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71,788
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10685
|
Discharge summary
|
report
|
Admission Date: [**2105-9-30**] Discharge Date: [**2105-10-13**]
Date of Birth: [**2077-12-2**] Sex: M
Service: SURGERY
Allergies:
Morphine / Ciprofloxacin
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Recurrent small bowel strictures related to Crohn's Disease
Major Surgical or Invasive Procedure:
1. Open ileocolectomy due to stricture with anastamosis
2. Exploratory laparotomy, resection of anastomosis,
ileostomy and mucus fistula.
History of Present Illness:
This young man had undergone three prior operations to resect
Crohn disease. He presented with a fixed stricture in the
neoterminal ileum which was symptomatic and resistant to medical
therapy, and therefore he was brought to the operating room.
Past Medical History:
Crohn's disease, diagnosed in third grade, complicated by
perirectal fistula
Bowel resections X 3
Nephrolithiasis, s/p lithotripsy
Social History:
Works as state park ranger.
Quit smoking 6 months ago.
Occasional etoh.
Single.
Family History:
IBD in maternal side, several cousins with [**Name (NI) 4522**] and UC
Physical Exam:
At Discharge:
Vitals: Afebrile VSS
GEN: NAD, A+OX3, supine on bed
CV: RRR
RESP: CTAB no wheezes/crackles/rhonchi
ABD: Soft, appropriately tender, non-erythematous around
incision site, site is c/d/i, exposed bowel pink, viable,
healthy appearing, covered with damp gauze,
ostomy pink and viable.
Extrem: no c/c/e
Pertinent Results:
Admit WBC: 14.7 (elevated likely from steroids)
Discharge WBC: 13.3 (elevated likely from steroids)
Peak WBC: 21.5 on [**10-4**]
Lacte [**10-6**]: 1.6
Admit hct: 36.6
Discharge hct: 27.2
Brief Hospital Course:
[**9-30**] POD 0 - Postoperatively the patient did well. His pain
was controlled on a PCA. He had a FTG. He did attempt to
ambulate a little post-operatively.
[**10-1**] POD 1 - He continued to do well. He had minimal pain.
His FTG was DCed at midnight.
[**10-2**] POD 2 - Patient failed his void trial. The FTG was put
back in. He started to develop chills at night however remained
afebrile.
[**10-3**] POD 3 - Pt febrile to 102 with chills. In addition
tachycardic in the 120s. EKG shows sinus tach. Blood and urine
Cx taken. UA was negative. Looking back, the patient never
recieved his dose of IV steroids. Steroids started immediately
in addition to 20 mg Prednisone PO. CXR does not show
consolidation. Hct stable.
[**10-4**] POD 4 - Pt afebrile but tachycardic in the 120s. Placed on
telemetry and started on Metoprolol 5 mg IV for his tachycardia.
Patient c/o diffuse tenderness on abdominal exam. His WBC is
elevated at 21.5. Continues to be afebrile. He is not passing
gas.
[**10-5**] POD 5 - Pt still afebrile, but WBC continues to
significantly elevated. Pt still tachycardic in the 110-120's.
No signficant events on telemetry. Abdominal exam appears
worse: still diffusely tender, some guarding, however he now
appears to have peritoneal signs. Originally the plan was to
obtain a CT of his abdomen, however given his elevation in WBC,
worsening abdominal exam, and the fact that it was POD 5 (likely
for leak), the patient was taken back to the OR and explored.
During the exploration, the surgical team discovered that the
patient did have a leak at the anastamosis and they decide to
resect the anastomosis and perform an ileostomy and mucus
fistula. After the surgery the patient was transferred to the
ICU intubated.
[**10-6**] POD [**4-19**] - The patient did well postoperatively in the ICU.
He was extubated on POD 1 without further complications. He
pain was well controlled on a PCA. His mucus fistula and ostomy
both appeared pink and healthy. All of his cultures were
negative.
[**10-7**] POD [**5-20**] - The patient was found to be hemodynamically
stable and was transferred out of the ICU to the floor. On the
floor the patient continued to do well. He was ambulating on
POD 2. His pain was controlled. There was no ostomy ouput yet.
[**10-8**] - [**10-13**] - Soon after, the patient's bowel function
returned. His diet was advanced slowly which he tolerated well.
There was no N/V. His ostomy was functioning well. His PCA
was switched to PO pain medications which controlled his pain
well. His steroids were converted to PO and his taper was
started in house. On the day of discharge, the patient is
afebrile, his vital signs are stable (normal HR and normal
tensive), his WBC is normal, he is tolerated PO intake well and
his ostomy is functioning well. He is ambulating without
difficulties. He is voiding without difficulties. He will be
discharged home with VNA for dressing changes/ostomy assistance.
Medications on Admission:
Prednisone 40', 6MP 50', Remicade q 6weeks, Percocet,
Pantoprazole
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime) for 1 months.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itchy: Apply to affected
areas.
3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever/HA: DO not exceed 4000mg in
24hrs. Take with oxycodone as indicated.
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for Anxiety for 2 weeks.
Disp:*25 Tablet(s)* Refills:*0*
6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 3 weeks.
Disp:*qs * Refills:*2*
7. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 3 weeks.
Disp:*qs * Refills:*2*
8. PICC Line Care
PICC Line Care per NEHT protocol.
9. Outpatient Lab Work
Weekly CBC, CHem-10, LFT, Vanco level. Fax results to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 35019**].
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO 3-4 times
per day as needed for Increase in liquid ostomy output: Do not
exceed 16mg in 24hrs.
Disp:*120 Capsule(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for pain for 3 weeks.
Disp:*75 Tablet(s)* Refills:*0*
13. Prednisone 2.5 mg Tablet Sig: Per steroid taper Tablet PO
once a day: Decrease by 2.5mg every 7 days.
Disp:*45 Tablet(s)* Refills:*0*
14. Prednisone taper
Decrease dose by 2.5mg every 7days.
1. 7.5mg daily from [**Date range (1) 35020**]/08
2. 5mg daily from [**Date range (1) 21525**]
3. 2.5mg daily from [**Date range (1) 35021**]/08
FINISHED
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Recurrent smal bowel strictures s/p resection of prior
ileocolonic anastomosis
Post-op Large anastamotic leak
Post-op urinary retention
.
Secondary:
Crohns-childhood, perianal disease, anal abscesses
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Visiting Nurses will assist/teach you with abdominal dressing
and ostomy care.
-Do not shower. Sponge baths are permitted
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 9**] next
Thursday [**10-22**]. Call to confirm appointment time.
2. Follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 931**] [**Telephone/Fax (1) 35022**] in 1
week and as needed.
.
Previous appointments:
1. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2105-10-19**] 10:15
2. Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2105-12-3**] 3:00
Completed by:[**2105-10-21**]
|
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22,030
| 119,317
|
21722
|
Discharge summary
|
report
|
Admission Date: [**2141-10-20**] Discharge Date: [**2141-11-5**]
Date of Birth: [**2122-2-2**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
bronchoscopy
mechanical ventilation
History of Present Illness:
19 yo male with history of childhood asthma never requiring
intubation, hospitalized x1, and mutiple steroid tapers
transferred here from an OSH for status asthmaticus. The patient
presented to [**Hospital 11074**] clinic on [**10-18**] with complaints of cough
productive of yellow sputum x2 days and increasing SOB without
fevers, nausea, vomiting, or diarrhea. He was given oral
prednisone, erythromycin, and ipratro + alb nebs x3 with poor
response. He was then transeferred by ambulance to [**Location (un) 16843**]
emergency department. In ED he continued to be short of breath
and was given solumedrol 125 IV, albuterol nebs, racemic epi and
epi 0.3mg SC. Arterial blood gas showed 7.31/53.4/82.8 and CXR
only showed hyperinflation. He was intubated. Pt was difficult
to ventilate and post-vent ABG was 7.08/98/430 so he required
paralysis. Admission labs significant for WBC 17.3 and 5%
bandemia. He was cont on steroids, started on azithromycin and
given q2hr [**Location (un) **]'s but cont to have poor oxy and vent with ABG of
7.3/61/76 and decision was made for transfer here.
Past Medical History:
Asthma- since childhood requiring hospitalization 3yrs ago and
multiple ED visits and steroid regimens with last 8 mo ago. Pt
[**Name (NI) 57099**] seen physician [**Last Name (NamePattern4) **] 3 yrs and uses family members' [**Name2 (NI) **]'s.
Social History:
Works at D&D making bagels, smokes approx 1ppd x 3yrs and lg
amount marijauna use with occasional MDMA use, sexually active
but uses condoms
Family History:
sister and father with asthma well controlled with inhalers. No
family history of early-onset lung diseases/copd.
Physical Exam:
T101.8 HR 116 BP 118/60
Vent RR17 TV620 PEEP8 FIO2 90%
gen: sedated/paralysed
pul: prolonged expiratory phase
cv: tachycardic, s1/s2, no murmurs/rubs/gallops
abd: soft,nt,nd, +bs
ext: no edema
Pertinent Results:
Admission: [**2141-10-20**]
WBC-15.7* RBC-4.77 Hgb-14.6 Hct-43.5 MCV-91 MCH-30.7 MCHC-33.7
RDW-13.2 Plt Ct-256
Neuts-99* Bands-0 Lymphs-0 Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0
Myelos-0
Glucose-134* UreaN-17 Creat-1.0 Na-146* K-4.7 Cl-104 HCO3-33*
AnGap-14
LD(LDH)-171 CK(CPK)-1567*
CK-MB-15* MB Indx-1.0 cTropnT-<0.01
Glucose-138* Lactate-2.6* K-4.4
BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG
Tricycl-NEG
ABG on admission:
[**2141-10-20**] 03:43PM BLOOD Type-ART Temp-39.9 Rates-17/ Tidal V-620
PEEP-8 O2-90 pO2-111* pCO2-83* pH-7.21* calHCO3-35* Base XS-2
AADO2-454 REQ O2-77 Intubat-INTUBATED Vent-CONTROLLED
O2 Sat-95
freeCa-1.26
On Discharge:
WBC-10.8 RBC-4.75 Hgb-14.5 Hct-42.5 MCV-89 MCH-30.6 MCHC-34.2
RDW-13.0 Plt Ct-317
Neuts-95* Bands-1 Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0
Myelos-1*
Glucose-83 UreaN-25* Creat-0.9 Na-135 K-4.8 Cl-99 HCO3-26
AnGap-15
Calcium-9.4 Phos-4.5 Mg-2.2
CK(CPK)-707*
[**2141-10-31**] 05:56AM BLOOD Type-ART pO2-89 pCO2-41 pH-7.45
calHCO3-29 Base XS-3
[**2141-10-24**] 4:05 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2141-10-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2141-10-30**]):
RARE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
[**2141-10-20**]: PORTABLE AP CHEST: No prior studies are available for
comparison. The endotracheal tube is in satisfactory position in
the mid trachea. An NG tube is present with the tip not
visualized, off the inferior film edge. There is no
pneumothorax. There is bibasilar atelectasis and bilateral
pleural effusions. No focal consolidations are seen.
[**2141-10-24**]: PORTABLE AP CHEST: 1. Worsening pneumomediastinum. 2.
Right apical pneumothorax, which appears new in the interval.
3. Bandlike areas of lucency in lower paraspinal region which
appear to represent a combination of posterior pneumomediastinum
and adjacent pulmonary interstitial emphysema on recent chest
CT.
4. Perihilar and basilar opacities, with overall improving
aeration at the lung bases.
[**2141-10-30**]: PORTABLE AP CHEST: 1. Tiny right apical pneumothorax
following chest tube removal. 2. Bibasilar opacities with
interval worsening at the left lung base. The area of worsening
could be due to a progressive infection or due to superimposed
aspiration.
CT CHEST W/O CONTRAST [**2141-10-22**] 11:31 AM
1. Multifocal bronchopneumonia with patchy consolidation and
bronchial wall thickening.
2. Collapse of both lower lobes with adjacent small effusions.
3. Pneumomediastinum and pulmonary interstitial emphysema.
4. Overinflation of ETT cuff.
Brief Hospital Course:
On admission to floor pt's vital were T 101.8 HR 116 BP 118/60
vented at 17/650/50% with 8 of peep with sats of 92% and initial
ABG of 7.21/83/11. He was cont continued on high dose
solumedrol, increased the azithromycin dose, given q1hr
combivent [**Month/Day/Year **]'s and sedated and paralyzed for better
ventilation.
1) Respiratory failure: His presentation was consistent with
poorly controlled asthma exacerbated by smoking although it is
unclear what was the precipitating factor for status
asthmaticus. With his elevated WBC, bandemia and spiking
fevers, CXR, sputum cx, blood cx, ucx were obtained for fever
workup. Blood culture showed strep viridans, but this was likey
contaminated. CT scan showed bullous lung disease, patchy
opacities, and collapse of lower lobes bilaterally. Pt was
empirically treated with azithro (for community acquired
pneumonia), vanco, and ceftriazone. Bronchoscopy showed small
amounts of thick mucus. BAL performed grew out pan-sensitive
klebsiella and oxacillin-sensitive staph.
Pt was difficult to ventilate and required paralytics and
sedation with propofol, then with versed/fentanyl. Sats ran in
the low 90's while intubated with
AC/RR18/PEEP5/TV550/FIO60-100%. High dose steroids were
continued. Albuterol [**Month/Day/Year **] 14-16puffs q1hr. After about five
days in the ICU, paralytics were discontinued but pt was kept
well-sedated on fentanyl. Oxygenation improved and FIO was
weaned down to 60's. Sedation was weaned off and on [**2141-10-29**], pt
was extubated and placed on high flow facemask. Pt was
transitioned to oral prednisone for a slow taper and antibiotics
were discontinued. Inhaled steroids were added while steroids
were tapered off.
On [**11-1**], the patient's sats were in the high 90's on 3L nasal
canula. Alpha1-antitrypsin and HIV serologies were sent to
workup etiology of the small bullous lesion seen on CT scan,
however both were negative and it is felt that the lesions were
due to barotrauma, as evident by pneumomediastinum, subcutaneous
emphysema, and bilateral pneumothoraces.
He was transferred to the floors on [**11-1**], and recovery was
uneventful. He had no further respiratory difficulties, with O2
sat of 96% on RA on the day of discharge. He was maintained off
abx and remained afebrile. He was kept on prednisone 50 mg PO
qday, which should be tapered slowly 10 mg q week. He is being
discharged on 40 mg PO qday as of [**2141-11-6**]. He has been
instructed to make an appointment with a primary care physician
as soon as possible, and to have them set him up with a
pulmonologist as well. He will be discharged on
Fluticasone/Salmeterol inhaler, as well as albuterol.
2) The patient had hyperglycemia due to steroid use while in
the ICU that was covered with RISS. He should have his glucose
checked by finger stick when he sees his new primary care
physician.
3) The patient had an elevated CK on admission to the ICU that
slowly trended down. His muscles were extremely week after
extubation, and he was seen by PT for rehab while in house with
rapid recovery of strength. It is thought that he was weak from
bedrest/prolonged paralytics.
4)Px-Protonix is important in this patient on high dose
steroids, and he should continue the protonix for as long as he
is one them. He is also being discharged with nystatin to help
prevent thrush.
Medications on Admission:
Pt takes family's [**Date Range **]'s
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) dose Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 doses* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
Disp:*2 aerosols* Refills:*2*
3. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 7 days: Take 4 pills for the first seven days, then drop
down to 3 pills each day for the next 7 days, then 2, etc.
Disp:*28 Tablet(s)* Refills:*0*
4. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
5. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for
7 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for white plaques in your mouth. for
14 days.
Disp:*280 ML(s)* Refills:*0*
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
respiratory failure
asthma
Discharge Condition:
Stable, good.
Discharge Instructions:
You will need to decrease your steroid dosage in increments.
Take 4 pills each day (40 mg) for the first 7 days, then 3 pills
each day for the next 7 days, then 2 pills each day for the next
7 days, and then 1 pill each day until you are told to stop. It
is very important that you make sure to see a primary care
physician within the next week or two. If you cannot find one
where you live, call [**Telephone/Fax (1) 250**] and make an appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] here at [**Hospital3 **]. You will also need an
appointment with a pulmonologist. Either have you primary care
physician make this for you, or call [**Telephone/Fax (1) 612**] for our
Pulmonary Clinic.
Use your inhalers everyday.
Return to the hospital if you feel short of breath or begin
wheezing again.
NO SMOKING! This is very important for you.
Followup Instructions:
You will need to followup with a pulmonologist as you taper your
steroids. You should get a primary care physician close to home
as soon as possible, however if this is not possible you should
call [**Telephone/Fax (1) 250**] and schedule an appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] here.
|
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icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,788
| 116,081
|
33759
|
Discharge summary
|
report
|
Admission Date: [**2119-2-2**] Discharge Date: [**2119-2-7**]
Date of Birth: [**2047-3-19**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Iodipamide Meglumine
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Hypotension and hypoxia
Major Surgical or Invasive Procedure:
Central Line Placement [**2118-2-4**] and removal on [**2119-2-7**]
History of Present Illness:
71 F with HTN, dyslipidemia, recent pacer placement for sinus
arrest complicated by recurrent hemorrhagic pericardial
effusions, admitted to [**Hospital1 18**] for episode of hypoxia in the
setting of worsened chest pain and DOE; on [**2-3**] she is
transferred to the ICU for hypotension, new O2 requirement and
confusion.
.
She was reportedly doing well at rehab s/p hemorrhagic
pericardial effusion after PPM placement, until the day prior to
presentation, when she developed worsening chest pain and SOB.
She reported that the pain felt like it was "going around her
heart", was sharp, worse with deep inspiration, and radiated to
the left jaw. She also had SOB, with worsening DOE while walking
at rehab. She otherwise denied n/v, diaphoresis. No lower
extremity pain or swelling. She was found to have an O2 sat of
69% on RA. She was placed on a NRB with improvement in O2 sat to
89%. Sent to ED for evaluation.
.
ED Course: O2 sats >97% on 3L by NC, and SBP remained > 100. She
had a bedside focused echo which showed a "small effusion and no
wall motion abnormalities." Pulsus measurements in the ED
remained < 10 mm Hg. A subsequent formal TTE showed a small to
moderate circumferential pericardial effusion that was echo
dense, consistent with "blood, inflammation or other cellular
elements", without echocardiographic signs of tamponade. Overall
EF 70%. She also received a V/Q scan for an elevated D-dimer
(h/o contrast allergy) which showed multiple large and small
matched defects through out all lobes of the lungs, consistent
with COPD. It also showed an unmatched defect (greater on
perfusion) in the posterior left lower lobe, thought related to
shifting effusion upon position change from ventilation to
perfusion. The study was read as intermediate probability.
.
Hospital Course: patient was admitted to medical service. Today
([**2-3**]) patient had trigger episode with hypotension responsive to
IVF (75/48), new O2 requirement (96% on 2L), mental status
changes - found to be cool and diaphoretic; this prompted her
transfer to the ICU team. ABG at the time was 7.33/43/145.
.
Recent [**Last Name (un) 1724**] Course: Initially presented to [**Hospital3 **] with
syncope and found to have sinus pause with junctional escape of
35. She received PPM on [**1-10**] @ [**Last Name (un) 1724**]. On [**2119-1-13**] (2 days after
discharge for pacer implantation) came back to [**Last Name (un) 1724**] with chest
pain and palpitations and was found to be in atrial fibrillation
with a rapid ventricular response of 190. She was electrically
cardioverted, but remained hypotensive. She was found to have a
pericardial effusion with tamponade. A pericardiocentesis
drained 200 cc of hemorrhagic fluid. However, she had recurrent
effusion later that same day, and ultimately underwent
mediastinotomy, where she was found to have a small bleeding
vessel "at the site of her prior pericardiocentesis." Her atrial
lead could also be seen in the atrium, though it was noted not
to be protruding through, and was oversewn. Also of note, she
was evaluated here for SIADH - found to have normal urine Osm
(656) and low serum Osm (278), urine Na of 81; this resolved
spontanteously. She was discharged to [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] at [**Location (un) 78090**] on [**2119-1-23**].
Past Medical History:
Hypertension
Hyperlipidemia
Parkinson's
Seizure disorder
s/p PPM placement for sinus arrest with syncope ([**Hospital3 **]
[**2119-1-10**])
c/b hemorrhagic effusion and tamponade physiology from "leaking
vessel"
Cerebellar anerysm s/p coiling
Blind in left eye [**1-28**] aneurysm
Social History:
Lives with daughter's family. Current tobacco, ~1ppd x 50yr. No
EtOH or illicits.
Family History:
NC
Physical Exam:
Vitals - T 96.4, BP 107/67, HR 91, RR 18, O2 sat 97% 2L NC, wt
56.1 kg, pulsus 10 mm Hg
General - elderly female, NAD
HEENT - L eye medially deviated. R eye EOMI. OP clr, MM dry, no
JVD
CV - RRR, no rubs
Chest - decr BS at L base
Abdomen - soft
Back - non-tender
Extremities - no edema
.
Pertinent Results:
[**2-1**] VQ Scan: INTERPRETATION:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 6 views
demonstrate multiplelarge and small defects through out all
lobes of the lungs, consistent with COPD.
Perfusion images in the same 6 views show matched defects with
the ventilation scan with a somewhat greater sized perfusion
defect seen in the posterior leftlower lobe, likely related to
shifting effusion upon position change fromventilation to
perfusion.
Chest x-ray shows a small left pleural effusion.
The above findings are consistent with an indeterminant
probability scan.
IMPRESSION: Indeterminant probability scan. Severe COPD.
[**2-5**] CXR:Comparison is made with prior study performed a day
earlier.
There has been progressive interval increase in
small-to-moderate right pleural effusion, moderate left pleural
effusion is unchanged as is left lower lobe retrocardiac
atelectasis. Left transvenous pacemaker leads terminate in the
standard position in the right atrium and right ventricle. Right
subclavian catheter tip remains in the proximal right atrium.
The aorta is elongated. Cardiac size is top normal. There is
engorgement of the pulmonary vasculature with no overt CHF.
Patient is post median sternotomy.
[**2119-2-1**] EKG: Sinus rhythm. T wave inversion in leads VI-V2 and T
wave flattening in leads aVL and V3 which is non-specific.
Ischemia should be considered. Clinical correlation is
suggested. No previous tracing available for comparison.
[**2119-2-3**] ECHO: The left ventricular cavity is small. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen. There is a moderate sized
pericardial effusion subtending the apex, right ventricular free
wall, and lateral wall. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. There are
no echocardiographic signs of tamponade. No right atrial or
right ventricular diastolic collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2118-2-2**], the findings are similar.
[**2119-2-1**] 05:15PM BLOOD WBC-12.3* RBC-4.87 Hgb-14.1 Hct-42.8
MCV-88 MCH-29.0 MCHC-33.0 RDW-14.6 Plt Ct-176
[**2119-2-5**] 02:01AM BLOOD WBC-8.6 RBC-3.58* Hgb-10.4* Hct-31.5*
MCV-88 MCH-29.0 MCHC-33.0 RDW-14.9 Plt Ct-157
[**2119-2-1**] 05:15PM BLOOD Neuts-82.1* Lymphs-13.5* Monos-4.0
Eos-0.3 Baso-0.1
[**2119-2-3**] 08:57PM BLOOD Neuts-92.4* Lymphs-4.2* Monos-3.3 Eos-0.2
Baso-0
[**2119-2-5**] 02:01AM BLOOD PT-13.0 PTT-34.8 INR(PT)-1.1
[**2119-2-1**] 05:15PM BLOOD D-Dimer-[**2076**]*
[**2119-2-5**] 02:01AM BLOOD Glucose-81 UreaN-17 Creat-0.5 Na-134
K-4.0 Cl-104 HCO3-25 AnGap-9
[**2119-2-3**] 12:45PM BLOOD ALT-8 AST-46* LD(LDH)-202 CK(CPK)-8*
AlkPhos-173* TotBili-0.4
[**2119-2-1**] 05:15PM BLOOD cTropnT-<0.01
[**2119-2-2**] 04:00AM BLOOD cTropnT-<0.01
[**2119-2-2**] 11:05AM BLOOD cTropnT-<0.01
[**2119-2-2**] 05:05PM BLOOD cTropnT-<0.01
[**2119-2-3**] 06:10AM BLOOD CK-MB-2 cTropnT-<0.01
[**2119-2-3**] 12:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2119-2-3**] 12:45PM BLOOD Albumin-2.4* Calcium-7.6* Phos-2.7 Mg-1.6
[**2119-2-5**] 02:01AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.5*
[**2119-2-2**] 11:05AM BLOOD Osmolal-272*
[**2119-2-3**] 06:10AM BLOOD TSH-3.9
[**2119-2-3**] 06:10AM BLOOD Free T4-1.3
[**2119-2-3**] 11:00PM BLOOD Cortsol-37.3*
[**2119-2-3**] 10:41AM BLOOD Lactate-1.6
[**2119-2-3**] 10:41AM BLOOD Type-ART pO2-145* pCO2-43 pH-7.33*
calTCO2-24 Base XS--3
Brief Hospital Course:
A/P: 71 F with HTN, dyslipidemia, recent pacer placement for
sinus arrest complicated by recurrent hemorrhagic pericardial
effusions, admitted to [**Hospital1 18**] for episode of hypoxia in the
setting of worsened chest pain and [**Hospital **] transferred to the ICU
for hypotension (75/48), new O2 requirement (96% on 2L) and
mental status changes. Was found to have Klebsiella UTI, was
started on broad spectrum ABX and then tailored to cipro.
Clinically improved, vitals stable >24hrs. Pt transferred back
to medicine floor on [**2-5**], where she remained until day of
discharge.
.
#) Klebsiella UTI/septicemia -- Pt presented with a high white
cell count and hypotension. She was started on broad spectrum
antibiotics. The urine culture grew Klebsiella, and with
subsequent sensitivities was changed to oral course of
ciprofloxacin. The WBC count improved and the hypotnesion
resolved on antibiotics. End date for ciprofloxacine is [**2119-2-17**]
for 14 day course.
.
#) Atrial fibrillation- Atrial fibrillation with RVR in the
setting of sepsis. She was hemodynamically stable without signs
of tamponade (pulses paradoxes <10). She initially required 15
iv metoprolol and 10 mg iv dilt to control her rate, and was
placed on dilt gtt temporarily for rate control. She continued
on her previous dose of amiodarone. She was not anticoagulated
given her recent history of hemorrhagic effusion. She converted
to Sinus Rhythm (SR) on dilt gtt and remained in SR for the
remainder of her hospitalization. She was transitioned to PO
diltiazem 30mg QID and dilt gtt was weaned. Following
conversion to sinus rhythms, the pt remained asymptomatic
throughout the remainder of her admission. We discharged the pt
on PO diltiazem and her outpt dose of amiodarone.
.
#) anemia, acute blood loss: In the setting of volume repletion
for hypotension/sepsis, and right subclavian line placement.
Guaiac has been negative. At rehab, the pt should have repeat
Hct drawn for the next 2 days to ensure that Hct does not
continue to decrease. At discharge, iron studies and vitamin
B12/folate were pending. Please call for results.
.
#) Hypoxia - initially pt required 2-3L supplemental O2 by nasal
cannula to maintain O2 sats. Given her long tobacco history, and
CXR findings, she likely has COPD and may now be at baseline. Pt
initially reported some symptoms of pleuritic CP, thus raising
the question of PE --> VQ scan was performed and demonstrated
multiple matched defects, cw COPD but intermediate probability
for PE. However, LENIs were negative. Anticoagulation was not
considered given recent h/o hemorrhagic pericardial effusion.
CXR did demonstrate [**Last Name (LF) 78091**], [**First Name3 (LF) **] pt was started on incentive
spirometry. Her hypoxia significantly improved throughout her
hospitalization, and she no longer had an O2 requirement by day
of discharge.
.
#) Pericardial effusion - no evidence of tamponade physiology on
exam: Pulsus wnl, hemodynamically stable. TTE was performed on 2
occasions during this hospitalization, both with no
echocardiographic signs of tamponade. She did not demonstrate
any symptoms or signs of tamponade during her admission.
.
#) Hyponatremia - SIADH. Admitted with Na of 129 but clinically
dehydrated, and with Bu:Cr > 20. Pt was administered NS to
alleviate hypotension. Serum Na improved to 130-134, with no
clinical signs of dehydration. [**Last Name (un) **] stim test and TSH were
normal. Pt did not demonstrate any sx/signs of hyponatremia this
hospitalization. At rehab, her SIADH can likely be managed with
free H2O restriction initially 2L and then less if needed and
close monitoring.
.
#) HTN - pt was hypotensive at admission, most likely due to
urosepsis/SIR. Thus, hypertension meds were held this admission.
Diltiazem was initiated for atrial fibrillation and worked well
for her hypotension throughout the remainder of her stay.
Lisinopril can be reinitiated at the discretion of her rehab
physcian.
.
#) Parkinsons: we continued outpt regimen of Sinemet. Pt
remained stable this admission.
.
#) Seizure Disorder: we continued outpt regimen of Depakote; pt
remained stable.
.
#) Code Status: was changed to full this admission (pt changed
from DNR/I to full code after discussions with family).
Medications on Admission:
Combivent
Amiodarone 200 qd
Lipitor 20 qd
Sinemet 25/100 2 tabs tid
Depakote 250 tid
folate 1 qd
lisinopril 10 qd
senna
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
three times a day.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location 1820**] Ctr.
Discharge Diagnosis:
Primary:
1) Urosepsis
2) Hypoxia due to atelectasis- resolved
3) Pericardial effusion- hemorrhagic- stable
4) Atrial fibrillation
.
Secondary:
HTN
Hyperlipidemia
Parkinson's
Seizure disorder
Discharge Condition:
Stable, improving.
Discharge Instructions:
Please return to the emergency room or call your rehab doctor if
you develop dizziness, heart racing, fevers, chills, confusion,
abdominal pain, nausea, vomiting, or any other worrisome
symptoms.
.
The following changes were made to your medications:
ADDED:
1) Ciprofloxacin- for treatment of your urinary tract infection
2) Diltiazem- for treatment of your atrial fibrillation.
3) Ipratropium-Albuterol Inhaler- prescribed to improve your
breathing/oxygenation
We stopped your lisinopril as we added diltiazem which is also a
blood pressure pill.
Followup Instructions:
Follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-28**] weeks.
|
[
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"285.1",
"401.9",
"599.0",
"253.6",
"995.92",
"511.9",
"785.52",
"564.00",
"496",
"799.02",
"272.0",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.49",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13486, 13537
|
8049, 12318
|
330, 399
|
13772, 13793
|
4510, 8026
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14391, 14488
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4182, 4186
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12489, 13463
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13558, 13751
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12344, 12466
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2229, 3762
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13817, 14368
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4201, 4491
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267, 292
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427, 2212
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3784, 4067
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4083, 4166
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,111
| 110,046
|
2934+55425
|
Discharge summary
|
report+addendum
|
Admission Date: [**2105-3-31**] Discharge Date: [**2105-4-6**]
Date of Birth: Sex: F
Service: [**Hospital Unit Name 153**]
HISTORY OF PRESENT ILLNESS: This is an 87 year old woman
with a history of Methicillin resistant Staphylococcus aureus
urinary tract infection, history of aspiration, status post
coronary artery bypass graft, who is a nursing home patient
with a recent admission for presumed urosepsis roughly one
and one half weeks ago. The patient was admitted under the
sepsis protocol and treated with Vancomycin once culture data
from her nursing home grew Methicillin resistant
Staphylococcus aureus in her urine. The patient defervesced
and was discharged home on Levofloxacin. Two days after her
discharge, the patient started to develop nausea and vomiting
and abdominal pains. The patient also noted a productive
cough of white sputum. At her nursing home, the patient was
found to have desaturated to 82% in room air and was
transferred to the Emergency Department at [**Hospital1 346**]. On arrival, the patient was
normotensive, in atrial fibrillation with a ventricular rate
of 150 and temperature of 103.8. The patient later became
hypotensive, systolic blood pressure in the 70s, requiring
fluid resuscitation. The patient was given 1.5 liters of
normal saline, one gram of Vancomycin, 500 mg of Levofloxacin
and 500 mg Metronidazole in the Emergency Department. The
patient was initially started on Levophed and Dobutamine
drips for hypotension. The patient was subsequently
transferred to the [**Hospital Unit Name 153**].
PAST MEDICAL HISTORY:
1. History of falls thought to multifactorial.
2. Hypertension.
3. Cerebrovascular accident in [**2092**], small cerebrovascular
accident or transient ischemic attack in [**2105-2-1**].
4. Left hemianopsia.
5. Coronary artery bypass graft with a porcine aortic valve
replacement in [**2092**], and the patient is currently on
Coumadin.
6. Degenerative joint disease.
7. Total hip replacement [**2100**].
8. Cataract surgery.
9. Congestive heart failure with questionable diastolic
heart failure, echocardiogram in [**2105**], showing an ejection
fraction greater than 65% with a 2.0 centimeter atrial
myxoma, symmetric left ventricular hypertrophy, mild dilation
of the left atrium.
10. History of paroxysmal atrial fibrillation.
11. Methicillin resistant Staphylococcus aureus urinary tract
infection in [**2105-2-1**].
12. Questionable aspiration pneumonia in the past.
13. Total abdominal hysterectomy.
14. Appendectomy.
15. Hemorrhoidectomy.
16. Colonic polypectomy.
ALLERGIES: Sulfa.
MEDICATIONS ON ADMISSION:
1. Artificial tears.
2. Detrol 1 mg twice a day.
3. Coumadin 2 mg q.h.s.
4. Levofloxacin 250 mg once daily.
5. Protonix 40 mg p.o. once daily.
6. Zoloft 75 mg p.o. once daily.
7. Aspirin 81 mg p.o. once daily.
8, Multivitamin.
9. Lopressor 25 mg twice a day.
10. Fluticasone.
11. Colace 100 mg once daily.
12. Fosamax 70 mg q.Friday.
13. Albuterol and Atrovent nebulizer every six hours.
14. Lipitor 10 mg once daily.
15. Calcium 500 mg twice a day.
16. Senna twice a day.
17. Iron Sulfate 325 mg once daily.
SOCIAL HISTORY: The patient is a resident at [**Hospital3 14109**] Home. She is DNR/DNI but pressors are OK.
PHYSICAL EXAMINATION: On admission, temperature was 99.4,
pulse 117, blood pressure 98/45, currently on Levophed,
respiratory rate 24, oxygen saturation 96% on two liters of
nasal cannula. Her CVP is 10. On general examination, she
is in no acute distress, awake, alert and oriented and
responsive. The pupils are equal, round, and reactive to
light and accommodation. Mucous membranes are dry. On lung
examination, she has crackles one third up bilaterally
without any evidence of wheezing. Heart examination is
irregularly irregular, tachycardic. Abdominal examination is
soft, nontender, nondistended. Extremities show no pedal
edema and no cyanosis with occasional ecchymosis. Neurologic
examination - The patient is alert and oriented times three,
grossly intact.
LABORATORY DATA: On admission, urinalysis was negative for
evidence of infection, less than one bacteria, no leukocyte
esterase, negative white blood cells. White blood cell count
on admission was 16.2, with 17 bands.
Chest x-ray showed no evidence of infiltrates but bilateral
basilar atelectasis. Electrocardiogram showed atrial
fibrillation at a rate of roughly 120s.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit under the sepsis protocol. The patient was given
aggressive fluid resuscitation and required Levophed pressor
for her hypotension. The Dobutamine drip initially was
weaned off as the patient was tachycardic.
The patient was initially febrile. The source was unclear
but thought to be partially treated Methicillin resistant
Staphylococcus aureus urinary tract infection and the
possibility of tracheobronchitis/pneumonia. The patient was
initially placed on Vancomycin and Imipenem for broad
spectrum coverage given that her blood pressure was low and
appeared to be septic. The patient was pancultured. Blood
cultures grew coagulase negative Staphylococcus aureus in two
out of four bottles. Urine culture was negative. Sputum
cultures were inconclusive. The patient was later switched
to , Tazobactam and Vancomycin
antibiotics for coverage. The patient had defervesced soon
after antibiotic administration. Echocardiogram was
performed to visualize evidence of vegetation and signs of
endocarditis. The transthoracic echocardiogram did not show
evidence of vegetations.
The patient was tachycardic during hospital course with heart
rates into the 120s with evidence of heart failure. Based on
prior echocardiograms, the patient had diastolic heart
dysfunction. Controlling the rate was difficult as the
patient was hypotensive. She was started on Digoxin. She
was loaded and given daily doses of Digoxin with better rate
control. The patient was also diuresed slightly with Lasix
given that she had mild oxygen requirement and evidence of
pulmonary edema. For the patient's atrial fibrillation, she
was continued on Coumadin and her coagulation was monitored
daily.
Once tachycardia was improved, blood pressure became normal
and the patient was weaned off Levophed pressor. The patient
maintained good urine output and mentation during her
hospital course.
At the time of dictation, the patient was being transferred
to a medical floor. Please see discharge addendum for
further details of hospital course.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Name8 (MD) 10402**]
MEDQUIST36
D: [**2105-4-6**] 16:57
T: [**2105-4-6**] 18:18
JOB#: [**Job Number 14113**]
Name: [**Known lastname **] [**Known lastname 2194**], [**Known firstname 634**] V. Unit No: [**Numeric Identifier 2195**]
Admission Date: [**2105-3-31**] Discharge Date: [**2105-4-7**]
Date of Birth: [**2017-8-23**] Sex: F
Service:
The patient was transferred to the General Medical floor on
[**2105-3-31**]. On transfer to the floor, patient was afebrile at
97.8, heart rate of 86, a blood pressure of 104/51,
respiratory rate of 20, and 96% on 2 liters. In general, she
was elderly, pleasant, alert in no apparent distress. Her
HEENT: She had right frontal resolving bruising with some
minor abrasions. No tenderness over her sinuses. Her mucous
membranes were moist. Her oropharynx was clear. Her neck
was supple. She had no LAD, no JVD. Her cardiovascular
examination is irregularly, irregular, no murmurs or rubs
were appreciated. Her pulmonary exam with diffuse
inspiratory and expiratory rhonchi, crackles were at the
bases bilaterally left greater than right. Her abdomen had
normoactive bowel sounds, soft, nontender, and nondistended,
no masses, and no hepatosplenomegaly. Extremities: Trace
edema in her lower extremities to mid calves bilaterally.
Warm, 1+ dorsalis pedis bilaterally.
On transfer, her white blood cell count was 6.8, her
hematocrit was 28.7. Her INR was 2.0. Her Chem-7 was
stable. Her dig level was 1.0.
FURTHER HOSPITAL COURSE FROM [**3-31**] TO [**2105-4-7**]:
1. Sepsis: This 87-year-old female, who had a recent MRSA
UTI, history of multiple aspirations, had recently been
partially treated for a urinary tract infection versus
aspiration pneumonia, which was seen on her initial chest
x-ray. The patient was continued on vancomycin and Zosyn for
coverage of Staph epi bacteremia and pneumonia with MRSA in
the sputum. The patient was improving on transfer to the
floor. She continued on Zosyn for several more days and then
was transferred to levo and Flagyl for further treatment of
her pneumonia. Her vancomycin troughs were followed. The
patient required no further pressor support during her stay
on the floor.
Explorations for further sources of sepsis were all negative.
Her fecal stool cultures were negative. Her C. difficile
assays were negative. Her blood cultures had no growth to
date the date of discharge. Her sputum culture did grow
MRSA. Her urine culture was no growth. A repeat P-A and
lateral chest x-ray on [**2105-4-6**] did show bilateral patchy
opacities, which could be consistent with aspiration
pneumonia. Given the verification, the patient did have
bilateral patchy opacities. A decision was made to treat the
patient as if she had aspiration pneumonia with sputum that
did grow MRSA. The patient will be continued on a two week
course of vancomycin, levofloxacin, and Flagyl. Her
vancomycin level was 20 the day prior to discharge, therefore
her vancomycin level was spaced out to q.48h.
Of note, the blood cultures from [**3-31**], which grew Staph
coag-negative 2/2 bottles were considered a contaminate by
the [**Hospital1 8**] laboratory. Blood cultures on [**3-24**] did not grow
out any infection and the blood cultures from [**4-3**] also were
no growth to date. The team recommends that the patient have
surveillance blood cultures drawn q week while the patient is
on her vancomycin, levofloxacin, and Flagyl. In addition, if
the patient spikes a temperature or becomes febrile after
discontinuing her two week course of antibiotics, the team
felt it would be wise at that time to obtain a
transesophageal echocardiogram to rule out endocarditis more
accurately. The patient did have a transthoracic
echocardiogram during this hospital stay, which did not show
any evidence of vegetations.
2. FEN: The patient has a history of multiple prior
aspiration pneumonias. She will be treated for a 14 day
course of antibiotics on the presumed diagnosis of repeat
aspiration pneumonia. The patient was continued on a low fat
cardiac and honey-thickened liquid diet. The patient should
be continued on aspiration precautions with the head of her
bed upright during mealtimes.
3. Congestive heart failure: The patient has a history of
diastolic congestive heart failure. On her chest x-ray, she
did have some evidence of congestive heart failure, however,
her oxygen saturations remained stable throughout this
hospital stay. She was restarted on her Lasix dose at 20 mg
p.o. q.d. with a goal diuresis of -500 to 1 liter q.d. The
patient did well on this regimen. Her ins and outs should be
monitored and if she appears dehydrated, her Lasix should be
reduced.
4. Atrial fibrillation: On the medical floor, the patient
was continued on digoxin and her metoprolol was increased to
25 p.o. b.i.d. The metoprolol was unable to be increased
further given that her blood pressure remained in the 100-115
range and her heart rate was more consistently in the 60s.
Therefore, it appears we will be unable to titrate up the
metoprolol in order to discontinue the digoxin altogether.
The patient will need to be continued on digoxin. She should
have her digoxin level monitored at minimum q month to make
sure that she is on the correct dose. Her level remained in
the target range during this hospital stay.
The patient was also continued on Coumadin, her goal INR is
[**2-3**]. The day prior to discharge her INR was 3.0. The
patient had just been started on levofloxacin and placed on
Zosyn, which she is on previously. Her Coumadin level was
decreased from 2 to 1 q.h.s. She should continue on the
lower dose of Coumadin while the patient is on levofloxacin.
Once she discontinues her antibiotics, her Coumadin dose will
likely need to be adjusted. Her INR should be monitored
three days after discharge to ensure she is on the proper
dosing. In addition, it should be monitored upon
discontinuation of the levofloxacin for further adjustments
of the Coumadin dose once the antibiotics are discontinued,
as antibiotics can elevate her INR.
5. Access: In the Intensive Care Unit, a right internal
jugular central venous catheter had been placed. The patient
had a PICC placed under Interventional Radiology guidance on
[**2105-4-6**] for the further two week course of vancomycin. Her
PICC catheter should be discontinued upon completion of her
IV antibiotics.
6. Code status: During the hospital stay, the patient was
DNR/DNI.
DISCHARGE CONDITION: Stable. The patient is sleeping well.
Maintaining good oxygen saturations on 2 liters nasal cannula
oxygen. She is comfortable in no apparent distress.
DISCHARGE STATUS: To nursing home.
DISCHARGE DIAGNOSIS/PRIMARY: Aspiration pneumonia,
methicillin-resistant Staphylococcus aureus lung infection
complicated by sepsis.
SECONDARY DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
graft.
2. History of CVA.
3. Paroxysmal atrial fibrillation.
4. Diastolic congestive heart failure.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg p.o. q.d.
2. Bisacodyl two tablets p.o. q.d.
3. Docusate 100 mg p.o. b.i.d.
4. Saline eyedrops 1-2 drops prn.
5. Sertraline 75 mg p.o. q.d.
6. Aspirin 81 mg p.o. q.d.
7. Multivitamin one capsule p.o. q.d.
8. Fosamax 70 mg p.o. q Friday.
9. Lipitor 10 mg p.o. q.d.
10. Calcium carbonate 500 mg one tablet p.o. t.i.d.
11. Ferrous sulfate 325 mg p.o. q.d.
12. Fluticasone two puffs inhaled b.i.d.
13. Tylenol 325 mg prn.
14. Oxycodone 5 mg p.o. q.4-6h. prn.
15. Trazodone 25 mg p.o. h.s. prn at bedtime.
16. Digoxin 125 mcg tablet p.o. q.d. Digoxin level should be
monitored.
17. Guaifenesin syrup [**5-11**] mL q.6h. prn cough.
18. Warfarin 1 mg p.o. h.s., until levofloxacin discontinued,
and then will need to increase dose likely to 2 mg p.o.
q.h.s. determined by patient's INR.
19. Sodium chloride nasal spray [**1-2**] sprays t.i.d. as needed
for dry nose.
20. Metoprolol 25 mg p.o. b.i.d.
21. Lasix 20 mg p.o. q.d.
22. Flagyl 500 mg p.o. q.8h. x2 weeks.
23. Levofloxacin 250 mg p.o. q.d. x2 weeks.
24. Vancomycin 1 gram q.48h. x2 weeks.
25. Combivent 1-2 puffs q.4-6h. prn shortness of breath or
wheezing.
OUTPATIENT LABORATORY WORK: The patient should have her INR
drawn three days after discharge to monitor her INR while she
is on levofloxacin. In addition, she should have followup q2
days while she continues on the antibiotics to ensure her INR
is in the therapeutic range. In addition, she should have
surveillance blood cultures drawn one week after discharge to
ensure her treatment regimen is adequate. She should also
have repeat surveillance blood cultures drawn on
discontinuation of antibiotics at two weeks.
DISCHARGE FOLLOWUP: The patient should have followup with
her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 25**] in one week after
discharge. Her primary care doctor, Dr. [**Last Name (STitle) 25**] will need to
followup on her INR level three days after discharge as well
as the surveillance blood cultures one week after discharge
and two weeks after discharge.
[**First Name11 (Name Pattern1) 2197**] [**Last Name (NamePattern4) 2198**], M.D. [**MD Number(1) 2199**]
Dictated By:[**Name8 (MD) 1314**]
MEDQUIST36
D: [**2105-4-7**] 08:14
T: [**2105-4-7**] 08:23
JOB#: [**Job Number 2202**]
|
[
"507.0",
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"428.33",
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"276.5",
"038.11",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
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icd9pcs
|
[
[
[]
]
] |
13182, 13509
|
13716, 15372
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2641, 3160
|
4446, 13160
|
13530, 13693
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3295, 4428
|
15393, 16037
|
184, 1592
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1614, 2615
|
3177, 3272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,878
| 107,015
|
28515
|
Discharge summary
|
report
|
Admission Date: [**2129-3-7**] Discharge Date: [**2129-3-18**]
Date of Birth: [**2055-9-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
EGD
colonoscopy
GI capsule study
History of Present Illness:
Mr. [**Known lastname **] is a 73 year old male with severe 3-vessel coronary
disease s/p complex PCI with 5 RCA bare metal stents placed in
[**2127**] (pt declined CABG), CHF with EF 40%, PVD, and seizure
disorder who is transferred from [**Hospital3 4107**] for management
of NSTEMI and anemia.
Mr. [**Known lastname **] presented to his PCP [**Last Name (NamePattern4) **] [**3-4**] with complaints of
exertional dyspnea and chest/epigastric discomfort for the past
2 weeks. At baseline he can walk 2 miles and climb 1 flt of
stairs w/o chest pain or dyspnea, but over the past 2 weeks
these symptoms are brought on with only 50ft of walking and last
about 1 hour with improvement with rest. He denies orthopnea,
PND, LE edema, LH or palpitations. At his PCP he was found to
have Hct of 22.9 and was sent to [**Hospital3 4107**]. On
presentation to [**Hospital1 **] his EKG showed sinus tachycardia with
rate 100, IVCD, horizontal ST depression V2-V6. He was treated
conservatively with BB, ACE, aspirin, plavix, and blood
transfusion (3U). His chest pain completely resolved and he was
pain free during his admission. He ruled in with a NQWMI, trop I
peak of 23.7, CK peak 670.
With regards to his anemia, he first notes that he was found to
be anemic a few months ago (after complaining of exertional
dyspnea). He was trasfused 2U pRBCs with improvement in symptoms
and as workup had an upper GI series with barium swallow, but no
endoscopy or C-scope. He denies any abdominal pain (other than
with angina), early satiety, constipation, + loose stool. He
notes 1 episode of melena a few months ago, but none since. He
notes no other blood loss. Denies alcohol consumption or FH of
GI malignancy. His OSH labs did show a ferritin of 5.7 and MCV
79.
Past Medical History:
recent NSTEMI - no intervention at osh [**3-5**] ?cabg.
ischemic CM (per report)
CHF (EF 15-20%)
?DM (pt denies)
COPD (dx ~6 mo ago)
HTN (50+ yrs)
seizure disorder ([**3-5**] head trauma)
Social History:
Lives with wife in [**Name2 (NI) **]. Smoked 20 years 4 ppd, quit ~10
years ago, denies alcohol presently, was drinking ~1 case / day
x 10 years, quit ~20 years ago, denies IVDU. Used to work with
heavy machinery.
Family History:
no premature CAD or SCD, mother "big heart", died in 80s, father
died of leukemia.
Physical Exam:
VS - HR 79 BP 114/60 RR 18 96% on RA
Gen: WDWN middle elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with non-elevated JVP.
CV: PMI difficult to palpate given barrel chest. Heart sounds
distant, but RR normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: Notable for barrel chest, no scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decrease breath-sounds
throughout, 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, diminished pulses.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
- guaiac negative
Pertinent Results:
[**2129-3-18**] 07:00AM BLOOD WBC-7.9 RBC-3.43* Hgb-9.3* Hct-28.7*
MCV-84 MCH-27.0 MCHC-32.3 RDW-16.1* Plt Ct-213
[**2129-3-14**] 12:16PM BLOOD PT-12.6 PTT-36.6* INR(PT)-1.1
[**2129-3-18**] 07:00AM BLOOD Glucose-99 UreaN-22* Creat-1.4* Na-139
K-4.1 Cl-107 HCO3-23 AnGap-13
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2129-3-15**] 5:06 PM
CHEST (PORTABLE AP)
Reason: ? ptx s/p ct removal
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? ptx s/p ct removal
INDICATION: 73-year-old man with status post CABG and chest tube
removal, evaluate for pneumothorax.
COMPARISON: [**2129-3-15**], 8:32 a.m. (9 hours prior to this
study).
SINGLE VIEW, CHEST: Interval removal of the chest tube and the
mediastinal drain. No evidence of pneumothorax. Small bilateral
pleural effusions, [**Year (4 digits) 1506**]. No new consolidations or
infiltrates are noted. Mild engorgement of the mediastinal
vasculature suggesting volume overload. Pleural calcifications
appear [**Year (4 digits) 1506**]. Endotracheal tube and nasogastric tube in
standard locations. Median sternotomy wires are evident without
evidence of sternal dehiscence. Swan catheter in standard
location.
IMPRESSION: No pneumothorax. Small bilateral pleural effusions
and mild volume overload [**Year (4 digits) 1506**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: [**Doctor First Name **] [**2129-3-17**] 10:46 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 69089**] (Complete)
Done [**2129-3-14**] at 9:50:17 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: [**2055-9-9**]
Age (years): 73 M Hgt (in): 69
BP (mm Hg): 126/ Wgt (lb): 145
HR (bpm): 53 BSA (m2): 1.80 m2
Indication: Intra-op TEE for CABG, ? MVR
ICD-9 Codes: 440.0, 441.2, 414.8, 424.0
Test Information
Date/Time: [**2129-3-14**] at 09:50 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 #: 2008AW209-9:4 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 3.9 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.2 cm
Left Ventricle - Fractional Shortening: *0.14 >= 0.29
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Left Ventricle - Stroke Volume: 93 ml/beat
Left Ventricle - Cardiac Output: 4.94 L/min
Left Ventricle - Cardiac Index: 2.75 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - LVOT VTI: 19
Aortic Valve - LVOT diam: 2.5 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of the LA. No spontaneous echo contrast is seen in
the LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Moderate regional LV systolic dysfunction. Moderately depressed
LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Mildly dilated descending aorta. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild to moderate ([**2-2**]+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
Dilated main PA. Dilated branch PA.
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 patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is mildly dilated. No spontaneous echo
contrast is seen in the body of the left atrium. No spontaneous
echo contrast is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with apical, inferior,
septal and anterior wall hypokinesis. Overall left ventricular
systolic function is moderately depressed (LVEF= 30 %).
Spontaneous echo contrast in noted in the LV, that resolved with
systemic heparinization.
3. The right ventricular cavity is mildly dilated with normal
free wall contractility.
4. There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-2**]+) mitral regurgitation is seen. Provocative
maneuvers were used, pt in trendelenburg, and BP 170/80,
Eccentric anterior jet seen, billowing of the posterior leaflet
and mild restriction of the anterior leaflet.
7. The main pulmonary artery is dilated. The branch pulmonary
arteries are dilated.
8. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on the MR at
0830hrs.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including Epinephrine and
phenylephrine, Pt is in Sinus tachycardia.
1. LV function is slightly improved. RV function is [**Last Name (STitle) 1506**]
2. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**]
3. Aorta is intact post decannulation
4. Other findings are [**Last Name (Titles) 1506**]
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2129-3-14**] 11:49
Brief Hospital Course:
The pt. was admitted on [**2129-3-8**] with severe exertional dyspnea
and epigastric distention for the past 2 weeks. He had an
MSTEMI and had a Hct of 22.9 at the outside hospital. He had an
echo which revealed a 30-35% LVEF with global hypokinesis and
1+MR. [**Name13 (STitle) **] underwent EGD on [**3-9**] which revealed erythema,
congestion and superifical erosions of the mucosa in the antrum.
He had mild gastritis and the rest of his mucosa was normal.
He was followed by cardiac surgery throughout this time. He
then had a colonoscoy which was negative. A capsule study
showed 2 areas fof bleeding in the samll intestine but his Hct
remained stable and he had a cardiac catth on [**3-11**] which revealed
no obstructive disease in the LMCA, a focally calcified mid LAD
lesion, 80% mid LCX lesions, and an 80% RCA stenosis.
ON [**2129-3-14**] he underwent a CABGx4(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **], and
PDA). He tolerated the procedure well and was transferred to
the CVICU on Epi, Neo, and Propofol in stable condition. He was
extubated on POD#1. The Epi was d/c'd on POD#1 and his chest
tubes were d/c'd on POD#2. He was transferred to the floor on
POD#2 and his epicardial pacing wires were d/c'd on POD#3. He
continued to progress with physical therapy and was discharged
to home in stable condition on POD#4.
He will undergo a small bowel enteroscopy with Dr. [**First Name (STitle) 908**] in 1
month.
Medications on Admission:
Toprol xL 25mg dailiy
Lisinopril 20mg daily
Lasix 40mg po daily
Zocor 20mg daily
Plavix 75mg daily
Aspirin 325mg daily
dilantin 300mg daily
Phenobarbital 64.8mg po bid
Omeprazole 20mg po daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. 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. Phenobarbital 15 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD
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.
Call our office for sternal drainage, temp>101.5
Do not use creams, lotions, or powders on wounds.
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 10543**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.Provider: [**Name10 (NameIs) **]
WEST,ROOM THREE GI ROOMS Date/Time:[**2129-4-14**] 9:00
Provider: [**Name10 (NameIs) **] PROCEDURES FELLOW Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2129-4-14**] 9:00
Completed by:[**2129-3-18**]
|
[
"428.0",
"211.2",
"414.8",
"414.01",
"440.21",
"428.22",
"455.0",
"535.50",
"280.0",
"584.9",
"496",
"455.3",
"345.90",
"578.9",
"401.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"39.61",
"36.13",
"99.04",
"45.23",
"88.55",
"37.22",
"36.15",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
14057, 14108
|
11012, 12470
|
285, 343
|
14156, 14164
|
3523, 3918
|
14490, 14939
|
2587, 2671
|
12714, 14034
|
3955, 3985
|
14129, 14135
|
12496, 12691
|
14188, 14467
|
2686, 3504
|
235, 247
|
4014, 10989
|
371, 2126
|
2148, 2337
|
2353, 2571
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,744
| 185,008
|
43994
|
Discharge summary
|
report
|
Admission Date: [**2102-6-24**] Discharge Date: [**2102-6-26**]
Date of Birth: [**2058-7-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
altered mental status (with low blood sugars)
Major Surgical or Invasive Procedure:
Hemodialysis performed [**2102-6-26**]
History of Present Illness:
43 y.o. w h/o IDDMI x 21 years, ESRD on HD, and LBKA in [**Month (only) **]
[**2101**] who presents with hypoglycemic episode to 42 and confusion.
Patient was confused at HD and did not improve with completion
of HD session. FS was checked and he was found to be have FS of
42; He was given 15 gm of glucose and EMS was called. Upon their
arrival, FS 71 and he was given 1 amp D5 which brought his FS to
90; Patient in ED was found to have FS of 160 but within 15
minutes his FS was down to 90. He was transfered to [**Hospital Unit Name 153**] for
frequent BS monitoring.
.
Patient states he has been at his usual state of health. He is
wheelchair bound and he is mobile by himself. He got up and his
FS this AM was 238, he took his insulin 6 units of novolog. He
then went to hemodialysis without eating (though told some
interviewers that he ate cereal.) Patient denies any f/c, no
n/v, no diaphogresis, no cp, no sob, no palpitations. He denies
any recent weight loss. Patient is being evaluted for a kidney
transplant by his nephrologist who also serves as his PCP. [**Name10 (NameIs) **]
has frequent hypoglycemia episodes (including one last week
requiring hospitalization at [**Hospital1 2025**]) due to presumed stacking of
insulin. Patient also was recently suddenly taken of his lyrica,
and his oxycodone dose was reduce to anticipate renal
transplant. He has had increased insomnia with halucinations due
to increased pain and potential side effects of requip and
pregabalin. Patient sees a psychiatrist for this condition. He
has not been able to sleep for last 3 days and feels very tired.
He denies any diarrhea/constipation. Reports normal diet
including [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Thursday night which made him throw up. He
denies any abdominal pain, but does not increase tension in his
abdomen that he associated in the past with volume overload.
Patient also has chronic lower extremity pain/contractures, and
also diffuse neuropathy/pain and phantom L leg syndrome. Patient
states he is compliant with his insulin and his diet.
.
Past Medical History:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Hospital1 2025**], receives dialysis at the Kidney
Center
1. ESRD - has been on HD for the past year on a MWF schedule,
plans to undergo kidney transplant with donation from sister as
soon as he recovers from amputation, baseline BUN: 50-60 with
creatinine: [**8-20**] per Kidney Center
2. Type I Diabetes - diagnosed 20 years ago
3. LUE DVT, on Coumadin
4. s/p left below knee amputation in [**2101-7-14**], currently
experiencing severe phantom limb pain, initial injury 6 years
ago from cat bite, inpatient stay at [**Hospital1 2025**] last week due to fall
related to recent amputation
5. Depression
6. GERD
7. HTN
8. Restless Leg Syndrome
9. Numerous sports-related injuries and surgeries
10. Reports echocardiogram shows a new murmur
11. nephrogenic fibrosing dermopathy, biopsy diagnosed 1 yr ago.
Social History:
Widowed for more than ten years. Lives with daughter and his
parents. Denies smoking, rarely drinks alcohol, denies IVDU.
Retired stockbroker and professional boxer. Caregiver [**First Name (Titles) **] [**Last Name (Titles) **]
Center reports concerns about patient's ability to care for self
at home since recent amputation.
Family History:
CAD. Type II DM on father's side of family.
Physical Exam:
T 97.6 P. 65 b/p 135/85 rr 20 oxygen sat 95 rm air
General: alert oriented, appropriate prior to ativan. became
sleepy following ativan for hemodialysis.
HEENT: eomi, perrla
oral: moist mucosa, clear
neck: no lymphadenopathy
heart: loud bruit at rusb (known chronic secondary hd catheter),
otherwise no murmurs
lung: ctab
abdomen: obese, nontender
extremities: left BKA
skin: diffusely thickened,most noticeable at hands and left
abdomen
wound descriptions per wound care consult nurse:
Wound assessment:
Type:partial-thickness
Location: center Left BKA site
Size:2x2cm
Wound bed:60% pink 40% yellow
Exudate: small yellow
Odor:none
Wound edges:attached
Periwound tissue: slight erythema
Wound Pain: 0 /10
Wound assessment:
Type:partial-thickness
Location: right 2nd toe (anterior)
Size:1.5x1cm
Wound bed:50% pink 50% yellow
Exudate: small yellow
Odor:none
Wound edges:attached
Periwound tissue: slight erythema
Wound Pain: 0 /10
Wound assessment:
Type:traumatic
Location: right posterior leg
Size:3x0.5cm
Wound bed:100% pink
Exudate: small yellow
Odor:none
Wound edges:attached
Periwound tissue: intact
Wound Pain: 0 /10
Pertinent Results:
[**2102-6-26**] 07:50AM BLOOD WBC-6.9 RBC-3.35* Hgb-11.7* Hct-34.9*
MCV-104* MCH-34.8* MCHC-33.5 RDW-18.0* Plt Ct-311
[**2102-6-26**] 07:50AM BLOOD Plt Ct-311
[**2102-6-26**] 07:50AM BLOOD Glucose-277* UreaN-57* Creat-7.1* Na-133
K-5.6* Cl-90* HCO3-31 AnGap-18
[**2102-6-25**] 08:40AM BLOOD CK(CPK)-44
[**2102-6-25**] 08:40AM BLOOD CK-MB-4 cTropnT-0.09*
[**2102-6-26**] 07:50AM BLOOD Calcium-8.9 Phos-7.6* Mg-2.8*
[**2102-6-25**] 08:40AM BLOOD Cortsol-16.4
[**2102-6-24**] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2102-6-25**] 08:53AM BLOOD Type-ART Temp-36.1 pO2-86 pCO2-46*
pH-7.47* calTCO2-34* Base XS-8 Intubat-NOT INTUBA
INDICATION: Fall and headache.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT.
FINDINGS: Evaluation is limited secondary to patient motion.
Given these
limitations, there is no evidence for intracranial hemorrhage.
The
ventricles, cisterns, and sulci maintain a normal configuration.
The
[**Doctor Last Name 352**]-white matter differentiation is difficult to evaluate.
There are
multiple lacunar infarcts located in the left globus pallidus
and right basal
ganglia and corona radiata that are unusual given patient's
young age. The
visualized paranasal sinuses are clear. The osseous structures
are
unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Scattered lacunar infarcts are atypical for patient's young
age.
HISTORY: Hypoglycemia. Assess for infiltrate.
Three radiographs of the chest demonstrate a normal
cardiomediastinal contour.
Allowing for patient positioning and technique, the lungs are
clear. There
may be mild hyperinflation of both lungs. No effusion is
detected. Trachea
is midline. No pneumothorax is seen. The questionable left
retrocardiac
opacity is seen on [**2102-6-24**] is not present on the current exam.
IMPRESSION:
No consolidation.
Probable sinus rhythm. Prolonged P-R interval. Non-specific ST-T
wave chnges.
Compared to the previous tracing of [**2101-10-11**] no change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 216 96 446/452.85 -29 -13 -178
Brief Hospital Course:
Mr. [**Known lastname 1726**] was admitted with hypoglycemia secondary to
reportedly not eating after morning insulin dose. He was treated
with dextrose and monitored in the ICU. Blood glucoses were
approximately 200 at the time of discharge on an 8 unit qhs
lantus dose with short acting insulin sliding scale coverage. He
was seen by [**Last Name (un) **] consultants. Additional problems are as noted
below.
1. DM1: as above
2. subtherapeutic INR with history upper extremity DVT nearly 1
year ago. Because his dvt was remote, his warfarin is increased
to 5mg each evening with plan to follow up INR with his PCP
[**Name Initial (PRE) 503**]. He will also have VNA services with capability to
follow this further.
3. ESRD: received dialysis [**6-26**].
4. lower extremity ulcers as described again. wound care consult
obtained,and recommendations are included in his discharge
instructions. VNA will assiste him with this at home. A vascular
consult was suggested [**First Name8 (NamePattern2) **] [**Last Name (un) **] for his RLE at risk for
worsening ulcerations.
5. chronic CO2 retention with compensatory alkalosis. He is
suspected to have sleep apnea by obervations this admission and
a sleep study is recommended outpatient.
6. HTN: controlled on home medications.
7. Nephrogenic fibrosing dermopathy: stable, followed by his
PCP/nephrologist. Pain regimen has recently been weaned for
this.
8. cocaine positive urine: pt denies use of cocaine.
9. mild elevation of TTs: no active ischemic sxs or ecg changes.
suspect secondary to esrd.
10. depression with recent psychiatric inpt evaluation:
continued celexa. no overt deompensation.
Medications on Admission:
Meds:
1.Lantus 6 U hs
2. Humalog sliding scale
3. metoprolol XL 100mg [**Hospital1 **]
4. neurontin d/c due to RF
5. coumadin 4mg hs - for h/o DVT
6. ambien 10mg hs prn - recently d/c [**3-17**] to ? hallucinations
7. renagel 3200 mg 3x daily with meals
8. PhosLo 3 tabs with meals
9. Zantac 150 [**Hospital1 **]
10.Lopid 600 [**Hospital1 **]
11.requip 2mg [**Hospital1 **] - recently d/c [**3-17**] to ? hallucinations
12.clonidine patch - insurance does not offer
13.quinine sulfate 200mg hs prn - does not take it anymore
14.senna 2mg hs
15.lyrica 75mg daily - stopped [**3-17**] to ? hallucinations
16.oxycontin 40mg TID (recently changed from 80mg [**Hospital1 **]) -not Rx
anymore
17.oxycodone 5 mg q3-4h prn
18.lisinopril 5mg daily
19. Ativan 0.5 mg before dialysis
20. Klonopin 0.5 mg [**Hospital1 **]
21. Lipitor 80 mg daily
22. Celexa 60 mg daily
23. Seroquel 100 mg [**Hospital1 **]
24. Fludracortisone for hyperkalemia has been d/c
.
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
3. Sevelamer 800 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day). Tablet(s)
4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS). Capsule(s)
11. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 8
Subcutaneous at bedtime. 8
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
13. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed: with hemodialysis. Tablet(s)
15. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day:
for restless legs.
16. Seroquel 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Hypoglycemia secondary to not eating following insulin dosing
Discharge Condition:
Good
Discharge Instructions:
Sleep clinic followup for sleep apnea
We recommend a follow up vascular evaluation for your right leg
if not done prior.
Your coumadin dose has been increased to 5 mg daily for a
subtherapeutic INR.
INR follow up tomorrow with your doctor, goal [**3-18**]. (results
faxed to Dr. [**Last Name (STitle) **].)
You will need continued attention to wound care of your left
stump ulcer and right posterior leg ulcer and right second toe.
Continue to check your glucoses before meals and call a doctor
if sugars are running low <70 or high >200 routinely. Your
lantus dosing has been changed to 8 units each night. Continue
sliding scale insulin as prior.
Sleep clinic followup for sleep apnea
We recommend a follow up vascular evaluation for your right leg
if not done prior.
Your coumadin dose has been increased to 5 mg daily for a
subtherapeutic INR.
INR follow up tomorrow with your doctor, goal [**3-18**]. (results
faxed to Dr. [**Last Name (STitle) **].)
You will need continued attention to wound care of your left
stump ulcer and right posterior leg ulcer and right second toe.
Continue to check your glucoses before meals and call a doctor
if sugars are running low <70 or high >200 routinely. Your
lantus dosing has been changed to 8 units each night.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] as scheduled at 10 AM tomorrow
morning.
Continue routine hemodialysis as previously scheduled and follow
up with Dr. [**Last Name (STitle) 2087**] your nephrologist.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2102-6-26**]
|
[
"250.81",
"707.12",
"403.91",
"V49.75",
"250.61",
"530.81",
"276.3",
"333.94",
"585.6",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11206, 11264
|
7229, 8876
|
360, 401
|
11370, 11377
|
5047, 7206
|
12684, 13047
|
3779, 3824
|
9872, 11183
|
11285, 11349
|
8902, 9849
|
11401, 12661
|
3839, 5028
|
275, 322
|
429, 2518
|
2540, 3419
|
3435, 3763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,654
| 152,231
|
14499
|
Discharge summary
|
report
|
Admission Date: [**2132-4-15**] Discharge Date: [**2132-4-27**]
Date of Birth: [**2075-7-17**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 56 year-old
male who was a transfer from [**Hospital3 1443**] Hospital
following a thrombotic transient ischemic attack presumed to
be from his right internal carotid and a possible small non Q
wave myocardial infarction. He was transferred for cardiac
catheterization following a positive stress test revealing
inferior and anterior apical artery reversible defects with
an EF of 25 to 30%. Two dimensional echocardiogram done at
[**Hospital3 1443**] revealed a mild MR. [**Name13 (STitle) **] presently complains
of symptoms of left sided weakness as well as a throat
burning with exertion typically ambulating one flight of
stairs.
PAST MEDICAL HISTORY: 1. Transient ischemic attack. 2.
Diabetes mellitus. 3. Hypertension. 4. Coronary artery
disease. 5. Peripheral vascular disease. 6. Congestive
heart failure with an EF of 30%. 7. Non Q wave myocardial
infarction. 8. Chronic obstructive pulmonary disease. 9.
Tobacco abuse. 10. Mild mitral regurgitation. 11.
Hyperlipidemia.
SOCIAL HISTORY: Notable for tobacco abuse. He has quit on
this admission.
LABORATORY STUDIES ON ADMISSION: His hematocrit is 36. His
white count is 7. His baseline BUN and creatinine are 21 and
1.0. His total cholesterol was 220 with an HDL of 35 and an
LDL of 143.
PHYSICAL EXAMINATION: Performed post procedure while on a
nitro drip, his blood pressure is 90/45. Heart rate is 64.
Oxygen saturations is 94% on room air. In general he is a
healthy appearing middle aged male in no acute distress. His
head, eyes, ears, nose and throat he is normocephalic,
atraumatic. Pupils are equal, round and reactive to light.
Heart has a regular rate and rhythm. Lungs are clear.
Abdomen is soft, nontender, nondistended. Extremities are
warm. Neurologically his tongue is midline. His face is
symmetric. His motor strength is 5 out of 5 throughout with
sensation intact.
MEDICATIONS ON TRANSFER: 1. Colace 100 mg po b.i.d. 2.
Enteric coated aspirin 325 mg po q day. 3. Lasix 20 mg po q
day. 4. Digoxin 0.125 mg po q day. 5. Glucotrol XL 10 mg
po q day. 6. NPH 5 units q.a.m. 7. Calcium carbonate 1250
mg po day. 8. Nicotine patch. 9. Ativan 1 mg po b.i.d.
10. Pravachol 10 mg po q day. 11. Zestril 10 mg po q day.
12. Lopressor 25 mg po b.i.d. 13. Imdur 30 mg po q day.
14. Lovenox 60 mg subQ q 12 hours.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service where he had a cardiac catheterization demonstrating
three vessel disease. Both the Vascular Surgery team and the
Cardiac Surgery teams were consulted for his symptomatic
transient ischemic attack and his coronary disease. He had a
carotid ultrasound that demonstrated less then 40% internal
carotid stenosis bilaterally. The Neurosurgery team was
asked to come and evaluate him. They found based on his MR
angiogram done at the outside hospital. He had right
internal carotid stenosis in the area of the petrous bone.
He was taken to angiography where he had a cerebral angiogram
that confirmed these findings. On [**2132-4-17**] the patient
had a cerebral angiogram with stent angioplasty of the
petrous right internal carotid artery. The patient's
procedure itself was unremarkable. Post procedure he was
started on Integrilin. Of note, they also believed that he
has a right subclavian steel syndrome. The patient was
continued on Integrilin for several post procedure days. All
of his neurologic checks were without deficits. His
Integrilin was stopped at midnight the night prior to his
operation.
On [**2132-4-21**] the patient was taken to the Operating Room
for a coronary artery bypass graft times five. His grafts
are left internal mammary coronary artery to left anterior
descending coronary artery, saphenous vein graft to left PD,
posterior descending coronary artery sequential and saphenous
vein graft to obtuse marginal to saphenous vein graft to
diagonal done end to side. The patient's cardiopulmonary
bypass time was 114 minutes. Cross clamp time was 93
minutes. Postoperatively, the patient was taken to the
Cardiac Surgery Intensive Care Unit. He was extubated on the
evening of his operation. He was started on Plavix post
procedure and over the course of the first postoperative day
he was weaned from multiple drips including nitroglycerin,
insulin and Nipride. On the afternoon of the first
postoperative day he was transferred to the hospital floor.
His Foley catheter was discontinued in a normal fashion. His
Lopressor was titrated up based on his heart rate and blood
pressure. He was ambulating with physical therapy. He had
oxygen requirement for several days, but by the day prior to
his discharge he had been adequately diuresed and no longer
required oxygen while at rest.
[**Last Name (STitle) 42843**]evelop a low grade temperature to 100.0 on
postoperative day number five with some scant sternal
drainage. For this reason his sternum was painted with
betadine and he was started on oral Levaquin therapy. By the
following day the drainage was noted to be very scant from
the interior edge of his dressing and it was felt he was safe
to be discharged home. He was discharged home on [**2132-4-27**] in stable condition in the care of his family with
visiting nurse assistance. He was instructed to follow up
with his primary care physician in one to two weeks. In
addition, he is to follow up with Dr. [**Last Name (Prefixes) **] in four
weeks and to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] with Neurosurgery
in approximately three months.
MEDICATIONS ON DISCHARGE: 1. Lopressor 50 mg po b.i.d. 2.
Pravachol 10 mg po q day. 3. Nicotine patch 14 mg
transdermal q day. 4. Glipizide XL 5 mg po q day. 5. NPH
5 units subQ q.a.m. 6. Plavix 75 mg po q day. 7. Enteric
coated aspirin 325 mg po q day. 8. Colace 100 mg po b.i.d.
9. Levaquin 500 mg po q day times seven days. 10. Lasix 20
mg po b.i.d. times seven days. 11. Potassium chloride 20
milliequivalents po b.i.d. times seven days. 12. Percocet
one to two po q 4 to 6 hours prn.
DISCHARGE DIAGNOSES:
1. Coronary artery disease now status post coronary artery
bypass graft times five.
2. Right intracranial internal carotid artery stenosis now
status post angioplasty and stent.
3. Hypertension, controlled.
4. Diabetes mellitus, controlled.
5. Hyperlipidemia, controlled.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2132-4-27**] 13:00
T: [**2132-4-30**] 06:00
JOB#: [**Job Number 42844**]
|
[
"410.71",
"435.2",
"496",
"424.0",
"998.12",
"250.00",
"427.41",
"433.10",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.23",
"36.14",
"39.90",
"88.53",
"36.15",
"88.56",
"88.41",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
6296, 6838
|
5790, 6275
|
2567, 5763
|
1506, 2090
|
173, 843
|
1320, 1483
|
2116, 2549
|
866, 1209
|
1226, 1305
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,149
| 140,593
|
54047
|
Discharge summary
|
report
|
Admission Date: [**2131-3-21**] Discharge Date: [**2131-4-12**]
Date of Birth: [**2082-11-8**] Sex: F
Service: PLASTIC
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
left thigh infection
Major Surgical or Invasive Procedure:
[**2131-3-21**] Debridement of left thigh necrotizing soft tissue
infection.
.
[**2131-3-22**]: Incision and debridement 25 x 40 cm left thigh
full-thickness skin, fat, fascia. Excision of the
Sartorius muscle.
.
[**2131-3-24**]: 1. Incision and drainage of wound and change of wound
V.A.C. of medial thigh. 2. Incision and drainage of the left
lateral thigh.
.
[**2131-3-27**] Incision and drainage of necrotizing fasciitis
with vacuum-assisted closure change, wound surface
area 375 cm2
.
[**2131-3-30**] Incision and drainage of necrotizing fasciitis
and application of VAC dressing
.
[**2131-4-2**]
1. Irrigation and debridement of the skin, subcutaneous tissue
of right groin (20 x 20 cm). 2. Delayed primary closure of left
lateral thigh wound (10cm). 3. Application of a vacuum-assisted
closure dressing (20 x 20 cm).
.
[**2131-4-5**] Split-thickness skin reconstruction of left groin
(30x16cm)
History of Present Illness:
48F with 4 days of left thigh erythema, induration, pain.
Presented to [**Hospital3 **] 2 days prior. L thigh was
observed, found to be getting worse. Was evaluated by surgery
there (Dr [**Last Name (STitle) 110791**] who felt an emergent debridement was
necessary but felt it should be done at a tertiary care center
so transfer to the [**Hospital1 18**] MICU was arranged. On transport, she
was hypotensive requiring a single pressor. On arrival, she was
hemodynamically stable and quite fluid responsive and pressors
were no longer needed. She was awake and alert on arrival,
though confused about whether her leg has worsened or improved
the past 48 hours. She has no other symptoms, just L thigh/hip
pain.
Past Medical History:
PMH: hypertension
tobacco abuse
obesity
alcohol abuse
dyslipidemia
hypothyroidism
depression
IBS
.
PSH: C-section
Social History:
- Tobacco: [**3-22**] cig/ day
- Alcohol: daily, 4 drinks daily, last drink was on [**3-19**]
- Illicits: patient denies
Family History:
non-contributory
Physical Exam:
Admission Exam (upon arrival/evaluation in MICU)
Vitals: T 100.4 P 104 BP 98/46 RR 20 O2 98% 2L
GEN: A&O, NAD, anxious
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, obese, nondistended, nontender, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: right lower extremity normal. Left foot/leg normal with
good
pulses and normal sensation. L thigh with significant
circumferential erythema. blistering on anteromedial proximal
thigh. indurated primarily on lateral portion. moderate pain
with
flexing knee and hip joint.
Pertinent Results:
OSH: Na 133, K 3.6, CO2 15, BUN 323, Cr 1.7, Gluocse 187, WBC
17,
Hgb 11, Hematocrit 31, Plt 185, Band 22, Bcx [**2131-3-19**]: no growth.
Troponin 0.01, CK 105, 78, 91. Cortisol 31, AST 27, ALT 24.
[**2131-3-21**] [**Hospital1 18**] Labs -
CBC - 15.2 > 30.6 < 189
N:98 Band:0 L:1 M:1 E:0 Bas:0
137 112 34
----------------< 161
3.4 14 1.4
Ca: 5.6 Mg: 1.3 P: 2.7
AST: 20 ALT: 27 AP: 84 Tbili: 0.7 Alb: 2.0 Vanco: <1.7
PT: 16.1 PTT: 29.6 INR: 1.5
Fibrinogen: 731 UA: mod positive
.
[**2131-4-3**] Creat-2.2*
[**2131-4-9**] Creat-1.3*
.
IMAGING:
CT LOW EXT W/O C BILAT [**2131-3-21**] IMPRESSION: Extensive changes of
cellulitis and subcutaneous edema. No specific features to
suggest necrotizing fasciitis such as soft tissue gas.
.
TTE (Portable) [**2131-3-22**] The left atrium is normal in size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is mildly depressed (LVEF= 40-50%). The number of
aortic valve leaflets cannot be determined. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. Moderate [2+]
tricuspid regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality due to body habitus. Mild
global LV systolic dysfunction. Moderate TR with normal PASP. RV
function is difficult to evaluate on this study
.
Radiology Report RENAL U.S. Study Date of [**2131-4-4**] 8:43 AM
IMPRESSION:
1. No hydronephrosis.
2. Difficult imaging of the left kidney with apparent greater
than 3-cm size discrepancy. Correlate for details of prior
medical history/reflux.
.
MICROBIOLOGY:
[**2131-3-21**] 6:52 pm SWAB LEFT INNER THIGH.
**FINAL REPORT [**2131-3-23**]**
GRAM STAIN (Final [**2131-3-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
WOUND CULTURE (Final [**2131-3-23**]):
BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 110792**] is a 48F which was transferred from [**Hospital3 **]
after a left thigh was evaluated by surgery there (Dr. [**Last Name (STitle) 110791**]
and felt an emergent debridement was necessary. Surgery was
consulted upon arrival to the MICU. At that time she had an
obvious severe left thigh infection. After obtaining an
operative-planning CT scan, she was immediately taken to the
operating room for debridement. Please see the operative report
from [**3-21**] for further details. Patient had a large amount of
necrotic tissue in the anterior and medial areas of her left
thigh, not extending to the knee or up above the inguinal
ligament. She was transferred to the ICU post-op and left
intubated given her profound sepsis, tachypnea, and planned
return to the operating room for further debridement the
following day. Patient returned to the OR on 5 more occassions
for further debridement and vac changes (see op note for [**3-22**],
[**3-24**], [**3-30**], 4,16) and then finally for skin graft to her left
thigh wound defect on [**2131-4-5**] with Plastic Surgery.
.
Her further course is outlined below by organ system:
Neurologic: She was given intermittent Dilaudid IV for pain
control, then was transferred to PO pain meds when tolerating
diet. She was begun on Seroquel for agitation and delerium HD 3.
She had been placed on a CIWA scale for concern for alcohol
withdrawal but did not require significant doses of Ativan.
Patient had occassional episodes of anxiety, relieved with
redirection and treated with Ativan.
.
Cardiovascular: She was initially showing signs of hemodynamic
instability but by HD 2 she had been weaned off pressors. She
had an episode of chest pain HD 4 but EKG and enzymes showed no
myocardial change. Her hematocrit decreased from baseline of 29
to 21 which was attributed to the repeated surgical explorations
and she received 2 units RBCs on HD13 with adequate increase in
hematocrit and again 2 units in HD 18.
.
Pulmonary: She has baseline OSA which was treated with CPAP at
night. Narcotics were minimized when possible to sustain her
respiratory drive.
.
Gastrointestinal: She was maintained on famotidine IV while
intubated, then transitioned to oral Zantac for stress ulcer
prophylaxis.
.
Nutrition: She was advanced to a regular diet [**3-25**] which she
tolerated well.
.
Renal: She initially had acute kidney injury from sepsis, but
that had resolved by HD 4. Patient had increased Cr again on
HD17 and at first it was attribute to AIN from a betalactam as
patient had +eos in urine and a morbilliform rash. The
antibiotics were discontinued and patient Cr remained elevated.
A Renal consult was placed and it was thought the [**Last Name (un) **] was
secondary to a low flow state given fluid losses. Renal
recommended Calcium Acetate 667 mg PO/NG TID. A foley
catheter was used to monitor urine output until HD 13. Patient
voided without difficulty. Foley was replaced on HD17 after
grafting, given location of injury and concern for contamination
of wound. Patient's foley was discontinued on HD21 after VAC
dressing was removed and patient was able to get out of bed to
use commode safely. Cr was monitored and by the time of
discharge, patient's creatinine continued to recover and was
1.3.
.
Endocrine: Her blood sugar was controlled by an insulin sliding
scale and she was maintained on her thyroid medication through
an IV equivalent until tolerating POs.
.
Infectious Disease: She presented in septic shock from left
thigh cellulitis. She was treated with broad spectrum
antibiosis: Vanc, Clinda, Zosyn ([**Date range (1) 19644**]) then transitioned to
Augmentin for 2 days. Her wound cultures from the first
debridement showed Group A streptococcus. The antibiotics were
then discontinued as the primary surgical team felt the
debridement had been completed. Patient's blood cultures and
urine cultures remained negative.
.
Patient was discharged to rehab facility on hospital day 23. The
patient was doing well, afebrile with stable vital signs,
tolerating a regular diet, voiding without assistance, and pain
was well controlled.
Medications on Admission:
Synthroid 175mcg daily
Diovan 360mg daily
HCTZ 12.5mg daily
Prozac 60 mg daily
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours)
as needed for pain.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. cetirizine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
13. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
14. diphenhydramine HCl 25 mg Capsule Sig: [**12-18**] Capsules PO Q6H
(every 6 hours) as needed for pruritus.
15. Prozac 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP < 110 or HR< 60 .
17. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
18. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
19. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
20. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
21. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
1. Necrotizing fasciitis of the left thigh
2. Septic shock
3. Acute renal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with necrotizing fasciitis of
your left thigh. You were taken to the operating room multiple
times to have the area of infection debrided. The wound defect
was then covered with a skin graft. Please follow these
discharge instructions.
.
Followup Instructions:
-You should continue taking your current medications.
-If the area of your skin graft in your left groin/thigh area
begins to worsen after discharge with an acute increase in
swelling or pain or redness, please call Dr.[**Name (NI) 2989**] office at
([**Telephone/Fax (1) 36264**]
- You should keep your right thigh donor site open to air and
leave the yellow xeroform dressing in place to dry out. Do not
get this area wet.
- Your left groin/thigh skin graft and repair sites will be
dressed with a xeroform dressing to graft areas, fluffed gauzes
covered with
kerlix and then ace wrap.
- Continue on oral antibiotics until you are seen in [**Hospital 702**]
clinic by Dr. [**First Name (STitle) 1022**]
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]. Please call his office to
schedule a follow up appointment in 1 week: ([**Telephone/Fax (1) 36264**].
.
Please follow up with your PCP to review the details of your
hospitalization. You were treated for necrotizing fasciitis
(beta streptococcus group A), septic shock and acute renal
insufficiency). You have completed your course of antibiotic
therapy and your creatinine is normalizing. You should have a
set of repeat electrolytes drawn at your PCP appointment to be
sure your kidney function continues to improve.
.
You should also schedule a follow up appointment with Nephrology
in [**12-18**] months after this hospitalization. Call for an
appointment:
([**Telephone/Fax (1) 10135**]
Completed by:[**2131-4-12**]
|
[
"584.9",
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"305.1",
"787.91",
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icd9cm
|
[
[
[]
]
] |
[
"86.22",
"83.45",
"86.69",
"86.28",
"83.44",
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] |
icd9pcs
|
[
[
[]
]
] |
11481, 11528
|
5218, 9367
|
312, 1224
|
11660, 11660
|
2931, 5195
|
12836, 13660
|
2257, 2275
|
9497, 11458
|
11549, 11639
|
9393, 9474
|
11811, 12083
|
2290, 2912
|
252, 274
|
1252, 1964
|
11675, 11787
|
1986, 2102
|
2118, 2241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,687
| 115,813
|
32019
|
Discharge summary
|
report
|
Admission Date: [**2169-11-2**] Discharge Date: [**2169-11-7**]
Date of Birth: [**2106-5-20**] Sex: M
Service: MEDICINE
Allergies:
Naproxen / Sulfa (Sulfonamides) / Doxycycline
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
Ventricular tachycardia
Major Surgical or Invasive Procedure:
Ventricular tachycardia ablation procedure and dual chamber
ICD(defibrillator) implantation.
History of Present Illness:
This is a 63 year old Pakistani male with hx type IDDM, HTN,
remote 70 pack year smoking history, CAD s/p MI and 4v CABG in
99, s/p cath and stent in [**2163**] anatomy unknown, who presented to
an OSH with palpitations. Pt reports that approximately 1 month
ago, while in [**State 108**], he noted palpitations. He went to see a
PCP at that point, who told him that his HR was "slow." He
decreased his lopressor dose at that time, and his palpitations
temporarily resolved.
.
He then reports that 1 week ago, he began to have worsening
shortness of breath, orthopnea, and LE edema. His dyspnea was
mostly on exertion, and he reports becoming windy after "several
step." This is far from his baseline exercise tolerance, which
is "several blocks of walking." He went to see his PCP at this
time 1 week ago and his lasix dose was increased with
improvement of his symptoms.
.
1 day prior to admission, at around 2 pm, he began to have
palpitations. He reports that these palpitations are similar to
the palpitations that he had previously 1 month ago. He also
notes that he began to have shortness of breath and also reports
feeling weak, tired, lightheaded and felt as though a "curtain
was going down in his field of vision." He denies LOC, chest
pain, fever, chills, cough.
.
At the OSH, he was found to have EKG c/w ventricular tachycardia
and was started on an amiodarone drip 150 mg bolus amio over 20
mins followed by 1 mg/min gtt. He was then given lidocaine bolus
with 2 mg/min which reportedly resulted in breaking his VT for 2
minutes, he was then given Magnesium sulfate x 3 boluses
followed by a 20mg/min gtt which resulted in sinus rhythm with
runs of VT. His palpitations resolved at 8pm yesterday.
.
EVENTS / HISTORY OF PRESENTING ILLNESS:
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Past Medical History:
Cardiac Risk Factors: Diabetes, Hypertension
.
Adenosquamous carcinoma s/p ??left upper lobe lobectomy
.
RLL lung nodule stable since [**11-11**]
.
PVD s/p left LE bypass graft done in [**Country 9819**] in [**2161**]
.
CRI baseline Cr 2.3
Social History:
Social history is significant for the absence of current tobacco
use. Remote tobacco use, [**3-11**] PPD x 35 years, last cigarette 10
years ago. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Brother died of pophyria. Father MI at age
60s, died of porphyria.
Physical Exam:
VS: Afebrile, BP 129/99 , HR 94 , 12 RR , O2 98% on 2L
Gen: WDWN middle aged male mildly diaphoretic, no resp distress
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8cm
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased breath sounds
on right lower base, bibasilar crackles.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
MEDICAL DECISION MAKING
Pertinent Results:
EKG demonstrated paroxysmal ventricular tachycardia, RAD
.
TELEMETRY demonstrated: paroxysmal ventricular tachycardia at HR
100s
.
2D-ECHOCARDIOGRAM performed in [**2167**] demonstrated:
40-45% mild LV enlargement and area of focal akinesis in
inferior wall and LV apex
Brief Hospital Course:
63 yo male with CAD s/p 4v CABG in [**2161**] and sytolic HF, EF now
25-30% who presents with a paroxysmal ventricular tachycardia.
.
1. Ventricular Tachycardia: He has a ventricular arrhythmia
with underlying structural heart disease, CAD with EF 25-30%.
focused VT was ablated and on EP testing, he was also found to
have inducible VT. There were no events on tele between the
ablation and the ICD placement. On [**11-6**] he had a ECHO which
showed LVEF 30% and increased wedge pressure. He had an ICD
placed on [**11-6**]. It was interrogated by EP. He remained
hemodynamically stable, and without evidence of end organ
ischemia. patient had lidocaine gtt and amiodarone gtt. pt
continued on home beta blocker. TSH is normal. home Lasix was
held, to re-evaluate with PCP
2. Acute systolic heart failure: Appeared mildly fluid
overloaded admission, resolved with PRN lasix. , likely
compounded by his tachycardia. On echo here, he was found to
have sytolic dysfunction with EF 25-30%, which is reduced from
his previous EF of 40-45% in [**2167**]. CHF at this time may be due
to ischemia or secondary to arrythmia. Took of standing home
lasix dose, because pt euvolemic after several PRN doses.
Cardiac markers negative for MI, but trace positive, probably
due to demand ischemia.
.
3. CAD: Cont ASA, statin, BB.
.
4. CKD: Acute on chronic renal failure on admission. Cr 2.8 on
admission, 2.3 at baseline. CKD likely secondary to DMII and
HTN. acute KD likely pre-renal secondary to poor renal perfusion
in the setting of frequent VTs. Normalized to baseline by
discharge.
.
5. Leukocytosis: No localizing symptoms. He is without cough,
dysuria, fever.
urinalysis, cx-ray, blood cxs all negative.
.
6. DM: Glargine 40, ISS, FSG QID. PRN glargine.
Medications on Admission:
Atrovent
ASA 81
Flovent 2 puffs
Glargine 40 daily
Lispro 4 before meals
lasix 60 [**Hospital1 **]
lopressor 50 [**Hospital1 **]
norvasc 5
pravachol 40
ranitidine 150
Avapro-->discontinued at OSH
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Insulin Lispro 100 unit/mL Solution Sig: Four (4) units
Subcutaneous qAC.
8. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous qAM.
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 1 days.
Disp:*4 Capsule(s)* Refills:*0*
10. Avapro 150 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Ventricular tachycardia
Sinus bradycardia
Acute renal failure
Congestive heart failure
Hypermagnesemia
.
SECONDARY DIAGNOSES:
Diabetes mellitus
HTN
Chronic renal insufficiency
Discharge Condition:
stable, ambulating
Discharge Instructions:
You were diagnosed with a ventricular tachycardia. You underwent
an ablation procedure and subsequent ICD(defibrillator) and
pacemaker placement without complications.
.
Please follow up with device clinic as indicated below.
.
Please take all medications as prescribed. You will have to take
antibiotics for 1 more day as prescribed.
.
Please take note that we increased your pravastatin to 80mg
because of your elevated cholesterol levels. Also note that
your lasix and norvasc have been discontinued.
.
Please return to the hospital or see your PCP if you have any
chest pain, shortness of breath, fever or pain in the insertion
site of your ICD/pacemaker.
Followup Instructions:
DEVICE CLINIC
Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2169-11-14**] 2:30
.
We have scheduled an appointment for you with your cardiologist,
Dr. [**Last Name (STitle) 62081**]([**Telephone/Fax (1) 75003**]) Tues, [**11-21**] at 3pm.
.
Please follow-up with your primary care physician in the next
7-10 days. You had an abnormal finding on your chest x-ray for
which you should follow with him. Please call Dr. [**Last Name (STitle) 3273**] at
[**Telephone/Fax (1) 45347**].
Completed by:[**2169-11-9**]
|
[
"443.9",
"584.9",
"250.40",
"428.23",
"427.1",
"403.90",
"427.89",
"585.9",
"V10.11",
"412",
"V45.81",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.27",
"37.94",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
7340, 7346
|
4425, 6183
|
330, 424
|
7585, 7606
|
4131, 4402
|
8315, 8827
|
3054, 3205
|
6428, 7317
|
7367, 7491
|
6209, 6405
|
7630, 8292
|
3220, 4112
|
7512, 7564
|
267, 292
|
452, 2572
|
2594, 2836
|
2852, 3038
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,886
| 175,305
|
41783
|
Discharge summary
|
report
|
Admission Date: [**2193-3-8**] Discharge Date: [**2193-3-16**]
Date of Birth: [**2128-5-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
left lower lobe lung cancer
Major Surgical or Invasive Procedure:
[**2193-3-8**]
1. Left thoracotomy.
2. Completion left pneumonectomy.
3. Buttressing of bronchial stump with intercostal muscle.
History of Present Illness:
The patient is a 64-year-old woman who underwent a left upper
lobectomy many years ago for stage 1 non-small cell lung cancer.
In follow up she developed a
deep lesion in the left lower lobe that on biopsy was positive
for non-small cell lung cancer. We felt that this was a new
primary cancer and therefore recommended a completion
pneumonectomy. Staging workup was negative for
metastatic disease and her pulmonary function was acceptable for
the proposed operation.
Past Medical History:
1. Thyroid cancer (papillary carcinoma), status post resection
on
[**2180-6-30**] and post-operative radioactive iodine;
2. Stage I nonsmall cell lung cancer (adenocarcinoma), status
post left upper lobe lobectomy on [**2180-6-30**];
3. Hypertension for over 5 years;
4. Hyperlipidemia for over 5 years;
5. Osteopenia/osteoporosis;
6. Possible asymptomatic chronic obstructive pulmonary disease.
Social History:
The patient is retired and was a former accountant. The patient
started smoking cigarettes at age 15, and smoked 2 packs per day
up to age 41. This places her at an approximate 50-pack-year
history of smoking. There is no history of significant alcohol
intake. There is no history of exposure to asbestos. There is
no history of exposure to heavy chemicals or radiation.
Family History:
Has family history of cancer. Father had lung cancer. Mother had
[**Name2 (NI) 499**] cancer as did maternal grandmother. [**Name (NI) **] other cancers in
the family.
Physical Exam:
Vitals: T 98.5, HR 74, BP 110/50, RR 20, O2 96%
Gen: A&O, NAD
CV: RRR
Pulm: Decreased breath sounds on left. R CTA. Incision c/d/i
without erythema/drainage/fluctuance
Abd: S/NT/ND
Ext: w/d, no edema
Pertinent Results:
[**2193-3-15**] 07:10AM BLOOD Hct-28.6*
[**2193-3-14**] 07:35AM BLOOD WBC-11.1* RBC-2.77* Hgb-8.6* Hct-24.7*
MCV-89 MCH-31.0 MCHC-34.8 RDW-15.5 Plt Ct-275
[**2193-3-11**] 09:32AM BLOOD PT-12.3 INR(PT)-1.1
[**2193-3-14**] 07:35AM BLOOD Glucose-100 UreaN-10 Creat-0.5 Na-137
K-4.2 Cl-100 HCO3-30 AnGap-11
[**2193-3-11**] 03:04AM BLOOD CK-MB-5 cTropnT-0.23*
[**2193-3-9**] 02:10PM BLOOD CK-MB-8 cTropnT-<0.01
[**2193-3-14**] 07:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
.
CXR ([**2193-3-15**]): FINDINGS: The patient is status post left
pneumonectomy. Slight increase in amount of pleural fluid since
the prior study, with major air-fluid level now at the left
sixth rib level. Small loculations of gas in the mid and lower
left hemithorax has slightly decreased as well, and subcutaneous
emphysema has slightly decreased. Within the right lung,
ground-glass and reticular opacities at the right upper lobe and
more confluent opacity at the right base have slightly improved.
Small right pleural effusion is unchanged.
Brief Hospital Course:
The patient was admitted to the Thoracic Sugery service after
elective operation. Her post-operative course is as follows:
.
Neuro: Epidural was placed pre-operatively which provided
adequate pain control. The epidural was removed POD 4 and she
was transitioned to oral pain medications with adequate control.
.
CV: The patient's vital signs were routinely monitored. On POD
1 she developed hypotension with systolic pressures in the 60-70
range. EKG showed lateral T-wave inversions. Cardiology was
consulted and ECHO was obtained. This demonstrated EF >55%, no
wall motion abnormalities, mild dilated RV with moderate PA HTN.
She was started on aspirin per cardiology recommendations. She
was started on Neo for blood pressure support and was given
Albumin as well. On POD 2 she went into Afib with RVR which
resolved after IV metoprolol was given. Serial cardiac enzymes
were checked with peak trop of 0.11 likely demand ischemia, and
cardiac enzymes trended down. Cardiology recommended continuance
of medical management. She went back into AFib on POD 3 which
resolved with metoprolol. A repeat ECHO suggested low
intravascular volume and a central line was placed to assist
with fluid management. She was given blood and fluids to
maintain intravascular volume and the Neo was weaned off on POD
4. She remained hemodynamically stable thereafter for the
remainder of the hospitalization. On POD 6 she was noted to
become dizzy while standing up and was orthostatic. Hematocrit
was 24 and she was transfused 1 unit of blood. On POD 7 she
noted some chest discomfort after attempting ambulation with PT.
An EKG was checked and was unchaged and the discomfort resolved
spontaneously. She had no further episodes of chest discomfort.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Her chest tube was removed
after drainage was at an acceptable rate. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout this hospitalization. She required oxygen throughout
her stay with low room air ambulatory saturations. She was
discharged on home oxygen therapy.
.
GI/GU/FEN: Post operatively, the patient was made NPO with IVF.
The patient's diet was advanced to regular on POD 4, which was
tolerated well. 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's white blood count and fever curves were
closely watched for signs of infection.
.
Endocrine: The patient's blood sugar was monitored throughout
this stay. She was continued on her home thyroid replacement
medication.
.
Hematology: The patient's complete blood count was examined
routinely. She received 2 units of blood on POD2 for hematocrit
of 24, with good response and then 1 unit on POD 6.
.
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 with normal O2 sat on oxygen. The
patient was tolerating a regular diet, ambulating, voiding
without assistance, and pain was well controlled. She was
evaluated by PT who recommended home PT which the patient agrees
to. She was discharged to home with clinic follow up. She will
wear home O2, and has home PT and VNA services set up.
Medications on Admission:
ATENOLOL-CHLORTHALIDONE, ATORVASTATIN, LEVOTHYROXINE 88',
LORAZEPAM, OMEPRAZOLE, ONDANSETRON, SERTRALINE, CaCO3, CoQ10,
colace
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK
(Six Times a Week).
Disp:*180 Tablet(s)* Refills:*2*
6. levothyroxine 88 mcg Tablet Sig: 0.5 Tablet PO QSUN (every
Sunday).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. home O2
low continuous O2, pulse dose for portability. Diagnosis: left
lung cancer s/p left pneumonectomy
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Left lung cancer s/p left pneumonectomy.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* wear your oxygen as provided
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-3-28**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
|
[
"276.50",
"V10.87",
"427.31",
"V15.82",
"401.9",
"272.4",
"997.1",
"786.50",
"733.90",
"162.5",
"458.29",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.59",
"38.93",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
7889, 7964
|
3214, 6695
|
310, 441
|
8049, 8049
|
2176, 3191
|
9768, 10258
|
1771, 1941
|
6872, 7866
|
7985, 8028
|
6721, 6849
|
8200, 9745
|
1956, 2157
|
243, 272
|
469, 943
|
8064, 8176
|
965, 1363
|
1379, 1755
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,157
| 108,176
|
35933+58048
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-1-2**] Discharge Date: [**2132-1-15**]
Date of Birth: [**2057-5-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
[**1-3**]: Placement of External Ventricular Drain
[**1-11**]: Endoscopic Biopsy
History of Present Illness:
74 y/o female brought to [**Hospital3 7362**] by her co-workers for
lethargy; Patient was falling asleep at work and difficult to
arrouse; CT there showed a third ventricular tumor with
hydrocephalus.
Past Medical History:
Unknown
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
BP: 116/56 HR:70's R 12 O2Sats 97%
Gen: Grimicing, shaking head from side to side
HEENT: Pupils: R: 6mm and hippus 6mm to 4mm brisk EOMs: Exam
limited secondary to lethargy and poor mental status.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Pt. oriented to self only, disoriented to place and year, has
significant difficulty staying awake for exam.
Cranial Nerves:
I: Not tested
II: Pupils as above
Motor: Normal bulk, weak hand grasps [**3-28**] bilaterally
Toes downgoing bilaterally
On Discharge pt is A&Ox2-3, MAE, follows commands. She is sl.
deconditioned in Upper extremities and has sl. quad weaknes on
the L however she is difficult to asses because although she
understand what questions are being asked she may not respond
approriately.
Pertinent Results:
Labs on Admission:
[**2132-1-2**] 07:45PM BLOOD WBC-13.5* RBC-4.28 Hgb-12.5 Hct-36.7
MCV-86 MCH-29.2 MCHC-34.0 RDW-13.2 Plt Ct-374
[**2132-1-2**] 07:45PM BLOOD Neuts-83.9* Lymphs-12.7* Monos-3.0
Eos-0.3 Baso-0.2
[**2132-1-2**] 07:45PM BLOOD PT-13.0 PTT-22.7 INR(PT)-1.1
[**2132-1-2**] 07:45PM BLOOD Glucose-106* UreaN-15 Creat-0.7 Na-138
K-4.1 Cl-102 HCO3-27 AnGap-13
[**2132-1-7**] 02:17AM BLOOD ALT-35 AST-55* AlkPhos-118* TotBili-0.1
[**2132-1-2**] 07:45PM BLOOD TSH-0.92
[**2132-1-6**] 11:05PM BLOOD Cortsol-14.2
Liver Function Test Trend:
[**2132-1-8**] 01:47AM BLOOD ALT-128* AST-203* AlkPhos-159*
TotBili-0.2
[**2132-1-9**] 03:07AM BLOOD ALT-159* AST-176* AlkPhos-146*
TotBili-0.2
[**2132-1-10**] 04:20AM BLOOD ALT-117* AST-71* AlkPhos-133* TotBili-0.1
[**2132-1-11**] 05:00AM BLOOD ALT-97* AST-53* AlkPhos-132* TotBili-0.2
[**2132-1-12**] 05:33AM BLOOD ALT-69* AST-23 LD(LDH)-172 AlkPhos-120*
TotBili-0.2
[**2132-1-13**] 09:16PM BLOOD ALT-46* AST-23 AlkPhos-96 TotBili-0.2
[**2132-1-14**] 06:40AM BLOOD ALT-45* AST-21 AlkPhos-104 TotBili-0.3
[**2132-1-15**] 05:14AM BLOOD ALT-35 AST-21 AlkPhos-89 TotBili-0.2
Labs on Discharge:
[**2132-1-15**] 05:14AM BLOOD WBC-7.7 RBC-3.39* Hgb-10.0* Hct-28.9*
MCV-85 MCH-29.5 MCHC-34.6 RDW-13.8 Plt Ct-495*
[**2132-1-15**] 05:14AM BLOOD PT-13.3 PTT-27.5 INR(PT)-1.1
[**2132-1-15**] 05:14AM BLOOD Glucose-94 UreaN-13 Creat-0.6 Na-139
K-4.1 Cl-103 HCO3-30 AnGap-10
[**2132-1-15**] 05:14AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.9
Imaging:
Head CT [**1-2**]:
IMPRESSION:
1. Interventricular mass in the left lateral ventricle appearing
to arise from the roof of the third ventricle causing
obstruction of the foramen of [**Last Name (un) 2044**] with subsequent
hydrocephalus. Diagnostic consideration include ependymoma or
intraventricular meningioma. If there is a history of tuberous
sclerosis, then a giant cell astrocytoma could be considered. A
choroid plexus papilloma may have a similar appearance, however,
unlikely given patient age.
CXR [**1-2**]:
IMPRESSION:
No acute intrathoracic process.
CSF Sample [**1-3**]:
Cerebrospinal fluid:
NEGATIVE FOR MALIGNANT CELLS.
ECG 12-lead [**1-3**]:
Sinus rhythm
Normal ECG
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 134 82 374/402 70 36 54
Head MRI [**1-3**]:
FINDINGS: The study is significantly limited due to motion
artifact,
rendering the T2 sequence nondiagnostic. Multiple attempts did
not
significantly improve motion artifact due to patient's inability
to hold
still.
Within the limitations of the study, there is a T1 hypointense
lobulated
intraventricular mass involving the left lateral ventricle and
measuring 1.8 x 1.4 cm. A ventriculostomy catheter is noted in
situ, frontal approach. The ventricles are asymmetric with left
ventricle being relatively dilated, this could result from mass
effect due to the intraventricular tumor. There are no other
obvious lesions, masses on pre- contrastr T1- weighted images.
Head MRA [**1-3**]:
MRA HEAD:
The study is somewhat limited due to motion artifacts. Within
these
limitations, the well visualized portions of the intracranial
internal carotid arteries, the anterior and the middle cerebral
and the distal vertebral and the basilar artery, appear to be
grossly patent, without focal flow-limiting stenosis or
occlusion. No aneurysm more than 3 mm within the resolution of
MR angiogram is noted on the well visualized portions of the
arteries.
On the axial T2-weighted images, there is increased signal in
the maxillary sinuses, and ethmoid air cells on both sides from
fluid and/or mucosal thickening along with retention cysts or
polyps in the maxillary sinus, the largest one in the left
maxillary sinus measuring approximately 2.5 x 1.7 cm.
CT of Chest/Abdomen/Pelvis [**1-5**]:
TECHNIQUE: MDCT axially acquired images were obtained from the
thoracic inlet to the symphysis after the uneventful intravenous
administration of 130 ml Optiray 350 contrast material.
Multiplanar reformatted images were obtained and reviewed.
CT CHEST WITH CONTRAST: Endotracheal tube and NG tube are in
standard
position. No axillary, mediastinal, or hilar adenopathy is
detected per CT
size criteria. Small lymph nodes are present within the
mediastinum. No
dissection flap is present within the thoracic aorta. There is
no pericardial effusion. Coronary artery calcifications are
present. Bibasilar atelectasis is noted within the lungs. Small
tree-in-[**Male First Name (un) 239**] opacities are present within the right lower lobe
with a 1.4 cm opacity (series 2: image 31). A subpleural nodular
density measuring 1 cm is noted in the lateral right upper lobe
CT ABDOMEN WITH CONTRAST: No masses are identified within the
liver. The
gallbladder, pancreas, spleen, and adrenal glands appear
unremarkable. No
free fluid or free air is present within the abdomen. Incidental
note is made of a retroaortic left renal vein. Calcified
atherosclerotic plaque is present within the abdominal aorta and
iliac branches without aneurysmal dilatation.
CT PELVIS WITH CONTRAST: A Foley catheter is noted within the
bladder lumen. The rectum, sigmoid colon, and unopacified loops
of small bowel appear unremarkable without evidence of
obstruction. No lymphadenopathy is detected.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
detected.
Moderate degenerative changes are present within the lower
lumbar spine with facet joint sclerosis.
CT w/3D rendering [**1-11**]:
FINDINGS: There have been no significant changes since the prior
study. Again identified is a mass arising within the frontal
[**Doctor Last Name 534**] of the left lateral ventricle. A ventriculostomy catheter
is in place. The mass is seen to be inhomogeneously hyperintense
on the post- contrast images currently available. Comparison
with prior studies indicates that this represents contrast
enhancement within the tumor. No other abnormalities are
detected.
The tumor volume measures 1.4 cc on the axial short TR images.
CONCLUSION: No change since the study of [**2132-1-4**]. Left frontal
[**Doctor Last Name 534**]
intraventricular tumor. This appears to arise from the choroid
plexus, and
thus choroid plexus-origin tumors such as meningioma or
papilloma appear to be the most likely diagnoses.
Head CT [**1-11**]:
FINDINGS: There is diffuse increased edema with blurring of the
sulci and
complete effacement of the basal cisterns, which is very
concerning for
impending transtentorial herniation. High-density fluid in the
left lateral ventricle (average 70 [**Doctor Last Name **]), which likely represents
contrast, although underlying hemorrhage cannot be excluded. A
left craniotomy with catheter tip terminating in the third
ventricle is noted. There is a 5-mm shift of normally midline
structures which is grossly unchanged since [**2132-1-11**]. There are
scattered opacifications in the paranasal sinuses, which are
unchanged since [**2132-1-4**]. The mastoid air cells are clear.
IMPRESSION:
1. There is complete effacement of the basal cisterns which is
concerning for impending transtentorial herniation. There is
diffuse brain edema, which has markedly increased since
[**2132-1-11**].
2. High-density fluid in the left lateral ventricle likely
represents
contrast, although evaluation for underlying hemorrhage is
limited.
ATTENDING NOTE: It is unclear how much of the effacement of
sulci and basal cistern obliteration is due to the presence of
contrast. However, complete obliteration of the quadrigeminal
cistern and deformity of the mid brain are suggestive of central
herniation.
Brief Hospital Course:
74F brought to [**Hospital3 7362**] by her co-workers for concerns of
lethargy. This patient was falling asleep at work and difficult
to arouse. The initial CT there showed a third ventricular
tumor with hydrocephalus. On initial presentation she was
febrile to 101.8 and ID was immediately involved pending her
neurological diagnosis over concern of potential infectious
process. CSF was sent which showed RBC 985 and WBC 720, Protein
59, and Glucose 46. He was started on broad spectrum
antibiotics (Vancomycin, Ampicillin, and Ceftriaxone) pending
isolation of sensitive organism. On [**1-5**] she underwent CT of
the torso to evaluate for alternate etiology of intracerebral
mass, which was negative to that effect. On [**1-8**] an additional
CSF sample was sent which showed no isolated WBC/leukocytes and
CSF had RBC of 900 and WBC of 0. On [**1-9**] her neurological
examination was much improved and she passed a speech and
swallow examination to allow leisure eating. She was also found
to have a bump in her LFT's but given the mild elevation, ID
opted to continue to monitor daily. On [**1-11**] she underwent 3rd
ventricular tumor biopsy and Rickham catheter placement. Post
operatively was initially nonverbal, and not following commands.
This was attributed to recovery from anesthesia in the setting
of a stable head CT. On [**1-13**] her examination was much improved
and following commands very briskly. As of [**1-14**] all cultures
have not returned any organism. At this point she had been on
antibiotics for 13 days, and ID felt very comfortable
discontinuing further treatment in the setting of no WBC in the
most recent CSF sampling. She was also evaluated by PT/OT and
determined appropriate for rehabilitation. She was discharged to
an appropriate facility on [**1-15**] with instructions to follow up
with Dr. [**First Name (STitle) **]
Medications on Admission:
unknown
Discharge Medications:
.
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): to continue until follow up appointment with Dr.
[**Last Name (STitle) **].
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
3rd Ventricular Mass
Hydrocephalus
Fevers
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-2**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
*Please call [**Telephone/Fax (1) 1669**] to schedule a follow up appointment
with Dr. [**First Name (STitle) **] in approximatley 4 weeks. You will be required to
have a MRI with contrast prior to you appointment.
Completed by:[**2132-1-15**] Name: [**Known lastname 13088**],[**Known firstname 6532**] Unit No: [**Numeric Identifier 13089**]
Admission Date: [**2132-1-2**] Discharge Date: [**2132-1-15**]
Date of Birth: [**2057-5-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 2112**]
Addendum:
Addendum to Follow-up in Discharge Summary:
As you have a newly diagnosed brain tumor, you will be required
to follow up with the [**Hospital1 8**] brain tumor clinic. You have an
appointment on [**2132-1-21**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 2314**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2115**] MD [**MD Number(2) 2116**]
Completed by:[**2132-1-15**]
|
[
"331.4",
"322.9",
"276.2",
"790.5",
"276.1",
"459.81",
"272.0",
"780.01",
"401.9",
"191.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"01.13",
"02.2",
"02.39",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14886, 15123
|
9110, 10980
|
281, 364
|
12054, 12078
|
1509, 1514
|
13661, 14863
|
677, 695
|
11038, 11865
|
11989, 12033
|
11006, 11015
|
12102, 13638
|
710, 1086
|
232, 243
|
2647, 9087
|
392, 595
|
1102, 1490
|
1528, 2628
|
617, 627
|
643, 661
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,516
| 180,149
|
24104
|
Discharge summary
|
report
|
Admission Date: [**2120-3-4**] Discharge Date: [**2120-3-9**]
Date of Birth: [**2081-6-2**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Diabetic Ketoacidosis and Angina
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 61277**] is a 38 year old man with IDDM admitted to an outside
hospital with nausea, vomitting, and lethargy. He was found to
be in diabetic ketoacidosis with bicarb < 10 and AG > 36. The
diabetic ketoacidosis was successfully treated with IV fluids
and insulin drip. No evidence of focal infection was found since
he had a clear chest x ray and urinalysis. However, the patient
had an episode of substernal chest pain while at rest lasting 10
minutes on the morning of admission, relieved with 3 sublingual
nitroglycerine. His EKG showed [**Street Address(2) 4793**] elevation in II, III, and
aVF (unchanged with CP and CP free). The CKs were flat but
troponin was up from 0.03 to 0.09. He was started on IV heparin
and transferred to this hospital for further care. At this
hospital he was chest pain free. EKG showed <1mm ST elevation
II>aVT>III. CK were flat. The anion gap closed.
Mr. [**Known lastname 61277**] [**Last Name (Titles) **] sick contacts, but admits to fever to 100 and
mild chills, cough, and diaphoresis.
Past Medical History:
Diabetes Mellitus type one, diagnosed [**2114**]
Social History:
smokes about once per week
drinks 5 times per week
works as an executive sous chef
Family History:
grandmother with type I DM, per patient
father with type II DM
Physical Exam:
T 99.2 BP 140/80 HR 84 RR 16 O2 sat 99 on RA finger sticks
214
Gen: NAD, pleasant and cooperative
HEENT: MMM, EOMI, PERRLA, neck supple
Cor: RRR no m/r/g
Pulm: CTAB no w/r/r
Abdomen: NT ND +BS, no guarding
Ext: WWP, strength 5/5 bilaterally upper and lower extremities
skin: no lesions
Neuro: A + O x 3
Pertinent Results:
[**2120-3-4**] 05:22PM GLUCOSE-256* UREA N-2* CREAT-0.6 SODIUM-140
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14
[**2120-3-4**] 05:22PM ALT(SGPT)-210* AST(SGOT)-306* LD(LDH)-265*
CK(CPK)-70 ALK PHOS-82 AMYLASE-20 TOT BILI-0.9
[**2120-3-4**] 05:22PM CK-MB-NotDone cTropnT-<0.01
[**2120-3-4**] 05:22PM TRIGLYCER-99 HDL CHOL-79 CHOL/HDL-2.3
LDL(CALC)-80
[**2120-3-4**] 05:22PM WBC-5.1 RBC-3.56* HGB-12.5* HCT-35.3* MCV-99*
MCH-35.1* MCHC-35.4* RDW-13.2
[**2120-3-6**] 05:10AM BLOOD Ret Aut-1.3
[**2120-3-7**] 05:05AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.7 Iron-59
[**2120-3-7**] 05:05AM BLOOD calTIBC-250* Ferritn-329 TRF-192*
[**2120-3-6**] 05:10AM BLOOD VitB12-1621* Folate-9.2
[**2120-3-7**] 10:06AM BLOOD %HbA1c-12.2*
[**2120-3-5**] 06:27AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE HAV
Ab-NEGATIVE IgM HAV-NEGATIVE
[**2120-3-5**] 06:27AM BLOOD HCV Ab-NEGATIVE
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2120-3-7**]): POSITIVE BY
EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2120-3-7**]):
POSITIVE BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2120-3-7**]): NEGATIVE <1:10
BY IFA.
CMV IgG ANTIBODY (Final [**2120-3-8**]): POSITIVE FOR CMV IgG ANTIBODY
BY EIA.
CMV IgM ANTIBODY (Final [**2120-3-8**]): NEGATIVE FOR CMV IgM ANTIBODY
BY EIA.
FINDINGS: The gallbladder appears normal without cholelithiasis.
The common duct is not dilated. The echotexture of the liver is
diffusely hyperechoic consistent with fatty infiltration. The
main portal vein demonstrates normal hepatopetal flow. The right
kidney measures 12.8 cm in length, the left 13.5 cm. Both
kidneys appear normal without mass, hydronephrosis, or
nephrolithiasis. The pancreas and spleen are unremarkable
without splenomegaly. The spleen measures 10.1 cm in length. The
caliber of the abdominal aorta is normal throughout the abdomen.
There is no ascites. IMPRESSION: Echogenic liver consistent with
fatty infiltration. However, other forms of liver disease and
more advanced liver disease, including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
Stress Test: The patient was exercised on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] treadmill
protocol which wqas stopped for fatigue after the completion of
10.5 minutes of exercise (good exercise tolerance). There was
chest tightness ([**6-28**]) near peak exercise. There were no ECG
changes. The rhythm was sinus without ectopy. The blood pressure
response to exercise was normal. IMPRESSION: Possible angina
without ischemic ECG changes.
MIBI IMPRESSION: 1) Normal myocardial perfusion. 2) Normal left
ventricular cavity size and function.
Transthoracic Echo: 1. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. 2. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
Brief Hospital Course:
Mr. [**Known lastname 61277**] is a 38 year old man with type I diabetes and
diabetic ketoacidosis which resolved before admission to our
medical intensive care unit. In terms his diabetes, once the
anion gap closed, the lantus and humalog were restarted. He was
able to tolerate a diabetic diet. He was seen by [**Last Name (un) **] who
titrated up his glargine and sliding scale.
# transaminitis: Mr. [**Known lastname 61277**] was found to have a transaminitis. A
RUQ ultrasound revealed a fatty liver. The patient works as a
chef, and it was thought that he could be exposed to infectious
agents but his hepatitis serologies and monospot were negative.
His ferritin level was not consistent with hemochromatosis. His
liver enzymes trended down over the course of his stay. Although
Mr.[**Known lastname 61277**] stated that he only drinks about 1 glass of wine per
day, he was encouraged to quit drinking alcohol altogether. He
was discharged with outpatient follow up in the hepatology
clinic.
# CP: Mr. [**Known lastname 61278**] chest pain resolved before hospitalization
and was not thought to be coronary in nature since he ruled out
for an MI. His stress MIBI normal, therefore did not support a
cardiovascular idiology either. His lipid profile was at goal.
# Hypertension: Mr. [**Known lastname 61277**] was found to be hypertensive, which
was a new diagnosis for him. He was started on metoprolol which
he tolerated well. He was sent home with toprol xl.
The patient has follow up with [**Hospital **] clinic within the next
month. He was also given a small blood glucose machine prior to
discharge.
Medications on Admission:
insulin glargine
regular insulin
Discharge Medications:
1. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: [**1-21**]
Tablet Sustained Release 24HR PO once a day.
Disp:*15 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
3. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
Disp:*QS ML(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
DM type I
viral URI
Discharge Condition:
good
Discharge Instructions:
Please continue your medications. Please follow up your abnormal
liver function tests with your doctor.
Call your doctor for high or low blood sugars, nausea,
vomitting, fevers, chills, or increased weakness.
Followup Instructions:
Please see your PCP for follow up of your abnormal liver
function tests or call [**Company 191**] at [**Telephone/Fax (1) 1247**] for an appointment
with me (Dr. [**Last Name (STitle) 2423**].
|
[
"401.9",
"250.11",
"465.9",
"571.8",
"079.99"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7102, 7108
|
4982, 6600
|
302, 308
|
7172, 7178
|
1982, 4959
|
7436, 7632
|
1574, 1638
|
6683, 7079
|
7129, 7151
|
6626, 6660
|
7202, 7413
|
1653, 1963
|
230, 264
|
336, 1386
|
1408, 1458
|
1474, 1558
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,345
| 196,295
|
9906
|
Discharge summary
|
report
|
Admission Date: [**2130-11-8**] Discharge Date: [**2130-11-20**]
Date of Birth: [**2061-2-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Jaundice, RUQ pain
Major Surgical or Invasive Procedure:
ERCP
open cholecystectomy on [**2130-11-9**]
History of Present Illness:
69 year old male with a h/o depression, hypercholesterolemia,
BPH, s/p stroke with residual R hemiplegia, aphasia, apraxia,
was recently discharged from [**Hospital1 18**] to acute rehab following a
right femoral hemiarthroplasty on [**2130-10-9**]. His wife states that
2 days prior to admission, Mr. [**Known lastname **] was noted to be jaundiced
at rehab with liver function tests which were markedly abnormal
(labs from rehab on [**11-7**] revealed AST 483, ALT 737, AP 403, INR
3.26, WBC 12.1). Abdominal ultrasound at rehab showed possible
gallstone. Following discussion with the patient's PCP, [**Name10 (NameIs) **]
transferred to [**Hospital1 18**] for ERCP ([**11-8**]) which revealed small
stones in CBD and biliary sludging. He underwent
sphincterotomy, but continued to have RUQ pain. On [**11-8**] RUQ
U/S showed findings consistent with cholecystitis. The patient
underwent laperoscopic cholecystectomy [**11-9**], but which was
converted to open when it was found the patient had a gangrenous
gallbladder.
* HPI obtained from wife and rehab notes as pt is aphasic from
CVA 2 years ago
Past Medical History:
CVA 2 years ago (residual R hemiplagia, aphasia, apraxia)
R carotid stenosis
DVT 2 years ago in RLE (on coumadin prior to hospitalization)
BPH
Depression
hypercholesterolemia
Social History:
Married, lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**]. 4 children (daughter is
psychiatrist). No tobacco. Occasional EtOH
Family History:
father d. CVA/carotid dz
Physical Exam:
Wt 97.7kg T 97.8 HR 97 BP 143/67 RR 24 98%2Lnc
Gen: sleeping, comfortable, NAD
HEENT: pupils 1mm, reactive and symmetric, anicteric, MM dry,
no sublingual jaundice
Neck: supple, no LAD
CV: RRR, no mrg, small R carotid bruit
Resp: CTA anteriorly
Abd: wound with drain RUQ, soft, ttp diffusely, decreased bowel
sounds
Skin: mild jaundice
Neuro: pt not participating in exam, moving LUE and LLE
Pertinent Results:
Initial Labs at [**Hospital1 18**]:
[**2130-11-8**] 07:45AM WBC-13.2* RBC-3.70* HGB-10.5* HCT-31.5*
MCV-85 MCH-28.5 MCHC-33.5 RDW-14.6 PLT COUNT-241
[**2130-11-8**] 07:45AM ALT(SGPT)-466* AST(SGOT)-215* CK(CPK)-30* ALK
PHOS-406* AMYLASE-36 TOT BILI-2.4* LIPASE-15
[**11-8**] ERCP:
Findings:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Pancreas: Pancreatic duct was normal.
Procedures: Given a small stone and sludge in the bile duct and
a possibility that these could drop in CBD and the fact that
patient may not be fit for cholecystectomy at present time a
decision to perform a sphincterotomy was made with the family. A
sphincterotomy was performed in the 12 o'clock position using a
sphincterotome over an existing guidewire.
Sludge was extracted successfuly from CBD.
Impression:
1. CBD was 4 mm in size. Cystic duct and gallbladder were not
visualized.
2. Given a small stone and sludge in the bile duct and a
possibility that these could drop in CBD and the fact that
patient may not be fit for cholecystectomy at present time a
decision to perform a sphincterotomy was made with the family. A
sphincterotomy was performed in the 12 o'clock position using a
sphincterotome over an existing guidewire.
3. Sludge was extracted successfuly from CBD.
4. Pancreatic duct was normal.
Labs on Transfer to [**Hospital Unit Name 153**]:
[**2130-11-9**] 08:45AM BLOOD WBC-14.0* RBC-3.69* Hgb-10.4* Hct-31.1*
MCV-85 MCH-28.3 MCHC-33.5 RDW-14.7 Plt Ct-259
[**2130-11-9**] 08:45AM BLOOD Plt Ct-259
[**2130-11-9**] 08:45AM BLOOD PT-13.7* PTT-25.0 INR(PT)-1.2
[**2130-11-9**] 08:45AM BLOOD Glucose-137* UreaN-10 Creat-0.8 Na-132*
K-3.6 Cl-96 HCO3-26 AnGap-14
[**2130-11-9**] 08:45AM BLOOD ALT-301* AST-151* LD(LDH)-261*
AlkPhos-364* Amylase-51 TotBili-2.6*
[**2130-11-9**] 08:45AM BLOOD Lipase-24
[**2130-11-9**] 08:45AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.6
[**2130-11-10**] 12:05AM BLOOD WBC-11.5* RBC-2.82* Hgb-8.3* Hct-24.7*
MCV-88 MCH-29.5 MCHC-33.7 RDW-16.2* Plt Ct-254
[**2130-11-10**] 04:12AM BLOOD WBC-14.2* RBC-2.91* Hgb-8.2* Hct-25.8*
MCV-89 MCH-28.1 MCHC-31.7 RDW-16.3* Plt Ct-278
[**2130-11-10**] 05:11PM BLOOD Hct-26.6*
[**2130-11-11**] 05:23AM BLOOD WBC-13.8* RBC-3.77*# Hgb-10.7*# Hct-32.9*
MCV-88 MCH-28.4 MCHC-32.5 RDW-15.8* Plt Ct-273
[**2130-11-11**] 12:30PM BLOOD Hct-32.5* Plt Ct-305
[**2130-11-12**] 06:25AM BLOOD WBC-15.1* RBC-3.78* Hgb-10.7* Hct-33.2*
MCV-88 MCH-28.4 MCHC-32.3 RDW-15.9* Plt Ct-344
[**2130-11-13**] 06:00AM BLOOD WBC-14.0* RBC-3.99* Hgb-11.3* Hct-34.5*
MCV-87 MCH-28.3 MCHC-32.7 RDW-15.7* Plt Ct-380
Brief Hospital Course:
Mr. [**Known lastname **] was admitted following an ERCP on [**2130-11-8**] for a
planned cholecystestomy which he underwent on [**2130-11-9**]. This
was begun laparoscopically but was converted to open when it was
found gangrenous. For details of the procedure, see operative
note. Post-operatively, the patient was transferred to the
intensive care unit for observation given the gangrenous
gallbladder and intra-operative hypertension. He was continued
on antibiotics.
69yo man with h/o depression, hypercholesterolemia, BPH, s/p
stroke with residual R hemipledia, aphasia, apraxia, now s/p
open cholecystectomy:
1. Cholecystitis: now s/p ERCP and open cholecystectomy
- finished course of levofloxacin and flagyl
- surgical wound bleeding stopped
- no new labs required at this time
2. DVT hx and s/p CVA: currently on ASA and pneumo boots
3. Hyperlipidemia: lipitor
4. BPH: continue tamsulosin
5. s/p R hip arthroplasty: physical therapy and occupational
therapy, pt seen by ortho who obtained films in lieu of office
follow-up visit
6. Pain control: controlled well without meds
7. PPx: SQ heparin and pneumoboots for DVT
Protonix po
8. FEN: tolerating regular diet, no IVF required
9. Access: piv x i
10. Communication: patient and his wife, [**Name (NI) **], [**Numeric Identifier 33218**]
11. Code: Full
Medications on Admission:
Discharge Medications:
1. Tamsulosin HCl 0.4 mg po qhs
2. Atorvastatin Calcium 80 mg po qhs
3. Aspirin 81 mg po qd
4. Escitalopram Oxalate 10 mg po qAM
5. Oxycodone-Acetaminophen 5-325 mg q 4-6 hr prn
6. Bisacodyl
7. Warfarin Sodium 5 mg po qhs (at 11/24 d/c)
Discharge Medications:
1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Hydromorphone HCl 2 mg Tablet Sig: 1-4 Tablets PO Q2H (every
2 hours) as needed.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
s/p open cholecycectomy on [**2130-11-9**]
s/p cva
s/p hip replacement
Discharge Condition:
good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Leave the steri strips on until they begin to peel, then you may
remove them. Staples and stitches will remain until your
follow-up
appointment.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
Be sure to take your complete course of antibiotics.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds. Take a shower immediately before
dressing changes by the visiting nurse.
Followup Instructions:
Call to schedule a follow-up appointment in [**11-19**] weeks with Dr.
[**Last Name (STitle) **]. His phone number is ([**Telephone/Fax (1) 9000**].
You should call for a follow-up appointment in one month with
Dr. [**Last Name (STitle) 1005**]. His phone number is ([**Telephone/Fax (1) 33219**].
Completed by:[**2130-11-20**]
|
[
"V54.81",
"577.0",
"276.8",
"V43.64",
"V64.41",
"600.00",
"V12.51",
"438.11",
"438.20",
"574.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"93.59",
"51.88",
"51.22",
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
7683, 7756
|
5081, 6446
|
333, 380
|
7871, 7877
|
2370, 5058
|
9068, 9401
|
1904, 1930
|
6756, 7660
|
7777, 7850
|
6472, 6472
|
7901, 9045
|
1945, 2351
|
275, 295
|
408, 1518
|
1540, 1717
|
1733, 1888
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,768
| 118,796
|
53601
|
Discharge summary
|
report
|
Admission Date: [**2199-6-20**] Discharge Date: [**2199-6-28**]
Date of Birth: [**2123-10-10**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Penicillins
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
75 y/o male presented to ED with hypotension, rapid A-fib, and
signs of sepsis.
Major Surgical or Invasive Procedure:
- incomplete AV graft resection [**2199-6-20**]
- completing AV graft resection [**2199-6-25**]
- trans esophageal echo [**2199-6-27**]
-placement of temporary hemodialysis line [**2199-6-25**]
History of Present Illness:
75 y/o male with h/o MR, HTN, ESRD on HD presented with 2day h/o
fivers/chills, chest pain c/w reflux, and c/o skin over graft
becoming red and painful after last dialysis session. In [**Name (NI) **] pt.
was hypotensive, in rapid a-fib, and demonstrated signs of
sepsis.
Past Medical History:
rectal ca
hypertension
diabetes mellitis
end stage renal disease on hemodialysis
mitral regurg
congestive heart failure
tonic-clonic seizures
Left retinal hemorrhage
left temporla meningioma
s/p cholecystectomy
gallstone pancreatitis
s/p resection of rectal ca
Social History:
lives with spouse
Family History:
non-contrib
Physical Exam:
Vitals:104-110 to 170's-24-130/85 100%
Gen:patient clearly uncomfortable. A&O
HEENT:
Chest:clear bilat
CV:RRR
Abd:soft, healthy appearing ostomy
Ext:R arm +thrill, extremely tender & erythematous
Pertinent Results:
[**2199-6-20**] 2:45 pm BLOOD CULTURE L AC.
**FINAL REPORT [**2199-6-23**]**
AEROBIC BOTTLE (Final [**2199-6-23**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110130**]
([**2199-6-20**]).
ANAEROBIC BOTTLE (Final [**2199-6-23**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110130**]
([**2199-6-20**]).
Findings TEE [**2199-6-27**]
This study was compared to the prior study of [**2198-2-6**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic function (LVEF>55%). Normal regional LV systolic
function. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild
AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Calcified tips of papillary
muscles. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: Based on [**2190**] 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.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is a small pericardial
effusion.
Compared with the prior study (tape reviewed) of [**2198-2-6**], the
severeity of mitral regurgitation has decreased (the blood
pressure is also lower on the current study).
Brief Hospital Course:
Pt. admitted to [**Hospital1 18**] [**2199-6-20**] after two day history of
fevers/chills and chest pain suggestive of reflux. He was taken
to the OR for incomplete excision of R AV loop graft. On the day
of admission the pt. went into afib with SBP initially of 130s
that dropped to 110s in the ER so the pt. was taken to an ICU
bed, cultures were sent, antibiotics (vanco/levo/flagyl) were
started, and a central line placed. Later that evening pt. HR
continued to icrease to 190-200s with SBP that was in the
60-70s.
[**6-21**] HD2 Pt. was on neo drip at 1.5 mcg/kg/min. also pt.s
temperature was down and blood pressures ranged from
95-137/41-48 and overall the pt. was clinically improving. Pt.
also evaluated by cardiology today b/c of afib ->rec to start
digoxin and getting an echo.
[**6-22**] HD3 pt. remained febrile overnight w/heart rate in 100s and
BP 99/42. PT. was successfully cardioverted with intermittent
PACs/afib tachy. weaned off neo. Seen by renal ->got HD today
and underwent placement of quinten for access
[**6-23**] hd4 Pt. desated, continued to require pressors to keep BP
up, Tmax of 100.4. PT. HD again today.
[**6-24**] hd5 pt. afebrile, neo d/ced, still on dilt drip, transfused
1u prbcs, pt. prepped for OR.
[**6-25**] hd6 pt. VQ scan negative, echo showed EF 60%. Pt.
afebrile, BPs fro 126-174/44-61. Pt weaned off of dilt. Pt.
went to OR today -> tolerated the completion graft excision and
placement of R temporary IJ dialysis catheter. Pt. did well
overnight.
Rest of pt.s hospital stay was uneventful. Pt. remained
afebrile, BPs ranged from 140-177/70-84 with HR in 70's and
medication at home were resumed (lopressor 200bid, losartan 50
qd and nifedipine ER 120 qd. He was tolerating POs. Pt underwent
TEE [**2199-6-27**] that demonstrated no vegetations.
He was closely followed by nephrology ( on HD at [**Location (un) 4265**] in
[**Location (un) **]; Dr [**First Name (STitle) 805**] is nephrologist) during this stay.
Outpatient dialysis arrangement were made with set up for
vancomycin dosing at hemodialysis per level for positive blood
cultures and graft on [**6-20**] for staph aureus coag positive for a
total of 6 weeks. Subsequent blood cultures on [**6-24**] are still
pending. Rectal screen for VRE and MRSA was negative.
Upon dischare the right forearm old graft site was slightly pink
with sutures and no drainage. A VNA referral was made to change
a dry sterile dressing then ace qd. He was scheduled to follow
up with Dr. [**First Name (STitle) **] in 1 week post discharge. Labs on d/c were
wbc 10.2, hct 29.6, plt 236, sodium 135, chloride 98, bicarb 25,
bun 56 and creatinine 8.7. A vanco level was pending. He was
given script for ostomy supplies.
Medications on Admission:
asa 325 qday
losartan 50 qday
metoprolol 200 [**Hospital1 **]
nifedipine er 120 qday
atorvastatin 2 qday
calcium carbonate 1000 qid
Discharge Medications:
- Vancomycin - for completion course of 6 weeks
1. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection every six (6) hours: 0-60 mg/dL 1 amp
D50 61-119 mg/dL0 Units
120-139 mg/dL 2 Units
140-159 mg/dL 4 Units
160-179 mg/dL 6 Units
180-199 mg/dL 8 Units
200-219 mg/dL 10 Units
220-239 mg/dL 12 Units
240-259 mg/dL 14 Units
260-279 mg/dL 16 Units
280-299 mg/dL 18 Units
> 301 mg/dL Notify M.D.
.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: tylenol. Tablet(s)
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): given in hemodialysis.
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day).
7. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
9. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous BY LEVEL () as needed for level < 15: to be dosed
in hemodialysis.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
- diabetes mellitis
- hypertension
- end stage renal disease on hemodialysis
- R AV graft infection. Removal of AV graft
- sepsis, staph aureus coag positive
-rapid Afib
-h/o colon ca with colostomy
Discharge Condition:
good
Discharge Instructions:
- please resume all home medications
- OK to shower
- Please [**Name8 (MD) 138**] MD or return to ER if T> 101.5, chills, nausea,
vomitting, erythema/drainage from wound site, severe pain or
numbness in right arm/hand, or any other concern
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-7-4**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2199-8-1**]
12:20
Completed by:[**2199-6-27**]
|
[
"486",
"682.3",
"780.39",
"427.31",
"250.00",
"428.0",
"E878.2",
"427.1",
"V44.3",
"996.62",
"V10.05",
"E849.8",
"403.91",
"038.11",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.42",
"38.95",
"99.61",
"88.72",
"39.95",
"39.43"
] |
icd9pcs
|
[
[
[]
]
] |
8121, 8179
|
3862, 6592
|
379, 576
|
8422, 8428
|
1462, 3839
|
8716, 9164
|
1214, 1227
|
6775, 8098
|
8200, 8401
|
6618, 6752
|
8452, 8693
|
1242, 1443
|
260, 341
|
604, 878
|
900, 1163
|
1179, 1198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,787
| 103,210
|
546
|
Discharge summary
|
report
|
Admission Date: [**2175-3-10**] Discharge Date: [**2175-5-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
Intubation, repostitioning G-Tube, change of G-tube to G-J tube
History of Present Illness:
Mr. [**Known lastname 4476**] is a [**Age over 90 **] year old man with a long history of
end-stage dementia for at least 10 years with recurrent
aspiration pneumonias and pressure ulcers who presents to the
[**Hospital1 18**] ED from [**Hospital **] Rehab with an aspiration. He was recently
discharged from [**Hospital1 18**] [**3-3**] after he had an aspiration and had a
prolonged intubation. He was treated with vanc/zosyn for a two
week course which was completed [**3-5**]. Today, nursing at [**Hospital1 **]
noted that his abdomen was somewhat distended. A KUB was
performed that showed the feeding tube was coiled in his stomach
in a different position. Tube feeds were restarted and the
feeding tube was noted to be further displaced with the phlange
out of place. The patient was turned and began vomiting and
gagging and was suctions. His VS when he was evaluated there
were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM.
.
The patient was brought to the [**Hospital1 18**] ED evaluation. In the ED,
he was immediately intubated, and started on
levaquin/vanc/flagyl for presumed aspiration pneumonia. He
transiently dropped his blood pressure to a systolic of 80's
over 30's and was started on levophed.
Past Medical History:
End-stage Alzheimers
Atrial fibrillation
Recurrent aspiration pneumonias
h/o MRSA and VRE colonization
Myoclonus
Social History:
Recently discharged from [**Hospital1 18**] to [**Hospital **] rehab.
Has been cared for by his daughter for the past three years.
Family History:
Noncontributory
Physical Exam:
VS: (on arrival to the MICU) T 98.9 HR 100 BP 75/33 RR 21 Sat
98%
Vent: AC Tv 500 RR 14 PEEP 8 FiO2 60%
GEN: unresponsive, intubated man on a intubated and sedated on a
ventilator
HEENT: Dry MM, sclerae anicteric, pinpoint pupils.
CV: Distant heart sounds, irregular
PUL: Coarse rhonchi throughout
ABD: Distended, no rebound or guarding.
EXT: 1+ edema
Pertinent Results:
ADMISSION LABS
[**2175-3-9**] 11:00PM BLOOD WBC-9.6 RBC-3.73* Hgb-10.9* Hct-33.8*
MCV-91 MCH-29.2 MCHC-32.3 RDW-18.5* Plt Ct-314
[**2175-3-9**] 11:00PM BLOOD Neuts-69.8 Lymphs-21.3 Monos-4.6 Eos-4.2*
Baso-0.2
[**2175-3-9**] 11:00PM BLOOD PT-13.3* PTT-25.6 INR(PT)-1.2*
[**2175-3-9**] 11:00PM BLOOD Glucose-128* UreaN-32* Creat-1.0 Na-139
K-4.4 Cl-97 HCO3-30 AnGap-16
[**2175-3-9**] 11:00PM BLOOD ALT-26 AST-41* AlkPhos-159* Amylase-66
TotBili-0.5
[**2175-3-9**] 11:00PM BLOOD Lipase-63*
[**2175-3-9**] 11:00PM BLOOD Albumin-3.6 Calcium-10.0 Phos-3.6 Mg-2.3
[**2175-3-9**] 11:00PM BLOOD Cortsol-26.2*
[**2175-3-9**] 11:00PM BLOOD CRP-158.4*
[**2175-3-10**] 04:13AM BLOOD Type-ART pO2-68* pCO2-38 pH-7.49*
calHCO3-30 Base XS-5
[**2175-3-9**] 11:00PM BLOOD Lactate-2.0
LAB TRENDS
CBC
[**2175-3-10**] 11:00AM BLOOD WBC-13.9* RBC-3.22* Hgb-9.6* Hct-29.1*
MCV-90 MCH-29.9 MCHC-33.1 RDW-19.1* Plt Ct-259
[**2175-3-13**] 04:28AM BLOOD WBC-10.7 RBC-3.01* Hgb-8.8* Hct-27.5*
MCV-92 MCH-29.4 MCHC-32.1 RDW-19.6* Plt Ct-274
[**2175-3-16**] 03:18AM BLOOD WBC-11.5* RBC-2.90* Hgb-8.9* Hct-26.8*
MCV-92 MCH-30.5 MCHC-33.1 RDW-19.3* Plt Ct-286
[**2175-3-20**] 04:52AM BLOOD WBC-10.0 RBC-2.79* Hgb-8.4* Hct-25.3*
MCV-91 MCH-30.3 MCHC-33.4 RDW-19.9* Plt Ct-380
[**2175-3-22**] 03:00AM BLOOD WBC-9.7 RBC-2.88* Hgb-8.6* Hct-26.3*
MCV-91 MCH-29.8 MCHC-32.7 RDW-19.9* Plt Ct-410
[**2175-3-26**] 03:49AM BLOOD WBC-11.9* RBC-2.68* Hgb-8.1* Hct-24.6*
MCV-92 MCH-30.2 MCHC-32.9 RDW-20.4* Plt Ct-283
[**2175-4-1**] 05:00AM BLOOD WBC-15.0* RBC-2.69* Hgb-8.2* Hct-25.4*
MCV-94 MCH-30.3 MCHC-32.2 RDW-21.6* Plt Ct-299
[**2175-4-3**] 04:10AM BLOOD WBC-15.1* RBC-2.87* Hgb-8.8* Hct-27.3*
MCV-95 MCH-30.8 MCHC-32.4 RDW-22.0* Plt Ct-349
[**2175-4-7**] 05:27AM BLOOD WBC-9.8 RBC-2.50* Hgb-7.5* Hct-23.8*
MCV-95 MCH-30.1 MCHC-31.6 RDW-21.8* Plt Ct-334
[**2175-4-13**] 03:24AM BLOOD WBC-8.1 RBC-3.00* Hgb-9.5* Hct-28.2*
MCV-94 MCH-31.5 MCHC-33.6 RDW-19.7* Plt Ct-263
[**2175-4-18**] 03:42AM BLOOD WBC-7.7 RBC-2.89* Hgb-8.7* Hct-27.5*
MCV-95 MCH-30.1 MCHC-31.7 RDW-19.7* Plt Ct-329
CHEMISTRY
[**2175-3-11**] 02:42AM BLOOD Glucose-124* UreaN-23* Creat-0.9 Na-141
K-3.1* Cl-105 HCO3-24 AnGap-15
[**2175-3-14**] 03:51AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-144
K-4.5 Cl-110* HCO3-24 AnGap-15
[**2175-3-17**] 03:52AM BLOOD Glucose-118* UreaN-41* Creat-0.9 Na-141
K-4.2 Cl-107 HCO3-25 AnGap-13
[**2175-3-18**] 04:07AM BLOOD Glucose-710* UreaN-38* Creat-1.0 Na-137
K-5.5* Cl-103 HCO3-26 AnGap-14
[**2175-3-20**] 04:52AM BLOOD Glucose-87 UreaN-46* Creat-0.9 Na-138
K-3.7 Cl-104 HCO3-27 AnGap-11
[**2175-3-23**] 05:15AM BLOOD Glucose-105 UreaN-54* Creat-0.9 Na-142
K-3.7 Cl-111* HCO3-21* AnGap-14
[**2175-3-27**] 03:58AM BLOOD Glucose-127* UreaN-72* Creat-1.1 Na-143
K-4.1 Cl-112* HCO3-21* AnGap-14
[**2175-3-30**] 02:18AM BLOOD Glucose-125* UreaN-76* Creat-1.2 Na-147*
K-4.0 Cl-113* HCO3-22 AnGap-16
[**2175-4-3**] 04:10AM BLOOD Glucose-122* UreaN-55* Creat-1.2 Na-143
K-4.2 Cl-110* HCO3-23 AnGap-14
[**2175-4-8**] 01:28AM BLOOD Glucose-139* UreaN-32* Creat-1.3* Na-144
K-4.2 Cl-111* HCO3-21* AnGap-16
[**2175-4-15**] 01:55AM BLOOD Glucose-103 UreaN-40* Creat-1.3* Na-138
K-3.5 Cl-103 HCO3-23 AnGap-16
[**2175-4-18**] 02:03PM BLOOD Glucose-128* UreaN-39* Creat-1.4* Na-142
K-3.9 Cl-104 HCO3-28 AnGap-14
COAGS
[**2175-3-11**] 02:42AM BLOOD PT-17.4* PTT-31.4 INR(PT)-1.6*
[**2175-3-16**] 03:18AM BLOOD PT-15.2* INR(PT)-1.4*
[**2175-3-18**] 04:07AM BLOOD PT-14.6* INR(PT)-1.3*
[**2175-3-31**] 12:38PM BLOOD PT-16.6* PTT-29.4 INR(PT)-1.5*
[**2175-4-8**] 01:28AM BLOOD PT-17.1* PTT-31.2 INR(PT)-1.6*
[**2175-4-18**] 03:42AM BLOOD PT-15.5* PTT-30.6 INR(PT)-1.4*
~
~
~
~
~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
RADIOLOGY
CHEST (PORTABLE AP) [**2175-3-9**] 10:48 PM
IMPRESSION: Bilateral pleural effusions with perihilar haze and
upper zone redistribution present. A focal opacity is present in
the left mid lung zone. Findings may represent CHF/volume
overload with concern for concomitant infection.
CHEST (PORTABLE AP) [**2175-3-19**] 3:49 PM
IMPRESSION: Mild-to-moderate pulmonary edema has developed since
[**3-16**], partially obscuring multifocal consolidation, and
accompanied by increasing moderate right pleural effusion. Large
cardiac silhouette is stable. No pneumothorax. ET tube and right
central venous line are in standard placements. No pneumothorax.
CHEST (PORTABLE AP) [**2175-3-21**] 9:51 AM
IMPRESSION: Worsening of the left upper lobe and left lower lobe
consolidations vs. left pleural effusion. 2) Improvement of the
right lower lobe consolidation.
CHEST (PORTABLE AP) [**2175-4-2**] 1:02 PM
FINDINGS: There is a frontal and a view dedicated to the right
lateral chest. The tracheostomy tube is unchanged. The right IJ
line with tip in the superior vena cava is unchanged. There
continue to be patchy areas of opacity in both lower lungs and
in the perihilar regions suggesting multifocal pneumonia. There
could also be an element of CHF
C1894 INT.SHTH NOT/GUID,EP,NONLASER [**2175-4-5**] 1:24 PM
CHANGE G-TUBE TO G-J TUBE
IMPRESSION: Successful placement of a MIC gastrojejunostomy tube
with the tip of the tube in the small bowel loop. This catheter
is ready to use
CHEST (PORTABLE AP) [**2175-4-6**] 12:33 PM
Right pleural effusion is again demonstrated grossly unchanged
as well as pleural effusion on the left. The position of the
various lines and tubes is unaltered and the left lower lobe
consolidation is again demonstrated
CHEST (PORTABLE AP) [**2175-4-11**] 5:59 AM
Moderately severe pulmonary edema and moderate left and small
right pleural effusion have increased over the past five days.
More discrete region of consolidation seen in the left perihilar
lung is now partially obscured but has not cleared and other
areas of pneumonia could be obscured by the effusions and edema.
Heart size is top normal. Tracheostomy tube and left subclavian
central venous catheter are in standard placements. No
pneumothorax.
CHEST (PORTABLE AP) [**2175-4-13**] 1:12 PM
IMPRESSION: Mild improvement of previously described pulmonary
edema
CHEST (PORTABLE AP) [**2175-4-17**] 4:48 AM
Elevation of the right lung base which has progressed slowly
since early [**Month (only) 547**] is probably due to a combination of lower lobe
atelectasis and moderate right pleural effusion. Left perihilar
consolidation and hazy opacification of most of the left lung is
probably due to a combination of mild pulmonary edema and
increasing moderate left pleural effusion. Although the heart is
not grossly enlarged, there is persistent mediastinal venous
engorgement. More intense consolidation in the left upper lung
is consistent with a coexistent pneumonia, unchanged since [**4-14**].
~
~
~
~
~
~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CARDIOLOGY
ECG Study Date of [**2175-3-10**] 3:51:00 AM
Atrial fibrillation with rapid ventricular response
Left axis deviation - anterior fascicular block
Ant/septal+lateral ST-T changes may be due to myocardial
ischemia
Repolarization changes may be partly due to rate/rhythm
Incomplete right bundle branch block
Since previous tracing, right bundle branch block now incomplete
ECHO Study Date of [**2175-3-11**]
Conclusions:
The left atrium is normal in size. There is symmetric left
ventricular
hypertrophy. 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.
The aortic root is moderately dilated. The ascending aorta is
mildly dilated. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are thickened. There is
probably mild aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension.
ECG Study Date of [**2175-3-19**] 12:11:06 PM
Atrial fibrillation. Axis to the left. T wave inversion in lead
aVL.
QR complexes in leads VI-V2. Non-specific T wave inversion in
lead aVL and low amplitude T waves in lead I. Right
bundle-branch block. Anteroseptal myocardial infarction. Left
axis deviation. Atrial fibrillation. Non-specific T wave
abnormalities. Compared to the previous tracing of [**2175-3-10**]
atrial fibrillation with tachycardia is no longer present.
Quality of tracing does not permit further assessment.
~
~
~
~
~
~
~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MICROBIOLOGY
Sputum: Pseudomonas multidrug resistant. Sensitve to Tobra,
intermediate to [**Last Name (un) **] and Gent.
KLEBSIELLA PNEUMONIAE
MRSA
C.Diff positive last on [**4-2**]
Brief Hospital Course:
CC:[**CC Contact Info 4477**].
HPI:
Mr. [**Known lastname 4476**] is a [**Age over 90 **] year old man with a long history of
end-stage dementia for at least 10 years with recurrent
aspiration pneumonias and pressure ulcers who presents to the
[**Hospital1 18**] ED from [**Hospital **] Rehab with an aspiration. He was recently
discharged from [**Hospital1 18**] [**3-3**] after he had an aspiration and had a
prolonged intubation. He was treated with vanc/zosyn for a two
week course which was completed [**3-5**]. Today, nursing at [**Hospital1 **]
noted that his abdomen was somewhat distended. A KUB was
performed that showed the feeding tube was coiled in his stomach
in a different position. Tube feeds were restarted and the
feeding tube was noted to be further displaced with the phlange
out of place. The patient was turned and began vomiting and
gagging and was suctions. His VS when he was evaluated there
were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM.
.
The patient was brought to the [**Hospital1 18**] ED evaluation. In the ED,
he was immediately intubated, and started on
levaquin/vanc/flagyl for presumed aspiration pneumonia. He
transiently dropped his blood pressure to a systolic of 80's
over 30's and was started on levophed.
Surgery was consulted
.
[**Age over 90 **]M with end-stage dementia noncommunicative for last 10 years
and inability to be weaned off vent p/w recurrent aspiration
pneumonias and likely aspiration. On IV flagyl for +c diff.
+Sputum cx pseudamonas on [**4-3**] in setting of hypotn, elevated
WBC and low grade fevers. s/p Tracheostomy [**3-31**].
.
# Pseudomonas pneumonia: Initially admitted with hypoxia, fevers
and hypotension with ?aspiration pneumonia however CXR unchanged
and started on vancomycin/zosyn ([**Date range (1) 4478**]) for coverage of
nosocomial peumonia. Subsequently abx d/c'd [**1-19**] +c diff in
stool. On [**3-24**] and [**3-26**] sputum cx grew resistant pseudamonas
([**Last Name (un) 36**] tobra, zosyn, meropenum) and pansensitive klebsiella
however clinically stable and no clear indication of pna on CXR.
s/p trach on [**3-31**]. [**Date range (1) 4479**] increasing WBC, hypotn and low
grade temp. Initially started on zosyn. Sputum again +for
pseudamonas and pt. started on meropenem, tobra. On [**4-11**]
meropenem was d/c and on [**4-14**] pt. grew pseudomonas out of sputum
- ID recommended only starting again if clinical picture
worsened. Pt's clinical picture did not worsen after this. Ctx
sensitive to zosyn and question if pt. was infected vs.
colonized as pt. w/ stable white count and not spiking
temperatures so decision was made to switch to single coverage.
