Glucose-98 UreaN-44* Creat-1.6* Na-133
K-7.4* Cl-105 HCO3-21* AnGap-14
[**2146-9-20**] 09:09PM BLOOD Glucose-76 UreaN-40* Creat-1.6* Na-139
K-6.2* Cl-111* HCO3-23 AnGap-11
[**2146-9-21**] 01:17AM BLOOD Glucose-151* UreaN-38* Creat-1.6* Na-136
K-7.0* Cl-107 HCO3-23 AnGap-13
[**2146-9-21**] 04:30AM BLOOD Glucose-193* UreaN-35* Creat-1.6* Na-136
K-7.0* Cl-107 HCO3-25 AnGap-11
[**2146-9-21**] 09:09AM BLOOD Glucose-134* UreaN-31* Creat-1.4* Na-138
K-6.8* Cl-106 HCO3-27 AnGap-12
[**2146-9-21**] 02:30PM BLOOD Na-136 K-5.7* Cl-104
[**2146-9-21**] 06:47PM BLOOD Glucose-104* UreaN-26* Creat-1.2 Na-136
K-5.9* Cl-104 HCO3-24 AnGap-14
[**2146-9-22**] 02:06AM BLOOD Glucose-107* UreaN-23* Creat-1.2 Na-134
K-5.2* Cl-102 HCO3-25 AnGap-12
[**2146-9-22**] 11:47AM BLOOD Glucose-155* UreaN-20 Creat-1.2 Na-131*
K-5.1 Cl-97 HCO3-27 AnGap-12
[**2146-9-23**] 06:27AM BLOOD Glucose-96 UreaN-20 Creat-1.2 Na-130*
K-4.4 Cl-94* HCO3-30 AnGap-10
[**2146-9-24**] 08:00AM BLOOD Creat-1.4* Na-133 K-4.5 Cl-96
[**2146-9-25**] 05:40AM BLOOD Glucose-52* UreaN-27* Creat-1.1 Na-134
K-4.0 Cl-99 HCO3-28 AnGap-11
[**2146-9-26**] 05:08AM BLOOD Glucose-52* UreaN-30* Creat-1.2 Na-138
K-4.0 Cl-102 HCO3-29 AnGap-11
[**2146-9-20**] 09:09PM BLOOD CK(CPK)-61
[**2146-9-21**] 04:30AM BLOOD CK(CPK)-52
[**2146-9-21**] 09:09AM BLOOD CK(CPK)-60
[**2146-9-20**] 09:09PM BLOOD CK-MB-3 cTropnT-<0.01
[**2146-9-21**] 04:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2146-9-21**] 09:09AM BLOOD CK-MB-3 cTropnT-<0.01
[**Known lastname 5684**],[**Known firstname **] [**Medical Record Number 20794**] M 68 [**2077-11-3**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2146-9-22**] 7:23
AM
[**Last Name (LF) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] CSRU [**2146-9-22**] 7:23 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 20795**]
Reason: eval for pulmonary congestion
[**Hospital 93**] MEDICAL CONDITION:
68 year old man s/p LE bypass
REASON FOR THIS EXAMINATION:
eval for pulmonary congestion
Final Report
INDICATION: 78-year-old male status post lower extremity bypass.
Evaluate
for pulmonary congestion.
EXAMINATION: Single frontal chest radiograph.
COMPARISONS: [**2146-9-20**].
FINDINGS:
A left approach internal jugular venous catheter tip terminates
at the
confluence of the brachiocephalic/SVC junction. Biventricular
PPM/AICD leads are in standard positions. The uppermost median
sternotomy wire is fractured. The remainder of the median
sternotomy wires are intact. Low lung volumes accentuate a
borderline heart size. The lungs are clear. There are no pleural
effusions or pneumothorax. The cardiomediastinal and hilar
contours are normal. Pulmonary vascularity is normal.
IMPRESSION: No acute cardiopulmonary process.
EKG: Sinus rhythm at upper limits of normal rate with
biventricular pacing. Since
the previous tracing the sinus rate has increased.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
100 0 132 354/424 0 -56 109
**RENAL CONSULT NOTE
Note Date: [**2146-9-21**]
Signed by [**Name6 (MD) **] [**Name6 (MD) **], MD on [**2146-9-21**] at 5:37 pm Affiliation:
[**Hospital1 18**]
Cosigned by [**Name (NI) 1877**] [**Last Name (NamePattern1) 1878**], MD, PHD on [**2146-9-21**] at 5:47 pm
Reason for Consult: Hyperkalemia
HPI: Mr. [**Known lastname **] is a 68 year old gentleman with a history of CAD
(s/p CABG), PVD, CHF (EF30% s/p AICD) who was directly admitted
for scheduled removal of infected R fem-[**Doctor Last Name **] graft on [**9-20**].
Initial
labs were sent from pre-op holding that showed potassium of 7.4.
The patient's hyperkalemia was treated aggressively in the OR
and
afterwards in the CVICU with kayexalate, IV lasix, calcium
gluconate, albuterol, and insulin.
Of note, in [**Month (only) 404**] of this year the patient developed a staph
infection of his R fem-[**Doctor Last Name **] graft that caused bacteremia and
septic shock. According to his family, he spent 1 month in the
ICU at [**Hospital3 **] hospital and then 3 additional months in
hospitals/rehabs. At this point his family reports that he still
has residual osteomyelitis and is on suppressive doxycycline.
During his stay in the ICU he developed acute kidney injury but
otherwise does not have any known history of kidney dysfunction.
The patient was admitted to [**Hospital1 18**] on [**8-10**] for angiography of his
infected fem-[**Doctor Last Name **] bypass. During that admission he was noted to
have creatinines up to 1.6 (above baseline of 0.8-1.1). His
potassium on arrival on [**8-10**] was 6.8 which with treatment was
normalized to 4.2 prior to discharge.
On [**2146-8-12**] he was discharged on his home medication regimen which
notably included KCL 20meq daily, Carvedilol, Spironolactone,
losartan, and digoxin. After discharge he saw his PCP who
according to patient's family (records not available at this
time) stopped KCL and his multivitamin but kept his medications
the same otherwise. However KCL was listed as a home med in the
nursing intake prior to surgery on [**9-20**]. It is uncertain if a
potassium was checked in that period. There is none in our
system. The next potassium measurement that we have in our
system
is from [**9-20**] which was drawn prior to surgery and was 7.4. He
received 2 units of pRBCs in the OR.
PMH:
MI s/p CABG
sCHF (EF 30%) s/p AICD
PVD s/p right femoral above-knee to popliteal bypass with a PTFE
graft - complicated by wound infection and sepsis
HTN
HLD
Home Meds:
CARVEDILOL 25 mg [**Hospital1 **]
DIGOXIN 250 mcg qd
LOSARTAN 25 mg qd
SPIRONOLACTONE 50 mg qd
POTASSIUM CHLORIDE 20mEq qd (?DC'ed?)
MULTIVITAMIN qd (?DC'ed?)
BACTRIM DS (finished [**9-19**])
DOXYCYCLINE HYCLATE 100 mg [**Hospital1 **]
FUROSEMIDE 20 mg
ISOSORBIDE MONONITRATE 30 mg qd
TAMSULOSIN 0.4 mg qd
CLOPIDOGREL 75 mg qd
ASPIRIN 81 mg qd
FAMOTIDINE 20 mg [**Hospital1 **]
GLIPIZIDE 10 [**Hospital1 **]
NOVOLOG SSI
SITAGLIPTIN 100 mg qd
HYDROXYZINE 25 mg qd
LIDOCAINE 5 % patch qd
METFORMIN 1,000 mg [**Hospital1 **]
OXYCODONE prn
LOVAZA 1gram [**Hospital1 **]
SIMVASTATIN 40 mg qd
Allergies: lisinopril
Family History:
non-contributory
Physical Exam:
VS 96.3 143/48 72 18 100% on RA
Gen: NAD, A+OX3
CV: RRR, 2/6 Systolic Murmur at LUSB.
Pulm: CTAB
Abd: Healing scabs on abdomen from prior disseminated rash.
Soft,
NT, ND. No HSM
Ext: Wound dressing clean dry and intact.
GU: Foley in place
Skin: Erythematous maculopapular rash on arms that is reportedly
much improved from prior
Labs: See OMR
Assessment/Plan: Mr. [**Known lastname **] is a 68 year old gentleman with a
history of CAD (s/p CABG), PVD, CHF (EF30% s/p AICD) who was
directly admitted for scheduled removal of infected R fem-[**Doctor Last Name **]
graft on [**9-20**] and was found to have hyperkalemia on arrival.
1. Hyperkalemia: After reviewing the time course from the
records
available it appears that this is most likely related to the
patient's home medications. Patient also arrived hyperkalemic
during the previous hospitalization on [**8-10**] and was treated
appropriately but was discharged on his previous home
medications
which included spironolactone, losartan, carvedilol, and KCL.
Additionally, patient arrived on [**9-20**] having just completed a
course of TMP/SMX on [**9-19**] which can also cause hyperkalemia.
- Agree with primary team's management of acute hyperkalemia
including frequent K checks, telemetry, and IV lasix.
- Would restart carvedilol prior to discharge as its effects on
potassium are typically small and cardiovascular benefit is
likely greater.
- Patient should have close follow-up (2-4 days) after discharge
with both PCP and his cardiologist Dr. [**Last Name (STitle) **]. He will need
frequent
electrolyte checks until his medication regimen is stabilized.
Would not restart losartan or spironolactone prior to discharge.
If patient's cardiologist feels that benefit for treatment of
CHF
outweighs risk, would restart losartan or spironolactone one at
a
time and at low dose with frequent electrolyte checks.
- Not entirely clear why patient was on TMP/SMX in addition to
doxycycline. Would avoid TMP in the future if possible, but if a
reasonable alternative is not available then would continue with
close electrolyte monitoring. TMP does not appear to have been
the predominant cause of his hyperkalemia as he was not taking
it
during his [**8-10**] admission.
- Please contact patient's PCP (Dr. [**Last Name (STitle) 20796**] to discuss medication
changes and also to gather collateral information including
interim potassium measurements if available. Also will need to
clarify duration of antibiotic therapy as patient's family
mentioned osteomyelitis however I do not have any records of
that
available.
- Please page renal fellow with any questions.
[**First Name4 (NamePattern1) 915**] [**Last Name (NamePattern1) **] MD [**Last Name (Titles) 4207**]-1
Addendum by [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], MD, PHD on [**2146-9-21**] at 5:47 pm:
On the day of service I was present with and reviewed the note
of
Dr. [**Last Name (STitle) **] for the key portion of the service provided. I agree
with the findings and plan of care.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**], MD PhD
Brief Hospital Course:
Mr. [**Known lastname **] was admitted as same day admission on [**2146-9-20**] and
underwent Removal of infected right graft, and replacement with
right common femoral to below-knee popliteal artery bypass with
non-reversed left greater saphenous vein and angioscopy. He was
started on Vancomycin, Ciprofloxacin, and flagyl
postoperatively. He tolerated the procedure well and was
transferred to the PACU. In the PACU, he was hyperkalemic with K
of 7.4, which was treated with bicarb, lasix, regular insulin,
and dextrose and K went down to 6.2. He was also hypotensive
with SBP 90s and tachycardic, so was transferred to the
cardiovascular ICU. The following day POD1, nephrology was
consulted for input regarding hyperkalemia. They recommended
that we hold spironolactone and losartan and have the patient
follow up 2-4 days after discharge. On POD 3, the patient
received concurrent lasix and NS boluses to reduce potassium and
promote diuresis. He was transferred out of ICU to stepdown ICU.
POD4, the patient received 2 units of packed red blood cells
with lasix for hematocrit of 22. Post hematocrit bumped
appropriately to 25. On POD 5, the patient was hypoglycemic to
52 with am labs and received dextrose IV. His blood sugars were
within normal limits the remainder of the day. Physical therapy
was consulted and the patient was deemed safe for home. On POD
6, he was again hypoglycemic to 58 with am labs. It was decided
to continue to hold Januvia and have the patient follow up with
his PCP. [**Name10 (NameIs) **] antibiotics were discontinued and PICC line was
removed. He was restarted back on doxycycline and will follow up
with his infectious Disease physician. [**Name10 (NameIs) **] the day of discharge,
he patient was ambulating independently, voiding adequate
amounts, with pain well controlled. Potassium was 4.0 at the
time of discharge. Patient is scheduled to follow up with his
PCP and cardiologist for potassium check and follow up of
medication regimen.
Medications on Admission:
aspirin 81mg po daily
clopidogrel 75mg po daily
digoxin 250mcg po daily
Imdur 30mg po daily
Carvedilol 25mg po daily
Losartan 25mg po daily
spironolactone 50mg po daily
Furosemide 20mg po daily
Klor con 20mEq po daily
Famotidine 20mg po BID
Vit C
Mag Oxide 400mg po BID
Simvastatin 40mg po daily
Tamsulosin 0.4mg po daily
Glipizide 10mg po BID
Metformin 1000mg po BID
Januvia 100mg po daily
Doxyclycine 100mg po BID
Lactobacillus
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. carvedilol 25 mg Tablet Sig: One (1) Tablet PO once a day.
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
11. doxycycline hyclate 100 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
14. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 7 days: Do not drive, drink
alcohol, or operate heavy machinery while taking this
medication. Use stool softeners to prevent constipation.
Disp:*40 Tablet(s)* Refills:*0*
16. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day:
Per home regimen.
17. Lovaza 1 gram Capsule Sig: One (1) Capsule PO twice a day.
18. lactobacillus acidophilus Capsule Sig: One (1) Capsule
PO twice a day: Per home regimen.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8930**] Home Care
Discharge Diagnosis:
Infected right femoral-popliteal graft
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
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 [**3-17**]
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
We have stopped your losartan, spironolactone, and Klor-Con at
the request of the renal doctors [**Name5 (PTitle) **] to your elevated potassium
levels when you came in to the hospital. Please see your PCP
this Wednesday and frequently thereafter to have your potassium
checked and to discuss restarting these medications if needed.
You should also follow up with Dr. [**Last Name (STitle) **] this week to discuss
restarting these medications if needed.
We have also held your Januvia due to your low blood sugars in
the morning. Please discuss this with Dr. [**Last Name (STitle) **] at your
appointment as well.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2146-10-3**] 1:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 19980**]
Date/Time: [**2146-9-28**] 10:00 am - To discuss elevated Potassium
levels while in hospital, medication regimen, and low morning
blood sugars. Discharge summary faxed to Dr.[**Last Name (STitle) 20797**] office.
Please follow up with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] this week to discuss your
medications.
Please follow up with your Infectious Disease Doctors.
Keep your appointment with Dr. [**Last Name (STitle) 20798**] for R foot wound care.
Completed by:[**2146-9-26**]
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53,964
| 168,567
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46678
|
Discharge summary
|
report
|
Admission Date: [**2153-6-13**] Discharge Date: [**2153-6-21**]
Date of Birth: [**2069-12-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Intubation, Mechanical Ventilation
Arterial Line placement
Central line placement
History of Present Illness:
83 year old male with multiple medical problems including [**Name2 (NI) **]
glioblastoma, coronary artery disease, aortic stenosis, and
hypertension was admitted from the ED with 4 days of cough and
fever.
He initially presented to his PCP [**Name Initial (PRE) **] week ago for cough, nasal
congestion, and sore throat. He was diagnosed with postnasal
drip and given a decongestant with little relief. Pt developed
increasing fatigue and chills over the past four days
accompanied by decreased po intake. This AM, his VNA noted a
fever to 103.1 as well as "low blood pressure," and referred him
to his PCP who sent him to the ED. Of note, pt completed his
last round of chemo/RT on [**2153-5-23**] and has since been on a
chronic steroid taper. He denies any sick contacts or recent
travel. No associated chest pain, shortness of breath, dizziness
or lightheadedness.
.
Upon arrival to the ED, VS: T 98.6, HR 74, BP 94/64. RR 18, and
pulse ox 98% on RA. His exam was notable for rales over RLL. His
labs were notable for lactate of 2.2. CXR demonstrated new
diffuse bilateral parenchymas opacity suggestion of pulmonary
edema and pneumonia. He received ceftriaxone 2gm VI x 1,
azithromycin 500mg IV x 1, and vancomycin 1g IV x 1 as well as
2.8L NS IV fluids and was subsequently transferred to the [**Hospital Unit Name 153**].
.
On the unit, pt reports continued fatigue, congestion, and sore
throat. ROS significant for abdominal discomfort and
constipation. No dysuria. No headache or neck stiffness.
Past Medical History:
1. Glioblastoma multiforme
2. Prostate Cancer
3. HTN
4. Hyperlipidemia
5. Total hip replacement
6. Erectile dysfunction
7. H/o hematuria
8. Aortic stenosis
9. Coronary artery disease
10. Irritable bowel syndrome
11. Lower back pain
12. Spinal stenosis
13. Osteoarthritis
14. Bilateral extensor tendon subluxation
Social History:
Home: Widowed and lives by himself; has VNA services 3x/week.
Occupation: Retired furrier.
EtOH: one shot of Scotch a day
Drugs: denies any recreational drug use
Tobacco: quit 30 years ago. He has about a 40-pack-year history
of smoking. He smoked two packs a day for 20 years
Family History:
- Mother: died in her 20s of childbirth.
- Father: died at 86 of renal failure.
Physical Exam:
The patient had no distal pulses, heart and lung sounds could
not be appreciated. Pupils fixed and dilated. Time of death
1:25pm.
Pertinent Results:
[**2153-6-13**] 02:10PM BLOOD WBC-6.3 RBC-3.73* Hgb-11.5*# Hct-33.1*#
MCV-89 MCH-30.8 MCHC-34.8 RDW-16.8* Plt Ct-141*
[**2153-6-13**] 02:10PM BLOOD Neuts-84.5* Lymphs-12.2* Monos-2.4
Eos-0.6 Baso-0.3
[**2153-6-13**] 02:10PM BLOOD PT-12.5 PTT-23.7 INR(PT)-1.1
[**2153-6-13**] 02:10PM BLOOD Glucose-82 UreaN-33* Creat-1.0 Na-144
K-3.8 Cl-108 HCO3-27 AnGap-13
[**2153-6-13**] 02:10PM BLOOD ALT-41* AST-46* LD(LDH)-492* AlkPhos-61
TotBili-0.8
[**2153-6-13**] 02:31PM BLOOD Lactate-2.2*
[**2153-6-13**] 06:22PM BLOOD Lactate-1.5
[**2153-6-13**] 11:58PM BLOOD Lactate-1.7
.
Micro:
[**2153-6-13**] Blood cultures
[**2153-6-13**] Urine culture
[**2153-6-13**] Legionella Ag: negative
[**2153-6-13**] Influenza DFA
.
Imaging:
.
[**2153-6-13**] CT head:
1. No acute intracranial pathology in the interval.
2. Hypodense left inferior collicular lesion which demonstrates
interval
decrease in density.
3. Unchanged right basal ganglia developmental venous anomaly.
.
[**2153-6-13**] CXR:
Brief Hospital Course:
83yo male with multiple medical problems including [**Name2 (NI) 99087**]
multiforme was admitted with fever and CXR findings suggestive
of pneumonia. After a prolonged course of hemodynamic
instability while ventilated, the family was consulted and
decided to focus on patient comfort. A moprhine drip was
started, his endotracheal tube was removed and he passed moments
later.
1. Pneumocystis pneumonia. Patient presented with increasing
respiratory distress in the setting of a steroid wean for his
brain cancer. He was initially covered broadly including
atipical and PCP [**Name Initial (PRE) 21150**]. His initial oxygenation on his ABG
was 40 and his was placed on 100% FiO2 which increased him to
about 80. A CMV viral load came back elevated but ID did not
real it warrented treatment given his immunosupression from
steroids. He did not improve and required intubation on [**2153-6-15**].
A BAL revealed PCP. [**Name10 (NameIs) **] patient was started on therapy
including steroids.
2. HTN: Patient arrived hypotensive and septic. His BP
medications were held and aggressive fluid resuscitation was
initated. He required blood pressure support at times to keep
his MAP > 65. After his initial fluids, he was volume
overloaded and required diuresis.
3. Thrush: Likely [**3-12**] immunosuppression on dexamethasone taper.
The patient was continued on Nystatin and prn medication for
comfort
4. GBM: Currently on prolonged dexamethasone taper [**3-12**] radiation
with resultant edema in brainstem. The patient's dexamethasone
taper was overridden by high dose steroids for PCP [**Name Initial (PRE) **].
Medications on Admission:
1. Atenolol 75mg PO daily
2. Atorvastatin 80mg PO daily
3. Dexamethasone taper 2mg
4. Nystatin suspension qid
5. Pantoprazole 40mg PO daily
6. Quinapril 20mg PO daily
7. Chondroitin Sulfate
8. Ibuprofen prn
9. Multivitamin daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Glioblastoma Multiforme
Pneumocystis Pneumonia
Discharge Condition:
Expired
Discharge Instructions:
Followup Instructions:
|
[
"607.84",
"401.9",
"785.52",
"112.0",
"253.6",
"995.92",
"V10.46",
"038.9",
"707.03",
"348.5",
"518.81",
"276.4",
"414.01",
"136.3",
"715.90",
"285.9",
"272.4",
"424.1",
"564.1",
"724.00",
"V15.3",
"191.8",
"518.4",
"707.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"96.72",
"38.91",
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5777, 5786
|
3838, 5465
|
322, 406
|
5877, 5887
|
2838, 3573
|
5940, 5940
|
2589, 2671
|
5745, 5754
|
5807, 5856
|
5491, 5722
|
5913, 5913
|
2686, 2819
|
277, 284
|
434, 1942
|
3582, 3815
|
1964, 2278
|
2294, 2573
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,739
| 167,534
|
16218
|
Discharge summary
|
report
|
Admission Date: [**2105-8-13**] Discharge Date: [**2105-8-21**]
Date of Birth: [**2054-7-8**] Sex: F
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
woman with hepatic failure likely secondary to alcohol abuse,
now sober for the past 18-19 months. The patient's hepatic
failure has led to grade I esophageal varices, ascites,
portal hypertension, encephalopathy, and jaundice. Her
recent laboratories have shown increased lipase and recent
right upper quadrant ultrasound showed reversible flow
consistent with cirrhosis. The patient was recently
discharged from the hospital after having abdominal pain,
emesis, and chills. The patient is now admitted for a liver
transplant to the [**Hospital1 69**].
PHYSICAL EXAMINATION: Vital signs: Temperature 97.9
degrees, blood pressure 102/48, heart rate 76, respiratory
rate 16, 100 percent on room air. General: The patient was
in no apparent distress and was alert and oriented times
three. Heart: The heart revealed a regular rate and rhythm
with no murmurs, rubs, or gallops. Lungs: Her lung
examination was clear to auscultation bilaterally with no
wheezes, rales, or rhonchi. Abdomen: The patient's abdomen
was nondistended with normoactive bowel sounds, soft and
nontender throughout. Her distal pulses were 2+ and she had
no distal edema at this time.
HOSPITAL COURSE: Thus, the patient was admitted at this time
with long-standing hepatic failure and the patient was
consented and preoperatively examined for liver transplant.
Laboratories, x-rays, and EKG were within normal limits and
the patient was brought down to the Operating Room for
transplant. The patient was typed and crossed preoperatively
for 2 units of blood. The patient tolerated the procedure
very well and was brought postoperatively to the Surgical
Intensive Care Unit. The patient came from the Operating
Room intubated and sedated at this time. The patient later
that day was still intubated but was taken off sedation and
was following commands and her physical examination was
within normal limits. The plan at this time was to keep the
patient intubated, control the patient's pain and give the
patient intravenous fluids for hydration.
On postoperative day number one, the patient was noted to be
doing very well in the Intensive Care Unit, was still off
sedation. The patient was being followed by the Surgical
Intensive Care Unit during this time and extubation was
performed on the first postoperative day in the Surgical
Intensive Care Unit. The patient tolerated this well.
On postoperative day number two, [**2105-8-15**], the patient
continued to progress well and stated that she was
comfortable and was now on the floor and was very happy with
having proceeded with the transplant. The plan at this time
was to continue her Solu-Medrol taper. The patient was on
Neoral at this time of 200 and 200 and CellCept 1 gram and 1
gram.
On [**2105-8-16**], the patient continued to progress well.
Early that morning, she had one episode of anxiety and
shortness of breath which was treated with Lasix and Haldol
and the patient noted later that morning to be feeling
significantly more comfortable and felt less anxious and less
short of breath than she had the previous evening and early
morning. The patient's immunosuppressive regimen was
continued during this time.
On [**2105-8-17**], postoperative day number four, the patient
was resting comfortably and noted that her pain was well
controlled. Her vital signs were within normal limits. The
patient was afebrile and the patient's central line was
removed and her Foley catheter was removed. The patient was
placed on Colace and Dulcolax to encourage bowel movements.
On [**2105-8-18**], the patient began to be evaluated by
Physical Therapy at this time for mobility, endurance, and
ability to be safe at home or at rehabilitation. They noted
that the patient was doing very well functionally and
anticipated a safe return to home after one to two physical
therapy sessions. On the next day, the Physical Therapy
Service noted that the patient was able to be discharged home
safely in terms of her functional mobility and recommended
home physical therapy due to the patient's history of
occasional falls at home. They recommended that the patient
ambulate at least four times per day during her hospital
stay.
On [**2105-8-19**], postoperative day number six, the patient
noted improvement in her appetite, was continuing to do very
well and was passing gas and having bowel movements at this
time. The patient was being screened actively for
rehabilitation or to go home and it was determined that all
of her medications could be taken orally at this time.
On [**2105-8-20**], postoperative day number seven, the patient
continued to progress well. It was noted that there was a
slight increase in her total bilirubin levels and alkaline
phosphatase levels from the previous days and a liver
ultrasound was arranged to assess arteriovenous flow to the
graft organ. The study came back normal and revealed normal
flow to the graft. Her medial [**Location (un) 1661**]-[**Location (un) 1662**] drain was taken
out at this time.
On [**2105-8-21**], postoperative day number eight, the day of
discharge, the patient continued to do well and had no
complaints, was tolerating a full diet, was out of bed and
ambulating. She was afebrile at this time and had one
[**Location (un) 1661**]-[**Location (un) 1662**] in draining small amounts of serosanguinous
fluid from the lateral aspect of her peritoneal cavity.
On [**2105-8-21**], postoperative day number eight, it was
noted that the patient's liver function tests trended
downwards again on this day and liver biopsy would not be
necessary at this time and that these laboratories could be
followed-up in the [**Hospital 1326**] Clinic as an outpatient and the
patient was able to be discharged to home at this time and
was in stable condition.
DISCHARGE DIAGNOSES: Status post orthotopic liver
transplant.
Alcoholic cirrhosis.
Grade I varices.
Portal hypertension.
Encephalopathy.
Hypothyroidism.
Endometriosis.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient is to be discharged to home with
visiting nurse assistance for once daily drain care and
emptying, glucose monitoring, and home safety evaluation and
instruction. The patient was able to be placed on a regular
diet and advanced as tolerated to home.
DISCHARGE MEDICATIONS:
1. MMF 1,000 mg p.o. b.i.d.
2. Protonix 40 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Percocet one to two tablets p.o. q. 4-6 hours p.r.n. pain.
5. Valganciclovir 150 mg p.o. b.i.d.
6. Fluconazole 200 mg p.o. q.d.
7. Cyclosporin 125 mg p.o. b.i.d.
8. Prednisone 15 mg p.o. q.d.
9. Bactrim single-strength one tablet p.o. q.d.
10. Lasix 20 mg p.o. q.d.
11. Benadryl 50 mg p.o. q.h.s.
12. Insulin regular human as directed.
13. Plavix 75 mg p.o. q.d. times two weeks.
The patient was discharged to home with visiting nurse
assistance. The patient is stable at this time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 25513**]
MEDQUIST36
D: [**2105-8-22**] 18:57:00
T: [**2105-8-22**] 19:45:39
Job#: [**Job Number **]
|
[
"572.8",
"244.9",
"574.10",
"789.5",
"571.2",
"572.3",
"456.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
6012, 6166
|
6501, 7366
|
1398, 5990
|
790, 1380
|
179, 767
|
6191, 6478
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,551
| 197,920
|
53420
|
Discharge summary
|
report
|
Admission Date: [**2138-5-26**] Discharge Date: [**2138-6-5**]
Date of Birth: [**2090-2-3**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11344**]
Chief Complaint:
intractactable partial epilepsy
Major Surgical or Invasive Procedure:
RIGHT TEMPORAL LOBECTOMY
History of Present Illness:
Ms. [**Known lastname 109867**] is a 48 year old woman with refractory seizure
disorder admitted for right temporal lobectomy. She was
evaluated extensively with prior admissions for long term
monitoring for pre-operative evaluation. Her seizures typically
involve the abrupt onset of confusion, and during seizures, she
often gets up and moves about.
The patient underwent right temporal lobectomy by Dr.
[**Last Name (STitle) 739**] without complication. She had one seizure
postoperatively. She was transferred to the neurology epilepsy
service for further monitoring.
On review of systems she reported mild headache relieved by
tylenol and oxycodone. She denied SI, HI, auditory or visual
hallucinations.
Past Medical History:
1. Epilepsy as per HPI s/p VNS ([**4-14**])
2. Left ovarian cyst s/p cystectomy and salpingectomy
3. ADHD
4. Behavioral disorder
5. Anxiety, Depression
6. Hypothyroidism
7. Migraines
Social History:
Denies smoking, alcohol, and illicit drug use. She
lives alone, and is on disability, having formerly worked as a
special ed teacher.
Family History:
Seizures in mother's family.
Physical Exam:
General: no acute distress
HEENT: neck supple, PERRLA,EOMI
Heart: regular rate and rhythm, without murmurs, rubs, or
gallops
Lungs: clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
Abdomen: soft, nontender, nondistended, +bowel sounds
Extremities: no clubbing, cyanosis, or edema, pulses: 1+
dorsalis pedis/1+ posterior tibial/1+ femoral/2+ radial,
capillary refill< 2 seconds,sensation intact to light touch,
nontender to palpation, no deformities, no ecchymoses,
Neuro: CNII-XII grossly intact
She is alert and oriented x3. PERRL. EOM's intact. MAEW. gait
steady. Slight end gaze nystagmus. No drift. Speech clear and
fluent. She has intermittent c/o aches and pains from falling
with seizures or when feeling off balance.
Pertinent Results:
[**2138-5-26**] 12:41PM GLUCOSE-135* UREA N-10 CREAT-0.8 SODIUM-143
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-23 ANION GAP-13
[**2138-5-26**] 12:41PM CALCIUM-7.8* PHOSPHATE-2.9 MAGNESIUM-2.1
[**2138-5-26**] 12:41PM PHENYTOIN-14.0
[**2138-5-26**] 12:41PM WBC-8.7 RBC-3.82* HGB-11.8* HCT-35.3* MCV-92
MCH-30.9 MCHC-33.4 RDW-13.5
[**2138-5-26**] 12:41PM PLT COUNT-291
[**2138-5-26**] 12:41PM PT-13.1 PTT-24.3 INR(PT)-1.1
CT HEAD W/O CONTRAST [**2138-5-26**] 2:29 PM
IMPRESSION: Right temporal craniectomy and partial temporal lobe
resection
with expected postoperative appearance.
[**2138-5-26**] Pathology Report Tissue: hippocampus:PENDING
Brief Hospital Course:
Ms. [**Known lastname 109867**] is a 48 yo woman with refractory epilepsy admitted
for Right temporal lobectomy. She was later observed on the
neurology service for medication titration post-operatively.
1) Right Temporal Lobectomy-
She was admitted [**2138-5-26**] to the Neurosurgery
Service(Dr.[**Last Name (STitle) **]) and underwent right temporal lobectomy
without complication. Follow up CT scans were with expected
post-operative changes. The patient was seizure free for five
days following the procedure. She was transferred to the
neurology epilepsy service for further monitoring.
2) Seizure disorder-
Pt seizure free until post-operative day number five. She had an
episode of epilepsia partialis continua with left facial
twitching, left arm shaking followed by arm > leg hemiparesis.
The episode lasted ~45 minutes despite ativan IV. She was
re-loaded on dilantin which may have resolved the episode. Her
dilantin level from the morning which this event occurred
returned at 12.1 which was thought to precipitate the event. Her
regular dilantin dosing schedule was increased with goal
corrected level 18-20. She was discharged to home on her prior
AED regimen and increased dilantin dosing. These medications
were called in and faxed to her pharmacy, which delivers to her
home.
3) Mood instability, behavioral dyscontrol, borderline
personality disorder-
Psychiatry was part of the care team throughout the patient's
hospitalization. She was kept on Ziprasidone. There were times
that the patient was "feeling manic," but her symptoms
stabilized and she was discharged to home with her usual close
network of outpatient providers.
Medications on Admission:
. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Ziprasidone HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lamictal 200 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
7. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Lyrica 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
9. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
10. Zonisamide 100 mg Capsule Sig: Five (5) Capsule PO AFTER
DINNER ().
11. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Dilantin Extended 200mg PO QAM, 300mg QPM NAME BRAND ONLY.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Ziprasidone HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lamictal 200 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
7. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Lyrica 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
9. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
10. Zonisamide 100 mg Capsule Sig: Five (5) Capsule PO AFTER
DINNER ().
11. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Dilantin Extended 100 mg Capsule Sig: Three (3) Capsule PO
twice a day: NAME BRAND ONLY.
Disp:*180 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Refractory Seizure Disorder
Discharge Condition:
Normal Neurological Examination.
Discharge Instructions:
You were admitted for a right temporal lobectomy for treatment
of refractory seizure disorder. You were monitored on the
neurology service post-operatively for seizures and medication
titration.
Your dilantin dose was increased to 300mg twice daily.
Call your doctor or 911 for further seizures, difficulty
speaking, weakness, numbness or any other concerning symptoms.
-Have a family member check your incision daily for signs of
infection
-Take your pain medicine as prescribed
-Exercise should be limited to walking; no lifting, straining,
excessive bending
-You may wash your hair only after sutures and/or staples have
been removed
-You may shower before this time with assistance and use of a
shower cap
-Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
-Please DO NOT DRIVE OR PERFORM STRENUOUS ACTIVITIES while
taking pain medication
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
-New onset of tremors or seizures
-Any confusion or change in mental status
-Any numbness, tingling, weakness in your extremities
-Pain or headache that is continually increasing or not relieved
by pain medication
-Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
-Fever greater than or equal to 101?????? F
-Anything else that is concerning to you
Followup Instructions:
You have an appointment at the epilepsy center with:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 876**] Date/Time:[**2138-6-9**] 11:15
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PRIOR TO
THIS APPOINTMENT
Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2138-6-16**] 1:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2138-6-23**] 12:00
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2138-8-28**] 11:20
|
[
"293.9",
"296.80",
"346.90",
"300.4",
"530.81",
"244.9",
"272.4",
"345.51",
"278.00",
"314.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
6735, 6741
|
2978, 4630
|
347, 374
|
6813, 6848
|
2304, 2955
|
8240, 8980
|
1496, 1527
|
5663, 6712
|
6762, 6792
|
4656, 5640
|
6872, 8217
|
1542, 2285
|
276, 309
|
402, 1114
|
1136, 1328
|
1344, 1480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,446
| 160,427
|
46255
|
Discharge summary
|
report
|
Admission Date: [**2199-8-8**] Discharge Date: [**2199-8-13**]
Date of Birth: [**2146-4-3**] Sex: F
Service: CCU
CHIEF COMPLAINT: Hypertension.
HISTORY OF PRESENT ILLNESS: A 53-year-old African-American
female, with multiple medical problems including refractory
hypertension, coronary artery disease status post AV repair,
and mitral valve repair, who presented to the Emergency
Department on the day of admission complaining of chest pain
and headache. The patient was in her usual state of health,
notable for approximately one month worsening chronic
headache, when she got into an altercation with her daughter
on the afternoon of admission. During the fight, the patient
apparently complained of chest pain, worsening headaches, and
speaking incomprehensibly to daughter who brought her to the
Emergency Room. The patient also complained of left arm
numbness. Further details of complaints not able to be
described by patient secondary to lethargy.
In the Emergency Room, the patient, on arrival, was
hypertensive to 183/75 and complained of worsened headache,
but was apparently chest pain free. She was treated with 6
mg of IV morphine, multiple doses of metoprolol IV and PO, 25
mg hydralazine, and a dose of labetalol without improvement
in her blood pressure or headache. She had a head CT that
was negative for acute bleed and was started on nitroprusside
drip and heparin drip for subtherapeutic INR. Her blood
pressure was marginally improved with Nipride, but she
subsequently developed episodic narrow complex irregular
tachycardia and atrial bigeminy, both of which resolved back
to normal sinus rhythm without further intervention. EKG on
admission was notable for increased T wave inversions in V1
and V2, unchanged incomplete right bundle branch block.
Subsequent EKG showed bursts of atrial tachycardia to 130-140
and frequent premature atrial contractions, all asymptomatic
and in the context of a K of 2.6. Given the failure of blood
pressure to correct with nitroprusside, the patient was
admitted to the CCU where labetalol drip was started with
rapid decrease in her blood pressure to 143/66, and
resolution of her headache.
In addition, the patient had had multiple complaints over the
past month notable for fatigue and worsening dyspnea on
exertion. She also had some tactile fevers and increased
diaphoresis over baseline.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post CABG [**2195-12-29**],
LIMA to the LAD, SVG to the OM1, SVG to the PDA.
2. Status post AVR, mechanical valve, mitral valve repair
with annuloplasty.
3. Hypertension, baseline blood pressure 170/85.
4. Hyperlipidemia.
5. [**Doctor Last Name 933**] disease leading to hyperthyroidism.
6. Major depression with psychotic features.
7. Post-traumatic stress disorder.
8. Discoid lupus.
9. Cancer, status post left colectomy.
10.COPD.
11.Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
12.Hemolytic anemia secondary to mechanical valve.
13.?History of cluster headache.
ALLERGIES:
1. Codeine.
2. Iodine.
3. Aspirin, regular.
4. Lipitor.
MEDS ON ADMISSION:
1. Ultram.
2. Lopressor 100 [**Hospital1 **].
3. Coumadin 2.5 q hs.
4. Lasix 40 qd.
5. Sublingual Nitroglycerin prn.
6. Zocor 10 qd.
7. Albuterol MDI.
8. Effexor 112.5 qd.
9. Fioricet 325/40/50, 1-2 tabs po q 6 h prn headache.
10.Protonix 40 qd.
11.Levothyroxine 0.125 mg.
PHYSICAL EXAMINATION: Vital signs - 97.2 in the ED, 101.8 on
arrival to the CCU. In the Emergency Room, 240/92, on
arrival to the CCU 143/66, heart rate 84, respiratory rate
14, satting 100% on 2 liters nasal cannula. Generally, this
is an obese female, appearing lethargic and confused,
complaining of headache, in no apparent distress.
HEENT: Normocephalic, atraumatic. Sclerae injected.
Proptotic eyes. Pupils 2 mm, equally round and reactive.
Oropharynx clear with moist mucous membranes.
NECK: Supple without lymphadenopathy, prominent carotid
pulsations, pulses 2+ bilaterally, JVP approximately 8 cm
with prominent A and V waves, no bruits, no thyromegaly,
well-healed tracheostomy scar at the midline.
CARDIOVASCULAR: Regular rate and rhythm, mechanical S2, RV
heave, II/VI systolic murmur in the left lower sternal border
radiating to axilla, positive S4.
LUNGS: Moving minimally air, crackles at bases, no wheezes
or rhonchi.
ABDOMEN: Soft, nontender, nondistended, multiple well-healed
scars, normal bowel sounds, no bruits, no masses.
EXTREMITIES: Trace bilateral pedal edema, no clubbing or
cyanosis.
NEURO: Lethargic, intermittently answering questions when
repeated, oriented x 3, cranial nerves II through XII grossly
intact. Strength 5/5 upper extremity, lower extremity, no
pronator drift.
SIGNIFICANT LABS: Hematocrit 37.4, INR 1.3, white count 9.4
(67% polys, 22% lymphs, 4% monos, 6% eos), potassium 2.6, CK
56, MB 2, troponin less than 0.1, lactate 0.9, ionized
calcium 1.14.
EKGS: As described above in HPI.
CHEST X-RAY: Lungs are clear, no focal consolidation or
pleural effusions.
CT OF HEAD: Calcified vertebral and carotids bilaterally, no
evidence of hemorrhage.
BRIEF HOSPITAL COURSE - 1) CARDIAC - ISCHEMIA: The patient
has a history of coronary artery disease with CABG, MI x 2.
Chest pain briefly resolved on arrival to ED and has been
chest pain free. Enzymes continued to be flat during this
hospitalization stay. Doubt that active ischemia was
involved with this examination. Likely due to hypertension
which induced demand ischemia. The patient was maintained on
aspirin and beta blockade for blood pressure control, and
simvastatin during this examination. The patient ruled out
for acute MI. The patient was maintained on labetalol to a
discharge dose of 400 mg tid with good blood pressure control
in-house.
RHYTHM: The patient had atrial ectopy on admission, likely
atrial tachycardia in the setting of hypokalemia and Nipride.
In addition, the patient had another episode of atrial
tachycardia on hospital day #3 secondary to likely her
missing her labetalol dose in the morning. Labetalol was
increased to 400 tid for improved beta blockade and rhythm
control. In addition, the patient was started on amiodarone
with 400 tid x 1 week, to 400 [**Hospital1 **] during next week, and then
400 qd. The patient had PFTs in-house and her TFTs and LFTs
were performed during this hospitalization stay.
PUMP: The patient had a history of AI and MR, now without
evidence of CHF. There was a low suspicion for a vegetation
during this examination, and no further work-up of her
previous valvular disease was done in-house. The patient was
continued on labetalol, initially on a drip, and then weaned
down to PO labetalol, and had a continued work-up for
hypertension.
HYPERTENSION: The patient initially presented with
hypertensive urgency and was maintained on a labetalol drip
when placed in the CCU with improvement in her blood
pressures to 130s. The patient was subsequently transferred
to the floor on hospital day #2 and was maintained on PO
labetalol with good blood pressure control. After an episode
of atrial tachycardia on hospital day #3, the patient's
labetalol was increased to 400 tid, and was restarted on
amiodarone as described above.
2) FEVER: The patient was febrile to greater than 101 on
admission, lethargy and sweats. The patient was
empirically covered on vancomycin and gentamicin on hospital
day #1, and blood cultures were drawn. The patient was
afebrile for the remainder of her course during the
hospitalization stay, and vanc and gent were DC'd on hospital
day #2. Blood cultures were no growth to date to the
patient's discharge from the hospital. There was no concern
for endocarditis at this time, and the patient's mental
status improved with improvement of her blood pressure.
3) MECHANICAL AVR: The patient with subtherapeutic INR on
admission. The patient was placed on heparin drip with
warfarin and a goal INR of 2.5 to 3.0. The patient was
subsequently started on Coumadin, and on the date of
discharge had an INR of 2.5, and will be discharged on 5 qd
of Coumadin.
4) HEADACHE: Improved with control of blood pressure, likely
related operating table the hypertensive urgency.
5) HYPOKALEMIA: The patient initially had a potassium of 2.6
on admission, and when transferred to the CCU had a K of less
than 1, and had q 2 h potassium checks with marginal
improvement of her potassium. We aggressively repeated her
potassium throughout this hospitalization stay, and on
hospital day #3 dropped down to qid potassium checks. The
patient had a stabilized potassium to 3.0 to 4.0 with
repletion, and on the day of discharge the patient had a
stable potassium of 4.0. Given her elevation in blood
pressure and the low potassium serum aldosterone levels were
obtained and are pending. A renal artery duplex study was
negative for renal artery stenosis.
6) FEN: The patient was maintained on cardiac diet, and her
electrolytes were repleted aggressively. Prophylactically,
the patient was maintained on heparin with Coumadin for DVT
prophylaxis, and a proton pump inhibitor for GI prophylaxis.
DISCHARGE STATUS: The patient was stable with good blood
pressure on discharge of 110/60s with no further episodes of
her abnormal rhythm, that is the atrial tachycardia. The
patient was started on labetalol to be ongoing and amiodarone
to be followed up with her primary care provider and
cardiologist in [**Hospital 197**] Clinic, as described below.
DISCHARGE MEDICATIONS:
1. Levothyroxine sodium 125 mcg 1 tab qd.
2. Folic acid 5 mg po qd.
3. Simvastatin 10 mg po qd.
4. Venlafaxine 150 mg po qd.
5. Labetalol 400 mg po tid.
6. Amiodarone 400 tid x 1 week started [**8-12**], last
dose [**8-18**].
Amiodarone 400 [**Hospital1 **] x 7 days, first dose [**8-19**], last
dose [**8-25**].
Amiodarone 400 po qd, first dose [**8-26**], to be
continued indefinitely until seen by cardiologist for
follow-up.
7. Pantoprazole 40 mg po qd.
8. Warfarin sodium 3 mg po qd.
FOLLOW-UP:
1. [**Hospital 197**] Clinic for appointment on Friday, [**2199-8-16**]; the
office will contact her regarding time and location; please
call ([**Telephone/Fax (1) 10844**] for questions.
2. Primary care provider, [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 665**], MD, to be seen by
intern, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**2199-8-20**] at 3:00 pm, phone#
([**Telephone/Fax (1) 1300**].
3. Cardiology, to be seen by Dr. [**Last Name (STitle) **] at [**Hospital1 18**] on
[**2199-9-4**] at 12:30 pm.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**]
Dictated By:[**Last Name (NamePattern1) 98336**]
MEDQUIST36
D: [**2199-8-13**] 12:35
T: [**2199-8-13**] 12:53
JOB#: [**Job Number 98337**]
|
[
"272.4",
"784.0",
"401.0",
"283.19",
"780.6",
"244.9",
"276.8",
"V42.2",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9511, 10839
|
3431, 9488
|
152, 167
|
196, 2390
|
3134, 3408
|
2412, 3120
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,833
| 126,477
|
5227
|
Discharge summary
|
report
|
Admission Date: [**2105-9-17**] Discharge Date: [**2105-9-29**]
Date of Birth: [**2036-3-26**] Sex: M
Service: MEDICINE
Allergies:
Accupril
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Abdominal wall soft tissue abcess incision & drainage [**9-16**]
Percutaneous Cholecystostomy [**9-18**]
History of Present Illness:
67 yo M h/o DM, PAF, HTN, recently d/ced from hospital s/p
anterior and posterior L5/S1 fusion [**9-1**] for recurrent isolated
L5 radicular symptoms who presents from rehab with 1 day of
mid-epigastric diffuse abominal pain/cramping that is constant
and sharp in quality. Non-radiating pain that started after
dinner the night of [**9-15**]. He vomited one time which was
non-bloody, non-billous. He denied poor po intake until his pain
started. He was doing well at rehab until this point. He did
complain of intermittent low back pain radiating down his right
leg into his foot similar to pain he experienced prior to his
surgery. In the rehab facility, he was noted to not appear well
and was relatively hypotensive to 95/44 with associated
lightheadeness (normal in 110-120s) and 88-94% 6 L. WBC was 18.2
with 13% bands. Abdominal incision was noted to have a small
yellow discharge. He was then transferred to [**Hospital1 18**] for further
evaluation. No fevers/chills/diarrhea/dysuria noted.
.
In the ED, initial VS: 98.1 76 92/48 18 96% on xx. Lowest blood
pressures recored in ED 78/53. 88% RA and 2-4 liters in mid-90s.
Wounds in tact (anterior approach performed by vascular and
posterior approach performed by spine). wbc elevated to 24.6
(10.1 on [**9-4**]). Cr elevated to 2.1 (1.1 prior to d/c [**9-4**] and 1.5
[**9-16**]). Lactate 2.3. Given 4-5 liters IVFs which iimproved his
blood pressure back to his baseline in the 110s. He remained
afebrile. CT abdomen notable for small abdominal wall abcess of
which vascular performed a bedside I/D. They felt this was
small, non-purulent and not likely source of infection. Also
noted to have spine locules of air near spine surgical site of
which spine states were typical post-surgical changes and not
likely to be the source. CXR: no acute changes. Pan cultured,
Started levo/vanc/flagyl. Vitals prior to transfer: 99 F 69
119/48 13 96% 2 liters.
.
Upon arrival to the MICU, patient c/o [**10-11**] abdominal pain
similar to his prior episode, however more severe, relieved with
4 mg IV morphine. He denies other complaints.
Past Medical History:
-Pafib
-hypertension
-insulin-dependent diabetes-A1C [**6-25**] 6.1%
-hypothyroidism
-GERD
-peripheral neuropathy
-Hyperlipidemia
-obesity
-Pneumonia - Viral - [**4-10**]- Hosp
-GI bleed-upper from peptic ulcers - about [**2100**] - no
transfusions thought [**2-3**] celebrex and plavix
-psoriatic arthritis, right hand
- s/p L5/S1 fusion secondary to severe foraminal stenosis and
isolated L5 radicular symptoms
Social History:
Retired from automotic industry.Lives with wife. Quit smoking 30
years ago after 30pack years of smoking, drinks ~1 alcoholic
beverage a week, no drug use.
Family History:
Father died of MI at age 70. Sister with MS.
Physical Exam:
VS: Temp:98 BP: 133/62 HR: 80 RR:12 O2sat 99% 2 L
GEN: pleasant, notably in abdominal pain, NAD
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no
jvd,
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, 1/6 systolic murmur heard best at apex
ABD: nd, +b/s, soft, TTP in mid-epigastrum. no masses or
hepatosplenomegaly
EXT: warm, well perfused. no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength in upper BLE and
LLL. unable to lift RLL due to weakness
Pertinent Results:
ADMISSION LABS:
[**2105-9-16**] 01:15PM BLOOD WBC-24.6*# RBC-3.00* Hgb-9.1* Hct-27.0*
MCV-90# MCH-30.3 MCHC-33.6 RDW-13.6 Plt Ct-525*#
[**2105-9-16**] 01:15PM BLOOD Neuts-94* Bands-1 Lymphs-1* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2105-9-16**] 01:15PM BLOOD PT-23.5* PTT-47.6* INR(PT)-2.2*
[**2105-9-16**] 01:15PM BLOOD Glucose-192* UreaN-35* Creat-2.1* Na-134
K-4.9 Cl-97 HCO3-27 AnGap-15
[**2105-9-16**] 01:15PM BLOOD ALT-49* AST-77* AlkPhos-124
[**2105-9-17**] 06:04AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.7
[**2105-9-28**] 05:57AM BLOOD WBC-14.5* RBC-2.85* Hgb-8.3* Hct-25.7*
MCV-90 MCH-29.1 MCHC-32.2 RDW-14.9 Plt Ct-421
[**2105-9-29**] 07:09AM BLOOD WBC-13.9* RBC-2.71* Hgb-7.8* Hct-24.6*
MCV-91 MCH-28.8 MCHC-31.8 RDW-14.7 Plt Ct-424
[**2105-9-29**] 07:09AM BLOOD Neuts-76.5* Lymphs-12.1* Monos-2.9
Eos-8.1* Baso-0.4
[**2105-9-29**] 07:09AM BLOOD PT-15.7* PTT-43.1* INR(PT)-1.4*
[**2105-9-29**] 07:09AM BLOOD Glucose-196* UreaN-76* Creat-6.8* Na-140
K-4.4 Cl-105 HCO3-24 AnGap-15
[**2105-9-29**] 07:09AM BLOOD Calcium-7.7* Phos-5.1* Mg-1.8
[**2105-9-28**] 10:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2105-9-28**] 10:10PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2105-9-28**] 10:10PM URINE RBC-5* WBC-10* Bacteri-FEW Yeast-NONE
Epi-0
[**2105-9-16**] 04:30PM URINE CastGr-<1 CastHy-[**3-6**]*
[**2105-9-16**] 04:30PM URINE Eos-NEGATIVE
[**2105-9-16**] 2:30 pm BLOOD CULTURE
**FINAL REPORT [**2105-9-23**]**
Blood Culture, Routine (Final [**2105-9-23**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
ESCHERICHIA COLI. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
ABIOTROPHIA/GRANULICATELLA SPECIES.
REPORTED BY PHONE TO DR. [**First Name (STitle) **] [**2105-9-19**] 09:50AM.
ISOLATED FROM ONE SET ONLY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- 8 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- 8 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
[**2105-9-17**] 1:30 am SWAB
**FINAL REPORT [**2105-9-23**]**
GRAM STAIN (Final [**2105-9-17**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2105-9-21**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 2 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2105-9-23**]):
PREVOTELLA SPECIES. SPARSE GROWTH. BETA LACTAMASE
NEGATIVE.
[**2105-9-28**] URINE URINE CULTURE-PENDING INPATIENT
[**2105-9-28**] SWAB GRAM STAIN-FINAL; WOUND
CULTURE-PRELIMINARY INPATIENT
[**2105-9-28**] SWAB GRAM STAIN-FINAL; WOUND
CULTURE-PRELIMINARY INPATIENT
[**2105-9-25**] SWAB WOUND CULTURE-FINAL INPATIENT
[**2105-9-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2105-9-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2105-9-20**] URINE URINE CULTURE-FINAL INPATIENT
[**2105-9-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2105-9-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2105-9-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2105-9-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2105-9-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2105-9-18**] BILE GRAM STAIN-FINAL; FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL INPATIENT
[**2105-9-18**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2105-9-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2105-9-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2105-9-17**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2105-9-16**] Radiology CT ABDOMEN W/O CONTRAST
CT OF THE ABDOMEN: The visualized lung bases show trace
bilateral pleural
effusions with adjacent compressive atelectasis. The visualized
heart and
pericardium appear unremarkable.
The evaluation of solid organs and intra-abdominal vasculature
is suboptimal
in the absence of IV contrast. Within this limitation, the
liver, spleen,
pancreas, and bilateral adrenal glands appear unremarkable. The
gallbladder
shows cholelithiasis without evidence of cholecystitis. There is
no free air
or free fluid within the abdomen. Intra-abdominal loops of large
and small
bowel appear unremarkable. Retroperitoneal and mesenteric lymph
nodes do not
meet CT size criteria for pathologic enlargement.
CT OF THE PELVIS: The bladder shows presence of a Foley. A
penile prosthetic
reservoir is noted within the pelvis. The rectum and sigmoid
colon appear
unremarkable. There is no free pelvic fluid. Pelvic lymph nodes
do not meet
CT size criteria for pathologic enlargement.
OSSEOUS STRUCTURES: Multilevel degenerative changes are noted.
The patient
is status post L5 laminectomy with L5-S1 discectomy and
posterior fusion.
In the anterior abdominal wall on series 2, images 68-74, there
is a rounded
collection of fluid and gas measuring 39 x 24 mm. There is
surrounding fat
stranding and tiny locules of gas inferior to this collection.
This finding is
concerning for abscess with gas forming organism. Also noted is
soft tissue
thickening anterior to the discectomy at L5-S1 with small
locules of gas noted
which may be related to recent surgery. There is no drainable
fluid collection
at this site.
IMPRESSION:
1. Locules of gas and soft tissue thickening anterior to L5-S1
discectomy, may
reflect post-surgical changes. Recommend clinical correlation.
2. Subcutaneous collection in anterior abdominal wall containing
gas and fluid
just adjacent to the anterior incision may represent abscess.
3. Old healed rib fractures.
4. Bilateral atelectasis.
Radiology Report GALLBLADDER SCAN Study Date of [**2105-9-17**]
INTERPRETATION: Serial images over the abdomen show prompt
uptake of tracer into
the hepatic parenchyma and excretion of activity through the
biliary system.
Tracer activity is noted in the small bowel at 7 minutes. There
is no
visualization of the gallbladder during 60 minutes.
At 60 minutes, 2 mg of morphine was administered IV, and
additional imaging was
performed. The gallbladder was still not visualized.
The above findings are consistent with cystic duct obstruction,
most likely
secondary to acute cholecystitis.
IMPRESSION: Non-visualization of the gallbladder initially and
after
administration of morphine is compatible with acute
cholecystitis.
Radiology Report LIVER OR GALLBLADDER US Study Date of [**2105-9-17**]
COMPARISONS: CT abdomen and pelvis [**2105-9-16**].
FINDINGS: Examination limited by body habitus. The liver
demonstrates no focal
gross masses or intrahepatic ductal dilatation. The gallbladder
is mildly
distended, with slightly thickened wall and questionable edema.
Trace
pericholecystic fluid. Small non-shadowing gallstones are seen
within the
gallbladder. Negative son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. Patient did
report diffuse
epigastric pain during the scan. The visualized head and
proximal body of
the pancreas are normal. The distal pancreas are obscured by
overlying bowel
gas. The extrahepatic common duct is normal in caliber without
shadowing
gallstones, measuring up to 4-5 mm. Intrahepatic portion of the
IVC is patent.
The main portal vein is patent with antegrade flow.
IMPRESSION: Examination is limited by body habitus. Mildly
distended
gallbladder containing small gallstones with questionable wall
edema. Trace
pericholecystic fluid. Pain diffusely in the epigastrium during
the
examination. Ultrasound findings are indeterminate for
cholecystitis and HIDA
scan can be pursued for further evaluation.
Radiology Report RENAL U.S. Study Date of [**2105-9-20**] 12:01 AM
RENAL ULTRASOUND
COMPARISON: CT abdomen and pelvis [**2105-9-16**].
RENAL ULTRASOUND
The right kidney measures 12.3 cm and the left kidney measures
12.3 cm. There
are no stones, masses or hydronephrosis. There are no
perinephric
collections. There is a catheter within the bladder and the
bladder is
decompressed.
IMPRESSION: No stones, no hydronephrosis.
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2105-9-24**]
11:31 AM
COMPARISON: [**2105-9-16**].
CT ABDOMEN: Moderate bilateral simple pleural effusions with
compressive
atelectasis are new since [**2105-9-16**]. The heart is
normal in size
without pericardial effusion. Multivessel coronary arterial
disease is
present.
There has been interval development of a small perihepatic
ascites. Within
limitation of non-contrast technique, the liver demonstrates no
focal lesion.
The gallbladder appears collapsed, with a percutaneous
cholecystostomy tube
coiled within the fundus via transcholecystic approach. The
spleen and
adrenal glands appear unremarkable. The pancreas is diffusely
atrophic
without focal lesion. Bilateral kidneys demonstrate no
hydronephrosis,
hydroureter, or nephrolithiasis. The stomach, duodenum, small
and large bowel
loops are normal in caliber. There is no mesenteric or
retroperitoneal
lymphadenopathy. Moderate atherosclerotic calcifications are
seen in the
infrarenal aorta and iliac arteries.
Redemonstrated is a small pocket of 3.6 x 2.4 cm peri-incisional
fluid
collection within the anterior abdominal soft tissue, minimally
changed as
compared to [**2105-9-16**]. Previously seen foci of adjacent
subcutaneous
emphysema is less conspicuous. There is no new collection. Mild
anasarca is
increased since most recent prior exam.
CT PELVIS: The bladder is partially collapsed, containing air in
the dome,
which could be related to recent instrumentation. A Foley
catheter is in
place. There is contrast progression to the rectum. Sigmoid
diverticulosis
is noted without diverticulitis. Positioning of the penile
prosthesis with a
right hemipelvic reservoir appears unchanged. There is no
inguinal or pelvic
lymphadenopathy. There is no free fluid within the pelvis.
BONE WINDOW: No concerning focal suspicious lytic or blastic
lesions. Mild
S-shaped lumbar scoliosis is noted. Severe lumbar spondylosis
appears
slightly progressed as compared to [**2103-1-17**]. There is
slightly
increased loss of height in T12 and L1 vertebral bodies. There
has been
interval posterior fusion of L5-S1 with intervertebral spacers,
rod and
pedicle screws in place.
IMPRESSION:
1. Persistent small peri-incisional anterior abdominal wall soft
tissue fluid
collection.
2. Collapsed gallbladder with a percutaneous cholecystostomy
catheter in
expected location via direct transcholecystic approach. New
small abdominal
ascites is likely of simple fluid, but bile leak cannot be
excluded. Suggest
clinical correlation and US guided tap for further evaluation if
needed.
3. Interval increase of pleural effusions, small ascites, and
mild anasarca,
overall suggestive of volume overload.
Brief Hospital Course:
69 yo M h/o DM, HTN, PAF on coumadin s/p recent L5/S1 fusion
presenting from rehab with leukocytosis, hypoxia, and relative
hypotension concerning for sepsis.
# SEPSIS: Pt hypotensive on admission with elevated WBC ct. He
was determined to have E. Coli and ABIOTROPHIA/GRANULICATELLA
SPECIES bacteremia and subsequently acute cholecystitis. He
underwent percutaneous cholecystotomy tube placement for
gallbladder decompression and was treated with a course of zosyn
to which the bacteria were sensitive. He will need to keep the
percutaneous drain in place unitl the time of surgery (per IR)
which should be about 2 weeks after discharge but will be
determined at patient's general surgery clinci appointment with
by Dr. [**Last Name (STitle) 853**]. Hypotension and leukocystosis resolved in the MICU
and the patient was transferred to the medical floor. On the
medical floor his condition continued to improve and all of his
subsequent blood cultures were negative.
# ACUTE CHOLECYSTITIS: Diagnosed by HIDA scan. Treated with perc
chole drain placement by Interventional radiology on [**9-18**].
Likely E.Coli bacteremia and ABIOTROPHIA/GRANULICATELLA SPECIES
bactermia related to acute cholecystitis. He completed a course
of zosyn for this infection. He will need outpt lap chole as
above.
# E.Coli/ABIOTROPHIA/GRANULICATELLA SPECIES Bacteremia: Likely
secondary to acute cholecystitis. He completed a course of
zosyn.
# Hypoxia: Mild hypoxia on admission likely related to splinting
in setting of abdominal pain. Hypoxia resolved with treatment of
his abdominal pain.
# Acute Renal Failure/ATN: Patient developed anuria on hospital
day 4. Urine electrolytes consistent with ATN. Nephrology was
consulted and concluded that this was likely ATN. Electrolytes
remained stable, he subsequently began having adequate urine
output and there was no need for HD. His Cr peaked at 8.2 and
subsequently improved to 6.8 on the day of discharge. He will
follow up with Dr. [**Last Name (STitle) 4090**] as an outpatient.
# Diabetes: Continued on glargine and ISS. Had some episodes of
hypoglycemia in the setting of not eating and glargine was held
and then slowly uptitrated as he started eating again. This
should be titrated up as needed for hyperglycemia.
# Atrial Fibrillation: Remained rate controlled. Started on
lower dose regimen of metoprolol given initial hypotension. INR
was reversed with FFP prior to perc chole drain placement.
Warfarin was restarted and titrated to INR of [**2-4**]. INR was 1.4
on discharge.
# Coagulopathy: Elevated PTT. No evidence of DIC. Thought
perhaps due to ARF w/ sensitivity to SC TID prophylactic doses.
Given persistent elevation of PTT a mixing study was sent. This
result was still pending on the day of discharge and should be
followed up.
# Rash: Patient developed a fungal rash on his groin and under
his panus that was treated with miconazole powder. He also
developed 3 distint circular, erythematous, pustular lesions on
his chest that were thought to be an allergic reaction to
telemetry leads. Both were swabed, grams stain was negative and
cultures are peding.
# PENDING LABS: A mixing study, outstanding urine culture from
[**9-28**] that needs to be followed as UA showed 10 WBC's, swab
cultures from abd pustules.
# Code: Patient was full code.
Medications on Admission:
Levothyroxine 150 mcg DAILY
Metoprolol Tartrate 50 in AM , 50 mg at 1400 and 100 in PM
Omeprazole 20 mg DAILY
Simvastatin 20 QPM
Sulfasalazine 1500 [**Hospital1 **]
Losartan 100 mg daily (was on valsartan 160 daily prior)
Baclofen 10 mg q 6 hours
Bisacodyl 10 mg daily prn
Colace 100 [**Hospital1 **]
Senna daily
iron 150 daily
Insulin Glargine 100 Eighty Units at bedtime.
Oxycodone 5 mg 1-2 Tablets PO Q4H as needed for pain.
Tamsulosin 0.4 mg HS
Coumadin 5mg daily
HCTZ 12.5 mg daily
Trazadone 75 qhs
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for Constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as
needed for insomnia.
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
14. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous once a day: in the morning.
15. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous four times a day: per sliding scale.
16. Iron 160 mg (50 mg Iron) Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary: Acute Cholecystitis with septic shock, Acute Renal
Failure, Anemia
Secondary: Hypertension, Diabetes type II, Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital because of an infection in
your gallbladder and blood causing abdominal pain and low blood
pressure. You were brought to the ICU and given many liters of
IV fluids and IV antibiotics, and a drain was placed in your
gallbladder to reduce the inflammation. A small fluid collection
in your abdomen was drained. You developed kidney failure but
did not require dialysis as this improved. Some of your
medications (listed below) were stopped to avoid further kidney
damage. You received one blood transfusion for anemia. Your
diabetes and thyroid medications were continued and you were
sent back to rehab with a plan to surgically remove your
gallbladder in mid-[**Month (only) 359**].
.
We made the following changes to your medications:
- STARTED CALCIUM CARBONATE
- STOPPED SULFASALAZINE, BACLOFEN, LOSARTAN AND
HYDROCHLOROTHIAZIDE
- DECREASED METOPROLOL TO 37.5 TWICE A DAY
______________________________
Please take all of your medications as prescribed. It was a
pleasure taking care of you at [**Hospital1 18**].
Followup Instructions:
Please go to the following appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2105-10-9**] 11:00
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2105-10-14**]
10:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2105-10-19**] 10:40
[**2105-10-15**] 01:00p [**Last Name (LF) **],[**First Name3 (LF) **]
DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **]
RENAL DIV-WSC (SB)
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2105-10-13**] at 1 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"696.0",
"244.9",
"285.9",
"356.9",
"038.42",
"998.59",
"574.01",
"799.02",
"E849.8",
"995.92",
"272.0",
"486",
"530.81",
"785.52",
"584.9",
"278.00",
"427.31",
"E878.8",
"250.00",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.01",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20868, 20965
|
15450, 18762
|
284, 391
|
21136, 21136
|
3746, 3746
|
22388, 23363
|
3137, 3183
|
19316, 20845
|
20986, 21115
|
18788, 19293
|
21312, 22053
|
3198, 3727
|
22082, 22365
|
230, 246
|
419, 2511
|
3763, 15427
|
21151, 21288
|
2533, 2948
|
2964, 3121
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,475
| 149,974
|
45419
|
Discharge summary
|
report
|
Admission Date: [**2150-8-25**] Discharge Date: [**2150-9-8**]
Date of Birth: [**2083-12-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Cardiac catheterization with stenting [**2150-8-25**] and returned to
cath [**2150-9-3**]
History of Present Illness:
66 yo F critical AS (valve area 0.6), CAD s/p PCIx4, severe
diastolic CHF, severe pulmonary [**Hospital 2754**] transferred from [**Hospital **] with respiratory distress. She was in USOH until 1 day
PTA, when she devleoped SOB. EMS came and pt was able to walk
out of the house to meet them. Shw was given Nitro SL, lasix,
and oxygen by NRB en route to hospital and her respiratory
condition deteriorated. She was intubated in the ED, with ABG
7.01/60/83. She was given insulin gtt. She ws given ativan and
morphine for sedation when she became agitated and pulling at
tubes.
The patient has been evaluated by CT surgery who was planning
valve surgery. The pt is a Jehovah's witness, so she refuses
blood products. She started EPO in [**Month (only) 547**], with the plan to
optimize her for an elective aortic valve replacement
Past Medical History:
rheumatic fever as child, aortic stenosis with regurgitation,
morbid obesity (BMI 51), DM2 (Hgb A1c 6.9%), dyslipidemia (TC
256), OA, chronic low back pain, ccy [**2118**], umbilical hernia
repair [**2132**], ex lap with LOA [**1-28**] small bowel obstruction in [**2144**]
Social History:
Lives in [**Location 10022**], former smoker 60 pack year history quit 35
years ago, no alcohol/drugs. Jehovah's Witness
Family History:
CAD, diabetes
Physical Exam:
Gen: sedated, intubated
HEENT: PEERL, mild JVD
Chest: good air movement in both sides.
CV: holosystolic murmur LUSB, radiating to carotids
ABD: obese, ND, NABS, no organomegaly
Ext: trace edema
Pertinent Results:
[**2150-8-25**] 10:49PM TYPE-ART RATES-14/ TIDAL VOL-700 PEEP-10
O2-70 PO2-93 PCO2-38 PH-7.40 TOTAL CO2-24 BASE XS-0 -ASSIST/CON
INTUBATED-INTUBATED
[**2150-8-25**] 10:49PM HGB-16.6* calcHCT-50 O2 SAT-96
[**2150-8-25**] 06:28PM GLUCOSE-211* UREA N-21* CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-20* ANION GAP-21*
[**2150-8-25**] 06:28PM ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-3.7
MAGNESIUM-1.5*
[**2150-8-25**] 06:28PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2150-8-25**] 06:28PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2150-8-25**] 06:28PM URINE RBC-[**2-28**]* WBC-[**6-5**]* BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2150-8-25**] 06:28PM URINE HYALINE-[**6-5**]*
[**2150-8-25**] 06:28PM URINE MUCOUS-MOD
.
Echo [**2150-8-26**]:
LV EF 35% mild LVH. nl cavity sz.
[**Month/Day/Year 96941**]: hypo inferior, lateral, anterior walls including
apex.
RV: nl size/fxn. TR gradient 31.
Ao stenosis: [**Location (un) 109**] 0.9 gradient 27. pk vel 3.5.
[**12-28**]+ AR, 2+ MR
.
Echo [**2150-8-30**]:
LV EF 30-35%
[**12-28**]+ AR, 1+ MR
[**Name13 (STitle) 96941**]: anterior, lateral, inferior hypokinesis
No masses/vegetations mitral or aortic valve.
.
Cath [**2150-8-25**]:
LMCA: patent
LAD: 90% mid
LCX: 90% ostial OM1 and thrombus after the stent
RCA: 80% mid after the stent
no stent placed, awaiting AVR/CABG.
RHC: CVP 19, PA 43/26. PCWP 24. CO 3.72 CI 2.41
.
COMMENTS: 1. Selective coronary angiography demonstrated
three
vessel coronary artery disease in this right dominant
circulation. The
LMCA was without angiographically apparent flow limiting
disease. The
LAD had a 90% stenosis in the mid vessel prior to the diagonal
branch.
The LCX circulation had a 90% stenosis at the ostium of the OM1
and
thrombus in and distal to the previously placed OM1 stent. The
OM2 was
without flow limiting disease. The RCA had a patent ostial stent
and had
an 80% mid RCA stenosis near the site of the previous PTCA.
2. Resting hemodynamics from right heart catheterization
demonstrated
elevated right and left sided filling pressures (RVEDP=19mmHg
and mean
PCWP=24mmHg). There was mild pulmonary arterial hypertension
present
(43/26). Cardiac output and index were mildly depressed at 3.7
L/min and
2.4 L/min/m2 respectively.
3. Left ventriculography was not performed due to elevated
filling
pressures.
4. PTCA of the previously placed OM1 stent using a 2.5mm balloon
with
excellent results (see PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated right and left sided filling pressures.
3. NSTEMI treated with PTCA of previously placed LCX-OM1 stent.
.
Cath [**2150-9-3**]:
COMMENTS: 1. Cardiogenic shock due to a combinatin of
Myocardial
infarction, myocardial ischemia, Severe AS and impaired LV
function.
2. Possibility of ongoing ishchemia from the LAD an the RCA
lesions.
3. Critical clinical state due to above and other co-morbities
3. Issues with blood transfusions as patient is a Jehova's
witness.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe aortic stenosis.
3. Severe systolic ventricular dysfunction.
4. Successful PCI and bare metal stent placement on the LAD and
the RCA
with no complications
Brief Hospital Course:
A/P
66 yo F critical AS (valve area 0.6), CAD s/p PCIx4, severe
diastolic CHF, severe pulmonary [**Hospital 2754**] transferred from [**Hospital **] with respiratory distress and demand ischemia. During
hospitalization, recieved angioplasty x2. Plan is to consider
surgery for AVR.
.
1. Cardiac:
Coronaries:
On the evening of admission, the pt arrived at the CCU with ECG
not suggestive of acute infarct, the Cardiac enzymes were found
to be elevated, and in the setting of sudden onset of SOB,
hemodynamic decompensation, and known h/o CAD, this was assessed
as concerning for acute infarct, pt was sent emergently to the
cath lab. In cath lab, pt was found to have 3 vessel dz with 90%
OM1, no thrombus. This lesion was ballooned, not stented with
the plan for possible AVR/CABG. After discussions with CT
surgery, the decision was made to return to cath for stenting
to LAD and RCA on [**9-3**]. There were no complications. The pt was
extubated a couple of days prior to disharge. She was
hemodynamically stable and tranferred out of CCU for one day of
additional monitoring.
.
Pump/:
The pt arrived on decompensated heart failure likely [**1-28**] acute
MI on top of chronic severe AS. The pt required mechanical
ventilation and diuresis for the first week of hospitalization.
Right heart cath confirmed elevated filling pressures, PCWP 24
CVP 19. BB, ACE were held during the hospitalization because the
blood pressure could not tolerate. Plan is to consider valve
surgery for critical AS. This decision is complicated by the
patient's status as a Jehovah's Witness, she will not accept
blood transfusion.
.
Rhythm:
Sinus rhythm.
.
2. MRSA PNA:
The pt had a fever to 101 and a WBC 19.3 on admission. She was
required mechanical ventilation for prolonged respiratory
failure for the first week in the hospital. This was related to
decompensated heart failure and MRSA PNA. She completed a course
pf empiric antibiotics for MRSA PNA.
.
3. GI bleed:
NG tube was guaiac positive, with small coffee grounds initially
at CCU. After the first hour, the NG lavage showed no gross
blood.
-follow crit. follow NG lavage for blood.
.
4. diabetes:
the pt was managed with RISS. She will resart her home NPH
regimen as an outpatient.
Medications on Admission:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Insulin
Please start your insulin as had been discussed prior to
discharge.
6. lisinopril
7. metoprolol
8. zetia
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Insulin
Please start your insulin as had been discussed prior to
discharge.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Unstable Angina
Discharge Condition:
good
Discharge Instructions:
Please make sure to take all medicines as directed.
Particularly,
take apirin and plaivx every day without missing a single dose.
Not taking the aspirin and plavix can lead to heart attack.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please follow directions regarding blood sugar as discussed
prior to discharge. Please start your insulin dose at 20 units
in AM and 20 units in PM and increase the dose by 3-5U each dose
if your blood sugars remains elevated.
Please check your blood sugars 4 times a day. If your blood
sugar is below 70 and does not improve after drinking [**Location (un) 2452**]
juice, call your doctor or go to the emergency room.
Followup Instructions:
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Where: [**Hospital6 29**] CARDIAC
SERVICES.
[**Location (un) **]. [**Location (un) 436**]
Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2150-9-25**] 1:30
|
[
"715.90",
"458.9",
"395.2",
"V45.82",
"578.0",
"V09.0",
"410.71",
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"038.9",
"482.41",
"272.0",
"V58.67",
"414.01",
"398.91",
"416.8",
"995.92",
"276.8",
"441.4",
"250.00",
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icd9cm
|
[
[
[]
]
] |
[
"89.64",
"96.07",
"96.72",
"96.6",
"36.05",
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"36.01",
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] |
icd9pcs
|
[
[
[]
]
] |
8495, 8554
|
5278, 7507
|
320, 412
|
8614, 8621
|
1970, 4494
|
9382, 9625
|
1724, 1740
|
8032, 8472
|
8575, 8593
|
7533, 8009
|
5047, 5255
|
8645, 9359
|
1755, 1951
|
277, 282
|
440, 1272
|
1294, 1570
|
1586, 1708
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,223
| 147,729
|
52746
|
Discharge summary
|
report
|
Admission Date: [**2173-6-2**] Discharge Date: [**2173-6-14**]
Date of Birth: [**2105-4-12**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Meperidine
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Bright red blood per rectum X 1 day
Major Surgical or Invasive Procedure:
Right inguinal hernia repair [**2173-6-8**]
History of Present Illness:
Mr. [**Known lastname **] is a 68 year-old male with a complicated PMHx
including HTN, DM type 2, hypercholesterolemia, and history of
AAA s/p repair and s/p CEA, and 2 recent psychiatric admissions
for depression s/p ECT in 04/[**2173**]. He presents with a 1-week
history of loose stools ([**6-9**] BMs per day), followed by onset of
abdominal pain on the day prior to admission in both lower
quadrants, R>L, worse with palpation, progressive. He also
developed BRBPR, frequency unclear. [**Name2 (NI) **] was seen in his PCPs
office 1 day PTA, at which time he was also found to be
hyponatremic. He was brought to the ED for further evaluation.
Of note, per the patient's sister, he apparently also fell on
the day prior to admission.
ROS negative for fever at home. No N/V. Review of records
indicates that his last colonoscopy revealed diverticulosis.
Poor PO intake over the past 2 days [**2-3**] abdominal pain.
In the ED, T up to 101.7. BP 160/64 --> SBP 79, which responded
to boluses of IV fluids. He was given a total of 5 liters in the
ED. He was started on Levo and Flagyl, and surgery was
consulted. He was subsequently admitted to the SICU for further
management.
Past Medical History:
Hypertension
Diabetes mellitus type 2
Hypercholesterolemia
Chronic obstructive pulmonary disease
History of laryngeal squamous cell ca, s/p resection and XRT
History of seizures, on Dilantin
History of CVA
Depression
Anxiety
Compression fractures
History of osteomyelitis of the jaw s/p bone graft
Past surgical history:
S/p AAA repair with aortobifem in [**8-/2172**]
S/p right femoral embolectomy [**8-/2172**]
S/p left CEA in [**6-/2172**]
S/p excision of leukoplakia, esophagoscopy, laryngoscopy [**2-/2172**]
Social History:
He currently lives with his sister and nephew in [**Name (NI) **]. His
sister acts as his primary caregiver. [**Name (NI) **] taught 5th grade for
many years in the [**Location (un) 86**] Public Schools. He has no children.
Active smoker, smokes [**2-4**] ppd for 40 years. History of alcohol
abuse/dependence, sober for 25 years. No history of IVDU.
Family History:
Sister with depression and alcoholism. Brother with depression,
possible death by suicide.
Physical Exam:
Physical examination per admission note:
VITALS: T 101.7, HR 103, regular, BP 146/56 --> 90s systolic, RR
20s
GEN: Frail-appearing, in NAD.
HEENT: EOMI. NC. Difficult fundoscopic exam.
NECK: C-spine immobilized.
RESP: CTAB.
CVS: RRR. 2/6 SEM.
GI: Soft, tender to palpation in both lower quadrants, R>L. +
Tap tenderness, negative rebound or guarding.
DRE: Groslly positive with mucous blood.
Ext: Well-perfused.
Pertinent Results:
Relevant laboratory data on admission:
[**2173-6-1**] 02:25PM
WBC-9.5# RBC-3.87* HGB-13.4* HCT-36.7* MCV-95 MCH-34.6*
MCHC-36.5* RDW-13.9
PLT COUNT-276
SED RATE-6
UREA N-16 CREAT-0.7 SODIUM-126* POTASSIUM-3.1* CHLORIDE-79*
TOTAL CO2-33* ANION GAP-17
GLUCOSE-116*
TSH-1.2
AST(SGOT)-20 CK(CPK)-132
Urinalysis:
URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1
Relevant imaging studies in hospital:
[**2173-6-2**] AP UPRIGHT PORTABLE CHEST X-RAY: 1) No acute
cardiopulmonary process. 2) Widely ectatic intrathoracic aorta.
******
[**6-2**] CT OF THE CHEST/ABDOMEN with IV CONTRAST:
1. Colitis, incompletely assessed. Discussed with Dr. [**Last Name (STitle) **]
in the morning of [**2173-6-3**]. Differential includes
infectious, inflammatory, and ischemic etiology.
2. Similar appearance of ectatic and aneurysmal thoracic aorta
with penetrating ulcers. Patent aortobifemoral graft. Stable
thrombosed aneurysm of the proximal celiac artery; it is unclear
whether there is antegrade flow through the celiac artery, or
whether filling is retrograde.
3. Similar appearance of L1 wedge compression fracture.
4. Periportal edema, with trace ascites.
5. Emphysema.
******
[**6-2**] CT HEAD: No evidence of intracranial hemorrhage, or
significant change since the prior study.
******
Laboratory data on transfer:
WBC 5.3, Hb 9.9, Hct 28.5, Plt 159
Na 137, K 3.5, Cl 106, HCO3 21, BUN 24, Creat 0.8, Gluc 100
CK 37 (Peak 142)
[**6-3**] Dilantin <0.6
Micro:
[**6-2**] Stool C. diff negative
[**6-1**] Urine culture negative
[**6-2**] Urine culture negative
[**6-2**] Blood culture negative
[**6-3**] Stool cx negative for C. diff, culture and O&P
[**6-5**] Stool cx negative for C. diff, culture and O&P
[**6-12**] Stool cx negative for C. diff, culture and O&P
[**2173-6-7**] CT ABDOMEN WITH CONTRAST: There is atelectasis at both
lung bases with trace effusion. Again noted is an aneurysmal,
ectatic descending thoracic aorta. There is no pericardial
effusion.
The liver, spleen, pancreas, and adrenals are unremarkable.
There is new marked dilatation of the mid small bowel, with
loops measuring up to 4.5 cm. The distal small bowel is
decompressed, and contrast has not yet passed to the terminal
ileum. There is a rounded fluid-filled structure in the right
groin with a thin enhancing rim that enhances similarly to the
small bowel wall. However, although this cannot be definitely
connected to the small bowel, the appearance is very concerning
for an incarcerated right inguinal hernia causing the bowel
obstruction. There is no evidence of pneumatosis. The abdominal
arterial and venous vasculature appears patent. Again noted is
marked edema within the descending colonic wall, unchanged, and
consistent with colitis.
PELVIS WITH CONTRAST: There is a Foley catheter and some gas
within the bladder. There is a moderate amount of free pelvic
fluid, increased in volume in the interval.
BONE WINDOWS: Osseous structures appear stable. There is
aneurysmal calcification within the proximal celiac artery,
unchanged.
Multiplanar reformatted images redemonstrate findings consistent
with a mechanical small bowel obstruction and the unusual
fluid-filled rounded structure in the right groin.
IMPRESSION:
1) New apparent mechanical small bowel obstruction with marked
dilatation of the mid small bowel to 4.5 cm. We cannot exclude
the presence of an incarcerated right inguinal hernia. Findings
were discussed by telephone with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Surgical
consultation and close physical exam recommended.
2) No evidence of pneumatosis. Persistent descending colitis.
3) Interval increase in volume of free fluid within the pelvis.
It is unclear whether this relates to colitis or the new small
bowel obstruction.
Brief Hospital Course:
68 year-old male with extensive [**Last Name (NamePattern1) 1106**] history and multiple
medical comorbidities, admitted with a 1-week history of
diarrhea and 1-day h/o abdominal pain and BRBPR. His hospital
course will be reviewed by problems.
1) GI: Mr. [**Known lastname **] was initially admitted to the SICU for close
hemodynamic monitoring. An initial CT was limited by the lack of
oral contrast, but suspicious for colitis. The GI service was
consulted, with an initial differential dx of ischemic colitis
in the setting of dehydration and low flow state, infectious
colitis, IBD (less likely given normal C-scope in [**11/2172**]), and
diverticulitis. In the SICU, he was kept NPO, fluid
resuscitated, and started on Protonix IV BID. He was also
continued on Levo and Flagyl for coverage of GI organisms. His
elevated lactate normalized on hospital day #2. He remained
hemodynamically stable, without pressor requirement. BRBPR
resolved, as well as fever. Of note, stool returned negative for
C. difficile.
Per GI, the most likely diagnosis was ischemic colitis. His diet
was advanced to clears on [**6-5**]. Unfortunately, he subsequently
developed worsening abdominal distension, and an AXR showed
dilated loops of bowel. An abdominal CT with oral contrast was
subsequently obtained, which showed a SBO with probable
incarcerated right inguinal hernia, and persistent bowel wall
edema in the descending colon consistent with persistent
colitis. He was taken to the OR on [**6-8**] for right groin
exploration and right inguinal hernia repair, without immediate
complications. His SBO had spontaneously reduced. He was
transferred back to medicine on [**6-9**]. His diet was advanced
slowly, and he tolerated a full diet on [**6-11**]. Antibiotics were
discontinued on [**6-11**] after a 10-day course of empiric therapy.
He continues to have loose stool at the time of discharge,
culture negative X 3 (C.diff, O&P, culture) and improving. He
will follow-up with Dr. [**First Name (STitle) 679**] in Gastroenterology on [**2173-6-28**] at
13:30.
2) CV: Patient with known mild systolic dysfunction with EF
45-50%. Last P-MIBI in [**2172**] with mild fixed inferior defect.
From a cardiovascular standpoint, his low BP in the ED responded
to IVF, and he subsequently remained HD stable. Medications were
resumed on hospital day #2. He had a mild troponin leak (peak
0.03) on admission, with flat CKs, likely in the setting of
acute renal failure and increased demand. Telemetry in the SICU
was without events.
His main CV issue in hospital was hypertension, with some
improvement after resuming his PO meds which include Metoprolol,
Hydralazine, Lisinopril, Amlodipine, and Clonidine.
Hydrochlorothiazide was transiently resumed, discontinued in the
setting of hyponatremia. Clonidine was titrated up to 0.2 mg PO
BID. Please consider up-titration of Clonidine to 0.3 mg PO BID
or Metoprolol to 150 mg PO BID if SBP remains persistently
elevated (>160).
3) ARF: His elevated creatinine came down with IV hydration.
Lisinopril was resumed on [**6-6**]. Bicarbonate infusion was also
given peri-CT for nephroprotection. Creatinine 0.5 on the day of
discharge.
4) Anemia: His hematocrit was stable in the high 20s in the
SICU. While on the floor, he was transfused 1 unit of PRBC on
[**6-5**], with an appropriate response. His hematocrit subsequently
remained stable. Of note, stools were guaiac negative on [**6-11**].
5) Seizure disorder: His Dilantin level was subtherapeutic in
hospital, and he was loaded with 300 mg PO X3 doses on [**6-5**].
His dilantin level was subsequently therapeutic in the low
teens, and he was continued on his out-patient dose of 100 mg PO
TID.
6) DM type 2: Patient with history of DM type 2, diet controlled
as an out-patient. He was kept on a regular insulin sliding
scale in the hospital, with minimal requirement. He was
discharged to rehab on a sliding scale [**Hospital1 **]:PRN, and can be
discharged on no medications.
7) FEN: Given prolonged NPO status, a PICC line was placed on
[**6-7**] and TPN started on [**6-7**]. Post-surgery, his diet was
slowly advanced, and TPN was discontinued on [**6-11**]. Please
continue [**Doctor First Name **], heart healthy (2gm) sodium. He requires
intermittent assistance for eating.
8) Psych: Mr. [**Known lastname **] has a history of severe depression, with 2
recent psychiatric admissions to [**Hospital1 **] 4 in [**Month (only) 547**] and recent ECT
therapy. Psychiatry was consulted on [**6-11**] given concern over
declining mood, with an impression of stable mood disorder and
possible mild dementia. Recommendation was made to discontinue
Trazodone, continue Ativan TID. No suicidal ideation.
9) Hyponatremia: Sodium down to 126 on [**6-14**]. His hyponatremia
coincided with the reinitiation of diuretic therapy,
subsequently discontinued. Although urine lytes were equivocal,
with FeUrea 46%, his hyponatremia was felt most likely
diuretic-induced, and he was given intravenous NS. Plan to
monitor sodium on Tuesday and Friday at the rehab facility.
Medications on Admission:
Ativan 1 mg PO TID
Amlodipine 10 mg PO QD
Protonix 40 mg PO QD
Lipitor 10 mg PO QD
ASA 81 mg PO QD
Metoprolol 100 mg PO BID
Clonidine 0.1 mg PO BID
Lisinopril 20 mg PO BID
KCl 10 mEq PO QD
Dilantin 300 mg PO QD
Hydralazine 75 mg PO QID
Hydrochlorothiazide 25 mg PO QD
Boost TID
Discharge Medications:
1. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily): Likely discontinue when discharge
from rehab. .
9. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) mL PO TID (3
times a day).
10. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: As directed
As directed Injection ASDIR (AS DIRECTED): Please see attached
sliding scale.
12. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Ischemic colitis
Incarcerated right inguinal hernia status post inguinal hernia
repair
Small bowel obstruction
Major depression
Hyponatremia
Anemia
Secondary diagnoses:
Diabetes mellitus type 2
Hypertension
Discharge Condition:
Patient discharged to an extended care facility in stable
condition.
Discharge Instructions:
Please return to the hospital or call Dr. [**Last Name (STitle) 1007**] if you develop
increasing abdominal pain, or if you see blood in your stools.
Please follow-up with Dr. [**Last Name (STitle) 1007**] and Dr. [**Last Name (STitle) **] (surgery) as
noted below.
Please call Dr.[**Name (NI) 19421**] office and schedule an appointment to
see him when you leave rehab. You should also schedule an
appointment to see Dr. [**First Name (STitle) **] (psychiatry) within a month of
discharge.
Please note that we have made some changes to your medications.
Please take all medications as prescribed.
Followup Instructions:
1) You have a scheduled appointment with Dr. [**Last Name (STitle) **] (surgery)
on [**6-18**]. Please see below for details.
- Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Where: LM [**Hospital Unit Name 41726**] ASSOCIATES Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2173-6-18**] 11:30
2) You also have a scheduled appointment in the cardiology
clinic with Dr. [**Last Name (STitle) 1016**] as indicated below.
- Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2173-6-22**] 10:00
3) You are scheduled to see Dr. [**First Name (STitle) 679**] in Gastroenterology on [**6-28**] at 13:30. It is important that you go to this appointment.
4) Please call Dr.[**Name (NI) 19421**] office and schedule an appointment to
see him when you leave rehab. His office number is [**Telephone/Fax (1) 10492**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
Completed by:[**2173-6-14**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,619
| 191,010
|
52561
|
Discharge summary
|
report
|
Admission Date: [**2139-3-8**] Discharge Date: [**2139-3-16**]
Service: MEDICINE
Allergies:
Ampicillin / Cephalexin
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
nausea, chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F Russian speaking (poor historian) who went to bed at 10pm
yesterday with nausea and chills. No diarrhea/vomitting. She
awoke with cough, fever, and nausea was found soaked in urine
and feces. Son in [**Name2 (NI) 7349**] who is HCP but the pt lives alone here but
has vna 3 hrs/day. She was presumably sent to ED by her home
aids where she was found to have BP in 180s-190s, VS 158/72,
65, 24, 99%3L, CXR with retrocardiac density concerning for PNA.
She received [**Last Name (LF) 14990**], [**First Name3 (LF) **], BB and 750cc IVF. She had a new R
bundle and TW inversions on her EKG, cards was consulted and not
concerned, her 1st set CEs were negative. She was admitted to
medicine for further workup.
.
On the floor for 3 days, the pt was treated with antibiotics but
then developed AF with [**First Name3 (LF) 5509**] x2 (the first time converting back to
sinus rhythm after lopressor and dilt boluses). During the
second major [**First Name3 (LF) 5509**] episode the pt received dilt 10 IV x2, HR was
in fib in 90-100s, BPs went from 130 to 100-110 and pt required
face mask oxygenation (up from 4L NC). MICU was called given the
pt's full code status and her worsening oxygen requirement. CXR
at the time was at baseline, ABG showed pO2 64, CO2 35, pH 7.43.
She was transferred to the ICU where she was placed on metop 50
TID and converted spontaneously to sinus. She was diuresed with
20 and 10 IV lasix and put out net -1.2L. Now pt is doing well
on the floor on 2L NC and ready for transfer back to the floor.
Pt is reported to not have BM for last 5 days.
.
ROS:
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
chest pain or tightness, palpitations. Denied vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
Gout
Hypercholesterolemia
hypertension
Colon CA
Mild LV systolic and diastolic dysfunction.
LVEF 40-45 (echo [**2136**]).
COPD
Depression
Psoriasis
Eosinophilia
Hyperlipid
Hypertension
Afib
Social History:
Lives at home. Has VNA services through [**Hospital6 1952**]
(nurse visits 2x per week, with personal care and cleaning
services daily). Son in [**Name2 (NI) **]. No tobacco or EtOH.
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
Vitals: T:96.1 P:158/84 BP:68 R:24 SaO2:96 2L NC
General: Awake, alert, belabored breathing
HEENT: NC/AT, EOMI without nystagmus, no scleral icterus noted
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: b/l crackles and exp wheeze
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Neurologic:
-mental status: follows commands, poor historian.
-motor/sensory: grossly intact
Pertinent Results:
[**2139-3-13**] 06:30AM BLOOD WBC-7.1 RBC-4.11* Hgb-11.7* Hct-36.2
MCV-88 MCH-28.4 MCHC-32.3 RDW-14.7 Plt Ct-161
[**2139-3-10**] 07:13AM BLOOD WBC-8.1 RBC-4.02* Hgb-11.5* Hct-35.0*
MCV-87 MCH-28.6 MCHC-32.8 RDW-15.0 Plt Ct-132*
[**2139-3-8**] 03:38PM BLOOD WBC-10.5 RBC-4.74 Hgb-13.8# Hct-41.4
MCV-87 MCH-29.1 MCHC-33.3 RDW-15.1 Plt Ct-132*
[**2139-3-12**] 03:57AM BLOOD Neuts-72.8* Lymphs-13.0* Monos-4.7
Eos-9.1* Baso-0.4
[**2139-3-12**] 03:57AM BLOOD PT-12.1 PTT-29.4 INR(PT)-1.0
[**2139-3-8**] 05:25PM BLOOD PT-13.0 PTT-24.6 INR(PT)-1.1
[**2139-3-13**] 06:30AM BLOOD Glucose-100 UreaN-54* Creat-1.7* Na-140
K-4.9 Cl-106 HCO3-24 AnGap-15
[**2139-3-12**] 03:57AM BLOOD Glucose-103* UreaN-56* Creat-1.9* Na-137
K-4.6 Cl-104 HCO3-24 AnGap-14
[**2139-3-9**] 06:10AM BLOOD Glucose-108* UreaN-31* Creat-1.7* Na-138
K-4.5 Cl-106 HCO3-18* AnGap-19
[**2139-3-10**] 07:13AM BLOOD CK(CPK)-230*
[**2139-3-9**] 06:10AM BLOOD ALT-9 CK(CPK)-85
[**2139-3-8**] 05:25PM BLOOD CK(CPK)-29
[**2139-3-9**] 06:10AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2139-3-8**] 05:25PM BLOOD cTropnT-0.03*
[**2139-3-13**] 06:30AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.3
[**2139-3-9**] 06:10AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.7
[**2139-3-8**] 03:53PM BLOOD Glucose-138* Lactate-2.8* Na-146 K-4.9
Cl-107 calHCO3-20*
[**2139-3-11**] 09:58AM BLOOD Type-ART pO2-64* pCO2-35 pH-7.43
calTCO2-24 Base XS-0 Intubat-NOT INTUBA
[**2139-3-8**] 04:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016
[**2139-3-8**] 04:00PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2139-3-8**] 04:00PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2139-3-8**] 04:00PM URINE CastGr-0-2 CastHy-0-2
.
.
[**2139-3-8**] URINE URINE CULTURE-FINAL INPATIENT
[**2139-3-8**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **] - negative
.
[**2139-3-8**] CXR: Interval worsening of right perihilar opacification
since [**2138-10-31**] that is worrisome for pneumonia. CT can help in
further delineating this region though given stated demographic,
alternatively, repeat radiograph status post appropriate
treatment can be obtained to evaluate for resolution and help
exclude an underlying mass.
.
[**2139-3-10**] CXR: Slight improvement in right perihilar opacity.
Recommend CT to rule out underlying mass/obstruction.
.
[**2139-3-15**] CXR: IMPRESSION: Persistent right lower lobe
consolidation suggestive of pneumonia with accompanying pleural
effusion. New left lower lobe opacity favoring atelectasis.
Brief Hospital Course:
[**Age over 90 **]F Russian speaking (poor historian) who p/w nausea and chills
and resp distress with infiltrate concern for PNA.
.
# PNA: on admission had new O2 req of 3L, retrocardiac opacity
on CXR, concerning for community acquired PNA. WBC slightly
elevated with 90% PMNs. UCx neg. sputum cannot be produced. The
pt was treated with [**Age over 90 14990**] renally dosed and
tylenol/guaifenesin/tessylon as needed for cough. She was also
given nebs prn shortness of breath. Her breathing slowly
improved but her lung sounds continued to be rhonchorous. She
likely also has some component of upper airway obstruction and
perhaps OSA. She was discharged on [**Age over 90 14990**] to be completed for
a total of 10 days. Of note, the original CXR for the pt
suggested that rpt imaging after resolution might be useful to
r/o possible malignancy but this was not seen in rpt CXR. In the
past, she has refused w/u of breast mass and other outpt
findings. If pt fails to improve in future, rpt imaging or
consultation with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to talk about rpt imaging
could be considered.
.
# Afib: Per report the pt has a h/o PAfib but on admission she
was in NSR on 12.5 [**Hospital1 **] of metoprolol. During her stay she
triggered three times for AF with [**Hospital1 5509**] up to 140s which responded
to boluses of IV dilt 10mg. She was also increased to 50 TID
metoprolol and spontaneously converted back to sinus with HR in
60s. Due to one of her episodes of [**Hospital1 5509**] she went into flash
pulmonary edema and required transfer to the ICU for diuresis
and potential cardioversion (although pt converted spontaneously
to sinus). She was called out of the ICU after one day when she
was breathing on 2L. She is discharged to a facility for tele
monitoring. She was kept on her home aspirin 325. If the pt has
an episode of [**Last Name (LF) 5509**], [**First Name3 (LF) **] her cardiologist it was recommended to
not start amiodarone or dronedarone due to its high risks. She
may start PO dilt on top of her metoprolol if needed but it
would be most ideal to simply titrate up her metoprolol (at
37.5mg TID on dicharge).
.
# CAD/CHF: Pt not on lasix at home. EF 40-45. Pt did not have
any CP and there was low concern for ACS although new RBBB and
TWIs. She ruled out for MI with cardiac enzymes x3. As noted
above, if the pt goes into [**First Name3 (LF) 5509**] she is prone to flash pulmonary
edema given her poor EF at baseline. She responds to IV lasix
10-20 mg boluses as she is relatively lasix naive.
.
# Gout: stable without flare this admission. We held her home
colchicine 0.6 in acute setting. We treated with tylenol prn.
.
# CKD: pt is discharged within her baseline of 1.7-2.0
.
# Social: Found in feces/urine at home. Concern for elder abuse
or poor social situation. Son is in NY and is HCP. [**Name (NI) **] is not
involved in care as his wife and the pt do not get along. SW
visited pt and did not find any concerns for elder abuse at this
time.
.
# Depression: stable. we continued home celexa.
.
# Contact: son [**Name (NI) **] (HCP) [**Numeric Identifier 108536**]
#) Code Status: Full (confirmed with pt and son this admission)
.
Medications on Admission:
Metoprolol tartrate 12.5 b.i.d.
ECASA 325
Citalopram 20
colchicine 0.6
Voltaren gel p.r.n.
fluticasone spray
lactulose
lidocaine patch
SLTNG 0.4 p.r.n.
polyethylene glycol
acetaminophen
vitamin C
docusate 100
MVI one daily,
senna 8.6
vitamin A and D ointment.
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q48H (every 48
hours): Stop date [**2139-3-22**].
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) as needed for cough.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob, wheeze.
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for rash.
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Community acquired pneumonia
Paroxysmal atrial fibrillation with rapid ventricular response
.
Secondary:
HTN
Chronic CHF
COPD
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted due to a pneumonia. You were initially treated
with antibiotics. You suffered from some episodes of a fast
heart rate called atrial fibrillation which we were able to
control with medications. You were in the ICU for one day due to
this leading to fluid build up in your lungs which was removed
with diuretics. When you returned to the medical floor your
breathing was improved and you were working with physical
therapy. Your heart rate has been in control as well. Please
take levofloxacin as prescribed for your pneumonia. Please take
metoprolol 37.5mg three times a day for control of your heart
rate. Please take guaifenesin and benzonatate as needed for
cough and nebulizers as needed for shortness of breath. There
were no other changes to your medications.
.
Please take all medications as prescribed.
Please follow up with all appointments
Please do not hesitate to return to the hospital if you have any
concerning symptoms at all.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with your primary care provider upon discharge.
Please follow up with the following providers:
Cardiology: [**Name6 (MD) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2139-4-16**] 1:20
Optometry: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2139-4-24**]
1:00
Primary Care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Last Name (NamePattern1) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2139-5-14**] 1:50
Completed by:[**2139-3-16**]
|
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"428.43",
"272.4",
"414.01",
"250.00",
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] |
icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
]
] |
10502, 10573
|
5801, 9019
|
245, 252
|
10752, 10752
|
3240, 5778
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|
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10925, 11975
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280, 2187
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2416, 2602
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,373
| 152,475
|
5393
|
Discharge summary
|
report
|
Admission Date: [**2183-7-3**] Discharge Date: [**2183-7-10**]
Date of Birth: [**2110-6-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Levofloxacin
Attending:[**First Name3 (LF) 6378**]
Chief Complaint:
Dyspnea, cough and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 73 y/o F with PMH of severe COPD (on 3L O2 at
home), atrial fibrillation on coumadin, and prior small cell
lung cancer s/p chemotherapy and radiation who presented to the
ED on [**7-3**] with increased fatigued, somnolence and
non-productive cough. Patient reports that on [**7-1**] she started
feeling extremely fatigued to the point that she did not want to
eat anything and just wanted to sleep. At the same time she had
noticed increasing O2 requirement and had non-productive cough.
She continued to feel the same for two days and was brought to
the ED by husband for further evaluation. Of note, she was
recently seen as an outpatient ([**2183-6-24**]) for a COPD
exacerbation which improved with prednisone which has since been
tapered. She denied any chest pain, palpitations, orthopnea,
PND.
.
On arrival to the ED, the patient was triggered for O2 sat of
80% on [**Last Name (LF) **], [**First Name3 (LF) **] irregularly irregular HR of 149 with RVR, and a
fever of 101.2. A WBC was 14.7, lactate of 2.3 and Cr 1.1
(baseline 0.8-0.9). A CTA was performed that did not show
pulmonary emboli or any specific infiltrates, but did reveal
stable right sided loculated pleural effusion. Started on
vancomycin and levaquin in ED due to fever and hypoxia as there
was concern for pulmonary source. Given tylenol and 3L of fluids
and sent to the MICU.
.
In the MICU she was transitioned to Azithromycin, and other
antibiotics stopped. She was slowly tapered on oxygen. It was
felt that the sudden weather heat wave, and a bout of bronchitis
had triggered a severe COPD exacerbation. She was called out to
the general medical floor within 2 days where she continued to
steadily recuperate until time of her discharge [**Last Name (un) **] on [**2183-7-10**].
.
.
Past Medical History:
1. Small cell lung cancer [**1-/2180**] s/p Cisplatin, etoposide, XRT.
2. COPD, oxygen dependent.
3. Sleep apnea on CPAP 14 cm with 2 liters of oxygen.
4. Atrial fibrillation on coumadin.
5. Rosacea.
6. Macular degeneration.
7. Squamous cell skin cancer right arm s/p excision.
10. CVA at age 50 while on XRT.
11. Status post cholecystectomy.
12. Status post hysterectomy.
13. Patent foramen ovale.
Social History:
Married, lives at home with her husband and still involved with
a family owned business/printing company. There is
a cat at home. She quit smoking in [**2179**] with an approximately
40-pack year history. She still babysits for her
grandchildren. No significant EtOH or recreation drug use
history. Admits to non-compliance with her prescribed home
oxygen as she placed NC on at variable times within 2-4L ranges.
Family History:
Paternal Grandmother - died of a stroke
Maternal grandfather - died of CHF
Mother - died of CHF at 91
Maternal Grandmother - died of a stroke
Physical Exam:
Vitals: 96.3 136/77 128 16 88%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Good air entry b/l, mild crackles at bases, no w/r/r
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
cholecystectomy scar
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
ADMISSION LABS:
[**2183-7-3**] 03:35PM BLOOD WBC-14.7*# RBC-6.02* Hgb-18.7* Hct-54.8*
MCV-91 MCH-31.0 MCHC-34.1 RDW-18.3* Plt Ct-100*#
[**2183-7-3**] 03:35PM BLOOD Neuts-91.1* Lymphs-4.2* Monos-4.4 Eos-0.1
Baso-0.2
[**2183-7-4**] 04:42AM BLOOD PT-29.4* PTT-36.1* INR(PT)-2.9*
[**2183-7-3**] 03:35PM BLOOD Glucose-286* UreaN-21* Creat-1.1 Na-129*
K-4.5 Cl-93* HCO3-23 AnGap-18
[**2183-7-5**] 02:17AM BLOOD Albumin-3.1* Calcium-7.5* Phos-2.0*
Mg-2.1
.
CTA: [**2183-7-3**]
Impression: Stable appearance of right para-hilar density and
loculated effusion. Chest radiograph findings explained by
likely post-radiation changes. No pulmonary embolism.
EKG [**7-6**]: Atrial fibrillation with rapid ventricular response
and ventricular premature beats. Right bundle-branch block.
Possible anterior myocardial infarction,age indeterminate.
Compared to the previous tracing of [**2183-7-3**] ventricular rate is
slower. Premature ventricular contractions are new.
.
CXR [**7-7**]: The somewhat heterogeneous opacification of both lungs
which had progressed from [**7-3**] to [**7-6**] is now more
confluent, and accompanied by new small fissural left pleural
effusion, almost likely due to cardiac decompensation,although
heart size is only mildly increased. Moderate right pleural
effusion, the larger is a chronic finding, as is enlargement of
the right hilus and thickening of the apical and mediastinal
pleural surfaces.
.
DISCHARGE LABS:
[**2183-7-10**] 06:00AM BLOOD WBC-12.3* RBC-5.06 Hgb-15.2 Hct-48.9*
MCV-97 MCH-30.1 MCHC-31.1 RDW-17.7* Plt Ct-193
[**2183-7-10**] 06:00AM BLOOD Plt Ct-193
[**2183-7-10**] 06:00AM BLOOD Glucose-303* UreaN-23* Creat-0.9 Na-139
K-4.1 Cl-95* HCO3-35* AnGap-13
[**2183-7-10**] 06:00AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.2
Brief Hospital Course:
Ms. [**Known lastname **] is a pleasant 73 year old female with PMH of severe
COPD (on 3L O2 at home), longstanding atrial fibrillation on
coumadin, and prior small cell lung s/p chemo and radiation who
presented to the ED on [**7-3**] with increased fatigued, somnolence
and non-productive cough for two days. Patient has serious COPD
flare felt to be from recent URI/bronchitis in conjunction with
recent humid weather changes and some additional atrial
fibrillation with RVR early in her hospitalization necessitating
a brief ICU stay before she was stable for the general medicine
wards and patient discharged to home on [**7-10**] with close PCP
[**Last Name (NamePattern4) 702**]. Please see below for more detailed hospital course.
.
.
# Dyspnea: The patient presented to the [**Hospital1 18**] ED with dyspnea,
fatigue and increased non-productive cough x2 days most likely
from acute bronchitis or a viral syndrome. Since patient was
recently tapered from prednisone in the outpatient setting for
what was felt to be a milder COPD exacerbation her rebound
increased SOB and increased O2 requirement was again felt to be
related to a COPD flare/exacerbation in the setting of acute
infection. Other contributing factors to patient SOB include
history of OSA, lung cancer, and some milder element of
pulmonary fibrosis from radiation therapy in the past with
resultant poor pulmonary functional reserve. She also has
presence of loculated stable pleural effusions which are chronic
in nature. Negative CTA ruled out PE and lack of consolidation
ruled out pneumonia. The CTA showed stable right sided pleural
effusion unchanged from the previous Chest CT Scans in [**Hospital1 18**]
records. Dyspnea less likely to be cardiac in origin given no
chest pain and negative cardiac enzymes. She received 1 dose of
levofloxacin for CAP coverage, but it was changed to
azithromycin as the patient reported mental status changes on
levofloxacin. Patient reported having home 02 sat levels most
commonly in the mid to high 80s with minimal exertion which was
an important baseline detail for her ongoing management as
patient clearly retains chronic Co2 levels with severe COPD
status. She completed her Azithromycin for COPD exacerbation
while inpatient and was placed on an additional 3 days of
prednisone taper for 3 more days after her discharge to complete
a pulse taper. She was also given albuterol nebs and ipratropium
nebs inpatient and continued on continuous O2 therapy with goal
to keep O2 in the high 80s to low 90s on 3-5L NC. Blood cultures
remained unremarkable and sputum was unrevealing as it showed
just e/o commensal respiratory flora. She was breathing at her
usual baseline at time of discharge and she refused any home VNA
services so set up with close PCP [**Last Name (NamePattern4) 702**].
.
# Atrial Fibrillation: Patient has a history of Afib with RVR on
Coumadin with therapuetic INR on admission. She is
rate-controlled at home with dilt 360mg and metoprolol succinate
50mg. On admission, the patient was tachy to 149 with RVR and
admitted to the MICU. She was rated controlled on diltiazem 90mg
PO QID and metoprolol 25mg PO TID. She continued to be
tachycardic and her dose of metropolol was further increased, as
was her diltiazem. As team did not want to worsen her pulmonary
status/COPD with high levels of beta blockade we ended up
increasing her home dose of diltiazem to 420mg daily before
discharge and she was rate controlled for 2-3 days in 60-90s
range before discharge home. Also ended up discharging her on
slightly increased coumadin dose to 5mg daily/alternating with
2.5mg and having level rechecked at her visit with PCP on [**Name9 (PRE) 766**]
[**2183-7-14**] as her INR at time of discharge was subtherapeutic at
1.5.
.
# Obesity hypoventilation syndrome: She uses CPAP at night due
to obstruction sleep apnea. Respiratory was consulted and gave a
recommendation of Nasal CPAP at night at 14 cm/h2o Supp O2: 4
L/min to maintain SpO2 to >87 and <94. This was continued
inpatient.
.
# Code: Full (discussed with patient) --she was kept as a full
code status for entire admission.
.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) inhaled four times a day as needed for shortness of
breath or wheeze
DILTIAZEM HCL - 360 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray(s) each nostril
twice a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 inhalation twice a day - RINSE MOUTH AFTER EACH
USE
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
METRONIDAZOLE - 0.75 % Cream - apply once a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 inh oral daily
WARFARIN [COUMADIN] - 2.5 mg Tablet - 2 Tablet(s) by mouth once
a
day
CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] - 600
mg-400 unit Tablet - 1 Tablet(s) by mouth [**Hospital1 **] - take with meals
.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
2. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day: RINSE MOUTH AFTER EACH
USE
.
3. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) INhalation Inhalation once a day.
4. MetroCream 0.75 % Cream Sig: One (1) Topical once a day:
apply once a day as directed .
5. Calcarb 600 With Vitamin D 600 mg(1,500mg) -400 unit Tablet
Sig: One (1) Tablet PO twice a day: take with meals
.
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray each nostril Nasal twice a day.
7. diltiazem HCl 420 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
Disp:*30 Capsule, Extended Release(s)* Refills:*1*
8. prednisone 10 mg Tablet Sig: AS DIRECTED Tablet PO AS
DIRECTED for 3 days: Take 5 tablets (50mg) on [**7-11**] tablets
(40mg) on [**7-12**], and 3 tablets (30mg) on [**7-13**]. Then discontinue.
.
Disp:*12 Tablet(s)* Refills:*0*
9. Coumadin 2.5 mg Tablet Sig: AS DIRECTED Tablet PO AS
DIRECTED : Please take 5mg on Friday [**7-11**], then 2.5mg on Sat
[**7-12**], then 5mg on Sun [**7-13**] and have INR checked at Dr. [**Last Name (STitle) 838**]
office on Monday [**2183-7-14**]. .
10. INR management
INR at time of discharge was 1.5 ( goal [**1-16**]).
Instructions: Please take 5mg on Friday [**7-11**], then 2.5mg on Sat
[**7-12**], then 5mg on Sun [**7-13**] and have INR level re-checked at Dr.
[**Last Name (STitle) 838**] office on Monday [**2183-7-14**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Acute bronchitis
2. COPD exacerbation
3. Atrial Fibrillation (with rapid ventricular response)
.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
.
It was a pleasure taking care of you during your [**Hospital1 18**]
hospitalization. You were admitted because you were feeling
excessively fatigued, had non-productive cough and you were more
short of breath from your usual baseline. In the emergency
department your oxygen saturation dropped to 80% on room air,
and you had a flare up of atrial fibrillation with rates in the
140s. You were directly admitted to the ICU for monitoring and
management of your breathing and your rapid heart rates. You
had imaging of your chest which did not show any pneumonia or
blood clots in your lungs. Your initial symptoms were most
likely from an acute bronchitis/viral syndrome as well as
potential weather triggers that led you to have a severe COPD
exacerbation. Therefore you were started on treatment for COPD
exacerbation with nebulizers, IV then oral steroids and a brief
5 day course of antibiotics (azithromycin).
Your increased heart rates were controlled with slightly higher
doses of metoprolol and oral and IV diltiazem after which you
were transferred to the medical floor. You were continued on
coumadin for your chronic atrial fibrillation with a few dose
adjustments. It is very crucial that you continue to wear your
CPAP machine at night and continuous oxygen everyday as
recommended at home. On discharge you were back to your
baseline breathing with excellent heart rates.
.
You had a few elevated glucose levels which are a side effect of
steroids. These will improve as you taper your dose in the
outpatient setting. You do not need any home insulin therapy.
Your primary care physician can follow this issue in the
outpatient setting.
.
Please follow up with your pulmonologist (as scheduled below)
for further management of your COPD. You have also been set up
with your PCP and your cardiologist (as scheduled below) for
monitoring of your atrial fibrillation and your INR levels.
.
MEDICATION CHANGES:
.
We have made the following medications changes for you.
1)Please INCREASE your daily dose of Diltiazem to 420mg daily
2)INCREASE coumadin dose to 5mg daily on Saturday and then 2.5mg
Sunday and have level rechecked at your visit with PCP on [**Name9 (PRE) 766**]
[**2183-7-14**].
3) Continue Prednisone taper as outlined below over the next 3
days:
-50mg on Friday [**7-11**]
-40mg on Saturday [**7-12**]
-30mg on Sunday [**7-13**]
* Then discontinue *
.
Otherwise, please continue all of your usual home medications as
previously prescribed.
.
Followup Instructions:
1) Primary Care Follow-Up:
Please see Dr. [**Last Name (STitle) 838**] on Monday [**7-14**] at 3:30pm at his [**Location 21908**]office location in [**Location (un) **].
.
2)Cardiology Appointment:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2183-8-21**] 3:00
.
3)Pulmonology Appointments:
Provider: [**Name10 (NameIs) 2788**] [**Name11 (NameIs) 1570**] CLINIC Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2183-8-28**] 1:15
Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2183-8-28**] 1:30
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**] MD, [**MD Number(3) 6385**]
Completed by:[**2183-8-22**]
|
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"V87.41",
"276.1",
"V58.61",
"V12.54",
"V15.3",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
12173, 12179
|
5444, 9578
|
324, 330
|
12342, 12342
|
3669, 3669
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12200, 12321
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257, 286
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358, 2156
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3685, 5088
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12357, 12469
|
2178, 2579
|
2595, 3014
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,174
| 198,736
|
13919
|
Discharge summary
|
report
|
Admission Date: [**2166-2-13**] Discharge Date: [**2166-3-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Mr. [**Known lastname 24110**] is an 85 yo M w/ h/o CAD s/p CABG who presents w/ 1
day h/o CP. Noontime on day PTA pt. noted sudden onset of [**4-3**]
midsternal, dull CP & SOB while seated and watching TV. CP
resolved on own over next few hours and pt. was able to perform
daily activities w/o additional pain/symptoms. The following
day, pt. awoke w/ [**8-3**] worsening, midsternal, dull CP and waited
approx. 30 min. before calling lifeline for assistance. He
denies diaphoresis, palpitations, dizziness, n/v, abd pain.
.
At OSH pt. was found to have ecg notable for elevations in V2-V4
and positive tropinin values of 1.2 and 0.39. Pt. was started on
heparin gtt, ASA, nitro, morphin, lopressor 2.5mg x 4 , & plavix
150mg with resolution of chest pain. PTT 150, and heparin gtt
was stopped.
.
Pt. was transferred to [**Hospital1 18**] ED for cardiac catheterization,
where found to be T: 98.2 HR:75 BP: 136/75 RR 18 & 100% 2L nc.
Evaluation revealed tropinin elevated to 1.27 although ecg was
no longer notable for ST elevations.
Past Medical History:
Aortic porcine valve replacement ([**2152**])
CABG
DM
CHF
MVA [**2148**] requiring shoulder/knee operations.
Social History:
Lives alone in top floor of house, rents bottom floor out.
Tenants help with shopping, etc. Only family in area is [**Name (NI) **],
HCP. Exsmoker, 32 pack-year history - quit 10 years ago. No
EtOH, IVDU, herbal supplements.
Family History:
No known h/o cardiac disease in fNo known h/o cardiac disease in
family. noncontributory.
Physical Exam:
VS: T 97.8, BP 87/51, HR 78, RR ,14 O2 100% on AC 500x14, PEEP
5, FiO2 100%
Gen: elderly male, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. ETT in place.
Neck: Supple without appreciable JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds. RR w/ occasional early beats. normal S1,
S2. [**1-29**] sys murmur at LUSB
Chest: Rhonchorous breath sounds bilaterally anteriorly
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Groin: R groin w/ IABP and PA catheter sheath. CDI. L groin w/o
hematoma or bruit.
Ext: Cool bilat LEs. Trace LE edema bilaterally. 2+ DP, PT
pulses bilat.
Pertinent Results:
CARDIAC CATH performed on [**2166-2-15**] demonstrated:
90% prox and mid LAD lesions s/p BMS x 3 and 80% D1 s/p POBA
RHC: RA mean 8, RV 64/5, PA 64/36, PCW 23. CO 4.06, CI 2.07 (on
IABP and dopamine gtt)
.
CARDIAC CATH performed on [**2166-2-14**] demonstrated:
1. Coronary angiography of this right dominant system revealed
three
vessel coronary artery disease. The LMCA was without
angiographically evident flow limiting stenosis. The LAD had a
90% proximal lesion, 90% mid lesion, diffuse distal disease, and
an 80% diagonal lesion. The LCx had 70% stenosis. RCA w/ 50%
proximal stenosis and 80% stenosis R-PL.
2. Limited resting hemodynamics revealed normal aortic systolic
pressure of 116 mm Hg.
3. Left ventriculography was not performed.
.
Echo [**2166-2-15**]:
The left atrium is dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with anteroseptal/anterior
hypokinesis/akinesis. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are moderately
thickened. There is mild to moderate aortic valve stenosis (area
1.1-1.2 cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion
.
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST [**2166-2-24**]:
1. Moderate bilateral pleural effusion with right lower lobe
opacification
and air bronchograms probably related to patient's recent
history of
aspiration pneumonia. Bilateral linear opacities abutting both
major fissures
likely reflect atelectasis.
2. Focal ground-glass opacities in the right upper lobe and LLL
6 mm nodule just inferior to the left major fissure. No
comparisons are available to assess stability - these is
nonspecific and may be infectious vs inflammatory. In the
absence of comparison studies to establish longitudinal
stability, followup chest CT of pulmonary nodule is recommended
in 12 months (assuming no risk factors for primary lung
malignancy).
3. Hyperdense exophytic focus arising from the left kidney. This
may represent a hyperdense cyst - renal ultrasound or MRI
suggested for further assessment of solid vs cystic character.
4. No evidence of abscess or pancreatitis, within the limits of
a CT
examination.
.
Video swallow [**2166-3-3**]:
Moderate-to-severe oropharyngeal dysphagia with aspiration noted
of barium of all consistencies.
.
MRI head [**2166-3-5**]:
No acute intracranial pathology including no hemorrhage or
infarction.
.
CARDIAC CATH performed on [**2166-3-10**] demonstrated:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel coronary artery disease. The LMCA had moderate diffuse
disease
without critical lesions. The LAD had a prior stent which was
occluded
proximally with thrombus noted. The LCx was a non-dominant
vessel with
70% noted in stent restenosis. The RCA was a dominant vessel
and was
not injected.