The decision was made to start Zosyn on [**4-23**] and was scheduled to
complete a 14 day course. Because of the proximity of the end
date to the projected date of discharge, vanco and zosyn were
continued through the date of discharge. These antibiotics
should be discontinued 1-2 days after the patient is transferred
to his long term treatment facility.
## C. Diff Colitis: Pt. was also found to have C. diff colitis
during hospitalization likely [**1-19**] antibiotics. Pt. initially
started on vanco and flagyl. Per ID recs, pt. only needs single
coverage for this, so vanco was d/c and flagyl continued. It is
imperative that the patient continue flagyl for 14 days AFTER
the last dose of Zosyn. Hence, this would correspond to 16 days
after transfer from [**Hospital1 18**].
.
## Hypotension: likely due to sepsis originally, but responsive
to fluid boluses. In SICU, pt. was started on pressors, but
stopped on [**3-13**]. Pt. maintained goal MAPs. IN the MICU pt.
likely remained hypotensive due to poor forward flow. - given
total clinic pictures decision was made that pressors were not
indicated and the goal MAP was b/t 50-60. Throughout stay in
MICU, pt. w/ stable BP w/ occassional fluid boluses for
decreasting MAPS. and infection responsive to fluid boluses. It
was decided by the MICU team, other medical and subspecialty
teams directly involved w/ pt's care, ethics committee that CPR
was not medically indicated in this pt
.
## Acute renal failure: Pt. w/ acute renal failure during his
stay at [**Hospital1 **]. Renal was consulted and this was felt to be
secondary to poor forward flow. Pt. appears to have pre-renal
failure in the setting of total volume overload. Per renal,
this is not reversible and therefore the decision was made that
dialysis was not medically indicated. Pt. w/ increasing
creatinine throughout stay. Renal followed and pt. was startd
on bicarb.
.
# Atrial fibrillation: was in good control until arrival to
floor but developed some RVR. Stable throughout SICU and MICU
stay. Pt. was rate controlled on his own.
.
# Decubitus ulcers: Pt. w/ sacral decubitus - stage 1 and right
heel stage 1. Pt. also w/ multiple skin tears from tape. Pt.
w/ hip wound. Wound care following. Pt. w/ wet to dry
dressings.
.
## G/J Tube - Pt. had a G/J tube placed by IR. During MICU
stay, there was a question of increased leakage around tube and
surgery was consulted. An IR study was done that showed that
tube was in place w/ no evidence of obstruction. On [**5-4**], it
was decided to feed the J portion of the tube and suction the G
portion as there was no surgery indicated. On [**5-5**], there was a
hole noted at the distal portion of the feeding tube. Pt. was
taken back to IR and a G tube was placed at daughter's
insistence despite the strong recommendation by the MICU team
and IR team to have G/J tube replaced.
.
# F/E/N: Pt. was originally on TPN because of aspiration event.
When pt. was in the MICU he was on TF. At the end of MICU stay,
pt. was tolerating Vivonex.
.
# Ppx: Throughout hospital stay, pt. was on PPI and Heparin
prophylaxis.
Medications on Admission:
Vancomycin 1gm q24h until [**3-5**]
Zosyn 2.25gm q8h until [**3-5**]
Docusate liquid 150 twice daily
ASA 325mg daily
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops
Ophthalmic PRN
Magnesium Hydroxide 15mg daily
Heparin 5000u sc bid
Albuterol neb q6h
Atrovent neb q6h
Lansoprazole 30mg daily
Donepezil 10mg qhs
Lasix 20mg daily
Milk of Magnesia 15cc daily
Lopressor 6.25 mg [**Hospital1 **]
Tylenol elixir prn
Tube feeds: Nepro 0.45% @ 70cc/hr
Discharge Medications:
1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please give 5000 units
subcutaneous heparin tid.
13. Potassium Iodide 1 g/mL Solution Sig: Ten (10) Drop PO TID
(3 times a day) as needed for via J tube.
14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily) as needed for down J-tube.
15. Artificial Tears Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED).
17. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
(3 times a day).
18. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
19. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: Please use 10 mL NS
followed by 2 ml of 100units/ml heparin (200 units heparin) each
lumen daily and PRN.
21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): please give 40 mg solution
IV q 24 hours.
22. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams
Recon Solns Intravenous Q 12H (Every 12 Hours) for 2 days:
Please give 2.25 g IV q 13 hours.
23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg IV Intravenous Q12H (every 12 hours) for
15 days: Please give 500 mg IV q 12 hrs .
24. Wound Care
25. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 gram
Recon Soln(s)IV Intravenous Q8H (every 8 hours).
26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram (200ml piggyback) Intravenous Q48H (every 48 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Aspiration Pneumonia
Acute Renal Failure
Hypotension
Alzheimers
Discharge Condition:
Stable
Discharge Instructions:
IT IS VERY IMPORTANT THAT THIS PT'S TRACH BE HUBBED AT ALL TIMES
AS IT SLIPS SOME DUE TO GRANULATION TISSUE IN TRACT.
Patient should follow up with your primary care physician in the
next week. Please take all the medications as directed. Pleas
continue wound care as outlined.
Followup Instructions:
You should follow up with your primary care physician in the
next week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"008.45",
"038.9",
"519.1",
"482.1",
"707.09",
"273.8",
"995.92",
"427.31",
"507.0",
"428.0",
"518.83",
"780.03",
"785.59",
"331.0",
"707.04",
"569.69",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"99.15",
"33.21",
"96.6",
"97.03",
"33.24",
"96.72",
"88.03",
"31.1",
"96.04",
"44.32",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
20054, 20159
|
11144, 16916
|
273, 338
|
20267, 20276
|
2286, 11121
|
20604, 20805
|
1881, 1898
|
17425, 20031
|
20180, 20246
|
16942, 17402
|
20300, 20581
|
1913, 2267
|
223, 235
|
366, 1579
|
1601, 1716
|
1732, 1865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,224
| 194,562
|
47245
|
Discharge summary
|
report
|
Admission Date: [**2178-7-31**] Discharge Date: [**2178-8-7**]
Date of Birth: [**2118-9-8**] Sex: F
Service: SURGERY
Allergies:
Tetracycline / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2178-7-31**]
Exploratory laparotomy
History of Present Illness:
59 F, without hx of abdominal surgery, presents for
evaluation of possible SBO. As per patient, she has been having
intermittent abdominal pain with 5 days of constipation ( as is
baseline). She took 2 bottles of magnesium citrate
Past Medical History:
PMH:HTN,HL, EtOH use, cocaine use, migraines with visual aura,
gout, anemia, leukopenia
PSH: Ln biopsy, Knee surgery, arm surgery, no abdominal
surgeries
Social History:
last cigarette and drink end of [**Month (only) 596**] but hx heavy drinking
and drug use (cocaine, marijuana),
patient reports last EtOH and cocaine use was 2 weeks ago.
Family History:
non contributory
Physical Exam:
Temp 99.7 HR 73 BP 112/52 RR 16 O2 sat 100% RA
Gen: Appears uncomfortable, but able to converse easily
CVS: RRR
Pulm Clear anteriorly
Abs distended, tender in the RLQ without rebound or guarding
No incisional scars
Recta;" No masses , guaiac neg
Ext: WWP
Pertinent Results:
[**2178-7-30**] 10:45PM WBC-4.6 RBC-3.37* HGB-11.0* HCT-32.5* MCV-97
MCH-32.8* MCHC-33.9 RDW-14.1
[**2178-7-30**] 10:45PM NEUTS-67.9 LYMPHS-26.2 MONOS-4.8 EOS-0.9
BASOS-0.3
[**2178-7-30**] 10:45PM PLT COUNT-309
[**2178-7-30**] 10:45PM ALT(SGPT)-33 AST(SGOT)-33 ALK PHOS-118* TOT
BILI-0.3
[**2178-7-30**] 10:45PM GLUCOSE-98 UREA N-25* CREAT-2.0* SODIUM-134
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-29 ANION GAP-12
[**2178-7-31**] KUB :
There are distended loops of small bowel with multiple air-fluid
levels concerning for small-bowel obstruction in appropriate
clinical setting. There is no free air.
[**2178-7-31**] CT Abd/pelvis :
1. Proximally distended loops of small bowel and collapsed loops
of distal
small bowel; possible transition point in the RLQ concerning for
small-bowel obstruction. Due to lack of oral contrast, it is
difficult to determine the grade of obstruction. No free fluid
or free air.
2. Cholelithiasis.
[**2178-7-31**] 5:15 am SWAB ABDOMINAL PERITONEAL.
GRAM STAIN (Final [**2178-7-31**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2178-8-2**]): NO GROWTH.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
ANAEROBIC CULTURE (Final [**2178-8-6**]): NO GROWTH.
Brief Hospital Course:
Ms. [**Known lastname **] was evaluated by the Acute Care team in the Emergency
Room and based on her physical exam and abdominal Ct she was
admitted to the hospital with a small bowel obstruction. She was
made NPO, hydrated with IV fluids and taken to the Operating
Room for an exploratory laparotomy. See formal op note for
details. She tolerated the procedure well and returned to the
PACU in stable condition. She maintained stable hemodynamics
and her pain was well controlled.
Following transfer to the Surgical floor she remained NPO with a
nasogastric tube in place for gastric decompression. After 3
days post op her bowel function returned and her NG tube was
removed. Her diet was advanced slowly and well tolerated. Her
oral pain medication required adjustment as she did not get
enough pain relief initially but she was controlled with
scheduled Tylenol, Ultram and Dilaudid 4-8 mg every 3 hours as
needed. Her abdominal wound had scant drainage at the umbilicus
and was covered for an additional 48 hours. There was no
cellulitis and she was afebrile.
On post op day 6 she developed pain and tenderness in her left
great toe and also had a gouty attack about 3 weeks ago. She
was treated with Colchicine and was able to bear weight on the
foot. She was encouraged to follow up with her PCP next week
for evaluation of her gout and also for a blood pressure check
as only half doses of her pre op antihypertensives were resumed
due to blood pressures in the 110-130/70 range. As she was
progressing daily, she was discharged to home on [**2178-8-7**] and
will follow up in the [**Hospital 2536**] Clinic next week for staple removal.
Medications on Admission:
verapamil 240 mg [**Hospital1 **]
lisinopril 20 mg daily
atenolol 100 mg daily
estrogen?
ASA 325 (since yesterday)
amitriptyling 100 mg qhs?
simvastatin- dose unknown
Omeprazole
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*40 Tablet(s)* Refills:*2*
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
5. lisinopril 40 mg Tablet Sig: [**1-11**] Tablet PO once a day.
6. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
7. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-19**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
* Your staples will be removed at your follow-up appointment.
* If your gout has not improved over the next 2-3 days call
your PCP for [**Name Initial (PRE) **] further evaluation.
Followup Instructions:
Call the Acute Care Cl;nic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 1 week for staple removal.
Call your PCP for an appointment next week to review your blood
ressure medications and have a blood pressure check.
Completed by:[**2178-8-7**]
|
[
"274.01",
"567.9",
"305.00",
"305.20",
"578.9",
"569.89",
"560.9",
"401.9",
"593.9",
"305.60",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
5688, 5694
|
2873, 4534
|
319, 360
|
5767, 5767
|
1325, 2494
|
7896, 8160
|
1010, 1028
|
4763, 5665
|
5715, 5746
|
4560, 4740
|
5918, 7376
|
7392, 7873
|
1043, 1306
|
2530, 2850
|
265, 281
|
388, 624
|
5782, 5894
|
646, 805
|
821, 994
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,704
| 199,716
|
28951+57617
|
Discharge summary
|
report+addendum
|
Admission Date: [**2118-7-19**] Discharge Date: [**2118-8-24**]
Date of Birth: [**2053-3-22**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillin G
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
RUE erythema/pain/swelling
Major Surgical or Invasive Procedure:
[**7-21**]: Right arm I&D- frank pus and fasciitis noted intra-op
[**7-22**]: Repeat RUE I&D
[**7-25**]: Repeat RUE I&D x 2, return to OR in PM for persistent
bleeding
[**7-27**]: Repeat RUE I&D w/ vac dressing placment
[**7-28**]: Repeat RUE I+D, vac change, resection of necrotic skin
[**7-30**]: Repeat RUE I&D/VAC change
[**8-1**]: Repeat RUE I&D/VAC change
[**8-3**]: Repeat RUE I&D/VAC change
[**8-8**]: Pigtail drain placed in L pleural cavity
[**8-12**]: Tracheostomy and PEG placement
[**8-18**]: Split thickness skin graft by plastic surgery
[**8-18**]: Removal of pigtail drain in L pleural cavity
[**8-23**]: VAC removal of anterior would
History of Present Illness:
65 yo M w/ DM2, htn, ich, etoh abuse transferred from OSH for
concern of nec fascitis/compartment syndrome of the RUE. He
initially presented to [**Hospital1 1474**] on [**7-17**] after sustaining a
traumatic injury (hitting his elbow on a cabinet) to the RUE
while drinking on [**2118-7-12**]. He had malaise, diarrhea and vomiting
over the next few days prior to presentation. He was also taking
large amounts of excedrin and aleve for a fever prior to his
accident. Per his wife he had fevers (tmax 103) for several days
prior to the incident. Also had a boil on his left finger which
he self I&D'd approx 3 weeks ago. At [**Hospital1 1474**] his labs were
significant for a climbing WBC to 17.8 w/ bandemia of 20, ck
3700 (trended down), Cr. 2.5, ESR 120 and reported GAS
bacteremia (4/4 bottles positive from [**2118-7-17**]). A CT of the RUE
w/ con showed cellulitis and superficial fascial edema in the
posterior right forearm. He was initially on vancomycin, unasyn
then changed to pcn/clinda. Per report, the pt. was evaluated at
the OSH by surgery for compartment syndrome, which was ruled out
(did not have increased pressures). He also had an aspiration of
the olecranon with was reportedly bland.
.
On arrival to [**Hospital1 18**] he was again evaluated by general surgery,
who do not feel he currently does not have necrotizing facsitis.
Orthopedics was consulted for evaluation of compartment syndrome
(compartment pressures again normal).
Past Medical History:
* Hypertension - Has been on medication for the past 10 years.
Baseline BP 170s-180s. Approximately PCP prescribed increase in
anti-hypertensive med to [**Hospital1 **]. Pt was non-compliant and continued
to take the medication daily.
DM2
Hyperlipidemia
Pilonidal cyst s/p repair
Social History:
SHx: Previously in the air force, then worked as a truck driver
for the [**Location (un) 86**] Globe. Quit smoking many years ago. +[**5-10**] shots of
whiskey per day. No illicit drug use.
Family History:
FHx: Paternal grandmother - brain aneurysm
Physical Exam:
vitals: T 100.6, bp 163/105, HR 98, 02sat 98% RA, RR 30's
General: confused, following directions, knows his name,
tremulous
HEENT: poor dentition w/ missing teeth.
CV: tachy, III/VI SEM at LLSB
Lungs: bibasilar rales
Abdomen: NT/ND normoactive BS
Ext: RUE is erythematous and swollen, TP on the right shoulder
and right side of neck. able to squeeze hand on the right but
cannot lift against gravity.
Neuro: AA0x1
Pertinent Results:
[**2118-8-1**] 08:02PM BLOOD Hct-25.3*
[**2118-8-1**] 03:39PM BLOOD Hct-21.7*
[**2118-8-1**] 01:10PM BLOOD Hct-24.2*
[**2118-8-1**] 08:06AM BLOOD Hct-23.7*
[**2118-8-1**] 12:56AM BLOOD WBC-5.2 Hct-22.2* Plt Ct-211
[**2118-7-31**] 05:33PM BLOOD Hct-21.3*
[**2118-7-31**] 12:45PM BLOOD Hct-18.5*#
[**2118-7-31**] 06:24AM BLOOD Hct-24.9*
[**2118-7-31**] 01:55AM BLOOD WBC-6.1 Hct-21.1* Plt Ct-293
[**2118-7-30**] 03:43PM BLOOD Hct-23.0*
[**2118-7-30**] 09:38AM BLOOD Hct-26.6*
[**2118-7-30**] 05:43AM BLOOD Hct-23.2*
[**2118-7-30**] 02:03AM BLOOD WBC-7.0 Hct-24.3* Plt Ct-299
[**2118-7-29**] 09:38PM BLOOD Hct-24.7*
[**2118-7-29**] 02:05PM BLOOD Hct-26.7*
[**2118-7-29**] 09:07AM BLOOD Hct-29.6*
[**2118-7-29**] 03:43AM BLOOD WBC-8.1 Hct-27.1* Plt Ct-249
[**2118-7-28**] 10:51PM BLOOD Hct-24.3* [**2118-7-28**] 05:25PM BLOOD
Hct-31.6*#
[**2118-7-28**] 02:25PM BLOOD Hct-24.2*
[**2118-7-28**] 04:19AM BLOOD Hct-29.2*
[**2118-7-28**] 01:47AM BLOOD WBC-11.1* Hct-29.6* Plt Ct-241
[**2118-7-27**] 11:36PM BLOOD Hct-32.5*
[**2118-7-27**] 08:15PM BLOOD Hct-29.6*
[**2118-7-27**] 04:00PM BLOOD Hct-26.3*
[**2118-7-27**] 01:30PM BLOOD Hct-31.5*
[**2118-7-27**] 10:25AM BLOOD Hct-27.4*
[**2118-7-27**] 05:15AM BLOOD WBC-12.5* Hct-25.5* Plt Ct-251
[**2118-7-27**] 12:30AM BLOOD Hct-24.2*
[**2118-7-26**] 09:23PM BLOOD Hct-27.0*
[**2118-7-26**] 02:55PM BLOOD Hct-24.8*
[**2118-7-26**] 10:56AM BLOOD Hct-27.0*#
[**2118-7-26**] 06:17AM BLOOD Hct-19.9*
[**2118-7-26**] 01:51AM BLOOD WBC-23.2* Hct-25.3* Plt Ct-244
[**2118-7-25**] 09:02PM BLOOD Hct-31.3*
[**2118-7-25**] 04:34PM BLOOD Hct-25.1*
[**2118-7-25**] 12:58PM BLOOD Hct-25.4*#
[**2118-7-25**] 10:52AM BLOOD Hct-19.3*
[**2118-7-25**] 07:16AM BLOOD Hct-24.5*
[**2118-7-25**] 02:02AM BLOOD WBC-21.0* Hct-27.2* Plt Ct-234
[**2118-7-24**] 06:15PM BLOOD Hct-24.6*
[**2118-7-24**] 10:30AM BLOOD Hct-25.5*
[**2118-7-24**] 03:54AM BLOOD WBC-16.6* Hct-29.0* Plt Ct-187
[**2118-7-23**] 09:50PM BLOOD Hct-30.3*
[**2118-7-23**] 02:35PM BLOOD Hct-25.0*
[**2118-7-23**] 10:23AM BLOOD Hct-27.0*
[**2118-7-23**] 03:09AM BLOOD WBC-17.2* Hct-26.3* Plt Ct-134*
[**2118-7-22**] 04:08PM BLOOD Hct-29.5*
[**2118-7-22**] 11:50AM BLOOD Hct-26.5*
[**2118-7-22**] 06:24AM BLOOD Hct-25.9*
[**2118-7-22**] 02:22AM BLOOD WBC-14.4* Hct-23.7* Plt Ct-107*
[**2118-7-22**] 12:33AM BLOOD Hct-26.2*
[**2118-7-22**] 12:00AM BLOOD Hct-29.2*#
[**2118-7-21**] 06:00PM BLOOD WBC-18.0* Hct-21.4*# Plt Ct-106*
[**2118-7-20**] 09:47AM BLOOD WBC-28.5* Hct-32.3* Plt Ct-134*
[**2118-7-20**] 12:10AM BLOOD WBC-22.5*# Hct-29.7*# Plt Ct-131*
[**2118-8-1**] 12:56AM BLOOD PT-14.3* PTT-40.9* INR(PT)-1.2*
[**2118-7-31**] 01:55AM BLOOD PT-14.8* PTT-43.1* INR(PT)-1.3*
[**2118-7-30**] 09:38AM BLOOD PT-15.1* PTT-41.2* INR(PT)-1.3*
[**2118-7-27**] 10:25AM BLOOD PT-15.7* PTT-46.2* INR(PT)-1.4*
[**2118-7-26**] 12:16PM BLOOD PT-18.5* PTT-43.6* INR(PT)-1.7*
[**2118-7-25**] 09:02PM BLOOD PT-17.8* PTT-41.9* INR(PT)-1.6*
[**2118-7-24**] 04:18AM BLOOD PT-16.8* PTT-35.9* INR(PT)-1.5*
[**2118-7-23**] 03:09AM BLOOD PT-16.6* INR(PT)-1.5*
[**2118-7-21**] 02:20AM BLOOD PT-14.8* PTT-29.6 INR(PT)-1.3*
[**2118-7-20**] 12:10AM BLOOD PT-13.5* PTT-36.1* INR(PT)-1.2*
[**2118-7-21**] 08:30PM BLOOD Fibrino-682* D-Dimer-2829*
[**2118-8-1**] 12:56AM BLOOD Fibrino-319
[**2118-7-22**] 02:22AM BLOOD ESR-90*
[**2118-7-25**] 02:02AM BLOOD ALT-72* AST-131* LD(LDH)-295*
AlkPhos-222* TotBili-2.3*
[**2118-7-21**] 02:20AM BLOOD CRP-252.0*
[**2118-7-22**] 02:22AM BLOOD CRP-142.1*
Brief Hospital Course:
65 yo M w/PMH of HTN, DM2, ICH, etoh abuse xfer from OSH w/ [**4-8**]
bottles GAS bacteremia, RUE cellulitis, ARF, elevated CKs & etoh
withdrawal. Transferred to MICU HD#2 for tachypnea and sepsis.
RUE examination and CT scan concerning for necrotizing
fasciitis. Started on clinda/pcn/levo per ID recs. Taken to the
OR [**2118-7-21**] for RUE exploration & debridement. Intra-op findings
and pathology c/w necrotiizing fascitis on debridement.
.
1.Infectious Disease: Initial ABx regimen of clinda/PCN/Levo
continuted [**Date range (1) 15663**] then tapered to PCN-G alone for treatment
of GAS present on OR cultures from RUE. Due to persistent fevers
ABx coverage was changed to Vancomycin on [**8-5**]. Vanco use
was c/b extensive whole body rash and all antibiotics were
discontinued on [**8-4**]. A seven day course of Fluconazole was
given for concern for fungemia in the setting of yeast growth
from urine and sputum cultures. On [**8-14**] Ceftazidime & Daptomycin
were started for infiltrate noted on CXR. Blood cultures
negative throughout [**Hospital1 18**] stay.
2.RUE necrotizing fasciitis: After initial debridment of RUE
performed on [**7-21**] the patient required multiple returns to the
OR for exploration + I&D - these were performed on: [**7-22**], [**7-25**],
[**7-27**], [**7-28**], [**7-30**], [**8-1**] & [**8-3**]. Vac dressings were started on
[**7-27**] and discontinued on [**8-1**]. Once debridement of all necrotic
tissue was completed partial closure of the RUE wound was
performed. Full closure could not be obtained and Plastic
Surgery was consulted for soft-tissue coverage. On [**8-18**] he
underwent a split thickness skin graft by plastic surgery to his
anterior wound and VAC placement to his posterior wound. The
dressing over his anterior wound was removed on [**8-22**] without
complication.
3.Coagulopathy: Throughout hospital stay the pts operative
course was complicated by significant coagulopathy and high
transfusion requirement. He was transferred to the TSICU on [**7-25**]
for continued aggressive resuscitation. Hematology oncology was
consulted and extensive coagulopathy work-up was performed which
lead to the identification of a lupus anticoagulant antibody and
widespread PLT dysfunction. Amicar infusion was started and he
received 6U PLTs over the following 3 days. During his final RUE
I+D factor VII was administered for further treatment of
coagulopathy. Transfusion requirement gradually resolved and his
last transfusion was given on [**8-5**]. During the hospital course he
received total of 57units RBC.
4.Respiratory: Remained intubated for frequent OR debridements
until HD#22 ([**2118-8-10**]). Initially treated for presumed aspiration
pneumonia with levofloxacin [**Date range (1) 15663**], found to have large
left-sided pleural effusion on chest CT that was tapped and
fluid samples sent for analysis to r/o empyema. Results were c/w
simple effusion. He was extubated on [**8-10**] without incident.
Following extubation, continued to have persistent desats and
frequent suctioning requirement, trach performed [**8-12**] due to
respiratory failure and for pulmonary toilet. Chest imaging
revealed infiltrate on [**8-14**] and he was started on
Daptomycin/Ceftazidime for PNA. Per ID recs he was changed to
Clinda/Ceftaz the following day for a 10 day course which will
end [**8-24**].
Throughout his stay he was seen by physical and occupational
therapy to improve his strength and mobility. He was also seen
by speech and swallow and was safe to take oral food and liquids
on [**8-23**]. He uses his passy muir valve appropriately and can
tolerated thin liquids and soft consitency solids. He also was
noted to have coccyx breakdown, stage 2, which was dressing with
douderm dressing.
Medications on Admission:
Cardizem CD 240mg daily
Atenolol 100mg daily
Vasotec 20mg daily
HCTZ
Glyburide 2.5mg [**Hospital1 **]
Crestor 5mg daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
RUE necrotizing fasciitis
Acute blood loss anemia
Respiratory failure
Coccyx breakdown stage 2
Discharge Condition:
Stable
Stable
Discharge Instructions:
If you notice any increaesd redness, drainage, or swelling, or
if you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Continue your home medications as previously prescribed.
If you notice any increaesd redness, drainage, or swelling, or
if you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Continue your home medications as previously prescribed.
Physical Therapy:
Activity: As tolerated Out of bed to chair daily
Treatments Frequency:
VAC change to posterior wound on right arm Q3 days
Xeroform then DSD daily over anterior skin graft site
Followup Instructions:
Follow up on [**2118-9-6**] with Dr. [**Last Name (STitle) 1005**] in orthopaedics, please
call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Please follow up with Plastic Surgery (Dr. [**Last Name (STitle) 23606**] on [**2118-9-12**]
at 10:30 at [**Hospital3 1810**] in the [**Company 14006**] Building [**Location (un) **]. The number to clinic is [**Telephone/Fax (1) 26564**].
Please follow up with Dr. [**Last Name (STitle) **] in trauma clinic for your trach
and PEG follow up in 2 weeks. Please call [**Telephone/Fax (1) 6429**] to
schedule that appointment.
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as
you have had multiple medication changes. The phone to clinic
is [**Telephone/Fax (1) 6699**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2118-8-24**] Name: [**Known lastname 5648**],[**Known firstname **] J Unit No: [**Numeric Identifier 11866**]
Admission Date: [**2118-7-19**] Discharge Date: [**2118-8-24**]
Date of Birth: [**2053-3-22**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillin G
Attending:[**First Name3 (LF) 7332**]
Addendum:
addendum for medications
Major Surgical or Invasive Procedure:
[**7-21**]: Right arm I&D- frank pus and fasciitis noted intra-op
[**7-22**]: Repeat RUE I&D
[**7-25**]: Repeat RUE I&D x 2, return to OR in PM for persistent
bleeding
[**7-27**]: Repeat RUE I&D w/ vac dressing placment
[**7-28**]: Repeat RUE I+D, vac change, resection of necrotic skin
[**7-30**]: Repeat RUE I&D/VAC change
[**8-1**]: Repeat RUE I&D/VAC change
[**8-3**]: Repeat RUE I&D/VAC change
[**8-8**]: Pigtail drain placed in L pleural cavity
[**8-12**]: Tracheostomy and PEG placement
[**8-18**]: Split thickness skin graft by plastic surgery
[**8-18**]: Removal of pigtail drain in L pleural cavity
[**8-23**]: VAC removal of anterior would
Past Medical History:
* Hypertension - Has been on medication for the past 10 years.
Baseline BP 170s-180s. Approximately PCP prescribed increase in
anti-hypertensive med to [**Hospital1 **]. Pt was non-compliant and continued
to take the medication daily.
DM2
Hyperlipidemia
Pilonidal cyst s/p repair
Social History:
SHx: Previously in the air force, then worked as a truck driver
for the [**Location (un) 42**] Globe. Quit smoking many years ago. +[**5-10**] shots of
whiskey per day. No illicit drug use.
Family History:
FHx: Paternal grandmother - brain aneurysm
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
11. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
12. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
15. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. HydrALAzine 10 mg IV Q2H:PRN SBP>190
18. Clindamycin 900 mg IV Q8H
19. Lorazepam 0.5 mg IV Q6H:PRN
20. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
Discharge Diagnosis:
RUE necrotizing fasciitis
Acute blood loss anemia
Respiratory failure
Coccyx breakdown stage 2
Discharge Condition:
Stable
Discharge Instructions:
If you notice any increaesd redness, drainage, or swelling, or
if you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Continue your home medications as previously prescribed.
Physical Therapy:
Activity: As tolerated Out of bed to chair daily
Treatments Frequency:
VAC change to posterior wound on right arm Q3 days
Xeroform then DSD daily over anterior skin graft site
Followup Instructions:
Follow up on [**2118-9-6**] with Dr. [**Last Name (STitle) 83**] in orthopaedics, please
call [**Telephone/Fax (1) 809**] to schedule that appointment.
Please follow up with Plastic Surgery (Dr. [**Last Name (STitle) 11867**] on [**2118-9-12**]
at 10:30 at [**Hospital3 5223**] in the [**Company 11868**] Building [**Location (un) 11869**]. The number to clinic is [**Telephone/Fax (1) 11870**].
Please follow up with Dr. [**Last Name (STitle) **] in trauma clinic for your trach
and PEG follow up in 2 weeks. Please call [**Telephone/Fax (1) 11871**] to
schedule that appointment.
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as
you have had multiple medication changes. The phone to clinic
is [**Telephone/Fax (1) 6073**].
[**First Name11 (Name Pattern1) 651**] [**Last Name (NamePattern1) 7334**] MD, [**MD Number(3) 7335**]
Completed by:[**2118-8-24**]
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[
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[
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icd9pcs
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15918, 15988
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|
16127, 16136
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3466, 6916
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239, 267
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14144, 14336
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,626
| 150,680
|
34647
|
Discharge summary
|
report
|
Admission Date: [**2145-8-6**] Discharge Date: [**2145-8-10**]
Date of Birth: [**2095-6-11**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
RIGTH sided weakness and RIGHT facial droop.
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
Ms [**Known lastname 79465**] is 50 year-old right-handed woman with a past medical
history significant for HTN, Hep C, GERD, TAH and unilateral
salpingo-oopherectomy for cyst who presents with a left basal
ganglia hemorrhage.
The patient was at her baseline (IADLs, works as a personal care
attendant) this morning when she went to work. Her patient
found
her sitting on her chair with a right sided weakness and
facial droop at 8:45am. He called EMS who reported a FSG of 166
and a BP of 163/87. She was taken to the [**Hospital3 417**]
Hospital where she was EET'd for airway protection. She was
loaded on 1g of dilantin and 25grams of mannitol. Neuroimaging
studies showed a large left basal ganglia infarct and more
limited right basal ganglia and high right parietal lobe were
noted. The coagulation studies were within normal range.
Past Medical History:
PMH:
1. HTN
2. Hep C
3. TAH and unilateral ovary removal.
4. Bilateral Knee pain, umbilical Hernia repair
6. Questionable positive PPD in OSH records, but not in PCP
[**Name Initial (PRE) 14453**].
7. GERD
Social History:
Social Hx:
Works as a health care assistant
Born in [**Country 16573**], she lives in [**Location (un) 538**].
She has three children.
She doesn't smoke tobacco, drink alcohol or take illicit drugs.
Family History:
Family Hx:
No family history of hemorrhage.
Her mother died of complications of diabetes.
Physical Exam:
Vitals: T: 99.4 P:82 R:14 BP:144/78 SaO2:100% on vent at CMV
mode.
General: Intubated and on propofol.
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: Intubated and sedated.
Doesn't open eyes or follow commands. She localizes pain when
propofol is held.
Cranial Nerves: Olfaction not tested. 1 mm bl pupils, not
possible to perform fundoscopic exam. Corneal reflexes: negative
on right eye, nasal tickle and gag reflexes were intact. Right
Facial droop.
Motor: propofol held
Moves the left arm at antigravity with noxious stimuli. The left
leg at 2. The right hemibody is paretic: not responsive to
noxious stimuli.
-Sensory: As above to noxious.
-Coordination: Untested
- Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Toes
C5 C7 C6 L4 S1 CST
L1 1 1 1 1 down
R1 1 1 1 1 down
-Gait: Untested
Pertinent Results:
135 98 15
---I----I----< 155
5.3 27 0.9
CK: 210 MB: 4 Trop-T: <0.01
Ca: 8.8 Mg: 2.2 P: 3.8
ALT: 56
AST: 74
Lip: 37
HCG:<5
13.1
4.6>---<258
36.9
N:57.0 L:34.7 M:5.1 E:2.4 Bas:0.9
PT: 13.7 PTT: 29.4 INR: 1.2
UA negative.
EKG:NSR at 60 with normal axis and normal intervals. TWI in III.
CXR: 08/ 09/ 08: In comparison with the study of [**8-6**], there is
little change. Endotracheal tube and nasogastric tube remain in
place. Cardiac silhouette is within upper limits of normal. No
evidence of vascular congestion, pleural effusion, or acute
pneumonia
08 08 08: Echocardiogram:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
08 08 08 NCHCT:large left basal ganglia bleed w/ 6mm midline
shift toward
right and compression of left lateral ventricle. compression of
lateral ventricle is progressive in comparison to outside study.
there is a 1 x 0.4 cm hyperdensity (image 17) in the rt
posterior
frontal/parietal lobe.
08 09 08:
CT HEAD:
The CT head again demonstrates a left-sided basal ganglia
hemorrhage with mass effect on the left lateral ventricle
midline shift and subfalcine and early uncal herniation. There
has been no significant change in the extent of the hemorrhage.
Peri-lesion edema is identified. A small area of hemorrhage in
the right posterior temporal lobe is again identified. There is
mild midline shift.
CT ANGIOGRAPHY OF THE HEAD:
CT angiography demonstrates tortuous vascular structures in the
arteries of anterior and posterior circulation. Some
irregularity of the basilar artery is identified due to
atherosclerotic disease but no evidence of vascular occlusion
seen. No distinct aneurysm is identified. The previous MRI has
demonstrated a small area of enhancement in the medial aspect of
the left basal ganglia hemorrhage where no abnormalities are
seen on the CT angiography. No distinct aneurysm is seen.
Vascular calcifications are
identified in the distal vertebral artery.
CT VENOGRAPHY:
The CT venography of the head demonstrates no evidence of venous
sinus
occlusion or thrombosis. Deep venous system is patent.
IMPRESSION:
1. Left basal ganglia hemorrhage and a small area of right
temporal
hemorrhage.
2. Somewhat tortuous intracranial arteries and mild
atherosclerotic disease
in the basilar artery. Otherwise, no evidence of stenosis or
occlusion of the
intracranial arteries and no definite evidence of aneurysm.
3. No evidence of venous sinus thrombosis.
08 11 08:
Cxr
1. Stable degree of pulmonary vascular congestion.
2. Bilateral, left greater than right, small effusions.
3. Left lower lobe opacity consistent with atelectasis.
CT CNS w/o contrast: 10:00 am
Comparison to a head CT of [**2145-8-7**].
FINDINGS: Again seen is a large left putaminal hematoma with
extensive
surrounding edema. There is no evidence of new hemorrhage.
However, there
appears to be a mild increase in the severity of left to right
midline shift,
dilatation of the contralateral frontal and temporal horns, and
left uncal
herniation.
CONCLUSION: No evidence of new hemorrhage. However, there is an
increase in
mass effect and midline shift since [**2145-8-7**].
Cxr: s/p bronchoscopy:
Bilateral small pleural effusion, mostly on the left associated
with left
retrocardiac atelectasis slightly decreased. Vascular congestion
is
unchanged. Mild cardiomegaly is unchanged. Incidentally,
bilateral
calcifications in the breasts are stable. There is no
pneumothorax.
CT CNS w/o contrast: 16:30 pm:
COMPARISON: Head CT of approximately five hours earlier.
TECHNIQUE: Contiguous axial images were obtained through the
brain. No
contrast was administered.
FINDINGS: The large left basal ganglia hematoma is unchanged in
size,
measuring approximately 50 x 34 mm in axial dimensions, with
surrounding
edema. An additional focus of hemorrhage within the right basal
ganglia
appears increased in size (2:11) compared to the prior exam. A
small right
parietal hematoma at the [**Doctor Last Name 352**]-white matter junction is
unchanged.
Since the prior study, there has been increased left uncal
herniation and
increased effacement of the suprasellar cistern. Subfalcine
herniation of
approximately 9 mm is unchanged, along with compression of the
left lateral ventricle. The right lateral ventricle remains
dilated.
The bones are unremarkable. There is mucosal thickening or fluid
in the left sphenoid and posterior ethmoid air cells.
Endotracheal and
orogastric tubes are present.
IMPRESSION:
1. Interval increase in uncal herniation from exam of six hours
previously.
2. Stable left basal ganglia hematoma. Stable small right
parietal lobar
hematoma. Increased right basal ganglia hematoma.
Findings discussed with Dr. [**First Name (STitle) **] at 7:15 p.m.
NOTE ADDED AT ATTENDING REVIEW: The linear hyperdensity
extending from the
right sylvian fissure towards the thalamus (series 2, images
[**9-9**]), may
correspond to a vascular structure rather than a hemorrhage. It
was present,
but less conspicuous on previous studies, likely due to
differences in
technique.
Brain Death Protocol scan: 08 12 08
No evidence of intracerebral perfusion. Consistent with brain
death
Brief Hospital Course:
Ms [**Known lastname 79465**] was admitted to the NSIC. Her repeat head CT showed
slight uncal herniation and ventricular enlargement. She was
placed on mannitol and Neurosurgery was consulted. It was felt
that close monitoring is adequate since her examination was
unchanged. No surgical intervention was carried out. She had
MRI and MRA/MRV, which ruled out secondary causes for ICH. She
developed a fever secondary to PNA on [**8-8**]. She underwent a
bronchoscopy on [**8-9**]. However, she was found to have fixed &
dilated pupils after the procedure. STAT head CT showed
worsening uncla herniation. Neurosurgery felt that surgical
intervention was futile. She was started on hypertonic saline &
hyperventilated. A perfusion scan the following day confirmed
brain death. She was extubated and pronounced dead on the
evening of [**8-10**].
According to the family's wishes the required documentation was
filled out so the patient's remains could be transported to
[**Country 480**].
Medications on Admission:
1. Cozaar 100 mg daily, Cardizem 240 mg daily
2. Oxybutin (urge incontinence) 5 mg daily
3. Protonix 40 mg daily
4. MVI
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral Hemorrhage
PNA
Discharge Condition:
the patient passed the way
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"276.0",
"342.90",
"348.8",
"458.9",
"V12.09",
"530.81",
"780.01",
"401.9",
"507.0",
"795.5",
"781.94",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.23",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9972, 9981
|
8774, 9773
|
360, 374
|
10053, 10081
|
3112, 4566
|
10133, 10254
|
1714, 1806
|
9944, 9949
|
10002, 10032
|
9799, 9921
|
10105, 10110
|
1821, 2347
|
276, 322
|
402, 1251
|
2483, 3093
|
4575, 8751
|
2362, 2467
|
1273, 1481
|
1497, 1698
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,440
| 151,999
|
29933
|
Discharge summary
|
report
|
Admission Date: [**2139-2-16**] Discharge Date: [**2139-2-23**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Levaquin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Rash, r/t allergic reaction to Levaquin
Itching
Coffee ground emesis
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This 85 year old female was transferred via EMS from a [**Hospital 71509**]
rehab facility to [**Location (un) 16843**] emergency department with
complaints of hives, itching, nausea and vomiting of coffee
ground emesis. She was found to be tachycardic with an elevated
white blood count. UA revealed UTI. NGT was placed d/t nausea
and vomiting. She was given vancomycin, flagyl, Ceftriaxone and
gentamycin IV. She was transferred to [**Hospital1 18**] for further work up
and [**Hospital1 **].
Past Medical History:
CAD s/p MI
HTN
DMII
UTIs
CHF
Hypercholesterolemia
AFib
Surgical History:
[**12-28**]: S/P Subtotal Colectomy for dilated megacolon. End
ileostomy, Hartmann's pouch, G-tube placement. Returned to OR
for completion sigmoid colectomy, repair of [**Last Name (un) **]-vesicular
fistula, small bowel repair.
Social History:
In [**2137**], lived independently, but in the same building with
daughter. [**Name (NI) **] 3 children, 2 daughters and 1 son. Daughter [**Name2 (NI) **]
is Durable Power of Attorney. The other daughter was recently in
a car accident and underwent surgery at [**Hospital1 2025**].
Has been in rehab since her discharge [**2139-1-20**].
Family History:
NC
Physical Exam:
T: 100.0 HR: 107 BP 110/34 RR 19 Spo2 97% on Ra
Constitutional: No acute distress
Head/Eyes: Pupils equal round reactive to light. Conjunctiva
pale, anicteric
ENT/Neck: supple, no lymphadenopathy
Chest/Respiratory: Clear to auscultation
Cardiovascular: Regular rate & rhythm, no murmur or
regurgitation
GI/Abdominal: + bowel sounds, tender to palpation in LLQ and
RLQ. Ileostomy, G tube.
Musculoskeletal: No lower extremity edema, palpable DPs 1+.
Skin: Urticaria on chest, neck, arms
Neuro: Alert & oriented x 3.
Pertinent Results:
[**2139-2-16**] 08:20PM BLOOD WBC-9.1 RBC-4.30 Hgb-12.0 Hct-35.2*
MCV-82 MCH-27.9 MCHC-34.2 RDW-16.2* Plt Ct-175
[**2139-2-16**] 08:20PM BLOOD Neuts-88.3* Lymphs-10.5* Monos-1.0*
Eos-0.2 Baso-0.1
[**2139-2-16**] 08:20PM BLOOD PT-14.4* PTT-35.0 INR(PT)-1.3*
[**2139-2-16**] 08:20PM BLOOD Glucose-298* UreaN-28* Creat-1.1 Na-130*
K-5.3* Cl-101 HCO3-19* AnGap-15
[**2139-2-16**] 08:20PM BLOOD ALT-15 AST-17 AlkPhos-93 Amylase-43
TotBili-0.3
[**2139-2-16**] 08:20PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.7
[**2139-2-17**] 07:58AM BLOOD Digoxin-0.3*
[**2139-2-20**] 06:15AM BLOOD WBC-5.8 RBC-3.53* Hgb-9.5* Hct-29.1*
MCV-83 MCH-27.0 MCHC-32.8 RDW-16.4* Plt Ct-170
[**2139-2-20**] 06:15AM BLOOD Glucose-140* UreaN-8 Creat-0.6 Na-138
K-3.7 Cl-105 HCO3-26 AnGap-11
.
PORTABLE ABDOMEN
.
IMPRESSION: Normal gas pattern with no evidence of bowel
obstruction or free intraabdominal air.
.
Cardiology Report ECG Study Date of [**2139-2-16**] 9:41:46 PM
.
Sinus rhythm with first degree atrio-ventricular conduction
delay. Diffuse non-diagnostic repolarization abnormalities.
Compared to the previous tracing of [**2138-12-23**] multiple
abnormalities persist without major change.
.
CHEST (PORTABLE AP)
IMPRESSION: No acute cardiopulmonary process.
.
[**2139-2-22**] 01:47PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2139-2-22**] 01:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2139-2-16**] 08:20PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2139-2-22**] 01:47PM URINE RBC-0-2 WBC-[**5-31**]* Bacteri-OCC Yeast-FEW
Epi-0-2
[**2139-2-16**] 08:20PM URINE RBC->50 WBC-1000* Bacteri-MANY Yeast-NONE
Epi-<1
Brief Hospital Course:
HD#1 Ms [**Known lastname 71508**] was admitted through the emergency department and
transferred to SICU. Work up revealed stable hematocrit,
hyperglycemia, and electrolyte abnormalities. She remained
afebrile. Abdominal x-ray and chest x-ray were unremarkable, see
pertinent results for details. She was held NPO with IV fluids,
Zosyn IV and NGT to low suction. She had no more episodes of
nausea or vomiting and only small amounts of clear drainage from
the NGT. GI consult was obtained for possible EGD, which was
never obtained due to the patients improving status. HD#2 she
was transferred to [**Hospital Ward Name 121**] 9 for further recovery.
Ms [**Known lastname 71508**] continued to improve with IV antibiotics and and IV
fluids. Her diet was advanced and she tolerated a diabetic diet
on HD#3. She was followed by physical therapy for strength and
mobility. Urine culture revealed susceptible enterococcus, she
was changed to Augmentin by mouth HD#5. She continued to have
soft formed stool and gas per ostomy throughout her admission.
Her home dose of Glargine insulin was increased to 24 units at
bedtime and her sliding scale insulin was increased due to
persistent hyperglycemia. Her home dose of Lasix was decreased
to 10 mg daily due to her initial fluid volume deficit. Foley
catheter was discontinued on HD#8 and she voided without
difficulty. At time of discharge her white count normalized and
her UA showed only occasional bacteria, see pertinent results
for details. She was transferred to rehab in stable condition,
with recommendation for follow up in 1 week with her primary
care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of home meds, and repeat labs. She is
to make an appointment to return to see Dr. [**Last Name (STitle) **] in 1
month.
Medications on Admission:
Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain, fever.
Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO
DAILY (Daily).
Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Potassium 20 meq po qd
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection [**Hospital1 **] (2 times a day): Please discontinue SQ Heparin
when ambulating regularly.
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
8. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-23**] Sprays Nasal
DAILY (Daily) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection [**Hospital1 **] (2 times a day): Please discontinue SQ Heparin
when ambulating regularly.
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24)
units Subcutaneous at bedtime.
14. Regular Insulin Sliding Scale
Breakfast Lunch Dinner Bedtime
0-60mg/dL [**12-23**] amp D50 [**12-23**] amp D50 1/2amp D50 [**12-23**] amp D50
61-140mg/dL 0 Units 0 Units 0 Units 0 Units
141-160mg/dL 2 Units 2 Units 2 Units 1 Units
161-180mg/dL 4 Units 4 Units 4 Units 2 Units
181-200mg/dL 6 Units 6 Units 6 Units 3 Units
201-220mg/dL 8 Units 8 Units 8 Units 4 Units
221-240mg/dL 10 Units 10 Units 10 Units 5 Units
241-260mg/dL 12 Units 12 Units 12 Units 6 Units
261-280mg/dL 14 Units 14 Units 14 Units 7 Units
281-300mg/dL 16 Units 16 Units 16 Units 8 Units
Potassium 10 meq po qd
Discharge Disposition:
Extended Care
Facility:
[**Hospital 71510**] Care Center
Discharge Diagnosis:
Rash
Urinary tract Infection
Dehydration
Discharge Condition:
good
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, foul smelling urine, inability to
urinate, or any other symptoms which are concerning to you.
No tub baths or swimming. You may shower.
Activity: as tolerated. Continue strengthening with physical
therapy
Medications: Resume your home medications.
Followup Instructions:
Please call [**Telephone/Fax (1) 3201**] and schedule an appointment to see Dr.
[**Last Name (STitle) **] in 4 weeks.
Please schedule an appointment to see your primary care
physician [**Last Name (NamePattern4) **] 1 week, to reassess need for lasix and the dosing,
as well as recheck of serum electrolytes.
Completed by:[**2139-2-23**]
|
[
"428.0",
"599.0",
"414.01",
"V44.1",
"427.31",
"276.51",
"272.0",
"782.1",
"V44.2",
"250.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8283, 8342
|
3863, 5654
|
314, 321
|
8427, 8434
|
2102, 3840
|
9004, 9345
|
1544, 1548
|
6462, 8260
|
8363, 8406
|
5680, 6439
|
8458, 8981
|
1563, 2083
|
199, 276
|
349, 845
|
867, 1173
|
1189, 1528
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,915
| 171,134
|
44481
|
Discharge summary
|
report
|
Admission Date: [**2151-9-17**] Discharge Date: [**2151-9-29**]
Date of Birth: [**2104-11-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Tegretol / Latex
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
PEG placement ([**2151-9-27**])
PICC placement
History of Present Illness:
This is a 46 yo F with severe chronic multiple sclerosis, who is
admitted to the MICU for hypoxia. She was recently admitted to
[**Hospital3 2358**] for 5 days last week (discharged [**9-13**]) for
pneumonia on a 14 day course of oral levofloxacin.
She had been feeling well until this afternoon when she became
acutely short of breath. Her home nurse checked her O2 sat on
room air was 80% and she was brought to the ED.
In the ED, initial VS: 97 111/79 95 88% on RA which increased to
96% on 3L by nc. A NIF was -22. Her chest x-ray showed fullness
at hilum bilaterally (my read) but was otherwise unrevealing.
She was sent for a CTA to r/o PE and better evaluate her lung
parenchyma. The CT was negative for PE and showed bilateral PNA.
She received a dose of vancomycin and CTX (? cefepime). Blood cx
sent. When she returned from CT, she was more hypoxic - 88% on
5L nc and which normalized to 95% on a 50% venti mask. She was
transferred to the ICU for hypoxia.
On evaluation on the floor, patient reports her breathing is
comfortable. She denies any current SOB, CP, abd pain, back
pain, HA or vision change. She does endorse mild nausea which
she associates with the fact that she hasn't eaten.
Past Medical History:
Chronic progressive MS, wheelchair bound dependant in all ADL's
Chronic Sacral Decubitus ulcer with wound vac
h/o [**Month/Day (4) 16169**] UTI with chronic foley
Social History:
Dependant for all ADL's, wheelchair bound. Has 24 hour care.
Lives with husband, has 2 adult children. No tobacco, EtOH or
drugs
Family History:
No family history of multiple sclerosis.
Physical Exam:
Admission Physical:
VS: 97.3 109/66 86 92% on 5L nc and high flow face tent
GEN: chronically ill appearing, NAD
HEENT: PERRL, EOMI, clear OP, MMM.
RESP: rhonchrous throughout with some bronchial breath sounds,
no wheezes or crackles appreciated.
CV: regular rate, no murmus appreciated
ABD: nd, +b/s, soft,
EXT: warm, well pefused, sensation in tact, 0/5 strength
throughout LE contracted and extended - chronic appearing
SKIN: multiple old and new echymosis on LE. Wound vac on sacral
decubits ulcer
NEURO: AAOx3. Spastic throughout with up going toes.
Pertinent Results:
I. Labs
A. Admission
[**2151-9-17**] 12:05PM BLOOD WBC-6.7 RBC-4.90# Hgb-14.2# Hct-42.7#
MCV-87 MCH-28.9 MCHC-33.1 RDW-13.6 Plt Ct-399#
[**2151-9-17**] 12:05PM BLOOD Neuts-55.2 Lymphs-36.7 Monos-4.0 Eos-2.9
Baso-1.3
[**2151-9-17**] 12:05PM BLOOD Plt Ct-399#
[**2151-9-17**] 12:05PM BLOOD Glucose-82 UreaN-18 Creat-0.6 Na-144
K-4.5 Cl-105 HCO3-30 AnGap-14
B. Discharge
[**2151-9-29**] 04:22AM BLOOD WBC-7.9 RBC-3.78* Hgb-11.1* Hct-32.8*
MCV-87 MCH-29.4 MCHC-33.9 RDW-14.1 Plt Ct-298
[**2151-9-29**] 04:22AM BLOOD Plt Ct-298
[**2151-9-29**] 04:22AM BLOOD Glucose-89 UreaN-12 Creat-0.3* Na-137
K-4.8 Cl-100 HCO3-32 AnGap-10
[**2151-9-29**] 04:22AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.2
C. Urine
[**2151-9-23**] 02:57PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2151-9-23**] 02:57PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2151-9-23**] 02:57PM URINE RBC-23* WBC-295* Bacteri-FEW Yeast-FEW
Epi-1 TransE-2
[**2151-9-22**] 03:34PM URINE CaOxalX-FEW
[**2151-9-23**] 02:57PM URINE Mucous-FEW
II. Microbiology
[**2151-9-22**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2151-9-22**] URINE URINE CULTURE-FINAL {YEAST}
[**2151-9-22**] 3:34 pm URINE Source: Catheter.
**FINAL REPORT [**2151-9-23**]**
URINE CULTURE (Final [**2151-9-23**]):
YEAST. >100,000 ORGANISMS/ML..
INPATIENT
[**2151-9-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2151-9-18**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2151-9-17**] BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY [**Hospital1 **]
[**2151-9-17**] BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY [**Hospital1 **]
III. Radiology
A. Speech and Swallow
STUDY TYPE: Video oropharyngeal swallow.
INDICATION: Progressive MS with likely aspiration pneumonia,
assess for
aspiration.
TECHNIQUE: Swallowing oropharyngeal video fluoroscopy was
performed in
conjunction with the speech and swallow division. Multiple
consistencies of
barium were administered.
FINDINGS: Barium enters the oropharynx without obstruction.
There is a slow
oral phase with difficulty initiating passage of the bolus into
the oropharynx
and esophagus with high oral residual. There is aspiration of
both
honey-thickened and thick barium. The patient had difficulty
initiating cough
to clear this aspirated material. For full details, please see
the speech and
swallow division note in the online medical record.
IMPRESSION: Aspiration with honey-thickened and thick barium.
B. Renal US
INDICATION: History of chronic progressive multiple sclerosis,
recent
hospitalization with pneumonia and rule out fungus ball or upper
tract disease
in kidneys.
COMPARISON: [**2145-3-3**].
FINDINGS: The study is technically limited due to poor acoustic
window.
Within these limitations, there is no evidence of renal mass,
abscess,
perinephric collection, or hydronephrosis. The right kidney
measures 8.6 cm
and the left kidney measures 8.7 cm. The bladder is collapsed
with Foley
catheter in situ.
IMPRESSION: No evidence of hydronephrosis or renal abscess.
Overall,
unremarkable son[**Name (NI) **] within technical limitations stated above.
The study and the report were reviewed by the staff radiologist.
C. CXR
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Severe MS [**First Name (Titles) 151**] [**Last Name (Titles) 16169**] aspiration pneumonia.
Comparison is made with prior study [**9-20**].
Cardiomediastinal contours are normal. Left PICC tip is in the
mid to lower
SVC. NG tube tip is coiled in the stomach. Right lower lobe
opacities have
improved consistent with improving atelectasis. Left perihilar
minimal
opacities are unchanged. This could be due to atelectasis or
aspiration.
There are no new lung abnormalities, pneumothorax or pleural
effusions.
D. PICC Placement
PICC LINE PLACEMENT
INDICATION: IV access needed for intravenous fluid bolus and
potential
intravenous antibiotics.
The procedure was explained to the patient. A timeout was
performed.
RADIOLOGISTS: Dr. [**Last Name (STitle) 14804**] and Dr. [**Last Name (STitle) 4686**] performed the
procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the
left brachial
vein was punctured under direct ultrasound guidance using a
micropuncture set.
Hard copies of ultrasound images were obtained before and
immediately after
establishing intravenous access. A peel-away sheath was then
placed over a
guidewire and a 5 French double-lumen PICC line measuring 40 cm
in length was
then placed through the peel-away sheath with its tip positioned
in the SVC
under fluoroscopic guidance. Position of the catheter was
confirmed by a
fluoroscopic spot film of the chest.
The peel-away sheath and guidewire were then removed. The
catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no
immediate
complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French
double-lumen PICC line placement via the left brachial venous
approach. Final
internal length is 40 cm, with the tip positioned in SVC. The
line is ready
to use.
E. CTA
NDICATION: Hypoxia.
TECHNIQUE: Multidetector helical CT scan of the chest was
obtained before and
after the administration of IV Optiray contrast. Axial, coronal,
sagittal,
and oblique reformations were prepared.
COMPARISON: Chest radiograph performed the same day.
FINDINGS: The pulmonary arterial tree is well opacified, and
there is no
evidence of pulmonary embolism. The aorta is normal in caliber
and
configuration. No evidence of acute aortic syndrome is seen.
Remaining great
vessels are normal, and the heart is unremarkable.Several
enlarged lymph nodes
are seen, including prevascular, subcarinal and bilateral hilar
stations. At
the left hilum, there is borderline enlargement measuring up to
11 mm in short
axis. No pleural or pericardial effusion is present.
Bibasilar linear opacities are seen, right greater than left.
Additionally,
there is opacification extending along the bronchovascular
bundles, radiating
from the hila, with bronchial wall thickening bilaterally. Fluid
and
secretions are seen within the trachea and extending into the
lower airways
bilaterally. The airways however are not completely occluded.
Ill-defined
nodular opacities are also noted scattered in both upper lobes.
No
pneumothorax is seen.
Limited views of the upper abdomen are unremarkable. No
concerning osseous
lesion is seen.
IMPRESSION: Bilateral lower lobe bronchial wall thickening and
opacification
along the bronchovascular bundles, with linear airspace
opacities. Findings
likely reflect bronchial inflammation or infection. Mediastinal
and hilar
lymphadenopathy is likely reactive.
IV. Cardiology
Sinus rhythm. Diffuse non-specific ST-T wave flattening.
Compared to the
previous tracing of [**2149-5-16**] the rate has slowed. Otherwise, no
diagnostic
interim change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 122 86 378/428 68 68 50
Brief Hospital Course:
46-year-old female with severe multiple sclerosis admitted to
MICU with hypoxia secondary to aspiration pneumonitis with
subsequent PEG placement and discussion with husband about
hospice.
# Aspiration with hypoxic respiratory distress
Likely from aspiration event on top of prior pneumonia. Patient
initially hypoxic to the high 80's which improved on oxygen.
Intubation not required. Clinical history of acute onset
(~30min) more consistent with aspiration rather than worsening
of pneumonia. CT findings suggesting aspiration pneumonitis.
Patient recently hospitalized for pneumonia at [**Hospital3 2358**].
Other possibilities include PE (ruled out on CT) or worsening of
her MS though the acuity makes this unlikely. She was initially
treated with vancomycin, cefepime, levofloxacin. After
resolution of hypoxia, patient called out to floor and weaned
from O2 with no further issues. Antibiotic coverage was narrowed
to a 7-day course of levaquin/flagyl. Repeat CXR showed no
apparent infiltrate or worsening lung disease. Blood, sputum
cultures were negative. Remained afebrile and hemodynamically
stable. Given [**Hospital3 16169**] aspiration, multiple failed
speech/swallow evaluation, and difficulty managing secretions,
she was made NPO with dobhoff tube feeds. PEG tube was
subsequently placed after discussion with husband. [**Name (NI) **]
subsequently tolerated tube feeds well and was discharged.
# Chronic Severe Multiple Sclerosis: Patient is followed by
[**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **]. Her MS medications were held or given at lower
dose given concern for altered sensorium and further aspiration
events. She was discharged on reduced dosage of gabapentin and
baclofen along with fluoxetine, oxycodone prn, tizanidine, and
ritalin.
Given end-stage MS, it was discussed with her husband about
hospice after Dr. [**Last Name (STitle) **] suggested this possibility. Palliative
care consult discussed with husband for further outpatient
consideration.
# Anemia
Patient had admission Hct 42.7 with discharge Hct 32.8. Minimal
blood loss per IR from PEG placement. Stools were hemoccult
negative. Etiology unknown but Hct stable at discharge. DDx
includes phlebotomy, critical illness, or poor nutrition with
marrow suppressive effect.
Advise outpatient Hct check to see if continues to stabilize.
# Sacral Decubitus Ulcer:
Patient has had long standing wound vac. Wound care consulted
for management and recommended pressure relief, frequent
repositioning. There were no signs of infection.
# Yeast on UA
Patient had UA with > 100,000 organisms/mL of yeast. Given
multiple sclerosis and likely functional bladder issues, concern
for colonization given foley vs. infection. Patient was afebrile
with no irritative symptoms. Renal US obtained to rule out upper
tract disease and was negative. Foley subsequently changed.
# Access
The patient lost access in the ICU with subsequent PICC placed
by IR for antibiotics. PICC line discontinued at discharge as no
further need for antibiotics.
# Code status: Full code, discuss further on outpatient basis.
Medications on Admission:
Levaquin 750mg through [**9-23**]
Adderall 501-mg qd
Baclofen 60mg tid
Fluoxetine 40mg qd
Gabapentin 600mg qid
Lorazepam 0.5mg tid prn spasm
Oxycodone/Aceta 10/325 1 tab tid prn pain
Tizanidine 2mg qhs
Discharge Medications:
1. methylphenidate 5 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO QAM (once a
day (in the morning)) as needed for alertness.
2. baclofen 10 mg Tablet [**Month/Year (2) **]: Four (4) Tablet PO TID (3 times a
day).
3. fluoxetine 20 mg Capsule [**Month/Year (2) **]: Two (2) Capsule PO DAILY
(Daily).
4. lorazepam 0.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO three times a
day as needed for spasm.
5. tizanidine 2 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at
bedtime).
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
7. ascorbic acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
9. Percocet 5-325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every four
(4) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Tube Feed
Isosource 1.5: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 95
ml/hr. Free water flushes: 150ml Q4. Add beneprotein 14g per
day.
11. Sarna Anti-Itch 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Topical four
times a day as needed for itching.
12. gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Two [**Age over 90 1230**]y (250)
mg PO every eight (8) hours.
Disp:*450 mL* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care Agency
Discharge Diagnosis:
Primary: Aspiration pneumonitis, Chronic Aspiration
Secondary: Chronic progressive multiple sclerosis, chronic
sacral decubitus ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mrs. [**Last Name (STitle) 95322**],
You were treated for a possible lung infection that we believe
was related to aspirating. You had a speech and swallow study
that confirmed you are aspirating. Our speech and swallow team
feel that it is not safe for you to eat either liquids or solids
given your aspiration. However, you and your husband would like
for you to continue eating pureed food for comfort despite the
risk of more aspiration events and possibly [**Last Name (STitle) 16169**] lung
infections. You had a gastric feeding tube placed in order to
provide constant nutrition and a constant means of getting you
your medications. This tube does not prevent you from aspirating
saliva though.
.
Medication changes:
START ascorbic acid for nutrition
START bisacodyl for constipation
START lansoprazole for stomach acid reduction
START sarna lotion which is an over the counter cream for itch
relief
CHANGE baclofen 60 mg by mouth three times daily TO 40 mg by
mouth three times daily
CHANGE gabapentin 600 mg by mouth four times daily to 250 mg by
mouth four times daily
CHANGE percocet 10/325 mg TO oxycodone 5 mg by mouth every 4
hours as needed for pain
Followup Instructions:
# Primary care: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: THE YAWKEY CENTER FOR OUTPATIENT CARE
Address: [**Street Address(2) 12266**], [**Location (un) **],[**Numeric Identifier 10614**]
Phone: [**Telephone/Fax (1) 29679**]
Date and Time: Monday, [**10-11**] @ 11:40 AM
# Neurology: [**Last Name (LF) **], [**First Name3 (LF) 730**]
[**Location (un) 830**]
[**Location (un) 86**] , [**Telephone/Fax (1) 95323**]
We were unable to reach her office to make an appointment.
Please call and make an appointment to be seen within the next
1-2 weeks.
|
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"507.0",
"112.2",
"707.03",
"285.9",
"518.81",
"338.29",
"707.24",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
14712, 14782
|
9768, 12882
|
301, 350
|
14960, 14960
|
2567, 9745
|
16292, 16859
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1934, 1976
|
13134, 14689
|
14803, 14939
|
12908, 13111
|
15097, 15807
|
1991, 2548
|
15827, 16269
|
254, 263
|
378, 1584
|
14975, 15073
|
1606, 1772
|
1788, 1918
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,718
| 152,639
|
10500
|
Discharge summary
|
report
|
Admission Date: [**2199-7-4**] Discharge Date: [**2199-7-9**]
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Imdur
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Right lung thoracentesis, exudative, 2.2 liters removed
Femoral line placement
External jugular line placement
CT scan of torso
History of Present Illness:
Ms. [**Known lastname 34631**] is a [**Age over 90 **] year old female with history of DM,
osteoporosis, CAD s/p PTCA of LAD, and R pleural effusion seen
on US done [**7-1**] who was brought to the ED from [**Hospital 100**] Rehab due
to progressive dyspnea. Over the past 7 days the patient had
been complaining of dyspnea on exertion. At baseline she
ambulates with a walker however recently she has been more
fatigued as has required 2L O2 to keep sats above 90%. She has
increasing edema in her LE bilaterally over the same period of
time. Her nurse also noted poor PO intake. She was also noted
to be in atrial fibrillation which is new for her and was
started on coumadin on [**7-2**]. At that time, zocor and zestril
were discontinued. Reportedly a CXR was done at rehab which
showed unilateral pleural effusion, abdominal US done showed
pericardial effusion. However, echocardiogram done on [**7-2**] did
not show pericardial effusion but showed 4+ TR, LVEF 35-40%, 1+
MR, 1+ AR.
In the ED, vital signs are BP 180/100, HR 70, RR 22, O2sat 100%
on NRB. She was immediately placed on CPAP and started on nitro
gtt. Labs were notable for WBC count 10.9, neut 85%, hct 52,
INR 4.5, normal lactate. CXR showed moderate opacification of
the entire right hemithorax likely related to both a
moderate-to-large sized right-sided pleural effusion and
reactive atelectasis. Some areas of right lung still
identified. The left lung appears clear. While in the ED the
BP improved to systolic 160 on the nitro gtt. Oxygen saturation
was 100% on CPAP and she was switched to a nonrebreather. She
was given a dose of Vancomycin and Levofloxacin as well as one
dose of Vitamin K. IP was contact[**Name (NI) **] regarding tapping the
effusion.
On arrival to the [**Hospital Unit Name 153**], the patient is accompanied by her
daughter. She says her breathing is improved from when she came
in to the hospital. She denies chest pain, fevers, chills,
abdominal pain. She denies any night sweats or recent weight
loss. She has a mild nonproductive cough. Her daughter notes
that she has not had LE edema in the past.
Past Medical History:
1. Hodgkin's lymphoma
2. Coronary artery disease, status post non-Q-wave myocardial
infarction in [**2186**], status post percutaneous transluminal
coronary angioplasty of her left anterior descending with an
ejection fraction of 77%.
3. Diabetes mellitus, type 2.
4. Hypertension.
5. Hypercholesterolemia.
6. Mild dementia.
7. Gastric carcinoma, status post partial gastrectomy in [**2173**].
8. Diverticulosis.
9. Glaucoma in right eye.
10. Anxiety.
11. Status post total hip replacement on right.
12. Chronic osteoporosis of lower limbs.
13. Arthritis
14. Newly diagnosed atrial fibrillation
Social History:
Social History
Occupation: Mostly stay at home mother. Worked briefly as
typist.
Key relationships: One daughter [**Name (NI) **] who lives in [**Name (NI) 47**].
Three grandchildren
Smoking, EtOH: Denies history of use.
Vision/Hearing: blind left eye, no hearing aides.
Functional Baseline
ADLs: Independent in dressing, feeding. Has assist with shower.
Normally participates in activities such as bingo.
IADLs: Daughter manages finances.
Assistive Device: Ambulates with walker.
Family History:
Non-contributory
Physical Exam:
General Appearance: Well nourished, Thin, Elderly
Eyes / Conjunctiva: EOMI, dry MM
Head, Ears, Nose, Throat: Normocephalic, +JVD
Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal),
(S2: Normal), (Murmur: Systolic), irregular
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: No(t) Symmetric, Paradoxical),
(Percussion: Dullness : Right), (Breath Sounds: Clear : Left,
No(t) Wheezes : , Absent : Right)
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: 3+, Left: 3+, No(t) Cyanosis, No(t)
Clubbing, to above knees bilaterally
Skin: Warm, No(t) Jaundice, cool feet b/l
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**7-2**] Echo:
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
regional systolic dysfunction consistent with coronary artery
disease. Mild (1+) aortic regurgitation. Mild (1+) mitral
regurgitation. Severe [4+] tricuspid regurgitation. Moderate
pulmonary artery systolic hypertension.
[**7-4**] CXR: IMPRESSION: Moderate opacification of the entire right
hemithorax likely related to both a moderate-to-large sized
right-sided pleural effusion and reactive atelectasis. Some
areas of right lung still identified. The left lung appears
clear.
EKG atrial fibrillation at 99 bpm, leftward axis, nl intervals,
Q waves in III, aVF, V1-V3TWI I, aVL, ? STD V6. Compared to EKG
dated [**2192-4-1**] unchanged.
PORTABLE CHEST, [**2199-7-5**]
COMPARISON: Previous study of earlier the same date.
INDICATION: Status post thoracentesis.
Right pleural effusion has markedly decreased in size. Small
residual pleural effusion following thoracentesis. No definite
pneumothorax is identified, but the most peripheral aspect of
the minor fissure is not well visualized. The possibility of a
very small lateral pneumothorax is thus not excluded. Left
hemidiaphragm appears poorly defined, possibly due to motion
artifact, but a small pleural effusion is also possible.
LOWER EXTREMITY ULTRASOUND
HISTORY: Bilateral lower extremity edema.
FINDINGS: [**Doctor Last Name **] scale and color Doppler son[**Name (NI) 1417**] were performed
of the
bilateral common femoral, superficial femoral, and popliteal
veins. Within
the left lower extremity, the distal portion of the left
superficial femoral vein did not completely compress. There also
was minimal flow seen through the segment of the left distal
superficial femoral vein. There is normal compressibility, flow
and augmentation of the right lower extremity. There is normal
compressibility and flow of the left popliteal vein, proximal
and mid superficial femoral vein and the left common femoral
vein.
IMPRESSION: Likely chronic non-occlusive small thrombus
localized to the
distal portion of the left superficial femoral vein. These
findings were
discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the time of review.
The study and the report were reviewed by the staff radiologist.
[**7-6**] Upper extremity ultrasound:
IMPRESSION: 1. DVT within one of the branches of the left
brachial vein and completely clotted left basilic vein. The left
cephalic vein was not visualized.
[**7-8**] CT Torso:
COMPARISON: CT torso, [**2192-8-14**].
CT CHEST WITH CONTRAST: There are no pathologically enlarged
axillary lymph nodes. Scattered calcifications associated with
hypoattenuation foci in the thyroid do not appear significantly
changed. The heart is normal in size, and there is no
significant pericardial effusion. Atherosclerotic
calcification of the coronary arteries and the thoracic aorta is
observed. A precarinal lymph node measures 16 x 10 mm,
previously 14 x 12 mm.
There has been significant increase in size of a now large right
pleural
effusion and development of a new small left pleural effusion.
The nodular
soft tissue density along the periphery of the right lower lobe
fissure seen in [**2192**] is less conspicuous today. No new lung
nodules are identified today. The airways appear patent to the
subsegmental level bilaterally. A few subcentimeter
hypoattenuating right hepatic lesions (2:58 and 52) are too
small to characterize and not definitively identified on prior
studies. The gallbladder is mildly distended and contains
multiple gallstones within. The spleen, pancreas and adrenal
glands appear unremarkable. The kidneys enhance symmetrically
and excrete contrast normally and there is no hydronephrosis or
hydroureter. A 15-mm interpolar left renal cyst is unchanged.
Other scattered bilateral hypoattenuating renal lesions are too
small to characterize. Intra-abdominal loops of large and small
bowel are unremarkable and there is no free air, free fluid or
pathologically enlarged mesenteric lymph nodes. Scattered
retroperitoneal lymph nodes do not meet CT criteria for
pathologic enlargement. The abdominal aorta is atherosclerotic
and tortuous as are its branches.
CT PELVIS WITH CONTRAST: Evaluation of the pelvis is limited due
to right hip prosthesis. The rectum and bladder appear
unremarkable. A Foley is present within the bladder. The sigmoid
colon contains diverticula without evidence of acute
diverticulitis. Calcifications within the uterus likely
represent fibroids. No pathologically enlarged pelvic lymph
nodes or free fluid is identified. Scattered subcutaneous
pockets of air likely related to injections.
Bone windows reveal osteopenia and severe multilevel
thoracolumbar
degenerative changes with fusion of the L3, L4 and L5 vertebral
bodies.
Thoracolumbar scoliosis, moderate, is also present.
IMPRESSION:
1. No evidence of new malignancy or recurrent lymphoma.
Precarinal lymph
node as described.
2. Large right and small left pleural effusion.
3. Cholelithiasis and diverticulosis
[**7-5**] Cytology: Pleural fluid: x2
NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes,
lymphocytes, blood and roteinaceous debris.
Admission Labs:
==============
[**2199-7-4**] 05:00PM BLOOD WBC-10.9# RBC-5.29# Hgb-16.6*# Hct-52.0*#
MCV-98 MCH-31.4 MCHC-31.9 RDW-14.7 Plt Ct-221
[**2199-7-4**] 05:00PM BLOOD Neuts-84.7* Lymphs-8.8* Monos-6.0 Eos-0.4
Baso-0.1
[**2199-7-4**] 11:16PM BLOOD Glucose-128* UreaN-39* Creat-0.8 Na-129*
K-5.2* Cl-94* HCO3-29 AnGap-11
[**2199-7-4**] 05:00PM BLOOD Glucose-111* UreaN-45* Creat-1.0 Na-127*
K-6.5* Cl-92* HCO3-26 AnGap-16
[**2199-7-5**] 05:30AM BLOOD ALT-28 AST-20 LD(LDH)-178 CK(CPK)-26
AlkPhos-50 TotBili-0.5
[**2199-7-4**] 06:30PM BLOOD proBNP-[**Numeric Identifier 34632**]*
[**2199-7-6**] 04:11AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.7
[**2199-7-5**] 05:30AM BLOOD TotProt-5.1* Albumin-3.1* Globuln-2.0
Calcium-8.7 Phos-3.0 Mg-1.8
[**2199-7-4**] 09:52PM BLOOD Type-ART pO2-148* pCO2-33* pH-7.53*
calTCO2-28 Base XS-5
[**2199-7-4**] 06:09PM BLOOD Lactate-1.4
Discharge Labs:
==============
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2199-7-9**] 08:00AM 9.2 4.69 14.9 47.1 100* 31.7 31.6 14.0
144
RENAL & GLUCOSE Glu bun Creat Na K Cl HCO3 AnGap
[**2199-7-9**] 08:00AM 105 15 0.6 130* 4.7 88* 36* 11
Brief Hospital Course:
#Right pleural effusion: exudative, gram stain negative, tapped
for 2.2 liters serosanguenous fluid. Gram stain negative.
Received lasix prn. CYTOLOGY NEGATIIVE FOR MALLIGNANCY X 2. Had
CT torso to eval for malignancy and no source found, but pleural
effusion on right has reaccumulated and is also slightly on
left. She did not complain of sob, feeling her breathing was
better, but did have an O2 requirement of 2L to keep sat over
90%. 4+ TR may also be contributing. She was given 10mg po lasix
on day of discharge as her Na and Cl were dropping consistent
with hypervolemia. She is very clear she does not want any more
invasive interventions and would like to return to [**Hospital 100**] Rehab.
Overall picture does point to malignancy given multiple thrombi
(see below), but would also focus on HF management as possible
second etiology and for symptom management.
# Afib: newly diagnosed prior to admission. She continued to be
tachycardic 90-110s, but as high as 140, had one episode of
bradycardia to 40s while sleeping. Beta blocker was titrated up.
Her tachycardia is most likely contributing to her HF and if
rate is controlled her HF may improve. Continue to titrate BB to
goal rate of 60-70.
# Acute on chronic diastolic and systolic congestive heart
failure EF 35-40%: This is a new diagnosis for her per daughter
(but records indicated [**2190**]). Does not have edema at baseline.
Not on lasix at baseline. Most likely secondary to rapid afib
and rate control will help manage. Diuresed with prn IV lasix.
Would consider restarting ACE-I as outpatient. Became
orthostatic with 10mg IV lasix, but tolerated 10mg po lasix.
# Acute Renal Failure: Cr increased to 1.0 on admission from
baseline of 0.6, was stable at discharge.
# Diabetes mellitus: is usually diet controlled. Covered with
sliding scale while inpatient with infrequent converage.
# Hyponatremia: Has h/o hyponatremia. NA dropped to 130 on [**7-9**],
most likely dilutional from volume overload. Improved when given
lasix.
# Leukocytosis: Initially slightly elevated WBC (10.9), trended
down. UA negative, no pneumonia on cxr. Received IV abd in ED
but none after.
# Coagulopathy, multiple thrombus: Superficial femoral DVT, non
occlusive and also LUE basilic occlusive thrombus. Was bridged
with lovenox. INR > 3 on [**7-8**], held x 1, was 2.8 on [**7-9**], to be
given 2mg coumadin tonight, was overlapped with lovenox for
48hrs. Given thrombus, if INR drops below 2.0 would resume
lovenox temporarily.
# CAD s/p PTCA of LAD: aspirin dose was decreased to 81mg. Beta
blocker increased. ACE-I on hold but should be restarted as
outpatient. Imdur discontinued since no h/o anginal symptoms per
patient and daughter.
# Hypertension Increase BB. Restart ACE-I as outpt.
# Osteoporosis: fosomax, vit d, ca
# Geriatric issues: albumin 3.1, given supplements. Bowel
regimen. ATC tylenol for pain control.
#Advance Directives:
HCP- Daughter
[**Name (NI) 7092**] Status- DNR/DNI
Goals of Care: spent significant amount of time discussing with
patient and daughter. patient is very clear she does not want
invasive measures and would prefer not to be hospitaized. I feel
she does have the capacity to make these decisions herself as we
had discussions on the consequences of not being hospitalized
and she understood. She would like to be kept at [**Hospital 100**] Rehab
and kept comfortable.
Medications on Admission:
Coumadin 5mg [**Date range (1) 135**] (INR 2.6)
Tylenol 650 QId
Fosamax 70mg [**7-2**]
Ecotrin 325 daily
Tenormin 75 daily
Tums 650 [**Hospital1 **]
Vitamin D 1000 daily
Imdur 30mg daily
Multivitamin daily
Phenergan for EMS
Morphine 4mg for pain, SOB
Roxycodone d/c'd on [**7-1**]
Zocor 10mg daily d/c on [**7-1**]
Zestril d/c'd [**7-1**]
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
6. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO every six (6) hours as needed for constipation.
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO Q6H
(every 6 hours).
13. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once tonight
[**7-9**]: Give 2mg tonight and then check PT/INR in am.
14. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Right exudative pleural effusion, reaccumulated after tapping.
Cytology negative, gram stain negative.
Left pleural effusion [**7-8**]
Acute on Chronic Congestive Heart Failure EF 35%
Acute Renal Failure
Hyponatremia
Left upper extremity basilic occlusive DVT
Left superficial femoral non-occlusive thrombus
Atrial Fibrillation
Coronary Artery Disease
Hypertension
Discharge Condition:
Fair
Discharge Instructions:
You were admitted for shortness of breath and were found to have
a collection of fluid in the lining of your lung. You had the
fluid drained and it came back. You had a series of tests to
find the cause of the collection and they were negative. Discuss
with your doctor whether you want further workup or would
instead want your symptoms managed.
Followup Instructions:
1. Goals of care discussion, patient is clear she does not want
aggressive curative treatment.
2. For symptomatic treatment a pleurex catheter may be able to
placed outpatient with interventional radiology.
3. consider restarting ACE-I as indicated
4. Monitor electrolytes closely as she has just started
furosemide
5. Blood cultures still pending. Call in two days for final
results.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2199-7-9**]
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,385
| 160,773
|
40820
|
Discharge summary
|
report
|
Admission Date: [**2196-4-17**] Discharge Date: [**2196-5-9**]
Date of Birth: [**2122-9-3**] Sex: F
Service: MEDICINE
Allergies:
Nafcillin
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
Purulent sputum
Major Surgical or Invasive Procedure:
-Irrigation and debridement of left septic shoulder, via open
arthrotomy
-C5-7 posterior laminectromy and evacuation of cervical epidural
abscess
History of Present Illness:
The patient is a 73 yo F with a PMH significant for diabetes,
HTN, HL, depression who was transferred from [**Hospital3 19345**] for concern for endocarditis. The patient was in her
usual state of health until 2 weeks ago when she developed a
single lesion on her back that was though to be zoster treated
with acyclovir. She then developed multiple joint pains
including shoulder, wrists and ankles. The patient was admitted
to [**Hospital3 **] on [**2196-4-15**] for polyarthritis and her labs
were significant for a WBC 16.3 and ESR 113. She had blood
cultures drawn and 3 sets returned growing S. aureus and she was
started on Vancomycin. She was also given Tordol for pain. She
remained afebrile during her hospitalization and x-rays of her
left ankle, b/l shoulders and left wrists only showed
degenerative changes. She reported dyspnea, but CXR did not show
any acute process. Additionally, on admission the patients Cr
was noted to be 0.8 and has increased to 1.24 at the time of
discharge. She was transferred to [**Hospital1 18**] this evening because she
could not get an ECHO on Sunday at [**Hospital6 3105**].
.
On arrive the patient has complaints of pain in multiple joints.
She also reports general fatigue and weakness. She denied any
F/C/NS/N/V/D. She denied any back pain, stool/bladder
incontinence or lower ext weakness/numbness. She denied any
recent dental work, but did get new dentures 3 days prior to
admission.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, orthopnea, PND, lower
extremity edema, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
Diabetes
HTN
HL
Depression
Restless Leg Syndrome
Social History:
Living Situation: Lives with her husband in an apartment
Tobacco: denied
EtOH: denied
IVDU: denied
Family History:
NC
Physical Exam:
On admission:
=============
Vitals: T: 97.7 82 135/48 34 100% on AC 400 x 14 FIO2: 50% at
PeeP 5
General: Intubated, sedated, paralyzed
HEENT: Sclera anicteric, dry MM, ET tube in tact
Neck: supple, C- spine collar in place, Drain in place.
Lungs: Clear to auscultation bilaterally, minimal rhonchi
bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, obese, distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis,
erythema around left ankle. 2+ pitting edema in BLE/BUE; Left
shoulder drain in place, bandage is c/d/i
.
On discharge:
=============
VS - Tc 98.3 BP 140/68 (138-145/64-70) HR 79 (79-88) RR 20 O2
sat 95%2L (91% RA)
I/O: 1820/4400 on [**2196-5-7**]
GENERAL - Elderly woman resting in bed, NAD, tachypnea with
speaking
HEENT - NC/AT, PERRL, sclerae anicteric, MMM, OP clear
NECK - supple, JVP difficult to assess given body habitus, no
carotid bruits
LUNGS - bibasilar rales with diffuse rhonchi,
HEART - RRR, , nl S1-S2, no m/r/g
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - Wound vac in place on left shoulder. 1+ edema of
the lower extremities to the ankles, minimal upper extremity
edema over the dorsal aspect of the hands. good palpable pulses
2+ in radial, DP.
SKIN - no noticeable rashes
NEURO - A&O x 3, Strength is [**3-22**] in the upper extremities
bilaterally, lower extremities [**4-21**] in lower extremities
bilaterally, sensation intact bilaterally.
Pertinent Results:
Admission labs:
===============
[**2196-4-18**] 05:00AM BLOOD WBC-18.0* RBC-2.88* Hgb-8.6* Hct-24.9*
MCV-87 MCH-29.9 MCHC-34.5 RDW-14.8 Plt Ct-334
[**2196-4-19**] 06:50AM BLOOD WBC-17.3* RBC-2.93* Hgb-8.4* Hct-25.5*
MCV-87 MCH-28.6 MCHC-32.8 RDW-14.6 Plt Ct-347
[**2196-4-18**] 05:00AM BLOOD Neuts-90.5* Lymphs-6.4* Monos-1.7*
Eos-1.1 Baso-0.3
[**2196-4-18**] 05:00AM BLOOD PT-16.2* PTT-26.9 INR(PT)-1.4*
[**2196-4-18**] 05:00AM BLOOD ESR-131*
[**2196-4-22**] 02:38AM BLOOD Fibrino-486*
[**2196-4-27**] 03:21AM BLOOD Ret Aut-2.1
[**2196-4-18**] 05:00AM BLOOD Glucose-111* UreaN-39* Creat-0.9 Na-132*
K-4.2 Cl-100 HCO3-22 AnGap-14
[**2196-4-19**] 06:50AM BLOOD Glucose-121* UreaN-32* Creat-0.7 Na-136
K-3.7 Cl-101 HCO3-23 AnGap-16
[**2196-4-18**] 05:00AM BLOOD ALT-7 AST-49* LD(LDH)-347* CK(CPK)-308*
AlkPhos-160* TotBili-0.6
[**2196-4-22**] 02:38AM BLOOD CK-MB-5 cTropnT-<0.01
[**2196-4-18**] 05:00AM BLOOD Albumin-2.2* Calcium-8.3* Phos-2.6*
Mg-2.3
[**2196-4-27**] 03:21AM BLOOD calTIBC-126* Ferritn-PND TRF-97*
[**2196-4-18**] 06:24AM BLOOD %HbA1c-7.2* eAG-160*
[**2196-4-18**] 05:00AM BLOOD CRP-283.4*
[**2196-4-21**] 03:14PM BLOOD Glucose-93 Lactate-0.9 Na-128* K-3.5
Cl-102
.
Discharge labs:
===============
[**2196-5-9**] 05:07AM BLOOD WBC-8.6 RBC-2.79* Hgb-8.4* Hct-24.5*
MCV-88 MCH-30.2 MCHC-34.3 RDW-15.7* Plt Ct-257
[**2196-5-9**] 05:07AM BLOOD PT-15.3* PTT-24.7 INR(PT)-1.3*
[**2196-5-7**] 05:55AM BLOOD ESR-132*
[**2196-5-9**] 05:07AM BLOOD Glucose-114* UreaN-27* Creat-1.4* Na-136
K-3.4 Cl-95* HCO3-33* AnGap-11
[**2196-5-9**] 05:07AM BLOOD ALT-3 AST-8 LD(LDH)-230 AlkPhos-79
TotBili-0.4
[**2196-5-9**] 05:07AM BLOOD Albumin-2.3* Calcium-8.9 Phos-4.4 Mg-1.9
Imaging:
========
[**4-18**] TTE: Suboptimal image quality. Normal biventricular cavity
sizes with preserved global biventricular systolic function.
Aortic valve sclerosis. No discrete vegetation or pathologic
valvular regurgitation identified.
.
[**4-18**] Shoulder x-rays: Two limited views show no definite bone or
joint space abnormality. If there is serious clinical concern
for septic joint, cross-sectional imaging could be considered.
.
[**4-18**] MRI L/T-spine:
1. Paravertebral multiloculated fluid collection at T12-L1
paravertebral
retrocrural space on the right.
2. Increased STIR signal and abnormal enhancement in the L1
vertebral body
suggests osteomyelitis.
3. Multiloculated fluid collection in the right paraspinal
muscle at L4-5. Small abnormal enhancing tissue in the epidural
space at right L4-5. Small
pocket of right psoas fluid collection.
4. Loculated right pleural effusion, likely suggesting empyema.
.
[**4-19**] MRI C-spine:
1. 2.2 cm x 0.5 cm posterior epidural collection at C6-7 level
causing thecal distortion.
2. Minor degenerative spondylotic changes as described above,
disc protrusion at C5-C6 level with moderate canal narrowing.
.
[**4-19**] MR shoulder:
1. Large joint effusion with synovitis and debris. Given the
patient's
history of bacteremia, these findings are concerning for a
septic joint with septic tenosynovitis. Abnormal signal within
the humeral head and erosion of the bicipital groove is
concerning for osteomyelitis, with interosseous abscess.
2. Severe tenosynovitis surrounding the long head of the bicep
tendon, which in its intra-articular portion is not visualized
and compatible with a tear.
3. Full-thickness tears involving the supraspinatus, and
subscapularis
tendon. Severe delamination of the infraspinatus tendon.
4. Severe edema involving all muscles of the rotator cuff,
deltoid, and
pectoralis minor.
5. SLAP tear. Severe glenohumeral joint degenerative change.
.
[**4-22**] CT chest:
1. Bilateral pleural effusions, with evidence of loculation and
pleural
thickening on the right, these features support the suspicion of
empyema,
which could be confirmed with percutaneous aspiration. A large
volume of fluid is loculated in the right major fissure.
2. Mild interstitial septal thickening, suggestive of mild
edema.
3. Subscapular gas since most likely relate to recent arthrotomy
and debridement.
4. L1 paravertebral abscess.
5. Bilateral lower lobe atelectasis.
.
[**4-26**] CXR: Stable left lower lobe atelectasis since [**2196-4-25**]. This,
however,
is new since [**2196-4-23**].
.
[**4-28**] MRI C/T/L Spine:
IMPRESSION:
1. Abnormal signal intensity in the body of L1 with new abnormal
signal
intensity in the body of T12 and T12-L1 disc space, most
consistent with
progression of the discitis/osteomyelitis at these levels. The
associated
anterior paravertebral multiloculated collection is stable since
the prior
MRI.
2. Interval increase in the multiloculated fluid collection in
the posterior
paraspinal musculature.
3. Interval increase in the epidural collection extending from
L4 down to S2.
4. Interval increase in the bilateral pleural effusions.
5. Laminectomies in the cervical spine with no evidence of a
residual
epidural collection in the cervical spine.
.
[**2196-5-3**] CXR:
1. Right PICC line in standard position.
2. Mild interval increase of opacity in the left lower lobe,
likely
represents an association of large pleural effusion and
atelectasis, but
infectious process cannot be excluded. Correlate clinically.
.
[**2196-5-5**]: ECHO
IMPRESSION: Suboptimal image quality due to body habitus. Left
ventricular systolic function is probably normal, a focal wall
motion abnormality cannot be excluded. The right ventricle is
not well seen. No evidence of endocarditis - cannot exclude on
the basis of this study.
.
[**2196-5-6**] CXR (PA and LAT):
Both the right and left decubitus view show small layering
pleural
effusions. The AP radiograph, however, shows slight improvement
in
ventilation of both lungs. There is unchanged mild cardiomegaly
and a small right basal atelectasis persists. No newly-appeared
focal parenchymal opacities.
.
.
MICRO:
[**2196-4-18**] 5:00 am BLOOD CULTURE
**FINAL REPORT [**2196-4-21**]**
Blood Culture, Routine (Final [**2196-4-21**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
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----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2196-4-20**] 5:25 pm JOINT FLUID Source: shoulder.
**FINAL REPORT [**2196-4-23**]**
GRAM STAIN (Final [**2196-4-20**]):
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 89182**] @ 1115PM @
[**2196-4-20**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
FLUID CULTURE (Final [**2196-4-23**]):
STAPH AUREUS COAG +. SPARSE 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----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2196-5-2**] 6:32 am URINE Source: Catheter.
**FINAL REPORT [**2196-5-4**]**
URINE CULTURE (Final [**2196-5-4**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2196-5-3**] 7:06 pm BLOOD CULTURE
**FINAL REPORT [**2196-5-9**]**
Blood Culture, Routine (Final [**2196-5-9**]): NO GROWTH.
[**2196-5-5**] 4:15 pm SWAB LEFT SHOULDER DEEP CULTURE.
GRAM STAIN (Final [**2196-5-5**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2196-5-7**]): NO GROWTH.
ACID FAST SMEAR (Final [**2196-5-6**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (Final [**2196-5-5**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2196-5-2**] 2:54 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2196-5-3**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2196-5-3**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
73 yo F h/o Diabetes, HTN, found to have MSSA endocarditis, left
shoulder septic arthritis and cervical epidural abscesses s/p
washout today in OR transferred to MICU for airway protection in
setting of purulent sputum in ET tube concerning for PNA.
.
ACTIVE ISSUES:
==============
# MSSA Bacteremia: Patient had blood cultures positive for MSSA.
Likely etiology was skin source from recently treated zoster.
She was subsequently found to have endocarditis, septic
arthritis, and cervical and lumbar epidural abscesses. She was
transferred to the MICU with purulent sputum and CT chest
showing empyemas. She was hypoxic likely in setting of pneumonia
and was intubated on [**4-21**]. IP was consulted but did not feel
there was enough to drain by thoracentesis. Patient had low
urine output and non-anion gap metabolic acidosis with pH 7.23
and bicarb of 19 on transfer to MICU. She was given IVF with
bicarbonate and acidosis resolved. Infectious disease was
following patient and recommended to continue IV naficillin.
Purulent sputum was likely due to MSSA pneumonia though sputum
culture only showed sparse yeast (taken after antibiotic therapy
was initiated). Orthopedics and neurosurgery were consulted and
drained left shoulder and cervical paravertebral abscesses.
There was erythema and small bullae on dorsum of left [**Last Name (un) 5355**] but
per orthopedics there was no joint involvement and no drainage
was performed. Cardiac surgery was also consulted and
recommended weekly echocardiograms with outpatient follow up in
2 months. Urine output steadily improved with IVF. She was
extubated on [**4-23**]. She did develop some dyspnea and found to be
fluid overloaded with rales on exam, and was given IV lasix with
adequate diuresis and improvement in hypoxia. She was ultimately
weaned down to 1L nasal cannula at time of transfer to the floor
on [**2196-4-27**]. Repeat imaging on [**5-3**] revealed a new lumbar
epidural abscess, but since her neurological exam was stable it
was decided that she would be monitored clinically and only
taken to the OR if she developed neurologic symptoms. While on
the floor she developed a drug rash to nafcillin and this was
changed to cefazolin 1gm IV Q12H. Her rash gradually resolved
and she did well on cefazolin 1gm Q12H. In addition, her left
shoulder incision site started to express pus from the wound.
Ortho came to evaluate it and she was sent back to the OR for a
washout of her site. She had a wound vac on her left shoulder
for a few days and it was removed on the day of discharge. She
will need daily dressing changes of the wound. She will have
repeat MRI imaging of the L spine on [**2196-6-1**] and follow up with
Ortho, cardiology, neurosurgery and infectious disease
.
# Hypoxia: likely initially due to MSSA pneumonia and empyemas.
She was intubated on [**4-21**] and extubated on [**4-23**] with subsequent
development of pulmonary edema which improved with lasix
diuresis. She was transitioned to 1L nsaal cannula at time of
transfer to the floor. She was changed from lasix drip to lasix
60mg IV with net goal output 500ml daily. She had severe fluid
overload and was aggressively diuresed. She had a persistent O2
requirement and her diuretics were uptitrated to lasix 100mg IV
TID with metolazone 5mg 30 minutes prior to her lasix dose.
During this aggressive diuresis she developed a contraction
alkalosis and she was switched to acetazolamide for 2 doses.
She was weaned off her O2 and she appeared close to euvolemic.
Given her rising albumin we will discharge her not on standing
diuretics with plan to reassess volume status in a few days
after she equilibrates. She was satting 95-98% RA at the time
of discharge.
.
# Acute GI bleed: Patient had multiple bowel movements starting
on [**2196-4-28**]. They were guaiac positive and her hct began to
trend down. Her hematocrit trended down and she required 2
units pRBC. She went for EGD that showed one ulcer at the GE
junction that was not the likely source of bleeding. Her H/H
was stable and it was recommended she have outpatient
colonoscopy when medically stable
.
# UTI: Patient found to have catheter associate UTI. the
catheter was replaced and she was started on bactrim and will
complete a 10 day course
.
# LUE cellulitis: While on the floor the patient developed LUE
cellulitis that was suspected to be secondary to a MRSA
super-infection. She was started on Bactrim 1 tab DS [**Hospital1 **] and
here cellulitis improved significantly. She will continue on a
10 day course of Bactrim to be completed on [**2196-5-12**].
.
# ARF: Admission Cr: 0.9 and peaked at 2. Patient was
intermittently on pressors in the OR, which may have caused
kidney injury, however she did not require prolonged pressor
support. Also, patient is on nafcillin, posing her to be at risk
for AIN though urine eosinophils were negative. Cr began
improving slightly and she was making sufficient urine with
lasix diuresis. See detailed description of diuresis above. At
the time of discharge the patient's creatinine was 1.4.
.
# Left Shoulder Septic Arthritis: s/p washout in OR with GPCs on
gram stain, likely MSSA given bacteremia. She had recurrent
infection of the joint and went for a second washout. The wound
appeared clean and stable at the time of discharge. She will
need daily dressing changes until output improves.
.
# Cervical Epidural Abscess: s/p washout by neurosurgery with
GPCs on gram stain, likely MSSA. She was continued on nafcillin.
Lumbar paravertebral abscesses were not large enough to be
drained and will be managed conservatively at this time with
repeat imaging in 1 month..
.
# Diabetes: continued HISS
.
TRANSITION OF CARE:
===================
# Endocarditis f/u: please obtain weekly EKG, f/u with Dr.
[**Last Name (STitle) 914**] in clinic in 2 months ([**Telephone/Fax (1) 170**]) and prior to visit
obtain an echo
# patient will need Orhto follow up on [**2196-5-31**]
# MRI Lumbar spine in 1 month ([**2196-6-1**])
# ID follow up and neurosurgery follow up
# Colonoscopy when medically stable
Medications on Admission:
Glucophage 500mg TID
Calcium 1200mg daily
Sinemet 25/100 [**Hospital1 **]
Actos 15mg daily
ASA 81mg daily
Nabumetone prn
Simvastatin 20mg daily
Atenolol 50mg daily
MV
Elavil 25mg TID
Ferrous Sulfate 65mg daily
Vicodin q6:prn
Acyclovir 800mg QID
Zovirax topical
Discharge Medications:
1. Glucophage 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. Calcium 600 600 mg (1,500 mg) Tablet Sig: Two (2) Tablet PO
once a day.
3. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
twice a day.
4. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO three times
a day.
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days.
11. cefazolin in dextrose (iso-os) 1 gram/50 mL Piggyback Sig:
One (1) Piggyback Intravenous Q12H (every 12 hours) for 8 weeks:
last dose [**2196-6-30**].
12. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
13. 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.
14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/Wheezing.
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
17. nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed for perineum.
18. Outpatient Lab Work
Weekly CBC, BUN/Cr, LFT, ESR, CRP, Attn: [**Doctor Last Name **] fax no.
([**Telephone/Fax (1) 1419**]
19. nabumetone 750 mg Tablet Sig: Two (2) Tablet PO twice a day
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary Diagnosis:
MSSA bacteremia
Septic Joint (left shoulder)
Cervical epidural abscess
Endocarditis
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 are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. you were
admitted for back pain and pain in multiple joints. You were
found to have bacteria in your blood, pockets of infection
around your spine and an infected left shoulder joint. You had
an operation to drain a pocket of infection around you cervical
spine. You also had an infection on your heart valve. You also
had your left shoulder joint washed out twice to get rid of the
bacteria there. You were admitted to the ICU for a short period
and then returned to the floor. Repeat imaging showed that your
areas of infection are stable. You also had a lot of extra
fluid on your body and we needed to give you a lot of medication
to get rid of it. You are doing much better and you are ready
for discharge to [**Hospital1 **]. You will need to go to Rehab for
further management of your Abx and also for strength training.
.
The following medications were STARTED:
Cefazolin 1gm IV every 12 hours until [**2196-6-30**] (for 8 weeks)
Oxycontin 20mg by mouth every 12 hours (can stop once pain is
resolving)
OxycoDONE (Immediate Release) 5 mg by mouth every 4 hours as
needed for pain
Pantoprazole 40mg by mouth Daily
Bactrim 1 DS tab twice a day by mouth until [**2196-5-12**]
Nystatin Ointment for treatment of your perineal rash
Nebulizers for shortness of breath.
.
Please take your other medications as prescribed
.
PLease have a colonoscopy when you are feeling better.
# Has ortho follow up on [**5-31**]
# MRI Lumbar spine in 1 month (scheduled [**2196-6-1**])
# Endocarditis f/u: please obtain weekly labs, f/u with Dr.
[**Last Name (STitle) 914**] in clinic in 2 months ([**Telephone/Fax (1) 170**]) and prior to visit
obtain an echo
# Follow up colonoscopy once feeling better.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2196-5-31**] at 4:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2196-5-30**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2196-6-13**] at 9:30 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY (MRI of L Spine)
When: WEDNESDAY [**2196-6-1**] at 1:40 PM
With: XMR [**Telephone/Fax (1) 327**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: WEDNESDAY [**2196-6-8**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,742
| 110,558
|
28485+57596
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-9-11**] Discharge Date: [**2132-9-18**]
Date of Birth: [**2057-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
s/p fall out of wheelchair
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74M w/h/o Afib, HTN, COPD, DM, PVD, CVA, s/p fall w/ SAH. Until
two days prior, when he presented to OSH for routine arterial
studies of RLE for PVD. Following studies, pt was brought to
entrance of clinic in wheelchair, and subsequently found to have
fallen out of wheelchair with abrasions to right frontal area of
head, as well as R arm. Taken there directly to OSH ED.
.
At OSH, initial labs INR 2.3, PTT 38, Hct 29.7, Plt 264. CT head
revealed bilat SAH, no midline shift. Pt was given two units
PRBCs and two units FFP. Received 1g fosphenytoin load, vitk 5mg
SC. Transferred to [**Hospital1 18**] for further evaluation.
.
At [**Hospital1 18**] ED, given 2units of Proplex, when INR on arrival was
1.9, Hct down to 25.2 from reported 29.7. Initially guaiac
negative in ED.
.
Since arrival, CT head again confirmed bilat SAH. Pt was started
on nimodipine to prevent cerebral vasospasm, all anticoagulation
held.
.
per wife: + DOE for the last year, only walk 20 ft, but no
CP/shoulder pain/neck pain/no palpitations/ n/v/diaphoresis. No
PND/orthopnea, syncope or presyncope. + bilateral claudication
+LE edema:R>L. Denies f/c/sweats, weight changes, abd pain,
melena, hematochezia, dysuria, urinary frequency,
arthralgia/myalgia or rashes. + cough and wheeze, but generally
well-controlled with inhalers, and not currently worse from
baseline.
Past Medical History:
HTN
NIDDM
Hypercholesterolemia
R rotator cuff injury s/p surgical repair
R knee surgery
R CEA
h/o polyps, nonmalignant
COPD (last PFTs this year, but unk results)
Atrial Fibrillation (on warfarin)
CVA w/ residual facial weakness 1/05
R CEA [**1-17**]
PVD s/p R Fem-[**Doctor Last Name **] bypass
R knee surgery
Last colonoscopy ?5 yrs ago, (+) polyps
BPH
Social History:
Lives with wife in [**Name (NI) **].
Tobacco: 2PPD X 52yrs, quit 10yrs ago.
Alcohol: 2drinks/day
Family History:
Noncontributory
Physical Exam:
T- 98.3 BP- 143/76 HR- 109 RR- 16 O2Sat 97% on RA
Gen: Lying in bed, NAD, in C collar
HEENT: NC/AT, moist oral mucosa
CV: irregular, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive. Speech
is fluent with normal comprehension. No dysarthria.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, no nystagmus. Sensation intact V1-
V3. Mild R facial droop. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 4+ 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
(pt. reports R delt weakness 2/2 rotator cuff injury)
Sensation: Intact to light touch throughout.
Reflexes:
+2 and symmetric throughout, except absent in R patella (site of
R knee surgery)
Toes downgoing bilaterally
Coordination: finger-nose-finger normal
Pertinent Results:
[**2132-9-11**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2132-9-11**] 06:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2132-9-11**] 06:00PM PLT COUNT-237
[**2132-9-11**] 06:00PM ANISOCYT-1+ MACROCYT-1+
[**2132-9-11**] 06:00PM NEUTS-76.9* LYMPHS-17.2* MONOS-4.2 EOS-1.3
BASOS-0.5
[**2132-9-11**] 06:00PM WBC-7.6 RBC-2.69* HGB-8.6* HCT-25.2* MCV-94
MCH-31.9 MCHC-34.0 RDW-16.3*
[**2132-9-11**] 06:00PM URINE HOURS-RANDOM
EKG: AFib 80, borderline inf axis, nonspecific TW flattening in
III, avF.
.
CTA Head:
Wet read: No aneurysm seen although reconstructions are pending.
Absent right vertebral artery.
.
CT Head:
IMPRESSION: Subarachnoid hemorrhage, greatest in the areas of
the sylvian fissures bilaterally. Though the etiology is likely
traumatic, an underlying aneurysm is not excluded.
The extensive nature of the hemorrhage, and the apparent
spherical area of high density in the left sylvian fissure
(seires 2 image 15) raise a concern of aneurysmal bleeding.
Recommend CTA, MRA, or catheter arteriography for further
evaluation.
.
CT Abd/Pelvis [**2132-9-11**]
1. No definite acute traumatic injury identified. There is very
mild wedging of the anterior portion of the T11 vertebral body,
of undetermined age.
2. Indeterminate left adrenal lesion. This may represent an
adenoma, but further evaluation with CT or MR is recommended.
3. Small bilateral pleural effusions.
4. Atherosclerosis of the abdominal aorta, with mild dilation of
the
infrarenal portion to 2.8 cm.
5. Enlarged prostate.
.
TTE [**2132-9-16**]: left and right atriums moderately dilated; mild
symmetric left ventricular hypertrophy; left ventricular
systolic function is normal (LVEF 70%); increased left
ventricular filling pressure (PCWP>18mmHg). No masses or thrombi
are seen in the left ventricle. Mild to moderate mitral
regurgitation is seen- the severity
of mitral regurgitation may be significantly UNDERestimated;
borderline pulmonary artery systolic hypertension; no
pericardial effusion.
.
CXR [**2132-9-16**]:persistence of small bilateral pleural effusions,
with minimal congestive heart failure/volume overload, mild
improvement from [**2132-9-13**].
.
[**2132-9-18**] 07:00AM BLOOD WBC-7.9 RBC-3.23* Hgb-9.9* Hct-28.7*
MCV-89 MCH-30.5 MCHC-34.3 RDW-19.5* Plt Ct-258
[**2132-9-16**] 06:35AM BLOOD Glucose-111* UreaN-62* Creat-3.3* Na-138
K-3.9 Cl-102 HCO3-22 AnGap-18
[**2132-9-17**] 07:00AM BLOOD Glucose-163* UreaN-54* Creat-2.6* Na-140
K-3.8 Cl-102 HCO3-23 AnGap-19
[**2132-9-18**] 07:00AM BLOOD Glucose-126* UreaN-47* Creat-2.1* Na-142
K-3.8 Cl-105 HCO3-23 AnGap-18
[**2132-9-17**] 07:00AM BLOOD WBC-7.7 RBC-3.37* Hgb-9.7* Hct-28.8*
MCV-86 MCH-28.8 MCHC-33.6 RDW-20.0* Plt Ct-256
[**2132-9-16**] 06:35AM BLOOD WBC-7.9 RBC-2.75* Hgb-8.4* Hct-24.3*
MCV-88 MCH-30.7 MCHC-34.7 RDW-17.6* Plt Ct-221
[**2132-9-15**] 06:05AM BLOOD calTIBC-211* TRF-162*
[**2132-9-14**] 09:47PM BLOOD Hapto-237* Ferritn-373
[**2132-9-13**] 09:00PM BLOOD VitB12-178* Folate-GREATER TH Ferritn-209
[**2132-9-16**] 06:35AM BLOOD PTH-81*
[**2132-9-14**] 05:15PM BLOOD Type-ART pO2-82* pCO2-33* pH-7.44
calTCO2-23 Base XS-0
Brief Hospital Course:
A/P: 74yoM w/ h/o DM, HTN, PVD, COPD, here s/p fall w/ SAH now
w/ SOB and ARF.
.
# Cards- Vasculopath, longstanding h/o HTN now w/SOB and pleural
effusion, cardiomegaly on CXR
- Pump- echo shows EF 70%
-- Hold on standing lasix
- Rate/Rhythm- A. Fib; rate controlled
-- continue Atenolol, Diltiazem
-- anticoagulation held [**2-14**] falls (was on ASA, plavix, coumadin
when fell)
- Coronaries
-- Plan for outpt w/u w/exercise stress when stable.
- HTN
-- d/c Atenolol, start Metoprolol, start hydralazine/isosorbide
dinitrate; Plan to restart ACE [**Last Name (LF) **], [**First Name3 (LF) **] d/c hydral/isosorbide
at that time.
.
# Renal- ARF on CRI(baseline Cr unknown), initiall oliguric, now
autodiuresing
-- Cr on admission 1.7, discharge creatinine 2.1 Pt w/ recent
h/o contrast studies [**2132-9-11**], [**2132-9-12**]; FENA 0.2- Prerenal/ATN.
- transfusion of 1 unit overnight followed by Diuril 500 mg IV
and IV Lasix 120 mg with improvement in UO
- Urine Alb/Cr ratio 0.7 likely secondary to long standing DM
and Hypertension
- Plan to restart ACE [**Month/Day/Year **] as above.
.
# Pulm- SOB, 92% on 6L, 80's on RA; ABG: 7.44/33/82
- Pleural effusions- most likely [**2-14**] CHF
-- continue to diurese
-- renal consulted, recommending fluid challenge followed by
diuresis.
-- f/u CXR showing resolution of effusions,
-- [**2132-9-17**] 97% on RA
- COPD
-- continue inhalers, nebs prn
-- continue O2 to maintain Sat>92%
.
# Neuro- new subarachnoid hemorrhage, h/o CVA- stable
- Subarachnoid Hemorrhage
-- Neurosurg following recs:
-- Plan to restart Plavix [**2132-9-18**], Plan to restart coumadin
[**2132-10-12**]
-- continue Nimodipine/Dilantin for 3 wk course
- h/o CVA- stable hemiparesis R side
-- continue ASA
.
# Heme
- Anemia- ?[**2-14**] SC absorption from numerous ecchymoses- iron
studies reveal anemia of chronic inflammation
-- pretreat w/ Tylenol, Benadryl for a ? transfusion reaction
with no evidence of hemolysis
-- Transfused with clinical improvmement.
- Continue to hold Plavix, warfarin for now
.
# [**Name (NI) **] pt w/ h/o chronic bronchitis
- Treated with Azithromycin, Ceftriaxone for possible PNA;
?retrocardiac opacity
.
# GI- unlikely to be GI source given Guaiac negative stools.
- continue PPI.
- bowel regimen.
.
# Endocrine- DM2- SSI
.
# FEN.- regular diet, replete lytes.
.
# PPX. SC heparin, PPI, bowel regimen
.
# Code: Full
.
# Communication: Primary Care Physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20561**] MD
[**Telephone/Fax (1) 26190**], [**Name (NI) 1094**] Wife: [**Telephone/Fax (1) 69044**] (cell)
.
# Dispo: d/c home when stable; f/u w/ Dr. [**Last Name (STitle) 548**] 6 wks
[**Telephone/Fax (1) 1669**]; fax d/c summary to Dr. [**Last Name (STitle) 20561**] on D/c office
ph:[**Telephone/Fax (1) 26190**]
Medications on Admission:
Diltiazem 240 mg QD
Zocor 40 mg QD
Combivent 8x/day
Advair 500/50 [**Hospital1 **]
Atenolol 100 QD
Lasix 80 QD
Metformin 500 QID
Prevacid 30 QD
Cozaar 50 [**Hospital1 **]
Allopurinol 300 QD
Coumadin 5 mg Q sunday, 2.5 mg Mon-Sat
Plavix 75 mg QD
ASA 81 mg QD
Lisinopril 40 mg QD
Tramodol 50 mg QID PRN
Terazosin 2 mg QID
Discharge Medications:
1. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-14**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 2 weeks.
Disp:*168 Capsule(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Hydralazine 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
Disp:*135 Tablet(s)* Refills:*2*
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Traumatic subarachnoid hemorrhage
ARF
hypoxia
Discharge Condition:
stable
Discharge Instructions:
Return to ER or call Dr.[**Name (NI) 2845**] office if you develop sudden
worsening headaches or any neurologic changes
[**Month (only) 116**] restart coumadin [**2132-10-12**].
Return to ER or call Dr.[**Name (NI) 2845**] office if you develop sudden
worsening headaches or any neurologic changes
[**Month (only) 116**] restart coumadin in 1 month.
Please follow up with Dr. [**Last Name (STitle) 20561**] in the next 2 weeks.
Please take your medications as directed.
Please recheck your labs including creatinine outpatient with
your primary care physician; if your creatinine is below 2.0,
please stop taking hydralazine/isosorbide dinitrate and restart
your Cozaar per your primary care physician.
Followup Instructions:
You have the following appointments:
Follow up with Dr. [**Last Name (STitle) 548**] on [**2132-10-15**]- head CT at 11:45 AM please
do not eat for 4 hours before CT, 1 PM appointment with Dr.
[**Last Name (STitle) 548**], call [**Telephone/Fax (1) 2992**] if you have questions.
Follow up with Dr. [**Last Name (STitle) 20561**], please call for appointment.
Please recheck your labs including creatinine outpatient with
your primary care physician; if your creatinine is below 2.0,
please stop taking hydralazine/isosorbide dinitrate and restart
your cozaar per your primary care physician.
[**Name10 (NameIs) 357**] schedule follow up colonoscopy.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Name: [**Last Name (LF) 11798**],[**Known firstname **] M Unit No: [**Numeric Identifier 11799**]
Admission Date: [**2132-9-11**] Discharge Date: [**2132-9-18**]
Date of Birth: [**2057-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1305**]
Addendum:
Explained to pt which of the meds he should no longer take that
he was taking pre-admission. Also, explained which meds are new.
Wife verbally agrees to understanding.
Discharge Medications:
1. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-14**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 2 weeks.
Disp:*168 Capsule(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Hydralazine 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
Disp:*135 Tablet(s)* Refills:*2*
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
14. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1307**]
Completed by:[**2132-9-18**]
|
[
"427.31",
"250.00",
"285.1",
"E884.3",
"491.20",
"440.21",
"600.00",
"401.9",
"852.01",
"584.9",
"585.9",
"999.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15424, 15629
|
6853, 9658
|
341, 348
|
11751, 11760
|
3626, 4344
|
12511, 13844
|
2237, 2254
|
13867, 15401
|
11682, 11730
|
9684, 10006
|
11784, 12488
|
2269, 2520
|
275, 303
|
376, 1729
|
2738, 3607
|
4353, 6830
|
2559, 2722
|
2544, 2544
|
1751, 2107
|
2123, 2221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,954
| 134,132
|
39997
|
Discharge summary
|
report
|
Admission Date: [**2158-12-11**] Discharge Date: [**2158-12-15**]
Date of Birth: [**2099-7-3**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath, chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a generally healthy 59-year-old woman with no
significant past medical history who is transferred from LGH for
bilateral lower extremity DVTs and PE. Patient states that she
was in her usual state of health until [**Holiday 1451**] when she
noticed some swelling in her left leg. She saw her PCP and was
diagnosed with a DVT; she was put on Lovenox bridge to coumadin
and according to patient, her INRs have been therapeutic.
Patient was doing well until [**Holiday **] time when she began
developing shortness of breath with minimal exertion and
pleuritic chest pain. She represented to LGH today where she
was diagnosed with a DVT of her right saphenous vein and
bilateral PEs (majority on right side). A large right-sided
consolidation was seen on CTA, consistent either with pneumonia
or less likely, pulmonary infarct. Patient was febrile at LGH
and was started on levaquin. She was transferred to [**Hospital1 18**] for
higher level of care.
.
Upon arrival in ED, initial vitals were: 100.4, 110, 114/76, 18,
100% 2L. An EKG showed sinus tachycardia without evidence of
right heart strain. Patient was transferred to ICU for close
monitoring in context of large clot [**Hospital1 8373**]. Upon transfer,
vitals were: BP: 118/64, HR: 106, 99% on 2L.
.
ROS: Positive for dyspnea on exertion, pleuritic right-sided
chest pain, weakness. Patient denies fevers/chills at home,
recent weight loss, change in her stools, vaginal bleeding, or
any other concerning signs or symptoms.
Past Medical History:
Recent left lower extremity DVT
Social History:
Patient lives with her husband, her daughter, and her
grand-daughter. [**Name (NI) **] is a great-grandmother. She is a
homemaker. Smoked 1PPD "forever" but recently cut down to 3-4
cigarettes/day after DVT diagnosis; used to drink 2 glasses of
wine/night but stopped now that on coumadin. No miscarriages.
Has not had a mammogram or a colonoscopy. Last pap smear was
over 10 years ago.
Family History:
Sister with DVT and Factor V Leiden mutation. Mother with
"breast lump" that was removed. Mother died of respiratory
failure and father died of AD.
Physical Exam:
Admission exam:
Afebrile, 113/52, 93, 99% on 2L
GENERAL: Well appearing thin female, no acute distress
HEENT: No cervical, submandibular, or supraclavicular
lymphadenpathy, throat is clear and non-erythematous
BREAST EXAM: Fibrous tissue in right breast, no nipple
discharge, no axillary LAD
CHEST: Dullness at right lower base, poor airmovement
throughout
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: Marked swelling of lower legs bilaterally, tender
GUAIC: Negative.
Discharge Exam:
Tm99.8 Tc98.8 90 106/50 (100-120) 18 98RA
GENERAL: Well appearing thin female, no acute distress
EXTREMITIES: Marked swelling of lower legs bilaterally, calves
minimally tender to palpation on right worse than left.
NEURO: CN II-XII intact. IV/V weakness on dorsiflexion, worse on
the left than right.
Pertinent Results:
Admission Labs:
[**2158-12-11**] 11:56PM PT-20.4* PTT-60.4* INR(PT)-1.9*
[**2158-12-11**] 11:38PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-<=1.005
[**2158-12-11**] 11:38PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-12-11**] 11:38PM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE
EPI-[**5-25**]
[**2158-12-11**] 05:30PM GLUCOSE-123* UREA N-12 CREAT-0.7 SODIUM-136
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-12
[**2158-12-11**] 05:30PM estGFR-Using this
[**2158-12-11**] 05:30PM ALT(SGPT)-65* AST(SGOT)-50* LD(LDH)-278*
CK(CPK)-62 ALK PHOS-102 TOT BILI-0.4
[**2158-12-11**] 05:30PM CK-MB-2 cTropnT-<0.01
[**2158-12-11**] 05:30PM ALBUMIN-3.5
[**2158-12-11**] 05:30PM WBC-13.8* RBC-3.43* HGB-10.1* HCT-29.2*
MCV-85 MCH-29.4 MCHC-34.5 RDW-13.9
[**2158-12-11**] 05:30PM NEUTS-85.2* LYMPHS-8.4* MONOS-5.8 EOS-0.1
BASOS-0.5
[**2158-12-11**] 05:30PM PLT COUNT-225
[**2158-12-11**] 05:30PM PT-20.4* PTT-32.1 INR(PT)-1.9*
Discharge Labs:
[**2158-12-15**] 05:40AM BLOOD WBC-6.0 RBC-3.11* Hgb-8.8* Hct-26.3*
MCV-85 MCH-28.2 MCHC-33.4 RDW-14.0 Plt Ct-495*
[**2158-12-15**] 05:40AM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-139
K-3.7 Cl-102 HCO3-29 AnGap-12
Notable Labs:
[**2158-12-11**] 05:30PM BLOOD CK-MB-2 cTropnT-<0.01
[**2158-12-12**] 04:30AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-215
[**2158-12-14**] 06:00AM BLOOD CEA-2.5 CA125-1249*
[**2158-12-14**] 09:31AM BLOOD CA [**66**]-9 -PND
[**2158-12-12**] 04:30AM BLOOD ALT-53* AST-39 LD(LDH)-252* CK(CPK)-54
AlkPhos-95 TotBili-0.4
[**2158-12-11**] 05:30PM BLOOD ALT-65* AST-50* LD(LDH)-278* CK(CPK)-62
AlkPhos-102 TotBili-0.4
EKG [**2158-12-12**]:
Baseline artifact. Sinus tachycardia. Short P-R interval. T wave
abnormalities. No previous tracing available for comparison.
Clinical correlation is suggested.
CXR [**2158-12-11**]:
chest read in conjunction with CT scanning of the chest
earlier in the day performed elsewhere: Heterogeneous
opacification at the base of the right lung conforms to the
appearance on CT scanning earlier today, most likely pneumonia
or extensive aspiration. Small right pleural effusion is
probably still present. The heart is normal size. Left lung is
clear. Mild emphysema is demonstrated on the CT scan.
ABDOMINAL ULTRASOUND [**2158-12-12**]
1. Minimal ascites, tiny right pleural effusion and cystic
pelvic masses,
one of which in the right hemi-pelvis has a solid component.
These findings are strongly concerning for ovarian carcinoma.
2. Gallstones and no evidence of acute cholecystitis or biliary
dilatation.
3. Normal-appearing liver.
CT ABDOMEN AND PELVIS W/WO CONTRAST [**2158-12-14**]
1. Large mixed solid and cystic pelvic mass, concerning for
gynecologic
malignancy (likely ovarian adenocarcinoma). Trace complex
ascites. No
definite evidence of intra-abdominal metastasis.
2. Evolving right lower lobe infarct, secondary to PE.
3. Bilateral DVT, involving the IVC and bilateral iliac/femoral
veins.
Brief Hospital Course:
This is a 59-year-old woman with a pmhx. significant for recent
left lower extremity DVT now with bilateral lower extremity DVTs
and PE, who was found to have a pelvic mass on CT concerning for
ovarian cancer.
.
ACTIVE ISSUUES:
1. PE/DVT: She was initially admitted to the ICU for management
of large PE/DVT, though there was no evidence of hemodynamic
compromise or right heart strain. Patient was started on
heparin gtt for anticoagulation and required high doses to
become therapeutic. Cardiac enzymes were cycled and were
negative. A right upper quadrant ultrasound performed for an
urelated reason showed ascites and a cystic pelvis mass
concerning for ovarian cancer, which was again seen on pelvic CT
scan. Hypercoagulable state of malignancy is a likely
precipitant in her case, though there is possibly a compressive
mass-effect of the mass as well causing hemostasis. She was
bridged to coumadin after transfer to the general medicine floor
and her heparin gtt was subsequently stopped on the day of
discharge. She was then switched to subQ lovenox prior to
discharge (80mg [**Hospital1 **]) due to its possibly higher efficacy in the
context of malignancy, and due to the fact that she promptly
clotted when she presented with a subtherapeutic INR. She will
likely require indefinite anticoagulation.
2. OVARIAN MASS: LFT abnormalities prompted an abdominal US,
which showed complex ascites and a pelvic mass with cystic and
solid components. A follow up CT scan confirmed the presence of
a mass highly concerning for ovarian adenocarcinoma. Her Ca125
was elevated above 1200. She was seen by the GYN/ONC and
HEME/ONC teams. She was not deemed to be a surgical candidate
due to her extensive clot [**Last Name (LF) 8373**], [**First Name3 (LF) **] a preliminary plan for
neoadjuvant chemotherapy prior to surgical debulking was
formulated, after obtaining tissue for confirmatory diagnosis
via CT-guided biopsy. Her INR will need to normalize before
this procedure, so she was transitioned to lovenox for ease of
reversal prior to procedures, and increased efficacy in
malignancy. She will be set up with Dr. [**Last Name (STitle) **] of
heme/onc early next week and her biopsy and chemotherapy will be
coordinated thereafter.
3. FEVER/CONSOLIDATION ON CT: She was started on levaquin in
the ICU on [**12-11**] for CXR evidence of RLL consolidation that was
thought to be infection versus infarction. She had low grade
fevers of around 100.5 during her first few days. CT scan of
the abdomen and pelvis revealed that this lesion was likely
infarction. Her levaquin was stopped on [**12-14**] as she was
afebrile without leukocytosis.
.
# TOBACCO ABUSE: Patient was counseled to stop smoking.
TRANSITIONAL ISSUES:
She will require prompt followup with Dr. [**Last Name (STitle) **] for
coordination of her biopsy and further care of a potential
ovarian malignancy. Ca [**66**]-9 pending at the time of discharge.
Medications on Admission:
Coumadin 6mg QD
Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
Disp:*60 syringes* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*3*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*3*
4. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
Disp:*30 packets* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
1. Pulmonary embolism
2. bilateral deep venous thromboses
3. pelvic mass concerning for ovarian cancer
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 87969**],
You were transferred from LGH for treatment for clots in your
legs and your lungs. You stayed briefly in the intensive care
unit, and were transferred to the floor after starting
anticoagulants to prevent worsening of your clots.
We also found an abnormal mass in your pelvis that is concerning
for ovarian cancer. The gynecology and heme/onc teams saw you,
and decided to get a definitive diagnosis with a biopsy before
starting chemotherapy, if necessary. Surgery may be part of
your long term care. You'll start lovenox instead of coumadin
to better prevent further clots, which were likely driven by
this mass, as it increases risk of clotting.
The following changes have been made to your medications:
1. STOP COUMADIN
2. START LOVENOX 80mg injection, twice a day
3. START COLACE 100mg twice a day as needed for constipation
4. START SENNA 8.5mg twice a day as needed for constipation
5. START MIRALAX 17g daily as needed for constipation
It was a pleasure taking part in your care, Ms. [**Known lastname 87969**].
Followup Instructions:
You have the following appointment with your PCP:
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 50166**] [**Last Name (un) 50167**]
When: Friday [**2158-12-22**] at 9:30 AM
Location: [**Hospital 46644**] MEDICAL ASSOCIATES,LLC
Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 59250**]
Phone: [**Telephone/Fax (1) 50168**]
|
[
"183.0",
"453.41",
"486",
"295.90",
"305.1",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9920, 10003
|
6377, 9104
|
336, 343
|
10153, 10153
|
3346, 3346
|
11425, 11830
|
2352, 2503
|
9392, 9897
|
10024, 10132
|
9352, 9369
|
10336, 11402
|
4393, 6354
|
2518, 3007
|
3023, 3327
|
9125, 9326
|
265, 298
|
371, 1872
|
3362, 4377
|
10168, 10312
|
1894, 1927
|
1943, 2336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,658
| 130,619
|
6276
|
Discharge summary
|
report
|
Admission Date: [**2135-4-26**] Discharge Date: [**2135-5-31**]
Date of Birth: [**2051-4-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
PICC Placement
Dobhoff tube placement, post pyloric
History of Present Illness:
83y M hx of a.fib on coumadin, CVA [**3-/2134**] w hospital course c/b
pneumonia, bacteremia and fungemia pt was recently hositalized
for GIB and displaced gtube (dc'd [**2135-4-15**]) now presenting from
rehab with fever, rigors. The patient reports mild cough and
palpitations. Tmax 103 at rehab.
.
In the ED inital vitals were T 98 138 103/65 20 100% 4L. Labs
notable for WBC 7.3 (N 83.2), Hct 32.5, plts 328, ALT 57, AST
66, bili wnl, alb 3.2, lipase 100, BUN 40 (chem 7 otherwise
wnl), lactate 1.8, INR 4.2. UA notable for mod leuk, wbc 30, few
bacteria, no nitr. He received 1L NS, dilt 10mg IV x 2, and
vanco/cefepime empirically (dosed at 1300). Vitals prior to
transfer 101 HR 104 BP98/43 RR20 O2sat 100 2L NC.
.
On arrival to the ICU, pt c/o 4 days of nonproductive cough,
diarrhea, nausea/vomiting, and mild abd pain. No BRBPR or
hematemesis. He denies dysuria, chest pain, SOB, pleurisy. Does
not have any complaints now.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
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:
R-sided MCA infarct [**2134**] with residual left sided weakness and
mild dysarthria
Atrial Fibrillation - on coumadin
Ischemic Stroke [**2132**] - left insula and left frontal (some gait
instability no other deficits)
Type II DM - HbA1c 6.4
Prostate Cancer s/p radiation and hormonal therapy in [**2128**]
?OSA
Low back pain
Social History:
- patient is a preacher at a Pentecostal Church
- married
- he has 2 children who are 52 and 53 yo.
He denies tobbaco, alcohol and illicit drug use.
Family History:
- His father died of cancer (unknown) in his 80's
- His mother died of unkown cause in her 80's
- Brother with DM
Physical Exam:
Physical Exam on Admission:
Vitals: T:99.5 BP: 84/58 P:110 R:20 18 O2: 93/2L NC
General: Alert, oriented to self, no acute distress
HEENT: Sclera anicteric, mucus membranes pink/dry, poor
dentition, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: poor respiratory effort, decreased lung sounds, no
wheezes, rales, rhonchi
CV: irregularly irregular rhythm, tachycardic rate, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, gtube site clean/dry/intact
GU: +foley
Ext: warm, well perfused, 2+ pulses, poor skin turgor, no
clubbing, cyanosis or edema, L picc line clean/dry/intact wo
evidence of erythema or discharge
Pertinent Results:
Lab results on Admission:
[**2135-4-26**] 01:13PM BLOOD WBC-7.3 RBC-3.76* Hgb-11.7* Hct-32.5*
MCV-86 MCH-31.0 MCHC-35.9* RDW-14.1 Plt Ct-328
[**2135-4-26**] 01:13PM BLOOD Neuts-83.2* Lymphs-10.3* Monos-4.7
Eos-0.6 Baso-1.1
[**2135-4-26**] 01:13PM BLOOD PT-42.6* PTT-50.7* INR(PT)-4.2*
[**2135-4-26**] 01:13PM BLOOD Glucose-172* UreaN-40* Creat-1.2 Na-139
K-4.7 Cl-100 HCO3-28 AnGap-16
[**2135-4-26**] 01:13PM BLOOD ALT-57* AST-66* AlkPhos-78 TotBili-0.3
[**2135-4-26**] 01:13PM BLOOD Albumin-3.2* Calcium-8.6 Phos-4.2 Mg-2.0
[**2135-4-26**] 01:13PM BLOOD IgM HAV-PND
[**2135-4-26**] 07:04PM BLOOD Type-CENTRAL VE Temp-37.5
[**2135-4-26**] 01:11PM BLOOD Lactate-1.8
[**2135-4-26**] 07:04PM BLOOD Lactate-1.2
[**2135-4-26**] 07:04PM BLOOD O2 Sat-58
[**2135-4-26**] 01:13PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2135-4-26**] 01:13PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-MOD
[**2135-4-26**] 01:13PM URINE RBC-3* WBC-30* Bacteri-FEW Yeast-NONE
Epi-0
[**2135-4-26**] 01:13PM URINE CastHy-4*
.
[**2135-5-30**] 07:10AM BLOOD WBC-6.6 RBC-3.87* Hgb-10.9* Hct-35.6*
MCV-92 MCH-28.2 MCHC-30.6* RDW-15.3 Plt Ct-265
[**2135-5-8**] 08:27PM BLOOD Neuts-76.6* Lymphs-14.8* Monos-7.5
Eos-0.5 Baso-0.6
[**2135-5-30**] 07:10AM BLOOD Glucose-146* UreaN-17 Creat-0.7 Na-140
K-4.0 Cl-103 HCO3-33* AnGap-8
[**2135-5-10**] 05:38AM BLOOD CK(CPK)-88
[**2135-5-3**] 05:59AM BLOOD ALT-20 AST-22 LD(LDH)-227 AlkPhos-60
TotBili-0.4
[**2135-5-10**] 10:05PM BLOOD proBNP-5736*
[**2135-5-10**] 05:38AM BLOOD CK-MB-5 cTropnT-1.31*
[**2135-5-9**] 02:24AM BLOOD CK-MB-5 cTropnT-1.48*
[**2135-5-8**] 08:27PM BLOOD CK-MB-5 cTropnT-1.72*
[**2135-5-6**] 04:15PM BLOOD CK-MB-6 cTropnT-1.26*
[**2135-5-30**] 07:10AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9
[**2135-5-3**] 05:59AM BLOOD Hapto-441*
[**2135-5-4**] 06:00AM BLOOD Triglyc-59
.
Studies:
[**2135-4-26**] CXR: IMPRESSION: New left mid-and-lower lung
consolidation compatible with
pneumonia in the proper clinical setting. Subtle opacity at the
right lung
base could represent atelectasis or developing infiltrate as
well. Recommend
repeat after treatment to document resolution.
.
[**4-29**] CT HEAD: IMPRESSION:
1. No acute intracranial hemorrhage.
2. Multifocal encephalomalacia in the coronae radiatae, left
occipital pole
and left cerebellar hemisphere, related to prior territorial
infarcts.
.
[**2135-5-3**] CT ABD:
IMPRESSION:
1. Malpositioned percutaneous gastrostomy tube, has retracted
with tip and
the balloon now terminating in the transverse colon. Contrast
administered
via the G-tube fills the colon. Possible residual fistulous
communication of the colon with the stomach.
2. No evidence of associated complication such as gross colonic
perforation; in particular, no free air or fluid in the abdomen.
3. Bilateral moderate-sized simple pleural effusions. Patchy
consolidation
in the right middle lobe may represent changes of aspiration, or
less likely early infection.
4. Fatty liver, cholelithiasis, and left adrenal hyperplasia.
5. Mild colonic wall thickening predominantly in the transverse
and
descending colon may be secondary to underdistension or less
likely due to
early mild colitis. No evidence of pseudomembranous colitis.
.
ECHO [**5-9**]:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is moderately dilated. There
is moderate symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with severe hypokinesis of the inferior and
inferolateral wall and mild global hypokinesis of the remaining
segments (LVEF = 35-40 %). Right ventricular chamber size is
normal with moderate global free wall hypokinesis. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace 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. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
.
IMPRESSION: Suboptimal image quality. Prominent symmetric left
ventricular hypertrophy with regional and global hypokinesis as
described above. Moderate to severe mitral regurgitation.
Moderate pulmonary artery hypertension. Moderate tricuspid
regurgitation.
Compared with the prior study (images reviewed) of [**2135-3-18**], the
severity of mitral regurgitation and tricuspid regurgitation
have increased, left ventricular systolic function is more
depressed and the estimated pulmonary artery systolic pressure
is higher.
.
[**2135-5-9**] HEAD CT:IMPRESSION:
1. No evidence of hemorrhage, edema or new infarction.
2. Chronic infarcts in bilateral MCA and left PCA distributions.
.
[**2135-5-25**] PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE UNDER CT
FLUOROSCOPY GUIDANCE IMPRESSION: Uncomplicated placement of 12
French Wills-[**Doctor Last Name 12433**] gastrostomy
tube under CT fluoroscopic guidance.
Brief Hospital Course:
84y M hx of afib on coumadin, CVA, HTN, GIB, gtube, prostate ca
and DM presenting with afib with RVR and fever, rigors
concerning for evolving sepsis, found to have LLL pneumonia and
treated with HCAP coverage given recent hospitalization. He had
a prolonged medical course following a CVA ([**Date range (2) 24375**]) and
GI bleed ([**Date range (2) 24376**]), where he was found abdominal wall
ulceration and gastro-colonic fistula in the setting of a
feeding tube. Please see prior discharge summaries. Dobhoff
tube placement has allowed for healing of the abdominal wall
area, and another G tube was placed by IR during this
hospitalization.
The patient has been noted to have significant agitation and
encephalopathy at times throughout his course but now appears to
be at his baseline per his wife. The [**Hospital 228**] hospital course
is also notable for nosocomial pneumonia, with a demand-mediated
ischemia and sepsis, and intermittent afib with rapid
ventricular response.
# Sepsis due to HCAP: Fever/rigors, afib/tachycardia and
hypotension concerning for underlying infectious process. L picc
and G-tube appeared clean and intact. Note mild systolic
dysfunction (EF 50% 2/[**2135**]). CXR showed L sided consolidation
with possibly evolving R sided opacities as well, concerning for
aspiration PNA given patient's risk factors. In ED, received 2L
NS, 10 mg IV diltiazem, vancomycin and cefepime for broad
antibiotic coverage. His blood pressure was ~80s on admission to
ICU so patient received additional 2L NS with improvement in his
BP to 100-110s. He was continued on vancomycin, cefepime and
ciprofloxacin was added. His urine legionella antigen was
negative. Blood cultures and urine cultures showed no growth.
On the floor he cont to improve without new source of infection.
His Cipro was stopped. However, his lung exam worsened on [**5-1**]
and repeat CXR suggested progression of his L sided infiltrate.
His WBC also increased to 16. Thus, Flagyl was added given
likelihood of persistent aspiration. Patient completed a 14 day
course of antibiotics during his hospital stay.
.
# Malpositioned G-tube: Patient found to have G-tube in colon
during last hospitalization, when he had a colonscopy to rule
out lower GI bleed. The site around G-tube was noted to be
friable and bleeding on contact, likely source of his GI bleed.
During last hospitalization, GI thought that the G tube was ok
to use, with care not to move it further, with plans to remove
it in [**3-19**] [**Known lastname **] after the tract was little more healed. During
this hospitalization, feculent output from G-tube was noted and
GI, ACS and IR were consulted for best way to replace his
G-tube. Unfortunately, his G-tube was no longer able to be used.
A nasogastric tube was placed on [**2135-5-6**] and was unable to be
advanced due to patient refusal but then was successfully
advanced to the jejunum and feeds were resumed as well as meds
by gut. On [**5-17**] tube study demonstrated the tube was in the
colon only without any movement of material into stomach. Per
surgery this indicated fistula had closed and stomach was safe
to be fed. They recommended cutting previous PEG, which was now
colic tube, proximal to hub and allowing it to fall in colon and
pas out through stool, this was done on [**5-22**] without incident. A
new PEG was placed on [**5-25**] and has been well-tolerated. He is
back on tube feeds to goal without abdominal pain.
.
# Periodic Breathing: Pt has OSA and was noted to have
[**Last Name (un) 6055**]-[**Doctor Last Name **]/Periodic breathing which include recent CVA and
CHF. He had recently intitiated on seroquel and had also
received haldol prior to a reported 15 s period of apnea while
he was in radiology. He was briefly transferred to the [**Hospital Unit Name 153**] for
further monitoring. He had no further apneic episodes, but he
continues to have periodic breathing, particularly when
sleeping. These improved dramatically, however, after
anti-psychotic were stopped on [**5-16**] and only happened during
sleep. O2 sats were never recorded to drop and patient was
stable on waking.
# Afib with RVR: Patient is on coumadin for his atrial
fibrillation with CHADS score of 6. Rate controlled with
metoprolol at [**Hospital3 **]. His rate was elevated to
130s-140s, likely exacerbated by underlying infection. After
fluid resuscitation, patient's HR came down to 90s with some
bursts into 110s. His metoprolol was initially held in the
setting of hypotension and restarted when his BP improved. His
INR was found to be supratherapeutic to 5 and his coumadin was
held during this hospitalization given concomitant
administration of antibiotics. On the floor, his Afib remained
uncontrolled, requiring increased metoprolol and the addition of
Diltiazem. He was transiently on a heparin gtt and IV
metoprolol when his G tube was not working and while there was
concern for an NSTEMI. Over time his HR improved and he was
transitioned to Metoprolol 25mg po q6 and warfarin once his INR
fell below 3. He does not require a bridge but will need
further monitoring until his INR is [**3-18**].
.
# Demand mediated ischemia: Patient complained of chest pain on
[**5-5**], EKG showing some dynamic changes and troponin found to be
elevated at 1.12 at that time. Patient was started on rectal
aspirin and heparin gtt given concern for NSTEMI. Family meeting
was had and family elected to not pursue cardiac cath, instead
opting for medical management. His blood pressure and HR was
optimized to decrease the cardiac demand. Cardiology was
consulted and recommended PR aspirin and atorvastin when able to
take po meds. They recommended that the heparin drip be stopped
after 24 hours of initial event. His Troponin downtrended and
he had no further chest pain. Once his Dobhoff tube was placed,
he was put on ASA 325mg, Atorvastatin 80mg, and Metoprolol as
above. ACE-I was held due to relatively low BP 90-100 systolic.
.
# Acute metabolic encephalopathy: On [**4-28**] on the medical floor
became more confused and agitated, stating he had a "gas tire"
around him. He was intermittently lucid, fitting a pattern of
delirium likely multifactorial. Geriatrics was consulted. CT
head negative for new bleeding. He was given haldol 0.5mg IV
periodically for agitation, which was quite effective. His QTc
remained stable. His Foley catheter was removed. His agitation
was a large issue during his hospitalization, especially given
the interventions needed to stabilize him, including dobhoff
placement. For this reason, he required Mitts and Restraints
once his Dobhoff was placed. He was transitioned to Seroquel
6.25mg TID with 0.5mg Haldol prn. He is sensitive to both
medications. On [**5-16**] he developed a period of apnea that was
likely related to OSA while sleeping and their were no signs of
instability. He was also more sedated and less responsive.
Therefore all anti-psychotics were stopped and he was much more
awake and alert. He remained difficult to understand due to
dysarthria and had occasional disorientation but was
reorientable. Mitts left on due to concern for G tube removal.
He did have periods of agitation but these were much more
behavioral with patient able to express extreme frustration with
them and usually related to understandable anger and frustration
with his debility, boredom, etc. Last dose of antipsychotics
was on [**2135-5-18**]. As he stabilized, all restraints were dced.
His wife reports that he now appears to be at his baseline at
the time of discharge.
.
# Acute Systolic CHF: Occurred as a result of volume
rescuscitation and NSTEMI. Repeat ECHO showed interval
worsening of his function. He was diuresed aggressively with
Lasix 40mg IV BID with good effect. This was transitioned to
PO. He was continued on ASA, BB, statin but ACEi held due to
borderline blood pressures. He eventually became clearly
hypovolemic and developed a contraction alkalosis so standing
furosemide was held without the development of volume overload.
Suspected that heart may have recovered from stunning in the
context of NSTEMI and EF improved. He is not on any diuretics
at discharge.
.
# Malnutrition, severe: Patient was placed on TPN when his G
tube became non-functional. NGT was attempted but failed due to
agitation. Subsequently, a post pyloric Dobhoff tube was placed
and Tube feeds were initiated. Due to his swallowing inability,
he is NPO for both food and medications. Speech and swallow
study was performed prior to discharge but the pt failed. He
should remain NPO for now. He can be re-evaluated in the
future.
.
#Thrush: Patient developed thrush that was noted as agitation
began to clear and likely developed due to inability to perform
mouth care during most agitated period due to aggressive
behavior and resistance to cares. He received nystatin
intiially which was difficult to tolerate so he was swtiched to
clotrimazole troches.
.
# Diarrhea: Patient experienced numerous episodes of watery
diarrhea on the floor, without abd pain. Possible causes
included C. diff, antbx, or tube feed related. Initial C. diff
was negative. Repeat C. diff with PCR was negative. As
patient's G-tube was found to be in his transverse colon, it is
possible that the diarrhea was related to tube feeds going into
colon and causing osmolar diarrhea. Diarrhea resolved on its
own.
.
# Chronic Anemia: Patient with chronic anemia, likely from GI
bleed. Admission hct of 32.5, which dropped to 27.6 after 4L NS
resuscitation. It was initially concerning for recurrent GI
bleed in setting of supratherapeutic INR, however, it remained
stable. His Hct was monitored daily and improved to the mid 30s.
.
# Transaminitis: Mild transaminitis on admission, possibly due
to congestive hepatopathy in setting of afib with RVR vs shock
physiology, though transaminitis was too low for shock liver. It
was monitored and improved with fluid resuscitation. Hepatitis A
IgM was obtained and was negative.
.
# DM2, controlled with comps: patient with type 2 diabetes, most
recent A1C 6.4% on [**2135-3-8**]. Patient on metformin and glipizide
as an outpatient, but on Lantus with insulin at rehab. His oral
diabetic medications were held during the hospitalization and he
was covered with humalog ISS.
.
# CVA prior: hx of ischemic stroke in [**2132**] and R sided MCA
infarct 1/[**2135**]. Patient is on systemic anticoagulation with
warfarin for his atrial fibrillation. No aspirin therapy. His
INR was supratherapeutic and it was monitored daily, resuming
warfarin 1mg daily once INR fell to 3. This remained stable.
He did have 2 CT Heads which were stable. He will be discharged
to rehab to continue PT.
.
# HL: His home simvastatin was initially held for mild
transaminitis but was restarted when LFTs normalized.
.
# HTN: His home lisinopril was initially held for hypotension,
but was restarted when his BP improved.
.
# Communication: Patient, Wife [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 24377**]
.
# Code: Confirmed Full (discussed with patient)
.
# Social: Palliative care was consulted during his stay.
Multiple family meetings were held to discuss his overall very
poor prognosis and potential for recovery. They understood his
extent of illness, but were hopeful for more of a recovery that
could allow him to leave rehab. We initially planned to
discharge him to acute rehab but he used up all of his acute
care days on his insurance plans so alternate plans were made
with the family to transition to a [**Hospital1 1501**] instead. The patient
continues to improve in terms of cognition, but remains weak.
His family has been updated with ongoing meetings and [**Hospital 24378**]
medical updates. They are comfortable with his current status,
and remain hopeful about the potential for recovery.
.
Medications on Admission:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation. Capsule(s)
2. insulin glulisine Subcutaneous
3. insulin regular human 100 unit/mL Solution Sig: sliding scale
Injection qachs: Sliding scale provided.
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day: hold for hr less than 55 or bp less than 100.
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Sepsis due to healthcare associated PNA
NSTEMI
Afib with RVR
Acute metabolic encephalopathy/delirium
Aspiration
Prior CVA
Dm2, controlled with complications
Malnutrition
Gastrocolic fistula, healed
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.can be OOB with assistance
Discharge Instructions:
It has been a pleasure to care for you during your admission. As
you and your family know, you were admitted with fever and
hypotension initially, attirbuted to sepsis. You were felt to
have pneumonia, and responded to antibiotics. Since then, you
were found to have a gastro-colonic fistula and your g-tube was
removed and then later replaced once the fistula had healed. You
are now back on tube feeds and are tolerating them well.
You also had atrial fibrillation with a rapid heart rate. Your
INR was initially high requiring adjustment of your warfarin.
Your heart was strained by the infections and you were treated
medically for this.
You were also confused and agitated at times, which we discussed
with you and your family. We suspect this delirium was related
to your infections and your underlying stroke.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 132**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**]
- within 2 [**Known lastname **] from discharge
Department: NEUROLOGY
When: FRIDAY [**2135-6-10**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please follow up with GI - Dr. [**Last Name (STitle) **] [**Name (STitle) **] at [**Hospital1 18**] within 2
[**Known lastname **] from discharge
|
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icd9cm
|
[
[
[]
]
] |
[
"99.15",
"43.11",
"96.6"
] |
icd9pcs
|
[
[
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] |
20784, 20869
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,280
| 168,085
|
5313+5314+5322+55663+55664
|
Discharge summary
|
report+report+report+addendum+addendum
|
Admission Date: [**2158-9-24**] Discharge Date: [**2158-12-25**]
Date of Birth: [**2114-8-15**] Sex: M
Service:
ADDENDUM
HOSPITAL COURSE: The patient remained dependent on the
ventilator, pressure support 5, PEEP of 5, FIO2 0.4.
Intermittently the patient would tolerate pressure support
22, 5 and 0.4 with episodes of what was suspected to be
anxiety and agitation. The patient was given Haldol and
placed back on AC during the episodes of rapid shallow
breathing.
The patient's central line and arterial line were
discontinued. The PICC line was placed. Reglan was
discontinued as the patient was having active bowel
movements. After the Reglan was discontinued, the patient
began to vomit having profuse NG tube output. Reglan was
restarted.
KUB demonstrated no evidence of obstruction. The patient's
vomiting episodes slowly declined. The patient's PEG tube.
The jejunal tube was found to be in the duodenum by CT of the
abdomen. The patient was scheduled for change of tube on
[**12-26**].
The patient worked with Physical Therapy and Occupational
Therapy who recommended acute rehabilitation for treatment.
The patient's mental status improve once he was discontinued
from sedatives. The patient had a passing .................
speaking valve placed. The patient was able to say a couple
of words.
The patient tracked actively following and intermittently
followed commands to lift extremities, to squeeze finger.
Lower extremities were with minimal movement. Physical
Therapy was reconsulted to evaluate the patient for
multipodis boot to avoid contractures.
On [**12-24**], the patient had a fever spike to 103.0??????.
Chest x-ray showed new left lower lobe infiltrate. The
patient also had persistent decline in hematocrit over two
days. CT of the chest and CT of the abdomen were ordered for
[**12-25**] to evaluate for hemothorax or retroperitoneal
bleed.
Chest tube was discontinued on [**12-20**]. Infectious
Disease recommended double antifungal coverage for four weeks
after [**12-20**] and single antifungal coverage for 6-10
weeks following the removal of the double coverage
antifungal. Intravenous PICC was placed on [**12-21**].
The patient was evaluated by Nutrition who recommended
Ultracal at goal of 90 U/hr. The patient tolerated tube
feeds with minimal residual.
On the patient's most recent physical exam, the patient was
generally alert and tracking. Cardiovascular was regular,
rate and rhythm. There was a holosystolic murmur at the left
lower sternal border, 3 out of 6. Lungs were with decreased
breath sounds at the right base, otherwise clear. The
patient was guaiac negative. Belly was soft and mildly
distended, and not appreciably tender. He had good bowel
sounds. Extremities with no edema. He had right PICC line.
Neurologically he moved upper extremities actively. He
followed commands intermittently. He was able to say a
couple of words with passing ............. There was minimal
to no movement in the lower extremities.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSIS:
1. Pulmonary: The patient was intubated for hypoxic
respiratory failure thought to be secondary to acute
respiratory distress syndrome for congestive heart failure
which is now improved. Recent chest x-ray showed left lower
lobe with possible pneumonia. Obtaining chest CT to evaluate
further. Will discuss with Infectious Disease
recommendations for antibiotics. Want to limit antibiotics
given the patient's fungemia, thought secondary to broad
antibiotic coverage. The patient had evidence of [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 563**] in the pleural fluids. The patient is status post
hemothorax in the left with bilateral chest tubes.
PLAN:
1. Maintain pressure support 25, 5 and 0.4. Wean from
ventilator. The patient will require prolonged weaning
secondary to long vent dependence. No thoracentesis, as
unsafe to drain due to small amount of fluid. 2. The
patient is status post redo homograft, aortic root
replacement and coronary artery bypass grafting times two
with debridement of mitral valve on [**11-1**]. Follow-up
echocardiogram revealed no aortic insufficiency, normal left
ventricular function, 4+ mitral regurgitation. Continue
Captopril 25 mg t.i.d., Aspirin once a day. Paroxysmal
atrial fibrillation now in normal sinus. Continue Amiodarone
200 mg once a day.
3. Renal: The patient has good renal function. Acute renal
failure normalized.
4. Foley catheter: Monitor urine output.
5. Infectious disease: The patient has intermittent fevers,
chronic leukocytosis, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] fungemia, fungal
................., fungal empyema. Continue ...............
500 mg IV q.d., started [**11-24**]. Continue for 10-12
weeks from [**12-20**]. AmBisome 250 IV q.24. Continue for
four weeks from [**12-20**] per Infectious Disease
recommendations. Continue Nystatin swish and swallow which is
5 cc p.o. q.i.d. Continue Ciprofloxacin eye drops, both eyes
q.4 hours for embolic chorditis. Continue Lacrilube ointment
q.4 hours to each eye.
6. Gastrointestinal: Chemical pancreatitis, resolving.
Grade IV esophagitis, likely ischemic in origin. Continue
tube feeds. Ultracal goal of 90 via PEG tube. Check
residuals. Continue Reglan 5 mg IV q.6 hours. Continue
Prevacid 3 cc p.o. q.d. Continue Peridex 15 cc p.o. t.i.d.
Continue Vitamin C.
7. The patient is with anxiety and seizure disorder.
Continue Klonopin 0.5 mg p.o. t.i.d. with p.r.n. Ativan and
Haldol. The patient has multiple repeat episodes of
tachycardia, hypertension, shaking, all possibly due to
anxiety; however, the patient had intermittent fevers and
history of hemothorax. Evaluate if hematocrit declines. MRI
on [**12-4**] showed small foci of increased T2 signal and
small subacute infarcts. Minimize sedation to improve vent
weaning. The patient has seizure history. Continue Kepra
500 b.i.d.
8. Endocrine: Sliding scale Insulin. The patient's blood
sugars have been stable.
9. Rehabilitation: Recommend physical therapy and
occupational therapy with frequent changes.
10. Lines: Right PICC from [**12-21**].
11. Prophylaxis: Heparin subcue t.i.d., Prevacid and
pneumoboots.
FO[**Last Name (STitle) **]P: With Infectious Disease Clinic at [**Hospital3 **].
Follow-up with Dr. [**Last Name (Prefixes) **] from Cardiothoracic Surgery.
Follow-up with Ophthalmology as needed. Follow-up with
Neurology for seizures.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 21669**]
MEDQUIST36
D: [**2158-12-25**] 13:59
T: [**2158-12-25**] 14:48
JOB#: [**Job Number 21670**]
Admission Date: [**2158-12-25**] Discharge Date: [**2158-12-25**]
Date of Birth: [**2114-8-15**] Sex: M
Service: MEDICAL IC
HISTORY OF PRESENT ILLNESS: This is a 44-year-old male with
history of aortic valve replacement secondary to
endocarditis, culture negative with aortic root abscess
status post AV and aortic root replacement with homograft and
reconstruction of coronary arteries in [**2157-12-30**]
complicated by a LV abscess who presented to the emergency
room on [**2158-9-24**] with complaint of fever, night
sweats and cough for one month. In addition, patient noted
increased shortness of [**Year (4 digits) 1440**] for two weeks and positional
left chest discomfort for one week. He reported recent
travel to [**Country 3594**].