2. Resting hemodynamics revealed normal right sided filling
pressures
with LVEDP 10 mmHg. The pulmonary artery systolic blood
pressure is
mildly elevated at 31 mmHg. The cardiac index is elevated at
5.42
L/min/m2. There is evidence of systemic arterial systolic and
diastolic hypotension with SBP 91 mmHg and DBP 52 mmHg.
3. Successful PTCA, thrombectomy and stenting of the mid LAD
with a 2.75
x 18 mm VISION BMS which was post dilated to 2.75 at high
pressure.
Final angiography revealed no residual stenosis in the stent, no
dissection and TIMI II flow (See PTCA comments)
4. Successful PTCA of the diagonal with a 2.0 x 15 mm voyager
balloon.
Final angiography revealed a 20% residual stenosis in the
diagonal, no
dissection and TIMI II flow. (See PTCA comments)
5. Successful IABP placement in Right groin.
.
Echo [**2166-3-11**]:
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild to moderate regional left ventricular
systolic dysfunction with akinesis of the anteroseptum and
anterior walls. There is no ventricular septal defect. Right
ventricular chamber size is normal. with borderline normal free
wall function. A bioprosthetic aortic valve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is mild pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-2-25**], the
left ventricular function is slightly worse. Mild pulmonary
artery systolic hypertension is now present
CXR [**2166-3-18**]: In comparison with the study of [**3-16**], the patient
has taken a somewhat better inspiration. There is persistent
enlargement of the cardiac silhouette, though the pulmonary
vascularity is essentially within normal limits. The blunting of
the costophrenic angles has decreased and the hemidiaphragms are
more sharply seen.
PERTINENT DISCHARGE LABS
Peak troponin T [**3-11**] at 4.4
PITUITARY TSH 2.2, free T4 0.60 ([**2166-3-4**])
Discharge weight: 86.5 kg
Discharge Cr 1.0, WBC 10.2, Hct 33.6
Brief Hospital Course:
Summary of long hospital course:
85 yoM w/ AS s/p porcine AVR, DM, htn presented [**2-13**] with STEMI
that was intitially interpreted at OSH as NSTEMI (but upon
further review was STEMI), cath here demonstrated 3VD with plan
for CABG but same evening developed chest pain, STEMI --> BMS to
LAD and POBA to D1 w/ aspirated on table requiring intubation
and complicated subsequent course including aspiration
pneumonia, sepsis, influenza type A, pseudomonas UTI, in-stent
thrombosis [**2-11**] in setting of holding plavix for PEG placement,
followed by re-BMS of LAD, angioplasty of diagonal branch c/b
peri-cath VT requiring 2 shocks, hypotension --> IABP placement,
pressors, and re-intubation with good recovery coming off
pressors, extubated and HD stable. Patient stable for discharge
to rehab placement.
.
Hospital course by problem:
85 yoM w/ AS s/p porcine AVR, DM, htn presented [**2-13**] with STEMI
.
# CAD/Ischemia
Presented [**2-13**] with STEMI that was intitially interpreted at OSH
as NSTEMI (but upon further review was STEMI), cath here
demonstrated 3VD (LMCA was without angiographically evident flow
limiting stenosis. The LAD had a 90% proximal lesion, 90% mid
lesion, diffuse distal disease, and an 80% diagonal lesion. The
LCx had 70% stenosis. RCA w/ 50% proximal stenosis and 80%
stenosis R-PL). Plan was for CABG but same evening developed
chest pain, STEMI --> BMSx3 to LAD and POBA to D1. Had in-stent
thrombosis [**2-11**] in setting of holding plavix for PEG placement,
followed by re-BMS of LAD, angioplasty of diagonal branch. Pt
was kept on aspirin 325mg, atorvastatin 80mg. An intervention
to the LCx may be considered once stabilized after a stress test
if pt wishes to do so. Patient was restarted on metoprolol
12.5mg PO BID on [**2166-3-17**], with HR 60s, SBP 90-100s. Continue
metoprolol on discharge, and can follow up with cardiologist
about addition of ACEi as tolerated after discharge.
.
# Pump/Acute Systolic Heart failure
Pt was initially in cardiogenic shock (as well as septic shock),
and needed IABP, pressors, then recovered with echo showing EF
45-55% and moderate regional left ventricular systolic
dysfunction with anteroseptal/anterior hypokinesis/akinesis.
CAme off IABP and pressors after a few days and diuresed,
started on BB and ACEi as BP tolerated, then low dose PO lasix
started to keep I/Os even. After in-stent restenosis again had
cardiogenic shock requiring IABP and pressors, this time needing
pressors for an extended period. Patient was restarted on
metoprolol 12.5mg PO BID on [**2166-3-17**], with HR 60s, SBP 90-100s.
Continue metoprolol on discharge, and can follow up with
cardiologist about addition of ACEi as tolerated after
discharge.
.
# Rhythm
Pt had new onset afib developing when septic after first
intervention. This was treated with DCCV and was amio loaded,
heparin gtt started with transition to coumadin intially.
Coumadin was held in anticipation for PEG and not restarted
since pt did not have recurrence of afib (monitored closely on
tele). Amio was kept at 200mg daily at the time of d/c as it
was felt that perhaps it was keeeping the pt in NSR.
At the time of the in-stent thrombosis pt had peri-cath VT, but
was monitored closely on tele and did not have any recurrence.
Given this was peri-cath it likely is not scar related (rather
ischemia). Patient discharged on amiodarone 200mg PO daily to
continue for 1 month after discharge from hospital
.
# ARF
Pt developed acute renal failure [**1-25**] hypotension during sepsis
and cardiogenic shock with creatinine peakeing at 1.8. Pt
recovered renal function while holding diuresis and ACEi briefly
and creatinine prior to d/c was 1.0. Patient's weight at
discharge was 86.5kg. Patient was discharged on PO lasix which
should be titrated to keep patient euvolemic to negative 500ml
out daily.
.
# ID
Pt aspirated on the table at the time of the first intervention
and developed aspiration pneumonia and levo, flagyl were started
at that time ([**2-15**]). CT torso demonstarted moderate bilateral
pleural effusions with right lower lobe opacification and air
bronchograms. Pt developed sepsis subsequently by HD numbers and
so on [**2-17**] d/c'd levo and vanco, flagyl, cefepime were started.
On [**2-22**] spiked a fever to 103.4 and at this time ID were
consulted and found to be positive for influenza type A with ID
recommending supportive care (no Tamiflu) and resp precautions
for 7 days per infection control. On [**2-23**] d/c'd vanco since
afebrile and on [**2-24**] d/c cefepime, flagyl. Pt remained afebrile.
Given MS changes (see below) was urine cultured with
pan-sensitive pseudomonas aeroginosa growing --> started cipro.
When had in-stent thrombosis restarted broad spectrum abx given
shock but was pan-cx negative --> d/c'd vanco, flagyl after 3
days empiric therapy aside from cipro which was continued for a
14 day course for complicated UTI. Cipro was discontinued on day
9 due to development of drug rash which improved with
discontinuation. Repeat UCx was equivocal. Foley discontinued
prior to discharge. Pt continues to be at great risk for
aspiration given abnormal swallowing and should be kept on
aspiration precautions and should have aggressive chest PT for
upper secretions.
.
# Focal ground-glass opacities in the right upper lobe and LLL 6
mm nodule inferior to the left major fissure. No comparisons
were available; nonspecific and infectious vs inflammatory per
rads --> followup chest CT of pulmonary nodule is recommended in
12 months.
.
# Hyperdense exophytic focus arising from the left kidney.
Likely a hyperdense cyst per rads. Recommend renal ultrasound
or MRI suggested for further assessment of solid vs cystic
character as an outpatient.
.
# Valves: s/p porcine AVR
Miniminally elevated gradient
.
# MS changes
On [**3-3**] was found to be unresponsive and therefore had head CT
and MRI negative for acute hemorrhage. TSH nl, B12/folate nl,
RPR neg EKG and CXR without change. Neuro were consulted who
thought this was toxic/metabolic. Pt was then found to have
pseudomonas UTI and after rx with copro the MS changes improved.
Per HCP pt was very independant at home and able to perform
ADLs. Also per HCP very jumpy when depressed/anxious. W/u
revelaed TSH nl, B12/folate nl, RPR neg EKG and CXR without
change. Patient at baseline mental status
.
# GI
Failed S+S [**2-25**], and [**2-26**] s/p extubation and again video swallow
[**3-3**]. Held coaumdin and plavix for 5 days given that GI, surgery
and IR were consulted and all declined PEG placement on plavix
and given that BMS was 3 weeks out (so thought to have had
epithelialized and healed stent). After recovering from
in-stent thrombosis had PEG placed by surgery. Pt had no
complication and TF's were started and advanced afterwards and
tolerated well.
Medications on Admission:
Glipizide ER 5mg po daily
Lasix 20mg po daily
Ibuprofen prn pain
Discharge Medications:
1. Aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.8 mg/5 mL Syrup [**Month/Year (2) **]: Five (5) ML PO BID (2 times a
day).
4. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Twenty (20) units
Subcutaneous QHS at bedtime.
7. Insulin Aspart 100 unit/mL Solution [**Last Name (STitle) **]: variable doses
subcutaneously Subcutaneous as indicated by insulin sliding
scale.
8. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml
Injection TID (3 times a day).
13. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) nebulizer
Inhalation Q6H (every 6 hours).
15. Camphor-Menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical
QID (4 times a day) as needed.
16. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day): Hold for SBP<80, HR<50.
17. Furosemide 40 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID (2
times a day): Hold for SBP<80.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
# ST elevation myocardial infarction with BMS to LAD and POBA to
D1
- 3VD on cath
# Aspiration pneumonia
# Sepsis
# Influenza type A
# Acute Renal Failure
# New onset afib s/p DCCV
- remained in SR after DCCV
# Focal ground-glass opacities in the right upper lobe and LLL 6
mm nodule inferior to the left major fissure
- followup chest CT of pulmonary nodule is recommended in 12
months
# Hyperdense exophytic focus arising from the left kidney
- recommend renal ultrasound or MRI suggested for further
assessment of solid vs cystic character as an outpatient
# Acute systolic heart failure
- LVEF 45-55%
# DM
# Hypertension
.
Secondary diagnosis:
# AS s/p porcine AVR [**2152**]
# s/p MVA [**2148**] requiring shoulder/knee operations.
Discharge Condition:
Stable
Discharge Instructions:
- You were admitted to [**Hospital1 18**] with an ST elevation myocardial
infarction.
- Please take your previous medications as prescribed including
aspirin to prevent another heart attack, atorvastatin 80mg daily
for your heart and for your cholesterol, lisinopril for your
heart and
blood pressure (prevents remodelling of the heart), Metoprolol
for your heart and blood pressure (prevents remodelling of the
heart), and clopidogrel (Plavix) 75 mg daily to keep your
cardiac stents open. You will need to take amiodarone for 1
month after discharge, also will continue on lasix for removal
of fluid.
- If you develop chest pain, jaw pain, or chest pressure with
pain
radiating into arm, or if you for any reason become concerned
about your medical condition please call 911 or present to
nearest ED.
- We also gave you Nitroglycerin tablets to take if you
experience chest pain, please call 911 or your doctor if chest
pain recurs even if it dissapears with nitroglycerine.
**DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO
DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO**
- Please make all of you appointments as outlined below.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **], your
cardiologist, on Monday [**3-31**] at 4:40pm. [**Telephone/Fax (1) 22476**]
Please also make an appointment to see your primary care
provider [**Name Initial (PRE) 176**] 2 weeks of discharge from the hospital. At this
appointment, please follow up on the following issues:
Started amiodarone for atrial fibrillation; LFTs were mildly
elevated, likely [**1-25**] venous congestion, and TSH was normal; CXR
at that time showed resolving aspiration pna. Will need LFTs
Q3months, TSH annually, and PFTs within one month of discharge
as well as complete eye exam within one month of discharge for
amiodarone safety monitoring.
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45,248
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38379
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Discharge summary
|
report
|
Admission Date: [**2128-4-10**] Discharge Date: [**2128-4-11**]
Date of Birth: [**2060-5-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
liver failure`
Major Surgical or Invasive Procedure:
[**Last Name (LF) 14938**], [**First Name3 (LF) **], EGD
History of Present Illness:
Mr. [**Known lastname 46014**] s a 67 y/o male with a PMH significant for
longstanding but "mild" EtOH abuse and depression who presented
to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital on [**4-9**] with SOB x 1 week, black
stools, and weakness. He admitted to recent worsening
depression ever since being arrested for DUI and having his
license taken away. He increased his EtOH use and has been in a
"downward spiral" per his wife. [**Name (NI) **] was reportedly drinking vodka
from morning until nightime, [**3-25**] drinks/day, with each "drink"
being 3 shots at a time. He has had worsening peripheral
neuropathy and falls in the past week and has been too weak to
walk. He had SOB with exertion and several dark black stools
without abdominal pain. No reported fevers.
.
He presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital ER, where he was found to
be hypotensive, in ARF (to 2.2), with multiple hepatic
abnormalities including elevated INR of 1.8, AST 1500, ALT 300,
platelets 114. Was also acidotic to 7.18. He was admitted to
their ICU and covered broadly with vancomycin and zosyn, and was
started on a bicarb gtt to correct his acidosis. Viral hepatitis
serologies and a tylenol level were sent. Overnight he was
hypotensive to the 70's, with altered mental status. A head CT
was negative.
.
This AM, he was more jaundiced and confused. His CBC has
developed a 42% bandemia (WBC count of 2.6). AST was acutely
elevated to 13,100, ALT 1686. INR elevated to 3.5, plts dropped
to 62, and Cr up to 2.8. Additionally, blood cx from admission
grew GNR 2/2 bottles. Repeat ABG pending but reportedly was
maintaining O2 and airway, did not need intubation. He was
started on phelyephrine periperhally and transfer was requested
to [**Hospital1 18**] for liver transplant eval. [**Location (un) 7622**] was called.
.
On arrival to [**Hospital1 18**], he is alert and oriented x 3 and
interactive. He denies ingestion of tylenol or any other
medication. He does state that he had "hepatitis from well
water" in the distant past.
Past Medical History:
# EtOH abuse as per HPI
# COPD
# h/o R nephrectomy for RCC in [**2118**]
# s/p ventral hernia repair
# h/o rib fractures c/b flail chest and splenic hematoma
Social History:
- Tobacco: smokes [**11-24**] ppd, has cut down from 1ppd x many years
- Alcohol: as per HPI
- Illicits: denies any h/o IVDU
Family History:
NC
Physical Exam:
Vitals: T: 96.5 BP: 81/66 P: 112 R: 27 O2: 96% 4L NC
General: jaundiced, tremulous, but A+O x 3
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: scattered anterior wheezes, bibasilar inspiratory
crackles
CV: regular tachycardia, no murmurs, rubs, gallops
Abdomen: non-tender, distended, + ascites with fluid wave
Rectal: dark black stool strongly guaiac positive
Neuro: marked asterixis
Ext: warm, well perfused, 2+ pulses
Skin: no spider angiomata. Many scattered ecchymoses, on RLE, R
shoudler, sacrum, R hip, from prior falls
Pertinent Results:
OSH:
AST/ALT 13,[**Telephone/Fax (1) 85464**]
tbili/dbili 10.7/6.7
albumin 3.2
amylase/lipase 133/956
TSH WNL
3 negative troponins
HCT 29.5
INR 3.5
Plts 35
Cr 2.8
lactate 15.5
tylenol level PND
.
Micro:
OSH:
BCx growing GNRs
UCx PND
viral hepatitis panel PND.
.
Images:
OSH:
[**4-9**] Head CT: unremarkable
[**4-9**] Abd CT: ascites, fatty liver, s/p right nephrectomy.
.
EKG:
sinus tachycardia, L axis, normal intervals, no diagnostic Q
waves, no ST depressions/elevations
.
[**2128-4-10**] 04:24PM ASCITES TOT PROT-1.0 ALBUMIN-<1.0
[**2128-4-10**] 04:24PM ASCITES WBC-[**Numeric Identifier **]* RBC-4000* POLYS-93*
LYMPHS-1* MONOS-6*
[**2128-4-10**] 04:00PM TYPE-[**Last Name (un) **] PO2-51* PCO2-43 PH-7.20* TOTAL
CO2-18* BASE XS--10 COMMENTS-GREEN TOP
[**2128-4-10**] 04:00PM LACTATE-11.2*
[**2128-4-10**] 04:00PM O2 SAT-74
[**2128-4-10**] 03:52PM GLUCOSE-87 UREA N-41* CREAT-2.7* SODIUM-134
POTASSIUM-3.9 CHLORIDE-86* TOTAL CO2-17* ANION GAP-35*
[**2128-4-10**] 03:52PM ALT(SGPT)-1624* AST(SGOT)-[**Numeric Identifier **]*
LD(LDH)-7800* ALK PHOS-248* AMYLASE-296* TOT BILI-13.1*
[**2128-4-10**] 03:52PM LIPASE-[**2098**]*
[**2128-4-10**] 03:52PM ALBUMIN-3.9 CALCIUM-7.4* PHOSPHATE-3.1
MAGNESIUM-1.4* IRON-221*
[**2128-4-10**] 03:52PM calTIBC-203* FERRITIN-GREATER TH TRF-156*
[**2128-4-10**] 03:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-4-10**] 03:52PM WBC-7.2 RBC-3.46* HGB-10.3* HCT-32.6* MCV-94
MCH-29.8 MCHC-31.6 RDW-19.7*
[**2128-4-10**] 03:52PM NEUTS-24* BANDS-40* LYMPHS-15* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-12* MYELOS-1* NUC RBCS-6*
[**2128-4-10**] 03:52PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
STIPPLED-2+ HOW-JOL-1+ PAPPENHEI-2+
[**2128-4-10**] 03:52PM PLT SMR-LOW PLT COUNT-84*
[**2128-4-10**] 03:52PM PT-23.1* PTT-38.7* INR(PT)-2.2*
.
ABD U/S:
1. Liver cirrhosis and intra-abdominal ascites.
2. Patent main portal vein with normal color and Doppler flow.
The portal
vein branches are not seen. Patent main, right and left hepatic
arteries.
3. Splenomegaly.
4. Common bile duct and gallbladder are not well seen.
.
CXR: FINDINGS: The trachea is deviated to the right as it enters
the chest. The endotracheal tube is adjacent to the right
lateral wall of the trachea. The tip is 4.4 cm above the carina.
There is bilateral lower lobe volume loss with bilateral pleural
effusions. The right IJ line tip is in the right atrium. The
etiology of the tracheal deviation would best be assessed by CT
scan.
Brief Hospital Course:
Patient was admitted to the MICU with acute liver failure. He
underwent paracentesis that revealed SBP and was treated with
broad spectrum abx (Vanc/zosyn/cipro). He required intubation
for respiratory distress. He had a [**Month/Day/Year 14938**] and a line placed. He was
persistently hypotensive and required 3 pressors (vasopressin,
levophed, neo). He then had a large hct drop to 18. GI was
consulted and EGD showed profuse bleeding in the stomach. GI was
unable to pass [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] tube into the stomach. At this point
the family confirmed that the patient would not want heroic
measures and he was transitioned to comfort measures only. He
died shortly thereafter at 3:05 pm.
Medications on Admission:
Transfer Medications:
Zosyn 2.25g IV q6h ([**4-9**] - )
Vancomycin (1g dose given in ED on [**4-9**] at 7PM)
Duonebs q4h prn SOB
zofran IV 4mg q8h prn
ativan 0.5 - 1mg po IV prn withdrawal or anxiety
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
Completed by:[**2128-4-11**]
|
[
"995.92",
"496",
"305.1",
"578.9",
"038.40",
"571.2",
"518.81",
"V45.73",
"356.9",
"458.29",
"584.5",
"570",
"V66.7",
"577.0",
"303.91",
"276.2",
"571.1",
"780.97",
"311",
"287.5",
"785.52",
"285.1",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"38.93",
"96.71",
"45.13",
"54.91",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7079, 7088
|
6056, 6796
|
330, 388
|
7140, 7150
|
3475, 3760
|
7207, 7246
|
2861, 2865
|
7046, 7056
|
7109, 7119
|
6822, 6822
|
7174, 7184
|
2880, 3456
|
276, 292
|
6844, 7023
|
416, 2520
|
3769, 6033
|
2542, 2702
|
2718, 2845
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,584
| 118,257
|
17005
|
Discharge summary
|
report
|
Admission Date: [**2168-4-4**] [**Month/Day/Year **] Date: [**2168-4-12**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Codeine
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 yo female s/p fall from toilet; she was taken to an area
hospital where she was found to have a Grade IV renal laceration
to her left kidney. She was then transferred to [**Hospital1 18**] for
further care.
Past Medical History:
HATN
MI
Afib
DJD
Mild dementia
Arthritis
GERD
Spinal Stenosis
Anemia
Hyperkalemia
Chronic rhabdo
s/p open CCY "80's
s/p Right TKR
Family History:
Noncontributory
Physical Exam:
Upon admission:
T 97.4 po HR 88 BP 150/70 RR 18
Gen: NAD
HEENT: EOMI
Neck: c-spine immobilized
Chest: CTA bilat
Cor: RRR
Abd: soft, NT, ND
GU: Foley intact; + gross hematuria +TTP over left flank
Extr: 2+ DP pulses
Skin: no rash
Musculosk: MAE
Neuro: alert & orientd x3
Pertinent Results:
*OSH CT from [**Hospital 1474**] Hospital shows multiple nodules including
at thyroid, RUL lung, liver. Pt will need followup imaging
nonacutely to confirm lesions and/or resolution.
RENAL U.S.
Reason: Please assess for hydronephrosis/evidence of
obstruction, or
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman s/p trauma L kidney
REASON FOR THIS EXAMINATION:
Please assess for hydronephrosis/evidence of obstruction, or
other pathology
INDICATION: 85-year-old woman with status post trauma, left
kidney.
RENAL ULTRASOUND: There is pleural effusion. There is
heterogeneity of the left kidney mainly in the medulla with
hypoechogenicity, representing laceration/hematoma seen on the
prior CT study. There is no perinephric fluid collection
identified on this ultrasound. There is mild hydronephrosis
versus ectatic extrarenal pelvis. There is small amount of
ascites. The atrophic right kidney was not identified on this
ultrasound.
IMPRESSION: Laceration/hematoma of the left kidney as seen on
the prior CT scan. Small ascites. Mildly dilated pelvis which
may represent mild hydronephrosis. Echogenicity in the pelvis
may represent clot in this area as suggested on the prior CT
study.
Cardiology Report ECHO Study Date of [**2168-4-5**]
ECHO
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular
systolic dysfunction with severe hypokinesis/akinesis of the
basal half of the
inferior and inferolateral walls. The remaining left ventricular
segments
contract normally. Right ventricular chamber size and free wall
motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis
is not present. Mild (1+) aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to
moderate ([**1-19**]+) mitral regurgitation is seen. There is mild
pulmonary artery
systolic hypertension. There is a small circumferential
pericardial effusion
without evidence for hemodynamic compromise. There are prominent
bilateral
pleural effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic
dysfunction c/w CAD. Mild-moderate mitral regurgitation. Mild
aortic
regurgitation. Pulmonary artery systolic hypertension. Bilateral
pleural
effusions.
CLINICAL IMPLICATIONS:
Based on [**2158**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a moderate risk (prophylaxis recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
[**2168-4-7**]
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: interval change? uretal obstruction? NO CONTRAST PLEASE
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman with Grade 4 renal lac, with intermittant low
[**Last Name (LF) **], [**First Name3 (LF) **] need stenting
REASON FOR THIS EXAMINATION:
interval change? uretal obstruction? NO CONTRAST PLEASE
CONTRAINDICATIONS for IV CONTRAST: single kidney w/ limited
function, rising cr
CLINICAL HISTORY: 85-year-old female with grade 4 renal
laceration with intermittent low urine output. Evaluate for
interval change.
COMPARISON: [**2168-4-4**].
TECHNIQUE: Non-contrast multidetector CT acquired axial images
of the abdomen and pelvis from the lung bases to the pubic
symphysis. Coronal and sagittal reformatted images were
obtained.
CT OF THE ABDOMEN: There are large bilateral pleural effusions
and adjacent compressive atelectasis, unchanged from [**2168-4-4**]. Again seen are two small round high-density foci within
the subcutaneous tissue of the left upper thorax (series 2,
image 1) which likely represents metallic foreign bodies. There
is a tiny low-density lesion within segment III of the liver
which is not characterized on this non-contrast study. The
gallbladder is not identified. The spleen, pancreas, adrenal
glands, and intra-abdominal loops of large and small bowel are
unremarkable. Left kidney demonstrates retained contrast from
prior imaging, although decreased compared to prior exam. The
appearance of the kidneys is unchanged, without evidence of
hematoma or hydronephrosis. The previously noted filling
defect/clot within the left renal pelvis is not evaluated given
lack of intravenous contrast. The right kidney is extremely
atrophic. No lymphadenopathy or discrete fluid collection is
identified within the abdomen.
CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, uterus, and
adnexa are within normal limits. A moderate amount of air is
seen within the bladder with tiny gas bubbles lateral to a Foley
balloon likely within a lateral recess. Intrapelvic loops of
small bowel are unremarkable. There are numerous sigmoid
diverticula without evidence of diverticulitis. Free fluid is
seen within the pelvis, the extent to which is unchanged from
[**2168-4-4**].
BONY WINDOWS: Degenerative changes are present within the hips.
Multiple rib fractures as well as a potential fractured
osteophyte at L2 is again identified. There is extensive
subcutaneous edema.
IMPRESSION:
1. Compared to prior CT from [**2168-4-4**], the appearance of
the left kidney is unchanged. There is no evidence of hematoma
or hydronephrosis. Without intravenous contrast, the previously
noted filling defect within the left renal pelvis and ureter is
not assessed.
2. Large bilateral pleural effusions and adjacent compressive
atelectasis, unchanged.
Brief Hospital Course:
She was admitted to the Trauma Service. Abdominal CT scan
revealed multiple left renal lacerations, Urology was
immediately consulted. She was transferred to the Trauma ICU
after stabilized in the Emergency department; placed o strict
bedrest; serial Hct's were followed q 4 hours; foley had been
placed in the ED, there was gross hematuria; repeat CT scan was
recommended as followup within 48 hours, this was performed and
was unchanged. Discussions regarding possible stenting took
place if she became obstructed. Follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 770**] is being recommended in 1 month.
Her urine output began to decrease and her creatinine began to
rise, it was initially 1.1 then increased to 1.2, peaking at 1.6
on HD#3. Nephrology was then consulted for ? ATN. A renal
ultrasound was recommended (see Pertinent results); her calcium
was corrected. Her creatinine eventually improved back to 1.1.
She will need to follow up with her primary Nephrologist after
[**Last Name (NamePattern1) **] from rehab.
Physical and Occupational therapy were consulted and have
recommended short term rehab stay.
Medications on Admission:
Dig .125'
Toprol XL 200'
Colace 100''
ASA 81'
Nexium 40'
Detrol LA 4'
Levoxyl 125'
Fosamax 70 q Sat
Senna
Predsinolone eye gtts
[**Last Name (NamePattern1) **] Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily): Apply OS.
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold for HR <60; SBP <110.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
13. Fosamax 70 mg po every Saturday
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital 39225**] & Rehab Center - [**Hospital1 1474**]
[**Hospital1 **] Diagnosis:
s/p Fall
Grade IV left kidney laceration
Left pleural effusion
Bilateral rib fractures
[**Hospital1 **] Condition:
Stable
[**Hospital1 **] Instructions:
Avoid any activites that may cause physical contact to your left
flank area because of your recent injury to your left kidney.
Report any signs of blood in your urine to the staff at the
rehab facility immediately.
Followup Instructions:
Follow up in Trauma Clinic in [**1-19**] weeks. Call [**Telephone/Fax (1) 6429**] for
an appointment.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**], Urology, in 1 month. Call
[**Telephone/Fax (1) 164**] for an appointment.
You will also need to follow up with your primary Nephrologist
after [**Telephone/Fax (1) **] from rehab as recoemmended by the Nephrology
team who saw you during your hospitalization. Call for an
appointment.
You must follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
from rehab for a thyroid finding on CT imaging.
Completed by:[**2168-4-12**]
|
[
"412",
"511.9",
"530.81",
"E884.6",
"753.0",
"807.02",
"414.01",
"715.95",
"958.5",
"E849.0",
"866.02",
"728.88",
"599.7",
"401.9",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6523, 7678
|
257, 264
|
998, 1264
|
9551, 10210
|
672, 689
|
3825, 3950
|
7704, 9011
|
704, 706
|
3392, 3788
|
209, 219
|
3979, 6500
|
9041, 9126
|
292, 503
|
720, 979
|
9154, 9280
|
525, 656
|
9311, 9528
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,328
| 108,944
|
33906+33907+57879+57880
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2178-4-24**] Discharge Date: [**2178-5-1**]
Service: SURGERY
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
left groin pain
Major Surgical or Invasive Procedure:
excision of L graft, oversewing of CFA/graft stump [**4-25**]
insertion of PICC line [**5-1**]
History of Present Illness:
84 F with past severe vascular disease s/p aorto-bifem
bypass, bilateral above-knee amputations, resection of left
femoral pseudoaneurysm on [**2178-2-23**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital3 8834**] that was complicated by wound
infection treated with antibiotics now represented with left
groin pain. She was evaluated at M-WH and found to have a
recurrence of pseudoaneurysm in setting of leukocytosis (WBC
19).
She was subsequently transferred to [**Hospital1 18**] for further
management.
Patient is a vague historian but states that her left groin pain
began upon waking this morning. It did not radiate anywhere. She
did not experience any trauma and does not recall having
swelling
there but states that this area is "hard to see and she wouldn't
know if it has been there."
Past Medical History:
severe atherosclerotic disease/PVD, HTN, Myocardial
infarction, [**12-9**]: Infected PTFE graft left leg, aorto-bifem bpg
'[**72**], multiple R fem-[**Doctor Last Name **] operations culminating in R AKA,
multiple L fem-[**Doctor Last Name **], fem-tibial operations culminating in L AKA,
repair of L femoral pseudoaneurysm [**2178-2-23**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Hospital1 **]) with bovine patch and sartorius flap (with
assistance of balloon occlusion of inflow during procedure).
Social History:
NC
Family History:
NC
Physical Exam:
VS: 98.1 HR 78 BP 118/74 RR 20 O2 Sat 98% RA
Alert and oriented x2. Hard of hearing. Poor recollection of
medical history. Appropriate and comfortable
Neck supple. Pulses symmetric. No bruits
CV: RRR S1 S2 nl.
Pulm: clear
Abd: well healed lower midline incision. Non-distended,
non-tender. + BS.
Ext: Well healed b/l AKA. Left groin with healed incision. Large
pulsatile mass, mildly tender to palpation. Some mild blanching
erythema with discoloration. No drainage or appreciable
fluctuance.
Radial pulses intact b/l
Pertinent Results:
[**2178-4-25**] 9:44 am TISSUE LEFT FEMORAL GRAFT.
**FINAL REPORT [**2178-4-29**]**
GRAM STAIN (Final [**2178-4-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final [**2178-4-28**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 2:25PM [**2178-4-27**].
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2178-4-29**]): NO ANAEROBES ISOLATED.
[**2178-4-24**] 12:35AM BLOOD WBC-16.6* RBC-4.07* Hgb-12.0 Hct-36.7
MCV-90 MCH-29.5 MCHC-32.7 RDW-15.1 Plt Ct-427
[**2178-4-24**] 12:35AM BLOOD PT-12.9 PTT-26.8 INR(PT)-1.1
[**2178-4-24**] 12:35AM BLOOD Glucose-124* UreaN-10 Creat-0.8 Na-136
K-3.6 Cl-99 HCO3-29 AnGap-12
[**2178-4-24**] 12:35AM BLOOD estGFR-Using this
[**2178-4-24**] 12:35PM BLOOD ALT-12 AST-14 AlkPhos-104 TotBili-0.3
[**2178-4-24**] 12:35PM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.3 Mg-2.1
[**2178-4-30**] 08:35AM BLOOD WBC-13.0* RBC-3.64* Hgb-10.8* Hct-33.3*
MCV-92 MCH-29.8 MCHC-32.5 RDW-15.4 Plt Ct-792*
[**2178-4-30**] 08:35AM BLOOD Plt Ct-792*
[**2178-5-1**] 09:00AM BLOOD Glucose-195* UreaN-15 Creat-0.8 Na-133
K-4.6 Cl-101 HCO3-24 AnGap-13
[**2178-5-1**] 09:00AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.8
Brief Hospital Course:
The patient was admitted to the surgery service for evaluation
and treatment. The patient was admitted for graft excision on HD
2. Mrs. [**Known lastname **] was discharged to an extended stay facility on
POD 6.
Neuro: The patient received prn pain meds with good effect and
adequate pain control. The patient was complaining of phantom
leg pain on POD 4 and received IV morphine and her neurontin was
increased to 600mg TID.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. The patient was stable on
his medications of diltiazem and statin medication.
Pulmonary: Mrs. [**Known lastname **] was successfully extubated
postoperatively. The patient was stable from a pulmonary
standpoint; vital signs were routinely monitored. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout this hospitalization.
GI/GU/FEN:
Post operatively, the patient was able to eat a regular, lactose
reduced diet.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient was started on Vancomycin and Zosyn on admission
for her graft infection. The patient's white blood count and
fever curves were closely watched for signs of infection. The
patient's wound and graft grew out pseudomonas and the patient
was changed to an antibiotic regimen of vancomycin, cefepime and
ciprofloxacin. She was discharged on a 2 week course of
vancomycin and cefepime. The ciprofloxacin will be a daily
medication.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, voiding without assistance,
and pain was well controlled.
Medications on Admission:
Diltiazem 180, [**Last Name (LF) 11346**], [**First Name3 (LF) **] 325, Fluoxetine 10, Folic Acid 1,
Gabapentin 300 [**Hospital1 **], Seroquel 12.5, Thiamine 100, Trazodone 50,
MVI, Vit C 500, Zinc 220,
Azithro 250 from [**Date range (1) 62721**] for ? pneumonia.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Insulin Regular Human Injection
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) dose Inhalation Q6H (every 6 hours) as needed.
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for Vascular Disease.
14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for pain.
15. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. Cefepime 2 gram Recon Soln Sig: Two (2) gm Intravenous once
a day for 2 weeks.
17. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous once a day for 2 weeks.
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) **]
Discharge Diagnosis:
peripheral vascular disease
hypertension
Myocardial infarction
Discharge Condition:
Good
Discharge Instructions:
WHAT TO EAT AND DRINK THE NIGHT BEFORE YOUR PET/CT SCAN & HOW TO
TAKE THE SPECIAL PREPARATION (CLEARSCAN)
The night before your scan at your regular dinnertime eat a high
fat, high protein no carbohydrate dinner. Avoid sugars
(glucose, fructose, sucrose, etc) until after your scan.
Your choice of dinner can include:
Fatty unsweetened foods (fried in butter or olive oil, broiled,
but not grilled):
Chicken, [**Country 1073**], fish,
meats (steak, ham etc),
meat only sausages, fried eggs, bacon, scrambled eggs prepared
without milk, omelet prepared without milk or vegetables, fried
eggs and sausages,
fried eggs and bacon, hotdogs (plain -without the bun),
hamburgers (plain - without the bun or vegetables)
You should not eat any food containing carbohydrates and sugars,
(and Splenda). Please do not eat the following foods:
Milk, cheese, bread, bagels, cereal, cookies, toast, pasta,
crackers, muffins, peanut butter, nuts, fruit juice, potatoes,
candy, fruit, rice, chewing gum, mints, cough drops, vegetables,
beans, alcohol
You should drink clear liquids without milk or sugars
Diet Pepsi or Diet Coke
Coffee without milk or sugar
Can use sweet n?????? low, nutra-sweet or equal
Tea without milk or sugar
Water
For an AFTERNOON appointment (after 1pm):
Eat this breakfast 3 ?????? 5 hours before your scan, nothing to eat
after breakfast.
BEFORE YOUR SCAN
You may drink water up to the time of your scan. Use only
water to take your medications.
Followup Instructions:
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2178-5-14**] 2:00, [**Hospital Ward Name 2104**] Bldg, [**Location 78342**]
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2178-5-14**] 2:00, [**Hospital Ward Name 2104**] Bldg, [**Location 78342**]
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2178-5-18**] 12:15 [**Hospital Unit Name **] [**Location (un) 442**]
([**Telephone/Fax (1) 1504**] Dr [**Last Name (STitle) 78343**]
[**1670-5-18**], Office Visit, [**Hospital Ward Name 23**] 9
PET Scan - ([**Telephone/Fax (1) 9595**], [**1520-5-11**], PET SCAN, [**Hospital Ward Name 23**] Bl
You have a MRI of the head. You are scheduled for one on [**5-5**] 1415 hrs. [**Telephone/Fax (1) 327**]. [**Location (un) **] [**Hospital Ward Name 23**] Building
Admission Date: [**2178-5-2**] Discharge Date: [**2178-5-15**]
Service: SURGERY
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
increasing rest pain in L AKA
Major Surgical or Invasive Procedure:
Excision of L graft, oversewing of CFA/graft stump [**2178-4-25**]
Ax-Profunda BPG [**2178-5-6**]
History of Present Illness:
Pt is a 84F discharged from Dr.[**Name (NI) 5695**] service
yesterday. She was transferred to [**Hospital1 18**] on [**2178-4-24**] from
[**Hospital3 8834**] with a pseudoaneurysm of the L
femoral
artery. On [**2178-4-25**] she underwent an exploration of left groin
and drainage of infected false aneurysm; excision of left limb
of
aortobifemoral graft and suture repair of common femoral
artery with debridement of the wound and primary closure. She
subsequently developed mottling of her L stump though her rest
pain was tolerable. Today at rehab the L stump was noted to be
more mottled and cool with increasing rest pain. She was
transferred to the [**Hospital1 18**] ED for the above complaints.
Past Medical History:
1. severe atherosclerotic disease/PVD
2. HTN
3. Myocardial infarction [**12-9**]
4. Infected PTFE graft left leg
5. aorto-bifem bpg '[**72**]
6. multiple R fem-[**Doctor Last Name **] operations culminating in R AKA
7. multiple L fem-[**Doctor Last Name **], fem-tibial operations culminating in L
AKA
8. repair of L femoral pseudoaneurysm [**2178-2-23**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Hospital1 **]) with bovine patch and sartorius flap (with
assistance of balloon occlusion of inflow during procedure).
9. exploration of left groin and drainage of infected false
aneurysm; excision of left limb of aortobifemoral graft and
suture repair of common femoral artery with debridement of the
wound and primary closure. [**2178-4-25**]
Social History:
NC
Family History:
NC
Physical Exam:
97.8 98 113/57 16 97%RA
NAD, Alert, somewhat confused (baseline).
CTA B/L
RRR
Abd soft, NT, ND
L groin incision C/D/I without erythema. staples in tact
L AKA stump cool to mid thigh, mottled
R AKA warm, well profused. Palp R femoral.
L AC PICC in place without erythema
Pertinent Results:
[**5-12**] KUB: FINDINGS: The nasogastric tube has been removed. Again
seen are mildly distended loops of large and small bowel. The
patient is post-laparotomy with surgical staples in place left
of midline as well as over the left inguinal region.
IMPRESSION: Unchanged appearance of mildly dilated loops of
small and large bowel, consistent with ileus.
[**5-5**] Echo:
1.No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are complex (>4mm) atheroma in the aortic arch.
5. There are complex (>4mm) atheroma in the descending thoracic
aorta.
6.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present.
7.Mild (1+) aortic regurgitation is seen.
8.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
[**5-4**] CT: CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST:
There is extensive emphysema present at the lung bases. There is
no pericardial or pleural effusion.
There is an NG tube with the tip in the stomach. There is
extensive dilatation of the small bowel, which is fluid filled.
The large bowel is not distended. There is intrahepatic biliary
dilatation, this is more prominent when compared to the prior
examination. The common bile duct measures 8 mm. There is stable
appearance to a left renal cyst. The spleen is not visualized
which likely represents prior splenectomy. The adrenal glands
appear unremarkable. There is stable atrophy of the lower pole
of the right kidney. There is no upper abdominal
lymphadenopathy.
CT PELVIS PRE- AND POST-ADMINISTRATION OF INTRAVENOUS CONTRAST:
The small bowel is dilated and fluid-filled. There is no
intraperitoneal free air or free fluid. The large bowel is not
dilated. There is a fat- containing right inguinal hernia. There
is a 41 x 40 mm fluid collection in the left inguinal region
which may represent sequelae of recent endovascular surgery.
CT ANGIOGRAM:
There is extensive atheromatous change in the aorta and the
coronary arteries. There is atherosclerosis present at the
origin of a single patent right renal artery. There is a single
patent left renal artery. The celiac artery comes of at an acute
angle from the abdominal aorta though this is patent. The
superior mesenteric artery is patent in its visualized course.
The aortobifemoral graft is seen in situ with only the right
limb of the graft displaying contrast. The left limb of the
aortobifemoral graft is completely occluded at its origin and
there is no contrast opacification of the native or the left
iliac bypass graft. There is no contrast opacification seen in
the left common femoral or the superficial femoral arteries.
The right limb of the aortofemoral graft is patent. The right
superficial femoral artery is occluded and there are two
occluded grafts in the right proximal to mid thigh. The right
and left profunda femoris arteies are diminutive in caliber
though these are patent.
MUSCULOSKELETAL:
There have been above knee bilateral amputations of the lower
extremities. There are multilevel degenerative changes present
in the spine with wedge compression and significant loss of
height of L1 vertebra. Superior endplate compression is also
seen at L3 and L4 levels.
CONCLUSION:
1. Dilated fluid-filled loops of small bowel, without any
definite transition point could represent ileus versus early
bowel ischemia. Mechanical obstruction is thought less likley
2. Prominence of the intrahepatic bile ducts with a common bile
duct measuring 8 mm and prior cholecystectomy.
3. Completely occluded left limb of the aortofemoral graft along
with occlusion of the left external iliac, common femoral and
superficial femoral arteries. There is also complete occlusion
of the right superficial femoral artery as described above.
[**5-4**] KUB: ABDOMEN, SINGLE VIEW: An NG tube and side hole are seen
to project below the diaphragm. Distended loops of small and
large bowel are again seen. There is contrast in the right
pelvicaliceal system and on the left, contrast is seen in the
right ureter. Status post CTA from earlier today. No gross
osseous abnormality. Surgical staples are seen to the left of
midline in the pelvis.
IMPRESSION: NG tube and sidehole projecting below the diaphragm,
with re-demonstration of ileus.
[**5-3**] KUB: FINDINGS: There is dilatation of the small bowel
measuring up to 5.8 cm. Multiple air-fluid levels are also
identified. Air is seen within the colon. There is no evidence
of free air.
IMPRESSION: Dilated loops of small bowel up to 5.8 cm likely
consistent with ileus.
[**2178-5-2**] 03:30PM BLOOD WBC-16.9* RBC-2.64*# Hgb-8.0*# Hct-24.8*#
MCV-94 MCH-30.2 MCHC-32.2 RDW-16.4* Plt Ct-701*
[**2178-5-4**] 07:00AM BLOOD WBC-25.6* RBC-3.03*# Hgb-9.2* Hct-27.2*
MCV-90 MCH-30.3 MCHC-33.7 RDW-17.8* Plt Ct-678*
[**2178-5-5**] 01:13PM BLOOD WBC-24.7* RBC-2.81* Hgb-8.6* Hct-25.7*
MCV-91 MCH-30.6 MCHC-33.5 RDW-17.6* Plt Ct-598*
[**2178-5-6**] 12:17AM BLOOD WBC-22.1* RBC-3.09* Hgb-9.3* Hct-28.1*
MCV-91 MCH-30.0 MCHC-33.0 RDW-17.4* Plt Ct-521*
[**2178-5-13**] 06:10AM BLOOD WBC-20.1* RBC-3.72* Hgb-11.2* Hct-33.5*
MCV-90 MCH-30.2 MCHC-33.5 RDW-16.9* Plt Ct-531*
[**2178-5-14**] 03:19AM BLOOD WBC-18.2* RBC-3.28* Hgb-10.2* Hct-29.7*
MCV-91 MCH-31.1 MCHC-34.3 RDW-16.9* Plt Ct-540*
[**2178-5-15**] 05:45AM BLOOD WBC-17.1* RBC-3.55* Hgb-10.6* Hct-33.2*
MCV-94 MCH-29.7 MCHC-31.8 RDW-16.8* Plt Ct-588*
[**2178-5-9**] 05:00AM BLOOD Neuts-87.9* Lymphs-8.4* Monos-3.1 Eos-0.5
Baso-0.1
[**2178-5-15**] 05:45AM BLOOD PT-26.4* PTT-79.8* INR(PT)-2.6*
[**2178-5-15**] 05:45AM BLOOD Glucose-81 UreaN-6 Creat-0.5 Na-132*
K-3.3 Cl-106 HCO3-17* AnGap-12
[**2178-5-2**] 03:30PM BLOOD CK(CPK)-3211*
[**2178-5-3**] 09:30PM BLOOD CK(CPK)-3098*
[**2178-5-7**] 08:45AM BLOOD CK(CPK)-1013*
[**2178-5-3**] 01:00AM BLOOD CK-MB-22* MB Indx-0.7 cTropnT-<0.01
[**2178-5-7**] 08:45AM BLOOD CK-MB-11* MB Indx-1.1 cTropnT-<0.01
[**2178-5-13**] 06:10AM BLOOD Vanco-12.4
Brief Hospital Course:
[**2178-5-2**] evaluated in ER for ischemic left aka. IV heparin
began.IV antibiotics vanco,cefepime and cipro started. blood c/s
obtained. wound c/s pseudomonas.
[**2178-5-4**] emesis-ileus by KUB. CT obtained ileus confirmed and CT
demonstrated occluded left limb of ABF graft.NTG placed for
ileus.
[**2178-5-5**] SURGERY: left Ax.-PFA bpg w 6mm PTFE graft.Transfered to
CVICU for vent support.
[**2178-5-6**] POD#1 graft dopperable IV heparin gtt
continued.Extubated. episodes of hypotension and low urinary out
put fluid resustated. antibiotics continued and patient
transfered to VICU.tube feed began.
[**Date range (1) 78344**] POD#[**1-5**] Diet advanced. remains confused. IV
heparin continued.
[**Date range (1) 63629**]/08 POD#5 diarrhea, c. diff c/c negative. but patient
emperically began on po flagyl.T transfused 1 unitPRBC's IV
fluids maintained.AKA flap remains ischemic.
VAC dressing placed.
[**Date range (1) 78345**] POD# [**5-10**] cooumadization began. rest pain improved.
Stump remains ischemic with VAC dressing.poor prognosis for
wouond healing.
Patient screen for rehab and transfered in stable condition.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
11. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 17 days.
Disp:*qs Capsule(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Please titrate dose for INR between [**1-4**].
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Insulin Regular Human Injection
17. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] SENIOR HEALTHCARE OF [**Location (un) **]
Discharge Diagnosis:
Occlusion of bypass graft
PMH:
Peripheral Vascular Disease
Hypertension
Myocardial infarction
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-4**]
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 the PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] as you
need to reschedule pulmonary function tests which you missed
while you were in the hospital.
You have an appointment with Dr. [**Last Name (STitle) **] on [**5-18**] at 12:15.
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2178-5-18**] 12:15
Completed by:[**2178-5-15**] Name: [**Known lastname 12627**],[**Known firstname 2219**] Unit No: [**Numeric Identifier 12628**]
Admission Date: [**2178-5-2**] Discharge Date: [**2178-5-15**]
Date of Birth: [**2094-1-27**] Sex: F
Service: SURGERY
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 1546**]
Addendum:
Pt with stage II pressure ulcer on the coccyx that developed on
[**2178-4-26**]. Treatmented with barrier cream, turning and
repositioning, use of a gaymar overlay and duoderm dressing.
Diagnosis of stage II coccyx pressure ulcer. Improved on DC
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 170**] SENIOR HEALTHCARE OF [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2178-6-1**] Name: [**Known lastname 12627**],[**Known firstname 2219**] Unit No: [**Numeric Identifier 12628**]
Admission Date: [**2178-5-2**] Discharge Date: [**2178-5-15**]
Date of Birth: [**2094-1-27**] Sex: F
Service: SURGERY
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 1546**]
Addendum:
Addendum:
Pt with stage II pressure ulcer on the coccyx that developed on
[**2178-4-26**]. Treatmented with barrier cream, turning and
repositioning, use of a gaymar overlay and duoderm dressing.
Diagnosis of stage II coccyx pressure ulcer. Improved on DC
Discharge Disposition:
Extended Care
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 170**] SENIOR HEALTHCARE OF [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2178-6-3**]
|
[
"412",
"518.89",
"458.29",
"442.3",
"492.8",
"996.62",
"401.9",
"353.6",
"E878.2",
"041.7",
"996.74",
"560.1",
"440.24",
"V49.76",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"99.04",
"39.29",
"38.93",
"56.82",
"88.72",
"39.52",
"86.22",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
27070, 27314
|
19435, 20568
|
11329, 11429
|
22266, 22274
|
13315, 19412
|
25101, 26139
|
13005, 13009
|
20591, 22021
|
22150, 22245
|
6459, 6725
|
22298, 24668
|
24694, 25078
|
13024, 13296
|
11259, 11291
|
11457, 12166
|
12188, 12968
|
12984, 12989
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,890
| 116,932
|
49370
|
Discharge summary
|
report
|
Admission Date: [**2169-1-27**] Discharge Date: [**2169-1-31**]
Date of Birth: [**2095-10-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Rapid Afib, Pulmonary Embolus, Dyspnea
Major Surgical or Invasive Procedure:
Expired
History of Present Illness:
This is a 73 yo F with a past medical history significant for
NSCLC s/p resection, in remission for 5 years, and marked COPD,
who presents to the ED after experiencing progressive dyspnea
over the last several weeks, requiring oxygen therapy around the
clock rather than just with exertion. In the ED she was found to
be in afib (new for this patient) with RVR to 170's. She was
sent for CTA and was found to have a small subsegmental PE and
was started on a heparin gtt. She was given a dose of
levofloxacin for ?infectious process given leukocytosis on CBC
to 26 and she was initiated on a dilt gtt after two doses of IV
dilt did not affect her HR that much.
She also notes swelling in her legs bilaterally and her left
arm, as well as a new mass in the left side of her neck which
per the patient grew in entirety over the last two weeks. Of
note, she also had knowledge of a breast mass, which had not yet
been worked up. Last mammogram seems to be in [**2161**]. Per the
patient's PCP [**Last Name (NamePattern4) **] [**6-13**], "She has adamantly refused all screening
and followup testing at this time. We discussed follow up chest
x-rays and CT scans for example and also mammograms, but she
refuses that. She refuses colon cancer screening. At this
point, she feels that she would not accept or take any further
medications or any further
therapies for any further diseases."
She is admitted to the MICU for further evaluation of her afib
with RVR and dyspnea.
Currently in the MICU, the patient is hemodynamically stable
with a HR in the 140's-150's. She is breathless on supplemental
O2. She denies fevers/chills, n/v or nightsweats. She admits to
some weight loss, and although does not entertain palpitations,
she felt something was wrong and attributed it to her chronic
anxiety. She denies calf tenderness, chest or abdominal pain.
She is refusing blood draws and foley catheter.
Past Medical History:
Status post stage III lung cancer s/p left upper lobe lobectomy,
with chemo/rads
COPD
glaucoma
Major depressive disorder
Anxiety
Social History:
2 ppd x 40 years, just quit several months ago. Was real estate
[**Doctor Last Name 360**], frequently travels to [**State **] for vaction. Has two
daughters, one is in [**Name (NI) 745**] who is HCP.
Family History:
non-contributory
Physical Exam:
VS: Temp: 97.6 BP:146/72 HR: 137 RR: 13 O2sat 99% on 4L NC
GEN: cachectic, comfortable, NAD but breathless when talking
HEENT: PERRL, EOMI, but right strabismus and left eyelid ptosis,
anicteric, MM dry, op without lesions. dentures in place.
NECK: large left sided nontender, nonmobile hard mass just
lateral to the thyroid, no jvd, no carotid bruits. RIJ in place.
RESP: No breath sounds at the right base. Scattered crackles and
+expiratory wheeze with prolonged E:I ratio.
CV: Tachcardic and irregularly irregular. No murmurs.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: nonpitting 2+ edema in the ext bilaterally, right UE with
1+ nonpitting edema. warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 4/5 strength throughout
(generally weak). No sensory deficits to light touch
appreciated. Essential tremor present. DTR's normoreflexive.
Breast exam refused.
Pertinent Results:
[**2169-1-27**] 11:20AM
WBC-25.3*# RBC-4.01* HGB-12.1 HCT-38.9 MCV-97 MCH-30.2 MCHC-31.1
RDW-14.4
NEUTS-96.4* BANDS-0 LYMPHS-1.4* MONOS-1.6* EOS-0.5 BASOS-0
[**2169-1-27**] 11:20AM GLUCOSE-212* UREA N-24* CREAT-0.8 SODIUM-141
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-29 ANION GAP-19
[**2169-1-27**] 11:20AM CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.0
EKG: Afib with RVR to 170's.
CXR:
1. Hazy opacity in the right lung base may represent a layering
pleural effusion, although pneumonia cannot be excluded; a
lateral view is recommended.
2. Stable emphysematous changes and volume loss on the left
related to left upper lobectomy.
CTA Chest:
1. Right lower lobe subsegmental pulmonary embolism. No
evidence of compression of the SVC.
2. Moderate-to-severe emphysema with interstitial septal
thickening consistent with underlying CHF. Small left greater
than right pleural effusions, with atelectasis in the right
lower lobe.
3. Status post left upper lobectomy with stable left volume
loss and post-radiation changes.
4. Interval development of hypodense mass likely arising from
the left lobe of the thyroid. Two left upper quadrant soft
tissue masses. Multiple mediastinal and hilar lymph nodes as
described above. Soft tissue nodule in the left breast and
subcentimeter likely lymph node in the presternal soft tissues.
Given the patient's history of lung cancer, these findings are
suspicious for malignancy.
Brief Hospital Course:
73 yo F with a past medical history of NSCLC status-post
chemo-radiation and right upper lobectomy admitted with
progressive dyspnea in the setting of multiple new masses, new
atrial fibrillation with RVR, and subsegmental PE.
# Dyspnea: Etiologies for the patient's dyspnea include atrial
fibrillation with RVR with decreased forward flow, progression
of COPD, interstitial lung disease secondary to radiation
therapy, metastasis and infection. Although she had a
leukocytosis, and possible effusion at the right base, she was
afebrile during her inpatient stay. She does have a very small
subsegmental PE, which could have also contributed to dyspnea.
Was rate controlled with a esmolol drip. Patient then became
suddenly hypoxic with short duration asystole the afternoon of
[**2169-1-31**], thought to be secondary to possible mucous plugging.
Daughter was [**Name (NI) 653**] concerning the event and her mother's
poor prognosis. At that time, she requested she be CMO. All
medications were stopped and she was given morphine IV for
comfort. She expired at 8:15pm on [**2169-1-31**] due to
cardiopulmonary arrest.
# Afib with RVR: Unclear if her known small subsegmental PE
would actually cause the patient's Afib with RVR. Other possible
causes could be dehydration in the setting of poor PO
intake/infection. Also rapidly growing mass contiguous with the
thyroid could be causing a relative thyroiditis, or be producing
thyroid hormone itself. TSH was check and was low normal. Rate
was controlled with an esmolol drip until the events immediately
preceding her death.
# Pulmonary Embolus: Known small subsegmental PE. Thus, she was
maintained on a heparin gtt. ED confirmed with Oncology that it
was okay to start heparin gtt without head imaging as long as
initiated without a bolus. PE thought to be likely [**3-11**] to
tumor. Heparin gtt was discontinued once patient was made CMO
on [**2169-1-31**].
# Neck Mass: Concerning for malignancy. Patient had a breast
mass noted on a mammogram from [**2163**] and has since refused follow
up screening. Concerned that this could represent a breast
primary with metastases to her thyroid and mediastinal nodes.
Unclear what left upper quadrant masses are at this time. Other
possibility is recrudescence of NSCLC, but this is unlikely
although she continued to smoke until this year. With poor oral
intake, fatigue and weight loss, malignancy was high on the
differential. Associated hoarseness could be secondary to
recurrent laryngeal nerve compression. Heme-onc was consulted
and recommended obtaining tissue for a diagnosis. General
surgery was consulted but determined she was too unstable during
her stay for tissue biopsy. Patient expired without clear
diagnosis and family declined autopsy.
# Anxiety/Depression: While inpatient was continued on
antidepressants and Ativan PRN.
# COPD: This ongoing issue likely contributed to her overall
respiratory distress while inpatient. She was treated with
Atrovent and Albuterol was used only minimally secondary to
concern for tachycardia.
Patient become increasingly dyspneic during the day of [**2169-1-31**].
At approximately 4pm, physicians were called to the bedside for
pulselessness and respiratory arrest thought to be secondary to
mucous plugging. Was treated with atropine and epinephrine and
subsequently regained a heart rhythm, blood pressure and pulse.
Pupils were noted to be unresponsive at that time. Her family
was notified of the acute change and poor prognosis and decided
to make her CMO status. All medications were discontinued
beyond those for comfort. Patient expired on [**2169-1-31**] at 8:15pm
secondary to cardiopulmonary arrest.
Medications on Admission:
Trazadone
Buspar
Wellbutrin
Triazolam
Atrovent
PPI
Veranicicline
Reglan TID
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Non-Small Cell Lung Cancer
Secondary: COPD, neck mass
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"296.20",
"V15.3",
"458.9",
"V15.82",
"198.89",
"174.9",
"V10.11",
"427.5",
"V66.7",
"933.1",
"365.9",
"288.60",
"V64.2",
"496",
"196.1",
"415.19",
"789.39",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8955, 8964
|
5101, 8797
|
362, 372
|
9071, 9081
|
3653, 5078
|
9137, 9284
|
2689, 2708
|
8923, 8932
|
8985, 9050
|
8823, 8900
|
9105, 9114
|
2723, 3634
|
284, 324
|
400, 2302
|
2324, 2455
|
2471, 2673
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,496
| 118,751
|
48351
|
Discharge summary
|
report
|
Admission Date: [**2134-1-2**] Discharge Date: [**2134-1-13**]
Date of Birth: [**2089-6-20**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
44 yo seen by her PCP on the [**2133-12-31**] for viral gastroenteritis
with N,V, diarrhea and food intolerance, who presented on the
[**2134-1-2**] with peristent nausea, resolved abd.pain and was found
to be in DKA with glucose of 1200, AG of 21 and a bicarbonate of
less than 3. A CT scan of the abdomen was done and was positive
for portal venous gas within the liver and pneumatosis within
loops of ileum in the right hemipelvis. Findings were worrisome
for ischemic bowel. Pt was admitted to the surgery team and was
started on Piperacillin-Tazobactam Na 4.5 gm IV and Vancomycin
HCl 1000 mg IV Q 12H. A repeat CT scan one day later was not
able to confirm the finding but showed interval development of
extensive thickening of the bowel wall of the ileum. She was
thought to have ischemic bowel from profound hypovolemia due to
DKA.
Pt was started on Insulin gtt for management of her DKA. Later
on admission day pt was noted to be in respiratory distress and
was intubated. A CT of the head was done and was negative. The
anion gap improved and the pt became more clear and stable. She
was extubated on the [**7-4**]. Anion gap now resolved.
The pt was also noted to have a drop in her hematocrit of 10
points on the [**7-3**]. She was found to be guaiac
positive but never had any gross GI bleed. The hematorcit was
attributed to slow grade GI bleed as well as hemodilution. No
hemolysis labs were send. The pt was transfused 2 u PRBC over
the subsequent day and increased with her Hct appropriately.
On the [**7-4**] the pt was also noted to have decreased
platelet counts, coming down from 395 on admission to 132. HIT
abx were sent and came back positive on the [**2134-1-6**]. All heparin
products were stopped and Argatroban was started. It was
recommended by hematology to start the pt on Coumadin with a
five day overlap to Argatroban for 5 days.
.
Pt currently states she is feeling fine. She denies HA, N, V,
abd. pain, CP, SOB, joint pain. She had two episodes of watery
diarrhea today, with blood (but currently with menstruation).
She denies any melena.
Past Medical History:
? Diabetes -diet controlled per patient for one year since
diagonsis
Asthma.
2 Abortions
Uterine Fibroids
Social History:
SH: divorced, originally from [**State 9512**], lives alone, has family
in [**Location (un) 86**], denies alcohol, tobacco or drug abuse currently or in
the past
.
Family History:
FH: Diabetes type II in several family members, no heart
disease, no malignancy
Physical Exam:
98.4 100/70 106 16 100RA
Gen: lying in bed, in NAD
HEENT: EOMI, PERRL, moist mucous membranes
NECK: JVD 8 cm, no LAD, no thyroideomegaly
Chest: CTA b/l, mild crackles at bases, negative egophony
CV: RRR, S1/S2 intact, [**2-1**] SM over RUSB radiating into the
axillae
Abd: obese, soft, NT, ND +BS
Ext: no c/c, 2+ DP, 2+ pitting edema of the b/l LE and 1+ of UE,
negative [**Last Name (un) 4709**] sign
Neuro: CN 2-12 intact. AAO x3. strength 5/5 grossly throughout,
reflexes 2+ b/l.
Pertinent Results:
[**2134-1-2**] 01:45PM PT-15.4* PTT-33.1 INR(PT)-1.6
[**2134-1-2**] 01:45PM PLT SMR-NORMAL PLT COUNT-395
[**2134-1-2**] 01:45PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2134-1-2**] 01:45PM NEUTS-88.5* BANDS-0 LYMPHS-6.5* MONOS-4.6
EOS-0.2 BASOS-0.2
[**2134-1-2**] 01:45PM WBC-21.2* RBC-4.24 HGB-13.4 HCT-43.7 MCV-103*
MCH-31.6 MCHC-30.6* RDW-16.9*
[**2134-1-2**] 01:45PM WBC-21.2* RBC-4.24 HGB-13.4 HCT-43.7 MCV-103*
MCH-31.6 MCHC-30.6* RDW-16.9*
[**2134-1-2**] 01:45PM CK-MB-4 cTropnT-<0.01
[**2134-1-2**] 01:45PM CK-MB-4 cTropnT-<0.01
[**2134-1-2**] 04:48PM LACTATE-2.2*
Brief Hospital Course:
As above before admission to medicine.
44 yo with possible type one diabetes, presenting in DKA with
pneumatosis coli/ileal thickening in the setting of severe
dehydration, anemia, and HIT-II with positive abx on argatroban.
.
# HIT: antibody positive, makes HIT II more likely although
platelets never lower than 90 000. Serotonin release assay
pending on discharge. Pt with increased risk of thrombosis due
to hypercoagulable status. All heparin products were stopped.
Argatroban was started with a goal of PTT 60-80. Coumadin was
started at 2mg QHS once PTT therapeutic for 24 hourse. Platelets
started to rise again to normal limits. No evidence of
thrombosis was found. As pt was low probability for thrombosis
she was switched to Fondaparinux and was sent home on
Fondaparinux, transitioning to Coumadin. Follow up was arranged
with Dr. [**Last Name (STitle) 101845**] for [**2134-1-15**]. [**Hospital 197**] clinic was informed
about the pt.
.
# Anemia: unclear etiology. Initial drop attributed to
hemodilution in the setting of preexisting anemia and low grade
GI bleed as guaiac postive. No surgical intervention done.
Hemolysis labs negative. 2U PRBC transfused. Also low Vit B12 -
possible related to bowel disease as resorption in the Ileum vs
pernicious anemia. Anti-intrinsic factor antibodies should be
check as an outpatient, also TTG to rule out celiac sprue should
be considered. On Vitamin B12 2000mcg QD for life. GI follow up
should be considered.
.
# Diabetes: Presented in DKA and body habitus more suspicious
for type I. Gap resolved. GAD/ Islet cell Abx were pending on
discharge. Sliding scale was adjusted according to [**Last Name (un) **]
recommendations with Glargine and ISSC. It is unusual in that
the patient had some mildly elevated sugars over the past year
or two and did not present with frank DKA until now.
.
# Ileal thickening: most likely ischemic bowel in the setting of
DKA and profound hypovolemia. Predominance in the Ileum would be
suspicious for Crohns disease or Yersinia. Stool cultures
negative for Cdiff and Yersinia. Initially with leukocytosis and
improvement with fluids and antibiotics therefore more likely
hypovolemia and/or infectious cause. Leukocytosis also seen in
DKA and severe stress reaction. Chronic low grade Crohns disease
affecting the ileum could be considered also given Vit B12
deficiency. Pain and diarrhea now resolved. Antibiotics (Flagyl,
Levofloxacin and Fluconazole) were discontinued on day of
transfer to medicine team. GI follow up should be considered.
.
# Peripheral edema: resolving
Medications on Admission:
none
.
on transfer:
Acetaminophen
Albuterol
Argatroban
Fluconazole
Insulin
Ipratropium Bromide MDI
Levofloxacin
Metronidazole
Pantoprazole
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: Do not exceed 4g per day.
Disp:*20 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*qs * Refills:*0*
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*qs * Refills:*2*
4. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection as directed: Please follow sliding scale.
Disp:*2 * Refills:*2*
6. One touch Ultra teststrips Sig: One (1) four times a day.
Disp:*200 * Refills:*5*
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*20 Tablet(s)* Refills:*0*
8. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): until INR is therapeutic.
Disp:*7 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary -
DKA
ischemic ileitis
HIT II
Anemia
Diabetes mellitus
Discharge Condition:
Good, anemia stable, abdominal pain resolved, diabetes
controlled with ISSC and INR 1.2 on Coumadin and Fondaparinux
Discharge Instructions:
Please come back to the hospital or see your primary care doctor
if you experience any abdominal pain, fevers, shortness of
breath, lower extremity swelling, pain or any other concern.
.
Please continue with all medications as prescribed.
Followup Instructions:
You will an appointment with [**Last Name (un) **] today at 4pm with Ms [**Name13 (STitle) 11712**]
for Diabetes teaching. They will arrange follow up with [**Last Name (un) **]
for you.
.
You will have VNA services to monitor your coagulation on
Coumadin.
Results will be faxed to your primary care doctor Dr. [**Last Name (STitle) 4390**].
She will adjust the Coumadin dose for you. She should also get
the following test on you: Test for consideration
post-discharge: anti-Tissue Transglutaminase Antibody, IgA.
You have an appointment with Dr. [**Last Name (STitle) 4390**] on the [**7-15**], at 2.35 pm.
.
You also have the following appointments scheduled for you:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 101846**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 95321**]
Date/Time:[**2134-3-8**] 9:30
|
[
"276.2",
"578.9",
"250.13",
"557.0",
"276.8",
"285.9",
"276.52",
"E934.2",
"287.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7766, 7824
|
4005, 6576
|
291, 303
|
7931, 8049
|
3337, 3982
|
8337, 9180
|
2738, 2819
|
6766, 7743
|
7845, 7910
|
6602, 6743
|
8073, 8314
|
2834, 3318
|
235, 253
|
331, 2410
|
2432, 2540
|
2556, 2722
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,875
| 164,530
|
52146
|
Discharge summary
|
report
|
Admission Date: [**2157-11-5**] Discharge Date: [**2157-11-29**]
Date of Birth: [**2109-8-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hepatitis, dark stools
Major Surgical or Invasive Procedure:
paracentesis
intubation
ART line
History of Present Illness:
46 yo M hx HTN, cirrhosis and alcohol abuse who presents after a
fall last evening. The patient states he had a mechanical fall
while intoxicated last night, cut his upper lip. The patient was
admitted here [**7-6**] with jaundice and at that time had a liver
biopsy consistent with toxic-metabolic injury. He was also
diagnosed with Zieve syndrome as he had hepatitis, hemolysis,
and hyperlipidemia. He has been followed by Dr. [**Last Name (STitle) **] in
hepatology and has had some recurrences of alcoholic hepatitis
vs Zieve syndrome over the last year. He has had recurrence of
alcohol abuse over the last month, drinking 1-1.5 pints of vodka
daily. Last night, he had a fall with a resulting upper lip
laceration and bleeding. Presented to the ED, where he was noted
to have continuing lip bleeding, INR was 2.7.
On presentation, his HR was 100, BP 110/60, noted to have guaiac
positive rectal exam. Head CT was negative.
He was transfused 2 Units of FFP and transferred to MICU.
Evaluated by hepatology with plan to perform upper endoscopy
once more fluid resuscitated.
On arrival, the patient denies any specific complaints. Notes
some lightheadedness and shakyness which he attributes to
recently started propranolol and possible alcohol withdrawal,
although his EtOH level was noted to be 440 in ED.
.
ROS: + melenic stools x3-4 days, + nausea, no vomiting. No
fever, chills, chest pain, abdominal pain, shortness of breath.
Past Medical History:
1. HTN
2. EtOH abuse
3. Zieve syndrome
4. EBV infection
Social History:
lives alone in [**Location (un) 86**] area; works as window washer; smokes 5
pack-years; abuses alcohol 1 quart vodka daily; denies any IV
drugs.
Family History:
No h/o liver disease.
No GI cancers
Physical Exam:
VS T 99.2, BP 135/67, HR 128, RR 22, O2 sat 94-97% on RA
Gen: elderly male lying in bed, slightly tremulous.
HEENT: very icteric sclerae, EOMI, PERRL, OP clear, upper lip
has stopped bleeding, no LAD, no JVD
CV: reg s1/s2, no m/r/g
Pulm: bilateral wheezes, no crackles
Abd: obese, +BS, soft, NT, ND, no clear ascites.
Ext: warm, 2+ DP B, no edema
Neuro: a/o x 3, CN 2-12 intact, strength 5/5 throughout UE/LE B,
tremor b/l without asterixis.
Pertinent Results:
[**2157-11-5**] 08:55AM PT-26.3* PTT-78.7* INR(PT)-2.7*
[**2157-11-5**] 08:55AM PLT COUNT-99*
[**2157-11-5**] 08:55AM NEUTS-74.8* LYMPHS-17.4* MONOS-6.9 EOS-0.7
BASOS-0.2
[**2157-11-5**] 08:55AM WBC-9.7# RBC-2.92*# HGB-10.8*# HCT-29.8*#
MCV-102* MCH-37.0* MCHC-36.3* RDW-18.3*
[**2157-11-5**] 08:55AM ASA-NEG ETHANOL-433* ACETMNPHN-14.8
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2157-11-5**] 08:55AM ALBUMIN-3.1* CALCIUM-8.3* MAGNESIUM-1.8
[**2157-11-5**] 08:55AM ALT(SGPT)-137* AST(SGOT)-708* ALK PHOS-175*
AMYLASE-47 TOT BILI-28.9*
[**2157-11-5**] 08:55AM GLUCOSE-145* UREA N-19 CREAT-1.1 SODIUM-136
POTASSIUM-3.3 CHLORIDE-96 TOTAL CO2-21* ANION GAP-22
[**2157-11-5**] 10:10AM AMMONIA-102*
[**2157-11-5**] 12:44PM PT-22.4* PTT-69.4* INR(PT)-2.2*
[**2157-11-5**] 12:44PM PLT COUNT-90*
[**2157-11-5**] 12:44PM HAPTOGLOB-<20*
[**2157-11-5**] 12:44PM LD(LDH)-404* DIR BILI-22.0*
Brief Hospital Course:
46-yo M hx alcoholic hepatitis, Zieve's syndrome p/w recent
fall, melenic stools x3-4 days and worsened anemia and
tachycardia.
.
While in the MICU the patient was managed for worsening
alcoholic hepatitis. On admission the patient was evaluated for
GI bleed, but was not found to have one. However, the patient
did have signs of lip bleeding on admission that was difficult
to control with elevated INR. With persistent lip bleeding and
worsening encephalopathy, the patient appeared to have aspirated
on the first week of admission. After this the patient
continued to have worsening respiratory status and was intubated
for both respiratory distress and worsening mental status.
# Respiratory distress- Initially intubated for airway
protection and treated with course of antibiotics for
aspiration/hospital acquired pneumonia. This resulted in
decrease in leukocytosis and fewer fevers, however the patient
still required high ventilator support. This occurred as the
patient had worsening acidosis and required respiratory
compensation. Though efforts were made to wean from both
sedation and the ventilator support, the patient was unable to
be weaned secondary to both agitation and tachycardia/tachypnea.
His respiratory status continued to worsen and on day of death
his family asked that his endotracheal tube be removed. The
patient passed shortly thereafter.
# Hepatic failure- Patient presented with severe transaminitis
and hyperbiliribunemia. Per liver recommendations, the patient
was started on numerous medications including rifaximin,
pentoxyphylline, ursodiol and lactulose. Despited this, the
patient had only mild improvement in LFTs and no obvious
improvement of his mental status. Additionally about [**11-19**] he
started to have worsening renal function thought likely due to
hepatorenal syndrome. Therefore the patient was started on
albumin, octreotide and midodrine. With the patinet's
increasing abdominal girth, a paracentesis was performed, but
there were no signs of peritonitis. Pt's hepatic failure
continued and eventually developed hepatorenal syndrome.
Unfortunately, liver felt this patient was not a candidate for
dialysis given his poor liver function
Medications on Admission:
Propranolol
Vitamin K
multivitamins
Discharge Medications:
.
Discharge Disposition:
Expired
Discharge Diagnosis:
.
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
|
[
"572.2",
"518.81",
"572.3",
"570",
"571.2",
"291.81",
"280.0",
"E885.9",
"303.90",
"995.92",
"571.1",
"456.21",
"707.8",
"038.9",
"276.2",
"792.1",
"873.43",
"572.4",
"276.0",
"286.7",
"789.5",
"584.5",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"38.93",
"27.51",
"96.72",
"45.13",
"99.04",
"54.91",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5866, 5875
|
3544, 5753
|
339, 373
|
5920, 5923
|
2616, 3521
|
5973, 5977
|
2100, 2138
|
5840, 5843
|
5896, 5899
|
5779, 5817
|
5947, 5950
|
2153, 2597
|
277, 301
|
401, 1840
|
1862, 1920
|
1936, 2084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,193
| 147,878
|
4012
|
Discharge summary
|
report
|
Admission Date: [**2178-7-30**] Discharge Date: [**2178-8-3**]
Date of Birth: [**2101-6-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
Endoscopy (EGD)
Angiography with embolization of GDA
History of Present Illness:
77 year old man with locally advanced, unresectable pancreatic
cancer s/p cyberknife and current rx with gemcitabine here UGIB.
He had mild abd pain and nausea on Sunday and went to the ED.
Stones noted in GB. Then had improvement in sx for a few days.
He went to clinic this am for chemo but felt fatigued. POS
orthostatics so received IVF. This evening he awoke at 9pm
feeling nauseated. He fell and hit his head. Subsequently had
large bout of hematemesis. Called EMS and brought to ED. Also
noted weakness but denied any diarrhea, black/bloody stool.
Denies recent NSAID use, heavy etoh, steroids, or tobb abuse.
EGD in [**3-6**] showed tumor infiltration seen in the duodenal bulb.
.
In the ED, initial BP 84/48 w HR 103. Received 4L IVF and BP
improved to 120s systolic. NGL positive clots then BRB which
did not clear for >2L. 2 18g and 1 16g placed. HCT 31 (down
from 40 in am). given Protonix 40 IV, 2u pRBCs, 3u FFP.
.
Currently, he feels fairly well. Mild nausea. no abd pain. No
F/C/SOB/CP.
Past Medical History:
Pancreatic cancer
- dx [**9-23**]: HOP mass. CBD obstruction. Invasion of celiac axis
and near commencemnet of the SMV and portal vein.
- [**8-3**]: ERCP w stent to CBD for malignant stricture. Cytology
c/w adenoca
- 10 cycles of gemcitabine. Cyberknife rx [**4-4**]
Diabetes
HTN
Social History:
100 pack yrs tobb. Quit 8 yrs ago. Occas etoh. Married w 6
children. Retired painter at [**University/College **]
Family History:
breast ca
Physical Exam:
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
VS: 98.4 82 135/65 95% RA RR17
GEN: dry MM. AAOx3, appropriate and interactive
HEENT: MM dry. JVP 6cm. NGT w bloody output
CARDS: RRR no MGR
RESP: slight rales right base. nl effort. otherwise clear
ABD: no epigastric discomfort. no rebound or guarding. BS+.
no tenderness anywhere. no masses. no organomegaly.
EXT: no edema
NEURO: AAOx3. follows commands. cn ii-xii intact. motor [**6-1**]
bilat upper/lower. [**Last Name (un) 36**] light touch. toes down bilat
ACCESS: 2 18s and 1 16
RECTAL: brown OB positive stool
Pertinent Results:
CA19-[**2088-7-4**] elevated at 1199, up from 475 in [**5-10**].4
3.2 >-----< 117
40.5 ---> 31
Gran-Ct: 2050
ALT: 37
AST: 40
LDH: 170
AP: 104
Tbili: 0.5
Alb: 3.5
PT: 15.6 PTT: 30.1 INR: 1.4
139 107 18
--------------< 195
4.5 23 0.7
.
EKG: NSR NA NI, TWI aVL, biphasic T V2
.
[**2178-7-27**] RUQ u/s:
Stone-filled gallbladder with a 1.3-cm gallbladder neck stone
Ill-defined thickened gallbladder unchanged since prior study.
Differential diagnosis is wide, includes, chronic cholecystitis,
radiation changes or neoplastic infiltration.
.
[**2178-7-29**] CT abd: WET READ: large stomach with possible partial
outlet obstruction. no acute pathology.
CXR [**2178-7-30**]: NG tube tip is in the stomach. Improvement of the
interstitial edema. Still present left lower lobe opacity, which
might be consistent with
aspiration.
Endoscopy (EGD)[**2178-7-29**]: Ulcers in the gastroesophageal junction
Blood in the whole stomach
Ulcer in the duodenal bulb
Ulcerated area in the cardia
Otherwise normal EGD to duodenal bulb
Angiography [**2178-7-30**]: Tumor encasement of distal common and proper
hepatic arteries and proximal middle and right hepatic arteries
and gastroduodenal artery. GDA is severly stenosed but was
successfully coil embolized with no further antegrade flow seen.
Probable underlying hepatic cirrhosis in this patient with tumor
encasement of hepatic and gastroduodenal arteries. No signs of
active bleeding on the selective arteriograms of the SMA,
hepatic, and left gastric arteries.
Brief Hospital Course:
77 year old man with locally advanced, unresectable pancreatic
cancer s/p cyberknife and current rx with gemcitabine here with
UGIB.
.
UGIB: Initially suspected tumor invasion in duodenum. [**Month (only) 116**] also
be related to the CBD stent placed [**8-3**] although less likely
with normal LFTs and no abd pain. Other possibilities included
[**Doctor First Name 329**] [**Doctor Last Name **], PUD, dieulafoys, varices.
Pt was given aggressive blood resuscitation, receiving 2 units
pRBC and 3 units FFP in the ED followed by 4 units pRBC on
arrival to the ICU. Pt was started on PPI IV BID. Clots were
washed out with 3L sterile water nasogastric lavage. Pt did
well overnight and underwent upper endoscopy in the morning.
Endoscopy revealed ulcer in the duodenal bulb and ulcerated
region in the cardia. Endoscopy was complicated by a drop in
oxygen saturation secondary to sedation. After the procedure pt
returned to baseline O2 saturations. Later that day pt underwent
angiography which revealed no actively bleeding vessels. It
showed tumor encasement of distal common and proper hepatic
arteries and proximal middle and right hepatic arteries and
gastroduodenal artery. GDA was severely stenosed but was
successfully coil embolized.
Pt experienced rebleeding later that night presenting as BRBPR
requiring an additional 2 units pRBCs. Patient responded well to
the transfusion. Gastroenterology, Oncology, and Radiation
oncology were consulted. The decision was made that there are
no appropriate interventions at this time. The patient's
condition and prognosis was discussed with the patient and his
family. The decision was made to become DNR/DNI. Without any
available treatment, the patient decided he would rather go home
than continue to be monitored in the hospital. Pain/Palliative
Care was consulted and the patient was set up with home hospice.
Patient was discharged home.
Wife [**Name (NI) 5627**] (HCP) [**Telephone/Fax (1) 17716**].
Medications on Admission:
Lisinopril 5
Metformin 1000 [**Hospital1 **]
Compazine 10 q4-6h prn
ASA 81
MVI
Ranitidine 150 [**Hospital1 **]
Discharge Medications:
1. 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*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
3. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 4-6 hours as needed for nausea.
Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*2*
4. Home Oxygen
Titrate to oxygen saturations in the mid 90s.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Primary: Upper gastrointestinal bleed secondary to locally
invasive pancreatic cancer; anemia secondary to blood loss
Secondary: Type 2 Diabetes Mellitus
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the ICU after experiencing an episode of
upper GI bleeding that was evident by your vomiting a large
quantity of blood. After you were admitted we transfused many
units of blood until your blood counts were stable and the
bleeding had stopped. Gastroenterology performed an upper GI
scope to confirm your pancreatic cancer as the cause of the
bleeding. Angiography was performed in an attempt to close off
the bleeding vessel. However there was subsequent bleeding
after the procedure. Oncology, Radiation-Oncology, and
Gastroenterology were all consulted. It determined that there
is no intervention at this time that would effectively prevent
future bleeding. Without any possible treatment you decided you
would rather return home than continue to be monitored in the
hospital. You met with our Palliative Care team that helped to
arrange home hospice care to ease your transition home for you
and your family and make you as comfortable as possible.
Followup Instructions:
contact oncology to determine if follow up is necessary
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"578.9",
"530.21",
"531.40",
"250.00",
"198.89",
"285.1",
"447.1",
"401.9",
"157.8",
"532.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"44.44",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6796, 6858
|
4102, 6077
|
326, 381
|
7056, 7065
|
2563, 4079
|
8096, 8291
|
1891, 1902
|
6238, 6773
|
6879, 7035
|
6103, 6215
|
7089, 8073
|
1917, 2544
|
282, 288
|
409, 1432
|
1454, 1739
|
1755, 1875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
317
| 173,307
|
18930+57000
|
Discharge summary
|
report+addendum
|
Admission Date: [**2113-10-24**] Discharge Date: [**2113-10-27**]
Date of Birth: [**2079-2-20**] Sex: M
Service:
CHIEF COMPLAINT: Status post ethanol ablation for HOCM.
HISTORY OF PRESENT ILLNESS: The patient is a 34 year-old
male with hypertrophic obstructive cardiomyopathy diagnosed
four years ago status post new
ethanol ablation on [**10-24**] this admission. He was active until
about last [**Month (only) **]
experiencing increased dyspnea on exertion even with short
walks and short climbs of stairs. Also often accompanied
by mild chest discomfort, which the patient has described as
aching/burning. Note this patient had a Holter monitoring in
[**Month (only) 216**], which was normal. The patient denies any
claudication, orthopnea, paroxysmal nocturnal dyspnea, but
positive lightheadedness since starting his medications. His
last echocardiogram in [**2113-7-21**] showed a dilated left atria,
also a posteriorly directed narrow jet flow of MR hugging the
wall of the LA with an asymmetric septal hypertrophy with [**Male First Name (un) **]
of the mitral valve and outflow track gradient of 102 mmHg.
Posterior wall thickening was 1.2 with fractional shortening
of at least 54%.
Denies any fevers or chills, nausea or vomiting.
The patient was admitted to Coronary Care Unit post planned
ethanol septal ablation for observation with temporary RV
pacemaker in place per protocol for risk of acute heart block
accompanying the ablation.
PAST MEDICAL HISTORY:
1. Depression.
2. HOCM diagnosed four years ago.
3. Left ankle surgery in [**2097**].
4. Partial parathyroidectomy for hypercalcemia in [**2107**].
5. Tonsillectomy in [**2107**].
ALLERGIES: General anesthesia gives him a violent reaction
when awakening up from it.
HOME MEDICATIONS:
1. Atenolol 50 q day.
2. Verapamil 120 SR q.d.
3. Aspirin 81 mg po q day.
SOCIAL HISTORY: Single, divorced male, has a supportive
girlfriend. Occasional ethanol use. No tobacco. No drugs.
Manages a construction company.
FAMILY HISTORY: Strong family history of HOCM. Mother and
maternal grandmother and aunts all with HOCM. No family
history of sudden death. Mother has had a history of
ventricular tachycardia and has required a defibrillator
placed and duel chamber pacemaker two years ago.
PHYSICAL EXAMINATION ON ADMISSION (from cath lab following
ablation): Temperature 98.3. Blood
pressure 134/69. Pulse 96. Respirations 18. O2 sat 95% on
room air. Examination generally no acute distress, alert and
oriented times three. HEENT pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
intact. Mucous membranes are moist. Neck supple. The
patient has a right ventricular temporary pacemaker placed
through a right IJ sheath. Dry and intact and functional.
Cardiovascular
regular rate and rhythm. Trace systolic murmur best heard at
the apex, blowing in nature. No gallops or rales.
Respirations clear to auscultation bilaterally. Abdomen soft,
nontender, nondistended. Bowel sounds present. No rebound or
guarding.
No costovertebral angle tenderness. Extremities no
clubbing, cyanosis or edema. Groin sites were dry and
intact. No hematoma. Bilateral pulses present, 2+. No
bruit appreciated. No hematoma appreciated on both groin
sites, the entry sites for the catheterization.
LABORATORIES ON ADMISSION: White blood cell count 11.7,
hematocrit 39.9, platelets 208, sodium 132, potassium 4.3,
chloride 104, bicarb 23, BUN 17, creatinine 1.5, glucose 155,
magnesium 1.7. His arterial blood gas was 7.36, 41, CO2 150
02 on room air, 24 bicarb, CK 1292, CKMB 174, troponin T was
3.39.
HOSPITAL COURSE: The patient was admitted for his cardiac
procedure. The patient was status post ethanol ablation,
which is a deliberate controlled myocardial infarction
hich was done without complication.
For coronary artery protection he was placed on
aspirin. His home dose of aspirin was increased to 325 mg po
q day. He tolerated well without any complications. He had
no chest pain until the day before discharge at which point
he complained of some chest pressure. No electrocardiogram
changes noted. No radiation and positionally changed more
comfortable in sitting forward position then laying backward,
but resolved with Ibuprofen since. No electrocardiogram
changes. His pre cath echocardiogram showed a HOCM with valve
[**Male First Name (un) **] and severe resting LVOT gradient, moderate eccentric
mitral regurgitation, biatrial enlargement, peak resting, LVOT
gradient of 60, PASP of 25 and his left ventricular EF was
greater then 75% and inducible gradient was 80-160 mmHg. At
conclusion following intervention, peak LVOT gradient in
presence dobutamine reduced to 20 mmHg.
In terms of his rate the patient was placed on a temporary
pacemaker in the cath lab. The temporary pacemaker was
initially set at a
rate of 70 with a threshold, which was about 1.5 to 2, which
upon the [**Hospital 228**] transfer to Coronary Care Unit the lead
had moved up from the right ventricle to the right atrium and
the patient was A pacing. At which point the Cardiology
Service was consulted and he had a bedside fluoroscopy,
readjustment of his pacemaker leads done and was replaced
back into the right ventricle without any difficulty. Follow
up chest x-ray showed patient's lead again correctly placed in
RV.
The patient had two episodes of occasional V pacing two days
prior to discharge when his heart rate dropped into the 50s.
Since then his heart rate parameter was decreased to 35 and
the problem was alleviated since then and the patient since
has not required any V pacing since he was in the Coronary
Care Unit.
In terms of his history of parathyroidectomy, his calcium was
checked on admission and his calcium levels had been within
normal limits and monitored closely without any difficulties.
In terms of his fluids, electrolytes and nutrition he
tolerated his diet well after the first day and no nausea or
vomiting and he was advanced to a regular diet cardiac since.
Prophylactically, he was on Protonix, Pneumoboots and a bowel
regimen and did well while he was here. Because of his age,
strong family history of HOCM, and high physical stress
occupation, the EP service was consulted re consideration of
future placement of AICD to lower risk of sudden death.
After talking to Dr.
[**Last Name (STitle) **] and the other cardiologists on service he is now
thinking about getting an ICD placed in a couple of weeks. He
has Dr.[**Name (NI) 1565**] number and will follow up
with. He is also to follow up with his cardiology
physician who is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1884**] in [**Location (un) 3844**] in the
next week. The patient is being discharged to home in stable
and good condition. The patient is to call or follow up if
any new chest pain or shortness of breath, lightheadedness,
difficulty breathing, palpitations develop, seek medical
attention as soon as possible.
FINAL DIAGNOSIS:
Familial HOCM, NYHA Class III on multidrug therapy. Status
post ethanol septal ablation this admission.
RECOMMENDED FOLLOW UP: The patient is to follow up with Dr.
[**Last Name (STitle) **] on [**2113-11-16**] at 1:00 p.m., [**Telephone/Fax (1) 3512**] at the [**Hospital Ward Name 23**]
Building. He is also to follow up with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 285**] in two weeks, call for an appointment. Also
follow up with his [**Location (un) 3844**] physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1884**]
within one week. Per usual protocol for ablation, repeat echo
should be performed in 3 months (LV will undergo continued
remodeling of outflow track in this interval). If outflow
gradient at rest and with provocation is minimal, tapering of
atenolol and/or verapamil may be considered at that time.
MAJOR SURGICAL AND INVASIVE PROCEDURES DONE WHILE IN SERVICE:
Status post ethanol septal ablation, status post cardiac
catheterization.
DISCHARGE CONDITION: Good, stable.
DISCHARGE MEDICATIONS:
1. Atenolol 50 mg po q day.
2. Verapamil 120 mg SR q 24 hours.
3. Aspirin 81 mg po q day.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2113-10-27**] 02:21
T: [**2113-10-30**] 08:03
JOB#: [**Job Number 51755**]
cc:[**Last Name (NamePattern1) 51756**] Name: [**Known lastname **], [**Known firstname **] T Unit No: [**Numeric Identifier 9620**]
Admission Date: [**2113-10-24**] Discharge Date: [**2113-10-27**]
Date of Birth: [**2079-2-20**] Sex: M
Service:
ADDENDUM: This is an Addendum to the previously Discharge
Summary. Please forward a copy of the patient's Discharge
Summary to the following address: To Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital1 **] Building, [**Apartment Address(1) 9621**], [**Location (un) **],
[**Numeric Identifier 9622**] (telephone number [**Telephone/Fax (1) 7723**]; fax
number [**Telephone/Fax (1) 9623**], or telephone number 1-[**Telephone/Fax (1) 9624**]).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1600**], M.D. [**MD Number(1) 1601**]
Dictated By:[**Dictator Info 9625**]
MEDQUIST36
D: [**2113-10-27**] 14:44
T: [**2113-10-30**] 08:13
JOB#: [**Job Number 9626**]
|
[
"423.9",
"425.1",
"996.01",
"424.0",
"311",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
8075, 8090
|
2035, 3357
|
8113, 9517
|
3669, 7009
|
7026, 7143
|
1789, 1867
|
7155, 8053
|
147, 187
|
216, 1475
|
3372, 3651
|
1497, 1771
|
1884, 2018
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,391
| 157,685
|
41587
|
Discharge summary
|
report
|
Admission Date: [**2104-3-2**] Discharge Date: [**2104-3-3**]
Date of Birth: [**2053-8-1**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Erythromycin Base / Zyprexa
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
36 yo F w/ PMH of hypothyroid, headaches and depression
presented with AMS. She was staying with a friend and said she
wanted a bottle [**Last Name (LF) **], [**First Name3 (LF) **] friend went to buy [**Company 19015**], called
her from store to ask if cans were okay, but when she came back
5 minutes later, she found pt lethargic and not quite
responsive, slurred speech. This was all within 30 minutes of
her taking her AM medicaitons. There were no pill bottles found
nearby. The friend called patients' husband who confirmed
abnormal mental status, so then she called 911, and patient was
found to be hypotensive in the 80s and brady in the 40s. The
night previously she had taken Benadryl, but denies taking
Tizanidine which she toook until recently for pain syndrome.
She is on an atypical very high dose pain regimen of several
medications.
.
On presentation to the ED her temp was 96.9 but then dipped to
95.2 prior to transfer to the floor so she was admitted to the
ICU. VS prior to transfer: 95.2 rectal, 55, 104/62, 15, 96% 2L
NC. EKG sinus brady w/ normal intervals. Got 8L NS and had put
out 300cc urine/5hrs. BP improved to 104/62 but was noted to be
hypothermic so admitted to ICU, got 10mg decadron for adrenal
insufficiency. Has history of suicide attempts by report from ED
(but patuient denies), and her son died recently.
.
She denies any suicidal ideation or taking extra medications.
She says she took her am clonazepam 2mg, gabapentin 1600mg,
mexilitine 250mg and wellbutrin 300mg and that her friend left
her at home in a normal condition and returned 10 minutes later
to find her unresponsive. She denies illicits and alcohol.
Denies any beta-blockers, CCBs or antihypertensives.
Past Medical History:
Chronic Migraine Headaches, seen at [**Hospital 90425**]
clinic since [**2097**]
Hypothyroidism
Depression - No history of suicide per patient and her husband
Generalized Anxiety disorder
Recent removal of occipital nerve stimulator 3 wks ago
Laminectomy
CAD: MI s/p stent [**2101**] (no betablocker due to bradycardia)
Chronic neck pain
Social History:
Married, lives in NJ, is here visiting friend [**Doctor First Name **]. No tobacco,
rare alcohol, no illicits, denies amphetamines specifically
(because urine tox screen was amphetamine positive). Son [**Name (NI) **]
died [**2103-8-12**] of cancer after battling aggressive lung cancer x
2 years at age of 21. Has a 23 yo daughter. Lives with husband
in [**Name2 (NI) **] [**Name (NI) 760**].
Family History:
Son with alveolar rhabdomyosarcoma, father with pacemaker.
Physical Exam:
Admission physical exam:
VS: Temp: 98F BP: 115/86 HR: 57 RR: 15 O2sat 94% RA
GEN: pleasant, comfortable, NAD, tearful
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: Crackles in bases bilaterally, no wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3, [**Doctor Last Name 1841**] in reverse, able to spell world backwards. Cn
II-XII intact. 5/5 strength throughout. No sensory deficits to
light touch appreciated.
RECTAL: Normal tone, brown stool
Discharge: VSS
Anicteric, OP clear, neck supple
Lungs CTA bilat
Cor: RRR no MRG
ABD: soft NT/ND
EXT: no edema
SKIN: lumbar, cervical and flank scars from stimulator (and its
battery) removal 3 weeks ago, C/D/I.
NERUO: A&O x 3, non-focal
Pertinent Results:
[**2104-3-2**] CT head
There is no evidence of infarction, hemorrhage, mass effect, or
extra-axial collection. The ventricles and sulci are normal in
size and
configuration. The [**Doctor Last Name 352**]-matter/white-matter differentiation is
preserved
throughout. The orbits appear normal. The mastoid air cells are
clear.
There is a high-riding left jugular bulb. The visualized
portions of the
paranasal sinuses are clear.
IMPRESSION: Normal study.
.
[**2104-3-2**] CXR
No definite evidence of pneumonia. Mild edema noted suggesting
volume overload. When clinically feasible, consider PA and
lateral
radiographs of the chest for further evaluation.
.
Admission labs:
[**2104-3-2**] 10:30AM WBC-3.1* RBC-3.53* HGB-10.5* HCT-31.2* MCV-88
MCH-29.8 MCHC-33.8 RDW-12.8
[**2104-3-2**] 10:30AM NEUTS-48.7* LYMPHS-38.4 MONOS-7.3 EOS-4.1*
BASOS-1.5
[**2104-3-2**] 10:30AM PT-12.9 PTT-24.1 INR(PT)-1.1
[**2104-3-2**] 10:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2104-3-2**] 10:30AM CORTISOL-7.8
[**2104-3-2**] 10:30AM TSH-8.6*
[**2104-3-2**] 10:30AM calTIBC-330 VIT B12-370 FOLATE-16.1
FERRITIN-15 TRF-254
[**2104-3-2**] 10:30AM cTropnT-<0.01
[**2104-3-2**] 10:30AM LIPASE-39
[**2104-3-2**] 10:30AM ALT(SGPT)-143* AST(SGOT)-118* LD(LDH)-347*
ALK PHOS-39 TOT BILI-0.2
[**2104-3-2**] 10:30AM GLUCOSE-129* UREA N-15 CREAT-0.7 SODIUM-136
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-27 ANION GAP-10
[**2104-3-2**] 10:36AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2104-3-2**] 10:36AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-<1
[**2104-3-2**] 10:36AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
.
Discharge labs:
[**2104-3-3**] 05:00AM BLOOD WBC-4.5# RBC-3.63* Hgb-10.6* Hct-31.6*
MCV-87 MCH-29.3 MCHC-33.7 RDW-12.4 Plt Ct-228
[**2104-3-3**] 05:00AM BLOOD Glucose-92 UreaN-9 Creat-0.5 Na-142 K-3.6
Cl-112* HCO3-22 AnGap-12
[**2104-3-3**] 05:00AM BLOOD ALT-371* AST-253* AlkPhos-66 TotBili-0.3
[**2104-3-3**] 05:00AM BLOOD Albumin-3.6 Calcium-8.0* Phos-3.0 Mg-1.7
[**2104-3-2**] 11:47PM BLOOD ALT-492* AST-427* LD(LDH)-400* CK(CPK)-60
AlkPhos-75 TotBili-0.2
[**2104-3-3**] 05:00AM BLOOD ALT-371* AST-253* AlkPhos-66 TotBili-0.3
[**2104-3-2**] 11:47PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2104-3-2**] 11:47PM BLOOD HCV Ab-NEGATIVE
[**2104-3-2**] 10:30AM BLOOD calTIBC-330 VitB12-370 Folate-16.1
Ferritn-15 TRF-254
Brief Hospital Course:
ICU course:
# Hypothermia: The patient had a temperature in the ED of
95.2F. Likely not sepsis, given HR 55 and no localizing source.
CXR, U/A negative. WBC 3.1 and hypotension could, however,
suggest sepsis. Likely secondary to 8L NS at room temperature.
Given a 70kg female with about 31.5L total body water where
Q=mC(deltaT) and room temperature saline being 23C, (excluding
the heat content of other tissues which is not significant) one
would expect the temperature of her TBW to be 34.16C, which is
93.48F, following adminisration of 8L saline. Patient was
breifly in a Bair hugger in ICU but her temperature quickly
normalized and remained so for the rest of her Hospital stay.
Her TSH and morning cortisol were within normal limits.
.
#. Hypotension: Resolved by arrival in the ICU, unlikely sepsis.
Likely secondary to medication interactions (i.e. benadryl,
klonipin, mexilitine) and/or side effect. No evidence of PNA or
UTI. Troponin negative. Hypotension, as well as cardiogenic
shock, are listed as adverse reactions to mexilitine overdose.
She may have ingested other medications that we are unaware of.
The acuity of onset of her symptoms would suggest ingestion and
not sepsis. Could be addisonian crisis given slightly elevated
eos, hyperkalemia and mild hyponatremia, already received 10mg
dexamethasone. The patient's blood pressure responded well to
the dexamethasone. Random cortisol was within normal limits,
however.
.
#Bradycardia: Baseline is in the 50s. Given degree of
bradycardia at time of ED presentation, could consider nodal
[**Doctor Last Name 360**] ingestion but could also have been vagal episode if
post-ictal. Patient resolved back to baseline by morning after
admission. Baseline bradycardia precludes use of Betablocker in
her, despite history of CAD.
.
#Altered mental status: Likely secondary to high clonazepam
dosing in light of liver failure, exacerbated by hypotension and
drug side effect of mexilitine. Appears to have happened
repeatedly before around time of her dosing and also given her
extremely large doses of clonazepam (9mg per day). The patient
was alert upon admission to ICU, so she was not given
flumazenil. Her confusion cleared in ICU and remained clear
throughout therefter. [**Hospital **] medical regimen was adjusted,
and patient was instructed not to drive or operate heavy
machinery. She was instructed not to take AMBIEN, BENADRYL,
TIZANIDINE, THORAZINE, or PREDNISONE until she had spoken with
her PCP.
.
# UTox (+) Amphetamine: Can be a false positive due to klonipin,
or other unreported OTC medication. Patient did not endorse
amphetamine use. Has no history of drug use. Reports taking
only that prescribed.
.
#. Hyperkalemia, along with mild hyponatremia. Possible
hypoadrenalism considered in ICU, but random cotrisol level
within normal limits, and no other probable association. This
resolved.
.
#. Transaminitis: The patient had transaminitis upon ICU
admission, likely secondary to mexilitine as this has been
described. Possibly made worse by hypotension. Acetaminophen
level negative. No evidence of acute liver failure as INR and
bilirubin normal. Trnasaminases improved, but will need to be
followed as outpatient. Her medications were adjusted given
degree of elevated liver enzymes. Mexilitine was discontinued,
especially as she was taking this for chronic pain, not
antiarrhythmic. She agreed to get repeat LFTs done in 48 hrs
with her PCP [**Name Initial (PRE) **]/or neurologist. She was instructed to stop
Zocor completely.
.
#. Depression. Patient does have recent stressor of son's death.
The patient had a 1:1 sitter during her ICU stay, though at no
time reported intent to harm self or suicidal ideation. When I
met her on the medical floor, the patient similarly denied SI,
and has no known history of this. Has very supportive husband,
and friend [**Name (NI) **], and supportive relationship with her daughter.
I discontinued 1:1. She agree to meet with Psychiatry consult
who agreed with non suicidal status. I made recommendations to
adjust her antidepressant regimen (which was higher than maximum
recommended dose to begin with) in light of her LFT
abnormalities. Patient has a grief counselor and [**Name (NI) 2447**].
She was instructed to follow up with the latter this week (and
indicated that she had an appointment the day after admission,
back in [**State 760**], where she lives). Celexa was moved from 40mg
[**Hospital1 **] to 20mg [**Hospital1 **] given her hepatotoxicity. Wellbutrin was moved
from 300mg daily to 150mg daily.
.
#. Normocytic anemia: Normal iron studies, B12, and folate.
Consider colonoscopy as outpatient procedure.
.
# Chronic pain: Is on incredibly high doses of Gabapentin
(1600mg TID) chronically, which supersedes the maximal
recommended dose (even for short term dosing). This was moved to
800mg TID. She was also on an off-label use of Mexilitine.
Mexilitine is likely cuplprit for hepatotoxicity, so this was
discontinued. She described takin intermittent Tizanidine until
about 1 week ago, as well as intermittent periodic Prednisone
tapers (over 2 weeks) and Thorazine regimens (for 5 days) for
her pain esacerbations. She was instructed to not take
MEXILITINE, PREDNISONE, TIZANIDINE at all, to follow up with her
PCP, [**Name10 (NameIs) 2447**] and neurologist to make sure that all were
speaking with each other about dose of medications being taken.
Polypharmacy is causing dangerous side effects.
.
# Insomnia: Chronic. Takes Beandryl and Ambien at night. She
was instructed to stop these medications completely until
further instruction by her PCP or [**Name10 (NameIs) 2447**]. They have high
risk of side effects.
Medications on Admission:
-Levoxyl 50 mcg Tab Oral 1 Tablet(s) Once Daily
-gabapentin 1600mg TID
-etodolac 300 mg Cap Oral 1 Capsule(s) Three times daily
-mexiletine 250 mg Qam, 250mg Qnoon and 250mg QPM
-bupropion HCl XL 300 mg 24 hr Tab Oral 1 Tablet Extended
Release 24 hr(s) Once Daily
-naproxen 250 mg Tab Oral Unknown # of dose(s) 550 mg tablet 3
times a day as needed for headache
-chlorpromazine 25 mg Tab Oral 1 Tablet(s) every hr as needed
for severe HA max 5 tablets a day
-Benadryl PRN insomnia
-Zocor 40mg Q24
-ASA 81mg daily
- clonazepam 2mg Qam, 3mg Qnoon, 2.5mg Q1600, 2mg Q2100
- Benefiber
- Celexa 40mg [**Hospital1 **]
Discharge Medications:
1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours: You may take maximum of 2mg per dose only if needed, but
start with 1mg dose.
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. Neurontin 800 mg Tablet Sig: One (1) Tablet PO three times a
day: do NOT exceed this dose, call your neurologist [**2104-3-4**].
6. aspirin, buffered 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Toxic encephalopathy -- most likely medication induced
Hepatotoxicity
Hypotension - resolved
Chronic Depression and Anxiety
Chronic Pain syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with change in mental status which we feel is
due to side effects of your medications. You denied intent to
hurt yourself, or taking non-prescribed meds, or additional
doses of prescribed medications. You were seen by myself and a
[**Month/Day/Year 2447**] and understand the concerns I have regarding
polypharmacy around your psychiatric and pain regimen. You
understand that you have liver toxicity very likely related to
you medications and low blood pressure component on hospital
arrival (also medication induced), and that this requires
cessation of particular meds, adjustment of dosage of other
meds, and that blood work needs to be followed up this week by
your physicians. Please take meds as prescribed in the
discharge list ONLY. You have agreed to call your [**Month/Day/Year 2447**]
today or tomorrow to be seen in the next 1-2 days. If you
cannot get in with your [**Month/Day/Year 2447**] or PCP or neurologist,
please let them know you need to have repeat liver function
tests performed with advice on how to adjust your medications.
I have recommended that you stop MIXELITINE (which you are
taking for an off-label reason) and stop ZOCOR completely.
Other adjustments to your medications have been made, please
make a note of this. Also, please do NOT take AMBIEN, BENADRYL,
TIZANIDINE, THORAZINE, or PREDNISONE until you have spoken with
your PCP.
Do not drive or operate heavy machinery until approved to do so
by your psychiatristm, neurologist, and/or PCP.
You should tell your physicians your liver function tests were
as follows:
ALT AST LD(LDH) CK(CPK) AlkPhos TotBili
DirBili
[**2104-3-3**] 05:00 371* 253* 66 0.3
[**2104-3-2**] 23:47 492* 427* 400* 60 75 0.2
[**2104-3-2**] 10:30 143* 118* 347* 39 0.2
Followup Instructions:
Call your pscyhiatrist no later than tomorrow morning.
Call your neurologist and PCP [**Name Initial (PRE) **].
Make sure ALL your physicians are aware of your hospitalization
and the medication changes I have recommended.
You need repeat blood work in 48 hours (liver function tests).
|
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23,697
| 115,610
|
6721
|
Discharge summary
|
report
|
Admission Date: [**2173-8-7**] Discharge Date: [**2173-8-12**]
Date of Birth: [**2105-5-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
Endoscopy X 2
History of Present Illness:
Mr. [**Known lastname 25586**] is a 68 year old man with a history of type II
diabetes, CRI not yet on hemodialysis, ischemic CVA in [**1-/2173**],
coronary disease s/p MI [**2153**] and well controlled crohns disease
who presents to the [**Hospital1 18**] ED w/ cc of 1 day of fatigue and s/p
black, dark stool X 1. Pt was in his USOH until day of admission
when he awoke with profound fatigue, weakness with minimal
exertion. He was unable to walk more than 10 steps w/o feeling
tired, weak, and SOB which requirred him to sit and rest. Pt
normally very functional, ADLs intact, walks around mall without
problems. [**Name (NI) **] was too weak to get out of bed all morning. Thought
his BS was low so checked FS=200. Later that morning, pt had BM
that was described as "stiff" dark in color-black. Has never had
this before. The day prior to admission pt only notes that he
had decrease in appetite. Pt was concerned about profound
fatigue and called ambulance for transport to ED.
.
Denied N,V, denied hemoptysis, no abd pain/epigastric pain.
Denied pain associated with eating, denied change in bowel
habits, (no diarrhea/no constipation). Besides ASA 325mg X
17yrs, he denies any other recent NSAID use.
.
Of note, about a week ago when he experienced a severe
unprovoked nose bleed.
.
He denies any fevers, chills, chest pain, or dyspnea on
exertion.
.
In the ED, he was given aspirin and IV protonix. His SBP was
80-100, and his hct was noted to be low. His NGL x250cc was
positive for coffee grounds and blood. hct noted to 21 from 38.
NGL positive for coffee grounds and blood.
.
EGD in ED with lots of blood and clots, without any obvious
source of bleeding aside from esophagitis, barrett's and hiatal
hernia. Pt transferred to ICU.
.
While in MICU, given IV PPI, carafate, pt transfused X 7. Pt
rescoped and noted to have no sig. changes. Pt c/o CP. EKG: mild
ST depression in lateral leads. Trop pos from Trop 0.21-> to
0.17, however CK, MB negative. Cards consulted recommended outpt
stress test. Repeat EGD nonactive bleed,consistent with first
EGD. Pt Hct remained stable and pt transferred to floor.
.
.
At time of transfer patient does not have any complaints. Denies
any cp/sob. Denies any n/v/d. Denies lightheadedness, dizziness.
Past Medical History:
1. CAD: s/p MI [**2153**], caths [**2153**], [**2163**], and [**2166**]: last w/ 30% LAD
lesion after the second diagonal branch, 30% lesion at the
origin of the second diagonal branch, 20% middle left circumflex
lesion, 30% proximal RCA lesion w/ patent stent
2. systolic dysfxn: echo [**1-25**] w/ LVEF 35%, resting regional WMA
include apical and mid and distal anterior and anteroseptal
akinesis.
3. DM type 2: c/b nephropathy
4. HTN
5. Chronic kidney disease: [**1-21**] DM2, baseline creat 3.2-3.3
6. Crohn's dz
7. Anemia of chronic renal dz: baseline HCT
8. s/p ischemic CVA: [**1-25**], minimal residual left hemiparesis.
CT/MRI with R basal ganglia ischemic infarct. MRA normal.
Carotid US with 40% stenosis b/l. TTE without LV thrombus.
Started on aggrenox. Coumadin entertained given EF 35%, areas of
akinetic LV, but PCP decided against it for now.
Social History:
Pt is a retired church decorator. He quit smoking in [**2153**], but
has ~75 pack-yr history. Social EtOH.
Family History:
NC
Physical Exam:
T 97.1 HR 65 BP 131/70 RR 18 Sat 98% RA
Gen: Pleasant well-nourished in NAD
HEENT: MMM, +conjunctival pallor, PERRL, sclerae anicteric
Neck: Supple, non-tender, no masses, no LAD appreciated
CV: Normal S1/S2, RRR, mild II/VI systolic murmur best heard at
sternal border
PUL: CTA b/l
Abd: Soft, NT, ND
Ext: No edema, no cyanosis, pulses 2+ throughout
Neuro:CNII-XII intact. LUE: deltoid [**2-21**], biceps/triceps [**2-21**]
RUE: [**4-23**] throughout
LLE: [**3-24**] Q, [**4-23**] hamstrings/TA/Dorsifle/Plant flex
RLE: [**4-23**] throughout
2+ reflexes throughout b/l
cerebellar: FTN,HTS intact
Pertinent Results:
[**2173-8-7**] 08:26PM GLUCOSE-221* UREA N-167* CREAT-3.7*
SODIUM-138 POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-14* ANION
GAP-18
[**2173-8-7**] 08:26PM CALCIUM-7.8* PHOSPHATE-3.9 MAGNESIUM-2.2
[**2173-8-7**] 08:26PM WBC-10.9 RBC-3.04*# HGB-9.3*# HCT-27.0*#
MCV-89 MCH-30.7 MCHC-34.5 RDW-15.6*
[**2173-8-7**] 08:26PM PLT COUNT-159
[**2173-8-7**] 02:10PM URINE HOURS-RANDOM
[**2173-8-7**] 02:10PM URINE GR HOLD-HOLD
[**2173-8-7**] 02:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2173-8-7**] 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2173-8-7**] 02:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2173-8-7**] 11:51AM LACTATE-1.4
[**2173-8-7**] 11:30AM GLUCOSE-289* UREA N-161* CREAT-3.7*
SODIUM-135 POTASSIUM-5.3* CHLORIDE-108 TOTAL CO2-15* ANION
GAP-17
[**2173-8-7**] 11:30AM CK(CPK)-41
[**2173-8-7**] 11:30AM cTropnT-<0.01
[**2173-8-7**] 11:30AM CK-MB-NotDone
[**2173-8-7**] 11:30AM URINE HOURS-RANDOM
[**2173-8-7**] 11:30AM URINE GR HOLD-HOLD
[**2173-8-7**] 11:30AM WBC-11.1* RBC-2.31*# HGB-7.2*# HCT-21.5*#
MCV-93 MCH-31.3 MCHC-33.6 RDW-13.5
[**2173-8-7**] 11:30AM NEUTS-88.4* BANDS-0 LYMPHS-8.0* MONOS-2.1
EOS-0.7 BASOS-0.7
[**2173-8-7**] 11:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SCHISTOCY-OCCASIONAL BURR-OCCASIONAL
[**2173-8-7**] 11:30AM PLT COUNT-195
[**2173-8-7**] 11:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2173-8-7**] 11:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2173-8-7**] 11:30AM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-NOTDONE
.
Studies:
[**2173-8-7**] CXR: No evidence of pneumonia. loss of the soft tissue
contour adjacent to the left clavicle, which may be suggestive
of supraclavicular lymphadenopathy or soft tissue swelling in
this location
.
[**2173-8-7**] EKG: Sinus rhythm
Left axis deviation
IV conduction defect
Anteroseptal infarct - age undetermined
Lateral ST-T changes may be due to myocardial ischemia
Since previous tracing of [**2173-4-23**], anterior T wave inversion is
resolving
.
[**2173-8-9**] EKG:
Sinus rhythm. Intraventricular conduction delay. Probable old
anterior
myocardial infarction. Compared to the previous tracing of
[**2173-8-8**] no change
.
Endoscopy: [**8-7**] - Grade 4 esophagitis; Mucosa suggestive of
Barrett's esophagus; Blood in the whole stomach; Medium hiatal
hernia
.
Endoscopy: [**8-10**]- Esophagitis in the lower third of the esophagus
compatible with mild esophagitis; Esophageal ulcer; Mild
erythema in the antrum, fundus and stomach body compatible with
mild gastritis; Small hiatal hernia Otherwise normal EGD to
second part of the duodenum
Brief Hospital Course:
68 man with past medical history significant for CAD, CHF, DM,
ESRD not yet on HD, presented with 1 day of fatigue, melena X 1
found to have anemia to 21. Transferred from MICU with stable
hct in low 30's.
.
# Gastroenterology-
Patient presented with 1 episode of melena in the setting of
profound fatigue. In the ED, he was found to have hct 21 (down
from basline of ~30)nasogastric lavage showed coffee grounds,
blood. On Endoscopy he was found to have no active bleed,
gastritis, esophagitis, esophagial nonbledding ulcer, [**Last Name (un) **]
esophagus,hiatal hernia, and repeat Endoscopy confirmed same
thing. He was admitted to the Medical ICU and transfused
approximately 6 units of packed RBC, IV PPI, and sucralfate was
started. Because patient has history of CAD, he was maintained
at a hematocrit to 30. Patient's hematocrit stabilized in the
low 30's and he was transferred to the floor in stable
condition. While on the floor, patient had one episode of
melena, however, he was hemodynamically stable and hematocrit
continued to be in low 30's, Patient did not require any more
transfusions. Patient was scheduled for gastroenterology
followup, along with followup with his primary care physician.
.
# Cardiovascular-
Patient has history of CAD, CHF. While in the MICU, patient
complained substernal chest pain, EKG was done which was
consistent with old EKG. Troponins were 0.21-->0.l8-->0.17,
however CK and MB negative X 3. Cardiology was made aware and
the EKG seemed to implicate an area near his prior infarct in
[**2153**]. Give the patient's chronic renal failure, the troponin
clearing is was believed to be impaired accounting for the
sustained high troponins, however given that the CK is not
elevated, it does not appear that patient indeed sustained MI.
Troponin levels along with CK would need to be elevated over
time in order to support NSTEMI. Given the patient's GI bleed,
anti-coagulation, plavix, and ASA 325mg was held.
.
However, while in MICU once GI bleed and hematocrit stabilized,
ASA was restarted at 81mg. Plavix continued to be held. Blood
pressure was controlled with metoprolol 100mg and hydralizine
25mg. Patient was discharged on ASA 81mg and plavix was held
secondary to further outpatient assessment with
gastroenterologist and cardiologist.
.
# Anemia: Likely due to both blood loss and chronic kidney
disease. Stable, Hct=30. Procrit 4000U was continued.
.
# Renal-
Patient has history of chronic kidney disease likely secondary
to diabetes. Upon admission, creatinine was around baseline with
an elevated BUN, likely due to upper GI source of bleeding.
Electrolytes, in particular potassium was monitored and reamined
within normal limits. Recommended patient continue to be
closely followed as an outpatient in regard to chronic renal
disease.
.
.
#DM-
Patient has history of diabetes type II, with secondary
retinopathy, nephropathy. Blood sugars were maintained in the
150's-200's with regular insulin sliding scale while inpatient.
Patient was discharged on home medications.
Medications on Admission:
ASA 325mg daily
Plavix 75mg daily
Lipitor 80mg daily
Glipizide 5mg daily
Isosorbide MN SR 30mg daily
Toprol 100mg daily
Hydralazine 25mg TID
Doxercalciferol 0.5 mcg daily
Cytra-2 5mg twice daily
Folic Acid 1mg daily
Florinef 0.1mg daily
Lasix 20mg daily
Procrit 4000u twice weekly
Tums 500mg twice daily
Vitamin B12 50mcg once daily
Discharge Medications:
1. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a
day. Tablet(s)
2. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Procrit 4,000 unit/mL Solution Sig: One (1) Injection twice
weekly.
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. 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*
9. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day): Please make into slurry (crush tablet and add to water).
Disp:*120 Tablet(s)* Refills:*2*
10. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day. Tablet Sustained
Release 24HR(s)
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day. Tablet
Sustained Release 24HR(s)
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1.Upper GI bleed (Esophagitis, gastritis, esophageal ulcer)
.
Secondary:
1.CAD
2.DM, type II
3.ESRD
Discharge Condition:
Stable
Discharge Instructions:
IMPORTANT INFORMATON:
.
1. Your aspirin was decreased from 325mg to 81mg because of your
recent GI Bleed. Please take aspirin 81mg once a day. Your
Plavix 75mg was stopped while you were in the hospital and we
did not restart this on discharge because of your GI bleed.
Please do not take Plavix 75mg. Given your history of heart
disease and recent GI bleed, it is very important that you
discuss whether or not you should restart your plavix and/or
increase your aspirin dose with your gastroenterologist and/or
your cardiologist. Please discuss this at your next
appointments. Please also discuss your episode of chest pain
with your cardiologist. He will decide whether you should have a
stress test to reevaluate your heart.
.
2.Please be sure to make your appointments listed below, if you
are unable to attend, call to reschedule.
.
3.Please return to primary care physician or emergency
department if you have recurrent profound fatigue, dark tarry
stools, blood per rectum, vomiting blood, or other concerns.
Followup Instructions:
1. Cardiology: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
[**2173-9-7**] 11:00
.
2. Gastroenterology:.[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D., [**2173-9-9**]
3:00PM.([**Telephone/Fax (1) 2306**]
.
3. Primary care physician-[**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) 1576**],[**Name11 (NameIs) 2352**], [**2173-9-28**]
8:50AM.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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2598, 3461
|
3477, 3586
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,334
| 153,633
|
1489
|
Discharge summary
|
report
|
Admission Date: [**2169-3-29**] Discharge Date: [**2169-4-14**]
Date of Birth: [**2108-1-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Vancomycin / Keflex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest tightness, weakness
Major Surgical or Invasive Procedure:
[**2169-4-4**] - CABGx3 (LIMA->LAD, SVG->OM, SVG->RCA)
[**2169-3-30**] - Cardiac Catheterization
History of Present Illness:
The patient is a 61-year-old man with a history of vascular
disease thought to be secondary to mantle radiation therapy to
the chest in [**2129**] for Hodgkin's disease, CAD s/p PTCA of LCx in
[**4-17**], bilateral subclavian stenosis s/p stents, left carotid
endarterectomy who presented with a 1 day history of chest
tightness and weakness while exercising.
The patient reported that he was exercising at the gym on the
day of admission, and reported doing a little more strenuous
exercise than usual. He began to feel more weak with a little
chest tightness, slight SOB, nausea, palpitations, neck
tightness, and right arm numbness. He denied diaphoresis and
dizziness. He reported that he has had more fatigue with
exertion, especially when walking uphill, over the past few
months. Of note these symptoms are similar to described anginal
symptoms for which he had a cardiac catheterization in [**2162**]. The
patient then went home. His symptoms persisted, so he had his
brother take him to the hospital. He does report taking his ASA
325 mg over the past 7 days. He did not take any nitro at home.
In the ED he was chest pain free with an EKG that was v-paced.
CEs showed TropT to 0.16, CK 253. CXR showed no evidence of
pneumonia or CHF.
Past Medical History:
-Hodgkins Lymphoma - located in neck, treated with surgical
resection and radiation therapy in [**2129**], in remission
-CAD: s/p Successful PTCA, rotational atherectomy, and Penta
stenting of the origin LCX in [**4-17**]
-Bilateral Subclavian Stenosis s/p left and right subclavian
arteries in [**7-19**] with Genesis stents
-Paroxysmal atrial fibrillation, not yet on Coumadin
-HTN
-Hyperlipidemia
-Carotid Stenosis s/p L carotid endarterectomy in [**2168-12-26**] for
70-79%
left ICA and 60-69% right ICA
-Dual Chamber Pacemaker ([**Company 1543**] EnRhyrhm dual chamber
pacemaker) on [**2166-9-8**] for sinus pause, type II 2nd degree AV
block, presyncope on ETT MIBI in [**2166-9-5**].
-Paroxysmal Atrial Fibrillation
-Anxiety
-Chronic cervical spine/shoulder pain - takes tylenol. Lumbar
and cervical spondylosis.
-Gout
-History of rheumatoid arthritis
-GERD
-History of thyroid nodule
Social History:
denies current tobacco use, last cig >10 years ago. There is a
history of alcohol abuse, stopped 2 years ago.
Single and lives in [**Location 1268**] with his brother. [**Name (NI) 4084**] married
and no children. Retired telephone company employee.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Admission:
VS T 97.7 BP 144/66 HR 66 RR 18 98%RA, wt. 59.4 kg
Gen: Thin, middle aged male in NAD. Oriented x3. anxious, affect
appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with no [**Doctor First Name **], JVD, bilateral carotid bruits L>R
CV: Distant heart sounds, RR, No m/r/g noted. No thrills, lifts.
No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Rectal: guaiac negative in ED
Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2169-4-11**] 05:25AM BLOOD WBC-6.3 RBC-2.99* Hgb-8.9* Hct-26.7*
MCV-89 MCH-29.9 MCHC-33.5 RDW-16.5* Plt Ct-304
[**2169-4-12**] 05:25AM BLOOD PT-16.2* PTT-62.7* INR(PT)-1.4*
[**2169-4-11**] 05:25AM BLOOD PT-14.2* PTT-63.4* INR(PT)-1.2*
[**2169-4-11**] 05:25AM BLOOD Glucose-106* UreaN-25* Creat-1.2 Na-133
K-4.2 Cl-97 HCO3-27 AnGap-13
CHEST (PA & LAT) [**2169-4-11**] 7:05 PM
CHEST (PA & LAT)
Reason: assess for effusions/infiltrates
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p cabg
REASON FOR THIS EXAMINATION:
assess for effusions/infiltrates
Bibasilar effusions, left greater than right, with associated
left atelectasis and volume loss. Improved aeration of right
lung. Difficult to exclude infectious consolidation at left lung
base given effusion. Sternal wires and pacer not changed.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 8782**] (Complete)
Done [**2169-4-4**] at 1:55:42 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2108-1-17**]
Age (years): 61 M Hgt (in): 65
BP (mm Hg): 95/54 Wgt (lb): 130
HR (bpm): 85 BSA (m2): 1.65 m2
Indication: Intraoperative TEE for CABG, ? MVR
ICD-9 Codes: 440.0, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2169-4-4**] at 13:55 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% >= 55%
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - Peak Gradient: 10 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 5 mm Hg
Aortic Valve - LVOT diam: 2.7 cm
Findings
Pt is AV paced at a rate of 85
LEFT ATRIUM: 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.
All four pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Severe regional LV systolic dysfunction. TSI demonstrates
significant LV dyssynchrony with significant septal wall
contraction delay (vs. lateral wall).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Normal
descending aorta diameter. Simple atheroma in descending aorta.
Focal calcifications in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AS. Mild to moderate ([**11-16**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be A-V paced. Results were personally reviewed with the MD
caring for the patient.
Conclusions
PRE CPB:
1. 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.
2. Left ventricular wall thicknesses and cavity size are normal.
There is severe regional left ventricular systolic dysfunction
with severe apical, mid distal anterior, anterolateral, lateral
walls and probable severe hypokinesis of septum.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The left coronary cusp is moderate to
severely immobilized. There is no aortic valve stenosis. Mild to
moderate ([**11-16**]+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. The tricuspid valve leaflets are mildly thickened.
8. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the study.
POST CPB: Pt is on an infusion of phenylephrine and Epinephrine
and is AV paced.
1. Biventricular function is unchanged
2. Aorta is intact post decannulation
3. Other findings are unchanged
Brief Hospital Course:
Mr. [**Known lastname 7749**] was admitted to the [**Hospital1 18**] on [**2169-3-29**] for further
management of his chest discomfort. He ruled in for a myocardial
infarction and plavix, heparin, aspirin, lipitor and lopressor
were started. He remained pain free. On [**2169-3-30**], Mr. [**Known lastname 7749**] [**Last Name (Titles) 8783**]t a cardiac catheterization which revealed severe three
vessel coronary artery disease with an ejection fraction of 35%.
Given the severity of his disease, the cardiac surgical service
was consulted for surgical management. Mr. [**Known lastname 7749**] was worked-up
in the usual preoperative manner including a carotid duplex
ultrasound which revealed the moderate plaque on the right with
a 60-69% internal carotid stenosis and a less than 40% internal
carotid artery stenosis on the left with a greater than 70% left
distal common carotid artery stenosis. A CT Scan of his schedt
was obtained which showed mild post-radiation changes involving
the paramediastinal upper lobes consistent with known treated
lymphoma. There was a large conglomerate calcified
retroperitoneal mass also resultant of treated lymphoma as well
as a right thyroid lesion, previously evaluated by ultrasound.
Plavix was allowed to clear from his system prior to surgery.
The electrophysiology service was consulted for interoggation
and reprogramming of his pacemaker. On [**2169-4-4**], Mr. [**Known lastname 7749**] was
taken to the operating room where he underwent coronary artery
bypass grafting to three vessels. Please see separate dictated
note for details. Postoperatively he was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, Mr. [**Known lastname 7749**] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. His pacemaker was again reprogrammed to DDD 50-125.
Mr. [**Known lastname 7749**] complained of left eye pain and the opthalmology
service was consulted. A left corneal abrasion was noted and
polysporin ointment and artificial tears (perservative free)
were prescribed with improvement in his symptoms. Follow up two
days later showed that it was healing well. On postoperative day
two, he was transferred to the step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. Beta
blockade, aspirin and a statin were resumed. Mr [**Known lastname 7749**] was noted
to have episode of intermittent Atrial fibrillation for which he
was started on Amiodarone and Warfarin. His creatinine rose to a
peak level of 1.5, but has dropped back to 1.3 today. Mr [**Known lastname 7749**]
continued to make progress in his activity level and on [**2169-4-14**]
was discharged home with VNA.
Medications on Admission:
-Atenolol 50 mg daily, but Dr. [**Last Name (STitle) **] trying to get VA to
dispense Toprol XL 50 daily currently
-Amlodipine 5 mg daily
-Simvastatin 40 mg qhs
-Aspirin EC 325 mg daily
-Allopurinol 100mg qdaily
-Ativan 0.5 mg [**Hospital1 **]
-Omeprazole 20 mg daily
-Nitro 0.3 mg SL PRN
-Multivitamin daily
-Ca 500 with Vit D 400 U daily
-FeSo4 325 daily
-Ensure [**Hospital1 **]
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Calcium 500 With D 500 (1,250)-400 mg-unit Tablet Sig: One
(1) Tablet PO once a day.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. 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*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 5 days then 400mg QD x7 days then 200mg QD.
Disp:*50 Tablet(s)* Refills:*2*
13. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): target INR 2-2.5.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p CABGx3(LIMA-LAD,SVG-OM,SVG-RCA)[**4-4**]
PMH:CAD/NSTEMI, Hypertension, Chronic Systolic Heart Failure,
Paroxysmal Atrial Fibrillation, Hyperlipidemia, Anxiety, Gout
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
1) Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
2) You have a follow up appointment in the DEVICE CLINIC
([**Telephone/Fax (1) 59**]) on [**2169-4-18**] at 9:30 in the [**Hospital Ward Name **] CLINICAL CTR,
[**Location (un) **].
3) You then have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
Cardiology ([**Telephone/Fax (1) 5003**]) on [**2169-4-18**] at 10:00 in the [**Hospital Ward Name **]
CENTER, [**Location (un) **].
4) You have a follow up appointment with Dr. [**Last Name (STitle) **] in Primary
Care ([**Telephone/Fax (1) 7477**]) on [**2169-4-21**] at 9:15a at [**State **]
([**Location (un) **], MA), [**Location (un) **].
5) You have a follow up appointment with Dr. [**Last Name (STitle) **] in Dermatology
on [**2169-4-26**] at 1:00p in the [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **].
Completed by:[**2169-4-14**]
|
[
"998.0",
"428.0",
"427.31",
"410.71",
"E878.2",
"V10.72",
"428.22",
"414.01",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"39.61",
"88.53",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
14006, 14064
|
9344, 12166
|
325, 424
|
14277, 14286
|
3895, 4336
|
15029, 15970
|
2898, 2980
|
12598, 13983
|
4373, 4398
|
14085, 14256
|
12192, 12575
|
14310, 15006
|
2995, 3876
|
260, 287
|
4427, 9129
|
452, 1699
|
1721, 2614
|
2630, 2882
|
9139, 9321
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,894
| 178,038
|
55019
|
Discharge summary
|
report
|
Admission Date: [**2168-7-18**] Discharge Date: [**2168-8-18**]
Date of Birth: [**2121-1-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
[**2168-8-12**] MVR(29mm tissue)
[**2168-8-12**] return to OR for chest exploration 2nd to bleeding
History of Present Illness:
Ms. [**Known lastname 112326**] is a 47yo woman with HCV cirrhosis, emphysema,
heroin IVDU, who was recently admitted from [**Date range (1) 112327**] for septic
shock, MSSA MV endocarditis ([**2168-6-16**]) c/b septic emboli to the
brain, spleen, kidneys, and digits (w necrosis of distal
extremities). Course was complicated by Klebsiella HCAP (sp 8d
Levofloxacin; BAL on [**6-23**] also showed 2+ budding yeast), [**Last Name (un) **] (Cr
1.1 --> 3.1), E. coli UTI (Dx: [**2168-6-16**]; sp 7d ciprofloxacin) and
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**]/glabarta peritonitis (Dx [**2168-6-30**]; sp
Micafungin and Flagyl). Pt was not CT [**Doctor First Name **] candidate as per CT
team (TEE on [**6-21**] showed MV vegetation: 2.4x1.4cm and on [**6-30**]
showed MV vegetation, measuring 1.3 cm x 0.9 cm). Pt was treated
with vanc and later discharged on nafcillin (day 1 [**6-17**] - [**7-29**]).
Pt presented again on [**7-18**] s/p unwitnessed fall w/ neck pain. In
[**Name (NI) **], pt was found to be febrile (102.3), tachycardic (120-140s),
SOB w O2 Sat to 90s on 3LNC. Exam was notable for being
combative and agitated, and [**2-23**] pansystolic murmur best heard
over the apex, and slight diffuse abdominal tenderness.
Extremities were still notable for necrotic fingers and feet
with 2+ pulses
bilaterally. In ED, CT Head was negative, CT spine showed
possible C5-6
diskitis (focal endplate irregularities and sclerosis), CXR
showed bl hazy opacities, and CTA chest showed lingular nodule
and multiple nodularities w fluid overload pattern and NO PE.
Echo [**2168-8-2**] showed a moderate-sized vegetation on the mitral
valve (posterior leaflet) and severe (4+) mitral regurgitation.
Csurg was reconsulted for evaluation for mitral valve
replacement.
Past Medical History:
Recent ICU admission for MSSA endocarditis, c/b septic shock,
respiratory failure, pneumonia, ATN, hand/foot necrosis, fungal
peritonitis, UTI, Hep. C not treated(being followed at [**Hospital1 2177**]),
Asthma, Vit. D deficiency, Asthma, Emphysema
Social History:
Currently separated from wife prior to admission because of
patient's polysubstance abuse. Pt actively using heroin, MJ, BZ,
cocaine, before last admission. Approximately 35 pack year
smoking hx. Two sons (24, 16). Two grandchildren
Family History:
Father deceased lung Ca
brother deceased ALL
Uncle deceased [**Name2 (NI) **] Ca + COPD
son bladder Ca
Physical Exam:
Admission
Temp: 98.6 Pulse: 116 B/P: 122/85 Resp: 22 O2 sat: 100%RA
Height: 65" Weight: 75kg
General: NAD, A&Ox3
Skin: Dry [x] intact [], gangrenous feet bilat, necrotic
fingertips bilat.
HEENT: EOMI [x]
Neck: Full ROM [x], +trach w/ Puissy Muir valve
Chest: +rhonchorous
Heart: Murmur - systolic [x] grade ______, tachy w/ reg rhythm
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Dry gangrene of b/l distal phalanges, R>L. Dry
gangrene of b/l feet (mid-foot to toes).
Neuro: Grossly intact [x]
Discharge:
VS: 99.2 97 reg 105/77 18 100% RA
Wt 76.6
Gen: nAD-lying in bed
Neuro: A&O x3, nonfocal exam
Pulm: clear, diminished in bases bilat. trach site CDI
CV: RRR, sternum stable, incision CDI
Abdm: soft, NT/ND/+BS. PEG site tender to touch/CDI
Ext: necrotic feet bilat-dopplerable PT pulse
necrotic fingertips- bilat
Pertinent Results:
[**7-31**] MRI head
1.Evolution of multiple abnormal FLAIR foci, in keeping with
infarcts,
throughout the brain parenchyma with some of them demonstrating
more apparent
hemorrhagic components. Different degrees of decreased FLAIR
intensity
involving some of the multiple infarcts. No evidence of acute
infarct.
2. The area of concern corresponds to expected evolution of a
focal infarct within the left cerebellum. No evidence of
abnormal enhancement.
[**2168-7-29**] CT torso
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Worsening of the bilateral nodular pulmonary densities, most
likely
infectious versus inflammatory in nature. These should be
followed with
repeat CT when the patient's current clinical scenario improves
to assure
complete resolution. There is also worsening of the lower lobe
atelectasis
and consolidations as well as worsening of the mediastinal
lymphadenopathy.
Pulmonary edema is similar in extent.
3. Stable splenic and renal infarcts.
4. Thrombosed right external iliac artery, an unchanged
finding.
5. Increased size of a left adnexal cyst. If patient is
postmenopausal then further evaluation is recommended with
pelvic ultrasound on a nonurgent basis (within 6 weeks).
CT OF THE ABDOMEN WITH IV CONTRAST [**2168-7-22**]:
Included views of the lung bases demonstrate small basilar
consolidations,
mild interstitial edema, moderate emphysema, and multiple
scattered
ground-glass nodular opacities, all improved since the [**2168-7-18**] chest CT examination. Small left pleural effusion. The
heart size is normal. There is no pericardial effusion.
Relative hypodensity of the blood pool with respect to the
intraventricular septum (2:6) is compatible with chronic anemia.
There has been interval resolution of previously-seen ascites.
The liver
contour is nodular, most compatible with cirrhosis. The spleen
is mildly
enlarged and contains a splenic infarct in the lateral upper
pole (2:12). The pancreas, adrenal glands, stomach, and
intra-abdominal loops of small bowel are normal. A gastrostomy
tube is appropriately positioned (2:31).
Relative hypodensity of the superior spleen (2:14) and along the
right renal cortex (2:29. 27) are better appreciated on the
contrast-enhanced study from [**2168-6-29**], reflecting infarcts.
Scattered prominent para-aortic lymph nodes (2:32) are slightly
enlarged since the [**2168-6-29**] examination.
ECHO REPORT [**2168-7-19**]
The left atrium is normal in size. The left ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are moderately
thickened. There is a moderate-sized vegetation on the mitral
valve. There is an abscess cavity seen adjacent to the mitral
valve (not as well seen as on the prior transesophageal
echocardiogram). Moderate to severe (3+) to severe (4+)
eccentric mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
Compared with the prior transesophageal study (images reviewed)
of [**2168-6-30**], the mitral vegetation now appears smaller. Mitral
regurgitation appears similar to slightly worse (severity of
mitral regurgitation was likely underestimated in the prior
report). An abscess/phlegmon is seen along the posterolateral
annulus (though not as well seen as on the prior transesophageal
echocardiogram).
[**2168-8-12**]
PRE BYPASS No thrombus is seen in the left atrial appendage.
Mild spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] There is an echolucent area
in the basal lateral and anterlateral walls, below the posterior
mitral annulus, that demonstrates blood flow within. This is
likely an aneurysm due to abscess. The right ventricle appears
to dispaly focal hypokinesis of the apical free wall. This may
be due to limited imaging. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. There are simple atheroma in the aortic arch. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. There is a
large vegetation on the mitral valve. The mitral regurgitation
vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results in the operating room at the time of the
study.
POST BYPASS There is normal biventricular systolic function.
There is a bioprosthesis located in the mitral position. It
appears well seated and displays normal leaflet motion. No
mitral regurgitation is appreciated. The maximum gradient
through the mitral valve was 15 mmHg with a mean gradient of 5
mmHg at a cardiac output of 6.5 liters/minute. The tricuspid
regurgitation may be slightly worse but is mild in total. The
rest of valvualr function is unchanged. The thoracic aorta is
inatct after decannulation
Radiology Report CHEST (PORTABLE AP) Study Date of [**2168-8-14**] 3:54
PM
Final Report
There is no evident pneumothorax. Moderate pulmonary edema has
worsened.
Right lower lobe and right perihilar opacities have increased
consistent with increasing atelectasis and pleural effusion.
Left lower lobe retrocardiac opacities have worsened, consistent
with worsening atelectasis. Swan-Ganz catheter tip is in the
main pulmonary artery. Right PICC tip is in the middle SVC.
Tracheostomy tube in standard position. Cardiomediastinal
contours are unchanged. Small left pleural effusion has
increased.
Discharge labs:
[**2168-8-17**] 05:36AM BLOOD WBC-5.6 RBC-2.86* Hgb-9.1* Hct-27.6*
MCV-96 MCH-31.6 MCHC-32.9 RDW-18.9* Plt Ct-102*
[**2168-8-16**] 06:30AM BLOOD WBC-6.4 RBC-3.16* Hgb-9.7* Hct-29.9*
MCV-95 MCH-30.8 MCHC-32.5 RDW-18.7* Plt Ct-93*
[**2168-8-15**] 02:34AM BLOOD WBC-8.0 RBC-2.79* Hgb-8.8* Hct-26.2*
MCV-94 MCH-31.5 MCHC-33.5 RDW-18.6* Plt Ct-82*
[**2168-8-17**] 05:36AM BLOOD UreaN-12 Creat-0.6 Na-134 K-3.5 Cl-103
[**2168-8-16**] 06:30AM BLOOD Glucose-111* UreaN-13 Creat-0.6 Na-133
K-3.3 Cl-101 HCO3-23 AnGap-12
[**2168-8-15**] 02:34AM BLOOD Glucose-136* UreaN-12 Creat-0.6 Na-135
K-3.5 Cl-103 HCO3-23 AnGap-13
[**2168-8-14**] 04:00PM BLOOD Glucose-149* UreaN-11 Creat-0.6 Na-130*
K-3.7 Cl-101 HCO3-21* AnGap-12
Brief Hospital Course:
MEDICAL COURSE:
47 yo F with a history of HCV, IVDU, recently d/c from ICU to
rehab on [**7-12**] after 1 month inpatient stay for MSSA endocarditis
(was on nafcillin) c/b shock, respiratory failure s/p trach,
pneumonia, [**Last Name (un) **] [**1-21**] to ATN, hand and foot necrosis and fungal
peritonitis who was admitted after fall at rehab with complaints
of fevers, tachycardia
1) Respiratory distress: The patient had intermittent
desaturations in the ED. Upon presentation to the ICU, was
initially doing well. Was found to have passey muir valve in
place, and reported leaving it in place for over a week without
taking out in evenings. Valve was removed. Patient quickly
desaturated to 60s-70s, RR 30s, HR 150s-160s, BPs 150s/90s-100s.
Became combative, agitated. Large mucous plugs were suctioned
along with albuterol nebulizer, 2 mg IV ativan, and 100% O2 to
bring her up to O2 sats in the 80s. She briefly required
ventilatory support with a PEEP of 5cmH2O and pressure support
of [**4-26**] cmH2O. Her respiratory status improved with suctioning
and humidified oxygen. She was instructed to remove her
Passey-Muir valve overnight to improve pulmonary hygeine.
Ultimately, it was felt that the single desaturation event was
secondary to mucous plugging, which was itself secondary to
continuous use of passey muir valve. She was sent to the floor
on trach mask at 40% FiO2. On the medical floor, her respiratory
status stabilized, and did well with intermittent suctioning and
maintained adequate cough. On [**7-29**] sputum cx grew colonies of
Chryseobacterium and STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
As pt was afebrile and had no leukocytosis, ID team felt that
there was no need for additional antibiotic coverge as this was
most likely benign colonization.
2) Fever likely secondary to HCAP and MSSA endocarditis:
The patient was febrile to 102.3 in the ED on initial
presentation. Contributing sources included pneumonia--likely
HCAP (sputum culture grew pseudomonas), persistent MSSA mitral
endocarditis, possible cervical osteomyelitis/discitis as seen
on cervical spine MRI. In addition, elevated beta glucan raised
potential of persistent or recurrent fungal peritonitis; CT was
performed, which showed no intra-abdominal or intrapelvic fluid
collections. CT, however, raised potential contribution of ?new
thrombophlebitis in the right iliac; this was not immediately
evaluated in ICU pending improvement in renal function (for
contrast load) and lack of acuity not requiring MRA. As patient
continued to spike fevers, the PICC line was also pulled after
placement of 2 peripheral IVs, and the PICC line tip was
cultured. Her outpatient nafcillin was held and she was
initially empirically treated with vancomycin 750mg IV q12h and
cefepime 2g IV q8h. The antibiotic spectrum was again changed
to nafcillin and cefepime in conjunction with ID, with a plan
for a total of 17 days of cefepime for the HCAP, and a complete
course of nafcillin of 8 weeks duration (ending on [**2168-9-28**]).
Given peristant fevers on [**2168-7-29**], a CT torso was performed,
which revealed the possibility of another/new infectious lesion
in the brain. For further evaluation, and MRI of the brain was
performed and revealed multiple septic emboli with hemorrhagic
components. Cardiac surgery was again consulted in re: the
timing of any MVR. A repeat echocardiogram was requested by them
to evaluate. This was performed and revealed severe (4+)
mitral regurgitation was seen and MVR was done on [**2168-8-12**]. The
explanted valve was sent to pathology and had cultures sent.
3) Right external iliac artery thrombus: This was seen on a non
contrasted study in the ICU. There were also some subtle
changed on prior imaging from prior hospitalization. A CT torso
on [**2168-7-29**] demonstrated thrombosis of the rt. ext iliac artery,
which radiology reported as 'an unchanged finding'. ID and
Vascular surgery were asked for input as to further specific
managment for this finding, if any, over concern for the
possible need for anticoagulation given possible nidus of septic
thrombophlebitis/ongoing endovascular infection, and recommended
heparin drip and would readdress operation after MVR with
cardiac surgery. Heparin drip was started after vascular
initially planned on operating on groin clot before C-[**Doctor First Name **].
Serial neuro checks were done while on heparin as pt had septic
emboli to brain and had hemmorrhagic components. Pt required a
head CT after starting drip which ruled out hemorrhage. Heparin
drip was discontinued as risk of intracranial hemorrhage
outweighed benefit of agressive anticoagulation for clot without
interval change and not symptomatic (no wet gangrene of R LE and
Doppler pulses of posterior tibialis).
4) C5-C6 chronic osteomyelitis with neck pain:
The patient had a head and neck CT that suggested only
discitis/osteomyelitis. There was no evidence of fracture. She
had no focal neurologic findings on exam. Her pain was treated
with oxycodone PRN, and antibiotic thearpy was continued as
above. On [**8-7**] pt complained of R shoulder pain (without
neurologic deficits) and this was concerning for acute
osteomyelitis- imaging should no signs of osteo.
5) Dry gangrene on extremities:
The patient's hands and feet show evidence of dry gangrene
secondary to septic emboli. She was seen by plastic surgery who
recommended waiting for the necrotic tissue to demarcate and
folowup in 2 weeks. Betadine was placed on hands and feet [**Hospital1 **] to
prevent conversion from dry to wet gangrene. Her extremities did
not develop signs of wet gangrene during her hospital stay.
Vascular surgery saw pt. and recommended outpatient follow up in
one month for possible amputation of the feet at a TMA site or
via BKA (TBD). Pt's pain was controlled with OxyContin,
oxycodone for breakthrough, and Tylenol.
6) Neuropathic pain:
The patient complained of burning pain in her legs that was
thought to be neuropathic in nature. She was started on
gabapentin 300mg PO TID which was subsequently increased to 600
mg TID.
7) Hep C: The patient's LFTs and INR remained stable during her
admission. She is not being treated for Hep C currently, and no
treatments were started during her admission.
8) Trach/PEG: Per IP, was going to defer downsizing tube before
surgeries as pt may need bronchoscopy and trach will be used by
anesthesia for procedures. In addition, IP also planned on
taking out PEG tube after procedures as well. PEG tube was not
used while on medical floor as pt was able to swallow
medications and food without difficulty.
SURGICAL COURSE:
47F seen by Cardiac Surgery on [**2168-6-17**] during an admission for
MSSA bacteremia and mitral valve endocarditis with multiple
embolic events (brain, spleen, R
kidney, [**Last Name (un) 1003**] lesions), presumably secondary to IV heroin use.
At the time of evaluation, pt was septic; thus, the initial
decision was to treat her medically (vanc/Zosyn -> nafcillin x 6
wks). She then defervesced, her blood cultures after [**6-16**] were
sterile, and a TEE failed to show progression; thus, surgery was
deferred even after she stabilized. Her hospital course was
also significant for Klebsiella pneumonia/respiratory failure
requiring trach (treated with levofloxacin x 8d), acute kidney
injury (Cr 3.1, presumed secondary to ATN, secondary to
hypotension), E.coli UTI (treated with cipro x7d), and fungal
peritonitis (treated with micafungin and Flagyl). She was
discharged to [**Hospital 100**] Rehab on [**2168-7-12**]. On [**2168-7-18**], pt was sent
back to ED s/p fall out of bed with neck pain and agitation. In
the ED, she was noted to be febrile (102.3), tachycardic
(120-140s), and hypoxic (mid-low 90s on 3L).
WBC was normal. CT and MRI C-spine demonstrated C5-6 chronic
osteomyelitis. CXR and CTA chest demonstrated multifocal
pneumonia. She was admitted to Medicine. Repeat echo
demonstrated that the MV vegetation had decreased in size.
Again, an abscess/phlegmon along the posterolateral annulus was
noted. MV regurgitation was noted to be similar/slightly worse.
All blood cultures since readmission have been sterile. On
[**2168-7-29**] pt was noted to be somnolent, febrile (100.8), and
tachycardic. CT head demonstrated a new R vertex ring-enhancing
lesion, ?early abscess. However, CTA torso also demonstrated
worsening pneumonia. Csurg was reconsulted to re-evaluate for
possible surgical intervention in the setting of continued
septic
emboli. [**2168-8-2**] Echo showed moderate-sized vegetation on mitral
valve. No MS. [**Name13 (STitle) 650**] (4+) MR. On [**2168-8-12**] the patient was
transferred to the cardiac surgical service.
The patient was brought to the operating room on [**2168-8-12**] where
the patient underwent MVR (29mm tissue). See operative report
for full details. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Later on the
night of POD#0 she was taken back to the operating room for
re-exploration for bleeding. POD 1 she was weaned from the
ventilator and able to maintain adequate oxygenation on trach
collar. She remained alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service and rehab was
recommended. She is non-weight bearing due to her dry necrotic
feet. By the time of discharge on POD 6 the patient was afebrile
on IV nafcillin, tolerating a regular diet but remained on
cycled tube feeds to maximize nutrition. She was eating well and
so the tube feeds can likely be discontinued soon. Trach and G
tube removal to be evaluated at rehab once procedures completed.
The sternal wound was healing and the pain in her extremities
and sternum was controlled with oral analgesics. She is to
continue Nafcillin until [**2168-9-9**] via PICC and had infectious
disease follow up arranged. The day before discharge she
experienced pain at her PEG tube site but it was found to be
clean, dry, and intact on inpection. Dr.[**Name (NI) 5070**] team, who
placed the tube on [**6-23**], asked for a tube study that revealed
that the tube was in in good position. They are hesitant to
remove the tube in this malnourished patient until the tube has
been in place for at least a total of 12 weeks due to the risk
of peritonitis. The patient was discharged to [**Hospital1 **]
[**Hospital1 8**] on POD 6 in good condition with appropriate follow up
instructions. Cardiac surgery and vascular follow up have been
arranged.
Medications on Admission:
Albuterol Inhaler [**1-23**] PUFF IH Q4H:PRN wheeze
Acetaminophen 650 mg PO Q6H pain Do not exceed 4g in one day
Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
Docusate Sodium (Liquid) 100 mg PO BID Hold for loose stools.
Nafcillin 2 g IV Q4H endocarditis
OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain in feet
Quetiapine Fumarate 25 mg PO HS:PRN agitation, insomnia
Senna 1 TAB PO BID:PRN constipation
Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
Discharge Medications:
1. Nafcillin 2 g IV Q4H
2. Heparin 5000 UNIT SC TID
3. Gabapentin 600 mg PO TID
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
5. Senna 1 TAB PO BID:PRN Constipation
hold for loose stools
6. Acetaminophen 650 mg PO Q4H pain
do not exceed 4g in one day
7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain in feet
hold for sedation, rr < 10
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
9. Amitriptyline 25 mg PO HS
10. Aspirin EC 81 mg PO DAILY
11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
12. Lorazepam 0.25 mg PO Q4H:PRN anxiety
13. Povidone Iodine 1/2 Strength 1 Appl TP ASDIR
hands and feet twice daily
14. Ranitidine 150 mg PO BID
15. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
hold for sedation and/or RR < 10
16. Metoprolol Tartrate 12.5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] in [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnoses:
Mitral valve endocarditis S/p MVR with return to operating room
for post-operative bleeding,
PMH:
Pseudomonas pneumonia, Mitral valve endocarditis-MSSA, cervical
osteomyelitis, necrotic finger tips and feet, hepatitis C,
endocarditis, IVDU, [**Last Name (un) **], hand foot necrosis, fungal peritonitis,
right iliac septic thrombus, , cirrhosis, asthma, emphysema, vit
D deficiency, chronic headaches,
PSH: tracheostomy, PEG
Discharge Condition:
Alert and oriented x3 nonfocal, anxious at times
[**Doctor Last Name 2598**] lift to chair
Incisional pain managed with oxycodone and oxycontin
Incisions:
Sternal - healing well, no erythema or drainage
Legs with dry black necrotic feet. Edema of both lower
extremities: 2+
UE with nectrotic fingers bilaterally
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
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**
Infectious disease Instructions:
OPAT Antimicrobial Regimen and Projected Duration:
[**Doctor Last Name **] & Dose: Nafcillin 2g IV Q4H
Start Date: [**2168-6-17**]
Stop Date: [**2168-9-9**]
CBC with differential (weekly)
Chem 7, BUN/Cr, AST/ALT/Alk Phos/Total bili, CPK, ESR/CRP
-weekly
All laboratory results should be faxed to the Infectious Disease
R.N.s at ([**Telephone/Fax (1) 4591**]. All questions regarding outpatient
parenteral antibiotics should be directed to the Infectious
Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the on-call ID fellow when
the clinic is closed
Infectious Disease Fellow: [**Doctor First Name **] [**Doctor Last Name **]
(First contact for patient-related matters, if unavailable
please
contact the ID fellow on-call [**Numeric Identifier 112328**])
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2168-9-8**] at 1:30p
in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Cardiologist: Needs referral
Infectious disease Clinic on [**2168-9-6**] at 09:00am in the [**Hospital **]
medical office building, [**Doctor First Name **] Basement
Infectious Disease Fellow: [**Doctor First Name **] [**Doctor Last Name **]
(First contact for patient-related matters, if unavailable
please
contact the ID fellow on-call [**Numeric Identifier 112328**])
Vascular surgery: VASCULAR LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time: [**2168-9-28**] 10:15 [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
Please call to schedule appointments with your
Primary Care Dr.[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 112329**] [**Telephone/Fax (1) 11463**] in [**3-24**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2168-8-18**]
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1,184
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29482
|
Discharge summary
|
report
|
Admission Date: [**2113-10-29**] Discharge Date: [**2113-11-2**]
Date of Birth: [**2040-4-27**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamides) / Aspirin / Quinine
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
central line placement
mechanical ventilation
History of Present Illness:
Ms [**Known lastname **] is a 73F with an extensive PMH including ?lung
resection? for breast CA, CAD s/p 3x CABG, CHF, chronic
hypercarbic respiratory failure requiring recent BIPAP at home.
She had recently been discharged to [**Hospital 100**] Rehab from a
West-[**Location (un) 669**] VA CCU admission for ?CHF exacerbation and was
discharged on bipap which she received for a few days and then
stopped because she was doing so well. She also experienced some
worsening skin rash/pruritis/burning and had been requesting
pain medications which were given conservatively at first. Then
(according to the family) she was given 20mg po Morphine "plus
some other narcotics" and was soon noted to be non-responsive.
EMS was called who gave her narcan, to which she responded.
.
Upon arrival to the [**Hospital1 18**] ED she was noted again to be
non-responsive and apneic. She became hypotensive and went into
PEA arrest. CPR was performed approximately x 30 seconds as per
ED report and she received epi and atropine x1 along with
amiodarone for unclear reason with return of blood pressure. She
was subsuquently intubated and started on a levophed drip. She
received levofloxacin, metronidazole. A femoral arterial line
and femoral chordus was inserted.
.
On ROS as per family, she endorsed burning skin as above, rash,
8lb wt gain in past week, denies SOB, dysuria, fevers, or other
concerns.
.
Past Medical History:
CAD s/p CABG [**4-/2104**], c/b atrial fibrillation and right phrenic
nerve injury
Hyperlipidemia
Hypertension, left ventricular hypertrophy
Stroke: [**5-7**] Left CEREBELLAR STROKE with hemorrhagic conversion
(on coumadin). MRA [**6-6**]: stenosis of middle cerebral, post
cerebral +basilar arteries, no carotid stenoses.
7/97 L PCA (vert art)STROKE [**6-/2104**]
Pulmonary hypertension
History of carcinoid, lung with RUL lobectomy, c/b ARDS
Right heart failure
Breast cancer, Left-sided, s/p lumpectomy, XRT -[**2100**]
Restrictive lung disease, on 2L O2 at home QHS, PRN
Type 2 Diabetes, on insulin since [**2104**], +proteinuria,
+retinopathy
Legal blindness
Obesity
Obstructive Sleep Apnea ? on BiPAP?
Hypothyroidism on levothyroxine
Psoriasis on calcipotriene and triamcinolone (unable to tolerate
other therapy Secondary to multiple medical problems)
RML pulmonary nodule, last 1 cm on [**10/2104**] CT chest
- no further f/u as pt not candidate for surgery/xrt with mult
pulm insults
- scarring L lobe s/p xrt
History of pneumonias. [**10/2110**] LLL retrocardiac, [**8-/2107**] RLL.
Osteoarthritis
GERD
History of UGIB in past
History of abdominal pain, attributed to gall bladder sludge/CBD
stone
- Admitted [**11/2112**] with RUQ pain radiating to back
S/p cholecystectomy
MRSA cultured from central line tip [**7-/2104**]
Social History:
Lives in [**Hospital 100**] Rehab. Has a very large devoted family who are
present during the interview
Family History:
n/c
Physical Exam:
on AC at 350x28, 60%, PEEP 5
Vitals: T 96.8 HR 64 BP 153/61 on levophed RR 23 100% Gen:
HEENT: Intubated/sedated, MM moist
Neck: very thick neck; unable to access JVP
CV: RRR no murmurs appreciated over vent
Pulm: ronchi/coarse BS anteriorly; difficult to assess
Abd: obese, non-tender, + BS
Skin: diffuse psoriatic plaques; erythema with multiple areas on
trunk with superimposed pustules, Rt nipple with
breakdown/cracking.
Ext: extensive verrucus changes and pachyderma, no edema
appreciated
.
Pertinent Results:
[**2113-10-29**] 10:06PM TYPE-ART PO2-370* PCO2-56* PH-7.19* TOTAL
CO2-22 BASE XS--7
[**2113-10-29**] 10:06PM LACTATE-2.9*
[**2113-10-29**] 09:15PM TYPE-[**Last Name (un) **] PO2-132* PCO2-69* PH-7.20* TOTAL
CO2-28 BASE XS--2
[**2113-10-29**] 09:15PM GLUCOSE-140* LACTATE-1.8 NA+-137 K+-5.6*
CL--101
[**2113-10-29**] 09:15PM HGB-11.5* calcHCT-35 O2 SAT-96 CARBOXYHB-3
MET HGB-0
[**2113-10-29**] 09:15PM freeCa-1.18
[**2113-10-29**] 09:00PM ALT(SGPT)-15 AST(SGOT)-17 CK(CPK)-59 ALK
PHOS-84 AMYLASE-22 TOT BILI-0.4
[**2113-10-29**] 09:00PM LIPASE-13
[**2113-10-29**] 09:00PM CK-MB-NotDone cTropnT-0.06*
[**2113-10-29**] 09:00PM ALBUMIN-2.9* CALCIUM-9.2 PHOSPHATE-5.1*
MAGNESIUM-2.0
[**2113-10-29**] 09:00PM ACETONE-NEG
[**2113-10-29**] 09:00PM WBC-16.6* RBC-3.76* HGB-10.9* HCT-33.9*
MCV-90 MCH-29.0 MCHC-32.2 RDW-16.5*
[**2113-10-29**] 09:00PM NEUTS-90.3* BANDS-0 LYMPHS-6.1* MONOS-3.0
EOS-0.6 BASOS-0.2
[**2113-10-29**] 09:00PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+
TEARDROP-OCCASIONAL
[**2113-10-29**] 09:00PM PLT SMR-NORMAL PLT COUNT-415
[**2113-10-29**] 09:00PM PT-14.7* PTT-28.3 INR(PT)-1.3*
.
Blood Cx + for [**12-5**] enterococcus
.
CXR:
Low lung volumes. Hazy opacity of the left lung field may
represent a layering effusion. Additionally, there may be
several patchy
opacities in the left upper and lower lung, and possibly in the
right
perihilar region.
Brief Hospital Course:
73 year old female with residual LLL PNA admitted with
unresponsiveness followed by PEA arrest, hypotension, and
respiratory failure intubation.
.
# PEA arrest: clinical history suggests apnea likely causing
hypoxia/hypercarbia and likely resultant PEA arrest.
.
# Respiratory failure: Pt with likely underlying hypercarbic
respiratory failure as per daughter's history. Ms
[**Last Name (un) 70759**] was attempted to ventilate at low tidal volumes
given her history of lung rescection. She was treated for
pneumonia broadly with vancomycin, levofloxacin, and
metronidazole. She eventually became further volume overloaded
as her renal failure progressed and more difficult to ventilate.
.
# shock: Etiology likely [**1-5**] sepsis from unknown source. Ms
[**Name13 (STitle) 70760**] was treated with broad spectrum antibiotics (Vancomycin,
levofloxacin, flagyl) to treat a presumed pulmonary source. Ms
[**Known lastname **] was maintined on vasopressors, initially with levophed.
As her hospital course progressed she became progressively
hypotensive despite IVF bolus. She she was started and
phenylephrine in addition but developed a severe lactic acidosis
and abdominal distension which was hypothesized to be secondary
to gut ischaemia and her pressors were changeed to dopamine and
vasopressin with high requirements.
.
# acute renal failure: Ms [**Known lastname **] was admitted with an elevated
Cr of 2.6 above her baseline of Cr 1.8, now 2.6. It was
considered likely to be [**1-5**] ATN + prerenal state. Her renal
failure worsened during her admission despite agressive fluid
recussitation and eventually became anuric and progressively
acidotic with a lactic acidosis. Discussions with nephrologists
and the families were held and it was decided that the family
did not want to pursue dialysis given her very poor overall poor
prognosis.
.
# Skin: Due to Ms [**Known lastname 70761**] severe skin changes,
dermatology was consulted who felt that her condition was likely
either Acute generalized erythematous pustulosis or severe
pustular psoriasis; they did not feel that it was superinfected.
She was treated with steroid creams but her condition worsened
with desquamation of her skin which likely contributed to her
electrolyte abnormalities and acidosis.
.
# Due to Ms [**Known lastname 70762**] severe illness which worsened despite
aggressive critical care, a meeting was held with the family and
the decsiion was to make the patient DNR and to not escalate
care (meaning not to initiate dialysis). She was maintaned on
vasopressors and antibiotics with ventilator support. Her
condition worsened over 24 hours and she became progressively
hypotensive, acidotic, and died of cardiac arrest. The family
was at her side and a priest was called. The family declined a
post-mortem examination.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac arrest (pulseless electrical activity)
septic shock
lactic acidosis
acute renal failure
acute generalized erythematous pustulosis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
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"276.2",
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"486",
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"410.71",
"995.92",
"250.00",
"785.51",
"518.81",
"276.7",
"584.9",
"428.0",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"99.60",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8193, 8202
|
5316, 8141
|
333, 380
|
8383, 8392
|
3838, 5293
|
8445, 8581
|
3301, 3306
|
8164, 8170
|
8223, 8362
|
8416, 8422
|
3321, 3819
|
273, 295
|
408, 1806
|
1828, 3164
|
3180, 3285
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,997
| 153,121
|
52426
|
Discharge summary
|
report
|
Admission Date: [**2116-12-2**] Discharge Date: [**2116-12-5**]
Date of Birth: [**2055-1-2**] Sex: M
Service: TRA
ADMISSION DIAGNOSES:
1. Status post motor vehicle collision.
2. Right frontal intraparenchymal hemorrhage.
3. Right frontal subdural hematoma.
4. HIV.
5. Hypertension.
6. Chronic renal insufficiency.
DISCHARGE DIAGNOSES:
1. status post motor vehicle collision.
2. Subarachnoid hemorrhage.
HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is a 62-year-old
gentleman who was involved in a motor vehicle collision where
he lost consciousness. He did not recall the events prior to
the accident or shortly thereafter.
HOSPITAL COURSE: Upon arrival to the emergency department
via emergency medical services, he had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale
of 15. He, otherwise, was hemodynamically normal and had no
other external evidence of injury. Given the mechanism of his
accident, the patient underwent CT of the head, C spine and
torso. The CT scans of the C spine and torso were normal.
But, the CT scan of the head demonstrated a 10 mm right
inferior frontal intraparenchymal hemorrhage as well as a
small right frontal subdural hematoma. The neurosurgical
service was consulted and the patient was admitted to the
trauma surgical service for further management. In terms of
his neurologic issues, the patient was started on Dilantin as
a seizure prophylaxis. He underwent serial CT scanning of the
head which actually demonstrated small increase in the amount
of subdural hematoma on hospital day 2. This was followed
clinically. The patient did not demonstrate any deterioration
in neurologic function. Subsequent CT scans remained stable.
Therefore, on conjunction with the neurosurgical services, it
was decided that the patient was stable without evidence of
further bleeding. He demonstrated no neurologic deficits.
There was the question as to whether this may have been a
primary cardiac event leading up to the accident, given that
there were small ST segment depressions in the lateral leads
on his admission EKG. His cardiac enzymes were mildly
elevated in terms of troponin but this was difficult to
interpret given his chronic renal insufficiency. Cardiology
service was consulted and felt that this was not secondary to
myocardial ischemia although they did recommend that the
patient undergo an echocardiogram. The echocardiogram
demonstrated mild symmetrica left ventricular hypertrophy and
otherwise an ejection fraction of 50-55% was seen. There was
1+ mitral regurgitation. There was also mild pulmonary
hypertension. Otherwise, no significant abnormalities. The
cardiology service recommended that the patient started
aspirin and change from diltiazem over to a beta blocker as
well as start lisinopril. The cardiology service
recommendations were followed. Otherwise, the patient was
maintained on his pre-accident antiretroviral medications for
treatment of his HIV. As the patient was doing well by
[**12-6**], ambulating with no significant pain, no
neurological deficits and tolerating a regular diet well, it
was felt that he was safe for discharge. He was, therefore,
discharged to home and to follow with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of
cardiology in one week. The patient would need an outpatient
stress test prior to that visit. In addition, he was to
follow up with [**First Name8 (NamePattern2) **] [**Doctor Last Name **] of neurosurgery.
DISCHARGE MEDICATIONS:
1. Phenantoin 100 mg p.o. t.i.d. for 7 days to complete a
10 day course as per neurosurgical recommendation. 2.
Lopressor 25 mg p.o. b.i.d.
2. He was to continue his antiretrovirals which included
Efavirenz 600 mg once daily, Combivir b.i.d.
3. The patient's diltiazem was discontinued.
[**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2116-12-8**] 16:10:09
T: [**2116-12-8**] 16:35:37
Job#: [**Job Number 108338**]
|
[
"E849.5",
"851.86",
"414.01",
"585.9",
"272.0",
"042",
"403.90",
"E813.0",
"790.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
357, 426
|
3544, 4143
|
695, 3521
|
156, 336
|
455, 677
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,850
| 182,885
|
4316
|
Discharge summary
|
report
|
Admission Date: [**2165-12-24**] Discharge Date: [**2165-12-25**]
Date of Birth: [**2093-8-21**] Sex: M
Service: MEDICINE
Allergies:
Zocor / Ciprofloxacin / Quinolones / Statins-Hmg-Coa Reductase
Inhibitors / Niacin
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with no stents on [**2165-12-24**]
History of Present Illness:
The patient is a 72 y/o M with PMHx significant for CAD s/p MI
and CABG, DM, HTN, PVD, prostate CA, and pancytopenia currently
being worked up, who was initially admitted to OSH on [**12-23**] with
unstable angina. Ruled out for MI with negative troponins, echo
showed inferolateral akinesis. Was transferred to [**Hospital1 18**] for
catheterization, which showed proximal LCx angulated high grade
lesion and distal OM branch tight lesion:
LMCA - non-obstructed
LAD - 80% mid-vessel ISR in the distal aspect of the stent
LCx - 90% ostial stenosis and there is a 90% stenosis in the
upper pole of the OMB
PCA - known occluded, not engaged
SVG-OM - known occluded, not engaged
RIMA-RCA - subselectively negaged and non-obstructed
In the cath lab, the OM lesion was wired and then ballooned open
using 2.0mm balloon to 4 ATM. The ostial LCx lesion was then
ballooned using a 2.5mm balloon. After, there was concern for
dissection vs. perforation in the area of PTCA in OM. Of note,
patient did not receive Plavix [**2-27**] pancytopenia. Given concern
for potential dissection vs. perforation, the patient did not
receive heparin, and angiomax was stopped. Echo performed in
cath lab showed no pericardial effusion. The patient was free of
chest pain throughout the entire procedure. Plan is for
overnight monitoring in the CCU with plan to return to cath lab
in [**1-27**] days for PCI to ostial LCX +/- PCI to prox LAD (and
relook at OM).
On arrival to the ICU, the patient's VS were T=96.5 BP=142/75
HR=65 RR=11 O2 sat=96%2LNC. He endorsed approx 1 month of
worsening exertional chest pressure that radiated into the neck.
Denied any associated lightheadedness, dizziness, palpitations,
nausea, diaphoresis. States that these symptoms were consistent
with prior anginal symptoms. He also endorsed recent hematuria
and polyuria.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: [**2149**] (RIMA- RCA, SVG- OM)
- PERCUTANEOUS CORONARY INTERVENTIONS:
--> [**2154**] Stenting of PLV branch distal to RIMA touchdown
--> [**2155**] Stenting of the prox/mid LAD w/ rescue of a jailed D1
branch
--> [**2160**] Stenting of distal RCA after the anastamosis of a RIMA
graft
--> [**2163**] Stenting of origin LCX
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
PAD
Prostate ca s/p radiation
Pancytopenia, bone marrow bx pending
Dyslipidemia - unable to tolerate statins, not on any medicine
at
present
GI bleed [**3-6**] r/t Plavix
Kidney stones
B knee replacement
Rotator cuff repair
Fusion of lumbar discs
Social History:
Lives at home with wife. Denies ETOH or illicit drug use. Former
smoker, smoked 1 ppd x 25 years. Disabled since back surgery.
Used to work as a carpenter.
Family History:
Father passed away from CAD at age 49, uncle with CAD age 50.
Mother with CVA in her 80's. No other cardiac history. No
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
Admission exam:
VS: T=96.5 BP=142/75 HR=65 RR=11 O2 sat=96%2LNC
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, with no JVD noted.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+
Left: DP 2+
Discharge exam: Unchanged, except for as below
Extremities: minimal bruising at right radial artery access
site, no hematoma or bleeding
Pertinent Results:
Labs:
[**2165-12-25**] 03:36AM BLOOD WBC-2.6* RBC-3.66*# Hgb-12.2*# Hct-35.1*
MCV-96 MCH-33.2* MCHC-34.7 RDW-14.3 Plt Ct-80*
[**2165-12-25**] 03:36AM BLOOD Glucose-149* UreaN-14 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
[**2165-12-24**] 10:45PM BLOOD CK-MB-2
[**2165-12-25**] 03:36AM BLOOD CK-MB-3
[**2165-12-25**] 03:36AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0
Procedures:
-Cardiac cath ([**2165-12-24**]) -
COMMENTS:
1) Selective coronary angiography of this right-dominant system
demonstrated native three-vessel coronary artery disease, with
progressive coronary disease in two native vessels. The LMCA
had no
angiographically-apparent coronary disease. The LAD had an 80%
mid-vessel in-stent restenosis in the distal aspect of the
stent. The
LCx had 90% ostial stenosis; there was also a 90% stenosis in
the upper
pole of the OM branch. The RCA is known to be occluded and was
not
engaged.
2) The RIMA-->RCA was subselectively engaged and had no
angiographically-apparent coronary artery disease. The SVG-->OM
was not
known to be occluded and was not engaged.
3) PTCA of OM1 branch and ostial LCX, complicated by dissection
at
position of balloon dilatation in the OM. This initially
appeared
suspicious for perforation, but echocardiogram showed no
evidence of
pericardial effusion, and patient remained hemodynamically
stable.
Procedure was terminated.
4) Limited resting hemodynamics revealed moderate systemic
arterial
hypertension, with a central aortic pressure of 154/76 mmHg.
5) A hemoband was applied to the right radial artery puncture
site, with
good hemostasis.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease.
2. PTCA of the lower pole of the OM branch, complicated by a
deep vessel
dye stain versus perforation. No blood was noted in the
pericardium on
bedside echocardiogram. The patient remained hemodynamically
stable
throughout.
3. Procedure terminated with a view to likely further procedure
to
relook at OM branch and possible PCI of ostial LCX or mid LAD
ISR.
4. Moderate systemic arterial hypertension.
-TTE ([**2165-12-25**]) - The left atrium is moderately dilated. The
right atrium is moderately dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The 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 structurally normal. There is no
mitral valve prolapse. Mild to moderate ([**1-27**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No pericardial effusion. Mild-to-moderate mitral
regurgitation. Ascending aorta dilation.
Brief Hospital Course:
72 y/o M with PMHx significant for CAD, DM, HTN, PVD, prostate
CA, and pancytopenia, who was admitted to OSH with unstable
angina and then transferred to [**Hospital1 18**] for cardiac cath. Now, s/p
PTCA of OM and ostial LCx lesions, complicated by concern for
coronary dissection vs. performation, admitted to the CCU for
monitoring.
ACTIVE ISSUES:
#CAD/PUMP - Pt was transferred from an OSH for cardiac cath
because of chest pain with a positive stress test, CK-MB at
[**Hospital1 18**] were noted to be negative. The cardiac cath showed native
triple vessel disease with stenoses in the LAD and LCx. During
PTCA of the OM1 artery, there was concern for dissection vs
perforation and the cath was terminated early. No stents were
placed. Immediate bedside echo did not show evidence of a
pericardial effusion. Formal transthoracic echo the next day
also did not show evidence of pericardial effusion. He will
follow-up with Dr. [**Last Name (STitle) **] after discharge and will likely have a
repeat cath with PCI of the above described lesions in
approximately 4 weeks. Aspirin was increased to 325mg daily.
He is not taking Plavix because of pancytopenia.
#RHYTHM - His home metoprolol was decreased from 50mg to 25mg
daily because of bradycardia to the 50s.
#Diabetes - On metformin at home, which was held during this
admission in the setting of cardiac cath. He was covered with
an insulin sliding scale and blood sugar remained reasonably
well controlled. At discharge, he will resume his home
metformin.
#HTN - Continued imdur at home dose. Metprolol was decreased as
above, amlodipine increased to 10mg for increased antianginal
benefits.
INACTIVE ISSUES:
#Pancytopenia - Plavix and heparin were held given low patelets.
He continue to be evaluated as anoutpatient for this. Hct
remained stable during admission.
#Prostate CA - In remission per pt report.
#H/o kidney stones - Continued home allopurinol
#Dyslipidemia - By report, he is unable to tolerate statins in
the past, none were started this admission.
#Constipation - Continued home Amitiza, also ordered for
senna/colace.
#Transitional issues
-Metoprolol was decreased from 50mg to 25mg daily, will need
this reevaluated as an outpatient
-Amlodipine increased to 10mg this admission, will need BP
followed-up as an outpatient
-Will likely need repeat cath for PCI as no stents were placed
during cath this admission
-Should continue to have pancytopenia followed-up as an
outpatient
Medications on Admission:
Aspirin 81 mg dialy
Metformin 500 mg qHS
Metoprolol 50 mg daily
Imdur 60 mh qAM
Norvasc 5 mg qPM
Allopurinol 300 mg qAM
Vesicare 10 mg qPM
Amitiza 24 mcg daily
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. metformin 500 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO QAM (once a day
(in the morning)).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
6. allopurinol 300 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Vesicare 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. lubiprostone 24 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Unstable angina
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your admission to
[**Hospital1 18**] for chest pain and cardiac catheretization. You had a
positive stress test which showed some poor blood flow in part
of your heart. You had a cardiac cath on [**12-24**] which showed
disease in all 3 of your coronary arteries. During the
procedure, no stents were placed because of difficulty accessing
some of the arteries. You will have a repeat cath after
discharge. You will follow up with Dr. [**Last Name (STitle) **] after discharge.
The following changes were made to your medications:
CHANGE metoprolol succinate to 25mg daily
CHANGE aspirin to 325mg daily
CHANGE amlodipine to 10mg daily
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 275**] C.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Street Address(2) 9646**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 3183**]
When: Friday, [**1-3**], 2:45 PM
|
[
"V10.46",
"412",
"250.00",
"E878.1",
"996.72",
"414.12",
"284.19",
"V15.82",
"414.01",
"414.02",
"401.9",
"V45.82",
"411.1",
"272.4",
"E849.7",
"564.00",
"V43.65",
"443.9",
"997.1",
"E879.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"37.22",
"00.66",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11157, 11163
|
7719, 8056
|
356, 417
|
11266, 11266
|
4748, 6335
|
12159, 12420
|
3732, 3908
|
10408, 11134
|
11184, 11245
|
10224, 10385
|
6352, 7696
|
11417, 12136
|
3923, 4591
|
2913, 3264
|
4607, 4729
|
306, 318
|
8072, 9385
|
445, 2805
|
9403, 10198
|
11281, 11393
|
3295, 3543
|
2827, 2893
|
3559, 3716
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,146
| 114,303
|
15587
|
Discharge summary
|
report
|
Admission Date: [**2147-11-23**] Discharge Date: [**2147-12-24**]
Date of Birth: [**2147-11-23**] Sex: M
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname **], twin #1, delivered at 30-4/7
weeks, with a birth weight of 1375 grams, was admitted to the
Intensive Care Nursery for management of prematurity.
estimated date of delivery of [**2148-1-27**]. Prenatal screens
included blood type A positive, antibody screen negative,
hepatitis B surface antigen negative, rubella immune, RPR
nonreactive and Group B Streptococcus unknown. The pregnancy
was remarkable for in [**Last Name (un) 5153**] fertilization with
dichorionic-diamniotic twin gestation. In addition to the
twin gestation, the pregnancy was complicated by gestational
at 28 weeks treated with magnesium sulfate. The mother
received a course of betamethasone prior to delivery. On day
of delivery, there was spontaneous rupture of membranes
prompting delivery by cesarean section with spinal
anesthesia.
[**Known lastname **] emerged with spontaneous cry, was dried, bulb suctioned
and received free-flow O2 in the delivery room. Apgar scores
were 7 and 8 at one and five minutes respectively.
PHYSICAL EXAMINATION: On admission, weight 1375 grams (50
to 75th percentile), length 40.5 centimeters (50th
percentile), head circumference 26 centimeters (10 to 25th
percentile). In general, pink bruised non-dysmorphic infant.
Skin with multiple bruises, petechiae on mid-sternum. Head
and Neck: Anterior fontanel open, flat, soft. Eyes with
positive red reflex bilaterally. Ears, Nose and Throat: No
cleft. Clavicles intact. Thorax symmetric. Lungs clear and
equal. Heart: Normal S1, S2, no murmur. Femoral pulses
present. Abdomen with three vessel cord. No
hepatosplenomegaly, no masses. Genitalia: Normal preterm
male. Testes descended bilaterally. Anus patent. Spine
straight and intact. Extremities stable. Hips stable.
Reflexes decreased tone.
HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: No respiratory distress. Has been in room
air since admission with comfortable work of breathing.
Respiratory rate 40s to 50s.
Had apnea of prematurity with several mild episodes per day
with the last episode on [**2147-12-16**]. Did not require
Xanthine therapy.
2. CARDIOVASCULAR: Received a normal saline bolus on
admission for a low mean blood pressure; has been
hemodynamically stable throughout hospitalization. Has an
intermittent soft murmur heard occasionally. Recent blood
pressure 68/34 with a mean of 44.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Initially maintained
on D10W. Enteral feeds were started on day of life one and
advanced to full volume feeds on day of life seven without
problems. The caloric density was gradually increased to 30
calories per ounce plus ProMod with good growth. Is
beginning to bottle or breast feed. Most recent nutrition
labs were on [**12-20**] which showed a sodium of 138, potassium of
4.3, carbon dioxide of 28, alkaline phosphatase 274, albumin
3.8, calcium 10.1 and phosphorus 6.5. Discharge
weight 2165g, oFC 28cm, length 47cm..
4. GASTROINTESTINAL: Received phototherapy for indirect
hyperbilirubinemia. Peak bilirubin total 7.8, direct 0.3.
5. HEMATOLOGY: Most recent hematocrit was on [**2147-12-1**],
and was 36.9%; did not require any blood transfusion during
this admission. Is receiving supplemental iron around 2 mg
per kg per day of elemental iron.
6 INFECTIOUS DISEASE: Following birth, received Ampicillin
and gentamicin for 48 hours for a rule out sepsis. The CBC
was benign and blood culture was negative. On [**12-3**], started
treatment for Staphylococcus epidermidis sepsis, initially
with Vancomycin and gentamycin for two days, then completed
the seven day course with Vancomycin. Received a seven day
course of erythromycin Ophthalmic Ointment for conjunctivitis
of the right eye starting on [**2147-12-6**].
7. NEUROLOGY: A head ultrasound on day of life seven was
normal. One month ultrasound showed choroid plexus cyst and
small germinal matrix hemorrhage. Repeat ultrasound is
recommended in [**8-23**] days to document stability of the hemorrhage.
8. SENSORY: Hearing screening was performed by Audiology
with automated auditory brain stem responses and passed both
ears.
9. OPHTHALMOLOGY: Eyes were examined most recently on
[**2147-12-20**], revealing mature retinal vessels. A follow-up exam
is recommended at eight months of age.
10. PSYCHOSOCIAL: The parents have visited often and are
looking forward to transfer to [**Hospital3 1280**].
CONDITION ON DISCHARGE: Stable growing preterm infant now a
month old.
DISCHARGE DISPOSITION: Transfer to [**Hospital6 3874**]. Name of primary pediatrician, Dr. [**Last Name (STitle) 45074**] and
[**Location (un) 12670**].
CARE RECOMMENDATIONS:
1. Feeds: Breast milk fortified with four calories per
ounce of human milk fortifier, four calories per ounce of MCT
Oil and two calories per ounce of Polycose and [**2-15**] teaspoon
of ProMod added to 90 cc. of formula or 100 cc. of breast
milk to equal 30 calories per ounce, plus ProMod; thus taking
150 cc. per kilo per day divided every four hours.
2. Medications: Fer-In-[**Male First Name (un) **] 0.15 cc. once a day; Vitamin E 5
International Units once a day.
3. Car seat positioning screening has not been done;
recommend prior to discharge.
4. State newborn screening status: State newborn screen was
sent on [**12-1**] and [**12-7**] and both were within normal limits.
5. Immunizations received: Has not received any
immunizations.
6. Immunizations recommended:
Synagis RSV Prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants that meet any of the three
criteria: 1) Born at less than 32 weeks; 2) born between 32
and 35 weeks with plans for day care during RSV season, with
a smoker in the household, or with preschool siblings or 3)
with chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
7. Follow-up appointments schedule recommended:
1) Repeat cranial ultrasound recommended in [**8-23**].
2) Ophthalmology examination recommended at eight months.
3) Early intervention referral recommended at discharge.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age 30-4/7 weeks preterm
male.
2. Twin #1.
3. Apnea of prematurity.
4. Rule out sepsis.
5. Staphylococcus epidermidis sepsis, resolved.
6. Conjunctivitis resolved.
7. Indirect hyperbilirubinemia, resolved.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 36138**]
MEDQUIST36
D: [**2147-12-22**] 16:32
T: [**2147-12-22**] 16:56
JOB#: [**Job Number 45075**]
|
[
"765.15",
"771.81",
"779.81",
"V31.01",
"771.6",
"V29.0",
"774.2",
"038.10",
"770.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.83"
] |
icd9pcs
|
[
[
[]
]
] |
4690, 4822
|
6509, 7024
|
4844, 5609
|
2011, 4592
|
1232, 1984
|
5637, 6488
|
4618, 4666
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,672
| 197,673
|
17674
|
Discharge summary
|
report
|
Admission Date: [**2140-9-7**] Discharge Date: [**2140-9-14**]
Date of Birth: [**2078-11-12**] Sex: M
Service: MEDICINE
Allergies:
Latex / Penicillins / Cephalosporins / Vancomycin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
palpitations while at HD
Major Surgical or Invasive Procedure:
Bronchoscopy on [**2140-9-13**] with tissue biopsy.
History of Present Illness:
61M ESRD also Renal CA, s/p failed transplant, recently
diagnosed NSCLC, paroxysmal afib, presented to ED after
experiencing palpitations and lightheadedness at HD center. He
describes feeling a "racing, pounding" sensation in his chest
while at dialysis, which he has not felt before. He does,
however, report approximately 2 weeks of "rough" pain in the
center of his chest while wearing nicotine patch; since
discontinuing nicotine patches, this seems to have resolved. The
palpitations were associated with lightheadedness after
dialysis, which resolved by the time he presented to the ED.
There was no diaphoresis, nausea, or vomiting.
.
Of note, he was recently discharged from [**Hospital 1281**] Hospital/[**Hospital 12914**] Med Ctr where he was treated for PNA with ceftriaxone and
a pleural effusion was drained.
.
In ED, got 30 dilt IV then 30 dilt po, rate stayed in 140s, 30
min later, pt converted to SR. Also started CTX/azithro because
? PNA on CXR. Admitted to ICU SBP 80s-90s after 3 liters IVF.
In MICU pt found be c.diff +, started on flagyl.
.
Past Medical History:
-Deafness since childhood. Secondary to antibiotics. Patient
knows ASL and lip reads.
-Small Cell Lung Cancer: After several months DOE, chest CT [**5-21**]
showed mass suspicious for malignancy, sputum positive for
NSCLC; followed by heme onc.
-ESRD requiring HD
-b/l Cadaveric renal transplant [**2-19**] - delayed graft fxn
-Atrophic R. kidney
-s/p L. nephrectomy [**3-18**] renal cell CA
-Schizophrenia?
-Anemia
-DM?
-Drug Abuse
Social History:
deaf but signs and reads lips, as above. lives with girlfriend.
+ smoking, but refuses to quantify; tried using nicotine patch
to quit but "gave up on them" approx two weeks ago. Denies
alcohol or illicit drug use. History in chart of marijuana use.
Family History:
No family history of kidney disease, no family history cancers
Per previous notes - mom w/ etoh abuse
Physical Exam:
On Admission:
96.6 108 (100-110) 90% 4L 115/63
GEN: alert, sitting up in bed,
HEENT: PERRL, EOMI, MM dry, OP clear
NECK: bulky supraclavicular LAD, + engorged superficial veins on
chest wall, tender TTP on L side.
CHEST: rhonchi diffusely with scattered wheezes
CV: s1, s2, no m/r/g
ABD: + BS, SND, voluntary guarding, no rebound,
EXT: LUE AV fistula, palpable thrill, + bruit
SKIN: no rashes
Pertinent Results:
[**2140-9-8**] 03:58AM BLOOD WBC-17.3*# RBC-2.89* Hgb-9.1* Hct-29.1*
MCV-101* MCH-31.5 MCHC-31.4 RDW-15.4 Plt Ct-342
[**2140-9-8**] 03:58AM BLOOD Neuts-91.2* Lymphs-2.0* Monos-4.9 Eos-0
Baso-0 Atyps-2.0*
[**2140-9-8**] 03:58AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2140-9-8**] 03:58AM BLOOD Plt Ct-342
[**2140-9-8**] 03:58AM BLOOD Glucose-96 UreaN-39* Creat-2.9* Na-136
K-4.0 Cl-99 HCO3-29 AnGap-12
[**2140-9-8**] 03:58AM BLOOD ALT-11 AST-14 LD(LDH)-676* CK(CPK)-31*
AlkPhos-70 TotBili-0.3
[**2140-9-8**] 03:58AM BLOOD HCG-<5
[**2140-9-8**] 03:58AM BLOOD Albumin-2.5* Calcium-8.0* Phos-4.2 Mg-1.8
[**2140-9-7**] 08:21PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2140-9-8**] 03:58AM BLOOD CK-MB-NotDone cTropnT-0.06*
.
[**9-9**] Sputum culture, Pending
.
[**9-8**] CT chest with contrast:
IMPRESSION:
1. Interval progression of bulky supraclavicular, mediastinal,
and hilar lymphadenopathy with progression of mass-like
consolidation of the right lower lobe. It is unclear to what
extent the progression of consolidation in the right lower lobe
represents progression of tumor versus superimposed pneumonia.
2. Consolidation in the right middle and upper lobes presumably
represents an infectious pneumonia.
3. Interval decrease in size of spiculated left upper lobe
nodule with interval development of a new spiculated right
middle lobe nodule and enlargement of right upper lobe nodule.
4. Bilateral pleural effusions, right greater than left.
5. Chronic supra-azygous SVC occlusion.
Brief Hospital Course:
61 deaf M with ESRD, recently diagnosed lung CA, discharged from
OSH two days prior to admission after treatment for PNA with
parapneumonic effusion, presented with afib/rvr c/b hypotension
after hemodialysis. Pt admitted in afib with RVR, converted in
ED with Dilt. Metoprolol ineffective. Pt received fluids and
started on diltiazem 30mg po QID with resolution of atrial
fibrillation and hypotension, but with residual tachycardia.
Called out from MICU on [**9-9**]. Transferred to the floor rather
than d/c home as pt had continued 02 requirement, and plan for
palliative care c/s and metastatic w/u in house. Bronchoscopy
performed on [**2140-9-13**] with biopsies obtained. Sputum cytology
positive for malignant cells. Patient also had gynecomastia, and
serum bHCG found to be negative. Follow-up appointments
scheduled with outpatient thoracic oncologist on [**2140-9-20**].
While an in house, the patient developed loose diarrhea which
was positive for C. difficile. He was placed on a two week
course of flagyl to be completed on [**2140-9-25**]. GI prophylaxis was
switched to a po H2-blocker.
The patient was maintained on dialysis every other day, and
home renal regiment. Prednisone was continued for failed renal
transplant.
A plan for pain was arranged by palliative care. The patient
did not wish to be on morphine at this time, though suffers from
pain and difficulty breathing. He will continue on a regimen of
tylenol with ultram for pain, and will increase as needed in the
future.
Code status was discussed, and the patient has now declared
his status to be DNR/DNI. His primary health care proxy is his
sister, [**Name (NI) **], and he has named his girlfriend [**Name (NI) **] as the
second proxy in the event that [**Name (NI) **] is absent.
Medications on Admission:
protonix 40mg daily
aspirin 81mg daily
Bactrim DS 3x/week
Prednisone 5mg daily
"renal vitamins"
fioricet prn for headaches
lorazepam 2mg Q4-6h prn for anxiety
oxycodone 5mg prn pain
furosemide 40mg [**Hospital1 **]
iron
procrit 12,500 units weekly
PhosLo 667mg tid w/meals
CaCO3 [**Hospital1 **]-tid prn indigestion
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed.
3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
5. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 11 days.
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Ultram 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3
to 4 Hours) as needed for pain or dyspnea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Hypotension
Episode of atrial fibrillation
Lung cancer
Renal Failure
Discharge Condition:
Stable.
Discharge Instructions:
Disharge to extended care facility with continued hemodialysis
every other day. Continue physical therapy and regular diet.
Call your doctor or return to hospital for and sudden worsening
of pain, difficulty breathing, or any other health concerns. You
have an appointment with oncology at [**Hospital1 18**] on [**2140-9-20**] at 12:15pm.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2140-9-20**] 12:15
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2140-9-20**] 12:15
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2140-9-20**] 1:40
|
[
"389.8",
"008.45",
"162.5",
"276.52",
"427.31",
"585.5",
"530.81",
"V10.52",
"459.2",
"458.21",
"E879.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7846, 7925
|
4314, 6091
|
335, 389
|
8038, 8048
|
2758, 4291
|
8437, 8869
|
2226, 2329
|
6458, 7823
|
7946, 8017
|
6117, 6435
|
8072, 8414
|
2344, 2344
|
271, 297
|
417, 1485
|
2358, 2739
|
1507, 1943
|
1959, 2210
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,426
| 185,088
|
23800
|
Discharge summary
|
report
|
Admission Date: [**2140-5-29**] Discharge Date: [**2140-6-16**]
Date of Birth: [**2117-6-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
IVC filter placement
Central line placement/removal
PICC line placement
History of Present Illness:
Mr. [**Known lastname 60749**] is a 22 yr old male who was transferred from [**Hospital3 25354**] on [**5-29**] for further management of seizure,
altered mental status, and fever. Pt was in his usual state of
health until 3 1/2 weeks prior to admission when he developed a
viral syndrome including rhinorrhea, body aches, warmth, night
sweats which lasted for 2 weeks. This happened approx a week
after he returned from spring break in [**State **]. He was fine for
a week after the illness. On [**5-26**] he developed olfactory
hallunications and seized. Was taken to [**First Name8 (NamePattern2) 189**] [**Hospital1 **]. CT scan at
the time was reportedly negative, and he was given an outpatient
Neuro appt. On [**5-29**] he again had an episode of generalized
seizure and was taken back to the LGH where a CT head was neg
for any acute bleed. An LP was done that showed 679 WBC with
lymph predominance, TP of 51 and Glucose of 81. Was given a dose
of Ceftriaxone/vanc/Acyclovir and transferred to [**Hospital1 18**]. On [**5-29**]
he had a Tmax of 102 where he was started on Ceftriaxone/Vanc
for possible bacterial meningitis, Acyclovir for aseptic
meningitis, and Bactrim to cover for listeria. He was also
started on methylprednisone as CT showed edema and was admitted
to [**Hospital Unit Name 153**].
Past Medical History:
1.)Asthma
2.)H/O EBV infection
Social History:
Mr. [**Known lastname 60749**] lives with his girlfriend and her parents. He works
at a desk job for an insurance company. Occasional ETOH. No
tobacco. No drugs.
Family History:
--father HTN
--mother arthritis
--grandparents - MI, DM, CHF, lung CA, prostate CA all died at
age 70s
--brother had generalized seizure in [**2139-5-14**]
Physical Exam:
T=103, BP=130s/80s, P=103, RR=28, O2sat=99% RA
GEN: lying in bed, nad
HEENT: EOMI, PERRL, MMdry, no lymphadenopathy, abrasions on
nose/lip
CV: rrr, nl s1/s2, no m/r/g
PULMO: CTAB
ABD: soft, BS+, nt, nd, no masses
EXT: warm, 2+ DP/PT, no c/c/e
SKIN: abrasions on knuckles, no rashes
NEURO: 5/5 strength upper/lower equal bilaterally; 2+ reflexes
biceps/patellar equal bilaterally; sensation to pain and light
touch intact throughout; CN 2-12 intact; toes downgoing
MENTAL STATUS: aphasia (receptive and expressive), anomia,
apraxia. For example, Pt has halting speech without much
intonation and has difficulty producing spontaneous speech,
naming, and repeating. He also has episodes where he speaks in
jibberish and has difficulty finding words. When asked to write
"I love chocholate" he wrote "I tool like", and when asked to
write "My name is [**Name (NI) **]" he wrote "My name closet" He was unable
to subtract 7s from 100, first saying "7, 6, 5, . . ." then when
asked again, saying "100, 99, 98, 97" When asked to read my name
tag he would say some words that were on the tag then say words
that were not on the tag like "international" along with
gibberish. When attempting to ask him to remember 3 objects, he
was unable to repeat the objects immediately back. He would say
car, the first word, then go into a gibberish-laden story that
did not make sense.
Pertinent Results:
CBC:
[**2140-5-30**] 02:50AM BLOOD WBC-8.5 RBC-4.02* Hgb-12.9* Hct-35.7*
MCV-89 MCH-32.0 MCHC-36.0* RDW-12.2 Plt Ct-237
[**2140-6-5**] 06:30AM BLOOD WBC-5.7 RBC-3.55* Hgb-11.3* Hct-31.9*
MCV-90 MCH-31.9 MCHC-35.6* RDW-13.2 Plt Ct-232
[**2140-6-12**] 05:42AM BLOOD WBC-5.9 RBC-3.22* Hgb-10.3* Hct-29.1*
MCV-90 MCH-31.9 MCHC-35.3* RDW-12.4 Plt Ct-273
Chem Panels:
[**2140-5-30**] 02:50AM BLOOD Glucose-123* UreaN-9 Creat-0.8 Na-131*
K-3.8 Cl-95* HCO3-28 AnGap-12
[**2140-6-12**] 05:42AM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-135
K-4.2 Cl-99 HCO3-30* AnGap-10
Anemia:
[**2140-6-2**] 06:30AM BLOOD calTIBC-195* VitB12-364 Folate-9.7
Ferritn-261 TRF-150*
CSF:
[**2140-5-30**] 08:50PM CEREBROSPINAL FLUID (CSF) WBC-1500 RBC-225*
Polys-2 Lymphs-92 Monos-6
[**2140-5-30**] 08:50PM CEREBROSPINAL FLUID (CSF) TotProt-258*
Glucose-54
Micro:
CSF HSV PCR: Positive for HSV
CRYPTOCOCCAL ANTIGEN (Final [**2140-5-31**]): CRYPTOCOCCAL ANTIGEN NOT
DETECTED.
Rapid Respiratory Viral Antigen Test (Final [**2140-5-31**]):
Respiratory viral antigens not detected. CULTURE CONFIRMATION
PENDING. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3
INFLUENZA A,B AND RSV.
Imaging:
MRI: Findings are consistent with encephalitis and meningitis.
The pattern of temporal lobe involvement is characteristic for
herpes encephalitis, with increased signal intensity along the
cortical margin of the left and right insula, more on the left
than the right, and also along the cortical margin of the
anterior and medial left temporal lobes, likely reflecting an
ischemic component of these areas, and not simply T2
shine-through.
EEG: This is an abnormal portable EEG obtained in drowsiness due
to the presence of disorganized severe focal and continuous
delta
frequency slowing in the left central temporal region. This
finding
suggests subcortical dysfunction in this region and is
consistent with
a mild and diffuse encephalopathy. No lateralization or
epileptiform
abnormalities were seen.
CT head: Hyperdense material consistent with acute
intraparenchymal hemorrhage located in the left temporal and
right frontal lobes with surrounding edema that on retrospective
view of limited brain images from the CT scan of the sinuses
dated [**2140-6-1**] also present. There is an additional stable low
attenuation lesion in the region of the right sylvian fissure
that appears to correspond to a region of increased T2 signal on
the previous MRI. There is slight left to right shift with mild
compression of the left lateral ventricle. If clinically
indicated, further evaluation with an MRI/MRA of the brain with
gadolinium may be performed.
CTA: 1. Small pulmonary embolus within a subsegmental branch of
the right pulmonary artery supplying the right lower lobe. Mild
bilateral lung base air space consolidation, left greater than
right. No air bronchograms are identified. Small bilateral
pleural effusions, right greater than left.
2. Small amount of free fluid within the pelvis.
Brief Hospital Course:
22 y/o male with asthma presented with seizures following 3
weeks of URI symptoms. found to have HSV meningoencephalitis,
whose course was complicated by intermittent fever, headaches,
and a pulmonary embolism.
1.)Meningoencephalitis: When Mr. [**Known lastname 60749**] presented, his
constellation of symptoms and findings lead everyone to believe
this was HSV meningoencephalitis. He came from the outside
hospital with LP results consistent with an aseptic meningitis
(plus red cells, already making HSV more likely). Here, at
[**Hospital1 18**], he had a repeat LP, again with a lymphocytosis and red
cells. Multiple studies were sent off. An MRI was performed
showing findings consistent with this presumed diagnosis (see
results section). The patient was empirically started on IV
acyclovir and continued on the the ceftriaxone and vancomycin
that were started at the outside hospital until their culture
data came back negative, at which point he was transitioned to
acyclovir only. In terms of his neurologic status, his main
deficit was cognitive, most specifically word-finding, with a
receptive and expressive aphasia. Over the course of his
hospitalization, this slowly improved, though the expressive
deficit persisted, though to a lesser extent. The
meningoencephalitis course was complicated by seizures at
presentation and intermittent headaches, as described below. At
the time of discharge, his adenovirus titer was negative,
cryptococcal negative, RXV negative, adenovirus negative, VZV
negative, West [**Doctor First Name **] and EBV were pending. He will likely need
outpatient speech therapy. He will be followed by neurology and
ID as outpatient.
2.)Seizures: This was the presenting symptoms, preceded by
olfactory and gustatory hallucinations. An abnormal portable
EEG obtained in drowsiness due
to the presence of disorganized severe focal and continuous
delta frequency slowing in the left central temporal region.
This finding suggests subcortical dysfunction in this region and
is consistent with a mild and diffuse encephalopathy. No
lateralization or epileptiform abnormalities were seen. He was
initially started on phenytoin, that made him excessively
somnolent, and this was weaned off while oxcarbezapine was
started. The patient tolerated this medication well, and
remained seizure free throughout the rest of the
hospitalization. He occasionally experienced odd smells and
tastes; this was discussed with neurology, who felt that as long
as he remained alert and oriented, this did not represent a
seizure, but more likely an effect from the temporal lobe
irritation.
3.)Headache and intracerebral/intraventricular bleed: During the
hospital course, Mr. [**Known lastname 60749**] began developing severe frontal
headaches. A CT of the head was peformed, showing hyperdense
material consistent with acute intraparenchymal hemorrhage
located in the left temporal and right frontal lobes with
surrounding edema. This was felt to be mostly unchanged when
compared to a sinus CT from three days prior, yet these cuts
were felt to be inadequate to fully comment. For the bleed, an
MRA was performed that was limited to the arteries just off the
Circle of [**Location (un) 431**], but did not show any abnormalities. A
follow-up head CT was performed two days later with no
significant change. In discussions with ID and neurology, this
was felt to be consistent with the disease process and the plan
was to have this followed as an outpatient; no further imaging
was felt necessary as his neurologic exam did not change.
4.)Pulmonary embolism: Mr. [**Known lastname 60749**] began complaining of right
upper quadrant pain during the admission. LFT's were normal, as
was a RUQ ultrasound. He initially improved with the relief of
his constipation, but as the pain did not fully resolve a CT of
the thorax with CTA was performed, demonstrating a subsegmental
PE. As this demonstrated that he was at increased risk of
further clots, an IVC filter was placed by interventional
radiology, as he was felt to be too high of a bleeding risk,
given the aforementioned intracerebral bleed. At no point did
he experience any related hemodynamic compromise. To note, his
IVC filter needs to be removed in the future. This should be
arranged by his PCP.
5.)Blurred vision: Although this was probably from dehydration
and orthostatic changes, with his CNS infection, there was
concern for extension to optic nerve or retinal involvement,
although this seemed less likely. However, given his risk, we
asked ophthamology to evaluate the patient, who felt there was
nothing on exam to suggest any abnormality, but that he should
follow-up non-urgently in the [**Hospital 18620**] clinic. The symptom
resolved without recurrence.
6.)Fevers: For approximately five days, Mr. [**Known lastname 60749**] [**Last Name (Titles) 28316**] daily
and, occasionally, twice daily fevers, up to 102, with drenching
night sweats. He was frequently cultured, a PPD placed, had
chest x-rays, LENI's, a RUQ ultrasound, and an abdominal CT, all
without findings that could explain the fever. The two major
theories left were drug fever (especially phenytoin) versus
central irritation for his intracerebral bleed. The
intracerebral bleed seems to be the most likely etiology, yet
the fevers subsided without a clear cause and did not recur.
7.)Anemia: There was no clear etiology, although the main theory
was decreased production from inflammation and viral infection.
It remained relatively stable throughout the course. His labs
(Fe studies, B12, and folate) were consistent with this theory;
Fe studies showed more of an anemia of inflammation picture. A
CBC should be checked again as an outpatient when he is through
the more acute phase of this process.
Medications on Admission:
Fluticasone-Salmeterol 100-50 1 puff [**Hospital1 **]
Albuterol prn
Discharge Medications:
1. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 diskus* Refills:*2*
2. Oxcarbazepine 300 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
Disp:*60 Tablet(s)* Refills:*2*
3. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q3H as needed
for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Disp:*1 bottle* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Morphine Sulfate 2 mg/mL Syringe Sig: Two (2) mg Injection
Q4H (every 4 hours) as needed for headache: if oxycodone fails.
11. IV flush
Heparin and saline flush per pharmacy protocol
12. Outpatient Speech/Swallowing Therapy
Outpatient speech therapy as directed
13. Acyclovir Sodium 500 mg Recon Soln Sig: Five Hundred (500)
mg Intravenous three times a day for 4 days: Last day is Sunday
[**6-19**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 3494**] TCU - [**Hospital1 8**]
Discharge Diagnosis:
Herpes simplex virus meningoencephalitis
Seizures
Intracerebral hemmorrhage
Pulmonary embolism
Secondary:
Asthma
Discharge Condition:
Good, with improving sx, afebrile
Discharge Instructions:
Please call your PCP or return to the ED for seizures, worsening
confusion, if the patient becomes unarousable, severe headache
that does not respond to pain medication or is associated with
confusion, fevers/chills, or other concerning symptoms.
Follow-up as below.
Take medications as prescribed.
Followup Instructions:
[**Hospital **] clinic [**6-24**] at 10 am with Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **]
[**Hospital **] Medical Building - basement. [**Last Name (NamePattern1) **], [**Location (un) 86**]
Provider: [**First Name8 (NamePattern2) 7805**] [**Name11 (NameIs) **], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2140-6-24**] 10:00
NEUROLOGY
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Where: KS [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) Date/Time:[**2140-6-27**] 10:30
ALLERGY - DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
You have an appointment on [**2140-7-19**], 1pm with Dr.[**Last Name (STitle) 2603**] BUT
you need to call your Primary care doctor (Dr.[**Last Name (STitle) 60750**]) for a
REFERRAL ([**Location (un) 436**] [**Hospital Ward Name 23**])
pls call to re-schedule this appt at ([**Telephone/Fax (1) 14819**] -
Completed by:[**2140-6-16**]
|
[
"368.8",
"431",
"285.9",
"784.3",
"458.0",
"493.90",
"054.3",
"780.39",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"38.93",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
13952, 14023
|
6490, 12285
|
279, 353
|
14180, 14215
|
3503, 5473
|
14564, 15606
|
1943, 2100
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12403, 13929
|
14044, 14159
|
12311, 12380
|
14239, 14541
|
2115, 2579
|
232, 241
|
381, 1694
|
5482, 6467
|
2594, 3484
|
1716, 1748
|
1764, 1927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,412
| 151,775
|
2113
|
Discharge summary
|
report
|
Admission Date: [**2115-8-27**] Discharge Date: [**2115-9-1**]
Date of Birth: [**2055-7-21**] Sex: M
Service: MEDICINE
Allergies:
Crixivan
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Shortness of breath, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 60 year old man with HIV (CD4 of 9, [**7-/2115**])
complicated by neuropathy, not on [**Year (4 digits) 2775**], with recent admission
for aspiration pneumonia ([**8-10**] - [**8-22**]) with hypotension requiring
ICU care initially treated with vancomycin and Zosyn,
transitioned to Meropenem to complete an 11 day total course. He
was discharged last Thursday and was notably still orthostatic
on discharge. He also continued to have mild dyspnea on
discharge and never fully reached his baseline prior to the
pneumonia.
He describes severe lightheadedness on standing which makes it
difficult for him to walk and this is further complicated by his
continued dyspnea especially with exertion. He noted that he was
taking in large amounts of fluids during his prior
hospitalization, but his fluid intake decreased on discharge. He
denies headache, vision changes, new weakness or numbness,
palpitations, or syncope. Regarding his dyspnea, he feels it is
stable since discharge, but worse than baseline. He denies
cough, wheezing, chest pain, feves, chills, nausea, vomiting,
sore throat, or upper respiratory symptoms.
He notes that he was supposed to be seen by VNA and PT on
Friday, but his VNA did not come until Tuesday and they found
him to be profoundly orthostatic and recommended that he go to
the ED.
In the ED he was afebrile with BP 89/72 and was noted to be
orthostatic (no vitals provided). Given his poor venous access,
a R subclavian triple lumen was placed. He was bolused 1L NS
with increase in BP to 110/76. He was given emperic Meropenum,
Vancomycin, and Bactrim. Labs were notable for leukopenia (3.2)
and stable chronic renal failure with cr of 2.5 (baseline
2.2-2.8) and normal lactate.
Of note, he is not currently on [**Month/Year (2) 2775**], but has follow up
scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital 4415**] and
he plans to start a regimen at his next appointment. He is
currently prescribed Bactrim three times per week, but has been
taking daily.
Overnight, he complains of lightheadedness on standing and
shortness of breath with minimal exertion. He is otherwise
without complaints. On ROS, he denies chest pain, shortness of
breath at rest, leg pain or swelling, wheezing, cough, fevers,
chills, nausea, vomiting, abdominal pain, diarrhea,
constipation, dysuria, hematuria, or blood per rectum.
Past Medical History:
- HIV (diagnosed in 8/94 via PCP [**Name Initial (PRE) 1064**])
- History of PCP, [**Name10 (NameIs) 11395**], [**Name10 (NameIs) **], [**Name10 (NameIs) 1074**] retinitis, [**Name10 (NameIs) 1074**] pancreatitis,
enterobacter sepsis, wasting syndrome
- HIV neuropathy
- Hypertension
- Chronic renal insufficiency
- Hepatitis B
- Nephrolithiasis [**1-10**] crixivan 8 yrs ago
- PTX [**1-10**] pentamidine
- Depression
Past Surgical History:
- Right nephrectomy (kidney donor for brother) [**2079**]
- Retinal implants bilaterally
Social History:
He lives with his girlfriend [**Name (NI) **] and two daughters and
grandchildren in [**Location (un) 686**], MA. Works as substance abuse
counselor for drug abusers with HIV/AIDS. Heroin 2g/d IV from
age 14-38 (quit, [**2092**]). Cocaine 0.5 g/d (speedball) IV from age
21-38. Smoked 2 packs per day for 20 years (40 pack-years), quit
[**2092**]. He has not used drugs, tobacco, or alcohol since [**2092**].
Family History:
Father killed, died of head trauma at age 25. Mother died of
stomach CA at age 62. 2 brothers deceased from [**Name (NI) 11398**] (one of which
had juvenile DM and received a kidney from pt). 1 brother alive
at 57 with DM1.
Physical Exam:
Admission physical exam:
Vitals: T:98.1 BP:109/71 P:80 R: 18 O2: 100% RA
General: Elderly appearing AA male in NAD
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: No edema
Discharge physical exam:
Vitals: Tc/m 98.2/98.4 HR 87 (70s-80s) BP 111/74
(110s-120s/70s-80s) RR 18 O2 100%RA
General: Pleasant man in NAD
HEENT: Sclera anicteric, MMM
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no rales or ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Neuro: CNII-XII intact bilaterally, full strength and sensation
throughout, normal gait
Ext: No edema
Pertinent Results:
Admission labs:
[**2115-8-27**] 04:52PM BLOOD WBC-3.2* RBC-3.59* Hgb-11.5* Hct-34.1*
MCV-95 MCH-32.0 MCHC-33.6 RDW-15.4 Plt Ct-305#
[**2115-8-27**] 04:52PM BLOOD Neuts-45.3* Lymphs-43.0* Monos-8.9
Eos-2.2 Baso-0.7
[**2115-8-27**] 04:52PM BLOOD Glucose-81 UreaN-32* Creat-2.5* Na-138
K-5.0 Cl-115* HCO3-16* AnGap-12
[**2115-8-28**] 10:00AM BLOOD Albumin-2.4* Calcium-7.4* Phos-3.0 Mg-2.1
[**2115-8-28**] 10:00AM BLOOD ALT-58* AST-41* LD(LDH)-178 AlkPhos-269*
TotBili-0.3
[**2115-8-29**] 04:20AM BLOOD Type-[**Last Name (un) **] pO2-98 pCO2-29* pH-7.32*
calTCO2-16* Base XS--9
[**2115-8-27**] 05:21PM BLOOD Lactate-0.9
Discharge labs:
[**2115-9-1**] 07:12AM BLOOD WBC-1.8* RBC-3.23* Hgb-10.3* Hct-31.3*
MCV-97 MCH-31.8 MCHC-32.8 RDW-15.2 Plt Ct-172
[**2115-8-31**] 04:59AM BLOOD Neuts-53.7 Lymphs-23.9 Monos-5.9
Eos-16.1* Baso-0.4
[**2115-9-1**] 07:12AM BLOOD Glucose-84 UreaN-20 Creat-2.1* Na-135
K-5.3* Cl-114* HCO3-17* AnGap-9
[**2115-9-1**] 07:12AM BLOOD Calcium-7.6* Phos-3.1 Mg-2.2
[**2115-8-29**] 04:20AM BLOOD Lactate-0.6
Micro:
[**2115-8-29**] Immunology ([**Numeric Identifier 1074**]) [**Numeric Identifier 1074**] Viral Load-FINAL
[**Numeric Identifier 1074**] Viral Load (Final [**2115-8-31**]):
[**Month/Day/Year 1074**] DNA detected, less than 600 copies/mL.
[**2115-8-29**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY
INPATIENT
[**2115-8-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
[**2115-8-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
[**2115-8-28**] MRSA SCREEN MRSA SCREEN-FINAL
[**2115-8-28**] URINE URINE CULTURE-FINAL no growth
[**2115-8-28**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-FINAL
[**2115-8-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
[**2115-8-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
[**2115-8-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
no growth
[**2115-8-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
Blood Culture, Routine (Final [**2115-9-2**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
[**2115-8-27**] URINE URINE CULTURE-FINAL no growth
Studies:
[**2115-8-28**] CHEST (PORTABLE AP)
FINDINGS: Frontal view of the chest was obtained. A right
subclavian central catheter terminates in the lower SVC.
Metallic clips overlie the right upper quadrant. The heart is
of normal size with normal cardiomediastinal contours. Vague
bibasilar opacities are nonspecific but may represent infection.
No pleural effusion or pneumothorax.
IMPRESSION: Vague bibasilar opacities, which may represent
infection in the appropriate clinical setting.
[**2115-8-27**] CHEST (PORTABLE AP)
FINDINGS: Single portable view of the chest compared to
previous exam from [**2115-8-14**]. Right subclavian line is
seen with catheter tip in the lower SVC. There is no visualized
pneumothorax. Previously seen right PICC and left subclavian
lines are no longer seen. Cardiomediastinal silhouette is within
normal limits. Osseous and soft tissue structures are
unremarkable.
IMPRESSION: New right subclavian line with tip in the lower
SVC. No pneumothorax.
[**2115-8-27**] ECG
Sinus rhythm. Normal ECG. Since the previous tracing of [**2115-8-15**]
limb lead
voltage is now more prominent. Otherwise, unchanged.
Pending results:
[**2115-8-31**] 04:04PM BLOOD HIV GENOTYPING-PND
[**2115-8-29**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY
INPATIENT
Brief Hospital Course:
60M with HIV/AIDS (last CD4: 9, VL: 75K, [**2115-8-4**] not on ARVs)
admitted with orthostatic hypotension, transferred to ICU with
hypotension refractory to 4L NS and tachycardia in the setting
of positive blood cultures concerning for sepsis.
# Sepsis: Patient initially admitted to medicine for orthostasis
and dyspnea (below), but developed rigors (without fevers) and
hypotension with tachycardia. He was given 4L NS IVF and started
emperically on vancomycin and meropenem prior to transfer to the
ICU. He was given an additional 2.5L with stabilization of his
blood pressure and improvement of his tachycardia. Blood
cultures (1/2 bottles) returned positive for pan-sensitive
coagulase negative staph. He did not have any further rigors or
temperature spikes. He was well enough for transfer to the
floor. SBPs remained in the 100s-130s on the floor and patient
was feeling much better. He remained stable following
discontinuation of antibiotics ([**8-27**] - [**8-31**]). [**Month/Year (2) 1074**] DNA detected
in his blood, but at a very low level. ID was not concerned
about this and did not recommend treatment.
# Dyspnea: Recent admission for multifocal pneumonia treated
with 11 days total of Vanc/Zosyn then Miropenem. Repeat CXR in
the ED revealed improvement in RML infiltrate from prior on [**8-14**].
In the abscence of clear source of infection without fever,
chills, nausea, vomiting, or cough on admission. Patient does
not have clinical signs of heart failure. He was thought to
simply be recovering from severe pneumonia. PE though on the
differential was felt to be less likley given that he is not
tachycardic or hypoxemic. Emperic antibiotics were initially
deferred given lack of symtpoms, above, but later in his
hospital course were initiated given concern for sepsis (above).
His chest x-ray is much improved from prior admission.
Dyspnea improved throughout admission, and he is satting 100% on
RA by discharge.
# Orthostatic hypotension: Patient has documented orthostasis
from prior admission that did not resolve prior to discharge. He
notes good PO fluid intake on last admssion, but this decreased
since discarge home. He is likely volume depleted given that he
improved with fluid bolus in the ED. This is likely complicated
by his underlying HIV neuropathy which may also be contributing
to orthostasis. Hematocrit is stable since discharge making
acute blood loss an unlikely explanation for orthostasis. He was
given IV fluids in the ED with reported improvment and had
negative orthostatic blood pressures prior to discharge.
# HIV/AIDS: CD4 9 on [**7-/2115**], VL 75k. He is not on [**Year (4 digits) 2775**]
currently, but will follow up with ID at [**Hospital1 3278**]. He is on bactrim
prophyliaxis, and ID felt that he did not need additional
prophylaxis. HIV genotyping was sent and Dr. [**Last Name (STitle) **] [**Name (STitle) 4648**] will
follow up on this result and make sure it gets to [**Hospital1 3278**] to his
outpatient ID doctor.
# CKD: Creatinine 2.1, which appears to be his stable baseline
since [**2104**]. He [**Last Name (un) **] started on a low potassium, low phos diet.
# Depression: Stable. Continued bupropion (Sustained Release)
150 mg PO QAM.
# GERD: Stable. Continued home omeprazole 20 mg PO BID.
# Prophylaxis: Subcutaneous heparin, ppi, bowel regimen
# Code: FULL
# Contact: Girlfriend, [**Name (NI) **] [**Telephone/Fax (1) 11411**]
# Transitional issues:
- HIV genotyping was sent and Dr. [**Last Name (STitle) **] [**Name (STitle) 4648**] ([**Hospital1 18**], ID) will
follow up on this result and make sure it gets to [**Hospital1 3278**] to his
outpatient ID
- Mycolytic blood cultures pending at discharge, no growth
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Omeprazole 20 mg PO BID
3. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR)
4. Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]:PRN dry/itchy eyes
5. Quetiapine Fumarate 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]:PRN dry/itchy eyes
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Omeprazole 20 mg PO BID
4. Quetiapine Fumarate 25 mg PO QHS:PRN insomnia
5. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
- Sepsis
Secondary diagnoses:
- HIV/AIDS, CD4 of 9, VL 75K
- Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital for fatigue and weakness. You
were found to have bacteria growing in your blood and you were
started on antibiotics. Your blood pressure dropped and your
heart rate increased, and you had to spend a day in the
intensive care unit. After antibiotics and fluids, your symptoms
improved. We kept you in the hospital for a day after
discontinuing antibiotics and you remained stable and felt well.
You were scheduled for follow up with an infectious disease
doctor so that you can start taking HIV medications.
It was a pleasure taking care of you at the [**Hospital1 18**]!
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
When: Dr. [**Last Name (STitle) 7800**] office is working on a follow up appoimtmnent
for you in [**3-17**] days after your hospital discharge. You will be
called with the appointment date and time. If you have not heard
from the office in 2 business days please call the number listed
below.
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
Department: Infectious Diseases
Name: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 11412**]
When: Friday [**2115-9-20**] at 9:00 AM
Location: [**Hospital1 **] [**Hospital1 336**]
Address: [**State 11413**] , [**Location (un) **],[**Numeric Identifier 4809**]
Phone: [**Telephone/Fax (1) 11414**]
Completed by:[**2115-9-7**]
|
[
"038.9",
"530.81",
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"585.9",
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"403.90",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
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icd9pcs
|
[
[
[]
]
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13423, 13481
|
9024, 12450
|
298, 304
|
13629, 13629
|
5022, 5022
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3752, 3978
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3220, 3310
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332, 2756
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5038, 5640
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13521, 13531
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13644, 13756
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12473, 12740
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2778, 3197
|
3326, 3736
|
4470, 5003
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,420
| 112,064
|
52207
|
Discharge summary
|
report
|
Admission Date: [**2188-7-12**] Discharge Date: [**2188-7-18**]
Date of Birth: [**2136-5-20**] Sex: F
Service: PODIATRY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4342**]
Chief Complaint:
Left foot infection
Major Surgical or Invasive Procedure:
Left foot I&D [**2188-7-12**], Left foot debridement [**2188-7-16**]
History of Present Illness:
52 yo DM2, IVDU, many foot infections in the past, presents to
the ED 3 days after stepping on a nail with her left foot.
.
Since that time, she has been experiencing fevers (but patient
is unsure how high), rigors, and nausea/vomitting x1. She has
been noticing drainage from a ulcer over the area of the foot
where the nail impaled her foot. She reports that she was unable
to come to the ER because ambulating was painful and she could
not obtain a ride. She reports poor po intake x1 day. Pain is
located in the anterior left foot and ankle, and is rated as
[**10-10**].
.
Of note, patient was admitted [**5-10**] with a right fourth digit
ulceration and osteomyelitis. Though surgery was planned, the
patient left AMA after her boyfriend was not allowed to sleep in
her hospital bed.
.
In the [**Hospital1 18**] ER, she was febrile to 104. She was noted to be
tachycardi with an EKG apparently consistent with MAT vs Afib,
which is new for her. Glucose was noted to be 500 but there was
no gap. A dime size necrotic lesion was noted over the plantar
sufrace of the first MTP joint. She received a 2L NS, tetanus
booster, morphine 4 mg IV, regular insulin 10 U, Vancomycin 1 g
IVx1, and Zosyn, 4 g IV x1. LEFT IJ was placed.
.
Patient was transferred to the OR by podiatry for I and D of
left foot. There was minimal blood loss, of about 15 cc. She
received 500 cc of saline. Local anesthesia was utilized with
MAC. The patient was transferred to the ICU for further
monitoring.
.
In the ICU patient reports [**10-10**] left foot pain, but otherwise
feels well. She was occassionally tachy to 140 and had HTN to
240's. This improved with morphine and lisinopril. Her cr fell
from 1.3 to 1.2.
Iron studies had a pattern (low TIBC, Tf) c/w Anemia of chronic
inflammation
Past Medical History:
H/o multiple diabetic ulcers s/p toe amputations
-Poorly controlled DM II
-Anxiety
-Depression
-H/o non-compliance and behavioral problems
-Peripheral neuropathy
-Hepatitis B core Ab positive, surface Ab and Ag negative
-Hx of Hepatitis C (neg vl since [**2182**])
-H/o IVDU and ETOH abuse
-HTN
-Peripheral vascular disease
-H/o osteomyelitis
-hysterectomy and removal of uterus and cervix due to
persistent, severe cervical dysplasia
-vaginal pap 2/09 WNLs
-terminated in [**2182**] from [**Hospital1 **] Psych (Dr. [**Last Name (STitle) 6496**] because pt not
keeping appts, abusing klonopin and doxepin b/c not fufulling
terms of contract with providers
Social History:
The patient was evicted from an apartment in [**Hospital1 778**] in [**5-8**]
after her boyfriend was arrested for drugs. She moved into a
room in an apartment in [**Location (un) 686**]. She denies current drug use
but her urine tox was positive for cocaine. Past notes indicate
heroin use as well. She was on methadone for many years. She
currently denies any smoking saying she quit in [**6-7**], but has
smoked in the past. She drinks ETOH occasionally. Domestic
violence: has experienced violence in the past. She currently
has a male partner who is >15 years younger than her and is an
alcoholic who is HIV+. Her adult daughter lives nearby. She is
on disability and does not work.
Family History:
She had one brother who was a police officer who committed
suicide. Diabetes runs in her family. She has no FH of cancer.
Physical Exam:
ICU Vitals: T: 102.2 BP: 162/84 P: 124 R: 14 O2: 100% 2lNC
.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: dressing to LLE, c/d/i, no swelling or edema
CN 2-12 intact - No JPS in RLE. Sensitive only to deep
palpation. Poor JPS of Hands. Preserved light touch.
Pertinent Results:
ADMISSION LABS:
[**2188-7-12**] 04:45PM BLOOD WBC-7.3# RBC-3.01* Hgb-8.1* Hct-23.8*
MCV-79* MCH-27.0 MCHC-34.1 RDW-14.3 Plt Ct-335#
[**2188-7-12**] 04:45PM BLOOD Neuts-82.1* Lymphs-13.0* Monos-4.3
Eos-0.2 Baso-0.5
[**2188-7-12**] 04:45PM BLOOD PT-14.3* PTT-31.4 INR(PT)-1.2*
[**2188-7-12**] 04:45PM BLOOD Glucose-510* UreaN-17 Creat-1.3* Na-127*
K-3.4 Cl-94* HCO3-27 AnGap-9
[**2188-7-12**] 10:42PM BLOOD Calcium-7.2* Phos-1.0*# Mg-1.5* Iron-7*
[**2188-7-12**] 10:42PM BLOOD calTIBC-146* Ferritn-219* TRF-112*
DISCHARGE LABS:
[**2188-7-18**] 06:00AM BLOOD WBC-3.8* RBC-2.92* Hgb-8.2* Hct-24.8*
MCV-85 MCH-28.1 MCHC-33.2 RDW-15.0 Plt Ct-376
[**2188-7-18**] 06:00AM BLOOD Plt Ct-376
[**2188-7-18**] 06:00AM BLOOD Glucose-282* UreaN-10 Creat-1.1 Na-139
K-3.3 Cl-100 HCO3-34* AnGap-8
[**2188-7-18**] 06:00AM BLOOD Calcium-8.2* Phos-4.4 Mg-1.7
FOOT XR [**7-12**]
There is a large ulcer crater at the plantar aspect of the
forefoot, at the second and third distal metatarsals. There is
associated periosteal reaction and ill definition of the cortex
of the head of the second
metatarsal, suspicious for osteomyelitis. Significant
circumferential foot
swelling noted. This is on a background of extensive
postsurgical changes,
which otherwise are grossly stable.
CXR [**7-12**]
No acute pulmonary process. Right internal jugular central line
as above with no pneumothorax noted.
[**2188-7-16**] Radiology CHEST PORT. LINE PLACEM: IMPRESSION: 1. New
bibasilar consolidations which are prominent on the left are
concerning for pneumonia. 2. New left small pleural effusion.
[**2188-7-16**] Radiology CHEST (PA & LAT): (WET READ): Interval
repositioning of left PICC line which is not seen beyond the
mid-SVC where it may terminate versus become obscurred by the
right internal jugular
central venous catheter. No catheter is seen within the right
atrium. Ill-
defined costophrenic opacity could represent early infection.
Small left
pleural effusion unchanged.
[**2188-7-17**] Radiology CHEST (PA & LAT): No change in right
costophrenic opacity and pleural effusion since exam of [**2188-7-16**].
Left PICC terminates in proximal SVC.
[**2188-7-16**] Radiology FOOT AP,LAT & OBL LEFT: FINDINGS: In
comparison with the study of [**7-12**], there has been resection of
the distal half of the second metatarsal and the proximal
portion of the proximal phalanx. Gas is seen projected over the
region, though it could merely be trapped underneath the
overlying bandage.
[**2188-7-16**] Pathology Tissue: LEFT 2nd DIGIT PHALAX, Left: Not
finalized.
[**2188-7-12**] 5:02 pm SWAB Source: left foot.
**FINAL REPORT [**2188-7-16**]**
GRAM STAIN (Final [**2188-7-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2188-7-16**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. HEAVY GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2188-7-16**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
[**2188-7-16**] 10:45 am SWAB Site: FOOT LEFT 2ND FOOT ULCER.
GRAM STAIN (Final [**2188-7-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): RESULTS PENDING.
[**2188-7-16**] 8:28 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2188-7-17**]**
GRAM STAIN (Final [**2188-7-17**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2188-7-17**]):
TEST CANCELLED, PATIENT CREDITED.
[**2188-7-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2188-7-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2188-7-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2188-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
Brief Hospital Course:
This is a 52 yo DM2, IVDU, many foot infections in the past,
presents to the ED 3 days after stepping on a nail with her left
foot. She was found to be septic (fever, tachycardia,
leukocytosis) and was admitted to the medicine service. She was
started on broad spectrum antibiotics and local wound care.
Podiatry performed a bedside debridement and wound cultures grew
MSSA. She was then switched to Nafcillin IV q6h. Daily wet to
dry dressing changes were performed. Daily labs were drawn and
electrolytes repleted as necessary.
On [**2188-7-16**], she was taken to the OR for left foot debridement
packed open. Cultures were taken. Please see operative report
for full details.
All of her home medications were continued. On [**2188-7-16**], a PICC
line was placed. Upon awaiting her PICC line placement, the
radiologist contact[**Name (NI) **] Dr. [**Last Name (STitle) **] regarding new bilateral
infiltrates concerning for pneumonia. She was switched back to
vancomycin and zosyn with a medicine consult. Repeat CXR showed
no change in the opacity. Sputum culture was sent which was
contaminated and pt refused a repeat culture. Her vitals and O2
sats remained stable during her admission. Outpatient [**Company 191**] follow
up was obtained and pt was encouraged to keep appointment. She
was also given the [**Hospital **] clinic number to establish follow up
for her diabetes insulin regimen.
Physical therapy was consulted but the patient refused to be
evaluated. Pt also refused rehab facility.
Her OR wound cultures showed no growth to date and pathology was
not finalized at the time of discharge.
On [**2188-7-18**] her PICC line was pulled and she was discharged with
10 days course of Augmentin with instructions to perform daily
dressing changes and to ambulate to left heel in a surgical shoe
with assistance of a walker.
Medications on Admission:
-insulin regular human recombinant 100 units/mL 0.1 units/kg [**Hospital1 **]
-metformin [**2178**] mg once a day (does not appear to be using)
-GlipiZIDE XL 10 mg once a day (does not appear to be using)
-Lantus 100 units/mL 12 units at bedtime
-Klonopin 1 mg q6hours prn
-doxepin 150mg qhs
-clonidine 0.1 mg/24 hr 1 PATCH 1X/W (does not appear to be
using)
-Neurontin 600 mg TID
-lisinopril 40 mg once a day
-Celexa 20mg once a day
-ibuprofen 800 mg TID prn with food
-Fioricet 325 mg-50 mg-40 mg 2 tab(s) Q4H prn
-Flonase 2 spray(s) once a day
Discharge Medications:
1. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Insulin
Insulin SC Fixed Dose Orders
Bedtime
Glargine 21 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Doxepin 25 mg Capsule Sig: Six (6) Capsule PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
Left foot ulcer infection
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:
Please resume all pre-admission medications. If you were given
new prescriptions, please take as directed.
.
Keep your dressing clean and dry at all times. You will need to
change your dressings daily.
.
You are to remain WEIGHT BEARING to your left heel in a surgical
shoe at all times with the assistance of a walker.
.
Call your doctor or go to the ED for any increase in LEFT foot
redness, swelling or purulent drainage from your wound, for any
nausea, vomiting, fevers greater than 101.5, chills, night
sweats or any worsening symptoms.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] next week. #[**Telephone/Fax (1) 543**]
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**] DPM 48-135
Completed by:[**2188-7-18**]
|
[
"584.9",
"995.91",
"250.80",
"250.60",
"038.9",
"707.15",
"276.3",
"682.7",
"070.30",
"300.4",
"443.9",
"285.29",
"401.9",
"V15.81",
"731.8",
"730.27",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"86.04",
"77.48",
"77.89",
"38.93",
"77.88"
] |
icd9pcs
|
[
[
[]
]
] |
13351, 13357
|
9621, 11466
|
335, 406
|
13426, 13426
|
4396, 4396
|
14177, 14434
|
3619, 3743
|
12065, 13328
|
13378, 13405
|
11492, 12042
|
13609, 14154
|
4923, 8836
|
3758, 4377
|
276, 297
|
8868, 9598
|
434, 2210
|
4412, 4907
|
13441, 13585
|
2232, 2891
|
2907, 3603
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
852
| 133,054
|
45510
|
Discharge summary
|
report
|
Admission Date: [**2156-3-23**] Discharge Date: [**2156-3-28**]
Date of Birth: [**2108-5-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
morbid obesity
Major Surgical or Invasive Procedure:
open roux-en-y gastric bypass
open cholecystectomy
History of Present Illness:
The patient is a 47-year-old gentleman with a
BMI of 61 and a weight of 463 pounds. He has been on
multiple supervised diets with a maximum of 125 pounds weight
loss with regain. He has recently been evaluated by [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] program and deemed a
suitable candidate for weight loss surgery. He has comorbid
conditions including hypertension, sleep apnea,
gastroesophageal reflux disease, dyslipidemia and asthma. He
is familiar with complications including mortality of 1%,
complications of 10%, reoperation of 5%. He fully understands
the risks of tracheostomy and ventilator dependence given his
longstanding history of smoking. He is familiar with
complications including leaks, internal hernias, external
incisional hernias, stenosis, internal hernias, retained
stones, abscesses, infections, bleeding, malnutrition, excess
skin and hair thinning. He agrees to diet, exercise, support
group and lifelong medical follow-up.
Past Medical History:
1. Asthma
2. Bronchitis
2. HTN
3. Morbid obesity
Social History:
quit tobacco [**2154**], 30 pack-year history
social EtOH
no other drug use
Family History:
NC
Physical Exam:
NAD, A&Ox3
PERRL
HEENT wnl
neck supple no masses or thyromegaly
no cervical LAD
chest CTAB
RRR no MRG. No JVD
abd obese, soft NTND with nl BS. No surgical scars.
full AROM UE and LE
Pertinent Results:
[**3-26**] HCT-36
Brief Hospital Course:
Pt was admitted through same day admission and taken to the OR
with Dr. [**Last Name (STitle) **] for an open gastric bypass with cholecystectomy,
see operative report for details. He tolerated the procedure
well and was extubated in the OR. Due to the length of the
operation, his morbid obesity, and his history of obstructive
sleep apnea, it was decided to keep Mr. [**Name13 (STitle) 39722**] in the PACU
overnight. He experienced some elevated heart rate and blood
pressure on POD#0 that was treated with IV lopressor with good
effect.
He otherwise had an uneventful first night and was transferred
to the surgical floor on the morning of POD#1. His NG tube was
removed and he was advanced to a stage I diet. Nutrition and
physical therapy were both consulted.
On POD#2 the Foley catheter was removed. A methylene blue
swallow test was done which was negative. He was advanced to a
stage II diet which he tolerated well. He was ambulatory with
physical therapy.
On POD#3 he was advanced to a stage III diet which he tolerated
well. By the time of discharge on POD #5 he was ambulating
well, saturating well on room air, and tolerating a stage 3 diet
well.
Medications on Admission:
HCTZ 25'
Singulair 10'
albuterol prn
Flovent 110"
Zyrtec 60"
Protonix 40'
Ambien prn
Lisinopril 20'
ASA
centrum
Buproprion SR 150'
Discharge Medications:
1. Flintstones Complete 30-200-3 mg-unit-mcg Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Zantac 15 mg/mL Syrup Sig: Ten (10) mL PO once a day for 1
months.
Disp:*qs for 1 month mL* Refills:*0*
3. Roxicet 5-325 mg/5 mL Solution Sig: [**5-12**] mL PO every [**4-8**]
hours as needed for pain for 1 months.
Disp:*250 mL* Refills:*0*
4. Roxicet 5-325 mg/5 mL Solution Sig: [**5-12**] mL PO every [**4-8**]
hours as needed for pain for 1 months.
Disp:*250 mL* Refills:*0*
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
morbid obesity
hypertension
obstructive sleep apnea
GERD
asthma
gout
bronchitis
dyslipidemia
Discharge Condition:
stable
Discharge Instructions:
Call your surgeon or go the ER if you experience:
-chest pain or shortness of breath
-fevers greater than 101.5 degrees, chills
-persistent nausea and vomiting
-severe abdominal pain
-inability to pass gas or stool
-redness or foul-smelling drainage at wound
Medications: Resume your usual home medications. Take the
Roxicet (oxycodone/acetaminophen liquid) as prescribed for pain.
In addition, you will need to take liquid Zantac (acid-reducer)
for 1 month and a chewable multivitamin every day.
Diet: Stay on a Stage III diet until follow-up. Do not
self-advance your diet. Do not chew gum or drink out of a straw.
Activity: You may resume your usual activities. However, you
should not lift anything heavier than [**10-17**] lbs for the next 6
weeks.
Wound Care: You may shower as you normally would, but no
swimming or bathing until after follow-up. The white paper
strips over the incisions will fall off on their own in about a
week. You can cover the incisions with a dry gauze if they are
draining, otherwise no dressing is needed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 28351**]
Date/Time:[**2156-4-14**] 12:45
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 97101**], MA, RN, LDN Phone:[**Telephone/Fax (1) 28351**]
Date/Time:[**2156-4-14**] 1:30
|
[
"780.57",
"V85.4",
"530.81",
"V15.82",
"401.9",
"278.01",
"493.90",
"272.4",
"575.11",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.31",
"93.90",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
4251, 4257
|
1841, 3008
|
327, 380
|
4394, 4403
|
1799, 1818
|
5495, 5812
|
1578, 1582
|
3189, 4228
|
4278, 4373
|
3034, 3166
|
4427, 5185
|
1597, 1780
|
273, 289
|
5197, 5472
|
408, 1397
|
1419, 1469
|
1485, 1562
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,267
| 145,642
|
3700
|
Discharge summary
|
report
|
Admission Date: [**2199-1-2**] Discharge Date: [**2199-1-7**]
Date of Birth: [**2159-8-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / clindamycin / clavulanic acid /
Aztreonam / Sulbactam / tazobactam / Cephalosporins
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Abnormal Hct
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 16696**] is a 39 year old female with a history of HTN, IDDM,
non-ischemic cardiomyopathy with EF 45% s/p recent
hospitalization for VF arrest with ICD placement after arctic
sun protcol, nonobstructive CAD, and ESRD on HD who is
transferred to the emergency room from her rehabilitation center
for a low hematocrit.
The patient was recently admitted on [**2198-12-3**] status post cardiac
arrest while at dialysis, thought to be secondary to hypokalemia
with a presumed R on T phenomenon lead to VT --> VF arrest. She
underwent Arctic sun cooling and re-warming, successful
extubation following prior failed attempt (required
re-intubation due to mucous plugging), and gradual recovery of
her baseline mental status, after frequent
work with PT and speech and swallow to resume PO intake. She was
dialyzed in-house by the renal team with a high K bath to
maintain her K around 5. EP placed a single chamber ICD (despite
significant concerns regarding her multiple comorbidities). She
had
evidence of significant ectopy on telemetry throughout her
hospitalization including frequent PVC's and occasional runs of
NSVT. She was discharged to rehab for continued recovery of her
physical function.
.
In the ED, initial VS were: 98.2 85 157/73 18 100% 2L. She
received 1 unit pRBCs for a hematocrit of 22.2. Other labs were
notable for a BUN/creatinine of 29/4.4, bicarb of 33, Trop of
0.08 in the setting of CRF, and a hapto <5 with normal bilirubin
and slightly elevated LDH at 330. Most notably, she felt unwell
and her glucose returned at 35. She was given D50 and a repeat
fingerstick was 158. Repeat at 12:15 = 60 and she was given
another amp of D50 with re-check at 1:20 = 50. Another amp was
given and she also ate a [**Country 1073**] [**Location (un) 6002**]. Another repeat at
2:45 = 45 and one more amp of D50 adminstered. Total D50 amps
x4. She was also complaining of worsening chest pain with EKG
showing no change from prior and improvement with morphine. CXR
showed no acute process. She was given Protonix 40mg IV for ?GI
bleed. She is admitted to the ICU for persistent hypoglycemia
in the setting of receiving her long-acting insulin at rehab
without eating.
.
On arrival to the MICU, she reported that she was itching since
the blood started. Also, she denied hematochezia, hematemesis,
hematoptysis, and menstruation. She reported that she has been
fatigued in the past week and has had a "head cold". She
confirmed that she took her insulin but did not eat.
.
Review of systems:
(+) Per HPI
Past Medical History:
- Nonobstructive CAD with 30% mid RCA stenosis, 30% PLB stenosis
in [**2192**]. In [**2-6**], LAD, Lcx with minor irregularities
- non-ischemic CM, LVEF 45%
- s/p cardiac arrest in [**9-/2198**], s/p ICD placement ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
Fortify VR)
- ESRD due to IDDM and HTN, on HD MWF via RUE AVG since [**2195**]
- HTN, difficult to control
- IDDM
- Pulmonary HTN (PASP above 50 mmHg on echo [**5-/2198**], at least
partially due to OSA)
- HL
- Obesity
- Hypothyroidism
- GERD
- Epilepsy
- Chronic back pain
- Anxiety and Depression
Social History:
1. aspirin 81 mg Tablet daily
2. lisinopril 30 mg Tablet daily
3. hydralazine 25 mg Tablet PO Q6H prn
4. calcitriol 0.50 mcg Capsule daily
5. B complex-vitamin C-folic acid 1 mg Capsule daily
6. nicotine 14 mg/24 hr Patch 24 hr
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
8. sevelamer carbonate 800 mg Tablet [**Hospital1 **]
9. carvedilol 50 mg Tablet [**Hospital1 **]
10. lidocaine 5 %(700 mg/patch) daily
11. Levemir 4 units qhs
12. Humalog 100 unit/mL Solution Sig: [**3-2**] U Subcutaneous as
instructed: As instructed per sliding scale.