In the emergency room, the patient was febrile to 101.5 F and
hemodynamically stable. Admitted to rule out endocarditis.
Admission chest x-ray showed an increased cardiomegaly and
EKG with new left axis deviation. Blood cultures times three
and ASB smear times three were negative. Chest CT Scan
showed multiple ill defined nodules throughout both lungs,
small left pleural effusion and 1.6 times 2.2 cm low
attenuation lesion in the right hepatic lobe and evidence of
prior infarcts in the left and right kidney.
PHYSICAL EXAMINATION: The patient's initial vitals on
physical examination were a temperature of 101.5 F, heart
rate 96, blood pressure 120/40, respiratory rate 18, O2
saturation 98% on room air. General: Pleasant male in mild
distress. Head, eyes, ears, nose and throat: Pupils equal
and reactive to light. Extraocular movements intact.
Anicteric sclerae. Moist mucous membranes. Neck is supple,
no lymphadenopathy. Carotids 2+ bilaterally. Lungs:
Crackles at the left base, otherwise clear. Cardiovascular:
Regular rate and rhythm, normal S1, S2, IV/VI diastolic
murmur at the left upper sternal border, II/VI systolic
murmur at the apex plus friction rub. Abdomen: Soft,
nondistended, mild left upper quadrant tenderness,
normoactive bowel sounds. Extremities: No edema, no
petechiae. Neuro: Cranial nerves II through XII intact.
Alert and oriented times three, nonfocal.
INITIAL LABORATORIES: CBC 12.6, 31.4, 309, 66 neutrophils, 3
bands, 15 lymphs. Chem-7: 137, 4.5, 100, 28, 28, 1.9, 99.
Baseline creatinine 1.4 to 1.6.
Chest x-ray as noted above.
HOSPITAL COURSE: Patient was referred for bronchoscopy to
evaluate right lower lobe lesion versus septic emboli.
Bronchoscopy on [**9-28**] revealed no intrabronchial
lesions. Bronchoalveolar lavage obtained from posterior
right upper lobe. Following bronch, patient had an episode
of respiratory distress with decreased oxygen saturation to
70% and was intubated for a anoxic respiratory arrest and
transferred to the MICU. Etiology of the respiratory failure
was thought to be secondary to worsening AI and pulmonary
edema. TEE on [**9-27**] revealed 4+ AR, 2+ MR, dilated LV
cavity, PA systolic hypertension and large anterior and
posterior echo-free space possibly representing a
paravalvular abscess.
The patient underwent extensive work up for endocarditis.
Negative cultures included blood, AFB, Bartonella brucella,
.............. fever, monospot, CMV, cryptococcus. Patient
was maintained on Vancomycin, Levofloxacin and Flagyl to
cover for possible bacterial endocarditis. PE complicated by
new onset atrial fibrillation which spontaneously converted
to normal sinus rhythm. MICU course complicated by
intermittent hypertension requiring Nitroglycerin. Also
complicated by pancreatitis requiring placement of post
pyloric GJ tube. Pancreatitis thought to be drug related and
acute renal failure thought to be ATN secondary to prerenal
azotemia due to AI. The patient continued to febrile and had
greater than 36 negative blood cultures.
From a respiratory standpoint, the patient remained
persistently hypoxic with increased fio2 requirement thought
secondary to ARDS versus congestive heart failure. On [**10-27**],
the patient was started on Dopamine for increased renal
profusion, but subsequently urine output decreased and
patient underwent hemodialysis for volume overload secondary
to failed diuresis.
On [**11-1**], patient went to the OR for redo of homograft root
replacement coronary artery bypass graft times two, SVG to
the distal RCA and SVG to the LAD and a debridement of the
mitral valve. Patient required intraoperative CVVH for
massive fluid overload. Surgeon unable to close chest
secondary to massive edema. Patient transferred to PACU on
................. Epinephrine and Neo-Synephrine. Levophed
with SBP 93 to 100. Patient received activated protein C
postoperatively and was continued on Vancomycin,
Levofloxacin, Flagyl, Ceftaz and Doxycycline. Patient
received multiple blood products for bleeding and
coagulopathy and received CVVH for total volume overload.
In the CSRU, the patient was slowly weaned off pressors and
renal function recovered. on [**2158-11-7**], the patient's chest
wall was closed. The patient remains persistently febrile
with a leukocytosis and WBC up to [**Numeric Identifier **]. Blood cultures and
Clostridium difficile were negative. The patient developed
funguria and was treated with amphobladder washings for five
days. CT Scan of the abdomen was performed which showed some
bowel wall thickening. Right upper quadrant ultrasound
showed gallbladder sludge, but no evidence of cholecystitis
given profound leukocytosis and evidence of bowel wall
thickening seen on CT Scan. Patient treated with a 14 day
course of Flagyl for presumed Clostridium difficile, although
Clostridium difficile negative times three.
The patient recovered renal function with increased urine
output and CVVH was discontinued on [**2158-11-14**]. Neuro was
consulted for an observed fascial twitching with a question
of seizure activity. The patient was started on Tegretol
which was subsequently discontinued secondary to increased
LFTs. On [**11-14**] t bilirubin 7.4. Neuro recommended
discontinuation of Haldol as it decreases seizure threshold
and using benzodiazepines p.r.n. for sedation.
On [**11-15**], the patient underwent a percutaneous tracheostomy
and bronchoscopy with placement of a percutaneous endoscopic
gastrostomy tube. Bronch revealed heavy secretions and
clotted blood consistent with tracheobronchitis. On [**11-18**],
Doxycycline was discontinued on day #16 as Bartonella PCR was
negative. Anaerobic blood cultures on [**11-14**] showed [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 563**] and patient was started on AmBisome. In addition,
the patient developed oral lesions found to be HSV1 and was
treated with a 14 day course of Acyclovir.
On [**11-18**], Ophthalmology was consulted and found bilateral
retinal hemorrhages and findings consistent with infective
endocarditis with dissemination. The found to be oozing
blood from trach and mouth which was treated with CDAVP. GI
was consulted for evaluation of blood from trach and
coffee-grounds in PEG site. EGD showed a grade IV
esophagitis, likely ischemic, with oozing in posterior
pharynx. CT Scan of the chest was obtained which revealed
that esophagitis was not full thickness, no stranding or
evidence of pneumomediastinum. Large left pleural effusion
was seen. A left chest tube was placed on [**11-19**] which was
complicated by bleeding. On [**2158-11-29**], pleural fluid grew
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]. Blood cultures from [**11-14**] to [**11-17**] also
grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]. Repeat echo showed resolution of AR,
ejection fraction greater than 55%, 4+ MR which was increased
from 2+ previous echo, but no evidence of endocarditis.
On [**11-23**], the patient was started on Caspofungin in addition
to AmBisome. Ceftaz was discontinued on day #14. Neurology
was reconsulted for persistent fascial twitching and EEG
showed no seizure activity. The patient was started on
Methadone to wean from narcotics. On [**11-10**], the patient had
a head which revealed right mastoid air cell opacification.
ENT was consulted which did not think there was significant
sinusitis. On [**2158-11-29**], the patient underwent an ultrasound
guided pleural tap. On [**2158-12-4**], patient had a MR of the
head to rule out a new lesion which showed several small tiny
foci, scattered diffusion abnormality involving the [**Doctor Last Name 352**]
white junction of the cerebral hemispheres most likely
consistent with small embolic subacute infarcts. No major
cortical infarct was demonstrated. Also showed pan sinus
disease, fluid retention within both mastoid sinuses.
On [**12-8**], the patient was subsequently transferred for
further management to the Medical ICU Team from the Cardiac
Surgery Team. Vancomycin and Zosyn were discontinued on
[**12-8**] at the recommendation of ID. Antibiotics
discontinued as cultures have been negative. On [**9-9**], the patient became hypotensive with increased heart
rate and unclear [**Name2 (NI) 1440**] sounds. Chest x-ray showed white out
of the left hemithorax. Chest tube draining sanguinous
fluid. Hematocrit noted to fall from 30 to 15. Patient's
chest tube was placed which drained 600 cc of blood. Patient
received five units of blood over a two hour period.
Hematocrit increased from 15 to 24. Patient was taken
urgently to the Operating Room for a thoracotomy and
exploration of traumatic bleeding.
Thoracotomy was performed. Within the left hemithorax
approximately two liters of blood clot was found. An area of
discreet heavy bleeding was seen after clot removed. Surgicel
with Thrombin treated the bleeding with good control. The
patient received two units and additional chest tubes were
placed within the left hemithorax and patient was returned to
the unit hemodynamically stable. Repeat CT Scan of chest to
evaluate effusions showed interval increase in opacification
within the left upper lobe which may represent an aspiration
or infection. Bilateral pleural effusions showed some
loculation within the right upper lobe, but slight interval
decrease in the left sided pleural effusion. Patient's chest
tubes remained in place draining fluid for a few days.
Pleural cultures were sent for gram stain, anaerobic culture,
fungal stain and culture which were negative.
The patient had repeated intermittent temperature elevations.
Infectious Disease recommended loculated fluid in the right
hemithorax. The patient had a CT Scan of the chest to
evaluate and possibly do a diagnostic tap at CT Scan. Repeat
CT Scan of the chest on [**12-20**] showed an interval
decrease in the size of the small bilateral pleural effusions
with a small amount of loculated fluid at the bases which was
too small to tap. Area of consolidation seen in the
posterior bilateral lower lobe concerning for aspiration or
pneumonia.
Patient had evidence of pancreatitis based on elevated
lipase, alkaline phosphatase and amylase. Patient had a
right upper quadrant ultrasound which showed no signs of
cholecystitis. Patient had stones within the gallbladder,
otherwise normal right upper quadrant ultrasound. LFTs
resolved. Patient's belly remained nontender, thought to be
secondary to chemical pancreatitis.
Ophthalmology reevaluated the patient and noted stable exam
and embolic lesions for past several months. Follow up is
needed. Patient was weaned off Methadone, Haldol and
Klonopin. Patient, however had repeat episodes of
diaphoresis, tachycardia, hypertension, tachypnea which
seemed responsive to Klonopin, Ativan and intermittently
Haldol. Patient was replaced on around the clock dose of
Klonopin 0.5 t.i.d. with Ativan and Haldol p.r.n.
Patient had repeat echo on [**12-11**] which showed normal
ejection fraction, no vegetation, MR 4+, TR 2+. Patient was
started on Captopril 25 t.i.d. for the MR.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 21669**]
MEDQUIST36
D: [**2158-12-25**] 13:39
T: [**2158-12-25**] 14:42
JOB#: [**Job Number 21671**]
Admission Date: [**2158-9-24**] Discharge Date: [**2159-1-24**]
Date of Birth: [**2114-8-15**] Sex: M
Service:
ADDENDUM: Please see OMR note dated [**2158-12-24**] for review of
AmBisome and Casofungin therapy for Candidemia as well as
plans for follow-up cultures. Additionally, please review
for encapsulated notes of ophthalmologic examination on
[**2158-12-26**] and [**2159-1-11**] as well as plans for follow-up
examinations.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 21698**]
MEDQUIST36
D: [**2159-1-24**] 03:15
T: [**2159-1-24**] 15:28
JOB#: [**Job Number 21699**]
1
1
1
R
Name: [**Known lastname 447**], [**Known firstname **] Unit No: [**Numeric Identifier 3614**]
Admission Date: [**2158-9-24**] Discharge Date: [**2159-1-1**]
Date of Birth: [**2114-8-15**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient continued to have
intermittent temperature spikes. Cultures have all been
negative. Caspofungin was discontinued. Infectious Disease
thinks Ambazone would be adequate coverage for another three
weeks for [**12-30**] to discontinue approximately [**1-19**]. Clostridium difficile toxin B was sent out, results
still pending. The patient was re-evaluated by Ophthalmology
on the [**12-26**], stable examination with many changes and
ophthalmic solutions. The patient had computerized
tomography scan of his abdomen and chest which were
unremarkable. Computerized tomography scan of the chest
showed bilateral small effusions not safe to tap, and
computerized tomography scan of the abdomen was negative.
The patient had his gastrojejunostomy tube changed on [**12-26**]. The patient had intermittent episodes of vomiting but
persistent stooling. Tube feeds were held intermittently and
Zofran and Reglan were given. The patient had a bronchoscopy
on [**12-27**] which showed moderate malacia at cuff site.
Cuff was changed on [**12-27**]. Caspofungin was discontinued
on [**12-27**]. Infectious Disease recommended magnetic
resonance imaging scan of head with Gadolinium and
electroencephalogram to workup fevers and mental status. On
[**12-28**] the patient had a possible aspiration episode.
The patient's vomitus showed similar suction material. Chest
x-ray was ordered and did not show new infiltrate. The
patient remained stable on the ventilator. The patient
continued to have repeated hypodynamic episodes with
tachypnea and tachycardia, diaphoresis and small lung
volumes. The patient responded to Haldol and Ativan,
intermittent with fluid boluses. Hematology was consulted
for a repeat low hematocrit. The patient got 1 unit of
packed red blood cells for a hematocrit of 21 with
transfusion goals less than 21. Hematology workup was
consistent with anemia of chronic disease. The patient's
reticulocyte count was corrected, less than 1, indicating not
consistent with an acute bleed. Fibrinogen and D-dimer to
rule out lowgrade DIC were negative. Recommended blood
product support as necessary, treating underlying infection
and Epogen 40,000 q. week. On [**12-30**], Gallium was
injected for a bone scan to be performed on [**1-1**] to
evaluate for osteomyelitis. The patient had increased
secretions, given D5/W for hyponatremia, tube feeds were
intermittently held. The patient had a repeat hypodynamic
episode, again responsive to the Haldol and Ativan and had a
spiked temperature on [**12-30**] and cultures were sent. All
cultures to date except for the ones noted above have been
negative. On the patient's most recent examination as far as
his mental status, he will intermittently follow commands to
squeeze hand. He moves upper extremities with slight
movement in the lower extremities on rare occasions. He will
track actively and is able to speak intermittently using the
Passe Muir valve a couple of words.
DISCHARGE MEDICATIONS: As far as discharge medications on
[**12-30**], which are to be asserted by the oncoming intern
for the service:
1. Ambazone 250 mg intravenously q. 24 to be continued until
[**1-20**]
2. Amiodarone 200 mg p.o. q. day/gastrostomy tube
3. Epogen 10,000 units subcutaneously q. week, consider
changing to 40,000
4. Senna one tablet p.o. q.h.s./gastrostomy tube
5. Citalopram 20 mg p.o. q. day/gastrostomy tube
6. Clonazepam 0.5 mg p.o. t.i.d./gastrostomy tube
7. Bacitracin/gastrostomy tube
8. Polymyxin B sulfate ophthalmic ointment one application
both eyes q. 6
9. Heparin 5000 units subcutaneously q. 8
10. Artificial tears one to two drops, both eyes, q.h.s.
11. Colace 100 mg p.o. b.i.d./gastrostomy tube
12. Vitamin C 500 mg p.o. b.i.d./gastrostomy tube
13. Captopril 25 mg p.o. t.i.d./gastrostomy tube
14. Keppra 500 mg p.o. b.i.d./gastrostomy tube
15. Peridex 15 mg p.o. t.i.d. oral solution
16. Nystatin oral suspension 5 ml p.o. q.i.d.
17. Reglan 10 mg intravenously q. 24
18. Lansoprazole 30 mg p.o., 30 mg nasogastric q.d.
19. Lacrilube ointment one application, both eyes, q.i.d.
20. Zinc sulfate 220 mg p.o. q.d./gastrostomy tube
21. Aspirin 81 mg p.o. q.d./gastrostomy tube
22. Free water boluses 125 cc q. 2 hours when tolerating
p.o.
23. Tylenol 650 mg p.o. q. [**3-4**] prn fever or pain/gastrostomy
tube
24. Ativan 0.5 to 2 mg p.o. q. [**3-4**] prn anxiety/gastrostomy
tube
25. Zofran 40 mg intravenously q. 6 prn nausea and vomiting
26. Haldol 1 mg p.o. t.i.d. prn anxiety, hypodynamic
episodes/gastrostomy tube.
DISCHARGE CONDITION: Stable.
DISCHARGE DISPOSITION: To rehabilitation.
FOLLOW UP:
1. Follow up with Ophthalmology prn
2. Follow up with Dr. [**Last Name (STitle) **], Cardiac Surgery
3. Follow up with Dr. [**Last Name (STitle) 3615**] regarding tracheostomy and
percutaneous endoscopic gastrostomy
[**First Name8 (NamePattern2) 77**] [**Name8 (MD) **], M.D. [**MD Number(1) 3616**]
Dictated By:[**Last Name (NamePattern1) 3617**]
MEDQUIST36
D: [**2158-12-30**] 16:12
T: [**2158-12-30**] 20:19
JOB#: [**Job Number **]
Name: [**Known lastname 447**], [**Known firstname **] Unit No: [**Numeric Identifier 3614**]
Admission Date: [**2158-9-24**] Discharge Date: [**2159-1-23**]
Date of Birth: [**2114-8-15**] Sex: M
Service:
1. Pulmonary - The patient has tolerated pressure support and
weaned from assist control as he is intermittently requiring
high levels of positive end-expiratory pressure up to 15 when
he is tachypneic and has low lung volumes. Over night of
positive end-expiratory pressure was 15 and pressure support
of 5 allowing for distal long segment recruitment and [**Known firstname **]
is able to expirate large volumes of intussusceptated sputum
and positive end-expiratory pressure over 15 causes a large
air leak around his foam cuff. His current vent settings are
CPAP with pressure support of [**7-8**]. He is on Ceptaz day 9 of
14 for vent-associated pneumonia/tracheobronchitis. [**Known firstname **]
will often become agitated and then will require small doses
of Ativan and Morphine for intermittent agitation. He
becomes diaphoretic, tachypneic and tachycardiac with these
agitation episodes. He typically has one to four episodes a
day requiring small doses of sedation.
2. Infectious disease - He has chronic intermittent lowgrade
fevers with occasional spikes above 101. He has had an
exhaustive workup including multiple chest, abdominal
computerized tomography scans and gallium scan, abdominal
ultrasound, blood cultures, urine cultures and sputum
cultures, a left axillary mass culture, status post left
axillary mass biopsy all of which have been negative to date.
[**Known firstname **] has had one culture a day for which was
positive in [**Month (only) 768**]. He had sputum cultures which were
positive for Pseudomonas and he was started on Ceptaz. He is
on day #9 of 14. [**Known firstname **] has also been on antifungal agents
in [**2158-11-18**]. He had one month of double coverage
for disseminated candidiasis and he is on Ambazone
monotherapy for 21 days. He is expected to complete his
Ampicillin therapy on [**2159-1-29**]. He will need
surveillance cultures drawn on [**2159-2-1**] for fungal
cultures. All computerized tomography scans and ultrasounds
have shown no acute changes since prior dictation. Drug
fever is most likely the cause of recurrent intermittent
fever. We will wean off of antibiotics and antifungals per
date of completion of current regimens.
3. Cardiovascular - No change. The patient is currently on
Captopril, Aspirin, Amiodarone and Lopressor. Repeat
echocardiogram showed mitral regurgitation and aortic
regurgitation without evidence of recurrent endocarditis.
4. Neurological - He had ICU neuropathy with minimal upper
extremity voluntary movement. It is getting progressively
better, however, he displays no voluntary lower extremity
movement as yet. Mental status is improving with decreased
sedation. He had repeat magnetic resonance imaging scan
which showed no change from previous magnetic resonance
imaging scan which indicated several small areas consistent
with old embolic infarcts, no evidence of mass lesion or loss
of graveway interface. Neurology performed
electroencephalogram which showed no current seizure
activity. He has remained seizure-free on Keppra
5. Fluids, electrolytes and nutrition - He has chronic
intermittent chemical pancreatitis. He had a percutaneous
endoscopic gastrostomy tube placed. He was tolerating his
tube feeds at goal and he has intermittent vomiting not
associated with feeding. He was evaluated by
Gastroenterology who performed esophagogastroduodenoscopy
which was relatively unremarkable. The Zofran was stopped
and his Reglan dose was decreased. [**Known firstname **] has tolerated
restarting of his tube feeds. He will have vomiting
intermittently. Working diagnosis per Gastroenterology is
drug-reaction, likely Amiodarone or Ambazone versus central
nervous system cause. He had less episodes with more
concentrated tube feed formula, intermittent chemical
pancreatitis with normal appearing pancreas on computerized
tomography scan and ultrasound. He tolerated feeding tube
pancreatitis and requires intermittent magnesium and
potassium replacement. The patient has chronic metabolic
acidosis with respiratory compensation, most likely due to
either a drug affect and renal tubular acidosis and/or
chronic drainage from his percutaneous endoscopic gastrostomy
tube. He was also noted to be hypercalcemic likely due to
immobilization. He had a normal TSH and his parathyroid
hormone was pending at discharge.
Access, he has a right a PICC placed [**2159-1-23**].
FOLLOW UP: He is to follow up with Dr. [**Last Name (STitle) **] in
[**Hospital 3618**] Clinic in three to four weeks. He is also to
follow up with Ophthalmology as needed.
DISCHARGE DIAGNOSIS:
1. Respiratory failure status post tracheostomy
2. Disseminated fungemia
3. An associated pneumonia
4. Endocarditis, status post aortic valve and route redo
status post coronary artery bypass graft times two
5. Percutaneous endoscopic gastrostomy placement
6. Chemical pancreatitis
7. Status post pneumothorax
8. Multiple pneumonias
9. Fever of unknown origin
10. ICU Neuropathy
11. Seizure disorder
12. Diabetes
13. Multiple embolic infarcts, brain and retinal as well as
renal
14. Hypertension
15. Bilateral pleural effusion
16. Hypercalcemia
17. Chronic vomiting
18. Hiccups
MEDICATIONS ON DISCHARGE:
1. Lorazepam .5 to 2 mg p.o. intravenously q. 4 to 6
2. Neutra-Phos one packet p.o. q.i.d.
3. Haloperidol 1 to 2 mg intravenously t.i.d.
4. Docusate Sodium 100 mg p.o. b.i.d.
5. Morphine Sulfate 2 to 4 mg intravenously q. 6
6. Captopril 6.25 mg p.o. t.i.d.
7. Metoprolol 25 mg p.o. b.i.d.
8. Heparin 5000 units subcutaneous q. 12
9. Calcitonin salmon 200 intranasal units q.d.
10. Ceftazidime 2 mg intravenously q. 8
11. Chlorpromazine 12.5 mg q. 4
12. 30 mg b.i.d.
13. Metoclopramide 10 mg q. 6
14. Tylenol
15. Aspirin
16. Bacitracin
17. Polymyxin B sulfate
19. Ophthalmologic ointment
20. Bisacodyl 10 mg p.o. q.d.
21. Albuterol
22. Ipratropium 1 to 2 puffs q. [**3-4**]
23. Senna 1 tablet q.h.s.
24. Amiodarone 200 mg p.o. patch q.d.
25. Ambazone 250 mg intravenously q. 24
26. Zinc Sulfate 220 mg p.o.
27. Nystatin oral suspension 5 ml p.o.
28. Keppra 500 mg b.i.d.
DISCHARGE CONDITION: Stable.
DISCHARGE DISPOSITION: Longterm vent rehabilitation
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Last Name (NamePattern1) 3619**]
MEDQUIST36
D: [**2159-1-25**] 19:36
T: [**2159-1-25**] 19:39
JOB#: [**Job Number 3620**]
|
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19,311
| 163,000
|
30544
|
Discharge summary
|
report
|
Admission Date: [**2120-2-14**] Discharge Date: [**2120-2-25**]
Date of Birth: [**2043-6-19**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Found Down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 male physician with colon cancer s/p surgery 4 wks ago at OSH
([**Hospital1 112**] system) who took "agonal breath" in bed per wife who called
911. Initial AED was "don't shock" then "shock" so was shocked
x2 for apparent VF. Then noted PEA, was intubated, underwent
CPR, then spontaneous circulation to sinus. Patient was started
on lidocane gtt. EKG with LBBB which per wife is old. Cardiac
hx unknown but he follows with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/[**Hospital 882**] hospital
cardiology. Patient was transferred from [**Hospital1 **] [**Location (un) 620**] ED to [**Hospital1 18**]
ED where he had head CT and CTA chest which were negative for
bleed and negative for PE or Aortic dissection. On arrival to
CCU patient intubated, unresponsive.
Past Medical History:
colon ca s/p surgery 4 weeks ago.
DVT for which he is on warfarin
IVC filter, removed (PE [**2119**])
H/O GIB
AFib
LBBB
Had stress thallium pre-surgery which showed partial revesible
septal defect
Social History:
married, physician works at [**Name9 (PRE) **] at [**Hospital 1411**] Medical
3 children
no tobacco
Family History:
positive for CAD; Father with MI
Physical Exam:
T: 98.0 HR 62 BP 168/83 O2Sat 100% AC Tv 600 RR 16 FiO2 60% PEEP
5
Gen: Patient not responive to physical or verbal stimuli
Heent: PERRLA, intubated
Chest: Good breath sounds throughout
Cardiac: RRR S1/S2 no murmurs
Abd: soft NT, decreased BS, surgical scar on abdomen intact
Ext: no edema; good DP and PT pulses +2
Neuro: unresponsive to verbal/noxious stimuli, PERRL, neg Doll's
eyes, intact DTRs
Pertinent Results:
[**2120-2-14**] 08:30AM WBC-13.4* RBC-4.11* HGB-13.0* HCT-37.9*
MCV-92 MCH-31.6 MCHC-34.3 RDW-13.8
[**2120-2-14**] 08:30AM NEUTS-80.7* LYMPHS-13.0* MONOS-4.0 EOS-2.0
BASOS-0.3
[**2120-2-14**] 08:30AM GLUCOSE-169* UREA N-16 CREAT-1.3* SODIUM-138
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
[**2120-2-14**] 08:30AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
.
EEG ([**2120-2-14**]):
This is an abnormal EEG due to the frequent electrographic
seizures. The seizures began in a generalized fashion and
evolved over
thirty seconds to become higher amplitude and slower with an
abrupt
cessation. Per the technician's notes, the seizures were
associated
with upward eye deviation. Between seizures, a suppressed and
disorganized background was seen, with occasional bursts of
generalized
slow transients. These findings suggest a severe encephalopathy,
which
may be seen with ischemia, medication effect, toxic metabolic
abnormalities or infections.
.
EEG ([**2120-2-16**]):
This 24-hour video EEG telemetry captured no clinical or
electrographic seizures. Background rhythms were decreased in
the delta
frequency range predominantly. In addition, there were some
generalized
bursts of delta slowing followed by low voltage suppressive
periods, as
well. No evidence for electrographic seizures was seen in this
day's
recording.
.
EEG ([**2120-2-21**]):
This is an abnormal EEG due to the suppressed background
rhythm, bursts of generalized slowing and generalized frequent
sharp and
slow wave discharges. This burst suppression pattern suggests a
severe
encephalopathy, which may be due to medication effect or
ischemic/hypoxic injury. No electrographic seizures were noted.
.
MRI ([**2120-2-17**]):
No evidence of acute infarct or enhancing lesions are
identified. Small area of increased signal in the medial right
occipital lobe could be due
to chronic infarct or due to an incidental slow flow in a small
venous structure along the surface of the brain. Mild changes
of small vessel
disease.
.
Head CT ([**2120-2-14**]):
No intracranial hemorrhage or mass effect.
.
CT angio chest ([**2120-2-14**]):
No evidence of pulmonary embolism or acute aortic syndrome.
Pulmonary venous congestion, as well as trace ascites about the
liver and small pleural effusions. Borderline aneurysmal
dilatation of the aortic root, and ectatic origin of the
innominate artery. Subcentimeter hypodense focus in the liver,
too small to characterize. Acute right-sided rib fractures.
Suspicious spiculated nodule in the right upper lobe, raising
strong concern for a primary lung cancer.
Brief Hospital Course:
Upon admission, the patient's cardiac enzymes were cycled and
were found to be mildly elevated. This, in conjunction with no
obvious signs of ischemia on his ECG, suggested that the
patient's primary event was somewhat unlikely be an ischemic
event. He was maintained on telemetry and had no evidence of
arrhythmias.
.
Due to his persistent unresponsiveness and the patient's history
of requiring defibrillation and possibly having stopped
breathing, the neurology team was consulted to assess for anoxic
brain injury. Due to concern for seizures (as suggested by his
down-beating nsytagmus), neurology recommended an EEG which was
performed on hospital day #1 and found him to be in status
epilepticus. He was loaded with IV phenytoin and kept on a
maintenance dosing with therapeutic levels. A subsequent
24-hour EEG over the next 2 days showed that he was no longer in
status epilepticus, though he remained completely unresponsive.
An MRI was performed and showed no obvious infarcts though, per
neurology, this did not at all rule out anoxic brain injury.
Another EEG was performed and showed a burst suppression pattern
which, per neurology, was suggesstive of a severe encephalopathy
and could be consistent with anoxic brain injury. He was
monitored for several more days (due to the concern that he may
have been in a prolonged post-ictal state) with still no change
in his neurologic status. A family meeting with the neurology
team was held on [**2-23**] during which the neurology team explained
the extremely low likelihood of the patient having any
meaningful neurologic recovery. The family and primary team
then met with Dr. [**Last Name (STitle) **] from the palliative care service on [**2-24**]
during which the family decided to pursue comfort measures only
(using the patient's living will as guidance). On [**2-25**], per the
family's wishes and the patient's living will, the patient was
extubated while receiving medications for comfort. He expired
shortly thereafter.
Medications on Admission:
warfarin
Atenolol 25mg
Tramadol
Darvocet
Lidoderm patch
neurotin 300mg
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
anoxic brain injury due to presumed v-fib arrest
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"427.41",
"348.1",
"V10.05",
"427.5",
"426.3",
"345.3",
"V58.61",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6707, 6716
|
4554, 6558
|
278, 284
|
6808, 6817
|
1929, 4531
|
6869, 6875
|
1461, 1495
|
6679, 6684
|
6737, 6787
|
6584, 6656
|
6841, 6846
|
1510, 1910
|
228, 240
|
312, 1107
|
1129, 1328
|
1344, 1445
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,226
| 159,832
|
42345
|
Discharge summary
|
report
|
Admission Date: [**2130-11-30**] Discharge Date: [**2130-12-3**]
Service: NEUROLOGY
Allergies:
Codeine / Penicillins / Levoxyl / Flagyl / Celebrex / Bactrim /
Lescol
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Left weakness and homonymous hemianopia
Major Surgical or Invasive Procedure:
IV tPA [**2130-11-30**]
History of Present Illness:
89 year old right handed man with PMHx of
Afib on Coumadin, recent INR 1.2, CAD s/p [**Hospital 8466**] transferred from
an OSH s/p tPA at 1500. Patient was walking down the stairs
earlier today when he felt lightheaded. He slowly fell on the
stairs, didn't hit head, no LOC. The daughter noticed left
facial
droop and left sided weakness. The patient was taken to the OSH,
where he was found to be in aflutter, at CT was done that was
unremarkable, at 1400 his left arm drift had resolved, however
when re examined 10 minutes later it reportedly returned and he
had developed a complete left hemianopsia. Discussion was had
with a Dr. [**First Name (STitle) **], (neurocall) who examined the patient in the
teleneurology at the OSH and recommended giving tpa. He was
given the 6 mg tPA bolus at 1500 and a 53 mg infusion at 15:02.
He was then transferred to [**Hospital1 18**] further monitoring and
treatment. Upon presentation, a code stroke was called and he
was given a score of 3, for left hemianopsia and neglect.
Otherwise he was in high spirits and had not complaints.
.
On neuro ROS, the pt denies headache, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough but has had some shortness of breath. Had some mild chest
pain on Wed, but currently denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. Has chronic leg cramps and arthritis
Past Medical History:
CAD, Afib, HTN, Asthma, hypothyroidism, CABG, MI at age 72,
bursitis, arthritis, allergies, hernias, and apendectomy
Social History:
lives with daughter, smoking for 60 years, no etoh, or
illict drugs
Family History:
father with heart disease and a stroke
Physical Exam:
Admission Physical Exam:
Vitals: T:97.3 P:70 R: 18 BP:145/57 SaO2:100% on 2L
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: no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
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 [**4-6**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia.
calculation intact.
.
-Cranial Nerves:
I: Olfaction not tested.
II: left surgical pupil 4 mm to 3 mm, and right 3 mm to 2 mm
Left field cut
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,
proprioception throughout. No extinction to DSS. decreased
vibration sense up to ankles bilaterally. +stereoagnosia
bilaterally? incosistent responses
.
-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.
Pertinent Results:
Laboratory studies:
Admission labs:
[**2130-11-30**] 04:35PM BLOOD WBC-8.2 RBC-4.36* Hgb-14.2 Hct-41.1
MCV-94 MCH-32.5* MCHC-34.5 RDW-12.4 Plt Ct-198
[**2130-11-30**] 04:35PM BLOOD Neuts-76.5* Lymphs-14.5* Monos-6.1
Eos-2.7 Baso-0.2
[**2130-11-30**] 04:35PM BLOOD PT-14.6* PTT-27.2 INR(PT)-1.3*
[**2130-11-30**] 04:35PM BLOOD UreaN-22*
[**2130-11-30**] 04:52PM BLOOD Creat-1.3*
[**2130-11-30**] 04:35PM BLOOD ALT-18 AST-22 CK(CPK)-57 AlkPhos-64
TotBili-0.7
[**2130-11-30**] 04:35PM BLOOD Lipase-23
.
Other pertinent labs:
[**2130-11-30**] 04:35PM BLOOD Lipase-23
[**2130-12-1**] 02:50AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.1 Mg-2.0
Cholest-PND
[**2130-12-1**] 02:50AM BLOOD %HbA1c-5.9 eAG-123
[**2130-12-1**] 02:50AM BLOOD Triglyc-PND HDL-PND
[**2130-11-30**] 04:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-11-30**] 04:59PM BLOOD Glucose-79 Na-136 K-4.7 Cl-94* calHCO3-28
.
CE trend:
[**2130-11-30**] 04:35PM BLOOD CK-MB-2 cTropnT-<0.01
[**2130-11-30**] 04:35PM BLOOD cTropnT-0.02*
[**2130-12-1**] 02:50AM BLOOD CK-MB-2 cTropnT-0.03*
.
.
Urine:
[**2130-11-30**] 03:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2130-11-30**] 03:15PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2130-11-30**] 03:15PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2130-11-30**] 03:15PM URINE Mucous-RARE
[**2130-12-1**] 12:52AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
[**2130-12-1**] 12:52AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2130-12-1**] 12:52AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2130-12-1**] 12:52AM URINE CastGr-4* CastHy-4*
[**2130-12-1**] 12:52AM URINE Mucous-RARE
.
.
Radiology:
MR [**First Name (Titles) **] [**Last Name (Titles) **] BRAIN W/O CONTRAST; [**Last Name (Titles) **] NECK W&W/O CONTRAST [**2130-11-30**]
9:28 PM
Findings:
MRI brain:
There is an area of slow diffusion involving almost the entire
right occipital
lobe with no evidence of increased T2-/FLAIR-signal. No foci of
susceptibility
artifact to represent hemorrhage. There is no abnormal
enhancement.
There is bilateral periventricular increased T2 FLAIR
hyperintensities likely
from chronic ischemic changes. The ventricles, cisterns and
sulci are
age-appropriate. The major intracranial flow voids including
those of the
major dural venous sinuses are preserved.
No shift of the midline structures or central herniation is
identified
The orbits and globes are unremarkable. There is mild fluid in
the ethmoid air
cells, mucosal thickening of the right sphenoid sinus and fluid
in the
bilateral mastoid air cells. The visualized bones and soft
tissues are within
normal limits.
[**Month/Day/Year **] Brain:
There is an abrupt cut-off of the distal right P2 segment of the
PCA,
representing an occlusion. There is irregularity of the flow
signal intensity
of the bilateral carotid siphons but no significant stenosis.
There is focal
stenosis of the right M1 segment. The anterior cerebral arteries
are
unremarkable.
No other significant stenosis, aneurysm or vascular malformation
is
identified.
[**Month/Day/Year **] Neck:
The aortic arch, brachiocephalic and common carotid arteries are
of normal
course and caliber. There is mild bifurcation disease but no
significant
stenosis. The bilateral internal carotid arteries are of normal
course and
caliber. There is high-grade stenosis of the right vertebral
artery. There is
mild stenosis of the left vertebral artery. The is a
long-segmental stenosis
of the distal V4 segment of the left vertebral artery.
The major venous structures enhance normally.
IMPRESSION:
1. Acute right PCA territorial infarct with occlusion of the P2
segement of
the right PCA.
2. Diffuse atherosclerotic disease, as described above, with
focal stenosis of
the M1 segment of the right MCA, long-segment stenosis of the V4
segment of
the left vertebral artery and high-grade stenosis at the origin
of the right
verterbal artery.
.
CHEST (PORTABLE AP) Study Date of [**2130-12-1**] 2:30 PM
FINDINGS: No previous images. There are opaque cerclage wires in
the midline
in a patient with cardiac silhouette at the upper limits of
normal. No
evidence of vascular congestion or pleural effusion. Several
small
opacifications are seen in the left upper zone of uncertain
etiology but
probably no clinical significance.
No evidence of acute focal pneumonia.
.
CT HEAD W/O CONTRAST Study Date of [**2130-12-1**] 3:35 PM
In comparison to one day prior, there has been interval
development of
hypodensity involving the right occipital lobe in a distribution
similar to
diffusion abnormality appreciated on MRI. This is compatible
with expected
evolution of right PCA territory infarct. There is no evidence
of hemorrhage.
There is no significant mass effect beyond effacement of the
regional sulci.
Elsewhere, the brain parenchyma is unchanged in attenuation,
with
redemonstration of scattered white matter hypodensities, likely
reflecting the
sequelae of chronic small vessel ischemia. There is mild global
prominence of
the sulci and ventricles, compatible with volume loss. There is
no shift of
midline structures or effacement of the basal cisterns.
Marked calcifications are seen involving the cavernous and
supraclinoid
carotid arteries bilaterally. Lesser calcifications of the V4
vertebral
segments are also noted.
There are no lytic or sclerotic osseous lesions. The visualized
paranasal
sinuses and mastoids are clear.
IMPRESSION:
Interval development of hypodensity in the right occipital lobe,
compatible
with expected evolution of right PCA territory infarct seen on
MRI one day
prior. No associated hemorrhage. Local mass effect without
evidence of
midline shift or central brain herniation.
.
.
Cardiology:
Portable TTE (Complete) Done [**2130-12-1**] at 9:46:01 AM FINAL
Conclusions
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %) secondary to inferior posterior akinesis.
The right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with depressed free wall
contractility. 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
([**2-5**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
89 year old right handed man with PMHx of Afib on Coumadin,
recent subtherapeutic INR 1.2, CAD s/p [**Hospital 8466**] transferred from an
OSH s/p tPA at 1500. Patient was walking down the stairs earlier
today when he felt lightheaded and felt his left leg was weak
and fell on the stairs, didn't hit head, no LOC. The daughter
noticed left facial droop and left sided weakness.
The patient was taken to the OSH, where he was found to be in
aflutter and OSH CT was unremarkable, at 1400 his left arm drift
had resolved, however when re examined 10 minutes later it
reportedly returned and he had developed a left hemianopia.
Discussion was had with a Dr. [**First Name (STitle) **], who examined the patient
in the teleneurology at the OSH and recommended giving tPA.
After this was administered, he was transferred to [**Hospital1 18**].
Upon arrival to [**Hospital1 18**] a code stroke was called and he was given
a score of 3, for left hemianopia and neglect. Patient was
admitted for ICU monitoring from the ED. Patient remained
hemodynamically and neurologically stable and had persistent
asymmetric homonymous hemianopia (worse on left field) and
superior field visual inattention. MRI showed acute right PCA
territorial infarct with occlusion of the P2 segement of the
right PCA with [**Hospital1 **] showing focal stenosis of the M1 segment of
the right MCA, long-segment stenosis of the V4 segment of the
left vertebral artery and high-grade stenosis at the origin of
the right vertebral artery.
24 Hr CT was stable and showed local mass effect without
evidence of midline shift or central brain herniation and no
ICH. Echo showed no LV thrombus with depressed EF 35% ? old and
mild AR with mild-moderate MR. [**Name13 (STitle) **] was started on warfarin and
aspirin on [**2130-12-1**] as a bridge but to stop aspirin when
warfarin is therapeutic.
Consideration of dabigatran therapy in the future will be made
at the time of outpatient follow-up.
During his hospitalization, he was noted to have a gout flare
and started on Naprosyn therapy for 7 days.
=============================================
.
Transitional issues:
1. Stroke: Neuro follow up, possibly change from warfarin to
dabigatran
2. Afib: INR checks with goal [**3-9**].
3. Gout: start Naproxen for several days.
Medications on Admission:
- Singulair 10
- lasix 20
- Levoxyl 125(brand name)
- Metoprolol ER 50 daily,
- pulmicort [**Hospital1 **]
- Coumadin 5mg qd
Discharge Medications:
1. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) as needed for gout for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO daily ().
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Systane Ophthalmic
6. Pulmicort Flexhaler Inhalation
7. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Outpatient Lab Work
please check INR
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Ischemic Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ([**Known lastname **]
or cane).
Discharge Instructions:
You were admitted to the [**Hospital3 **] Medical center for further
assessment and treatment after starting tPA therapy for a
stroke.
MRI revealed a stroke in the back portion of the brain that
likely caused your symptoms. You were given aspirin and then
converted back to coumadin.
You should continue to take coumadin after leaving the hospital.
You will need to get your INR level check in the next 2 days.
While hospitalized, you were found to have Gout in your right
foot. You were started on a medication to treat your pain an
inflammation that you should continue for 1 week after
discharge.
Please note that the following medication changes:
START
- coumadin 2.5mg daily (this dose might change based on your
INR; please get this checked in the next 2 days at your PCP
coumadin clinic or PCP [**Name Initial (PRE) 3726**])
- naproxen (for gout, please take this for 1 week and follow up
with your PCP)
- simvastatin (to reduce your cholesterol, please note that you
had a reaction to similar medication in the past with muscle
pain- please report any such symptoms to your PCP)
Please continue to take your other medications as prescribed by
your physicians.
Followup Instructions:
PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] call your PCP's office and schedule an INR check in
the next 2 days. This is very important.
You will have a follow up appointment with Dr. [**Last Name (STitle) **] in [**3-9**]
weeks. Please call [**Telephone/Fax (1) 44**] to confirm the date of this
appointment.
|
[
"V45.88",
"V45.89",
"427.31",
"412",
"593.9",
"434.11",
"244.9",
"V45.81",
"728.87",
"V58.61",
"493.90",
"V45.79",
"274.01",
"401.9",
"368.46"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14787, 14858
|
11569, 13688
|
328, 353
|
14918, 14918
|
4853, 4874
|
16314, 16637
|
2377, 2418
|
14042, 14764
|
14879, 14897
|
13892, 14019
|
15116, 15751
|
3539, 4834
|
2458, 2898
|
13709, 13866
|
15772, 16291
|
249, 290
|
381, 2134
|
4890, 5354
|
5376, 11546
|
14933, 15092
|
2156, 2275
|
2291, 2361
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,562
| 166,275
|
2098
|
Discharge summary
|
report
|
Admission Date: [**2210-8-17**] [**Month/Day/Year **] Date: [**2210-8-24**]
Date of Birth: [**2164-10-3**] Sex: F
Service: MEDICINE
Allergies:
chocolate / caffeine / tomatoes
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2210-8-18**] Endotracheal Intubation
[**2210-8-19**] Bedside MICU Bronchoscopy
Right internal jugular central catheter placement
History of Present Illness:
Ms. [**Known lastname 10029**] is a 45 year old female with cerebral palsy with
chronic indwelling Foley for urinary retention, recurrent
aspiration pneumonia with multiple intubations and tracheostomy
(now reversed), history of complex partial seizure (right facial
twitching), s/p PEG tube and non-verbal (other than yes-no) who
was doing well at her Bay Cove Human Services until ten days
ago. She has had nasal congestion, cough and sneezing for past
ten days with new shortness of breath and difficulty with
breathing and lethargy noted yesterday morning along fever of
101.3 which led to [**Hospital1 18**] ED admission.
In the ED, initial vitals were 97.7, 81/43, 91, 26, O2Sat
95%4LNC. Labs are notable for WBC 16.4, Hgb 13.8, Plt 201,
Neutrophils 89.6%, normal CHEM 7, normal coagulation panel,
normal LFTs, negative ASA, serum acetaminophen 6, lactate 1.4,
ABG 7.41/42/51/28, UA + for small leuk and few bacteria but 0
epi and neg nitr, and UCG negative. She had left IJ placed due
to difficult access. CXR confirmed location of the line and
retrocardiac opacity. Patient received 750 mg IV levofloxacin,
500 mg IV metronidazole, and total of 2250 mL of IVF. Patient
had 850 mL of urine output. Nursing was able to suction
secretion and patient is able to cough per nursing report. VS
upon transfer 99F, 113/75, 19, O2Sat 100% RA.
On the floor, she was continued on levaquin/flagyl. She was
noted to have fever again along with worsening oxygen
requirement this morning requiring nonrebreather. ABG showed
7.43/33/89. CXR showed worsening left lung opacity +/- effusion.
She was given IV vancomycin and ordered for cepepime (not
given) and transferred to MICU for increased work of breathing
and impending intubation.
In the MICU, she was intubated without any complications and
sedation with fentanyl/versed.
Past Medical History:
-Infantile Cerebral Palsy: dx at age of 2, spastic type spastic
quadriparesis wheelchair dependent
-Seizure Disorder with tonic clonic type since 6 years of age,
f/b neurology
-Dysphagia; PEG tube in; changed [**2208-3-2**] by GI; [**First Name4 (NamePattern1) 3613**]
[**Last Name (NamePattern1) **], MD; patient NPO
-history of MRSA over right shoulder in [**6-/2210**] (s/p burn), s/p
Keflex then Bactrim x 1 week completed at the end of 8/[**2209**].
-Asthma
-Hx of aspiration pneumonia
-urinary retention
-hx GI bleed
-Severe osteoporosis: BMD [**3-/2210**] [**Hospital1 **], Rx'd fosamax, ca and vit
D
-hx right femur fx [**2200**]
-legally [**Year (4 digits) 11345**] due to b/l cataracts s/p surgery
-recurrent UTIs
-last mammogram [**8-27**] normal
-Pap smear: abnl [**2207-3-24**]; colposcopy done [**2207-9-9**];
-S/P tracheostomy- This is now closed
Social History:
- Lived at Baycove group home.
- No tobacco, ETOH, or drugs.
- Non-verbal (except yes and no) at baseline.
- wheelchair bound
- Mother [**First Name8 (NamePattern2) **] [**Name (NI) 11333**]) [**Telephone/Fax (1) 11340**] is the HCP; sister [**Name (NI) **]
is a 2nd contact ([**Telephone/Fax (1) 11361**])
- code status: full code (confirmed with the mother)
Family History:
Unable to assess.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS [**Age over 90 **]F, 131/78, 86, 20, 92% 2l
GEN Alert, oriented to self (unable to assess the other
orientation questions), no acute distress
HEENT: EOM tracks to voice but has a slow continuous rolling
motion, pupils shapes are irregular, sclera anicteric, mucous
membrane slightly dry
Neck: right IJ site dressed, minimal oozing, dressing intact,
neck supple, no JVD
Resp: + upper respiratory sound with secretion, difficult to
assess for crackles. No wheeze present
CV: RRR, no m/r/g appreciated
Abd: soft, NT, ND, BS+, no HSM
Extremities: warm, dry, 1+ edema,
Skin: right shoulder has a well demarcated healing wound on the
top and there is an area with dressing in place on the posterior
shoulder
Neuro: alert, follows simple commands slowly (close your eyes,
raise your right arm), moves right arm sponataneously, did not
move left arm or LE for me.
[**Age over 90 894**] PHYSICAL EXAM:
T97.9 p80 BP 119/68 R22 95% on 35% aerosolized O2 via face tent
GEN: Lethargic, awakens to verbal and tactile stimuli, no acute
distress
HEENT: pupils shapes are irregular and nonreactive on R,
minimally on the left, sclera anicteric, mucous membrane moist.
Neck: L IJ site dressing clean/dry/intact, neck supple, no JVD
Resp: Course respiratory sounds anteriorly, with B/L air entry.
Decreased excursion/effort
CV: S1, S2 regular
Abd: soft, BS+, G tube site slight erythema around area.
Extremities: warm, dry, 1+ edema,short and contracted legs
Skin: right shoulder with well healing wound/scab
Neuro: Opens eyes to verbal stimuli, Does not track, not
following commands, No UE/LE movement
Pertinent Results:
ADMISSION LABS:
[**2210-8-17**] 10:45AM BLOOD WBC-16.4*# RBC-4.27 Hgb-13.8 Hct-40.4
MCV-95 MCH-32.3* MCHC-34.1 RDW-11.8 Plt Ct-201
[**2210-8-17**] 10:45AM BLOOD Neuts-89.6* Lymphs-7.1* Monos-2.7 Eos-0.4
Baso-0.3
[**2210-8-17**] 10:45AM BLOOD PT-11.8 PTT-33.2 INR(PT)-1.1
[**2210-8-17**] 10:45AM BLOOD Plt Ct-201
[**2210-8-17**] 10:45AM BLOOD Glucose-98 UreaN-9 Creat-0.5 Na-136 K-3.7
Cl-100 HCO3-26 AnGap-14
[**2210-8-17**] 10:45AM BLOOD ALT-35 AST-28 AlkPhos-83 TotBili-0.6
[**2210-8-17**] 10:45AM BLOOD Lipase-21
[**2210-8-17**] 10:45AM BLOOD Albumin-3.9
[**2210-8-18**] 08:25AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.8
[**2210-8-17**] 10:45AM BLOOD ASA-NEG Acetmnp-6*
[**2210-8-17**] 10:49AM BLOOD Type-[**Last Name (un) **] pO2-51* pCO2-42 pH-7.41
calTCO2-28 Base XS-1 Comment-GREEN TOP
[**2210-8-17**] 10:49AM BLOOD Lactate-1.4
[**2210-8-17**] 10:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.003
[**2210-8-17**] 10:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
[**2210-8-17**] 10:55AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
[**Month/Day/Year 894**] LABS:
[**2210-8-24**] 06:53AM BLOOD WBC-7.3 RBC-3.50* Hgb-11.2* Hct-33.6*
MCV-96 MCH-32.0 MCHC-33.3 RDW-12.2 Plt Ct-230
[**2210-8-24**] 06:53AM BLOOD Glucose-100 UreaN-13 Creat-0.5 Na-143
K-3.8 Cl-107 HCO3-27 AnGap-13
[**2210-8-24**] 06:53AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
MICRO:
Sputum Cx Respiratory Flora
Blood Cx x2 negative, pending x1
Legionella negative
Urine Cx negative
ECG:
Sinus tachycardia. Possible prior inferior wall myocardial
infarction.
Compared to the previous tracing of [**2208-10-18**] no diagnostic
interval change.
IMAGING:
CXR [**8-17**]
IMPRESSION: Retrocardiac opacity, similar to [**2208-10-18**],
which may
represent aspiration in the correct clinical setting.
CXR [**8-18**]
IMPRESSION:
1. There is spinal hardware in place. The patient is markedly
rotated on the current examination, which limits evaluation of
the cardiac and mediastinal contours. There does appear to be
an increasing opacity overlying the left hemithorax, which has
the appearance more likely of layering pleural fluid.
Underlying airspace diseas such as aspiration or pneumonia
cannot be excluded on this limited examination. Clinical
correlation is advised to help explain the apparent increase in
left pleural effusion and left airspace disease. The visualized
right lung appears grossly clear. No pneumothorax is seen. A
right internal jugular central line remains in position with its
tip in the
distal SVC. No pneumothorax.
CXR [**8-19**]
IMPRESSION:
1. Spinal hardware is again seen obscuring some of the detail.
A right
internal jugular central line continues to have its tip
unchanged in position likely in the distal SVC. An endotracheal
tube is in position with its tip approximately 2 cm above the
carina. Once again, the patient is markedly rotated left
limiting evaluation of the cardiac and mediastinal contours.
There has been interval improvement in aeration in the left
upper and mid lung but there is still likely lower lobe
collapse. A superimposed infectious process cannot be entirely
excluded. There also possibly is a layering left effusion. The
right lung remains grossly clear. No pneumothorax is seen.
CT CHEST [**8-18**]
IMPRESSION:
1. Obstruction of the left mainstem bronchus most likely due to
mucus
plugging, although tumor cannot be fully excluded. Further
evaluation is
recommended. Due to the occlusion, the majority of the left
lung is collapsed with only slight aeration in the apex,
anterior lingula and left base.
2. Right basilar atelectasis, likely due to the scoliosis.
3. Trace pericardial effusion.
Brief Hospital Course:
45 year old female with cerebral palsy with chronic indwelling
Foley for urinary retention, recurrent aspiration pneumonia with
multiple intubations and tracheostomy (now reversed), history of
complex partial seizure (right facial twitching), s/p PEG tube
and non-verbal (other than yes-no) who presents with 10 days of
nasal congestion/cough and one day of fever and shortness of
breath with CXR concering for left lung opacity +/- effusion ->
CT Chest showed lung collapse. Pt transferred out of MICU s/p
extubation. She was treated for a 8-day course for healthcare
acquired pneumonia.
# Respiratory Failure: Developed respiratory distress once she
arrived on the medicine floor. Transferred to MICU. She was
subsequently intubated in the setting of increased work of
breathing likely from pneumonia plus a component of worsening
pleural effusion in setting of IVF of 3LNS over 24 hours. Post
intubation CXR showed progressive effusion versus mucous
plugging. She was started on Vancomycin, Zosyn, and Azithromycin
due to history of multiple resistant organism/pneumonia and
concern for postviral pneumonia. Home albuterol, iprotropium,
and budesonide were continued. Blood cxs and sputum cx were
negative (which did not grow any organisms). Bedisde U/S with
attending did not identify a parapneumonic effusion. A CT scan
was obtained which was read as a obstruction of the left
mainstem bronchus most likely due to mucus plugging, although
tumor cannot be fully excluded and as a result the left lung was
mostly collapsed. A bedside bronchoscopy on [**2210-8-19**] showed
minimal secretions. Patient improved and eventually extubated
successfully. It appeared that patient responded well to the
bronchoscopy and it was believed that a mucous plug was removed
leading to the improvement. She was transferred to the medicine
floor. However since the patient is nonverbal and unable to
express her symptoms, Vancomycin/Zosyn/Azithromycin were
continued for post-viral or HCAP with MDR risk factors and
coverage for atypicals for a planned 8 day course to be
completed [**8-25**]. Her face tent with aerosol blow-by was kept at
40% then attempted to be set at 30%. However the patient's
saturations dipped to the mid-high 80s so it was increased again
to 35%, after which she has saturated well. She has responded to
aggressive pulmonary rehab and should continue these measures.
Her prior baseline oxygen saturation is within normal limits on
room air.
CHRONIC ISSUES:
# Cerebral Palsy w/ Chronic Foley: There was initially a concern
for a UTI. UA was normal. Urine cx was negative. Foley was
replaced in the MICU since it had been in place for 2 weeks.
# Nutrition (NPO and Tube Feeds)- Monitored G-tube site for
signs of infection
Her regimen was: 1. Replete with Fiber bolus 1 can 4 times a day
= 948
kcals/ 59 g protein
2. Flush 50 ml before and after bolus feeds
3. Hold for residual greater than 200 ml
# Osteoporosis: Continued home calcium, vitamin D and
calcitonin-salmon
# Asthma: Continued home albuterol, ipratropium, and budesonide.
Caution that Budesonide may increase her risk of pulmonary
infections.
# History of Seizure: Continued home keppra, and zonisamide.
Seizure precautions were ordered and patient remained stable
# Right Shoulder Wound: Healing well. No signs of infection over
the wound at the time. It was monitored and had daily dressing
changes. MRSA nasal swab was negative.
TRANSITIONAL ISSUES:
1) Aggressive pulmonary rehab. Wean humidified O2.
2) Aspiration precautions
3) Patient is Full Code
4) Mother [**Name (NI) **] [**Name (NI) 11333**] (HCP) H [**Telephone/Fax (1) 11340**] C [**Telephone/Fax (1) 11355**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Baycove.
1. Jevity *NF* (food supplement, lactose-free) 237 mL G tube QID
check residual, if > 100 mL hold for 1 hour and recheck.
2. Nystatin Cream 1 Appl TP TID
under the breast
3. Multivitamins 1 TAB NG DAILY
through G tube
4. Loratadine *NF* 10 mg G tube daily
5. Calcitonin Salmon 200 UNIT NAS DAILY
6. Omeprazole 20 mg PO DAILY
through G tube
7. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY right shoulder
wound
8. Scopolamine Patch 1 PTCH TP Q72 HR
9. Vitamin D 400 UNIT PO DAILY
10. Ipratropium Bromide Neb 1 NEB IH Q8H
11. Albuterol 0.083% Neb Soln 1 NEB IH Q8H
12. Ascorbic Acid (Liquid) 500 mg PO BID
13. LeVETiracetam Oral Solution 1500 mg PO BID
14. Timolol Maleate 0.5% 1 DROP RIGHT EYE [**Hospital1 **]
15. budesonide *NF* 0.25 mg/2 mL Inhalation [**Hospital1 **]
16. cranberry *NF* NA G tube qPM
Cranberry juice instead of capsule
17. Lactulose 20 g NG DAILY
hold if has loose bowel movement
18. Senna 2 TAB NG HS
hold if has loose bowel movement
19. Calcium Carbonate 500 mg NG QPM
G tube
20. Zonisamide 200 mg PO QHS
through G tube
21. Milk of Magnesia Dose is Unknown NG DAILY
22. Acetaminophen 650 mg PO Q4H:PRN fever or pain
23. Guaifenesin 200 mg PO QID PRN cough
[**Hospital1 **] Medications:
1. Nystatin Cream 1 Appl TP TID
under the breast
2. Multivitamins 1 TAB NG DAILY
through G tube
3. Loratadine *NF* 10 mg G tube daily
4. Calcitonin Salmon 200 UNIT NAS DAILY
5. Omeprazole 20 mg PO DAILY
through G tube
6. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY right shoulder
wound
7. Scopolamine Patch 1 PTCH TP Q72 HR
8. Vitamin D 400 UNIT PO DAILY
9. Ipratropium Bromide Neb 1 NEB IH Q8H
10. Albuterol 0.083% Neb Soln 1 NEB IH Q8H
11. Ascorbic Acid (Liquid) 500 mg PO BID
12. LeVETiracetam Oral Solution 1500 mg PO BID
13. Timolol Maleate 0.5% 1 DROP RIGHT EYE [**Hospital1 **]
14. budesonide *NF* 0.25 mg/2 mL Inhalation [**Hospital1 **]
15. cranberry *NF* 1 cup of juice G TUBE QPM
Cranberry juice instead of capsule
16. Lactulose 20 g NG DAILY
hold if has loose bowel movement
17. Senna 2 TAB NG HS
hold if has loose bowel movement
18. Calcium Carbonate 500 mg NG QPM
G tube
19. Zonisamide 200 mg PO QHS
through G tube
20. Milk of Magnesia 15-30 mL PO DAILY
21. Acetaminophen 650 mg PO Q4H:PRN fever or pain
22. Guaifenesin 200 mg PO QID PRN cough
23. Azithromycin 500 mg IV Q24H
24. Heparin 5000 UNIT SC TID
25. Piperacillin-Tazobactam 4.5 g IV Q8H
26. Vancomycin 1000 mg IV Q 12H
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
[**Location (un) **] Diagnosis:
Primary: acute hypoxemic respiratory failure, healthcare
associated pneumonia
Secondary: seizure disorder, cerebral palsy
[**Location (un) **] Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable. She will
usually open her eyes to voice.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
You were admitted to the medical intensive care unit and briefly
required a breathing tube secondary to pneumonia. Your pneumonia
improved with antibiotic therapy but you are still requiring
oxygen and having mucous plugging. You are being sent to a rehab
facility for continuing antibiotic therapy and further pulmonary
rehab.
Followup Instructions:
Please follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
from rehab:
[**Last Name (LF) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 608**]
Completed by:[**2210-8-26**]
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] |
icd9cm
|
[
[
[]
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] |
[
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"96.6"
] |
icd9pcs
|
[
[
[]
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|
15520, 15699
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|
3213, 3574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,638
| 158,546
|
15378
|
Discharge summary
|
report
|
Admission Date: [**2172-9-17**] Discharge Date: [**2172-9-29**]
Date of Birth: [**2108-5-29**] Sex: F
Service: [**Hospital Unit Name 21325**]
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
obese white female with a history of hypertension, coronary
artery disease status post myocardial infarction in [**2164**] and
[**2168**], in anterior and inferior distributions with an ejection
fraction of 10%. She was transferred from [**Hospital **] Hospital
for congestive heart failure and Electrophysiology
management. The patient also has peripheral vascular disease,
bilateral lower extremity embolectomies, history of pulmonary
embolism, chronic atrial fibrillation, and a small
ventricular septal defect.
The patient's cardiac history began in [**2164**] when she
sustained an anterior wall myocardial infarction and
subsequent percutaneous transluminal coronary
angioplasty/stent, with an left anterior descending with an
ejection fraction of 30 to 35%. In [**2168**], she sustained an
inferior wall myocardial infarction. Ejection fraction at
that time was 25%.
The patient is followed by Dr. [**Last Name (STitle) **]. An echocardiogram from
his office reveals a dilated left ventricle with hypokinesis
of the proximal anterior and inferior walls, dyskinesis of
the septum and akinesis with an ejection fraction of 10%.
The patient also had moderate bilateral atrial enlargement,
mild mitral regurgitation and tricuspid regurgitation.
The patient recently underwent an increase in her diuretic
regimen with Zaroxolyn. She had symptoms of fluid retention
which improved but she developed nausea, vomiting and
diarrhea with a decrease in weight of 25 pounds. She was
admitted to [**Hospital **] Hospital where she was given intravenous
fluids for dehydration. Her creatinine was noticed to be
increased and she had an elevated digoxin level. Telemetry
at the outside hospital revealed pauses. She was transferred
on [**9-17**] to [**Hospital1 69**] for
evaluation for a biventricular pacer and for advanced
congestive heart failure management.
It was also noted during her hospitalization at [**Hospital **]
Hospital that her INR was around 10. The patient states that
she did not feel well until after she had her second
myocardial infarction. She has felt worse over this summer
with increased fluid retention, fatigue, some orthopnea and
increased lower extremity edema. The patient also cites some
epigastric discomfort over the summer and some recent
diarrhea.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post anterior inferior
myocardial infarction in [**2164**] and [**2168**].
2. Congestive heart failure with an ejection fraction of
10%.
3. Hypertension.
4. Pulmonary embolism.
5. Peripheral vascular disease with bilateral lower
extremity embolectomies in [**2164**].
6. Obesity.
7. Small ventricular septal defect.
8. Osteoarthritis.
9. Chronic atrial fibrillation.
10. Status post IVC filter.
11. Status post thyroid surgery.
SOCIAL HISTORY: She is a former smoker. She denies use of
alcohol and drugs. She is unmarried and she has no children.
FAMILY HISTORY: Positive for maternal cardiac history.
MEDICATIONS:
1. Lasix 40 twice a day.
2. Norvasc 5 mg q. day.
3. Lisinopril 40 mg q. day.
4. Prevacid and Zocor, dosages are unclear.
5. Zaroxolyn discontinued.
6. Digoxin discontinued.
7. Coumadin discontinued.
ALLERGIES: No known drug allergies but is sensitive to
adhesive tape.
PHYSICAL EXAMINATION: Temperature of 98.3 F.; blood pressure
102/56; pulse 46; respiratory rate 18; oxygen saturation 96%
on room air. In general, an obese female lying in bed, in no
apparent distress. HEENT: Pupils equally round and reactive
to light. Extraocular muscles are intact. Mucous membranes
were moist. Oropharynx is clear. Neck: Jugular venous
distention 7 cm of water. No carotid bruits. Scar from
previous thyroid surgery. Cardiac: Irregularly irregular;
II/VI systolic ejection murmur. Pulmonary: Clear to
auscultation bilaterally. No rales, no wheezes. Abdomen
soft; mild tenderness in left lower quadrant. Normoactive
bowel sounds. Extremities: Two plus lower extremity edema
to the knees. Rectal: Deferred. Neurologic: Alert and
oriented times three; cranial nerves II through XII grossly
intact. Examination otherwise nonfocal.
LABORATORY: Data on admission showed a white count of 5.9,
hematocrit of 44.4 and a platelet count of 141. Sodium was
141, potassium was 3.8, chloride was 99, bicarbonate was 25,
BUN was 39, creatinine was 1.0. Digoxin level was 1.4. TSH
5.1. Albumin was 3.8, calcium was 9.6 and magnesium was 2.0.
EKG showed atrial fibrillation with a rate of 86 beats per
minute. There was left axis deviation and a left bundle
branch block.
Chest x-ray disclosed cardiomegaly without evidence of
failure.
HOSPITAL COURSE: The patient was admitted to [**Hospital Unit Name 196**] Service
for further management. The hospital course will be relayed
by systems:
1. CARDIOLOGY: A) Ischemia - the patient was continued on
her statin. It was unclear why she was not on an aspirin so
aspirin was started. The patient underwent a VO2 stress test
on [**9-21**]. The patient exercised for 4.25 minutes of a
modified [**Doctor Last Name 4001**] protocol and requested the test be stopped
for nausea. The resting oxygen consumption was 3.2 ml per kl
per minute with a respiratory exchange ratio of 0.75. Peak
exercise her oxygen consumption increased to 11 mm per kl per
minute with an expiratory exchange ratio of 0.86. The peak
oxygen consumption was 45% of predicted. The oxygen
consumption at the onset of the anaerobic threshold was 9.9
ml per kl per minute. This test was not limited by muscle
fatigue, no arm, neck or back discomfort was reported by the
patient throughout the study. The ST segments are
uninterpretable for ischemia in the setting of baseline left
bundle branch block. The rhythm was atrial fibrillation with
several isolated VPCs and two ventricular couplets. Blunted
systolic blood pressure response to exercise.
The patient underwent a cardiac catheterization on [**9-22**]. The cardiac output was 3.6. The cardiac index was 1.56
with a pulmonary capillary wedge pressure of 22 mm of
Mercury. There was no in-stent restenosis in the left
anterior descending. There is a recanalized lesion in the
mid-RCA.
B) Rhythm - the patient was monitored on Telemetry throughout
her hospital stay. She was initially noted to be in atrial
fibrillation. On [**9-22**], she underwent an
Electrophysiology Study with mapping of the left ventricle.
On the night of [**9-22**], she was transferred to the
Cardiac Care Unit where she was administered Dobutamine to
optimize for the best cardiac index. On [**9-23**], a
biventricular pacer and ICD was placed. She was started on
amiodarone 400 mg three times a day for five days. She will
then continue on Amiodarone 400 mg a day for 90 days, and
then will be tapered down to Amiodarone 200 mg q. day.
On [**9-29**], the pacer was interrogated and was found to be
working well.
C) Pump - the patient was initially on Norvasc when she came
in to the hospital. She was started on Coreg 3.125 mg twice
a day. An echocardiogram on [**9-21**], disclosed an
ejection fraction of 15%; there was right atrium and left
atrium dilatation. The left ventricle was moderately
dilated. There was severe global left ventricular
hypokinesis. Overall left ventricular systolic function was
severely depressed. The right ventricle cavity was mildly
dilated. Right ventricular systolic function was depressed
and with mild one plus mitral regurgitation.
Following placement of her pacemaker on [**9-23**], the
patient was transferred back to the Cardiac Care Unit where
she was noted to be hypotensive with systolic blood pressure
in the high 70s. The hypotension was attributed to
hypovolemia. There was concern for blood loss after the
pacemaker insertion, possibly from the carotid sinus. The
patient was placed on Neo-Synephrine times two days. On
[**9-24**], it was noted that her hematocrit dropped from 30
to 28.2. She was transfused two units of packed red blood
cells.
2. GASTROINTESTINAL: The patient initially presented with a
complaint of diarrhea. Stool studies were sent as well as
ova and parasites and Clostridium difficile; all studies were
negative. The patient was administered Protonix during her
hospitalization.
3. RENAL: On the date of admission, the patient's
creatinine was 1.0. On [**9-19**], the creatinine increased
to 1.8. Etiology of the patient's acute renal insufficiency
was believed to be due to her prerenal azotemia. Her Lasix
and ACE inhibitor were held and the patient was hydrated.
Prior to her catheterization on [**9-22**], the patient was
hydrated and given Mucomyst. Her acute renal insufficiency
resolved.
4. ENDOCRINE: The patient is status post thyroid surgery in
[**2144**]. The patient's TSH was found to be slightly elevated at
5.1 on the day of admission. The patient does not take
Levothyroxine because she states that she does not tolerate
thyroid medications.
5. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
maintained on a low sodium cardiac diet. A Nutrition
Consultation was placed and the patient was educated about
the importance of the low sodium diet.
6. PERIPHERAL VASCULAR DISEASE: The patient has a history
of bilateral lower extremity emboli and has an IVC filter.
The patient's Coumadin was held during most of her hospital
stay and she was anticoagulated with heparin with a goal of
PTT of 50 to 70. The patient was discharged on Lovenox and
Coumadin and will have her INR monitored.
7. PHYSICAL THERAPY: The patient underwent Physical Therapy
during her hospitalization and will receive home Physical
Therapy upon discharge.
CODE STATUS: Full.
DISPOSITION: To home. The patient desires to go home and
she will live with her sister. The patient will receive
visiting nurse assistance and home Physical Therapy.
DISCHARGE MEDICATIONS: The patient has the following
follow-up appointments.
1. On [**10-2**], she will follow-up in Dr.[**Name (NI) 44654**] clinic
at 10:30 a.m. to have her INR checked. She is currently on
80 mg of Lovenox twice a day and Coumadin 5 mg q. day.
2. On Tuesday, [**10-6**], she will follow-up with her
Cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the number is [**Telephone/Fax (1) 44655**].
3. On [**10-13**], she will follow-up in the congestive heart
failure clinic with Dr. [**Last Name (STitle) **] at 10 a.m.
4. On [**10-19**], she will follow-up in the
Electrophysiology Clinic on [**Hospital Ward Name **]-4 for testing of her
defibrillator.
5. The patient was instructed to maintain a low salt diet.
6. She should have her liver function tests, thyroid
function tests and pulmonary function tests, and a slit lamp
examination done since she has been started on Amiodarone.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Biventricular congestive heart failure.
2. Status post biventricular pacemaker / AICD placement.
DISCHARGE MEDICATIONS:
1. Zocor: The patient to continue on her outpatient dosage.
2. Prevacid: The patient to continue on her outpatient
dose.
3. Lisinopril 5 mg p.o. q. day.
4. Amiodarone 400 mg p.o. q. day times 90 days, then patient
to take Amiodarone 200 mg p.o. q. day. The patient to have
liver function tests, thyroid function tests and pulmonary
function tests monitored. The patient should also undergo a
slit lamp examination.
5. Digoxin 0.125 mg q. day.
6. Lasix 40 mg p.o. q. day.
7. Carvedilol 3.125 mg p.o. twice a day.
8. Aspirin 81 mg p.o. q. day.
9. Coumadin 5 mg p.o. q. day.
10. Lovenox 80 mg subcutaneously q. 12 hours to be continued
until the patient reaches her therapeutic INR.
Note, this discharge summary should be faxed to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], the patient's cardiologist; his office number is
[**Telephone/Fax (1) 44655**]. This discharge summary should be faxed there
prior to the patient's appointment on [**10-6**].
[**Doctor First Name 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. [**MD Number(1) 9632**]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2172-9-29**] 15:34
T: [**2172-9-29**] 15:48
JOB#: [**Job Number 44656**]
cc:[**Telephone/Fax (1) 44657**]
|
[
"427.31",
"428.0",
"397.0",
"424.0",
"412",
"276.5",
"V45.82",
"458.2",
"429.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.94",
"37.26",
"37.22",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
3186, 3519
|
11078, 11181
|
11204, 12525
|
4911, 9742
|
9761, 10075
|
3542, 4893
|
11048, 11057
|
178, 200
|
229, 2552
|
2574, 3046
|
3063, 3169
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,948
| 119,478
|
15432
|
Discharge summary
|
report
|
Admission Date: [**2122-12-22**] Discharge Date: [**2122-12-25**]
Date of Birth: [**2089-2-18**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
admitted for milrinone therapy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
33 yo male with a history of dilated cardiomyopathy (TTE [**8-2**]:
EF 20%), h/o ventricular tachycardia s/p ICD, atrial
fibrillation on Coumadin, h/o L PCA CVA, and hypothyroidism
secondary to Amiodarone who presents for diuresis and milrinone
infusion. Patient was admitted for aggressive treatment by his
outpatient Cardiologist. Per the patient, he has been admitted
to the hospital 3 times in the last month for CHF exacerbations.
First on [**11-25**] and again 8 days after discharge. Most recently
he was admitted 4 days ago with worsening LE edema and abdominal
distention. He was admitted overnight for IV diuresis. His edema
improved and he was discharged home. The patient's wife came to
[**Hospital1 **] today to pick up medications for her husband and she conveyed
to his Cardiologist that the patient has had multiple recent
hospitalizations. Given this, the decision was made for
admission for more aggressive treatment and consideration of
home milrinone therapy.
.
In the ED vitals were T 96.8 HR 90 BP 96/61 RR 16 100% RA. CXR
showed no significant change. He was admitted to the CCU for
milrinone gtt. Currently the patient feels well. He denies CP or
SOB. He denies orthopnea. He reports that his LE edema is
improved.
Past Medical History:
-Dilated Cardiomyopathy, TTE [**8-2**]: EF 20%, diagnosed after
presenting with Class III CHF symptoms in [**9-27**], thought to be
viral etiology, s/p AICD
-CHF, dry weight 100 kg
-Ventricular Tachycardia, first noted in [**9-27**], s/p syncope from
VT in [**9-1**], ICD in place
-Atrial Fibrillation, on Coumadin, diagnosed in the setting of
hyperthyroidism
-CVA (L PCA, thought to be cardioembolic)
-Hyperthyroidism, secondary to Amiodarone (d/ced [**3-1**]), s/p
prednisone and methimazole-->hypothyroidism
-SDH s/p fall [**12-28**] syncope in [**9-1**] (Coumadin held [**Date range (1) 9358**])
-Fe deficiency Anemia
-Obesity
-Depression
-Osteoporosis
-s/p R knee surgery
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Portuguese speaker,
moved from [**Country 4194**] in [**2113**]. Lives with wife and two young
children. Pt does not work. Used to have job as dishwasher. Wife
works at Honey Dew Donuts and this is the only income source for
the family. Pt is primary child caretaker.
Family History:
Father with "[**Last Name **] problem" at age 52; mother with "[**Last Name **]
problem" at age 25, also with a thyroid condition.
Physical Exam:
VS - T 98.4 HR 85, irreg, 95/59, R 20, 99% RA
Gen: Lying flat, comfortable, NAD. Oriented x3. Mood, affect
appropriate. Portugese speaking.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: supple. JVP 6mm
CV: Irregularly irregular, I/VI HSM LLSB,
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND, obese. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: Trace LE edema b/l, warm.
Skin: b/l venous stasis changes
Pertinent Results:
Admission labs:
[**2122-12-22**] 03:33PM NEUTS-75.7* LYMPHS-16.1* MONOS-3.5 EOS-4.2*
BASOS-0.4
[**2122-12-22**] 03:33PM WBC-10.2 RBC-4.53* HGB-12.3* HCT-36.1*
MCV-80* MCH-27.1 MCHC-34.0 RDW-17.8*
[**2122-12-22**] 03:33PM GLUCOSE-88 UREA N-46* CREAT-1.8* SODIUM-136
POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-29 ANION GAP-15
[**2122-12-22**] 03:33PM CK-MB-4 proBNP-2561*
Brief Hospital Course:
Patient is a 32M with idiopathic dilatated CM (EF 20%), afib,
CVA, SDH, and hypothyroidism who is admitted for diuresis and
milrinone.
.
# PUMP: CHF/Dilated Cardiomyopathy: TTE [**8-3**] showed EF 20%,
diagnosed after presenting with Class III CHF symptoms in [**9-27**],
thought to be viral etiology, s/p AICD. He was admitted for a
more robust diuresis after multiple recent admissions with
attempted diuresis. On admission he appeared volume overloaded,
with lower extremity edema and an S3 heart sound. Beta blocker
was increased given the arrythmogenic effects of milrinone, and
then milrinone was bolused and continued as a drip. MAP remained
greater than 40. Furosemide drip was started. He diuresed ~1 L
daily for two days. He was discharged on an increased dose of
beta blocker, decreased ACEI, and his previuos outpatient
torsemide dose.
.
# RHYTHM: Chronic atrial fibrillation, on Coumadin, diagnosed in
the setting of hyperthyroidism. INR was initially 3.5 on
admission, and coumadin was held until INR fell into the
therapeutic range. Half-dose (2.5 mg) coumadin was given on
[**12-24**] when INR 2.1, and he was discharged on 5 mg daily with
plans to f/u for repeat INR on [**12-28**]. Metoprolol was increased to
suppress milrinone-induced arrhthmias. Rate was well controlled
on this regimen.
.
# h/o Ventricular Tachycardia: First noted in [**9-27**], had non
sustained 30 second run seen on Holter [**8-29**], s/p syncope from
VT in [**9-1**]. He had an ICD in place and was monitored on
telemetry this admission with no events.
.
# NEURO: Patient was s/p CVA, SDH, and seizure [**9-2**] on Keppra
for seizure prophylaxis. This medication was continued and there
was no evidence of seizure.
.
# Thyroid dysfunction: Synthroid was continued for
amiodarone-induced hypothyroidism.
.
# Chronic renal insufficiency: Creatinine was near baseline
1.7-1.8 on admission and improved with diuresis.
.
# Anemia: Baseline Hct in low 30s. Iron studies were consistnet
with chronic disease.
.
# Osteoporosis: Calcium and vitamin D were continued.
Medications on Admission:
Digoxin 125 mcg daily
Torsemide 100mg [**Hospital1 **]
Levothyroxine 75 mcg daily
Lisinopril 2.5 mg [**Hospital1 **]
Metoprolol 100mg tid
Spironolactone 25 mg daily
Warfarin 5mg daily, except 7.5mg on sundays
Colcicine 0.6mg qod
Keppra 250mg [**Hospital1 **]
Vit D 800 units daily
Allopurinol 100mg daily
Calcium 500mg [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
primary: dilated cardiomyopathy
secondary: atrial fibrillation, depression
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital to receive a medication to
help get fluid off your body. This was successful.
.
Your coumadin dose was decreased to 5 mg every day (5mg on
sunday as well) because your level was high. Your metoprolol
was increased. You should only take lisinopril once a day now.
Otherwise, please resume all of your home medications.
.
Please return to the emergency department or call the ED if you
experience chest pain, trouble breathing, high fevers and
chills, or other symptoms that are concerning to you.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 L
Followup Instructions:
Please follow up on Monday, [**12-28**] to have your INR checked at [**Hospital 191**]
[**Hospital3 **].
Cardiology: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2122-12-29**] 1:00
Primary Care: [**First Name8 (NamePattern2) 21015**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2123-2-4**] 3:30
Completed by:[**2122-12-25**]
|
[
"780.39",
"428.0",
"907.0",
"733.00",
"E929.4",
"V58.61",
"425.4",
"311",
"E942.0",
"427.31",
"585.9",
"428.23",
"790.92",
"280.9",
"244.3",
"V45.02",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6351, 6357
|
3902, 5964
|
312, 318
|
6478, 6487
|
3506, 3506
|
7194, 7641
|
2697, 2830
|
6378, 6457
|
5990, 6328
|
6511, 7171
|
2845, 3487
|
242, 274
|
346, 1587
|
3523, 3879
|
1609, 2288
|
2304, 2681
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,930
| 167,838
|
29952
|
Discharge summary
|
report
|
Admission Date: [**2145-9-6**] Discharge Date: [**2145-9-23**]
Date of Birth: [**2077-10-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Fever, SOB, cough
Major Surgical or Invasive Procedure:
Endotrachial intubation
Bronchoscopy
Foley catheter placement
Left subclavian line placement
History of Present Illness:
67 y/o F with a h/o HTN, T2DM, and hyperlipidemia who presented
to the ED with a 4 day h/o cough, SOB, and fever. Of note, the
patient recently returned from a trip to [**Country 3587**] to visit
relatives. The patient had been living in [**State 108**] for several
years and recently moved to the [**Location (un) 86**] area. She flew back from
[**Country 3587**] this past Friday and began to feel unwell on the
following Saturday. She had a productive cough of pink, frothy
sputum. She also had a fever at home (no exact measurement). She
also reported myalgias and decreased PO intake. She presented to
the ED for further evaluation of her symptoms.
Past Medical History:
1. T2DM
2. HTN
3. Hyperlipidemia
Social History:
No tobacco or ethanol use
Family History:
NC
Physical Exam:
On transfer from MICU:
Vitals: T 98.4 HR 81 BP 115/44 RR 22 94-100% on 2L NC
General: 67 F in NAD
HEENT: NC/AT. MM moist. OP clear.
Neck: No JVD.
CV: Regular rhythm. nl s1, s2; No m/r/g.
Pulm: CTAB, mildly decreased BS RUL.
Abd: Soft, non-distended, non-tender, with normoactive BS.
Ext: Feet cool. 2+ DP's bilaterally. 2+ edema around ankles
bilaterally, 1+ edema in UEs around wrists.
Skin: No rash.
Neuro: A/O x 3. Strength and sensation intact throughout.
Access: Left subclavian in place
Pertinent Results:
Initial Labs ([**9-6**]):
WBC 17.5 Hb 13.6 Hct 39.8 Plt 233
Diff - 66N + Dohle bodies, 21 Bands, 10 lymphs
NA 135 Chloride 96 BUn 41 Glucose 224
K 4.1 Bicarb 26 Cr 2.1
Lactate 3.0
Ck 1297 CK MB 7 Trop T < 0.01
ABG 7.29/53/83 21:07 [**9-6**]
ABG 7.26/63/70 06:00 [**9-7**]
Mixed Venous 7.43/55/169 [**9-16**]
Fe studies:
Iron 81 ug/dL 30 - 160
Iron Binding Capacity, Total 252* ug/dL 260 - 470
Ferritin 513* ng/mL 13 - 150
Transferrin 194* mg/dL 200 - 360
Micro:
BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; FUNGAL
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PENDING
CMV, EBV negative
Legionella negative
Mycoplasma IgG, IGM negative
Multiple blood culture, urine culture, respiratory culture
negative
Imaging:
[**9-6**] PA and Lateral: CHEST, TWO VIEWS: There is dense
opacification of the right upper lung with associated air
bronchograms. There is thickening of the right minor fissure
likely due to a small amount of fluid in the fissure. The right
posterior costophrenic sulcus is blunted consistent with a small
pleural effusion. The left lung is clear. The heart size is
normal. The aorta is tortuous.
IMPRESSION: Dense opacification of the right upper lobe, likely
representing a lobar pneumonia. An endobronchial obstructing
lesion cannot be excluded on these radiographs. Followup imaging
after treatment is suggested.
[**9-7**] ECHO Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and regional/global systolic
function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved left ventricular systolic function. Mild valvular
thickening with no signifcant stenosis or regurgitation.
[**9-21**] PA and lateral chest compared to [**9-14**] through [**9-18**]:
A small amount of volume loss persists in the right upper lobe.
There is no good evidence of recurrent pneumonia. Mild
cardiomegaly is stable. Mediastinal vascular engorgement has
improved.
There is an unusual configuration to gas shadows in the upper
abdominal midline, probably unusual displacement of the gastric
antrum. If patient has referable symptoms to abdominal pathology
I would reevaluate with routine abdominal radiographs.
Tip of the left subclavian line projects over the upper SVC. No
pneumothorax. Medical student [**Last Name (un) 71534**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4887**]
were both paged to report these findings at the time of
dictation.
Brief Hospital Course:
In the ED, her vital signs were T 99.9 HR 120 BP 114/50 RR 32
95%NRB. A chest x-ray [**Last Name (un) **] da RUL pneumonia, and ECG showed
afib with RVR. Her lactate was 3.0 and creatinine 2.1. She was
pan-cultured, given a dose of antibiotics, and transferred to
the MICU for presumed septic shock.
.
# Respiratory failure/Septic Shock:
In the MICU she quickly went into severe hypoxic hypercarbic
failure (7.26/59/63 on NRB) requiring intubation. She became
hypotensive, requiring transient pressors and a total of 13
liters net volume resuscitation. Culture data including EBV,
CMV, and TB were consistently negative, even after bronchoscopy.
She completed a ten day course of ceftriaxone and azithromycin,
but was also on vancomycin. By chest x-ray, her consolidation
resolved quickly after 5 days (post-bronchoscopy for cultures),
suggesting increased secretions were a major component of her
pulmonary dysfunction. She had a prolonged intubation ([**Date range (1) **])
with hypoxia during spontaneous breathing trials for many days.
She was extubated on [**9-18**] with steadily decreasing secretions and
O2 requirements. She had an O2 requirement for 1-2 days on the
floor that improved with incentive spirometry and walking with
PT.
.
# Rhabdomyolysis
Upon presentation in the MICU, her CK was 1297 with large blood
and few RBCs in the urine suspicious for rhabdomyolysis. Her
troponins wer negative. Her CPKs peaked at [**Numeric Identifier 6235**] on [**9-15**] along
with transaminases in the 300's. She was treated by aggressive
volume resuscitation and lasix to achieve UO > 100cc/hr. She
never had any bump in her creatinine. Her last CK [**9-20**] was 3000,
and she continued to have a stable creatinine until discharge.
.
# Atrial fibrillation
The patient's MICU course was also complicated by atrial
fibrillation for 3-4 days not properly rate controlled on
metoprolol or diltiazem. Echocardiography showed a normal heart
with LVH and preserved EF (>55%). She was therefore begun on an
amiodarone drip, leading to documented conversion on [**9-10**], after
which the drip was D/Ced. She was anticoagulated for a total of
5 days. In discussions with the cardiology consult service, it
was felt that the transient risk factor for atrial fibrillation
(septic shock) had resolved and that long-term anticoagulation
would not be warranted. She remained in sinus rhythm for 9 days
on telemetry after her cardioversion, after which telemetry was
discontinued. She reported no palpitations at any point in her
stay.
.
# Weakness
Ms. [**Known lastname 1001**] was initially weak while recovering from her extesnive
MICU course. She improved rapidly with hospital PT, however, and
was felt safe for discharge with home PT services to aid her
recovery.
.
# Anemia
She had a labile hematocrit during this admission, likely
consistent with a dilutional effect from high volume
resuscitation. On discharge, she has borderline macrocytic
anemia with near-appropriate reticulocyte production and Fe
studies consistent with anemia of chronic disease. She was
guaiac negative. Further w/u as an outpt may be clinically
indicated.
.
# Hypertension
Her blood pressure was titrated with IV beta-blocker in the MICU
and switched oiver to PO beta-blocker once the patient was
taking good POs. ACE-I was D/Ced out of concern for renal
toxicity while rhabdomyolysis resolving. Pt discharged on
stable regimen of metoprolol 75mg [**Hospital1 **] with BPs in the 120s -130s
except before morning meds. Outpt resumption of ACE-I can be
considered for this hypertensive patient with diabetes mellitus.
.
# DM2
Pt was on humalog sliding scale during the majority of this
admission. She was restarted on Metformin before discharge, and
had FSBG in the 100s without humalog support. Pt reports she ahs
always had normal blood sugars on metformin, and so she was sent
home on her home regimen.
.
#Hyperlipidemia
Crestor was held durign this admission out of concern for
potentially exacerbating rhabdomyolysis. Resumption of a statin
as an outpatient is likely clinically indicated.
.
# Nasal congestion
Ms. [**Known lastname 1001**] complained of nasal congestion post-intubation, which
was initially treated with Afrin x 3 days. She was sent home
with Ocean nasal spray.
.
The patient was discharged in good condition on [**2145-9-23**].
Medications on Admission:
Lisinopril 40 mg PO daily
Tylenol PRN
Ibuprofen PRN
Ambien PRN
Metformin 500 mg PO BID
Crestor 20 mg PO daily
Atenolol 50 mg PO daily
ASA 81 mg PO daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain.
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ocean Nasal 0.65 % Spray, Non-Aerosol Sig: Two (2) sprays
Nasal twice a day: each nostril.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
Primary:
Lobar pneumonia
Hypoxic and hypercarbic respiratory failure
Septic shock
Rhabdomyolysis
Atrial fibrillation
Critical illness myopathy
Secondary:
Hypertension
Diabetes mellitus type 2 controlled
Discharge Condition:
good. tolerating oral medications and nutrition. ambulating
without assist on room air.
Discharge Instructions:
You have been evaluated and treated for a severe pneumonia.
Your course was complicated by severe breathing difficutly
requiring a breathing machine to temporarily support your
breathing. Also, there was evidence of temporary muscle
breakdown that was resolving by the time of discharge. During
the most severe period of your illness, you developed a rapid
irregular heartbeat. As this resolved as you recovered, no
direct therapy was started for this heartbeat. Should you
notice a return of your irregular heartbeat, you should contact
your doctor as soon as possible.
Please take the medications as prescribed.
Some of your medications have been changed. You may want to
re-address these medications with your PCP at your next
appointment.
Please attend the recommended follow-up appointments.
Please continue to practice incentive spirometery at home until
your appointment with your PCP.
If you develop any new or concerning symptom such as shortness
of breath, chest pain, fevers to greater than 101F, or a fast
irregular heartbeat; please seek medical attention as soon as
possible.
Followup Instructions:
Primary care physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 11:45AM Friday [**10-1**] [**Doctor Last Name 50531**]Health Center [**Telephone/Fax (1) 7976**]
|
[
"785.52",
"584.9",
"570",
"038.9",
"518.81",
"995.92",
"359.81",
"401.9",
"427.31",
"250.00",
"481",
"728.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.91",
"38.93",
"96.04",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9812, 9864
|
4728, 9059
|
289, 383
|
10112, 10202
|
1716, 4705
|
11348, 11571
|
1182, 1186
|
9262, 9789
|
9885, 10091
|
9085, 9239
|
10226, 11325
|
1201, 1697
|
232, 251
|
411, 1067
|
1089, 1123
|
1139, 1166
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,723
| 190,123
|
53280
|
Discharge summary
|
report
|
Admission Date: [**2171-8-29**] Discharge Date: [**2171-9-10**]
Date of Birth: [**2108-12-10**] Sex: F
Service: VSURG
Allergies:
Losartan / Ceftriaxone / Captopril / Vitamin K
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Cold, numb right lower extremity secndary to thrombosed femoral
graft
Major Surgical or Invasive Procedure:
Right femoral graft thrombectomy and profundoplasty with Dacron
patch
History of Present Illness:
Mrs. [**Known lastname 1557**] was in usual state of delicate health prior to
current episode. She initially presented to [**Hospital 1474**] Hospital
with cc of pain and cyanosis in the R lower ext, and was
subsequently transferred to [**Hospital1 18**] under the care of Dr.
[**Last Name (STitle) **]. Denied other current symptoms at time of
presentation.
Past Medical History:
Coronary artery disease
Mycardial infarction x2 (EF=35%)
Mesenteric Ischemia
Peripheral vascular disease
V-Tach
Chronic renal insufficiency
Renal stenosis
Abdominal Aortic Aneurysm
Polycythemia
Atrophied R kidney
S/p L CVA
Social History:
+Tobacco
Family History:
N/A
Physical Exam:
ALLERGIES: Captopril, Ceftriaxone, Losarten
98*F 124/61 81 16 99%@RA
AOx3, distressed
PERRLA, atraumatic
CTA, rales on L
RRR
NT/ND, soft
EXT: LLE -cold, cyanotic to calf
RLE -cold, cyanotic to groin
PULSE
carotid +2 B, radial +1 B, Fem +2L negR, [**Doctor Last Name **] dopL negR; no
pulses distal to popliteal on either leg to [**Last Name (un) **] or palp
Pertinent Results:
[**2171-8-29**] 09:45PM BLOOD WBC-11.2* RBC-4.25 Hgb-11.8* Hct-36.7#
MCV-86 MCH-27.7 MCHC-32.1 RDW-18.9* Plt Ct-93*
[**2171-8-29**] 09:45PM BLOOD Plt Smr-LOW Plt Ct-93* LPlt-2+
[**2171-8-30**] 03:58AM BLOOD PT-16.6* PTT-76.1* INR(PT)-1.8
[**2171-8-30**] 03:58AM BLOOD Glucose-104 UreaN-45* Creat-1.1 Na-140
K-2.5* Cl-110* HCO3-19* AnGap-14
[**2171-8-30**] 03:58AM BLOOD CK-MB-14* MB Indx-2.1 cTropnT-0.73*
[**2171-8-30**] 03:58AM BLOOD Calcium-6.2* Phos-2.7 Mg-1.5*
[**2171-8-31**] 08:35AM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEG
[**2171-9-10**] 06:07AM BLOOD WBC-6.5 RBC-3.28* Hgb-9.8* Hct-27.9*
MCV-85 MCH-29.9 MCHC-35.2* RDW-17.7* Plt Ct-97*
[**2171-9-10**] 06:07AM BLOOD Plt Ct-97*
[**2171-9-10**] 06:07AM BLOOD PT-17.1* PTT-88.9* INR(PT)-1.9
[**2171-9-6**] 07:00AM BLOOD Glucose-96 UreaN-15 Creat-0.8 Na-135
K-3.4 Cl-94* HCO3-33* AnGap-11
[**2171-9-6**] 07:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.7
Brief Hospital Course:
Admitted on [**8-29**] and taken to OR for urgent thrombectomy of R
femoral graft with a commesurate profundoplasty. Although the
surgery was without complication, she was admitted thereafter to
the SICU for post-op monitoring, telemetry and stabilization.
Given her extensive cardiac history and elevated enzymes at
presentation, a Cardiology consult was obtained on [**8-30**] for
management recommendations; active infarction was ruled out.
Anticoagulation on heparin and coumadin was restarted
post-operatively; she was transferred from the SICU on [**9-3**] to
the VICU, came off telemetry and underwent a bilateral angiogram
to assess LE vascular status as well as surveylance of her AAA.
Pt was made floor status on [**9-4**], and was also noted to ooze
venous blood from her L femoral cath site. [**9-5**] the bleeding
was stitched at the bedside, but rebled the following day; it
was finally controlled by d/c'ing the heparin when INR>1.5, and
DSG with surgicell and pressure. Pt was placed on a short
course of Levoquin the day on [**9-5**] prophylacticly for the
bleed's proximity to the underlying vascular construction. Pt's
HCT was noted to drop gradually following transfer to the floor,
and thus was given 2U PRBCs on [**9-9**]. During her admission,
Physical Therapy was involved in her gradual return to
ambulation. Pt was kept in house until her HCT>28, INR>1.5 and
hemostasis was acheived at the cath site. These criteria were
fulfilled on [**9-10**]. S/p her thrombectomy, pulses in her feet
were biphasic to [**Last Name (un) **] interrogation.
Medications on Admission:
Same as below
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Clonazepam 1 mg Tablet Sig: 1-2 Tablets PO QHS (once a day
(at bedtime)).
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
9. Warfarin Sodium 4 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] HOME CARE
Discharge Diagnosis:
Primary Dx: Right femoral graft thrombis, resulting in right
cold extremity.
Secondary Dx:
Cerebral vascular accident
Chronic renal insufficiency
Renal artery stenosis
Deep venous thrombosis
Myocardial infarction
Abdominal aortic aneurysm
Discharge Condition:
Good
Discharge Instructions:
Dicharge to home with [**Hospital 31940**] rehab evaluation and follow-up at
re-admission coumadin clinic
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**3-19**] weeks
([**Telephone/Fax (1) 3121**]). Call [**Telephone/Fax (1) 109653**] for [**Location (un) 6138**] Home Care.
Also follow-up at pre-admission coumadin clinical for
anti-coagulation management.
|
[
"427.1",
"412",
"238.4",
"E878.2",
"996.74",
"441.4",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.48",
"38.93",
"88.42",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
4919, 4977
|
2460, 4035
|
375, 447
|
5261, 5267
|
1534, 2437
|
5421, 5689
|
1127, 1132
|
4099, 4896
|
4998, 5240
|
4061, 4076
|
5291, 5398
|
1147, 1515
|
266, 337
|
475, 838
|
860, 1085
|
1101, 1111
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,479
| 196,307
|
51165
|
Discharge summary
|
report
|
Admission Date: [**2163-11-3**] Discharge Date: [**2163-11-12**]
Date of Birth: [**2102-11-17**] Sex: M
Service: GENERAL SURGERY
CHIEF COMPLAINT: Bright red blood per rectum, dizziness and
orthostatic hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old
African American male with a very complicated past surgical
in [**2151**] complicated by a large ventral hernia, which was
repaired with a large prosthetic mesh. The patient's hernia
repair was complicated by a prolonged hospital stay with
respiratory failure, acute renal failure, tracheostomy and
ultimately an enterocutaneous fistula, which was treated with
multiple abdominal wound debridements and was definitively
treated with an exploratory laparotomy with a small bowel
patient's postoperative course was complicated by a deep
venous thrombosis in which an IVC filter was placed. The
patient presented to the [**Hospital1 69**]
Emergency Room despite most of his care being given to an
outside hospital secondary to the outside hospital being on
diversion. The patient presented with a large amount of bright
red blood per rectum over the course of six hours with signs
of hypovolemia. The patient was evaluated in the Emergency
Room and was aggressively resuscitated and was admitted to
the Medical Intensive Care Unit for serial hematocrits and
hemodynamic monitoring.
PAST MEDICAL HISTORY: Chronic pain, hypertension, history of
deep venous thrombosis, dilated cardiomyopathy, history of
gastrointestinal bleed.
PAST SURGICAL HISTORY: Left colectomy in [**2151**], ventral
hernia repair after that. Multiple abdominal debridements
and eventually an exploratory laparotomy with a small bowel
resection and hernia repair and an IVC filter placement.
MEDICATIONS ON ADMISSION: Zantac, Labetalol, Buspirone,
Colace, Morphine and Simvastatin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient quit tobacco ten years
previously, but was a thirty pack year smoker. The patient
is a social alcohol user.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit. A GI consult was obtained on [**2163-11-4**].
The patient underwent an upper endoscopy, which showed mild
gastritis but no active bleeding and no obvious source for
his large blood volume loss. The patient continued to have
gastrointestinal bleeding and was transfused 9 units of
packed red blood cells as well as plasma and on [**2163-11-5**]
underwent a bleeding scan, which demonstrated brisk
positivity in the cecal region. The patient went onto
angiography and an ileocolic vessel at the cecum was seen
with active bleeding into the cecum. The patient was started on
low dose intraarterial vasopressin and this resolved the bleeding
and the patient's bleeding resolved over the course of the next
twelve hours. The patient was resuscitated with packed red
blood cells and hemodynamically improved. On [**2163-11-6**] the
vasopressin was stopped in the evening and the patient was
stable until the evening of [**2163-11-7**] when he began passing
copious amounts of bright red blood per rectum again.
Secondary to the patient's history of abdominal surgeries and
complicated surgical course, surgery was not chosen as a
first line therapy, but secondary to his failure to progress
with nonoperative management it was decided that an
operative procedure would be the best course of action due to
the danger of embolizing an end artery to the cecum. The
patient underwent an exploratory laparotomy through the
previous mesh incision and a partial right colectomy with a
primary anastomosis was performed. The patient tolerated the
procedure well and was kept in the Intensive Care Unit and
hemodynamically stabilized. The patient's transfusion
requirement resolved. The patient had a nine beat run of
ventricular tachycardia on postoperative day two, which was
treated with electrolyte repletion. A Cardiology consult was
obtained and no requirement for intervention was necessary.
The patient was restarted on his preoperative medications
with advance to a regular diet as he showed bowel function and
on postoperative day five he was discharged to home with a
stable hematocrit and no further bright red blood per rectum
and no further ventricular ectopy by telemetry.
It should be noted that this patient due his multiple blood
transfusions in the past has built up many antibodies and is
extremely difficult to cross-match for compatible blood.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed.
2. Nonsustained ventricular tachycardia.
3. Hypovolemia.
4. Angina.
5. Difficult Blood Cross-Match
IMAGING STUDIES ON THIS ADMISSION: Red blood cell scan,
plain films and an angiogram.
PROCEDURES: Angiogram with intraarterial vasopressin
delivery and right colectomy for cecal bleeding.
DISCHARGE STATUS: The patient will be discharged in stable
condition tolerating a regular diet on oral pain medication
to home.
DISCHARGE MEDICATIONS: Percocet one to two tablets po q 4 to
6 hours prn for pain, Zantac 150 mg po q day, Labetalol as
previously dosed. Buspirone, Colace 100 mg po b.i.d. and
Simvastatin per previous dosage.
DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 02.915
Dictated By:[**Last Name (NamePattern1) 33621**]
MEDQUIST36
D: [**2164-2-3**] 13:08
T: [**2164-2-9**] 06:39
JOB#: [**Job Number **]
|
[
"276.5",
"996.64",
"562.12",
"599.0",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"46.73",
"99.15",
"45.73",
"45.13",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
4494, 4954
|
4978, 5401
|
1786, 1889
|
2046, 4472
|
1544, 1759
|
163, 232
|
261, 1374
|
1397, 1520
|
1906, 2028
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,123
| 141,254
|
2462
|
Discharge summary
|
report
|
Admission Date: [**2136-5-4**] Discharge Date: [**2136-5-15**]
Date of Birth: [**2058-7-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
recent vfib arrest
Major Surgical or Invasive Procedure:
redo sternotomy, AVR(21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Porcine)CABGx2(SVG>Ramus>OM),
IABP placement [**5-7**]
History of Present Illness:
77 yo M s/p MI x 2 and CABG x 4 in [**2122**]. Did well until [**2136-2-10**]
when he had a VF arrest and had cardiac cath with LCx and RCA
stents at [**Last Name (un) 1724**]. He was also found to have [**1-24**]+ MR and was
referred for surgery.He wears an external defib life vest.
Past Medical History:
chronic systolic heart failure, CAD s/p CABG x4 95, MI [**01**], 95,
MR, B/L varicosities, HTN, NIDDM, BPH, hyperchol, Afib, COPD,
CRI, external defibrillator, b/l hernia repairs
Social History:
retired engineer
denies tobacco, etoh
lives with wife
Family History:
NC
Physical Exam:
HR 72 RR 18 BP 142/78
Elderly M in NAD
Well healed median sternotomy
Lungs CTAB
Heart Irregular rhythm, +murmur
Abdomen benign
Extrem warm, no edema, 2+ pp
71" 66.6 kg
Pertinent Results:
[**2136-5-14**] 06:45AM BLOOD WBC-10.3 RBC-3.37* Hgb-9.7* Hct-29.5*
MCV-88 MCH-28.9 MCHC-32.9 RDW-16.2* Plt Ct-234
[**2136-5-15**] 05:55AM BLOOD PT-14.1* INR(PT)-1.2*
[**2136-5-14**] 06:45AM BLOOD Glucose-147* UreaN-32* Creat-0.9 Na-133
K-4.8 Cl-94* HCO3-27 AnGap-17
Radiology Report CHEST (PORTABLE AP) Study Date of [**2136-5-14**] 2:56
PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2136-5-14**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 12606**]
Reason: ptx s/p ct removal
[**Hospital 93**] MEDICAL CONDITION:
77 year old man s/p CABG
REASON FOR THIS EXAMINATION:
ptx s/p ct removal
Final Report
CLINICAL HISTORY: 77-year-old male status post CABG. Evaluate
for
pneumothorax status post chest tube removal.
AP chest radiograph compared to [**2136-5-14**] at 10:32 a.m. shows
removal of a
left apical chest tube with subsequent small apical
pneumothorax. The
remainder of the exam is unchanged. The heart size remains
moderately
enlarged. Post surgical changes related to a median sternotomy
and CABG are
redemonstrated. No consolidation is identified. Small bilateral
pleural
effusions persist.
The study and the report were reviewed by the staff radiologist.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 12607**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 12608**]Portable TTE
(Complete) Done [**2136-5-10**] at 3:05:36 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2058-7-7**]
Age (years): 77 M Hgt (in): 70
BP (mm Hg): 110/49 Wgt (lb): 171
HR (bpm): 110 BSA (m2): 1.95 m2
Indication: s/p CABG, AVR
ICD-9 Codes: V42.2, 414.8, 424.0
Test Information
Date/Time: [**2136-5-10**] at 15:05 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) **] F.
[**Doctor Last Name **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W032-1:15 Machine: Vivid [**5-28**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 5.1 cm
Left Ventricle - Fractional Shortening: *0.14 >= 0.29
Left Ventricle - Ejection Fraction: 20% to 25% >= 55%
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aortic Valve - Peak Velocity: *2.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 18 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - E Wave deceleration time: *138 ms 140-250 ms
TR Gradient (+ RA = PASP): *29 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized.
LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity.
Severe regional LV systolic dysfunction. No LV mass/thrombus. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No
MVP. Mild mitral annular calcification. Mild thickening of
mitral valve chordae. Moderate to severe (3+) MR. LV inflow
pattern c/w restrictive filling abnormality, with elevated LA
pressure.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**11-23**]+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is severe regional left ventricular systolic
dysfunction with anterior, anteroseptal and apical akinesis.
There is moderate hypokinesis of the remaining segments (LVEF =
20-25%). Right ventricular chamber size and free wall motion are
normal. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal leaflet
motion and transvalvular gradients. No aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is no mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Dilated left ventricle with severe regional
dysfunction, c/w multivessel CAD. Normally-functioning aortic
valve bioprosthesis. Moderate to severe mitral regurgitation.
Mild pulmonary hypertension.
Brief Hospital Course:
He was admitted to cardiac surgery preoperatively for IV heparin
and preoperative testing. He was taken to the operating room on
[**5-7**] where he underwent redo sternotomy, AVR and CABG x 2 and
IABP placement, please see operative note for details.It was
determined that his AS was more severe than anticipated, with
some MR still present. He was transferred to the ICU in stable
condition on epinephrine and levophed. Chest tube was placed
postoperatively for pneumothorax. IABP was dc'd and He was
extubated on POD #1. He was seen by electrophysiology for ICD
consideration but will continue to wear his life vest for 3
months postop. He was transferred to the floor on POD #3.
Mediastinal tubes removed and left pleural tube remained. Pacing
wires removed without incident. Coumadin restarted for chronic A
Fib. Left chest tube removed with residual small left apical
pneumothorax. He was ready for discharge home on POD #8.
Coumadin to be followed by [**Hospital1 2025**] coumadin clinic as prior to
surgery.
Medications on Admission:
plavix 75, lisinopril 10, lopressor ER 100, metformin 1000",
zetia 10, lipitor 80, flomax 0.4, ASA 162, coumadin MWF 5, TThSS
7.5
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*0*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 days: 5 mg MWF, 7.5 mg TThSSu as prior to surgery. Check INR
[**5-17**] with results to [**Hospital1 2025**] Anticoag Management Service.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
AS s/p AVR/CABG
chronic systolic heart failure
CAD s/p CABG x4 95, MI [**01**], 95, MR, B/L varicosities, HTN, NIDDM,
BPH, hyperchol, Afib, COPD, CRI, external defibrillator, b/l
hernia repairs
Discharge Condition:
Stable.
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 in 10 weeks.
No driving until follow up with surgeon.
Continue wearing life vest as prior to surgery.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 11367**]/Dr. [**Last Name (STitle) 2232**] in 3months - Life vest until f/u visit
Echocardiogram prior to office visit with Dr [**Last Name (STitle) 11367**]
Coumadin per [**Hospital1 2025**] coumadin clinic
Completed by:[**2136-5-15**]
|
[
"428.0",
"427.31",
"496",
"512.1",
"414.01",
"250.00",
"585.9",
"403.90",
"396.2",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"39.61",
"36.12",
"88.72",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9445, 9503
|
6643, 7661
|
294, 442
|
9741, 9751
|
1254, 1847
|
10111, 10480
|
1045, 1049
|
7841, 9422
|
1887, 1912
|
9524, 9720
|
7687, 7818
|
9775, 10088
|
5416, 6620
|
1064, 1235
|
236, 256
|
1944, 5367
|
470, 756
|
778, 958
|
974, 1029
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,570
| 175,329
|
41690
|
Discharge summary
|
report
|
Admission Date: [**2127-1-7**] Discharge Date: [**2127-1-15**]
Date of Birth: [**2062-3-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
[**2127-1-7**]
1. Right thoracoscopy.
2. Right thoracotomy and right upper lobectomy.
3. Mediastinal lymph node dissection.
[**2127-1-9**]
Flexible bronchoscopy with therapeutic suctioning of
secretions from the bronchus intermedius and right middle lobe.
History of Present Illness:
Ms. [**Known lastname **] is a 64 year old woman with a history of emphysema
and a new right lung mass seen on chest CT from OSH. Ms. [**Known lastname **]
was seen in Thoracic Surgery clinic [**2126-10-17**] for an initial
evaluation of this mass. She returns today following repeat
chest
CT which showed slight enlargement of the spiculated right upper
lobe, FDG avid mass.
Since last being seen, Ms. [**Known lastname **] [**Last Name (Titles) 44646**] continued R flank and
iliac pain, for which she continues to be treated with low dose
percocet. She underwent an MRI at an OSH for this pain and was
notable for possible disc herniation as well as possible "spine
cancer" per patient. Aside from this, Ms. [**Known lastname **] says she feels
"a little tired" but otherwise has no complaints, with no SOB,
cough or increased sputum production.
Past Medical History:
Emphysema
osteoarthritis
Social History:
Cigarettes: [ ] never [ ] ex-smoker [X] current
Pack-yrs:_46___
quit: ______
ETOH: [ ] No [x] Yes drinks/day: _5-7___
Drugs:
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation:
Marital Status: [ ] Married [ ] Single [x] Divorced
Lives: [ ] Alone [ ] w/ family [ ] Other: 2
children
Other pertinent social history:
Travel history:
Family History:
Mother: Parkinsons, Arthritis
Father: Died from Liver Cancer at age 56
Physical Exam:
BP: 144/88. Heart Rate: 81. Weight: 114.8. Height: 66.25. BMI:
18.4. Temperature: 97. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 98.
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [x] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal, no tenderness for
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
[**2127-1-6**] 11:00AM WBC-12.7* RBC-3.72* HGB-14.0 HCT-41.9
MCV-113* MCH-37.7* MCHC-33.5 RDW-12.1
[**2127-1-6**] 11:00AM PLT COUNT-414
[**2127-1-6**] 11:00AM PT-12.4 PTT-25.0 INR(PT)-1.0
[**2127-1-7**] 05:48PM GLUCOSE-121* UREA N-10 CREAT-0.5 SODIUM-137
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11
[**2127-1-6**]
Chest CT :
1. Mild interval enlargement of a now 2.1 x 1.6 cm spiculated
right upper
lobe pulmonary nodule with associated adjacent pleural
thickening, presumed malignant.
2. Severe upper lobe predominant pulmonary emphysema.
3. Stable, top normal right hilar, right lower paratracheal and
prevascular lymph nodes.
4. Fusiform dilation of the ascending aorta and moderate aortic
valve
calcification of unknown hemodynamic significance.
[**2127-1-9**] CTA Chest :
1. No pulmonary embolism is main pulmonary artery. Due to
suboptimal
opacification of lobar, segmental and subsegmental branches of
pulmonary
artery, assessment of emboli within these branches was limited.
2. There is no evidence of middle lobe torsion, however, it is
remarkable for complete collapse secondary to the occlusion of
middle lobe bronchus, likely from secretions.
3. Multifocal aspiration in left lung.
4. Complete occlusion of the right bronchus intermedius, likely
from
secrections with partial atelectasis of the right lower lobe.
5. Moderate, nonhemorrhagic, posterior right pleural effusion
with
compressive atelectasis of the adjacent lung, mild right
pneumothorax and
subcutaneous emphysema are likely following recent surgery.
6. Pulmonary artery hypertension.
7. Sever aortic valve calcification, unknown hemodynamic
significance.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the hospital and taken to the
Operating Room where she underwent a right thoracoscopy and
right thoracotomy with wedge resection of the right upper lobe.
See formal Op note for details. She tolerated the procedure
well and returned to the PACU in stable condition. She had an
epidural catheter placed for pain control which was minimally
effective.
Following transfer to the Surgical floor she was able to use her
incentive spirometer and her pain was controlled with a
Bupivacaine epidural and a Dilaudid PCA. Unfortunately her
epidural fell out and her pain medication was changed to
Oxycodone.
Late in the evening of post op day #1 she suddenly desaturated
to the mid 80's and had a pO2 of 54 on 5L NC. She was placed on
a 100% non rebreather and her saturations came up to 90%. Her
chest xray showed a new LL lobe opacity and she subsequently had
a Chest CTA done which ruled out PE but demonstrated RML
collapse due to an occluded right [**Hospital1 **]. Following transfer to the
SICU she underwent a diagnostic and therapeutic bronchoscopy.
She had thick mucous plugging which was aspirated and she
immediately improved. She remained in the ICU for a few
additional days for vigorous pulmonary toilet including
nebulizers, mucolytics, chest PT and incentive spirometry. She
was also placed on a 7 day course of Vancomycin and Zosyn. No
sputum cultures were obtained. She continued to improve daily.
She remained afebrile with a normal WBC (12K prior to starting
ABX). Her chest tube was removed after the serosanguinous
drainage tapered off and her thoracotomy incision was healing.
Following transfer to the Surgical floor she continued to
require oxygen and would desaturate off of it with exertion.
The Physical Therapy service evaluated her and recommended rehab
for pulmonary toilet. Hopefully in time her oxygen will be able
to be weaned off prior to returning home. Although she is small
and slight in stature she is able to tolerate a fair amount of
narcotics and still has some discomfort but she also took
Percocet prior to admission for multiple arthritic aches and
pains. She takes prn Lorazapam at home and has continued on
that but this morning Valium 5 mg was given additionally and was
effective. Replacing the Lorazapam with Valium may be an option
of needed. She was eating well and ambulating frequently. Her
antibiotics will end on [**2127-1-16**]. After a prolonged hospital
course she was discharged to rehab on [**2127-1-15**] and will follow up
in the Thoracic Clinic in 2 weeks.
Medications on Admission:
Folic acid, Antacid, Cigotine smoking cessation aid
Lorazepam 1 mg q hs for insomnia, Vitamins and herbs,
Percocet5/325 [**5-15**] daily, fosamax, zoloft, calcium, fishoil,
zinc, vit B12
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
8. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours).
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for break through pain .
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
14. piperacillin-tazobactam 4.5 gram Recon Soln Sig: 4.5 Gm
Intravenous every eight (8) hours: thru [**2127-1-16**].
15. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Recon Soln Intravenous Q 8H (Every 8 Hours): thru [**2127-1-16**].
16. sodium chloride 3 % Solution for Nebulization Sig: Fifteen
(15) ML Inhalation Q 8H (Every 8 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Nonsmall-cell lung cancer
Post op RLL collapse
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:
* You were admitted to the hospital for lung surgery and
developed pneumonia post op requiring readmission to the ICU.
You've recovered well but you will need to go to rehab for a
short time to regain your strength and continue pulmonary
toilet.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
* You still need oxygen and the nurses at the rehab will help
you wean off of it was you get stronger.
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2127-1-28**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report to the Radiology Department on the [**Location (un) **] of
the [**Hospital Ward Name 23**] Clinical Center 30 minutes prior to your appointment
with Dr. [**First Name (STitle) **] for a chest Xray.
Call Dr. [**Last Name (STitle) 24522**] when you get home from rehab to arrange for a
follow up appointment
Completed by:[**2127-1-15**]
|
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"997.39",
"530.81",
"486",
"305.1",
"V64.41",
"518.0",
"518.51",
"733.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"32.29",
"40.3"
] |
icd9pcs
|
[
[
[]
]
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10160, 10242
|
5702, 8277
|
326, 585
|
10343, 10343
|
4026, 5679
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12056, 12719
|
1980, 2053
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8515, 10137
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10263, 10322
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8303, 8492
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10526, 12033
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2068, 4007
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270, 288
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613, 1465
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10358, 10502
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1487, 1514
|
1946, 1964
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,945
| 182,239
|
5219
|
Discharge summary
|
report
|
Admission Date: [**2181-7-19**] Discharge Date: [**2181-7-23**]
Date of Birth: [**2115-3-11**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
EGD [**2181-7-19**]
IR guided embolization of GDA [**2181-7-20**]
History of Present Illness:
Dr. [**Known firstname **] [**Known lastname 2805**] is a 66 year old man with a history Alport's
syndrome s/p CABG x 4 on [**2181-7-2**] presents from OSH with GI bleed.
After recent discharge from [**Hospital1 18**] for CABG he went to [**Location (un) **]
the recover. A few days ago he started feeling "orthostatic".
Due to decreased potassium on routine labs and weight loss he
believed this was due to over diuresis so he discontinued his
lasix. His lightheadedness persisted and he developed shortness
of breath with activity. He held his antihypertensives
(metoprolol and amlodipine) and [**2181-7-18**] as he believed his
symptoms were due to low blood pressures. That evening he got
up to use the bathroom and lost consciousness. His blood When
in the bathroom he lost consciousness and had a large dark bowel
movement. His son was home and helped him up. He went to the
local Emergency Department where he was found to have a
hematocrit of 15. He was reportedly hemodynamically stable. He
was transfused 3 units of blood overnight and admitted to the
ICU. He had no further bowel movements or emesis. His repeat
hematocrit was 22. He was transfused two additional units and
transported to [**Hospital1 18**] ICU for further management.
.
On arrival to the [**Hospital1 18**] MICU he denied any active symptoms. He
denied any recent chest pain, palpitations, abdominal pain,
gastroenteritis or dizziness at rest. He admits to shortness of
breath and lightheadedness with activity over the last several
days. He admits to a long history of intermittent nausea and
heaving along with a recent episode after his syncopal episode.
He denies seeing any blood in his emesis. On questioning he
admits to dark stools. He denies seeing any frank blood in his
stools. He denies any history of recent alcohol, NSAID, or
steroid use. He takes a daily aspirin 81 mg. He denies a
history of liver disease or bleeding disorders. He admits to
history of EGD years ago and [**Hospital1 336**] for "GI upset" that revealed
an esophageal erosion but he denies any history of GI bleeding.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough. Denied chest pain or tightness, palpitations. No
recent change in bladder habits. No dysuria. Denied arthralgias
or myalgias.
Past Medical History:
Alports syndrome with renal failure (glomerulonephritis,
proteinuria)and hearing loss (bilateral hearing aids) renal
function monitored by Dr. [**Last Name (STitle) 7473**] and is currently being
worked up for transplant.
CAD s/p Coronary Artery Bypass Graft x 4 [**2181-7-2**]
Hypertension
Hyperlipidemia
[**2181-5-23**]: syncope- unclear etiology
Gastroesophageal reflux disease
Gouty attacks due to renal insufficiency
2 stable pulmonary nodules
Elevated PSA with normal biopsy
Anemia d/t renal failure
Colonic polyps
Gallstone
Social History:
Married with children. Denies and use of alcohol, tobacco,
illicit drugs or herbal medications. Employed as a [**Month/Day/Year 21339**]
at [**Hospital1 18**].
Family History:
(Per OMR) Brother had atypical back pain at age 58, diagnosed
with an MI,
s/p CABG. Father had an MI in his late 70s. No history of liver
of bleeding disorders.
Physical Exam:
On [**7-22**]:
VS: T 96.8 HR 99 BP 130/85 RR 20 O2 sat 98% on RA
Gen: AOx3, NAD
HEENT: Moist mucus membranes. No JVD. Neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, ND no g/rt.
Extremities: wwp, trace edema. DPs 2+ and symmetric.
Skin: No rashes
Neuro/Psych: CNs II-XII intact. No focal deficits.
Pertinent Results:
ADMISSION LABS:
.
[**2181-7-19**] 10:41PM HCT-24.7*
[**2181-7-19**] 06:17PM HCT-27.5*
[**2181-7-19**] 01:54PM GLUCOSE-105* UREA N-113* CREAT-5.1*#
SODIUM-140 POTASSIUM-5.6* CHLORIDE-114* TOTAL CO2-16* ANION
GAP-16
[**2181-7-19**] 01:54PM CALCIUM-8.1* PHOSPHATE-4.2 MAGNESIUM-2.0
[**2181-7-19**] 01:54PM WBC-10.9 RBC-3.19* HGB-9.7* HCT-27.8* MCV-87
MCH-30.6 MCHC-35.0 RDW-15.1
[**2181-7-19**] 01:54PM PLT COUNT-325
[**2181-7-19**] 01:54PM PT-11.2 PTT-17.9* INR(PT)-0.9
[**2181-7-19**] 01:54PM RET AUT-2.4
.
[**2181-7-23**] H. pylori IgG- pending
.
Studies:
[**2181-7-19**] ECG: Sinus rhythm with atrial premature depolarizations.
Inferior myocardial infarction of indeterminate age. Diffuse
non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2181-7-2**] there is no diagnostic change.
.
[**2181-7-19**] EGD:
Findings: Esophagus: Long linear erosion from 36 to 32 cm
healing not bleeding
Stomach:
Mucosa: Three Erosions of the mucosa was noted in the antrum of
the stomach.
Duodenum:
Excavated Lesions A single cratered non-bleeding 7 mm ulcer was
found in the posterior bulb. A single cratered 2.5 mm ulcer was
found in the distal bulb and first part of the duodenum. A
visible vessel suggested recent bleeding. 2 2.5 cc.Epinephrine
1/[**Numeric Identifier 961**] injections were applied for hemostasis without success.
A gold probe was applied for hemostasis unsuccessfully. One
triclip was successfully applied for the purpose of hemostasis.
However, the ulcer was hard and very broad and attempts to place
further clips were not successfull. The injection of epinephrine
provoked some bleeding which then stopped.
Impression: Long linear erosion from 36 to 32 cm healing not
bleeding
Erosions in the stomach
Ulcer in the posterior bulb
Ulcer in the distal bulb and first part of the duodenum
(injection, thermal therapy, endoclip)
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
66 year old man with history of Alport's syndrome (CKD and
hearing loss) s/p CABG on [**2181-7-2**] who presents from OSH with GI
bleed.
.
# Blood loss anemia secondary to GI bleed: Patient was admitted
to the MICU, where he underwent EGD which showed a long linear
erosion from 36 to 32 cm (healing not bleeding), erosions in the
stomach, an ulcer in the posterior bulb, and an ulcer in the
distal bulb and first part of the duodenum with visible vessel
(not actively bleeding), which was intervened on with injection,
thermal therapy, and endoclip. He underwent angiogram by IR on
[**7-20**] with prophylactic embolization of the gastroduodenal artery
with Amplatzer vascular plug x 2 via right groin. Patient
received 4 units of blood during his MICU stay and was
transferred to the floor as his hemodynamic status stabilized.
He was started on IV pantoprazole [**Hospital1 **] which was transitioned to
PO pantoprazole on discharge. A serum H. pylori IgG was sent and
was pending on discharge. His symptoms continued to improved-
bowel movements became more brown, less black, and he was able
to tolerate a regular diet. On discharge, patient's hematocrit
was 26.1 - he was hemodynamically stable and feeling well. He
was instructed to have his hematocrit checked on Wed [**7-25**], to be
followed up by Dr. [**Last Name (STitle) **].
.
# CAD: Patient s/p CABG x 4 on [**2181-7-2**]. Metoprolol and aspirin
were initially held due to concern for hemodynamic stability
with GI bleeding. CT surgery was notified and followed patient
during admission. After transfer to the floor, patient's heart
rate was in the 90s with occasional transient jumps above 100.
His blood pressures increased to the 140-150 range. He was
restarted on metoprolol, at a dose of 25 TID and discharged with
instructions to gradually uptitrate this back to his home
regimen of 75 mg TID as his heart rate and blood pressures
allowed. He was also discharged back on his 81 mg of aspirin as
well as misoprostol, with instructions to start taking the
misoprostol [**Hospital1 **] and uptitrate to QID until he followed up with
Dr. [**Last Name (STitle) **].
.
# Chronic renal insufficiency: Patient with known Alports
syndrome being evaluated for renal transplant. Followed by Dr.
[**Last Name (STitle) 7473**] in outpatient. He received 3 amps of bicarb on
admission followed by an additional 3 amps post IR guided
embolization. His urine output and creatinine were monitored
during admission and his creatinine actually trended down to 4.5
from 5.1 on admission.
.
# Hypertension- Patient was initially hypotensive on
presentation in setting of GI bleed. Pressures increased as his
bleeding was stabilized. His amlodipine and metoprolol were
initially held. He was restarted on his metoprolol prior to
discharge at a low dose with instructions to gradually uptitrate
(with close follow up by Dr. [**Last Name (STitle) **]. Amlodipine was held on
discharge with instructions to follow up with Dr. [**Last Name (STitle) **]
before restarting.
.
# Hypercholesterolemia- Patient was continued on his home
statin.
.
#PPX: PPI, pneumoboots followed by ambulation once the patient
was able.
Pending on Discharge:
H. pylori IgG
Medications on Admission:
1. Docusate Sodium 100 mg po bid
2. Amlodipine 5 mg po daily
3. Aspirin 81 mg po daily
4. Atorvastatin 80 mg daily
5. Metoprolol Tartrate 75 mg TID (held the day of presentation)
6. Calcitriol 0.25 mcg po 5 days per week
7. Lasix 20 mg po daily (held for the last several days)
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) 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:*1*
3. Misoprostol 100 mcg Tablet Sig: One (1) Tablet PO with meals
and at bedtime: Please start taking twice daily and gradually
uptitrate to one tablet with meals and at bedtime.
Disp:*120 Tablet(s)* Refills:*1*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Gastrointestinal Bleed
Alports Syndrome
Coronary Artery Disease status post Coronary Artery Bypass Graft
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because you had active
bleeding from your gastrointestinal tract. You underwent an EGD
which showed an ulcer in the first part of your duodenum which
is believed to be the source of your bleeding. The vessel
supplying this area was embolized by interventional radiology to
prevent further bleeding. You received blood transfusions while
you were hospitalized. At the time of discharge, your hematocrit
was stable and you had no signs of active bleeding.
We have made the following changes to your medications:
- please START taking pantoprazole 40 mg twice daily
- please CHANGE your dose of metoprolol from 75 mg three times
daily to 25 mg three times daily; you may uptitrate this
gradually under the guidance of Dr. [**Last Name (STitle) **]
- please START taking misoprostol as indicated until you follow
up with Dr. [**Last Name (STitle) **]; we recommend that you start taking 100
mcg twice daily and gradually uptitrate to 100 mcg with meals
and at bedtime
- please RESTART taking aspirin 81 mg daily
- please STOP taking your amlodipine
- please RESTART your lasix 20 mg daily; you can discuss this
further with Dr. [**Last Name (STitle) 4883**]
You may continue taking your calcitriol and docusate sodium as
you were previously.
Please contact Dr. [**Last Name (STitle) **] or return to the emergency room if
you have black stools, vomit blood, feel lightheaded or have any
other symptoms that concern you.
It was a pleasure taking care of you at the [**Hospital1 18**]. We wish you a
speedy recovery.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] and have your hematocrits
checked as he discussed with you. Your first hematocrit and
electrolyte check will be on Wed [**7-25**] at [**Hospital1 18**] [**Location (un) 620**].
Please follow up with Dr. [**Last Name (STitle) **] at the appointment below:
Department: [**Hospital3 249**]
When: THURSDAY [**2181-8-2**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please follow up at your previously scheduled appointments:
Department: CARDIAC SURGERY
When: THURSDAY [**2181-8-9**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: MONDAY [**2181-11-5**] at 2:00 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
Completed by:[**2181-7-24**]
|
[
"532.40",
"V45.81",
"V12.72",
"285.21",
"389.9",
"759.89",
"272.4",
"285.1",
"403.90",
"585.9",
"530.81",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.44",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
10258, 10264
|
6051, 9225
|
287, 354
|
10479, 10479
|
4089, 4089
|
12203, 13613
|
3529, 3693
|
9583, 10235
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10285, 10458
|
9280, 9560
|
10630, 11146
|
3708, 4070
|
9239, 9254
|
11175, 12180
|
2504, 2778
|
233, 249
|
382, 2485
|
4105, 6028
|
10494, 10606
|
2800, 3333
|
3349, 3513
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,934
| 199,802
|
29912
|
Discharge summary
|
report
|
Admission Date: [**2195-12-18**] Discharge Date: [**2195-12-29**]
Date of Birth: [**2195-12-18**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname **] #1 was the 2220 gram product
of a 34 3/7 weeks twin gestation pregnancy to a
34-year-old G9, P5-7 mother with [**Name (NI) 37516**] [**2196-1-26**].
Prenatal labs included blood type A-positive, antibody
negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative, and GBS unknown. Pregnancy was
notable for spontaneous di-di twins with concordant growth
and normal fetal surveys. Mother did have history of tobacco
and marijuana use, but not during this pregnancy.
Mother presented on the day of delivery with preterm labor.
Ultrasound revealed vertex-transverse lie and given advanced
gestational age, she was taken for C-section delivery.
Membranes were intact at delivery and no fever was noted. At
delivery, twin #1 emerged with good tone and cry, but
required vigorous stimulation, suctioning, and blow-by oxygen
for intermittent apnea and copious secretions. Overall status
gradually improved, and the infant was brought to the NICU on
blow-by oxygen. Apgars were 6 and 8.
PHYSICAL EXAM ON ADMISSION: Weight 2220 grams (50th-75th
percentile), head circumference 32.5 cm (50th-75th
percentile), length 45 cm (25th-50th percentile). Vital
signs: Temperature 98.4, heart rate 170s-180s, respiratory
rate 50s, blood pressure 73/42 with a mean of 54, O2
saturations 70%-80% on room air, 100% with blow-by O2.
General: Well-developed, premature infant responsive to exam,
mild-to-moderate respiratory distress at rest. Skin: Warm,
pink, no rash. HEENT: Fontanel soft and flat. Ears/nares:
Normal. Palate: Intact. Positive respirations bilaterally.
Neck: Supple, no lesions. Chest: Coarse moderate aeration,
mild-to-moderate retractions, and intermittent grunting.
Cardiac: Regular rate and rhythm, no murmur. Abdomen: Soft,
no hepatosplenomegaly, no masses, quiet bowel sounds. GU:
Normal male. Testes: Palpable bilaterally. Anus: Patent.
Extremities, hips/back: Normal. Neuro: Appropriate tone,
mildly diminished activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Baby was started on CPAP after birth and
weaned to room air on day of life 2 and has been on room
air since that time with no spells.
2. Cardiovascular: At birth, baby was stable. Never needed
any cardiovascular stabilization. Has no murmur.
3. Fluid, electrolytes, and nutrition: Baby was started NPO
on fluids and started on feeds on day of life 3. He
worked up on PO feeds since that time and is feeding ad-
lib breast milk 24 or Similac 24 growing well. His current
weight is 2.19 kilograms.
4. GI: Baby had hyperbilirubinemia with a peak of 13.2 on
day of life 8. He required two days of phototherapy.
His rebound bilirubin on [**12-28**] was 8.4/0.5 which
is down from previous.
5. Hematology: At birth, baby's white count was 20.9,
hematocrit was 50.7, and platelets were 242. He has never
required transfusion.
6. Infectious disease: At birth, white count was 20.9 with
54 polys and 1 band. He was started on ampicillin and
gentamicin for 48 hours until blood cultures were
negative. He has had no issues since then.
7. Neurology: Baby has had a normal neuro exam and is in
open crib. He has never needed a head ultrasound.
8. Sensory:
Audiology: Hearing screen was performed with
automated auditory brainstem responses which the baby
passed on [**12-28**].
Ophthalmology: Patient has not been examined secondary to
his advanced gestational age. An ophthalmologic exam is
recommended for 9 months of age for all premies.
CONDITION AT DISCHARGE: Excellent.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20670**] [**Location (un) 6409**]
([**Telephone/Fax (1) 71483**]. Fax ([**Telephone/Fax (1) 71484**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Please continue breast milk 24 or
Similac 24 at home ad-lib PO until about 9 months of age.
2. Medications: Baby is on no medications currently.
3. Car seat position screening: Patient had a car seat
position screening test which was passed.
4. State newborn screening was sent on [**12-21**] and
had an elevated 17-OHP thought to be secondary to birth
stress. An electrolyte panel was done and was
normal. A repeat newborn screen is currently pending.
5. Immunizations received: Baby received hepatitis B
vaccination on [**2195-12-27**] and synagis vaccination on
[**2195-12-29**].
6. Immunizations recommended:
A. Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1) born at less
than 32 weeks; 2) born between 32-35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
or school-age siblings; or 3) with chronic lung disease.
B. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the 1st 24 months of the child's
life, immunization against influenza is recommended for
household contacts and out-of-home caregivers.
7. Follow-up appointments scheduled/recommended: Baby will
follow up with PCP [**Last Name (NamePattern4) **] [**2195-12-30**]. VNA has been
called for home visit.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Rule out sepsis.
3. Respiratory distress resolved.
4. Abnormal newborn screen - repeat pending
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 69933**]
MEDQUIST36
D: [**2195-12-29**] 08:25:25
T: [**2195-12-29**] 09:02:59
Job#: [**Job Number 71485**]
|
[
"774.2",
"770.81",
"779.3",
"V29.0",
"779.89",
"769",
"V05.3",
"796.4",
"765.27",
"V31.01",
"765.18"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55",
"99.15",
"93.90",
"96.6",
"99.83"
] |
icd9pcs
|
[
[
[]
]
] |
3783, 3991
|
5599, 5997
|
4013, 4023
|
2180, 3732
|
4037, 4658
|
4689, 5578
|
1223, 2152
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,553
| 194,571
|
3339
|
Discharge summary
|
report
|
Admission Date: [**2165-5-8**] Discharge Date: [**2165-5-13**]
Date of Birth: [**2119-11-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
vision changes, headache
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Patient is a 45yo male with PMH of multiple kidney stones,
question gouty arthritis, and an episode of 1 week of hematuria
1 year ago who presents with hypertensive emergency
characterized by SBP244, visual changes, and headache. Patient
had sudden onset [**4-25**] bitemperal headache yesterday, with
associated slurred speech, blurry vision and visual field
changes and diaphoresis. He also had pain behind his left knee.
He denies other focal neurological deficits, and denies chest
pain, palpitations, dyspnea, N/V/D. He took aspirin with
improvement of symptoms later during the day. His symptoms
improved after sleep, with 1/10 headache this morning. He came
to the ED after being told that this could be stroke.
In the ED, initial vitals were T:98.8 HR:98 BP:244/162 RR:16
O2sat:100%. Patient was noted to be diaphoretic, with
unremarkable optic disks, normal cardiopulmonary exam, and
non-focal neurologic exam. His SBP maximum was 255 in the ED.
ECG showed sinus tachycardia, with evidence of LVH and ST
elevation in V1. Troponin was elevated at 0.04. Creatinine was
also elevated at 1.8 with unknown baseline. Patient received
labetalol 20 mg IV x 3, followed by labetalol gtt with goal 25%
reduction in blood pressure. Chest X-ray was unremarkable and
non-contrast CT head showed no signs of bleed or acute
pathology. On transfer to the unit, he had labetalol gtt at 0.5
with SBP to the 190's.
.
On arrival to the MICU, vital signs were T:98.5 BP:190/125 P:76
R:18 O2:96% Room air. He did not have headache, blurry vision,
or
Past Medical History:
renal stones x3, did not seek medical attention
hematuria for one week last year, did not seek medical attention
broken collar bone
Social History:
- Tobacco: quit smoking 14 years ago, no other tobacco
- Alcohol: drinks 2-3 wines per night, on the weekend drinks [**12-17**]
pint of scotch and several beers
- Illicits: denies ever using
-single, lives alone, not sexually active
-drinks herbal teas 2-3 per day, namely "liquid gold" tea and
monkey-picked oolong tea from Tevana
-owns and operates a privste pharmacy
Family History:
grandfather had diabetes and had an amputation
mother has had multiple hospital visits for renal stones
brother has CAD
no cancers or tumors in the family that he knows of
Physical Exam:
Admission exam
Vitals: T:98.5 BP:190/125 P:76 R:18 O2:96% Room air
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Discharge exam
VS: 98.2 180/102 (150-180-88-118) 76 (76-91) 16 98RA
General: pleasant, well appearing gentleman, NAD, alert and
oriented
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1, S2, no murmurs/rubs/gallops
Lungs: clear to auscultation b/l, no wheezes/rhonchi/crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, normal muscle strength and sensation
throughout, no visual field deficit
Pertinent Results:
Admission labs
[**2165-5-8**] 11:00AM BLOOD WBC-6.4 RBC-5.48 Hgb-16.2 Hct-47.6 MCV-87
MCH-29.5 MCHC-34.0 RDW-12.5 Plt Ct-233
[**2165-5-8**] 11:00AM BLOOD Neuts-64.8 Lymphs-27.0 Monos-4.5 Eos-2.4
Baso-1.3
[**2165-5-8**] 11:00AM BLOOD PT-10.4 PTT-30.8 INR(PT)-1.0
[**2165-5-8**] 11:00AM BLOOD Glucose-88 UreaN-18 Creat-1.8* Na-139
K-3.4 Cl-99 HCO3-28 AnGap-15
[**2165-5-8**] 11:00AM BLOOD cTropnT-0.04*
[**2165-5-8**] 08:09PM BLOOD cTropnT-0.04*
[**2165-5-8**] 11:00AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.0
[**2165-5-8**] 11:00AM BLOOD TSH-2.1
[**2165-5-8**] 11:00AM BLOOD Cortsol-13.7
[**2165-5-8**] 11:00AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2165-5-8**] 11:18AM BLOOD Lactate-1.6
aldosterone....pending
metanephrines...pending
renin...pending
Urine
[**2165-5-8**] 12:29PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2165-5-8**] 12:29PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR
[**2165-5-8**] 12:29PM URINE RBC-<1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1
[**2165-5-8**] 12:29PM URINE Mucous-OCC
[**2165-5-8**] 12:29PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Imaging
ECG (admission) sinus tachycardia, with evidence of LVH and ST
elevation in V1
CT head w/o contrast
1. No evidence acute intracranial process.
2. Findings suggesting inflammatory sinus disease.
Renal ultrasound (prelim report)
The right kidney measures 11.7 cm.
The left kidney measures 12.3 cm.
Both kidneys are normal without hydronephrosis, stone, or mass.
The bilateral renal arteries and main renal veins are patent.
The main renal and segmental arteries demonstrate normal
waveforms with sharp upstroke and normal resistive indices. The
bladder is moderately distended and appears normal.
IMPRESSION: Normal renal duplex ultrasound.
ECHO:
IMPRESSION: Normal left ventricular cavity size with severe
symmetric left ventricular hypertrophy and mildly depressed left
ventricular systolic function with wall motion abnormalities as
described above. Increased left ventricular filling pressure.
Mildly dilated ascending aorta. Mild aortic regurgitation.
Indeterminate pulmonary artery systolic pressure.
abdominal u/s:
IMPRESSION: Diffusely mildly ectatic aorta with no focal
aneurysm identified.
Discharge labs:
[**2165-5-13**] 07:50AM BLOOD WBC-5.7 RBC-4.43* Hgb-13.9* Hct-38.8*
MCV-88 MCH-31.5 MCHC-36.0* RDW-12.7 Plt Ct-170
[**2165-5-13**] 07:50AM BLOOD Glucose-94 UreaN-15 Creat-1.4* Na-140
K-4.3 Cl-105 HCO3-28 AnGap-11
[**2165-5-13**] 07:50AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0
Brief Hospital Course:
Patient is a 45yo male with PMH of multiple kidney stones,
question gouty arthritis, and an episode of 1 week of hematuria
1 year ago who presents with hypertensive emergency
characterized by SBP244, visual changes, and headache. He was
started on labetalol gtt in the ED and transferred to the unit
for emergent blood pressure management.
# Hypertensive emergency: Patient noticed blurry vision,
headache, diaphoresis, and leg pain on the day prior to
admission and was found to have SBP 244 in the ED. He was
initially admitted to the MICU for hypertensive emergency and
started on labetolol drip which improvement in his symptoms.
While in the MICU, his pressures dipped into the 130's systolic
and the patient was briefly started on neo drip. Neo drip was
soon stopped and the patient was weaned off labetolol drip and
was called out of unit after being started on captopril 25 mg
TID. His blood pressure regimen was ultimately uptitrated and
upon discharge he was taking Labetolol 200 mg [**Hospital1 **], and
lisinopril 20 mg daily, as well as Lasix 10 mg daily. While in
the unit, work up for secondary HTN was initiated and [**Male First Name (un) 2083**],
renin, and metenphrine levels were checked. TSH and cortisol
were normal. Renal u/s was negative for any e/o renal artery
stenosis. The patient also had normal A1c. Cholesterol was
slightly above normal, and was started on a statin as well.
While on the general medical [**Hospital1 **], the patient's pressures were
maintained in the 150-170 range as much as possible so as to
ensure adequate cerebral perfusion in the setting of his likely
chronically elevated high blood pressure.
The patient also had ECHO done to assess for any evidence of
heart dysfunction given his likely chronic HTN (see below). The
patient also had abdominal ultrasound for AAA screening.
# [**Last Name (un) **] vs. more likely CKD III due to longstanding hypertension:
Unclear what the patient's baseline creat is; likely high in the
setting of his uncontrolled HTN. Admission Fena 1.5%. The
patient's creatinine was monitored, and ultimately downtrended
to 1.4 by discharge. Renal ultrasound was negative for any
obstruction, or e/o renal artery stenosis. Medications were
renally dosed and nephrotoxic agents avoided.
# focal wall motion abnormalities: The patient was found to
have evidence of hypokinesis on recent ECHO, and very slight
wideinging of the ascending aorta with slight AoR. His
abdominal u/s was negative for AAA, revealing only a diffusely
ectatic aorta with calcification. This WMA on echocardiogram
likely represents a prior myocardial infarction. EKG from this
admission with e/o LVH, but no evidence of ischemia or Q waves.
The patient was also ruled out for ACS by serial troponin T
assay. He was continued on Lisinopril, Labetolol, and Lasix as
above. He was also discharged on ASA and a statin (given likely
prior MI and LDL over 100).
# Etoh use: The patient drinks 2-3 glasses of wine daily, with a
half pint of scotch on the weekend. He reports that his last
drink was two days prior to admission. The patient was
monitored for s/s withdrawal, but never needed treatment for
withdrawal. He was counseled to abstain from etoh given his
severe hypertension.
Transitional Issues:
- The patient will need to have his labs checked at his next
follow up appt. He was started on Lasix upon discharge, and
will need his electrolytes checked.
Medications on Admission:
none
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
6. blood pressure cuff (OMRON)
diagnosis: hypertension
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
hypertensive emergency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 15513**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you were
having a headache and changes in your vision. You were found to
have a VERY elevated blood pressure. You were initially
admitted to the intensive care unit because of this. We
controlled your blood pressure and we started you on medications
to help control it.
It is VERY important that you take these medications, as well as
follow up with a primary care doctor (see below for
appointments). Moreover, you were also found to have some heart
and kidney dysfunction, which we think is all related to having
long-standing high blood pressure. Please also see a heart and
kidney specialist (appts below). It will also be important to
check your labs in one week, as the Lasix can cause some
abnormalities in your electrolytes.
Please get a blood pressure cuff and check your pressures once
daily. Please call your doctor if you have any light
headedness, dizziness, headache, blurry vision, new
numbness/tingling, or any other symptoms that concern you.
Please start the following medications:
Labetolol 200 mg by mouth twice daily
Lisinopril 20 mg by mouth daily
Simvastatin 20 mg daily
Aspirin 81 mg daily
Lasix 10 mg by mouth daily
Followup Instructions:
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
When: MONDAY [**2165-5-20**] at 3:20 PM
With: Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NOTE: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2165-5-22**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], 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
Department: CARDIAC SERVICES
When: MONDAY [**2165-5-27**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2165-7-10**] at 3:00 PM
With: [**Name6 (MD) 15514**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NOTE: Dr [**Last Name (STitle) **] is a resident and your new physician in [**Name9 (PRE) 191**].
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] over sees this doctor and both will be
involved in your care. You will need to call your insurance
company and name Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as your Primary Care
Physician. [**Name10 (NameIs) **] MUST BE DONE BEFORE YOUR FOLLOW UP APPT ON [**5-20**] IN THE [**Hospital 894**] CLINIC.
Completed by:[**2165-5-14**]
|
[
"305.01",
"403.00",
"584.9",
"274.00",
"412",
"447.72",
"585.3",
"276.8",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10646, 10652
|
6581, 9832
|
328, 336
|
10738, 10738
|
3943, 6269
|
12232, 14374
|
2468, 2642
|
10067, 10623
|
10673, 10673
|
10038, 10044
|
10889, 12209
|
6286, 6558
|
2657, 3924
|
9853, 10012
|
264, 290
|
364, 1907
|
10692, 10717
|
10753, 10865
|
1929, 2063
|
2079, 2452
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,464
| 120,511
|
1736
|
Discharge summary
|
report
|
Admission Date: [**2120-9-19**] Discharge Date: [**2120-10-17**]
Date of Birth: [**2051-3-9**] Sex: F
Service: SURGERY
Allergies:
Protonix
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Mass in pancreatic head
Major Surgical or Invasive Procedure:
[**2120-9-19**]
1. Pylorus preserving pancreaticoduodenectomy.
2. Open cholecystectomy.
[**2120-9-26**]
1. Revision and repair of dehisced pancreaticojejunostomy.
2. Feeding jejunostomy-combined gastrostomy tube placement.
History of Present Illness:
Mrs. [**Known lastname 3075**] is a 72-year-old woman who underwent a right
nephrectomy several years ago for a right kidney cancer.
Unfortunately she has recurred in that
she has a large mass in the head of her pancreas which is a
metastasis from the renal cell cancer. It has eroded through the
duodenal wall and has been causing recalcitrant gastrointestinal
bleeding necessitating continual transfusions of packed red
blood cells. This is also disqualifying her from certain types
of antitumor therapy. The patient is now admitted for resection
of the lesion by Whipple pancreaticoduodenectomy.
Past Medical History:
Metastatic renal cell cancer (mets to parotids, lung, pancreas)-
dx'ed in [**2111**], s/p R nephrectomy- [**2111**]
h/o +PPD
HTN
TIA
osteoporosis
Social History:
works as receptionist at [**Hospital **] Medical Society
no tobacco, quit 40 years ago
no alcohol
Family History:
lung cancer- father
Physical Exam:
On physical exam
Gen: well-nourished, relatively thin, no acute distress
[**Name (NI) 4459**]: No jaundice, absent parotid gland on the left, but
otherwise, her head and neck exam is unremarkable. She has no
jugular venous distention.
Pulm: Her respiratory rate is unlabored, and her breath sounds
symmetrical.
CV: Her cardiac rate and rhythm is normal.
ABD: Her abdomen is soft, nondistended, and nontender with no
masses at all.
Ext: Extremities show no edema.
Pelvic and rectal exam were not
performed.
Pertinent Results:
[**2120-9-19**] 02:17PM BLOOD WBC-12.5* RBC-4.06* Hgb-10.9* Hct-32.3*
MCV-80* MCH-26.9* MCHC-33.7 RDW-15.6* Plt Ct-372
[**2120-9-19**] 02:17PM BLOOD PT-14.1* INR(PT)-1.3
[**2120-9-19**] 02:17PM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-139
K-5.0 Cl-108 HCO3-23 AnGap-13
[**2120-9-26**] 10:35AM BLOOD ALT-30 AST-25 CK(CPK)-25* AlkPhos-323*
Amylase-55 TotBili-1.0 DirBili-0.5* IndBili-0.5 Lipase-27
[**2120-9-20**] 02:14PM BLOOD Calcium-8.1* Phos-4.9* Mg-1.5*
[**2120-9-29**] 03:05AM BLOOD Triglyc-80
[**2120-9-26**] 03:08AM URINE Hours-RANDOM Creat-147 Na-73 K-73 Cl-69
Calcium-1.7 Phos-152.1 Mg-2.6 HCO3-LESS THAN DIAGNOSIS:
PATHOLOGY REPORT [**2120-9-19**]
I Gallbladder and proximal jejunum (A-D):
a) Chronic cholecystitis, mild.
b) Small bowel segment, with chronic inactive inflammation. (see
note #1).
II Pancreas, Whipple procedure (E-Y):
1. Metastatic renal cell carcinoma, 6.7 cm, involving the
duodenum and pancreas (see note #2).
2.All resection margins are free of tumor.
3. Five regional lymph nodes, no malignancy identified (0/5).
4. Small foci of inactive chronic pancreatitis.
5. Rare focus of pancreatic intraepithelial neoplasia (PanIN,
grade I).
6. Chronic focally active duodenitis (see note #1).
Note:
1. The duodenal and jejunal mucosa show chronic inflammation
with marked villous shortening, probably related to stasis and
bacterial proliferation. Other causes including celiac disease
should also be considered.
2. The tumor morphology is consistent with that of a
conventional (clear cell) renal cell carcinoma. Approximately
60% of the tumor cells have granular eosinophilic cytoplasm.
Approximately 15% of the tumor showed spindle cells
(sarcomatoid) growth. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 9885**] reviewed the tumor slides.
Brief Hospital Course:
Patient was admitted on the day of surgery after undergoing
pre-admission testing previously. The patient underwent a
Whipple procedure for excision of the mass in the head of her
pancreas. She tolerated the procedure well and was extubated
post-op. She was followed as per typical Whipple clinical
pathway. She remained NPO with an NG tube in place and was on
bed rest immediately post-op. The patient was out of bed
beginning POD#2. The NG tube, epidural catheter, and the foley
were removed on POD#3. The patient was pain controlled with a
PCA after the epidural was d/c'd. The patient was seen by
physical therapy on POD#3 and followed the patient throughout.
The patient's central line was d/c's on POD#4 and the patient
was started on sips of clear liquids. The diet was advanced to
clear liquids on POD#5 and Reglan was started. Her JP drain was
pulled on the evening of POD#5. The patient began to feel some
abdominal discomfort later that night. She continued to feel
abdominal discomfort the following day and she required fluid
boluses for blood pressure control on the night of POD#[**7-16**]. She
then began to develop abdominal pain, with a CT scan on the
morning of [**9-26**] that demonstrated that she was leaking on
the basis of a presumed enteric dehiscence from either the
pancreatic, biliary or duodenojejunostomy anastomoses. She was
emergently returned to the operating room on [**9-26**]. While she
required quite a bit of fluid before she went into the operating
room, she was reasonably stable hemodynamically but had a low
urine output and the operation was performed on an emergency
basis. A revision of the pancreaticojejunostomy was performed
and a feeding G-J tube was placed. Antibiotics were started
(Vanco, Levo, Flagyl) for positive cultures from the OR (strep
viridans, enterococcus, & gram-negative rods). The patient was
transferred to the SICU post-op and remained there until [**2120-10-12**].
She failed extubation on the first attempt [**10-4**]. This was
likely due to pulmonary edema from overall total body fluid
overload. She self-extubated on [**10-7**]. She was diuresed
aggressively while in the SICU. After extubation she remained
stable but had one episode of respiratory distress manifested by
an acute desaturation which was possibly an episode of flash
pulmonary edema. She was continued on diuresis and did well
after this episode. She also had a very brief episode of Afib
and was started on an amiodarone drip on [**10-9**]. She swiftly
converted back to normal sinus and remained stable thereafter on
PO amiodarone. Cycled cardiac enzymes at that time were
negative and an echo performed later was unchanged from previous
reports with a normal LVEF. She was seen by ophthomology and
neurology for a visual field deficit and was noted to have a
condition compared to [**Doctor Last Name 4116**] syndrome. A head CT revealed
bilateral effacement of the occipital sulci. MRI showed
bilateral occipital signal abnormalities consistent with
posterior reversible encephalopathy syndrome. An MRA as well as
bilateral carotid ultrasound showed no pathology. The patient
will need to be followed by neurology for this finding as an
outpatient. The patient was transferred to the floor on [**10-12**] and
continued to progress. She was tolerating a regular diet,
ambulating, and had normal bowel function upon discharge.
Medications on Admission:
Prevacid, Fe, Calcium
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-11**]
Drops Ophthalmic PRN (as needed).
3. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times
a day).
12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Renal cell cancer with metastasis to pancreatic head.
Discharge Condition:
Good
Discharge Instructions:
Please call if you experience new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also, call if your wound becomes red, swollen, warm, or produces
pus.