13. ferrous sulfate 324 mg (65 mg iron) [**Hospital1 **]
14. simvastatin 40 mg Tablet daily
15. levothyroxine 150 mcg daily
16. levetiracetam 500 mg [**Hospital1 **]
17. levetiracetam 500 mg Tablet PO EVERY MONDAY, WEDNESDAY AND
FRIDAY AFTER DIALYSIS
18. docusate sodium 100 mg Capsule [**Hospital1 **]
20. trazodone 50 mg Tablet qhs
Family History:
+ DM, + HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97, BP 168/73, P 77, R 8, O2 100%
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, + systolic murmur,
no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
Pertinent Results:
ADMISSION LABS:
[**2199-1-1**] 11:15PM BLOOD WBC-5.7 RBC-2.26* Hgb-7.3* Hct-22.2*
MCV-98 MCH-32.3* MCHC-32.9 RDW-16.1* Plt Ct-258
[**2199-1-1**] 11:15PM BLOOD Neuts-34.7* Lymphs-46.1* Monos-4.8
Eos-13.8* Baso-0.7
[**2199-1-1**] 11:15PM BLOOD PT-11.1 PTT-32.4 INR(PT)-1.0
[**2199-1-1**] 11:15PM BLOOD Glucose-35* UreaN-29* Creat-4.4*# Na-133
K-4.6 Cl-93* HCO3-33* AnGap-12
[**2199-1-1**] 11:15PM BLOOD LD(LDH)-330* TotBili-0.3
[**2199-1-1**] 11:15PM BLOOD cTropnT-0.08*
[**2199-1-1**] 11:15PM BLOOD Hapto-<5*
[**2199-1-1**] 11:21PM BLOOD Glucose-34* K-4.3
[**2199-1-1**] 11:21PM BLOOD Hgb-7.9* calcHCT-24
.
IMAGING:
[**1-2**] CXR NOT YET RED
Brief Hospital Course:
Ms. [**Known lastname 16696**] is a 39 year old female with a history of
hypertension (HTN), insulin dependent diabetes (IDDM),
non-ischemic cardiomyopathy with EF 45% status post recent
hospitalization for vfib arrest with ICD placement, and end
stage renal disease (ESRD on HD), now presenting with a low
hematocrit and persistent hypoglycemia.
.
ACTIVE ISSUES BY PROBLEM:
# Persistent hypogylcemia: Patient states that she did get her
4units of long-acting insulin + 10units humalog at the rehab
night prior to admission as well as 8units humalog in the
morning. After this, she did not have anything to eat. She has
a history of being very sensitive to insulin. She was treated
with IV fluids with dextrose 5% in half-normal saline and her
blood sugars were measured every 1 hour in the ICU. Also, she
was able to eat a diabetic/cardiac diet. She corrected her
sugars quickly and was able to start her home insulin regimen.
.
# Acute on chronic Anemia: She recieved one unit of packed RBCs
in the emergency department. The differential includes gradual
downtrend secondary to kidney disease and nutritional
deficiencies vs. source of bleeding or intravascular hemolysis.
She denies any bleeding outside the body and does not endorse
pain consistent with internal bleeding. Although her
haptoglobin was very low and her LDH was mildly elevated, her
other hemolysis labs (Tbili, INR) were not consistent with
ongoing hemolysis. Her RDW was already elevated which argued
against an acute bleed. Also, she has an MCV in the range of
98-100s which suggests chronic synthetic deficiencies including
B12 and folate, or mixed picture anemia. Further review of her
past hamtocrits shos that she had an acute drop following
placement of her ICD likley related to per-procedural blood
loss. She was given 2 units PRBCs at dialysis on the day of
discharge.
.
CHRONIC ISSUES BY PROBLEM:
# Non-ischemic cardiomyopathy status post ICD: Significant
history which we think is due to prolonged QT interval and then
electrolyte abnormalities, known to have minimal coronary artery
stenosis. Continued home BB, ACE-i, statin, and ASA.
.
# ESRD on HD: Cause is likely combination HTN/DM nephropathy.
She was dialysed on her schedule with high K bath.
.
# Hypothyroidism: continued home levothyroxine
.
# Epilepsy: continued home antiepileptics
.
# PPD: placed in rehab on [**12-31**], read as negative on [**1-2**]
.
# Communication: Patient, [**Name (NI) 16697**] McGee (aunt) - [**Telephone/Fax (1) 16698**]
.
TRANSITIONAL ISSUES:
- Please continue to make sure that she has high K baths with
her dialysis to avoid vfib arrest
- Please continue home services for ICD
- Should have a further workup for her anemia since she is
already taking iron supplements, folic acid, vitamin B12.
Medications on Admission:
1. aspirin 81 mg Tablet daily
2. lisinopril 30 mg Tablet daily
3. hydralazine 25 mg Tablet PO Q6H prn
4. calcitriol 0.50 mcg Capsule daily
5. B complex-vitamin C-folic acid 1 mg Capsule daily
6. nicotine 14 mg/24 hr Patch 24 hr
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
8. sevelamer carbonate 800 mg Tablet [**Hospital1 **]
9. carvedilol 50 mg Tablet [**Hospital1 **]
10. lidocaine 5 %(700 mg/patch) daily
11. Levemir 4 units qhs
12. Humalog 100 unit/mL Solution Sig: [**3-2**] U Subcutaneous as
instructed: As instructed per sliding scale.
13. ferrous sulfate 324 mg (65 mg iron) [**Hospital1 **]
14. simvastatin 40 mg Tablet daily
15. levothyroxine 150 mcg daily
16. levetiracetam 500 mg [**Hospital1 **]
17. levetiracetam 500 mg Tablet PO EVERY MONDAY, WEDNESDAY AND
FRIDAY AFTER DIALYSIS
18. docusate sodium 100 mg Capsule [**Hospital1 **]
20. trazodone 50 mg Tablet qhs
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
4. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
11. Levemir 100 unit/mL Solution Sig: Four (4) Subcutaneous at
bedtime.
12. insulin lispro 100 unit/mL Solution Sig: [**1-28**] Subcutaneous
three times a day: take as directed according to sliding scale.
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO AFTER
DIALYSIS ON MWF ().
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & [**Hospital **] Care Center - [**Location 1268**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hypoglycemia due to insulin medications
Chronic macrocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 16696**],
.
You were admitted to the hospital because you had low blood
sugar and anemia. You were given several units of blood to
treat the anemia. In the future, you can notice the symptoms of
anemia such as bleeding in your stool, fatigue, shortness of
breath, and dizziness, you should let your healthcare provider
know [**Name9 (PRE) 2678**].
.
Also, you were given some IV fluids with sugar in them to treat
the low blood sugar. Your sugars improved and we restarted your
home insulin regimen. To avoid dropping your sugars too much
again, you should always eat a balanced diet and not skip meals.
.
While you were here we made no changes to your medications
.
It is also important that you keep all of the follow-up
appointments listed below. Also, weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2199-1-8**] at 9:40 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2199-1-31**] at 8:30 AM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2199-1-31**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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32,026
| 170,434
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33139
|
Discharge summary
|
report
|
Admission Date: [**2190-2-21**] Discharge Date: [**2190-3-4**]
Date of Birth: [**2142-6-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
s/p fall, ?seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name13 (STitle) 77028**] is a 47 yo man with schizophrenia who was found down
at his group home today and brought to [**Hospital1 18**] by EMS.
.
Most of the history was derived from the pt's group home
manager.
.
The pt was in his USOH until the night prior to admission, when
he awoke grunting and clutching his abdomen or penis. he was
disoriented at this time. EMS was called, his initial blood
pressure was allegedly 192/91, and he was taken to [**Hospital 882**]
Hospital, where he was diagnosed with anxiety and discharged
back to his group home.
.
On the day of admission, he was more quiet than usual and had
diarrhea all day. At approximately 7 p.m., the pt wandered out
of his room and fell on his face without attempting to rbeak his
fall. There was evidence of seizure activity, and he later began
grunting. According to report, he lost control of his bladder
and bowel.
.
The group home manager noted that the pt drinks about 8 glasses
of liquid per day on a chronic basis. He avoids water, however.
.
In the emergency department, his initial VSs were 99.6, 91,
162/102, 22, 94%RA. His initial GCS was 3, and he was intubated
for airway protection. There was evidence of posturing and LE
twitching per report. Propofol and lorazepam were administered.
A trauma workup demonstrated no evidence of traumatic injury. He
received 5 L NS in the ED for hyponatremia.
.
ROS was unobtainable, although the group home manager noted that
the pt has lost a significant amount of weight in recent months.
Past Medical History:
Schizophrenia / mental retardation
Nephrolithiasis
Social History:
Lives at group home located at [**Doctor Last Name 77029**] in [**Location 10050**]. Chain smoker per group home staff.
Family History:
unknown
Physical Exam:
Vitals: T: 100.1 BP: 139/98 P: 98 R: 28 SaO2: 98%
General: sedated, intubated
HEENT: PERRL 4->3.5, MM moist
Neck: no significant JVD
Pulmonary: Lungs CTA bilaterally anteriorly, no wheezes, ronchi
or rales
Cardiac: RR, soft S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.
Pertinent Results:
[**2190-2-21**] 08:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2190-2-21**] 08:05PM WBC-18.6* RBC-3.64* HGB-13.0* HCT-33.2*
MCV-91 MCH-35.7* MCHC-39.1* RDW-12.5
[**2190-2-21**] 08:05PM NEUTS-81.0* LYMPHS-14.3* MONOS-3.5 EOS-1.1
BASOS-0.1
[**2190-2-21**] 08:05PM PLT COUNT-257
.
[**2190-2-21**] 08:05PM PT-13.7* PTT-24.6 INR(PT)-1.2*
[**2190-2-21**] 08:05PM FIBRINOGE-249 D-DIMER-633*
.
[**2190-2-21**] 08:11PM GLUCOSE-98 LACTATE-3.1* NA+-120* K+-3.2*
CL--83* TCO2-24
[**2190-2-21**] 08:05PM UREA N-9 CREAT-0.7
[**2190-2-21**] 08:05PM CK(CPK)-5153* AMYLASE-32
[**2190-2-21**] 08:05PM OSMOLAL-248*
[**2190-2-21**] 08:05PM TSH-2.7
[**2190-2-21**] 08:05PM CORTISOL-29.5*
.
[**2190-2-21**] 09:15PM URINE HOURS-RANDOM UREA N-102 CREAT-13
SODIUM-47 POTASSIUM-6 TOT PROT-<6
[**2190-2-21**] 09:15PM URINE OSMOLAL-163
[**2190-2-21**] 09:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2190-2-21**] 09:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2190-2-21**] 09:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-2-21**] 09:15PM URINE RBC-0-2 WBC-<1 BACTERIA-RARE YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2190-2-21**] 09:15PM URINE HEMOSID-NEGATIVE EOS-NEGATIVE
[**2190-2-21**] 11:05PM TYPE-ART TEMP-37.6 TIDAL VOL-600 O2-100
PO2-322* PCO2-39 PH-7.44 TOTAL CO2-27 BASE XS-2 AADO2-375 REQ
O2-65 -ASSIST/CON INTUBATED-INTUBATED
Stress test:
INTERPRETATION:
The image quality is adequate but limited due to left arm
attenuation.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 61% with an
EDV of 95 ml.
IMPRESSION:
1. Normal myocardial perfusion at the level of exercise
achieved.
2. Normal left ventricular cavity size and systolic function.
Brief Hospital Course:
## Syncope/? seizure: Given hyponatremia, acute course, and
history from the field, we determined that Mr [**Name13 (STitle) 77028**] had likely
had a seizure. Continuous EEG for >24 hrs was unrevealing as
there were no further events in the hospital and there was no
focality to the EEG, which revealed slowing consistent with
encephalopathy (Mr [**Name13 (STitle) 77028**] was still sedated during this
assessment) but no seizure activity. A CT head was also
unrevealing of any mass lesion or clear seizure foci. There was
no evidence of trauma other than a superficial facial ecchymosis
c/w his fall. He had no arrythmias while with us. Porphyria
labs, and heavy metal labs were normal. His CKs were quite
elevated and took several days to trend down; his peak was [**Numeric Identifier 1871**]
- these trended down. His mental status returned to baseline
over the admission per his family and caretakers.
He did not have evidence of polydipsia with us while awake and
his group home staff had not observed this; given that he
apparently prefers juice and coffee as his drinks and does not
like drinking water alone it is unlikely that he would have been
able to keep up a significant undetected input to explain
hyponatremia. Paxil could have caused hyponatremia but he had
been on a steady dose for some time and it is not clear why this
would have developed now. SIADH seemed like a prominent
possibility but his hyponatremia resolved here; if this had been
a paraneoplastic syndrome we would have expected it to continue,
although this should be followed to ensure that there is not a
recurrence. The most likely possibility at this point is the
most pedestrian in a long differential: he had a diarrheal
illness, became dehydrated, got hypovolemic hyponatremia, and
because he was on two medicines that lowered seizure threshold
and perhaps because of a low inherent seizure threshold (though
he has no previous seizure history as far as we were able to
determine), he seized in response to this. To support this
theory we might have to postulate that Mr [**Name13 (STitle) 77028**] actually had an
underactive thirst mechanism in response to his diarrheal
illness, and it may be useful to closely follow his input as the
acute episode resolves. Apparently as an outpatient Mr [**First Name (Titles) 77028**] [**Last Name (Titles) 77030**]y drinks coffee which has some diuretic effect and might
have slightly accentuated his dehydration relative to his fluid
intake.
.
Furthermore, he experienced persistant orthostasis with
tachycardia (sinus rhythm) on the medical [**Hospital1 **]; this was only
resolved with aggressive IV hydration, which did ultimately
succeed in resolving his orthostasis.
.
Psych and neuro services followed and were involved in
assessment and plan as described above. Additionally psychiatry
talked to his outpatient treater who said that Mr [**Name13 (STitle) 77028**] does
tend to decompensate while off of his medicines, so his
medications were restarted, and his sodium remained stable
throughout the admission.
.
## Hyponatremia: It was unclear whether this was chronic vs
acute and cause of seizure or [**3-20**] seizure. We came to believe
that it was the precipitating event given that there was no
evidence of an underlying seizure disorder, though this
certainly would benefit from further outpatient follow-up. The
last sodium before this admission which we were able to find was
from [**Month (only) 956**], which was normal; if he has had sodium levels
taken since then it would be useful to compare them to confirm
that this was an acute hyponatremia leading to seizure which is
our current favored sequence of events. Causes of hypovolemic
hyponatremia include adrenal insufficiency (there was no clear
evidence of this); salt-wasting enteropathy (but his
hyponatremia resolved); meds (unlikely as his doses had been
stable for some time), and as above, diarrhea (which pt had had
all day, according to group home manager). Causes of euvolemic
hyponatremia include SIADH (olanzapine, paroxetine, seizure, no
h/o or evidence of pulmonary disease), hypothyroidism (his TSH
was within normal limits), psychogenic polydypsia (although as
above unlikely to be taking in >8 L/day), low salt diet (not per
manager at group home). Urine sodium was elevated for degree of
hyponatremia, which is c/w renal losses of sodium. Urine osms
when he came in were c/w SIADH, adrenal insufficiency or
hypothyroidism, but they corrected; additionally his cortisol
and TSH levels ruled out the second and third possibilities and
his lack of ongoing hyponatremia suggested against the first.
Serum osms did not suggest an ingestion. Given the totality of
the data and the response to aggessive hydration, he most likely
had hypovolemic hyponatremia from dehydration.
.
## Neuropsychiatric disorder(s): He carries a chart diagnosis of
schizophrenia but of note he also has reported mental
retardation and he is on a mood medication, suggesting that his
neuropsychiatric status may be more complex than simple
schizophrenia. At any rate we held his paxil and olanzapine for
concern for med side effects as precipitants or contributors to
the inciting event, though as above psychiatry suggested
restarting these, and they were restarted without incident.
.
## Contact: manager at group home, [**Name (NI) 5321**] [**Name (NI) **] [**Telephone/Fax (3) 77031**]; brother [**Name (NI) **] [**Telephone/Fax (1) 77032**]
.
Of note, finally, in the evaluation of his tachycardia, a CTA
was completed which was negative for PE, but that suggested
significant coronary calcifications including one seemingly in
the mid LAD distribution. Given this, as stress test was
completed, which was normal.
.
In light of this finding, other medical optimization and
evaluation was entertained regarding the possibility of occult
CAD, including eval for diabetes (a1c normal), BP monitoring (no
hypertension), and cholesterol panel (this was not fasting,
however, calculated LDL was not in a range requiring treatment).
He was started on an aspirin daily.
Medications on Admission:
Paroxetine 20 mg daily
Olanzapine 25 mg daily
Calcium
MVI
Discharge Medications:
1. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: 2.5 Tablet,
Rapid Dissolves PO DAILY (Daily).
Disp:*75 Tablet, Rapid Dissolve(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day.
Disp:*30 patches* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure due to hyponatremia
Dehydration
There is no evidence of diabetes
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed. Return to the [**Hospital1 18**]
Emergency Department for: lightheadedness, seizure, confusion,
fever, chest pain
Followup Instructions:
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26**] [**Telephone/Fax (1) 6803**]; call for follow up appointment
for within one week of leaving the hospital for repeat
evaluation including check of serum sodium level.
|
[
"728.88",
"276.1",
"295.62",
"780.39",
"348.30",
"276.51",
"507.0",
"317",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11261, 11267
|
4608, 10680
|
289, 295
|
11385, 11394
|
2546, 4584
|
11593, 11852
|
2067, 2076
|
10789, 11238
|
11288, 11364
|
10706, 10766
|
11418, 11570
|
2091, 2527
|
231, 251
|
323, 1839
|
1861, 1914
|
1930, 2051
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,022
| 104,234
|
38063
|
Discharge summary
|
report
|
Admission Date: [**2143-9-30**] Discharge Date: [**2143-10-4**]
Date of Birth: [**2085-6-27**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12657**]
Chief Complaint:
progressive neck swelling
and decreased PO intake
Major Surgical or Invasive Procedure:
open incision and drainage of abscess
History of Present Illness:
Mr. [**Known lastname 84988**] is a 58 M with 2 days of progressive neck swelling
and decreased PO intake. Yesterday he had pain/difficulty
swallowing food. Today he states he forced self to drink
minimal water w/AM meds. He reports being afraid to sleep for
fear his throat will close. He endorses nightsweats x 2-3 days.
No
fever/chills. No other pain or swelling. No SOB. No stridor.
The patient reports his voice has been getting progressively
more muffled since this morning. He denies any previous issues
with neck swelling in the past.
Shortly after presentation he was found to have a 2.7x2.4cm rim
enhancing collection suggestive of an infected thyroglossal duct
cyst on CT scan. On exam, there was significant supraglottic
edema.
Past Medical History:
1. CAD, s/p MI
2. Hypercholesterolemia
3. Hypertension
4. s/p lacunar infarct
5. Pulmonary nodules
6. Obesity
7. Cervical disc disease
8. Impaired fasting glucose
9. h/o colon polyp
10. Harmartoma, left hand
Social History:
Works as the chief engineer for a hotel. Married, lives with
wife and son. Quit smoking almost a year ago, about 1 ppd
previously. Rarely drinks alcohol.
Family History:
Father had an MI at age 44
Physical Exam:
VITALS: 98.7 61 165/92 16 96-RA
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
Neck incision without evidence of infection, nontender.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2.
RESP: Clear to auscultation bilaterally. Breathing comfortably.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses.
Pertinent Results:
[**2143-9-30**] 03:45PM BLOOD WBC-12.6* RBC-4.23* Hgb-13.3* Hct-36.9*
MCV-87 MCH-31.4 MCHC-36.0* RDW-13.8 Plt Ct-205
[**2143-10-4**] 04:40AM BLOOD WBC-9.7 RBC-3.85* Hgb-11.8* Hct-34.3*
MCV-89 MCH-30.6 MCHC-34.3 RDW-13.1 Plt Ct-253
[**2143-9-30**] 03:45PM BLOOD Glucose-97 UreaN-20 Creat-1.2 Na-145
K-3.3 Cl-106 HCO3-29 AnGap-13
[**2143-10-4**] 04:40AM BLOOD Glucose-109* UreaN-17 Creat-1.0 Na-142
K-3.4 Cl-105 HCO3-24 AnGap-16
CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of [**2143-9-30**]
1. 2.7 cm rim-enhancing midline collection just superior to the
hyoid bone, most compatible with thyroglossal duct cyst with
probable superinfection. Surrounding edema notably involving the
epiglottis, likely reactive.
2. 1cm left thyroid nodule. Ultrasound can be obtained if
indicated.
[**2143-9-30**] 11:21 pm SWAB Site: NECK
GRAM STAIN (Final [**2143-10-1**]):
THIS IS A CORRECTED REPORT [**2143-10-2**].
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
PREVIOUSLY REPORTED AS ([**2143-10-1**]).
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2143-10-1**] AT
0315.
WOUND CULTURE (Preliminary):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. MODERATE
GROWTH.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
SECOND MORPHOLOGY.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
Brief Hospital Course:
It was decided to take the patient to the OR for surgical
management of his presumed infected thyroglossal duct cyst.
After proper consent was received from the patient, he was
admitted the ORL service for open incision and drainage. The
patient tolerated the procedure without intra-operative
complications. Please refer to Dr. [**Last Name (STitle) 3878**]??????s dictated operative
note for complete details. Post-operatively, the patient was
transferred to the surgical ICU, intubated and in stable
condition. He was later extubated per SICU protocol and
remained in the SICU for one additional night for monitoring
before being transferred to the floor. On the floor the
remainder of his postoperative course was without complication.
His foley was removed, a penrose drain from the operation was
removed from his incision, and his diet was advanced.
* HEENT: Pt's OC/OP/NC clean with no active bleeding or oozing,
moist mucosa, face symmetric without palsy or deficits & normal
voice. The patient's neck incision remained clean, dry, & intact
with sutures without hematoma or infection. His neck penrose
drain was removed at bedside; he tolerated this well without
complication.
* N: The patient's pain was initially well controlled with IV
pain medication, he was then transitioned to PO liquid pain
medication once extubated and his pain stayed well-controlled.
When he was awake enough to follow commands, CN 2-12 remained
grossly intact throughout admission without deficit.
* CV: The patient's blood pressure was noted to be elevated at
several points throughout the admission, with SBP as high as
approximately 180. This was managed with his home medications
and iv hydralazine. He is instructed to follow up with his PCP
for this.
* P: Once extubated, the patient was gradually weaned to room
air. At time of discharge he was ambulating independently
without supplemental oxygen.
* GI: The patient was initially NPO. He was slowly advanced,
but this was limited initially due to pain with swallowing; this
resolved with the roxicet. At time of discharge he was
tolerating his diet without nausea, vomiting, or diarrhea.
* GU: The patient initially had a foley catheter. This was
removed on [**2143-10-3**] and he subsequently voided without
complications.
* HEME: The patient was offered SCH and pneumoboots throughout
admission for DVT prophylaxis.
* ID: The patient received perioperative antibiotics, and
remained on iv unasyn while in the hospital. Upon discharge, he
was given PO augmentin, which he will take until his follow up
visit, at which point he can receive further instructions
regarding length of treatment.
The remainder of the hospital course was relatively
unremarkable, and patient was discharged in stable condition,
ambulating well independently, voiding regularly, and with
adequate pain control. It was incidentally noted on his CT scan
that he had a 1-cm thyroid nodule; he was instructed to follow
up with his PCP for this.
Today, on POD#4, both the patient and staff feel that he is
ready & stable for discharge home. The patient was given
explicit instructions to call Dr. [**Last Name (STitle) 3878**] for a follow-up
appointment, and to follow-up with his PCP [**Last Name (NamePattern4) **] [**2-3**] weeks. He was
also given detailed discharge instructions outlining wound care,
activity, diet, follow up care, and the appropriate medication
prescriptions.
Medications on Admission:
[**Last Name (LF) **], [**First Name3 (LF) **], Lisinopril, metop, rosuvastatin
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain: no alcohol or
driving. do not take additional tylenol when taking this drug.
take an over the counter stool softener when taking this drug.
Disp:*300 ML(s)* Refills:*0*
7. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
infected suspected thyroglossal duct cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- Seek immediate medical attention if you experience difficulty
breathing, increased trouble swallowing, fever (> 101.5) or
chills, signs of wound infection (increasing redness, increasing
swelling, draining pus, increased pain), throat swelling, chest
pain, shortness of breath, abdominal pain, or anything else that
is troubling you.
- Wound: Tape called Steri-strip is on your wound. These will
fall off by themselves. You may get them wet. Your sutures are
dissolvable and do NOT need removal.
- Activity: Walk as tolerated; do not vigorously exercise
until after your follow-up appointment, at least. Do not get
wound wet for 48 hours after surgery or your last drain was
removed. After 48 hours you may get wound wet during showers,
however avoid soaking the incision site (no baths, swimming, hot
tubs) for 2-4 weeks after surgery.
- Diet: You may consume a regular diet as previously
tolerated.
- Medications: Take medications as prescribed. You may resume
home medications. Do not drive or drink alcohol while taking
narcotic pain medications. Narcotic pain medications may cause
constipation. If this occurs, take an over the counter stool
softener. If you prefer you may take over the counter Tylenol in
place of your prescribed pain medication. DO NOT take Ibuprofen
or Aspirin for at least 3 days.
- Please call Dr.[**Name (NI) 37129**] office to schedule a follow-up
visit, at [**Telephone/Fax (1) 29891**]. Call your primary care provider to make
[**Name Initial (PRE) **] follow up appointment in [**2-3**] weeks.
Followup Instructions:
Please call Dr.[**Name (NI) 37129**] office to schedule a follow-up visit,
at [**Telephone/Fax (1) 29891**].
Call your primary care provider to make [**Name Initial (PRE) **] follow up appointment
in [**2-3**] weeks. Please discuss your blood pressure and your 1-cm
left thyroid nodule seen on CT scan.
Completed by:[**2143-10-4**]
|
[
"V12.54",
"722.91",
"272.0",
"412",
"278.00",
"759.2",
"518.89",
"V45.82",
"414.01",
"241.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"06.09"
] |
icd9pcs
|
[
[
[]
]
] |
8224, 8230
|
3902, 7320
|
361, 401
|
8316, 8316
|
2183, 3630
|
10033, 10368
|
1597, 1625
|
7451, 8201
|
8251, 8295
|
7346, 7428
|
8467, 10010
|
1640, 2164
|
272, 323
|
3665, 3824
|
429, 1178
|
3860, 3879
|
8331, 8443
|
1200, 1409
|
1425, 1581
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,935
| 151,031
|
8102
|
Discharge summary
|
report
|
Admission Date: [**2198-8-13**] Discharge Date: [**2198-8-17**]
Date of Birth: [**2154-4-10**] Sex: F
Service: MEDICINE
Allergies:
Tylenol / Sulfa (Sulfonamide Antibiotics) / Doxycycline / Latex
/ Gastrografin / Zyrtec / Ciprofloxacin / ceftriaxone
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
fever, concern for aspiration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
44 year old female with spinal muscular atrophy type 2,
osteogenesis imperfecta, and chronic neuromuscular respiratory
failure on AVAPS and BiPAP presents with of fever and cough in
setting of possible aspiration event.
Patient recently treated for sinusitis with azithromycin,
started on last Friday by Dr. [**First Name (STitle) **] (PCP). Patient had been
having sinus pain nd congestion for x 2 weeks. Had tried
neosynephrine, nasal fluticasone, sudafed, guaifenesin, and also
saline mist nebulizers but with no improvement. Developed fever
to 100.4. Given SMA, risk for sinopulmonary infxn, treated with
azithromycin for course of ~5 days with plan to broaden coverage
if symptoms worsened.
Initially felt better, but aspirated pills 1 day prior to
admission at 3PM (colace and probably azithromycin as well).
Over the course of weekend, developed fevers (to 101 at home),
coughing, night sweats x1 night (woke up in puddle of sweat),
increasing dyspnea and difficulty breathing. Sats were jumping
around from 90-97%. Performed chest PT, cough assist x 8 hrs,
and did not improve shortness of breath. Also felt like AVAPS
settings were insufficient (the settings cannot be changed).
Called Dr. [**Last Name (STitle) **] (pulmonology) and triage, who sent her to ED.
Uses AVAPS during the day, but using more frequently currently,
and nighttime BiPAP at 8/4, with expiratory sensitivity of 30%,
rise time of 400 milliseconds, and a backup rate of 12. The
daytime setting is on the AVAPS mode, which is volume averaged
and volume target pressure support, with a tidal volume of 300
mL, IPAP [**8-12**], EPAP 4, and a backup of 12. Recommended not to
use AVAPS at night.
Of note, she has several MDs at [**Hospital3 1810**] who can be
of
assistance as well if there are questions about medication
doses.
Regarding SMA2 and OI, she is actively followed by pulmonary
(Dr. [**Last Name (STitle) **] and neurology here as well as at Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**]
(orthopedics at CHB). Disease course has been complicated by
chronic pain in the hip/legs requiring oxycodone as well as
clonazepam and ibuprofen. She is followed at [**Hospital2 **] [**Hospital3 28901**] pain
center for pain management. She has felt incerasing weaknesses
as well, sometimes requiring help to bring food to her mouth as
well as bringing arm up to control her wheelchair. She has also
had difficulty with pill swallowing, although has not previously
choked or aspirated. Her PFTs, performed at CHB, have been
stable, although grossly abnormal (see below). She has also had
issues with frequent UTIs and is on oxybutynin.
In ED:
98.5 85 112/60 20 100%
Received albuterol for dyspnea.
Received ceftriaxone and flagyl. Also continued azithromycin.
Also received potassium 40 mEq
On floor, VS: AVSS.
Tried to continue her usual vent care on floor, with portable
ventilator (AVAPS) and BiPap at night. Respiratory therapy
stopped by to see, and recommended [**Hospital3 **] for ventilator needs.
Clinically stable, but pulmonary exam "worse than film looks."
Respiratory said will require humidified air and nebulizers and
careful management of secretions.
Transferred to MICU because of standard ventilator care.
Past Medical History:
1. Spinal muscular atrophy type 2.
2. Osteogenesis imperfecta.
3. Multiple bone fractures.
4. Restless legs syndrome.
5. Polycystic ovarian disorder.
6. Migraines.
7. Frequent UTIs.
8. Pyelonephritis, last in [**2184**].
9. Recurrent aspiration and bacterial pneumonia, most recently
pseudomonas treated with PO ciprofloxacin and inhaled tobramycin
[**2197-3-10**].
10. DVT in 05/[**2192**].
11. Severe Restrictive Lung Disease [**2-1**] neuromuscular disorder,
on "trilogy" ventilator at home. (PFTs [**2196-8-4**]: FVC of 0.72,
which is 25% predicted; [**2196-8-15**]: FVC of 0.68, which is 21%
predicted)
12. s/p appendectomy, reduction of cecal volvulus
13. Sleep disordered breathing
14. Chronic sinusitis
.
Social History:
Ms. [**Known lastname 28896**] lives at home with nearly around-the-clock help from
Personal Care Assistants. She lives in a [**Location (un) 448**] apartment
with a level entry and a ramp going to the front entrance. Her
entire apartment is wheelchair accessible. She does not have any
special devices for transfer such as a [**Doctor Last Name 2598**] lift, as all
transfers are made by physically lifting her.
.
She has never been a smoker. She has about one glass of wine
each night. She denies any illicit drug use.
Family History:
She is of Irish and English heritage. Her family lineage also
consists of Mennonitism, Mormonism, orthodox Judaism, and amish
people; she explains that there was inbreeding in her family,
resulting in unique circumstances such as "my mother is her own
cousin."
.
She does have a family history of SMA: she had one sister who
had
SMA as well as hepatitis C and passed away at the age of 22; she
also had a brother with SMA, who was much more significantly
affected (never sat up, had several bouts of aspiration
pneumonia, etc.), and passed away at the age of six. Both of
these siblings were diagnosed based on clinical history and
muscle biopsy.
.
She also has a family history of osteogenesis imperfecta, as her
mother, sister, grandfather and aunts had all been afflicted
with
this. There are multiple family members who have restless leg
syndrome, sleep apnea, and insomnia. Her father has
hypertension. Her brother and mother both had heart problems.
[**Name (NI) **] sister, mother, and grandmother all had depression.
.
Physical Exam:
Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear,
EOMI, PERRL
Neck: Supple, no LAD
CV: Tachycardic, regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Poor respiratory effort with decreased breath sounds
throughout
Abdomen: Soft, non-distended, bowel sounds present
GU: no foley
Ext: Cool, well perfused, with cyanosis L > R. No edema.
Neuro: CNII-XII grossly intact but weakness with jaw closure and
tongue protrusion although no clear atrophy or fasciculations,
moderate dysarthria, significant weaknesses in UE with severe
atrophy distally > proximally and decreased tone throughout, did
not test LE by patient request, grossly normal sensation,
wheelchair bound
Physical Exam on Discharge:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear,
EOMI, PERRL
Neck: Supple, no LAD
CV: Tachycardic, regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Poor respiratory effort with decreased breath sounds
throughout
Abdomen: Soft, non-distended, bowel sounds present
GU: no foley
Ext: Cool, well perfused, with cyanosis L > R. No edema.
Neuro: CNII-XII grossly intact but weakness with jaw closure and
tongue protrusion although no clear atrophy or fasciculations,
moderate dysarthria, significant weaknesses in UE with severe
atrophy distally > proximally and decreased tone throughout, did
not test LE by patient request, grossly normal sensation,
wheelchair bound
Pertinent Results:
Admission Labs:
[**2198-8-13**] 01:46PM LACTATE-1.1
[**2198-8-13**] 01:40PM GLUCOSE-93 UREA N-4* CREAT-0.1* SODIUM-141
POTASSIUM-2.7* CHLORIDE-101 TOTAL CO2-32 ANION GAP-11
[**2198-8-13**] 01:40PM estGFR-Using this
[**2198-8-13**] 01:40PM CALCIUM-8.4 PHOSPHATE-2.0*# MAGNESIUM-2.1
[**2198-8-13**] 01:40PM WBC-8.9 RBC-3.87* HGB-11.7* HCT-35.1* MCV-91
MCH-30.3 MCHC-33.3 RDW-13.6
[**2198-8-13**] 01:40PM NEUTS-67.7 LYMPHS-23.4 MONOS-4.5 EOS-4.0
BASOS-0.5
[**2198-8-13**] 01:40PM PLT COUNT-265
Discharge Labs:
[**2198-8-15**] 02:14AM BLOOD WBC-5.7 RBC-3.67* Hgb-11.2* Hct-33.6*
MCV-92 MCH-30.6 MCHC-33.4 RDW-13.6 Plt Ct-244
[**2198-8-15**] 02:14AM BLOOD Plt Ct-244
[**2198-8-15**] 02:14AM BLOOD Glucose-125* UreaN-4* Creat-0.1* Na-143
K-3.6 Cl-106 HCO3-27 AnGap-14
[**2198-8-15**] 02:14AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.8
Micro:
[**2198-8-14**] 12:18 am URINE Source: CVS.
**FINAL REPORT [**2198-8-15**]**
URINE CULTURE (Final [**2198-8-15**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2198-8-14**] 1:27 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2198-8-14**]**
GRAM STAIN (Final [**2198-8-14**]):
[**10-25**] PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2198-8-14**]):
TEST CANCELLED, PATIENT CREDITED.
[**2198-8-15**] 6:05 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Pending):
CHEST (PORTABLE AP) Study Date of [**2198-8-15**] IMPRESSION:
Essentially unchanged chest radiograph from prior imaging with
no evidence for acute pulmonary process.
[**2198-8-13**]
Chest AP portable:
COMPARISONS: Portable AP chest radiograph from [**2197-6-6**], CT
of the abdomen and pelvis from [**2197-6-6**].
FINDINGS: Single portable AP radiograph was provided. Severe
chest wall deformity and levoscoliosis with posterior fusion rod
is unchanged. Patchy opacities in the lower lung fieldsare
unchanged and could represent atelectasis. There is no effusion
or pneumothorax. Cardiomediastinal silhouette is unchanged.
IMPRESSION: No significant change from prior radiograph.
Patchy opacities at the bases may reflect atelectasis, though
infection cannot be excluded.
[**2198-8-15**]
FINDINGS: Single frontal image of the chest was obtained.
There is severe chest wall deformity and levoscoliosis again
seen. No focal opacities are visualized in the lungs. There is
no pneumothorax or pleural effusion seen. Cardiomediastinal
silhouette appears unchanged.
IMPRESSION: Essentially unchanged chest radiograph from prior
imaging with no evidence for acute pulmonary process.
Brief Hospital Course:
# Aspiration pneumonia vs aspiration pneumonitis: Patient with
known aspiration event, presented with constitutional symptoms
and respiratory distress. Thought to be be complicated by known
neuromuscular disease, which leaves patient with poor
respiratory reserve. In addition to antibiotics in ED, patient
was started on zosyn and tobramycin overnight. In the morning of
hospital day 2, however, decision was made to discontinue
antibiotics because of non-toxic appearance, no leukocytosis, no
fevers while in house, unchanged CXR, and unconcerning history
(no frank aspiration of gastric contents; only pills). Although
patient with known low respiratory reserve, the team felt that
continuing antibiotics would be inappropriate. Patient was
monitored for another 24 hours for any signs of fever,
infection, etc. Chest XR was repeated given patient complaints.
There was no interval change. Patient remained afebrile and did
not show evidence of respiratory distress. Sputum cultures and
blood cultures were followed, which were unrevealing for any
infection.
# Postnasal drip: During admission, patient complained of
dripping sensation down back of throat, and developed tenderness
to palpation along the sinuses. Normal saline nasal spray was
given, and patient's home fluticasone nasal spray was continued.
Although afebrile, given patient's history of SMA as well as
patient preference, azithromycin course was initially continued
(prescribed as outpatient for sinusitis). This was subsequently
discontinued as primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] team did not feel
that patient required antibiotics.
# Diarrhea: Patient developed diarrhea on hospital day 2. While
loose, the stool was not consistent with cdiff diarrhea. Cdiff
studies were sent, which was negative. Patient was started on
loperamide as well as hydrocortisone cream PR for perianal
itching and discomfort.
# Spinal muscular atrophy type 2: Chronic. Was stable. Patient
was continued on home pain medications as well as levocarnitine
(at double dose when sick). Urine analysis and culture were also
sent because patient's history of repeated UTI [**2-1**] atrophic
bladder with SMA2. Patient with dirty catch urine showed yeast
on UA, about which she was extremely anxious. Patient was given
one dose of fluconazole. Patient did note feeling bloated, and
reported taking her own, home furosemide without discussion with
healthcare providers. She was advised to ask for furosemide from
her nurse [**First Name (Titles) **] [**Last Name (Titles) 21334**].
# Depression/Anxiety: Continued home buspirone, citalopram
# [**Hospital 8304**] medical issues: Continued fluticasone, oxybutynin.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs(s)
inhaled every 4 to 6 hours as needed
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 neb inhaled six times daily as needed for
shortness of breath
BUDESONIDE - 0.5 mg/2 mL Suspension for Nebulization - 1
inhlation(s) inhaled twice daily
BUSPIRONE - 15 mg tablet - 2 (Two) Tablet(s) by mouth twice
daily **use this prescription while the 30mg buspirone tablets
are on back order**
CLONAZEPAM - 0.5 mg tablet - 1 tablet(s) by mouth 4 times daily
as needed for may take an extra as needed for pain
EPINEPHRINE [EPIPEN JR] - 0.15 mg/0.3 mL (1:2,000) Pen Injector
- use as needed prn
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray nasal once a
day
FUROSEMIDE - 20 mg tablet - 1 Tablet(s) by mouth once a day as
needed for edema
LEVOCARNITINE - 330 mg tablet - 3 Tablet(s) by mouth twice daily
OXYBUTYNIN CHLORIDE - 5 mg tablet - 1 Tablet(s) by mouth once
daily
OXYCODONE - (Prescribed by Other Provider) - 15 mg tablet - 2
Tablet(s) by mouth every 4 hours as needed for pain
RIZATRIPTAN [MAXALT-MLT] - 5 mg tablet,disintegrating - [**1-1**]
tablet(s) by mouth daily as needed for migraine
WHEELCHAIR EVALUATION - - Please evaluate for new wheelchair
Also reports take over the counter:
ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg
capsule, extended release - 1 Capsule(s) by mouth daily
CALCIUM CARBONATE - (Prescribed by Other Provider) - 400 mg
(1,000 mg) tablet, chewable - 1 Tablet(s) by mouth twice a day
MULTIVITAMIN - (Prescribed by Other Provider) - tablet,
chewable - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. budesonide *NF* 0.5 mg/2 mL Inhalation [**Hospital1 **]
* Patient Taking Own Meds *
4. BusPIRone 30 mg PO BID
5. Clonazepam 0.5 mg PO QID
6. Ascorbic Acid 500 mg PO DAILY
7. Calcium Carbonate 1000 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. rizatriptan *NF* 5-10 mg Oral DAILY:PRN headaches
* Patient Taking Own Meds *
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR Q12H rectal
pain
12. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
hold for sedation, rr < 12
13. Oxybutynin 5 mg PO DAILY
14. Levocarnitine 990 mg PO BID
15. Furosemide 20 mg PO DAILY:PRN edema
16. Bismuth Subsalicylate 15 mL PO TID:PRN diarrhea
17. Guaifenesin-Dextromethorphan [**5-10**] mL PO Q6H:PRN cough
18. Loperamide 4 mg PO QID:PRN diarrhea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: loose stool, respiratory distress
Secondary: osteogenesis imperfecta, spinal muscular atrophy type
II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 28896**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital for
respiratory distress and concern for aspiration pneumonia. A
chest x-ray and laboratory testing did not reveal any infections
and your respiratory status improved with your usual home
pulmonary therapy. You also had loose stools, possibly due to
antibiotics, without any evidence of [**Last Name (un) **] infection. You were
treated with medications to slow down your bowel movements.
Your vital signs remained at your baseline.
Please follow up with your [**Last Name (un) 21334**] as recommended below.
Medication changes:
Bismuth subsalicylate 15 ml PO three times a day as needed for
diarrhea
Loperamide 4 mg PO four times per day as needed diarrhea
Hydrocortisone rectal cream 2.5% every 12 hours as needed for
rectal pain
Please take all other medications as previously prescribed.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2198-8-21**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2198-9-5**] at 2:50 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2198-9-5**] at 3:10 PM
With: DR. [**Last Name (STitle) 28902**]/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"787.91",
"473.9",
"786.09",
"756.51",
"780.60",
"300.4",
"346.90",
"335.11",
"333.94",
"256.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15740, 15746
|
10466, 13170
|
408, 414
|
15901, 15901
|
7598, 7598
|
17003, 17898
|
4980, 6011
|
14831, 15717
|
15767, 15880
|
13196, 14808
|
16052, 16695
|
8120, 10443
|
6026, 6040
|
6830, 7579
|
16715, 16980
|
339, 370
|
442, 3689
|
7614, 8104
|
6054, 6802
|
15916, 16028
|
3711, 4425
|
4441, 4964
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,943
| 125,173
|
46762+46763
|
Discharge summary
|
report+report
|
PLEASE REFER TO DISCHARGE SUMMARY OF [**2107-11-11**] FOR CORRECTED
INFORMATION.
Name: [**Known lastname **], [**Known firstname 4092**] Unit No: [**Numeric Identifier 99250**]
Admission Date: [**2107-11-2**] Discharge Date: [**2107-11-11**]
Date of Birth: [**2027-5-26**] Sex: F
Service: [**Last Name (un) **]
SERVICE: Minimally invasive surgery.
HISTORY OF PRESENT ILLNESS: This is an 80 year-old female
with history of hypertension, hyperlipidemia and bipolar
disorder. She comes in with abdominal pain of less than 1
days duration. She describes the pain as sharp and epigastric
and band-like in nature. She has had some nausea with a few
episodes of vomiting without signs of hematemesis. She was
found by social working writhing in pain at her group home.
She, of note, has a long history of constipation but no
recent diarrhea. She reports no chest pain, shortness of
breath or other associated symptoms. Otherwise, had been
taking a normal diet for the last 2 days.
PAST MEDICAL HISTORY: Significant for hyperlipidemia,
hypertension; history of ventricular fibrillation with
cardiac arrest. She has a converting device in place.
Status post cholecystectomy. Obsessive compulsive disorder,
bipolar disorder and B-12 deficiency with a questionable
allergy to sulfa and Zoloft.
PHYSICAL EXAMINATION: On admission, temperature was 99.4
Fahrenheit; heart rate 84; blood pressure 108/64; respiratory
rate 20 and breathing 97% on room air. General: She was a
moderately distressed elderly appearing female. She was
normocephalic, atraumatic. Pupils were equally round and
reactive to light. Extraocular movements intact. Oropharynx
was clear and mucous membranes were moist. Neck was supple
with no lymphadenopathy. No masses or thyromegaly were
appreciated. Heart was regular rate and rhythm with no
murmur, rub or gallop. Normal S1 and S2, clear to
auscultation bilaterally without wheezes, rales or rhonchi.
Abdomen was firm, diffusely tender with hypoactive bowel
sounds and was severely distended. There were no signs of any
rebound or guarding at this time and there were no masses
palpated on exam. There was no hepatosplenomegaly. Extremity
exam revealed no clubbing, cyanosis or edema. Neurologic
exam revealed the patient to be alert and oriented to person
and place but not time and occasionally seemed confused and
disturbed by the situation at hand. Her strength was [**3-31**]
throughout and her sensation was normal throughout.
HOSPITAL COURSE: At this time, the patient was further
evaluated in the emergency department. A kidney, ureter,
bladder film was performed that revealed marked dilation of
the descending and transverse colon to 10.7 cm and then a
distinct transition point in the descending colon. There was
no free air and no dilated loops of small bowel. There was no
air in the rectum. At this point, cecal volvulus was
considered primarily with question of perforation. There was
also free air on this film under the diaphragm on the right
side, tracking down to the hip. Also at this time, a CAT
scan was performed. An attempt was made to decompress with a
rigid sigmoidoscope. This was unsuccessful. This was done by
the gastroenterology service; thus, the patient required an
emergent trip to the operating room. On the CAT scan, there
was also notable free air retroperitoneal and subcutaneous
and a cecal volvulus with colon up to 15 cm. The patient was
consented and brought to the operating room urgently after
intravenous fluids and antibiotics were instituted. Under
general anesthesia, the procedure was performed which
included a right colectomy, a repair of a sigmoid
perforation, primarily an end ileostomy and an end transverse
colostomy. The patient tolerated the procedure well under
general anesthesia and received 4500 ml of Crystalloid. She
had a urine output of 345 ml during the case. A drain was
also placed at this time and her estimated total blood loss
was 250 ml. The right colon, at this time, was sent for
pathology.
In the immediate postoperative period, the patient's pain was
fairly well controlled. Her sedation was weaned and she was
extubated on postoperative day number 2. She was placed on
Metoprolol at this time and she was continued on intravenous
fluids and antibiotics. The electrophysiology service was
also consulted for her converting device and suggested that
she have an appointment as an outpatient in [**2108-1-25**] and
that the device was indeed functioning normally after
interrogation. The patient also had inpatient nutritional
assessments at this time and they suggested she would likely
need TPN. Also, at this time, the psychiatry service was
consulted. They suggested using Haldol as needed for
agitation. This recommendation was followed by the general
surgery service. They also suggested starting Klonopin when
the patient was taking p.o. again.
On postoperative day number 3, the patient continued to
improve. She was on a Nitro drip at this time for blood
pressure elevation. She began to self diurese. On
postoperative day number 4, it was determined that the
patient would be made DNR/DNI for the family. The Nitro drip
was weaned. She was continued on sips. The plan was for
discharge to the floor in the next 1 to 2 days. On [**2107-11-7**], postoperative day number 5, the patient was
transferred to the floor. She was continued on hydration with
intravenous fluids. On postoperative day number 6, the
patient continued to progress well. She began to be seen by
physical therapy. She was started on full liquids and her
[**Location (un) 1661**]-[**Location (un) 1662**] drain was removed. She also had wicks in the
wound. At this point, every other wick was removed and the
wound looked clean, dry and intact without any signs of
erythema or purulent drainage. Also, at this time, a
geriatrics consult was sought. They saw the patient on
[**2107-11-9**]. Following their recommendations, we began
Tylenol as a standing order, 1 gram 3 x a day and Oxycodone
2.5 mg 3 x a day. They also suggested starting her back on
her home medications which were Klonopin 0.5 q. h.s. and
Lamictal 25 mg q. day. At this point, Haldol was also
discontinued. The patient continued to improve throughout
the postoperative period. On [**11-11**], she was taking a
regular diet. She was off all intravenous fluids and all
intravenous medications. She was being followed by physical
therapy. Her confusion seemed to be improving though she
continued to have occasional bouts of incontinence. This also
began to improve as she resumed her home medication regimen.
She was deeded fit for discharge to a rehabilitation
facility. The case was discussed at length with her daughter,
[**Name (NI) 2048**] [**Name (NI) **], who agreed with this plan.
DISCHARGE INSTRUCTIONS: The patient will be discharged to a
having worsening pain, fevers, chills, nausea and vomiting,
shortness of breath, chest pain, redness or drainage about
the wounds or if there were any questions or concerns. The
patient was to take medications as directed.
DISCHARGE MEDICATIONS: Metoprolol 12.5 mg p.o. b.i.d.,
Oxycodone 2.5 mg p.o. q. 8 hours prn. Lamictal 25 mg p.o. q.
day. Klonopin 0.5 mg p.o. q. h.s., Acetaminophen 1000 mg
p.o. t.i.d. Escitalopram 5 mg p.o. q. Day. Seroquel 100 mg
p.o. q a.m., 200 mg p.o. q h.s. Pantoprazole 40 mg p.o. q.
day. Insulin per the sliding scale attached. Heparin 5000
units subcutaneous t.i.d.
DISPOSITION: The patient is to be discharged to rehab in
stable condition.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2107-11-10**] 17:34:18
T: [**2107-11-10**] 18:59:19
Job#: [**Job Number 99251**]
Admission Date: [**2107-11-3**] Discharge Date: [**2107-11-11**]
Date of Birth: [**2027-5-26**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
right colectomy, repair of sigmoid colon perforation primarily,
end ileostomy and transverse colostomy, central venous line
placement, peripheral venous line placement, Foley catheter
placement, nasogastric tube placement, [**Doctor Last Name 406**] drain placement,
endotracheal intubation
History of Present Illness:
80 F (poor historian-some of the history was obtained from the
social worker who was present with the patinet) developed
diffuse abdominal pain at nursing facility about 6 hours prior
to presentation in the emergency department. The pain had
gradual onset, was constant and severe at times, and had no
aggrevating or alleviating factors. Patient had nausea, no
vomiting, no fevers, one episode of diarrhea, and it was unclear
whether she passed flatus.
Past Medical History:
s/p MI [**2096**] complicated by vfib arrest, AICD placement
bipolar disorder s/p ECT
hypercholesteremia
sleep apnea
B 12 deficiency
HTN
open cholecystectomy [**2099**]
Physical Exam:
temp- 95 HR- 60 BP- 108/64 RR 20 O2 sat- 97% RA
Gen-appears uncomfortable
Cor-RRR
Lungs-CTA bilaterally
Abd-distended, soft, moderate diffuse tenderness-worse on R
side, no peritoneal signs
Rectal-no masses, guiac negative
Pertinent Results:
[**2107-11-2**] 05:40PM WBC-10.1 RBC-4.14* HGB-12.9 HCT-36.8 MCV-89
MCH-31.2 MCHC-35.1* RDW-12.9
[**2107-11-2**] 05:40PM CALCIUM-9.2 PHOSPHATE-2.8 MAGNESIUM-1.7
[**2107-11-2**] 05:40PM NEUTS-70.4* LYMPHS-24.9 MONOS-3.2 EOS-1.0
BASOS-0.5
[**2107-11-2**] 05:40PM PLT COUNT-260
[**2107-11-2**] 05:40PM LIPASE-22
[**2107-11-2**] 05:40PM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-53
AMYLASE-50 TOT BILI-0.2
[**2107-11-2**] 05:40PM GLUCOSE-168* UREA N-22* CREAT-1.0 SODIUM-140
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-17
[**2107-11-2**] 07:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
Brief Hospital Course:
A KUB was obtained in the ED which was read as having a cut-off
in the descending colon and the transverse colon measured 10.7
cm. There was no free air noted. Based upon these findings and
the suspicion for sigmoid volvulus by radiology read, a rigid
sigmoidoscopy was performed in the ED by the surgical service.
Decompression was not achieved. At this point, a GI consult was
obtained for possible colonoscopic decompression. It was
decided to obtain a CT scan prior to any further
intervention-this revealed a cecal volvulus and a significant
amount of free air in the abdomen. The free air was also seen
on a KUB obtained by the ED to confirm NGT placement. Based
upon these findings, the patient was taken the operating room.
The details of the operation can be seen in the formal operative
report. In brief, a right colectomy was performed as it was
grossly necrotic. An end ileostomy, end transverse colostomy,
and primary repair of the rectal perforation was also performed.
[**Doctor Last Name 406**] drains were left in the pelvis. Postoperatively, the
patient was transferred to the ICU for her initial care. She
was maintained on broad spectrum antibiotics, and was extubated
on post op day (POD) 1. The cardiology service (EPS) performed
an AICD check which was okay and the psychiatry service and
geriatrics service made recommendations for medication
management. The NGT was removed and the patient was transferred
to the floor for the remainder of her surgical care on POD 3.
The incision showed no signs of infection. Physical therapy
began working with patient and the patient was also started on a
clear liquid diet. Her diet was advanced with no difficulty and
there was appropriate ostomy output. The [**Doctor Last Name 406**] drains were
removed as they had minimal output. The patient was transferred
to rehab tolerating a regular diet.
Medications on Admission:
vit D
fosamex 70 q week
buspirone 10 mg qd
lamictal 100 mg qd
mobic 7.5 mg qd
lexapro 20 mg qd
detrol 4 mg qd
lipitor 10 mg qd
seroquel 100 mg qd
protonix 40 mg qd
asa 81 qd
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
4. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
8. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP<100, HR<60.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
cecal volvulus, hypertension, dyslipidemia, bipolar disorder,
obsessive compulsive disorder, B12 deficiency
Discharge Condition:
stable
Discharge Instructions:
Patient to be discharged to rehabilitation facility and to make
MD aware if having worsening pains, fevers, chills, nausea,
vomiting, shortness of breath, chest pain, or if there are any
questions or concerns. Patient to take medications as directed,
to have physical therapy at rehab, to have ostomy cared for at
rehab.
Followup Instructions:
Patient to follow up with Dr. [**Last Name (STitle) **] in one to two weeks and to
call to schedule an appointment at [**Telephone/Fax (1) 64379**]
Scheduled Appointments :
Provider DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2108-2-13**]
9:30
|
[
"560.2",
"557.0",
"569.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.10",
"45.73",
"89.49",
"38.93",
"54.64",
"47.19",
"40.11",
"46.20"
] |
icd9pcs
|
[
[
[]
]
] |
12981, 13051
|
10001, 11880
|
8080, 8373
|
13203, 13212
|
9316, 9978
|
13582, 13845
|
12104, 12958
|
13072, 13182
|
11906, 12081
|
2513, 6801
|
13236, 13559
|
9065, 9297
|
1349, 2495
|
8026, 8042
|
8401, 8857
|
8879, 9050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,109
| 163,080
|
49909
|
Discharge summary
|
report
|
Admission Date: [**2156-8-31**] Discharge Date: [**2156-9-8**]
Date of Birth: [**2088-6-21**] Sex: F
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 3063**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Tunneled HD catheter placement
History of Present Illness:
Ms. [**Known lastname 33858**] is a 68 year old woman with a history of CAD, dCHF
(EF 50-55% [**8-/2156**]), and stage V CKD who is being transferred
from [**Hospital1 **] with worsening respiratory distress. She
originally presented to [**Hospital1 **] [**Location (un) 620**] on [**2156-8-28**] with several days
of diarrhea. Her hospital stay was complicated by hypoxemia,
waxing and [**Doctor Last Name 688**] mental status, non-ST elevation MI, and
hypotension.
When the patient first presented to [**Hospital1 **]-N, labs showed worsening
renal function with creatinine of 5.5-6.0 up from 3.4 in [**Month (only) 116**].
She was initially treated with IVF because pre-renal azotemia
from diarrhea was suspected however she did not improve with
fluids.
The patient was reportedly oxygenating well on arrival to [**Hospital1 **]-N,
but she became hypoxemic shortly after admission and was
transferred to their ICU. A CXR showed possible LLL opacity.
There was concern for aspiration pneumonia and so she was
treated with vancomycin and zosyn.
Labs were also notable for a Troponin-T which trended up to a
peak of 0.469 on [**8-29**]. It is not clear that she had any
symptoms related. She was not treated with heparin or cardiac
catheterization since it was ascribed to demand ischemia. Of
note she had an NSTEMI back in [**Month (only) 956**] where she was treated
medically. At that time troponin peaked at 0.75 on [**2-/2073**] but
trended down to 0.03 by [**3-21**].
During the admission she also had an exacerbation of her chronic
gastroparesis. She had an NG tube placed to suction with some
relief. There was no KUB or other documentation of concern for
SBO. There was also some report of brown "possibly"
coffee-ground emesis which was guiaic positive at [**Location (un) 620**]. Stool
guiaic was negative. HCT was 28-29 which is around her baseline.
Vital signs at [**Hospital1 **] were stable until the morning of
transfer where she dropped her SBPs to the 70s. She apparently
received Imdur as well as an extra dose of amlodipine the night
prior. She was initiated on pressors and had femoral a-line and
femoral CVL placed. She also had worsening of her respiratory
status during a similar time period. At the time of transfer she
was reportedly breathing with a respiratory rate in the 20s and
sats of 95-100% on a non-rebreather.
On arrival to the MICU at [**Hospital1 18**] she is normotensive off of
pressors. She was on a non-rebreather but she was quickly able
to be lowered to a 40% face mask with O2 sats in the mid 90s.
She is not in any acute distress. Her biggest complaint is dry
mouth.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies wheezing. Denies
chest pain, chest pressure, palpitations. Denies dysuria,
frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
-Stage V kidney disease (first fistula attempt failed awaiting
second evaluation for fistula), recent temporary HD requirement
-CAD s/p NSTEMI [**3-/2156**] managed medically
-Chronic diastolic heart failure
-Hypercalcemia
-anemia secondary to renal disease on Aranesp
-known kidney stone
-hypertension
-gout
-diabetes on insulin
-diabetic neuropathy s/p L 5th toe amputation
Social History:
Marital Status: Single. Children: None. Occupation: Office
Manager for an Insurance Agency. Tobacco: None. Alcohol: None.
Family History:
Fam hx + for hypertension.
Mother: died AMI age 57 was diabetic
Father:Died AMI age 82 was diabetic
Siblings 4 sisters, 2 with diabetes and alive, one sister died
of COPD and the other of pancreatic carcinoma
Physical Exam:
Admission exam:
Vitals: 97.7; 73; 120/47; 78; 16; 96% 2L NC
General: Alert, no acute distress
HEENT: Sclera anicteric, dry MM
Neck: supple
Lungs: crackles at bases
CV: Regular rate and rhythm, soft systolic murmur, no rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, + edema b/l LE
Discharge exam:
Afebrile, HR 70s, BP 130s-150s/70s-80s, satting well on room air
General: A and O x3, NAD
HEENT: atraumatic, moist MM
Lungs: crackles at right base, otherwise clear, breathing
comfortably
CV: RRR, soft systolic murmur, no rubs or gallops
Abd: soft, NTND
Ext: warm, trace edema in lower extremities
Pertinent Results:
Labs on Admission:
[**2156-8-31**] 03:55PM TYPE-ART TEMP-36.5 O2-70 PO2-63* PCO2-52*
PH-7.36 TOTAL CO2-31* BASE XS-2
[**2156-8-31**] 03:55PM LACTATE-0.8
[**2156-8-31**] 03:42PM GLUCOSE-143* UREA N-133* CREAT-5.5*#
SODIUM-150* POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-28 ANION GAP-19
[**2156-8-31**] 03:42PM estGFR-Using this
[**2156-8-31**] 03:42PM ALT(SGPT)-24 AST(SGOT)-20 LD(LDH)-220
CK(CPK)-49 ALK PHOS-72 TOT BILI-0.2
[**2156-8-31**] 03:42PM CK-MB-4 cTropnT-0.34*
[**2156-8-31**] 03:42PM CALCIUM-8.9 PHOSPHATE-5.9* MAGNESIUM-2.9*
[**2156-8-31**] 03:42PM WBC-13.5*# RBC-2.75*# HGB-8.1*# HCT-25.4*#
MCV-93 MCH-29.5 MCHC-31.8 RDW-17.1*
[**2156-8-31**] 03:42PM NEUTS-92.0* LYMPHS-4.6* MONOS-3.2 EOS-0.1
BASOS-0.2
[**2156-8-31**] 03:42PM PLT COUNT-154
[**2156-8-31**] 03:42PM PT-12.8* PTT-34.0 INR(PT)-1.2*
Discharge labs:
[**2156-9-8**] 08:00AM BLOOD WBC-7.6 RBC-3.30* Hgb-10.0* Hct-31.1*
MCV-94 MCH-30.2 MCHC-32.0 RDW-17.2* Plt Ct-224
[**2156-9-7**] 01:25PM BLOOD PT-11.0 PTT-40.9* INR(PT)-1.0
[**2156-9-8**] 08:00AM BLOOD Glucose-145* UreaN-32* Creat-2.8* Na-133
K-4.9 Cl-96 HCO3-30 AnGap-12
[**2156-9-8**] 08:00AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
[**2156-9-2**] 06:50PM BLOOD PTH-145*
[**2156-9-2**] 11:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2156-9-2**] 11:00AM BLOOD HCV Ab-NEGATIVE
[**2156-9-1**] 04:34AM BLOOD freeCa-1.14
Imaging:
CXR [**2156-8-31**]
FINDINGS: Two frontal images of the chest demonstrate new
bilateral pleural effusions, right greater than left. An NG
tube is seen passing along the expected course and out of view
and then returning into view before terminating in the stomach.
Cardiomegaly is seen. There is some increased vascular
congestion since prior exam.
IMPRESSION: Bilateral pleural effusions. Pulmonary vascular
congestion and cardiomegaly consistent with new mild pulmonary
edema.
Abdominal X-ray [**2156-9-1**]
IMPRESSION: Unremarkable bowel gas pattern with no evidence of
obstruction. NG tube coiled in the stomach with distal tip
pointing towards the fundus, although it is not completely
imaged on this exam.
CXR [**2156-9-1**]
FINDINGS: There is moderate vascular congestion and an enlarged
cardiac
silhouette, which suggests mild pulmonary edema. There are
moderate bilateral pleural effusions. There are consolidations
in the lower lobes bilaterally which could simply be areas of
lung collapse, however pneumonia cannot be ruled out on this
exam. Recommend repeat chest radiograph after diuresis to rule
out pneumonia at the lung bases.
IMPRESSION: Bibasilar consolidations, likely lung collapse, but
cannot rule out pneumonia. Recommend repeat chest radiograph
after diuresis to reassess for pneumonia.
CXR [**2156-9-4**]
Right lower [**Month/Day/Year 3630**] collapse is persistent. Left lower [**Month/Day/Year 3630**]
atelectasis have
markedly improved. Mild vascular congestion is unchanged.
Cardiomegaly and widened mediastinum are grossly unchanged. HD
catheter is in standard
position. There is no evident pneumothorax. Bilateral pleural
effusions are small.
CT of Chest [**2156-9-4**]
LUNGS/AIRWAYS: Interval development of bilateral upper [**Month/Day/Year 3630**]
predominant
ground-glass opacities, demonstrating a bronchovascular
distribution. New
bilateral lower [**Month/Day/Year 3630**] atelectasis, worse on the right, with
intrinsic air
bronchograms. The endobronchial tree is clear without evidence
of endoluminal mass centrally however the distal branches appear
narrowed. Moderate right and small left pleural effusion.
MEDIASTINUM: Visible portions of the thyroid gland demonstrate
homogeneous attenuation. Subcentimeter supraclavicular and high
paratracheal lymph nodes do not meet CT criteria for pathologic
enlargement by size. Additional stable high right paratracheal
lymph node measuring 8 mm on short axis (2:14). Interval
enlargement of low right paratracheal lymph node measuring 1.3 x
1.3 cm, previously 1.0 cm. Scattered small AP window lymph
nodes are stable, the largest measuring 6 mm on short axis.
Evaluation for hilar lymphadenopathy is limited due to absence
of IV contrast. Normal caliber thoracic aorta with moderate
atherosclerosis. Atherosclerotic calcifications of the branches
of
the aortic arch. The pulmonary trunk is upper limits of normal
by size.
Cardiomegaly. Diffuse atherosclerotic calcifications of the
coronary
arteries. No pericardial effusion. Dense calcifications of the
mitral
annulus.
ABDOMEN: Atherosclerosis of the abdominal aorta.
Atherosclerotic
calcifications of the intrahepatic and splenic arteries. The
remaining
visible upper abdominal organs are within normal limits.
BONES AND SOFT TISSUES: Multilevel degenerative disc disease
with
osteophytes. No acute fracture or destructive osseous process.
Coarse
calcifications in the glandular tissue of both breasts,
unchanged. Soft
tissues of the chest wall are normal.
IMPRESSION:
1. New multifocal bilateral patchy ground-glass opacities
predominantly
involving the upper lobes with a bronchovascular distribution
are nonspecific. Differential considerations include alveolar
edema/hemorrhage, or an infection/inflammatory process.
Recommend follow up CT chest in 6 to 8 weeks to ensure
resolution.
2. New bilateral lower [**Month/Day/Year 3630**] atelectasis, worse on the right.
Underlying
infectious consolidation cannot be excluded. This will be
re-evaluated at the time of follow up imaging.
3. Essentially stable mediastinal lymph nodes, with mild
interval enlargement of low right paratracheal lymph node.
Findings are likely reactive. A ttention on follow up imaging.
4. Moderate right and small left pleural effusion.
5. Coarse calcifications in the glandular tissues of both
breasts. Please
correlate with mammography.
6. Coronary artery calcifications of uncertain hemodynamic
significance.
Microbiology:
Blood cultures x 2 from [**2156-8-31**]: no growth
ECG ([**2156-9-6**])
Sinus rhythm. A-V conduction delay. Left atrial abnormality.
Lateral
and anterolateral ST segment abnormality consistent with
possible ischemia or left ventricular hypertrophy. Compared to
the previous tracing of [**2156-8-31**] the lateral and anterolateral ST
segment abnormality is more prominent. Clinical correlation is
suggested.
ECG ([**2156-9-8**])
Sinus rhythm. P-R interval prolongation. Left atrial
abnormality. Possible left ventricular hypertrophy. Diffuse ST-T
wave abnormalities may be related to left ventricular
hypertrophy but cannot rule out underlying myocardial ischemia.
Compared to the previous tracing of [**2155-9-6**] multiple described
abnormalities persist. Clinical correlation is suggested.
Brief Hospital Course:
Patient is a 68 year old female with history of stage V chronic
kidney disease, coronary artery disease, and diabetes mellitus
who presented to an outside hospital with diarrhea, with
complicated course including hypoxia, hypotension, and NSTEMI,
transferred for further management.
Active issues:
#) Hypoxia: On non-rebreather at time of transfer. Patient
completed 5 day course of vanc/zosyn for possible pneumonia
given aspiration risk. However, symptoms were most likely due to
volume overload in the setting of ESRD not yet on HD after
receiving IVF at [**Hospital1 **]-N. Patient was volume overloaded on exam,
with pleural effusion on CXR, and 8 kg above dry weight on
admission. Failed IV diuresis and was started on HD, with
significant improvement of respiratory status. She was
discharged off oxygen. Repeat CXR read as showing collapse of
right lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] CT scan was obtained to evaluate for masses
and showed new multifocal bilateral patchy opacities
predominantly in upper lobes which were non-specific. Repeat
imaging suggested in [**6-11**] weeks to ensure resolution.
#) Stage V chronic kidney disease: Worsening of renal function
noted at time of admission to outside hospital, which may have
been ATN in setting of diarrhea and/or progression of underlying
disease. Renal consult was called, and plans were made for
placement of tunneled HD line, which was placed on [**9-2**] and
patient was started on HD with good results. Attempt was made at
placing right axillary loop AV graft on [**9-7**], but this was
unsuccessful due to heavy arterial calcifications. Patient was
discharged with tunneled line in place and will get MWF HD.
#) Anemia: Patient's Hct was 25.4 on admission in the setting of
possible history of hematemesis. Patient had no signs of GI
bleeding during admission and Hct was initially stable, so this
may have been due to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear in the context of
nausea/wretching due to uremia and possible gastroenteritis.
Although patient was given DDAVP prior to tunneled line
placement, she developed significant site bleeding following the
procedure which required additional DDAVP and stitch placement.
She was given 2 units of PRBCs and HCT was stable for the
remainder of the admission.
#) Blood pressure control: Patient hypotensive on admission,
which resolved relatively quickly and may have reflected
aggressive up-titration of blood pressure medications. She was
initially restarted on beta-blocker only, but continued to be
hypertensive and clonidine was added. She was called out to the
floor following HD initiation, but was hypertensive to the 190s
and was given additional 100mg of labetolol at approximately
1:30am on [**9-2**]. At 4am, 4 second asystolic pause was noted on
telemetry, code was called and patient was transferred back to
the ICU. Beta blockers were held, no further arrythmias noted.
Patient transferred back to the floor on [**9-3**]. She was
hypertensive to the 200s systolic upon arrival to the floor, and
was given a bolus of hydralazine and dialyzed the next day. Her
home metoprolol was restarted at half dose, then increased to
home dose as patient had no further events on telemetry. Blood
pressures continued to run high, so nifedipine was also
restarted with good results.
#) Coronary artery disease: Patient with elevated cardiac
enzymes at [**Hospital1 **], which trended down following transfer.
Echocardiogram was performed which showed no new wall motion
abnormalities. No further episodes concerning for ACS. Pt did
have some ECG changes on a routine ECG performed during
admission (see ECG reports above); however, she denied any
symptoms of chest pain. Troponins were difficult to interpret
given kidney disease. However, CK was downtrending throughout
admission.
#) Type II diabetes: Patient on sliding scale insulin during
admission, with worsening blood sugar control after re-starting
PO intake. Sugars in 300s intermittently on the day prior to
discharge, patient discharged back on 14 units of Lantus but
will likely need further titration as an outpatient.
#) Altered mental status: Oriented but intermittently not
appropriate at beginning of admission. Likely multifactorial
with marked uremia as well as scopolamine and small dose of
lorazepam overnight for insomnia. Nonfocal neuro exam. Her
mental status improved following the institution of HD, and
patient was back at her baseline on discharge.
Transitional issues:
- Repeat CT scan in [**6-11**] weeks to evaluate for resolution of
ground glass opacities
- Monitor blood sugar control. Patient's blood sugars were
elevated in the 300s the day prior to discharge, and her insulin
was increased, but she will likely need continued titration
- Monitor blood pressure control
- Continue MWF dialysis
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Allopurinol 100 mg PO EVERY OTHER DAY
2. Lidocaine 5% Patch 1 PTCH TD DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Atorvastatin 40 mg PO DAILY
5. Bumetanide 3 mg PO QAM
6. Bumetanide 2 mg PO QPM
7. Glargine 10 Units Breakfast
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. darbepoetin alfa in polysorbat *NF* 60 mcg/0.3 mL Injection
Q3weeks
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Aspirin 81 mg PO DAILY
15. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
16. guanFACINE *NF* 1 mg Oral qhs
17. NIFEdipine CR 90 mg PO DAILY
Discharge Medications:
1. Allopurinol 100 mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Metoprolol Tartrate 25 mg PO BID
6. Nephrocaps 1 CAP PO DAILY
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
9. Vitamin D 1000 UNIT PO DAILY
10. darbepoetin alfa in polysorbat *NF* 60 mcg/0.3 mL Injection
Q3weeks
11. Ferrous Sulfate 325 mg PO DAILY
12. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
13. CloniDINE 0.1 mg PO TID
hold for SBP < 100
RX *clonidine [Catapres] 0.1 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*2
14. NIFEdipine CR 60 mg PO DAILY
RX *nifedipine [Adalat CC] 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
15. guanFACINE *NF* 1 mg Oral qhs
16. Lidocaine 5% Patch 1 PTCH TD DAILY
17. Glargine 14 Units Breakfast
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Acute on chronic renal failure
Uremia
Possible aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname 33858**],
You were transferred to [**Hospital1 18**] from [**Hospital1 18**] [**Location (un) 620**] with low blood
pressures, difficulty breathing and kidney failure. After
transfer, you completed a course of antibiotics for possible
pneumonia. You had a tunneled dialysis catheter placed and began
hemodialysis.
Changes to your home medications include:
-STOP taking Bumex
-DECREASE dose of nifedipine CR to 60mg daily
-START clonidine 0.1mg three times per day
-RE-START clopidogrel 75mg daily
Your blood sugar has been elevated in the hospital. Please take
14 units of glargine daily and check your blood sugars four
times a day for the next week. Please call your doctor right
away if your sugar continues to be elevated over 300.
You should keep the dressing on your right arm for another day
and can remove it tomorrow. Please keep wound dry. You can
shower but not soak in the bath.
It was a pleasure taking care of you during your hospitalization
and we wish you the best going forward.
Followup Instructions:
You will start outpatient dialysis [**Last Name (LF) 2974**], [**2156-9-8**] at
8:00am at:
[**University/College **] Dialysis Center
[**Hospital1 104254**] ????????????' Lower Level
[**University/College **] [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 104255**]
Nephrologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**]
Outpt hd schedule will be every Mon, Wed & Fri at 8:00am
Department: PHYSICIAN SUITE
When: [**Last Name (NamePattern1) **] [**2156-9-10**] at 8:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], NP [**Telephone/Fax (1) 721**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: TRANSPLANT CENTER
When: MONDAY [**2156-9-13**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 8598**]
Thursday [**9-16**] at 2:45PM
You were found to have an area of your lung that had been
partially deflated on our scans. While your breathing has been
stable, you should followup with a pulmonary doctor within a
month. Please call Phone: ([**Telephone/Fax (1) 513**] for an appointment.
Completed by:[**2156-9-18**]
|
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"V49.72",
"V49.86",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"83.09",
"38.95"
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icd9pcs
|
[
[
[]
]
] |
18017, 18080
|
11435, 11719
|
308, 341
|
18192, 18192
|
4746, 4751
|
19428, 20958
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3811, 4022
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17086, 17994
|
18101, 18171
|
16322, 17063
|
18375, 19405
|
5588, 11412
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4037, 4411
|
4427, 4727
|
15964, 16296
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3003, 3254
|
261, 270
|
11734, 15608
|
369, 2984
|
4765, 5572
|
18207, 18351
|
3276, 3655
|
3671, 3795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,908
| 181,185
|
15116
|
Discharge summary
|
report
|
Admission Date: [**2111-3-18**] Discharge Date: [**2111-3-19**]
Date of Birth: [**2066-9-14**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 44-yera-old male with
a history of coronary artery disease, status post myocardial
infarction in [**8-11**], status post stent proximal and mid-RCA
lesion and OM lesion. He had a Myoview on [**2-9**] which showed
fixed inferior wall defect but no evidence of ischemia. He
has been getting short of breath with exertion times one
month and also has occasional chest tightness. He denies
orthopnea, edema, paroxysmal nocturnal dyspnea, diaphoresis,
claudication. He also has history of hypertension, high
cholesterol and noninsulin dependent diabetes mellitus. He
underwent cardiac catheterization today which revealed OM, no
obstructive disease, left anterior descending minimal
disease, left circumflex 40% mid-stenosis. Right coronary
artery 100% mid-stenosis. Echo in [**8-11**] showed LVF of 75%
with moderate dilatation of the descending aorta. He is now
preop for a coronary artery bypass graft.
PAST MEDICAL HISTORY: Noninsulin dependent diabetes
mellitus, hypertension, high cholesterol, coronary artery
disease, status post myocardial infarction in [**8-11**]. Status
post stent.
MEDICATIONS:
1. Folic Acid.
2. Metformin.
3. Norvasc.
4. Aspirin.
5. Lopressor.
6. Lipitor.
7. Diovan.
8. Hydrochlorothiazide.
ALLERGIES: Penicillin, sulfa and Codeine.
FAMILY HISTORY: Strong coronary artery disease.
SOCIAL HISTORY: No tobacco, no alcohol, lives with wife.
PHYSICAL EXAMINATION: The patient is in no acute distress,
vital signs stable. Normocephalic, atraumatic. Pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements intact. Oropharynx clear. Neck
supple. Full range of motion, no lymphadenopathy. No
thyromegaly. Carotids 2+ bilaterally without bruits. Lungs
clear to auscultation bilaterally. Cardiac: Regular rate
and rhythm. No murmurs, rubs or gallops. Abdomen obese,
soft, nontender without masses, no hepatosplenomegaly,
positive bowel sounds without cyanosis, clubbing or edema.
Pulses 2+ bilaterally throughout. Neurological: Nonfocal.
The patient was admitted to the hospital on [**2111-3-18**] and taken
to the operating room on [**2111-3-19**] where coronary artery bypass
graft times four was performed. He initially required
nitroglycerin drip. He had chest tube and pacing wires in
place. Received perioperative Vancomycin.
Postoperative day one the chest x-ray showed a collapsed left
upper lobe. PEEP was increased and a chest x-ray checked the
following morning. The patient subsequently did well, chest
tubes were removed at the appropriate time, pacing wires
removed at the appropriate time. The patient was discharged
to the regular cardiothoracic floor where his
anti-hypertensives were manipulated to improve his heart rate
and blood pressure. The patient did well on the floor, was
seen by physical therapy who quickly cleared him to go home
on [**2111-3-23**] and the patient was in good condition. Being
discharged to home. The patient may shower but should not
take baths. Should avoid strenuous activity. Should not
drive while on pain medication. He is to follow-up with Dr.
[**Last Name (STitle) **] in four weeks, Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 6955**] in one to two weeks.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44107**] in 2 to 3 weeks.
He is on Lopressor 100 mg twice a day. Metformin 500 mg
twice a day. Lasix 20 mg twice a day times seven days.
Potassium 20 mEq twice a day times seven days. Potassium
chloride 20 mEq times seven days, Plavix 75 mg p.o. q day,
Isosorbide 60 mg q day, Percocet p.r.n., Entericoated aspirin
325 mg q day. Colace 100 mg twice a day p.r.n. Lipitor 20 mg
p.o. q day. Folate 1 mg q day.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 275**] 02-248
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2111-3-23**] 15:23
T: [**2111-3-23**] 16:16
JOB#: [**Job Number 44108**]
|
[
"414.01",
"272.0",
"411.1",
"250.00",
"412",
"V45.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"36.15",
"88.56",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
1466, 1499
|
1581, 4111
|
159, 1079
|
1102, 1449
|
1516, 1558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,673
| 118,120
|
37827
|
Discharge summary
|
report
|
Admission Date: [**2132-11-13**] Discharge Date: [**2132-11-19**]
Date of Birth: [**2052-9-17**] Sex: M
Service: SURGERY
Allergies:
Ambien / Codeine
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
fever and hypotension
Major Surgical or Invasive Procedure:
[**2132-11-13**]
CT guided drainage of abdominal fluid collection and tube
placement
[**2132-11-18**]
CT guided pigtail catheter placement in abdominal fluid
collection
[**2132-11-18**]
PICC line placement Right brachial vein
History of Present Illness:
80M with history of splenic abcess/splenectomy c/b colonic EC
fistula and long complicated hospital course with tracheostomy,
discharged earlier today to rehab, returns woth fevers 101.6 and
SBP 80s at rehab facility. Not compaining of any pain or
shortness of breath. No nausea or vomiting, no chest pain.
Received 1L NS and Imipenem on transfer, and Vancomycin on
arrival to ED.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- splenic trauma s/p coiling c/b abcess and splenectomy
- tracheostomy
- COPD
- CAD
- HTN
- hypercholesterolemia
- pneumonia
PSH:
- splenectomy
- Coronary stent
- embolization of splenic artery branches
Social History:
He is widowed and lives alone. He denies ETOH and has a remote
smoking history.
Family History:
Noncontributory
Physical Exam:
T98.7 HR107 BP86/51 RR18 95% Trach mask
Gen: no distress, alert and oriented
HEENT: PERLA, EOMI, anicteric, MMM, Dobhoff tube in place
Neck: trach site clean
Chest: RRR, lungs with rhonchi bilaterally
Abdomen: soft, protuberant, healing midline incision with good
granulation tissue at the base with a small area of necrosis at
the base of the incision, colocutaneous fistual track without
discharge and no surrounding erythema, flank edema
Ext: 1+ edema
Neuro: moves all extremities well, strength and sensation intact
Pertinent Results:
[**2132-11-12**] 09:40PM WBC-15.5* RBC-3.13* HGB-8.0* HCT-26.7* MCV-85
MCH-25.7* MCHC-30.1* RDW-16.2*
[**2132-11-12**] 09:40PM NEUTS-56.8 LYMPHS-35.7 MONOS-6.8 EOS-0.1
BASOS-0.7
[**2132-11-12**] 09:40PM PLT COUNT-467*
[**2132-11-12**] 09:40PM ALT(SGPT)-22 AST(SGOT)-21 CK(CPK)-9* ALK
PHOS-70 TOT BILI-0.4
[**2132-11-12**] 09:40PM GLUCOSE-129* UREA N-24* CREAT-0.5 SODIUM-136
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-34* ANION GAP-6*
[**2132-11-13**] CT Chest/Abd/Pelvis : 1. Rim-enhancing fluid
collections adjacent to the descending colon concerning for
abscess. This is increased in size. In addition, there is foci
of air within some of these fluid collections as well as within
the splenectomy bed. Known colocutaneous fistula is again
identified.
2. Bilateral pleural effusions and atelectasis.
3. Emphysematous changes with loculated hydropneumothorax on the
right.
4. Small pericardial effusion and pleural effusions.
5. Small hypodensities, some of which are cysts and others are
too small to characterize or incompletely characterized.
6. Cholelithiasis.
7. Liver hypodensity, stable.
8. Infrarenal abdominal aortic aneurysm, stable.
9. Diverticulosis.
[**2132-11-16**] Left upper ext ultrasound : No left upper extremity
DVT.
Brief Hospital Course:
Mr. [**Name13 (STitle) 1358**] was admitted to the Trauma ICU, pan cultured and
hydrated. He underwent an abdominal CT which revealed a fluid
collection adjacent to the descending colon. It was
percutaneously drained for 350 cc. and a drainage catheter was
left in place. The fluid culture grew Bacteroides and sputum
culture grew 2 types of Pseudomonas and Stenotrophonomas. Urine
culture was negative and blood cultures are negative to date.
The Infectious disease service was consulted for drug coverage
and they recommended a 2 week course of Meropenum, Tobramycin,
Bactrim and Fluconozole followed by reimaging. Following
drainage of the fluid collection he had no further temperature
spikes but his WBC remained elevated at 13-17K. He had no
abdominal tenderness. He may need long term treatment with
antibiotics if his colocutaneous fistula persists but for the
present time percutaneous drainage and antibiotics for multi
drug resistent Pseudomonas. His abdominal wound is clean and
granulating well with [**Hospital1 **] dressing changes.
He was transferred to the Trauma floor with stable hemodynamics,
continuation of antibiotics and daily assessment by ID. His
pulmonary status was stable in that he maintained good O2
saturations with a 35% trach collar. He had a very strong cough
and was able to cough his secretions up for the most part. He
was seen by the Speech and Swallow service to try a PM valve
however he had severe coughing with slow deflation of the trach
cuff and lots of secretions. Down sizing the trach tube was
recommended at some point prior to using a PM valve. His tube
feeds continued via a Dobhoff feeding tube and were tolerated
well.
On [**2132-11-18**] he underwent a repeat abdominal CT for re-evaluation
of the fluid collection. The study showed that the fistula is
from the small bowel. The drainage catheter was replaced in IR
and he subsequently had his PICC line replaced as well for IV
antibiotics. On [**2132-11-19**] he was discharged to rehab after
receiving all three of his post splenectomy vaccines including
Pneumovax, Haemophilus and Meningococcus.
He will follow up in 2 weeks for a repeat abd CT.
Medications on Admission:
Heparin 5,000 unit TID
Insulin Regular Per sliding scale units Injection
Albuterol Sulfate 90 mcg Q4H as needed for wheeze/sob.
Ipratropium Bromide 17 mcg Q4H as needed for wheeze/sob.
Fluoxetine 10 mg DAILY
Acetaminophen 325-650 mg Q6H as needed for fever >101.5.
Oxycodone 5 mg/5 mL Solution Q4H as needed for pain.
Docusate Sodium 50 mg/5 mL Liquid 2 teaspoons [**Hospital1 **]
Metoprolol 12.5 mg TID
Ferrous Sulfate 325 mg DAILY
Ondansetron 4 mg Q8H as needed for nausea.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
3. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
Twenty (20) mg Intravenous Q12H (every 12 hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 2.5 mg Inhalation Q6H (every 6 hours).
6. Tobramycin Sulfate 40 mg/mL Solution Sig: Four [**Age over 90 1230**]y
(450) mg Injection Q48H (every 48 hours).
7. Meropenem 1 gram Recon Soln Sig: One (1) Recon Soln(s)Gm.
Intravenous Q8H (every 8 hours).
8. Fluconazole in Saline(Iso-osm) 400 mg/200 mL Piggyback Sig:
Four Hundred (400) mg Intravenous Q24H (every 24 hours).
9. Trimethoprim-Sulfamethoxazole 80-400 mg/5 mL Solution Sig:
Four Hundred (400) mg Intravenous Q8H (every 8 hours).
10. Morphine 2 mg/mL Syringe Sig: 2-4 mg Injection Q4H (every 4
hours) as needed for pain.
11. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day):
thru [**2132-11-19**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis
s/p percutaneous drainage of left paracolic abscess
Secondary diagnoses
- splenic trauma s/p coiling c/b abcess and splenectomy
- tracheostomy
- COPD
- CAD
- HTN
- hypercholesterolemia
- pneumonia
Discharge Condition:
Stable blood pressure, afebrile, strong cough to keep trach
clear but unable to tolerate PMV. Tube feedings continue.
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.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or [**Location (un) 269**] nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. You should have a
repeat CT scan of the abdomen and pelvis just prior to that.
Call ([**Telephone/Fax (1) 2300**] to schedule both.
Completed by:[**2132-11-19**]
|
[
"272.4",
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"518.0",
"995.91",
"041.82",
"038.9",
"441.4",
"V44.0",
"401.9",
"511.9",
"482.1",
"492.8",
"562.10",
"V45.82",
"414.01",
"567.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7075, 7145
|
3159, 5332
|
299, 529
|
7404, 7524
|
1890, 3136
|
9966, 10194
|
1315, 1332
|
5861, 7052
|
7166, 7383
|
5358, 5838
|
7548, 9943
|
1347, 1871
|
238, 261
|
557, 942
|
964, 1201
|
1217, 1299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,976
| 189,426
|
46830
|
Discharge summary
|
report
|
Admission Date: [**2167-12-18**] Discharge Date: [**2167-12-26**]
Date of Birth: [**2105-6-4**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Haldol / Darvon / Keppra
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Black stools
Major Surgical or Invasive Procedure:
s/p EGD [**2167-12-19**], blood transfusion
History of Present Illness:
This is a 62 y/o female with PMH significant for HCV/ESLD, h/o
GIB, recently admitted from [**Date range (1) 99375**] for a signficant LGIB
s/p TIPS, p/w black stools, lethargy, and confusion. Pt noted to
have a HCT of 18 and was transfused 2 Units PRBC's at 0530 on
[**12-17**].
Most recent hospitilization was c/b respiratory failure [**2-13**]
pulmonary edema and nosocomial PNA, she was intubated for 10
days and completed a course of antibiotics for 12 days as well
as diuresis with lasix. Her LGIB was thought to be [**2-13**] rectal
hemorrhoids and required [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] at some point during her
course. She was discharged to rehab on [**12-9**] in stable condition
with a Hct of 30.
In the ED, initial VS were T 97.4, 68, 99/60, 14, 100% RA. An
abdominal u/s was performed and demonstrated a patent TIPS. Head
CT revealed no acute intracranial hemorrhage, edema, or mass
effect. HCT was 24.4. Foley with 400 cc of UO.
She was given vitamin K 10 Units SC, 40 mg IV protonix,
lactulose 30 ml, and 2 U FFP. The hepatology service was made
aware and plan to scope her tomorrow. She was admitted to the
MICU for further management.
Upon admit she is encephalopathic and moaning. Unable to obtain
history.
Past Medical History:
1) iron deficiency anemia
2) GI bleed - presumed secondary to hemorrhoids
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duoenal polyps and duodenitis
6) MGUS
7) ?etoh/ HCV cirrhosis followed by Dr. [**Last Name (STitle) 497**] (vl 9k in [**5-15**])
8) psychotic disorder
9) remote polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) compex partial seizures
Social History:
History of tobacco and EtOH abuse. She is originally from
[**State 3908**], and changed her name when she became a practicing
Muslim. She worked as an administrative assistant when she was
younger, but is now on SSDI (for schizophrenia and seizure
disorder, per pt, both now quiescent).
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy.
Physical Exam:
VS: T97.2 142/73 84 15 96/RA
General: Verbalizing with intermittently sensible answers, A&Ox2
HEENT: MMM, sclera icteric, not following commands for neuro
exam
Chest: CTAB anteriorly and in axilla, cannot roll to listen
posteriorly
CV: RRR difficult to ausculate m/g/r as patient continues to
talk
Abd: (+) BS, soft, NT/ND
Ext: 2+ pitting edema, strong pulses; RUE hand 2+ edema
Pertinent Results:
[**2167-12-18**] 12:00PM PT-17.7* PTT-46.5* INR(PT)-1.6*
[**2167-12-18**] 12:00PM WBC-8.9 RBC-2.68* HGB-8.4* HCT-24.4* MCV-91
MCH-31.4 MCHC-34.6 RDW-19.8* NEUTS-79* BANDS-4 LYMPHS-11*
MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2167-12-18**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2167-12-18**] 12:00PM ALT(SGPT)-51* AST(SGOT)-109* ALK PHOS-72
AMYLASE-209* TOT BILI-5.7*
[**2167-12-18**] 12:00PM AMMONIA-86*
[**2167-12-18**] 12:00PM
GLUCOSE-99 UREA N-98* CREAT-1.9* SODIUM-145 POTASSIUM-6.0*
CHLORIDE-110* TOTAL CO2-23 ANION GAP-18 LACTATE-1.9 K+-6.7*
[**2167-12-18**] 01:57PM K+-4.8
[**2167-12-18**] 12:35PM URINE
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
Brief Hospital Course:
1. Acute blood loss anemia secondary to GI hemorrhage- The
patient was admitted for melena, likely secondary to an upper GI
bleed. She received a total of 2 U PRBCs upon admission with
Lasix following the transfusion. She was started on Protonix IV
bid on admission. An abdominal u/s in the ED demonstrated a
patent TIPS. Her hematocrit remained stable overnight and she
was planned for endoscopy the following morning. She was quite
encephalopathic upon admission and refused to take any of her
medications, including lactulose and rifaximin. Due to the
encephalopathy and mental status, the patient was electively
intubated prior to the EGD on [**2167-12-19**], without any
complications. An EGD on [**2167-12-19**] showed portal gastropathy only
without any evidence of active bleeding. There was no evidence
of varices. She was extubated successfully the following day on
[**2167-12-20**] and her respiratory status has been stable since on room
air. Since her EGD she was without further episodes of BRBPR or
melena. Her HCT was slowly downward trending and on [**2167-12-25**]
she received one additional unit 1u PRBC with an appropriate HCT
increase to 28.9. Haptoglobin was also checked and found to be
<20, consistent with either slight hemolysis or could be
attributed to underlying liver disease. Otherwise, most likely
has subacute bleeding as a chronic issue secondary to
gastropathy or hemorrhoids. Upon discharge, was sent to an
extended care facility with instruction to transfuse for any HCT
less than 25, and to check a CBC every other day.
# HCV Cirrhosis with AMS - Known to have h/o hepatic
encephalopathy, was not tolerating lactulose/rifaximin so NGT
was placed. Given lactulose with improvement. She later
self-discontinued the NGT and subsequently tolerated oral
medications. She was continued on rifaximin & lactulose and her
mental status returned to baseline. Was also restarted on low
dose Lasix and Aldactone, which she tolerated well prior to
discharge.
# Hypernatrema - Thought to be [**2-13**] decreased oral intake and
dehydration. Initially she was corrected with free water
boluses with her tube feeds. After removal of the NGT, she was
given IV D5W for correction given that she was unable to take in
enough oral hydration to correct it herself. Over several days,
she was slowly corrected and the day of discharge had a sodium
level of 140. Upon discharge, instructions were given to her
extended care facility for monitoring or her sodium levels, as
well as instructions for correction based on the current level.
# Acute renal failure with Chronic Renal Insufficiency -
Creatinine at recent baseline (1.7-2.0), and admitted with
creatinine 1.9. Unclear etiology, but originally thought to be
likely secondary to end stage liver disease. Increased BUN may
be secondary to GI Bleed. Also may be elevated from baseline
given free water deficit. Later improved to baseline after
treatment of free water deficits. Upon discharge, his
creatinine was 1.3. Extended care facility given instruction to
monitor creatinine and dose diuretics appropriately.
# COPD - Admitted at baseline without evidence of acute flair,
and clear pulmonary exam. Was intubated due to AMS, but was
later successfully extubated, as described above. The morning
of [**12-23**], had acute onset wheezing, thought to be most likely
due to volume overload in the setting of increased free water
rather than acute flair. Was treated with IV Lasix and
albuterol nebulizers with symptomatic improvement. Once fluid
repletion was done more gently and home diuretics were
restarted, she had no further episodes of dyspnea.
Medications on Admission:
- Lansoprazole 30 mg daily
- Olanzapine 5 mg tid prn
- ?Beclomethasone Dipropionate 80 mcg as needed for SOB.
- Camphor-Menthol 0.5-0.5 % Lotion TID as needed for itching.
- Albuterol nebs q6 hrs
- Albuterol nebs q 1-2 hrs prn
- Ipratropium q6 hrs
- Lactulose 30 mL qid
- Rifaximin 400 mg tid
- ?Labetalol 100 mg [**Hospital1 **]
- Haloperidol 0.5 mg tid
- ?Lasix 40 mg daily
- ?Spironolactone 50 mg daily
Discharge Medications:
1. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
2. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID -
QID: You will need to titrate this medication to 4 BM's per day;
this medication is necessary to keep her mentally clear.
3. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day) as needed.
4. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Nebulizer
Inhalation Q6H (every 6 hours).
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Nebulizer Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily):
Hold for SBP < 100 .
8. Spironolactone 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily): Hold for SBP < 100 or potassium > 5 .
9. Outpatient Occupational Therapy
Please evaluate and treat while at extended care facility.
10. Outpatient Physical Therapy
Please evaluate and treat while inpatient at facility. Given
patient's physical decompensation, exercise may need to be
primarily with upper extremities.
11. Outpatient Lab Work
Please check basic chemistry and CBC every other day and adhere
to the following guidelines:
***Contact the facility physician [**Name Initial (PRE) **]***
1. If Hct < 25 or has dropped more than 5 points from prior
level, transfuse 1u PRBC and perform repeat Hct.
2. If Na (sodium) level is 143-145, please give 1L D5W at
100cc/hour. If Na (sodium) level is 146-148, please give 1.5L
D5W at 100cc/hour.
3. If Cr if > 1.8, hold lasix for the day and recheck lab the
following morning.
4. If potassium (K) > 4.8, hold spironolactone until potassium
is less than 4.5.
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Name Initial (PRE) **]: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Primary: Hepatitis C Cirrhosis, hemorrhoids
Secondary: COPD, iron defciency anemia, psychotic disorder,
diverticulosis, MGUS
Discharge Condition:
Hemodynamically stable and afebrile
Discharge Instructions:
You were admitted for black stools and increased confusion in
the setting of ongoing blood loss in your colon. You were
treated with blood transfusions and evaluated with an EGD. You
were also continued on your medications for your other ongoing
medical problems. Once improved, you were discharged back to
your extended care facility for further rehabilitation.
Please continue taking all medications as prescribed. You
living facility has been provided with a list of all your
current medications.
Please keep all medical appointments. You will also be treated
by the facility physician while you are living there.
Please return to the hospital or consult your facility physician
if you notice black stools, bright red blood in your bowel
movements, inability to eat enough food to maintain your weight,
increased confusion, bloody vomit or for any other symptom which
is concerning to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2168-1-15**] 2:20
|
[
"276.6",
"285.1",
"571.5",
"537.89",
"496",
"276.0",
"455.6",
"578.9",
"584.9",
"070.44",
"585.9",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9894, 9968
|
3762, 7416
|
315, 360
|
10137, 10175
|
2928, 3739
|
11124, 11279
|
2373, 2509
|
7873, 9871
|
9989, 10116
|
7442, 7850
|
10199, 11101
|
2524, 2909
|
263, 277
|
388, 1653
|
1675, 2053
|
2069, 2357
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,273
| 102,912
|
41949
|
Discharge summary
|
report
|
Admission Date: [**2166-9-22**] Discharge Date: [**2166-9-25**]
Date of Birth: [**2090-5-28**] Sex: F
Service: NEUROLOGY
Allergies:
tobramycin
Attending:[**First Name3 (LF) 2927**]
Chief Complaint:
unresponsive episodes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 76yo W with a history of atrial fibrillation, chronic
obstructive pulmonary disease, squamous cell carcinoma (s/p
radiation and chemotherapy), chronic trach/[**First Name3 (LF) 282**] dependent who
developed acute unresponsiveness on [**2166-9-21**]. She was
recently discharged from the [**Last Name (un) 1724**] ICU approximately one week or
so ago where she was hospitalized for pneumonia/pneumonitis.
During this hospitalization, she was trach'd/[**Last Name (un) 282**]'d and
transferred to [**Hospital3 **] for vent weaning. The
patient happened to be seen at [**Last Name (un) 1724**] on the afternoon of
[**2166-9-21**] by the on call neurologist. These are his first
impressions:
"This morning in rehab she had been fine, alert and
communicating with her husband through lip [**Location (un) 1131**] and writing.
Suddenly at 11:45 a.m. her head slumped to one side and eyes
rolled upward. She arrived in the emergency room at 12:06. On
arrival, she was unresponsive. A stroke burst page was
activated. Noncontrast head CT was negative. CT angiogram was
negative. Because of multiple risks (recent tracheostomy, chest
tube and [**Location (un) 282**] placement, INR 3 yesterday, and NIH stroke score of
greater than 25), she was not felt to be a tPA candidate. I
examined her immediately after the head CT, prior to MRI. At
that time, she had no response to voice or sternal rub. There
was no withdrawal of the limbs to nailbed pressure, although if
a limb was raised passively, she could hold it in place. There
was no clear asymmetry of strength. There was no meningismus.
The right pupil was 7 mm, left 5 mm, both sluggishly reactive.
Corneal reflexes were present bilaterally. Oculocephalic
responses were absent, although there were occasional
spontaneous eye movements to both the right and left. There were
some weak blinking movements of the eyelids, but no other
spontaneous motor activity. The exam raised a concern for
nonconvulsive seizure. She was given lorazepam 1 mg IV prior to
the MRI. MRI of the brain showed no acute infarction or other
obvious structural lesion. On arrival in the emergency room,
again she was given another milligram of lorazepam IV and I
recommended a loading dose of IV phenytoin."
Following her load of phenytoin, the patient did not receive her
complete 1gm dose of IV phenytoin because after the first 500mg,
she became hypotensive to the 70/43. Dilantin was stopped. This
also occurred in the setting of having received ativan as noted
above. She was aggressively fluid resuscitated and transferred
to the intensive care unit. At that time, the neurologist once
again had the pleasure of examining the patient. These were his
impressions at the time:
"When I reexamined her at 2:15 p.m., she could open eyes
spontaneously and look to voice. She followed a few simple
commands including closing the mouth, opening the eyes and
sticking out the tongue. She made weak attempts to grip with
both the right and left hands. She appropriately shook her head
no when asked if her name was [**Doctor First Name **] but weakly nodded to [**Known firstname **].
She could bend her knees to command. Pupils were 6 mm on the
right, 5 mm on the left, each constricting by 1 mm with light.
Eye movements were full. Corneal reflexes were symmetric. More
detailed sensory testing was not possible. There was no clear
facial weakness. The tongue was midline. Strength appeared
symmetric without clear weakness. Reflexes were 2+ and
symmetric in the biceps,
brachioradialis and patellar tendons, 1+ at the Achilles
tendons. Plantar stimulation produced withdrawal bilaterally.
Sensory exam was limited in the limbs, although she appeared to
feel nailbed pressure in all 4 limbs."
Later that day, [**Known firstname **] became more alert, in the setting of
initiating dilantin TID dosing. Overnight, she did well. This
morning, the patient was noted to be more drowsy and
unresponsive. The precise story is unclear. The patient's family
today report that she was more "anxious" but that in fact she
did become more "unresponsive". She also did complain of some
chest/stomach discomfort that was initially thought to be
cardiac in nature. She received some nitroglycerin which dropped
her blood pressures, and ultimately required more fluid boluses.
Her EKG and cardiac enzymes were normal. Later, they thought
that perhaps it might have been related to problems with [**Name2 (NI) 282**]
tube feeds. Her [**Name2 (NI) 282**] feeds were stopped and she received a CT
scan of her abdomen/pelvis which only showed evidence of
pancreatic ductal dilatation without free fluid or
intraperitoneal air. Her "responsiveness" also subsequently
improved throughout the course of this day. Since this OSH was
not able to check an EEG, she was ultimately transferred to the
[**Hospital1 18**] for EEG monitoring and further work up for possible NCSE.
Review of Systems: As mentioned above in the HPI. The patient's
family reports that she has had some tremors in the past week
which they recognize as possibly related to seizures (?). These
were mainly of her lower extremities. Otherwise, they deny any
fevers, dysuria, pain complaints, difficulties with diplopia,
dizziness.
Past Medical History:
1. Squamous cell lung carcinoma diagnosed in [**Month (only) 116**]. Status post
chemotherapy and radiation, reportedly completed in [**Month (only) 205**]. Course
complicated by radiation pneumonitis which has required multiple
steroid tapers.
2. COPD, on home oxygen for 2 years.
3. Atrial fibrillation, on anticoagulation with Coumadin. Also
on amiodarone/diltiazem for rate control
4. Recent pneumonia and pneumothorax, with a most recent
admission to [**Hospital3 **] from [**8-30**] to [**9-12**].
During that admission, she had placement of a chest tube,
tracheostomy on [**9-9**] and [**Month (only) 282**] tube placement [**9-10**].
5. Hypothyroidism.
6. Anemia of chronic disease.
7. Hypertension.
8. Herpes zoster, reportedly involving the right eye and face
early this year.
Social History:
Strong family support system, married. Never smoker, non
alcoholic
Family History:
Positive for "grand mal" seizures in her grandson
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: AF, 109/56, 67, 96%, 19
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, tracheostomized
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: Thin, [**Month (only) 282**] in place, soft, NT/ND, no masses or
organomegaly noted.
Extremities:warm and well perfused
Skin: Multiple erythematous/purple bruises over bilateral upper
and lower extremities.
Neurologic:
-Mental Status: Alert, oriented to [**2166-10-6**]. She speaks
without a PMV and literally whispers. Her eyes tend to remain
closed when she is not interactive, but will quickly open her
eyes when you call her name. Her language is fluent without
naming errors or paraphasias.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6-4mm and brisk.
III, IV and VI: EOM are intact and full, sustained nystagmus on
right lateral gaze
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted. In general, she moves all extremities well.
Symmetric proximal muscle weakness (4 to 4+/5) prominently in
deltoids, triceps, iliopsoas.
-Sensory: No deficits to light touch throughout
-DTRs: [**Name2 (NI) 20772**] throughout
Plantar response: Mute
-Coordination: No intention tremor
-Gait: Not tested
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8, 99/54, 65, 16, 98% on CPAP
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, tracheostomized
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: Thin, [**Name2 (NI) 282**] in place, soft, NT/ND, no masses or
organomegaly noted.
Extremities:warm and well perfused
Skin: Multiple erythematous/purple bruises over bilateral upper
and lower extremities.
Neurologic:
-Mental Status: Alert, oriented to [**2166-9-13**] but not the
date. She intermittently thinks she is at a hospital. She
speaks without a PMV and whispers. Her eyes tend to remain
closed when she is not interactive, but will quickly open her
eyes when you call her name. Her language is fluent without
naming errors or paraphasias. She is able to follow commands.
-Cranial Nerves:
I: Olfaction not tested.
II: L pupil 6->3mm and R pupil 5->3mm, both mildly sluggish.
III, IV and VI: EOM are intact and full, sustained nystagmus on
right lateral gaze
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted. In general, she moves all extremities well.
Symmetric proximal muscle weakness (4 to 4+/5) prominently in
deltoids, triceps, iliopsoas.
-Sensory: No deficits to light touch throughout
-DTRs: [**Name2 (NI) 20772**] throughout
Plantar response: Mute
-Coordination: No intention tremor
-Gait: Not tested
Pertinent Results:
ADMISSION LABS:
[**2166-9-22**] 08:45PM BLOOD WBC-4.5 RBC-2.88* Hgb-8.9* Hct-28.0*
MCV-97 MCH-31.0 MCHC-31.9 RDW-16.2* Plt Ct-200
[**2166-9-22**] 08:45PM BLOOD PT-43.8* PTT-40.2* INR(PT)-4.5*
[**2166-9-22**] 08:45PM BLOOD Glucose-108* UreaN-10 Creat-0.3* Na-141
K-4.0 Cl-103 HCO3-30 AnGap-12
[**2166-9-22**] 08:45PM BLOOD ALT-52* AST-25 LD(LDH)-277* CK(CPK)-22*
AlkPhos-56 TotBili-0.3
[**2166-9-22**] 08:45PM BLOOD CK-MB-2 cTropnT-<0.01
[**2166-9-23**] 04:03AM BLOOD CK-MB-2 cTropnT-<0.01
[**2166-9-22**] 08:45PM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.8 Mg-1.7
[**2166-9-22**] 08:45PM BLOOD Phenyto-16.1
DISCHARGE LABS:
[**2166-9-25**] 02:11AM BLOOD WBC-3.9* RBC-3.03* Hgb-9.7* Hct-28.9*
MCV-95 MCH-32.1* MCHC-33.7 RDW-16.4* Plt Ct-205
[**2166-9-25**] 07:48AM BLOOD PT-33.3* INR(PT)-3.3*
[**2166-9-25**] 02:11AM BLOOD Glucose-98 UreaN-15 Creat-0.5 Na-141
K-3.7 Cl-103 HCO3-33* AnGap-9
[**2166-9-23**] 11:16PM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
[**2166-9-24**] 04:34PM BLOOD Type-MIX pO2-35* pCO2-57* pH-7.42
calTCO2-38* Base XS-9
IMAGING:
CXR [**2166-9-23**]: FINDINGS: No previous images.
There is substantial scoliosis with degenerative change
involving the thoracic spine, convex to the right, which makes
it somewhat difficult to properly evaluate the heart and lungs.
The right lung and visualized portion of the left lung are clear
without evidence of vascular congestion. Opacification at the
left base most likely reflects atelectasis and effusion. Right
subclavian catheter extends to the mid-to-lower portion of the
SVC.
TTE [**2166-9-24**]: Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF 65%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
KUB [**2166-9-24**]: IMPRESSION: No evidence of obstruction or ileus.
Brief Hospital Course:
This is a 76yo W with a history of squamous cell carcinoma of
the lung, atrial fibrillation on coumadin, history of radiation
pneumonitis who was recently tracheostomized and gastrostomized
and doing well in rehabilitation who had an acute episode of
unresponsiveness concerning for seizure, transferred here for
EEG monitoring.
.
# Neuro: While here on [**9-24**] she had another episode of
unresponsiveness after having been given haldol for ICU
delirium. She was on continuous EEG monitoring, which showed no
seizure activity. Therefore, her unresponsiveness episodes are
more likely related to medications or metabolic issues and not
seizure activity. She should not receive haldol in the future.
We used seroquel as needed instead, which did not cause pt to
have unresponsiveness episodes. She was put on AEDs at the OSH,
so it is possible that if she was having seizures before we
aren't seeing them because they are now controlled. When she
arrived, we stopped her dilantin and increased her keppra to
750mg [**Hospital1 **]. Her MRI (which was brought in by pt's son on CD) was
unremarkable. Given her lung cancer we consider leptomeningeal
carcinomatosis as a possible cause of her unresponsiveness
episodes, however this is extremely unlikely to cause
intermittent unresponsiveness. We were unableto obtain an LP
while she was here because her INR was persistently elevated
(likely in part because of interaction with dilantin), and we
felt it was too dangerous to reverse her anticoagulation. At
some point in the future, if she becomes more persistently
unresponsive while also being more medically stable, it may be
worth considering an LP.
# Cardiovascular: we cotinued her home diltiazem and amiodarone
for rate control. She did have some episodes of atrial
fibrillation while being monitored on telemtery with some [**1-16**]
second pauses, which were asymptomatic. This will need to be
further monitored in the future. We continued her on her home
simvastatin for primary prevention. When she got here, her INR
was supratherapeutic, reaching a peak of 4.7. Her coumadin was
held and when she left her INR was 3.3. She will need her
coumadin restarted once her INR drifts lower.
# Optho: pt with hx of open angle glaucoma, followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 91057**] ([**Telephone/Fax (1) 91058**]), s/p iridotomies bilaterally, not
on any eye drops per pt and Dr. [**Last Name (STitle) 91057**], who on admission was
noted to have bilaterally dilated and minimally reactive pupils,
new since last exam in [**Month (only) 116**]. We consulted optho for concern of
open angle glaucoma crisis (she was alert and conversant with no
neurological reason for the eye findings), but they found normal
pressure in both eyes. Optho felt that her eye findings were
secondary to ipratropium nebs given at the OSH, and surely
enough, the next day (after not having gotten ipratropium at our
institution) her eyes were smaller and more reactive.
# Pulmonary: She was able to be off of CPAP through her trach
for almost 24 hours, but became very tired and so we decided to
keep her on CPAP at night at least to prevent fatigue from WOB.
She was continued on PRN albuterol but not ipratropium as above.
Her sputum culture grew GNRs, but pt was asymptomatic, and this
was from a culture taken on arrival. We decided not to treat,
but if she has any issues in the future, she may need
antibiotics.
# CODE: full - confirmed with patient and family, contact
daughter: [**Telephone/Fax (1) 91059**]
PENDING RESULTS:
Sputum Culture speciation [**2166-9-23**]
BCx x2 [**2166-9-23**]
Final read of EEG from [**Date range (1) **], however prelim reads by an
attending epileptologist showed no seizure activity.
TRANSITIONAL CARE ISSUES:
Patient will need her INR followed and her coumadin restarted
when her INR drifts down further. Her vent weaning will need to
be continued while at rehab.
Medications on Admission:
Nitroglycerin tablet sublingual 0.4 mg p.r.n. as needed for
chest pain
potassium chloride 20 mEq once
citalopram p.o. 10 mg daily
atorvastatin p.o. 30 mg at bedtime,
amiodarone p.o. 100 mg daily
quetiapine p.o. 12.5 mg q. 6 hourly PRN
haloperidol tablet p.o. 0.5 mg q. 8 hourly PRN
Bactrim suspension p.o. 20 mL every Monday, Wednesday, Friday
Florastor p.o. 250 mg b.i.d.
risperidone p.o. 0.25 mg [**Hospital1 **] PRN
prednisone p.o. 30 mg daily
lansoprazole sublingual 30 mg daily,
diltiazem p.o. 60 mg q.i.d.
AccuNeb 1 neb q. 4 hourly p.r.n.,
DuoNeb 1 neb q. 6 hourly p.r.n.
Keppra 500 mg IV q. 12 hourly
Dilantin IV 100 mg t.i.d. and
Discharge Medications:
1. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. citalopram 20 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
3. atorvastatin 10 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
4. amiodarone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
5. risperidone 1 mg/mL Solution [**Hospital1 **]: 0.25 mg PO BID (2 times a
day) as needed for agitation.
6. quetiapine 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a
day) as needed for agitation.
7. prednisone 10 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation every four (4) hours as
needed for shortness of breath, wheezing.
11. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5,000 units
Injection TID (3 times a day).
12. simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas/bloating.
13. levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day).
14. nystatin 100,000 unit/mL Suspension [**Age over 90 **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
15. nitroglycerin 0.4 mg Tablet, Sublingual [**Age over 90 **]: One (1)
Sublingual twice a day as needed for chest pain.
16. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]:
6-8 Puffs Inhalation Q6H (every 6 hours) as needed for
wheezing/respiratory distress.
17. 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.
18. Florastor 250 mg Capsule [**Age over 90 **]: One (1) Capsule PO twice a
day.
19. Bactrim 400-80 mg Tablet [**Age over 90 **]: One (1) Tablet PO Mon, Wed,
Fri: or can give 20mL suspension Mon, Wed, Fri.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Medication side effect
Atrial fibrillation
COPD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
NEURO EXAM: AAOx2 (knows place, year and month, but not date), R
pupil reactive 5->3mm, L pupil 6->3mm; moves all 4 extremities
Discharge Instructions:
Dear Ms. [**Known lastname 4135**],
You were seen in the hospital for suspected seizures that caused
you to become unresponsive. While here, you were monitored with
continuous EEG monitoring which showed no seizures even when you
had an episode of unresponsiveness while here. Therefore, we
think that your unresponsive episodes are related to medications
or medical issues and are not seizure-related.
We made the following changes to your medications:
(The below changes are those made to your transfer meds, not
home meds):
1) We STOPPED your HALOPERIDOL.
2) We STOPPED yout DUONEBS because the ipratoprium was effecting
your pupils.
3) We STOPPED your DILANTIN because it was interacting with your
coumadin.
4) We DECREASED your SEROQUEL to 12.5mg twice a day as needed
for agitation.
5) We INCREASED your KEPPRA to 750mg twice a day. This can
likely be tapered then stopped once you are more medically
stable.
6) We STARTED you on TYLENOL 325-650mg every 6 hours as needed
for fever or pain.
7) We STARTED you on SUBCUTANEOUS HEPARIN injections, 5,000
units three times a day to prevent DVTs. You can stop this
medication once you are no longer chronically in bed or your INR
is therapeutic.
8) We STARTED you on SIMETHICONE 80mg four times a day as n
eeded for gas pains.
9) We STARTED you on NYSTATIN SUSPENSION 5mL four times a day as
needed for thrush.
10) We STARTED you on ALBUTEROL INHALER, 6-8 puffs every 6 hours
as needed for wheezing/respiratory distress when on CPAP.
11) We STARTED you on a HEPARIN FLUSH 2mL intravenously in your
PICC line as needed to flush the line. This medication can stop
once you no longer need your PICC.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
We recommend that you follow-up with your [**Hospital6 2561**]
neurologist within the next 1-2 months.
If you would prefer to make an appointment with one of our
neurologists you can call [**Telephone/Fax (1) 2756**] and be connected to our
appointment line.
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68,310
| 119,302
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39118
|
Discharge summary
|
report
|
Admission Date: [**2144-2-21**] Discharge Date: [**2144-2-28**]
Date of Birth: [**2069-3-20**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
L sided weakness - code stroke
Code stroke paged 12:44pm
Patient evaluated 12:52pm
NIHSS
L visual field cut 1
L facial droop 1
L sided numbness 2
Mild dysarthria 1
L sided extinction/inattention 1
Total 6
Major Surgical or Invasive Procedure:
IV tPA
TEE
History of Present Illness:
Patient is a 74 yo LHW with hx of CAD, stroke, HTN and
hypercholesterolemia who was discharged from an OSH just
yesterday found down in the bathroom with L sided weakness per
daughter. [**Name (NI) **] was last seen normal at 10 am when she went
into the bathroom. Then about 10 to 15 minutes later, patient
was yelling for help and the daughter found the patient fallen
forward in the bathroom with L sided weakness hence EMS was
called.
Patient initially taken to [**Hospital1 **] [**Location (un) 620**] where she was found to
have
NIHSS of 7 with L sided weakness. Head CT revealed no acute
issues including hemorrhage but because patient appeared to
improve, she was transferred to [**Hospital1 18**] without intervention. As
for the specifics of her improvement, its unknown and not
documented.
Code stroke was activated 12:44pm and initial evaluation showed
L
sided numbness, mild neglect and L field cut totaling NIHSS of
6.
Although patient was close to the 3 hour mark since she was last
known to be normal, given the findings, IV tPA was administered.
ROS reveals that patient was discharged from OSH just yesterday
with a new diagnosis of Parkinson's disease and started on
Sinemet. Patient also reports that she had about 20~25lb weight
loss in the last 2 months.
Past Medical History:
1. CAD
2. Stroke
3. HTN
4. Recently diagnosed Parkinson's.
5. Osteoporosis
6. Hypercholesterolemia
7. Depression
Social History:
Lives alone. Daughter [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 23818**] ([**Telephone/Fax (1) 86668**]) is
HCP, full code. No tobacco, EtOH or illicit drugs.
Family History:
FH: NC
Physical Exam:
T 97.9 BP 123/75 HR 66 RR 16 O2Sat 97% RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No carotid or vertebral bruit
CV: RRR, no murmurs/gallops/rubs
Lung: Clear anteriorly
Abd: +BS, soft, nontender
Ext: No edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam. Oriented
to person, hospital, and [**Month (only) 958**]/10. Attentive, says DOW
backwards. Speech is fluent with normal comprehension and
repetition; naming intact. Mild dysarthria. [**Location (un) **] intact. No
right left confusion. No evidence of apraxia or neglect.
Cranial Nerves:
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. L visual field cut.
III, IV & VI: Extraocular movements intact bilaterally, no
nystagmus.
V: Sensation intact to LT.
VII: L facial droop.
VIII: Decreased hearing 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 or pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF
R 4+ 5 5 5 5 5 5 5- 5 5 5 5
L 4+ 5 5 5 5 5 5 5- 5- 5 5- 5
Sensation: Numb to LT on L side (arm and leg but face sparing)
Reflexes:
+2 and symmetric throughout but no ankle jerks.
Toes downgoing on R but up on L.
Coordination: FTN, FTF normal.
Gait: Deferred.
Pertinent Results:
[**2144-2-25**] 04:40AM BLOOD WBC-6.5 RBC-3.76* Hgb-12.1 Hct-34.0*
MCV-91 MCH-32.3* MCHC-35.6* RDW-13.3 Plt Ct-204
[**2144-2-24**] 06:45PM BLOOD Hct-36.2
[**2144-2-24**] 05:55AM BLOOD WBC-5.5 RBC-3.70* Hgb-11.8* Hct-33.5*
MCV-91 MCH-31.9 MCHC-35.2* RDW-13.3 Plt Ct-206
[**2144-2-23**] 04:28AM BLOOD WBC-3.9* RBC-3.51* Hgb-11.1* Hct-30.7*
MCV-88 MCH-31.6 MCHC-36.0* RDW-13.1 Plt Ct-158
[**2144-2-22**] 12:22PM BLOOD WBC-4.3 RBC-3.85* Hgb-11.5* Hct-34.0*#
MCV-88 MCH-29.9 MCHC-33.8 RDW-13.3 Plt Ct-166
[**2144-2-22**] 04:12AM BLOOD WBC-5.3 RBC-3.78* Hgb-12.0 Hct-34.2*
MCV-90 MCH-31.8 MCHC-35.2* RDW-13.3 Plt Ct-190
[**2144-2-21**] 12:56PM BLOOD WBC-6.9 RBC-4.41 Hgb-14.1 Hct-40.1 MCV-91
MCH-31.9 MCHC-35.1* RDW-13.2 Plt Ct-219
[**2144-2-21**] 12:56PM BLOOD Neuts-83.3* Lymphs-10.2* Monos-4.4
Eos-1.7 Baso-0.4
[**2144-2-25**] 04:40AM BLOOD Plt Ct-204
[**2144-2-24**] 12:45PM BLOOD PT-11.6 PTT-24.0 INR(PT)-1.0
[**2144-2-22**] 04:12AM BLOOD PT-12.3 PTT-25.1 INR(PT)-1.0
[**2144-2-21**] 12:56PM BLOOD PT-11.7 PTT-21.8* INR(PT)-1.0
[**2144-2-22**] 04:12AM BLOOD ESR-5
[**2144-2-25**] 04:40AM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-140
K-3.9 Cl-103 HCO3-29 AnGap-12
[**2144-2-24**] 12:45PM BLOOD Glucose-86 UreaN-10 Creat-0.7 Na-140
K-4.0 Cl-101 HCO3-28 AnGap-15
[**2144-2-24**] 05:55AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-140
K-4.4 Cl-103 HCO3-29 AnGap-12
[**2144-2-23**] 04:28AM BLOOD Glucose-91 UreaN-8 Creat-0.6 Na-140 K-3.7
Cl-108 HCO3-27 AnGap-9
[**2144-2-22**] 04:12AM BLOOD Glucose-94 UreaN-11 Creat-0.6 Na-141
K-3.8 Cl-106 HCO3-28 AnGap-11
[**2144-2-24**] 12:45PM BLOOD ALT-3 AST-26 LD(LDH)-257* AlkPhos-77
Amylase-45 TotBili-0.6
[**2144-2-24**] 12:45PM BLOOD Lipase-14
[**2144-2-25**] 04:40AM BLOOD Calcium-9.8 Phos-4.3 Mg-2.2
[**2144-2-24**] 12:45PM BLOOD Albumin-4.1 Calcium-10.0 Phos-3.6 Mg-2.2
[**2144-2-24**] 05:55AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.2
[**2144-2-22**] 04:12AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.0 Cholest-155
[**2144-2-22**] 04:12AM BLOOD %HbA1c-5.6 eAG-114
[**2144-2-22**] 04:12AM BLOOD Triglyc-133 HDL-53 CHOL/HD-2.9 LDLcalc-75
[**2144-2-21**] 12:56PM BLOOD CRP-0.7
[**2144-2-21**] 12:57PM BLOOD Comment-GREEN TOP
[**2144-2-21**] 12:57PM BLOOD Glucose-122* Lactate-1.2 Na-141 K-4.0
Cl-101 calHCO3-26
[**2144-2-24**] 02:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2144-2-21**] 08:06PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2144-2-24**] 02:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2144-2-21**] 08:06PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2144-2-24**] 02:50PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2144-2-21**] 08:06PM URINE RBC-[**2-14**]* WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2144-2-21**] 8:06 pm URINE Source: Catheter.
**FINAL REPORT [**2144-2-22**]**
URINE CULTURE (Final [**2144-2-22**]): NO GROWTH.
CT head/CTA head/ neck [**2-21**]
1. Right MCA distribution acute ischemic infarct with thrombus
extending from
right MCA bifurcation into M2 and M3 segments with apparent
distal
reconstitution. Ischemic infarction is evident on CT perfusion
as matched
increase of mean transit time and decreased blood volume blood
flow to the
right MCA distribution.
2. Mild atherosclerotic disease involving aortic arch, great
vessel origins,
and right common carotid bifurcation without significant
stenosis or
occlusion.
CT head [**2-22**]
IMPRESSION:
1. No intracranial hemorrhage.
2. Very subtle evolution of a previously seen right MCA
territorial
infarction.
3. Stable left frontal hypodensity.
CXR [**2-22**]
There is no focal consolidation, the CP angles are clear.
Pulmonary vascular
markings, heart and mediastinal contours are normal in this
patient with a
scoliotic thoracic spine, convex to the right.
IMPRESSION: No acute cardiopulmonary disease.
X ray abd (supine and erect) [**2-24**]
IMPRESSION: Moderate fecal retention throughout the entire
colon, likely
secondary to constipation. No evidence of bowel obstruction.
TEE [**2-26**]
The left atrium is dilated. 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. Right atrial appendage ejection velocity is good (>20
cm/s). A secundum type atrial septal defect is seen by color
Doppler with right-to-left flow. After intravenous saline
injection at rest, there is prompt appearance of contrast in the
left heart. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen.
IMPRESSION: Aneurysmal intraatrial septum with secundum atrial
septal defect and right to left flow at rest. No LA/LAA/RA/RAA
thrombus seen. Simple plaque seem in descending aorta.
US legs [**2-26**]
FINDINGS: Waveforms in the bilateral common femoral veins are
normal and
symmetric. The bilateral common femoral, superficial femoral,
and popliteal
veins demonstrate normal compressibility, color flow, and
response to
augmentation. The posterior tibial veins on the right
demonstrate
non-compressibility and decreased color flow. One of these veins
appears to
be completely occluded while the other has some nonocclusive
thrombus within
it. The right peroneal, left peroneal, and left posterior tibial
veins
demonstrate normal flow.
IMPRESSION:
Thrombosis of paired right posterior tibial veins.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to neurology service for evaluation of
sudden onset weakness on the left side of body. In the ED, she
was found to have right MCA stroke, most likely as a result of
occlusion form embolus and was treated with IV tPA after code
stroke was activated.
She was later transfered to Neuro ICU for evaluation and close
observation. Her initial physical examination was suggestive of
significant left sided weakness with left heminegelct, however,
post IV tPA , she showed consistent steady improvement and has
very mild left sided weakness with no neglect on the left side
at discharge.
She underwent TEE for finding out the source of potential
embolus as vessel imaging did not show any evidence. TEE showed
ASD with PFO and septal aneurysm, she underwent ultrasound of
legs which showed DVT in right posterioir tibial veins. and it
was decided to start on coumadin and lovenox bridge. Her INR was
therapeutic at discharge and she was registered in coumadin
clinic and HCP at [**Name2 (NI) **], keeping her PCP [**Name Initial (PRE) 23491**].
As she was on aspirin at home, it was changed to plavix during
the course of hospitalisation for better antiplatelet effect,
which was stopped after starting coumadin.
she underwent secondary risk factor assesment, glycated Hb was
5.6 and lipids were in accepatable range and she was continued
on simvastatin in the dose of 40 mg per day.
She had episode of nausea and vomiting on [**2-24**] as well as [**2-25**].
She was evaluated with CBC chem 10 UA and LFTs with abd Xray ,
all of which were normal. after careful review and GI consult,
it was found that nausea was related to sinemet dose and she was
started on carbidopa additional dose. she was started on proton
pump inhibitors for better control of gastritis.
Medications on Admission:
1. Boniva weekly
2. ASA 81mg daily
3. Sinemet 25/100 TID
4. Carvedilol 3.125mg [**Hospital1 **]
5. Imdur 10mg [**Hospital1 **]
6. Detrol LA 4mg daily
7. Cipro 500mg [**Hospital1 **]
8. Mevacor 40mg daily
9. MVI
10. Wellbutrin XL 300mg daily
11. Folic acid 1mg daily
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*50 Tablet(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for c.
Disp:*30 Tablet(s)* Refills:*3*
9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: as discussed with
PCP on phone about the dose.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. 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*
12. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
please take 3 mg tablet on [**3-19**], [**3-1**] and check blood work
on Monday in [**Hospital1 18**] [**Location (un) 620**] as discussed and [**Hospital 86669**] clinic
would adjust the dose.
Disp:*90 Tablet(s)* Refills:*2*
13. Boniva 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Carbidopa 25 mg Tablet Sig: One (1) Tablet PO three times a
day: Please take with sinemet to decrease nausea.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
acute Right MCA stroke, s/p IV t PA with improvement in left
hemiparesis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted for evaluation of weakness on the left side of
body. You underwent CT scan of head with CTA head/ neck which
showed acute infarct in right MCA. You were given a medicine
called "tPA" to lyse the blood clot blocking brain vessel
leading to weakness on the left side of your body, with
considerable improvement in the weakness.
You underwent TEE (transesophageal cardiac ultrasound) which
showed a hole in septum of heart called PFO, ASD with a small
septal anerysm. You had ultrasound of legs which showed small
blood clot in veins of right leg.
You were evaluated by physical, occupational therapist who
suggested vna service, home OT/ PT as an outpatient at
discharge.
You have been started on medicine called coumadin for DVT. Your
blood level will be checked by coumadin clinic and the dose
would be adjusted.
You had nausea and vomiting in the hospital, you were seen by GI
specialist who felt that this is related to sinemet. We have
decreased your sinement dose to half. If you develop any
concerns like stiffness, rigidity , slowness of movements, call
[**Telephone/Fax (1) 8717**] and have on call neurologist answer your questions
over the weekend. During week you can call Dr.[**Name (NI) 34043**] office
for assistance.
Followup Instructions:
Please call [**Telephone/Fax (1) 10676**] to provide additional information
before neurology appointment as
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2144-4-14**] 2:00
|
[
"272.0",
"790.01",
"733.00",
"535.50",
"E884.6",
"V58.61",
"332.0",
"434.11",
"401.9",
"453.42",
"745.5",
"783.21",
"924.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
13368, 13426
|
9319, 11118
|
489, 502
|
13542, 13542
|
3693, 9296
|
14967, 15242
|
2173, 2182
|
11434, 13345
|
13447, 13521
|
11144, 11411
|
13690, 14944
|
2197, 2427
|
242, 451
|
530, 1817
|
2798, 3674
|
13557, 13666
|
2451, 2451
|
1839, 1954
|
1970, 2157
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,476
| 100,289
|
37232
|
Discharge summary
|
report
|
Admission Date: [**2147-10-3**] Discharge Date: [**2147-10-9**]
Date of Birth: [**2084-2-4**] Sex: M
Service: MEDICINE
Allergies:
Enoxaparin / Gammagard
Attending:[**Last Name (NamePattern1) 9662**]
Chief Complaint:
Diarrhea, Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 7168**] is a 63-year-old gentleman with stage IV small cell
lung cancer w/ metastatic disease to brain and liver s/p last
chemo [**9-19**] and radiation in [**2147-6-18**] presenting with profuse
diarrhea and shortness of breath, and fluid responsive
hypotension in the setting of large PE in right pulmonary artery
extending into segmental branches. He reports going to ED for
profuse, "projectile" diarrhea. Patient does have chronic
intermittent diarrhea, usually worsened with courses of
chemotherapy. He does have occasional nausea and vomiting that
is usually associated with po intake. Patient has not been
tolerating po well for several weeks. He denies any dysphagia,
chest pain, fevers, cough, abdominal pain. Patient has not
noticed a significant change in his shortness of breath. He had
a PE in [**2146-10-18**] treated with lovenox for 2 months and then
developed high fevers associated with medication. Patient was
then switched to a 6 month course of Arixtra.
In the ED, initial VS were: 96.8 118 98/79 26 100% on 2L NC
ED course:
-Reportedly short of breath and speaking in short sentences.
-Heparin bolus followed by drip
-Hypotension to systolic of 90's was responsive to 2L NS.
-Levofloxacin 500mg x1
-pt on chronic steroids and hypotensive in triage: concern for
adrenal insufficiency; gave 100mg hydrocortisone IVx1
On arrival to the MICU: AF 116/75 HR 90 sat 99% on 2L NC
He denies any pain or change in his dyspnea.
Review of systems: As per above
Past Medical History:
Past Medical History:
1. Small cell lung cancer, metastatic to liver and brain.
Followed by [**Year (4 digits) **] [**Year (4 digits) 40356**] with [**Hospital1 18**]. Last chemo was [**2147-9-19**]
and last radiation was [**2147-6-18**].
2. Dermatomyositis (paraneoplastic syndrome),
3. Hx of bronchitis
4. Hx L ankle fracture; other bone fractures
5. BPH
6. Pulmonary embolism [**10/2145**], cancer and IVIG related.
7. right 5th toe fracture ~[**2146-6-20**].
ONCOLOGIC HISTORY:
[**2144-7-18**]: Presented with rash over forearms and torso.
[**2144-8-18**]: Later developed muscle weakness. Saw dermatologist, Dr
[**Last Name (STitle) 16077**] - biopsy positive for dermatomyositis. Started on
prednisone 60 mg daily with good improvement of his rash and
weakness. He was also referred to a rheumatologist and
neurologist for further evaluation. Dysphagia symptoms also
apparent, evaluated by a speech and swallow therapist at [**Hospital1 18**].
[**2144-10-18**]: Radiographical workup - CT scanning showed a prominent
right hilar node and a lesion in the liver. Liver lesion by MRI
on [**2144-11-9**] at [**Hospital6 1109**] was equivocal.
[**2144-11-23**]: PETCT scan performed at [**Hospital1 **] showed abnormal
uptake in the right paratracheal lymph node, right hilum, liver
nodule in the mid portion of the right lobe, also a region of
the gallbladder.
[**2144-11-17**]: [**2144-11-26**]- an ultrasound guided liver biopsy was
performed at [**Hospital1 **]; lesion consistent with small cell lung
cancer. Staining shows positivity for synaptophysin, TTF-1, with
weak positivity for CK 7 and chromogranin (Pathologist Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 83828**]). Dr [**Last Name (STitle) **] from neurology ordered anti-[**Doctor Last Name **]
and anti-striate muscle antibody which are positive, done on
[**2144-12-7**]. (Anti-[**Doctor Last Name **] positive by immunofluorescence, but was not
positive by Western blot). A head MRI was performed on [**12-16**]
and showed no evidence of intracranial malignancy.
[**2144-12-18**]: Started chemotherapy
[**2145-3-18**]: Complete chemotherapy
[**2145-6-17**]: Dermatomyositis flare; subsequently given course of
steroids, IVIG, methotrexate. Interval CT scans do not show
obvious evidence of cancer progression.
[**2145-10-18**]: Pulmonary Embolism [**2145-11-7**], started on Lovenox
[**2145-11-17**]: hematochezia thought to be inflammatory colitis,
resolved with rectal steroids
[**2145-12-18**]: Dermatomyositis (DM) flare with fevers and ulcerative
lesions; CT on [**2146-1-7**] shows no progression of cancer
[**2146-2-15**]: Fevers, DM continue; lovenox implicated as one of
causes of fevers; fondiparinux substituted for lovenox. Hi dose
IV steroids used to control DM sx.
[**2146-3-18**]: Fevers abated with use of fondiparinux. PETCT suggests
inflammatory changes rather than overt SCLC recurrence.
[**2146-5-18**]: Recurrent disease seen mainly in liver on PETCT
[**2146-6-6**].
TREATMENT HISTORY:
FIRST LINE REGIMEN: carboplatin (5 AUC on day 1) and
etoposide(80mg/m2 on days 1, 2, and 3) every 21 days per cycle.
-Started [**2144-12-21**] and completed 6 cycles. Last chemo given on
[**2145-4-9**].
SECOND LINE REGIMEN: carboplatin (5 AUC on day 1) and etoposide
(80mg/m2 on days 1, 2, and 3) every 21 days per cycle. Repeated
regimen since was >1 year at time of recurrence. Had response.
-Started [**2146-6-14**] C1 D1, and completed 6 cycles without
complication, last chemo on [**2146-10-6**].
[**2146-11-22**] - continues on chemotherapy break after good response on
CT
Social History:
Unmarried, has one daughter- [**Name (NI) 40785**] ; girlfriend - [**Name (NI) 553**].
Computer engineer; unemployed
-Smoking Hx: quit ~[**2144**]; 45 pkyr hx, has used Chantix.
-Alcohol Use: 2 drinks approximately 3-4 times per week.
-Recreational Drug Use: None
Worked as construction supervisor.
Family History:
Autoimmune disorders. Sister has Grave's disease, mother had
some sort of thyroid disease, 2 nephews have ulcerative colitis.
Physical Exam:
Admission:
Vitals: AF 116/75 HR 90 sat 99% on 2L NC
Gen: NAD, well-nourished
Neck: no JVD or masses
CV: NR, RR, no murmurs
Pulm: CTAB
Abd: soft, NT, ND
Ext: no peripheral edema
Neuro: A&O, no gross deficits, moving all extremities,
Skin: no lesions noted
Pertinent Results:
[**2147-10-3**] 12:20PM BLOOD WBC-6.9# RBC-2.99* Hgb-9.5* Hct-28.5*
MCV-95 MCH-31.7 MCHC-33.3 RDW-16.8* Plt Ct-256#
[**2147-10-3**] 12:20PM BLOOD Neuts-65 Bands-0 Lymphs-13* Monos-14*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-2* Promyel-4*
[**2147-10-3**] 12:20PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Tear Dr[**Last Name (STitle) **]1+
[**2147-10-3**] 12:20PM BLOOD PT-13.7* PTT-30.7 INR(PT)-1.3*
[**2147-10-4**] 04:31AM BLOOD Glucose-94 UreaN-21* Creat-0.9 Na-142
K-3.1* Cl-107 HCO3-24 AnGap-14
[**2147-10-3**] 12:20PM BLOOD Glucose-138* UreaN-25* Creat-1.9*# Na-140
K-3.2* Cl-98 HCO3-27 AnGap-18
[**2147-10-3**] 12:20PM BLOOD cTropnT-<0.01
[**2147-10-3**] 09:21PM BLOOD cTropnT-<0.01
[**2147-10-4**] 04:31AM BLOOD cTropnT-<0.01
[**2147-10-3**] 12:34PM BLOOD Lactate-2.1*
[**2147-10-3**] 12:20PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.8
CTA Pulmonary [**2147-10-3**]: Acute pulmonary emboli to the right
main, upper, middle and lower lobar pulmonary arteries. Small
focus of thrombus in the distal left main pulmonary artery.
Focal consolidation in the right lower lobe may represent
pulmonary infarct or pneumonia.
Brief Hospital Course:
Mr. [**Known lastname 7168**] is a 63-year-old gentleman with stage IV small cell
lung cancer s/p carboplatin, etoposide, and irinotecan C4 with
metastases to brain and liver, now presenting with complaint of
profuse diarrhea, shortness of breath, and fluid-responsive
hypotension in the setting of a newly diagnosed large pulmonary
embolism and [**Last Name (un) **].
# PULMONARY EMBOLISM: In setting of active malignancy.
Patient was initially started on a heparin gtt then subsequently
transitioned to fondaparinux and coumadin (allergy to lovenox).
Discharged when INR was 2.1 (given fondaparinux on day of
discharge so technically bridged for 24 hours). Patient was
written for coumadin 5mg QD but switched to 4mg QD on discharge
given steep rise of INR. Did not have oxygen requirement on
discharge. Mr. [**Known lastname 7168**] should likely remain on coumadin
indefinitely. He will follow-up with PCP for INR check (this
was confirmed with Dr. [**First Name (STitle) 391**] [**Name (STitle) **] on day of discharge).
Patient will have blood drawn for INR checks by VNA).
# ACUTE KIDNEY INJURY WITH HYPOTENSION: Prerenal etiology.
Creatnine normalized with fluids.
# DIARRHEA: Likely irinotecan related. Resolved. Stool studies
negative.
# CONSTIPATION: Although initially admitted with diarrhea,
patient subsequently developed consipation. He moved his bowels
on day of discharge after receiving an aggressive bowel regimen.
He will be discharged on stool softeners and laxatives to use
as needed.
# PAIN MANAGEMENT: Patient denied pain during this admission,
and said that he was not taking oxycontin at home. This
medication was stopped on discharge (as it wasn't needed), but
can be resumed at patient's and PCP's discretion. He can
continue percocet as needed.
# SMALL CELL LUNG CANCER: Metastatic disease to brain and liver,
now s/p C4 irinotecan and s/p carboplatin and etoposide. Last
chemotherapy dosing on [**2147-9-19**]. Mr. [**Known lastname 7168**] will have close
follow-up with his outpatient heme/onc providers.
# DERMATOMYOSITIS (paraneoplastic syndrome): Long-standing,
complicated issues that even pre-dates his cancer diagnosis. No
acute issues during this hospitalization. Patient was continued
on cellcept at 1500 [**Hospital1 **].
# ANEMIA: Likely secondary to chemotherapy. Patient's hct
trended down during admission and he was given 1 unit of blood
on [**2147-10-5**] to increase his reserve. He has no evidence of
bleeding and likely his hct was concentrated at time of
admission.
# CODE: FULL, confirmed, would not want prolonged care
# DISPOSITION: Home with VNA.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Dexamethasone 4 mg PO DAILY
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN rash
4. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea
5. Opium Tincture 10 DROP PO Q4H:PRN diarrhea
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Lorazepam 0.5 mg PO HS:PRN insomnia
8. Docusate Sodium 100 mg PO BID
9. Ranitidine 150 mg PO BID
10. Mycophenolate Mofetil 1500 mg PO BID
11. Lidocaine Viscous 2% 20 mL PO QID:PRN mouth pain
swish and swallow
12. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
13. Oxycodone-Acetaminophen (5mg-325mg) [**12-19**] TAB PO Q6H:PRN pain
14. Nystatin 1,000,000 UNIT PO Q6H
5 ml by mouth four times a day swish and spit
15. Calcium Carbonate 500 mg PO TID
16. Amitriptyline 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Amitriptyline 25 mg PO QHS:PRN insomnia
2. Calcium Carbonate 500 mg PO TID
3. Dexamethasone 4 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Lidocaine Viscous 2% 20 mL PO QID:PRN mouth pain
swish and swallow
6. Lorazepam 0.5 mg PO HS:PRN insomnia
7. Mycophenolate Mofetil 1500 mg PO BID
8. Nystatin 1,000,000 UNIT PO Q6H
5 ml by mouth four times a day swish and spit
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Oxycodone-Acetaminophen (5mg-325mg) [**12-19**] TAB PO Q6H:PRN pain
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Ranitidine 150 mg PO BID
13. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN
rash
14. Warfarin 4 mg PO DAILY
RX *warfarin [Coumadin] 1 mg Four tablet(s) by mouth Once a day
Disp #*60 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose One packet
by mouth Once a day Disp #*30 Packet Refills:*0
16. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1-2 tablets by mouth For
constipation Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
VNA carenetwork
Discharge Diagnosis:
Pulmonary Embolism
Diarrhea induced by chemotherapy
Constipation
Anticoagulation management
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 7168**],
It was a pleasure taking care of you during your admission to
[**Hospital1 18**]. You came in for progressive shortness of breath and
diarrhea and were ultimately found to have a new lung blood
clot. You were started on blood thinners (initially a heparin
drip and then a daily shot of fondaparinux), and you will be
discharged on a medication called warfarin. You will need to
have your INRs (measure of how thin your blood is) checked on a
regular basis. This will be done at your hematology/oncology
appointment on [**10-10**] as well as by your primary care doctor.
Your diarrhea was likely due to the chemotherapy irinotecan, and
this issue resolved. You subsequently had constipation but you
did move your bowels before you were discharged.
You will have follow up with your oncologist Dr. [**Last Name (STitle) **] soon
after your discharge and determine the next steps of cancer
management.
PATIENT INSTRUCTIONS:
1. Warfarin check at hematology/oncology appointment on [**10-10**].
2. Stop anti-diarrheals
3. Stop oxycontin as your pain is well-controlled without it
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2147-10-10**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2147-10-10**] at 9:30 AM
With: [**Name6 (MD) 80068**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2147-10-10**] at 10:15 AM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name:[**Name6 (MD) **] [**Name7 (MD) 83829**],MD
Specialty: Primary Care
Location: [**Hospital1 **] INTERNAL MEDICINE
Address: [**Location (un) **], [**Apartment Address(1) 5524**], [**Location (un) **],[**Numeric Identifier 7331**]
Phone: [**Telephone/Fax (1) 7401**]
When: Thursday, [**10-12**] at 2:00pm
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70,641
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Discharge summary
|
report
|
Admission Date: [**2197-2-2**] Discharge Date: [**2197-2-9**]
Date of Birth: [**2117-7-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
subdural hematoma, CLL
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
Mr. [**Known lastname 1820**] is a 79 yo M with CLL s/p chemo, HTN, HL and COPD
p/w acute on chronic subdural hematoma. Pt recently began
treatment for his CLL, admitted to [**Hospital6 **] for
pancytopenia requiring transfusions. Noted to have some
confusion and left facial droop/hand weakness, head CT done
showing acute right subdural hematoma. Plt count was 12 at OSH,
received 6 pack of platelets prior to transfer for further care.
.
In the ED inital vitals were, 99.1 84 108/60 16 95% and
neurosurgery was consulted. Their recommendations were repeat CT
head now and at 24 hours; SBP<140, plt goal 100k; start keppra
1g IV now and then begin 500mg [**Hospital1 **]; admission to ICU for further
management. CT head done in ED and per prelim read is stable
from OSH scan (could not be uploaded to PACS). Patient received
another unit of platelets and his plts came up to 53.
.
On arrival to the ICU, pt appears little sleepy but able to wake
up to voice. Able to relate some of the history, says that he
went "loopy" last Saturday in the hospital. Per discharge
summary, pt was agitated the morning of admission, received
ativan/haldol, complained of headache which resolved with
tylenol. When he was working with PT, he was noted to have L
sided face droop and weakness of left hand/arm and CT scan
showed multiple small subdural hematoma as above.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache, blurry vision, or
paresthesia. Denies sore throat, cough, shortness of breath, or
wheezing. Denies chest pain, palpitations. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Past Medical History (per PCP [**Name Initial (PRE) **]):
- CLL (CHRONIC LYMPHOBLASTIC LEUKEMIA) on CHEMO XXX
- COPD
- HYPERCHOLESTEREMIA
- HYPERTENSION
- GERD (GASTROESOPHAGEAL REFLUX DISEASE)
- HISTORY OF ASBESTOS EXPOSURE (pleural plaques by CT)
- HISTORY OF COLONIC POLYPS
- OSTEOARTHRITIS
- SPINAL STENOSIS IN CERVICAL REGION
- CERVICAL RADICULOPATHY
- GENERALIZED OSTEOARTHRITIS OF MULTIPLE SITES
- PARKINSON'S DISEASE
- CHRONIC CONSTIPATION
- HELICOBACTER PYLORI GASTRITIS, dx on [**12-15**] treated
- s/p inguinal hernia repair
Social History:
- Tobacco: history of smoking, quit while ago
- Alcohol: occasional
- Illicits: denies
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
.
General: Alert, oriented to person, place and time (knows [**2-3**], initially says "12th year" - [**2096**], but corrects to [**2196**]. No
acute distress
HEENT: PERRL, difficulty following commands for extraocular
motion. Sclera anicteric, MMM, oropharynx clear.
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Scattered petechiae.
Neuro: PERRL (3mm -> 2mm bilaterally), difficulty following
commands for extraocular motion but saccades intact to right,
does not look to left as much. L facial droop, asymmetric mouth
opening from facial droop, uvula/tongue midline. SCM intact
bilaterally.
Motor: pt able to lift his LUE parallel to ground antigravity
and resist somewhat 3+/5, with antigravity, elbow flexion about
[**3-9**], elbow extensor 3+/5, fingergrip [**3-9**]. RUE elbow
flexor/extensor/finger grip [**4-8**], +resting tremor. LLE hip flexor
4+/5, knee flexor/extensor and ankle flexor/extensor [**4-8**]. RLE
[**4-8**] throughout.
Sensation: grossly intact to light touch bilaterally
Reflexes: biceps/patellar 2+ bilaterally, downgoing babinski
Gait deferred.
.
DISCHARGE EXAM:
l.ARM 4/5 weakness.
.
Pertinent Results:
.
Labs:
Labs from OSH: WBC 2.6 HCT 26.3 Plt 12 Na 140 BUN 17 Creat 0.75
.
[**2197-2-9**] 06:25AM BLOOD WBC-1.4* RBC-3.01* Hgb-8.5* Hct-26.3*
MCV-87 MCH-28.3 MCHC-32.4 RDW-15.9* Plt Ct-65*
[**2197-2-8**] 06:45AM BLOOD WBC-1.5* RBC-3.29* Hgb-9.5* Hct-28.6*
MCV-87 MCH-29.0 MCHC-33.4 RDW-16.0* Plt Ct-65*
[**2197-2-7**] 06:10AM BLOOD WBC-1.1* RBC-2.74* Hgb-8.0* Hct-24.3*
MCV-89 MCH-29.1 MCHC-32.8 RDW-16.3* Plt Ct-60*
[**2197-2-6**] 06:40AM BLOOD WBC-1.2* RBC-2.91* Hgb-8.4* Hct-25.2*
MCV-87 MCH-28.9 MCHC-33.4 RDW-16.2* Plt Ct-63*
[**2197-2-5**] 07:00AM BLOOD WBC-1.0* RBC-2.99* Hgb-8.6* Hct-26.6*
MCV-89 MCH-28.9 MCHC-32.4 RDW-16.5* Plt Ct-77*
[**2197-2-4**] 07:00PM BLOOD Hct-26.5* Plt Ct-49*
[**2197-2-4**] 07:45AM BLOOD WBC-1.2* RBC-2.83* Hgb-8.4* Hct-25.3*
MCV-89 MCH-29.8 MCHC-33.4 RDW-16.9* Plt Ct-60*
[**2197-2-3**] 12:02PM BLOOD Hct-26.7* Plt Ct-66*
[**2197-2-3**] 05:45AM BLOOD WBC-1.7* RBC-2.91* Hgb-8.6* Hct-25.5*
MCV-87 MCH-29.7 MCHC-34.0 RDW-17.1* Plt Ct-65*
[**2197-2-2**] 08:35PM BLOOD WBC-2.1* RBC-3.03* Hgb-8.9* Hct-25.9*
MCV-86 MCH-29.3 MCHC-34.2 RDW-17.7* Plt Ct-34*
[**2197-2-7**] 06:10AM BLOOD Neuts-32.5* Bands-0 Lymphs-62.9*
Monos-2.3 Eos-2.3 Baso-0
[**2197-2-6**] 06:40AM BLOOD Neuts-25.8* Bands-0 Lymphs-70.5*
Monos-0.9* Eos-1.5 Baso-1.3
[**2197-2-4**] 07:45AM BLOOD Neuts-10.2* Bands-0 Lymphs-86.4*
Monos-0.9* Eos-2.3 Baso-0.1
[**2197-2-3**] 05:45AM BLOOD Neuts-8* Bands-0 Lymphs-92* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2197-2-2**] 08:35PM BLOOD Neuts-12.7* Bands-0 Lymphs-85.8*
Monos-0.4* Eos-0.9 Baso-0.2
[**2197-2-3**] 05:45AM BLOOD PT-12.8* PTT-29.8 INR(PT)-1.2*
[**2197-2-2**] 08:35PM BLOOD PT-12.1 PTT-27.5 INR(PT)-1.1
[**2197-2-9**] 06:25AM BLOOD Glucose-91 UreaN-21* Creat-0.7 Na-139
K-3.7 Cl-104 HCO3-28 AnGap-11
[**2197-2-7**] 06:10AM BLOOD Glucose-94 UreaN-18 Creat-0.7 Na-137
K-3.8 Cl-102 HCO3-29 AnGap-10
[**2197-2-5**] 07:00AM BLOOD Glucose-82 UreaN-13 Creat-0.6 Na-137
K-3.4 Cl-101 HCO3-30 AnGap-9
[**2197-2-4**] 07:45AM BLOOD Glucose-75 UreaN-12 Creat-0.6 Na-138
K-3.7 Cl-103 HCO3-30 AnGap-9
[**2197-2-3**] 05:45AM BLOOD Glucose-85 UreaN-16 Creat-0.7 Na-139
K-3.8 Cl-103 HCO3-30 AnGap-10
[**2197-2-2**] 08:35PM BLOOD Glucose-99 UreaN-16 Creat-0.7 Na-136
K-3.9 Cl-101 HCO3-31 AnGap-8
[**2197-2-7**] 06:10AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9
[**2197-2-6**] 06:40AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.9
[**2197-2-5**] 07:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9
[**2197-2-3**] 05:45AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0
[**2197-2-2**] 08:40PM BLOOD Lactate-0.8
.
Head CT [**2-2**]:
IMPRESSION:
1. Stable superimposed acute on chronic right subdural hematoma
with minimal local mass effect. No subfalcine or transtentorial
herniation.
2. Prominent extra axial space overlying the left frontal lobe,
also
unchanged.
3. Mucosal thickening in the ethmoid air cells and left mastoid
air cells.
.
[**2-3**] CXR:
IMPRESSION:
1. Probable chronic lung disease related to asbestos exposure
2. No acute cardiopulmonary process
.
[**2-3**] CT head:
IMPRESSION:
1. Stable acute on chronic subdural hematomas with minimal local
mass effect. No subfalcine or transtentorial herniation.
2. Unchanged mucosal thickening in the ethmoid and mastoid air
cells
.
Head CT [**2-4**]:
IMPRESSION:
In comparison to [**2197-2-3**] exam, there is no significant change
in acute on
chronic right subdural hematoma. No new focus of acute
intracranial
hemorrhage is noted.
ATTENDING NOTE: Some change in appearance is likely due to
redistribution. No new hemorrhage.
.
[**2-5**] CT head:
IMPRESSION: No change in exam compared to next preceding study
with stable
chronic bifrontal subdural hematomas and unchanged right frontal
and
parafalcine internal foci of hyperattenuation, suggesting more
acute
hemorrhage.
.
[**2-8**] CT head:
Preliminary ReportIMPRESSION:
Preliminary Report1. Stable acute on chronic right subdural
hematoma and unchanged chronic left
Preliminary Reportfrontal subdural hematoma.
Preliminary Report2. No subfalcine or transtentorial herniation
.
Microbiology:
ucx-no growth
bcx-no growth
Brief Hospital Course:
Assessment and Plan: 79 yo M with CLL on chemo, admitted to OSH
for transfusion for pancytopenia, noted to have new L.sided
deficit and found to have R. sided subdural hemorrhages in
setting of thrombocytopenia.
.
# acute on chronic Subdural hematoma: Pt was seen in ED by
neurosurgery with recommendation for repeat scan in ED and in 24
hours that appeared stable per radiology, subsequent scans have
also been stable. He was loaded on Keppra and continued on a
maintainence dose of 500mg [**Hospital1 **] while will continue upon
discharge. He required transfusion of platelets given concern
for his neurosurgical bleeding. Goal plt count per neurosurgery
was 100. However, given pt's CLL, on chemotherapy, and
?autoimmune component to thrombocytopenia for which patient had
been on steroids as an outpt, this goal was not achievable and
goal was set at 50 which transfusion prn to meet this goal and
pt remained clinically stable with this goal with serial head
CTs showing stability of SDH. On arrival to the ICU, patient
examined and seemed to have worsening LUE weakness, but overall
appeared stable. Repeat head CT was reassuring, as noted. Q2
hour neurochecks were stable. His systolic blood pressure was
maintained < 140 mmHg. Neurosurgery would like follow-up as an
outpatient in 4-weeks, with head CT prior to appointment, given
his clinical stability and noted no need for operative
intervention. This appointment has been scheduled, see below. It
was thought that pt, experienced SDH due to low platelet count.
Plt goal was >50 as it seemed near impossible to achieve goal of
100. Pt remained stable on this regimen. Several serial head
CT's were stable. Of note, pt has a L.upper extremity weakness
3-4/5, with L.sided facial droop. This persisted during
admission, while on the medical floor, and at the time of
discharge. Of note, neuro exam and clincal exam remained stable
on the medical floor, but pt did experience times of
delerium-see below. He will be discharged to rehab facility to
continue physical therapy. Last plt transfusion [**2197-2-4**].
Discharge plt count 65.
.
# Pancytopenia with neutropenia and thrombocytopenia- Patient
admitted to [**Hospital1 392**] for severe/symptomatic anemia. He required
platelet transfusion in the setting of his low platelets, goal
being > 50,000. His RBC transfusion goal was set at > 25% for
his hematocrit. He was maintained on neutropenic precautions and
his CLL is has been managed by Dr. [**Last Name (STitle) **] from oncology. Pt last
received chemotherapy bendamustine [**Date range (1) 21656**]. This is currently
on hold given cell counts. Pt will follow up with Dr. [**Last Name (STitle) **]
after discharge. Appointment scheduled. See below. Of note, pt
is thought to have a possible autoimmune component to his
thrombocytopenia and was on steroids as an outpatient. Oncology
recommended that pt receive 60mg daily x2 days, then 40mg daily
x2 days (to start [**2197-2-10**]), then decrease to 20mg daily with
further instructions for taper to be determined by patient's
outpatient oncologist Dr. [**Last Name (STitle) **]. Pt was continued on PPI therapy
started on bactrim for PCP [**Name9 (PRE) **], calcium and vitamin D for bone
ppx while on steroids. As above, plt goal is >50, and HCT goal
>25.
.
#encephalopathy, metabolic, Pt appeared to sundown during
admission. He also unfortunately experienced occasional
paranoid/delusional hallucinations surrounding his wife. Likely
[**Name2 (NI) 30636**] related to hospitalizations, Parkinsons, SDH.
This improved during hospitalization. Should maintain sleep/wake
cycle and provide patient with frequent reorientation.
.
# CLL: Patient began treatment 2 weeks prior to admission with
bendamustine. Pt is now neutropenic and chemotherapy is on hold.
He is currently on steroids and will be following up with
oncology after discharge for ongoing care.
.
# Parkinson's disease: Patient on levodopa-carbidopa as an outpt
and this was continued at home regimen
..
# COPD: patient on symbicort as an outpatient, no evidence of
exacerbation or respiratory distress. Recent admission for
exacerbation, on prednisone taper. Continued inhaler. On
steroids for above
.
# GERD: continued omeprazole
.
# Hyperlipidemia: continued home simvastatin
.
# History of hypertension, but per Atrius record, with new
orthostatic hypotension, likely related to his Parkinson's
disease. On no antihypertensives at this time.
- Per neurosurgery, goal SBP < 140, monitor BP closely. Pt did
not have hypertension while on the medical floor and no
medications were given. Pt was found to have orthostatic
hypotension a few days prior to discharge with dizziness.
However, this improved and pt was able to ambulate with physical
therapy without symptoms on the day of discharge.
.
#depression-continued SSRI
.
#DVT ppx-pneumoboots
.
#code-DNR/DNI
.
Transitional care
-at least daily monitoring of CBC to monitor for neutropenia,
and need for transfusion of plt for plt <50 or PRBCs for HCT <25
-neurosurgery f/u in 4weeks with repeat head CT, scheduled
-oncology f/u for CLL and continued instructions on prednisone
taper, scheduled.
-PCP f/u upon discharge from rehab.
Medications on Admission:
Medications (per discharge summary from [**Hospital1 392**], not confirmed):
- folic acid 1 mg Tab Oral 1 Tablet(s) Once Daily
- omeprazole 20 mg Tab, Delayed Release Oral 1 Tablet, Delayed
Release (E.C.)(s) Once Daily
- Celexa 20 mg Tab Oral 1 Tablet(s) Once Daily
- simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
- Symbicort 2 HFA Aerosol Inhaler(s) Twice Daily
- carbidopa-levodopa 25 mg-100 mg Tab Oral 1.5 Tablet(s) Three
times daily
- Miralax [**12-5**] Powder in Packet(s) Once Daily, as needed
- Senokot 8.6 mg Tab Oral 1 Tablet(s) Once Daily
- Colace 100 mg Cap Oral 1 Capsule(s) Twice Daily
- prednisone 5 mg Tab Oral 1 Tablet(s) Once Daily
- Lotrimin cream to penis
- Nystatin swish/swallow
Discharge Medications:
1. carbidopa-levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO TID
(3 times a day).
2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Symbicort 80-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation twice a day.
8. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
12. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 days: start [**2-10**], 40mg daily x2 days, then start 20mg daily
until intructed to change by neuro-oncologist.
13. prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day:
to start after 2 days of 40mg daily. Further taper per oncology.
14. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO three
times a week: while on steroids.
15. Caltrate 600 + D 600 mg(1,500mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day: while on steroids.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Subdural hematoma
CLL
Thrombocytopenia
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were transferred from [**Hospital3 **] with a subdural
hematoma due to low platelets. You were transfused blood
products and seen by Neurosurgery who did not recommend any
surgical intervention at this time. Therefore, you were
monitored closely and given platelet transfusions as needed. The
physical therapists recommended that you attend rehab after
discharge to regain your strength.
.
medication changes:
1.start keppra to prevent seizures
2.prednisone taper
3.start bactrim and calcium and vitamin d while on steroids
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Department: Hematology/ Oncology
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: [**2197-2-15**] at 10:15 AM
Location: [**Location (un) **] HEMATOLOGY ONCOLOGY
Address: [**Location (un) 10726**], [**Hospital1 **],[**Numeric Identifier 10727**]
Phone: [**Telephone/Fax (1) 10728**]
Department: Head CT Scan- RADIOLOGY
When: TUESDAY [**2197-3-14**] at 1:00 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2197-3-14**] at 2:15 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"781.94",
"311",
"332.0",
"204.10",
"E933.1",
"V49.86",
"348.31",
"288.03",
"729.89",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15716, 15813
|
8306, 13477
|
292, 319
|
15903, 15903
|
4248, 7227
|
16735, 17574
|
2781, 2799
|
14244, 15693
|
15834, 15882
|
13503, 14221
|
16088, 16482
|
2814, 4190
|
4206, 4229
|
1725, 2101
|
16502, 16712
|
230, 254
|
347, 1706
|
8003, 8283
|
15918, 16064
|
2123, 2660
|
2676, 2765
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,137
| 194,803
|
30239
|
Discharge summary
|
report
|
Admission Date: [**2107-1-6**] Discharge Date: [**2107-1-13**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Lower GI bleed
Major Surgical or Invasive Procedure:
[**2107-1-7**]: colonoscopy
[**2107-1-11**]: colonoscopy (Unable to traverse past the sigmoid colon)
History of Present Illness:
67M with COPD, CHF (EF 25%), Chronic Kidney Disease Stage
IV, h/o HCC and EtOH cirrhosis s/p OLT [**2104-8-22**] now transferred
from [**Hospital3 **] Hospital with a lower GI bleed. He initially
presented to [**Hospital **] hosp with lethargy, change in mental status and
black stools as well as diarrhea with bright red blood. Pt also
reported non-bloody bilious emesis prior to admission. Pt
admitted to [**Hospital **] hosp on [**2107-1-5**] with a Hct of 10%. A tagged RBC
scan [**1-5**] showed increased activity in the left mid abdomen
which conformed to a loop of bowel and demonstrated a transit
over time c/w an acute GI bleed in the descending colon. He was
admitted to the ICU and transfused 5 units of PRBC with a Hct
rise from 10% to 31% this morning [**1-6**]. The pt was then
tansferred here to [**Hospital1 18**] for futher management. Pt had a peak
troponin I of 0.12 which decreased to 0.11 at the time of
transfer.
Past Medical History:
liver transplant ([**2104-8-22**])
EtOH cirrhosis
HCC
anemia
essential thrombocytosis
prior complications of ascites
malnutrition
portal [**Month/Day/Year **] with grade 2 esophageal varices
h/o duodenitis [**7-18**]
grade 1 rectal varices
grade 2 esoph varices and gastritis by EGD [**3-/2106**]
CAD: ([**2104-7-1**] coronary angiography -inferolateral akinesis &
substantial lateral hypokinesis. 50% LAD lesion. Circ occluded
distally. RCA 40% stenosis)
CHF: ECHO [**9-19**], EF 25%
failure to thrive s/p PEG
Social History:
The patient owns business in [**Hospital3 **]: a clothing store and a
limousine business. Recently he started working from home due to
his poor health. He lives with his wife, who is very supportive.
He smokes. No drugs. Stopped EtOH in 6/[**2103**].
Family History:
Non contributory
Physical Exam:
Temp 97.9, HR 73, BP 133/91, RR 18, O2 Sat 100RA
Gen: Cachectic male, alert and oriented, appropriate and
conversive
HEENT: No sceral icterus, EOMI, MMM
CV: RRR, No R/G/M
RESP: Lungs CTAB
ABD: Soft, NT, ND, Well healed OLT surgical incisions, PEG
clamped, flushed with 100cc H2O with clear return on aspiration
Ext: Malnurished, extremely thin extremities, no peripheral
edema, feet WWP
Rectal: External hemorrhoids, no blood in rectal vault, Guaiac +
Pertinent Results:
On Admission: [**2107-1-6**]
WBC-16.1*# RBC-3.50* Hgb-10.0* Hct-29.8* MCV-85 MCH-28.6#
MCHC-33.6# RDW-18.2* Plt Ct-261#
PT-11.8 PTT-28.3 INR(PT)-1.0
Glucose-118* UreaN-160* Creat-3.4*# Na-141 K-4.6 Cl-103 HCO3-23
AnGap-20
ALT-14 AST-26 CK(CPK)-56 AlkPhos-52 Amylase-111* TotBili-0.4
Albumin-3.1* Calcium-7.6* Phos-4.8*# Mg-2.1 Iron-99
[**2107-1-6**] calTIBC-261 Ferritn-315 TRF-201
On Discharge [**2107-1-13**]
WBC-5.0 RBC-4.31* Hgb-12.2* Hct-36.5* MCV-85 MCH-28.4 MCHC-33.5
RDW-17.0* Plt Ct-120*
Glucose-103 UreaN-102* Creat-3.3* Na-140 K-4.2 Cl-110* HCO3-17*
AnGap-17
ALT-14 AST-24 AlkPhos-80 TotBili-0.7
Calcium-7.9* Phos-5.0* Mg-1.9
Brief Hospital Course:
67 y/o male well known to transplant clinic who presents on
transfer from OSH with a lower GI bleed. His Hct on admission
was 29.8% but this was following a 5 unit transfusion at [**Location (un) 21541**] Hospital for a reported Hct of 10%
He received an additional 3 units of RBCs on day of admission,
and 2 more units and cryoprecipitate on HD 2.
On [**1-7**] he underwent colonoscopy which was limited due to prep
and also to the diverticuli in the proximal sigmoid colon.
Findings included:
-Diverticulosis of the sigmoid colon
-No active source of bleeding visualized.
-Polyps in the sigmoid colon
-Otherwise normal colonoscopy to proximal sigmoid colon
He was kept in the intensive care unit and and serial Hcts were
folowed. From [**1-8**] on the hcts remained stable and he required
no further transfusion.
On [**1-11**] he underwent an additional colonoscopy due to the
limited first exam.
Findings included:
-No evidence of active bleeding but nemerous diverticula
visualized.
-Unable to traverse past the sigmoid colon.
-Colitis seen in visualized portion of colon.
-Polyps seen but not removed at this time.
He will continue to be followed as an outpatient for evidence of
further bleeding.
All cardiac medications were maintained and no chages were made
to the cardiac regimen. Diuretics were reinstated on HD 3. Of
note the patients weight was down another 3 kg since his
hospitalization in [**Month (only) **].
The patient was re-evaluated by the transplant nutrition service
while in house. He was restarted on tube feeds via the PEG tube
which has been in place. He was at goal by the time of discharge
and will be followed at home by [**Location (un) 511**] Home Therapies.
Immunsuppression was followed by no dosage chages occurred
during this hospitalization. His LFTs were all WNL.
Chronic renal failure was evaluated by the renal consult
service. His creatinine was 3-3.4 during this hospitalization.
Urine output was about a liter daily, even on diuretics. There
is still no acute need for hemodialysis at this time.
Patient will be followed by his outpatient cardiologist with
routine, scheduled appointments.
Medications on Admission:
Procrit 20,000 Units SC Qweek, Peptamen TF 240ml 1 can TID
with 30ml H20 before and 60ml H20 after each can, Lasix 160
QDay,
Zaroxolyn 5pm PO QAM prior to lasix, Imdur 30, Norvasc 5,
Rapamune 2, Coreg 25 [**Hospital1 **], Dualcitra liquid 30ml [**Hospital1 **], Creon 2 tab
TID c meals, Testosterone TD 2.5mg daily, Zocor 10, Calcitriol
0.25, Remeron 15, Prednisone 5, Pepcid 20
Discharge Medications:
1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule,
Delayed Release(E.C.) Sig: [**2-12**] Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
5. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Loperamide 2 mg Tablet Sig: 1-2 Tablets PO QID (4 times a
day) as needed for diarrhea: No more than 16 mg daily.
Disp:*120 Tablet(s)* Refills:*1*
14. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
Diverticulosis/Diverticulitis with lower GI bleed
Severe regional LV systolic dysfunction (last Echo [**9-19**])
s/p liver transplant [**2104**]
Malnutrition
Discharge Condition:
Fair
Ambulatory
A+Ox3
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in a day.
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, increased diarrhea, inability to
tolerate the tube feeds or any other concerning symptoms
Labs faxed to transplant clinic per their recommendations for
lab draws
DO NOT alter your tube feed recommendations. You must take them
24 hours daily at your goal rate. If you are having problems
tolerating the tube feeds call the transplant clinic. Do not
discontinue tube feeds without discussion with the transplant
clinic
Followup Instructions:
Dr [**Last Name (STitle) 72014**] (Cardilogist) Appointment [**1-19**]
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for appointment
Completed by:[**2107-1-17**]
|
[
"577.8",
"261",
"496",
"V85.0",
"428.0",
"V10.07",
"V44.1",
"V42.7",
"211.3",
"403.90",
"414.01",
"285.9",
"562.13",
"585.4",
"425.4",
"799.4",
"428.22",
"305.1",
"V11.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
7158, 7224
|
3383, 5518
|
327, 430
|
7426, 7450
|
2722, 2722
|
8115, 8316
|
2216, 2234
|
5948, 7135
|
7245, 7405
|
5544, 5925
|
7474, 8092
|
2249, 2703
|
273, 289
|
458, 1396
|
2736, 3360
|
1418, 1931
|
1947, 2200
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,000
| 136,576
|
13537
|
Discharge summary
|
report
|
Admission Date: [**2105-5-30**] Discharge Date: [**2105-6-4**]
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is an 85 year old
gentleman who presents on referral from an outside hospital
with a chief complaint of ten to 14 days of headache and a
three day history of vague mental status changes noted by the
patient's daughter.
The patient was taken to an outside hospital on the day of
admission, where a head CT scan showed a large left acute
versus subacute subdural hematoma 1.5 to 2 cm extending from
frontal posterior parietal occipital area with 9 mm of
midline shift, left to right. The patient was transferred to
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for further management.
PAST MEDICAL HISTORY: 1. Coronary artery disease, status
post coronary artery bypass grafting times three in [**2095**]. 2.
Cholecystectomy in [**2096**].
MEDICATIONS ON ADMISSION: Coumadin 5 mg alternating with 7
mg p.o.q.d., Zocor 20 mg p.o.q.d., Zestril 10 mg p.o.q.d.,
Isordil 60 mg p.o.q.d., Ambien p.r.n.
ALLERGIES: Phenobarbital.
PHYSICAL EXAMINATION: On physical examination, the patient
had a blood pressure of 139/64, heart rate 61, respiratory
rate 16 and oxygen saturation 95% in room air. He was awake,
alert and oriented times three. Speech was with minimal
occasional slurring. Pupils were equal, round, and reactive
to light. Extraocular movements were full. Tongue was
midline. He had no drift. He had mild right upper extremity
weakness 4+/5 in all groups, otherwise full power in other
extremities. Sensation was intact to light touch. Deep
tendon reflexes were 2+ bilaterally. Toes were equivocal.
Short term memory impairment, was slow to simple math. Neck
was supple. Lungs were clear to auscultation bilaterally.
Cardiovascular showed a regular rate and rhythm, no murmur,
rub or gallop. Abdomen was soft, nontender, nondistended.
Extremities showed no cyanosis, clubbing or edema.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit. On [**2105-5-31**], he underwent left
craniotomy for evacuation of his subdural hematoma and
placement of subdural drain.
The patient was monitored in the Surgical Intensive Care
Unit, where was awake, alert and oriented times three, moving
all extremities, with improvement of the right upper
extremity weakness. The patient had no drift
postoperatively.
The patient was transferred to the regular floor after a head
CT scan showed good evacuation of the subdural hematoma on
postoperative day number two. His vital signs remained
stable and he was afebrile. He was out of bed ambulating,
followed by physical therapy and occupational therapy and
found to require a short rehabilitation stay prior to
discharge home.
DISCHARGE MEDICATIONS:
Percocet one to two tablets p.o.q.4h.p.r.n.
Zantac 150 mg p.o.b.i.d.
Zocor 20 mg p.o.q.d.
Zestril 10 mg p.o.q.d.
Tylenol 650 mg p.o.q.4h.p.r.n.
Isordil 60 mg p.o.q.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) 1327**] with a repeat head CT scan in two weeks' time. He
will follow up for staple removal also at that time, on
postoperative day number ten.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 40919**]
MEDQUIST36
D: [**2105-6-4**] 09:56
T: [**2105-6-4**] 10:32
JOB#: [**Job Number **]
|
[
"V45.81",
"401.9",
"852.20",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
2857, 3025
|
987, 1146
|
2047, 2834
|
1169, 2029
|
126, 801
|
824, 960
|
3050, 3547
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,646
| 134,912
|
14405
|
Discharge summary
|
report
|
Admission Date: [**2167-5-30**] Discharge Date: [**2167-6-3**]
Date of Birth: [**2126-12-9**] Sex: M
Service: Medicine, [**Doctor Last Name **] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old
homeless male with no known past medical history who was
brought in by Emergency Medical Service after being found in
[**Location (un) 19903**]vomiting coffee-grounds on [**5-30**].
The patient states that he drank a 12-pack of beer. Upon
arrival in the Emergency Room, the patient was intoxicated
and was lethargic and not protecting his airway. At that
point he was intubated. An nasogastric tube lavage with 250
cc of dark brown fluid which was clear and no coffee-grounds.
The patient was transferred to the Medical Intensive Care
Unit, given intravenous fluids, and put on DT prophylaxis.
He was extubated 10 hours after intubation without any
complications. The patient was then noted to develop an
increasing heart rate and agitation. He was held for
observation and medication for possible delirium tremens.
The patient was stable with a standing dose of Valium 10 mg
t.i.d. with Ativan 2 mg to 4 mg q.2-4h. as needed. He was
then transferred on [**6-1**] to CC7 in fair condition.
PAST MEDICAL HISTORY: The patient has no significant past
medical history.
ALLERGIES: He has no known medical allergies.
MEDICATIONS ON ADMISSION: He was on no medications (by
report).
SOCIAL HISTORY: His social history revealed he has been
homeless for the past nine months. He was in a shelter
before then. He has no family in the area. He is of Mexican
decent. Alcohol wise, he states that he has had prior heavy
drinking episodes and that he often gets shakes with his
drinking. Tobacco use revealed he smokes half a pack per day
for the past three years. He denies any drug use.
FAMILY HISTORY: Family history was none (by report).
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 98.4, heart rate of 69, blood pressure
of 130/67, respiratory rate of 17, oxygen saturation was 100%
on room air. In general, he was an alert man who was
oriented to hospital and knew that the date was [**2167-5-9**];
although, he was not clear as to the specific date. Head and
neck examination revealed pupils were equal and reactive to
light. The nares were clear. Mucous membranes were moist.
Good dentition. Sinuses were nontender, and no
lymphadenopathy. Cardiac examination showed a regular rate
and rhythm. No murmurs. Chest had some mild expiratory
wheezes throughout. There was no costovertebral angle
tenderness. The abdomen was nontender and nondistended. No
hepatosplenomegaly, and positive bowel sounds. His
extremities showed no edema, warm. Distal pulses were 2+
bilaterally. Neurologically, his reflexes were 2+
bilaterally with no nystagmus. A mild tremor was noted while
at rest and also increasing with intention.
PERTINENT LABORATORY DATA ON PRESENTATION: His complete
blood count revealed a white blood cell count of 4.8,
hematocrit of 40.1, platelets of 276. Sodium of 144,
potassium of 4.1, chloride of 102, bicarbonate of 28, blood
urea nitrogen of 8, creatinine of 0.8, blood glucose of 132.
His INR was 1.1. Albumin of 4.3. His creatine kinase
was 986, CK/MB was 2. ALT was 194, AST was 264, alkaline
phosphatase was 98, total bilirubin was 0.2, LDH was 516,
amylase was 28, lipase was 37. Calcium of 8.3, magnesium
of 2. Alcohol level was 619. Arterial blood gas was
7.44/39/80. Urine cultures was negative. Blood cultures was
negative. Thyroid-stimulating hormone was 0.27. Urinalysis
was negative.
RADIOLOGY/IMAGING: CT was negative for intracranial bleed.
An electrocardiogram showed normal sinus rhythm at 85, normal
axis, T wave inversions in aVL. No ischemia. Normal QRS.
Normal Q-T.
A chest x-ray showed no congestive heart failure, right
basilar atelectasis. No effusions. Possible retrocardiac
infiltrates.
HOSPITAL COURSE: During his hospital course, his white
blood cell count increased to 11.4, but then decreased back
down to 7. His creatine kinase rose to a high of 1211
before decreasing to 531. His liver function tests revealed
his ALT eventually came down to 82, and his AST to 65, and
his alkaline phosphatase to 86.
While in the hospital, the patient was monitored for
increasing signs of alcohol withdrawal on a regimen of
Valium 10 mg three times per day and Ativan 2 mg every two
hours as needed for a CIWA of greater than 10. The patient
was also given thiamine and folate.
The patient had a temperature spike of 101.8. At this point,
he was considered to be at risk for possible aspiration
pneumonia and was placed on Levaquin 500 mg p.o. q.d. The
patient was placed on Protonix 40 mg p.o. q.d. for possible
gastritis and also for prophylaxis. He was also given
vigorous intravenous fluids in order to avoid rhabdomyolysis
given his high creatine kinases.
An Addiction consultation was requested; however, the patient
refused inpatient detoxification. The patient did agree to
look into Spanish Alcohol Anonymous as an outpatient.
The patient was found to be needing less Ativan p.r.n. and
stable on his standing Valium 10 mg p.o. t.i.d. At that
point, the Valium was weaned down to 10 mg p.o. b.i.d., and
the patient did not need any Ativan p.r.n. for any CIWA
greater than 10. At that point, the patient was considered
to be stable to be discharged.
CONDITION AT DISCHARGE: The patient was discharged in good
condition.
DISCHARGE DIAGNOSES: Alcohol intoxication and withdrawal.
MEDICATIONS ON DISCHARGE: Discharged on no medications.
DISCHARGE FOLLOWUP: Follow-up appointment on [**6-8**] with
new primary care physician at [**Hospital6 733**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21189**], M.D. [**MD Number(1) 41641**]
Dictated By:[**Last Name (NamePattern1) 4988**]
MEDQUIST36
D: [**2167-6-4**] 17:06
T: [**2167-6-5**] 10:18
JOB#: [**Job Number 35489**]
|
[
"291.0",
"780.01",
"518.81",
"303.00",
"535.31",
"E980.9",
"980.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"96.33",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1838, 3934
|
5506, 5544
|
5571, 5602
|
1375, 1414
|
3953, 5422
|
5437, 5484
|
5624, 5994
|
195, 1223
|
1246, 1348
|
1431, 1821
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,465
| 184,576
|
10559
|
Discharge summary
|
report
|
Admission Date: [**2144-6-10**] Discharge Date: [**2144-6-26**]
Date of Birth: [**2061-11-16**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Partial Small Bowel Obstruction
Nausea, Vomiting
Major Surgical or Invasive Procedure:
Right Portacath Placement
History of Present Illness:
This is a 82 year old male with a h/o bladder cancer requiring 4
resections and recently diagnosed metastatic squamous cell
cancer involving the rectum. He also had a recently elevated INR
of 12.4. He has fecal incontinence secondary to squamous cell
carcinoma infiltrating the pelvis. He underwent a diverting
colostomy approximately 10 days ago. Following surgery, the
patient developed ileus and experienced continued nausea w/o
vomiting. He was discharged from the hospital 5 days ago. He has
done poorly at home and reports persistent nausea, anorexia, and
decreased stoma output. He had continued nausea and poor
appetite at home w/1 episode of vomiting triggered by brushing
his teeth.
He was admitted to the hospital for FTT, persistent ileus and
placement of a port for systemic sensitization chemotherapy/.
Bladder Cancer (Papillary urothelial carcinoma, diagnosed [**2139**])
- s/p several cycles of therapy with BCG, interferon,and most
recently on intravesicular mitomycin (last dose [**2144-4-30**]), and
recent lap end colostomy now w evidence of peritoneal drop
metastasis in the lower pelvis. Recent hosp course c/b partial
SBP. [**4-/2144**] CT torso was notable for thickening from the
rectum to the sigmoid colon and increased mediastinal nodes.
Past Medical History:
Hypertension
Bladder Cancer (Papillary urothelial carcinoma, diagnosed [**2139**])
Ureteral strictures
Pyelonephritis/MRSA urinary tract infection
Chronic renal insufficiency w/ baseline Cre 2.3-2.5
MRSA bacteremia
s/p Pacemaker [**2137**] (tachy-brady syndrome)
Atrial Fibrillation
Gout
Diverticulosis
Bilateral inguinal hernias
Abdominal Aortic aneurysm
PSH:
[**2144-6-10**]: Placement of a single-lumen Infuse-A-Port via the
right
subclavian vein.
[**2144-6-1**]: Laparoscopic end colostomy with partial
sigmoidectomy.
[**2144-5-13**]: Multiple core anorectal biopsies.
[**2144-2-11**]: Transurethral resection of bladder tumor, L
retrograde
pyelogram, L ureteroscopy, L ureteral stent placement.
[**2143-8-6**]: Cystoscopy w/ R retrograde pyelogram, R ureteroscopy,
R directed biopsy, R ureteral brushing., L ureteroscopy.
Bilateral ureteral stent placement, and transurethral
fulguration
of bladder tumor and directed bladder biopsies.
[**2143-6-24**]: Resection of large bladder tumor and fulguration.
[**2142-12-17**]: Resection of medium bladder tumor and fulguration.
Social History:
lives with wife who is HCP, retired
drinks 1 glass wine per night, denies tobacco and illicit drug
use.
Family History:
Non-contributory
Physical Exam:
VS: Temp 97.8 HR 62 (R) BP 118/76 RR 20 SpO2 96% on RA
Gen: NAD, awake, alert, and communicative
HEENT: no scleral icterus, PERRL, EOMi, no cervical or
supraclavicular LAD; NGT draining sanguinous fluid
CV: RRR, SEM II/VI at apex
Lungs: CTA bilaterally
Abd: belly soft, NT/ND, no bowel sounds detected, no HSM; ostomy
in place, moist, intact, and non-erythematous, not currently
draining
Extremities: large ecchymoses on L shin
Neuro: CN2-12 intact to direct testing; full sensation to light
touch throughout extremities; motor strength 4+/5 throughout all
extremities; finger-nose-finger intact, no asterixis
.
At Discharge:
Pertinent Results:
[**2144-6-13**] 06:10AM BLOOD WBC-9.9 RBC-3.31* Hgb-10.1* Hct-31.9*
MCV-96 MCH-30.6 MCHC-31.8 RDW-16.1* Plt Ct-336
[**2144-6-18**] 06:00AM BLOOD PT-12.3 PTT-29.0 INR(PT)-1.0
[**2144-6-11**] 03:50PM BLOOD PT-35.8* PTT-38.2* INR(PT)-3.8*
[**2144-6-10**] 11:43AM BLOOD PT-93.5* PTT-45.7* INR(PT)-12.4*
[**2144-6-11**] 03:50PM BLOOD Fibrino-330# D-Dimer-853* Thrombn-22.1*
[**2144-6-18**] 06:00AM BLOOD Glucose-149* UreaN-50* Creat-1.3* Na-139
K-3.6 Cl-107 HCO3-22 AnGap-14
[**2144-6-11**] 06:45AM BLOOD ALT-11 AST-24 AlkPhos-77 TotBili-0.5
[**2144-6-18**] 06:00AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.1
[**2144-6-11**] 06:45AM BLOOD calTIBC-196* Ferritn-242 TRF-151*
[**2144-6-12**] 09:15AM BLOOD Triglyc-98
.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2144-6-10**] 12:15 PM
FINDINGS: A pacemaker/AICD overlies the left lateral thoracic
chest wall with leads in unchanged position. A nasogastric tube
and right-sided port have been placed with the port tip in the
cavoatrial junction. There is no
pneumothorax. Borderline cardiomegaly persists. The pulmonary
vasculature is normal. Lateralization of the apex of the right
hemidiaphragm which may
suggest a small underlying subpulmonic effusion. There is no
focal
consolidation.
.
Radiology Report PORTABLE ABDOMEN Study Date of [**2144-6-10**] 12:16
PM
IMPRESSION: Findings concerning for early or partial small bowel
obstruction. Nasogastric tube likely extends into the duodenum.
.
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2144-6-12**]
11:59 AM
IMPRESSION:
1. Persistent dilatation of the small bowel, without a discrete
transition
point. Although early or partial obstruction is difficult to
exclude, the
appearance is more consistent with an ileus.
2. Anasarca.
3. Suspected peritoneal drop metastasis in the lower pelvis,
with overall
evaluation for metastatic disease highly limited by technique.
4. Asymmetric thickening along the pylorus, in the setting of
more diffuse
gastric wall thickening, which may be inflammatory in etiology.
Clinical
correlation suggested.
.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2144-6-16**]
3:04 PM
FINDINGS: Grayscale and color Doppler son[**Name (NI) **] of bilateral
common femoral, superficial femoral, and popliteal veins were
obtained. There is normal compression, flow, and augmentation.
Color flow in the superficial veins of bilateral calves is
demonstrated. A moderate amount of subcutaneous edema is seen
within bilateral lower extremities.
IMPRESSION: No evidence of DVT of bilateral lower extremities.
CT abdomen/pelvis [**6-12**]:
INDICATION: 82-year-old man with end-colostomy for bladder
tumor, now with
nausea, vomiting and higher nasogastric tube output.
COMPARISONS: CT from [**2144-4-28**] and more recent radiograph from
[**2144-1-11**].
TECHNIQUE: Axial non-contrast CT images of the abdomen and
pelvis were
obtained with oral but not intravenous contrast, and sagittal
and coronal
reconstructions were also performed.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are moderate
bilateral pleural
effusions, greater on the right than left, of low density with
associated
parenchymal opacities, most likely represent atelectasis. A
dual-lead
pacemaker device is noted along the most superior images. The
gallbladder is
full, but not markedly distended. A nasogastric tube terminates
immediately
beyond the pylorus, which shows asymmetric thickening up to 12
mm. The liver,
pancreas, spleen, and adrenal glands are within normal limits.
The kidneys
again appear atrophic.
There is a persistent moderate hydronephrosis of the left
kidney, slightly
increased, with mural thickening of the left ureter and again a
suspected
filling defect, as noted before. A similar 3- cm focal fusiform
aneurysm of
the mid infrarenal aorta is also present.
The patient is status post diverting colostomy. The stomach and
entire bowel
show mild-to-moderate wall thickening, and there is diffuse
stranding in the
mesentery and along the subcutaneous tissues of the flanks.
There is also
moderate ascites of low density, particularly adjacent to the
lateral aspect
of the spleen. There is no free air.
At the time of the scan, some of the enteric contrast had
entered the cecum.
The more distal bowel up to the colostomy site contains air and
stool, and is
not collapsed. However, the distal small bowel is again
moderately dilated to
a similar extent as on a plain film from two days ago.
The lack of intravenous contrast makes it difficult to evaluate
for metastatic
disease, but limiting evaluation, particularly in the setting of
diffuse
edema.
CT OF THE PELVIS WITHOUT IV CONTRAST: The rectal stump appears
diffusely
thickened, as noted previously. The prostate and seminal
vesicles appear
grossly normal in size. Along the anterior and right side of the
bladder,
there is marked thickening as noted previously.
In the lower pelvis, there is a dense area along the dependent
portion of the
ascites, most likely representing a metastatic nodule of 13 mm
in diameter. A
small some amount of ascites layers in the pelvis. No discrete
lymph nodes
are identifiable.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Persistent dilatation of the small bowel, without a discrete
transition
point. Although early or partial obstruction is difficult to
exclude, the
appearance is more consistent with an ileus.
2. Anasarca.
3. Suspected peritoneal drop metastasis in the lower pelvis,
with overall
evaluation for metastatic disease highly limited by technique.
4. Asymmetric thickening along the pylorus, in the setting of
more diffuse
gastric wall thickening, which may be inflammatory in etiology.
Clinical
correlation suggested.
XR abdomen [**2144-6-18**]:
INDICATION: Fecal incontinence from anal stricture status post
laparoscopic
end colostomy. Nausea, vomiting, and poor ostomy output. Please
evaluate new
NG tube placement.
COMPARISON: CT abdomen and pelvis, [**2144-6-12**].
FINDINGS: Nasogastric tube courses through the distal
mediastinum with tip
and sideport overlying the expected region of the stomach. There
has been
interval increase in dilation of a loop of small bowel in the
left abdomen
measuring 5.1 cm. No mucosal or submucosal abnormality is
suggested to this
loop within the limitations of this radiograph. Dual-lead
pacemaker leads are
noted in the periphery of the film in gross standard position.
Degenerative
changes within the spine, not well evaluated on this radiograph.
IMPRESSION:
1. Nasogastric tube in standard position.
2. Findings suggestive of high-grade small-bowel obstruction
CT w/o contrast [**2144-6-19**]:
HISTORY: 82-year-old male with bladder cancer status post
partial colectomy
and colostomy, suspected ileus/obstruction.
COMPARISON: [**2144-6-12**].
TECHNIQUE: MDCT axial images were obtained from the lung bases
to the
symphysis pubis without the administration of IV contrast.
Coronal and
sagittal reformations were obtained.
CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Visualized heart
and
pericardium reveal no evidence of pericardial effusion.
Moderate-sized
bilateral pleural effusions are present, with associated
atelectasis of the
lung.
Non-contrast views of the liver, gallbladder, spleen, pancreas,
and adrenal
glands are unremarkable. Both kidneys are atrophic, with
persistent moderate
hydronephrosis of the left kidney similar to prior study.
There is an NG tube coursing into the stomach. There is
persistent distention
of the small bowel to the level of the ileocecal valve, with
decompression of
the colon to the colostomy in the left lower abdominal wall.
There are no
findings to suggest associated ischemia of the small bowel as
the bowel wall
does not appear thickened, and there is no evidence of
pneumatosis or portal
venous air. There is no free intraperitoneal air.
Diverticulosis of the remaining colonic stump is seen without
diverticulitis.
There continues to be a moderate amount of ascites, similar to
prior study.
Diffuse atherosclerotic calcification of the abdominal aorta,
with an
infrarenal abdominal aortic aneurysm is unchanged.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is persistent
thickening along
the anterior right side of the bladder. Prostate is
unremarkable. Rectal
stump appears diffusely thickened as noted previously. No pelvic
lymphadenopathy is definitively identified. Previously noted
metastatic
nodule in the pelvis is not as well appreciated on this study
likely due to
technical reasons.
OSSEOUS STRUCTURES: Multilevel degenerative changes are present.
No
suspicious lytic or sclerotic lesion is identified.
IMPRESSION:
1. Persistent dilatation of the small bowel to the ileocecal
valve. Although
this may represent an ileus, a mechanical obstruction in the
region of the
ileocecal valve cannot be entirely excluded.
2. Anasarca with bilateral pleural effusions and ascites.
3. Wall thickening of the right wall of the bladder.
4. Persistent left hydronephrosis
Labs upon discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2144-6-26**] 06:15AM 14.4* 2.99* 8.9* 28.7* 96 29.8 31.1 15.6*
414
[**2144-6-25**] 06:30AM 13.5* 2.97* 9.3* 28.3* 95 31.2 32.8 15.9*
383
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2144-6-25**] 06:30AM 88.6* 5.9* 3.3 2.1 0.2
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2144-6-26**] 06:15AM 414
[**2144-6-26**] 06:15AM 43.9* 40.3* 4.9*
[**2144-6-25**] 06:30AM 383
[**2144-6-25**] 06:30AM 39.9*1 38.5* 4.3*
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2144-6-26**] 06:15AM 109* 52* 1.3* 140 4.1 108 21* 15
[**2144-6-25**] 06:30AM 86 53* 1.3* 139 4.4 109* 22 12
TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2144-6-26**] 06:15AM 8.1* 4.5 2.1
[**2144-6-25**] 06:30AM 8.1* 3.9 2.0
[**2144-6-20**] 9:09 am BLOOD CULTURE Source: Line-PORT-A-CATH.
**FINAL REPORT [**2144-6-26**]**
Blood Culture, Routine (Final [**2144-6-26**]): NO GROWTH.
[**2144-6-21**] 3:07 am SEROLOGY/BLOOD Source: Venipuncture.
**FINAL REPORT [**2144-6-22**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2144-6-22**]):
POSITIVE BY EIA.
(Reference Range-Negative).
[**2144-6-25**] 8:24 am URINE Source: CVS.
**FINAL REPORT [**2144-6-26**]**
URINE CULTURE (Final [**2144-6-26**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
Brief Hospital Course:
This is a 82 year old male with bladder cancer requiring 4
resections and recently
diagnosed metastatic squamous cell cancer involving the rectum.
He had continued nausea and poor appetite at home and did not
pass stool or flatus through his ostomy.
He was admitted following a Right portacath placement.
# Partial small bowel obstruction/Ileus: Likely related to
metastasis. He was NPO with NGT and started on TPN for
nutritional support. The NGT output was high initially,
~1500cc/day. His abdomen was slightly distended and round.
A CT ABD was done on [**2144-6-12**] and showed persistent dilatation of
the small bowel, without a discrete transition point. Although
early or partial obstruction is difficult to exclude, the
appearance is more consistent with an ileus.
The NGT output decreased over the next several days and he began
having scant thick brown stool output from the ostomy. He had a
NGT clamp trial and the NGT was removed on HD 5. He was started
on sips on HD6. He continued to complain of intermittent nausea
and received Zofran. He again was made NPO.
His GI tract had poor function possibly secondary to tumor
infiltration thought to invade the myenteric plexus with
suspected ileus (per Surgery, Dr. [**Last Name (STitle) 1120**]. He was started on
Erythromycin for GI motility. He was still having minimal stool
output from the ostomy. His abdominal exam was remarkable for
significant distension, tympany and hypoactive bowel sounds.
Due to inability to take PO, patient was started on TPN.
Patient was evaluated by GI for placement of PEG tube for
decompression and eventually to Rehab facility with TPN. This
attempt was unsuccessful ([**6-19**]) and while receiving the
procedure, NTG was removed with suspected aspiration.
.
On [**6-19**] evening pt had O2 desaturation episode and went into
respiratory distress, sats in 70s on RA and was acutely
tachypneic, code blue was called. VS: 95% NRB HR 71 142/76 RR
30. ABG 7.41/27/107/18 and CXR showed no clear infiltrates but
looked like left pleural effusion. He was transferred to ICU.
.
In ICU, pt was treated for suspected aspiration PNA, with
flagyl/levo (started on [**2144-6-20**]), received lasix 20mg IV with
-1L response overnight. His coumadin was restarted and INR was
2.2 on [**6-21**]. LENI showed no DVTs. An investigation of PE was
not pursued as a clear cause of desaturation existed and hypoxia
resolved.
CXR on [**6-21**] showed persistent cardiomegaly which was stable,
bilateral pleural effusions and a left retrocardiac opacity.
Patient was weaned from NC O2 to room air with saturations of >
94%. By [**6-23**], pt was alert and felt fatigued. He had no CP, SOB,
abdominal pain or vomitting. There has been no flatus or output
in stoma since admission to the ICU.
.
A repeat CT was performed on [**6-22**] showing
1. Persistent dilatation of the small bowel to the ileocecal
valve. Although
this may represent an ileus, a mechanical obstruction in the
region of the
ileocecal valve cannot be entirely excluded.
2. Anasarca with bilateral pleural effusions and ascites.
3. Wall thickening of the right wall of the bladder.
4. Persistent left hydronephrosis.
Patient was continued on TPN starting on [**2144-6-23**]. By [**6-24**]
patient began to have stoma output with loose material of >
200cc per day. At time of discharge ([**6-26**]), his abdomen remains
dystended, tympanitic but nontender. There is no n/v. His NGT
was removed on [**2144-6-26**] as patient was able to tolerate 250 cc PO
the day prior. The next steps for this patient are anticipated
to be increasing PO intake and weaning off TPN hydration.
# Bladder cancer requiring 4 resections and recently diagnosed
metastatic squamous cell cancer involving the rectum. At time
of the resection during the hospitalization of [**6-5**], it was
unclear of the origin of the cancer. Mr. [**Known lastname 34754**] case was
discussed at UG and GI tumor boards and it was felt that the
cancer most likely is of the urothelial origin. A consultation
was obtained for possible radiation therapy and this was not
deemed to be a viable option due to the extent of the disease.
Dr. [**Last Name (STitle) **] and the oncology team recommened palliative
chemotherapy (carboplatin/taxol). After a discussion with
patient and family, a decision was made to go ahead with first
treatment and clinic meeting with Dr. [**Last Name (STitle) **] scheduled on [**2144-7-2**].
Patient's functional status will be re-evaluated prior to
chemotherapy to ensure that he is fit for this treatment
modality.
# Elevated INR: INR continued to be elevated despite
administration of Vitamin K. A hematology consult was obtained.
They felt the possible causes of the patient's elevated
coagulation studies include Coumadin overdose, malnutrition, and
excessive heparin response; less likely possibilities include
liver failure and
acquired coagulation factor deficiencies. The fact that the PT
was elevated to a much greater degree than the PTT points to
warfarin effect and/or and vitamin K deficiency. It was felt
that the patient's poor intake over the period of
hospitalization and has likely resulted in underproduction of
coagulation factors; It was felt that patient's recent nausea
and vomiting is unlikely secondary to brain metastases from his
bladder cancer. No MRI of head was indicated.
- No further VitK administration at this time as INR normalized
following IV VitK.
With this regimen, patient's INR became subtherapeutic and pt
was restarted on 5mg of coumadin QD. Due to erroneous
adminstration of vitamin K in TPN, patient's INR again became
subtherapeutic on [**6-23**]. He was given a dose of 7.5mg of
coumadin and vitamin K was held from TPN. Subsequently INR was
elevated on [**6-25**] and [**6-26**] at 4.2 and 4.9 respectively.
Patient's coumadin was withheld during those dates. His INR
should be monitored and coumadin regimen adjusted to ensure
target of 2 - 3.
CV: He is V-paced with chronic A-fib. He has known chronic
systolic heart failure. He remained stable from a CV standpoint
throughout this hospitalization.
Once the INR stabilized, he was restarted on his Coumadin dose
and his INR was monitored closely (please see above for
anticoagulation discussion).
LE edema/anasarca: Most likely due to metastatic disease. Edema
is pitting, bilateral and is noted up to thigh level. LENI were
done and negative for DVT. The edema was likely related to
metastatic disease, CHF (LVEF 25 - 30% from [**1-16**]) and low
albumin. Patient also has CKD with baseline Cr 1.3 - 1.5. His
feet were elevated and foot care was performed. Patient was
continued on Lasix 40mg QD. This regimen may require an
increase to 40 [**Hospital1 **] or IV lasix to improve pedal edema as patient
has been volume even over [**6-23**] - [**6-26**].
.
Nutrition: Patient was started on TPN on [**2144-6-11**], which was
stopped [**1-11**] respiratory distress and was restarted on [**6-22**]. Of
note, TPN should not include vitamin K as patient is on
warfarin. TPN formula is listed shown below: 2000cc, AA 85,
Dextrose 325, Fat 50; No trace elements, No vitamin K, NaCL 0,
NaAc 50, NaPO4 20, KCl 40, KAc 45, KPO4 0, MgSO4 15, CaGluc 15,
no heparin, famotidine, Insulin 20 U, Zinc 10mg, cycled over 12
hours. Patient has improving PO intake and should be
encouraged. As PO intake increases, TPN parameters can be
adjusted accordingly.
.
Atrial fibrillation - patient was rate controlled on Metoprolol
12.5mg PO BID. INR supratherapeutic on day of discharge at 4.9.
.
Suspected UTI - Pt w/ episodes of urinary incontinence. UCx on
[**6-25**] growing coagulase negative staphylococcus 10 - 100K.
Patient with Hx of MRSA bacteremia. Thus Vancomycin 1g Q24hrs
(renally adjusted) was started.
.
Tachy/brady syndrome s/p pacer - patient was V paced at 70.
.
Prophylaxis: On coumadin. Will cont promotility agents. Cont
lansoprazole.
.
Access: port
.
Code: full; discussed with patient, wife, and son.
Contacts: [**Name (NI) **] [**Name (NI) 12130**] (wife) [**Telephone/Fax (1) 34755**]. Son [**Telephone/Fax (1) 34756**] or
[**Telephone/Fax (1) 34757**]. Wife is HCP.
.
Functional status - physical therapy evaluation and treatment
were performed. Patient unable to ambulate on own at this time
and requires assisstance. He was deemed to require PT/OT
services at discharge for at least one week.
.
Patient was discharged in hemodynamically stable, yet cautious
condition. He will required follow up of his INR upon admission
to the care facility and close monitoring. Patient will also
require PT/OT evaluation and treatment. His UTI treatment shoud
be continued and followed. He will be see in the oncology
clinic by Dr. [**Last Name (STitle) **] on [**2144-7-2**].
Medications on Admission:
Home:
lisinopril 20 mg
atenolol 50 mg
allopurinol 300 mg
lipitor 5 mg
norvasc 2.5 mg
coumadin 5 mg MWF, 2.5 mg TThSa
aspirin 81mg
Discharge Medications:
1. Atorvastatin 10 mg Tablet [**Date Range **]: 0.5 Tablet PO DAILY (Daily).
2. Tolterodine 1 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a
day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension [**Date Range **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable [**Date Range **]: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for reflux.
5. Menthol-Cetylpyridinium 3 mg Lozenge [**Date Range **]: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
6. Phenol-Phenolate Sodium Mouthwash [**Date Range **]: One (1) Spray
Mucous membrane Q6H (every 6 hours) as needed for sore throat.
7. Acetaminophen 325 mg Tablet [**Date Range **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain, headache.
8. Temazepam 15 mg Capsule [**Date Range **]: One (1) Capsule PO HS (at
bedtime) as needed.
9. Furosemide 40 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
10. Metronidazole 500 mg Tablet [**Date Range **]: One (1) Tablet PO TID (3
times a day) for 2 days.
11. Levofloxacin 750 mg Tablet [**Date Range **]: One (1) Tablet PO Q48H
(every 48 hours) for 2 days.
12. Prochlorperazine Maleate 10 mg Tablet [**Date Range **]: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
13. Metoprolol Tartrate 25 mg Tablet [**Date Range **]: 0.5 Tablet PO BID (2
times a day).
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: [**12-11**] Injection
Q8H (every 8 hours) as needed for nausea.
16. Erythromycin Lactobionate 500 mg Recon Soln [**Month/Day (2) **]: 0.5 Recon
Soln Intravenous Q6H (every 6 hours).
17. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day (2) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (2) **]: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day (2) **]: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 7 days.
20. Detrol LA 4 mg Capsule, Sust. Release 24 hr [**Month/Day (2) **]: One (1)
Capsule, Sust. Release 24 hr PO once a day.
21. Allopurinol 300 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Squamous cell carcinoma of the pelvis, likely of bladder origin
Right Portacath placement
Nausea, Vomiting
Partial small bowel obstruction
Secondary:
Chronic Systolic Heart Failure; EF 25-30%
Discharge Condition:
Fair
Discharge Instructions:
You were admitted after your port line placement for Nausea,
vomiting, and poor ostomy output. While in the hospital you
experienced ileus (inability to move yoru bowels) and
respiratory distress requiring intensive care unit placement.
You were treated for aspiration pneumonia. Your ileus was felt
to be due to the cancer in of your bladder. You were given
agents to help move your bowels, intravenous fluids and
intravenous nutrtion. Your ileus has improved and you now have
output from your ostomy.
A meeting with Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] oncologist, has also been set up for
you, to evaluate whether you will be able to undergo a
palliative chemotherapy treatment. This is scheduled for the
date of [**2144-7-2**] or [**2144-7-3**] at 10am .
It was also noted that the level of blood thinning from your
coumadin was too high. You coumadin was stopped, your nutrition
was adjusted and coumadin was restarted at 5mg once daily. You
coumadin was held during [**6-25**] and [**2144-6-26**] to allow normalization
of INR (it was too high).
You will require daily INR monitoring and adjustment by the
staff at the facility. Your kidney function tests and
electrolytes should also be monitored daily.
HTN and kidney disease medication - please HOLD your lisinopril
dose until you follow-up with your PCP.
Should you develop chest pain, shortness of breath, new
abdominal pain, n/v, cough, fever, chills, pain with urination
or any other symptoms concerning to you, you should contact the
facility staff for assisstance and facility physician.
Issues to be addressed at LTAC facility:
1. Pt required daily INR and coumadin dose adjusted as needed
2. It is recommended taht pt continue Flagyl/Levofloxacin at
current doses to complete treatment on [**2144-6-28**]
3. It is recommended that pt continue TPN (as described in DC
summary) and his regimen should be adjusted for PO intake,
followed by daily chemsitry labs
4. It is recommended that patient complete 7 days of Vancomycin
1mg IV q24 hours for UTI Tx as he has Hx of MRSA bacteremia.
5. It is recommended that patient undergo PT/OT evaluation and
treatment to improve functional status
6. For further information and recommendations, please refer to
discharge summary.
Followup Instructions:
1. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **], [**Hospital **] clinic, Please call
([**Telephone/Fax (1) 694**] to confirm your appointment on [**2144-7-2**] or [**2144-7-3**]
at 10am.
2. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2144-7-15**]
1:30
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2144-7-15**] 2:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2144-6-26**]
|
[
"041.19",
"428.0",
"599.0",
"403.90",
"V44.3",
"511.9",
"197.5",
"560.9",
"197.6",
"V10.51",
"518.81",
"427.31",
"585.9",
"591",
"428.22",
"V45.01",
"274.9",
"507.0",
"427.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"45.13",
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
25492, 25535
|
14127, 22874
|
327, 355
|
25772, 25779
|
3580, 12552
|
28102, 28768
|
2896, 2914
|
23055, 25469
|
25556, 25751
|
22900, 23032
|
25803, 28079
|
2929, 3545
|
3561, 3561
|
239, 289
|
12569, 14104
|
383, 1656
|
1678, 2758
|
2774, 2880
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,690
| 171,598
|
37764
|
Discharge summary
|
report
|
Admission Date: [**2139-11-24**] Discharge Date: [**2139-12-4**]
Date of Birth: [**2073-7-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
C4 to T10 fusion with T6 corpectomy
History of Present Illness:
This is a 66 y/o M with hx of metastatic melanoma who presents
from clinic today with lower extremity weakness, numbness and
tingling. Patient reports waking up this morning and feeling
weak in his legs, finding himself unstable as he walks. At
baseline, patient ambulates well, without use of walker or cane.
He also endorses waking up and feeling numbness and tingling in
both lower extremities. He denies any changes in urinary, does
not endorse any incontinence, and feels like the strength in his
upper extremities are unchanged. He is also chronically
constipated, and has some abdominal pain secondary to
constipation. His last BM was Sunday. He denies any F/C, HA.
He reports chronic nausea with recent poor po intake. He also
endorses chronic back pain, which he feels has worsened last
week since he lifted his dog.
.
Patient was seen in clinic to be screened for clinical trial
09-021 (modar +/- PARP inhibitor). His vitals were BP: 167/106;
HR: 66; T: 96.6; RR 16; O2 96 RA. On exam he was felt to have
assym reflexes and unsteady gait. Recieved diluadid 1mg iv and
decadron 10mg iv at 4pm.
.
Currently, patient does not have any complaints.
.
ROS: He occasionally is SOB, in particular when lying on his
back, and has some chronic [**Location (un) **]. He denies any new rashes,
dysuria, hematuria, bloody stools. Otherwise ROS is negative.
Past Medical History:
The patient is a 66 yo man who was diagnosed with cutaneous
melanoma 35 years ago. A lesion on the left upper back was
removed, and an axillary lymph node dissection was performed.
Approximately six months ago, he developed progressive fatigue.
He also had the insidious onset of back pain. Within the past
month, he began losing weight (about 20 lbs) and had a
diminished appetite. He underwent diagnostic imaging which
disclosed a lung mass and bony tumors concerning for lung
cancer. Both of these areas were biopsied and were, in fact,
melanoma. Immunohistochemical stains performed on cell block
preparation reveal the tumor cells are immunoreactive for MART-1
and S-100. No reactivity is seen in AE1/AE3, kappa or
lambda light chains.
.
PMH:
Hypertension
Childhood seizures, none recently
Social History:
His married with one son. [**Name (NI) **] is retired; formerly he worked at
the [**Location (un) 12017**] Naval base, designing submarines. He had some
radiation exposure in [**2104**]. He drinks alcohol on occasion, and
smoked 1ppd for 20 years, quitting 25 years ago.
Family History:
His paternal grandmother and 1st cousin on that side both had
melanoma. His father died of lung cancer.
Physical Exam:
Vitals - 110/78 18 52 96% 1L
GEN: NAD
HEENT: Anicteric, OP clear, nonerythematous
LYMPH: No cervical or supraclavicular LAD; No axilliary LAD
CARD: RR, no m/r/g
LUNG: CTAB no w/r/r
ABD: Soft NT, ND No HSM
EXT: No c/c/e
RECTAL: Normal tone
NEURO: A&O x3, PERRL, EOMI, tongue midline, facial sensation
intact [**6-2**] SCM/trap; No pronator drift, sensation to light touch
in UE intact bl; sensation to light touch in LE intact bl;
reduced sensation in pinprick on RLE up to knee compared to LLE.
4+/5 strength in knee extension bl, [**5-3**] knee flexion bl, [**6-2**]
hip flexion/extension bl, 5/5 strength in UE bl. Gait
imbalanced, romberg sign and heel-shin deferred. Normal finger
to nose.
On DISCHARGE;
FULL STRENGTH in all extremities
Pertinent Results:
[**2139-11-24**] 03:26PM GRAN CT-5600
[**2139-11-24**] 03:26PM PLT COUNT-250
[**2139-11-24**] 03:26PM WBC-8.7 RBC-5.40 HGB-15.3 HCT-47.0 MCV-87
MCH-28.4 MCHC-32.6 RDW-13.1
[**2139-11-24**] 03:26PM ALBUMIN-4.1 CALCIUM-9.7 PHOSPHATE-4.4
MAGNESIUM-2.8*
[**2139-11-24**] 03:26PM ALT(SGPT)-22 AST(SGOT)-27 LD(LDH)-583* ALK
PHOS-218* TOT BILI-0.6 DIR BILI-0.3 INDIR BIL-0.3
[**2139-11-24**] 03:26PM estGFR-Using this
[**2139-11-24**] 03:26PM UREA N-22* CREAT-1.2 SODIUM-140 POTASSIUM-4.4
CHLORIDE-100 TOTAL CO2-32 ANION GAP-12
CBC on discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2139-12-2**] 12:25PM 13.3* 3.01* 8.6* 25.7* 86 28.5 33.4 14.3
274
Brief Hospital Course:
66 y/o M with recurrent metastatic melanoma to lungs and C+L
spine who presents from clinic with LE weakness, numbness and
tingling. Was admitted to rule out cord compression. He was
found to have T6 compression fracture and taken to the OR on
[**11-27**]. He was brought to the ICU where he was closely monitored
and later extubated. His Hct was monitored and received 2 units
RBCs was neurologically intact post-op and transferred to the
floor where he worked well with PT and tolerated a PO diet. His
follow-up appoinments were arranged and was sent to [**Hospital 8323**] on [**2139-12-4**].
Medications on Admission:
Amlodipine 10 mg daily
Atenolol 100 mg qAM
Cyclobenzaprine 5 mg tid
Gabapentin 100 mg tid
Reglan 10 mg q4-6hr PRN
Omeprazole ? dose
Oxcarbazepine 150 mg [**Hospital1 **]
Oxycontin 30 mg [**Hospital1 **]
Oxycodone 5 mg 1-2 tabs q4hr PRN
Prochlorperazine 10 mg PRN
Simvastatin 20 mg qHS
Tamsulosin 0.4 mg qHS
Bisacodyl PRN
Docusate PRN
Milk of Mag PRN
Discharge Medications:
1. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day).
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for nausea.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
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) as needed for constipation.
10. Dronabinol 2.5 mg Capsule Sig: Four (4) Capsule PO TID (3
times a day) as needed for nausea.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
13. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
15. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
17. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.5 ml Injection Q3H
(every 3 hours) as needed for BRT pain.
18. Insulin Sliding Scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary: Metastatic Melanoma, Cord Compression
Discharge Condition:
Stable.
Discharge Instructions:
You were seen in the hospital because of your weakness. An MRI
of the spine showed that you have metastatic disease to your
cevical and thoracic spine. Some of these metastasis have
caused compression of your spinal cord. You were treated with
steroids, and received a brace for your back.
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? You are required to wear your back brace at all times.
?????? You may only shower with back brace on.
?????? 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.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? 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).
If you experience numbness, tingling, or weakness to any or your
arms or legs, please call your PCP or come to the emergency
room.
PLEASE SUPPORT THE NECK AT ALL TIMES WHEN PATIENT IS BEING
LIFTED FROM BED!!
Followup Instructions:
??????Please return to the office in 5 days for removal of your
staples and a wound check
Please return to see Dr. [**Last Name (STitle) 739**] in 1 month. You will need
a CT Scan of your Cervical and Thoracic spine prior to your
appointment. Please call ([**Telephone/Fax (1) 84563**]
You will need to follow up with the [**Hospital **] Clinic. You have
been scheduled for [**12-22**] at 2:30PM in the [**Hospital **] Clinic with
Dr. [**Last Name (STitle) 1729**]. Please call ([**Telephone/Fax (1) 84564**] with any questions.
A consultation has been arranged by the Caritas [**Hospital3 **]
Radiation Oncology team on 8:30AM, [**2139-12-8**] with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. He should be transported directly to the radiation
oncology department in the basement, they will help with
registration there.
The contact information for the radiation oncology team at
Caritas [**Hospital3 **] is:
[**Hospital6 5016**]
[**Street Address(2) 77570**]
[**Location (un) 7661**], [**Numeric Identifier 84565**]
Phone: ([**Telephone/Fax (1) 84566**]
Fax: [**Telephone/Fax (1) 82963**]
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2139-12-4**]
|
[
"V10.82",
"336.3",
"338.3",
"401.9",
"733.13",
"198.5",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"81.03",
"03.53",
"81.05",
"84.52",
"81.04",
"84.51",
"00.94",
"81.64"
] |
icd9pcs
|
[
[
[]
]
] |
7130, 7177
|
4504, 5104
|
329, 367
|
7268, 7278
|
3781, 4321
|
9289, 10539
|
2894, 3000
|
5504, 7107
|
7198, 7247
|
5130, 5481
|
7302, 9266
|
3015, 3762
|
4335, 4481
|
281, 291
|
395, 1764
|
1786, 2588
|
2604, 2878
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,294
| 101,974
|
129
|
Discharge summary
|
report
|
Admission Date: [**2119-1-17**] Discharge Date: [**2119-3-31**]
Date of Birth: [**2073-3-6**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Zofran / Toradol / Phenobarbital / Trazodone /
Compazine / Oxycodone
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
encephalopathy
Major Surgical or Invasive Procedure:
Blood transfusion
Paracentesis x2 ([**1-17**], [**1-23**])
[**2119-3-14**] liver transplant
History of Present Illness:
45 y/o male with ESLD from HCV, HBC, and EtOH who had a TIPS
done on [**2119-1-5**] who presented to the OSH yesterday with altered
mental status. The patient was treated with lactulose at the OSH
with some improvement in his encelpalopathy. There was concern
that there was a problem with the TIPS and he was transferred to
[**Hospital1 18**] for further workup.
Denied chest pain, shortness of breath, fevers, chills. He
reports abdominal pain slightly worse than his baseline. No
melena or BRBPR.
.
Labs at the OSH significant for AST/ALT 186/124, TB 12, DB 5,
Ammonia 330, Na 132.
Past Medical History:
# L4,L5,S1 fusion
# Decompensated liver cirrhosis [**1-28**] to HCV, HBC, and alcohol c/b
encephalopathy and ascites
# Chronic pancreatitis
# Non bleeding grade 2 esophageal varices in [**4-3**]
# GERD-Barrett's esophagus
# COPD
# s/p incarcerated umbilical hernia repair [**11-3**], recent
admission on [**2118-12-26**] to [**2118-12-30**] for concern for cellulitis
around his surgical incision, started on clindamycin then vanc
then bactrim for a total course of 7 days
#OLT [**2119-3-14**]
Social History:
Married, but separated, has 3 children. Lives with roommates -
limited support. Smokes a pack every 3 days. Quit cocaine and
heroine in [**2114**]. Quit EtOH in [**2101**].
Family History:
Family Hx: No known family history of hepatitis or liver
disease
Physical Exam:
VS: 97.5 95/69 90 12 93%RA
Gen: awake, oriented x 2 (able to state month and year, stated
he was at B+W's)
HEENT: NC/AT. PERRL, EOMI, MMM. OP clear.
Neck: Supple, no LAD.
CV: RRR, S1, S2 no m/r/g.
Chest: CTAB no wheezes or crackles.
ABD: Distended, + tense ascites, TTP diffusely
Ext: WWP, no edema. + asterixis
Pertinent Results:
Upon admission, a CT of the abd/pelvis was done [**2-1**]
demonstrating:
1. Large amount of ascites. Tiny amount of high-density fluid
layers in the deep pelvis consistent with blood not changed from
prior study at 2:13 a.m. today, [**2119-2-1**]. No subcapsular hepatic
hematoma.
2. Small subcentimeter focus of arterial enhancement of hepatic
segment VIII becomes isodense to liver parenchyma on the delayed
phase. This is more conspicuous compared to [**2118-12-27**] and [**2118-11-9**].
Finding is non- specific but given cirrhosis a small focus of
hepatocellular carcinoma cannot be excluded. Continued imaging
surveillance is recommended.
3. Cirrhosis with splenomegaly indicating portal hypertension.
4. Patent TIPS.
On [**2-25**] a ruq u/s was performed showing a patent TIPS with
increased velocities, little changed.
Head CT was negative and EEG was abnormal with findings
consistent with moderate encephalopathy . There were no
epileptiform features and no seizure activity.
.
[**2-27**] ct chest:
1. Abnormality in the right upper lobe demonstrates marked
panlobular
emphysematous changes. No evidence of pneumothorax.
2. Atelectasis within the right upper and bilateral lower lobes.
No evidence
of airspace consolidation.
3. Limited images through the upper abdomen show a large volume
ascites,
TIPS, and splenomegaly.
Brief Hospital Course:
Patient initially transfered from OSH with encephalopathy and
concern for clotted TIPS. TIPS initially placed [**2119-1-5**].
Ultrasound showed patent TIPS and his mental status improved
with lactulose and regular bowel movements. The patient was
tapped for a large amount of ascites and it was negative for
SBP.
He continued to have waxing and [**Doctor Last Name 688**] encephalopathy, He
required admission to the MICU twice for unresponsiveness, both
times which he was intubated for airway protection, and given
additional lactulose. His head CT on first MICU admission was
negative for any acute process such as intracranial bleed. EEG
findings were consistent with encephalopathy without seizure
activity.
An attempted Re-Do TIPS to divert blood through portal veins and
not the TIPS was attempted, but technically unsuccessful and
complicated by small hemoperitoneum that required transfusion
but otherwise self-limited. He finally had successful TIPS
revision on [**2119-2-6**].
He continued to receive therapeutic paracentesis. Ultrasound
initially showed patent TIPS but subsequent ones showed
increased velocities concerning for stenosis. He was restarted
on diuretics because his sodium was improved from prior
admissions, but these were held for worsening renal function.
He was continued on 1500ml fluid restriction and Cipro for SBP
prophylaxis. CVVHD was started.
A CXR showed new right sided infiltrate and the patient had
moderate growth of MRSA from his sputum with sparse growth of 2
colonies of GNR. He was treated with vancomycin and zosyn.
On [**3-14**] he underwent Orthotopic deceased donor liver transplant
(piggyback), portal vein-portal vein anastomosis, common bile
duct-common bile duct anastomosis with no T-tube, branch patch
(recipient) to celiac patch (donor)hepatic artery anastomosis.
Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please see operative report
for further details. EBL was 2 liters replaced with PRBC, plt,
FFP, cryo and cellsaver. Two JPs were placed. He was maintained
on CVVHD during the case. He received HBIG intraop and on pod
[**12-31**]. HBsAb titers were greater than 450. HBIG IM was given on
pod 7 and 14. Entecavir was started immediately postop. This
dose was renally dosed.
Postop, he was transferred to the SICU per protocol. He was
extubated on POD 2. CVVHD continue for ~ 2 days then lasix was
started. He received prbc/plt/ffp on pod 0. Labs were monitored
q 6 hours. US of the liver demonstrated difficulty detecting
the expected hepatic arterial supply to the left lobe. Otherwise
U/S was normal. LFTs trended down. The medial JP was removed on
pod 5. The lateral JP continued to drain large amounts of
ascites. Outputs were as high as 4.5liters per day. He received
IV fluid replacements and albumin for JP outputs. Of note,
creatinine started trending up off CVVHD as high as 4.3 from
2.7. Urine output averaged 1000-1200cc/day. Nephrology was
consulted. It was felt that he had ATN on resolving hepatorenal
syndrome. Fluconazole dose was renally dosed to 200mg qd as this
was felt to increase the prograf level. Creatinine slowly
trended down to 2.9. Hyperkalemia was a persistent problem that
required treatment with insulin, dextrose, lasix and kayexalate.
Hyperkalemia improved with improved renal function. A low
potassium diet was ordered.
The lateral JP was removed on [**3-29**] for outputs of 600cc. The
transplant incision remained clean, dry and intact. His abdomen
appeared a little distended
PT evaluated him and initially recommended rehab, but he
improved significant and it was felt that he would be safe for
discharge to home. He was also started on insulin for
hyperglycemia. Glargine and humalog sliding scale were given.
Immunosuppression consisted of cellcept 1 gram [**Hospital1 **], steroids
were tapered to prednisone 20mg qd per protocol, and prograf was
started on pod 1. Prograf was decreased to 2.5mg [**Hospital1 **] per trough
levels of [**8-8**].2.
VNA services were arranged for home.
Medications on Admission:
1. Morphine 30 mg SR [**Hospital1 **]
2. Lactulose 30ML PO TID
3. Pantoprazole 40 mg Q24H
4. Folic Acid 1 mg DAILY
5. Oxycodone 5 mg Q6H as needed for Pain.
6. Colace 100 mg twice a day
7. Ciprofloxacin 250 mg Q24H
8. Entecavir 0.5 mg DAILY
9. Hexavitamin Daily
--Of note, has been off diuretics since last admission [**1-28**]
hyponatremia
.
Allergies: PCN, zofran, toradol, phenobarbital, trazadone
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
10. Entecavir 0.05 mg/mL Solution Sig: Three (3) ml PO DAILY
(Daily).
Disp:*50 ml* Refills:*2*
11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 MDI* Refills:*0*
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day.
15. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
16. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day.
17. Insulin Syringes
Low dose syringes for qid injections
25 guage needle
supply: 1 box
Refill: 1
Discharge Disposition:
Home with Service
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
ESLD from HCV/HBV/ETOH cirrhosis
Hepatic encephalopathy
Hepatorenal syndrome
ARF, improving
malnutrition
Chronic back pain
Barrett's esophagus
GERD
COPD
s/p incarcerated umbilical hernia repair
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
weight loss, jaundice, abdominal incision appears red, bleeds or
has drainage.
Labs every Monday and Thursday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2119-4-5**] 9:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2119-4-12**] 9:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2119-4-12**]
10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2119-3-31**]
|
[
"564.00",
"403.90",
"263.9",
"789.59",
"456.21",
"571.2",
"572.4",
"784.7",
"507.0",
"276.7",
"427.1",
"285.9",
"070.22",
"537.89",
"572.3",
"530.85",
"V09.0",
"284.1",
"276.1",
"568.81",
"584.5",
"458.29",
"070.44",
"585.9",
"276.3",
"724.5",
"530.81",
"251.8",
"496",
"305.63",
"E932.0",
"518.81",
"305.03",
"482.41",
"787.91",
"311",
"286.9",
"305.53",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"45.13",
"50.59",
"38.95",
"00.93",
"88.64",
"39.95",
"96.04",
"50.0",
"39.49",
"99.15",
"54.91",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9622, 9705
|
3567, 7644
|
355, 449
|
9943, 9950
|
2202, 3543
|
10249, 10862
|
1789, 1855
|
8096, 9599
|
9726, 9922
|
7670, 8073
|
9974, 10226
|
1870, 2183
|
301, 317
|
477, 1064
|
1086, 1582
|
1598, 1773
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,678
| 177,350
|
2844
|
Discharge summary
|
report
|
Admission Date: [**2190-9-24**] Discharge Date: [**2190-9-24**]
Date of Birth: [**2125-6-1**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
aspirin allergy, needs pentasa desensitization
.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo female with history of asthma, UC, Crohn's, and atrial
tachycardia who presents to CCU for monitoring and observation
during Pentasa desensitization. The patient states she was
found to have an allergy to aspirin, develops hives and rash.
Attempted to undergo desensitization of aspirin but unable to
tolerate secondary to hives on her back. The Pentasa
desensitization needs to be done so that she can be treated with
this for her Crohn's disease.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She denies
recent fevers, chills or rigors. Weight, appetite and energy
level have all been stable. No recent rash. All other ROS
negative.
.
*** Cardiac review of systems is notable for absence of chest
pain, dyspnea on exertion, orthopnea, ankle edema, palpitations,
syncope or presyncope.
Past Medical History:
asthma
Crohn's
UC s/p colectomy and ileostomy
kidney stones
HTN
atrial tachycardia
GERD
Social History:
Social history is significant for the absence of current or
previous tobacco use. There is no history of alcohol abuse.
There is no family history of premature coronary artery disease
or sudden death, father died of heart disease at age 74, mother
with lung cancer.
Physical Exam:
Gen: appears well, stated age, NAD, mood, affect appropriate.
Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, no JVD.
CV: Normal s1/s2, no murmurs, rubs or gallops. No carotid
bruits
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: soft, NT, ND, NABS. Ostomy bag in place with normal
output.
Ext: No c/c/e. Multiple varicosities on LE. No femoral bruits.
Skin: warm, dry, no rashes
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Brief Hospital Course:
ASSESSMENT AND PLAN: 65 yo female with Crohn's disease needing
pentasa treatment, complicated by severe aspirin allergy
requiring Pentasa desensitization.
.
# Allergy- Patient underwent Pentasa desensitization per
protocol. Developed slight itchyness after third dose, without
any other associated symptoms. Was given benedryl, and
itchyness resovled. Patient completed protocol, and was
monitered for 2 hours without complication.
Medications on Admission:
singulair 10 mg
flovent 2 puffs qhs
metoprolol 25 mg daily
cardia 120 mg daily
dig .125 mg daily
protonix 40 mg daily
allopurinol 300 mg daily
Discharge Medications:
singulair 10 mg
flovent 2 puffs qhs
metoprolol 25 mg daily
cardia 120 mg daily
dig .125 mg daily
protonix 40 mg daily
allopurinol 300 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
ASA allergy here for desensitazation
Chron's disease
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after scheduled
admission for desisitization to Pentasa desensitization. You
have now completed the desensitization protocol. You should
take your medications as prescribed. If you develop any
concerning symptoms, including lightheadedness, shortness of
breath, confusion, or chest pain, take 50mg of Benadryl and call
the allergist on call or 911.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 8122**] [**Last Name (NamePattern4) 8123**], M.D. Phone:[**Telephone/Fax (1) 2977**]
Date/Time:[**2190-9-27**] 9:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Date/Time:[**2190-11-22**] 9:00
Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2190-12-20**] 10:00
|
[
"424.0",
"530.81",
"427.89",
"555.9",
"995.3",
"E947.9",
"V14.8",
"V15.09",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
3217, 3223
|
2420, 2857
|
316, 323
|
3320, 3329
|
3772, 4255
|
3050, 3194
|
3244, 3299
|
2883, 3027
|
3353, 3749
|
1698, 2397
|
228, 278
|
351, 1288
|
1310, 1400
|
1416, 1683
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,389
| 135,838
|
39115
|
Discharge summary
|
report
|
Admission Date: [**2157-5-29**] Discharge Date: [**2157-6-2**]
Date of Birth: [**2126-7-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30M s/p MCC, helmeted,+LOC, +EtOH. Intubated at OSH for GCS 8,
received paralytics en route for fighting [**Last Name (LF) **], [**First Name3 (LF) **] report, has
not spontaneously moved LUE. Transported to [**Hospital1 18**] for further
care.
Past Medical History:
Denies
Social History:
Married
Family History:
Noncontributory
Pertinent Results:
[**2157-5-29**] 03:44PM GLUCOSE-138* UREA N-8 CREAT-1.1 SODIUM-141
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14
[**2157-5-29**] 03:44PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.8
[**2157-5-29**] 03:44PM WBC-14.5* RBC-4.56* HGB-13.5* HCT-38.4*
MCV-84 MCH-29.7 MCHC-35.3* RDW-13.6
[**2157-5-29**] 03:44PM PLT COUNT-307
[**2157-5-29**] 04:50AM ASA-NEG ETHANOL-109* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
IMAGING:
CT head-no acute intracranial process. no fracture. large left
lac over the left frontal bone.
CT c-spine-multiple transverse foramen fractures: Bilateral C4,
left C5, left C6, Bilateral C7, minimally displaced comminuted
fracture of the superolateral aspect of vertebral body C7.
CTA neck- 1. No CTA evidence of occlusion, flow-limiting
stenosis, or dissection or other acute traumatic injury
involving the extracranial arterial vasculature.
2. Multiple fractures through the transverse foramina of C3
through C7,
completely delineated and described on the separate report of
concurrent
cervical spine CT examination.
CT torso-nondisplaced right 5th rib fracture
CXR-intubated, poor inspiration
Brief Hospital Course:
He was admitted to the Trauma service and transferred to the
Trauma ICU sedated and intubated. His sedation was eventually
stopped and he was weaned off of the ventilator. He was later
transferred to the regular nursing unit.
His spine injures were evaluated by the Ortho Spine service and
was managed with a hard cervical collar. He was noted with some
right upper extremity weakness concerning for a possible
brachial plexus injury; this did improve during his hospital
stay. He will follow up with the Hand clinic in 2 weeks as an
outpatient or sooner if his weakness worsens.
His pain was controlled with oral narcotics, he was started on a
bowel regimen as well.
He was evaluated by Physical and Occupational therapy and was
cleared for discharge to home. Because of his closed head
injury, low GCS and the loss of consciousness associated with
his crash it is being recommended that he follow up as an
outpatient in Cognitive [**Hospital 878**] clinic.
Medications on Admission:
Denies
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motorcycle crash
Bilateral transverse foraminal fractures C4-C7
Left forehead laceration
Rib fractures on right
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent - requires
intermittent contact guard.
Discharge Instructions:
You were hospitalized following a motorcycle crash where you
sustained fractures to the spine bones in your neck but no
injury to your spinal cord. The injuries did not require any
surgery. A cervical collar was recommended to be worn by the
Orthoepdic Spine specialist.
You were noted with an injury to a nerve in your left arm called
the brachial plexus. This can cause soem wekaness in your arm
and hand. You were fitted with a splint that allows your fingers
to be free for motion. When you follow up with Dr. [**Last Name (STitle) 363**] in 2
weeks he will re-evalaute you and determine if a referral to a
Hand specialists would be needed.
You must continue to wear the neck collar for at least 8 weeks
or until told that it is OK to remove it by Dr. [**Last Name (STitle) 363**].
It is important that you take the medications as prescribed. If
taking narcotics please DO NOT drink alcohol, drive, operate
heavy machinery and/or take illict drugs while on these
medications.
Take a stool softener and laxative while on narcotics for pain
to avoid constipation.
Followup Instructions:
You will need to follow up with your primary care doctor in the
next 1-2 weeks for further evaluation of a thyroid nodule found
on CT imaging that was done when you were first brought into the
hospital. If you do not have a PCP you may call [**Hospital1 771**] at [**Telephone/Fax (1) 13471**] and ask for Doctor
line.
Follow up in 2 weeks in Hand clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by
calling [**Telephone/Fax (1) 3009**] for an appointment if your hand weakness
does not improve after your evlauation by Dr. [**Last Name (STitle) 363**]..
Follow up in [**3-9**] weeks with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Cognitive
Neurology; call [**Telephone/Fax (1) 6335**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 363**], Orthopedic Spine. Call
[**Telephone/Fax (1) 3573**] for an appointment.
Completed by:[**2157-6-29**]
|
[
"807.01",
"241.0",
"873.42",
"E812.2",
"805.08"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3225, 3231
|
1885, 2848
|
333, 339
|
3390, 3390
|
721, 1862
|
4672, 5606
|
685, 702
|
2905, 3202
|
3252, 3369
|
2874, 2882
|
3578, 4649
|
273, 295
|
367, 614
|
3405, 3554
|
636, 644
|
660, 669
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,540
| 165,084
|
46898
|
Discharge summary
|
report
|
Admission Date: [**2108-5-8**] Discharge Date: [**2108-5-17**]
Date of Birth: [**2033-8-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with placement of Cypher drug-eluting
stents
History of Present Illness:
74M PMH GERD--hiatal hernia, admitted for STEMI (proximal LAD
occlusion), s/p 2 stents to LAD. Pt initially noted chest pain
(pressure, SS, no radiation) that woke him from sleep at 1:45
AM. He took PPI and calcium bicarbonate with no relief. He had
no other symptoms including SOB, palpitations, N/V, diaphoresis.
Pt eventually came in to ED, where he was found to have ST
elevations in anterior and lateral leads, was taken to cath with
2 cypher stents placed in LAD.
Past Medical History:
GERD/hiatal hernia
Hip replacement, s/p fall
Social History:
Married. No current smoking. Occasional ETOH.
Family History:
NC
Physical Exam:
G: Obese male, NAD
HEENT: MMM, Clear OP
Neck: JVP to jaw
Lungs: BS BL, No W/R/C
CV: RR, NL rate. Normal S1S2. S3 present. [**1-22**] holosystolic
murmur at apex.
Abd: Soft, NT, ND BS+
Ext: 1+ edema, R>L(chronic R LE edema per pt, [**1-18**] hip surgery)
Neuro: Grossly intact
Pertinent Results:
[**2108-5-8**] 08:45AM BLOOD WBC-7.6# RBC-4.87 Hgb-13.7* Hct-42.7
MCV-88 MCH-28.1 MCHC-32.0 RDW-13.3 Plt Ct-178
[**2108-5-8**] 08:45AM BLOOD Neuts-77.4* Lymphs-15.4* Monos-6.9
Eos-0.3 Baso-0.1
[**2108-5-8**] 08:45AM BLOOD PT-11.5 PTT-25.6 INR(PT)-0.9
[**2108-5-8**] 08:45AM BLOOD Plt Ct-178
[**2108-5-8**] 08:45AM BLOOD Glucose-125* UreaN-16 Creat-0.8 Na-140
K-4.6 Cl-102 HCO3-28 AnGap-15
[**2108-5-8**] 08:45AM BLOOD CK(CPK)-899*
[**2108-5-8**] 07:41PM BLOOD CK(CPK)-2170*
[**2108-5-9**] 05:16AM BLOOD CK(CPK)-1310*
[**2108-5-10**] 03:18AM BLOOD CK(CPK)-516*
[**2108-5-8**] 08:45AM BLOOD CK-MB-116* MB Indx-12.9*
[**2108-5-8**] 11:37AM BLOOD CK-MB-414* MB Indx-14.4* cTropnT-17.88*
[**2108-5-8**] 07:41PM BLOOD CK-MB-278* MB Indx-12.8*
[**2108-5-9**] 05:16AM BLOOD CK-MB-100* MB Indx-7.6*
[**2108-5-10**] 03:18AM BLOOD CK-MB-18* MB Indx-3.5
[**2108-5-8**] 08:45AM BLOOD Calcium-9.7 Phos-2.4* Mg-2.1
[**2108-5-9**] 11:57AM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
74 yo M w/ hx GERD a/w STEMI s/p 2 DES to LAD. Post procedure
w/ persistent CP and STE w/ pericardial rub attributed to
evolving infarct. Pt w/out integrillin post-cath [**1-18**] bleeding
at groin [**1-18**] ? arterial tract.
*
CARDIAC:
.
A) Cor: Pt found to have totally occluded LAD on cath, 2 DES
placed with TIMI [**1-19**] flow (improved vascularization, but not
complete. [**Name (NI) 2076**], pt developed persistent CP, with EKG
changes consistent with pericarditis. Pt received NSAIDs for
pain relief with good response. Post-cath anticoagulation was
held due to persistent groin bleeding. Post-cath Echo showed EF
30% with 1+MR, HK of anterior and septal walls and AK of apex
with no evidence of aneurysm. Patient was started on heparin,
with plan for discharge on coumadin for apical akinesis.
Patient was started on plavix, lipitor, and metoprolol.
Continued on ASA.
.
B) Pump: As above, EF 30% with wall motion abnormalities
post-cath. The patient had baseline R LE edema [**1-18**] frequent hip
surgeries, but developed BL edema in setting of new heart
failure. Also noted an increase in weight (190lbs at home -->
200lbs). Patient was diuresed with lasix 10mg IV with good
response, and was started on daily lasix 20mg PO. ACEI was
initially held due to hypotension and concerns about rate
control requiring higher doses of metoprolol and ultimately
restarted on 5 lisinopril.
.
C) Rhythm: The patient was noted to have a 1st degree AV block,
with RBBB and LAFB that were seen on prior old EKGs. About [**3-20**]
days post-cath he was noted to have paroxysms of atrial
tachycardia with regular rates of 150s, concerning for ectopic
atrial tachycardia vs re-entrant SA tachycardia. He was rate
controlled with PO, then IV metoprolol. He was seen by EP, who
planned on placing a PPM as well as an ICD, but was awaiting
resolution of diarrhea. Ultimately, atrial ablations were
performed w/implntation of ICD.
*
DROP IN HCT: Most likely was in the setting of blood loss during
and immediately after cath. Hct was stable following.
*
PULMONARY: Pt having snoring and episodes of apnea.
--Pt will need sleep study as OP
*
GI: Watery diarrhea, likely med related (Protonix and plavix are
two possible culprits) vs viral gastroenteritis. Concern for
decreased absorption of PO meds as above. Ultimately, diarrhea
resolved.
*
DIABETES: Pt noted to have fasting blood glucoses > 126 on
several labs. A1C was 6.1%. Nutrition discussed diet
counselling with patient. Continued FS as part of patient
education.
*
GERD: Cont H2B, Maalox
*
FEN: Cardiac/HH/diabetic diet. Replete lytes.
*
PPX: Heparin gtt, H2B, Bowel regimen.
*
ACCESS: PIVs.
*
CODE: FULL throughout hospital stay
Medications on Admission:
Folate
Prilosec
Metoprolol
Gavescon
Cardia
Stool softeners
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): 1 month supply.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 300 days: 1 month supply.
Disp:*30 Tablet(s)* Refills:*2*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed): 1 month supply.
Disp:*10 Tablet, Sublingual(s)* Refills:*2*
4. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a
day).
5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): 1 month supply.
Disp:*30 Tablet(s)* Refills:*2*
6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): 1 month supply.
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: 90 day supply.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: 90 day
supply.
pt to take 1 tablet daily.
Disp:*90 Tablet(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): 1 month supply.
Disp:*60 Tablet(s)* Refills:*2*
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day: 90 day supply.
Disp:*180 Tablet(s)* Refills:*2*
11. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
once a day: 90 day supply.
Disp:*90 Tablet(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): 1 month supply.
Disp:*30 Tablet(s)* Refills:*2*
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime): 1
month supply.
Disp:*15 Tablet(s)* Refills:*2*
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily): 1
month supply.
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
15. Outpatient Lab Work
Please have INR and potassium checked at your next appointment
with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2472**].
16. One Touch Basic System Kit Sig: One (1) Miscell. once
a day.
Disp:*1 glucometer* Refills:*2*
17. One Touch UltraSoft Lancets Misc Sig: One (1) Miscell.
four times a day.
Disp:*qs lancets* Refills:*2*
18. One Touch II Test Strip Sig: One (1) Miscell. four
times a day.
Disp:*qs strips* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Myocardial infarction
Congestive heart failure
Diabetes mellitus, diet controlled.
Atrial Tachycardia s/p ablation
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as written. You received 90 day
prescriptions for the medications that we expect to remain
stable: aspirin, plavix(clopidogrel), lipitor(atorvastatin), and
ranitidine.
Your doses of lisinopril, Toprol XL(metoprolol),
warfarin(coumadin) and lasix(furosemide) may be adjusted by Dr.
[**Last Name (STitle) **] at your next appointment so you received only 1 month
supply.
The psyllium is over the counter as needed for constipation.
Check and record your fasting finger stick glucoses every other
morning until you follow up with your primary care physician.
Weigh yourself daily. If you gain > 2 lbs/day, please call your
primary care physician.
Have your blood drawn for INR and follow up the results with
your PCP.
If you experience shortness of breath, chest pain,
nausea/vomiting, lightheadedness, palpitations, or loss of
consciousness, call your physician [**Name Initial (PRE) **]/or go to the Emergency
Dept.
You can do light activity as tolerated, but do not expect to be
back to your normal activities for at least 4 weeks.
Followup Instructions:
Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2472**], on
Monday [**5-21**] at 10:30 am. He can monitor your blood pressure,
your diabetes, and your bloodwork to make sure your warfarin
dose is in the ideal range.
You have an echocardiogram (ultrasound of the heart) scheduled
for Thursday [**6-7**] at 1 pm at [**Hospital Ward Name 517**] [**Hospital Unit Name 723**],
Floor 4.