Followup Instructions:
Please call Dr.[**Name (NI) 9886**] office for follow-up. [**Telephone/Fax (1) 476**]
Please follow-up with neurology for your visual deficits
|
[
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"567.2",
"401.9",
"997.4",
"998.59",
"428.0",
"535.60",
"427.31",
"785.52",
"575.11",
"518.5",
"197.8",
"038.9",
"197.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"54.59",
"46.93",
"99.15",
"00.17",
"96.72",
"52.7",
"51.22",
"96.6",
"99.07",
"46.39",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8388, 8467
|
3816, 7218
|
291, 516
|
8565, 8572
|
2007, 3793
|
8809, 8955
|
1445, 1466
|
7290, 8365
|
8488, 8544
|
7244, 7267
|
8596, 8786
|
1481, 1988
|
228, 253
|
544, 1144
|
1166, 1313
|
1329, 1429
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,617
| 132,697
|
30278
|
Discharge summary
|
report
|
Admission Date: [**2111-10-1**] Discharge Date: [**2111-10-7**]
Date of Birth: [**2085-8-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
25 [**Last Name (un) 9232**] with MG s/p thymectomy, xrt on prednisone and mestinon.
presenting with 1.5 weeks of DOE. Notes tachycardia when
walking up stairs and positional. She was evaluated by her
neurologist at [**Hospital1 **], where echo performed with mild MR, EF 60%,
ekg, nl, CTA with possible radiation pneumonitis in the upper
lobes L>R, where she presented to [**Hospital1 18**].
.
She only complains of recent DOE increasing, and associated
tachycardia, no n/v/fc/eye weakness, mouth weakness, otherwise
recently was treated with keflex for cellulitis on foot.
Past Medical History:
Raynaud's phenomenon
Arthritis in bilateral knees as teenager
MG- noted initially [**12-21**]- with drooping of R eyelid, started on
mestinon [**1-21**], s/p thymectomy in [**4-20**], then xrt 28cycles last on
8/107, now on mestinon/prednisone
Social History:
She lives alone at the medical school, is a lifelong nonsmoker,
does not drink, and has no other toxic exposures.
Family History:
Notable for type 1 diabetes mellitus and asthma.
She has a brother with hyperthyroidism and her father has a
history of prostate cancer. A maternal aunt has breast cancer.
There is no history of autoimmune disease other than the above.
Physical Exam:
99.1 62 105/59 15 98RA
GEN: NAD, thin, pleasant,
HEENT: PERRL, EOMI, OP Clear,
CHEST: CTA b/l
CV RRR no mrg
ABD +BS nt/nd
EXT no c/c/e
NEURO: AAox3, CNII-CNXII intact, no focal deficits
Pertinent Results:
INTIAL LABS/ WORK UP:
[**2111-9-30**] 09:45PM BLOOD WBC-8.8 RBC-4.13* Hgb-10.1* Hct-32.1*
MCV-78*# MCH-24.6*# MCHC-31.6 RDW-14.2 Plt Ct-433#
[**2111-9-30**] 09:45PM BLOOD Neuts-83.4* Lymphs-12.0* Monos-4.3
Eos-0.2 Baso-0.1
[**2111-9-30**] 09:45PM BLOOD Glucose-93 UreaN-12 Creat-0.8 Na-140
K-3.8 Cl-100 HCO3-26 AnGap-18
[**2111-9-30**] 09:45PM BLOOD LD(LDH)-190
[**2111-10-2**] 04:21AM BLOOD ALT-13 AST-11
[**2111-9-30**] 09:45PM BLOOD Iron-18*
[**2111-10-2**] 04:21AM BLOOD Calcium-9.8 Phos-5.0*# Mg-2.3
[**2111-9-30**] 09:45PM BLOOD calTIBC-519* VitB12-296 Ferritn-2.8*
TRF-399*
[**2111-10-2**] 04:21AM BLOOD Ferritn-5.9*
[**2111-10-2**] 04:21AM BLOOD TSH-1.5
[**2111-10-2**] 04:21AM BLOOD T4-10.2
[**2111-10-1**] 07:45PM BLOOD Type-ART pO2-170* pCO2-34* pH-7.50*
calTCO2-27 Base XS-4
[**2111-10-1**] 07:45PM BLOOD Lactate-1.4
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Transmitral
Doppler E>A and TDI E/e' <8 suggesting normal diastolic
function, and normal LV filling pressure (PCWP<12mmHg). No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Normal aortic valve leaflets (3). Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal mitral valve supporting structures. Normal LV inflow
pattern for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. Mild (1+) aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal regional and global biventricular function.
Mild aortic regurgitation.
CT CHEST W/O CONTRAST
Reason: ? evidence of radiation injury
[**Hospital 93**] MEDICAL CONDITION:
26 year old woman with history of myasthenia s/p thymectomy and
radiation now with dyspnea
REASON FOR THIS EXAMINATION:
? evidence of radiation injury
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Myasthenia [**Last Name (un) 2902**], status post thymectomy and
radiation therapy with dyspnea.
TECHNIQUE: Multidetector thin section images were obtained
through the chest without contrast in lung and standard
algorithm. Coronal reformatted images were obtained.
COMPARISON: CT chest [**2111-3-24**] and [**2111-2-8**]. Chest radiograph
[**2111-9-30**].
CT CHEST WITHOUT CONTRAST:
Findings: The tracheobronchial tree is normal. Bilateral
paramediastinal radiation fibrosis, left greater than right is
mild-to moderate. There are no nodules, masses or areas of
airspace consolidation.
The patient is status post median sternotomy and thymoma
resection. A focus of anterior mediastinal soft tissue (2:26)
measures 1.6 cm. Metallic clips are noted in the superior
mediastinum. The heart size and great vessels are normal. There
is no pericardial or pleural effusion. There is no nodularity of
the pleural surfaces. No pathologic enlargement of central lymph
nodes by size criteria.
Limited evaluation of the subdiaphragmatic region shows
unremarkable the imaged portions of the liver, spleen and
kidneys. The adrenal glands are normal.
There are no bony findings of malignancy.
IMPRESSION:
1. New mild paramediastinal lung radiation fibrosis.
2. Status post thymoma resection. Focal anterior mediastinal
soft tissue may represent postoperative changes, but given the
propensity of thymoma to locally recur, this area should be
reevaluated in the future with contrast- enhanced CT scan in no
more than six months.
Brief Hospital Course:
Ms. [**Known lastname 10528**] is a 26 year old woman diagnosed with of myasthenia
[**Last Name (un) 2902**] in [**2110-12-15**], now s/p thymectomy ([**4-20**]) and XRT in
[**7-21**] who presented 2 days prior to admission here (on [**9-29**]) to
her neurologist for routine follow up and reported progressive
dyspnea. She was evaluated at [**Hospital6 **] by her
neurologist and cardiologist with work up including ECG, CXR,
Echo and CTA chest with question of radiation pneumonitis. She
was referred to [**Hospital1 18**] because she had thymectomy and XRT here
(Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] respectively). She was admitted [**10-1**].
She reported progressive dyspnea over the last two weeks along
with palpitations. On further history, it seems that
tachycardia is antecedent to dyspnea. Her course here has been
significant for:
.
1.Dyspnea/Tachycardia: Within a few hours of telemetry
monitoring, patient noted to have significant tachycardia with
minimal exertion. At rest her heart rate was in the 70's to
80's but with activity rate to 140's to 160's. Sinus rhythm
throughout on telemetry and ECGs. Patient had repeat chest CT
which demonstrated post surgical and radiation changes not
consistent with radiation pneumonitis and not sufficient to
explain dyspnea/tachycardia. Hematocrit 30, TSH wnl 1.5. CTA
reviewed from [**Hospital1 **], no evidence of pulmonary embolus. Patient
hydrated with change in tachycardia/dyspnea. Repeat cardiac
echo with preserved EF, no pulmonary hypertension, pericardial
effusion or other abnormality to explain. Patient was
transferred to the ICU night of HD#1 with concern that symptoms
could represent worsening of myasthenia [**Last Name (un) 2902**], diaphragmatic
compromise. She was monitored overnight by RT with q4 hour NIFs
which ranged 53-64 and vital capacities (3-3.3L). Minimal
elevation of left hemidiaphragm on CT but no felt to be in
myasthenic crisis. Therefore, returned to the floor on [**10-2**]
evening. Patient underwent PFT's which showed decrease in FVC,
FEV1, DLCO with increased FEV1/FVC. (see report ).
Changes were mild and felt consistent with post
surgical/radiation changes and also related to left hemidiaghram
but did not clearly indicate restrictive disease or progression
of MG.
Neurology at [**Hospital1 18**] and Dr. [**First Name (STitle) **] from [**Hospital1 **] involved. Multiple
pulmonary consultants as well.
Diagnostic possibilities included primarily:
a)surgical or fibrotic injury to vagal system
b)dysautonomia from MG
c)POTS-postural orthostatic hypotension syndrome
d)dysautonomia from concurrent undiagnosed AI or paraneoplastic
disease, or
e) radiation injury to vagus.
As per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], radiation oncology, radiation injury
very unlikely and literature review without definite cases.
Decision made to pursue autonomic etiologies and attempt to
control rate/symptoms by HD#3. Therefore on [**10-3**], decision
made to initiate beta blocker in attempt to control symptoms.
Beta blocker was titrated over [**10-4**] with good effect on heart
rate and symptoms.
.
2. Myasthenia [**Last Name (un) **]: As above. Maintained on prednisone and
mestinon throughout stay. Symptoms largely controlled
.
3. Severe iron deficiency with anemia: Microcytic with ferritin
of 2.8. Crit around 30. Given ferrlicet x 1 and started on PO
replacement. Recommend colonoscopy/EGD as outpatient. No
evidence of bleeding. Denies heavy menses.
4. B12 deficiency: Given IM shot x 1 and then started on 2000mcg
daily.
.
# ? Mass on CT Chest- Concerning for thymoma recurrence. Have
outside CT from [**Hospital3 **]. Should have follow-up scan, and
discuss ongoing management with primary MG physician and ENT
surgeon.
- Needs follow-up imaging, discussion with regular care team
Medications on Admission:
Prednisone 60mg/50mg QOD
Mestinon 60-90 q4h
Lorazepam
OCP
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*60 Tablet(s)* Refills:*2*
2. Prednisone 50 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Lopressor 50 mg Tablet Sig: one half Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Postural tachycardic syndrome
myasthenia [**Last Name (un) 2902**]
Discharge Condition:
stable
Discharge Instructions:
You were admitted with dyspnea and tachycardia and found to have
postural tachycardic syndrome. You will need to take the beta
blocker prescribed and continue to wear the compression
stockings while you are active during the day. You should call
your PCP or return to the ER at [**Hospital1 18**] if you develop worsening
shortness of breath, palpitations, or new symptoms.
Followup Instructions:
Dr. [**Last Name (STitle) 1274**] at [**Telephone/Fax (1) 8139**] on Friday [**10-16**] at 11AM in Shipiro
[**Location (un) **]
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-12-4**] 5:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21833**], MD Phone:[**0-0-**]
Date/Time:[**2111-12-10**] 2:00
You will also need to follow up with your PCP regarding your
iron deficiency anemia. Your hematocrit should be rechecked in
one month. Please continue to take your iron supplementation
daily (take with vitamin C).
|
[
"443.0",
"358.00",
"280.9",
"337.9",
"427.89",
"266.2",
"786.09"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11221, 11227
|
6122, 10000
|
319, 326
|
11338, 11347
|
1812, 4335
|
11771, 12358
|
1350, 1589
|
10108, 11198
|
4372, 4463
|
11248, 11317
|
10026, 10085
|
11371, 11748
|
1604, 1793
|
276, 281
|
4492, 6099
|
354, 933
|
955, 1201
|
1218, 1334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,502
| 100,182
|
43461
|
Discharge summary
|
report
|
Admission Date: [**2165-4-29**] Discharge Date: [**2165-5-15**]
Service: MEDICINE
Allergies:
Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Chest pain, total body pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o F with PMHx of CAD, CHF with EF of 40%, recent admission
with respiratory failure requiring intubation who presents with
total body pain and chest pain. The patient's current symptoms
began on Saturday with nausea. The following day (one day prior
to admission), the patient experienced aching throughout her
body, including her back, chest, and the back of her head. This
morning, the patient awoke from sleep at 6am due to right index
finger pain, erythema, swelling, and calor which then spread to
the rest of her body (back, chest, back of head). Finger pain
is described as stiff, sore, and achy with associated calor.
Total body pain is described as sharp body aches which is
generalized, which lasted until she received Morphine in the ED.
The patient describes chest pain along with her total body
pain, and received SL Nitro x3 without relief. The pain had
similar features to her prior anginal equivalent, during which
she experienced chest pain, shortness of breath, and upper back
pain, but her current pain consists of nausea without dyspnea or
lightheadedness.
.
In the ER, vitals were T99.9 BP 156/61 P76 R18 PO2 100% 2L.
Chest pain was [**7-18**] on arrival and she was started on a nitro
gtt without significant relief of symptoms. However, symptoms
resolved with morphine, currently 0/10. EKG revealed sinus
rhythm with baseline LBBB and no acute EKG changes. She
received Morphine and a 500cc bolus while en route with EMS, and
received additional Morphine in the ED.
.
On evaluation on the floor, pt was asymptomatic and complaining
of thirst. She denies PND, reports 2 pillow orthopnea which has
remained unchanged for years.
.
.
REVIEW OF SYSTEMS:
She 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. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. Denies fevers/chills,
night-sweats, abdominal pain, diarrhea, dysuria, rash. She does
report (+) congestion/cough with white sputum since
hospitalization, helped by albuterol. 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, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
# Diabetes
# Dyslipidemia
# Hypertension
# Coronary Disease - s/p NSTEMI [**9-16**] medically managed and Cath
s/p stent in [**3-20**].
# Chronic systolic/diastolic congestive heart failure, most
recent EF>60%
# Chronic renal failure, stage III CKD - Dr [**Last Name (STitle) **]
# Hypertension
# Hyperlipidemia, intolerant of statins
# Type 2 diabetes, diet-controlled
# GERD
# Breast Cancer - diagnosed in [**2145**], s/p lumpectomy in [**State 108**]
# s/p total abdominal hysterectomy [**2094**] for fibroids
# Cataracts
Social History:
She lives at home alone, but has family in the area. Social
history is significant for the absence of current tobacco use,
remote social tobacco use in college. There is no history of
alcohol abuse. Has home [**Year (4 digits) 269**] w tele reports daily and PT.
Presents from rehab following multiple admissions.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her father had hypertension. Her sister is
alive and healthy at 93.
Physical Exam:
On admission
VS: T=98.6 BP=146/70 HR=75 R=20 PO2 sat= 100% 2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of <9 cm.
CARDIAC: RRR, normal S1, S2. GII systolic murmer at LSB, no
gallops, rubs. S4 present at LSB and apex. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bases b/l;
no egophany. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. NABS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
On discharge
VS: 97.3, 120/47, 52, 18, 100%RA
I/O: 120/350 today, [**Telephone/Fax (1) 93520**] yesterday
GENERAL: AAOx3, pleasant elderly female in NAD. Fatigued, but
interactive.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP of <9 cm while sitting at 90 degrees
CARDIAC: RRR, normal S1, S2. S4 present at LSB and apex.
LUNGS: mild kyphosis. Resp were unlabored, no accessory muscle
use. soft crackles bibasilarly, breath sounds at bases decreased
ABDOMEN: Soft, NTND. No HSM or tenderness. NABS.
EXTREMITIES: No c/c/e.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
CXR ([**4-29**]): Two views are compared with the bedside examination
obtained some 10 hours earlier, as well as previous examinations
of [**4-16**] and [**2165-4-19**]. There has been clearing of the findings of
CHF and bilateral pleural effusions, with residual rounded LV
enlargement and atherosclerotic change involving the thoracic
aorta. The lungs appear hyperinflated, suggestive of underlying
obstructive disease; however, there is no focal airspace
opacity. There is diffuse osteopenia with slight anterior
wedging of several thoracic vertebrae and resultant slight
kyphosis. There is no acute abnormality of the thoracic
skeleton.
.
CXR ([**5-5**]):
1. Worsening pulmonary edema and increasing small pleural
effusions.
2. Bilateral lower lobe airspace opacities, which may be due to
dependent
areas of pulmonary edema or superimposed secondary process such
as aspiration or infectious pneumonia. Followup radiographs
after diuresis may be helpful in this regard.
.
CXR ([**5-6**])
CHEST, AP: Mild interstitial edema has slightly worsened. Mild
cardiomegaly and small bilateral pleural effusions are
unchanged. Bibasilar consolidation is stable. The cardiac
silhouette is normal. The aorta is calcified and tortuous.
IMPRESSION: Slightly increased vascular congestion.
.
SUPINE ABDOMEN ([**5-6**])
Limited study with partially imaged left abdomen. Bowel gas
pattern present is nonobstructive with air seen in non-dilated
loops of small and large bowel. There is no free intraperitoneal
air or pneumatosis. The cardiac silhouette is moderately
enlarged. There is a questionable deep sulcus sign in the right
hemithorax, which in the right clinical setting, may represent a
pneumothorax. There is small opacification in the left lower
lung.
.
CBC
[**2165-5-13**] 05:15AM BLOOD WBC-8.3 RBC-3.41* Hgb-10.1* Hct-30.1*
MCV-88 MCH-29.7 MCHC-33.7 RDW-15.2 Plt Ct-402
[**2165-5-12**] 04:35AM BLOOD WBC-8.4 RBC-3.45* Hgb-10.5* Hct-30.3*
MCV-88 MCH-30.5 MCHC-34.7 RDW-14.9 Plt Ct-355
[**2165-5-11**] 06:10AM BLOOD WBC-7.8 RBC-3.28* Hgb-9.7* Hct-28.7*
MCV-88 MCH-29.5 MCHC-33.7 RDW-15.0 Plt Ct-369
[**2165-5-10**] 05:20AM BLOOD WBC-6.0 RBC-3.09* Hgb-9.1* Hct-27.1*
MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 Plt Ct-389
[**2165-5-9**] 05:30AM BLOOD WBC-5.6 RBC-3.16* Hgb-9.1* Hct-27.2*
MCV-86 MCH-28.9 MCHC-33.5 RDW-14.7 Plt Ct-341
[**2165-5-8**] 05:15AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.1* Hct-26.5*
MCV-87 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-286
[**2165-5-7**] 06:02AM BLOOD WBC-6.6 RBC-3.02* Hgb-9.0* Hct-26.2*
MCV-87 MCH-29.9 MCHC-34.5 RDW-14.8 Plt Ct-305
[**2165-5-6**] 12:48AM BLOOD WBC-7.4# RBC-3.03* Hgb-8.9* Hct-25.7*
MCV-85 MCH-29.4 MCHC-34.7 RDW-14.8 Plt Ct-239
[**2165-5-5**] 04:10AM BLOOD WBC-4.5 RBC-2.71* Hgb-8.3* Hct-23.8*
MCV-88 MCH-30.6 MCHC-35.0 RDW-14.9 Plt Ct-248
[**2165-5-4**] 07:30AM BLOOD WBC-4.9 RBC-3.01* Hgb-9.1* Hct-26.6*
MCV-88 MCH-30.3 MCHC-34.3 RDW-15.0 Plt Ct-239
[**2165-5-3**] 05:05AM BLOOD WBC-5.7 RBC-3.06* Hgb-9.4* Hct-27.2*
MCV-89 MCH-30.6 MCHC-34.4 RDW-15.3 Plt Ct-242
[**2165-5-2**] 05:25AM BLOOD WBC-5.8 RBC-3.36* Hgb-10.1* Hct-29.2*
MCV-87 MCH-30.0 MCHC-34.6 RDW-15.0 Plt Ct-225
[**2165-5-1**] 07:30AM BLOOD WBC-8.6 RBC-3.31* Hgb-9.9* Hct-29.5*
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-245
[**2165-4-30**] 10:50AM BLOOD WBC-7.8 RBC-3.29* Hgb-9.8* Hct-28.6*
MCV-87 MCH-29.7 MCHC-34.1 RDW-15.2 Plt Ct-215
[**2165-4-30**] 07:25AM BLOOD WBC-9.9 RBC-3.36* Hgb-10.3* Hct-29.9*
MCV-89 MCH-30.7 MCHC-34.5 RDW-15.5 Plt Ct-245
[**2165-4-29**] 07:55AM BLOOD WBC-16.0*# RBC-3.75* Hgb-11.3* Hct-32.3*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.6* Plt Ct-269
Coags
[**2165-5-11**] 06:10AM BLOOD PT-12.7 PTT-30.2 INR(PT)-1.1
[**2165-5-10**] 05:20AM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.0
[**2165-5-9**] 05:30AM BLOOD PT-12.0 PTT-28.0 INR(PT)-1.0
[**2165-5-8**] 05:15AM BLOOD PT-12.8 PTT-28.9 INR(PT)-1.1
[**2165-5-7**] 06:02AM BLOOD PT-12.6 PTT-31.4 INR(PT)-1.1
[**2165-5-6**] 01:01AM BLOOD PT-13.1 PTT-26.5 INR(PT)-1.1
[**2165-4-30**] 07:25AM BLOOD PT-13.2 PTT-28.4 INR(PT)-1.1
Chemistry
[**2165-5-13**] 05:15AM BLOOD Glucose-117* UreaN-116* Creat-3.7*
Na-131* K-3.5 Cl-78* HCO3-40* AnGap-17
[**2165-5-12**] 04:35AM BLOOD Glucose-121* UreaN-117* Creat-3.5*
Na-131* K-3.7 Cl-78* HCO3-39* AnGap-18
[**2165-5-11**] 06:10AM BLOOD Glucose-131* UreaN-117* Creat-3.7*
Na-130* K-3.8 Cl-79* HCO3-38* AnGap-17
[**2165-5-10**] 05:20AM BLOOD Glucose-118* UreaN-119* Creat-3.7*
Na-130* K-4.0 Cl-79* HCO3-37* AnGap-18
[**2165-5-9**] 05:30AM BLOOD Glucose-109* UreaN-119* Creat-3.7*
Na-129* K-3.2* Cl-79* HCO3-35* AnGap-18
[**2165-5-8**] 05:15AM BLOOD Glucose-111* UreaN-118* Creat-3.9*
Na-128* K-3.4 Cl-77* HCO3-34* AnGap-20
[**2165-5-7**] 06:02AM BLOOD Glucose-115* UreaN-116* Creat-4.1*
Na-125* K-3.3 Cl-76* HCO3-34* AnGap-18
[**2165-5-6**] 04:08PM BLOOD UreaN-112* Creat-4.2* Na-129* K-3.7
Cl-81* HCO3-32 AnGap-20
[**2165-5-6**] 12:48AM BLOOD Glucose-137* UreaN-108* Creat-4.4*
Na-123* K-3.8 Cl-75* HCO3-29 AnGap-23*
[**2165-5-5**] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3*
Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19
[**2165-5-4**] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126*
K-3.9 Cl-80* HCO3-29 AnGap-21*
[**2165-5-3**] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125*
K-4.2 Cl-81* HCO3-28 AnGap-20
[**2165-5-5**] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3*
Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19
[**2165-5-4**] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126*
K-3.9 Cl-80* HCO3-29 AnGap-21*
[**2165-5-3**] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125*
K-4.2 Cl-81* HCO3-28 AnGap-20
[**2165-5-3**] 05:05AM BLOOD Glucose-136* UreaN-91* Creat-3.6* Na-127*
K-4.1 Cl-85* HCO3-29 AnGap-17
[**2165-5-2**] 05:25AM BLOOD Glucose-135* UreaN-84* Creat-3.1* Na-135
K-4.0 Cl-92* HCO3-28 AnGap-19
[**2165-5-1**] 07:30AM BLOOD Glucose-110* UreaN-82* Creat-3.0* Na-136
K-4.3 Cl-94* HCO3-32 AnGap-14
[**2165-4-30**] 10:50AM BLOOD Glucose-186* UreaN-81* Creat-2.9* Na-135
K-3.4 Cl-92* HCO3-32 AnGap-14
[**2165-4-30**] 07:25AM BLOOD Glucose-109* UreaN-81* Creat-2.9* Na-136
K-3.4 Cl-92* HCO3-32 AnGap-15
[**2165-4-29**] 07:55AM BLOOD Glucose-163* UreaN-84* Creat-2.9* Na-138
K-3.5 Cl-94* HCO3-30 AnGap-18
[**2165-5-13**] 05:15AM BLOOD Calcium-9.0 Phos-5.1* Mg-3.8*
[**2165-5-12**] 04:35AM BLOOD Calcium-9.0 Phos-4.7* Mg-4.0*
[**2165-5-11**] 06:10AM BLOOD Calcium-8.7 Phos-4.2 Mg-4.0*
[**2165-5-10**] 05:20AM BLOOD Calcium-8.5 Phos-4.1 Mg-4.0*
[**2165-5-9**] 05:30AM BLOOD Calcium-8.8 Phos-5.3* Mg-3.8*
[**2165-5-8**] 05:15AM BLOOD Calcium-8.6 Phos-5.4* Mg-4.0*
[**2165-5-7**] 06:02AM BLOOD Calcium-9.2 Phos-6.5* Mg-4.1*
[**2165-5-6**] 12:48AM BLOOD Albumin-3.6 Calcium-9.2 Phos-5.8* Mg-3.6*
[**2165-5-5**] 04:10AM BLOOD Calcium-8.9 Phos-6.1* Mg-3.3*
[**2165-5-4**] 07:30AM BLOOD Calcium-9.1 Phos-5.1* Mg-3.0*
[**2165-5-3**] 05:05AM BLOOD Calcium-9.1 Phos-4.2 Mg-3.0*
[**2165-5-2**] 05:25AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.7*
[**2165-5-1**] 07:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.9*
[**2165-4-30**] 10:50AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.6
[**2165-4-30**] 07:25AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.5
[**2165-4-29**] 07:55AM BLOOD Calcium-9.9 Phos-4.2 Mg-2.5
Cardiac Enzymes
[**2165-5-6**] 12:48AM BLOOD CK(CPK)-17*
[**2165-5-5**] 04:10AM BLOOD CK(CPK)-11*
[**2165-5-2**] 05:25AM BLOOD CK(CPK)-16*
[**2165-5-1**] 09:14PM BLOOD CK(CPK)-20*
[**2165-4-30**] 07:25AM BLOOD CK(CPK)-17*
[**2165-4-30**] 03:40AM BLOOD CK(CPK)-15*
[**2165-4-29**] 03:05PM BLOOD CK(CPK)-19*
[**2165-4-29**] 07:55AM BLOOD CK(CPK)-20*
[**2165-5-6**] 12:48AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2165-5-5**] 04:10AM BLOOD CK-MB-1 cTropnT-0.19*
[**2165-5-2**] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2165-5-1**] 09:14PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2165-4-30**] 07:25AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2165-4-30**] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2165-4-29**] 03:05PM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-[**Numeric Identifier 93521**]*
[**2165-4-29**] 07:55AM BLOOD cTropnT-0.03*
Brief Hospital Course:
[**Age over 90 **]yoF with CAD s/p stent to mid-[**Name (NI) **], PTCA of jailed OM1, IVUS of
LMCA with MLA presenting with body pain and chest pain.
.
# CORONARIES: Patient has h/o prior stent to [**Name (NI) **] and PTCA of
jailed OM1 presenting with atypical chest pain not concerning
for ACS. There were no significant EKG changes in light of LBBB
(by Sgarbossa criteria), and CE's were negative. The patient
was continued on Aspirin 162mg daily and Clopidogrel 75 mg daily
per outpatient regimen.
.
# PUMP/CHF: Patient has a history of chronic systolic and
diastolic heart failure with EF 40% [**3-/2165**], moderate (2+) MR,
small secundum ASD with left-to-right shunt across the
interatrial septum at rest. She appeared clinically fluid
overloaded without hypoxia, with BNP >45,000. Pt had complex
course on the medicine floor with multiple episodes of worsening
resp status thought due to flash pulm edema. Initially, her
symptoms responded to lasix and additional BP control. However,
the renal function slowly worsened and she had a decreasing
response to diuresis. Pt became progressively uremic and
confused on [**5-5**] with mild respiratory distress. She was
transferred to the CCU on [**5-6**] and received 240mg Lasix IV bolus
followed by gtt. She was aggressively diuresed, per renal recs,
started on Lasix 80mg PO BID. She has had good volume output
with the lasix. Patient has been in good volume status since,
has not had any further episodes of flash pulmonary edema. Has
had fluctuating O2 requirements, at times saturating well on
room air and other times requiring 2L of O2.
.
# Chronic renal failure: Stage III CKD, followed by Dr [**Last Name (STitle) **].
Patient has baseline Cr of 1.5 until [**Month (only) 956**] when baseline
increased to 2.4. On this admission patient had worsening renal
function with creatinine rising from 2.9 to 4.3. It was unclear
whether the patient's increasing creatinine was due to
dehydration vs volume overload - particularly given her
recurrent episodes of flash pulmonary edema and CXR showing
evidence of fluid overload. She was aggressively diuresed in
the CCU and her volume status has been stable on 80 mg of PO
lasix [**Hospital1 **]. Patient and family have decided to decline
hemodialysis and focus more on comfort measures.
# Renal Artery Stenosis: Patient with atrophic right kidney,
left renal artery stenosis. Very likely that this is the reason
that she is very difficult to diurese and the reason why she
flashes easily. She was originally planned for renal artery
stenting, but the procedure was held off because she was
unstable, requiring CCU transfer. Goals of care were discussed
with patient and renal stenting was tabled as patient decided
against aggressive management and to focus more on comfort.
.
# Body Pain: Patient describes body pain since waking up in
the morning of her admission. Unclear etiology, but likely
viral symptoms vs non-specific findings [**3-12**] CHF exacerbation.
Infectious workup was negative. Leukocytosis resolved on
discharge. Patient has had 2 transient episodes of chest pain
on this admission which was reproducible with palpation and
worse with movement, likely of musculoskeletal etiology,
relieved with 0.5 mg of PO morphine.
.
# Right Finger Pain: Pt initially presented with right index
finger with erythema, swelling, calor consistent with gout;
septic arthritis or osteomyelitis was less likely given no
fevers, no effusion, no nidus of infection. Resolved without
intervention.
.
# Hypertension: Patient's home antihypertensives were initially
continued, but following her CCU transfer for recurrent flash
pulmonary edema, she was changed to amlodipine, carvedilol,
furosemide, and imdur. Following her CCU admission she has been
stable with SBP ranging in 110s-130s.
.
# Hyperlipidemia: Pt is intolerant of statins, and was not
given statins after discussion with her PCP [**Last Name (NamePattern4) **]: goals of the
patient's care.
.
# Type 2 diabetes: diet-controlled. Covered with SSI in-house.
.
# GERD: Continued Famotidine 20 mg Tablet per outpatient
regimen
.
# Goals of care: patient was made DNR/DNI while in the CCU.
Patient and family decided against starting hemodialysis,
preference was for comfort directed care. Just prior to
discharge from the hospital, patient was asked to sign a DNR/DNI
form which would continue her DNR/DNI status during transport
and at the nursing facility, which she refused to sign. Patient
repeatedly stated that she DID NOT want to be resuscitated,
however refused to sign the form. She is amenable to her
daughter (HCP) signing the DNR/DNI forms for her, however the
daughter was not available prior to discharge to sign the
papers. The daughter understands that she would be able to sign
the DNR/DNI papers at the nursing facility. At the nursing
facility, patient's care should be focused on comfort care.
Medications on Admission:
1. Senna 8.6 mg [**Hospital1 **]
2. Famotidine 20 mg Tablet
3. Calcitriol 0.25 mcg Capsule PO QMOWEFR
4. Aspirin 162mg daily
5. Clopidogrel 75 mg daily
6. Cyanocobalamin 500 mcg daily
**7. Hydralazine 10 mg q6hr
**8. Isosorbide Mononitrate 20 mg [**Hospital1 **]
9. Docusate Sodium 100 mg [**Hospital1 **]
10. Felodipine 10 mg daily
11. Carvedilol 12.5 mg [**Hospital1 **]
**12. Furosemide 40 mg Tablet [**Hospital1 **]
13. Iron (Ferrous Sulfate) 325 mg daily
14. Nitrostat 0.4 mg Tablet, Sublingual prn
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
up to 3 tablets as needed for chest pain 5 minutes apart.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath, wheezing.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS
OFF ().
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
16. Miralax 17 gram Powder in Packet Sig: Seventeen (17) grams
PO once a day as needed for constipation.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every
six (6) hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Systolic and Diastolic Heart Failure
Pulmonary Edema
Left Renal Artery Stenosis
Secondary Diagnosis:
Hypertension
Diabetes
Coronary Artery Disease
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You presented to the hospital for body pain and chest pain.
Your EKG and blood tests did not show any evidence of a heart
attack, but you were found to be in heart failure. While in the
hospital, you had frequent episodes of shortness of breath was
improved with starting you on Lasix to help remove fluid.
During this admission, we had many discussions about whether or
not to start dialysis. Your final decision was for dialysis
not to be started, but instead to pursue hospice care instead.
You will be discharged to a nursing facility where they can help
with treating your symptoms and making you comfortable.
.
Your medications have changed, please only take the medications
as
listed below:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
up to 3 tablets as needed for chest pain 5 minutes apart.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath, wheezing.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS
OFF ().
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
16. Miralax 17 gram Powder in Packet Sig: Seventeen (17) grams
PO once a day as needed for constipation.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every
six (6) hours as needed for pain.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please call and schedule an appointment to see your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] ([**Telephone/Fax (1) 250**]), as needed.
|
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"250.00",
"723.1",
"440.1",
"366.9",
"745.5",
"428.0",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20719, 20809
|
13156, 18076
|
293, 300
|
21037, 21037
|
5227, 13133
|
24100, 24324
|
3608, 3758
|
18630, 20696
|
20830, 20830
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18102, 18607
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21221, 24077
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3773, 5208
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2035, 2711
|
226, 255
|
328, 2016
|
20968, 21016
|
20849, 20947
|
21052, 21197
|
2733, 3260
|
3276, 3592
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,230
| 199,546
|
7340+7341+7361
|
Discharge summary
|
report+report+report
|
Admission Date: [**2158-3-23**] Discharge Date: [**2158-3-28**]
Date of Birth: [**2085-8-8**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
male with a past medical history of coronary artery disease
status post coronary artery bypass grafting nine years and
PTCA and stenting of the right coronary artery, diabetes
mellitus, cervical disease, status post effusion, who has
been on chronic narcotics, who presented to [**Hospital6 1760**] for catheterization.
He was transferred to the CCU for management of congestive
heart failure. He presented to the outside hospital with
decreased mental status. He had a negative head CT. He also
had acute renal failure with a creatinine of 1.8, shortness
of breath and dyspnea on exertion. He had been on OxyContin
60 q.d. for chronic cervical pain at the outside hospital and
initially received Narcan. He was diuresed empirically and
treated for bronchitis and Ceftriaxone. Chest x-ray showed
no evidence of pneumonia but did show some mild congestive
heart failure.
On [**3-18**], the patient had a repeat change in mental status
with an oxygen desaturation to 82%. Chest x-ray showed
congestive heart failure. He was diuresed with Lasix,
received Nitroglycerin drip and Nutracort. He also had a
slight elevation in troponin to 0.26. He had a positive
Dobutamine stress test for posterolateral defect that was
reversible.
He was sent to [**Hospital6 256**] for
catheterization. He had a cardiac output was 5.1, cardiac
index of 2.26. Pulmonary capillary pressures were with a
mean of 39, PA pressure of 58/26, showing elevated filling
pressures, and mean pulmonary capillary wedge of 37%, PAD of
40, severe pulmonary hypertension. Oxygenation was marginal,
and pCO2 was elevated. The numbers improved with
Nitroglycerin and Lasix. The patient received 100 IV Lasix
with 2 L negative diuresis. Also in catheterization lab,
LMCA had a 40% distal lesion supplying the ramus intermedius.
Left anterior descending was occluded. The left circumflex
was occluded. Right coronary artery was occluded. The OM2 was
occluded and fills
by collaterals. This is a change from catheterization in
[**2155**]. SVG to PDA with 40% PDA origin stenosis and 20% mid
stenosis, LIMA to LDA was patent with a 50% touchdown
stenosis. Filling defects seemed possibly due to a string or
suture. Unchanged from prior catheterization in [**2155**].
PHYSICAL EXAMINATION: Vital signs: The patient was sent to
the floor. The patient had a right Swan placed in the groin.
Heart rate was 73, blood pressure 128/62, PA pressure 51/23,
CVP 15, 92% 4 L oxygen. General: Te patient was in no acute
distress. He was lying flat in bed. HEENT: Extraocular
movements intact. Anicteric. Pupils equal, round and
reactive to light. Moist mucous membranes. Heart: Regular,
rate and rhythm. S1 and S2. There was a 1/6 systolic
ejection murmur over the precordium. No jugular venous
distention appreciated secondary to anatomy and patient's
position. Lungs: Clear to auscultation anteriorly.
Abdomen: Obese. No rebound tenderness. Mild distention.
Extremities: No clubbing, cyanosis, or edema. Bilateral
posterior tibial pulses. Neurological: Cranial nerves
II-XII intact. All four extremities 4 out of 4 strength.
Oriented times three.
REVIEW OF SYSTEMS: Paroxysmal nocturnal dyspnea, dyspnea on
exertion and back pain.
He had spike a temperature to 101?????? at the outside hospital on
[**2-22**] with normal cultures that were positive. He
denied bright red blood per rectum or melena.
At [**Hospital1 **], the patient had two sets of blood
cultures on the 20th and a urine culture on the 27th which
were negative.
ALLERGIES: BEE STING, LIPITOR, NEURONTIN.
PAST MEDICAL HISTORY: Glaucoma. Coronary artery disease.
Status post coronary artery bypass grafting nine years ago.
Percutaneous transluminal coronary angioplasty times two in
the right coronary artery. Diabetes mellitus. Narcotic
dependence. Chronic pain. Depression. Seizure. Cervical
stenosis status post fusion. Congestive heart failure.
MEDICATIONS ON TRANSFER: Lasix 40 q.d., Aspirin 325 q.d.,
Rocephin 1 g q.d., Imdur 30 mg q.d., Protonix 40 q.d.,
Vasotec 10 q.d. on hold, Methadone 10 b.i.d., Paxil 30 q.d.,
Nitroglycerin drips were turned off prior
to transfer. Also as an outpatient, the patient takes
regular Insulin 5 in the morning NPH. OxyContin 60 q.d.,
Solu-Medrol 2 puffs b.i.d., Xalatan, Alphagan, and Dietrol 4 mg
q.h.s.
SOCIAL HISTORY: Positive tobacco, quit five years ago.
Ambulates with a walker. He lives with his significant
other.
LABORATORY DATA: On presentation hematocrit was 33.6, on
the 31st was 44.6, white count 7 on presentation, 5.9 on the
31st, platelet count 171 on presentation, 169 on the 31st;
glucose 115 at presentation, 118 on the day of discharge, BUN
39 on the 28th, 19 on the day of discharge, creatinine 1.1 on
the 28th, 0.9 on the day of discharge, potassium 4.2, bicarb
31 on presentation, 33 on the day of discharge; on the 20th
ALT was 132, AST 75, alkaline phosphatase 50, albumin 0.4,
calcium 8.8, phosphorus 3.4, magnesium 1.8, B12 and folate
within normal limits; hemoglobin A1C was 5.6; triglyceride
137, HDL 35, LDL 131, TSH 4.1.
As stated earlier at the outside hospital, the had a myoview
Dobutamine stress test with anterior fixed defects,
posterolateral wall reversible defect, ejection fraction of
25-30%, 29% maximum heart rate, dilated left ventricular
cavity. Electrocardiogram showed sinus at 96, normal axis,
PR prolonged, normal QRS and QTC, poor R-wave progression,
and evidence of previous anterior myocardial infarction.
CT of the chest showed bilateral pleural effusions and large
mediastinal lymph nodes, 2.5 cm and 2 x 1 cm on the other
side.
HOSPITAL COURSE: This was a 72-year-old male with a past
medical history of coronary artery disease, hypertension,
chronic renal failure, 25-30%, who presented from the outside
hospital for catheterization status post positive Dobutamine
stress test who was found to be in congestive heart failure.
1. Cardiovascular/CHF: He was initially placed on
Nitroglycerin drip and received 100 IV Lasix with
approximately 2 L output. He was then placed on a Nutracort
drip, and Nitroglycerin drip was discontinued. He had a
further 3.5 L negative for his hospital stay. On the day of
discharge, he was roughly actually 6 L negative, and 92% in
room air.
He was started on an ACE inhibitor, being titrated up to
Captopril 25 t.i.d. on the day of discharge. Imdur was also
started on the day of discharge, at 30 p.o. q.d.
On the 31st, the patient developed ..................., and
Nutracort drip was stopped. Acetazolamide 250 q.d. was
added, and his bicarb dropped from 35 to 33. The patient's
beta-blocker was initially held due to acute congestive heart
failure, and was restarted on the day of discharge.
The patient was placed on Bumex initially 2 IV b.i.d. and
then converted to 2 p.o. b.i.d.
2. Chronic obstructive pulmonary disease: The patient had
no intervention on his cardiac catheterization. There were
no lesions that could be intervened. He was continued on
Aspirin, metoprolol 25 b.i.d. Again his ACE inhibitor was
restarted; initially we waited a few days after this to see how
his kidneys would do after this in view of acute renal failure
at the outside
hospital. His creatinine was stable throughout his stay
here, and in fact was 0.7-0.1. He was in normal sinus rhythm
with no events on telemetry.
He was placed on sliding scale Humalog with good glucose
control. He will be discharged on his regular Insulin and
NPH Insulin as he goes to rehabilitation with sliding scale
for tight control.
3. Infectious disease: The patient remained afebrile during
his hospital stay. Cultures were negative.
4. Pulmonary: The patient was placed on a Solu-Medrol
inhaler. He was also treated with nebs p.r.n. Given the CAT
scan and enlarged mediastinal lymph nodes, he will need to be
followed. This will be communicated to his cardiologist Dr.
[**Last Name (STitle) 27082**] to have follow-up CAT scan.
5. Cervical disease: The patient is status post fusion.
The patient was continued on Methadone 10 p.o. b.i.d. which
was started at the outside hospital. He seems to have good
pain control. The patient was continued on Protonix 40 p.o.
q.d. and required bowel regimen for constipation given the
Methadone; this included Senna, Colace and Lactulose p.r.n.
6. Depression: The patient was continued on his Paxil
prophylaxis. The patient was placed on subcue Heparin,
pneumoboots. He was seen by Physical Therapy who thought he
would benefit from a stay in [**Hospital 3058**] rehabilitation to
improve mobility, balance and gait performance.
7. Fluids, electrolytes and nutrition: The patient his
potassium monitored given the extensive diuresis, and he was
repleted. He was on a cardiac-diabetic diet.
DISCHARGE DIAGNOSIS:
1. Glaucoma.
2. Coronary artery disease status post coronary artery
bypass grafting, status post percutaneous transluminal
coronary angioplasty.
3. Congestive heart failure.
4. Diabetes mellitus.
5. Chronic cervical stenosis.
6. Chronic narcotic dependence.
7. Depression.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS: Metoprolol 25 p.o. b.i.d., Imdur 30
p.o. q.d., .................. 2 p.o. b.i.d., Captopril 25
p.o. t.i.d., ................... 30 mg p.o. q.d.,
Pantoprazole 40 mg p.o. q.d., Methadone 10 mg p.o. b.i.d.,
Ecotrin coated 325 mg p.o. q.d., ................ 250 p.o.
q.d., this may be discontinued when the patient's bicarb is
less than or equal to 30, Solu-Medrol 1-2 puffs inhaled
b.i.d., Albuterol 1-2 puffs inhaled q.6 hours p.r.n.
shortness of breath, Insulin 5 U q.a.m., regular 12 U q.p.m.
NPH with sliding scale of Humalog Insulin, Xalatan drops O.U.
b.i.d.,, Alphagan drops, O.U. t.i.d., ............... drops
O.U. h.s., Colace 1 tab p.o. b.i.d., Senna 1 tab p.o. q.d.,
Lactulose 30 cc p.o. q.6 hours p.r.n.
This medication will most likely be amended as this is being
dictated prior to the patient's discharge. An addendum will
be added regarding final list of discharge medications.
FOLLOW-UP: The patient is to have a follow-up appointment
with Dr. [**Last Name (STitle) 27082**] on Thursday, [**2166-4-14**]:15 a.m. to modify
his medication regimen to optimize his congestive heart
failure as an outpatient, as well as to follow-up on the CT
findings.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Dictator Info 27083**]
MEDQUIST36
1
D: [**2158-3-28**] 09:06
T: [**2158-3-28**] 09:23
JOB#: [**Job Number 27084**]
Admission Date: [**2158-3-23**] Discharge Date: [**2158-3-28**]
Date of Birth: [**2085-8-8**] Sex: M
Service:
ADDENDUM:
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg p.o. q.a.m.
2. Lisinopril 10 mg p.o. q.p.m.
3. Protonix 40 mg p.o. q.d.
4. Imdur 30 mg p.o. q.a.m.
5. Heparin 5,000 units subcutaneous b.i.d. if the patient is
not ambulating.
6. Bumex 2 mg p.o. b.i.d.
7. Lumigan .003% one drop OU h.s.
8. Alphagan .02% one drop OU t.i.d.
9. Latanoprost drops .005% OU b.i.d.
10. NPH Insulin 10 units q.a.m.
11. Sliding scale Humalog insulin.
12. Salmeterol 1-2 puffs inhaled b.i.d.
13. Albuterol 1-2 puffs inhaled q. 6 p.r.n. shortness of
breath or wheezing.
14. Ecotrin 325 mg p.o. q.d.
15. Methadone 10 mg p.o. b.i.d.
16. Paroxetine HCl 30 mg p.o. q.d.
17. Senna 1 tablet p.o. q.h.s.
18. Colace 1 tablet p.o. b.i.d.
19. Lactulose 30 cc q. 8 p.r.n. constipation.
DIET: Fluid restricted, 1,500 cc per day, 2 grams sodium
diet, heart healthy.
DISPOSITION: He is being discharged to an extended care
facility.
DISCHARGE INSTRUCTIONS:
1. Follow the patient's potassium and creatinine q.d. and to
send these values as well as any change in weight of the
patient greater than 2 kg to notify the doctor [**First Name (Titles) 4120**]
[**Last Name (Titles) **] of the patient's diuretic.
2. The patient was given a follow-up appointment on [**2158-4-14**]
at 11:15 AM.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2158-3-28**] 11:37
T: [**2158-3-28**] 11:50
JOB#: [**Job Number 27085**]
Admission Date: [**2158-3-23**] Discharge Date: [**2158-3-28**]
Date of Birth: [**2085-8-8**] Sex: M
Service:
ADDENDUM:
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg p.o. q.a.m.
2. Lisinopril 10 mg p.o. q.p.m.
3. Protonix 40 mg p.o. q.d.
4. Imdur 30 mg p.o. q.a.m.
5. Heparin 5,000 units subcutaneous b.i.d. if the patient is
not ambulating.
6. Bumex 2 mg p.o. b.i.d.
7. Lumigan .003% one drop OU h.s.
8. Alphagan .02% one drop OU t.i.d.
9. Latanoprost drops .005% OU b.i.d.
10. NPH Insulin 10 units q.a.m.
11. Sliding scale Humalog insulin.
12. Salmeterol 1-2 puffs inhaled b.i.d.
13. Albuterol 1-2 puffs inhaled q. 6 p.r.n. shortness of
breath or wheezing.
14. Ecotrin 325 mg p.o. q.d.
15. Methadone 10 mg p.o. b.i.d.
16. Paroxetine HCl 30 mg p.o. q.d.
17. Senna 1 tablet p.o. q.h.s.
18. Colace 1 tablet p.o. b.i.d.
19. Lactulose 30 cc q. 8 p.r.n. constipation.
DIET: Fluid restricted, 1,500 cc per day, 2 grams sodium
diet, heart healthy.
DISPOSITION: He is being discharged to an extended care
facility.
DISCHARGE INSTRUCTIONS:
1. Follow the patient's potassium and creatinine q.d. and to
send these values as well as any change in weight of the
patient greater than 2 kg to notify the doctor [**First Name (Titles) 4120**]
[**Last Name (Titles) **] of the patient's diuretic.
2. The patient was given a follow-up appointment on [**2158-4-14**]
at 11:15 AM.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2158-3-28**] 11:37
T: [**2158-3-28**] 11:50
JOB#: [**Job Number 27126**]
|
[
"304.91",
"V45.4",
"428.0",
"584.9",
"414.01",
"V45.81",
"416.8",
"723.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.57",
"00.13",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
12574, 13439
|
8977, 9258
|
5826, 8956
|
13463, 14057
|
2462, 3336
|
3356, 3766
|
159, 2439
|
4145, 4522
|
3789, 4119
|
4539, 5808
|
9283, 9290
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,612
| 169,541
|
39231
|
Discharge summary
|
report
|
Admission Date: [**2127-2-17**] Discharge Date: [**2127-2-19**]
Date of Birth: [**2076-2-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Shortness of breath and chest pain.
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
stomach antral biopsy X1
duodenal biopsy X1
History of Present Illness:
Pt is a 50 yo male with history of HTN and dyslipidemia admitted
on [**2127-2-17**] with significant anemia and suspected upper GI bleed.
In [**2126-12-3**], pt began taking naproxen 250 mg po bid for
joint pain (took this for 45 days). Late [**2127-1-3**] he began
experiencing chest pain, DOE, was feeling increasingly tired,
and had orthostatic symptoms (was feeling dizzy when he arose to
urinate at night). He presented to an OSH, where he was found to
be anemic, and an EGD found a duodenal vs. gastric ulcer. He was
given 2U of blood, was discharged on pantoprazole, and
discontinued his naproxen. 2 days after his discharge, he again
began experiencing DOE, chest pain, was increasingly fatigued
and had 2 near syncopal episodes.
.
On review of systems, pt states that he has had frequent
diarrhea for the past 10-20 years. He states he has noticed his
stool has been black for the past year or so, and that the
frequency of his diarrhea has increased to 6 BM's in the morning
over the past month or so. Of note, he did have one episode of
melena 3 days ago. He has not had a BM in the past 2 days. He
denies N/V, though is having some mild epigastric discomfort. He
has been able to ambulate around his room, and is currently not
complaining of CP, SOB, or dizziness. Pt denies recent weight
loss, fevers, or chills
Past Medical History:
-HTN
-Dyslipidemia
-Depression
-PUD: patient states that he has had gnawing epigastric pain for
years, and that it is decreased with meals (worse on an empty
stomach). Recent EGD at OSH in late [**Month (only) 404**] showed ?gastric vs.
duodenal ulcer (OSH records not immediately available)
Social History:
Pt has lived in the past in the Phillipines and in [**Country 11150**], though
denies any past H. Pylori testing. Has smoked in the past, but
is a current non-smoker. Drank quite extensively while living in
the Phillipines, however currently drinks only socially. Is
recently divorced, and raising 6 y/o son alone (with help of his
sister and mother).
Family History:
Father died in early 40s of MI, mother is in good health. Has 3
siblings, all of whom have htn and dyslipidemia. No family
history of gastric or duodenal ulcers.
Physical Exam:
Vitals: T 97.1 BP 127/77 HR 75 RR 16 O2Sat 99RA
Gen: well appearing, lying in bed, appropriate
HEENT: NC/AT, PERRL, OP clear, MMM
Neck: supple, no LAD
Lungs: CTAB, no wheezes or crackles
Heart: RRR, s1/s2 present, -mrg
Abd: +BS, soft, mildly tender in the epigastrium without rebound
or guarding
Ext: no lower extremity edema
Neuro: AOx3, 5/5 strength in all 4 ext
Pertinent Results:
[**2127-2-17**] 12:40PM BLOOD cTropnT-<0.01
[**2127-2-17**] 12:40PM BLOOD CK-MB-2
[**2127-2-17**] 12:40PM BLOOD WBC-6.3 RBC-2.89* Hgb-6.8* Hct-21.7*
MCV-75* MCH-23.6* MCHC-31.4 RDW-17.6* Plt Ct-311
[**2127-2-17**] 05:19PM BLOOD Hct-19.3*
[**2127-2-17**] 06:04PM BLOOD Hct-19.7*
[**2127-2-17**] 10:11PM BLOOD Hct-18.8*
[**2127-2-17**] 11:17PM BLOOD Hct-21.7*
[**2127-2-18**] 04:56AM BLOOD WBC-5.0 RBC-3.10* Hgb-7.6* Hct-23.2*
MCV-75* MCH-24.5* MCHC-32.6 RDW-16.3* Plt Ct-242
[**2127-2-18**] 01:22PM BLOOD WBC-6.4 RBC-3.50* Hgb-9.3* Hct-26.8*
MCV-77* MCH-26.5* MCHC-34.7 RDW-17.5* Plt Ct-290
[**2127-2-18**] 09:49PM BLOOD Hct-27.5*
[**2127-2-19**] 05:15AM BLOOD WBC-6.6 RBC-3.67* Hgb-9.8* Hct-28.6*
MCV-78* MCH-26.7* MCHC-34.2 RDW-17.5* Plt Ct-264
[**2127-2-17**] 12:40PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-3+
Macrocy-NORMAL Microcy-3+ Polychr-1+ Ovalocy-2+ Schisto-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2127-2-17**] 12:40PM BLOOD Glucose-97 UreaN-19 Creat-0.9 Na-138
K-3.9 Cl-104 HCO3-23 AnGap-15
[**2127-2-18**] 04:56AM BLOOD Glucose-88 UreaN-16 Creat-0.9 Na-139
K-3.9 Cl-109* HCO3-20* AnGap-14
[**2127-2-19**] 05:15AM BLOOD Glucose-72 UreaN-15 Creat-1.0 Na-139
K-4.3 Cl-107 HCO3-20* AnGap-16
[**2127-2-18**] 04:56AM BLOOD LD(LDH)-144 TotBili-1.3 DirBili-0.3
IndBili-1.0
[**2127-2-19**] 05:15AM BLOOD Albumin-3.8 Calcium-7.8* Phos-2.9 Mg-2.0
-H. Pylori Antibody Test: NEGATIVE
-Tissue Transglutaminase: PENDING at time of discharge
.
Imaging/Studies:
[**2127-2-17**] EKG: Sinus rhythm. Modest inferior and anterolateral
lead T wave changes are non-specific. No previous tracing
available for comparison.
.
[**2127-2-17**] CXR: The cardiomediastinal contours are within normal
limits. There is no focal consolidation, effusion or
pneumothorax. The right costophrenic angle is excluded from the
film. There is no definite evidence of free air below the
diaphragm. IMPRESSION: No acute cardiopulmonary process.
.
[**2127-2-19**] EGD: Findings: Esophagus: Normal esophagus. Stomach:
Mucosa: Erythema, congestion and erosion of the mucosa were
noted in the antrum. Cold forceps biopsies were performed to
assess for H. pylori at the stomach antrum. Duodenum: Mucosa:
Question minimal scalloping folds of the mucosa was noted in the
second part of the duodenum. Cold forceps biopsies were
performed to assess for celiac disease at the second part of the
duodenum. Impression: Question minimal scalloping folds in the
second part of the duodenum (biopsy) Erythema, congestion and
erosion in the antrum (biopsy). Otherwise normal EGD to third
part of the duodenum.
Brief Hospital Course:
Pt presented to the [**Hospital1 18**] ED on [**2127-2-17**] with 2 near syncopal
episodes, DOE and non-radiating chest pain, with initial cardiac
enzymes negative x1 and an initial hct of 21.
..
# Shortness of breath:
Pt initially presented with non-radiating chest pain and dyspnea
on exertion. Cardiac enzymes were negative x1. CXR was normal.
EKG in ICU was unremarkable. On discharge pt was no longer
complaining of SOB, and was able to ambulate without difficulty.
.
Anemia:
Pt's initial hct in the ED was found to be 21. An NGT was
subsequently placed, and showed BRB which cleared with lavage.
He received 4 units of blood, and his hct continued to trend
upwards. Pt was initially sent to the ICU given concern of
bright pink blood via NGT, however he remained hemodynamically
stable in the ICU, with an unremarkable EKG. GI was consulted
and felt his bleed was most consistent with an UGI bleed given
bright red lavaged on NGT, however given pt did experience one
episode of melena 3 days prior, a lower GI bleed could not be
excluded. GI recommended an inpatient EGD and outpatient
colonoscopy. An EGD was performed and showed erosive gastritis
with scalloping folds of the duodenal mucosa. Biopsies were
taken with results pending at the time of discharge. HPylori
antibody testing was negative and Tissue transglutaminase
results were pending at the time of discharge. On discharge pt
was able to eat and hct remained stable at 28.6 after having
received 4 units of blood. He does need to have an outpatient
colonoscopy within 1-2 weeks to rule out a lower GI source of
his bleeding (which pt will call to schedule). Pt was advised to
have his hemoglobin and hct rechecked in a week (Wednesday
[**2127-2-26**]) and have these results sent to his PCP (Dr. [**Last Name (STitle) 5193**].
Finally, enalapril was held during hospitilization and pt was
discontinued on this medication, and advised to follow-up with
this medication in discussion with his PCP.
Medications on Admission:
-Omeprazole 40mg [**Hospital1 **]
-Simvastatin 20mg daily
-Enalapril 20mg daily
-Mirtazapine 30 mg po qhs
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Outpatient Lab Work
Please have your hemoglobin and hematocrit checked next
wednesday, [**2127-2-26**]. Please have these results faxed to Dr.
[**Last Name (STitle) 5193**].
Discharge Disposition:
Home
Discharge Diagnosis:
Erosive Gastritis
Duodenal scalloping
Discharge Condition:
Alert. No acute distress. ambulating without difficulty.
Discharge Instructions:
You were admitted to the hospital with shortness of breath,
chest pain, and found to have anemia. Given your history of
known GI bleeding it was suspected that you once again had upper
GI bleeding. You were transfused 4 units of blood and underwent
a esophagogastroduodenoscopy. This procedure showed
inflammation of your stomach and a scalloped duodenum. Stomach
and duodenal biopsies were taken but the results will not be
back for a week.
You will need to call Dr.[**Name (NI) 86826**] office at [**Telephone/Fax (1) 2986**] to
receive these biopsy results.
You will need to have a colonoscopy performed within 1-2 weeks.
Please call Dr.[**Name (NI) 86826**] office to schedule this procedure.
You will need to have a blood count checked next wednesday with
the results faxed to Dr.[**Name (NI) 86827**] office.
If you experience any further black or bloody stool you must
call Dr. [**Last Name (STitle) 5193**].
Please stop taking enalipril. Please speak with Dr. [**Last Name (STitle) 5193**]
before you restart this medicaiton.
Followup Instructions:
You will need to have a colonoscopy performed within 1-2 weeks.
Please call Dr.[**Name (NI) 86826**] office at [**Telephone/Fax (1) 2986**] to schedule this
procedure.
You will need to follow-up with Dr. [**Last Name (STitle) 5193**] in [**1-4**] weeks to
check your blood pressure and to decide whether to restart the
enalipril.
|
[
"533.90",
"V17.3",
"280.0",
"311",
"401.9",
"272.4",
"535.41",
"E935.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
8207, 8213
|
5626, 7595
|
351, 424
|
8295, 8355
|
3042, 5603
|
9444, 9778
|
2479, 2642
|
7751, 8184
|
8234, 8274
|
7621, 7728
|
8379, 9421
|
2657, 3023
|
276, 313
|
452, 1778
|
1800, 2093
|
2109, 2463
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,464
| 171,753
|
36394
|
Discharge summary
|
report
|
Admission Date: [**2191-5-29**] [**Month/Day/Year **] Date: [**2191-6-16**]
Date of Birth: [**2171-2-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2191-5-29**] I&D right leg with IM nail and VAC placement
[**2191-6-1**] Left central line placement
[**2191-6-2**] Local debridement and irrigation and VAC dressing change
[**2191-6-13**] Debridement open fracture down to and inclusive of bone
and
application of VAC sponge.
History of Present Illness:
Ms. [**Known lastname 35832**] is a 20 year old female who was an unrestrained
driver of a car vs tree. She was taken to [**Hospital **] Hospital and
found to have an open right tibia fracture. She was then
transferred to the [**Hospital1 18**] for further evaluation and care. Of
note she received Td booster at [**Hospital **] Hospital.
Past Medical History:
Denies
Family History:
Noncontributory
Physical Exam:
Upon admission:
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: RLE: +sensation/movement, +ecchymosis, open grade
3 visible fracture.
Pertinent Results:
[**2191-5-29**] 10:50PM HCT-33.0*
[**2191-5-29**] 03:47PM PH-7.29*
[**2191-5-29**] 03:47PM GLUCOSE-124* LACTATE-3.2* NA+-140 K+-4.3
CL--104 TCO2-24
[**2191-5-29**] 03:47PM HGB-11.5* calcHCT-35
[**2191-5-29**] 03:47PM freeCa-1.08*
[**2191-5-29**] 01:18PM GLUCOSE-107* LACTATE-2.1* NA+-142 K+-4.4
CL--106 TCO2-24
[**2191-5-29**] 01:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2191-5-29**] 01:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2191-5-29**] 01:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2191-5-29**] 01:15PM URINE RBC-[**11-11**]* WBC-[**2-24**] BACTERIA-FEW
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2191-5-29**] 01:00PM UREA N-13 CREAT-0.8
[**2191-5-29**] 01:00PM LIPASE-21
[**2191-5-29**] 01:00PM WBC-19.1* RBC-4.32 HGB-12.7 HCT-36.3 MCV-84
MCH-29.4 MCHC-35.0 RDW-14.5
[**2191-5-29**] 01:00PM PLT COUNT-251
[**2191-5-29**] 01:00PM PT-12.5 PTT-23.7 INR(PT)-1.1
[**2191-5-29**] 01:00PM FIBRINOGE-414*
Tibia/Fibula xray [**2191-5-29**] (admission)
IMPRESSION: Displaced fractures of the mid shafts of the right
tibia and
fibula.
CT ABD/Pelvis:
IMPRESSION:
1. Interval worsening of diffuse bilateral ground-glass
opacities in the
lungs, with more focal consolidations at the bilateral bases.
This is
consistent with evolving ARDS, with superimposed multifocal
pneumonia. Given the location, aspiration should be considered.
Fat emboli are also a
consideration given the history of trauma and fracture.
2. Persistent linear low-attenuation focus at the dome of the
left lobe of
the liver, with interval development of a small sliver of
slightly hyperdense perihepatic fluid. Findings are most
suggestive of a small grade 1 liver laceration. Mild
heterogeneity at posterior margin of segment 7, may represent
contusion.
3. Diffuse soft tissue edema, with new periportal edema,
suggests fluid
overload.
4. No evidence for mesenteric or bowel injury.
5. Small amount free fluid in pelvis.
Pathology Examination
SPECIMEN SUBMITTED: bone right leg.
Procedure date Tissue received Report Date Diagnosed
by
[**2191-6-7**] [**2191-6-7**] [**2191-6-10**] DR. [**Last Name (STitle) **]. FU/dsj??????
DIAGNOSIS:
Bone, right leg:
1. Fragment of bone with focal osteonecrosis and fibrin. No
chronic or acute inflammation seen.
2. Special stains including Gram, GMS and PAS are negative
with satisfactory controls.
Clinical: Infected right tibia.
Gross: The specimen is received fresh labeled with the patient's
name, "[**Known firstname **] [**Known lastname 35832**]", the medical record number and
additionally labeled "bone right leg". It consists of multiple
fragments of tan-pink bone measuring in aggregate 0.5 x 0.4 x
0.3 cm. They are entirely submitted in A for decalcification.
Brief Hospital Course:
#1 Tib/Fib fracture: Ms. [**Known lastname 35832**] presented to the [**Hospital1 18**] on
[**2191-5-29**] via transfer from [**Hospital **] Hospital with an open right
tibia fracture. She was taken to the trauma ICU for close
monitoring. She was evaluated by the orthopaedic and trauma
surgery service, admitted, consented, and prepped for surgery.
She was taken to the operating room and underwent an I&D of her
right open tibia fracture with IM nail placement and VAC
closure. On [**6-2**] she underwent local debridement and irrigation
and a VAC dressing change and again was taken back to the
operating room on [**6-13**] debridement open fracture down to and
inclusive of bone with application of VAC sponge. She tolerated
all procedures well. Lovenox injections were later started.
#2 Hypoxia: On HD #3 while on the regular nursing unit she was
noted with worsening hypoxia requiring intubation. CT cuts of
lower lungs revealed multifocal pneumonia. Increasing O2
requirement, worsening symptoms despite treatment with
azithromycin then levofloxacin for CAP, and CXR appearance
suggested ARDS-like picture. Antibiotic coverage broadened to
vanc/zosyn to cover HAP or aspiration PNA given rapidly
progressive changes on CT. She was ventilated with low-tidal
volumes for ARDS with fentanyl/versed for sedation. CTA
negative for PE. Bronch showed blood-tinged fluid without
evidence of frank hemorrhage or purulent material. Sputum and
blood cultures were sent.
.
#3 Hypotension: She was hypotensive in setting of positive
pressure on vent as well as sedation. There was concern for
sepsis in setting of infection; cardiogenic etiologies
considered less likely as TTE was without evidence of depressed
EF or wall motion abnormality (although could develop RV
dysfunction with fat emboli from long bone fracture). Patient
was without evidence of continued blood loss. IVF were given to
maintain MAP >60. She transiently required pressors (Levophed).
Sepsis was treated with antibiotic as above.
.
#4 Anemia: Hct 36 on admission, nadir value was 22 on POD#3
thought to be due to post-op fluid shifts. She received 3 u
PRBC and Hct increased to 26. Normal bilirubin not suggestive
of hemolysis.
.
#5 Fevers: Patient with Tmax 102 on POD#4, coinciding with
multilobar pneumonia seen on chest CT. Surgical wounds appeared
clean. LENI's did not reveal DVT. She was treated with
vanc/zosyn for pneumonia and fever curve improved.
She remained in the trauma ICU for several days and was
eventually weaned and extubated and was transferred to the
regular nursing unit. Her oxygen saturations have been stable on
room air. She is on a regular diet and tolerating this; her pain
is well controlled with oral narcotics. She was evaluated by
Physical and Occupational therapy and recommended for acute
rehab.
Medications on Admission:
None
[**Month/Year (2) **] Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) MG
Subcutaneous Q12H (every 12 hours).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
PO BID (2 times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for indigestion.
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation.
[**Month/Year (2) **] Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
[**Location (un) **] Diagnosis:
s/p Motor vehicle crash
Right open tibia fracture
Massive degloving injury right leg
Respiratory failure/ARDS/Pneumonia
Acute blood loss anemia
[**Location (un) **] Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
[**Location (un) **] Instructions:
Coontinue to be partial weight bearing on your ri
Continue your Lovenox injections as instructed until told to
discontinue by Orthopedics.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP/Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
Orthopaedics in 2 weeks; please call [**Telephone/Fax (1) 1228**] to schedule
that appointment.
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery in 2 weeks for follow
up of your pneumonia. Call [**Telephone/Fax (1) 2359**] for an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab for a general physical. You will need to call for an
appointment.
Completed by:[**2191-6-22**]
|
[
"864.12",
"E816.0",
"416.8",
"823.32",
"518.5",
"278.01",
"E849.5",
"958.1",
"730.06",
"285.1",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.47",
"79.66",
"38.93",
"96.04",
"79.36",
"38.91",
"96.72",
"86.22",
"88.72",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
4256, 7073
|
350, 633
|
1325, 4233
|
8577, 9203
|
1049, 1066
|
7099, 8087
|
1081, 1083
|
8119, 8265
|
287, 312
|
8297, 8377
|
8412, 8554
|
661, 1003
|
1098, 1306
|
1025, 1033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,764
| 150,778
|
13605
|
Discharge summary
|
report
|
Admission Date: [**2130-10-15**] Discharge Date: [**2130-10-29**]
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
male with multiple medical problems including chronic
obstructive pulmonary disease with a history of four previous
intubations and respiratory distress / respiratory failure,
status post recent hospitalization at [**Hospital1 190**] from [**2130-9-20**] until [**2130-9-26**], for
respiratory distress and pneumonia, history of left lower
extremity cellulitis, history of Methicillin resistant
Staphylococcus aureus in sputum, hypertension, and atrial
fibrillation on Coumadin. He presented as a transfer from an
extended care facility after the onset of increased lethargy,
decreased oxygen saturation to 60% on room air.
The patient was recently discharged on [**2130-9-26**], after a
chronic obstructive pulmonary disease flare with intubation.
He was discharged on nebulizer treatments, Prednisone,
Levofloxacin, Vancomycin, and metronidazole for empiric
Clostridium difficile. He finished antibiotic therapy and
was doing well at rehabilitation until the day prior to
admission. At that time, the staff noticed increased
erythema and edema of the left lower extremity, resulting in
re-initiation of Vancomycin therapy.
On the day of admission, the patient was noted to have
altered mental status, increased respiratory distress with
respiratory rate 28 to 32, and decreased oxygen saturation to
67 to 76%. At that time, blood pressure was 78/50;
temperature 97.2; heart rate 110 to 117. On arrival to the
Emergency Department, the patient was moaning, not alert or
oriented. Respiratory rate was elevated with blood pressure
50s to 60s systolic, heart rate 110 to 120. He was intubated
emergently after administration of succinylcholine and
Atomodate. In the Emergency Department, he also received
Solu-Medrol 125 mg intravenously; Ceftazidine 1 gram;
Clindamycin 600 mg intravenously. Electrolytes were repleted
with calcium gluconate 2 grams, magnesium sulfate 4 grams,
and he also received intravenous fluid therapy.
The patient's blood pressure ranged from 50 to 60 systolic in
the Emergency Department for a good ten to twenty minutes;
therefore, a central venous line was placed. The patient was
started on dopamine pressor therapy. This resulted in
tachycardia to the 150s and therefore Dopamine was changed to
Levophed.
Blood pressure remained tenuous even after maximum doses of
Levophed and therefore Neo-Synephrine was added.
PAST MEDICAL HISTORY:
1. History of respiratory distress requiring intubation
times four in the past, [**5-/2129**], [**11/2129**], [**3-/2130**], 10/[**2129**].
2. Chronic obstructive pulmonary disease on two to three
liters of home O2.
3. History of right lower lobe pneumonia, 10/[**2129**].
4. Left lower extremity cellulitis 09/[**2129**].
5. Epididymitis.
6. History of atrial fibrillation / multifocal atrial
tachycardia; ejection fraction of 50% on transthoracic
echocardiogram in [**2128**]; on Coumadin for anti-coagulation.
7. Hypertension.
8. History of anemia with guaiac positive stools.
9. Status post left kidney donation.
10. History of prostate cancer status post radiation
approximately seven to eight years ago.
11. History of peptic ulcer disease status post Billroth
procedure.
12. Chronic venous insufficiency.
13. Osteopenia, status post multiple compression fractures on
chronic opiate therapy.
14. History of vancomycin resistant enterococcus in urine in
[**2129-5-14**].
15. Hypothyroidism.
16. History of left axillary vein deep vein thrombosis in
[**2129**].
17. History of Methicillin resistant Staphylococcus aureus
positive sputum in 10/[**2129**].
18. History of burn injuries to thighs bilaterally.
ALLERGIES: The patient reports no known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Albuterol nebulizer.
2. Atrovent nebulizer.
3. Diltiazem 120 mg p.o. q. day.
4. Multivitamin with minerals.
5. Oxazepam 10 mg p.o. q. h.s. p.r.n.
6. Synthroid 100 micrograms p.o. q. day.
7. Protonix 40 mg p.o. q. day.
8. Actigall 35 mg p.o. q. Monday.
9. Loperamide 2 mg p.o. p.r.n. diarrhea.
10. Aspirin 325 mg p.o. q. day.
11. Lasix 80 mg p.o. q. day.
12. Flovent four puffs inhaled twice a day.
13. Oxycodone 5 mg q. four to six hours p.r.n. pain.
14. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day.
15. Caltrate 600 mg p.o. three times a day.
16. Duragesic patch 150 micrograms per hour q. 72 hours.
17. Compazine 25 mg p.o. q. day.
18. Vancomycin one gram intravenously times two doses for
recurrent left lower extremity cellulitis.
SOCIAL HISTORY: The patient was discharged after his last
hospitalization to [**Hospital3 1186**] [**Hospital3 **] facility.
He has a significant tobacco history, unknown quantity pack
years, having quit tobacco two years ago. He is dependent in
all of his activities of daily living. He is incontinent of
bowel and bladder at baseline. He is a full code per his
daughter. His daughter, [**Name (NI) **] [**Name (NI) 30864**], serves as his health
care proxy.
PHYSICAL EXAMINATION: Upon admission, temperature 93.7 F.;
blood pressure 78/30 up to 127/64 on Levophed and
neo-synephrine; pulse 102; respiratory rate 25; ventilatory
settings at assist control, total volume 600, respiratory
rate 14, pressure support zero, PEEP of 5, FIO2 of 100%.
General appearance, intubated, sedated, breathing
comfortably, in no acute distress; cachectic in appearance.
HEENT: Normocephalic, atraumatic. Bilateral cataracts.
Pupils minimally reactive. Neck supple with no masses or
lymphadenopathy. Lungs with bibasilar crackles. Scattered
rhonchi, anterior laterally with poor air movement.
Cardiovascular with regular rate and rhythm, S1 and S2 heart
sounds auscultated. No murmurs, rubs or gallops. Abdomen
scaphoid, prominent staples, nodular objects underneath his
skin likely from prior Billroth procedure. Abdomen is
nondistended. Hypoactive bowel sounds. Extremities with
left calf with marked erythema, warmth, edema to knee. Right
leg with chronic venous stasis changes. Neurologically:
Intubated and sedated. Moving extremities spontaneously.
Pupils minimally reactive. Not following commands. Skin:
Mottled, cyanotic.
LABORATORY: Upon admission, white blood cell count 7.3,
hematocrit 31.7, MCV 97, total platelets 393. Coagulation
profile showed PT 27.5, PTT 49.7, INR of 5.0.
Serum chemistry showed sodium of 141, potassium 4.3, chloride
110, bicarbonate 21, BUN 55, creatinine 4.0. Please note
patient's baseline is 1.5 to 2.0.
Cardiac enzymes shows CK 85, MB fraction not performed.
Troponin T 0.52.
The initial chemistry showed calcium 6.0, phosphorus 6.0,
magnesium 1.0.
Urinalysis showed urine to be [**Location (un) 2452**], cloudy, large blood,
100 protein, moderate leukocyte esterase, nitrites positive.
Zero to two epithelial cells, greater than 50 white blood
cells, moderate bacteria.
Arterial blood gases right after intubation showed pH 7.09,
Carbon dioxide 71, oxygen 87, bicarbonate 23, lactate 1.8.
Chest x-ray showed bilateral diffuse right greater than left
parenchymal opacities, not significantly changed from prior
study dated [**2130-9-21**]. Also noted were small bilateral
pleural effusions suggestive of aspiration versus pneumonia
on top of chronic parenchymal scarring. There was some
question of right upper lobe and right lower lobe collapse.
EKG was irregularly irregular with no regular P waves;
therefore, atrial fibrillation with a ventricular response in
the 120s, frequent premature ventricular contractions. There
were no acute ST-T wave changes.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Medical Intensive Care Unit Service as a transfer from
an extended care facility with increased lethargy, mental
status change, respiratory distress, and respiratory failure
status post intubation in the Emergency Department. He
required a central venous line placement and multiple
intravenous pressors for hypotension, presumed sepsis and
severe acidemia.
1. RESPIRATORY FAILURE: It was fel that the patient's
respiratory failure was most likely secondary to a chronic
obstructive pulmonary disease flare due to underlying
tracheobronchitis versus pneumonia versus aspiration. He was
started on Ceftazidine and Clindamycin in the Emergency
Department for infectious etiologies as well as coverage for
aspiration. Vancomycin was added for coverage in light of
his history of Methicillin resistant Staphylococcus aureus
positive sputum.
The Medical Intensive Care Unit staff ended up discontinuing
ceftazidime and clindamycin and instead covering the patient
with Zosyn for additional anti-Pseudomonal coverage.
He was maintained on an aggressive respiratory regimen with
metered dose inhalers, chest Physical Therapy, aggressive
pulmonary toilet and high dose steroids.
A CT scan of the chest was performed which showed a large
bibasilar pneumonia with a small right pleural effusion. The
right pleural effusion was deemed too small for a
thoracentesis.
The patient was maintained on assist controlled ventilatory
setting for several days. He was dramatically over breathing
at a rate of high 20s to low 30s, which was his respiratory
rate, likely in compensation for his underlying metabolic
acidosis.
On [**2130-10-24**], the patient became more awake and alert. He
was able to undergo a pressure support trial which he
tolerated well. He was aggressively diuresed and bicarbonate
therapy was added to his medication regimen in order to
assist potential extubation. He was extubated on [**2130-10-27**].
He tolerated this well and was able to maintain good
oxygenation and ventilation on room air.
Ultimately, the patient's sputum culture grew out Methicillin
resistant Staphylococcus aureus as well as E. coli. In light
of the pan sensitivity of the E. coli, the patient's
antibiotic regimen was changed to Vancomycin and Bactrim. He
completed a ten day course of antibiotics. Steroids
continued to be tapered.
Again, throughout, the patient was maintained on aggressive
respiratory therapy regimen with nebulizers and metered dose
inhalers, chest physical therapy, aggressive pulmonary
toilet.
2. SEPSIS: The patient had multiple possible sources for
sepsis including left lower extremity cellulitis, pneumonia,
urinary tract infection. He was originally covered with
Vancomycin and Zosyn. He was pan cultured. A PICC line was
in place from his last hospital course which was discontinued
in light of possible line infection. A catheter tip of
culture done was negative.
Blood cultures had failed to reveal any pathogen. Urine
culture was positive for yeast. Sputum culture was positive
for Methicillin resistant Staphylococcus aureus as well as E.
coli. The patient's antibiotic regimen was scaled down in
light of sputum culture results and he was maintained on
Vancomycin and Bactrim.
He completed a total of a ten day course of both Vancomycin
and Bactrim. Vancomycin was dosed by level in light of his
chronic renal insufficiency.
3. HYPOTENSION: The patient's blood pressure in the
Emergency Department was decreased to 50s to 60s systolic for
a prolonged period of time. This required a central venous
line placement, intravenous fluids resuscitation and pressor
support. He was maintained on Levophed, Neo-Synephrine and
vasopressin to keep his mean arterial pressure greater than
65. He was able to have his pressor therapy weaned, and by
[**2130-10-18**], was off all pressors.
Throughout his hospital course, he was aggressively bolused
with intravenous fluid to maintain mean arterial pressure
greater than 65. At the time of discharge, his hypotension
had resolved.
4. ACUTE RENAL FAILURE: It was felt that the patient's
elevated creatinine was likely secondary to ATN from sepsis
and in light of his prolonged hypotension in the Emergency
Department. Renal Service was consulted. The patient's
urine and sediment was evaluated and was consistent with
acute tubular necrosis with muddy brown casts.
Early on in the hospital course, he had a low urine output,
putting out 200 to 300 cc of urine for 24 hours. He was
treated supportively with intravenous fluid therapy and
eventually his urine output increased.
Slowly throughout his course, his renal function improved.
At the time of discharge, his BUN and creatinine were
approaching his baseline.
5. ACIDOSIS: Originally, the patient's acidosis was felt
due to respiratory causes, especially in light of his
respiratory failure. However, he then demonstrated an anion
gap metabolic acidosis. It was felt that this was likely
secondary to sepsis as well as acute renal failure. His gap
closed with increased peripheral perfusion after a pressor
and intravenous fluid therapy. Lactate continued to
decrease.
In order to help correct his underlying acidosis, he was
diuresed with Lasix; KayCiel was repleted and he received
supplemental bicarbonate therapy.
6. CELLULITIS: The patient presented with a left lower
extremity cellulitis. He was continued on Vancomycin therapy
dosed by trough. At the time of discharge, his left lower
extremity cellulitis was improving but had not yet completely
resolved. He will likely need to continue several doses of
Vancomycin treatment status post discharge.
7. CHRONIC ATRIAL FIBRILLATION: The patient had a slight
troponin leak upon admission. It was felt that this was
demand ischemia in the setting of sepsis. There were no EKG
changes. Creatinine kinase levels remained flat. In light
of hemodynamic instability, he was not initially
anti-coagulated, however, upon discharge back to
rehabilitation facility, he should likely resume Coumadin
therapy.
8. SUPER-THREAPEUTIC INR: The patient had been on Coumadin
therapy for atrial fibrillation. He also had a history of
upper extremity deep vein thrombosis; however, on admission,
his INR was markedly elevated greater than 5.0. In light of
this, his Coumadin therapy was held. The patient should
likely restart Coumadin upon discharge back to rehabilitation
facility in light of his underlying atrial fibrillation.
9. ANEMIA: The patient was anemic on admission. Iron, B12,
folate, were evaluated. All told, the patient had studies
consistent with anemia of chronic disease. He did require
several blood transfusions during his hospitalization;
however, no frank source of bleeding was defined.
On [**2130-10-28**], he had a drop in his hematocrit from 27 to 22.
At the time of this dictation, the site of occult bleed was
being evaluated.
10. HYPOTHYROIDISM: The patient had a history of
hypothyroidism. He was continued on his outpatient dose of
Synthroid.
11. FUNGAL URINARY TRACT INFECTION: The patient's urine
cultures demonstrated growth of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**] species. He was
treated with a five day course of Fluconazole. He is likely
colonized with the [**Female First Name (un) 564**].
12. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
originally kept n.p.o. in the setting of sepsis. Several
days into his hospital course he was begun on tube feeds. He
tolerated this well. Status post extubation, he was able to
tolerate a soft consistency, thickened liquid diet. He
should likely undergo a formal speech swallow evaluation and
check for aspiration.
Also on admission it was noted patient's extreme electrolytes
abnormalities with hypomagnesemia and hypocalcemia. In light
of this, his electrolytes were aggressively repleted. He
should likely have his electrolytes followed and repleted as
necessary after discharge through the rehabilitation
facility.
CODE STATUS: Initially, the patient was full code. In light
of his underlying severe medical problems as well as this
complicated hospital course, discussions were held with his
daughter, [**Name (NI) **], discussing his code status. He was made "Do
Not Resuscitate" on [**2130-10-19**]; however, the patient's
daughter stated that she would like her father re-intubated
should he fail extubation.
After extubation, the patient's advanced directives were also
discussed with the patient himself, and he re-iterated that
he would like to be re-intubated should he fail extubation.
He also stated that he would not be adverse to tracheostomy
placement if he required prolonged ventilatory support.
He did, however, state that he would reject percutaneous
gastrostomy tube placement as well as hemodialysis if needed
to maintain him medically.
The remainder of the [**Hospital 228**] hospital course, including
condition on discharge, discharge status, discharge diagnoses
and discharge medications with follow-up plans will be
dictated as a separate addendum to this report.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 8038**]
Dictated By:[**Last Name (NamePattern1) 41068**]
MEDQUIST36
D: [**2130-10-29**] 17:11
T: [**2130-10-29**] 17:53
JOB#: [**Job Number 41069**]
cc:[**Last Name (NamePattern1) 41070**]
|
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"584.5",
"682.6",
"482.41",
"427.31",
"428.0",
"491.21",
"276.2",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"99.04",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7702, 17109
|
3845, 4646
|
5137, 7673
|
122, 2511
|
2533, 3813
|
4664, 5113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,495
| 144,636
|
27601
|
Discharge summary
|
report
|
Admission Date: [**2185-5-20**] Discharge Date: [**2185-5-30**]
Date of Birth: [**2114-1-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
transfer from [**Hospital1 **] for hypotension and pneumonia and COPD
Major Surgical or Invasive Procedure:
Arterial line (left hand)
Left subclavian line
PICC line placement
History of Present Illness:
71M with hx COPD, respiratory failure s/p trach, transferred for
hypotension, new infiltrate, sepsis. Came from [**Location (un) 47**] ICU
with COPD flare when he was trached and peg'd. Pt transferred to
[**Hospital3 105**] for vent weaning and has been off ventilator
support for the last 3 days. He had his trach downsized to size
6 and he was speaking with a Passy-Muir valve. Yesterday he had
a barium swallow. Barium swallow showed severe aspiration with
pudding, ineffective cough/clearance. No witnessed aspiration
event. This am pt had respiratory distress (desat) and was
placed back on the vent, became hypotensive. CVL (R fem) line
placed and pt started on levophed and dopamine. Received ceftaz,
clindamycin and vancomycin, 100mg hydrocortisone. CXR showed
large L infiltrate.
.
ROS: Unable to obtain [**1-20**] poor mental status
Past Medical History:
s/p ablation for dysrhythmia (per family)
end stage COPD
size 6 trach
Social History:
Unknown
Family History:
Noncontributory
Physical Exam:
VS: 99.8 BP 71/45 HR 100 R 20 99%
AC 16 X 450 P5, FiO2 50% Ppeak 36
Gen: intubated, arouseable, but does not answer questions, not
sedated
HEENT: EOMI, PERRL
Neck: no LAD
Chest: decreased BS L side, expiratory wheezes throughout
CV: tachy, RRR, s1 s2 present, no mrg
Abd: soft, NT, ND +BS
Ext: no edema, no rash, R fem line in place
Neuro: moves all 4. A&O X 0.
Pertinent Results:
Labs: From OSH, [**5-20**] notable for Cr 1.3, gap 1. WBC 3.0, Hct
36.4. plt clumped. ABG [**5-19**] 7.51/49/45
.
Studies:
[**5-20**] CXR (OSH): Process predominantly in perihilar region on the
L side and L upper lobe with suspected patchy diffuse infiltrate
through the L lower lobe.
Brief Hospital Course:
Mr. [**Known lastname 67436**] is a 71M with endstage COPD s/p trach who was
transferred from [**Hospital **] Rehab with likely aspiration PNA and
sepsis. He arrived to the [**Hospital Unit Name 153**] in a very tenuous condition while
on 2 pressors. He was noted to be in hypoxic and hypercarbic
respiratory failure (hypoxic and hypercarbic), likely secondary
to endstage COPD coupled with aspiration pneumonia. He was
initially ventilated on AC mode via his trach. He was also noted
to be in septic shock and was significantly hypotensive (60/30s)
on 2 pressors on arrival to [**Hospital Unit Name 153**]. He was started on IVF, stress
dose steroids, and a 3 pressor regimen with Dopamine, Levophed
and Vasopressin. His blood pressure stabilized on this regimen.
.
He was broadly covered with Vanc, Ceftazidime and Clindamycin at
the rehab. In the [**Hospital Unit Name 153**] he was transitioned to Zosyn, Levoflox
and Vanc. and maintained on a sepsis protocol. He was given
Albuterol MDI, Atrovent MDI and Flovent for COPD exacerbation.
His sputum cultures were significant for Ecoli (S to Zosyn) and
P. aeruginosa. His Levoflox and Vanc were discontinued.
.
Mr. [**Known lastname 67436**] has a gradual improvement in his ventilation status
status during the hospitalization. He was noted to have an
APACHE score of >25 for which he was started on 96h of Xigris.
His sedation was eventually weaned off and his blood gases
improved. His blood pressure remained stable off of pressors.
He did become hypernatremic with a sodium which peaked at 150.
This resolved with the addition of free water boluses to his
tube feedings.
.
Transitioned to PS vent. Pressors weaned off o/n b/w [**5-24**]- [**5-25**].
Had a trach mask trial on [**5-25**], which he failed. He was noted to
be sig vol overloaded but he started autodiuresing as his vent
settings were weaned down. His respiratory status improved and
he tolerated longer and longer periods on the trach mask. His
antibiotics were converted to Zosyn 4.5g IV q8 once his blood
and sputum cultures grew sensitive E.Coli. Due to his
bacteremia, he was to continue a course of 14 days for his
aspiration PNA with E.coli bacteremia (day#11 on discharge -
last dose [**2185-6-2**]). Prior to discharge, patient was able to
complete wean from the vent and remained on a 50% trach mask.
.
Patient was transferred to his prior rehab hospital to continue
with trach management as well as to complete a 2 week course of
ABx. Pt is to remain on tube feedings as he represents a
permanent swallow risk as evaluated by S&S.
Medications on Admission:
Lidocaine jelly around trach
ativan 1mg q2h prn
tylenol 650 mg 4-6h prn
dulcolax 10 mg qd prn
morphine 1-2 mg SQ q1h prn
albuterol MDI q2h prn
duoneb QID prn
clindamycin 600 mg q8 IV (started [**5-16**])
colace 100 mg PO BID
Protonix 40 mg PO qD
Free H2o 250 ml q6 hr
Promod TF
Novasource Renal 30 mg TID
Fragmin [**Numeric Identifier 16351**] SQ daily
combivent 4p q4hr
prednisone 60 mg daily
Ceftaz
Vanc
Discharge Medications:
1. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 gram Recon
Solns Intravenous Q8H (every 8 hours) for 3 days: Last doses on
[**2185-6-2**]).
[**Date Range **]:*qs Recon Soln(s)* Refills:*0*
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Eight
(8) Puff Inhalation every six (6) hours.
[**Date Range **]:*qs inhalations* Refills:*0*
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*qs inhalation* Refills:*2*
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed for anxiety.
[**Hospital1 **]:*60 Tablet, Rapid Dissolve(s)* Refills:*0*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
[**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please give through G-tube.
[**Hospital1 **]:*60 Capsule(s)* Refills:*2*
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
[**Hospital1 **]:*qs units* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: as per scale
below units Injection three times a day: Check BS qid:
For BS 150-200, give 2 units. For 200-250, give 4 units. For
250-300, give 6 units. For 300-350, give 8 units. For 350-400,
give 10 units. For >400, give 12 units and call doctor.
[**Last Name (Titles) **]:*qs units* Refills:*2*
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP<100.
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO once a day.
11. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day
for 3 days: [**2185-5-31**]: 10mg
[**2185-6-1**]: 5mg
[**2185-6-2**]: 5mg
[**2185-6-3**]: off. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8629**]
Discharge Diagnosis:
Septic shock due to aspiration pneumonia
E.Coli bacteremia from aspiration pneumonia
COPD flare
Pancreatitis
Discharge Condition:
stable to be discharged to rehab
Discharge Instructions:
Please take medications as outlined below.
.
If you develop fever, respiratory distress, difficulty
oxygenating on the venilator, vomiting, or any other concerning
symptoms, seek medical attention immediately.
Followup Instructions:
Please follow up with your doctor at the rehab as needed.
Completed by:[**2185-5-30**]
|
[
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"507.0",
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"286.9",
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
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icd9pcs
|
[
[
[]
]
] |
7091, 7137
|
2186, 4756
|
385, 454
|
7290, 7325
|
1877, 2163
|
7584, 7673
|
1462, 1479
|
5212, 7068
|
7158, 7269
|
4782, 5189
|
7349, 7561
|
1494, 1858
|
276, 347
|
482, 1327
|
1349, 1421
|
1437, 1446
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,493
| 127,847
|
31920
|
Discharge summary
|
report
|
Admission Date: [**2165-10-11**] Discharge Date: [**2165-12-9**]
Date of Birth: [**2107-10-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
infected pancreatic necrosis/pseudocyst
Major Surgical or Invasive Procedure:
Pancreatic Necrosectomy
Cholecystostomy tube
G-tube
J-tube
[**Doctor Last Name 406**] drains x 4
s/p Ex-lap, modified [**State 19827**] patch approach, Debridement of
necrotic abdominal wall
s/p Washout and reapproximation of temporary bag closure
Exploration of abdomen and washout of upper abdomen. Repair of
ventral hernia with biological mesh.
Tracheosotomy [**2165-10-28**].
Decannulated [**11-25**]
History of Present Illness:
This is a 57 year old male recently admitted to Dr.[**Name (NI) 2829**]
service with gallstone pancreatitis s/p ERCP/papillotomy/stent
on [**9-25**] complicated by
pancreatic necrosis & pseudocyst replacement presents with
infected pancreatic necrosis/pseudocyst. He has had absolutely
no change since discharge in his level of abdominal pain, degree
of nausea or presence of fevers, chills, rigors or steatorrhea.
His sole concern leading to a visit to his PCP was progressive
hyperglycemia since discharge, requiring escalating doses of
insulin. On [**10-11**] his PCP [**Name Initial (PRE) 15598**]'t "like the way (he) looked", so
he sent him to [**Hospital3 3765**] where he has found to have a
leukocytosis with 54% band neutrophils. Subsequent abdominal CT
demonstrated slightly larger area of pancreatic necrosis and
cyst, but with diffuse gas throught the collection. He was
hemodynamically normal transferred to [**Hospital1 18**] for management.
Past Medical History:
Diabetes, non-insulin dependent
Hypertension
Lumbar disk bulge (L4)
Gallstone pancreatitis as above
Social History:
Married, non-drinker
Physical Exam:
PE: 98.9 81 101/58 22 95%/2L
Gen: NAD, MMdry, (-)jaundice
Pul: CTAB
Cor: RRR
Abd: soft/ND(+)periumbilical tenderness (-)tympani (-)guarding
Ext: warm, well perfused
Pertinent Results:
[**2165-10-11**] 03:00AM BLOOD WBC-12.3* RBC-3.73* Hgb-12.0* Hct-33.0*
MCV-89 MCH-32.2* MCHC-36.3* RDW-15.5 Plt Ct-451*#
[**2165-10-12**] 04:19AM BLOOD WBC-28.7*# RBC-3.58* Hgb-11.1* Hct-33.5*
MCV-94 MCH-31.0 MCHC-33.1 RDW-15.7* Plt Ct-773*
[**2165-10-13**] 07:12PM BLOOD WBC-18.8* RBC-3.08* Hgb-9.6* Hct-27.8*
MCV-90 MCH-31.2 MCHC-34.6 RDW-16.3* Plt Ct-428
[**2165-10-18**] 02:30AM BLOOD WBC-8.9 RBC-3.20* Hgb-9.9* Hct-29.3*
MCV-92 MCH-30.9 MCHC-33.8 RDW-17.1* Plt Ct-236
[**2165-10-11**] 10:53AM BLOOD Glucose-268* UreaN-12 Creat-0.7 Na-129*
K-3.8 Cl-95* HCO3-24 AnGap-14
[**2165-10-14**] 08:51AM BLOOD Glucose-96 UreaN-16 Creat-0.8 Na-128*
K-3.8 Cl-98 HCO3-26 AnGap-8
[**2165-10-18**] 02:30AM BLOOD Glucose-139* UreaN-18 Creat-0.7 Na-138
K-4.7 Cl-102 HCO3-31 AnGap-10
[**2165-10-11**] 03:00AM BLOOD ALT-13 AST-15 AlkPhos-83 Amylase-43
TotBili-0.7
[**2165-10-13**] 02:54AM BLOOD ALT-152* AST-286* AlkPhos-63 Amylase-16
TotBili-0.5
[**2165-10-16**] 02:05AM BLOOD ALT-55* AST-45* AlkPhos-89 Amylase-18
TotBili-1.3
[**2165-10-11**] 03:00AM BLOOD Lipase-23
[**2165-10-16**] 02:05AM BLOOD Lipase-14
.
CHEST (PORTABLE AP) [**2165-10-13**] 12:07 PM
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with necrotizing pancreatitis, now septic,
recieving massive fluid resuscitation
INDICATION: Sepsis.
A single AP view of the chest is obtained semi-upright at 1215
hours and compared with the prior radiograph performed [**2165-10-12**].
The patient remains intubated with the tip of the ET tube
approximately 3 cm above the carina. Right-sided IJ line is
unchanged in position. Diffuse haziness is seen over both lung
fields consistent with layering pleural effusion tracking
posteriorly. Increased retrocardiac density is seen on the left
side consistent with airspace disease/atelectasis of the left
base.
IMPRESSION:
Findings are consistent with pleural effusions layering
posteriorly, more marked on the left side than on the right and
apparently increasing since the prior examination.
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74828**]Portable TTE
(Complete) Done [**2165-10-15**] at 11:55:01 AM FINAL
Findings
Intravenous administration of echo contrast was used due to poor
native endocardial border definition.
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Aortic valve not well seen. No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV
inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - ventilator.
Conclusions
The left atrium is mildly dilated. The left ventricular cavity
size is normal. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The left ventricular inflow pattern suggests
impaired relaxation. There is no pericardial effusion.
.
CT ABDOMEN W/O CONTRAST [**2165-10-22**] 1:09 PM
IMPRESSION:
1. Interval decrease in the size of a peripancreatic tissue and
air collection, with three drains in appropriate position.
2. Additional small right rectus sheath fluid collection, with a
small hemorrhagic component.
3. 5.2 cm fluid collection in the left pelvis is new when
compared to the prior study.
.
UNILAT LOWER EXT VEINS LEFT [**2165-10-27**] 3:20 PM
IMPRESSION: No evidence of left lower extremity deep venous
thrombosis.
.
CT ABDOMEN W/O CONTRAST [**2165-11-12**] 11:35 AM
IMPRESSION:
1. Decrease in size of pancreatic fluid collection due to
necrotizing pancreatitis with air and surrounding fat stranding
and small fluid, with multiple drains. Open wound in the mid
upper abdomen, with significant amount of oral contrast leakage,
suggestive of direct fistulous communication between the wound
and stomach, possibly from the G tube site, or less likely loop
of bowel, fluid collection with additional connection to the
bowel loops.
2. Decreased pleural effusion with atelectasis.
3. Foley catheter with balloon in the prostatic urethra, which
needs repositioning.
4. Limited study due to lack of intravenous contrast [**Doctor Last Name 360**].
.
CT HEAD W/O CONTRAST [**2165-11-16**] 1:16 PM
IMPRESSION:
1. Partial opacification of both mastoid air cells. Otherwise
unremarkable examination.
.
MRCP W/SECRETIN (ABD W&W/O C) [**2165-11-25**] 3:16 PM
IMPRESSION:
1. No appreciable increase in peripancreatic fluid following the
administration of secretin to suggest leak in the pancreatic
bed.
2. Small fluid collection adjacent to the pancreatic head about
a [**Month/Day/Year 19843**] tip is unchanged. This is the site that on the CT
abdomen and pelvis on [**2165-11-12**] had extraluminal oral contrast
that was not reported. This may be from a duodenal injury.
3. Unchanged 19 x 18 mm peripancreatic fluid collection adjacent
to the portal vein.
4. Minimal residual pancreatic tissue within the lateral tail,
dorsal head, and pancreatic uncinate process.
5. Hemosiderosis.
6. Left pleural effusion.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2165-12-1**] 8:55 PM
CONCLUSION:
1. No pulmonary embolism or aortic dissection. Atherosclerosis
is present in the proximal left anterior descending coronary
artery.
2. Large left basal effusion with passive atelectasis of the
left lower lobe.
3. 6-mm low-attenuation focus in the left lobe of the thyroid
gland should be further evaluated with a thyroid ultrasound.
.
.
[**2165-11-26**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2165-11-24**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2165-11-23**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2165-11-18**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2165-11-18**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2165-11-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-11-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-11-12**] URINE URINE CULTURE-FINAL INPATIENT
[**2165-11-12**] ABSCESS GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA, LACTOBACILLUS SPECIES}; ANAEROBIC
CULTURE-FINAL; FUNGAL CULTURE-FINAL INPATIENT
[**2165-11-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2165-11-4**] SWAB NOT PROCESSED INPATIENT
[**2165-11-4**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA}; ANAEROBIC CULTURE-FINAL; FUNGAL
CULTURE-FINAL INPATIENT
[**2165-11-4**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-11-4**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2165-11-4**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-11-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2165-10-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2165-10-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2165-10-28**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2165-10-28**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-10-28**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-10-26**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {PROBABLE
ENTEROCOCCUS, LACTOBACILLUS SPECIES, GRAM NEGATIVE ROD(S),
STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC CULTURE-FINAL
INPATIENT
[**2165-10-22**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2165-10-21**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {KLEBSIELLA PNEUMONIAE, VIRIDANS STREPTOCOCCI,
STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC CULTURE-FINAL
INPATIENT
[**2165-10-21**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2165-10-21**] URINE URINE CULTURE-FINAL {GRAM POSITIVE
COCCUS(COCCI)} INPATIENT
[**2165-10-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2165-10-21**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2165-10-21**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-10-21**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2165-10-21**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-10-14**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-10-14**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2165-10-14**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2165-10-12**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2165-10-11**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{KLEBSIELLA PNEUMONIAE, VIRIDANS STREPTOCOCCI}; ANAEROBIC
CULTURE-FINAL; FUNGAL CULTURE-FINAL
.
ASCITES CHEMISTRY Amylase
[**2165-11-23**] 11:15AM [**Numeric Identifier 74829**]
1 VERIFIED BY DILUTION
[**2165-11-22**] 09:02PM [**Numeric Identifier 74830**]
.
Brief Hospital Course:
This is a 57 year old male with copious amounts of extraluminal
gas in his
pancreatic pseudocyst. Amazingly, he is not toxic appearing, but
this could change rapidly. The source of the air is likely the
bowel gas transmitted across the biliary stent placed in ERCP
ten days ago and may not be from gas-forming bacteria presently.
Regardless, even if it is not currently infected, it would only
be a matter of time before communication with the gut flora
would result in just such an infection.
He was admitted for aggressive IVF, NPO, FTG and IV abx
(meropenem/fluconazole). He went to the OR for pancreatic
necrosectomy on [**10-11**] (1 liter of purulent fluid),
cholecystostomy tube, g tube, j tube, [**Doctor Last Name 406**] X 4 (#1-gallbladder
area, #2-pancreatic head, #3-body, #4-tail)
He remained intubated in the ICU with drains in place
Significant Events:
-[**10-11**], underwent debridement of his pancreas with 1.5L of pus
drained
-[**10-14**] his wound culture started growing pan-sensitive Klebsiella
and Viridans strep.
-[**10-23**] Washout: peritoneal fluid grew Klebsiella, Viridans strep
and rare coagulase negative staph.
-[**10-28**] Ex lap, washout and debridement; wound grew
enterococcus(mod), lactobacillus(mod), gram negative
rods(sparse) and coag negative staph(sparse). Tracheostomy
-[**10-31**] and [**11-4**] washouts with attempt at ventral hernia closure
with mesh (disintegration of graft). Gent, Amikacin and Ceftaz,
on [**11-6**] and changed to Ceftazidime and Colistin on [**11-7**].
-[**11-4**] abd swab: Pseudomonas (S to ceftaz)
-[**11-12**] CT showed a gastic fistula, and decreased pancreatic fluid
collection
-[**11-16**] Head CT WNL. (s/p fall when attempting to get OOB while
confused)
-[**11-16**] CT Abd: Open wound in the mid upper abdomen, with
significant amount of oral contrast leakage, suggestive of
direct fistulous communication between the wound and stomach,
possibly from the G tube site, or less likely loop of bowel,
fluid collection with additional connection to the bowel loops.
[**11-17**]: transfused 2u PRBC, 2u FFP
-[**11-25**] MRCP with secretin: no increase in peripanc fluid with
secretin, stable 19x18mm fluid adj to PV, stable fluid [**Last Name (un) **] adj
to panc uncinate with [**Last Name (LF) 19843**], [**First Name3 (LF) **] panc tissue in splenic hilum &
uncinate, herosiderosis
-[**11-25**] tracheostomy decannulated
-[**12-2**] CTA: no PE
.
Culture:
[**10-11**] pancreatic abscess: Klebsiella (pan S), S. viridans
[**10-21**] peritoneal fluid: Klebsiella (pan S)
[**10-21**] blood: neg
[**10-26**] abd swab: prob Enterococcus, Lactobacillus, GNRs sparse
growth, coag neg Staph
[**11-3**] C. diff: neg
[**11-4**] abd swab: Pseudomonas (S to ceftaz)
[**11-12**] ucx: neg
[**11-12**] wound cx: Pseudomonas (S to ceftaz), Lactobacillus
[**11-18**] MRSA & VRE screen: neg
[**11-18**] cath tip: neg
[**11-23**] C.diff: neg
[**11-24**] C.diff: neg
ID was following along.
Prior ABX:
Flagyl [**Date range (1) 74831**]
Meropenem [**10-11**]-
Vanco([**Date range (1) 74832**], [**Date range (1) 74833**]
Gentamicin([**11-6**]-
ABX:
CeftazIDIME 2 gm IV Q8H ([**11-7**]-)
Colistin 120 mg IV Q12H ([**11-7**]-)
Fluconazole 400 mg IV Q24H ([**Date range (1) 74834**])
Vancomycin 1000 mg IV Q 12H ([**Date range (1) 74833**])
MICRO:
10/5 BLOOD No growth
[**10-11**] SWAB: KLEBSIELLA PNEUMONIAE Pan sensitive
[**10-21**] BLOOD No growth
[**10-23**] Peritoneal Fluid: :KLEBSIELLA PNEUMONIAE-Pan sensitive.
VIRIDANS STREPTOCOCCI. STAPHYLOCOCCUS, COAGULASE NEGATIVE.
[**10-26**] Swab: PROBABLE ENTEROCOCCUS. LACTOBACILLUS SPECIES.
GRAM NEGATIVE ROD(S). STAPHYLOCOCCUS, COAGULASE NEGATIVE.
[**11-4**] SWAB: PSEUDOMONAS AERUGINOSA Resistant to all but Ceftaz,
colistin sensi pend
C.Diff toxin negative [**10-22**], [**10-28**], [**10-30**], 10/28
[**11-10**]:
Renal function slightly worse today cont cef/colisitin day [**3-11**]
Sensi return Intermediate to amikacin await sensi to colistin
[**11-11**]: Creat up to 1.7 (baseline 0.6). D/C Colistin, change
ceftaz to q12h dosing. Check urine eos. Colistin sensitivities
are [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 74835**], [**First Name3 (LF) **] take 10 days to get back.
[**11-13**] Creat stable at 2.4, renal now following, think it is
related to colistin. CT showed oral contrast extravasating into
pancreatic area, concerning for enteric fistula. Plan to follow
one more day until know surgical plan for enteric fistula, etc.
Will set final course of abx tomorrow.
[**11-14**] watching one more day, if afebrile will set abx course
tomorrow and probably sign off.
ID said to continue Vancomycin, Fluconazole, and Ceftaz. The
Vancomycin and fluconazole were stopped on [**11-20**] after 30 and 41
days respectively. The Ceftaz was stopped on [**12-2**] after
completing a 4 week course.
Acute Renal Failure: Has had long SICU course complicated by
wound dehiscence requiring multiple "wash-outs" and mesh
placements.
Current issue is mesh disintegration secondary to Pseudomonas
infection for which the patient was initially placed on
gent+amikacin, and then colistin, all of which caused
nephrotoxic ATN. Creatinine stable and expect tubules to heal
over time.
[**11-14**]: Creatinine=2.3 (plateaued), supportive ATN care and
renally-dosing meds
[**11-15**]: Cr plateaued and UOP excellent, tubules expected to heal
over 10-14 days.
Gastric Fistula: He remained NPO due to the fistula. He was
physically able to eat and swallow, but due to the fistula, was
prevented from doing so. He had a +grape juice test at the
bedside, with extravasation of juice.
He continued on J-tube feeding for nutrition.
His abdomen remained open with a VAC dressing being changed q3d.
We were using the white foam VAC sponge due to the exposed
bowel. There was also a Malecott tube helping to [**Month/Day (4) 19843**] the open
abdomen that was to wall suction.
His drains are as follows: cholecystostomy tube, g tube, j tube,
[**Doctor Last Name 406**] X 4 (#1-gallbladder area, #2-pancreatic head, #3-body,
#4-tail). The [**Doctor Last Name 406**] drains have sequentuially been worked out,
2-cm at a time, and resutured in. Only 2 [**Doctor Last Name **] drains now
remain. The Cholecystostomy biliary tube must remain in place
and is currently capped. The G-tube was to gravity drainage in
order to fascilitate fistula healing. The Malecott [**Doctor Last Name 19843**] was
removed on [**12-6**] and the White Sponge VAC remains in place.
Post-op Orthostasis: When attempting to get OOB with assistance,
he was having issue of orthostasis. This was probably due to
prolonged ICU course and due to fluid loss from his abdominal
wound. PT and OT continued to work with him and we attempted to
stay up with his fluid loss, but providing fluid resuscitation.
He improved gradually, and was able to maintain his blood
pressure with transfers and sitting. We held all hypertensive
medications in order to help his his symptomatic orthostasis.
Post-op Hyperglycemia: Currently on Lantus [**Hospital1 **] and SS Regular
which seems to have helped smooth out his highs and lows. Be
careful not to increase Lantus too much as he is on high rate
TF's and will be in trouble if they are interrupted.
He was followed by [**Last Name (un) **] for continued blood glucose control.
Neuro: He had confusion in the ICU and at times was difficult to
reorient. Once out on the floor, his mental status continued to
improve. He is now AA+O x 3, with no apparent deficits.
Medications on Admission:
toprolXL 100, lisinopril 20, ASA
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution [**Last Name (un) **]: [**10-26**] mL PO Q6H
(every 6 hours) as needed for fever.
2. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) [**Month/Year (2) **]: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: Two (2) PO BID (2
times a day).
4. Bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Paroxetine HCl 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Atorvastatin 10 mg Tablet [**Month/Year (2) **]: One (1) 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. Morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 1-5 mg PO Q4H (every 4
hours) as needed.
10. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: See Scale
Subcutaneous twice a day: 34 Units qam. 38 Units qpm.
11. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: See Sliding
Scale Injection every six (6) hours.
12. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital 11042**] Hospital Rehabilitation
Discharge Diagnosis:
Pancreatic Pseudocyst
pancreatic Necrosis
Hyperglycemia
Gastic fistula
Acute renal failure
Infected Mesh with Pseudomonas infection
Respiratory Distress
Prolong intubation requiring tracheostomy
Orthostasis
Malnutrition
Discharge Condition:
Good
Tolerating tubefeedings
VAC in place
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
.
* Continue to amubulate several times per day.
* No heavy lifting >10 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2165-12-27**] 9:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2166-1-14**] 4:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2166-1-14**] 4:00
Please follow-up with [**Hospital **] [**Hospital 982**] Clinic. Call ([**Telephone/Fax (1) 17256**] to schedule an appointment.
Completed by:[**2165-12-9**]
|
[
"577.2",
"574.10",
"038.49",
"537.4",
"553.21",
"518.81",
"577.0",
"250.00",
"998.59",
"995.92",
"728.86",
"286.9",
"584.5",
"998.31",
"584.9",
"511.9",
"785.52",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.3",
"54.72",
"52.22",
"53.61",
"99.07",
"93.59",
"96.6",
"96.33",
"96.72",
"46.39",
"31.1",
"38.93",
"43.19",
"51.03"
] |
icd9pcs
|
[
[
[]
]
] |
20328, 20403
|
11347, 18832
|
355, 762
|
20667, 20711
|
2116, 3261
|
21829, 22377
|
18915, 20305
|
3298, 11324
|
20424, 20646
|
18858, 18892
|
20735, 21806
|
1926, 2097
|
276, 317
|
790, 1749
|
1771, 1872
|
1888, 1911
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,085
| 161,428
|
1074
|
Discharge summary
|
report
|
Admission Date: [**2188-12-29**] Discharge Date: [**2189-1-5**]
Service: Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
white male with significant arteriosclerotic disease, last
perfectly well in [**2174**]. Had routine follow-up with primary
care physician three weeks prior to admission and was found
to have guaiac positive stools with a hematocrit of 36
without weakness or dizziness. The patient was referred for
colonoscopy and had never had a colonoscopy prior to this
time, [**2188-12-17**], two weeks prior to admission, and
was found to have (1) sessile polyp in cecum, (2) 4 cm mass
in cecum, which was the source of bleeding, (3) diminutive
polyp at splenic flexure, (4) pedunculated polyp in the
rectum, (5) diverticulosis in the sigmoid colon, and (6)
internal hemorrhoids. Then patient found Dr. [**Last Name (STitle) 957**] for
surgery. Patient was diagnosed with mitral regurgitation and
atrial fibrillation after patient suffered stroke in [**2178**] and
began seeing Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in cardiology, who started
him on Coumadin. His last EKG was [**2188-10-18**] showing
atrial fibrillation. Last echocardiogram showed bilateral
atrial enlargement, [**2185-5-3**], mitral valve normal, normal
left and right ventricular function. P-MIBI left ventricular
ejection fraction 64%, within normal limits. Patient had
baseline electroencephalogram on day of admission showing
generalized multi-focal slowing, nothing sustained or
seizure-like, consistent with old strokes.
PAST MEDICAL HISTORY:
1. Prostate cancer, treated with radiation therapy .... last
PSA 1.2 which was one year prior to admission.
2. Arteriosclerosis.
3. Amaurosis fugax.
4. Mitral regurgitation.
5. Atrial fibrillation.
6. Diphtheria in [**2128**], World War II.
7. Cerebrovascular accident times one in [**2178**].
8. Transient ischemic attack times one in [**2184**].
PAST SURGICAL HISTORY:
1. Appendectomy at age nine.
2. Lumbar laminectomy.
3. Left carotid surgery in [**2184**], left common carotid plus
external carotid endarterectomy and intravascular patch
angioplasty, tailored closure of internal carotid artery
opening.
ALLERGIES: Penicillin (rash).
FAMILY HISTORY: A brother had lung cancer and died at age 30
and was a smoker.
SOCIAL HISTORY: The patient is a boat builder, previously
was an investment banker, sail maker ......level athlete,
played hockey at [**University/College **]. He has a 15 pack year smoking
history, quit 20 years ago. Social drinker, one to two beers
daily, without intravenous drugs. Originally, the patient
had told us he was a social drinker and drank one to two
beers a day but, later, it was found that the patient is a
much heavier drinker and drinks two to three strong vodka
drinks per day.
MEDICATIONS ON ADMISSION: Coumadin 3 mg q. Monday, Tuesday,
Thursday, Friday, Saturday, 4 mg Wednesday and Sunday,
patient had 2 mg for the last two days, digoxin 250 mcg q.d.,
Lipitor 10 mg q.d., magnesium oxide 400 mg q.d.,
hydrochlorothiazide 25 mg one-half tablet q.d., folic acid 2
mg q.d., aspirin 81 mg q.d., B6 100 mg q.d., B12 100 mg q.d.
REVIEW OF SYSTEMS: The patient has no fever, chills, no
headaches, no nausea, vomiting, no shortness of breath, no
chest pain, no abdominal pain, no frank blood in stool,
patient does not notice change in stool color or caliber, no
dysuria, hematuria, no weakness of extremities.
PHYSICAL EXAMINATION: On physical examination, the patient
was afebrile at 98.8 with a heart rate of 80 and blood
pressure of 138/80 and respiratory rate of 18, oxygen
saturation 98% in room air. Head, eyes, ears, nose and
throat: Pupils equal, round, and reactive to light and
accommodation, extraocular movements intact, head wrapped
after EEG. Neck: Supple without lymphadenopathy, no jugular
venous distention, no bruits. Cardiovascular: Irregularly
irregular and muffled. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, nontender, nondistended,
positive bowel sounds, positive reducible umbilical hernia.
Rectal: Guaiac negative, slightly enlarged prostate.
Extremities: Warm and well perfused without cyanosis,
clubbing or edema, pulses showed 2+ carotid, 2+ radial, 2+
femoral, 2+ anterior tibialis, 2+ dorsalis pedis bilaterally.
Neurologic examination: Alert and oriented times three,
cranial nerves II through XII intact, gait normal.
LABORATORY DATA: Admission white blood cell count 10.5,
hematocrit 41.5, platelet count 341,000, prothrombin time
17.2, partial thromboplastin time 26.7, INR 2, sodium 142,
potassium 3.8, chloride 101, bicarbonate 31, BUN 13,
creatinine 1, glucose 126, calcium 9.3, magnesium 2.1 and
phosphorous 4.4. Electrocardiogram showed irregularly
irregular rhythm, no acute ST segment changes. Chest x-ray
showed mild emphysema with no acute cardiopulmonary disease.
Electroencephalogram showed baseline general multi-focal
slowing, nonsustained, without seizure activity and
consistent with old strokes.
HOSPITAL COURSE: The patient was admitted for symptomatic
polyp and mass in cecum and was admitted for a left colectomy
and placed on bowel prep and clear liquids the day prior to
surgery.
The patient was taken to the Operating Room on [**2188-12-30**] with a preoperative diagnosis of cecal cancer mass,
postoperative diagnosis the same, procedure was a right
colectomy. Surgeon was Dr. [**Last Name (STitle) 957**], assistants Dr. [**Last Name (STitle) 7011**], Dr.
[**Last Name (STitle) **]. Anesthesia was general endotracheal anesthesia,
intravenous fluids 1,900 cc intraoperatively, estimated blood
loss 50 cc, urine output 165 cc. Findings: Greater than 4
cm mass. Complications: None. Disposition: Stable to the
Post Anesthesia Care Unit. Incidentally, the umbilical
hernia was also repaired at the time of surgery.
On postoperative day number one, the nasogastric tube was
noted to be guaiac positive and the patient was placed on
alternating Carafate and Mylanta for gastric protection. The
patient's patient controlled analgesia pump was discontinued
and the patient was alert and oriented from 11:00 a.m. to
2:00 p.m. on [**2188-12-31**] which is postoperative day
number two. However, he was somewhat confused on the morning
of postoperative day number two and it was attributed to
being the patient controlled analgesia pump. This was then
discontinued and the patient was lucid from 11:00 a.m. to
2:00 p.m. and, after 2:00 p.m., continued to become confused.
Blood sugar was 128, the patient was afebrile with stable
vital signs with an oxygen saturation of 95% in room air.
The senior resident was notified and the altered mental
status was worked up by the neurology on-call resident and
thought to be secondary to Dilaudid use. However, on further
history, the patient was found to be a heavy drinker and
these changes in mental status were attributed to delirium
tremens. The patient was started on thiamine and Ativan.
His mental status continued to be altered and the patient was
transferred to the Intensive Care Unit on [**2189-1-1**],
which was postoperative day number two, for closer
neurological monitoring. As the patient received scheduled
Ativan, the patient continued to improve and was tolerating
sips on postoperative day number three, however, continued to
require restraints.
On [**2189-1-2**], the patient's sedating medications were
held and he was much more oriented. The patient began
passing flatus on [**2189-1-4**] and was transferred to the
floor on that day. The patient was much more alert and
oriented on [**2189-1-5**] and was stable for home after
already being on his home regimen of Coumadin for the past
for days prior to discharge. The patient was restarted on
all of his home medications prior to discharge and was able
to tolerate orals. The patient was discharged on
postoperative day number six and was placed on oral
vancomycin because of a positive Clostridium difficile toxin
while he was in the unit. The patient was discharged without
event.
FINAL DIAGNOSES:
1. Status post right colectomy.
2. Clostridium difficile.
3. Intraoperative electroencephalogram.
4. Delirium tremens.
5. Prostate cancer, status post radiation therapy.
6. Arteriosclerosis with amaurosis fugax.
7. Mitral regurgitation.
8. Atrial fibrillation.
9. Cerebrovascular accident.
10. Transient ischemic attack.
11. Diphtheria.
The patient as instructed to call his doctor if he
experienced a temperature greater than 101.4 or if he
experienced any redness or swelling around the wound site.
He was also encouraged to continue to walk and not to lift
anything heavier than ten pounds for a period of six weeks.
He was also encouraged not to drive and told it was normal to
experience fatigue for at least two weeks. He was given Dr.[**Name (NI) 7012**] postoperative instruction sheet for further
instructions.
DISCHARGE MEDICATIONS:
Cyanocobalamin 100 mg one-half tablet p.o.q.d.
Thiamine 100 mg p.o.q.d.
Lopressor 50 mg p.o.b.i.d.
Vicodin 5/500 mg p.o.q.4-6h.p.r.n. pain.
Pepcid 20 mg p.o.b.i.d.
Digoxin 250 mcg p.o.q.d.
Coumadin 1 mg tablets 3 mg p.o.q. Monday, Tuesday, Thursday,
Friday and Saturday and 4 mg on Wednesday and Sunday.
Vancomycin 125 mg p.o.q.6h. times 12 days.
DISPOSITION: To home.
CONDITION ON DISCHARGE: Good.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) 957**] in his office in one week, and to call for an
appointment.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern4) 7013**]
MEDQUIST36
D: [**2189-1-5**] 04:58
T: [**2189-1-5**] 17:05
JOB#: [**Job Number 7014**]
|
[
"292.81",
"211.3",
"440.9",
"427.31",
"V10.46",
"E935.2",
"362.34",
"553.1",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.49",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
2260, 2324
|
8930, 9302
|
2855, 3178
|
5047, 8058
|
1969, 2243
|
8075, 8907
|
3483, 4320
|
3198, 3460
|
122, 1567
|
4345, 5029
|
1589, 1946
|
2341, 2828
|
9327, 9723
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,429
| 147,762
|
5123+5124
|
Discharge summary
|
report+report
|
Admission Date: [**2143-11-1**] Discharge Date: [**2143-11-7**]
Date of Birth: [**2085-9-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
metastatic renal cell carcinoma who is four years past right
radical nephrectomy Stage T3B. The patient subsequently in
[**2140-7-16**], had two lesions resected from the left
posterior lung lobe consistent also with metastatic renal
cell carcinoma. He has been followed with serial
surveillance CT scans. He had a scan from [**2143-9-30**]
which showed a lesion in his solitary left kidney
approximately 2 cm in diameter. Patient had no hematuria, no
abdominal pain, no nausea or vomiting, no weight loss, no
fever or chills. He had a bone scan done on [**2143-10-9**]
which showed no metastatic disease and his BUN and creatinine
at that time were 18 and 1.1. He presented for evaluation of
the left renal mass and was scheduled for a left partial
nephrectomy.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: Right nephrectomy with IVC
thrombectomy in [**2138**], left lung resection in [**2139**].
MEDICATIONS: Hydrochlorothiazide 25 po q.d., Norvasc 10 mg
po q.d., Zestril 20 mg po q.d.
SOCIAL HISTORY: Patient drinks three to four glasses of wine
per night.
PHYSICAL EXAMINATION: On initial physical examination, the
patient is a well-developed, well-appearing male in no
apparent distress. His neck was supple, no masses. His
chest was clear to auscultation bilaterally. Cardiovascular:
Regular rate and rhythm. His abdomen contained no palpable
masses. Liver and spleen were within normal limits. No
hernias were found. He had no palpable lymphadenopathy. His
anus and perineum were within normal limits. His
genitourinary exam was normal. His prostate was
approximately 40 grams. He was neurologically intact.
LABORATORIES: White blood cell count was 7.2, hematocrit
39.6, platelets 242,000. Urinalysis was negative. His PT
was 13, PTT 22.9, INR 1.2. His sodium was 138, potassium
4.3, chloride 99, C02 24, BUN 15, creatinine 1.0. AST and
ALT were 28 and 27 respectively. Alkaline phosphatase was
40. His total bilirubin .7. Albumin 4.4.
BRIEF HOSPITAL COURSE: Mr. [**Known lastname 467**] was admitted on [**2143-11-1**]. He underwent a left partial nephrectomy under
general endotracheal anesthesia. Intraoperative, he had
significant blood loss of approximately two liters for which
he received 1200 cc of crystalloid. He had a number one JP
drain and a Foley catheter placed. There were no
complications. He was transported to the Recovery Room
intubated and in stable condition, however, he was requiring
pressors to keep his pressure up. His initial blood gases in
the Post Anesthesia Care Unit were 7.28, 42, 149, 21 with a
base excess of 6. Based on this and his pressor requirement,
he was kept intubated and transferred to the Intensive Care
Unit. Overnight, he was weaned off of his pressor and weaned
off of the ventilator. He was extubated on postoperative day
number one without incident and transferred to the regular
floor. Patient had received three units of blood
intraoperatively and one unit in the Post Anesthesia Care
Unit. On postoperative day one, his hematocrit was 27.7,
however, on postoperative day number three, it progressively
decreased to 22, 23.5 on repeat. 02 was given, one unit of
packed red blood cells, hematocrit increased to 24 and was
25.8 on discharge. He was kept on Ancef perioperatively. He
remained afebrile throughout his hospital course. He was not
discharged on any antibiotics. His urine output remained good
throughout his hospital course and his BUN and creatinine
were 18 and 1.3. His diet was advanced on postoperative day
number five, he was ambulating independently and tolerating a
regular diet and his pain was controlled on oral pain
medication. He initially had some high output from his JP
drain about 600 cc per day. JP creatinine was checked which
was 2 and his drain was taken out on postoperative day number
six.
CONDITION OF DISCHARGE: Patient is afebrile, hemodynamically
stable, tolerating a regular diet, ambulating independently,
tolerating oral pain medication.
DISCHARGE DIAGNOSES:
1. Renal cell carcinoma. Clear cells variant.
2. Status post left partial nephrectomy, a solitary kidney.
3. Hypertension.
DISCHARGE MEDICATIONS:
1. Dilaudid 2-4 mg po q. 4 hours prn pain.
2. Colace 100 mg po b.i.d.
3. Iron sulfate 325 mg po t.i.d.
FOLLOW-UP: Patient is to follow-up with Dr. [**Last Name (STitle) 4229**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 13920**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2143-11-11**] 14:09
T: [**2143-11-11**] 14:09
JOB#: [**Job Number 21039**]
Admission Date: [**2143-11-1**] Discharge Date: [**2143-11-7**]
Date of Birth: [**2085-9-26**] Sex: M
Service:
DIAGNOSIS: Metastatic renal cell carcinoma.
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
metastatic renal cell carcinoma admitted for phase 1 and 2
trial of PEG-Intron with IL-2 for advanced renal cell
carcinoma.
ONCOLOGIC HISTORY: Patient initially presented with
asymptomatic hematuria in [**2138**]. Biopsy revealed renal cell
carcinoma and he underwent a radical nephrectomy. He
subsequently underwent resection of two lesions of the left
posterior lung also consistent with renal cell carcinoma.
Serial CT scans in [**2143-9-16**] revealed a solitary left
kidney mass of 2 cm and subsequently underwent a left partial
nephrectomy. He was enrolled in a phase III adjuvant trial
comparing IL-2 with observation and randomized to the
observation arm. A follow-up CT scan performed on [**2144-2-24**] showed evidence of increased metastatic disease with
mediastinal lymphadenopathy, pulmonary nodules and increase
size of the mass of lower pole of left kidney. MRI confirmed
the disease progression in the left kidney and pulmonary
metastases. He is currently enrolled in a phase [**12-18**] trial
with outpatient PEG-Intron with IL-2 for advanced renal cell
carcinoma.
PAST MEDICAL HISTORY: Significant for hypertension.
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS: Norvasc 10 mg a day, Zestril 40 mg
po q.d., hydrochlorothiazide 25 mg po q.d. All his
hypertensives have been held since [**89**] hours, as well as
Tylenol po prn.
SOCIAL HISTORY: He is a former smoker and quit 20 years ago.
He was employed as a machinist. He is married with three
children and drinks a couple of glasses of wine at night.
FAMILY HISTORY: Father died of an myocardial infarction.
Mother hypertension.
PHYSICAL EXAMINATION: Height 63 inches. Weight 76.5. Body
surface area 1.8 meters squared. ECOG status 0-1. Vital
signs: Blood pressure 150/90. Heart rate 100. Respiratory
rate 20. Temperature 98.5. 99% on room air. Pleasant in no
acute distress., Head, eyes, ears, nose and throat: Sclera
were conjunctive. Clear oropharynx, pink with exudate, no
oral mucoid cutaneous lesions. Neck: No anterior, posterior
cervical lymphadenopathy. No supraclavicular axillary
lymphadenopathy. Lungs clear to auscultation in all fields.
Heart: Regular rate and rhythm, no murmurs, rubs or gallops.
Abdomen soft, nontender, nondistended, active bowel sounds,
no hepatosplenomegaly. Extremities: No peripheral edema, no
rashes. Neurological: Alert and oriented times three.
Cranial nerves II through XII are grossly intact.
LABORATORIES: White blood cell count 5.8, hematocrit 40.4,
platelets 214,000. Sodium 135, potassium 4.2, chloride 97,
bicarbonate 26, BUN 17, creatinine 1.2, glucose 94, ALT 17,
AST 18, LDH 186, alkaline phosphatase 51, T bilirubin .71,
calcium 9.4.
HOSPITAL COURSE: He was admitted on [**3-19**] with a
performance status of 0-1 to begin. He received IL-2 at 5
million units per meter squared per dose q. 8 hours times
three which equalled 9 million units subcutaneously. He also
received his first dose of PEG-Intron at 2 mcg/kg per week
equalling a dose of 153 mcg. His first dose was received at
4 p.m. He tolerated the two medications without incident.
His blood pressure remained stable. He denied any nausea,
vomiting or diarrhea. He had no skin flushing. He had a
temperature of 101.2 several hours after the initial
interferon. At time of discharge, he was afebrile. He was
otherwise without complaint tolerating good po intake. He
had no appreciable toxicities. The Learning Center came and
instructed him on the use of subcutaneous injections of IL-2.
He was discharged on IL-2 and instructed to use 9 million
units subcutaneously five days a week times four a week, each
dose given at 6 p.m. Wednesday through Sunday. He will
receive PEG-Intron on a weekly basis in clinic.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2144-3-20**] 11:10
T: [**2144-3-20**] 11:10
JOB#: [**Job Number 21040**]
|
[
"458.2",
"197.0",
"189.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.4"
] |
icd9pcs
|
[
[
[]
]
] |
2206, 4198
|
6615, 6678
|
4219, 4346
|
4369, 4984
|
7781, 9101
|
1020, 1203
|
6253, 6419
|
6701, 7763
|
5013, 6136
|
6159, 6228
|
6436, 6598
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,409
| 173,983
|
3916
|
Discharge summary
|
report
|
Admission Date: [**2170-9-15**] Discharge Date: [**2170-9-28**]
Date of Birth: [**2100-6-6**] Sex: F
Service: MEDICINE
Allergies:
Percodan
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Gi bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a 70yo female with DM2, HTN, ESRD on HD, breast
ca s/p mastectomy who was transferred from [**Hospital3 **] for
management of acute GIB. She could not provide history due to
her AMS but per OSH report presented with hematemesis
accompanied by a HCT of 16. An NGT revealed coffee grounds and
she was subsequently transfused 2 units PRBCs along with IV
protonix bolus and gtt.
.
In the [**Hospital1 18**] ED, she remained hemodynamically stable with
pressures in the 129-169 range. She received a right femoral
cordis line. Her initial HCT was 25.8, and she was typed and
crossed for 2 units PRBCs (she received no [**Hospital1 **]). She had heme
+ brown stool. GI was consulted who recommended adding DDAVP due
to her uremia with plans for likely inpatient EGD. She was also
begun on octreotide gtt. Vitals prior to transfer were: 97.9,
78, 169/78, 100%2L.
.
Upon arrival to the MICU, her initial vitals were:T100.1, P76,
BP 141/93, Sat100% RA. She was nonverbal and could not answer
questions nor cooperate in the physical examination. She was
accompanied by her Brother [**Name (NI) **] and his wife, who related a
recent history of PEG tube placement about a week ago at [**Hospital1 2519**] for caloric support. She was discharged back to her
nursing home, but represented back to [**Hospital1 **] with fevers
prompting a several-day admission before resolving. She just
returned back to her nursing home yesterday. She apparently had
large volume coffee ground emesis, though no staff was
available overnight at the NH to comment. Per her brother, she
may have previously had a GIB, but his details are vague. She
is on no NSAIDS, anticoagulants, and no significant ETOH
history.
.
At baseline, she has mild dementia but speaks to her family, is
aware, answers questions well. She was moved to [**Hospital3 17461**]
several years ago due to inability to care for herself at home.
She tends to get confused with fevers and during hospital
admissions. Her MS clears upon returning home, and was normal
as of a few days ago.
.
She undergoes HD T, Th, Sat. Her nephrologist is Dr. [**Last Name (STitle) **] at
Stauton. She missed an HD visit today. She has a maturing left
HD fistula though only a month old. She gets HD via right
tunnel IJ catheter.
.
ROS could not otherwise be addressed
Past Medical History:
- diabetes mellitus type 2
- ER negative DCIS s/p mastectomy [**2162**]
- hypertension
- ESRD on HD T, Th, Sat
Social History:
Lives in [**Hospital3 17461**] Nursing home, Unit Manager [**First Name8 (NamePattern2) 13842**]
[**Last Name (NamePattern1) 6104**] [**Telephone/Fax (1) 17462**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Director of Nursing
[**Telephone/Fax (1) **]. Mild dementia. Smoked 30 PY, quit 20 years ago.
Infrequent ETOH.
Family History:
DM, HTN
Physical Exam:
ADMISSION EXAM
Vitals: T100.1, P76, BP 141/93, Sat100% RA
General: eyes closed, nonverbal, contracted posture though not
rigid
HEENT: Sclera anicteric, MMM, oropharynx clear. NGT in place,
draining coffee grounds.
Neck: supple, right IJ dialysis catheter in place. Difficult to
assess meningismus due to general resistance to passive
movement.
Lungs: Clear to auscultation on anterior exam, would not
cooperate for posterior exam. no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM at the apex
radiating to the axilla, and the 2nd ICS radiating to the
carotid.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. G tube site
nonerythematous without exudates.
GU: no foley in place
Ext: 4cm AV fistula in the left antecube. Warm, well perfused,
2+ DP pulses, no clubbing, cyanosis or edema
.
DISCHARGE EXAM
Physical Exam:
VS 98.1 157/68 71 18 99/RA FS 191
General: thin elderly female lying in bed with eyes closed,
doesn't open eyes to voice or follow commands
HEENT: NCAT pupils 3 mm, equal, reactive to light, MMM
Neck: JVP non-distended R chest HD line in place
Lungs: limited anterior exam, minimal air movement, shallow
breathing
CV: RRR chainsaw systolic murmur loudest LUSB radiates to
carotids
Abdomen: soft nondistended, G-tube in place
GU: no foley
Ext: WWP 1+ pulses no edema, in pneumoboots
Neuro: as above. also note normal tone, toes downgoing. 2+
reflexes.
Pertinent Results:
ADMISSION LABS & LABS OF NOTE
.
[**2170-9-15**] 02:52PM [**Month/Day/Year 3143**] WBC-12.4* RBC-2.89* Hgb-8.8* Hct-25.8*
MCV-89 MCH-30.3 MCHC-34.0 RDW-15.2 Plt Ct-140*
[**2170-9-15**] 02:52PM [**Month/Day/Year 3143**] Neuts-77.6* Lymphs-17.1* Monos-4.5
Eos-0.4 Baso-0.4
[**2170-9-15**] 02:52PM [**Month/Day/Year 3143**] PT-13.4 PTT-24.0 INR(PT)-1.1
[**2170-9-15**] 02:52PM [**Month/Day/Year 3143**] Glucose-208* UreaN-113* Creat-3.6* Na-140
K-5.7* Cl-103 HCO3-23 AnGap-20
[**2170-9-15**] 07:06PM [**Month/Day/Year 3143**] ALT-15 AST-30 AlkPhos-92 TotBili-0.3
[**2170-9-15**] 02:52PM [**Month/Day/Year 3143**] Calcium-8.6 Phos-3.9 Mg-2.4
[**2170-9-16**] 08:37PM [**Month/Day/Year 3143**] TSH-0.55
[**2170-9-17**] 12:24AM [**Month/Day/Year 3143**] Lactate-1.6
.
SERIAL CARDIAC ENZYMES
[**2170-9-15**] 02:52PM [**Month/Day/Year 3143**] cTropnT-0.13*
[**2170-9-16**] 08:37PM [**Month/Day/Year 3143**] CK-MB-3 cTropnT-0.20*
[**2170-9-17**] 01:37AM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.23*
.
DISCHARGE LABS
[**2170-9-28**] 05:45AM [**Month/Day/Year 3143**] WBC-9.1 RBC-3.34* Hgb-10.1* Hct-30.6*
MCV-92 MCH-30.2 MCHC-32.9 RDW-16.0* Plt Ct-393
[**2170-9-28**] 05:45AM [**Month/Day/Year 3143**] Glucose-185* UreaN-31* Creat-2.9*# Na-138
K-3.6 Cl-95* HCO3-29 AnGap-18
[**2170-9-28**] 05:45AM [**Month/Day/Year 3143**] Calcium-8.7 Phos-3.4 Mg-2.3
.
MICROBIOLOGY
.
BCX [**9-15**], [**9-16**], [**9-17**], [**9-18**], [**9-20**] - NEGATIVE
MRSA NASAL SWAB **FINAL REPORT [**2170-9-17**]** POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS
[**2170-9-26**] 8:15 am URINE CULTURE (Final [**2170-9-27**]): YEAST.
10,000-100,000 ORGANISMS/ML. (TWO PREVIOUS URINE CULTURES ALSO
POSITIVE)
.
IMAGING
.
CT head [**9-15**]:
IMPRESSION:
1. No acute intracranial process. No hemorrhage.
2. Stable hypoattenuation in the left cerebellum consistent with
encephalomalacia, likely secondary to prior infarct.
NOTE ADDED IN ATTENDING REVIEW: There is fairly marked
disproportionate ventriculomegaly, which has progressed since
the remote study. For example,the transverse dimention of the
lateral ventricular frontal horns measures 4.9 cm (at the level
of the caudate heads), whereas it measured 3.8 cm, previously;
that dimension of the anterior 3rd ventricle now measures 18 mm
(at the level of the foramina of [**Last Name (un) 2044**]), whereas it measured 13
mm before. In addition, there is now further symmetric confluent
low-attenuation adjacent to, particularly, the lateral
ventricular horns.
While this may simply represent progressive preferential central
atrophy, underlying communicating hydrocephalus is a
consideration and these findings should be closely correlated
clinically.
tent with
encephalomalacia, likely secondary to prior infarct
.
[**9-20**] EGD:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Other
findings: Large amount of [**Month/Year (2) **] and clots were seen in the
fundus, which were painstakingly removed via snare. The mucosa
underneath the clots in the fundus appeared to be normal. Normal
esophagus Dieulafoy lesion seen at the GE junction on
retroflexion which was actively bleeding and appeared to be the
source of the hematemesis. Epinephrine 1/[**Numeric Identifier 961**] hemostasis with
success in the gastro-esophageal junction. One endoclip was
successfully applied to the gastro-esophageal junction for the
purpose of hemostasis. Normal duodenum
Impression: Large amount of [**Numeric Identifier **] and clots were seen in the
fundus, which were painstakingly removed via snare. The mucosa
underneath the clots in the fundus appeared to be normal.
Normal esophagus
Dieulafoy lesion seen at the GE junction on retroflexion which
was actively bleeding and appeared to be the source of the
hematemesis. (injection, endoclip)
Normal duodenum
Otherwise normal EGD to third part of the duodenum
.
[**9-23**] EGD
PEG tube seen in body.
Ulcers in the whole stomach
Clip was seen at the GE junction.
Otherwise normal EGD to third part of the duodenum
.
[**9-24**] EGD
[**Month/Day (4) **] in the stomach
There was a bleeding lesion next to the clip seen on the gastric
side of the GE junction. (thermal therapy)
There was some oozing of [**Month/Day (4) **] at the clip site at the GE
junction. (thermal therapy)
[**Month/Day (4) **] in the duodenum
The PEG insertion site was mobalized and examined. There was no
ulcer under the gastric side of the PEG.
Otherwise normal EGD to third part of the duodenum
.
CXR [**2170-9-15**]
Nasogastric tube courses in expected position, with side port in
the distal esophagus and tip just beyond the gastroesophageal
junction. A large bore dialysis catheter enters the right
subclavian vein and terminates in the mid right atrium. There
are no pleural effusions or pneumothorax. Lungs are clear. Heart
size is top normal. Calcifications are noted in the aortic arch.
IMPRESSION: NG tube just beyond GE junction, recommend
advancement by 2-4 cm.
.
CXR [**2170-9-18**]
FINDINGS: In comparison with the study of [**9-17**], the area of
opacification at the left base medially is less prominent and
the hemidiaphragm is more sharply seen. This could reflect some
clearing of either aspiration or atelectasis.
There is a somewhat ill-defined area of opacification in the
left suprahilar region, which could represent a focus of
aspiration.
Brief Hospital Course:
70yo female with ESRD, HTN, DM2 who presents with UGIB and
altered mental status.
.
# ACUTE UPPER GI BLEED.
Admission HCT 25.8 with reported history of hematemesis and
coffee grounds localize her lesion to the upper GI tract.
Received DDAVP which should help platelet function in the
setting of uremia. Patient was placed on IV PPI ggt. GI was
consulted who proceeded with an EGD which demonstrated an
actively Dieulafoi lesion which was injected with epi and
clipped. Per GI effective hemostasis was achieved.
Post-procedure serial HCTs were monitored. Patient with no
further episodes of GI bleed. In total she was transfused 2u at
the OSH as well as 2units here. She was transitioned to [**Hospital1 **] PPI
on [**9-18**]. At time of transfer out of the MICU, patient with LIJ
access. Hct stabilized at ~25 and gradually self-corrected
thereafter. She was continued on a PPI (changed to lansoprazole
which could be dosed through PEG tube). [**9-23**] pt with melena and
decreased HCT to 21, though hemodynamically stable. Was
transferred to the MICU for urgent endoscopy which showed ulcers
in the stomach, sucralfate was initiated and pt transferred back
to the floor. On [**9-24**] pt again with decreased HCT, bleeding on
PEG lavage, started on PPI gtt, transferred back to the MICU,
again underwent EGD showing bleeding lesion next to the clip
seen on the gastric side of the GE junction and oozing of [**Month/Day (4) **]
at the clip site at the GE junction. Pt transitioned to PPI IV
BID, continued on sucralfate. HCTs remained stable, hemodynamics
remained stable. Last Hct 30.6 (baseline 29-30). She was
discharged on carafate 2 g QID (high dose per GI recommendation)
and lansoprazole max dose [**Hospital1 **].
.
# ASPIRATION PNA
She was running low grade temperatures to 100.1 in the MICU.
Also noted leukocytosis. Source initially unclear. [**Name2 (NI) **] and
urine cultures did not grow (except yeast in urine). Started
vancomycin/cefepime on [**9-18**] due to coughing, leukocytosis, low
grade temps, and equivocal left suprahilar opacification, which
was concerning for aspiration. She did have a witnessed
aspiration event in the ED, and spiked a fever to 102 2d
thereafter. Started on vanc/cefepime. Leukocytosis resolved
within 2d thereafter. Antibiotics were changed to vanc/ceftaz to
cover oral flora for aspiration PNA, and for ease of
administration qHD. These were stopped after an 8d course, when
patient had been afebrile x several days. Recommend aspiration
precautions at nursing home and during future hospitalizations.
.
# ALTERED MENTAL STATUS
Patient thought to be in marked hypoactive delirium. At time of
admission, thought to be "inexpressive" by family, a marked
departure from baseline though apparently common in the hospital
setting for her. Initial differential included toxic/metabolic
encephalopathy from uremia, fever, possible infection. Possibly
exacerbated by hospital setting. Head CT negative for acute
process. Her low-baseline mental status gradually improved as
her leukocytosis improved. At time of transfer out of the MICU
she did not open eyes to voice and minimally responded to pain.
By time of discharge she was still in hypoactive delirium and
not following commands but was tracking eyes to voice and
occasionally moved limbs spontaneously. Expected to improve to
baseline similar to prior episodes.
.
# CANDIDIASIS OF THE BLADDER
Pt with yeast in the urine and evidence of vulvovaginal
candidiasis. Started on fluconazole x14 days day [**3-5**] on
discharge. Pt unable to verbalize if she has pain with urination
but UA was persistently positive, urine culture positive for
yeast X 3 and urine appeared grossly hazy.
.
# RENAL FAILURE on HD
Patient is on T, Th, Sat HD scheduled. Dialyzed via R tunneled
HD catheter without complications. Received vancomycin at HD.
Was started on phosphate binders, but developed hypophosphatemia
so this was initially stopped; restarted sevelamer TID at time
of discharge given mild hyperphosphatemia (Phos 4.6).
.
# DIABETES MELLITUS:
History of type 2 DM, though home insulin regimin was unclear.
Covered with a sliding scale.
.
# ELEVATED TROPONIN:
Initially had elevated troponin without ischemic EKG changes.
Thought to be a combination of demand ischemia from GIB-induced
anemia and severe renal dysfunction. Hct goal >25 in this
context.
.
# HYPERTENSION:
Initially held home anti-hypertensives in light of her GIB. Had
relative hypotension as her BP is normal despite holding
numerous anti-hypertensives. Restarted on home losartan,
amlodipine, lopressor in the MICU. These were continued, and she
maintained pressures wnl on the floor. However, her BPs trended
upwards to systolic 140-160 after starting carafate, suggesting
that carafate decreased gastric absorption of her
antihypertensives. Suggest administering antihypertensive meds
30 minutes before carafate when the administration times
coincide.
.
# Communication was with patient's brother [**Name (NI) **] [**Telephone/Fax (1) 17463**]
and with brother [**Name (NI) **] who is HCP. [**Name (NI) 6419**] brothers confirmed the
patient's desire for code status DNR/DNI.
.
TRANSITIONAL ISSUES
.
1. FOLLOW-UP HEMATOCRIT (check daily through [**10-1**] then
qMonday/Wednesday/Friday for two weeks thereafter). NURSES
INCLUDING DARK OR BLOODY STOOLS. WE EXPECT DARK STOOLS [**Month (only) **]
CONTINUE FOR A FEW DAYS BUT IF THEY PERSIST >3 DAYS, ARE LARGE
VOLUME, OR BECOME DIARRHEA-LIKE AND DARK, NURSES SHOULD NOTIFY
MD AND RETURN PATIENT TO THE HOSPITAL.
.
2. FOLLOW-UP URINALYSIS FOR PERSISTENT YEAST FUNGEMIA IN 2
WEEKS, AFTER STOPPING ANTIFUNGAL TREATMENT.
.
3. PATIENT NOTED TO HAVE ULCERS ON EGD, WILL NEED H PYLORI
TESTING AS AN OUTPATIENT AT GI FOLLOW-UP APPOINTMENT.
.
4. FOLLOW-UP [**Month (only) 3143**] PRESSURE, ENSURE PT NOT RECEIVING BP MEDS AND
CARAFATE SIMULTANEOUSLY AS THIS [**Month (only) **] DECREASE ABSORPTION.
Medications on Admission:
Home Medications (per OSH records)
- losartan 100mg daily
- omeprazole 40mg daily
- renagel 800mg PO TID
- colace 200mg daily
- labetalol 200mg [**Hospital1 **]
- tylenol 650mg Q4hr
- dulcolax suppository 10mg QOD
- amlodipine 5mg daily
- clonidine 0.2mg tab
- prostat 30mg
- metoclopramide 5mg TID
- inslin lispo
.
MEDS FROM MICU TRANSFER:
Vancomycin 1000 mg IV HD PROTOCOL (d1=[**9-18**])
CefePIME 1 g IV Q24H (d1=[**9-18**])
Labetalol 200 mg PO/NG [**Hospital1 **]
Amlodipine 5 mg PO/NG DAILY
Losartan Potassium 100 mg PO/NG DAILY
Pantoprazole 40 mg IV Q12H
Sevelamer CARBONATE 800 mg PO TID W/MEALS
Insulin sliding scale
Acetaminophen IV 1000 mg IV Q6H:PRN pain,fever
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] Health Care Center - [**Location (un) 5110**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
UPPER GASTROENTEROLOGICAL BLEED
.
SECONDARY DIAGNOSES
ASPIRATION PNEUMONIA
CHRONIC RENAL FAILURE
DEMENTIA
HYPOACTIVE DELIRIUM
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital for bloody vomit.
We found that you were bleeding into your stomach from a [**Location (un) **]
vessel near the boundary of your stomach and esophagus. You
required multiple [**Location (un) **] transfusions. You also underwent three
endoscopic procedures by the hospital gastroenterologists, to
directly visualize your stomach lining and treat the bleeding
sites they saw. Your [**Location (un) **] counts were stable after the third
endoscopy -- we thought you had stopped bleeding.
You also developed pneumonia while you were here, requiring
treatment with antibiotics. Your pneumonia resolved by the time
you went home. However, we think you are at-risk for pneumonia
in the future, from swallowing saliva down the wrong pipe. We
recommend that you always have your bed at a 45* angle (or
upright).
We made the following changes to your medications:
1. STARTED FLUCONAZOLE FOR YEAST INFECTION, TAKE 100 MG DAILY
FOR 11 DAYS (for a total 14-day course, 3 doses received
in-hospital).
2. STARTED CARAFATE, 2 GRAMS TWICE PER DAY, ADMINISTER 2 HOURS
BEFORE OR AFTER ANY OTHER MEDICATIONS ([**Month (only) **] DECREASE ABSORPTION)
3. STARTED LANSOPRAZOLE, TAKE 30 MG TWICE PER DAY
4. INCREASED tylenol TO 1000 MG EVERY SIX HOURS AS NEEDED, MAX
DOSE 4 GRAMS PER DAY.
5. STOPPED OMEPRAZOLE
6. STOPPED CLONIDINE
7. STOPPED PROSTAT
Please review the attached medication list and take all
medications as prescribed.
Followup Instructions:
We scheduled a follow-up gastroenterology appointment here:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2170-10-9**] at 1:30 PM
With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], 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
**Please bring records from the Hct labs from rehab to this
appointment.**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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277, 282
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16911, 16911
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,548
| 140,200
|
46058
|
Discharge summary
|
report
|
Admission Date: [**2174-8-27**] Discharge Date: [**2174-9-2**]
Date of Birth: [**2098-1-8**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Sulfonamides / Penicillins / Erythromycin Base
Attending:[**Location (un) 1279**]
Chief Complaint:
hypotension and bradycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 76 year old woman with PMH significant for idiopathic
dilated CM with EF <20% who has had multiple previous admissions
for hypotension and bradycardia. She was found by her home
health aid to have HR to the 40's and BP pf 84/48. She went to
[**Hospital **] hospital on the day of admission and was found to have a
digoxin level of 3.2, and a CXR with LLL effusion/pneumonia, so
she was put on levoquin and transferred to [**Hospital1 18**] on a
nonrebreather. She denied all symptoms except constipation,
including headache, chest pain, SOB, abd pain, nausea, vomiting,
diaphoresis, or other complaints.
Past Medical History:
1) Idiopathic dilated cardiomyopahty leading to CHF x 26 yrs
with EF 15-20% on [**4-29**] echo, undergoing eval for biventricular
pacer
2) 1+ AR, 2+MR
3) HTN
4) hypercholesterolemia
5) spinal stenosis
6) depression
7) Chronic diarrhea with abdominal pain
8) CCY, TAH
9) pancreatitis
10) syncope
11) recurrent or chronic UTI
12) CRF (1.1-1.3)
13) Afib with failed cardioversion [**4-29**] after (-) TEE
Social History:
Lives at home with husband and grandson. [**Name (NI) **] two home health
aids who provide care from 8am-10 pm, and husband provides
remainder of care. Ex [**Name (NI) 1818**]. No alcohol or drugs. Walks with
walker, independent with eating, needs assistance to bathe.
Family History:
Diabetes, CAD, HTN
Physical Exam:
V: HR 50 RR13 BP 103/55 97%
Gen: cachectic, talkative
HEENT: PERRL, OP clear, MM dry
Resp: L base with decreased sounds, otherwise clear
CV: irreg irreg nl s1s2 grade II/VI HSM at apex, JVP 7 cm, PMI
laterally displaced
Abd: sl TTP diffusely, ND, no R no G, +BS
Ext: no edema
Neuro: A+Ox2, moves all extremities well
Pertinent Results:
141 | 100 | 26 /
----------------- 96
3.9 | 27 | 1.1 \
Ca: 9.4 Mg: 1.7 P: 4.2
Dig: 2.7
\ 12.9 /
19.9 ------ 308
/ 40.1 \
N:89.9 Band:0 L:6.5 M:2.9 E:0.6 Bas:0.1
Hypochr: 1+ Anisocy: 1+ Poiklo: 1+ Microcy: 1+ Ovalocy: 1+
Tear-Dr: OCCASIONAL
PT: 20.6 PTT: 33.1 INR: 2.7
urine culture: gram negative rods
CXR [**2174-8-29**]
The apparent new haziness at the bases may represent fluid
within the major fissures, especially on the left. Infiltrate in
the right middle or lower lobe may account for the appearances
on the right where there is no obvious pleural effusion seen
otherwise.
Brief Hospital Course:
1) hypotension, bradycardia - This was likely multifactorial due
to the combination of amiodarone, digoxin, bethanechol, and
carvedilol. These medications were all held, and her pulse
improved to the 60's and BP to the low 100's. Captopril was
added back and slowly titrated as tolerated given its benefit in
heart failure. It was considered to put a biventricular
pacemaker to help with symptoms, but this decision was deferred
to the outpatient setting as she improved on medical management
alone.
2) atrial fibrillation - The patient was in slow A. fib per EKG
when admitted. Her coumadin was held for two days as she was
being evaluated for pacemaker placement, but then restarted at
4-5 mg PO, which will be changed to 2.5 mg PO as an outpatient.
She will likely need more after her levofloxacin course is
finished, as her amiodarone was discontinued. Her INR will be
followed as an outpaitient, and was therapeutic at discharge.
3) digoxin toxicity - her digoxin level was 3.2 at the outside
hospital. Therapeutic for this patient was likely closer to
0.8-1.0. Her digoxin was held during hospitalization, and can be
restarted as an outpatient if it is felt that this medication
will be of benefit to this patient.
4) congestive heart failure - The patient has a history of
idiopathic dilated cardiomyopathy with an EF of 15-20%. She
appered hypovolemic at presentation, and was rehydrated with
small boluses of normal saline until she was euvolemic. Her neck
veins were never distended during hospitalization. She was
discharged per CHF guidelines.