You are on the waitlist for an appointment with Dr. [**Last Name (STitle) **]
within 3-4 weeks. His assistant, [**Doctor First Name 2155**], should be calling you
with the appointment. You will be fit into his schedule, but
they could not give exact time today. Please call Dr. [**Name (NI) 44319**] office at [**Telephone/Fax (1) 6197**] if you have not heard from
[**Doctor First Name 2155**] by noext week or if you have any questions or concerns.
Other appointments:
Please follow up with Dr. [**Last Name (STitle) 172**] as needed for your heartburn.
You would likely benefit from a repeat endoscopy.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 569**],BEC [**Hospital **] [**Hospital 11099**] CLINIC Where: [**Hospital **]
[**Hospital 11099**] CLINIC Date/Time:[**2108-8-10**] 7:30
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Where: [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2110-1-24**] 9:00
|
[
"443.9",
"600.00",
"414.01",
"427.89",
"250.00",
"285.9",
"530.81",
"311",
"410.71",
"428.0",
"787.91",
"411.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"36.07",
"37.23",
"99.20",
"88.56",
"37.26",
"37.27",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
7607, 7665
|
2351, 5053
|
324, 395
|
7824, 7833
|
1364, 2328
|
8948, 10455
|
1049, 1053
|
5192, 7584
|
7686, 7803
|
5079, 5169
|
7857, 8925
|
1068, 1345
|
274, 286
|
423, 897
|
919, 970
|
986, 1033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,031
| 139,533
|
6719+55783
|
Discharge summary
|
report+addendum
|
Admission Date: [**2171-6-30**] Discharge Date: [**2171-7-17**]
Date of Birth: [**2089-4-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2171-7-3**] Off Pump CABG x 3(LIMA to LAD, SVG to OM, SVG to RCA)
History of Present Illness:
Mr. [**Known lastname **] is an 82 year old gentleman with long standing
history of diabetes and end stage renal disease, who has
required hemodialysis since [**2170-10-12**]. He presented to
[**Hospital6 1109**] with unstable angina. Cardiac
catheterization revealed severe three vessel coronary artery
disease, including a critical 70% left main lesion. Given his
coronary anatomy, he was urgently transferred to the [**Hospital1 18**] for
cardiac surgical intervention.
Past Medical History:
Coronary Artery Disease
End Stage Renal Disease - requires Hemodialysis
Type I Diabetes Mellitus
Hypertension
History of colon cancer
Cataracts
Appendectomy
Cholecystectomy
Social History:
Denies tobacco. Admits to occasional ETOH. Former Soviet [**Hospital1 1281**]
Naval Captain.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: T 96.4, BP 170/62 , HR , RR 16, SAT 96 on room air
General: elderly male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
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:
[**2171-6-30**] Chest x-ray: No acute pulmonary process.
[**2171-6-30**] 02:45PM BLOOD WBC-3.6* RBC-3.59* Hgb-12.2* Hct-35.0*
MCV-98 MCH-34.0* MCHC-34.8 RDW-18.6* Plt Ct-118*
[**2171-6-30**] 02:45PM BLOOD PT-11.9 PTT-37.4* INR(PT)-1.0
[**2171-6-30**] 02:45PM BLOOD Glucose-179* UreaN-45* Creat-3.7*# Na-139
K-4.8 Cl-103 HCO3-27 AnGap-14
[**2171-6-30**] 02:45PM BLOOD ALT-29 AST-23 AlkPhos-69 TotBili-0.5
[**2171-7-2**] 08:26PM BLOOD CK-MB-3 cTropnT-0.07*
[**2171-7-3**] 03:14AM BLOOD CK-MB-3 cTropnT-<0.01
[**2171-6-30**] 02:45PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.3
[**2171-7-2**] 09:50PM BLOOD %HbA1c-5.8
[**2171-7-2**] Carotid Ultrasound: Less than 40% ICA stenosis on each
side.
[**2171-7-3**] Intraoperative TEE:
1. No atrial septal defect is seen by 2D or color Doppler.
2.Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4.The ascending aorta is mildly dilated. 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.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The aortic regurgitation jet is eccentric.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7. Post revascularization (off pump) biventricular function
unchanged.
Brief Hospital Course:
PREOPERATIVE COURSE: Admitted under cardiac surgery, he
underwent routine preoperative evaluation. Carotid ultrasound
found minimal disease of the internal carotid arteries. He
otherwise remained pain free on medical therapy and continued
his routine dialysis schedule. The night before surgery, was
noted to have an episode of acute onset weakness, associated
with diaphoresis and " muscle twitching". Some non-sustained VT
was noted at that time. He had no chest pain. Blood sugar at
that time was noted to 44. Symptoms did improve with D50 and he
was transferred to the CSRU for closer observation. No futher
ventricular arrhythmias were noted. He was ready for discharge
to an extended care facility on post-operative day 14.
OPERATIVE COURSE: On [**7-3**], Dr. [**First Name (STitle) **] performed off pump
coronary artery bypass grafting. For surgical details, please
see seperate dictated operative note.
POSTOPERATIVE COURSE:
CARDIAC: Given the off pump procedure, Plavix was initiated and
should continue for at least three months. He experienced bouts
of rapid atrial fibrillation on postoperative day six which
resolved after Amiodarone boluses and an increase in beta
blockade. Since postoperative day six, he remained in a normal
sinus rhythm without further episodes of atrial or ventricular
arrhythmias. He remained on Amiodarone and beta blockade. Also
required Clonidine patch for persistent hypertension. By
discharge, he did have complaints of lightheadedness for which
medical therapy was titrated and the complaint resolved. There
was no evidence of orthostasis. By post-operative day 14 he was
ready for discharge to a rehabiliatation facility.
RENAL: Followed closely by the renal service, he remained on his
dialysis schedule.
PULMONARY: Extubated on postoperative day one. Chest x-ray prior
to discharge showed small bilateral pleural effusions and
bibasilar atelectasis.
NEURO: Initially experienced confusion/delirium, mostly at
night. He intermittently required Haldol. Over his hospital
stay, his mental status did improve. He did require one on one
observation for some time. The geriatric service was consulted
and performed a medication review. No medications were changed
and it was stressed that nonpharmologic management is the
mainstay of therapy(sitter and family presence).
OTHER: Speech and swallow evaluation on [**7-5**] demonstrated
overt signs of aspiration with thin liquids as well as subtle
signs of aspiration with purees. NPO recommendations were made,
and tube feedings were initiated. Unfortunately, he was unable
to tolerate tube feedings secondary to nausea and vomiting.
Videofluoroscopic examination on [**7-10**] confirmed silent
aspiration. A repeat swallow evaluation on [**7-12**] revealed no
further signs of aspiration. A repeat videofluoroscopic
examination was performed which confirmed no aspiration. An oral
diet was therefore initiated and advanced as tolerated.
Medications on Admission:
Lantus 8units qam
Glypizide 10 qpm
Avandia 4 [**Hospital1 **]
Cartia XT 240 qd
Folate
Nephrocaps
Clonidine
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
11. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Paxil 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): For one month or as directed by cardiologist.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Coronary Artery Disease -s/p Off Pump CABG
Postop Delirium
Postop Atrial Fibrillation
Postop Aspiration - resolved by discharge
End Stage Renal Disease - requires Hemodialysis
Type I Diabetes Mellitus
Hypertension
History of colon cancer
Cataracts
Appendectomy
Cholecystectomy
Anemia of Chronic Disease
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 5102**] for 1-2 weeks.
Make an appointment with Dr. [**First Name (STitle) **] for 3-4 weeks.
Make an appointment with Dr. [**First Name (STitle) **] for 4 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2171-7-17**] Name: [**Known lastname **],[**Known firstname 2734**] Unit No: [**Numeric Identifier 4406**]
Admission Date: [**2171-6-30**] Discharge Date: [**2171-7-17**]
Date of Birth: [**2089-4-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Please be aware of preoperative findings of chest XRAY dated
[**7-2**] recommending follow-up chest CT.
RADIOLOGY Final Report
CHEST (PRE-OP PA & LAT) [**2171-7-2**] 6:11 PM
CHEST (PRE-OP PA & LAT)
Reason: CORONARY ARTERY DISEASE
[**Hospital 5**] MEDICAL CONDITION:
82 year old man with CAD
REASON FOR THIS EXAMINATION:
preop cardiac surgery
[**46**]-year-old male with coronary artery disease, preop prior to
cardiac surgery.
COMPARISON: [**2171-6-30**].
PA AND LATERAL CHEST RADIOGRAPHS: Lungs are clear. Two well
defined sub 5mm pulmonary nodules are present within the
periphery of the right lower lobe on PA projection, not seen on
lateral projection. The heart, hila, and pleurae are within
normal limits. The aorta is mildly tortuous. Surgical clips are
identified within the right upper quadrant.
IMPRESSION: No acute cardiopulmonary process. Pulmonary nodule.
Recommend non-emergent CT for further evaluation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 4407**]
DR. [**First Name11 (Name Pattern1) 168**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4408**]
Approved: WED [**2171-7-3**] 12:08 AM
Approved: SUN [**2171-6-30**] 9:14 PM
Chief Complaint:
n/a
Major Surgical or Invasive Procedure:
[**2171-7-3**] Off Pump CABG x 3(LIMA->LAD, SVG->OM, RCA)
History of Present Illness:
n/a
Past Medical History:
n/a
Social History:
n/a
Family History:
n/a
Physical Exam:
n/a
Pertinent Results:
n/a
Brief Hospital Course:
n/a
Medications on Admission:
n/a
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2171-7-18**]
|
[
"411.1",
"997.1",
"427.1",
"403.91",
"427.31",
"414.01",
"285.21",
"458.21",
"518.89",
"287.5",
"585.6",
"787.2",
"250.01",
"V10.05",
"112.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.95",
"99.04",
"99.05",
"96.6",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
10530, 10545
|
10443, 10448
|
10214, 10274
|
10592, 10597
|
10415, 10420
|
10649, 10774
|
10371, 10376
|
10502, 10507
|
10566, 10571
|
10474, 10479
|
10621, 10626
|
10391, 10396
|
10171, 10176
|
9235, 10154
|
9181, 9206
|
10302, 10307
|
10329, 10334
|
10350, 10355
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,129
| 104,541
|
49166
|
Discharge summary
|
report
|
Admission Date: [**2130-2-11**] Discharge Date: [**2130-2-16**]
Date of Birth: [**2077-11-28**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
Transesophageal echocardiography
History of Present Illness:
This is a 52 yo man with hx HTN, HIV+, Hx STDs in past, Hx
rectal ca in past, polysubstance abuse, heart murmur, Hep A, B,
C, "mild seizures" (unclear hx, on no AEDs), and
anxiety/depression who presents from home with change in mental
status - markedly somnolent, weak, and vomiting. He had been in
USOH until the night prior to the admission - went out to have
drinks at 11PM and used many drugs including: beer, ecstasy,
crystal meth, "GBL." He was depressed for the notice of benefit
cut. He told his friend that he was "very high" and called his
partner at this point to let him know where he was - apparently
sounding normal on the phone.
He then began to get sick, vomiting profusely - he was given
sthg to drink (Propel, like Gatorade) and chocolate - he began
slurring his words at this point, and the friend took him home
and put him to bed (around 5AM). He
slept until 2PM and woke up feeling ill, still slurring his
words and complaining of a headache. His temp was 96.0. He was
c/o no pain, but was very sleepy. He got sleepier and sleepier
until his partner came home from work at 5PM and pt could barely
stay awake, was slurring his speech, and was vomiting once
again. He also was incontinent of urine. His PCP's office at
[**Hospital1 778**] was
contact[**Name (NI) **] for advise and they instructed friend/partner to bring
pt to ER. He needed help to get out of bed and couldn't walk -
his friend and partner took him to [**Hospital1 18**] ER where he was noted
to have unequal pupils (below) and CT showed bilateral
cerebellar hypodensities. We were consulted shortly thereafter.
Past Medical History:
PMH:
HTN
recent ankle fx
HIV+ - dx'ed [**2103**], on haart, last cd4s per partner 300-400
Hx STDs (syphillis, chlamydia, gonorrhea, HPV)
Hx rectal ca in past
Polysubstance abuse
Known heart murmur (last OMR note)
Hep A, B, C
"mild seizures" - per partner, these are when he is "so angry he
blacks out"
Anxiety
Depression
Meds:
unknown to partner; per last omr note (unknown doses):
combivir
nevirapine
celexa
testim
oxandrin
valium
Allergies: sulfa
Social History:
Lives with partner, [**Name (NI) **], who is [**Name (NI) 68407**] (paperwork is in calif.)
Polysubstance abuse as above.
Family History:
sister with skin ca; other cancers in family and cad per notes
Physical Exam:
T 98.4 HR 87 BP 152/96 RR 14 97%RA
General appearance: very ill appearing, very somnolent,
plethoric
and sweaty
HEENT: dry MM, white/green coating on tongue
Neck: supple, no bruits
Heart: regular rate and rhythm, III/VI systolic murmur at apex
Lungs: coarse bilaterally, most in RU lung field
Abdomen: +voluntary guarding with palpation
Extremities: warm, well-perfused, +pulses
Skull & Spine: No TTP along spine
Mental Status: Very somnolent - when asked questions he requires
gentle sternal rub to keep awake - markedly slurred speech, says
few words at a time which are unintelligible, could hear
"positive" when asked of HIV status, but no other clear speech.
Falls back asleep after 1-2 seconds of no stimuli. He became
more and more somnolent throughout the interview
Cranial Nerves:
Discs look sharp
Some blinking to threat bilat with eyes held open
+corneals bilat
R pupil 1mm, trace reactive
L pupil 6mm, unreactive
Bilateral INO (no adduction past midline of either eye with OCR)
+nasal tickle
No facial asymmetry with grimace
Did not yet test gag - with intubation, reported +gag
Sensorimotor: he w/d x 4 ext to stim, and provides good
resistance with all 4 ext, but did not participate in formal
strength testing due to current somnolent state
Reflexes: DTRs brisk throughout, bilaterally upgoing toes
Coordination: When he is more awake (beginning of exam) he
appears very ataxic when reaching for thing with R hand more
than
L hand - exam deteriorates as above
Pertinent Results:
LABS:
10.4 >17.7/49.9< 170
Diff N:63.2 L:29.1 M:4.5 E:1.0 Bas:2.1
138 99 7 93 AGap=15
------------------
4.6 29 0.9
CK: 661 MB: 6 Trop-T: <0.01
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
TC 174, TG 165, HDL 44, LDLc 97Cholesterol:174
Head CT ([**2-10**]):
Hypodensities within bilateral thalami and cerebellar
concerning for subacute infarction involving the posterior
circulation. An MRI is recommended for further evaluation.
These findings were discussed at the immediate conclusion of the
examination with the ordering physician.
MRI:
There are acute/subacute infarcts within the territory of the
posterior circulation with involvement of the medial thalami,
the left mid brain, and both superior cerebellar artery
territories.
MRA:
The left vertebral artery is dominant and it is completely
occluded distally. There is a small right vertebral artery
with some flow in the basilar artery.
Repeat head CT ([**2-11**]):
Similar appearance of areas of hypodensity in the thalami
bilaterally, the midbrain and cerebellar hemispheres, again
concerning for subacute infarcts. No definite hemorrhagic
transformation, allowing for study degradation due to patient
motion.
Repeat head CT ([**2-12**]:
Similar appearance of areas of hypodensity in the thalami
bilaterally, the midbrain and cerebellar hemispheres, again
concerning for subacute infarcts. No definite hemorrhagic
transformation, allowing for study degradation due to patient
motion.
Head CT/CTA ([**2-12**]):
1. Left vertebral artery proximal occlusion with retrograde
filling.
2. Right vertebral artery lumen irregularity at its origin
could represent an artifact versus stenosis. If clinically
indicated, MRA could be performed.
3. Multilevel degenerative changes of the cervical spine.
Head CT ([**2-13**]):
Unchanged infarcts in the cerebellum, mid brain, thalami and
basal ganglia.
Brief Hospital Course:
In summary patient is a 52 yo man with hx HTN and multiple drug
abuse, HIV, STDs with basilar artery thrombosis. On exam, he has
brainstem abnormalities including addcutor paresis at the left
eye, dilated L pupil 6mm/unreactive and R pupil 1mm/trace
reactive, significant bilateral limb ataxia (Left worse than
Right).
#1 Basilar stroke
Pt has been intubated for deteriorating mental status and to
keep sedated for MRI. MRI/A/V revealed signal deficit in the
basilar likely to be clot, with bilateral cerebellar infarcts,
infarct of vermis, bilateral thalami, and some elev signal
central brainstem on DWI (midbrain) suggestive of top of the
basilar syndrome.
Repeat CTA showed Left vertebral artery proximal occlusion and
reconstitution of flow in the intracranial portion of the left
VA and basilar. We have therefore suspected extracranial VA
dissection with seconday artery-to-artery embolism.
Patient was placed on Heparin dirp (goal PTT 50-70) and Coumadin
was initated based on the discussion with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 103141**]
regarding to the drug interaction to HIV medications.
Serial CT did not show any evidence of obstruction of IVth
ventricle, hydrocephalus.
His neurological condition was improved over the course
including attention level and recapture of upgazing at the left
eye.
Patient was transferred to rehabilitation facility for intensive
rehabilitation.
#2 Multiple drug abuse
Patient did not show withdrawal symptoms during the stay.
#3 AIDS
Stable over the course. Antiviral regiment at home was
continued.
Medications on Admission:
unknown to partner; per last omr note (unknown doses):
combivir
nevirapine
celexa
testim
oxandrin
valium
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
adjusted based on INR. Target INR 2.0-3.0.
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
8. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Nine [**Age over 90 **]y Five (925) units/hour Intravenous ASDIR
(AS DIRECTED): Target PTT 50-70. Until Warfarin reaches target
INR.
12. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Basilar artery infarction; Medial thalami, the left midbrain,
and both superior cerebellar artery territories
Discharge Condition:
Stable/Improved.
Awake and alert mental status with mildly limited attention.
Anisocoria (L>R, poor reaction to light). Almost full lateral
gaze (adduction problem of left eye), mild upgaze limitation.
Unable to downgaze. Mild-moderate dysarthria. Full strength.
Discharge Instructions:
Please return to ED ASAP if you experience, new weakness,
numbness, change in vision, hearing, vertigo (spinny feeling,
dizziness), difficulty in swallowing.
Please take your instructed medication. Especially your Coumadin
needs to be adjusted based on INR ([**2-25**]).
Please follow up with Neurology [**Hospital 4038**] Clinic.
Followup Instructions:
Please follow up with [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2130-4-11**] 1:30. [**Hospital1 18**], [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) **]. Please call prior to your visit to confirm your
appointment and to update your personal and insurance
information prior to your appointment.
.
Please make an appointment to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 103141**]
upon discharge from rehab.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2130-2-16**]
|
[
"305.90",
"780.39",
"042",
"070.32",
"070.54",
"433.01",
"V10.06"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9013, 9092
|
6098, 7676
|
307, 342
|
9246, 9511
|
4181, 6075
|
9891, 10605
|
2601, 2665
|
7832, 8990
|
9113, 9225
|
7702, 7809
|
9535, 9868
|
2680, 3094
|
244, 269
|
370, 1971
|
3472, 4162
|
3109, 3456
|
1993, 2446
|
2462, 2585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,803
| 131,539
|
24083
|
Discharge summary
|
report
|
Admission Date: [**2112-2-13**] Discharge Date: [**2112-3-15**]
Date of Birth: [**2040-1-13**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Amiodarone
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
HPI: The patient is a 72 yr old female with hx of CAD s/p CABG,
colon cancer s/p hemicolectomy, AVR, h/o UGIB who presents to
OSH ([**Hospital6 10353**]) complaining of 2 days of nausea and
multiple episodes of vomiting coffee grounds. She has also noted
darker stools than normal. In ED, she received 2U PRBCs and her
hct trended from 38.3-->33-->28.5. On arrival to [**Name (NI) **], pt's BP was
initially in the 110s but over the next several hours, dropped
to the 70s. She then received 2U FFP (for INR 2.0) and 3.5L of
crystalloid. She then became hypoxic and was found to have rales
on exam so she was given 40iv lasix and transferred to [**Hospital1 18**] for
further management.
At [**Hospital1 18**], pt's initially hr 105, sbp 83/35, rr 44, 97%o2;
Initial hct 20.8, inr 2.1. Was suctioned via NGT w/ 40cc of
coffee ground emesis and then lavaged 1L w/ near-clearing.
Received 3u prbcs, 2u ffp, and 4l on ns -> hr 100s, sbp 90-100s,
hct 35. With ongoing resuscitation, the pt developed progressive
respiratory distress and hypoxia and was intubated for abg of
7.16/56/82 on nrb. Following intubation and sedation (propofol),
pt became hypotensive to sbp 70s and was started on
norepinephrine.
Past Medical History:
1. colon cancer s/p resection
2. atrial fibrillation post-cabg
3. CAD s/p CABG in [**7-31**]
4. DM2
5. GERD
6. AVR in [**7-31**] (tissue)
7. hx of pleural and pericardial effusions following CABG/AVR
8. CRI
9. h/o UGIB (?duodenal per family) 3 yrs ago
10. h/o easy bruising and thrombocytopenia (?med-related)
Social History:
h/o daily etoh use (none in 5 years), remote tobacco
daughter is [**Hospital1 18**] cath lab nurse
Family History:
CAD
Physical Exam:
PE: 97.0/98.2, hr 78 (80-110), sbp 104/34 (80-110/30-50s),
MAP 66 (50-70); uo: 60cc
rr 20-25 ac: 500/20/10/100%
gen: intubated, sedated
heent: anicteric, pupils 4->2 bl
neck: rt ij cordis in place
cv: rrr, 2/6 sem
lungs: diffuse crackles
abd: hypoactive bs, moderately distended; soft, nt, no
rebound/guarding
ext: faint sp/pt pulses but warm ext; no edema
neuro: intubated, sedated. intially aa0x3, cn 2-12 intact,
moving all extremities
Pertinent Results:
**Heme**
[**2112-2-13**] 08:26PM BLOOD WBC-14.7* RBC-2.38* Hgb-6.8* Hct-20.8*
MCV-88 MCH-28.6 MCHC-32.7 RDW-15.6* Plt Ct-138*
[**2112-2-14**] 02:28AM BLOOD Neuts-45* Bands-41* Lymphs-4* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1*
.
**after blood transfusions:
[**2112-2-14**] 02:28AM BLOOD WBC-30.13*# RBC-4.04*# Hgb-11.6*#
Hct-35.4*# MCV-88 MCH-28.8 MCHC-32.8 RDW-15.6* Plt Ct-198
.
**coags**
[**2112-2-13**] 08:26PM BLOOD PT-18.2* PTT-32.7 INR(PT)-2.1
[**2112-2-14**] 02:28AM BLOOD Fibrino-349 D-Dimer-4601*
[**2112-2-14**] 05:58PM BLOOD Lupus-NEG
[**2112-2-13**] 10:17PM BLOOD Hapto-28*
.
**chemistry**
[**2112-2-13**] 10:17PM BLOOD Glucose-126* UreaN-90* Creat-3.1*# Na-143
K-3.7 Cl-104 HCO3-23 AnGap-20
[**2112-2-14**] 02:28AM BLOOD ALT-18 AST-40 LD(LDH)-347* CK(CPK)-168*
AlkPhos-44 Amylase-73 TotBili-4.7*
[**2112-2-13**] 08:26PM BLOOD Lipase-15
[**2112-2-14**] 06:32AM BLOOD Calcium-6.8* Phos-6.4*# Mg-1.6
.
** [**Last Name (un) 104**] stim**
[**2112-2-16**] 12:55PM BLOOD Cortsol-32.8*
[**2112-2-16**] 01:30PM BLOOD Cortsol-47.2*
[**2112-2-16**] 01:49PM BLOOD Cortsol-49.8*
.
**ABGs on admission and after intubation**
[**2112-2-14**] 01:18AM BLOOD Type-ART Temp-36.1 FiO2-100 pO2-82*
pCO2-56* pH-7.16* calHCO3-21 Base XS--9 AADO2-595 REQ O2-95
Intubat-NOT INTUBA
.
[**2112-2-14**] 02:56AM BLOOD Type-ART Temp-36.1 Rates-20/5 Tidal V-500
PEEP-10 FiO2-100 pO2-140* pCO2-45 pH-7.22* calHCO3-19* Base
XS--9 AADO2-548 REQ O2-88 -ASSIST/CON Intubat-INTUBATED
.
[**2112-2-14**] 02:56AM BLOOD Lactate-2.4*
.
ECHO:
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. There are complex (>4mm
and/or mobile) atheroma in the aortic root. A bioprosthetic
aortic valve prosthesis is present and appears well-seated. The
prosthetic aortic leaflets appear normal. The transaortic
gradient is normal for this prosthesis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension.
*
[**2-17**]: Abdominal X ray
IMPRESSION: Successful placement of a weighted feeding tube with
tip at the third portion of the duodenum.
*
[**2112-2-19**]
Abdominal Ultrasound:
FINDINGS: Transabdominal ultrasound examination of the right
upper quadrant was performed. The gallbladder is distended and
contains sludge. There is gallbladder wall edema. There are no
gallstones. Ascites is present. There is no intrahepatic biliary
ductal dilatation. The common duct is not dilated. Limited
evaluation of the liver demonstrates no focal lesions. There is
hepatopetal flow in the main portal vein.
IMPRESSION: Distended gallbladder filled with sludge
demonstrating gallbladder wall edema. Note is made of ascites.
In the proper clinical context, these findings may be consistent
with acalculous cholecystitis. These findings are also
consistent with prolonged fasting state and third spacing into
the gallbladder wall. Clinical correlation and correlation with
laboratory values is recommended. If there is continued concern
for cholecystitis, evaluation with a HIDA scan with CCK may be
considered.
*
[**2112-2-25**] Abdominal Ultrasound:
TECHNIQUE: Limited right upper quadrant ultrasound.
FINDINGS: The examination is markedly limited due to body
habitus. There is a large amount of intra-abdominal ascites. The
gallbladder is nondistended and contains no stones. The
gallbladder wall is nonthickened. The portal vein is patent with
flow in the proper direction. The common bile duct measures 4
mm.
IMPRESSION: No evidence of biliary ductal dilatation or
cholecystitis. Ascites.
*
Repeat Echo
Echo [**2112-2-26**]
:
The left atrium is elongated. Left ventricular systolic function
is
hyperdynamic (EF>75%). A mid-cavitary gradient is identified.
Right
ventricular systolic function is normal. There is abnormal
septal
motion/position. A bioprosthetic aortic valve prosthesis is
present. The
aortic prosthesis appears well seated, with normal leaflet/disc
motion and
transvalvular gradients. The mitral valve leaflets are
moderately thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
There is
moderate pulmonary artery systolic hypertension. There is no
pericardial
effusion.
*
CT scan of thorax: [**2112-3-6**]
RADIOLOGY Final Report
CT CHEST W/O CONTRAST [**2112-3-6**] 1:55 PM
CT CHEST W/O CONTRAST
Reason: assess for atelectesis, pna, effusions...underlying lung
par
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman with difficulty weaning from vent...
REASON FOR THIS EXAMINATION:
assess for atelectesis, pna, effusions...underlying lung
parenchymal disease
CONTRAINDICATIONS for IV CONTRAST: acute renal failure
HISTORY: 72-year-old woman, with difficulty weaning from
ventilation. History of coagulopathy.
TECHNIQUE: Multiple axial images of the chest were obtained
without IV contrast.
CT CHEST WITHOUT IV CONTRAST: The patient is intubated, and the
endotracheal tube tip is at the thoracic inlet in satisfactory
position. There is a right subclavian line whose tip is in the
upper SVC. There is a right-sided chest tube, whose tip is in
the posterior right upper lobe. There is subcutaneous air in the
tissues of the right chest.
There is cardiomegaly. The patient has a prosthetic aortic
valve. There is extensive calcification seen in the aorta. There
is an NG tube seen coursing through the esophagus, whose tip is
in the stomach.
No significantly enlarged axillary or hilar lymph nodes are
seen. There is 11 mm precarinal lymph node seen. The patient is
status post median sternotomy, and numerous sternal wires are
seen.
Images of the lung parenchyma demonstrate a small pneumothorax
in the right, seen on series 2, image 33 through 38. Within both
lungs, in the lower lobes, there are patchy areas of
ground-glass opacification, right greater than left. In
addition, there is a small loculated effusion on the left with
increased attenuation. There is a similar high attenuation small
effusion on the right as well. In the right upper lobe seen on
series 2, image 13, there is a 4-mm nodule posteriorly.
Few images through the abdomen demonstrate extensive ascites,
with a cirrohitic appearing liver with fluid surrounding both
the liver and spleen.
BONE WINDOWS: No suspicious lytic or blastic lesions.
IMPRESSION:
1) Tiny right-sided pneumothorax.
2) Small bilateral increased attenuation effusions, partially
loculated on the left. In this patient with a coagulopathy this
could represent hemothorax.
3) Ascites.
4) 4-mm nodule in the right upper lobe, for which a followup
study in 3 months is recommended to document stability in the
absence of prior studies.
*
Brief Hospital Course:
a/p: 72f w/ sig h/o UGIB, CAD s/p cabg, dm, colon ca s/p
resection who presents with UGIB, hypovolemic shock and
subsequent development of respiratory failure.
.
1. Upper GI Bleed: On arrival to [**Hospital1 18**], pt was found to be
hypotensive with a systolic BP in the 80s and a further hct drop
to 20. A cordis was placed in the right IJ and PRBCs were
emergently obtained from the blood bank. Over the first several
hours in the ICU, she received 4 units of PRBCs and 4 units of
FFP through the cordis and her hct rose to 35. Pt had an NGT on
arrival and an NG lavage was performed which revealed coffee
ground emesis that eventually cleared. GI performed an EGD in
the morning following admission and found no evidence of active
bleed, only esophagitis, evidence of NGT trauma and gastritis in
gastric cardia consistent with NSAID use. Pt was placed on IV
Protonix and ASA was discontinued. Her hct was monitored q6hrs
at first but immediately stabilzed at 35 and there was no more
evidence of active bleed. Her stool then became guiac negative
upon discharge.
.
2. Shock: On admission to the ICU, pt was hypotensive with a
systolic BP in the 80s. Her blood pressure initally responded
to PRBCs and IVF but eventually, she required pressors after
intubation. Initially, her hypotension was thought to be [**12-30**]
volume loss from her GI bleed but a swan was placed in the left
subclavian and revealed high CVP, high PA pressures, high wedge
and a low SVR of only 700-800 on Levophed indicative of a
distributive physiology. A cortisol stim test was performed and
was normal. Pt, at the time, had no evidence of infection but
was started empirically on Levo/Flagyl for ? of aspiration
pneumonia on CXR. Her blood pressures improved initially and
she was able to be weaned off Levophed. Later in her hospital
stay, pt became hypotensive and febrile. Cultures were drawn
and pt was found to have several bottles growing MRSA.
.
3. Sepsis: As above, pt became febrile several days into her
hospital stay and was found to have MRSA growing in several
blood cx bottles as well as her sputum. A bronchoscopy was done
to obtain better specimen for culture and this also grew MRSA.
Her Levaquin was changed to Vancomycin. Meropenem was added due
to the pt's critically ill status and to cover possible
acalculous cholecystitis. Flagyl was continued as she was found
to be c diff +. All lines were changed and both the arterial
femoral line and the right IJ cordis tips grew MRSA. Pt
required levophed to maintain MAPs in the 60s. Pt [**Name (NI) **] regimen
narrowed to Flagyl and C diff course completed. Pt remained
Afebrile and did well. Subsequent surveillance blood cultures
without growth.
.
4. Respiratory failure: On night of admission, pt developed
worsening resp distress likely [**12-30**] to the large amount of fluids
she required for volume resuscitation. An ABG showed
hypercarbic resp failure so she was intubated. Over her
hospital stay, her FiO2 and PEEP requirements increased. An
esophageal balloon study was done due to increasing concern for
ARDS and showed an optimal PEEP of 16. She was switched to
pressure control ventilation to avoid barotrauma. With
treatment of her pneumonia along with diuresis and an agressive
pulmonary toilette her ventilatory requirement decreased. (The
patient responds very well to deep suctioning and several times
during her hospitalization her tidal volumes increased in
response to deep suctioning during which prurulent secretions
were removed.) She was eventually weaned to minial pressure
support (PSV = 18-20 with PEEP of 5) with RIBIs less than 100
but was unable to be weaned off the vent secondary to tachypnea
and difficulty handling secretions during spontaneous breathing
trials. She underwent a CT scan of her thorax which revealed
findings consistent with pulmonary edema and a resolving
pneumonia. In light of this the patient agreed to undergo
tracheostomy and plans were made to transfer her to a long term
care facility where she could remain on a ventilator as needed
while undergoing rehabilitation. Pt did well s/p trach and was
able to tolerate T-piece without ventilator support. Passy-muir
valve placed without difficulty. On day of discharge Pt with
increased secretions, most likely secondary to oral secretions.
Pt afebrile without signs/symptoms of underlying PNA. Pt will
need regular suctioning and pulmonary toilet. If secretions
persist at skilled nursing facility, consider sending sputum for
GS and culture.
.
5. Increased direct bilirubin: On hospital day #6, it was noted
that pt had some scleral icterus so LFTs were checked and she
was found to have a bilirubin of 6.9. A RUQ was done which
showed gall bladder wall edema and sludge consistent with third
spacing vs acalculous cholecystitis. Although futher imaging
such as a CT scan of the abdomen or HIDA scan might have been
helpful it was felt that the patient was too sick to leave the
floor to go for this study thus we continued to monitor her by
serial liver function tests and RUQ ultrasounds. We also
consulted surgery who felt that the patient would not benefit
from percutaneous drainage since her clinical status was so
tenouso. Her bilirubin stabalized and a repeat RUQ ultrasound
revealed a normal gall bladder.
.
6. Cirrhosis:
The patient underwent CT scan of her thorax to evaluate for
reversible causes of her failure to wean off of the ventilator.
Cuts of her liver revealed a cirrhotic liver. Per the patient's
daughter the patient has a history of alcohol abuse. In order
to determine the etiology of her cirrhosis hepatitis serologies
and [**First Name8 (NamePattern2) **] [**Doctor First Name **] were sent, the results of which are pending at this
time.
.
7. Renal Failure: Pt's baseline creatinine is 2.2 and was
elevated to 3.1 on admission. Her urine was spun and muddy brown
casts were seen consistent with acute tubular necrosis. Her
creatinine peaked at 3.9 and she became oliguric. Her ATN
eventually resolved and gradually her urine output. Upon
discharge her creatinine was 1.1- improved from her baseline.
.
8. Coagulopathy
Upon admission her INR was 2.1. The etiology of her elevated INR
was unclear. The finding of a cirrhotic liver along with a low
albumin on admission raised the possibility of occult liver
disease and vitamin K deficiency. The patient's INR normalized
with subcutaneous vitamin K administration and remained wnl for
the lenght of her hospitalization. At discharge INR 1.4
.
9. SVT:
During her admissiong the patient had several episodes of
supraventricular tachycardias-mostly atrial fibrillation. With
discontinuation of levophed the frequency of these arrythmias
decreased. The patient easily cardioverted with 5mg IV
lopressor. With attainment of stable blood pressures and an
improvement in her pulmonary status, the patient was started on
low dose po lopressor [**Hospital1 **] with good effect. Titrated up to 75 mg
PO BID.
.
10. Hypernatremia:
This resolved with free water flushes-we were limited to 125cc
q2hrs due to position of dobhoff.
.
11. Diabetes Mellitus
Upon admission her glucophage was held and she was started on an
insulin drip. She was then transisitioned to glargine and an
insulin sliding scale.
.
12. Thrombocytopenia:
The patient has a h/o low platelets for which she has undergone
bone marrow biopsy twice. The results of these biopsies are
unknown to us at this time. With initiation of SQ heparin her
platelets decreased from 140 to 68 and with discontinuation of
heparin her platetlets then increased. A HIT antibody was sent
which was negative. We discontinued all sources of heparin as
precautionary measure.
.
13.
Wound:
The patient developed a sacral decubitus. Continued regular skin
care and air mattress.
.
11. Prophylaxis
She was continued on a PPI [**Hospital1 **] and pneumoboots.
.
12. Communication
-husband [**Name (NI) **] (HCP) [**Telephone/Fax (1) 61240**]
-daughter [**Name (NI) **] (is a [**Hospital1 18**] nurse): [**Telephone/Fax (1) 61241**]
.
13. FULL CODE
Medications on Admission:
atenolol 100
tricor 145
asa 81
glucophage 500 [**Hospital1 **]
prilosec
calcium
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed.
4. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
5. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
6. Metoclopramide HCl 5 mg/mL Solution Sig: One (1) mL Injection
Q6H (every 6 hours).
7. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
8. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed).
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID
(2 times a day).
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous q-breakfast.
15. Insulin Regular Human 500 unit/mL Solution Sig: 6-14 units
Injection qachs as needed for hyperglycemia: check FSBG QACHS
FSB>150=6 units
FSBG>200=8 units
FSBG>250=10 units
FSBG>300=12 units
FSBG>350=14 units.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
*
Upper GI bleed
MRSA pneumonia
Clostridium Difficile
ARDS
*
Secondary:
H/o colon cancer
H/o atrial fibrillation post-cabg
Coronary Artery Disease s/p CABG in [**7-31**]
Diabetes Mellitus Type II
Gastroesophageal Reflux Diseae
Aortic Valve replacement
Chronic Renal Insufficiency
H/o upper GI bleed (?duodenal per family) 3 yrs ago
Discharge Condition:
Good, s/p tracheostomy
Discharge Instructions:
Please return to the emergency room if you experience severe
nausea, vomit blood, have black stools, bright red blood per
rectum, feel light headed, have fever or chills or experience
chest pain.
*
Please take all medications as prescribed.
*
Please make all follow-up appointments as recommended.
Followup Instructions:
Pt was found to have a 4 mm nodule in the right upper
lobe-please follow up with a CT scan in 3 months.
*
Please call your PCP for an appointment in one week after
discharge from the hospital
|
[
"286.9",
"512.8",
"285.9",
"V45.81",
"578.9",
"571.5",
"785.52",
"008.45",
"584.9",
"V42.2",
"427.31",
"287.5",
"V09.0",
"482.41",
"995.92",
"250.00",
"518.81",
"038.11",
"996.62",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"45.13",
"33.24",
"38.91",
"31.1",
"99.04",
"38.93",
"99.15",
"96.6",
"34.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
19543, 19615
|
9841, 17899
|
297, 302
|
20000, 20024
|
2479, 7589
|
20370, 20565
|
1999, 2004
|
18030, 19520
|
7626, 7681
|
19636, 19979
|
17925, 18007
|
20048, 20347
|
2019, 2460
|
249, 259
|
7710, 9818
|
330, 1533
|
1555, 1867
|
1883, 1983
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,998
| 130,854
|
35147+57980
|
Discharge summary
|
report+addendum
|
Admission Date: [**2101-10-19**] Discharge Date: [**2101-11-4**]
Date of Birth: [**2030-2-14**] Sex: F
Service: MEDICINE
Allergies:
Anesthesia Tray
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
bilateral lower extremity paralysis
Major Surgical or Invasive Procedure:
intubation/sedation for MRI and post-operative
posterior spinal fusion and laminectomy
History of Present Illness:
Patient is a 71 yo woman with morbid obesity, DMII, HTN possible
h/o ankylosing spondylitis, anticoagulated on coumadin for a
left popliteal DVT o who presented to an [**Hospital3 12594**] on [**10-15**] s/p fall. Pt reports walking back to bed from
commode, tripping and falling onto her R side and back. Hit the
front of her head against her furniture. She went to the OSH ED,
where plain films were taken and were negative. Her INR was 6.1
at the time. She went home, then gradually lost ability to use
legs with total paralysis & preserved sensation. By [**10-17**]
couldn't move legs at all and was readmitted to hospital. Also
c/o constipation since her fall, and normally moves her bowel
daily. Incontinent at baseline. Denies saddle anesthesia. On
[**10-18**] orthopedics was consulted and patient was totally unable
to move legs, although had intact sensation. Presumptive dx
based on hx, exam, and elevated INR, was hematoma compressing
spinal cord. Her relative (brother) is a radiologist and
convinced her to get further studies and transfer to tertiary
care facility as a direct admission.
Past Medical History:
Diabetes: insulin-dependent
HTN
Hyperlipidemia
glaucoma
Morbid obesity
ankylosing spondylitis dx by chiropracter
baseline urinary incontinence
Social History:
lives at home with daughter ([**Name (NI) **]). No smoking or EtOH, no
drugs. Used to walk with a walker. Reports she performs all ADLs
at baseline. Fell over the weekend
Family History:
N/C
Physical Exam:
VS: 96.1 117/57 104-106 18 99% on RA
GA: obese F lying in bed, sleeping, but easily arousable
HEENT: PERRLA, EOMI, MM slightly dry, no LAD. neck supple.
Cards: RRR S1/S2 heard, no m/g/r.
Pulm: CTAB no wheezing
Abd: soft, NT, +BS. no guarding or RT.
Extremities: edematous BL. +weeping blisters on BL lower
extremities covered in gauze.
Neuro/Psych: AOx3. CNs II-XII intact. 5/5 strength in upper
extremities. unable to move lower extremities bilaterally or
move toes. sensation intact to LT, vibration, temp in lower
extremities. poor pinprick in stocking/glove distribution. poor
proprioception.
reflexes 1+ BL on patellar, achilles. babinski downgoing BL.
Rectal: poor, minimal rectal tone present. stool present in
vault.
Brief Hospital Course:
87F w/ CAD, HTN, ankylosing spondylitis, currently being
anticoagulated with coumadin for L popliteal DVT who p/w BL
lower extremity paralysis, constipation, and s/p fall 1 week
ago.
.
#Lower extremity paralysis: Patient reportedly had been
paralyzed x72 hours on admission. Exam concerning for cauda
equina syndrome versus retropulsion of vertebral disks (lower
extremity paralysis, poor rectal tone, incontinence).
Orthopedics was immediately consulted and recommended emergent
whole spine MRI -- MRI was attempted with conscious sedation the
night of admission, but patient was unable to tolerate it [**1-29**]
claustrophobia and refused, as she had at the outside hospital.
Anesthesia was consulted and performed an intubated/sedated MRI
the following day. MRI showed T11/T12 cord compression, DJD, and
blood in the thecal sac. T8-L2 posterior spinal fusion w/ T11
laminectomy was performed the next day. Pain was controlled with
morphine and stool removed with bowel regimen and enema. Patient
was transfered to the SICU where an electrophysiology consult
was obtained for a. fib with tachycardia. Patient was started
on short acting metoprolol tid per electrophys and then
transferred to the medical floor. On the medical floor, PT and
OT were continued, the patient was repositioned in bed q2h to
decrease her risk of bed sores. She was also begun on
intermittent straight cathing to decrease her risk of UTI, and
her foley catheter was pulled.
.
#Pleural effusions: Patient developed bilateral pleural
effusions, left greater than right, that were thought to be
secondary to severe atelectasis. Chest PT was performed q4h.
The patient did not undergo thoracentesis, however, but this
procedure should be considered if the patient becomes short of
breath. She had only intermittent, occasional episodes of
shortness of breath during her hospital stay, and these episodes
responded to albuterol and ipratroprium nebs.
.
#Lower extremity DVT: Reports having left popliteal DVT and
being anticoagulated with coumadin. LENIs showed no evidence of
lower extremity DVT. Given epidural bleed and contraindication
to anticoagulation, IR was consulted to place an IVC filter.
Afterward, the patient was later started on warfarin. The goal
INR is [**1-30**]. The patient should be continued on heparin SQ until
her INR reaches this level, and her warfarin should be adjusted
as needed.
.
# C diff: Patient had diarrhea and positive c diff toxin and
was treated with flagly. She will continue treatment for a
total of two weeks.
.
# UTI: Patient had a urine culture that showed probably
enterococus and was started on ampicillin and later transitioned
to amoxicillin. She will continue treatment for a total of 10
days.
.
#Chronic Renal failure: Patient's renal failure is chronic but
mild, as her Cr is 1 to 1.2 at baseline. Her creatinine was
stable during the majority of her hospital stay.
.
#CAD: EKG showed patient was in atrial fibrillation with some T
wave inversions concerning for ischemia. An electrophysiology
consult was obtained and the patient was started on metoprolol
tid with adequate rate control. Her aspirin was initially held
in the setting of an epidural hematoma but later restarted.
.
#DMII: The patient was maintained on an insulin sliding scale.
.
#HTN: Patient's ultimately became modestly hypotensive, likely
secondary to neurogenic hypotension, and her ACEi and beta
blocker were intially held. The beta blocker was restarted for
rate control in the setting of atrial fibrillation.
.
#Hyperlipidemia: Patient was continued on tricor.
.
#Urinary incontinence: Patient is straigth-cathed q4h to prevent
incontinenence. A foley was d/c'd to decrease the risk of UTI,
as data in spincal cord injury patients shows that intermittent
straight cathing, either by the patient herself (preferable) or
by another person, decreases the risk of UTI when compared to an
indwelling catheter.
.
#Decubital ulcers, abdominal ulcers/blisters: The wound nurse
made recommendations on wound care and the plastic surgery team
was also consulted to debride a gluteal ulcer.
Medications on Admission:
Pravastatin 40mg po daily
Lisinopril 2.5mg po daily
Actos 30mg po QAM
Tricor 134mg po daily
Lantus 50U SQ QPM (changed to 70/30 25U [**Hospital1 **])
HISS
Lasix 40mg po daily
silvadine to leg ulcers daily
Bactrim po bid x 3 days
Lovenox given x1
HCTZ 25 mg PO daily
Metoprolol XL 50 PO daily
Coumadin (unknown dose)
Tramadol (unknown dose)
Discharge Medications:
1. Influen Tr-Split [**2100**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED).
2. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ASDIR (AS DIRECTED).
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
Disp:*33 tab* Refills:*0*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no
bowel movement in previous day. Tablet, Delayed Release
(E.C.)(s)
11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
12. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
13. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 6 days. Capsule(s)
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml SC
Injection TID (3 times a day).
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
18. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
20. Insulin Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary:
Spinal Cord Injury
.
Secondary:
Deep Vein Thrombosis
Atrial Fibrillation
Morbid Obesity
Hypertension
Hypercholesterolemia
Diabetes Mellitus Type II
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with bilateral lower extremity paralysis and
diagnosed with cord compression. You had posterior spinal fusion
surgery and a laminectomy. You were also diagnosed with a
bacterial infection of your bowels and bladder and treated with
antibiotics.
.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
.
Please call your doctor or return to the hospital if you
experience fevers, chills, sweats, chest pain, shortness of
breath or anything else of concern.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**12-29**] weeks after discharge from
....
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 65542**]
Please follow up with Dr. [**Last Name (STitle) 1007**] at two weeks from the date of
discharge. You have a scheduled appointment on [**2101-11-16**] at
10.30am. If you have any questions, please call [**Telephone/Fax (1) **]
Provider ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2101-11-16**] 10:10
Completed by:[**2101-11-11**] Name: [**Known lastname 12899**],[**Known firstname 69**] F. Unit No: [**Numeric Identifier 12900**]
Admission Date: [**2101-10-19**] Discharge Date: [**2101-11-4**]
Date of Birth: [**2030-2-14**] Sex: F
Service: MEDICINE
Allergies:
Anesthesia Tray
Attending:[**First Name3 (LF) 10881**]
Addendum:
Note that the patient's pulmonary edema, as described in clinic
notes between [**10-23**] and [**10-27**], were chronic and not acute in
nature.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 3465**] - [**Location (un) 824**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10888**] MD [**MD Number(2) 10889**]
Completed by:[**2101-11-16**]
|
[
"427.31",
"276.1",
"585.3",
"707.22",
"707.11",
"682.6",
"V58.67",
"344.1",
"E849.0",
"564.09",
"707.03",
"806.29",
"518.0",
"720.0",
"278.01",
"596.54",
"276.2",
"E934.2",
"285.1",
"511.9",
"041.04",
"E885.9",
"599.0",
"E929.3",
"250.02",
"707.05",
"790.92",
"V02.54",
"008.45",
"459.81",
"414.01",
"787.6",
"514",
"458.29",
"403.90",
"707.25"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"03.53",
"77.49",
"77.79",
"99.04",
"81.63",
"38.7",
"81.05",
"86.28",
"96.6",
"38.93",
"03.59"
] |
icd9pcs
|
[
[
[]
]
] |
10976, 11209
|
2675, 6772
|
313, 402
|
9293, 9302
|
9871, 10953
|
1905, 1910
|
7163, 8997
|
9113, 9272
|
6798, 7140
|
9326, 9848
|
1925, 2652
|
238, 275
|
430, 1534
|
1556, 1701
|
1717, 1889
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,172
| 176,094
|
2611+55394
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-5-22**] Discharge Date: [**2167-6-1**]
Date of Birth: [**2098-1-23**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CHEST PAIN AND SHORTNESS-OF-BREATH
Major Surgical or Invasive Procedure:
-Operative treatment of left intertrochanteric hip fracture with
trochanteric femoral nail
- PICC line placement
History of Present Illness:
64F with uncontrolled DM, HTN, HLD who presents to the ED with
chief complaint of chest pain and difficulty breathing. Patient
said that she was in her usual state of health until this
morning. She was lying on the couch with her granddaughter for
about 1.5 hours dozing in and out of sleep when she suddenly
woke up by a sense of diffuse chills and shaking. She became
very short of breath and then began to have sharp midline chest
pain over her sternum that radiated over her right breast. She
also had associated nausea without vomiting. She became very
concerned and had her daughter call EMD. According to EMS she
reported a few days of chest pain and back pain. She was found
to have a temp of 101.2 and was hypertensive. EMS reported
bilateral rales as well. She was brought to the ED for further
evaluation.
.
The patient denies recent fevers, chills, night sweats, URI
symptoms, vomiting, abdominal pain, diarrhea, urinary frequency,
dysuria, joints, muscle pains, anxiety or depression.
She does say that she has long history of weeping fluid from her
RLE. Over the last two weeks, she feels that her RLE has become
slowly increasingly eryhematous, painful to touch and warm.
This has not occurred on the left. She also feels that it is
weeping more than usual. She has a long history of being unable
to make it to see her PCP at [**Name9 (PRE) **]clinic and has not
been there since [**2165**].
In the ED, initial VS were: 101.2 120 141/110 30 97% 15L
Non-Rebreather. Physical exam in the ED (according to signout)
- anxious appearing, tachypnic, tachycardic but RR normal S1S2,
lungs difficult to assess but no obvious wheezing or rales,
bilateral lower extremity edema with weeping on R. Labs
significant for a WBC of 11.2 (N:90.4 L:5.7), lactate of 3.1,
BNP 118, trop <0.01, CXR showed mild right basilar atelectasis
and concern for pleural effusions, given Lasix 20mgx1, Morphine
5mg x1, Vanc/Ceftriaxone/Azithromycin. IVF running slowly for
tachycardia.
Past Medical History:
-Uncontrolled IDDM (last A1C 9.3 on [**2-5**])
-Hepatitis C (viral load 1,230,000 IU/mL in [**2161**])
-HTN
-T spine compression fractures
-H/O exertional dyspnea
-Vertigo
Social History:
Lives with daughter and with her daughter's three children. She
is widowed. She does not drink, smoke or use any illicit
substances. Former teacher, currently disabled.
Family History:
No early MI, malignancy. Reports DM in mother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: BP: 180/69, HR: 120, RR 27, 93% 2L
General: Alert, oriented, very agitated and anxious about being
in the ICU and not sleeping, welled up in tears that she could
not sleep.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP difficult to assess, no LAD
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Difficult to asucultate, but could her faint inspiratory
crackles at the bases bilaterally that did not clear with cough
Abdomen: large abdomen, soft, non-distended, bowel sounds
present, no organomegaly that could be palpated, tenderness to
palpation in RLQ and RUQ, no rebound or guarding
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 98.3 151/69 [115-155/52-69] 90-111 20 95% RA
I/O: 790/950
General: obese elderly F, tearful, appears uncomfortable, lying
supine in bed. AAOx1.5 (to person,hospital [but thinks this is
[**Hospital1 2177**]], year but not month/day of week)
HEENT: NCAT. MMM. OP clear
NECK: Supple; no JVD, LAD or thyromegaly
COR: +S1S2, RRR, no m/g/r.
PULM: CTAB anteriorly, no w/r/[**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **]: +NABS 4Q, soft, ND, slight TTP in right periumbilical area
EXT: L hip bandaged, did not take down. DP pulses 1+
bilaterally. Sensation intact bilaterally. RLE cellulitis has
significantly receded from marked borders since admission;
+several nonpurulent appearing yellowish crusts on right
anterior shin.
NEURO: moving all extremities equally. Able to wiggle toes of
left foot. Poor flexion/extension of left hip [**2-26**] pain.
Pertinent Results:
ADMISSION LABS:
-WBC-11.2*# RBC-4.48 Hgb-14.5 Hct-46.4 MCV-104* MCH-32.4*
MCHC-31.3 RDW-13.4 Plt Ct-143*
-Neuts-90.4* Lymphs-5.7* Monos-2.8 Eos-0.7 Baso-0.3
-Glucose-443* UreaN-10 Creat-0.6 Na-136 K-4.5 Cl-101 HCO3-24
AnGap-16
-ALT-37 AST-60* AlkPhos-170* TotBili-0.9
-Calcium-8.5 Phos-2.5* Mg-2.0
-D-Dimer-652*
-Lactate-3.1*
-URINALYSIS: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 Blood-SM
Nitrite-NEG Protein-100 Glucose-1000 Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-6.0 Leuks-NEG RBC-4* WBC-4 Bacteri-FEW Yeast-NONE
Epi-1
.
HCT TREND:
-[**2167-5-22**]: 46.4
-[**2167-5-23**]: 42.6
-[**2167-5-24**]: 37.3
-[**2167-5-25**]: 41.2
-[**2167-5-26**]: 38.4
-[**2167-5-27**]: 38.0
-[**2167-5-28**]: 36.1
-[**2167-5-29**]: 34.1
-[**2167-5-30**]: 33.8
-[**2167-5-31**]: 31.1
-[**2167-6-1**]: 31.6
.
ANEMIA WORKUP:
- B12: 914* (high)
- Folate: 11.4
- Iron: 28* (low, normal is 30-160)
- TIBC 267, Ferritin 85, Transferrin 205
.
DISCHARGE LABS
-WBC-6.0 RBC-3.04* Hgb-9.9* Hct-31.6* MCV-104* MCH-32.5*
MCHC-31.2 RDW-15.1 Plt Ct-306
-Glucose-134* UreaN-34* Creat-0.7 Na-144 K-4.2 Cl-112* HCO3-28
AnGap-8
.
MICROBIOLOGY:
- BCx ([**5-22**]): 2/2 bottles group B strep, pan-sensitive to
antibiotics
- BCx ([**5-23**], final): negative
- BCx ([**5-24**], final): negative
- BCx ([**5-26**], pending): no growth to date
- HCV viral load ([**2167-5-29**]): pending
.
CHEST X-RAY ([**2167-5-22**]): A small hazy opacification at the right
base most consistent with atelectasis. No other consolidations
are present. There is no pleural effusion or pneumothorax. There
is no pulmonary edema. Mild-to-moderate enlargement of the
cardiac silhouette is unchanged from the prior exams.
IMPRESSION:
1. Mild right basilar atelectasis.
2. No acute cardiopulmonary process.
.
CTA CHEST ([**2167-5-22**]): No nodules are seen in the unenhanced
thyroid gland. The thoracic aorta is normal in caliber without
evidence of intramural hematoma or dissection. Pulmonary
arterial vasculature is visualized to the subsegmental level
without filling defect to suggest pulmonary embolism. There is
no axillary or hilar lymphadenopathy. A top normal size
precarinal lymph node measures 1.0 cm in short axis, previously
1.2 cm on [**2166-4-25**] (3:18). The heart is enlarged with moderate
coronary artery calcifications. The pericardium and three-vessel
takeoff are within normal limits aside. There is no pericardial
effusion. A trace right pleural effusion is seen. No left
effusion. Evaluation of the lung fields is limited by motion
artifact, particularly at the lung bases. There is right basilar
atelectasis adjacent to the effusion. Mild left basilar
dependent atelectasis. There is no worrisome nodule, mass or
consolidation. Airways are patent to the subsegmental levels
bilaterally.
This study is not tailored for subdiaphragmatic evaluation. The
visualized portions of the liver, spleen, and kidneys are
unremarkable. Again seen is a right adrenal lesion measuring 2.9
x 3.2 cm, previously 2.7 x 2.9 cm, with attenuation of 5 [**Doctor Last Name **],
compatible with an adenoma.Soft tissue in the left hypochondrium
represents the patients known spelnorenal shunt.
BONE WINDOWS: No bone finding suspicious for infection or
malignancy is seen. Compression deformities in the mid thoracic
spine are unchanged from [**2166-4-25**].
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Left adrenal adenoma is slightly increased in size from
[**2166-4-25**].
.
AP/LATERAL HIP X-RAY ([**2167-5-26**]): There is a comminuted
intertrochanteric fracture of left proximal femur, with slight
varus angulation. There is a separate lesser tuberosity
component. There is an equivocal additional greater tuberosity
component. The hip joint itself is obscured by overlying soft
tissues and underpenetration.
.
LEFT LOWER EXTREMITY FLOUROSCOPY ([**2167-5-26**]): Fluoroscopic images
of the left hip from the operating room demonstrates interval
placement of a short intramedullary rod with distal interlocking
screw and proximal pin. There is also a minimally displaced
lesser trochanter fracture fragment. The total intraservice
fluoroscopic time was 178.9 seconds. Please refer to the
operative note for additional details.
Brief Hospital Course:
64 yo F with poorly controlled IDDM, HTN, HLD p/w chest pain and
difficulty breathing, found to have GBS bacteremia and RLE
cellulitis, with course c/b left hip communuted
intertrochanteric fracture and anemia.
.
# GROUP B STREP BACTEREMIA [**2-26**] RLE CELLULITIS: Patient was
febrile with mild leukocytosis and left shift on admission; WBC
increased to max of >20K/mL within 24 hours of admission. Exam
was notable for prominent nonpurulent RLE cellulitis and marked
BLE and dusky appearance, suggesting that an underlying chronic
venous stasis could have contributed to development of
cellulitis. Patient empirically started on Vancomycin in ED. BCx
from [**2167-5-22**] subsequently grew pan-sensitive Group B strep, and
patient was narrowed to Ceftriaxone 2mg IV q12 hours to complete
a total two week course (last day [**2167-6-9**]). Repeat blood
cultures on [**5-2**] and [**5-26**] all returned negative.
.
# DYSPNEA/HYPOXEMIA: On presentation to ED, patient was
initially tachypneic and hypoxemic with O2 sat 94% on 3L. Acuity
of her respiratory symptoms (along with presence of sinus tach
not responsive to IV fluids) was concerning for PE, dissection,
or myocardial ischemia but CTA chest, chest x-ray, EKG and
cardiac enzymes were all reassuring. She briefly required NRB in
ED so was subsequently admitted to ICU and started on standing
nebs. O2 was rapidly weaned and she was called out to the
regular medical floor the next morning. After this her O2 sats
remained stable in high 90s on room air throughout rest of
hospitalization. Ipratropium/albuterol standing nebs were
continued during hospitalization. She will continue albuterol
PRN on discharge.
.
#.COMMINUTED INTERTROCHANTERIC LEFT FEMORAL FRACTURE: On [**2167-5-27**]
patient suffered a mechanical fall and was found to have
comminuted intertrochanteric left femoral fracture. She had
uncomplicated surgical repair by Orthopedic Surgery on [**5-27**] with
placement of left trochanteric femoral nail. Pain management was
provided with IV dilaudid, then tapered to PO oxycodone. She
continued to report poor pain control although per her daughter
she has extremely low threshold for pain and did report severe
pain even before fracturing her hip. On discharge she is
prescribed oxycontin 10mg PO q12 hours and oxycodone 5mg PO q4
hrs PRN breakthrough pain, as well as standing Tylenol 1000mg PO
q8 hrs. For DVT prophylaxis she was started on Lovenox 30mg SC
q12 hours, to be continued for a total of 4 weeks. She will
follow up with Orthopedics for repeat x-rays, suture removal and
examination on [**2167-6-9**].
.
# DM2/HYPERGLYCEMIA: Patient has uncontrolled IDDM; last A1c 9.3
in 1/[**2167**]. Blood glucose was in 400's on admission. UA showed
proteinuria (100) and glucosuria (1000), likely representing
early diabetic nephropathy. She was started on her home Lantus
33units qAM as well as insulin sliding scale, which are to be
continued on discharge to rehab. She will need follow-up insulin
regimen monitoring/diabetes education by PCP/home VNA.
.
# HEPATITIS C: In [**2161**], viral load was 1,230,000 IU/mL. HCV
viral load was rechecked during this hospitalization and is
pending upon discharge.
.
# HYPERTENSION: Normotensive on admission. Continued lisinopril
30mg PO Daily.
.
# VERTIGO: Asymptomatic throughout hospitalization. Continued
home meclizine 12.5mg PO q6 hrs PRN dizziness.
.
# LEFT EYE BLINDNESS: reported by patient and family on
admission; has not seen an ophthalmologist. Significant cataract
apparent on exam. She will need outpatient ophthalmology f/u for
this issue.
.
===================
TRANSITION OF CARE:
-Please check CBC on [**2167-6-3**] (pt HCT trended down to ~31 after
hip fracture secondary to hip and abdominal hematomas)
-Please F/U HCV viral load
Medications on Admission:
- Lantus 100 unit/mL Sub-Q 33 units once a day
- aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth DAILY (Daily)
- lisinopril 30 mg Tab 1 Tablet(s) by mouth DAILY (Daily)
- meclizine 12.5 mg Tab 1 Tablet(s) by mouth every six (6) hours
as needed for dizziness
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
2. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours) for 7
days.
Disp:*14 Tablet Extended Release 12 hr(s)* Refills:*0*
3. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous every twelve (12) hours for 9 days: First
day = [**2167-5-27**]
Last day = [**2167-6-9**].
4. insulin glargine 100 unit/mL Solution Sig: Thirty Three (33)
units Subcutaneous qAM.
5. 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.
6. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 3 weeks.
Disp:*42 syringes* Refills:*0*
10. 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.
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
19. Outpatient Lab Work
Please check CBC on [**2167-6-3**].
20. 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.
21. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous qAC,HS: please dose according to enclosed sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Right leg cellulitis
- Group B Strep bacteremia
SECONDARY DIAGNOSIS:
- Comminuted intertrochanteric fracture of left femur (from fall
during hospitalization)
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 participating in your care at [**Hospital1 771**]. You were admitted to the hospital for
fever and shortness of breath. You were found to have bacteria
growing in your blood (probably caused by an infection of your
right leg), so you were admitted to the ICU for close monitoring
and IV antibiotics.
.
Your symptoms improved greatly with antibiotics, but
unfortunately you then had a fall in the hospital and broke your
left hip. The hip fracture was repaired by orthopedic surgery.
.
Please attend your follow-up appointment with Orthopedic Surgery
listed below. They will perform x-rays, examine your leg and
remove the stitches placed during surgery.
.
We made the following changes to your medications:
1. STARTED oxycontin 10mg by mouth every 12 hours
2. STARTED oxycodone 5mg by mouth every 4 hours as needed for
breakthrough pain
3. STARTED enoxaparin (lovenox) 30mg subcutaneous every 12 hours
for four (4) weeks
4. STARTED tylenol 1000mg every 8 hours
5. STARTED Ceftriaxone 2 grams every 12 hours for two weeks
(first day = [**2167-5-27**], last day = [**2167-6-9**])
6. STARTED docusate (Colace) 100mg by mouth twice daily for
constipation until no longer taking oxycodone/oxycontin
7. STARTED senna one tab twice daily for constipation until no
longer taking oxycodone/oxycontin
8. STARTED bisacodyl and polyethylene glycol (Miralax) daily as
needed for constipation
9. STARTED calcium 500mg by mouth three times daily
10. STARTED vitamin D 800mg by mouth daily
11. STARTED Sarna lotion four times daily as needed for itching
12. STARTED albuterol nebulizer every 6 hours as needed for
wheezing/shortness of breath
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2167-6-9**] at 10:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2167-6-9**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital 9380**] CLINIC
When: TUESDAY [**2167-6-23**] at 4:30 PM
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
Name: [**Last Name (LF) 1970**],[**First Name3 (LF) 153**] Unit No: [**Numeric Identifier 1971**]
Admission Date: [**2167-5-22**] Discharge Date: [**2167-6-1**]
Date of Birth: [**2098-1-23**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 175**]
Addendum:
ADDENDUM to Problem #1: Patient had GBS SEPSIS at time of
admission, secondary to LLE cellulitis. Had [**2-28**] SIRS signs
(fever and leukocytosis) and BCx growing GBS likely hematogenous
spread of cellulitis. On discharge she was afebrile and
leukocytosis had resolved, and the rest of her surveillance
cultures were negative.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**] MD [**MD Number(1) 182**]
Completed by:[**2167-7-5**]
|
[
"366.9",
"995.91",
"682.6",
"E849.7",
"250.42",
"780.4",
"V85.38",
"V18.0",
"278.00",
"070.70",
"272.4",
"V58.67",
"820.21",
"369.8",
"459.81",
"401.9",
"038.0",
"583.81",
"786.50",
"E888.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.21",
"79.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19255, 19459
|
8978, 12748
|
336, 451
|
15732, 15732
|
4748, 4748
|
17610, 19232
|
2863, 2911
|
13057, 15437
|
15529, 15529
|
12774, 13034
|
15908, 16637
|
2951, 3828
|
16666, 17587
|
262, 298
|
479, 2465
|
15620, 15711
|
4764, 8955
|
15548, 15599
|
15747, 15884
|
2487, 2661
|
2677, 2847
|
3853, 4729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,597
| 130,613
|
7910
|
Discharge summary
|
report
|
Admission Date: [**2141-3-11**] Discharge Date: [**2141-3-29**]
Date of Birth: [**2069-9-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Vomiting/?Hematemesis
Major Surgical or Invasive Procedure:
Reopening of recent laparotomy.
Repair of biliary ductal leak from liver laceration.
Exploratory laparotomy.
Extended adhesiolysis.
Small bowel resection in ileum.
Enterotomy for decompression of small bowel.
History of Present Illness:
71 year old man with known unresectable pancreatic
anedocarcinoma s/p palliative duodenal stenting in [**12/2140**] who
presents with two episodes of hematemesis this morning. He
reports waking up early this morning and having one episode of
emesis (without nausea) that was [**Location (un) 2452**]-colored; this was
followed shortly by an episode of dark red emesis which the
patient thought was blood (more than a cupfull) and so he called
EMS. In the ambulance, he reports an additional episode of dark
red emesis. He denies any fevers, chills, abdominal pain, change
in PO intake, chest pain, lightheadedness, dizziness,
palpitations, melena, or BRBPR.
.
In the ED, his initial vitals were T 98.4, BP 115/56, HR 118,
Sat 96% on room air. NG lavage revealed approx 800cc of dark
brown material, guiac +. A hematocrit was 29 (baseline 31 last
week). He received a 250cc NS bolus and pantoprazole 40mg IV x1.
.
Pt was transferred to [**Hospital Ward Name 332**] ICU, where he was placed on IV BID
PPI, had Hct monitered, kept NPO, and had NG tube to suction
with some dark material noted. Pt's Hct went from 29.4 -> 25.7,
and was therefore transfused 1 unit of pRBC, which bumped Hct
appropriately to 28.3. KUB demonstrated evidence of ileus versus
early SBO. Pt otherwise remained hemodynamically and
symptomatically stable. He was brought for ERCP on day after
admission to evaluate his duodenal stent (?blockage versus
eroding into duodenal mucosa as etiology of pt's symptoms),
which demonstrated food impaction at the level of the stent,
with no evidence of new or old bleeding.
.
Currently, the patient is afebrile with stable vital signs, and
c/o slight nausea and some lower abdominal pain. Otherwise, ROS
is negative.
.
Past Medical History:
-Duodenal stent [**2140-12-30**] for stricture
- inoperable pancreatic cancer diagnosed [**6-15**] s/p ERCP with
stent placement, laporatomy with attempted Whipple, on
gemcitabine (received 3 weekly treatments starting [**2139-9-22**],
followed by a week off, then a fourth dose yesterday [**2139-10-20**])
- h/o SBO
- h/o cholangitis ([**6-15**]) with Enterococcus, Pseudomonas, and
Strep Viridans
- h/o bacteremia with Enterococcus fecalis (Vanc sensitive) and
Pseudomonas (sensitive to Zosyn)
- s/p choecystectomy tube (fell out [**7-16**])
- Hypertension
- ankylosing spondylitis
- right kidney cystic lesion
- Moderate Aortic stenosis
- intermittent SVT
- anemia
- tinea corporis
Social History:
Lives at Orchard care [**Hospital3 **] facility run by [**Hospital 100**]
Rehab, sister also lives there. No tob, rare etoh. No need for
cane/walker. Mostly independent in ADLs, does get help
showering.
Family History:
Mother died of breast cancer, sister had uterine cancer, father
died of heart disease at 84.
Physical Exam:
EXAM IN THE ER ([**3-11**]):
T 98.7 BP 131/61 HR 121 RR 22 Sat 96% on ra
Gen: elderly man lying comfortably in bed
HEENT: (+)NGT, OP clear with mildly dry MM, no scleral icterus
Neck: JVP 7cm, no carotid bruits, no cervical/clavicular
lymphadenopathy
CV: tachycardic, regular, II/VI systolic murmur at RUSB, nl s1s2
Chest: (+) bibasilar rales 2" up from bases; no wheezes
Abd: (+)LUQ tenderness to deep palpation; ?ventral hernia;
hypoactive bowel sounds; no palpable masses
Extr: no edema, warm, 2+ DP pulses
Neuro: A&O x3, stuttering speech
Skin: no jaundice
.
EXAM ON THE FLOOR on transfer out of the [**Hospital Unit Name 153**] ([**3-16**]):
Vitals - 96.0 94 128/69 19 96%RA
Gen - 71 yo M, thin, diaphoretic, comfortable, NAD
HEENT - NC/AT, MM dry, op clear
CVS - RRR with III/VI SEM at the base radiating to the neck and
a loud IV/VI SEM at the LLSB radiating across the precordium.
Lungs - CTAB with bibasilar rales
Abd - distended, +BS, no rebound or guarding but ttp in the
lower quadrants.
Ext - no e/c/c, wwp, 2+DP pulses
Pertinent Results:
ADMISSION LABS --->
[**2141-3-11**] 08:45AM PT-13.0 PTT-28.6 INR(PT)-1.1
[**2141-3-11**] 08:45AM WBC-10.7 RBC-4.60 HGB-9.0* HCT-29.4* MCV-64*
MCH-19.6* MCHC-30.7* RDW-18.9*
[**2141-3-11**] 08:45AM NEUTS-85.8* BANDS-0 LYMPHS-13.1* MONOS-0.5*
EOS-0.2 BASOS-0.3
[**2141-3-11**] 08:45AM DIGOXIN-0.4*
[**2141-3-11**] 08:45AM ALBUMIN-3.1*
[**2141-3-11**] 08:45AM ALT(SGPT)-26 AST(SGOT)-27 ALK PHOS-110
AMYLASE-29 TOT BILI-0.6
[**2141-3-11**] 08:45AM GLUCOSE-138* UREA N-17 CREAT-0.7 SODIUM-139
POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-30 ANION GAP-15
[**2141-3-11**] 04:01PM HCT-26.3*
[**2141-3-11**] 09:51PM HCT-25.7*
.
DISCHARGE LABS --->
[**2141-3-28**] 06:19PM BLOOD Hct-26.7*
[**2141-3-28**] 11:14AM BLOOD WBC-47.7* RBC-4.56* Hgb-11.2*# Hct-32.7*
MCV-72* MCH-24.5*# MCHC-34.2# RDW-22.9* Plt Ct-1421*
[**2141-3-28**] 04:16AM BLOOD WBC-60.3* RBC-4.13* Hgb-8.7* Hct-29.1*
MCV-71* MCH-21.2* MCHC-30.0* RDW-24.4* Plt Ct-1667*
[**2141-3-27**] 03:45PM BLOOD Neuts-88* Bands-4 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2141-3-27**] 03:45PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-2+
Macrocy-1+ Microcy-2+ Polychr-1+ Spheroc-2+ Target-OCCASIONAL
Tear Dr[**Last Name (STitle) **]1+
[**2141-3-28**] 06:19PM BLOOD PT-16.6* PTT-49.4* INR(PT)-1.5*
[**2141-3-28**] 02:48PM BLOOD Glucose-154* UreaN-44* Creat-1.5* Na-149*
K-3.4 Cl-100 HCO3-34* AnGap-18
[**2141-3-27**] 04:15AM BLOOD CK(CPK)-29*
[**2141-3-27**] 04:15AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2141-3-26**] 08:38AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2141-3-26**] 01:00AM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2141-3-28**] 02:48PM BLOOD Calcium-7.9* Phos-4.8* Mg-2.6
[**2141-3-12**] 08:06AM BLOOD calTIBC-200* Ferritn-457* TRF-154*
[**2141-3-27**] 04:49PM BLOOD Type-ART Temp-36.6 Rates-/22 pO2-73*
pCO2-34* pH-7.50* calTCO2-27 Base XS-3 Intubat-NOT INTUBA
.
KUB ([**2141-3-11**]):
Moderately dilated loops of small bowel, with presence of air
and stool in the colon, gas pattern worrisome for ileus. Early
small bowel obstruction cannot be ruled out. Osseous findings
suggestive of ankylosing spondylitis.
.
CXR ([**2141-3-11**]):
No evidence of acute cardiopulmonary process.
.
ECG ([**2141-3-11**]):
sinus tachycardia at 118 bpm; normal axis, normal intervals;
LVH; ST-T wave depression in I, aVL, V3-V6 (old)
.
[**3-13**] CT Abd/Pelvis:
IMPRESSION:
1. Small bowel obstruction with focal transition point noted
within the right lower quadrant. This is likely related to
adhesions; while the appearance has one that could be seen in
internal hernias, this is felt less likely because of the
location. 2. Stable appearance to known pancreatic head mass
without change in pancreatic duct dilation. 3. Interval
appearance of pneumobilia, likely related to recent ERCP with
stable appearance to intrahepatic biliary dilatation. 4.
Interval appearance of new small bilateral pleural effusions
(left greater than right). 5. Stable appearance to ankylosing
spondylitis.
.
[**3-27**] CT abd pelvis: Extensive small bowel obstruction with
extensive pneumatosis and air within the mesenteric vein. Stable
appearance to known pancreatic head mass. Unchanged pneumobilia
and intrahepatic biliary duct dilatation. Interval resolution of
right pleural effusion, stable small left pleural effusion.
.
Brief Hospital Course:
On admission to the hospital, the following issues regarding Mr
[**Known lastname 16268**] were present:
.
## Acute blood loss anemia: likely due to malfunction of
duodenal stent
- q6h Hcts; transfuse for evidence of active bleeding
- GI input appreciated; may require stent re-placement
- active T&S; 2 large-bore PIVs
- [**Hospital1 **] IV ppi
- consent for blood transfusion
- prn ondansetron for nausea
- hold Lasix, spironolactone for now; give short-acting,
reduced-dose beta-blockade
.
## Possible SBO: per patient, last BM was yesterday; KUB shows
evidence of possible ileus vs early SBO
- NGT in place right now (clamped)
- keep NPO for now and monitor serial abdominal exams
.
## Pancreatic adenocarcinoma with duodenal stricture, s/p
palliative stenting in [**12/2140**]; followed by Dr. [**Last Name (STitle) **]
- may get re-placement of palliative duodenal stenting by GI (as
above)
- prn Percocet for pain control
.
## Tachycardia: unclear if this is true volume depletion given
his pulmonary rales and history of SVT
- ECG appears to show sinus tachycardia
- will give reduced-dose beta-blockade for now and consider
small NS boluses in addition to maintenance IVFs
- check digoxin level
.
## Systolic CHF (LVEF 45% in [**11/2139**]): has mild pulmonary rales
on exam, though mucous membranes are slightly dry
- hold Lasix and spironolactone for now, but consider resuming
if Hct remains stable
- reduced-dose beta-blockade as above
.
## HTN: holding some of BP regimen as above; will resume once
Hct is shown to be stable
.
## FEN: D5 1/2 NS at 75cc/hr for maintenance hydration; trend
lytes; NPO for now
=========================
=========================
On [**3-16**], he was transfered out of the [**Hospital Ward Name 332**] ICU and to the
floor, under the Oncology service. At this time, her pertinent
issues were as follows:
.
# SBO: Initially thought [**1-13**] malfunction of duodenal stent - ?
obstruction of stent vs erosion of stent into duodenal mucosa vs
migration of stent. ERCP [**3-12**] demonstrated impacted food at the
level of the duodenal stent, which was removed. Again noted was
tumor infiltrating the stent, but this alone was not the cause
of the patient's nausea/vomiting. No active or past bleeding
noted.
With onset of feculent vomiting s/p ERCP, NGT was replaced to
cont suction and patient was sent down for stat CT abd/pelvis
which confirmed an SBO distal the stent. Surgery was consulted
who recommended conservative management (NGT to cont suction,
NPO, IVF, serial abdominal exams) for 48 hours and if no
flatus/BM at that point will take patient to the OR.
Now ?hematemesis at all versus just SBO w/ feculent vomiting.
HCt has been stable throughout admission.
Plan to:
- NPO, IVF titrate to UOP >50cc/hr
- NGT to continuous suction
- f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] recs - slightly improved on [**3-15**] w/ conservative
management, still plan for OR on [**3-16**] per surgery- will readdress
on the day of planned surgery
- ondansetron PRN
.
# Pancreatic adenocarcinoma: Pt has known advanced stage
pancreatic adenocarcinoma with duodenal stricture, s/p
palliative stenting in [**12/2140**]; followed by Dr. [**Last Name (STitle) **]. Get
chemo q thursday. Plan to:
- management of duodenal stent as above
- further oncologic care per primary team
.
# Tachycardia: unclear if this is true volume depletion given
his pulmonary rales and history of SVT. ECG on admission shows
sinus tachy. Plan to:
- monitor on tele
- NPO with NGT to cont suction, so cannot give outpt BB/digoxin
- standing IV BB for now
- IVF as needed to maintain UOP>50cc/hr
.
# Systolic CHF (LVEF 45% in [**11/2139**]): has mild pulmonary rales
on exam, though mucous membranes are slightly dry. No evidence
of pulmonary edema on CXR. Plan to:
- hold PO meds for now
- standing IV BB
.
# HTN: On toprol XL, dig, lasix, spironolactone as outpt. As
above, holding lasix, spironolactone and decreased dose of
metoprolol in setting of GIB. Plan to:
- holding outpt meds for now as pt NPO
- standing IV BB
=============================
=============================
Surgery was involved from the day Mr [**Known lastname 16268**] was seen in the
Emergency Room. He had a CT scan obtained of his abdomen, which
showed a bowel obstruction (see above for report). After
conservative management (NGT, NPO, IV fluids) failed, it was
decided Mr [**Known lastname 16268**] would require surgical intervention. He was
taken to the OR on [**3-16**] for his procedures:
1. Exploratory laparotomy.
2. Extended adhesiolysis.
3. Small bowel resection in ileum.
4. Enterotomy for decompression of small bowel.
During the case, the surgery was complicated by a liver
laceration (see operative note for furthur details). He
tolerated the procedure well, and was brought to the ICU in a
stable condition. Overnight of POD0, Mr [**Known lastname 28444**] pressures
remained low, and he remained tachycardic with low urine output.
He was given normal saline boluses with little marginal
improvement. His labs did not indicate hemorrhage. In the
morning of POD1 ([**3-17**]), there was evidence of staining of his
surgical dressing with bile. As a result, he was taken back to
the OR for:
1. Reopening of recent laparotomy.
2. Repair of biliary ductal leak from liver laceration.
Postop of his second surgery, he did well. He remained intubated
until [**3-21**] (slowly weaned over the course of 4 days). He
remained NPO, and TPN was started for a short period of time to
maintain nutrition. On [**3-19**], there was a short time he was on a
T-piece, and was given 1 Unit of PRBC for persistent tachycardia
with good effect (for postoperative anemia). The patient was
extubated on [**3-21**] without difficulty.
Mr [**Known lastname 16268**] was called out to the floor on [**3-22**]. He was getting
out of bed to the chair by this time. Over the course of the
next few days, Mr [**Known lastname 16268**] did well - we awaited return of bowel
function, removed his NGT when its output was minimal and
started him on sips once he was passing flatus. He was then
started on a regular diet on [**3-26**]; he tolerated this well. He
was seen by physical therapy and was ambulating and no pain
issues. His wound (midline incision) showed evidence of
breakdown, with approximately [**2-12**] staples pulling apart. The
wound remained without evidence of infection (some serosang
drainge present) and it was dressed with dry gauze. He was seen
by wound care for furthur care. On [**3-25**], he developed an
arrythmia (SVT/AFib) with a heart rate in the 130's range.
Cardiology was consulted - his digoxin was stopped and he was
started on diltizem orally. His EKG was unremarkable and his
enzymes remained unremarkable per Cardiology. His CXR was also
unremarkable and Mr [**Known lastname 16268**] [**Last Name (Titles) 15797**] chest pain or other symptoms
during this period. He was given 5mg IV lopressor x 3 with good
effect; in addition, adenosine was pushed by Cardiology for
rhythm determination. He remained in normal sinus rhythm
overnight.
Overnight of POD [**9-29**] ([**3-26**]), Mr [**Known lastname 16268**] was noted to have
increasing abdominal distention on the floor with an elevated
white count to 17,000. On examination, he was found to be
diaphoretic, but [**Known lastname 15797**] abdominal pain, chest pain or shortness
of breath. He continued to make good urine and his wound
remained unchanged. His BP was stable, and heart rate in the
130-140 range (SVT/ST). Cardiology was called, who felt it was
not necessary to make adjustments to his medication at this
time; Mr [**Known lastname 16268**] was given 5mg IV Lopressor x 2 with moderate
effect (SBP down to 100's).
The following morning ([**3-27**]), he had a CT abdomen which showed
extensive pneumatosis; he was started on broadspectrum
antibiotics and IV fluids. On this day, his white count was
elevated to 42,000 (it would later peak at 60,000). Throughout
this 24 hour period, his blood pressure remained stable
(systolic between 100-130's), but his heart rate remained in the
130-140 range, going back and forth between sinus tachycardia
and supraventricular tachycardia. Cardiology was again called,
but no furthur adjustments were made to his medications. SBP
remained stable. He was transfered to the ICU in the evening for
furthur care; a groin line was inserted. His heart rate remained
in the 130's (ST/SVT). He was started on a diltizaem drip, but
his SBP dropped, and hence it was stopped and switched to Neo in
the morning. He was also started on a heparin gtt at a rate of
800 units/hour, with an intial bolus of 1800 units (goal PTT
50-60).
On POD [**11-21**] (14/17), there was a discussion between Dr
[**First Name (STitle) **], Dr [**Last Name (STitle) 5856**] and the patient, as well as his sister
(health care proxy). It was decided that Mr [**Known lastname 16268**] would be made
DNR/DNI, as per the patient's wishes. Throughout the day, he
required an increasing dose of Neo to maintain his pressures.
His urine output remained adequate; his abdomen remained
distended and his pain was well controlled. In the evening,
another discussion was held between the ICU resident, the Rabbi
and the surgical resident. At this time, it was decided to make
the patient [**Last Name (LF) 3225**], [**First Name3 (LF) **] the patient's wishes. All questions were
answered and his expectations and desires were met. His Neo gtt
was stopped, and he was started on a morphine gtt. He was
comfortable, with sister at bedside. He fell asleep through the
night and became asystolic and apneic in the early morning. He
expired at 0516 on [**2141-3-29**]. The sister [**Date Range 15797**] an autopsy.
Medications on Admission:
Home Meds:
Toprol XL 200mg daily
digoxin 0.125mg daily
omeprazole daily
atorvastatin 10mg daily
docusate 100mg [**Hospital1 **]
Percocet 1-2 tabs q4-6h prn
Lasix 60mg po daily
spironolactone 12.5mg q48h
.
Medications on transfer:
Metoprolol 50 mg PO BID
Ondansetron 4 mg IV Q8H:PRN nausea
Oxycodone-Acetaminophen [**12-13**] TAB PO Q4-6H:PRN pain
Atorvastatin 10 mg PO DAILY
Pantoprazole 40 mg IV Q12H
Digoxin 0.125 mg PO DAILY
Docusate Sodium 100 mg PO BID
Discharge Medications:
N/A (expired)
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A (expired)
Discharge Condition:
N/A (expired)
Discharge Instructions:
N/A (expired)
Followup Instructions:
N/A (expired)
Completed by:[**2141-3-29**]
|
[
"721.0",
"518.5",
"E931.5",
"995.92",
"427.1",
"693.0",
"038.9",
"998.2",
"401.9",
"157.8",
"E879.8",
"568.89",
"537.0",
"428.20",
"996.59",
"998.32",
"560.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.72",
"38.91",
"45.93",
"96.34",
"45.62",
"99.04",
"51.79",
"54.59",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17980, 17989
|
7704, 17433
|
335, 546
|
18046, 18061
|
4420, 7681
|
18123, 18167
|
3256, 3350
|
17942, 17957
|
18010, 18025
|
17459, 17664
|
18085, 18100
|
3365, 4401
|
274, 297
|
574, 2308
|
17689, 17919
|
2330, 3017
|
3033, 3240
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,546
| 142,013
|
19812
|
Discharge summary
|
report
|
Admission Date: [**2113-1-28**] Discharge Date: [**2113-2-20**]
Date of Birth: [**2062-10-12**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Abdominal pain, knee pain
Major Surgical or Invasive Procedure:
Arthrocentesis of right knee, paracentesis, I&D right knee
History of Present Illness:
This is a 50 year old woman with PMH of HCV cirrhosis,
hemorrhagic stroke [**9-25**], HTN, thrombocytopenia, anemia, and s/p
R knee partial medial meniscectomy on [**2113-1-12**] who presents to
the ED c/o abdominal pain, increased abdominal girth and knee
pain.
Ms. [**Known lastname 34030**] states her abdomen has gradually increased in girth
since a paracentesis was performed on [**2112-12-2**] and a recent 10
lb weight gain. She states that she has a constant, dull
non-radiating lower abdominal pain that has also gradually
increased over the same time period to a [**9-2**] on a ten-point
scale. She also reports an intermittent sharp ??????pulling?????? pain
over her lower abdomen that is provoked by movement over the
past 2 days.
Ms. [**Known lastname 34030**] [**Last Name (Titles) 1834**] a right knee partial medial meniscectomy
on [**2113-1-12**]. She reports 2-3 days of increased R knee pain,
decreased ROM, swelling and warmth, and some yellow discharge on
the knee dressing.
Ms. [**Known lastname 34030**] reports being subjectively febrile (does not own
thermometer), having chills, having nausea x 3 days, vomiting
twice over the past three days (yellowish, no blood), and having
a decreased appetite. She also states she has had intermitting
SOB or ??????congestion?????? in her chest when she lies down for 2 days,
along with cough productive of ??????whitish-yellow?????? mucous; though
this morning she coughed up mucous with a slight pink tinge
once. She denies pleurisy, change in bowel or bladder function
(including melena, dysuria, hematuria increased or decreased
frequency of urination/BM), pharyngitis, sick contacts. She
denies history of hematemesis or hemoptysis. She denies prior
SBP and denies being on SBP prophylaxis.
In the ED, Ms. [**Known lastname 34030**] had a low grade fever at Tmax: 99.6, was
hypertensive to 158/72. She received morphine (2 mg IV x 1,
morphine 4 mg IV x 1) for pain control, was started on Unasyn 2
g IV, and was noted to be wheezing so received one combivent
nebulizer.
Past Medical History:
-HCV cirrhosis
-HTN
-Hemorrhagic stroke [**9-/2111**]
-Anemia
-Thrombocytopenia
-Hyperlipidemia
-?antiphospholipid antibody
-s/p Right knee partial medial meniscectomy and lysis of
adhesions [**2113-1-12**] for R knee medial meniscus tear and osseous
fragment
-s/p CCY [**2108**]
Social History:
: Lives in [**Location 4628**] with her 16-year-old daughter [**Name (NI) **].
Previously worked with microfilm, but quit many years and was
full-time parent. Has 4 daughters. She now smokes [**12-27**] ppd
(estimated 20-30 pack year history), previously drank occasional
beer, but denies alcohol since diagnosis of cirrhosis, denies
illicit drug use. She has a boyfriend, but states she is
currently not sexually active
Family History:
Mother died of leukemia at age 57. Father died of Alzheimer??????s
disease; MI. No siblings. Denies family history of HTN, DM,
early heart disease, and cancer (including breast and colorectal
cancer).
Physical Exam:
On physical exam, Ms. [**Known lastname 34030**] is somnolent, repeatedly falling
asleep in the midst of speaking and throughout the examination.
She is overweight, appears her stated age, and is in NAD.
Vital signs:
Temp: 100.4 BP: 140/80 Pulse: 80 RR: 12 O2 Sat: 98%
RA Wt: 79.1 kg
Skin:
Skin warm. Jaundiced. Nails without clubbing or cyanosis.
Numerous small scars and scabs on both legs, stomach and face.
No rash or ecchymoses.
HEENT:
Head NC/AT. Icteric, slightly pale conjunctiva. PERRL, EOMs
intact. Oropharynx clear, nonerythematous, + petechiae on hard
palate. Mucous membranes moist. Neck supple. Thyroid not
enlarged and without nodules. No LAD.
Cardiac:
JVP ~4 cm above the sternal angle at 30?????? elevation. Carotid
pulses 2+ bilat.; upstrokes brisk; without bruits. Regular rate
and rhythm, II/VI systolic murmur best appreciated at RUSB.
Pulmonary:
CTA bilaterally, but limited by poor inspiratory effort
secondary to patient??????s somnolence.
Abdomen:
Protuberant and tense abdomen. + shifting dullness. Quiet but
present BS. Soft. Diffusely tender to light palpation. On CVA
thumb, reports pain in anterior abdomen. No rebound, no
guarding.
Extremities:
R knee swollen, warm, tender to light touch, decrease passive
and active ROM with pain movement. Mild asterixis. WWP
bilaterally. Radial, post tib, and DP pulses all 2+
bilaterally. Good capillary refill bilat. 2+ LE edema
bilaterally.
Neuro:
MMSE: AOx3. Poor attention, repeatedly falling asleep during
examination
CNs: II-XII intact to direct testing.
Sensory: Deferred given patient inattentiveness
Motor: Deferred given patient??????s inattentiveness and R knee pain
DTRs: R biceps, brachioradialis 2+ ; L bicep, brachioradialis 2.
L Achilles, L patellar, R Achilles all 2. R toe up; L toe
mute.
Coordination: Deferred, given patient inattentiveness.
Pertinent Results:
Admission Labs:
[**2113-1-27**] 03:24PM WBC-11.1*# RBC-3.42*# HGB-11.1* HCT-32.7*
MCV-96# MCH-32.3* MCHC-33.8 RDW-17.7*PLT COUNT-85*
[**2113-1-27**] 03:24PM NEUTS-74.9* LYMPHS-19.0 MONOS-4.9 EOS-1.0
BASOS-0.1
[**2113-1-27**] 03:24PM ANISOCYT-1+ MACROCYT-1+
[**2113-1-27**] 09:25PM PT-15.7* PTT-36.5* INR(PT)-1.6
[**2113-1-27**] 03:24PM GLUCOSE-123* UREA N-25* CREAT-0.9 SODIUM-141
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11
[**2113-1-27**] 03:24PM ALT(SGPT)-68* AST(SGOT)-153* ALK PHOS-164*
AMYLASE-158* TOT BILI-4.5* DIR BILI-1.8* INDIR BIL-2.7
[**2113-1-27**] 03:24PM LIPASE-72*
[**2113-1-27**] 03:24PM ALBUMIN-3.1* CALCIUM-8.9
[**2113-1-28**] 06:00AM JOINT FLUID WBC-500* RBC-[**Numeric Identifier 53561**]* POLYS-89*
LYMPHS-4 MONOS-7
[**2113-1-28**] 11:20AM BLOOD Triglyc-92 HDL-14 CHOL/HD-7.6 LDLcalc-74
Subsequent Labs:
[**2113-1-28**] 11:20AM BLOOD WBC-9.9 RBC-3.02* Hgb-9.9* Hct-29.5*
MCV-97 MCH-32.6* MCHC-33.5 RDW-17.4* Plt Ct-68*
[**2113-1-30**] 06:45AM BLOOD WBC-10.0 RBC-2.18*# Hgb-6.9*# Hct-20.8*#
MCV-96 MCH-31.6 MCHC-33.0 RDW-18.1* Plt Ct-85*
[**2113-1-30**] 09:20AM BLOOD Hct-19.7*
[**2113-1-30**] 09:36PM BLOOD WBC-9.5 RBC-2.48* Hgb-8.0* Hct-23.3*
MCV-94 MCH-32.3* MCHC-34.4 RDW-17.7* Plt Ct-69*
[**2113-1-31**] 03:41AM BLOOD Hct-21.2*
[**2113-1-31**] 08:45AM BLOOD WBC-10.1 RBC-2.83* Hgb-8.9* Hct-25.9*
MCV-92 MCH-31.4 MCHC-34.2 RDW-18.2* Plt Ct-66*
[**2113-1-31**] 11:34AM BLOOD Hct-27.1*
[**2113-1-31**] 08:57PM BLOOD Hct-25.8*
[**2113-2-1**] 06:49PM BLOOD Hct-27.2*
[**2113-1-30**] 06:45AM BLOOD Anisocy-2+ Macrocy-1+
[**2113-1-30**] 09:20PM BLOOD Fibrino-161
[**2113-1-31**] 08:45AM BLOOD Ret Aut-3.9*
[**2113-1-31**] 11:34AM BLOOD LD(LDH)-359* AlkPhos-97 TotBili-4.5*
DirBili-2.1* IndBili-2.4
[**2113-1-30**] 06:45AM BLOOD Hapto-<20*
Discharge Labs:
---------
[**2113-1-27**] U/S Abdomen/Liver: The patient is status-post
cholecystectomy. The common bile is normal in appearance,
measuring 5 mm. There is a moderate amount of ascites fluid
present, although no dominant collection was identified, and no
spot was marked for paracentesis at the bedside.The liver is
echogenic and somewhat nodular in appearance, consistent with
cirrhosis. There is hepatopetal flow of the main portal vein.
IMPRESSION 1. Ascites. 2. No dominant fluid collection was seen,
and the abdomen was not marked for paracentesis.
[**2113-1-28**]: Radiograph RIGHT KNEE 3 VIEWS: Effusion is present. Some
degenerative changes present with some narrowing of the medial
joint space and marginal osteophyte formation. No areas of
erosion or destruction seen. No evidence of osteomyelitis.
IMPRESSION: Degenerative changes in fusion. No radiographic
evidence for osteomyelitis.
[**2113-1-28**]: CXR: Comparison is made to prior study of [**2112-11-20**].
FINDINGS: Cardiac and mediastinal silhouettes are within normal
limits. There are no focal pulmonary opacities, pleural
effusions, or evidence of pneumothorax. Osseous structures are
unremarkable. IMPRESSION: No evidence of acute cardiopulmonary
disease.
[**2113-1-28**] Paracentesis: Uneventful ultrasound-guided paracentesis.
A site suitable for paracentesis was marked in the right lower
quadrant. A 20- gauge needle was advanced into the peritoneum
and approximatelt 30mls of clear fluid was aspirated and sent
for microbiologic analysis.
[**2113-1-31**] CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST:
IMPRESSION:
1. No evidence of retroperitoneal hematoma. 2. Right middle and
lower lobe pneumonia. 3. Large amount of ascites. The ascitic
fluid is low in density and not suggestive of hemoperitoneum. 4.
Splenomegaly. Taken in conjunction with ascites, this finding is
consistent with portal hypertension.
[**2113-1-31**] CT LOW [**Year/Month/Day **] W/O C RIGHT; CT RECONSTRUCTION The osseous
structures are intact. There are no periarticular erosions or
fractures. The knee demonstrates medial compartment narrowing,
medial femoral condyle, subarticular cystic changes and
sclerosis secondary to degenerative disease. The joint space is
distended with heterogeneous but predominantly hyperdense fluid
containing punctate foci of air. This is consistent with
hemarthrosis. The air is likely secondary to the recent surgery.
Surgical staples are noted in the midline anteriorly. Evaluation
of the remainder of the soft tissues demonstrate obliteration of
the fat planes in the proximal, anterior compartment of the
calf. Clinical correlation is requested to exclude a compartment
syndrome. Additionally, there is diffuse circumferential edema
about the leg. Evaluation of the pelvis is limited; however, a
large amount of free fluid is present. IMPRESSION: 1. Right knee
hemarthrosis. 2. Obliteration of the flat planes in the anterior
compartment as described above. Clinical correlation is
requested.
Brief Hospital Course:
50-year-old woman with h/o HCV cirrhosis, & hemorrhagic stroke
presented initially with fever/chills, ascites, and DOE. She
was transferred to the ICU on [**2113-2-2**] and intubated for acute
hypoxia s/p FFP infusion for therapeutic tap. While in the ICU
she developed ARDS, inability to extubate, worsening acites, and
sepsis. Her condition continued to worsen despite very broad
spectrum antibiotics and aggressive ICU care including input
from hepatology, infectious disease, and orthopaedic teams.
After several weeks of unsuccessful care and worsening disease
her family decided to change care goals to comfort only. She
was extubated on [**2113-2-19**], and died on the morning of [**2113-2-20**].
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory arrest
Discharge Condition:
Dead
|
[
"719.16",
"711.06",
"518.5",
"571.2",
"717.6",
"785.52",
"789.5",
"038.9",
"303.93",
"401.9",
"287.4",
"285.1",
"572.3",
"285.29",
"998.11",
"995.92",
"305.1",
"715.96",
"070.71",
"272.4",
"572.8",
"790.92",
"V16.6",
"428.0",
"278.00",
"482.82",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"99.07",
"80.16",
"38.93",
"99.15",
"33.24",
"80.86",
"96.04",
"80.76",
"99.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10899, 10908
|
10137, 10847
|
302, 362
|
10970, 10977
|
5318, 5318
|
3203, 3408
|
10870, 10876
|
10929, 10949
|
7124, 10114
|
3423, 5299
|
237, 264
|
390, 2442
|
5334, 7107
|
2464, 2745
|
2762, 3187
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,478
| 171,250
|
13062
|
Discharge summary
|
report
|
Admission Date: [**2106-1-17**] Discharge Date: [**2106-2-1**]
Date of Birth: [**2028-12-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Generalized Weakness
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
The patient is a 77 year old male with a history of CAD s/p MI
in [**2090**] and recent CABG x 4 [**5-16**], cutaneous T-Cell lymphoma, PAF
who was admitted to [**Hospital 1474**] Hospital on [**2106-1-4**] after
presenting with ocmplaints of generalized weakness. The patient
patient had been experiencing 1-2 months of pressive dyspnea and
orthopnea in early [**2105**]. A exercise MIBI was obtained, with a
hypotensive
blood pressure response to exercise low level exercise. Ischemic
ECG
changes in the absence of typical anginal symptoms with
nonspecific ST. Nuclear imaging only showed a small, fixed,
moderate apical and distal septal defect. He underwent cardiac
catheterization, which revelaed 3VD, and subsequent CABG in [**Month (only) 116**]
[**2105**] without complication.
segment changes. Perioperative ECHO showed normal global and
regional biventricular systolic function, mild to moderate
aortic regurgitation, and mild functional mitral stenosis from
MAC.
.
The patient's post-operative course has been notable for
conintuned progressive functional decline. CT surgery follow up
notes comment on continued persistent lower extremity edema and
congestive heart failure symptoms with ongoing AF. Additonally,
he has demonstrated an overall picture of failure to thrive,
with poor PO intake, and notable weight loss over the last 6
months. He has had recent hospitalizations for acute on chronic
renal failure as well as UTIs. With progessive profound
weakness, as well as pain in left knee and worseing erythema of
chronic LLE ulcer, the patient presented to an OSH. He was
admitted for potential LE cellulitis as well as failure to
thrive.
.
The patinet was found to have an enteroccocus UTI on admission,
and was treated with a course of unasyn to cover both his
urinary pathogen, as well as a potential LE cellulities. Stool
was sent for c.diff during the hospitalization, which returned
positive. He was intiated on both flagyl and PO vanc was started
on [**2106-1-11**]. He was started on parental TPN throughout his
hospitalization.
.
The patinet was additionally found to be profoundly
coagulopathic, with an INR elevatd to 5.6 and and PTT to 67.3,
both deranged compared a normal coagulation panel in [**11-16**]. It
was initially believed that his coagulopathy was secondary to
malnutriion, however, his INR remained levated despite vitamin K
supplementation. In order to reverse his INR in order to pursue
a thoracentesis, the patinet was given a total of 12 untis of
FFP, but without effect. Hematology was consulted, who felt that
he had aquired a prothrombin inhibitor, potentially due to
exposure to bovine thrombin. The patient had several episodes of
bleeding, including profound epistaxis requiring ENT packing,
and a drop in his HCT from 30 to low 20s which aparently
responded to several units of PRBCs.
.
In the setting of transfusing of multiple units of FFP, the
patient developed respiratory failure believed to be due to
acute pulmonary edema. The patient was weened to PS of [**7-12**],
reportedly passing his SBT. At the time of transfer, he remains
intubated, on AC 500/20/5/50%. The patient was transfered to
[**Hospital1 18**] upon family request for further care.
Past Medical History:
CAD, S/P MI s/p POBA [**2090**]; s/p Coronary artery bypass grafting x
4 (left internal mammary artery grafted to the diagnal/saphenous
vein grafted to the distal left anterior descending
artery/obtuse marginal/ and PLB)on [**2105-5-8**]
GERD
Depression
HTN
HL
CRI (Cr ~ 2.0)
S/P right ankle fracture remote past
H/O Folliculotropic cutaneous T-cell lymphoma
New onset atrial fibrillation on rate control not anticoagulated
Social History:
He is married with two grown children. He does not smoke. He
rarely drinks alcohol. He denies any illegal substance use. He
is semi-retired in public relations.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. He is only
son.
Physical Exam:
Vitals: T: 96.5 P: 80 BP: 148/79 R: 30 SaO2: 93% on 35% O2 by
shovel mask
General: Cachectic, awake, alert, with mild tachypnea.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus.
Balloon in place in right nostril with dried blood below.
Oropharynx dry without lesions.
Neck: supple, JVP flat when upright
Pulmonary: Decreased breath sounds at bilateral bases, clear
above.
Cardiac: Irregularly irregular, nl S1S2, II/VI systolic murmur.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 2+ bilateral pitting LE edema.
Lymphatics: No cervical, supraclavicular LAD.
Skin: friable skin and eccymoses in arms.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: diffusely weak but without localized deficits.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
.
Pertinent Results:
[**2106-1-29**] 04:53AM BLOOD WBC-7.3 RBC-2.53* Hgb-8.1* Hct-24.8*
MCV-98 MCH-31.9 MCHC-32.5 RDW-16.2* Plt Ct-219
[**2106-1-28**] 01:18AM BLOOD WBC-8.1 RBC-2.82* Hgb-9.4* Hct-28.3*
MCV-101* MCH-33.4* MCHC-33.3 RDW-15.8* Plt Ct-220
[**2106-1-17**] 10:24PM BLOOD WBC-8.6 RBC-3.44* Hgb-11.0* Hct-33.0*
MCV-96 MCH-31.8 MCHC-33.2 RDW-17.2* Plt Ct-208
[**2106-1-28**] 01:18AM BLOOD PT-44.7* PTT-72.0* INR(PT)-4.8*
[**2106-1-26**] 06:15AM BLOOD PT-43.0* PTT-66.3* INR(PT)-4.6*
[**2106-1-23**] 05:58AM BLOOD PT-50.3* PTT-82.4* INR(PT)-5.5*
[**2106-1-22**] 12:02PM BLOOD PT-51.8* PTT-82.4* INR(PT)-5.7*
[**2106-1-21**] 05:47AM BLOOD PT-52.2* PTT-83.0* INR(PT)-5.8*
[**2106-1-20**] 05:00AM BLOOD PT-54.3* PTT-78.5* INR(PT)-6.0*
[**2106-1-17**] 10:24PM BLOOD PT-43.3* PTT-69.6* INR(PT)-4.6*
[**2106-1-27**] 05:16AM BLOOD Fact V-4.0*
[**2106-1-20**] 05:00AM BLOOD Fact V-1.8*
[**2106-1-19**] 04:05AM BLOOD FacVIII-248*
[**2106-1-18**] 06:10PM BLOOD Fibrino-614*#
[**2106-1-18**] 06:10PM BLOOD Thrombn-12.2
[**2106-1-19**] 04:05AM BLOOD VWF AG-295*
[**2106-1-20**] 05:00AM BLOOD Lupus-POS
[**2106-1-19**] 04:05AM BLOOD ACA IgG-<10 ACA IgM-<10
[**2106-1-18**] 06:10PM BLOOD Inh Scr-INDETERMIN
[**2106-1-29**] 04:53AM BLOOD Glucose-98 UreaN-127* Creat-3.9* Na-138
K-4.8 Cl-101 HCO3-27 AnGap-15
[**2106-1-28**] 04:16PM BLOOD UreaN-122* Creat-3.6* K-4.8
[**2106-1-28**] 01:18AM BLOOD Glucose-126* UreaN-117* Creat-3.4* Na-140
K-4.5 Cl-103 HCO3-26 AnGap-16
[**2106-1-25**] 06:04AM BLOOD Glucose-153* UreaN-86* Creat-2.7* Na-149*
K-4.1 Cl-107 HCO3-33* AnGap-13
[**2106-1-24**] 05:50AM BLOOD Glucose-172* UreaN-81* Creat-2.7* Na-151*
K-4.2 Cl-110* HCO3-33* AnGap-12
[**2106-1-21**] 04:59PM BLOOD Glucose-182* UreaN-77* Creat-2.9* Na-149*
K-3.2* Cl-107 HCO3-32 AnGap-13
[**2106-1-20**] 05:00AM BLOOD Glucose-100 UreaN-76* Creat-2.8* Na-152*
K-3.7 Cl-108 HCO3-31 AnGap-17
[**2106-1-17**] 10:24PM BLOOD Glucose-94 UreaN-66* Creat-2.5* Na-150*
K-3.9 Cl-106 HCO3-34* AnGap-14
[**2106-1-27**] 05:16AM BLOOD CK(CPK)-65
[**2106-1-18**] 03:55AM BLOOD TotBili-0.9 DirBili-0.5* IndBili-0.4
[**2106-1-17**] 10:24PM BLOOD ALT-36 AST-51* LD(LDH)-229 TotBili-1.0
[**2106-1-27**] 05:16AM BLOOD CK-MB-NotDone cTropnT-0.32*
[**2106-1-28**] 01:18AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.3
[**2106-1-17**] 10:24PM BLOOD Albumin-2.6* Calcium-8.8 Phos-4.7* Mg-2.5
[**2106-1-17**] 10:24PM BLOOD VitB12-608 Hapto-156
[**2106-1-23**] 05:58AM BLOOD Triglyc-50
[**2106-1-18**] 03:55AM BLOOD Triglyc-115 HDL-39 CHOL/HD-3.2 LDLcalc-62
[**2106-1-17**] 10:24PM BLOOD TSH-2.2
[**2106-1-18**] 06:10PM BLOOD PEP-NO SPECIFI
[**2106-1-19**] 04:05AM BLOOD Digoxin-1.7
[**2106-1-28**] 04:30PM BLOOD Type-MIX Temp-35.6 Tidal V-430 FiO2-50
pO2-40* pCO2-72* pH-7.25* calTCO2-33* Base XS-1 Intubat-NOT
INTUBA
[**2106-1-27**] 05:58AM BLOOD Type-ART pO2-84* pCO2-72* pH-7.28*
calTCO2-35* Base XS-3
[**2106-1-17**] 10:17PM BLOOD Type-ART Rates-20/ Tidal V-500 PEEP-5
FiO2-100 pO2-362* pCO2-42 pH-7.52* calTCO2-35* Base XS-10
AADO2-328 REQ O2-58 -ASSIST/CON Intubat-INTUBATED
[**2106-1-21**] 01:27PM BLOOD Glucose-126* Lactate-0.9 Na-148 K-2.9*
Cl-102
[**2106-1-27**] 09:48PM BLOOD VITAMIN B1-PND
[**2106-1-27**] 12:23PM BLOOD VITAMIN C-PND
[**2106-1-18**] 06:10PM BLOOD REPTILASE TIME-Test
[**2106-1-27**] 02:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2106-1-27**] 02:00PM URINE Blood-LG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2106-1-27**] 02:00PM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2106-1-27**] 02:00PM URINE CastGr-1*
[**2106-1-19**] 12:05PM URINE Mucous-RARE
[**2106-1-19**] 12:05PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
[**2106-1-19**] 12:05PM URINE Hours-RANDOM Creat-21 TotProt-47
Prot/Cr-2.2*
.
.
.
[**2106-1-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2106-1-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2106-1-27**] URINE URINE CULTURE-FINAL {ENTEROBACTER AEROGENES}
INPATIENT
[**2106-1-18**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
.
.
.
CXR
Final Report
REASON FOR EXAM: Evaluate pleural effusion. Patient getting
diuresed.
Comparison is made with prior study performed a day earlier.
Large right and moderate left pleural effusion have probably
increased in the
right side allowing the difference in positioning of the
patient. Cardiac
size cannot be evaluated. Mild-to-moderate interstitial
pulmonary edema has
worsened. NG tube tip is in the stomach. Right PICC remains in
place.
Sternal wires are aligned. Patient is status post CABG.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: [**First Name8 (NamePattern2) **] [**2106-1-28**] 12:44 PM
.
.
CXR
Final Report
HISTORY: CABG with increasing oxygen requirement.
FINDINGS: In comparison with the study of [**1-20**], there is little
overall
change. The large right and moderate left pleural effusions
persist with
underlying compressive atelectasis. No evidence of pneumothorax
or vascular
congestion. Right PICC line remains in place and the extensive
sternal wires
remain aligned. No definite focal pneumonia, though the area
behind the heart
cannot be properly evaluated on this single frontal view.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: WED [**2106-1-27**] 9:10 AM
.
.
CT Head
Final Report
HISTORY: 77-year-old man with elevated INR and increased
somnolence. Question
intraparenchymal hemorrhage.
COMPARISON: None.
FINDINGS: A non-contrast CT of the head was obtained. The
[**Doctor Last Name 352**]-white matter
differentiation is preserved. There is no intraparenchymal
hemorrhage, mass,
or mass effect. There are periventricular white matter
hypodensities which
are most likely attributed to chronic ischemic microvascular
disease. Also
noted are focal hypodensities within the bilateral basal
ganglia, most likely
representing small lacunes. There is diffuse parenchymal atrophy
and ex vacuo
dilatation of the ventricles. The extra-axial spaces are normal
in
appearance. Calcifications are noted involving the cavernous
carotid arteries
and bilateral vertebral arteries. The calvarium is intact. There
is near-
complete opacification of the right maxillary sinus which
contains high
density material. There is thinning of the medial wall of the
right maxillary
sinus. Also noted is mucosal thickening and partial
opacification of the
bilateral ethmoid sinuses, most prominent in the right anterior
ethmoid air
cells. Calcification is noted within the cavernous carotid
arteries and
vertebral arteries.
IMPRESSION:
1. No acute intracranial process.
2. Near-complete opacification of the right maxillary sinus
which contains
high density material. The differential diagnosis includes blood
products
versus chronic fungal sinusitis. Clinical correlation is
recommended.
3. Partial opacification of the bilateral ethmoid sinuses.
These findings were communicated to Dr. [**Last Name (STitle) 39943**] on [**2106-1-21**] at
5:30 pm.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39944**]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: [**First Name8 (NamePattern2) **] [**2106-1-21**] 6:01 PM
.
.
.
TTE
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). There is moderate symmetric left ventricular
hypertrophy with normal cavity size and regiona/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The right ventricular free wall is
hypertrophied. The aortic valve leaflets (3) are moderately
thickened with mild aortic valve stenosis (valve area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened with characteristic
rheumatic deformity and minimally increased gradient consistent
with trivial mitral stenosis. Moderate (2+) mitral regurgitation
is seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a small
circumferential pericardial effusion without echocardiographic
signs of tamponade.
Compared with the prior study (images reviewed) of [**2105-5-5**],
mild aortic stenosis is now present and the estimated pulmonary
artery systolic pressure has increased. Biventricular systolic
function and the severity of mitral regurgitation are similar
(mitral regurgitation was underestimated upon review of the
prior study).
.
.
CXR
Final Report
AP CHEST, 10:30 P.M. ON [**1-17**]
HISTORY: Respiratory distress. Intubated.
IMPRESSION:
AP chest compared to [**5-25**]:
Moderate-to-large right pleural effusion and small left pleural
effusion have
increased substantially. Mild-to-moderate cardiomegaly has
increased slightly
and there is mild pulmonary vascular congestion but no edema.
Opacification
at the lung bases is probably atelectasis. ET tube tip is at the
upper margin
of the clavicles, right jugular line ends at the junction of
brachiocephalic
veins. Right PIC catheter ends in the mid SVC. No pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: MON [**2106-1-18**] 4:32 PM
.
.
Brief Hospital Course:
77M with a history of CAD s/p MI and recent CABG, dCHF with mod
AR, CRI (Cr ~2.0) who presented to an OSH with failure to
thrive, found to have a UTI, developed c.diff, unresolving
coagulopathy requiring multiple transfusion, and acute pulmonary
edema (sent to MICU), extubated transferred to the floor, then
sent back to MICU for resp distress, worsening renal failure,
finally made CMO and expired peacefully.
.
# Failure to thrive: pt has had chronic failure to thrive of
unclear etiology since his CABG in early [**2105**]. ultimately, the
pt was not tolerating POs, was placed on TPN, but was finally
made CMO in the ICU given his continual decline with his
coagulopathy, CHF, respiratory distress, and renal failure.
.
# Epistaxis -
At [**Hospital1 18**], patient was seen by ENT who recommended leaving the
OSH packing in place until [**11-23**] with epistaxis precautions in
the meantime. He was seen by heme/onc and outside results showed
a likely acquired factor V inhibitor as the source for his
coagulopathy. He was diuresed with improvement in his
respiratory status and extubation. He was continued on IV
flagyl for his Cdiff and cefazolin as prophylaxis while he had
nasal packing in place. His nasal packing was removed by ENT
without any bleeding complications.
.
# Coaguloapathy -
INR of 5.6 at the OSH despite vit K and FFP. Results from OSH
showed a Factor V inhibitor, a repeat study here was still
pending at time of death here despite extensive studies sent by
hematology. Pt had a positive DILUTE [**Location (un) 39945**] VIPER VENOM TEST
which suggests lupus anticoagulant and may interfere with the
factor V inhibitor study. The factor inhibitor may have been a
sign of an underlying malignancy or perhaps exposure to bovine
graft material during his CABG; however, all of these
explanations are theoretical and there is no clear cause of why
the pt had developed this inhibitor or even if he truly had it
positive. He did not suffer from any further bleeding diathesis
other than his epistaxis mentioned above.
.
# Diastolic CHF -
Has had persisent LE edema and orthopnea since CABG surgery in
[**Month (only) 116**], with escalating doses of lasix. On exam appears total body
fluid overloaded but intravascularly dry, and has
hypoalbuminemia. He required intermittent diuresis w/ IV lasix
to improve his fluid overload and resp distress, while also
balancing between his hypernatremia which was thought to be due
to a lack of free water as well as his rising renal failure. His
home digoxin was held in the setting of renal failure.
.
# Hypoxia: Respiratory failure in the setting of high volume
transfusions on [**1-15**]. Has bilateral R>L pleural effusions,
likely due to fluid overload and poor nutritional status. Low
suspicion for pneumonia. Thoracentesis was not an option with
coagulopathy. Ultimately the pt was sent to the MICU again after
being on the floor and slightly improving due to resp distress.
As mentioned above it was difficult to balance his pulm edema
and pleural effusions given his renal failure and hypernatremia.
.
# Acute on chronic kidney disease: Had worsening of kidney
function in setting of diuresis and acute disease. Ultimately
the pt decided to become CMO due to progression of renal failure
and coagulopathy.
.
.
# C.Diff:
C-diff positive at OSH, started on IV flagyl / PO vanc on [**1-11**].
The pt ultimately continued to have diarrhea in the setting of
poor PO intake otherwise, so he was placed on PO vanco and
initially had a flexiseal placed.
.
# Paroxysmal Atrial Fribrillation:
Was noted to be in Atrial Fibrillation throughout
hospitalization, but adequately rate controlled with dilt and
metoprolol. Not on coumadin given coagulopathy.
.
# CAD: had h/o CABG mentioned above. no concern for ACS during
admission. he was continued on lipitor, BB, but his ASA was held
in setting of epistaxis.
.
# Patient was made DNR/DNI on [**1-21**] and then CMO on [**1-29**] due to
rising renal failure, persistant coagulopathy, respiratory
distress due to chronic CHF/fluid overload, and chronic
cachexia.
.
Medications on Admission:
HOME MEDICATIONS--
.
Lipitor 80mg daily
ASA 81mg daily
Warfarin
Metoprolol 50mg daily
Citalopram 10mg daily
Lasix 40mg daily
Digoxin 0.125mg daily
Diltiazem 120mg daily
.
MEDICATIONS AT TRANSFER:
ASA 81 mg daily
Lipitor 80mg daily
Citalopram 10mg daily
Digoxic 0.125mg q48h
Dilt 120mg daily
Lasix 40mg daily
Toprol 50mg daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Diastolic Heart Failure
coagulopathy from factor V inhibitor causing life threatening
epistaxis
acute on chronic renal failure
.
Secondary Diagnoses:
Clostridium Difficile Infection
Hypernatremia
Atrial Fibrillation
Coronary Artery Disease
chronic malnutrition / cachexia / failure to thrive
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"785.59",
"707.02",
"707.22",
"202.10",
"518.81",
"784.7",
"707.04",
"584.9",
"707.25",
"427.31",
"707.07",
"289.81",
"008.45",
"403.90",
"530.81",
"799.4",
"276.0",
"707.23",
"414.00",
"799.02",
"428.33",
"428.0",
"272.4",
"585.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19424, 19433
|
14931, 19016
|
335, 347
|
19804, 19813
|
5357, 14908
|
19869, 19879
|
4229, 4361
|
19392, 19401
|
19454, 19454
|
19042, 19369
|
19837, 19846
|
5151, 5338
|
4376, 5055
|
19640, 19783
|
275, 297
|
375, 3586
|
19473, 19619
|
5070, 5134
|
3608, 4035
|
4051, 4213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,878
| 138,866
|
39278
|
Discharge summary
|
report
|
Admission Date: [**2109-7-26**] Discharge Date: [**2109-8-24**]
Date of Birth: [**2026-6-30**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Therapeutic and diagnostic thoracentesis to maximize ventilation
as patient having difficulty weaning from mechanical
ventilation.
DRAINAGE HEMATOMA/FLUID UNDER CT GUIDANCE DRAINAGE
History of Present Illness:
HPI: 83yF who was discharged yesterday after a Whipple procedure
on [**2109-7-16**]. Her hospital stay was uneventful and she was
discharged home in stable condition. She then developed
shortness
of breath at home and presented to [**Hospital **] hospital where she
received vancomycin and Zosyn for an assumed pneumonia. She was
also complaining of nausea, R flank pain, and was having coffee
ground emesis. She was transferred to [**Hospital1 18**] for further
management. Here she was hypoxic in the 80's on room air. A CXR
showed bilateral pleural effusions and pulmonary edema. She was
also hypotensive in the high 80's-low 90's SBP. Given her
respiratory distress, she was intubated in the ED for airway
protection. An OGT was placed and put out 1L of coffee ground
liquid immediately.
Past Medical History:
PMH: HTN, hyperlipidemia
PSH: Tosillectomy
Social History:
Tobacco-17 pack years, EtOH-4 drinks per week.
Lives alone in FL during the [**Doctor Last Name 6165**]. Currently lives alone in
[**Location (un) **] Beach
Family History:
Father died of PNA, Mother died of Heart Failure. Pt denies any
family history of cancer.