5) anorexia - The patient has a history of 25 pound weight loss
over the last few months. Her husband reports that she has not
had much appetite. It was considered that the amiodarone could
partially be contributing to her anorexia. An albumin level
showed that she was mildly malnourished, and a nutrition consult
was obtained. She was started on Megace with some improvment in
her eating, and will follow up with nutrition as an outpatient.
6) delirium - On multiple occasions, she became combative and
agitated, insulting the staff and stating that she wanted to go
home. She was given zyprexa for these episodes, and haldol on
one occastion. The social worker and psychiatry staff were both
consulted to evaluate her. Psychiatry was consulted for
evaluation of insight and judgment, and found the patient not
able to make her own decisions. A sitter was obtained for her. A
delerium workup was done which showed a positive UA. She was
treated for this UA, with marked resolution of her mental status
once she was started on bactrim.
7) urinary tract infection - A UA was obtained on HD#2 and was
positive. She was completely asymptomatic but was treated
empirically with levofloxacin. Final culture showed Klebsiella
pneumoniae, resistant to levofloxacin. The patient had an
allergy to penicillins and bactrim, so ID was consulted who
recommended giving bactrim as the allergy history was
questionable. She received two doses of bactrim without any
reaction and was discharged on a 7 day total course.
8) urinary incontinence - the patient had a foley catheter
during the first two days of hospitalization. When this was
d/c'd, the patient became incontinent of bladder. Her bethanchol
was restarted, as this was felt not to contribut significantly
to her bradycardia.
9) hypercholesterolemia - her statin was continued.
10) DNR/DNI - The patient's husband stated that she wanted to be
DNR per a discussion when she was admitted to the OSH. She
stated during the hospitalization that she "wanted to go home to
die". A palliative care consult visit can be done as an
outpatient.
11) Coordination of care - a family meeting was conducted toward
the end of hospitalization to coordinate goals of care.
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*4*
5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
Disp:*30 Tablet, Rapid Dissolve(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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for confusion.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Pleas have your PT/INR checked on [**2174-9-6**] and send results to
Dr. [**Last Name (STitle) 58**].
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
14. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days: please take all pills. If you have shortness of
breath, rash, or other concerns, please call Dr. [**Last Name (STitle) 58**].
Disp:*12 Tablet(s)* Refills:*0*
15. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime: Dr.
[**Last Name (STitle) 58**] will modify the dose on Tuesday [**2174-9-2**].
Disp:*60 Tablet(s)* Refills:*2*
16. Megace Oral 40 mg/mL Suspension Sig: One (1) ml PO four
times a day for 1 months: for appetite stimulation.
Disp:*120 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary:
congestive heart failure
digoxin toxicity
hypotension, bradycardia
anorexia
delirium
urinary tract infection
Secondary:
urinary incontinence
hypercholesterolemia
atrial fibrillation
Discharge Condition:
pt was stable, ambulating, eating food, had no chest pain or
shortness of breath, and wanted to go home.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases or
decreases by more than 3 lbs.
Adhere to 2 gm sodium diet, but try to eat high calorie foods.
Fluid Restriction: 1500 ml per day
Please follow up as below.
If you experience [**Name8 (MD) 9140**] shortness of breath, chest pain,
palpitations, dizziness, confusion, bleeding, rash, or other
concerns, please call Dr. [**Last Name (STitle) 58**] or return to the ED.
Followup Instructions:
Please have your INR checked on Tuesday [**2174-9-6**], and have your
coumadin dose adjusted by Dr. [**Last Name (STitle) 58**] as needed. Your last INR
was 2.2 on Thursday [**2174-9-2**].
Please follow up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5080**], M.D. [**Telephone/Fax (1) 3329**] in
[**11-26**] weeks for coordination of care.
Please make an appointment with nutritional services for your
weight loss: [**Telephone/Fax (1) 3681**] within 2-3 weeks to evaluate intake
and evaluate for continuation of Megace.
Please also follow up with Dr. [**First Name (STitle) 2031**]: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 98015**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2174-9-8**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2174-11-15**] 2:15
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8677, 8740
|
2728, 6498
|
350, 356
|
8975, 9081
|
2101, 2705
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9572, 10555
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1729, 1749
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384, 999
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,488
| 180,176
|
49027+49028+59132+59133+59134+59135
|
Discharge summary
|
report+report+addendum+addendum+addendum+addendum
|
Admission Date: [**2153-9-25**] Discharge Date:
Date of Birth: [**2082-12-1**] Sex: F
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
woman with a complicated past medical history including
end-stage renal disease (on [**Hospital1 13241**]), type 2 diabetes,
[**Hospital1 862**] disorder including episode of status with prolonged
intubation, recent zoster, now admitted with hypotension
during [**Hospital1 13241**] today.
The patient was in her usual state of health when at
[**Hospital1 13241**] today began feeling weak as if she would pass
out. She was noted to have a [**Hospital1 **] pressure in the 80s (?)
and transferred to the Emergency Department. These symptoms
have subsequently subsided. She states that the nurse [**First Name (Titles) **]
[**Last Name (Titles) 13241**] there told her "pus" was in her Port-A-Cath line
which she cleaned out. No fevers or chills during
[**Last Name (Titles) 13241**] or since. She has had complaints of chronic
right-sided chest pain and diffuse abdominal and back pain,
all of which have been present for greater than one year and
are at baseline, positive chronic diarrhea and constipation
which chronically alternate (most recently diarrhea). No
melena or bright red [**Last Name (Titles) **] per rectum. Denies nausea or
vomiting. States zoster pain is well controlled.
PAST MEDICAL HISTORY:
1. [**Last Name (Titles) **] disorder, history of status.
2. End-stage renal disease, on [**Last Name (Titles) 13241**].
3. Hypothyroidism.
4. Type 2 diabetes with neuropathy, nephropathy; not taking
medications or insulin.
5. Multiple lacunar infarcts.
6. History of question HPA disorder.
7. Hypothermia, however hypothermia may be due to dialysis.
8. Mild pancytopenia.
9. Pulmonary hypertension.
10. Obesity.
11. [**2153-9-3**] echocardiogram with moderate mitral
regurgitation with an ejection fraction of 55%.
12. Cholecystectomy.
13. Appendectomy.
14. Shingles.
15. Depression.
16. Anxiety.
17. History of elevated alkaline phosphatase with negative
hepatitis A, hepatitis B, and hepatitis C.
ALLERGIES: HITT ANTIBODY, LASIX OTOTOXICITY, PENICILLIN.
SOCIAL HISTORY: Lives alone, day care on days without
[**Year (4 digits) 13241**]. Has home health aide and physical therapy. No
tobacco or alcohol.
MEDICATIONS ON ADMISSION: Dilantin 75 mg p.o. b.i.d.,
Synthroid 200 mcg p.o. q.d., Zantac 150 mg p.o. q.h.s.,
Phos-Lo t.i.d., Neurontin 200 mg after [**Year (4 digits) 13241**],
Epogen 3000 subcutaneous after [**Year (4 digits) 13241**], Zoloft 50 mg
p.o. q.d.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97, pulse 71,
respirations 18, [**Year (4 digits) **] pressure 104/47, saturation 100% on
room air. In general, upright in bed, in no acute distress.
HEENT revealed pupils were equal, round, and reactive to
light. Extraocular muscles were intact. Chest had diffuse
inspiratory wheezes, no crackles. Cardiovascular with a
regular rate and rhythm. No murmurs, rubs or gallops.
Abdomen was obese, diffusely tender and firm with guarding
(says this is baseline for years). Extremities had 1+ edema
bilaterally of lower extremities to shins, grade 2 decubitus
ulcer on left heel. Skin had extensive zoster on right
abdomen and back about T9.
LABORATORY DATA ON ADMISSION: White count 7.5,
hematocrit 38.1, platelets 116. Sodium 136, potassium 4.4,
chloride 105, bicarbonate 23, BUN 14, creatinine 3.3,
glucose 151. PT greater than 150, INR 3 to 2.9 to 2.5.
ALT 34, AST 70, alkaline phosphatase 398; all baseline.
Total bilirubin 0.8, fibrinogen 394. Creatine kinases 27 and
17, troponin of less than 0.3.
RADIOLOGY/IMAGING: Chest x-ray had no focal infiltrate of
congestive heart failure. No change.
Electrocardiogram was normal sinus at 70, axis and intervals
within normal limits. Question of left atrial enlargement,
poor R wave progression, J point elevation in V2 and V3;
unchanged from [**9-10**].
HOSPITAL COURSE: (Until [**10-3**] by system)
1. GASTROINTESTINAL: The patient was noted to have a
hematocrit drop the night of admission from 38 to 31.1.
Noted to have melena as well as maroon stools. She stopped
the Zantac and started on Protonix. Nasogastric lavage was
negative.
Gastrointestinal was consulted and esophagogastroduodenoscopy
was performed. An ulcer in the stomach was found, ulcers in
the distal bulb; otherwise normal esophagogastroduodenoscopy
to second part of the duodenum. Serial hematocrits were
followed, and the patient was transfused as needed. To date
she has had 3 units of packed red [**Month (only) **] cells.
The patient was found to be Helicobacter pylori positive, so
she was started on metronidazole and clarithromycin, as she
is penicillin allergic, to treat for 14 days.
The patient continued to have melena and guaiac-positive
stools as well as a trending downward hematocrit. She was
unable to drink GoLYTELY bowel preparation, and so
nasogastric tube was placed and GoLYTELY was given.
Colonoscopy was performed. A few diverticula were seen in
the sigmoid colon; otherwise, normal colonoscopy to cecum.
Therefore, a repeat esophagogastroduodenoscopy was performed
which found erythema, congestion, and erosion of the mucosa
in the antrum. A few erosions noted healing in the antrum.
A single-crater nonbleeding 10-mm ulcer in the fundus that
was not there previously. Erosion healing in the second part
of the duodenum. The patient will continue to be followed
for melena, and if she has melena Gastrointestinal will be
called. Hematocrits will continue to be followed, and she
will be continued on Protonix.
2. HEMATOLOGY: The patient has received 3 units of packed
red [**Month (only) **] cells to date, and hematocrit will continue to be
followed. She was found to have an elevated PTT and INR
after heparin at dialysis. She received subcutaneous
vitamin K for three days, and coagulations returned to
baseline. She was found to be HIT positive. The Renal team
was notified. Heparin was not used in dialysis after that.
3. NEUROLOGY: The patient's Dilantin was changed from 75 mg
b.i.d. to 50 mg t.i.d. secondary to complaints of sleepiness
after Dilantin dose. The patient was noted on [**10-2**] to
be anxious and then possibly have a 1-minute [**Month (only) 862**] when she
became unresponsive to voice and touch; although, she awoke
and this all resolved on its own. Dilantin level was noted
that night to be 4.6. After discussion with Neurology, her
Dilantin was increased to 50/50/100, and Dilantin level will
be rechecked. The patient also was noted at times to have a
waxing and [**Doctor Last Name 688**] mental status. This was felt to be most
likely delirium. Psychiatry was consulted and agreed that
this was most likely delirium.
A head CT was obtained as the patient had noted possibly
falling in the past, but there was no change from prior
examination.
4. RENAL: The patient underwent dialysis Tuesday, Thursday,
and Saturday. Renal team followed the patient.
5. CARDIOVASCULAR: The patient ruled out for myocardial
infarction and had no electrocardiogram changes. She had one
episode of possible chest pain; although, it was unclear as
she also had the shingle pain. Electrocardiogram was
obtained and no changes were noted. She ruled out for
myocardial infarction again. She also was noted to have a
couple of episodes of hypotension; one after receiving Versed
and Demerol for her procedures, and this resolved; another
when her hematocrit was low and resolved when she received a
unit of packed red [**Doctor Last Name **] cells.
6. ENDOCRINE: The patient is hypothyroid and was continued
on Synthroid. TSH was found to be 2.3.
7. DIABETES MELLITUS: She is on a sliding-scale insulin but
has not required any insulin. She was noted to have a low
SFH and LH and high estradiol without source. An abdominal
and pelvic ultrasound were attempted; however, secondary to
patient intolerance, a limited study could be performed, and
the patient did not tolerate a transvaginal ultrasound.
Abdominal ultrasound showed normal post cholecystectomy,
hepatobiliary system. No etiology for elevated alkaline
phosphatase found, and pelvis showed no gross abnormalities
but limited. The patient's primary care physician noted in
his chart that the patient had an endometrial biopsy in [**2153-6-3**] that was negative with Dr. [**Last Name (STitle) 52362**], and an
ultrasound at that time which was normal but should be
followed up, and it is unclear whether the patient ever had
that followed up.
Endocrine was consulted, and a CT of the head and abdomen to
assess cella, pituitary, ovaries, and adrenals were obtained
and are pending at this time.
Elevated alkaline phosphatase and AST without clear etiology.
Limited abdominal ultrasound as above. This could also be
from another source; pelvis and femur films are pending at
this time to asses to Paget or osteomalacia, as the patient
also has leg pain.
8. SOCIAL: Physical Therapy and Occupational Therapy have
seen the patient. Social Work and Protective Services are
involved and ongoing meetings are involved with patient
services as well secondary to whether the patient needs to go
to rehabilitation or whether she is able to go home.
This completes the hospital course through [**10-3**]. The
rest of the dictation will be completed by the next intern,
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] E. 12-155
Dictated By:[**Last Name (NamePattern1) 4572**]
MEDQUIST36
D: [**2153-10-3**] 17:52
T: [**2153-10-6**] 04:09
JOB#: [**Job Number 102909**]
Admission Date: [**2153-9-26**] Discharge Date:
Date of Birth: [**2082-12-1**] Sex: F
Service: Medicine
This is a discharge addendum to this [**Hospital 228**] hospital
course discharge summary dated [**2153-11-3**].
HOSPITAL COURSE: This discharge summary will cover from [**2153-11-30**] until [**2153-12-13**].
The initial part of the discharge summary will go up until
[**12-2**] at which time she was transferred back to the
Intensive Care Unit.
1. Cardiovascular: On [**11-29**], she had an episode of
hypotension, which was associated with hyperthermia. It may have
indicated sepsis at that time. Her [**Month (only) **] pressure increased with
reverse Trendelenburg and remained stable through the day. On
[**2153-12-1**] the patient developed an episode of ventricular
tachycardia. At that time her [**Year (4 digits) **] pressure was 118/doppler and
she was awake and alert with no hemodynamic instability. She did
feel "funny" and had a distressed look on her face according to
the nurse's note.
2. Pulmonary: She had tracheostomy at this point. She had
evaluation for placement of a valve to aid in her speech. Her O2
was weaned to keep the O2 sats above 93% and she also had O2 sats
that were stable.
3. Renal: She had dialysis almost every other day Tuesday,
Thursday and Saturday. There were no further complications
during the dialysis except on [**2153-12-1**] when her
[**Year (4 digits) 13241**] was deferred, because of her hypotension. She
received dialysis the following day.
4. Neurological: She had some [**Year (4 digits) 862**] disorder. Her CT scan on
[**11-23**] showed no evidence of postmeningeal hydrocephalus.
The Trileptal and Dilantin was continued. The Trileptal was
increased on a weekly basis. The Trileptal dosing goal was to 50
mg po b.i.d. The Dilantin was 50 mg po q.a.m., 50 mg po q.p.m.
q.o.d. Trileptal to have a goal of at least 600 or 700 mg po q
over the course of the day.
5. Hematology: She had a heparin induced thrombocytopenia.
She was given one dose of lepireudin, which was cleared renally.
She still had elevated PTT and she required FFP for procedures.
She also had increasing INR of unclear etiology.
6. Gastrointestinal: The patient had PEG tube placed for
enteral feeds. The enteral feeds were done through the PEG
tube.
7. Endocrine: The patient had diabetes mellitus and
hypothyroidism. Her NPH was continued. Thyroxine was continued.
On [**12-2**], the patient was transferred from the floor to the
Intensive Care Unit for persistent hypotension and mental status
changes prior to having [**Month (only) 13241**]. She had an episode of
hypotension on [**2153-12-1**]. On the morning of [**2153-12-2**] she had an episode of hypotension of a systolic [**Year (4 digits) **]
pressure decreased down to 90. She was given fluids. Her
systolic [**Year (4 digits) **] pressure dropped down to 70. She received
intravenous fluids and her systolic [**Year (4 digits) **] pressure increased to
90.
Cardiac issues while she was in the Intensive Care Unit for a
few days included: 1. Cardiovascular hypotension, which
had been a recurrent problem throughout her hospital stay.
The thinking was that it was most likely due to sepsis at
that time. Consequently she was started on antibiotics.
There was some concern that she may need to be on pressors.
The pressor for that situation would have been either Levophed or
Dopamine. There was concern that the event may progress. There
was a prolonged PR interval on EKG, but starting her on
antibiotics would require long term course. Her [**Year (4 digits) **] pressures
remained low and she was on a norepinephrine drip. The cause of
her hypotension was thought to be due to sepsis.
The other causes could have included adrenal insufficiency. A
cortisol stimulation test was sent for. Echocardiogram was also
ordered. This was for her history of congestive heart failure.
Additional fluid boluses were given more gingerly. After her
cultures returned negative, adrenal insufficiency was thought to
be the most likely cause. Subsequently she was started on
steroids. Her [**Year (4 digits) **] pressure did improve with the steroids.
As for the endocarditis, the PICC lines' last day was [**2153-12-5**]. Her Vancomycin at that point on [**12-4**] was
subtherapeutic. An eight-week course had been completed and she
did not receive another dose. Her Hydrocortisone was gradually
tapered. She was brought to the floor on [**2153-12-4**].
2. Pulmonary: The patient was thought to have perhaps a
pseudomonal infection. Her status was stable and her O2 sats
were stable. She was having no secretions from the trach. There
was question of mild pneumonia. It was unlikely to be due to
congestive heart failure. Her respiratory status remained stable
until transfer to the floor on [**2153-12-4**].
3. Renal: The patient has end stage renal disease and requires
[**Year (4 digits) 13241**].
4. Gastrointestinal: She had a gastrointestinal bleed early
in the admission, due to gastroduodenal ulcers. Her hematocrits
were monitored and stable. Goal hematocrit was above 25. Her
tube feeds were continued. She was continued on Prevacid. She
had no further gastrointestinal issues.
5. Infectious disease: The patient was thought to be in
sepsis initially, however, her [**Year (4 digits) **] pressure responded to
the steroids. Her eight-week endocarditis regimen was completed
on [**2153-12-5**]. It is a possibility that she had an angitis
or pneumonia. Another possibility was sepsis or line sepsis.
Tobramycin was started for pseudomonal pneumonia coverage. Her
Vancomycin was continued for two more days until [**2153-12-5**].
By [**2153-12-4**] she had no longer any signs of infection,
and the Tobramycin was discontinued.
6. Hematology: The patient had a coagulopathy with increased
PTT and INR. It was thought to be due to a single dose of
lepirudin that occurred a long time ago. For any procedure she
will need FFP to prevent a source of bleeding. Her hematocrits
were followed and were stable.
7. Endocrine: The patient was thought to be in adrenal
insufficiency. She had a cortisol which went from 9 to 14. She
was given large doses of steroids. She was started on stress
dose steroids 100 mg IV q 8 hours of Hydrocortisone. As the
[**Year (4 digits) **] pressure increased, the dose was decreased. She also had
hypothyroidism for which she took Levothyroxine; type 2
diabetes, mellitus, for which she takes regular and NPH insulin.
On [**2153-12-4**] she was transferred back to the floor.
Her [**Year (4 digits) **] pressure improved and she was subsequently weaned
off the norepinephrine. Her [**Year (4 digits) **] pressure remained mildly
low and required small amounts of fluid boluses and increased
the Hydrocortisone did not have much effect at all. When she was
brought to the floor she had similar issues.
1. Cardiovascular: She had episodes of hypotension on the
floor. However, because she was able to mentate and did not
have any change in her mental status, no aggressive intervention
was done. During the rest of her hospital course she
occasionally had low [**Year (4 digits) **] pressure. It was thought that the
hypotension might be related to her adrenal insufficiency. Her
steroids were tapered over the course of a few days and then she
was started on a low dose of Dexamethasone.
2. Pulmonary: The patient has been using a trach mask over
her trach. She has had O2 sats that have been generally low
at 94%. Her O2 requirements have decreased slightly, but she
still requires supplemental oxygen.
3. Endocrine: While she was on the floor, the Endocrine service
had been formally consulted. She was continued with
Levothyroxine for her hypothyroidism. Because of the concern for
adrenal insufficieny, they recommended an MRI of the abdomen
also, because of abnormalities in the female sex hormones, which
was later attributed to increased adiposity. The MRI of the
abdomen revealed a possible adrenal adenoma. However, this would
not account for her adrenal insufficiency. She did not have a
cough during this admission. The Endocrine Service was concerned
about her female sex hormones. There was some question as to
whether she may have a pituitary involvement in the disease. MRI
of the head was taken and was negative for any macroadenoma. She
pulled out her VAS catheter on [**12-6**] through [**2153-12-7**].
The left subclavian VAS catheter was placed on [**2153-12-8**].
4. Infectious disease: She completed an eight-week course of
Vancomycin. She again became hypothermic during the last few
days of her hospital stay. Cultures remained negative.
5. Renal: She has end stage renal disease and was started on
Metyridine for supporting her [**Year (4 digits) **] pressure during dialysis,
usually given before dialysis. She was able to go every Tuesday,
Thursday and Saturday ever since she has been back on the
medical floor.
6. Hematology: The patient's hematocrit had been drifting
downward. It had a nadir of 23. She received 2 units of [**Year (4 digits) **]
transfusions at the dialysis. She also has elevated INR and PTT.
The PTT elevation could have been initially explained by
lepirudin and its decreased renal clearance. On [**2153-12-13**]
the patient had a drop in her platelets. Her platelets decreased
to 99. She has a history of heparin induced thrombocytopenia.
She did have some bleeding issues. She did take out her right EJ
vascular catheter access. She may have been confused at that
time. After she had taken it off it was decided to place a left
subclavian. Interventional radiology was able to perform the
procedure.
7. Neurological: It had been decided that she would be
transitioned off the Dilantin and onto Trileptal. The Trileptal
dose was increased from 200 mg in the morning and 150 mg in the
evening to 300 mg b.i.d. Trileptal level was checked and the
dose level was subtherapeutic. Her Trileptal was increased to
200 b.i.d. The Dilantin levels remained the same.
8. Gastrointestinal: The patient had three tubes going through
the PEG tube. Her PEG site was not erythematous, but scarred
over and the wound itself was draining yellowish discharge of a
consistency similar to the tube feeds. She also had increased
residuals with the tube feeds. She is having skin break down
from the diarrhea.
This dictation essentially takes us up until [**2153-12-13**]. Additional summary will be added on.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2153-12-13**] 19:43
T: [**2153-12-14**] 08:21
JOB#: [**Job Number 18791**]
Name: [**Known lastname **], [**Known firstname 1118**] Unit No: [**Numeric Identifier 16619**]
Admission Date: [**2153-10-9**] Discharge Date:
Date of Birth: [**2082-12-1**] Sex: F
Service:
The previous addendum was done by [**First Name8 (NamePattern2) 16622**] [**Last Name (NamePattern1) **], dated
[**2153-9-25**]. The patient was eventually transferred to the
Medical Intensive Care Unit on [**2153-10-9**] with the following
occurrence:
There was mental status changes with hypoxic respiratory
failure on behalf of the patient. This 70 -year-old woman
with multiple medical problems and a complex history
presented multiple times this year with recurrent weakness
and changes in mental status and lethargy, including a
protracted Intensive Care Unit stay with status epilepticus
and tracheotomy, presented to the Emergency Department after
feeling on [**2153-9-25**], weak and presyncopal at hemodialysis
with reported blood pressures in the 40s and a comment of pus
in or around the Port-A-Cath. She had a chest pain episode
in the Emergency Department and review of systems was
positive for vaginal bleeding. There was no treatment done
at [**Hospital1 **]. There was melena and hematocrit drop,
normotensive after intravenous fluid bolus.
After being admitted to the hospital, the melena was worked
up with an esophagogastroduodenoscopy and a colonoscopy and
consistent with an upper gastrointestinal bleed secondary to
multiple erosions and ulcers. There were intermittent
decreases in her blood pressure with a systolic blood
pressure to below 60s and waxing and [**Doctor Last Name 2364**] mental status.
She had an E level and T down to 91.9. CT scan of the head
on [**10-4**] showed unchanged encephalopathy with no
abnormal sella findings. Endocrine was consulted. CT scan
of the abdomen and pelvis.
Estrogen levels were decreased and testosterone was decreased
to 91.9. And also he had decreased luteinizing hormone and
follicular stimulating hormone, hypothermia, and seizure
disorder, and elevated estradiol. A CT scan of the head
showed normal appearance to sella. Pituitary abnormality
could not be excluded on CT scan examination. The MRI is the
method of choice for evaluation of this region. Multiple
unchanged areas of encephalomalacia were noted.
An Endocrine consult was requested. CT scan of the abdomen
and pelvis showed no gross ovarian pathology, but the
transvaginal ultrasound was determined to be helpful in
ruling out ovarian pathology. There was a plum, but not
definitively enlarged right adrenal gland and with the poor
resolution of this CT scan, the adrenal cannot be well
described with regards to its composition. Bilateral pleural
effusions were noted, not significantly changed since the
prior study.
She was seen on [**2153-10-8**] to be lethargic again, but
arousable. The RN at midnight noticed she was alert and
oriented times person, but the patient thought she was at
home. At 04:00 AM the patient was found slumped in the bed
with eyes deviated right, hypoxic and somnolent. The patient
was intubated and transferred to the Medical Intensive Care
Unit with decreased blood pressure and she was responsive to
Dopamine.
Her Medical Intensive Care Unit course can be described as
follows: On day two of her Medical Intensive Care Unit stay,
the patient had an lumbar puncture done by Interventional
Radiology because on physical examination she was noted to
have a stiff neck and she was minimally responsive. The
lumbar puncture was consistent with bacterial meningitis.
During the course of her Medical Intensive Care Unit stay,
the patient has also been diagnosed with endocarditis,
multi-focal, ventilator-associated pneumonia, yeast cystitis,
and persistent hypotension.
Cardiology: Endocarditis, 2+ mitral regurgitation. Upon
recommendation of Infectious Disease and one set of positive
blood cultures on [**10-8**], her methicillin - resistant
Staphylococcus aureus, a transesophageal echocardiogram was
done to evaluate for endocarditis with the following results.
There was bileaflet mitral valve endocarditis with leaflet
perforation and moderate mitral regurgitation. In light of
these findings, the patient was continued on vancomycin dosed
by level, and was determined to fulfill an eight week course.
The patient's PR interval was also checked daily to rule out
abscess and has not been prolonged through [**11-1**]. It
was decided that because of the [**Hospital 1325**] medical condition
at the time, being comatose and pressor dependent, she would
not be a candidate for valve replacement surgery.
Hypotension: Upon admission to the Medical Intensive Care
Unit, the patient required Dopamine which was later changed
to Vasopressor to Levophed. It was thought at the time that
the patient's hypotension was due to sepsis. The patient was
weaned off all pressors however, and she still remained
comatose. On approximately [**10-18**], the patient became
hemodynamically unstable again for unclear reasons. A repeat
echocardiogram showed the following results: while the
mitral valve remained thickened, there was no evidence of
vegetations present. By report, the severity of the mitral
regurgitation is unchanged. The left ventricular cavity size
is normal and the overall left ventricular systolic function
was found to be normal with the left ventricular ejection
fraction of greater than 55%.
The patient continued to require doses of Levophed at 0.7 mcg
per minute, was not able to be weaned off until [**11-3**],
and she has not been on Levophed from that time. It was
thought there might be an autonomic instability component and
the patient was started on Midodrine to no effect.
Subsequent cortisol levels were found to be normal.
Pulmonary: The patient had multi-focal pneumonia, ventilator
assisted, and congestive heart failure. The patient was
originally intubated for airway protection. She did not have
intrinsic lung disease. Repeat x-ray on [**10-15**] showed
new multi-focal pneumonia, thought to be ventilator
associated. The patient had previously been on ceftriaxone
2.0 gm q twelve hours for meningitis which was changed to
meropenem. The patient had positive sputum for Pseudomonas
that was sensitive to imipenem, gentamicin, and tobramycin.
The patient was set to complete an eighteen day course of
meropenem for her pneumonia.
From a congestive heart failure perspective, the patient had
several x-rays consistent with congestive heart failure,
which seems to improve post dialysis. She is not on any
maintenance fluids. Approximately 2.0 kg were taken off with
each hemodialysis.
Tracheotomy: The patient has been evaluated for tracheotomy,
but it was felt that the patient was not a candidate because
she was not improving clinically. This was considered to be
possibly readdressed if the patient began to improve from a
neurological perspective (see next addendum for patient's
progress after [**11-3**]).
Renal: The patient has had end stage renal disease on
hemodialysis. The end stage renal disease predates the
hospital admission. She has mild hyperphosphatemia which is
being monitored. She uses dialysis three times a week. Her
end stage renal disease is thought to be due to diabetes
mellitus.
Infectious Disease: Endocarditis, meningitis, yeast cystitis
(treated), DZV zoster results, multi-focal pneumonia,
methicillin - resistant Staphylococcus aureus bacteremia
(resolved). When the patient was admitted to the Medical
Intensive Care Unit she had a stiff neck and suspicion for
meningitis which was high. She also had a zoster on her
right abdomen which started in [**Month (only) 5298**]. By the time the
patient was admitted to the Medical Intensive Care Unit, many
of her lesions were healing and were scabbed over.
Although the suspicion for DZV meningitis was low, the
patient was started on acyclovir and continued until the
Varicella - zoster virus and herpes simplex virus PCR were
negative per the spinal analysis. The first lumbar puncture
had the following results: on [**2078-10-9**] white blood
cells, 250 red blood cells, 65 protein, 73 glucose. The
patient was continued on ceftriaxone, vancomycin, and
acyclovir. The first CSF fluid grew out one rare colony of
gram negative rod. The culture stated it was a
non-Pseudomonas gram negative rod, but no further
characterization was made.
Infectious Disease felt that this pathogen may be a
contaminant, although unusual. The patient had a repeat
lumbar puncture on [**10-16**] which showed 14 white blood
cells, 47 red blood cells, 30 white blood cells, 965 red
blood cells, with 59 protein and 134 glucose. The patient
was switched from ceftriaxone to meropenem when she developed
the multi-focal pneumonia because of the positive sputum
culture with Pseudomonas, which was the reason for
ceftriaxone.
Infectious Disease felt that the meropenem would adequately
cover the central nervous system infection. To clarify, the
patient had been receiving meningitis doses of ceftriaxone on
meropenem since [**2153-10-8**]. The patient needed a
repeat lumbar puncture. It was determined that the patient
may have needed a repeat lumbar puncture in the future to
document resolution of the meningitis.
Endocarditis: The patient had endocarditis according to
transesophageal echocardiogram done on [**2153-10-16**].
The patient had positive methicillin - resistant
Staphylococcus aureus blood cultures on [**2153-10-8**]. A
left subclavian dialysis catheter was also positive for
methicillin - resistant Staphylococcus aureus. It was
thought that the patient's methicillin - resistant
Staphylococcus aureus sepsis bacteremia was due to a line
infection which then ceded her valve. The patient has an
eight week course of vancomycin which is dosed by level.
Multi-focal pneumonia: The patient had an episode of hypoxia
and increased sputum production on [**2153-10-15**]. The
chest x-ray revealed a new multi-focal pneumonia which is
treated with meropenem for a course of eighteen days.
Yeast cystitis: The patient had a positive yeast with white
blood cells on several straight catheterizations analyses of
her urine. The patient was treated with amphotericin bladder
washings. The peak urine culture since that time has been
negative for yeast.
Methicillin - resistant Staphylococcus aureus bacteremia: As
mentioned before, being treated with vancomycin. Repeat
blood cultures have been negative for methicillin - resistant
Staphylococcus aureus.
Gastrointestinal: Diarrhea, history of gastrointestinal
bleed. The patient's episode of diarrhea during the
hospitalization that worsened with po magnesium oxide. She
was then Clostridium difficile negative on multiple times.
She has an OG-tube placed through [**11-3**] and the patient
has occult positive stool during her Medical Intensive Care
Unit stay. Her hematocrit has been monitored and she has
been transfused prn any hypotension or bleeding. She has not
had any overt gastrointestinal bleeds since her Medical
Intensive Care Unit stay.
Genitourinary: The patient has a Foley, possible
enterovesicular fistular cystitis result. The patient had
two urine cultures that were consistent with fecal matter.
The patient also had a history of diverticulosis and it was
thought that she may have developed an enterovesicular
fistula. Because of the patient's overall medical condition,
the work up for this has been deferred.
Iron deficiency anemia: Possibly myelodysplastic syndrome
from the site of the coagulopathy and HIT positive. The
patient has been monitored everyday and has been transfused
prn. She had thrombocytopenia, increased PTT INR that was
thought to be due to low grade dic which has since resolved.
She also has HIT positive and has been receiving heparin in
her dialysis catheter which has since been discontinued. She
has had a persistent elevated INR that has not resolved.
Endocrine: Diabetes mellitus, hypothyroidism, outpatient
work up of possible adrenal tumor. The patient has diabetes
mellitus type 2 and has been treated with NPH 14 units [**Hospital1 **]
with a regular insulin sliding scale. This patient is
currently under outpatient thyroid dose. Her thyroid
function tests are consistent with sick euthyroid. She has
been followed by the Endocrine service since signed off. The
patient has a long history of hypothermia which has been
attributed to hypothyroidism in the past and it is no longer
clear whether this is the true etiology.
Before coming to the Medical Intensive Care Unit, the patient
was in the process of an extensive endocrine work up. She
apparently had increased estradiol and decreased LH and FSH.
It was thought that the patient may have had an adrenal
tumor. On abdominal CT scan she was noted to have plump
adrenals. An estrogen secreting work up. This has been
deferred since the patient has been in the Medical Intensive
Care Unit.
Neurologic: History of nonconclusive status epilepticus,
seizure disorder, comatose meningitis. In the patient's
previous Medical Intensive Care Unit stay in [**2153-2-1**],
the patient was comatose as well and the electroencephalogram
at the time revealed evidence of non-convulsive seizure
activity. The patient was started on Dilantin. Of note, the
patient became apneic during infusion of Dilantin load. She
apparently had a prolonged lag in her mental status. She was
noted to be therapeutic on her Dilantin. Lethargy and
somnolence was attributed to her high Dilantin levels.
Since being discharged from her [**2153-2-1**] Medical Intensive
Care Unit stay, the patient has been maintained on Dilantin.
During this Medical Intensive Care Unit admission, the
patient was noted to be supertherapeutic on her Dilantin
level. Dilantin was held during the first week of her
Medical Intensive Care Unit stay and although she remained
within therapeutic range, the patient began to have head and
arm movements that were felt to be consistent with seizure
activity. The patient was restarted on her Dilantin and
through [**11-3**] was taking 100 mg IV q day which was being
dosed by free Dilantin levels. She had two
electroencephalogram which showed encephalopathy, but no
evidence of seizure activity. The patient remained comatose
for approximately three weeks and only recently, as of
[**11-3**], had shown some improvement in terms of opening
her eyes and withdrawing to pain.
Head CT scans have shown encephalomalacia, but no acute
process. Infectious Disease felt at the time that her
meningitis had been adequately treated. Neurologic would
like another lumbar puncture to insure resolution of her
meningitis. This request has since been discontinued.
Prophylaxis: She was on Venodyne and Protonix. It was
determined that the patient has a CPR not indicated.
Communication: The daughter, [**Name (NI) **] [**Name (NI) **], is the patient's
eldest daughter. She stated that she is the spokesperson of
the family. The other members, four children and the
husband, have not expressed what they feel their mother's
wishes would be. The family has refused family meetings.
Ethics and Legal were involved to determine: 1) who was the
next of [**Doctor First Name **], and 2) what the patient's wishes would be in
this situation. Of note, Protective Services were
investigating the patient's home situation for questionable
neglect. It appears that several home health aides, the
[**Hospital 1325**] medical problems were being inadequately treated at
home. Before coming to the Medical Intensive Care Unit, the
patient was being evaluated for an skilled nursing facility
disposition. The patient requires Medical Intensive Care
Unit level of care.
What has just been stated is the course of the [**Hospital 1325**]
hospital stay from [**2153-9-25**] through [**2153-11-3**],
under the care of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. and the care of [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], M.D.. Please see the next addendum of the [**Hospital 1325**]
hospital course from [**11-3**] onward.
[**Last Name (LF) 1035**],[**Name8 (MD) 1034**] M.D.90-109
Dictated By:[**Last Name (NamePattern1) 771**]
MEDQUIST36
D: [**2153-11-12**] 15:57
T: [**2153-11-13**] 10:21
JOB#: [**Job Number 16623**]
Name: [**Known lastname **], [**Known firstname 1118**] Unit No: [**Numeric Identifier 16619**]
Admission Date: [**2153-10-9**] Discharge Date:
Date of Birth: [**2082-12-1**] Sex: F
Service: MICU ORANG
DISCHARGE SUMMARY ADDENDUM: This dictation covers [**11-3**]
through [**2153-11-17**]. [**11-3**] was hospital day 40.
The overall progress of Ms. [**Known lastname **] during this time is that
she improved clinically with marked improved mental status.
SUMMARY BY SYSTEM: For all details prior to this time please
consult all of the other discharge summaries and addendum.
1. PULMONARY - The patient had been intubated from [**2153-10-9**].
By [**2153-11-3**] she was on CPAP with the pressures 25 and
5 with FIO2 of 35%. She remained stable on pressure support
of 20 and 5 and peat which was modified to AC assist control
during the various procedures she underwent but returned soon
afterwards to CPAP. Her respiratory status improved to the
point that she underwent cycled spontaneous breathing trials
with the best respiratory being 78. It was determined that
since she would not be weaned any time soon a tracheostomy
was performed on [**11-13**]. This was performed without
complication by Dr. [**Last Name (STitle) **] and the patient remained stable
on CPAP.
2. CARDIOVASCULAR - Hypertension - The patient's hypotension
had been consistently an issue through her first month in the
MICU. However by [**11-3**] her maps improved consistently
to above 60 so that Norepinephrine drip was stopped, remained
off on temporarily and restarted after procedures requiring
sedations such as IR line placement. Because of the
difficulties weaning the patient off and on the
Norepinephrine line it was hypothesized that she had adrenal
insufficiency. However cortisone levels were found to be
normal.
Coronary artery disease - There were no issues.
Electrophysiology - During analysis the patient had three,
five second runs of polymorphic VT. This polymorphic VT
actually turned out to be motion artifact and did not recur.
Congestive heart failure - The patient had moderate
improvement of her CHF achieved by dialysis when two liters
to three liters was typically removed.
3. RENAL - The patient remained with end stage renal disease
requiring hemodialysis three times a week typically on a
Tuesday, Thursday and Saturday schedule. End stage renal
disease was felt to be secondary to Type II diabetes.
4. INFECTIOUS DISEASE - The patient has meningitis resolving,
MRSA, bacteremia which has resolved, pseudomonas bacteremia,
endocarditis and multi focal pneumonia.
A. Meningitis - The patient was treated with Meropenem and
her symptoms have been resolving.
B. Endocarditis - The patient is undergoing an eight week
course of Vancomycin dose by trough levels below 15 she
receives 1 gram. Her final day of treatment will be [**2153-12-5**].
C. Multi focal pneumonia - The patient completed an 18 day
course of Meropenem.
D. Bacteremia - The patient's blood glucose declined, her
body temperature became elevated to 98 to 99 F. Blood and
sputum cultures to rule out pseudomonas aeruginosa resistant
to virtually every antibiotic including Cefepime,
............. ............. and was sensitive only to
Tobramycin and Colistin. The patient was initiated on IV
Tobramycin for 14 days with the final day planned to be
[**2153-11-23**]. It was dosed after hemodialysis. It was
decided not to use Colistin so that it could be used if the
current regimen was not effective in eliminating infections.
Surveillance cultures drawn two days after removal of the
essential catheters showed no growth.
5. GASTROINTESTINAL - The patient has a history of
aspiration pneumonia and had been given nutrition via an OG
tube intubated after tracheostomy. The patient received a PEG
tube placed by Dr. [**Last Name (STitle) **] on [**2153-11-15**]. It
functioned normally and tube feeds were then continued
through the PEG tube.
6. NEUROLOGIC - The patient's mental status improved
considerably during the time interval so that by [**2153-11-15**] she was alert and responded to questions with head
shaking and hand grasping. Ms. [**Known lastname **] has a history of
status epilepticus and seizures though she had none from
[**11-3**] onward. Phenytoin was dosed at alternating
doses of 100 milligrams q A.M. alternating 150, 100
milligrams [**Location (un) **] doses anti Phenytoin levels between 2 and
2.5 pre Phenytoin. It was difficult to maintain appropriate
levels drifting either up or down below the target.
7. HEMATOLOGY - The patient has an anemia of chronic disease
which was treated with erythropoietin 2,000 units during
hemodialysis. She has coagulopathy positive for hit H
Heparin induced thrombocytopenia and cardiolipin antibodies.
Her INR was consistently 1.5 so she was treated with FFP
procedure.
8. ENDOCRINE - The patient has Type II diabetes which was
treated NPH 14 units q A.M., q P.M. It was held during
development of the pseudomonal bacteremia and the patient's
glucose was then controlled with regular insulin sliding
scale. The patient's hypothyroid was treated with Synthroid
200 micrograms q day.
9. OCCUPATIONAL / PHYSICAL THERAPY - The patient has
contractures of her hands which were treated with splints.
Follow up therapy will be required on discharge. Tent access
the patient has a right arm double Lumen PIC line from
[**2153-11-8**] on the right. External jugular double Lumen
catheter placed on [**2153-11-14**].
10. PROPHYLAXIS - Phenytoin, Prevacid, splints, MRSA zoster
precautions for the patient.
11. COMMUNICATION - The patient's daughter, [**Name (NI) 2039**] [**Name (NI) **]
is the health care proxy. She claims to speak for entire
family.
12. DISPOSITION: The patient is full code and please see
the next addendum for discharge summary for her course
between [**2153-11-17**] and [**2153-12-1**].
[**Last Name (LF) 3353**],[**First Name3 (LF) 3354**] N. M.D. [**MD Number(1) 7079**]
Dictated By:[**Last Name (NamePattern1) 771**]
MEDQUIST36
D: [**2153-11-27**] 18:51
T: [**2153-12-3**] 11:00
JOB#: [**Job Number **]
Name: [**Known lastname **], [**Known firstname 1118**] Unit No: [**Numeric Identifier 16619**]
Admission Date: [**2153-10-9**] Discharge Date:
Date of Birth: [**2082-12-1**] Sex: F
Service: MICU ORANG
ADDENDUM: This addendum covers her course from [**2153-11-18**]
through [**2153-11-29**]. [**2153-11-29**] being hospital day 66
for the patient.
On [**2153-11-29**] she was transferred to the General
Medical Floor. Overall the patient improved clinically with
marked improved mental status.
1. PULMONARY - The patient's respiratory status improved
from a pressure support 15 and 5 with a trach to being on
trach mask for nearly 48 hours. Her ability to breathe
without a ventilator has led to her being able to be
transferred to the regular Medical service.
2. CARDIOVASCULAR - Hypertension - The patient's mean
arterial pressures remained above 60 throughout the remainder
of her stay in the MICU. She needed brief support with an
Epinephrine drip during one episode of hemodialysis.
Coronary artery disease - No issues.
Electrophysiology - No issues.
Congestive heart failure - Moderate improvement was achieved
by dialysis when two liters was typically was removed.
3. RENAL - The patient remained with end stage renal disease
requiring hemodialysis three times a week, Tuesday, Thursday
and Saturday. The end stage renal disease was thought to be
secondary to diabetes mellitus. The patient is being
dialyzed by a right EJ catheter which is suboptimal and a
tunnel catheter is preferred. The reason the EJ was left in
place is that the interventional radiology service felt that
there were few available sites and it was preferred to leave
in any working catheter as long as possible. This evaluation
was appreciated by the renal service but a long term solution
for hemodialysis access has not yet been determined.
4. INFECTIOUS DISEASE - The patient was treated successfully
so far for endocarditis and pseudomonas bacteremia.
Endocarditis - The patient is on an eight week course of
Vancomycin dose by trough level with dosing below 15 with 1 g
[**Doctor First Name **] of Vancomycin. The final day of treatment will be [**2153-12-5**].
Bacteremia - The patient's blood glucose declined and body
temperature became elevated between 98 to 99 F. Blood and
sputum cultures grew out pseudomonas aeruginosa. This was all
back [**11-8**] and [**11-9**]. This pseudomonas was
resistant to virtually every antibiotic including
............. , Ticarcillin, ............. and was sensitive
only to Tobramycin and Colistin. The patient was treated,
initiated on IV Tobramycin for 14 days with a final dose
being on [**2153-11-23**]. The Tobramycin was dosed after
hemodialysis and peaks and troughs were checked. It was
decided not to use Colistin so that it could be used if the
current regimen was not effective in eliminating the
infection of pseudomonas. Surveillance cultures drawn two
days after the removal of the central catheters showed no
growth of pseudomonas.
5. GASTROINTESTINAL - The patient has a history of aspiration
pneumonia and was given nutrition via an OG tube while
intubated. After tracheostomy the patient received a PEG
tube placed on [**2153-11-15**]. It was functioning normally
so tube feeds were continued through the PEG tube.
6. NEUROLOGIC - The patient's mental status improved
considerably during the time interval of [**2153-11-18**]
through [**2153-11-29**] so that by [**2153-11-16**] she
was alert and responded to questions with head shaking and
hand grasping. She also by [**2153-11-29**] was able to
engage in conversation though her voice could not
specifically be heard well because she was on a tracheostomy
tube. However it could be heard as a whisper and she was
able to engage in small conversation about various issues.
In addition neurologically the patient has a history of
status epilepticus and seizures though she had none during
her stay from [**11-3**] onward. Phenytoin has been used as
the anti-seizure medication with target dose being 2 to 2.5
of pre Phenytoin levels. However dosing has been unreliable
with levels slowly increasing over time. The Neurology
service recommended switching to oxcarbazepine trade name
Trileptal whose levels do not have to be checked as with
Dilantin. However monohydroxy metabolite MHD levels can be
checked of oxcarbazepine if necessary. Serum sodium should be
monitored for evidence of hyponatremia a side effect of
oxcarbazepine. Note it is not known how dialysis will affect
the levels oxcarbazepine and this issue needs to be
addressed.
7. HEMATOLOGY - The patient has anemia chronic disease which
was treated with erythropoietin 6,000 units during
hemodialysis. She has coagulopathy positive for Heparin
induced thrombocytopenia antibodies and cardiolipin
antibiotics. Her INR was consistently 1.5 so she was treated
with FFP per procedure. The patient was given one dose of
Lepirudin which is non-dialyzable. PTT levels has remained
increased and may serendipitously provide effective
anti-coagulation for the purpose of keeping the right EJ
catheter.
8. ENDOCRINE - The patient has Type II diabetes which was
treated with NPH 14 units A.M. and q P.M. It was held during
the development of the pseudomonas bacteremia and the
patient's glucose was controlled with regular insulin sliding
scale. After improvement the patient was started with NPH 4
units q A.M. and 2 units q P.M. The patient's hypothyroid
was treated with Synthroid 200 micrograms q day.
9. OCCUPATION THERAPY / PHYSICAL THERAPY - The patient has
contractures of her hands which was treated with splints.
Follow up therapy will be required now that the patient is
interactive.
10. ACCESS - The patient has a right arm double Lumen PIC
line placed on [**2153-11-8**] and a right EJ double Lumen catheter
placed on [**2153-11-14**].
11. PROPHYLAXIS: Phenytoin, Prevacid, splints. The patient
is on precautions for MRSA and zoster.
12. COMMUNICATIONS: The patient's daughter, [**Name (NI) 2039**] [**Name (NI) **],
is the health care proxy. She claims to speak for her entire
family. This has been confirmed verbally by [**First Name8 (NamePattern2) **] [**Known lastname **],
the separated but not divorced husband of the patient's as
well as by [**First Name8 (NamePattern2) **] [**Known lastname **], the patient's son. Addressed by Dr.
[**Last Name (STitle) **] to both [**First Name8 (NamePattern2) **] [**Known lastname **] and [**First Name8 (NamePattern2) 2039**] [**Known lastname **] to get a signed
verification of [**First Name8 (NamePattern2) 2039**] [**Known lastname **] being the [**Hospital 1325**] health care
proxy have not yet received written confirmation of this
status, just oral confirmation which has been documented by
me, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
13. DISPOSITION: The patient is full code.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6658**]
Dictated By:[**Last Name (NamePattern1) 771**]
MEDQUIST36
D: [**2153-11-29**] 18:02
T: [**2153-12-3**] 13:00
JOB#: [**Job Number **]
Name: [**Known lastname **], [**Known firstname 1118**] Unit No: [**Numeric Identifier 16619**]
Admission Date: Discharge Date: [**2153-12-21**]
Date of Birth: [**2082-12-1**] Sex: F
Service: [**Doctor Last Name 633**]
DISCHARGE SUMMARY ADDENDUM: For [**2153-12-21**] following hospital
course from last discharge summary by systems is as follows:
1. Endocrine - The patient underwent cortisol stimulation test
during her hospitalization which showed both a decreased
aldosterone and a decreased cortisol level. Consequently the
patient was started on chronic Florinef and corticosteroid
therapy as a result.
2. Hematology - The Hematology service was consulted regarding
the history of heparin induced thrombocytopenia and positive
anti-cardiolipin antibodies and demonstrating possible evidence
of a DVT in her right upper extremity. A repeat ultrasound was
performed of her right upper extremity which was negative for
DVT. Repeat coagulation studies were sent at the end of her
hospital course and the results will be followed up by her
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16624**]. Due to her Heparin induced
thrombocytopenia she is not to receive any Heparin products.
DISCHARGE MEDICATIONS:
1. Hydrocortisone 20 milligrams per G tube prn and then 10
milligrams per G tube q P.M.
2. Reglan 5 milligrams per G tube qid.
3. Trileptal 450 milligrams per G tube q A.M., 300
milligrams per G tube q P.M. On [**2153-12-24**] the dose is to
increased to 450 milligrams per G tube [**Hospital1 **]. On [**2153-12-31**] the
dose is to increase to 600 milligrams per G tube q A.M. and
450 milligrams per G tube q P.M. On [**2154-1-7**] increase to 600
milligrams per G tube [**Hospital1 **].
4. Dilantin 50 milligrams per G tube [**Hospital1 **].
5. Zinc Sulfate 220 milligrams per G tube q day.
6. Vitamin C 250 milligrams per G tube [**Hospital1 **].
7. Tube feeds promote goal rate of 65 milliliters per hour.
Check residuals q four hours. If residuals greater than 100
milliliters stop for one hour and restart it at 10
milliliters per hour less than prior rate.
8. ... to clean G tube site every day.
9. Stomal adhesive wafer to skin around percutaneous G tube
site.
10. NPH 8 units subcutaneous 8 A.M., 6 units subcutaneous q
HS.
11. Mitogen 10 milligrams per G tube by dialysis for blood
pressure less than 120.
12. Combivent two puffs q four hours prn.
13. Levothyroxine 20 micrograms per G tube q day.
14. Percocet 30 milligrams per G tube q day.
15. Nephrocaps 1 tablet per G tube q day.
16. Tums three tablets per G tube tid.
17. Calcijex 1 microgram IV TIW with hemodialysis.
18. Epogen 5,000 units IV given with dialysis.
19. Dulcolax 10 milligrams po q day prn.
20. Florinef 0.1 milligrams per G tube q day.
21. Regular insulin sliding scale blood sugar 150 to 200
please give 2 units of subcutaneous insulin, if glucose 201
to 250, 4 units subcutaneous insulin if glucose 251 to 300, 6
units subcutaneous regular insulin if glucose 301 to 350, 8
units subcutaneous regular insulin if glucose 351 to 400, 10
units of subcutaneous regular insulin if greater than 400, 12
units subcutaneous regular insulin and please call physician
with results.
22. TPA prn for dialysis catheter clotting if needed.
DISCHARGE DIAGNOSIS:
1. Methicillin resistant staphylococcus aureus sepsis with
endocarditis.
2. Hyper induced thrombocytopenia.
3. Diabetes.
4. Adrenal insufficiency.
5. Seizure disorder.
6. End stage respiratory distress on hemodialysis.
DISCHARGE STATUS: Stable. Follow up with Dr. [**Last Name (STitle) 16624**] of
[**Hospital1 **] Associates [**Telephone/Fax (1) 16625**].
DISCHARGE DATE: [**2153-12-21**] to [**Hospital3 **] [**Telephone/Fax (1) 16626**]. She
will need to undergo dialysis on [**2153-12-22**].
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Name8 (MD) 2639**]
MEDQUIST36
D: [**2154-2-1**] 11:31
T: [**2154-2-4**] 11:14
JOB#: [**Job Number 16627**]
|
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icd9cm
|
[
[
[]
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|
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|
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|
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|
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|
2214, 2350
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,532
| 197,709
|
51804
|
Discharge summary
|
report
|
Admission Date: [**2103-7-10**] Discharge Date: [**2103-7-19**]
Date of Birth: [**2040-4-27**] Sex: F
Service: MEDICINE
Allergies:
Motrin / Latex
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
tracheostomy evaluation, concern for altered mental status
Major Surgical or Invasive Procedure:
1. Flexible bronchoscopy.
2. Tracheostomy tube change
History of Present Illness:
This is a 62 year old female, with a past medical history of
atrial fibrillation, memory loss s/p hypoglycemic coma with
anoxic brain injury, chronic low back pain, subarachnoid
hemorrhage, chronic hypercarbic respiratory failure with
tracheostomy in place, who now presents for removal of trach,
and concern for altered mental status.
This patient has a complicated past medical history in which she
was admitted for subarachnoid hemorrhage ([**Date range (1) 107251**]),
discharged and then subsequently re-admitted for hyperbaric
respiratory failure requiring intubation ([**Date range (1) 107252**]). Her
hypercarbic respiratory failure is thought to be due to multiple
causes, including central and obstructive apnea, a chronic
paralyzed right hemidiaphragm, and obesity hypoventilation. On
her third admission ([**Date range (1) 107253**]), again for acute
hypercarbic respiratory failure requiring intubation, she was
found to have a tracheal tear seen on chest CTA, and confirmed
on bronchoscopy. Tracheostomy was performed to bypass the area
of the tear, as the patient was at high risk for repeated
intubation and the risk of causing perforation would be greater
in setting of re-intubation. The initial plan was to re-evaluate
the tracheostomy in 8 weeks after the tear healed. However, in
the interim, patient decided with her PCP to leave the trach in
place as treatment for the patient's presumed OSA. Trach removal
was further delayed by two hospitalizations at [**Hospital3 **] for pneumonia. She now presents for removal of trach.
Her husband is also concerned for the patient's worsening mental
status, with confabulation and loss of memory. She has
reportedly been confused, not recognizing her husband and other
family members. She has baseline dementia as a result of anoxic
brain injury and hypoglycemic coma, but he reports that over
this has worsened over the last few weeks to months. The patient
denied these symptoms and further denied any fever, chills,
headache, vertigo or focal weakness.
Past Medical History:
Left Temporal Intraparenchymal hemorrhage
COPD - no prior h/o tobacco use, + secondhand exposure
afib - was on coumadin for last few years,anti-coagulation was
discontinued after her ICH
TIA - had prior episodes of flashes of light going across her
visual field, was placed on plavix.
Dementia - secondary to diabetic coma with anoxic brain injury
Chronic Low Back Pain
Anemia
GERD
Chronic hypercapnic respiratory failure with history of
traumatic tracheal tear, s/p Tracheostomy placement on [**2103-3-8**]
- apparently multifactorial in etiology, including central and
obstructive apnea, chronically paralyzed R hemidiaphragm, and
obesity hypoventilation. Seen by sleep [**2103-2-26**] who recomended
her BiPAP settings.
Social History:
Lives with husband until recent admission, used to work as the
press secretary to a state senator in the state house. no
[**Month/Day/Year **]/etoh or illicits. Husband was mechanically ventillating
patient at night at home.
Family History:
NC
Physical Exam:
Admission Vitals: T:98.1 BP:175/51 P:86 RR 19 O2: 95%3L
Discharge vitals: T 96.2 BP: 148/50 P:60 RR: 21 02: 05% on 2L
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation, respirations unlabored, no
accessory muscle use
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin:
Neuro: A&Ox3, appropriate, CNs II-XII grossly intact, muscle
strength 5/5 throughout, sensation grossly intact throughout,
DTRs 2+ and symmetric
Spine: c/t/l-spine without TTP
.
Pertinent Results:
[**2103-7-16**] 03:26PM BLOOD Type-ART pO2-78* pCO2-58* pH-7.43
calTCO2-40* Base XS-11
[**2103-7-17**] 02:42AM BLOOD Type-ART pO2-82* pCO2-63* pH-7.40
calTCO2-40* Base XS-10 Intubat-NOT INTUBA
[**2103-7-13**] 05:11AM BLOOD WBC-12.6* RBC-4.08* Hgb-10.4* Hct-33.5*
MCV-82 MCH-25.6* MCHC-31.2 RDW-16.7* Plt Ct-320
[**2103-7-10**] 11:15AM BLOOD WBC-10.0# RBC-4.36# Hgb-11.2*# Hct-35.9*#
MCV-82# MCH-25.7*# MCHC-31.2 RDW-17.1* Plt Ct-359
[**2103-7-12**] 04:55AM BLOOD PT-12.6 PTT-23.5 INR(PT)-1.1
[**2103-7-13**] 05:11AM BLOOD Glucose-261* UreaN-13 Creat-0.6 Na-136
K-4.0 Cl-100 HCO3-25 AnGap-15
[**2103-7-11**] 03:24AM BLOOD Glucose-142* UreaN-11 Creat-0.6 Na-142
K-3.8 Cl-103 HCO3-27 AnGap-16
[**2103-7-11**] 03:24AM BLOOD ALT-6 AST-13 CK(CPK)-19* AlkPhos-94
TotBili-0.3
[**2103-7-12**] 04:55AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9
[**2103-7-11**] 03:24AM BLOOD VitB12-649
[**2103-7-10**] 12:10PM BLOOD Lactate-1.1
CXR [**2103-7-10**]: Low lung volumes limit evaluation of the lung
parenchyma.
Mild nodular interstitial thickening especially within the left
lower lobe may represent atelectasis versus early pneumonia.
Clinical correlation is recommended.
CT Head [**2103-7-10**]: The ventricles are moderately enlarged given
the lack of
significant atrophy, particularly the third ventricle. Overall,
the size of the ventricles is not significantly changed when
viewed over serial images dating back to the patient's
presentation in [**Month (only) 958**] of this year. There is continued evolution
of the left temporal lobe hematoma, with vague lucency, though
no evidence to suggest interval bleeding. No persistent
intraventricular blood products are seen. There is hyperostosis
frontalis. There are no findings of acute infarct by CT. The
visualized paranasal sinuses and mastoid air cells are clear.
CXR [**2103-7-13**]: Right low lung volume with elevation of the right
hemidiaphragm is stable. New airspace opacity in the right lung
suggests early pneumonia in the right clinical setting. Left
lung is grossly clear.
CT abd/pelvis [**2103-7-14**]: Acute compression fracture at T12
without other evidence to explain abdominal pain.
Brief Hospital Course:
This is a 62 year old female, with a past medical history of
atrial fibrillation, memory loss s/p hypoglycemic coma with
anoxic brain injury, chronic low back pain, subarachnoid
hemorrhage, chronic hypercarbic respiratory failure with
tracheostomy in place, who presented to the emergency department
for removal of trach, and concern for altered mental status. The
patient was initially admitted to the ICU in order to receive
mechanical ventilation at night. In the MICU, she was weaned off
of the vent, and when transfered to floor, was able to cap her
trach during the day and remove the cap at night--no other
respiratory intervention was thought to be necessary.
Additionally, while in th ICU, the patient complained of back
and RUQ pain; abdominal CT to evaluate these complaints did not
show any acute intraabdominal pathology, but did show an acute
thoracic compression fracture. There was some concern that the
patient was developing pneumona, as she had increasing white
count, increased secretions over a few days prior to transfer to
the floor, as well as a chest xray with new infiltrate in the
right lower lung.
.
#1. Chronic hypercapnic respiratory failure: Apparently the pt's
respiratory failure is the result of etiologies, including
central and obstructive sleep apnea, a chronic paralyzed R
hemidiaphragm, and obesity hypoventilation. The patient was
evaluated in [**2-22**] by sleep pulmonology and recommendations for
outpatient sleep study and empiric BiPAP were made. Although the
patient did well with nocturnal ventilator/BiPAP weaning in the
MICU, on the floor, she had rising bicarb (from 25 to 35 over 4
days) and sleep pulmonology was consulted to provide
recommendations on whether the patient should be on any kind of
positive pressure ventilation at night, and if so, at what
settings. ABGs were checked during the day and while the patient
was asleep on BiPAP to assess for hypercarbia on those
settings--pCO2 was stable from 58 (day) to 63 (night) and the
patient's O2Sat was 94% overnight. Per their recommendations,
the patient was re-started on BiPAP 10/5 with 2L 02 [**Date Range 5910**] with
full face mask and capped trach. The patient should also sleep
at 35 degrees at all times to optimize pulmonary mechanics. The
patient is scheduled for out-patient sleep study and follow up
with Dr. [**Last Name (STitle) **]. During her hospitalization, her respiratory
status remained stable with RR ranging 20-24, O2Sat >93% on 2L
of 02. At night, she was >89% on 4-5L.
.
#2. Tracheal tear s/p tracheostomy: As noted in HPI, pt's trach
was supposed to be re-evaluated in [**4-23**] weeks but this never
happened due for multiple reasons as noted above. The patient
was evaluated by IP while in the MICU, and had her tracheostomy
downsized from #7 to #6 [**Last Name (un) 295**]. The initial plan was to cap the
trach for 72 hrs, and, if tolerated, then change it to a
[**Location (un) **] tracheal cannula to preserve the stoma while she got
tested for OSA. However, the patient was unable to tolerate
capping of the trach during the night. When transfered to the
floor, she was capping the trach during the day and leaving it
uncapped at night. The patient needs to follow up with IP as
well as sleep pulmonlogy as an out-patient.
.
#3. Pneumonia: On transfer to the floor, there was concern for
developing pneumonia, given that the patient had increasing
WBCs, increasing respiratory secretions and new right lower lobe
infiltrate on [**2103-7-13**] chest xray. ID consult was obtained to
provide antibiotic recommendation and the patient was started on
Meropenem IV for 7 days, per susceptibilties from OSH cultures.
Sputum cultures from [**7-11**] and [**2103-7-13**] subsequently grew
PSEUDOMONAS AERUGINOSA and SERRATIA MARCESCENS, two of the same
organisms seen in the OSH cultures. Her last day of antibiotics
(Meropenem) is [**2103-7-21**].
.
#4. Altered Mental Status: While admitted, the patient's
mentation appeared completely appropriate during the day. At
night, she did seem to experience some degree of sundowning as
she occasionally became confused about what hospital she was at
and how long she had been admitted; she would also confabulate
stories about things she had supposedly done with her family on
preceding days. She was very re-directable and could be
reoriented easily. During the day, she was alert and oriented x
3. Work up included a Head CT negative for any new large stroke
or hemorrhage, B12 normal, and RPR negative. Her mental status
was stable during her admission on the floor and her husband
reported that she was at baseline.
.
#5. Acute anterior compression fracture at T12: The patient's
compression fracture was discovered incidentally on a ct abdomen
obtained to evaluate the patient's complaint of abdominal pain.
She was then seen by orthopedics, who recommended TLSO brace and
follow up in 2 weeks with Dr. [**Last Name (STitle) 1007**]. PT evaluated the patient
and recommended rehab after discharge. Given the concern for
osteoporosis in the setting of incidental compression fracture,
the patient was started on vitamin D and calcium
supplementation. The patient is weight-bearing with TLSO brace.
without brace, HOB cannot be >40 degrees. She was given
percocet and fentanyl patch for pain control.
.
#6. Atrial fibrillation: On her home regimen of Acebutolol, the
patient became bradycardic. It was decreased to 100mg [**Hospital1 **] with
good rate control. Anti-coagulation with coumadin 5mg daily was
re-started as an in-patient, with neurosurgery's approval. She
will need her INR checked and her coumadin dose adjusted as
needed.
.
#7. Left Temporal Intraparenchymal hemorrhage: The patient's
head CT was consistent with evolution of prior bleed; no
extension or new hemorrhage was seen. The patient will need
follow up with neurosurgery in 3 months with repeat head CT.
Additionally, the patient no longer needs to take keppra for
seizure prophylaxis, per neurosurgery.
.
#8. Diabetes: While admitted, the patient's home oral glycemic
agents were held and she was maintained on a regular insulin
sliding scale. She required addition of pm Lantus dose (16
units) for improved glucose control. She was discharged on her
oral hypogylcemic regimen.
.
#9. Hypertension: blood pressure control was achieved with
Acebutolol 100 [**Hospital1 **] and Enalapril 20mg twice daily.
.
# RUQ Abdominal pain: while in the MICU, the patient had normal
LFTS and an abdominal CT that was negative for acute
intra-abdominal process. She had negative C. diff toxin assay x
1. Her pain improved on a bowel regimen and pain control for
her thoracic compression fracture.
.
Medications on Admission:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed.
2. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
7. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
8. Acebutolol 200 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
9. Rosiglitazone 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
10. Glipizide 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a
day).
11. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO [**Hospital1 **] (once a day (at bedtime)) as needed for
agitation.
13. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic Q8H
(every 8 hours): both eyes.
14. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS
(at bedtime): both eyes.
15. Humalog/Regular insulin sliding scale (not clear per
husband)
per protocol q[**Name (NI) **]
16. Januvia 100 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
(not clear per husband).
17. Enalapril Maleate 20 mg PO DAILY
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Name (NI) **]:
2-4 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
2. Fluticasone 110 mcg/Actuation Aerosol [**Name (NI) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed for rash.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Do not take more than 4g of Tylenol
in 24 hours.
7. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic Q8H
(every 8 hours).
8. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
9. Enalapril Maleate 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO twice a
day.
Disp:*90 Tablet(s)* Refills:*0*
10. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain: Do not drive while
taking this medication. Do not take more than 4g of Tylenol
daily. Do not take if you become very sleepy or have difficulty
breathing.
Disp:*30 Tablet(s)* Refills:*0*
11. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
13. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
14. Trazodone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
15. Meropenem 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 4 days: Day #1 [**2102-7-14**].
Last day [**2103-7-21**].
Disp:*qs Recon Soln(s)* Refills:*0*
16. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day/Year **]: 2-6 Puffs
Inhalation QID (4 times a day).
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
18. Acebutolol 200 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO twice a
day.
19. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve [**Month/Day/Year **]: One (1)
Tablet, Rapid Dissolve PO at bedtime as needed for agitation.
20. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable
[**Month/Day/Year **]: One (1) Tablet, Chewable PO twice a day.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
21. oxygen
3-6 L of O2 titrated into BIPAP for nocturnal use.
22. BIPAP
BIPAP machine at 10/5 CM of H20 with heated humidification.
23. Acebutolol 200 mg Capsule [**Month/Day/Year **]: 100mg Capsules PO twice a
day.
24. Rosiglitazone 4 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
25. Glipizide 5 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO twice a day.
26. Januvia 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
27. Fentanyl 12 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
28. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day/Year **]: One (1)
Tablet, Chewable PO TID (3 times a day) as needed for calcium
supplementation.
29. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 46972**]
Discharge Diagnosis:
Primary diagnoses:
1. Chronic hypercapnic respiratory failure with history of
traumatic tracheal tear, s/p Tracheostomy
2. hospital-acquired pseudomonas pneumonia
3. Acute anterior compression fracture at T12
4. Dementia
Secondary diagnoses:
1. Left Temporal Intraparenchymal hemorrhage
2. Atrial fibrillation
3. Diabetes mellitus
4. COPD
5. Hypertension
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for revision of your tracheostomy. You had
your tracheostomy downsized from a 7mm to a 6mm tube by
interventional pulmonology. There was concern that you were
developing a pneumonia, as you had increasing secretions,
increaseing white count, and possibly a new infiltrate on chest
x-ray. You were started on an IV antibiotic, called Meropenam,
for this and you will need 7 days of antibiotic therapy. You
had complaints of abdominal pain while admitted, and had a CT
scan of your abdomen--it did not show any intraabdominal
pathology but did show a compression fracture of your thoracic
spine (T12). Additionally, we discussed your case with
neurosurgery, who made the recommendations that your Keppra
(Levetiracetam) 500mg twice daily can be stopped and that we
could re-start your Coumadin (aka Warfarin--a blood thinner,
which you take because your atrial fibrillation increases your
risk of clotting).
Medication changes:
We stopped your Keppra 500mg twice daily.
We started Coumadin (Warfarin) 5g daily for atrial fibrillation.
We changed your Enalapril from 20mg daily to 20mg twice a day to
improve your blood pressure control.
We decreased your Acebutolol dose from 200mg twice daily to
100mg twice daily.
We started calcium and vitamin D supplementation to help
strengthen your bones.
We started several medications to help control your pain from
the compression fracture:
1. you may take tylenol 325mg (1 or 2 tabs) every 6 hours as
needed for pain.
2. you may take 1 percocet (hydrocodone + tylenol). every 6
hours as needed for pain.
3. you may place a lidocaine patch on your back for 12 hours
daily to help with pain.
4. you may place a fentanyl patch (12.5mcg) every 72 hours to
help with your pain.
Be careful not to drive while using the percocet and fentanyl
patch. Be careful not to take more than 4g of Tylenol in a day.
5. Meropenem was started for pneumonia and will be continued
until [**2103-7-21**].
Please speak with your doctor at rehab if you have any decrease
in your mental status or somnolence (severe sleepiness),
confusion, any difficulty breathing, any increased cough or
respiratory secretions, chest pain, fever, chills, nausea,
vomiting, worsening or changed abdominal pain, diarrhea, leg
weakness, incontinence of bowel, or any other new and concerning
symptom
Followup Instructions:
You have had referrals made by your regular doctor and have the
following appointments:
1. SLEEP APNEA FOLLOW-UP
[**2103-7-20**] (Friday) 9 AM
[**Hospital Ward Name **] 8, NEUROLOGY SUITE
DR. [**First Name (STitle) **] AND DR. [**Last Name (STitle) **]
2. You can call Interventional Pulmonology at ([**Telephone/Fax (1) 513**] to
make an appointment to evaluate your tracheostomy.
3. You have an appointment scheduled with Dr. [**Last Name (STitle) 1007**] (with
orthopedics) on [**2103-7-25**] at 4pm.
You have an appointment on [**2103-8-1**] 1130am with your regular
doctor Dr. [**Last Name (STitle) 74756**], ph [**Telephone/Fax (1) 81655**].
Location: [**Hospital1 641**]
Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 6086**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,586
| 141,608
|
28293
|
Discharge summary
|
report
|
Admission Date: [**2171-9-10**] Discharge Date: [**2171-10-3**]
Date of Birth: [**2091-3-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Right sided weakness and expressive aphasia with left frontal
brain mass
Major Surgical or Invasive Procedure:
Stereotactic left frontal lobe brain mass biopsy ([**2171-9-25**])
History of Present Illness:
80yo M with COPD, CAD s/p CABG, CVA s/p CEA, who was transferred
from OSH with intracranial mass with hemorrhage. The patient
initially present to [**Doctor Last Name 38554**] Hospital following onset of
right sided weakness and difficulty speaking that had reportedly
developed over a week. The pt & family reported difficulty
walking and using right side. He had been unable to write and
noticed his hand has been shaking. He states his daughters
became concerned on the day of admission when they noticed his
speech was slurred and sent him to the ER. Pt reports falling
approximately two weeks ago but denies hitting his head. He went
to [**Hospital3 10310**] Hospital and then transferred here after a
head CT showed a possible left frontal mass with a the bleed.
Of note, pt has not gone to physcian for 4 years.
Pt endorses SOB w/cough which he is unsure is worse than
baseline. Denies fever/chills. No chest pain/palpitations/[**Doctor Last Name **]
Extremity swelling; no abdominal pain/N/V/D/C.
.
Past Medical History:
1. COPD, no oxygen prior to admission
2. S/P MI with coronary artery bypass (years ago)
3. s/p aneursym clipping x 2 (L frontal & L temporal)
4. Cerebral vascular accident (occurred 10 yrs ago, fell off
roof and broke both legs, found to have had a stroke with R arm
weakness, "couldn't speak") seen innitially at [**Hospital3 10310**]
Hospital then transferred to [**Hospital1 2025**]
5. s/p carotid endarterectomy at [**Hospital1 112**]
6. s/p AAA repair
7. Hypertension
8. h/o migraine
9. cochlear implants
10. Benign prostatic status post TURP
11. Gastroesophageal reflux
12. depression
.
Social History:
-Retired carpenter, lives with wife, who is ill; has 4 grown,
supportive children.
-Health care proxy is eldest son [**Name (NI) 4334**] [**Name (NI) 58115**] (papers have been
signed to establish this) Work #[**Telephone/Fax (1) 68696**]; home
#[**0-0-**].
-Former smoker, 50 pack year history not smoking now, quit 10
yrs ago
No alcohol or illict drugs
.
Family History:
His mother had neck cancer. Father died of an aneurysm.
Physical Exam:
Tm 98.7 Tc 97.6 BP 120/60, 73, RR 22, Sat94% on 2L NC
Pt sitting up in bed, NAD, cooperative and pleasant, alert and
oriented person, place, and time
neck supple, JVP 7.5 cm
distant heart sounds RRR no M/R/G
Diffuse ronchi w/ high pitched wheezes, decreased breath sounds
R>L
soft NT/D + BS, (+)surgical scars
no C/C/E
CN 2-12 intact, 4+/5 Left upper and lower extremity strength,
3+/5 Right upper and lower extremity strength; pt has word
finding difficulties though understands language
Pertinent Results:
[**9-10**] HEAD CT:
1. Large intraparenchymal hematoma in the left frontal lobe. The
finding could be a result of amyloid angiopathy or underlying
neoplasm.
2. Post-operative changes- see above report for findings.
3. Status post aneurysm repair, with evidence of a small
residual aneurysm in the left suprasellar cistern region.
.
[**9-13**] CT TORSO:
IMPRESSION:
1. Emphysema with spiculated 10 mm nodular opacity in right
lower lobe. Although this could be infectious or inflammatory in
etiology, given the emphysema, there is suspicion for primary
lung neoplasm. Short-term CT followup is recommended.
2. 4-cm infrarenal abdominal aortic aneurysm. No evidence of
leak.
3. Right inguinal hernia w/ nonincarcerated/nonobstructed small
bowel.
4. Diverticulosis, without evidence of acute diverticulitis.
5. Air in the bladder. If there is a prior history of Foley
catheter placement, this could be a sequela. If not, correlate
with UA results as urinary tract infection is also possible.
6. Multiple thyroid nodules.
.
Head CT [**9-25**]: 1. Expected post-biopsy changes surrounding the
large left superior frontal hemorrhagic mass with significant
surrounding vasogenic edema. 2. New focus of subarachnoid
hemorrhage in the left parietal lobe.
.
Head CT [**2171-9-27**]: No change in the large hemorrhagic superior
left frontal lobe mass. The small amount of subarachnoid
hemorrhage along the left parietal lobe has evolved and now
appears isointense to [**Doctor Last Name 352**] matter. No new intracranial
hemorrhage is noted. Stable vasogenic edema as before.
.
[**2171-10-2**] CXR:
IMPRESSION: AP chest compared to [**9-24**] and 29:
Lung volumes are lower. Irregular opacification of the lung
bases is atelectasis. This could be due to aspiration but does
not suggest pneumonia. Focal opacities in the right lung on two
previous studies are less obvious today and could represent
sparing of fissural pleural loculations.
Upper lungs demonstrate severe emphysema, right worse than left.
Heart is normal size. The vertical component of sternal wiring
shows several breaks, but no interval change. No pneumothorax
appreciable. Pleural effusion is present.
.
EKG [**9-10**]: NSR 80, nl intervals, 1 mm QW in III, RSR' in v2, flat
TW in v2, no ST changes, no prior EKG for comparison
.
Micro
[**9-10**] urine cx: enterococcus, pan sensitive except to
tetracycline
[**9-10**] bld cx x 2 negative
[**9-18**] sputum gram stain shows gram negative bacilli.
[**2171-9-10**] 07:10PM WBC-9.7 HGB-15.2 HCT-43.4 MCV-76* RDW-14.8
[**2171-9-10**] 07:10PM CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-2.1
[**2171-9-10**] 07:10PM cTropnT-<0.01 CK(CPK)-45
[**2171-9-10**] 07:10PM GLUCOSE-107* UREA N-22* CREAT-1.1 SODIUM-136
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13
[**2171-9-10**] 09:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2171-9-20**] 08:13AM BLOOD Type-ART pO2-57* pCO2-46* pH-7.40
calTCO2-30
[**2171-9-23**] 10:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
[**2171-10-3**] 05:20AM BLOOD WBC-13.0*# RBC-5.51 Hgb-14.7 Hct-43.5
MCV-79* MCH-26.6* MCHC-33.7 RDW-15.2 Plt Ct-201
[**2171-10-2**] 05:30AM BLOOD WBC-7.2 RBC-5.50 Hgb-14.7 Hct-43.2
MCV-79* MCH-26.8* MCHC-34.2 RDW-15.1 Plt Ct-182
[**2171-10-3**] 05:20AM BLOOD Glucose-95 UreaN-23* Creat-1.0 Na-139
K-4.3 Cl-98 HCO3-30 AnGap-15
[**2171-10-3**] 05:20AM BLOOD Phenytoin-18.7
Brief Hospital Course:
80 yo M with CAD s/p CABG, HTN, CVA s/p CEA p/w PNA and COPD
exacerbation awaiting medical stabilization for bx of brain
mass.
.
Mestatic Carcinoma: The patient was transferred from
[**Doctor Last Name 38554**] Hospital for evaluation and management of his
left frontal mass. He was admitted to the SICU and neurology
and neuro-onocology were consulted. The patients right sided
weakness and expressive aphasia (which have persisted during his
hospitalization) were attributed to the left frontal mass. The
patient underwent staging scans (given that the mass was
possibly metastatic). The scans were remarkable for a 10mm
spiculated mass in the right lower lobe of the lung. There were
also some thyroid nodules noted. The patient underwent
sterotatic brain biopsy (with local anethesia only), with
pathology consistent revealed metastic carcinoma. Though the
final pathologic stains have not yet been completed, the general
consensus is that the carcinoma is of lung origin. Given the
patient's overall condition (with severe COPD,
pneumonia/probable aspiration pneumonitis), he was not
considered to be a surgical candidate--this was discussed at a
multidisciplinary meeting involving medicine, neurosurgery and
neuro-oncology. Whole brain radiation was instead recommended
and the patient began this treatment, following consultation by
radiation oncology, on [**2171-10-2**]. The patient has tolerated the
first two sessions of whole brain irradiation well. He is
scheduled to receive a total of 10 radiation treatments at [**Hospital 61**] [**Hospital **] Medical Center. Medical-oncology was consulted
for evaluation of probable lung cancer. They recommended
follow-up with a pulmonary oncologist once the patient's
radiation treatment is complete and the final path results are
complete. Of note, the patient's poor pulmonary status was not
thought to be relate to his lung mass given how small the lung
mass is--the patient clearly has severe underlying emphysema as
well as probable recurrent aspiration. The patient was treated
supportively for the brain mass with high dose steroids
(dexamethasone 4 mg PO Q6H) and phenytoin (100 TID, with dose
adjusted per level; goal level [**10-18**]). He will need to stay on
these at least until his radiation is complete, if not beyond
that point.
Subarachnoid hemorrhage: following brain biopsy, the patient had
routine post-surgical head CT which showed a small subarachnoid
hemorrhage in the left parietal region. The patient had no
change in his neurological exam associated with this. Follow-up
head CT was stable (no progression of hemmorhage).
COPD: The patient had an exacerbation of his emphysema when he
was transferred to [**Hospital1 18**]. He was treated with steroids (which
were dosed for his brain mass), nebulizers, and
levofloxacin--for possible RML pneumonia. After resolution of
the exacerbation, the patient continued to receive regular
nebulizer treatments. He was requiring 2 liters of oxygen by
nasal cannula at the time of discharge. Off oxygen his
saturations would occasionaly drop into the mid-to-high 80's.
Of note, the patient was asymptomatic during these episodes, and
his saturations improved with nebulizer treatment and
supplemental oxygen.
.
Community Acquired Pneumonia: as above, upon admission, the
patient found to have a right middle lobe pneumonia, for which
he recieved a 7 day course of levofloxacin. The patient's
pulmonary status did improve with treatment; however, during his
stay he was noted to have difficultly clearing secretions and
ronchorus breath sounds. Sputum cultures were persistently
negative/contaminated.
Aspiration pneumonitis: the patient's exam (diffuse ronchi and
poor cough) and chest x-rays were all suggestive of aspiration.
The pt underwent video swallow study which was negative for
aspiration. Despite this, he was put on aspiration precautions.
Chest PT was recommended at least once daily to help the
patient clear secretions. Mucinex and mucormyst were also given.
Given his somewhat tenuous state, the patient was given empiric
antibiotic therapy (levo and flagyl) for possible aspiration
pneumonia--he is on day 6 of 7 of treatment on the day of
discharge.
UTI: the patient was treated for enterococcal urinary tract
infection with a 7 day course of ampicillin.
HTN: pt was not hypertensive during his admission. He remained
on an beta-blocker throughout his stay
H/O CAD: the patient underwent cardiac-preoperative risk
stratification. He had a Persantine MIBI which showed LVEF 61%
and now definite perfusion abnormality. EKG was unremarkable
for active disease (see results section). He was kept on
beta-blocker; however, aspirin was held for surgery (and given
his hemorrhagic brain mass) as was statin given LDL 78.
GERD: the patient was kept on famotidine.
BPH: the patient was started on flomax 0.4mg daily.
Mild leukocytosis: the pt was noted to have mild leukocytosis
(13) on day of discharge. The patient is afebrile, non-toxic,
and without complaints. His chest xray has been unchanged. The
elevated WBC is likely due to stress response to radiation
(started yesterday) and perhaps steroid-associated as well. It
should be followed up next monday when phenytoin level is
checked.
Code status: DNR/DNI (established on [**2171-10-3**] as per patient;
also d/w'd the [**Hospital 228**] health care proxy).
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
4. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Guaifenesin 100 mg/5 mL Syrup Sig: Twenty (20) ML PO Q4H
(every 4 hours).
8. Acetylcysteine 10 % (100 mg/mL) Solution Sig: 1 to 10 ML
Miscell. TID (3 times a day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed for dyspnea.
14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 days: To complete 7 day course [**2171-10-5**].
16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days: Day [**7-5**] on [**2171-10-4**].
17. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day): Check phenytoin level 1 to 2
times weekly and adjust dose for goal level of [**10-18**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
-Metastatic Carcinoma (primary likely lung with metatasis to
left frontal lobe of brain)
-Emphysema
-Probable micro-aspirations
-Pneumonia
-Subarachnoid hemorrhage (post-surgical)
-Right-sided weakness
-Expressive Aphasia
.
Secondary:
-Urinary tract infection
-Coronary artery disease
-History of cerebral vascular disease
-Cochlear implants (cannot have MRIs)
-Benign prostatic hypertrophy
-Gastroesophageal refulx
Discharge Condition:
Stable
Discharge Instructions:
Please contact a doctor or go to the emergency room if you
develop chest pain, shortness of breath, headache, fever,
abdominal pain, or any other concerning change in your
condition.
-You will receive 8 more sessions of radiation.
Followup Instructions:
-The patient is scheduled for 8 more sessions of whole brain
irradiation at [**Hospital1 69**] ([**Hospital Ward Name 5074**]). Their phone number is ([**Telephone/Fax (1) 9710**]. They should be
in touch with your facility to arrange transportation to and
from the treatment sessions. If you have any questions, please
contact them.
[**Name2 (NI) **] will have a treatment session tomorrow ([**2171-10-5**]) likely at
9am. His next session will be on Tuesday [**2171-10-8**]. His last
session will be on [**2171-10-16**] (unless the radiation oncology
doctors inform [**Name5 (PTitle) **] otherwise).
-The patient needs an appointment scheduled with pulmonary
oncologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital Ward Name 23**] Building at [**Hospital1 18**]
([**Telephone/Fax (1) 5562**] after he completes his radiation therapy on
[**2171-10-16**].
-The patient should have an appointment with his primary care
doctor shortly after discharge from rehab [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 68697**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
|
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"401.9",
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"600.00",
"530.81",
"507.0",
"198.3",
"438.20",
"431",
"246.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"92.29",
"01.13"
] |
icd9pcs
|
[
[
[]
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13823, 13902
|
6597, 11986
|
389, 457
|
14371, 14380
|
3093, 3104
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2581, 3073
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276, 351
|
485, 1496
|
3113, 6574
|
1519, 2116
|
2132, 2491
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,911
| 173,885
|
39866
|
Discharge summary
|
report
|
Admission Date: [**2166-1-13**] Discharge Date: [**2166-2-12**]
Date of Birth: [**2101-7-30**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Evaluation for liver transplant
Major Surgical or Invasive Procedure:
Multiple paracenteses
CVVH
Multiple bone marrow biopsies
Multiple blood transfusions
Central line placement
History of Present Illness:
64 yo M with h/o alcoholic and ?HCV cirrhosis transferred from
[**State 792**]Hospital for decompensated liver failure. Pt was
admitted to OSH [**2165-12-26**] for an elective TIPS procedure for
refractory ascites. Pt underwent TIPS on [**2165-12-26**] complicated
by liver laceration and massive hemorrhage requiring
transfusion. He subsequently underwent IR embolization of
superior medial liver segment via the right superior
subsegmental branch (segment 8). Following embolization on [**12-27**]
the pt was transferred to the SICU, and on [**2165-12-28**] pt
underwent TIPS revision by IR using a covered endograft stent
extending the TIPS shunt slightly further into the main portal
vein, excluding part of the left portal vein and right portal
vein branches in an attempt to stop bleeding felt to be
originating at either the extracapsular portion of the shunt or
possibly a right posterior and inferior portal vein branch. Pt's
mental status continued to be poor following TIPS revision, and
lactulose was started for hepatic encephalopathy. He was finally
intubated on [**2166-1-3**] for worsening mental status and hypoxia.
Pt was treated for sepsis with broad spectrum abx and ?PNA, now
only being treated with zosyn. During the last week patient was
been more stable, weaning on his pressors (currently on
vasopress in only) and is being transferred for urgent
transplant evaluation. According to [**Location (un) **] pt had an episode
of seizure activity on transfer, for which he received 2mg of
ativan and this resolved.
Past Medical History:
Past Medical History: EtOH/HCV cirrhosis
.
Past Surgical History:
[**2165-12-26**] TIPS procedure
[**2165-12-27**] IR embolization of subsegmental branch of RHA (segm 8)
[**2165-12-28**] TIPS revision and 4L paracentesis
Social History:
Social History: h/o EtOH abuse (last drink 4 months ago)
Family History:
Family History: Unknown at this point.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
T 95.6 HR 67 BP 99/71 RR 18 SO2 100%/CMV 50% 460x18 PEEP 10
General: Intubated, off sedation. Skin macerated. Ecchymotic
lesions throughout the extremities and flanks.
Neuro: Non-responsive off-sedation. No voluntary movements, does
not respond to pain. Appropriate pupillary, corneal and ME
reflexes.
Lungs: Diminished breath sounds on both bases.
Cardiac: Regular rate and rhythm, S1/S2
Abd: Soft, mod to severe distension (ascites), nontender.
Rectal: Normal tone, no gross blood, guaiac negative
Extrem: Warm, well-perfused, 2+ edema bilaterally.
Pertinent Results:
Admission labs:
[**2166-1-13**] 11:58PM BLOOD WBC-0.7* RBC-3.18* Hgb-9.9* Hct-28.2*
MCV-89 MCH-31.1 MCHC-35.0 RDW-20.6* Plt Ct-33*
[**2166-1-13**] 11:58PM BLOOD Neuts-24* Bands-0 Lymphs-42 Monos-28*
Eos-2 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2166-1-13**] 11:58PM BLOOD PT-33.6* PTT-44.3* INR(PT)-3.4*
[**2166-1-13**] 11:58PM BLOOD Fibrino-114*
[**2166-1-13**] 11:58PM BLOOD Glucose-201* UreaN-137* Creat-6.9* Na-139
K-4.5 Cl-103 HCO3-14* AnGap-27*
[**2166-1-13**] 11:58PM BLOOD ALT-18 AST-22 LD(LDH)-275* AlkPhos-59
Amylase-102* TotBili-6.2*
[**2166-1-13**] 11:58PM BLOOD Lipase-138*
[**2166-1-13**] 11:58PM BLOOD Albumin-3.1* Calcium-8.3* Phos-9.2*
Mg-3.1* Iron-91
[**2166-1-13**] 11:58PM BLOOD calTIBC-91* Hapto-44 Ferritn-[**2104**]*
TRF-70*
Please see attached paperwork with lab trends.
[**2166-1-14**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-
**FINAL REPORT [**2166-1-14**]**
TOXOPLASMA IgG ANTIBODY (Final [**2166-1-14**]):
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
0.0 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
TOXOPLASMA IgM ANTIBODY (Final [**2166-1-14**]):
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
[**2166-1-14**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB-FINAL;
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM
AB-FINAL
**FINAL REPORT [**2166-1-16**]**
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2166-1-16**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2166-1-16**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2166-1-16**]):
NEGATIVE <1:10 BY IFA.
[**2166-1-14**] 11:58 am IMMUNOLOGY **FINAL REPORT [**2166-1-15**]**
HCV VIRAL LOAD (Final [**2166-1-15**]):
HCV-RNA NOT DETECTED.
[**2166-1-14**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM
ANTIBODY-
CMV IgG ANTIBODY (Final [**2166-1-14**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA. 8 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2166-1-14**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
[**2166-1-14**] SEROLOGY/BLOOD VARICELLA-ZOSTER IgG SEROLOGY-
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2166-1-14**]):
POSITIVE BY EIA.
[**2166-1-14**] SEROLOGY/BLOOD Rubella IgG/IgM Antibody-
Rubella IgG/IgM Antibody (Final [**2166-1-14**]):
POSITIVE by Latex Agglutination.
[**2166-1-14**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST
**FINAL REPORT [**2166-1-14**]**
RAPID PLASMA REAGIN TEST (Final [**2166-1-14**]):
NONREACTIVE.
Reference Range: Non-Reactive.
Micro:
[**2166-2-10**] RESPIRATORY CULTURE- YEAST
[**2166-2-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2166-2-9**] Ascitic Fluid Culture - NGTD
[**2166-2-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2166-2-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2166-2-1**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-no
growth; ANAEROBIC CULTURE-no growth
[**2166-2-1**] CATHETER TIP-IV WOUND CULTURE-no growth
[**2166-2-1**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-F{YEAST}
[**2166-2-1**] URINE URINE CULTURE-FINAL
[**2166-1-31**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE- no
growth; ANAEROBIC CULTURE-no growth
[**2166-1-31**] BLOOD CULTURE - no growth
[**2166-1-31**] BLOOD CULTURE - no growth
[**2166-1-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST}
[**2166-1-23**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE- no
growth; ANAEROBIC CULTURE- no growth; FUNGAL CULTURE-no growth;
ACID FAST SMEAR-- no growth; ACID FAST CULTURE-NGTD
[**2166-1-19**] Ascitic fluid cx-no growth
[**2166-1-19**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-no
growth; ANAEROBIC CULTURE-no growth; ACID FAST CULTURE-NGTD;
ACID FAST SMEAR-FINAL
[**2166-1-15**] Mini-BAL GRAM STAIN-FINAL; RESPIRATORY CULTURE-no
growth; POTASSIUM HYDROXIDE PREPARATION-FINAL; FUNGAL
CULTURE-{YEAST}
[**2166-1-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2166-1-14**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-no
growth; ANAEROBIC CULTURE--no growth; FUNGAL CULTURE-no growth
[**2166-1-14**] BLOOD CULTURE -no growth
[**2166-1-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-no
growth
[**2166-1-14**] URINE CULTURE - no growth
[**2166-1-13**] BLOOD CULTURE - no growth
[**2166-1-13**] BLOOD CULTURE - no growth
Imaging:
CXR [**2-10**]:
Some air is now present within the left lung, though a large
left hemothorax is still present with mediastinal shift.
IMPRESSION: Some re-expansion of left lung. Mediastinal shift
persists.
CT torso [**2-7**]:
CT OF THE CHEST: There is a large left pleural effusion,
distributed in
almost entire left hemithorax, leading to right-sided
displacement of
mediastinal structures. The remnant left lung tissue seen
predominantly in
the anterior aspect of the left hemithorax demonstrates diffuse
ground-glass opacities. The left pleural effusion demonstrates
layering of the fluid with dependent area measures 40 Hounsfield
units in attenuation, consistent with hemorrhagic component.
There is moderate right pleural effusion measuring 15 [**Doctor Last Name **] in
attenuation with adjacent areas of compressive atelectasis,
essentially
unchanged from [**2166-1-30**] exam. The visualized portions of
the right
lung demonstrates diffuse opacities which are likely infectious
in etiology. The heart is of normal size without pericardial
effusion. The right and left internal jugular central venous
catheters terminate within the SVC. The endotracheal tube
terminates several centimeters above the carina.
CT OF THE ABDOMEN: There is massive ascites within the abdomen,
unchanged
from [**2166-1-30**] exam. There is hyperdense fluid material in
the most
dependent area within the left upper abdomen measuring 70
Hounsfield units in attenuation suggestive of the hemorrhagic
component. The liver is markedly diminished in size. The surface
morphology appears nodular, consistent with cirrhosis. A TIPS
shunt is in unchanged position. Within limitations of a
non-contrast exam, spleen, adrenal glands, and kidneys appear
unremarkable.
An IVC filter within the infrarenal IVC is noted.
Intra-abdominal aorta is
notable for calcified atherosclerotic disease without aneurysmal
changes.
CT OF THE PELVIS:
A Foley catheter is in place. Large amount of fluid within the
pelvis is
noted. There is no free air. The rectum is displaced posteriorly
and there
is an adjacent area of hyperdense fluid measuring 50 Hounsfield
units in
attenuation, consistent with hemorrhagic fluid.
OSSEOUS STRUCTURES:
No suspicious lytic or sclerotic lesions are seen.
IMPRESSION:
1. Large left pleural effusion with hemorrhagic component with
right-sided
displacement of the mediastinal structures.
2. Moderate right pleural effusion, unchanged from [**2166-1-30**] exam.
3. Visualized portions of the lungs demonstrate diffuse
opacities, likely
infectious in nature.
4. Massive amount of ascites, unchanged from [**2166-1-30**]
exam, however, there are areas of hyperdense fluid within the
left upper abdomen and pelvis with high attenuation, consistent
with hemorrhage.
5. The liver is markedly diminished in size and nodular in
morphology
consistent with cirrhosis. A TIPS shunt is in unchanged
position.
CTA abd/pelvis [**1-30**]:
IMPRESSION:
1. Cirrhosis, splenomegaly, and varices. Changes of
chemoembolization and
TIPS. Resolving hemoperitoneum, without evidence of active
extravasation.
2. Enlarging left and stable moderate right pleural effusions.
3. Bibasilar consolidation, consistent with pneumonia.
4. L2 compression fracture and L1-L3 posterior fixation.
5. Post-pyloric tube placement.
Bone marrow biopsy [**1-27**]:
DIAGNOSIS:
CELLULAR BONE MARROW WITH TRILINEAGE MATURING HEMATOPOIESIS,
INCREASED HISTIOCYTES AND MORPHOLOGIC FEATURES HIGHLY SUGGESTIVE
OF MARROW INJURY. SEE NOTE.
Note: The bone marrow evaluation is significant for evidence of
cellular injury and macrophage infiltration with frequent
hemophagocytic histiocytes in a background of left-shifted
myelopoiesis and reactive plasmacytosis. The findings are
similar to the patient's previous bone marrow biopsy, and the
differential diagnostic considerations for marrow injury include
drugs/medication, toxins, infections, metabolic and immune
causes. The presence of hemophagocytic histiocytes is itself a
non-specific finding and must be interpreted in the appropriate
clinical context. Importantly, neutropenia developed after the
TIPS procedure and in concert with metabolic decompensation.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
Erythrocytes are decreased and exhibit marked anisocytosis with
microcytic and macrocytic forms, and marked poikilocytosis with
numerous echinocytes, acanthocytes, and scattered red cell
fragments and schistocytes. Few forms with coarse basophilic
stippling and Pappenheimer bodies are seen. The white blood
cell count appears markedly decreased. Neutrophils include some
forms with toxic granulation. Rare hemophagocytic histiocytes
are noted. platelet count appears markedly decreased.
differential shows: 5% neutrophils, 0% bands, 26% lymphocytes,
43% monocytes, 25% eosinophils, 1% basophils.
Aspirate Smear:
The aspirate material is adequate for evaluation. It consists of
several cellular spicules. any background histiocytes are
present, some containing ingested debris and several with
ingested marrow precursor cells and erythrocytes
(hemophagocytosis). The M:E ratio is 1.6:1. Erythroid
precursors are normal n number with normoblastic maturation.
myeloid precursors appear normal in number and show left-shifted
maturation. Megakaryocytes are present in decreased numbers.
Based on a 500 cell Differential: 2% Blasts, 31% Promyelocytes,
14% Myelocytes, 2% Metamyelocytes, 3% Bands/Neutrophils, 11%
plasma cells, 2% Lymphocytes, 35% Erythroid.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation, and consists of
trabecular bone with an overall marrow cellularity of 40-50%.
Scattered collections of histiocytes containing ingested debris
and cellular material are present. Plasma cells are abundant
and present singly and in small clusters, comprising
approximately 20% of overall cellularity. Focal marrow fibrosis
is seen. The M:E ratio estimate is normal. Erythroid precursors
are normal in number and have normoblastic maturation. Myeloid
elements are normal in number and exhibit normal maturation.
Megakaryocytes are present in decreased numbers. Marrow clot
section adds no additional information. The findings are very
similar to those seen on a previous bone marrow biopsy
(S10-[**Numeric Identifier **], M10-735).
CT head [**1-14**]:
IMPRESSION: No evidence for an acute intracranial process.
Abd US [**1-14**]:
IMPRESSION:
Nodular cirrhotic liver, TIPS stent in situ, which is patent
with normal flow. The main portal vein is patent with normal
flow. The hepatic veins and hepatic artery patent with normal
flow. Large amount of intra-abdominal ascites.
TTE [**1-14**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60%). The right ventricular cavity is markedly
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. Mild (1+) mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
CT torso [**1-14**]:
IMPRESSION:
1. Large amount of intra-abdominal and intrapelvic free fluid
with Hounsfield units suggesting a combination of ascites and
hemoperitoneum consistent with patient's known ascites and
recent liver laceration.
2. Bilateral patchy airspace consolidations are suggestive of
multifocal
pneumonia. There is also bilateral moderate pleural effusions
with adjacent relaxation atelectasis.
3. Shrunken liver consistent with cirrhosis with hyperdense
material in
segment VII and VIII consistent with recent embolization. TIPS
catheter is
visualized in place from the main portal vein to the inferior
vena cava.
4. L2 compression fracture with L1 through L3 posterior fixation
and
bilateral pedicular screws through L1 and L3.
5. Gastric tube and endotracheal tube tips remain in place.
Brief Hospital Course:
SICU course [**2166-1-13**] - [**2166-2-4**]
Mr. [**Known lastname **] was admitted to the SICU with fulminant liver failure
following a TIPS procedure complicated by a bleed requiring
embolization of segment 8 and revision of his TIPS. On initial
admission, his GCS was 3. He was transferred from [**State 40074**]Hospital intubated and on levophed for blood pressure support.
A full workup for transplant listing was initiated which
included serologies, liver duplex, ECHO, CT Torso, CT head and
placement of a Dobhoff tube postpyloric for feeding. An initial
CT scan of his head was negative for any significant pathology
and it was felt that his current mental status was likely due to
his liver failure. Neurology was consulted for evaluation of
his mental status and during that time he had a tonic-clonic
seizure for which he was loaded and maintained on Keppra. An
initial diagnostic paracentesis of his abdomen excluded
spontaneous bacterial peritonitis and CVVH was initiated for his
acute renal failure after his acute decompensation at [**Hospital 13548**]Hospital. He was intially treated with zosyn at [**Hospital 13548**]Hospital during his decompensation and shortly after the
start of zosyn, he developed neutropenia. His zosyn was
discontinued here, and cefepime was started emprically for his
pneumonia. A BAL culture eventually grew yeast and he was
started on fluconazole for coverage.
Hematology was consulted regarding his neutropenia and a bone
marrow biopsy was performed on [**2166-1-16**] which eventually showed
agranulocytosis, likely acute reaction to acute illness or
medication. He continued to remain neutropenic and
coagulopathic from his liver disease with intermittent need for
trasnfusions. He also remained on CVVH for fluid removal, with
an inability to tolerate HD due to labile blood pressures. His
mental status improved and on [**1-17**], he was arousable and able
to follow commands.
On [**2166-1-21**] he continued to require ventilatory support, but was
awake and following commands. He underwent a therapeutic
paracentesis for 7 liters of ascitic fluid. The cefepime was
discontinued with no positive culture data and levofloxacin was
started for neutropenic prophylaxis. He underwent a second
paracentesis on [**2166-1-24**] for 2.2 liters. He continued to remain
neutropenic with a WBC of 0.7 with the continuation of his
neupogen and he continued to require intermittent CVVH for fluid
removal. Attempts to wean him from ventilatory support failed
and he continued to remain coagulopathic from his liver disease.
A repeat bone marrow biopsy was performed on [**2166-1-27**] and during
this time had a hypotensive episode requiring neosynephrine for
blood pressure support. He was eventually weaned from his
requirement for neosynephrine. The bone marrow biopsy did not
demonstrate any signs of a malignant process and on [**2166-1-28**] his
WBC started to increase (1.4). He remained intubated with an
inability to be weaned, likely secondary to his deconditioned
state. His neutropenia continued to improve with a WBC of 2.7
on [**1-30**] and 5.5 on [**1-31**]. Although he had a normal WBC on [**2166-1-31**],
he remained neutropenic and developed a neutropenic fever to
101.6 that morning with hypotension requiring neosynephrine and
empiric vancomycin, meropenem, and micafungin was started and
later stopped without positive culture data. Multiple cultures
were sent with only positive cultures growing yeast, the last of
which was [**2166-2-1**] from a BAL. He continued to remain
coagulopathic with a need for intermittent blood product
transfusions and on ventilatory support for his deconditioned
respiratory failure. He also remained on neosynephrine without
a clear etiology.
On [**2166-2-4**], it was decided at liver allocation meeting that Mr.
[**Known lastname **] was not a liver transplant candidate. Dr. [**Last Name (STitle) 497**] had an
extensive meeting with the family to notify them that he would
not be listed for liver transplant and his care was transitioned
to the MICU service at this time.
=====================
MICU Course [**Date range (3) 87707**]
# Hypotension: The patient was transferred with continued need
for pressors (neo). Initially was felt hypovolemia as patient
was 3L net negative for LOS. However, hct began to trend down
with an 8 point hct drop over 12 hours on [**2166-2-6**]. CXR and CT
chest revealed hemothorax on left where left HD line had been
placed. Given his tenuous clinical status and his lack of
synthetic function making clotting difficult it was decided not
to evacuate this with a chest tube but instead to support him
with blood products, including platelets and cryo. His hcts did
stabilize, however, he still required pressor support.
Anitbiotics were broadened to Vanc(day [**2166-2-7**] for a planned 7
day course)/aztreonam(day [**2166-2-7**] for a planned 7 day
course)/cipro(day [**2166-2-7**] for a planned 7 day course)/flagyl(day
[**2166-2-7**] for a planned 7 day course)/micafungin(day 1 [**2166-2-1**] for
a planned 14 day course for yeast in the sputum) in the hope of
treating a septic etiology but he continued to be reliant on neo
to keep MAPS>60. At this point it was felt the hypotension may
be secondary to vasodilation in setting of liver failure.
Midodrine was added on [**2-11**] and uptitrated to 5 mg po tid on
[**2-12**] in hopes of weaning him off neo.
# Respiratory Failure: Patient was transferred to the MICU after
having been intubated for >40days. Tracheostomy had been
deferred in SICU [**2-26**] neutropenia, however, on transfer to MICU
patient was no longer neutropenic. Unfortunately, patient did
develop the hemothorax (see above) and continued to require
pressor support so tracheostomy was deferred. Additionally
concerns regarding a trach in the setting of his coagulopathy
prevented pursual of trach placement. He failed daily SBTs and
required assist control ventilation likely due to deconditioning
from his prolonged hospitalization.
# Acute Renal Failure: Thought [**2-26**] hepato-renal syndrome.
Patient was transferred to the MICU on CVVH. In setting of
hypotension CVVH was initially run even and then with hemothorax
around HD line discontinued. His creatinine contineud to trend
up off CVVH ([**2-12**] is 5 days off CVVH). Renal did not feel CVVH
was indicated as he was not a transplant candidate and that he
would be unable to tolerate intermittent HD in the setting of
hypotension requiring neo.
# Cirrhosis/Liver failure: Patient was initially transferred to
[**Hospital1 18**] for workup for liver transplant however was deemed not a
candidate [**2-26**] deconditioned state. Family was interested in
transfer to [**Hospital1 498**] for possible transfer and he was accepted for
transfer on [**2-12**]. During his stay in the MICU he underwent a
therapeutic paracentesis (due to abd pain from increasing
ascites) on [**2-9**] during which 6 L of ascitic fluid was removed.
Of note, he will need cipro weekly for SBP ppx once off broad
spectrum antibiotics.
# Goals of care: Multiple discussions have been held with the
patient's wife (his HCP) regarding his poor prognosis, however
she wishes for further evaluation for liver transplant. She
contact[**Name (NI) **] a transplant surgeon at [**Hospital6 15083**] who
agreed to accept him in transfer for further evaluation for
liver transplantation.
# Code status: Full code.
Medications on Admission:
Meds on transfer: Zosyn 2.25, Octreotide 1000 tid, Chlorhexidine
oral rinse, hydrocortisone 100 tid, ISS, Lactulose 40 [**Hospital1 **],
Reglan
5 tid, Protronix 40 daily, Rifaximin 400 tid, Vasopressin gtt
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for irritation.
5. levetiracetam 100 mg/mL Solution Sig: Five (5) mL PO DAILY
(Daily).
6. phenylephrine HCl 10 mg/mL Solution Sig: 0.5-5 mcg/kg/min
Injection Titrate to SBP >85.
7. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous twice a day.
8. insulin regular human 100 unit/mL Solution Sig: One (1)
sliding scale Injection every six (6) hours: Glucose Insulin
Dose
71-119 mg/dL 0Units
120-159mg/dL 4Units
160-199mg/dL 6Units
200-239mg/dL 8Units
240-279mg/dL10Units
280-319mg/dL12Units
320-359mg/dL14Units
360-399mg/dL16Units
> 400mg/dL Notify M.D.
.
9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation QID (4 times a day).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
secretions.
11. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
12. midodrine 5 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
16. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP)
Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by
Heparin as above daily and PRN.
17. Micafungin 100 mg IV Q24H
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Pantoprazole 40 mg IV Q12H
20. Ascorbic Acid 250 mg IV Q24H
21. Ciprofloxacin 400 mg IV Q24H
22. Aztreonam 1000 mg IV Q24H
23. MetRONIDAZOLE (FLagyl) 500 mg IV Q12H
24. Fentanyl Citrate 25-50 mcg IV Q2H:PRN pain
25. vancomycin 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous dosed by level.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary-
Liver failure
Hypercarbic respiratory failure
Acute kidney injury likely due to hepatorenal syndrome
Hemothorax
Persistent hypotension
Secondary -
Alcoholic cirrhosis
Deconditioning
Discharge Condition:
Mental Status: Confused - always. Does not consistently follow
commands. Is not oriented to place or time.
Level of Consciousness: Alert and interactive sometimes, other
times sleepy but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were transferred to [**Hospital1 18**] from [**Hospital 792**]Hospital on
[**1-13**] for evaluation for liver transplant. You had a prolonged
hospitalization with complications including kidney failure
requiring continuous dialysis, continued respiratory failure
requiring mechanical ventilation, persistent hypotension
requiring medications to elevated your blood pressure, as well
as a bleed into your chest requiring multiple blood
transfusions. After a lengthy evaluation the liver transplant
team did not feel you were a transplant candidate.
The liver transplant team at the [**State 1558**]
agreed to accept you in transfer for further evaluation for
liver transplant.
Medication changes:
Please see the attached medication list.
Followup Instructions:
You are being transferred to the [**Hospital 1558**]
Hospital and will receive further care there.
Completed by:[**2166-2-12**]
|
[
"038.9",
"288.00",
"285.1",
"117.9",
"789.59",
"572.4",
"584.5",
"486",
"995.92",
"518.81",
"286.9",
"284.1",
"263.9",
"276.2",
"785.52",
"571.2",
"780.39",
"511.89",
"070.44"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"33.24",
"38.95",
"34.91",
"96.72",
"96.6",
"54.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
26095, 26110
|
16008, 23451
|
297, 407
|
26346, 26346
|
2971, 2971
|
27368, 27498
|
2324, 2349
|
23707, 26072
|
26131, 26325
|
23477, 23477
|
26599, 27283
|
2060, 2217
|
2364, 2385
|
27303, 27345
|
226, 259
|
435, 1972
|
2987, 15985
|
2399, 2952
|
26361, 26575
|
2016, 2037
|
2249, 2292
|
23495, 23684
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,188
| 158,257
|
38528
|
Discharge summary
|
report
|
Admission Date: [**2196-8-19**] Discharge Date: [**2196-8-21**]
Date of Birth: [**2138-10-15**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
metastatic melanoma
Major Surgical or Invasive Procedure:
Right occipital craniectomy resection of cerebellar mass
History of Present Illness:
HPI:57 y/o M with metastatic melanoma presents today in clinic
s/p MRI head revealing increase in size of R cerebellar lesion.
Patient has received Gamma Knife and cyberknife treatment for
lesions in cerebellar region prior to this. He did present to
BTC
with headaches, but currently has none. He also denies any n/v,
dizziness, gait instability, or blurred vision.
PMHx:metastatic melanoma R parietal scalp lesion s/p resection,
R
cerebellar lesion, R parotid lesion, s/p resection.
All:NKDA
Medications prior to admission:--------------- ---------------
--------------- ---------------
Active Medication list as of [**2196-8-16**]:
Medications - Prescription
LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet(s) by mouth daily
PREDNISONE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 5 mg Tablet - 1 and [**2-1**] Tablet(s) by mouth once a day
total dose 6.5 mg daily.
TESTOSTERONE [ANDROGEL] - (Not Taking as Prescribed) - 1.25
gram
per Actuation (1 %) Gel in Metered-dose Pump - 4 pumps daily
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider; OTC; Dose
adjustment - no new Rx) - 500 mg Tablet - 2 Tablet(s) by mouth
every 4 hours as needed for headaches
--------------- --------------- --------------- ---------------
Social Hx:pilot, 6 beers/week, +tobacco ages 15-20
Family Hx:NC
ROS:as above
Past Medical History:
1. Hypothyroid.
2. Gastroesophageal reflux.
3. Malignant melanoma.
Social History:
Married, four children, owns business in sheet metal parts,
non-smoker, drinks 2-4 beers daily, denies illicit drug use.
Family History:
No malignancy in family.
Physical Exam:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic
Pupils: 3-2mm bilaterally EOMs: intact
Neck: Supple.
Lungs: no audible wheezing.
Cardiac: RRR
Abd: Soft, NT
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-31**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-2**] throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
PHYSICAL EXAM UPON DISCHARGE:
non-focal
Pertinent Results:
[**8-19**] CT-Head: IMPRESSION:
1. Status post suboccipital craniotomy for mass resection with
expected
post-surgical appearance.
2. Right cerebellar edema with possible small amount of blood in
the
resection site, though this could be artifactual given typical
artifacts in the posterior fossa.
3. Hypodensity in the right subinsular region corresponding to
known
metastatic lesion.
[**8-20**] MRI Brain:
CONCLUSION: Status post right suboccipital craniectomy with
expected
postoperative changes and continuing posterior fossa mass
effect. Multiple
other brain metastases appear unchanged.
Brief Hospital Course:
Patient was admitted to Neurosurgery on [**8-19**] and underwent the
above stated procedure. He was extubated without incident and
transferred to the ICU for further mangement post op Head Ct
showed no hemorrhage, post operative changes. He remained stable
overnight, complaining only of nausea.
On 7.23 an Brain MRI was obtained which revealed good resection.
He was cleared for transfer to the floor. PT/OT were consulted
for assistance with discharge planning.
On [**8-21**] he was again neurologically stable. Nausea has resolved
and he was tolerating PO. Foley was discontinued and decadron
was tapered oever 5 days to 2mg [**Hospital1 **]. PT cleared the patient for
discharge.
Medications on Admission:
levothyroxine, prednisone, androgel
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper: 4mg PO
Q8hrs on [**8-21**], 3mg PO Q8hrs on [**8-22**],2mg PO Q8hrs on [**8-23**],2mg PO
Q12hrs [**8-24**] & til f/u.
Disp:*80 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right suboccipital brain lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
Followup Instructions:
Follow-Up Appointment Instructions
??????You need an appointment in the Brain [**Hospital 341**] Clinic on in [**1-31**]
weeks. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. They will contact you regarding date and time of
your appt. Please call if you need to change your appointment,
or require additional directions.
Completed by:[**2196-8-21**]
|
[
"V58.65",
"V10.82",
"348.5",
"244.9",
"197.0",
"530.81",
"197.7",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.06"
] |
icd9pcs
|
[
[
[]
]
] |
5498, 5504
|
3951, 4638
|
330, 388
|
5580, 5580
|
3334, 3928
|
7081, 7613
|
2000, 2026
|
4725, 5475
|
5525, 5559
|
4664, 4702
|
5731, 7058
|
2056, 2269
|
944, 1751
|
270, 292
|
3303, 3315
|
416, 913
|
2562, 3273
|
5595, 5707
|
1773, 1845
|
1861, 1984
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,148
| 166,799
|
5675
|
Discharge summary
|
report
|
Admission Date: [**2108-11-21**] Discharge Date: [**2108-11-25**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]M w/ h/o CHF, CAD s/p NSTEMI, Afib on dabigatran, brought in
by his son due to confusion lethargy and markedly slurred speech
for approximately one week. At baseline, he has clear speech, is
oriented, and can walk independently for very short distances.
Per the patient's son, the patient has had no specific
complaints, however for the last week and a half he has had
slurred speech and dizziness. He was recently changed from
Plavix to dabigatran. [**2108-10-30**] he was seen in the ED for hypoxia
and discharged on an increased dose of Lasix 120mg daily.
[**2108-11-19**] his son called his cardiologist's office with a
complaint of dizziness. The next day he was noted to be
hypotensive with a pressure 70/60. His lasix was held, but he
continued to have symptoms. This morning, his son held all his
medications except for ASA 81 and dabigatran. He has had a
couple of mild episodes of epistaxis. He continued to have
slurred speech and hypotension, so he was brought in to the ED.
.
In the ED, initial vs were: 86.9 50 120/48 18, on a
Non-Rebreather. Noted to have an intact neuro exam except for
incomprehensible speech. Started on bair hugger and given warmed
fluids. Found to have guaiac positive brown stool. SBPs down to
the 70s, so a R IJ was placed. Head CT negative. CXR showed
chronic R sided effusion. Soon after 98% on RA. Patient was
given vanc, zosyn and 3L IV fluids. He was given 1 unit PRBC's.
lactate 2.0.
.
On the floor, patient is coherent, though his speech remains
slurred. He denies pain and is unable to provide further ROS.
Past Medical History:
- CAD s/p NSTEMI in [**6-/2107**], [**7-/2107**], and [**11/2107**] treated
medically
- CHF EF 25% to 30% on [**6-/2107**] TTE
- Aortic stenosis (valve area 0.8cm2, peak gradient 38, mean
gradient 24 in [**6-/2107**] TTE)
- Hypertension
- Chronic kidney failure (baseline Cr 1.7-2.0)
Social History:
The patient lives with his wife of 72 years and his son. [**Name (NI) **] has
a visiting nurse come once per week and nurses aid several times
per week. He is able to walk up the stairs by himself, but his
son always walks with him.
-Tobacco history: Denies
-ETOH: Drinks occasional EtOH at temple services.
-Illicit drugs: No drugs.
Family History:
There is no family history of premature coronary artery disease
or sudden death
Physical Exam:
General: Alert, oriented to self and month, but not place
HEENT: Sclera anicteric, R pupil reactive, dry mucous membranes,
oropharynx clear
Neck: supple, JVP just above the clavicle, no LAD
Lungs: Clear to auscultation anteriorly, diminished at right
base.
CV: Regular rate, distant, faint, harsh systolic
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 1+ pulses, mild LE edema bilaterally
Neuro: A&Ox1.5, CNII-XII intact except for left eye and
dysarthric speech, sensation and strength grossly intact in all
extremities
Pertinent Results:
[**2108-11-21**] 03:30PM BLOOD WBC-5.4 RBC-3.14* Hgb-8.6* Hct-27.7*
MCV-88 MCH-27.5 MCHC-31.1 RDW-15.6* Plt Ct-130*#
[**2108-11-21**] 03:30PM BLOOD PT-35.7* PTT-120.3* INR(PT)-3.6*
[**2108-11-21**] 03:30PM BLOOD Glucose-209* UreaN-76* Creat-2.3* Na-137
K-5.1 Cl-98 HCO3-30 AnGap-14
[**2108-11-21**] 03:30PM BLOOD ALT-25 AST-36 CK(CPK)-29* AlkPhos-60
TotBili-0.3
[**2108-11-21**] 03:30PM BLOOD cTropnT-0.03*
[**2108-11-21**] 03:30PM BLOOD Calcium-9.1 Phos-4.9* Mg-2.5
ECHO
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is severe regional left ventricular systolic
dysfunction with anteroseptal/anterior hypokinesis/akinesis with
apical akinesis/dyskinesis. Right ventricular chamber size and
free wall motion are normal. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] The aortic root is mildly dilated at
the sinus level. The aortic valve leaflets are severely
thickened/deformed. There is aortic valve stenosis which is
probably severe (valve area 0.8-1.0cm2) but the gradient is low;
since left ventricular systolic function is severely depressed
is possible that the aortic valve area would be larger with a
higher stroke volume. Trace aortic regurgitation is seen.
Trivial mitral regurgitation is seen. Mild to moderate ([**1-8**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.
Brief Hospital Course:
[**Age over 90 **]M w/ h/o CHF, CAD, Afib on dabigatran, brought by his son due
to confusion lethargy and markedly slurred speech for
approximately one week. He was found to have a pneumonia and was
treated with antibiotics. He also had an anemia, likely
secondary to GI blood loss secondary to decreased clearance of
dabigaran in the setting of renal impairment. Despite
antibiotics, he worsened and the decision was made to transition
to comfort-oriented care. He passed away comfortably at 11:05 pm
on [**11-24**].
Medications on Admission:
- dabigatran 75mg [**Hospital1 **]
- furosemide 120mg daily (being held)
- isosorbide mononitrate 30mg daily
- lidocaine 5% patch daily
- metoprolol 50mg daily
- nitroglycerin 0.4mg SL tabs PRN
- polyethylene glycol 17gm/dose PRN
- simvastatin 40mg QHS
- aspirin 81mg daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
pneumonia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
none
|
[
"486",
"414.00",
"578.9",
"428.0",
"280.0",
"276.52",
"785.52",
"403.90",
"599.0",
"287.5",
"276.7",
"272.0",
"585.9",
"410.71",
"785.50",
"428.22",
"412",
"424.1",
"286.9",
"038.9",
"780.65",
"276.0",
"427.31",
"584.9",
"995.92",
"E934.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5964, 5973
|
5092, 5611
|
263, 270
|
6027, 6037
|
3296, 5069
|
6093, 6101
|
2550, 2631
|
5935, 5941
|
5994, 6006
|
5637, 5912
|
6061, 6070
|
2646, 3277
|
214, 225
|
299, 1874
|
1896, 2182
|
2198, 2534
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,993
| 169,806
|
11142+11143+56211
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2143-10-28**] Discharge Date: [**2143-11-4**]
Date of Birth: [**2090-7-31**] Sex: F
Service: CT Surgery
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: The patient is a 53 year old
female with a past medical history significant for a mitral
valve replacement. She presented to the her primary care
physician for ankle edema. Ultimately, she was referred to
Dr. [**Last Name (STitle) **] and an echocardiogram was performed as well as a
magnetic resonance imaging scan, done at an outside hospital.
The results from those studies revealed that patient, in
fact, had a mitral valve prolapse but also had an incidental
finding of an ascending aortic aneurysm. She was therefore
referred to Dr. [**Last Name (Prefixes) **] for definitive care and Bental
procedure.
PAST MEDICAL HISTORY: 1. Mitral valve prolapse since her
20s. 2. Rheumatoid arthritis. 3. Lower extremity edema
times two months. 4. Hypothyroidism. 5. High porphin
levels in blood, undergoes phlebotomy every six months.
PAST SURGICAL HISTORY: 1. Partial hysterectomy in [**2129**]. 2.
Left axillary lymph node removal in [**2139**]. 3. Right lymphoma
excision from the right arm in [**2131**].
MEDICATIONS ON ADMISSION: Levoxyl 88 mcg p.o.q.d., Naproxen
500 mg p.o.b.i.d., Azulfidine 500 mg p.o.b.i.d., folic acid 1
mg p.o.q.d., Lasix 20 mg p.o.q.d., Klor-con 10 mg p.o.q.d.
and Climera patch 0.05 mcg q. week.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Family history is significant for the
patient's aunt dying at age 80 of coronary artery disease.
Another aunt, aged 78, is still alive, however, also
suffering from coronary artery disease.
SOCIAL HISTORY: The patient has drunk approximately 15
glasses of vodka per week for the last 20 to 30 years as well
as having a 40+ pack year smoking history, quit approximately
two years prior to admission.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2143-10-28**] and underwent a Bental procedure with
homograft. Once the patient was closed and on the Operating
Room, she was noted to go into a ventricular
tachycardia/ventricular fibrillation arrest and was
subsequently emergently reopened on the operating table. At
this time it was seen that the reimplanted right coronary
artery had been occluded. Therefore, she underwent an
emergent saphenous vein graft harvest from the right lower
extremity for emergent coronary artery bypass grafting from
the homograft site to the distal right coronary system.
Postoperatively, the patient remained intubated and was care
for in the CSRU. Her postoperative laboratory data were
significant for a hematocrit of 33, down from a baseline of
40 taken on [**2143-10-10**]. Additionally, her BUN and
creatinine were 16 and 0.7, baseline 21 and 0.9 from [**2143-10-10**]. She had a lactate of 2.7. Liver function tests
were within normal limits. She remained intubated and
sedated. They attempted to wean her dobutamine on
postoperative day number one as well as attempting to
discontinue her Lidocaine drip.
Once she was extubated, the patient was started on aspirin,
Lopressor and Lasix as well as having her diet advanced to a
cardiac diet. She resumed her daily Lasix. By postoperative
day number two, her Lidocaine was completely weaned. She was
taking oral supplements, eating a cardiac diet without
difficulty. Her blood pressure was stable, in the 110s to
120s systolic. She was in normal sinus rhythm
postoperatively with rates in the 70s. She therefore had her
Swan-Ganz catheter removed and was deemed appropriate for
discharge to the floor.
The patient was continued on Ancef during the perioperative
period for groin drainage from the right and left groin
sites. She had been maintained on an intra-aortic balloon
pump postoperatively and the wound where they had inserted
the balloon pump did have a serous effluent, thought possibly
secondary to a lymphatic leak. Additionally, there was clear
effluence seen at the right saphenous vein graft harvest
site.
By postoperative day number three, the patient was stable on
the floor. She was receiving aggressive pulmonary toilette.
She was ambulating at a level two to three. Her chest tubes
were removed and her laboratory data at that time showed a
hematocrit of 27, that was stable from the previous day of
27. Her potassium was 3.8, which was repleted. Her BUN and
creatinine were 21 and 0.8, magnesium 1.7 and the remainder
of electrolytes were within normal limits.
After repleting electrolytes as needed and receiving
aggressive physical therapy and rehabilitation screening, and
pulmonary toilette from the respiratory therapists, the
patient's clinical course steadily improved. She did
subjectively complain of continued shortness of breath and,
as a consequence, she was worked up for this. A chest x-ray
on postoperative day number revealed bilateral pleural
effusions, left greater than right, with left lower lobe
collapse, thought to be secondary to atelectasis. Given
this, she was continued on aggressive diuresis with Lasix and
given incentive spirometry, coughing and deep breathing
training as well as ambulation three times a day to four
times a day, with maximum distances of 400 to 500 feet per
trip.
By postoperative day number five, the patient's respiratory
status was steadily improving. She was without chest tubes.
Her wires had already been removed. She was urinating on her
own and tolerating a cardiac diet. By this point, she had
reached a level four activity level.
By postoperative day number seven, the patient was deemed
stable and appropriate for discharge. The patient was
reluctant to leave and, as a consequence, we allowed her to
stay an additional 24 hours for continued physical therapy
and pulmonary toilette.
By postoperative day number eight, patient's was off of her
Ancef and was started on oral Keflex for some erythema around
the staple sites at the inferior margin of her sternum.
The patient's discharge examination is significant for a
temperature of 99, blood pressure 99/60, pulse 86 and
regular, respiratory rate 20 and oxygen saturation 94% in
room air. She was in no acute distress. Her sternum was
stable, there was no exudate. She did have some
peri-incisional erythema, that was noncellulitic in nature,
around the staple insertion sites at the inferior margin of
the wound. Her heart was regular without murmur. Her lungs
were clear, with decreased breath sounds at the left base
with occasional inspiratory crackle. Her abdomen was
unremarkable. Her lower extremities were warm and well
perfused without evidence of edema. She had palpable
dorsalis pedis and posterior tibialis pulses bilaterally.
Discharge laboratory data were remarkable only for a
hematocrit of 27, which was stable from [**2143-11-2**], as
well as electrolytes that were within normal limits and a
creatinine of 0.9.
DISCHARGE MEDICATIONS:
Levoxyl 88 mcg p.o.q.d.
Azulfidine 500 mg p.o.b.i.d.
Folic acid 1 mg p.o.q.d.
Lasix 20 mg p.o.q.a.m.
Climera patch 0.05 mcg q. week.
Percocet 5/325 one to two tablets p.o.q.4-6h.p.r.n.
Colace 100 mg p.o.b.i.d. while on Percocet.
K-Dur 20 mEq p.o.q.d. to be taken with Lasix.
Lopressor 25 mg p.o.b.i.d.
Aspirin 325 mg p.o.q.d.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
Ascending aortic aneurysm, status post Bental procedure with
homograph, followed by saphenous vein graft coronary artery
bypass grafting from the homograft to the right coronary
artery secondary to postoperative ventricular
tachycardia/ventricular fibrillation arrest; patient is
currently stable.
DI[**Last Name (STitle) **]ION/FOLLOW-UP: The patient will be discharged to
home with home VNA services for blood pressure monitoring,
heart rate monitoring as well as wound check. She will have
her wound checked in one week in the outpatient clinic at
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] with cardiac surgery
physician assistant, as well as seeing Dr. [**Last Name (Prefixes) **] in one
month from the time of discharge. She will see her
cardiologist in two to four weeks from the time of discharge
to have her medications titrated appropriately.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2143-11-4**] 13:42
T: [**2143-11-4**] 13:41
JOB#: [**Job Number **]
Admission Date: [**2143-10-28**] Discharge Date: [**2143-11-8**]
Date of Birth: [**2090-7-31**] Sex: F
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: This patient had lower extremity
swelling for two months prior to coming in for preadmission
testing.
PAST MEDICAL HISTORY:
1. Mitral valve prolapse.
2. Rheumatoid arthritis of ankles.
3. Lower extremity edema times two months.
4. Question hypothyroidism.
5. Status post hysterectomy [**2129**].
6. Status post left axillary lymph node removal in [**2139**].
7. Status post right lymphoma excision, right arm, [**2131**].
8. High porphyrin level for which patient undergoes
phlebotomy every six months; [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35902**] is the
Hematologist.
MEDICATIONS PRIOR TO ADMISSION:
1. Levoxyl 88 micrograms q. day.
2. Naproxen 500 mg p.o. twice a day.
3. Azulfidine 500 mg p.o. twice a day.
4. Folic acid 1 mg p.o. q. day.
5. Lasix 20 mg p.o. q. day.
6. Klor-Con 10 mg p.o. q. day.
7. Climara 0.05 patch q. week.
ALLERGIES: She had no known drug allergies.
PHYSICAL EXAMINATION: On her examination a couple of weeks
prior to admission, she was alert and oriented. Extraocular
muscles are intact. Her pupils are equally responsive and
reactive to light and accommodation. Her neck was supple;
she had no jugular venous distention. No lymphadenopathy or
thyromegaly and no carotid bruits. She had decreased breath
sounds slightly on the right side, but her lungs were clear
bilaterally and without any wheezing. Heart was a regular
rate and rhythm; she has an S1, S2, and she had a Grade
III/IV systolic murmur heard best at the right sternal border
and left sternal border which radiated to the second ICS.
Her abdominal examination was benign. She had bilateral
varicosities. Her neurologic examination was grossly intact
with normal motor and sensory function. She had good distal
pulses.
LABORATORY: Prior to admission, her catheterization showed
normal coronaries with two plus mitral regurgitation and an
ejection fraction of 60% as well as ascending aortic
aneurysm, which had been found incidentally, preoperatively,
on TTE.
Preoperative labs were sodium 139, potassium 3.7, chloride
99, CO2 22, BUN 21, creatinine 0.8, hematocrit 40.3, platelet
count 244,000, and a white count of 8.4.
Additional laboratory work showed a blood sugar of 156, ALT
of 13 and LDH of 243. PT 12.1, PTT 29.3 and INR of 1.0.
Preoperative chest x-ray showed no evidence of a pneumonia or
heart failure.
HO[**Last Name (STitle) **] COURSE: On [**10-28**], the patient underwent a
Bentall procedure with aortic homograft as well as aortic
Dacron graft and a coronary artery bypass grafting times one
with a vein graft to the right coronary artery by Dr. [**Last Name (Prefixes) 411**]. The patient was transferred to the Cardiothoracic
Intensive Care Unit in stable condition.
On postoperative day one, the patient did have an episode of
ventricular tachycardia in the Operating Room the prior
evening. The patient was on Cefazolin, Amiodarone at 1.0,
Dobutamine at 3, Lidocaine at 2, Propofol at 30, Aprotinin
drip as well as Sucralfate and Zantac. Postoperative
hematocrit was 33, potassium 4.8, BUN 16, creatinine 0.7,
with a blood sugar of 239, lactate 2.7, calcium 1.11,
alkaline phosphatase 24, ALT 24, AST 103, and a total
bilirubin of 0.6. The patient remained intubated at that
time with plans to wean to extubate and have the Propofol
turned down as the patient was being sedated. Lungs were
clear bilaterally. Incisions were clean, dry and intact.
Abdomen was slightly distended. Amylase was ordered to be
checked and the patient continued on perioperative
antibiotics.
The patient was seen by Physical Therapy and Case Management
reviewed the chart.
On postoperative day two, the patient was off pressors and
remained on Lidocaine at 1 and continued perioperative
antibiotics. The patient had some wheezes. Heart was
regular in rate and rhythm; it was in the 70s in sinus rhythm
with a good blood pressure of 111/52. Abdominal examination
was benign. White count 9.0, hematocrit 27.8, platelet count
114,000, sodium 137, potassium 5.5, chloride 104, CO2 26, BUN
20, creatinine 0.8; a CK of 961. Magnesium 1.8. Calcium was
low and this to be repleted. Neurologic examination was
negative. The patient was receiving Lidocaine which was
discontinued so that the patient could start Lasix diuresis
and have Lopressor and aspirin, and the Swan was to be
discontinued as well as restarting the thyroid medications.
The patient was followed by Physical Therapy and was
transferred out to the Floor.
On postoperative day three, the patient had some complaints
of shortness of breath in the sub-xiphoid area, had a
temperature maximum of 99.2 F., was maintaining good blood
pressure and saturating 94% on four liters. Chest tubes
remained in place for an increased output since midnight the
day prior. The patient had bibasilar crackles with some poor
respiratory excursion. Heart was regular in rate and rhythm;
no murmur, no jugular venous distention. Abdominal
examination was negative. Extremities had no edema. Chest
x-ray showed no congestive heart failure, but had stable
effusions bilaterally. EKG showed normal sinus rhythm with
no ST or T wave changes or ischemia. The patient continued
with aggressive pulmonary toilet, was out of bed. Chest
tubes were discontinued, labs were rechecked and discharge
planning was begun.
On postoperative day four, the patient still had occasional
shortness of breath and received some nebulizers. The
patient was ambulatory, was hemodynamically stable,
saturating 97% on three liters with a blood pressure of
107/65 in sinus rhythm. There were decreased breath sounds
bilaterally with occasional crackles, and no edema
peripherally. The patient continued with ambulation and
pulmonary toilet, and was seen again by Respiratory Care as
well as Case Management.
On postoperative day five, the patient was feeling improved
with decreased shortness of breath and pain under control.
The patient was hemodynamically stable. Still had
bilaterally occasional crackles but the sternum was stable.
Heart was regular in rate and rhythm. The patient continued
with ambulation and chest Physical Therapy with plans for
discharge the day after if possible.
On the night of the 9th, the patient was found on the floor
of the bathroom at approximately midnight in a kneeling
position. She slipped on some urine in the bathroom. She
denied hitting her head or pain or discomfort from her fall.
At the time, her vital signs were 114/62; heart rate of 93;
respiratory rate of 18; a temperature maximum of 98.9 F.; she
was saturating 95% on two liters. She was assisted back to
bed. The covering physician was made aware.
On postoperative day seven, the patient had no complaints;
her shortness of breath was improved. The patient was
hemodynamically stable. Heart rate in sinus in the 80s. Her
blood pressure 99/60. The patient had some new inferior
wound erythema at the staples on the sternal incision with no
drainage. The sternum is stable. Heart was regular rate and
rhythm. Extremities had no cyanosis, clubbing or edema. The
patient continued to improve and was ambulating and having
pulmonary toilet. The patient continued also to receive
nebulizer for part of that pulmonary regimen.
Th[**Last Name (STitle) 1050**] complained of some vision changes on the 10th.
She had some complaints to nursing about the way "her eyes
were working". A routine EEG was performed and Neurology
consultation was obtained on the 10th. The patient was
complaining of blurry vision which had been getting a little
bit worse and Neurology made some recommendations, and an MRI
study was ordered. The attending Neurologist noted that this
was possibly an old lesion in mid-brain or thalamus and it
may be related to stroke, but was too small to be seen on
MRI. The MRI report is on record. Please note the final
report. They did tell the patient that she had a good
prognosis with excellent recovery to be expected, but the
final report of the MRI was not available at that moment for
the neurologist. Dr. [**Last Name (Prefixes) **] signed off to make sure that
everyone understood that it was okay for the patient to have
an MRI.
The patient did have occasional tachy dysrhythmias over 36
hours with scant drainage from the inferior margin of her
sternum with mild erythema around her staples but her sternum
was stable. Her white count was 10, hematocrit 32. The
patient did have an episode of atrial fibrillation.
Otherwise, the patient felt okay. She felt that her vision
is somewhat improved. Sodium was 136, potassium 4.1,
hematocrit 32, platelet count 383,000. Chloride 98, CO2 28,
BUN 14, creatinine 0.9 with a blood sugar of 120. Heart was
regular in rate and rhythm. Her lungs were clear
bilaterally. Her extremities were negative.
At this point there was a question whether or not this was a
posterior circulation cerebrovascular accident. Labs were
reasonable and the plan was to let the patient discharge to
home soon, as soon as Physical Therapy felt the patient was
safe to ambulate at home.
Final report of the MRI was being awaited.
The patient, on the 14th, said that she would like to see the
Neuro-ophthalmologist. Vital signs were stable. Inferior
aspect had some erythema with very scant yellow exudate.
Right thigh incision was okay. Left groin incision had some
mild erythema with no exudate. Sternum was stable with
staples in place. Again, the patient did continue to have a
postoperative supra-nuclear upward gaze, question of a palsy,
but this was not seen definitively on the MRI/MRA.
The patient was seen by Neuro-Ophthalmology on the 14th prior
to discharge, who noted that this palsy was most likely
reflective of a pontine hypoperfusion injury secondary to
this difficult surgical procedure that she had. Please refer
to the final report of the MRI, and Dr. [**First Name (STitle) 2523**],
Neuro-Ophthalmology, recommended that the patient be seen in
the Eye Clinic for more detailed evaluation the following
week, and the patient was discharged to home on [**2143-11-8**], with services provided by the [**Hospital1 1474**] [**Hospital6 1587**].
DI[**Last Name (STitle) 408**]E INSTRUCTIONS:
1. The patient had instructions to see Dr. [**Last Name (Prefixes) **]
within 30 days.
2. To see the Neuro-Ophthalmologist, Dr. [**First Name (STitle) 2523**] at [**Hospital1 1444**] in one week.
3. As well, follow-up with her primary care physician.
DISCHARGE DIAGNOSES:
1. Status post Bentall procedure with homograft with
coronary artery bypass grafting times one.
2. Status post mitral valve prolapse.
3. Rheumatoid arthritis, fingers.
4. Hypothyroidism.
5. Porphyria with q. six months phlebotomy.
6. Status post abnormal ocular gaze with a question of
pontine injury; final results on MRI.
DISCHARGE MEDICATIONS:
1. Dilaudid 2 mg q. four hours p.r.n.
2. Compazine 10 mg p.o. q. eight hours p.r.n.
3. Combivent Multi-Dose Inhaler two puffs p.r.n. q. four
hours.
4. Xanax 0.25 mg p.o. p.r.n. q. 12 hours.
5. K-Dur 20 mEq p.o. q. day times seven days.
6. Lasix 20 mg p.o. q. day times seven days.
7. Climara Patch 0.05 mg q. Wednesdays.
8. Keflex 500 mg p.o. four times a day times two weeks.
9. Colace 100 mg p.o. twice a day.
10. Amiodarone 400 mg p.o. three times a day times one week.
11. Amiodarone 400 mg p.o. twice a day times the following
week.
12. Amiodarone 400 mg p.o. q. day times the final two weeks,
and then discontinue Amiodarone.
13. Aspirin 325 mg p.o. q. day.
14. Folic acid 1 mg p.o. q. day.
15. Azulfidine 500 mg p.o. twice a day.
16. Levoxyl 88 micrograms p.o. q. day; please note that this
is 88 micrograms.
17. Lopressor 50 mg p.o. twice a day.
The patient was also given instructions to leave the staples
intact and to return to [**Hospital 409**] Clinic in one week, on F-6 as
well as the other postoperative proscribed visits recommended
in the prior paragraph.
DISPOSITION: The patient was discharged to home on [**2143-11-8**].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2143-12-31**] 11:01
T: [**2144-1-2**] 14:06
JOB#: [**Job Number 27714**]
Name: [**Known lastname 6397**], [**Known firstname **] Unit No: [**Numeric Identifier 6398**]
Admission Date: [**2143-10-28**] Discharge Date:
Date of Birth: [**2090-7-31**] Sex: F
Service:
ADDENDUM: The patient was admitted on [**2143-10-28**] for aortic
root repair and underwent a Bentall procedure followed by an
emergent coronary artery bypass grafting secondary to
intraoperative arrest including saphenous vein graft in the
right lower extremity. This was anastomosed from the proximal
aorta to the right coronary artery.
The postoperative course of the patient was relatively
unremarkable until postoperative day seven which correlates
with [**2143-11-4**] where she began to experience complaints of
visual complaints, visual difficulty. She stated that she
had inability to focus on objects and felt very "unsteady" on
her feet. As a consequence the patient was evaluated in
suspicion for a possible stroke or other neurologic
catastrophe was suspected. She underwent a stat,
non-contrast CT scan of the head on [**2143-11-4**] that
ultimately revealed no evidence of parenchyma hemorrhage, no
axial blood, no midline shift. Given the persistent nature of
the visual deficit and the severity of it impairing her
ability to walk without assistance, neurology consultation
was immediately obtained.
The initial evaluation by the neurology staff here felt that
the patient may have suffered some type of subthalamic or sub
midbrain lesion perhaps a medial longitudinal fascicular
lesion that would explain the neurologic deficits which were
she had the inability to perform saccadic movements, scanning
movements were however intact. She had difficulty with
vertical gaze and given the nature of the supra nuclear
vertical gazed palsy and the inability to converge the lesion
was therefore presumed to be localized at either a lower mid
brain or thalamic region. Ultimately an MRI / MRA was
recommended.
First an EEG was performed to rule out any possible disease
that might be contributing to this. This ultimately was done
on [**2143-11-5**] which is postoperative day eight. This was
negative. There was no seizure activity demonstrated and this
was read as a normal study.
On[**2143-11-6**] she underwent an echocardiogram of the heart to
rule out any possible thrombus or abnormality in the graft
that might explain an embolic phenomena that could explain
the neurologic deficit. This ultimately showed an enlarged
left atrium in the LV wall was thickened and the cavity was
noted to be normal in size. There was mildly decreased left
ventricular function with an EF of 45 to 55%. The initial
[**Location (un) **] on the echocardiogram by staff cardiologist was that
there was evidence of left to right shunt at the top of the
intraventricular septum between the left ventricular outflow
tract and the right ventricular consistent with a ventricular
septal defect. However further review by the attending
physician, [**Last Name (NamePattern4) **]. [**Last Name (Prefixes) **] he felt that this might just be an
abnormal jet that has picked up after the patient received
the Bentall procedure and not something related to an
intraoperative error in technique. Addition
echocardiographic findings were of a moderately thickened
mitral valve leaflets, and moderate 2+ MR, mild pulmonary
artery systolic hypertension. The remainder of the study is
unremarkable. No thrombus was identified. However this was a
transthoracic echocardiogram and not a transesophageal echo.
On [**2143-11-6**] the patient underwent an MRI MRA. The MRI of
the brain revealed no acute territorial infarctions seen on
diffusion weighted images. There was no midline shift, no
masses or hemorrhage that was seen. There is evidence of
increased of T2 signal intensity in the brain stem at the
level of the lower pons probably secondary to ischemia.
However on diffusion weighted images there was no restriction
in flow. The likelihood of an acute ischemic event in the
setting of no restricted diffusion flow on diffusion weighted
image is less likely, however still possible. Additional
findings of MRI of the brain were scattered foci with
increased T2 signal intensity in the paraventricular white
matter and centrum semiovale. This was thought to be possibly
secondary to chronic ischemic, microvascular disease or
demyelinating disease such as multiple sclerosis and the
clinical correlation was suggested.
MRA of the head and neck was also performed which showed no
hemodynamically significant stenoses in the internal or
external carotids. The bifurcation of the carotids were
intact with no evidence of dissection. There was anterior
growth grade flow in the vertebral arteries. MRA of the
intracranial vessels showed patent vertebral arteries with a
left dominant system. No intracranial occlusive disease was
seen. Subsequently with all of these findings the staff
neurologist felt that the patient's deficits may be secondary
to an upper mid brain lesion or something in the thalamus. It
is most likely a small stroke but it is not being seen on the
MRI. The fact that the image does not show up on the MRI
apparently is a harbinger of a good prognosis and excellent
recovery. She is scheduled for follow up with Dr. [**First Name (STitle) 2557**] at
the [**Hospital1 **] who is a neuro ophthalmologist for
ultimate evaluation. She was deemed stable for discharge by
the neurology service by postoperative day 11, [**2143-11-8**].
The patient was ultimately discharged to home.
DISCHARGE MEDICATIONS:
1. Dilaudid 2 to 4 milligrams po q four hours prn.
2. Compazine 10 milligrams po eight hours prn.
3. Combivent MDI two puffs two four prn.
4. Xanax 0.25 milligrams po bid prn.
5. K-Dur 20 milliequivalents po q day times seven days.
6. Lasix 20 milligrams po q day times seven day.
7. Climara patch 0.05 milligrams to skin q week each
Wednesday.
8. Keflex 500 milligrams po q day times two weeks for the
mild incisional erythema at the inferior aspect of the
external wound as well as the left groin wound.
9. Colace 100 milligrams tablets po bid.
10. Amiodarone 400 milligrams po tid times one week, 400
milligrams po bid times another week and 400 milligrams po q
day times two weeks and then to stop after one month of
therapy.
11. Aspirin 325 mg po q day.
12. Folic acid 1 milligram po q day.
13. Azulfidine 500 milligrams po bid.
14. Levoxyl 88 micrograms po q day.
15. Lopressor 50 milligrams po bid.
[**Last Name (STitle) 6399**]tments and frequency include instructions for no
heavy lifting greater than 10 lbs. times 30 days, no driving
times 30 days. She may shower. Staples should stay intact.
She will return for a wound check one week from time of
discharge here in the Wound Care Clinic on the sixth floor,
[**Hospital Ward Name **] Building on the [**Hospital1 536**]
that is staffed by the cardiovascular physician [**Name Initial (PRE) 6400**].
Additionally she will have home monitoring, blood pressure
checks and neuro visual evaluation with wound care checks
with visiting nurse assistant. She will have follow up Dr. [**Last Name (Prefixes) 1815**] in 30 days from time of discharge. She will see Dr.
[**First Name (STitle) 2557**] at the [**Hospital1 536**] in
approximately one week from time of discharge.
DISCHARGE STATUS: Home.
CONDITION ON DISCHARGE: Stable. Neurologically still
exhibiting a vertical gaze palsy as well as inability to
converge and left lateral gaze preference and difficulty with
depth perception. Otherwise her neurologic exam is
completely normal.
DIAGNOSIS:
1. Status post Bentall procedure aortic root repair with
homograft insertion followed by intraop cardiac arrest
requiring emergent coronary artery bypass graft times one,
right saphenous vein graft to the right coronary artery was
utilized.
2. Postoperative atrial fibrillation.
3. Postoperative possible ischemic/CVA to the mid brain or
thalamic nuclei with visual deficit.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Last Name (NamePattern4) 935**]
MEDQUIST36
D: [**2143-11-8**] 13:21
T: [**2143-11-8**] 13:25
JOB#: [**Job Number 6401**]
|
[
"997.1",
"424.0",
"518.0",
"427.5",
"997.02",
"997.3",
"202.80",
"441.2",
"427.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"38.45",
"39.61",
"36.11",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
1512, 1703
|
19194, 19525
|
26524, 28291
|
7364, 8702
|
1249, 1495
|
1932, 6930
|
1066, 1222
|
9368, 9654
|
9677, 19173
|
7305, 7343
|
8731, 8834
|
8856, 9336
|
1720, 1914
|
28316, 29179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,473
| 146,741
|
13088
|
Discharge summary
|
report
|
Admission Date: [**2102-11-25**] Discharge Date: [**2102-12-13**]
Date of Birth: [**2036-5-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
SOB; V-tach
Major Surgical or Invasive Procedure:
CPR
Swan Ganz catheter insertion
Intubation
History of Present Illness:
This 64 year old male has a history of ischemic cardiomyopathy
with an EF of [**9-3**]%. He is s/p CABG in [**2086**] with SVG to PLA,
LIMA to LAD. He was evaluated for a biventricular ICD at [**Hospital1 **] in [**2098**], but did not qualify at that time, based on
his QRS duration and tissue Doppler imaging. He has been
medically managed since then.
.
He has a h/o ?COPD and c/o cough productive of clear sputum, and
worsening wheezing and SOB. He thought he had the flu but denies
fevers, chills, HA, myalgia, or night sweats. He reports stable
2-pillow orthopnea, denies PND. He was treated presumptively for
?bronchitis vs PNA? with a week-long course of azithromycin
without improvement. He also reports eating almost nothing in
the past 2 weeks and drinking very little. He has been compliant
with all meds including diuretics. He denies chest pain and
endorses light headedness only with coughing. He has felt his
ICD go into ATP but denies any shocks.
.
This AM he presented to [**Hospital6 **] for this
worsened shortness of breath where his VSS were 112/70 P 95 rr20
92% on RA. He was given levoquin 750, CTX, albuterol. He was
found to have intermittent SVT that was terminated by ATP. He
was given amiodarone 150mg IV x1 and started on a drip which
decreased the rate of his VT such that his AICD did not fire; he
was therefore transferred to [**Hospital1 18**] emergency department.
.
In [**Hospital1 18**] ED given ASA, plavix, nebs, CXR?RML pna? 100mg
lidocaine and drip at 3mg/hr. EP service interrogated his pacer
and found frequent episodes of VT terminated by ATP beginning
[**11-22**]. They changed the thesholds of his AICD and it did
appropriately respond to several more runs of VT. He had
approximately 10 runs SVT that were pace-terminated in the [**Hospital1 18**]
emergency department. He was started on a lidocaine drip at 3mg,
given nebs, bolused 800cc and admitted to the CCU.
.
In the CCU on transfer he felt well other than fatigue and SOB.
He denied CP, nausea, vomiting, myalgias. He was alert and
oriented x 3 and appropriately conversant. His vital signs were
T 97.2 BP 68/44, HR 71, 100% 3L n/c with PE significant for loud
wheezes, mild respiratory distress and neck veins elevated to
ear lobe while sitting up at 45 degrees. He was bolused 250 cc
without improvement in his BP. He was oliguric to about 5-10cc
in his first hour. Over that hour he became progressively
hypotensive with SBP in the 60's-90 range in both arms (mainly
60's'-70's) with HR in the 70's. He was asymptomatic with these
pressures and mentating well. He then began feeling more
fatigued/generally poor with SBPs consistently in the 60's. He
was started on levophed via peripheral IV, and while attempting
arterial placement the patient became apneic and unresponsive.
CPR was initiated for PEA arrest and he was intubated. He
received 3 rounds epi and within about 45 minutes, he regained a
pulse. Bedside echo showed a severely depressed EF and no
pericardial effusion.
Past Medical History:
Significant vascular disease:
bilateral renal artery stenosis s/p stenting [**2097**]
T.O right internal carotid
left internal carotid stenosis s/p left endarterectomy
AAA
chronic renal insufficency, baseline creat 2.9
remote gastric ulcer
ankle arthritis treated with steroid injections
COPD
past ETOH abuse, currently drinks socially
CABG
appy
hernia repair
Social History:
married
Family History:
NC
Physical Exam:
PE prior to cardiac arrest:
Ht: 5'6
Wt: 170 lbs
T 97.2 BP 68/44, HR 71, 100% 3L n/c
Gen: elderly male, appearing tired but NAD. alert and oriented x
2
CV: RRR no m/r/g; JVD to level of ear
Pulm: loud wheezes throughout, no accessory muscle use.
Abd: s/nd/nt + BS
extremities: cool, absent pulses
Pertinent Results:
[**2102-11-25**] CXR: Mild congestive heart failure has developed with
perihilar haziness, peribronchial cuffing and septal thickening
as well as a small right pleural effusion.
.
[**2102-11-27**] ECHO: LVEF <20% The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated with severe global hypokinesis. No
masses or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
wtih severe global free wall hypokinesis.The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Moderate (2+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is no pericardial
effusion.
.
[**2102-12-1**] Renal dopplers: IMPRESSION:
1. Left main and intrarenal arteries demonstrate abnormal parvus
waveforms. There is associated cortical thinning of the left
kidney. Findings suggest chronic left renal artery stenosis or
intrinsic renal disease. Conventional or MR angiography of the
renal arteries is recommended for further evaluation.
.
2. Mildly elevated right-sided renal resistive indices.
.
[**2102-12-5**] RUQ U/S: CONCLUSION: Small volume ascites, small left
effusion, splenomegaly and dilatation of the hepatic veins and
inferior vena cava. Pulsatile nature of portal vein flow is also
noted and the findings are suggestive of right heart failure
with passive hepatic congestion as a possible explanation for
elevated LFTs.
.
Gallbladder sludge also noted, but no evidence of cholecystitis,
cholelithiasis, or bile duct abnormalities.
.
Brief Hospital Course:
Mr. [**Known lastname **] is a 66 year old man with a history of coronary
artery disease, ischemic cardiomyopathy with EF 10-15%, s/p [**Hospital1 **]-V
ICD, presenting with SOB and found to have multiple episodes of
VT. s/p intubation for respiratory failure and PEA arrest x 2.
.
# hypotension/shock/PEA arrest on admission: Was likely
cardiogenic shock [**12-22**] extremely low baseline EF (10-15%) +
decompensation from hypovolemia and bradycardia with coronary
hypoperfusion. It was unlikely ACS is underlying etiology given
lack of chest pain, EKG unchanged, negative CE's. and an eccho
that was grossly unchanged. Pt again PEA arrested AM
post-admission (resolved with epi/atropine x2) with telemetry
findings sinus brady rate 54, concerning for failure of LV
capture. He developed VT developed post arrest which was
associated with normotension and was pace-terminated.
Electrophysiology was consulted who changed his pace-maker's
back-up rate to 70; he subsuquently had no further episodes of
PEA arrest or of hypotension.
.
#) CARDIAC:
a) RHYTHM: Mr [**Known lastname **] presented after having multiple episodes
of VT at home [**2102-11-22**], per interrogation by EP. At an OSH he was
initially managed with amio boluses, causing VT to slow down
which was not recognized by his pacemaker. EP adjusted the
parameters on his pacemaker and then he was managed with
lidocaine gtt. Mr [**Known lastname **] had one witnessed episode of VT upon
coming out of his PEA arrest; this broke with lidocaine drip
(which was stopped shortly thereafter). Other than this, he had
one short episode of VT found on telemetry which was ATP
terminated on teh 2nd cycle. He was subsuquently started on
amiodarone; he should have q6 month LFTs, thyroid tests; yearly
PFTs and eye exam while on this drug
.
With regards to his [**Hospital1 **]-V pacer; it was theorized that his BP was
unable to tolerate bradycardia and his back-up ventricular rate
was increased rate to 70. He had no other hypotensive episodes
after this change.
.
b) PUMP: severe, ischemic cardiomyopathy. EF likely <10%. He was
initially hypovolemic due to continued diuretic use and poor PO
intake. He was given IVF which improved his BP as did increasing
his back-up [**Hospital1 **]-V pacer rate to 70. He was resumed on carvedilol
12.5 [**Hospital1 **] which he tolerated. ACE inhibitor was held [**12-22**] ARF.
Aldactone was attempted but d/c'd [**12-22**] hyperkalemia. He may need
a standing diuretic at a later date, but he has taken in very
poor po and may not need this.
.
c) ISCHEMIA: EKG does not show any changes suggestive of
ischemia. Cardiac enzymes were flat on admission and post-code.
Doubtful that ACS is involved. he was continued ASA, plavix,
statin.
.
#) ID: pt w/ cough x1wk unresponsive to azithro. He may have had
a viral URI vs. COPD exacerbation. He was treated with 4d CTX
for bronchitis/COPD. He was treated with 2d vancomycin to
prophylax lines placed during code situation.
.
#) hyperbilirubinemia: Mr [**Known lastname **] had slight elevation of
transaminases with a normal RUQ US. It was thought to be [**12-22**]
congestive hepatopathy vs shock liver. He should have LFTs
followed on amiodarone.
.
#) Dyspnea/resp failure: clinical picture (pre-decompensated)
very suspicious for COPD exacerbaton. Pt was intubated for
several days for cardiac arrest. He did well post extubation
and was given a prednisone taper; he was treated x4d with CTX
for ?infection. He has standing nebs and his home COPD regimen
of montelukast, combivent, he was vaccinated for influenza and
pneumococcus. He should also take guaifenessin.
.
#) Renal: CKD with Cr max at 2.7, baseline ~2. His ACE
inhibitor was held; he has had poor po intake and appears dry;
he should be encouraged to drink 2L/day. he developed
hyperkalemia on aldactone; this should not be restarted.
.
#) Anemia: He was transfused 2U pRBCs for hct<30; this has been
stable
.
#) F/E/N: cardiac/low-salt diet. Experienced hyperkalemia
requiring kayexalate on aldactone; this should not be resumed.
.
# Swallowed teeth: Mr [**Known lastname **] dentures were evidently knocked
loose during emergent intubation and during mouth care one day
they were swallowed. An incident report filed; the teeth were
retrieved from the esophagus by endoscopy. This should be fixed
as an outpatient; he needs prophylaxis with amoxicillin 2g x 1
30minutes prior to dental procedure.
.
#) code: full
.
#) PPX: PPI, pneumoboots
Medications on Admission:
hctz 25mg tues-fri
lasix 80mg qAM; 40mg qPM
isordil 10mg [**Hospital1 **]
Coreg 15mg [**Hospital1 **]?
lipitor 40mg
plavix 75 qod
ASA
KCl 20mEa
folate 1mg [**Hospital1 **]
flomax 0.4mg qAM
trental 100mg qAM
singulair 10mg
tiotropium qday
albuterol qday
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H (Every 3 to 4 Hours) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
PEA arrest
Ventricular tachycardia
CHF with EF 10%
COPD exacerbation
acute renal failure
hyperkalemia on aldactone
Discharge Condition:
fair,
AFVSS
Discharge Instructions:
You were admitted because of frequent ventricular tachycardia;
we have changed your pacemaker settings to be able to stop this
irregular rhythm. If you feel your pacemaker defibrillate
(feels like a shock), you need to go to the emergency
department. We have also started an antiarrhythmic medication
called amiodarone. Because of this your cardiologist will need
to obtain yearly pulmonary tests, eye exam, and [**Hospital1 **]-annual
thyroid studies and liver studies.
.
Please take all medications as prescribed; we have made several
changes to these medications including decreasing your
carvedilol dose. We have also added a new medication called
amiodarone to help decrease the amount of ventricular
tachycardia you have been experiencing.
.
We are finishing a prednisone taper because you came in with
some breathing troubles. We will give you instructions on how
to taper this.
.
Please come to the emergency department if you have any chest
pain, shortness of breath, light-headedness, fevers, chills, or
for any other concerns.
Followup Instructions:
With Dr. [**Last Name (STitle) **] (you will be contact[**Name (NI) **] with an appt time)
[**Telephone/Fax (1) 14525**]
|
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icd9cm
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[
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[
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icd9pcs
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12067, 12155
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329, 375
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6440, 10582
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3414, 3776
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3792, 3801
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,183
| 164,048
|
32879
|
Discharge summary
|
report
|
Admission Date: [**2155-4-1**] Discharge Date: [**2155-4-3**]
Date of Birth: [**2120-11-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
hemodialysis, [**2155-4-2**]
History of Present Illness:
Mr. [**Known lastname 4702**] is a 34 yoM with a PMH significant for ESRD and
difficult to control hyptertension who presented to the ED with
two days of left-sided chest pain, found to be hypertensive. The
pt reports he was in his usual state of health until two days
ago. After HD this past Monday, he noted the onset of a sharp,
deep, aching pain in the left side of this thorax. The pain
radiates slightly to the left shoulder and upper abdomen. The pt
cannot recall whether it began abruptly or gradually; it has
progressed in severity since its initial onset and now comes in
waves of severity, [**9-6**] at it's worst. In terms of associated
symptoms, the pt notes that he has been coughing since his HD
session with producting of a small amount of white sputum. He
has also felt somewhat nauseated.
.
On arrival to the ED tonight, initial vitals were 98.5, 117, 26,
197/134, 97% RA. The pt was noted to be writhing in pain on his
stretcher. A CTA of the chest was obtained which was negative
for PE or dissection. A labetalol drip was started for suspected
hypertensive emergency. The pt's pain was treated and controlled
with dilaudid (3 mg), [**Month/Year (2) **], Zofran and Morphine (6 mg). The pt is
now admitted to the [**Hospital Unit Name 153**] for ongoing evaluation and managment.
.
On arrival to the floor, the pt is in moderate discomfort, but
denies any acute symptomes. His pain is improved and he is
breathing comfortably.
.
On ROS, the pt denies any history of trauma to his thorax. No
fevers or chills. No pain elsewhere in the chest or abdomen. No
dysuria, constipation or abnormal bowel movements.
Past Medical History:
- ESRD secondary to HTN - started on dialysis in [**12/2152**]
- HTN
- h/o medication non-compliance
- h/o substance abuse
- h/o right internal jugular vein thrombus associated with HD
catheter
- h/o pulmonary edema in the setting of hypertensive urgency
- h/o intubation in the setting of hypertensive urgency/flash
pulmonary edema
- dyslipidemia on statin
- s/p appendectomy
- s/p ex-lap
Social History:
He used to work as a plasterer, but is now on disability. Mother
died 4 months ago.
Tobacco: 1PPD x 20 years, currently 3 cigarettes a day.
EtOH/Drugs: Denies recent alcohol, cocaine and marijuana use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Father - Died at age 36 from unknown cancer
Mother - Died at age 58 of MI, had HTN
Maternal grandmother - on hemodialysis for end-stage renal
disease.
Physical Exam:
Gen: Well appearing adult male, moderate discomfort.
HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD. No tenderness with
palpation.
Chest: CTAB anterior and posterior. With cough, some yellow,
purulent sputum is produced.
Cor: Normal S1, S2. Mildly tachycardic. No murmurs appreciated.
No pain elicited with chest wall palpation.
Abdomen: Soft, non-tender and non-distended. +BS, no HSM.
Extremity: Warm, without edema. 2+ DP pulses bilat.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
Pertinent Results:
[**2155-4-1**] 09:30PM GLUCOSE-118* UREA N-48* CREAT-11.8*#
SODIUM-143 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-23*
[**2155-4-1**] 09:30PM NEUTS-81.1* LYMPHS-13.5* MONOS-3.4 EOS-1.9
BASOS-0.2
[**2155-4-1**] 09:30PM PLT COUNT-306
.
Chest CTA ([**2155-4-2**])
IMPRESSION:
1. No pulmonary embolus. No aortic dissection.
2. Diffuse ground-glass opacity with air trapping at bases
suggests small
airways disease and/or poor respiratory effort. Mild pulmonary
edema.
3. Right chest wall collaterals suggest stenosis, occlusion of
the right
subclavian vein.
4. Persistent coronary artery calcifications.
5. Stable appearance of calcified right renal mass.
6. Pulmonary hypertension given enlarged diameter of pulmonary
artery.
7. Dilated ascending aorta, stable from prior.
8. Stable cardiomegaly.
Brief Hospital Course:
34 yoM presents with hypertensive urgency/emergency and left
sided chest pain.
## hypertensive urgency/emergency: Occuring in the setting ESRD.
Although pt endorsed medication adherence, and denies use of
recreational drugs, either of these could contribute to his
current presentation. Pain is also likely an important factor.
BP was well-controlled with a labetalol gtt on arrival to the
MICU, and the drip was able to be rapidly weaned. Unclear that
pt has actually had end-organ damage from elevated BP, thus will
view this presentation as hypertensive urgency. He was called
out to the medical floor where he underwent HD on his first full
hospital day. His BP remained stable in the normotensive range
on his home BP regimen for the remainder of his hospitalization.
## left sided chest pain: Thought most likely musculoskeletal
pain in the setting of increased coughing. No PE or aortic
dissection was seen on CTA. The pt's pain was easily controlled
with NSAIDS. His cardiac enzymes were elevated at baseline [**12-30**]
ESRD and he was monitored for one day on tele with no
significant events.
## cough/leukocytosis: The pt was afebrile throughout his stay.
Given lack of infiltrate on CT, this was suggestive of atypical
or viral infection. The pt was treated for atypical infection
with with a course of azithromycin.
## ESRD: Thought secondary to chronic hypertension. The pt
underwent HD on the first full hospital day.
## hyperlipidemia: Home statin continued.
## anemia: HCT currently at baseline. Recent Fe studies
consistent with anemia of CKD.
Medications on Admission:
1. Sevelamer HCl 1600 mg TID
2. Calcium Acetate 667 mg two caps TID
3. Isosorbide Mononitrate 30 mg SR daily
4. Lisinopril 40 mg [**Hospital1 **]
5. Simvastatin 80 mg daily
6. MVI daily
7. Aspirin 325 mg daily
8. Ferrous Sulfate 325 mg daily
9. Nifedipine 90 mg daily
10. Terazosin 1 mg QHS
11. Nitroglycerin SL PRN
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
[**Hospital1 **]:*3 Tablet(s)* Refills:*0*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
[**Hospital1 **]:*10 Tablet(s)* Refills:*0*
13. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
[**Hospital1 **]:*20 Tablet(s)* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: hypertensive urgency, musculoskeletal chest wall pain
Secondary: ESRD on HD, HTN, hyperlipidemia
Discharge Condition:
good, stable, O2 sats mid- to high-90s on room air, pain
controlled with PO medications
Discharge Instructions:
You were evaluated for left-sided chest pain and found to have
very elevated blood pressure. This was quickly controlled with
IV medication and remained stable on your regular home meds.
Your chest pain is thought to be musculoskeletal and improved
with medication.
If you have worsening chest pain, headache, weakness, confusion,
episodes of loss of consciousness, shortness of breath, or any
other concerning symptoms, call your doctor.
Followup Instructions:
Follow up with your primary care provider as scheduled; you have
an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] on [**2155-4-23**] at 3:30pm. Call
her office at [**Telephone/Fax (1) 250**] with any questions.
Resume your regular hemodialysis schedule.
|
[
"272.4",
"276.6",
"V45.89",
"403.91",
"285.21",
"786.59",
"459.2",
"585.6",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7741, 7747
|
4352, 5921
|
325, 355
|
7897, 7987
|
3523, 4329
|
8475, 8778
|
2659, 2892
|
6287, 7718
|
7768, 7876
|
5947, 6264
|
8011, 8452
|
2907, 3504
|
275, 287
|
383, 2010
|
2032, 2423
|
2439, 2643
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,019
| 171,783
|
47700
|
Discharge summary
|
report
|
Admission Date: [**2130-10-3**] Discharge Date: [**2130-10-4**]
Date of Birth: [**2073-12-16**] Sex: M
Service: MEDICINE
Allergies:
All drug allergies previously recorded have been deleted
Attending:[**First Name3 (LF) 32275**]
Chief Complaint:
Abdominal discomfort
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
56 yo M w/ DM, HTN, EtOH/HCV cirrhosis presented as transfer
from OSH for ERCP, and transferred to [**Hospital Unit Name 153**] tonight after
anesthesia did not feel comfortable extubating pt. Per ERCP
fellow (no OSH records in chart), pt presented to [**Hospital1 3793**] 1 week ago with delta ms, abdominal pain, and elevated
LFTs. He also reported a weight loss on ROS (unclear
amount/duration). AST 46, ALT 81, total bili 1.5, alk phos 217.
An abdominal CT showed a possible pancreatic head mass and liver
lesions c/w mets. He was transferred here for ERCP for further
evaluation.
.
He was electively intubated for ERCP due to concern for his
airway given delta ms and h/o COPD. Procedure showed a minimally
dilated pancreatic duct without stricture, and otherwise
completely normal study. Per fellow and attg, very unlikely to
have pancreatic head mass. Post-procedure, anesthesia did not
feel comfortable extubating pt due to lethargy, inconsistently
following commands. He asked the pt to be transferred to the
[**Hospital Unit Name 153**] for further monitoring and extubation when mental status
improved.
.
In [**Hospital Unit Name 153**], following commands, indicating that he wanted to be
extubated. His RSBI was 21 and tolerated a SBT of 5/0 for 45 min
comfortably. He was extubated to shovel mask with sats 95%.
Past Medical History:
DM, CRI, HTN, DM, EtOH abuse, HCV cirrhosis, bipolar d/o,
schizophrenia, osteoarthritis, h/o tracheostomy
Social History:
Lives at a nursing home, unemployed. Sister [**Name (NI) 717**] [**Name (NI) 1263**] is
power of attorney, [**Telephone/Fax (1) 100740**]
Family History:
Noncontributory
Physical Exam:
T 99, BP 109/57, HR 100, RR 20, O2 sat 95% PS 5/0, FiO2 0.5
Gen: Resting on bed, NAD
HEENT: PERRL, EOMI, anicteric, mmm
Neck: Supple
CV: RRR Nl S1 S2, II/VI SEM at RSB
Pulm: Bibasilar faint rales
Abd: NABS, soft, mild TTP of mid-abdomen, no guarding or rebound
Extr: No c/c/e, wwp
Neuro: Lethargic appearing but re-orientable, oriented x 3,
moves all extremities to command, LUE slightly weaker than RUE
.
Pertinent Results:
pH
7.33 pCO2
51 pO2
62 HCO3
28 BaseXS
0
Type:Art; Not Intubated; Nebulizer; FiO2%:70; Temp:37.2
Na:148 K:4.8 Cl:120 Glu:87 freeCa:1.15 Lactate:1.0
7.9 \ 8.9 / 309
-------
30.7
N:72.8 L:20.6 M:4.0 E:2.3 Bas:0.2
Hypochr: 3+ Anisocy: 2+ Poiklo: 1+ Microcy: 2+
[**2130-10-4**] 05:09AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.7
[**2130-10-4**] 12:54AM BLOOD ALT-74* AST-44* AlkPhos-218* Amylase-25
TotBili-1.8*
ERCP:
Medications: general anesthesia
Glucagon 0.6 mg
ASA Class: P4
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
general anesthesia. The patient was placed in the prone position
and an endoscope was introduced through the mouth and advanced
under direct visualization until the second part of the duodenum
was reached. Careful visualization was performed. The procedure
was not difficult. The quality of the preparation was good. The
patient tolerated the procedure well. There were no
complications.
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was performed with
a sphincterotome using a free-hand technique. Contrast medium
was injected resulting in complete opacification. Cannulation of
the pancreatic duct was performed with a 5-4-3 tapered catheter
using a free-hand technique. Contrast medium was injected
resulting in complete opacification.
Biliary Tree: The common bile duct, common hepatic duct, right
and left hepatic ducts, biliary radicles and cystic duct were
filled with contrast and well visualized. The course and caliber
of the structures are normal with no evidence of extrinsic
compression, no ductal abnormalities, and no filling defects
Pancreas: The main pancreatic duct was mildly dilated with no
strictures or other irregularity.
Impression: 1. Normal biliary tree.
2. The main pancreatic duct was mildly dilated with no
strictures or other irregularity.
Recommendations: Juices today when awake, alert and at baseline
Return to outside hospital under Dr. [**Last Name (STitle) 1968**] [**Name (STitle) **] care
Consider liver biopsy if diagnosis is uncertain of liver lesions
seen on CT.
Brief Hospital Course:
56 yo M w/ EtOH and HCV cirrhosis, COPD on [**Name (NI) 100741**] (unclear true
pulm function), bipolar/ schizophrenia presented to [**Hospital Unit Name 153**] post
ERCP for monitoring mental status prior to extubation, now
extubated.
.
1. Respiratory: Patient was intubated electively for airway
protection given mental status, rather than respiratory
failure-- now s/p extubation. His ABG still shows respiratory
acidosis. His exam shows mild rales, and patient has history of
COPD. His CXR was signfiicant for atelectasis as well as hilar
congestion c/w fluid overload and poor inspiratory efforts. His
respiratory acidosis was likely secondary to poor ventilation
from atelectasis, COPD, as well as possible pulm edema. Patient
was given 20 mg IV Lasix. On transfer patient was on NC with
oxygen sats in the mid-90s. He was also given nebs prn.
.
2. Delta MS: It was unclear how much was his baseline, given
multiple potential insults including liver disease, bipolar,
schizophrenia. Patient was placed on a CIWA scale, but showed no
evidence of withdrawal or agitaiton. His LFTs were followed and
were stable. His psych meds were held because doses were
unknown.
.
3. GI: It was unclear how referred for pancreatic mass eval but
no abnormalities per ERCP. His LFTs/amylase/lipase were stable.
ERCP was negative for dilatation. It is possible that patient
has intrahepatic obstruction, and liver biopsy may be indicated
if lesions are still suspected. Reimaging would also be helpful
for characterization of lesions.
.
4. DM: Patient was placed on FSBG QID, with ISS. His diet was
advanced.
.
5. FEN: Patient was NPO overnight, and was placed on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet
in am.
6. Proph: Patient was given subcutaneous heparin, pneumoboots,
and protonix PPI.
.
7. Dispo: Patient was stabilized, and returned to [**Hospital 487**]
Hospital.
Medications on Admission:
Albuterol/ atrovent, glyburide, HCTZ, ISS, protonix, depakote,
risperdal, trazodone, effexor, cogentin, colace
Discharge Medications:
Meds on transfer:
Heparin 5000 SC tid
Albuterol/ipratropium q6 prn
Protonix 40 qd
Insulin SSI.
Discharge Disposition:
Home
Facility:
Transfer to outside hospital
Discharge Diagnosis:
Abdominal pain.
Elective intubation for ERCP.
Discharge Condition:
Stable.
Discharge Instructions:
Please follow up with your PCP.
Followup Instructions:
Please follow-up with your PCP.
|
[
"496",
"401.9",
"V58.49",
"296.7",
"250.00",
"577.8",
"571.5",
"593.9",
"295.90",
"780.79",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
7088, 7134
|
4921, 6807
|
340, 346
|
7223, 7232
|
2461, 4898
|
7312, 7346
|
2002, 2019
|
6968, 6968
|
7155, 7202
|
6833, 6945
|
7256, 7289
|
2034, 2442
|
280, 302
|
374, 1701
|
1723, 1831
|
1847, 1986
|
6986, 7065
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,551
| 143,320
|
37955
|
Discharge summary
|
report
|
Admission Date: [**2151-2-3**] Discharge Date: [**2151-5-20**]
Date of Birth: [**2096-11-16**] Sex: M
Service: EMERGENCY
Allergies:
Bee Pollen / Lorazepam
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Allogenic Stem Cell Transplant
Major Surgical or Invasive Procedure:
Central Venous Line Placement
History of Present Illness:
Mr. [**Known lastname **] is a 54 year old male with history of Myelofibrosis,
diagnosed in the last year admitted today for allogenic stem
cell transplant. He initially presented to his PCP with fatigue
and lower extremity swelling. Ultrasound was negative for DVT.
Cardiac work-u normal. He was noted to be anemic on lab work
and have splenomegally on exam. He was referred to Dr. [**First Name4 (NamePattern1) 402**]
[**Last Name (NamePattern1) **] for evaluation. Bone marrow biopsy at that time was
suggestive of myelofibrosis. He was referred to [**Hospital1 18**], under
the care of Dr. [**Last Name (STitle) 410**] for evaluation. Pathology reviewed his
BM bx and agreed with diagnosis of myelofibrosis. He has had
continued fatigue with need for frequent naps. He has a
hematocrit baseline ~30-31 and platelet baseline 150. He has
not been transfusion dependent. He is admitted today for allo
stem cell transplant. On review of symptoms, he notes a rash on
his buttocks, occasionally pruritic, non vesicular, usually in
the winter months only. He denies fever, chills, sore throat,
cough, rhinorrhea, shortness of breath, chest pain,
palpitations, N/V/D, dyuria, consitpation, abdominal pain,
weakness, parasthesias, headache, changes in vision, changes in
hearing.
Past Medical History:
- "lazy eye"
- s/p Pneumovax, a meningococcal vaccine, flu shot in fall [**2149**]
Social History:
Non-smoker; previously drank alcohol socially, however has not
been drinking since [**52**]/[**2149**]. No drug use. Lives with
girlfriend. Technical writer at medical filter manufacturing
company. No known exposures.
Family History:
No family history of malignancy, leukemia or
lymphoma. Father - diabetes, hypertension, PVD, CAD and
TIA. Mother, sisters (2) and brother are [**Name2 (NI) 84820**].
Physical Exam:
VITALS: T: 98.8 BP: 114/60 HR: 82 RR: 20 O2: 100%RA
GEN: NAD, lying in bed comfortably
HEENT: Pupils equal and reactive, eyes with disconjugate
movement (chronic), oropharynx clear, EOMI
NECK: No LAD, No JVD, right tunneled line in place
CV: RRR, no m/g/r
LUNGS: CTAB, no wheezes of rhonchi
ABD: soft, splenomegally across midline and to top of illiac
crest, +BS, no guarding or rebound
EXT: no c/c/e, DP pulses palpable bilaterally in LE, radial
pulses palpabel and equal in bilateral UE.
NEURO: Alert, oriented x 3, strength 5/5 in all 4 extremities,
sensation intact throughout. No disdiadochokinesis. Gait not
assessed.
SKIN: discreet erythematous rash over bilateral buttocks with
some scaling of skin, no exudate or pus, no sign of infection.
Pertinent Results:
Admission Labs:
[**2151-2-3**] 10:05AM BLOOD WBC-9.5 RBC-4.13* Hgb-9.6* Hct-31.7*
MCV-77* MCH-23.2* MCHC-30.3* RDW-16.7* Plt Ct-155
[**2151-2-3**] 10:05AM BLOOD Neuts-71* Bands-0 Lymphs-16* Monos-7
Eos-2 Baso-1 Atyps-1* Metas-0 Myelos-2* NRBC-2*
[**2151-2-3**] 10:05AM BLOOD PT-14.7* PTT-35.8* INR(PT)-1.3*
[**2151-2-3**] 10:05AM BLOOD UreaN-19 Creat-0.8 Na-138 K-5.1 Cl-102
HCO3-25 AnGap-16
[**2151-2-3**] 10:05AM BLOOD ALT-9 AST-15 LD(LDH)-492* AlkPhos-72
TotBili-0.6 DirBili-0.2 IndBili-0.4
[**2151-2-3**] 10:05AM BLOOD TotProt-7.8 Albumin-4.1 Globuln-3.7
Calcium-9.3 Phos-4.2 Mg-2.1 UricAcd-5.6
[**2151-2-3**] 10:05AM BLOOD IgG-2052* IgA-125 IgM-84
[**2151-2-11**] Abdomninal U/S - 1. There is small amount of ascites and
a small right pleural effusion. 2. Gallbladder wall thickening
and pericholecystic fluid is likely secondary to the patient's
underlying disease process and ascites. However, if there is
clinical concern for cholecystitis, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scan (nuclear
medicine) should be considered. 3. Severe splenomegaly.
[**2151-2-19**] CT Abdomen and Pelvis - 1. No evidence of
retroperitoneal bleed. 2. Massive splenomegaly. 3. Diffusely
mottled appearance of the bones, consistent with the history of
MDS/myelofibrosis.
Brief Hospital Course:
Mr. [**Known lastname **] is a 54 year old gentleman with history Myelofibrosis
who had a long and complicated hospital course including a
failed allogenic stem cell transplant from his brother and then
a failed double cord transplant on [**4-21**]. He expired on [**2151-5-20**]
due to sepsis.
# Myelofibrosis s/p Failed Allo Stem Cell Transplant s/p Double
Cord Transplant -
Mr. [**Known lastname **] was admitted for allogenic stem cell transplant for
treatment of his myelofibrosis. On admission, he had a tunneled
catheter placed by interventional radiology. He received
ablative therapy with Fludarabine, ATG and Busulfan. He
recieved his stem cell transplant without complication.
Prophylactic acyclovir, fluconazole and cipro were started per
protocol as well as cyclosporine. On day +34, patient's
chimerism results returned 45% donor cells despite an ANC of 50.
He was then initiated on splenic radiation therapy on [**3-19**] in
the hope of aiding engraftment. The patient's ANC did improve on
[**3-27**] to a peak of 198. After transfer to the [**Hospital Unit Name 153**] on [**4-19**], the
patient was given a 2 cord stem cell transplant on [**4-21**] without
complication, while intubated for fluid overload. Due to renal
toxicity of cyclosporine, patient was maintained on IV
methylprednisolone [**Hospital1 **] dosing in addition to his mycophenolate
mofetil. Mr. [**Known lastname 84821**] hospital course was complicated by GI bleed,
acute renal failure, and neutropenic fever (see below). He
ultimately died from spesis with DIC.
# Neutropenic fever/sepsis:
The patient experienced several episodes of neutropenic fever,
first on [**2-20**] at which time he was placed on Cefepime and
Vancomycin. Acyclovir was initiated at the time of admission,
but was held when his Cr rose above 1.5. The patient's fever
resolved and he did not experience any further episodes until
spiking to 103.3 on [**3-11**] in the context of a presumed aspiration
event with a brief episode of hypoxia. A CXR at the time
demonstrated some increased opacities, so Metronidazole was
added with resolution of his fever and hypoxia, but he spiked
again on [**3-12**]. ID was consulted and per their recommendations,
his antibiotics were broadened to Daptomycin, Meropenem,
Voriconazole, & Flagyl. He remained afebrile afterwards, but had
several episodes of hypothermia with a nadir of 94.4. An
infectious work-up was negative and the patient never exhibited
hemodynamic instability. In the context of low cell counts, the
Infectious disease team later review the patient's medications
and recommended discontinuing his Flagyl and switching his
Meropenem to Ciprofloxacin to prevent any medication driven
reduction in his cell counts. His antibiotics were changed per
ID recommendations several times during his [**Hospital Unit Name 153**] stay, and he
returned to the BMT service on [**4-26**] on acyclovir, atovaquone,
cefepime, micafungin, and vancomycin. He was started on
Ambisome on [**5-8**] for positive yeast culture in blood and urine.
He had Hickman cath removed on [**5-9**] by IR. On [**2151-5-10**] changed
micafungin to voriconazole. Later in his hospital course he
developed acute lethargy, and was found to be hypothermic and
hypotensive. He also c/o worsening abdominal pain. He was
transferred back to the [**Hospital Unit Name 153**] for presumed sepsis. ID was
consulted overnight and his antibiotics were broadedned. A
central line and arterial line were placed and he was started on
pressors. He was noted to be in DIC with platelets below 10.
He had developed acute on chronic renal failure, lactic acidosis
of 11.7, acidemia with pH 6.95 and was intubated for a
respiratory rate near the 40s. A catheter was placed for HD.
However, the following morning, his family decided to change his
goals of care to comfort measures only. All medications were
stopped. He expired shortly after.
# Acute Renal Failure:
On [**3-1**], the patient's previously stable renal function began to
climb from a baseline of 0.6-0.8. A Vancomycin trough was found
to be elevated to 40.6 in conjunction with the patient's
Cyclosporine. The Vancomycin was stopped, but the Cr continued
to rise. Nephrology was consulted and diagnosed the patient with
ATN [**1-5**] to his Cyclosporine + Vancomycin. The patient's Cr
peaked at 2.9 and slowly began trending down reaching a new low
of 1.8 on [**3-21**]. At that time, the patient was given a dose of
Lasix & a single dose of Acyclovir and his Cr began to rise
again reaching a peak of 2.3. Renal was re-consulted and, based
on a bland urine sediment, felt that this was a new injury not
consistent with ATN. On [**4-19**], patient's creatinine was noted to
be trending upwards again, likely in the setting of having
re-started his cyclosporine. On transfer to the [**Hospital Unit Name 153**], the
cyclosporine was stopped, patient's renal function continued to
worsen and he was briefly placed on CVVH, to facilitate handling
the fluid boluses he was receiving with antibiotics and stem
cell transplant and to help diurese him in the setting of acute
systolic CHF. Patient was started on IV methylprednisolone
dosing [**Hospital1 **] instead of cyclosporine to avoid further cyclosporine
toxicity. He was successfuly taken off CVVH. However, as above
he continued to have chronically elevated creatinine. Just
prior to his death, he developed acute renal failure in the
setting of sepsis with a creatinine 3.3. Attempts were made to
initate CVVH, however his goals of care changed and he was made
comfort measures.
# GI bleed:
One week after transplant, Mr. [**Known lastname **] had an acute drop in
hematocrit. A CT abdomen and pelvis was negative for acute
retroperitoneal bleed. He was placed on IV PPI, transfused 2
units PRBCs and continued on fluids. Stool was documented as
gauiac negative and hematocrit stabilized, and an IV PPI was
discontinued. The patient had repeated episodes of rectal bleed
and melanotic stool. GI was consulted on a couple of occasions,
but did not favor endoscopic intervention unless the patient
became hemodynamically unstable, given the patient's overall
tenuous state, complete neutropenia and significant
thrombocytopenia. Patient was transfused as needed with blood
products, though hematocrit drops appeared to be mostly related
to marrow suppression. Of note, patient received >50 units of
pRBCs and >80 units of platelets during this hospitalization.
# Respiratory distress:
On [**4-19**], patient developed respiratory distress on the floor in
setting of fluid overload and was transferred to the [**Hospital Ward Name 332**] ICU.
On [**4-20**], his respiratory distress appeared to be worsening, he
appeared to be fatigued, and was subsequently intubated from
[**Date range (1) 61876**]. His respiratory status was stable after extubation.
He was reintubated according to his wishes the night prior to
his death due to respiratory distress with a rate in the 40s.
# Acute Systolic Congestive Heart Failure:
Upon transfer to the [**Hospital Unit Name 153**] on [**4-19**], the patient's volume status
was concerning for heart failure. TTE revealed dramatic decrease
in the patient's ejection fraction from normal to 20-25%,
thought to possibly be secondary to cyclophosphamide toxicity.
Cardiology was consulted and recommended aggressive IV diuresis
and beta blockade, as well as holding ace inhibitors, given
acute kidney injury. Prior to transfer back to the floor one
week later, the patient had a repeat Echocardiogram which showed
mild improvement in EF to 35%. Upon transfer back to the BMT
floor on [**4-26**], patient was noted to complain of significant
abdominal pain; he was noted to have large volume ascites and
increasing splenomegaly, likely the cause of his pain. The
ascites was felt to be secondary to acute heart failure.
Because he could not undergo paracentesis in the setting of
neutropenia and thrombocytopenia, patient was given furosemide
one-time doses to attempt diuresis. Because he was felt to be
intravascularly volume depleted, furosemide doses were given
after receiving pRBCs, which he received almost daily for
depressed counts.
# Abdominal Pain:
Patient was started on oxycontin 10 mg [**Hospital1 **] due to chronic pain
from myelofibrosis. Upon transfer to the [**Hospital Unit Name 153**] for respiratory
distress [**4-19**], his pain medications were held, given his
respiratory status. Following extubation, he was complaining of
significant epigastric abdominal pain, and was given PRN doses
of IV dilaudid. Abdominal film was suboptimal but did not show
free air in the abdomen. He did not undergo CT at that time,
given his contraindications to IV or PO contrast (renal failure
and nausea/vomiting, respectively). Following transfer back to
the BMT service, his pain was controlled with a morphine PCA
pump. He underwent a non-contrast abdominal CT which ruled out
perforation or major bleed but did show large volume ascites,
likely secondary to heart failure, and massive splenomegaly,
which were both likely the major contributors to his pain.
Because patient could not undergo therapeutic or diagnostic
paracentesis in setting of neutropenia and thrombocytopenia,
slow diuresis was attempted with furosemide prn doses.
Medications on Admission:
- folic acid 1 mg a day
- Provigil
- Vicodin prn,
- Tylenol arthritis
- Glucosamine chondroitin
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"E879.8",
"368.00",
"038.9",
"425.4",
"E878.0",
"996.85",
"789.59",
"428.0",
"054.2",
"584.5",
"578.9",
"707.25",
"999.31",
"E933.1",
"112.5",
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"289.51",
"285.1",
"573.0",
"238.76",
"284.89",
"518.81",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"99.25",
"96.71",
"33.24",
"92.29",
"38.93",
"00.92",
"38.95",
"99.15",
"99.28",
"41.03",
"00.91",
"96.04",
"41.06"
] |
icd9pcs
|
[
[
[]
]
] |
13771, 13780
|
4298, 13592
|
315, 346
|
13831, 13840
|
2987, 2987
|
13893, 13900
|
2027, 2196
|
13739, 13748
|
13801, 13810
|
13618, 13716
|
13864, 13870
|
2211, 2968
|
245, 277
|
374, 1664
|
3003, 4275
|
1686, 1771
|
1787, 2011
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,954
| 152,377
|
6634
|
Discharge summary
|
report
|
Admission Date: [**2173-1-7**] Discharge Date: [**2173-1-18**]
Date of Birth: [**2125-1-14**] Sex: F
Service: MEDICINE
Allergies:
Darvon
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
chills/sweats x 2 days
Major Surgical or Invasive Procedure:
cardiac catheterization w/ DES to the LAD
History of Present Illness:
This is a 47 y/o female with ESRD [**1-14**] IDDM, s/p living donor
renal transplant [**2164**], significant vascular disease, s/p recent
right 5th toe debridement [**1-14**] osteomyelitis, presenting with
chills and sweats for the last two days. Per patient, onset was
two days ago with her chills and sweats occuring intermittently
3-4 times a day, now only 1-2 times today. No fevers at home.
This morning she developed nausea and vomited 3 times - no
hematemesis or bilious emesis. No abdominal pain, change in
bowel habits, BRBPR/melena/hematochezia. Reports a dry,
non-productive cough for the last two days with slight
associated SOB with exertion yesterday. No chest pain or
pleurisy. No recent sick contacts or travels. On Augmentin for
last one month s/p right toe debridement.
Pt reports having mild myalgias and generalized fatigue. Had flu
vaccine in [**8-17**]. Her sugars at home have been within normal
limits. Took her BP meds only PTA.
.
ROS - In addition to above, denies any H/A, vision changes,
photophobia, neck stiffness, dizziness/lightheadedness, URI
symptoms, dysuria, hematuria, extremity swelling,
weakness/numbness/loss of sensation.
.
In the ED, was given 2 L of NS, one dose of Vancomycin and
Zosyn, 10 units of regular insulin, and her BP medications.
Past Medical History:
1. s/p living donor renal transplant [**2164**] [**1-14**] ESRD (kidney from
sister) - ESRD [**1-14**] IDDM, on cellcept and rapamune since [**2164**];
baseline Cr 2.5-3.4
2. IDDM since age 11 - retinopathy, nephropathy, neuropathy
3. PVD with b/l fem-[**Doctor Last Name **] [**2165**]
4. HTN
5. Hypercholesterolemia
6. Anemia - on procrit, Fe supplements
7. CVA x 2 [**2165**] - presentation of aphasia, no residual deficits
8. TAH [**2170**] [**1-14**] menometorrhagia
9. Laser eye surgery
[**76**]. s/p Bartholin cyst/abscess drainage [**2167**]
11. Right 5th toe debridement [**1-14**] osteomyelitis - 1 month ago
Social History:
Lives at home with her boyfriend. [**Name (NI) **] two children in the area.
Does not work. Former 30 pack-year smoker, quit in [**2165**]. No EtOH
use or illicit drug use.
Family History:
non-contributory
Physical Exam:
VS: T 98.4, BP 142/90, HR 85, RR 18, sats 100%/RA
General: Pleasant, middle-aged woman in NAD, appears slightly
pale. AO x 3.
HEENT: NC/AT, PERRL, EOMI. No conjuctival injection, no scleral
icterus. MMM, OP clear.
Neck: no LAD or JVD noted
Chest: Decreased BS over right base, + slight egophany over
right base; no dullness to percussion or decreased tactile
fremitus noted. Otherwise clear.
CV: RRR, s1 s2 normal. II/VII systolic murmur over LSB with
radiation to carotids. No rubs or gallops.
Abd: soft, NT/ND, NABS, no masses or organomegaly
Ext: trace edema b/l, weak distal pulses, right 5th toe w/o any
erythema, warmth, drainage or swelling; right calf > left calf
without any tenderness
Skin: white, scaly skin over lower legs b/l
Neuro: AO x 3, CN II-XII intact, MS [**4-16**] throughout, sensation
grossly intact
Pertinent Results:
[**2173-1-7**] 11:00PM CK(CPK)-183*
[**2173-1-7**] 11:00PM CK-MB-7 cTropnT-0.32*
[**2173-1-7**] 11:00PM PT-13.7* PTT-150* INR(PT)-1.2*
[**2173-1-7**] 07:45PM CK(CPK)-176*
[**2173-1-7**] 07:45PM CK-MB-8 cTropnT-0.26*
[**2173-1-7**] 04:30PM GLUCOSE-388* UREA N-47* CREAT-2.8* SODIUM-138
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-18* ANION GAP-19
[**2173-1-7**] 04:30PM CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.7
[**2173-1-7**] 06:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2173-1-7**] 06:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2173-1-7**] 06:45AM URINE RBC-21-50* WBC-21-50* BACTERIA-OCC
YEAST-NONE EPI-[**2-14**]
[**2173-1-7**] 05:46AM GLUCOSE-492* LACTATE-1.3 K+-4.8
[**2173-1-7**] 05:30AM GLUCOSE-471* UREA N-48* CREAT-2.9* SODIUM-140
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-18* ANION GAP-21*
[**2173-1-7**] 05:30AM CK(CPK)-132
[**2173-1-7**] 05:30AM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-1.7
[**2173-1-7**] 05:30AM WBC-12.2*# RBC-3.59* HGB-9.7* HCT-29.1*
MCV-81* MCH-27.0 MCHC-33.2 RDW-15.8*
[**2173-1-7**] 05:30AM NEUTS-86.8* LYMPHS-9.0* MONOS-2.8 EOS-0.6
BASOS-0.9
[**2173-1-7**] 05:30AM HYPOCHROM-1+ POIKILOCY-1+ MICROCYT-1+
[**2173-1-7**] 05:30AM PLT COUNT-401
.
CT ABDOMEN: Again noted are moderate bilateral pleural effusions
and bibasilar atelectasis. Within the limits of this noncontrast
study, the liver is normal. Cholelithiasis is again identified.
The pancreas, spleen, adrenal glands and atrophic kidneys are
stable in appearance. Stomach and bowel loops are unremarkable.
There is no free air or free fluid. No mesenteric or
retroperitoneal lymphadenopathy is identified.
.
CT PELVIS: The bladder, sigmoid colon, rectum, right pelvic
transplant kidney are again seen. A femoral-femoral bypass graft
is again identified. There is no evidence of groin or
retroperitoneal hematoma. There is no free fluid and no pelvic
or inguinal lymphadenopathy.
.
CARDIAC CATHETERIZATION: The angiogram showed a mid 70% lesion
in the LAD. We planned to direct stent this. Heparin and reopro
were used
prophylactically. Reopro was preferred due to her renal failure.
A 6F [**Doctor Last Name **]
0.75 guide provided adequate support. We then derectly deployed
a 2.5 X
18mm Cypher stent at 14 at. The final angiogram showed TIMI III
flow
with no residual stenosis, no dissection and no embolisation.
The
patient left the lab in a stable condtion.
Brief Hospital Course:
Pt is a 47 y/o female with IDDM c/b ESRD (s/p living donor renal
transplant [**2164**]), PVD (s/p recent right 5th toe debridement [**1-14**]
osteomyelitis), HTN, and CVA x2 who presented to [**Hospital1 18**] with
chills and sweats x2d. She was admitted to general medicine and
treated broadly for CAP (CXR w/ lingular and RLL opacities) w/
zosyn/vanco given her immunosuppressed state. In the context of
this treatment course, the patient was noted to have
persistently elevated blood glucose values and was started on an
insulin gtt. Also, CE drawn at her admission demonstrated a
troponin of 0.26 w/ TWI anteriorly and inferiorly. She was
taken urgently to the cath lab where she received a DES to the
LAD and was sent to the CCU for further monitoring. Following
her transfer out of the CCU, the following issues were
addressed:
.
# Hypoxia: Patient received R thoracentesis for a transudative
effusion that was likely [**1-14**] her significantly fluid overloaded
state. 900cc was removed. After the thoracentesis the patient
was quickly weaned from 6L O2 by NC back down to room air. An
HD catheter was placed and the patient received a total of 3
runs of HD for ultrafiltration, with continued symptomatic
improvement. There was no reaccumulation of per pleural
effusion on discharge.
.
# CAP: Patient presented with a LLL opacity on admission, which
was initiallytreated with Levaquin. With her respiratory
decompensation preceding her thoracentesis, she was switched to
Zosyn for coverage amid concern for possible infectious cause.
She completed a course of Zosyn for this opacity, and was
discharged without any additional antibiotics. She was
restarted on her Bactrim for prophylaxis on discharge, given her
immunosuppression.
.
# Blood Pressure Control: Following her CCU admission with
coronary angioplasty, the patient was transferred back to the
medical [**Hospital1 **]. She received all of her antihypertensive
medications as well as some pain medication all in close
proximity to eachother, and then suffered a hypotensive episode
with SBP in the 70s. The patient was transferred to the MICU
briefly for this hypotension. She was very fluid responsive,
had a normal lactate, normal WBC count, and no fever. Concern
for an RP bleed was briefly entertained given the recent cath,
but CT abd/pelvis was normal. With slight modification of her
antihypertensive regimen, she suffered no additional hypotensive
episodes. In fact, she returned to her baseline level of
hypertension. She was discharged on high dose Toprol XL,
Nifedipine CR, and clonidine. The clonidine can be changed to
catapres patch after discharge. She was also taking lasix for
volume overload. It is expected that her hypertension will
become easier to control with improved renal function as her
kidney recovers from the dye insult.
.
# Acute on Chronic renal failure: Patient is s/p renal
transplant in [**2164**]. Baseline cr of 2.8 elevated to 4.9 in ICU,
which was presumed [**1-14**] contrast nephropathy. The patient
developed progressive fluid overload, requiring thoracentesis as
above. She had an HD catheter placed and recieved several runs
of HD during her hospitalization, which she tolerated well. At
the time of discharge, her Cr was in the mid-3 range. It is
hoped that her kidney will gradually improve after discharge
back to baseline level as it recovers from the contrast
nephropathy. The HD catheter was discontinued prior to
discharge. The patient was discharged on Cellcept, low dose
prednisone, and sirolimus. She will have very close follow up
with Dr.[**Doctor Last Name 4849**]. She was continued on lasix at discharge as
well, to prevent worsening fluid overload at home. She was
making good urine at the time of discharge.
.
# Ischemia/CAD: Patient is now s/p anterior NSTEMI with DES x1
to LAD. She experienced no further CAD symptoms or chest pain
during her hospitalization. The patient was discharged on
[**Last Name (LF) **], [**First Name3 (LF) **], Statin, B-blocker, and her CCB. She was not
started on an ACE-I or [**Last Name (un) **] due to her elevated Cr.
.
#. Hyperlipidemia: Lipitor was continued during the remainder of
the hospitalization. No changes were made to this medication on
discharge.
.
# DM: The patient experienced some blood sugar lability during
her stay, likely [**1-14**] to underlying infection (CAP) as well as
her cardiac ischemic event. She was briefly on high dose
Prednisone after her Cr increase, which further exacerbated her
blood sugar issues. However, on discharge she was only taking
low dose prednisone and her sugars were reasonably controlled.
She was followed by [**Last Name (un) **] during her stay, and will follow up
after discharge.
.
# Anemia: Patient had a brief drop in her Hct during her stay,
raising concern for RP bleed, which was ruled out as noted
above. In retrospect, the decreased Hct was likely [**1-14**] volume
overload due to her contrast nephropathy. The patient was
continued on Epo and iron repletion, managed at hemodialysis.
Medications on Admission:
1. Rapamune 4mg qd
2. Cellcept [**Pager number **] mg [**Hospital1 **]
3. Nifedipine 60 mg [**Hospital1 **]
4. Lopressor 150 mg qAM, 100 mg qPM
5. Diovan 80 mg qd
6. Lipitor 10 mg qd
7. Insulin - Humulin N 30 units qAM, HSS
8. Catapres #3 patch qweek
9. Lasix 20 mg qd
10. Tricor 54 mg qd
11. Nirefex 150 mg qd
12. EC [**Hospital1 **] 325 mg qd
13. Epo 1,000 units qweek
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
4. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000. units
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs units* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*90 Tablet(s)* Refills:*0*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
10. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*0*
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
12. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
13. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*0*
14. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*0*
15. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
16. Humulin N 100 unit/mL Suspension Sig: Thirty (30) units
Subcutaneous qAM.
Disp:*qs qs* Refills:*2*
17. Humulin N 100 unit/mL Suspension Sig: Twelve (12) units
Subcutaneous at bedtime.
Disp:*qs qs* Refills:*2*
18. Humalog 100 unit/mL Solution Sig: Per sliding scale units
Subcutaneous four times a day.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Renal Failure
Non-ST Elevation Myocardial Infarction
Hypotension
Hypoxia
Pleural Effusion
Diabetes Mellitus I
Orthotopic Renal Transplant
Discharge Condition:
Stable, tolerating adequate PO and ambulating without
assistance.
Discharge Instructions:
If you experience fevers, chills, nausea, vomiting, chest pain,
shortness of breath, or any other concerning symptoms, contact
your physician or return to the emergency room.
.
Please weigh yourself every day, and if you gain more than 10
pounds call Dr.[**Name (NI) 19918**] office.
Followup Instructions:
Please call Dr.[**Name (NI) 19918**] office in the morning at ([**Telephone/Fax (1) 4923**]
to organize your appointment. We have called ahead for you and
your appointment should be approved. It is essential that you
see Dr.[**Name (NI) 4849**] on [**1-21**] or [**1-22**].
.
Please call [**Last Name (un) **] Diabetes Center at ([**Telephone/Fax (1) 17484**] for an
appointment in the next 2-4 weeks.
.
If you would like to establish care with a new Primary Care
Physician at [**Hospital1 18**], call [**Telephone/Fax (1) 250**] for an appointment.
Ideally you should be seen by a primary care doctor within the
next month.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2173-2-1**]
|
[
"250.41",
"486",
"250.11",
"731.8",
"E849.8",
"414.01",
"250.51",
"424.0",
"250.61",
"440.22",
"362.01",
"730.27",
"996.81",
"280.9",
"585.6",
"583.81",
"357.2",
"410.71",
"E878.0",
"403.91",
"799.02",
"250.81",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.45",
"00.40",
"37.22",
"39.95",
"99.20",
"34.91",
"88.72",
"36.07",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
13576, 13582
|
5869, 10924
|
288, 331
|
13770, 13838
|
3373, 5846
|
14170, 14948
|
2496, 2514
|
11346, 13553
|
13603, 13749
|
10950, 11323
|
13862, 14147
|
2529, 3354
|
226, 250
|
360, 1646
|
1668, 2290
|
2306, 2480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,727
| 177,151
|
51422+51423
|
Discharge summary
|
report+report
|
Admission Date: [**2197-10-21**] Discharge Date:
Date of Birth: [**2127-3-9**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
gentleman with chronic pancreatitis who presented early in
[**2195**] with a 23 pound weight loss and jaundice. At that time
patient was found to have dilated biliary ducts on CT scan.
Patient underwent multiple ERCP procedures and common bile
multiple removals and revisions of stents due to infection.
Patient's washings for cytology from his multiple ERCP
procedures were all negative for malignant cells. Patient
underwent choledochojejunostomy in [**2196-6-26**] to bypass
biliary obstruction from the common bile duct. Patient had
multiple pancreatic biopsies at that time that were negative
for malignancy. Patient did well until several months later
the spring of [**2196**] for nutritional support as well as
undergoing gastrojejunostomy to bypass the duodenum secondary
to gastroparesis. Patient has had increasing ascites for the
last several months which was tapped at an outside hospital
and found to be exudative. Patient presented to [**Hospital6 11896**] with several hours of vomiting blood on
[**2197-10-16**]. Patient was found to be hypotensive in the
emergency room with hematocrit of 19. Patient was
resuscitated with packed red blood cells and propranolol.
Patient was found to have grade 2 varices on EGD on [**10-17**]
that were not acutely bleeding. Over the next few days
patient was treated with fluids and medicated for anxiety
with large quantities of opiates and benzodiazepines.
Patient became increasing obtunded and was eventually
transferred to [**Hospital1 18**] for liver biopsy. Of note, patient had
two negative ultrasounds of his right upper quadrant which
ruled out [**Hospital1 32004**] vein thrombosis. On presentation patient
had developed coagulopathy with increased PT/PTT.
PAST MEDICAL HISTORY: As per HPI. Also a history of
coronary artery disease status post CABG. History of
hypertension. History of type 2 diabetes. History of
pulmonary nodules. History of post traumatic stress
disorder.
ALLERGIES: Morphine and codeine as well as plastic tape,
nylon tape.
MEDICATIONS ON TRANSFER: Elavil 25 mg p.o. once a day,
Ambien 10 mg p.o. once a day, Duragesic 75 mg q.72 hours,
Risperdal 0.5 mg b.i.d., Ativan p.r.n., tobramycin eyedrops,
Lacri-Lube eyedrops, lactulose 30 cc b.i.d., Inderal 20 mg
t.i.d., Protonix GGT at 8 mg per hour, regular insulin
sliding scale as well as 15 of NPH and 4 units of regular
insulin in the morning.
PHYSICAL EXAMINATION: On admission temperature was 98.3,
blood pressure 122/70, pulse 80, breathing 30 times a minute,
sating 93% on 2 liters. Patient was obtunded. He moved his
extremities spontaneously, but did not respond to sternal
rub. Pupils were equal, round and reactive to light
bilaterally. Chest was roughly clear to auscultation,
although patient had minimal inspiratory effort.
Cardiovascular exam revealed regular rate, normal S1, S2, no
murmurs. Abdomen was distended and firm with caput medusae.
Patient had a recently healed midline incision. Patient had
normoactive bowel sounds. Extremities showed trace edema
bilaterally in his lower extremities. On neurological exam
patient was unable to follow commands. He did have
withdrawal to painful stimuli on his extremities, but did not
respond to sternal rub and did spontaneously move all four
extremities.
LABORATORY DATA: Chest x-ray on admission showed patchy
infiltrates diffusely in the right lung versus question of
right sided effusion. Electrolytes on admission were sodium
139, K 4.0, chloride 108, bicarb 23, BUN 15, creatinine 0.6.
Free calcium was 1.13. INR was 1.5, PTT 31.9. Patient had
white count of 9.6, hematocrit 34, platelets 206. Patient's
t-bili was 1.8, alka phos was markedly elevated at 318, LDH
was elevated at 179, AST and ALT were mildly elevated at 52
and 48 respectively. Patient's albumin on admission was 2.4.
Patient's ABG on admission was 7.50, 30, 57 on 2 liters nasal
cannula which improved to 7.54, 26 and 198 on 100% face mask.
ASSESSMENT: In short, this is a 70 year old male with a long
complicated GI history who presented with new ascites in the
last several months and with a large GI bleed at [**Hospital6 11896**] on [**2197-10-16**]. Patient is hemodynamically
stable with stable hematocrit, but completely obtunded and
with new coagulopathy on admission.
HOSPITAL COURSE:
1. Encephalopathy. Patient was found to be profoundly
encephalopathic upon admission. It was not clear whether
this was entirely due to hepatic encephalopathy or due to
excessive sedation. All sedative medications were held for
the course of the patient's hospitalization. Patient was
started on lactulose. Patient's mental status improved with
lactulose throughout the next several days. Patient was
alert and oriented, able to follow conversation, although did
remain somewhat confused about larger issues. Patient
remained alert and oriented throughout the rest of his
hospital stay on lactulose.
2. GI bleed. Patient had a large GI bleed at the outside
hospital. Because of this patient was started on octreotide,
Protonix infusion and continued on propranolol. Serial
hematocrits were checked. Patient underwent banding of his
varices on [**2197-10-26**]. At that time patient's EGD report noted
grade 3 varices in the lower third of the esophagus that were
not bleeding.
3. Hepatic decompensation. Patient had elevated LFTs upon
admission and no clear cause for his liver failure.
Ultrasound of the right upper quadrant was repeated in-house
which did show nonocclusive [**Date Range 32004**] vein thrombosis. Patient
was transferred, as noted above, for transjugular liver
biopsy which patient underwent. Unfortunately, there was not
enough sample tissue obtained to make a definitive diagnosis.
However, the tissue that was present was suggestive of
cirrhosis. Patient's LFTs trended down and were within
normal limits upon the time of discharge with the exception
of his coagulation factors and his albumin which remained
markedly elevated and depressed respectively. Patient did
have difficulty with ascites during his hospitalization. He
was started on spironolactone to try to mobilize fluid with
some success. However, patient continued to develop
progressive ascites and lower extremity edema. Patient had a
diagnostic tap upon admission which was consistent with
transudative ascitic fluid secondary to [**Date Range 32004**] hypertension,
grew no organisms and gram stain was unremarkable. At the
time of this dictation therapeutic tap of patient's ascites
was being considered.
4. Infectious disease. Patient was thought to have
aspiration pneumonia upon admission and was started on levo
and Flagyl of which he was supposed to finish a 10 day
course. Unfortunately, patient lost the GJ-tube that had
been placed at the outside hospital and had a new tube
replaced which, unfortunately, became infected and began to
show purulent discharge. Because of this patient was
continued on levo and Flagyl and started on vanco. At the
time of this dictation patient has been afebrile with a
steady white blood cell count. He is currently on vanc, levo
and Flagyl. However, he will likely continue to be treated
with vancomycin alone since he has a history of MSSA.
Cultures are pending at the time of this dictation.
5. Hematology. Patient's hematocrit remained roughly stable
throughout the course of his admission, between 28 and 32.
Patient's hematocrit was monitored frequently. Patient had
no evidence of acute bleeding during the course of his
hospital stay. Patient's platelets were 206 on admission.
They trended down to a nadir of 96. Heparin antibodies were
checked and found to be negative. Patient's platelets were
continued to be followed. They remained stable in the low
100s at the time of this dictation. Patient's INR and PTT
remained elevated throughout the course of his
hospitalization. He had minimal response to p.o. vitamin K.
His INR was as high as 2.2. PTT was as elevated as 45.
Patient had been switched from p.o. to subcu vitamin K and
his coagulation factors were trending down at the time of
this dictation.
6. Endocrine. Patient had a history of type 2 diabetes
requiring insulin. While patient was NPO, he was maintained
on regular insulin sliding scale. When patient was fed p.o.
and/or taking tube feeds, he was maintained on NPH standing
dose as well as regular insulin sliding scale with good
glycemic control.
7. Fluids, electrolytes and nutrition. Nutrition was a
[**Last Name 16423**] problem during the patient's admission. His G-tube
fell out and needed to be replaced, which was done under
fluoroscopy in interventional radiology. Patient tolerated
tube feeds well, however, his tube began to show purulent
discharge several days after it was placed surrounding the
opening site. Patient had marked tenderness around the site.
Feeds were stopped and patient was started on antibiotics.
The discharge around the site resolved after treatment with
vancomycin as did the tenderness and erythema. At this
dictation it is still being decided whether patient should be
fed with tube feeds versus TPN. Another issue with his
GJ-tube is that as his ascites has expanded, patient has
begun to develop leakage of stool around the GJ-tube site.
Tube placement was checked again by IR. It was not found to
be leaking into the peritoneum. It was thought that the
stool is likely small bowel contents refluxing into patient's
gastric space. It should be noted again that patient has
gastrojejunostomy secondary to gastroparesis and the tube
itself is a GJ-tube. Patient required frequent repletion of
his calcium, potassium and magnesium while in-house.
8. Cardiovascular. Patient had a history of coronary artery
disease. This issue was not active during the course of his
hospitalization. Patient had no signs of heart failure or
ischemia.
9. Renal. Patient had good urine output while he had a
Foley in. However, once the Foley was discontinued, patient
had some difficulty urinating and needed to be straight
cathed several times for urine output. Patient's urine was
checked and sent for culture. Cultures were negative two
days prior to discharge. Patient's BUN and creatinine
remained stable throughout the course of his hospitalization.
10. Psych. Patient has a history of post traumatic stress
disorder secondary to having been imprisoned in a Japanese
war camp in the [**Country 31115**] as a child. Patient has a great
deal of anxiety and claustrophobia secondary to this.
Patient was evaluated by psychiatry in-house who felt patient
would benefit from Risperdal. Patient was treated with
Risperdal throughout the course of his hospitalization with
good control of his anxiety. Patient's family also brought
patient a VCR on which he watched movies which also helped
soothe patient's anxiety. Psychiatry felt patient likely had
some element of reversible dementia and should have formal
neurocognitive evaluation as an outpatient.
11. Disposition. At this time patient is awaiting rehab
placement or transfer back to [**Hospital6 **] to be cared
for by [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 3100**] who is his primary gastroenterologist.
At this time patient is in stable condition.
MEDICATIONS AT TIME OF DICTATION:
1. Regular insulin sliding scale.
2. Propranolol 20 mg p.o. or per NG t.i.d. with parameters
to hold for systolic blood pressure less than 100.
3. Protonix 40 mg p.o. b.i.d.
4. Risperdal 1.5 mg p.o. b.i.d. as well as 1 mg p.o. b.i.d.
p.r.n. agitation.
5. Levofloxacin 500 mg p.o. q.24 hours.
6. Flagyl 500 mg t.i.d.
7. Vancomycin 1 gm q.12 hours.
8. Vitamin K 10 mg subcutaneously q.day.
9. Lacri-Lube ointment ophthalmologic as well as tobramycin
ophthalmologic solutions.
10. Lactulose 30 mg p.o. q.eight hours p.r.n. titrated to
four bowel movements a day.
DISCHARGE DIAGNOSES:
1. Cirrhosis, etiology unclear.
2. [**Name2 (NI) **] vein thrombosis, nonocclusive.
3. Esophageal varices, status post banding.
4. Hepatic encephalopathy.
5. Coronary artery disease, status post CABG.
6. Type 2 diabetes mellitus.
7. Hypertension.
8. Post traumatic stress disorder.
9. Anxiety.
10. Status post open cholecystectomy.
11. Status post choledochojejunostomy.
12. Status post gastrojejunostomy.
13. Status post GJ-tube placement.
An addendum to this discharge summary will be added at such
as the patient is discharged.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 21723**]
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2197-11-3**] 19:52
T: [**2197-11-3**] 20:31
JOB#: [**Job Number 106625**]
Admission Date: [**2197-10-21**] Discharge Date: [**2197-11-14**]
Date of Birth: [**2127-3-9**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 70-year-old
male transferred from an outside hospital with a history of
chronic pancreatitis. The patient initially presented to
medical attention early in [**2195**] with a 23 pound weight loss
and jaundice. Workup for this found that he had dilated
biliary ducts on CT. The patient underwent multiple ERCP
procedures with common bile duct stenting starting in [**2196-3-27**]. The patient had multiple removals and revisions of
his stents. The patient also had multiple washings for
cytology which had been negative for malignant cells.
The patient underwent choledochojejunostomy in [**2196-6-26**]
to bypass his biliary obstruction. He had multiple
pancreatic biopsies at that time which were negative for
malignancy. The patient did well until several months later
when he developed nausea and vomiting again, thought to be
due to gastroparesis. He had a G tube placed in the spring
of [**2196**] for nutritional support as well as a repeat
gastrojejunostomy to bypass his duodenum. The patient had
increased ascites which has been tapped several times and
been negative for cytology.
The patient presented to an outside hospital on [**2197-10-16**] with
several hours of vomiting blood. He was found to be
hypotensive in their ED with a hematocrit of 19. He was
resuscitated with packed red blood cells and found to have
grade II varices on a [**2197-10-17**] EGD. However, they were not
banded at that time.
Over the next few days, the patient became increasingly
obtunded and was transferred to [**Hospital6 2018**] for liver biopsy. Of note, the patient had an
ultrasound which showed normal [**Hospital6 32004**] vein flow and no
evidence of [**Hospital6 32004**] vein thrombosis. The patient developed
coagulopathy at the outside hospital.
PAST MEDICAL HISTORY:
1. GI history, as above.
2. Coronary artery disease, status post CABG.
3. Hypertension.
4. Type 2 diabetes.
5. Multiple pulmonary nodules.
6. Post-traumatic stress disorder.
MEDICATIONS ON TRANSFER:
1. Elavil 25 mg p.o. q.h.s.
2. Ambien 10 mg p.o. q.h.s.
3. Protonix 8 micrograms per hour.
4. Regular insulin sliding scale with 16 of NPH and 4 units
of regular in the morning.
5. Inderal 20 mg t.i.d.
6. Lactulose 30 cc b.i.d.
7. Duragesic patch 75 micrograms q. 72 hours.
8. Risperdal 0.5 mg b.i.d.
9. Tobramycin eyedrops.
10. Lacrilube.
11. Ativan p.r.n.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.3, blood pressure 122/70, pulse 80, saturating 92% on 2
liters. General: The patient was obtunded. Would move
extremities to sternal rub and withdrawal from painful
stimuli but did not open his eyes spontaneously. The pupils
were equal, round and reactive. The chest was clear to
auscultation bilaterally. Cardiovascular: Regular rate.
Abdomen: Distended, firm, with a noticeable caput medusae
and a recently healed midline incision. The patient had
normoactive bowel sounds. The patient had trace bilateral
edema in his lower extremities. Neurologically, the patient
would not follow commands.
LABORATORY DATA/OTHER STUDIES: The chest x-ray was notable
for patchy infiltrates diffusely in the right lung.
The laboratories on admission revealed a sodium of 139,
potassium 4.0, chloride 108, bicarbonate 23, BUN 15,
creatinine 0.6. The patient's INR was 1.5, PTT 31.9. The
patient's hematocrit was 34. His total bilirubin was 1.8,
albumin 2.4, alkaline phosphatase 318, LD 179, AST 48, ALT
62. The patient had ABGs which showed him to be 7.50, PC02
30, P02 57 on 2 liters nasal cannula. The patient then had a
repeat ABG which showed a pH of 7.54, PC02 26, P02 198 on
100% face mask.
HOSPITAL COURSE: In short, this was a 70-year-old man with a
long GI history who presented with new ascites in [**2197-6-26**] and with a GI bleed on [**2197-10-16**]. He presented
hemodynamically stable and with a stable hematocrit but
completely obtunded and with a new coagulopathy.
1. GASTROINTESTINAL BLEED: The patient was started on a
Protonix drip as well as Octreotide. His Inderal was also
continued. The patient remained hemodynamically stable. He
underwent EGD with initial banding of his varices while
in-house. The patient had no further evidence of GI bleed.
While he was hospitalized, the patient had a re-look which
showed his bands to still be in place prior to discharge.
The patient was scheduled to follow-up with GI for repeat
banding on [**2197-12-1**].
2. LIVER FAILURE: The patient's liver failure is of an
unclear etiology. He was evaluated by the Liver Service. He
underwent a right upper quadrant ultrasound which showed that
there was some evidence of [**Date Range 32004**] vein thrombosis. The
patient also underwent an MRI/MRCP which showed him to have
some element of thrombosis also in his [**Date Range 32004**] vein but not in
any of his other [**Date Range 32004**] vasculature. The patient's MRI/MRA
was poor quality given to the patient's inability to lie flat
due to shortness of breath.
The patient underwent a liver biopsy which was nondiagnostic
secondary to inadequate sample. However, it did appear to be
consistent with cirrhosis.
3. ASCITES: The patient continued to develop progressive
ascites during his hospitalization. The patient initially
underwent diagnostic paracentesis which showed no evidence of
spontaneous bacterial peritonitis. The patient underwent
therapeutic paracentesis in which 6 liters was drained and
the patient had subsequent albumin infusion. The patient was
started on Lasix and Aldactone as his blood pressures and
renal function could tolerate.
4. MENTAL STATUS: The patient came in on an enormous number
of sedatives. All of these were discontinued upon admission.
The patient was given Lactulose which was titrated to his
bowel movements. The patient became awake and alert, able to
converse. The patient was evaluated by the Psychiatry
Service for management of his post-traumatic stress disorder
and agitation. The patient was started on Risperdal which he
tolerated well.
The patient was also evaluated by Psychiatry to discuss his
competence to make decisions for himself and found to be
completely competent.
5. NUTRITION: The patient had a G tube on admission.
Placement of this G tube was confirmed by Gastrografin. This
G tube eventually fell out, however, and needed to be
replaced. The patient had a new G tube replaced in
Interventional Radiology, however, with expanding ascites,
the patient experienced a large amount of leakage around the
site of the G tube as well as some purulent discharge. Feeds
were stopped through the tube. The patient was treated with
vancomycin for coagulase-positive Staphylococcus which grew
from a swab taken from around his G tube.
The patient had a seven day course of vancomycin and no
positive blood cultures.
6. INFECTIOUS DISEASE: The patient was initially started on
levofloxacin for infiltrates on his admission chest x-ray.
The patient completed a ten day course of levofloxacin. The
patient also began to complain of pain and swelling in his
testicles. He had pyuria and was thought to have
epididymitis. The patient was started on ciprofloxacin for a
seven to ten day course and treated with analgesia.
7. HEMATOLOGY: The patient's hematocrit remained roughly
stable throughout the course of his admission. It did drop
somewhat and the patient received three units of packed red
blood cells throughout the course of his admission. The
patient remained Guaiac negative. The patient also had
elevated INR and PTT. The patient was started on vitamin K
10 mg subcutaneously q.d. His INR and PTT remained stable.
8. CARDIOVASCULAR: The patient had a history of
cardiovascular disease. He had an element of chest pain that
resolved with sublingual nitroglycerin. Question of an
elevated ST in V2 on EKG compared to admission. The patient
was ruled out for MI uneventfully.
9. PSYCHIATRY: The patient had a history of post-traumatic
stress disorder secondary to being in a prison camp as a
child. He was seen by Psychiatry who started him on
Risperdal which the patient tolerated well. The patient was
also brought in a television from home and watched movies to
soothe his anxiety. The patient was also started on Remeron
q.h.s. which he tolerated well.
10. CODE STATUS: This was an issue of much discussion
throughout the [**Hospital 228**] hospital stay. The patient's family
wished for him to be DNR/DNI given his poor prognosis.
However, the patient was not clear that this is what he
wanted. The patient fluctuated, occasionally saying that he
wished to be resuscitated and other times stating that he
wished for us to euthanize him.
The patient was evaluated by Psychiatry for issues of
competency and deemed competent. The patient then stated
firmly that he did not wish to be resuscitated and the
patient was discharged to home with hospice level care.
DISCHARGE MEDICATIONS:
1. Remeron 7.5 mg q.h.s.
2. Insulin NPH 8 units subcutaneously q.a.m. and with
dinner.
3. Sliding scale of regular insulin.
4. Spironolactone 25 mg p.o. q.d.
5. Protonix 40 mg p.o. q. 12 hours.
6. Risperdal 0.5 mg p.o. b.i.d.
7. Vitamin K 10 mg subcutaneously q.d.
8. Ciprofloxacin 500 mg p.o. q. 12 hours for 14 days.
9. Lactulose 20 cc q. eight hours p.r.n.
10. Oxycodone IR 10 mg one to two tablets q. four hours
p.r.n. pain.
11. Magnesium oxide 250 mg p.o. b.i.d.
DISPOSITION: The patient was discharged home with hospice to
follow-up with his primary care doctor at [**Hospital6 **]
as well as with our Gastroenterology Department for repeat
banding of varices on [**2197-12-1**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 21723**]
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2198-1-6**] 01:49
T: [**2198-1-9**] 06:54
JOB#: [**Job Number **]
|
[
"456.20",
"571.5",
"577.1",
"507.0",
"572.2",
"309.81",
"536.41",
"572.3",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"42.33",
"45.13",
"96.6",
"97.03",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
12047, 14770
|
21917, 22837
|
16652, 18584
|
2596, 4462
|
142, 1903
|
15402, 16634
|
18600, 21894
|
14998, 15387
|
14792, 14973
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,555
| 154,470
|
23880
|
Discharge summary
|
report
|
Admission Date: [**2141-5-7**] Discharge Date: [**2141-5-14**]
Date of Birth: [**2092-2-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2141-5-9**]
CABGx4(LIMA->LAD, SVG->OM1, OM2, PDA) [**2141-5-10**]
History of Present Illness:
49 year old with past hx of hypercholesterolemia, dystonia,
developed acute onset "dizziness" and sudden loss of
consciouness after running
around the track this afternoon. He recalls events with detail.
States he had some chest tightness while running, but has only
recently started running again (2wks ago, after 6 week hiatus
due
to left calf pain). He reports he was walking to his car and
suddenly became dizzy, remembers 'blacking out' and next thing
remembers being in the ambulance. Bystander saw the event and
started CPR until ambulance came; no apparent convulsive events
noted. He apparently lost urinary continence though. Pt was
brought to [**Hospital1 18**] emergency room where his coma scale=15 on
arrival. A laceration to his right occiput was noted. No other
complaints.
Past Medical History:
Hypercholesterolemia
Depression
Left hand dystonia
Transient Ischemic Attacks
Social History:
Lives with wife and children. Works as an attorney. Drinks 3
drinks weekly.
Family History:
Father with Bypass surgery in his 50's
Mother Aortic aneurysm.
Physical Exam:
VS: T: 100.4rectal BP:123-141/68-75 P:80-99 RR:16 O2
sat:100%NC
General: WNWD, NAD
HEENT: Anicteric, MMM without lesions, OP clear
Neck: Supple, no LAD, no carotid bruits, no thyromegaly
CV: RRR s1s2 no m/r/g
Resp: CTAB no r/w/r
Abd: +BS Soft/NT/ND no HSM/masses
Ext: No c/c/e, distal pulses intact
Skin: No rashes, petechiae
MS: A&O x 3, interactive, appropriate, following all commands
Spells WORLD backwards, names months of year backwards, makes
change
Speech fluent w/o paraphasic errors, +naming of wholes & parts,
+repetition, +comprehension
No evidence of neglect with visual or tactile stimulation
CN: I - not tested, II,III - PERRL, VFF by confrontation;
III,IV,VI - EOMI, no ptosis, no nystagmus; V- sensation intact
to LT/PP, masseters strong symmetrically; VII - no facial
weakness/asymmetry; VIII - hears finger rub B; IX,X - voice
normal, palate elevates symmetrically; [**Doctor First Name 81**] - SCM/Trapezii [**5-18**] B;
XII - tongue protrudes midline, no atrophy or fasciculations
Motor: nl bulk and tone, no tremor, rigidity or bradykinesia. L
fingers have tendency to flex on pronator drift or with
distraction. No asterixis.
Deltd Bicep Tricp ECR/U ExDig FlDig DorsI OppPB
Axill mscut [**Month/Day (1) 21443**] [**Name6 (MD) 21443**] [**Name8 (MD) 21443**] md/ul ulnar medin
C5 C5-6 C7 C6-7 C7 C8 T1
C8-T1
L 5 5 5 5 5 5 5
5
R 5 5 5 5 5 5 5
5
Ilpso Qufem Hamst TibAn [**First Name9 (NamePattern2) 2778**] [**Last Name (un) 938**]
Femor femor [**First Name9 (NamePattern2) 21444**] [**Last Name (un) 18709**] tibil dpper
L1-2 L3-4 L5-S2 L4-5 S1-2 L5
L 5 5 5 5 5 5
R 5 5 5 5 5 5
DTRs: [**Name2 (NI) **] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar
L 3 3 3 3 2 down
R 3 3 3 3 2 down
Sensory: LT, temperature, vibration, and joint position intact.
Graphesthesia intact.
Coord: finger tap rapid & symm, F N & FNF intact B.
Gait: deferred.
Pertinent Results:
[**2141-5-7**] 05:35PM PT-13.6 PTT-22.1 INR(PT)-1.2
[**2141-5-7**] 05:35PM WBC-6.9 RBC-4.84 HGB-15.6 HCT-43.3 MCV-89
MCH-32.3* MCHC-36.2* RDW-12.6
[**2141-5-12**] 06:40AM BLOOD WBC-13.2* RBC-2.95* Hgb-9.6* Hct-26.0*
MCV-88 MCH-32.5* MCHC-37.0* RDW-12.5 Plt Ct-108*
[**2141-5-10**] 06:35AM BLOOD Neuts-69.1 Lymphs-22.4 Monos-4.8 Eos-3.4
Baso-0.3
[**2141-5-12**] 06:40AM BLOOD Plt Ct-108*
[**2141-5-14**] 05:50AM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-136
K-3.5 Cl-99 HCO3-30* AnGap-11
[**2141-5-9**] 03:19PM BLOOD ALT-59* AST-35 AlkPhos-61 Amylase-24
TotBili-0.9
[**2141-5-14**] 05:50AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.0
[**2141-5-11**] 03:24AM BLOOD freeCa-1.19
Head CT [**2141-5-8**]
1) No evidence of acute intracranial hemorrhage.
2) Right superior parietal scalp hematoma.
EKG [**2141-5-7**]
Sinus rhythm. J point elevation with early repolarization in
anterior
precordial leads may be normal variant. No previous tracing
available for
comparison.
[**2141-5-8**] Exercise Stress Test
1. Moderate reversible defect of the mid and distal anterior
wall
and apex, corresponding to the territory of a mid-LAD defect. 2.
Mild left
ventricular enlargement, with calculated LVEF of 49%.
[**2141-5-8**] ECHO
1. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded.
2. The aortic root is mildly dilated.
[**2141-5-8**] Carotid Duplex Ultrasound
Examination within normal limits.
[**2141-5-9**] EEG
This is an abnormal EEG obtained in wakefulness and stage II
sleep due to intermittent focal slowing with bursts of sharp
transients
in the left anterior region. This finding suggests a possible
focal
subcortical structure lesion in this area. This is a relatively
non-specific finding regarding evaluation for seizures.
[**2141-5-9**] Cardiac Catheterization
1. Selective coronary angiography revealed a right dominant
system with
severe two vessel CAD. The LMCA had no angiographic evidence of
CAD. The
LAD had an ostial 20% stenosis and serial 80% lesions in the
proximal
vessel. The mid vessel had serial stenoses with sub-total
occlusion in
the mid-vessel. The distal vessel has no flow-limiting
stenoses. The
LCx had a large bifurcating OM that had 70% upper and lower pole
stenoses. The RCA had mid-vessel 50% stenosis, a 50% stenosis
in the
distal postero-lateral branch and a 50% stenosis in the origin
of the
PDA.
2. Limited hemodynamics revealed normal arterial pressures and
LVEDP.
There was no gradient on pull-back of the catheter from the LV
to the
aorta.
3. Left ventriculography revealed a low-normal ejection fraction
without
evidence of wall motion abnormality or mitral regurgitation.
[**2141-5-11**] CXR
Interval removal of multiple lines and tubes including the ET
tube. Tiny left apical pneumothorax.
Brief Hospital Course:
Mr. [**Name14 (STitle) 60910**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2141-5-8**] for further evaluation of his syncopal
episode. Neurology work-up was negative thus suggesting a
cardiac cause. He was worked-up with a variety of tests listed
previously including an exercise tolerance test which was
positive. Ultimately a cardiac catheterization was performed
which revealed severe two vessel disease. Due to the severity of
his disease, the cardiac surgical service was consulted for
surgical revascularization and Mr. [**Name14 (STitle) 60910**] was worked-up in
the usual preoperative manner. On [**2141-5-10**], Mr. [**Name14 (STitle) 60910**] was
taken to the operating room where he underwent coronary artery
bypass grafting to four vessels. Postoperatively he was taken to
the cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**First Name (Titles) 60910**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. He was then 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 was titrated for optimal heart rate and blood
pressure support. Mr. [**Name14 (STitle) 60910**] continued to make steady
progress and was discharged home on postoperative day four. He
will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his
primary care physician as an outpatient.
Medications on Admission:
Vitamin E
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Crestor 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*120 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. 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:
Coronary artery disease.
Discharge Condition:
Good.
Discharge Instructions:
Follow meidcations on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) 27482**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2141-6-16**]
|
[
"272.4",
"411.1",
"850.11",
"333.7",
"414.01",
"780.2",
"285.9",
"873.0",
"E888.9",
"E939.1",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"36.15",
"39.61",
"86.59",
"36.13",
"88.53"
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icd9pcs
|
[
[
[]
]
] |
9522, 9580
|
6621, 8243
|
327, 422
|
9649, 9656
|
3730, 6598
|
9899, 10074
|
1459, 1523
|
8303, 9499
|
9601, 9628
|
8269, 8280
|
9680, 9876
|
1538, 3711
|
280, 289
|
450, 1249
|
1271, 1350
|
1366, 1443
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,737
| 163,271
|
42493
|
Discharge summary
|
report
|
Admission Date: [**2192-12-3**] Discharge Date: [**2192-12-22**]
Date of Birth: [**2139-4-15**] Sex: M
Service: MEDICINE
Allergies:
Risperdal Consta / Heparin Agents / vancomycin
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Unresponsive, found down in the field
Major Surgical or Invasive Procedure:
Mechanical Intubation and Ventilation
Central Subclavian Placement
Arterial line placement
History of Present Illness:
Patient is a 53 M with PMH of COPD, schizoaffective disorder,
depression, HTN who was found down w/albuterol inhaler at side.
He was found to be hypoxic to the 70s. He was intubated at the
scene with succinylcholine, etomidate, fentanyl 250 mg, versed 3
mg by EMS. He also received magnesium 2 mg iv. He was taken to
[**Hospital6 204**] where his initial VS on arrival to
[**First Name4 (NamePattern1) 189**] [**Last Name (NamePattern1) **] were: P: 112, BP: 56/41, 80% ventilated. He was
started on levophed and neosynephrine. Had large A-a gradient
and was difficult to ventilate. He remained hypoxic despite high
PEEPs and 100% FiO2. A non-contrast CT was performed at OSH
which showed left sided pleural effusion and large
consolidation. Imaging also showed an old 9th rib fracture,
normal CT head and neck. CT abdomen was unremarkable. He was
started on heparin drip for concern of PE given the difficulty
in ventilating the patient. He then developed UGIB with 1L BRB
per OGT, at which point heparin stopped and he was given
Protonix drip. He also received albuterol, vanc, flagyl,
levaquin, solumedrol, Ceftriaxone. For sedation, he received an
additional 12 mg ativan, 30 mg iv morphine.
.
On arrival to [**Hospital1 18**], his VS were P: P: 87, BP: 105/70, RR: 14,
02 84% on ventilator. NG lavage showed only coffee ground emesis
and no further BRB. He was given albuterol nebs. A groin line
was placed. On transfer to the MICU, his most recent VS were P:
87, BP: 115/62, RR: 14, O2 89% on CMV PEEP 20, FiO2 98%, plateau
37 on phenylepinephrine 1 mcg/kg/ min.
.
On arrival to the MICU, patient was intubated, minimally
responsive. Guaic negative brown stools.
Past Medical History:
Obesity
COPD
HTN
schizoaffective disorder
Depression
Dematitis
Tobacco use
Hx of Seizures
Hypercholesterolemia
Social History:
Social History:
- Tobacco: yes
- Alcohol: unknown
- Illicits: unknown
Family History:
Family History: unknown
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.7, BP: 137/77 P: 90 R: 17 18 O2: 91% on CMV, TV
500, PEEP 20, RR 14, FiO2 100%
General: intubated, sedated
HEENT: Sclera anicteric, crusted blood at oropharynx
Neck: obese, beard in place, unable to assess JVP
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diminished breath sounds over LLL and L middle lobe;
right lung clear with no wheezes, rales or rhonchi
Abdomen: obese, soft, non-tender, hypoactive bowel sounds
present, no organomegaly
RECTAL: guaic neg brown stools
GU: foley in place
Ext: cool extremities, poor distal pulses
Neuro: Pupils 3 mm->2 mm. winces to forced opening of eyes,
otherwise not responding to pain
Pertinent Results:
Admission labs:
[**2192-12-4**] 12:05AM BLOOD WBC-17.3* RBC-4.56* Hgb-13.8* Hct-42.3
MCV-93 MCH-30.3 MCHC-32.6 RDW-16.2* Plt Ct-198
[**2192-12-4**] 12:05AM BLOOD Neuts-96* Bands-0 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3*
[**2192-12-4**] 12:05AM BLOOD PT-14.5* PTT-31.5 INR(PT)-1.4*
[**2192-12-4**] 12:05AM BLOOD Glucose-188* UreaN-59* Creat-2.1* Na-131*
K-4.8 Cl-92* HCO3-30 AnGap-14
[**2192-12-4**] 12:05AM BLOOD ALT-4286* AST-5738* AlkPhos-136*
TotBili-0.5
[**2192-12-4**] 12:05AM BLOOD Calcium-8.7 Phos-5.9* Mg-2.8*
[**2192-12-3**] 10:59PM BLOOD Type-ART pO2-50* pCO2-77* pH-7.20*
calTCO2-31* Base XS-0
Brief Hospital Course:
53 yom obesity, COPD, schizoaffective disorder, depression, HTN
who was found down w/ albuterol inhaler at side who presented
with respiratory failure and shock.
#Respiratory Failure/ ARDS: Patient admitted with respiratory
failure after requiring intubation in the field for respiratory
distress and unresponsiveness. Pneumonia and pleural effusion
were the main cause of hypoxia. No PE seen on CT but no contrast
given in the setting of his elevated creatinine. LENIs showed no
DVT. He was kept on ARDS net protocol for his mechanical
ventilation. He was given albuterol and ipratroprium MDI q4h.
His pneumonia was treated with vancomycin/ zosyn / levofloxacin
for an 8 day course. The patient failed extubation on two
occasions during the current hospitalization. Recommendation
was made to proceed with tracheotomy tube placement, but
following extensive and comprehensive discussions with the
patient's HCP, tracheotomy tube placement and chronic mechanical
ventilation were not consistent with the patient's previously
expressed wishes.
Plans were initiated to optimize [**Hospital 228**] medical condition in
preparation for a final extubation trial without plans for
reintubation or resussitation (DNR/DNI). Following optimization
of medical condition, the patient was extubated, and remained
stable over the intitial 24 hours, primarily demonstrating
aggitation and restlessness, but without meaningful neurological
interaction. Patient gradually developed respiratory distress
and hypoxemia, and following additoinal discussions with the
patient's HCP, focus of care transitioned to comfort as the
primary goal.
Patient expired comfortably.
#Pulmonary Embolus: patient diagnosed with PE on [**12-12**] and
started on heparin drip. LENIs showed extensive clot in RLE.
Determined to be HIT+ while receiving heparin, so argatroban was
substituted.
#A. Fib: Patient developed a. fib with RVR in setting of new PEs
on [**12-12**]. He was given iv metoprolol and dilt with limited
response and was loaded with amiodarone and then started on po
amiodarone with metoprolol 100 mg po TID.
#Upper GI bleed: [**1-17**] ulcer in antrum in the setting of being
placed on heparin drip. He was treated initially with
pantoprazole drip and pantoprazole [**Hospital1 **]. His hematocrit remained
stable and he did not require a blood transfusion.
# Cardiac ischemia - Cardiac enzymes were elevated and EKG had
ST changes attributed to shock and demand ischemia. ECHO showed
old wall abnormalities. Troponins stabilized. He was continued
on aspirin 81 mg.
#Shock Liver: Patient's transaminitis were likely secondary to
shock liver in the setting of hypotension and hypoxia.
Acetaminophen level negative in tox screen. LFTs continued to
trend down.
#. ARF: Likely secondary to shock and hypovolemia. Creatinine
continued to normalize. He maintained good urine output.
# Schizoaffective disorder: Lives in group home. He was
continued on his citalopram and topamax. Wellbutrin was stopped
as outside records indicated he had had a recent suspected
seizure.
Medications on Admission:
Aspirin 81 mg po daily
Ativan 0.5 mg po qHS prn
Benadryl 25 mg po qhs
cogentin 1 mg po BID
Hyzaar (losartan-HCTZ) 100/25 mg po qAM
Khlor-Con
Multivitamin
Nifedipine 90 mg po qAM
Pro-air 2 puff prn
simvastatin 80 mg po daily
Topamax 100 mg po BID
Celexa 20 mg po qAM
Wellbutrin SR 150 mg po qAM- should not be restarted
Nicotine patch
Motrin 800 mg po TID prn pain
Vicodin 5-500 mg po q4-6 hrs prn pain
Miralax powder
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2192-12-29**]
|
[
"807.01",
"584.9",
"293.0",
"345.90",
"V85.42",
"427.31",
"289.84",
"785.52",
"414.8",
"278.01",
"038.9",
"428.0",
"427.89",
"496",
"518.81",
"995.92",
"415.19",
"276.1",
"311",
"453.42",
"486",
"E928.9",
"531.40",
"401.9",
"412",
"295.72",
"705.1",
"305.1",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"45.13",
"86.11",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7354, 7363
|
3795, 6855
|
346, 439
|
7414, 7423
|
3142, 3142
|
7479, 7644
|
2397, 2407
|
7322, 7331
|
7384, 7393
|
6881, 7299
|
7447, 7456
|
2447, 3123
|
269, 308
|
467, 2138
|
3158, 3772
|
2160, 2273
|
2305, 2364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,819
| 186,446
|
31574+57757
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-9-3**] Discharge Date: [**2190-9-19**]
Date of Birth: [**2121-6-18**] Sex: F
Service: MEDICINE
Allergies:
Zocor / [**Year (4 digits) **] / Crestor
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
1. Bronchoscopy
2. Endotracheal intubation
History of Present Illness:
69F PMH severe COPD (2L NC home O2, FEV1/FVC 55%, FEV1 30%
predicted, also restrictive defect with TLC 72% of predicted),
tracheobronchomalacia s/p stent placement [**2190-8-6**], initially
admitted to the IP service [**2190-9-3**] for acute shortness of
breath and increased cough thought secondary to mucus plugging.
Of note, the patient underwent bronchoscopy [**2190-8-13**] for mucus
plugging and recently finished a prednisone taper [**2190-8-23**] for
COPD exacerbation. The patient underwent bronchoscopy [**2190-9-3**]
that showed that the stent itself appeared to be patent with
minimal secretions. Granulation tissue was seen at the distal
end of the stent in both the right and the left main stem
bronchi. The patient underwent stent removal [**2190-9-6**],
complicated by respiratory distress and hypercarbic respiratory
failure with pCO2 as high as 111. The patient was intubated and
transferred to the SICU. The patient was started on
levofloxacin 750 IV QD and methylprednisolone 80 mg IV Q8H
[**2190-9-7**] for empiric treatment of pneumonia and COPD flare. The
patient was also diuresed with lasix presumably for volume
overload. The patient was extubated [**2190-9-9**]. Patient required
BiPap until the morning of transfer. At the time of transfer,
the patient was breathing comfortably on 6L NC. Denies
shortness of breath, chest pain.
.
The patient's blood pressure was uncontrolled at times requiring
labetolol gtt, but the patient was on an oral regimen on
transfer
Past Medical History:
Past Medical History:
1. Severe COPD (FEV1/FVC 55%, FEV1 30% predicted, also
restrictive defect with TLC 72% of predicted)
2. Diabetes mellitus type 2
3. Hypertension
4. Hyperlipidemia
5. Status post total thyroidectomy [**2155**]
.
Past Surgical History: Tracheal stent as above.
Social History:
Social History: Lives alone. Remote 30 pack-year smoking
history. Rare EtOH.
Family History:
Family History: No history of heart or pulmonary disease.
Physical Exam:
on admission:
Physical Examination:
Vital signs: T 97.0 P 87 BP 149/57 RR 17 O2sat 95%6L
General: Lying in bed, breathing comfortably
HEENT: Sclera anicteric, extraocular movements intact, mucus
membranes dry
Heart: Regular rate and rhythm, 2/6 systolic early peaking
murmur, no rubs or gallops
Lungs: Distant breath sounds, increased expiratory phase, no
wheezes/rales/rhonchi
Abdomen: Obese, normoactive bowel sounds, soft, nontender,
nondistended
Extremities: No clubbing, cyanosis, or edema
Skin: Warm, no rashes
Neurologic: Sleepy, arouses to touch, oriented x 3
Pertinent Results:
CHEST (PORTABLE AP) Study Date of [**2190-9-10**]
The patient was extubated in the meantime interval with removal
of the NG tube. The cardiomediastinal silhouette is stable.
Previously demonstrated patchy opacities did not change
significantly in the meantime interval. [**Month (only) 116**] be atelectasis but
infection cannot be ruled out. Close followup is recommended to
exclude the possibility of developing pneumonia.
.
CHEST (PORTABLE AP) Study Date of [**2190-9-7**]
IMPRESSION:
1. Decreased right lower lobe patchy opacities likely
reflecting resolving atelectasis and/or pneumonitis.
2. OGT tip terminating within the gastric fundus with side port
likely at or above the GE junction. [**Month (only) 116**] benefit from mild
advancement.
.
CHEST (PORTABLE AP) Study Date of [**2190-9-6**]
IMPRESSION:
1. Endotracheal tube in satisfactory position.
2. Bibasilar streaky opacities likely reflects underlying
atelectasis, difficult to exclude pneumonia.
.
LABS
.
CHEM/CBC
[**2190-9-6**] 04:37PM BLOOD Hct-36.7
[**2190-9-8**] 03:00AM BLOOD WBC-7.2 RBC-2.81* Hgb-9.1* Hct-27.0*
MCV-96 MCH-32.5* MCHC-33.8 RDW-15.8* Plt Ct-292
[**2190-9-18**] 05:50AM BLOOD WBC-19.3* RBC-2.67* Hgb-8.6* Hct-26.1*
MCV-98 MCH-32.3* MCHC-33.0 RDW-15.4 Plt Ct-328
[**2190-9-18**] 11:30AM BLOOD Hct-29.7*
[**2190-9-19**] 07:05AM BLOOD WBC-17.7* RBC-2.85* Hgb-9.1* Hct-27.5*
MCV-96 MCH-31.9 MCHC-33.1 RDW-16.0* Plt Ct-364
[**2190-9-6**] 04:37PM BLOOD Glucose-172* UreaN-7 Creat-0.4 Na-141
K-3.6 Cl-99 HCO3-34* AnGap-12
[**2190-9-7**] 03:01AM BLOOD Glucose-140* UreaN-9 Creat-0.4 Na-138
K-3.2* Cl-98 HCO3-31 AnGap-12
[**2190-9-18**] 05:50AM BLOOD Glucose-66* UreaN-9 Creat-0.4 Na-138
K-3.4 Cl-99 HCO3-33* AnGap-9
[**2190-9-19**] 07:05AM BLOOD Glucose-83 UreaN-10 Creat-0.4 Na-142
K-4.8 Cl-101 HCO3-35* AnGap-11
.
CARDIAC LABS
[**2190-9-10**] 02:01AM BLOOD proBNP-542*
[**2190-9-6**] 04:37PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-9-6**] 04:37PM BLOOD CK(CPK)-41
.
BLOOD GASES
[**2190-9-6**] 07:23PM BLOOD Type-ART FiO2-100 pO2-274* pCO2-111*
pH-7.11* calTCO2-38* Base XS-1 AADO2-331 REQ O2-60 Intubat-NOT
INTUBA Comment-O2 DELIVER
[**2190-9-6**] 08:51PM BLOOD Type-ART pO2-184* pCO2-73* pH-7.27*
calTCO2-35* Base XS-4
[**2190-9-10**] 10:44PM BLOOD Type-ART pO2-123* pCO2-60* pH-7.40
calTCO2-39* Base XS-10
[**2190-9-11**] 08:30AM BLOOD Type-ART Temp-35.7 pO2-61* pCO2-53*
pH-7.47* calTCO2-40* Base XS-12 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
Brief Hospital Course:
IN THE MICU:
Assessment/Plan: 69F PMH severe COPD (FEV1/FVC 55%, FEV1
30%predicted, also restrictive defect with TLC 72% of
predicted), tracheobronchomalacia with recent stent removal
transferred from SICU for managment of presumptive COPD flare.
.
# Respiratory Distress. Patient has history of severe COPD with
frequent exacerbations and this likely represents a COPD flare.
Patient has no history of CHF and does not appear fluid
overloaded. Unlikely pulmonary embolus given prophylaxis.
Patient on 2L NC at baseline.
- Continue advair, tiotropium, standing albuterol, tessalon
perles, codeine PRN;
- Continue levofloxacin for presumptive pneumonia for 7-day
course started [**2190-9-7**] (course finished on [**2190-9-14**]); changed to
500 mg PO
- Slow steroid taper, taper methylprednisolone to prednisone 60
mg [**Last Name (LF) 244**], [**First Name3 (LF) **] decrease to 50 tomorrow and taper over 10-14d
- Consider TTE as outpatient to evaluate cardiac function
-BiPap machine attempted at night. not tolerated thought pt did
well on NC
-OOBed to chair
- wean NC from 6 to 2L as tolerated with goal sat low 90s (home
02 requirement 2Lpm)
.
#Agitation - currently resolved though pt jittery, likely froms
steroids
-Possibly from steroids, has had problems in past
-Discussed briefly with Son, functions well at baseline
-PRN haldol, small doses (.5mg w/ good result overnight)
-Will follow
.
# Leukocytosis. Likely due to steroids versus pneumonia given
increased cough prior to admission. The patient has remained
afebrile. No other localizing signs or symptoms.
- Continue levofloxacin for CAP
- Blood cultures pending
-follow Diff
-UA negative for infection, cx + for coag _ staph, likely
contaminat. will hold on tx unless pt develops sx
.
# Hypernatremia. Appears hypovolemic; patient given lasix
earlier in course. Approximately 3.5L free water deficit.
Gentle IVF with 1/2 NS, Na improved this AM, now 144
-Will follow Na
.
# Acid-base status. pH normal; likely respiratory acidosis of
COPD with metabolic alkalosis from volume depletion.
- Treatment as above
.
# Anemia. Normocytic, stable from this admission, although
baseline appears mid-30s. [**Month (only) 116**] be due to hypothyroidism.
- Guaiac all stools
- Iron studies, folate, B12
- TSH
.
# Hypertension. Has required labetolol gtt during admission but
now improved control. on diltiazem 60 mg QID
- Consider amlodipine if hypertensive (patient allergic to
[**Last Name (LF) 26302**], [**First Name3 (LF) **] have bronchspasm with beta-blocker)
.
# Diabetes. home metformin restarted. Continue FSG and ISS.
.
# Hypothyroidism. No active issues. Continue current regimen.
.
# Hypercholesterolemia. Continue current regimen.
.
FEN: regular diet, replete K prn
.
Access: PIV, A-line
.
Comm: [**Name (NI) **]
.
Prophy: Heparin SC, PPI
.
Code: Full
.
Dispo: call out
.
The patient's respiratory status steadily improved. She
continued her slow PO steroid taper which was recommended by IP
to occur over 3 weeks to be continued at the ECF. She also has 2
days left of her levofloxacin regimen for presumed pneumonia.
Currently, the patient's O2 sat is 99% on 2L which is her
baseline oxygen requirement at home.
.
In terms of her leukocytosis, the cause is unknown and presumed
to be secondary to her steriod taper. The patient remained
afebrile and without a focal source for infection. Her WBC count
remained stable between 14-17 with bands as high as 2. Her
studies for infection source were all negative including ua,
ucx, blood cx, sputum cx, chest, abd, and pelvis CT. Following
this negative workup, the decision was made to repeat her cbc
count following completion of the steriod taper as we would
expect the wbc count to have decreased.
.
During her course on the medical floor, Mrs. [**Known lastname **] also
experienced limited hemoptysis which resolved over time. At
most, the pt reported cupping up to [**3-7**] of a cup of bright red
blood daily. IP was made aware and the pt's aspirin and mucinex
were held and her codeine was made standing. Over the course of
3 days, these symptoms resolved.
.
The pt's chronic issues of anemia, htn, DM, hypothyroidism, and
hyperlipidemia were all managed on the floor without
complications.
Medications on Admission:
.
Pre-hospital medications: Aspirin 81 mg, Diltiazem 240 mg,
Metformin 850 mg [**Hospital1 **], Pravastatin 10 mg, Levothyroxine 75 mcg,
Ezetimibe 10 mg, Tiotropium Bromide 18 mcg,
Fluticasone-Salmeterol 250-50 [**Hospital1 **], Pantoprazole 40 mg,
Prednisone 10 mg ending [**2190-8-23**], Mucinex 600 mg [**Hospital1 **], Albuterol,
Codeine prn cough.
.
Medications on transfer:
Heparin 5000 UNIT SC TID
Insulin SC
Acetylcysteine 20% 1-10 ml NEB Q2H:PRN
Levothyroxine Sodium 75 mcg PO DAILY
Acetaminophen 325-650 mg PO Q6H:PRN
Levofloxacin 750 mg IV Q24H
Albuterol 0.083% Neb Soln 1 NEB IH Q4H
Ipratropium Bromide Neb 1 NEB IH Q6H
HydrALAzine 25 mg PO Q6H
Mucinex *NF* 1200 mg Oral [**Hospital1 **]
Aspirin 325 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Benzonatate 100 mg PO TID
Pravastatin 10 mg PO DAILY
Codeine Sulfate 15-30 mg PO Q6H:PRN cough
MethylPREDNISolone Sodium Succ 80 mg IV Q8H
Ezetimibe 10 mg PO DAILY
Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **]
Tiotropium Bromide 1 CAP IH DAILY
.
Allergies: Zocor / [**Hospital1 **] / Crestor
Discharge Medications:
1. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
11. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6PRN as
needed for cough.
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed for SOB, coughing,
wheezing.
13. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 4 days: Only on [**10-23**], [**9-26**], [**9-27**].
Disp:*8 Tablet(s)* Refills:*0*
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days: Only on [**10-18**], [**9-30**], [**10-1**].
Disp:*4 Tablet(s)* Refills:*0*
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day:
Only on [**10-2**].
Disp:*1 Tablet(s)* Refills:*0*
16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day:
Only on [**9-25**], [**9-22**], [**9-23**].
Disp:*12 Tablet(s)* Refills:*0*
17. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID PRN.
18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): One tablet on [**2190-9-20**]. One tablet on [**2190-9-21**]
to finish 7-day course.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 24806**] Care Center - [**Hospital1 1562**]
Discharge Diagnosis:
Primary:
Chronic obstructive pulmonary disease exacerbation
Secondary:
Diabetes
Hypertension
Hyperlipidemia
Tracheal stent
Discharge Condition:
Good, good 02 sat on 2L, her baseline.
Discharge Instructions:
You were admitted to the hospital for shortness of breath. While
you were here, the stent that was in your airways was reomoved
and you were treated for an exacerbation of your COPD. You
completed a full course of antibiotics for this exacerbation and
are still completing taper of steroids.
Please continue your home medications. In addition, please take
the following medications:
1. Finish your prednisone taper as follows:
[**2101-9-20**], 19, 20: 30 mg daily
[**2105-9-24**], 23, 24: 20 mg daily
[**2109-9-28**], 27, 28: 10 mg daily
Continue the last 2 days of your levofloxacin antibiotic on [**9-20**]
and [**9-21**]
Please return to the hospital if you experience shortness of
breath, chest pain, fevers, bloody coughing or any concerns.
Followup Instructions:
Please make an appointment to see your pulmonologist or 'lung
specialist' [**Last Name (LF) **], [**Name8 (MD) **] MD [**Telephone/Fax (1) 3020**] for follow-up within
the next two weeks.
Please also make an appointment to see your primary care [**First Name8 (NamePattern2) **]
[**Last Name (LF) **],[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 74129**] within the next 1-2 weeks
for follow-up
Name: [**Known lastname 6577**],[**Known firstname **] A. Unit No: [**Numeric Identifier 12272**]
Admission Date: [**2190-9-3**] Discharge Date: [**2190-9-19**]
Date of Birth: [**2121-6-18**] Sex: F
Service: MEDICINE
Allergies:
Zocor / Diovan / Crestor
Attending:[**First Name3 (LF) 1455**]
Addendum:
Addendum: Patient will be discharged to ECF to complete steroid
taper. She is s/p full 7 day course of levofloxacin so will not
need antibiotics after discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24**], MD
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12273**] Care Center - [**Hospital1 2946**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**]
Completed by:[**2190-9-19**]
|
[
"486",
"786.3",
"E878.4",
"491.21",
"996.79",
"401.9",
"272.0",
"276.6",
"285.9",
"276.1",
"518.5",
"519.19",
"244.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"96.04",
"38.91",
"96.71",
"98.15"
] |
icd9pcs
|
[
[
[]
]
] |
14861, 15082
|
5454, 9691
|
321, 366
|
12964, 13005
|
2977, 5431
|
13802, 14838
|
2329, 2372
|
10798, 12691
|
12817, 12943
|
9717, 10072
|
13029, 13779
|
2174, 2201
|
2387, 2387
|
2424, 2958
|
261, 283
|
395, 1896
|
2402, 2402
|
10097, 10775
|
1940, 2151
|
2233, 2297
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,892
| 175,171
|
46758
|
Discharge summary
|
report
|
Admission Date: [**2125-6-3**] Discharge Date: [**2125-6-19**]
Date of Birth: [**2056-4-9**] Sex: F
Service: SURGERY
Allergies:
Red Dye / Shellfish
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
1. Abdominal pain
Major Surgical or Invasive Procedure:
[**2125-5-29**]: Primary left total knee replacement for osteoarthritis
and arthrofibrosis.
History of Present Illness:
69F s/p L TKR [**5-29**] by Dr [**Last Name (STitle) **] had abd pain and distension after
the surgery. She threw up at least once. She comes in because
of worse abd pain. It becomes [**9-11**] after she eats. Currently
[**7-12**]. She has been throwing up everything she tries to eat. She
did pass gas this am but has not had a bm since surgery. She
does not have a h/o of constipation. She has never had abd
surgery. No fevers. Pain is diffuse.
Past Medical History:
1. Crohn's- stable for 6-7 years on sulfasalazine
2. Atrial fibrillation/flutter since [**2098**], on anticoagulation
since
[**2116-3-5**] s/p TEE-DCCV [**3-2**]
3. HTN
4. H/O Idiopathic dilated cardiomyopathy (resolved)
5. s/p RLE DVT [**2116**]
Social History:
Lives alone in Mission park. No alcohol or smoking. Former
administrative assistant for Lucent bur retired x7yrs.
Family History:
father w/ MI before age 59, mother w/ MI at 75
Physical Exam:
99.7 77 99/42 18 97
Sitting in bed, NAD
RRR
CTAB
Abd - distended, soft, minimally ttp, no scars, no hernias
Rectal - vault empty, no blood
Ext - 2+ pulses, no edema
Pertinent Results:
[**2125-6-3**] 05:50PM PT-31.0* PTT-36.8* INR(PT)-3.1*
[**2125-6-3**] 05:50PM PLT SMR-NORMAL PLT COUNT-230#
[**2125-6-3**] 05:50PM PLT SMR-NORMAL PLT COUNT-230#
[**2125-6-3**] 05:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2125-6-3**] 05:50PM NEUTS-67 BANDS-20* LYMPHS-8* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-1*
[**2125-6-3**] 05:50PM WBC-12.2* RBC-3.08* HGB-10.3* HCT-31.4*
MCV-102* MCH-33.3* MCHC-32.7 RDW-15.2
[**2125-6-3**] 05:50PM ALBUMIN-3.3*
[**2125-6-3**] 05:50PM LIPASE-17
[**2125-6-3**] 05:50PM ALT(SGPT)-27 AST(SGOT)-43* ALK PHOS-114* TOT
BILI-0.7
[**2125-6-3**] 05:50PM GLUCOSE-129* UREA N-56* CREAT-4.1*#
SODIUM-136 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-21* ANION GAP-24
[**2125-6-3**] 11:14PM LACTATE-2.6*
[**2125-6-16**] 02:04PM BLOOD Hct-28.6*
[**2125-6-19**] 06:06AM BLOOD PT-34.3* INR(PT)-3.5*
[**2125-6-18**] 06:53AM BLOOD PT-28.7* INR(PT)-2.8*
[**2125-6-17**] 08:11AM BLOOD PT-21.5* PTT-113.1* INR(PT)-2.0*
[**2125-6-10**] 05:03PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2125-6-4**] 12:34AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.021
[**2125-6-10**] 05:03PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2125-6-10**] 05:03PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2125-6-3**]:
[**2125-6-3**] 11:00 pm BLOOD CULTURE
**FINAL REPORT [**2125-6-11**]**
Blood Culture, Routine (Final [**2125-6-11**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
DOXYCYCLINE AND Tigecycline REQUESTED BY DR. [**Last Name (STitle) **]
AND DR
[**Last Name (STitle) **].
Tigecycline Sensitivity testing performed by Etest ,
DOXYCYCLINE
sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
Tigecycline = 0.19 MCG/ML, SENSITIVE. DOXYCYCLINE =
RESISTANT.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final [**2125-6-4**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 99236**] @ 2136 ON [**6-4**] -
CC6C.
GRAM NEGATIVE ROD(S).
[**2125-6-7**]: ABD CT:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Diffuse multifocal bilateral airspace disease. Given the
presence of
interlobular septal thickening, small bilateral pleural
effusions and
cardiomegaly, CHF is the top consideration. Differential does
include ARDS
and multifocal pneumonia.
3. Resolution of portal venous gas and pneumatosis with
enhancement of the
small bowel wall. Findings are consistent with improvement of
the small bowel
ischemia. The persistent diffuse small bowel dilation and
additional focal
areas of small bowel and colonic wall thickening are likely
related to the
recent ischemic event to the bowel. Note that the dilation is
diffuse and
small-bowel obstruction is not favored.
4. Hypoperfusion of the pancreatic tail and spleen likely due to
complete
occlusion of the celiac axis. Also note marked attenuation of
the SMA, though
it does fill with contrast.
5. Multiple bilateral acute renal infarctions noting severe
attenuation of
the bilateral renal arteries.
6. Large left-sided thyroid mass which can be evaluated in the
future with
ultrasound as the clinical condition warrants.
[**2125-6-7**]: CARDIAC ECHO:
IMPRESSION: Mild to moderate global left ventricular systolic
dysfunction. Mild mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2125-6-4**], LV
function has declined. TR severity has slightly increased. The
other findings are similar.
Brief Hospital Course:
General Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. She was admitted in ICU on [**6-4**]:
Admitted to SICU for SBO.
[**6-5**]: D/c from SICU
[**6-6**]: Re-admitted to SICU [**3-6**] afib with RVR. Cardiology
consulted. Flagyl re-started. Pt tachypneic, failed BiPAP,
intubated. CT torso negative for PE, looks like ARDS picture.
Started on Amio bolus/gtt, rate controlled in PM however with
episode of asystole for 3-4 seconds, continues on pressors
(started after intubation)
[**6-7**]: Unstable Afib with RVR, hypotensive, recieved 200J shock X
2, then shock x 3 (100J-->50 J-->50J) CE cycled, cards
[**Name (NI) 653**], esmolol gtt improved rate, x 1 ffp. Drop in Plts,
sent off HIT antibodies and changed out catheter to
non-heparinized line, Knee tap by ortho showing WBC=2278, gram
stain pending. Repeat TTE
[**6-8**]: Platelet drop leveling off. No signs of active bleeding.
[**6-10**]: Nurses noted stool from vagina, flexiseal placed, had
transient episode of tachypnea which responded with suctioning
(happened after pt was turned). On Lasix gtt for CHF on CXR.
[**6-11**]: Heparin gtt started. Bronch negative, U/S of lungs showed
no pleural effusions, extubated without problem
[**6-12**]: d/c NGT
CV: Given that she is not likely to be taking PO medications in
the near future and was previously rhythm-controlled on sotalol,
would favor short term use of
amiodarone to control heart rate and rhythm.
- can give 150mg IV x 1 followed by 1mg/min IV infusion x 6
hours
followed by 0.5mg/hour x 18 hours
- please maintain INR between [**3-7**] if no evidence of bleeding;
with heparin bridge if coumadin must be held or reversed for
surgery
- plan to discontinue amiodarone and resume sotalol once
surgically stable and able to take POs. Patient was restarted on
Sotalol and Atenolol. Coumadin was started on [**6-14**], patient INR
on [**6-19**] was 3.5, we hold her Coumadin. Please rechaeck INR on
[**6-20**] prior restarting Coumadin.
Pulmonary: Patient was extubated on [**6-11**] without problem, daily
CXR showed resolution of her pneumania. Volume overload was
treated with Lasix IV. Continue to use 1 L O2 via nasal cannula.
GI: Patient was NPO with TPN for nutrition. Her diet was
advanced to clears when tolerated and advanced further to
regular.
GYN: In ICU fecal content visualized by [**Name8 (MD) **] RN around the foley
catheter. GYN consulted and they performed vaginal exam. Vaginal
apex fully visualized. No fecal material visualized. Small
amount of bleeding noted from trauma from speculum.
Scolpette placed without fecal material visualized. Vaginal
cul-de-sacs visualized and no fecal material visualized.
Assessment: No macroscopic evidence of recto-vaginal fistula on
speculum exam at this time.
ID: Patient's blood cultured revealed E.coli infection. She was
started on Ceftriaxone, which was changed to Meropenem on [**6-12**]
for two weeks total.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: Admission labs were further significant for a
macrocytic anemia
(received 1 unit PRBCs on [**6-4**]) and an elevated INR which
continued to rise despite her Coumadin being on hold. On [**6-7**] she
had a rather acute platelt drop from 220 to 88, it is now in the
20's. She has no signs of bleeding.
She received FFP on [**6-7**] b/c INR 9.0. It seems that on [**6-6**] she
had been receiving s.c. Heparin as well as Heparin flushes for
her line. After her TKR she had been on
therapeutic Lovenox for at least 4 days. She has now worsening
thrombocytopenia and an elevated INR despite holding her
Coumadin.
(1) coagulopathy: Her elevated INR is likely secondary to
previous use of Coumadin and current Vitamin K
deficiency(intubated, NPO). Further contributing is the use of
antibiotics. Given her significant thrombocytopenia we recommend
to give
Vitamin K 5 mg i.v. slowly and to provide Vitamin K through her
TPN.
(2) thrombocytopenia: no schistocytes seen on the peripheral
blood smear, she does not have splenomegaly, HIT was ruled out
by negative [**Doctor First Name **]. The most likely explanation is her sepsis. No
further intervention required at this point unless the patient
would start bleeding. Continue to monitor her platelet count and
avoid medications that could cause thrombocytopenia.
(3) macrocytic anemia: chronic but below baseline, possibly
secondary to recent TKR, no RBC abnormailties in peripheral
smear DDX: B12/Folate deficiency, hypothyroidism, MDS check
B12/Folate and TSH
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Atenolol
100 mg Tablet
1 Tablet(s) by mouth once a day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 30 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Hydrochlorothiazide
12.5 mg Tablet
0.5 Tablet(s) by mouth once a day [**2124-5-23**]
Renewed [**Location (un) **],
[**Doctor Last Name **] 90 Tablet 3 (Three) [**Last Name (LF) 5263**], [**First Name7 (NamePattern1) 402**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Levothyroxine [Levoxyl]
50 mcg Tablet
1 Tablet(s) by mouth once a day brand name only. NO
SUBSTITUTION.
No Substitution [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 30 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Lisinopril
40 mg Tablet
1 Tablet(s) by mouth once a day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 30 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Sotalol
80 mg Tablet
1.5 Tablet(s) by mouth twice a day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 90 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Sulfasalazine
500 mg Tablet
3 Tablet(s) by mouth twice a day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 180 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
nr Timolol
Dosage uncertain
(Prescribed by Other Provider) [**2123-11-4**]
Recorded Only [**Location (un) **],
[**Doctor Last Name **] J
nr Travoprost (Benzalkonium) [Travatan]
Dosage uncertain
(Prescribed by Other Provider) [**2123-11-4**]
Recorded Only [**Location (un) **],
[**Doctor Last Name **] J
Warfarin
2 mg Tablet
4 Tablet(s) by mouth per day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 285 Tablet
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
2. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation QID (4 times a day) as needed for
wheeze.
3. Hydrochlorothiazide 12.5 mg Capsule Sig: 0.5 Capsule PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO twice a
day.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Mn,
Tu, We, Th, Sa, Sn
Hold if INR > 3.0
Check INR on [**6-20**] prior restarting pt's Coumadin.
11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Give
on Friday
Hold if INR > 3.0
Check INR on [**6-20**] prior resatrting Coumadin.
12. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
14. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
15. Timolol Maleate 0.25 % Drops Sig: One (1) Ophthalmic once a
day.
16. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 6 days: Stop on [**6-26**].
17. Ondansetron 4-8 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1. Small bowel obstruction
2. E. coli bacteremia
3. Persistent atrial fibrillation with rapid ventricular
response
4. Thrombocytopenia and coagulopathy
5. Macrocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-11**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2125-6-29**] 10:00
.
Provider: [**Name10 (NameIs) 1423**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2125-7-4**] 9:30
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2125-8-16**] 9:00
.
Please call [**Telephone/Fax (1) 2998**] to arrange a follow up appointment with
Dr. [**First Name (STitle) 2819**] (General Surgery) in [**3-7**] weeks after discharge.
Completed by:[**2125-6-19**]
|
[
"287.5",
"785.52",
"518.5",
"281.9",
"V58.61",
"560.89",
"584.9",
"555.9",
"995.92",
"998.59",
"427.31",
"038.42",
"286.9",
"401.9",
"425.4",
"V43.65",
"276.51",
"427.32",
"557.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.15",
"38.93",
"33.24",
"81.91",
"99.62",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14701, 14774
|
5893, 10720
|
295, 389
|
14991, 14991
|
1542, 5839
|
15776, 16486
|
1293, 1341
|
12972, 14678
|
14795, 14970
|
10747, 12949
|
15174, 15753
|
1356, 1523
|
238, 257
|
417, 874
|
15006, 15150
|
896, 1145
|
1161, 1277
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,646
| 159,850
|
12675
|
Discharge summary
|
report
|
Admission Date: [**2167-7-29**] Discharge Date: [**2167-10-27**]
Date of Birth: [**2099-6-25**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Abdominal pain/vomiting
Major Surgical or Invasive Procedure:
[**2167-7-30**] ex lap
[**2167-8-2**] enterotomy repair
[**2167-8-3**] bedside washout, enterotomy repair
[**2167-8-6**] bedside washout, ileal drain, vac placement
[**2167-8-8**] bedside washout, repair of enterotomy
[**2167-8-10**] bedside washout, LUQ drain placement
[**2167-8-10**] Trache and vac change
[**2167-9-2**] STSG to abdomen from left thigh
[**2167-9-16**] FTSG to left face from left chest
[**2167-10-5**] picc
[**2167-10-27**] sternal pustule I&D
History of Present Illness:
VS: T 98.6 HR 130 BP 119/67 RR 20 98%
GEN: NAD, appears uncomfortable, AAOx3, answers questions
HEENT: dry mucous membranes, no scleral icterus
CHEST: CTA B/L, no wheezes, rales, rhonchi
HEART: S1/S2, sinus tachy
ABD: soft, well-healed midline scar, G-tube to gravity draining
greenish fluid, mildly distended, slightly tender periumbilical
(was given morphine, unable to assess for peritoneal signs), BS
normoactive
EXT: warm, 2+ edema
LABS:
142 113 16 AGap=12
-------------< 110
3.8 21 0.9
Ca: 7.9 Mg: 2.3 P: 2.5
ALT: 10 AP: 186 Tbili: 0.5 Alb: 2.2
AST: 11
Lip: 72
11.6
8.4 >< 374
36.9
N:73.2 L:24.0 M:2.1 E:0.1 Bas:0.6
PT: 16.3 PTT: 30.0 INR: 1.4
[**7-29**] CT ABD (wet read from OSH): Dilated loops of small bowel,
measuring up to 5 cm, with transition in distal ileum. Distal
and
terminal ileum are collapsed, compatible with SBO. No free air
or
pneumatosis. Moderate sized pleural effusions bilaterally. Small
free fluid throughout abdomen.
Past Medical History:
Dyslipidemia
hypertension
migraines
s/p hysterectomy
h/o amaurosis fugax
s/p cervical disc surgery [**76**] yrs ago
osteoarthritis
Social History:
-Married with several children. Family supportive
- 3 children-Tobacco history: 45 pack year history (current)
-ETOH: occ
-Illicit drugs: denies
Family History:
Sister died of pancreatic cancer a few months ago. No stroke ,
CAD
Physical Exam:
VS: T 98.6 HR 130 BP 119/67 RR 20 98%
GEN: NAD, appears uncomfortable, AAOx3, answers questions
HEENT: dry mucous membranes, no scleral icterus
CHEST: CTA B/L, no wheezes, rales, rhonchi
HEART: S1/S2, sinus tachy
ABD: soft, well-healed midline scar, G-tube to gravity draining
greenish fluid, mildly distended, slightly tender periumbilical
(was given morphine, unable to assess for peritoneal signs), BS
normoactive
EXT: warm, 2+ edema
LABS:
142 113 16 AGap=12
-------------< 110
3.8 21 0.9
Ca: 7.9 Mg: 2.3 P: 2.5
ALT: 10 AP: 186 Tbili: 0.5 Alb: 2.2
AST: 11
Lip: 72
11.6
8.4 >< 374
36.9
N:73.2 L:24.0 M:2.1 E:0.1 Bas:0.6
PT: 16.3 PTT: 30.0 INR: 1.4
[**7-29**] CT ABD (wet read from OSH): Dilated loops of small bowel,
measuring up to 5 cm, with transition in distal ileum. Distal
and
terminal ileum are collapsed, compatible with SBO. No free air
or
pneumatosis. Moderate sized pleural effusions bilaterally. Small
free fluid throughout abdomen.
Pertinent Results:
[**7-29**] CT abd/pelvis: Dilated loops of small bowel, measuring up to
5 cm, with transition in distal ileum. Distal and terminal ileum
are collapsed, compatible with SBO. No free air or pneumatosis.
Moderate sized pleural effusions bilaterally. Small free fluid
throughout abdomen.
[**7-30**] Echo - Small LV with EF 40%. 4+ tricuspid regurgitation. No
effusion.
[**7-30**] CXR - Moderate B/L pleural effusions with adjacent bibasilar
atelectases have increased on the left. There is new mild
vascular congestion.
[**7-31**] CXR - Interval increase in mediastinal vascular caliber -
probably pulmonary edema. Progressive RML consolidation.
[**8-1**] CXR - bibasilar effusions and consolidation, unchanged
pulmonary
edema.
[**8-2**] CXR - The endotracheal tube, Swan-Ganz catheter, left-sided
central venous catheter, and feeding tube are all unchanged in
position. There is increase in the bronchovascular markings
compatible with some fluid overload. There are more confluent
areas of consolidation within the bases, which may represent
fluid overload versus aspiration. Left retrocardiac opacity is
seen. There is increase in the left-sided pleural effusion since
the previous study.
[**8-3**] Echo - Left ventricular cavity is unusually small, LVEF
50-55%. Right ventricular cavity is dilated with moderate global
free wall hypokinesis. Severe [4+] tricuspid regurgitation is
seen.
[**8-3**] CXR - Multifocal pneumonia most notable in left upper and
right lower lung. Decreased pulmonary edema.
[**8-4**] CXR - Bibasilar opacifications are again consistent with
atelectasis and effusion. There is increasing indistinctness of
pulmonary vessels, consistent with pulmonary edema.
[**8-5**] CXR - No evidence of pneumothorax. Resolving left upper and
right lower lobe consolidation. Unchanged left lower lobe
atelectasis and subsegmental right lower lobe atelectasis.
[**8-5**] ECHO - Improving LV/RV function, EF 50%
9/15 CXR - OGT advanced
[**8-6**] CXR - slight increase in pre-existing opacities at the
right lung base, including a basolateral rounded area of
consolidation. No new opacities.
[**8-7**] CXR - Essentially stable, continued fluid overload
[**8-8**] CXR - There is mild cardiomegaly. Bibasilar opacities left
greater than right are unchanged, could be atelectasis but
superimposed infection cannot be totally excluded. Small
bilateral pleural effusions are stable. Pulmonary edema has
markedly improved, now mild.
[**8-9**] CXR - Unchanged
[**8-9**] RUQ U/S - No definite fluid collection. Trace ascites,
small right pleural effusion.
[**8-10**] CXR - atelectasis vs. pneumonia radiographically
indeterminate
[**8-11**] CXR - increased opacity in the left perihilar and lower
lung that might be consistent with unilateral pulmonary edema
versus
aspiration
[**8-12**] CXR - stable LLL collapse, increased R effusion
[**8-13**] CXR - decreased R effusion
[**8-14**] CXR - This could reflect increasing aspiration or worsening
diffuse pulmonary edema.
[**8-19**] CXR - interval improvement in pulm edema, but still present
bibasilar consolidations and bilateral eff substantial.
[**8-20**] CXR - mild improvement in pulmonary edema, stable b/l
effusions
[**8-24**] ECHO: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
akinesis/aneurysm of the basal half of the inferior wall. The
remaining segments contract normally (LVEF = 45 %). No
intraventricular thrombus is seen. The right ventricular cavity
is moderately dilated with focal basal free wall hypokinesis.
There is abnormal septal motion/position. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**11-22**]+) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Compared with the
findings of the prior study (images reviewed) of [**2167-8-5**], the
right ventricular cavity is smaller with slightly improved
systolic function. The severity of mitral regurgitation is
increased.
[**8-24**] CXR: minimal increase in R pleural effusion, L pleural
effusion unchanged.
[**8-24**] CT face: Subcutaneous edema, fat stranding, and fascial
thickening extending from the left lateral orbit to the left
mandible without evidence of drainable fluid collection. Soft
tissue opacification of the sphenoid sinus, mastoid air cells
and the
external auditory canal bilaterally.
[**8-24**]: Echo indicates slight improvement in RV function (with
slight worsening of MR).
[**8-25**] CXR: Continued bilateral pleural effusions with bibasilar
atelectatic change.
[**8-26**] CXR: Little overall change in the appearance of the heart
and lungs except for some increase in the retrocardiac
opacification
[**8-27**] CXR: Persistent bilateral pleural effusions and
retrocardiac opacity.
[**8-27**]: LLE U/S - limited exam as patient unable to tolerate. No
DVT seen in left common femoral vein.
[**8-28**] CXR: Stable appearance of bilateral pleural effusions and
large
retrocardiac opacity.
[**8-31**] CXR: Persistent mod pl effusions with apparent loculation
on the right
[**9-1**]: b/l LE US - no DVT; Psych states pt is delirious,
recommend replace benzo when given for anxiety w/ haldol (or
zyprexa), & check QTc.
[**9-2**] CXR: Moderate-to-severe cardiomegaly unchange since [**8-21**].
Edema improved since [**9-1**]. Right pleural effusion unchanged or
slightly smaller. Chronic LLL collapse.
[**9-3**] CXR: No short interval change in R pleural effusion, LLL
atelectasis and mild edema.
[**9-8**] UNILAT UP EXT VEINS US LEFT:No evidence of deep vein
thrombosis in the left arm.
[**9-24**] fistulogram: loop of bowel in direct communication with
the anterior abdominal wall. No distal obstruction of contrast
material beyond the fistulous tract is identified.
[**9-24**] AXR:no contrast w/in abdomen after fistulogram.
[**9-29**] CT Head: no acute intracranial process.
[**2167-9-30**] blood cx: coag neg staph in [**11-22**] bottles (from PICC).
[**2167-9-30**] urine cx: citrobacter, klebsiella, enteroccocus (VRE)
[**2167-10-2**] urine cx: enterococcus (VRE) and pseudomonas
Brief Hospital Course:
This is a 68 y/o female s/p cardiac surgery service of [**Hospital1 18**]
after a RV MI requiring a RVAD,who returned with SBO.She was
admitted to the ICU and underwent ex lap,lysis of adhesions,
small bowel resection x3, small bowel entero-enterostomy with
terminal ileum/colon discontinuation and temporary abdominal
closure. Intra-op she received 3L crystalloid, 500 cc albumen, 4
U FFP, 5 U PRBC, and EBL was 2L. UOP in case was only 100 cc.
The patient required pressor support intra-op. Post-op labs
stable, Hct 35.7. Patient was tachycardic to 120-140s,with
hypotension, and was started on Neo gtt for pressure support. On
HD 3,the patient received 9L LR boluses and 500ml albumin for
low pressures. Cefazolin was re dosed to 2g q8hr. Foley was
changed for yeast in urine. Hands/ feet noted to be mottled (neo
at low doses).On HD 4,[**8-1**]: Pt was transfused 2u PRBC and 4u
FFP. On HD5,[**8-2**] the pt was taken to the OR for washout and
repair of leak.
[**8-3**]: sputum grew yeast and Fluconazole started. A bedside ex
lap was performed - leak at staple line was over sewed, small
bowel decompressed. TPN was started. Washout was performed,
enterotomy was found and closed.
[**8-5**]: started on milrinone, changed to vasopressin; repeat echo
w/ improved LV/RV function,
[**8-6**]: ex lap in AM with washout, replacement terminal ileostomy
tube and repair enterotomy. [**Last Name (un) 104**] stim test without adequate
response hydrocortisone started. yeast in urine - changed Foley
and culture urine; Cipro discontinued and replaced with cefepime
for pseudomonas coverage given sensitivities from PICC.
[**8-7**]: started 1/2NS @ 75cc/hr, Epi weaned
[**8-8**]: bile drained from wound sump, ex-lap'd and washout at
bedside, ileostomy tube re-sewn, bile appeared to be coming from
RUQ, DC'd hydrocortisone
[**8-9**]: RUQ U/S ordered to eval biliary leak and elevated alk phos
and bili, pan cx, fluconazole changed to micafungin, heparin
started, trending Q6H lactate.
[**8-10**]: Patient opened at bedside for bile leak in AM and at noon,
bile leak noted at ileostomy tube site, enterotomy at staple
line repaired; 250cc albumin x3 for SBP in 80s, neo up to 1
[**8-11**]: IVF increased to 150mL/hr, TPN continued. Repeat BCx sent.
The patient was bronched with removal of thick sputum. A BAL was
sent and CXR showed improved aeration. The IJ was rewired [**12-23**]
concern for infection.
[**8-12**]: IVF decreased and TPN continued.
[**8-13**]: off sedation, on neo 0.5, prn albumin boluses for
hypotension, +2.5L [**8-12**], TPN continued, washout of abdomen was
uneventful
[**8-14**]: off pressors, fluids even for [**8-13**]. Wound VAC changed.
re-bronched, BAL sent.
[**8-15**]: Tachypneic with rising pCO2, required CMV overnight.
[**8-17**]: LUE Duplex to eval swelling negative for DVT. IVF to KVO,
20mg Lasix given with good result.
[**8-18**]: Trached. 2.1L of free water deficit, corrected with D5W
and decreased Na on TPN. Received Lasix 20 [**Hospital1 **] and 2.2L
negative. NGT placed.
[**8-19**]: Continued TPN with low Na and started D5W@50. Lasix 20
[**Hospital1 **].
[**8-21**]: Stopped all antibiotics, holding diuretics. D/C'd D5W. RIJ
with some erythema - watching. Labetalol q6 w/ hold parameters
[**8-22**]: On Lasix gtt (goal 500cc-1L). Hypernatremia improving.
Echo ordered to evaluate fluid status per cardiology.
[**8-23**]:Continued TPN, Lasix gtt for goal of 1 L negative. Off
Lasix gtt as pt diuresing well.
10:4: Cardiac Echo indicates slight improvement in RV function
(with slight worsening of MR).
[**8-25**]: Fentanyl replaced by Dilaudid for primary pain med. Vanco
started. GTube clamped.
[**8-26**]: Patient autodiuresing, Lasix gtt stopped. Plastics bedside
debridement with Ketamine for anesthesia. Prealbumin came back 7
[17-34]
[**8-27**]: VAC changed. LLE duplex incomplete (pt non-compliant).
Vanc dose held for elevated trough.
[**8-28**]: Tolerated trach mask and changed to PMV so that she can
speak, eval'd by S&S.
[**8-29**]: continued Vanc per ID recs.
[**8-30**]: Vac changed with plastics wound change. Heparin in TPN
(sqh stopped). Anxiety during day given 1 mg Versed. psych
consult for agitation.
[**8-31**]: Face wound dressing changed with versed/ketamine.
Increased ativan dose to 0.25 q6h for increased
agitation/anxiety.
[**9-1**]: b/l U/S w/ no DVT.
Psych states pt delirious & will follow. Recommended changing
ativan w/ haldol (or zyprexa). Changed labetolol to metoprolol.
[**9-2**]: Added haldol instead of ativan. To OR for abdominal graft
(STSG from L thigh) - tolerated very well.
[**9-3**]: PICC placed by IR. R IJ removed (site indurated w/
superficial hematoma). a-line removed. Received 20 lasix in pm
and was -300 for the day and -300 overnight. Did not need haldol
overnight.
[**9-4**]: Dressing changes with dilaudid (d/c'ed
ketamine/fentanyl). Vanc trough 20, repeating in AM per primary
team.
[**9-5**]: vanc trough 22, holding am vanc dose on [**9-6**].
Transferred to floor from ICU.
[**9-6**]: Transfused 1 unit pRBC for HCT 25.8.
[**9-7**]: Failed swallow eval (aspirated thins, spilled PO): made
NPO.
[**2167-9-16**]: To OR by plastics for split thickness skin graft to L
face. Required 500 cc bolus X2 and 2 doses of 100 mcg ephedrine
for hypotension to SBP 80s after metoprolol in PACU with
hemodynamic stability since episode.
[**2167-9-18**]: Speech swallow eval with aspiration of thins and
tolerance of small volumes of nectar-thickened liquids.
[**2167-9-19**]: episodes of anxiety with crying. Vanco held for high
trough. Feculent drainage around Woundvac noted.
[**9-21**]: PICC line discontinued for erythema/purulent drainage
around site. Culture subsequently positive for Pseudomonas.
[**9-22**]: L upper extremity ultrasound negative for thrombus.
[**9-23**]: L face STSG bolster removed by plastics with viable graft
underneath.
[**9-24**]: Nausea/vomiting. Fistulogram study inadequate. GTube
replaced after dislodgement; started on tube feeds with Vivonex.
[**9-26**]: Started on Imodium for leakage from Woundvac w/o
improvement in output.
[**9-28**]: Geriatric consult obtained for delirium/hallucinations,
recommending CT Head for altered mental status. Head CT normal.
TF discontinued due to Woundvac drainage and TPN increased to
full strength.
[**9-30**]: urine and blood cultures obtained per geriatrics recs.
Started on Cipro empirically for positive UA. Blood from PICC
subsequently positive for coag neg stap in [**11-22**] bottles and urine
positive for Citrobacter, klebsiella, and enterococcus.
[**10-1**]: started on vancomycin for positive blood culture (as
above).
[**10-2**]: tracheostomy tube downsized to #6. Patient
self-discontinued PICC. Venous access team unable to replace
PICC; scheduled for IR PICC placement after weekend. Urine
culture obtained: subsequently positive for enterococcus and
pseudomonas.
[**10-3**]: restarted on tube feeds to maintain nutrition while no
access for TPN. Increased output from Woundvac and [**Doctor Last Name 406**] drain
noted.
[**10-4**]: Tube feeds stopped due to vomiting.
[**10-5**]: PICC replaced and TPN started. Sensitivities back on
urine cultures: vancomycin-resistant enterococcus and
pseudomonas sensitive only to ceftazidime. Cipro and vancomycin
discontinued. Started on daptomycin for VRE, ceftazidime for
pseudomonas, and Bactrim for Citrobacter. VAC changed
demonstrating good healing of wound. Attempted to
self-discontinue PICC but PICC tip in good position on CXR.
[**2167-10-7**]: Pseudomonas cultured from urine. Blood culture neg.
[**2167-10-9**] tracheostomy successfully decannulated.
[**2167-10-13**]: Swallow eval: okay for thin liquids and pureed solids.
Patient fell while sitting on edge of bed and needed assistance
to be replaced in bed. C/o left ankle and sacral/coccygeal pain.
Rays of these areas obtained, which were negative. Did not c/o
hitting head and neuro exam grossly wnl, but given unreliable
neuro exam, head CT obtained, which was negative for
intracranial process.
[**2167-10-16**] tachycardic to 110-120s and hypotensive to 80s/40s but
asymptomatic. Responded to 500 cc bolus. Blood cultures
negative. Urine mixed c/w fecal contamination. [**Last Name (un) **] stim test
wnl (cortisol 25.5/29.2).
[**2167-10-19**]. Vac removed due to skin irritation and replaced with
dry dressing and drain in fistula, with improvement in skin
erythema. Tachycardic to 130s and hypotensive to 80s/40s, which
responded to 500 mL bolus and 1 u pRBC (HCT 25.3 to 28.1
post-transfusion). Urine culture demonstrated 10-100k
pseudomonas with intermediate sensitivity to ceftazidime.
[**2167-10-20**]: Daptomycin and Bactrim discontinued. Ceftazidime
continued for urine pseudomonas.
[**2167-10-21**]: Infection disease consulted, recommending continuation
of ceftazidime at higher dose for 14 days from negative urine
culture of [**10-20**].
[**2167-10-27**]: Cardiac surgery in to evaluate 1cm erythematous,
fluctuant sternal area. I&D with damp NS to dry gauze dressing
(edge of 2x2). 5-10 cc of bloody, non-purulent fluid expressed.
Wound shallow and granulating. No need for chest CT at this
time.
Physical therapy consult was obtained upon transferring out of
SICU. Initially, she was bed bound requiring [**Doctor Last Name **] lifting. At
time of discharge strength had improved to allow for 2 person
assisted transfer. Rehab was recommended. A bed was available at
[**Hospital 100**] Rehab. She is transferring there today.
Medications on Admission:
1. insulin sliding scale
2. simvastatin 20 mg daily
3. carvedilol 25 mg [**Hospital1 **]
4. Aspirin 325 mg daily
5. Acetaminophen prn
6. Miconazole QID
7. Ibuprofen prn
8. Loperamide 2 QID prn diarrhea
9. Lorazepam 0.5 mg prn anxiety
10. Heparin 5000 units TID
11. Diltiazem 30 mg QID
12. Diphenhydramine
12.5prn, KCl 20 mEq
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: follow
printed sliding scale Injection four times a day.
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for skin irritation.
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
9. haloperidol lactate 5 mg/mL Solution Sig: 0.25 mg Injection
Q6H (every 6 hours) as needed for agitation: monitor QT
interval.
10. ceftazidime 1 gram Recon Soln Sig: Two (2) Recon Soln
Injection every eight (8) hours for 1 weeks: UTI started [**10-5**]
continue until [**11-3**].
11. Outpatient Lab Work
Weekly labs: cbc, chem 10, ast, alt, alk phos, t.bili, albummin,
pt/inr
please fax to Dr.[**Name (NI) 670**] office
[**Telephone/Fax (1) 22248**]
12. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
13. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) dose PO
Q6H (every 6 hours) as needed for pain.
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. TPN (as ordered per printed req)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
h/o MI with RVAD c/b sbo obstruction
SB resection, multiple washouts
enterocutaneous fistula
s/p stsg to abd wound from left thigh
left facial cellulitis/wound s/p FTSG from Left chest
occipital deculbitus
UTI, klebiella, enterococcus, citrobacter, pseudomonas (ESBL)
delerium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. (see PT notes)
Discharge Instructions:
You will be transferring to [**Hospital 100**] Rehab.
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of
the following warning signs: fever, chills, nausea, vomiting,
increased fistula output, abdominal wound has
redness/bleeding/purulence, or left face wound has
redness/drainage/bleeding
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-11-9**] 10:20 [**Last Name (NamePattern1) 439**] [**Location (un) 86**]. [**Hospital 2577**]
Medical Office Building [**Location (un) **]
Call [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**] (Cardiac
Sugeon) to schedule f/u in 1 week
Completed by:[**2167-10-27**]
|
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"346.90",
"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"54.59",
"45.62",
"31.1",
"86.69",
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icd9pcs
|
[
[
[]
]
] |
21385, 21451
|
9566, 19001
|
338, 804
|
21773, 21773
|
3232, 9294
|
22319, 22743
|
2147, 2216
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19376, 21362
|
21473, 21752
|
19027, 19353
|
21966, 22296
|
2231, 3213
|
275, 300
|
832, 1814
|
9303, 9543
|
21788, 21942
|
1836, 1968
|
1984, 2131
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,383
| 113,553
|
16348
|
Discharge summary
|
report
|
Admission Date: [**2126-1-5**] Discharge Date: [**2126-1-14**]
Date of Birth: [**2060-8-31**] Sex: M
Service: CARDIAC
ADMISSION DIAGNOSES: 1) Coronary artery disease. 2)
Myocardial infarction.
DISCHARGE DIAGNOSES: 1) Coronary artery disease. 2)
Myocardial infarction. 3) Status post coronary artery bypass
graft x 3.
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
male who was being transferred from [**Hospital3 **]. He
presented to that hospital while complaints of sudden onset
nausea and vomiting. EKG there demonstrated inferolateral ST
elevation MI with decreased ST anterior lead suggestive of
posterior involvement. The patient is transferred for urgent
cardiac catheterization. He received aspirin, heparin,
Aggrestat, prior to departure.
PAST MEDICAL HISTORY: 1) Hypercholesterolemia. 2)
Hypertension. 3) Angina.
MEDICATIONS: 1) lipitor, 2) Nitroglycerin prn.
PHYSICAL EXAMINATION: Vital signs - temperature 96.9, heart
rate 91, blood pressure 83-88/50-60, oxygen saturation 100%,
weight 89.4 kg. General - the patient is intubated and
sedated postcatheterization. Neck is supple, midline, with
no masses or lymphadenopathy. No bruit. Cardiovascular -
regular rate and rhythm. Patient currently has an
intra-aortic balloon pump. Chest clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended.
Extremities are warm, noncyanotic, no redness x 4. Palpable
distal pulses.
LABS ON ADMISSION: CBC - 7.8/38.8/162. INR 1.3, PTT 77.
Chemistries 140/3.5/104/26/20/0.9. First set of cardiac
enzymes - CK 120, MB 5, troponins negative, less than 0.3.
HOSPITAL COURSE: The patient was transferred via LifeFlight
for emergent cardiac catheterization. Cardiac
catheterization revealed a right dominant coronary
circulation with severe three-vessel coronary artery disease.
Left main had 20% distal tapering, LAD was totally occluded
proximally after the takeoff of a diffusely diseased diagonal
branch, moderate sized RI had 80% proximal lesion, left
circumflex is totally occluded, RCA was a large vessel with
40% lesion in the proximal aspect and a thrombotic occlusion
midvessel. An intra-aortic balloon was deployed after
stenting of the RCA because of the patient's hypotension and
requirement of a dopamine drip. Subsequent to
catheterization, the patient was transferred to the CCU for
support. He was continued on his dopamine drip.
On hospital day #1, the patient was seen to have a brief run
of NSVT. He was maintained on aspirin, heparin drip and
statin. Cardiothoracic surgery consultation was obtained who
agreed with urgent revascularization. The patient had
several further runs of what looked to be V-tach in the unit.
The patient was maintained on IABP. Dopamine was weaned off
on hospital day #3.
On [**2126-1-7**], the patient was taken to the operating room for
urgent coronary artery bypass graft x 3. The patient
tolerated the procedure well and was taken to the CSRU
postoperatively.
On postoperative day #1, the patient was extubated. He was
A-paced at a rate of 70s. The patient was on multiple drips
including amiodarone, insulin, neo, epi, at different times
through his CSRU course. They were all weaned appropriately.
On postoperative day #2, the balloon pump was discontinued.
Neo was also weaned off. The patient had a brief run of
atrial fibrillation. Once the patient began working with
physical therapy, it was seen that he had some difficulties
with abduction of both of his arms. He appeared
neurologically intact and without any other sensorimotor
deficits. The patient did have other episodes of rapid
atrial fibrillation, but ultimately converted back to a sinus
rhythm. He was begun on anticoagulation for this.
The patient was transferred to the floor on postoperative day
#3. OT consultation was also obtained who agreed with
transfer to rehab facility. The patient had ultimately an
unremarkable floor stay, and chest tubes and wires were
removed appropriately. The patient was ultimately discharged
to rehab facility for further work with movement of his arms,
as well as simple gait conditioning and activities of daily
living. He was discharged tolerating a regular diet, and
adequate pain control on PO pain meds, and having a
therapeutic INR. No more episodes of angina, or nausea or
vomiting.
PHYSICAL EXAMINATION ON DISCHARGE: An elderly man in no
acute distress. Vital signs were stable, afebrile. Chest
was clear to auscultation bilaterally. Cardiovascular was
regular rate and rhythm without murmurs, rubs or gallops.
There was no sternal click or sternal drainage. Abdomen was
soft, nontender, nondistended, no masses or organomegaly.
Extremities were warm, noncyanotic with 1+ pedal edema
bilaterally. Musculoskeletal - the patient had difficulty
with abduction of his arms and neural usage of his arms
particularly when trying to abduct them beyond a horizontal
level. Neuro grossly intact without specific sensory
deficits. Of note, the upper extremity movement was
bilateral in nature, but function was returning.
MEDICATIONS ON DISCHARGE: 1) lopressor 25 mg [**Hospital1 **], 2) lasix
20 mg qd x 10 days, 3) potassium chloride 20 mEq qd x 10
days, 4) amiodarone 400 mg [**Hospital1 **], 5) Lipitor 10 mg qd, 6)
percocet 5/325, [**12-6**] q 4 h prn, 7) aspirin 325 mg qd, 8)
ibuprofen 400 mg q 6 h, 9) colace 100 mg [**Hospital1 **], 10) coumadin to
be dosed appropriately to an INR between 1.5 and 2.0. On
discharge, the patient was taking coumadin in the 1 to 2 mg qd
range.
DISCHARGE CONDITION: Stable.
DISPOSITION: To rehab facility.
DIET: Cardiac.
INSTRUCTIONS: The patient should follow-up in one to two
weeks with his cardiologist. He should address the needs of
diuresis and/or adjustment of cardiac medications at that
time. The patient should follow-up with Dr. [**Last Name (STitle) **] in four
week's time. The patient is to continue aggressive physical
and occupational therapy to return to his activities of daily
living. INR checks should be done twice weekly and coumadin
dosing adjusted by either the rehab facility or his primary
care provider, [**Name10 (NameIs) **] alternatively the coumadin clinic.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**MD Number(1) 46561**]
MEDQUIST36
D: [**2126-1-14**] 12:42
T: [**2126-1-14**] 11:42
JOB#: [**Job Number 46562**]
|
[
"E879.0",
"997.1",
"414.01",
"427.1",
"427.31",
"785.51",
"410.71",
"458.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"36.15",
"36.12",
"37.78",
"39.61",
"36.06",
"96.04",
"37.23",
"99.20",
"88.56",
"37.61",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
5577, 6478
|
239, 345
|
5116, 5555
|
1650, 4371
|
161, 217
|
943, 1462
|
4386, 5089
|
374, 792
|
1477, 1632
|
815, 920
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,658
| 123,009
|
3586
|
Discharge summary
|
report
|
Admission Date: [**2103-10-18**] Discharge Date: [**2103-10-24**]
Date of Birth: [**2025-10-17**] Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
[**Company **] adapta L ADDRL1 implantation on [**2103-10-19**]
History of Present Illness:
77 year-old woman with history of hypertension here with few
days of profound fatigue and found to be in complete heart block
with wide escape from the left posterior fascicle at a rate of
20-30bpm and BP of 80-90/40-50s.
.
In the ED, initial vitals were 97.6 32 91/41 15 96%. EKG
signficant for complete heart block with excape at a rate of
20-30bpm. Labs signficant for Trop-T: 8.13, kidney failure with
Cr at 4.7(baseline from [**2100**] at 1.1), phos-4.7, K-4.9, NA-132,
and elevated WBC to 13.24 (80%N, no bands) and a relatively
negative CXR. The pateint was initially given dopamine and be
came nauseated which resolved with zofran. Dopamine is now off.
Also given 500ml of NS. A cordis was placed with a temporary
pacing wire, now paced at 80 with a good BP. A CXR was obtained
demonstarting good positioning of corditis without complication.
Prior to transfer vitals were P-80 BP-89/56, 97% on 2L.
.
On arrival to the floor, patient had no complaints. She was on
5 of dopamine, which was quickly weaned.
Past Medical History:
HTN
Social History:
Married and lives at home, active. Takes active care of her
husband and hates being apart from him!
Family History:
Non contributory.
Physical Exam:
ADMISSION EXAM:
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP not elevated. Temporary pacing wire in place
via right IJ.
CHEST: 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. Scattered crackles at
bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE EXAM:
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Moist mucosa, no icterus, EOMI.
NECK: Supple, JVP not elevated. Right neck with resolving rash
at site of tegaderm.
CHEST: Regular rate, on tele A Paced, native ventricular
contractions.
LUNGS: Clear to auscultation, .
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Palpable b/l LE DP/PT
NEURO: No focal deficits, CN 2-12 grossly intacat.
Pertinent Results:
ADMISSION LABS:
[**2103-10-18**] 06:00PM BLOOD WBC-13.4*# RBC-4.36 Hgb-12.0 Hct-38.2
MCV-88 MCH-27.6 MCHC-31.5 RDW-13.3 Plt Ct-253
[**2103-10-18**] 06:00PM BLOOD Neuts-80.6* Lymphs-11.6* Monos-7.3
Eos-0.1 Baso-0.5
[**2103-10-18**] 06:00PM BLOOD Glucose-153* UreaN-62* Creat-4.7*#
Na-132* K-4.9 Cl-94* HCO3-23 AnGap-20
[**2103-10-18**] 06:00PM BLOOD cTropnT-8.13*
[**2103-10-19**] 04:00AM BLOOD CK-MB-9 cTropnT-7.13*
[**2103-10-18**] 06:00PM BLOOD Calcium-9.4 Phos-4.7* Mg-2.3
[**2103-10-19**] 04:00AM BLOOD %HbA1c-5.8 eAG-120
[**2103-10-19**] 04:00AM BLOOD Triglyc-122 HDL-31 CHOL/HD-5.2
LDLcalc-106 LDLmeas-110
.
DISCHARGE LABS:
[**2103-10-24**] 07:12AM BLOOD WBC-8.8 RBC-3.89* Hgb-10.9* Hct-33.2*
MCV-86 MCH-28.1 MCHC-32.9 RDW-13.6 Plt Ct-280
[**2103-10-24**] 07:12AM BLOOD Glucose-101* UreaN-38* Creat-1.6* Na-142
K-4.0 Cl-110* HCO3-23 AnGap-13
.
MICRO:
[**2103-10-18**] Urine culture: no growth
[**2103-10-19**] Blood culture: no growth to date
.
IMAGING:
[**2103-10-18**] Portable CXR: There is slight tortuosity and
calcification along the thoracic aorta. The heart is probably at
the upper limits of normal size. There is vague patchy hilar
opacification on each side, which may suggest slight congestion.
Patchy retrocardiac opacity, probably in the left lower lobe, is
most suggestive of minor atelectasis.
IMPRESSION: Suspicion for slight congestion, otherwise
unremarkable.
.
[**2103-10-19**] ECHO: A pacemaker wire is seen in the right atrium and
right ventricle. The tip of the pacemaker wire appears to
penetrate the right ventricular free wall and may protrude beyon
the epicardial surface of the right ventricular free wall
(through-and-through perforation). The left atrium is dilated.
The right atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF = 45%) secondary to hypokinesis of the inferior
and posterior walls, and to pacemaker-induced dyssynchrony. The
right ventricular free wall thickness is normal. 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. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. An eccentric, posteriorly directed jet of
moderate (2+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
[Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is
mild pulmonary artery systolic hypertension. There is a small
pericardial effusion subtending the epicardial surface where the
pacemaker wire tip emerges. There is no sign of cardiac
tamponade. Compared with the findings of the prior study (images
reviewed) of [**2099-7-6**], the following findings are new:
(1) pacemaker wire now seen in RA/RV, entering and probably
perforating RV free wall
(2) small pericardial effusion now seen subtending area where
pacemaker wire tip seen (no sign of cardiac tamponade)
(3) pacemaker-induced LV dyssynchrony is now present
(4) inferior posterior wall hypokinesis now present
(5) RV is now dilated and hypocontractile
.
[**2103-10-22**] PA/LAT CXR: Left-sided battery pack with pacemaker lead
wires terminating in the right atrium and right ventricle
without change in position. Bilateral pleural effusions are
present. Mild pulmonary edema from [**2103-10-21**] is mostly
resolved.
Brief Hospital Course:
This is a 77 year old female with past medical history
significant for hypertension presenting in complete heart block
s/p temporary pacemaker placement and kidney failure (acute vs.
CKD).
# Complete Heart Block - Etiology [**3-8**] a recent MI given elevated
trop to 8 with inferior q-waves on EKG leading to complete heart
block. Dual chamber permanent pacer placed and set to 80 bpm.
PA/LAT CXR showed appropriate positioning. Pt received 4 doses
of prophylactic IV Vancomycin. No abx on discharge. Completed
physical therapy that suggested home with PT. EP interrogated
the pacer on discharge and was OK with discharge.
.
# Completed Inferior MI - Given q waves and lack of ST changes
and elevated troponins, pt had MI in the near past, reports
chest discomfort a week or so ago. ECHO showed EF 45%. We
started medical management with [**Last Name (LF) **], [**First Name3 (LF) **] 325, Atorva 80,
Metop XL 25, Echo showed inferior posterior wall hypokinesis,
and EF 45%. Pt was without chest pain during her admission.
.
# Acute Kidney Injury with possible CKD - Cr 4.7 on admission.
Cr 1.6 on Discharge. We treated her with gentle IVF, renally
dosing meds, avoiding nephrotoxins, and fixing her conduction
system allowing appropriate forward flow. The etiology is
unclear given unknown baseline Cr, mostly like it is ATN [**3-8**] to
poor forward flow. On discharge we restarted [**First Name8 (NamePattern2) **] [**Last Name (un) **].
.
# HTN - We initially held all home BP meds (Dilt, HCTZ,
telmasartan) during the admission given her low BPs. Patient was
instructed to restart telmasartan, and she was started on
metoprolol.
.
### Transitions of care:
- BP has been low during hospital stay, consider starting ACEi
for remodeling benefit as outpatient.
Medications on Admission:
1. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
2. Ranitidine 150 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Diltiazem Extended-Release 300 mg PO DAILY
5. Micardis *NF* (telmisartan) 80 mg Oral daily
6. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Ranitidine 150 mg PO DAILY
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
6. Hydrocortisone Cream 1% 1 Appl TP QID itching
apply to rash on right neck
7. Micardis *NF* (telmisartan) 40 mg Oral daily
this is one half your dose
8. Metoprolol Succinate XL 25 mg PO DAILY
Hold SBP < 100, HR < 60
RX *metoprolol succinate 25 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
national health solutions
Discharge Diagnosis:
Complete Heart block
Hypertension
Ventricular perforation with pacer wire.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
it was a pleasure taking care of you at [**Hospital1 18**].