Physical Exam:
General: obese famale, trach in place, no apparent distress
HEENT: small pupils, PERRL,
Neck: No LAD or thyromegaly appreciated, trach in place, dressed
and C/D/I
Cardiovascular: RR, nl rate, no murmurs, rubs or gallops
appreciated
Respiratory: limited exam secondary to patient compliance,
bibasilar crackles, anterior examination, no wheezes appreciated
Gastrointestinal: +BS, soft, nondistended, no evidence of
tenderness, R side wound with dressing, roughly 8 cm long,
borders appear dusky, serosanguinous fluid, no evidence of
cellulitis in surrounding area
Musculoskeletal: spontaneously moves all extremities
Skin: no rashes or skin breakdown appreciated
Pertinent Results:
[**2109-7-26**] 09:56PM TYPE-ART PO2-89 PCO2-40 PH-7.30* TOTAL
CO2-20* BASE XS--5
[**2109-7-26**] 09:56PM LACTATE-2.1*
[**2109-7-26**] 09:43PM GLUCOSE-108* UREA N-33* CREAT-2.7* SODIUM-135
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-18* ANION GAP-16
[**2109-7-26**] 09:43PM cTropnT-0.02*
[**2109-7-26**] 09:43PM CALCIUM-7.2* PHOSPHATE-4.2 MAGNESIUM-2.2
[**2109-7-26**] 09:43PM WBC-21.7* RBC-2.84* HGB-7.9* HCT-24.7* MCV-87
MCH-27.7 MCHC-31.9 RDW-15.7*
[**2109-7-26**] 09:43PM PLT COUNT-527*
[**2109-7-26**] 07:13PM GLUCOSE-89 LACTATE-2.2* K+-3.2*
[**2109-7-26**] 07:13PM freeCa-0.99*
[**2109-7-26**] 04:39PM TYPE-ART PO2-68* PCO2-37 PH-7.33* TOTAL
CO2-20* BASE XS--5
[**2109-7-26**] 04:39PM LACTATE-1.7
[**2109-7-26**] 04:21PM GLUCOSE-95 UREA N-35* CREAT-2.9* SODIUM-137
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-19* ANION GAP-16
[**2109-7-26**] 04:21PM CALCIUM-7.4* PHOSPHATE-4.5 MAGNESIUM-2.0
[**2109-7-26**] 04:21PM WBC-29.0* RBC-3.25* HGB-9.1* HCT-27.8* MCV-86
MCH-28.2 MCHC-32.8 RDW-15.7*
[**2109-7-26**] 04:21PM PLT COUNT-538*
[**2109-7-26**] 04:21PM PT-15.4* PTT-37.6* INR(PT)-1.4*
[**2109-7-26**] 10:03AM TYPE-ART PO2-70* PCO2-50* PH-7.21* TOTAL
CO2-21 BASE XS--8
Brief Hospital Course:
EVENTS:
[**7-26**]:Admitted to hospital, intubated. Patient was transferred to
IR for drainage of perihepatic abscess. On pressors (levophed
->neo/vaso).
imaging:
KUB: Mild-to-mod dilatation of small bowel loops suggestive of
partial SBO. Apparent small volume ectopic air in RUQ [**7-26**]: CT
A/P: demonstrated large R layering pleural effusion w/ near
total collapse of RLL. Opacities in L base, concerning for
multifocal PNA/aspiration. Perihepatic fluid w/ locules of air
within fluid, no discrete capsule. Probable collection adjacent
to pancreaticojejunostomy. Possible anastomotic leak w/ free
locules of air in RUQ. New nodules in L ant abd, concerning for
mets.
Micro data
BCx: [**7-26**] MRSA: neg, bile abscess cx: mixed org, BAL: budding
yeast with pseudohyphae 10-100k, GPRs, UCx: neg
[**7-27**]: Patient transfused 2U PRBC, and started on TPN and started
SQH. IR drain amylase was 9000. CXR demonstrated RLL
consolidation and LLL consolidation(unchanged) and R pl
effusion.
[**7-28**]: Patient received lasix and started on metoprolol for rate
control. CXR w/increase in R pleural effusion, large, at least
partially
loculated. Widespread parenchymal opacities unchanged. Sputum
cultures with sparse yeast, klebsiella
[**7-29**]: switched abx to levo, stopped all others. R pleural
effusion tapped for 1600cc, GS with 1+ PMNs, no orgs. Albumin
given for low BP with good effect. Purulent material expressed
from old JP site - cultures sent. Follow-up CXR with Interval
reduction of R pleural effusion s/p thoracentesis with small
residual fluid. Wound swab gram [**Last Name (un) **] with GNR.
[**7-30**]: Continued diuresis (close to 2L negative) with lasix.
[**7-31**]: Continued to Diurese with lasix (2.5L). Hep GTT started
for anticoagulation for given history of AFib.
[**8-1**]: Blood cx positive for Coag neg staph. Lopressor increased
to 10 q6, lasix 20 q6, net -2L negative. patient continued on
TPN. A-line replaced and patient started on fluconazole for
+BAL. Later in day patient spiked a temp 101.3 and new cultures
were sent. Sputum cultures were positive for Klebsiella
[**8-2**]: Patient with blood gas consistent with metabolic alkalosis
(7.43/51/31). Patient was bronched and TEE performed
demonstrated no thrombus. LVEF >55%. [**Last Name (un) **] showed erythematous
airways with copious RLL secretions. BAL continued to be
positive for GNR/Yeast.
[**8-3**] - Continued metab alkalosis, optimized K level, given
diamox. 6-hour urine K pending. Also gave lasix, more than 1 L
neg. IP eval'd effusions but not enough to tap. Replaced CVL for
fever and sent IJ for cx - NGTD. Continued to spike fevers
(101.8). Loaded with amio, continued in Afib, rate controlled.
GS on cath tip with coag neg staph
[**8-4**]: Patient had Afib requireing cardioversion, NSR. Patient
continued amiodarone drip.
[**8-5**]: Underwent CT torso- found to have LUL lobar PE and
subhepatic fluid collection, as well as pleural effusion.
Planning IR drainage of fluid collection on [**8-6**] and continue
heparin gtt. LENIs P. Spiked temp to 101.7- recultured. Urine
cx: with >100K yeast and sputum cx with Klebsiella.
[**8-6**]: Spiked temp again to 101.7 overnight and was recultured.
Pt. expressed 5-10 cc purulent drainage from wound site
overnight which was cultured. Liver abscess cultures with 2+
[**Female First Name (un) 564**] albicans, rare growth.
[**8-7**]: Amiodarone gtt stopped since patient has been in NSR.
Started lasix 30 IV TID. Increased hep gtt to be therapeutic.
Family meeting, decided to pursue trach [**8-8**]. Changed foley for
100K yeast. Opened the wound, expressed small amount of purulent
material, started [**Hospital1 **] w-t-d dressing changes. 1st degree AV
block noted from prior admission, monitor only.
[**8-8**]: Patient went to OR for Perc trach #8 Portex. Subhepatic
pigtail catheter removed. Sputum: Klebsiella/yeast, Perihepatic
fluid collection: [**Female First Name (un) 564**] growth. Continue TPN for now (added
fats, inc to 30 kcal).
[**8-9**] - Decreased Lasix. ID consult for [**Female First Name (un) 564**]/Klebsiella ->
switched abx to Micafungin/flagyl/ceftriaxone. Pt back into
afib, lytes wnl, rate controlled w/ Lopressor. TF's started.
[**8-10**] - Continued to Diurese w/ light lasix (10tid), increased
Lopressor to 10q6
[**8-11**] - Decreased lasix to 20 [**Hospital1 **] to keep even. Started coumadin
for PE and Afib. Still on hep gtt. Temp to 101.4, pan-cx'd.
Lopressor increased to TID. CXR showed improved L pleural
effusion and vasc congestion, unchanged R pleural effusion.
Blood cxs, Ucx, Cdiff were negative
[**8-12**]: Octreotide restarted. Lopressor changed from IV to PO.
Wound growing [**Female First Name (un) 564**] -switched back to fluconazole, tolerated
24hrs trach collar. CXR with unchanged bilateral
atelectasis/pleural effusions
[**8-13**]: PICC placed. CVL dc'ed. Hep gtt held x 1hr for bleeding
around trach site stable, protocol adjusted, goal 60-80.
Continue wet to dry wound care. PMV valve throughout day, but
cuff inflated for bleeding. Continues coumadin (2.5). Plan for
video swallow [**8-14**]. C diff antibiody neg. CXR showed Worsening
pulmonary edema with right basilar and left medial base
consolidation.
[**8-14**]: Coumadin redosed at 2.5 mg for INR of 1.5. Given volume
overload, increased Lasix 20 mg IV TID, BP in 120s-140s. Cycle
tube feeds, currently at 65cc/hr.
[**8-15**] - D/C'ed NGT, D/C'ed Flagyl. Heparin gtt at 1050 with PTT
75.5 - Diamox x 3 doses given for alkalosis/diuresis, Lasix 40
mg IV BID given for goal diuresis of 2L - stopped cyclic TFs and
attempted PO intake with ground/pureed diet. Will require NGT as
she has minimal PO intake. C.diff negative. PM lytes WNL. No
bleeding at trach site.
[**8-16**] - Calorie counts ordered. Encouraged PO intake. Remains on
hep gtt. Ceftriaxone dc'ed.
[**8-17**]: tolerating PO, lasix PRN positive fluid balance. CXR with
bilateral pleural eff, R>L, RLL infiltrate.
[**8-18**]: Lasix 20mg IV x1, goal neg 500cc, fluconazole discontinued,
hep gtt discont
[**8-19**]: Coumadin held. Calories counts.
[**8-20**]: 1U FFP, INR 5.5 -- PM coags; calorie counts; await transfer
today
[**Date range (1) 30966**]: After patient was transferred to the floor she was
encouraged to take in PO diet and ambulate with the help of PT.
She contained to be stable from a respiratory stand point and
tolerated PMV during the day time. Rehab screening was initiated
and patient was accepted to a rehab compatible with her needs.
Medications on Admission:
[**Last Name (un) 1724**]: Metoclopramide 10 "", Acetaminophen prn, Pantoprazole 40,
Oxycodone prn, Diltiazem HCl 240, Olmesartan 20,
Hydrochlorothiazide 12.5", Simvastatin 20, Niacin 500
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for sob, wheezing.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Niacin 50 mg Tablet Sig: Five (5) Tablet PO BID (2 times a
day).
9. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day as
needed for afib: Please continue to wean amiodarone if Afib
continues to resolve. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] - [**Hospital1 8**]
Discharge Diagnosis:
Respiratory failure
pneumonia
perihepatic fluid collection
UTI (yeast)
Anastomotic leak
sympathetic effusion
Acute Renal Failure.
Afib
line sepsis
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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-22**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 2 weeks of
leaving the hospital. Please call his office for an appointment
at ([**Telephone/Fax (1) 2363**].
|
[
"995.92",
"997.39",
"567.22",
"276.3",
"038.8",
"998.59",
"997.4",
"507.0",
"272.4",
"996.74",
"157.0",
"584.9",
"518.81",
"112.2",
"511.9",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"31.1",
"38.93",
"96.72",
"34.91",
"54.91",
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11297, 11360
|
3606, 10114
|
333, 518
|
11551, 11551
|
2388, 3583
|
13956, 14168
|
1598, 1690
|
10352, 11274
|
11381, 11530
|
10140, 10329
|
11734, 13933
|
1705, 2369
|
274, 295
|
546, 1340
|
11566, 11710
|
1362, 1407
|
1423, 1582
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,219
| 186,851
|
27593+57554
|
Discharge summary
|
report+addendum
|
Admission Date: [**2176-4-10**] Discharge Date: [**2176-4-27**]
Date of Birth: [**2110-5-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Dilaudid / Colchicine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2176-4-10**] Redo-Sternotomy, Drainage of old pericardial effusion
and partial pricardectomy
History of Present Illness:
65 y/o male who underwent coronary artery bypass graft x 3 on
[**2175-6-6**]. Re-admitted with tamponade and underwent
pericardiocentesis. During that admission had recurrent effusion
and he then underwent right VATS/window on [**2175-7-15**]. Went home
shortly after and was readmitted again on [**7-20**] with recurrent
effusion. Underwent subxiphoid window and discharged several
days later. Patient recently completed 3 months of Prednisone
and still c/o SOB/DOE. Echo on [**2176-3-26**] shows pericardial clot at
mid RV level.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
[**6-5**], Pericardial Effusion s/p Percardiocentesis and R
VATS/window 7/15/006 and s/p Subxiphoid window [**2176-7-23**],
Hypertension, Hyperlipidemia, Gastroesophageal Reflux Disease,
Depression
Social History:
Lives with wife, works as a carpenter.
Cigs: quit in [**2138**]
ETOH: 1-2 drinks/day
Family History:
Unremarkable.
Physical Exam:
VS: 74 20 130/80 5'7" 215#
Gen: Well-appearing male in NAD
HEENT: EOMI, PERLL, NC/AT
Neck: Supple, FROM, -JVD, -bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft-, NT/ND, +BS and obese
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: MAE, non-focal, A&O x 3
Pertinent Results:
[**4-22**] CXR: Decreased right-sided pulmonary edema with improved
right lower lobe atelectasis and stable left lower lobe
atelectasis.
[**4-15**] Echo: 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. Right ventricular systolic
function is normal. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. Trivial mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion. IMPRESSION: Mildly dilated right ventricle
with preserved global biventricular systolic function. Moderate
tricuspid regurgitation. Mild pulmonary hypertension. Compared
with the prior study (images reviewed) of [**2176-7-26**], the right
ventricle is slightly more dilated. Otherwise, no change.
[**4-15**] Chest CT: Pulmonary embolism through the right upper and
right lower lobes. Stable left lower lobe partial collapse.
Findings in the right lung are most likely due to asymmetric
pulmonary edema. Small right pneumothorax. Small stable left
pleural effusion. Small hiatal hernia.
[**4-15**] LE U/S: No evidence of DVT in either lower extremity.
[**4-14**] Chest CT: 1. Extensive small pulmonary emboli to the right
upper and right lower lobes. Relative sparing of the right
middle lobe. Some of these are chronic in appearance. 2.
Associated airspace abnormalities can represent infarction or
pneumonia or both. 3. Left lower lobe partial collapse. 4.
Evidence of recent sternotomy. 5. Small left pleural effusion.
6. Small hiatal hernia.
[**2176-4-10**] Echo: PRE PERICARDIECTOMY: Overall left ventricular
systolic function is normal (LVEF>55%). The left ventricular
cavity is small. Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. There is a large pericardial effusion which appears
loculated, compressing on the inferior wall of the left
ventricle . The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade. Mild to moderate ([**1-2**]+)
mitral regurgitation is seen. No atrial septal defect is seen by
2D or color Doppler. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate mitral regurgitation present.
POST PERICARDIECTOMY: The loculated effusion is no longer
present with resolution of the inferior wall compression. The
mitral regurgitation is somewhat improved and appears to be mild
now. The rest of the exam is unchanged from pre
periocardiectomy.
[**2176-4-10**] 01:38PM BLOOD WBC-11.0 RBC-3.85* Hgb-10.7* Hct-32.2*
MCV-84 MCH-27.8 MCHC-33.2 RDW-15.1 Plt Ct-196
[**2176-4-16**] 03:15AM BLOOD WBC-7.9 RBC-3.50* Hgb-9.5* Hct-29.4*
MCV-84 MCH-27.0 MCHC-32.2 RDW-15.4 Plt Ct-196
[**2176-4-25**] 06:20AM BLOOD WBC-14.6* RBC-5.17 Hgb-14.1 Hct-44.4
MCV-86 MCH-27.3 MCHC-31.8 RDW-15.2 Plt Ct-636*
[**2176-4-10**] 01:38PM BLOOD PT-14.5* PTT-24.2 INR(PT)-1.3*
[**2176-4-25**] 06:20AM BLOOD PT-35.1* PTT-36.1* INR(PT)-3.8*
[**2176-4-10**] 01:38PM BLOOD UreaN-19 Creat-0.9 Cl-106 HCO3-29
[**2176-4-10**] 01:38PM BLOOD UreaN-19 Creat-0.9 Cl-106 HCO3-29
[**2176-4-25**] 06:20AM BLOOD Glucose-131* UreaN-28* Creat-1.0 Na-144
K-4.0 Cl-102 HCO3-33* AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 56963**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On [**4-10**] he was brought
to the operating room where he underwent a redo-sternotomy with
drainage of old pericardial effusion and partial pericardectomy.
Please see operative report for details. Following surgery he
was transferred to the CSRU for invasive monitoring in stable
condition. Later on op day he was weaned from sedation, awoke
neurologically intact and extubated. His pre-op meds were
restarted and was started on beta blockers and diuretics as
well. He was gently diuresed towards his pre-op weight. Later on
post-op day one he was transferred to the telemetry floor. On
post-op day two his chest tubes were removed. On post-op day two
and three he was c/o of some shortness of breath and required
additional oxygen support via nasal canula secondary to room
oxygen sats of 87-91%. Mr. [**Known lastname 56964**] shortness of breath
progressively worsened and on post-op day four a chest CT
revealed a pulmonary embolism. He was transferred back to the
CSRU and early on post-op day six he re-intubated for worsening
hypoxia. A bronchoscopy was performed and he was started on IV
heparin. Pulmonary and hematology were consulted on this day as
well. His WBC was also elevated and blood cultures were taken
and he was started on broad spectrum antibiotics. Infectious
disease and Rheumatology were consulted on post-op day six. He
remained intubated for several more days while recovering from
the pulmonary embolism. Antibiotics were stopped after blood
cultures came back negative. On post-operative day nine he was
weaned from sedation, awoke neurologically intact ant extubated.
Over next couple of days he received aggressive pulmonary toilet
and required hi-[**Last Name (un) **] O2. Coumadin was started and was titrated
during his hospital until his INR was therapeutic. His
respiratory condition slowly improved and was doing well on
post-op day fourteen and transferred back to the telemetry
floor. While on the floor he worked with physical therapy to
regain his strength and mobility. Cleared for discharge to rehab
on POD ........... Target INR is 2.0- 3.0.
Medications on Admission:
Lipitor 80mg qd, Lisinorpil 20mg qd, Prilosec 20mg qd, Aspirin
81mg qd, MVI, Fluoxetine 40mg qd, Felodipine 10mg qd, Zetia 10mg
qd, Chlorthalidone 25mg qd, Bisoprolol 5mg qd, Advil 200mg [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
Recurrent Pericardial Effusion s/p Drainage of old pericardial
effusion and partial pricardectomy
PMH: Coronary Artery Disease s/p Coronary Artery Bypass Graft x
3 [**6-5**], Pericardial Effusion s/p Percardiocentesis and R
VATS/window 7/15/006 and s/p Subxiphoid window [**2176-7-23**],
Hypertension, Hyperlipidemia, Gastroesophageal Reflux Disease,
Depression
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 6254**] in [**2-3**] weeks
Dr. [**First Name (STitle) **] in [**1-2**] weeks [**Telephone/Fax (1) 60170**]
PT/INR goal 2.0-3.0 for pulmonary embolism
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Name: [**Known lastname 11676**],[**Known firstname 63**] L Unit No: [**Numeric Identifier 11677**]
Admission Date: [**2176-4-10**] Discharge Date: [**2176-4-27**]
Date of Birth: [**2110-5-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Dilaudid / Colchicine
Attending:[**First Name3 (LF) 265**]
Addendum:
Additions to discharge summary done on [**4-27**].
Brief Hospital Course:
Cleared for discharge to rehab on POD thirteen with a target INR
2.0- 3.0.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. Outpatient [**Name (NI) **] Work
PT/INR as needed
goal 2.0-3.0 for pulmonary embolism
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*1*
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Potassium Chloride 20 mEq Packet Sig: One (1) PO BID (2
times a day).
14. Warfarin 1 mg Tablet Sig: daily dose Tablet PO DAILY
(Daily): daily dose [**Name6 (MD) **] rehab MD- target INR 2.0-3.0; hold dose
[**4-26**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4886**] Long Term Health - [**Location (un) 4887**]
Discharge Diagnosis:
Pulmonary embolism
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2176-4-29**]
|
[
"V45.81",
"401.9",
"272.4",
"428.0",
"518.5",
"V45.4",
"423.0",
"530.81",
"415.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"96.72",
"88.72",
"96.6",
"38.93",
"37.31",
"00.17",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11199, 11290
|
9543, 9620
|
318, 415
|
8241, 8247
|
1695, 5267
|
8758, 9520
|
1376, 1391
|
9643, 11176
|
11311, 11451
|
7518, 7723
|
8271, 8735
|
1406, 1676
|
259, 280
|
443, 976
|
998, 1258
|
1274, 1360
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,162
| 114,765
|
8722
|
Discharge summary
|
report
|
Admission Date: [**2166-12-30**] Discharge Date: [**2167-1-9**]
Date of Birth: [**2109-11-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Benadryl
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
CABGx4(LIMA-LAD,SVG-OM, SVG-PVL, SVG-Diag)[**1-1**]
History of Present Illness:
57 yo F admitted to [**Hospital3 **] with right flank pain, had
chest pain prior to dialysis and ruled in for MI. Transferred to
[**Hospital1 18**] cath lab.
Past Medical History:
HTN, ^chol, ESRD/HD(polycystic KD), PAFib, Anxiety, Gout, +tob
Tonsillectomy, Tubal [**Last Name (LF) **], [**First Name3 (LF) **] tumor removal
Social History:
works as stay at home mom
+ tobacco - 1.5 ppd x 30 years
denies etoh
lives with husband and son
Family History:
mother deceased from MI at 44
Physical Exam:
Admission:
VS HR 76 RR 22 BP 218/83
NAD
Rt subclavian tunneled cath
Lungs CTAB
RRR 2/6 systolic murmur
Abdomen soft/NT/ND, obese
Extrem warm, trace edema
Varicosities none
Neuro grossly intact
Discharge:
VS T98.2 HR 68SR BP 155/84 RR 18 O2sat 94% RA
Gen NAD
Neuro A&Ox3, nonfocal exam
Pulm Decreased Left base, otherwise clear. Rt subclav tunnel
line
CV RRR, no M/R/G. Sternum stable, incision CDI
Abdm soft, NT/ND/+BS
Ext warm, 2+ pedal edema
Pertinent Results:
[**2166-12-30**] 10:05PM PLT COUNT-145*
[**2166-12-30**] 02:30PM GLUCOSE-149* UREA N-31* CREAT-5.5*#
SODIUM-131* POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-20* ANION GAP-17
[**2166-12-30**] 02:30PM ALT(SGPT)-13 AST(SGOT)-13 CK(CPK)-23* ALK
PHOS-70 AMYLASE-90 TOT BILI-0.6
[**2166-12-30**] 02:30PM CK-MB-NotDone cTropnT-0.53*
[**2166-12-30**] 02:30PM ALBUMIN-3.6
[**2166-12-30**] 02:30PM %HbA1c-5.3
[**2166-12-30**] 02:30PM WBC-7.4 RBC-2.93*# HGB-8.8* HCT-25.8* MCV-88#
MCH-29.9 MCHC-34.0 RDW-17.6*
[**2166-12-30**] 02:30PM PT-28.9* PTT-77.9* INR(PT)-2.9*
[**2167-1-9**] 06:30AM BLOOD WBC-7.9 RBC-3.21* Hgb-9.6* Hct-28.8*
MCV-90 MCH-29.9 MCHC-33.3 RDW-17.6* Plt Ct-246
[**2167-1-9**] 06:30AM BLOOD Plt Ct-246
[**2167-1-4**] 02:50AM BLOOD PT-12.3 PTT-25.9 INR(PT)-1.0
[**2167-1-9**] 06:30AM BLOOD Glucose-105 UreaN-34* Creat-5.6* Na-134
K-4.1 Cl-96 HCO3-25 AnGap-17
[**2166-12-30**] 02:30PM BLOOD ALT-13 AST-13 CK(CPK)-23* AlkPhos-70
Amylase-90 TotBili-0.6
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2167-1-8**] 8:24 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
57 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
eval for pleural effusions
INDICATION: 57-year-old status post CABG.
COMPARISON: [**2167-1-2**].
PA AND LATERAL CHEST: The patient is status post median
sternotomy and CABG. A right subclavian hemodialysis catheter
terminates in the distal SVC. Moderate degree of cardiomegaly
appears unchanged. Mediastinal and hilar contours are stable.
There is slight increased size of a moderate left and small
right pleural effusion. There is improved aeration at the left
lung base. No pneumothorax is identified. Mild degenerative
changes are noted in the mid thoracic spine.
IMPRESSION: Slight interval increase in a moderate left and
small right pleural effusion. Improving left basilar
atelectasis.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 30530**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 30531**] (Complete)
Done [**2167-1-1**] at 9:37:47 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2109-11-1**]
Age (years): 57 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG
ICD-9 Codes: 402.90, 786.05, 786.51, 799.02, 440.0, 424.0
Test Information
Date/Time: [**2167-1-1**] at 09:37 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: [**Pager number 30532**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *4.7 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Aortic Valve - Valve Area: 3.2 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. The lateral wall of the LV is hypokinetic. The
remaining left ventricular segments contract normally. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post bypass: Good RV systolic fxn. The lateral LV wall shows
some improved systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2167-1-1**] 16:04
Brief Hospital Course:
Cardiac cath showed 3VD. She was transferred to the CCU for
hypertensive urgency and was weaned from her hydralazine,
nipride and nicardipine. She was continued on argatroban instead
of heparin for concern of HIT, and she was seen by hematology.
She continued on dialysis. HIT was negative and she was taken to
the operating room on [**1-1**] where she underwent a CABG x 4. She
was transferred to the ICU in stable condition. She was
extubated on POD #1. She was given 48 hours of vanocmycin as she
was in the hospital preoperatively. She was transfused. She was
transferred to the floor on POD #3. She continued on HD M-W-F.
She was ready for discharge home on POD8
HD is set up at [**Location (un) **] Dialysis Center.
Medications on Admission:
Lipitor 80', ASA 81', Imdur 120' Lopressor 75", Renegal 400''',
Nephrocap 1', Diazepam 2.5 Q8/prn, PhosLo 667 QMon/Wed,
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO resume preop schedule
as needed.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
CAD s/p CABG
HTN, ^chol, ESRD/HD(polycystic KD), PAFib, Anxiety, Gout, +tob
Tonsillectomy, Tubal [**Last Name (LF) **], [**First Name3 (LF) **] tumor removal
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 4469**] 2 weeks
Dr. [**Last Name (STitle) 10543**] 2 weeks
Completed by:[**2167-1-9**]
|
[
"414.01",
"272.4",
"585.6",
"287.5",
"410.41",
"V17.3",
"458.21",
"753.12",
"305.1",
"276.7",
"403.91",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"89.60",
"37.22",
"36.15",
"39.61",
"99.04",
"36.13",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8721, 8784
|
6999, 7722
|
316, 370
|
8986, 8994
|
1370, 2462
|
9306, 9459
|
854, 885
|
7892, 8698
|
2499, 2526
|
8805, 8965
|
7748, 7869
|
9018, 9283
|
5939, 6976
|
900, 1351
|
260, 278
|
2555, 5895
|
398, 557
|
579, 725
|
741, 838
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,166
| 129,062
|
11876
|
Discharge summary
|
report
|
Admission Date: [**2198-7-4**] Discharge Date: [**2198-7-10**]
Service: CCU
CHIEF COMPLAINT: Chest pain.
HISTORY OF THE PRESENT ILLNESS: This is an 84-year-old
female with a history of CAD, status post coronary artery
bypass graft in [**2197-1-31**] with LIMA to LAD, SVG to PDA,
SVG to OM, and SVG to diagonal to OM 2. The patient also has
a history of PAF, hypertension, CHF. The patient also has a
history of noninsulin-dependent diabetes mellitus and
hypercholesterolemia. In [**2197-10-1**], the patient had
stents placed from the SVG to the PDA and SVG to the diagonal
to OM2. The patient was recently hospitalized from [**2198-6-21**]
to [**2198-6-23**] with acute pulmonary edema. She ruled in for MI
with peak CK of 107, MB index of 12. She was found to have
anterolateral T wave inversions. An echocardiogram at the
outside hospital showed inferoseptal hypokinesis and an EF of
40%. Catheterization showed a 40% left main lesion, diffuse
LAD lesions, 70% diagonals, patent LIMA to LAD, patent
diagonal to OM2, SVG jump graft. The patient was found to
have total occlusion of the RCA and total occlusion of her
SVG to diagonal. The patient had PTCA and drug-eluding
stents of the RCA and native OM with resolution of TIMI-III
flow.
Of note, the stents that were placed in [**2197-10-1**],
being the SVG to diagonal in addition to the SVG to PDA were
completely blocked off.
The patient now presents with the same substernal chest pain
that she initially had on presentation in [**2198-5-31**]. The
patient's pain started on Saturday, [**2198-6-30**]. The pain
was up to [**8-9**], radiating to the left breast, no diaphoresis,
nausea, vomiting, palpitations. The patient was admitted to
[**Hospital 487**] Hospital on [**2198-7-2**] with dizziness, transferred to
the ICU as her pain got worse. Of note, the patient has been
faithfully taking Ticlid with Benadryl, despite having bad
side effects including dizziness and headache. The patient
is generally allergic to Plavix and Ticlid and gets a rash in
response to these medications.
On [**2198-7-4**], the patient had pain all day at rest, no worse
with activity. She was started on nitroglycerin, heparin,
Integrelin drip. She received some relief with nitroglycerin
and morphine. The patient was transferred to [**Hospital1 18**] for
further evaluation and possible catheterization. Currently,
the patient states that her pain is [**6-9**], no nausea,
vomiting, fevers, chills, diarrhea, constipation, melena, or
bright red blood per rectum.
PAST MEDICAL HISTORY:
1. CAD, status post CABG in [**2197-1-31**] with LIMA to
LAD, SVG to PDA, SVG to OM, and SVG to diagonal to OM.
Status post stent in SVG to diagonal and SVG to PDA in
[**2197-10-1**]. Status post MI in [**2198-5-31**], status
post stenting of RCA and diagonal to OM2, SVG jump graft.
2. Hypertension.
3. Status post lumpectomy and XRT to the breast on the right
side.
4. Hypercholesterolemia.
5. Noninsulin-dependent diabetes.
6. PAF.
7. CHF.
MEDICATIONS ON TRANSFER:
1. Atenolol 25 mg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3. Glucotrol 5 mg p.o. b.i.d.
4. Colace.
5. Zantac.
6. Persantine 75 mg p.o. t.i.d.
7. Heparin drip.
8. Integrelin.
9. Nitroglycerin drip.
10. Protonix.
SOCIAL HISTORY: Positive tobacco history, quit 25 years ago.
No alcohol.
FAMILY HISTORY: The patient's brother died of an MI in his
40s.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.6, pulse 74, blood pressure 146/47, respiratory rate 24,
02 saturation 100%. General: The patient was in no apparent
distress. HEENT: Mucous membranes slightly dry. Neck: 5
cm JVP, no carotid bruits. Cardiovascular: Regular rate and
rhythm, II/VI systolic ejection murmur at the left upper
sternal border. Lungs: Inspiratory crackles on the left,
clear on the right. Abdomen: Soft, nontender, nondistended,
normoactive bowel sounds. Hemoccult negative. Extremities:
Warm, 1+ PT and DP pulses bilaterally. Bilateral femoral
bruits are noted. Neurologic: Alert and oriented times
three.
LABORATORY/RADIOLOGIC DATA: White count 10.6, hematocrit
26.2, platelets 332,000. INR 1.2. Sodium 140, potassium
4.5, chloride 110, bicarbonate 19, BUN 26, creatinine 1.2,
down from 1.7. CK 30. Calcium 9.1, magnesium 1.8,
phosphorus 3.1.
EKG revealed a normal sinus rhythm at 60 beats per minute,
normal axis and intervals, 0.[**Street Address(2) 1755**] elevation in V1,
question of J point elevation, T wave inversion in V4 through
V6. There was no change from EKG on [**2198-6-23**].
HOSPITAL COURSE: In short, this is an 84-year-old female
with a history of noninsulin-dependent diabetes, CAD,
hypertension, hypercholesterolemia, status post four vessel
coronary artery bypass grafting in [**2197-1-31**], status
post stenting of SVG to diagonal and SVG to PDA in [**2197-10-1**] with closure of the stents, recent rule in for MI,
with stenting of RCA and native OM two vessels. The patient
now presents with progressive chest pain times three to four
days.
1. CAD: The patient's chest pain was not thought to be
cardiac initially. Although the pain was similar to the pain
that she had during her MI in [**2198-5-31**], it was unusual in
that the pain lasted all day. Also, the pain was no worse
with activity. Finally, the pain was relieved by Tylenol.
The patient had no new EKG changes, and her CKs remained flat
and she ruled out for MI. Based on this, it was unlikely
that she had any rethrombosis or in-stent restenosis with the
new stents. However, given the possibility of OM involvement
and the difficulty of picking up posterior ischemia on EKG,
we could not totally rule out a cardiac source. The patient
was initially kept on heparin, Integrelin, and nitroglycerin.
Once she ruled out, these medications were weaned. The
patient was responding well to Tylenol and eventually was
pain-free.
The patient received a stress test on [**2198-7-6**], an exercise
MIBI. The patient exercised up to 85% of her maximum heart
rate on the ten minute modified [**Last Name (un) 37450**] protocol. The patient
was found to have moderately reversible perfusion defects in
the lateral, inferior, distal, and anterior walls with an EF
of 47%. Based on this, the patient went to catheterization
on [**2198-7-9**]. She was found to have discreet 30% RCA lesion.
Her RCA and native OM stents were totally intact. Otherwise,
her catheterization was unchanged.
Otherwise, the patient's Lopressor was titrated up as
tolerated. The patient was placed back on Ticlid but she
refused to take it siting that it makes her feel terrible
with dizziness, severe headache. She also refused to take
Benadryl because of its unwanted side effects.
2. PUMP: The patient has a history of CHF. Her most recent
EF was 47%. The patient is normally on Bumex 2 mg p.o. q.d.
and Aldactone 25 mg p.o. q.d. Her diuretics were held while
in-house secondary to blood pressure concern. The patient
did not develop any significant CHF during her
hospitalization even though she was off these diuretics. The
patient was restarted on Aldactone on discharge.
3. HEMATOLOGY: The patient was noted to have a drop in her
hematocrit on presentation from 31 to the outside hospital to
26. The patient's baseline is at 30. Given her history of
CAD and possible ischemia, the patient was transfused 2 units
with an appropriate bump. Of note, the patient was noted to
have red streaked stool. She does have a history of
hemorrhoids. The patient's hematocrit remained stable.
Given that the stool was streaked on the outside, this was
consistent with hemorrhoids rather than a GI bleed.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Atenolol 37.5 mg p.o. q.d.
2. Zestril 10 mg p.o. q.d.
3. Aldactone 25 mg p.o. q.d.
4. Ticlid times two weeks, may take with Benadryl if needed.
5. Aspirin 325 mg p.o. q.d.
6. Colace.
7. Protonix.
8. Glucotrol 5 mg p.o. b.i.d.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with her
PCP. [**Name10 (NameIs) **], we have encouraged her to stay on the Ticlid for
at least two weeks. She understands that she is very prone
to in-stent restenosis if she does not take the Ticlid.
Otherwise, the patient's PCP may restart the Bumex if they
think that it is indicated in the future.
DISCHARGE DIAGNOSIS:
1. Chest pain, unlikely cardiac.
2. Status post cardiac catheterization with intact stents in
right coronary artery and native OM2.
3. Noninsulin-dependent diabetes.
4. Hypertension.
5. Hypercholesterolemia.
6. Paroxysmal atrial fibrillation.
7. History of congestive heart failure.
8. Hemorrhoids.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2198-7-18**] 02:29
T: [**2198-7-26**] 09:31
JOB#: [**Job Number 37451**]
|
[
"428.0",
"V45.81",
"410.72",
"414.01",
"V45.82",
"401.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
3351, 3421
|
7712, 7950
|
8330, 8902
|
4581, 7657
|
7975, 8309
|
104, 2541
|
3436, 4563
|
3040, 3259
|
2563, 3015
|
3276, 3334
|
7682, 7689
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,290
| 126,921
|
25432
|
Discharge summary
|
report
|
Admission Date: [**2117-5-15**] Discharge Date: [**2117-6-5**]
Date of Birth: [**2084-8-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
32 year old male status post pedestrian vs car
Major Surgical or Invasive Procedure:
-Right hemothorax s/p CT [**5-15**]; Open [**Female First Name (un) **] 7/6/5
-Left tib/fib s/p ORIF 6/20/5
-Left hip s/p ORIF 6/20/5
History of Present Illness:
Patient was a pedestrian struck by a car (unknows speed).
Assisted by EMS, endotracheal intubation, IV placement, spinal
immobilization and transfer to the Emergency Department to
[**Hospital6 3105**].
Past Medical History:
None
Social History:
Alcohol use
Family History:
Non pertinent with the trauma admission
Physical Exam:
Patient with Endotracheal Entubation, medically sedated.
Neck: Cervical collar from Trauma transfer.
Chest: decreased breath sounds on the right hemithorax.
Abdomen: abraded, distended.
Rectal: decreased rectal tone.
Extremeties: left leg with tib/fib fracture.
Pertinent Results:
[**2117-5-15**] 08:20PM TYPE-ART TEMP-38.7 RATES-22/ TIDAL VOL-600
PEEP-5 O2-40 PO2-70* PCO2-43 PH-7.34* TOTAL CO2-24 BASE XS--2
INTUBATED-INTUBATED
[**2117-5-15**] 08:20PM LACTATE-2.8*
[**2117-5-15**] 07:18PM HCT-31.6*
[**2117-5-15**] 07:18PM PLT COUNT-121*
[**2117-5-15**] 07:18PM PT-12.9 PTT-25.9 INR(PT)-1.1
[**2117-5-15**] 05:10PM TYPE-ART TEMP-39.3 RATES-22/ TIDAL VOL-600
PEEP-5 O2-50 PO2-127* PCO2-34* PH-7.37 TOTAL CO2-20* BASE XS--4
INTUBATED-INTUBATED
[**2117-5-15**] 03:23PM TYPE-ART TEMP-38.8 TIDAL VOL-600 PEEP-5 O2-50
PO2-109* PCO2-45 PH-7.31* TOTAL CO2-24 BASE XS--3 -ASSIST/CON
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2117-5-15**] 02:47PM WBC-8.8 RBC-4.03*# HGB-12.3*# HCT-34.0*
MCV-84# MCH-30.6 MCHC-36.3* RDW-14.7
[**2117-5-15**] 11:42AM HCT-32.0*#
[**2117-5-15**] 08:42AM TYPE-ART PO2-196* PCO2-36 PH-7.25* TOTAL
CO2-17* BASE XS--10
[**2117-5-15**] 04:15AM WBC-20.7* RBC-3.52* HGB-10.6* HCT-31.9*
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.8
[**2117-5-15**] 04:15AM FIBRINOGE-107*
[**2117-5-15**] 04:15AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.035
Brief Hospital Course:
Patient transfer to the [**Hospital1 69**]
from [**Hospital6 3105**] (Trauma Transfer).
INJURIES:
-Right hemothorax s/p Chest Tube [**5-15**];
-9cm liver lac that did not require surgical treatment.
-Left tib/fib s/p ORIF [**5-17**]
-Left hip s/p ORIF [**5-17**]
-Open Thoracotomy [**6-2**] and Decortication for residual Hemothorax.
Medications on Admission:
None
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
2. Ketorolac Tromethamine 15 mg/mL Cartridge Sig: One (1)
Injection Q6H (every 6 hours) as needed for 3 days.
Discharge Disposition:
Home
Discharge Diagnosis:
Motor Vehicle Accident.
32M pedestrian struck by car, with right hemothorax
INJURIES:
right hemothorax s/p CT [**5-15**]; Open [**Female First Name (un) **] [**6-2**]
9cm liver lac
L tib/fib s/p ORIF 6/20
L hip s/p ORIF [**5-17**]
Discharge Condition:
Stable, no complains, tolerating diet, walking.
Discharge Instructions:
1. Diet as tolerated
2. Analgesic as needed
3. If any fever, pain go to the Emergency Room
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2117-6-5**]
|
[
"692.6",
"864.02",
"E865.4",
"958.4",
"310.2",
"518.5",
"860.2",
"E814.7",
"926.19",
"861.22",
"807.4",
"820.09",
"482.2",
"823.20",
"578.9",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"79.35",
"34.09",
"99.06",
"99.07",
"34.04",
"93.54",
"96.6",
"45.25",
"38.7",
"79.36",
"34.51",
"79.29",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2908, 2914
|
2268, 2604
|
360, 496
|
3188, 3237
|
1140, 2245
|
800, 841
|
2659, 2885
|
2935, 3167
|
2630, 2636
|
3261, 3509
|
856, 1121
|
274, 322
|
524, 727
|
749, 755
|
771, 784
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,455
| 147,387
|
5293
|
Discharge summary
|
report
|
Admission Date: [**2137-4-23**] Discharge Date: [**2137-4-28**]
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
woman with a history of severe chronic obstructive pulmonary
disease on home O2 2 liters and congestive heart failure,
diastolic dysfunction, who presents with shortness of breath.
Per report, the patient went to the [**Hospital **] Clinic on day
of admission. Noted at that time that her O2 tank ran out of
oxygen. Was in waiting room with plans to go home, but had
shortness of breath and possible anxiety, and a code was
called. She went to the [**Hospital1 69**]
Emergency Room, and received prednisone, oxygen, and felt
better, and was waiting to be discharged to home.
In the Emergency Room waiting department, however, she had
increased lethargy, diaphoretic with an arterial blood gas on
8:53 of 7.15, 94, 92, 35. The patient was placed on CPAP and
BiPAP. She was pale and cyanotic with O2 sats around 70% at
the time. She received Solu-Medrol 1215 mg IV and albuterol
with 1 amp of D50. She was previously intubated in [**2135-1-13**].
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Hypertension.
3. Reflux.
4. Hyperlipidemia.
5. Anxiety.
6. Iron deficiency anemia.
7. Lung nodule on CT scan.
8. Peripheral vascular disease.
9. Congestive heart failure, normal ejection fraction in
[**10-12**].
10. MRSA positive.
11. She was intubated on [**2-9**]. She was admitted on [**12-14**]
for congestive heart failure flare.
MEDICATIONS ON HER LAST DISCHARGE:
1. Albuterol.
2. Flovent.
3. Accolade.
4. Serevent.
5. Quinine.
6. Lasix.
7. Lipitor.
8. K-Dur.
9. Protonix.
SOCIAL HISTORY: Lives at home alone in [**Hospital3 4634**]. She
has a 50 pack year history of smoking. No alcohol abuse.
EXAMINATION: Pulse 92, blood pressure 111/53, respiratory
rate 22, and O2 saturation is 97% on room air. On CPAP
630/22 with a FIO2 of 21%, and a pressure support of 10, PEEP
of 5. General: Pleasant woman able to speak [**6-18**] word
sentences at a time, no respiratory distress. HEENT: Pupils
are equal, round, and reactive to light. Extraocular
movements are intact. Oropharynx dry. Neck is supple.
Lungs: Diffuse wheezes at the bases. Cardiovascular:
Distant sounds. Abdomen: Positive bowel sounds, nontender,
and nondistended. Extremities: Trace edema. Neurologic:
Alert and oriented to AQ. Strength is [**4-15**].
LABORATORIES ON ARRIVAL: White count 7.5, hematocrit 42,
platelets 233, and 59 lymphocytes, 28 monocytes, 4
eosinophils. Electrolyte panel: 141/5.6, 100/27, 19/1.2,
204. Arterial blood gas on [**1-24**] baseline is 7.38, 60, 53,
and 37.
ELECTROCARDIOGRAM: Sinus tachycardia with normal axis and
normal intervals.
HOSPITAL COURSE:
1. Chronic obstructive pulmonary disease exacerbation:
Patient was continued on BiPAP and then weaned to 4 liters of
oxygen overnight. The patient maintained her O2 saturation.
The patient is given Solu-Medrol IV and then switched to po
prednisone with albuterol and Atrovent inhalers. Accolade
was added. In-house we avoided an elevated pAO2 given the
respiratory history.
2. Congestive heart failure: The patient was maintained on
her Lasix.
3. The patient had complicated course in the MICU, and was
called out .................. 2 liters. Per report in the
evening, she had some dyspnea for which respiratory care was
called to provide nebulizer treatments. However, there was
PEA, V-fib event on the morning of [**4-26**]. Per report at 4:30
am, the nurses were called to beside to help with commode.
The nurse noted some shortness of breath and tachypnea, and
nurse was called.
Upon arrival of the code team, the patient was PEA and CPR
was initiated. The patient was intubated and after 20
minutes, the patient obtained a pulse with a systolic blood
pressure of 100/40. The patient then went into V-fib and
rapid atrial fibrillation. Patient was returned to the MICU.
On [**4-27**], the patient developed jerks associated with
myoclonic status. Neurology was consulted.
Electroencephalogram was performed, and the assessment and
plan was determination of postanoxic myoclonic status,
prolonged cardiac arrest followed by myoclonic status with
burst suppression, electroencephalogram nonresponsive
indicating hypoxic ischemic cerebral injury with very poor
prognosis.
DNR/DNI and on [**4-27**] the family communicated to the house
that they would like their sister extubated.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D.
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2137-4-27**] 12:11
T: [**2137-5-2**] 07:08
JOB#: [**Job Number 21592**]
|
[
"428.30",
"427.31",
"348.1",
"427.41",
"530.81",
"491.21",
"401.9",
"428.0",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"93.90",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
2785, 4747
|
100, 122
|
151, 1134
|
1156, 1683
|
1700, 2768
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,876
| 179,619
|
16924
|
Discharge summary
|
report
|
Admission Date: [**2126-9-15**] Discharge Date: [**2126-9-17**]
Date of Birth: [**2094-11-20**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Conventional Cerebral Angiogram
History of Present Illness:
The pt is a 31 year-old right-handed woman G3P3 post-partum
day 7, who presents with sudden onset of severe headache
starting
at 3am. She reports that her most recent pregnancy was
complicated by being GBS positive, and developing a temperature
of 100.8. According to her husband, there was some concern
about
the baby's HR, so she was induced at that time. No excessive
bleeding, and otherwise uncomplicated delivery on [**9-6**]. On [**9-10**]
she reports developing a sore throat with mild exudate on her
tonsils. She saw her PCP [**Last Name (NamePattern4) **] [**9-11**], and reportedly tested
negative
for strep. Her symptoms of sore throat improved, and she was
feeling better until 3am on [**9-14**]. She reports that she awoke
with
a headache, initially [**6-23**], that escalated to [**11-23**] within 30
minutes. This was accompanied by photo and phonophobia, as well
as nausea and vomiting. She notes that movement tended to make
her symptoms worse. She took Motrin and 2 Excedrin with no
relief, and around 9:30am called her PCP. [**Name10 (NameIs) **] was told to try
caffeine, to see if that improved her symptoms, and if not, to
come to the ED for further evaluation. In the ED she was given
Dilaudid and Compazine, which improved her symptoms, and
hydralazine for elevated blood pressure.
As an adult, she has had headaches every few months described as
throbbing. Usually the headaches are behind her left eye. Does
not have nausea, vomiting, photophobia, or phonophobia, or
autonomic symptoms with her headaches. HA start gradually. They
respond well to Motrin or Excedrin. She has a first cousin with
migraines but no other family member has migraines. [**Known firstname 26317**] had
one headache during her second trimester that was throbbing and
associated with photophobia.
She notes increased frequency of headaches during her
pregnancies but they were not as severe as the one described
above during her second trimester.
She denies any neck stiffness, rash, or confusion.
No diplopia or blurred vision. She reports that she has been
able to produce a small amount of milk, but has primarily been
giving her child formula. This is similar to how things were
during her prior pregnancies.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Hypothyroidism
- Anemia
Social History:
The patient lives in [**Location 2251**] with her husband and
children. She currently is a stay-at-home Mom, but used to work
as director of Multicultural affairs at a local [**Location (un) **]. No
EtOH, smoking or illicits.
Family History:
Heart disease on maternal side, DM on paternal side.
Physical Exam:
Vitals: P:52 R: 16 BP:164/62 SaO2: 95% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**4-16**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] 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, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
Admission Labs:
PT-11.8 PTT-29.9 INR(PT)-1.0
PLT COUNT-354
NEUTS-56.8 LYMPHS-38.5 MONOS-3.3 EOS-0.6 BASOS-0.7
WBC-5.9 RBC-4.88 HGB-12.2 HCT-39.4 MCV-81* MCH-25.0* MCHC-31.0
RDW-14.4
URIC ACID-6.3*
ALT(SGPT)-167* AST(SGOT)-89* ALK PHOS-102 TOT BILI-0.3
GLUCOSE-83 UREA N-10 CREAT-1.0 SODIUM-144 POTASSIUM-4.4
CHLORIDE-106 TOTAL CO2-25 ANION GAP-17
ALT(SGPT)-128* AST(SGOT)-49* ALK PHOS-92
[**2126-9-14**] 03:00PM URINE
RBC-[**4-18**]* WBC-[**4-18**] BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-0-2
BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM COLOR-Straw
APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2126-9-15**] 12:57AM
CEREBROSPINAL FLUID (CSF) WBC-17 RBC-[**Numeric Identifier 47655**]* POLYS-83 LYMPHS-14
MONOS-3
CEREBROSPINAL FLUID (CSF) WBC-4 RBC-[**Numeric Identifier **]* POLYS-60 LYMPHS-34
MONOS-4 ATYPS-2
CEREBROSPINAL FLUID (CSF) PROTEIN-253* GLUCOSE-74
ALBUMIN-3.9
LIPASE-76*
CT HEAD W/O CONTRAST Study Date of [**2126-9-14**] 2:52 PM
Diffuse sulcal effacement involving the right posterior frontal
and parietal regions. Differential considerations include
subacute subarachnoid hemorrhage or focal meningitis. MRI is
recommended for further assessment.
MR HEAD W & W/O CONTRAST Study Date of [**2126-9-14**] 8:46 PM
1. Areas of negative susceptibility with enhancement in the
cerebral sulci in the right frontal and the parietal lobes,
raises the possibility of
hemorrhage, with or without superimposed inflammation/infection
related to
cerebritis or meningitis. No acute infarction.
2. Associated cerebral edema involving the right cerebral
hemisphere as
described above.
3. No mass effect.
4. Patent major intracranial arteries without obvious evidence
of aneurysm.
5. Consultation with interventional neuroradiology/neurosurgery,
for further evaluation if necessary, by conventional angiogram
can be considered, after performing a non-contrast CT head
study, to document the presence of hemorrhage.
6. Patent major dural venous sinuses. Evaluation for cortical
veins is
limited on the present study. Correlation with clinical
neurological
examination and LP can also be considered given the imaging
findings above.
CTA HEAD W&W/O C & RECONS Study Date of [**2126-9-15**] 2:50 AM
1. Evidence of high attenuation in the right-sided cerebral
sulci, which can relate to hemorrhage or enhancement from prior
gadolinium administration, which may relate to leptomeningeal
enhancement related to cerebritis or meningitis. Effacement of
the cerebral sulci with associated edema on the right side, as
seen on the prior study.
2. Patent major intra- and extra-cranial arteries without focal
flow-limiting stenosis, occlusion, or aneurysm.
3 Prominent nasopharyngeal soft tissues, and tonsils, which can
be correlated with direct visualization, with narrowing of the
oropharynx. Mild right maxillary sinus disease.
4. Heterogeneous thyroid- non-emergent ultraosund can be
considered.
Conventional Angiogram on [**9-16**]: (prelim impression by Dr.
[**Last Name (STitle) **]
Mild beading of multiple distal vessels in the right MCA
territory. No aneurysm or dissection or other vascular
malformation seen.
Brief Hospital Course:
Ms. [**Known lastname **] is a 31 year-old G3P3 woman with a history of
hypothyroidism who delievered her baby on [**9-6**] and then on
[**9-14**] had onset of a severe bifrontal headache, associated
with photo- and phonophobia, nausea and vomiting, over a period
of 30 minutes.
On arrival, the patient's exam was notable for hypertension.
She was felt to have normal cognition, mild photophobia, and no
meningismus. Laboratory results were remarkable for elevated
LFTs (normal on [**9-3**]),
with normal platelets. CT brain was suggestive of a small right
frontal, parietal, temporal subarachnoid hemorrhage. LP was
consistent with subarachnoid hemorrhage ([**Numeric Identifier **] RBCs in Tube 4).
She was initially admitted to the ICU/Neurosurgery service for
monitoring. She underwent conventional angiogram which did not
show an aneurysm or AVM. She was hemodynamically and
neurologically stable and therefore transferred to the
neurology floor. Given the improvement in symptoms and lack of
findings on neurologic exam, she was discharged with plans for
follow-up in the stroke clinic. It was felt that the patient's
presentation was most consistent with post partum cerebral
angiopathy (otherwise known as Call [**Doctor Last Name 8271**] syndrome). Much less
likely would be thrombosis of a small cortical vein then leading
to right-sided subarachnoid hemorrhage. She was started on
verapamil SR 180mg daily to prevent vasospasm from the SAH. She
was given Keppra 500mg [**Hospital1 **] for seven days, then Keppra 500mg
daily for three days, and then instructed to stop [**Doctor Last Name (ambig) 13401**]. [**Known firstname 26317**]
was told not to drive, bath in a tub by herself, bath her
children in a tub by herself, or climb for the next month. She
was instructed to refrain from strenuous physical activity for
three months (should not lift objects more than 20lbs.)
At the time of discharge, RF, CRP, ESR as well as ANCA, [**Doctor First Name **],
Homocystine, Protein C, S and ACA was pending.
Medications on Admission:
- Levothyroxine
- Iron
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*5 Tablet(s)* Refills:*0*
3. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*3*
4. Over the counter fiber supplement
for constipation. Use as directed.
5. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: take two tablets each day for seven days, then take one
tablet daily for three days, then off.
Disp:*17 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Post-partum cerebral angiopathy (Call-[**Doctor Last Name 8271**] Syndrome)
Subarachnoid hemorrhage
Migraine headaches.
Discharge Condition:
Normal neurological examination
Discharge Instructions:
You were admitted for a severe headache and found to have a
small amount of bleeding on top of your brain in the
subarachnoid space. This was likely due to abnormal narrowing of
your blood vessels related to pregnancy and your history of
migraines. You have a normal neurological examination. Your
condition is expected to improve while taking verapamil as
indicated.
You should refrain from strenuous physical activity for three
months. Please avoid any driving, tub bathing, swimming alone or
any other activity where you may injure yourself or others
should you suddenly lose consciousness for two weeks.
Please return to the emergency room if you experience any new or
different nature of your headaches. Difficulty speaking, visual
loss, numbness, tingling or weakness or any other concerning
symptoms.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] on Wednesday, [**2126-10-2**] at 4pm in
the stroke neurology division at [**Hospital1 **]. Office
is located on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building, [**Location (un) 858**].
Completed by:[**2126-9-17**]
|
[
"348.5",
"285.9",
"437.9",
"277.39",
"430",
"346.90",
"674.04",
"648.24",
"244.9",
"648.14"
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icd9cm
|
[
[
[]
]
] |
[
"03.31",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
11876, 11882
|
9071, 11100
|
291, 325
|
12046, 12080
|
5871, 5871
|
12938, 13218
|
3268, 3322
|
11173, 11853
|
11903, 12025
|
11126, 11150
|
12104, 12915
|
4475, 5852
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3337, 3843
|
243, 253
|
353, 2956
|
5887, 9048
|
3858, 4458
|
2978, 3005
|
3022, 3251
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,226
| 135,314
|
30655
|
Discharge summary
|
report
|
Admission Date: [**2106-4-2**] Discharge Date: [**2106-5-13**]
Date of Birth: [**2029-3-29**] Sex: F
Service: SURGERY
Allergies:
Oxycodone / Percocet / Hydrochlorothiazide / Visipaque /
tramadol
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy [**2106-4-9**] and [**2106-4-27**]
Total colectomy and ileostomy [**2106-5-1**]
History of Present Illness:
Ms. [**Known lastname 72668**] is a 77 year-old woman with a history of aortic
dissection status post repair, coronary artery disease status
post bypass grafting, atrial fibrillation, mechanical aortic
valve on coumadin, chronic kidney disease, recent right hip
replacement [**2106-3-8**] who presented with a few weeks of
intermittent abdominal pain and diarrhea. The diarrhea and
abdominal pain started after her recent admission for right hip
replacement.
Of note, transfer note from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 72672**] stated that
patient's recent admission to [**Hospital **] Hospital for right hip
replacement was complicated by Clostridium difficile. However,
patient reports being told she had two negative tests for C.
diff.
Past Medical History:
1. Anemia
2. Chronic renal insufficiency status post right renal artery
stent
3. Hypertension
4. Perioperative atrial fibrillation
5. History of gastrointestinal bleeding
6. History of transient ischemic attack in [**3-21**] with aphasia
that improved without treatment
Past Surgical History:
1. [**2104-6-24**] Splenectomy
2. S/p Aortic root repair for dissection
3. 1-vessel CABG
4. Aortic valve replacement (now on coumadin)
ALLERGIES: Visipaque (anaphyllaxis), hydrochlorothiazide,
oxyycodone/percocet/tramadol (hallucinations: "seeing bugs")
Social History:
She is an exsmoker with a 25 pack year history. She reports
drinking 2 alcoholic drinks per month.
Family History:
Her mother-died at 63, HTN, MI, CHF, CVA, DM.
Her father is on "digitalis".
Physical Exam:
ADMISSION EXAM:
VS: 98.2 132/65 84 18 96% RA; [**2104-3-22**] generalized abdominal pain
GEN: No apparent distress initially, then had acute abdominal
pain which caused mild distress
HEENT: No trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: Regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: Soft, tender to palpation in LLQ, non-distended; no
guarding/rebound
EXT: No clubbing/cyanosis/edema; 2+ distal pulses
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**4-17**] motor function globally
DERM: No lesions appreciated
DISCHARGE EXAM:
General: Patient doing well, ambulating with assist, patient
measuring ileostomy output independently, pain controlled,
respiratory status stabilized.
VS: 98.4, 97.7, 55, 107/60, 16, 99%RA
Neuro: A&OX3
Cardiac: Afib on tell 70's-110
Lungs: deminished at bases, no shortness of breath
Abd: soft, flat, ileostomy with liquid stool and gas, midline
incision closed and intact staples removed and steri-strips
applied.
Lower Extremities: No significant edema, gait stable.
Pertinent Results:
ADMISSION LABS:
[**2106-4-2**] 05:07PM LACTATE-1.5
[**2106-4-2**] 04:20PM GLUCOSE-102* UREA N-22* CREAT-1.4* SODIUM-137
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13
[**2106-4-2**] 04:20PM estGFR-Using this
[**2106-4-2**] 04:20PM ALT(SGPT)-16 AST(SGOT)-20 ALK PHOS-99 TOT
BILI-0.3
[**2106-4-2**] 04:20PM LIPASE-62*
[**2106-4-2**] 04:20PM ALBUMIN-2.5*
[**2106-4-2**] 04:20PM WBC-7.7 RBC-3.26* HGB-9.5* HCT-30.1* MCV-93
MCH-29.1 MCHC-31.4 RDW-18.2*
[**2106-4-2**] 04:20PM NEUTS-76.2* LYMPHS-12.1* MONOS-11.0 EOS-0.5
BASOS-0.3
[**2106-4-2**] 04:20PM PLT COUNT-333
[**2106-4-2**] 04:20PM PT-22.7* PTT-27.3 INR(PT)-2.2*
MICROBIOLOGY:
[**2106-4-2**] BLOOD CULTURE: NEGATIVE
[**2106-4-3**] 2:33 am STOOL CONSISTENCY: NOT APPLICABLE
C. difficile DNA amplification assay (Final [**2106-4-3**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
FECAL CULTURE (Final [**2106-4-5**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2106-4-5**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2106-4-5**]):
NO E.COLI 0157:H7 FOUND.
[**2106-4-4**] URINE CULTURE: MIXED FLORA
[**2106-4-10**] 4:30 am Immunology (CMV) Source: Line-PICC.
CMV Viral Load (Final [**2106-4-13**]): CMV DNA not detected.
[**2106-4-20**] 12:01 pm STOOL CONSISTENCY: FORMED Source:
Stool.
FECAL CULTURE (Final [**2106-4-22**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2106-4-22**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2106-4-22**]):
NO E.COLI 0157:H7 FOUND.
RADIOLOGY:
CHEST XRAY [**2106-4-2**]:
1. No acute cardiopulmonary process.
2. Rounded opacity in the right hilum and possibly
representative of a
confluence of pulmonary vascular markings. However, dedicated
PA and lateral chest radiographs are recommended for further
evaluation.
ABDOMINAL XRAY [**2106-4-2**]: Distended loops of large bowel -
correlate with findings from subsequent CT.
CT ABDOMEN/PELVIS W/O CONTRAST [**2106-4-2**]:
This is a limited study due to the lack of intravenous contrast.
1. There is fecal loading noted throughout the entire colon.
Additionally, there is mild fascial thickening surrounding the
descending colon along with mild wall thickening of the sigmoid
colon. As a result, these findings may be a result of a mild
colitis. Otherwise, there is no evidence of perforation or
other acute abdominal or pelvic processes.
2. There is a multi-septated fluid low density lesion on the
right extending from the greater trochanter to the right gluteus
medius measuring 8.4 (transverse) x 2.7 cm (antero-posterior) x
9.0 cm (craniocaudal) with evidence of peripheral
calcifications. This colletion is not fully evaluated due to the
lack of intravenous contrast but appears to be likely old given
the calcifications.
3. Stable infrarenal abdominal aortic aneurysm.
4. Unchanged left adrenal nodule.
5. Cholelithiasis without evidence of cholecystitis.
ECG [**2106-4-6**]: Sinus bradycardia. Widespread T wave inversions.
Since the previous tracing of [**2104-6-26**] the rate is slower.
Atrial premature beat is not seen. T wave inversions are new.
Clinical correlation is suggested.
SIGMOIDOSCOPY [**2106-4-9**]:
- Friability and congestion in the sigmoid colon compatible with
colitis (biopsy)
- Normal mucosa in the rectum
- Otherwise normal sigmoidoscopy to 25 cm
MR ENTEROGRAPHY [**2106-4-17**]:
1. Left-sided colitis. Differential diagnosis includes
infectious and
inflammatory causes, and ischemia cannot be excluded and
clinical correlation is recommended. The findings appear a
little bit more diffuse and progressive when compared to prior
CT from [**2106-4-2**]. No bowel obstruction.
2. Dependent gallstones identified within the gallbladder
without evidence of gallbladder wall thickening or
pericholecystic fluid.
3. Stable left adrenal gland adenoma.
4. Atrophic right kidney status post right renal artery
stenting, with
multiple simple renal cysts, unchanged when compared to prior
CT.
5. Infrarenal 3.7 x 3.9 cm abdominal aortic aneurysm,
unchanged. Unchanged occlusion of the [**Female First Name (un) 899**].
REPEAT SIGMOIDOSCOPY [**2106-4-27**]:
- Normal mucosa in the rectum
- Friability and erythema starting at ~15 cm
- Stenosis starting at 20 cm
- Otherwise normal sigmoidoscopy to 20 cm
Recommendations: The abnormal mucosa was not biopsied because of
the patient's elevated INR (2.7).
Findings consistent with ischemic colitis. Multi-disciplinary
discussion scheduled for tomorrow with the patient, her family,
her hospitalist team and colorectal surgery to determine plan
moving forward.
[**2106-5-13**] 05:20AM BLOOD WBC-6.4 RBC-2.61* Hgb-8.0* Hct-26.2*
MCV-101* MCH-30.8 MCHC-30.7* RDW-18.1* Plt Ct-433
[**2106-5-9**] 05:20AM BLOOD WBC-8.3 RBC-2.64* Hgb-8.0* Hct-25.8*
MCV-98 MCH-30.1 MCHC-30.8* RDW-18.3* Plt Ct-367
[**2106-5-8**] 04:19AM BLOOD WBC-8.9 RBC-2.69* Hgb-8.1* Hct-26.4*
MCV-98 MCH-30.1 MCHC-30.6* RDW-18.3* Plt Ct-336
[**2106-5-7**] 08:33AM BLOOD WBC-10.8 RBC-2.81* Hgb-8.5* Hct-27.2*
MCV-97 MCH-30.4 MCHC-31.4 RDW-18.4* Plt Ct-304
[**2106-5-7**] 05:32AM BLOOD WBC-11.5* RBC-2.80* Hgb-8.5* Hct-27.1*
MCV-97 MCH-30.4 MCHC-31.4 RDW-18.5* Plt Ct-318
[**2106-5-6**] 06:02AM BLOOD WBC-12.4* RBC-2.96* Hgb-8.7* Hct-28.2*
MCV-95 MCH-29.3 MCHC-30.7* RDW-18.5* Plt Ct-283
[**2106-5-5**] 05:20AM BLOOD WBC-13.6* RBC-3.07* Hgb-9.4* Hct-29.7*
MCV-97 MCH-30.7 MCHC-31.8 RDW-19.0* Plt Ct-259
[**2106-5-4**] 04:12AM BLOOD WBC-18.7* RBC-3.28* Hgb-9.7* Hct-30.8*
MCV-94 MCH-29.5 MCHC-31.4 RDW-19.0* Plt Ct-245
[**2106-5-3**] 06:02AM BLOOD WBC-20.3* RBC-3.03* Hgb-9.2* Hct-28.5*
MCV-94 MCH-30.3 MCHC-32.2 RDW-19.5* Plt Ct-230
[**2106-5-13**] 05:20AM BLOOD Plt Ct-433
[**2106-5-13**] 05:20AM BLOOD PT-27.9* INR(PT)-2.7*
[**2106-5-12**] 05:05AM BLOOD PT-25.6* PTT-48.3* INR(PT)-2.5*
[**2106-5-12**] 03:00AM BLOOD PTT-50.5*
[**2106-5-11**] 09:35PM BLOOD PTT-46.4*
[**2106-5-11**] 03:15PM BLOOD PTT-52.1*
[**2106-5-11**] 07:30AM BLOOD PT-22.3* PTT-51.9* INR(PT)-2.1*
[**2106-5-11**] 03:00AM BLOOD PTT-56.2*
[**2106-5-10**] 06:55PM BLOOD PTT-48.7*
[**2106-5-10**] 01:00PM BLOOD PTT-60.2*
[**2106-5-10**] 05:35AM BLOOD PT-23.9* PTT-62.8* INR(PT)-2.3*
[**2106-5-9**] 05:20AM BLOOD PT-18.3* PTT-84.7* INR(PT)-1.7*
[**2106-5-8**] 04:19AM BLOOD PT-14.5* PTT-53.2* INR(PT)-1.4*
[**2106-5-7**] 08:33AM BLOOD Plt Ct-304
[**2106-5-7**] 08:33AM BLOOD PT-14.4* PTT-78.4* INR(PT)-1.3*
[**2106-5-7**] 05:32AM BLOOD PT-14.9* PTT-65.7* INR(PT)-1.4*
[**2106-5-6**] 06:02AM BLOOD PT-14.3* PTT-56.4* INR(PT)-1.3*
[**2106-5-5**] 06:15AM BLOOD PT-14.0* PTT-38.4* INR(PT)-1.3*
[**2106-5-2**] 04:36AM BLOOD PT-15.4* PTT-32.9 INR(PT)-1.4*
[**2106-5-1**] 02:45PM BLOOD PT-13.2* PTT-29.9 INR(PT)-1.2*
[**2106-5-1**] 05:33AM BLOOD PT-13.2* PTT-29.5 INR(PT)-1.2*
[**2106-4-30**] 06:36AM BLOOD PT-14.5* PTT-53.0* INR(PT)-1.4*
[**2106-4-29**] 04:55AM BLOOD PT-16.1* INR(PT)-1.5*
[**2106-4-28**] 06:21AM BLOOD PT-20.6* INR(PT)-2.0*
[**2106-4-27**] 04:14AM BLOOD PT-29.1* PTT-27.6 INR(PT)-2.8*
[**2106-4-26**] 07:30AM BLOOD PT-25.0* PTT-62.6* INR(PT)-2.4*
[**2106-4-25**] 05:25AM BLOOD PT-24.3* PTT-61.6* INR(PT)-2.3*
[**2106-4-23**] 04:45AM BLOOD PT-19.2* PTT-65.0* INR(PT)-1.8*
[**2106-4-22**] 06:33AM BLOOD PT-18.4* PTT-70.2* INR(PT)-1.7*
[**2106-4-22**] 04:45AM BLOOD PT-18.0* PTT-72.2* INR(PT)-1.7*
[**2106-4-16**] 08:24AM BLOOD PT-32.3* INR(PT)-3.1*
[**2106-4-15**] 05:24AM BLOOD PT-31.8* INR(PT)-3.1*
[**2106-4-12**] 05:18AM BLOOD PT-25.3* INR(PT)-2.4*
[**2106-5-12**] 05:05AM BLOOD Glucose-85 UreaN-26* Creat-1.5* Na-140
K-4.2 Cl-111* HCO3-19* AnGap-14
[**2106-5-11**] 07:30AM BLOOD Glucose-93 UreaN-29* Creat-1.6* Na-143
K-4.5 Cl-112* HCO3-23 AnGap-13
[**2106-5-10**] 05:35AM BLOOD Creat-1.6* Na-143 K-4.3 Cl-110*
[**2106-5-9**] 05:20AM BLOOD Glucose-82 UreaN-48* Creat-1.5* Na-144
K-4.9 Cl-110* HCO3-25 AnGap-14
[**2106-5-8**] 04:19AM BLOOD Glucose-110* UreaN-47* Creat-1.5* Na-140
K-4.8 Cl-107 HCO3-25 AnGap-13
[**2106-5-7**] 08:33AM BLOOD Glucose-102* UreaN-47* Creat-1.5* Na-141
K-4.3 Cl-106 HCO3-24 AnGap-15
[**2106-5-7**] 05:32AM BLOOD Glucose-89 UreaN-46* Creat-1.5* Na-141
K-4.3 Cl-105 HCO3-25 AnGap-15
[**2106-5-6**] 06:02AM BLOOD Glucose-102* UreaN-47* Creat-1.6* Na-143
K-3.3 Cl-106 HCO3-27 AnGap-13
[**2106-5-5**] 05:20AM BLOOD Glucose-105* UreaN-44* Creat-1.7* Na-142
K-3.3 Cl-108 HCO3-26 AnGap-11
[**2106-5-4**] 04:12AM BLOOD Glucose-115* UreaN-35* Creat-1.8* Na-140
K-3.5 Cl-108 HCO3-24 AnGap-12
[**2106-5-3**] 06:02AM BLOOD Glucose-108* UreaN-39* Creat-1.9* Na-138
K-4.2 Cl-107 HCO3-21* AnGap-14
[**2106-5-2**] 05:45PM BLOOD Glucose-95 UreaN-38* Creat-1.7* Na-138
K-4.9 Cl-106 HCO3-24 AnGap-13
[**2106-5-2**] 04:36AM BLOOD Glucose-108* UreaN-44* Creat-1.6* Na-137
K-5.2* Cl-105 HCO3-24 AnGap-13
[**2106-5-1**] 01:48PM BLOOD Glucose-158* UreaN-43* Creat-1.1 Na-134
K-4.6 Cl-105 HCO3-20* AnGap-14
[**2106-4-29**] 04:55AM BLOOD Glucose-99 UreaN-42* Creat-0.9 Na-134
K-4.8 Cl-104 HCO3-24 AnGap-11
[**2106-4-28**] 06:21AM BLOOD Glucose-106* UreaN-41* Creat-0.9 Na-135
K-4.4 Cl-104 HCO3-25 AnGap-10
[**2106-4-26**] 06:06AM BLOOD Glucose-94 UreaN-39* Creat-0.8 Na-136
K-4.0 Cl-105 HCO3-26 AnGap-9
[**2106-4-25**] 05:25AM BLOOD Glucose-113* UreaN-37* Creat-0.8 Na-138
K-3.7 Cl-106 HCO3-24 AnGap-12
[**2106-5-5**] 01:11PM BLOOD CK(CPK)-13*
[**2106-5-5**] 05:20AM BLOOD CK(CPK)-16*
[**2106-5-4**] 10:24PM BLOOD CK(CPK)-17*
[**2106-4-20**] 06:40AM BLOOD ALT-65* AST-55* AlkPhos-106* TotBili-0.2
[**2106-4-19**] 06:40AM BLOOD ALT-69* AST-71* TotBili-0.2
[**2106-4-18**] 05:56AM BLOOD ALT-85* AST-116* AlkPhos-113* TotBili-0.2
[**2106-5-12**] 05:05AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
[**2106-5-11**] 07:30AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1
[**2106-5-9**] 05:20AM BLOOD Albumin-2.3* Calcium-8.4 Phos-4.5 Mg-2.6
[**2106-5-8**] 04:19AM BLOOD Calcium-8.2* Phos-4.2 Mg-2.2
[**2106-5-7**] 08:33AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.1
[**2106-5-6**] 06:02AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.1
[**2106-5-5**] 05:20AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0
[**2106-5-4**] 04:12AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.3
[**2106-5-2**] 05:45PM BLOOD Calcium-8.0* Phos-5.4* Mg-2.0
[**2106-5-2**] 04:36AM BLOOD Calcium-7.5* Phos-4.8* Mg-1.9
[**2106-5-1**] 06:05PM BLOOD Calcium-7.8* Phos-5.3*
[**2106-4-11**] 10:22AM BLOOD calTIBC-100* VitB12-1189* Folate-12.3
Ferritn-163* TRF-77*
[**2106-4-8**] 08:00AM BLOOD Triglyc-86
[**2106-4-7**] 01:20PM BLOOD Osmolal-296
[**2106-5-9**] 05:20AM BLOOD TSH-0.59
[**2106-4-20**] 01:10PM BLOOD CRP-12.5*
[**2106-4-3**] 07:57AM BLOOD CRP-126.5*
[**2106-5-1**] 06:56PM BLOOD Type-MIX Comment-GREEN
[**2106-4-7**] 01:46PM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-36 pH-7.26*
calTCO2-17* Base XS--9 Comment-GREEN TOP
[**2106-5-2**] 05:17AM BLOOD Lactate-1.2
[**2106-5-1**] 06:56PM BLOOD Lactate-3.3*
[**2106-4-12**] 10:22PM BLOOD Lactate-1.4
Brief Hospital Course:
77 year-old woman with extensive cardiac history and vascular
disease presented with several weeks of gastrointestinal
symptoms after recently having had hip surgery. CT ABDOMEN
[**2106-4-2**] and sigmoidoscopy [**2106-4-9**] revealed colitis. Infections
including C. diff and CMV were ruled out. Ultrasound was
performed to assess blood flow. She had normal celiac and SMA
artery blood flow, but [**Female First Name (un) 899**] was not visualized. MRE revealed
chronically occluded [**Female First Name (un) 899**] and an infrarenal AAA. Vascular said
that no intervention needed to be done for the chronically
occluded [**Female First Name (un) 899**] and the infrarenal AAA could be followed as an
outpatient. Of note, the patient fell during her inpatient stay
without injury.
Her abdominal pain and loose stools. She was empirically
hydrated to manage possible ischemic colitis and given a short
course of steroids for possible IBD. Biopsies from first
sigmoidoscopy was non-diagnostic. A 2nd sigmoidoscopy was
performed on [**2106-4-27**] which revealed new stricturing in the
distal colon and no improvement in colitis, thus a diagnosis of
ischemic colitis was made. The patient was transferred to the
colorectal surgery inpatient [**Hospital1 **] and received bowel prep as
well as was evaluated by the wound/ostomy nursing team for stoma
marking. She underwent total colectomy with ileostomy on
[**2106-5-1**]. The entire colon appeared diseased to some extent.
Intraoperatively she experienced atrial fibrillation with rapid
ventricular response and was stabilized. She was sent directly
to the ICU after surgery for close monitoring.
ICU Course:
PRIMARY PROBLEM:
# Ischemic colitis s/p total colectomy with ileostomy. Initially
it was unclear what was causing her colitis. Infections ruled
out. IBD ruled out with biopsies and trial of steroids and
antibiotics. Supportive care was given with IV fluids without
improvement.
Sigmoidoscopy was performed on [**2106-4-9**]. Biopsies were taken that
showed diffusely ulcerated mucosal fragments with extensive
granulation tissue formation, chronic active inflammation and
fibrinopurulent exudate. Antibiotics were started, but stopped
when colonic infections were ruled out. MRE showed left-sided
colitis, chronically occluded [**Female First Name (un) 899**]. After repeat sigmoidoscopy
on [**2106-4-27**] showed worsening of colitis and showed new colonic
stricturing, a diagnosis of ischemic colitis was made. The
patient opted for surgical resection which took place on
[**2106-5-1**].
In the [**Hospital Unit Name 153**], she required multiple fluid boluses as well as
albumin for low urine output and SBPs in the 80-90s. Lactate
was also elevated to 3.3 after her colectomy which improved to
1.2 with fluids. She did not require pressors and was mentating
well despite her hypotension. Her hemodynamics improved and she
was transferred to the surgery service.
OTHER PROBLEMS:
# GNR bacteremia. She was found to have GNRs in her BCx from
[**4-30**]. She was started empirically on Zosyn.
# Malnutrition, moderate, with albumin 2.1. Patient was started
on TPN on [**2106-4-8**].
# Atrial fibrillation: Rate controlled. She had an episode of
rapid ventricular rate intra-operatively, but was stabilized.
# [**Last Name (un) **] [**1-14**] pre-renal failure from poor PO intake and increased GI
losses. Resolved with IV fluid resuscitation.
# Anemia, normocytic. Received 1 unit pRBC transfusion on [**4-11**] units on [**4-23**].
# Coronary artery disease: s/p CABG, stable. Not on ASA because
she is on warfarin.
# Aortic dissection s/p mechanical AVR/aortic root repair, INR
goal [**1-15**]. Warfarin stopped for surgery. She was started on a
heparin gtt on POD1 for anticoagulation.
# Hypertension, benign, stable.
# Hyperlipidemia: Continued home Simvastatin
The patient was transferred to the inpatient colorectal surgery
floor on [**2106-5-2**]. The patient was stable. She was followed
closely on the inpatient [**Hospital1 **] by the wound/ostomy nursing team,
social work, and physical therapy. The geriatric medical team
was consulted for medical recommendations. Pn [**2106-5-4**] the
patient was noted to have diminished lung sounds in the bases
and slightly productive cough. Her abdomen was documented by the
nursing staff to be softly distended however, she had liquid
green stool in the ostomy bag and gas. On [**2106-5-4**] restarted
metoprolol 100 mg twice daily and Coumadin mg with heparin gtt.
The heparin drip was monitored closely with PPT values and the
INR was monitored with a goal of 2.5-3.5. The patient was
triggered for rapid heart rate and was found to be in rapid
atrial fibrillation and was treated with intravenous Lopressor.
The patient had a chest film [**2106-5-4**] which showed:
small-to-moderate bilateral pleural effusions which were
unchanged from prior imaging. During this time, the patient was
also noted to have hallucinations and confusion which was
attributed to opioid medications. Lisinopril was discontinued at
recommendation of the Geriatric Medicine team. She was continued
on Amlodipine. Overnight into [**2106-5-5**] the patient was noted to
have nausea despite having output from ileostomy and a
nasogastric tube was placed, the patient was NPO with the NGT
however continued TPN and PCA pain medication. She continued to
be treated with Zosyn/ Vancomycin IV. She was continued on the
heparin drip throughout this time period. On [**2106-5-5**] the
Lopressor was increased to 100 mg tid for more effective blood
pressure and heart rate control. The patient was noted to have
crackled in lung bases bilaterally. On [**2106-5-6**] the patient's
Foley catheter was removed and her urine output was stable. On
[**2106-5-7**] the JP drain was removed and the patient again
restarted restarted Coumadin 5mg daily. On [**2106-5-7**] the patient
had adequate bowel function and the nasogastric tube was removed
and the patient tolerated small amounts of a regular diet
however continued TPN. The patient worked with physical therapy
and began to increase her activity with assistance and her
delirium cleared. The patient continued TPN and the vancomycin
was discontinued. The patient's ambulatory sat 98% however she
was triggered [**2106-5-7**] for rapid atrial fibrillation with a heart
rate to the 140's. Geriatric Medicine was consulted on [**2106-5-8**]
and evaluated the patient for acute pulmonary edema BPN was
monitored, the patient's BUN and Creatinine was monitored
closely and recovered steadily over this time period. On
[**2106-5-8**] the patient received 10mg of Coumadin, [**12-14**] bag TPN, and
her antibiotics were discontinued. The patient was evaluated for
fluid overload [**2106-5-9**] Lasix 20mg was started PO (dry weight
131 from 121 on admission) BNP was 1247. She likely had
congested heart failure. [**2106-5-9**] it was decided to discontinue
the TPN and encourage a regular diet. The patient was started on
pain medications by mouth which she tolerated well. Her central
venous line was removed. The patient was noted to have elevated
ileostomy output on [**2106-5-11**] and she began to take a regimen of
loperamide 4 TID, this proved to not be adequate to control her
output on [**2106-5-12**] Metamucil wafers were initiated twice daily
which controlled the output nicely. On
[**2106-5-12**] the patient's INR stabilized at 2.5 and the patient
continued Coumadin 4mg daily and the heparin drip was
discontinued. The patient was noted to have an hematocrit of
25-26 which is the patient's baseline which she was monitored
closely and treated as an outpatient with Arenesp injections.
The patient's outpatient provider was consulted and because of
insurance issues, the patient was started on Procrit and the
first injection was given on [**2106-5-12**]. She will need to monitor
the hematocrit and hemoglobin weekly on Tuesday and if
hemoglobin is greater than 11 hold Wednesday dose. The patient
has a follow-up appointment with nephrology to monitor this
medication. The patient continued to have improved mental status
and respiratory status. She was stable and ready for discharge
and with insurance approval, the patient was ready for discharge
to rehabilitation facility on [**2106-5-13**]. The staples were removed
on [**2106-5-13**] and steri strips were applied and the incision was
intact. The patient will be discharged on 4mg of Coumadin daily.
Medications on Admission:
Aranesp (polysorbate) 100 mcg/0.5 mL Syringe every 3 weeks
Acetaminophen 500 mg 2 Tablets by mouth four times a day as
needed for pain
calcitriol 0.25 mcg 1 Capsule by mouth 2 days a week
Furosemide 20 mg 1 Tablet by mouth once a day
Lisinopril 40 mg 1 Tablet by mouth once a day
Simvastatin 10 mg 1 Tablet by mouth once a day
metoprolol tartrate 100 mg 1 Tablet by mouth twice a day
Warfarin 5 mg 1-1.5 Tablets by mouth once a day
amlodipine 5 mg 1 Tablet by mouth once a day
gabapentin 100 mg 2 Capsules by mouth 1 AM, and 2 PM (never
started)
Multivitamin one Capsule by mouth daily
Coenzyme Q10 100 mg 1 Capsule by mouth daily
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. epoetin alfa 20,000 unit/mL Solution Sig: 20,000 units
Injection once a week: check hematocrit and hemaglobin weekly
and hold for greater than hemaglobin greater than 11.
3. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q8H (every 8 hours) for 5 days: Do not give more
than 4000mg of tylenol daily.
4. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): continue until symptoms resolve.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 5 days: hold for increased sedation.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please monitor fluid balance by wght and ileostomy output.
8. loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day): ileostomt output should be 500cc-1200cc.
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day:
Please monitor INR, goal 2.5-3.5.
11. psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a
day): monitor ileostomy output, should be 500cc-1200cc in 24
hours.
12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
PRIMARY DIAGONSES:
- Ischemic colitis s/p colectomy and ileostomy
- Malnutrition, moderate
- Acute kidney injury
SECONDARY DIAGNOSES:
- Mechanical aortic valve replacement
- Atrial fibrillation
- Coronary artery disease
- Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were found to have ischemic colitis from vessel disease.
This required you to have your colon removed on [**2106-5-1**]. You
have recovered from this procedure well and you are now ready
for dicharge to a rehabilitation facility. you are taking
narcotic pain medications there is a risk that you will have
some constipation. If you have any of the following symptoms
please call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or constipation.
You have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high and you have had elevated ileostomy output and are
currently on a regimen of imodium and metamucil wafers. The
stool is no longer passing through the large intestine which is
where the water from the stool is reabsorbed into the body and
the stool becomes formed. You must measure your ileostomy output
for the next few weeks. The output from the stoma should not be
more than 1200cc or less than 500cc. If you find that your
output has become too much or too little, please call the office
for advice. The office nurse or nurse practitioner can recommend
medications to increase or slow the ileostomy output. Keep
yourself well hydrated, if you notice your ileostomy output
increasing, take in more electrolyte drink such as Gatorade.
Please monitor yourself for signs and symptoms of dehydration
including: dizziness (especially upon standing), weakness, dry
mouth, headache, or fatigue. If you notice these symptoms please
call the office or return to the emergency room for evaluation
if these symptoms are severe. You may eat a regular diet with
your new ileostomy. However it is a good idea to avoid fatty or
spicy foods and follow diet suggestions made to you by the
ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. You
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until you are comfortable caring
for it on your own.
You have a long vertical incision on your abdomen and the
staples were removed from the incision line and replaced with
steri strips prior to your discharge. This incision can be left
open to air or covered with a dry sterile gauze dressing if the
staples become irritated from clothing. Please leave the
steri-strips in place Please monitor the incision for signs and
symptoms of infection including: increasing redness at the
incision, opening of the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever. Please call the office if
you develop these symptoms or go to the emergency room if the
symptoms are severe. You may shower, let the warm water run over
the incision line and pat the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
exercise with Dr. [**Last Name (STitle) 1120**] or [**Doctor Last Name **].
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please call the colorectal surgery clinic to make an appointment
with [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP for 2 weeks after discharge. Please call
the clinic at [**Telephone/Fax (1) 160**] to make this appointment or with any
questions or concerns related to your surgery or ileostomy
output.
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2106-5-17**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2106-5-19**] at 2:30 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2106-11-17**] at 11:20 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
Completed by:[**2106-5-13**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"45.24",
"46.23",
"45.25",
"45.82",
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] |
icd9pcs
|
[
[
[]
]
] |
24659, 24773
|
14204, 22637
|
338, 443
|
25047, 25047
|
3221, 3221
|
29590, 30948
|
1947, 2024
|
23318, 24636
|
24794, 24908
|
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|
25198, 29567
|
1559, 1815
|
2039, 2716
|
24929, 25026
|
2732, 3202
|
284, 300
|
471, 1243
|
3237, 14181
|
25062, 25174
|
1265, 1536
|
1831, 1931
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,486
| 128,770
|
17847
|
Discharge summary
|
report
|
Admission Date: [**2155-8-19**] Discharge Date: [**2155-8-26**]
Date of Birth: [**2090-6-11**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 55-year-old gentleman,
with known coronary artery disease, who underwent a
four-vessel coronary artery bypass four years ago, who
presented on [**2155-8-18**] with complaints of crescendo angina
over the past week. The patient's cardiac enzymes were
negative for myocardial infarction. The patient was
transferred to [**Hospital6 256**] for
cardiac catheterization.
PAST MEDICAL HISTORY:
1. Status post MI [**62**] years ago.
2. Status post CABG in [**2150**] with all vein grafts.
3. Status post PCI with stent in [**2155-4-17**].
4. Hypertension.
5. Hypercholesterolemia.
6. GERD.
ALLERGIES: Rocephin which gives him a rash.
PREOPERATIVE MEDICATION:
1. Lotrel [**4-26**], 1 tablet po qd.
2. Atenolol 50 mg po qd.
3. Zocor 20 mg po bid.
4. Enteric-coated aspirin 325 mg po qd
5. Protonix 40 mg po qd.
6. Imdur 15 mg po qd.
7. Plavix 75 mg po qd.
ADMISSION PHYSICAL EXAM: Pulse 60, regular rate and rhythm,
blood pressure 161/81, respiratory rate 16, room air oxygen
saturation 97%. The patient is alert and oriented x 3
without JVD. No carotid bruits. No thyromegaly. Heart -
S1, S2, no S3 or S4. Muffled heart tones. Lungs are clear
to auscultation. Abdomen is soft, nontender, nondistended,
positive bowel sounds, no hepatosplenomegaly. Extremities
without clubbing, cyanosis or edema.
ADMISSION LABORATORY DATA: Significant for a white blood
cell count 6.2, hematocrit 41.6, platelet count 246,
potassium 4.3, BUN 7, creatinine 0.9. EKG showed sinus
rhythm, 66, T wave inversions in V1 and V6.
HOSPITAL COURSE: The patient was taken to the Cardiac
Catheterization Lab on day of admission, [**2155-8-19**], where
they found 85% ostial LAD lesion proximal to the area
previously stented, with a 60% in-stent restenosis, mild
proximal circumflex disease, heavily calcified RCA with
midvessel occlusion. The previous graft to the OM was
nonoccluded. The vein graft to the PDA was nonoccluded and
not studied. The patient was referred to cardiac surgery for
operative repair of his coronary artery disease.
The patient was taken to the operating room on [**2155-8-21**] for a redo CABG x 3 with LIMA to LAD, SVG to LAD, and
SVG to PDA. In the operating room, transesophageal
echocardiogram showed an ejection fraction greater than 55%
with mild mitral regurgitation prior to the operation, which
was reduced to trace mitral regurgitation after
revascularization.
The patient was transferred to the Intensive Care Unit on a
Neo-Synephrine and propofol infusion. The patient was
quickly weaned and extubated from mechanical ventilation. On
postoperative day #0, the patient required a moderate amount
of volume resuscitation with subsequent blood transfusions.
The patient continued to be hypotensive in the Intensive Care
Unit requiring Neo-Synephrine to maintain adequate blood
pressure. The patient's chest tubes were removed on
postoperative day #2.
On the evening of postoperative day #3, while the patient had
previously been A-paced for sinus bradycardia, the patient
went into atrial fibrillation with rates 150-160 which was
controlled with IV and PO Lopressor. The patient remained
hemodynamically stable during this time, and the
Neo-Synephrine had been weaned off. On postoperative day #4,
the patient continued to be in atrial fibrillation. The
patient was started on amiodarone, and with an initial bolus
of 150 mg of IV amiodarone, the patient converted into sinus
rhythm.
On postoperative day #4, the patient was transferred from the
Intensive Care Unit to the floor where he remained stable
without any further atrial fibrillation. The patient worked
with physical therapy, and by postoperative day #5 was able
to complete a Level 5 with physical therapy which is
ambulating 500' and climbing one flight of stairs while
remaining hemodynamically stable and without requiring
oxygen. The patient was cleared for discharge to home.
CONDITION ON DISCHARGE: T-max 99, pulse 76, in sinus rhythm,
blood pressure 99/53, respiratory rate 16, oxygen saturation
94% on room air. The patient is awake, alert, oriented x 3.
Neurologically nonfocal. Heart is regular rate and rhythm
without rub or murmur. Lungs are clear bilaterally without
wheezes, rhonchi or rales. Abdomen is soft, nontender,
nondistended, positive bowel sounds. The patient is
tolerating a regular diet. Extremities are warm,
well-perfused, trace to 1+ pitting edema. Sternal incision
is intact with staples. There is no erythema or drainage.
The sternum is stable. The right lower extremity vein
harvest site is intact with Steri-Strips. There is no
erythema or drainage.
LABORATORY DATA: White blood cell count 8.3, hematocrit
26.7, platelet count 235, sodium 133, potassium 4.2, chloride
98, bicarb 28, BUN 15, creatinine 1.1, glucose 111.
DISCHARGE MEDICATIONS:
1. Colace 100 mg po bid.
2. Lasix 20 mg po bid x 7 days.
3. Potassium chloride 20 mEq po bid x 7 days.
4. Enteric-coated aspirin 325 mg po qd.
5. Percocet 5/325, [**12-19**] po q 4-6 h prn.
6. Lopressor 25 mg po bid.
7. Amiodarone 400 mg po qd.
8. Protonix 40 mg po qd.
9. Simvastatin 20 mg po qd.
10.Plavix 75 mg po qd.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft in [**2150**].
3. Status post redo coronary artery bypass graft x 3.
4. Postoperative atrial fibrillation.
5. Hypertension.
6. Hypercholesterolemia.
The patient is to be discharged to home with visiting nurse
to monitor his heart rate and rhythm. The patient is in
stable condition. The patient is to follow-up with Dr.
[**Last Name (STitle) **] in [**12-19**] weeks. The patient is to follow-up with Dr.
[**Last Name (STitle) 49510**] in [**12-19**] weeks. The patient is to follow-up with Dr.
[**Last Name (STitle) **] in [**2-18**] weeks. The patient is to return to Far-2 in 2
weeks for staple removal.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 28087**]
MEDQUIST36
D: [**2155-8-26**] 12:13
T: [**2155-8-26**] 11:30
JOB#: [**Job Number 49511**]
|
[
"414.02",
"272.0",
"401.9",
"458.2",
"997.1",
"411.1",
"530.81",
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"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"88.56",
"37.22",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5328, 6294
|
4985, 5307
|
1730, 4076
|
1074, 1712
|
184, 563
|
585, 1058
|
4101, 4962
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,736
| 143,451
|
35007
|
Discharge summary
|
report
|
Admission Date: [**2137-12-28**] Discharge Date: [**2138-1-3**]
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
Ms [**Known lastname 80042**] is an 84 year old woman with history of labile
hypertension, coronary artery disase (per report with 40% RCA
lesion seen in [**2-/2137**] cath), CLL, h/o breast cancer s/p left
mastectomy and ischemic cardiomyopathy, presenting with new
episode of chest pain this evening.
.
History is obtained via russian interpreter; patient reports she
was at home resting when she started having severe chest pain
localized to the left chest and which radiated to the left arm.
Patient took imdur and diovan and pain resolved in approximately
5 minutes. Denies any dizziness, syncope or pre-syncope, nausea,
vomiting, diarrhea, diaphoresis, but did feel some difficulty
breathing.
.
Patient denies any recent joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors.
.
Patient believes this pain is more of a "pressure" than the pain
she has been experiencing for the last few months. Denies
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
In the ED, 181/94, 70, 26 200% RA. Given 5mg IV lopressor,
aspirin, plavix and heparin drip after discussion of ECG with
cardiology fellow. Patient admitted for further evaluation.
Past Medical History:
Hypertension
Diet-controlled diabetes
Congestive heart failure
Breast cancer diagnosed 15 years ago, s/p left mastectomy
CLL
Social History:
No smoking history. Denies EtOH or illicit drugs. Widowed. Lives
alone. Competent in IADLs. Grandchildren live nearby.
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
VS: 97.9 140/55 71 20 99% RA
GENERAL: Well appearing elderly femaly in no distress. Appears
frustrated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 16 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: trace bilateral pedal edema
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:
[**2137-12-28**] 09:00PM BLOOD WBC-8.8 RBC-4.14* Hgb-12.7 Hct-36.1
MCV-87 MCH-30.7 MCHC-35.2* RDW-13.9 Plt Ct-221
[**2137-12-28**] 09:00PM BLOOD PT-12.5 PTT-23.8 INR(PT)-1.1
[**2137-12-28**] 09:00PM BLOOD Glucose-148* UreaN-13 Creat-0.7 Na-139
K-3.6 Cl-100 HCO3-26 AnGap-17
[**2137-12-28**] 09:00PM BLOOD CK(CPK)-79
[**2137-12-29**] 05:40AM BLOOD ALT-20 AST-34 CK(CPK)-200*
[**2137-12-29**] 01:10PM BLOOD CK(CPK)-173*
[**2137-12-30**] 05:35AM BLOOD CK(CPK)-102
[**2137-12-31**] 05:30AM BLOOD CK(CPK)-62
[**2138-1-1**] 05:25AM BLOOD CK(CPK)-51
[**2137-12-28**] 09:00PM BLOOD CK-MB-4 proBNP-255
[**2137-12-28**] 09:00PM BLOOD cTropnT-0.03*
[**2137-12-29**] 05:40AM BLOOD CK-MB-19* MB Indx-9.5* cTropnT-0.38*
[**2137-12-29**] 01:10PM BLOOD CK-MB-14* MB Indx-8.1* cTropnT-0.25*
[**2137-12-30**] 12:05AM BLOOD CK-MB-7 cTropnT-0.16*
[**2137-12-30**] 05:35AM BLOOD CK-MB-6 cTropnT-0.15*
[**2137-12-31**] 05:30AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2138-1-1**] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2137-12-29**] 05:40AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.3 Iron-71
[**2137-12-29**] 05:40AM BLOOD calTIBC-347 Ferritn-58 TRF-267
Cardiology Report ECG Study Date of [**2137-12-28**] 8:54:32 PM
Sinus rhythm. Left anterior fascicular block. Inferolateral T
wave
abnormalities are non-specific but cannot exclude ischemia.
Since the previous
tracing of [**2137-12-17**] sinus bradycardia is absent. Clinical
correlation is
suggested.
[**12-28**] CXR
IMPRESSION: No evidence of pneumonia. Probable trace right
pleural effusion.
[**12-31**] TTE
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 hypokinesis of the basal inferolateral wall.
The remaining segments contract normally (LVEF = 50 %). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild to moderate ([**12-13**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction c/w CAD. Mild moderate mitral
regurgitation. Mild pulmonary artery systolic hypertension.
CLINICAL IMPLICATIONS:
Based on [**2135**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
..
[**2138-1-1**] CARDIAC CATHETERIZATION:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
one vessel CAD. The LMCA, LAD and LCX had no angiographically
apparent
flow limiting disease. The RCA had a calcified ostial 95% lesion
with
left to right collaterals to the distal RCA.
2. Successful rotational atheretomy, PTCA and stenting of the
ostial
RCA with two overlapping Cypher (3x18mm distal; 3.5x13mm) drug
eluting
stents postdilated distally with a 3.25mm balloon and 3.5mm
balloon
proximally. Final angiography demonstrated no angiographically
apparent
dissection, no residual stenosis and TIMI III flow throughout
the vessel
(See PTCA comments).
3. Successful closure of the right femoral arteriotomy site
with a Mynx
closure device.
4. Limited resting hemodynamics demonstrated systemic arterial
hypertension, with BP of 180/72 mmHg.
5. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful rotational atheretomy, PTCA and stenting of the
ostial RCA
with two overlapping Cypher drug eluting stents.
3. Successful closure of the right femoral arteriotomy site with
a Mynx
closure device.
Brief Hospital Course:
Ms [**Known lastname 80042**] is an 84 year old woman with history of CAD,
systolic heart failure, presenting with complaint of chest pain.
.
# NSTEMI: Patient with complaints of chest pain the day of
admission. She was chest pain free after SL nitro. She ruled
in for NSTEMI with a peak Trop of 0.38. She was started on
heparin and integrelin gtt. She was also given ASA 325, plavix
loaded with 600mg and continued on 75mg daily, and continued her
BB. She remained chest pain free thoughout her admission. She
underwent cardiac cath on [**1-1**] and showed One vessel coronary
artery disease with 95 % occluded proximal RCA. She then
underwent successful rotational atheretomy, PTCA and stenting of
the ostial RCA
with two overlapping Cypher drug eluting stents as well as
successful closure of the right femoral arteriotomy site with a
Mynx closure device. She will plan on long-term Plavix therapy.
.
# CHRONIC SYSTOLIC HEART FAILURE: The patient underwent ECHO on
[**12-31**] and showed an EF 50%. She was continued on her BB and [**Last Name (un) **]
therapy.
.
# HYPERTENSION: Pt with labile blood pressures during her stay.
Her BP would be elevated into SBP 150's later in the evening.
Her valsartan was changed to noon time dosing to improve evening
pressures. Her BP improved with the adjustment. She was
continued on Diltiazem, Isosorbide, Metoprolol, and valsartan.
.
# Diabetes: She is diet controlled. Her AM glucose has been
elevated with a high of 148. She was monitored with QACHS FS and
covered with an ISS. She should have outpatient follow-up
regarding further management.
.
# Glaucoma: She was continued on her outpatient regimen
.
# FEN: Cardiac/ Diabetic diet was continued and her electrolytes
were monitored daily and repleted as needed.
.
# ACCESS: PIV's
.
# PROPHYLAXIS: Heparin drip
.
# CODE: The patient was maintained as a full code status for the
entirety of her hospital course and this was confirmed with
family
.
# CONTACT: [**Name (NI) **]-daughter [**Name (NI) 15139**] ([**Telephone/Fax (1) 80043**] / ([**Telephone/Fax (1) 80044**]
Medications on Admission:
-- Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-- Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
-- Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
-- Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
-- Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
9. Betimol 0.5 % Drops Sig: One (1) Ophthalmic once a day
Discharge Medications:
1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO once a day.
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Ophthalmic Daily
().
5. Polyvinyl Alcohol 1.4 % Drops Sig: [**12-13**] Ophthalmic prn.
6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
NSTEMI
Hypertension
Diet-controlled diabetes
Diastolic Congestive heart failure
Discharge Condition:
stable, chest pain free, ambulating, O2 sat >95% on RA
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of a heart attack.
You underwent cardiac catheterization that showed a blockage of
one of the arteries of your heart and you had a stent placed.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take aspirin 325 mg daily instead of 81 mg daily
2. Please take plavix 75 mg daily. It is very important that
you take this medication every day. Do not stop this medication
until you are told to do so by your cardiologist.
3. You will start taking Toprol XL 150mg daily
4. Your Diltiazem was decreased to 180mg daily
5. You were started on omeprazole 40mg daily
6. You will start Lipitor 80mg daily
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
You have an appointment with your primary care physician [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**1-15**] 4:30. If this is not convenient
you can call and reschedule. The office number is [**Telephone/Fax (1) 589**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2138-2-3**]
2:20
Completed by:[**2138-1-6**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"00.40",
"36.07",
"00.66",
"99.20",
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icd9pcs
|
[
[
[]
]
] |
10807, 10873
|
6745, 8823
|
228, 242
|
11006, 11063
|
2746, 5278
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12212, 12660
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1803, 1863
|
9602, 10784
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10894, 10985
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8849, 9579
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6470, 6722
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11087, 12189
|
1878, 2727
|
5301, 6453
|
178, 190
|
270, 1502
|
1524, 1651
|
1667, 1787
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,478
| 147,259
|
10165
|
Discharge summary
|
report
|
Admission Date: [**2153-12-30**] Discharge Date: [**2154-1-2**]
Date of Birth: [**2084-8-25**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Confusion, Poor PO intake, [**Last Name (un) **], Hyperkalemia, UTI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name13 (STitle) 12101**] is a 69-year-old gentleman with a pmhx. significant
for IDDM, bladder cancer s/p cystectomy with ileal conduit
creation in [**9-3**], COPD, HTN, and hyperlipidemia who presents to
the ED after his daughter found him confused and hallucinating
at home.
.
According to patient, he has felt "not-himself" for the past 3
weeks. During this time, he complains of erratic blood sugars,
increased pain in his back, and worsening infection of his feet.
He has also started falling during this time: the most recent
episode was the day before admission while he was taking
communion. Patient states that when he falls, he doesn't feel
lightheaded or dizzy, but his legs just "give out." He denies
any head trauma with these episodes. According to the patient's
daughter, she is worried that Mr. [**Name13 (STitle) 12101**] isn't taking care of
himself anymore at home. Daughter found patient at home acting
strangely, and called [**Company 191**] to complain of erratic behavior;
daughter was told to bring patient into the ED. Of note,
patient has had multiple admissions for hypoglycemia. However,
his sugars have been running high over the past few days (in the
400s), and he was told by his PCP to increase insulin dosage
from 12 to 15 units/day. He uses a pre-filled pen for
injections.
.
In the ED, initial VS were: 97.4 104 115/53 20 96%. UA was
positive and he was given Cipro 400mg IV x1. Vanc also given for
? cellulitis in lower extremity. His blood sugar was 511 with
anion gap 14, so DKA diagnosed and insulin gtt started. His K+
was 6.6, with peaked T waves on EKG; he was given calcium
gluconate and kayexalate in addition to the insulin gtt. He was
also given 1 liter of normal saline. Upon admission to the
MICU, vitals were: afebrile, BP: 140/74, HR: 69, SP02 100% on
RA. C-collar was removed as no evidence of fracture on CT.
Insulin drip was continued and labs were rechecked.
Past Medical History:
DM - A1c 7% [**2153-11-5**]
Asthma, COPD, smoker - PNA in [**3-3**]
CKD - Cr 1.4
CAD s/p CABG [**2143**], multiple stents to LAD, cath [**2147**], subclavian
bare metal [**Last Name (LF) **], [**First Name3 (LF) **] 56% by MIBI
Hyperlipid
HTN
H/o small stroke 1y ago: right parietal lobe w/ left arm
affected
Obesity
GERD
Anxiety
Chronic back pain
Partial blindness
Invasive bladder Cancer
Social History:
Lives alone. Has 4 children. Works as a cab driver and school
bus driver. Quit smoking >7 years ago after 2ppd x 50 years.
Used to drink alcohol heavily but now sober. Denies illicit
drug use.
Family History:
Mom with heart attack @ 86, Dad HTN and heart attack at 36.
Physical Exam:
Admission exam
Vitals: T: 97 BP: 138/45 P: 69 R: 16 SPO2: 100% on RA
GENERAL: Alert , oriented, no acute distress (but thought that
this [**First Name3 (LF) 766**] was New Year's Day)
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Wheezes on exhale, no dullness or consolidation
Abdomen: soft, non-tender, non-distended, bowel sounds present,
ileal conduit in place, ?puss in bag
GU: no foley
EXT: Erythema bilaterally, no ulcerations
Discharge exam
Pertinent Results:
Admission labs
[**2153-12-30**] 01:40PM BLOOD WBC-9.1 RBC-3.92* Hgb-10.9* Hct-33.8*
MCV-86 MCH-27.7 MCHC-32.1 RDW-16.3* Plt Ct-384
[**2153-12-30**] 01:40PM BLOOD Neuts-86.1* Lymphs-7.7* Monos-5.0 Eos-1.0
Baso-0.3
[**2153-12-30**] 01:40PM BLOOD PT-10.7 PTT-24.9* INR(PT)-1.0
[**2153-12-30**] 01:40PM BLOOD Glucose-511* UreaN-89* Creat-2.5* Na-125*
K-6.6* Cl-98 HCO3-13* AnGap-21*
[**2153-12-30**] 01:40PM BLOOD ALT-14 AST-9 LD(LDH)-147 AlkPhos-157*
TotBili-0.2
[**2153-12-30**] 06:00PM BLOOD CK-MB-3 cTropnT-0.02*
[**2153-12-30**] 01:40PM BLOOD Albumin-3.6 Calcium-9.4 Phos-3.7 Mg-1.8
[**2153-12-30**] 06:00PM BLOOD VitB12-385 Folate-10.9
[**2153-12-30**] 06:00PM BLOOD TSH-0.92
[**2153-12-30**] 01:40PM BLOOD ASA-NEG Acetmnp-NEG
[**2153-12-30**] 02:01PM BLOOD Glucose-494* Lactate-2.2* Na-127* K-6.0*
Cl-101 calHCO3-16*
.
Discharge labs
[**2154-1-1**] 06:20AM BLOOD WBC-6.2 RBC-3.57* Hgb-10.0* Hct-30.4*
MCV-85 MCH-28.0 MCHC-32.8 RDW-16.7* Plt Ct-316
[**2154-1-2**] 06:20AM BLOOD Glucose-128* UreaN-42* Creat-1.6* Na-133
K-5.0 Cl-105 HCO3-18* AnGap-15
[**2154-1-2**] 06:20AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.8
.
URINE STUDIES
[**2153-12-30**] 03:00PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2153-12-30**] 03:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2153-12-30**] 03:00PM URINE RBC-11* WBC-127* Bacteri-FEW Yeast-FEW
Epi-<1
[**2153-12-30**] 03:49PM URINE Hours-RANDOM UreaN-459 Creat-82 Na-34
K-29 Cl-10
[**2153-12-30**] 03:49PM URINE Osmolal-356
.
MICROBIOLOGY
[**2153-12-30**] Blood cultures pending x 2- No growth to date
.
URINE CULTURE (Final [**2153-12-31**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
.
EKG
The underlying rhythm is likely sinus with intra-atrial
conduction abnormality. Low QRS voltage in the limb leads.
Compared to the previous tracing of [**2153-12-30**] R wave progression
has improved in the precordial leads and the rate is faster
.
HEAD CT WITHOUT INTRAVENOUS CONTRAST: No intra- or extra-axial
hemorrhage, mass effect, or shift of midline structures is
demonstrated. Confluent periventricular and subcortical white
matter hypodensities are again demonstrated in the cerebral
hemispheres bilaterally most likely compatible with chronic
microvascular infarction. Punctate hypodensities within the
basal ganglia bilaterally likely reflect chronic lacunar
infarcts as well as within the right caudate head. Widening of
the ventricles and sulci bilaterally is compatible with
age-appropriate involutional change. Opacification of the right
mastoid air cells suggests an ongoing inflammatory process.
Minimal opacification of an inferior mastoid air cell on the
left is also noted. The paranasal sinuses are clear. Surrounding
osseous and soft tissue structures are otherwise unremarkable.
IMPRESSION: No acute intracranial hemorrhage or mass effect.
.
CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: No
fracture, change in alignment, or prevertebral soft tissue
swelling is demonstrated. There are multilevel degenerative
changes identified, worst at C6/7 where posterior osteophyte
results in moderate canal narrowing. There is bilateral moderate
to severe neural foraminal narrowing present at this level as
well. Mild grade 1 retrolisthesis of C5 on C6 is unchanged.
Ossification of the nuchal ligament is noted posterior to C6.
Carotid vascular calcifications are most pronounced at the
bifurcations bilaterally. Surrounding soft tissue structures
otherwise are unremarkable. A vascular [**Date Range **] is noted within the
proximal right subclavian artery, and is partially imaged.
Severe emphysematous changes are noted within the lung apices.
Ossification of the right mastoid air cell suggests ongoing
inflammation.
.
IMPRESSION: No acute fracture or subluxation. Moderate cervical
spondylosis, worst at C6/7 with moderate central canal narrowing
and moderate to severe bilateral neural foraminal narrowing.
Emphysema within the lung apices.
.
PA AND LATERAL VIEWS OF THE CHEST: Patient is status post median
sternotomy and CABG. Vascular [**Date Range **] is noted within the right
subclavian artery. Heart size is normal. Coronary arterial
vascular [**Date Range **] is also demonstrated. The mediastinal and hilar
contours are unchanged. The pulmonary vascularity is normal.
There is hyperinflation of the lungs with attenuation of the
pulmonary vascular markings towards the apices, compatible with
emphysema. Minimal interstitial opacities are seen predominantly
within the lung bases, likely reflecting chronic changes. No
focal consolidation, pleural effusion or pneumothorax is
present. There are mild degenerative changes of the thoracic
spine. Degenerative spurring is also noted within the right
acromioclavicular joint.
IMPRESSION: Emphysema with chronic interstitial changes, but no
evidence for pneumonia or congestive heart failure.
Brief Hospital Course:
Mr [**Known lastname 12100**] is a 69-year-old gentleman with a past medical history
of of IDDM, CAD s/p CABG, CVA, HTN, HL, invasive bladder CA s/p
cystectomy, and CKD, who presents with anion gap, falls,
confusion, poor PO intake, [**Last Name (un) **], Hyperkalemia, and UTI.
.
# ANION GAP: Patient with anion gap of 15 in the setting of
elevated blood sugar and lactate of 2.2. No ketones in urine to
suggest overt DKA. Likely combination of dehydration and renal
failure. He has had substantial N/V for abotu 1 week. He was
briefly in the MICU after admission. Gap closed quickly with
fluid and insulin (only 2units/hour on drip). Lactate trended
down to normal quickly with IVF. He was called out to the floor
where he continued to do well and was ultimately discharged to a
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] on [**2154-1-2**].
.
# HYPERGLYCEMIA: Potentially HONK, with precipitant being
possible infection (cellulitis), dehydration and renal failure
(patient unable to excrete glucose). Patient is an elderly type
II diabetic, presenting with dehydration and change in mental
status. He improved with minimal insulin (per above), and mostly
with IVF. He was initially restarted on his home dose of
insulin. [**Last Name (un) **] was consulted and recommended decreasing lantus
to 8 units at night and intiating a humalog sliding scale with
meals and at bed time. Blood glucose control improved and FSG
were in the 100-200s at the time of discharge. The patient will
follow-up with [**Last Name (un) **] Diabetes Center as an outpatient.
Underlying infection was treated per below.
.
# CONFUSION: Likely a combination of infection, dehydration,
and hyperglycemia superimposed on ?more chronic memory decline.
Head CT unrevealing, but only prelim report. Underlying issues
were treated per respective paragraphs. TSH, B12, and folate
were checked and were normal. Mental status improved with
correction of acidosis and hydration. The patient may benefit
from neurocognitive testing as an outpatient to evaluate for
underlying dementia.
.
# HYPERKALEMIA: Likely secondary to [**Last Name (un) **] and acidosis. EKG with
peaked T's on admission, given calcium gluconate, kayexalate,
and insulin drip. K+ lowered to 5.0 in MICU. Losartan was held.
On the floor potassium remained stable at around 5.0. Losartan
was restarted at the time of discharge.
.
# UTI: On admission, urine with blood, leuks, and WBC clumps.
Evidence of pus in urine bag. Last urine culture with
klebsiella sensitive to ciprofloxacin. It was unclear if this
was represntative of a true UTI as the patient has an iliostomy
especially as urine culture showed mixed bacterial flora. He was
started bactrim 7 day course as below.
.
# CELLULITIS: Patient with bilateral erythema of his feet. No
evidence of blisters or pustules that would suggest a MRSA
infection. Patient was given a dose of vancomycin in the ED. He
was initally strated on bactrim/keflex and then narrowed to
bactrim alone for a planned 7 day course (3 more days). Erythema
and pain were noted to improve. The patient was afebrile with a
noraml white blood cell count throughout this admission.
.
# ACUTE ON CHRONIC RENAL FAILURE: Likely pre-renal in setting
of severe volume depletion secondary to DKA. Urine lytes show
FeNA of 0.8%. He was given IVF and with improvement in his
creatinine
.
# FREQUENT FALLS: Likely reflective of mechanical instability
exacerbated in the setting of dehydration. History was not
consistent with a syncopal event, there was no nausea,
lightheadedness to suggest vaso-vagal episode. Troponin were
negative. There were no signs of arrythmia on tele. The
development of falls coincides with patient's overall decline
since [**Month (only) 216**]. The patient was evaluated by PT who recommended
acute rehab as above.
.
# Non gap acidosis: Patient contined to have persistently low
bicarb despite correction of hyperglycemia and gap acidosis.
This was felt to be possibly resultant from iliostomy, although
worsening of renal function may also be contributing.
Bicarbonate was noted to increase over the course of the
admission
.
# HTN: The patients home losartan was held in setting of
hyperkalemia. He was continued on his home metoprolol succinate
50mg daily at home.
.
# COPD/ASTHMA: Continued home Advair, albuterol, ipratropium
.
# CAD: Continued home ASA, plavix, simvastatin.
.
# DEPRESSION: Continued home citalopram.
.
# GERD: Continued ranitadine, renally dosed.
.
# BACK PAIN: Continued tylenol, oxycodone
===============================
Transitional issues
- Blood culures were pending at the time of discharge
- Patient was full code throughout this admission
- Patient will follow-up with [**Last Name (un) **] regarding management of his
insulin regimen
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs(s) inhaled every four (4) hours
CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth once a day for
depressed
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].
[**First Name (STitle) **] - 75 mg Tablet - 1 Tablet(s) by mouth once a day
currently not taking -- last dose of plavix [**2153-4-23**].
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 (One) puff inhaled twice a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth qam as needed
for for edema
INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin
Pen - 12 units once a day
IPRATROPIUM-ALBUTEROL - 0.5 mg-2.5 mg/3 mL Solution for
Nebulization - 3 cc q4 as needed for shortness of breatth use
with nebulizer
LACTULOSE [CONSTULOSE] - 10 gram/15 mL Solution - 15 ml by mouth
once a day as needed for for constipation
LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
(One) Tablet(s) by mouth once a day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 sublingually as
needed for chest pain
OXAZEPAM - 10 mg Capsule - 1 Capsule(s) by mouth once a day as
needed for anxiety
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 or 2 Tablet(s)
by mouth q4 as needed for back pain do not exceed 8 tablets in
one day
RANITIDINE HCL - 150 mg Capsule - 1 (One) Capsule(s) by mouth
twice a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by
mouth Daily
UREA - 40 % Cream - apply twice a day
Medications - OTC
ASPIRIN - (OTC; Dose adjustment - no new Rx) - 81 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - use
as
directed to test blood sugar
BLOOD-GLUCOSE METER [FREESTYLE LITE METER] - Kit - use as
directed to check blood sugar up to three times a day.
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by
mouth once a day
INSULIN NEEDLES (DISPOSABLE) [PEN NEEDLE] - 29 gauge X [**12-24**]"
Needle - use as directed qd
LANCETS [LANCETS,THIN] - Misc - use as directed three times a
day
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
9. urea 40 % Cream Sig: One (1) application Topical twice a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
12. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) nebulizer Inhalation every six (6)
hours as needed for shortness of breath or wheezing.
13. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15)
mL PO once a day as needed for constipation.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. insulin glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
17. Humalog 100 unit/mL Solution Sig: see below Subcutaneous
four times a day: see sliding scale .
18. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for back pain: hold for RR < 12.
19. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
20. oxazepam 10 mg Capsule Sig: One (1) Capsule PO once a day as
needed for anxiety.
21. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual As Needed as needed for chest pain.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] at [**Location (un) 1821**] for Nursing and Rehab
Discharge Diagnosis:
Primary Diagnosis
Hyperglycemia
Dehydration
Cellulitis
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted due to confusion. This was most likely caused
by several factors including high blood sugar, dehydration, and
pain medications. You were given fluids and insulin and your
mental status improved. The diabetes doctors started [**Name5 (PTitle) **] on
insulin with your meals which you will need to continue. You
will need to follow up at [**Last Name (un) **] Diabetes Center. You were seen
by our physical therapist who felt you would benefit from
inpatient rehab. You were therefore discharged to a rehab
facility
We made the following changes to your medications
1. START humalog insulin according to sliding scale
2. DECREASE lantus to 8 units at night
3. HOLD losartan until instructed to restart this medication by
Dr. [**First Name (STitle) **]
4. START Bactrim for 3 more days
You should continue to take all other mediations as instructed.
Please feel
Followup Instructions:
[**Last Name (un) **] Diabetes Center and [**Hospital **] Clinic
One [**Last Name (un) **] Place
[**Location (un) 86**], [**Numeric Identifier 718**]
([**Telephone/Fax (1) 3258**]
[**1-28**] at 2pm with Dr. [**Last Name (STitle) 33928**]
Please call [**Company 191**] at [**Telephone/Fax (1) 250**] to make an appointment to see
Dr. [**First Name (STitle) **] with 1-2 weeks of discharge from rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
|
[
"338.29",
"682.7",
"585.9",
"041.3",
"298.9",
"V44.2",
"250.12",
"V10.51",
"599.0",
"403.90",
"278.00",
"276.7",
"272.4",
"584.9",
"V45.89",
"493.20",
"305.1",
"724.5",
"530.81",
"349.82",
"276.51",
"300.4",
"369.00",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17845, 17991
|
8586, 13384
|
340, 347
|
18099, 18099
|
3625, 8563
|
19328, 19860
|
2951, 3013
|
15660, 17822
|
18012, 18078
|
13410, 15637
|
18250, 19305
|
3028, 3606
|
232, 302
|
375, 2309
|
18114, 18226
|
2331, 2723
|
2739, 2935
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,806
| 176,469
|
27139
|
Discharge summary
|
report
|
Admission Date: [**2150-4-13**] Discharge Date: [**2150-4-17**]
Date of Birth: [**2114-7-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
35 year old gentleman with h/o marfan's disease s/p bentall with
mechanical AVR and MVR in [**2143**]. He had a residual chronic
dissection from the end of the graft to his renal arteries. Seen
by Dr. [**Last Name (STitle) **] complaining of a 2 day history of back pain. As it
was uncertain if this pain was related to his spine disc
compression or his dissection. He was thus referred to the [**Hospital1 18**]
for work-up.
Past Medical History:
Marfan's Syndrome
Wrist surgery
Appendectomy
HTN
MV repair [**2140**] Minimally invasive
[**Last Name (LF) 66608**], [**First Name3 (LF) **]. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 66609**] CABGx1 [**2143**]
AAA Repair [**2142**]
Social History:
Lives with wife. Does not smoke.