You had an abnormal heart rhythm called complete heart block and
needed a temporary pacing wire that was changed to a permanant
pacemaker to help your heart beat normally. Your blood pressure
was low during this time but is normal now. You had a heart
attack before you came in to the hospital so we have started
some medicines to help your heart recover from the heart attack.
Followup Instructions:
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2103-11-14**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: MONDAY [**2103-10-29**] at 3:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Name6 (MD) 5106**] [**Name8 (MD) **], MD
Specialty: Primary Care
Location: [**Hospital **] HOSPITAL [**Location **]
Address: 1400 VFW PARKWAY, [**Location **],[**Numeric Identifier 16354**]
Phone: [**Telephone/Fax (1) 9075**]
Please call Dr. [**Last Name (STitle) 16355**] office and make an appointment to be
seen within 1 week of your discharge from the hospital. Let them
know you will need a post-hospitalization appointment.
|
[
"584.5",
"426.0",
"412",
"585.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83",
"37.78"
] |
icd9pcs
|
[
[
[]
]
] |
9596, 9652
|
6813, 8455
|
302, 368
|
9771, 9771
|
3002, 3002
|
10386, 11373
|
1575, 1594
|
8867, 9573
|
9673, 9750
|
8604, 8844
|
9922, 10363
|
3632, 6790
|
1609, 2471
|
2487, 2983
|
255, 264
|
396, 1415
|
3018, 3616
|
9786, 9898
|
8476, 8578
|
1437, 1442
|
1458, 1559
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,359
| 178,699
|
48154
|
Discharge summary
|
report
|
Admission Date: [**2140-4-3**] Discharge Date: [**2140-4-8**]
Date of Birth: [**2074-2-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Nausea, vomiting, and chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66F with PMH of DM2 not on insulin, HL, depression and alcohol
abuse who initially presented with nausea and vomit. She was in
her prior state of health until ~5 days prior to admission when
she started feeling very depressed and the voices she normally
hears started to tell her to injure herself. She denies any plan
or thoughts of harming others. Then, she started feeling very
nauseous and within 24 hours she started having yellow-green
vomit, leading to decreased PO intake. Then 3 days ago she
started drinking abour 8 oz of Vodka daily for three days. She
states she was hydrating herself adequately during this time.
Denies any blurry vision, double vision, lightheadedness,
dizziness, chest pain, shortness of breath, palpitations,
abdominal pain, diarrhea, constipation, skin rashes, fever,
chills, rigors or any focal signs of infection.
On the day of admission she started having sub-sternal chest
pain of [**8-16**], sharp in quality, lasting 30 sec to 5 minutes, not
associated with activity, without radiation, may worsen with
inspiration. Therefore, she decided to come to the [**Hospital1 18**] for
evaluation.
In the ER her initial VS were T 99.4, HR 117 BPM, BP 131/79
mmHg, SpO1 100% on 2L NC. She was tachycardic throughout the ED
admission with otherwise stable VS. Her initial BS was 273. She
was guaiac positive with an otherwise normal exam. Her ECG
showed sinus tachycardia with TWI in the infero-lateral leads.
She initially was found to have a gap of 47 with bicarbonate of
5, creatinine of 2.5 with BUN of 44, WBC 14 with 1% bands and
83% PMNs. Her CK was 981, MB 45, Trop-T 0.02, Lypase 546. Her
serum alcohol level was 84 and her urine was positive for
opioids. Otherwise negative tox screen. Her CXR was clean as
well as her UA. Patient received 2 L NS, a Banana bag, folate,
thiamine, MVI, Aspirin 325 mg and was started on Insulin gtt,
Vanc/Zosyn for a leukocytosis. She also received Zofran 4 mg IV
and morphine 4 mg IV for chest pain. Her gap started to close up
to 27. At that time her ABG was: 7.27/27/102 with a lactate of
4.2. She was admitted to the ICU for further management of the
gap and insulin drip. Her VS prior to admission were HR 105 BPM,
BP 160/125 mmHg, RR 24 X', SpO2 98% 2 L.
Past Medical History:
#DM, dx [**2134**], last HbA1C 6.3% ([**3-/2139**]), not on any medications
for this at this time, performs fingersticks QAM, BS usually
88-174
#Hypercholesterolemia.
#Depression.
#Alcohol use.
#Alopecia areata, [**2129**]
#History of GI bleeding in [**2128**]. Colonoscopy demonstrated
diverticuli of the sigmoid colon. Has not had recent bleeding.
#Alcoholic hepatitis.
#Colonic polyps, last colonoscopy [**3-/2139**]
Social History:
Receptionist in psychiatry department at [**Hospital6 **].
Married twice, second husband died 10yrs ago of massive MI while
lifting heavy-object, and depression began around his death. She
has one adult son who lives in [**Name (NI) 1468**]. Patient lives alone in
[**Location (un) 686**] in basement apartment. Used to live with brother who
died 2 years ago, also contributing to depression. Has a
nephew. Denies any current or past history of tobacco. She has
chronic alcohol. Denies any illegal drug use.
Screening: negative [**Last Name (un) 3907**] ([**9-15**]), colonoscopy ([**3-15**]).
Family History:
Son, 47, well, but benign heart murmur.
Sister, 30, died of cirrhosis.
Sister, 43, died of MI.
Brother, 45, died of MI.
Brother, 65, died of liver failure, "heart problems."
Mother, age 50, died of pneumonia .
Physical Exam:
VITAL SIGNS - Temp 99.7 F, BP 154/79 mmHg, HR 105 BPM, RR 22 X',
O2-sat 100% RA
GENERAL - sick-appearing woman in distress secondarely to pain,
uncomfortable, appropriate, not jaundiced (skin, mouth,
conjuntiva)
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
pin-point pupils bilateraly with full range of motion of both
eyes
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no RG, nl S1-S2, systolic
bar-like murmum on apex radiating towards axila [**2-13**]
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
Pertinent Results:
Admission Results:
CXR: The cardiac silhouette is normal in size. The mediastinal
and hilar contours are unremarkable. The lungs are clear without
focal consolidation. No pleural effusion or pneumothorax is
present. No acute skeletal abnormalities seen.
.
ECG: NSR 1:1 conduction at 100 BPM with mild sings of atrial
enlargement, PR isoelectric and 180 ms, QRS axis 60 degrees with
80 ms [**First Name (Titles) **] [**Last Name (Titles) 101514**], TWI in III, aVF, V2-V5 with normal ST-segment.
QT 400 ms.
[**2140-4-3**] 07:25PM
WBC-14.0*# RBC-3.60* Hgb-10.6* Hct-33.4* MCV-93 Plt Ct-208
Neuts-83* Bands-1 Lymphs-12* Monos-4 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
Glucose-257* UreaN-44* Creat-2.5*# Na-132* K-5.0 Cl-81* HCO3-5*
AnGap-51*
ALT-46* AST-108* CK(CPK)-981* AlkPhos-70 TotBili-0.7 Lipase-546*
CK-MB-45* MB Indx-4.6 cTropnT-0.02*
CK-MB-47* MB Indx-4.3 cTropnT-0.04*
CK-MB-42* MB Indx-2.7 cTropnT-0.04*
Calcium-7.3* Phos-1.3*# Mg-1.5*
pO2-102 pCO2-27* pH-7.27* calTCO2-13* Base XS--12
Discharge Labs: [**2140-4-8**] 06:22AM
WBC-6.7 RBC-3.26* Hgb-9.9* Hct-30.4* MCV-93 Plt Ct-188
Glucose-115* UreaN-4* Creat-0.8 Na-143 K-3.7 Cl-102 HCO3-31
AnGap-14
Calcium-8.6 Phos-3.3 Mg-2.3
Brief Hospital Course:
66F with PMH of DM2 not on insulin, HL, depression and alcohol
abuse presenting with acute renal failure and metabolic disarray
in the setting of recent decreased PO intake and binge drinking.
#. Anion Gap Metabolic Acidosis - Likely secondary to
ketoacidosis in the setting of decreased PO intake and alcohol
abuse with a potential small contribution from diabetic
ketoacidosis. Resolved with IV fluid hydration and Insulin
therapy.
#. Pancreatitis - Patient with recent increase in alcohol
intake, now coming with nausea, vomit and lipase of 546. Patient
was initially made NPO, and had her diet slowly advanced. She
was tolerating a regular diet for two days prior to discharge.
#. Acute kidney failure - Initial creatinine of 2.5 from her
baseline of 1. Likely secondary to volume depletion in the
setting of decreased PO intake and vomiting. Resolved with fluid
hydration.
#. Chest pain: Troponin stable at 0.02, 0.04, and 0.04. Chest
pain symptoms more consistent with epigastric pain, thought to
be secondary to alcoholic pancreatitis +/- alcoholic gastritis.
#. Depression: Patient was continued on her home regiment. She
spoke over the phone with her outpatient psychiatrist and plans
to follow-up with her after discharge. The dangers of decreased
PO intake and alcohol were reviewed several times, and patient
was urged to contact a family member, her psychiatrist, or her
PCP if she felt her depression worsening or her appetite
decreasing in the future.
#. Alcohol abuse - Patient with chronic alcohol use and abuse
with last drink on the day of discharge. She showed no signs of
withdrawal throughout her stay.
Medications on Admission:
Citalopram 40 mg PO Daily
Hydrochlorothiazide 25 mg PO Daily
Trazodone 100 mg PO QHS
Aspirin 325 mg PO Daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for Insomnia.
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute renal failure
Hypophosphatemia
Hypomagnesemia
Hypokalemia
Hypocalcemia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with acute renal failure and very low levels
of potassium, calcium, phosphorous, and magnesium. This was
likely caused by not eating and drinking a lot of alcohol. This
can be a life-threatening combination, and I encourage you to
call your Psychiatrist or Dr.[**Last Name (STitle) **] if you ever feel like you
are in danger of doing this again.
No changes have been made to your home medication regiment.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2140-4-11**] at 1:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"250.00",
"V12.72",
"275.2",
"584.9",
"276.8",
"311",
"577.0",
"275.41",
"275.3",
"535.30",
"272.0",
"305.01",
"276.2",
"285.9",
"786.50"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8017, 8023
|
5912, 7546
|
346, 352
|
8143, 8143
|
4702, 5697
|
8740, 9063
|
3689, 3900
|
7706, 7994
|
8044, 8122
|
7572, 7683
|
8290, 8717
|
5713, 5889
|
3915, 4683
|
274, 308
|
380, 2615
|
8158, 8266
|
2637, 3061
|
3077, 3673
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,220
| 117,626
|
26800
|
Discharge summary
|
report
|
Admission Date: [**2148-5-3**] Discharge Date: [**2148-5-7**]
Date of Birth: [**2128-5-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
nausea, vomiting, DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Name13 (STitle) 12101**] is a 19 yo woman pregnant at 7w2d with h/o DM1
(poorly controlled) on insulin pump, myasthenia [**Last Name (un) 2902**] s/p
thymoma removal [**12-8**], and [**Doctor Last Name 933**] disease (poorly controlled)
who presents with 3d of nausea and vomiting. FS at home have
been 300s-400s for 3 days and she has had large ketones on
dipstick. She presented to her OB today with these symptoms and
was sent to the ER where she was found to be in DKA with anion
gap of 19. She was started on insulin drip and given IVF.
Repeat chem 7 in ER showed anion gap had closed at 10. She was
seen by endocrine who recommended very tight control of her FS
(80-120 for 4-5 hours while still on drip) before transitioning
back to her pump given her history of very poor control.
.
ROS: baseline cough, denies sputum, no dysuria, no other
symptoms. reports feeling much better than at home earlier
today.
Past Medical History:
- pregnant at 7w2d, past TAB x 1
- DM type I x 11 yrs seen by Dr. [**Last Name (STitle) **] at [**Last Name (un) **], on insulin
pump with basal 3u/hr., does not carb count, infrequent FS, does
not give self boluses; A1C 12.5 as of [**2148-4-16**]
- Myasthenia [**Last Name (un) 2902**] s/p thymoma removal at [**Hospital1 2025**]
- [**Doctor Last Name 933**] disease - was on tapazole, changed to PTU on [**2148-4-16**] at
first OB visit. by report has never been well controlled and was
to have surgery vs radioablation. TSH 0.028/FT4 1.4 as of
[**2148-4-16**]
- psych ("mood disorder" - "low grade bipolar") previously on
abilify but now none
Social History:
works as a hairdresser and at the [**Company 3596**]. smokes 1.5 ppd. single.
Family History:
mother with celiac sprue, hypercholesterolemia, htn, DM2. father
s/p suicide.
Physical Exam:
98.6, 97, 128/64, 96% RA
Gen: pleasant, NAD, conversant
HEENT: PERRL, no OP injection, NCAT, no lid lag
Neck: thyroid fulness, + thyroid bruit, no LAD
Cor: s1s2, III/VI fine holosystolic murmur heard best at RUSB,
nonradiating
Pulm: CTAB
Abd:soft, NT, ND, +BS
Ext: no c/c/e, 2+ pt
Neuro: non focal
Pertinent Results:
[**2148-5-3**] 11:45AM BLOOD WBC-7.8 RBC-5.29 Hgb-15.4 Hct-42.0
MCV-79* MCH-29.1 MCHC-36.7*# RDW-14.0 Plt Ct-331
[**2148-5-7**] 06:25AM BLOOD WBC-5.1 RBC-4.45 Hgb-12.8 Hct-35.8*
MCV-81* MCH-28.8 MCHC-35.7* RDW-14.4 Plt Ct-267
[**2148-5-3**] 11:45AM BLOOD Neuts-81.8* Lymphs-12.2* Monos-4.8
Eos-0.3 Baso-1.0
[**2148-5-3**] 11:45AM BLOOD Plt Ct-331
[**2148-5-6**] 04:26AM BLOOD PT-11.4 PTT-20.5* INR(PT)-1.0
[**2148-5-3**] 11:45AM BLOOD Glucose-317* UreaN-13 Creat-0.8 Na-131*
K-4.6 Cl-96 HCO3-16* AnGap-24*
[**2148-5-7**] 06:25AM BLOOD Glucose-60* UreaN-10 Creat-0.4 Na-137
K-3.9 Cl-104 HCO3-22 AnGap-15
[**2148-5-3**] 11:45AM BLOOD ALT-18 AST-14 AlkPhos-161* Amylase-10
TotBili-0.8
[**2148-5-3**] 11:45AM BLOOD Lipase-13
[**2148-5-3**] 11:45AM BLOOD Albumin-4.9* Calcium-10.2 Phos-3.6 Mg-1.8
[**2148-5-7**] 06:25AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.7
[**2148-5-3**] 11:45AM BLOOD Acetone-MODERATE
[**2148-5-3**] 11:45AM BLOOD TSH-0.024*
[**2148-5-3**] 11:45AM BLOOD T3-181 Free T4-2.2*
[**2148-5-4**] 02:06PM BLOOD HBsAg-NEGATIVE
[**2148-5-7**] 06:25AM BLOOD antiTPO-992*
[**2148-5-4**] 02:06PM BLOOD HIV Ab-NEGATIVE
[**2148-5-4**] 02:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2148-5-4**] 02:06PM BLOOD CYSTIC FIBROSIS, DNA PROBE ANALYSIS-Test
.
cardiac ECHO [**2148-5-7**]
Impression: normal study
.
Brief Hospital Course:
[**Known firstname **] [**Last Name (NamePattern1) 12101**] is a 19 yo woman who presented in DKA, pregnant
at 7w2d with h/o DM1 and [**Doctor Last Name 933**], both poorly controlled, as well
as myasthenia [**Last Name (un) 2902**] s/p thymomectomy who presents with 3d
nausea/vomiting and was found to be in DKA. Ms. [**Name13 (STitle) 12101**] was
admitted to the Medical ICU for DKA. Her DKA was treated using
our standard ICU protocol with aggressive fluid repletion, FS
measured every hour, and insulin drip. Her anion gap closed
while she was still in the ER and remained closed throughout the
rest of her stay. After her FS dropped below 200 she was
started on D5 1/2 NS for fluids. When her FS dropped below 150
she was allowed to begin eating and her insulin pump was turned
on at her usual basal dose of 3units/hr. She bolused herself
from her insulin pump with a 1:10 carb ratio with meals. She
continued to have high fingersticks, but was no longer in DKA
and anion gap had been closed for three days upon discharge from
the ICU to the floor. The patient was followed by endocrine,
diabetes in pregnancy, and high risk OB during her stay in the
unit.
.
Per OB, we also sent some basic labs including HIV, RPR, Rubella
antibody, Hep B SAg and CF gene (per pt, her ex-boyfriend is
[**Name2 (NI) **]). These will be followed up as an outpatient in OB High
risk clinic. She was kept on a prenatal vitamin during her stay.
Ms. O??????[**Doctor Last Name **] was repeatedly counseled regarding the high
potential for adverse effects on the fetus that her current
health situation presents. Given her elevated A1c ([**12-15**] % on
recent [**Last Name (un) **] readings), macrosomia, and fetal congenital
defects are quite possible. The patient elected to continue the
pregnancy. She has outpatient Ob/Gyn followup, and testing at
appropriate time (16-18 wks) via CVS/amnio/U/S. Her obstetrical
exam was unremarkable at a recent appointment.
.
The patient was kept on PTU for her [**Doctor Last Name 933**] disease during her
stay. Her [**Doctor Last Name 933**] is not well controlled at present, however she
is following with Dr. [**Last Name (STitle) **] as an outpatient and had her
first visit there two weeks ago, when PTU was started. Endocrine
recommended continuing on her usual dose and rechecking thyroid
studies as an outpatient in 2 weeks.
.
The patient is an active cigarette smoker, however she has
decreased from 1.5 packs per day to 5 cigarettes per day. We
discussed the importance of smoking cessation in pregnancy as
well as for her general health.
.
In the medicine [**Hospital1 **], the pt was able to maintain improved
control of blood glucose levels in hospital with insulin pump,
and has demonstrated her ability to correctly program her pump
and make appropriate adjustments. Her current regimen of
baseline humalog was titrated to prevent against transient
hypoglycemia observed in [**Hospital Unit Name 153**]. Patient used ??????carb counting?????? with
1:10 insulin:carbohydration, with correction factor 1:25 for
hyperglycemia. She was closely followed by the endocrine team.
.
On [**2148-5-7**], the pt decided to leave against medical advise. She
was counseled about the potential risks of leaving prematurely,
including potential hypo or hyperglycemia on current insulin
regimen as well as the risk to her fetus including death and
deformity. The pt was urged to follow with her PCP, [**Name10 (NameIs) 65981**]
and Endocrinologist as out-patient.
Medications on Admission:
MEDS from OMR:
Insulin ?????? pump [**First Name8 (NamePattern2) **] [**Last Name (un) **]/Endocrine consult recommendations.
Currently Humalog 3U/hr during day, 2.5U/hr at night.
Ferrous Sulfate 325 mg po qd
Nephrocaps
Colace / Senna
ALL: NKDA
Discharge Medications:
Pt left against medical advise
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) DKA
2) Pregnancy
Secondary:
1. Hyperthyroidism; patient managed with PTU, recent management
with tapazol. Has been considered for outpatient ablation.
2. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]
3. Thymoma s/p surgical resection [**12-8**]
Discharge Condition:
Pt left against medical advise
Discharge Instructions:
Pt left against medical advise
Followup Instructions:
Pt left against medical advise
Completed by:[**2148-6-26**]
|
[
"358.00",
"242.00",
"646.63",
"648.43",
"276.52",
"250.12",
"V45.85",
"648.03",
"648.13",
"296.80",
"V23.9",
"648.93",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7704, 7710
|
3856, 7353
|
334, 340
|
8026, 8058
|
2491, 3833
|
8137, 8198
|
2075, 2154
|
7649, 7681
|
7731, 8005
|
7379, 7626
|
8082, 8114
|
2169, 2472
|
273, 296
|
368, 1294
|
1316, 1964
|
1980, 2059
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,253
| 184,487
|
402
|
Discharge summary
|
report
|
Admission Date: [**2141-10-8**] Discharge Date: [**2141-10-17**]
Service: MEDICINE
Allergies:
Valium
Attending:[**First Name3 (LF) 3544**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
PEG tube placement
History of Present Illness:
[**Age over 90 **] yo male with h/o Parkinson's dz, spinal compression fractures
and recent admission at [**Hospital1 **] from [**Date range (1) 3550**] for PNA who presents
from an OSH with PNA and stable hypoxia. On [**10-3**] he was
admitted to OSH with worsening SOB. His sats were 89- 91% on a
NRB and he was noted to be somnolent and in severe respiratory
distress. ABG was 7.30/60/88/29. CXR showed LLL infiltrate and
wbc was 11.9. He was intubated and treated for suspected PNA
with zosyn and vancomycin at the OSH. He was ultimately
transferred to the [**Hospital1 **] for continued care per request of the
patient's wife.
.
In the MICU, pt was continued on unasyn to complete 10 day
course of antibiotics for his aspiration pneumonia. He was
witnessed to aspirate repeatedly leading to changes in mental
status and worsening hypoxia. This prompted the placement of a
G-tube by GI on [**10-12**]. On [**10-13**], tube feeds were started per
nutrition recs. Pt's respiratory status remained tenuous but
stable and improved slowly every day. For decreased urine
output, he received several IVF boluses. He was then transferred
to the medical [**Hospital1 **].
Past Medical History:
Osteoporosis
Parkinson's Disease
T11-12 compression fracture
s/p laminectomy L4-5
left LE osteomyelitis
liver disease-granulomatous disease
LUE rotator tear
prostate CA-In [**2126**], he had an orchiectomy for prostate cancer
Social History:
The patient has a sixty-pack-year history of tobacco. He quit in
[**12/2098**]. He lives in a NH for the past 2 years. He is a retired
history professor. He reports no alcohol intake.
Family History:
Non-contributory
Physical Exam:
VS:Tc 96.2 HR 78 Bp 156/74 o2 sat 97% on 5 L NC RR 18
Gen: chronically ill appearing elderly male in NAD
HEENT: anicteric, mouth with thick yellow respiratory secretions
NEck:supple, no JVD
Pulm: rhonchorus breath sounds throughout, no crackles
Cardio: difficult to hear heart sounds given diffuse rhonchi,
RRR, no murmurs or gallops
Abd: soft, NT, ND, +BS
Ext: LE with 1+ lower extremity edema; legs hairless, cool feet
but faint DPs bilaterally
Neuro: AO x 3, + cogwheel rigidity
.
Pertinent Results:
[**2141-10-8**] 07:34PM TYPE-ART TEMP-37.1 RATES-/42 O2-50 PO2-87
PCO2-44 PH-7.44 TOTAL CO2-31* BASE XS-4 INTUBATED-NOT INTUBA
[**2141-10-8**] 05:59PM GLUCOSE-107* UREA N-11 CREAT-0.7 SODIUM-150*
POTASSIUM-3.7 CHLORIDE-113* TOTAL CO2-29 ANION GAP-12
.
CXR [**10-8**]: New left-sided effusion. Bibasilar airspace opacities.
Diagnostic considerations include pneumonia.
.
Brief Hospital Course:
.
A/P: [**Age over 90 **] yo male with Parkinson's dz, granulomatous disease, and
spinal compression fractures who presents from an OSH with
hypoxia and bilateral PNA [**1-5**] chronic aspiration.
.
*Hypoxia: The patient's hypoxia was thought to be [**1-5**] chronic
asp PNA. He was witnessed to aspirate in the ICU as well as had
pills suctioned during nasotracheal suction. The patient would
desat to the high 80s for a brief period after an aspiration
event. He had been started on Unasyn at the OSH and completed a
10 day course of Unsayn. He was treated with scheduled
Ipratropium nebs and PRN albuterol nebs in the ICU which help
with his symptomatic dyspnea.
.
*Oliguria: Pt responds well to fluid boluses. However +2.7L
since being in ICU so may benefit from IV lasix given that he is
likely no longer dry (nl BUN/cr). Euvolemic at time of discharge
but will need monitoring of fluid status. Currently receiving
free water boluses per PEG, no need for furosemide at this time.
.
*Parkinson's disease: Stable during this admission. The patient
was continued on his [**Known lastname 3545**] outpatient regimen of Parkinson's
medications including Comtan, Mirapex, and Carbidopa/Levodopa.
.
*Granulomatous Dx: Stable during this admission. The patient has
a history of likely granulomas found on chest CT scan as well as
mention of granulomas found in liver on CT scan. He will
require yearly chest CT scan f/u to ensure these granulomas are
stable.
.
*Hx of osteomyelitis: Stable during this admission. The patient
has a hx of osteomyelitis in bilateral lower extremities. His
lower extremity exam was stable throughout his admission and
there was no evidence of infection. Per the patient's wife, he
has not had problems with drainage in many years.
.
*Compression fractures: Stable during this admission. The
patient did not complain of pain. He was continued on
calcitonin and neurontin.
.
# asymptomatic candiduria: removed foley catheter. no treatment
indicated.
.
*FEN: A PEG tube was placed this admission after the patient
aspirated multiple times. Tube feeds were started and these
were tolerated well
.
*PPX: Pt was continued on Senna, Docusate for bowel regularity,
Protonix for GI prophylaxis and SQ Heparin for DVT prophylaxis
.
*Code status: Full code (Reviewed this with his proxy [**Name (NI) 3551**]
(wife). Reviewed with Dr. [**Last Name (STitle) **] (PCP) and wife and patient
still full code
.
Medications on Admission:
Home Meds:
Mirapix 0.125 6x/day
Sinemet 25/100 qid
comtan 200 mg 7x/day
neurontin 100 mg [**Hospital1 **]
ASA 325 mg qd
Miacalcin qd
Ibuprofen 400 mg qd
Vitamin D 400 units qd
vitamin E 400 untis qd
colace 100 mg TId
Lasix 20 mg qd
Ipratropium nebs qid
Albuterol nebs qid
Levofloxacin 500 mg qd
Calcium Carbonate 750 mg qd
Hexaviamine one capsuel qd
Senekot one tab [**Hospital1 **]
refresh tears [**Hospital1 **]
xalatan L eye, 0.005% qd
cosopty one gtt to L eye [**Hospital1 **]
Vicodin 2 tabs qd
Klonopin 0.5 mg qd
[**Doctor First Name **] 60 mg [**Hospital1 **]
Iron textran 4 wk cycle
Tessalon perles 100 mg prn
.
Discharge Medications:
1. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
3. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
6. Vitamin E 50 unit/mL Drops Sig: Eight (8) mL PO DAILY
(Daily).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-5**]
Drops Ophthalmic PRN (as needed).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Entacapone 200 mg Tablet Sig: One (1) Tablet PO q 3 hours ()
as needed for parkinsons.
11. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO q 3 hours
() as needed for parkinsons.
12. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
Q3 HOURS ().
13. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
14. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO
Q6H (every 6 hours) as needed for fever or pain.
15. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
16. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain: do not
exceed 2000mg of acetaminophen per day.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
18. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
primary: aspiration pneumonia
secondary: Parkinson's disease
Discharge Condition:
Good.
Discharge Instructions:
Call your doctor if you have chills, fevers, nausea with
vomiting, chest pain, or shortness of breath.
.
Followup Instructions:
Call Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 457**]) for an appointment within the
next month.
|
[
"428.32",
"428.0",
"507.0",
"V10.46",
"518.81",
"515",
"733.00",
"332.0",
"572.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
7869, 7948
|
2848, 5283
|
223, 243
|
8053, 8061
|
2448, 2825
|
8215, 8324
|
1908, 1927
|
5953, 7846
|
7969, 8032
|
5309, 5930
|
8085, 8192
|
1942, 2429
|
176, 185
|
271, 1441
|
1463, 1690
|
1706, 1892
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,981
| 162,851
|
39707
|
Discharge summary
|
report
|
Admission Date: [**2189-5-1**] Discharge Date: [**2189-5-4**]
Date of Birth: [**2158-1-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / morphine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for R retromastoid craniotomy for
microvascular decompression of the 5th cranial nerve
Major Surgical or Invasive Procedure:
[**2189-5-1**]: R retromastoid craniotomy for microvascular
decompression of the 5th cranial nerve
History of Present Illness:
She presented with pain in the right maxillary and mandibular
area after a dental procedure seven years ago. The pain was a
sharp shooting pain,
which was exacerbated by chewing, cold wind, and this has become
more chronic over time and is almost associated with a burning
sensation in her face. She had blurring of vision transiently
and she saw an ophthalmologist. There was no diplopia noted at
that time. She has had a recurrent ear infection and has also
had a history of a right tympanic membrane rupture. She has had
Sjogren disease.
Past Medical History:
Lupus, antiphospholipid syndrome, and Sjogren disease.
Septoplasty, right wrist torn ligament.
Social History:
She worked as a radiology tech but is now applying for
disability. She does not smoke and takes alcohol socially.
Family History:
NC
Physical Exam:
Pre-op:
On examination, she is awake, alert, and oriented x3. Her
pupils
are equal and reacting to light. Extraocular movements are
full.
Visual fields full. Face is symmetric. Shoulder shrug is
symmetric. Hearing is intact bilaterally. Palate elevation is
symmetric. Tongue is in the midline. Speech is fluent. Her
motor strength is full in all four extremities. Sensation to
light touch is diminished in the right V2 distribution.
Reflexes
are 2+ and symmetric. She does not have clonus. Gait is within
normal limits.
Pertinent Results:
[**2189-5-1**] Head CT:
IMPRESSION: Status post trigeminal decompression surgery, with
expected
pneumocephalus. No intracranial hemorrhage detected. Small
extra-axial fluid collection in the right posterior cranial
fossa.
Brief Hospital Course:
31F admitted electively for a R retromastoid crani for MVD of
5th nerve. Post-operatively, she as admitted to the ICU for
monitoring. Her post-operative Head CT was stable with expected
post-op changes. On [**5-2**], she was transferred to the floor from
the ICU. Her home medications were started per the
recommendations of her Rheumotologist. Her activity was
increased she ambulated in the hallway and tolerated a regular
diet. Her pain was improving on the right side of her face but
had intermittent electrical type pain, she felt the pain meds
were improving. Neurologically she had no deficits on discharge.
Medications on Admission:
gabapentin 100 mg q.h.s., Keppra 500 mg t.i.d., levothyroxine,
colchicine, Evoxac, azathioprine, meloxicam, ery tab (started
[**4-29**] x10d course) and aspirin 81 mg.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Use while taking pain meds.
Disp:*40 Capsule(s)* Refills:*0*
4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO 5X DAILY
().
5. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q 8H (Every 8 Hours) for 8
days.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): use while taking prednison.
Disp:*20 Tablet(s)* Refills:*0*
8. cevimeline 30 mg Capsule Sig: One (1) Capsule PO 4x/day ().
9. colchicine 0.6 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. dexamethasone 2 mg Tablet Sig: See instructions Tablet PO
2mg Q6xX1 day; 2mg Q8 X 2 days, 2 mg [**Hospital1 **] X 2 days then stop.
Disp:*14 Tablet(s)* Refills:*2*
12. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days: Start after 2mg dose.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Trigeminal Neuralgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You may resume your Aspirin, colchicine, and cevimeline. You
can start Imuran 10 days after your surgery [**5-11**] if there is
no sign of infection.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 2 weeks with no images please
call [**Telephone/Fax (1) 4296**] to make these appointments.
Have your sutures removed on Friday [**5-9**] either here or at
your primary care's office. If you choose to come here call the
number to make an appointment
Completed by:[**2189-5-4**]
|
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"V17.49",
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icd9cm
|
[
[
[]
]
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[
"04.41"
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icd9pcs
|
[
[
[]
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4272, 4278
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2153, 2770
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388, 489
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4343, 4343
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1905, 1920
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5662, 5997
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2989, 4249
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1929, 2130
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4358, 4470
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1087, 1184
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1200, 1317
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,550
| 131,780
|
3397
|
Discharge summary
|
report
|
Admission Date: [**2195-4-3**] Discharge Date: [**2195-4-16**]
Date of Birth: [**2160-8-4**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Drainage (of intraperitoneal abdominal abscess),
end-sigmoid colostomy and Hartmann turn-in, peritoneal
washout with antibiotics
History of Present Illness:
34F with complex medical history who presented to [**Hospital1 18**]
emergency department on [**2195-4-2**] for abdominal pain. She was seen
earlier this day in the clinic of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or pulmonary
consultation. Pt reports a [**10-25**] day course of LLQ pain that
has worsented. She was initially examined by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6426**]
on [**2195-3-26**] for polychondritis follow-up. CT of trachea/chest
done on [**3-26**] showed extensive pneumomediastium and air within
the mesentery with ? pneumatosis of visualized left colon.
Past Medical History:
PMH:
Polychondritis
Asthma
Raynaud's
Diverticulitis [**7-/2194**]
Migraine HA
Interstitial cysitis
Hemorrhagic ovarian cysts
Fibromyalgia
PSH:
Diagnostic Laparoscopy + ovarian cystectomy [**6-/2187**]; [**5-/2189**]
arthroscopic right knee surgery [**2176**]
Family History:
Maternal Grandfather: Pancreatic CA
Maternal Grandmother: Breast CA
Physical Exam:
Admission Exam [**2195-4-2**]
----------------
98.4 90s 140s/70 20s 98% RA
A+Ox3, anxious, well-developed
no scleral icterus
rrr, no murmurs
ctab with end expiratory wheezes
abd: focal tenderness in LLQ with (+) rebound and (+)guarding,
(+)obturator sign; no hernias, periumbilical scar, fullness in
LLQ, mildly distended but soft, (+)bs
ext warm, no edema, no lesions/rahses
rectal: guiaic (+), brown stool in vault
Pertinent Results:
Admission Labs
-----------------
[**2195-4-2**] 06:35PM BLOOD WBC-23.0* RBC-3.47* Hgb-11.3* Hct-33.1*
MCV-95 MCH-32.6* MCHC-34.2 RDW-14.5 Plt Ct-473*
[**2195-4-2**] 06:35PM BLOOD Neuts-91.2* Lymphs-5.2* Monos-2.3 Eos-1.3
Baso-0.1
[**2195-4-2**] 06:35PM BLOOD PT-11.7 PTT-20.0* INR(PT)-1.0
[**2195-4-2**] 06:35PM BLOOD Glucose-108* UreaN-13 Creat-0.9 Na-141
K-5.0 Cl-101 HCO3-29 AnGap-16
[**2195-4-3**] 02:07AM BLOOD ALT-42* AST-22 LD(LDH)-191 AlkPhos-75
Amylase-27 TotBili-0.2
[**2195-4-3**] 02:07AM BLOOD Lipase-20
[**2195-4-3**] 02:07AM BLOOD Albumin-2.8* Calcium-7.1* Phos-1.8*
Mg-1.9
[**2195-4-2**] 07:38PM BLOOD Lactate-1.5
Discharge Labs
-----------------
[**2195-4-14**] 04:23AM BLOOD WBC-15.5* RBC-3.02* Hgb-9.8* Hct-28.5*
MCV-94 MCH-32.4* MCHC-34.3 RDW-15.8* Plt Ct-434
[**2195-4-3**] 02:07AM BLOOD Neuts-95.2* Bands-0 Lymphs-2.5*
Monos-1.9* Eos-0.3 Baso-0.1
[**2195-4-14**] 04:23AM BLOOD Plt Ct-434
[**2195-4-14**] 04:23AM BLOOD Glucose-122* UreaN-6 Creat-0.6 Na-139
K-3.7 Cl-96 HCO3-36* AnGap-11
[**2195-4-8**] 09:34PM BLOOD ALT-16 AST-14 AlkPhos-56 Amylase-113*
TotBili-1.6*
[**2195-4-14**] 04:23AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2
[**2195-4-12**] 04:43AM BLOOD calTIBC-133* Ferritn-223* TRF-102*
STUDY: CT abdomen and pelvis dated [**2195-4-3**]
CLINICAL HISTORY: 34-year-old woman with history of
diverticulitis, now with abdominal pain in the left lower
quadrant. Evaluate for intra-abdominal pathology.
Comparison made to prior CT trachea dated [**2195-3-26**].
TECHNIQUE: Multiple transaxial images of the abdomen and pelvis
were obtained after the administration of IV and oral contrast.
Coronally and sagittally reformatted images were also obtained.
CT ABDOMEN: There is mild dependent atelectasis at the
visualized lung bases. No pleural or pericardial effusions.
There is extensive intraperitoneal free air. In the left lower
abdomen, there is a gas-filled structure containing a small
amount of fluid that communicates with a loop of left colon
(sequence 2, image #66). This structure may represent redundant
sigmoid colon, but cannot exclude extraluminal collection
predominantly containing gas. As there is no oral contrast in
the left colon, a followup CT may be helpful see if this
collection contains contrast on delayed-phase imaging. Several
diverticula are identified in the left colon. There are adjacent
loops of small bowel that demonstrate diffuse wall thickening
with adjacent free fluid. The distal sigmoid colon is
unremarkable.
The liver is unremarkable. The gallbladder, pancreas, spleen and
adrenal glands are unremarkable. The kidneys demonstrate
symmetric enhancement without hydronephrosis or focal lesions.
CT PELVIS: There is a Foley catheter within the urinary bladder.
The rectum, uterus and adnexa are unremarkable. No significant
pelvic free fluid or lymphadenopathy.
No suspicious osseous lesions.
Findings were initially discussed by on-call resident with
surgery resident, Dr. [**Last Name (STitle) 15737**], on [**2195-4-3**] at 1:45 a.m.
IMPRESSION: Findings most consistent with perforated
diverticulitis, with associated extensive intraperitoneal free
air and inflammation of adjacent small bowel loops. Thin-walled,
predominently gas-filled structure in the left abdomen may
represent redundant colon, but cannot exclude collection. No
discrete abscess is identified.
Operative Note
-----------------
PREOPERATIVE DIAGNOSIS: Perforated sigmoid with peritonitis.
POSTOPERATIVE DIAGNOSIS: Perforated sigmoid with
peritonitis.
PROCEDURE: Drainage (of intraperitoneal abdominal abscess),
end-sigmoid colostomy and Hartmann turn-in, peritoneal
washout with antibiotics.
ASSISTANT: Dr. [**First Name (STitle) 15738**] [**Name (STitle) 15737**], RES and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], M.D.
INDICATIONS: This patient was seen by me in the emergency
room at 1:15 a.m. on [**2195-4-3**]. She had been seen by
members of the surgical staff earlier and by emergency room
staff who started antibiotics empirically. The history went
back several weeks when she was seen by Dr. [**Last Name (STitle) 6426**] for
abdominal and chest pain associated with an indolent but not
controlled arthritic situation. As part of the workup, he
ordered the CT scan of the chest. In the report of the CT
scan and, in my review of the CT scan, there was free air
along the colon which was easily visible and visible by the
radiologist who, in their report, stated that they had
discussed these findings with Dr. [**Last Name (STitle) 6426**]. Despite this, the
patient was discharged to [**Location (un) 15739**], [**State 531**]. In the
intervening period, she had been placed on prednisone for an
asthmatic situation and took continual pain medicine,
including Vicodin, almost nonstop with gradually increasing
abdominal pain, evidence of partial obstruction, distention
of 8 inches according to the patient, early satiety and
inability to eat a reasonable meal. She was seen by Dr.
[**Last Name (STitle) **] yesterday on [**2195-4-2**], who noted rebound
tenderness in the left lower quadrant which apparently had
been present since [**3-26**], according to the patient, and he
ordered the CT scan which again showed free air, including
loculated free air, in the left lower quadrant as well as
some stranding of the sigmoid colon. There was no
retroperitoneal collection although this seemed likely on the
part of the patient's history.
When the patient was admitted at 1:15 a.m. of [**4-3**], I
decided that, since she had not received adequate
resuscitation, had been on steroids and was quite ill, that
we would do better and she would get a better operation to
wait until the morning and spend the intervening period to
replete her with Crystalloid and let some antibiotics, in
this case, ampicillin, gentamicin and Flagyl, take an effect
and, in general, try and get antibiotic control. It was
clearly a septic situation with a white count of 21,000 and a
shift to the left with a bandemia of 93%. This was carried
out and, although she stabilized as far as her vital signs,
her pain continued to get worse and start extending off over
to the right abdomen, and her bowel sounds, which previously
had been present, were lost. I, therefore, decided that it
was time we went to the operating room.
At the time of operation, she had a dense collection of pus
from a perforation in the sigmoid vasculature which was
identified by myself and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who came into
the operating room at my request and put in place a rectal
tube and, in fact, she did have a perforation in the
sigmoid, and we resected the bowel above this and actually
right through the perforation and turned in the distal end as
a Hartmann, leaving the sutures long so her colon could be
found at some future time. The following procedure was
carried out.
DESCRIPTION OF PROCEDURE: Under satisfactory general
anesthesia, the patient was placed supine and TKO stirrups
and prepped and draped in the usual manner.
A midline incision was made since it seemed likely that, on
physical examination, she had a phlegmon in the left lower
quadrant and that she would require colostomy and, therefore,
we wanted a situation in which the colostomy could be cleared
from both the anterior-superior iliac spine and the left
lower quadrant as well as from the midline incision. The
incision was then made slightly above the umbilicus and below
the umbilicus.
We entered the abdomen where there was free air which popped.
Some fluid initially, which did not appear to be too septic,
although we aspirated it for culture. There was some
additional fluid in the upper quadrants, sort of thin
purulent material, which was again cultured and then,
finally, as we extended the incision, before we extended the
incision, we had placed the wound towels with the ends soaked
with Kefzol to protect the wound from what was undoubtedly
going to be contaminated. This was successful, and we
extended the incision and then lifted up the omentum and
began to dissect free the small bowel loops, taking care not
to damage them. This was carried out without too much problem
and, as we got down to the retroperitoneal area of the left
lower quadrant, there was a large amount of pus, probably
about 150 cc of thick, creamy pus emanating from a
retroperitoneal perforation of the sigmoid which was nicely
demonstrated. We had trouble finding the ureter on the left
side, largely because of the reaction in the retroperitoneum
and, in fact, all of her blood vessels were hypertrophic, and
she bled rather easily from any and all areas. We did,
however, identify the sigmoid and mobilized it from the left
side, taking care not to injure the iliac vessels or the
ureter and then, after we had this, Dr. [**Last Name (STitle) **] came in the
operating room and passed a rectal tube. We irrigated the
sigmoid with saline and saw the perforation clearly, which
had already been identified. [**Female First Name (un) 3224**] stapler was then stapled
across the sigmoid right in the area of perforation. The
distal side was oversewn with 3-0 Prolene and tied, and these
were left long, and the proximal side was held with four 3-0
silk sutures to be used to take the colostomy up through the
abdominal wall and mature it subsequently. The blood supply
was then secured with 0 Vicryl and, by working together, Dr.
[**Last Name (STitle) 15737**] and myself, we were able to get the sigmoid up to the
abdominal wall without causing any damage to the sigmoid.
After this, the abdomen was copiously irrigated with Kefzol
until there was no residual. We placed a #19 [**Doctor Last Name 406**] drain in
the bed of the perforation, bringing it out through a stab
wound in the right lower quadrant.
Gloves, gowns and drapes were then changed. The wound was
then closed in layers with #1 chromic catgut on the
peritoneum, #1 Prolene on the fascia which held very nicely,
3-0 Vicryl on the subcutaneous tissue over a #19 [**Doctor Last Name 406**] drain,
again, because of possible contamination of the subcutaneous
tissue, and 4-0 Monocryl as a subcuticular closure. The
colostomy was then matured after the manner of [**Doctor Last Name **] after
the wound had been closed, and we were able to separate this
with Steri-Towels from the abdominal wound with four 3-part
sutures of 4-0 Vicryl and four 2-part sutures, giving a nice
opening; however, the blood supply to this was also
extensive. We sent part of the apex of the colostomy for a
specimen because this is where the perforation was.
The patient tolerated the procedure well. Estimated blood
loss was 450 cc. She received 750 of Albumisol and 700 of
crystalloid, making good urine throughout, approximately 800
cc. She was extubated immediately postoperatively without too
much difficulty. We did keep in touch with husband throughout
with his cell phone, telling him what was going on.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 15740**] was evaluated in the emergency deparment at [**Hospital1 18**]
on [**2195-4-2**]. WBC count was 23.0; KUB showed intraperitoneal free
air. She was admitted to the surgery service under the care of
Dr. [**Last Name (STitle) 957**]. She wad taken to the ICU for further
resuscitation. She was started on Amp/Gent/Flagyl for empiric
coverage. An abdominal/pelvic CT scan was completed which showed
findings consistent with perforated diverticulitis. At HD 2 she
was taken to the operating room where she underwent drainage of
intraperitoneal abdominal abscess; end-sigmoid colostomy and
Hartmann turn-in; and peritoneal washout with antibiotics. Three
drains were placed. She tolerated the procedure well and was
taken to SICU stable and extubated. An epidural and PCA were
provided for pain control. IV steroids at home dose were
maintained. At POD 2 the OR swab was (+)GNR. Amp/Gent/Flagyl
were continued. AT POD 4 she was afebrile and with (+)flatus
from ostomy. She was transitioned from IV to oral prednisone.
Her diet was advanced to clear liquids. At POD 5 the epidural
was discontinued. Later in the afternoon she became less
responsive, tachycardic, and hypotensive. Narcan was
administered with some response. Fluid boluses and ephedrine
was used to raise blood pressure. She was afebrile, Hct was
stable at 31.7, and urine output was WNP. IV hydrocortisone was
restarted. WBC count was elevated at 27.3. Abdominal exam was
benign. She was transferred to the SICU. KUB showed a markedly
dilated stomach. An NGT was placed. She had an uneventful ICU
course and was transferred to the floor on POD 7. At POD 9 she
was afebrile, ambulatory and doing well. She was tolerating a
regular diet. The foley catheter and PCA were discontinued. PO
meds were restarted. At POD 10 she had significant diuresis.
Her pain was controlled and her ostomy was functioning well. WBC
count was 15.5. At POD 12 her drains were all removed. She was
discharged home in good condition. She was to follow up with Dr.
[**Last Name (STitle) 957**] on [**2195-4-29**]. During hospitalization her blood glucose was
elevated and treated with SSI. She was given a glucometer and
regular insulin with teaching prior to discharge. Discharge
services include continued blood glucose monitoring and
teaching; physical therapy; and new ostomy care.
Medications on Admission:
Prednisone 40 [**Hospital1 **]
Neurontin 1200 [**Hospital1 **]
Nabumetone, trazodone, Hydroxyzine, Felodipine, ASMANEX,
Albuterol, Singulair, Nasonex, Humibid LA 300-600, Maxalt,
Cryselle, Ultram, Vicodin, Prevacid, Zaditor, Folgard, Completed
a treatment with Diflucan and Augmentin the past 5 days for a
urinary tract infection
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
4. Cryselle (28) 0.3-30 mg-mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Trazodone 100 mg Tablet Sig: 3-6 Tablets PO HS (at bedtime)
as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please hold for loose stools.
Disp:*60 Capsule(s)* Refills:*2*
8. Nabumetone 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO QHS (once
a day (at bedtime)).
10. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed.
13. Folgard OS 500-1.1 mg Tablet Sig: One (1) Tablet PO qday ().
14. Diazepam 5 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
15. Felodipine 5 mg Tablet Sustained Release 24 hr Sig: 1-1.5
Tablet Sustained Release 24 hrs PO once a day.
16. Asmanex Twisthaler 220 mcg (60 doses) Aerosol Powdr Breath
Activated Sig: Two (2) puffs Inhalation twice a day.
17. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2)
puffs Nasal twice a day: PRN.
18. Maxalt 10 mg Tablet Sig: One (1) Tablet PO once a day: PRN.
19. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day as needed for
indigestion.
20. Zaditor 0.025 % Drops Sig: Two (2) drops Ophthalmic once a
day: PRN.
21. Folgard OS 500-1.1 mg Tablet Sig: Two (2) Tablet PO at
bedtime.
22. FOSAMAX 35 mg Tablet Sig: One (1) Tablet PO once a week.
23. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**6-19**]
hours as needed for PAIN.
Disp:*30 Tablet(s)* Refills:*0*
24. Insulin Regular Human 100 unit/mL Solution Sig: See Sliding
Scale See Sliding Scale Injection ASDIR (AS DIRECTED): Please
dispense one vial for sliding scale dosing.
Disp:*qs See Sliding Scale* Refills:*2*
25. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**First Name9 (NamePattern2) 15741**] [**Location (un) 15739**] Monrooe County
Discharge Diagnosis:
Perforated Sigmoid Diverticulitis
Discharge Condition:
Good
Discharge Instructions:
Please return or contact for:
* Fever (>101 F) or chills
* Persistent nausea or vomiting
* No gas or stool from ostomy
* Increasing or persistent abdominal pain
* Any other concerns
You may shower. Please keep dressing intact. No baths or
immersion for 2-3 weeks. No lifting over 15 pounds or abdominal
stretching exercises for 4-6 weeks.
Please follow up with your primary doctor regarding your blood
glucose control.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**] in clinic on [**2195-4-29**] at 9:45am
located on the [**Location (un) 470**] of the [**Hospital Unit Name **]. You may call
[**Telephone/Fax (1) 2359**] for any questions or concerns.
Completed by:[**2195-4-16**]
|
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"729.1",
"E932.0",
"493.90",
"251.8",
"567.21",
"346.90",
"458.29",
"V58.65",
"443.0",
"562.10",
"536.1",
"733.99"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.41",
"03.90",
"46.11",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
18133, 18243
|
12914, 15297
|
327, 458
|
18321, 18328
|
1957, 12891
|
18799, 19071
|
1429, 1498
|
15678, 18110
|
18264, 18300
|
15323, 15655
|
18352, 18776
|
1513, 1938
|
273, 289
|
486, 1130
|
1152, 1413
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,599
| 179,363
|
26421
|
Discharge summary
|
report
|
Admission Date: [**2182-5-1**] Discharge Date: [**2182-5-8**]
Date of Birth: [**2111-6-19**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Rifampin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
septic shock and respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 70 year old man who was discharged after a 3 month
complicated hospitalization who presents with hypotension and
respiratory failure. His recent medical problems started after
he sustained a C7 vertebral fracture in [**12-21**]. He underwent a
ORIF of C6-7 with posterior fusion, laminectomy, and iliac crest
bone graft with wire placement in [**1-21**]. His course was
complicated by a CSF leak which was repaired, but then followed
by development of MRSA meningitis, cerebritis, sinusitis, and
mastoiditis, PE/DVT, NSTEMI, acute interstitial nephritis and
hypersensitivity desquamative dermatitis believed secondary to
vancomycin or rifampin, respiratory failure from pneumonia, ICU
neuropathy/myopathy, candidemia, and mental status changes.
.
He now presents following an episode of depressed mental status
and hypotension at [**Hospital1 **]. Fluid was given and EMS was called.
He had an ABG of 7.14/74/83 on unknown O2 settings and was found
to be satting 91% on NRB mask and have systolic pressures from
40-60, so he was intubated and transported to [**Hospital1 18**]. His
pressures stauyed in the 40-60's and he was started on levophed
and fluids. With his hypotension, lactate of 3.8 and WBC 28 with
17% bands, a code sepsis was called. He was given 4L more fluid
and a right IJ sepsis line was placed with CVP from [**5-23**]. Urine
and blood cultures were drawn. He was transferred to the MICU.
Past Medical History:
1. Diabetes Mellitus Type II Uncontrolled w/ Complications
2. Coronary Artery Disease s/p CABG x 3
3. Hypertension
4. Anxiety
5. Hypercholesterolemia
6. L3-L4 Surgery
7. BPH
8. Recent hospitalization notable for:
Traumatic Comminuted C7 Verterbral Fracture [**2182-1-2**]
ORIF/Laminectomy/Instrumentation/Posterior Fusion [**2182-1-23**]
CSF Leak - Wound infection s/p drainage and dural repair
[**2182-2-9**]
Incision and drainage and hardware exchange [**2181-2-12**]
MRSA Meningitis
MRSA Pneumonia
Left Heart Failure
Non-ST Elevation Myocardial Infarction
Left Occipital Stroke vs MRSA Cerebritis
RLE Deep Venous Thrombosis
Pulmonary Embolism
Non-Sustained Ventricular Tachycardia
Hypersensitivity Desquamative Dermatitis (Rifampin vs
Vancomycin) Eosinophilia
Hypoxic Respiratory Failure
Septic vs. Anaphylactic Shock
Delirium
Cholestasis
RUE Paresis
Bilateral Lower Extremity Myopathy
Dysphagia
GI Bleed
Nosocomial LLL Pneumonia
Anemia - multifactorial: Illness, blood loss, CKD.
Sacral and Heel Ulcers
MRSA/VRE Colonization
Candidemia
decub ulcer
Hep C
RP bleed
Social History:
No smoking, etoh or IVDA. Was plumber. Lived with wife until
[**Name (NI) 404**], but was at [**Hospital3 **] since C spine fusion, then
[**Hospital1 18**], then [**Hospital1 **]
Family History:
NC
Physical Exam:
V: Tm 103.5 Tc 96 P70 BP 121/44 R12 100% CVP 6-8
Vent: AC 450x16 60% P5 PIP 21 Plat 16
Gen: intubated, sedated but appears comforatable
HEENT: Pupils reactive bilaterally. ETT in place.
Neck: no JVD
Resp: clear bilaterally no rhonchi
CV: RRR nl s1s2 + [**2-18**] WEM LUSB
Abd: Soft NTND G tube in place
Ext: warm, 1+ edema hands, no edema legs
Back: stage 2 sacral decub ~8 cm
Neuro: not following commands.
Pertinent Results:
[**2182-5-1**]
148 114 44 AGap=17
-------------< 216
4.5 22 1.8
Ca: 8.0 Mg: 1.6 P: 6.0 D
96
27.9 \ 7.7 / 461
/ 26.1\
N:80 Band:17 L:1 M:2 E:0 Bas:0
PT: 29.5 PTT: 51.6 INR: 3.1
[**2182-5-6**] 05:46AM BLOOD WBC-6.8 RBC-3.25* Hgb-9.2* Hct-28.8*
MCV-89 MCH-28.5 MCHC-32.1 RDW-18.0* Plt Ct-309
[**2182-5-5**] 06:00AM BLOOD Neuts-60.0 Bands-0 Lymphs-24.3 Monos-6.2
Eos-9.0* Baso-0.6
[**2182-5-6**] 05:46AM BLOOD Plt Ct-309
[**2182-5-6**] 05:46AM BLOOD Glucose-130* UreaN-31* Creat-1.3* Na-145
K-3.6 Cl-116* HCO3-21* AnGap-12
[**2182-5-2**] 09:43PM BLOOD CK(CPK)-42
[**2182-5-2**] 09:43PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2182-5-2**] 03:25PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2182-5-2**] 07:57AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2182-5-2**] 04:57AM BLOOD Cortsol-23.2*
[**2182-5-2**] 07:57AM BLOOD Cortsol-31.2*
[**2182-5-2**] 08:30AM BLOOD Cortsol-33.5*
[**2182-5-3**] 04:12AM BLOOD Triglyc-168* HDL-27 CHOL/HD-3.6
LDLcalc-37
[**2182-5-5**] 05:58AM BLOOD Type-ART pO2-83* pCO2-35 pH-7.39
calHCO3-22 Base XS--2
[**2182-5-4**] 09:18AM BLOOD Lactate-1.1
[**2182-5-3**] 08:45PM BLOOD O2 Sat-80
MICRO
[**2182-5-4**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2182-5-4**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2182-5-4**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2182-5-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2182-5-2**] CATHETER TIP-IV WOUND CULTURE-FINAL {PSEUDOMONAS
AERUGINOSA} INPATIENT
WOUND CULTURE (Final [**2182-5-4**]):
PSEUDOMONAS AERUGINOSA. >15 colonies.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
[**2182-5-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA} INPATIENT
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 4 S
MEROPENEM------------- 0.5 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
[**2182-5-1**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA,
2ND ISOLATE} INPATIENT
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
[**2182-5-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING EMERGENCY [**Hospital1 **]
[**2182-5-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
Cardiology Report ECHO Study Date of [**2182-5-3**]
Conclusions:
1. No atrial septal defect or patent foramen ovale is seen by
2D, color
Doppler or saline contrast with maneuvers.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function cannot be reliably assessed.
3. The mitral valve leaflets are mildly thickened.
4. Compared with the prior study (images reviewed) of [**2182-4-18**],
there is no
significant change.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2182-5-2**] 1:50 PM
CONCLUSION: Negative right upper quadrant ultrasound.
CHEST (PORTABLE AP) [**2182-5-2**] 7:08 AM
IMPRESSION:
1. Slight improvement of a longstanding left retrocardiac
atelectasis (less likely pneumonia) and associated effusion.
2. New right IJ catheter without pneumothorax.
MR [**Name13 (STitle) **] W& W/O CONTRAST [**2182-5-4**] 3:50 AM
IMPRESSION: No evidence of new fluid collection seen or an area
of new enhancement identified. Focal increased signal seen
within the spinal cord at C7 level which could be secondary to
myelomalacia. No evidence of discitis or osteomyelitis.
Continued mild increased signal within the posterior soft
tissues at the laminectomy site could be due to inflammatory
changes without evidence of focal fluid collection.
Brief Hospital Course:
1) Septic shock with respiratory failure from pseudomonas line
infection - Pt was hypoxic and hypotensive on presentation and
intubated in the field. With elevated lactate, WBC, and
respiratory failure, this represented septic shock. The
potential sources were recurrence of meningitis/cervical fluid
abscess, UTI, C dif given antibiotic use, PICC line infection,
persistent candidemia, sacral decub inflammaion. He received 1
dose vancomycin in the ED and levo/flagyl, but on admission to
the MICU was changed to linezolid and cefepime to add
pseudomonas coverage. He was continued on voriconazole for
history of [**Female First Name (un) **] blood infection. His PICC line was pulled. He
got >10 liters of fluid and SVo2 was >90% despite fluids, so an
echo was done which showed no shunt. After 2 days, he was weaned
from levophedrine then extubated with improvement in SVO2 to the
80's. ID was consulted and recommended continuing linezolid and
cefepime, and obtaining MRI of the neck area which showed no
drainable fluid collection. His previous neck surgeon was
consulted and found no signs of infection in the neck area, so
the decision was jointly made not to perform LP. The next day,
cultures revealed pseudomonas sensitive to cefepime. He
continued to do well and was afebrile. He will be continued on
cefepime for 14 days total, and doxacycline indefinitely for
MRSA prophylaxis. He should have follow up with ID.
2) Sacral decub - wound care was consulted and noted that his
sacral decub ulcer had a black thick eschar on sacral decub 9x13
cm, increased from 2-3 cm on last discharge. Plastic surgery
felt not need for surgical interventions.
Copntinue care as directed.
3) EKG changes/demand ischemia - The patient was noted to have
new inferior flipped T waves on admission, and slightly elevated
troponins in the setting of systolic blood pressures to the
40's. This was felt to be demand ischemia, as he has a previous
history of CABG. HE should follow up with his cardiologist and
stress test or cath should be considered when his rehabilitation
is completed. He was continued on aspirin, and beta blocker and
captopril were restarted when blood pressure tolerated.
4) Vancomycin allergy with eosinophilia - The patient had a
history of severe desquamative reaction/AIN/hypotension and
fevers in recent hospitalization to vanco/rifampin. He received
a dose of vancomycin in ED and developed eosinophila, but no
evidence of rash or kidney failure. Urine eos were negative.
5) Acute renal failure - He had acute renal failure likely
secondary to sepsis, but FENA 3.67 so likely had some ATN in
addition to prerenal component. His creatinine improved with
hydration to baseline.
6) history of PE/DVT, on anticoagulation - He was reversed on
admission with 1 mg IV vitamin K in anticipation of possible LP,
but then started on heparin when INR was < 2. He was restarted
on coumadin 5 mg po qd on the evening of [**2182-5-6**]. Currently dose
2.5 mg/qhs. Goal 2-3mg
7) Hypernatremia: Increase Sodium on [**2182-4-7**]. Likely lack of
free water intake.
Currently getting 250 free water QID. Na trending down.
8) code status - His code status was extensively discussed with
his family on admission given his poor prognosis. He was
initially "do not shock, no CPR" but this was changed back to
full code after personal phone call from daugter morning of
[**5-2**].
Medications on Admission:
Acetaminophen 325 mg PO Q4-6H
Aspirin 325 mg PO DAILY
Nystatin 100,000 unit/g Cream Topical [**Hospital1 **]
Zinc Oxide-Cod Liver Oil 40 % Ointment [**Hospital1 **]
Mupirocin Calcium 2 % Cream Topical [**Hospital1 **]
Albuterol Sulfate 0.083 % Solution Q2H as needed.
Ipratropium Bromide 0.02 % Solution Inhalation Q6H (every 6
hours) as needed.
Sodium Chloride [**12-17**] Sprays Nasal TID (3 times a day).
Amlodipine 10 mg PO DAILY
Hydrochlorothiazide 25 mg PO DAILY
Lansoprazole 30 mg PO DAILY
Metoprolol Tartrate 100 mg PO TID
Folic Acid 1 mg PO DAILY
Epoetin Alfa 10,000 unit/mL QMOWEFR (Monday -Wednesday-Friday).
Doxycycline Hyclate 100 mg PO Q12H (every 12 hours).
Captopril 25 mg PO TID
Voriconazole 200 mg Intravenous Q12H through [**5-1**]
Insulin sliding scale
Heparin sliding scale
coumadin since [**4-26**]
linezolid started at [**Hospital1 **] [**5-1**]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): to be continued indefinitely for MRSA
prophylaxis.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): may titrate as tolerated to keep pulse around
60.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**])
units SQ Injection QMOWEFR (Monday -Wednesday-Friday).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
13. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): may titrate to keep systolic blood pressure between 120
and 140.
14. Warfarin 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime):
adjust as needed, goal INR [**1-18**]. .
15. Insulin Regular Human Subcutaneous
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO ONCE (Once) for 1 doses.
17. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
19. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q12H
(every 12 hours) for 8 days: last day [**2182-5-15**]. Then please DC
PICC line.
20. free water
Please give 250 freww water QID through G tube.
Follow up sodium closely
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
pseudomonal line septic shock with urine and sputum colonization
respiratory failure
vancomycin allergy
acute renal failure
Discharge Condition:
Good
Discharge Instructions:
contineu your medications as prescribed
If you have hypotension, fevers, respiratory distress or other
concerns, please return to the ED.
Followup Instructions:
Please follow up with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 65335**], 1
week after discharge from rehab.
Please follow up with your surgeon, Dr. [**Last Name (STitle) **], 1 week after
discharge from rehab.
Please follow up with your cardiologist in [**12-17**] months regarding
the need for stress testing.
|
[
"584.9",
"250.00",
"518.81",
"785.52",
"401.9",
"599.0",
"038.43",
"276.0",
"414.00",
"707.03",
"995.92",
"996.62",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"38.91",
"38.93",
"00.14",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14626, 14705
|
8067, 11451
|
316, 322
|
14873, 14880
|
3523, 8044
|
15066, 15448
|
3075, 3079
|
12372, 14603
|
14726, 14852
|
11477, 12349
|
14904, 15043
|
3094, 3504
|
240, 278
|
350, 1772
|
1794, 2863
|
2879, 3059
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,507
| 169,669
|
31397
|
Discharge summary
|
report
|
Admission Date: [**2100-9-14**] Discharge Date: [**2100-9-20**]
Date of Birth: [**2027-4-3**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 yo woman with no significant [**Hospital **] transferred
from OSH after a seizure earlier this am. History is
provided per the OSH records and the patient's husband and son.
By routine, she woke up around 3am, checked on the house.
However, the patient did not return to bed for 15 to 20 minutes,
and her concerned husband went to look for her. She was found
on
the floor of the kitchen, unresponsive. He called EMS and did
not
note any seizure activity while awaiting their arrival. EMS
found
her to be having a "full seizure grand mal" for ~30
seconds,associated with "snoring respirations, unresponsive."
She
had left eye deviation and a left facial droop. She was brought
to [**Doctor Last Name 38554**] Hospital, still noted as unresponsive, with
left gaze deviation but no facial droop, moving the right arm
and
leg. At ~ 4 am, she was given ativan 2mg, then pavulon 10mg IV,
thiamine, and cerebyx 1gm. She had a head CT, which showed
bilateral frontal intracerebral hemorrhages. She was given an
additional 10mg pavulon IV and then transferred here. She was
given an additional 2mg IV fentanyl prior to neurology consult.
Somehat more irritable in recent days after attending funeral;
otherwise no complaints and at normal functioning baseline.
Past Medical History:
No significant past medical history per family. Patient visited
physician for regular [**Name9 (PRE) 73962**].
Social History:
Active woman who lived at home with her husband.
Family History:
Non-contributory
Physical Exam:
VS: Afebrile , BP 110-170/60-80, RR 12, SaO2 96-99%/vent
General: elderly thin female, NAD
HEENT: orally intubated, sedated
Neck: C-collar in place
CV: RRR, nl S1, S2, no m/r/g
Chest: ventilated breath sounds
Abd: soft, NTND, BS+
Ext: warm and dry
Neurologic examination (paralytics given several hrs prior):
Mental status: unresponsive to all stimuli, eyes closed
Cranial nerves: pupils symmetric and reactive, 2->1mm; unable to
check Doll's eyes due to c-collar, absent corneals, nasal
tickle,
and gag
Motor: no movement to stim
Sensory: no movements of extremities to noxious stimuli
DTRs: absent, toes down
Pertinent Results:
[**2100-9-14**] 09:11PM TYPE-ART PO2-522* PCO2-34* PH-7.43 TOTAL
CO2-23 BASE XS-0 INTUBATED-INTUBATED
[**2100-9-14**] 09:03PM OSMOLAL-293
[**2100-9-14**] 07:27PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2100-9-14**] 07:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.031
[**2100-9-14**] 07:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2100-9-14**] 07:26PM CK(CPK)-455*
[**2100-9-14**] 07:26PM CK-MB-17* MB INDX-3.7
[**2100-9-14**] 05:07PM GLUCOSE-128* UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-19* ANION GAP-16
[**2100-9-14**] 05:07PM ALT(SGPT)-16 AST(SGOT)-31 CK(CPK)-441*
[**2100-9-14**] 05:07PM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-3.6
MAGNESIUM-2.5
[**2100-9-14**] 05:07PM ACETONE-NEGATIVE OSMOLAL-295
[**2100-9-14**] 05:07PM PHENYTOIN-14.2
[**2100-9-14**] 05:07PM WBC-15.2* RBC-3.86* HGB-12.7 HCT-37.7 MCV-98
MCH-32.9* MCHC-33.7 RDW-13.6
[**2100-9-14**] 05:07PM NEUTS-88.5* LYMPHS-7.6* MONOS-3.8 EOS-0.1
BASOS-0.1
[**2100-9-14**] 05:07PM PLT COUNT-252
[**2100-9-14**] 05:07PM PT-11.2 PTT-23.8 INR(PT)-0.9
[**2100-9-14**] 10:14AM URINE HOURS-RANDOM
[**2100-9-14**] 10:14AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2100-9-14**] 06:45AM GLUCOSE-159* UREA N-19 CREAT-0.9 SODIUM-142
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-21* ANION GAP-20
[**2100-9-14**] 06:45AM estGFR-Using this
[**2100-9-14**] 06:45AM ALT(SGPT)-19 AST(SGOT)-34 LD(LDH)-219
CK(CPK)-198* ALK PHOS-72 AMYLASE-89 TOT BILI-0.5
[**2100-9-14**] 06:45AM LIPASE-47
[**2100-9-14**] 06:45AM CK-MB-8 cTropnT-<0.01
[**2100-9-14**] 06:45AM ALBUMIN-4.2
[**2100-9-14**] 06:45AM OSMOLAL-302
[**2100-9-14**] 06:45AM PHENYTOIN-22.3*
[**2100-9-14**] 06:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2100-9-14**] 06:45AM URINE HOURS-RANDOM
[**2100-9-14**] 06:45AM URINE GR HOLD-HOLD
[**2100-9-14**] 06:45AM WBC-12.0* RBC-4.20 HGB-13.9 HCT-39.9 MCV-95
MCH-33.2* MCHC-34.9 RDW-13.8
[**2100-9-14**] 06:45AM NEUTS-84.4* BANDS-0 LYMPHS-11.6* MONOS-3.4
EOS-0.4 BASOS-0.1
[**2100-9-14**] 06:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2100-9-14**] 06:45AM PLT SMR-NORMAL PLT COUNT-263
[**2100-9-14**] 06:45AM PT-10.8 PTT-20.6* INR(PT)-0.9
[**2100-9-14**] 06:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2100-9-14**] 06:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
CTA of the head and neck ([**2100-9-14**]):
1. There are large bilateral frontoparietal intraparenchymal
hemorrhages with associated surrounding edema, but without
significant shift and no evidence of herniation. There is
evidence of a fluid-fluid level within the left frontoparietal
hemorrhagic region. There is no prior exam available at this
time with which to compare and to evaluate the evolution of the
hemorrhage.
2. CTA of the head and neck reveals no evidence of aneurysm,
stenosis,
occlusion or vascular malformations. The venous system also
appears patent, with no evidence of thrombosis. A followup scan
after the resolution of the hematoma is recommended in order to
better evaluate the etiology of the hemorrhage.
CT head ([**2100-9-15**]): The appearance of the left frontal
intraparenchymal hemorrhage is not significantly changed from
the prior study. There is slight increase in the
intraventricular hemorrhage in the occipital [**Doctor Last Name 534**] of the left
lateral ventricle and there is minimal decrease in the rightward
shift of the normally midline structures. Otherwise there are
no other interval changes noted. There is no evidence of
hydrocephalus or uncal herniation.
MRI/A of head ([**2100-9-15**]):
1. Similar overall appearance of large recent bilateral lobar
hemorrhages, as well as intraventicular and subarachnoid
hemorrhages. Although subarachnoid hemorrhage appears more
diffuse, this could relate to the greater sensitivity of MR or
to redistribution of blood products.
2. No evidence of abnormal enhancement or vascular
malformation.
3. Numerous punctate foci of prior hemorrhage throughout the
cerebral
hemispheres. This appearance supports the possibility of
amyloid angiopathy. However, follow-up examination in
approximately six weeks is recommended, to be performed with
gadolinium, to better exclude the possibility of an underlying
mass lesion.
CXR ([**2100-9-14**]):
1. ET tube in position. NG tube can be advanced further as the
sideport is likely in the esophagus.
2. No acute cardiopulmonary process.
EKG ([**2100-9-15**]): Atrial fibrillation, mean ventricular rate 122.
Prolonged QTc interval. Compared to previous tracing cardiac
rhythm is now atrial fibrillation.
EKG (815/07, later): Sinus rhythm. Marked diffuse repolarization
abnormalities. Compared to previous tracing cardiac rhythm is
now sinus mechanism.
Brief Hospital Course:
[**Known firstname 2048**] [**Known lastname **] was admitted to the Neuro-ICU for further
evaluation and management. A CTA of the head and neck on
admission showed large bilateral frontoparietal intraparenchymal
hemorrhages with associated surrounding edema, but without
significant shift and no evidence of herniation. There was
evidence of a fluid level within the left frontoparietal
hemorrhagic region. However, there was no evidence of aneurysm
or other vascular malformation. The venous system also appeared
patent, with no evidence of thrombosis. A follow up MRI/MRA of
the head on the following day revealed a similar overall
appearance of the bilateral lobar hemorrhages, as well as
intraventicular and subarachnoid hemorrhages. There was no
evidence of abnormal enhancement or vascular malformation.
Interestingly, there were numerous punctate foci of prior
hemorrhage throughout the cerebral hemispheres, an appearance
suggestive of the possibility of amyloid angiopathy.
The patient showed little improvement clinically in the ensuing
days. Although she did exhibit occassional eye opening but
otherwise remained obtunded. Her course was complicated by runs
of tachycardia (including an episode of atrial fibrillation on
EKG), associated with troponin leakage. Cardiology was
consulted and it was thought that these phenomena were likely
related to the intracranial hemorrhage. As her QT was
prolonged, beta-blockers were not recommended at standing doses
for concern of degenerative arrhythmias. Given the hemorrhage,
anti-coagulation was not indicated. She was also treated for a
UTI with bactrim.
After extensive discussion with the family regarding the
patient's wishes, her poor prognosis given her lesions/deficits,
and limited chance of meaningful recovery, the patient's husband
and sons decided to place her on comfort measures only.
Extubation was carried out and comfort care enacted on [**2100-9-20**],
and the patient expired later that afternoon.
Medications on Admission:
None
Discharge Medications:
Not applicable (N/A)
Discharge Disposition:
Expired
Discharge Diagnosis:
Bilateral intraparenchymal lobar hemorrhages, likely secondary
to amyloid angiopathy.
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"277.30",
"599.0",
"432.9",
"780.39",
"518.81",
"427.31",
"459.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9671, 9680
|
7581, 9571
|
323, 329
|
9809, 9818
|
2499, 7558
|
9870, 9987
|
1833, 1851
|
9626, 9648
|
9701, 9788
|
9597, 9603
|
9842, 9847
|
1866, 2176
|
276, 285
|
357, 1616
|
2248, 2480
|
2191, 2232
|
1638, 1751
|
1767, 1817
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,556
| 156,289
|
6989
|
Discharge summary
|
report
|
Admission Date: [**2199-6-29**] Discharge Date: [**2199-7-9**]
Date of Birth: [**2119-2-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Worsening SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 yo male with COPD p/w worsening dyspnea, SpO2 86% on room air
per EMS. Recently discharged on [**6-26**] with diagnosis of COPD
flare, sent home on prednisone taper and azithromycin x 5 days.
Went to Dr. [**Last Name (STitle) 1968**] for PCP appointment two days after discharge,
and no changes in medication and was feeling well. He was doing
well until day prior to admission when he reports worsening
dyspnea with exertion, barely able to ambulate from room to room
today. He slept overnight with 3 pillows and wife reports that
he had labored breathing with wheezing. He awoke from afternoon
nap with acute dyspnea, was reported white in face by son, and
wife called EMS. Denies fevers, but reports some lightheadness.
In the [**Name (NI) **], pt's vitals were 97.9, 79, 156/84, 22, 99% 4L. He was
given combivent, solumedrol, and levofloxacin 750 mg IV, and EKG
showed normal sinus rhythm at rate of 73. He was transfered to
the medicine floor. This is his second hospitalization (first
being the discharge on [**2199-6-26**]).
On the floor, patient complained of shortness of breath, cramps
in the legs that is chronic, and productive cough and x1 bought
of watery diarrhea without blood; but denies chest pain,
palpitations, fever, chills, nausea, vomitting, constipation,
dysuria, muscle, or swelling in legs.
Past Medical History:
-Hypertension
-Tobacco abuse
-COPD
-s/p AAA repair in [**2196-5-8**] c/b brief postoperative atrial
fibrillation
-Chronic Kidney Disease (seconary to vascular disease)
-Prostate cancer s/p radiation therapy and leupron
-Skin cancer
Social History:
Lives with wife. Smokes [**1-9**] ppd; used to smoke >1ppd for >50yrs.
Former alcoholic, quit 28yrs ago.
Family History:
Noncontributory
Physical Exam:
VS 97.2, 132/68, 72, 96% RL, 72.4 kg
Gen: lying flat in bed, dyspenic, with oxygen, "puckered"
breathing
HEENT: NCAT, EOMI, PEERLA, no LAD, MMM
CV: s1, s2 appreciated, no MRG
Lungs: use of accessory muscles when breathing, harsh breath
sounds, wheezing heard throughout, hyperinflation
Abd: ventral hernia, vertical scar, soft, NTND, +BS
Ext: WWP, no CCE
Neuro: A&O x3, moves all extremities, normal tone, follow
commands
Pertinent Results:
CXR:
PA AND LATERAL CHEST RADIOGRAPHS: The heart size remains normal
and the aorta is mildly unfolded. Again, there is hyperinflation
of the lungs. Increased interstitial markings, particularly in
the perihilar region likely represent interstitial pulmonary
edema in this patient with underlying COPD. There is no evidence
of pneumothorax and no definite pleural effusions seen. The
osseous structures appear unremarkable.
IMPRESSION: Interstitial pulmonary edema in the setting of COPD.
EKG:
Cardiology Report ECG Study Date of [**2199-6-29**] 5:07:04 PM
Sinus rhythm. Non-specific septal T wave changes. Compared to
the previous
tracing of [**2197-7-29**] there is no significant diagnostic change.
ECHO:
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. 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. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is moderate pulmonary artery systolic hypertension. There
is an anterior space which most likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Moderate pulmonary artery systolic
hypertension.
Brief Hospital Course:
80 y/o male with COPD exacerbation and PNA, died of hypotension
and MSOF.
The patient was initially admitted to the hospital on [**2199-6-29**].
He had been recently discharged on [**6-26**] with diagnosis of COPD
flare, sent home on prednisone taper and azithromycin x 5 days.
He was thought to have COPD exacerbation/
PNA and was treated with Levaquin PO and long steroid taper, and
remained on 2-3L NC. On [**7-4**] because of low grade fevers and
unimproved oxygen requirement a CT chest, non contrast was done
that showed diffuse peribronchovascular and periperhal
parenchymal opacities with associated bronchial wall thickening,
as well as centrilobular emphysema, concerning for fungal
infection. For this reason, pulmonary consult was called for
bronchoscopy, as well as ID. On [**7-4**], he was found to be in afib
with RVR. He was started on heparin gtt and rate control with
increasing doses of metoprolol and diltiazem. He continued to be
in a fib with RVR and on [**7-6**] triggered for tachycardia. He was
digoxin loaded an started on daily dig.
On [**7-8**], he desatted on 2L NC, diaphoretic and dyspneic. The
patient reports sudden onset of shortness of shortness of breath
when getting up to go to the bathroom. He was evaluated by the
pulm consult service for a bronch and was thought to not be
stable enough, and they intiated a [**Hospital 12145**] transfer to stabilize
him for bronch. An ABG was done which was: 7.49/34/48/27. He was
transferred to the MICU for further stabilization of respiratory
status. He was satting 95% on high flow max 95%, tachy to the
120s, with BP 116/61. Also described choking on food the day
prior to transfer.
The pt's condition rapidly deteriorated in the MICU. He was
intubated due to increasing respiratory distress. A central line
was successfully placed. Mr. [**Known lastname 8764**] became hypotensive and was
bolused 2L NS, which were ineffective. He was placed on
phenylepherine and vasopressin. He had progressively increasing
O2 requirements on the vent, set at AC with high O2, TV, and
PEEP. Vancomycin and Cipro were added to the voriconazole and
cefepime to broaden antibiotic coverage. In the afternoon of
[**7-8**], Mr. [**Known lastname 8764**] continued to recieve fluid resuscitation with
NS and LR, to mild effectiveness. As the pt's underlying
condition was unclear, he was bronched, which showed pulmonary
macrophages, inflammatory cells and fungal forms suggestive of
aspergillus (results returned postmortem). As pt continued to
be hypotensive and tachycardic, LR was continued at 500cc/hr. An
ABG showed severe acidosis, so the pt was given bicarb.
Nebulizer treatments were continued.
A family meeting was held, during which the decision was made to
make the patient DNR, but allow him to continue aggressive care
while intubated. Overnight, the patient's hypotension became
unresponsive to fluids and pressors, his sats dropped, he became
increasingly tachycardic. He passed away on the morning of
[**2199-7-9**]. The underlying cause is unknown; aspergillus multilobar
pneumonia is in the differential diagnosis but the cause is
uncertain.
.
Pt's other issues were as follows:
#. CKD Stage 3: Stayed near his baseline creatinine of 1.9 until
respiratory failure.
#. Tobacco Abuse: Counceled on smoking cessation. Nicotene patch
started.
#. HTN: Continued home meds lisinopril, HCTZ, atenolol until
became hypotensive with respiratory distress.
#. s/p AAA repair: Continued ASA, lipitor.
#. Depression: Continued zoloft.
#. Atrial Fibrillation: New AFib. Was on atenolol at home, but
was changed to metoprolol 200 mg [**Hospital1 **] for rate control. Started
on Heparin Drip.
Medications on Admission:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO at bedtime.
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule,
Delayed Release(E.C.)(s)
10. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
11. Prednisone 10 mg Tablet Sig: see below Tablet PO once a day
for 5 days: Please take 5 pills (50mg) on [**6-27**] pills (40mg)
on [**6-28**] pills (30mg) on [**6-29**] pills (20mg) on [**6-30**] pill
(10mg) on [**7-1**], then STOP.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Medications:
1. Oxygen
Oxygen 2L continuous for portability, pulse dose system.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
6. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 weeks: please take 2 pills for two days, then one pill for
two days, than a half a pill for two days and then stop.
Disp:*7 Tablet(s)* Refills:*0*
9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
Disp:*30 Nebs* Refills:*0*
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Disp:*30 Neb* Refills:*0*
13. Nebulizer & Compressor For Neb Device Sig: One (1)
Device Miscellaneous every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 Device* Refills:*0*
14. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 INH* Refills:*3*
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
COPD exacerbation
Atrial Fibrillation
Tobacco use
Discharge Condition:
Expired
Discharge Instructions:
None indicated.
Followup Instructions:
Autopsy offered to pt's family. Wife requested a chest-only
autopsy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2199-7-24**]
|
[
"276.2",
"288.60",
"117.3",
"403.90",
"799.02",
"584.9",
"486",
"518.84",
"272.4",
"427.31",
"491.21",
"585.3",
"458.9",
"275.42",
"285.21",
"305.1",
"786.06",
"E947.9",
"785.0",
"401.9",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10775, 10784
|
4127, 7800
|
286, 292
|
10888, 10897
|
2518, 4104
|
10961, 11189
|
2042, 2060
|
9015, 10752
|
10805, 10867
|
7826, 8992
|
10921, 10938
|
2075, 2499
|
232, 248
|
320, 1646
|
1668, 1902
|
1918, 2026
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,761
| 180,548
|
39662
|
Discharge summary
|
report
|
Admission Date: [**2139-6-27**] Discharge Date: [**2139-7-1**]
Date of Birth: [**2112-11-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
Lumbar Puncture
Pt was intubated en route to hospital
History of Present Illness:
26 YO healthy male found down at home earlier on the day of
admission. The patient was reportedly in good health, working at
a golf [**Last Name (un) 10128**] in [**Hospital3 **]. He did not show up for work on [**6-27**] so
his coworker reportedly went to his home where the patient was
found to be unresponsive, jerking with his eyes rolling back in
his head. EMS was called and he was transported to an OSH where
he was given 1g ctx, narcan, valium and intubated for airway
protection. [**Location (un) 7622**] loaded the patient with dilantin although
they noted no further seizure activity. Exam upon arrival to
[**Hospital1 18**] was notable for upgoing toes b/l and lack of response to
painful stimuli. Labs were notable for AST 60 and LDH of 510. He
was given ceftriazone 1g and vancomycin 1g. LP was done. Per ED
resident, the tap was traumatic with intial blood in the needle
which cleared. MRI/A head and neck were done with results
pending at his time of transfer.
.
The patient is intubated and sedated and unable to provide
additional information.
.
Past Medical History:
s/p clavicle and shoulder frx with ORIF
s/p ankle fracture
syncopal episode 2 yrs ago in [**Location (un) 5354**], denies any seizure-like
component, work up in local ED negative
Social History:
Living on [**Hospital3 4298**] for the summer, working as golf
pro, tri-athlete, goes to school in the winter. Father denies
any
drugs or illicits. No tobacco. Moderate EtOH.
Family History:
No h/o seizures, strokes, aneurysms, sudden cardiac death
Physical Exam:
On transfer to floor:
98.4 BP 96-111/62-70 53-59 18 100% on RA
Uop: 800/700
Exam:
General: awake, alert, oriented, no acute distress- cannot
remember events during unresponsive period
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, NT, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact; 4/5 strength bilaterally in UE/LE; more
weak on R UE than L UE; Babinski's downgoing
Pertinent Results:
MRI/MRA HEAD:
IMPRESSION:
1. No focal lesions in the brain parenchyma. Correlate with EEG
and if
necessary clinically, consider follow up for any changes.
2. Patent major intracranial arteries as described above.
3. Evaluation of the origin of the arch vessels in the cervical
arteries is somewhat limited due to inaccurate bolus timing. The
arteries are better seen on the delayed images, hence,
assessment of any flow-related abnormalities is somewhat
limited. Within these limitations no flow-limiting stenosis or
occlusion or aneurysm noted.
4. Small retention cyst in the left maxillary sinus; mild
mucosal thickening in the left maxillary sinus along with fluid
in the nasopharynx.
.
On admission:
[**2139-6-27**] 05:30PM BLOOD WBC-5.5 RBC-4.66 Hgb-13.5* Hct-40.6
MCV-87 MCH-29.0 MCHC-33.2 RDW-13.9 Plt Ct-206
[**2139-6-28**] 03:32AM BLOOD Neuts-66.2 Lymphs-24.3 Monos-8.0 Eos-1.2
Baso-0.3
[**2139-6-27**] 05:30PM BLOOD PT-11.8 PTT-25.6 INR(PT)-1.0
[**2139-6-28**] 03:32AM BLOOD Glucose-81 UreaN-14 Creat-1.0 Na-142
K-4.0 Cl-106 HCO3-29 AnGap-11
[**2139-6-27**] 05:30PM BLOOD ALT-25 AST-60* LD(LDH)-510* AlkPhos-62
TotBili-0.5
[**2139-6-27**] 05:30PM BLOOD Lipase-41
[**2139-6-27**] 05:30PM BLOOD Calcium-9.1 Phos-4.4 Mg-2.4
[**2139-6-29**] 11:49AM BLOOD HIV Ab-NEGATIVE
[**2139-6-27**] 05:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2139-6-28**] 10:52AM BLOOD Type-ART pO2-150* pCO2-48* pH-7.37
calTCO2-29 Base XS-2
[**2139-6-27**] 05:41PM BLOOD Glucose-87 Lactate-1.4 Na-144 K-4.3
Cl-99* calHCO3-26
[**2139-6-27**] 10:50PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-319*
Polys-35 Lymphs-49 Monos-15
[**2139-6-27**] 10:50PM CEREBROSPINAL FLUID (CSF) TotProt-39 Glucose-63
LD(LDH)-15
Micro: RPR negative, Lyme negative, CSF and blood cx's NGTD
EEG:
INDINGS:
ROUTINE SAMPLING: Generally a low voltage delta rhythm of [**11-30**]
Hz, with
occasional bursts of generalized delta slowing of [**11-30**] Hz rhythm,
was
observed throughout the record. There were also brief periods of
[**7-5**].5
Hz posterior dominant rhythm visualized in the most awake
stages.
PUSHBUTTON ACTIVATIONS: There were none.
SPIKE DETECTION PROGRAMS: There were none.
SEIZURE DETECTION PROGRAMS: There were none.
SLEEP: No clear sleep architecture was present.
CARDIAC MONITOR: Normal sinus rhythm and rate of 60 bpm.
IMPRESSION: This is an abnormal VEEG telemetry due to the
presence of
generalized low voltage delta frequency background with
occasional
bursts of delta slowing for a majority of the recording.
Although a
normal alpha frequency posterior dominant rhythm activity was
observed,
these events were infrequent and brief. Overall, these findings
suggest
a diffuse encephalopathy, but the etiology is non-specific and
could be
due to a medication-related effect. No focal abnormalities or
evidence
of epileptiform activity were observed.
Xray arm:
STUDY: AP and lateral views of the left forearm [**2139-6-30**].
COMPARISON: None.
INDICATION: 26-year-old male, evaluate for osseous process in
left forearm.
FINDINGS: Mild soft tissue swelling of the mid forearm. A
healing transverse
fracture of the ulnar diaphysis is seen with mild blurring of
the fracture
line and callus formation surrounding the fracture. No other
fractures are
identified. No dislocations. The visualized wrist and elbow
joints are
unremarkable.
IMPRESSION: Healing ulnar mid diaphyseal fracture, as above.
8
Brief Hospital Course:
Summary: 26 YO healthy male found unresponsive transferred via
Lifeflight, initially intubated for airway protection, extubated
on HD2, transferred to the floor for further management
.
# Altered mental status. LP, Head CT and MRI, and EEG were all
performed. LP returned normal; HSV PCR negative. Head CT and MRI
were both unremarkable. Tox screen negative. EEG showed possible
encephalopathy. On the day of discharge, all viral studies that
had returned (HIV, Lyme, enterovirus) were negative. Antibiotics
and antivirals were eventually discontinued as studies returned
negative. Several infectious studies were pending at the time of
discharge - EEE, CSF lyme, etc. The patient's mental status
cleared the day after admission. He was alert and oriented on
the day of discharge. The etiology of the unresponsiveness was
unknown. Both infectious disease and neurology teams were
consulted. It was presumed that the event represented a seizure
and the patient was started on Dilantin and switched to
Trileptal. Contact information for neurology follow-up was
provided.
.
# Urethral discharge. The patient complained of some urethral
discharge. GC/chlamydial swab returned negative
.
#L arm swelling: The patient complained of 2 months of L arm
swelling. An Xray was taken and showed a healing ulnar fracture.
Ortho was consulted and believed this was a stress fracture
related to his training for triathlons.
.
The patient was placed on subQ heparin for DVT prophylaxis and
remained full code while admitted.
Medications on Admission:
MTV
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO twice a
day: If you are tolerating the medication, please increase dose
to 600 mg [**Hospital1 **] (twice per day) on Monday, [**2139-7-6**]. .
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Unresponsiveness - likely seizure
-healing L ulnar stress fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted to the ICU having
been found unresponsive. The etiology of your unresponsiveness
is still unclear, however, it is presumed this was a seizure.
The infectious studies performed on your spinal fluid and blood
have, thus far, returned negative. You were also found to have
had a healing ulnar stress fracture of your left forearm.
You also had an MRI and CT scan of the head, which returned
normal. Your spinal tap showed normal results as well.
The following changes were made to your medication regimen:
We STARTED Oxcarbazepine (Trileptal) 300 mg twice per day (this
should be increased to 600 mg twice per day on [**7-6**] if you are
tolerating the medication)
You should follow-up with both a neurologist and a primary care
provider. [**Name10 (NameIs) **] is especially important that you see a neurologist
to f/u with management of your seizure medication. You should
make this appointment in [**3-3**] weeks. You can either call [**Hospital 87429**] with the phone number below or you can call
[**Hospital1 18**] epilepsy clinic at [**Telephone/Fax (1) 5285**]. Also, [**Hospital1 **] has a primary care practice, which you can reach at
[**Telephone/Fax (1) 250**].
Followup Instructions:
[**Hospital6 **]
Location: [**Street Address(1) 87430**], [**Location (un) **], [**Numeric Identifier 84713**]
Phone: [**Telephone/Fax (1) 31996**]
*Please call this number to get established with a PCP and
Neurologist. It is important that you follow up for management
of your anti-seizure medications as well as your broken arm.
|
[
"788.7",
"780.39",
"V54.22",
"427.89",
"780.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
7985, 7991
|
6099, 7610
|
331, 387
|
8112, 8112
|
2664, 3354
|
9544, 9878
|
1893, 1952
|
7664, 7962
|
8012, 8091
|
7636, 7641
|
8263, 9521
|
1967, 2645
|
275, 293
|
415, 1481
|
3368, 6076
|
8127, 8239
|
1503, 1684
|
1700, 1877
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,863
| 131,515
|
3334
|
Discharge summary
|
report
|
Admission Date: [**2134-8-28**] Discharge Date: [**2134-9-9**]
Date of Birth: [**2057-5-15**] Sex: F
Service: NEUROLOGY
Allergies:
Dilantin / Tegretol
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 yo woman transferred from [**Hospital3 417**] Hospital after
having unresponsive episode at home followed by vomitting that
was witnessed by husband. History obtained from husband and [**Name (NI) **]
records as patient is currently intubated. Husband reports
patient had a staring spell followed by dizzy/drunken walking to
the bathroom and being unable to get there in time. She had
urinary incontinence. Patient was subsequently carried to bed by
husband where she was proceeded to vomit. Husband called 911 and
she was taken to [**Hospital3 417**] Hosppital. VS 186/82 88 18 AOx3,
GCS15. For unknown reasons, patient was subsequently intubated.
Head CT revealed large R frontal IPH. She was subsequently
trasnferred to [**Hospital1 18**]
for further management.
In ED, BP 122/77 AF. Nsurg was contact[**Name (NI) **] and assess that no
surgical intervention was indicated. Neurology was then
consulted.
Past Medical History:
1. left PICA aneurism clipping after prior SAH [**2126**], [**2129**]
2. two other aneurisms, one at the left C2 segment of the
caroted and another at the ophthalmic segment of the left
internal carotid
3. amyloid angiopathy [**5-28**] - episode of ptosis on the right
along with mild right facial droop in mid-may. MRI showed new
small areas of susceptibility, suggesting amyloid angiopathy.
Often a prodrome for A.D. D/c'd her coumadin and increased the
keppra.
4. osteoporosis
5. generalized convulsive seizures [**11/2128**] - EEG that showed right
frontal theta and sharp waves but no spike-slow waves. There is
evidence of old right frontal infarct where she had prior
intraparenchymal blood at the time of her SAH. She was placed on
AEDs to prevent seizures from this right frontal cortical
lesion.
6. atrial fibrillation/AV paced - h/o vasovagal syncope on
autonomic testing with Dr. [**First Name (STitle) **], who also has a history of
recurrent palpitations associated with atrial fibrillation and
atrial flutter.
pcp is [**First Name8 (NamePattern2) 4468**] [**Last Name (NamePattern1) 15505**]
[**Name9 (PRE) **] DM, HTN, hyperlipidemia
Social History:
former teacher of cosmatology for vocational school, no Tob or
ETOH, lives with husband of 49 years in a house.
Family History:
irregular heart beat, father, brother
Physical Exam:
vitals: T 97 rectal, 122/77 afib AV paced, 74, 100% CMV 450X18
100% PEEP 5
Gen: Lying in bed, NAD
HEENT: intubated, arousable to voice
Neck: ETT
CV: RRR, Nl S1 and S2
Lung: well ventilated bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Intubated and responsive to voice. Follows
commands opens eyes, lets go on R hand and wiggles toes
bilaterally.
Cranial Nerves:
Pupils equally round and reactive to light, 2.2->2 mm
bilaterally, ?right gaze preference, grimace to nasal tickle
bilaterally, corneals and gag are intact.
Motor:
Normal bulk bilaterally. Increased tone R>L bilaterally. No
observed myoclonus or tremor.
Reflexes:
3+ brisk L>R throughout, bilateral babinski
Pertinent Results:
[**2134-8-28**] 03:35AM BLOOD WBC-7.0# RBC-3.94* Hgb-12.6 Hct-36.8
MCV-93 MCH-32.0 MCHC-34.3 RDW-14.7 Plt Ct-153
[**2134-8-28**] 03:35AM BLOOD Neuts-90.6* Bands-0 Lymphs-7.9*
Monos-1.1* Eos-0.2 Baso-0.2
[**2134-8-28**] 03:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2134-8-28**] 03:35AM BLOOD PT-12.1 PTT-22.0 INR(PT)-1.0
[**2134-9-7**] 03:29AM BLOOD Glucose-140* UreaN-42* Creat-0.5 Na-136
K-4.1 Cl-105 HCO3-24 AnGap-11
[**2134-8-30**] 07:08AM BLOOD Calcium-8.2* Phos-1.4*# Mg-2.3
[**2134-8-30**] 06:35PM BLOOD Osmolal-309
[**2134-8-30**] 07:08AM BLOOD Digoxin-0.6*
[**2134-8-28**] 03:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2134-8-28**] 03:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-15 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2134-9-6**] 4:17 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2134-11-8**]**
GRAM STAIN (Final [**2134-9-6**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2134-9-10**]):
OROPHARYNGEAL FLORA ABSENT.
MORAXELLA CATARRHALIS. HEAVY GROWTH.
BETA STREPTOCOCCI, NOT GROUP A. SPARSE GROWTH.
LEGIONELLA CULTURE (Final [**2134-9-16**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Final [**2134-9-21**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2134-9-7**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Final [**2134-11-8**]): NO MYCOBACTERIA
ISOLATED.
STUDIES:
[**8-28**] Head CT: Unchanged large right frontal intraparenchymal
hemorrhage with intraventricular extension as before. Subfalcine
herniation is unchanged. Newly apparent subarachnoid blood
within the sulci of the left frontal lobe.
[**8-28**] Head CT: Large right frontal intraparenchymal hemorrhage
with intraventricular extension and questionable subfalcine
herniation.
[**8-28**] EEG: This is an abnormal EEG due to the poorly formed
background
activity and bursts of generalized slowing. These abnormalities
suggest
diffuse cortical dysfunction, which may be seen with infections,
medication effect, toxic metabolic abnormalities or ischemia.
The
sharply contoured activity over the F4 electrode was consistent
with
electrode artifact.
EKG: Sinus rhythm. When the sinus rate slows ventricular pacing
is seen. Since the previous tracing of [**2130-5-15**] native beats show
T wave inversions in leads V1-V2.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 122 98 412/435.85 -45 70 112
[**8-29**] CTA Head:
1. No significant interval change in appearance of the brain
compared to yesterday's study. Again demonstrated is a large
right frontal intraparenchymal hemorrhage with intraventricular
extension and associated subfalcine herniation to the left. A
small amount of subarachnoid blood of the left frontal lobe
sulci appears similar.
2. Patency of the carotid and vertebrobasilar circulations as
well as the circle of [**Location (un) 431**] and its major tributaries. See
above report for findings.
Brief Hospital Course:
In summary, 77RH W w/right frontal ICH that presented with
seizure-like activty (starring) in PM [**8-27**], emesis, all after an
argument with husband. Differential dx included ateriovenous
malformation, aneurysm rupture, mass, hypertension or amyloid
(most likely).
On head CT, there was a 4cm x 13 slices right frontal hemorrhage
with extension to 3rd ventricle.
Her exam revealed patient intubated, withdrew x 2, right gaze
preference, upgoing toes bilaterally.
NEURO:
Patient was admitted to the NeuroICU. Repeat head CT [**8-28**] showed
no major change. Patient was weaned and extubated however did
not become more alert or awake despite discontinuing sedating
medications. Concern that she might be seizing, an EEG was
performed and showed diffuse cortical dysfunction. She was
started on Keppra for seizure prophylaxis. On [**8-29**], patient
developed impaired upgaze, emesis, concern for hydrocephalus.
CTA was negative for aneurysm. Unable to obtain MRI due to
pacemaker.
Patient was started on mannitol due to increased ventricular
size. On [**8-31**] Head CT, show increased communicating
hydrocephalus. Repeat EEG showed [**12-28**] Hz rhythmic spike wave
complexes bifrontal. On keppra 1000mg [**Hospital1 **]. Patient continued to
be minimally responsive, not opening eyes and conferred a poor
prognosis for recovery. Please see below.
CV: Patient was kept on PRN labetelol keeping MAP >105 and <
130. Patient continued on cardiac telemetry.
PULM: Extubated on [**8-28**] successfully however did not become more
alert and awake despite stopping sedating medications. She was
subsequently reintubated due to concern of airway protection.
Patient did develop pneumonia and grew MORAXELLA CATARRHALIS on
sputum culture. She was placed on appropriate antibiotics.
FEN: Glucose control and repleted lytes.
PPX: pneumoboots, bowel reg, ppi, RISS
DISPO: Family meeting was held on [**9-3**] to discuss goals given
poor prognosis. Nsurg offered EVD and clot evacuation. However,
family thought the patient would want these procedures given the
poor functional status. Patient was made CMO, extubated and
passed on [**2134-9-9**]. Family was notified.
Medications on Admission:
1. Lasix 20 mg daily
2. Aspirin
3. Atenolol 12.5 mg daily
4. Digoxin 200 mcg
5. Keppra 750 mg b.i.d.
6. Florinef 0.1 mg QD
7. Actonel once a week
8. KCl 10 mEq daily
9. baby aspirin every other day
10. vitamin E
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2134-12-5**]
|
[
"933.1",
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"277.3",
"E912",
"431",
"428.0",
"348.8",
"331.4",
"401.9",
"287.5",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"96.6",
"96.72",
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icd9pcs
|
[
[
[]
]
] |
9096, 9105
|
6646, 8833
|
284, 290
|
9157, 9160
|
3344, 5119
|
9210, 9353
|
2551, 2590
|
9126, 9136
|
8859, 9073
|
9184, 9187
|
2605, 2846
|
241, 246
|
318, 1231
|
3014, 3325
|
5363, 6623
|
2885, 2998
|
2870, 2870
|
1253, 2405
|
2421, 2535
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,989
| 190,638
|
7007+55808
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-3-5**] Discharge Date: [**2142-3-13**]
Date of Birth: [**2104-8-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2142-3-7**] - CABGx3 (Lima->Lad, SVG->Diagonal, SVG->Posterior left
ventricular artery)
History of Present Illness:
The patient is a 37-year-old man who has undergone multiple
angioplasties and placement of an ICD for a sustained
ventricular tachycardia and who presented with ejection fraction
of 18% and severe 2-vessel disease. He underwent a cardiac
catheterization a week ago however returns today with chest pain
relieved with nitroglycerin and heparin. It was elected to
proceed with bypass surgery.
Past Medical History:
CAD s/p MI [**2135**], s/p multiple stents to RCA w/ in-stent stenosis
s/p brachytherapy to mid and prox stents
s/p AICD in context of NSVT and low EF in [**11-12**]
CHF w/ EF 30-40%
HTN
hypercholesterolemia
obesity
h/o drug seeking
h/o tobacco (80pack-yr)
LBP - on oxycontin
Social History:
Lives alone, never married, no children. Works as a carpenter.
Used to smoke [**4-14**] ppd x20 years, now smokes [**3-16**] cigarettes/day.
Denies alcohol. Denies any history of drug use including
cocaine.
Family History:
Father had CAD and several MI's, first in 40s.
Physical Exam:
Vitals: BP 119/66, HR 77, RR 14, SAT 96% on 2L
General: well developed male in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD
Heart: regular rate, normal s1s2
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds, obese
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2142-3-5**] 02:35PM PT-12.8 PTT-23.7 INR(PT)-1.1
[**2142-3-5**] 02:35PM PLT COUNT-276
[**2142-3-5**] 02:35PM WBC-11.9* RBC-5.39 HGB-16.8 HCT-45.9 MCV-85
MCH-31.2 MCHC-36.7* RDW-15.2
[**2142-3-5**] 02:35PM cTropnT-<0.01
[**2142-3-5**] 02:35PM CK(CPK)-71
[**2142-3-5**] 02:35PM GLUCOSE-104 UREA N-10 CREAT-1.0 SODIUM-140
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
[**2142-3-12**] 06:30AM BLOOD WBC-8.3 RBC-3.82* Hgb-11.9* Hct-32.6*
MCV-85 MCH-31.1 MCHC-36.5* RDW-15.5 Plt Ct-164
[**2142-3-12**] 06:30AM BLOOD Plt Ct-164
[**2142-3-12**] CXR
1. Low lung volumes likely account for perihilar haziness, but
followup radiograph with improved inspiratory level may be
helpful to exclude early CHF.
2. Patchy bibasilar opacities, which may relate to atelectasis
or aspiration. Attention to these areas on followup chest x-ray
would be helpful as well.
[**2142-3-7**] EKG
Sinus tachycardia. Compared to the previous tracing of [**2142-3-6**]
heart rate is now increased. Otherwise, multiple abnormalities
persist without major change.
Brief Hospital Course:
Mr. [**Known lastname 7635**] was admitted to the [**Hospital1 18**] on [**2142-3-5**] for further
management of his chest pain. He was started on heparin and
nitroglycerin with relief of his chest discomfort. The cardiac
surgery service was consulted as surgical revascularization was
indicated. Mr. [**Known lastname 7635**] was worked-up in the usual preoperative
manner. The psychiatry service was consulted as Mr. [**Known lastname 7635**]
became aggressive and loud. He quickly calmed down and ativan
was added for anxiety related to his surgery. The
electrophysiology service was consulted given his internal
cardiac defibrillator and an interrogation was performed.
Arrythmia therapies were disabled for his upcoming surgery. On
[**2142-3-7**], Mr. [**Known lastname 7635**] was taken to the operating room where he
underwent coronary artery bypass grafting to three vessels.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mr. [**Known lastname 7635**] [**Last Name (Titles) 26228**] neurologically intact and was extubated. Aspirin, plavix
and beta blockade were resumed. Given his preoperative use of
OxyContin, it was resumed for management of his pain. Xanax was
resumed for anxiety. On postoperative day three, he was
transferred to the cardiac surgical step down unit for further
recovery. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. Mr.
[**Known lastname 7635**] was gently diuresed towards his preoperative weight.
Flovent and Combivent were started for wheezing and atelectasis.
Mr. [**Known lastname 7635**] was pan cultured for a fever and intravenous
vancomycin was continued. Atelectasis was assumed to be the
culprit for his fevers and incentive spirometry, inhaler therapy
and chest physiotherapy was continued. Mr. [**Known lastname 7635**] continued to
make steady progress and was discharged home on postoperative
day six. His chest x-ray on discharge showed bibasilar
atelectasis. He was in normal sinus rhythm with a rate of 90-110
for which his beta blockade was increased. His room air oxygen
saturations were 95%. He will follow-up with Dr. [**Last Name (STitle) **], his
cardiologist, the electrophysiology service and his primary care
physician as an outpatient.
Medications on Admission:
Lisinopril 20mg QD
Xanax
Oxycodone 40mg [**Hospital1 **]
Ritalin 10mg QD
Folate 1mg QD
Plavix 75mg QD
Aspirin 325mg QD
Lopressor 200mg [**Hospital1 **]
Imdur 30mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
2. Ritalin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*0*
6. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*120 Tablet Sustained Release 12HR(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*30 Tablet(s)* Refills:*1*
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
16. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) Puffs
Inhalation four times a day.
Disp:*1 1* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
s/p MI
s/p multiple stenting of RCA
s/p AICD placement for NSVT/Low EF
Hyperlipidemia
HTN
Ischemic cardiomyopathy
Obesity
ADHD
Discharge Condition:
Good
Discharge Instructions:
1) Weigh yourself every morning. Report any weight gain of
greater then 2 pounds in 24 hours or 5 pounds in 1 week.
2) Adhere to 2 gm sodium diet
3) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
4) Report any fever greater then 100.5.
5) Take lasix 20mg twice daily with potassium 20mEq twice daily
for 1 week then stop or as instructed by cardiologist.
6) No lotions, creams or powders to wound until it has healed.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. Call ([**Telephone/Fax (1) 1504**] for
appointment.
Follow-up with Cardiologist/primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16958**]
([**Telephone/Fax (1) 26229**] in [**2-12**] weeks. Call for appointment.
Follow-up with DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2142-4-16**] 3:00
Follow-up with DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2142-4-16**] 3:30
Completed by:[**2142-3-23**] Name: [**Known lastname 263**],[**Known firstname 126**] Unit No: [**Numeric Identifier 4550**]
Admission Date: [**2142-3-5**] Discharge Date: [**2142-3-13**]
Date of Birth: [**2104-8-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4551**]
Addendum:
Patient is to follow up in 4 weeks postop with Dr. [**First Name4 (NamePattern1) 255**] [**Last Name (NamePattern1) 256**],
his cardiac surgeon [**Telephone/Fax (1) 1477**]
(NOT Dr. [**Last Name (STitle) **], as previously dictated)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**]
Completed by:[**2142-3-28**]
|
[
"428.22",
"401.9",
"314.01",
"V45.02",
"412",
"428.0",
"414.8",
"414.01",
"496",
"427.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9490, 9703
|
2881, 5207
|
331, 424
|
7678, 7685
|
1803, 2858
|
8234, 9467
|
1387, 1435
|
5423, 7422
|
7524, 7657
|
5233, 5400
|
7709, 8211
|
1450, 1784
|
281, 293
|
452, 845
|
867, 1145
|
1161, 1371
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,168
| 156,566
|
40412
|
Discharge summary
|
report
|
Admission Date: [**2156-10-20**] Discharge Date: [**2156-11-11**]
Date of Birth: [**2099-1-16**] Sex: M
Service: SURGERY
Allergies:
Hydromorphone
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Locally-advanced rectal cancer
status post chemoradiation therapy
Major Surgical or Invasive Procedure:
Robotic converted and laparoscopic converted to open
proctosigmoidectomy, takedown splenic flexure, splenectomy and
distal pancreatectomy, colonic jejunal pouch to anal anastomosis
and diverting loop ileostomy.
History of Present Illness:
Patient refered to Dr. [**Last Name (STitle) 1120**] for surgical management of rectal
cancer after chemotherapy and radiation.
Past Medical History:
PMH: Locally advanced rectal ca, OSA, alopecia, multiple actinic
keratoses, HTN (no meds)
PSH: RIH w mesh, proctosigmoid colectomy [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-anal
anastamosis, temp ileostomy w J-pouch, splenectomy, subtotal
distal pancreatectomy ([**10-20**])
Social History:
Partner involved in care. Please see social work notes related
to traumatic childhood events. Patient worked for many years
with the postal service, recently retired.
Physical Exam:
General: Patient doing well, ambulating the floor independently,
working with nursing staff on drain care, tolerating regular
diet, ileostomy output stable, midline incision staples removed,
voiding, pain controled with PO pain medications. Port-a-cath in
left chest deaccessed prior to discharge. New perirectal/pelvic
drain replaced over a wire prior to discharge which was
tolerated well by the patient.
VS: 98.5,98.4, 102, 142/90, 20, 93-97% RA
Neuro: A&OX3, balance and strength much improved
Cardiac: RRR
Lungs: Lungs improved, slightly deminished at bases, atelectasis
dramatically improved on last imaging study, desating to 80's
while sleeping related to significant history of sleep apnea.
Continuous O2 sat monitoring 93-97% on RA on tele.
Abd: Obese, all staples removed from incision line and
steristrips applied, midline incision healing well, healing
eschar in incision between staples, small amount of superficial
yellow drianage in inferior aspect of incision line. Non-tender.
Left Upper Quadrant JP drians in place and draining scant
amounts of thin yellow/white stable drainage, incertion sites
w/o signs of infection. IR drains in place in Left upper
quadrant and pelvis, moderate amounts of drainage. Pelvis drain
draining small amount of red/brown thick drainage.
Lower Extremities: equal strength bilaterally
Pertinent Results:
[**2156-11-9**] 07:09AM BLOOD WBC-9.5 RBC-2.99* Hgb-8.4* Hct-26.3*
MCV-88 MCH-28.1 MCHC-32.0 RDW-14.8 Plt Ct-540*
[**2156-11-8**] 09:20AM BLOOD WBC-10.6 RBC-2.97* Hgb-8.8* Hct-26.5*
MCV-89 MCH-29.6 MCHC-33.2 RDW-14.2 Plt Ct-592*
[**2156-11-7**] 05:52AM BLOOD WBC-12.0* RBC-2.92* Hgb-8.6* Hct-25.9*
MCV-89 MCH-29.4 MCHC-33.1 RDW-14.3 Plt Ct-688*
[**2156-11-6**] 06:31AM BLOOD WBC-18.2* RBC-3.14* Hgb-9.0* Hct-28.3*
MCV-90 MCH-28.7 MCHC-31.8 RDW-14.6 Plt Ct-687*
[**2156-11-4**] 06:15AM BLOOD WBC-15.1* RBC-2.94* Hgb-8.7* Hct-26.1*
MCV-89 MCH-29.5 MCHC-33.2 RDW-14.1 Plt Ct-702*
[**2156-11-3**] 04:31AM BLOOD WBC-16.5* RBC-3.04* Hgb-9.0* Hct-27.7*
MCV-91 MCH-29.5 MCHC-32.4 RDW-14.2 Plt Ct-775*
[**2156-11-1**] 05:40AM BLOOD WBC-18.1* RBC-3.11* Hgb-9.3* Hct-28.3*
MCV-91 MCH-29.8 MCHC-32.9 RDW-14.0 Plt Ct-696*
[**2156-10-31**] 04:00AM BLOOD WBC-20.5*
[**2156-10-30**] 04:20AM BLOOD WBC-19.4*
[**2156-10-28**] 04:15AM BLOOD WBC-13.4* RBC-3.27* Hgb-9.9* Hct-29.9*
MCV-91 MCH-30.3 MCHC-33.1 RDW-13.9 Plt Ct-466*
[**2156-10-26**] 07:15AM BLOOD WBC-15.1* RBC-3.10* Hgb-9.4* Hct-28.6*
MCV-92 MCH-30.3 MCHC-32.9 RDW-14.8 Plt Ct-335
[**2156-10-27**] 11:08AM BLOOD WBC-13.7*
[**2156-10-25**] 04:21AM BLOOD Hct-26.3*
[**2156-10-24**] 09:30AM BLOOD WBC-16.1* RBC-3.19* Hgb-9.7* Hct-28.9*
MCV-91 MCH-30.5 MCHC-33.7 RDW-14.2 Plt Ct-301
[**2156-10-23**] 05:40AM BLOOD WBC-14.2* RBC-3.23* Hgb-9.7* Hct-28.7*
MCV-89 MCH-30.1 MCHC-33.9 RDW-14.4 Plt Ct-242
[**2156-10-22**] 02:57PM BLOOD Hct-28.1*
[**2156-10-22**] 02:53AM BLOOD WBC-17.4*# RBC-3.62* Hgb-11.0* Hct-31.6*
MCV-87 MCH-30.5 MCHC-34.9 RDW-14.6 Plt Ct-224
[**2156-10-21**] 08:40PM BLOOD Hct-32.9*
[**2156-10-21**] 11:36AM BLOOD Hct-38.6*
[**2156-10-21**] 06:00AM BLOOD WBC-9.9 RBC-4.15* Hgb-12.7* Hct-37.3*
MCV-90 MCH-30.7 MCHC-34.2 RDW-14.4 Plt Ct-270
[**2156-10-21**] 02:07AM BLOOD WBC-9.9 RBC-4.11* Hgb-12.8* Hct-37.0*
MCV-90 MCH-31.1 MCHC-34.6 RDW-14.5 Plt Ct-267
[**2156-10-20**] 09:57PM BLOOD WBC-9.8 RBC-4.26* Hgb-12.8* Hct-38.2*
MCV-90 MCH-30.2 MCHC-33.7 RDW-14.7 Plt Ct-258
[**2156-10-20**] 04:45PM BLOOD WBC-13.3*# RBC-3.24*# Hgb-9.7*#
Hct-29.1*# MCV-90 MCH-29.9 MCHC-33.2 RDW-14.6 Plt Ct-193
[**2156-10-22**] 02:53AM BLOOD Neuts-81* Bands-9* Lymphs-6* Monos-3
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2156-10-28**] 04:15AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
[**2156-10-22**] 02:53AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ellipto-OCCASIONAL
[**2156-11-9**] 07:09AM BLOOD Plt Ct-540*
[**2156-11-8**] 09:20AM BLOOD Plt Ct-592*
[**2156-11-7**] 05:52AM BLOOD Plt Ct-688*
[**2156-11-6**] 06:31AM BLOOD Plt Ct-687*
[**2156-11-6**] 06:31AM BLOOD PT-14.2* PTT-29.3 INR(PT)-1.2*
[**2156-11-5**] 05:55AM BLOOD Plt Ct-791*
[**2156-11-4**] 06:15AM BLOOD Plt Ct-702*
[**2156-11-3**] 04:31AM BLOOD Plt Ct-775*
[**2156-11-2**] 04:20AM BLOOD Plt Ct-766*
[**2156-10-22**] 02:53AM BLOOD PT-13.3 PTT-29.1 INR(PT)-1.1
[**2156-10-21**] 06:00AM BLOOD PT-12.1 PTT-26.7 INR(PT)-1.0
[**2156-10-21**] 02:07AM BLOOD PT-12.4 PTT-25.7 INR(PT)-1.0
[**2156-10-20**] 09:57PM BLOOD PT-12.1 PTT-25.3 INR(PT)-1.0
[**2156-10-20**] 06:15PM BLOOD PT-12.9 PTT-31.9 INR(PT)-1.1
[**2156-10-20**] 04:45PM BLOOD PT-13.7* PTT-31.9 INR(PT)-1.2*
[**2156-11-10**] 04:57AM BLOOD Glucose-94 UreaN-11 Creat-1.4* Na-139
K-3.5 Cl-100 HCO3-28 AnGap-15
[**2156-11-9**] 07:09AM BLOOD Glucose-103* UreaN-11 Creat-1.6*# Na-143
K-3.1* Cl-102 HCO3-32 AnGap-12
[**2156-11-1**] 05:40AM BLOOD Glucose-85 UreaN-14 Creat-0.5 Na-144
K-3.4 Cl-104 HCO3-25 AnGap-18
[**2156-10-31**] 04:00AM BLOOD Glucose-88 UreaN-14 Creat-0.5 Na-143
K-3.2* Cl-103 HCO3-26 AnGap-17
[**2156-10-29**] 04:10AM BLOOD Glucose-96 UreaN-20 Creat-0.8 Na-140
K-3.9 Cl-100 HCO3-29 AnGap-15
[**2156-10-28**] 09:59AM BLOOD Glucose-114* UreaN-20 Creat-0.6 Na-138
K-4.1 Cl-99 HCO3-29 AnGap-14
[**2156-10-27**] 07:05AM BLOOD Glucose-115* UreaN-22* Creat-0.6 Na-142
K-3.8 Cl-103 HCO3-36* AnGap-7*
[**2156-10-26**] 09:11PM BLOOD Glucose-108* UreaN-21* Creat-0.6 Na-141
K-3.7 Cl-101 HCO3-29 AnGap-15
[**2156-10-25**] 08:54PM BLOOD Glucose-131* UreaN-14 Creat-0.5 Na-146*
K-4.1 Cl-107 HCO3-27 AnGap-16
[**2156-10-24**] 09:30AM BLOOD Glucose-136* UreaN-17 Creat-0.6 Na-145
K-4.1 Cl-109* HCO3-27 AnGap-13
[**2156-10-22**] 02:53AM BLOOD Glucose-142* UreaN-14 Creat-0.8 Na-144
K-4.1 Cl-110* HCO3-29 AnGap-9
[**2156-10-21**] 06:00AM BLOOD Glucose-155* UreaN-14 Creat-0.7 Na-138
K-4.7 Cl-107 HCO3-25 AnGap-11
[**2156-10-20**] 09:57PM BLOOD Glucose-208* UreaN-14 Creat-0.8 Na-139
K-4.4 Cl-105 HCO3-22 AnGap-16
[**2156-11-2**] 03:48PM BLOOD Amylase-200*
[**2156-10-22**] 02:53AM BLOOD ALT-20 AST-29 AlkPhos-53 TotBili-0.4
[**2156-11-10**] 04:57AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7
[**2156-11-9**] 07:09AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8
[**2156-11-1**] 05:40AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.1
[**2156-10-29**] 04:10AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
[**2156-10-28**] 09:59AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0
[**2156-10-27**] 07:05AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
[**2156-10-26**] 09:11PM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
[**2156-10-26**] 07:15AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2
[**2156-10-25**] 08:54PM BLOOD Calcium-8.5 Phos-4.0 Mg-2.1
[**2156-10-24**] 09:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.6
[**2156-10-23**] 05:40AM BLOOD Calcium-8.0* Phos-1.8* Mg-2.6
[**2156-10-21**] 06:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8
[**2156-10-20**] 09:57PM BLOOD Calcium-8.2* Phos-4.2 Mg-1.8
[**2156-11-9**] 07:09AM BLOOD Vanco-21.8*
[**2156-11-8**] 09:20AM BLOOD Vanco-30.0*
[**2156-11-7**] 01:00AM BLOOD Vanco-25.9*
[**2156-11-5**] 10:10AM BLOOD Vanco-12.8
[**2156-10-20**] 11:57PM BLOOD Lactate-4.2*
[**2156-10-20**] 05:38PM BLOOD Glucose-170* Lactate-4.0* Na-136 K-3.5
Cl-115*
[**2156-10-20**] 04:57PM BLOOD Glucose-175* Lactate-4.8* Na-135 K-4.0
Cl-107
[**2156-10-20**] 05:38PM BLOOD Hgb-10.3* calcHCT-31 O2 Sat-98
[**2156-10-20**] 04:57PM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-98 COHgb-1
MetHgb-0
[**2156-10-21**] 06:12AM BLOOD freeCa-1.14
[**2156-10-21**] 02:21AM BLOOD freeCa-1.09*
[**2156-10-20**] 10:12PM BLOOD freeCa-1.11*
[**2156-10-20**] 05:38PM BLOOD freeCa-0.79*
[**2156-10-20**] 04:57PM BLOOD freeCa-0.93*
CT GUIDED NEEDLE PLACTMENT Study Date of [**2156-11-6**] 4:42 PM
IMPRESSION:
Technically successful CT-guided presacral and peripancreatic
abscess
drainages with 8 French pigtail drain insertion. 10 mL of
purulent fluid was aspirated from the presacral collection, and
85 cc from the peripancreatic collection. Sample were sent for
microbiological analysis and cell count and differential from
each collection.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2156-11-5**] 6:47 PM
IMPRESSION:
1. Stable appearance of fluid collection in the splenectomy bed
surrounding
the tail of pancreas which appears edematous.
2. Basilar atelectasis and small to moderate left pleural
effusion, stable.
3. Stable presacral fluid collection with foci of gas, which
could be
post-surgical fluid collection or phlegmon.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2156-11-2**] 12:17 PM
IMPRESSION:
1. Stable appearance of a fluid collection within the
splenectomy bed. The
fluid collection is seen surrounding the tail of the pancreas
which appears edematous. There is associated thickening of the
Gerota's and left
lateroconal fascia. The fluid collection is not drainable.
2. The pancreas appears slightly more edematous from [**2156-10-26**]
exam, may
represent inflammation, correlate clinically.
3. Stable appearance of bibasilar atelectasis and
small-to-moderate
nonhemorrhagic left pleural effusion.
4. A presacral fluid collection with tiny foci of gas is
essentially
unchanged from prior study. This finding may represent
postsurgical fluid
collection or phlegmon formation. No discrete abscess formation
in this
region. This collection may be amenable for needle aspiration.
5. Partial small bowel obstruction seen on [**2156-10-26**] exam
appears resolved.
CHEST (PA & LAT) Study Date of [**2156-11-1**] 9:02 AM
IMPRESSION:
1. Left Port-A-Cath tip at the mid-to-low SVC.
2. Probably stable bilateral moderate pleural effusions and mild
bibasilar
atelectasis.
PORTABLE ABDOMEN Study Date of [**2156-10-29**] 6:16 PM
The NG tube is coiled in the stomach with its tip located at the
fundus. The patient is after recent abdominal surgery. Several
borderline bowel loops are noted in the right abdomen, not
necessarily concerning for obstruction but close monitoring is
recommended. Surgical drains are projecting over the left
abdomen.
CT ABD & PELVIS & Chest WITH CONTRAST Study Date of [**2156-10-26**]
11:25 AM
IMPRESSION:
1. Moderate left pleural effusion. Bibasilar consolidation.
2. No evidence of central or segmental pulmonary embolus
allowing for phase of contrast.
3. Fluid and fat stranding noted within the splenectomy site
adjacent to the tail of pancreas. This may represent
postoperative change. No drainable collection identified.
4. Diffuse dilation of the small bowel with multiple air-fluid
levels down to the level of the distal ileum where there is a
transition to more normal caliber bowel. This may represent a
partial small bowel obstruction.
5. Fluid and air present within the presacral space within
pelvis. No
drainable collection identified. This may represent
postoperative change.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 88575**],[**Known firstname **] [**2099-1-16**] 57 Male [**-1/4173**]
[**Numeric Identifier 88576**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd
SPECIMEN SUBMITTED: Rectum and Sigmoid, Omentum, Spleen, Distal
Portion of Pancrease, Portion of Colon, Anastomotic Donut.
Procedure date Tissue received Report Date Diagnosed
by
[**2156-10-20**] [**2156-10-20**] [**2156-10-26**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/dsj??????
Previous biopsies: [**-1/2233**] Slides referred for
consultation.
************This report contains an addendum***********
DIAGNOSIS:
I. Rectosigmoid colon, resection (A-AQ):
Invasive adenocarcinoma of the rectum; see synoptic report.
Fourteen regional lymph nodes with no carcinoma seen (0/14).
Diverticular disease.
II. Omentum (AR-AT):
Unremarkable fibroadipose tissue with no carcinoma seen.
III. Spleen, splenectomy ([**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]):
Splenic parenchyma with no diagnostic abnormalities recognized;
no carcinoma seen.
IV. Distal pancreas, partial pancreatectomy (AW-AX):
Pancreatic parenchyma with no diagnostic abnormalities
recognized; no carcinoma seen.
Three lymph nodes with no carcinoma seen (0/3).
V. Colon, segmental resection (AY-BD):
Colonic segment with diverticular disease and a rare prominent
lymphoid aggregate; no carcinoma seen.
One lymph node, negative for metastatic carcinoma (0/1);
additional adipose tissue blocks to evaluate for more potential
lymph nodes will be submitted and results reported in an
addendum.
VI. Anastomotic donuts (BE):
One colonic/rectal segment with ischemic features, consistent
with adjuvant therapy effect; no carcinoma seen.
Second colonic segment with no diagnostic abnormalities
recognized; no carcinoma seen.
Brief Hospital Course:
Post-operatively the patient was admitted to the MICU for close
monitoring after his initial procedure which included a
splenectomy. MICU course: The patient was admitted to the ICU
post-operatively. He was extubated on POD 1. Hematocrits were
monitored Q 4 hours. [**2156-10-21**] Respiratory acidosis on ABG. CMV
to PSV at MN - [**10-20**]. Minute volume improved. He had persistent
sinus tachycardia. He was given 1L LR and dilaudid for pain
control. He became somnolent and apneic with Dilaudid and was
given Narcan on the evening of [**10-21**]. Sinus tachycardia was
managed with beta blockade. On [**2156-10-22**] the patient was
transferred to the inpatient surgical floor in stable condition.
[**2156-10-23**] Orientation waxed & waned, hesistancy with speach. No
focal neurologic deficit, symptoms improved with time. On
[**2156-10-23**] the patient became more oriented after Morphiene PCA
was discontiniued and put on intermittent morphine. On [**2156-10-23**]
ostomy was noted to have some gas and moderate stool abd tge
patient was advanced to sips and matinance intravenous fluids.
On [**2156-10-24**] the patient started a clears liquid diet and was
advance to regular while recieving 5mg of intravenous reglan
every eight hours. On [**2156-10-25**] the patient all appropriate
vaccines for after splenectomy and began oral pain medications.
The right pelvic JP was removed. On [**2156-10-25**] metoprolol IV was
transitioned to 12.5 po three times daily. [**2156-10-25**] the foley
catheter was removed and the patient failed to void, was noted
to be incontinent with a bladder scan of 450cc and the foley
catheter was reinserted. Also [**2156-10-25**] JP amylases: LUQ 16,195;
LLQ: [**2109**] and this was attributed to be a small pancreatic leak.
The patient was noted to be tachycardic to the, EKG showed sinus
tachycardia and was treated with intravenous Lopressor. [**2156-10-25**]
the patient was noted to be desaturating to the 80's and
standing nebs we ordered. Chest Xray showed bibasilar
atelectasis which was unchanged from [**2156-10-22**]. The patient was
monitored closely, chest PT was preformed which improved
respiratory function. [**2156-10-25**] the patient triggered for
tachycardia above 130 treated with 5mg IV Lopressor and
responded well. Standing IV and PO Lopressor was initiated and
tolerated well. [**2156-10-26**] the ostomy bridge was removed and the
patient was given, 20IV Lasix with a liter of urine out in
response. [**2156-10-26**] CT torso showed bilateral atelectasis, mod L
pl effusion, no e/o pancreatitis/pancreatic fluid collection and
small collection in the pelvis as well as a dilated stomach.
[**2156-10-26**] Reglan increased 5 iv q8 to 10 iv q6, put on clears
which he continued to tolerated well. The patient reported
improved pain control and less nausea with morphine INJ and
abdominal binder. The patient's intraoperative pathology was
back on [**2156-10-26**] and showed T3,N0 - 0/14 lymph nodes. [**2156-10-27**]
the patient tolerated a clear liquid diet and was advanced to a
regular diet and was out of bed. Her oxygen was weaned O2 3L ->
2L. [**2156-10-27**] the patient was out of bed ambulating, respirations
were becoming deeper and the patient's respiratory status
continued to improve. The patient was monitored on telemetry
with continuous oxygen saturation monitoring. On [**2156-10-28**] the
patient attempted to be weaned of oxygen however oxygenation
saturation remained in the 80's and the patient was 90-93% on 3L
of oxygen. A chest xray was obtained which showed decreasing
atelectasis and pleural effusions as well as a large gastric
bubble. The patient had been tachycardic and intermittently
nauseated although continued to pass a stable amount of output
through the ileostomy. An nasogastric tube was placed which
immediately had 1500 cc of bilious output. The patient was made
NPO and intravenous fluids were restarted. Frequency of
nebulizing treatments were increased. On [**2156-10-28**] ABG showed
metabolic alkalosis, and his EKG was unchanged. The patient
continued to have an elevated white blood cell count, the cause
of this was unknown and possibly attributed to the splenectomy.
On [**2156-10-29**] Started Ceftazamide to cover possible respiratory
source with the intention of if WBC was stable [**10-30**] antibiotics
would be discontinued. On [**2156-10-29**] heart rate was improved to
the 90s, and O2 saturation was 100% on 3L. On [**2156-10-29**] NGT
output continued to be high at 2000L, a KUB was done to check if
NGT in duodenum and this was stable. [**2156-10-29**] Respirations
improved, the patient was more alert and active, JP Output had
decreased. [**2156-10-31**] clamp trial preformed with 300 cc residual
and the patient's WBC continued to be 20.6. An additional clamp
trial was preformed which was 200 cc. The nasogastric tube was
removed. On [**2156-11-1**] the patient did not have any nausea or
vomiting or abdominal distension, drain output was down.
[**2156-11-1**] the patient's Foley catheter was discontinued and the
patient was voiding. The patient was tolerating sips and
ambulating. [**2156-11-3**] physical therapy cleared the patient to be
discharged home with services. Elevated amylase/lipase;
pancreatic edema on CT [**2156-11-3**] started on Zosyn, Flomax and
flow max for some urinary incontinence. The patient tol a clear
liquid diet. [**2156-11-4**] the patient complained of urinary
incontinence upon standing a urinalysis was sent and was clean,
the patient was consulted by Dr. [**Last Name (STitle) **] and reassured that this
would improved. Because of continued leukocytosis a serial CT
scans were preformed which showed peripancreatic and perirectal
collections. The patient was given intravenous Zosyn and
vancomycin. The WBC was monitored and continued to be elevated
it was decided that on [**2156-11-6**] radiology would preform
CT-guided drainage of peripanc and perirectal collections. These
collections were drained and the drains were left in place. The
drains were cared for appropriately by the floor nursing
staff.The patent tolerated a regular diet throughout this time.
Vancomycin troughs were monitored closely, and prior to
discontinuation, the Vancomycin Trough was elevated and caused a
slight increase in the patient's creatinine which improved with
hydration. On [**2156-11-9**] Started Augmentin to complete a 14 day
course. On [**2156-11-10**] the patient was stable for discharge with
all drains in place however, at time of discharge, the
perrectal/pelvis drain was noted to be cracked in a portion of
the drain catheter that cannot be replaced. The patient stayed
overnight until [**2156-11-11**] when the drain was replaced over a wire
in radiology. After the patient recovered and finished bedrest
after the procedure, he was discharged home with all appropriate
discharge instructions. Please see results section of summary
for lab details. The patient's white blood cell count
dramatically improved after IR drainage.
Medications on Admission:
Finasteride 5mg qd
ASA 81mg qd
Vitamin B12mg qd
MVI qd
Prilosec 20mg qd
Fish Oil qd
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*1*
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
Disp:*30 Tablet(s)* Refills:*2*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 7 days: Please do not drink alcohol or
drive a car while taking this medication. .
Disp:*45 Tablet(s)* Refills:*0*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.25 Tablet
PO DAILY (Daily).
9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
10. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 14 days: Please take for a
total of 14 days, last day of therapy is [**2156-11-22**].
Disp:*25 Tablet(s)* Refills:*0*
11. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection
once a day: please flush forward into IR placed drains as
instructed (drains with bags) and aspirate back, leave drains to
gravity.
Disp:*30 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**] [**Hospital1 487**]
Discharge Diagnosis:
Locally-advanced rectal cancer status post chemoradiation
therapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the inpatient colorectal surgery service
after open proctosigmoidectomy, takedown splenic flexure,
splenectomy and distal pancreatectomy, colonic jejunal pouch to
anal anastomosis and diverting loop ileostomy to surgicall treat
your rectal cancer. During this procedure, Dr. [**Last Name (STitle) 1120**] [**Name (STitle) 88577**]
some bleeding near your spleen and because of this bleeding, the
spleen was removed and during the removal of the spleen a very
small area of your pancreas was affected. You continued to have
some elevation in enzymes and this required leaving the surgical
drains in place near the spleen bed/pancreas. You also had a
small amount of fluid collect in the area where the spleen was
and in your pelvis. This caused your white blood cell cound to
rise and 2 radiology placed drains were placed in your abdomen
and these will stay in place until at least your follow-up
appointment. It is imprortant that the drain sites are clensed
daily by applying a saline soaked gauze around the skin where
the drain is inserted and then apply a dry sterile gauze
dressing to the site. You may shower with the drains in. The
drains with bags should be flushed daily with 10 cc of sterile
saline and pulled back as you are taught by the nursing staff.
The two JP (bulbs) drains should not be flushed. Please keep
track of the output of these drains as shown by the nursing
staff. You will take the antibiotic Augmentin by mouth for a
total of 14 days, your last day of antibiotics will be [**2156-11-22**].
You have recovered from this procedure well and you are now
ready to return home. Samples from your colon were taken and
this tissue has been sent to the pathology department for
analysis. You will receive these pathology results at your
follow-up appointment. If there is an urgent need for the
surgeon to contact you [**Name2 (NI) 19605**] these results they will
contact you before this time. You have tolerated a regular diet,
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next 3-4 days. 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, prolonges 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. 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 gatoraide. 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 mosified regular diet with your new ileostomy. However
it is a good idea to avoid
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 buldging 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 [**Name2 (NI) **] 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 that is closed
with steri-strips. This incision can be left open to air or
covered with a dry sterile gauze dressing if becomes irritated
from clothing. 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
the steri-strips.
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
excersise with Dr. [**Last Name (STitle) 1120**].
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 make a follow-up appointment with Dr. [**Last Name (STitle) 1120**] for 3-4 weeks
after discharge. Call [**Telephone/Fax (1) 160**] to make this appointment.
Please make an appointment with the ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) **] 7
days after discharge. Call the wound/ostomy nurse [**Last Name (Titles) **] to make
this appointment.
Completed by:[**2156-11-11**]
|
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"285.1",
"998.2",
"518.0",
"V64.41",
"560.1",
"998.11",
"288.60",
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"293.0",
"327.23",
"518.51",
"562.10",
"276.2",
"V15.3",
"E878.2",
"785.0",
"704.00",
"997.49",
"300.4",
"567.22",
"041.04",
"998.59",
"V87.41",
"154.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.29",
"54.91",
"99.10",
"48.69",
"54.21",
"17.42",
"46.01",
"41.5",
"52.52",
"45.94"
] |
icd9pcs
|
[
[
[]
]
] |
22563, 22633
|
13962, 20962
|
341, 554
|
22743, 22743
|
2587, 13939
|
28957, 29361
|
21098, 22540
|
22654, 22722
|
20988, 21075
|
22894, 28934
|
1230, 2568
|
236, 303
|
582, 711
|
22758, 22870
|
733, 1031
|
1047, 1215
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,383
| 156,039
|
49877
|
Discharge summary
|
report
|
Admission Date: [**2138-9-8**] Discharge Date: [**2138-9-11**]
Date of Birth: [**2092-4-2**] Sex: F
Service: PLASTIC
Allergies:
Compazine / Adhesive Tape / Mold/Yeast/Dust
Attending:[**First Name3 (LF) 10416**]
Chief Complaint:
hypotension post-op
Major Surgical or Invasive Procedure:
medial thigh lift, mastopexy, L arm scar revision and autologous
fat transfer to face, liposuction thighs
History of Present Illness:
Ms. [**Known lastname **] is a 46yo F w/ a PMH of morbid obesity s/p RYGB and
paniculectomy who presents for complex plastic surgery today
(s/p medial thigh lift, mastopexy, L arm scar revision and
autologous fat transfer to face, liposuction thighs) who was
hypotensive post-operatively. Her BP fluctuated intraoperatively
from 60s-170s, though they trended down towards the end of her
procedure to the 90s. Anethesia details are as follows:
Intraop: IVF = 3700/1230 (300 EBL); PACU: IVF = 2550/110
Bolus meds: midazolam 2mg, fentanyl 250mcg, propofol 200mg,
ephedrine 75mg, dexamethasone 8mg, glycopyrrolate 0.6mg,
clonidine 0.1mg, succinylcholine 120mg, cefazolin 6gm,
hydromorphone 6mg, phenylephrine 1000mcg, ondansetron 4mg.
Infusion meds: ketamine 83.62mg, phenylephrine 15.81mg,
bupivicaine 0.1% 65.97mg
.
Postop in PACU: BP dropped to 70/40 -> started neo. BP improved
to 100s-110s systolic. Sats stable 99-100% on 3L nc. Bupivicaine
was discontinued at 1740. Neosynephrine was started w/
improvement in SBP. Started on dilaudid PCA at [**2045**]. MS Contin
120mg PO x1 given at [**2060**]. Epidural catheter was removed at 2045
due to dense LLE numbness/paresthesia and slow recovery of
function. Ketamine gtt was started at [**2130**] in its place, with
the idea that it would help her wean off of neosynephrine. SBP
remained in the 80s so patient was transferred to the [**Hospital Unit Name 153**] for
further monitoring.
.
On arrival to the [**Hospital Unit Name 153**], the patient was mentating well. Foley
catheter was in place and draining clear yellow urine. Pt was
awake and interactive, but sometimes slow to respond. Pupils
were pinpoint but she was AAOx3 and answered all questions
appropriately. States that she was in pain in her mid-section
and in her breasts, but denied pain in any other location. She
was using her PCA frequently and states that she will need "a
lot" of dilaudid. Her only other complaint was numbness in her
LLE from her toes to her knee that is gradually improving.
.
ROS:
denies fevers, chills, dizziness, LH, vision changes, URI sx,
[**Last Name (LF) **], [**First Name3 (LF) **], chest pain, palpitations, n/v/d, hematuria, dysuria,
LE edema, numbness or tingling in her hands or feet, bruising,
or bleeding
+ for constipation; + numbness in LLE from toes to knee
Past Medical History:
# Morbid obesity
# RYGB [**6-/2133**] - successful 250 lb weight loss
# Bilateral PE s/p TPA [**7-/2133**]
# DVT [**2120**] (on OCPs), [**2132**] (s/p surgery)
# s/p paniculectomy [**7-27**] complicated by wound dehiscience
# Menorrhagia
# Discoid lupus
# Spinal stenosis
Social History:
Works as a clinical social worker at [**Hospital3 1810**]. No
tob, no EtOH, no recreational drug use.
Family History:
PGF w/ DM; MGM w/ heart failure; M is a breast cancer survivor,
also has osteoporosis and hiatal hernia. Has 2 younger sisters,
both of whom are healthy. No h/o blood clots or bleeding.
Physical Exam:
VS - T 96.1, BP 83-121/38-63, HR 53-77, RR 11-17, sats 97-100%
3L nc
wt 97.8kg
Gen: WDWN middle aged female in NAD.
HEENT: Sclera anicteric. Pupils pinpoint, minimally reactive
bilaterally. OP clear. L EJ in place, L subclavian. Both lines
are nontender, w/o any erythema.
CV: Bradycardic, regular, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly and at bases bilaterally. No crackles,
wheezes, rhonchi.
Abd: Soft, NTND. Multiple bandages along her lower abdomen,
c/d/i.
Ext: No pitting edema. Ext warm, well perfused. No cyanosis. 2+
radial and DP pulses bilaterally. Oozing wound in R upper thigh,
nontender to palpation. Multiple port entry sites in LUE, dsg
c/d/i.
Neuro: AAOx3. Pupils pinpoint, but pt responding to questions
appropriately. CN otherwise appear intact. Strength in UE are
[**4-26**] at triceps, biceps and deltoids. Strength is [**4-26**] on
dorsiflexion and plantarflexion bilaterally. Pt can raise legs
off bed bilaterally, bending at knee on own bilaterally.
Sensation to LT intact in UE bilaterally and in LE bilaterally.
Pertinent Results:
[**2138-9-8**] 07:04PM HCT-32.4*
[**2138-9-9**] 11:34AM Hct-21.7*
[**2138-9-10**] 11:37AM Hct-25.5*
Brief Hospital Course:
A/P: 46yo F w/ a PMH of morbid obesity s/p plastic surgery who
was admitted to the [**Hospital Unit Name 153**] for post-operative hypotension due to
oversedation and intraoperative blood loss.
.
HYPOTENSION. Patient had hypotension due to volume loss
intraoperatively and pain medication/oversedation. She was
initially treated with IVFs and neosynephrine drip. She was
weaned off the neosynephrine drip within 24 hours. CVP improved
with IVF boluses. Patient was mentating well and had good urine
output throughout stay. BP was in ??? upon discharge.
.
Anemia. Hematocrit was initially 41.4 on [**8-18**] and dropped to 21
following surgery. Patient was transfused 2 units PRBCs.
.
S/P MULTIPLE PLASTIC SURGERY PROCEDURES. Patient had extensive
surgery with intraoperative time of 9hrs 25 minutes. Estimated
blood loss of 300cc. Patient was given cefazolin 1gm IV Q8 and
given lovenox for post-op DVT prophylaxis.
.
PAIN. Pt has chronic pain issues, for which she is followed at
[**Hospital1 112**] Pain Clinic (bilateral hip pain, nerve pain in her LUE, and
spinal stenosis). At home, she takes: lyrica, cymbalta, [**Doctor Last Name **],
oxycodone, butalbital/APAP, tigan, ketorolac, alprazolam.
Patient was initially treated with ketamine drip and dilaudid
PCA, which was stopped on [**9-10**]. Patient was treated with
oxycontin, oxycodone, MS contin, cymbalta, and lyrica. Pain
appeared well controlled.
.
Communication: w/ patient and her husband [**Name (NI) **] [**Name (NI) 75697**]
#[**Telephone/Fax (1) 104201**]; #[**Telephone/Fax (1) 104202**] (cell); HCP is pt's sister [**Name (NI) **]
[**Name (NI) **]
.
FULL CODE
.
Medications on Admission:
[**Doctor Last Name 18928**] (MS Contin) 120mg PO BID
Lyrica 150mg PO TID
Cymbalta 60mg PO QD
Oxycodone 20mg PO Q4 prn
Butalbital/APAP/caffeine/codeine 60mg PO Q6h prn
Tigan 300mg PO prn
Ketorolac 10mg PO QID prn
Alprazolam .25mg [**12-24**] tab PO TID prn (takes 0.75mg PO QHS)
Protonix 40mg PO QD
Triamterene 37.5/HCTZ 25mg PO QD **for "water weight", not HTN
Lactulose prn
MVI
Polyethylene glycol QD prn
vitamin C
benadryl 50mg PO QD prn
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous QD
().
Disp:*7 * Refills:*0*
2. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1.S/P medial thigh lift, mastopexy, L arm scar revision and
autologous fat transfer to face, liposuction thighs
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital for your surgery. Your
post-operative course was complicatted by low blood pressure
which required ICU care for a brief time period.
Please return to the hospital if you experience fevers greater
then 101.4, chills, or other signs of infection. Also return to
the hospital if you experience chest pain, shortness of breath,
redness, swelling, or purulent discharge from the incision site.
Return if you experience worsening pain or any other concerning
symptoms.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
Restart taking all your regular medications once you arrive at
home.
.
Please do not place any pressure at the surgical site. .
Please resume previous medications as prior to your surgery.
Please take pain medications and stool softener as prescribed.
.
Please follow-up as directed.
Followup Instructions:
Please f/u with Dr. [**Last Name (STitle) **] as scheduled.
|
[
"285.1",
"458.29",
"695.4",
"E878.8",
"V45.86",
"724.02",
"701.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.6",
"86.83",
"86.3",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7074, 7080
|
4603, 6249
|
322, 429
|
7245, 7252
|
4476, 4580
|
8415, 8478
|
3206, 3394
|
6741, 7051
|
7101, 7224
|
6275, 6718
|
7276, 8392
|
3409, 4457
|
263, 284
|
457, 2774
|
2796, 3070
|
3086, 3190
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,193
| 185,261
|
14411
|
Discharge summary
|
report
|
Admission Date: [**2137-3-27**] Discharge Date: [**2137-4-1**]
Date of Birth: [**2077-4-23**] Sex: F
Service: MEDICINE
Allergies:
Cardizem / Morphine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
maroon stool
Major Surgical or Invasive Procedure:
upper endoscopy
red blood cell transfusions
History of Present Illness:
59 yo F with h/o PUD, CAD (s/p stenting x3 RCA, s/p restenting
[**3-2**] for NSTEMI) p/w maroon stools. The pt was recently
transferred from NEBH [**3-14**] for NSTEMI, for which she was taken
to the cath lab, received 2 BMSs to her RCA. The pt had been
holding her asa/[**Month/Year (2) 4532**] given an L3-S1 laminectomy a few days
prior. In the setting of the above MI, she received a [**Month/Year (2) 4532**]
load, asa 325, and was placed transiently on heparin,
integrillin, and nitro drips. The cath had no complications and
the pt was transferred back to NEBH post-procedure day #1. At
the time of transfer the pt's hct was 23 (down from a baseline
of 30). The pt was discharged from NEBH on [**3-19**] after a stable
hospital stay. The pt was discharged to [**Hospital3 2558**] where she
has had at least two lab checks demonstrating a stable Hct, most
recently on [**3-25**] (hct=30). The pt has reportedly been doing well
at [**Location (un) **] until this afternoon when she syncopized while on
the toilet and had dark stools. No vital signs available on
report from CH. The pt reports being confused and lightheaded at
the time and does not recall if she had been having dark stools.
Pt taken to [**Hospital1 **] via EMS.
.
In the ED initially: 98.7, hr 90, 88/42, rr 15, 100% ra. Hct 13.
EKG: NSR@90bpm, lbbb. 2 18g IVs placed. Protonix 40 mg iv x 1, 3
units prbcs given. CT abd did not demonstrate any acute process,
though did demonstrate two small seromas. NGL was attempted x 3
though the pt was combative during the procedure. GI was
consulted and recommended EGD in the MICU. In the MICU EGD
demonstrated a single erosion with visible vessel at the GE
junction, which was cauterized.
.
In MICU, patient required total 6 units PRBC to maintain stable
Hct. 7th unit given to maintain Hct > 30. BP meds held in ICU
given bleeding. Restarted low dose beta-blocker prior to
call-out. GI believes erosion may be culprit vessel, but if
re-bleeds will need colonoscopy.
Past Medical History:
CAD, s/p stents x 3 to RCA, s/p restenting [**3-14**] with 2 BMS.
tobacco abuse
obesity s/p gastric bypass
s/p left knee replacement in [**2129**]
s/p left hip replacement in [**2130**]
s/p right hip replacement in [**2133**] with revision in [**2134**]
EtOH abuse
hepatitis
panic attacks
hyperlipidemia
hypertension
depression
attempted suicide in the past
H/O PUD with GIB
sleep apnea
chronic back pain
Past Surgical History: as above, s/p gastric bypass,
laminetcomy, hip replacement
Social History:
Pt quite smoking one month ago. Prior to this she smoked 1.5 PPD
x 4.5 years. Before that she had not smoked for 25 years, prior
to which she had initially been a smoker. She does not drink but
has a prior history of EtOH abuse. She formerly works as a bus
driver but is now disabled due a work-related fall.
Family History:
The pt's faterh died at 76 from a cardiac cause. The pt's mother
is alive and has arthritis. No history of premature CAD or other
familial illnesses. The pt's daughter had [**Initials (NamePattern4) **] [**Name (NI) 42686**] tumor at age
three.
Physical Exam:
BP 172/80, HR 85, Resp 18, O2 98% RA
Gen - WDMN middle-aged woman, uncomfortable, alert, no acute
distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, [**2-28**] SM at LSB
Abd - Soft, non-tender, non-distended, mild TTP in
LLQ/suprapubic, abdominal incision site with steri-strips and
w/o exudate/erythema or crepitus.
Extr - No edema. 2+ DP pulses bilaterally
Skin - no rashes, incision over back is w/o exudate, drainage,
and dressing c/d/i.
Pertinent Results:
*******************LABS*****************
CBCs:
[**2137-3-27**] 11:25AM
WBC-14.0* RBC-1.46*# Hgb-4.4*# Hct-13.2*# MCV-91 MCH-30.0
MCHC-33.0 RDW-14.8 Plt Ct-516*#
[**2137-3-27**] 07:37PM
Hct-22.4*#
[**2137-3-28**] 02:08AM
WBC-14.8* RBC-3.19*# Hgb-9.5*# Hct-27.1* MCV-85 MCH-29.8
MCHC-35.0 RDW-15.5 Plt Ct-341
[**2137-3-28**] 10:09AM
Hct-26.8*
[**2137-3-28**] 06:19PM
Hct-29.4*
[**2137-3-31**]
WBC-9.6 RBC-3.65* Hgb-10.9* Hct-32.2* MCV-88 RDW-16.1* Plt
Ct-449*
.
COAGs:
[**2137-3-31**]
PT-12.9 PTT-28.6 INR(PT)-1.1
.
CHEM:
[**2137-3-27**]
Glucose-137* UreaN-39* Creat-0.7 Na-139 K-4.4 Cl-104 HCO3-23
AnGap-16
[**2137-3-31**]
Glucose-98 UreaN-13 Creat-0.8 Na-137 K-4.3 Cl-102 HCO3-26
AnGap-13 Calcium-8.9 Phos-4.0 Mg-2.2
.
LFTs:
[**2137-3-27**]
ALT-7 AST-18 CK(CPK)-210* AlkPhos-58 TotBili-0.2
.
CE's:
[**2137-3-27**] 11:25AM BLOOD CK-MB-6 cTropnT-0.04*
[**2137-3-28**] 02:08AM BLOOD CK(CPK)-238* CK-MB-7 cTropnT-0.06*
.
URINE:
[**2137-3-31**]
Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 Blood-NEG Nitrite-NEG
Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG
pH-5.0 Leuks-NEG
[**2137-3-27**] 2:30 pm URINE Site: CATHETER
**FINAL REPORT [**2137-3-29**]**
URINE CULTURE (Final [**2137-3-29**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2137-3-30**] 8:05 am URINE Source: CVS.
**FINAL REPORT [**2137-3-31**]**
URINE CULTURE (Final [**2137-3-31**]): <10,000 organisms/ml.
.
[**2137-3-27**] CT Abd/Pelvis:
IMPRESSION:
1. No evidence of bleeding or complications at the site of local
spinal surgery, with no retroperitoneal bleed.
2. L2 through S1 spinal fusion is seen with no evidence of
hardware failure.
3. Small seroma in the subcutaneous soft tissues overlying the
posterior surgical site.
4. Second probable seroma in the subcutaneous tissues of the
anterior abdominal panniculus.
5. Bilateral hip replacements.
------------------
ECG [**2137-3-27**] 11:10:08 AM
Sinus rhythm
Left bundle branch block
Consider inferior infarct - age undetermined - although is
nondiagnostic
Consider prior anterior myocardial infarction - although is
nondiagnostic
Since previous tracing of [**2137-3-15**], no significant change
.
Rate PR QRS QT/QTc P QRS T
90 144 120 396/448 48 9 -132
------------------
[**2137-3-27**] Endoscopy:
Impression: Erosion in the gastroesophageal junction (thermal
therapy)
Normal mucosa in the whole stomach. Evidence of a previous
?stomach surgery noted. Normal mucosa in the first part of the
duodenum and second part of the duodenum Otherwise normal EGD to
second part of the duodenum.
.
[**2137-3-31**] CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
1. No intraperitoneal or retroperitoneal cause for the patient's
symptoms.
No retroperitoneal hematoma.
2. Anterior and posterior subcutaneous fluid collections similar
in
configuration compared with the prior study of [**2137-3-27**] as
is psot-
operative change in the areas of posterior laminectomies.
Infection in these areas cannot be excluded, however.
3. Spinal hardware at L2-S1 is unchanged in appearance from
prior study.
4. Multiple splenules and cortical defect in left kidney,
unchanged, the
latter probably from prior infection/infarct.
5. Mildly increased distention of the stomach (where there is an
anastamosis) compared to the prior study, but with free passage
of contrast.
Brief Hospital Course:
Patient was admitted to the ICU with GI bleed for Endsocopy.
.
#GIB: An erosion in the GE Junction was treated with
electrocautery. Patient given 7 units of blood in total, with
goal Hct of 30 given coronary disease and recent NSTEMI. She
was thereafter with stable Hct on repeat checks. Called out from
ICU and monitored thereafter with stable Hct. Hct stable for
further 48 hours on Aspirin and [**Year (4 digits) 4532**]. Started on [**Hospital1 **] IV PPI in
ICU and transitioned to [**Hospital1 **] PO on floor. Plan for outpatient
colonoscopy for further evaluation.
.
#CAD: Aspirin, [**Hospital1 4532**], beta-blocker, ACE, clonodine all held in
ICU given GIB. Restarted on beta-blocker, baby aspirin and
[**Name2 (NI) 4532**] on the floor. Beta blocker was uptitrated prn for
hypertension, increased up to 75mg TID of metoprolol prior to
discharge. ACE inhibitor was also uptitrated to 20mg daily
before discharge. Clonodine held in ICU and not restarted.
.
#Pain: With continued back pain from recent laminectomy. No
evidence of infection by exam or by CT. Patient requesting
frequent doses of oxycodone for breakthrough pain, and so long
acting oxycodone SR was uptitrated as needed (to 60mg [**Hospital1 **] at
discharge). Neurontin was restarted. Additional pain control was
achieved with lidocaine patch, stading tylenol, and duloxetine.
.
#UTI: Concern for UTI given leukocytosis at presentation.
Initial U/A was abnormal although possible contaminant. Culture
grew 10-100K E. Coli. Started on ceftriaxone and repeat U/A was
w/o evidence of infection. Discontinued after 3 days of therapy
([**3-29**] - [**4-1**]).
.
#Depression: Stable. Continued on outpatient medications. Had
evidence of bizarre beliefs at times, but no active psychosis by
history. Recommend outpatient follow-up.
.
#Leukocytosis: As noted above. DDx includes GIB/Stress reaction
vs UTI.
.
# PPx - used sQ heparin [**Hospital1 **] after stabilization of HCT, PPI as
above, and aggressive bowel regimen given opiate needs for pain
control.
.
# Code - full code.
Medications on Admission:
caltrate 600 mg daily
Mg 300 mg daily
oxycontin 10 mg [**Hospital1 **]
cymbalta 60 mg
lipitor 80 mg daily
neurontin 600 mg tid
clonidine 0.1 q8h
oxycodone 5-10 mg q 6 h
oxycodone 5-10 mg q 3 h prn pain
labetalol 200 mg daily
docusate
bisacodyl
tylenol
Discharge Medications:
1. Caltrate Plus 600-400 mg-unit Tablet Sig: One (1) Tablet PO
twice a day.
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24 PRN () as needed
for pain: to left flank - where patient describes pain .
8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
10. OxyContin 60 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day.
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed: hold ofr oversedation or RR <12.
12. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
Upper GI bleed
.
Secondary:
# CAD, s/p stents x 3 to RCA, s/p restenting [**3-14**] with 2 BMS.
# tobacco abuse
# obesity s/p gastric bypass
# s/p left knee replacement in [**2129**]
# s/p left hip replacement in [**2130**]
# s/p right hip replacement in [**2133**] with revision in [**2134**]
# EtOH abuse
# hepatitis
# panic attacks
# hyperlipidemia
# hypertension
# depression with attempted suicide in the past
# H/O PUD with GIB
# sleep apnea
# chronic back pain
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with a gastrointestinal bleed.
You required blood trasfusions to maintain a normal blood count.
Our gastroenterologists performed an upper endoscopy and found a
blood vessel that was likely responsible for the bleeding. This
was cauterized and your blood counts stabilized. You will be
taking a new, twice daily medicine called pantoprazole
(Protonix) to minimize any further risk of bleeding. It is
important for you to see your PCP in order to schedule a routine
screening colonoscopy in the near future.
.
You were restarted on your cardiac medications without evidence
of further bleeding. Your chronic pain medicines were increased
and expanded to better contorl your pain. you will be going to
rehab to improve your pain-free mobility and functional status
before going home.
.
You were also treated with antibiotics for 3 days for a urinary
tract infection.
.
Please take all medicines as prescribed. Please keep all
outpatient appointments. If you experience any symptoms which
disturb you such as chest pain, worsening shortness of breath,
or repeat episdodes of bloody bowel movements, please call your
doctor or report to the ED.
Followup Instructions:
Please schedule a followup appointment with your PCP in the next
2 weeks. They can refer you for a colonoscopy.
.
Please schedule a followup appointment with your cardiologist
Dr. [**Last Name (STitle) **] in the next 2 weeks.
|
[
"305.00",
"578.9",
"V45.86",
"780.57",
"311",
"V43.65",
"305.1",
"724.2",
"401.9",
"300.01",
"412",
"V45.82",
"414.00",
"V43.64",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12074, 12160
|
8151, 10205
|
292, 338
|
12681, 12690
|
4069, 8128
|
13913, 14143
|
3203, 3449
|
10508, 12051
|
12181, 12660
|
10231, 10485
|
12714, 13890
|
2800, 2860
|
3464, 4050
|
240, 254
|
366, 2350
|
2372, 2777
|
2876, 3187
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,038
| 107,432
|
43853
|
Discharge summary
|
report
|
Admission Date: [**2104-4-23**] Discharge Date: [**2104-5-2**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Increased oxygen requirement, volume overload
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is an 87 yo man w/ h/o CAD s/p CABG (LIMA-D1,SVG-LAD,
SVG-Ramus;SVG--OM;SVG--PDA), Afib ( on warfarin), diet
controlled DM, CHF (EF 35%) who presents with 1 week of volume
overload from his nursing home. Pt has baseline CHF who is on 3L
O2 at baseline, on 40mg IV lasix [**Hospital1 **] at baseline. Over past
week, has noted increased volume overload, increased O2
requirement to 5L NC. He has been more edematous. He denies any
recent fevers, chills, chest pains, cough, or sputum production.
The only change in his medication has been increasing doses of
lasix. Today, attempted diuresis with lasix 40mg PO x 1,
followed by 80mg IV x1, followed by 100mg IV x 1, followed by
metolazone. UOP on these interventions only 200cc, so patient
sent to ED.
.
On presentation to [**Name (NI) **], pt was afebrile, RR 18, O2 sat 100% on
NRB. Exam notable for mild resp distress, elevated JVP, crackles
on exam. Lactate noted to be 2.5. ABG: 7.44/35/112. EKG: V
paced, unchanged. CXR shows fluid overload. He was treated with
metolazone 5mg PO then lasix 200mg IV with 200cc UOP. Patient
admitted to CCU for further management.
.
Currently, he feels quite well. He reports decreased SOB and has
been weaned to 5L NC. He is alert and interactive. He denies any
chest pain, abdominal pain, shortness of breath at rest. At
night, he uses 1 pillow to sleep.
Past Medical History:
1. CAD s/p CABG in [**2089**]
2. CHF, last ECHO w/EF 30%
3. Atrial fibrillation
4. s/p ICD in [**7-27**]; upgrade to BiV/ICD in [**7-28**]; generator change
in [**2-28**]; device and lead extraction on [**2104-2-4**] for MRSA
bacteremia and temporary pacemaker on [**2104-2-4**]
5. History of idiopathic intrinsic lung disease
- on 3L O2 at home
6. Type 2 DM, diet controlled
7. BPH
8. Hx of GI bleed
9. Hypothyroidism
10. Right ear melanoma s/p exicision
Social History:
Used to deliver milk for job. Lives by himself but son is in
same house, widower, retired. Denies tobacco past or present,
previous moderate EtOH use, no IVDU.
Family History:
Per [**Name (NI) **] father with TB
Mom died of AMI age 70s
Brother died of AMI age 70s
Physical Exam:
VS: T 97.7 BP 97/54 HR 81 RR 17 O2 98% 5L
Gen: AAO to person, place, time, month, situation. interactive,
NAD, comfortable
HEENT: NCAT, anicteric, PERRLA, MM mildly dry
Cards: JVP 15cm, PMI at 6th intercostal space, RRR nl S1S2 II/VI
holosystolic murmur loudest at apex, no thrills. no S3S4
Chest: sternotomy scar well healed. pacer site without erythema.
steri strips in place without purulent drainage.
Resp: nonlabored. no accessory muscle usage. rales 1/3 up
bilaterally with scattered rhonchi. soft wheezes.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits. no rebound
Ext: deep pitting edema bilaterally upper and lower. symmetric.
no cyanosis, clubbing
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Pertinent Results:
Admission labs:
133 99 37
-------------< 124
4.6 22 1.7
CK: 25 - 16 - 22
MB: Notdone
Trop: 0.02 - 0.02 - 0.03
Ca: 8.8 Mg: 2.3 P: 3.6
ALT: 11 AP: 89 Tbili: 0.6 Alb: 3.5
AST: 19 LDH: Dbili: TProt: 6.8
[**Doctor First Name **]: 89 Lip:
.
9.7
12.8 >----< 357
30
N:81 Band:1 L:9 M:8 E:1 Bas:0
.
[**4-23**] admission CXR: Examination very limited secondary to
patient motion. Mild pulmonary edema with associated pleural
effusions is likely present and reflective of congestive heart
failure. Unchanged appearance of opacity within the lingula.
Repeat radiography may be helpful
.
[**4-23**]: ECG: Ventricular paced rhythm with ventricular premature
complex
Ventricular couplets
.
Trends/dispo labs:
[**2104-4-30**] Glucose-107* UreaN-46* Creat-1.7* Na-127* K-4.2 Cl-88*
HCO3-31
[**2104-4-30**] WBC-7.7 RBC-3.52* Hgb-9.2* Hct-28.6* Plt Ct-312
[**2104-4-29**] PT-26.7* PTT-44.2* INR(PT)-2.7*
Iron 13, TIBC 355, Folate 15, Ferritin 13
TSH 6.4
FT4 1.2
.
Micro:
C diff pos
blood cx NGTD
Brief Hospital Course:
87 yo man w/ h/o CAD s/p CABG, Afib s/p BiV pacer, DM, CHF (EF
35%) who presented with 1 week volume overload, increased O2
requirement. Hospital course by problem:
.
#) Cardiac Pump/Goals of care: Pt w/ h/o CHF, EF 35% on last
ECHO in [**3-1**], also moderate MR and mod-severe TR, RV moderately
dilated, presented w/ apparent CHF exacerbation with increased
volume overload, increased O2 requirement, no response to
increased lasix at NH. We treated him in the CCU with
aggressive diuresis. He required a lasix gtt (up to 20/h) and
metolazone. He diuresed >12L but still had persistent O2
requirement and inability to ambulate without significant
dyspnea. We also added spironolactone temporarily. Given his
end stage CHF and poor functional capacity, we discussed his
prognosis with the patient and family. The patient very much
wanted to go home. He had an understanding of the severity of
his disease. He requested to go home with hospice care to focus
on comfort. Per his request, we left the foley in place. He
was discharged on lasix 40-60 mg daily to be titrated to a goal
of 1-2L negative per day of diuresis. If fluid overload
worsens, he will likely develop worsening O2 requirement. Given
the goals of hospice and comfort, we have prescribed ativan and
morphine to be administered if patient is exhibiting signs of
respiratory distress.
.
# Respiratory: as above. Patient also has an underlying
interstitial lung disease (PFTs with restrictive pattern) which
likely worsened his symptoms. We treated with albuterol and
atrovent nebs which made some change in his resp status. He is
discharged on these medications.
.
# CAD: continued carvedilol. no ASA given allergy. CE neg. no
chest pain
.
# Rhythm: hx of AFib w/ slow ventricular response, s/p
pacer/AICD placement. He was VPaced. After the family meeting,
we had the ICD turned off to congruence with the goals of care.
We also stopped the amio, digoxin, and coumadin.
.
# ID: Patient had C diff and came in on flagyl. we completed
>14 day course and d/c'd this medication prior to discharge.
.
# Chronic renal failure. Baseline creatinine 1.4. He was
slightly worsened with diuresis.
.
# Iron Deficiency Anemia: profound iron deficiency. Hct stable.
Discharged on iron. We felt that administration of blood would
likely precipitate pulmonary edema.
.
# Code: DNR/DNI. Comfort measures, per d/w patient and HCP
.
# Contact: [**Name (NI) **] is HCP named [**Name (NI) **]: [**Telephone/Fax (1) 94177**].
.
# Dispo status: Patient largely bedridden. Can pivot with
assistance but with significant exertion. He has bibasilar
crackles and remains on 6L O2. His mood is generally well and
he is looking forward to going home.
Medications on Admission:
Amiodarone 200mg daily
carvedilol 6.25mg [**Hospital1 **]
B12 100mcg daily
Digoxin 0.0625 every other day MWF
finasteride 5mg daily
advair 250/50 [**Hospital1 **]
lasix 40mg IV BID
ISS
levothyroxine 25mcg daily
flagyl 500mg TID
MVI
Pantoprazole 40mg daily
simvastatin 20mg daily
tamsulosin 0.4mg qhs
warfarin 2.5mg daily
tylenol prn
albuterol nebs
atrovent nebs
ambien 2.5mg qhs
nystatin topically prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, or temp>101.
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*1*
3. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*1*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*20 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: [**4-3**] ml PO BID (2
times a day).
Disp:*200 ml* Refills:*2*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
12. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-10 mg PO
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*200 ml* Refills:*0*
13. Ativan 0.5 mg Tablet Sig: 0.5-1.0 mg (liquid formulation) PO
every four (4) hours: please provide the liquid formulation per
hospice.
Disp:*40 mg (in liquid formulation)* Refills:*0*
14. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. Lasix 20 mg Tablet Sig: 2-3 Tablets PO once a day: please
aim for 1-2L negative per day fluid status.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary:
- decompensated CHF
- atrial fibrillation s/p AICD/pacer (AICD turned OFF)
- c diff colitis
- iron deficiency anemia
Secondary:
- s/p MRSA bacteremia and pseudomonas UTI in [**1-2**]
- hx CAD s/p CABG in [**2089**]
- BPH
- DMII
- hx of GI bleed on asa
- hypothyroidism
- hyperlipidemia
Discharge Condition:
comfortable
Discharge Instructions:
You were admitted with a CHF exacerbation. We treated you in
the cardiac intensive care unit and removed a significant amount
of fluid. You felt symptomatically improved. We met with you
and your family and, with the assistance of hospice home care,
have discharged you to home.
Please take your medications as instructed. Please contact your
PCP with any questions.
Followup Instructions:
please contact your PCP to discuss followup plans
|
[
"V10.82",
"250.00",
"584.9",
"V58.67",
"600.00",
"008.45",
"V45.81",
"585.9",
"427.31",
"V53.32",
"280.9",
"428.0",
"244.9",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9408, 9459
|
4349, 4486
|
261, 267
|
9798, 9812
|
3326, 3326
|
10232, 10285
|
2318, 2408
|
7521, 9385
|
9480, 9777
|
7094, 7498
|
9836, 10209
|
2423, 3307
|
176, 223
|
4514, 7068
|
295, 1645
|
3342, 4326
|
1667, 2124
|
2140, 2302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,618
| 177,154
|
9408
|
Discharge summary
|
report
|
Admission Date: [**2180-7-4**] Discharge Date: [**2180-7-12**]
Date of Birth: [**2123-8-14**] Sex: M
Service: GEN. [**Doctor First Name 147**].
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old man
with a history of metastatic melanoma who presented for
elective resection of an anterior abdominal wall mass. The
patient was in his usual state of health until [**2176-5-23**] when
he presented with an 8 mm ulcerated melanoma of his right
calf. He had a recurrence in [**2177-8-24**] and underwent a
right frontal node dissection. He then developed a right
inguinal recurrence after two months, after receiving
interferon therapy. This occurred in [**2178-11-24**].
He received resection and radiation therapy. He was enrolled
in the ECOG 4697 study, receiving GNCSF and a peptide
vaccine. He then developed a new right groin nodule in
[**2179-8-24**]. Follow-up CT scan revealed a 3.9 x 2.2 cm soft
tissue mass in his abdomen as well as tiny nodes in the
mesentery. He underwent partial small bowel resection with
complete resection of tumor in [**2179-9-24**].
In [**2179-12-25**], he developed subcutaneous nodules in the
right shoulder. He was started on the allovectin trial. In
[**2179-12-25**], he developed new nodules near his abdominal
surgical scar. He was then taken off the allovectin trial,
started on biochemotherapy.
He now presents for elective resection of an abdominal
anterior wall mass.
PAST MEDICAL HISTORY:
1. Metastatic melanoma.
2. Status post vasectomy.
3. Anxiety disorder.
MEDICATIONS: Ativan p.r.n.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco or illicit substances. Social
alcohol.
FAMILY HISTORY: Grandmother with ureteral cancer. Otherwise
no cancer.
PHYSICAL EXAMINATION: Temperature 97.0, heart rate 60,
respiratory rate 18, oxygen saturation 100% on room air,
blood pressure 123/72. HEENT: Normocephalic, atraumatic.
Pupils equal, round and reactive to light. Extraocular
movements intact. Mucus membranes moist. Nasopharynx clear.
Neck supple. No jugular venous distention. No
lymphadenopathy. No thyromegaly. Heart regular rate and
rhythm. No murmurs, rubs or gallops. Lungs clear to
auscultation bilaterally. Abdomen: Normal bowel sounds,
non-distended, non-tender, no hepatosplenomegaly. Midline
surgical scar. Extremities: No clubbing, cyanosis or edema.
Neuro: Nonfocal.
RADIOLOGY: CT scan of chest, abdomen and pelvis [**2180-6-9**], notable for interval increase in the size of the
periumbilical subcutaneous nodules and two mesenteric
nodules. Also notable for failure to visualize the
previously noted subcutaneous nodule on the left back. CT
scan of the head from [**2180-4-25**], notable for no
hemorrhage, mass effect or mass.
HOSPITAL COURSE: The patient was admitted to Green Surgery
and underwent abdominal wall resection, component release of
ventral herniorrhaphy, resection of small bowel mesenteric
metastases, and small bowel resection with anastomosis.
Please see operative note for full details of procedure. He
tolerated the procedure well, and was transferred to the
floor. Pain was well controlled on epidural. He was started
on Kefzol IV. On postoperative day one, the patient was
noted to experience a seizure. His brother noted that he
first stared off into space, then began to shake his right
arm and leg, which then progressed to be described as similar
to a generalized tonic-clonic seizure. Per report, this
lasted between one and five minutes. Electrolytes, CBC and
fingersticks were normal. He was noted to be postictal on
examination but vital signs were stable. CT scan of the head
was notable for a large left frontal enhancing mass, new
since prior CT scan. No intracranial bleed was noted, but
surrounding edema was concerning. The patient was loaded
with Decadron and then started on 4 mg p.o. q. 6h. He was
also started on fosphenytoin, and transferred to the
Intensive Care Unit for further monitoring. In the Intensive
Care Unit, he did well and experienced no further seizures.
An MRI, on [**2180-7-6**], with and without contrast was
notable for a 4 cm left frontal lobe mass adjacent to the falx
with a lobular component. Beneath the falx in the right
frontal lobe surrounding edema was noted. The corpus callosum
and frontal [**Doctor Last Name 534**] were inferiorly displaced. Midline shift to
the right was noted. A second focus of enhancement was noted
in the right parietal lobe, representing another likely
metastatic focus. No other abnormalities were noted.
He was then transferred back to the floor on postoperative
day five where he continued to do well with no further
seizures. His vital signs were stable and urine output
adequate. On postoperative day six, his antiseizure regimen
was changed to Dilantin 200 mg p.o. b.i.d. per recommendation
of Neurology. On postoperative day seven his Decadron was
changed to p.o. per recommendations of Neurosurgery. He was
clinically stable and deemed ready for transfer to rehab.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Discharge to extended care facility.
DISCHARGE DIAGNOSES:
1. Metastatic melanoma.
2. Seizure.
DISCHARGE INSTRUCTIONS: The patient was instructed to notify
his M.D. if he experienced a change in mental status,
seizures, fever or chills, nausea or vomiting, or inability
to eat. He was also instructed to follow up with Dr. [**Last Name (STitle) 519**] in
two weeks and to follow up with Dr. [**First Name (STitle) **] in Brain [**Hospital 341**] Clinic
in one to two weeks.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcutaneously b.i.d.
2. Protonix 40 mg p.o. q. day.
3. Phenytoin 200 mg p.o. b.i.d.
4. Decadron 4 mg p.o. q. 6h.
5. Percocet 5/325 mg one to two tablets p.o. q. 4-6h. p.r.n.
6. Colace 100 mg p.o. b.i.d. p.r.n.
7. Insulin sliding scale as per attached flow sheet.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 2512**]
MEDQUIST36
D: [**2180-7-11**] 21:13
T: [**2180-7-11**] 21:15
JOB#: [**Job Number 32124**]
|
[
"V10.82",
"198.2",
"197.6",
"780.39",
"197.4",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.3",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
1702, 1759
|
5153, 5192
|
5597, 6168
|
2792, 5051
|
5217, 5574
|
1782, 2774
|
5066, 5132
|
194, 1452
|
1474, 1616
|
1633, 1685
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,876
| 182,248
|
12092+12093+56329+56336
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2119-9-11**] Discharge Date: [**2119-9-16**]
Date of Birth: [**2061-5-27**] Sex: M
Service: ENT [**Doctor First Name 147**]
PRINCIPAL DIAGNOSIS:
1. History of poorly differentiated thyroid carcinoma
removed in [**2118-12-13**] with positive margins and skeletal
muscle invasion and total laryngectomy and neck dissection
for local control of disease.
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
male who was known to have thyroid cancer which was poorly
differentiated follicular carcinoma with lymph and vascular
invasion. This was taken out with total thyroidectomy and
parathyroidectomy in [**2118-12-13**]. On that excision there
were positive margins for tumor and skeletal muscle invasion
and the patient had a tracheostomy placed on [**8-23**] of this
year for stridor and local invasion of cancer into his
airway.
He had presented to Dr. [**Last Name (STitle) **] for a total laryngectomy
and neck dissection and afterwards is planning to receive XRT
to his neck for potential hopeful control of his thyroid
follicular carcinoma.
HOSPITAL COURSE: He came in to the hospital and was taken to
the Operating Room on [**2119-9-11**], and underwent a
DICTATION ENDS
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**MD Number(1) 11390**]
Dictated By:[**Last Name (NamePattern1) 31862**]
MEDQUIST36
D: [**2119-9-15**] 19:00
T: [**2119-9-15**] 20:15
JOB#: [**Job Number 37916**]
Admission Date: [**2119-9-11**] Discharge Date:
Date of Birth: [**2061-5-27**] Sex: M
Service: ENT [**Doctor First Name 147**]
FINAL DIAGNOSIS:
1) Metastatic thyroid follicular carcinoma, status post
total laryngectomy.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 58-year-old
gentleman who is known to have a poorly differentiated
follicular thyroid carcinoma with lymphovascular invasion,
which was removed initially in [**2118-12-13**]. At that
time, there was positive margins and skeletal/muscle
invasion. He had a tracheostomy placed on [**2119-8-23**] for
stridor and occlusion of his airway. He was treated by
Dr. [**Last Name (STitle) **] with a total laryngectomy with resection.
The plan was after healing to have radiation to the neck to
try to prevent the spread of thyroid carcinoma.
The patient came into the hospital and was taken to the
operating room on [**2119-9-11**], where he underwent a total
laryngectomy with resection and stoma creation and NG tube
placement. The patient tolerated the procedure well and was
taken to the Intensive Care Unit for initial recovery. He
had two J-P drains in place, one on either side, and an NG
tube in place. He was weaned quickly from ventilator support
to just stoma collar humidified air support. His calciums
were quite low initially and ionized calcium was below 1.
Endocrine became involved with his care and recommended
medication for increasing his calcium. He remained on Ancef
and Flagyl throughout his admission for pharyngeal flora. On
postoperative day #2, tube feeds were started through his NG
tube and were advanced slowly to goal, which is Promit with
fiber. Once he was at goal, he was switched to bolus tube
feeds and TPN four times a day. The patient's Foley was
removed. His calcium was continued to be checked and
corrected up into the 7 range after he was started on the
Rocaltrol and calcium carbonate. On discharge, he drained
less than 30 cc per 24 hours. Each of the J-P was removed
without any residual swelling.
The patient was taught how to administer his tube feeds and
medications and how to care for his stoma. He is to remain
NPO on tube feeds until he has followup. He was given a #8
laryngectomy tube to keep with him at all times in case of
difficulty breathing.
PAST MEDICAL HISTORY: Only positive for the follicular
thyroid carcinoma.
PAST SURGICAL HISTORY: Only significant for his total
thyroidectomy, parathyroidectomy in [**2118-12-13**]. In early
[**Month (only) **], he had a tracheostomy.
HOME MEDICATIONS:
1) Alprazolam.
2) Ambien.
3) Calcitriol.
4) Percocet.
5) Levoxyl.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient is awake, alert and
oriented times three, in no acute distress. His lungs are
clear to auscultation bilaterally. His incision is healing
well with staples with no erythema and very minimal swelling
in the area. His oropharyngeal cavity is non-swollen and
with no masses. His stoma site is clean with minimal
swelling. The J-P drain exit sites are also clean and
without erythema.
LABORATORY RESULTS: As mentioned before, his calcium at
discharge was around 7 and albumin was around 3.0. His
calcium was higher than that and then near-normal range.
OPERATIONS: As above.
COMPLICATIONS: None.
DISCHARGE MEDICATIONS:
1) Calcitriol 25 mcg twice a day.
2) Zantac elixir 150 mg two times a day.
3) Lorazepam 0.5 to 1 mg q.6 hours as needed for anxiety.
4) Roxicet elixir 5 - 10 ml q.4-6 hours p.r.n. pain.
5) Docusate sodium 100 mg twice a day.
6) Levoxyl 200 mcg once a day.
7) Flagyl 500 mg three times a day.
8) Keflex 500 mg four times a day.
All of the medications are to be given via the NG tube for
now, and the Flagyl and Keflex are to be continued until the
patient sees Dr. [**Last Name (STitle) **] in the office.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Home with VNA nursing services.
Dr.[**Name (NI) 37917**] office will call for a followup appointment.
The patient is to see Dr. [**Last Name (STitle) 9287**] from ENT in 10 to 14
days, and to call his office to set up that appointment. The
patient is to remain strict NPO until he sees Dr. [**Last Name (STitle) **]
in the office. The VNA nurses will work on stoma care and
tube feedings for the patient. They will need to draw his
blood for a calcium check in three to four days after
discharge. The patient is to be sent home with a #8
laryngectomy tube to keep with him at all times. He is to go
to his nearest emergency room if he has trouble breathing.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**MD Number(1) 11390**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2119-9-15**] 22:28
T: [**2119-9-15**] 23:19
JOB#: [**Job Number 37918**]
Name: [**Known lastname 6847**], [**Known firstname **] Unit No: [**Numeric Identifier 6848**]
Admission Date: [**2119-9-11**] Discharge Date: [**2119-9-18**]
Date of Birth: [**2061-5-27**] Sex: M
Service:
ADDENDUM: Please change the discharge date to [**2119-9-18**].
Please add to the Discharge Summary:
HOSPITAL COURSE: On postoperative day #5, the patient
continued to have a significant amount of anxiety and was not
tolerating his tube feed boluses particularly well with early
satiety. The tube feeding arrangement was decreased from
eight cans a day to seven cans a day, and this schedule as
given out per patient such that he got a full seven cans in a
day, so he began giving himself [**12-14**] cans as tolerated every
few hours while awake. Throughout the course of the day, the
patient was taught how to do his own tube feeds, taught stoma
care, and he was educated on the use of his medications. He
was weaned from a 40% mask down to room air.
On the following day, the wife was upset with the [**Name (NI) **] company
that had been set up for them. They had used this company in
the past and were not pleased with the services. Due to the
fact that it was Sunday, it was very difficult to contact any
other companies to switch the arrangement for the family so
therefore, the patient stayed until Monday, [**2119-9-18**],
when a new [**Year (4 digits) **] company could be set up by the Case Managers.
The patient is stable at this time. He is doing all of his
own tube feeds and tolerating them quite well. He is much
more comfortable breathing room air and learning how to do
his own medications.
He is discharged to home in stable condition with [**Year (4 digits) **] nursing
services once a day. He is to follow-up as previously
dictated in the discharge summary.
[**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) 1846**], M.D.
Dictated By:[**Last Name (NamePattern1) 6858**]
MEDQUIST36
D: [**2119-9-17**] 17:23
T: [**2119-9-20**] 20:13
JOB#: [**Job Number 6859**]
Name: [**Known lastname 6847**], [**Known firstname **] Unit No: [**Numeric Identifier 6848**]
Admission Date: [**2119-9-11**] Discharge Date: [**2119-9-18**]
Date of Birth: [**2061-5-27**] Sex: M
Service: .
ADDENDUM:
Please add to the prior dictation:
FOLLOW-UP INSTRUCTIONS:
1. The patient on discharge on [**2119-9-18**], has been advised
by the Endocrinology Staff at the [**Hospital1 4242**] that he should follow-up with his
endocrinologist in [**State 6529**], who is [**Doctor Last Name **] [**Doctor Last Name 6879**], at
[**Hospital1 6880**]. He has been advised to call Dr. [**Last Name (STitle) 6879**] for a
follow-up appointment once reaching home.
2. In addition, I have emailed Dr. [**Last Name (STitle) 6879**] regarding Mr.
[**Known lastname 6881**] progress in the hospital and will call her in the
morning.
[**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) 1846**], M.D. [**MD Number(1) 4800**]
Dictated By:[**Last Name (STitle) 4801**]
MEDQUIST36
D: [**2119-9-18**] 17:53
T: [**2119-9-21**] 17:51
JOB#: [**Job Number 6882**]
|
[
"197.3",
"V44.0",
"V10.87",
"252.1",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"30.3",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
4842, 5357
|
6698, 8722
|
1663, 1741
|
3912, 4052
|
4070, 4180
|
4203, 4819
|
1769, 3813
|
8746, 9571
|
3835, 3888
|
5381, 6680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,682
| 196,956
|
45266
|
Discharge summary
|
report
|
Admission Date: [**2151-9-1**] Discharge Date: [**2151-9-2**]
Date of Birth: [**2075-4-7**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin / Heparin Agents / Shellfish Derived
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
tarry stools
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Ms. [**Known firstname 10683**] [**Known lastname 13461**] is a 76 yo w with history of DM2, HTN,
ESRD on HD, moderate aortic stenosis, CAD s/p cardiac arrest who
presents with dizziness after syncopal episode at home. Patient
describes feeling weak and lightheaded for the last two to three
days. She describes passing out in her kitchen earlier this
morning. She describes feeling "faint" and the room getting
dark. She believes she only lost consciousness for a matter of
seconds. When she awoke she called for her grandson to help her
up. She then told her daughter and called her primary care
provider who instructed her to come to the Emergency Department.
.
In the ED, initial vs were: T 97.8 P 77 BP 108/49 R 19 O2 sat
100% RA. EKG was unchanged from prior and without ischemic
changes. Patient was found to have a hematocrit of 24 down from
her recent baseline of 42. On further questioning she reports a
history of black tarry stools for the last week. Rectal exam in
the Emergency Department revealed black guaiac positive stools.
She underwent NG lavage which was negative. A 22g peripheral IV
was placed in her R forearm. She was started on IV pantoprazole
bolus and drip. GI team was notified and patient was admitted to
the ICU.
.
On arrival to the ICU she remained hemodynamically stable. She
denied any chest pain, shortness of breath, abdominal pain,
nausea, vomiting or diarrhea. She denies recent use of
steroids, NSAIDS, etoh. She reports use of antibiotic for foot
infection a few weeks ago.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. Denied arthralgias or myalgias.
.
Past Medical History:
- Diabetes Mellitus (type 2)
- Hypertension
- Nonhealing L Foot ulcer followed by Podiatry
- Stage IV chronic kidney disease in the setting of type 2
diabetes mellitus and hypertension, started HD [**3-31**]
- Monoclonal gammopathy of uncertain significance with
monoclonal IgA lambda, both in the blood and urine
- Asthma
- Moderate aortic stenosis, valve area 1.0-1.2cm2 in [**3-31**]
- Chronic systolic congestive heart failure
- PEA arrest [**3-31**] s/p Artic Sun protocol
- HITT [**3-31**] diagnosed from thrombocytopenia and positive antiPF4
at [**Hospital 882**] Hospital (with DIC)
- DIC [**3-31**] possibly due to Artic Sun protocol
Social History:
She lives with her daughter [**Name (NI) 16697**] who is her health care proxy.
She denies any use of tobacco, etoh or illegal drugs. She is a
Jehovah's Witness
Family History:
No known history of CAD.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, R tunnelled IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Patient expired
Pertinent Results:
[**2151-9-1**] 11:20AM PT-13.6* PTT-29.8 INR(PT)-1.2*
[**2151-9-1**] 11:20AM PLT COUNT-253
[**2151-9-1**] 11:20AM NEUTS-65.3 LYMPHS-24.1 MONOS-4.2 EOS-6.1*
BASOS-0.3
[**2151-9-1**] 11:20AM WBC-4.4 RBC-2.68*# HGB-7.8*# HCT-24.6*#
MCV-92 MCH-29.2 MCHC-31.9 RDW-16.9*
[**2151-9-1**] 11:20AM calTIBC-231* HAPTOGLOB-96 FERRITIN-304*
TRF-178*
[**2151-9-1**] 11:20AM IRON-66
[**2151-9-1**] 11:20AM LD(LDH)-274*
[**2151-9-1**] 11:20AM estGFR-Using this
[**2151-9-1**] 11:20AM GLUCOSE-195* UREA N-67* CREAT-3.8*#
SODIUM-139 POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-33* ANION GAP-13
[**2151-9-1**] 11:37PM freeCa-1.06*
[**2151-9-1**] 11:37PM HGB-6.3* calcHCT-19
[**2151-9-1**] 11:37PM GLUCOSE-106* LACTATE-0.8 NA+-136 K+-4.2
CL--100
[**2151-9-1**] 11:37PM TYPE-ART PO2-114* PCO2-43 PH-7.44 TOTAL
CO2-30 BASE XS-5
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
5.1 2.00* 5.7* 19.3 96 28.7 29.7* 17.0* 298
Glucose UreaN Creat Na K Cl HCO3 AnGap
79 84 4.3 141 4.9 102 14 30
CTA abdomen/pelvis:
1. No evidence of active contrast extravasation.
2. Marked atherosclerotic disease involving all major
intrabdominal vessels.
3. No intra-abdominal hemorrhage.
4. Duodenum mostly collapsed.
5. Fibroid uterus.
6. Renal cysts.
EGD:
Impression: Blood in the stomach
Scope traversed 100 cm likely to 4th portion of duodenum. Red
blood note starting at 90 cm with distal bleeding visualized
reflecting a potential distal small bowel source. No AVM or
active bleed visualized in duodenal bulb or 1st, 2nd portion of
the duodenum. Otherwise normal EGD to 100 cm, likely 4th part
of the duodenum Recommendations: Red blood noted distal small
bowel likely past 90 cm reflecting a distal small bowel source
of active bleed likely AVM. Recommend repeat discussion
regarding blood transfusion, tagged red cell scan vs CTA and
angio urgently. Continue PPI gtt in the interim
Brief Hospital Course:
76 year old woman with multiple medical problems presents with
dizziness after an episode of syncope and found to have a
significant drop in hematocrit (baseline 44--->25). She was
hemodynamically stable and admitted to the ICU for monitoring.
During the night she became hypotensive with blood pressures
falling to systolic blood pressures in the 80s. Patient and
family repeatedly declined blood transfusions based on her
religious beliefs. GI team was notified adn urgent EGD was
performed at 1:00 am. Findings noted above identified source of
hemorrhage as distal duodenal but was unable to intervene.
Interventional Radiology team and surgical teams were notified.
CTA was performed in attempt to localize the bleeding vessel for
embolization. The CTA was negative and IR team saw no indication
for IR procedure. Surgical service evaluated the patient and
found her to be a very poor surgical candidate given her falling
blood pressures and hematocrit. The family was notified and
reported to her bedside. The decision was made to change her
code status to DNR/DNI and to change goals of care to comfort
care only. Patient was managed overnight in the ICU with IV
fluid boluses and a PPI IV drip. The patient's blood pressure
continued to fall and she was found to be without a pulse at
10:00 am. She was apneic, pulseless and without detectable
blood pressure or neurologic function. Time of death 10:15 am.
Family was at bedside and declined post mortem exam. Primary
care physician was notified.
Medications on Admission:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath, wheezing.
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO once a day.
5. Lactulose 10 gram/15 mL Solution Sig: [**1-23**] tablespoons PO at
bedtime.
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Multivitamin Oral
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Upper GI hemorrhage- expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
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"427.31",
"273.1",
"250.40",
"403.91",
"428.22",
"585.6",
"537.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8033, 8042
|
5580, 7094
|
320, 325
|
8114, 8123
|
3661, 5557
|
8179, 8189
|
3088, 3114
|
8004, 8010
|
8063, 8093
|
7120, 7981
|
8147, 8156
|
3129, 3642
|
268, 282
|
1899, 2225
|
354, 1881
|
2247, 2892
|
2908, 3072
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
395
| 137,967
|
16508
|
Discharge summary
|
report
|
Admission Date: [**2127-6-16**] Discharge Date: [**2127-6-28**]
Date of Birth: [**2053-5-2**] Sex: F
Service: NEUROLOGY
Allergies:
Benadryl / Iodine; Iodine Containing / Sulfa (Sulfonamides) /
Penicillins / Morphine / Ambien
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
The pt is a 74 year-old right-handed woman with multiple medical
problems who presented with alteration in consciousness.
The pt was unable to offer a history at the time of my
encounter. Therefore, the following history is per the medical
record, and the pt's daughter who was present at bedside.
The pt had been complaining to her daughter of generalized
malaise over the past two days. She had no known fever or focal
signs of infection such as cough, abdominal pain, vomiting,
diarrhea, dysuria. She had been otherwise her usual
interactive, relatively independent self. At approximately 2pm
today, she
awoke from a nap and complained to her daughter of right
temporal headache. She described the headache as sharp. At
about this time, the pt decided to check her fsbs and her
daughter noted that the pt was having difficulty managing
putting the test strips into the glucometer and appeared
confused. Her daughter helped her and her fsbs was 357. She
complained of not feeling
well, so her daughter helped her to her bedroom. There, she
became more confused and per the daughter was answering some
questions inappropriately. The daughter noted that she seemed
to be perseverating on certain answers to questions. After
another half an hour, the pt's speech became unintelligible and
she became less and less responsive to her name. Her daughter
called
EMS.
EMS reports that on their arrival, the pt was "awake, non
verbal, not following commands". They also document gaze to
left. She was taken to an OSH where she was noted to have "lip
smacking and bilateral limb jerking."
Work-up included reportedly "negative CT", normal CBC,
electrolytes notable for glucose of 317 and creatinine of 1.2.
No temperature was documented on OSH records. At the OSH, she
received 2g IV ceftriaxone, 800mg IV acyclovir, 2mg IV ativan.
She was transferred to [**Hospital1 18**] for further management.
The pt was unable to offer a review of systems.
Past Medical History:
-hypertension
-hyperlipidemia
-type II diabetes mellitus, insulin dependent, with neuropathy
-PVD s/p fem-[**Doctor Last Name **] bypass
-CAD with h/o MI
-h/o cataracts s/p removal
-h/o Barrett's esophagus
-hypothyroidism
-h/o multiple "TIAs"--symptoms were disorientation per OMR
Social History:
Pt lives with her daughter, but is fully independent in all
ADLs. Daughter describes her as "sharp". No history of
tobacco, alcohol, illicit drug abuse.
Family History:
No history of seizures or neurological disease.
Physical Exam:
Vitals: T: 101.4F pr P: 107 R: 16 BP: 168/P SaO2: 97% 3L NC
General: Lying in bed with eyes closed.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: tachycardic, RR, nl. S1S2, no M/R/G noted
Abdomen: some TTP in epigastrium noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Does not respond to verbal command but opens
eyes briskly noxious stimuli. She mutters incomprehensible
sounds. She does not follow commands.
-cranial nerves: PERRL 3 to 2mm and brisk. Funduscopic exam
technically impossible as pt firmly holds eyelids closed on
attempted examination of fundi. EOMI to oculocephalic maneuver.
Corneal reflex and nasal tickle present bilaterally. No overt
facial asymmetry. Gag reflex intact.
-motor: Normal bulk throughout. Paratonic throughout. Withdraws
briskly to noxious stimuli in all four extremities. Irregular
orobuccal movements noted (old per daughter, and attributed to
use of reglan in the past). Pt did have episodes of bilateral
limb myoclonus, occurring in each limb independently.
-sensory: Grimaces to noxious stimuli in all four extremities.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 3 4
R 3 3 3 3 4
Plantar response was extensor bilaterally.
Pertinent Results:
[**2127-6-15**] 07:35PM BLOOD WBC-10.8 RBC-4.35# Hgb-13.6# Hct-38.9#
MCV-89 MCH-31.3 MCHC-35.0 RDW-13.2 Plt Ct-561*#
[**2127-6-20**] 05:05AM BLOOD WBC-10.6 RBC-3.28* Hgb-10.1* Hct-30.1*
MCV-92 MCH-30.7 MCHC-33.4 RDW-14.1 Plt Ct-485*
[**2127-6-16**] 03:31AM BLOOD PT-13.4* INR(PT)-1.2*
[**2127-6-15**] 07:35PM BLOOD Glucose-316* UreaN-27* Creat-1.1 Na-134
K-4.5 Cl-94* HCO3-25 AnGap-20
[**2127-6-20**] 08:53AM BLOOD Glucose-141* UreaN-16 Creat-1.4* Na-140
K-3.6 Cl-110* HCO3-17* AnGap-17
[**2127-6-15**] 07:35PM BLOOD ALT-20 AST-22 CK(CPK)-47 AlkPhos-100
Amylase-30 TotBili-0.3
[**2127-6-16**] 03:31AM BLOOD Albumin-3.7 Calcium-8.0* Phos-3.3 Mg-1.6
[**2127-6-16**] 01:50AM BLOOD TSH-2.9
[**2127-6-16**] 03:31AM BLOOD Osmolal-331*
[**2127-6-16**] 11:14AM BLOOD Osmolal-299
[**2127-6-16**] 11:14AM BLOOD CRP-22.1*
[**2127-6-16**] 01:50AM BLOOD Phenyto-7.7*
[**2127-6-20**] 05:05AM BLOOD Phenyto-14.1
[**2127-6-15**] 07:35PM BLOOD ASA-5 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2127-6-15**] 11:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2127-6-15**] 11:00PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2127-6-15**] 11:00PM URINE RBC-[**3-9**]* WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2127-6-15**] 11:00PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
-----
[**2127-6-15**] 09:10PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-950*
Polys-71 Lymphs-17 Monos-12
[**2127-6-15**] 09:10PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-665*
Polys-72 Bands-1 Lymphs-23 Monos-4
[**2127-6-15**] 09:10PM CEREBROSPINAL FLUID (CSF) TotProt-51*
Glucose-152
HSV PCR neg.
----
BCx neg
UCx neg
[**2127-6-15**]:
CT HEAD W/O CONTRAST
FINDINGS: No intra- or extra-axial hemorrhage is identified.
There is no mass effect or shift of normally midline structures.
There is no hydrocephalus. Again seen is a 5 mm hypodensity in
the white matter of the left frontal lobe posteriorly consistent
with a remote lacunar infarct. The visualized paranasal sinuses
and mastoid air cells are clear. Surrounding soft tissue
structures appear unremarkable.
IMPRESSION: No evidence of intracranial hemorrhage or mass
effect.
EEG ([**2127-6-16**]):
ABNORMALITY #1: Throughout this recording the presence of
diffusely
slowed mixed frequency background rhythms in the delta and theta
range
were observed.
ABNORMALITY #2: Generalized bursts of mixed frequency delta
slowing
followed by periods of suppression were observed.
ABNORMALITY #3: There were infrequent brief bursts of sharp
theta
slowing seen over the left temporal region. No sustained
epileptiform
activity was observed.
BACKGROUND: Described as above.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No definitive sleep wake cycles were observed.
CARDIAC MONITOR: Showed a sinus tachycardia with a rate of
approximately 100 bpm.
IMPRESSION: This is an abnormal EEG due to the presence of
diffusely
slowed background rhythms along with bursts of generalized mixed
frequency delta and theta slowing. No suppressions following
these. In
addition there appears to a focal area of irritability over the
left
temporal region with frequent bursts over theta activity seen
here. No
electrographic seizures were recorded. No sustained epileptiform
activity was seen. This is most consistent with a moderate
Causes of an encephalopathy included: medications, metabolic
changes,
and infectious processes. Origin and correlation should done to
rule
out a focus in the left temporal region as sharp features were
observed
here during this recording.
EEG ([**2127-6-19**]):
FINDINGS:
ABNORMALITY #1: Throughout the recording there were frequent
bursts of
generalized mixed frequency slowing, often in the delta range.
ABNORMALITY #2: The background rhythm was slow and disorganized
typically reaching a [**6-11**] Hz maximum in most areas.
ABNORMALITY #3: There was occasional additional slowing in the
temporal
regions bilaterally followed more on the left.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal portable EEG due to the bursts of
generalized
slowing and slow background along with occasional temporal
slowing. The
first two abnormalities signify a widespread encephalopathic
condition
affecting both cortical and subcortical structures. Medications,
metabolic disturbances, and infection are among the most common
causes.
The temporal slowing raises the possibility of additional
subcortical
dysfunction in each hemisphere, but the etiology cannot be
specified by
the tracing. There were occasional sharp features but no overtly
epileptiform abnormalities.
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST ([**2127-6-23**]):
MRI BRAIN: This examination is severely limited by patient
motion. No evidence of severe hydrocephalus, large hematoma, or
herniation is seen. Evaluation of the brain parenchyma, signal
intensity, and patterns of contrast enhancement are limited
given the presence of severe motion. Scattered areas of abnormal
signal seen in the periventricular white matter and pons are
unchanged compared to [**2127-5-23**].
MRA BRAIN: Both internal carotid arteries, anterior cerebral
arteries, posterior cerebral arteries, middle cerebral arteries,
and the basilar artery are patent; however, evaluation of the
intracerebral arterial vasculature is severely limited by
patient motion.
IMPRESSION: Severely limited examination secondary to patient
motion shows no hydrocephalus, large hematoma, or herniation. If
warranted, repeat imaging could be performed (if patient motion
artifact could be improved).
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN ([**2127-6-28**]):
FINDINGS: The diffusion images demonstrate no evidence of slow
diffusion to indicate acute infarct. The ventricles and
extraaxial spaces are mildly prominent due to mild brain
atrophy. A few small foci of T2 hyperintensity are noted in the
white matter including a chronic lacune in the left corona
radiata. These findings are unchanged from the previous study of
[**2127-6-22**]. There is no evidence of acute or chronic blood products
seen. No mass effect or hydrocephalus.
IMPRESSION: Somewhat limited study due to motion.
Gadolinium-enhanced images could not be obtained as patient was
unable to continue. Unchanged appearances compared with [**2127-6-22**]
with small vessel disease and chronic left basal ganglia lacune.
No acute infarct.
Brief Hospital Course:
1. Neuro: The pt is a 74 year-old woman with multiple medical
problems who presented with fever and altered mental status. On
neurologic examination, she was profoundly encephalopathic with
episodic myoclonus and has brisk but symmetric reflexes with
ankle clonus and upgoing toes. Otherwise, there were no
lateralizing signs. The presence of fever and altered mental
status was concerning for central nervous system infection.
There was also concern for infectious and toxic-metabolic
processes. A CXR was normal. A head CT showed a 5 mm
hypodensity in the white matter of the left frontal lobe
posteriorly consistent with a remote lacunar infarct only. She
had a mildly elevated WBC ct in the serum. An LP showed 4 WBCs
and 600-950 RBCs. Protein was slightly elevated and glucose was
normal. Gram stain was negative. She was started on Vancomycin,
ampicillin, acyclovir (with IVF bolus to prevent ARF), and
ceftriaxone.
She was initially admitted to the ICU for close monitoring. She
was initially very confused and agitated without verbal output.
She then slowly improved over the next several days, gradually
speaking more and following more commands. She became more
oriented to her surroundings and less agitated.
The antibiotics were stopped after cultures were negative for 3
days. The acyclovir was stopped after her HSV returned
negative. Tox screens showed only + opiates which she is on at
home. Opiate overdose was considered, but not consistent with
her presentation.
She had an EEG which showed generalized slowing and a focal area
of irritability over the left temporal region with frequent
bursts over theta activity and sharp features. It was
ultimately postulated that her presentation was likely due to
seizure. She had no observed seizure activity. She was on
dilantin for most of the hospital stay, but she easily developed
toxic levels. She was therefore switched to keppra prior to
discharge. Two MRIs were performed in attempt to identify
seizure focus, but the pt was unable to tolerate these studies
very well due to underlying anxiety and superimposed tardive
dyskinesia. Therefore, no clear seizure focus was elucidated.
She will follow-up in [**Hospital 878**] Clinic after discharge.
2. CAD/HTN:We continued her home Plavix and ASA. Her
antihypertensives were initially held, but were then restarted
when her BP began to be elevated. These were norvasc and
metoprolol. She was also started on a clonidine patch. This
controlled her BP well.
3. Endocrine: She was continued on her home levoxyl. She was
also continued on glargine and RISS without problems. She was
initially hyperglycemic, and serum osms were checked and
returned at 331. Hyperosmolar coma was considered, but her
glucose was not high enough for this diagnosis. A repeat osm ~6
hours later, after glucose was corrected was normal at 290.
4. Funguria: The pt was found to have yeast in the urine. She
was treated with a 7 day course of oral fluconazole.
5. Clostridium difficile gastroenteritis: The pt complained of
nausea and abdominal pain once her mental status cleared. She
developed diarrhea which was positive for c.diff. She was
treated with a fourteen day course of metronidazole, to be
completed as an outpatient.
6. Anemia: The pt did have a slight drop in her hematocrit and
was found to have guaiac positive stool. She did require a
transfusion of one unit of PRBCs. Gastroenterology was called
and they felt that further work-up could be done on an
outpatient basis after her hematocrit stabilized following
transfusion.
7. Anxiety: The pt was seen by the psychiatry service as she had
complaints of worsening anxiety. They recommended discontinuing
effexor, buspar and amitriptyline and starting seroquel. She
responded well to this change.
8. ARF: The pt had a slight bump in her creatinine to 1.4 after
treatment with acyclovir which normalized after aggressive IVF
and discontinuation of this drug.
Medications on Admission:
-lipitor 10mg po daily
-gabapentin 600mg po tid
-ASA 81mg po daily
-protonix 40mg po daily
-effexor 75mg po daily
-buspirone 5mg po bid
-insulin glargine and humalog sliding scale
-levothyroxine 25mg po daily
-plavix 75mg po daily
-amitriptyline 50mg po qhs
-vicodin prn
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days: Take one tablet per day for three days, then
take one tablet [**Hospital1 **] for three days, then take one tablet in the
morning and two tablets in the evening for three days, then take
two tablets [**Hospital1 **] thereafter.
Disp:*120 Tablet(s)* Refills:*2*
11. Insulin
Please continue your insulin regimen as prior to admission
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
Discharge Diagnosis:
-probable seizure
-hypertension
-diabetes mellitus
-funguria
-clostridium difficile enterocolitis
Discharge Condition:
Stable. Neurologic examination notable for orobuccal dyskinesias
but otherwise normal.
Discharge Instructions:
Please call your primary care physician or return to the
emergency room if you experience loss of consciousness, limb
shaking, new onset numbness or weakness, difficulty speaking,
difficulty walking, or other concerning symptoms. Please
continue all medications as prescribed and attend all follow-up
appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) 9977**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-7-22**] 2:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-9-17**]
10:30
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-9-17**]
11:00
Please follow-up with your primary care doctor within 7-10 days
after discharge.
Neurology: Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 575**] at [**Hospital1 18**] [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) 858**]. [**2127-9-28**] at 4pm.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"357.2",
"272.4",
"443.9",
"401.9",
"780.39",
"285.9",
"250.60",
"244.9",
"117.9",
"300.00",
"584.9",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"96.6",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
16710, 16758
|
10983, 14938
|
363, 381
|
16900, 16989
|
4332, 10960
|
17352, 18031
|
2858, 2907
|
15260, 16687
|
16779, 16879
|
14964, 15237
|
17013, 17329
|
3520, 4313
|
2922, 3343
|
314, 325
|
409, 2365
|
3358, 3502
|
2387, 2669
|
2685, 2842
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,291
| 119,487
|
7760
|
Discharge summary
|
report
|
Admission Date: [**2140-12-3**] Discharge Date: [**2140-12-16**]
Date of Birth: [**2097-6-28**] Sex: M
Service: SURGERY
Allergies:
Penicillin G
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Failure to thrive/hepatic lesions
Major Surgical or Invasive Procedure:
Exploratory laparotomy [**2140-12-6**]
CT guided drainage [**2140-12-12**]
History of Present Illness:
Pt is a 43M with a history of chronic pancreatitis who is
s/p Partial pancreatic head resection, pancreaticojejunostomy,
right and left hepaticojejunostomy, cholecystectomy and feeding
jejunostomy [**10/2132**] (Dr. [**Last Name (STitle) 1305**]. He was admitted to [**Hospital 1474**]
Hospital 10/11-19/07 with fevers, chills, sweats, and elevated
blood sugars in the 300s. At that time denied abdominal pain.
His WBC was 20.4 and HCT 31.7. He was diagnosed with and
treated
for PNA. He had a CT of the abdomen which, by report, showed a
"portal vein thrombus without evidence of hepatic mass.
Gallbladder is irregular in attenuation and contour with a small
amount of fluid surrounding the gallbladder. Pancreas is
calcified though not well seen." He was started on Coumadin.
Hepatitis panels were negative. LFTs were normal. Sputum
cultures were negative. He was discharged home [**2140-11-4**], though
again felt unwell several days after discharge.
He presented to the [**Hospital1 18**] ED on [**2140-12-3**] with c/p epigastric
pain
radiation to his back intermittently for the past few months.
CT
scan in the ED demonstrated multiple liver lesions, and he was
subsequently admitted to the medical service.
He states that he has been feeling unwell for several months,
with fatigue and weight loss over that time amounting to about
50
pounds of weight loss. He has had the progressive abdominal pain
that goes to his back that has been persistent over that time.
He
states that the pain in the abdomen and back feels distinct from
his old pain he had with chronic pancreatitis in that it is
higher and of slightly different quality. The pain does not seem
to get better or worse with deep inspiration, and it seems to be
unchanged with eating. At the time of this note, patient denies
pain.
Past Medical History:
1. chronic pancreatitis
2. DM, insulin dependent
3. back pain
Social History:
smoked [**1-19**] ppd. Drinks occasional EtOH. Single, has one
daughter. [**Name (NI) 1403**] in excavation.
Family History:
Mother and father both with CAD
Physical Exam:
Physical Exam:
Vitals: T 99.0 BP 140/88 P 106 RR 18 100% on RA
General: Cachectic appearing male, uncomfortable, sleepy but
arousable, in NAD
HEENT: NCAT, PERRL, dry MM
Neck: supple, no JVD
Chest: Pt not cooperative with exam, bases rhonchorus
CV: tachycardic, nl s1s2
Abdomen: +BS, soft, nontender, umbilical hernia nontender
Ext: wasted appearing, decreased muscle tone, scaling skin, 2+DP
pulses
Pertinent Results:
[**2140-12-3**] 12:30PM PT-26.2* PTT-49.7* INR(PT)-2.7*
[**2140-12-3**] 12:30PM PLT COUNT-756*#
[**2140-12-3**] 12:30PM NEUTS-85.1* LYMPHS-10.4* MONOS-4.0 EOS-0.4
BASOS-0.2
[**2140-12-3**] 12:30PM WBC-19.8*# RBC-3.35* HGB-10.4* HCT-30.2*
MCV-90 MCH-31.0 MCHC-34.4 RDW-16.0*
[**2140-12-3**] 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-12-3**] 12:30PM ALBUMIN-2.6* CALCIUM-8.7 PHOSPHATE-5.3*
MAGNESIUM-2.8*
[**2140-12-3**] 12:30PM CK-MB-6 cTropnT-<0.01
[**2140-12-3**] 12:30PM LIPASE-6
[**2140-12-3**] 12:30PM ALT(SGPT)-50* AST(SGOT)-75* LD(LDH)-140
CK(CPK)-101 ALK PHOS-400* AMYLASE-6 TOT BILI-0.6
[**2140-12-3**] 12:30PM estGFR-Using this
[**2140-12-3**] 12:30PM GLUCOSE-39* UREA N-33* CREAT-1.6* SODIUM-128*
POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-26 ANION GAP-15
[**2140-12-3**] 09:44PM GLUCOSE-244* UREA N-24* CREAT-1.3*
SODIUM-129* POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-21* ANION GAP-15
[**2140-12-3**] 10:00PM LACTATE-1.4
[**2140-12-3**] 10:00PM TYPE-[**Last Name (un) **]
[**2140-12-3**] 11:10PM URINE HYALINE-0-2
[**2140-12-3**] 11:10PM URINE RBC-[**3-21**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**3-21**]
[**2140-12-3**] 11:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.0
LEUK-NEG
[**2140-12-3**] 11:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.034
[**2140-12-16**] 05:45AM BLOOD WBC-12.5* RBC-2.67* Hgb-8.0* Hct-24.3*
MCV-91 MCH-29.9 MCHC-32.8 RDW-16.2* Plt Ct-656*
[**2140-12-6**] 03:03PM BLOOD Neuts-90* Bands-3 Lymphs-2* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2140-12-16**] 05:45AM BLOOD Plt Ct-656*
[**2140-12-16**] 05:45AM BLOOD Glucose-176* UreaN-16 Creat-0.9 Na-133
K-4.0 Cl-101 HCO3-25 AnGap-11
[**2140-12-16**] 05:45AM BLOOD ALT-92* AST-72* AlkPhos-207* TotBili-0.4
[**2140-12-15**] 04:51AM BLOOD Lipase-7
[**2140-12-16**] 05:45AM BLOOD Albumin-2.2* Calcium-7.8* Phos-3.8 Mg-2.0
[**2140-12-13**] 08:21AM BLOOD calTIBC-95* Ferritn-1641* TRF-73*
.
[**2140-12-5**] 3:15 pm ABSCESS ABSCESS.
**FINAL REPORT [**2140-12-9**]**
GRAM STAIN (Final [**2140-12-5**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 1141**] [**Last Name (NamePattern1) 17910**] @ 8PM ON [**2140-12-5**].
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
WOUND CULTURE (Final [**2140-12-8**]):
STREPTOCOCCUS MILLERI GROUP. MODERATE GROWTH.
ANAEROBIC CULTURE (Final [**2140-12-9**]): NO ANAEROBES ISOLATED.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 28135**],[**Known firstname **] [**2097-6-28**] 43 Male [**-7/4579**] [**Numeric Identifier 28136**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 395**]/dif
SPECIMEN SUBMITTED: LIVER.
Procedure date Tissue received Report Date Diagnosed
by
[**2140-12-6**] [**2140-12-6**] [**2140-12-14**] DR. [**Last Name (STitle) **]. BROWN,DR. [**Last Name (STitle) **].
[**Doctor Last Name 7001**]/cma??????
Previous biopsies: [**Numeric Identifier 28137**] GALLBLADDER, BILE DUCT,
PANCREAS & JEJUNUM/sr.
DIAGNOSIS:
I. Liver, permanent (A-C):
A. Focal necrosis, acute and chronic inflammation with abscess
formation and granulation tissue.
B. Focal residual entrapped hepatocytes with fatty change and
reactive changes.
C. Iron and trichrome stains evaluated.
II. Liver biopsy (D-F):
A. Focal necrosis, acute and chronic inflammation with abscess
formation and granulation tissue.
B. Focal residual entrapped hepatocytes with fatty change and
reactive changes.
Clinical: Chronic pancreatitis, abdominal pain.
Gross: The specimen is received fresh in two parts, both
labeled with "[**Known firstname **] [**Known lastname **]" and the medical record number.
Part 1 is additionally labeled "permanent liver" and consists of
a fragment of red tan tissue measuring 3 x 4 x 0.4 cm. The
fragment appears to be a portion of a cystic cavity with minimal
attached normal liver. The specimen is serially sectioned
revealing focally hemorrhagic to dark brown tissue, and
otherwise an unremarkable cut sections. The specimen is entirely
submitted in A-C.
Part 2 is additionally labeled "liver" and consists of fragments
of tan brown tissue measuring 2.5 x 2.0 x 0.4 cm. A portion of
the lesion was frozen with a frozen section diagnosis by Dr. [**Last Name (STitle) **].
[**Doctor Last Name 10165**] of: "Dense acute and chronic inflammation with necrosis.
No carcinoma seen." The specimen is entirely submitted as
follows: D = frozen section remnant, E-F = remainder of tissue.
Studies:
CTA CAP: IMPRESSION:
1. Multiple low-attenuation lesions seen scattered throughout
the liver, concerning for metastasis, or possibly abscesses. No
primary lesion identified.
2. Post surgical changes of the pancreas. No normal pancreatic
tissue seen in expected location of pancreatic head and uncinate
process--correlate with prior surgical history.
3. Edematous colon seen, nonspecific, and may relate to
infection, inflammation, vascular outflow obstruction. Portal
vein, mesenteric veins, splenic vein not assessed on this
arterial-phase study.
4. No evidence aortic dissection or abdominal aortic aneurysm.
No evidence of pulmonary embolism.
5. Suspicious sclerotic focus in left iliac. Compression
deformities of T4 and T6, of uncertain chronicity. Possible
lytic lesion in T6. Given findings in the liver, metastases
should be considered in these lesions and pathologic fractures.
6. Multiple subcentimeter nodular densities in the left upper
lobe. With presumed malignancy, three-month followup is
recommended to assess stability.
7. Mucous plugging, left upper lobe.
ECHO [**12-12**]
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral and
tissue Doppler imaging suggests normal diastolic function, and a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
descending thoracic aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No valvular pathology or pathologic flow identified. Mild
pulmonary artery systolic hypertension.
Brief Hospital Course:
The patient was admitted on [**12-3**] for evaluation and treatment
of his symptoms above to the medicine service. He was placed on
IV fluids, telemetry, empiric antibiotics, and closely
monitored. CT and ultrasound scans were obtained.
On [**12-5**] the patient was triggered for tachycardia, fever to
102/3. Transplant surgery was consulted and recommended IR
drainage of all identified abscesses and leaving drains in
place. IR aspirated 80 cc of fluid from the liver but did not
leave a drain in place.
[**12-6**]- Meropenem started, vancomyocin continued, cipro/flagyl
discontinued. Patient taken to the operating room for an
exploratory laparotomy, drainage of intrahepatic abscess, and
debridement of necrotic liver tissue. He was transferred to the
ICU intubated, for close monitoring.
[**12-7**]- patient was weaned from ventilatory support and exubated.
TPN was started to replenish the patient's poor nutritional
status.
[**12-8**]- the patient was transferred to from the ICU to the floor
for continued monitoring and rehabilitation.
[**12-9**]- NGT and foley catheter discontinued, patient voiding
spontaneously; started on clear liquid diet [**12-10**]
Antibiotics and TPN were continued and physical therapy was
consulted to help in ambulation of the patient.
[**12-12**] CT guided drainage of fluid; echo cardiogram performed.
[**12-14**] PICC line placed for transition to home/rehab IV
antibiotics.
[**12-15**] antibiotics changed to ceftriaxone 2gm IV q 24hr.
[**12-16**] TPN weaned and stopped. Rehab cleared patient for home.
Patient will be discharged to his mother's house where he will
receive nursing assistance for IV antibiotics, drain teaching
and insulin teaching.
Medications on Admission:
Humolog 54 units qam
Coumadin 1mg qday
Levalbuterol prn
Percocet prn
Xanax prn
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Ruptured hepatic abscess
portal vein thrombosis
Discharge Condition:
Fair
Discharge Instructions:
Please call your doctor or return to the nearest emergency room
if you have a fever greater than 101.5 F, increased abdominal
pain, nausea, vomiting, decreased oral intake, weight loss,
increasing purulent drainage from the drain or any other symptom
that may concern you.
Please record the drain output daily and empty daily.
You will need blood work twice per week (Chem 7, transaminases,
bilirubin, INR) and have these results faxed to the infectious
disease department at [**Telephone/Fax (1) 1419**].
You have been started on insulin due to high blood sugars. You
may have these followed by your local primary physician or by
the [**Hospital **] clinic here within 1-2 weeks to have your insulin
adjusted. Please call ([**Telephone/Fax (1) 3537**] to make an appointment for
[**Last Name (un) **]. Please record your blood sugars daily.
Please adhere to the following sliding scale
0-70 Juice
71-80 0 units
81-120 2 units
121-160 4 units
161-200 6 units
201-240 8 units
241-280 10 units
281-320 12 units
>320 notify MD
You are also being re-started on Coumadin (a blood thinner).
You will need your INR checked prior to your appointment with
Dr. [**First Name (STitle) **] next week.
Followup Instructions:
Please call the department of Infectious Disease to make an
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] at ([**Telephone/Fax (2) 4170**]Provider:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2140-12-23**] 3:20
Completed by:[**2140-12-16**]
|
[
"577.1",
"423.9",
"571.49",
"783.7",
"571.1",
"038.0",
"303.91",
"276.51",
"572.0",
"238.71",
"452",
"995.91",
"584.9",
"250.80",
"285.29",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.12",
"38.93",
"54.91",
"50.91",
"99.04",
"99.15",
"50.0"
] |
icd9pcs
|
[
[
[]
]
] |
11705, 11774
|
9864, 11575
|
306, 383
|
11866, 11873
|
2923, 9841
|
13118, 13485
|
2454, 2488
|
11795, 11845
|
11601, 11682
|
11897, 13095
|
2518, 2904
|
233, 268
|
412, 2223
|
2245, 2309
|
2325, 2438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,385
| 155,935
|
41868
|
Discharge summary
|
report
|
Admission Date: [**2191-12-13**] Discharge Date: [**2192-1-14**]
Date of Birth: [**2142-12-9**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2191-12-14**] Exploratory laparotomy, drainage of
subdiaphragmatic bilateral abscess, drainage of pelvic
abscess, drainage of pericolic gutter abscess both on the
right and left side. Drainage interloop abscess.
[**2191-12-16**] 1. Exploratory laparotomy.
2. Washout, drainage interloop abscess and component
separation.
3. Ventral hernia repair with mesh. (open abdomen)
[**2191-12-22**] Exploratory laparotomy, abdominal washout.
[**2191-12-25**] Exploratory laparotomy, Hartmann's procedure, and rigid
sigmoidoscopy for distal sigmoid perforation
PICC line placement [**2191-12-21**]
Picc Left side placed [**2192-1-4**]
Paracentesis [**2192-1-3**]
Post pyloric feeding tube [**2191-12-20**]
2 Pigtail drains placed [**2192-1-4**]
abdominal wound vac placed [**2191-12-30**]
History of Present Illness:
49 year old female with recently diagnosed alcoholic
cirrhosis and transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for abdominal pain.
Patient has been complaining of intermittent abdominal pain for
the past 4 weeks. This has been getting progressively worse for
the past 3-4 days, diffuse and sharp in nature. Associated with
fevers, chill, decreased urine output and diarrhea x 4 days. She
was diagnosed with ESLD about 3 months ago without h/o SBP. She
states she was drinking 6 glasses of wine a day, but has not
been
drinking for the past weeks. She went to OSH yesterday, she was
noted to have leukocytosis with WBC 30.8, was given
vancomycin/zosyn and transferred to the MICU at [**Hospital1 18**]. In the
MICU patient had diagnostic tap which showed 6000 WBC, 85 polys
and the culture is growing GNRs. She was treated empirically for
SBP and transferred to the floor as she was hemodinamically
stable. Given worsening abdominal pain and tenderness a CT was
done showing diffuse loculated free air concerning for
pneumatosis and visceral perforation.
ROS:
(+) per HPI
(-) Denies unexplained weight loss, bleeding, syncope,
paresthesias, nausea, vomiting, hematemesis, melena, BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
Past Medical History: Asthma, alcoholic cirrhosis
Past Surgical History: Appendectomy at age 19
Social History:
- Tobacco: [**1-16**] pack per day, extensive history
- Alcohol: 6 drinks per day, last drink 1 week ago
- Illicits: Denies
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: VS T 98.7 HR 97 115/54 RR 20 97%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Distended, tense with diffuse tenderness to palpation.
Positive guarding and slight rebound on left flank.
Ext: No LE edema, LE warm and well perfused
Laboratory:
Lactate:2.0
136 101 80
-------------< 103
2.7 17 1.9
Ca: 8.3 Mg: 1.8 P: 4.2
ALT: 11 AP: 92 Tbili: 1.8 Alb:
AST: 37
19.8 > 30.0 < 126
PT: 18.3 PTT: 54.0 INR: 1.7
Imaging:
RUQ U/S:
1. Coarse echotexture and lobulated contour of the liver,
suggestive of cirrhosis. No discrete hepatic lesion is
identified.
2. CBD is dilated measuring up to 11 mm in maximum diameter. No
biliary stone is visualized.
3. Moderate-to-large amount of ascites within the abdomen with
increased echogenicity and internal septations.
CT A/P (prelim):
1. Diffuse intra-abdominal ascites and free air with areas of
loculated air (also possibly pneumatosis)consistent with
perforated viscous. Small bowel appears thickened (image 2:63)
which in the setting of ascites may be a result of portal
hypertension, however the constellation of findings indicates
visceral perforation possibly on the basis of ischemia. The
exact
area of perforation is unable to be determined.
2. Bilateral pleural effusions
3. No evidence of hydronephrosis or nephrolithiasis.
[**2192-1-3**] 2:45 pm ABSCESS LEFT POVACOLIC AREA.
GRAM STAIN (Final [**2192-1-3**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2192-1-6**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
YEAST, PRESUMPTIVELY NOT C. ALBICANS.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS. IDENTIFICATION PERFORMED PER DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**]
[**2192-1-11**].
Pertinent Results:
[**2191-12-12**] 10:45PM BLOOD WBC-25.6* RBC-3.49* Hgb-11.5* Hct-34.3*
MCV-98 MCH-32.9* MCHC-33.4 RDW-13.0 Plt Ct-192
[**2192-1-12**] 08:15AM BLOOD WBC-13.3*# RBC-3.58*# Hgb-11.1*#
Hct-33.1*# MCV-93 MCH-30.9 MCHC-33.4 RDW-16.9* Plt Ct-225#
[**2192-1-12**] 05:50AM BLOOD PT-20.7* PTT-28.0 INR(PT)-2.0*
[**2192-1-12**] 05:50AM BLOOD Glucose-113* UreaN-15 Creat-0.4 Na-140
K-3.4 Cl-110* HCO3-25 AnGap-8
[**2192-1-12**] 05:50AM BLOOD ALT-14 AST-28 AlkPhos-116* TotBili-1.2
[**2192-1-12**] 05:50AM BLOOD Albumin-2.1* Calcium-7.6* Phos-2.4*
Mg-1.9
[**2191-12-13**] 03:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2192-1-11**] 09:30AM BLOOD Vanco-17.9
[**2191-12-12**] 11:00 pm PERITONEAL FLUID
**FINAL REPORT [**2191-12-17**]**
GRAM STAIN (Final [**2191-12-13**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85896**] CC6C [**Numeric Identifier 43205**] @
0204 ON
[**2191-12-13**].
FLUID CULTURE (Final [**2191-12-16**]):
ESCHERICHIA COLI. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2191-12-17**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
Time Taken Not Noted Log-In Date/Time: [**2192-1-1**] 2:42 pm
URINE Site: NOT SPECIFIED
**FINAL REPORT [**2192-1-2**]**
URINE CULTURE (Final [**2192-1-2**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2192-1-3**] 1:33 pm ABSCESS Source: paracolic gutter abscess.
GRAM STAIN (Final [**2192-1-3**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. RARE
GROWTH.
Fluconazole SENSITIVITY PERFORMED PER DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**]
[**2192-1-11**].
BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final [**2192-1-10**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
49 F with h/o ETOH abuse and newly diagnosed cirrhosis,
presented from outside hospital with abdominal pain, found to
have SBP. She was admitted to the MICU and started on Ceftaz.
Creatinine was acutely elevated and she was acidotic. Lactate
was 2.3 in the ED. This was most likely secondary to
hypoperfusion in the setting of infection. Patient received 2L
of crystalloid in the ED. Liver US demonstrated dilated CBD
measuring up to 11 mm in maximum diameter without stone. There
was moderate-to-large amount of ascites with septations.
Surgery was consulted for rising lactate, worsening abdominal
pain and tenderness. CT showed diffuse loculated free air
concerning for pneumatosis and visceral perforation. On
[**2191-12-14**], she was taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for free
air and suspected perforation. Exploratory laparotomy, drainage
of subdiaphragmatic bilateral abscess, drainage of pelvic
abscess, drainage of pericolic gutter abscess both on the right
and left side. Drainage interloop abscess. Postop, she was
managed in the SICU. She was taken back to the OR on [**2191-12-16**] for
exploratory laparotomy, washout, drainage interloop abscess and
component separation and ventral hernia repair with mesh.
Postop, she went back to the SICU, weaned off pressors and was
extubated. A post pyloric dobhoff was placed and restaints
placed as pt attempted to remove dobhoff. PICC line was placed
on [**12-21**]. Psych was consulted for agitation/confusion. Zyprexa
was recommended.
On [**12-22**] she went back to OR for ex-lap, abd was left open, as
source of leak was not identified. 2RBC, 2FFP, and 1400 NS were
required. She became hypotensive and tachycardic. Albumin, NS
bolus and levophed were given. Hct improved to 32.
Abdomen was closed on [**12-25**] (fascia closed with interposition
mesh, skin closed with staples)end colostomy when a
recotosigmoid leak was identified. She was extubated, continued
on TPN, started on vancomycin again.
She was transferred to the floor on [**12-28**]. On [**12-30**] a wound vac
was placed to promote granulation and healing since her wound
began to dehisce. On [**12-23**] ortho was consulted for recent h/o
shoulder fracture. Xrays were done (right humeral fx)and
non-operative management was recommended. By [**1-2**] the wound was
completely open and vac remained in place. she was briefly
started on TPN and then on TFs which she is leaving on. She was
sent to IR to tap fluid collection in abdomen which were d'c'ed
on [**1-8**] (R) and [**1-14**] (L). She was spiking fevers w/
leukocytosis until [**1-12**]. Her WBC count remains high, but is
currently afebrile and on azithromycin for mycoplasma grown from
a wound culture and fluconazole for [**Female First Name (un) **] from a wound
culture. She is also on zosyn for empiric gram negative
coverage.
#EtOH Abuse: Patient with history of EtOH abuse. Has not had
significant withdrawal episodes in the past. Last drink was 5
days ago. Patient most likely outside of the window for DT.
-CIWA precaution
-Thiamine, folate, multivitamin
-Social work consult
Medications on Admission:
Albuterol prn, Ibuprofen prn
Discharge Medications:
1. Outpatient Lab Work
Twice Weekly (Monday and Friday)
cbc, chem 10, ast, alt, alk phos, t.bili, albumin, pt/inr, ptt
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
5. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezes.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
7. insulin regular human 100 unit/mL Solution Sig: see sliding
scale Injection ASDIR (AS DIRECTED).
8. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain: do not give more than 2000mg per
day.
9. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours).
10. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours).
11. micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
12. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
13. famotidine(PF) in [**Doctor First Name **] (iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours).
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
15. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) dose Intravenous Q8H (every 8 hours).
16. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
17. azithromycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
18. fluconazole in NaCl (iso-osm) 200 mg/100 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours).
19. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
rectosigmoid perforation
[**Doctor Last Name **] procedure
peritonitis, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
abdominal abscess
uti, yeast
abdominal wound
malnutrition
anemia
bilateral pleural effusions
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if any of the warning
signs listed below
Patient will followup with ID in 2 weeks and she needs a CT scan
of her abdomen with PO contrast prior to this appt.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2192-1-23**] 9:00
Provider: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2192-1-24**] 1:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2192-2-15**]
11:00
|
[
"305.1",
"493.90",
"572.2",
"567.23",
"112.2",
"293.0",
"572.4",
"041.49",
"V54.11",
"V49.87",
"567.22",
"112.89",
"569.83",
"263.9",
"571.2",
"276.52",
"303.91",
"562.10",
"584.5",
"789.59",
"553.21",
"041.3",
"572.8",
"998.32",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.10",
"45.76",
"54.12",
"99.15",
"48.23",
"54.19",
"38.97",
"53.61",
"54.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13654, 13725
|
8232, 11371
|
319, 1104
|
14000, 14000
|
4711, 7744
|
14423, 14883
|
2724, 2743
|
11450, 13631
|
13746, 13979
|
11397, 11427
|
14178, 14400
|
2541, 2566
|
2773, 4401
|
264, 281
|
1132, 2445
|
4440, 4692
|
14015, 14154
|
2489, 2518
|
2582, 2708
|
7779, 8209
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,025
| 183,954
|
44913+44914
|
Discharge summary
|
report+report
|
Admission Date: [**2187-9-27**] Discharge Date: [**2187-9-28**]
Date of Birth: [**2142-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 45 male with cardiac history significant for
diabetes, hypertension and dyslipidemia with non-obstructive
coronaries in [**2184**] presents with 4 day history of intermittent
substernal chest pressure associated with exertion. He also
reports 4 day history of left chest wall muscle strain. He also
reports one year history of dizziness associated with getting up
too quickly.
.
On the floor, he reports no chest pain/discomfort, shortness of
breath, nausea, presycope or syncope.
Past Medical History:
DIABETES, TYPE II
HYPERCHOLESTEROLEMIA
MORBID OBESITY
ATYPICAL CHEST PAIN [**11/2181**]
?ATTENTION DEFICIT DISORDER [**2182**]
HX PROSTATITIS
LATERAL EPICONDYLITIS
S/P RIGHT KNEE ARTHROSCOPY
S/P LEFT INGUINAL HERNIA REPAIR
RESTLESS LEG SYNDROME [**2182**]
MULTIPLE UTI'S
Social History:
The patient works at [**Company 6692**] Airport driving a vehicle for UPS.
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
No family history of premature coronary artery disease
Physical Exam:
Tm: 98.8 P:74-101 BP:115-140/69-91 RR:18-20 O2sat: 90-95%RA
Gen: Obese male in no acute distress
Neck: Supple neck.
Chest: TTP @ left chest wall. Appropriate chest wall rise with
inspiration. Clear to auscultation bilaterally. No
crackles/wheezing
Abdomen: Soft, nontender and nondistended.
External: No edema
Skin: Hyperpigmentation @ b/l elbows and neck. No ulcers
Neuro: Alert and oriented x 3. CN 2-12 grossly intact
Pertinent Results:
Pertinent Labs
[**2187-9-27**] 07:35PM BLOOD WBC-8.5 RBC-4.51* Hgb-11.9* Hct-35.4*
MCV-79* MCH-26.4* MCHC-33.6 RDW-15.7* Plt Ct-157
[**2187-9-27**] 07:35PM BLOOD Neuts-59.4 Lymphs-35.9 Monos-2.7 Eos-1.7
Baso-0.3
[**2187-9-27**] 07:35PM BLOOD PT-12.8 PTT-22.2 INR(PT)-1.1
[**2187-9-27**] 07:35PM BLOOD Glucose-81 UreaN-12 Creat-1.1 Na-138
K-3.5 Cl-103 HCO3-25 AnGap-14
.
[**2187-9-27**] 07:35PM BLOOD CK(CPK)-124
[**2187-9-28**] 02:00AM BLOOD CK(CPK)-105
[**2187-9-28**] 09:25AM BLOOD CK(CPK)-103
.
[**2187-9-28**] 02:00AM BLOOD CK-MB-2 cTropnT-<0.01
.
Pertinent Reports
CXR ([**2187-9-27**])
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Patient is a 45 male with cardiac history significant for
diabetes, hypertension and dyslipidemia with non-obstructive
coronaries in [**2184**] presents with 4 day history of atypical chest
pain.
.
#. Atypical chest pain: Musculoskeletal vs demand ischemia. With
non-obstructive coronaries on cath in [**2184**], unlikely to have
significant CAD. His EKG showed TWI in V2 and V3 which were new
compared to previous EKG which are likely benign. Troponins
negative x 2. Chest pain reproducible on palpation and improved
with ibuprofen during his hospital stay so likely due to
musculoskeletal strain. Will give ibuprofen 400 mg po TID x
five days for musculoskeletal strain.
.
Will increase his Toprol XL to 100 mg qdaily to see if it is
anginal pain. Continue imdur 30 mg po qdaily.
.
#. Hypertension: Amlodipine, lisinopril and imdur were continued
while Toprol XL was increased to 100 mg qdaily.
.
# Hyperlipidemia: Simvastatin 80 mg po qdaily was continued.
.
# Diabetes Mellitus: Well controlled with sliding scale insulin
Medications on Admission:
aspirin 81 mg a day
Toprol-XL 50 mg daily
lisinopril 5 mg daily
amlodipine 2.5 mg daily
simvastatin 80 mg daily
imdur 30 mg daily
insulin (U500 25 units in AM and 25 units in PM)
Fluoxetine 30 mg daily
Discharge Medications:
1. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*15 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Fluoxetine 20 mg Capsule Sig: 1.5 Capsules PO DAILY (Daily).
9. Insulin
Insulin U-500. 35 U at breakfast and with dinner.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Musculoskeletal pain
.
Secondary Diagnosis
Hypertension
Hyperlipidemia
Diabetes Mellitus Type 2
Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you had chest pain. You
electrocardiogram and blood test for heart attack were negative.
You were started on a medication called IBUPROFEN to help with
your muscle strain.
.
Following medication changes were made to your regimen:
INCREASE TOPROL XL to 100 mg by mouth once a day
START IBUPROFEN 400 mg three times by mouth for five days
.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2187-10-23**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2187-11-28**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
Admission Date: [**2187-9-28**] Discharge Date: [**2187-10-7**]
Date of Birth: [**2142-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 45 year old male with history of HTN, HL, Type II
DM, and morbid obesity who presents with chest pain and syncope.
Patient notes onset of chest pain while doing outside work
about 5 days prior to current admission. He reports spending 8
hours per day sitting in a [**Doctor Last Name **] for the 2 days prior to the onset
of his symptoms.
Pain was substernal, pleuritic in nature, non-radiating, and
associated with dyspnea. Patient presented to the ED on [**2187-9-27**]
and was admitted for further evaluation. Was found to have TWI
in V2 and V3 which were new compared to previous EKG, CE were
negative X2, was felt to have musculoskeletal chest pain based
on reproducability and was discharged on [**9-28**] with recs for
Ibuprofen and increased toprolol dosage.
Patient notes that upon return home, pleuritic chest pain
recurred, with worsening dyspnea as he climbed one flight of
stairs. He reports collapsing on couch and losing
consciousness. He lives with his mother, and she did not note
any seizure-like activity. He had no loss of bowel or bladder
control. He was unconscious for "a few minutes", after which
time EMS was called, and the patient was transferred back to the
ED.
.
In the ED, initial VS were 98 112/59 98 19 82% RA -> 92% on
100% NRB. CTA chest obtained showed bilateral PEs. Patient was
guaiac (-), and was started on heparin gtt and transferred to
the ICU.
Past Medical History:
1. Diabetes type 2.
2. Hypertension.
3. Hypercholesterolemia.
4. Morbid obesity.
5. Iron deficiency anemia.
6. Chest pain with a negative cardiac catheterization in [**Month (only) 359**]
[**2185**], however slow flow c/w microvascular disease
7. Mild diastolic and focal systolic left ventricular
dysfunction with 1+ MR seen on cath\
8. Depression with h/o SI
Social History:
Retired in [**2187-4-16**] previously worked at [**Location (un) 6692**] Airport driving
a vehicle for UPS.
Tobacco: Denies
EtOH: social
Illicits: quit using cocaine in [**2181**]
Family History:
Mother with DVT after long car ride. Mother with history of
breast cancer. Brother diagnosed with scleroderma is now
deceased. Maternal aunt with [**Name2 (NI) 499**] cancer. Maternal aunt with
rheumatoid arthritis.
Physical Exam:
VS: 107/68 81 95% on 40% face mask RR 16
GEN: morbidly obese, AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
fixed split S2 with loud P2. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: obese, soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: warm, dry, hyperpigmented region on LE consistent with
venous stasis changes
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
Pertinent Results:
ADMISSION LABS:
.
[**2187-9-28**] 08:27PM K+-4.7
[**2187-9-28**] 08:15PM D-DIMER->[**Numeric Identifier 3652**]
[**2187-9-28**] 08:15PM PT-14.4* PTT-21.7* INR(PT)-1.2*
[**2187-9-28**] 06:55PM POTASSIUM-6.7*
[**2187-9-28**] 06:55PM GLUCOSE-175* UREA N-16 CREAT-1.2 SODIUM-137
POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
[**2187-9-28**] 06:55PM WBC-8.9 RBC-4.56* HGB-11.9* HCT-35.5* MCV-78*
MCH-26.2* MCHC-33.6 RDW-15.4
[**2187-9-28**] 06:55PM NEUTS-65.5 LYMPHS-29.6 MONOS-2.8 EOS-1.7
BASOS-0.3
[**2187-9-28**] 06:55PM PLT COUNT-154
[**2187-9-28**] 06:55PM PT-14.9* PTT-22.9 INR(PT)-1.3*
[**2187-9-28**] 09:25AM GLUCOSE-184* UREA N-11 CREAT-1.0 SODIUM-139
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2187-9-28**] 09:25AM CK(CPK)-103
[**2187-9-28**] 09:25AM CK-MB-2 cTropnT-<0.01
[**2187-9-28**] 09:25AM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-1.8
IRON-46
[**2187-9-28**] 09:25AM calTIBC-325 FERRITIN-268 TRF-250
[**2187-9-28**] 09:25AM WBC-7.3 RBC-4.33* HGB-11.3* HCT-34.3* MCV-79*
MCH-26.2* MCHC-33.1 RDW-15.3
[**2187-9-28**] 09:25AM PLT COUNT-141*
[**2187-9-28**] 02:00AM CK(CPK)-105
[**2187-9-28**] 02:00AM CK-MB-2 cTropnT-<0.01
[**2187-9-27**] 07:35PM GLUCOSE-81 UREA N-12 CREAT-1.1 SODIUM-138
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
[**2187-9-27**] 07:35PM CK(CPK)-124
[**2187-9-27**] 07:35PM cTropnT-<0.01
[**2187-9-27**] 07:35PM CK-MB-2
[**2187-9-27**] 07:35PM WBC-8.5 RBC-4.51* HGB-11.9* HCT-35.4* MCV-79*
MCH-26.4* MCHC-33.6 RDW-15.7*
[**2187-9-27**] 07:35PM NEUTS-59.4 LYMPHS-35.9 MONOS-2.7 EOS-1.7
BASOS-0.3
[**2187-9-27**] 07:35PM PLT COUNT-157
[**2187-9-27**] 07:35PM PT-12.8 PTT-22.2 INR(PT)-1.1
.
Discharge Labs:
.
[**2187-10-7**] 08:00AM BLOOD WBC-9.6 RBC-4.76 Hgb-11.9* Hct-36.8*
MCV-77*
MCH-25.0* MCHC-32.4 RDW-15.0 Plt Ct-208
[**2187-10-7**] 08:00AM BLOOD Glucose-137* UreaN-14 Creat-1.0 Na-138
K-4.4
Cl-100 HCO3-29 AnGap-13
[**2187-10-7**] 08:00AM BLOOD PT-22.4* PTT-61.9* INR(PT)-2.1*
.
.
[**2187-9-29**] ECG:
sinus rythm, normal axis, S1Q3T3 + SRWP/IRBBB which are not new
compared to tracing from 3/[**2187**]. V1-V4 TWI which are new and are
first seen on tracing from [**2187-9-27**].
IMAGING:
.
[**2187-9-28**] CTA Chest:
1. Massive bilateral pulmonary embolism involving all lobar
branches.
2. Subpleural triangular-like opacity in the superior segment of
left lower lobe, concerning for pulmonary infarct. Less specific
subpleural opacity in the left upper lobe could also represent
for additional sites for pulmonary infarct.
3. An 11-mm nodule in the left upper lobe, concerning for
neoplastic process. Close interval follow-up or alternatively
PET-CT are recommended.
.
[**2187-9-29**] ECHO: RV dilation and dysfunction (with apical sparring)
consistent with acute pulmonary embolism and RV strain.
.
[**2187-9-29**] Bilateral Lower extremity dopplers:
Calf veins not well evaluated. Otherwise, no evidence of
bilateral lower extremity DVT.
Brief Hospital Course:
Mr. [**Known lastname **] is a 45 year old man with PMH of HTN, HL, Type II
insulin dependent DM, non-obstructive coronaries on cath in
[**2184**], Iron deficient anemia and obesity who was admitted with
bilateral submassive PE.
.
# bilateral PE: Mr. [**Known lastname **] was admitted for syncope and
complaints of 5 day of chest pain. He was hypoxic but not
hypotensive upon presentation to the ER. CTA demonstrated
bilateral pulmonary embolism involving all lobar branches and a
triangular-like opacity in the superior segment of the left
lower lobe, concerning for pulmonary infarct. Also demonstrated
was an 11-mm nodule in the left upper lobe which is concerning
for neoplasm. LENIs were negative but study reported to be
technically difficult d/t obesity. Echocardiography demonstrated
LVEF-55% with RV dilation and dysfunction consistent with RV
strain secondary to acute pulmonary embolism. Mr. [**Known lastname **] was
admitted to the MICU for hypoxia and was treated with
non-rebreather mask and started on IV heparin and PO warfarine,
in the ICU he was normotensive and did not require pressors. He
was subsequently weaned from oxygen and transfered to the floor
where he continued to be normotensive and stable on RA. Bridging
of heparin and warfarine was continued until a theraputic INR
was reached and the patient was discharged for continued
ambulatory follow up with his PCP and the [**Name9 (PRE) 2786**]
clinic at [**Company 191**].
In terms of possible etiologies for thromboembolism Mr. [**Known lastname **]
did report two 8 hour-long car rides on the two days which
perceded the onset of his symptoms. His mother had a provoked
episode of DVT and there is otherwise no family history of
non-provoked thromboembolism. He had a normal colonoscopy in
2/[**2187**]. He was noted to have LUL solitary nodule, new compared
to CTA in [**2185**], which will need close follow up with PET or
repeat CT. A outpatient hematologist consultation for
consideration of work up for hypercoagulable conditions was also
arranged.
.
#Syncope- Mr. [**Known lastname **] was admitted after an episode of syncope,
there was anterior tongue biting but no tonic clonic movements
or incontinence. His syncope was likely secondary to a vasovagal
reaction to chest pain or caused by reduced cardiac output in
the setting of a massive PE. Mr. [**Known lastname **] was hemodynamoically
stable throughout his admission, telemetry did not demonstrate
any arrhythmias and no further episodes of syncope occurred.
.
#Lung nodule: as mentioned above an 11-mm nodule was
demonstrated on CTA in the left upper lobe, new compared to CTA
in [**2185**], which will require further PET/CT follow-up in the
outpatient setting.
.
#HTN - Prior to his admission Mr. [**Known lastname **] was on Toprolol,
Lisinopril, amlodipine and imdur. These medications were held
upon his admission and were not restarted as he continued to be
normotensive throughout his stay. His normal blood pressures off
his usual anti-hypertensive regimen may indicate some
hemodynamic effect of his PE. His blood pressures will continued
to be followed in the outpatient setting and his
anti-hypertensive medications will be renewed as needed at the
discretion of his primary care physician.
.
#DM - Mr. [**Known lastname **] had labile blood glucose levels on the initial
days of his admission. [**Last Name (un) **] Diabetic Center team was consulted
and he was stabilized on a regimen of long and short acting
insulin according to their recommendations. Mr. [**Known lastname **] was
discharged with lantus and sliding scale insulin and should
continue outpatient follow up at the [**Last Name (un) **] center.
Medications on Admission:
aspirin 81 mg a day
Toprol-XL 50 mg daily, recently increased to 100 mg daily
lisinopril 5 mg daily
amlodipine 2.5 mg daily
simvastatin 80 mg daily
imdur 30 mg daily
insulin (U500 25 units in AM and 25 units in PM)
Fluoxetine 30 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Warfarin 5 mg Tablet Sig: 2.5 Tablets PO Once Daily at 4 PM:
patient must follow [**Hospital 2786**] clinic guidance on warfarin
dosage adjustment.
Disp:*60 Tablet(s)* Refills:*0*
4. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Continue your home insulin fixed dose + sliding scale as
prescribed by your [**Last Name (un) **] consultant
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for complaints of chest pain and an episode of
fainting. You were found to have a blood clot in your lungs
which interfered with the delivery of oxygen to your blood. You
were admitted to the Intensive Care Unit and were treated with
oxygen to raise the level of oxygen in your blood and with
intravenous and oral blood thining medication to prevent the
clot from growing bigger and allow it to dissipate. You then
felt better and were transferred to the internal medicine floor
where you continued the blood thinning treatment. You will need
to continue taking your blood thinning pill - warfarin - at
home. You will be followed by the [**Hospital 2786**] clinic to
monitor your blood tests and guide you in medication dosing.
The following changes were made to your medications:
1. Toprolol, Lisinopril, amlodipine and imdur were stopped
becuase of low blood pressures during your stay. You should see
your PCP about restarting these.
2. Warfarin was added. You must follow the direction of the
[**Hospital 2786**] clinic regarding the exact dosage of this
medication which may change depending on the results of your
blood tests. For now, plan to take 12.5 mg (2.5 tablets)
tomorrow, unless you are told otherwise by the clinic.
3. Omeprazole was added to reduce acidity in your stomach and
prevent bleeding
Followup Instructions:
On Monday [**10-8**] you will need to come in to the clinic to have a
blood test to check your INR. This is coordinated by the [**Hospital 263**]
clinic at [**Hospital3 249**]([**Company 191**]) ([**Location (un) **], [**Hospital Ward Name 23**]
Building). The anti-coagulation nurse will contact you and give
you further instructions. If you do not hear from her by Monday
morning please call [**Telephone/Fax (1) 2173**].
.
Please keep the following appointments:
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2187-10-10**] at 2:35 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is to follow up after your hospitalization.
.
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2187-12-7**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], 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
.
You should discuss the following with your PCP:
.
1. refer you to a PET-CT of your lung to follow up on a small
nodule seen on your former CT scan.
2. refer you to a gastroenterologist - to consider colonoscopy
for investigation of your GI bleeding.
3. Discusses screening for prostate cancer with you.
4. refer you to follow up by a cardiologist.
Completed by:[**2187-10-19**]
|
[
"455.2",
"250.02",
"V58.67",
"401.9",
"780.2",
"415.19",
"518.89",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17137, 17143
|
12467, 16143
|
6438, 6444
|
17206, 17206
|
9441, 9441
|
18714, 20279
|
8482, 8700
|
16431, 17114
|
17164, 17185
|
16169, 16408
|
17357, 18691
|
11151, 12444
|
8715, 9422
|
6391, 6400
|
6472, 7884
|
9457, 11135
|
17221, 17333
|
7906, 8269
|
8285, 8466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,012
| 169,151
|
35264
|
Discharge summary
|
report
|
Admission Date: [**2160-12-30**] Discharge Date: [**2161-1-26**]
Date of Birth: [**2098-6-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Pt. presented on this admition with increased lethargy, a CT
scan revealed increase in the size of the ventricles and
developing hydrocephalus.
Major Surgical or Invasive Procedure:
[**12-31**] Right Cranioplasty with bone flap replacement
[**1-2**] External ventricular Drain placement
[**1-18**] Ventricular-Peritoneal Shunt Placement
History of Present Illness:
62 yo M with hx traumatic ICH s/p R craniectomy and R-temporal
lobectomy ([**11-12**]) admitted on [**12-30**] for fever and MS change.
Patient was admitted from [**Date range (1) 80447**] after falling off ladder.
He was found to have ICH and emergent R craniectomy and
evacuation of hematoma was performed on [**12-19**]. Course was
complicated by increasing midline shift necessitating widening
of R temporal lobectomy on [**11-24**]. Pt also had PEG-tube and IVC
filter placed.
He was discharged to [**Hospital 1319**] rehab on [**12-3**]. According to wife,
pt had been doing well until day of admission on [**12-30**] when he
was noted to be less responsive with temp of 100.6. On day
prior to admission he had been more interactive and was able to
participate with physical therapy.
Past Medical History:
-Intracranial hemorrhage s/p R sided craniectomy and evacuation
of hematoma. s/p right sided temporal lobectomy ([**11-12**])
-Hypercholesterolemia
-HTN
-s/p PEG [**11-12**]
-s/p IVC filter [**11-12**] (placed because of prolonged
immobilization
in setting of recent bleed.)
Social History:
Married, admitted from rehab facility
Family History:
N/C
Physical Exam:
On Admission:
T:97.6 BP:160/88 HR:57 RR:18 O2Sats 100%
Gen: Intubated and Sedated
HEENT:Lg L occipital scalp lap Pupils:L 3mm-2mm, R 2mm-1mm
EOMs can't be tested
Neck: C-collar in place
Extrem: Warm and well-perfused with lateral lac on L scapula.
Neuro:
Mental status: Sedated
Orientation: Sedated
Recall: Sedated
Language: Intubated
Naming intact. Intubated
Cranial Nerves:
I: Not tested
II: Pupils reactive to light, L 3mm to 2mm, R 2mm-1mm. Visual
fields not tested
III, IV, VI: Extraocular movements not tested
V, VII:Unable to test
VIII: Unable to test
IX, X: Unable to test
[**Doctor First Name 81**]: Unable to test
XII: Unable to test
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Moving upper ext. spont. Unable to test pronator drift
Sensation: Sedated
Toes downgoing bilaterally
Coordination: Not tested
Exam on Discharge:
Minimal verbalization, +eye opening to loud voice. Baseline
right ptosis and right facial droop. Spontaneous and purposeful
movements of the upper extremities R>L. Wiggles toes on right
foot to command. Left foot is flacid.
Pertinent Results:
Labs on Admission:
[**2160-12-30**] 12:00PM BLOOD WBC-9.6 RBC-3.82*# Hgb-11.9*# Hct-33.0*#
MCV-86 MCH-31.2 MCHC-36.2* RDW-13.5 Plt Ct-417
[**2160-12-30**] 12:00PM BLOOD Neuts-81.4* Lymphs-10.1* Monos-4.6
Eos-3.5 Baso-0.3
[**2160-12-30**] 12:00PM BLOOD PT-13.1 PTT-27.7 INR(PT)-1.1
[**2160-12-30**] 12:00PM BLOOD Glucose-114* UreaN-24* Creat-0.7 Na-136
K-4.5 Cl-98 HCO3-32 AnGap-11
[**2160-12-30**] 12:00PM BLOOD ALT-104* AST-42* CK(CPK)-28* TotBili-0.3
[**2160-12-30**] 12:00PM BLOOD Lipase-46
[**2160-12-30**] 12:00PM BLOOD cTropnT-<0.01
[**2160-12-31**] 04:00PM BLOOD Calcium-11.9* Phos-3.9 Mg-1.9
[**2161-1-13**] 03:00AM BLOOD PTH-61
Labs on Discharge:
[**2161-1-25**] 05:53AM BLOOD WBC-6.3 RBC-2.64* Hgb-7.8* Hct-22.5*
MCV-85 MCH-29.7 MCHC-34.8 RDW-14.2 Plt Ct-223
[**2161-1-23**] 03:52AM BLOOD Neuts-79.8* Lymphs-11.1* Monos-3.5
Eos-5.5* Baso-0.1
[**2161-1-26**] 05:28AM BLOOD PT-14.1* PTT-53.9* INR(PT)-1.2*
[**2161-1-25**] 05:53AM BLOOD Glucose-123* UreaN-24* Creat-0.7 Na-137
K-3.7 Cl-106 HCO3-25 AnGap-10
Imaging:
[**12-30**]: IMPRESSION: Low lung volumes with bibasilar atelectasis.
No pneumonia.
[**12-30**]: EKG Sinus rhythm. No previous tracing available for
comparison.
[**12-30**] HCT: IMPRESSION:
1. No new acute intracranial hemorrhage. Slightly improved
leftward shift of midline structures.
2. New hydrocephalus, especially of the left lateral ventricle
and third
ventricle. No definitive obstructing mass seen.
[**1-3**] HCT: IMPRESSION:
1. Status post right frontal cranioplasty with unchanged
pneumocephalus and post-surgical changes in the right middle
cranial fossa.
2. Interval increase in right subdural fluid collection
measuring 14 mm.
Unchanged leftward shift of normally midline structures,
approximately 7 mm.
3. Persistent dilatation of the left lateral ventricle. Interval
placement
of a left ventriculostomy catheter.
MRI [**1-6**] Head:
IMPRESSION:
1. No large areas of acute infarction or new hemorrhage.
Evaluation for
subtle foci of restricted diffusion is somewhat limited due to
the presence of blood products in the parenchyma as well as in
the occipital horns.
2. Subdural fluid collection in the right frontoparietal and
surgical
resection cavity filled with fluid in the right middle cranial
fossa, with
edema of the cerebral parenchyma and mass effect on the right
lateral
ventricle and 8 mm shift of the midline structures to the left,
not
significantly changed compared to the prior study of [**2161-1-3**],
allowing for the technical differences.
3. Enhancement around the periphery of the subdural fluid
collection in the surgical resection cavity may relate to
post-surgical changes or other causes of inflammation/infection
if there is clinical concern for infection.
HCT [**1-17**]:
IMPRESSION:
1. Unchanged right subdural hematoma with mass effect causing 5
mm leftward
subfalcine herniation.
2. There is focus of high attenuation in the lower pons, which
could reflect
artifact at the skull base. However, pontine hemorrhage cannot
be excluded
and MRI to rule out hemorrhage is recommended.
MRI [**1-18**] Head:
No evidence for acute hemorrhage in the pons as questioned on
the recent CT. Slight increase in size of the subgaleal
collection on the right compared to previous examination from
[**1-7**], but no significant change compared to yesterday's
CT.
Stable right subdural collection with stable enhancement along
its medial
margin.
HCT [**1-20**]:IMPRESSION:
1. Interval removal of a drain from the right subdural
collection, which is not significantly changed in size.
2. Persistent hydrocephalus and stable leftward shift of the
midline.
MRI Head [**1-22**]: No evidence of hemorrhage or infarction. No
change in subgaleal and subdural fluid collections with mass
effect.
Brief Hospital Course:
On [**12-30**] Pt. was admitted for w/u of his fevers and
hydrocephalus, he went to the OR on [**12-31**] for
cranioplasty(replacement of bone flap), he was extubated in the
OR and transferred to the floor. On [**1-1**], he developed
respiratory distress and fevers and was transferred to the ICU,
a fever w/u revealed a UTI with Coag Negative Staph in the
urine. [**1-2**], it was noted on physical exam that pt. had
significant Nuchal rigidity, an LP was performed and later and
ID was consulted. An external ventricular drain was placed for
surveillance of the CSF and in the interim until a permanent
shunt could be placed. Cultures from CSF have to date, not grown
any organism, and WBC thought to be pilocytic in nature. On
[**1-2**], swabs from the bone flap grew the organism p. acne, and
appropriate antibiotics were started(Cefepime for two weeks and
Vancomycin 4wks). On [**1-6**], routine LENIS were performed and
massive bilateral DVT's were identified. He was started on
heparin infusion until INR could be therapeutic. [**1-13**] Upper
extremity ultrasound performed to identify superficial
thrombosis in R basilic/cephalic veins. Warfarin therapy was
deferred until [**1-14**] in the setting of pending systemic cultures
to determine if in fact bone flap was infected, and may
necessitate removal. His nuchal rigidity continued to improve,
and VPS was cleared for placement by infectious disease on
[**1-18**]. Procedure was uneventful. On [**1-20**], his LFTs were noted
to have mild elevation and cefepime was discontinued. He was to
continue on Vancomycin until [**1-30**]. He continued to have
temperatures to 101.9. In the setting of subsequent negative
cultures, the fevers were thought to related to antibiotics, and
they were discontinued on [**1-25**]. The p. acne that was isolated
from the bone flap was determined to be pathogenic. On [**1-26**] he
was again febrile to 101.4, however in the setting of recently
discontinued vancomycin(thought to be causative of ongoing
fever), and relatively long half life, he was not cultured. His
WBC was 6.3 on [**1-25**], and thereby not suggestive of ongoing
infectious process. He was seen and evaluate by physical and
occupational therapy and determined to be appropriate for rehab
disposition. He was discharged to an appropriate facility on
[**1-27**] where his warfarin transition is to continue(Goal INR
2.5-3)
Medications on Admission:
1) Appl Ophthalmic PRN (as needed).
2. Clonidine 0.3 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a
day).
3. Lisinopril 40 mg Tablet [**Month/Year (2) **]: Tablet PO DAILY (Daily).
Hydralizine 50mg Q6
Hydroclorothiazide 25mg
4. Simvastatin 20 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) ML
Injection TID (3 times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Year (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Famotidine 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: Ten (10) ML's PO BID
(2 times a day).
amlodipine 10mg daily
Dilantin 600mg QHS
10. Acetaminophen 160 mg/5 mL Solution [**Month/Year (2) **]: [**11-19**] PO Q4H (every
4 hours) as needed for fever or pain.
11. Oxycodone 5 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO every 4-6 hours as
needed for pain.
12. Dulcolax 10 mg Suppository [**Month/Year (2) **]: One (1) Rectal at bedtime
as needed for constipation
Discharge Medications:
1. Amlodipine 5 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
3. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Month/Year (2) **]: One
(1) Appl Ophthalmic PRN (as needed).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO BID (2 times a day)
as needed.
7. Nystatin 100,000 unit/mL Suspension [**Month/Year (2) **]: Five (5) ML PO QID
(4 times a day) as needed for fungal infection.
8. Levetiracetam 100 mg/mL Solution [**Month/Year (2) **]: One (1) PO BID (2
times a day).
9. Thiamine HCl 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
11. Modafinil 100 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO QD ().
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: Five
(5) ml PO DAILY (Daily).
14. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO
TID (3 times a day).
15. Hydralazine 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours).
16. Erythromycin 5 mg/g Ointment [**Last Name (STitle) **]: apply Ophthalmic QID (4
times a day): Apply to Both Eyes.
17. Spironolactone 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO DAILY
(Daily).
19. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
20. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Last Name (STitle) **]: 1200 (1200) units/hr Intravenous ASDIR (AS
DIRECTED): Please titrate to goal PTT 50-70 until INR is
Therapeutic.
21. Hydralazine 20 mg/mL Solution [**Last Name (STitle) **]: 0.5 ml Injection Q4H
(every 4 hours) as needed for SBP>160.
22. Warfarin 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO ONCE (Once) for
1 doses: Loading dose to be given at 1600 on [**1-26**]. Please check
INR in am. .
23. ISS
Refer to Nursing Insulin Sliding Scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Aseptic meningitis
Hemiparesis
Hydrocehpalus
Fevers, etiology: drug
Protien/calorie deficiency
Discharge Condition:
Neurologically Stable
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Your Sutures have been removed, and thereby an office
appointment for this purpose is not indicated
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with
Dr.[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2161-1-26**]
|
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"599.0",
"780.61",
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"V15.59",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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[
[
[]
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12867, 12937
|
6739, 9132
|
464, 621
|
13076, 13100
|
2966, 2971
|
14379, 14745
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1815, 1820
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10324, 12844
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12958, 13055
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9158, 10301
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13124, 14356
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1835, 1835
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281, 426
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3623, 6716
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649, 1443
|
2232, 2701
|
2720, 2947
|
2985, 3604
|
2125, 2216
|
1465, 1744
|
1760, 1799
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,481
| 158,281
|
32872
|
Discharge summary
|
report
|
Admission Date: [**2151-12-28**] Discharge Date: [**2152-1-2**]
Date of Birth: [**2103-6-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CC:[**CC Contact Info 76535**].
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 25356**] at [**Hospital 15953**] Medical Group
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr. [**Known lastname 76536**] is a 48yo M with h/o AIDS, Hep C, prior h/o UGIB
(esophageal tear per OSH records) who initially presented to
[**Hospital3 **] ED on [**12-27**] with hematemesis and UGIB. By OSH
HPI, pt vomited blood x5, ~1 hr after snorting heroin. He was
originally hypotensive (though BP there was recorded as 119/78),
but his BP responded to IVF. His Hct was 35. NG lavage at that
time showed BRB that did not clear. He was transferred to the
ICU and his rpt Hct came back at 26. He was given several units
of pRBC overnight. He had a L subclavian placed for better
access. EGD was performed on [**12-28**] that showed a large amount of
blood in the stomach and clot was visualized on the gastric side
of the GE junction. During the exam, he developed active
bleeding at the site of clot. Attempts were made at cauterizing
the bleeding, but the pt became agitated and was thus intubated
for airway protection. EGD was continued and the site of active
bleeding was again injected with epinephrine and BICAP
coagulation was performed with achievement of hemostasis.
Approximately 12h after first EGD at OSH, EGD was repeated for
"brisk rebleeding." At that time, the ulcer at GE junction was
visiualized w/ clot, but without active bleeding; his duodenum
was clear. The ulcer was again treated with epinephrine and
BICAP. There was concern for perforation given the depth of
BICAP cauterization. He was continued on protonix IV bid,
octreotide gtt, and ancef (for prophylaxis). The decision was
transferred here to the SICU on [**12-28**] under thoracics care for
possible need of surgical intervention.
Other notable information from the OSH:
- he required a total of 7units prbcs and 2 units FFP prior to
transfer; Hct prior to transfer was 30
- post EGD/intubation, he had multiple episodes of jerking of
shoulders, neck, upper extremities; it was unclear if it was
myoclonus vs. seizure so pt was started on ativan gtt.
- admission labs at the OSH were notable for WBC 2.6, Hct 35.5
(but it trended down to 26.4 w/in 3 hrs), plt 90, Cr 1.0, BUN
10, K 3.3, ALT 58, AST 63, tbili 0.5, alb 3.8. PT 10.6, PTT
28.7, INR 1.0. EtOH level was negative. He was initially
afebrile.
.
In the SICU here, his temperature was 103.1. His Hct was
monitored [**Hospital1 **] and he remained stable. He had coffee ground ouput
(~125cc) from his NGT initially and then it became bilious; he
also had black liquid stool via rectal tube (~150cc). He
remained intubated and sedated. He was on an ativan gtt,
fentanyl gtt and propofol gtt. A PPD was placed on [**12-29**]. After
evaluation by thoracics, no surgical intervention was felt to be
indicated and he was transferred to the MICU service on [**12-29**]
for further management. Hct remained stable at 27-29. He was
also seen by the GI service who felt that no further
intervention was indicated at this time given his high risk of
rebleed. Differential for his ulcer included HIV ulcer, CMV/HSV,
GERD, neoplasia, MW tear, impaction, pill induced.
Recommendations were for IV protonix [**Hospital1 **] and to advance his diet
as tolerated to clears. Plan is for repeat EGD in [**4-16**] weeks for
biopsy of the ulcer.
.
At the time of transfer to our MICU service his hematocrit
remained stable and he was also hemodynamically stable. He has
not required any further blood products at [**Hospital1 18**]. His Tmax today
was 100.8. He was extubated in the AM on [**12-30**] and was able to
maintain stable O2 sats. His mental status remained lethargic.
He is able to follow commands but is unable to provide any
additional history. He states that he was otherwise free of
symptoms, including fever, chills, NS, weight loss, vision
changes, headaches, LH, chest pain, SOB, cough, n/v, diarrhea,
or urinary symptoms. It is unclear if pt actually understands or
is accurately answering these questions.
Past Medical History:
# HIV/AIDS - not on meds; last CD4 28 and VL 136 million ini
[**1-17**]
# HCV - VL not known
# Anemia
# Thrombocytopenia
# MRSA leg infection in [**1-17**]
# h/o alcohol abuse
# IV heroin use
Social History:
+tobacco, +EtOH (amounts not known). Last heroin use [**12-27**]
(snorted, not injected). Recently d/c from rehab in [**Hospital1 1559**],
had been there for 7 mos for drugs. Since d/c, has been living
in shelter in [**Hospital1 189**]. Next of [**Doctor First Name **] is father [**Name (NI) 122**] who lives in
VA.
.
Family History:
NC
.
Physical Exam:
VS: Tm 100.8, Tc 100.1, BP 117/73 (98-167/64-113), HR 90
(64-100), RR 22, sats 98% on 4L nc, I/O 2108/3415 today; yest
3049/3170
GEN: Somnolent, but arousable. Able to answer questions but
falls asleep easily. In NAD.
HEENT: [**Name (NI) 2994**], pt unable to cooperate w/ EOM testing, sclera
anicteric, MMM, OP without lesions but dentition is poor w/
multiple missing or rotting teeth.
NECK: No supraclavicular or cervical lymphadenopathy. No JVD.
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: Soft, ND. + BS throughout. Mild RUQ tenderness, no [**Doctor Last Name 515**]
sign. ? liver edge about 2 fingerbreadths below RCM. No masses,
no appreciable splenomegaly.
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: Deferred as pt unwilling to cooperate w/ exam.
.
Pertinent Results:
[**2151-12-28**] 11:41PM GLUCOSE-114* UREA N-22* CREAT-0.8 SODIUM-143
POTASSIUM-3.7 CHLORIDE-113* TOTAL CO2-24 ANION GAP-10
[**2151-12-28**] 11:41PM estGFR-Using this
[**2151-12-28**] 11:41PM ALT(SGPT)-24 AST(SGOT)-34 ALK PHOS-46
AMYLASE-55 TOT BILI-0.4 DIR BILI-0.2 INDIR BIL-0.2
[**2151-12-28**] 11:41PM ALT(SGPT)-24 AST(SGOT)-34 ALK PHOS-46
AMYLASE-55 TOT BILI-0.4 DIR BILI-0.2 INDIR BIL-0.2
[**2151-12-28**] 11:41PM ALBUMIN-2.8* CALCIUM-6.6* PHOSPHATE-2.7
MAGNESIUM-1.6
[**2151-12-28**] 11:41PM WBC-3.0* RBC-3.42* HGB-10.7* HCT-29.2* MCV-85
MCH-31.3 MCHC-36.7* RDW-15.1
[**2151-12-28**] 11:41PM PLT SMR-VERY LOW PLT COUNT-72*
[**2151-12-28**] 11:41PM PT-13.3 PTT-37.7* INR(PT)-1.1
[**2151-12-28**] 11:41PM FIBRINOGE-138*
[**2151-12-28**] 11:41PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2151-12-28**] 11:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
.
CXR:IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Lungs clear. Heart size normal. No pleural abnormality or
mediastinal widening. ET tube tip at the thoracic inlet is in
standard placement, and left subclavian line tip projects over
the left brachiocephalic vein. Nasogastric tube passes into the
stomach and out of view.
.
CXR:HISTORY: HIV, upper GI bleed, extubation.
IMPRESSION: AP chest compared to [**12-28**]:
NG tube ends in the stomach. Endotracheal tube has been removed.
Left subclavian line ends in the brachiocephalic vein.
Opacification of the right lung base is probably atelectasis,
but should be evaluated clinically for possible aspiration. Left
lung clear. Heart size normal.
.
EKG:Sinus rhythm. Low limb lead QRS voltage, is non-specific and
could be normal
variant. Tracing is otherwise, within normal limits. No previous
tracing
available for comparison.
.
CXR:IMPRESSION: Very subtle ill-defined opacity right infrahilar
region could represent early developing pneumonia.
Brief Hospital Course:
Imp: 48 yo male with history of AIDS, hepatitis C and
polysubstance abuse presented to an outside hospital with an
UGIB from esophageal ulcer s/p epinephrine and BICAP
cautherization, transferred to [**Hospital1 18**] for further management.
.
# Upper gastrointestinal bleed: This was found to be secondary
to an ulcer at the gastro-esophageal junction. At the time of
admission he was status post two EGDs at the outside hospital
with epinephrine injections and BICAP used during both
procedures. The patient was followed by our gastro-enterology
service while in-house. Per their evaluation, the differential
diagnosis for his bleed included HIV ulcer, CMV/HSV ulcer, GERD,
neoplasia, MW tear, impaction, or pill induced ulcer. His last
CD4 count in [**1-17**] was <50 (here on [**12-29**] CD4 was 32, VL
>100,000) so the patient was considered at risk for CMV or HSV.
Since his transfer to [**Hospital1 18**] and throughout his hospitalization,
his hematocrit remained stable and he required no furher blood
products.
.
# Fever: The patient had a temperature to 103.5 on presentation
to SICU. Originally, this was felt to be transfusion reaction.
However, the patient's sputum from [**12-28**] grew out coag positive
staph and strep pneumo. His CXR has some patchy bibasilar
densities (read as atelectasis vs. possible aspiration in the
right lower lobe) and pt continues to have low grade temps.
Given recent intubation, low CD4+ count, and continued fevers,
the patient was covered with broad spectrum antibiotics,
including vancomycin and ceftriaxone, initially. Later he was
changed to vancomycin alone given the above sputum cultures.
Ultimately the patient left against medical advice before
sensitivities could return on his sputum. It was recommended
that he continue on vancomycin until MRSA could be properly
ruled out. Linezolid was felt to not be an option for the
patient given his globally low complete blood count. The patient
refused to stay in the hospital for further evaluation and
treatment. He left the hospital AMA and was given presciptions
for levofloxacin, prophylactic bactrim, and prophylactic
azithromycin.
.
# ALTERED MENTAL STATUS: After extubation the patient had a
depressed mental status but otherwise nonfocal neuro exam. This
was felt to likely be toxic-metabolic, given the ativan,
fentanyl, and propofol he had received prior to extubation.
After transfer to the floor his mental status cleared quickly.
Ultimately, the patient was competent and able to weigh the
risks and benefits of his medical decisions at the time of his
leaving AMA.
.
# HIV/AIDS: During this hospitalization, the patient's CD4 count
was found to be 32, and viral load greater than 100,000. Per
records, the patient had been noncompliant with HAART in the
past. The patient's ANC was low during the hospitalization and
was 630 at the time of his leaving AMA. The dangers of leaving
the hospital with this ANC without proper evaluation and
treatment were explained. He, nonetheless, elected to leave the
hospital.
.
# HEPATITIS C: The patient has had no known treatment. During
this admission his HCV viral load was undetectable. His LFTs
remained largely within normal limits.
.
# PANCYTOPENIA: This was felt to be likely be multifactorial in
the setting of HIV, and alcohol abuse, and liver disease. Though
his hemtocrit was low throughout the hospitalization, it was
stable at the time of discharge as above.
.
# SUBSTANCE ABUSE: The patient has a history of alcohol and
heoin abuse. He was placed on a CIWA scale once extubated.
.
# F/E/N: At the time of his leaving AMA, the patient was on a
full diet. His electrolytes were repleted as needed.
.
# PPx: The patient was placed on a PPI and pneumoboots.
.
# CODE: full
Medications on Admission:
MEDS (on admission): none
Discharge Medications:
1. Hydrocortisone 1 % Ointment Sig: One (1) Appl Topical QID (4
times a day).
Disp:*1 tube* Refills:*2*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) as needed for mAC ppx.
Disp:*30 Capsule(s)* Refills:*2*
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
8. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
upper gastrointestinal bleed
pneumonia
HIV/AIDS
pancytopenia
Discharge Condition:
The patient has pneumonia and leukopenia and is leaving before
completed treatment against medical advice.
Discharge Instructions:
You were admitted to evaluate for gastrointestinal bleeding and
fever. Your endoscopy at the outside hospital found an ulcer as
the source of your bleeding. The bleeding was controlled and you
have had no further evidence of bleeding.
You have a serious pneumonia requiring an intravenous antibiotic
(vancomycin). You are requesting to leave against medical advice
before you can complete treatment for the pneumonia. Your lungs
are infected with two known organisms. Given the information
available at this stage, there is only one appropriate
antibiotic available in pill form (linezolid) to treat one of
the organisms. However, this medication is not safe given your
platelet count. The other organism is likely susceptible to
levofloxacin, but information is incomplete at this time. We
will prescribe levofloxacin for you. As the treatment is
incomplete, you will likely develop a worsening lung infection
and die. We strongly recommend that you remain in the hospital.
You also have a worsening white blood cell count. This means
your immune system is weakening. Your white blood cell count
needs to be followed in the hospital. Because you are not
agreeing to be followed in the hospital, you will likely develop
a serious infection and die due to your weakened immune system.
You should return to the hospital immediately should you develop
shortness of breath, chest pain, heart palpitations, fever,
chills, or any other symptom that concerns you.
You should take all medications as prescribed.
You should make an appointment to be seen by a new primary care
doctor as below.
Followup Instructions:
You should follow-up with a new primary care physician. [**Name10 (NameIs) **] may
set up a new patient appointment at the [**Hospital 191**] clinic here at
[**Hospital1 18**]. The phone number is [**Telephone/Fax (1) 250**].
|
[
"304.00",
"292.0",
"284.1",
"531.40",
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"042",
"291.81",
"285.1",
"V60.0",
"305.60",
"303.90",
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icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12512, 12518
|
7801, 9951
|
453, 460
|
12623, 12732
|
5785, 7778
|
14370, 14599
|
4919, 4926
|
11614, 12489
|
12539, 12602
|
11564, 11591
|
12756, 14347
|
4941, 5766
|
274, 415
|
488, 4349
|
9966, 11538
|
4371, 4565
|
4582, 4903
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,257
| 165,063
|
15215
|
Discharge summary
|
report
|
Admission Date: [**2177-7-31**] Discharge Date: [**2177-8-27**]
Date of Birth: [**2134-10-11**] Sex: F
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 42 year-old
woman with no significant past medical history otherwise
healthy. She is transferred from the outside hospital to the
[**Hospital1 69**] for management of a
possible necrotic pancreatitis. Basically, she was admitted
to [**Hospital 14959**] Hospital in [**State 32926**] for suspected
pancreatitis in [**2177-7-19**]. She presented to that
hospital with a chief complaint of upper abdominal pain with
vomiting for 24 hours. On questioning she stated that she
had similar episodes of pain for approximately three years
without any further workup. She reported heavy alcohol use
in the past, but quit about two months ago prior to this
hospitalization. She is admitted for presumptive diagnosis
of gallstone pancreatitis and she had an endoscopic
retrograde cholangiopancreatography on [**2177-7-22**], which
showed negative for common bile duct stones and there is a
mild dilation of the common bile duct and a sphincterectomy
was performed to 5 mm secondary to edema with endoscopic
retrograde cholangiopancreatography procedure. During that
stay the patient subsequently developed respiratory distress
with hypovolemia and hypocalcemia required Intensive Care
Unit stay for three to four days, but without any intubation.
Her enzymes normalized by [**2177-7-24**] and she was started
with Zosyn and Levaquin, but she still spiked a fever on
these. Subsequent CT of the abdomen showed accumulation of
ascites and markedly enlarged edematous pancrease with
changes consistent with necrotizing pancreatitis. Since
[**7-25**], she continued to have fever with increased white
blood cell counts and she was started empirically on [**7-31**]
with Imipenem, Vancomycin, the Levaquin was discontinued and
she was on total parenteral nutrition and transferred to [**Hospital1 1444**] for further management.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: The patient takes no home medications.
PAST MEDICAL HISTORY: No significant past medical history or
surgical history.
PHYSICAL EXAMINATION ON ADMISSION: The patient is a sick
looking middle aged woman having a temperature of 99.4
degrees Fahrenheit. Blood pressure is 110/74. Heart rate is
116. She is breathing 20 times per minute on 2 liters of
oxygen with O2 saturation at 90. She is bed bound. Her
chest is clear to auscultation bilaterally. The heart has a
regular rate and rhythm with no murmurs. The abdomen is soft
and with epigastric distention and tender on palpation
especially on the upper quadrants. She has active bowel
sounds.
LABORATORY: White blood cell count 29.4, hematocrit 26.9,
platelets of 726. Her INR is 1.2 with PT of 13 and PTT of
27.6. Her sodium was 131, potassium 4.9, chloride 96, bicarb
24, BUN 10, creatinine 0.5 and blood sugar level at 190. Her
liver function tests were within normal limits with amylase
of 57 and a lipase of 51. Her calcium is 8.1, magnesium is
1.8 and phosphate is 3.4.
HOSPITAL COURSE: The patient is brought to the Operating
Room on [**2177-8-1**] for debridement of the necrotizing
pancreatitis. By report, the patient has large amount of
ascites and cystic pockets around her pancrease, which was
extensively lavaged during operation. She also had a
cholecystectomy, which had multiple gallstones in the
gallbladder and an intraoperative cholangiogram was
performed, which showed a patent common bile duct and all the
biliary systems were patent. Her operation had an estimated
blood loss of 200 cc, however, because of her large amount of
fluid collection intraabdominally she required large amounts
of fluid resuscitation. She eventually had 10 liters of
crystalloid and 4 units of packed red blood cells despite
that the operation is only 2 to 3 hours in duration.
Intraoperatively a J tube was also placed for feeding
purposes and two large [**Doctor Last Name 406**] drains were also left in place.
The patient is transferred postoperatively to the CICU
intubated and sedated for further management.
Over the following several weeks the patient remained in the
Surgical Intensive Care Unit for management of her fluid
status. She was kept with intravenous antibiotics, Imipenem,
Vancomycin and Fluconazole and she was also put on total
parenteral nutrition and tube feeds. Her culture from the
peripancreatic fluid grew out Klebsiella, which is adequately
covered by her antibiotics. During the Intensive Care Unit
stay she required several units of packed red blood cells
transfusion. She was then successfully weaned off from the
ventilator on postoperative day number fourteen and her
follow up blood, urine and fluid cultures remained negative.
She continued to improve. On [**8-4**] her first follow up
abdominal CT was obtained that showed again a small amount of
ascites and pleural effusion bilaterally and also showed the
[**Doctor Last Name 406**] drain in good position. She was eventually transferred
to the regular floor on postoperative day number twenty when
her white blood cell count was 9.1 and hematocrit was 31.2.
She continued to recover well. Another follow up CT was
obtained on [**2177-8-25**], which showed resolution of the
pleural effusion and decreased stranding of free fluid in the
abdomen and showed a large pseudocyst with enhancing wall and
surrounding fat stranding containing the drainage catheter in
the place where her pancrease use to be. At the time of
discharge she had minimal complaints of pain and she is
afebrile with blood pressure running around 120s/80s and her
O2 sats is at 95% on room air and her abdomen is nontender
and drainage was effectively working. Both the JP and J tube
were in place. She is then discharged to rehab facility with
a follow up appointment with Dr. [**Last Name (STitle) 468**] within the next two
weeks.
DISCHARGE MEDICATIONS: Insulin 20 units NPH q breakfast, 18
NPH at bedtime, Protonix 40 mg po q day, amylase and lipase
proteus two caps t.i.d. with meals, Metoprolol 100 mg b.i.d.
and Percocet one to two tabs every four to six hours as
needed. She is discharged with wet to dry dressing changes
on her abdominal wounds twice a day and the drain dressing
changed every day is also arranged.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSIS:
Status post pancreatic debridement, status post necrotizing
pancreatitis.
DISCHARGE STATUS: To rehab facility.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Dictator Info 44293**]
MEDQUIST36
D: [**2177-12-8**] 12:01
T: [**2177-12-11**] 10:28
JOB#: [**Job Number 41484**]
|
[
"250.01",
"997.3",
"518.5",
"511.9",
"574.10",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"54.11",
"87.53",
"46.39",
"38.93",
"54.91",
"52.22"
] |
icd9pcs
|
[
[
[]
]
] |
6391, 6398
|
5999, 6369
|
6419, 6787
|
3157, 5975
|
174, 2135
|
2252, 3139
|
2158, 2237
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,126
| 133,221
|
34297
|
Discharge summary
|
report
|
Admission Date: [**2146-7-26**] Discharge Date: [**2146-7-28**]
Date of Birth: [**2124-10-2**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Penicillins
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Tachypena and tachycardia
Major Surgical or Invasive Procedure:
Endotracheal intubation [**7-25**], extubated [**7-26**]
History of Present Illness:
This is a 21 year-old male with a history of psychiatric
illness, with question of schizophrenia, who presents after
ingesting a "hand-full" of Zolpidem in front of his parents. En
route to ED, patient told EMS he had been hearing voices, which
instructed him to take the pills.
According to the patient's mother, he complained of anxiety
attack at work. Patient then told his mother that he was hearing
voices which were telling him to hurt himself. Patient then went
to his room and perseverated regarding the voices. Patients
mother took medications away but he kept a bottle of [**Month/Year (2) **], and
took a full fist of medications. She also mentioned that he had
loratadine in his room, but does not believe he took this
medication. He has been off his citalopram, sertraline and
seroquel since [**Month (only) 1096**].
In the ED, VS: 98.4 HR 146 BP 154/97 RR: 40 SaO2: 94% RA. The
patient was closely monitored and was found to be progressively
more tachypneic, tachycardic and somnolent and felt to not be
able to protect his airway, was intubated and transferred to the
ICU for further management. OG tube was placed, initially
misplaced but adjusted before transfer.
Past Medical History:
History of anxiety, prior episode of psychosis last summer with
paranoid delusions.
Herpes Zoster last [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] tremmor in right hand, unclear etiology (? sequela from
meningitis)
Social History:
Patient works for computer company. Occassional alcohol and
marijuana use.
Family History:
sister with autism
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-nourished, intubated, sedated
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: Moves all 4 extremities. Patellar DTR +1. Plantar reflex
downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
[**2146-7-26**] 12:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2146-7-26**] 05:50PM HCT-45.0
[**2146-7-26**] 09:31AM TYPE-ART O2-70 PO2-68* PCO2-37 PH-7.41 TOTAL
CO2-24 BASE XS-0 INTUBATED-NOT INTUBA
[**2146-7-26**] 05:30AM GLUCOSE-96 UREA N-7 CREAT-1.0 SODIUM-143
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-22 ANION GAP-16
[**2146-7-26**] 05:30AM CALCIUM-8.4 PHOSPHATE-4.6* MAGNESIUM-2.0
[**2146-7-26**] 12:11AM ALT(SGPT)-36 AST(SGOT)-16 LD(LDH)-160 ALK
PHOS-72 TOT BILI-0.4
[**2146-7-26**] 12:11AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2146-7-26**] 12:11AM PLT COUNT-332
[**2146-7-26**] 12:11AM PT-14.2* PTT-27.0 INR(PT)-1.2*
Brief Hospital Course:
21 year-old male with a history of psychiatric illness, with
question of schizophrenia, who presents after ingesting a
"hand-full" of Zolpidem in front of his parents with episode of
acute psychosis.
<br>
# Toxic ingestion: Per report patient ingested a handful of
Zolpidem because he heard voices commanding him to kill himself,
with a question of loratidine ingestion as well, though after
rediscussion with pt and mother - only [**Name2 (NI) 13426**]. His urine and
serum tox screen were negative on arrive and he did not have any
acid-base disturbance. He was intubated in the ED for airway
protection as it appeared he could not clear his secretions,
though he remained tachypneic and tachycardic in the ED. He did
not receive flumazenil or charcoal. The patient remained stable
overnight in the ICU and was extubated successfully the next
morning. He remained alert and oriented and his EKGs also
remained unchanged. Toxicology was consulted and said that
zolpidem has a short half life and the effects had already worn
off. Given that there was some question as to what he actually
ingested, we followed their recommendations to get serial EKGs
to look for QT prolongation, which he did not have in the ICU
and after 1 days observation on the floor. Pt's labs followed
and wnl, also given pt with diffuse myalgia complaints CK also
wnl. His sx along with sore throat (without sig exam findings),
low grade temps (no fever) night prior to transfer - sx/s all
more consistant with URI, unlikely withdrawal sx at this time.
(also noted sx improvement with tylonol with recs to continue po
prn). Suicide precautions continued, as pt stable currently d/w
psychiatry service, will be transferred today to inpatient psych
facility for further care. Per recs, started seroquel 25mg [**Hospital1 **]
for anxiety/psychosis sx - pt with positive responce, haldol was
ordered prn but was not needed on floor.
<br>
#Tachcardia: Sinus Tachycardia 100-110 while awake, NSR 80-90
while sleeping. The tachycardia did not improve with fluid
bolus or ativan. He denies significant drug or alcohol abuse,
and is not likely withdrawing. Given the patient's history and
the change in HR overnight, anxiety is the most likely cause.
Pt's HR in 80s in am, stable for transfer.
<br>
#. Psychotic episode: Psychiatric history unclear, but report of
hearing voices which instructed paitent to harm self. He
continued to hear voices throughout his stay int he ICU but by
morning 2, they were no longer commanding him to kill himself.
Given his age and symptoms, suspect schizophrenia but the time
course is too short to be diagnosed. Also has traits of
Personality disorder. Psychiatry was consulted and the patient
agreed to inpatient psychiatric stay. He was given haldol prn
agitation once in the ICU and started on seroquel as above. Per
inpatient psych team for further titration of medications.
<br>
#. Hypertension: Currently not active off of prior home dose of
HCTZ. Will d/c home HCTZ at this time with d/c BP at 115/90.
PCP will need to f/u. Inpatient psych center to schedule pt an
appointment at time of d/c from their fascility.
<br>
#Access: PIV, d/c at time of d/c (not needed on floor).
#Prophylaxis: Patient refused subQ heparin, will wear
pneumoboots, PPI, bowel regimen
# Code Status: Full
#Dispo: inpatient psych today
Medications on Admission:
Hydrochlorothiazide 25mg
Zolpidem 10mg
Loratadine ?
Citalopram 20mg (self d/c'd [**2145-11-6**])
Fluoxetine 20mg (self d/c'd [**2145-11-6**])
Seroquel 100mg (self d/c'd [**2145-11-6**])
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 882**] Hospital (acute inpatient psychiatric unit)
Discharge Diagnosis:
Primary Diagnosis: Zolpidem Overdose
Secondary Diagnoses: Psychosis, anxiety, HTN
Discharge Condition:
stable
Discharge Instructions:
You were admitted for management of Zolpidem overdose. We made
no changes to your home medications. You are being transferred
to an inpatient psychiatric facility for ongoing care. If you
develop chest pain, shortness of breath, vomiting, suicidal
ideation or auditory command hallucinations or any general
worsening of your condition please contact your PCP or come to
the emergency department.
Followup Instructions:
Please call PCP to set up a follow up appointment once you know
you'll be discharged from psych center - this will be to follow
up on your blood pressure. Your blood pressure was stable here
off of your hydrochlorothiazide, we would recommend to hold off
of this medication till re-evaluated.
Follow up with Psych as per inpatient recs
Completed by:[**2146-7-28**]
|
[
"963.0",
"298.9",
"276.51",
"E950.2",
"E950.4",
"401.9",
"967.8",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7188, 7277
|
3293, 6642
|
308, 367
|
7403, 7412
|
2545, 3270
|
7859, 8228
|
1951, 1971
|
6880, 7165
|
7298, 7298
|
6668, 6857
|
7436, 7836
|
1986, 2526
|
7356, 7382
|
243, 270
|
395, 1582
|
7317, 7335
|
1604, 1843
|
1859, 1935
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
402
| 169,538
|
8188
|
Discharge summary
|
report
|
Admission Date: [**2154-12-31**] Discharge Date: [**2155-1-10**]
Date of Birth: [**2105-9-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracyclines / Plaquenil / Chloroquine /
Sulfonamides / Floxin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
direct admit for CHF and pulmonary hypertension management
Major Surgical or Invasive Procedure:
tunneled central venous catheter placement
flolan titration.
History of Present Illness:
HPI: 49 year old with hx of lupus, pulmonary hypertension, RV
enlargement and failure and an ASD who is being admitted for
management of CHF/pulm HTN. The patient has had progressively
worsening dyspnea over the past one year. She has noticed
diminished exercise tolerance. Was able to climb the stairs in
her home without difficulty. Now she becomes dyspnea. Also
becomes dyspneic when ambulating on flat ground. Occasionally
notices a sensation of pressure across chest and arms. Pt was
seen by Dr. [**Last Name (STitle) 1016**] in cardiology on [**11-25**] for evaluation. As
part of his work-up the pt had a TTE which demonstarted moderate
to severe pulmonary hypertension, markedly dilated right
ventricle and R to L shunting c/w an ASD/PFO. A p-MIBI
demosnstrated a markedly increased right ventricular cavity size
with severe global hypokinesis with evidence of right-sied
pressure and volume overload. The patient is to be admitted to
[**Hospital Ward Name 121**] 6 for further evaluation of the pt's pulm HTN and
management of her CHF.
Past Medical History:
PMH:
systemic lupus erythematosus (22 years) treated with prednisone
and intermittent Plaquenil, mycophenolate,
methotrexate, and cyclophosphamide
glomerulonephritis in [**2144**]
type 2 diabetes
fibromyalgia
migraines
sinusitis
frequent urinary tract infections
Social History:
SH: Denies etoh, illicits. Has never smoked.
Family History:
FH: negative for CAD
Physical Exam:
Temp 96.9
BP 110/85
Pulse 113
Resp 18
O2 sat 92% RA
Gen - Alert, no acute distress
HEENT - mucous membranes moist
Neck - JVP 7 cm, no cervical lymphadenopathy
Chest - minimal crackles [**1-21**] way up b/l
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - 1+ pitting edema above ankles b/l. 2+ DP pulses
bilaterally
Neuro - Alert and oriented x 3, non-focal
Skin - No rash
Pertinent Results:
echo [**2154-12-26**]
Conclusions:
The left atrium is elongated. The right atrium is moderately
dilated. A right-to-left shunt across the interatrial septum is
seen at rest after contrast injection consistent with and
ASD/PFO. Left ventricular wall thicknesses are normal. The left
ventricular cavity is unusually small. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is markedly dilated. There is severe global right
ventricular free wall hypokinesis. There is abnormal septal
motion/position consistent with right
ventricular pressure/volume overload. The aortic arch is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial
mitral regurgitation. There is moderate to severe pulmonary
artery systolic hypertension.
.
IMPRESSION: Moderate to severe pulmonary hypertension. Markedly
dilated right ventricle. Severe right ventricular dysfunction.
Right to left shunting across interatrial septum at rest c/w
ASD/PFO.
.
[**2154-12-25**] p-mibi
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
3. Markedly increase right ventricular cavity size with severe
global hypokinesis with evidence of right-sied pressure and
volume overload
.
[**2154-12-31**] 05:19PM GLUCOSE-149* UREA N-15 CREAT-0.8 SODIUM-141
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15
[**2154-12-31**] 05:19PM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-1.6
[**2154-12-31**] 05:19PM estGFR-Using this
[**2154-12-31**] 05:19PM WBC-3.7* RBC-4.19* HGB-14.1 HCT-41.5 MCV-99*
MCH-33.7* MCHC-34.0 RDW-13.8
[**2154-12-31**] 05:19PM PT-12.9 PTT-21.8* INR(PT)-1.1
Brief Hospital Course:
Hospital Course: 49 year old with hx of lupus, pulmonary
hypertension, RV enlargement and failure and an ASD who is being
admitted for management of CHF and treatment of pulmonary artery
hypertension.
.
While in the CCU, the patient underwent a R heart cath which
showed: 1.Resting hemodynamics revealed normal right and left
sided pressures
(mean RA pressure was 5mmHg, mean PCWP was 9mmHg). There was
severe
pulmonary hypertension (mean PAP was 50mmHg, PVR 667
(dyne*sec)/cm5).
CArdiac index was normal at 2.4L/min/m2.
2.With 100% O2 therapy alone, the mean PAP was 41mmHg with PVR
553
(dyne*sec)/cm5.
3.With 100% O2 and Nitric Oxide vasodilator, the mean PAP was
46mmHg
with PVR 693 (dyne*sec)/cm5.
.
An ECHo as done that showed a small secundum atrial septal
defect/stretched PFO with bidirectional shunting. Two right
sided pulmonary veins and one large common left pulmonary vein
are seen entering the left atrium. There was no evidence of
partial anomalous pulmonary venous return.
.
The patient was then transferred to the MICU team to begin
treatment with flolan for her pulmonary artery htn.
.
Pulmonary Hypertension: Likely from lupus. An HIV test was
negative. Patient was monitored in the ICU with a swan ganz
catheter, showing elevated pulmonary artery pressures and
pulmonary vascular resistence. Flolan was titrated up, with
improvement in pulmonary vascular flow and patient's dyspnea.
At a rate of 14, the patient began feeling flushed, with severe
headache and pain in her jaw. Additionally, her foward
pulmonary flow did not improve after the increase from [**1-2**],
and her PCWP rose precipitously, and it was settled that 12
would be her dosage for discharge from the hospital. She had
extensive teaching from the flolan educators about needs at
home. The patient learned well and is ready for the home
infusions. She was also set up with home [**Month/Year (2) 20358**] and pulse
oximeter. A tunneled groshaun line was placed and is in working
order.
.
CHF: The patient was diuresed with lasix over the course of her
hospital stay, and will be discharged on lasix 20mg PO QD.
.
Thrombocytopenia: It was noticed that the patient's platelets
dropped during her stay. Heparin was discontinued and A HIT
antibody test was negative. The hematology team was consulted,
and concluded that her thrombocytopenia is likely due to either
HIT (even with a negative screen), or flolan. At the end of her
stay, the platelets stabilized at 108, and she will need a
followup CBC in 1 week to further evaluate.
.
UTI: during her hospital stay, Ms. [**Known lastname **] developed a urinary
tract infection that grew cipro sensitive klebsiella. She was
treated for 3 days with cipro, and a repeat urine culture was
negative.
.
DM2: She was treated with an insulin sliding scale during her
stay, and upon discharge, will restart her metformin at ome
dose.
.
SLE: She was continued on her home prednisone regimen.
.
fibromyalgia: She was continued on her home regimen of
amitryptiline, gabapentin, and pain meds prn
.
THe patient is full code.
Medications on Admission:
meds:
amiloride 5 mg once daily
allopurinol 100 mg daily
Relafen 1500 mg daily
metformin 850 b.i.d.
prednisone 10 mg (varying between 10 and 60 mg
mg, depending on the activity of her lupus)
Premarin 0.625 mg daily
[**Doctor First Name **] 180 mg daily
fluconazole 100 mg daily
amitriptyline 200 mg q.i.d. (for fibromyalgia)
Ambien 10 mg q.p.m.
gabapentin 600 mg three tablets daily (for fibromyalgia)
hydrocodone/APAP 5/500
.
all: Tetracyclines, sulfa drugs (rash), penicillin, Plaquenil
(rash), chloroquine (rash), Imuran (depression),
cyclophosphamide (nausea), methotrexate (fatigue), CellCept
(nausea)
Discharge Medications:
home [**Doctor First Name 20358**] 2-4 Liters continuous
Allopurinol 100 mg QD
Prednisone 10 mg Tablet QD
Conjugated Estrogens
Fexofenadine 60 mg QD
Amitriptyline 50 mg 4 tabs QHS
Zolpidem 5 mg 2 QHS
Gabapentin 300 mg 2 QAM
Gabapentin 400 mg 3 QHS
Nabumetone 500mg 3 tabs QAM
Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
Epoprostenol 0.5 mg Recon Soln Sig: One (1) Recon Soln
Intravenous INFUSION (continuous infusion) as needed for
Pulmonary HTN: 12ng/kg/minute infusion.
Loperamide pulse oximeter
Furosemide 20 mg QD
Potassium Chloride 10 mEq 2 tabs QD
[**Doctor First Name **] saturation monitor to monitor [**Doctor First Name 20358**] saturations. PAtient
to [**Name8 (MD) 138**] MD [**First Name (Titles) **] [**Last Name (Titles) **] saturation less than 92%
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical
Discharge Diagnosis:
Pulmonary arterial hypertension
lupus
thrombocytopenia
Discharge Condition:
stable.
Discharge Instructions:
Please continue to take all medications as prescribed. Your
flolan infusion should be continued at a rate of 12. You should
avoid all heparin products until instructed by Dr. [**Last Name (STitle) **].
.
If you have worsening headaches, flushing, jaw pain or other
difficulties please bring this up with Dr. [**Last Name (STitle) **]. If you have
fevers, chills, light headedness, easy bruising, bleeding, or
rash please seek medical attention.
.
We have started you on a new medicine called lasix. You should
take this for a week until you see Dr. [**Last Name (STitle) **]. She will need to
check your potassium level with this medicine.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2155-1-14**]
11:00
|
[
"V58.65",
"287.4",
"729.1",
"710.0",
"250.00",
"745.5",
"428.0",
"416.8",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"00.12",
"37.21",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
8951, 9009
|
4295, 4295
|
399, 462
|
9108, 9117
|
2446, 4272
|
9810, 9936
|
1902, 1925
|
8022, 8928
|
9030, 9087
|
7390, 7999
|
4312, 7364
|
9141, 9787
|
1940, 2427
|
300, 361
|
490, 1537
|
1559, 1823
|
1839, 1886
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,339
| 106,247
|
19213
|
Discharge summary
|
report
|
Admission Date: [**2125-7-11**] Discharge Date: [**2125-8-29**]
Date of Birth: [**2060-8-9**] Sex: F
Service: LIVER TRANSPLANT SURGERY
CHIEF COMPLAINT: The patient comes in after a fall.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
woman, status post autologous liver transplant on [**2125-6-27**]
for primary sclerosing cholangitis, diabetes type II. She
came in for a visit at the [**Hospital 1326**] Clinic Center today,
one day after falling on the floor at home landing on her
ribs and forehand. The patient reports no loss of
consciousness, lightheadedness, chest pain, shortness of
breath at this time. She did report that her legs have been
feeling very weak lately. The patient was helped to her feet
by her brother and the patient resumed her activities for the
day without complaint. Today, the patient complained of
significant pain in her left lower ribs. The patient also
reports having decreased appetite since discharge. No nausea
or vomiting, positive flatus, positive bowel movement,
describes "not liking the sight of food".
The patient has a recent hospital admission on [**2125-6-27**] to
[**2125-7-5**]. The patient's diagnosis was end-stage liver
disease, status post orthotopic liver transplant followed by
duplex ultrasound revealing normal arterial and venous flow,
cholangiogram revealing no stricture or lesion of the biliary
system. Condition at the time of discharge was stable. She
was discharged to home without services. At the time, she was
on MMF 1,000 b.i.d., prednisone 15 q d, Inderal 275 b.i.d.
PAST MEDICAL HISTORY: Status post autologous liver
transplant 06/[**2125**]. Primary sclerosing cholangitis, status
post stents. Diabetes type 2. Hyperthyroidism.
Gastroesophageal reflux disease. Diverticulosis. Laminectomy.
Appendectomy. Cholecystectomy. Ulcerative colitis. BRCA
status post mastectomy and chemotherapy.
MEDICATIONS ON ADMISSION:
1. Ativan 0.5 mg p.r.n.
2. Fluoxetine 60 mg q d.
3. Levothyroxine 150 mg q d.
4. Multivitamin, one q d.
5. Alendronate 70 mg q week.
6. Bactrim SS, one q d.
7. Fluconazole 400 mg q d.
8. Lispro, one unit q.i.d. SS.
9. Lantus 12 units q p.m.
10. MMF 1,000 [**Hospital1 **]
11. Protonix 40 mg q d.
12. Valcyte 450 b.i.d.
13. Prednisone 15 q d.
14. Neoral 275 b.i.d.
15. Furosemide 20 q d.
PHYSICAL EXAMINATION: On admission, she was in no apparent
distress. She was alert and oriented times three. Cranial
nerves II-XII were intact. Pupils equal, round and reactive
to light. Extraocular movements intact. Moist mucous
membranes. Regular rate and rhythm with 1-2/6 diastolic
rolling murmur. Clear to auscultation bilaterally.
Exquisitely tender along the left lateral lower costal
margin. Abdomen was nondistended, normal abdominal
examination, soft, nontender, well healing incision with
staples in place, no erythema or signs of drainage.
Extremities: Dorsalis pedis was present, no edema. Vital
signs on admission: Temperature 97.1, blood pressure 123/65.
LABORATORY DATA: Hematocrit 28.5, white blood cell count
14.9, platelets 419, sodium 131, potassium 6.7, chloride 98,
bicarbonate 20, BUN 59, creatinine 2.2, glucose 308, calcium
9.6, phosphate 5.4, magnesium 2.7, ASG 28, ALT 44, alkaline
phosphatase 148, total bilirubin 3.5, PT 13.3, PTT 25.5, INR
1.2, fibrinogen 504. Her first cyclosporin level for the next
day was 1,330. She was continued on prednisone 15 q d. She
was put on 275 b.i.d. for the first two doses and after the
level, she was held one dose and then started on 200. The
repeated mostly held with occasional dosing with levels
slowly declining from 1,000 to 540 by [**2125-7-21**].
HOSPITAL COURSE: Status post fall. The patient came with
confusion. She developed respiratory insufficiency and
decreasing mental status with changes. She required
intubation. She had developed ascites and hydrothorax, which
were drained. Despite a normal ultrasound on admission,
magnetic resonance imaging showed portal vein thrombosis.
She received TPA times three and Wall stenting of the portal
vein and flow was reestablished.
There was still some clot in the superior mesenteric vein.
Her symptoms decreased and she improved clinically. Her
ascites resolved as she became ambulatory while requiring
tube feeds presently. It is possible that she no longer will
require the tube feeds. Pain is well controlled on oral
medication. Regarding cultures, on [**2125-7-15**], she had a
blood culture that is negative. On [**2125-7-16**], she has a BAL
that was negative. She received several methicillin resistant
Staphylococcus aureus screenings, which were negative on
[**2125-7-23**]. On [**2125-7-24**], cultures through her hospital stay
have failed to grow anything or show anything of clinical
significance.
On [**2125-7-29**], the patient received MR [**First Name (Titles) 151**] [**Last Name (Titles) **]
contrast MRCP so she had the MR of the abdomen with and
without contrast and reconstruction for indications status
post recent liver transplant and elevated alkaline
phosphatase. Impression was portal vein thrombosis from
confluence of the IMV this point being higher up, mild to
moderate intrahepatic biliary ductal dilatation with no fixed
filling defect and no strictures seen.
The patient was discharged to the [**Hospital1 **] , which is an
extended care facility.
DISCHARGE INSTRUCTIONS: They are to monitor her for the
following: Fevers, chills, nausea, vomiting, inability to
tolerate food or drink. If any of these occurs, they are to
contact the physician immediately or their in-house physician
if they are unable to reach.
FINAL DIAGNOSES: Portal vein thrombosis, hydrothorax, thorax
respiratory insufficiency requiring intubation.
COMORBIDITIES: Diabetes type 2, hypothyroidism, ulcerative
colitis, gastroesophageal reflux disease, diverticulitis,
cholecystectomy, laminectomy, appendectomy, breast cancer
status post chemotherapy and mastectomy.
FOLLOW UP: Liver [**Hospital 1326**] Clinic [**2125-9-3**] at 10:20 a.m.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] [**2125-9-11**] at 2:10 p.m. Liver [**Hospital 1326**] Clinic
[**2125-9-17**] at 9:20 a.m. Phone number for the clinic is [**Telephone/Fax (1) 28347**] and the same for Dr. [**Last Name (STitle) 816**].
PROCEDURES PERFORMED: Chest tube and intubation.
CONDITION ON DISCHARGE: Afebrile and tolerating a regular
diet. Pain well controlled on oral medications.
DISCHARGE MEDICATIONS:
1. Levothyroxine sodium 150 mcg tablets, one tablet p.o. q d.
2. Alendronate 70 mg tablets, one tablet p.o. q week Fridays.
3. Bactrim SS tablets, one tablet p.o. q d.
4. Multivitamin.
5. Lansoprazole 30 mg capsules delayed release, one capsule
p.o. q d.
6. Artificial tear ointment.
7. Polyvinyl alcohol drops.
8. Albuterol nebs.
9. Fluconazole 200 mg tablets, one tablet p.o. q 24 hours.
10. Visicol 10 suppository h.s. as needed.
11. Ipratropium bromide nebs as needed.
12. Docusate 100 mg, one capsule p.o. b.i.d.
13. Valganciclovir 450 mg tablets, one tablet p.o. q d.
14. Spironolactone 25 mg tablets, one tablet p.o. q d.
15. Acetaminophen.
16. Lorazepam 0.5 mg tablets p.o. b.i.d. as needed for
anxiety.
17. Fluoxetine HCL 20 mg capsules, one capsule p.o. q d.
18. Sliding scale insulin.
19. Warfarin. She should take 0.5 mg every day.
20. Mycophenolate mofetil 200 suspension for
reconstitution 2.5 p.o. q d four times a day, which is 500
mg four times a day.
21. Prednisone 5 mg tablets. Take two tablets p.o. q d,
which is 10 mg every day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 46274**]
MEDQUIST36
D: [**2125-8-29**] 14:09:03
T: [**2125-8-29**] 15:19:26
Job#: [**Job Number 52365**]
|
[
"V42.7",
"789.5",
"511.9",
"518.81",
"452",
"567.2",
"584.9",
"512.8",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"88.47",
"03.31",
"99.15",
"50.11",
"96.04",
"38.93",
"96.6",
"96.72",
"88.48",
"99.10",
"38.95",
"54.91",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
6485, 7891
|
1922, 2341
|
3685, 5355
|
5380, 5623
|
5641, 5952
|
5964, 6354
|
2364, 2958
|
174, 210
|
239, 1572
|
2973, 3667
|
1595, 1896
|
6379, 6462
|
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