Family History:
None
Physical Exam:
BP 146/74 HR 66 Wt 235
GEN: NAD
HEENT: Benign
NECK: Supple, FROM
LUNGS: Clear
HEART: RRR, I/VI SEM
ABD: Benign
EXT: Warm, well perfused no edema
NEURO: Nonfocal
Pertinent Results:
[**2150-4-13**] 06:05PM URINE RBC-0 WBC-[**5-23**]* BACTERIA-FEW YEAST-NONE
EPI-0
[**2150-4-13**] 06:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2150-4-13**] 06:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.047*
[**2150-4-13**] 06:05PM PT-30.9* PTT-33.9 INR(PT)-3.3*
[**2150-4-13**] 06:05PM PLT COUNT-104*
[**2150-4-13**] 06:05PM NEUTS-61.7 LYMPHS-31.0 MONOS-5.7 EOS-1.0
BASOS-0.5
[**2150-4-13**] 06:05PM WBC-8.5 RBC-4.29* HGB-12.5* HCT-36.5* MCV-85
MCH-29.3 MCHC-34.3 RDW-13.3
[**2150-4-13**] 06:05PM GLUCOSE-88 UREA N-8 CREAT-0.7 SODIUM-138
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2150-4-14**] CT Scan
1. Status post thoracic aorta repair, with persisting extensive
type A aortic dissection extending superiorly into the
brachiocephalic artery and extending inferiorly to the level of
the common iliac arteries, the most inferior aspect imaged on
this study.
2. All of the abdominal arterial branches with the exception of
the right renal artery are fed by the true lumen and are patent
without occlusion or dissection. No evidence of organ
infarction.
3. Status post aortic valve replacement.
4. Cholelithiasis without evidence of cholecystitis.
5. Suboptimal opacification of the coronary arteries which
appear patent on the source images. An addendum will be added
after 3D volume and MIP reconstructions are available.
[**2150-4-16**] Spine MRI
MRI OF THE CERVICAL SPINE:
The sagittal T2- and STIR-weighted sequences are limited by
patient motion. They suggest abnormal cord signal throughout the
cervical and upper thoracic spine. Axial gradient echo and
T2-weighted sequences, however, do not confirm this and I
suspect this represents artifact. There is no evidence of a
focal disc protrusion. There is no evidence of canal stenosis or
foraminal stenosis on the axial images. There is no evidence of
abnormality at the level of the foramen magnum. There is a small
central disc protrusion at T3-4 only visualized on the sagittal
images.
IMPRESSION: Somewhat limited study. See above comment regarding
the appearance of the cervical cord. No definite evidence of
cervical disc protrusion. Small disc protrusion at T3-4.
MRI OF THE THORACIC SPINE:
Once again the T2-weighted sequences and the STIR sequences are
limited by patient motion. There is a small central disc
protrusion at T3-4 not significantly encroaching upon the
thoracic cord. There is no definite evidence of high-grade canal
stenosis.
IMPRESSION: Somewhat limited study. Focal disc protrusion at
T3-4.
[**2150-4-15**] MRI Lumbar Spine
Somewhat limited study. Appearance of the thecal sac raising the
question of dural ectasia. Small focal disk protrusion at L5-S1
with features as discussed above. Mild degenerative disease with
retrolisthesis at L2-L3 attributable to posterior facet
degenerative disease. Reverse spondylolisthesis is not
ordinarily seen in spondylolysis.
Brief Hospital Course:
Mr. [**Known lastname 66610**] was admitted to the [**Hospital1 18**] on [**2150-4-13**] for further
evaluation of his back pain. He was evaluated by the cardiac
surgical service and vascular surgery service. A CT scan was
obtained which showed a persisting extensive type A aortic
dissection extending superiorly into the brachiocephalic artery
and extending inferiorly to the level of the common iliac
arteries. All of the abdominal arterial branches with the
exception of the right renal artery are fed by the true lumen
and are patent without occlusion or dissection. There was no
evidence of organ infarction. Tight blood pressure control was
performed. The orthopedic service was consulted for evaluation
of his back pain. An MRI was performed which showed a normal
cervical spine, a focal disc protrusion at T3-4 and an atypical
appearance of the thecal sac which raised the question of dural
ectasia, a small focal disk protrusion at L5-S1, mild
degenerative disease with retrolisthesis at L2-L3 attributable
to posterior facet degenerative disease. His pain was controlled
with oxycodone and percocet. Coumadin was continued as per pre
admission without any changes. Given that there was no
significant urgent change in his dissection, Mr. [**Known lastname 66610**] was
discharged home on [**2150-4-17**]. He will follow-up with Dr. [**Last Name (STitle) 914**]
and Dr. [**First Name (STitle) **] within 1 month. He will follow-up with Dr. [**Last Name (STitle) 363**]
of orthopedics in 1 week. He will also follow-up with his
primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2150-4-20**] for continued coumadin
management. No changes were made to his coumadin dosing and he
remains on his prior dose of 5mg daily except for Wednesday and
Sundays where he takes 10mg. Perscriptions were given to Mr.
[**Known lastname 66610**] for all medications that changed while in house.
Medications on Admission:
Labetolol
Lisinopril
Coumadin
Noorvasc
Acupril
Discharge Medications:
1. Quinapril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while taking narcotics to prevent
constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
8. Warfarin 1 mg Tablet Sig: 5mg once daily except Wednesday and
Sunday when you will take 10mg Tablets PO DAILY (Daily): As
instructed by your physician.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*1*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Marfan's Disease
Chronic back pain
AAA repair [**2142**]
[**Year (4 digits) 66608**] with AVR/MVR [**2143**]
Residual aneurysm (graft to renal vessels
Discharge Condition:
Stable
Discharge Instructions:
1) Resume coumadin dosing and management as per prior to
admission. (5mg daily except Wednesday and Sunday when you take
10mg). Please have your PT/INR checked with Dr. [**Last Name (STitle) **] on Monday
[**2150-4-20**] to assess any changes that may need to made to your
coumadin dosing.
2) Medication perscriptions will be provided for all medications
that have changed. Continue taking the listed discharge
medications as instructed. Please call primary care provider for
refills.
3) Keep all appointments.
4) Monitor at home blood pressure.
5) Call with any questions or concerns.
Followup Instructions:
Follow-up with orthopedic surgeon Dr. [**Last Name (STitle) 363**] in 1 week. ([**Telephone/Fax (1) 18552**]. Please call to arrange appointment.
Follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. This will be arranged and
you will be called with appointment date.
Follow-up with Dr. [**First Name (STitle) **] at [**Hospital3 1810**] within 1 month.
This will be arranged and you will be called with appointment.
Resume care with Dr. [**Last Name (STitle) **] for coumadin management. Please see
[**2150-4-20**] for coumadin management.
Completed by:[**2150-4-17**]
|
[
"401.9",
"759.82",
"V45.81",
"724.5",
"441.02",
"V58.61",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7572, 7578
|
4338, 6264
|
330, 337
|
7773, 7782
|
1339, 4315
|
8416, 8994
|
1137, 1143
|
6361, 7549
|
7599, 7752
|
6290, 6338
|
7806, 8393
|
1158, 1320
|
281, 292
|
365, 792
|
814, 1071
|
1087, 1121
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,982
| 192,746
|
3212
|
Discharge summary
|
report
|
Admission Date: [**2139-4-13**] Discharge Date: [**2139-5-29**]
Date of Birth: [**2069-8-5**] Sex: F
Service: MEDICINE
Allergies:
Captopril / Neurontin / Shellfish / Nsaids / Promethazine /
Valproate Sodium
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
SOB, cough, fevers
Major Surgical or Invasive Procedure:
Intubation
Mechanical Ventilation
CVL placement
PICC placement
History of Present Illness:
69 y.o. female with COPD, CHF, DM2, GERD/esophagitis, who was
admitted initially on [**4-13**] for cough, SOB, and fever. She was
diagnosed with flu/MRSA pneumonia and underlying COPD flare and
treated appropriately with tamiflu, antibiotics, and steroids.
However, on [**4-16**] she was transferred to the MICU for increasing
respiratory distress. Her symptoms gradually improved with
supportive care and was transferred back to the medical floor on
[**4-20**]. However, the patient next had persistent hypoglemia to the
70s with associated mental status changes requiring D50 and
D5NS. Because of difficult to control blood sugars, he was
transferred back to the MICU.
.
Then, on [**4-22**], she was noted to have lower quadrant pain. She
underwent CT scan demonstrating a significant abdominal wall
rectus sheath hematoma on the left side, 12x5cm. Her Hct dropped
from 35.1 to 19.1, requiring 14 units PRBCs, 12 units plasma,
and 1 cryo, possibly due to punctured epigastric vein. IR/Vasc
surgery was consulted and she underwent angio embolization of
the L inferior epigastric vein with insicion and hematoma
evacuation x2 followed by VAC. She was taken by the SICU service
and was intubated. During her course on the surgical services
she had received 24u PRBC, 13FFP, 5 plts, 1 cryo. She then had
low grade fevers with spikes to 101, growing pseudomonas from
her sputum and urine. Her CVL was changed on [**5-11**] and she
underwent trach placement for persistent need for ventilator
support. She was started on meropenem on [**5-12**] for the pseudomonal
infection. Lastly, she developed acute renal failure with
baseline Cr 1.5-1.7 increasing to 2.3->2.7 with FENa of 1.3%.
Patient has since been monitored for the aforementioned medical
problems during her course in the ICU until discharge.
Past Medical History:
DM2
GERD
h/o esophagitis (ischemic vs fungal) in post op setting
COPD (on home 02 at night, FEV1 in [**2133**] of 32% predicted)
OSA, cannot tolerate CPAP.
Depression
HTN
s/p TAH
s/p PE in [**2135**], with IVC filter, not anticoagulated after
developed abdominal wall hematoma
Focal seizures
Diastolic CHF, ECHO [**6-17**] EF >55%, mild pulm artery hypertension
OA
s/p CVA x 2 with right facial droop
CKD
s/p right tibial stress fracture
Social History:
Retired seamstress, waitress. Living in [**Month/Year (2) 15049**] house [**Hospital 4382**] facility. Daughter [**Name (NI) **] is HCP, incidentally pt's other
daughter is also hospitalized on [**Hospital Ward Name **] for complications
of her recently diagnosed APML. Pt was a former smoker, 3ppd x
30 years, quit in [**2128**], per the records pt has a distant history
of ETOH abuse ([**2091**]), denies current drinking, denies illicit
drug use. Many sick contacts at [**Name (NI) 15049**] house
Family History:
Malignancy (pancreas, larynx), CAD, HTN, DM, asthma;
daughter recently diagnosed with leukemia
Physical Exam:
Vitals: T:99.1 BP:160/80 P:120 R:24 SaO2:99%2L
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated.
? lipodystrophy. + right shoulder lipoma.
Pulmonary: Significant wheezing in all lung fields, prolongation
of respiratory phase.
Cardiac: Tachycardic, regular, nl S1 S2, no murmurs, rubs or
gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted. large midline scar, well healed.
Extremities: No edema, 2+ radial, DP pulses b/l. Tender to
palpation on right.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty.
Pertinent Results:
ADMISSION LABS:
===============
[**2139-4-13**] 06:40AM PLT SMR-NORMAL PLT COUNT-274#
[**2139-4-13**] 06:40AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
[**2139-4-13**] 06:40AM NEUTS-83.4* BANDS-0 LYMPHS-12.4* MONOS-3.1
EOS-0.7 BASOS-0.4
[**2139-4-13**] 06:40AM WBC-8.4 RBC-4.04* HGB-11.0* HCT-35.1* MCV-87
MCH-27.4 MCHC-31.4 RDW-16.7*
[**2139-4-13**] 06:40AM cTropnT-0.07*
[**2139-4-13**] 06:49AM LACTATE-1.8
[**2139-4-13**] 06:49AM COMMENTS-GREEN TOP
[**2139-4-13**] 08:00AM CK-MB-7 proBNP-202
[**2139-4-13**] 08:00AM cTropnT-0.08*
[**2139-4-13**] 08:00AM CK(CPK)-231*
[**2139-4-13**] 08:00AM estGFR-Using this
[**2139-4-13**] 08:00AM GLUCOSE-118* UREA N-30* CREAT-1.6*
SODIUM-146* POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-32 ANION GAP-17
[**2139-4-13**] 08:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2139-4-13**] 08:30AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2139-4-13**] 08:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2139-4-13**] 08:30AM URINE UHOLD-HOLD
[**2139-4-13**] 08:30AM URINE HOURS-RANDOM
[**2139-4-13**] 10:55PM CK-MB-6 cTropnT-0.04*
[**2139-4-13**] 10:55PM CK(CPK)-159*
STUDIES:
=========
CT Abdomen ([**4-22**]):
IMPRESSION: Large hemorrhage into the subcutaneous fat of the
left lower abdomen/back. The largest collection in the left
lower abdominal wall measures 12.5 x 5.3 cm and is virtually
unchanged in dimensions when compared to the ultrasound
examination performed eight hours earlier at the same day. Of
note, there is an extension of the hematoma around the left
flank into the left lower back. The superior margin of this
posterior collection is not completely included in the study.
The hemorrhage may have been caused by puncture of a superficial
vessel, such as the superficial epigastric vein, during s.q.
heparin injection.
.
MICROBIOLOGY:
=============
[**2139-5-24**] 2:15 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2139-5-24**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. SPARSE
GROWTH.
sensitivity testing performed by Microscan.
GRAM NEGATIVE ROD #3. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| NON-FERMENTER, NOT
PSEUDOMONAS AERUGIN
| |
AMIKACIN-------------- 8 S =>64 R
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S =>16 R
CEFTRIAXONE----------- =>32 R
CIPROFLOXACIN--------- =>4 R =>2 R
GENTAMICIN------------ =>16 R =>8 R
IMIPENEM-------------- =>8 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 4 S 8 I
PIPERACILLIN---------- R =>64 R
PIPERACILLIN/TAZO----- <=4 S =>64 R
TOBRAMYCIN------------ =>16 R =>8 R
TRIMETHOPRIM/SULFA---- =>2 R
.
[**2139-5-20**] 3:21 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2139-5-20**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2139-5-25**]):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. MODERATE
GROWTH.
sensitivity testing performed by Microscan.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| NON-FERMENTER, NOT
PSEUDOMONAS AERUGIN
| | PSEUDOMONAS
AERUGINOSA
| | |
AMIKACIN-------------- 8 S 4 S
CEFEPIME-------------- 8 S 16 I =>64 R
CEFTAZIDIME----------- 4 S 16 I =>64 R
CEFTRIAXONE----------- =>32 R
CIPROFLOXACIN--------- =>4 R =>2 R =>4 R
GENTAMICIN------------ =>16 R =>8 R =>16 R
IMIPENEM-------------- =>8 R
LEVOFLOXACIN---------- R
MEROPENEM------------- 4 S 8 I 4 S
PIPERACILLIN---------- <=4 S 64 I =>128 R
PIPERACILLIN/TAZO----- <=4 S 64 I =>128 R
TOBRAMYCIN------------ =>16 R =>8 R 8 I
TRIMETHOPRIM/SULFA---- R
FUNGAL CULTURE (Preliminary):
ASPERGILLUS FUMIGATUS.
.
[**2139-5-11**] 2:45 pm URINE Source: Catheter.
**FINAL REPORT [**2139-5-13**]**
URINE CULTURE (Final [**2139-5-13**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
.
[**2139-5-2**] 7:53 pm CATHETER TIP-IV Source: R rad art line.
**FINAL REPORT [**2139-5-6**]**
WOUND CULTURE (Final [**2139-5-6**]):
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
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
.
[**2139-4-27**] 4:30 pm TISSUE LEFT FLANK SKIN.
**FINAL REPORT [**2139-5-1**]**
GRAM STAIN (Final [**2139-4-27**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
REPORTED BY PHONE TO [**Doctor First Name **] LIMA CC5B 19:35 [**2139-4-27**].
TISSUE (Final [**2139-4-30**]):
ENTEROCOCCUS SP.. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2139-5-1**]): NO ANAEROBES ISOLATED.
.
[**2139-4-16**] 4:59 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2139-4-18**]**
GRAM STAIN (Final [**2139-4-16**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2139-4-18**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. HEAVY GROWTH.
Please contact the Microbiology Laboratory ([**8-/2437**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
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.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
Blood cultures are all negative or show no growth to date.
.
Stool cultures have all been negative.
Brief Hospital Course:
69 F with COPD/CHF, DM2, admitted with COPD/flu/PNA, s/p rectus
sheath hematoma and bleed s/p epigastric vein embolization,
intubation and trach, with psuedomonal UTI/PNA also with
worsening [**Hospital **] transferred to the MICU for further care. The
following issues were investigated during this hospitalization:
.
#Respiratory Failure: Multifactorial in etiology including
flu/PNA, chronic COPD, potential component of edema. s/p trach
on [**5-11**]. Patient was started on a trial off the vent on [**5-25**]
which she has continued to tolerate well. She has completed
treatment for PNAs. Of note, she was found to have aspergillus
in her sputum, but CT chest was unremarkable and clinical exam
was improving. Thus, treatment was deferred. She may need
continued Lasix PRN for diuresis.
.
#Acute Renal Failure: Likely ATN from hypotension. Patient
received two sessions of HD and has since been voiding to Lasix
with improvement of BUN/creatinine.
.
#UTI: Positive for pseudomonas. Fully-treated with Meropenem.
.
#Hematoma: s/p embolization. Hct has remained stable in mid 20s.
HD stable. Patient is also s/p debridement of wound given poor
healing. Vac dressing in place with dressing changes every 3
days.
.
#Eye twitiching: Patient has a history of seizure disorder and
given eye twitching without other explanation, EEG was obtained
which showed no epiliteform changes, but did show toxic
metabolic encephalopathy, which has been attributed to the
patient's multiple co-morbidities. No further work-up was
pursued.
.
#Thrombocytopenia: Brief period of thrombocytopenia thought to
be due to medications. HIT antibody was negative and platelet
count has since rebounded. No further issues.
.
#COPD: Patient was continued on nebulizers as well as
Prednisone, which was gradually tapered down with goal of
reaching a lower, maintenance dose (previously on 20 mg).
.
#HTN: Patient was maintained on Diltiazem, but given increasing
blood pressure, Hydralazine and Metoprolol were added with
better control. Ace-inhibitor was held given renal failure.
.
#DM2: Monitored with figersticks and Humalog Insulin sliding
scale and standing NPH.
.
# Kidney Lesions: New lesion found on R kidney appears enlarged
and worrisome for RCC. Will need further imaging for
reevaluation once stable vs. outpatient
.
#FEN: Continue tube feeds
Medications on Admission:
albuterol
amlodipine 10 daily
atorvastatin 20
Diltiazem XR 180
Fluticasone 1-2puffs 50mcg daily
Home 02, 2L NC at night
Atrovent
MVI
Reglan with meals
Nortriptyline 50 QHS
Oseltamavir (started [**4-9**]) 75mg [**Hospital1 **]
Nystatin Oral suspension
Trileptal 300 [**Hospital1 **]
Percocet [**2-11**] QID
Protonix 40 daily
KCL 20mg daily
Sucralfate 1g QID
ASA 81 daily
colace
predinsone 20
70/30 NPH/humolog (35 QAM, 5QPM)
Senna
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-11**]
Drops Ophthalmic PRN (as needed).
3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q4H (every 4 hours).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
Q4H (every 4 hours).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
11. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
12. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY
(Daily).
13. Oxcarbazepine 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
14. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
15. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
16. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
Continue very slow steroid taper, decreasing by 2.5 mg every
week. Start 15 mg on [**5-29**] and continue decreasing by 2.5 mg
every Friday, to off, as tolerated. .
17. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
18. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) for 10 days.
19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
20. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
21. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
22. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
23. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
24. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: One (1)
Injection Q4H (every 4 hours) as needed for breakthrough pain.
25. Insulin Sliding Scale
Continue your Insulin regimen, per the sliding scale included.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
Flu
MRSA PNA
Rectus Sheath Hematoma
Pseudomonas PNA
Pseudomonas UTI
Renal Failure
.
Secondary
DM2
GERD
Esophagitis
COPD
OSA
Depression
HTN
s/p TAH
History of PE w/ IVC filter
Focal seizures
Diastolic CHF
OA
s/p CVA x 2 with right facial droop
CKD
Discharge Condition:
Stable.
Discharge Instructions:
You were seen and evaluated for the flu and a pneumonia, both of
which were appropriately treated. Your hospital course was then
complicated by a large hematoma (blood collection) in your leg,
which was repaired surgically. During the course of surgical
repair and recuperation, you had breathing difficulty, which was
felt to be due to a new pneumonia. Ultimately, you had to
receive a tracheostomy to assist with your breathing and you
have continued to be monitored for your breathing status, kidney
function and hematoma. You have improved a great deal, though
you need continued therapy and rehabilitation. You are now being
discharged to [**Hospital3 7**], where you can continue to be
cared for.
Take all of your medications as directed.
Keep all of your follow-up appointments.
Call your doctor or go to the ER for any of the following: chest
pain, shortness of breath, fevers/chills, nausea/vomiting,
worsening pain or swelling in your leg, decreased urinary output
or any other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2139-7-3**] 10:30
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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4,292
| 176,904
|
1440
|
Discharge summary
|
report
|
Admission Date: [**2125-11-1**] Discharge Date: [**2125-11-9**]
Date of Birth: [**2054-1-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Metoprolol
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Left hip fracture
Major Surgical or Invasive Procedure:
Open Reduction Internal Fixation of Left Femoral Neck Fracture
History of Present Illness:
HPI: Briefly, this is a 71 yo M with a history of CAD s/p
CABGx4, vascular dementia, ESRD on HD, prior TIAs, and recent
postive stress test, who was transferred to [**Hospital1 18**] after
sustaining a L femoral neck fx after a mechanical fall. ED
workup normal except for hip fx and EKG showing sinus brady with
first degree AV block and inferolateral abnormalities.
Intention for OR to fix hip, but in light of recent stress
results demonstrating reversible inferolateral changes, needs
clearance from cardiac standpoint before OR.
.
This morning, he complains of [**5-10**] pain in his left hip and some
minor discomfort in his lower back. Otherwise, he feels well,
and denies CP and SOB.
.
Review of systems:
(+) Per HPI, + orthopnea (2 pillows, 6-8 months), + chronic LBP
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations, PND, peripheral edema. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
-CAD s/p CABG, [**2114**])
-Positive stress test for reversible defects in lateral and
posterolateral walls, [**2125-10-5**]
-LV Diastolic Dysfunction
-HTN, labile
-Hyperlipidemia
-ESRD, on HD since [**2122**], MWF
-Anemia, secondary to ESRD, baseline hematocrit low 30s
-Hypertensive Encephalopathy
-Vascular Dementia
-Subcortical WMD w/ Brain atrophy
-Sleep apnea
-Osteoarthritis
-Spinal Stenosis
-Peripheral Neuropathy
-Depression
-GERD
-BPH
-Nephrolithiasis
Social History:
-Married with one son, one daughter
-Lives with wife in [**Name (NI) **]
-Independent in ADLs, including ambulation
-Tobacco: quit smoking 20 years ago, smoked approx 3
cigarettes/day for 20-30 years.
-Alcohol: none
-Illicits: none
Family History:
His mother died of a stroke at age 87, dad had brain surgery for
a tumor and died as a result of it. One sister has [**Name2 (NI) 8381**]
disease at 71, and one sister had a massive MI and passed away
in her 60's.
Physical Exam:
Admission Exam:
Vitals: T 97.7 BP 131/92 HR 77 RR 20 O2 96/RA
General: NAD, awake, talkative
HEENT: sclera anicteric, dMM, oropharynx clear
Neck: supple, no JVD, no LAD, * L carotid bruit.
Chest: lungs CTAB, 4-5 cm purple ecchymosis just superior to
left nipple
CV: RRR, no MRG
Abdomen: surgical scars consistent with history; soft, ND/NT, no
HSM, +BS
GU: foley in place, draining yellow urine
Ext: warm, well-perfused, non-palpable distal pulses, no edema
or ulcers
MSK: able to flex and abduct L thigh to 30 deg w/ mild pain.
severe TTP at L hip.
Neuro: AOX3, grossly intact, moving all extremities
Discharge Exam:
Pertinent Results:
Admission Labs:
[**2125-11-1**] 10:05PM BLOOD WBC-6.7 RBC-3.65* Hgb-10.6* Hct-34.7*
MCV-95 MCH-28.9 MCHC-30.4* RDW-20.2* Plt Ct-244
[**2125-11-1**] 10:05PM BLOOD PT-18.2* PTT-26.8 INR(PT)-1.6*
[**2125-11-1**] 10:05PM BLOOD Glucose-87 UreaN-28* Creat-5.7*# Na-142
K-3.8 Cl-103 HCO3-24 AnGap-19
[**2125-11-1**] 10:05PM BLOOD CK(CPK)-41*
[**2125-11-1**] 10:05PM BLOOD CK-MB-3 cTropnT-0.05*
[**2125-11-1**] 10:05PM BLOOD Calcium-8.7 Phos-4.8* Mg-2.3
Discharge Labs:
[**2125-11-8**] 07:30AM BLOOD WBC-5.3 RBC-3.23* Hgb-9.4* Hct-31.0*
MCV-96 MCH-29.2 MCHC-30.4* RDW-21.5* Plt Ct-176
[**2125-11-8**] 07:30AM BLOOD PT-18.2* PTT-27.7 INR(PT)-1.6*
[**2125-11-8**] 07:30AM BLOOD Glucose-101* UreaN-32* Creat-5.3*# Na-134
K-3.6 Cl-91* HCO3-33* AnGap-14
[**2125-11-8**] 07:30AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
Cardiac Labs:
[**2125-11-1**] 10:05PM BLOOD CK-MB-3 cTropnT-0.05*
[**2125-11-2**] 08:50AM BLOOD cTropnT-0.04*
[**2125-11-3**] 10:10AM BLOOD cTropnT-0.08*
[**2125-11-3**] 06:02PM BLOOD CK-MB-5 cTropnT-0.11*
[**2125-11-3**] 10:45PM BLOOD CK-MB-4 cTropnT-0.12*
Relevant Heme:
[**2125-11-3**] 11:00PM BLOOD Lactate-2.9*
[**2125-11-4**] 09:49PM BLOOD Lactate-1.9
[**2125-11-4**] 09:49PM BLOOD Type-[**Last Name (un) **] pH-7.28*
[**2125-11-3**] 10:17AM BLOOD Type-ART pO2-70* pCO2-46* pH-7.40
calTCO2-30 Base XS-2
Chemistries:
ALT AST LD(LDH) CK(CPK) AlkPhos
Amylase TotBili
[**2125-11-4**] 15:00 326* 1604* 1222* 136* 0.4
[**2125-11-7**] 07:30 38 212* 324* 112 0.5
STUDIES:
ECG Study Date of [**2125-11-1**] 9:54:18 PM
Sinus rhythm. Occasional premature atrial contractions. Left
ventricular
hypertrophy. Inferolateral ST-T wave changes most likely related
to left
ventricular hypertrophy. Compared to the previous tracing of
[**2125-5-29**] there is no significant diagnostic change.
CT HEAD W/O CONTRAST Study Date of [**2125-11-1**] 8:54 PM
IMPRESSION: No acute intracranial process.
HIP UNILAT MIN 2 VIEWS LEFT Study Date of [**2125-11-1**] 9:14 PM
IMPRESSION: Fracture of the femoral neck with lateral angulation
of the
femoral head with respect to the femoral neck with possible
impaction of the femoral head. Findings less convincing on
cross-table lateral films. If there is concern for femoral neck
fracture, cross-section imaging may be obtained for
confirmation. Recommend physical examination and clinical
correlation.
CHEST (SINGLE VIEW) Study Date of [**2125-11-6**] 3:56 PM
FINDINGS: In comparison with the study of [**11-4**], there is
continued
substantial enlargement of the cardiac silhouette with
atelectatic changes in the retrocardiac area. There has been the
development of moderate
interstitial edema.
LUNG SCAN Study Date of [**2125-11-6**]
INTERPRETATION:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views
demonstrate
heterogeneous distribution of tracer bilaterally, compatible
with airways
disease.
Perfusion images in the same 8 views show heterogeneous tracer
distribution, with a defect in the superior segment of the right
lower lobe (best seen on the RPO projection), with a peripheral
rim of preserved tracer, and a matching ventilation defect.
Additionally, a small perfusion defect in the medial left upper
lung (best seen on the LPO projection) has a matching
ventilation defect. There are no mis-matched perfusion defects.
Chest x-ray shows cardiac enlargement, without pleural effusion
or
consolidation. The above findings are consistent with a low
likelihood of pulmonary embolus.
IMPRESSION:
Low likelihood of pulmonary embolus.
Airways disease.
Brief Hospital Course:
Mr. [**Known lastname 4643**] is a 71 yo M with a history of CAD s/p CABGx4,
vascular dementia, ESRD on HD, prior TIAs, and recent postive
stress test, who was transferred to [**Hospital1 18**] after sustaining a L
femoral neck fx after a mechanical fall.
.
ACTIVE ISSUES:
.
#Hip: Mr. [**Known lastname 4643**] was admitted for repair of a left femoral neck
fracture that was diagnosed at an OSH. Given his abnormal
cardiac stress test results at the beginning of Novemeber,
demonstrating a reversible inferolateral abnormality, he was
evaluted by the Cardiology service. They felt that he was
stable for surgery and did not require revascularization prior,
but recommended low-dose Metoprolol (6/25 mg IV BID) for risk
reduction. He underwent ORIF of his left femoral neck fracture
on HD #2. He did well in the immediate post-operative period,
but overnight into HD #3 (POD#1) he developed a new oxygen
requirement of 3L nasal cannula. He had crackles bilaterally
throughout his lungs. Given his history, there was a concern
for a cardiac cause of this change, namely ACS or CHF secondary
to fluid overload. Repeat EKG was negative, CXR did not
demonstrate any evidence of fluid overload or acute process, and
an ABG only demonstrated hypoxemia. Shortly after the return of
these studies, he triggered for hypotension, with a systolic
blood pressure in the 60s. He was managed per protocol, but
given ongoing hypotension, he was transferred to the Medical
Intensive Care Unit for further management.
- Follow-up with Orthopedics in 2 months
- Discharge to rehab with physical therapy
#Hypotension: Due to pt's hypotension he was admitted to MICU.
His hypotension was believed to be due to the metoprolol he
received as patient is known to be very sensitive to this
medication and is now listed as an allergy. BP responded with
IVF. LFT's were elevated after his hypotension and led to shock
liver. LFT's trended back down shortly there after with improved
perfusion and no other intervention. Pt stabilized and
transferred back to the floor. On the floor his blood pressure
remained in the 100-120s systolic and he was able to be taken
off the supplemental oxygen.
#Hypoxia: At baseline, the patient has no oxygen requirement. He
has a 30 pack year smoking history and also has a recent stress
that showed a decreased EF. Given his hip fracture,
immobilization, hypoxia and hypotension, PE was a serious
consideration. V/Q scan was negative. He likely was hypoxic in
the setting of being mildly fluid overloaded on his chronic lung
disease as well as post op atelectasis. He was taken off
supplemental O2 as he improved, and he was 93-95% on room air.
An echocardiogram was not done. He will be seen by Dr. [**Last Name (STitle) 911**] as
an outpatient. Cardiology did not feel as though he needed and
echo inpatient.
#Rash: He developed a rash between the OR and MICU. Possible
causes were chlorhexadine bath for the OR, antibiotics during
surgery, and metoprolol. All possible offending agents were
stopped around the same time. At time of dischargethe rash was
improving.
#CAD: The patient has long-standing CAD, with a history of a
four-vessel CABG in [**2114**] and a recent abnormal stress test.
Given the need for surgery, we held his Plavix, but continued
his home Aggrenox and Statin. Cardiology risk stratified him. We
also started him on Metoprolol in advance of surgery (as
described [**Last Name (un) 8585**]), which was subsequently stopped. He will be seen
by Dr. [**Last Name (STitle) 911**] as an outpatient for his abnormal stress test.
-Continue Plavix
-Continue Aggrenox
-Continue Statin
.
#End Stage Renal Disease: He has long-standing ESRD secondary to
HTN, and is on HD with access via an AV fistula. While in the
hospital, he continued his home Monday-Wednesday-Friday schedule
of HD, with supervision by the Renal team. We also continued
him on his home Cinacalcet and Nephrocaps, and added Sevelamer.
#Diastolic and Systolic Dysfunction: See above workup given O2
requirement.
INACTIVE ISSUES:
#Anemia: He has long-standing anemia, secondary to his ESRD.
His hematocrit at admission was 34. We monitored his hematocrit
regularly, which stayed at or around baseline throughout his
hospitalization. We therefore considered him stable for
discharge from this standpoint.
#Hypertension: He has a history of labile HTN. His blood
pressures were in the 130s on admission, so we did not initiate
any therapy. As explained above, he was triggered for
hypotension, with further management by the MICU.
#Spinal Stenosis: He suffers from chronic lower back pain
secondary to spinal stenosis. We treated him with a Lidocaine
patch, consistent with his outpatient regimen. His pain was
well-controlled, so we considered him stable for discharge from
this standpoint.
#Depression: He has long-standing depression, so we continued
him on his home Citalopram and are discharging him with the same
medication.
#Peripheral Neuropathy: He has long-standing peripheral
neuropathy, so we continued him on his home Gabapentin and are
discharging him with the same medication.
#Benign Prostatic Hypertrophy: He is on Tamulosin at home, but
given that a Foley catheter was placed on admission given his
poor ambulation, we held his Tamulosin. He was without
complaints related to this condition. Because of his hypotension
this medication was held at time of discharge. He also makes
very little urine in the setting of his ESRD.
#GERD: He has long-standing GERD, so we continued him on his
home Pantoprazole and are discharging him with the same
medication and is on PPI at home.
TRANSFER OF CARE: Mr. [**Known lastname 4643**] was discharged to a rehab center
for physical therapy of his hip. He has follow-up with
orthopedics in 2 months and the Cardiology clinic will contact
him with an appointment. There are no tests pending at time of
discharge.
Medications on Admission:
-Simvastatin 40 mg tablet one daily
-Plavix 75 mg tablet one daily ON HOLD
-Aggrenox 200/25 mg capsule one capsule [**Hospital1 **]
-Sevelamer 800 mg tablet TID with meals
-Cinacalcet 30 mg tablet one daily
-Nephrocaps daily
-Lidoderm patch
-Gabapentin 300 mg capsule one daily
-Citalopram 40 mg tablet two daily
-Pantoprazole 40 mg daily
-Tamsulosin 0.4 mg capsule one daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime). Capsule(s)
7. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. citalopram 40 mg Tablet Sig: Two (2) Tablet PO once a day.
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day): Until ambulatory.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q 8H (Every 8
Hours) as needed for pain.
17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
18. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5399**] Nursing Home
Discharge Diagnosis:
Primary: left femoral neck fracture
Secondary:
Coronary Artery Disease
End Stage Renal Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 4643**],
It was our pleasure caring for you at [**Hospital1 827**].
You were admitted after a fall for treatment of your left hip
fracture. You underwent surgery to repair your hip.
You were also seen by our Cardiology Service regarding your
recent abnormal stress test results, and they felt that
catheterization was not required before your procedure.
We also continued you on your regular hemodialysis schedule
while you were here.
You had a period of low blood pressure and low oxygen and
required a few days of monitoring in the ICU. You were stable
and managed back on the general medicine floor prior to
discharge. Your low oxygen was in the setting of having extra
fluid on your lungs, and small breaths after surgery.
The following changes were made to your medications:
-STOPPED Flomax
-STARTED Bowel regimen with docusate, senna, bisacodyl, and
miralax
-STARTED Heparin injections to prevent blood clots
-STARTED Sevelamer for your kidneys
-STARTED lidocaine patches for pain
-STARTED Oxycodone for pain
-STARTED sarna lotion for itchy rash
Followup Instructions:
Name: [**Last Name (LF) 911**], [**First Name7 (NamePattern1) 919**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
*[**Doctor First Name **] from Dr. [**Last Name (STitle) 8586**] office will call you to make an
appointment. You should be seen within 2 weeks. Call the number
above if you dont hear from [**Doctor First Name **] in 2 business days.
Department: ORTHOPEDICS
When: TUESDAY [**2126-1-8**] at 12:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2126-1-8**] at 1 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2125-11-10**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
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] |
14719, 14778
|
6763, 7021
|
302, 367
|
14931, 14931
|
3141, 3141
|
16219, 17368
|
2271, 2488
|
13079, 14696
|
14799, 14910
|
12679, 13056
|
15114, 16196
|
3604, 6740
|
2503, 3105
|
3122, 3122
|
1110, 1520
|
245, 264
|
7036, 10784
|
395, 1091
|
10802, 12653
|
3157, 3588
|
14946, 15090
|
1542, 2005
|
2021, 2255
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,641
| 184,082
|
13238
|
Discharge summary
|
report
|
Admission Date: [**2178-2-19**] Discharge Date: [**2178-2-27**]
Date of Birth: [**2101-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin / Clindamycin / Quinidine / Niacin /
Persantine / Diuril IV / Metolazone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug eluting stents x2 to left
circumflex artery
History of Present Illness:
76 y/o F with PMH of CAD s/p CABG in [**2146**], redo in [**2173**]
((LIMA-LAD, SVG-RCA 'y' graft to OM 'Y' graft to PDA), CKD with
baseline Cr of 2.6 transferred to CCU in setting of ACS s/p DES
x2 to native LCx.
Patient had sudden onset typical angina ([**8-31**] chest discomfort,
dyspnea, weakness) at 11am while taking out her trash. She
initially presented to OSH where EKG uninterpretable in setting
of v-paced rhythm. 1st set of enzymes were negative, but second
set revealed troponin 0.2 (increased from 0.06), MB 18, and CK
179; pro BNP 1573. Patient started on heparin gtt, given ASA
325mg (plavix deferred as on chronic therapy). Pain was treated
with morphine - reportedly made her feel worse- and nitro gtt.
At time of transfer, patient complained of persistant chest
discomfort, rated [**1-1**].
Upon arrival to [**Hospital1 18**], patient complained of persistent
discomfort despite high nitro gtt causing SBP in 80-90s. She
was taken semi-emergently to the cath lab and reloaded with
plavix. Angiography revealed thrombus in prox Cx which was
treated with prox and mid DES. Both grafts to cx were occluded;
the LIMA and SVG to RCA remained patent.
Cardiac review of systems is notable for [**2-24**] pillow orthopnea.
She denies dyspnea on exertion, paroxysmal nocturnal dyspnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: REDO CABG x 4 on [**2174-2-24**] (LIMA to LAD, SVG to RCA with "y"
graft to SVG to OM, SVG to OM graft has "y" graft to SVG to
DIAG) Prior CABG ([**2149**])
-PERCUTANEOUS CORONARY INTERVENTIONS: PTCA in RCA [**2161**]
-PACING/ICD: pacer/AICD
-CHF with EF 40%
3. OTHER PAST MEDICAL HISTORY:
CKD with Cr of 2.6
Anemia, due to CKD
Nonhodgkins Lymphoma s/p chemo/XRT
Gout
PVD
Lymphedema on left leg
Pituitary adenoma, likey cause of frequent headaches
IBS
GERD
Arthritis
Social History:
-Lives alone in [**Location (un) 2973**], performs all IADL's incl driving
-cleaning lady comes once a week
-Tobacco history: former smoker 1ppd x25 years, quit [**2161**]
-ETOH: none
-Illicit drugs: none
Family History:
Her father died at the age of 59 from CAD. Extensive family
history of heart disease. No family history of arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION EXAM
VS: T=Afebrile BP=104/36 HR=74 RR=20 O2 sat=92% on 4L
GENERAL: Very sleepy and tired. Oriented x3. Responded
appropriately to questions
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple difficult to assess JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. systolic murmur [**1-25**]. No thrills, lifts.
No S3 or S4.
LUNGS: Mild kyphosis. Resp were unlabored, no accessory muscle
use. Crackles bilaterally halfway up posterior lung fields, no
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
GROIN: angioseal in both groin sites, femoral bruit over right
groin, no obvious tenderness at either site, no hematoma felt
EXTREMITIES: Asymmetric peripheral edema noted in left leg,
trace edema at right ankle
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ PT 1+
Left: DP 2+ PT 2+
Pertinent Results:
# CARDIOLOGY
[**2-19**] Cardiac Catheterization
.................
[**2178-2-20**] TTE
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 25 %)
secondary to severe hypokinesis/akinesis of the inferior,
posterior, and lateral walls, and of the apex. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The aortic root is mildly dilated at the sinus
level. The aortic arch is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve is not well
seen. The study is inadequate to exclude significant aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Moderate to severe (3+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared to prior study of [**2174-2-28**], left ventricular
ejection fraction and mitral regurgitation now much worse.
# RADIOLOGY
[**2-20**] ULTRASOUND OF RIGHT FEMORAL CATH SITE
IMPRESSION: Small collateral coming off the right common femoral
artery, but no evidence of AV fistula or pseudoaneurysm. No
evidence of hematoma.
[**2-21**] CXR (PA/Lat)
IMPRESSION:
1. Mildly improved interstitial edema. 2. Small bilateral
pleural effusions and left retrocardiac opacity which may
represent atelectasis, although consolidation cannot be
excluded.
[**2-23**]
ECHO
Left ventricular wall thicknesses and cavity size are normal.
There is mild to moderate regional left ventricular systolic
dysfunction with mild aneurysm/akinesis of the basal inferior
septum, inferior, and inferolateral walls, and hypokinesis of
the more distal inferior , distal lateral, and apical segments.
The remaining segments contract normally (LVEF = 35-40 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] No
masses or thrombi are seen in the left ventricle. The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
Compared with the prior study (images reviewed) of [**2178-2-20**],
there has been interim improvement in systolic function of the
distal 2/3rds of the inferior/inferolateral wall and global
LVEF.
# LABORATORY DATA
- Cardiac Enzymes
[**2178-2-20**] 01:46AM BLOOD CK-MB-191* cTropnT-2.20* MB Indx-15.8*
[**2178-2-20**] 09:15AM BLOOD CK-MB-242* cTropnT-4.00*
[**2178-2-20**] 03:30PM BLOOD CK-MB-174* cTropnT-4.51* MB Indx-13.4*
[**2178-2-21**] 04:44AM BLOOD CK-MB-61* MB Indx-8.3*
- Admission Labs
[**2178-2-20**] 01:46AM BLOOD WBC-8.1 RBC-2.92* Hgb-10.4* Hct-31.3*
MCV-107*# MCH-35.6*# MCHC-33.2 RDW-18.4* Plt Ct-216
[**2178-2-20**] 01:46AM BLOOD Neuts-87.3* Lymphs-8.7* Monos-3.1 Eos-0.1
Baso-0.8
[**2178-2-20**] 01:46AM BLOOD PT-12.6 PTT-40.6* INR(PT)-1.1
[**2178-2-20**] 01:46AM BLOOD Glucose-140* UreaN-68* Creat-2.9* Na-138
K-4.8 Cl-102 HCO3-21* AnGap-20
[**2178-2-20**] 01:46AM BLOOD CK(CPK)-1210*
[**2178-2-21**] 04:44AM BLOOD Lipase-31
[**2178-2-20**] 01:46AM BLOOD Calcium-10.1 Phos-6.6*# Mg-2.5
- Discharge Labs
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
11.5* 3.00* 10.2* 29.5* 99* 34.1* 34.6 19.2* 254
Glu 115*1
Na+ 131*
K+ 4.0*
BUN 133
Cr 3.8
Cl 89*
HCO3 25
Ca [**76**].7* Mg 3.7 Phos 2.3
Brief Hospital Course:
76 y/o F with PMH of CAD s/p CABG in [**2146**], redo in [**2173**]
((LIMA-LAD, SVG-RCA 'y' graft to OM 'Y' graft to PDA), CKD with
baseline Cr of 2.6 transferred to CCU in setting of ACS/MI s/p
DES x2 to native LCx.
# STEMI/CAD: Patient presented with ACS/STEMI with elevated
cardiac enzymes and an uninterpretable EKG. Cardiac
catheterization revealed a 95% occlusion proximally in the LCx
with filling defect/thrombus; the patient received [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2.
CK-MB peaked at 15.8. She has been chest pain free since cath.
Post-cath, she was noted to have a femoral bruit, however there
was no evidence of aneursym on right groin ultrasound. Patient
received aspirin 325mg, Plavix 75mg and atorvastatin 80mg. She
was started on metoprolol which was continued on discharge. She
was not started on an ace inhibitor or [**Last Name (un) **] given acute on
chronic renal failure. Given the extent of her mitral valve
disease, surgery was consulted for the possibility of MVR but
she was deemed not to be a suitable candidate. Her dysfunction
will be managed medically.
# Acute on chronic CHF: Patient was in acute on chronic
congestive heart failure with pulmonary edema on chest xray.
Diuresis is difficult secondary to acute on chronic renal
failure. O2 requirement increased overnight. TTE on [**2-20**] showed
left ventricular systolic function that was severely depressed
(LVEF= 25 %) secondary to severe hypokinesis/akinesis of the
inferior, posterior, and lateral walls, and of the apex. Patient
received a Lasix drip with additional doses of metolazone and
diuril given to augment urine output. Repeat chest xray showed
mild improvement in pulmonary edema. In order to improve her
cardiac output, she was started on digoxin (+ ionotropic effect)
and metoprolol (to decrease HR and improve Cardiac output). Her
Pacemaker settings were changed to decrease AV delay to 150ms to
provide more effective atrial kick. She was continued on low
dose digoxin. Her lasix gtt was converted to torsemide PO, she
was discharged on Torsemide 60mg PO Daily.
# Acute on chronic renal failure: Creatinine was elevated
(baseline Cr 2.6, now 4.0), likely secondary contrast-induced
nephropathy secondary to dye load from cardiac catheterization.
We expect creatinine to peak at 48-72 hours post-exposure. No
electrolyte abnormalities currently. Medications were renally
dosed. Fractional excretion of urea was <30%, which indicated a
pre-renal component as well. Urine culture showed 2 epis, sm
leuk, 3 WBC, few bacteria, 14 hyaline casts. Her Cr improved
slightly with diuresis to 3.7 but essentially stabalized close
to 4. She will need further monitoring and workup of her renal
failure after discharge.
# Leukocytosis: WBC increased from 8.1 to 11.6. Had elevated
temperature but not true fever, and it spontaneously resolved.
No bandemia on differerential. She had an infectious workup
which included urinalysis and culture as well as a chest xray.
Lipase was within normal limits.
# Nausea: Patient had intermittent nausea which resolved with
ondansetron. Etiology unclear.
# Hyperlipidemia: Chronic. Patient is currently receiving
atorvastatin 80mg daily. Her gemfibrozil was held in setting of
high-dose atorvastatin. She was discharged on atorvastatin 80mg
daily
# Rash/Allergy: She developped an itchy maculopapular rash that
progressed to cover her entire body. Dermatology was consulted
and they recommended clobetasol cream [**Hospital1 **] which she is
continuing on discharge. Her reaction was thought [**12-24**] either
metolazone or diuril which she received slightly prior to the
rash.
# GERD: Chronic, stable. Omeprazole was discontinued and patient
was started on famotidine instead.
# Anemia: Chronic; patient receives Procrit injections twice a
month and is on folic acid and vitamin B12 supplementation. Her
hematocrit trended down; etiology unclear. and she was
transfused with 1U pRBCs on [**2178-2-22**]. She was started on iron
supplementation in addition to folic acid & vit B12. She
received a similar dose of Procrit based on hospital dosing, but
should resume her previous dosing of Procrit upon discharge.
# Gout: Stable. Allopurinol was stopped temporarily given
worsening renal function.
# Diet: Patient was on a diabetic, heart healthy, low sodium,
low potassium diet.
# DVT Prophylaxis: Patient received heparin products during this
admission.
# Code status: her code status was discussed and changed to DNR
but okay to intubate.
Medications on Admission:
aldactone 12.5mg [**Hospital1 **]
allopurinol 150mg qod
aspirin 81mg daily
calcitriol 25mg daily
colace 100mg prn
coreg 12.5mg [**Hospital1 **]
diovan 40mg daily
folic acid 1mg daily
iron 325mg daily
lasix 80mg [**Hospital1 **]
lopid 600mg daily
nitro 0.4mg prn
plavix 75mg daily
prilosec 20mg daily
zocor 10mg daily
vitamin d 800mg daily
B12 monthly
procrit 60,000 q2weeks
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): stop when pt is
ambulatory.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. famotidine 20 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24
hours).
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
10. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. epoetin alfa 20,000 unit/mL Solution Sig: Three (3) ML
Injection EVERY TWO WEEKS.
12. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily): KEEP UNTIL YOU CAN START TAKING MONTHLY
INJECTIONS AGAIN.
15. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
16. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 2 weeks: STARTED [**1-26**], END [**2-9**].
17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
18. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
19. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day.
20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
21. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
22. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily): Titrate up or down depending on daily weight.
23. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Acute on Chronic systolic congestive heart failure: not on
[**Last Name (un) **]/ACE because of [**Last Name (un) **]
Non ST Elevation myocardial Infarction
Acute on Chronic Kidney Injury
Iron Deficient anemia
Non-Hodgekins Lymphoma
Pacer/Internal defibrillator
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack and required two drug eluting stents be
placed in your left circumflex artery. Your heart function is
weaker now so we adjusted your medicines and geve you diuretics
to get rid of the extra fluid. Your kidney function is worse so
we stopped some medicines until after your kidneys improve. Your
blood pressure was low but is normal now after medication
adjustment. You tallked to a cardiac surgeon about fixing your
mitral valve but surgery is not a safe option for you so you
will continue to be treated with medicines to help your heart
work as efficiently as possible.
.
We made the following changes to your medicines:
1. Stop taking Furosemide
2. Start taking Torsemide 80 mg daily instead to get rid of
extra fluid
3. Increase aspirin to 325 mg and continue Plavix daily for at
least one year. Do not stop taking these medicines unless Dr.
[**Last Name (STitle) 40352**] says it is OK to do so.
4. Stop taking Prilosec, aldactone, allopurinol, calcitriol,
lopid and diovan. You should restart these medicines when your
kidneys improve.
5. Start taking potassium daily to increase your potassium
levels
6. STart taking Heparin injections until you are walking
regularly to prevent blood clots
7. Start taking colace, senna, miralax and bisacodyl to prevent
constipation
8. STart Sevelamer to decrease your phosphate levels. Stop
Calcitriol for now. Dr. [**Last Name (STitle) **] can adjust these medicines
9. Change B12 to daily pills until you are able to return for
your [**Hospital1 **] weekly injections
10. STart Trazadone to help you sleep
11. STart Hydroxyzine and Clobesetrol to help with the itch
12. STart tylenol as needed for pain
13. Stop simvastatin and start Atorvastatin to lower your
cholesterol.
14. Start Metoprolol succinate to lower your heart rate and help
your heart pump better.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 40352**] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days.
Follow a low salt diet.
Followup Instructions:
Please make an appt with Dr. [**Last Name (STitle) 174**] after you get out or
rehabilitation.
.
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Address: [**Location (un) **], [**Apartment Address(1) 29156**], [**Location (un) **],[**Numeric Identifier 2876**]
Phone: [**Telephone/Fax (1) 14967**]
Appointment: Monday [**2178-3-16**] 10:00am
Name: [**Last Name (LF) **], [**Name8 (MD) 8726**] MD
Location: [**Hospital **] MEDICAL CARE, P.C.
Address: [**Street Address(2) 8727**], STE 125E, [**Hospital1 **],[**Numeric Identifier 8728**]
Phone: [**Telephone/Fax (1) 8729**]
Appointment: Tuesday [**2178-3-3**] 1:15pm
|
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|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
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] |
14632, 14729
|
7466, 11978
|
380, 460
|
15035, 15035
|
3915, 7443
|
17203, 17872
|
2665, 2856
|
12402, 14609
|
14750, 15014
|
12004, 12379
|
15186, 17180
|
2871, 3896
|
1951, 2218
|
330, 342
|
488, 1843
|
15050, 15162
|
2249, 2427
|
1865, 1931
|
2443, 2649
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,554
| 113,175
|
42952
|
Discharge summary
|
report
|
Admission Date: [**2164-6-9**] Discharge Date: [**2164-6-14**]
Date of Birth: [**2108-12-4**] Sex: F
Service: MEDICINE
Allergies:
Motrin / Compazine / Haldol / Nitrofurantoin / Iodine /
Vancomycin Hcl
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 yo female with history of HIV (last CD4
>1000 with VL undetectable), HCV, HBV, former IVDU, CHF,
recurrent UTI with VRE/ESBL, and recurrent DVT on warfarin who
presented with fever and low back pain. The patient was recently
hospitalized from [**Date range (1) 23527**], again for fever and lower back
pain. During this previous hospitalization, she was found to
have an elevated INR to 13 of unknown etiology, and her INR
decreased without intervention. She was treated for HCAP with a
7-day course of linezolid and cefepime given her history of VRE
and diuresed for pulmonary edema given dCHF. She was continued
on her home dose of methadone, dilaudid and gabapentin for her
chronic pain disorder (including back, leg, neck, head). After
discharge she says she was feeling okay at home but two days ago
developed fevers, dysuria, increased urinary frequency, and
nausea/vomiting with blood in her emesis. She denied any new
weakness, no numbness or tingling, no radiation to legs or
urinary retention. She stated that her back pain was of the same
quality as usual but more intense.
On arrival to the ED, VS were 101.7, 112, 151/112, 100% on O2.
Labs were notable for UA with few bacteria/large leukocytes/51
WBCs, INR 11.1, normal WBC of 9.7 (80% PMNs). She was started on
empiric IV cefepime and linezolid for infection and given 5 mg
PO vitamin K for elevated INR. Blood cultures were sent. She was
also given sumatriptan for headache and zofran for nausea. CXR
showed mild pulmonary vascular congestion (unchanged from prior
CXR) and bibasilar airspace opacities. She was noted to be
guaiac positive. Several hours after arrival to the ED, the
patient became more lethargic and was started on IVF. CT head
was obtained given elevated INR and headache but did not reveal
acute process. She received 2L of IV normal saline because
pressures dropped to 83/40 and improved to 90s/50s with fluid.
She was also was noted to have a cellulitic looking patch of
skin on her RLE. Her tox screen is positive for methadone. She
was transferred to the MICU for further management of her
hypotension, where she did not require pressors and was
continued on her home medications and started on meropenem. The
patient covertly took some of her home methadone in the ICU, but
she remained afebrile and stable for several hours and was
transferred to medicine for further care.
Her vital signs on transfer were T99 BP 140/83 HR 83 RR 13 94%
4L.
Past Medical History:
1. HIV, sexually transmitted, diagnosed [**2150**] on HAART (last CD4
greater than 1000, viral count undetectable)
2. Hepatitis B and Hepatitis C virus (sexually transmitted,
diagnosed [**10/2151**], s/p IFN x 6 months with failure to suppress
VL)
3. Asthma
4. Ovarian cancer (diagnosed [**2142**], s/p oophorectomy and chemo)
5. Morbid obesity
6. s/p MVA with L4-L5 laminectomy in [**2151**], operation c/b
infection, including VRE requiring re-exploration and drainage
7. Chronic back pain and Left leg pain
9. Cholecystectomy, [**2142**]
10. Osteoarthritis involving bilateral knees
11. Recurrent UTIs (including ESBL UTI, [**4-/2163**] and [**8-/2163**])
12. Recurrent cystitis consistent with urethral syndrome or
chronic cystitis
13. QT Prolongation induced by Abilify
14. s/p tibial fracture on [**2160-11-5**], medically managed
15. s/p ORIF right proximal tibia fracture with [**Last Name (un) 101**]
plate ([**2161-7-13**])
16. History of DVT s/p ORIF right proximal tibia fracture (on
Coumadin)
17. OSA (failure to comply with home CPAP)
18. Diastolic CHF (preserved EF)
19. Osteomyelitis of leg
20. H/o alcohol dependence
21. H/o opioid dependence
22. Anxiety disorder
23. Depression
24. ?Bipolar disorder
Social History:
Lives alone in apartment in [**Location (un) 86**], limited contact with family.
Mother recently died. Only has support with a few friends,
especially her HCP; attests to tobacco use of 120 pack-year and
currently smokes [**11-28**] PPD (previous 3-PPD); no current alcohol
use; denies recreational substance use.
Family History:
Father is deceased and had HTN, CAD. Mother is deceased after
long course with ESRD, HTN, multiple strokes and CHF. Aunt with
neuroblastoma, otherwise no other cancers.
Physical Exam:
Physical Exam:
General: Alert, oriented, no acute distress, appears drowsy
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: diffuse inspiratory and expiratory wheezes, poor air
movement at bases bilatrally, no crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema, 4 cm diameter
round area of warmth and erythema on RLE with central scab
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation
Discharge Exam:
Vitals: T 98.3 BP 116/62 HR 68 RR 18 94% 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Faint heart sounds, but regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Poor air movement, otherwise CTAB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no RUQ tenderness
Ext: warm, well perfused, 2+ pulses, no edema, 4 cm diameter
round area of erythema on RLE with central scab and warmth, not
expanded.
Neuro: 5/5 strength upper extremities, grossly normal sensation
Skin: Erythema consistent with tinea cruris.
Pertinent Results:
ADMISSION LABS:
[**2164-6-9**] 12:25PM BLOOD WBC-9.7 RBC-4.72 Hgb-14.7 Hct-47.3
MCV-100* MCH-31.2 MCHC-31.1 RDW-18.4* Plt Ct-163
[**2164-6-9**] 12:25PM BLOOD Neuts-80.1* Lymphs-12.0* Monos-4.6
Eos-2.0 Baso-1.3
[**2164-6-9**] 02:30PM BLOOD PT-108.2* PTT->150* INR(PT)-11.1*
[**2164-6-9**] 12:25PM BLOOD Glucose-104* UreaN-7 Creat-0.6 Na-136
K-5.0 Cl-97 HCO3-28 AnGap-16
DISCHARGE LABS:
[**2164-6-14**] 09:00AM BLOOD WBC-6.1 RBC-3.75* Hgb-12.0 Hct-38.2
MCV-102* MCH-31.8 MCHC-31.3 RDW-17.8* Plt Ct-160
[**2164-6-14**] 09:00AM BLOOD PT-14.3* PTT-39.0* INR(PT)-1.3*
[**2164-6-14**] 09:00AM BLOOD Glucose-110* UreaN-14 Creat-0.4 Na-138
K-4.4 Cl-95* HCO3-39* AnGap-8
[**2164-6-14**] 09:00AM BLOOD ALT-72* AST-97* AlkPhos-242* TotBili-1.7*
[**2164-6-14**] 09:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8
LFT TREND:
[**2164-6-11**] 05:31AM BLOOD ALT-82* AST-127* AlkPhos-275*
TotBili-2.7*
[**2164-6-12**] 11:20AM BLOOD ALT-76* AST-112* AlkPhos-257*
TotBili-3.1*
[**2164-6-14**] 09:00AM BLOOD ALT-72* AST-97* AlkPhos-242* TotBili-1.7*
MICROBIOLOGY:
[**2164-6-9**] URINE CULTURE-FINAL
**FINAL REPORT [**2164-6-13**]**
URINE CULTURE (Final [**2164-6-12**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefepime sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- I
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- 2 S
[**2164-6-9**] BLOOD CULTURE -NO GROWTH
[**2164-6-9**] BLOOD CULTURE -NO GROWTH
IMAGING:
# CHEST (PORTABLE AP) Study Date of [**2164-6-9**]
Semi-upright portable chest radiographs were obtained. The
examination is
limited due to poor penetration likely secondary to body habitus
and portable technique without evidence of focal consolidation.
Retrocardiac opacities are not well assessed on this single
radiograph but appear improved compared to the radiograph from
[**5-16**]. For better evaluation, consider PA and lateral views.
Heart is moderately enlarged. Mild pulmonary vascular
engorgement appears slightly improved. Right humeral fixation
hardware is incompletely assessed.
IMPRESSION: Improved retrocardiac opacities and pulmonary
vascular congestion on this limited study. For better
evaluation, two-view chest radiograph could be obtained.
# CHEST (PA & LAT) Study Date of [**2164-6-9**]
Low lung volumes are present. Moderate cardiomegaly is
unchanged. The
mediastinal contours are stable with calcification of the
thoracic aorta which is mildly tortuous. There is mild
pulmonary vascular congestion unchanged from the radiograph
performed earlier in the day. Streaky opacities in lung bases
are re- demonstrated. No pleural effusion or pneumothorax is
identified. Evaluation the osseous structures is limited due to
the patient's large body habitus. Partially imaged is
orthopedic hardware within the right humeral head.
IMPRESSION:
Mild pulmonary vascular congestion unchanged compared to the
radiograph from earlier in the day. Bibasilar airspace
opacities could reflect areas of infection but are improved from
[**2164-5-16**].
# CT HEAD W/O CONTRAST Study Date of [**2164-6-9**]
FINDINGS: Study slightly suboptimal due to noisy images. There
is no acute intracranial hemorrhage, edema, mass effect or major
vascular territorial infarction. Exam is essentially unchanged
from the recent comparison. Ventricles and sulci remain mildly
prominent, compatible with age-related involutional changes.
Right basal ganglia hypodensity could reflect a prominent VR
space and is unchanged. There is no shift of normally midline
structures. [**Doctor Last Name **]-white matter differentiation is preserved.
Imaged paranasal sinuses and mastoid air cells are well aerated.
There is no fracture.
IMPRESSION: No acute intracranial hemorrhage or mass effect.
# LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2164-6-12**]
FINDINGS: The liver is diffusely echogenic, consistent with
fatty
infiltration. No concerning liver lesion is identified. No
biliary
dilatation is seen and the common duct measures 0.8 cm. The
portal vein is patent with hepatopetal flow. The patient is
status post cholecystectomy. The pancreas and midline
structures are obscured from view by overlying bowel gas. The
spleen is at the upper limits of normal measuring 13.0 cm.
IMPRESSION: Echogenic liver consistent with fatty infiltration.
Other forms of liver disease and more advanced liver disease
including significant hepatic fibrosis/cirrhosis cannot be
excluded on this study.
Brief Hospital Course:
55 yo female with history of HIV (last CD4 >1000 with VL
undetectable), HCV, HBV, former IVDU, CHF, and recurrent DVT on
warfarin presented with fever and low back pain, with evidence
of UTI. She was transferred to the MICU for hypotension, where
she was stabilized without use of pressors and transferred to
medicine.
ACTIVE ISSUES:
# UTI: In the ED was tachycardic, hypotensive and febrile,
requiring ICU admission. Her symptoms improved with aggressive
fluid resuscitation and broad spectrum antibiotics. She was
initially treated with meropenem given her history of ESBL and
VRE in the past. Her urine culture grew ESBL E. coli, and she
was narrowed to Bactrim once sensitivities returned. She
remained stable and was discharged with plan to complete a 14
day course, last dose [**2164-6-24**].
#Elevated INR: Pt with INR elevated to 11 on admission. Etiology
unclear but had recent INR of 13 and variable INR in the past
above goal range of [**12-30**]. She reports compliance with medication,
however she often misses INR monitoring. She had guaiac positive
stools and occasional blood streaked vomitus and received
vitamin K in the ED. She refused FFP. Her Coumadin was held and
her INR dropped to subtherapeutic levels without evidence of
bleed. She initially refused Coumadin in house, and then refused
daily monitoring. Her Coumadin dose was decreased to 3 mg daily
given risks of elevated INR associated with Bactrim use. She was
set up with daily VNA for continued INR monitoring.
# Lethargy: Patient was originally lethargic in the MICU, likely
due to use of pain medications, UTI, and retention of carbon
dioxide. A head CT did not show bleed.
Her Dilaudid, Klonopin, gabapentin, sumatriptan, and Dilaudid
were all held and she improved shortly after transfer to
medicine. There was concern that she was taking her own dose of
methadone while in house and these medications were placed in
the safe for the remainder of her hospitalization.
CHRONIC ISSUES:
# Elevated LFTs: The patient has hepatitis B and hepatitis C and
has had transiently elevated LFTs in the past. She did not
appear jaundiced and her LFTs were trended during her hospital
course when blood draws could be obtained. A RUQ ultrasound
showed only fatty infiltration.
# Depression: The patient was originally treated with linezolid
for broad-spectrum coverage, and her home Escitalopram was held
given risk of serotonin syndrome. She was restarted on
Escitalopram shortly after linezolid was discontinued, and her
depressive symptoms were well-controlled.
# HIV: The patient's most recent CD4 count is >1000. During
hospitalization, the patient was continued on her home HAART
regimen.
#Headaches: The patient complained of chronic headaches with a
description suggestive of migraines. Imitrex 50mg PRN was
continued to control her headaches.
# Asthma: continued home meds with Advair in place of symbicort
(non formulary med) and PRN nebs. Pt remained stable throughout
hospitalization.
# Chronic dCHF: Pt was continued home Lasix 40mg PO daily.
# Intertrigonal [**Female First Name (un) **]: Continued her home miconazole.
# Chronic pain: Continue her home methadone 30mg TID, Dilaudid 2
mg PRN. The patient stated that she was on 10 mg Dilaudid q 4 hr
at home but did not require this dosing in house.
#Constipation: Patient was kept on home bowel regimen, but she
did not have a bowel movement by the time that she was medically
cleared for discharge. She was given an enema prior to
discharge.
TRANSITIONAL ISSUES:
Pt has had very difficult to control INR. She was set up with
daily INR monitoring through VNA. Her Coumadin dose will likely
need to be increased once her Bactrim course is completed.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Miconazole Powder 2% 1 Appl TP TID
5. Clonazepam 1 mg PO TID
fo not drive, operate machinery, or take other sedating
medications while on this medication
6. Docusate Sodium 100 mg PO BID
7. Methadone 30 mg PO TID
8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN breakthrough pain
fo not drive, operate machinery, or take other sedating
medications while on this medication
9. RiTONAvir 100 mg PO DAILY
10. Atazanavir 300 mg PO DAILY
11. Furosemide 40 mg PO DAILY
12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
13. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION 2 PUFFS TWICE DAILY
14. Escitalopram Oxalate 5 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Ranitidine 150 mg PO HS
17. Gabapentin 800 mg PO QID
18. Senna 1 TAB PO BID:PRN constipation
19. Sumatriptan Succinate 100 mg PO ONCE migraine Duration: 1
Doses
20. Acetaminophen 500 mg PO Q6H:PRN fever
do not exceed 3 grams daily
21. Albuterol Inhaler 2 PUFF IH Q4H prn wheezing or SOB
22. Warfarin 10 mg PO DAILY16
Discharge Medications:
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN fever
Do NOT exceed 2 grams/day
2. Atazanavir 300 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Clonazepam 1 mg PO BID
hold for sedation or RR <10
5. Docusate Sodium 100 mg PO BID
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Escitalopram Oxalate 5 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Gabapentin 800 mg PO Q8H
10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
11. Methadone 30 mg PO TID
do not drive, operate machinery, or take other sedating
medications while on this medication
12. Miconazole Powder 2% 1 Appl TP TID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Ranitidine 150 mg PO HS
15. RiTONAvir 100 mg PO DAILY
16. Senna 1 TAB PO BID:PRN constipation
17. Sumatriptan Succinate 100 mg PO DAILY:PRN migraine
18. Sulfameth/Trimethoprim DS 1 TAB PO TID
RX *Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth three times a
day Disp #*26 Tablet Refills:*0
19. Albuterol Inhaler 2 PUFF IH Q4H prn wheezing or SOB
20. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION 2 PUFFS TWICE DAILY
21. Warfarin 3 mg PO DAILY16
RX *Coumadin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
22. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
do not drive, operate machinery, or take other sedating
medications while on this medication
23. Outpatient Lab Work
Please have INR checked daily.
ICD 9: 453.8
Please fax results to [**Last Name (LF) **],[**First Name3 (LF) **] J.
Phone: [**Telephone/Fax (1) 798**]
Fax: [**Telephone/Fax (1) 21392**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY:
UTI
supratherapeutic INR
SECONDARY:
HIV
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 827**]. You were admitted with a urinary tract infection
and very high INR (blood level of coumadin). We treated you with
antibiotics and your symptoms improved. We also decreased your
dose of coumadin because of possible interactions with the
antibiotics. It is important that you have your INR checked as
directed by VNA and [**Hospital3 **].
Please make the following changes to your medications:
# START bactrim DS one tablet three times a day, last dose 7/27
# DECREASE coumadin to 3mg daily while on the bactrim. This dose
will be adjusted based on your INR by the coumadin clinic and
your visiting nurse.
# DECREASE gabapentin to 800 mg three times a day for your
kidney function and oversedation
# We recommend decreasing your clonazepam to 1mg twice a day, as
you were very sleepy when you were admitted
# We also recommend decreasing your dilaudid, again since you
were very sleepy while here. You did not require any dilaudid in
the hospital.
Please continue all other medications as prescribed.
Followup Instructions:
The following appointments have been scheduled for you:
[**2164-6-20**] at 3:00 pm with Dr. [**Last Name (STitle) **]
[**2164-6-27**] at 4:20 pm with Dr. [**Last Name (STitle) **]
[**2164-7-23**] at 3:50pm with Dr. [**Last Name (STitle) 1140**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
Completed by:[**2164-6-19**]
|
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icd9cm
|
[
[
[]
]
] |
[
"00.14"
] |
icd9pcs
|
[
[
[]
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] |
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11255, 11575
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|
18069, 18069
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|
18084, 18228
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,981
| 192,877
|
7285
|
Discharge summary
|
report
|
Admission Date: [**2123-11-4**] Discharge Date: [**2123-11-16**]
Date of Birth: [**2044-3-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Inderal / Morphine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
post-op bleeding after tooth extraction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo woman with history of a-fib, CHF s/p bioprosthetic mitral
and s/p tricuspid valve annuloplasty, who initially was admitted
to [**11-4**] after she presented to ED with persistent bleeding
following L tooth extractions and posterior superior palate I
and D. Patient initially had INR elevated to 2.1 secondary to
warfarin use for atrial fibrillation. In ED ENT was consulted
and pt was packed to help control bleeding. Her INR was reversed
with vitamin K, 2 units FFP and her INR now is 1.1. She was
hypotensive with SBP in 80's on admission and was admitted to
the ICU. Hct was 21 on admission (baseline 30) and the patient
required 3 units of PRBCs on [**11-4**]. Her Hct has been stable at
28-29 x more than 24 hours and she was called out from the ICU
today.
.
Pt currently denies any feelings of light-headedness, no chest
pain or difficulty breathing. Denies pain in her mouth, no
recent fevers or chills. Further ROS negative.
Past Medical History:
- MVR in [**2089**], [**2101**], [**2114**] last with bioprosthetic valve
- Severe pulmonary HTN
- TR
- Right-sided heart failure
- Chronic AF
- CVA x 2
- HTN
- Mild renal insuff, hyperkalemia
- Anemia - Last c-scope >10 years ago - had a few polyps removed
- Aorto-Femoral bypass
- Last Echo [**1-15**]: EF >65%, mild LVH, severe Pulmonary HTN and
(4+) TR, 1+ MR/AR.
Social History:
Lives alone, children nearby. 6 children and 12 grandchildren.
Born in [**Country 4754**] but moved to the US at a young age. Denies tob,
ETOH, IVDU. Walks with a cane.
Family History:
n/c
Physical Exam:
GEN: awake, alert, thin, NAD
HEENT: atraumatic, anicteric, gauze in mouth, no active bleeding
NECK: no LAD, no JVP
CV: [**3-15**] holosystolic murmur heard throughout, irregularly
irregular
LUNGS: mild crackles at bases, good air movement, no accessory
muscle use
ABD: soft, nt, non-distended, nabs
EXT: warm, dry. Trace edema B/L, chronic venous stasis
pigmentation changes. Some eccymoses on UE
NEURO: A/O x3, answers questions appropriately, follows commands
Pertinent Results:
[**2123-11-3**] 10:50AM PT-24.6* PTT-35.8* INR(PT)-2.5*
[**2123-11-3**] 10:50AM WBC-4.8 RBC-3.54* HGB-10.0* HCT-29.8* MCV-84
MCH-28.4 MCHC-33.7 RDW-16.6*
[**2123-11-3**] 10:40PM PT-26.6* PTT-35.7* INR(PT)-2.7*
[**2123-11-3**] 10:40PM WBC-4.9 RBC-3.24* HGB-9.0* HCT-27.1* MCV-83
MCH-27.7 MCHC-33.2 RDW-16.6*
[**2123-11-3**] 10:40PM GLUCOSE-120* UREA N-90* CREAT-2.5* SODIUM-134
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-27 ANION GAP-16
[**2123-11-4**] 06:07AM FIBRINOGE-304
[**2123-11-4**] 06:07AM NEUTS-75.7* LYMPHS-14.3* MONOS-7.3 EOS-1.9
BASOS-0.8
[**2123-11-4**] 06:07AM WBC-3.1* RBC-2.54* HGB-7.1* HCT-21.3* MCV-84
MCH-28.2 MCHC-33.5 RDW-16.6*
[**2123-11-4**] 06:07AM CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-2.7*
[**2123-11-4**] 06:07AM GLUCOSE-93 UREA N-91* CREAT-2.3* SODIUM-137
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-31 ANION GAP-11
[**2123-11-4**] 09:40AM HCT-22.8*
[**2123-11-4**] 07:34PM HCT-28.4*
.
CHEST (PORTABLE AP) [**2123-11-4**] 2:39 AM
FINDINGS: There is stable cardiomegaly. Elevation of right
hemidiaphragm persists. There is chronic pleural thickening on
the right, with right basilar atelectasis and small pleural
effusion present. There are no consolidations. Pulmonary
vascularity is normal.
IMPRESSION: No radiographic evidence of congestive heart
failure. Right chronic pleural thickening. Small right-sided
pleural effusion, probably unchanged. Right basilar atelectasis.
.
EKG- HR 86 Probable atrial fibrillation with multifocal PVCs or
aberrant ventricular
conduction
Right axis deviation
Right bundle branch block
Low QRS voltages in limb leads
.
CHEST (PA & LAT) [**2123-11-14**] 1:56 PM
Bilateral pleural effusions and bibasilar atelectasis. Pneumonia
is not excluded.
Cardiomegaly, unchanged.
Mild kyphotic angulation at a mid thoracic level. Finding may be
better assessed with dedicated thoracic spine radiographs, if
clinically indicated. No fracture is seen.
Brief Hospital Course:
79 yo female with h/o a Atrial Fibrillation, s/p bioprosthetic
mitral valve replacement, admitted with post-op bleeding
following dental extraction and palate I and D two days prior to
the admission in the setting of being anticoagulated (INR in
therapeutic range).
.
# Bleeding: Post-op due to anticoagulation with warfarin use for
atrial fibrillation. Bleeding started on [**11-2**], increased [**11-3**]
in ED packed and pressure applied. INR 2.7, and hematocrit 27,
SBP in the 80's to 90's. Hematocrit lowest at 21 on admission.
Bleeding from posterior palate Incision and drainage site.
Bleeding resolved with no events in the ICU. HD stable. Last
transfusion on [**2123-11-4**]. Received 2 units of FFP, one unit of
PRBC, fluid boluses and vitamin K. To medicine floor at
Hematocrit stable [**11-6**], but that night encountered bleeding
from I&D site, Afrin spray applied and pressure with resolution,
no PRBC's given, hematocrit 27.7. No further bleeding during
course of admission. Coumadin restarted [**11-10**] as per instruction
with Dr. [**First Name (STitle) **], and Dr. [**Last Name (STitle) **]. 3 mg initial dose, given risk for
stroke in patient with A-fibb. As per wishes of patient and
family, patient remained in house until incision site appeared
healed, INR increased and no evidence of bleed. Discharged with
follow-up by cardiology and her oral surgeon. Clindamycin 450 PO
Q6 for abscess stopped after IV then PO course for 10 days.
Coumadin increased to 5 mg on discharge.
.
# Atrial fibrillation: Rate control with beta-blocker. Continue
Statin/ beta-blocker. Held Coumadin until [**11-10**] when restarted
given decreasing concern of rebleed. In discussion with Dr.
[**Name (NI) **], pt's Cardiologist in regards to anticoagulation.
.
# CHF: EF >65% in 1/[**2123**]. Continued beta-blocker. Restarted
[**Year (4 digits) 11573**] per outpatient dose 4 days into admission. Had been held
in MICU given hypotension. Fluids also given. Held Aldactone
during admission given elevated potassium and hypotension. With
increasing work of breathing 3 days prior to discharge, evidence
of increasing overload on CXR, [**Year (4 digits) 11573**] given. Pt stable on 40 PO
[**Year (4 digits) 11573**] and resuming 25 Aldacton [**Hospital1 **] at discharge with follow-up
in the heart failure clinic.
.
# Hypotension: likely secondary to hypovolemia. Fluids given on
admission. Stopped as evidence of overload. Baseline low normal.
.
# CRI: Creatinine slowly trending up. Baseline ranging from
1.9-3.0. Stable as baseline at discharge. Continued renal diet
.
# FEN: Soft diet given abscess site tenuous for rebleed.
.
# Contact: Daughter [**First Name8 (NamePattern2) 26941**] [**Name (NI) 1356**] [**Telephone/Fax (1) 26942**]
Medications on Admission:
[**Telephone/Fax (1) 11573**] 40 mg twice a day
Toprol-XL 25 mg daily
spironolactone 50 mg daily
Lipitor 10 mg daily
Omeprazole 20 mg twice a day
Ferrous Sulfate
Coumadin 2.5 mg
Carafate 1 gram qid
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: until
discussion with outpatient provider.
[**Name10 (NameIs) 357**] check INR in two days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: bleeding from palate abcess I&D and tooth extraction
site
Secondary: CHF
CRI
thrombocytopenia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a bleed from an incision and drainage
site. Youe were transfused and have not had bleeding from your
mouth since [**11-6**].
-Please take all medications as you previously had in addition
to the increased dose of coumadin to 5 mg pending repeat INR
check and follow up with your doctor.
-Please check coumadin level [**First Name8 (NamePattern2) **] [**Hospital1 882**] labs, as previously
had with next check in two days.
-Please maintain follow up appointments.
-Please return to the hospital if you are experiencing shortness
of breath, weight gain, bleeding, chest pain, fainting, swelling
or any other symptoms concerning to you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3070**], unable to be
reached, please call for an appointment.
Please have INR checked in two days, with information faxed to
Dr. [**Last Name (STitle) 10865**] office. via [**Hospital1 882**] lab. Contact[**Name (NI) **] Dr.[**Name (NI) 19264**]
office with recs. [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 9486**]
Please follow up with Dr. [**First Name (STitle) 437**] in the heart failure clinic
[**Telephone/Fax (1) 3512**]. They have been contact[**Name (NI) **] and are awaiting
confirmation. Please call if you have not received confirmation
within one day.
.
Please contact your oral surgeon. Dr. [**Last Name (STitle) 10166**] for follow-up on
abcess site, and bleed.
|
[
"528.3",
"790.92",
"585.9",
"403.90",
"427.31",
"416.8",
"398.91",
"V42.2",
"E934.2",
"287.5",
"276.52",
"396.3",
"285.1",
"397.0",
"998.11",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
8206, 8212
|
4347, 7095
|
334, 341
|
8382, 8391
|
2412, 4324
|
9097, 9912
|
1907, 1912
|
7343, 8183
|
8233, 8361
|
7121, 7320
|
8415, 9074
|
1927, 2393
|
254, 296
|
369, 1310
|
1332, 1703
|
1719, 1891
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,065
| 198,394
|
17041
|
Discharge summary
|
report
|
Admission Date: [**2137-5-13**] Discharge Date: [**2137-5-13**]
Date of Birth: [**2065-2-1**] Sex: F
Service: MEDICINE
Allergies:
Amlodipine
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Resp distress
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
72 Yo F from [**Hospital3 **] in USOH throughout the day, found
unresonsive in room after vomiting. Pt has PMH sig for CVA,
dementia, DMII, hyperlipidemia, PVD, and unclear hx of GIB. By
report, pt found in room with vomit around mouth, unresponsive
and gurgling. EMS called, and found pt with SaO2 of 77%, RR-36,
BP 195/91, HR 127, Temp 100.8. FSBS was 502. Unable to intubate
in the field. Pt arrived to ED and was intubated. Lactate 3.5.
Blood cx drawn. Pt received Vanc/ Ceftaz for LLL seen on CXR. BP
dropped to 100's after pt received propofol. Received 10 units
insulin IV and FSBS 400.
Past Medical History:
-Diabetes
-Hypertension
-Urinary tract infections
-Hx CVA-> L MCA with R hemiparesis, dysphagia.
-PVD
-Dementia
-PUD, hx upper GIB.
- Vit B 12 def
-Iron def anemia
- Diabetic Gastroparesis
Social History:
Lives at [**Hospital3 **].
Family History:
Unknown.
Physical Exam:
T:100 (rectal) BP: 86/61 HR: 115 RR: 26 O2saturation 99% vent
(650/24, 5, 0.6)
Gen: Intubated and sedated, minimally responsive to pain.
HEENT: eyes appear surgical, minimal pupil rxn to light, R>L.
NECK: Supple. No cervical or supraclavicular lymphadenopathy. No
JVD.
CV: Tachy, Normal S1 and S2. No murmurs.
LUNGS: Decreased BS at bases, ant and lat fields clear.
ABD: Hypoactive BS, soft, No guarding.
EXT: Warm and well perfused. No clubbing or cyanosis. No lower
extremity edema, bilaterally.
SKIN: No rashes, ulcers, petechiae, or pigmented lesions. No
ecchymoses. No xerosis.
NEURO: intubated and sedated. Pupils as above. toes upgoing b/l.
minimally withdraws to pain. With decreased sedation pt does
have strong gag.
Pertinent Results:
Admission Labs:
135 100 14
------------<428
4.2 20 0.9
estGFR: 62/74 (click for details)
CK: 129 MB: 4
Ca: 8.6 Mg: 1.6 P: 3.7
ALT: 15 AP: 113 Tbili: 0.3 AST: 22 [**Doctor First Name **]: 217 Lip: 56
9.6
17.0>---<513
30.4
N:91.5 Band:0 L:4.1 M:3.9 E:0.3 Bas:0.2
Hypochr: 1+ Anisocy: 3+ Poiklo: 1+ Macrocy: OCCASIONAL Microcy:
3+ Ovalocy: 1+ Plt-Est: High
PT: 12.4 PTT: 25.2 INR: 1.1
UA: Color Straw Appear Clear SpecGr 1.011 pH 5.0 Urobil Neg
Bili Neg Leuk Neg Bld Neg Nitr Neg Prot Neg Glu 1000 Ket
Tr
Lactate:3.9
ABG: pH 7.30 pCO2 39 pO2 51
Head CT [**2137-5-13**]: Large intraparenchymal hemorrhage with massive
subfalcine and uncal herniation as described above. Hemorrhage
extends into the ventricles, and there is moderate
hydrocephalus.
NOTE ADDED AT ATTENDING REVIEW: The hydrocephalus in the
temporal [**Doctor Last Name 534**] of the left lateral ventricle is likely due to
trapping from the herniation. The grey white matter
differentiation is poorly assessed. There is a possibility of a
low attenuation area in the left frontal lobe consistent with an
acute infarct. This could be confirmed by MRI.
Brief Hospital Course:
72 year old woman with h/o diabetes, peripheral vascular
disease, hypertension, cerebrovascular accident admitted after
being found down with pneumonia, hypoxic respiratory failure,
found to have large intraparenchymal hemorrhage with subfalcine
and uncal herniation. On exam she had minimal gag reflex
initially, no response to pain, unresponsive pupils. She was
assessed by neurosurgery, given a trial of mannitol 100gm iv and
showed no improvement. She then had brain death testing which
showed that she did not have apnea. However neurosugery felt
that she was rapidly progressing towards brain death and would
not survive ventriculostomy and would only survive in a
persistent vegetative state. A family meeting was held where it
was decided to change the goals of care to comfort measures.
Morphine drip was started and extubation was done. She expired
very shortly thereafter.
Medications on Admission:
Compazine prn
NPH
aspirin
plavix
Vit B12
Toprol XL 100
Reglan 10 TID
Neurontin 300 hs
Famotidine 20 hs
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage with herniation, hypertension,
diabetes melitus, peripheral vascular disease, dementia.
Discharge Condition:
Expired.
Discharge Instructions:
None.
Followup Instructions:
None.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"401.9",
"431",
"294.8",
"507.0",
"272.4",
"438.20",
"536.3",
"250.60",
"438.82",
"443.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4193, 4202
|
3125, 4010
|
284, 291
|
4361, 4371
|
1958, 1958
|
4425, 4562
|
1186, 1196
|
4163, 4170
|
4223, 4340
|
4036, 4140
|
4395, 4402
|
1211, 1939
|
231, 246
|
319, 914
|
1974, 3102
|
936, 1126
|
1142, 1170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,102
| 191,948
|
3008
|
Discharge summary
|
report
|
Admission Date: [**2170-6-17**] Discharge Date: [**2170-6-21**]
Date of Birth: [**2124-1-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
traumatic accident - bicycle vs auto
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46yo M bicyclist s/p bike vs auto, hit at 30-35mph & thrown
30-40ft into air, landed on head. No helmet. LOC x5min.
+confusion
Past Medical History:
none
Social History:
married, occasional alcohol, unknown tobacco. employed
Family History:
non-contributory
Physical Exam:
afebrile hemodynamically
3mm R parietal hemorrhage
2cm lac R parietal (stapled)
subgaleal hematoma
R rib fx mildly displaced [**3-20**] except 6
subcutaneous emphysema on R
small R PTX
hypodensity in dome of liver
CTAB but painful breathing
RRR no mrg
S NT ND no HSM
MAE [**6-11**] B LE and UE
A+O x 3
Pertinent Results:
[**2170-6-18**] 01:52AM BLOOD WBC-12.2* RBC-4.70 Hgb-15.4 Hct-42.5
MCV-90 MCH-32.6* MCHC-36.1* RDW-12.7 Plt Ct-341
[**2170-6-17**] 11:15AM BLOOD WBC-14.0* RBC-4.75 Hgb-15.9 Hct-42.5
MCV-90 MCH-33.5* MCHC-37.4* RDW-12.5 Plt Ct-418
[**2170-6-18**] 01:52AM BLOOD Plt Ct-341
[**2170-6-18**] 01:52AM BLOOD PT-12.8 PTT-25.3 INR(PT)-1.1
[**2170-6-17**] 11:15AM BLOOD PT-11.7 PTT-22.9 INR(PT)-1.0
[**2170-6-17**] 11:15AM BLOOD Plt Ct-418
[**2170-6-17**] 11:15AM BLOOD Fibrino-208
[**2170-6-18**] 01:52AM BLOOD Glucose-166* UreaN-16 Creat-1.2 Na-140
K-4.6 Cl-103 HCO3-26 AnGap-16
[**2170-6-17**] 11:15AM BLOOD UreaN-17 Creat-1.1
[**2170-6-17**] 11:15AM BLOOD Amylase-60
[**2170-6-18**] 01:52AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.1
[**2170-6-17**] 11:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-6-17**] 11:15AM BLOOD GreenHd-HOLD
[**2170-6-17**] 11:29AM BLOOD pH-7.41 Comment-GREEN TOP
[**2170-6-17**] 11:29AM BLOOD Glucose-147* Lactate-3.5* Na-139 K-3.9
Cl-104 calHCO3-20*
[**2170-6-17**] 11:29AM BLOOD freeCa-1.02*
Brief Hospital Course:
46yo M bicyclist s/p bike vs auto, hit at 30-35mph & thrown
30-40ft into air, landed on head. No helmet. LOC x5min.
+confusion
Injuries incurred:
3mm R parietal hemorrhage
2cm lac R parietal (stapled)
subgaleal hematoma
R rib fx mildly displaced [**3-20**] except 6
subcutaneous emphysema on R
small R PTX
hypodensity in dome of liver
maging:
[**6-17**] CT Head: 3mm R parietal IPH
[**6-17**] CT Torso: Multiple R sided rib fractures, R ptx
[**6-17**] CXR: R sided ptx w/subcutaneous ai
Chest tube placed, pain service consulted for epidural and pain
management.
Was admitted to TSICU for 24 hours for neuro monitoring and
exams.
Patient transferred to floor without difficulty, chest tube able
to be d/c'ed with decreasing output. Epidural discontinued with
good oral pain regimen transition.
Left tib-fib fracture found during hospital course, and
ORTHOPAEDICS was consulted.
Air walking boot/cast was placed, and the patient was stable for
discharge by Physical therapy with appropriate trauma and
orthopaedic follow-up appointments.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed
for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
multiple traumatic injuries:
3mm R parietal hemorrhage
2cm lac R parietal (stapled)
subgaleal hematoma
R rib fx mildly displaced [**3-20**] except 6
subcutaneous emphysema on R
small R PTX
hypodensity in dome of liver
Discharge Condition:
stable, weight bearing as tolerated to bilateral lower
extremities, tolerating usual diet, ambulating independently
without difficulty
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* 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.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
You are to call Dr.[**Name (NI) 12389**] office ASAP for a follow-up
appointment in the trauma clinic.
You are to call Dr.[**Name (NI) 4016**] office ASAP for a follow-up
appointment IN ONE WEEK in the Orthopaedic surgery clinic
You are to call your primary care physician [**Name9 (PRE) 2678**] for [**Name Initial (PRE) **]
post-hospitalization follow-up appointment.
|
[
"853.02",
"573.8",
"530.81",
"V45.4",
"873.0",
"958.7",
"E813.6",
"807.08",
"860.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"34.04",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
3397, 3403
|
2058, 2413
|
350, 357
|
3665, 3802
|
987, 2035
|
5018, 5391
|
629, 647
|
3154, 3374
|
3424, 3644
|
3125, 3131
|
3826, 4656
|
4671, 4995
|
662, 968
|
274, 312
|
385, 513
|
2422, 3099
|
535, 541
|
557, 613
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,825
| 172,575
|
30101
|
Discharge summary
|
report
|
Admission Date: [**2117-9-2**] Discharge Date: [**2117-9-16**]
Date of Birth: [**2078-1-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
EtOH intoxication, finding of significant hemoperitoneum in
emergency department.
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy with evacuation of hemoperitoneum.
2. Small intestinal resection with anastomosis.
3. Appendectomy
History of Present Illness:
39-year-old homeless man with a history of alcoholism who
entered the emergency
room several hours earlier with an alcohol level of 450. He
underwent an ultrasound of the abdomen which revealed free
intraperitoneal fluid. A subsequent CT scan suggested the
presence of significant hemoperitoneum. There was no obvious
parenchymal or viscous injury. There was no clear-cut active
extravasation of contrast. He was admitted to the trauma service
and initially observed. However, his initial hematocrit, which
had been 34, eventually drifted to 28 over approximately [**4-26**]
hours. He received 2 units of transfusion;
but his hematocrit increased only to 30. He remained
tachycardiac to the 120s with unresolved abdominal tenderness.
Past Medical History:
polysubstance abuse
depression
bipolar disorder (treated at [**Hospital3 **])
Social History:
Currently homeless alternates between staying on the street and
with friends. Occasional marijuana use. Drinking x 21 years
since age 16 y.o. Pt reports history of DTs with seizures when
treated at [**Hospital1 2177**], denies IVDA, no cocaine x2 months.
Family History:
Mom - lives in [**Country 29586**], could not give mother's medical
history; Dad - died in 50's with h/o alcoholism.
Physical Exam:
On admission:
General - WN/WD, NAD, intoxicated
[**Country 4459**] - PERRL, normocephalic, small abrasion on head, no
cervical tenderness
CV - RRR
Chest - no crepitus
Abdomen - soft, diffuse tenderness
GU - guiac negative, foley placed
Extremities - L foot tenderness to palpation
Skin - no abrasions appreciated
On discharge:
General - NAD, AOx3
[**Country 4459**] - Normocephalic
CV - RRR
Resp - CTA bilaterally
Abdomen - soft, midline tenderness, wound wet-to-dry dressing
clean, mild erythema
Extremities - L foot in cast
Pertinent Results:
[**2117-9-2**] 11:36PM LACTATE-3.4*
[**2117-9-2**] 11:36PM HGB-11.0* calcHCT-33
[**2117-9-2**] 11:30PM PT-14.0* PTT-22.8 INR(PT)-1.2*
[**2117-9-2**] 08:45PM URINE HOURS-RANDOM CREAT-75 TOT PROT-115
PROT/CREA-1.5*
[**2117-9-2**] 08:45PM URINE HOURS-RANDOM
[**2117-9-2**] 08:45PM URINE GR HOLD-HOLD
[**2117-9-2**] 08:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2117-9-2**] 08:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2117-9-2**] 08:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2117-9-2**] 08:45PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0 RENAL EPI-0-2
[**2117-9-2**] 08:32PM GLUCOSE-173* UREA N-8 CREAT-1.4* SODIUM-140
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-21* ANION GAP-20
[**2117-9-2**] 08:32PM estGFR-Using this
[**2117-9-2**] 08:32PM ASA-NEG ETHANOL-451* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2117-9-2**] 08:32PM WBC-6.2# RBC-3.51*# HGB-11.3*# HCT-34.2*
MCV-97# MCH-32.1* MCHC-33.0 RDW-14.1
[**2117-9-2**] 08:32PM NEUTS-77.9* LYMPHS-17.9* MONOS-3.4 EOS-0.5
BASOS-0.2
[**2117-9-2**] 08:32PM PLT COUNT-181
Brief Hospital Course:
Mr [**Known lastname **] is a 39yo male admitted to [**Hospital1 18**] on [**2117-9-2**] via
the emergency department. He initially presented with an EtOH
level of 450 and was noted on ultrasound and subsequent CT scan
to have a significant hemoperitoneum. He was taken to the OR on
[**2117-9-3**], for an exploratory laparotomy that resulted in
the evacuation of the hemoperitoneum and discovery of an area of
mesenteric avulsion in the terminal ileum that was resected
along with the appendix. The patient tolerated the procedure
well and was extubated successfully. He was also noted to have
multiple metatarsal fractures of the left [**Last Name (un) 5355**] for which he was
placed in a cast. His hospital stay was notable for the
development of an ileus that resolved successfully and by an
area of erythema affecting the distal portion of his abdominal
incision. The incision staples were removed from this area and
the incision packed with wet-to-dry dressings changed twice
daily.
He had another episode of emesis on [**9-15**] which prompted a CT
scan to evaluate for an obstruction or for abscess. The CT scan
was reassuring in that there was no abscess. He did have a small
amount of narrowing at the site of his small intestine
anastomosis. This could be from post-operative inflammation. He
was not clinically obstructed, passing gas and having bowel
movements.
He is stable condition, but needs wet-to-dry dressing changes
[**Hospital1 **] for his abdominal wound. He is to follow up in office with
Dr. [**Last Name (STitle) 519**] in 2 weeks for wound evaluation and also to ensure that
his bowel function is adequate.
Medications on Admission:
None known
Discharge Medications:
Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times
a day).
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
Oxycodone 5-10mg po q4h prn:pain
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 11009**] House
Discharge Diagnosis:
hemoperitoneum with peritonitis, presumed blunt trauma to
abdomen with mesenteric avulsion
non-displaced fractures at the bases of 2d, 3rd, and 4th
metatarsals
- Hemoperitoneum with peritonitis, presumed blunt trauma to
abdomen with mesenteric avulsion
- Non-displaced fractures at the bases of 2d, 3rd, and 4th
metatarsals
Discharge Condition:
stable/good
Discharge Instructions:
- Continue wet-to-dry dressing changes twice a day for until
your follow up appointment in 2 weeks.
- Please take your prescribed medications as directed
- For your foot fracture, you are to be heel weight bearing only
until your first orthopaedic clinic visit, use crutches as
needed.
- Please contact the office or proceed to the nearest emergency
department if you have temperatures greater than 101.5F or have
significant drainage from your abdominal incision site
Followup Instructions:
- Follow-up in general surgery clinic in 2 weeks with Dr.
[**Last Name (STitle) **], please call [**Telephone/Fax (1) 6429**] to schedule this appointment.
- Follow-up in orthopedics clinic in 4 weeks, please call
[**Telephone/Fax (1) 1228**] to schedule this appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2117-9-16**]
|
[
"997.4",
"910.0",
"567.9",
"780.39",
"V60.0",
"E878.8",
"868.03",
"296.80",
"825.25",
"863.89",
"303.00",
"560.1",
"E928.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"45.62",
"47.19",
"99.07",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5573, 5680
|
3583, 5227
|
395, 522
|
6050, 6064
|
2354, 3560
|
6581, 7013
|
1674, 1792
|
5288, 5550
|
5701, 6029
|
5253, 5265
|
6088, 6558
|
1807, 1807
|
2135, 2335
|
274, 357
|
550, 1285
|
1821, 2121
|
1307, 1386
|
1402, 1658
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,755
| 175,430
|
4329
|
Discharge summary
|
report
|
Admission Date: [**2165-1-26**] Discharge Date: [**2165-1-27**]
Date of Birth: [**2123-1-27**] Sex: F
Service: MEDICINE
Allergies:
Codeine / E-Mycin / Motrin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hematamesis/melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
41 yo female with h/o hypothyroidism and gastiric ulcer due to
motrin use in the [**Last Name (un) 18712**], presents to the ED with melena and
recent h/p hemetamesis. Patient reports that she returned from
the Carribbean on [**2165-1-14**] and felt well till [**2165-1-20**], when she
felt quezy, nauceaous, and had emesis times 2 (non-bloody and
bilious). Patient then felt quezy and had mild nausea Monday
through Wednesdy and also had very poor PO intake. Patient then
felt slightly better on Thursday and ate a rare steak on
Thursady night. SHortly there after, she noted hemetamesis (not
sure of the quantity of blood). Patient had [**1-25**] more episodes or
hematamesis. Patient noted on Friday that she had black stool
(multiple small black BMs). Hence, patient presents to the ED.
In the ED, patient's SBP 140, HR 90 and HCT 40. 2PIVs placed,
patient received iL NA and 40mg IV protonix and anzemet given.
Patient lavaged and it cleared after 700cc. Patient seen by GI
and plans made for MICU admission for EGD.
Past Medical History:
1. hypothyroidism
2. s/p appendectpmy
3. s/p tonillectomy
4. gastric ulcer in setting of motrin use
5. urterocele- s/p repair
6. gestational DM
Social History:
married, 2 children 5 and 11, no TOB, 1-2 beers per night, works
as a data analyst
Family History:
father with ulcers
mother- COPD, emphysema, depression
Physical Exam:
PE: 99.5 143/79 90 17 100% RA
NAD, A and O times 3
NCAT, EOMI, OP clear, MMM, no JVD
RRR no M
CTAB
+BS, soft, NT, ND, no HSM
no c/c/e
CN II-XII intact, strength 5/5 Bilat, nonfocal
Pertinent Results:
[**2165-1-26**] 10:56PM ALT(SGPT)-15 AST(SGOT)-48* ALK PHOS-85 TOT
BILI-1.3
[**2165-1-26**] 10:56PM ALBUMIN-3.5
[**2165-1-26**] 10:56PM WBC-7.2 RBC-3.16* HGB-11.6* HCT-32.2*
MCV-102* MCH-36.8* MCHC-36.1* RDW-12.5
[**2165-1-26**] 10:56PM PLT COUNT-83*
[**2165-1-26**] 04:51PM TOT BILI-1.2 DIR BILI-0.5* INDIR BIL-0.7
[**2165-1-26**] 04:51PM IRON-29*
[**2165-1-26**] 04:51PM calTIBC-282 HAPTOGLOB-101 FERRITIN-262*
TRF-217
[**2165-1-26**] 04:51PM AFP-11.0*
[**2165-1-26**] 04:51PM WBC-7.4 RBC-3.56* HGB-12.8 HCT-36.2 MCV-102*
MCH-35.8* MCHC-35.3* RDW-12.6
[**2165-1-26**] 04:51PM PLT SMR-LOW PLT COUNT-87*
[**2165-1-26**] 04:51PM PT-16.0* PTT-27.5 INR(PT)-1.5*
[**2165-1-26**] 04:51PM FDP-0-10
[**2165-1-26**] 04:51PM FIBRINOGE-248 D-DIMER-269
[**2165-1-26**] 04:51PM RET AUT-1.6
[**2165-1-26**] 02:30PM URINE HOURS-RANDOM
[**2165-1-26**] 02:30PM URINE UCG-NEGATIVE
[**2165-1-26**] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2165-1-26**] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-8.5*
LEUK-NEG
[**2165-1-26**] 02:30PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2165-1-26**] 02:30PM URINE HYALINE-0-2
[**2165-1-26**] 02:13PM HGB-12.9 calcHCT-39
[**2165-1-26**] 10:37AM URINE HOURS-RANDOM
[**2165-1-26**]: RUQ US
The liver is somewhat coarse and increased in echogenicity
without focal mass. The gallbladder is normal without stones or
sludge. The common bile duct measures 3 mm. No free fluid is
seen in the right upper quadrant. The spleen is normal in size.
Pulse color Doppler imaging of the hepatic vasculature
demonstrates normal color flow with normal waveforms in the main
portal vein, left, anterior and posterior right portal veins,
splenic, and superior mesenteric veins. Normal color flow is
seen within the IVC and hepatic veins. Normal color flow and
waveforms are seen in the splenic artery. No varices are seen in
the splenic hilum.
IMPRESSION:
Increased echogenicity of the liver consistent with fatty
infiltration. Patent hepatic vasculature and splenic vein. No
evidence of splenic varices.
[**2164-1-27**] EGD:
EGD showed 1+ esophageal varices (non bleeding, no stigmata of
bleeding). Antrum had multiple erosions w/o bleeding. yellow
bile in stomach and duodenal bulb, which was normal.
Asses: Bleeding likely from erosive gastritis. Esophageal
varices indicate liver disease in all liklihood. Suggest abd CT
and US to characterize liver, hepatitis serologies, iron
studies,
AFP.
[**2165-1-26**] 10:37AM URINE UHOLD-HOLD
[**2165-1-26**] 10:10AM GLUCOSE-213* UREA N-11 CREAT-0.8 SODIUM-137
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
[**2165-1-26**] 10:10AM ALT(SGPT)-22 AST(SGOT)-70* LD(LDH)-340* ALK
PHOS-111 TOT BILI-1.7*
[**2165-1-26**] 10:10AM ALBUMIN-4.3
[**2165-1-26**] 10:10AM NEUTS-76.5* LYMPHS-18.6 MONOS-3.4 EOS-1.0
BASOS-0.5
[**2165-1-26**] 10:10AM WBC-7.5 RBC-4.02* HGB-14.5 HCT-40.8 MCV-101*#
MCH-36.1* MCHC-35.6*# RDW-12.5
[**2165-1-26**] 10:10AM MACROCYT-1+
[**2165-1-26**] 10:10AM PLT COUNT-107*
[**2165-1-26**] 10:10AM PT-15.3* PTT-27.1 INR(PT)-1.4*
Brief Hospital Course:
1. Upper GIB: DDx included [**Doctor First Name 329**] [**Doctor Last Name **] tear, ulceration,
gastritis, AVM. EGD consistent with erosions and grade I
esophageal varices. Nature of varices not clear, but GI work up
of portal HTN started with RUQ US, which revealed a fatty liver
and normal flow on dopplers. Patient also noted to have
thrombovytopenia to 80s, elevated t. bili at 1.3 and mildly
elevated AST. DIC work-up negative and these lab abnormalities
felt likely secondary to mild liver disease vs low grade
hemolysis. COOMS test sent and pending at time of discharge.
Given stability of Plt CT and LFTs and patient's keen desire to
go home, as well as hemodynamic stability, patient dcd to home
with PCP follow up. Patient was advised to continue on [**Hospital1 **] PPI
and to avoid ETOH and offending foods. Patient also told that
she needs liver follow. At time of DC, Immunoglobulins, ASA,
hepatitis serologies and iron studies were pending and need to
be followed up by PCP.
In terms of her GI bleed, patient remained hemodynamically
stable and was maintained on [**Hospital1 **] IV Protonix. HCT stabilized to
32 (from 40). This drop felt likely secondary to IN hydration.
Patient initially NPO, but diet advanced after EGD. Patient
tolerated without event.
2. Hypothyroidism: Continued on home synthroid.
3. DM: Patient with h/o gestational DM. She was maintianed on
ISS and had fasting BS > 120. Patient's HBA1C sent and was
pending at time of discharge. This will need tp be followed up
by PCP. [**Name10 (NameIs) **] wa started on Metformin at 500mg QD and advised
of the side effects. will continue on ISS fo rnow and will
likely need outpatient follow up.
4. FEN: NPO initially and hten advanced.
5. PPx: [**Hospital1 **] IV PPI, pneumobots
6. Code: Full
7. Access: 2P IVs
8. Dispo: To floor once stable
9. Communication: Husband
Medications on Admission:
1. Synthroid 175mcg QD
2. MVI
3. Calcium
Discharge Medications:
1. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Gi Bleed secondary to gastric erosions
Hyperglycemia
Elevated Liver Fuction Tests
Thrombocytopenia
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as prscribed. Please report to your
primary care physician with nay nausea, vomiting, reflux
sensation in throat, fevers, chills, abdominal pain, diarrhea,
BRBPR, blood in your vomit.
Followup Instructions:
Please call your primary care physician [**Last Name (NamePattern4) **] [**2165-1-28**] and set up
follow up.
Your primary care physician needs to follow up on your
Hemoglobin A1C, imunoglobulins, hepatitis serologies, iron
studies.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2165-1-27**]
|
[
"715.90",
"250.00",
"456.1",
"244.9",
"790.4",
"287.5",
"535.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7435, 7441
|
5113, 6976
|
313, 319
|
7590, 7599
|
1929, 5090
|
7859, 8260
|
1656, 1712
|
7067, 7412
|
7462, 7569
|
7002, 7044
|
7623, 7836
|
1727, 1910
|
255, 275
|
347, 1372
|
1394, 1540
|
1556, 1640
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,957
| 142,430
|
50675
|
Discharge summary
|
report
|
Admission Date: [**2137-7-27**] Discharge Date: [**2137-7-30**]
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**Last Name (un) 2888**]
Chief Complaint:
chest pain and SOB
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
[**Age over 90 **] year old man with severe CAD s/p CABG with severe 3VD
non-intervenable, PPM, DM2, HTN, HLD, dCHF LVEF 55%, presents
with intermittent left sided chest pain and SOB. He has angina
at baseline but per his son, his chest pain became more frequent
over the past two weeks, now occuring twice daily. At midnight
the night of admission he developed persistent pressure like
chest pain. He took nitro x2 with relief of pain, but rapid
recurrence of pain within minutes. Denied arm, back or jaw pain.
He received 325mg aspirin by EMS.
His 3VD has been evaluated on several occasions. He has chronic
stable angina that is not amenable to percutaneous or surgical
coronary intervention due to the diffuse nature of disease.
In the ED, initial VS were: 96.6 120 157/94 24 100% 12L NRB. ECG
showed Vpaced/tach @ 125, LAD w/negative sgarbossa's criteria.
Labs notable for trop 0.06, Cr 2.3 (baseline 1.6), HCO3 21, WBC
11.2, HCT 29.5, Plt 117, INR 1.2. CXR showed cardiomegaly, new
pulmonary edema and a small left pleural effusion. Received
morphine 5mg x2, nitro SL. Pain recurred thus prompting
initiation of a nitroglycerin drip. Vitals prior to transfer HR:
125, RR: 22, BP: 140/83, Rhythm: Paced Rhythm, O2Sat: 98,
O2Flow: 3l NC.
Pt brought to the [**Hospital1 1516**] service and while there had trop and CKMB
34 rising and was subsequently brought to the cath lab for
immediate intervention.
.
REVIEW OF SYSTEMS:
+ Intermittent dry cough, 2 episodes of diarrhea 2 weeks ago
- Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
-CAD: Severe 3 vessel disease s/p 3v CABG [**2108**](SVG=>D1=>LAD,
SVG=>OM1=>OM3, SVG= >AM). SVG=>D1=>LAD was stented [**2128**]. Repeat
cath [**7-12**] showed inoperable disease. During admit [**10-12**], had CP
a/w some dynamic ST segment depressions in anterior leads,
medically managed with aspirin, [**Month/Year (2) 4532**], ACE, imdur, and
betablocker. LVEF >55% on Echo done 12/[**2131**].
-Incarcerated paraesophageal hernia s/p laparoscopic repair with
fundoplication in [**10-12**]; associated gastric outlet obstruction
resolved with surgical repair
-Lower gastrointestinal bleed secondary to hemorrhoids and
colonic polyps, admit [**2129-11-20**]
-Hypertension with mild symmetric LVH
-Afib, first noted post-op during [**10-12**] admission post op after
paraesophageal hernia repair, converted to NSR on 11/[**2131**]. Off
coumadin [**2-7**] significant bleeding issues.
-Hyperlipidemia
-Diabetes type II
-By MRI/MRA: left posterior parietal infarct, chronic
periventricular microvascular ischemic changes, moderate disease
resulting in 60-70% stenosis of the right precavernous and
cavernous ICA
-s/p bilateral carotid endarterectomy
-Peripheral vascular disease status post left toe amputation,
followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 105256**] of prostate cancer status post radiation therapy
-Cataracts
-Symptomatic bradycardia s/p pacemaker placement on [**2137-6-4**]
Social History:
Lives with his wife [**Name (NI) 1446**] and son [**Name (NI) **] who is active in his
care. Retired physical therapist, musician and barber.
Independent of ADLs except for showering. Wife does the bills.
He does his own medications and his son supervises. 3 children,
3 grandchildren and 7 great grandchildren.
# Tobacco: none
# Alcohol: none
# Illicit: none
Family History:
Father died at 78 due to probable MI. Mother died at 86 due to
probable MI.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITALS: afebrile, 140/97, 125 94% 2L
GENERAL: lethargic, yet oriented x3, labored breathing, cool and
clammy skin
HEENT: PERRL, EOMI, MMM
NECK: no carotid bruits, JVD to level of earlobe
LUNGS: using accessory muscles of respiration, crackles [**2-8**] way
up
HEART: sinus tachycardia, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: 1+ pitting LE and UE edema, distal erythema in
distal UE bilaterally, venous statis changes on lower ext.
DISCHARGE PHYSICAL EXAM:
VITALS: T 97.6, HR 72, BP 135/72, RR 18 100 RA
LOS: > -4300cc
24 hr I/O: 1250/1500
8hr I/O: 0/400
GENERAL: Alert, oriented x3, NAD
HEENT: PERRL, EOMI, edentulous, MMM
NECK: Supple, JVD 8 cm.
LUNGS: No increased use of respiratory muscles. CTAB.
HEART: sinus tachycardia, normal S1 S2, no GCMR
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: no edema, warm, well perfused, venous stasis, feet
resting in boots to minimize pressure sore.
Pertinent Results:
ADMISSION LABS:
[**2137-7-27**] 01:35AM WBC-11.2*# RBC-3.16* HGB-9.6* HCT-29.5*
MCV-93 MCH-30.5 MCHC-32.7 RDW-15.4
[**2137-7-27**] 01:35AM NEUTS-82.0* LYMPHS-13.0* MONOS-3.0 EOS-1.6
BASOS-0.5
[**2137-7-27**] 01:35AM PT-13.1* PTT-30.0 INR(PT)-1.2*
[**2137-7-27**] 01:35AM PLT COUNT-117*
[**2137-7-27**] 01:35AM cTropnT-0.06*
[**2137-7-27**] 01:35AM GLUCOSE-262* UREA N-68* CREAT-2.3* SODIUM-140
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-21* ANION GAP-19
[**2137-7-27**] 01:55AM LACTATE-1.3
[**2137-7-27**] 06:20AM CK-MB-34* MB INDX-10.3* cTropnT-0.38*
[**2137-7-27**] 06:20AM CK(CPK)-331*
DISCHARGE ADMISSION LABS:
[**2137-7-30**] 08:17AM BLOOD WBC-7.2 RBC-3.06* Hgb-9.2* Hct-28.4*
MCV-93 MCH-29.9 MCHC-32.2 RDW-15.3 Plt Ct-112*
[**2137-7-29**] 04:45AM BLOOD PT-13.1* PTT-28.3 INR(PT)-1.2*
[**2137-7-30**] 08:17AM BLOOD Glucose-155* UreaN-65* Creat-1.8* Na-137
K-3.6 Cl-100 HCO3-25 AnGap-16
[**2137-7-28**] 06:08AM BLOOD CK-MB-58* cTropnT-4.27*
[**2137-7-27**] 09:54AM BLOOD Type-ART pO2-111* pCO2-39 pH-7.40
calTCO2-25
[**2137-7-27**] 09:54AM BLOOD Lactate-1.4
___________________________________
ECG Study Date of [**2137-7-27**] 2:53:48 PM
Probable atrio-ventricular sequential pacing with low amplitude
atrial pacingartifacts. Compared to the previous tracing of the
same date the rate is significantly slower and now appears to be
atrial paced rather than likely sinus. Morphology of the paced
QRS complexes is unchanged, with appropriate secondary
repolarization abnormalities.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 0 174 462/477 0 -83 99
_____________________________________________________
CXR (AP) [**2137-7-27**]
FINDINGS:
Left-sided pacemaker ends in the right atrium and right
ventricles. Moderatecardiomegaly and pulmonary edema, new
compared to [**2137-6-12**]. There is a small left pleural
effusion.
_____________________________________________________
PRE-CATH ECHO [**7-27**]
IMPRESSION: (EF 30-35%) Suboptimal image quality. Mild symmetric
left ventricular hypertrophy with regional left ventricular
systolic dysfunction c/w multivessel CAD. Mild right ventricular
systolic dysfunction. At least moderate mitral regurgitation.
Mild aortic regurgitation. Borderline pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2137-3-20**],
more extensive regional dysfunction is present with extensive
hypokinesis of the distal third of the ventricle and
anterolateral wall. The severity of mitral regurgitation has
increased.
___________________________________________________
Cardiac Cath [**2137-7-27**]
1.Three vessel coronary artery disease
2.Occlusion of the SVG-OM
3.Occlusion of the SVG to the Acute Marginal
4.Patent stents in the SVG to the diagonal-LAD with progressive
of disease in the native LAD
5.Successful bare metal stent to the native LAD at the
anastomotic site
_____________________________________________________
Post Cath Echo [**2137-7-28**]
There is mild symmetric left ventricular hypertrophy. There is
mild (non-obstructive) focal hypertrophy of the basal septum.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is low normal (LVEF 50%) secondary
to dyskinesis of the basal segment of the inferior and posterior
walls. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2137-7-27**], the left ventricular ejection fraction is
significantly increased due to normalization of contractile
function of the apex and of the midventricular and apical
segments of the inferior free wall and posterior wall. The
mitral regurgitation is reduced. Right ventricular contractile
function is improved as well.
_____________________________________________________
Pacemaker interrogation [**2137-7-30**]
Normal device function with mode switching likely during
episodes
of paroxysmal atrial fibrillation.
Brief Hospital Course:
[**Age over 90 **] year old man with severe CAD 3VD, who presented with left
sided chest pain and SOB, found to have elevated cardiac
biomarkers consistent with NSTEMI requiring LHC and BMS to the
LAD.
ACTIVE DIAGNOSES:
# NSTEMI: The patient has an extensive h/o CAD with severe 3VD
s/p CABG. He presented with chest pain and was noted to have
increasing troponin and elevated CK-MB. The degree of myocardial
involvement was unclear as his EKG showed pacemaker pacing. He
was initially placed on heparin drip, nitro drip for pain
control, and aspirin. Cath lab showed 3 vessel CAD, occlusion
of SVG-OM, occlusion of SVG-acute marginal, patent stents in the
SVG-diagonal with progressive disease in the native LAD 80%
focal stenosis. BMS was placed in the LAD at the anastomotic
site. His tolerated this procedure well and was then transferred
to CCU for monitoring before his transfer to the floor. He was
started on [**Age over 90 4532**] 75 mg (>1 month goal therapy) and metoprolol.
He was also continued on aspirin and his home statin. His nitro
drip was easily tapered off 24 hrs after cath. He was not
started on ACEI was held due to [**Last Name (un) **]. He was consulted on the
proper diet and exercise if on the [**Hospital1 1516**] service. He will
follow-up with Dr. [**First Name (STitle) 437**] as an outpatient.
# Acute systolic heart failure and acute on chronic diastolic
heart failure: The patient had history of diastolic CHF (EF>50%
last year) with acute exacerbation in the setting of the NSTEMI
(EF pre-cath was 30-35%). Post-cath (described above) he
required aggressive Lasix gtt diuresis in the CCU. After
achieving euvolemia, he was started on an increased dose of
furosemide. He was also started on metoprolol. Notably, his EF
post-cath was >55%. He will follow-up with Dr. [**First Name (STitle) 437**].
# Atrial Fibrillation: The patient has history of atrial
fibrillation, rate controlled on metoprolol. He was not recently
on coumadin given history of bleeding. Pt also had a h/o
symptomatic bradycardia s/p pacemaker. Pacemaker interrogation
during his admission showed paroxysmal atrial fibrillation. He
was not started on anticoagulation this admission given his
bleeding history. This issue to be addressed by Dr. [**First Name (STitle) 437**] at
next outpt appointment.
# [**Last Name (un) **]/Pre-renal Azotemia: Pt with baseline Cr 1.4, but marked
elevation to 2.6 after aggressive diuresis with Lasix gtt in the
CCU, thus representing pre-renal state. His urine output
remained stable. His Cr was downtrending at the time of
discharge to 1.8. His PCP will follow creatinine levels after
discharge.
CHRONIC DIAGNOSES:
# DM2: Poorly controlled, likely to stress response. At baseline
controlled with januvia alone. While in house, given insulin
glargine and ISS. PCP to follow
# HLD: Stable, continued statin.
TRANSITIONAL ISSUES:
-[**Last Name (un) **] x 1 month, watch carefully as he is predisposed to
bleeding
-Afib seen on pacemaker interrogation. Recommend discussing
anticoagulation on coumadin etc at next cardiology outpt
appointment eventhough he is known to bleed easily.
-His Furosemide was increased to 20mg daily dosing, metoprolol
to 50mg XL and
-Cr to be followed by PCP.
[**Name10 (NameIs) **] code status
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 20 mg every other day
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. Simvastatin 40 mg PO DAILY
9. sitaGLIPtin *NF* 50 mg Oral daily
10. Acetaminophen 500 mg PO Q6H:PRN pain
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Vitamin D 400 UNIT PO BID
14. Multivitamins 1 TAB PO DAILY
15. Psyllium 1 PKT PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
4. Calcium Carbonate 500 mg PO BID
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
12. Psyllium 1 PKT PO DAILY
13. Simvastatin 40 mg PO DAILY
14. Vitamin D 400 UNIT PO BID
15. Clopidogrel 75 mg PO DAILY
RX *[**Hospital1 **] 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
16. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
17. Metoprolol Succinate XL 50 mg PO DAILY
HOLD IF SBP <100 and HR <60
Please call HO if holding
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
18. sitaGLIPtin *NF* 50 mg Oral daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Non ST-Segment Elevation Myocardial Infarction (Heart attack)
Systolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 105255**],
You were admitted with shortness of breath likely due to a
heart attack. We were able to treat the blockage in your heart
with a stent which we placed non-invasively. Initially, the
heart attack caused a worsening of the squeeze of your heart,
however this quickly recovered to near normal.
The following medication changes have been made while you were
here:
Increase Furosemide (lasix) to 20mg daily from 20mg every other
day to prevent shortness of breath.
START [**Known lastname 4532**] to prevent clotting in your stent.
START metoprolol to prevent further heart attacks.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: GERONTOLOGY
When: FRIDAY [**2137-8-2**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2137-8-5**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2137-8-26**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2137-8-1**]
|
[
"250.00",
"486",
"427.89",
"410.72",
"414.01",
"585.9",
"272.4",
"V53.31",
"427.31",
"403.90",
"414.02",
"787.91",
"410.71",
"E930.8",
"V45.82",
"428.0",
"443.9",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14643, 14690
|
9426, 9629
|
256, 281
|
14830, 14830
|
4937, 4937
|
15716, 16702
|
3856, 3933
|
13500, 14620
|
14711, 14809
|
12740, 13477
|
14981, 15693
|
3948, 3958
|
3980, 4448
|
12319, 12714
|
1737, 2027
|
198, 218
|
309, 1718
|
5566, 9403
|
14845, 14957
|
9648, 12298
|
2049, 3462
|
3478, 3840
|
4473, 4918
|
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